Repro Txs Flashcards
Mx for ovulation supression
1st line: yasmine and eloine COC
-GnRH agonists
- Danazol (gnrh inhibitor)
-Oestrogen
- bilateral oopherectomy and hysterectomy with add back oestrogen only
breech presentation management
primiparous- external cephalic version (ECV) at 36 weeks
multiparous- ECV at 37
if not worked/ contraindicated- casarean
Cervical shock tx
Removing product from cervix
(Sometimes IV and uterotonics required)
(complication of miscarriage)
Threatened miscarriage tx
Micronised progesterone
(to try and prevent a true miscarriage)
Molar pregnancy management
how long must pregnancy be avoided afterwards
Surgical-(uterine evacuation) and tissues sent for histology to ascertain type
pregnancy should be avoided for 1 year after
Bacterial vaginosis tx
(and avoid…)
Metronidazole oral/gel
Avoid alcohol
Chlamydia
and If pregnant
doxycycline is first line
if pregnant: azithromycin/erythromycin/ amoxicillin
Hyperemesis gravidarum management
saline + potassim chloride (fluid replacement)
IV or IM antiemetics
thiamine + folic acid
TED stocking and LMWH
what anti-emetics are used for nausea and vomiting in pregnancy (& for hyperemesis gravidarum)
and their side effects
first line: antihistamines- oraal cylizine or promethazine-
end in zine
2nd: oral ondansetron (SE 1st trim, cleft palate)
oral metoclopramide or domperidone:
(meto SE- extrapyramidal, do not use for longer than 5 days)
Lifestyle advice for infertility
Stop smoking (and don’t replace with other nicotine products)
Bmi 18.5-30
Reduce/stop alcohol
Moderate caffeine
Stop recreation drugs/methadone for at least 12 months
Folic acid
Pcos infertility tx
1st line: clomifene citrate / tamoxifen +/- metformin
2nd: gonadotrophin injections (risks multiple pregnancy, overstimulation) (basically LH and FSH injections)
Needs supervision
3rd : laproscopic ovarian diathermy
Clomifene resistence
Add metformin
Male infertility treatment
Ivf
…
Blocked fallopian thbes tx
IVF
Sometimes if it is a very small blockage u can cannulate and open it
Pregnancy of unkown location
Expectant management (will resolve itself)
Medical- methotrexate
How long should a women wait to conceive after methotrexate management
6 months
Ruptured cyst
premenopausal: conservative unless hypovolaemic shock
postmenopausal: laparoscopy
Pelvic inflammatory disease management
oral ofloxacin + oral metronidazole
or
IM ceftriaxone + oral doxy + oral metronidazole
(IV ceft if very severe)
Advice she use barrier contraception as IUD removal should be considered
Bartholins abscess/cyst tx
Conservative if small cyst
Antibiotics broad spectrum- if infected and systemically unwell
usually treated with:
-Word catheter
-Marsupialization
TOP missed miscarriage medical tx
Mifepristone orally + bucall/sublingual/ vaginal misoprostol 24-48 hrs later
all women should be offered antiemetic and pain relief
Dose/frequency dependant on gestation
surgical abortion management
(under anaesthesia)
misoprostol/osmotic dilators given before
up to 13+6 weeks:
-Electric vacuum aspiration
-Manual vacuum aspiration
> 14wks
-Dilatation and evacuation
incomplete miscarriage medical tx
single dose of misoprostol (vaginal, oral or sublingual)
all women should be offered anti-emetics and pain relief
choosing type of TOP (termination of pregnancy)
medical or surgical offered up to and including 23+6 weeks
after 9 weeks medical abortions become less common (as inc risk of seeing products of conception pass and dec success rate)
<10 weeks medical abortions usually done at home
What is screening must all women undergo for TOP
STI screening,
VTE risk screening- if high risk give LMWH after abortion. if v high risk give before +/- continue
Contraception consultation and offered contraception
who receives antibiotic prophylaxis at time of abortion and regimen
those undergoing surgical TOP (STOP)
those undergoing MTOP with an increased risk of STI (if screening not performed/results unavailable)
regimen= 7 days doxcy
rhesus isoimmunisation who to treat at time of abortion
if rhesus d negative and at risk, higher gestation and surgical procedure increases risk
anti D is the tx
Diagnosing gonnococcal urethritis on microscopy
Gram negative intracellular diplococci- gonnococcal urethritis (gonnorhea)
Primary genital hsv tx
When to admit
Aciclovir tx 400mg 3x a day 5 days
+ supportive tx
Admit if urinary retention/ cant swallow
Syphillis tx
Benzathine penicillin
No sex
…
Lichen schlerosus tx
1- genital skin care: gentle wash (dermovate(, avoid tight clothing, irritabts etc
- apply emollient
2- super potent topical steroid- 12 week regimen (30g tube) then on an as required basis
When would a cystectomy be carried out
If cyst is >5cm
(As there is risk of torsion)
PMS tx mild
regular frequent balanced meals rich in complex carbohydrates
pms moderate symptoms
COCP
severe PMS tx
SSRI- continuously or just during the luteal phase
mx of gestational diabetes: fasting glucose >5.6 & <7
1st: trial of diet and exercise,
2nd: if targets not met within 1-2 weeks + metformin
3rd: ADD (not switch) short acting insulin if targets not met after a further 1-2 weeks
what are the blood glucose targets for women with gestational diabetes
fasting: </= 5.3mmol
2 hours postprandial: 6.4 mmol/L
gestational diabetes tx: >7mmol
1st; start short acting insulin immediately
what kind of insulin used for gestational diabetes
short acting!
Atypical endometrial hyperplasia tx
pre-menopausal- hysterectomy -
post menopausal- hysterectomy + bilateral salphingo-oopherectomy
simple endometrial hyperplasia- w/o atypia tx
high dose progestogens with repeat sampling in 3-4 months.
levonorgestrel intra-uterine system may be advised
neiserria gonorrhoeae 1: what agar, type of bacteria
requires chocolate agar to grow
gram negative diplococci
neisseria gonorrhoeae II antibiotic tx
1st line: Ceftriaxone IM single dose
chlamydia trachomatis II tx
doxcy or azithromycin
women with vulva-vaginal atrophy (from menopause) tx
vaginal oestrogen.
can be used in combination with HRT or be the alternative to HRT for women who it is contraindicated in
women with premature ovarian insufficiency tx (<40)
- give HRT till the average age of menopause (51)
- CHC (continuously) could be considered as alternative unless CI
- HRT does not add risks compared to women without POI
- continue with contraception
Women with early menopause (40- 44) tx
- consider strongly giving HRT till the average age of menopause (51)
when can contraception be stopped in women aged 40-49
-2 years after last “natural” menstrual period or
- 2 years after 2 results of FSH of ≥ 30 IU/l, taken at least 4-6 weeks apart
when can contraception be stopped in women >/=50
-1 year after last “natural” menstrual period or
-1 year after 1 result of FSH of ≥ 30 IU/l
when can contraception be stopped >/=55
Age ≥ 55: contraception can be stopped even if still having periods
when would you give transdermal HRT over oral HRT
increased VTE risk or BMI >30
transdermal always preferred
management of menorrhagia secondary to fibroids
(1st, second and third line)
1: levonorgestrel intrauterine system (LNG-IUS) (mirena coil)
- useful if the woman also requires contraception
- cannot be used if there is distortion of the uterine cavity
2nd: NSAIDs e.g. mefenamic acid
3rd: tranexamic acid
surgical management of ectopic pregnancy
salpingectomy
2nd: salpingotomy (rf for infertility eg contralateral tube damage)
hirsutism and acne in PCOS tx
1st: third generation COC / co-cyprindol
2nd: topical elfornithine
Pregnant women with epilepsy: principles of management
pregnant women should continue anti-epileptics
Folic acid, 5mg daily
avoid valproate,
if taking phenytoin + vit k
carbamezapine considered least teratogenic
Hypertension tx for pregnant women
(and what to avoid)
1st line: labetolol
2nd: methyldopa/nifedpine
Avoid ace/arb
Beta blockers MAY inhibit foetal growth
If >160/110bp then ADMIT and OBSERVE
(Bp falls during 2nd trimester)
Nausea and vomiting preganant women tx
(first line only)
Cyclizine first line
UTI pregnant women tx
1st line: nitrofurantoin
2nd: amox/ cefelaxin
1st line treatment for pain in pregnant women
paracetomol
who requires VTE prophylaxis during pregnancy?
what is the VTE prophylaxis
2 or more risk factors:
obesity, age >35yrs, smoking, para>3
prophylaxis tx: LMWH at delivery and up to 7 days post partum
Tx of venous thromboembolism in pregnancy
and what to avoid
therapeutic dose of low molecular weight heparin
avoid warfarin (teratogenic early, risk of haemorraghe late)
Who gets pre eclampsia prophylaxis and what is the treatement
75-100mg aspirin daily
Women with one high risk or 2 moderate risk factors (eg. Over 40)
active management of third stage of labour
prophylactic administration of syntometerine
1ml ampoule: 500micrograms ergometrine maleate & 5IU oxytocin
cord claming and cutting
controlled cord traction
bladder emptying
plan for delivery placenta praevia
C/section : If placenta covers os or <2cm from cervical os
Vaginal delivery if placenta>2cm from os and no malpresentation
antepartum haemorraghe general tx
Kleihauer test (check if there has been blood transfusion)( only if rhesus negative), if test is += Anti-D
give corticosteroids if risk of preterm birth and <34 weeks
rescus if necessary,
admit for obs etc
Antepartum haemorrhage= bleeding from the genital tract >24 weeks pregnancy, prior to delivery of the fetus
antibiotic management of suspected sepsis
and if penicillin allergic pregnant woman
IV co-amoxiclav within “golden hour” +/- gentamicin depending on severity and clindamycin if sore throat (GAS)
Clindamycin + gent if penicillin allergic
antibiotic management of septic shock in pregnant woman
Tazocin , clindamycin + gentamicin
GBS risk (previous baby infected with GBS)/detected in pregnancy management; management
antibiotic prophylaxis
1st: Benzylpenicillin
2: Clindamycin
post partum endometritis tx (not penillin allergic)
Treatment with co-amoxiclav +/- surgical evacuation of uterus if significant RPOC (retained products of pregnancy)
post partum endometritis tx if penicillin alergic
Co-trimoxazole +metronidazole
+/- surgical evacuation of uterus if sig.fig. RPOC
epidural abscess tx
Vancomycin, metronidazole and cefotaxime +/- surgical decompression (if no response or neurological concerns)
drain abscess
placental abruption tx <36 weeks and fetus alive
fetal distress: immediate caesarean
no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
placental abruption tx >36 weeks and fetus alive
fetal distress: immediate caesarean
no fetal distress: deliver vaginally
1st line tx for magnesium sulfate induced respiratory depression
calcium gluconate
chicken exposure management vs
chicken pox management
(in pregnancy)
exposure:
1st line- oral aciclovir 7 days after exposure for 7 days.
2nd (varicella zoster immunoglobulins)
chicken pox:
give aciclovir if >20 weeks and woman presents within 24h of onset of rash
treatment for Persistent Pulmonary Hypertension of the newborn
Ventilation, O2, nitric oxide, sedation inotropes
if above fails: ECLS machine (mechanical lung)
ectopic pregnancy:
criteria for expectant management
size <35mm
hcg <1000IUL
asymptomatic
ectopic pregnancy:
criteria for medical management
size<35mm
hcg <1500IUL
no significant pain
not suitable if there is another intrauterine pregnancy
ectopic pregnancy:
surgical management criteria
if its ruptured or
size >35mm/
pain/
foetal heartbeat/
hcg>5,000IUL
post partum haemorraghe tx (overview)
1st: ABCE and IV warmed crystalloid
2nd: (mechanical) rub uterine fundus and catheterise
3rd:medical uterotonics etc
4th line: intrauterine tamponade
post partum haemorrhage- medical management
IV oxytocin
ergomotine IV-unless hx of hypertension
carboprost IM- unless hx of asthma
misoprotol subingual
fibrocystic change management
exclude malignancy
reassure
excise if necessary (unusual)
fibroadenoma mx
if greater than 3xm excise
radial scar tx
excise or vacuum biopsy
duct ectasia management
stop smoking
excise ducts- michrodochectomy if young or total duct excision if older
(Duct ectasia is a dilatation and shortening of the terminal breast ducts within 3cm of the nipple. It is common and the incidence increases with age. It typically presents with nipple retraction and occasionally creamy nipple discharge. )
1st line tx for uterine fibroids
<3cm- IUS for menorrhagia and gnRH analogues to reduce size
>3cm- surgical management eg myomectomy
thrush tx (and contraindication) (candidias)
(4)
1st line: oral fluconazole single dose
2nd: clotrimazole intravaginal single dose if oral contraindicated
if vulval symptoms too + topical imidazole
if pregnant oral tx contraindicated
how long should magnesium sulfate be continued for seizure pregnancy
24 hours after delivery or last seizure- whichever is later
intrahepatic cholestasis of pregnancy management
ursodeoxycholic acid
INDUCTION OF LABOUR AT 37-38 WEEKS ( as inc risk of still birth)
vit k supplementation
Preterm prelabour rupture of the membranes
(preterm- before 37 weeks)
oral erythromycin should be given for 10 days
antenatal corticosteroids
delivery should be considered at 34 weeks of gestation
current breast cancer is a contrindication for which contraceptives
all hormonal contraceptives
rhesus negative woneb- when should she recieve anti D
at 28 weeks and 2nd dose at 34 weeks
Treatment to shrink/remove fibroids
medical- gnrh agonists
surgical- myomectomy, hysteroscopic endo ablation, hysterectomy
uterine atery embolisation
what advice should be given, regarding folate supplementation, to women hoping to concieve
Women should be encouraged to take folic acid 400mcg OD 3 months before conception up to 12 weeks gestation
stress incontinence tx (3 lines of management)
1st: pelvic floor muscle training
2nd: surg procedures
3rd: duloxetine
urge incontinence tx
include if frail/elderly
- bladder retraining
antimuscarinics: oxybutnin
mirabegron- if frail/elderly
non HRT menapause vasomotor symptoms tx
SSRIs
fluoxetine/citalopram or venlafaxine (SNRI)
mode of delivery, labour in women with HIV
vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
a zidovudine infusion should be started four hours before beginning the caesarean section
neonatal antiretroviral therapy
zidovudine orally to the neonate if maternal viral load is <50 copies/ml.
Otherwise triple ART for 4-6 weeks.
what are the haemoglobin cut offs for tx- non preg, early preg, late preg, after childbirth
115 for non-pregnant women, 110 in early pregnancy, 105 in later pregnancy, and 100 after childbirth
when can COC be given after labour
never before day 21 post partum due to risk of vte
if breast feeding: 6 weeks - 6 months postpartum
if inc risk of VTE then not in the first 6 weeks
what contraception can be given immedietely after labour
- progesterone only pill
- implant
- injection
- condoms
(IUS and IUD but not after 48 hours.)
when can IUD/IUS be given post partum
within 48 hours after labour
or
4 weeks later
what type of drug is cabergoline
long acting dopamine agonist
Fetal transverse lie management
<36 weeks- no management
> 36 weeks- external cephalic version of foetus- offered in all cases of vag delivery
or
elective caesarean
cant do ECV if membranes have ruptured
when is induction of labour offered to women with intrahepatic cholestasis
37-38 weeks
when do postpartum women require contraceptives
not required before day 21 postpartym. earliest date of ovulation is day 28
when must levonogestrel be taken regarding emergency contraception
within 72 hours of unprotected sexual intercourse
emergency contraception: ulipristal (progesterone receptor modulator)- when can it be taken and contraindications
no later than 120 hours after intercourse (5 days)
*caution with those with severe asthma
if bishop score is 6 or less management
vaginal prostoglandins/ oral misprostol
balloon catheter if higher risk of hyperstimulation/previous caesarean
if bishop score is greater than 6 management
amniotomy and IV oxytocin infusion
> 37 weeks women with pre-eclampsia + mild/moderate hypertension tx
delivery within 24-48 hours
consider magnesium sulphate if birth is planned within 24 hours or if there is a concern that the woman may develop eclampsia
primary dysmenorrhoea tx
(painful periods)
1st line: NSAIDs eg mefenamic acid/ibuprofen.
2nd line:COCP
Pregnant women uti tx
1st line: niturofurantoin
2nd- amox or cefalexin
7 day course!!! (3 in non pregnant)
perineal tears tx
1st degree- no repair required
2nd degree- suture on ward by midwife or clinician
3rd: repair in theatre by clinicial
4th: same^
what is the only fibroid treatment which maintains fertility
myomectomy
what ovarian cysts, found on imaging, require referral to gynaecology (5)
-irregular solid tumour
-ascites
-at least 4 papillary structures
- irregular multilocular sold tumour growth with largest diameter >/= 100mm
- very strong blood flow
which medication can be used to supress lacation
cabergoline- dopamine agonist
what is category 1 caesarean
caesarean for mother where there is an immediate threat to the life of the mother or baby
delvery wtihin 30 mins of making decision
what is category 2 caesarean
maternal or fetal compromise which is not immediately life-threatening
delivery of the baby should occur within 75 minutes of making the decision
prophylaxis for anti -D, who gets it and when
all women who are rhesus negative whether sensitised or not get anti- d prophylaxis at
-28 weeks
&
-34 weeks
endometriosis tx
first line: NSAIDs and/or paracetamol
second: COCP or POP
3rd: GnRH analogues
(^all symptomatic relief)
endometriosis: tx for women trying to concieve
laparoscopic excision or ablation of endometriosis plus adhesiolysis as this has been shown to improve the chances of conception. Ovarian cystectomy (for endometriomas) is also recommended
cord prolapse tx
- presenting part of fetus may be pushed back into uterus to avoid compression
- if cord is past level of intoitus- minimal handling, keep warm and moist- to prevent vasospasm
-get patient to go on all fours
-tocolytics (reduce contractinos)
-retrofill bladder
cesarean- unless cervix fully filated and head is low- instrumental delivery.
suspected PE pregnant women with confirmed DVT management
treat with LMWH first then investigate to rule in/out
when should post exposure prophylaxis chickenpox be given
day 7-day 14
if pregnant women has chicken pox treatment
oral aciclovir within 24 hours of onset of rash
(if <20 weeks consider aciclovir with caution)
Second stage labour management
- forceps if possible
- caesarean otherwise (inc risk of mortality/morbidity)
Oxcytocin can be used only if there is a problem with contrations
Genital warts tx
1st: topical podophyllum or cyrotherapy (solitary warts better for cyrotherapy)
2nd: iniquimod
Genital herpes- what hsv is it and tx
Hsv 1/2
General: saline bathing, analgesia, lidocaine (anaesthetic)
- oral aciclovir - frequent exacerbations
What organisms are genital warts
Human papilloma virus 6 & 11
What organisms assoc with cervical canver
Human Papilloma virus -16, 18, 33
cervical cancer tx
1A- hysterectomy +/- lymph node clearance.
- maintain fertility: cone biopsy w/ negative margins
1b - radiotherapy + chemo or radical hyst w/pelvic lymph node dissection
II & III- radiation + chemo
IV- radiation +/ or chemo, possibly palliative chemo.
HRT key points
topical over oral
if menapause has not been reached/perimenopausal then: cyclical/sequential
(post menopausal- continuous)
if patient has a uterus then combined is required
pre-labour rupture of the membranes management and what is it
PROM- rupture of the membranes pre labour and >37 weeks.
mx- induce labour if it has not spontaneously occured after 24 hours
if infection/foetal compromise immedietley induce or caesarean may be necessary
pcos cocp tx rule
cocp have a widthdrawal bleed once every 3 months to reduce risk of endometrial hyperplasia
antiphosphoilipid synrome in pregnancy tx
low dose aspirin as soon as pregnancy is confirmed
lmwh as soon as fetal heart is seen on us- discontinue at 34 weeks
