Women’s health Flashcards
What sort of HRT doesn’t increase VTE risk?
Transdermal HRT
Side effects of HRT
nausea, breast tenderness, fluid retention, weight gain.
Possible complications of HRT
Increased risk of breast cancer, endometrial cancer, VTE, stroke.
Combined test: when and what is being tested
11-13 weeks + 6. If later, do triple/quadruple test.
US for nuchal translucency + serum testing for b-HCG and PAPP-A.
Tests for Down’s, Edward’s, Patau’s.
Results of combined test indicating Down’s
Increased nuchal thickness and HCG, decreased PAPP-A.
Classic sx of endometriosis
THINK PAIN Dysmenorrhea Dyspareunia Pelvic pain Subfertility Can get painful bowel motions and many urinary sx
Inv and mx for endometriosis
Laparoscopy = gold standard
1st) NSAIDs/paracetamol
2) hormonal: COCP, then prog only, then mirena (provided not trying to conceive).
If don’t respond then GnRH analogues induce a pseudo menopause.
What is hyperemesis gravidarum?
Mx
Extreme vomiting + dehydration + weight loss in pregnant women. Possibly ketonuria.
Anti-histamines (promethazine)
Complication of hyperemesis gravidarum and mx
Wernicke’s due to vitamin and mineral deficiencies.
Expect ataxia and diplopia. Mx with pabrinex (IV Vit B and C)
How long is contraception required when undergoing the menopause?
12 months after LMP if over 50, 24 months if under.
Most common cause of PPH + mx
Uterine atony
ABC
IV syntocinon 10 units. Can try ergometrine IV or IM carboprost.
Surgical options = B-lynch sutures.
When are anti-D prophylaxis injections given to rhesus -ve women?
28 weeks then 34 weeks.
When does the early scan occur to confirm dates and number of pregnancies?
10-13 weeks + 6
When is the anomaly scan?
18-20 weeks + 6
Differentiating placenta praevia vs. Abruption
Praevia = painless bleeding with non-tender uterus. Shock in proportion to visible loss. Normal fetal heartbeat. Possibly abnormal lie and presentation.
Abruption = constant painful bleeding. Tender, tense uterus. Bleeding out of proportion to visible loss. Normal presentation and lie. Distressed or absent fetal heartbeat. Often coag disease.
What should you be aware of in placental abruption?
DIC, anuria, pre-eclampsia.
What should not be performed in primary care for antepartum haemorrhage?
Vaginal exam- further haemorrhage possible.
When and why is misoprostol used?
Soften cervix to induce labour.
What drug is used to cease breastfeeding?
Cabergoline- dopamine receptor agonists inhibit prolactin production.
Recommendations if patient wishes to stop breastfeeding
Stop suckling, supportive bra and analgesia, possibly cabergoline if required.
Classic physical presentation of Turner’s
Short stature, webbed neck, widely spaced nipples, shield chest.
RF and impact of group B strep on baby
RF = prolonged rupture of membranes, premature, previous sibling GBS infection.
Can cause severe early onset infection of newborn.
Testing of group B strep
DO NOT offer routine testing, even if asked, unless clinically indicated. Offer late testing to women with previous pregnancy with GBS carriage- risk now = 50%.
Offer 35-37 weeks.
Mx of GBS + criteria
Intrapartum AB prophylaxis: benzylpenicillin. Offer to any woman pre-term, pyrexial in labour, or previous GBS infected baby, regardless of GBS status.
Sudden collapse after rupture of membranes
Amniotic fluid embolism
Define pre-eclampsia
Pregnancy induced hypertension with proteinuria after 20 weeks gestation (oedema can be present).
What does Sheehan’s syndrome describe?
Hypopituitarism following significant blood loss and ischaemic shock (causes ischaemic necrosis). Get amenorrhea, hypoadrenalism, agalactorrhoea.
What does Asherman’s syndrome describe?
Intrauterine adhesions, often following dilatation and curretage. Can get amenorrhea as endometrium doesn’t respond to oestrogen as normal.
Mx of breech
<36w, baby can spontaneously move.
If still breech at 36w, try external cephalic version. If unsuccessful, either planned vaginal or CS.
Complication of breech
Cord prolapse
How much folic acid and for how long?
400micrograms for 12w.
If high risk, 5mg preconception to 12 weeks.
High risk RF for NTD
FH, suffererer, BMI over 30, mum has DM, thalassemia trait, coeliac or isn’t on anti-epileptics.
Inv for ovarian ca
CA125 + US, possibly diagnostic laparoscopy
CA125 also raised in endometriosis, menstruation etc
Forms of emergency contraception
Levonorgeterol (in 72 hours), SE 1% vomit so repeat if within 3 hours. Hormonal contraception unaffected.
Ulipristal within 120 hours, barrier for 5 days then can restart hormonal contraception. Delay breastfeeding for a week.
IUD up to 120 hours, offers LT.
What is Ovarian hyper stimulation syndrome?
Potential life threatening side effect of ovarian induction. Ovaries enlarge, cysts and fluid shift can cause hypovolemic shock.
Get GI sx, can get sob, peripheral oedema and AKI.
Ovarian torsion and mx
Sudden onset deep fossa pain + vom. Ovarian mass and OHSS = RF. US shows whirlpool sign.
Laparoscopy is both diagnostic and therapeutic.
Counselling for POP
Take pill at same time every day. If under 3 hours late, take as normal, if over 3 hours then take missed pill asap and use extra protection until pill use has been correctly established for 48 hours. No pill break.
If starting pill up to and including 5th day of cycle, it provides immediate protection. Otherwise, use other protection for first 48 hours (unless switching from COCP).
SE: irregular vaginal bleeding.
Define pre-eclampsia
Pregnancy induced hypertension with proteinuria (oedema can be present).
Complications of pre-eclampsia
Foetus: preterm, IUGR
Mum: eclampsia, haemorrhage, cardiac failure.
Mx of pre-eclampsia
If at moderate risk, 75mg aspirin from 12 weeks gestation till birth.
If above 160/100, only curative option is to deliver baby if over 34 weeks, Give labetalol, or nifedipine if asthma. IV MgSO4 for seizure prophylaxis (eclampsia). Epidural anaesthesia when inducing labour can help lower bp.
What is red degeneration and how does it present?
Fibroid growth outstrips blood supply, as grows in pregnancy in response to oestrogen. Tumour haemorrhages into itself, causing low fever, pain and vomiting. Usually in first or second trimester.
Mx of red degeneration
Supportive, rest + analgesia, lasts 4-7 days.
COCP use before surgery
Stop 4 weeks before and switch to POP (for major elective surgery)
Mx of fibroid
Levonorgestrel releasing IUS (Merina) = first line.
Alternative mx = COCP or tranexamic acid.
Possibly surgery, can use GNRH agonists ST to make smaller, or UAembolization.
Inv for ovarian ca
CA125 + US
RF for ovarian cancer
Many ovulations: early menarche, late menopause, nulliparity.
Sx of ovarian ca
VAGUE Abdo bloating/distension Abdo pain/pelvic pain Diarrhoea Urinary urgency Early satiety
Inv and Mx ovarian ca
Surgery, chemo. Poor outcomes as often dx late.
Counselling for POP
Take pill at same time every day. If under 3 hours late, take as normal, if over 3 hours then take missed pill asap and use extra protection until pill use has been correctly established for 48 hours.
SE: irregular vaginal bleeding.
What cancers does the COCP increase and decrease risk of?
Increased risk of breast and cervical ca.
Protects against endometrial and ovarian ca (suppresses number of ovulations in a lifetime and endometrial cell proliferation).
Anticoagulant use in pregnancy
Contraindicated as can cause placental haemorrhage.
NOACs (rivarox) and warfarin are not safe. Use LMWH if a necessity.
Pt presents with incontinence, what investigation should be performed to rule out UTI and DM?
Urinalysis to rule out UTI and DM
What should be considered in epileptic women choosing contraception?
AEDs are enzyme inducers, so go for an IUS.
Gestational DM levels (fasting and 2 hour)
5.6 fasting
2 hour of 7.8
COCP use before surgery
Stop 4 weeks before and switch to POP.
Mx of PPH
ABCDE IV syntocinin or syntometrine. Fundus massage Cord traction. If this fails, consider blood transfusion and manual removal of placenta.
Methotrexate rules for pregnancy
Teratogenic, can cause bone deformities.
Both partners must stop 6 months before conceiving.
What is a threatened miscarriage?
Painless vaginal bleeding usually 6-9 weeks, closed os and light bleeding.
What is fetal fibronectin? If a woman is positive, what is the mx?
FFn is released by the gestational sac. High level can be indicative of early labour, although not guaranteed.
Mx: optimise everything, inform NICU, admit and give IM steroids for neonatal lung maturity. BMs every hour, adjust insulin accordingly.
Whether you admit is based on calculation of risk, whether they’re experiencing tightenings.
What is lochia and how long should it normally last?
Passage of blood/mucous/tissue for 4-6 weeks. Beyond this, US for retained products of conception.
What and when is the best test for ovulation?
Progesterone level on day 21 (or 7 days before expected period). E.g. 35 day cycle, measure on day 28.
Progesterone peaks seven days after ovulation.
Initial investigations for infertility
Semen analysis
Serum progesterone 7 days prior to next period.
General advice for infertility
BMI 20-25
Sex every 2-3 days.
Folic acid.
Stop smoking/drinking throughout pregnancy.
What is CTG?
A cardiotocograph. Two transducers. One measures foetal heartbeat using US, the other measures contractions by assessing tension of the uterus (indirect measure of pressure).
What do late decelerations on a CTG indicate?
Indicates insufficient blood flow to uterus and placenta. Causes fetal hypoxia and acidosis.
Causes: pre-eclampsia, maternal hypotension.
Contraceptives: time to offer protection
IUD: immediate - 5 years
POP: 2 days
7 days: COCP, IUS (mirena), injection, implant
IUS protects for 5 years.
Mx of gestational diabetes
If fasting is 7 or above, start insulin, or if 6 or above + complications like macrosomia.
If under 7, trial diet (foods with low GI), exercise, if 2 weeks later still poorly controlled, try metformin, then insulin.
How does HELLP present clinically and in investigations?
Malaise, headache, nausea/vom.
Haemolysis, elevated LFTs, low platelets, hypertension with proteinuria. Maybe abdo pain.
Describe intrahepatic cholestasis of pregnancy and its complications
Most common liver disease in pregnancy, usually occurs third trimester. Increased risk of stillbirth.
How does IHCP present clinically and in investigations?
Pruritus, often in palms and soles.
Jaundice is rare.
Mx of intrahepatic cholestasis of pregnancy
Ursodeoxycholic acid for sx relief.
Weekly LFTs
Often induced at 37 weeks.
What AED is recommended in pregnancy?
Lamotrigine
What is chorioamnionitis and how does it present?
Bac infection of amniotic fluid/membranes/placenta. Clinical dx based on foul discharge and a tender uterus. EMERGENCY.
RF and mx of chorioamnionitis
Preterm prolonged rupture of membranes (although can still occur if membranes are intact).
Prompt delivery and IV AB.
How often does the contraceptive patch need to be changed?
Wear weekly for 3 weeks then have 1 week not wearing a patch. Advise regarding missed changing of patches depends on which week this occurs in.
What type of cyst is suspicious of ovarian cancer?
Multi-loculated.
Mx of suspicious ovarian cysts (loculated)
Perform Ca-125, AFP and BHCG. Book for cystectomy with biopsy.
How does BV present (including cell type)
Thin, grey-white fishy discharge.
Clue cells.
Mx of BV
Oral metronidazole
How does trichinomas present?
Offensive, green-yellow frothy discharge. Possibly strawberry cervic.
Mx of trichonomas
Oral metronidazole BD 5-7 days. Avoid sex for 1-2 weeks.
How does candida (thrush) present?
Cottage-cheese discharge, itch, vulvitis.
Not an STI but more likely to get it if sexually active.
Top 4 causes of abnormal discharge
Physiological
Candida
Trichonomas
BV
Mx of gonorrhoea
Single dose IM ceftriaxone
Mx of thrush
Treat with clotrimazole cream/pessaries for internal/external use.
Recurrent thrush RF
Immunosuppressed, DM, regular steroids
Mx for chlamydia
Doxycycline BD 7 days.
Don’t need test of cure.
Avoid sex for course of tx.
Contact trace last 6 months of partners.
What sign in a pregnant lady is commonly associated with pre-eclampsia?
Brisk tendon reflexes
How should severe pre-eclampsia be managed?
Think vomiting, headache, blurred vision, pappiloedema
IV MgSo4 and plan for immediate delivery
Drug mx of pre-eclampsia reaching 160/110
Labetalol or nifedipine if asthmatic.
How do pre-eclampsia and pregnancy-induced hypertension differ?
Both occur after 20 weeks but PIH has no proteinuria.
When is the test of cure for women treated for CIN I, II and III?
6 months later (if still +ve- colposcopy)
What’s the routine recall pathway in women over 50 for cervical cancer?
Every 5 years
Pathway for cervical cancer
1) Check for presence of HPV 16 + 18
2) Assess cytology for abnormality (dyskaryosis)
3) Colposcopy if abnormal cytology, establishes CIN status
First line tx for MgSO4 induced respiratory depression
Ca gluconate
What’s the greatest risk of unopposed oestrogen?
Endometrial ca
What investigation tests ovulation?
Day 21 progestrone
