Women's Health Flashcards
1
Q
What are the different methods of contraception?
A
Barrier
- condoms
- diaphragms and cervical caps
Daily
- COCP
- POP
LARCs
- Implantable contraceptives
- Injectable contraceptives
- IUS
- IUD
2
Q
What should be used alongside barrier contraception?
A
- Use spermicide alongside diaphragms and cervical caps
- If latex allergic, use polyurethane condoms
- Do not use oil based lubricants with latex condoms
3
Q
How does the COCP work?
A
Inhibits ovulation
4
Q
What are the advantages of the COCP?
A
- Highly effective
- Lighter, regular, less painful periods
- Reduces risk of OVARIAN AND ENDOMETRIAL CANCER (persists decades after cessation)
- Reduces risk of COLORECTAL cancer
- Protects against PID
- Reduces ovarian cysts, benign breast disease and acne
5
Q
What are the disadvantages of the COCP?
A
- Increased risk VTE, BREAST, CERVICAL CANCER, STROKE, IHD
6
Q
How should the COCP be initiated?
A
If started within first 5 days of cycle > no need for additional contraception
If started any other time, use barrier for first 7 days
7
Q
How should the COCP be taken?
A
Same time each day
Tailored regime - eg. three packs back to back (tricycling) before 4 or 7 days break
8
Q
What should you do if someone misses a pill of the COCP?
A
1 pill missed (at any time):
- Take last pill even if it means taking 2 pills in one day then continue taking pills daily
- No additional contraception needed
If 2 pills missed, take the last pill even if it means taking two pills one day and use barrier until has taken pills 7 days in a row
Emergency contraception
1. In week 1 > GIVE
2. In week 2 > no need
3. In week 3: omit pill free interval, no need for emergency
9
Q
How should you change COCPs?
A
Miss pill free interval if progesterone changes to ensure effectiveness
10
Q
What are the absolute contraindications to COCP?
A
- 35yo and smoking >15 cigs
- personal hx VTE/thrombogenic mutation
- personal hx stroke/IHD
- breast feeding <6w post-partum
- uncontrolled htn
- current breast cancer
- major surgery with prolonged immobilisation
- positive antiphospholipid antibodies
11
Q
How does the POP work?
A
Thickens cervical mucus (excluding desogestrel/cerazette which inhibits ovulation)
12
Q
What are the advantages of the POP?
A
- Highly effective
- Can use whilst breastfeeding
- Can use when COCP contraindicated
13
Q
What are the disadvantages of the POP?
A
- Narrow window
- Common SE of irregular periods
- Increased incidence ovarian cysts
- Breast tenderness/weight gain/acne/headaches
14
Q
How is the POP inititated?
A
If commenced up to and including D5 of cycle (whilst menstruating) > immediate protection
Otherwise use barrier for first 2 days
If switching from COCP, take pill directly from end of pill packet > no barrier needed
15
Q
How is the POP taken?
A
SAME TIME every day without a pill-free break
16
Q
What should you do if someone misses a pill of the POP?
A
<3h - nothing
>3h - take missed pill ASAP and use barrier until pill taking normally for 48h
17
Q
Which POP has a longer ‘missed pill’ time frame?
A
Cerazette - 12h
18
Q
How does the implant work? eg. Nexplanon
A
Releases progesterone hormone etonogestrel which prevents ovulation
19
Q
What are the advantages of the implant?
A
- MOST effective form
- Lasts 3 years
- No oestrogen
- Can insert immediately after termination
20
Q
What are the disadvantages of the implant?
A
- Irregular heavy bleeding (can coprescribe COCP)
- Needs additional contraception for 7d if not inserted in D1-5
- Efficacy reduced by antiepileptics and rifampicin (should switch or use additional contraception until 28d after stopping treatment)
21
Q
What are the absolute contraindications for Nexplanon?
A
Current breast cancer
22
Q
How do injectable contraceptives work?
A
Inhibit ovulation
2ndry effects - cervical mucus thickening and endometrial thinning
23
Q
How is Depo provera (medroxyprogesterone acetate) given?
A
IM injection every 12 weeks
Can have 14 week gap without extra contraception
24
Q
What are the disadvantages of depo provera?
A
- Irreversible
- 12m return to fertility
- Weight gain and osteoporosis
25
What is the absolute contraindication to depo provera?
Current breast cancer
26
How does the IUS (Mirena) work?
Levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening
27
How is the IUS initiated?
- Use barrier for 7d after insertion
- Mirena is effective for 5y unless as endometrial protection for HRT (4y)
- Jaydess 3y
- Kyleena 5y
28
What are the advantages of the IUS?
Adv:
- MOST EFFECTIVE
- Long acting 5y
Disadv:
- Initial frequent uterine bleeding and spotting
- Risk of uterine perforation
- Increased proportion ectopic pregnancy
- Increased risk of PID in first 20 days
- Risk of expulsion in first 3 months
- Cannot use if pt has a history of PID
29
How does the IUD work?
- Decreases sperm motility and survival
30
How is the IUD initiated?
- Instant use (no barrier needed)
- Effective for 5-10 years
31
What are the advantages and disadvantages of the IUD?
Adv:
- MOST EFFECTIVE
- Long lasting
Disadv:
- Heavier prolonged periods
- Risk of uterine perforation
- Increased proportion ectopic pregnancy
- Increased risk of PID in first 20 days
- Risk of expulsion in first 3 months
32
How does the combined patch (Evra) work?
Inhibits ovulation
33
How is the combined patch given?
Lasts 4 weeks:
- Wear daily for 3 weeks (change weekly)
- Take off for last week (withdrawal bleed)
34
What are the missed change rules for the combines patch?
If delayed at end of week 1/2:
<48h - change, no barrier
>48h - change, 7d barrier, emergency contraception if sex <5d ago
If delayed at end of week 3:
Change ASAP, no barrier
If delayed at end of week 4:
Use additional barrier for 7d
35
What are the Fraser guidelines?
GPs can provide contraception to under <16 provided that they:
- understand professional advice
- can't be persuaded to inform parents
- likely to continue sex regardless
- likely to suffer if not using contraception
- best interest decision
36
What is the LARC of choice for young people?
Nexplanon
IUD/IUS not ideal <20yo
37
After UPSI when should young people take STI tests?
2 and 12 weeks after
38
How does contraception advice change in over 40yos?
COCP:
- Lower dose <30 oestrogen
Injection:
- reduced BMD
39
When should you stop contraception in <50yo?
Non-hormonal > stop after 2y amenorrhoea
COCP, depo > can continue up to 50yo
Implant, POP, IUS ? can continue beyond 50yo
40
When should you stop contraception in >50yo?
Non hormonal > stop after 1y amenorrhoea
COCP, depo > switch to non-hormonal or POP
Implant, POP, IUS > continue
41
How can FSH levels be used in stopping contraception?
If amenorrhoiec check FSH and stop after 1y if FSH >30
If not, stop contraception at 55 years
42
What are the 2 methods of emergency hormonal contraception in the UK? How do they work and when do you use?
LEVONORGESTREL
- stops ovulation and inhibits implantation
- take ASAP and within 72h
- double dose if high BMI
- repeat dose if vomit within 3h
- can be used multiple times
ULIPRISTAL
- inhibits ovulation
- take ASAP and within 120h
- don't use in severe asthma
- can be used multiple times
- not whilst breastfeeding!
43
When can usual contraception be restarted after emergency hormonal contraception?
Levonorgestrel > immediately
Ulipristal > wait 5 days, use barrier methods
44
How does the emergency IUD work? How is it givn?
- inhibits fertilisation/implantation
- Most effective, encourge !!!!!
- insert within 5d
- if after 5d can insert up to 5d before likely ovulation date
- can give prophylactic abx if at high risk of STIs
45
Do you have to stop taking COCP if on antibiotics?
Erythromycin - NO
Rifampicin (enzyme inducer) - take barrier contraception
46
Describe the phases of the menstrual cycle
Follicular phase:
- Encompasses menstruation and proliferative phase up to ovulation
- Uterine lining shedsthen proliferates and dominant follicle forms
- All hormones initially low
- Estrogen and FSH increase in proliferative cycle to prepare release of egg
Ovulation:
- D13-15
- When the dominant follicle reaches 2cm it bursts and an egg leaves the ovary into the fallopian tube
- High oestrogen causes dramatic increase in LH just before ovulation > this causes egg to release
- Oestrogen levels drop right after ovulation
Luteal phase:
- Endometrium lining secretes chemicals (secretory phase)
- High progesterone causes release of prostaglandins which cause cramps to initiate period
- Follicule becomes corpus luteum which makes progesterone and oestrogen to support pregnancy
- If pregnancy doesnt happen, corpus lutum breaks down
- High progesterone and oestrogen, low FSH/LH
47
Whatare the features and management of PMS?
- Emotional and physical sx in the luteal phase of the normal menstrual cycle due to high progesterone
- Manage with leftstyle advice and COCP (Yasmin - drospirenone/ethinylestradiol), consider SSRI during luteal phase
48
What are primary and secondary amenorrhoea and how are they investigated?
PRIMARY: No period by 15 in girls with normal secondary sexual characteristics or 13 in absence
SECONDARY: Cessation of period for 3-6 months in women with previously normal menses or 6-12 in women with previous oligmenorrhoea
INVESTIGATIONS:
- Exclude pregnancy
- FBC, U&Es, coeliac, TFTs, gonadotrophins, prolactin, androgens, oestradiol
49
What are the causes of primary amenorrhoea?
- Gonadal dysgenesis eg. in Turners syndrome
- Testicular feminisation
- Congenital malformations of genital tract
- Functional hypothalamic amenorrhoea (secondary to anorexia)
- Congenital adrenal hyperplasia
- Imperforate hymen
50
What are the causes of secondary amenorrhoea?
- Hypothalamic amenorrhea (eg. stress, excessive exercise)
- PCOS
- Hyperprolactinaemia
- Premature ovarian failure
- Thyrotoxicosis
- Sheehan's syndrome (postpartum hypopituitarism due to blood loss/pituitary necrosis)
- Asherman's syndrome (intrauterine adhesions)
- Kallmans syndrome (abnormal hypothalamus, low FSH/LH, absence of sense of smell)
51
How is amenorrhoea managed?
Primary:
- Treat underlying cause
- HRT for primary insufficiency
Secondary:
- Exclude pregnancy, lactation, menopause
- Treat underlying cause
52
What is the definition of premature ovarian insufficiency and what causes it?
Onsert of menopausal symptoms and elevated gonadotrophin levels before age 40
Causes:
- Idiopthic (no 1!!)
- Bilateral oophorectomy
- Radio/chemotherapy
- Infection eg. mumps
- AI disorders
- Resistant ovary syndrome
53
How is premature ovarian insufficiency treated and managed?
Bloods - raised FSH, LH (demonstrate FSH>40 on 2 blood samples taken 4-6 weeks apart), low oestradiol (<100)
Manage with HRT or COCP - note pts with mirena can use this as progesterone component and take oral oestrogen
54
What are the features of androgen insensitivity syndrome?
- X-linked recessive condition caausing male children to have a female phenotype (due to resistance to testosterone)
- Causes primary amenorrhea, groin swelling secondary to undescended testes, breast development
55
How is androgen insensitivity syndrome diagnosed and managed?
Diagnosis:
- Buccal smear/chromosomal analysis reveals 46XY genotype
- Testosterone levels will be slightly elevated
Management:
- Counselling (raise child as female)
- Bilateral orchidectomy (due to risk of testicular cancer)
- Oestrogen therapy
56
How is PCOS diagnosed?
Perform investigations to exclude other conditions in first instance:
- FSH, LH, prolactin, TSH, testosterone, SHBG
- Impaired glucose tolerance
- Pelvis USS
Rotterdam Criteria - PCOS present if 2 of 3:
1. Infrequent or no ovulation
2. Clinical and/or biochemical signs of hyperandrogenism
3. Polycystic ovaries on USS (>12 follicles in one or both ovaries)
57
How is PCOS managed?
General:
- Weight reduction
- COCP to regulate cycle
Hirsutism/acne:
- COCP or co-cyprindiol (risk of VTE)
- Topical eflornithine
- Specialist: spiro, flutamide, finasteride
Infertility:
- Weight reduction
- Specialist: metformen, clomifene
58
What are the features of primary and secondary dysemonrrohea?
Primary:
- No underlying pelvic pathology
- Appears within 1-2 years of menarche
- Will start a few hours before period
- Due to excessive prostaglandins
Secondary:
- Develops many years after menarche
- Will start 3-4 days before period
- Due to pelvic pathology (endometriosis, adenomyosis, PID, IUD, fibroids)
59
How is dysmenorrhoea managed?
Primary:
- NSAIDs such as mefenamic acid
- COCP second line
Secondary:
- Refer to gynaecology for investigation
60
What are the features of endometriosis?
- Abnormal tissue growth outside the uterus
- Chronic pelvic pain, secondary dysmenorrhoea, deep dyspareunia, subfertility, urinary symptoms, dyschezia
- Reduced mobility and tender nodularity on pelvic examination
61
How is endometriosis diagnosed and managed?
Diagnosis:
- Laparopscopy (gold standard)
Management:
- NSAIDs/paracetamol
- COCPS or progesterones
- Mirena coil
- GnRH analogues will induce pseudomenopause
Surgical:
- Laparopscic excision/ablation of endometriosis plus adhesiolysis (if trying to concieive)
- Ovarian cystectomy
- Hysterectomy last line
62
What are the features of adenomyosis?
- Abnormal tissue growth in uterine muscle
- Causes pelvic pain, abnormal bleeding and menorrhagia
63
How is adenomyosis diagnosed and managed?
Diagnosis:
Management:
- IUS and other contraceptives
- Tranexamic acid/mefenamic acid
Surgery:
- Endometrial ablation
- Hysterectomy
64
What are the features of PID?
- Lower abdominal pain, fever, deep dyspareunia, dysuria, discharge, cervical excitation
- Chalmydia is most common causative organism
65
How is PID investigated and managed?
Investigation:
- Pregnancy test to exclude ectopic
- High vaginal swab (may be negative)
- Screen for chlamydia/gonorrhoea
Management:
- Oral ofloxacin + oral metronidazole OR
- IM ceftriaxone + oral doxycycline + oral metronidazole
- Consider removing IUD if severe
66
What are the complications of PID?
- Fitz-Hugh Curtis syndrome (perihepatitis) - RUQ pain
- Infertility
- Chronic pelvic pain
- Ectopic pregnancy
67
What is menorrhagia and what causes it?
Excessive blood loss which interferes with QoL
Causes:
- Dysfunctional uterinebleeding (no pathology found)
- Anovulatory cycles
- Uterine fibroids
- Hypothyroidism
- IUDs
- PID
- Bleeding disorders eg. von WIllebrand
68
How is menorrhagia investigated and managed?
Investigations:
- FBC for all women
- TVUSS if structural/histological abnormality expected
- Consider hysteroscopy
Management (requires contraception):
- Mirena is first line
- COCP/long acting progesterones
Management (no contraception required):
- TXA 1g TDS for up to 4 days around menstruation. (max dose 4g)
OR
- Mefenamic acid 500mg TDS (particularly if coexistent pain)
- Start both on 1st day of period
Can also give norethisterone 5mg TDS as short term option to rapidly stop heavy bleeding
69
How are ovarian cysts subdivided?
1. Physiological
2. Benign germ cell tumours
3. Benign epithelial tumour
4. Benign sex cord stromal tumours
70
Describe physiological ovarian cysts
Follicular cysts:
- Most common
- Due to non-rupture of dominant follicle of failure of atresia in non-dominant follicle
- Regress after several cycles
Corpus luteum cyst:
- Failure of corpus luteum to break down properly
- Present with intraperitoneal bleeding
71
Describe benign germ cell tumours
Dermoid cyst:
- AKA mature cystic teratoma
- Most common benign tumour under age of 30 years
- Usually asymptomatic but more likely to tort
72
Describe benign epithelial tumours
Serous cystadenoma:
- arises from ovarian surface epithelium
- most common
Mucinous cystadnemona
- arises from ovarian surface epithelium
- large and can become MASSIVE
- may rupture and cause pseudomyxoma peritone
73
What are the features of fibroids?
- Benign smooth muscle tumours of the uterus
- Develop in response to oestrogen
- Cause menorrhagia, bulk related symptoms and subfertility
- More common in Afro-Caribbean women
- Generally regress after the menoapuse
74
How are uterine fibroids diagnosed and managed?
Diagnosis:
- TVUSS
Management:
- Nil if aysmptomatic
- IUS/NSAIDs/TXA/COCP for menorrhagia
- GnRH agonists to shrink fibroid (goserelin)
- Myomectomy/ablation/hysterectomy
- Uterine artery embolization
75
How are suspected ovarian/cysts tumours investigated?
Refer for TVUSS
Premenopausal women:
- Simple cyst <5cm, repeat USS in 8-12 weeks and consider referral if persists
- Otherwise refer
Postmenopausal
- Refer to gynae ASAP regardless of size/nature
76
What are the features of ovarian cancer?
- Majority are epithelial (serous)
- May have family hx of BRCA1/BRCA2 gene
- History of increased ovulation (ie. early menarche, late menopause, nulliparity)
- Presents as bloating, pain, urinary sx, early satiety, diarrhoea
77
How is ovarian cancer investigated and managed?
Investigation:
- CA125 (may be falsley high due to endometriosis, menstruation, cysts)
- If Ca125 >35, order urgent USS abdo/pelvis
- Diagnosis with laparotomy
Management:
- Surgery + platinum based chemotherapy
- Poor prognosis due to late presentation
78
What are the features of endometrial cancer?
- Good prognosis as detected early
- Presents as post menopausal bleeding or IMB
- RF include excess oestrogen, metabolic syndrome, tamoxifen, hereditary colorectal ca
- PF include multiparity, COCP, smoking
79
How is endometrial cancer investigated and managed?
Investigations:
- 2WW TVUSS if PMB
- Diagnose with hysteroscopy + endometrial biopsy
Management:
- Total abdominal hysterectomy with bilateraly saplingo-oophorectomy
- + radiotherapy if advanced disease
- Progesterone therapy for frail elderly women who are not surgical candidates
80
What is the cervical screening programme in the UK?
SMEAR TEST + HPV test - take mid cycle if possible!
25-49 years old: 3 yearly screening
50-64 years old: 5 yearly screening
Do not offer if over 64
Special situations:
- Delayed 3m post-partum unless missing screening or previously abnormal
- Can opt out if never sexually active
81
How are smear tests interpreted?
Negative HPV - return to normal recall unless:
- Test of cure pathway
- Untreated CIN1 pathway
- Follow up for boderling changes in endocervical cells
Positive HPV - examine cytologically:
1. Abnormal cytology > colposcopy
2. Normal cytology > repeat test in 12 months, if still +ve, further 12 months > if still +ve, colposcopy
Inadequate sample:
- Repeat in 3 months
- If two inadequate samples > colposcopy
82
What is CIN and how is it treated?
Cervical intraepithelial neoplasia (CIN1/2/3)
Treat with large loop excision of transformation zone (LLETZ)
83
What are the features of cervical cancer?
- Highest incidence 25-29 years
- 80% SCC, 20% adenocarcinoma
- Presents as abnormal smear, abnormal bleeding, vaginal discharge
- RF include HPV, smoking, HIV, high parity, lower SES, COCP
84
Which HPV serotypes are linked to cervical cancer?
HPV 16, 18, 33
16 - produces E6 oncogene which inhibits p53 suppressor gene
18 - produces E7 oncogen which inhibits RB suppressor gene
85
How is cervical cancer investigated and managed?
Investigation:
- 2WW if unexplained PMB
- Punch/excisional biopsy
- If confirmed will stage with CT/MRI/EUA
Managment:
- Excision, hesterectomy +/- adjuvant chemo/radiotherapy/brachytherapy
86
What are the features of vulval cancer?
- 80% SCC
- Presents as lump/ulcer on labia, inguinal lympadenopathy
- RF include HPV, VIN, immunosuppression, lichen sclerosis
87
How is vulval cancer investigated and managed?
Investigation:
- 2WW if unexplained lump/ulceration
Management:
- Surgical +/- adjuvant radio/chemo
88
Name some DDx for vulval lumps
Bartholin's cyst:
- Painful and soft
- Treat with hot compresses +/- I&D
Condylomata lata:
- Wart-like lesions in secoondary syphillis
Lipoma:
- Soft, do not grow rapidly
89
How is vaginal candidiasis managed?
1st line - single 150mg oral fluconazole
2nd line - clotrimazole 500mg pessary
Consider adding topical imidazole if vulval itch
If pregnant do not use oral treatment
90
How is recurrent vaginal candidiasis managed?
Defined as >4 episodes yearly
- Check compliance with treatment
- Confirm diagnosis with HVS
- Test for diabetes (predisposing)
- Consider induction maintenance regime (oral fluconazole every 3 days for 3 doses then oral fluconazole weekly for 6 months)
91
How is BV managed?
Metronidazole
92
How is trichomonas managed?
Oral metronidazole 400-500mg BD for 5-7 days OR
Single dose 2g metronidazole/tinidazole
TREAT PARTNERS FROM LAST 4 WEEKS SIMULTAENOUSLY
ABSTAIN FROM SEX FOR 1 WEEK AFTER TREATMENT
93
What are the features of an ectopic pregnancy?
- Typically presents with lower abdo pain + vaginal bleeding on a background of 6-8 weeks amenorrhoea
- May have shoulder tip pain, syncope or symptoms of pregnancy
- Cervical excitation on pelvic exam
- Serum bHCG >1500
94
How is an ectopic pregnancy diagnosed and managed?
Diagnosis:
- TVUSS
Management:
1. Expectant
- suitable if <35mm, unruptured, asymptomatic, no fetal heartbeat, hCG<1000
- involves monitoring bhCG over 58h; if symptoms worsen or levels rise, intervene
2. Medical
- suitable if <35mm, unruptured, no significant pain, no fetal heartbeat, hCG>1500
- give methotrexate, must follow up patient
3. Surgical
- suitable if size>35mm, ruptured, pain, visible heart beat, hCG>5000
- involves salpingectomy if no RF
- do salpingotomy if other risk factors for infertility (eg. contralateral tube damage)
95
What is a threatened miscarriage?
- Painless vaginal bleeding before 24 weeks
- Indicates potential for miscarraige but pregnancy still ongoing
- Usually at 6-9 weeks
- Cervical os is closed
96
What is a missed miscarriage?
- Gestational sac which contains dead fetus before 20 weeks without symptoms if expulsion
- Light bleeding/symptoms of pregnancy
- Cervical os is closed
97
What is an inevitable miscarriage?
- Heavy bleeding with clots and pain
- Cervical os is open
98
What is an incomplete miscarriage?
- Not all products of conception have been expelled
- Pain and vaginal bleeding
- Cervical os is open
99
How is a miscarriage managed?
1. Expectant
- First line, involves waiting for 7-14 days
2. Medical
- If last trim, coagulopathies, previous traumatic pregnancy, infection
- Vaginal misoprostol (causes strong myometrial contractions)
- Give with antiemetics and pain relief
3. Surgical
- Vacuum aspiration (suction curettage) or surgical management in theatre
100
What is the definition of recurrent miscarriage and what causes it?
3 or more consecutive spontaneous abortions
Causes:
- Antiphospholipid syndrome
- Endocrine disorders
- Uterine abnormalities
- Parenteral chromosomal abnormalities
- Smoking
101
What are the legalities around abortion and how is a termination carried out?
Legalities
- Two registered practitioners must sign a legal document (or one in an emergency)
- Must be before 24 weeks gestation
Medical:
- Mifepristone followed 48h later br misoprostol
- Pregnancy test 2W after to confirm
Surgical (more common after 9 weeks):
- Vacuum aspiration, electric vacuum aspiration and dilatation and evacuation
- Cervical priming with misprostol +/- mifepristone is used before procedures
102
How does body temperature change during ovulation?
Falls prior to ovulation due to influence of oestradiol
Rises following ovulation due to high progesterone
103
What are the absolute contraindications to HRT?
- Current or past breast cancer
- Any oestrogen sensitive cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
- Active or recent thromboembolic disease
- Active liver disease with abnormal LFTs
- Pregnancy
- Thrombophilic disorder
104
What non-HRT strategies can be used in menopause?
Vasomotor symptoms
- fluoxetine, citalopram, venlafaxine
Vaginal dryness
- lubricant or moisturiser
Psyschological:
- CBT, antidepressants
Urogenital:
- Vaginal oestrogen
Tibolone - synthetic steroids with weak oestrogenic, progesterogenic and adronergic properties, cant be used within 12 months of last period
105
What are the risks of HRT?
- VTE (increased by addition of progesterone)
- Stroke
- Coronary heart disease (if taken >10y post menopause)
- Breast cancer (increased by addition of progesterone)
- Ovarian cancer (decreased by addition of progesterone)
106
What are the side effects of HRT?
- Nausea
- Breast tenderness
- Fluid retention and weight gain
107
What are the different options for combined HRT?
1. Monthly cyclical regimen - oestrogen daily + progesterone at end of cycle for 10-14 days
2. Three monthly cyclical regime - oestrogen daily + progesterone for 14 days every 13 weeks
3. Continuous combined - oestrogen and progesterone daily
108
When can you NOT give continuous combined HRT?
Perimenopause or within 12 months of last menstrual period
109
What is the definition of infertility and what causes it?
Infertility- failure to conceive after 1 year
Causes:
1. Male factor
2. Unexplained
3. Ovulation failure
4. Tubal damage
5. Other causes
110
How is infertility investigated?
1. Semen analysis
2. Serum progesterone 7d prior to expected next period (ie day 21)
3. Serum gonadotrophins
4. TFTs
5. Prolactin
6. Chlamydia screening
If progesterone:
<16 - repeat and refer to specialist if low
16 - 30 - repeat
>30 - indicated ovulation
Advise regular sexual intercourse, abstaining from alcohol/stress/smoking
Consider early referral to specialist if women >36 or if known fam hx or personal predisposing factors
111
Describe the 3 main types of fertility treatment
1. Medical - eg. clomifene
2. Surgical - eg. laparoscopy for ablation of endometriosis or surgical correction of epididymal blockage in men with obstructe azoospermia
3. Assisted reproduction - eg. intrauterine insemination, IVF, intracytoplasmic sperm injection
112
What is ovarian hyperstimulation syndrome?
Complication of infertility treatment in which the presence of multiple leteinzied cysts in the ovaries results in very high levels of VEGF > increased membrane permeability > fluid loss from intravascular compartment
Usually seen with gonadotrophin of hCG treatment or IVF
Mild - abdo pain/bloating
Moderate - +N&V, US evidence of ascites
Severe - clinical ascites, oliguria, low protein
Critical - VTE, ARDS, anuria, tense ascites
113
How is ovarian hyperstimulation syndrome managed?
Conservative - analgesia, antiemetics, VTE prophylaxis
Paracentesis of ascites if severe
114
How is urinary incontinence managed?
- Bladder diaries for minimum of 3 days
- Vaginal examination to exclude prolapse
- Urine dip and culture
- Urodynamic studies
115
What is stress incontinence and how is it managed?
Leakage of small amounts of urine when coughing or laughing
Management:
- Pelvic floor muscle train (8 contractions TDS for 3 months)
- Surgical tapes
- Duloxetine (enhances sphincter muscles)
116
What is urge incontinence and how is it managed?
AKA overactive bladder - Due to detruser overactivity
Management:
- Bladder training and bladder stabilising drugs (eg. oxybutynin, tolterodine, darifenacin)
- Mirabegron can be used but caution in elderly pts due to anticholinergic side effects
117
What is overflow incontinence?
Incontinence due to bladder outlet obstruction eg. prostate enlargement
Manage with prostate drugs - alfuzosin
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What is functional incontinence ?
Comorbid conditions impair patients ability to get to bathroom in time - eg. dementia, sedating medication, injury
119
Which drugs should be avoided in breastfeeding?
- Antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
- Psychiatric drugs: lithium, benzodiazepines
- Aspirin (risk of Reye's syndrome)
- Carbimazole
- Methotrexate
- Sulfonylureas
- Cytotoxic drugs
- Amiodarone
120
What are the risks of chicken pox in pregnancy?
- 5x greater risk of maternal pneumonitis
- Fetal varicella syndrome
- Shingles in infancy
- Severe neonatal varicella
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How is chicken pox exposure and diagnosis managed in pregnancy?
Exposure:
- If any doubt re previous exposure, check blood urgently for varicella antibodies
- If not immune and <20 weeks gestatin, give aciclovir up to 10d post exposure
- If not immune and >20 weeks gestation give aciclovir 7-14d after exposure
Diagnosis (manage by specialist):
- If <20 weeks aciclovir with caution
- If >20 weeks oral aciclovir if within 24h onset
122
What are the risks of rubella in pregnancy and how is it prevented?
- Viral infection caused by togavirus
- Risk of damage to fetus high in first 8-10 weeks
- Congenital rubella syndrome (triad of sensorineal deafness, eye abnormalities and congenital heart disease)
- Suspected cases should have IgM blood test and refer to local health protection unit
DO NOT GIVE MMR DURING PREGNANCY - ADVISE MUMS TO STAY AWAY FROM RUBELLA AND GET IN POST-NATAL PERIOD
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What is the definition of hypertension in pregnancy?
- Systolic >140 or diastolic >90
- Increase above booking readings of >30 or >15 systolic/diastolic respecively
Types include:
1. Pre-existing htn - BP >140/90 before 20 weeks gestation, no proteinuria or oedema
2. Pregnancy-induce htn - BP >140/90 after 20 weeks gestation, no proteinuria or oedema
3. Pre-eclampsia - as above + proteinuria >0.3g/24h or other organ involvement
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How is hypertension in pregnancy managed?
Pre-existing - stop ACEi or ARB and start labetolol whilst awaiting specialist review
Pregnancy-induced - 1st line - oral labetalol, 2nd line - nifedipine or hydralazine
- Deliver baby in 24-48h if >37w and mild-moderate gestational htn
Usually resolves following birth
If high risk of pre-eclampsia (1 of hypertension, CKD, AI disease, diabetes or 2 of first pregnancy, age >40, last pregnancy >10y ago, BMI >35, family hx, multiple pregnancy), start aspirin 75mg from 12 weeks until birth
125
How is pre-eclampsia managed?
- Arrange emergency secondary care assessment
- If BP >160/110 will usually be admitted and observed
- 1st line treatment is oral labetolol
- Risks include eclampsia, fetal complications, liver involvement, haemorrhage and cardiac fialure
126
What is eclampsia and how is it managed?
Definition:
- Development of seizures in association with pre-eclampsia
Management:
1. IV magnesium 4g STAT followed by 1g/hour infusion - contrinue until 24h after last seizure or delivery
2. Monitor UO, reflexes, RR and oxygen - if respiratory depression give calcium gluconate
3. Fluid restriction
127
What is HELLP syndrome? How is it managed?
Features:
- Severe form of pre-eclampsia which includes Haemolysis, Elevated Liver enzymesm Low Platelets
- Presents as N&V, malaise and headache
- Proteinuria and schistocytes seen
Management:
- IV dexamethasone
- IV magnesium
- Control of BP
- Replacement of blood products
128
How is epilepsy in pregnancy managed?
- Aim for monotherapy
- Lamotrigine is the most safe
- If taking phenytoin should have vit K in last month to prevent clotting disorders of the newborn
- Breastfeeding is safe with all AEDs except the barbs
129
Which supplements should pregnant women take?
Healthy individual:
Folic acid 400 micrograms + vitamin D 10 micrograms
High risk of neural tube defects (BMI>30, on AEDs, coeliac, diabetic, thalassemia trait, previous or fam hx NTD)
Folic acid 500 micrograms + vitamin D 10 micrograms
130
What is recommended for N&V in pregnancy?
Natural remedies - ginger and acupuncture (by wrist)
Antihistamines 1st line - eg. promethazine
131
What is hyperemesis gravidarum and how is it managed?
-N&V during pregnancy due to high levels of hCG
- Triad of 5% weight loss, dehydration and electrolyte imbalance
- Common between 8-12 weeks but can persist to 20 weeks
- Can score with PUQE
Management:
- 1st line - oral cyclizine, promethazine, prochlorperazine
- 2nd line - ondansetron (not in first trim), metoclopramide for <5d due to risk of EPS
- Admit if unable to tolerate liquids, ketonuria, >5% weight loss or comorbidity
CHECK TFTS AS BHCG CAN CAUSE HYPERTHYROIDISM
132
What are the risks of smoking, drugs and alcohol in pregnancy?
Smoking:
- Increased risk of miscarriage, pre-term labour, stillbirth, IUGR and sudden unexpected death
Alcohol:
- Fetal alcohol syndrome (particulalry if binge drinking)
Cannabis:
- As per smoking
Cocaine:
- Maternal; hypertension and placental abruption
- Fetal; prematurity, neonatal abstinence syndrome
Heroine:
- Neonatal abstinence syndrome
133
What can cause jaundice in pregnancy?
Intrahepatic cholestasis of pregnancy:
- common in 3rd trimester
- presents with pruritus and high bilirubin
- poor flow causes build up of bile salts in the skin and placenta
- managed with ursodeoxycholic acid for symptomatic relief
- weekly LFTs and induction at 37 weeks
- can lead to sudden asphyxial events in the foetus
Acute fatty liver of pregnancy:
- common in 3rd trim or after delivery
- ALT elevated
- Supportive management
HELLP syndrome:
- haemolysis, elevated liver enzymes, low platelets
134
What is the screening programme for gestational diabetes and how is it diagnosed?
Oral glucose tolerance test
- If previous GD - perform ASAP after booking and again at 24-28 weeks if negative
- Other women should be offered it at 24-28 weeks
Diagnosis:
1.Fasting glucose >5.6mmol/L
2.2 hour glucose >7.8 mmol/L
135
How is gestational diabetes managed?
1. Within 1 week of diagnosis - joint diabetes and antenatal clinic
2. If fasting glucose <7, trial conservative mgmt - if targets not met within 1-2 weeks, start metformin and then short-acting
3. If fasting glucose >7, start insulin straight away (or if 6-6.9 and complications evident)
4. Offer flibenclamide for women who cannot tolerate metformin or decline insulin
136
How is pre-existing diabetes managed in pregnancy?
- Recommend weight loss if BMI >27
- Stop oral hypoglycaemic agents except for metformin and start insulin
- Folic acid 5mg/day from conception to 12 weeks
- Detailed anomaly scan at 20 weeks
- Tight glycaemic control
- Treat retinopathy as can worsen during pregnancy
137
What are the complications of diabetes in pregnancy?
Maternal:
- Polyhydramnios (due to fetal polyuria)
- Preterm labour
Neonatal:
- Macrosomia
- Hypoglycaemia
- Respiratory distress syndrome (delated surfactant production)
- Polycythaemia and jaundice
- Malformation rates
- Stillbirth
- Low mg and calcium
- Shoulder dystocia and Erb's palsy
138
How does a molar pregnancy present and how is it managed?
- Benign tumour or trophoblastic material, can be partial or complete
- Occurs when empty egg is fertilised by single sperm so all 46 chromsoomes are of paternal origin
- Presents with early bleeding, hyperemesis, uterus large for dates and high hCG
Management:
- Urgent referral to specialist of revacuation of uterus
- Advised to avoid pregnancy for next 12 months
- Risk of developing choriocarcinoma
139
What is choriocarcinoma?
A malignant, trophoblastic cancer usually of the placenta
140
What is oligohydramnios and what causes it?
Reduced amniotic fluid (<500ml at 32-36 weeks)
Causes:
- PROM
- Potter sequence (bilateral renal agenesis and pulmonary hypoplasia)
- IUGR
- Post term gestation
- Pre-eclampsia
141
What is placenta accreta?
- Attachment of the placenta to the myometrium due to a defective decidua basalis
- Risk of PPH during labour
142
What is placenta praevia?
- Placenta lying wholly or partly in the lower uterine segment
- Assoc with multiparity, multiplre pregnancy, previous c-section
- Presents as painless bleeding, abnormal lie
- Do not preform digital examination due to risk of severe haemmorhage
- Usually picked up on 20 week USS, can also do TVUSS to improve accuracy
143
What is placental abruption?
- Separation of a normally sited placenta from the uterine wall resulting in haemorrhage
- Associatd with proteinuria, cocaine, multiparity, maternal trauma, age
- Presents as shock, PAIN and bleeding with a tender woody uterus, coagulation problems
144
What is PPH and how is it managed?
Definition:
- Blood loss >500ml after a vaginal delivery
- May be primary or secondary
Primary (<24h) due to 4Ts:
Tone (uterine atony)
Trauma (perineal tear)
Tissue (retained placenta)
Thrombin (clotting/bleeding disorder)
Secondary:
Due to retained placental tissue or endometritis
Management (primary):
- ABC + IV warmed crystalloid
- Rub uterine fundus to stimulate contractions
- IV oxytocin, IV ergometrine (unless HTN), IM carboprost (unless asthmatic), SL misoprostol
- If failed medical options, intrauterine baloon tamponade
- May need hysterectomy as lifesaving procedure
145
How is anaemia in pregnancy managed?
Screen at booking visit and 28 weeks
Treat with oral ferrous sulfate/fumarate for 3 months after deficiency isc corrected
Cut offs:
1st tri - <110
2nd/3rd tri - <105
postpartum - <100
146
How are reduced fetal movements investigated/managed?
<24 weeks:
- If previously felt, handheld doppler to confirm heartbeat
- If never felt, refer to maternal fetal medicine unit
24-28 weeks:
- Handheld doppler to confirm heartbeat
>28 weeks:
- Handheld doppler to confirm heartbeat; if nil detected for immediate USS
- If heartbeat detected, CTG for 20 minutes
- If ogoing concern, USS within 24h
147
What prophylaxis is given to prevent premature labour and when?
Offer vaginal progesterone or cervical cerclage to women who have a history of spontaneous premature birth or loss and TVUSS shows cervical length <25mm
148
How is premature labour diagnosed and managed?
Diagnosis:
- Speculum examination to look for pooling of amniotic fluid
- If inconclusive, insulin-like growth factor binding protein 1 test of vaginal fluid
Management:
<29+6 weeks - tocolysis (nifedipine) and steroids
>30 weeks and TVUSS cervical length <15mm - tocolysis and steroids
Give Mg for neuroprotection (esp if <29+6 weeks)
Give synthetic surfactant if <32 weeks
149
What are the indications for induction of labour?
- Prolonged pregnancy (1-2 weeks after EDD)
- Prelabour premature rupture of membranes where labour does not start
- Diabetic mother >38w, pre-eclampsia, obstetric cholestassi
- Intrauterine fetal death
150
How is the bishop score used in induction of labour?
Takes into account cervical position, consistency, effacement, dilataion and fetal station to decide whether to induce.
Score <5 indicates that labour is unlikely to start without induction
Score of 8 or more indicates that cervix is favourable - high chance of spontaneous labour od response to interventions
151
What are the steps in induction of labour?
Membrane sweep, offered at 40 (nulliparous) or 41 (parous) weeks
If Bishop score <= 6
- Vaginal prostaglandins or oral misoprostol
- Consider balloon catheter if previous c section
If Bishop score >6
- Amniotomy and IV oxytocin infusion
152
What are the complications of induction of labour?
Uterine hyperstimulation:
- Prolonged and frequent uterine contractions ('tachysystole')
- Can cause fetal hypoxemia and acidemia and uterine rupture
- Manage by removing vaginal prostaglands and stopping oxytocin, consider tocolysis
153
What are the types of breech presentation and how is it managed?
Types:
1. Frank breech - hips flexed and knees fully extended
2. Footling breech - one or both feet come first with bottom at higher position
Management:
<36w - may turn spontaneously
>36w - external cephalic version (or 37w if multiparous)
Contraindications to ECV:
- APH within last 7 days
- Abnormal CTG
- Major uterine anomaly
- Ruptured membranes
- Multiple pregnancy
154
What is Dr C BRaVADO?
Mnemonic to assess the features of a CTG in a structured way:
Dr - define risk
C - contractions
BRa - baseline rate
V - variability
A - accelerations
D - decelerations
O - overall impression
155
How is Group B strep infection managed?
Previous GBS - Offer intrapartum antibiotic prophylaxis (IAP) OR testing in late pregnancy (35-37 weeks)
Previous baby with GBS disease, preterm labour, pyrexia during labour - Offer IAP
Benpen is abx of choice!
156
What is chorioamnionitis and how is it managed?
- Ascending bacterial infection of the amniotic fluid/membranes/placenta
- Major risk factor is PPROM
- Manage with prompt delivery and IV abx
157
What is puerperal pyrexia and how is it managed?
- Defined as T>38C in first 14 days following delivery
- If endometritis suspected, refer to hospital for IV clindamycin and gentamicin until afebrile for at least 24h
158
How are Rhesus negative mothers managed in pregnancy?
1. Test for D antibodies at booking
2. Give anti-D to non-sensitized mothers at 28 and 34 weeks
3. Give anti-D ASAP for any major event
4. At delivery, take cord blood to assess FBC, blood group and direct Coombs test
159
How do you managed Rhesus affected babies?
Presents as oedea, jaundice, anaemia, hepatosplenomegaly, HF kernicterus
Treatment: transfusions, UV phototherapy
160
What are the RF for shoulder dystocia and how is it managed?
SD occurs due to impaction of the anterior fetal sholder on the maternal pubic symphisis. RF include macrosome, high maternal BMI, FM, prolonged labour
Management:
- Senior help
- McRoberts' manoeuvre (flexion and abduction of maternal hips to increase pelvic angle)
- Episiotomy second line
Complications:
Maternal: PPH, perineal tears
Fetal: Brachial plexus injury, neonatal death
161
What is an episiotomy?
An incision in the posterior wall of the vagina and perineum that is performed in the second stage of labour to facilitate the passage of the fetus
162
What initial antenatal testing is offered for Down's syndrome?
1. Combined test:
- Between 11 and 13+6 weeks
- Nuchal translucency (thick) + serum B-HCG (high) + PAPP-A (low)
- High chance is 1 in 150 or less
2. Quadruple test:
- Between 15 and 20 weeks
- Offered if women book later in pregnancy
- AFP + unconjugated oestriol + HCG + inhibin A
- Downs syndrome > AFP and oestrol low, HCG and inhibin A high
- Edwards syndrome > AFP, oestriol, HCG low, inhibin A equivocal
- High chance is 1 in 150 or less
163
What is offered if a woman has a high chance of Downs syndrome baby?
Either:
1. Non-invasive prenatal screening test:
- Analysis small DNA fragments in the blood of a pregnant women
- High specificity and senstivity
- This is now the norm
2. Diagnostic:
- Amniocentesis or chorionic villus sampling
- Risk of miscarraige
164
How are perineal tears managed?
1st degree:
- Superficial damage with no muscle involvement
- No repair required
2nd degree:
- Injury to perineal muscle not involving the anal sphincter
- Requires suturing on the ward by a suitably experienced midwife or clinician
3rd degree:
- Injury to perineum involving the anal sphincter complex
- Requires repair in theatre
4th degree:
- Injury to perineum involving anal sphincter complex and rectal mucosa
- Requires repair in theatre
165
How is HIV managed in pregnancy?
Screening:
- Offer to all women
ART:
- Offer to all HIV positive women
Mode of delivery:
- Vaginal delivery if viral load <50 at 36 weeks, otherwise c-section
- Start zidovudine infusion 4h before beginning of c-section
Neonatal ART:
- Administer zidovudine orally to neonate if maternal viral load <50 copies/ml
- Otherwise triple ART for 4-6 weeks
Breastfeeding:
- Advise AGAINST
166
How are postpartum mental health problems managed?
Screen with Edinburgh Postnatal Depression Scale
Baby blues:
- Typically 3-7d after birth
- Reassure and support
Post-natal depression:
- Typically 1-3 months
- Reassure and support
- Consider CBT and SSRIs (sertraline, paroxetine)
Puerperal psychosis:
- Typically first 2-3 weeks after birth
- Similar to bipolar disorder + disordered perception
- Admit to Mother & Baby Unit
- High risk of recurrence in future pregnancies
167
How is rheumatoid arthritis managed in pregnancy?
- Symptoms tend to improve with flare following delivery
- Stop methotrexate 6m before conception
- Stop leflunomide
- Continue sulfasalazine and hydroxychloroquine
- Low dose steroids okay to continue
- NSAIDs until 32 weeks, after this risk of early closure of ductus arteriosus
- Refer to obstetric anaesthatist
168
When will pregnancy tests be positive?
- 9 days post conception until 20w of pregnancy (will be positive in 98% of patients by day 11)
- Levels peak at 10-12 weeks gestation
- will remain positive 5d after a miscarriage or fetal death
169
What is round ligament pain?
- Brief, sharp stabbing pain or longer lasting dull ache in the lower abdomen or groin
- Experienced by pregnant women in the 2nd trimester due to uterus pulling on the round ligament
170
What are Braxton-Hicks contractions?
- False labour
- Sporadic uterine contractions that usually are felt in the 2nd or 3rd trimester of pregnancy
