Random gynae Flashcards
Risk factors for Lichen Sclerosis
Autoimmune: T1DM, HypOthyroidism, alopecia, vitiligo
Preceding infections may play a part
Peaks of lichen sclerosis?
Pre-pubertal and post-menopausal
Tx of lichen sclerosis?
Topical steroids, e.g. Clobetasol propionate
Describe the histology of the cervix
Endocervix = columnar epithelium -produce mucus
Ectocervix = mature squamous epithelium
Where they meet = squamocolumnar junction
Inbetween = transformation zone (sub-columnar cells multiply and transform into immature squamous cells through metaplasia)
How often is cervical screening offered and for which age groups?
25-49 = every 3 years 50-65 = every 5 years
Factors that protect against T1 endometrial cancer?
- Breastfeeding
- Pregnancy at a later age
- Hormonal contraceptives
RFs for endometrial cancer?
- Tamoxifen
- Oestrogen therapy (w/o progesterone)
- Obesity
- HNPCC
- Chronic anovulation (e.g. PCOS)
- Nulliparous
- Late menopause
- Diabetes
What might you see on a TVUS for endometrial cancer?
Endometrial thickness > 4cm
What are the symptoms of ovary hyperstimulation?
- Abdo pain
- N+V
- Shifting dullness
What is a Bartholin abscess? Management?
Bartholin’s glands are a pair of glands located next to the entrance to the vagina. These are normally about the size of a pea, but can become infected and enlarge - forming a Bartholin’s abscess.
This can be treated by antibiotics, by the insertion of a word catheter or by a surgical procedure known as marsupialization.
Complication of fibroids in pregnancy? Presentation? Management?
Red degeneration - haemorrhage into tumour - commonly occurs during pregnancy.
This usually presents with low-grade fever, pain and vomiting.
The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.
Threatened miscarriage
- Cervical os is closed
- Mild bleeding w/ mild/no pain
- < 6 weeks - watchful waiting
Inevitable miscarriage
- Cervical os is open
- Bleeding + clots
- Pain
Incomplete miscarriage
- Cervical os is open
- Partially expelled products of contraception
Complete miscarriage
- Cervical os is closed
- Hx of pregnancy, US now shows no fetal tissue
Missed miscarriage
- Cervical os is
- Fetus dead but retained
- Uterus = small for dates
- May have a history of threatened miscarriage
- Persistent dark brown discharge
RFs for ectopic
- PID
- Tubal surgery
- Prev ectopic
- Smoking
- Gynae surgery
- > Age
- IVF
- IUCD use
- Adhesions from infection/inflammation
Mx of ectopic
Check if haemodynamically stable, ABCDE, crossmatch, fluids, FBC
- Early, haem stable + hCG declining –> watchful waiting
- If found later –> methotrexate w/contraception
- Haem unstable –> surgery (salpingectomy/salpingotomy)
SEs of methotrexate
- Conjunctivitis
- Stomatitis
- Diarrhoea
- Abdo pain
How would a ruptured ectopic present?
Referred shoulder pain (blood in peritoneum)
- particularly on urination/defecation
Most common location for ectopic?
Ampulla of fallopian tubes
Risks to mother in multiple preg
- Anaemia
- Pre-term
- Polyhydramnios
- HTN
- Malpresentation
- Instrumental delivery
- PPH
Risks to babies in multiple preg
- TTT syndrome
- Miscarriage/stillbirth
- Fetal growth restriction
- Prematurity
- Locked twins (heads intertwined - monoamniotic)
- Twin anaemia-polycythaemia syndrome
- Congenital abnormalities
Antenatal care in multiple preg
FBC @ booking, 20wks, 28wks
USS 2-weekly from 16wks for monochorionic; 4-weekly from 20wks for dichorionic
Planned birth (32 –> 37+6wks), triplets before 35+6wks
CORTICOSTEROIDS
3 puerperium infections - organisms + presentation + management
Endometritis:
- Group A beta-haem strep
- Fever/low abdo pain
- IV Clindamycin and Gentamicin (Refer to the hospital)
UTI:
- E.coli, klebsiella, proteus
- Fever/low abdo pain/dysuria/freq/urgent
- Trimethoprim
Lactation mastitis:
- S. Aureus
- Breast pain/erythema, fever
- Oral flucloxacillin if bacterial culture/infected nipple fissure
Chorioamnionitis:
- Tx with erythromycin (Post-labour)
Drugs that can NOT be used in breastfeeding
- Abx: Ciprofloxacin, Tetracycline, Chloramphenicol, Sulphonamide
- Psych: Lithium, Benzos, Fluoxetine
- Aspirin
- Carbimazole
- Methotrexate
- Sulphonylureas
- Cytotoxic drugs
- Amiodarone`
Tx of UTI in pregnancy
- Nitrofurantoin (NOT 3rd tri due to haem disease of newborn)
- Amoxicillin (NOT if allergic)
- Cefalexin
7 days of treatment
NOT trimethoprim in 1st tri due to neural tube defects, ideally never in pregnancy
RFs associated with UTIs in pregnancy
- Preterm delivery and preterm PROM
- Placental abruption
- Pre-eclampsia
- Low birth weight
Anaemia in pregnancy
Defining Hb level?
< 105 g/L
antenatal Hb screening when?
Booking
28 weeks
Anaemia in pregnancy
RFs
- Multiple preg
- Frequent preg
- Prev anaemia (hookworm/malaria/mennorrhagia)
- Poor diet
Discuss rhesus incompatibility
- Baby = anti-D +ve
- Mum = anti-D -ve
Baby’s blood gets into mum at birth or sensitisation events (e.g. APH/amniocentesis procedure/abdo trauma) –> mum creates anti-D antibodies –> destroys baby’s blood cells —> fine in this pregnancy BUT in future pregs —> antibodies can cross the placental membrane and destroy babies blood cells
When should you give anti-D
- Routinely at 28 weeks gestation and birth
- Within 72hrs of any sensitisation event
What is Kleihauer test?
After 20 weeks gestation - assesses how much of foetal blood is in mother
WHich SSRIs are safe in breastfeeding
Sertraline or Paroxetine
RFs of VTE in preg
- Fx of unprovoked VTE
- > 35yrs
- > 30 BMI
- Smoker
- Immobility
- Varicose veins
- Pre-eclampsia
- Low risk thrombophilia
- Multiple pregnancy
What should you always think of in collapsed pregnant/post partum woman?
VTE! PE!!!
Tx of VTE in preg
ANY risk factor –> LMWH and for 6weeks post-partum
Start if suspecting VTE and continue until ruled out
Might adjust the dose according to Anti-factor Xa levels
Warfarin is CI in preg
Definition of hyperemesis
- Preg vomiting that continues beyond normal 4-10wks
- Weight loss >5% body mass
- Ketosis
- Electrolyte imbalance and dehydration
Pathophysiology of hyperemesis
- hCG from trophoblastic cells peaks at 10/11 weeks and can cause vomiting
- Therefore, conditions associated with higher hCG levels are more likely to cause vom (MOLAR pregs or multiple pregs)
When does pre-eclampsia occur?
- 20 weeks into gestation and up to 6 weeks postpartum
What is pre-eclampsia
- Hypertension (> 140syt or >90 dyst)
- Proteinuria (>0.3g/24hrs)
(If no proteinuria –> gestational HTN)
Pathophys of pre-eclampsia
- Spinal artery fails to dilate completely due to incomplete trophoblastic invasion of spinal artery –> decreased placental blood flow
- Fibrosis and ischaemia of placenta –> release inflammatory proteins –> travel into mums arteries and cause damage:
o Vasoconstriction (HTN)
o Increase vascular permeability (proteinuria)
o Clotting dysfunction
High risk for pre-eclampsia and Tx?
- Pre-eclampsia/HTN in prev preg
- CKD
- Autoimmune disease, e.g. SLE, antiphospholipid
- DM1/2
–> Give aspirin at 12 weeks if one of these
Moderate risk for pre-eclampsia and Tx?
- Age > 35/40
- BMI > 25
- First pregnancy
- > 10 yrs since the last preg
- Multiple pregnancy
- Fx of preeclampsia
–> Give aspirin at 12 weeks if >1 of these
HELLP
Haemolysis Elevated Liver enzymes Low Platelets
GBS in pregnancy
- 30% = colonised with GBS normally
- In pregnancy - can cause problems
Mother: endometritis, cystitis, chorioamnionitis (may cause miscarriage/premature labour/intrauterine fetal death)
Baby: pneumonia, sepsis, meningitis, septic arthritis
Treat with Ben Pen/Clindamycin
If isolated during labour - give prophylactic few hours b4 birth
Measles in pregnancy
- Measles = Paramyxovirus
- Symptoms: CCCK, rash - maculopapular
- If a maternal rash appears 6 DAYS before delivery or after delivery - give human normal immunoglobulin to baby immediately after birth/exposure
- Prevents neonatal subacute sclerosing parencephalitis
Rubella in pregnancy
- Foetus most at risk in 1st 16 WEEKS
- If IgM found in first 16wks a TOP is offered
- Woman should have MMR pre-pregnancy (can’t have in pregnancy as live vaccine)
- Can be tested for immunity and if not, can have two doses of vaccine 3 months apart pre-pregnancy
- Can also have the vaccine post-birth
- BABY: congenital deafness (5-7 wks), congenital cataracts (8-9wks), congenital heart disease (PDA/pulmonary stenosis) (5-10 wks), learning difficulties
Cytomegalovirus in pregnancy
- Maternal infection - mild
- If mum infected –> 40% of foetuses are infected
Out of these: 90% = normal at birth, 10% = symptomatic - Congenital problem: IUGR, MICROCEPHALY, hearing/vision loss, jaundice, learning difficulties, hepatosplenomegaly, thrombocytopenia
- Ganciclovir for babies born with CMV
- Can be detected at birth (Guthries) - PCR of DNA
Toxoplasmosis
- RISK if higher LATER in preg but SEVERITY is higher EARLIER in preg
- Symps: fever, rash, eosinophilia
- BABY: Triad = intracranial calcification, hydrocephalus, chorioretinitis (inflamm of choroid + retina)
- Treat mother with SPIROMYCIN
Parvovirus B19
(slapped cheek syndrome)
- In pregnancy - often asymp or slapped cheek
- BABY: foetal suppression of erythropoiesis, cardiac toxicity, fetal hydrops fetalis, severe foetal anaemia
- Mum: pre-eclampsia looking syndrome, miscarriage
- Serial US looking for anaemia
Hep B
- ALL MOTHERS SHOULD BE SCREENED
- Give IMMUNIGLOBULINS and VACCINATE BABIES of carriers/infected mothers
Varicella Zoster in preg
- Mum: varicella pneumonitis, hepatitis, encephalitis
- Baby: Severe neonatal varicella syndrome
Exposure in preg:
- If had chickenpox = safe
- If not sure about immunity –> check VZV IgG
- If not immune –> Give IV VZV immunoglobulins within 10 days of exposure
Developing VZV in preg
- ORAL ACICLOVIR if within 24hrs and >20wks - 7-day course
- Admission if chest/CNS symptoms
Congenital VZV:
- IUGR
- Microcephaly, hydrocephalus, learning disability
- Scars and skin changes
- Limb hypoplasia
- Cataracts/inflamm of eyes
Gonococcal conjunctivitis
- 4 days post-birth –> PURULENT DISCHARGE and LID SWELLING
- BABY: Cefotaxime and Chloramphenicol
- MOTHER: Active gonorrhoea infection –> Ben Pen
Placental abruption RFs
- Maternal HTN
- Previous abruption
- Maternal trauma
- Smoking/alcohol/drugs - COCAINE
- Short umbilical cord
- Sudden decompression of uterus
- Thrombophilia
- Multiparity
- Maternal age >35yrs
- Multiple pregnancies
Placenta praevia RFs
- Insufficient uterine wall (prev. C/S, abortion, uterine surgery, multiparity)
- Multiple pregnancies
- Maternal age >35yrs
- Fibroids
- Maternal smoking
- Assisted conception
- Prev placenta praevia
What is placenta accreta
- Placenta invade the uterine wall
o Usually myometrium = increta
o Can be serosa too, and even reach other organs = percreta - Colour doppler USS
- C-section + Steroids
- Complex uterine surgery but hysterectomy is recommended
What is vasa praevia
- fetal vessels run across os
- Unprotected by the umbilical cord
- Membrane ruptures –> risk of fetal haemorrhage
- Need C/S
4T’s of PPH
T- Tone (uterine atony - doesn’t contract back down) = most common
T - Trauma (tears/repairs)
T - Tissue (retained placenta)
T- Thrombin (bleeding disorder/DIC/pre-eclampsia)
PPH blood loss definition
Loss of:
- 500 ml after vaginal birth
- 1000 ml after C/S
Minor: 500-1000
Mod: 1000-1500
Sev: 1500-2000
BAD: >2000
PPH other criteria
- 10% decrease in haematocrit
- Change in HR, BP, O2 sats
PPH Tx
If emergency:
- ABCDE
- 15L/min O2
- TWO large bore cannulas!
- Crossmatch 4-6L of blood
Mechanical:
- Fundal massage
- Empty bladder
Medical:
- Oxytocin/Syntoncinon
- Ergometrine (NOT if HTN)
Surgical:
- Balloon tamponade
- B-lynch suture
- Evacuation of retained products
- Uterine artery ligation
- LAST RESORT = hysterectomy
Define prem labour
Contractions of sufficient strength + frequency to effect progressive effacement of the dilation of cervix BEFORE 37 WEEKS
How to investigate preterm labour risks
- TVUS - measure cervical length
- Vaginal swab - Fetal fibronectin!
Tx of preterm labour
- Mother: tocolytics
- Baby: steroids (lungs) + Magnesium sulphate (neuroprotectin - cerebral palsy)
define PROM
< 37 weeks
RFs of PROM
- infection
- multiple preg
- polyhydramnios
- malpresentation
Tx of PROM
- < 24 weeks = poor prognosis (pulmonary hypoplasia even w/steroids)
- 24-34 weeks = steroids + erythromycin, daily review
- 34+ weeks = induce labour!
DO NOT PUT FINGERS IN, SPECULUM EXAM ONLY
Shoulder dystocia manoeuvres
- McRoberts’ manoeuvre - flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen –> increases the relative anterior-posterior angle of the pelvis
- Episiotomy (may make delivery easier)
- Internal rotation manoeuvres
- Last line = Symphysiotomy and the Zavanelli (but cause sig. maternal mortality so last resort)
Amniotic fluid embolism
- LIQUOR enters the maternal circulation
- ANAPHYLAXIS, DYSPNOEA, HYPOXIA, HTN
- May be accompanied by seizures +/- DEATH
- Can happen w/membrane rupture, labour, C/S, TOP
- RF = eclampsia
- Tx = resus, supportive
