Obstetrics & Gynaecology Flashcards
Both syst and diast ____ by 10-15mmHg in the first 2 trimesters but _____ 10mmHg in last trimester returning to baseline towards term thus chronic HTN can be masked in pregnancy
Decreases, increases
What is defined as pre-existing/chronic hypertension?
BP >140/90 prior to 20 weeks GA, persisting >7 weeks post-partum
What is defined as gestational hypertension?
sBP > 140 or dBP > 90 developing after 20th week GA in the absence of proteinuria in a women known to be normotensive before pregnancy
Physical exam of mother with hypertensive disorders in pregnancy
Body weight, CNS (presence/severity of headache, visual disturbances – blurring, scotomata – loss of part of the visual field), tremulousness, irritability, somnolence, hyperreflexia), hematologic (bleeding, petechiae), hepatic (RUQ or epigastric pain, severe N/V), renal (decreased urine output), non-dependent edema (hands and face)
Complications of Hypertensive Disorders in Pregnancy
Liver dysfunction (edema/subcapsular hematoma), renal dysfunction (hypoperfusion), seizure/eclampsia, abruptio, LV failure/pulmonary edema, DIC (release of placental thromboplastin consumptive coagulopathy), HELLP syndrome, hemorrhagic stroke (50% of deaths)
Complications to fetus due to GHTN
Secondary to placental insufficiency – IUGR, prematurity, abruption, IUFD
Labs/investigations of hypertensive disorders in pregnancy?
CBC (heme) + ALT/bilirubin/uric acid/LDH (hepatic) + Creatinine/Protein: Creatinine Ratio (renal) + PTT/INR/fibrinogen (if abnormal LFTs or bleeding, coagulopathy) + urate
Given that urine takes 1 day to come back, do urine dip (UA) – look for 2+ proteinuria (marker)
Management for both Pre-existing + Gestational HTN
Labetalol, α-methyldopa. Ask patient to get BP cuff and parameters for when to come in. Hydralazine and nifedipine are short acting.
No ACEI, ARBs, diuretics, prazosin, or atenolol
What is defined as pre-eclampsia?
New-onset hypertension (blood pressure [BP] > 140/90 mm Hg) plus new unexplained proteinuria (> 300 mg/24 hours after 20 weeks or a urine protein/creatinine ratio of >0.3)
In the absence of proteinuria, preeclampsia is also diagnosed if pregnant women have new-onset hypertension plus new onset of any of the following
Platelets < 100,000, LFTs twice normal, severe RUQ/epigastric pain, renal insufficiency (Cr >1.1 or double serum Creatinine), pulmonary edema, new onset headache/visual disturbances, and could later see hyperreflexia/clonus
What is the definitive treatment for PEC?
Delivery
For management of PEC - Immediate delivery is recommended for:
Pregnancy of > 37 weeks, Eclampsia, Preeclampsia with severe features if pregnancy is >34 weeks, Deteriorating renal, pulmonary, cardiac, or hepatic function (eg, HELLP syndrome), Nonreassuring results of fetal monitoring or testing
General management for PEC?
Hospitalized, Antenatal corticosteroids should be considered if GA <34wk, Delivery if >37weeks, Anti-HTN, MgSO4
Who are considered high risk for PEC?
<18yo, muiltiprip, pre HTN, Hx preeclampsia
What prevention should high risk women for PEC be on?
Low dose ASA AND Calcium if low Ca intake ASA 162mg (2 tab) a night administered at bedtime starting pre-pregnancy or from diagnosis of pregnancy and continue until delivery starting at 12-16 weeks GA
How do you define eclampsia?
The occurrence of =>1 grand mal seizures and/or coma in the setting of pre-eclampsia and the absence of other neurologic conditions occurring before/during/after labour (48-72 hr)
What are the symptoms of eclampsia?
Tonic-clonic seizure lasting 60-75 seconds; symptoms that occur before seizure are persistent frontal or occipital headache, blurred vision, photophobia, RUQ pain, altered mental status, hyperreflexia
Management of eclampsia
ABCs + roll patient in LLDP + supplement O2 to treat hypoxemia due to hypoventilation (while convulsing) + aggressive anti-HTN tx for sustained diastolic pressures > 105 or systolic > 160 + prevention of recurrent convulsions + MgSO4 and DELIVERY – doesn’t matter what age, it reduces the risk of maternal morbidity and mortality; mode of delivery depends on clinical situation/condition
What is HELLP syndrome?
Hemolytic anemia + Elevated Liver enzymes + Low Platelet count
Define primary and secondary infertility
Primary: no pregnancies ever
Secondary: has been pregnant before
Causes of male infertility
- Sperm disorders - reduced sperm count, impaired motility, reduced ejaculate volume
- Testicular damage - scrotal injuries, testicular torsion, infections such as mumps, gonorrhea
- Cryptorchidism
- Scrotal hyperthermia (varicocele)
- Medication - anabolic steroids, spironolactone, corticosteroids, cimetidine
- Thyroid disorders
- Chronic diseases - liver cirrhosis, renal insufficiency, obesity
- Inherited disorders: Klinefelter syndrome, Kallmann syndrome
- Sexual dysfunction - impaired libido, anejaculation
- Pituitary and hypothalamic tumors
- Hyperprolactinemia
List the main category of causes of female infertility
- Ovarian reserve dysfunction
- Ovarian dysfunction
- Outflow Tract Abnormalities
- Endometriosis
Tx for hyperprolactinemia
Administer bromocriptine, a dopamine agonist, which suppresses prolactin.
Tx for PCOS
Treat with clomiphene or letrozole +/- metformin, weight loss.
Tx for pituitary insufficiency
Treat with intramuscular luteinizing hormone/follicle-stimulating hormone (LH/FSH) or clomiphene.
What is the definition of infertility
Inability to conceive after 12 months of regular coitus under 35 years of age and after 6 months in women 35 years of age and over
Investigations for male infertility?
- Semen analysis: sperm count + morphology + motility
- Mixed antiglobulin reaction test for antisperm antibodies
- TSH levels
- Prolactin levels
- Karyotype test (Kallmann syndrome, Klinefelter syndrome)
- Scrotal/Testicular U/S: look for varicocele, obstruction, retrograde ejaculation into bladder
Investigations for female infertility?
- Basal body temperature monitoring (biphasic pattern)
- Hormone tests 3-5 day of the menstrual cycle
- Midluteal serum progesterone levels (day 21-23): progesterone should increase shortly after ovulation - failure of progesterone levels to rise indicates anovulation
- Endometrial bx
- Imaging: Hysterosalpingogram, Hysteroscopy
Which hormone tests should be done for female infertility
- Ovulation prediction test (detect LH levels)
- Androgen levels – negative feedback on ovulation
- TSH levels: elevated levels in hypothyroidism
- Prolactin levels: hyperprolactinemia
- Ovarian reserve:
- Early follicular FSH levels: elevated in ovarian insufficiency and indicate reduced ovarian reserve
- Early follicular estradiol levels
- Anti-Mullerian hormone levels
Causes of ovarian reserve dysfunction?
- <40 – Primary ovarian insufficiency
- >40 – menopause Tx: no treatment, adoption
Causes of ovarian dysfunction?
- Pituitary insufficiency
- Hyperprolactinemia
- PCOS
- Other causes: Hyper/hypothyroid, androgen excess, obesity/starvation, galactorrhea, stress.
Causes of outflow tract abnormalities?
- Tubal Factors: PID, ligations/occlusion
- Uterine Factors: congenital (bicornate/septate uterus), acquired: adhesions (Asherman’s Syndrome), fibroids/polyps, endometrial ablation
- Cervical Factors: hostile/acidic cervical mucus, anti-sperm antibodies, structural defects
What is letrozole
Aromatase inhibitor
What is defined as acute pelvic pain?
Pain below the umbilicus lasting less than 6 months - occurs suddenly, sharply, and briefly
What is defined as chronic pelvic pain?
6 months of pain below the umbilicus severe enough to cause functional disability or require tx
Etiology for pelvic pain?
- Pregnancy: ectopic pregnancy, spontaneous abortion, abruption placenta, uterine rupture, endometritis
- Gynecological:
- Ovary (e.g., ruptured cyst, torsion, neoplasia)
- Tube (e.g., pelvic inflammatory disease, endometriosis)
- Uterus (e.g., leiomyoma, endometriosis)
- Other (dysmenorrhea, ovulation pain (Mittelschmerz), dyspareunia) - Systemic conditions:
- Urologic (interstitial cystitis, renal colic)
- Musculoskeletal (fibromyalgia, diastasis of the pubic symphysis due to previous vaginal deliveries)
- Gastrointestinal (irritable bowel, diverticulitis, inflammatory bowel disease, hernias)
- Neurologic: pudendal neuralgia, anterior abdo wall nerve entrapment
- Vascular: pelvic congestion syndrome - Mental health issues
- Depression, somatization
- Sexual, physical, and psychological abuse/domestic violence
Two emergencies to consider with acute pelvic pain?
- Ruptured ectopic pregnancy
- Ovarian torsion
History for pelvic pain?
- HPI: First occurrence, PQRST. Relation to position changes (pudendal neuralgia) or menstruation (adenomyosis, endometriosis)
- Obs history: MSK - pelvic floor myofascial pain syndromes, No prior pregnancies increase your risk of having endometriosis, PID, adhesions
- Surgical history – nerve injury, adhesions
- Last menstrual period (LMP) and menstrual history.
- Gastrointestinal (GI) complaints such as nausea, vomiting, diarrhea, or constipation
- Sexual history: Dyspareunia.
- Social history (marital discourse, depression, stress, history of physical or sexual abuse)
Physical exam for pelvic pain
- VS – elevated temp, tachy, hypo
- Abdomen – palpated for tenderness, masses, and peritoneal signs. Rectal examination is done to check for tenderness, masses, and occult blood
- Back – sacroiliac joints
- Vulva – visual inspection, sensory exam to sharpness, dullness and light touch – rule out neuralgia
- Pelvic examination: external genitals, speculum examination, bimanual examination. The cervix is inspected for discharge, uterine prolapse , and cervical stenosis or lesions. Bimanual examination should assess cervical motion tenderness, adnexal masses or tenderness, and uterine enlargement or tenderness.
What is Carnett’s test?
Carnett’s test - The patient voluntarily contracts her abdominal muscles by raising her head or legs. An increase in the pain indicates a myofascial origin (positive), whereas a decrease indicates an intraperitoneal disorder/visceral source.
Red flags for pelvic pain?
- Syncope or hemorrhagic shock (eg, tachycardia, hypotension)
- Peritoneal signs (rebound, rigidity, guarding)
- Postmenopausal vaginal bleeding
- Fever or chills
- Sudden severe pain with nausea, vomiting, diaphoresis, or agitation
Investigations for pelvic pain?
- Complete blood count (CBC) with differential: An elevated white blood cell count (WBC) may indicate an infection.
- Pregnancy test.
- RPR, if positive then a confirmatory test such as a VDRL or FTA-ABS, HIV, gonorrhea/chlamydia cultures.
- Urinalysis (UA) and urine culture.
- Fecal occult blood.
Imaging studies for pelvic pain?
o Pelvic sonogram: Best to evaluate ovarian cyst/neoplasms or uterine fibroids.
o For further evaluation: Computed tomography (CT)/magnetic resonance imaging (MRI)-best to evaluate for abdominopelvic masses or malignancies.
What is endometriosis?
Endometrium outside of the endometrial cavity
Pelvic pain that is not primary dysmenorrhea should be considered ____ until proven otherwise
Endometriosis
What is the pathophysiology of endometriosis?
▪ The ectopic endometrial tissue is physiologically functional. It responds to hormones and goes through cyclic changes, such as menstrual bleeding.
▪ The result of this ectopic tissue is “ectopic menses,” which causes bleeding, peritoneal inflammation, pain, fibrosis, and, eventually, adhesions.
Presentation of endometriosis?
Pelvic pain (that is especially worse during menses, but can be chronic):
- Secondary dysmenorrhea (pain begins up to 48 hr prior to menses).
- Dyspareunia (painful intercourse) as a result of implants on pouch of Douglas; occurs commonly, with deep penetration.
- Dyschezia (pain with defecation): Implants on rectosigmoid.
- Dysuria
Infertility, Intermenstrual bleeding, Cyclic bowel or bladder symptoms (hematuria).
Up to one-third of women may be asymptomatic.
Signs of endometriosis?
Retroverted uterus, uterosacral ligaments + rectovaginal nodules, adnexal masses (endometriomas).
Diagnosis of endometriosis?
Laparoscopy or laparotomy: Ectopic tissue must be biopsied for definitive diagnosis. The gold standard for diagnosis is laparoscopy with biopsy proven hemosiderin laden macrophages.
Medical and surgical treatments for endometriosis?
Medical (temporizing):
- Mild-to-moderate: Empirical medical therapy with NSAIDs and continuous hormonal contraceptives
- Severe sx: GnRH agonists (e.g., buserelin, goserelin) and estrogen-progestin OCPs
Surgical:
- Conservative (if reproductivity is to be preserved): Laparoscopic lysis and ablation of adhesions and implants.
- Definitive: Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO).
What is adenomyosis?
Ectopic endometrial glands and stroma are found within the myometrium, resulting in a symmetrically enlarged and globular uterus.
Presentation of adenomyosis?
Presentation: parous women in their 40’s to 50’s, uterus enlarged and boggy, pelvic pain (usually noncyclical), dysmenorrhea, and menorrhagia, dyspareunia
Investigations for adenomyosis?
Transvaginal U/S or MRI to differentiate between adenomyosis and uterine fibroids
Management of adenomyosis?
Management: No proven medical therapy for treatment.
- GnRH agonist, NSAIDs, and OCPs may be used for pain and bleeding.
- Hysterectomy: Definitive therapy if childbearing is complete. The diagnosis is usually confirmed after histologic examination of the hysterectomy specimen.
What is Pelvic Inflammatory Disease?
A bacterial infection that spreads beyond the cervix to infect the upper female reproductive tract, including the uterus, fallopian tubes, ovaries, and surrounding tissue.
Acute pain can occur with degeneration of these, torsion of pedunculated subserosal fibroids, or expulsion of pedunculated intracavitary myomas through the cervix.
Leiomyomas
What is pelvic congestion?
Characterized by chronic pelvic discomfort exacerbated by prolonged standing and coitus in women who have periovarian varicosities on imaging studies
Symptoms of pelvic congestion
Dull chronic ache, worsened at the end of the day, standing, premenstrual, or postcoital = pelvic varicosities.
Treatment of pelvic congestion
Treatment: hormonal suppression, percutaneous embolotherapy, surgery.
A tender hard band or nodule of the muscle associated with pelvic pain?
Myofascial trigger point
What is dyspaurenia?
Genital pain before, during, or after sexual intercourse
What are the risk factors for dyspaurenia?
Risk Factors: PID, peri/postmenopausal, anxiety, depression, prior sexual assault, female circumcision
What is vestibulodynia?
Vulvar pain characterized by severe pain on touch/entry, tenderness to pressure within the vestibule, limited to erythema for physical findings
What is vaginismus and how do you treat?
Involuntary spasm of perineal and levator muscles – psychological issues or conditioned response to pain
What is vulvodynia and how do you treat?
Unprovoked stinging/burning/irritation/pain on vulva – treat with xylocaine 5% ointment PRN, or gabapentin
How do you treat vulvovaginal atrophy?
Premarin cream 0.5g qhs x 4 weeks, estring, vagifem tablets, lubricants PRN
Definition of menopause?
Menopause: permanent cessation of menses for >12 months
Definition of premature ovarian failure?
Premature ovarian failure is defined as menopause occurring before age 40
Describe the hypothalamic-pituitary-ovarian axis
GnRH is released in a pulsatile fashion. This pulsatility induces release of FSH. FSH then stimulates folliculogenesis of the ovaries and estrogen is released.
What happens to the hormones in menopause?
Estrogen levels begin to decline from peak in mid-to-late 30’s, begins perimenopause. As women age, we see endocrine markers – high FSH and low estradiol - cycle variability increases
Menopause is characterized by an elevated FSH due to
- ↓ inhibin (inhibin inhibits FSH secretion; it is produced in smaller amounts by the fewer oocytes).
- Resistant oocytes require more FSH to successfully mature, triggering greater FSH release.
Why do women begin to ovulate less frequently?
This is due to a shortened follicular phase. The length of the luteal phase does not change.
HPO: decrease in HPO sensitivity to estrogen (no LH surge = failure of estrogen(+) feedback)
What are the autonomic symptoms of menopause?
- Increased sweating, hot flashes, and heat intolerance
- Vertigo
- Headache
What is the most common cause of post-menopausal bleeding.
Vaginal atrophy resulting from lack of estrogen
Treatment options for hot flashes?
SSRIs, specifically venlafaxine, can be used to control symptoms
Lower temp of sleeping area, cold drink at the beginning of a flash
What are the mental symptoms in menopause?
- Impaired sleep (insomnia and/or night sweats)
- Depressed mood or mood swings
- Anxiety/irritability
- Loss of libido
- Poor memory/concentration
What are the atrophic symptoms of menopause?
- Breast tissue atrophy: breast tenderness and reduced breast size
- Vulvovaginal atrophy: atrophy of the vulva, cervix, vagina leading to vaginal dryness, pruritus, and dyspareunia
- Urinary atrophy: atrophy of the urinary tract leading to urinary incontinence, dysuria, urinary frequency, urgency, and increased urinary tract infections
- Osteoporosis
When should HRT be considered for menopause
If moderate or severe symptoms.
Treatment for vaginal atrophy in menopause?
Local estrogen cream (Premarin) or Vaginal Suppository (VagiFem) or ring (Estring) or lubricant
Prevention of osteoporosis in menopause?
1000-1500mg calcium + 800-1000IU VD3, weight exercise, no smoking, bisphosphonates (if diagnosed with osteoporosis)
Treatment options for decreased libido in menopause?
Decreased Libido: vag lubrication, counselling, androgen replacement
Treatment options for CVD in menopause?
CVD: manage risk factors with weight loss, BP control, etc.
Contraindications to HRT in menopause
Contraindications (ABCD): acute liver disease, undiagnosed vaginal bleeding, cancer (breast or endo), cardiovascular disease, DVT
Treatment if HRT is contraindicated in menopause?
If contraindicated: antidepressants + clonidine (alpha agonist) + gabapentin (start at 300mg at HS)
When is ERT—estrogen alone indicated in menopause?
Indicated in women status post hysterectomy.
Why do we use estrogen + progesterone for HRT?
The progesterone component is needed to protect the endometrium from constant stimulation and resultant increase in endometrial cancer. It is indicated for women who still have their uterus.
At what point should a conversation be had to determine if therapy is still indicated for menopause symptoms?
Short-term therapy (< 5 yr) is acceptable for menopausal symptom relief – after 5 yrs need to have a conversation.
Risks of HRT?
Risks: estro only ~ endometrial hyperplasia/carcinoma + thromboembolic +stroke/MI (1st year of treatment) + ^breast ca. risk (w/ combo) + gallbladder dx
Breast Cancer Risk: increases after 5 years with combo use
Side effects of HRT?
Side Effects: AUB, mastodynia, edema, bloating, nausea, heartburn, mood changes
Definition of vulvovaginitis?
Vaginitis is a general term for a group of disorders affecting the vagina, caused by infection, inflammation, or changes in the normal flora.
What is normal discharge?
Normal Discharge (pH 3.5-4.5): white/yellow, odorless, no associated vulvar or vaginal symptoms
What should be asked on history for vulvovaginitis?
History: get full OBHx and GyneHx (pap smear hx, pelvic infection hx, procedures done to cervix, endometriosis/PCOS?)
Timeline/severity of all sx
Sexual: partners, practices, protection from STDs, past history of STDs, prevention from pregnancy
GI/GU: pelvic pain, urinary pain, vaginal pain, dyspareunia, ask about colour/amount/smell/blood, re: discharge
Consider: recent Abx use, pregnancy, OCP, immunosuppression, DM, vaginal douching (CANDIDIASIS), semen, drugs, chemicals
Physical exam for vulvovaginitis?
Check for pruritis, burning, foul-smelling discharge, change in amount/consistency/colour, check abdo
Ensure that you are doing a speculum and bimanual exam (to r/o ascending infection (PID)); assess discharge/pooling, assess cervix, tenderness, or signs of blood - smell?
Signs/symptoms of reactive arthritis/syphillis?
Inspect eyes for conjunctivitis, uveitis, rash, mucosal ulcerations (syphilis)
Signs/symptoms of candida vaginitis?
Itch + burn + white/curdy discharge + PLENTY of mucosal erythema + wet mount findings of hyphae KOH
Signs/symptoms of bacterial vaginosis?
Fishy odour + gray discharge + NO mucosal erythema, CLUE CELL
Signs/symptoms of trichomonas vaginitis?
Dyspareunia/dysuria, green and frothy discharge, pH 5-6, + variable erythema, wet mount finding of trich
DDx for vulvovaginitis?
Infective/chemical/atrophic vaginitis (50+), cervicitis (STIs), malignancy, PID, foreign body, disrupted vag flora (BV)
Workup for vulvovaginitis?
Serology (syphilis, HIV) + pH + Wet Mount + Whiff Test + Endocervical/Vag/Urethral Swab (HSV PCR + Syphilis PCR + Trich/BV/Yeast (+/- G&C)) + Urinalysis (NAAT first catch, culture/sensitivity for gonorrhea/chlamydia) + Biopsy
What is bacterial vaginosis?
Overgrowth of Gardnerella vaginalis
Treatment of bacterial vaginosis?
Metronidazole PO (500mg BID x 7d) or clindamycin (300mg PO BID x 7d) or topical
Treatment of candida vaginitis?
Fluconazole PO (150mg) (watch liver) or OTC imidazole or polyene antifungals (1d - 7d doses)
Treatment of gonorrhea and chlamydia?
G (Cefixime 800mg PO single dose + Azithromycin 1g PO, 1 dose), C (Azithromycin 1g PO, 1 dose)
Treatment of trichomonas vaginitis?
metronidazole PO (2g x 1d) or topical metro/clotrimazole (BID x 5d) o TREAT SEXUAL PARTNER TOO + REPORT
What are the notifiable STIs?
G / C / S / Chancroid / HIV / Trich / LGV / MPC / Granuloma Inguinale
Treatment for HPV genital warts?
Patient applied (imiquimod cream) or provider applied (liquid nitrogen, several visits)
MOA of progestin in hormonal contraception?
Progestin: prevents LH surge, suppresses ovulation, thickens cervical mucus, decreases tubal motility, decidualizes endometrium
MOA of estrogen in hormonal contraception?
Estrogen: suppresses FSH and follicular development, causes endometrial proliferation
Explain the feedback regulation of E2/progesterone on LH/FSH?
Feedback Regulation: E2/progesterone have positive feedback action on LH/FSH (unless E2 is there for a long time alone, then it can convert to positive feedback as it does in the menstrual cycle. Thus, a combination pill avoids positive feedback that leads to ovulation.
What do combined oral contraceptive pills contain?
Most contain low dose ethinyl estradiol plus progestin
What is the failure rate of OCPs?
Failure rate (0.3% to 8%) depending on compliance
What do transdermal contraceptive patches contain?
Continuous release of 6mg norelgestrominn and 0.60mg ethinyl estradiol into bloodstream
Where should you avoid placing the transdermal patch?
Can be placed on the buttocks, upper outer arms, lower abdomen, or upper torso (but not the breast)
How often are transdermal patches changed?
Worn for 3 consecutive weeks (changed every wk) with 1wk off to allow for menstruation
A population where transdermal patches may not be as effective?
Maybe less effective in women >90kg
What is the failure rate of transdermal patches?
As effective as OCP in preventing pregnancy (>99% with perfect use)
What is a contraceptive ring (Nuva Ring)?
Thin flexible plastic ring; releases etonogestrel and estradiol, works for 3wk then removed for 1wk to allow for menstruation
What is the failure rate of the contraceptive ring?
As effective as OCP in preventing pregnancy (98%)
Specific side effects of contraceptive ring?
Side effects: vaginal infections/irritation, vaginal discharge
Before prescribing a hormonal contraceptive, what should you do, when should you see them in follow-up?
Thorough history and physical exam, including blood pressure and breast exam
Can start at any time during cycle but ideal if within 5d of LMP
Follow-up visit 6wk after hormonal contraceptives prescribed
Pelvic exam not required as STI screening can be done by urine and pap smear screening does not start until >21 yr
List advantages of combined estrogen and progestin methods
Highly effective, does not interfere with intercourse
Reversible
Cycle regulation
Decreased dysmenorrhea and heavy menstrual bleeding (less anemia)
Decreased benign breast disease and ovarian cyst development
Decreased risk of ovarian and endometrial cancer Increased cervical mucus which may lower risk of STIs Decreased PMS symptoms
Improved acne
Osteoporosis protection (possibly)
What are the estrogen-related side effects of hormonal contraceptives?
Estrogen-related: Nausea, Breast changes (tenderness, enlargement), Fluid retention/bloating/edema, Weight gain (rare), Migraine, headaches, Thromboembolic events, Liver adenoma (rare), Breakthrough bleeding (low estradiol levels) - Irregular breakthrough bleeding often occurs in the first few months after starting OCP; usually resolves after three cycles
What are the progestin-related side effects of hormonal contraceptives?
Progestin-related: Amenorrhea/breakthrough bleeding, Headaches, Breast tenderness, Increased appetite, Decreased libido, Mood changes, HTN, Acne/oily skin* Hirsutism*
What are the absolute contraindications for hormonal contraceptives?
- < 6 weeks post -partum & Breastfeeding (decreases milk production)
- Smoker > 35 (> 15 cigarettes/day)
- Hypertension (>160 />100)
- Current/Past VTE
- Ischemic Heart Disease
- History of cerebrovascular accident
- Migraine with focal neurological symptoms (risk of stroke)
- Severe cirrhosis
- Liver tumour (adenoma or hepatoma)
- Breast cancer (current)
- Diabetes with complications – neuropathy, nephropathy, retinopathy
What are the relative contraindications for hormonal contraceptives?
- Smoker > 35 yr (<15 cigs/day
- Controlled HTN, HPT (150 - 159/ 90 - 99)
- Migraine over age 35 years old
- Symptomatic GB disease (estrogen increases likelihood of stones)
- Mild cirrhosis
- History of OC-related cholestasis
- Use of meds that interfere with OCP metabolism
What are the drug Interactions/risks of hormonal contraceptives?
Rifampin, phenobarbital, phenytoin, griseofulvin, primidone, and St. John’s wort can decrease efficacy, requiring use of back-up method
What are the indications for using a progestin-only method of contraception?
Indications: Suitable for postpartum women (does not affect breast milk supply), Women with contraindications to combined OCP (e.g. thromboembolic or myocardial disease), Women intolerant of estrogenic side effects of combined OCPs
What does the progestin-only pill (“minipill”) rely on for contraception
Relies on the progestin effects on the cervical mucous and endometrial lining
To ensure reliable effect, what must you do with the progestin-only method?
Must be taken daily at same time of day to ensure reliable effect; no pill free interval
The progestin-only method is highly effective for whom?
Highly effective if also post-partum breastfeeding, or if >35yr and smoke
What is the failure rate of the progestin-only pill (“minipill”)?
Higher failure rate (1.1-13% with typical use, 0.51% with perfect use) than other hormonal methods
How often is ovulation inhibited by the progestin-only pill (“minipill”)?
Ovulation inhibited only in 60% of women; most have regular cycles (but may cause oligo/amenorrhea)
What is Depo-Provera?
Injectable depot medroxyprogesterone acetate given by a health-care professional in the upper arm or buttocks every 12 to 13 weeks (four times a year)
When should you start Depo-Provera?
Initiate ideally within 5d of beginning of normal menses, immediately postpartum in breastfeeding and non-breastfeeding women. Can consider quick start
What is the failure rate of Depo-Provera?
Highly effective 99%; failure rate 0.3%
What is a disadvantage about Depo-Provera?
Disadvantage: restoration of fertility may take up to 9mo
Specific side effect of Depo-Provera?
Side effect: decreased bone density (may be reversible) and weight gain
Side effects of the progestin-only methods
Side effects: Irregular menstrual bleeding, Weight gain, Headache, Breast tenderness, Mood changes, Functional ovarian cysts, Acne/oily skin, Hirsutism
What percentage of women have amenorrhea after 1-2 yrs use of Depo-Provera?
Irregular spotting progresses to complete amenorrhea in 70% of women (after 1-2yr of use)
How long should the diaphragm and cervical cap remain in the vagina after intercourse?
Must be left in the vagina for 6 to 8 hours after intercourse. Spermicide should be reapplied in the vagina for each repeated act of intercourse (optional for the cervical cap)
Disadvantage of the diaphragm and cervical cap?
Disadvantages: Must be available at time of intercourse, The use of spermicide may cause irritation of the vaginal and rectal walls and increase the risks of contracting human immunodeficiency virus (HIV), Diaphragm may increase the risk of persistent UTI, Cervical cap should not be used during menstruation and may cause vaginal odour and discharge, Does not protect against certain STIs
What is the failure rate of the female condom?
Typical Use – 79%, Perfect Use – 95%
What are sponge and spermicides?
- The sponge is a soft, disposable, polyurethane foam device impregnated with a spermicide
- Sponge - Fits over the cervix, Traps and absorbs sperm to augment effect of spermicide
- Spermicides - Ingredient that impairs sperm, Should be used with another form of contraception
What is the calendar method for contraception?
A woman tracks the days of her menstrual cycle on a calendar for several months, to identify her fertility period – the period when a woman is most likely to become pregnant after having unprotected sexual intercourse. Avoid day 10-18
Failure rate of the withdrawal method
Typical Use – 73%, Perfect Use – 96%
What are the 2 types of intrauterine devices?
o Copper-Containing IUD (Nova-T®)
o Progesterone-Releasing IUS (Mirena, Kyleena®, Jaydess®)
How does the copper-containing IUD (Nova-T®) work?
Mild foreign body reaction in endometrium; toxic to sperm and alters sperm motility - A T-shaped device with a copper wire around it, inserted into uterus
How does the progesterone-releasing IUS (Mirena, Kyleena®, Jaydess®) work and what do they contain?
Decidualization of endometrium and thickening of cervical mucus; minimal effect on ovulation - Contains a hormone called levonorgestrel (a progestin) that is released slowly over time
How effective are IUDs?
Highly effective (99.8%); failure rate 0-1.2%
How quickly does endometrial pattern return after IUD is removed?
Contraceptive effects last 5 yr Reversible, private, convenient - Endometrial pattern returns to normal in 24hrs once removed
What are the side effects of both Copper and Progesterone IUD?
Both Copper and Progesterone IUD: Breakthrough bleeding, Expulsion (5% in the 1st yr, greatest in 1st mo and in nulliparous women), Uterine wall perforation (1/1000) on insertion, If pregnancy occurs with an IUD, increased risk of ectopic, Increased risk of PID (within first 10 d of insertion only)
What are the side effects of Copper IUD?
Copper IUD: increased blood loss and duration of menses, dysmenorrhea
What are the side effects of Progesterone IUD?
Progesterone IUD: bloating, headache
Contraindications to IUDs?
Pregnancy (bHCG prior to insertion) PID/STI ACTIVE Abnormal cavity Post septic abortion Unexplained PV bleed Uterine/Cervical CA Copper allergy (copper IUD) Breast cancer? – PR positive Malignant GTN – increased perforation
What is the expulsion rate of postplacental IUD?
Expulsion rate is higher (24%)
When should the Kyleena be used for?
Kyleena is used for nulliparious women - Great option for menorrhagia
Time period for the use of Yuzpe method?
Efficacy decreased with time (e.g. less effective at 72 h than 24 h)
What is the follow up for after emergency postcoital contraception?
3-4wk post treatment to confirm efficacy (confirmed by spontaneous menses or pregnancy test)
What is the expulsion rate of postplacental IUD?
Expulsion rate is higher (24%)
Side effects of the Yuzpe method?
Side Effects: Nausea (due to estrogen; treat with Gravol), Irregular spotting
What is 1st line emergency postcoital contraception if <24 hrs?
Plan B
What is Plan B?
Consists of levonorgestrel 750 μg q12h for 2 doses (can also take 2 doses together); taken within 72 h of intercourse. Can be taken up to 5d
In whom is Plan B less effective?
Less effective in overweight individuals (>75 kg less effective, >80 kg not recommended)
Side effect of Plan B
No estrogen thus very few contraindications/side effects (less nausea)
What is the most effective emergency postcoital contraception up to 7 days?
Postcoital IUD (Copper)
For permanent contraception in women, the fallopian tubes may be
● Cut and a segment is excised
● Closed by ligation, fulguration, or various mechanical devices (plastic bands or rings, spring-loaded clips)
● Completely removed
Women who become pregnant after sterilization procedure are at increased risk of?
Ectopic pregnancy
Complications in women having transcervical (hysteroscopic) procedures?
In women having transcervical (hysteroscopic) procedures, complications may include tubal perforation (in 1%-3% of women), improper coil placement (in 0.5%-3% of women), expulsion of occlusion device (in 0.4%-2.2% of women), nickel hypersensitivity (in 0.01% of women)
Complications in women having laparoscopy procedures?
In women having laparoscopy, complications may include mortality (rare, ~0.01%), usually due to anesthesia-related complications, minor or major morbidity (in about 0.9%-1.6% overall).
What is the reversibility of tubal ligation?
Reversibility: cannot reverse clipping due to scarring/ligation, but can reverse by excising clip scar. If whole tube taken out, cannot reverse.
Effectiveness of tubal ligation?
Effectiveness: 10-year cumulative failure rate about 1.9% for abdominal tubal sterilization procedures, reported to have similar efficacy as long-acting reversible contraceptive methods but may have increased morbidity compared with IUD
What is a vasectomy?
For this procedure, the vasa deferentia are cut, and the cut ends are ligated or fulgurated.
How long does sterility take after a vasectomy?
Sterility requires about 20 ejaculations after the operation and should be documented by 2 sperm-free ejaculates, usually obtained 3 months after the operation. A back-up contraceptive method should be used until that time.
Complications of vasectomy
● Hematoma (5%)
● Sperm granulomas (inflammatory responses to sperm leakage) - surgery may be needed to remove the granuloma
● Spontaneous reanastomosis, which usually occurs shortly after the procedure
● Inflammation of the epididymis tubes (congestive epididymitis)
Reversibility of vasectomy
Reversibility: can reverse, but not after 10 years (reversal not covered)
Effectiveness of vasectomy
Effectiveness: very effective (99.85%) birth control method. 1-2 women/1,000 ~ unplanned pregnancy in 1st year after partners have had a vasectomy.
At what GA should a pregnant women be screened for diabetes?
Due to hCS being highest at 24-28 weeks
Explain the 2 step screening process for GDM?
Step 1: Random non-fasting 50g OGTT o > 11.1 mmol/L is GDM o If 1hr PG 7.8-11.1 mmol/L, proceed to step 2 Step 2: fasting (8hrs) 75g OGTT GDM if >1 of: ▪ FPG > 5.3 mmol/L ▪ 1hr PG > 10.6 mmol/L ▪ 2hr PG > 9.0 mmol/L
Risk Factors for GDM
Prior GDM, prior delivery of macrosomia infant, high risk population (aboriginal/Hispanic/SouthAsian/Asian/African), age >35, BMI >30, acanthosis nigricans, corticosteroid use.
Post-partum screening for pregnant women with GDM?
Women with GDM should undergo screening at six to 12 weeks postpartum with a fasting glucose measurement or 75-g two-hour glucose tolerance test
When should women with multiple risk factors be screened for GDM
Women with multiple risk factors should be screened for T2DM in T1 w/ A1C
Management of GDM?
Chemstrips (F/PP), urine ketones, dietary counselling, exercise/increasing activity, insulin up to 4 times daily, oral hypoglycemic agents in pregnancy are generally not safe except glyburide (does NOT cross the placenta) and metformin (DOES cross placenta)
Preconception counselling recommendations?
- Folic acid supplementation (400 mcg daily) to reduce the risk of neural tube defects. 8-12 wks pre-conception until end of T1 to prevent NTDs
- Iron supplementation, prenatal vitamins
- BMI – achieve a healthy body weight before becoming pregnant
- DM – good glycemic control
- Teratogenic medications - ACE inhibitors, Accutane, statins, warfarin.
- Screen for STIs
- Update hepatitis B; influenza; measles, mumps, rubella; Tdap; and varicella immunizations
- Social: smoking, alcohol, drug use, domestic violence
When should 5 mg folic acid be recommended?
0.4-1 mg daily in all women; 5 mg if previous NTD, antiepileptic medications, DM, or BMI >35 kg/m2, ethnic group (Celtic, Sikh, N Chinese)
What is Naegle’s rule?
1st day of LMP + 1 year + 7days - 3months
Initial history for new pregnancy?
- Desirability of pregnancy
- Symptoms of pregnancy
- Obstetrical: any previous complications (GDM, GHTN, delivery related – PTL, PPROM, operative delivery, C/S, or neonatal related – IUGR, IUFD), GTPAL
- Gyne: any abnormal paps? Any pelvic infections of any kind? Cervical procedures (Colpo/LEEP)? Endo/PCOS, etc.?
- Social: smoking (~IUGR), alcohol (FASD/GDD), cocaine (abruption, IUGR, PTL), SES, IPV, domestic violence
- Prescription and non-prescription medications
- Family: genetics (aneuploidy/ONTD/AR), maternal (GDM/GHTN/Multips), or obstetric
- Review of Systems: headache, vision changes, swelling of hands/face, nausea, vomiting, UTI’s, trauma, SOB, bowel/bladder function, weight loss, etc.
Initial physical exam for new pregnancy?
- Measure BMI
- BP, HR, HEENT, breast, RESP, CV, abdo, reflexes, varicosities, pelvic exam
- Pap smear (only if required according to patient history and provincial screening guidelines)
What are the symptoms of pregnancy?
Amenorrhea, breast tenderness, N/V, fatigue, urinary frequency, bleeding
What is gravidity (G)?
Gravidity (G): total number of pregnancies of any gestation (multiple gestation = one pregnancy) – includes pregnancy, abortions, ectopics, and hydatidiform moles
What is parity (TPAL)?
Parity (TPAL): T is the number of term infants delivered (>37wk), P is number of premature infants delivered, (20-36+6wk), A is number of abortions (loss of intrauterine pregnancy prior to viability of fetus <20wk and/or <500g fetal weight) – induced (therapeutic or spontaneous (miscarriage), L is number of living children
Initial investigations for new pregnancy?
- Blood work
- CBC (esp Hb and platelets, remember you can have physiologic anemia)
- Blood group and Rh status + antibody screen (Rh/D – would be eligible for IgG for Rh even in 1st pregnancy!!!) Given at 28 weeks - Screening for STIs
- HIV
- Syphilis screening (Syphilis during pregnancy)
- Hepatitis B surface antigen testing
- Hepatitis C screening (Anti-HCV antibody testing)
- Gonorrhea/Chlamydia testing - Cystic fibrosis screening recommended for 4. Glucose/HA1c
- TSH
- Urine dipstick protein testing: screening for proteinuria (baseline value is vital for comparison with results in later pregnancy to rule out preeclampsia); performed during every prenatal visit
- Urine culture: screening for asymptomatic bacteriuria
- Rubella and varicella antibody
Categories of teratogens?
- A (controlled studies show no risk)
- B (adverse in animals, but no risk in humans)
- C (adverse in animal, unknown risk in humans)
- D (evidence of risk in human, rare situations benefits > risk)
- E (toxic, contraindicated)
Complications of smoking during pregnancy?
Lower fertility, spontaneous abortion, preterm birth, placental insufficiency, placental abruption, ectopic pregnancy, SIDS, PPROM, low birth weight
Complications of using cocaine during pregnancy?
Classic association with placenta abruption, low birth weight, prematurity, microcephaly, miscarriage
Should you use NSAIDs or Tylenol during pregnancy?
CONTRAINDICATED - switch to Tylenol! Inhibit COX-1 and COX-2, which convert arachidonic acid into prostaglandins. risk of early closure of ductus arteriosus
Which antibiotics are contraindicated in pregnancy?
Generally penicillin, cephalosporins, macrolides, azithromycin, erythromycin, clarithromycin, clindamycin (if penicillin allergic) are fine – but NOT metronidazole/sulfonamide (inhibits DNA synthesis), streomycin/gentamycin/kanamycin (ototoxicity/deafness), and tetracycline (bone/teeth staining)
Counselling of the pregnant woman - nutrition?
- Calcium: 3-4 servings of milk products daily (greater if multiple gestation). 1200-1500 mg/d
- Vitamin D: 1,000 IU - promotes calcium absorption
- Iron: 0.8 mg/d in T1, 4-5 mg/d in T2, and >6 mg/d in T3 - supports maternal increase in blood cell mass, supports fetal and placental tissue; required amounts exceed normal body stores and typical intake, and therefore need supplemental iron - iron is the only known nutrient for which requirements during pregnancy cannot be met by diet
- Essential Fatty Acids: supports fetal neural and visual development - contained in vegetable oils, margarines, peanuts, fatty fish
- Daily caloric increase of ~100cal/d in the first trimester, and ~300cal/d in second/third, ~450cal/d in lactation
Counselling of the pregnant woman - caffeine?
Diuretic and stimulant that readily crosses placenta – less than 300mg/d is not thought to contribute to miscarriage or preterm birth (ACOG) – relationship with IUGR is unknown; SOGC states 1-2cups/d are safe
Counselling of the pregnant woman - food borne illnesses?
- Listeriosis (Listeria monocytogenes) and toxoplasmosis (Toxoplasma gondii) concerning during pregnancy
- Avoid consumption of raw meats, fish, shellfish poultry, hotdogs, raw eggs, unpasteurized dairy products
- Avoid unpasteurized soft cheeses, deli meats, smoked salmon, and pates ~ potential sources of Listeria - Fish: limit consumption of top predator fish such as shark, swordfish, king mackerel, tilefish
Counselling of the pregnant woman - exercise?
‘talk test’ – should be able to speak while exercising, avoid supine position after 20 weeks GA, should be low risk trauma sports
Absolute contraindications of exercise in the pregnant woman?
Ruptured membranes, preterm labour, HTN disorders of pregnancy, incompetent cervix, IUGR, multiple gestation (>3)
Counselling of the pregnant woman - optimal weight gain?
BMI 18-24.9: 25-35 pound weight gain normal
BMI 25-29.9: 15-25 pound weight gain normal
BMI >30: 15 pound weight gain normal
Counselling of the pregnant woman - work?
Strenuous work, extended hours and shift work during pregnancy may be associated with greater risk of LBW, prematurity, and spontaneous abortion
Counselling of the pregnant woman - air travel?
Is acceptable in second trimester, airline cut off for travel is 36-38 week gestation depending on airline, to avoid giving birth on the plane
Counselling of the pregnant woman - sexual intercourse?
May continue, except in patients at risk for abortion, preterm labour, or previa – breast stimulation may induce uterine activity and is discouraged in high-risk patients near term
Counselling of the pregnant woman - alcohol?
No amount of alcohol is safe in pregnancy, encourage abstinence from EtOH during pregnancy – increases risk of abortion, stillbirth, and congenital anomalies – fetal alcohol syndrome
When is the dating ultrasound preformed?
7-13w
What does the first trimester screening consist of?
Ultrasound (Nuchal Translucency)
PAPP-A + bHCG
When is the first trimester screening performed?
11-13+6w
What does the first trimester screen for?
Tri-21 + Tri-18 + Tri-13
What is an abnormal amount of nuchal translucency and what is it suggestive of?
> 3mm ~ congenital defects, aneuploidy, warrants further imaging (sees fluid at back of neck + nasal bone)
First trimester invasive prenatal testing for extra/missing chromosomes
Chorionic Villi Sampling (11-13+6)
When can NIPT be offered?
Offer beyond 10 weeks if (+). Accurate at detecting Down Syndrome, Turners, T18, T13
What does the second trimester screening consist of?
AFP
Maternal Serum Quad Screen
(E2 + HCG + Inhibin A + AFP)
When is the 2nd trimester screening performed?
15-20+6w
If FTS is done, just add ___ to test for neural tube defects.
AFP
When is the anatomic ultrasound preformed?
18-20w
What does the 2nd trimester screen for?
Tri-21 + 18 + Neural Tube Defects + Spina bifida
2nd trimester prenatal invasive testing for extra/missing chromosomes
Amniocentesis (16+)
Indications for invasive testing?
- Age >40
- (+)FTS or Quad
- Abnormal U/S (IUGR, soft mark’r, etc)
- FHx or previous child w/ chromo abn
Risk factors of post-partum depression?
PHx or FHx of depression (incl. PPD), prenatal dep/anxiety, stressful life situation, poor support system, unwanted pregnancy, colicky or sick infant
What is post-partum depression?
Major depression occurring within 6 months of childbirth
Symptoms of post-partum depression?
If blues last beyond 2 weeks, or severe symptoms in those 2 weeks (extreme disinterest in baby, suicidal/homicidal/infanticidal ideation) – use Edinburgh Postnatal Depression Scale
Treatment of post-partum depression?
Antidepressants, psychotherapy, supportive care, ECT if refractory
Cardiovascular changes during pregnancy?
- Increase blood/plasma volume by 40-50%
- Increase CO (HR and SV) + RBC by 30-40%
- BP decreases usually overall due to lower TPR, decreased response to vasopressors
Respiratory changes during pregnancy?
- Progesterone increases medullary respiratory center sensitivity to CO2 = hyperventilation for more O2 to baby (normal!) = blow off more CO2 and the kidneys respond by lowering HCO3 = compensated respiratory alkalosis
- Increased O2 consumption
- Enlarged abdominal mass can affect breathing/diaphragm
MSK/Derm changes during pregnancy?
- Increase BMI (10-15kg)
- Stretch marks
- Low back pain
- Lordosis
- Carpal tunnel syndrome
- Sciatica
- Increase skin pigmentation
Gynaecological changes during pregnancy?
- Breast enlargement
- Areolar pigmentation
- Uterine hypertrophy and stretching (increases 10x)
- Cervical gland hypertrophy (thick mucous plug)
- Vagina – lactobacilli proliferation. Increase lactic acid – decreases pH
Renal changes during pregnancy?
- Increased GFR (due to more blood, higher renal blood flow, no change to filtration fraction)
- Glucosuria (secondary to increased GFR, normal but could be gestational diabetes too)
- Increased vasopressor (RAAS) activity, but decreased vasopressor responsiveness
Hematological changes during pregnancy?
- Increased RBC mass
- Increased WBC count
- Increased iron needs (50-60 elemental Fe daily, 1000mg overall)
- Increased clotting (estrogen stimulates protein synthesis (clotting factors but NOT platelets)
- 2/3 of Virchow’s triad – stasis, hypercoagulability
Gastrointestinal changes during pregnancy?
- Decreased GI smooth muscle activity
- Nausea/vomiting, GERD common (take ranitidine – Zantac)
- Increased glucose tolerance (check at 24-28weeks due to high HCS at that point)
- Weight gain (usually 2-4kg (4.5-8lbs) in first 20 weeks, then 0.5kg (~1lb) per week)
How often should a pregnant women be seen during the pregnancy?
For uncomplicated pregnancies, SOGC recommends q4-6wk until 30wk, q2-3wk from 30wk, and q1-2wk from 36wk until delivery
What should be asked in history for subsequent prenatal visits?
Fetal movements: Notice first movement (“quickening”) at 18-20 weeks in primigravidas and ~1-2 weeks earlier in; if the patient is concerned about decreased fetal movement, counsel them to choose a time when the fetus is normally active to count movements (usually recommended after 26 wk)
Uterine bleeding: LMP? Which trimester is it? Cramping? Colour of blood? Clots/tissue? Painless or painful?
Leaking, cramping (contractions), questions, concerns
What should be done on physical exam for subsequent prenatal visits?
- Weight monitoring: to avoid fetal developmental problems (if weight gain is less than the recommended amount), fetal macrosomia, or maternal obesity (if weight gain is above normal)
- Blood pressure monitoring: early detection of pregnancy-induced hypertension
- SFH – pubic symphysis to uterine fundus. GA 20-40 wks
- Fetal position (starting 28-32 wks): Leopold’s maneuvers for lie, position, and presentation of fetus
- Determine FHR (starting at 12 wks) using Doppler US. Normal between 120-160
- Cervical exam at 37 weeks in case require IOL
Most common symptoms of all 3 trimesters?
Urinary frequency + fatigue + poor sleep + back pain
Investigations for subsequent prenatal visits?
- Urine dipstick for glucosuria and proteinuria in high risk women
- Fetal heart rate starting at 10-12 wk using Doppler U/S
- Prenatal screening for Group B streptococcus performed between 36 0/7 and 37 6/7 weeks of gestation (vaginal and rectal swab for culture and gram staining) because colonization by this bacteria may cause chorioamnionitis and neonatal infection. Treated w/ Pen G IV
- Repeat Hb from the 24th week of pregnancy.
- 50-g, one-hour oral glucose challenge test (initial screening) at 24-28 weeks gestation
- Repeat rhesus screening: An unsensitized Rh(D)-negative women should receive anti(D)-immune globulin. Protective for 12 weeks only so may need another dose, also give for any other risk of maternal/fetal blood contact
Management if GBS positive at delivery?
5mU Pen-G IV bolus, then 2.5 mU Pen-G IV q4h until delivery
What is the test done if the 1 hr OGTT is positive?
100-g, three-hour oral glucose tolerance test (oGTT) to confirm diagnosis in case of positive initial screening
What should you counsel pregnant women regarding fetal movement?
- If there is a subjective decrease in fetal movement, try drinking juice, eating, changing position, or moving to a quiet room and count for 2 h; ≥6 movements in 2 h expected
- If there are <6 movement counts in 2 h, patient should present to labour and delivery triage
When is the movement first noticed in pregnancy?
Notice first movement (“quickening”) at 18-20 weeks in primigravidas and can be 1-2 weeks earlier in multigravidas – can occur 1-2 weeks later if placenta is implanted on the anterior wall of the uterus
DDx of decreased fetal movements?
DASH:
- Death of fetus
- Amniotic fluid decreased
- Sleep cycle of fetus
- Hunger/thirst
What are the components of the biophysical profile?
- Limb extension + flexion = tone
- AFV 2cm + 2cm – fluid pocket, most important
- Movement (3 discrete)
- Breathing (one episode x 30s) – usually not until 32 weeks
Indications for biophysical profile
Post-term pregnancy, decreased fetal movement, IUGR, any other signs of fetal distress or uteroplacental insufficiency
Indications for NST?
Run these if suggestion of uteroplacental insufficiency or suspected compromise in fetal well-being
Normal NST findings?
Baseline: 110-160 bpm
Variability: Moderate or Absent/Minimal (<40m)
Decelerations: None / Occasional UV <30s
Accelerations: 2, =>15bpm of >15s in <40m (>32w)
2, =>10bpm of >10s in <40m (<32w)
Atypical NST findings?
Baseline: <110 or >160 for <30m, rising baseline
Variability: Absent/Minimal (40-80m)
Decelerations: UV 30-60s
Accelerations: 2, =>15bpm of >15s in 40-80m (>32w)
2, =>10bpm of >10s in 40-80m (<32w)
Abnormal NST findings?
Baseline: <110 or >160 for >30m, erratic baseline
Variability: Absent/Minimal (>80m), Marked (>10m)
Decelerations: UV >60s or Late
Accelerations: 2, =>15bpm of >15s in >80m (>32w)
2, =>10bpm of >10s in >80m (<32w)
What is menorrhagia?
Menses that are excessive (>80 mL) or prolonged (> 7 days)
Bleeding that is unrelated to menses, occurring irregularly between
Metrorrhagia
Bleeding that is excessive during menses and occurs irregularly between menses
Menometrorrhagia
Etiology of excessive/irregular/abnormal vaginal bleeding?
PALM COEIN
- Polyp: endometrial or cervical polyps - hyperplastic overgrowths of endometrial glands and stroma
- Adenomyosis: painful, endometrial glands/stroma present in uterine musculature
- Leiomyoma: fibroids, benign smooth muscle (or submucoasal) tumors.
- Malignancy: endometrial adenocarcinoma
- Coagulopathy: vWF most common or therapeutic anti-coagulation - heavy menstrual bleeding since menarche
- Ovulatory Dysfunction: endocrine disorders preventing ovulation, causing deviation from normal cycle (PCOS, hypothyroidism, hyperprolactinemia, anorexia, cirrhosis)
- Iatrogenic:
Platelet arterial clots – Clopidogrel, ASA, NSAIDs.
Venous factor thrombus – Warfarin, NOAC, warfarin
Equipment – Cu-IUD
- Not Yet Classified: causes of AUB that are not well-understood or not yet described
Most common neoplasm in women with reproductive age.
Leiomyoma
History for excessive/irregular/abnormal vaginal bleeding?
- History of present illness should include quantity (eg, by number of pads used per day or hour) and duration of bleeding, as well as the relationship of bleeding to menses and intercourse
- Menstrual history, including date of last normal menstrual period, age at menarche and menopause (when appropriate), cycle length and regularity, and quantity and duration of typical menstrual bleeding
- Previous episodes of abnormal bleeding, including frequency, duration, quantity, and pattern (cyclicity) of bleeding
- Sexual history, including possible history of rape or sexual assault
- ROS:
- Missed menses, breast swelling, and nausea: Pregnancy-related bleeding
- Abdominal pain, light-headedness, and syncope: Ectopic pregnancy or ruptured ovarian cyst
- Chronic pain and weight loss: Cancer
- Easy bruising and excessive bleeding due to toothbrushing, minor lacerations, or venipuncture: A bleeding disorder
Physical exam findings for excessive/irregular/abnormal vaginal bleeding?
- Vital signs, BMI, thyroid exam, skin (pallor, bruising, petechiae, hirsutism, acanthosis nigricans), abdo exam (masses, distension)
- Gynecologic examination is done unless abdominal examination suggests a late-stage pregnancy; then, digital pelvic examination is contraindicated until placental position is determined. In all other cases, speculum examination helps identify lesions of the urethra, vagina, and cervix. Bimanual examination is done to evaluate uterine size and ovarian enlargement.
Red flags for excessive/irregular/abnormal vaginal bleeding?
- Hemorrhagic shock (tachycardia, hypotension)
- Premenarchal and postmenopausal vaginal bleeding
- Vaginal bleeding in pregnant patients
- Excessive bleeding
- In children, difficulty walking or sitting; bruises or tears around the genitals, anus, or mouth; and/or vaginal discharge or pruritus
Investigations for excessive/irregular/abnormal vaginal bleeding?
- Heme: CBC, TSH, prolactin, vWF, PT and PTT
- Urine: chlamydia, gonorrhea, pregnancy test
- Imaging: pelvic U/S or MRI, saline-infusion sonohysterogram (polyps) and in other scenarios (fertility workup)
Indications for endometrial biopsy?
Indications include age >35, risk factors (obese, PCOS, HNPCC), significant intermenstrual bleeding, post-menopausal bleeding, endometrial thickening > 4 mm
Contraindications for combined hormonal contraceptives
Smoking > 35yo (15 cig/day), multiple risk factors for arterial cardiovascular disease (^age, smoking, DM, HTN), HTN (sBP>160 or dBP>100), venous thromboembolism, known thrombogenic mutations, known ischemic heart disease, Hx of stroke, complicated valvular heart disease, systemic lupus erythematosus, migraine with aura at any age, breast cancer, cirrhosis, hepatocellular adenoma or hepatoma
Medical management of excessive/irregular/abnormal vaginal bleeding?
- NSAIDS: reduce PGs, promoting uterine vasoconstriction
- Tranexamic Acid: anti-fibrinolytic; caution w/ risk for venous thromboemboli
- Combined Hormonal Contraceptives: ESTROGEN/progesterone (pill, patch, ring), continuous, etc
- IUD
- Gonadotropin release hormone agonists
Side effects of combined hormonal contraceptives?
Side effects: nausea, breast tenderness, bloating, spotting (break-through-bleeding)
Side effects of progesterone only contraceptive?
Spotting, breast tenderness, bloating, weight gain, nausea.
Surgical management of excessive/irregular/abnormal vaginal bleeding?
- Endometrial Ablation
- Hysterectomy
Symptoms of uterine leiomyomas?
Majority asymptomatic. Heavy or prolonged menstrual bleeding (AUB), bulk-related symptoms (pelvic pressure, pain), and/or reproductive dysfunction (i.e. infertility or obstetric complications)
Where do uterine leiomyomas typically arise from and how are they described?
Benign monoclonal tumors arising from the smooth muscle cells of the myometrium. Fibroids are typically described according to their location in the uterus (submucosal, intramural, subserosal, cervical).
Diagnosis of uterine leiomyomas?
Clinical, based on pelvic imaging – likely a pelvic or trans-vaginal U/S (indications include pelvic pain/pressure/infertility or enlarged uterus on pelvic examination). Pathology confirmation not required to proceed with management, except in cases if another lesion suspected (i.e. uterine sarcoma). Saline Infusion Sonography (sonohysterography) improves characterization of protrusion extent/intracavitary lesions not seen on U/S.
Medical management of uterine leiomyomas?
- NSAIDs + OCP/depo-provera
- Selective Progesterone Receptor Modulators: ulipristal (Ella), will shrink fibroids (~20% smaller volume at 3 months) and decrease menstrual blood loss (90% reduction). Only approved for short duration (3-6 months). Can be useful pre-operatively. Smaller fibroids = easier surgery. Increased iron stores, hemoglobin.
Surgical management of uterine leiomyomas?
Myomectomy: hysteroscopic, laparoscopic, abdominal or Uterine Artery Embolization
What is adenomyosis?
Ectopic endometrial glands and stroma are found within the myometrium, resulting in a symmetrically enlarged and globular uterus.
Presentation of adenomyosis?
Parous women in their 40’s to 50’s, uterus enlarged and boggy, pelvic pain (usually noncyclical), dysmenorrhea, and menorrhagia.
Investigations for adenomyosis?
Transvaginal U/S or MRI to differentiate between adenomyosis and uterine fibroids
Management of adenomyosis?
- No proven medical therapy for treatment.
- GnRH agonist, NSAIDs, and OCPs may be used for pain and bleeding.
- Hysterectomy: Definitive therapy if childbearing is complete. The diagnosis is usually confirmed after histologic examination of the hysterectomy specimen.
Most common gyne malignancy?
Endometrial cancer
Types of endometrial cancer?
- Type I (endometroid adenocarcinoma): MOST COMMON (75%). Estrogen-related. Slower growing, related to obesity. Comes from thinning of the uterus
- Type II (nonendometroid carcinoma): non-estrogen related. MORE AGGRESSIVE. Thin patient
- can have hyperplasia with atypia (precursor for endometrial cancer, 40% have concurrent cancer).
Risk factors for endometrial cancer?
- Metabolic syndrome (obesity, type II DM) - adipose tissue makes more estrogen than normal
- Early menarche, Late menopause
- PCOS
- Nulliparity
- Estrogen-only HRT
- Lynch syndrome – FHx history of colon cancer
- Personal history with breast cancer - Tamoxifen – estrogen-like effects on uterine tissue.
Presentation/symptoms of endometrial cancer?
Abnormal vaginal bleeding either postmenopausally, abnormally heavy irregular bleeding in reproductive years. Later stages pelvic pain and palpable mass.
Diagnosis of endometrial cancer?
- NEED TO SAMPLE/BIOPSY ENDOMETRIAL TISSUE. How? No anesthetic, go through cervix and get a quick biopsy through a pipelle (aspiration curettage). If negative biopsy and AUB persists, need D&C or hysteroscopy! Hysteroscopic view – look at lining of uterus, if its fluffy and thick – not normal. DON”T DO BIOPSY IN PREGNANT WOMEN
- Can do a transvag U/S – but this is not diagnostic, just suggestive! Wall thickness in postmenopausal women <5mm = low risk, >10mm = high risk.
- CXR/CT scan to rule out mets
Surgical treatment for endometrial cancer?
Standard of care, early stage is hysterectomy, BSO (bilateral salpingo-oophorectomy) and staging
- Traditional open laparotomy – longer recovery, more pain, risk of infection
- MIS (lap) - shorter recovery, less bleeding, infection and post op pain
- Lymph Nodes – helps determine spread of disease, upstages patients
- ICG Infared Technology - Inject the tumour with ICG and it follows the lymphatics to the first/sentinel lymph node. Taking out sentinel nodes and not all their pelvic nodes decreases lymphedema
Medical treatment for endometrial cancer?
Unfit for surgery – mirena IUD, oral high dose progesterone, letrozole (aromatase inhibitor)
Radiation treatment for endometrial cancer?
Two types – vaginal vault or full pelvic RT. Decreases risk of recurrence in pelvis or vaginal vault. DOES NOT REDUCE RISK OF DISTANT RECURRENCE.
Which syndrome is associated with endometrial cancer?
Lynch syndrome – includes higher incidence of colon cancer and some ovarian cancer
Acute and chronic S/E of pelvic RT?
- Acute – fatigue, rashes, nausea
- Chronic – looser stools, radiation cystitis/hematuria, altered sexuality
Indications for offering hormonal therapy for endometrial cancer?
- Medically and surgically unfit for OR. Frail elderly, too many surgical risks
- Grade 1 – wanting to preserve fertility. Standard of care still TAH BSO. Do TAH BSO after childbearing finished
- If counseled, compliant in follow up, understand risks, 6-12 month trial high dose progesterone
- Need to follow, re sample endometrial biopsy
Symptoms of ovarian cancer?
Symptoms: nonspecific symptoms – bloating, pain, bowel changes
- U/S – ascites, large mass
Treatment of ovarian cancer?
- If we can’t debulk, start chemo – one of the best solid tumors to see a response to.
- Bevacizumab is ab against VEGF and is used commonly for bowel cancer.
- Surgery might be an option after several rounds.
- We offer all women with high grade serous cancer a BRCA1/2 test.
- Olaparib may actually improve overall survival - biggest thing to happen in the last 30 years for women with these mutations
Definition of preterm labour?
Regular painful contractions accompanied by cervical dilatation/effacement between 20-37wks.
Etiology of preterm labour?
- Idiopathic (most common)
- Maternal: infection (recurrent pyelonephritis, untreated bacteriuria, chorioamnionitis), HTN, DM, chronic illness, mechanical factors (previous obstetric, gynecological, and abdominal surgeries); socio-environmental (poor nutrition, smoking, drugs, alcohol, stress), pre-eclampsia
- Maternal-fetal: PPROM (common), polyhydramnios, placenta previa, abruptio placentae, or placental insufficiency
- Fetal: multiple gestation, congenital abnormalities, fetal hydrops
- Uterine: excessive enlargement (hydramnios, multiple gestation), malformations (intracavitary leiomyomas, septate uterus, and Müllerian duct abnormalities
Risk factors of preterm labour?
- Prior history of spontaneous PTL is the most important risk factor
- Prior history of large or multiple cervical excisions (cone biopsy) or mechanical dilatation (D&C)
- Cervical length: measured by transvaginal U/S (cervical length >30 mm has high negative predictive value for PTL before 34 wk)
- Infection (uterine, placental, maternal) + bacteriuria
- Shorter inter-pregnancy interval
- Family history of preterm birth
- Smoking
- Late maternal age
- Multiple gestation
- Polyhydramnios – increased pressure
- History of bleeding in 2nd or 3rd TM
Signs and symptoms of preterm labour?
- Early Sx: menstrual-like cramps or mild/irregular contractions, lower back ache, vaginal pressure, bloody show
- True Sx: regular uterine contractions (2 in 10 min, >6/h) accompanied by change in cervical dilatations and/or effacement (>1 cm dilated, >80% effaced, or length <2.5 cm)
