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Flashcards in Gynaecology Deck (202)
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What is used in the medical management of miscarriage?

Vaginal misoprostol
Bleeding should start within 24 hours
NOTE: also give antiemetics and analgesia for the symptoms


What is the surgical management option for miscarriage?

Manual vacuum aspiration

NOTE: surgical management of miscarriage requires anti-D in RhD-negative patients


Which tests should be requested in a patient with recurrent miscarriage?

Antiphospholipid antibodies (anticardiolipin and lupus anticoagulant)
Cytogenetics (products of conceptions or both partners)
Ultrasound scan for structural anomalies
Screen for thrombophilia (e.g. factor V Leiden)


How is antiphospholipid syndrome in pregnancy treated to reduce risk of miscarriage?

Low-dose aspirin + LMWH


What conditions need to be fulfilled for expectant management of ectopic pregnancy?

Size < 30 mm
No foetal heartbeat
Serum hCG < 200 IU/L and declining
Expectant management involves taking serial serum hCG measurements until the levels are undetectable


What is the medical management of ectopic pregnancy and what conditions need to be fulfilled for this option?

IM Methotrexate
• No significant pain
• Unruptured ectopic pregnancy with adnexal mass < 35 mm with no visible heartbeat
• Serum -hCG < 1500 iU/L
• No intrauterine pregnancy (confirmed by USS)


How should a patient be followed-up after medical management of ectopic pregnancy?

2 serum hCG measurements on days 4 and 7
1 serum hCG measurement every week until negative
Don't have sex during treatment
Don't conceive for 3 months after treatment
Avoid alcohol and prolonged sun exposure


What conditions need to be fulfilled to consider surgical management of ectopic pregnancy?

• Significant pain
• Adnexal mass > 35 mm
• Ectopic pregnancy with a foetal heartbeat visible on ultrasound scan
• Serum b-HCG > 5000 iU/L


Describe the follow-up after salpingectomy and salpingotomy.

Salpingectomy - urine pregnancy test at 3 weeks
Salpingotomy - 1 serum hCG per week until negative


Is anti-D required after ectopic pregnancy or miscarriage?

Only if they were managed surgically
NOTE: also required for all cases of molar pregnancy


What is the first line management option for molar pregnancy?

Suction curettage
NOTE: methotrexate may be used as chemotherapy


What advice should be given to women who have had a molar pregnancy?

If receiving chemotherapy, do not get pregnant for 1 year
Do not conceive until follow-up is complete
COCP and IUD can be used once hCG has normalised


Which investigations should be used in secondary amenorrhoea?

o Urinary or serum hCG (exclude pregnancy)
o Gonadotrophins (low indicates hypothalamic cause, high indicates ovarian cause)
o Prolactin
o Androgen (high in PCOS)
o Oestradiol
o TFTs


What are the Rotterdam criteria for PCOS?

Clinical or biochemical hyperandrogenism
Polycystic ovaries on ultrasound


How should PMS be investigated?

Symptom diary for 2 cycles


What are some medical management options for PMS?

Transdermal oestrogen
GnRH analogues (if severe)
SSRI (if severe)

Conservative: stress reduction, alcohol and caffeine reduction, exercise


Which investigation should be performed in all women with heavy menstrual bleeding?



What are the management options for menorrhagia of no known cause or menorrhagia caused by < 3 cm fibroids or adenomyosis?

 1st line: LNG-IUS
 2nd line non-hormonal:
• Tranexamic acid
• NSAIDs (e.g. mefenamic acid)
 2nd line hormonal:
• Cyclical oral progestogens
 Surgical:
• Endometrial ablation
• Hysterectomy


What are some medical management options for menorrhagia caused by fibroids > 3 cm?

Non-Hormonal: tranexamic acid, NSAIDs
Hormonal: Ulipristal acetate, LNG-IUS, COCP and cyclical oral progestogens

NOTE: ulipristal acetate carries a risk of liver injury


What are some surgical management options for fibroids > 3 cm?

Transcervical resection of fibroid (for submucosal)
Uterine artery embolisation


What are the 1st and 2nd line management options for dysmenorrhoea?

1st line: NSAIDs
2nd line: COCP


What are the three forms of emergency contraception and what is the window for taking them after UPSI?

Levonorgestral (Levonelle) - 72 hours
Ulipristal Acetate (EllaOne) - 120 hours
Copper IUD - 120 hours

NOTE: levonorgestrel and ulipristal should NOT be taken together, but both can be used more than once in a single cycle


How long after taking emergency contraception must it be repeated if the patient vomits?

2 hours


What are the main side-effects and risks of the COCP?

Side-Effects: headache, nausea, breast tenderness
Risks: VTE, breast and cervical cancer, stroke, ischaemic heart disease


How do periods tend to change with the COCP?

Usually makes periods regular, lighter and less painful


How long before an elective operation should the COCP be stopped?

4 weeks


How should a patient on the COCP who has missed 1 pill be counselled?

Take last pill


How should a patient on the COCP who has missed 2 pills be managed?

• Use condoms until pill has been taken correctly for 7 days in a row
• 2 Missed in Week 1: consider emergency contraception
• 2 Missed in Week 2: no need for emergency contraception
• 2 Missed in Week 3: finish pills in current pack and start the new pack immediately with no pill-free break


Aside from emergency contraception, what else should be offered to women coming in asking for emergency contraception?

STI screen
Long-acting contraception

NOTE: this should be discussed with all TOP patients as well


Describe how progesterone-only pills should be taken.

1 pill at the same time every day with no pill-free week