Women's Health Flashcards
Pre-eclampsia definition
New hypertension in pregnancy (after 20 weeks gestation) with end-organ dysfunction, notably with proteinuria
Pre-eclampsia triad
Hypertension
Proteinuria
Oedema
Eclampsia definition
Seizures as a result of pre-eclampsia
Pre-eclampsia high risk factors
Pre-existing hypertension
Previous hypertension in pregnancy
Existing autoimmune condition
Diabetes
Chronic kidney disease
Pre-eclampsia moderate risk factors
Older than 40
BMI >35
>10 years since pregnancy
Multiple pregnancy
First pregnancy
Family Hx of pre-eclampsia
Pre-eclampsia preventative medication & indication
Aspirin from 12 weeks
1 high risk factor
>1 moderate risk factor
Pre-eclampsia NICE definition and symptoms
Headache
Visual disturbance or blurriness
Nausea and vomiting
Upper abdominal or epigastric pain (this is due to liver swelling)
Oedema
Reduced urine output
Brisk reflexes
NICE guidelines state diagnosis with bp >140/90 (only need diastolic or systolic)
PLUS any of proteinuria, organ dysfunction, placental dysfunction
Pre-eclampsia medical management
Labetolol = first-line
Nifedipine = second-line
IV hydralazine
IV magnesium sulfate (during labour & in 24hrs after)
Fluid restriction
HELLP syndrome definition
Combination of features occurring due to pre-eclampsia/eclampsia
Haemolysis
Elevated Liver enzymes
Low Platelets
Premature ovarian insufficiency definition & biochem presentation
Menopause under the age of 40 (amenhorrea for 1 year; high FSH at 2 samples >4 weeks apart)
High LH/FSH
Low oestradiol
Premature ovarian insufficiency management
HRT until usual age of menopause (reduces cardiovascular, osteoporosis, cognitive, and psychological risks ass. w/ premature menopause)
Traditional HRT (increased risk of VTE, give transdermally)
Combined oral contraceptive pill
Placental abruption definition
Placenta separates from wall of uterus during pregnancy
Significant cause of antepartum haemorrhage
Placental abruption risk factors
Previous placental abruption
Pre-eclampsia
Bleeding early in pregnancy
Trauma (consider domestic violence)
Multiple pregnancy
Fetal growth restriction
Multigravida
Increased maternal age
Smoking
Cocaine or amphetamine use
Placental abruption presentation
Sudden onset severe abdo pain (continuous)
Vaginal bleeding
Shock (hypotension & tachycardia)
CTG showing fetal distress
Woody abdomen on palpation
Concealed abruption definition
Placental abruption when cervical os remains closed, with bleeding contained within uterine cavity
Fertility investigations
BMI
Chlamydia
Semen analysis
Rubella immunity (mother)
Female hormonal testing
Management of anovulation
Weight loss
Clomifene
Letrozole
Gonadotrophins
Metformin
Female hormone testing details
Serum LH and FSH on day 2 to 5 of the cycle
Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).
Anti-Mullerian hormone
Thyroid function tests when symptoms are suggestive
Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea
High FSH suggests poor ovarian reserve
High LH suggests PCOS
Rise in progesterone on day 21 indicates that ovulation has occurred
Stages of labour
First stage - from onset of labour (true contractions) to 10cm dilation
Second stage - from 10com dilation to delivery of baby
Third stage - from delivery of baby to delivery of placenta
Stages of first stage of labour/what happens
Cervical dilation and effacement, loss of mucus plug
Latent phase - 0-3cm dilation & irregular contractions
Active phase - 3-7cm dilation & regular contractions
Transition phase -7-10cm dilation & strong, regular contractions
Braxton-Hicks contractions
Occasional irregular contractions of the uterus
Usually during second and third trimester
Not true contractions
Diagnosing onset of labour
Show (mucus plug)
Rupture of membranes
Dilating cervix
Regular, painful contractions
Prematurity definition
Birth before 37 weeks gestation
Non-viabilty definition
Babies below 23 weeks gestation
Management of preterm labour
Fetal monitoring
Nifedipine (blocks Ca ion channels to prevent smooth muscle contraction)
Atosiban (oxytocin receptor agonist, use when nifedipine contraindicated)
Maternal corticosteroids (<35 weeks, helps develop fetal lungs)
IV magnesium sulphate
Delayed cord clamping
Signs of magnesium toxicity
Reduced respiratory rate
Reduced blood pressure
Absent reflexes
Induction of labour - beneficial situations
Prelabour rupture of membranes
Fetal growth restriction
Pre-eclampsia
Obstetric cholestasis
Existing diabetes
Intrauterine fetal death
Options for induction of labour
Membrane sweep - insert finger to cervix to stimulate onset of labour
Vaginal prostaglandin E2
Cervical ripening balloon (silicone balloon inserted into cervix and gently inflated to dilate)
Artificial rupture of membranes with oxytocin (only if prostaglandins can’t be used/haven’t worked)
Oral mifepristone & misoprostol where intrauterine foetal death has occurred
Uterine hyperstimulation definition
Main complication of induction of labour with vaginal prostaglandins
Contraction of uterus is prolonged and frequent, causing foetal distress & compromise
IU contractions >2 mins duration
>5 contractions every 10 minutes
Uterine hyperstimulation complications
Foetal compromise w/ hypoxia and acidosis
Emergency c-section
Uterine rupture
Management of uterine hyperstimulation
Removing vaginal prostaglandins/stopping oxytocin
Tocolysis w terbutaline
Sepsis 6
Three tests:
Blood lactate level
Blood cultures
Urine output
Three treatments:
Oxygen to maintain sats 94-98%
Broad-spectrum antibiotics
IV fluids
Ectopic pregnancy definition
Pregnancy implanted outside the uterus, most commonly the fallopian tube
Ectopic pregnancy risk factors
Prev ectopic preg
Prev pelvic inflammatory disease
Prev surgery
IU devices
Older age
Smoking
Ectopic pregnancy presentation
Missed period
Constant lower abdo pain in R/L iliac fossa
Vaginal bleeding
Lower abdo/pelvic tenderness
Cervical motion tenderness
Ectopic pregnancy ultrasound findings
Gestational mass in fallopian tube
Blob/bagel/tubal ring sign (mass with empty gestational sac)
Empty uterus/fluid in uterus
Ectopic pregnancy management options
Expectant management (await natural termination)
Medical management (methotrexate)
Surgical management (salpingectomy/salpingotomy)
Ectopic pregnancy expectant management criteria
Follow up needed
Unruptured ectopic
Adnexal mass <35mm
No visible heartbeat
No significant pain
HCG <1,500 IU/L
Ectopic pregnancy medical management criteria
Follow up needed
Unruptured ectopic
Adnexal mass <35mm
No visible heartbeat
No significant pain
HCG <5,000 IU/L
Confirmed absence of IU pregnancy
Should not get pregnant for 3 months following
Ectopic pregnancy surgical managements
Laparoscopic salpingectomy - general anaesthetic & key-hole surgery to remove affected fallopian tube
Laparoscopic salpingotomy - avoids removing whole tube e.g. for women who have a risk of infertility if tube is removed
Anti-rhesus D prophylaxis given to rhesus negative women
PCOS definition & key features
Polycystic ovarian syndrome is a common condition causing metabolic and reproductive problems in women
Key features:
Anovulation - lack of ovulation
Oligoovulation - irregular, infrequent ovulation
Amenorrhoea - lack of periods
Oligomenhorrhoea - irregular, infrequent periods
Hyperandrogenism - effects of high levels of androgens (i.e. male sex hormones)
Hirtuism (male pattern facial hair growth)
Insulin resistance - lack of response to hormone insulin
Rotterdam criteria
Used for making a diagnosis of PCOS
Anovulation/oligoovulation (presents a missed or irregular periods)
Hyperandrogenism (hirsutism and acne)
Polycystic ovaries on ultrasound
PCOS presentation
Oligomenorrhoea or amenorrhoea
Infertility
Obesity (in about 70% of patients with PCOS)
Hirsutism
Acne
Hair loss in a male pattern
PCOS complications
Insulin resistance and diabetes
Acanthosis nigricans
Cardiovascular disease
Hypercholesterolaemia
Endometrial hyperplasia and cancer
Obstructive sleep apnoea
Depression and anxiety
Sexual problems
Differential diagnoses of hirsutism
PCOS
Medications e.g. testosterone, corticosteroids, ciclosporin
Androgen secreting tumours
Cushing’s syndrome
Congenital adrenal hyperplasia
Mechanism of insulin resistance in PCOS
Insulin promotes release of androgens from ovaries & adrenal glands
Higher levels of insulin result in higher levels of androgens
Insulin also suppresses sex hormone-binding globulin production by the liver, which normally binds to androgens and suppresses their functions
Reduced SHBG further promotes hyperandrogenism in PCOS
High insulin levels contribute to halting development of the follicles in the ovaries, leading to partially developed follicles and anovulation
Blood tests for PCOS/results
Testosterone
SHBG
LH
FSH
Prolactin (may be mildly elevated)
TSH
Would see:
High LH
High LH:FSH ratio
High testosterone
High insulin
Normal or raised oestrogen
PCOS investigations
Pelvic ultrasound
Transvaginal ultrasound
May see follicles around the edge of ovary, giving appearance of a string of pearls
Diagnostic criteria = >=12 developing follicles in one ovary, or ovarian vol of >10cm^3
Also 2-hr 75g oral glucose tol test
General PCOS management
Weight loss
Low glycaemic index, calorie-controlled diet
Exercise
Smoking cessation
Antihypertensive medications where required
Statins where indicated (QRISK >10%)
PCOS managing risk of endometrial cancer/mechanism of increased risk
Loss of progesterone due to amen/anovulation leads to loss of uterine shedding and continued proliferation due to oestrogen, increasing risk of endometrial cancer
Mirena coil gives continual endometrial protection
Cyclical progestogens or combined oral contraceptive pill allow for withdrawal bleed every 3-4 months
PCOS managing hirsutism
Co-cyprindiol (combined oral contraceptive) which has anti-androgenic effects, but increases risk of VTE - only take for 3 months at once
Topical eflornithine
Electrolysis
Laser hair removal
Spironolactone
Finasteride
Flutamide
Cyproterone acetate
Monitoring whilst on magnesium sulphate
urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
Placenta praevia definition
a placenta lying wholly or partly in the lower uterine segment
Placenta praevia presentation
Painless vaginal bleeding, ranging from spotting to life threatening haemorrhage
Mean initiation of bleeding is 30 weeks
shock in proportion to visible loss
no pain
uterus not tender
lie and presentation may be abnormal
fetal heart usually normal
coagulation problems rare
small bleeds before large
Placenta praevia differential diagnoses
Placental abruption - usually painful, with a woody abdomen on examination
Miscarriage - often accompanied by cramp-lie pain, and is more common in 1st/2nd trimester (3rd is more common for placenta praevia). Cervical os may be open, and products of conception may be lost
Placenta accreta - placenta invades too deeply into uterine wall. Ultrasound used to differentiate
Placenta praevia investigations
Ultrasound
Full blood count
Blood type and cross match for surgery
Fetal cardiotocography
Biochem to rule out pre-eclampsia
Placenta praevia management
If serious haemorrhage, ABCDE
corticosteroids where gestational age <34 weeks
Tocolytics to delay age
Anti-D prophylaxis to rhesus negative mothers
C-section usually arranged
Perineal tears classification
first degree
superficial damage with no muscle involvement
do not require any repair
second degree
injury to the perineal muscle, but not involving the anal sphincter
require suturing on the ward by a suitably experienced midwife or clinician
third degree
injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS)
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: IAS torn
require repair in theatre by a suitably trained clinician
fourth degree
injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
require repair in theatre by a suitably trained clinician
When to refer for lack of foetal movements
If fetal movements have not yet been felt by 24 weeks, referral should be made to a maternal fetal medicine unit
Indications for high dose folic acid
Take MORE Folic acid (5mg) if:
M- Metabolic disease (diabetes or Coeliac)
O- Obesity
R- Relative or personal Hx of NTDs
E- Epilepsy (taking antiepileptic medications)
+ Sickle Cell and Thalassaemia
Pre-term rupture of membranes management
admission
regular observations to ensure chorioamnionitis is not developing
oral erythromycin should be given for 10 days
antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
delivery should be considered at 34 weeks of gestation - there is a trade-off between an increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
Placenta praevia grading
I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV (‘major’) - placenta completely covers the internal os
