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Toni's Obs and Gynae > Management > Flashcards

Flashcards in Management Deck (31):
1

Post Menopausal Bleeding

Bimanual & speculum
Cervical smear if not up to date
TVUS to measure endometrial thickness
If >4mm or >1episode PMB:
- endometrial biopsy +- hysteroscopy
pipelle, hysteroscopy under paracervical LA block or under GA

2

Bleeding in early pregnancy

Admit if: ectopic suspected, septic miscarriage, heavy bleeding
Resuscitate if req
Remove any products in os (pain, bleeding, vasovagal shock)
If non viable + heavy bleeding: IM ergometrine
If septic: swabs + IV abx
Rhesus -ve + medical/surgical/expectant>12wks:

3

Threatened miscarriage I.e. Viable

90% with viable fetus detected at 8 wks will not miscarry

Bed rest, progesterone and hCG do not prevent miscarriage

4

Non-viable pregnancy

Expectant: if not septic
Medical: misoprostol, incomplete 600 mcg, missed 800mcg
Surgical: if heavy bleeding/septic/preferred by patient
ERPC- under anaesthetic vacuum aspiration

5

Complications of miscarriage management

Expectant + medical: heavy painful bleeding 24hr direct access to emergency gynae service for advice/treatment
May require surgical evacuation
Infection rates are all 3%
Surgical: uterus perforation / asherman's syndrome if part of endometrium removed, more expensive

6

Symptomatic ectopic pregnancy

Admit (NBM) + fluid resus if req
IV access, Hb + cross match
Urine B-HCG
TVUS
Either: laparoscopy/otomy or medical management

7

Subacute ectopic pregnancy

Surgical: laparoscopy with salpingostomy/ectomy
Medical: if unruptured with no cardiac activity,

8

Acute PID

Urine dip, MC+S
High vaginal swab, endocervical swab
Abx: doxycycline + metronidazole
Analgesia + Contact tracing
Complications: tubo-ovarian abscess, Fitz-Hugh-Curtis synd (peri hepatitis+ adhesions), tubal infertility, ectopic preg, chronic pelvic pain

9

Endometriosis

Medical:
Analgesia: tranexamic acid
COCP: microgynon 30
Progestogens: medroxyprogesterone acetate
GNRH analogues: triptorelin up to 6 months
Antiandrogens
Danazol: anti-oestrogen, anti- progesterone, 3-6 months
Surgical: to improve fertility
IVF often indicated

10

Placenta praevia

Admit
Stabilise
Heavy/far from hospital admit from 30-32 wks until delivery
Planned Caesarean section 38-39 wks
Major haemorrhage -> emergency c section

11

Chorioamnionitis

Deliver without delay: oft c section
Abx for mother + baby
Paediatricians present

12

Pre labour SROM

No digital examination - introduces infection
Obtain sample liquor
Sterile speculum exam: visualise cervix, cough
At term: immed induction of labour or expectant management
Which should NOT exceed 96 hrs, generally induced at 48hrs post SROM

13

Pyelonephritis

MSU: dip, M C + S
Renal US: hydronephrosis
Uterine tightenings = risk of preterm labour + bacteraemia
Speculum as silent cervical dilation can occur
Rx: analgesia, fluids, Iv abx

14

UTI

Freq, dysuria, suprapubic pain, fever, tachycardia
Uterine tightenings, perform speculum
MSU: dipstick with M C + S
Fx: cephradine, amoxicillin
Recurrent UTI req further investigation

15

Suspected ectopic + shock

ABC!
Fluid resuscitate, urine BHCG, urgent cross match,
prep for theatre:
Urgent laparotomy

16

Obstetric cholestasis

For itching: chlorphenamine
Fetal monitoring: incr risk pre term delivery, intracranial haemorrhage, fetal distress, intrauterine death
Deliver 37-38 wks
Severe cases = ursodeoxycholic acid to reduce bile acids

17

Ovarian cancer

Bloods: CA125, Pelvic+ abdo US, CXR, CT CAP
Specialist gynae cancer unit
Benign: laparoscopy- excision or drainage
Epithelial malignant: hysterectomy + bilat oophorectomy, infracolic omentectomy.... Oft palliative debulking
Intraperitoneal disease: obstruction, cachexia
Liver mets
Malignant pleural effusion

18

Prolapse

Pelvic floor exercises may improve incontinence
Won't improve established prolapse
HRT: increased oestrogen + vaginal blood flow = improved connective tissue function
Surgical: anterior/posterior repair, hysterectomy

19

Premature labour

Confirm EDD correct
Exam: abdo, spec with swabs, urine dip, mat bloods, CTG, US
Inform special care baby unit/ transfer to hospital with facilities for preterm babies
Corticosteroids
Tocolytics
Vaginal delivery if appropriate

20

Uterine inversion

Help
Start maternal resus
Do not attempt to separate placenta, attempt to manually replace uterus and placenta to relieve vasovagal shock
Tocolytic therapy
O'Sullivans: 2L warned fluids PV
Johnson's transvaginal fundal pressure
Huntington: traction on round ligaments at laparotomy with simultaneous vaginal pressure
Haultain's incise uterine fundus to allow manual re inversion
Hysterectomy = last resort
Prophylactic abx and oxytocin once uterus resited

21

PPH medical management

Atonic uterus:
Empty bladder, rub up uterine contractions, admin oxytocics,
Bolus IV ergometrine -> oxytocin infusion
Bimanual compression
Carboprost IM
For infection: cefuroxime + metronidazole

22

PPH surgical management

laparotomy:
carboprost into myometrium,
B lynch suture, under sew placental bed, tamponade test - balloon uterine or internal iliac artery ligation,
Last resort: hysterectomy

23

Stage 1+2 endometrial cancer

Radical hysterectomy
Bilateral salpingo-oophorectomy +- lymphadenectomy
Adjuvant radiotherapy if high risk of recurrence

24

Stage 3 endometrial cancer

Surgical debulking
Radiotherapy
Chemotherapy

25

Stage 4

Palliative care
Incurable

26

Fibroids

Medical: progesterone tablets, GNRH analogues
Surgical: myomectomy, uterine artery embolisation, hysterectomy

27

Uterine rupture

Stop any oxytocin infusion
Immed laparotomy req to deliver baby and arrest bleeding
Repair uterus if possible, otherwise emergency hysterectomy

28

Stress incontinence

Conservative
Pelvic floor exercises with physio - 3 months
8 contractions 3x /day, continue if beneficial
Surgical

29

Urge incontince/overactive bladder

Weight loss
Smoking cessation
Physiotherapy
Solifenacin
Fesoterodine

30

Vasomotor sx in menopause

HRT
Elleste solo: estradiol only if other source of progestogens with uterus (endometrial hyperplasia/cancer)
Elleste duet: estradiol + norethisterone
Evorel: estradiol + norethisterone
Oestrogen implants?

31

Stillbirth

Oral mifepristone
Vaginal misoprostol

If indicated I.e. Wrong lie -> c section