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MSRA > Women's Health > Flashcards

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

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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
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3
Q

How does the COCP work?

A

Inhibits ovulation

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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
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5
Q

What are the disadvantages of the COCP?

A
  • Increased risk VTE, BREAST, CERVICAL CANCER, STROKE, IHD
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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

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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

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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

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9
Q

How should you change COCPs?

A

Miss pill free interval if progesterone changes to ensure effectiveness

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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
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11
Q

How does the POP work?

A

Thickens cervical mucus (excluding desogestrel/cerazette which inhibits ovulation)

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12
Q

What are the advantages of the POP?

A
  • Highly effective
  • Can use whilst breastfeeding
  • Can use when COCP contraindicated
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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
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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

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15
Q

How is the POP taken?

A

SAME TIME every day without a pill-free break

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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

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17
Q

Which POP has a longer ‘missed pill’ time frame?

A

Cerazette - 12h

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18
Q

How does the implant work? eg. Nexplanon

A

Releases progesterone hormone etonogestrel which prevents ovulation

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19
Q

What are the advantages of the implant?

A
  • MOST effective form
  • Lasts 3 years
  • No oestrogen
  • Can insert immediately after termination
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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)
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21
Q

What are the absolute contraindications for Nexplanon?

A

Current breast cancer

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22
Q

How do injectable contraceptives work?

A

Inhibit ovulation

2ndry effects - cervical mucus thickening and endometrial thinning

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23
Q

How is Depo provera (medroxyprogesterone acetate) given?

A

IM injection every 12 weeks
Can have 14 week gap without extra contraception

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24
Q

What are the disadvantages of depo provera?

A
  • Irreversible
  • 12m return to fertility
  • Weight gain and osteoporosis
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25
Q

What is the absolute contraindication to depo provera?

A

Current breast cancer

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26
Q

How does the IUS (Mirena) work?

A

Levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening

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27
Q

How is the IUS initiated?

A
  • Use barrier for 7d after insertion
  • Mirena is effective for 5y unless as endometrial protection for HRT (4y)
  • Jaydess 3y
  • Kyleena 5y
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28
Q

What are the advantages of the IUS?

A

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

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29
Q

How does the IUD work?

A
  • Decreases sperm motility and survival
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30
Q

How is the IUD initiated?

A
  • Instant use (no barrier needed)
  • Effective for 5-10 years
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31
Q

What are the advantages and disadvantages of the IUD?

A

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

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32
Q

How does the combined patch (Evra) work?

A

Inhibits ovulation

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33
Q

How is the combined patch given?

A

Lasts 4 weeks:
- Wear daily for 3 weeks (change weekly)
- Take off for last week (withdrawal bleed)

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34
Q

What are the missed change rules for the combines patch?

A

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

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35
Q

What are the Fraser guidelines?

A

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

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36
Q

What is the LARC of choice for young people?

A

Nexplanon

IUD/IUS not ideal <20yo

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37
Q

After UPSI when should young people take STI tests?

A

2 and 12 weeks after

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38
Q

How does contraception advice change in over 40yos?

A

COCP:
- Lower dose <30 oestrogen

Injection:
- reduced BMD

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39
Q

When should you stop contraception in <50yo?

A

Non-hormonal > stop after 2y amenorrhoea

COCP, depo > can continue up to 50yo

Implant, POP, IUS ? can continue beyond 50yo

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40
Q

When should you stop contraception in >50yo?

A

Non hormonal > stop after 1y amenorrhoea

COCP, depo > switch to non-hormonal or POP

Implant, POP, IUS > continue

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41
Q

How can FSH levels be used in stopping contraception?

A

If amenorrhoiec check FSH and stop after 1y if FSH >30

If not, stop contraception at 55 years

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42
Q

What are the 2 methods of emergency hormonal contraception in the UK? How do they work and when do you use?

A

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!

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43
Q

When can usual contraception be restarted after emergency hormonal contraception?

A

Levonorgestrel > immediately

Ulipristal > wait 5 days, use barrier methods

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44
Q

How does the emergency IUD work? How is it givn?

A
  • 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
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45
Q

Do you have to stop taking COCP if on antibiotics?

A

Erythromycin - NO

Rifampicin (enzyme inducer) - take barrier contraception

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46
Q

Describe the phases of the menstrual cycle

A

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

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47
Q

Whatare the features and management of PMS?

A
  • 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
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48
Q

What are primary and secondary amenorrhoea and how are they investigated?

A

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

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49
Q

What are the causes of primary amenorrhoea?

A
  • Gonadal dysgenesis eg. in Turners syndrome
  • Testicular feminisation
  • Congenital malformations of genital tract
  • Functional hypothalamic amenorrhoea (secondary to anorexia)
  • Congenital adrenal hyperplasia
  • Imperforate hymen
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50
Q

What are the causes of secondary amenorrhoea?

A
  • 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)
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51
Q

How is amenorrhoea managed?

A

Primary:
- Treat underlying cause
- HRT for primary insufficiency

Secondary:
- Exclude pregnancy, lactation, menopause
- Treat underlying cause

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52
Q

What is the definition of premature ovarian insufficiency and what causes it?

A

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

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53
Q

How is premature ovarian insufficiency treated and managed?

A

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

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54
Q

What are the features of androgen insensitivity syndrome?

A
  • 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
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55
Q

How is androgen insensitivity syndrome diagnosed and managed?

A

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

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56
Q

How is PCOS diagnosed?

A

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)

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57
Q

How is PCOS managed?

A

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

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58
Q

What are the features of primary and secondary dysemonrrohea?

A

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)

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59
Q

How is dysmenorrhoea managed?

A

Primary:
- NSAIDs such as mefenamic acid
- COCP second line

Secondary:
- Refer to gynaecology for investigation

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60
Q

What are the features of endometriosis?

A
  • 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
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61
Q

How is endometriosis diagnosed and managed?

A

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

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62
Q

What are the features of adenomyosis?

A
  • Abnormal tissue growth in uterine muscle
  • Causes pelvic pain, abnormal bleeding and menorrhagia
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63
Q

How is adenomyosis diagnosed and managed?

A

Diagnosis:

Management:
- IUS and other contraceptives
- Tranexamic acid/mefenamic acid

Surgery:
- Endometrial ablation
- Hysterectomy

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64
Q

What are the features of PID?

A
  • Lower abdominal pain, fever, deep dyspareunia, dysuria, discharge, cervical excitation
  • Chalmydia is most common causative organism
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65
Q

How is PID investigated and managed?

A

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

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66
Q

What are the complications of PID?

A
  • Fitz-Hugh Curtis syndrome (perihepatitis) - RUQ pain
  • Infertility
  • Chronic pelvic pain
  • Ectopic pregnancy
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67
Q

What is menorrhagia and what causes it?

A

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

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68
Q

How is menorrhagia investigated and managed?

A

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

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69
Q

How are ovarian cysts subdivided?

A
  1. Physiological
  2. Benign germ cell tumours
  3. Benign epithelial tumour
  4. Benign sex cord stromal tumours
70
Q

Describe physiological ovarian cysts

A

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
Q

Describe benign germ cell tumours

A

Dermoid cyst:
- AKA mature cystic teratoma
- Most common benign tumour under age of 30 years
- Usually asymptomatic but more likely to tort

72
Q

Describe benign epithelial tumours

A

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
Q

What are the features of fibroids?

A
  • 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
Q

How are uterine fibroids diagnosed and managed?

A

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
Q

How are suspected ovarian/cysts tumours investigated?

A

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
Q

What are the features of ovarian cancer?

A
  • 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
Q

How is ovarian cancer investigated and managed?

A

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
Q

What are the features of endometrial cancer?

A
  • 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
Q

How is endometrial cancer investigated and managed?

A

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
Q

What is the cervical screening programme in the UK?

A

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
Q

How are smear tests interpreted?

A

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
Q

What is CIN and how is it treated?

A

Cervical intraepithelial neoplasia (CIN1/2/3)

Treat with large loop excision of transformation zone (LLETZ)

83
Q

What are the features of cervical cancer?

A
  • 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
Q

Which HPV serotypes are linked to cervical cancer?

A

HPV 16, 18, 33

16 - produces E6 oncogene which inhibits p53 suppressor gene

18 - produces E7 oncogen which inhibits RB suppressor gene

85
Q

How is cervical cancer investigated and managed?

A

Investigation:
- 2WW if unexplained PMB
- Punch/excisional biopsy
- If confirmed will stage with CT/MRI/EUA

Managment:
- Excision, hesterectomy +/- adjuvant chemo/radiotherapy/brachytherapy

86
Q

What are the features of vulval cancer?

A
  • 80% SCC
  • Presents as lump/ulcer on labia, inguinal lympadenopathy
  • RF include HPV, VIN, immunosuppression, lichen sclerosis
87
Q

How is vulval cancer investigated and managed?

A

Investigation:
- 2WW if unexplained lump/ulceration

Management:
- Surgical +/- adjuvant radio/chemo

88
Q

Name some DDx for vulval lumps

A

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
Q

How is vaginal candidiasis managed?

A

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
Q

How is recurrent vaginal candidiasis managed?

A

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
Q

How is BV managed?

A

Metronidazole

92
Q

How is trichomonas managed?

A

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
Q

What are the features of an ectopic pregnancy?

A
  • 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
Q

How is an ectopic pregnancy diagnosed and managed?

A

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

  1. Medical
    - suitable if <35mm, unruptured, no significant pain, no fetal heartbeat, hCG>1500
    - give methotrexate, must follow up patient
  2. 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
Q

What is a threatened miscarriage?

A
  • Painless vaginal bleeding before 24 weeks
  • Indicates potential for miscarraige but pregnancy still ongoing
  • Usually at 6-9 weeks
  • Cervical os is closed
96
Q

What is a missed miscarriage?

A
  • Gestational sac which contains dead fetus before 20 weeks without symptoms if expulsion
  • Light bleeding/symptoms of pregnancy
  • Cervical os is closed
97
Q

What is an inevitable miscarriage?

A
  • Heavy bleeding with clots and pain
  • Cervical os is open
98
Q

What is an incomplete miscarriage?

A
  • Not all products of conception have been expelled
  • Pain and vaginal bleeding
  • Cervical os is open
99
Q

How is a miscarriage managed?

A
  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
Q

What is the definition of recurrent miscarriage and what causes it?

A

3 or more consecutive spontaneous abortions

Causes:
- Antiphospholipid syndrome
- Endocrine disorders
- Uterine abnormalities
- Parenteral chromosomal abnormalities
- Smoking

101
Q

What are the legalities around abortion and how is a termination carried out?

A

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
Q

How does body temperature change during ovulation?

A

Falls prior to ovulation due to influence of oestradiol

Rises following ovulation due to high progesterone

103
Q

What are the absolute contraindications to HRT?

A
  • 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
Q

What non-HRT strategies can be used in menopause?

A

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
Q

What are the risks of HRT?

A
  • 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
Q

What are the side effects of HRT?

A
  • Nausea
  • Breast tenderness
  • Fluid retention and weight gain
107
Q

What are the different options for combined HRT?

A
  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
Q

When can you NOT give continuous combined HRT?

A

Perimenopause or within 12 months of last menstrual period

109
Q

What is the definition of infertility and what causes it?

A

Infertility- failure to conceive after 1 year

Causes:
1. Male factor
2. Unexplained
3. Ovulation failure
4. Tubal damage
5. Other causes

110
Q

How is infertility investigated?

A
  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
Q

Describe the 3 main types of fertility treatment

A
  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
Q

What is ovarian hyperstimulation syndrome?

A

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
Q

How is ovarian hyperstimulation syndrome managed?

A

Conservative - analgesia, antiemetics, VTE prophylaxis

Paracentesis of ascites if severe

114
Q

How is urinary incontinence managed?

A
  • Bladder diaries for minimum of 3 days
  • Vaginal examination to exclude prolapse
  • Urine dip and culture
  • Urodynamic studies
115
Q

What is stress incontinence and how is it managed?

A

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
Q

What is urge incontinence and how is it managed?

A

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
Q

What is overflow incontinence?

A

Incontinence due to bladder outlet obstruction eg. prostate enlargement

Manage with prostate drugs - alfuzosin

118
Q

What is functional incontinence ?

A

Comorbid conditions impair patients ability to get to bathroom in time - eg. dementia, sedating medication, injury

119
Q

Which drugs should be avoided in breastfeeding?

A
  • Antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
  • Psychiatric drugs: lithium, benzodiazepines
  • Aspirin (risk of Reye’s syndrome)
  • Carbimazole
  • Methotrexate
  • Sulfonylureas
  • Cytotoxic drugs
  • Amiodarone
120
Q

What are the risks of chicken pox in pregnancy?

A
  • 5x greater risk of maternal pneumonitis
  • Fetal varicella syndrome
  • Shingles in infancy
  • Severe neonatal varicella
121
Q

How is chicken pox exposure and diagnosis managed in pregnancy?

A

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
Q

What are the risks of rubella in pregnancy and how is it prevented?

A
  • 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

123
Q

What is the definition of hypertension in pregnancy?

A
  • 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

124
Q

How is hypertension in pregnancy managed?

A

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
Q

How is pre-eclampsia managed?

A
  • 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
Q

What is eclampsia and how is it managed?

A

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
Q

What is HELLP syndrome? How is it managed?

A

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
Q

How is epilepsy in pregnancy managed?

A
  • 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
Q

Which supplements should pregnant women take?

A

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
Q

What is recommended for N&V in pregnancy?

A

Natural remedies - ginger and acupuncture (by wrist)
Antihistamines 1st line - eg. promethazine

131
Q

What is hyperemesis gravidarum and how is it managed?

A

-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
Q

What are the risks of smoking, drugs and alcohol in pregnancy?

A

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
Q

What can cause jaundice in pregnancy?

A

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
Q

What is the screening programme for gestational diabetes and how is it diagnosed?

A

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
Q

How is gestational diabetes managed?

A
  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
Q

How is pre-existing diabetes managed in pregnancy?

A
  • 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
Q

What are the complications of diabetes in pregnancy?

A

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
Q

How does a molar pregnancy present and how is it managed?

A
  • 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
Q

What is choriocarcinoma?

A

A malignant, trophoblastic cancer usually of the placenta

140
Q

What is oligohydramnios and what causes it?

A

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
Q

What is placenta accreta?

A
  • Attachment of the placenta to the myometrium due to a defective decidua basalis
  • Risk of PPH during labour
142
Q

What is placenta praevia?

A
  • 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
Q

What is placental abruption?

A
  • 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
Q

What is PPH and how is it managed?

A

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
Q

How is anaemia in pregnancy managed?

A

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
Q

How are reduced fetal movements investigated/managed?

A

<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
Q

What prophylaxis is given to prevent premature labour and when?

A

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
Q

How is premature labour diagnosed and managed?

A

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
Q

What are the indications for induction of labour?

A
  • 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
Q

How is the bishop score used in induction of labour?

A

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
Q

What are the steps in induction of labour?

A

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
Q

What are the complications of induction of labour?

A

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
Q

What are the types of breech presentation and how is it managed?

A

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
Q

What is Dr C BRaVADO?

A

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
Q

How is Group B strep infection managed?

A

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
Q

What is chorioamnionitis and how is it managed?

A
  • Ascending bacterial infection of the amniotic fluid/membranes/placenta
  • Major risk factor is PPROM
  • Manage with prompt delivery and IV abx
157
Q

What is puerperal pyrexia and how is it managed?

A
  • 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
Q

How are Rhesus negative mothers managed in pregnancy?

A
  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
Q

How do you managed Rhesus affected babies?

A

Presents as oedea, jaundice, anaemia, hepatosplenomegaly, HF kernicterus

Treatment: transfusions, UV phototherapy

160
Q

What are the RF for shoulder dystocia and how is it managed?

A

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
Q

What is an episiotomy?

A

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
Q

What initial antenatal testing is offered for Down’s syndrome?

A
  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
Q

What is offered if a woman has a high chance of Downs syndrome baby?

A

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
Q

How are perineal tears managed?

A

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
Q

How is HIV managed in pregnancy?

A

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
Q

How are postpartum mental health problems managed?

A

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
Q

How is rheumatoid arthritis managed in pregnancy?

A
  • 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
Q

When will pregnancy tests be positive?

A
  • 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
Q

What is round ligament pain?

A
  • 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
Q

What are Braxton-Hicks contractions?

A
  • False labour
  • Sporadic uterine contractions that usually are felt in the 2nd or 3rd trimester of pregnancy

MSRA (24 decks)

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