Women's Health Flashcards
DDx Bleeding in Pregnancy
- Ectopic Pregnancy
- Early Pregnancy Loss/Miscarriage
- PID/STI e.g Chlamdyia
- Trophoblastic Disease
- Cervical Polyp
- Cervical Cancer
- Cervical Ectropion
Investigations for Bleeding in Pregnancy
- FBC ?haemorrhage
- Maternal Blood Group and Antibody Testing
- Serial Quantitative Beta-HCG, serial at 2-3 days
- Obstetric Ultrasound Transvaginal - to ascertain foetal viability
- Explain need for representation if red flags, e.g pre-syncopal
Emergency Contraception
- 2 options
- Emegency contraceptive pill
a. 1.5mg levonorgestrel (Progestogen)
i. Can be taken up to 5 days after sex, however efficacy decreases with incr time post-sex - Copper Intrauterine device can also be used as emergency contraceptive device up to 5 days post sex
Additionally it will also provide ongoing contraceptive effect as an IUD
DDx for breastfeeding pain and discharge
- Nipple trauma 2ary to suboptimal latch
- Infant factors - strong suck/biting
- Incorrect breast pump use - wrong size, too much force
- Nipple bacterial infection
- Nipple eczema/contact dermatitis
- Nipple vasospasm
Blocked milk duct
Breast Engorgement
Eczema/Dermatitis
Mastitis
Bacterial Infection
Candida Infection
HSV
Breastfeeding Hx
○ Onset of breast pain
§ First days - poor latch
§ Infection comes later at weeks since starting breastfeeding
○ Description of pain incl clinical setting
§ Fullness pain may be oversupply
§ Only with pumping may be pump trauma
○ Feeding history
§ Frequency and duration, latching assmt
○ Prev breastfeeding experience
○ Hx of yeast infection
○ Maternal breast surgery - reduction/piercing/implants
○ Hx of pain or nipple sensitivity during pregnancy
○ Hx of Raynaud’s - nipple vasoconstriction
- Other Hx ○ Pregnancy history ○ Mode of delivery and complications ○ PMHx, PSurgHx ○ Current Meds ○ Feeding habits ○ Social Supports ○ Mental Health
Tx for Nipple Candidiasis
Fluconazole 150mg every 2nd day for 3 doses
After fluconazole completed, commence Nystatin 1,000,000 TDS, and miconazole oral gel to nipples QID
Treat infant - miconazole oral gel QID
Sterilise baby’s dummy daily
Hand sanitation
Ensure nipples clean and dry
Sx of nipple thrush
Burning/stinging nipple pain during/after feed
Nipples tender to touch
deep aching breast pain, esp after feeds
Breasts will appear normal
Baby may have white oral plaques
Antenatal Care at K4-10
1st Visit
Confirm Pregnancy and EDC Antenatal Bloods FBC, Blood Group and Rh+Antibody Screen Rubella Antibody Status Serum Ferritin Varicella Serology HBV, HCV Serology HIV Serology Syphillis Serology
Medical and Family History
Exam
- ht, wt, BP, BMI
MSU - Dip
Consider CST
Diet, Smoking, Exercise, Drugs
Folate 0.5mg for all, or 5mg for high risk (Prev NTD, anti-epileptics, BMI>30, malabsorptive dx)
Consider early ultrasound if LNMP uncertain or at risk of ectopic pregnancy. Optimal timing for determining gestational age is for the ultrasound to be done between 7-13 weeks
When safe in pregnancy to give Rubella and Varicella?
4/52 prior to Conception, bc live vaccines
Antenatal Screening 11-13 weeks
11-13 weeks
- Free Beta-HCG - PAPP-A - Nuchal Translucency - defining risk of Trisomy 13+18+21 - Assess risk of pre-eclampsia, and consider low-dose aspirin if high risk - NIPT
What is NIPT Testing
- free fetal DNA testing at >10 weeks
○ Checks for aneuploidy 13, 18, 21 + XY abnormalities
If positive, amniocentesis or chorionic villus biopsy would be reqd to confirm
When is OGTT
Most - 26-29 weeks
14-20 weeks - Early if high risk for GDM (BMI>30 or Age >40, ATSI)
When to check Rhesus Antibodies
Rh Negative mother
28+34 weeks
When to Genital Swab for GBS ?
36 weeks
For each antenatal visit
- Weight
- BP
- Uterine size, fundal height
- Fetal heart from 18-20 weeks with doppler
- Fetal movements
- Lie, presentation and position of fetus
- Presence of oedema
Urinalysis
Pruritis in Pregnancy
○ Usually assoc with cholestasis due to oestrogen sensitivity in the third trimester
○ Order LFT’s and if not elevated reassure and prescribe a soothing skin preparation - aqueous cream + glycerol
○ Monitor LFTs every 2 weeks
If elev. Markedly, or severe symptoms Refer specialist
Supplementation in Pregnancy
- Fe only if deficient, not if iron replete
- Folate for all
- Vit B12 is essential, B12 injection if suspected deficit which should be tested for
○ Vegetarians/vegans - Iodine
○ Supplementation for all, with Iodised cooking salt and a multivit
§ For thyroid fx, and prevention of neurological development - Vitamin D
○ May be a case for routine testing
○ However definitely test dark-skinned women and/or veiled
§ Aim for level >70
§ Supplement with cholecalciferol as reqd - Omega 3
○ If little seafood intake, supplement - Calcium
○ If woman avoids dairy, then consider supplementation
Toxoplasmosis
CMV/Parvovirus
Listeriosis
Mercury in Pregnant Diet
How to remain safe? and foods to avoid
• Toxoplasmosis
○ Avoid cat litter
○ Avoid garden soil
○ Avoid undercooked meats
○ Wash all fruit and vegetables
• Cytomegalovirus and Parvovirus B19
○ Hand hygiene
○ Use gloves to change nappies (particularly if a childcare or health care worker)
• Listeriosis
○ Avoid soft cheese
○ Avoid pre-packaged salads
○ Avoid deli meats and chilled/smoked seafood
• Mercury
○ Limit fish containing high levels of mercury
• Food handling
○ Discuss safe food handling, particularly management of ‘leftovers’
• Assess possible nutritional deficiencies
○ Vegetarian/vegan (B12, iron and calcium)
○ Lactose intolerance
Vitamin D deficiency due to lack of sun exposure
When to consider anti-D antibodies
- women who have a negative blood group, discuss the need for prophylactic anti-D during pregnancy, as well as the potential need for anti-D immediately if any sensitising events (such as PV bleeding) occur during the pregnancy
- Anti-D should be given as soon as possible after a sensitising event and ideally within 72 hours - routine administration of 625 IU of anti-D at 28 and 34 weeks gestation for all rhesus negative women who do not have pre-existing anti-D antibodies
- Anti-D should be given post-natally, within 72 hours to all Rh (D) negative women who deliver an Rh (D) positive baby.
Sensitizing events in pregnancy include
□ Miscarriage
□ Termination of pregnancy
□ Ectopic pregnancy
□ CVS, amniocentesis or cordocentesis
□ Abdominal trauma considered sufficient to cause feto-maternal haemorrhage
□ Proven feto-maternal haemorrhage
□ Revealed or concealed antepartum haemorrhage
External cephalic version (performed or attempted)
What are the options for screening for foetal chromosomal abnormalities and timing?
- Combined first trimester screening – blood test (free βHCG and PAPP-A) with a nuchal translucency measurement. Done from K9-K13+6
- Non-invasive prenatal testing (NIPT) – detection of cell-free fetal DNA in the maternal blood stream. Available from K10. Although not a requirement, some practitioners also requested a K12 ultrasound for other detectable morphological abnormalities
Risk factors for GDM
○ Obesity (BMI>30kg/m2)
○ Previous GDM
○ First degree relative with diabetes
○ Previous elevated blood glucose level
○ Maternal age ≥40 years
○ Polycystic Ovarian syndrome or metabolic syndrome
○ Previous macrosomia (baby with birth weight ≥4500g or >90th centile)
High risk ethnic group (Asian, Indian, Aboriginal, Torres Strait Islander, Pacific Islander, Maori, Middle Eastern, Non-white African)
Maternal/Foetal Risks of GDM
Maternal risks include:
- Pre-eclampsia, higher rate of caesarean delivery, maternal birth injury and postpartum haemorrhage
Fetal/Neonatal risks include:
- Macrosomia, growth restriction, birth injuries, respiratory distress, hypoglycaemia and jaundice
Signs/Sx of Preeclampsia
§ Hyperreflexia and clonus
§ Visual changes (blurred vision, diplopia, blindness)
§ Headache
§ Oedema e.g. pulmonary, facial, hand
§ Oliguria
§ Upper abdominal pain/epigastric or right hypochondrial tenderness
Foetal well being and signs of growth restriction
Management of Preeclampsia
Urgent transfer to hospital
urine for protein creatinine ratio, FBE, E/LFT, Uric Acid, and Coags
Outpatient medications used
- Labetalol (avoid if asthmatic) 100mg to 400mg BD-QID (maximum 2400mg/ 24 hours)
- Methyldopa 250mg to 500mg BD-QID (maximum 2g/ 24 hours)
- Nifedipine SR (used as a second agent) 10mg to 20mg BD-TDS (max 120mg/24 hours)
Define Menopause? Premature/Early?
What is Premature Menopause?
Causes?
Menopause is a retrospective diagnosis made after 12 months of amenorrhea in women over 50 and two years in women under 50
Premature menopause is before age 40, whilst early menopause is 40-45
- Premature Ovarian Insufficiency
○ Disorder in ovarian function <40y
§ Causes;
□ Idiopathic - Primary Ovarian Failure
□ Genetic
□ Iatrogenic - chemotherapy, oophorectomy
□ Autoimmune
□ Infection
□ Metabolic Disease
Untreated POI is assoc w increased osteoporosis, heart disease, cognitive impairment and death
Investigations for Menopause?
Menopause is a clinical diagnosis however, one can consider confirmation of menopause and r/o other aetiology; • FBC/Iron Studies - ?HMB/AUB • Lipids and fasting BGL • LFT's • TFT • Urinalysis • Mammography, screening • TV-US if AUB Bone Density if risk factors
DDx for Menopause to be ruledout
• Depression • Anaemia • Diabetes • Thyroid dysfx • Hyperparathyroid • Medications DUB
Contraindications to HRT
- Active oestrogen dependent neoplasm - Endometrial/Breast Ca
- DVT
- Ischaemic Heart Disease, history of coronary artery disease
- Cerebrovascular Disease
- Uncontrolled HTN
- Undiagnosed PV Bleeding
- Acute liver disease
- Active SLE
- Pregnancy
- Otosclerosis
Management of Menopause - Broad
- Support and explanation
a. menopause is a normal part of life and a natural transition
b. lifestyle modifications; diet, exercise, weight, calcium intake, smoking cessation, safe alcohol intake - Hormone Therapy (HRT)
a. Primarily to relieve troublesome vasomotor symptoms
b. Se right for contraindications - Medical options for hot flashes include
a. Gabapentin Clonidine and antidepressants including SSRI’s and SNRI’s - complementary therapies include black cohosh, red Clover, soy products and other phytoestrogens
Although limited efficacy
Notes on HRT
- The prime treatment for an oestrogen deficiency disorder is oestrogen.
- Use oestrogen-only therapy for women without a uterus.
- If a uterus is present, give combined oestrogen-progestogen therapy.
○ A SERM is a new alternative to progestogen. - Use cyclical MHT in perimenopausal women and continuous MHT in postmenopausal women.
• Always start with a low dose of oestrogen.
• Allow about 6 months to stabilise with MHT.
• Yearly follow-up is advised.
Problematic loss of libido can be treated with tibolone.
Transdermal therapy has less effect on thromboembolic and stroke risk.
What is cyclical MHT? O+P
Who do we use it in?
Combined Oestrogen + Progesterone
- Women with uterus
• Oestrogen treats symptoms; progesterone protects the endometrium (from hyperplasia and increased risk cancer)
○ Suitable to use continuous oestrogen and cyclic progestogen combinations at peri-menopause or if less than 12 months amenorrhea
• All women who have an intact uterus require combination MHT (oestrogen only is used for women who have had a hysterectomy).
