PACEs gynae Flashcards
RFs for miscarriage
- advances maternal age
- previous miscarriages
- chronic conditions (e.g. uncontrolled diabetes)
- cervical or uterine abnormalities
- smoking
- alcohol
- illicit drug use
- underweight or overweight
counselling in miscarriage
breaking bad news
- explain diagnosis: reassure this is common and under reported (1/5 pregnancies), risk increases with age, explain most of the time there is no cause
- explain management options (expectant, medical, surgical)
- if medical: explain what to expect (pain, bleeding, nausea),
- antiemetics and pain relief given
- advise to do pregnancy test after 3 weeks
- safety net: return if symptoms get worse, bleeding persists after 7-14 days
RFs in ectopic pregnancy
PID
smoking
IUD/IUS
tubal surgery
counselling in ectopic
- implantation of pregnancy outside the womb, means it is not viable
- risks: damage to surrounding structures, bleeding and rupture
- treatment options are based on US findings and level of pregnancy hormone in blood
explain ectopic medical management
- 1 x IM injection
- expect: tummy pain, nausea, diarrhoea - should pass within few days
- can go home after injection but need to come back a couple of times over next week for a blood test
- avoid sex during treatment, don’t concieve for 6 months, avoid drinking alcohol/ excess sunlight
- risk of treatment failure requiring further intervention
- discuss ongoing contraception
explain surgical management
- salpingectomy is best procedure
- salpingotomy is considered if fertility issues/problems with other tube
- salpingotomy 1/5 chance of needing more
- fertility isn’t drastically reduced
- follow up
- discuss ongoing contraception
GTD RFs
- advances maternal age
- prior molar pregnancy
- prior miscarriages
- Asian heritage
counselling in GTD
- foetus doesn’t form properly and baby doesn’t develop, instead there is an irregular mass of pregnancy tissue
- risks: treat because can invade and damage other tissues
- immediate management: suction curettage
- F/U: referral to trophoblastic screening centre to monitor pregnancy hormone levels
- molar pregnancy does not affect fertility (1/80 chance of recurrence)
- do not get pregnant until F/U is complete
key aspects of history in contraception
RFs: smoking, VTE Hx, migraine, breast cancer, stroke, HTN, liver disease
menstrual problems
explain about contraception
split in to long acting and short acting
PCOS counselling
- disease with no clear cause
- leads to abnormalities in hormone levels (leads to symptoms experienced)
- very common (1/10 women)
- main consequences: irregular periods, subfertility, metabolic syndrome, CVD, acne
- Mx based on pt concerns
- fertility = weight loss, clomiphene, LOD
- periods = COCP, progestogens (3-4 bleeds per year)
- metabolic syndrome = check for DM, high cholesterol, heart disease
termination of pregnancy counselling
- best option dependent on how many weeks pregnant as more weeks = more pregnancy tissue
- medical: 1 pill by mouth, another in 24-48 hours (bleeding can last about 2 weeks, pregnancy test after 3 weeks, occasionally needs further surgey)
- surgical: gently dilate cervix, remove pregnancy using suction tube. Takes 10 mins, need to ripen cervix first, LA or GA
subfertility RFs
- advances maternal age
- smoking
- alcohol use
- obesity
- irregular periods
subfertility counselling
- still a chance of getting pregnant naturally
- 15% of couples fail to conceive after 1 year
- like to start investigations (blood tests looking at hormone levels, USS looking at uterus/ follicle count)
- continue having unprotected sex at least every other day
- Management options depending on likely cause
menopause counselling
- usual changes that occur at menopause (hot flushes, sexual dysfunction, mood changes)
- lifestyle factors: healthy diet, weight loss, smoking cessation
- explain medical options (HRT, SSRIs, topical oestrogen/lubricants)
- explain risks and Ses
- explain need for contraception (>1 year no period if >50, >2 years of <50)
- advice on bone health, keep up to date with breast and cervical screening, contraception, support groups
thrush counselling
- explain diagnosis
- tx: intravgainal clotrimaxole or oral flucanzole
- hygiene measures: not cleaning too often, avoid fabric conditions/ soap substitues
PID counselling
- infection that has spread up to the womb
- explain risks of PID: infertility, ectopic pregnancy, chronic pelvic pain
- treated with antibiotics (1 injection and 2 tablets taken for 14 days)
- do not have sec until course is complete
- full STI screen and contact tracing
- discuss contraception
- F/U: 3 days time and in 2-4 weeks
RFs for stress incontinence
age
traumatic delivery
obesity
previous pelvic surgery
RFs for urge incontinence
age obesity smoking FH DM
couselling for incontience
- stress incontinence is due to weak pevlic floor
- urge due to bladder muscle overactivity
- lifestyle measures: control fluid intake, avoid caffeine, lose weight
- treatment: urge (bladder retrain for 6 weeks, inc time between going to toilet), stress (pelvic floor training for 3 months)
- medical and surgical
prolapse counselling
- explain diagnosis
- lifestyle modifications (lose weight, healthy diet, stop smoking)
- conservative (pelvic floor exercises, oestrogens)
- explain ring pessary or surgery
Bartholin’s cyst RFs
nulliparoud
child bearing age
previous one
Bartholin’s cyst counselling
- blockage of a duct in your vagina that has become infected
- Mx:
conservative = observation and Abx
word catheter insertion
marsupilisation - recommend STI screen
endometriosis RFs
early menarche FH nulliparity prolonged menstruation short menstrual cycles
Endometriosis counselling
- condition where tissue that lines the womb starts appearing outside womb
- very common: 10%
- Mx:
conservative = NSAIDs
medical = COCP, LNG-IUS, POP
surgical = diagnostic laparoscopy, excision/ablation - explain potential impact on ferility
fibroids counselling
- common smooth muscle masses
- can cause heavy menstrual bleeding and fertility issues
- very common, increases with prevalence until menopause
- management:
HMB = LNG-IUS, COCP
Fertility = surgery, tranexamic acid
Sx = tranexamic acid
CIN counselling
- explain purpose of screening and results
- management:
CIN 1 = repeat smear in 1 year
CIN 2, 3 and CGIN = LLETZ or cone biopsy
LLETZ = otpt procedure with LA
Cone biopsy = larger lesions, GA
risk: mid trimester loss, preterm birth - F/U: repeat smear in 6 months and test for cure
endometrial hyperplasia counselling
- abnormal thickening of endothelium
- can be caused by benign things
- taken seriously because of risk to progression to cancer (further investigations)
- Mx:
no atypia = LNG-IUS, review in 3-6 months (with biopsy)
Atypia = total hysterectomy + BSO
RFs for ovarian cancer
age FH obesity HRT endometriosis smoking diabetes
protective factors for Ovarian Ca
COCP
breastfeeding
hysterectomy
ovarian Ca counselling
- explain diagnosis
- further investigations may be necessary
- definitive Mx = surgery +/- chemo
Thrush counselling
- return if symptoms not improved in 7-14 days
- avoid predisposing factors
- ask if partner has any Sx
- not STI but can be spread by sexual contact
menstrual bleeding important points
any blood/coagulation problems in family
iron supplements?
important sx with endometriosis
pain with bowel movements and urination
PCB
causes of dysmennorhoea
endometriosis
adenomyosis
PID
fibroids
PMB counselling
- PMB can be caused by many things, lots of which are quite harmless e.g. trauma/infection
- priority is to rule out things that could be harmful e.g. cancer
- refer for scan (TVUSS) to visualise reproductive organs
- from here we can start a plan
- further testing may be needed based on scan result
what to do if emergency/bleeding?
ABCDE approach
senior help
send G+S
medical management and follow up in ectopic emergency
IM Methotrexate
bHCG: 4, 7, 11 day then weekly until undetectable
HRT risks
VTE, stroke, CHD, breast/ovarian cancer
Breast risk = 5 more per 1000
Ovarian risk = 1 more per 1000
menopause advice
all features of menopause
experienced by most women
they can be really debilitating
3 avenues of treatment: lifestyle modifications, HRT, non-HRT
fertility support
fertility friends
adoption UK, surrogacy UK
human fertilisation and embryology authority = provides informaiton on all types of fertility treatment
PCOS counselling
- multiple fluid filled sacs in ovaries
- these can derange levels of hormones and prevent ovulation
- also leads to increased production of testosterone ( = weight gain + acne)
what is first line treatment for confirmed miscarriage?
expectant management for 7-14 days
emergency contraception counselling
- offer STI screen
- recommend taking pregnancy test if next period is late
- ongoing contraception
prolapse questions
bladder, bowel, intercourse
obstetric complications
constipation
ddx of prolpase
sebacous cyst
Bartholin’s cyst
vulval/vaginal Ca
prolapse surgery
pelvic repair surgery (with mesh)
hysterectomy
what makes up bulk of perineum?
levator ani
- puborectalis
- pubococcygeus
- illiococcygeus
what if TVUSS shows empty uterus?
miscarriage completed
no intervention needed
investigations in recurrent miscarriages
APL abs
cytogenic analysis
TVUSS for uterine malformations
screen for inherited thrombophillia
what if it is early pregnancy?
booking visit
first scan
Rhesus?
