Gynaecology Flashcards
Extra gynae questions to ask in ToP
Why do you want to go ahead with this?
How did you get pregnant?
How are you feeling about all of this?
ToP investigations
- No examination
* Confirm pregancy (TVUSS: measure crown-rump length to get gestational age)
ToP first trimester (<13 weeks) counselling
- You are x weeks pregnant
- We have medical and surgical options but medical would be best
- Mifepristone and misoprostol 24 hours apart - first one here then next at home
- Come back if vomiting within 2 hours
- Will also provide analgesia, antibiotics, pregnancy test, and STI screen to go home with
- Expect bleeding
- Pregnancy test 3 weeks later
- 5% can fail - we would offer further misoprostol or surgery
- Offer counselling
- Give leaflet with 24/7 mobile number etc.
ToP second trimester management
Mifepristone given 1 hour before
- Vacuum aspiration
- Dilation, evacuation(forcepts and instruments to crush the skull) and Curettage (scrape remaining tissue)
Done under GA
Give anti-D within 72 hours
ToP specific surgical complication
Asherman’s syndrome
Post-ToP contraception
Mirena - stops HMB, acts locally
Miscarriage investigations
Bedside, bloods, imaging approach
- Obs
- Abdominal examination - tenderness, guarding
- Speculum - cerival os, fluid
- Urine dipstick
- Urine b-hCG
• FBC, G&S (if bleeding)
- TVUSS
- Fetal doppler
Miscarriage counselling
- As you know, we did some tests and scans and wanted to talk to you about what’s been going on
- Anyone you would like with you?
- Unfortunately the tests are worrying and showing that you are having a miscarriage
- This is must be really difficult to process and we are here to support you all the way
- This is not your fault
- There is info (e.g. miscarriage association document) and counselling services we can offer
- Would you like to know how we will go ahead with this?
- Medical (vaginal or oral misoprostol)/surgical
- Analgesia
- Anti-emetics
Ectopic pregnancy investigations
Bedside, bloods, imaging approach
- Obs
- Abdominal examination
- Speculum
- Bimanual - cervical exciation
- Urine dip
- Urine hCG
- Bloods: FBC, U&E, LFT (Fitz-Hugh-Curtis if PID), bHCG, G&S, X-match
- TVUSS
Ectopic pregnancy initial counselling
- As you know, we did some tests and scans and wanted to talk to you about what’s been going on
- Anyone you would like with you?
- Unfortunately the tests are worrying and showing that a fertilised egg has grown in one of the tubes leading to your womb, which can’t develop any further into a complete pregnancy
- Are you okay to continue?
- We call this an ectopic pregnancy and it is not possible to save this pregnancy
- Worried about your health if this continues so we advise removing the pregnancy tissue
Ectopic expectant counselling
Low risk, haem stable, asymptomatic, decreasing bHCG
• Pregnancy tissue will dissolve by itself
• Regular blood tests to check hCG
• Some vaginal bleeding - use pads or towels
• Paracetamol for tummy pain
Ectopic medical management
- Methotrexate injection
- Regular blood tests
- If this doesn’t work - second dose or surgery
- May feel tummy pain, dizzy, nausea etc.
- Use contraception for at least 3 months after treatment as methotrexate can be harmful for baby if you become pregnant again
- Avoid alcohol as methotrexate can damage your liver
Ectopic surgical management
Surgery done if ruptured or haem unstable
- Keyhole surgery - thin viewing tube and small surgical instruments inserted through incisions
- Given anaesthetic
- If the other fallopian tube looks healthy, the entire fallopian tube with the pregnancy tissue will be removed
- Should be able to leave few days after surgery
• Offer counselling services
bHCG changes in early pregnancy
Rise of over 66% over 48 hours
Ectopic pregnancy risk factors
- PID
- Assisted conception
- Pelvic surgery
- Previous ectopic
- Smoking
- IUD
Molar pregnancy investigations
Bedside, bloods, imaging approach
• Pregnancy test
• Speculum
• Bimanual - no uterine or adnexal tenderness
- Serum hCG
- TVUSS - snowstorm/bunch of grapes
Molar pregnancy counselling
- As you know, we did some tests and scans and wanted to talk to you about what’s been going on
- Anyone you would like with you?
- Unfortunately the tests are worrying and show that you have a non-viable pregnancy, which means that this pregnancy does not have a chance of a baby being born
- Are you okay to continue?
- Not your fault and nothing you have done has caused this
- Sperm and egg haven’t fused properly
- Abnormal cells can grow as it’s stimulated by hormones
- Growth can damage the reproductive organs so best to remove it
- Done under GA using a small tube and suction
- Doesn’t affect future chance of getting pregnant, but can increase the risk of having another molar pregnancy so have to monitor
- Pregnancy test 3 weeks later
- Trophoblastic screening centre follow-up 6 months later
- Use barrier contraception until follow-up
Molar pregnancy management
- Ripen with prostaglandins
- May give methotrexate (+ folinic acid)
- Suction curretage
- Send for histology
- Anti-D if needed
• Pregnancy test 3 weeks later
Partial vs complete mole
Partial - empty egg fertilised by 2 sperm (abnormal foetal parts)
Complete - normal egg fertilised by 2 sperm (no foetal parts)
Subfertility investigations
Hormones
• Early follicular phase FSH, LH, oestradiol (day 2-3)
• Anti-Mullerian hormone (ovarian reserve)
• Mid-luteal progesterone (7 day before end)
• TFTs, prolactin, and testosterone if irregular cycle
STI screen
• HIB, hep B, hep C if assisted reproductive technology
TVUSS
• Antral follicle count (<4 = poor)
• Identify pathology
Tubal assessment
• Hysterosalpingography if risk factors for tubal damage e.g. PID
Semen analysis
• 2 tests 3 months apart
Subfertility management
Ovulation induction - clomiphene or FSH Intrauterine insemination (mild endometriosis) Donor insemination IVF Donor egg with IVF Surgical management (pathology)
Subertility initial counselling
- RF contribute (age, smoking, obesity, irregular periods, STI)
- Chance of getting pregnant naturally
- Start investigations
- Encourage regular unprotected sex every other day
- Management options depend on cause of subfertility
PCOS investigations
Bedside, bloods, imaging approach • Obs • Inspection - hirsutism, acne • BMI • Abdo examination • Pregnancy test
- Progesterone, prolactin, TSH, testosterone
- Lipid panel
- OGTT
• TVUSS
Rotterdam criteria
• Oligo/anovulation > 2 years
• Clinical/biochemical features of hyperangrogenism
• Polycystic ovaries (>=12)
