Reproductive health Flashcards
Complications of a postpartum haemorrhage
Anaemia
Blood transfusion
Hypovolaemic shock
DIC
Hysterectomy
Sheehan’s Syndrome
Death
Clinical features of a PPH
Tone- On abdominal palpation high, broad, ‘boggy’ uterus
Trauma- Visible tears to vagina and/or perineum. Be aware some high vaginal/cervical tears may only be visualised with good light and adequate analgesia
Tissue- Examination of placenta and membranes to ensure complete
Initial management for a PPH
CALL FOR HELP (Obstetric Emergency Team)
ABCDE approach (remember, with ongoing bleeding the ‘tap’ needs to be turned off or A-E approach will not work).
Airway- open airway, consider anaesthetic support
Breathing- apply O2 @ 15 litres via a non-rebreathe mask
Circulation - IV access - 2 wide bore cannulas (obtain bloods)
IV fluids – consider need for blood transfusion
Estimate blood loss - ?ongoing bleeding
Establish cause of bleeding to guide further management
Further management for PHH- Tone (most common cause)
- Rub up a contraction (massage uterus per abdomen)
- Expel any clots from uterus and vagina
- Empty bladder (FSRC)
- If blood loss continues consider bi-manual compression (tamponade effect) to prevent further blood loss while drugs taking effect
Drugs for PPH
1) 3rd stage- Syntocinon (5iu IV or 10iu IM) or Syntometrine (1 ampoule IM)
2) Uterotonics 1st line- Can repeat Syntometrine 30 mins following 3rd stage dose. Ergometrine (500ug or 250ug) (use with caution and only if no syntometrine given for 3rd stage). Oxytocin infusion (40iu in 500mls N. Saline over 4hrs)
3) Antifibrinolytic 2nd line- Tranexamic Acid 1gm IV slowly. Repeat after 30 mins if bleeding ongoing. Second line for atonic uterus First line for trauma
4) PGF2alpha 3rd line- Haemobate 250ug deep IM (repeat 15mins up to 8 doses) (Atonic uterus)
Treatment for PPH- trauma/tissue and thrombin
Trauma- any trauma should be sutured, may need to go to theatre for repair
Tissue- go to theatre for manual removal of placenta or retained tissue
Thrombin- administer Tranexamic acid and liase with haematology re.management
Care following PPH
Continue Syntocinon infusion
One-to-one care on CDS until stable
Continue to monitor PV loss and vital signs
Blood transfusion as required
FBC to check Hb – iron therapy (oral or IV as required)
(Repeat Hb with GP following discharge if necessary)
Debrief woman and birth partner
Discuss management of future labour/deliveries
Atrophic vulvo-vaginitis
Dryness and atrophy of the vaginal mucosa due to lack of oestrogen, symptom of menopause. The mucosa becomes thinner, less elastic and more dry. Changes to the vaginal pH and microbial flora that contribute to localised infection. Lack of oestrogen can cause pelvic organ prolapse and stress incontinence
Symptoms of atrophic vulvo-vaginitis
- Itching
- Dryness
- Dyspareunia
- Bleeding due to localised inflammation
- Recurrent UTI, stress incontinence or pelvic organ prolapse
Examination of atrophic vulvo-vaginitis
- Pale mucosa
- Thin skin
- Reduced skin folds
- Erythema and inflammation
- Dryness
- Sparse pubic hair
Management of atrophic vulvo-vaginitis
- Vaginal lubricants help with symptoms of dryness
- Estriol cream, applied using an applicator (syringe) at bedtime
- Estriol pessaries, inserted at bedtime
- Estradiol tablets (Vagifem), once daily
- Estradiol ring (Estring), replaced every three months
- Contraindications of topical oestrogen include breast cancer, angina and VTE
Benign prostatic Hypertrophy
Enlargement of the prostate gland causing urinary symptoms
Risk factors: age (80% of 80 year olds will have BPH), black > white > Asian
Symptoms of benign prostatic hypertrophy
- Voiding symptoms (obstructive): weak or intermittent urinary flow, straining, hesitancy, terminal dribbling, incomplete emptying
- Storage symptoms (irritative): urgency, frequency, urgency incontinence, nocturia
- Post-micturation: dribbling
- Complications: UTI, retention, obstructive uropathy
Assessment of benign prostatic hypertrophy
- dipstick urine
- U&Es: particularly if chronic retention is suspected
- PSA: should be done if there are any obstructive symptoms, of if the patient is worried about prostate cancer
- urinary frequency-volume chart= should be done for at least 3 days
International Prostate Symptom Score (IPSS)
tool for classifying the severity of lower urinary tract symptoms (LUTS) and assessing the impact of LUTS on quality of life
* Score 20–35: severely symptomatic
* Score 8–19: moderately symptomatic
* Score 0–7: mildly symptomatic
Treatment of benign prostatic hypertrophy
- Alpha 1-antagonist i.e. tamsulosin, alfuzosin. Recommended in moderate to severe voiding symptoms. Side effects: dizziness, postural hypotension, dry mouth, depression
- 5 alpha- reductase inhibitors i.e. Finasteride. When there is a significantly enlarged prostate. Side effects, erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
- Combination= alpha-1 antagonist and 5 alpha-reductase inhibitor. For moderate to severe voiding symptoms and prostatic enlargement
- If symptoms persist after treatment with an alpha-blocker alone, then use an antimuscarinic (anticholinergic) drug (tolterodine or darifenacin)
- surgery- transurethral resection of prostate (TURP)
Candidiasis- definition and risk factors
Thrush is an extremely common condition, 80% are caused by Candida albicans
Risk factors:
* Diabetes mellitus
* Drugs: antibiotics, steroids
* Pregnancy
* Immunosuppression: HIV
Features of Candidiasis
- ‘Cottage cheese’ non offensive discharge
- Vulvitis: superficial dyspareunia, dysuria
- Itch
- Vulval erythema, fissuring, satellite lesions may be seen
Investigations- often a clinical diagnosis, though a high vaginal swab can be used
Management of Candidiasis
- Oral fluconazole 150 mg as a single dose first-line
- Clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
- If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal
- If pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
Recurrent vaginal candidiasis
- BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
- Compliance with previous treatment should be checked
- Confirm the diagnosis of candidiasis- high vaginal swab for microscopy and culture, consider a blood glucose test to exclude diabetes
- Exclude differential diagnoses such as lichen sclerosus
- Consider the use of an induction-maintenance regime, induction: oral fluconazole every 3 days for 3 doses, maintenance: oral fluconazole weekly for 6 months
Cervical ectropian
On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix
Features of cervical ectropian
- vaginal discharge
- post-coital bleeding
Treatment of cervical ectropion
Problematic bleeding is an indication for the treatment of cervical ectropion. Treatment involves cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy. Usually stops when the patient goes off the pill or is no longer pregnant
Cervical polyp
A piece of skin that sticks out from the cervical canal. Most common in women who have had children and have now stopped their periods. Symptomless except for irregular vaginal bleeding
Treatment for cervical poylp
Twisting the polyp off the cervix, does not require local anaesthetic. Cant be felt, except for crampy abdominal pain
Chorioamnionitis
A potentially life-threatening condition to both mother and foetus and is a medical emergency. It is the result of an ascending bacterial infection of the amniotic fluid / membranes / placenta. The major risk factor is the preterm premature rupture of membranes (can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens. Prompt delivery of the foetus (via cesarean section if necessary) and administration of intravenous antibiotics is done
Symptoms of chorioamniotis
- Fever
- Mother or fetus has rapid heartbeat
- Tender or painful uterus
Vaginal discharge with an unpleasant smell or unusual colour - Sweating
Complications of chorioamnionitis
- Infection in the pelvic region and abdomen
- Endometriotis
- Blood clots in the pelvis or lungs
- Sepsis
- Newborn complications: sepsis, meningitis, pneumonia
Risk factors for chorioamnionitis
- Premature labour
- Water breaks more than 24 hours before delivery
- Long labour
- Vaginal infection or STI
- Group B strep
- Frequent vaginal exams after your water breaks
- Internal fetus or uterine monitoring
Placenta praevia
When the placenta lies wholly or partly in the lower uterine segment
Associated factors= Multiparity, multiple pregnancies, previous caesarean section
Clinical features of placenta praevia
- Shock in proportion to visible loss
- No pain
- Uterus not tender
- Lie and presentation may be abnormal
- Fetal heart usually normal
- Coagulation problems rare
- Small bleeds before large
Diagnosis of placenta praevia
- Digital vaginal examination should not be performed before an ultrasound as it may provoke a severe haemorrhage
- Placenta praevia is often picked up on the routine 20 week abdominal ultrasound
- The RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe
Classical grading of placental praevi
- I - placenta reaches lower segment but not the internal os
- II - placenta reaches internal os but doesn’t cover it
- III - placenta covers the internal os before dilation but not when dilated
- IV (‘major’) - placenta completely covers the internal os
If low lying placenta at the 20 week scan
- Rescan at 32 weeks
- No need to limit activity or intercourse unless they bleed
- If still present at 32 weeks and grade I/II then scan every 2 weeks
- Final ultrasound at 36-37 weeks to determine the method of delivery: elective caesarean section for grades III/IV between 37-38 weeks. If grade I then a trial of vaginal delivery may be offered
- If a woman with known placenta praevia goes into labour prior to the elective caesarean section an emergency caesarean section should be performed due to the risk of post-partum haemorrhage
Placental praevia with bleeding
- admit
- ABC approach to stabilise the woman
- if not able to stabilise → emergency caesarean section
- if in labour or term reached → emergency caesarean section
Prognosis with placental praevi
- death is now extremely rare
- major cause of death in women with placenta praevia is now PPH
Placental abruption
Separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
Cause of placental abruption
Not known but associated factors:
* proteinuric hypertension
* cocaine use
* multiparity
* maternal trauma
* increasing maternal age
Clinical features of placental abruption
- shock out of keeping with visible loss
- pain constant
- tender, tense uterus
- normal lie and presentation
- fetal heart: absent/distressed
- coagulation problems
- beware pre-eclampsia, DIC, anuria
Placental abruption, fetus alive and <36 weeks
- fetal distress: immediate caesarean
- no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Placental abruption: Fetus alive and >36 weeks
Fetus dead
Fetus alive and > 36 weeks
* fetal distress: immediate caesarean
* no fetal distress: deliver vaginally
Fetus dead= induce vaginal delivery
Complications of fetal abruption
- Maternal= shock, DIC, renal failure, PPH
- Fetal= IUGR, hypoxia, death
- Prognosis= associated with high perinatal mortality rate, responsible for 15% of perinatal deaths
Endometrial hyperplasia
An abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer
Types of endometrial hyperplasia and features
- simple
- complex
- simple atypical
- complex atypical
Features: abnormal vaginal bleeding i.e. intermenstrual
Management of endometrial hyperplasia
- simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
- atypial: hysterectomy is usually advised
Features of a UTI
- dysuria
- urinary frequency
- urinary urgency
- cloudy/offensive smelling urine
- lower abdominal pain
- fever: typically low-grade in lower UTI
- malaise
Treatment for non-pregnant women UTI
- Trimethoprim (first line) or nitrofurantoin for 3 days
- send a urine culture if: aged > 65 years, visible or non-visible haematuria
Treatment for pregnant women UTI (symptomatic)
A urine culture should be sent in all cases, should be treated with an antibiotic for first-line: nitrofurantoin (should be avoided near term), second-line: amoxicillin or cefalexin. Trimethoprim is teratogenic in the first trimester and should be avoided during pregnancy
Treatment for pregnant women asymptomatic: UTI
A urine culture should be performed routinely at the first antenatal visit. An immediate antibiotic prescription of either nitrofurantoin (should be avoided near term), amoxicillin or cefalexin. This should be a 7-day course. the rationale of treating asymptomatic bacteriuria is the significant risk of progression to acute pyelonephritis. a further urine culture should be sent following completion of treatment as a test of cure
Treatment of UTI (men)
- an immediate antibiotic prescription should be offered for 7 days
- as with non-pregnant women, trimethoprim or nitrofurantoin should be offered first-line unless prostatitis is suspected
- a urine culture should be sent in all cases before antibiotics are started
Treatment for UTI: catheterised patients
- do not treat asymptomatic bacteria in catheterised patients
- if the patient is symptomatic they should be treated with an antibiotic
- a 7-day, rather than a 3-day course should be given
- consider removing or changing the catheter as soon as possible if it has been in place for longer than 7 days
Treatment for acute pyelonephritis
- For patients with sign of acute pyelonephritis hospital admission should be considered
- the BNF currently recommends a broad-spectrum cephalosporin or a quinolone (for non-pregnant women) for 10-14 days
