reproductive Flashcards
describe the HP-GA axis
hypothalamus releases GnRH which stimulates anterior pituitary to secrete LH and FSH.
LH and FSH stimulate the follicle and in return oestrogen is secreted that inhibits the axis.
Theca granulosa cells around the follicle secrete
oestrogen
physiological role of oestrogen is for
development of female sex organs, uterine blood vessels and endometrial development
physiological role of progesterone
thickens both the cervical mucous and maintains endometrium and increases body temp.
age of puberty in females
8-14
age of puberty in males
9-15
average length of puberty
4 years
why may girls with low weight have a delayed puberty
lack of aromatase due to reduced adipose deposits
female puberty starts with development of
breast buds, then pubic hair and then menarche
scale for measuring puberty development is
tanner scale
during puberty FSH levels plateau how long before menarche?
a year
a follicle develops receptors for FSH in which stage?
secondary follicle stage
ovulation occurs what day of the cycle?
day 14
what hormone maintains the corpeus luteum and where does this originate?
HCG from the syncytiotrophoblast
during menstruation what does the stromal cells release
prostaglandins
primary oocyte is contained within
pregranulosa cells surrounded by outer basal lamina layer
three layers of the primary follicle
primary oocyte, zona pellucida and the granulosa cells
as the follicle grows id develops a further surrounding layer called the
theca folliculi
the inner theca folliculi name and function
theca interna secretes androgen hormones
theca externa consists of
connective tissue, smooth muscle and collagen
development of the secondary follicle involves
growth of the antrum within the granulosa. the granulosa cells surrounding the follicle as referred to as the corona radiata.
role of LH in ovulation
surge of LH triggers the theca externa to squeeze releasing the ovum.
primary oocyte meiosis creates
a polar body and a haploid cell called the secondary oocyte.
development of the fertilised cell as it migrated along the fallopian tube
zygote->morula->blastocyst which contains the embryoblast and surrounding this is the trophoblast.
the cells of the trophoblast undergo adhesion with the
stroma of the endometrium
endometrial stroma cells in contact with the trophoblast convert into the
decidua
a week after fertilisation the embryoblast forms into
yolk sac and the amniotic cavity
the choroin surrounds the embryonic complex and has two sides called
cytotrophoblast (inner) and the syncytiotrophoblast (outer)
the outer ectoderm layer forms
skin, hair, nails, teeth, CNS
the middle mesoderm layer forms
heart, muscle, bone, connective tissue, blood and kidneys
inner endoderm layers forms
GI tract, lungs, liver, pancreas, thyroid and reproductive system
at how many weeks does the heart form and start to beat?
6 weeks
the myometrium sends of arteries into the endometrium called
spiral arteries
the placenta originates from the
chorion frondosum
spiral arteries degenerate int
lacunae (lakes of blood)
lacunae form around what week?
week 20
if spiral arteries maintain vascular resistance this runs the risk of
pre-eclampsia
functions of the placenta are
respiration, nutrition, excretion, endocrine and immunity
HCG plateus around what week of gestation?
ten weeks
placental oestrogen role
softens tissue and increases flexibility to expand pelvis and soften cervix.
which has a higher affinity for oxygen foetal or adult haemoglobin
foetal
placental progesterone role
maintain pregnancy through muscle relaxation
hormonal changes during pregnancy include
raised ACTH, prolactin, progesterone, oestrogen, HCG, T3 and t4 and melanocyte stimulating hormone
consequences of increased ACTH during pregnancy are
rise in cortisol and aldosterone (steroids) improving autoimmune conditions but increased risk of diabetes.
consequences of increased melanocyte stimulating hormone are
linea nigra and melasma
role of prostaglandins prior to delivery
breakdown collagen in cervix enabling dilation
CV changes during pregnancy
increase: blood volume, cardiac output and decreased peripheral vascular resistance and blood pressure in early pregnancy
respiratory changes during pregnancy
increased tidal volume and respiratory rate
renal changes during pregnancy
increased blood flow, GFR, aldosterone, protein excretion and hydronephrosis
haematological and biochem changes during pregnancy
raised ESR, d-dimer, Alk P, WBC and platelets but reduced albumin.
stage one of labour is
onset of contractions until 10cm cervical dilation
stage two of labour is
delivery of baby
third stage of labour is
placental delivery
braxton hicks contractions are
irregular contractions of the uterus during second and third trimester
three phases of the first stage of labour
latent phase (o.5 cm per hour, irregular contractions) active phase (1cm per hour) Transition phase (strong regular contractions)
stage 2 depends upon the three P’s
Power - uterine contractions
Passenger (size, attitude (position), Lie, presentation
Passage
different presentations of the passenger include
cephalic, shoulder, breech
three different types of breech include
complete (hips and knees flexed)
frank (hips flexed but knees extended)
footling (foot hanging through cervix)
cardinal movements of labour are
Engagement Descent Flexion Internal Rotation Extension Restitution and external rotation Expulsion
active management of the third stage of labour may involve
an intramuscular injection of oxytocin.
what fraction of couples struggle to conceive naturally?
1/7
investigation for infertility should occur after
12 months, or six months if >35yrs
commonest causes for infertility
mixed (40%) sperm problems (30%) tubal problems (15%)
general advice for infertility
The woman should be taking 400mcg folic acid daily
Aim for a healthy BMI
Avoid smoking and drinking excessive alcohol
Reduce stress as this may negatively affect libido and the relationship
Aim for intercourse every 2 – 3 days
Avoid timing intercourse
initial investigations for infertility
Body mass index (BMI) (low could indicate anovulation, high could indicate PCOS) Chlamydia screening Semen analysis Female hormonal testing (see below) Rubella immunity in the mother
female hormone testing for infertility involves
Serum LH and FSH on day 2 to 5 of the cycle
Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).
Anti-Mullerian hormone
Thyroid function tests when symptoms are suggestive
Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea
high FSH in infertility indicates
poor ovarian reserve
high LH in infertility indicates
PCOS
high Anti-mullerian hormone in infertility indicates
high ovarian reserve
further investigations for infertility include
US, hysterosalpingogram, laparoscopy, and dye test.
management of anovulation in infertility includes
clomifene, ovarian drilling, metfromin, weight loss and gonadotrophins
clomifene is a
selective oestrogen receptor modulator (anti oestrogen)
management of tubal factors for infertility include
Tubal cannulation during a hysterosalpingogram
Laparoscopy to remove adhesions or endometriosis
In vitro fertilisation (IVF)
management of sperm problems for infertility include
surgical sperm retrieval, surgical correction, intra-uterine insemination, intracytoplasmic sperm injection and donor insemination
sperm sample analysis looks at
volume, semen pH, concentration, total number, motility, vitality, and percentage
pre-testicular causes of infertility include
Pathology of the pituitary gland or hypothalamus
Suppression due to stress, chronic conditions or hyperprolactinaemia
Kallman syndrome
testicular causes of infertility
Mumps Undescended testes Trauma Radiotherapy Chemotherapy Cancer genetic congenital
investigations into infertility for men include
LH, FSH, testosterone, geentic testing, MRI, US, vasography and testicular biopsy
post testicular causes of infertility
Damage to the testicle or vas deferens from trauma, surgery or cancer
Ejaculatory duct obstruction
Retrograde ejaculation
Scarring from epididymitis, for example, caused by chlamydia
Absence of the vas deferens (may be associated with cystic fibrosis)
Young’ syndrome is
(obstructive azoospermia, bronchiectasis and rhinosinusitis)
success rate of IVF
25-30%
IVF process
Suppressing the natural menstrual cycle Ovarian stimulation Oocyte collection Insemination / intracytoplasmic sperm injection (ICSI) Embryo culture Embryo transfe
methods for suppression of natural menstruation cycle
GnRH agonists or GnRH antagonists
ovarian stimulation is through
injections of FSH, once follicles have developed then injection of HCG 36 hours before collection
fertilised eggs in IVF are observed until the
blastocyst stage (day 5)
complication of IVF treatment is
ovarian hyperstimulation syndrome
pathology of ovarian hyperstimulation syndrome
increase in VEGF (vascular endothelial growth factor), fluid leaks to the extravascular space causing oedema, ascites and hypovolaemia
OHSS is specifically triggered by
HCG injection 36 hours prior to oocyte collection
monitoring for OHSS risk is through
serum oestrogen and US
risk reduction for OHSS is through
lower doses of hCG and GnRH antagonist
symptoms of OHSS
Abdominal pain and bloating Nausea and vomiting Diarrhoea Hypotension Hypovolaemia Ascites Pleural effusions Renal failure Peritonitis from rupturing follicles releasing blood Prothrombotic state (risk of DVT and PE)
management of OHSS is through
Oral fluids
Monitoring of urine output
Low molecular weight heparin (to prevent thromboembolism)
Ascitic fluid removal (paracentesis) if required
IV colloids (e.g. human albumin solution
haematocrit may be monitored to assess
volume of fluid in the intravascular space
folic acid 400mcg should be started in pregnancy from
12 weeks
why is folic acid taken in pregnancy?
reduces risk of neural tube defects
why should unpasturised dairy or blue cheese be avoided in pregnancy?
listeriosis
typically what weeks does ectopic pregnancies present?
6-8 weeks
presentation of an ectopic
Female patient with delayed menstruation and a history of sexual intercourse
Lower abdominal pain – constant and in the iliac fossa
Vaginal bleeding
Lower abdominal tenderness
Cervical excitation
criteria for methotrexate in an ectopic pregnancy
Unruptured Adnexal mass < 35mm No visible heart beat No significant pain hCG level <1500 IU / l Confirmed absence of intrauterine pregnancy on ultrasound
criteria for surgery in ectopic pregnancy
anything that doesn’t meet methotrexate criteria
miscarriage occurs in what fraction of pregnancies
1/5
missed miscarriage definition
foetus has died <20 weeks but inside uterus
threatened miscarriage definition
vaginal bleeding with closed cervix but foetus alive
incomplete miscarriage definition
retained products of conception
inevitable miscarriage
bleeding with open cervix
complete miscarriage
full miscarriage with no products of conception left
anembryonic pregnancy refers too
gestational sac present but n embryo
treatment for incomplete miscarriage
misoprostol vaginal pessary or evacuation of retained products of conception via surgery
recurrent miscarriage is referred to as
> 3 miscarriages in a row
causes of recurrent miscarriage
idiopathic, antiphospholipid syndrome, uterine abnormalities, genetic factors or chronic histiocytic intervillositis
investigations for recurrent miscarriage
antiphospholipid antibodies, pelvic US or genetic testing
diagnosis of chronic histiocytic intervillositis is made by
histology showing mononuclear infiltrate in the intervillous spaces of the placenta
medical abortion procedure
mifepristone followed 1-2 days by misoprostol
mifepristone is what type of drug?
anti-progestogen
misoprostol is what kind of drug
prostaglandin
two types of surgical abortion
cervical dilatation and suction of contents (15 weeks) or evacuation (15-24 weeks)
nausea vomiting in pregnancy peaks around
8-12 weeks gestation
correlation between high bHCG levels and
morning sickness due to molar pregnancies and multiple pregnancies
criteria for diagnosis of hyperemesis gravidarum
> 5% weight loss, dehydration and electrolyte imbalance
measuring severity of morning sickness is out of
pregnancy unique quantification of emesis score (PUQE) (15)
antiemetics for hyperemesis gravidarum
prochlorperazine or cyclizine
admission for hypermesis gravidarum should be considered for
unable to tolerate fluid.
Ketones on dipstix.
electrolyte imbalances and other medical conditions.
severe hypermesis gravidarum Tx
IV fluids, IV antiemetics, thiamine supplements and thromboprophylaxis.
complete mole pregnancy is caused by
two sperm fertilising an ovum with no genetic material
partial mole pregnancy occurs when
two sperm fertilise a normal ovum
presentation of molar pregnancy
More severe morning sickness. Vaginal bleeding Increased enlargement of the uterus Abnormally high bHCG Thyrotoxicosis
US appearance of molar pregnancy
snowstorm appearance
diagnosis confirmation of molar pregnancy is by
histology
risk of what malignancy with molar pregnancy
gestational trophoblastic disease
pregnancy anaemia checks around
8-12 weeks and 28 weeks
anaemic pregnant women should be started on
ferrous sulphate 200mg three times daily
women with low B12 should be tested for
pernicious anaemia
pre-eclampsia triad
hypertension, proteinuria and oedema
eclampsia refers to
seizures as a result of pre-eclampsia
high risk factors for pre- eclampsia
Pre-existing hypertension Previous pre-eclampsia Existing autoimmune conditions (e.g. SLE, antiphospholipid syndrome) Diabetes Chronic Kidney Disease
moderate risk factor for pre-eclampsia
Older than 40 Obese (BMI >35) More than 10 years since previous pregnancy Multiple pregnancy First pregnancy Family history of pre-eclampsia
pre-eclampsia has symptoms of
Headache Visual disturbance / blurriness Upper abdominal / epigastric pain Reduced urine output Brisk reflexes Nausea and vomiting Oedema
pre-eclampsia epigastric pain is due to
liver swelling
prophylaxis for pre-eclampsia involves
75mg aspirin from 12 weeks to birth if high risk or several moderate risk factors
first line anti-hypertensive in pre-eclampsia is
labetolol
when is magnesium sulphate given in pre-eclampsia
during labour and 24 hours post or IV bolus in eclampsia
monitoring in pre-eclampsia involves
blood pressure, symptoms, urine dipstick, platelets, liver enzymes, U+E, foetal movement, amniotic fluid volume, growth scans and doppler.
HELLP syndrome refers too
haemolysis, elevated liver enzymes and low platelets.
what treatment does a rhesus positive mother during pregnancy require?
none
what is the consequence of sensitization between a rhesus negative mother and rhesus positive son
haemolytic disease of the newborn
prevention of rhesus sensitisation is through
anti-D medication given routinely at 28 weeks and again at birth or during any events
the test to assess blood transfer during a sensitisation event is called
Kleihauer test
if you have the risk factors for gestational diabetes when should you be tested?
oral glucose tolerance test at booking and 26 weeks gestation
risk factors for gestational diabetes are
Raised BMI (>30)
Previous gestational diabetes
Asian, black Caribbean, Middle Eastern
Previous macrocosmic baby (or large for dates baby on scans)
Family history of diabetes (first degree relative)
after an OGTT blood sugars are baseline and 2 hours should be
<5.6 at baseline and at 2 hours <7.8
management for those >7 blood sugars during pregnancy
insulin, less is exercise and diet.
safe diabetic agents for pregnancy?
insulin or metformin only.
diabetic screening during pregnancy should occur for
retinopathy
small foetus is defined as
below the 10th centile for their gestational age
causes of foetal growth restriction
Idiopathic Pre-eclampsia Maternal smoking Maternal alcohol Anaemia Malnutrition Infection
growth restricted babies have a tendency towards
hypertension and type 2 diabetes
large for gestational age is defined as
born at a weight of more than 4kg
complications of chicken pox during pregnancy
varicella pneumonitis in the mother, or foetal varicella syndrome resulting in developmental abnormalities
for mothers prophylaxis against chickenpox then treatment with
IV varicella immunoglobulins
congenital rubella syndrome refers too
congenital disease, sensorineural deafness and cataracts
the rubella vaccine is what type of vaccine?
live
should pregnancy women receive live vaccines?
no
chickenpox rash in pregnancy should be treated within 24 hours with
aciclovir
chorioamnioitis presents with
Fever
Abdominal pain
Sepsis (tachycardia, tachypnoea, hypotension)
Evidence of fetal compromise on CTG
with monoamniotic twins should aim to deliver around
32-34 weeks
with diamniotic twins should aim to deliver around
37-38 weeks
twin twin transfusion syndrome cause
one donor to become starved and the other fluid overloaded
first choice test for down’s syndrome is
combined test
US for nuchal translucency and maternal blood tests of high BHCG and low PAPPA
nuchal thickness of what mm sign of down’s syndrome
> 6mm
triple test for down’s syndrome involves
BHCG (high), AFP (Low) and serum oestriol (low)
antenatal testing is offered if risk is greater than
1/150
antenatal testing comes in the forms of
chorionic villus sampling or amniocentesis samples for karyotyping.
placenta praevia refers too
placenta covering lower portion of the uterus below the foetus
presentation of placenta praevia
painless bleeding around 36 weeks
management of placenta praevia
US scans, elective caesarean AVOID VAGINAL EXAMS
placental abruption refers too
large maternal haemorrhage
presentation of placental abruption is
“woody” abdomen, CTG abnormalities, shock (hypotension, tachycardia), vaginal bleeding and continuous severe pain.
placental abruption resus of mother Tx
2 x grey cannula
Bloods including crossmatch and coagulation studies
Fluid and blood resuscitation as required
May need a fresh frozen plasma infusion
further treatment for placental abruption is through
delivery of baby, Anti-D and monitoring for post partum haemorrhage
presentation of obstetric cholestasis
Later in pregnancy (third trimester)
Itchiness, particularly to the palms of the hands and soles of the feet
No rash
Abnormal LFTs and Bile acids
managment of obstetric cholestasis is
Ursodeoxycholic acid, emollients, antihistamines, vit K and birth of baby.
a rare cause of acute hepatitis in third trimester of pregnancy is
acute fatty liver of pregnancy
presentation of acute fatty liver of pregnancy is
General malaise
Nausea and vomiting
Jaundice
Abdominal pain
biochemistry for acute fatty liver of pregnancy
Liver function tests will show elevated liver enzymes, particularly ALT.
risk factors for a DVT or PE in pregnancy
Smoking Parity >3 Age >35 BMI >30 Reduced mobility Multiple pregnancy Personal history of VTE Family history of VTE Low risk thrombophilia
situations to initiate labour early?
macrosomia, reduced foetal movements, pre-eclampsia and premature rupture of membranes
Bishop score is for
to determine whether to induce labour
A bishop score of what is sufficient for successful induction of labour
8
criteria of Bishop’s score
feotal station cervical position cervical dilatation cervical effacement cervical consistency
two main methods of induction are
membrane sweep or vaginal pessaries
membrane sweep induction involves
finger stimulation of cervix
vaginal pessaries induction involves
prostaglandin E2
indications for continuous CTG
Sepsis Oxytocin Meconium Pre-eclampsia (with blood pressure >160 / 110) Antepartum haemorrhage
key features of CTG are
Contractions Baseline Rate Variability Accelerations Decelerations
what drugs are used for stimulating uterine contraction
syntocinon (oxytocin), ergometrine and syntometrine.
active management of third stage of labour involves
empty bladder, IM syntocin, cord clamping, palpation of abdomen and controlled cord traction to deliver placenta in one piece.
optimum uterine contraction ratio is
4 contractions every 10 minutes.
indications for caesarean are
Previous caesarean Placenta praevia Breech presentation Cephalopelvic Disproportion (large baby small pelvis) Female choice (after full discussion about pros and cons) IUGR Post-maturity Uncontrolled HIV infection Cervical cancer
target decision time for emergency threat to mother or baby for C section is
30 minutes
post op emergency C section should be offered
thromboprophylaxis
survival of 23 weekers are
10%
term is birth after how many weeks?
> 37 weeks
methods for prophylaxis of preterm labour are
vaginal progesterone and cervical cerclage (stitch in cervix)
diagnosis of preterm prelabour rupture of membranes is through
speculum, insulin-like growth factor binding protein or placental alpha-microglobin-1
management of preterm prelabour rupture of membrane should involve
prophylactic antibiotics
preterm labour with intact membranes require
foetal monitoring, tocolysis (stop contractions with nifedipine), maternal corticosteroids and magnesium sulfate.
corticosteroids should be given if a preterm labour is before how many weeks?
less than 36 weeks gestation
how to monitor for magnesium toxicity?
reflex times
IV magnesium sulfate in premature delivery protects from?
cerebral palsy
risk factors for a amniotic fluid embolism are
Increasing maternal age
Induction of labour
presentation of amniotic fluid embolism is
Shortness of breath Cough Respiratory failure Tachycardia Hypotension Fever Haemorrhage
uterine rupture requires
emergency laparotomy
risk factors for uterine rupture are
Vaginal birth after caesarean (VBAC) Previous uterine surgery Increased BMI High parity Induction of labour
initial management of a shoulder dystocia may require
episiotomy or a McRoberts manoeuvre
mcrobert’s manoeuvre of a shoulder dystocia requires
hyperflexing the mother at the hip (bringing her knees all the way to her abdomen) provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way.
Rubin’s manoeuvre of a shoulder dystocia requires
reaching into the vaginal to put pressure on the posterior aspect of the babies anterior (stuck) shoulder to help it deliver under the pubic symphysisis.
wood screw manoeuvre of shoulder dystocia requires
hilst doing Rubins Manoeuvre, the other hand is used to reach in the vaginal and put pressure on the anterior aspect of the posterior shoulder. This way you encourage the baby to twist sideways and be delivered. If this doesn’t work, the reverse motion can be tried (pushing the top shoulder backwards and the bottom shoulder forwards).
Zavanelli Manoeuver of shoulder dystocia involves
The Zavanelli manoeuvre involves pushing the babies head back into the vagina so that the baby can be delivered by emergency caesarean.
complications of shoulder dystocia are
Fetal hypoxia (and subsequent cerebral palsy)
Erb’s palsy (due to damage of the brachial plexus)
Perineal tears
Postpartum haemorrhage
biggest risk factor for cord prolapse is
abnormal lie after 37 weeks
diagnosis of cord prolapse is through
CTG, vaginal examination or speculum.
management of cord prolapse is
emergency C section, presenting part pushed back in, not handling the cord (vasospasm), left lateral lie and toclytic medication (nifedipine)
ventouse delivery involves
suction cup on babies head and cord traction
ventouse delivery risk
cephalohaematoma
forceps delivery risk is
facial nerve palsy and temporary fat necrosis
episiotomy procedure
diagonal 45 degree cut downwards and laterally
post partum haemorrhage is defined as
500ml after normal delivery or 1l after C section
four causes T’s of post partum haemorrhage
Tone
Tissue
Trauma
Thrombin
risk factors for post partum haemorrhage
Previous PPH Multiple pregnancy Grand multipara (5 or more normal vaginal deliveries) Large baby Slow or failure to progress in second stage of labour Pre-eclampsia Retained placenta Anaesthetic
prevention of PPH is through
treatment of anaemia, empty bladder, oxytocin during third stage of labour and tranexamic acid
managment of PPH is with
resus, large bore cannula, major haemorrhage protocol, group and cross match
mechanical treatment of PPH
rubbing the uterus from the abdomen and catheter
medical treatment of PPH
IV 10 units of syntocinon, carboprost and misoprostol prostaglandin analogues and tranexamic acid
surgical treatment of PPH
B-lynch suture, balloon tamponade, uterine artery ligation or last resort hysterectomy
uterine inversion is
when the uterus drops don into the cervix causing PPH
Johnson’s manoeuvre is when
hand to push back an inverted uterus back into the abdomen
postnatal check is usually performed around
6 weeks same time as the newborn baby check
key areas for a post natal check are
bleeding, healing, breast feeding, blood fasting glucose if gestational diabetes, blood pressure and urine dipstick for pre-eclampsia
post partum Hb<100g/l you should
start oral iron ferrous sulphate
post partum Hb<70g/l you should
give a blood transfusion in addition to oral iron
mastitis is
inflammation of the breast tissue due to accumulation of milk in the ducts
presentation of mastitis is
Breast pain and tenderness (unilateral)
Erythema
Local warmth and inflammation
Fever
infective mastitis may be caused by
Staph aureus
initial managment of mastitis should be
expressing and analgesia
second line active treatment of mastitis is through
flucloxacillin, with milk sent for culture and sensitivities
post natal depression is seen by what fraction of women?
one in ten
peak of postnatal depression is
3 months
“baby blues” occur commonly around the
first week
puerperal psychosis is seen by what fraction of women
1/1000 starting a few weeks after birth
what is the screening tool for post natal depression?
Edinburgh postnatal depression scale
significant score on the Edinburgh postnatal depression scale is
score 10/30 is significant
common post partum endocrine issue is
postpartum thyroiditis
hyperthyroidism is managed with
propranolol
hypothyroidism is managed with
levothyroxine
sheehan’s syndrome is a complication of
post partum haemorrhage
sheehan’s syndrome refers to
necrosis of the pituitary gland
pathology of sheehan’s syndrome
anterior pituitary gland blood supply is from the hypothalamo-hypophysial portal system which is susceptible to rapid drops in blood pressure
presentation of sheehan’s syndrome
Reduced lactation (lack of prolactin)
Amenorrhea (lack of LH and FSH)
Adrenal Insufficiency (lack of ACTH)
Hypothyroidism (lack of TSH)
what contraception would you want to avoid in breast cancer?
avoid any hormonal contraception and opt for copper coil
cervical and endometrial cancer contraception advice?
avoid the intrauterine system - mirena
what contraception advice would you give for someone with wilson’s disease?
avoid the copper coil.
COCP specific risk factors
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura
History of VTE
Aged over 35 smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
Systemic lupus erythematosus and antiphospholipid syndrome
progesterone injection and COCP can be used up to
age fifty
fertility post pregnancy isn’t considered until
21 days
COCP after pregnancy should be started until
6 weeks to avoid concurrent use during breastfeeding
diaphragms and cervical caps are utilised with
spermicide gel
COCP mechanims is through
preventing ovulation, thickens cervical mucous and inhibits endometrial proliferation
first lien COCP is
levonorgestrel
cancer risk with COCP is what and returns to normal when?
breast and cervical but returns to normal ten years post
COCP started day 0-5 of cycle provides
immediate protection
COCP after day 5 of cycle requires
7 days of protection
missing one COCP pill (<72 hours) requires
taking missed pill ASAP (even if double pilling)
missing one COCP pill >72 hours require
additional contraception and potentially emergency contraception if day 1-7, and taking missing pill ASAP
what else classifies as missing the pill for COCP?
vomiting and diarrhoea
prior to a major op COCP should be stopped how many weeks prior
4 weeks
CI for pop is
active breast cancer
traditional POP or desogrestel only pill a missed dose is counted as
trad > 3hrs or desogrestel >12 hours
POP day 1-5 of cycle confers
immediate protection
POP >5 days req.
48 hours of protection
primary adverse effect of POP is
unscheduled bleeding; third no bleed, third normal and third prolonged or heavy
missed pill POP guidance
pill ASAP, extra contraception and if had intercourse then emergency contraception
progestogen injection timetable
every 12-13 weeks
depo-provera route of delivery
IM injection
risk factors for injectable progestogen
weight gain, irregular bleeding and osteoporosis
benefits for injectable progestogen are
improves endometriosis, dysmenorrhoea, risk of ovarian and endometrial cancer and severity of sickle cell crisis
progestogen only implant lasts for
3 years
implant contraception CI in
active breast cancer
implant problematic bleeding treatment is
COCP
CI for coils are
Pelvic inflammatory disease or infection Immunosuppression Pregnancy Unexplained bleeding Pelvic cancer Uterine cavity distortion (e.g. by fibroids)
examination required prior to coil insertion is
bimanual
check up after how many weeks post coil insertion?
3-6 weeks
risks relating to coil insertion are
Bleeding
Pain on insertion
Vasovagal reactions
Uterine perforation (1 in 1000, higher in breastfeeding women)
Pelvic inflammatory disease (particularly in the first 20 days)
The expulsion rate is highest in the first three months
vasovagal reaction refers too
(dizziness, bradycardia and arrhythmias)
problematic bleeding with coil insertion is common for the first how many months?
6
women with smear tests may reveal what organism if they have a coil?
actinomyces like organisms
emergency contraception levonorgestrel should be taken within
72 hours s
emergency contraception ulipristal should be taken within
120 hours
copper coil should be inserted within as an emergency contraception
5 days
most effective emergency contraception is
copper coil as not affected by BMI, enzyme inducing drugs or malabsorption
risk of copper coil as emergency contraception
pelvic inflammatory disease if STI risk
ilipristal should be avoided in patients with
severe asthma
female sterilisation involves
tubal occlusion with filshie clips via laparoscopy
failure rate of female sterilisation
1/200
vasectomy failure rate is
1/2000
sperm testing should take place how many post weeks for vasectomy?
12 weeks
Gillick competence refers too
understanding and intelligence of a child to voluntarily consent to treatment on a case by case basis
what are the frazer guidelines
- mature and intelligent enough to understand
- They can’t be persuaded to discuss it with their parents or let the health professional discuss it
- likely to have intercourse regardless of treatment
- physical or mental health likely to suffer
- in their best interest
1st trimester screening consists of
Statistical analysis of maternal age, NT measurement & biochemical markers free beta HCG and PAPP-A
1st trimester screening occurs during what gestation?
11+2 - 14+1 G
parents can opt for screening for what conditions
Screening for Trisomies 21, 18 and 13.
trisomy 13 refers to
Patau’s syndrome
trisomy 18 refers too
edward’s syndrome
2nd trimester occurs in what gestation?
14+2 - 20 weeks
2nd trimester screening involves
Quadruple maternal serum screening (statistical analysis of maternal age & biochemical markers AFP, Beta HCG, Inhibin A, oestradiol).
high risk for down syndrome (>1/150) involves what test next line?
Non-invasive prenatal testing (NIPT)
NIPT or non invasive prenatal testing involves
detection of free fetal DNA in maternal symptom
High risk on NIPT warrants use of
Chorionic villus sampling (CVS)
Amniocentesis
Cordocentesis (Fetal blood sampling FBS)
risk of foetal loss with invasive testing is
approx 0.5 - 1% for CVS or Amniocentesis
as what week in gestation does an anomaly scan take place
20 weeks
20 week anomaly scan looks at
structural anomalies and also for “soft markers “ of chromosomal abnormality
3rd trimester scan involves
Serial Scanning every 4 weeks from 28 weeks gestation is undertaken as a screening for Fetal Growth Restriction.
