Obstetrics and Gynaecology Short Flashcards
Summary of important topics
Breech presentation
When the presenting part of the foetus is the buttocks or feet
Most spontaneously correct to cephalic by 36 weeks
Offer external cephalic version (ECV) at 36 weeks if primiparous, 37 weeks if multiparous
Absolute contraindications: C-section indicated for any other reason, APH < 7 days, non-reassuring CTG, placental abruption or placenta praevia, uterine abnormality
Ovarian cancer
RIsk factors: unopposed exposure to oestrogen
Key features: abdominal discomfort, bloating, early satiety, urinary frequency/bowel habit changes
2ww if ascites, pelvic or abdominal mass (late signs)
Ix: combination of CA-125 (>35 IU/mL), pelvic ultrasound and menopausal status then CT staging and biopsy for histology
Stages:
- 1: confined to ovary
- 2: spread beyond ovary but within pelvis
- 3: spread beyond pelvis but within abdomen
- Spread beyond abdomen (distant metastasis
Mx: gynae oncology MDT, combination of surgery and chemotherapy
Endometrial cancer
Key features: PMB = endometrial cancer until proven otherwise, intermenstrual bleeding, pelvic pain, abdo discomfort/bloating, weight, anaemia
RFs: unopposed oestrogen e.g. PCOS, no or fewer pregnancies, early menarch, late menopause, obesity
Protective factors: mirena coil, COCP, multiparity, smoking
Dx: 1st line: TV USS, thickness >5mm = hysteroscopy and biopsy
Stage:
1- confined to uterus
2- to cervix
3- to ovaries, fallopian tubes or lymph nodes
4- bladder, rectum or beyond pelvis
Mx: radial hysterectomy with bilateral salping-oophorectomy (removal of uterus, cervix and adnexa)
Termination of pregnancy
- < 24 weeks gestation if elective
- Any gestation if risk to mother’s life,, risk of serious handicap, grave danger to mother’s physical/mental health
Medical:
Mifepristone (progesterone antagonist - stops pregnancy) and misoprostol (prostaglandin analogue to expel)
Surgical: vacuum aspiration or dilatation and curettage
Fat necrosis of the breast
Benign tumour caused by adipose tissue necrosis in the breast, common in obesity
Features: mimics malignancy - firm, irregular lump, inflamed/warm/red overlying skin
2WW criteria NICE
- > 30 with unexplained breast lump
- > 50 with nipple changes (skin changes, discharge, retraction)
Placental abruption
The detachment of the placenta from uterine wall. Obstetric emergency!
RFs: previous PA, pre-eclampsia, smoking, cocaine, maternal age > 35
Revealed: bleeding is seen from the vagina
Concealed: bleeding is hidden behind the placenta and no bleed externally
Key features: tense, firm, woody uterus. Foetal distress.
Dx: clinical dx, vital signs (BP, HR,RR, SpO2), bloods: FBC, U+E, LFTs, coagulation screen, group and save
Mx:
- Foetal distress or maternal compromise = emergency C-section
- No foetal distress or maternal compromise = induction of labour
Pre-eclampsia
New HTN in pregnant woman (140/90 or more) with proteinuria and end-organ dysfunction occurring after 20 weeks gestation.
RFs: high: existing HTN, SLE or SKD, previous pre-eclampsia, moderate: FHx, nulliparity, BMI 30 or more.
High risk = 1 high or 2 moderate
Key features: headache, vomiting, blurred vision, swelling of face, hands and feet
Dx: BP: 140/90 or more AND EITHER proteinuria (+1 on dipstick)), OR end-organ dysfunction (e.g. raised creatinine)) OR placental dysfunction (e.g. abnormal doppler)
Proteinuria = protein: creatinine > 30mg/mmol, or albumin: creatinine > 8mg/mmol
Mx: admit if 160/110 or more
Outpatient: 2x weekly FBC, LFTs and U+Es, BP monitoring at least every 48 hours, ultrasound monitoring of foetus, amniotic fluid and dopplers every 2 weeks, BP control <1350/85, offer medication if persistently 140/90 or over,
High risk = secondary care review + aspirin as prophylaxis from 12 weeks gestation
Labetalol as antihypertensive if established pre-eclampsia
Delivery: <34 weeks up to 37 weeks = monitor and deliver if foetal/ maternal compromise, give IV corticosteroids and Mg sulphate. > 37 weeks = delivery
Breast cancer type + risk factors
RFs: female (99%), BRCA 1 and 2 gene, FHx (first degree), more dense (glandular) tissue, obesity, smoking
- Ductal carcinoma in-situ (DCIS) - pre-cancerous originating from epithelial cells
- Lobular carcinoma in-situ (LCIS) - precancerous often in pre-menopausal women
- Invasive ductal carcinoma NST - most common type of invasive breast cancer, from breast ducts
- Invasive lobular carcinoma - 10%, from breast lobules
- Inflammatory breast disease - presents like mastitis or abscess. Warm, swollen, tender, peau d’orange skin, not responsive to abx
- Paget’s disease of the nipple - erythematous, scaly skin around the nipple/areola, presents like eczema. Often DCIS
Breast cancer investigations
NICE 2ww criteria:
> 30 with unexplained breast lump
50 with unexplained unilateral nipple changes
30 with unexplained lump in axilla
Breast clinic for triple assessment
- History and clinical examination
- Ultrasound (younger) or mammogram (older)
- Core biopsy and histology
Breast cancer management
- Wide local excision + radiotherapy
- Mastectomy with immediate or delayed reconstruction
- Neoadjuvant/adjuvant chemotherapy
Breast cancer receptors
- Oestrogen receptor (ER): tamoxifen for pre-menopausal, letrozole or anastrozole for post-menopausal
- Progesterone receptor (PR)
- Human epidermal growth factor (HER2) - Trastuzumab (cardiac monitoring needed)
Fibroadenoma
Highly mobile, firm, painless, well-circumscribed lump in the breast - “breast mouse”
Common in pre-menopausal women as they respond to oestrogen
Usually < 3cm
Menopause
Defined as at least 12 months after last menstrual period, the time leading up to menopause is peri-menopause
Symptoms: hot flushes, low mood, emotional liability, joint pain, reduced libido, vaginal dryness and atrophy
Dx: 45 or over = clinical, FSH for < 40 suspected premature ovarian failure or 40 - 45 with perimenopausal symptoms
FSH + LH high and oestrogen low
Mx: none, HRT, SSRI, CBT, vaginal oestrogen creams, vaginal moisturisers
Contraception: > 50 for one year after LMP, <50 for two years after LMP
Placenta praevia
Low-lying placenta (grade 1/2), placeta praevia is when it covers the internal os, usually detected at 20-week anomaly scan
RFs: previous C-section, multiparity, older maternal age, maternal smoking, uterine abnormalities e.g. fibroids)
Key feature: painless vaginal bleeding
Grade 1: encroaches internal os, but does not reach it
Grade 2: reaches internal os but does not cover it
Grade 3: partially covers
Grade 4: completely covers
Mx: monitor and repeat TV USS at 32 and 36 weeks
If 34 - 35+6 weeks - then corticosteroids in case of preterm delivery
Planned delivery considered at 36 - 37 weeks to reduce risk of APH
Emergency c-section might be needed, with blood transfusions, intrauterine balloon tamponade etc.
Ectopic pregnancy (definitely going to be in exams according to the guy who writes the exams)
When an embryo implants outside of the uterus, most commonly the ampulla of the fallopian tube.
RFs: previous ectopic, PID, previous surgery to fallopian tubes, intrauterine devices (coils), older age, smoking
Key features: all child-bearing age females with lower abdominal pain, think ectopic! Missed period, lower abdominal pain in either LIF or RIL, right shoulder tip pain, vaginal bleedingm cervical moption tenderness
Ix: urine beta-hCG, ultrasound to locate pregnancy
Positive pregnancy test + abdo pain/tenderness = referral to Early Pregnancy Assessment Unit
Management of ectopic pregnancy
Expectant management if
- Follow-up possible to ensure successful termination
- Unruptured
- B-hCG < 1500UI/L
- adnexal mass < 35mm
- No significant pain
- No visible heartbeat
Medical management with IM methotrexate same as expectant but:
- B-hCG < 5000 UI/L
- Confirmed absence of intrauterine pregnancy by USS
Surgical management with salpingotomy or salpingectomy if:
- Anyone that does not meet criteria for expectant or medical mx:
- Pain
- Visible heartbeat
- Adnexal mass > 35mm
- B-hCG > 5000UI
Urinary incontinence
Urge - uncontrollable need to urinate leading to involuntary leak of urine = overactivity of the detrusor muscle
Stress - urine leak during times of increased abdominal pressure e.g. laughing or coughing = weakness of pelvic floor
Mixed - mixture of both
Overflow - urinary retention leading to leakage from overflow of urine
RFs: perineal tears, post-menopausal status, multiparity, pelvic floor surgery, pelvic organ prolapse, neuro conditions e.g. MS
Dx: bladder diary, urine dipstick for infection, post-void residual bladder volume - scan to measure volume left after voiding
Mx: stress: avoid caffeine, pelvic floor exercises, lose weight, duloxetine (SNRI)
Urge: bladder retraining, oxybutynin (anticholinergic), Botox injections
Fibrocystic changes of the breast
When breast tissue becomes fibrous (hard and irregular) and cystic (fluid-filled), in response to differing levels of oestrogen and progesterone and fluctuates through the menstrual cycle.
Key features: lumpiness, pain/tenderness (mastalgia), fluctuations in breast size
Mx: supportive bra, NSAIDs, apply heat, avoid caffeine, tamoxifen or danazol under specialist
Polycystic ovarian syndrome
Rotterdam criteria:
- Anovulation/oligo-ovulation
- Hyperandrogenism (hirsutism, oligomenorrhoea and acne)
- polycystic ovaries or ovarian volume > 10cm3 on USS
Other features: acanthosis nigricans, obesity, sub/infertility, mood disorders
Insulin resistance is present, high levels of insulin contributes to halting follicular development and increase androgen production = worsening PCOS symptoms.
Dx: LH:FSH raised, testosterone: normal/slightly raised, fasting and OGTT for insulin resistance
Mx:
- Lifestyle changes
- Co-cyprindrol: reduces hirsutism and regulates menstruation
- COCP regulates menstrual cycle + endometrial cancer protection
- Metformin to regulate menstrual cycle and enhance fertility
- Clomiphene to induce ovulation if trying to conceive
Cervical cancer
HPV 16 and 18
90% squamous cell carcinoma
Risk factors: non-engagement with screening, sexual activity at younger age, multiple sexual partners, smoking, FHx, immunosuppression
Clinical features: non-specific, abnormal vaginal discharge, post-cortical bleeding, urinary/bowel changes, suprapubic pain.
O/E with speculum: white/red patches on cervix, pelvic mass
Dx: FBC (anaemia), LFTs (liver involvement), U+Es (renal involvement), colposcopy for biopsy and CT staging
Stages:
- confined to cervix
- spreads to uterus or upper 2/3 vagina
- spreads to pelvic wall or lower 1/3 vagina
- Bladder, rectum or beyond pelvis
Mx:
- Cervical intraepithelial neoplasia and early stage 1a: LLETZ
- Advanced but still early stage: radical trachelectomy (removal of cervix and surrounding tissue)
- Stage 1B - 2A: radical hysterectomy with local lymph node removal + chemo + radiotherapy
- Stage 2B - 4A: chemo and radiotherapy
- Stage 4B: palliative care with surgery, radiotherapy, chemo
What is cervical intraepithelial neoplasia
Grade of cervical epithelial dysplasia found on colposcopy, not to be confused with dyskaryosis on cervical screening.
CIN I: mild dysplasia affecting 1/3 thickness of epithelium, likely to return to normal without tx
CIN II: moderate dysplasia, affecting 2/3 thickness of epithelium, likely to progress to cancer if untreated
CIN III (cervical carcinoma in situ): severe dysplasia, very likely to progress to cancer if untreated
Miscarriage
RFs: previous miscarriage, older maternal age, maternal smoking and alcohol during pregnancy
Early = up to 12 weeks
Late = 12 - 24 weeks
Types of miscarriage
- Missed - foetus is no longer alive but no symptoms have occurred
- Threatened - mild vaginal bleeding +/- abdominal pain cervical os is closed and foetus is alive
- Inevitable - heavy vaginal bleeding + abdominal pain + clots, cervical os is open, leading to complete or incomplete miscarriage
- Complete - miscarriage has occurred with no products of conception left
- Incomplete - vaginal bleeding + abdominal pain, miscarriage occurred but retained products of conception
- Recurrent: 3 or more miscarriages before 24 weeks gestation
Dx and Mx of miscarriage
Dx: TV USS to confirm viability and check size, heartbeat and pole
Mx:
- Expectant: 1 - 2 weeks allowed for products to pass, repeat urine BhCG after 3 weeks
- Medical: misoprostol (prostaglandin analogue) orally or vaginal pessary: heavier bleed, pain, vomiting, diarrhoea
- Surgical: manual or electric vacuum aspiration, offer anti-D for women undergoing this
If no risks of heavy bleeding or infection = expectant management
If > 6 weeks with bleeding = refer to EPAU
Threatened - monitoring and analgesia (paracetamol)
Complete - counselling and analgesia (paracetamol)
Incomplete- medical/surgical (+curettage) + counselling + analgesia
Recurrent - find underlying cause (e.g. antiphospholipid syndrome)
Ovarian cyst
Fluid-filled sacs on ovaries, functional cysts respond to fluctuations in menstrual cycle = pre-menopausal women
Follicular cysts = most common
Post-menopause, cysts = Ix for ?malignancy
Key features, asymptomatic, pelvic pain, bloating, abdo fullness, palatable mass if large
Risks of ovarian torsion or rupture
Always keep ovarian cancer in mind, rule out red flags (bloating, early satiety, change in urinary/bowel habit, weight loss, ascites, lymphadenopathy , assess risk factors and protective factors
Mx:
Pre-menopausal:
- < 5cm = resolve within 3 cycles
- 5 - 7cm = routine gynae referral + yearly USS
- > 7cm - MRI scan or surgical evaluation
Post-menopausal:
- CA-125 and gynae referral
- Normal CA-125 and <5cm = USS every 4 - 6 months
- Abnormal CA-125 = gynae
- Growing cysts = surgical intervention (laparoscopic ovarian cystectomy +/- oophorectomy
Gestational diabetes
New onset diabetes during pregnancy
RFs: previous gestational diabetes, previous macrosomia (>4.5kg), BMI > 30, Ethnicity (Afro-Caribbean, Middle Eastern, South Asian), FHx (first degree)
Previous GDM = OTTG at booking
Otherwise high-risk at 24 - 28 weeks
Fasting glucose 5.6 mmol/L or more
OTTG (75g glucose drink then measure blood glucose after 2hrs) = 7.8mmol/L or more
Mx:
Fasting glucose > 7mmol/L = insulin
Fasting glucose < 7mmol/L: trial lifestyle changes for 1 - 2 weeks then metformin if ineffective
Post-natal complication: neonatal hypoglycaemia if <2mmol/L = IV dextrose + nasogastric feeding), macrosomia (>4.5kg), jaundice (raised bilirubin), congenital heart disease
Pre-existing diabetes 1 and 2 in pregnancy
- 5mg folic acid
- Same insulin target levels as GDM
- Type 1 = insulin, type 2 = metformin + insulin (stop all other meds)
- Retinopathy screening = refer to ophthalmology for diabetic retinopathy
Planned delivery 37 - 38+6 weeks
Sliding scale of insulin regime for type 1 diabetes during delivery
Placenta accreta
When there is abnormal adhesion of the placenta to the uterine wall. Major cause of PPH!
RFs: previous placenta acrreta, previous endometrial curettage (e.g. miscarriage/abortion), previous C-section, multigravida, LLP/placenta praevia, increased maternal age
Key features: usually asymptomatic, maybe bleeding in third trimester, antenatal ultrasound
Accreta - when the placental villi attaches to the myometrium surface
Increta - when the placental villi invade through the myometrium but does not invade past it
Percenta - when the placental villi invades past the myometrium and the serosa (perimetrium) reaching other organs e.g. bladder
Mx: planned delivery between 35 - 36+6 weeks and antenatal steroids for foetal lung maturation
MDT, might need blood transfusion, intensive care for mother and baby, complex uterine surgery
During C-section, hysterectomy or uterine preserving surgery might be required
Induction of labour
If 41 - 42 weeks, pre-eclampsia, diabetes, foetal death then IOL
Bishop score 8 or more = IOL likely successful, less than 8 = cervical priming needed
Membrane sweep from 40 weeks to try and induce labour within 48 hours
Vaginal pessary (Propess) or tablet (prostin) = vaginal prostaglandin E2 stimulates cervical effacement and uterine contraction
Artificial rupture of membrane with oxytocin infusion - after vaginal prostaglandin have been tried
Oral mifepristone and oral misoprostol if intrauterine foetal death
Monitoring using CTG (foetal HR and uterine contractions) + bishop score
Risk is uterine hyperstimulation (prolonged and frequent contractions) - remove vaginal prostaglandin/stop oxytocin infusion, tocolysis with terbutaline
Intrauterine growth restriction (IUGR)
Two types:
- Placenta mediated: idiopathic, pre-eclampsia, maternal smoking+ alcohol, anaemia, malnutrition, infection, maternal health conditions
Non-placenta mediated: genetic abnormalities, foetal infections
Features: oligohydramnios, abnormal dopplers, reduced foetal movement, abnormal CTGs
Short and long-term complications of IUGR
Short term complication
- Foetal stillbirth/death
- Birth asphyxia
- Hypothermia
- Hypoglycaemia
Long-term complication
- CVD - particularly HTN
- Diabetes
- Obesity
- Mood and behavioural issues
Small for gestational age baby (SGA)
Risk factors:
- Previous SGA
- Pre-eclampsia
- Antepartum haemorrhage
- Obesity, hypertension, pre-existing diabetes (metabolic syndrome)
- Smoking
- Older mother > 35
- Antiphospholipid syndrome
Mx: Low-risk: SFH measurement from 24 weeks.
If 3 or more minor RFs, one or more major RFs = serial growth scans with umbilical artery doppler
Consider early delivery if growth static or other problems e.g. abnormal doppler results
Vulvar cancer
Most common squamous cell carcinoma
Clinical features: non-healing, ulcer, itching, vulvar pain , =/- lymphadenopathy
Dx: examination of vulva, CT chest, abdomen and pelvis for staging, biopsy to confirm Dx
Mx: stage 1a = wide local excision, more advanced cases need radial vulvectomy and neoadjuvant chemo. Palliative radiotherapy
Congenital rubella syndrome
Triad of cataracts, sensorineural hearing loss and congenital heart disease. Blueberry muffin rash
Serology testing of rubella-specific IgM antibodies
Management: MDT - ophthalmology for eye review, cardiology for heart defect, audiology for hearing. Regular follow-up
Fibroids
Benign tumours of the smooth muscle of the uterus, oestrogen sensitive
- Intramural - within the myometrium
- Submucosal - just under the endometrium
- Subserosal - just under the perimetrium (serosa)
Key feature: menorrhagia (heavy menstrual bleeding), sub/infertility if large enough, urinary/bowel symptoms
Ix: bimanual exam, transvaginal USS for size and location of fibroids
Management: < 3cm, no distortion and menorrhagia = Mirena coil 1st line, NSAIDs + TXA, COCP
< 3cm + distortion: endometrial ablation, resection in colposcopy
> 3cm +/- distortion - refer to gynae for Ix and Mx:
- Mirena coil
- NSAIDs and TXA
- COCP
- uterine artery embolization
- Myomectomy/hysterectomy
Can give goserelin (GnRH agonist) to women with menorrhagia before surgery to help with bleed
Red degeneration of fibroids
Ischaemia, infarction and necrosis of a fibroid due to disrupted blood supply.
Presents as severe abdominal pain and low-grade fever, tachycardia and vomiting, likely 2nd or 3rd trimester
Mx: supportive, rest, fluid and analgesia
Intraductal papilloma
Warty lesion that grows inside one of the breast ducts, proliferation of ductal cells
Key features: clear or blood-stained discharge, but often asymptomatic and incidentally found on USS or mammogram
Benign but associated atypical hyperplasia and breast cancer
Dx: triple assessment
MX: surgical excision
Mastitis
Mastitis is inflammation of breast tissue with/without infection, can be caused by duct obstruction
- Erythematous, swollen, tender, hard wedge-shaped area on breast
- Fever
- Painful breast
Common in breastfeeding mothers = lactational mastitis
Infective if fever, purulent discharge +/-nipple fissure
Mx: continue breastfeeding, heat packs, express milk, massage, resolve within 12 - 24 hours, if not then flucloxacillin
If non-lactational = analgesia, antibiotics tx underlying eczema or candida infection (broad-spectrum e.g. co-amoxiclav + erythromycin + metronidazole)
Breast abscess
Collection of pus in area of breast, can be lactational or non-lactational
Most common cause = staphylococcus aureus
ACUTE = presents within a few days
Key features: swollen, fluctuant (movable fluid on palpation), tender lump, pain, fever, malaise
Mx:
- Continue feeding + expressing
- Refer to on-call surgery team
- Abx
- USS to confirm Dx
- Drainage via needle aspiration or surgical incision + drainage
- Microscopy, culture and sensitivities
Pelvic inflammatory disease
STI that spreads from vagina into cervix and upper genital tracts
Causes: 20% caused by chlamydia and gonorrhoea
Dx: clinical dx based on symptoms: bilateral abdominal pain, abnormal vaginal discharge, post-coital bleeding, fever, dysuria, adnexal tenderness, cervical motion tenderness
Mx: IM single dose ceftriaxone + doxycycline + metronidazole
Endometriosis
When endometrial tissue grows outside of the uterus - fallopian tubes, bladder, bowel
Key features: dysmenorrhoea, deep dyspareunia, infertility
Ix: transvaginal USS is 1st line, diagnostic laparoscopy is gold standard and can excise/ablate the abnormal tissue
Mx:
- Medical mx: paracetamol/NSAIDs, mefenamic acid, COCP
- Surgical: ablation/excision of endometrial tissue, hysterectomy
Pelvic organ prolapse
Pelvic floor - muscle that supports the pelvic organs (uterus, bladder, rectum) , that could become weak leading to the collapse of the pelvic organs.
RFs: multiple vaginal/instrumental deliveries, advanced age, post=menopausal status, chronic disease causing cough, chronic constipation, obesity
Uterine prolapse - uterus descends into vagina
Vault - after hysterectomy, top of vagina descends into vagina
Cystocele - defect in anterior vagina wall allowing bladder to prolapse
Rectocele - defect in posterior vaginal wall allowing rectum prolapse
Key features - feeling of something coming down, heavy dragging sensation, worse on coughing, urinary incontinence, retention, weak stream etc./constipation
Dx: clinical examination via SIm’s speculum
Mx: pelvic floor exercises, lifestyle changes, weight loss, vaginal pessaries to support pelvic floor (shapes include rings, donuts, shelf, cube), surgery = include hysterectomy? (vaginal mesh = avoid according to NICE!)
Infertility
Inability of a couple to conceive over 2 years, refer to fertility services after 12 months. If over 35, refer after 6 months.
RFs/causes: advancing age, obesity, genetic abnormalities e.g. 45XO, endometriosis (uterine), fibroids (uterine), PCOS (endocrine), testicular disorders: testicular cancer, oligospermia, retrograde or premature ejaculation
Ix: 7 days before period progesterone (increased if ovulation occurred), FSH high and oestrogen low = ovarian failure. LH:FSH ratio high = PCOS, semen analysis
Secondary care Ix: TV USS, laparoscopy and dye in presence of PID, endometriosis etc.
Mx:
- Conservative: weight loss, reduce stress, exercise, folic acid
- Medical: clomiphene
- Surgical: endometrial ablation/diathermy, removal of fibroids, adhesion in PID, IVF
- Male: surgical sperm retrieval, correct structural defect e.g. blocked vas deferens, intrauterine insemination
Herpes simplex virus
Chlamydia
Chlamydia trachomatis
RFs: not using barrier conception, multiple sexual partners, under 25
Key features: most asymptomatic in women, dysuria, abnormal vaginal discharge, pelvic pain. In men, most are asymptomatic, dysuria, non-specific uteritis, urethral discharge/discharge
Dx: women: vulvovaginal or endocervical swab for NAAT test (DNA/RNA of chlamydia), men: urethral swab
Mx: doxycycline for 7 days, contraindicated in pregnancy and breastfeeding (azithromycin), no sex for 7 days of tx, refer to GUM for contact tracing
Complications: PID, ectopic pregnancy, epididmyo-orchitis, reactive arthritis
Gonorrhoea
Neisseria gonorrhoea, gram-negative diplococcus
RFs: multiple sexual partners, not using barrier contraception
Key features:
- Women (50% symptomatic): odourless purulent yellow/green discharge, dysuria, pelvic pain
- Men (90% symptomatic: odourless purulent yellow/green urethral discharge, dysuria, testicular inflammation/swelling (epididymo-orchitis)
Dx: endocervical, vulvovaginal or urethral swab for NAAT, AND charcoal swab for microscopy, culture and sensitivities due to increased antibiotics resistance
Mx: single dose of IM ceftriaxone if sensitivities not known, single dose 500mg oral ciprofloxacin if sensitivities known, refer to GUM for diagnosis, treatment and contact tracing
Complications: PID, infertility, Fitz-Hugh-Curtis syndrome (liver capsule inflammation + adhesions), epididymo-orchitis, septic arthritis, neonatal conjunctivitis
Trichomoniasis
Trichomonas vaginalis, flagellated protozoa
Key features: up 50% asymptomatic, fishy-smelling, frothy + yellow/green discharge, itching, dysuria, balanitis (inflammation of glans penis), strawberry cervix
Dx: charcoal swab from posterior fornix of vagina, urethral swab or first catch urine in men - sent for microscopy, culture and sensitivities
Mx: GUM referral for diagnosis, treatment and contact tracing, tx is with metronidazole
Perineal tears
Tear in the perineum during delivery, different degrees
RFs: Asian ethnicity, nulliparity, instrumental, macrosomia, shoulder dystocia
- 1st: external perineum affected
- 2nd: perineal muscle affected
- 3(a): less than 50% of external anal sphincter affected
- 3(b): more than 50% of external anal sphincter
- 3(c): external and internal anal sphincter affected
- 4th degree: rectal mucosa affected
Mx: episiotomy is a perineal cut made anterolaterally to give more space 1st degree: conservative. 2nd: sutures, 3rd - 4th might need repair in theatre
Complications: pain, bleeding, infection, urinary incontinence, anal incontinence (3rd/4th), sexual dysfunction and dyspareunia, mental health impacts
Adenomyosis
Endometrial tissue in the myometrium
Key features: menorrhagia, dysmenorrhoea, dyspareunia, infertility, miscarriage, preterm birth, PPROM
Dx: TV USS is 1st line, histology of uterus after hysterectomy is gold standard
Mx: same as menorrhagia
1st line if not wanting pregnancy = Mirena coil
2nd line: COCP or cyclical oral progesterone
1st line if wanting to get pregnant:
- Tranexamic acid if no pain - anti-fibrinolytics
- Mefenamic acid if pain - NSAIDs
Specialist consideration: GnRH to induce menopause like state, uterine artery embolization, endometrial ablation, hysterectomy
Cord prolapse
When the umbilical cord descends past the foetal presenting part into the vagina, after rupture of membrane
Biggest RF is foetus in abnormal lie (unstable, transverse, oblique etc.) after 37 weeks, space for cord to descend
Key features: non-reassuring CTG, foetal compromise
Dx: vaginal examination or speculum examination to confirm Dx
Mx: emergency c-section as compromised foetal blood supply = foetal hypoxia, keep cord warm, minimal handling as can cause vasospasm during transfer to theatre. Mother in left lateral position or knee-chest position to reduce pressure on the cord
Candidiasis
Yeast infection of the vagina, most common candida albicans
RFs: increased oestrogen exposure (e.g. pregnancy), uncontrolled diabetes
Key features: thick, white vaginal discharge, vulvar itching/discomfort
Dx: clinical and speculum examination
Mx: anti-fungal vaginal pessary (e.g. clotrimazole), anti-fungal cream (clotrimazole) - NICE recommends single intravaginal dose of clotrimazole (5g 10% at night) or a single dose of clotrimazole pessary
Canesten duo is OTC tx, fluconazole pessary and clotrimazole pessary
Preterm premature rupture of membrane (PPROM)
Antepartum haemorrhage
Most significant causes are placenta praevia, placenta abruption and vasa praevia - associated with high mortality and morbidity
Postpartum haemorrhage
Vaginal delivery > 500ml
Caesarean > 1000ml: subdivided into moderate: 1000 - 2000ml, major: > 2000ml
Primary PPH: within 24 hrs of delivery
Secondary PPH: 24 hrs to 12 weeks after delivery
RFs: previous PPH, placenta acrreta, prolonged third stage, multiple pregnancy, pre-eclampsia, obesity, perineal tear or episiotomy
Causes: 4 Ts: Tone - atony (uterus not contracting), Trauma, Tissue (retained placenta), Thrombin (underlying clotting disorder)
Mx:
ABCDE, 2x large bore cannula, fluid resus if shock (tachycardia, hypotensive), group and save and cross match 4 units, oxygen (regardless of sats)
Stop bleeding:
- Rubbing uterus through the abdomen
- Catheterisation (full bladder helps to stem blood loss)
- Uterotonic drugs: e.g. oxytocin inclusion (40 units over 500ml)
- Misoprostol (sublingual) (prostaglandin analogue to stimulate uterine contractions)
- IV TXA - antifibrinolytic to stop bleeding
Surgical: haemostatic sutures, intrauterine balloon tamponade, hysterectomy (last resort)
Secondary PPH likely due to retained placenta or endometritis, USS for retained product and surgical evaluation. Endocervical or high vaginal swab for infection and abx
Vasa praevia
When the foetal vessels (two umbilical arteries and one vein) pass over the internal cervical os during pregnancy.
Usually vessels are protected by placenta or umbilical cord, but in vasa praevia, they are exposed.
Risk of rupture when membrane ruptures
Ideally detected on antenatal USS, presents as bleeding in second or third trimester, or detected on vaginal examination at labour as pulsating vessels through membrane
If bleeding after rupture of membrane, then very bad prognosis even with emergency C-section
Mx: corticosteroid from 32 weeks, planned elective c-section from 34 - 36 weeks
Emergency c-section if APH
Hyperemesis gravidarum
Severe nausea and vomiting during pregnancy (beyond what is normal):
- More than 5% weight loss from before pregnancy
- Clinical dehydration
- Electrolyte imbalance
Graded with Pregnancy-Unique Quantification of emesis, out of 15
< 7 = mild
7 - 12 = moderate
> 12 = severe
Mild = oral emetics
- Prochlorperazine
- Cyclizine
- Ondansetron
- Metoclopramide
Consider admission
- Ketone in urine dipstick (2+)
- Unable to keep fluids or anti-emetics down
- 5% weight loss compared to pre-pregnancy
- Any other medical conditions that need tx
Mx in hospital: IV fluids with added potassium chloride and anti-emetics (prochlorperazine), daily U+E checks while on IV therapy, thiamine supplement, thromboembolism prophylaxis - compression stockings and LMWH
Ovarian torsion
Twisting of an ovary = ischaemia/necrosis of ovary
Key features: severe, sudden onset abdominal pain, low-grade fever, nausea and vomiting, palpable mass if due to mass and tenderness
Dx:
- Transvaginal (transabdominal if not possible) is 1st line, “whirlpool” sign due to free fluid in pelvis and oedema of the ovary.
- Laparoscopic surgery is definitive diagnosis
Mx: detorsion and oophorectomy
Antenatal appointments
- Booking appointment - 8 - 10 weeks
- Dating scan - 11 + 2 - 14+1 weeks
- 16 weeks - antenatal appointment to discuss results and plan for future
- 18 - 20 weeks - anomaly scan
25, 28, 31, 34, 36, 28, 40, 41 and 42
Additional milestones:
- OGTT at 24 - 28 weeks
- Anti-D immunisation at 28 and 34 weeks
- USS at 32 weeks for placenta praevia identified at anomaly scans
Routine appointment:
- Urine dipstick for pre-eclampsia
- BP for pre-eclampsia
- Urine for microscopy and culture for asymptomatic bacteriuria
- Measure SFH from 24 weeks
- Ask about baby’s movements
- Abdominal exam for foetal presentation from 36 weeks
Screening tests for Down’s syndrome
Combined test (11 - 13 weeks): nuchal translucency, pregnancy-associated plasma protein-A (PPAP-A), B-hCG
Triple test: B-hCG, AFP and unconjugated oestriol
Quadruple test
- Inhibin A
- B-HCG
- AFP
- Unconjugated oestriol
UP: HIT, DOWN: APE
Preterm prelabour rupture of membrane
Amniotic sac rupture before 37 weeks gestation.
Ix: speculum examination reveals a pool of amniotic fluid in the vagina
Mx: prophylactic erythromycin 250mg 4x a day for 10 days to prevent chorioamnionitis
Bacterial vaginosis
Caused by an imbalance in the vaginal bacterial flora. Usually dominated by lactobacillus, keeps vaginal pH <4.5.
Not STI
But BV = taken over by anaerobes e.g. Gardnerella vaginalis
RFs: multiple sexual partners, recent antibiotics, excessive cleaning products on vagina, smoking, copper coil
Dx: strong, fishy smell, swab and pH paper, pH > 4.5, charcoal swab taken during speculum exam or self, clue cells under microscopy
Mx: metronidazole or clindamycin, advise not to irrigate vagina and only use water to clean so not to disrupt the natural flora
