Obstetrics & Gynaecology Flashcards
Treating Herpes Simplex, including pregnant and immunocompromised pts
Acyclovir 400mg TDS 7-10d first ep, 3-4 days recurrent episodes.
Fine in pregnancy.
Valcyclovir- more expensive. Both reduce viral shedding. Reduce symptoms. Also shorten viral excretion time and the duration of illness.
Immunocompromised pts require IV acyclovir
Complications of PCOS
- NIDDM
- Endometrial cancer
- Nonalcoholic steatohepatitis
Maternal and fetal complications of shoulder dystocia
Fetal
1) hypoxic ischaemic encephalopathy (chest compression by vagina or cord compression by pelvis can lead to hypoxia)
2) brachial plexus injury (Erb’s palsy: C5-C7; Klumpke’s palsy: C8-T1), 90% resolve within 6 mo
3) fracture (clavicle, humerus, and cervical spine)
4) death
Maternal
1) perineal injury
2) PPH (uterine atony)
The window for antenatal treatment with corticosteroids
23-34 weeks
Risk factors for ovarian torsion
- Women of repro age in 20s and 30s
- Pregnancy
- Anything involving induction of ovulation
- Ovarian tumours (benign) (usually dermoid cysts)
Management of endometrial polyps
dx: pelvic ultrasound and treatment is d/c + bx to exclude cancer
Risk factors for amniotic fluid embolus
placental abruption
rapid labour
multiparity
uterine rupture
uterine manipulation
induction medication and procedures
Endometrial cancer risk factors
- Oestrogen exposure
- Nulliparity (2-3x increase)
- Early menarche Late menopause
- Unopposed menopausal oestrogen use
- PCOS (relative risk of 3)
- Diabetes
- Oestrogen producing ovarian tumours
- Obesity (2-3x increase in risk)
- High doses of tamoxifen
- Hypertension
- Thyroid disease
- Gallbladder disease
- Caucasian
Management of placenta previa
Two categories of management: Not ready to deliver eg fetal immaturity. Stabilise the patient. Give a tocolytic to suppress labour. It buys time. Then give corticosteroids to promote fetal lung development. Deliver by caesarean if you have mature lungs. Fetal distress is a good reason.
How to treat acute pyelonephritis in pregnancy
Acute pyelonephritis in pregnancy is treated in hospital with ivabx (Ceftriaxone) until the pt is afebrile for 24-48h and symptomatically improved
Complications of uterine rupture
Maternal death 1-10%
1) maternal hemorrhage, shock, DIC
2) amniotic fluid embolus
3) hysterectomy if uncontrollable hemorrhage
4) fetal distress, associated with infant mortality as high as 15%
Shoulder dystocia- risk to fetus of long term disability
1%
Name a specific maternal contraindication to antenatal corticosteroids
Active TB
atrophic vaginitis tx
topical estrogen
Gardnerella vaginalis is the cause of what? And with which other organism is it commonly associated?
Bacterial vaginosis
Associated frequently with Mycoplasma Hominis
Management of seizures in eclampsia
Loading dose of magnesium sulphate 4-6g followed by an infusion 2g/hr.
Treatment of endometritis
Tx clindamycin + gentamicin
Complications of bacterial vaginosis
- second and third trimester premature labour and birth
- Post natal endometritis
- Sometimes PID
Risk factors for placental abruption
- Trauma
- Cocaine
- Polyhydramnios
- Chronic hypertension
- Pre-eclampsia Eclampsia
- PROM- prolonged
- Chorioamnionitis
- Previous ischaemic placental disease (IUGR)
- Maternal age
- Parity
- Smoking
- Male infant
Name the condition:
Agalactorrhea, post-partum amenorrhea, secondary hypothyroidism, adrenalinsufficiency
Sheehan’s syndrome
Definition of post partum haemorrhage
Blood loss >500mls after the third stage of labour
Name the most common STI in Canada
Chlamydia
Indications for the induction of labour
Pre-eclampsia
Bad fetal signs
Placental abruption
Preg is 42w or more
Sites of endometriosis
Ovaries 60%
Broad ligament
Vesicoperitoneal fold
Cul de sac
Rectosigmoid colon + appendix
Also reported in liver, brain, lung & old scars
Physical examination in endometriosis
Physical exam: uterosacral nodularity on rectovaginal exam, fixed retroverted uterus
The drug of choice for chlamydia when a) not pregnant b) pregnant
a) Doxycycline b) Azithromycin
Definitive diagnosis of endometriosis
Laparoscopy
Drug of choice to reduce blood pressure in eclampsia
Labetolol
Defining characteristics of pre-term labour
Regular contractions (2 in 10 mins)
cervix >2cm
>80% effaced prior to term (20-37w)
What is colpitis macularis (strawberry cervix) associated with?
Trichomonas infection
Risk factors for placenta previa
- Mutiparity
- Prior caesarian
- Fibroids + uterine abnormalities
- Smoking + cocaine use
- Multifetal pregnancy
- Advanced maternal age
- Infertility Rx
- Previous uterine surgery
Management of uncomplicated UTI in pregnancy
First line: amoxicillin (250-500 mg PO q8h x 7 d)
alternatives: nitrofurantoin (100 mg PO bid x 7 d) or cephalosporins follow with monthly urine cultures
Treatment of syphilis
Penicillin G 2.4 million IU IM x 1 dose if early syphilis
(3 doses if late syphilis)
Monitor VDRL monthly
If penicillin G allergic: clindamycin 900 mg IV q8h
What is the significance of acanthosis nigricans?
It indicates insulin resistance
What’s the drug of choice for trichomoniasis?
Metronidazole
Indications to hospitalise a patient with pelvic inflammatory disease
Pregnant
Lack of response or tolerance of oral meds
Can’t take oral meds/ vomiting
Severe illness
Pelvic abscess incl tubo-ovarian abscess
Non-compliance
Complications of placenta previa
Placenta accreta. It attaches to the myometrium.
Placenta increta- invades the myometrium
Placenta percreta- perforates the myometrium
Pre-term delivery
IUGR
Prem rupture of membranes
Congenital anomalies
Contraindications to medically managing an ectopic pregnancy
- Hemodynamically unstable
- Signs of impending or actual ectopic mass rupture
- Size larger than 3.5cm or fetal heart rate activity
- Immunodeficiency, active pulmonary disease, peptic ulcer disease
- Coexisting intrauterine pregnancy
- Non-compliance risk
- Breast-feeding
- Hypersensitivity to methotrexate
Chlamydia complications
- PID
- Infertility
- Ectopics
- Reactive arthritis
- Perinatal infection
Investigation of choice for suspected ovarian torsion
Do a transvaginal and abdominal US as a first measure Differentiate it from a ruptured ovarian cyst by the absence of peritoneal fluid on US
Chancroid organism
Haemophilus ducreyi
Causes of postpartum haemorrhage
The four Ts
Uterine atony- loss of strength of uterine muscle causes failure of contraction and retraction of the uterus. Caused by over distended uterus - fetal macrosomia, twins etc. Most common cause of PPH
Tissue- placenta not properly expelled after delivery
Trauma- during delivery. Incl uterine rupture
Thrombosis. Ay kind. Eg thrombocytopenia, low platelets
Ectopic pregnancy risk factors
- Age >35
- Prev ectopic (15% chance of recurrence)
- Hx PID (scarring fallopian tube)
- Tubal pathology and surgery
- IUD
- Multiple sexual partners (dt risk of PID)
- Smoking due to impaired immunity in smokers
- Prior induced abortion
- In utero diethylstilbestrol exposure
- Infertility (tubal abnormalities)
Management of mild and moderate placental abruption at term
Mild- You can try a vaginal delivery if there is no fetal compromise Moderate- deliver urgently regardless of gestational age
Diagnosis of PCOS
The Rotterdam criteria, 2/3
Oligomenorrhoea/irreg periods for 6m
Hyperandrogenism
Polycystic ovaries on US
The AMSEL criteria for diagnosis of bacterial vaginosis
Whiff test (fishy odour KOH) and clue cells.
Cause of pain associated with fibroids
fibroid outgrows blood supply
Typical presentation of endometrial polyps
vaginal bleeding between periods
Definition of uterine hyperstimulation
Defined as contractions that are 2mins in length or less.
So more than 5 in ten minutes
Diagnosis and treatment of chancroid
Dx “school of fish” on Gram stain → Tx azithromycin or ceftriaxone
Breastfeeding contraindications
Active herpetic breast lesions
Active TB
Untreated brucellosis
After radioactive isotopes
Chemotherapy
Recreational drugs
Causes of vulvar/ vaginal itching
- Bacterial vaginosis
- Vaginal/vulvar candidiasis
- Trichomonas vaginalis
- Chemical vaginitis
Commonest sites of ectopic pregnancies
ampullary (70%), isthmic (12%), fimbrial (11%)
Any woman presenting with abdominal pain, vaginal bleeding and amenorrhea is what until proven otherwise?
An ectopic pregnancy
Teratogenic antibiotics
Tetracyclines Fluoroquinolones Aminogylcasides Sulfonamides
A patient failing to lactate after a delivery with heavy blood loss
Sheehan syndrome
Uterine bleeding at 18 weeks. No products expelled. Os is open.
Inevitable abortion
Uterine bleeding at 18 weeks. No products expelled. Os is closed.
Threatened abortion
Most common cause of amenorrhea
Pregnancy
The term for heavy bleeding during and between menstrual periods
Menometrorrhagia
Therapy for PCOS
Weight Loss and OCPs. Consider metformin.
Laparoscopic findings in endometriosis
Powder burns and chocolate cysts
Most common location for an ectopic pregnancy
The AMPULLA of the oviduct
Patient has increased vaginal discharge and petechial patches in the upper vagina and cervix
Trichomonal vaginitis
Most common cause of bloody nipple discharge
intraductal papilloma
Breast malignancy presenting as itching, burning and erosion of the nipple
Paget disease
Annual screening for women with a strong family Hx of ovarian cancer
CA-125 and transvaginal ultrasonography
Non-surgical options for stress incontinence
Kegel exercises
Estrogen
Pessaries for stress incontinence
Lab values suggestive of menopause
Increased FSH
Most common cause of female infertility
- Ovulation disorders
- Endometriosis
Molar pregnancy containing fetal tissue
Partial mole
Typical Abx for GBS prophylaxis
IV penicillin or ampicillin
Investigation of choice in a woman w postmenopausal bleeding
Hysteroscopy. Not US
Difference between a total and a radical hysterectomy
A total hysterectomy removes the whole uterus and cervix.
In a radical hysterectomy, a surgeon removes the whole uterus, tissue on the sides of the uterus, the cervix, and the top part of the vagina. Radical hysterectomy is generally only done when cancer is present.
Rx if endometrial cancer is confined to the uterus:
Total extrafascial abdominal hysterectomy w bilateral salpingo-oophorectomy + pelvic + para-aortic LN dissection, with CA-125 as a marker for F/U
Rx if endometrial cancer is beyond stage II
Hysterectomy, bilateral slapingo-oophorectomy, and if it’s stage II or greater do radiotherapy
Rx for a vaginal recurrence of endometrial cancer
Transvaginal brachytherapy
First line treatment abnormal uterine bleeding
Ibuprofen
Fibrinolytics
COCP (but not in a smoker >35, thromboembolism). Note that oestrogen therapy on it’s own would make it worse
Progestins on days 10-14
Mirena coil
Danazil
Causes of post-coital bleeding
Cervical malignancy (squamous cell 95%, adeno 5%)
Polyps
Vaginal atrophy
Clinical examination findings in endometriosis
Fixed, retroverted uterus, nodular ligaments, firm adnexal mass (endometrioma)
Sites of endometriosis (in descending order)
- Ovaries 60%
- Broad ligament
- Vesicoperitoneal fold
- Cul de sac
- Rectosigmoid colon + appendix
- Also reported in liver, brain, lung + old scars
Treatment options for endometriosis
NSAIDs for mild sx
OCPs help the vast majority by preventing ovulation which leads to thinning of the endometrium
GnRH agonist- Leuprolide (US: Lupron), suppresses O production
Excision directly or by lasers to preserve fertility
Hysterectomy
Initial work up PCOS
Serum testosterone
Prolactin
17-OH progesterone
17 hydroxyprogesterone
17 OHP LH, FSH, oestradiol DHEAS TSH
Effect of pregnancy on thyroid hormones
Total T4 ↑bcs of ↑ THBG
Effect of pregnancy on creatinine
Creatinine ↓bcs of the increased GFR
Effect of pregnancy on GFR
GFR ↑ by 50%, this can lead to glycosuria which is not abnormal
The cure for eclampsia
Delivery
Risk of eclampsia in future pregnancies
Increased risk in future pregs, 25-50% increase in risk
Higher future risk if you have it at less than 34w gestation, or another preg <2 or >10y
Should a woman with Hep B breastfeed
Yes apparently benefits outweigh risks
Rx for hot flashes of menopause
SSRIs. Fluoxetine, paroxetine, sertraline. Also SNRIs- venlafaxine
Herpes simplex- what kind of virus?
Large DNA virus
Painless red vaginal bleeding in pregnancy which stops spontaneously w a soft non tender uterus.
Placenta previa
Typical timing of placenta previa
After 20w, usu 29/30 weeks
Management of painless red vaginal bleeding in pregnancy which stops spontaneously w a soft non tender uterus, presenting at 20 weeks
If someone presents early arrange a US between 28-36w to determine placental location. In the absence of any other comps you don’t need to keep repeating the sonography.
Pregnant woman with Pain Vaginal bleeding (but bleeding might be concealed) Uterine hypertonus
Placental abruption
Placental abruption- diagnosis
Clinical
Management of placenta accreta
Hysterectomy
Lower abdo pain, adnexal tenderness, cervical motion tenderness, not pregnant
PID
Turner’s syndrome abnormal lab tests
Gonadal dysgenesis will result in low oestrogen. FSH & LH increase oestrogen. These will both be high in Turner’s syndrome.
Treatment for Turner’s syndrome to achieve adult height
Early Rx w GH is the DOC for helping pmts gain adult height. Giving oestrogen too early can lead to closure of epiphyseal plates so this starts at 12
80% of pyelonephritis is caused by which bug
E Coli
What’s different about the pain from appendicitis vs ovarian torsion?
The latter is sudden onset
Diagnosis of gonorrhoea
Urethral discharge - culture + gram stain.
Characteristic gram - diplococci
Nucleic acid amplification test (NAAT)
Diagnosis of chlamydia
Tissue culture. You can’t see it on a gram stain
Complications of shoulder dystocia
hypoxic ischemic encephalopathy (chest compression by vagina or cord compression by pelvis can lead to hypoxia)
brachial plexus injury (Erb’s palsy: C5-C7; Klumpke’s palsy: C8-T1), 90% resolve within 6 mo
fracture (clavicle, humerus, and cervical spine)
death
Antiretroviral triple therapy in pregnancy reduces HIV transmission to what?
reduces transmission to <1%
First line Rx UTI of pregnancy
First line: amoxicillin (250-500 mg PO q8h x 7 d)
Pre-term labour- purpose of tocolytics
The primary purpose of tocolytic therapy is to delay delivery for 48 hours to allow the maximum benefit of glucocorticoids to decrease the incidence of RDS.
Do tocolytics delay delivery?
No
Maternal contraindications to tocolysis
- Bleeding (placenta previa or abruption)
- maternal disease (HTN, DM, heart disease)
- preeclampsia or eclampsia,
- chorioamnionitis
Fetal contraindications to tocolysis
- erythroblastosis fetalis
- severe congenital anomalies
- fetal distress/demise
- IUGR
- multiple gestation (relative)
Antenatal ultrasound (fetal biophysical profile)- what it looks at
Fetal breathing: considered abnormal if there is absent breathing or no breathing episode for ≥20 seconds within a 30 minute lapse
Fetal tone: considered abnormal if there is slow extension with return to partial flexion or absent fetal movement
Fetal movement (gross body movement): considered abnormal if there is <2 episodes of body/limb movements within a 30 minute lapse
Amniotic fluid volume: considered abnormal if the largest pocket is <2 x 2 cm
Absolute contras to the COCP
< 6 wks postpartum
- smoker > 35 (>15 cigs day)
- hypertension
- current or past hx of venous thromboembolism (VTE)
- ischemic heart disease
- hx of cerebrovascular accident
- complicated valvular heart disease (pulmonary –hypertension, AF, hx subacute bact endocarditis)
- migraine headache w focal neurology
- breast cancer (current)
- diabetes with retinopathy/nephropathy/neuropathy
- severe cirrhosis
- liver tumour (adenoma or hepatoma)
Sacral backache with menses and deep dyspareunia
Endometriosis
Commonest cause of pregnancy loss in a) the first trimester b) the second trimester
a) chromosomal abnormality
b) cervical insufficiency, often secondary to a hx of cervical trauma
Natural history of genital warts
50% disappear in four months without Rx, and 75% in 2 years they recur with treatment
Rx for genital warts with the lowest rate of recurrence
Surgical excision
Causes of galactorrhea
- Hypothalamic or infundibular lesions
- Tumors Craniopharyngioma Germinoma Meningioma
- Infiltrative disorders Histiocytosis Sarcoidosis
- Rathke’s cleft cysts
- Pituitary lesions Prolactinoma Acromegaly
- Breast surgery
- Burns
- Herpes zoster
- Spinal cord injury
- Trauma
- Hypothyroidism
- Renal insufficiency
- Medication-induced hyperprolactinemia
- Idiopathic hyperprolactinemia
The risk factor for endometrial cancer with the highest relative risk
Postmenopausal estrogen (2-10)
PCOS next (3)
What are the two types of hydatidiform mole and how do they differ?
Complete. Contains no fetal tissue, it is made of abnormal placental tissue. They are DIPLOID (androgenic 46XX or biparental 46XY)
Incomplete, contains fetal tissue, the placenta grows abnormally into molar tissue. They are triploid 69XXX or 69XXY
Contraceptive effects of levonorgestrel IUD (Mirena)
- Mucous thickening preventing sperm entering uterus
- inhibits sperm motility
- sometimes prevents ovulation
The most likely cause of postpartum fever after caesarian delivery
Endometritis.
Usually day 2.
Fever, foul smelling discharge, leukocytosis
What is lochia?
The vaginal discharge in the puerperal period. Lasts 4-6 weeks, not offensive smelling.
Mechanism of action of a copper IUD
Spermicidal environment
Management of uterine inversion
- The Johnson manœuvre- fist to reposition uterus
- Hydrostatic reduction (following sublingual GTN)- with warm saline (the O’Sullivan technique)
Young woman with aysmptomatic small ovarian cyst <5cm- management
Repeat US 12 weeks
Factors associated with poor outcome in TOLAC (trial of labour after caesarian)
High BMI >40
Hx or 2 or more caesarians
>35 years maternal age
Fetus >4kg
Induction of labour
Preferred anticoagulant for venous thrombosis a) in pregnancy b) breastfeeding
a) LMW heparin b) Warfarin
Single most important risk factor for endometritis
Caesarian section
The Pap smear is better at detecting which type of cervical cancer?
Squamous > adeno
When does the Canadian cervical screening programme start?
Age 25 for women with a hx of sexual activity, with three yearly smears
Higher rates of cervical metaplasia are associated with which types of HPV?
HPV 16 and 18
At risk groups for cervical cancer in Canada
immigrant Canadians
First Nations Canadians
geographically-isolated Canadians
sex-trade workers l
ow socioeconomic status Canadians
Low-grade squamous intraepithelial lesion (LSIL)- potential options
Colposcopy or repeat cytology in 6/12 (if negative, repeat again in 6/12, if negative for a second time revert to routine 3 yearly screening)
High-grade squamous intraepithelial lesion (HSIL)- potential options
Colposcopy
The Jarisch–Herxheimer reaction is traditionally associated with what?
Treatment of syphilis
What is The Jarisch–Herxheimer reaction?
It occurs after initiation of antibacterials when treating Gram-negative infections such as E coli, syphilis and louse- and tick-borne infections. It usually manifests 1–3 hours after the first dose of Abx as fever, chills, rigor, hypotension, headache, tachycardia, hyperventilation, vasodilation with flushing, myalgia (muscle pain), exacerbation of skin lesions and anxiety. The intensity of the reaction indicates the severity of inflammation. Reaction commonly occurs within two hours of drug administration, but is usually self-limiting.
Management of transverse lie in labour
Emergency caesarian section
Definition of prolonged PROM
24 hours
Definition of retained placenta
Failure to deliver the placenta within 30 minutes of birth
Management of molar pregnancy associated hyperthyroidism
It usually resolves with the treatment of the gestational trophoblastic disease. Some pts will require antithyroid medication. Tachycardia and hypertension can be managed with propranolol ***
Management options for missed, incomplete or inevitable abortion
Expectant- wait, F/U with US, serial beta-hcgs
Medical- mifeprostone followed by misoprostol or misoprostol alone
Surgical- D+C
***
Sudden frop in fetal heart rate during premature labour after PROM at 32 weeks. Fetus is in transverse lie. What is most likely cause?
Cord prolapse.
Should be considered with any sudden drop in fetal heart rate or sudden change in the fetal trace. It is most common in preterm pregnancies where there is unstable lie and spontaneous ROM has occurred.
***
Breastfeeding when HIV+?
No
***
Signs of magnesium sulphate toxicity
Loss of patellar tendon reflexes
Hot/ flushed
Muscular paralysis
Respiratory depression
Death
***
