Womens Flashcards
Menopause - duration of amenorrhoea for Dx
12 months
Premature menopause
age
cause
<40 yo
primary ovarian insufficiency
give 4 premenopausal Sx
Systemic: Hot flushes
Emotional lability or low mood
Premenstrual syndrome (PMS)
MSK: Joint pains
Gynae:
Vaginal dryness and atrophy
Reduced libido
Heavier or lighter periods
Irregular periods
Menopause can be dx clinically, or with the help of which test?
FSH blood test
(should be high due to lack of oestorogen –> lack of -ve feedback on pit. gland)
When is contraception needed around menopause
Effective contraception is needed for:
* 2yrs post LMP if <50 yo
* 1yr post LMP in >50 yo
contraception options in premenopausal women
Options in premenopausal women
UKMEC1 ( no restrictions)
everything: coils, progesterone, sterilisation
remember: Progesterone depot injection ( only in <45 years)
2 main S/E: weight gain, reduced BMD
Osteoporosis risk makes it unsuitable in >45
UKMEC2 (advantages > risks)
o COCP <50 yo
o Norethisterone/ levonorgestrel have low VTE risk
What are the suitable forms of HRT in
Uterus? (Y/N)
Period in last 12m? (Y/N)
Uterus?
* No: continuous oestrogen-only HRT.
* Yes: combined HRT (inc progeesterone)
Period in last 12m?
* Perimenopausal (yes) = cyclical combined HRT.
* Postmenopausal (no) = continuous combined HRT.
Give 3 C/I of HRT
- Undiagnosed vaginal bleeding
- Pregnancy
- Breastfeeding
- Oestrogen receptor-positive breast cancer
- Acute liver disease
- Uncontrolled hypertension
- History of breast cancer or venous thromboembolism (VTE)
- Recent stroke, myocardial infarction or angina
HRT increases the risk of (5 - 2x cancer, 3x vascular)
Cancer: breast, endometrial
Vascular: VTE, stroke, IHD
define
endometrioma
chocolate cyst
adenomyosis
- endometrioma lump of endometrial tissue outside the uterus
- chocolate cysts endometriomas in the ovaries
- Adenomyosis endometrial tissue within the myometrium (uterine muscle layer).
give 7 endometriosis Sx
Can be Asx or Sx:
* cyclical abdominal or pelvic pain
* Deep dyspareunia
* Dysmenorrhoea
* Infertility
* Cyclical bleeding from other sites (e.g haematuria)
Other cyclical sx:
* Urinary symptoms
* Bowel symptoms
give 3 examination findings in endometriosis
- Speculum: endometrial tissue visible in the vagina (esp in posterior fornix)
- Bimanual:
o A fixed cervix
o Tenderness in the vagina, cervix and adnexa
Gold standard test in endometriosis
Laparoscopic surgery
definitve Dx = biopsy of the lesions during laparoscopy.
(Pelvic US can also be used but may be unremarkable )
endometriosis stepwise Mx
PRN analgesia (NSAIDs/paracetamol 1st line)
Hormonal mx (contraceptives/GnRH agonist)
Surgical : laporascopic excision/adhesiolysis
hysterectomy
define salpingitis
inflammation of the fallopian tubes (PID)
defime parametritis
infection of the parametrium ( PID)
give 3 potential STI causes of PID. Which form produces more severe PID?
N. Gonorrhea (most severe)
Chlamydia trachomatis
Mycoplasma genitalium
Give 43 non-STI causes of PID
G. Vaginalis ( also causes bacterial vaginosis)
H.Influenza ( also causes resp infections)
E. coli ( also causes UTI)
give 4 examination findings suggestive of PID
Pelvic tenderness
Cervical excitation
Inflamed cervix
Purulent discharge
give 3 risk factors for PID
STI risk, PID Hx, IUD
absence of what finding under microscope can exclude PID
pus cells
medical mx for PID
IM ceftriaxone 1g stat, Doxyclycine 100mg BD 14/7, Metronidaxole 400mg BD 14/7
ceftriaxone -gonorrhoea
Doxycycline - chlamydia and Mycoplasma genitalium)
Metronidazole - anaerobes such as Gardnerella vaginalis)
Ceftriaxone and doxycycline - cover -other bacteria, including H. influenzae and E. coli.
give 6 complications of PID
- Sepsis
- Abscess
- Infertility
- Chronic pelvic pain
- Ectopic pregnancy
- Fitz-Hugh-Curtis syndrome
waht is the presentation of Fitz-Hugh-Curtis syndrom?
RUQ pain that referrs to right shoulder tip
Fitz-Hugh-Curtis Syndrome - inflammation and infection of the liver capsule causing adhesions between the liver and peritoneum.
what is the Ix for Fitz-Hugh-curtis syndrom
laproscopy ( visually & adhesiolysis (tx)
a 23 yo attends the clinic with severe bilateral lower abdominal pain.
bimanual examination: adnexal tenderness and the moments of extreme pain during the examination.
What is the most important initial investigation?
Beta-HCG . tis presentation suggests PID, but its important to exclude ectopic
swabs etc would be suitable to explore PID, once ectopic excluded
what organism causes a painful, potentially necrotic genital lesion, associated w/ painful lymphadenopathy & bleeding on contact
defined - chancroid ( STI)
cause: Haemophilus ducreyi - G-ve bacillus
- The bacterium is sexually transmitted and can cause a genital ulcer and inflammation of the inguinal lymph nodes.
a pt presents with symptoms suggestive of chancre, what key (non-sex related) picece of infomration should eb asked about in their PMHx?
recent travel
chancroid is more common in tropical areas & greenland
how does genital infection with Haemophilus ducreyi present?
painful genital lesipon
may bleed on contact
painful swollen lymph nodes (lymphadenopathy), may rupture and discharge pus
Sx develop 4-10days post ex-posure
multiple small vesicular lesions which become ulcers
accompanied by fever & malaise
cause?
HSV
painless ulcer and generalised non-tender lymphadenopathy
syphilis
do not confuse with chancroid which is PAIFUL lesion, blleds to touch, painful lymphadenopathy
painless ulcer or papule, followed by pain
lymphogranuloma venereum
( lymdenopathy which is painful called bubo - similar to chancroid)
Mx chancroid
antibiotics ( ceftriaxone, azithromycin, ciprofloxacin)
analgesia
incision & drainage (buboes)
a pt attends the GP clinic with a 2week old geneital lesion & enlarged nofdes around the region. the pt is sexually active so you suspect Chancroid. a penile swab is taken, describe the appearance of the findings
gram -ve rods
school fish patter
why is migraine with aura CI in COCP?
significantly increased stroke risk
Syphilis is casued by a bacteria
- name
- appearance
Name Treponema pallidum
appearance: spirochete (spiral shaped bacteria)
how long is the syphilis incubation period
21 days
How many stages are there in syphilis infection, how do these present
(5)
Primary syphilis
* painless ulcer (chancre) at original site of infection.
Secondary syphilis
* Systemic sx (especially of the skin and mucous membranes)
* Sx resolve after 3 – 12 weeks, then goes to latent stage.
Latent syphilis
* occurs after 2ᴼ stage
* Sx disappear & patient ASx (despite still being infected).
* 2 subcategories
o Early latent syphilis - within 2yrs of the initial infection
o Late latent syphilis – from 2yrs post initial infection.
Tertiary syphilis
* many years after the initial infection
* affects many organs of the body (causes the development of gummas sores that grow deep and eat away at the area where they develop, such as the skin, lungs, liver, or bone (Gummatous syphilis) and cardiovascular and neurological complications.
Neurosyphilis occurs
* CNS infection, presenting with neurological symptoms.
what eye finding is associated with syphilis
Argyll-Robertson pupil i ( propstitues puil)
constricted pupilm that accommodates (when focusing on near objects) but does not react (to light)
Tx syphilis
deep IM benzathine benzylpenicillin (or cef/amoxicillin/dox)
what type of bacteria is chlamydia trachomatis?
gram -ve, intracellular organism
describe the National Chlamydia screening programme
screen sexually active people <25yo
Annually / when sexual partner is changed
In positive test:
- treatment
- re-test in 3 months
what is the main complication of induction of labour
uterine hyperstimulation
tachysystole (high contraction frequency), for >20mins. May/may not have fetal distress
what is a normal rate of contractions in labour
<4 contractions in 4mins
Give risk factors for uterine hyperstimulation
oral misoprostol
foetal tachycardia
> 160bpm
risk factors for uterine rupture
multiparous
connective tissue disease
Macrosomia
Multiple pregnancy
Give 5 indications for induction of labour
- Weeks 41-42
- PRoM
- Fetal growth restriction
- Pre-eclampsia
- Obstetric cholestasis
- Existing diabetes
- Intrauterine fetal death
the bishops score has a minimum of 0 and maximum of 13. What is the
- use of the score
- the categories of it
Determining whether to induce labour
SCOPED
* Station of foetal head (foetal station: 0 – 3)
* Consistency of the cervix (scored 0 – 2)
* Position of cervix(scored 0 – 2)
* Effacement of the cervix (scored 0 – 3)
* Dilatation of the cervix (scored 0 – 3)
9-13 = cervix facouurable for IOL
Give the 5 methods used in IOL
Membrane sweep (fingers - should induce in <48hrs)
Vaginal prostaglandin E2 (dinoprostone) - (gel, tablet. pessary inserted)
Cervical ripening balloon (dilates cervix, where prostaglandins not preferred e.g. C-section Hx/ muliparous/ prostaglandins havenent worked
Oxytocin infusion (where prostaglandis haven’t worked
when os oral mifeprostone + misoprostol combined in IOL ?
interuterine death
Oral mifepristone (anti-progesterone)
what are the 3 risks of the main complication of IOL with prostaglandins
- foetal compromise ( hypoxia and acidosis)
- emergency C-section
- uterine rupture
prostaglandin - e.g. misoprostol
Mx uterine hyperstimulation
removing inducing agent ( prostaglandin/ oxytocin infuction)
Tocolysis ( using terbutaline)
HTN in pregnancy
1st line
if asthmatic
1st line - oral labetalol
2nd line nifedipine + hydralazine
What antiHTN should be vavoided in pregnancy
ACEi, ARBs, Thiazide & thaizide-like diuretics (cause congenital abnormalities), and most B-blockers
what cuses pre-eclampsia
malformation of spiral arteries of the placenta –> vascuar resistance
1st shows after 20wks
pre-eclampsia features triad:
HTN, substantial proteinuria, oedema
- substantial as mild proteinuria may be subsequent to the chronic HTN (e.g. protein +1)
the risk factors of pre-eclampsia can be sorted into high risk/ moderate risk. what are the high risk factors>
- Hx HTN (including in pregnancy)
- Hx autoimmune conditions (e.g.SLE)
- Diabetes
- CKD
the risk factors of pre-eclampsia can be sorted into high risk/ moderate risk. what are the moderate risk factors?
- > 40
- BMI > 35
- More than 10 years since previous pregnancy
- Multiple pregnancy
- First pregnancy
- FHx pre-eclampsia
You are assessing a pregnant pt for pre-eclampsia risk, when and using what criteria would you offer prophylctic medication
medication: Aspirin
from 12 wks
in 1 high risk factor
>1mod risk factor
pre-eclampsia Sx
Headaches, visual disturbances, brisk reflexes
N&V
epigastric pain
Oedema
Oliguria
Pre-eclampsia diagnostic features
- BP > 140/90 mmHg
PLUS any of: - Proteinuria (>1+ on urine dipstick)
- Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
- Placental dysfunction
Preeclampsia Mx
HTN Mx
Seizure prevention during labour
fluid overload prophylaxis
HTN: Labetolol (1st) Nifedipine (2nd) Methyldopa(3rd)
IV hydralazine - in critical care in severe pre-eclampsia or eclampsia
Seizure prophylaxis: IV magnesium sulphate - give 24hrs pre & during labour
Fluid overload - Fluid restriction during labour in severe pre-eclampsia or eclampsi
Preeclampsia can continue for 1m post delivery, what medical Mx is used (1st to 3rd line)
- Enalapril
- Nifedipine or amlodipine (1st line Afro-Caribbean )
- Labetolol or atenolol
Give 2 complications of pre-eclampsia and their Mx
Eclampsia - IV MgSO4
HELLP Syndrome ( Haemolysis, Elevated Liver enzymes, low Platelets) - delivery
Management: Pt presents with placental abruption at 3t6 wks. The foetus is alive and not showing signs of distress.
- Adx
- Administer steroids ( lung maturation)
- deliver at 37-38 wks (risk of stillbirth)
Pt presents with placental abruption at 36 wks. There are signs of foetal distress. What is the correct management?
immediate C-section ( the stage of labour doesn’t matter, foetal distress + placental abruption = C-section immediately)
give 3 placental abruption risk factors
- Previous placental abruption
- Pre-eclampsia
- Bleeding early in pregnancy
- Trauma (consider domestic violence)
- Multiple pregnancy
- Fetal growth restriction
- Multigravida
- Increased maternal age
- Smoking
- Cocaine or amphetamine use
typical presentation of placental abruption
sudden onset CONTINUOUS pain, with WOODY abdomen
what is the most significant foetal complication in maternal GDM?
macrosomia
what risk factors suggest a need to test for GDM?
- Personal Hx GDM
- FHx GDM (1st degree relative)
- Hx macrosomic baby (≥ 4.5kg)
- BMI > 30
- Ethnic origin (black Caribbean, Middle Eastern and South Asian)
what test is used to screen for GDM
OGT
measure blood sugar –> 75g glucose drink –> 2hrs repeat of blood sugar
normal : <5.6mmol (fasting)
<7.8mmol (2hrs)
in pt with GDM, the Mx is 1-2wks lifestyle trial (1st line), then metformin (2nd line) , then insulin (3rd line).
what is the indicator for starting metformin & insulin immediately
fasting glucose> 7mmol/l
fasting glucose >6mmol/l plus macrosomia
what is the folic acid regimen in women with pre-existing diabetes wanting t get pregnant
mg folic acid from preconception until 12 weeks gestation.
at what gestational age should women with diabetes
- pre-existing
- GDM
give birth
pre-existing diabetes : 37- 38 + 6 wks
GDM: up to 40 + 6
What screening is important to do for pregnant women with diabetes?
retinopathy screening - 28wks
when should GDM pts stop their medication post-natally?
immediately
diabetes improves immediately after birth
when should a follow up test of fasting glucose be done in GDM pts post labour
after 6 weeks
Give 6 neonatal complications following maternal diabetes
macrosomia
neonatal hypoglycaemia ( the 2 main ones)
polycythaemia, jaundice, congenital heart disease, cardiomyopathy
What is the management for a hypoglycaemic neonate (BM <2mmol/L
IV dextrose
or
NG feeding
how long after a ToP does the urine pregnancy remain positive
up to 4 weeks following termination.
Following termination of pregnancy, HCG decreases by about 50% every two days.
- A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast
so a pt who’s urine pregnancy test remains +ve should repeat 4 weeks following ToP
who should anti-D prophylaxis be given to in ToP?
RhD-ve women with ToP >10+0 weeks
ToP regime
mifepristone ( porgesterone)
then mifoprostol (oprostaglandin) 48 hrs later
how long should barrier contraception be used when moving from POP to COCP
7 days
what triad of features suggest vasa previa
rupture of membranes
then
painless vaginal bleeding
and
fetal bradycardia
what is the standard folic acid dose in women wanting to be pregnant
0.4mg ( 400mcg)
what is the folic acid dose in women at increased NTD risks?
give examples of women in this high risk category
5mg
previous child w/ NTD
DM
on AED
Obese
HIV+ve on co-trimoxazole
sickle cell, coeliac, thalassaemia
second line in endometriosis medical management
1st line - ibuprofen + / paracetamol
2nd line COCP/ progestogen
