Reproductive Flashcards
Antenatal care timetable
What do late decelerations indicate?
Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction
Indicates foetal distress e.g. asphyxia or placental insufficiency
Ix: urgent foetal blood sampling (foetal hypoxia, acidosis).
* pH >7.2 in labour = normal
Mx: Urgent delivery should be considered if foetal acidosis
Give an overview of the disorders of reproductive development incl definition of primary amenorrhoea, problems in HPG axis and structural abnormalities
Primary amenorrhoea:
* No periods by 13yrs + no secondary sexual characteristics
* No periods by 15yrs + normal secondary sexual characteristics
Secondary amenorrhoea - prev periods but stopped for ≥6m
HPG Axis: Kisspeptin –> signal to start puberty –> Hypothalamus –GnRH–> pituitary –FSH/LH–> ovary –> follicles –oestrogen–> -ve/+ve feedback on hypothalamus (depending on position in menstrual cycle)
Axis problems can occur at:
* Hypothalamus - HYPOthalamic HYPOgonadism (low FSH/LH –> low oestrogen):
* Functional hypothalamic amenorrhoea (low BMI, exercise, stress)
* Kallmann’s syndrome - failure of neurone migration (+ reduced smell)
* Systemic - hyper/hypothyroidism, congenital adrenal hyperplasia, virilizing tumours
* Pituitary - pituitary HYPOgonadism (low FSH/LH –> low oestrogen):
* Sheehan’s syndrome - infarction of pituitary after haemorrhage e.g. labour (panhypopituitarism)
* Pituitary tumour esp. prolactinoma (Mx: cabergoline/bromocriptine)
* Ovary - ovarian pathology (prepuberty/later, high FSH/LH, low oestrogen)
* POI/menopause - no more eggs –> no more oestrogen made
* Turner’s syndrome - streak ovaries, nothing prod oestrogen
* Gonadal dysgenesis, androgen insensitivity
Structural problems - outflow obstruction (no period)
* Imperforate hymen(& cervical stenosis) - tight seal across vagina, blood stuck in uterus despite periods = hematocolpos
* Rokitansky (MRKH) syndrome —> disorders of development esp. vagina (& uterus) –> exam under anaesthesia + neovagina formation
* Asherman’s syndrome - after surgical miscarriage/ToP - IU adhesions (also related to endometriosis/PID) –> endometrium not producing thickened layer with each cycle –> no blood prod
Fertility
* Regular sexual intercouse (2-3x/wk) - 84% conceive within 1yr, 92% within 2yrs
* Ix: if failed to conceive after 1yr of reg unprotected sexual intercourse, male - semen analysis (repeat after 3m if abn), women - mid luteal phase D21 progesterone (7d before expected period) +/- D2-4 LH/FSH, TSH, prolactin
* Mx: refer to fertility services if <36yrs and failed to conceive after 1yr
Give an overview of PCOS
Rotterdam criteria (req 2/3 + exclusion of other dx)
* Irregular/absent ovulations (cycle >42 days, >2yrs) - ≤3 menstruations/year in PCOS increases risk of endometrial hyperplasia/carcinoma
* Clinical/biochem hyperandrogenism (acne, alopecia, hirsutism)
* USS polycystic ovaries (≥12 antral follicles in one ovary, measuring >2mm on one ovary/ovarian volume >10ml)
Ix:
* Preg test, LH/FSH (high), TFTs, prolactin (slight high), testosterone on day 2-5 of cycle for ‘basal’ reference range (x2)
* TVUS ‘string of pearls’ sign
* Karyotype (if absent uterus/Turner’s worry)
Mx:
* Conservative - WL/Sx control
* Medical: Dianette COCP (increased VTE risk)/LNG-IUS, Metformin
* Fertility Tx: WL, ovulation induction (<6m) - clomifene (SERM) +/- metformin (others - letrozole, low-dose step-up exog gondatrophins), other - laparoscopic ovarian drilling, IVF
Menopause overview
Menopause = final permanent cessation of menstruation after 12 months amenorrhoea, average age 51/52yrs
* Ovaries stop producing eggs –> ovaries stop produces oestrogen (and progesterone) –> symptoms
PC:
* Vasomotor - poorly tolerated temperature changes e.g. hot flushes (± night sweats)
* Menstrual irregularities
* Breast tenderness, vaginal dryness –> dyspareunia, reduced libido
* Low mood (impending doom), fatigue, sleep disturbance
Diagnosis
* >45yrs by clinical presentation/no Ix needed after 12m amenorrhoea
* 40-45 = early menopause
* <40yrs = Premature ovarian failure/POI
Ix: preg test, serum FSH (2, 4-6wks apart) - normally used if <40yrs (sometimes if 40-45) –> elevated FSH suggests menopause if amenorrhoea
HRT:
* Oestrogen replacement ONLY if have had hysterectomy (risk of endometrial cancer)
* Combined oestrogen and progesterone if have uterus as progesterone is protective against endometrial cancer
* Cyclical- if menses: oestrogen tablet OD, progestogen (norethisterone) on last 14 days of the cycle (depending how often)
* After 1yr cyclical therapy/established menopause (no withdrawal bleeding -> combined Tx daily
* For POI –> treatment with OCP/HRT until 51yrs (av age menopause)
Urogenital atrophy –> vaginal oestrogen ± vaginal lubricants/moisturisers
HRT risks/benefits:
- Combined HRT gives small increased risk of breast cancer
- Increased risk of blood clots (VTE) with tablets but not patch
- No sig increased risk of CVD if started before 60yrs (heart disease, stroke)
- Reduces risk of osteoporosis
Causes of antepartum haemorrhage
BLEEDING IN LATE PREGNANCY = PLACENTAL ABRUPTION, placenta praevia - painless/vasa praevia - painless with Rupture of membranes (RoM)
* Dark bleed in abruption vs fresh and profuse with praevia
* Foetus lie may be abnormal in praevia
Placenta praevia - placenta in lower segment uterus
* PC: painless PV bleed, abn lie/breech, USS incidental findings
* Ix: bloods, CTG, USS
* Mx: if ≤20wks - wait until 36wks -> if <2cm from OS for elective CS, if acute bleed admit ?delivery
Vasa praevia - fetal blood vessels are unprotected by the umbilical cord or placenta and run near the cervix
Placental abruption - separation of normally sited placenta from uterine wall -> maternal haemorrhage into intervening space
* PC: Sudden onset constant abdo pain, tense woody uterus, can have ‘concealed’ bleeding
* Ix: urine, speculum (blood pooling), CTG (long deceleration), USS
* Mx: stabilise, <34wks stable - observe, CS, delivery at 37-38wks, >34wks - IoL if stable
Post-partum haemorrhage overview
Definition: >500ml (>1L emergency call, >1.5L 2222), primary = <24hrs, secondary >24hrs
Causes (4Ts):
* Tone 70% - atonic uterus = uterus slow to contract (possibly given synto for too long)
* Trauma 20% - episiotomy/tears/CS
* Tissue 10% - retained placenta/fragments
* Thrombin (clotting) <1% - abruption/PET (pre-eclampsia)/DIC, vWF/Haemophilia
Ix: red blood from closed os, boggy uterus
Mx:
* Bimanual compression
* Syntocinon IV (2nd - Ergometrine IM/Carboprost IM/Misoprostol PR)
* Surgery - EUA, direct uterine massage, uterine packing, balloon compression +/- hysterectomy
VTE in pregnancy Ix & Mx
Ix:
* Exertional HR/sats
* ECG, US doppler LL (D-dimer not appropriate = already raised in preg)
* CTPA, can offer VQ scan instead ±CXR
* CTPA has increased radiation for mother breast tissue, less for baby
* If can’t identify anything on VQ would have CTPA anyway
* Magnetic Resonance Venography (MRV)
Management
* Conservative – compression stockings + elevation
* LMWH throughout pregnancy + 3-months post-partum
* Haem follow-up @3-months PP
Give an overview of problems during labour
Shoulder dystocia
* Impaction of anterior foetal shoulder on maternal pubic symphysis
* Assoc w/ postpartum haemorrhage + perineal tears in mum and brachial plexus injury in foetus
BIG RISK TO BABY = BRACHIAL PLEXUS INJURY
* Damage to upper brachial plexus - Erb’s palsy - “waiter’s tip” (adduction + internal rotation of arm + pronation of forearm)
* Damage to lower brachial plexus - Klumpke’s palsy - affects nerves innervating hand muscles
Management
* McRoberts – take legs straighten and re-bend again = 90% EFFECTIVE
* Episiotomy gives more room for later manoeuvres:
* Suprapubic pressure followed by Woodscrew’s/Reverse Woodscrew’s manoeuvre (2 fingers on either side – behind anterior shoulder and in front of posterior shoulder –> rotate baby)
* Delivery of posterior arm
* All fours and repeat above
* Finally – Cleidotomy (breaking baby’s clavicle)/Symphysiotomy (cut mum’s symphysis pubis)/Zanvenelli (push baby back inside mum and do CS)
Placental abruption - covered in antepartum haemorrhage card
Breach presentation Mx:
* External cephalic version (rotate baby manually) –fail–> EMCS
* Elective CS
Umbilical cord prolapse
* Umbilical cord presentation = membranes intact
* Umbilical cord prolapse = membranes ruptured
* Mx: Relieve pressure on cord – elevate presenting part, all fours position and deliver
Foetal bradycardia
* Deceleration – drop from baseline >15 for >15s
* Bradycardia - >3 mins deceleration
* Mx: change position (LLP), examine, delivery by fastest/safest route (if does not recover)
Placenta accreta - attachment of placenta to myometrium from defective decidua basalis –> placenta does not properly separate during labour –> risk of post-partum haemorrhage
* Accreta: chorionic villi attach to myometrium, rather than being restricted within decidua basalis
* Increta: chorionic villi invade into myometrium
* Percreta: chorionic villi invade through perimetrium
* Mx:
* Definitive - hysterectomy w/ placenta left in-situ (attempts to actively remove placenta can cause sign haemorrhage)
* Medical: oxytocin/ergometrine - manage post-partum haemorrhage
PERINEAL TEARS - Classification:
* 1st degree: superficial damage w/ no muscle involv
* 2nd degree: injury to perineal muscle, not involv anal sphincter
* 3rd degree: injury to perineum involv anal sphincter complex (external and internal):
* 3a: <50% EAS thickness torn
* 3b: >50% EAS thickness torn
* 3c: IAS torn
* 4th degree: injury to perineum involv anal sphincter complex (internal and external) and rectal mucosa
Hypertension in pregnancy classification including overview of pre-eclampsia
Pre-eclampsia
* ≥20wks + BP >160/10 + proteinuria OR
* ≥20wks + BP >140/90 + proteinuria + Sx
* HELLP Syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets) = severe form of pre-eclampsia
Ix:
* Measure basic obs esp. BP, cardio + abdo exam
* Urine dipstick, PCR for protein: creatinine ratio
* Bloods: FBC, U&E, LFTs (AST, ALT), creatinine, possibly clotting screen, BM, LDH
* Foetal ultrasound scan, umbilical artery doppler and CTG to check foetal wellness
Mx:
* Stabilise:
* Control BP – oral Labetalol/Nifedipine (severe – IV labetalol/hydralazine)
* Prevent seizures – IV Magnesium Sulfate
* Monitor: QDS BP, urine IP/OP + PCR, bloods, US/CTG
* DVT Mx - LMWH + stockings
* Birth plan - deliver if ≥37wks (34-36 is case by case)
Eclampsia Mx = seizure: ECLAMPSIA BOX
* Airway - LLP
* Breathing - high flow O2
* Circulation - IV hypertensive (IV labetalol)
* Disability - control seizures - IV Mg SO4 (Mg toxicity –give–> Ca gluconate)
* Foetal assessment - US, umbilical artery doppler, CTG –» emergency CS
Hyperemesis gravidarum overview
HG - Triad: 5% pre-preg weight loss, dehydration, electrolyte imbalance
Ix:
* Pregnancy-Unique Qualification of Emesis (PUQE) - classify severity of NVP
* Urine dip/MSU
* Bloods
* Foetal US + nuchal translucency
When to ADMIT for nausea & vomiting in preg:
* Unable to keep down liquids/oral antiemetics
* Ketonuria/weight loss >5% body weight, despite treatment w/ oral antiemetics
* Confirmed/suspected comorbidity (unable to tolerate oral abx for UTI)
Mx:
* No volume loss - Conservative = ginger 250mg PO QDS, smaller more freq diet (2nd - oral AHs/anti-emetics)
* Volume depletion - ADMIT, IVF, Anti-emetics (Promethazine/Cyclizine), steroids if refractory, thiamine, VTE prophylaxis
Gestational DM overview
GDM Definition - 5678: Fasting plasma glucose ≥5.6 OR 2-hour plasma glucose ≥7.8
Antenatal Mx:
* Conservative (2wks if fasting glucose <7) - food, exercise, diabetic nurse, scans
* Medical - aspirin after 12wks to minimise pre-eclampsia risk, if BM <7 - metformin, >7 - insulin
Intrapartum Mx:
* Hourly BMs, on labour ward, IoL at 40wks (ideally at 36-38wks)
Postnatal Mx: stop meds, feed baby asap, check BMs, annual HbA1c
Obstetric cholestasis overview
Obstetric cholestasis: affects liver during pregnancy causing build up of bile acids in body
* PC: Pruritus (no rash, worst night, palms/soles/abdo), 20% jaundice, bili raised >90%
* Ix: bile acids, LFTs, viral serology, AI screen, coag, US-liver/biliary
* Mx: Ursodeoxycholic acid, AHs for sleep, Vit K suppliment if severe, IoL at 37-38wks
Post-partum thyroiditis overview
Three stages:
1. Thyrotoxicosis
2. Hypothyroidism
3. Normal thyroid function (high recurrence rate in future pregnancies)
NOTE: Thyroid peroxidase antibodies are found in 90% of patients
Dx: within 12m giving birth, hypothyroid features, TFTs support Dx
Mx:
* Anti-thyroid drugs for thyrotoxic phase (as thyroid is not overactive)
* Propranolol for symptom control
* Thyroxine for hypothyroid phase
Reduced foetal movement Mx
<10 mov within 2 hrs in preg > 28 wks gestation –> assessment
Handheld doppler to confirm heartbeat -> US if no heartbeat, if heartbeat - CTG ≥20mins (if normal but still concern for US in 24hrs)
Exomphalos vs Gastroschisis
Exomphalos (omphalocele) - bowel contents through umbilicus in sac -> C-section -> gradual closure over 6-12 months
Gastroschisis - bowel contents through defect in abdo wall (not umbilicus) and no sac -> wrap newborn abdo with occlusive wrap (reduce fluid/heat-loss) -> URGENT SURGICAL CLOSURE WITHIN 4HRS
Miscarriage vs Ectopic preg vs
Molar preg Overview
Miscarriage <24wks (most <12wks)
Types:
* Early (<13wks), late (13-24wks)
* Complete (all products of conception expelled, and bleeding stopped)
* Incomplete (non-viable preg but bleeding with RPC)
* Missed (NVP on US scan with pain/bleeding)
* Threatened (vaginal bleed, viable pregnancy in first 24wks)
* Inevitable (NVP, bleeding, cervical os open, RPC)
* Recurrent (3+ consecutive preg before 2wks)
NOTE: pregnancy of uncertain viability = crown-rump length <7mm with no cardiac activity (present by 7-9wks)
TVUS - crown-rump length >7mm + no cardiac activity = Dx miscarriage
Mx of miscarriage:
* W&W 14d - if stops bleeding/pain preg test after 3wks
* Medical: misoprostol - bleeding for 3wks, preg test after 3wks
* Surgical: Manual vacuum aspiration (MVA) under LA/ERPC
Ectopic pregnancy - mostly at ampulla
* PC: pain, bleeding, amenorrhoea, haemodynamic instability (ruptured), cervical motion tenderness
* Ix: preg test, vaginal exam, TVUS, bloods, b-GCG >100/unstable = ECTOPIC
* Mx: >6wks gestation + bleeding -> EPAU
* Expectant if low-risk (<35mm, b-HCG <1000) - monitor for >48hrs
* Medical if mod-risk (b-HCG <1500) - STAT IM Methotrexate with 3wks F/U OR Surgery + post-surgical methotrexate
* Surgical if high-risk (b-HCG >1500/ruptured/foetal heart beat) - surgery + post-surgical methotrexate + Salphingectomy (not salphingostomy unless contralat tube damaged)
Molar pregnancy - abnormal growth of cells formed from start of embryo, not viable pregnancy
* Complete mole = entirely paternal - 1 sperm fertilises empty oocyte and undergoes mitosis → diploid tissue usually 46 XX, no foetal tissue, just proliferation of swollen chorionic villi)
* Partial mole = two sperms entering one oocyte, usually triploid, variable evidence of foetus
PC:
* Bleeding in first/early second trimester
* Exaggerated Sx of preg e.g. hyperemesis
* Uterus large for dates
* Very high serum levels of human chorionic gonadotropin (hCG)
* ± HTN and hyperthyroidism (b-hCG can mimic TSH –> high T4/3 –> -ve feedback on TSH)
Ix:
* Bloods - b-HCG high, low TSH, high thyroxine
* TVUS “snowstorm appearance” for complete mole
Mx:
* Complete/small partial - emergency ERCP (evac retained products of conception)
* Large partial/twin - medical with mifepristone + misoprostol
* Other: contraception to avoid preg for 12m
Gestational trophoblastic neoplasia
* 2-3% go on to develop choriocarcinoma
* Check b-HCG carefully after treatment (15% complete moles, 0.5% partial moles)
* Further treatment depends on risk of neoplasia: low - methotrexate + folic acid, high - COMBO CHEMO (etoposide, dactinomycin)
Pelvic pain overview
Urinary incontinence overview
Definitions:
* Stress - invol leak on coughing/laughing
* Urge - invol leak + “urge”
* Mixed - Tx predominant Sx (urge/stress)
* Overactive bladder syndrome - increased freq/nocturia +/- urge incontinence
Ix:
* PV/PR exam ?pelvic organ prolapse
* Urine dip
* 3d bladder diary
* Post-void residual volume (before and after pee)
* Urodynamic study (only if uncertain Dx/?surgery)
Mx:
* Conservative incl physio (pelvic floor - 3 months)/bladder training (only for urge/mixed 6wks)
* Medical:
* Stress - pseudoephidrine (2nd - duloxetine)
* Urge/overactive bladder - anticholingergic e.g. tolterodine/oxybutynin (not >80y)
* If cause of urge incontinence = detrusor overactivity -> botox inj/PC sacral nerve stim (2nd - augmentation cystoplasty/urinary diversion)
* Surgery - colposuspension/rectal fascia sling
Pelvic organ prolapse
* Older women + sensation of pressure/heaviness/’beaing down’ + urnary sx (incontinence/freq/urgency)
* Ix: POP-Q score
* Mx:
* Conservative - vaginal oestrogen (if atrophy), 16wk pelvic physio (if Sx + POP-Q 1/2), vaginal pessary, clinic R/V every 6m
* Surgery - if uterine prolapse for vaginal hysterectomy ±sacrospinous fixation OR sacrospinous hysteropexy OR manchester repair
Menorrhagia/Dysmenorrhoea DDx
Menorrhagia
* Ix: FBC, TVUS (PCB, IMB, pelvic pain/pressure)
* Mx:
* if no contraception needed - NSAID (mefenamic acid)/TXA on first day of period
* Contraception - IU-LNG (2nd - COCP, long acting progestogen)
Premenstrual syndrome - mood disturbance assoc w/ luteal phase of menstrual cycle (2nd half - progesterone high)
* PC: anxiety, stress, fatigue, mood swings + bloating/breast pain
* Mx: COCP, low dose SSRI (for day 15-28 menstural cycle),
* 2nd - LNG-IUS/high-dose SSRI
* 3rd - GnRH analogue + HRT (induce menopause)
* 4th - surgery +/- HRT
Fibroids - benign tumour of myometrium (most common pelvic tumours in repro-age)
* Submucosal (just below endometrium) - T0 (uterine cavity), T1 (<50% into myometrium), T2 (>50% into myometrium)
* Intramural (within myometrium)
* Subserosal (within myometrium, just below outer serosal layer)
PC: menorrhagia/IMB, pelvic pressure/pain, infertility, urinary freq/incomplete emptying, constipation
Ix: TVUS +TAUS (dark masses), saline infusion sonohysterography OR hysteroscopy - endometrial biopsy
Mx:
* W&W - if asymptomatic with periodic size review
* Medical: NSAIDS/TXA
* If don’t want preg & no uterine distortion - Marina coil/OCP
* Acute bleed - progestogens (Norethisterone) awaiting surgical Mx
* Shrink pre-surgery - GnRH agonist
* Surgical:
* Submucosal - Hysteroscopic myomectomy for submucosal
* Intramural/subserosal - lap myomectomy
* Hysterectomy - if completed family, big fibroid
* Interventional radiology = uterine artery embolization (can be considered if want children, risk of uterine rupture/reduced placental blood supply from myometrial ischaemia)
Fibroids in pregnancy
* Uterine fibroids = sensitive to oestrogen –> grow during pregnancy
* If growth exceeds blood supply –> red/’carneous’ degeneration
* Red degen presentation: low-grade fever, pain and vomiting
* Mx: conservative - rest/analgesia –> resolves within 4-7 days
Endometriosis - presence of endometrial tissue outside of the uterus
PC: chr pelvic pain, dysmenorrhoea, deep dyspareunia, cyclical GI/urinary Sx, infertility
Ix: TVUS, MRI (bladder/bowel involvement), definitive Dx: laparoscopy + biopsy (staging)
DDx: adenomyosis - endometrial tissue in myometrium = globular shape on TVUS
* PC: older women, dysmenorrhoea, menorrhagia, enlarged boggy uterus
* Ix: Pre-operative MRI, laparoscopy (may reveal concurrent endometriosis), histopath exam of uterus post-hysterectomy
* Mx: GnRH agonists, hysterectomy
Mx:
* NSAIDs + hormonal Tx (OCP, progestogens, GnRH agonist)
* Surgery - to protect fertility (or for pain/endometrioma >3cm/failed fertility Tx) -> laparoscopy OR hysterectomy
* If fertility required - controlled ovarian hyperstim (clomifene), IVF
Cervical ectropion - cervical errosion
* On ectocervix = transformation zone: stratified sq epithelium meets columnar epithelium of cervical canal
* Elevated oestrogen lvls (ovulatory phase, preg, COCP use) –> larger area of columnar epithelium being present on ectocervix
* Features: vaginal discharge, PCB
* Mx: severe - ablation ‘cold coagulation’
Ovarian torsion Mx
Ovarian torsion PC:
* Sudden onset unilateral lower abdo pain - onset may coincide w/ exercise
* N&V common
* Unilateral, tender adnexal mass on exam
CLINICAL DIAGNOSIS but often end up having a scan
* DDx: ovarian cyst (+ accident/rupture), appendicitis (ectopic if not done preg test)
* Ovarian cyst presentation = chronic unilateral dull ache (intermittent/during sex), if large –> abdo swelling/pressure on bladder
Mx:
* Speculum, bimanual, pregnancy test, urine dip, bloods (FBC, U&E, LFTs, CRP, coag, G&S)
* TVUS if possible (whirlpool sign)
* NBM, analgesia, IV fluids, anti-emetics
* Senior review –> transfer to theatre: Cystectomy (maintain fertility but risk of future infection) vs oophorectomy
STD overview
Pelvic inflammatory disease - inflam upper female genital tract due to STI (chlamydia/gonorrheoa) -
* Pelvic pain, fever, purulent discharge -> chr = risk of ectopic preg, infertility
* Ix: preg test, endocervical/high vag swab, bloods, TVUS +/- laparoscopy
* Mx: empiral abx: Ceftriaxone IM STAT, doxy + metro PO 14 days
Chalmydia - STD from C. trachomatis
* Asymptomatic, abn vag discharge, dysuria, lower abdo pain, dyspareunia
* Ix: NAAT, urine/vaginal swab
* Mx: PO Doxycycline 7d OR Azithromycin 3d
Gonorrhoea - STD from G- diplococcus N. ognorrhoeae (2nd most common STD after chlamydia)
* 50% asymptomatic, vaginal discharge, lower abdo pain, dysuria
* Ix: NAAT, gram stain, culture - abx sensitivity
* Mx: IM Ceftriaxone (or oral cipro if sensitivity known)
Bacterial vaginosis - large amount of normal vaginal flora
* Fishy smell esp post-intercourse, microscopy “clue cells”, positive amine test
* Mx: metronidazole
Vaginal candidiasis - 80% from candida albicans
* PC: ‘cottage cheese’ discharge, vulvitis (erythema), dyspareunia, dysuria, itchy
* Mx: clotrimazole pessary (or oral itra/fluconazole)
Trichomonas vaginalis - second most common cause vag discharge (after candidiasis)
* Sexually acquired -> yellow/green frothy discharge, vulvovaginal irritation, dyspareunia, dysuria, ‘strawberry cervix’
* Mx: GUM clinic + metronidazole -> follow-up swab (test of cure)
Genital ulcers:
* HSV - recurrent painful, grouped vesicles -> viral PCR swab -> Aciclovir
* T. pallidum (sypillis) - single painless indurated chancre -> dark field microscopy/serology (RPR, TPHA) -> ben pen
* H. ducreyi (chancroid) - multiple painful soft ulcers - ragged edges -> culture -> axithromycin/ceftriaxone
Genital warts - caused by HPV (6/11)
* Clinical Dx +/- biopsy, HPV DNA, colposcopy
* Mx: topical imiquimod, cryotherapy/laser/surgical exicision
How to note number of pregnancies
Gravidity - number of pregnacies
Parity - number of births ≥24wks
+ number of birthds <24wks
e.g. G2 P0 + 2
Antenatal infection Mx
Listeria (G+) - from contaminated food products -> Amox + Gent
Syphilis - T. pallidum -> STAT ben pen
Congen toxoplasmosis -> Spiramycin
Emergency contraception
Contraception options
Abortion Mx
- <9wks - oral mifepristone, followed 24-48hrs by oral misoprostol
- <14wks - surgical dilatation + manual vacuum aspiration
- > 14wks - surgical dilation and ERPC (D&E)
HPV types causing cancer vs genital warts
Cervical screening
Warts - 6/11
Cancer - 16/18
25-64yrs cervical screening - HPV assoc with cervical SCC
* HPV primary screening via PAP smear (if no HPV recall in 3yrs, ≥50yrs - 5yrs; if only HPV - 1yr rescreen unless ≥3 +ve -> colposcopy, if inadequate sample rpt after 3m) - NOTE cervical screening delayed 3 months post-partum
* If cytology shows high-grade changes for colposcopy - apply acetic acid ± biopsy (shows CIN/cervical cancer)
* Imaging for cancer staging
CIN 2/3 require treatment (won’t get better by themselves) -> LLETZ/cone biopsy -> invite for test of cure after 6 months
Key management cervical cancer:
* Microinvasive disease (stage 1a) –> cone biopsy
* Stage 1-2a:
* -ve nodes –> surgery (radical hysterectomy/trachelectomy - if want to preserve fertility)
* +ve nodes –> chemo-radiotherapy
* Stage 2b+ –> chemo-radiotherapy
Gynae cancers
Ovarian cancer
* PC: vague non-specific (abdo Sx/FLAWS) ≥3m, FHx/BRCA 1/2 mutation (protective factors - COCP/preg/hysterectomy)
* Ix: CA-125 if ≥35 IU/ml -> TAUS -> CT-CAP (no biopsy as risk of spreading cancer)
* Mx: 2WW pathway - IA/B, G1/2 -> surgery + staging (if high stage/grade add chemo)
Endometrial cancer
* PC: post-menopausal bleeding, adenexal/uterine mass, FLAWS
* Ix: TVUS -> OP endometrial biopsy +/- hysterectomy
* Mx: 2WW pathway -> surgery + staging (I - limited to endometrium, II - cervix)
Endometrial hyperplasia - abn endometrial prolif -> can develop into endometrial cancer
* PC: abn endometrial bleeding
* Mx: no atypia -> high-dose progestogens/LNG-IUS, atypia -> hysterectomy + BSO
Vulval cancer - 80% SCC
* VIN - atypical vuval epithelium changes assoc with HPV 16 (warty/basaloid SCC) OR lichen sclerosis (keratinising SCC)
* PC: >65yrs, rare, lumps/ulcers on labia majora, inguinal LNs, itchy/irritation
* Mx: 2WW pathway -> wide local excision (1a) +/- groin LNs/radical vulvectomy
Stages of labour
- Stage 1: from onset of true labour (4cm + reg contractions) to when cervix is fully dilated (10cm)
- Stage 2: from full dilation to delivery of foetus
- Stage 3: from delivery of foetus to when placenta/membranes completely delivered
Physiological changes in pregnancy
Cancer screening ages
- Breast - 50-7yrs every 3yrs
- Cervical - 25-64yrs every 3-5yrs
- Bowel cancer screening - 1 off flexi sig at 55yrs, Home FIT test every 2yrs age 60-74
- Targeted lung cancer screening - 55-74yrs at high risk invited for LDCT scan (reinvited every 2yrs)
