Women's health Flashcards
Mode of action of contraceptives
-COCP: inhibits ovulation
-Progesterone only: thickens cervical mucus
-Desogestrel-only pill: inhibits ovulation
-Injectable: inhibits ovulation
-Implant: inhibits ovulation
-ICD: decreases sperm motility and survival
-IUS (levonorgestrel): prevents endometrial proliferations
Mode of action for emergency contraception
-Levonorgestrel: inhibits ovulation
-Ulipristal (Ella): inhibits ovulation
-IUD: toxic to sperm
Urgent C Section catagories
Category 1: Immediate threat to the life of the woman or fetus. The procedure should be performed within 30 minutes.
Category 2: there is maternal or fetal compromise which is not immediately life-threatening. Delivery should be planned as soon as possible, and within 60-75 minutes.
Category 3: delivery is required, but mother and baby are stable
Category 4: elective
Contraindication to Vaginal birth after Caesarean (VBAC)
previous uterine rupture or classical caesarean scar (longitudinal incision in the upper segment of the uterus)
Ectopic pregnancy investigation + Mx
Investigation: transvaginal ultrasound
Management:
Medical: <35mm, no heartbeat, no sig. pain- Methotextrate (only if patient is willing to attend follow up)
Surgical: >35mm, pain, ruptured, visible heartbeat, hCG >5,000IU/L, Salpingectomy (first line)
- Salpingotomy should be considered for women with risk factors for infertility such as contralateral tube damage around 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or a salpingectomy)
Causes of folic acid deficiency
Phenytoin
Methotextrate
Pregnancy
Alcohol Xs
Consequences of folic acid deficiency in pregnancy
-macrocytic, megaloblastic anaemia (hypersegmented neurtophils, low Hb, high MCV)
-Neural tube defects
Prevention of neural tube defects protocol
- all women take 400mcg folic acid until 12th week
-women at high risk take 5mg of folic acid from before conception to 12 weeks
High risk criteria:
-partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
-the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
-woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
Food to avoid in pregnancy
-listeriosis: avoid unpasteurised milk, ripened soft cheeses (Camembert, Brie, blue-veined cheeses), pate or undercooked meat
-salmonella: avoid raw or partially cooked eggs and meat, especially poultry
Rare complication of uterine fibroids
polycythaemia secondary to autonomous production of erythropoietin
Mx of menorrhagia secondary to fibroids
levonorgestrel intrauterine system (LNG-IUS)
useful if the woman also requires contraception
cannot be used if there is distortion of the uterine cavity
Treatment to remove/shrink uterine fibroids
Medical: GnRH agonist (but menopause like symptoms) + loss of bone mineral density
Surgical: myomectomy
Forms of ovulation induction
-For PCOS women (weight loss)
-Letrozole: increases FSH production
Hypogonadism
Lack of sex hormones oestrogen and testosterone
Sheehan’s syndrome
post-partum pituitary necrosis due to significant blood loss in delivery
Sx: difficulty breastfeeding, amenorrhoea, hypothyroidism, hypogylcaemia
Tx: hormone replacement e.g. oestrogen, cortisol, thyroid
Turner’s syndrome
45XO
Sx: short stature, shield chest and widely spaced nipples
webbed neck
bicuspid aortic valve/coarctation of aorta
primary amenorrhoea
Lymphoedema
Von Willebrand disease
-most common inherited bleeding disorder (autosomal dominant)
Oestrogen side effects
Nausea +bloating
Breast swelling/tenderness
Headaches
Leg Cramps
Progesterone side effects
Mood swings
Bloating
Fluid retention
Weight gain
Acne/greasy skin
Causes of primary postpartum haemorrhage
PPH (4 Ts)
- Tone (uterine atony)
- Trauma (e.g perineal tear)
- Tissue (retained placenta)
- Thrombin (clotting/bleeding disorder)
PPH management
A-E approach
-Two peripheral cannulae (14 gauge)
-lie flat
-group and save
-crystalloid infusion
Mechanical: rub fundus and catheterise
Medical: IV oxytocin, IV ergometrine (unless HTN Hx), IM carboprost
Surgical: intrauterine balloon tamponade
Breastfeeding drug contraindications
-antibiotics: ciprofloxacin, tetracycline
-psychiatric: lithium, benzodiazepines
-aspirin
-carbimazole
-methotrexate
-amiodarone
Mastitis Mx
Flucloxacillin and analgesic
Quadruple tests for: Down’s, Edward’s, Neural tube defects
Down’s: low alpha, low oestriol, high hCG high inhibin A
Edward’s: low alpha, low oestriol, low hCG normal inhibin A
Neural: high alpha, normal oestriol, normal hCG normal inhibin
PMS mangement
- regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
-COCP
-SSRI
COCP UKMEC guidance
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
3:
>35 less than 15 cigarettes
BMI >35
Immobility e.g. wheelchair use
BRAC 1/2 carrier
4:
>35 +>15 cigarettes/day
VTE, stroke, IHD Hx
Breast feeding <6 weeks post-partum
positive anti-phospholipid antibodies e.g. SLE
Major surgery with immobility
Migraine with aura
Meigs’ syndrome
Fibroma + ascites + pleural effusion
Pre-eclampsia Dx
new-onset BP ≥ 140/90 mmHg after 20 weeks AND ≥ 1 of proteinuria, organ dysfunction
Uterine fibroids in pregnancy
growth of pre-existing fibroids due to oestrogen, low-grade fever, pain and vomiting
implant pros/cons
Pros: highly effective: failure rate 0.07/100 women-years - it is the most effective form of contraception
long-acting: lasts 3 years
doesn’t contain oestrogen so can be used if past history of thromboembolism, migraine etc
can be inserted immediately following a termination of pregnancy
Cons: additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5 of a woman’s menstrual cycle
irregular/heavy bleeding is the main problem: this is sometimes managed using a co-prescription of the combined oral contraceptive pill. It should be remembered to do a speculum exam/STI check if the bleeding continues
Pregnancy induced HTN Mx
1st line: Oral labetalol
2nd line: oral nifedipine
What is the most important aetiological factor causing cervical cancer?
Human papillomavirus infection (particularly 16,18 & 33)
chickenpox exposure in pregnancy Mx
maternal blood should be urgently checked for varicella antibodies
oral aciclovir given at day 7 to day 14 after exposure, not immediately
hormones and cancer risk
HRT: progesterone increases breast cancer risk
Unopposed oestrogen: endometrial cancer
IUS insertion after vaginal delivery
IUS up to 48 hours after delivery or after 4 weeks
Postmenopausal bleeding causes
-Vaginal atrophy
-HRT
-endometrial hyperplasia/ cancer
-cervical cancer
-ovarian cancer
Women >55 with postmenopausal bleed should get 2ww US for endometrial cancer
Potter sequence
cause of oligohydramnios (vilateral renal agenesis and pulmonary hypoplasia)
Preterm pre-labour rupture of membranes abx
Oral erythromycin 10 days
gestational diabetes diagnosis threshold
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
-If fasting<7 trial diet/exercise if not met in two weeks start metformin
-If still not met add short-actin insulin
-If >7 at diagnosis start insulin
Trophoblastic Disease
The growth of abnormal trophoblast cells in the uterus after conception, rather than the development of a healthy fetus. The predominant type of gestational trophoblastic disease is a hydatidiform mole.
How soon after emergency contraception can you start COCP
Immediately
-Levonorgestrel MOA stop ovulation and prevent implantation
5 days post ulipristal acetate inhibits ovulation
Turner’s syndrome Ix
Increased FSH/LH
Low FSH, LH and 10 day progestin challenge, does not induce a withdrawal bleed.
hypothalamic dysfunction
Menopause confirmation test
FSH
Tocolytics
Mx for preventing labour induction by slowing uterine contractions e.g. indomethacin, salbutamol, terbutaline
High-risk factors for pre-eclampsia
-hypertensive disease in a previous pregnancy
-chronic kidney disease
-autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
-type 1 or type 2 diabetes
-chronic hypertension
Take low dose aspirin for first trimester
how soon postpartum do you require contraception?
21 days
Types of miscarriage
-Threatened: painless bleed, os closed
-Missed/delayed: no expulsion, closed os
-Inevitable: heavy bleeding, open os
-Incomplete: pain, bleeding open os
Placenta praevia Mx
Scan at 32 weeks
Elective caesarean for grade III/IV at 37-38 weeks
Emergency c section is woman gos into labour
Types of incontinence
A) Urge incontinence - urgency/frequency/wake up at night
B)overflow incontinence - poor stream/incomplete emptying
C) stress incontinence - leak when cough
D) functional incontinence - physical disability prevent from urinate (eg.wheelchair/bedridden)
E) mixed incontinence - (UI + SI)
Ix suspected PPROM: no fluid in posterior vaginal vault
Perform IGF binding protein-1 testing
Menorrhagia, anaemia, bulk-related symptoms e.g. bloating/urinary frequency?
uterine fibroids
For how long is the COCP contraindicated in breastfeeding women?
6 weeks
Recurrent vaginal candidiasis
Order HbA1c to rule of diabetes
HELLP syndrome
Haemolysis (H), elevated liver enzymes (EL), and low platelets (LP).
Pre-eclampsia Mx
Labetalol → Largely Used, Lung disease caution (asthma)
Nifedipine → Narrow airways (asthma) friendly
Magnesium Sulfate → Seizure Prevention and neuroprotection
Ultrasound pelvic findings
Whirlpool sign- ovarian torsion
Hyperechoic mass- fibroid
Snow storm- complete hydatidiform mole
PCOS infertility mx
Clomifene
