PBGYN Flashcards
Pregnancy: DVT/PE path
- ↑ in factors VII, VIII, X and fibrinogen
- ↓ in protein S
- Uterus presses on IVC causing venous stasis in legs
Pregnancy: DVT/PE management
Management
* Warfarin is contraindicated
* S/C low-molecular weight heparin preferred to IV heparin (less bleeding and
thrombocytopenia)
Pregnancy: DVT/PE invest
CXR ALL
The decision to perform a V/Q or CTPA should be taken at a local level after discussion with the patient and radiologist
* CTPA exposes the fetus to about 10-30% of the radiation dose of a V/Q scan
* V/Q scanning exposes the maternal breast tissue to less radiation than a CTPA
Cholestasis in Pregnancy: features
Features:
* Seen across maternal ages and in both nulliparous and primiparous women
* More common in women with a history of cholestasis associated with OCP use and those who
have a family history of cholestasis in pregnancy.
* Itching is the commonest symptom of cholestasis of pregnancy
* Severe jaundice is uncommon.
* Both ALT and Alk P are ↑.
Cholestasis in Pregnancy: Prognosis & Mangement:
Prognosis & Mangement:
* Long-term maternal outcome is good, although the risk of gallstones is ↑.
* The condition rapidly resolves after delivery of the child.
* Prior to delivery, antihistamines, benzodiazepines and ursodeoxycholic acid may all have a role
to play in symptom relief
Peripartum Cardiomyopathy:
Peripartum Cardiomyopathy: is a dilated cardiomyopathy of uncertain aetiology occurring in the last month of pregnancy or within 6 months after delivery. Symptoms are the same as those of cardiac failure in non-pregnant patients.
Peripartum Cardiomyopathy: Management:
- Same as for cardiac failure, although ACE inhibitors should be avoide
- Mainstay of medical treatment is digoxin and loop diuretics. If indicated nitrates and inotropic
support with dobutamine should be used. - Heparin (during pregnancy) or Warfarin (postpartum) for the hypercoagulopathy (caused by
cardiomyopathy + peripartum) - Salt or Na+ restriction
Prognosis: - 50% recover to normal
- Recurrence is high in further pregnancies
- If no recovery, heart transplantation is needed
Polycystic ovarian syndrome (PCOS) features
Features
* Subfertility and infertility
* Menstrual disturbances: oligomenorrhea and amenorrhoea
* Hirsuitism, acne (due to hyperandrogenism)
* Obesity
* Acanthosis nigricans (due to insulin resistance)
PCOS INVEST
Investigations
* Pelvic ultrasound
* FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a
‘classical’ feature but is no longer thought to be useful is diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
* Check for impaired glucose tolerance
Management:
PCOS weight
Management:
General
* Weight reduction if appropriate
* If a women requires contraception then a combined oral contraceptive (COC) pill may help
regulate her cycle and induce a monthly bleed (see below)
Hirsuitism
PCOS hirtuismm
- A COC pill may be used help manage hirsuitism. Possible options include a third generation
COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action.
Both of these types of COC may carry an ↑ risk of venous thromboembolism - If doesn’t respond to COC then topical eflornithine may be tried
- Spironolactone, flutamide and finasteride may be used under specialist supervision
PCOS infertility
nfertility
* Weight reduction if appropriate
* The management of infertility in patients with PCOS should be supervised by a specialist.
There is an ongoing debate as to whether metformin, clomifene or a combination should be
used to stimulate ovulation
* A 2007 trial published in the New England Journal of Medicine suggested clomifene was the
most effective treatment. There is a potential risk of multiple pregnancies with anti-estrogen*
therapies such as clomifene
* Metformin is also used, either combined with clomifene or alone, particularly in patients who
are obese
* Gonadotrophins
Pelvic inflammatory disease (PID) cause
Causative organisms
* Chlamydia trachomatis - the most common cause
* Neisseria gonorrhoeae
* Mycoplasma genitalium
* Mycoplasma hominis
Pelvic inflammatory disease (PID) fears
Features
* Lower abdominal pain
* Fever
* Deep dyspareunia
* Dysuria and menstrual irregularities may occur
* Vaginal or cervical discharge
* Cervical excitation Investigation
* Screen for Chlamydia and Gonorrhoea
PID
Management
* Due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment
* Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
* RCOG guidelines suggest intrauterine contraceptive devices may be kept in in mild cases
Complications
* Infertility - the risk may be as high as 10-20% after a single episode
* Chronic pelvic pain
* Ectopic pregnancy
family history that suggests increased risk of breast cancer and indicates referral to a specialist breast clinic.
Mother or sister diagnosed with breast cancer before the age of 40 years
* Close relatives from the same side of the family diagnosed with breast cancer at least one must
be a mother, sister or daughter
* 3 close relatives diagnosed with breast cancer at any age
NICE issued guidelines in 2004 that set out the criteria for a family history that suggests increased risk of breast cancer
- Mother or sister diagnosed with breast cancer before the age of 40 years
- Close relatives from the same side of the family diagnosed with breast cancer at least one must
be a mother, sister or daughter - 3 close relatives diagnosed with breast cancer at any age
The Only MRCP Notes You’ll Ever Need
433 / 546 www.sudamedica.com - Father or brother diagnosed with breast cancer at any age
- Mother or sister with breast cancer in both breasts (the first cancer diagnosed before the age of
50 years) - 1 close relative with ovarian cancer and one with breast cancer, diagnosed at any age at least
one must be a mother, sister or daughter.
Ovarian cancer RF
Risk factors
* Family history: mutations of the BRCA1 or the BRCA2 gene
* Many ovulations: early menarche, late menopause, nulliparity
It is traditionally taught that infertility treatment ↑ the risk of ovarian cancer, as it ↑ the number of ovulations. Recent evidence however suggests that there is not a significant link. The combined oral contraceptive pill ↓ the risk (fewer ovulations) as does having many pregnancies.
Clinical features are notoriously vague
* Abdominal bloating
* Pelvic pain
* Urinary symptoms e.g. Urgency
* early satiety, bloating
Cervical Cancer:
Risk Factors:
Cervical Cancer:
Risk Factors: (Christiana is a poor lady who smoked cigarettes and became prostitute at a young age)
* Christians (male non-circumcision)
* Low socioeconomic status
* Smoking
* Multiple partners
* Commencement of sexual intercourse and/or pregnancy at young age
* Human papillomavirus (HPV), of course the 1st risk factor
Cervial cancer - Screening:
- Women are sent their first invitation for routine screening at 25 years age.
- Then invited for screening every three years until the age of 49 years.
- From 50 to 64 years they are invited for screening every five years.
- Women who have had treatment for abnormal cells on the cervix may need to have a screening
test more often. - After 65 years no need to have cervical screening unless they have had recent cervical changes,
or for some reason they have not had a screening test since the age of 50 years.
If the result shows mild cell changes or CIN1
repeat smear in 6 months. Sometimes these slightly abnormal cells can go back to normal by themselves.
If the next smear is abnormal,
then referral is made for colposcopy.
