gynaecology Flashcards
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Pregnancy advice after previous puerperium DVT
- increased risk of 20% for DVT in next pregnancy
- avoid oral contraception
- subsequent pregnancies should be managed in consultation with haematologist / specialist physician and obstetrician
- SCREEN for clotting propensity (thrombophilia screen) prior to next pregnancy: anticardiolipin antibody, lupus anticoagulant, protein S, protein C, anti-thrombin 3, factor V Leiden,
- if thrombophilia screen positive anticoagulants throughout pregnancy and puerperium.
- if no thrombophilia and no longer on anticoagulants can choose for only anticoagulants in puerperium ( until 4-6 weeks postpartum) or start in gestation week 14
- choose heparin or enoxaparin BD, followed by warfarin postpartum
- no warfarin as 5% teratogenic in 1e trimester and increased miscarriage rate, feral and maternal haemorrhage, neurological problems and stillbirth.
- avoid immobilisation, consider compression stockings,
- deliver in controlled manner at 38- 39 weeks, hold morning dose and start induction, restart after delivery.
Fundus greater than date
- multiple pregnancy
- macrosomic (maternal diabetes, maternal obesity, excessive weight gain)
- uterine fibroids
- polyhydramnios (fetal malformation CNS, GI, abdo wall, elsewhere; infection with CMV or toxo) (chorioangioma placenta)
- Can lead to malpresentation, PROM, premature labour, placental abruptio)
- see specialist in few days
- warn to present if thinks in labour even if early,
- speculum so see cervix may be indicated
- consider profylactic steroids for resp distress
- rule out diabetes even if glucose challange was negative
Post partum heamorrhage causes
- 80% uterine atony
- retained placenta
- abnormal placenta attachment
- coagulopathy
- genital tract laceration (vagina, cervix, uterine rupture)
- inversion uterus during (traction) placental delivery
- ‘HELLP’
Post partum heamorrhage work-up
- iv canula
- cross match
- LFT’s (HELLP), coags, EUC/creat/lactate consider for severe shock
- speculum examination
- US +/- CT after initial treatment
Post Partum heamorrhage management
ABC FIRST - iv line, cross match see work-up - N saline rapid infussion - O2 TONE: - massage fundus - ergometrine/oxytocin - urine urethral catheter to empty bladder - manually remove cloths / tissue LACERATION: - speculum examination - suture or pack Coagulopathy: - FFP, thrombo's CALL HEAMATO If ongoing bleeding --> theatre inspection under general
Alcohol abuse in pregnancy, complications
ALCHOHOL:
- miscarriage
- intra uterine growth restriction
- Fetal alcohol syndrome (: growth restriction, facial skeletal and cardiovascular defects, neurological dysfunctions (intellectual, behavioral, emotional, failure to thrive resulting in death)
- premature birth
–> refer to obstetrician, counsel, support etc, ensure every drink less is no further harm.
smoking in pregnancy, complications
one of worst correctable risk factors for adverse pregnancy outcomes nicotine and tar –> hypoxia, vasoconstriction, increased thickness villous membrane, decreased intervillous perfusion, carboxyhaemoglobin formation
- miscarriage (2x normal)
- Intra Uterine Growth Restiction
- placenta previa
- abruptio placentae
- PROM
- preterm birth
- chorioamnionitis
- still birth
- perinatal morbidity and mortality
- baby: anencephaly, congenital heart defects, orofacial clefts, SIDS, growth and intelect deficiencies, behavioural problems, respiratory (like pneumonia and asthma), ear infections
Avoid nicotine patches as toxic for fetus! Invole partner, counsel, support, inform etc. Every cigarette not smoked is no furhter harm, refer to obstetrician
Trophic vaginitis invx and management
vaginal dryness due to thinning or shrinking of mucosal tissue and decreased lubrication leading to chronic inflammation susceptible for infection, can have discharge or even blood stained discharge.
invx;
- pap smear
- MC&S swab
- transvaginal US to rule out endometrial cancer
- endometrial curettage or biopsy (consider after above)
- hormone levels to confirm menopause optional.
management:
- local oestrogen (pessaries, rings, cream, tablet)
- lubricants/moisurizing creams can work hours to one day
- water suluble vaginal lubricant during intercourse (not oil or petroleum based as may damage condom or increase infection change)
- avoid scented soaps, lotions or douches
- consider HRT if other menopause symptoms but inform of risks
fetal intra-uterine death definition and causes
< 20 weeks: spontaneous abortion > 20 weeks stillbirth most common causes in Australia: - unexplained 24% - maternal disease 17% (infection, PROM, early labour, coagulopathy, poor controlled glycaemia, antibodies, TFT) - major fetal anomaly 15% - multiple pregnancy 11%
still birth management
EMPATHY!!!
Delivery:
- give women choise of delivery or await spontaneous labour (max 3 weeks for risk of consumptive coagulopathy, often adviced earlier for emotional trauma)
- 3th trimester: oxytocin iv with or without cervical ripening with misoprostol
- 2nd trimester: Prostaglandin (eg misoprostol) vaginally
- <18 weeks D &C (ideally only to 16 weeks)
refer for counseling or peer support, let them hold baby as long as they want, suggest foto’s or lock’s of hair
still birth investigations
- photo’s of baby and placenta
- cord blood testing
- pathology and microbiology of placenta and cord
- Autopsy (if consent)
- Kleihauer test for meassuring fetomaternal haemorrhage
- urine toxicology
- FBE, LFT
- Coags + coagulation screen
- syphilis
- fasting glucose
- blood antibody screen
- TFT
Gestational diabetes management and diagnosis
fasting suger > 5.5, 2 hour level >8.0
- refer to (or consult with if remote) diabetiv physician
- first try with diet to control BGL <7.0 during the day, if not possible add insulin.
- 3-4 times/day BGL esp 2 hours after meal
- US at 32-34 weeks and SC if macrosomnic
- Weekly CTG, twice weekly if on insuline from 32-34 weeks (stillbirth risk)
- deliver no later than due date
- regular BGL during delivery
- check GTT every 5 years
primary amenorrhoea causes
to be included
Gestational diabetes risks
- DM later in live (counsel) (30%)
- Macrosomia
- fetal death in-utero
- Hyaline membrane disease (steroid can help lung development but worsens GD)
- pre-eclampsia
primary amenorrhoea investigation
- vulval inspection (no speculum if not sexually active) and tanner stage of breast and hair growth
- ultrasound: uterus and vagina
- hormones: FSH, LH, prolactin, oestradiol
if all is normal, review again in 12 months according to AMC clinical guide (i would do 6 months)
