Women's Health Flashcards

1
Q

Acute cystitis in pregnancy (medication, follow up)

A

Medication:
● First line: nitrofurantoin 100mg PO 6 hourly for 5 days
● Trimethoprim can be used in 2nd or 3rd trimester
Follow up: repeat urine MCS in 1-2 weeks post-completion of treatment

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2
Q

Amenorrhoea (primary vs. secondary)

A

Definition
- Primary: never bled
- Secondary: has not had bleed for 3 months from previous
Approach
● Pregnancy test, serum LH/FSH, TSH, prolactin levels, pelvic US
**Refer to page 47-48 of GP study notes

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3
Q

Antenatal depression

A

● If mild to moderate depression develops during pregnancy, use psychotherapy as first-line
● Consider starting an antidepressant for moderate depression (e.g. sertraline)
● Avoid paroxetine or fluoxetine

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4
Q

Breast-feeding - low breast milk supply (signs, practical points)

A
Signs
< 3 wet nappies per 24 hours
Concentrated urine (crystals)
Scant stools
Weight loss > 10%
< 20g weight gain per day
Failure to regain birth weight by 2 weeks of age
Breast fullness and heaviness post-feeds
Persistent jaundice, sleepiness or lethargy
Practical points 
Skin to skin contact
Frequent breastfeeding (3 hourly)
Good attachment
Switch feed
Express post-feeds
Compress or massage breast to promote let down
Domperidone 10mg/TDS
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5
Q

Lactational mastitis (organism, contributing factors, approach)

A

Organism: Staph aureus
Contributing factors: poor infant positioning, milk stasis, nipple damage
Approach:
● No systemic symptoms - no antibiotics required
● Systemic symptoms - antibiotics required
○ Flucloxacillin 500mg QID for 5-10 days
○ Cephalexin 500mg QID for 5-10 days (if allergic to above)
● General
○ Encourage breastfeeding on affected breast
○ Express milk post-feeds
○ Warm compress pre-feeds, cold compress post-feeds
○ Gentle massaging of the affected area
● Imaging: consider ultrasound if symptoms do not improve in 24-48 hours ? abscess

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6
Q

Postpartum lactation suppression (indication, medication)

A

Indication: stillbirth/neonatal death, personal choice, medical conditions.
Medication: cabergoline 1mg PO single dose
● Should not be taken until 4 hours after anti-emetics
● Most effective if given in first 12 hours

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7
Q

Gestational diabetes (definition, prognosis, screening, diagnosis, management, education)

A

Definition: Glucose intolerance that begins or is first diagnosed during pregnancy.
Prognosis: 41% of women return to normal by 6-8 weeks postpartum.
Screening: First trimester, 24-28 weeks gestation (not previous history), repeat OGTT 6-12 weeks postpartum
Diagnosis:
● Fasting BSL >=5.5 or,
● Two-hour BSL >=8.0
Management: Lifestyle interventions, education and insulin. Follow up OGTT at 6-12 weeks postpartum. Fasting BSL
and HbA1c every 3 years thereafter. For annual OGTT for women contemplating pregnancy.
Education:
● Benefits of breastfeeding in reducing the risk of women developing T2DM in the future
● Associated with risk of baby developing obesity, heart disease and/or diabetes in the future

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8
Q

Menorrhagia - approach

A

Exclude pregnancy-related bleeding (ectopic), coagulation disorders or anovulatory cycles in acute severe cases.

Summary

  1. Exclude pregnancy, perform CST (if due), Hx and Ex, initial Ix (FBE, ferritin, coag profile, TSH)
  2. If Ix suggest gynae cause, perform US
  3. Treat underlying cause

** Refer to page 182 of GP Study Notes

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9
Q

Menorrhagia - investigations and indications for referral

A

Investigations
● CST (if due)
● Transvaginal ultrasound to assess endometrial thickness (day 5-10 of menstrual cycle)
● Specialist investigations: saline-infused sonography, hysteroscopy, endometrial biopsy

Indications for specialist referral
General
● Has not resolved after 6 months
Early referral
● Severe dysmenorrhoea
● Dysmenorrhoea that does not respond to medications after 3 months
● Patients that wish to conceive
● Fibroids > 3 cm
● Endometrial polyps
● Risk of endometrial cancer
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10
Q

Menorrhagia - medications

A

Hormonal
Mirena - 52mg in uterus, replace 5 yearly
● Possible irregular bleeding in first few months
Combined OCP
● Prolonged or continuous use can minimise withdrawal bleeding
Oral progesterone
● Not recommended
● Can be used for short-term
● Regular cycles: Need to be given 21 out of 28 days of the menstrual cycle
● Irregular cycles: Take for 12 days at the same time each calendar month
Depot - medroxyprogesterone 150mg IM every 12 weeks

Non-hormonal
Tranexemic acid - 1 to 1.5g 6-8 hourly for first 3-5 days of each cycle
● More effective than NSAIDs
NSAIDs - naproxen 500 mg initially, then 250mg every 6-8 hours

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11
Q

Hormonal replacement therapy - key points, factors to consider

A

Key points
● Starting systemic HRT contraindicated in >60 yrs (but can be continued if started earlier)
● Individuals with increased risk of VTE can use transdermal but not oral
● All individuals with migraine have an increased risk of stroke - transdermal is preferred
Factors to consider: presence of uterus, individual preferences and tolerance.

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12
Q

Hormonal replacement therapy - medical options and regimes

A

Options:
Oestrogen
- Forms: oral, patch, implant, infection, topical.
- Goal: prescribe the lowest dose possible to relieve symptoms.
Progesterone
- Must be used with oestrogen if the woman has a uterus.
- Can be given continuously or cyclical.
- Avoid continuous use in perimenopausal women because of heavy irregular bleed.
Testosterone (50mg implant
3-12 monthly)
- Reserved for patients whose libido does not improve with HRT.
- Should be given concurrently with oestrogen.
Tibolone (2.5mg PO daily)
- Unsuitable for perimenopausal women.
- Should be considered for women who are surgically postmenopausal or who have had not a natural menstrual bleed for at least 12 months.
- May improve libido.
- Not associated with increased risk of VTE.

Regimes
** Refer to page 185 of GP Study Notes

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13
Q

Hormonal replacement therapy - contraindications, benefits vs. harms

A

Contraindications

  • Oestrogen-dependent tumour
  • Recurrent thromboembolism
  • Uncontrolled hypertension
  • Undiagnosed vaginal bleeding
  • Active SLE
  • Pregnancy
  • Otosclerosis
Benefits 
Reduces risk of:
● Fractures
● Diabetes
● Colorectal cancer
● Vasomotor symptoms
Harms 
Increases risk of:
● Breast cancer
● Stroke
● VTE
● Gallbladder issues
● Demential
● Urinary incontinence
● CHD
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14
Q

Menopause - non-hormonal options

A
Non-hormonal options for vasomotor symptoms:
● SSRI: Paroxetine 10mg PO daily
● SNRI: Venlafaxine 37.5mg daily
● Gabapentin 100-300mg PO nocte
● Clonidine 25 microg BD
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15
Q

Hyperthyroidism in pregnancy

A

Key points:
● Low or suppressed TSH during first trimester not usually cause for concern
● Self-limiting as hCG concentration declines (TSH receptor hypersensitive to hCG)
● Graves disease = +ve TSH-receptor antibody +/- thyroid peroxidase antibody or thyroglobulin

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16
Q

Hypothyroidism in pregnancy - pre-pregnancy, during pregnancy

A

Pre-pregnancy
● Reserve TSH testing for patient with risk factors for thyroid dysfunction or on thyroxine
● Start on thyroxine if TSH >4

During pregnancy
Key points:
● Inadequate replacement increases risk of pregnancy complications as well as foetal neurocognitive
development
Replacement aims:
- First trimester = 0.1 to 2.5
- Second trimester = 0.2 to 3.0
- Third trimester = 0.3 to 3
New-onset or previously untreated hypothyroidism:
● New-onset = start thyroxine IMMEDIATELY + specialist input
● Subclinical = test for thyroid peroxidase antibody (if +ve can increase pregnancy complications)
○ Start thyroxine IF: 1. TSH above reference range + thyroid peroxidase antibody positive OR 2. TSH
above 10 regardless of antibodies
Pre-existing hypothyroidism before conception:
● Optimise for preconception TSH <2.5
● Increase dose by 25-30% at 4-6 weeks, then to baseline postpartum
● Consider testing every 6 weeks (if unstable), at 30 weeks (if stable)

17
Q

Pain in pregnancy - lower back vs pelvic pain

A

Low back
● Occurs in 50-70% of women
● Management includes back strengthening exercises with fit ball or water-based in addition to simple
analgesia (paracetamol)

Pelvic pain
● Originates from sacroiliac joint and/or pubic symphysis
○ Gap of 1cm in pubic symphysis normal during pregnancy
○ Pubic diastasis can occur during labour - takes up to several years to resolve
● Management is strengthening exercises

18
Q

Polycystic ovarian syndrome (epidemiology, presentation, diagnosis, management)

A

Epidemiology: Aboriginal and Torres Strait Islanders, South-East Asians, obese individuals

Presentation:

  • Hirsutism
  • Irregular or absent menstrual cycles
  • Sub-fertility or infertility
  • Psychological symptoms
  • Metabolic features

Diagnosis: up to 70% of cases picked up on ultrasound
- Two of the following: oligo/anovulation, hyperandrogegism, PCOS on US

Management:
● Weight loss (5-10%)
● COCP +/- spironolactone
○ Consider intermittent progestin if can’t have COCP
● Psychology/counselling
● Screen for impaired glucose, hyperlipidaemia, HTN
○ Consider metformin

19
Q

Post-menopausal bleeding (common cause, concern, RF, imaging, gold standard Ix)

A

Common causes: endometrial atrophy, endometrial polyps
Concern: endometrial carcinoma
Risk factor for malignancy: chronic anovulation, unopposed oestrogen, PCOS, tamoxifen family history of endometrial
or colon cancer, nulliparity, obesity, endometrial thickness >8mm.
Imaging: transvaginal ultrasound always indicated
● Should be used for routine surveillance of endometrium if bleeding persists after 6 months of HRT
Gold standard: endometrial biopsy
● Indicated for patients on tamoxifen

20
Q

Post-menopausal bleeding - approach

A

** Refer to page 240-242 of GP Study Notes

21
Q

Postnatal depression (significance, treatment)

A

Significance: Can affect the parent-infant relationship.
Treatment: Aim to refer to a perinatal specialist if severe/complex.
● First line: CBT, interpersonal therapy, group therapy
● Medication: indicated for severe cases
○ Sertraline
○ Avoid fluoxetine if breastfeeding
Good resource: PANDA (Perinatal Anxiety and Depression Australia

22
Q

Postpartum thyroiditis (key points, differentials, treatment)

A

Key points
● Most common issue postpartum
● Transient hyperthyroidism
● Most revert back in 1 year
● Increased risk of developing hypothyroidism in 10 years postpartum
Differentials: Grave’s disease (positive TSH receptor antibody)
Thyroid peroxidase antibody: elevated in severe disease
Treatment:
● Propranolol in hyperthyroid phase
● Thyroxine in hypothyroid phase

23
Q

Supplementation in pregnancy - Vitamin D, folate, iodine

A

Vitamin D
● Testing is not routinely recommended if asymptomatic
● Only advised for supplementation if levels <50

Folate
Low risk (0.5mg/day)
High risk (5mg/day): pre-pregnancy diabetes mellitus, obesity.

Iodine - 150 microg/day

24
Q

Vaginal bleeding in pregnancy

A

Key points
● All women who are Rh(D) negative should receive anti-D immune globulin

First trimester
Key points: Common, occurs in 20-40%
Causes: ectopic, early pregnancy loss, implantation of pregnancy, cervical/vaginal/uterine pathology

Second and third trimester
Key points: Less common, more concerning
Causes: bloody show, pregnancy loss, placenta previa, abruptio placentae, uterine rupture (rare), vasa previa (rare)
Approach to late pregnancy bleed (>20 weeks)

** Refer to page 297 of GP Study Notes

25
Q

Placenta previa (definition, key points)

A

Definition: placental tissue that extends over internal cervical os.
Key points:
● Should consider in any woman presenting with PV bleeding in second half of pregnancy
● Generally presents without pain and uterine contractions
** Avoid digital examination of the cervix if placenta previa is suspected due to risk of severe haemorrhage

26
Q

Abruptio pacentae (definition, RF, presentation)

A

Definition: premature separation of placenta
Risk factors: prior placental abruption, trauma, HTN, smoking, cocaine use, PPROM
Presentation: PV bleeding, pain, uterine contractions

27
Q

Placenta accreta spectrum (definition, significance, RF)

A

Definition: Comprises several conditions where the placenta is too deeply embedded in the uterus.
Significance: Life-threatening haemorrhage at delivery.
Risk factors: Placenta previa after prior caesarean delivery.

28
Q

Vasa previa (definition, significance)

A

Definition: rupture of foetal blood vessels in membrane covering internal cervical os.
Significance: obstetric emergency and may lead to foetal death.

29
Q

COCP contraindications

A

Absolute contraindications
< 6 wks postpartum
smoker over the age of 35 (>15 cigarettes per day)
hypertension (systolic > 160mmHg or diastolic > 100mmHg)
current of past histroy of venous thromboembolism (VTE)
ischemic heart disease
history of cerebrovascular accident
complicated valvular heart disease (pulmonary hypertension, atrial fibrillation, histroy of subacute bacterial endocarditis)
migraine headache with focal neurological symptoms
breast cancer (current)
diabetes with retinopathy/nephropathy/neuropathy
severe cirrhosis
liver tumour (adenoma or hepatoma)
BMI > 35

Relative contraindications
smoker over the age of 35 (< 15 cigarettes per day)
adequately controlled hypertension
hypertension (systolic 140 - 159mmHg or diastolic 90 - 99mmHg)
migrain headache over the age of 35
currently symptomatic gallbladder disease
mild cirrhosis
history of combined OCP-related cholestasis
users of medications that may interfere with OCP metabolism