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RACGP > Women's Health > Flashcards

Women's Health Flashcards

1
Q

DDx Bleeding in Pregnancy

A
  • Ectopic Pregnancy
    • Early Pregnancy Loss/Miscarriage
    • PID/STI e.g Chlamdyia
    • Trophoblastic Disease
    • Cervical Polyp
    • Cervical Cancer
    • Cervical Ectropion
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2
Q

Investigations for Bleeding in Pregnancy

A
  • 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
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3
Q

Emergency Contraception

- 2 options

A
  1. 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
  2. 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
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4
Q

DDx for breastfeeding pain and discharge

A
  • 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
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5
Q

Breastfeeding Hx

A

○ 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
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6
Q

Tx for Nipple Candidiasis

A

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

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7
Q

Sx of nipple thrush

A

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

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8
Q

Antenatal Care at K4-10

1st Visit

A 
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

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9
Q

When safe in pregnancy to give Rubella and Varicella?

A

4/52 prior to Conception, bc live vaccines

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10
Q

Antenatal Screening 11-13 weeks

A

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
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11
Q

What is NIPT Testing

A
  • 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
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12
Q

When is OGTT

A

Most - 26-29 weeks

14-20 weeks - Early if high risk for GDM (BMI>30 or Age >40, ATSI)

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13
Q

When to check Rhesus Antibodies

A

Rh Negative mother

28+34 weeks

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14
Q

When to Genital Swab for GBS ?

A

36 weeks

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15
Q

For each antenatal visit

A
  • 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
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16
Q

Pruritis in Pregnancy

A

○ 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

17
Q

Supplementation in Pregnancy

A
  • 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
18
Q

Toxoplasmosis
CMV/Parvovirus
Listeriosis
Mercury in Pregnant Diet

How to remain safe? and foods to avoid

A

• 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

19
Q

When to consider anti-D antibodies

A
  1. 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
  2. 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
  3. Anti-D should be given post-natally, within 72 hours to all Rh (D) negative women who deliver an Rh (D) positive baby.
20
Q

Sensitizing events in pregnancy include

A

□ 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)

21
Q

What are the options for screening for foetal chromosomal abnormalities and timing?

A
  1. Combined first trimester screening – blood test (free βHCG and PAPP-A) with a nuchal translucency measurement. Done from K9-K13+6
  2. 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
22
Q

Risk factors for GDM

A

○ 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)

23
Q

Maternal/Foetal Risks of GDM

A

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

24
Q

Signs/Sx of Preeclampsia

A

§ 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

25
Q

Management of Preeclampsia

A

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)
26
Q

Define Menopause? Premature/Early?

What is Premature Menopause?

Causes?

A

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

27
Q

Investigations for Menopause?

A 
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
28
Q

DDx for Menopause to be ruledout

A 
• Depression
	• Anaemia
	• Diabetes
	• Thyroid dysfx
	• Hyperparathyroid
	• Medications
DUB
29
Q

Contraindications to HRT

A
  1. Active oestrogen dependent neoplasm - Endometrial/Breast Ca
  2. DVT
  3. Ischaemic Heart Disease, history of coronary artery disease
  4. Cerebrovascular Disease
  5. Uncontrolled HTN
  6. Undiagnosed PV Bleeding
  7. Acute liver disease
  8. Active SLE
  9. Pregnancy
  10. Otosclerosis
30
Q

Management of Menopause - Broad

A
  1. 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
  2. Hormone Therapy (HRT)
    a. Primarily to relieve troublesome vasomotor symptoms
    b. Se right for contraindications
  3. Medical options for hot flashes include
    a. Gabapentin Clonidine and antidepressants including SSRI’s and SNRI’s
  4. complementary therapies include black cohosh, red Clover, soy products and other phytoestrogens
    Although limited efficacy
31
Q

Notes on HRT

A
  • 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.

32
Q

What is cyclical MHT? O+P

Who do we use it in?

A

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).

RACGP (3 decks)

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