Women's Health Flashcards
Acute cystitis in pregnancy (medication, follow up)
Medication:
● First line: nitrofurantoin 100mg PO 6 hourly for 5 days
● Trimethoprim can be used in 2nd or 3rd trimester
Follow up: repeat urine MCS in 1-2 weeks post-completion of treatment
Amenorrhoea (primary vs. secondary)
Definition
- Primary: never bled
- Secondary: has not had bleed for 3 months from previous
Approach
● Pregnancy test, serum LH/FSH, TSH, prolactin levels, pelvic US
**Refer to page 47-48 of GP study notes
Antenatal depression
● If mild to moderate depression develops during pregnancy, use psychotherapy as first-line
● Consider starting an antidepressant for moderate depression (e.g. sertraline)
● Avoid paroxetine or fluoxetine
Breast-feeding - low breast milk supply (signs, practical points)
Signs < 3 wet nappies per 24 hours Concentrated urine (crystals) Scant stools Weight loss > 10% < 20g weight gain per day Failure to regain birth weight by 2 weeks of age Breast fullness and heaviness post-feeds Persistent jaundice, sleepiness or lethargy
Practical points Skin to skin contact Frequent breastfeeding (3 hourly) Good attachment Switch feed Express post-feeds Compress or massage breast to promote let down Domperidone 10mg/TDS
Lactational mastitis (organism, contributing factors, approach)
Organism: Staph aureus
Contributing factors: poor infant positioning, milk stasis, nipple damage
Approach:
● No systemic symptoms - no antibiotics required
● Systemic symptoms - antibiotics required
○ Flucloxacillin 500mg QID for 5-10 days
○ Cephalexin 500mg QID for 5-10 days (if allergic to above)
● General
○ Encourage breastfeeding on affected breast
○ Express milk post-feeds
○ Warm compress pre-feeds, cold compress post-feeds
○ Gentle massaging of the affected area
● Imaging: consider ultrasound if symptoms do not improve in 24-48 hours ? abscess
Postpartum lactation suppression (indication, medication)
Indication: stillbirth/neonatal death, personal choice, medical conditions.
Medication: cabergoline 1mg PO single dose
● Should not be taken until 4 hours after anti-emetics
● Most effective if given in first 12 hours
Gestational diabetes (definition, prognosis, screening, diagnosis, management, education)
Definition: Glucose intolerance that begins or is first diagnosed during pregnancy.
Prognosis: 41% of women return to normal by 6-8 weeks postpartum.
Screening: First trimester, 24-28 weeks gestation (not previous history), repeat OGTT 6-12 weeks postpartum
Diagnosis:
● Fasting BSL >=5.5 or,
● Two-hour BSL >=8.0
Management: Lifestyle interventions, education and insulin. Follow up OGTT at 6-12 weeks postpartum. Fasting BSL
and HbA1c every 3 years thereafter. For annual OGTT for women contemplating pregnancy.
Education:
● Benefits of breastfeeding in reducing the risk of women developing T2DM in the future
● Associated with risk of baby developing obesity, heart disease and/or diabetes in the future
Menorrhagia - approach
Exclude pregnancy-related bleeding (ectopic), coagulation disorders or anovulatory cycles in acute severe cases.
Summary
- Exclude pregnancy, perform CST (if due), Hx and Ex, initial Ix (FBE, ferritin, coag profile, TSH)
- If Ix suggest gynae cause, perform US
- Treat underlying cause
** Refer to page 182 of GP Study Notes
Menorrhagia - investigations and indications for referral
Investigations
● CST (if due)
● Transvaginal ultrasound to assess endometrial thickness (day 5-10 of menstrual cycle)
● Specialist investigations: saline-infused sonography, hysteroscopy, endometrial biopsy
Indications for specialist referral General ● Has not resolved after 6 months Early referral ● Severe dysmenorrhoea ● Dysmenorrhoea that does not respond to medications after 3 months ● Patients that wish to conceive ● Fibroids > 3 cm ● Endometrial polyps ● Risk of endometrial cancer
Menorrhagia - medications
Hormonal
Mirena - 52mg in uterus, replace 5 yearly
● Possible irregular bleeding in first few months
Combined OCP
● Prolonged or continuous use can minimise withdrawal bleeding
Oral progesterone
● Not recommended
● Can be used for short-term
● Regular cycles: Need to be given 21 out of 28 days of the menstrual cycle
● Irregular cycles: Take for 12 days at the same time each calendar month
Depot - medroxyprogesterone 150mg IM every 12 weeks
Non-hormonal
Tranexemic acid - 1 to 1.5g 6-8 hourly for first 3-5 days of each cycle
● More effective than NSAIDs
NSAIDs - naproxen 500 mg initially, then 250mg every 6-8 hours
Hormonal replacement therapy - key points, factors to consider
Key points
● Starting systemic HRT contraindicated in >60 yrs (but can be continued if started earlier)
● Individuals with increased risk of VTE can use transdermal but not oral
● All individuals with migraine have an increased risk of stroke - transdermal is preferred
Factors to consider: presence of uterus, individual preferences and tolerance.
Hormonal replacement therapy - medical options and regimes
Options:
Oestrogen
- Forms: oral, patch, implant, infection, topical.
- Goal: prescribe the lowest dose possible to relieve symptoms.
Progesterone
- Must be used with oestrogen if the woman has a uterus.
- Can be given continuously or cyclical.
- Avoid continuous use in perimenopausal women because of heavy irregular bleed.
Testosterone (50mg implant
3-12 monthly)
- Reserved for patients whose libido does not improve with HRT.
- Should be given concurrently with oestrogen.
Tibolone (2.5mg PO daily)
- Unsuitable for perimenopausal women.
- Should be considered for women who are surgically postmenopausal or who have had not a natural menstrual bleed for at least 12 months.
- May improve libido.
- Not associated with increased risk of VTE.
Regimes
** Refer to page 185 of GP Study Notes
Hormonal replacement therapy - contraindications, benefits vs. harms
Contraindications
- Oestrogen-dependent tumour
- Recurrent thromboembolism
- Uncontrolled hypertension
- Undiagnosed vaginal bleeding
- Active SLE
- Pregnancy
- Otosclerosis
Benefits Reduces risk of: ● Fractures ● Diabetes ● Colorectal cancer ● Vasomotor symptoms
Harms Increases risk of: ● Breast cancer ● Stroke ● VTE ● Gallbladder issues ● Demential ● Urinary incontinence ● CHD
Menopause - non-hormonal options
Non-hormonal options for vasomotor symptoms: ● SSRI: Paroxetine 10mg PO daily ● SNRI: Venlafaxine 37.5mg daily ● Gabapentin 100-300mg PO nocte ● Clonidine 25 microg BD
Hyperthyroidism in pregnancy
Key points:
● Low or suppressed TSH during first trimester not usually cause for concern
● Self-limiting as hCG concentration declines (TSH receptor hypersensitive to hCG)
● Graves disease = +ve TSH-receptor antibody +/- thyroid peroxidase antibody or thyroglobulin
Hypothyroidism in pregnancy - pre-pregnancy, during pregnancy
Pre-pregnancy
● Reserve TSH testing for patient with risk factors for thyroid dysfunction or on thyroxine
● Start on thyroxine if TSH >4
During pregnancy
Key points:
● Inadequate replacement increases risk of pregnancy complications as well as foetal neurocognitive
development
Replacement aims:
- First trimester = 0.1 to 2.5
- Second trimester = 0.2 to 3.0
- Third trimester = 0.3 to 3
New-onset or previously untreated hypothyroidism:
● New-onset = start thyroxine IMMEDIATELY + specialist input
● Subclinical = test for thyroid peroxidase antibody (if +ve can increase pregnancy complications)
○ Start thyroxine IF: 1. TSH above reference range + thyroid peroxidase antibody positive OR 2. TSH
above 10 regardless of antibodies
Pre-existing hypothyroidism before conception:
● Optimise for preconception TSH <2.5
● Increase dose by 25-30% at 4-6 weeks, then to baseline postpartum
● Consider testing every 6 weeks (if unstable), at 30 weeks (if stable)
Pain in pregnancy - lower back vs pelvic pain
Low back
● Occurs in 50-70% of women
● Management includes back strengthening exercises with fit ball or water-based in addition to simple
analgesia (paracetamol)
Pelvic pain
● Originates from sacroiliac joint and/or pubic symphysis
○ Gap of 1cm in pubic symphysis normal during pregnancy
○ Pubic diastasis can occur during labour - takes up to several years to resolve
● Management is strengthening exercises
Polycystic ovarian syndrome (epidemiology, presentation, diagnosis, management)
Epidemiology: Aboriginal and Torres Strait Islanders, South-East Asians, obese individuals
Presentation:
- Hirsutism
- Irregular or absent menstrual cycles
- Sub-fertility or infertility
- Psychological symptoms
- Metabolic features
Diagnosis: up to 70% of cases picked up on ultrasound
- Two of the following: oligo/anovulation, hyperandrogegism, PCOS on US
Management:
● Weight loss (5-10%)
● COCP +/- spironolactone
○ Consider intermittent progestin if can’t have COCP
● Psychology/counselling
● Screen for impaired glucose, hyperlipidaemia, HTN
○ Consider metformin
Post-menopausal bleeding (common cause, concern, RF, imaging, gold standard Ix)
Common causes: endometrial atrophy, endometrial polyps
Concern: endometrial carcinoma
Risk factor for malignancy: chronic anovulation, unopposed oestrogen, PCOS, tamoxifen family history of endometrial
or colon cancer, nulliparity, obesity, endometrial thickness >8mm.
Imaging: transvaginal ultrasound always indicated
● Should be used for routine surveillance of endometrium if bleeding persists after 6 months of HRT
Gold standard: endometrial biopsy
● Indicated for patients on tamoxifen
Post-menopausal bleeding - approach
** Refer to page 240-242 of GP Study Notes
Postnatal depression (significance, treatment)
Significance: Can affect the parent-infant relationship.
Treatment: Aim to refer to a perinatal specialist if severe/complex.
● First line: CBT, interpersonal therapy, group therapy
● Medication: indicated for severe cases
○ Sertraline
○ Avoid fluoxetine if breastfeeding
Good resource: PANDA (Perinatal Anxiety and Depression Australia
Postpartum thyroiditis (key points, differentials, treatment)
Key points
● Most common issue postpartum
● Transient hyperthyroidism
● Most revert back in 1 year
● Increased risk of developing hypothyroidism in 10 years postpartum
Differentials: Grave’s disease (positive TSH receptor antibody)
Thyroid peroxidase antibody: elevated in severe disease
Treatment:
● Propranolol in hyperthyroid phase
● Thyroxine in hypothyroid phase
Supplementation in pregnancy - Vitamin D, folate, iodine
Vitamin D
● Testing is not routinely recommended if asymptomatic
● Only advised for supplementation if levels <50
Folate Low risk (0.5mg/day) High risk (5mg/day): pre-pregnancy diabetes mellitus, obesity.
Iodine - 150 microg/day
Vaginal bleeding in pregnancy
Key points
● All women who are Rh(D) negative should receive anti-D immune globulin
First trimester
Key points: Common, occurs in 20-40%
Causes: ectopic, early pregnancy loss, implantation of pregnancy, cervical/vaginal/uterine pathology
Second and third trimester
Key points: Less common, more concerning
Causes: bloody show, pregnancy loss, placenta previa, abruptio placentae, uterine rupture (rare), vasa previa (rare)
Approach to late pregnancy bleed (>20 weeks)
** Refer to page 297 of GP Study Notes
