Week 4 Flashcards
What are 12 Components of Postnatal Care?
- Care of mother and baby
- Care tailored to needs of the mother.
- Parent crafting – bond between mother and child
- Lactation
- Analgesia
- Wound and Perineal management Physiotherapy
- Bladder care
- Thromboprophylaxis
- Contraception
- Advice regarding spacing and future pregnancies Management of complications
- Perinatal mental health
- Debrief
Why are post-partum women at risk of thrombosis?
- 4 thromboprophylactic interventions?
Thromboprophylaxis – clotting factors increase by 40% during pregnancy but due to hemodilution etc during pregnancy this is ok, post-partum diuresis to get rid of extra volume but relatively slower fall in clotting factors = relative concentration of clotting factors = high risk of thrombosis.
What advice should be given to women post-partum regarding spacing of pregnancies?
What advice should be given to women post-partum regarding contraception? Can you use COCP?
Spacing of pregnancies
* Spacing- necessary to ensure recovery especially if complications
* Perineal recovery following extensive tears and 3rd / 4th degree tears
* Spacing after caesarean section to allow strengthening of uterine scar to allow VBAC
Complications in the Puerperium - Sepsis
- Outline sepsis as a cause of direct maternal death? Prevention?
Puerperium Complications -Sepsis
- Cause of direct maternal death
- Prevention- prophylactic antibiotics at caesarean section
- Wound and perineal care
- Appropriate and timely management of intrapartum and postnatal infection
- Clinical observations (heart rate, blood pressure, respiratory rate and temperature) should be taken early and regularly in women with suspected sepsis
- Plotting clinical observations on a maternity early warning chart may help in the recognition of sepsis
Complications in the Puerperium - Sepsis
- 9 Signs of Sepsis?
- 10 Symptoms of Sepsis?
- Group A Streptococcus sepsis?
Clinical features: two or more of the following should be present
1. Fever
2. Pelvic pain
3. Abnormal vaginal discharge
4. Abnormal smell/foul odor discharge
5. Delay in uterine involution
10 risk factors for post-partum sepsis?
- Incidence?
- Retained products of conception
- Manual removal
- Prolonged ruptured membranes
- Caesarean section
- Premature labour
- Obesity
- Following an invasive intrauterine procedure (e.g. amnio, CVS)
- Cervical suture
- Impaired immunity
- Diabetes mellitus
List 7 Possible Sites of sepsis in the post-partum woman?
- Diagnostics?
- Treatment?
- Complications?
- Wound infection
- Endometritis
- UTI
- Respiratory infection
- Thrombophlebitis/DVT
- Perineal infection
- Mastitis
Outline the initial Monitoring, Investigations and Treatment for a post-partum woman with sepsis?
- Sepsis 6?
Sepsis - Initial management
1. Call for help
2. Airway – high-flow O2
3. Breathing
4. Circulation - IV access, IV fluids, Blood tests
Complications in the Puerperium - Sepsis
- Prompt IV antibiotic treatment?
- Prompt IV fluid resuscitation?
Explain the involutionary process.
- 6 Key events?
Uterine involution is a natural process that occurs in the postpartum period, which refers to the time immediately after childbirth when the uterus returns to its non-pregnant state. After childbirth, the uterus needs to undergo a series of physiological changes to shrink back to its pre-pregnancy size and shape. The process of uterine involution typically takes several weeks, and by about 6 to 8 weeks postpartum, the uterus usually returns to its pre-pregnancy size and weight. However, it’s important to note that factors such as breastfeeding, the number of pregnancies, and the use of certain medications can influence the speed and effectiveness of uterine involution.
Describe the six week post-partum visit for the mother as it relates to contraception.
Advice regarding the timing of resumption of sexual intercourse is variable, with most centres recommending a 4–6 week interval. Looking at the list of common postpartum problems identified by women, it is not surprising that libido may be decreased. This can
be exacerbated by decreased oestrogen levels (especially if breastfeeding), body image changes, and fear of pregnancy. These issues should be explored with both the mother and her partner, with reassurance that sexual dysfunction postpartum is common. Dyspareunia may be eased with vaginal lubricants or
vaginal oestrogen. There are many options for contraception, with the
oral combined pill contraindicated during lactation. The timing of ovulation postpartum varies significantly and may occur before menstruation. It is important to discuss and commence contraception as early
as possible.
What are the options for Postpartum Contraception for a Full term delivery?
Long-acting reversible contraceptives (LARCs) are particularly recommended by guidelines as they can be inserted immediately after birth and are effective for years.
Explain the post-partum management for normal vaginal delivery.
- Immediate Postpartum Period (First Few Hours)? = 3
- Recovery and Observation (First 24-48 Hours)? = 6
- 3) Postpartum Check-ups and Follow-up (First Few Weeks)? = 5
- 4) Long-Term Care? = 3
Explain how contraceptive advice to breast-feeding mothers needs to be addressed differently to non breast-feeding mothers.
Explain the physiology of lactation.
Explain the physiology of lactation.
- Hormonal regulation? (2)
- Milk Synthesis and Secretion?
- Stages of milk production? (3)
- Letdown reflex? (2)
- Demand-Supply Relationship?
- Nutritional and Immune Factors? (2)
Breastfeeding and Demand-Supply Relationship:
- Supply and Demand: The more frequently the infant feeds, the more milk is produced. This feedback loop helps establish a balance between the infant’s demand and the mother’s milk production.
- Cluster Feeding: Periods of frequent feeding, known as cluster feeding, can signal the body to increase milk production to meet the infant’s growing needs.
Nutritional and Immune Factors:
- Antibodies: Breast milk contains immunoglobulins and other immune factors that help protect the infant from infections and diseases.
- Nutrition: Breast milk provides balanced nutrition with the right proportions of proteins, fats, carbohydrates, vitamins, and minerals for the infant’s growth and development.
Mastitis
- Definition - Puerperal vs Nonpuerperal?
- Epidemiology?
- Aetiology - Infective vs. Non-infective?
- Pathophysiology?
Mastitis is defined as inflammation of the breast, with or without infection.
- Puerperal mastitis: mastitis associated with lactation.
- Nonpuerperal mastitis: Mastitis not associated with lactation. May affect subareolar ducts (periareolar or periductal mastitis) or peripheral parenchyma.
Epidemiology
- Puerperal mastitis occurs in up to 10% of nursing mothers (particularly 2–3 weeks postpartum).
- Nonpuerperal mastitis is rare (approx. 1–2% of symptomatic breast conditions).
Mastitis
- 5 Clinical Features?
- Diagnostics?
Clinical features of Mastitis
1. Typically localized, tender, firm, swollen, erythematous breast (generally unilateral)
2. Systemic symptoms (malaise, fever, and chills)
3. Pain during breastfeeding
4. Reduced milk secretion
5. Reactive axillary lymphadenopathy (less common)
Inflammatory breast cancer may manifest with features similar to mastitis and should be evaluated for in patients with inadequate response to empiric treatment of mastitis.
Mastitis - Differential diagnoses of Common breast problems in the puerperium?
Mastitis - Approach to management?
Mastitis - Treatment
- Puerperal vs. Nonpuerperal mastitis?
- Antibiotics?
Premenstrual Syndrome
- Epidemiology?
- Clinical features?
- Diagnostics?
- Treatment?
- PMS vs. PMDD?
Treatment of Premenstrual Syndrome
- Lifestyle changes can be beneficial (e.g., regular exercise, healthy diet, avoiding individual triggers like alcohol, caffeine, or nicotine).
First-line treatment
1. NSAIDs (e.g., naproxen)
2. OCPs
3. SSRIs (e.g., fluoxetine) in the case of severe PMS and PMDD
4. Dietary supplements: reduce symptoms and improve mood swings: Calcium (1,200 mg/day), Vitamin E, Vitamin D
5. In the case of water retention/bloating: Diuretics (e.g., spironolactone) & Magnesium
Describe the changes in mood and behaviour associated with the menstrual cycle and the influence of psychological factors on the premenstrual syndrome.
- Changes in Mood and Behavior During the Menstrual Cycle?
- Influence of Psychological Factors on Premenstrual Syndrome (PMS)?
- It’s important to note that while many individuals experience mild PMS symptoms, some individuals may experience a more severe form known as Premenstrual Dysphoric Disorder (PMDD). PMDD involves severe emotional and physical symptoms that significantly interfere with daily functioning.
- Addressing PMS involves a combination of strategies, including lifestyle modifications (healthy diet, regular exercise, stress reduction), cognitive-behavioral therapy, and, in severe cases, medical interventions. Recognizing the interplay of hormonal, psychological, and environmental factors is key to understanding and effectively managing the changes in mood and behavior associated with the menstrual cycle. If PMS symptoms are significantly impacting one’s quality of life, consulting a healthcare professional is recommended to explore appropriate management options.
Peripartum depression
- Definition?
- Epidemiology?
- Diagnostics?
- Screening?
Peripartum depression
- Definition: MDD that occurs during pregnancy or within a month after delivery
- Epidemiology: Affects up to 14% of pregnancies, Patients with a previous history of depression are at increased risk of developing peripartum depression.
- Diagnostics: Same as MDD
- Screening: Screen at least once in the peripartum period. Optimum screening intervals are unclear; consider at least once antenatally and once within 12 weeks of delivery. The American Academy of Pediatrics recommends screening at well-child visits (at 1, 2, 4, and 6 months post-delivery).
Postnatal depression
- Management? Tx?
Only social support and psychological treatments may be appropriate, depending on the severity of the depressive episode. If there is a need for medication, (in individuals who have moderate depression where there are risks or non response to other treatments, or in individuals with severe depression), consideration needs to be given to whether the patient is breastfeeding. If not, recommended management of depression will be the same as in a non-breastfeeding woman. If breastfeeding, the risk benefit ratio of different antidepressants needs to be discussed with the patient, so they can make their own choice about treatment. Again published guidelines recommend different antidepressants for use in breastfeeding women, so it may be best to seek advice from pharmacy colleagues or specialist Perinatal Psychiatry Services.
Differential diagnosis of postpartum low mood?
Differential diagnosis of postpartum low mood?
What is Postpartum (Puerperal) Psychosis?
- 16 Signs & Symptoms?
- Management?
- Feeling ‘high’, ‘manic’ or ‘on top of the world’.
- Low mood and tearfulness.
- Anxiety or irritability.
- Rapid changes in mood.
- Severe confusion.
- Being restless and agitated.
- Racing thoughts.
- Behaviour that is out of character.
- Being more talkative, active and sociable than usual.
- Being very withdrawn and not talking to people.
- Finding it hard to sleep, or not wanting to sleep.
- Losing your inhibitions, doing things you usually would not do.
- Feeling paranoid, suspicious, fearful.
- Feeling as if you’re in a dream world.
- Delusions: odd thoughts or beliefs that are unlikely to be true. For example, you might believe you have won the lottery. You may think your baby is possessed by the devil, or that people are out to get you.
- Hallucinations: you see, hear, feel or smell things that aren’t really there.
Explain the significance of parental mental illness for infants and young children. (11 points)
Parental mental illness can have significant and lasting effects on infants and young children. The early years of a child’s life are critical for their emotional, cognitive, and social development, and the presence of mental illness in a parent can influence various aspects of their well-being. Addressing parental mental illness involves a holistic approach that considers the well-being of both the parent and the child. Early identification, access to mental health services, support systems, and a nurturing environment can significantly mitigate the potential negative impact of parental mental illness on infants and young children.
Describe the management of a woman who has had a stillbirth, including the issue of suppression of lactation.
Experiencing a stillbirth, the loss of a baby after the 20th week of pregnancy, is a devastating and emotionally complex event. The management of a woman who has had a stillbirth involves a combination of medical care, emotional support, and guidance to address the physical and emotional aspects of the situation. The issue of suppressing lactation, which can be particularly challenging, is an important consideration as well.
Describe the suppression of lactation in a woman who has had a stillbirth.
- Immediate Suppression of Lactation Postpartum?
- Non-pharmacological Methods for Lactation Suppression?
- Pharmacological Methods for Lactation Suppression?
- Apply breast pads to assist in soaking up any breastmilk leakage. Encourage changing pads when they become soaked
- Advise woman to lie on her back or on one side with an extra pillow to support her breasts. If she would like to lie on her front, place a pillow under her hips and stomach to ease the pressure on her breasts. A soft towel or cloth nappy can be placed across her breasts to soak up any leaking milk.
Define:
- Premenopause?
- Perimenopause?
- Menopause?
- Postmenopause?
Clinical features of Menopause?
- In the US, more intense and longer-lasting vasomotor symptoms are reported for Black individuals than individuals of other racial or ethnic groups.
- In menopausal individuals, estrogen production mainly results from the conversion of adrenal androgens by peripheral aromatase in adipose tissue. The onset of menopause may occur later in individuals with obesity, who have additional estrogen from adipose stores.
- Menopausal HAVOCS: Hot flashes/Heat intolerance, Atrophy of Vagina, Osteoporosis, Coronary artery disease, Sleep impairment.
Subtypes & Variants of Menopause
- Induced: Aetiology, Clinical features & Treatment?
- Premature: Aetiology, Clinical features, Diagnostics & Treatment?
- Early?
Early menopause
- The occurrence of physiological menopause between 40 and 45 years of age with no other identified cause
- Affects 5% of women.
- Clinical features and diagnostics are the same as for older patients.
- Systemic HRT is usually recommended to reduce risks associated with early menopause, e.g.: Increased risk of heart disease, Dementia, Increased risk of overall mortality
- Smoking is associated with earlier onset of menopause.
Diagnosis of Menopause
- General principles?
- 2 Supportive studies to confirm menopause?
- 6 studies to exclude differential diagnoses of menopause?
- 2 Studies for complications of menopause?
General principles
- In individuals ≥ 40 years of age, perimenopause and menopause are diagnosed clinically.
- A pelvic examination is usually performed to confirm GSM or evaluate for other causes.
- The effects of oral contraceptives can mask the signs and symptoms of menopause.
- Diagnostic testing is reserved for:
1. Premature menopause
2. Patients with an unreliable menstrual cycle history
3. Suspected differential diagnoses of menopause and perimenopause
Menopause - Treatment
- Approach?
- Symptom specific management?
Approach to Treating Menopause
1. Determine the severity of symptoms and their impact on the patient’s quality of life.
2. All symptomatic patients: Initiate symptom-specific nonpharmacological interventions for menopause.
3. For patients with moderate to severe symptoms, consider adding pharmacological therapy for menopause.
4. Screen for and treat associated conditions and/or complications and provide appropriate preventive care.
5. Screen for depression.
6. Educate patients on the increased risk of osteoporosis and heart disease and initiate: Primary prevention of ASCVD & Prevention of osteoporosis
- Hormone replacement therapy is not indicated for all patients but should be prescribed for premature menopause, early menopause, and patients with moderate to severe symptoms of menopause.
- Evidence does not support the use of alternative medical therapies for menopause, e.g., soy, black cohosh, omega-3 supplementation, and acupuncture.
Menopause - Systemic hormone replacement therapy (HRT)
- General principles?
- 4 Indications?
- 5 Contraindications?
- 10 Adverse effects: 2 Serious? 6 Common? 2 Other?
Systemic hormone replacement therapy (HRT) - General principles
- Reevaluate patients on HRT yearly.
- Short-term use (< 5 years) may be preferred to reduce the risk of adverse effects (e.g., breast cancer).
- There is no consensus on how to taper or when to discontinue HRT.
- Approx. 50% of individuals using HRT experience a recurrence of symptoms upon discontinuation.
-
Menopause - Systemic hormone replacement therapy (HRT)
- Options for Patients without a uterus?
- Options for Patients with a uterus?
Menopause - Vaginal hormone therapy
- Indication?
- Options?
- 4 Contraindications?
- 5 Adverse effects?
Menopause - Vaginal hormone therapy
- Indication: Vaginal hormone therapy is indicated for moderate to severe genitourinary symptoms of menopause.
- Some low doses of vaginal estrogen preparations (e.g., creams, rings) slightly increase serum estrogen levels; there is currently no research on whether this increase has any clinical significance (e.g., increased risk of cardiovascular disease or endometrial cancer).
What are some of the Nonhormonal therapies available to treat menopause?
Menopause
- 2 Complications?
- Associated conditions?
Complications of Menopause
1 - Coronary artery disease
- Estrogen exerts protective effects on the cardiovascular system.
- Menopause is associated with increased triglycerides, LDL, weight gain, and hypertension.
2 - Osteoporosis
- Decreased circulating estrogen impairs bone formation.
Describe the psychological effects of the peri-menopause and menopause. (12)
The peri-menopause and menopause are transitional phases in a woman’s life marked by hormonal changes and the cessation of menstruation. These phases can have significant psychological effects due to the fluctuations and decline in hormones, primarily estrogen and progesterone.
What is done at the 6 week postnatal check?
- 9 Examinations at postpartum visit?
Examinations at postpartum visit
1. Signs of anaemia
2. Blood pressure
3. Breasts and nipples
4. Breastfeeding position
5. Perineum – check wounds
6. LUCS wound
7. Thyroid
8. Uterine fundus
9. Urine – exclude UTI, protein, glucose
List 10 Investigations to consider at the postpartum visit (6 weeks)?
Perineal lacerations/tears
- Definition?
- Epidemiology?
- 8 Risk factors?
- Clinical features?
- Diagnosis?
Perineal lacerations: tear of the perineal area due to significant or rapid stretching forces during labor and delivery
Epidemiology: most common obstetric injury of the pelvic floor
Risk factors
1. Macrosomia
2. Forceps delivery
3. No previous delivery
4. Prolonged second stage of labor
5. Occiput posterior delivery
6. Rapid delivery of head in breech presentation
7. Head extension before crowning
8. Lack of perineal elasticity (e.g., perineal edema)
Perineal lacerations/tears
- Classification?
- First degree: cutaneous to subcutaneous tissue tear (skin, fourchette, posterior vaginal wall) with no involvement of the perineal muscles
- Second degree: first-degree lacerations plus laceration of the perineal muscles without involvement of the anal sphincter
-
Third degree: second-degree lacerations plus involvement of the external anal sphincter (may lead to fecal incontinence due to sphincter involvement)
A: < 50% of the external anal sphincter is torn.
**B: **> 50% of the external anal sphincter is torn.
C: external and internal anal sphincters are torn. - Fourth degree: third-degree lacerations plus lacerations of the anterior wall of the anal canal or rectum
Perineal Tears
- 5 Complications?
- Treatment?
Complications of Perineal tears
- Primarily associated with third- and fourth-degree lacerations.
- Complications include:
1. Pain and dyspareunia
2. Rectovaginal fistulae
3. Hemorrhage
4. Infection
5. Wound dehiscence
Perineal Tears
- Prevention?
Prevention: application of warm compress to perineum during delivery
Episiotomy
- Consists of an incision of the perineum (usually in the midline) to enlarge the vaginal opening during delivery
- No longer routinely recommended.
- Can be considered if vaginal delivery needs to be expedited and maternal perineal tissue is thought to pose a signficant obstacle, e.g.:
1. Shoulder dystocia
2. Inability to insert instruments required for assisted vaginal delivery
3. Vaginal breech delivery
Flow Chart: Perineal assessment and repair?
OASIS = Obstetric anal sphincter injury or injuries
How do you manage a woman complaining of a painful intercourse some 6 weeks post delivery with a perineal tear?
Resumption of sexual activity
There is currently no evidenced-based research demonstrating the ideal time to resume sexual intercourse following a perineal injury. Thus, the abstinence period is typically determined by the woman during her recovery period. The median time of return to intercourse is six to eight weeks postpartum.
Postoperative management of Perineal lacerations? (6)
A woman at 30 weeks pregnancy is noted to have a symphysis - fundal height of 34cm. What could this mean (if the dates are correct)? What should be done?
RANZCOG Guidelines - Although the prediction of macrosomia is imprecise, elective caesarean birth may be beneficial for newborns with suspected macrosomia who have an estimated fetal weight of 5000g or more in women without diabetes and an estimated fetal weight of 4500g or more in women with diabetes.
A 30 year old woman attends at 8 weeks of amenorrhoea with severe vomiting for 2 weeks. How would you manage this?
- 10 Steps?
Severe vomiting during pregnancy, known as hyperemesis gravidarum, can lead to dehydration, electrolyte imbalances, and weight loss, and it requires prompt medical attention and management.
Hyperemesis gravidarum
- What is it? (3)
- Epidemiology?
- Aetiology and Pathophysiology?
- 7 Risk Factors?
Hyperemesis gravidarum refers to persistent and severe vomiting during pregnancy, which leads to weight loss, dehydration and electrolyte imbalances.
- It affects 0.3 – 3.6% of pregnant women, and is one of the more common reasons for hospital admission during pregnancy.
- Nausea and vomiting of pregnancy (NVP) normally starts between 4 and 7 weeks’ gestation. It reaches a peak in the 9th week, and settles by week 20 in 90% of women.
- Hyperemesis gravidarum (HG) is diagnosed when there is prolonged and severe NVP with:
1. More than 5% pre-pregnancy weight loss
2. Dehydration, and
3. Electrolyte imbalances.
Hyperemesis gravidarum
- 5 Clinical features?
- PUQE score?
- 10 Differentials?
An objective scoring system can be used to classify the severity, for example the Pregnancy-Unique Quantification of Emesis (PUQE) score; a score of 6 correlates to mild NVP, 7-12 moderate and 13-15 severe.
1. Nausea, vomiting
2. Physical signs of dehydration
3. Hypersalivation,
4. Orthostatic hypotension
5. Malnourishment
Hyperemesis gravidarum - Diagnostics/Ixs
- 2 Bedside tests?
- 4 Lab tests?
- 4 tests for Refractory or Severe Cases?
- Imaging?
Diagnostics
1. Clinical diagnosis
2. Laboratory analysis
- Electrolyte disturbances: hypokalemia and hypochloremic metabolic alkalosis or metabolic acidosis
- Signs of dehydration (e.g., ↑ hematocrit)
- Ketonuria
Hyperemesis Gravidarum - Treatment
- Mild, Moderate, Severe?
- 5 Treatments?
- Recommended Antiemetic Therapies: 1st, 2nd, 3rd line?
Treatment
1. Antiemetic therapy
2. May require glucocorticoid therapy (see stepwise approach above)
3. IV fluid resuscitation/replacement (see IV fluid therapy)
4. Electrolyte and thiamine repletion
5. Enteral feeding or TPN is recommended in patients with persistent symptoms and weight loss despite antiemetic therapy.
Order of prescription of Antiemetics in pregnancy? (1-4)
List 8 Indications for Hysterectomy?
- Heavy menstrual bleeding
- Pelvic pain
- Uterine prolapse (vaginal hysterectomy)
- Gynaecological malignancy (usually ovarian, uterine or cervical)
- Risk reducing surgery, usually in cases of BRCA 1 or 2 mutations, or Lynch syndrome.
- Hysterectomy may also be performed as a life saving procedure in the management of major postpartum haemorrhage.
What are the 5 types of Hysterectomy?
A hysterectomy can be classified by the amount of tissue resected:
1. Total hysterectomy – removal of the uterus and cervix.
2. Sub-total hysterectomy – removal of the body of the uterus only, leaving the cervix behind.
3. Total hysterectomy and bilateral salpingo-oophorectomy – removal of the uterus, cervix, fallopian tubes and ovaries.
4. Radical hysterectomy – removal of the uterus and cervix, the parametrium, a vaginal cuff and part of or the whole of the fallopian tubes.
This procedure is carried out in selected cases of cervical cancer.
The ovaries may be removed or may be left behind, depending on the patient’s age.
What are the 3 ways a hysterectomy can be performed?
What are the 3 ways a hysterectomy can be performed?
List 8 indications for bilateral salpingo-oophorectomy.
Salpingo-oophorectomy is the removal of the fallopian tube (salpingectomy) and ovary (oophorectomy). A unilateral salpingo-oophorectomy is appropriate for patients in whom an ovary is unable to be preserved, including cases of ruptured ectopic pregnancy with an inability to achieve hemostasis without removal of the tube and ovary, adnexal torsion in which the ovary and tube are necrotic, a tuboovarian abscess not responsive to antibiotics, or a benign ovarian mass in which there is no remaining normal ovarian tissue able to be conserved. A bilateral salpingo-oophorectomy is generally one of three types: elective at time of hysterectomy for benign conditions, prophylactic in women with increased risk of ovarian cancer, or because of malignancy.
6 Disadvantages of a Bilateral Salpingo-oophorectomy?
Explain the concept of risk reductive surgery as it applies to bilateral salpingo-oophorecetomy.
Who is a risk-reducing BSO suitable for?
Your doctor, gynaecologist or genetic counsellor may have discussed having a risk-reducing BSO with you. This will usually be considered if you are at increased risk of ovarian cancer, for example, if you are known to have a cancer-causing BRCA1 or BRCA2 gene variant or if you have a significant family history of ovarian cancer. There is currently no effective screening for ovarian cancer, so risk-reducing surgery is an option that all at risk women are currently asked to consider.
At what age should I consider a risk-reducing BSO?
A BSO is not usually recommended in women under age 40, as ovarian cancer risk is still low up to this age, and having a BSO will immediately bring on menopause. You will be able to discuss the best timing of having a BSO with your doctor
What happens to the endometrium through the menstual cycle ?
Outline a Clinical Approach to the Gynae Patient.
- 14 Problems?
- 13 Tools?
- 13 Management options?
How do the following hormones change throughout the menstrual cycle?
- LH/FSH
- Oestradiol
- Progesterone
- Gonadotrophin releasing hormone from the hypothalamus
- FSH from the pituitary stimulates follicular growth
- LH releases egg and lutienises the follicle
- Estradiol from the follicle causes endometrial growth
- Progesterone from the corpus luteum, stabilises endometrium, and when it falls the endometrium sheds
Outline a Clinical Approach to Vaginal Bleeding.
Outline a Clinical Approach to Vaginal Bleeding in Pre- and Peri-menopausal women.
Outline a Clinical Approach to Vaginal Bleeding in Postmenopausal women.
Postmenopausal Bleeding
* Principle is to exclude endometrial Ca
* Limitations of U/S false +ve and false -ve
* Histopathlogy
* Endometrial hyperplasia and atypia
* Atrophic vaginitis Dx of exclusion
What are the causes of Amenorrhoea - Levels of failure
- 3 Brain?
- 1 Hypothalamus?
- 2 Pituitary?
- 2 Thyroid?
- 1 Adrenal?
- 2 Ovary?
- 3 Uterus?
5 Investigations for Amenorrhoea?
Amenorrhoea
* Primary or secondary Pregnancy &
breastfeeding
* Levels of failure
* Hypothalamus
* Pituituary
* Ovarian
Investigation of Amenorrhoea
1. LH/FSH
2. Prolactin
3. TFT
4. Pregnancy
5. E2 withdrawal bleed
Pharmacology in O&G - Gonadotropin Releasing Hormone (GnRH)
- Release of GnRH?
- Uses?
- GnRH agonists use?
Gonadotropin Releasing Hormone (GnRH)
- Hypothalamus to Pituitary to release FSH and LH
- 10 amino acid poly peptide
- In pulses each 90 mins
- Pulses modified by endorphins: Exercise reduces – so amenorrhoea & Opiate antagonists can reverse (naloxone)
- Can be used in therapy (pulsatile pump and injection line) but needs 2+ weeks of treatment.
- Hypothalamic Amenorrhoea / Kallmans syndrome
Pharmacology in O&G - Follicle Stimulating Hormone (FSH)
- Structure?
- MOA?
- Uses?
- Fertility - Risk of which syndrome?
FSH Follicle Stimulating Hormone
* 2 chain polypeptide with sugars - glycosalation changes biologic activity (hence not all assays give true indication of biologic potency)
* Alpha chain same as LH, TSH, HCG
* Drives follicular growth and granulosa cell activity (especially aromatase and so estrogen)
* Drives sertoli cell activity in the male
* FSH Is high if there is ovarian (or testicular) failure
* Most fertility treatments aim to elevate FSH
Pharmacology in O&G - Lutienising Hormone (LH)
- Structure?
- MOA?
- Uses?
- Fertility - Risk of which syndrome?
Pharmacology in O&G - Estrogen
- Where is it produced?
- 3 Actions?
- Causes of unopposed estrogen?
- Lack of estrogen?
- 3 Types?
Estrogen - types
1. Ethinyl estradiol – common – used in the “Pill”
2. Natural estrogen made in nature – from horses – Premarin – but has equilin and other non human estrogens (may be useful as longer life)
3. Natural estrogen made in vats – estradiol
Can be given orally (nb first pass effect and liver proteins hence clotting), transcutaneously, vaginally, by subcutaneous implant.
Estrogen Medications - 4 Uses & 4 Risks?
Estrogen - Uses
1. “The Pill” - combined Estrogen & Progesterone
2. Estrogen: used to replace it in its absence
3. Generally for low estrogen - symptoms (flushes) or risks (bone loss)
4. So mainly menopause but some hypoestrogenic states (ie using the Pill in athletes)
Note tachyphyllaxis and need to measure Estrogen if symptoms after implant
Pharmacology in O&G - Anti-Estrogens
- 2 Examples?
- MOA?
- Uses?
- Risks?
- What are SERMS?
Anti -estrogens
- ‘Traditional’ anti-estrogens are Tamoxifen and Clomiphene – they are both agonists and antagonists
- Occupy the receptor – have some effect, then continue to bind and so stop replenishment of receptor thus having an antagonist effect
- Used in infertility treatment to elevate FSH to stimulate follicular growth - Twins 1/12, triplets 1/200, eye symptoms rare but real
- Used in estrogen dependant cancers
- Can cause endometrial polyp growth
- Newer – true antagonists or aromatase inhibitors
What is Progesterone?
- Where is it produced?
- 6 Actions?
- Biochemical reaction?
**Progesterone **
- Steroid hormone derived from cholesterol.
- Produced in small amount by the adrenal.
- Produced by the corpus luteum after ovulation and by the placenta during pregnancy.
- Actions:
1. Changes endometrium to secretory
2. Withdrawal causes endometrium to shed.
3. Inhibits uterine contraction.
4. Increases temperature about 0.5C
5. Makes cervical mucous thicker (hence contraception)
6. Tends to give symptoms of bloating, fluid retention and breast sensations.
Outline 3 Physiological Uses of Progesterone and 2 Non-physiological use?
Progesterone use 3: Physiologic
3) Replacing Luteal Progesterone
- Used in PMS – but very variable effects and progesterone symptoms are PMS symptoms – so can make worse.
- Molimina – bloating, fluid retention, breast symptoms
- short half-life of progesterones – 12 hours or so oral (but can have slow release – over years depending on method))
- Not useful for low luteal progesterone and infertility – the low progesterone is a result of poor follicular development - not the cause!
Pharmacology in O&G - Combined estrogen and progesterone
- Regimen?
Pharmacology in O&G - Anti Progesterone - Mifipristone
- Use?
Combined estrogen and progesterone
- If cyclic (prog 2 weeks on 2 weeks off) then gives a cycle and is not (very) contraceptive
- In the Pill - Progesterone is prolonged – 3 weeks of 4 – results in ovulation suppression and often thin endometrium
- If combined continuous – 90% get no period/bleed but irregular bleeding can happen
- Why was ‘the Pill’ set at a 4 week cycle? = historical & so that people would have a bleed and prove they werent pregnant.
Pharmacology in O&G - Androgens & Antiandrogens
- Uses?
- Examples?
- Side effects?
- Which occupation are they banned in?
Androgens
- Androgens are used to suppress endometrial growth – mainly ectopic endometrium in endometriosis
- Danocrine is the most common
- Side effects are – weight gain, oily skin and hair, hair growth, deeper voice (and masculinisation of a female fetus if pregnant so contraception is necessary)
- Has been prescribed with exercise to make the most of the anabolic effect and to limit weight
- They are banned substances in sport (remember to check occupation/ interests)
- Occasionally androgens are used for loss of libido especially after menopause – especially surgical early menopause
- Most problems with libido relate to the biggest sexual organ – the brain – be careful to avoid harm
Pharmacology in O&G - Prolactin and antagonists
- 2 Examples?
- Uses?
- Side effects?
- Which medications increase prolactin?
Pharmacology in O&G - Uterine Activity: Oxytocics
- MOA?
- 3 Uses?
- 2 Examples?
Pharmacology in O&G - Uterine Activity: Tocolytics
- MOA?
- Examples?
Pharmacology in O&G - Prostaglandin E2
- MOA?
- Examples?
ABCD of Pharmacology in Pregnancy?
Pharmacology in O&G - Examples
- Analgesia?
- SSRIs?
- Bladder?
- Mehotrexate?
Methotrexate
- Killing trophoblast
1. Molar pregnancy
2. Ectopic pregnancy
3. In WA at some clinics for termination of pregnancy
Pharmacotherapy during pregnancy - Antibiotics
- 5 Drugs of choice?
- 6 Drugs to avoid and why?
Pharmacotherapy during pregnancy - Antibiotics
1. Penicillin group : ampicillin, amoxicillin, flucloxacillin, penicillin V, propicillin
2. Cephalosporins
3. Macrolides: erythromycin, azithromycin
4. Metronidazole
5. Fosfomycin (see also: “UTI in pregnancy”)
Pharmacotherapy during pregnancy - Antihypertensives
- 4 Drugs of choice?
- 4 Drugs to avoid and why?
Pharmacotherapy during pregnancy - Antifungals
- Drugs of choice - Topical? Vaginal? Systemic?
- 3 Drugs to avoid and why?
Pharmacotherapy during pregnancy - Antifungals
1. Topical: imidazoles
2. Vaginal: nystatin
3. Systemic: amphotericin B
Pharmacotherapy during pregnancy - Antivirals
- 3 Drugs of choice?
- 6 Drugs to avoid and why?
Pharmacotherapy during pregnancy - Antivirals
1. Acyclovir and valacyclovir for herpes
2. Oral oseltamivir and zanamivir for influenza
3. Zidovudine PLUS lamivudine PLUS nevirapine PLUS atazanavir for HIV infection
Pharmacotherapy during pregnancy - Anticoagulants
- 2 Drugs of choice?
- 3 Drugs to avoid and why?
Pharmacotherapy during pregnancy - Anticoagulants
Drugs of choice
1. Heparin: anticoagulant of choice (does not cross the placental barrier)
2. Aspirin (ASA) - Low doses may be prescribed for high-risk preeclampsia. High doses should be especially avoided in the third trimester.
Pharmacotherapy during pregnancy - Analgesics
- 2 Drugs of choice?
- 2 Drugs to avoid and why?
Pharmacotherapy during pregnancy - Analgesics
Drugs of choice
1 - Non-opioid analgesics
- Acetaminophen, especially in the third trimester
- NSAIDs in the first trimester only
2 - Opioid analgesics (e.g., fentanyl, codeine) for moderate to severe pain
Pharmacotherapy during pregnancy - Thyroid agents
- 2 Drugs of choice?
- 4 Drugs to avoid and why?
Pharmacotherapy during pregnancy - Thyroid agents
Drugs of choice
- Antithyroid drugs
1. First trimester: propylthiouracil
2. Second and third trimester: methimazole
- L-thyroxine
Which 3 Antiepileptic drugs should be avoided in pregnancy and pre-pregnancy and why?
List 10 further medications to avoid in pregnancy and their harmful effects?
- First-generation antihistamines (e.g., chlorpheniramine) may be used as antiallergenics during pregnancy.
- Second-generation antihistamines (e.g., loratadine, fexofenadine, cetirizine) may be considered if chlorpheniramine is not tolerated.
- Loratadine is the best-studied second-generation antihistamine.
What are the Aims of the First Antenatal Visit Appointment?
- History?
First Antenatal Visit
- Examination?
First Antenatal Visit
- Counselling for genetic testing/screening?
First Antenatal Visit
- Investigations?
- CST
- Culture for GC and chlamydia
- FBC & TFTs - anaemia and thrombocytopenia
- Blood group - ABO and rhesus status, and detect any abnormal Ab
- Serology - hepatitis, HIV, syphilis, rubella, varicella immune status
- Urine MSU - protein & bacteria (asymptomatic bacteruria in 5% of pregnant women, if untreated, 25-30% will get a UTI in pregnancy, increases risk of preterm labour)
Explain the pathophysiology of 6 obstetric causes in disseminated intravascular coagulation.
Disseminated Intravascular Coagulation (DIC) is a complex and potentially life-threatening disorder characterized by widespread activation of the clotting cascade, which leads to both excessive clot formation (thrombosis) and simultaneous depletion of clotting factors and platelets, resulting in bleeding tendencies. Obstetric causes are among the many triggers that can lead to DIC. These causes are related to pregnancy, childbirth, and complications thereof.
Outline the pathophysiology of DIC In Obstetrics?
Describe the diagnosis of obstetric disseminated intravascular coagulation.
DIC severity staging in obstetrics?
Describe the management of obstetric disseminated intravascular coagulation. (9)
