Womens health Flashcards
What happens to BP in the first half of pregnancy?
Falls
How long do different contraceptives take to be effective?
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
Doses of folic acid used in pregnancy?
400mcg unless risk then 5mg
IUD id copper or mirena?
Device is copper
Non-hormonal treatment for vasomotor symptoms of menopause?
SSRIs
For how long after birth do you not need contraception?
21 days
What fluid level is defined as oligohydramnios and what are the cuases?
<500ml
premature rupture of membranes fetal renal problems e.g. renal agenesis intrauterine growth restriction post-term gestation pre-eclampsia
Timetable of antenatal appointments?
8 - 12 weeks (ideally < 10 weeks)
- Booking visit
- general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
- BP, urine dipstick, check BMI
- Booking bloods/urine
- FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
- hepatitis B, syphilis
- HIV test is offered to all women
- urine culture to detect asymptomatic bacteriuria
10 - 13+6 weeks
- Early scan to confirm dates, exclude multiple pregnancy
11 - 13+6 weeks
- Down’s syndrome screening including nuchal scan
16 weeks
- Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
- Routine care: BP and urine dipstick
18 - 20+6 weeks
- Anomaly scan
25 weeks (only if primip) - Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
28 weeks
- Routine care: BP, urine dipstick, SFH
- Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron
- First dose of anti-D prophylaxis to rhesus negative women
31 weeks (only if primip) - Routine care as above
34 weeks
- Routine care as above
- Second dose of anti-D prophylaxis to rhesus negative women*
- Information on labour and birth plan
36 weeks
- Routine care as above
Check presentation - offer external cephalic version if indicated
- Information on breast feeding, vitamin K, ‘baby-blues’
38 weeks
- Routine care as above
40 weeks (only if primip)
- Routine care as above
- Discussion about options for prolonged pregnancy
41 weeks
- Routine care as above
- Discuss labour plans and possibility of induction
Diagnostic criteria for hyperemesis gravidarum?
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
Smear results what to do if HPV +ve but cytology normal?
Repeat in 1 year,
If the repeat test is now hrHPV negative they can return to normal recall.
If the repeat test is still hrHPV positive and cytology is still normal they should have a further repeat test 12 months later. This is the case for the patient in the scenario.
If the second repeat test at 24 months is negative for hrHPV, they can return to normal recall.
If the second repeat test at 24 months is positive for hrHPV, they should be referred for colposcopy.
How to interpret smear results?
Cytology only done if HPV +ve
If no HPV - normal recall
if HPV +ve but normal cytology the repeat in 12 months (twice)
If cytology abnormal then - colposcopy
If inadequate then repeat within 3 months and if inadequate again then colposcopy
Management of women who have previously had gestational diabetes?
Women who have previously had gestational diabetes should have an oral glucose tolerance test as soon as possible after booking
Recurrent thrush treatment?
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
Depot provera contraception SEs?
Weight gain and risk of osteoporosis
Issues with abx and COCP - what advice should you give?
Only need to worry if its an enzyme inducing abx (rifampicin)
Management of PCOS?
Generally:
- Weight loss
- COCP if needs contraception
Hirsuitism and ACNE
- a COC pill may be used help manage hirsutism. A third generation COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. May carry an increased risk of venous thromboembolism
- if doesn’t respond to COC then topical eflornithine may be tried
- spironolactone, flutamide and finasteride may be used under specialist supervision
Infertility:
- Weight loss (specialist management)
- Clomifene is superior to metformin
- Gonadotrophins
Bishops score use and result meaning?
Used to calculate if will go into labour
<8 unlikely
>8 likely
If inducing labour what is first line?
Membrane sweep
then vaginal prostaglandins
then oxytocin or rupture of membranes or ‘cervical ripening balloon’
First line treatment for mennorhagia?
Mirena coil
cervical excitation indicates what?
Pelvic inflammatory disease, ectopic pregnancy, ovarian torsion
What drugs should be avoided in breast feeding?
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides psychiatric drugs: lithium, benzodiazepines aspirin carbimazole methotrexate sulfonylureas cytotoxic drugs amiodarone
Management of gestational diabetes?
- newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week
- women should be taught about self-monitoring of blood glucose
- advice about diet (including eating foods with a low glycaemic index) and exercise should be given
if the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered
- if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
- if glucose targets are still not met insulin should be added to diet/exercise/metformin
- gestational diabetes is treated with short-acting, not long-acting, insulin
if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
if the plasma glucose level is between 6-7 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered
glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
When should you give the MMR to a pregnant woman if she wants it?
Postnatally if she is not immune
Hormone bloods in menopause?
raised FSH, LH levels
e.g. FSH > 40 iu/l
low oestradiol
e.g. < 100 pmol/l
What age would you say menopause was premature?
<40
When do patients with secondary dysmenorrhoea need to be referred to gynaecology?
Always
Examples of antimuscarinic meds?
Solifenacin, tolterodine and oxybutynin
UKMEC 4 absolute contraindication to COCP rules with age and smoking?
More than 35 years old and smoking more than 15 cigarettes/day
Methods of abortion as per length on pregnancy?
less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
less than 13 weeks: surgical dilation and suction of uterine contents
more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
Management of PMS?
mild symptoms can be managed with lifestyle advice
apart from the usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP)
examples include Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg)
severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI)
this may be taken continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length)
Management of BGS (group b strep) in pregnancy?
women who’ve had GBS detected in a previous pregnancy should be informed that their risk of maternal GBS carriage in this pregnancy is 50%. They should be offered intrapartum antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive
if women are to have swabs for GBS this should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date
IAP should be offered to women with a previous baby with early- or late-onset GBS disease
IAP should be offered to women in preterm labour regardless of their GBS status
women with a pyrexia during labour (>38ºC) should also be given IAP
benzylpenicillin is the antibiotic of choice for GBS prophylaxis
Presentation of placental abruption?
shock out of keeping with visible loss pain constant tender, tense uterus normal lie and presentation fetal heart: absent/distressed coagulation problems beware pre-eclampsia, DIC, anuria
Does placenta praevia present with abdo pain?
No
What is adenomyosis?
extension of endometrial tissue into the uterine myometrium.
- presents with dysmenorrhoea
How often is smear testing?
Age 25 years: first invitation.
Age 25-49 years: screening every 3 years.
Age 50-64 years: screening every 5 years.
How do contraceptive agents prevent pregnancy?
Combined oral contraceptive pill
- Inhibits ovulation
Progestogen-only pill (excluding desogestrel)
- Thickens cervical mucus
Desogestrel-only pill
- Primary: Inhibits ovulation
- Also: thickens cervical mucus
Injectable contraceptive (medroxyprogesterone acetate) - Primary: Inhibits ovulation
Implantable contraceptive (etonogestrel)
- Primary: Inhibits ovulation
- Also: thickens cervical mucus
Intrauterine contraceptive device
- Decreases sperm motility and survival
Intrauterine system (levonorgestrel)
- Primary: Prevents endometrial proliferation
- Also: Thickens cervical mucus
Which HPV viruses are associated with cancer and which warts?
16 and 18 cancer (and 33)
11 and 6 are warts
Higher is worse
Patients with diabetes (T1 or 2) - what changes to drug therapy during pregnancy?
take aspirin 75mg daily from 12 weeks gestation to reduce the risk of pre-eclampsia.
5mg folic acid daily, whilst trying to conceive until 12 weeks gestation
If above 50 y/o and on contraception what contraception needs to be stopped/switched?
Oestrogen methods - i.e. COCP and depo-provera
When should you remove the IUD for <50 and >50 women
> 50 after 1 year of amennorhoea
<50 after 2 years of amenorrhoea
Phases of the menstrual cycle?
Menstruation 1-4
Follicular phase (proliferative phase) 5-13
Ovulation 14
Luteal phase (secretory phase) 15-28
A surge in what hormone leads to ovulation?
LH
Which phases of the cycle is progesterone high and which oestrogen?
Oestrogen - menstruation and follicular (first 14 days)
Progesterone - Ovulation and luteal (last 14 days)
Contraindications to HRT?
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
Risks of HRT?
VTE - all oral HRT
Coronary heart disease
Breast and ovarian cancer
Stroke - only oral oestrogen
How long does the implantable contraceptive last?
3 years
What are the recommended antiepileptics in pregnancy?
Lamotrigine, carbamazepine and levetiracetam
What is the recommended contraception for young people?
The implant (nexplanon)
What is a bartholin cyst, how does it present?
A Bartholin’s cyst is a small, fluid-filled cyst on the vulva that is caused by an obstructed Bartholin’s gland duct. Bartholin’s cysts typically are painful and soft on examination.
How does vulval cancer present?
Hard lump with inguinal lymphadenopathy
Emergency contraception options and timescale?
Levonorgestrel- within 3 days
UPA - within 5 days of UPSI or 5 days of earliest estimated date of ovulation (but no longer than 5 days)
IUD - within 5 days
Management of chickenpox exposure in pregnancy - unsure about immunity
if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies
if the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible
- VZIG is effective up to 10 days post exposure
if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure
How do you work out the symphysis-fundal height?
After 20 weeks, symphysis-fundal height in cm = gestation in weeks
Presentation of PID?
bilateral lower abdominal pain associated with vaginal discharge and high fever. There can be urinary symptoms
What might rise CA125 (that isn’t cancer)?
Endometriosis, menstruation and benign ovarian cysts.
Previous pre-eclampsia, what medication should you give at 12-14 weeks?
Low dose aspirin
How long do uncomplicated pregnancies have to take folic acid?
For first 12 weeks
Unopposed oestrogen highest risk?
Endometrial cancer
Drugs to administer if premature labour is threatened?
Tocolytics and steroids
If ectopic has a heartbeat what is the management?
Surgical (slapingectomy)
What is the edinburgh scale used for?
Post natal depression
Cancer risks in COCP?
increased risk of breast and cervical cancer
protective against ovarian and endometrial cancer
What USS for ectopic?
Trans vaginal
Body temp rises just before or just after ovulation?
Just after
Management of ovarian cysts?
Premenopausal women
a conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
Postmenopausal women
by definition physiological cysts are unlikely
any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessme
Definition of HTN in pregnancy?
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
Two first line/conservative approaches to urinary incontinence in women? for urge and stress incontinence?
Urinary incontinence - first-line treatment:
urge incontinence: bladder retraining
stress incontinence: pelvic floor muscle training
How does ovarian hyperstimulation syndrome present?
in order of severity:
Abdo pain and bloating Nausea and vomiting Ascites Oliguria Thromboembolism ARDS
COCP pill missed rules?
If 1 pill is missed (at any time in the cycle)
- take the last pill even if it means taking two pills in one day
- no additional contraceptive protection needed
If 2 or more pills missed:
- take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
- the women should use condoms or abstain from sex until she has taken pills for 7 days in a row.
- if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
- if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
- if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
What drugs (for HTN) might worsen stress incontinence?
Doxazosin
I suppose maybe diuretics too?
Quad test results for downs (or high chance)?
↑ HCG, ↓ PAPP-A, thickened nuchal translucency
Advice re: breastfeeding in HIV +ve pts?
all HIV positive women should be advised not to breastfeed
When trying to conceive what is the advice re giving up methotrexate for women and men?
6 weeks before trying in both men and women
Gold standard investigation for endometriosis?
Laparoscopy
What is a summary of the things that increase risk for ovarian cancer?
It’s increased amount of cycles so late menopause early menarche, less pregnancy, etc
Treatment for active chickenpox in pregnancy?
oral aciclovir
When do you give anti d in rhesus negative women?
anti-D at 28 + 34 weeks
Management of endometriosis?
NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief
if analgesia doesn’t help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried
rudimentary digits, limb hypoplasia and microcephaly associated with what infection in pregnancy
Varicella zoster
What does rubella exposure in pregnancy result in when born?
ensorineural deafness, eye abnormalities and congenital heart disease
What is the definition of a missed miscarriage?
gestational sac containing a dead fetus before 20 weeks without the symptoms of expulsion
Cholestasis of pregnancy features?
pruritus - may be intense - typical worse palms, soles and abdomen
clinically detectable jaundice occurs in around 20% of patients
raised bilirubin is seen in > 90% of cases
Management of intrahepatic cholestasis in pregnancy?
induction of labour at 37-38 weeks is common practice but may not be evidence based
ursodeoxycholic acid - again widely used but evidence base not clear
vitamin K supplementation
What bloods should you do and when to confirm ovulation?
Take the serum progesterone level 7 days prior to the expected next period
Most common type of ovarian cyst?
follicular cyst
If >35 when should you investigate for failure to get pregnancy?
After 6 months
Management of candidal breast infection if breast feeding?
In order to fully treat the infection both the mother and child should be treated, usually with miconazole cream applied to the nipple post feed and the oral mucosa of the infant. Breast feeding should be continued during treatment.
UKMEC 4 COCP?
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation
UKMEC 3 COCP?
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
current gallbladder disease
What would warrant expectant management for an ectopic?
1) An unruptured embryo
2) <35mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of <1,000IU/L and declining
Management of breech presentation?
if < 36 weeks: many fetuses will turn spontaneously
if still breech at 36 weeks NICE recommend external cephalic version (ECV)- this has a success rate of around 60%. The RCOG recommend ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women
if the baby is still breech then delivery options include planned caesarean section or vaginal delivery
Investigation for ?ovarian cancer?
CA125
Risks to baby associated with smoking during pregnancy?
Increased risk of miscarriage (increased risk of around 47%)
Increased risk of pre-term labour
Increased risk of stillbirth
IUGR
Increased risk of sudden unexpected death in infancy
Most common type of ovarian cancer?
Serous carcinoma
What are chocolate (ovarian) cysts otherwise called?
Endometriotic cyst
Most common benign ovarian tumour in women under the age of 25 years?
Dermoid cyst (teratoma)
What is Meigs syndrome?
Meigs’ syndrome is a benign ovarian tumour (usually a fibroma) associated with ascites and pleural effusion
Features of threatened miscarriage?
painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
the bleeding is often less than menstruation
cervical os is closed
complicates up to 25% of all pregnancies
Features of inevitable miscarriage?
heavy bleeding with clots and pain
cervical os is open
Missed POP pill rules traditional pills (Micronor, Noriday, Nogeston, Femulen)
If less than 3 hours late
no action required, continue as normal
If more than 3 hours late (i.e. more than 27 hours since the last pill was taken)
action needed - see below
If action needed:
- take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
- continue with rest of pack
- extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
Missed POP pill rules for desorgestrel
If less than 12 hours late
no action required, continue as normal
If more than 12 hours late (i.e. more than 36 hours since the last pill was taken)
action needed - see below
If action needed:
- take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
- continue with rest of pack
- extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
What abx can you use in breastfeeding?
penicillins, cephalosporins and trimethorpim
Most common cause of spontaneous miscarriage?
Antiphospholipid syndrome
When and how often is breast screening offered?
From 50-70 women are offered screening (mammogram) every 3 years
What abx should you give if GFR <30 for UTI?
Trimethoprim, if contraindicated then give fosfomycin
Most common SE of POP?
Irregular bleeding
Treatment for raynauds?
Nifedipine
