Women's health Flashcards
Ectopic pregnancy
RF = Previous ectopic / PID / Surgery to fallopian tubes / Coils / Old age / Smoking
Presentation - typically 6-8 weeks gestation with missed period - constant lower abdo pain (RIF / LIF), Vaginal bleeding, abdominal tenderness +/- pain radiation to the L shoulder
O/E bimanual palpation reveals cervical motion tenderness
!TIP - always ask about anemia symptoms e.g dizziness, syncope etc
Investigation
* * Pregnancy test - Women may have a +ve pregnancy test. Normally HCG doubles every 48hrs so a rise <63% after 48 hours indicates an ectopic (a fall of >50% indicates miscarriage)
* Gold standard =** transvaginal ultrasound**
USS will show a ‘blob/bagel’ sign which does not move with the ovaries- gestational sac containing a yolksac or fetal pole in the fallopian tube
Management of Ectopic pregnancy
- Expectant management - if <35mm unruptured ectopic with no visible heartbeat, no significant pain and HCG <1500
- Medical management (Methotrexate IM) - if HCG < 5000 & same as above
- Surgical management (Salpingectomy 1st line, Salpingotomy if risk of infertility)- if pain, adnexal mass >35mm, Visible heartbeat or HCG >5000
!NOTE - rhesus -ve women having surgical removal need Anti-D prophylaxis
Miscarriage
Sx = Painless vaginal bleeding
Types;
* Threatened = vaginal bleeding with closed cervix but alive fetus
* Inevitable = Vaginal bleeding + open cervical os
* Incomplete = Retained products of conception after miscarriage
* Complete = gestational sac present but no embryo
Investigations;
1. 1st line = **Ultrasound **
Features to look for on USS in early pregnancy + indicators of miscarriage
- Mean gestational sac diameter - *should be >25mm - this is when you would expect to see a fetal pole
- Fetal pole + crown rump length - this should be 7mm - this is when you would expect to see a heartbeat
- Fetal heartbeat - Pregnancy is viable when heartbeat is visible
Note - if no fetal pole is seen but sac >25mm then repeat scan in 1 week before confirming miscarriage. Also if crown-rump length >7mm but no heartbeat or crown-rump length <7mm with a heartbeat repeat in 1 week before confirmation.
Management of miscarriage
<6 weeks gestation = expectant management + repeat urine pregnancy test in 7-10 days.
> 6 weeks gestation = refer to EPAU for USS. Options then include;
* Expectant management
* Medical management = misoprostol
* Surgical management = misoprostol + manual/electric vaccuum aspiration
Indications for surgical management of miscarriage
Increased risk of haemorrhage
Late 1st trimester
Previous adverse/traumatic experience (e.g stillbirth)
Evidence of infection
Investigations for recurrent miscarriage
- Antiphospholipid anitbodies
- Heriditary thrombophilias testing
- Pelvic USS
- Genetic testing (on the products of conception & on parents)
1967 Abortion act / 1990 Human Fertilisation + Embryology act
- 24 weeks is the latest gestational age where abortion is legal
- A woman can abort <24 weeks if continuing pregnancy involves greater risk to physical/mental health of the woman or existing children of the family
- A woman can abort at any time in pregnancy if continuing the pregnancy is likely to risk the life of the woman or cause grave physical/mental effects OR the child is at substantial risk of severe handicap
2 registered medical practitioners must sign. Must be carried out by registered practitioner on NHS hospital or premise.
Medical ToP
- Most appropriate earlier in pregnancy. uses a combination of
1. Mifepristone (anti-progestogen) - relaxes cervix
2. Misoprostol (prostaglandin analogue) - taken 2 days later. Stimulates uterine contractions. Every 3 hours until expulsion is achieved.
Surgical ToP
First the patient is given mifepristone + misoprostol,
Then surgical dilation + suction of uterine contents
Or if >15wks = surgical dilation + evacuation of contents using forceps
How long can a pregnancy test remain +ve following ToP
4 weeks
Hyperemesis gravidarum
Diagnosis = Protracted N&V + >5% weight loss or Dehydration or Electrolyte imbalance
Severity = assesed using the PUQE
Management;
* Antiemetics - 1st line is prochlorperazine, then cyclizine/promethazine, then ondansetron, then metaclopramide
* Can try ginger or acupressure on the wrists
Severe cases may need IV antiemetics + Fluids and monitoring of U&Es. If really severe then thiamine supplementation + thromboprophylaxis needed.
When to admit a patient with hyperemesis gravidarum
- Unable to tolerate oral anti-emetics or retain fluids
- > 5% weight loss
- Ketones in urine
- Comorbidities
Complications of Hyperemesis gravidarum
- Wernicke’s encephalopathy
- Mallory-weiss tear
- Central pontine myelinosis
- ATN
- IUGR
Hydadiform mole
= type of tumour which grows like a prengnacy inside the uterus
Sx;
* extreme morning signess
* vaginal bleeding
* Increased enlargement of uterus (bigger than date)
* abnormall high HCG
* thyrotoxicosis - *hcg can act like TSH - bloods show high T3/T4 and low TSH
Investigations;
1. Pelvic USS - shows a ‘snowstorm’ appearance
2. Histology - confirms diagnosis after evacuation.
Management = evacuation + histology + monitoring of hcg until return to normal.
Down’s syndrome combined test results
High B-HCG, Low PAPP-A, Thickened nuchal translucency.
Screening for down’s syndrome >15weeks gestation
Quadruple test
Low AFP, Low Oestriol, High B-HCG, High Inhibin-A.
Low b-HCG, Oestriol & AFP and Normal Inhibin-A
Edward’s syndrome
Neural tube defect - Quadruple test result
High AFP, Low oestriol & b-hcg and normal inhibin
If combined/quadruple testing shows higher chance of Down’s syndrome, what is next?
1st line = NIPT
Gold standard for diagnosis= CVS (9-12wk) or Amniocentesis (15-19wks)
Management of hypothyroidism in pregnancy
increase levothyroxine dose by 30-50%
Management of HTN in pregnancy
Stop: ACEi / ARBs or Thiazide diuretics
Replace with B-blockers, CCBs or Alpha blockers
Pre-eclampsia prophylaxis with 75mg Aspirin OD
Management of epilepsy in pregnancy
5mg Folic acid before conception + during
Should be well controlled on monotherapy prior to conception.
Avoid: Sodium valporation + phenytoin
Safe = Lamotrigine / Carbamazepine / Levetiracem
Management of Rheumatoid arthritis in pregnancy
Methotrexate should be stopped by either parents 6 months prior to conception.
Safe = hydroxychloroquine. Corticosteroids can be duirng flare ups and NSAIDs are safe until week 33.
Lithium is associated with what congenital abnormality
Ebsteins anomoly
Salt and pepper chorioretinitis in a newborn
Indiates congenital rubella
(Rubella infection <20 weeks gestation)
Features of congenital rubella
Sensorineural deafness
congenital cataracts
PDA or Pulmonary stenosis
LDs
Growth retardation
Purpuric skin lesions
Salt and pepper chorioretinitis
Why must blue cheese be avoided in pregnancy
Due to risk of Listeria (gram +ve bacteria causing listeriosis)
Causes a flu-like illness (can lead to pneumonia or meningoencephalitis) and poses a high risk of miscarriage/fetal death or severe neonatal infection if acquired in pregnancy.
Congenital CMV features
Infected cells have an ‘Owl’s eye appearance’ due to intranuclear inclusion bodies
Features;
* Fetal growth restriction
* Microcephaly
* Hearing loss
* Vision loss
* LDs
* Seizures
* CMV retinitis
Congenital toxoplasmosis Triad
- Intracranial calcification
- Hydrocephalus
- Chorioretinitis
Complications of congenital Parvovirus B19
Miscarriage/fetal death
Severe fetal anemia
Hydrops fetalis
Mirror syndrome
Zika virus
Spread by the aedes mosquito or by sex with infected person.
Congenital zika syndrome;
1. Microcephaly
2. Fetal growth restriction
3. Intracranial abnormalities - Cerebellar atrophy/ventriculomegaly.
When should Anti-D antibodies be given?
Any woman who is rhesus D -ve at 28 weeks & birth and at any additional sensitising event:
* Late miscarriage (>12ks)
* ToP
* Abdominal trauma
* Amniocentesis procedures
* Bleeding
What test can be done after a sensitising event to determine if more Anti-D is needed?
Kleinhauer test
Women who are high risk for SGA baby get serial ultrasound scans to measure what?
- Estimated fetal weight
- Abdominal circumfrence
- Umbilical artery pulsatility index (UA-PI) - *to measure flow through the umbilical artery *
- Amniotic fluid volume
If a fetus is confirmed to be SGA, what additional investigations into the underlying cause should be done?
BP / Urine dip (pre-eclampsia)
Uterine artery doppler
Fetal anomaly scan
Karyotyping
Testing for infections
UTI in pregnancy
May increase risk of preterm birth
Asymptomatic bacteremia is tested for at booking scan + antenatal scans
Mx = Nitrofuantoin (avoid in 3rd trimester)
Trimethoprim (avoid in 1st trimester)
Cefalexin
Pre-eclampsia
= New HTN in pregnancy with end organ dysfunction occuring >20 weeks gestation (if present before 20 weeks then it was existing HTN).
Diagnostic criteria: BP >140/90 after 20 wks +
* Proteinuria - PCR > 30 or Albumin:creatinine >8
* Organ dysfunction - e.g raised creatinine, LFTs, seizures, Haematological abnormality
* Placental dysfunctiong - e.g SFGA
Additional invx = PIGF at 20-35 weeks (will be low)
Sx;
May cause headache / visual disturbance / N&V / Epigastric pain / Oedema / reduced urine output / Brisk reflexes / oligohydramnios
Management;
- High risk women given Aspirin prophylaxis from week 12
- Close monitoring of BP (every 48 hours) & weekly USS
- Labetalol 1st line
- Nifedpine if asthmatic
When to admit in pre-eclampsia
If BP >160/110 admit for IV hydralazine + IV magnesium sulfate if eclampsic.
Risk factors for pre-eclampsia
Moderate RF;
* Age >40
* BMI >35
* >10yrs since last pregnancy
* Multiple pregnancy
* 1st pregnancy
* FHx
High RF;
* Pre-existing HTN
* Previous gestational HTN
* Autoimmune conditions
* DM
* CKD
Criteria for Aspirin prophylaxis in pregnancy
1 high risk factor or 2+ moderate
Eclampsia
Seizures - due to pre-eclampsia
Management = IV magnesium sulfate (also give 24hrs after labour)
HELLP syndrome
Features occuring as a complication of pre-eclamspia
1. Haemolysis
2. Elevated liver enzymes
3. Low platelets
Gestational diabetes screening
OGTT done at 24-28wks.
*also at booking test if previous gestational DM.
Diagnosis is;
* Fasting glucose >5.6mmol/L
* 2hrs post glucose >7.8mmol / L
What are the target BM levels for gestational diabetes patients
Fasting <5.3
2hr post meal < 6.4
Avoid hypoglycemia (<4)
Birthing advice for women with diabetes
Uncomplicated gestational diabetes = Should give birth no later than 40 + 6 (offer induction or C-section on this date)
Existing T1DM/T2DM = Should have induction or C section planned for 37 - 38 + 6 weeks.
Features of gestational diabetes
- Large for gestational age fetus
- Polyhydramnios
- Glucose on urine dip
- Polydipsia
- Polyuria
Management of gestational diabetes
If fasting glucose <7mmol/L = trial diet + exercise for 1-2 weeks, if no improvement then Metformin, then insulin
If fasting glucose >7mmol/L or >6mmol/L + Macrosomia = Metformin + Insulin
Obstetric cholestasis
= Intrahepatic cholestasis of pregnancy. Typically develops >28wks of pregnancy (thought to be a result of oestrogen/progesterone levels)
Presentation - Late in pregnancy with;
* Pruritus - particularly on hands/feet
* Fatigue
* Dark urine + pale stools
* Jaundice
Investigations -LFTs show hepatic picture with raised ALT, AST and GGT (ALP will also rise but this is normal in pregnancy)
Management;
1. Ursodeoxycholic acid - improves LFTs and itching
2. Calamine lotion
3. Anti-histamines
4. Vitamin K (if PT is derranged)
*Weekly monitoring of LFTs is needed and **induced Labour at 37 weeks. **
Main compication of obstetric cholestasis
Still birth
Acute fatty liver of pregnancy
Rare condition occuring in 3rd trimester due to rapid acculumation of fat within hepatocytes causing acute hepatitis.
Typically caused by a fetal LCHAD deficiency
Presentation;
* malaise + fatigue
* N&V
* Jaundice
* hypoglycemia
* Abdo pain, Anorexia + Ascites
Invx: LFTs show raised liver enzymes, WBC count and low platelets.
Management = obstetric emergency requiring urgent delivery of baby.
Most recover after birth.
Planceta praevia
Where the placenta is attached to lower portion of uterus (may cover cervical os)
Features;
* Many are asymptomatic
* Painless vaginal bleeding - typically 36+ weeks
Grading;
1 - placenta is lower than uterus but not reaching internal os
2 - Placenta reaches but does not cover internal os
3 - placenta is partially obstructing internal os
4 - Placenta is completely covering internal os
Invx = usually picked up on 20 week anomaly scan
Management;
- Repeat USS at 32 + 36 weeks
- Planned C section for 36-37 weeks (Give mum Corticosteroids for baby surfactant)
Placental abruption
- When the placenta separates from wall of uterus during pregnancy resulting in antepartum haemorrhage
Presentation
* Sudden & severe abdo pain
* Vaginal bleeding
* Shock (hypotension + tachycardia) - *pt may have no clear sign if concealed abruption.
* CTG abnormalities
O/E the pt may have a “woody” appearance to the abdomen (suggesting haemorrhage)
Invx; largely a clinical diagnosis - Can do USS to rule out praevia as a cause of bleed
Management;
* If < 36 weeks + fetal distress = C section (if not fetal distress just monitor)
* If > 36wks = vaginal delivery or C section if fetal distress
*NOTE - ensure to give maternal corticosteroids if delivering < 34 weeks + give Anti-D prophylaxis if woman is rhesus -ve.
Risk factors for Placental abruption
- Previous abruption
- Pre-eclampsia
- Trauma
- Multiple pregnancy
- Multigravida
- fetal growth restriction
- Cocaine & amphetamines
- Smoking
- Polyhydramnios
Placenta accreta
Where the placenta implants deeper into the myometrium (makes it difficulte to deliver the placenta)
Typically asymptomatic but may present with some bleeding in 3rd trimester.
Diagnosis = picked up on USS or at birth when placental delivery is difficult. MRI can be used to asses depth and width of invasion.
Mx;
* Planned C secrion between 35 - 36 + 6 weeks (give corticosteroids)
* If extensive disease then hysterectomy may be recommended during surgery or can try and do uterus preserving surgery.
If natural birth (i.e was not pre diagnosed) but delayed placental delivery pt may need hysterectomy.
Management of baby born to Hep B surface antigen +ve mothers
Hep B vaccine and 0.5ml HBIG within 12 hours. ofbirth
And then 2nd Vaccine 1-2 months later
Indications for continuous CTG monitoring while in labour
- Suspected chorioamnionitis or sepsis or temp >38
- Severe HTN 160/110
- Oxytocin use
- The presence of significant meconium
- Fresh vaginal bleeding occuring in labour
RF for VTE in pregnancy
Smoking
Parity >3
Age >35
BMI >30
Multiple pregnancy
Pre-eclampsia
Varicose veins
FHx
Thrombophilia
IVF
VTE prophylaxis guidelines in pregnancy
Prophylaxis with LMWH throughout pregnancy + 10 days postnatally (withheld during labour) from;
* Booking scan if previous unprovoked VTE (and 6 weeks post-natally)
* 1st trimester if 4+ risk factors
* 28 weeks + if 3+ risk factors
If contraindications for LMWH (e.g bleeding disorder or postpartum haemorrhage) Give intermittent pneumatic compression stockings.
Management of PE/VTE in pregnancy
Thrombolysis is obvious contraindicated in pregnancy (can cause catostrophic haemorrhage of placenta)
So for massive PE + haemodynamic comprimise:
1. Unfractionated heparin
2. Surgical embelectomy.
Hb Targets during/after pregnancy
Booking scan >110g/L
At 28 weeks >105 g/L
Post-partum >100g/L
Vasa praevia
A condition where fetal vessels lie across the internal cervical os
RF = placenta praevia /IVF / Multiple pregnancy
Presentation; Classic triad;
1. Rupture of membranes followed by
2. Vaginal bleeding and
3. Fetal distress
Diagnosis = Sometimes picked up antenatally with USS. Often presents during labour with vaginal bleeding or during vaginal examination.
Mx = Carries v high fetal morality due to risk of asphyxiation or hypoxia.
If pre-diagnosed then Elective C section at 34-36weeks (+ corticosteroids).
If presenting in labour = push baby back in (NOT cords) and go to emergency C section
Management of stillbirth
Vaginal birth is 1st line (unless contraindicated)
* Give mifepristol +/- Misoprostol to induce labour
Expectant management can be done
*Give Carbergoline (dopamine agonsit) after birth to suppress lactation.
Chorioamnionitis
Bacteria infection of the placenta and amniotic fluid
Sx;
* Uterine tenderness
* Bad smelling amniotic fluid (brown discharge)
* Baseline fetal tachycardia
Mx = prompty delivery of fetus (by C section if needed) followed by IV antibiotics
Management of antenatal GBS
Intrapartum IV Benzylpenecillin - required to reduced neonatal transmission.
Note - Universal GBS screening is not offered. However women who have had GSB in previous pregnancies should be offered intrapartum prophylaxis or testing at 35-37 weeks as their risk remains 50%.
IAP should be offered to any women in preterm labour (regardless of GBS status) and those with fever >38 degrees during labour
Aortocaval compression
This can occur if a pregnant lady lays on her back and causes compression of the IVC and aorta, reducing venous return to the heart therefore reducing CO leading to hypotension.
Place woman in the left lateral position to relieve the compression and improve venous return to the heart
When should you first begin to feel fetal movements
between 18-20 weeks (sometimes 16 if multiparous)
If no movements have been felt by 24 weeks then further investigation is needed.
RCOG definition of reduced fetal movements
<10 movements in 2 hours for pregnancies >28 weeks
RF for reduced fetal movements
- Posture - generally less prominent when sitting/standing
- Distraction
- Placental position - anterior placentas may cause less feeling
- Fetal position - anterior fetal position means movements are less noticable
- Body habitus
- Amniotic fluid volume
- Fetal size
Investigation for a woman 23 weeks gestation presenting with reduced fetal movements (when previous movements were felt)
Handheld doppler
What is the main hormone involved in the stimulation of labour
Prostaglandins
What monitoring is required in labour
FHR every 15 mins (or continuous CTG if indicated)
Contractions assesed every 30 mins
Maternal pulse every 60 mins
Maternal BP + Temp every 4hrs
VE every 4 hours to check progression
Maternal urine dip (ketons/protein) every 4 hours
What is the normal fetal lie
Longitudinal cephalic
Transverse lie
This is common <32 weeks but usually does correct itself.
Management = if >36 weeks then ECV should be tried (can’t be done if ROM already). If unsuccesful then C section.
Contraindications to ECV
Antepartum haemorrhage in past 7 days
Abnormal CTG
Major uterine abnormality
Ruptured membranes
Multiple pregnancy
Indications for forceps delivery
Fetal distress during 2nd stage of labour
Maternal distress in 2nd stage
Failure to progress
Control of head in breech delivery
What determines success in the 2nd stage of labour
Power = strenght of contractions
Passenger = size, attitude, lie + presentation of fetus
Passage = size and shape of the pelvis
P-PROM
Preterm pre-labour rupture of membranes
Invx = Speculum reveals pooling of amniotic fluid in the vagina
Mx x = Prophylactic Erythromycin (to prevent chorioamnionitis) + Induction of labour (if 34+ weeks)
make sure to give maternal corticosteroids.
What tests can be done to confirm rupture of membranes
- IGFBP-1 = a protein present in amniotic fluid (raised levels in vaginal fluid indicates PPROM)
- PAMG-1
Pre-term labour with intact membranes
Regular painful contractions + cervical dilation but no rupture.
Dx = if <30 weeks clinical diagnosis.
If >30 weeks;
* Transvaginal USS to assess cervical length (if >15mm then preterm labour is unlikely)
* Fetal fibronectin - found in the vaginal during labour (<50ng/ml means labour is unlikely)
Mx;
* If between 24 and 33+6 then use tocolysis with Nifedipine
* Maternal corticosteroids
* IV mangesium sulfate (if delivering <34 weeks to protect babys brain)
* Delayed cord clamping (can increase circulating blood volume and Hb in baby at birth)
Bishop score
Scoring system to determine the ripeness of the cervix.
Based on;
* Fetal station
* Cervical position
* cervical dilation
* cervical effacement
* cervical consistency
Score 8+ shows a ripe cervix and high chance of spontaneous labour
Options for inducing labour
- Membrane sweep - used from 40wks +, may induce labour within 48hrs
- Vaginal Dinoprostone - prostaglandin E2 - done in hospital setting
- Cervical ripening balloon - used when prostaglandins are not preferred e.g previous C section or multiparous women or if prostaglandins didn’t work
- Oxytocin infusion - often used after dinoprostone
- Oral mifepristone + misoprostol (used when fetal death has occured)
What should the baseline rate be on CTG
110-160bpm
100-109 or 160-180 is non-reassuring
<100 or >180 = Abnormal/concerning
What should variability be on CTG
Normal variance = between 5-25
Non-reassuring = <5 for 30-50mins or >25 for 15-20 mins
Abnormal/concerning = <5 for 50+ minutes, >25 for 25+ minutes.
Types of decelerations on CTG and what they mean
-
Early decelerations = gradual dips + recoveries in HR corresponding with uterine contractions. Fairly normal
2.** Late decelerations** = gradual falls in HR starting after uterine contractions - concerning as can indicate hypoxia **
3.Variable deceleratons - Abrupt decelerations unrelated to uterine contractions. A fall of >15bpm from baseline may indicate cord compression** (if bried period of acceleration before + after then fairly reassuring)
4.Prolonged decelerations - last between 2-10mins with a drop of >15bpm = cord compression + an emergency
What CTG pattern may be seen in vasa praevia
A rare pattern of CTG indicating severe fetal anemia (often due to vasa previa)
- shows a sine wave, with regular ups and downs and an amplitude of 5-15
Fetal bradycardia
Defined as <100bpm
Urgent intervention required
Baby should be delivered by 15 mins
Partogram
Monitoring of the 1st stage of labour.
3rd stage of labour
Birth - Delivery of placenta
Active management is encouraged to reduce the risk of haemorrhage.
1. First clamp the cord within 5 mins of birth
2. then give IM oxytocin
3. Palpate the abdomen to assess for uterine contraction
4. Use controlled cord traction to help deliver the placenta
Cord prolapse management
Main RF = fetus in abnormal lie or AROM.
Management;
* Emergency C section
* Cord should be kept warm & wet with minimal handling (to prevent vasospasm)
* Women should be positioned on all fours
* Limit compression on the cord - push baby back inside if out
* Give tocolysis (e.g terbutaline)- to minimise contractions whilst waiting for surgery
Turle neck sign
when the head is delivered but then retracts back into vagina. -due to shoulder Dystocia
McRoberts procedure
1st manoevre for Shoulder dystocia
Hyperflex + Abduct mums hips (to provide posterior pelvic tilt) - to lift pubic symphysis up
Rubins manoevre
Pressure applied to babies anterior shoulder via inside vagina to help delivery in shoulder dystocia
Zavanelli’s manouevre
Push the babys head back into the vagina so baby can be delivered by C section
Indications for instrumental delivery
Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in various fetal positions
Note - to quality for this the cervix must be fully dilated an dthe head of the baby should be low (> +1 fetal station) + One off dose of co-amoxiclav needed.
Cephalohematomas are associated with which type of instrumental delivery
Ventouse
Main complication of Forceps delivery
Facial nerve palsy
Bruising to babies face
Amniotic fluid embolism
Rare/severe condition where amniotic fluid passes into the mothers blood during labour - causes an immune reaction leading to systemic illness.
Presentation;
–> presents similarly to sepsis or PE with SOB, Hypoxia, hypotension etc
Mx = medical emergency. ABCDE management
*Post-mortem would show fetal squamous cells with debrs in maternal pulmonary vasculature.
Uterine rupture risk factors
Previous C section
Previous uterine surgery
High BMI
High parity
Old age
Oxytocin use
Uterine inversion
Rare complication where the fundus drops down through uterine cavity/cervix turning the uterus inside out - can occur as a consequence of pulling too hard. on umbilical cord during placental delivery
Presentation;
* large postpartum haemorrhage
* Maternal shock
* Collapse
Mx = life threatening emergency!
1. Johnson’s manouevre = use hand to push fundus back up and hold for several minutes - then give oxytocin to create tension and leave it there
2. Surgery
Causes of post-partum haemorrhage
Tone - uterine atony (most common cause)
Trauma - e.g perineal tear
Tissue - e.g retained placenta
Thrombin - bleeding disorder
Management of PPH
- ABCDE - 2 x large bore cannulas, bloods, 4 unit blood, warm IV fluids, Oxygen, FFP
- Stop the bleeding
Methods;
> Mechanical - rub the uterus + catheterise
> Medical - Oxytocin injection followed by infusion
a. Can use ergometrine or Carboprost or TXA
> Surgical - intrauterine balloon tamponade, B-lynch suture, uterine artery ligation etc
Indications for C section
Placenta praevia
Pre-eclampsia
Fetal distress in labour
Prolapsed cord
Failure to progress
Malpresentations: brow or breech
Placental abruption (only if fetal distress)
Vaginal infection e.g active herpes
Cervical cancer
Categories of C section
Category 1 = immediate threat to mother/fetus, deliver within 30 minutes
Category 2 = maternal/fetal comprimise deliver within 75mins
Category 3 = delivery is required but both are stable
Category 4 = elective
Layers of the abdomen cut through during C section
Skin –> Camper’s fascia (superficial) –> Scarpa’s fascia –> anterior rectal sheath –> rectus abdominis –> Transervsalis –> abdominal periteneum –> uterus
Lochia
Normal bleeding after birth - mixed with tissue and mucus.
Should settle in 6 weeks - if it doesn’t then USS shoud be done
Contraception after birth
Fertility returns 3 weeks (21 days) after birth (bottle feeding women will get menstruation)
Exclusively Bottle feeding women have lactational amenorrhoea for 6 months.
Options for bottle-feeding/combination women;
* POP - can be started any time after birth + are safe in breastfeeding
* COCP - AVOID in breastfeeding for first 6 weeks
* Coil - insert <48hrs after birth or >4 weeks after
Postpartum endometritis
Infection of the endometrium following labour. Most common after c section (hence why ABx are given)
Presentation;
* Foul smelling lochia/discharge
* bleeding which does not improve
* abdo pain / fever / sepsis
Invx = Vaginal swabs + Urine culture. USS can be done to rule out retained products of conception as cause of bleed. Sepsis 6 if severe
Management = Co-amox
Retained products of conception
When pregnancy tissue remains in uterus causing persistent bleeding postpartum.
Diangosis = USS
Management = ERCP (evacuation + curretage)
Complications of ERCP
Endometritis or Ashermanns syndrome (adhesions in uterus. -may bind the walls together potentially resulting in infertility)
Management of post-partum anemia
If Hb <70g/L = blood transfusion + oral iron
If Hb <90g/L = Iron infusion + oral iron
If Hb <100g/L = oral iron
Contraindication to iron infusion
Active infection
Diagnostic criteria of post-natal depression
- Low mood
- Anhedonia
- Low energy
Symptoms must last at least 2 weeks for diagnosis (typically presents 3 months post natal)
Invx = Edinburgh scale
Management of post-natal depression
Mild = Self-help & support
Moderate = CBT 1st line, then try SSRIs
Severe = if presence of psychosis = urgent referall to hospital
Puerperal psychosis
Features;
* Delusions
* Hallucinations
* Depression
* mania
* confusion
* thought disorder
Management = urgent admission to mother + baby unit
CBT, meds + ECT may be used
Sheehans syndrome
Ischemia of the anterior pituitary due to post partum haemorrhage.
Features;
* Reduced lactation - Low Prolactin
* Amenorrhoea - low LH/FSH
* Adrenal insufficiency / Addisonian crisis -* low ACTH*
* Hypothyroidism -*low TSH
Management;
1. Oestrogen + progesterone HRT
2. Hydrocortisone
3. Levothyroxine
4. Growth hormone
Which drugs must be avoided. inbreastfeeding
- Antibiotics - ciprofloxacin, tetracyclines, chloramphenicol, sulphonamides
- Psychiatric drugs - lithium, benzo’s, clozipine
- Aspirin
- Carbimazole
- Methotrexate
- Sulfonylureas
- Cytotoxic drugs
- Amiodarone
Contraindication to digitial vaginal examination in pregnancy
Vasa praevia (i.e avoid in any undiagnosed vaginal bleeding due to this risk)
Causes of primary amenorrhoea
- Hypo/hypergonadotropic hypogonadsim
- Kallman’s syndrome
- Congenital adrenal hyperplasia
- Androgen insensitivity syndrome
- Structural pathologies e.g imperforate hymen, transverse vaginal septae, vaginal agenesis, absent uterus.
Which types of primary amenorrhoea will have a raised tesosterone?
PCOS
Androgen insensitivity syndrome
Congenital adrenal hyperplasia
Fibroids
Benign oestrogen sensitivie tumours of uterine smooth muscle.
Sx;
* Often asymptomatic
* May present with heavy bleeding or prolonged menstruation
* Abdominal pain (worse on menstruation)
* Bloating / Fullness
* Urinary / bowel symptoms
* May present with dyspareunia or fertility problems.
* May present with red degeneration (during pregnancy)
Invx;
1. Abdo exam + bimanual palpation (may reveal palpable pelvic mass / enlarged non tender uterus)
2. Hysteroscopy = 1st line invx for submucosal fibroids
3. Pelvic USS may be needed for larger fibroids
Management of fibroids
If < 3cm;
* Mirenal coil 1st line + NSAIDs for symptomatic management
* COCP/POP may be of benefit
* Endometrial ablation
If > 3cm;
* Refer to gynae
* Likely to need surgical resection +/- myomectomy (to improve fertility)
* GnRH agonists (e.g gosrelin) before surgery to reduce the size
* Uterine artery embolisation can be done for lagrer fibroids (basically blocks the aterial supply causing them to shrink)
What can happen in pregnancy to fibroids
Red degerenation of fibroids;
Essentially ischemia, infarction and necrosis of fibroids due toa reduced blood suppy - more likely in larger fibroids during 2nd/3rd trimesters.
Sx = Severe abdominal pain + low grade fever + tachycardia.
How does endometriosis present
Cyclical pelvic pain + Deep dyspareunia. May have dysmenorrhoea / infertility / urinary or bowel symptoms.
*Consider extra-pelvic manifestations e.g Haemoptysis and bowel/urinary symptoms.
Adhesions may cause chronic, non-cyclical pain.
Investigations for endometriosis
Pelvic exam should be performed which may show pelvic massess or tissue in the posterior fornix etc.
- Transvaginal USS - this may show large endometriomas & **Chocolate cysts **
- Gold standard & needed for diagnosis = Laparoscopy + biopsy
- If suspecting adenomyosis then MRI is best invx
Management of endometriosis
1st line = NSAIDs + analgesia
2. Hormonal treatment = Mirena coil, COCP or POP
3. If hormonal treatment is not desirred then symptomatic relief with TXA or mefanamic acid.
3. Surgery - excision/ablation (best option for woman wanting to conceive) or hysterectomy if desired.
Adenomyosis
Endometrial tissue inside the myometrium.
Presents in similar way to endometriosis but will have an **enlarged & tender uterus on pelvic examination. ** (thought softer than a uterus containing fibroids)
Diagnosis = technically requires histology after hysterectomy to diagnose but transvaginal USS will do.
Management;
1. Hormonal management -Mirena coil is best, COCP or POP can. beused
2. For women who don’t want contraception, symptomatic relief can. beoffered with TXA or Mefanamic acid (if associated pain)
3. GnRH analgues can be used to induce menopausal state
3. Surgery
Management of menopause related symptoms
- HRT - natural oestrogens. +synthetic progestogens = 1st line treatment of vasomotor symptoms e.g flushing, insomnia headaches
- Tibolone - synthetic HRT
- Testosterone - can treat reduced libido
- Vaginal oestrogen - *for vaginal dryness/atrophy *
Non-HRT options;
* Fluoxetine / SSRIs for Vasomotor symptoms
* Clonidine can helpt
Contraindications to HRT
- Current or past breast cancer
- Any oestrogen receptor +ve cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
Premature ovarian insufficiency
= Menopause <40yrs
Causes;
* Idiopathic
* Iatrogenic (chemotherapy /oophorectomy)
* Autoimmune (coeliac, T1DM, Thyroid disease)
* Infection e.g mumps, TB or CMV
Diagnosis = Elevated FSH (>25) on 2 consecutive samples 4 weeks apart
Oestradiol will be low
Management
–> Due to oestrogen depletion women are at higher risk of CVD, Stroke, Osteoporosis, Dementia etc so need replacement
1. HRT - until atleast age 51yrs (better than COCP as associated with lower BP)
PCOS
A condition causing metabolic + reproductive issues.
Characterised by Multiple ovarian cysts, infertility, oligomenorrhoea, hypergonadism + insulin resistance.
Presentation - *amenorrhoea, infertility, obesity, hituism, acne, hair loss in male pattern, Insulin resistance *
Also associated with - diabetes, acanthosis nigricans, CVD, Hypercholesterolemia, Endometrial hyperplasia/Cancer, OSA
Diagnosis. = Rotterdam Criteria - requires 2 of the following;
1. Oligovulation or anovulation (usually presents with irregular/absent periods)
2. Hyperandrogenism (hirtuism / Acne)
3. PCOS on ultrasound (or ovarian volume >10cm or 12+ follciles)
Investigations;
* Bloods - show High LH:FSH ratio + High insulin, prolactin, testosterone, oestrogen.
* Imaging - Transvaginal USS is gold standard - shows a ‘string of pearls’
Screening: OGTT is used to screen for diabetes
Management;
* Weight loss!!! (orlistat may be used) + lifestyle changes + risk factor modification.
* Mirena coil - or POP to prevent endometrial hyperplasia
* Clomifene can be used to manage infertility
Management of Hyperandrogenism related symptoms in PCOS (Acne / Hitruism)
Acne;
1. COCP - co-cyprindol (Dianette) is best option has this has best anti-androgen effects (beware of VTE risk, ideally stay on for < 3 months)
2. Topical **Eflornithine ** - for hirtuism
3. Others = electrolysis, laser hair removal, Spirinolactone, Finasterine, Flutamide etc)
Most common form of ovarian cysts
Follicular - functional cyst with thin walls + no internal structures
Benign tumor of the ovarian epthelium
Serous cystadenoma
Dermoid ovarian cyst
Benign germ cell tumor (teratomas). Common in woman <25yrs & associated with ovarian torsion.
Investigation + management of ovarian cysts
- USS - first line investigation. Pre-menopausal women if simple ovarian cyst <5cm do not need further investigation.
- Bloods
- Ca125 - Ovarian cancer tumor marker
- LDH & AFP & b-HCG - germ cell tumor marker
Ovarian cancer - risk of malignancy index;
This estimates. therisk of an ovarian mass being malignant based on;
1. Menopausal status
2. USS findings
3. Ca125 level
Management;
* 2WW referal for suspected malignancy
* <5cm simple syst - usually resolve within 3 cycles. if not then further scan
* 5 - 7cm = routine gynae referal + annual USS
* > 7cm = Consider MRI / Surgical referal
Meig’s syndrome
- Ovarian fibroma
- Pleural effusion
- Ascites
Note - removal of the benign tumor results in complete resolution of ascites and PE.
Krukenburg tumour
An ovarian met (usually from GI cancer) - has a “signet-ring” appearance on histology
RF for ovarian cancer
- Age - peaks at 60yrs
- BRCA1/BRCA2 genes
- Increased number of ovulations
- Nulliparity
- Obesity
- Smoking
- Clomifene use
Protective factors = Breastfeeding, pregnancy & COCP use
Signs & Symptoms of Ovarian cancer
Typically women aged 60yrs with non-specific symptoms
* Abdominal bloating / Early satiety
* Loss of appetite
* Pelvic pain
* Hip/groin pain - an ovarian mass may press on the obturator nerve
* Urinary / Bowel symptoms
* Weight loss
* Ascites
> 70% present once its metastasised beyond hte pelvis
Referral criteria for suspected ovarian cancer
2ww if;
* Ascites + Pelvic/abdominal mass
Do Ca125 blood test + refer in woman >50yrs with;
* New symptoms of IBS / change in bowel habit
* Abdo bloating/early satiety
* Pelvic pain
* Urinary symptoms
* Weight loss
Ashermann’s syndrome
Adhesion formation within the uterus = following damage to the uterine epithelium (often related to curretage procedures e.g ToP or retained membranes). May cause uterus to seal shut resulting in obstruction.
Presentation;
Typically presents recently after birth/surgery with;
- Secondary amenorrhoea / Significantly lighter periods / Dysmenorrhoea
Diagnosis;
1. Hysteroscopy = gold standard
2. Hystersalpingography = contrast injection + xray
3. sonohysterography (uterus filled with fluid then USS)
Ovarian torsion
Sx;
Sudden onset severe unilateral pelvic pain which gets progressively worse + N&V.
Investigatios;
1. Transvaginal USS 1st line. -shows. a* ‘whirlpool sign’* + free fluid inthe pelvis/oedema of ovary
2. Laparoscopic surgery = definitive diagnosis
Management;
* emergency laparoscopic surgery for detorsion or oophorectomy.
Cervical ectropion
- when the columnar epithelium of the endocervix has extended out to the ectocervix. These cells are more prone to trauma and more likely to bleed. (Transformation zone will be visible)
Presentation; Typically presents in younger women (more common on those with COCP or pregnant)
* Postcoital bleeding
* Increased vaginal discharge
* Dyspareunia
O/E - speculum will reveal a well demarcated border between the redder columnar epithelium and pale pink squamous epithelium.
Management;
* Asymptomatic ones require no treatment - *Typicalyl resolves with age COCP cessation or end of pregnancy *
* Problematic bleeding is a indication for treeatment - either silver nitrate cuterization or cold coagulation
Nobathain cysts
Fluid filed csysts on the surface of the cervix. Usually up to 1cm in size.
Cause - *often happens after birth, trauma or cervicitis - due to mucus from the columnar epithelium becoming trapped by the squamous epithelium.
Usually asymptomatic - O/E smooth rounded bumps on the cervix usually near the os. Typically 2mm-30mm in size with whiteish yellow colour
No management needed - if uncertain refer for colposcopy.
Management of cystocele
anterior colporrhaphy or colposuspesion
Management of uterine prolapse
Hysterectomy or sarcohysteroplexy
Atrophic vaginitis
Dryness and atrophy of the vaginal mucosa due to lack of oestrogen (associated with menopause).
Sx;
* Postmenopausal women with itching, dryness, dysparunia & bleeding.
* May also have reccurent UTIs, stress incontinence or prolapse
O/E - there will be a pale mucosa, thin skin, reduced skin folds, dryness, sparse pubic hair and erythema.
Management;
- Vaginal lubricants e.g sylk or replens
- Topical oestrogen cream / pessaries
Contraindications for topical oestrogen
Same as HRT - active breast cancer, angina, VTE etc.
Bartholian’s cyst
Blockage of bartholian duct leads to cyst formation (or abscess if becomes infected)
Presentation;
* Unilateral cyst - tender on palpation and 1-4cm in size lateral to the introitus
* An abscess will be hot, tender and red and >4cm in size
Management;
- Bartholian cyst will resolve with good hygeine + warm compresses (biopsy may be needed if age >40yrs and suspecting vulval malignancy)
- Bartholian abscess needs Abx and may need a word catheter for pus drainage or marsupilization (surgcial drainage)
Lichen sclerosus
Chronic inflammatory skin condition typically affecting genitalia (men & women)
–> an autoimmune condition: associated with T1DM, Alopecia, Hypothyroid, Vitiligo
Sx;
* Vulval itching and skin changes (typically age 45-60yrs)
* Superficial dyspareunia
* Koebner phenomenon - symptoms worsened by friction
O/E - patches of “porcelain white” skin around the labia, perineum and perianal region. Shiny, purple flat topped raised areas with white lines across surface.
Management;
* Can’t be cured. Should be followed by every 3-6 months by gynae
* Potent topical steroids (e.g dermovate) for symptom control & to reduce the risk of malignancy
* Emollients
Complications = 5% risk o developing vulval squaous cell carcinoma.
Androgen insensitivity syndrome
Condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors.
X-linked recessive condition
Patients are geneticaly male (XY) - but the absent response to tesosterone ledas to increased oestrogen production resulting in female secondary characteristics.
Presentation;
- Externale female genitalia + breast tissue but will have testicles in their abdomen/inguinal canal (no ovaries, uterus etc): *This is because the testes produce Anti-mullerian hormone which prevents the production of uterus etc *
Invx = Raised LH + FSH, Normal/raised tesosterone for a post-pubesent male + Raised oestrogen (for a male)
Management = refer to specialists.
Bilateral orchidectomy needed to prevent formationof testicular cancer
Oestrogen therapy.
Risk Factors for cervical cancer
- HPV (type 16 + 18) - anything which increases the risk of catching this e.g early sexual activity, numerous sexual partners, unprotected sex, no vaccine etc
- Non-engagement with cervical screning
- Smoking
- HIV
- COCP for >5yrs
- FHx
- Multiparity
- Exposure to diethylestribestrol (used <1971)
How does HPV cause cervical cancer
HPV produces two proteins (E6 & E7) which inhibit the P53 and pRb tumor supressor genes respectively.
What may be seen on examination in cervical cancer
Ulceration, inflammation, bleeding or a visible tumour.
CIN staging of cervical cancer
Diagnosed on colposcopy - grades the level of dysplasia in cervical cells.
* CIN I = mild dysplasia, likely to return to normal with no treatment
* CIN II = Moderate dysplasia, affects 2/3 thickness of epithelium, likely to progress to cancer if untreated
* CIN III = severe dysplasia - in situ carcinoma
*
Management of cervical cancer
CIN or stage 1a = LLETZ or cone biopsy
Stage 1b - 2A = radical hysterectomy + removal of local lymph nodes + chemo/radiotherapy
Stage 2b - 4a = chemotherapy + radiotherapy
Stage 4b = palliation
Evacuzimab = monoclonal antibody used in metastatic or recurrent cervical cancer
Endometrial cancer risk factors
All related to exposure to unopposed oestrogen
* Endometrial hyperplasia
* Increased age
* Earlier onset of menstruation / Late menopause
* Oestrogen only HRT
* Nulliparity
* Obesity
* PCOS
* Tamoxifen
* T2DM
* HNPCC or Lynch syndrome
Protective factors in endometrial cncer
Increased pregnancies
COCP
Mirena coil
Smoking
Signs & Symptoms in endometrial cancer
Postmenopausal bleeding is endometrial cancer until proven otherwise.
- Postcoital bleeding
- abnormal vaginal discharge
- instrumental bleeding
- haematuria
- anemia
- Raised platelet count
Investigations for endometrial cancer
2ww referal for Transvaginal USS if;
* postmenopausal bleeding >12m after last period
* Age >55yrs with unexplained vaginal discharge, visible haemturia, raised platelets, anemia or raised glucose.
Transvaginal USS = to assess endometrial thickness (should be<4mm)
Pipelle biopsy = highly sensitivity
Hysteroscopy + biopsy
Manageemnt of endometrial hyperplasia
Progestogens: either mirena coil or oral POP
Management of endometrial cancer
- Stage 1 / 2 = TAH + BSO
- More advanced disease may need radical hysterectomy + radio/chemo
- Progesterone treatment can slow progression
What are the risks associated with HRT
Breast cancer (inc risk if combined HRT)
Endometrial cancer (only if oestrogen-only HRT)
VTE
Stroke + CAD
Ovarian cancer
*NOTE. -The risks are not increased in women <50yrs & there is no risk of endometrial cancer in women without a uterus.
Oestrogen only HRT does not inc risk of CAD.
MOA & SE’s of Clonidine
Alpha-2 adrenergic receptor agonist
It lowers BP and HR & is helpful for vasomotor symptoms + hot flushes
SE = dry mouth, headaches, dizziness, fatigue. Sudden withdrawl may result in rapid BP increase.
Steps to choosing the most suitable HRT
- Do they have local or systemic symptoms? - local can be treated with topical oestrogen
- Do they have a uterus? no uterus = oestrogen only. Uterus = combined for endometrial protection (mirena coil licensed for 4yrs)
- Have they had a period in the past 12 months? perimenopausal = cyclical combined HRT with breakthrough bleed, postmenopausal = continuous.
Side effects of HRT
Oestrogen effects = nausea, bloating, breast swelling, headaches, leg cramps
Progestogen effects = mood swings, bloating, fluid retention, weight gain, acne + greasy skin.
UK medical eligibility criteria
UKMEC 1 = no restriction in use
UKMEC 2 = beneftis outweight the risks
UKMEC 3 = Risks generally outweight the benefits
UKMEC 4 = Unacceptable risk (contraindicated)
Contraindication to copper coil
Wilson’s disease!!
Also general contraindications for either coils;
* PID
* Immunosupression
* Pregnancy
* Unexplained bleeding
* Pelvi cancer / Uterine cavity distorsion
COCP
99% effective with perect use (91% with typical use)
Licensed up to age 50yrs.
Usually has a breakthrough bleed
MOA = Prevents ovulation, thickens cervical mucus + inhibits the proliferation of the endometrium.
Options;
1. 1st line contraceptive = microgynon or leostrin (as levonorgestrol has lower VTE risk)
2. 1st line for premenstrual syndrome = Yasmin continuous use (drospirenone has anti-androgen & anti-mineralocorticoid activity so helps with bloating + mood changes)
3. 1st line for Acne / Hirtuism = Dianette (cyproterone acetate hs anti-androgen effects - but higher VTE risk so stop after 3 months)
Contraindications to the COCP
- Uncontrolled HTN (>160/100)
- Migraine + aura
- VTE history / vascular disease / IHD / Cardiomyopathy / AF
- Age >35yrs + Smokes >15 per day
- Liver cirrhosis or tumours
- SLE & Antiphospholipid syndrome
- BMI >35
Advice for additional contraception when starting the COCP
If starting on day 1 of cycle = immediate protection
Starting after day 5 = 7 days additional protection e.g condoms
POP
99% effective (91% with typical use)
Much fewer contraindications - only UKMEC4 is active breast cancer
Types;
1. Traditional POP (e.g norgestron) - doesn’t inhibit ovulation, cannot be delayed >3 hours
2. Desorgestrel (e.g cerazette) = can be taken 12hrs later
MOA = inhibits ovulation, thickens cervical mucus, inhibits proliferation of endometrium + reduces ciliary action in fallopian tubes
SE’s: 40% have regular bleeding and 40% have troublesome bleeding. Breast tenderness, headaches, acne.
Increases risk of ovarian cysts, ectopic pregnancy _ breast cancer.
Advice for additional contraception when starting the POP
Day 1-5 = immediate protection
Day 5+ = additional contraception for 48hrs.
If starting a POP when currently on COCP - best to change on day 1-7 of hormone free period as no additional contraception needed. If switching when taking the active pills then additional contraception needed for 48hrs.
Progesterone Depot
99% effective but 94% with typical use.
Injection every 12 weeks (ideally day 1-5 as immediate protection, if not 7 days extra protection required)
Contraindications: UKMEC4 is breast cancer.
Heart disease, vaginal bleeding, liver cirrhosis etc all contraindications too.
SE = May take up to 12months for fertility to reutn. Weight gain, acne, bleeding, osteoporosis (not licensed in women >50yrs)
Beneftis = improves dysmenorrhoea + endometriosis symptoms. Also reduces risk of ovarian + endometrial cancer.
Progesterone implant
99% effective.
Pros = no restrictions for use in obese pts or those with VTE risk. no effect on bone mineral density and can make periods stop altogether.
Cons =requires minor op. Can worsen acne. Porblematic bleeding. Can become deeply implanted.
**Affected by enzyme inducers **(e.g rifampicin)
Actinomyces-like organisms detected on smear test
This is common in women with coils - they do not require treatment unless symptomatic (= removal of coil)
Emergency contraception options
- Levonorgestrel = take within 72 hours. Can begin COCP (= condoms for 7) or POP (+condoms for 2) immediately after. 3mg needed if >70kg or BMI >26.
- Ullipristal =take within 120 hours = Selective estrogen receptor modulator. Delays ovulation. Should wait 5 days before starting COCP or POP. Avoid breastfeeding for 1 week + avoid in severe asthma
- Copper coil = within 5 days. Best option + best for patietns with high BMI.
When is emergency contraception required for patients on the COCP
If unprotected sex in the pill free (days 1-7) window when 2 or more pills missed
Mirena coil
Particularly useful in menorrhagia
Management of stress incontinence
Lifestyle chnges
Duloxetine (SNRI)
Surgery - tension free vaginal tape or colposuspension
Management of Urge incontinence
Bladder retraining
Oxybutynin (or other anti-cholingerics e.g tolteridone or solifenacin)
Mirabegon - an alternative in dementia etc (avoid in HTN)
Others - botox injection, percutaneous sacral nerve stimulation or surgery can be done.
investigation of choice for urge incontinence
urodynamic testing
Bacterial vaginosis
Overgrowth on anaerobic bacteria (e.g garnerella vaginalis) and loss of lactobacilli.
RF = multiple sexual partners, excessive cleaning, recent Abx , Smoking, Copper coil.
Sx = Fishy smelling wartery grey or white vaginal discharge
Invx;
* Speculum + Charcoal (high vaginal or self-taken low vaginal) swab - *microscopy shows Clue cells *
* Vaginal pH (will be >4.5)
Management;
1. Metronidazole (oral or vaginal)
2. Clindamycin is 2nd line
Complications = inc risk of sti, miscarriage, preterm labour, PROM, Chorioamnionitis, Low birth weight, Postpartum endometritis.
Candidiasis
RF = Inc oestrogen (e.g pregnancy), Diabetes, Immunosupression, Antibiotics.
Sx = Thick white discharge & vaginal itching.
Severe infection may cause ertyehma, fissures, dyspareunia etc.
Management;
1. Oral fluconazole 150mg 1st line
2. Clotrimazole pessary if oral is contraindicated.
3. Consider adding topical imidazole if there are vulval symptoms
Canesten duo (OTC) contains fluconazole tablet + cotrimazole cream.
> 4 infections per year need induction/maintenance regime over 6 months
Chlamydia
Gram -ve bacteria. Most common STI in UK and associated with PID / Infertility.
Sx = Abnormal vaginal/urethral discharge, pelvic pain, dyspareunia, epididymo-orchitis (men) & reactive arthritis.
O/E = purulent discharge + cervical motion tenderness.
Invx = Endocervical NAAT swab.
Every sexually active individual <25yrs should have annual testing or test when they change sexual partners. Anyone who tests +ve should have a test 3 months after treatment.
Management;
1. 1st line = Doxycycline 100mg for 7 days. (contraindicated in pregnancy or BF so give azithromycin)
Complications of chlamydia
PID
Infertility
Ectopic prgnancy
Reactive arthritis
Chlamydial conjunctivitis
Lymphogranuloma vereneum = Affects lymphoid tissue around site of infection, mainly affects homosexual males. Severe disease causes protocolitis. Treat with 21days doxycycline.
Gonorrhoea
Gram -ve diplococcus which infects columnar epithelium.
Sx = odourless purulent discharge (yellow or green) + dysuria + pelvic pain or epididyomorchitis in men
Diagnosis = NAAT endocervical swab / charcoal swab
Management;
1. IM Ceftriaxone 1g - if sensitivites unknown
2. Oral Ciprofloxacin 500mg - if sensitivites known
All patietns shoud undergo a test of cure after 72 hours (for culture), 7 days (for RNA). or14 days (for DNA).
Disseminated gonococcal infection
A complication of gonorrhea where bacteria spreads to skin and joints causing;
* migratory polyarthralgia
* non specific skin lesions
* Tenosynovitis
* Systemic symptoms
Pus cells on microscopy is indicative fo what?
Pelvic inflammatory disease
Fitz hugh curtis syndrome
Infammation of the glissons capsule (on the liver) leading to adhesions between liver and peritoneum.
Results in RUQ pain with radiation to R shoulder tip.
Trichomonas infection
Organism = protozoan + flagella (4 at front 1 at back)
Sx = forthy yellow green discharge with fishy odour
O/E = strawberry cervix (due to cervicitis)
Diagnosis = Vaginal pH >4.5
Charcoal swab from **posterior fornix ** should be taken.
Treatment = metronidazole same as BV
Genital herpes
Caused by HSV-2 (HSV-1 causes cold sores)
After initial infection it becomes latent in the scaral nerve ganglia. Most infective in first 12 months.
Presentation;
* Symptoms appear within 2 weeks
* Ulcers or blistes on genitalia
* Neuropathic type pain
* Flu like symptoms + Dysuria + lymphadenopathy
Management = Aciclovir
- if contracted <28weeks gestation = treat with aciclovir = prophylactic aciclovir from 36+ weeks
- if contracted >28weeks, treat with aciclovir + prophylactic aciclovir and recommend C section
Syphillis
Ogransim = treponema palidum (spirochete)
Stages;
1. Primary = painless ulcer on genitals
2. Secondary = Systemic symptoms (particularly of skin + mucus membranes) lasting 3-12weeks
3. Latent = symptoms dissapear (within 2yrs)
4. Tertirary = many years after infection and affects many organs. Gumma development + neurosyphilis.
Arygll-robertson pupil is a specific finding in neurosyphilis (accomodates but does not react)
Testing = Antibody testing via microscopy or PCR for T.pallidum antibodies.
Treatment = single deep IM Benpen
Management of PID
Give Ceftriazone (gonorrhoea), Doxycycline (chlamydia) + Metronidazole (trichomonas)
