Obstetrics & Gynaecology Flashcards
1
Q
Reason for folic acid supplementation in pregnancy
A
↓ risk of neural tube defects
2
Q
Standard folic acid supplementation in pregnancy
A
400 micrograms/day for ~3 months before conception until 12th week of pregnancy
take 5mg/day if high risk group
3
Q
Groups requiring 5mg folic acid supplementation
A
previous neural tube defects family history of NTDs Diabetes Coeliacs Thalassaemia Anti-epileptic medication obese women (>30kg/m^2)
4
Q
recommendation for alcohol intake in pregnancy
A
recommended to not consume any alcohol
but if women choses to drink ≤1-2 units/week
5
Q
Complications of smoking in pregnancy
A
IUGR low birth weight miscarriage still birth premature delivery placental issues
6
Q
foods to avoid in pregnancy
A
uncooked meat/fish, raw egg, unpasteurised milk, soft cheese, raw shellfish
7
Q
epilepsy medication considered safe in pregnancy
A
lamotrigine
8
Q
dangerous anti epileptics in pregnancy
A
sodium valproate
phenytoin
9
Q
Antidepressants safe in pregnancy
A
Fluoxetine
amitriptyline
10
Q
Mood stabiliser to avoid in pregnancy
A
lithium
11
Q
Diabetes drugs and pregnancy
A
discontinue all hypoglycaemic agents except metformin
supplement metformin with insulin if needed
12
Q
anithypertenisve medication in pregnancy
A
Stop ACE-Is & ARBs
Stop Statins
13
Q
Timing of booking appointment
A
8-12 weeks
ideally at <10weeks
14
Q
Purpose of booking visit (8-12 weeks)
A
General info e.g. diet/folic acid/Vit D/alcohol/smoking
BP
Urine dipstick
BMI check
Booking bloods (FBC,HIV, Hep B, Syphilis, Rhesus status, red cell allo antibodies, haemoglobinopathies)
Urine culture (for asymptomatic bacteriuria)
GDM screen if risk factors
15
Q
10-13+6 weeks check
A
early scan to confirm dates & exclude multiple pregnancy
16
Q
11-13+6 weeks check
A
Down syndrome screening (nuchal translucency, beta-hCG, PAPPA)
17
Q
18 - 20+6 week check
A
anomaly scan (USS)
18
Q
Extra antenatal care dates for primips
A
25 weeks
31 weeks
40 weeks
all routine care (BP, urine dip, SFH)
19
Q
28 week check
A
routine care (BP, urine dip, SFH) second anaemia screening Give first dose of anti-D prophylaxis if Rh -ve
20
Q
34 week check
A
routine care (BP, urine dip, SFH) Birth planning/labour info Give second dose of anti-D prophylaxis if Rh -ve
21
Q
36 week check
A
check presentation & offer external cephalic version if indicated routine care (BP, urine dip, SFH)
22
Q
Conditions screened for in all pregnant women
A
anaemia bacteriuria blood group Rh status anti-red cell antibodies Down's syndrome fetal anomalies Hep B HIV NTDs syphilis
23
Q
Down syndrome screening
A
11-13+6 weeks gestation
consisting of nuchal translucency, beta-hCG, PAPP-A)
24
Q
Results suggesting Trisomy 21
A
↑nuchal translucency
↑beta-hCG
↓PAPP-A
NB trisomy 13/18 give similar results but lower PAPP-A values
25
Triple/Quadruple test for Down syndrome screening
used if booked late, so offered at 15-20 weeks
Triple test = AFP, uncojugated oeastriol (uE3), beta-hCG, Quadruple test =AFP, uncojugated oeastriol (uE3), beta-hCG, inhibit-A
results suggestive of Downs:
AFP ↓, uncojugated oeastriol (uE3) ↓, beta-hCG ↑, inhibit-A ↑
26
Positive Down syndrome prenatal diagnosis
offer diagnostic testing with chronic villous sampling (<13 weeks) or amniocentesis (<15 weeks)
if diagnosed offer TOP or continue pregnancy with appropriate support
27
chronic villous sampling (<13 weeks) or amniocentesis (<15 weeks) risk of miscarriage
~1% (1/100)
28
Antenatal rubella infection
suspected Rubella infection in pregnancy should be discussed with health protection unit
offer MMR vaccination in postnatal period
29
Antenatal Varicella Zoster infection
Risk of fatal varicella syndrome
Management:
check maternal blood for varicella immunity
if not immune:
<20 weeks: give varicella-zoster immunoglobulin (VZIG)
>20 weeks: give VZIG or aciclovir days 7-14 post exposure
30
antenatal CMV infection
no effective treatment
| ensure good personal hygiene and avoid infected individuals
31
HIV infection in pregnancy
screened for in all pregnant women
- Maternal antiretroviral therapy (Zidovudine + 2 other antiretrovirals)
- Elective C-section at 38-39 weeks (consider delaying to >39 weeks if viral load >50copies/ml)
- neonatal antiretorviral therapy (Zidovudine)
- avoid breastfeeding (bottle feeing only)
if all prophylactic steps taken then mother to child transmission <1%
32
Hep B in pregnancy
screened for in all pregnant women
give full immunisation + Hep B immunoglobulin to baby of Hep B infected mother
33
define theses alloimmunisation
Rh -ve mothers may develop anti-D IgG antibodies if sensitised e.g. previous Rh +ve pregnancy, delivery, miscarriage, TOP, ectopic pregnancy, antepartum haemorrhage
34
preventing Rh alloimmunisation
test for anti-D antibodies for all Rh -ve mothers at booking
routine anti-D prophylaxis at 28&34 weeks if not sensitised
if sensitising event in 2nd/3rd trimester = large dose of anti-D & perform Keinhauer test
35
When to give anti-D immunoglobulin
Give within 72h of event
```
delivery of Rh +ve infant (stillbirth/live)
TOP
Miscarriage at >12 weeks gestation
ectopic pregnancy
ECV
antepartum haemorrhage
amniocentesis
chorionic villous sampling
fatal blood sampling
abdominal trauma
```
36
Nausea & vomiting in pregnancy
affects ~75% of pregnancies
usually resolves by 16 weeks of gestation
symptoms beginning at >12 weeks usually have other causes
37
hyperemesis gravidarum
severe protracted nausea & vomiting associated with weight loss >5% of pre-pregnancy weight, fluid loss, dehydration, electrolyte imbalance
usually occurs between 8-12 weeks
38
Admission criteria for hyperemesis gravidarum
continued N&V + unable to keep down liquids/oral antiemetics
| continued N&V + ketonuria and/or weight loss >5%
39
Obstetric cholestasis/intrahepatic cholestasis of pregnancy
pruritic condition of pregnancy due to impaired bile flow allowing bile salts to be deposited into the skin & placeenta
40
risk of recurrence of ectopic pregnancy
10-20%
41
Conditions associated with obstetric cholestasis/intrahepatic cholestasis of pregnancy
↑ risk of foetal distress
↑ risk of intrauterine death
↑ risk of premature birth
↑ maternal morbidity
42
Investigating obstetric cholestasis/intrahepatic cholestasis of pregnancy
Bile acid ↑
LFTs (AST ↑, ALT ↑, Gamma-GT ↑, ALP ↑)
Bilirubin↑
43
Management of obstetric cholestasis/intrahepatic cholestasis of pregnancy
weekly LFTs
Ursodeoxycholic acid
Vit K supplement
induction of labour at 37-38 weeks
44
Gestational diabetes mellitus (GDM)
a degree of glucose intolerance with its first onset during pregnancy & usually resolving shortly after delivery
45
Diagnostic criteria for gestational diabetes mellitus (GDM)
Fasting glucose ≥ 5.6mmol/L
2h postprandial glucose ≥7.8mmol/L
NB: the rule is 5678
46
Screening for gestational diabetes mellitus (GDM)
oral glucose tolerance test at booking & 24-28 weeks
47
Managing gestational diabetes mellitus (GDM)
1st line: blood glucose monitoring, diet & exercise, weight loss
2nd line: add metformin if not controlled by diet after 1-2 weeks
3rd line: insulin
NB if fasting glucose ≥7mmol/L start insulin
48
Complications of gestational diabetes mellitus (GDM)
```
macrosomia
large for gestational age
pre-eclampsia
↑ risk of shoulder dystocia
↑ risk of neonatal hypoglycaemia
```
49
Managing pre-existing diabetes in pregnancy
aim for BMI<27
stop all oral hypoglycaemics except metformin & commence insulin
folic acid 5mg pre-conception till 12 weeks gestation
50
Pre-existing hypertension in pregnancy
BP >140/90 either at booking or prior to 20 weeks gestation, no protein uria/oedema
Stop ACE-Is & ARBs and switch medication
aim for BP <150/100
51
Gestational hypertension
BP >140/90 after 20 weeks gestation without proteinuria / oedema
usually resolves spontaneously after birth
52
Termination of pregnancy (TOP)
| also referred to as termination or abortion
medically directed miscarriage prior to independent viability using surgical/pharmacological means
53
complications of gestational hypertension & pre-existing hypertension in pregnancy
```
↑ risk of placental abruption
↑ risk of cerebrovascular event
↑ risk of DIC
↑ risk IUGR
↑ risk of prematurity
↑ risk of intrauterine death
```
54
Pre-eclampsia
condition seen at >20 weeks gestation characterised by new onset hypertension >140/90 associated with proteinuria & oedema
55
Eclampsia
pre-eclampsia with the development of seizures/convulsions
56
Risk factors for pre-eclampsia/eclampsia
```
Primiparity
BMI >30
↑ maternal age (>40 yrs)
multiple pregnancy
FHx of pre-eclampsia/eclampsia
pre-existing diabetes/HTN/CKD/SLE/antiphospholipid syndrome
```
57
Preventing pre-eclampsia/eclampsia
75mg - 150mg of aspirin from week 12 till delivery
58
Presentation of pre-eclampsia/eclampsia
```
BP >140/90 + ≥1+ protein on urine dipstick
headaches
upper abdo pain
oedema
visual disturbances/blurry vision
papilloedema
```
Seizures if eclampsia
59
Investigating pre-eclampsia/eclampsia
Urinalysis
FBC/LFTs/U&Es/renal function
USS to assess foetal growth/amniotic fluid levels
60
Severe pre-eclampsia
BP >170/110 + proteinuria
or
proteinuria 3+/4+
headache, visual disturbances, blurry vision, papilloedema, RUQ/epigastric pain, hyperrefelxia
platelets <100x10^9/L
abnormal LFTs
HELLP syndrome
61
Management of pre-eclampsia/eclampsia
4x daily BP monitoring, 2-3x weekly FBC/U&Es/LFTs/renal function
Antihypertensives:
1st line: labetalol
2nd line: nifedipine
```
Seizure control:
Magnesium sulphate (4g loading dose over 5-10min then 1g/h for 24h)
```
Delivery = only curative treatment, generally try to deliver at >34 weeks
62
HELLP syndrome
```
complication of pregnancy presenting in women with pre-eclampsia/eclampsia
characterised by:
-Haemolysis (H)
-Elevated liver enzymes (EL)
-Low platelets (LP)
```
63
Presentation of HELLP syndrome
```
nausea&vomiting
hypertension
brisk tendon reflexes
RUQ pain
headache
oedema
```
64
Investigating HELLP syndrome
```
FBC (↓ Hb, ↓platelets)
Blood film (fragmented RBCs)
LDH (↑ >600IU/L)
LFTs (AST/ALT ↑ >70IU/L)
platelets (<100x10^9/L)
bilirubin (↑)
```
65
Managing HELLP syndrome
definite treatment = delivery of baby
66
Chorioamnionitis
medical emergency, due to ascending infection leading to inflammation of the foetal membranes
67
Chorioamnionitis risk factors
Preterm premature rupture of membranes (PPROM)
smoking
alcohol use
↑ number of vaginal examinations
68
Chorioamnionitis presentation
```
maternal fever
uterine tenderness
baseline fetal tachycardia (>160)
maternal leucocytosis
purulent cervical discharge
```
69
Chorioamnionitis management
IV Abx e.g. ampicillin
| prompt delivery of fetus
70
Anaemia in pregnancy
normal physiological changes in pregnancy include the ↑plasma volume causing haemodilution so the Hb drops to ~115g/L
most frequently caused by iron deficiency (↓MCV)
often asymptomatic
71
screening for anaemia of pregnancy
at booking visit & 28 weeks
72
definition of anaemia in pregnancy
Hb <110g/L at booking, or Hb <105/L in 2nd/3rd trimester
73
Management of placenta accreta
C-section (open at site distant to placenta, have blood products ready)
if placenta acreata confirmed do not remove it (high risk of major obstetric haemorrhage), but perform hysterectomy
74
Polyhydramnios
abnormally large amount of amniotic fluid associated with adverse pregnancy outcomes
uterus presents large for date on examination
75
Polyhydramnios causes
```
most often idiopathic
congenital abnormalities/genetic disorders
Gestational diabetes
multiple pregnancy
congenital infections
```
76
Oligohydramnios
too little amniotic fluid (<500ml at 32-36 weeks) associated with IUGR & ↑perinatal mortality
77
Oligohydramnios causes
```
rupture of membranes
congenital absence of functional renal tissue (renal agenesis)
↓ renal perfusion
post-term gestation
placental abruption
drugs (ACE-Is, indomethacin)
pre-eclampsia
PROM
```
78
VTE in pregnancy
pregnancy is a physiological hypercoaguable state, leading to a 10x ↑ risk compared to non pregnant women
79
Risk factors for VTE in pregnancy
```
hereditary hypercoaguable states e.g. Factor V Leiden
obesity (BMI>30)
immobilisation
previous thrombotic event
cancer
antiphospholipid syndrome
↑ maternal age
pre-eclampsia
```
80
VTE management in pregnancy
LMWH (prophylaxis & treatment)
NB IV UFH treatment of choice in acute VTE management
continue treatment till at least 6-12 weeks postpartum
81
Ectopic pregnancy
fertilised ovum implanting & maturing outside the uterine endometrial cavity, 97% are tubal, most commonly in the ampulla
NB the most dangerous place is an ectopic in the isthmus
82
Risk factors for an ectopic pregnancy
```
previous ectopic
damage to tubes (e.g. PID)
endometriosis
IVF
IUD/IUS
```
83
Ectopic pregnancy presentation
6-8 weeks of amenorrhoea
lower abdo pain/pelvic pain
abdo tenderness on palpation
PV bleeding ± clots
If ruptured: dizziness, fatigue, syncope, haemodynamic instability
84
Investigating an ectopic pregnancy
beta-hCG
transvaginal USS
if pregnancy of unknown location = serious beta-hCGs
85
Expectant management for ectopic pregnancy
if size <35mm, unruptured, asymptomatic, no fetal heart beat, serum eta-hCG <1000IU/L
monitor over 48h, if symptoms develop/ ↑ beta-hCG = intervene
86
Medical management of ectopic pregnancy
if size <35mm, unruptured, no significant pain, no fetal heart beat, serum eta-hCG <1500IU/L
single dose methotrexate
3-6 months of contraception as methotrexate = teratogenic
87
Surgical management of ectopic pregnancy
if size >35mm, ruptured/unruptured, significant pain, visible fetal heart beat, serum eta-hCG >1500IU/L
usually laparoscopic salpingectomy
laparoscopic salpingotomy if other infertility risk factors
88
risk of recurrence of ectopic pregnancy
10-20%
89
Miscarriage
involuntary loss of pregnancy before 24 weeks gestation
90
Threatened miscarriage
painless PV bleeding at <24 weeks with a closed cervical OS
91
Inevitable miscarriage
heavy PV bleeding + clots, painful, open cervical OS
92
Incomplete miscarriage
incomplete expulsion of products of conception, may often be unrecognised missed miscarriage
93
complete miscarriage
products of contraception fully expelled i.e. no pregnancy tissue on USS
94
Missed miscarriage
gestational sac containing dead fetus without symptoms of expulsion, often presents with light bleeding + dark brown discharge
95
recurrent miscarriage
≥3 consecutive pregnancies lost spontaneously at <24 weeks
most common causes include antiphospholipid syndrome, endocrine disorders e.g. PCOS, parental chromosomal abnormalities, cervial incompetence
96
Investigating miscarriage
```
Transvaginal ultrasound (TVUS)
serum beta-hCG (2 tests 48h apart)
```
97
Expectant management of miscarriage
waiting for a spontaneous miscarriage
| wait 7-14 days then repeat pregnancy test
98
Medical management of miscarriage
vaginal misoprostol (stimulates contractions)
review if bleeding not started in 24h
perform pregnancy test 3 weeks later
99
Surgical management fo miscarriage
vacuum aspiration (suction curettage) or surgical removal (evacuation of retained products of contraception -ERPC)
100
The law around termination of pregnancy (TOP)
1967 abortion act (amended in 1990)
2 registered medical professionals must sign a legal document (HSA1 form)
TOP legal before 24 weeks gestation
- if it reduces the risk to a woman life
- if it reduces risk to her physical/mental health
- if it reduces the risk of physical/mental health of her existing children
- if baby has substantial risk of being seriously mentally/physically handicapped
No limit to gestational age if
- risk to mother's life
- risk of grave/permanent injury to mothers physical/mental health
- substantial risk that child born would have such physical mental abnormalities as to be seriously handicapped
101
Medical termination of pregnancy (TOP)
mifepristone followed after 48h by misoprostol
102
surgical termination of pregnancy (TOP)
cervical dilation followed by suction of uterine contents
103
Complete hydatiform mole
benign tumour of trophoblastic material, empty egg fertilised by 1 sperm
features: bleeding in 1st/early 2nd trimester with exaggerated symptoms of pregnancy & a large for date uterus
very high beta-hCG levels
104
partial mole
normal haploid egg fertilised by 2 sperms/1 sperm with duplicated paternal chromosomes
fetal parts may be seen
105
Breech presentation
when the caudal end of the fetus occupies the lower segment instead of the cephalic presentation
associated with ↑ morbidity & mortality for mother and baby
106
Management of breech presentation
offer external cephalic version (ECV) at 36 weeks if nulliparous or 37 weeks if multiparous
if unsuccessful then the mode of delivery is C-section
107
contraindications for external cephalic version
```
antepartum ahemorrhage in last 7 days
abnormal CTG
major uterine abnormality
ruptured membranes
other indications for c-section
```
108
Monoamniotic monozygotic twins risks
↑ risk of spontaneous miscarriage
↑ perinatal mortality
↑ rate of malformation/IUGR/prematurity
↑ risk of twin to twin transfusion syndrome
109
Fetal movements
first movements usually around 18-20 weeks
| Red flag if not established by 24 weeks
110
Fetal distress
presents as ↓ fetal movements
investigate with handheld doppler to confirm heartbeat
consider USS if no heartbeat
otherwise monitor with CTG
111
Placenta praevia
defined as placenta overlying the cervial OS i.e. low-lying placenta that is partially/fully inserted into the lower segment
commonest cause of antepartum haemorrhage (bleeding at >24 weeks)
112
Risk factors for placenta praevia
uterine scarring (e.g. pervious c-section)
multiparity
multiple pregancy
prior placenta praevia
113
Presentation of placenta praevia
often incidental finding on USS e.g. at 20 week scan
Painless PV bleeding (usually sudden & profuse)
abnormal lie/presentation
NO uterine tenderness
114
Investigations for placenta praevia
have a high clinical suspicion PV bleeding at >20weeks gestation
TVUS/Abdominal ultrasound
115
Management of placenta praevia
if major placenta praevia do C-section at 37-38 weeks
if pt has bleeding then encourage hospital admission from 34 weeks
NB do not attempt vaginal examination if pt is actively bleeding
116
Placenta accreta
describes the attachment of the placenta to the myometrium due to defective decidua basalis, meaning the placenta is unable to properly separate during labour =↑ risk of PPH
117
Types of placenta accreta
defined by depth of implantation
accreta = attach to myometrium
increta = attach in myometrium
percreta = penetrate into peritoneum
118
Conditions associated with placenta accreta
retained placental products
PPH
preterm delivery
119
Risk factors for placenta accreta
previous C-section
placenta praevia
↑ maternal age
120
Placental abruption
premature separation of a normally located placenta from the uterine wall occurring before delivery of the fetus
121
Types of placental abruption
concealed: ~20%, haemorrhage confided to uterine cavity, more severe form as blood loss often underestimated
revealed: ~80%, blood draws from cervix, usually less severe, often incomplete detachment of palcenta
122
Presentation of placental abruption
```
PV bleeding
constant abdo pain
uterine contraction
level of shock not correlating to visible blood loss
tense, tender, woody uterus on palpation
```
123
Risk factors of placental abruption
```
smoking
cocaine use
trauma
multiple pregnancy
pre-eclampsia
uterine malformation
previous abruption
```
124
Investigating placental abruption
```
USS
CTG
platelet count
FBC
cross match blood
```
125
Management of placental abruption
NB Mother takes priority
fetus alive >36 weeks = emergency c-section if fetal distress otherwise vaginal delviery
fetus alive <36weeks = emergency c-section if fetal distress, otherwise close monitoring + corticosteroids
dead fetus = induced vaginal delivery
126
Uterine rupture
usually occurs during labour however C-section scars from previous pregnancies may rupture during the 3rd trimester
127
Dehiscence
incomplete separation of a uterine scar with intact serosa and ↑ risk of uterine rupture
128
Presentation of uterine rupture
```
sudden tearing uterine pain
vaginal haemorrhage
cessation of uterine contractions
regression of fetus
CTG abnormalities
Scar pain/tenderness
fetal parts may be palpable per abdomen as they pass into abdominal cavity
```
129
Management of uterine rupture
urgent surgical delivery
| uterine repair or hysterectomy
130
Cord prolapse
involved the umbilical cord descending ahead of the presenting part of the fetus, if untreated can lead to cord compression or cord spasm which may cause fatal hypoxia
131
Risk factors of cord prolapse
```
prematurity
multiple pregnancy
breech/transverese lie
placenta praevia
high fetal station
cephalopelvic disproportion
artificial rupture of membranes (ARM)*
```
132
Presentation of cord prolapse
may occur with no outward physical features/normal fetal heart trace
ill fitting/non presenting part on abdominal examiantion
cord prolapse felt PV
cord visible beyond introitus
abnormal CTG
133
Management of cord prolapse
pushing presenting part back into uterus to avoid cord compression
use of tocolytics e.g. indomethacin/nifedipine
place pt on all fours (pt in doggy position as she is grown a tail i.e. the cord)
usually need emergency C-section
134
Most important risk factor for cord prolapse
artificial rupture of membranes (ARM)
135
Post partum haemorrhage (PPH)
excessive bleeding post delivery, usually defined as >500ml
136
Types of post partum haemorrhage (PPH)
Primary: within 24h of delivery
Secondary: 24h - 12 weeks after delivery
137
Causes of primary post partum haemorrhage (PPH)
4T's of PPH
Tone (uterine atony, ~90% of PPH)
Trauma (to uterus/cervix/vagina)
Tissue (e.g. retained placenta i.e. delayed 3rd stage)
Thrombin (pre-existing/acquired coagulopathies)
138
Risk factors for primary PPH
```
previous PPH
prolonged labour
pre-eclampsia
↑ maternal age
emergency C-section
placenta praevia/accreta
BMI >35
assisted vaginal delivery
```
139
Presentation of primary PPH
bleeding which fails to stop after delivery of placenta
| signs of shock e.g. hypotension (this is then defined as a major obstetric haemorrhage (MOH), usually >1500ml lost)
140
Management of primary PPH
ABCDE assessment
bilateral large bore cannulas
cross match blood & make units ready
```
Medication:
syntocinon (5 unit bolus + 40 units IV)
TXA (1g IV)
Ergometrin (500 micrograms)
Carboprost (250 micrograms every 15 min up to 5 doses)
Misoprostol (800 micrograms)
```
Surgical/physical:
Bimanual uterine compression & stimulation
Balloon tamponade
B-lynch compression sutures
ligation of uterine/internal iliac arteries
hysterectomy
141
Active management of 3rd stage of labour
done to ↓ risk of PPH
5 units of syntocinon IM
consider following with 40 units IV if necessary
142
Secondary post partum haemorrhage (PPH) causes
infection especially endometritis
| retained products of conception
143
Presentation of secondary PPH
```
prolonged/excessive bleeding
fever
abdo pain
offensive smelling lochia
dyspareunia
```
144
Managing secondary PPH
Oral/IV Abx for endometritis
elective curetage + Abx if retained products
NB 95% of endometritis treated with Abs improves within 48-72h, if this is not the case you must reassess
145
Lochia
vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth.
146
Sheehan's syndrome
postpartum pituitary necrosis leading to hypopituitarism which is usually caused by massive PPH leading to hypotension & shock
Presents as failure to lactate, breast convolution, amenorrhoea
147
Shoulder dystocia
a complication of vaginal cephalic delivery, which entails the inability to delivery the body of the fetus using gentle traction after the head has been delivered as the anterior shoulder impacts on maternal pubic synthesis
148
Associated injuries to fetus in shoulder dystocia
brachial plexus injuries (Erb's/Klumpke's palsy)
149
Risk factors for shoulder dystocia
```
Gestational diabetes
fetal macrosomia
BMI >30
induced labour
prolonged labour
```
150
Management of shoulder dystocia
call additional help ASAP
Stop mother from pushing & avoid downward traction on fetal head
McRobert's manoeuvre: hyper flex & abduct mothers hips (i.e. knees to chest) to flatten lumbrosacral angle
episiotomy to facilitate secondary manoeuvres e.g. Rubin's & woods' screw
consider C-section
151
Amniotic fluid embolus
when fetal cells/amniotic fluid enters the maternal systemic circulation & stimulates a sudden cardiovascular collapse
152
presentation of amniotic fluid embolus
```
sudden cardiovascular collapse
acute LV failure
pulmonary oedema
DIC
bleeding diathesis
respiratory distress (similar to PE)
uterine atony
shivers, seizures, LOC
arrythmia
```
153
Diagnosing amniotic fluid embolus
diagnosis of exclusion
154
Classic presentation of amniotic fluid embolus
older multiparous women in advanced labour that suddenly collapses
155
Preterm premature rupture of membranes (PPROM)
PPROM = rupture of membranes prior to onset of labour in a pt <37 weeks gestation
PROM = rupture of membranes occurring prior to onset of labour in a pt ≥37 weeks gestation
156
Preterm premature rupture of membranes (PPROM) risk factors
smoking
previous preterm delivery
vaginal bleeding during pregnancy
157
Presentation of Preterm premature rupture of membranes (PPROM)
popping sensation/ gush of fluid PV
continuous watery liquid draining PV after initial gush
wet pad/underwear
pooling of amniotic fluid in posterior vaginal vault on sterile speculum examination
158
Examinations to avoid in Preterm premature rupture of membranes (PPROM)
DO NOT perform a vaginal examination as it ↑ risk of ascending infection
159
management of Preterm premature rupture of membranes (PPROM)
admission & CTG monitoring
oral erythromycin for 10 days
antenatal corticosteroids
monitor for infection
160
Perineal tear classifications
1st degree: superficial damage with no muscle involvement
2nd degree: injury to perineal muscle but on involvement of anal sphincter
3rd degree: injury to perineum involving anal sphincter complex
4th degree: injury to perineum involving anal sphincter complex & rectal mucos
161
Risk factors for perineal tears
primigravida
macrosomia
shoulder dystocia
forceps delivery
162
Episiotomy
controlled cutting of the perineum to prevent tearing which is performed during the 2nd stage of labour
163
Complications of perineal tears
urinary/faecal incontinence
pain
infection
164
Prolonged labour
inability of women to proceed with childbirth upon going into labour
165
Failure to progress
can occur in 2 phases of labour :
- latent phase
- active phase (this is where problems arise)
166
Causes of failure to progress/prolonged labour
fetal malpresentation
poor uterine contractions
cervical stenosis
dystocia
167
Presentation of failure to progress/prolonged labour
labour >18h
maternal exhaustion
pain
fetal distress
168
Management of failure to progress/prolonged labour
assisted vaginal delivery
| C-section
169
Requirements for assisted vaginal delivery
```
fully dilated cervix
occipital-anterioir posiiton
ruptured membranes
cephalic presentation
engaged presenting part
pain relief adequate
sphincter (bladder) empty
```
170
Indications for assisted vaginal delivery
maternal/fetal distress in 2nd stage of labour
| failure to progress/inadequate progress in 2nd stage of labour (>3h)
171
Symphysis pubis dysfunction
pregnancy associated pain, instability & dysfunction of the symphysis pubis joint and/or the sacroiliac joint. Due to ligament laxity in response to hormonal changes occurring during pregnancy
common, effecting ~20% of pregnancies
172
Presentation of symphysis pubis dysfunction
pain over pubic synthesis
difficulty walking/ waddling gait
trouble weight bearing
pain/discomfort lying in certain positions
173
Management of pubic symphysis dysfunction
exercise
physiotherapy
analgesia
NB pain generally resolved within 6 months of delivery
174
Induction of labour
the process of starting labour artificially
| used in ~20% of pregnancies
175
Bishops score
to calculate the chance of successful induction of labour
made up of:
cervical position, cervical consistency, cervical effacement, cervical dilation, fetal station
Score <5 indicates natural labour unlikely to start without induction
score >9 indicates labour will likely commence spontaneously
176
Indications for induction of labour
prolonged pregnancy
PROM where labour doesn't spontaneously start
diabetic mother >38weeks
Rh incompatibility
IUGR
HTN/pre-eclampsia
planned delivery is in best interest of baby
177
Method of inducing labour
membrane swee/artificial rupture of membranes (ARM)
prostaglandin gell/pessary
Oxytocin + ARM
178
Postnatal blues
seen in ~50% of women
usually 3-10 days post delivery mother is tearful, anxious, irritable
Key is reassurance
179
Postnatal depression
seen in ~10% of women
screened for using Edinburgh postnatal depression scale
usually starts within 1 month of birth, with peak at 3 months
features include anhedonia, loss of libido, low mood, low energy, low self-esteem, feelings of worthlessness
Managed with reassurance, CBT, Sertraline (1st line med) or paroxetine
180
Puerperal psychosis
~0.2% of women post delivery
onset within 2-3 weeks post birth
features: mood swings, disordered perception, schizophrenic symptoms, major depression, may have high suicidal drive
requires urgent admission to mother-baby unit
181
Postpartum contraception
should be discussed within 1 week postpartum, with earliest date fo ovulation being at 27 days post partum contraception is needed from 21 days post partum
182
From when is postpartum contraception needed
21 days post partum
183
Recommendations regarding inter pregnancy periods
avoid pregnancy for at least 1 year postpartum
184
Options for post partum contraception
POP:
can be used while breastfeeding
give any time postpartum
COCP
contraindicated while breastfeeding
IUD/IUS
can be inserted immediately post birth or at 4 weeks
Lactational amenorrhoea method (LAM)
in women who is fully breastfeeding & amenorrhoeic <6 months post partum
185
Polycystic ovarian syndrome (PCOS)
complex condition of ovarian dysfunction, common in women of reproductive age
aetiology not fully understood
NB the majority of women with polycystic ovaries do not have PCOS
186
Polycystic ovarian syndrome (PCOS) presentation
sub fertility/infertility
menstrual disturbance (oligomenorrhoea/amenorrhoea)
hirsutism, acne, acanthosis nigricans, alopecia
obesity/difficulty loosing weight
psychological symptoms
187
Rotterdam criteria
diagnostic criteria for PCOS
pt with 2/3 of the following
-polycystic ovaries (≥12 follicles / ↑ovarian volume ?10cm^3)
-oligo-ovulation/anovulation
-clinical/biochemical signs of hyperandrogegism
188
Investigating Polycystic ovarian syndrome (PCOS)
Pelvic USS (multi cystic ovaries)
FSH/LH/prolactin/TSH/Testosterone (all ↑)
OGTT (commonly shows impaired glucose tolerance)
189
Management of Polycystic ovarian syndrome (PCOS)
Weight control/↓ weight & exercise (improve fertility & metabolic features)
COCP (to regulate cycles + manage hirsutism/acne)
Topical eflornithine (if hirsutism/acne don't respond to COCP)
metformin/clomifene
190
Management of Polycystic ovarian syndrome (PCOS) related infertility
Weight loss
| Clomifene (1st line) or metformin or both
191
Complications of Polycystic ovarian syndrome (PCOS)
```
↑ risk of CVS
diabetes
OSA
endometrial hyperplasia/cancer
infertility
```
192
Endometriosis
Presence of endometrial tissue outside the uterine cavity most commonly in the peritoneal cavity
A chronic oestrogen dependent condition
193
Adenomyosis
invasion of the myometrium by endometrial tissue
194
Risk factors for endometriosis
```
positive family history
nulliparity
early menarche
late menopause
late first sexual encounters
```
195
Presentation of endometriosis
```
dysmenorrhoea
chronic/cyclical pelvic pain
dyspareunia (especially deep)
subfertility
bloating, lethargy, constipation, lower back pain, urinary symptoms
posterior fornix/adnexal tenderness
```
196
Investigating endometriosis
```
laparoscopy (gold standard)
Transvaginal USS (TVUS)
```
197
Management of endometriosis
NSAIDs + paracetamol for pain relief
1st line: COCP (suppress ovarian function) or progesterones (e.g. medroxyprogesterone)
2nd line: IUS
surgical (laparoscopic excision / laser ablation)
198
Uterine fibroids
also known as leiomyomata, are benign tumours of the uterus primarily compromised of smooth muscle & fibrous connective tissue
199
Epidemiology of uterine fibroids
very common
~20% of white women
~50% of black women (more common in afro carribbean population)
200
Presentation of uterine fibroids
1/2 will be asymptomatic
usually presents between 30-50 yrs of age
menorrhagia
lower abdo pain (cramping pain often during menstruation)
bloating
sub fertility
palpable mass
201
Investigating uterine fibroids
```
Transvaginal USS (TVUS)
endometrial biopsy
```
202
Management of uterine fibroids
Mirena coil (IUS)/COCP
TXA
GnRH agonist (to ↓ size of fibroids)
surgical: myomectomy to retain fertility or hysterectomy
203
Complications of uterine fibroids
red degeneration: haemorrhage into fibroid often occurring during pregnancy
204
Pelvic inflammatory disease (PID)
a spectrum of inflammatory disorders of the upper female genital tract usually due to ascending infection from cervix
205
Causes of Pelvic inflammatory disease (PID)
Chlamydia trichromatis
Neisseria gonorrhoea
mycoplasma genitalium
mycoplasma hominis
NB in 50% of cases no organism is identified
206
Presentation of Pelvic inflammatory disease (PID)
```
often mild/absent/atypical symptoms
lower abdo pain
deep dyspareunia
abnormal PV bleeding (post-coital, intermenstrual, menorrhagia)
purulent vaginal/cervical discharge
fever
cervical motion tenderness
```
207
Investigating Pelvic inflammatory disease (PID)
pregnancy test (rule out ectopic)
cervical/high vaginal swabs
vaginal secretion sampling for gonorrhoea/chlamydia
laparoscopy (gold standard)
208
Management of Pelvic inflammatory disease (PID)
Abx (if clinically suspected) e.g. IM ceftriaxone (Gonorrhoea) + PO metronidazole + PO doxycycline (chlamydia)
consider IUD removal
management of sexual partners including STI screening
209
complications of Pelvic inflammatory disease (PID)
perihepatitis (Fitz-Hugh Curtis syndrome)
infertility/subfertility
↑ risk of ectopic pregnancy
210
Normal physiological discharge
white/clear, non offensive discharge that varies with menstrual cycle
thickness/stickiness varies with hormonal cycle
211
bacterial vaginosis
most common cause of abnormal vaginal discharge in women of reproductive age, caused by overgrowth of predominantly aerobic bacteria in the vagine e.g. gardenella vaginalis which replace lactobacilli =↓lactic acid production leading to ↑pH
212
Presentation of bacterial vaginosis
offensive fishy smelling vaginal discharge
| generally thin, off white/greyish discharge
213
Amsel's criteria for diagnosis of Bacterial vaginosis
3/4 of the following
- thin white homogenous discharge
- clue cells on microscopy (stippled vaginal epithelia cells)
- vaginal pH >4.5
- positive whiff test (add KOH = fishy odour)
214
Management of bacterial vaginosis
```
avoid vaginal douching, wash outside of vagina only with pH neutral soap
PO metronidazole (5-7 days)
```
NB do not treat asymptomatic women unless pregnant (may cause preterm labour/chorioamnionitis in pregnancy)
215
Vaginal candidiasis
yeast infection of the lower female reproductive tract, 90% of which are caused by candida albicans
also known as thrush
peak incidence age 20-40 yrs
216
Risk factors for vaginal candidiasis
diabetes
Abx/steroid treatment
pregnancy
immunosuppression
217
Presentation of vaginal candidiasis
```
white, 'cottage cheese' on offensive thick discharge
pruritus vulvae
vulval soreness
dyspareunia
vulval erythema/vaginal mucosa erythema
satellite lesions/excortications
```
218
Treatment of vaginal candidiasis
no internal cleaning & good personal hygiene
1st line: intravaginal clotrimazole/miconazole pessary
2nd line: oral anti fungal e.g. fluconazole (if severe/systemic symptoms)
219
Recurrent candidiasis
≥4 episodes in 1 year
| confirm initial diagnosis via high vaginal swab
220
Trichomonas vaginalis
common STI caused by a protozoa
221
Presentation of trichomonas vaginalis
green-yellow, frothy, offensive discharge
vulvovaginitis (erythema of vulva&vaginal mucosa)
strawberry cervix
222
Investigating trichomonas vaginalis
high vaginal swab for NAAT
pH > 4.5
wet microscopy (at GUM clinic)
contact tracing
223
Management of trichomonas vaginalis
avoid intercourse for minimum 1 week post treatment
| 2g single dose PO metronidazole (treat both partners)
224
Other causes of vaginal discharge
Chlamydia trachomatis: purulent/mucopurulent discharge
Neisseria gonorrhoea: purulent discharge
Foreign object e.g. tampon: foul smelling, bloody purulent discharge
Erosive lichen plans: visible on examination
225
Indications for emergency contraception
no contraception used in a consensual sexual intercourse/rape/sexual assault
contraceptive failure e.g. barrier methods
incorrect use of contraception
unprotected sexual intercourse (UPSI)
226
Levornogestrel emergency contraception MOA
stops ovulation & prevents implantation
can be used more than once per menstrual cycle
227
Levornogestrel emergency contraception timing
must be taken within 72h of UPSI as single 1.5mg dose
generally well tolerated, but repeat dose if vomiting within 3h of administration
228
Ulipristal (ellaOne) emergency contraception MOA
inhibits ovulation
can be used more than once per menstrual cycle
229
Ulipristal (ellaOne) emergency contraception timing
can be taken up to 120h post UPSI as single 30mg dose
can be used more than once per menstrual cycle
230
Ulipristal (ellaOne) emergency contraception interaction with hormonal contraception
may reduce effectiveness, so restart hormonal contraception 5 days after taking ellaOne & use barrier methods in the mean time
231
Copper IUD as emergency contraception MOA
inhibits fertilisation & implantation
most effective form of emergency contraception
232
Copper IUD as emergency contraception timing
insert within 5 days of UPSI
if ≥5 days after UPSI then can be fitted within 5 days of the likely ovulation date (usually length of period in days -14 i.e.if 28day cycle then day 14)
233
Copper IUD as emergency contraception removal
can be kept in long term as ongoing contraception
if client wants IUD removed then must stay in till at least the next period after insertion
234
Important points for emergency contraception
return for pregnancy test if no normal period within 7 days of their normal expected period date or if regular bleeding
235
Combined oral contraceptive pill (COCP) MOA
works by inhibiting ovulation, thickens cervical mucus, inhibits implantation
236
Risks of taking Combined oral contraceptive pill (COCP)
↑ risk of breast cancer
↑ risk of cervical cancer
↑ risk fo VTE
↑ risk of MI/Stroke
237
Advantages of the Combined oral contraceptive pill (COCP)
↓risk of ovarian/endometrial/colorectal cancer
menses tends to be lighter
improves PMS
238
Contraindications for Combined oral contraceptive pill (COCP)
```
migraine + aura
BMI >35
smoking >15 cigarettes at age >35
history of VTE
breastfeeding <6 weeks postpartum
uncontrolled HTN
breast cancer
history of stroke/IHD
>20 yrs of diabetes
```
239
Drugs ↓ effectiveness of Combined oral contraceptive pill (COCP)
rifampicin
phenytoin
carbamazepine
240
Starting the Combined oral contraceptive pill (COCP)
start on first day of menstrual bleed/within 5 days of this day = no additional contraception required
if started on other days of cycle must use other form of contraception for first 7 days
241
How to take Combined oral contraceptive pill (COCP)
take pill at same time everyday
take 21 days then 7 day pill free window
may be able to tricycling (3x 21 day packets back to back)
242
1 missed Combined oral contraceptive pill (COCP)
1 pill missed anywhere in packet, i.e. >24h without pill
take last pill asap even if it means taking 2 pills in one day, then continue as normal & take 7 day break as normal
NB if they are in week 4 of their packet i.e. the sugar pills then no action required (day 22-28)
243
≥2 missed Combined oral contraceptive pill (COCP)
take last missed pill ASAP & omit any earlier pills + used additional contraception for next 7 days
If pills missed in week 1 (days 1-7): consider emergency contraception if unprotected intercourse in pill free interval/week 1
If pills missed in week 2 (days 8-14): no need for emergency contraception if pills taken correctly the last 7 days, finish packets as normal
if pills missed in week 3 (days 15-21): finish current packet as per usually and omit pill free break
244
Progesterone only pill (POP) MOA
inhibits ovulation & thickens cervical mucous
245
Progesterone only pill (POP) contraindications
past breast cancer
| SLE
246
Progesterone only pill (POP) advantages
can be used while breastfeeding
can be used when oestrogen contra indicated e.g. VTE
can be used when having major surgery
247
Starting the Progesterone only pill (POP)
if commenced up to & including day 5 of the cycle it provides immediate protection
otherwise requires 2 days of additional contraception after commencing
248
How to take Progesterone only pill (POP)
must be taken at exactly same time everyday (within a 3h window of when pill was taken previous day)
>3h late = missed pill
249
Missed pill for Progesterone only pill (POP)
if a pill is >3h late = missed
If missed pill, then take missed pill as soon as possible, use extra contraception until regular pill taking reestablished for 48h
250
Injectable contraceptive (Depo Porvera) MOA
inhibiting ovulation & thickening cervical mucous
Slowly releases progestogen
251
How Injectable contraceptive (Depo Porvera) is used
IM injection every 12 weeks
252
Disadvantages of Injectable contraceptive (Depo Porvera)
not quickly reversible
weight gain*
irregular bleeding
253
Injectable contraceptive (Depo Porvera) contraindications
current/past breast cancer
| avoid in <18y/o due to ↓ bone mineral density
254
Contraceptive proven to cause weight agin
injectable contraceptive (Depo Provera)
255
Implantable contraceptive (Nexplanon) MOA
inhibits ovulation & thickens cervical mucous
Slowly releases progestogen
256
how the Implantable contraceptive (Nexplanon) works
lasts 3 years
inserted in the proximal non-dominant arm, just overlying the tricep
take additional contraception for 7 days if not inserted on day 1-5 of cycle
257
Intrauterine contraceptive device (IUD)
also known as the copper coil
inhibits fertilisation & is cytotoxic for sperm
lasts for 5-10years
effective immediately after insertion
258
Intrauterine contraceptive device (IUD) complications
heavy/prolonged periods
| ↑risk of ectopic pregnancy
259
Intrauterine system (IUS) (mirena coil)
levornogestrel releasing device
inhibits endometrial proliferation = prevents implantation and thickens cervical mucous
lasts for 5 years
260
Intrauterine system (IUS) (mirena coil) advantages
can be used to manage menorrhagia, as HRT, endometrial hyperplasia, endometriosis
often lighter menses/amenorrhoea
261
Contraceptive of choice in younger people
Implantable contraceptive (nexplanon) is the LARC of choice in young people
262
Age of consent for sexual encounters
Age < 13 means a pt is unable to consent, so if a child comes in this should trigger child protection meausres
generally age of consent = 16 but can be lower if fraser competent
263
The Fraser guidelines
Used in those <16 years old
The following points should be fulfilled:
- the young person understands the professional's advice
- the young person cannot be persuaded to inform their parents or allow the professional to contact them on their behalf
- the young person is likely to begin, or continue having, sexual intercourse with or without contraceptive treatment
- unless the young person receives contraceptive treatment, their physical or mental health, or both, is likely to suffer
- the young person's best interests require them to receive contraceptive advice or treatment with or without parental consent
264
Menopause
onset of menopause is defined as the cessation of menses for at least 12 consecutive months without other causes of amenorrhoea
as women move towards menopause their mensturation may become erratic but if there is still bleeding it is not menopause
average age = 51 yrs
265
Contraception and menopause
contraception is indicated until 12 months after last period if >50y/o
if <50y/o contraception is indicated till 24 months after last period
266
Presentation of menopause
```
menstrual irregularity
hot flushes/sweats
vaginal dryness & atrophy
urinary frequency
sleep disturbances
mood changes (anxiety, depression, difficulty concentrating)
↓ libido
```
267
Management of menopausal symptoms (excluding HRT)
lifestyle modifications e..g weight loss, regular exercise etc
fluoxetine/citalopram/venlafaxine for hot flushes/vasomotor symptoms
lubricants & moisturisers for vaginal dryness
vaginal oestrogen's for vaginal atrophy
268
HRT (hormone replacement therapy)
in women with uterus = oestrogen + progestogen
in women without uterus = only oestrogen
give continuous combined regime if amenorrhoea >12 months/sequential HRT received for >12 months
give sequential combined regimes if amenorrhoea <12 months
269
HRT (hormone replacement therapy) contraindications
current/past breast cancer
oestrogen-sensitive cancer
undiagnosed vaginal bleeding
untreated endometrial hyperplasia
270
Complications of HRT (hormone replacement therapy)
↑ risk of breast cancer
↑ risk of endometrial cancer
↑ VTE risk
271
Premature ovarian failure
onset of menopausal symptoms & ↑ gonadotrophin levels before the age of 40
272
Investigating premature ovarian failure
```
FSH ↑
LH ↑
estradiol ↓
TVUS
TFTs
prolactin
```
273
Management of premature ovarian failure
specialist referral
Sex steroid replacement till at least 51 yrs of age (e.g. via HRT or COCP)
egg donation if attempting conception
274
Female genital mutation (FGM)
also known as female circumcision is widely practiced throughout africa & the middle east
WHO definition: all procedures that involve the partial or total removal of the external female genitalia or other injuries to the female genital organs for non medical reasons
275
Type I Female genital mutation (FGM)
clitoridectomy: partial/complete removal of the clitoral glans and/or the prepuce/clitoral hood
276
Type II Female genital mutation (FGM)
excision: partial or total removal of the clitoris & labia minor with or without excision of the labia major
277
Type III Female genital mutation (FGM)
infibulation: narrowing of the vaginal orifice with the creation of a covering seal by cutting/repositioning the labia minor and/or labia major
278
Type IV Female genital mutation (FGM)
all other harmful procedures to the female genitalia for non medical purposes e.g. piercing, pricking, scraping, cauterising
279
Female genital mutation (FGM) and the law
all HCPs are required to report/record FGM if they see it in a patient or if there is a family history of FGM
It is an offence for UK nationals/permanent UK residents to carry out FGM in the UK or abroad as well as to aid/abet/counsel/procure the carrying out of FGM abroad even in countries where the practice is legal
280
Cervical cancer
a human papilloma virus (HPV) related malignancy of the uterine cervical mucosa, 80% are SCC
peak incidence in those aged 29-25 yrs
281
HPV subtypes implicated in cervical cancer
types 16 & 18
282
Risk factors for cervical cancer
```
HPV infection*
smoking
early first intercourse
multiple sexual partners
immunosuppression (invasive cervical cancer = AIDS defining illness)
lower socioeconomic class
```
283
Presentation of cervical cancer
often detected at routine cervical screening
abnormal vaginal bleeding (post coital/intermenstrual/postmenopausal)
vaginal discomfort
vaginal discharge
urinary/bowel symptoms
abnormal appearance of cervix on examination
284
Investigating cervical cancer
```
vaginal/speculum examination
colposcopy
cervical biopsy
HPV testing (usually +ve)
CT
```
285
Staging cervical cancer
FIGO staging
Cervical intraepithelial neoplasia (CIN)
-CIN I confined to lower 1/3 of epithelium
-CIN II confined to lower 2/3 of epithelium
-CIN III full thickness of epithelium affected
Stage I - confined to cervix
Stage II - spread beyond cervix but not to pelvic wall/ lower 1/3 of vagina
Stage III - tumour extends to pelvic wall/ into lower 1/3 of vagina
Stage IV - tumour spreads beyond pelvis, or involves bladder/bowel
286
Managing cervical cancer
Early on: radical hysterectomy ± lymph node clearance (Gold standard)
NB cone biopsy/local excision to retain fertility
Later on: radical hysterectomy + chemo/radiotherpay
287
Complications of cone biopsy/local excision of cervical cancer
(LLETZ procedure = loop excision of transformation zone)
↑ risk of preterm labour due to shortened cervix (cervical incompetence) but can be treated with cervical cerclage
cervical stenosis
pyometra (A pyometra is a collection of pus distending the uterine cavity. It occurs principally when there is a stenosed cervical os)
288
Prevention of cervical cancer
HPV vaccination for all boys & girls aged 12-13
| quadrivalent vaccine vs types 16,18 (cervical cancer) & 6,11 (genital warts)
289
Cervical cancer screening
smear test offered to all women aged 25-64
age 25-49 = 3 yearly
age 50-64 = 5 yearly
screens for high risk HPV, if +ve then cytology is performed
290
Cervical screening in pregnancy
usually delayed until 3 months post partum unless missed screening or previous abnormal smear
291
Inadequate sample protocol for cervical smear
repeat sample after 3 months
| if inadequate again then perform colposcopy
292
If negative cervical smear
normal recall
i.e.
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
293
if positive cervical smear with abnormal cytology
colposcopy
294
if positive cervical smear with normal cytology
repeat in 12 months time
if positive smear with normal cytology at 12 months then repeat in 12 months
if positive smear with normal cytology at 24 months then colposcopy
if repeat test after 12/24 months is negative then return to normal recall
295
Endometrial cancer
an epithelial malignancy of the uterine corpus mucosa usually in the form of an adenocarcinoma, its an oestrogen dependent tumour
classically seen in postmenopausal women
296
hormone related to endometrial cancer
oestrogen
297
Risk factors for endometrial cancer
```
nulliparity
obesity
early menarche/late menopause
PCOS
endometrial hyperplasia
unopposed oestrogen
tamoxifen
diabetes
```
298
Presentation of endometrial cancer
classically postmenopausal PV bleeding
| abnormal/intermenstrual PV bleeding if premenopausal
299
investigating endometrial cancer
TVUS
| endometrial biopsy ± hysteroscopy
300
Management of endometrial cancer
if localised = radical hysterectomy + bilateral sapling-oophrectomy ± radiotherapy
progestogen therapy in those not fit for surgery
301
Ovarian cancer
malignancy arising form the ovaries often epithelial (cystadenocarcinoma) (90%)
leading cause of death from gynaecological cancer in the UK
peak incidence ~60 y/o
302
Risk factors for ovarian cancer
```
BRCA 1/BRCA2
smoking
obesity
nulliparity
early menarche/late menopause
```
303
Protective factors for ovarian cancer
COCP
304
Presentation of ovarian cancer
```
insidious onset & vague early symptoms
abdominal distension/bloating
abdo discomfort
early satiety
diarrhoea
urinary symptoms
pelvic/abdo mass
ascites
```
305
Investigating ovarian cancer
CA125 (>35IU/ml)
pelvic USS/ TVUS
CT/MRI pelvis
306
Management of ovarian cancer
explorative laparotomy + histopathology/staging
total abdominal hysterectomy + bilateral sapling-oophrectomy + platinum based chemo
307
Prognosis of ovarian cancer
~80% present with advanced disease
| ~5% of all UK female cancer death are due to ovarian cancer
308
Endometrial hyperplasia
abnormal proliferation of the endometrium greater than the normal proliferation that occurs during the menstrual cycle
309
Risk factors for endometrial hyperplasia
```
obesity
tamoxifen
unopposed oestrogen
PCOS
diabetes
```
310
Presentation of endometrial hyperplasia
abnormal PV bleeding (intermenstrual/irregular bleeding/menorrhagia/post menopausal bleeding)
311
Investigating endometrial hyperplasia
endometrial biopsy via hysteroscopy (if atypical hyperplasia = premalignant)
TVUS (↑ endometrial thickness, >3-4mm if postmenopausal, >7mm if premenopausal)
312
Management of endometrial hyperplasia
progestogen therapy
1st line = IUS (levornogestrel)
2nd line = continues oral progestogen (e.g. POP)
if atypical hyperplasia then total hysterectomy is advised
313
Adenomyosis
characterised by the presence of endometrial tissue within the myometrium leading to thickened utuerus
presents with dysmenorrhoea, menorrhagia, enlarged globular uterus
investigate with TVUS
managed with simple analgesia, IUS/COCP or GnRH agonist (e.g. danazol)
314
Cervical ectropion
when columnar epithelium of the endocervix is displayed beyond the cervical OS, ie a change in the cervical transformation zone
usually due to ↑ oestrogen levels (e.g. COCP use or pregnancy)
315
Presentation of cervical ectropion
often asymptomatic
vaginal discharge
post coital PV bleeding
red ring around cervical OS on examination
316
Management of cervical ectropion
stop COCP & conservative management
317
Ovarian cysts
very common benign growth that generally occur in premenopausal women
318
Presentation of ovarian cysts
```
mostly asymptomatic
dull ache/pain in lower abdomen
lower back pain
dyspareunia
palpable mass on examination
torsion/rupture = serve abdo pain often after exercise
```
319
Investigating ovarian cysts
TVUS (gold standard)
pregnancy test
CA125
CT/MRI
320
Management of ovarian cysts
small cysts (<50mm) = usually self resolve, no follow up neded
larger cysts (>50mm) or complex cysts need USS follow up and consider surgical treatment fi conservative approach fails
321
Types of ovarian cysts
Follicular = most common, due to non rupture of dominant follicle, often regress spontaneously
Corpus luteum cysts = failure of corpus lute to break down, often presents as intraperiotneal bleeding
Dermoid cysts = may contain hair/nails/skin, most common benign tumour in <30y/o
serous cyst adenoma = most common bening epithelial tumour, may resemble serous carcinoma
mucinous cyst adenoma = often large and may become massive, may rupture causing pseudomyxoma peritonea (mucin in peritoneal cavity)
322
genitourinary prolapse
descent of one or more of the pelvic organs including the uterus/blader/rectum/vaginal vault
323
Risk factors of genitourinary prolapse
```
↑ age
↑ parity/multiparity
vaginal delivery
obesity
previous hysterectomy
previous prolapse
```
324
Presentation of genitourinary prolapse
```
mild prolapse is often asymptomatic
sensation of pressure/fullness/heaviness
sensation of bulge/protrusion
difficulty retaining tampons
feeling of bearing down
urinary symptoms (incontinence, frequency, urgency, incomplete emptying)
dyspareunia
constipation
```
325
Management of genitourinary prolapse
conservative : weight loss, pelvic floor exercises, ring pessary
Surgical management
326
Urinary incontinence
involuntary loss of urine
| common problem especially in elderly female,
327
Types of urinary incontinence
stress incontinence: involuntary leak on effort/exertion/sneezing/coughing , usually small amounts
urge incontinence: involuntary leak immediately proceed by urgency of micturition
Mixed: mix of urgency & stress
overflow incontinence: usually due to chronic bladder outflow obstruction
328
Risk factors for urinary incontinence
```
↑ age
previous pregnancy/childbirth
vaginal delviery
↑ BMI
FHx
hysterectomy
pelvic organ prolapse
congiuntive impairment
```
329
Investigations for urinary incontinence
bladder diary
vaginal/speculum examination
urine dipstick & culture
urodynamic studies
330
Management of urge urinary incontinence
1st line bladder retraining
2nd line bladder stabilising drugs (antimuscarinics e.g. oxybutynin, tolterodine)
331
Management of stress urinary incontinence
pelvic floor exercises
duloxetine
surgical management
332
Management of mixed urinary incontinence
pelvic floor exercises + bladder retraining
333
Infertility/subfertility causes
```
male factors ~30%
unexplained ~25%
ovulation failure/ovulatory disorders ~25%
tubal damage ~15%
other causes ~10%
```
334
Investigating Infertility/subfertility
```
semen analysis (after min 3 days abstinence)
serum progesterone (7 days prior to next expected period, so for 28 day cycle = day 21, <16nmol/L = abnormal, >30nmol/L indicated ovulation)
FSH/LH
```
335
Ovarian hyperstimulation syndrome (OHSS)
complication of induced ovulation as part of assisted conception
presents as bloating, abdo pain, ascites, anuria, acute respiratory distress
336
Bartholin's cysts/abscess
Bartholins glands are a pair of glands located next to the entrance fo the vagina, the ducts of these glands may occlude leading to cyst formation
generally unilateral
usually in women of childbearing age
337
Bartholin's cysts/abscess presentation
small cysts often asymptmatic
vulval/perineal mass
vulval pressure/fullness
abscesses may be painful, labial oedema/erythema
on examination = unilateral labial mass
cysts = soft, fluctuant, non-tender
abscess = tesne, ahrd, painful with surrounding erythema
338
Management of Bartholin's cysts/abscess
```
conservative therapy (if small)
simple incision & drainage
Marsupialisation (gold standard & definitive treatment)
```
339
Postmenopausal bleeding
vaginal bleeding occurring after >12 months of amenorrhoea in a women at the age where menopause cane expected
340
Causes of postmenopausal bleeding
```
vaginal atrophy (most common)
HRT
endometrial hyperplasia
endometrial cancer
trauma
polyps
```
341
Investigating postmenopausal bleeding
TVUS
urine dipstick
CA-125
endometrial biopsy/hysteroscopy
342
Managing vaginal atrophy
topical/vaginal oestrogens + lubrication
343
Dysmenorrhoea
characterised by excessive pain during menstrual periods
344
Primary dysmenorrhoea
no underlying pathology, affects ~50% of menstruating women, often developing soon after menarche
pain usually starts just before/within a few hours of period starting
management: NSAIDs e.g. mefenamic acid
COCP (2nd line)
345
Secondary dysmenorrhoea
often due to underlying pathology, generally develops years after menarche
pain starts 3-4 days pre period
Causes: PID, endometriosis, adenomysosis, fibroids
refer to gynaecologist
346
Menorrhagia
menstrual blood loss which interferes with a women physical/emotional/social/maternal QoL
generally if quantity >80ml or bleeding >7days
peak age 30-49 yrs
347
Causes of menorrhagia
```
dysfunctional uterine bleeding (DUB) i.e. primary menorrhagia, ~50% of cases
anovulatory cycles
fibroids
endometrial polyps
endometriosis
adenoymyosis
PID
copper coil
```
348
Investigating menorhagia
TVUS
FBC
TFTs
349
Management of menorhagia
mefenamic acid + TXA 1g
Mirena coil (1st line if contraception required)
350
Amenorrhoea
absence or cessation of menstruation, which may be physiological as before the menarche, due to pregnancy, or after menopause
351
Primary amenorrhoea
Menses has not occurred by the time of expected menarche i.e. age 14 if absence of secondary sexual characteristics or age 16 if secondary sexual characteristics present
Causes include constitutional delay, imperforate hymen, ovarian failure, hypothalamic failure
352
Secondary amenorrhoea
menstruation absent for ≥6months but having previously been established
causes: pregnancy, hypothalamic amenorrhoea, PCOS, hyperprolactinaemia, premature ovarian failure
353
Investigations for amenorrhoea
```
pregnancy test
gonadotrophin levels i.e. FSH/LH (↑ if ovarian cause, ↓ of hypothalamic cause)
prolactin
androgen levels
TFTs
pelvic USS
```
354
Complications of forceps delivery
Maternal:
perineal tear, vaginal lacerations, sphincter injury, pelvic organ prolapse
Fetal:
facial lacerations, ocular trauma, skull fracture, subgaleal haematoma
355
Complications of ventouse delviery
maternal:
extension of vaginal laceration, perineal tears
fetal:
scalp laceration, cephalohaematoma, retinal haemorrhage
356
Use of GnRH agonist in fibroids
e.g. Triptorelin or Goserelin
used to ↓ size of fibroids, especially in the short term while awaiting surgery
357
Hypothalamic amenorrhoea
Due to ↓GnRH = ↓ LH & ↓ FSH
causes include excessive weight loss, eating disorders, obesity, stress
358
Causes of inadequate cervical smear
failure to sample full 360° of cervical circumference
blood on smear
cervical inflammation
age related atrophic changes
359
Imperforate hymen
cause of primary amenorrhoea
usually presents as lower abdominal pain, which gets worse from time to time (usually when periods would be)
in a girl with present secondary sexual characteristics
usually treated with incision of the hymen
