Women's Health Flashcards
Antenatal care: Treatments
Nausea and vomiting:
Vitamins:
ginger and acupuncture of P6 (by wrist)
Promethazine
Vitamin D
Signs and symptoms:
Ectopic pregnancy
Placental abruption
Placenta praevia
Vasa praevia
6-8 weeks of amenorrhoea with lower abdominal pain.
Shoulder tip pain and cervical excitation.
Constant lower abdominal pain, women more shocked than expected. Tender tense uterus, normal lie and and presentation, fetal heart distressed
Vaginal bleeding, no pain, non-tender uterus, lie and presentation may be abnormal
Rupture of membranes followed by immediate vaginal bleeding. Foetal bradycardia classically seen
Breast feeding contraindications:
Antibiotics:
Psychiatric drugs
NSAIDs
Misc:
Ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
Lithium, benzodiazepines, clozapine
Aspirin
Carbimazole, methotrexate, sulfonylureas, amiodarone
Which medication may be used to suppress lactation?
Cabergoline
Management of breech presentations:
Absolute contraindications to ECV:
If <36 weeks: most turn spontaneously
If still breach at 36 weeks -> ECV offered from 36 weeks for nulliparous women and 37 weeks in multiparous women.
When C-section required
Antepartum haemorrhage within last 7 days
Major uterine abnormality
ruptured membranes
multiple pregnancy
C sections: Categories and timings
Cat 1: delivery of baby should occur within 30 minutes of making decision
Cat 2: delivery within 75 minutes
Cat 3: Delivery is required but mother and baby are stable
Cat 4: elective caesarean
Treatment of chickenpox exposure in pregnancy:
when given?
Treatment of chickenpox infection:
post-exposure prophylaxis:
Oral Aciclovir at any stage of pregnancy
Day 7 to 14 following exposure
Oral Aciclovir provided woman is >20 weeks and she presents wihtin 24 hours of on-set of rash
Eclampsia:
Seen after how many weeks gestation?
Signs/symptoms
Treatment
If respiratory depression:
20
Pregnancy-induced hypertension, proteinuria
Magnesium sulphate
Calcium gluconate
Side effects in pregnancy: AEDs
Sodium valproate
Carbamazepine
Phenytoin
Lamotrigine
Associated with neural tube defects
Least teratogenic of older AEDs
Associated with cleft palate
low rate of congenital malformations - may be increased in pregnancy
Gestational diabetes:
Test of choice:
Diagnostic threshold BMs
Treatment:
If declining insulin
OGTT performed as soon as possible after booking and again at 24-28 weeks
Fasting glucose > 5.6
2 hour glucose > 7.8
Think (5,6,7,8)
If fasting glucose <7, diet and exercise advice should be offered.
If glucose targets not met within 1-2 weeks add metformin
if still not met or fasting glucose >7 at diagnosis : add insulin
Glibenclamide should be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets but decline insulin
Group B streptococcus
Risk factors:
Management
Who should it be offered to:
prolonged rupture of membranes
previous sibling GBS infection
Maternal pyrexia - secondary to chorioamnionitis
Intrapartum antibiotic prophylaxis (IAP) benzylpenicillin
Women with previous baby with GBS
Women with a pyrexia of >38 during labour
Postpartum haemorrhage
Blood loss greater than:
4Ts
Treatment:
500mls
Tone (uterine atony in majority of cases), Trauma, Tissue, Thrombin
ABC -> mechanical (palpate uterine fundus) -> IV oxytocin, ergometrine IV or IM, carboprost IM (unless asthmatic) -> misoprostol SL -> Surgical (intrauterine balloon tamponade) -> B-lynch suture, ligation of uterine arteries or internal iliacs
COCP: UKMEC 4
> 35 y/o and smoking /15/day
migraine with aura
history of VTE/stoke/IHD or thrombogenic mutation
breastfeeding <6weeks postpartum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation
APL
Contraception: MoA
COCP
POP
Desogestrel only pill
Injectable contraceptive
Implant
IUD
IUS
COCP: Inhibits ovulation
POP: Thickens cervical mucous
Desogestrel only pill: inhibits ovulation AND thickens cervical mucous
Injectable contraceptive: inhibits ovulation AND thickens cervical mucous
Implant: inhibits ovulation AND thickens cervical mucous
IUD: Decreases sperm motility and survival
IUS: Prevents endometrial proliferation AND thickens cervical mucous
Emergency contraception MoA:
Levonorgestrel
Ulipristal
IUD
Inhibits ovulation
Inhibits ovulation
Toxic to sperm and ovum and inhibits implantation
What should all pregnant women at risk of pre-eclampsia take
When?
Hypertension in pregnancy numbers:
Management:
If asthmatic
Aspirin 75 mg
From 12 weeks until birth of the baby
> 140/90 or increase from booking of > 30/15 mmhg
Labetalol
Nifedipine and hydralazine
Induction of labour methods (6)
Which method to induce labour (Bishops score)
Main complication of induction of labour:
Membrane sweep
Vaginal prostaglandin E2
Oral Prostaglandin E1
Maternal oxytocin infusion
Amniotomy
Cervical ripening balloon
If Bishops <6 - Vaginal PGE2 or oral misoprostol
If Bishops > 6 amniotomy and IV oxytocin infusion
Uterine hyperstimulation - prolonged and frequent contractions
Manage by removing PGE2 and stopping oxytocin infusion
Intrahepatic cholestasis of pregnancy management:
Induction of labour at 37-38 weeks (not evidence based)
Urseodeoxycholic acid
Vit K supplementation
Secondary PPH timescale:
Causes
24 hours - 12 weeks
Retained placental tissue or endometritis
Anaemia pregnancy:
When screened:
Cut-offs:
Management:
How long shold treatment continue for post-correction?
Booking visit (8-10 weeks) and 28 weeks
1TM - <110
2TM - <105
3 TM < 100
Ferrous fumarate or sulphate -> Should be continued for 3 months post-correction
Obese women in pregnancy management
Folic acid dose:
Screening for which diseases
Delivery precautions based on BMI?
Folic acid 5 mg (rather than 400mcg)
Gestational diabetes screening with OGTT at 24-28 weeks
If BMI > 35 patient should give birth in consultant led unit
If BMI > 40 antenatal consultation with obstetric anaesthetist
Preterm prelabour rupture of membranes
How to confirm:
Management:
Sterile speculum examination looking for pooling of amniotic fluid - NO digital exam (risk of infection)
Test fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein 1
US may also be useful
Admission
Erythromycin for 10 days
Antenatal corticosteroids
Consider delivery at 34 weeks
Most common cause of puerperal pyrexia:
Other causes:
Management
Endometritis
UTI, Wound infection, mastitis, VTE
If endometritis suspected pt. should be referred for IV antibiotics (clindamycin and gentamicin)
When to give anti-D immunoglobulin
Tests:
Coombs and Keihauer
Symptoms in affected foetus:
Treatment:
Delivery of a rhesus positive infant
Any ToP
Miscarriage if greater <12 weeks
Ectopic pregnancy (if managed medically with methotrexate, anti-D not required)
Antepartum haemorrhage
Amniocentesis CVS, foetal blood sampling
Abdominal trauma
All babies born to Rh -ve mother should have cord blood taken at delivery
Coombs test: direct antiglobulin - will demonstrate antibodies on RBCs of baby
Kleihauer test: Add acid to maternal blood, fetal cells resistant
Oedematous
Jaundice, hepatosplenomegaly, heart failure, kernicterus
Rheumatoid arthritis in pregnancy:
Which drugs are not safe and when should they be stopped:
Which drugs are considered safe?
NSAIDS?
Methotrexate - at least 6 months prior to conception
Leflunomide
Sulphasalazine and hydroxychloroquine
Low dose corticosteroids may be used in pregnancy to control symptoms
NSAIDS may be used until 32 weeks buy after this time should be withdrawn due to risk of early closure of ductus arteriosus
Manoeuvre for shoulder dystocia:
complications of shoulder dystocia
McRoberts
Maternal: PPH, perineal tears
Foetus: Brachial plexus injury, neonatal death
Investigations for amenorrhoea
Exclude pregnancy - HCG
Gonadotrophins - low levels suggest hypothalamic cause where as raised levels suggest ovarian problem
Prolactin
Androgen levels (may be raised in PCOS)
Oestradiol
Androgen insensitivity syndrome
Biologically which gender appearing as which gender?
46XY (MALE) with female phenotype
Cervical cancer:
HPV risk types
Other risk factors
16,18,33
Smoking, HIV, early first intercourse, many sexual partners, high parity, COCP
Ectopic pregnancy management:
<35mm, unruptured, asymptomatic, no foetal heart beat, hCG <1000
<35mm, no foetal heartbeat, hCG <1500
> 35mm, can be ruptured, pain, foetal heartbeat hCG >5000
Expectant management - monitoring
Medical management - methotrexate
Surgical management - Salpingectomy if no other risk factors for infertility. Salpingotomy if risk factors
Cancer which occurs largely due to unopposed oestrogen
Risk factors:
Protective factors:
Investigations:
Management:
Endometrial cancer
Early menarche, late menopause, nulliparity, obesity, DM, HNPCC
Smoking, COCP, multiparity
First line investigation is TVUS -> Hysteroscopy with endometrial biopsy
Surgery -> Progrestogen therapy considered if frail, old women not fit for surgery
Endometriosis
Investigation:
management:
Laparoscopy
NSAIDs/paracetamol -> COCP/progestogens -> referral to secondary care for GnRH analogues, surgery
Menorrhagia:
1) what is management dependent on:
2) Management:
3) Medication which can be used in short term only to rapidly stop heavy bleeding:
1) Need for contraception
2) No contraception: Mefanamic acid or tranexamic acid started on first day of period
2) Requires contraception: IUS (first line)
COCP
3) Norethisterone
Current or past breast cancer
Any-oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
Are all contraindications for which drug therapy
HRT
1) Medical management of miscarriage:
2) When should patients be offered pregnancy test after this:
3) Surgical management of miscarriage
1) Oral Mifepristone -> 48 hours -> PO, PV, SL Misoprostol (strong myometrial contractions)
If bleeding has not started within 48 hours of misoprostol treatment contact healthcare professional
2) 3 weeks from ToP
3) 2 options -> vacuum aspiration (suction curettage) or surgical management in theatre
Ovarian cysts
1) Most common type of physiological cyst:
2) Most common benign ovarian tumour in women <30
3) Most common benign epithelial tumour
4) Second most common benign epithelial tumour which if ruptures may cause psuedomyxoma peritonei
1) Follicular cyst
2) Dermoid cysts
3) Serous cystadenoma
4) Mucinous
Commonest cause of pelvic inflammatory disease
First line treatment for suspected PID:
Chlamydia trachomatis
IM ceftriaxone followed by 14 days of doxycycline and metronidazole
1) Name of criteria for diagnosis of PCOS:
2) Management of hirsutism in PCOS
3) Management of infertility in PCOS
1) Rotterdam criteria
2) COCP -> topical eflornithine if not responding
3) lose weight -> ongoing debate - Clomifene and/or metformin (contesteD)
1) Increase in gonadotrophins with menopausal symptoms in a female less than 40 y/o
2) Treatment:
3) Until what age
1) Premature ovarian failure
2) HRT
3) 51 (average age of menopause
1) Management of menorrhagia secondary to fibroids
2) Treatment to shrink fibroids
1) IUS (only if uterine cavity NOT distorted), NSAIDS (mefanamic acid), Tranexamic acid, COCP, Progestogens
2) Medical - GnRH agonists - may reduce the size of the fibroid
Surgical - myomectomy, hysteroscopic endometrial ablation
1) Management of vaginal candidiasis
2) If recurrent
1) Oral fluconazole as single dose (first-line) -> Clotrimazole pessary (if oral therapy contraindicated)
2) Once confirmed - induction maintenance regime Fluconazole for 3 doses (3 day intervals) then oral fluconazole for 6 months (weekly)
Vaginal discharge:
1) Cottage cheese discharge, vulvitis itch
2) Offensive yellow/green frothy discharge, vulvovaginitis, strawberry cervix
3) Offensive thin white/grey fishy discharge
1) Candida
2) Trichomonas vaginalis
3) Bacterial vaginosis
Hyperemesis, vaginal bleeding in first or early second trimester.
Large for dates, non-tender uterus
HcG level?
2-3% go on to develop:
Molar pregnancy
Elevated (very high)
Choriocarcinoma
Contraception in epilepsy:
UKMEC 1
Phenytoin, carbamazepine, Topiramate: Depo-provera, IUD, IUS
Lamotrigine: POP, implant, depo-provera, IUD, IUS
In essence, IUD, IUS, depo-provera appear to be safest bets for epilepsy meds.
COCP tends to be UKMEC3 - less appt.
1) Most effective form of contraception
2) Mechanism:
3) secondary mechanism
4) Additional contraception required if:
5) Main side effect:
Implant
Inhibits ovulation
Thickens cervical mucous
Not inserted on day 1-5 of a woman’s menstrual cycle
Irregular/heavy bleeding
Injectable contraceptives:
1) Mechanism
2) How often does it need injected?
3) Adverse effects
Inhibits ovulation
Every 12 weeks (can be given up to 14 weeks without additional precautions
Irregular bleeding, weight gain, increased risk of osteoporosis, delay in fertility
Implantable contraceptives:
1) IUD mechanism
2) IUS mechanism
3) IUD/IUS may be depended on after:
Prevention of fertilisation by decreasing sperm motility and survival
Prevents endometrial proliferation and causes mucous thickening
IUD instantly, IUS after 7 days
Post-partum, after how many days should a female re-start contraception?
POP - when may it be started?
COCP - when may it be started?
Length of time after child-birth in which IUD/IUS may be inserted
21 days (3 weeks)
Anytime, additional contraception required for 2 days.
Absolutely contraindicated if breast feeding and <6 weeks
Should not be used in the first 3 weeks post-partum due to risk of VTE
Within 48 hours or after 4 weeks
Lactational amenorrhoea method
How long is it effective for?
what are the conditions
amenorrhoeic, exclusively breast feeding and <6 months post-partum
Progestogen only pill:
Most common side effect:
Immediate protection if started:
If not started in this time, how long should condoms be used for?
Missed pills: how long constitutes missed?
if > X hours late -> extra precautions?
Buffer zone for missed pill with Cerazette (desogestrel) ?
Irregular vaginal bleeding
Within 5 days of cycle
2 days (2 days to become active)
> 3 hours
Take as soon as possible. Condoms until pill taking has been re-established for 48 hours
12 hours
