WOMENS HEALTH Flashcards
Sub-fertility
What and management
After ONE Year after trying activity to get pregnant (2-3 times weekly)
Always take history Do 21 day progesterone (or cycle -7) 1st line = life style 2nd = clomifene citrate If hyperprocalin - halt medications, start brominecriptine
Factors = sub fertility
Factors impacting fertility - Alcohol (No more than 1 to 2 units per week), Smoking (reduces fertility), Obesity (over 30 BMI - take longer to conceive), Low body weight (below 19 BMI), tight underwear (Men), Occupation, Amount of sex (should be having every 2-3 days)
Menopause contraception
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
Offer IUD
Menopause symtom management
Lifestyle modifications - increase exercise, sleep hygiene,
Hormone replacement therapy (HRT) - CI in breast cancer, oestrogen senstivie cancer, vagnal bledding,endometrial hyperplasia
Give combined oestrogren and progesterone (If the woman has a uterus then it is important not to give unopposed oestrogens as this will increase her risk of endometrial cancer - if not transdermal can give in MIUD)
Does not have a uterus then oestrogen alone can be given either orally or in a transdermal patch
Risks of HRT
Venous thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
Stroke: slightly increased risk with oral oestrogen HRT.
Coronary heart disease: combined HRT may be associated with a slight increase in risk.
Breast cancer: there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised.Â
Ovarian cancer: increased risk with all HRT.
Urge incontinence
Presentation and management
Âinvoluntary urine leakage accompanied by or immediately preceded by urgency - There are often trigger factors such as hearing running water, cold weather, etc. There are typically large volumes of leakage compared to stress incontinence.
Treat - bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
- bladder stabilising drugs: antimuscarinics are first-line. oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation).
- mirabegron (a beta-3 agonist) may be useful if there is concern about
stress incontinence
Presentation and management
involuntary leakage of urine during increased intra-abdominal pressure (ie on exertion) - typical after child birth due to detrusor muscle overactivity
RF - childbirth, older age,obesity, white, dementia,pelvic organ prolaspe
Presents with -Involuntary urine leakage on effort, exertion, sneezing, or coughing, vaginal/prolapse,Âusually with frequency and nocturia, in the absence of urinary tract infection or any other obvious pathology.
Investigations
-full exam and history, Bladder diary, Urodynamic studies.
Manage
Lifestyle alterations (ie decrease fluid intake, weight loss)
pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. bulking and colpolsuspention
Miscarriage
first trimester the most common cause of miscarriage is chromosomal abnormality (50-60%) (16, 45X)
2nd trimester = incompetence cervix
Other causes are fetal abnormalities or uterine structure abnormalities
Management of miscarriages
Expectant (No pain, less than 35mm(
NO HEART Beat
Medical (Misoprostol)
Surgical (Dilation and curettage (D&C)
RF’s
- Increased maternal age, alcohol, drug use, obesity, high caffeine,
PID management
History, exam - think if acutely unwell ABCDE and Sepsis SIX
White cell count (blood)
TVUS
Pelvic CT/MRIÂ
Laparoscopy
Empirical antibiotics should be started as soon as possible.
- 1st line would be ceftriaxone and doxycylcine (second
levofloxacin)
PID risk factors
RF:Risk factors for developing PID include:-Young age (younger than 25 years). Early age of first coitus. Multiple sexual partners. Recent new partner (within the previous 3 months). History of STI in the woman or her partner
Smears
when ref to colospoy
HPV+ and abnormal smear = colopscopy
High grade dyskaryosis (moderate, severe dyskaryosis or worse) -> ref straight to colposcopy (regardless of HPV)
or 3x inadequate
Fibroid management
Manage
Mirena
tranexamic acid, combined oral contraceptive pill etc
GnRH agonists may reduce the size of the fibroid but are typically short-term
surgery - myomectomy (fertility ) hysteroscopic endometrial ablation, hysterectomy
PCOS management
nvestigations USS FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a 'classical' feature Glucose intolerance Manage weight COCP Fertility (think metformin or clomifene)
Endometrious management
Investigation Pregnancy test FBC (anemia) Clotting - von Willebrand disease (vWd) includes von Willebrand factor antigen (vWF:Ag), ristocetin cofactor activity (vWF:RCoF), and factor VIII activity. Imaging USS May need endometrial biopsy Manage Pain if any COCP Transamic acid Surgical abaltion Full hysterectomy
Breast cancer presentation
The typical presentation is a painless breast mass, with/without:
Discharge
Nipple changes
Skin tethering or dimpling
Tethering to underlying tissues, e.g. muscle
Ulceration (late sign)
Ductal carcinoma in situ
Premenopausal and post-menopausal women. Usually patients are 40-60 years of age. May be extensive, and associated with fibrosis, in which case it will be a large palpable mass
Defined as a cancer that has not spread beyond the basement membrane of the ducts
May present as Paget’s Disease of the nipple (rare)
Have a risk of 30-50% of becoming invasive
Which breast cancer?
Usually occur in pre-menopausal women
Occurs in the lobules and don’t affect the ducts
Very difficult to detect – as it does not present as a lump, or cause many other signs.
Often multifocal and bilateral
No specific features on mammography
Lobular carcinoma in situ
Mucinous carcinoma characteristics
Account for 2-3% of invasive carcinomas
Their borders are not well defined, and they do not cause inversion of the nipple, or tethering of the skin.
Better prognosis than invasive ductal or lobular carcinomas
Breast cancer screening
Women in England who are aged from 50 to their 71st birthday and registered with a GP are automatically invited for screening every 3 years. (mammogram)
You may be eligible for breast cancer screening before the age of 50 if you have a very high risk of developing breast cancer.
Women aged over 70 years are invited to make their own appointments every 3 years.
If you have been found to have an increased risk of developing breast cancer, you may have yearly MRI scans or mammograms, depending on your age and your specific level of risk.
if a faulty gene (for example BRCA1 or BRCA2) has been identified in the family, direct referral to a specialist genetics service should be offered.
What is the triple approach to assessment of abnormalities that are found on screening?
exam, imaging and histology
Mammography involves compression views of the breast across two views (oblique and craniocaudal), allowing for the detection mass lesions or microcalcifications.
Ultrasound scanning is more useful in women <35 years and in men, due to the density of the breast tissue in identifying anomalies. This form of imaging is also routinely used during core biopsies.
A biopsy is required of any suspicious mass or lesion presenting to the clinic, most commonly obtained via core biopsy.
Four biopsy procedures
fine needle aspiration (FNA), which uses a very small needle to extract fluid or cells from the abnormal area.
core needle (CN) which uses a large hollow needle to remove one sample of breast tissue per insertion.
vacuum-assisted device (VAD) which uses a vacuum powered instrument to collect multiple tissue samples during one needle insertion.
wire localization, in which a guide wire is placed into the suspicious area to help the surgeon locate the lesion for surgical biopsy.
BRCA1
What is the mutation
What does this increase the risk of
Mutation on chromosome 17
Lifetime risk of breast cancer is about 75%
Lifetime risk of ovarian cancer is about 50%
Men with the gene also at increased risk
Also increased risk of bowel cancer, ovarian cancer (50% lifetime risk) and prostatic cancer (men)
BRCA2
What is the mutation
What does this increase the risk of
Mutation on chromosome 13
Lifetime risk of breast cancer 40-85%
Lifetime risk of ovarian cancer <25%
Lifetime risk of breast cancer for men is about 6%
HER2 mutation BC - targeted treatment
Has specific treatment in the form of the monoclonal antibody Trastuzumab (Herceptin). This will bind to the receptor, and cause the production of p27 within the cell, which reduces cell proliferation
As a result of this specific treatment, breast cancers are routinely tested for HER2/neu presence.
ER Positive breast cancer
Treatment?
tamoxifen
PR Positive breast cancer
Treatment?
anastrozole
Tamoxifen Which of the following is an adverse effect of this drug?
Tamoxifen may cause increased risk of endometrial cancer
Paget’s disease of the nipple is most likely to be associated with which lesion
Invasive ductal carcinoma
Brown-green nipple discharge
Duct etasia
This is a condition often found in women around the menopause and occurs due to a dilation of the milk duct as a result of ageing. This may or may not be associated with a small lump right under the nipple.
CA 15-3 is a marker for?
Breast cancer
CA 125 is a marker for?
ovarian cancer
CA 125 is a marker for?
ovarian cancer
CA 19-9
pancreatic cancer
Common in women under the age of 30 years
Often described as ‘breast mice’ due as they are discrete, non-tender, highly mobile lumps
Fibroadenoma
Carcinoembryonic antigen (CEA) is a marker for?
Colorectal cancer
Alpha-feto protein (AFP) is a marker for?
Hepatocellular carcinoma, teratoma
Chlamydia (Chlamydia Trachomatis) presentation
Males: Mucopurulent urethral discharge, dysuria, scrotal pain, proctitis.
Females: Mucopurulent vaginal discharge, cervicitis, cervical bleeding upon contact, proctitis, post-coital bleeding, intermenstrual bleeding.
Chlamydia (Chlamydia Trachomatis) test and management
Nucleic Acid Amplification Test (NAAT)
- Can take 2 weeks to show up.
1.Doxycycline 100mg PO twice daily for 7 days (contraindicated in pregnancy)
or
Azithromycin 1g PO, followed by 500mg daily for 2 days
2.Full STI Screen
3.Contact tracing and partner notification offered (No sex until all partners tested and treated)
4. Test of cure (TOC) 5 weeks; <25yrs repeat in 3m
ALWAYS CONTACT TRACE
Complications of Chlamydia
COMPLICATIONS: • Pelvic inflammatory disease (PID)- increases the risk of ectopic pregnancy and infertility • Epididymitis • Prostatitis • Reactive arthritis
Gonorrhoea
(Neisseria Gonorrhoea)
presentation
Males: Mucopurulent urethral discharge, dysuria, orchitis.
Females: Mucopurulent cervical discharge with cervicitis, cervical bleeding upon contact, dyspareunia, pelvic pain.
Rectal infection can cause: rectal bleeding
Gonorrhoea Test and management
- Nucleic Acid Amplification Test (NAAT)
- Can take 2 weeks to show up. - Cultures (urethral, cervical, anal and oropharyngeal) to assess abx susceptibility.
- microscopy diagnosis: Gram-negative intracellular diplococci
1.Ceftriaxone 1g IM single dose
or
Ciprofloxacin 500mg PO single dose (only where antimicrobial sensitivities are known prior to treatment)
or
Cefixime 400mg PO single dose with Azithromycin 2g PO single dose (if IM injection is contraindicated)
2.Full STI Screen
3. Contact trace
• Fitz-Hugh-Curtis syndrome
- secondary to PID there is inflammation of the hepatic capsule leading to perihepatic adhesions
Syphillis ( Treponema Pallidum) test and treatment
Dark ground microscopy of chancre fluid – (shows motile spring-shaped bacteria in primary syphilis).
Syphilis PCR swab ulcerated lesion.
Treponemal-specific serology remains positive throughout life: EIA, TPHA, TPPA
Cardiolipin serology tests indicator of disease activity, staging and treatment efficacy. These include: Rapid Plasma Reagin (RPR), Venereal Disease Research Laboratory (VDRL)
Repeated at 12 weeks post-exposure, and if considered high-risk at 6 weeks as well
Benzathene benzylpenicillin IM injection, however, the dose depends on the nature of the infection
Prednisolone is given alongside antibiotics in cases of neurosyphilis.
Primary, secondary and early latent syphilis: Benzathine benzylpenicillin 2.4 million units IM injection as a single dose
Late latent, cardiovascular and gummatous syphilis: Benzathine benzylpenicillin 2.4 million units IM injection weekly for three weeks (three doses)
- Full STI Screen
- Contact trace
Herpes (HSV-1 and HSV-2) test and treatment
HSV PCR from swabs taken from lesions (burst the lesion)
Some centres use NAAT
HSV does not form part of routine STI screening in the UK!!!
Primary episode: Aciclovir 400mg oral three times a day for 5 days (commenced within 5 days of symptom onset)
Recurrent episodes: Aciclovir 800mg oral three times a day for 2 days
Prophylaxis in patients with >5 episodes per year: Aciclovir 400mg twice daily
Saltwater baths, topical petroleum jelly, oral analgesia and topical lidocaine gel can be used for pain control.
- Full STI Screen
- No need for contact tracing, but patients should be advised to refrain from sex when have lesions and disclose in relationships. Condoms can reduce the rate of spread and should be encouraged.
Trichomoniasis (Trichomonas vaginalis) presentation
Females: Vaginal discharge (thin, frothy yellow coloured with a ‘fishy’ smell), vulval pruritus, vulvovaginitis, dysuria, dyspareunia
Males: urethral discharge, dysuria, balanitis
Trichomoniasis (Trichomonas vaginalis) treatment
Metronidazole 2g oral as a single dose or 400-500mg twice daily for 5-7 days (note alcohol should be avoided during treatment and for 72 hours afterwards)
A full STI screen including blood tests should be performed. Contact tracing and partner notification need to be offered.
Advise that all forms of sexual intercourse need to be avoided until both parties are tested and treated. Test of cure is not routinely required.
Nutrition in pregnancy
Vitamin D recommendation?
women with darker skin (such as those of African, African–Caribbean or South Asian family origin
women who have limited exposure to sunlight, such as women who are housebound or confined indoors for long periods, or who cover their skin for cultural reasons.
Gestation date scan
10 weeks 0 days and 13 weeks 6 days to determine gestational age and to detect multiple pregnancies
Date of Abnormality scan
normally between 18 weeks 0 days and 20 weeks 6 days.
Routine screening in pregnancy
Anemia
Testing for blood group and rhesus D status in early pregnancy (antenatal anti‑D prophylaxis is offered to all non‑sensitised pregnant women who are rhesus D‑negative)
sickle cell diseases and thalassaemias, including carrier status ((ideally by 10 weeks)
Down’s syndrome (‘combined test’ (nuchal translucency, beta‑human chorionic gonadotrophin, pregnancy‑associated plasma protein‑A) (11 weeks 0 days and 13 weeks 6 days)
Asymptomatic bacteriuria by midstream urine culture early in pregnancy
Serological screening for hepatitis B virus
HIV infection
Screening for syphilis should be offered to all pregnant women
Routine screening in pregnancy is NOT offered for
BV Chlamydia Cytomegalovirus Fragile X Hep C Group B strep Toxoplamosis
Gestational Hypertension
pregnant women at high and moderate risk of pre-eclampsia - prescribe?
50 mg of aspirin1 daily from 12 weeks until the birth of the bab
Factors that = High risk of Pre-eclampsia
- hypertensive disease during a previous pregnancy
- chronic kidney disease
- autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome
- type 1 or type 2 diabetes
- chronic hypertension.
Factors that = Moderate risk of Pre-eclampsia
1 + first pregnancy age 40 years or older pregnancy interval of more than 10 years BMI of 35 kg/m2 or more at first visit family history of pre-eclampsia multi-fetal pregnancy.
Target blood pressure in pregnancy (women on BP med)
135/85 mmHg or less.
Chronic hypertension in pregnant women - Treat?
1st line labetalol
2nd line nifedipine
3rd line methyldopa
BP in pregnancy to admit?
BP to give Labetalol
160/110
140/90
Postpartum hemorrhage?
what is Minor
Major (moderate and severe)
minor (500–1000 ml) or major (more than 1000 ml). Major could be divided to moderate (1000–2000 ml) or severe (more than 2000 ml).
Causes of Postpartum hemorrhage?
4 T’s
Tone - (multiple pregancy,prolonged labour, prior haemoraage, large baby)
Trauma - (ie Episiotomy)
Tissue - retained tissue ie placenta acretia
Thromin
Urine atony management
Fundus massage, IV synmaticn (cause contractions) TXA, Intrauterine balloon tamponade worse case = hysterectomy
RF for pre-eclampsia
age 40 years or older nulliparity pregnancy interval of more than 10 years family history of pre‑eclampsia previous history of pre‑eclampsia body mass index 30 kg/m2 or above pre‑existing vascular disease such as hypertension pre‑existing renal disease multiple pregnancy.
Pre eclampsia presentation
Can present w/
severe headache
problems with vision, such as blurring or flashing before the eyes
severe pain just below the ribs
Vomiting
sudden swelling of the face, hands or feet.
Thresholds for considering planned early birth in pre-ecampsia
inability to control maternal BP despite using 3 or more classes of antihypertensives in appropriate doses
maternal pulse oximetry less than 90%
progressive deterioration in liver function, renal function, haemolysis, or platelet count
ongoing neurological features, such as severe intractable headache, repeated visual scotomata, or eclampsia
placental abruption
reversed end-diastolic flow in the umbilical artery doppler velocimetry, a non-reassuring cardiotocograph, or stillbirth.
What is HELLP
(haemolysis, elevated liver enzymes and low platelet count)
HELLP
Presents with tired, retaining fluid, headache, nausea, upper right abdominal pain, blurry vision, nosebleeds, and seizures.
Complications may include disseminated intravascular coagulation, placental abruption, and kidney failure
he only current recommended and most effective treatment is delivery of the baby, as the signs and symptoms diminish and gradually disappear following the delivery of the placenta.
Advise continuous cardiotocography if any of the following risk factors are present at initial assessment or arise during labour:
maternal pulse over 120 beats/minute on 2 occasions 30 minutes apart
temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive occasions 1 hour apart
fresh vaginal bleeding that develops in labour
severe hypertension: 160/110
contractions that last longer than 60 seconds (hypertonus), or more than 5 contractions in 10 minutes (tachysystole)
oxytocin use.
Reading CTG
baseline rate - reassuring = 110 to 160 beats/minute - non-reassuring: (100 to 109 or 161 to 180 beats/minute) - abnormal: below 100 beats/minute or above 180 beats/minute.
baseline variability - reassuring = 5 to 25 beats/minute, non-reassuring:less than 5 beats/minute for 30 to 50 minutes or more than 25 beats/minute for 15 to 25 minutes - abnormal:less than 5 beats/minute for more than 50 minutes, more than 25 beats/minute for more than 25 minutes or sinusoidal.
presence or absence of decelerations, and concerning characteristics of variable decelerations if present (see decelerations)
presence of accelerations - the presence of fetal heart rate accelerations, even with reduced baseline variability, is generally a sign that the baby is healthy
Shoulder dystonia Risk factors
you have had shoulder dystocia before you have diabetes
your body mass index (BMI) is 30 or more your labour is induced
you have a long labour
you have an assisted vaginal birth (forceps or ventouse).
Shoulder dystonia Management
reposition you to give your baby more room inside the vagina; you will be asked to lie on your back with your legs pushed outwards and up towards your chest (this is known as the McRoberts manoeuvre)
Screw = 2nd line
Consider making a cut (episiotomy) to enlarge the vaginal opening.
Shoulder dystonia Complications
Maternal - Vaginal tears -> postpartum haemorrhage
Fetal -> Brachial plexus injury (BPI), which may cause loss of movement to the arm. The most common type of BPI is called Erb’s palsy. It is usually temporary and movement will return within hours or days. Permanent damage is rare.
What is Hydrosalpinx?
How does this present?
The fallopian tube is blocked and fills with serous or clear fluid near the ovary -> major cause for distal tubal occlusion is pelvic inflammatory disease (PID), usually as a consequence of an ascending infection by chlamydia or gonorrhea
Ovarian Mass
Present and investigations
Can present with pain, bleeding, bloating
Diagnosis – USS, Ca-125, CT, fine needle biopsy - If follicular cyst -repeat in 6weeks to see if cyst has reduced
small (less than 50 mm diameter) simple ovarian cysts
- Management
generally do not require follow-up as these cysts are very likely to be physiological and almost always resolve within 3 menstrual cycles.
simple ovarian cysts of 50–70 mm in diameter- management
should have yearly ultrasound follow-up and those with larger simple cysts should be considered for either further imaging (MRI) or surgical intervention.
Endomterial polpys
Presentation
RF
Investigations
Presents - Irregular menstrual bleeding, infertility, Bleeding between menstrual periods
RF - Being perimenopausal or postmenopausal, Having high blood pressure (hypertension), Being obese, Taking tamoxifen, a drug therapy for breast cancer
Investigating - history/exam, TVUSS, biopsy
Diabetic pregnancy RF
Risk factors for gestational diabetes
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Screening for gestational diabetes
women who’ve previously had gestational diabetes: oral glucose tolerance test (OGTT) should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
women with any of the other risk factors should be offered an OGTT at 24-28 weeks
Diagnostic thresholds for gestational diabetes
these have recently been updated by NICE, gestational diabetes is diagnosed if either:
fasting glucose is >= 5.6 mmol/l
2-hour glucose is >= 7.8 mmol/l
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 selfmonitoring 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
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 6-6.9 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
Management of pre-existing diabetes
weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation
aspirin 75mg/day from 12 weeks until the birth of the baby, to reduce the risk of pre-eclampsia
detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy
Placental abruption
Causes
Cause - not known but associated factors: proteinuric hypertension cocaine use multiparity maternal trauma increasing maternal age
Placental abruption clinical features
Clinical features shock out of keeping with visible loss pain constant tender, tense uterus normal lie and presentation fetal heart: absent/distressed coagulation problems
Placental abruption Management
Fetus alive and < 36 weeks
fetal distress: immediate caesarean
no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Fetus alive and > 36 weeks
fetal distress: immediate caesarean
no fetal distress: deliver vaginally
Fetus dead
induce vaginal delivery
Chorioamnionitis
ascending bacterial infection of the amniotic fluid / membranes / placenta
The major risk factor in this scenario is the preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens.
Prompt delivery of the foetus (via cesarean section if necessary) and administration of intravenous antibiotics is widely considered the mainstay of initial treatment for this condition.
Induction of labour
Indications
prolonged pregnancy, e.g. > 12 days after estimated date of delivery
prelabour premature rupture of the membranes, where labour does not start
diabetic mother > 38 weeks
rhesus incompatibility
Method membrane sweep intravaginal prostaglandins breaking of waters oxytocin
C-sec indications
Indications (apart from cephalopelvic disproportion/praevia, most are relative) absolute cephalopelvic disproportion placenta praevia grades 3/4 pre-eclampsia post-maturity IUGR fetal distress in labour/prolapsed cord failure of labour to progress malpresentations: brow placental abruption: only if fetal distress; if dead deliver vaginally vaginal infection e.g. active herpes cervical cancer (disseminates cancer cells)
Serious Risks of C-section
Maternal: emergency hysterectomy need for further surgery at a later date, including curettage (retained placental tissue) admission to intensive care unit thromboembolic disease bladder injury ureteric injury death (1 in 12,000)
Future pregnancies:
increased risk of uterine rupture during subsequent pregnancies/deliveries
increased risk of antepartum stillbirth
increased risk in subsequent pregnancies of placenta praevia and placenta accreta)
Frequent risk of C-section
Maternal:
persistent wound and abdominal discomfort in the first few months after surgery
increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
readmission to hospital
haemorrhage
infection (wound, endometritis, UTI)
Fetal:
lacerations, one to two babies in every 100
HIV in pregnancy - reducing vertical transmission
Factors which reduce vertical transmission (from 25-30% to 2%) maternal antiretroviral therapy mode of delivery (caesarean section) neonatal antiretroviral therapy infant feeding (bottle feeding)
HIV pregnancy - mode of delivery
Mode of delivery
vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
a zidovudine infusion should be started four hours before beginning the caesarean section
HIV - Neonatal antiretroviral therapy
Neonatal antiretroviral therapy
zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.
Infant feeding
in the UK all women should be advised not to breast feed
Risk factors for incompetent cervix i
Short cervical length
Prior miscarriage
Prior preterm delivery
Prior D&C procedure (dilation and curettage), which is a procedure used to clear the uterine lining after a miscarriage or pregnancy termination. It can also be used to diagnose and treat certain uterine conditions.
Prior loop electrosurgical excision procedure (LEEP) to remove abnormal/potentially cancerous cells from the cervix.
History of other surgical procedures involving the cervix
Diagnosis of incompetent cervix in a previous pregnancy
Twins or multiples pregnancy
Injury from a previous childbirth (obstetric trauma) during which the cervix was torn
Repeated or late-term abortion
Uterine abnormalities and anomalies
Exposure to the drug diethylstilbestrol (DES), a synthetic form of the hormone estrogen
Late Intrauterine death diagnosis
Auscultation and cardiotocography should not be used to investigate suspected IUFD.
Real-time ultrasonography is essential for the accurate diagnosis of IUFD.
Ideally, real-time ultrasonography should be available at all times.
Late Intrauterine death tests
Maternal standard haematology and biochemistry including CRPs and bile salt (Pre-Eclampsia)
Kleihauer - Anti-D
Parents should be offered full postmortem examination to help explain the cause of an IUFD.
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_55.pdf
oligohydramnios
reduced amniotic fluid. Definitions vary but include less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile.
Causes premature rupture of membranes fetal renal problems e.g. renal agenesis intrauterine growth restriction post-term gestation pre-eclampsia
Fetal growth restriction (FGR
when a pathological process has restricted genetic growth potential. This can present with features of fetal compromise including reduced liquor volume (LV) or abnormal doppler studies.
The likelihood of FGR is higher in a severe SGA fetus.
Small for gestational age (SGA)
an infant with a birth weight <10th centile for its gestational age.
Severe SGA – a birth weight < 3rd centile.
Small for gestational age (SGA) RF
Maternal age >40 Smoker ≥11/day Previous SGA baby Maternal/paternal SGA Previous stillbirth Daily vigorous exercise Heavy bleeding Low PAPP-A^
Small for gestational age (SGA) Management
Management
Prevention
Modifiable risk factors should be managed to help prevent SGA, including promoting smoking cessation and optimising maternal disease.
Women at high risk for pre-eclampsia should be started on 75mg of aspirin 16 weeks gestation until delivery.
Surveillance
UAD should be the primary surveillance tool in the SGA fetus. If it is normal repeat every 14 days. If it is abnormal repeat more frequently or consider delivery.
Other tests useful in surveillance include symphysis fundal height (SFH), middle cerebral artery (MCA) Doppler, ductus venosus (DV) Doppler, cardiotocography (CTG) and amniotic fluid volume.
Delivery
If delivery is being considered between 24 and 35+6 weeks gestation a single course of antenatal steroids should be given.
The table below demonstrates the indications for delivery by gestation and the recommended mode of delivery.
Small for gestational age (SGA) complications
Neonatal complications Long-term complications
Birth asphyxia Cerebral palsy
Meconium aspiration Type 2 diabetes
Hypothermia Obesity
Hypo-/hyperglycaemia Hypertension
Polycythaemia. Precocious puberty
Retinopathy of prematurity Behavioural problems
Persistent pulmonary hypertension Depression
Pulmonary haemorrhage Alzheimer’s disease
Necrotising enterocolitis
• Kallman syndrome presentation
elayed or absent puberty and an impaired sense of smell. This disorder is a form of hypogonadotropic hypogonadism, which is a condition resulting from a lack of production of certain hormones that direct sexual development.
Signs and symptoms of Kallmann syndrome
Undescended, or partially descended, testicles.
Small penile size.
Facial defects, such as cleft lip or palate.
Short fingers or toes, especially the fourth finger.
Development of only one kidney.
Hearing loss.
Color blindness.
Abnormal eye movements.
• Kallman syndrome treatment
treatment for both males and females with KS/CHH normally consists of one of three options which can be used for both hormone replacement therapy and/or fertility treatment.[2][3]
Sex hormone replacement (testosterone or oestrogen & progesterone).
Gonadotropin therapy (medications that replicate the activity of FSH and LH).
GnRH pulsatile therapy.
Vulva Vestibulitis
increased sensitivity to pain at the opening of the vagina (vestibule), making even gentle touch or stimulation painful.
Usual symptoms of vulvar vestibulitis include pain, soreness, burning, and a feeling of rawness that is aggravated by stress, exercise, tight clothing, coitus, and tampon use.
Lifestyle changes may help reduce symptoms:
wear cotton underwear and loose-fitting skirts or trousers
avoid scented hygiene products, such as feminine wipes, bubble bath and soap (an emollient is a good substitute for soap)
apply cool gel packs to your vulva to soothe the pain
use petroleum jelly before swimming to protect the vulva from chlorine
antidepressants called amitriptyline and nortriptyline – possible side effects include drowsiness, weight gain and dry mouth
anti-epilepsy medicines called gabapentin and pregabalin – possible side effects include dizziness, drowsiness and weight gai
Ectopic pregnancy presentation
Typically history of 6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later. Shoulder tip pain and cervical excitation may be present
Hydatidiform mole presentation
Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high
Placental praevia presentation
Vaginal bleeding, no pain. Non-tender uterus* but lie and presentation may be abnormal
Vasa praevia presentation
Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen
Vasa praevia management
In the presence of confirmed vasa praevia in the third trimester, elective caesarean section should ideally be carried out prior to the onset of labour.
The ultimate management goal of confirmed vasa praevia should be to deliver before rupture of membranes while minimising the impact of iatrogenic prematurity. Based on available data, planned caesarean delivery for a prenatal diagnosis of vasa praevia at 34–36 weeks of gestation is reasonable in asymptomatic women.
Administration of corticosteroids for fetal lung maturity should be recommended from 32 weeks of gestation due to the increased risk of preterm delivery.
Placental praevia management
ASYMPTOMATIC -
●Determine whether the previa resolves with increasing gestational age
●Determine whether the placenta is also morbidly adherent (placenta accreta)
●Reduce the risk of bleeding
●Determine the optimal time for planned cesarean delivery if the previa persists
Monitoring placental position = placental position is indicated in women whose placental position covers or is <2 cm from the internal os on a second-trimester ultrasound examination.
At the 36-week follow-up examination:
•If the placental edge covers the internal os, cesarean delivery is scheduled. (See ‘Timing of delivery’ below.)
•If the placental edge does not cover but is <2 cm from the internal os, the risks and benefits of a trial of labor should be discussed with the patient. The risk of bleeding increases as the distance between the placental edge and internal os decreases and if vasa previa is present
Obstetric cholestasis
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
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
Acute fatty liver of pregnancy
Acute fatty liver of pregnancy is rare complication which may occur in the third trimester or the period immediately following delivery.
Features abdominal pain nausea & vomiting headache jaundice hypoglycaemia severe disease may result in pre-eclampsia
Investigations
ALT is typically elevated e.g. 500 u/l
Management
support care
once stabilised delivery is the definitive management
Pelvic tuberculosis
Pelvic tuberculosis is an infectious disease caused by the bacterium Mycobacterium tuberculosis (MTB) (95%) or Mycobacterium bovis (5%).
The antibiotics most commonly used are isoniazid, rifampicin, para-amino-salicylic acid (PAS) and streptomycin derivatives, and treatments can be prolonged, taking several months.
Müllerian agenesis,.
Mayer–Rokitansky–Küster–Hauser syndrome (MRKH) or vaginal agenesis, is a congenital malformation characterized by a failure of the Müllerian duct to develop, resulting in a missing uterus and variable degrees of vaginal hypoplasia of its upper portion.
= primary amenorrhea with otherwise typical growth and pubertal development.
Primary vaginal elongation by dilation is the appropriate first-line approach in most patients because it is safer, patient-controlled, and more cost effective than surgery.
VBAC risks
Risk of uterine rupture – 0.5% (higher if VBAC and induced)
5% risk of anal sphincter injury
Risk of maternal death – 4 in 100,000
VBAC management
hospital setting
Avoid induction
decisions about both induction and augmentation require input from a senior obstetrician.
After 39 weeks an elective repeat caesarean is recommended delivery method.
VBAC Contraindications
Absolute – classical caesarean scar, previous uterine rupture and any other contraindications for vaginal birth that apply to the clinical scenario (for example placenta praevia).
Relative – complex uterine scars or >2 prior lower segment Caesarean sections.
breech management
ECV at 36weeks
still breech = breech vaginal or elective C-sec
Vaginal breech delivery
higher mortality
However, occasionally the baby does not deliver spontaneously, and some specific manoeuvres are required:
Flexing the fetal knees to enable delivery of the legs.
Using Lovsett’s manoeuvre to rotate the body and deliver the shoulders.
Using the Mauriceau-Smellie-Veit (MSV) manoeuvre to deliver the head by flexion.
A contraindication to vaginal breech delivery is footling breech, as the feet and legs can slip through a non-fully dilated cervix, and the shoulders or head can then become trapped.
RF for ovarian cancer
Nulliparity Early menarche Late menopause Hormone replacement therapy containing oestrogen only Smoking Obesity
Simple ovarian cyst
Only contains FLUID
Complex ovarian cyst
can be irregular and can contain solid material, blood or have septations or vascularity.
Serous cystadenoma
Benign Neoplastic
reflects the most common type of malignant ovarian tumour and is usually unilocular with up to 30% being bilateral.
Mucinous cystadenoma –
Benign Neoplastic
these are often multiloculated and usually unilateral.
Brenner tumour –
Benign Neoplastic
unilateral with a solid grey or yellow appearance.
Mature cystic teratoma (Dermoid cysts)
10% are bilateral, usually occur in young women and occur frequently in pregnancy. As germ cell in origin they can contain teeth, hair, skin and bone.
Ovarian Fibroma
the most common stromal tumour. Important to know about as up to 40% present with Meig’s syndrome which is the association between these tumours and ascites/pleural effusion.
Meig’s syndrome
benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor.
Trachelectomy
What is this
Indications
Removal of the cervix, upper vagina and parametrium (tissue surrounding the cervix).
Optimal treatment for women of age ≤40 years with a desire to preserve fertility and stage IA2 or mild stage IB1 disease
Remains FERTILE (higher risk pregnancy)
Pelvic organ prolapse - RF
Risk factors increasing age multiparity, vaginal deliveries obesity spina bifida
Pelvic organ prolapse presentation
Presentation
sensation of pressure, heaviness, ‘bearing-down’
urinary symptoms: incontinence, frequency, urgency
Pelvic organ prolapse management
Management
if asymptomatic and mild prolapse then no treatment needed
conservative: weight loss, pelvic floor muscle exercises
ring pessary
surgery (vaginal hysterectomy, with or without vaginal sacrospinous fixation with sutures or vaginal sacrospinous hysteropexy with sutures or Manchester repair)
Consider vaginal oestrogen for women with pelvic organ prolapse and signs of vaginal atrophy.
Urinary incontinance - Indications for referral to a specialist service
In women with urinary incontinence, indications for consideration for referral to a specialist service include:
persisting bladder or urethral pain
palpable bladder on bimanual or abdominal examination after voiding
clinically benign pelvic masses
associated faecal incontinence
suspected neurological disease
symptoms of voiding difficulty
suspected urogenital fistulae
previous continence surgery
previous pelvic cancer surgery
previous pelvic radiation therapy. [2006]
Risk factors for cord prolapse
prematurity multiparity polyhydramnios twin pregnancy cephalopelvic disproportion abnormal presentations e.g. Breech, transverse lie placenta praevia long umbilical cord high fetal station
Management of cord prolapse,
immediately escalate
the presenting part of the fetus may be pushed back into the uterus to avoid compression. Tocolytics may be used.
Women on all fours - until preparations for an immediate caesarian section have been carried out.
Phyllodes Tumour features
This is rare (1% of breast tumours)
Composed of epithelial and stromal tissue which grows in a “leaf-like pattern”.
Other forms of breast tumour include mucinous, tubular, papillary and lymphoma.
Management of ER positive tumours
Treat with Tamoxifen (oestrogen receptor antagonist) if premenopausal or Anastrozole (aromatase inhibitor) if postmenopausal.
Side effects of Tamoxifen
Increased risk of DVT/PE
Increased risk of endometrial cancer – the drug is a weak agonist on endometrial tissue
Other inadvertent beneficial effects includes reduced risk of cardiovascular disease and osteoporosis.
Fibroadenoma of the breast
Common features include:
Young age of presentation (peaking in early 20s) Firm, non-tender mass Rounded with smooth edges Highly mobile Normally don't grow beyond 3cm
Lactational Breast abscess
Clinical Features
Fever or rigors
Malaise
Pain and erythema over an area of the breast
There may a fluctuant mass present, but this is not always palpable.
History of recent or current mastitis
Management
Incision and drainage or needle aspiration (with or without diagnostic ultrasound)
Amstel Criteria for Bacterial Vaginosis
In order to diagnose bacterial vaginosis, the Amstel criteria are used. Three out of four features are needed to confer a diagnosis:
Vaginal pH >4.5
Homogenous grey discharge
Whiff test - 10% potassium hydroxide produces fishy odour
Clue cells present on wet mount
Chancroid
Chancroid is a condition characterised by a painful, potentially necrotic genital lesion. Associated symptoms include painful lymphadenopathy and bleeding on contact.
caused by infection with Haemophilus Ducreyi
The infection is treated using Ciprofloxacin and Ceftriaxone.
Chlamydia infection
Treatment is either by using doxycycline BD for 7 days or Azithromycin 1g single dose. There is no need for a test of cure.
Candida infection is associated with
pregnancy, antibiotic use and immunosuppression
Trichomoniasis
profuse, frothy, yellow vaginal discharge. There can also be vulval irritation and dyspareunia present.
Diagnosis: Direct microscopy and culture
Treatment: Metronidazole (PO state or BD for 7 days), follow up in one week, screen sexual contacts.
Absolute Contraindications to Contraception (UKMEC 4)
Known or suspected pregnancy, smoker over the age of 35 who smokes >15 cigarettes, obesity, breast feeding <6 weeks post partum, Fx of thrombosis before 45 years old, breast cancer or cancer within last few years, BRCA genes
Features of the Contraception injection
It can last for 12 weeks, can be used when breast feeding, and the patient does not have to remember to adhere to a treatment regimen.
The patient’s periods can stop, become irregular or last longer. It is associated with weight gain also, and is the only contraceptive option whereby a patient may take time to return to fertility (6-12 months).
Contraceptive implant
Features
It works for 3 years but can be taken out sooner. When removed, fertility returns to normal quickly.
It is the contraceptive of choice for girls aged 16 and below, as it does not require daily adherence to a medication regimen.
Periods may stop, become irregular or last longer. Acne may occur or worsen.
It is important to warn the patient that a small procedure is required to fit and remove the implant, and a local anaesthetic should be used in order to fit the device
There may be some tenderness, bruising and swelling at the site of implantatio
Ellaone as an Emergency contraceptive (features)
Ellaone works by inhibiting ovulation. It can be taken within 5 days of UPSI.
It is contraindicated in liver disease and asthma. Breast feeding must be avoided for one week after taking the medication.
It can cause painful periods, mood swings and back pain.
If the patient vomits within 3 hours, she will need to see the doctor again as the pill will not have been absorbed.
Clinical features of HSV
After an incubation period of around 1-2 weeks, the patient may present with multiple painful genital ulcers. These can then crust and heal, at which point virus ceases to be shed from the lesions. Atypical presentations include small erosions or fissures, dysuria, fever,malaise, headache and urinary retention.
Recurrent episodes are considered less severe than a primary episode. There may not be a clearly identifiable trigger. The recurrent episode may have a prodromal phase, such as tingling in the sciatic nerve.
Management genitical herpes
Oral antivirals are the primary treatment for genital herpes simplex infection — treatment should commence within 5 days of the start of the episode, or while new lesions are forming for people with a first clinical episode of genital herpes simplex virus (HSV).
Treatment should be started for established HIV infection when:
CD4+ <350
AIDS diagnosis
Serious bacterial infection with CD4+ <200
HIV related co-morbidity irrespective of CD4 count (HIV associated neuropathy, ITP)
Non AIDS defining malignancies requiring immunosuppressive radiotherapy or chemotherapy
Co-infection with Hep B or Hep C if CD4+ <500
Reduction of transmission, if CD4>350 and there is a wish to start cART
Features of the IUS
Irregular bleeding or spotting is common in the first 6 months, periods may stop altogether. There is a small risk of infection during first 20 days after insertion. The patient may get ovarian cysts.
If fitted after 45, it can stay in place until menopause. Women are also taught to check the IUS is in place.
It is useful for women who experience heavy or painful periods.
Jarisch-Herxheimer Reaction
Jarisch-Herxheimer reaction is a classical reaction to penicillin treatment in syphilis infection, characterized by fever, rash, rigors and tachycardia.
It is thought that as the bacteria are lysed by the antibiotic, they secrete an endotoxin which can cause an inflammatory response
It does not occur in all cases, but it is imperative to warn patients that this may occur during treatment.
Lymphogranuloma Venereum
Chlamydia trachomatis serovars L1/L2/L3 cause lymphatic destruction of genital tissues,leading to a painless non-indurated lesion on the penis, followed by the ‘Groove sign’. This is swelling of the inguinal ligament, leading to noticeable grooves above and below.
Management of missed pills
If vomiting within 2 hours of taking a pill, another one should be taken as soon as possible.
The pill free week is the 7 days between taking packets of pills. There is occasionally a breakthrough bleed, a small bleed similar to a period, however the absence of a breakthrough bleed does not indicate pregnancy.
Missed pill rules:
If pills are missed in week 1: use emergency contraception if she had UPSI in pill free interval for 1 week
If pills are missed in week 2: no need for emergency contraception
If pills are missed in week 3: Take the last pill that was missed, finish the current pack and start the next pack immediately after.
Pelvic inflammatory disease
The diagnosis is made clinically.
Symptoms include: bilateral abdominal pain, discharge, post coital bleeding.
Signs include: Adnexal tenderness, cervical motion tenderness on bi-manual, fever
10% of patients present with RUQ, which is secondary to inflammation of the liver capsule, also known as Fitz Hugh Curtis syndrome
Pneumocystis Pneumonia
The patient can present with:
Fever
Non productive cough (however can have superimposed bacterial infection)
Exertional breathlessness associated with onset of infection
Exertional breathlessness is a specific sign for PCP, and is used to stratify severity.
On examination, the chest is often clear, however sometimes there are end inspiratory crackles present.
Investigations in PCP
In PCP (pneumocystis pneumonia), chest X-ray commonly shows bilateral bihilar interstitial infiltrates. In 10% of cases there can be a completely normal Chest X-Ray.
If a Chest X-ray is normal and PCP is suspected, a high resolution CT can be requested, to look for cysts and nodules.
The definitive diagnostic investigation is using bronchoscopy associated with bronchoalveolar lavage. Induced sputum samples can be used, but this is a less specific diagnostic investigation.
Samples are stained using Grocott’s stain, and lead to the characteristic ‘‘Mexican hats’’ appearance.
Management of PCP
Treatment is based on clinical or radiological evidence of infection or clinical indicators of general immune deficiency.
The first choice agent in the treatment of PCP, regardless of severity, is Co-trimoxazole
Alternative therapy can be used if Co-trimoxazole does not eliminate infection. This includes Clindamycin-primaquine, dapsone, IV pentamidine.
If the patient has p02 <9.3kPa and an arterial alveolar 02 gradient >4.7kPa, is it important to consider adjuvant corticosteroids. This has a proven reduction of mortality.
Clinical settings where HIV testing is routine
GUM/Sexual health clinics Antenatal services Termination of pregnancy services Drug dependency services Suspected TB, Hep B, Hep C and lymphoma
Single penile ulcers
Single penile ulcers are most commonly caused by primary syphilis. These are painless in nature, with an indurated base.
Other causes of a single penile ulcer include carcinoma, circinate balanitis, lichen sclerosus, LGV, Donovanosis and self inflicted trauma.
Primary syphilis features
Infection occurs 9-90 days after exposure. Lesions are found at the site of inoculation and are often genital or perianal. Lesions tend to be painless and solitary in nature. They are round with an indurated base, and heal within 3-10 weeks.
Secondary Syphilis features
Occurs 4-8 weeks after primary infection. It presents with a maculopapular symmetrical rash on the palms, legs, soles and face. There is also lymphadenopathy and ulcers present on the mucous membranes. Other less common features include malaise and fever
Tertiary Syphilis features
It is rare due to the advent of penicillin, but if found it must be treated with urgently. Tertiary features include syphilitic aortitis, tabes dorsalis, ocular manifestations such as Argyll-Robertson pupil and the presence of granulomatous-type lesions on the skin. If Tertiary Syphilis is confirmed, a CSF examination is indicated in order to test for CNS involvement.
Suitability for PEP
Raltegravir and Truvada
Receptive anal sex: PEP is recommended regardless of HIV status of partner
Insertive anal sex: PEP is considered if HIV status of partner is unknown, it is recommended if partner is HIV +ve
Oral sex with ejaculation: PEP is considered regardless of HIV status of partner
Oral sex without ejaculation:PEP is not recommended
Ejaculate in the eye: PEP is considered if partner is HIV+ve
choice of contracepion for epliespy
depo
multiple uniform smooth lesions present around the coronal margin of the glans.
pearly penile papules
Bartholins gland cyst:
occurs when the duct from the gland becomes blocked, resulting in palpable swelling and pain at the site of the Bartholin’s gland
abcess when this gets infected
Management
Incision and drainage: under local anaesthetic, the swollen gland is incised and allowed to drain. A Word catheter may also be inserted to promote continued drainage
Antibiotics in cases of abscess
Salt water baths may relieve pain
Surgery may be required in recurrent cases
Risk factors for cervial ancer
HPV 16 and 18 infection (accounts for 70% of cases)
Multiple sexual partners
Smoking
Immunosuppression (e.g. HIV or organ transplants)
The treatment for cervical cancer depends on the stage of the cancer, and also whether the woman wants to retain fertility.
For very small cancers in stage IA treatment can be treated by conisation with free margins if aiming to spare fertility. Conisation is done using a scalpel (cold-knife conisation), laser, or electrosurgical loop, and is usually performed as an outpatient.
Radical trachelectomy can be done for slightly more advanced, yet still early-stage cancers when the aim is to spare fertility. This involves removal of the cervix, the upper vagina and pelvic lymph nodes.
Where remaining fertile is not an aim a laparoscopic hysterectomy and lymphadenectomy is offered for women for early-stage cancer.
Dysmenorrhoea
investigation
Investigations
Rule out sexually transmitted infection
Examination for abdominal tenderness/mass, bimanual examination assessing for cervical tenderness
Pelvic ultrasound if investigations suggest pathology (e.g. fibroids, endometriosis)
Management
Dysmenorrhoea
Management Non-steroidal anti-inflammatory drugs (e.g. Ibuprofen, Mefenamic acid Combined oral contraceptive pill Progesterone-only pill Progesterone intrauterine device
Surgical Management of ectopic indications
The patient is in a significant amount of pain
There is an adnexal mass of size ≥35mm
B-hCG levels are ≥5000IU/L
Ultrasound identifies a foetal heartbeat
salpingectomy where the Fallopian tube containing the ectopic is removed
woman with only one functioning Fallopian tube, and they wish to remain fertile, a salpingotomy may be done where only the ectopic is removed.
Risk factors for endo cancer
Exposure to unopposed oestrogen leads to an increased risk of endometrial cancer. This can be in the form of
Nulliparity
Obesity
Early menarche
Late menopause
Polycystic ovary syndrome
Infertility
Definition
The diminished ability of a couple to conceive a child. This may result from a definable cause (e.g. ovulatory, tubal, or sperm problem), or may be unexplained failure to conceive over a 2-year period.
What are the normal chances of conceiving a child
Statistically a couple stands an 80% chance of conceiving within 1 year if:
The woman is <40yo
They do not use contraception
They have regular intercourse
The overall probability increases to 90% if considered over 2 years.
irreg menstural bleeding
causes
Causes Physiological (e.g. menarche or menopause) Genitourinary infection e.g. chlamydia Endometrial hyperplasia Endometrial or cervical cancer Fibroids Pregnancy
irreg menstural bleeding investigation
Investigations
Pelvic examination, including speculum examination +/- cervical smear if overdue
Pregnancy test
Pelvic ultrasound (if examination findings suggest e.g. fibroids)
Cervical biopsy if cervical smear abnormal +/- abnormal findings on examination
Endometrial biopsy if endometrial pathology is suspected
Investigation Menorrhagia
A full blood count should be done as a minimum to exclude iron deficiency anaemia.
Clotting studies should be performed if clinically indicated, such as bleeding elsewhere.
Trans-vaginal ultrasound should be considered to look for underlying causes such as fibroids or endometrial polyps.
Other tests for endocrine disease (e.g. TFTs) should only be done if clinically indicated
Greg periods Investigations
LH:FSH ratio: Increased (>2). This is also helpful in excluding menopause where the ratio is normal.
Total testosterone: normal/slightly raised
Fasting and oral glucose tolerance tests: helps diagnose insulin resistance.
Other tests that might be indicated if other pathologies are suspected include:
TFTs (thyroid dysfunction)
17-hydroxyprogesterone levels (CAH)
Prolactin (hyperprolactinaemia)
DHEA-S and free androgen index (androgen secreting tumours)
24-hour urinary cortisol (Cushing’s syndrome)
pcos Pharmacological treatment for women not planning pregnancy
Co-cyprindrol - Useful for reducing hirsutism and inducing regular menstruation.
Combined Oral Contraceptive Pill (COCP) - Used to reduce irregular bleeding and protects against endometrial cancer.
Metformin - Helps with menstrual regularity, hirsutism and acne.
pcos Pharmacological treatment for women wishing to conceive
lomiphene - Induces ovulation and improves conception rates.
Metformin - Can be used with/out clomiphene to increase the chances of a pregnancy.
Ovarian drilling - is a 2nd line laparoscopic surgical procedure where diathermy or laser is used to damage the hormone producing cells of the ovary.
Gonadotrophins - Can induce ovulation if clomiphene and metformin have failed.
Causes of primary amenorrhoea:
Constitutional Delay in puberty
Chromosomal or genetic abnormalities such as Turner syndrome (45 XO), Kallmann syndrome and androgen insensitivity syndrome.
Disruption of the functioning of the hypothalamic or pituitary glands. For example as a result of:
Anorexia and other eating disorders,
Excessive exercise
Extreme physical or psychological stress
Structural abnormalities of the genital tract such as:
Imperforate hymen obstructing menstrual flow (leading to haematocolpos)
Uterine agenesis
causes
Secondary amenorrhoea is the absence of menstruation for 6 months or longer in a woman with previously present menstrual cycles.
Causes
Pregnancy (most common cause) and breastfeeding
Menopause
Intrauterine adhesions causing outflow tract obstruction (Asherman’s syndrome)
Polycystic Ovary Syndrome (PCOS)
Drug-induced amenorrhoea (e.g. oral contraceptive)
Physical stress, excess exercise and weight loss
Pituitary gland pathology such as Sheehan syndrome or hyperprolactinaemia
Hypothyroidism or hyperthyroidism
Clinical features of vasa praevia (classic triad):
Painless vaginal bleeding
Rupture of membranes
Foetal bradycardia (or resulting foetal death)
Vulvar cancer may present as:
Lump with or without lymphadenopathy
Itching
Non-healing ulcer
Vulval pain
whirllpoor sign USS
ovarian torsion
size of fibroid to indicate surgery
over 3cm
Management of antepartum haemorrhage
first step in management of antepartum haemorrhage is always to assess the haemodynamic status. If haemodynamic compromise is present due to major haemorrhage resuscitation should be commenced
n almost all circumstances women with antepartum haemorrhage should be admitted to hospital for observation.
Haemorrhage may be concealed and thus the degree of blood loss visible per vaginum may be disproportionate to the actual loss of blood volume.
Intravenous access should be obtained and the following bloods should be obtained:
Group and save, crossmatch
Full blood count
Coagulation screen
Urea and electrolytes
LFTs
Kleihauer test should be taken in rhesus negative women to determine the dose of anti-D immunoglobulin required.
Ultrasound may be required to exclude placenta praevia and cardiotocography should be used to assess and monitor the foetus.
If there is risk of preterm birth and the woman is between 24 weeks and 34 weeks of gestation, antenatal corticosteroids should be offered to aid foetal lung maturation.
Absolute contraindications to External Cephalic Version
Caesarean section is already indicated for other reason
Ante-partum haemorrhage has occurred in the last 7 days
Non-reassuring cardiotocograph
Major uterine abnormality
Placental abruption or placenta praevia
Membranes have ruptured
Multiple pregnancy (but may be considered for delivery of the second twin)
Congenital Cytomegalovirus infection
Features at birth include
Low birth weight
Jaundice
Microcephaly
Seizures
Pneumonia
Petechial rash.
In first few years of life the neurological consequences of
Hearing loss
Visual impairment
Learning disability often become evident.
Congenital Rubella Syndrome
ewborns with CRS commonly present with sensorineural deafness, cataracts or retinopathy and congenital heart disease.
Other features include:
Organ dysfunction
Microcephaly
Micrognathia
Haematological abnormalities
Low birth weight
Later children may have developmental delay and learning disability
Neonates also may develop a characteristic petechial rash described as a “blueberry muffin” rash.
Congenital Toxoplasmosis
linical features in the infant
Clinical features in the infant include:
CNS problems such as cerebral palsy, epilepsy and hydrocephalus
learning disability
visual impairment
hearing loss
Management
The antibiotic spiramycin is used to treat toxoplasmosis during pregnancy and is thought to reduce transmission to the baby.
Contraindications to vaginal examination in preg
Undiagnosed vaginal bleeding i.e. if there is possibility of placenta praevia. Performing a digital examination in a woman with placenta praevia can provoke serious haemorrhage.
Preterm prelabour rupture of membranes without clear contractions. This is to avoid introducing ascending infection into the uterus.
Cord Prolapse
management
The foetus should be delivered as rapidly as possible, e.g. via an instrumental delivery, or if the cervix is not fully dilated, caesarean section
While preparing for delivery, prevent further prolapse by adopting a ‘knees-to-chest’ position
Filling the bladder with 500ml warmed saline can aid in preventing further prolapse
Avoid exposure and handling of the cord, reduce cord into the vagina
Tocolytics e.g. terbutaline to stop uterine contractions
Diabetes in pregnancy
Foetal complications
Macrosomia (birthweight >4kg). This is due to excess maternal blood glucose crossing the placenta and inducing increased neonatal insulin production. Macrosomia can increase the risk of shoulder dystocia, birth injuries and emergency Caesarean section.
Pre-term delivery, which may lead to respiratory distress syndrome.
Hypoglycaemia in the baby shortly after birth due to sustained high foetal insulin levels after delivery. Severe hypoglycaemic episodes may lead to seizures in the baby.
Increased risk of developing type 2 diabetes for the baby in later life.
Diabetes in pregnancy
Maternal complications
Maternal complications
Hypertension and pre-eclampsia
Increased risk of gestational diabetes in future pregnancies
Increased risk of developing type 2 diabetes later in life
Management of an eclamptic seizure involves the following steps:
Call for help and use an ABC approach (with airway support, adequate oxygenation and IV access)
Place the woman in a left lateral tilt position.
Give IV magnesium sulphate as soon as possible to help stabilise the cerebral membranes. This can be used as prophylaxis or treatment of eclampsia.
Once the mother is stable and the seizure has ceased the foetus should be monitored and plans for delivery should be made.
Management of epilepsy in pregnancy
Pre-pregnancy Management
Neurology review should be sought to assess existing anti-epileptic medication and aim for monotherapy (single drug regime). The lowest effective dose of the medication should be used.
Carbamazepine and lamotrigine are the safest anti-epileptic medications to use during pregnancy. Sodium valproate should be avoided in pregnancy as it carries the highest risk of congenital defects.
In general women with history of epilepsy but with no high risk of unprovoked seizures can be managed as low risk pregnancies and if no fits have occurred for at least 2 years consider stopping all medication.
Drug compliance must be emphasised and the woman should be advised to continue her medication through pregnancy.
All need to take 5mg/day of folic acid pre-conceptually until at least the end of the first trimester. This is to minimise the risk of neural tube defects and folate deficiency.
Management of epilepsy in pregnancy
Antenatal Management
All pregnant women with epilepsy should be under joint medical and obstetric care.
Plasma anti-epileptic drugs levels should be monitored regularly, as levels are likely to decrease with increasing plasma volume during pregnancy.
The foetus should be monitored throughout pregnancy for abnormalities with serial growth and anomaly scans.
Anti-epileptic regimes may inhibit foetal clotting factor production so vitamin K therapy should be given from 36 weeks’ gestation.
Pregnant women with epilepsy should be reassured that most will have an uncomplicated labour and delivery and that there are no specific differences in labour management compared to non-epileptic women.
If epileptic seizures do occur during labour, they should be terminated as quickly as possible with benzodiazepines in order to avoid maternal and foetal hypoxia.
Note that if a pregnant women with no previous diagnosis of epilepsy presents after the first trimester with seizures, the immediate management guidelines for eclampsia should be followed until a definitive neurological diagnosis can be made.
Factors affecting foetal growth
Maternal BMI and Nutritional status (including poor weight gain during pregnancy)
Co-morbidities such as diabetes, anaemia, hypertension, infection, sickle cell anaemia, pulmonary or cardiovascular disease, renal disease, coeliac disease
Cigarette smoking, alcohol and substance abuse
Structural uterine malformations
Foetal factors
Chromosomal defects
Multiple pregnancy
Vertically transmitted infection (e.g. CMV, rubella, toxoplasmosis)
Placental factors
Utero-placental insufficiency
Pre-eclampsia
Listeria Monocytogenes in pregnancy
When a pregnant mother is infected, the bacterium may be transmitted through the placenta or during delivery and cause in utero infection of the foetus.
Clinical features
Presentation is usually that of neonatal sepsis, meningitis, or respiratory distress due to aspiration of infected amniotic fluid. Manifestation of the infection may be early onset or late onset.
Infection can also lead to chorioamnionitis, premature labour and stillbirth.
Management
Antibiotic treatment involves ampicillin and an aminoglycoside.
Meconium aspiration syndrome
Clinical features
Signs to look for to aid recognition of meconium aspiration syndrome:
Presence of meconium stained liquor during rupture of membranes or at birth (greenish or yellowish appearance of the amniotic fluid)
Green staining of the infant’s skin, nail beds or umbilical cord
Signs of respiratory distress in the newborn (increased respiratory rate, grunting, cyanosis, noisy breathing, use of accessory muscles)
Limp infant or low APGAR score
Crackles on auscultation of the foetal lungs
Naegele’s rule
Naegele’s rule is used to calculate the EDD based on the first day of the woman’s last menstrual period (LMP).
The calculation is to add one year and seven days to the first day of the LMP and subtract three months.
This method may not be accurate in women with irregular or long cycles, or those who had recently been using the combined oral contraceptive pill.
Important to stress this is an ESTIMATE.
Oligohydramnios
causes
oligohydramnios is the presence of a lower than normal volume of amniotic fluid in the uterus.
Uteroplacental insufficiency leading tointrauterine growth restriction. This may be due to maternal disease such aschronic hypertension or pre-eclampsia, maternal smoking and placental abruption.
Abnormalities with the foetal urinary system(amniotic fluid is derived mainly from foetal urine). Examples include renal agenesis, polycystic kidneys or urethral obstruction.
Premature rupture of membranes
Post-term gestation
Chromosomal anomalies
Maternal use of certain drugs (prostaglandin inhibitors, ACE-inhibitors)
Complications of oligohydramnios
Oligohydramnios is the presence of a lower than normal volume of amniotic fluid in the uterus.
Complications of oligohydramnios are related to reduced “space” surrounding the foetus and that reduced amniotic fluid for foetal lung growth and development.
Complications due to space limitation and subsequent foetal compression include clubbed feet, facial deformity and congenital hip dysplasia.
Underdevelopment of the lung due to lack of amniotic fluid can result in pulmonary hypoplasia in the foetus. A combination of the above features is commonly known as Potter syndrome.
Hydrops foetalis
Diagnosis and Management of Hydrops foetalis
It can be diagnosed on ultrasound and management involves frequent monitoring of the foetus with foetal blood transfusions if necessary.
Perineal tears Third degree tear subtypes
3a: less than 50% of the thickness of the external anal sphincter is torn
3b: more than 50% of the thickness of the external anal sphincter is torn, but the internal anal sphincter is intact
3c: external and internal anal sphincters are torn, but anal mucosa is intact
Placental abruption
Risk factors
Maternal trauma for example assault, road traffic accident, iatrogenic
Pre-eclampsia or hypertension
Multiparity or increased maternal age
Polyhydramnios
Previous history of abruption
Substance abuse during pregnancy (particularly smoking and cocaine)
Existing coagulation disorders
Post-partum contraception
Intrauterine contraceptives - can be inserted at the time of delivery, or up to 48 hours after uncomplicated vaginal delivery or caesarean section. After 48 hours, insertion should be postponed until 28 days after childbirth.
Copper intrauterine device (Cu-IUD)
Levonorgestrel-releasing intrauterine system (LNG-IUS)
Progestogen injection - can be started at anytime after delivery
Progestogen implant - can be started at anytime after delivery
Progestogen-only pill (POP) - can be started at anytime after delivery
Lactational amenorrhoea = Can be used as effective contraception if the woman is fully breastfeeding, amenorrhoeic and is less than 6 months postpartum
Combined hormonal contraceptive pill (CHC) including pills, patches and vaginal rings - should not be started in the first three weeks postpartum. After this period, a risk assessment should be carried out for venous thromboembolism. COCP should not be prescribed to women with other risk factors for VTE within the first 6 weeks postpartum
Postnatal thromboprophylaxis
Those with four or more risk factors are usually recommended 6 weeks of postnatal thromboprophylaxis however individual risk assessment should be carried out.
Risk factors
Previous VTE Thrombophilia Medical comorbidities (e.g. cancer, heart failure, systemic inflammatory conditions) Age >35 BMI >30 Parity >3 Smoking Multiple pregnancy Pre-eclampsia Caesarean section Prolonged labour Operative delivery Preterm birth Stillbirth Postpartum haemorrhage >1000mL Other surgical procedure carried out Immobility Systemic infection
The causes of postpartum haemorrhage (PPH) may be remembered as the 4 ‘T’s.
Tone
The most common cause of PPH is uterine atony, which is the failure of the uterus to contract after delivery.
Trauma
PPH may come from a birth canal injury or tear. This risk is increased in instrumented deliveries.
Tissue
Retained placental or foetal tissue can lead to continued bleeding
Thrombin
Coagulopathies can lead to continued bleeding due to a failure of clotting.
Pregnancy of unknown origin
Investigations
Serial serum B-hCGs 48 hours apart can help give an indication of the location and prognosis of the pregnancy.
If the levels fall then it is suggested that the foetus will not develop or there has been a miscarriage.
If there is only a slight increase or a plateau in B-hCG levels then this may indicate an ectopic pregnancy.
A large increase in B-hCG suggests the foetus is growing normally intrauterine.
Pharmacological management of premature labour
Corticosteroids should be given to accelerate foetal lung maturation (betamethasone or dexamethasone).
Intravenous antibiotics should be given if there is increased risk of infection (evidence of Group B Streptococcus (GBS) in current or previous pregnancy, presence of maternal fever).
Penicillin is the antibiotic of choice if there is no allergy.
Tocolytic agents may be considered to buy time for administration of corticosteroids, but risk of side effects and benefits should be weighed up.
Nifedipine is the recommended first-line tocolytic agent.
Polymorphic eruption of pregnancy (PEP) features
PEP occurs most frequently in the third trimester and presents with itchy papules, typically first appearing on striae gravidarum, but may spread to the entire abdomen, thighs and buttocks. It may progress to a widespread eczematous rash with fluid-filled vesicles. PEP can be treated with emollients and and topical corticosteroids.
Rhesus isoimmunisation
The D antigen is found on red blood cells and is an important antigen in the rhesus factor system.
Rhesus isoimmunisation can occur when a rhesus negative mother has a baby which is rhesus positive. If any foetal red blood cells enter the maternal circulation, the mother will form anti-D antibodies against them.
The maternal anti-D antibodies can cross the placenta in subsequent pregnancies and cause Rhesus Haemolytic Disease if the future baby is rhesus positive.
Sensitisation events
Sensitisation” events are events which cause foetal blood to cross the placenta into the maternal circulation and thus these are indications for anti-D prophylaxis.
Examples of sensitisation events include:
Antepartum haemorrhage
Placental abruption
Abdominal trauma
External cephalic version
Invasive uterine procedures such as amniocentesis and chorionic villus sampling
Rhesus positive blood transfusion to a rhesus negative woman
Intrauterine death, miscarriage or termination
Ectopic pregnancy
Delivery (normal, instrumental or Caesarean section)
Risks of induction of labour
he induction may be unsuccessful and subsequently there may be need for emergency caesarean section
Uterine hyper-stimulation. Excessive contractions can lead to foetal bradycardia, and increase risk of uterine rupture and placental abruption.
Cord prolapse
Uterine rupture. There is a greater risk of this particularly in women with a past history of caesarean section or uterine surgery
Secondary Postpartum Haemorrhage
Secondary postpartum haemorrhage (PPH) is excess per vaginal bleeding occurring between 24 hours and 12 weeks afterbirth.
Causes
Causes include:
Endometritis (endometrial infection). This is often accompanied with offensive discharge and may be due to retained placental tissue leading to uterine atony.
Displacement of a retained blood clot
Poor healing of a perineal tear or genital tract trauma
Abnormal involution of the placental site
Choriocarcinoma (rare)
Medical termination of pregnancy (MTOP)
Comprises two ‘parts’
Mifepristone (‘First Part’): Progesterone receptor antagonist. Functions to inhibit the action of circulating progesterone, causing endometrial degeneration, cervical softening and increases the uterine sensitivity to prostaglandins.
Misoprostol (‘Second Part’): Prostaglandin analogue. Causes smooth muscle contractions of the myometrium, resulting in expulsion of uterine contents..
tocolytic agents
Uses
They are indicated in pre-term labour to delay delivery by a few days, usually to buy time for maternal steroids to work or allow transferal of the mother to the appropriate care unit.
Examples
There are several agents which can be used, for example:
Nifedipine (Calcium channel antagonist)
Atosiban (Oxytocin receptor antagonist)
Indomethacin (NSAID)
Terbutaline (beta-2-agonist)
Magnesium Sulphate may be administered for its foetal neuroprotective effects
Currently in the UK, nifedipine is recommended as the first line tocolytic agent.
Contraindications to tocolysis
eneral contraindications to tocolysis include:
Greater than 34 weeks gestation
Non-reassuring cardiotocograph, fatal foetal anomaly or intrauterine death
Intrauterine growth restriction or placental insufficiency
Cervical dilation greater than 4cm
Chorioamnionitis
Maternal factors such as pre-eclampsia, ante-partum haemorrhage, haemodynamic instability
Important considerations for VBAC to discuss with the mother
delivery (such as major placenta praevia).
VBAC usually has a success rate of around 60-80%. Thus, there is still a risk of having to perform an emergency Caesarean section. Risk is increased with increasing number of prior Caesarean deliveries.
There is an increased risk of uterine rupture during labour at the location of the scar
The mother will require close CTG monitoring during delivery at hospital.
Gum - a flagellated protozoan
Trichomonas Vaginalis,
Follicular cysts
commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
commonly regress after several menstrual cycles
Serous cystadenoma
the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
bilateral in around 20%
