Repro Management Pathways (God help us all) Flashcards
Medical management of DUB
Progestrogen (synthetic progesterone) COPC NSAIDs Anti-fibrinolytics e.g. tranexamic acid Mirena coil
Surgical management of DUB
Endometrial resection/ablation
Hysterectomy
What HRT is required after an endometrial ablation and hysterectomy?
Endometrial ablation - combined HRT
Hysterectomy - oestrogen only HRT
Indications of intra-uterine insemination
Sexual problems
Same sex relationships
Discordant blood borne viruses
Abandoned IVF
Indications for IVF
Unexplained (>2 years duration) Pelvic disease (endometriosis, tubal disease, fibroids) Anovulatory infertility (after failed ovulation induction) Failed intra-uterine insemination (after 6 cycles)
What are the 5 steps in IVF?
- Down regulation (give GnRH agonist [buserelin] to suppress spontaneous ovulation)
- Ovarian stimulation (SC FSH with maybe LH)
- Oocyte collection
- Fertilisation
- Embryo transfer (usually 1)
Would also give progesterone suppositories for 2 weeks then do pregnancy test after 16 days
Management of male infertility
Lifestyle advice (common sense)
Treat any specific cause
Intracytoplasmic sperm injection (may require surgical sperm aspiration)
Donor insemination
Medical abortion procedure <10 weeks gestation
Mifepristone 200mg PO (progesterone antagonist)
Misoprostol 800mcg PV/SL (24-48 hours later)
Can self-administer misoprostol at home (not if under 16)
Medical abortion procedure >10 week gestation
Mifepristone 200mg PO (progesterone antagonist)
Repeated doses of misoprostol 800mcg PV/SL (24-48 hours later, up to 4 doses)
Inpatient procedure
When would MTOP have to be performed in England?
20 weeks and over.
Surgical abortion procedure <14 weeks gestation
Cervical priming via misoprostol or osmotic dilators
Electric vacuum aspiration (general anaesthetic)
Manual vacuum aspiration (up to 10 weeks, local anaesthetic)
Surgical abortion procedure >14 weeks gestation
Cervical priming via misoprostol or osmotic dilators
Dilatation and evacuation
Needs to be done in specialist centre in England
When is antibiotic prophylaxis required for abortion?
All surgical termination of pregnancy
Medical termination of pregnancy with increased risk of STI
What is the antibiotic prophylaxis for abortion?
7 days 100mg doxycycline BD
OR
1g oral azithromycin and 500mg for 2 days after
What three things do you need to consider prophylaxis for after abortion?
Antibiotics
Rhesus iso-immunisation (anti-D to at risk Rhesus negative women)
VTE (high risk get LMWH for 1 week post abortion)
What is the guidance of women receiving hormonal contraception after abortion?
Immediately effective if started within 5 days after abortion
If after 5 days:
POP effective after 2 days
CHC/DMPA/SDI/IUS effective after 7 days
What 3 drugs can you use to treat hypertension in pregnancy?
Labetalol
Methyldopa (alpha blocker)
(Nifedipine unlicenced but can still use)
Drug management of N&V in pregnancy.
Cyclizine
Drug management of UTI in pregnancy.
Nitrofurantoin, cefalexin
Trimethoprim in 3rd trimester
Drug management of pain in pregnancy.
Paracetamol
Drug management of heartburn in pregnancy.
Antacids
Management of pregnant women with significant VTE risk/VTE.
LMWH at delivery and up to 7 days post-partum
Definition of highly active anti-retroviral therapy
A combination of 3 drugs from at least 2 drug classes to which the virus is susceptible
How long to give PEP to a neonate who’s mother has HIV?
4 weeks
Drugs included in PrEP
Tenofovir
Disoproxil/emtricitabine
PrEP eligibility criteria
MSM condomless anal sex with 2+ partners in last year and likely in next 3 months
Rectal bacterial STI in last year
Partner of someone with HIV VL >50
What prophylactic treatment is given for women at high risk of pre-eclampsia, and what are the risk factors?
Apirin 75mg daily from 12 weeks until birth
Risk factors:
Hypertensive disease during previous pregnancy
CKD
Autoimmune disease
Diabetes
Chronic hypertension
Management of cervical shock.
Remove products from cervix
IV fluid resuscitation
Uterotonics may be required
Management of pregnancy in patient with anti-phospholipid syndrome or thrombophilia.
Low dose aspirin
Daily LMWH injections
Management of patient with ectopic pregnancy who is well and compliant with follow up visits
Watchful waiting
Management of ectopic pregnancy in woman who is stable, has low bhCG and the ectopic is small and unruptured
Medical management:
Methotrexate
Management of ectopic pregnancy in woman who is acutely unwell
Surgery (salpingotomy/salpingectomy)
Molar pregnancy management
Surgical and tissue for histology
Follow up with molar pregnancy services
Chlamydia management in pregnancy
Erythromycin
Amoxicillin
Test of cure at 3 weeks
When should you give anti-D to a rhesus negative pregnant lady?
Any surgery
First line medications for hyperemesis gravidarum
Cyclizine
Prochlorperazine
Both IV or IM
Second line medications for hyperemesis gravidarum
Ondansetron (serotonin inhibitor)
Metoclopramide
XONVEA UK
Supplementary medications for hyperemesis gravidarum
Thiamine/pabrinex
Ranitidine and PPI (omeprazole)
Oral prednisolone tapered
Management of large for dates delivery with no diabetes
Do not do induction of labour
Management of polyhydramnios
Counsel patient (increased risk in labour)
Serial USS
IOL by 40 weeks
Management of twin-to-twin transfusion syndrome (TTTS)
Before 26 weeks - fetoscopic laser ablation
After 26 weeks - amnioreduction/septostomy
Deliver between 34-36 weeks
When would you do a caesarian section in multiple pregnancy?
Triplets or more
Mono-chorionic mono-amniotic twins
What is the HbA1C target for type 1 and 2 diabetes pre-pregnancy?
48mmol/mol
At what HbA1c should pregnancy be avoided?
Above 86 mmol/mol
What drugs should you give if planning a pre-term pregnancy and why?
Steroids (foetal lung maturity) Magnesium sulphate (some protection against cerebral palsy)
Should you change asthma therapy in pregnancy?
No, the drugs are safe (can even take during labour)
Management of VTE risk in the perpuerium?
LMWH
Switch to warfarin on 5th post-natal day
6 weeks-3 months therapy
Management of anti-phospholipid syndrome that has previously caused pregnancy complications
Low dose aspirin and LMWH
After what gestation should you offer induction of labour?
42 weeks
Management of foetal distress
Change maternal position IV fluids Stop syntocinon Scalp stimulation Consider tocolysis (terbutaline s/c) Maternal assessment Foetal blood sampling Operative delivery
What are the conditions that must be met to do an operative vaginal delivery?
Cervix must be fully dilated
Head below ischial spine
Indications for instrumental delivery
Delay (failure to progress stage 2)
Foetal distress
These are main ones but there are a few others
Management of anti-phospholipid syndrome that has previously caused pregnancy complications
Low dose aspirin and LMWH
Management of pre-eclampsia
Antenatal screening
Treat hypertension
Maternal and foetal surveillance
Timing of delivery
Prophylactic management of women with risk factors for pre-eclampsia
150mg aspirin started before 16 weeks
When would you treat hypertension in pregnancy and what is the target?
If BP >150/100 regardless of aetiology
Aim for 140-150/90-100
Does treating hypertension in pregnancy decrease risk of pre-eclampsia?
No
First line drugs for hypertension in pregnancy?
Methyldopa
Labetolol
Nifedipine SR
Second line drugs for hypertension in pregnancy?
Hydralazine
Doxazosin
When should you deliver a baby in pre-eclampsia?
If at term Inability to control BP Rapidly deteriorating biochem/haematology Eclampsia Other crisis Foetal compromise (US/CTG)
Prophylactic/treatment of eclamptic seizures
Magnesium sulphate (loading dose then infusion)
If further seizures administer 2g
If persistent seizures consider diazepam IV
What medication should you give in labour with pre-eclampsia and what should you not give and why?
Give epidural (lowers blood pressure) Don't give ergometrine (increases blood pressure)
Management of peurperal psychosis
Emergency admission to specialised mother-baby unit Antidepressants Antipsychotics Mood stabilisers ECT
Management of mild-moderate post-natal depression.
Self help
Counselling
Management of moderate-severe post-natal depression.
Psychotherapy
Anti-depressants
Maybe admission
Lowest risk SSRIs in pregnancy
Sertraline
Fluoxetine
Lowest risk TCAs in pregnancy
Imipramine
Amitriptyline
Are atypical or typical antipsychotics safer in pregnancy?
Typical
Is lithium safe in breastfeeding?
No
Placental abruption management
Resuscitate mother
Assess and deliver the baby
Manage complications
Placenta praevia management
Admit for at least 24 hours until bleeding has ceased
Anti-D if rhesus negative
Steroids if not at term
TED stockings
Prevent and treat delivery
Delivery plan at/near term
Give magnesium sulphate if planning delivery early
When to do c-section or vaginal delivery in pregnancy?
C-section - if placenta covers os or <2cm from os
Vaginal - placenta >2cm from os and no malpresentation
Placenta accreta management
Prophylactic internal iliac artery balloon Caesarean hysterectomy Blood loss >3l expected OR Conservative management
Vasa praevia management
Steroids
Consider inpatient management if risk of preterm birth
Delivery by elective c-section 34-36 weeks
If ante-partum haemorrhage do emergency c-section
Send placenta for histology
What do you give in active management of the 3rd stage of labour?
Syntocinon/syntometrine IM/IV
What are the drugs you would use in post-partum haemorrhage and what do they do?
Syntocinon - oxytocin analogue Ergometrine Carboprost/haemabate Misoprostol (all contract uterus) Tranexamic acid (anti-fibrinolytic)
What are the non-medical parts of managing post-partum haemorrhage?
Uterine massage (bi-manual compression)
Insert
Foley catheter for tamponade
Examination under anaesthesia if persistent bleeding
What can interventional radiology and surgery do to control post-partum haemorrhage?
Radiology - arterial embolisation Surgical: Undersuturing Brace sutures (B-lynch) Uterine artery ligation Internal iliac artery ligation Hysterectomy
Management of cord prolapse
Immediate delivery (caesarean or forceps)
Tocolytics
Maternal positions to relieve pressure
Management of amniotic fluid embolus
Supportive ITU
Shoulder dystocia management
Call for help Evaluate for episiotomy Legs to chest (McRoberts' manoeuvre) Suprapubic pressure Remove posterior arm Roll patient on to hands and knees
Breech presentation management
If not in labour can do external cephalic version (ECV)
Obstetric input
Prolapse management
Conservative (stop smoking, lose weight, stop straining, exercise/physio)
Pessaries
Surgery (depends on type of prolapse)
How long should women try lifestyle advice before referring to physio for prolapse?
3 months
What is the non-pharmacological management of menopause?
Lifestyle advice (diet, weight loss, exercise idk why this would help lol)
Caffeine and alcohol intake reduction (reduces hot flushes)
CBT
Mindfulness
Management of menorrhagia in menopause.
Mefenamic acid (NSAID) Tranexamic acid Progesterones IUS Endometrial ablation Hysterectomy
What are the contra-indications for HRT?
Breast cancer Undiagnosed abnormal vaginal bleeding Endometrial cancer Pregnancy Active thrombo-embolic disorder Recent MI Active liver disease Porphyria cutanea tarda
If women aren’t suitable for HRT, what can they be given to help with menopause symptoms?
Clonidine (for flushing)
SSRIs
Vaginal lubricants (regelle, yes, sylk)
Ovarian germ cell cancer management
Fertility sparing
Unilateral salpingoophrectomy with maybe chemo
Non-germ cell ovarian cancer management
Stage 1A - only surgery
The rest - chemo and surgery
What all needs to be removed in ovarian cancer surgery for staging?
Total abdominal hysterectomy
Bilateral salpino-oophrectomy
Infracolic omentectomy
(retroperitoneal lymph node assessment)
Should you give neo-adjuvant chemo before operating on stage III-IV ovarian cancer?
Yes
Better progression free and overall survival
What can be used to medically manage fibroids?
GnRH analogues
Mirena coil
Progesterones
What are the 3 main chemotherapy drugs used in gynae malignancy?
Cisplatin
Carboplatin
(paclitaxel less important?)
At what stage does cervical cancer need chemoradiotherapy?
Ib2 and above
When would cervical cancer be treated with palliative intent?
If it has spread out of the pelvis
Radial scar management
Excise or sample extensively by vacuum biopsy
