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Year 3- placement > Reproductive health > Flashcards

Reproductive health Flashcards

1
Q

Complications of a postpartum haemorrhage

A

Anaemia
Blood transfusion
Hypovolaemic shock
DIC
Hysterectomy
Sheehan’s Syndrome
Death

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2
Q

Clinical features of a PPH

A

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

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3
Q

Initial management for a PPH

A

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

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4
Q

Further management for PHH- Tone (most common cause)

A
  • 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
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5
Q

Drugs for PPH

A

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)

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6
Q

Treatment for PPH- trauma/tissue and thrombin

A

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

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7
Q

Care following PPH

A

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

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8
Q

Atrophic vulvo-vaginitis

A

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

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9
Q

Symptoms of atrophic vulvo-vaginitis

A
  • Itching
  • Dryness
  • Dyspareunia
  • Bleeding due to localised inflammation
  • Recurrent UTI, stress incontinence or pelvic organ prolapse
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10
Q

Examination of atrophic vulvo-vaginitis

A
  • Pale mucosa
  • Thin skin
  • Reduced skin folds
  • Erythema and inflammation
  • Dryness
  • Sparse pubic hair
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11
Q

Management of atrophic vulvo-vaginitis

A
  • 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
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12
Q

Benign prostatic Hypertrophy

A

Enlargement of the prostate gland causing urinary symptoms
Risk factors: age (80% of 80 year olds will have BPH), black > white > Asian

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13
Q

Symptoms of benign prostatic hypertrophy

A
  • 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
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14
Q

Assessment of benign prostatic hypertrophy

A
  • 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
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15
Q

International Prostate Symptom Score (IPSS)

A

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

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16
Q

Treatment of benign prostatic hypertrophy

A
  • 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)
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17
Q

Candidiasis- definition and risk factors

A

Thrush is an extremely common condition, 80% are caused by Candida albicans

Risk factors:
* Diabetes mellitus
* Drugs: antibiotics, steroids
* Pregnancy
* Immunosuppression: HIV

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18
Q

Features of Candidiasis

A
  • ‘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
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19
Q

Management of Candidiasis

A
  • 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
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20
Q

Recurrent vaginal candidiasis

A
  • 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
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21
Q

Cervical ectropian

A

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

22
Q

Features of cervical ectropian

A
  • vaginal discharge
  • post-coital bleeding
23
Q

Treatment of cervical ectropion

A

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

24
Q

Cervical polyp

A

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

25
Q

Treatment for cervical poylp

A

Twisting the polyp off the cervix, does not require local anaesthetic. Cant be felt, except for crampy abdominal pain

26
Q

Chorioamnionitis

A

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

27
Q

Symptoms of chorioamniotis

A
  • Fever
  • Mother or fetus has rapid heartbeat
  • Tender or painful uterus
    Vaginal discharge with an unpleasant smell or unusual colour
  • Sweating
28
Q

Complications of chorioamnionitis

A
  • Infection in the pelvic region and abdomen
  • Endometriotis
  • Blood clots in the pelvis or lungs
  • Sepsis
  • Newborn complications: sepsis, meningitis, pneumonia
29
Q

Risk factors for chorioamnionitis

A
  • 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
30
Q

Placenta praevia

A

When the placenta lies wholly or partly in the lower uterine segment
Associated factors= Multiparity, multiple pregnancies, previous caesarean section

31
Q

Clinical features of placenta praevia

A
  • 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
32
Q

Diagnosis of placenta praevia

A
  • 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
33
Q

Classical grading of placental praevi

A
  • 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
34
Q

If low lying placenta at the 20 week scan

A
  • 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
35
Q

Placental praevia with bleeding

A
  • admit
  • ABC approach to stabilise the woman
  • if not able to stabilise → emergency caesarean section
  • if in labour or term reached → emergency caesarean section
36
Q

Prognosis with placental praevi

A
  • death is now extremely rare
  • major cause of death in women with placenta praevia is now PPH
37
Q

Placental abruption

A

Separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space

38
Q

Cause of placental abruption

A

Not known but associated factors:
* proteinuric hypertension
* cocaine use
* multiparity
* maternal trauma
* increasing maternal age

39
Q

Clinical features of placental abruption

A
  • 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
40
Q

Placental abruption, fetus alive and <36 weeks

A
  • fetal distress: immediate caesarean
  • no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
41
Q

Placental abruption: Fetus alive and >36 weeks
Fetus dead

A

Fetus alive and > 36 weeks
* fetal distress: immediate caesarean
* no fetal distress: deliver vaginally

Fetus dead= induce vaginal delivery

42
Q

Complications of fetal abruption

A
  • Maternal= shock, DIC, renal failure, PPH
  • Fetal= IUGR, hypoxia, death
  • Prognosis= associated with high perinatal mortality rate, responsible for 15% of perinatal deaths
43
Q

Endometrial hyperplasia

A

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

44
Q

Types of endometrial hyperplasia and features

A
  • simple
  • complex
  • simple atypical
  • complex atypical

Features: abnormal vaginal bleeding i.e. intermenstrual

45
Q

Management of endometrial hyperplasia

A
  • 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
46
Q

Features of a UTI

A
  • dysuria
  • urinary frequency
  • urinary urgency
  • cloudy/offensive smelling urine
  • lower abdominal pain
  • fever: typically low-grade in lower UTI
  • malaise
47
Q

Treatment for non-pregnant women UTI

A
  • Trimethoprim (first line) or nitrofurantoin for 3 days
  • send a urine culture if: aged > 65 years, visible or non-visible haematuria
48
Q

Treatment for pregnant women UTI (symptomatic)

A

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

49
Q

Treatment for pregnant women asymptomatic: UTI

A

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

50
Q

Treatment of UTI (men)

A
  • 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
51
Q

Treatment for UTI: catheterised patients

A
  • 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
52
Q

Treatment for acute pyelonephritis

A
  • 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

Year 3- placement (34 decks)

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