OBGYN Flashcards
(153 cards)
1
Q
What are the risk factors of pelvic organ prolapse?
A
Multiparity (biggest RF)
Obesity Age CTD (Ehlers Danlos) Race: White > Black / asian Increased abdominal pressure (constipation, straining, obesity, other)
2
Q
What is the first line conservative and medical treatment for pelvic organ prolapse?
A
Pelvic Floor Exercises
Pessary
3
Q
What is a complication of using pessary for pelvic organ prolapse?
A
Ulcers from irritation
Odour from secretions
4
Q
What is the surgical management of pelvic organ prolapse?
A
Obliterative - Unable to have sex, the vagina is stitched up, ensure the patient is happy with this choice!
Reconstructive - Restore normal pelvic anatomy, a variety of approaches. Sutures, meshes, biomaterial. Vaginal, abdominal.
5
Q
What are the 4 characterstics of hyperemesis gravidum?
A
- N&V (persistent and prolonged)
- Dehydration + Derranged U&E
- Ketones +++
- > 10% drop in BW
6
Q
What are the risk factors of hyperemesis?
A
Anything that causes an increase in B-hCG
- Previous hyperemesis
- Twins or multiple pregnancies
- Molar pregnancy
- TSH
7
Q
What is your immediate management for a patient with hyperemesis?
A
- Fluids IV - Crystalloid
- Antiemetic - Cyclizine*
- Vitamine - Thiamine & Folic Acid
- DVT prophylaxis
*Metclopramide and domperidone not used due to oliguric extrapyramidal side effects
8
Q
What is a major complication of hyperemesis?
A
Wernickes Encephalopathy (due to depletion of Thiamine from excessive emesis)
9
Q
What medication may be prescribed to resolve refractory hyperemesis?
A
Prednisolone
10
Q
What may you find in a complete miscarriage?
A
Expulsion of all contents OS closed PV bleeding Abdo pain Uterus not felt with bleeding settled
11
Q
What may you find in an incomplete miscarriage?
A
Incomplete expulsion
OS open
Crampy abdominal pain
Products visible
12
Q
What is the risk of retained products in an incomplete miscarriage?
A
Cervical shock, remove products to prevent this
13
Q
What may you find in an inevitable miscarriage?
A
OS open
Products not expelled
Still bleeding
Crampy lower abdominal pain
14
Q
What may you find in a threatened miscarriage?
A
OS closed
Viable pregnancy
15
Q
What may you find in a missed miscarriage?
A
Asymptomatic
Gestational sac with NO fetal pole
25 weeks or 7 weeks
16
Q
What is a recurrent miscarriage?
A
3 or more CONSECUTIVE miscarriages
17
Q
What are the causes of recurrent miscarriages occurring in the 1st, 2nd and 3rd trimester?
A
1st - X abnormalities
2nd - APL syndrome, ANA
3rd - APL syndrome, Endocrine abnormalities, Age (maternal and paternal)
Most common reason / cause is antiphospholipid syndrome (APL)
18
Q
What blood test should you perform in a patient with recurrent miscarriage?
A
Test for SLE, APL, X abnormalities (if 3rd loss), USS
If all test are normal»_space;> unexplained miscarriage (TLC for the mother)
19
Q
What is the Kleihauer-Betke test?
A
Blood test to measure amount of fetal hB transferred to mothers blood stream.
Results used to determine dose of Anti-D Ig
20
Q
What are the options for managing an incomplete miscarriage and what are the success rates for each?
A
- Conservative (50-60% success) if NOT bleeding. Watch and wait for 14 days, call back unless bleeding within those days, and then do a pregnancy test.
- Medical (80% success).
Misoprostol (uterine contractions) + Mifepristone (terminate fetal heartbeat).
If bleeding stops > send home.
If bleeding continues > Surgical - Surgical (90% success)
Suction / Manual Evacuation
21
Q
What risks are there in the surgical management of an incomplete miscarriage?
A
Bleeding
Uterine perforation
Cervical trauma
22
Q
What may a negative sliding scale on USS be indicative of?
A
Ectopic pregnancy
Implanted strongly to structure therefore pressure applied will not result in movement of the gestation.
23
Q
What is the clinical presentation of an ectopic pregnancy?
A
Amenorrhoea + sexually active Colicky abdo pain Dark or Fresh PV bleeding* Fainting/dizziness** Previous surgery (e.g. appendectomy) PID Conception after infertility
- Ddx of PV bleeding, miscarriage, PID, cervicitis
- *fallopian tube distention and stimulation of ANS
24
Q
What are the risk factors for ectopic pregnancy?
A
Cause is usually tubular abnormalities. Things that affect this include…
Previous ectopic Endometriosis Smoking Salpingitis; surgery Progesterone IUD Sexual partners
25
How may the levels of B-hCG affect your management of ectopic pregnancy?
<500 - Conservative
500-1500 - Medical
>5000 - Surgical
26
How may the presence of a fetal heart beat affect the management of an ectopic pregnancy
>>> Always SURGICAL!
27
What is the difference between a salpingostomy and a salpingectomy?
Salpingostomy - Creating of a new opening into fallopian tube
Salpingectomy - removal of fallopian tube
hint: salpingOstomy, Opening
salpingEctomy, ecsize
28
What is the management of an ectopic pregnancy?
1. Give Anti-D
2. IVI for shock
3. BHCG (dipstix + blood)
4. TV USS + CTG for fetal heart beat
5. Immediate laparotomy
6. Methotrexate*
7. Follow up twice a wk until BHCG <20
*MUST arrange a follow up if given methotrexate! Cannot conceive for 3 months, provide adequate contraception.
29
What is a molar pregnancy?
aka hyaditiform moles
What is the typical appearance on USS?
Complete: No genetic material in ovum, sperm from father, 46XY or 46XX
Incomplete: Two sperms, empty ovum
*snowstorm appearance on USS
30
What are the key diagnostic features of a molar pregnancy?
```
1st trimester of pregnancy
Vaginal bleeding (frogspawn)
Amenorrhoea / Missed period
Extremes of reproductive age (<20yrs, >35yrs)
Severe Hyperemesis
```
31
What is the management of molar pregnancies?
Surgical - Suction
Regular BHCG monitoring for 6months to 1 year
Avoid pregnancy for 1 year
32
What is the prognosis for a patient who has had a molar pregnancy?
Increased risk of recurrent molar pregnancy
Risk of choriocarcinoma, fortnightly B-hCG rest required to see if normalised, otherwise requires referring to molar pregnancy specialist
33
At what BMI should you do an OGTT in antenatal care?
>30
34
What is the mnemonic for interpreting CTG's?
DR C BRAVADO
Define Risk
Contractions
Baseline RAte
Variability
Acceleration
Deceleration
Overall plan
35
What are the features of pre-eclampsia?
PRE-eclampsia
Proteinuria (>0.3g/24h)
Rising blood pressure (>140/90)
Edema of the legs
36
What are the fetal and maternal complications of gestational diabetes?
Fetal: Macrosomia, Respiratory Destress Syndrome, Neonatal Hypoglycaemia, Congeintal Abnormalities (CHD)
Maternal: C-Section, pre-eclampsia, type 2 diabetes
37
What are the risk factors for pre-eclampsia?
```
Nulliparity
FHx
Obesity
Diabetes
HTN
Extreme's of ages (<20 or >30)
```
38
At how many weeks pregnancy does pre-eclampsia usually develop?
~20 weeks
39
What are the clinical features of pre-eclampsia?
Headache
Nausea
Visual distrubances
Epigastric pain
40
What complications may arise from untreated UTI in pregnancy? What are the symptoms?
Pyelonephritis
(Fever, rigors, nausea, vomiting, loin pain)
Premature labour
41
What signs may be present, and should you comment about, during an obstetric examination?
hint: SSSUM
Symmetry - symmetrical / assymetrical abdominal distention
Scars - low transverse scar from C-sect, laparoscopic
Skin changes - Linea nigra (dark line from xiphisternum to pubis), Striae gravidum (purple stretch marks denoting current parity), Striae albicans (silvery stria denoting previous parity)
Umbilicus - flattened, eversion (polyhydramnios / multiple)
Movements - Fetal movements (occuring after 24 weeks)
42
What rate is a normal fetal heart beat?
110 - 160
43
What are some causes / associations of polyhydramnios?
Type 2 Maternal Diabetes
Macrosomia
Multiple pregnancies
Impaired swallowing by fetus
44
What are some consequences of polyhydramnios?
Pre-term labour
Placental abruption
Malpresentations (breech)
45
What are some causes of oligohydramnios?
1. Inability of fetus to contribute to fluid, i.e. urinate (renal dysgenesis, polycystic kidneys, Potter's syndrome)
or
2. Rupture of amniotic membranes
46
What is a consequence of oligohydramnios?
Poor development of fetal lung tissue
47
What syndromes are assessed on nuchal scanning?
Pataus syndrome
Edwards syndrome
Downs syndrome
Nuchal scan measures the "fat PED" of the neck
48
At what weeks is the nuchal scan performed?
10-14 weeks
49
What invasive procedures are available for assessing whether a baby has a syndrome and at what week are they performed?
What risks do these tests carry and what is the probability of it happening?
Chorionic Villus Sampling (11-14 wks) - Needle into tummy
Amniocentesis (16 wks) - obtain babies cell from surrounding fluid
1/100 chance of miscarriage
50
What are the causes of PPH (4T's)?
Tone - Abnormal uterine contraction
Tissue - Retained products of conception
Trauma - of genital tract
Thrombin - abnormal coagulation
51
What are the risk factors and protective factors of ovarian cancer?
Risk factors
- Early menarche
- Late menopause
- Nulliparity
- Fhx of ovarian/breast cancer
Protective factors
- Multiparity
- Lactation
- COCP use
52
What are the symptoms of ovarian cancer?
Abdominal pain and distension
Abnormal vaginal bleeding
Changes in bowel habits
Ovarian / pelvic mass
Evidence of pleural effusion, bowel obstruction or breast symptoms due to metastesis
53
What are the risk factors for cervical cancer?
```
HPV
STIs e.g. chalmydia
Multiple sexual partners
Smoking
Sex at a young age
```
54
What are the symptoms of cervical cancer?
Post-coital bleeding
Offensive vaginal discharge
Intermenstrual + Post-Menopausal bleeding may also be seen.
Late features include altered bowel habits, painless rectal bleeding, haematuria and chronic urinary frequency
55
What are some differentials for late pregnancy bleeding?
Divide by structures affected
1. Cervical: Cervicitis, Polyp, Cancer
2. Vaginal: Lacerations (more sensitive in pregnancy)
3. Uterine: Rupture
4. Placental: Abruption, previa, vasa previa
5. Other: Hemorrhoids (notices only after BOed?)
56
What are the symptoms and RF of placental abruption
Painful between contractions!
Bleeding! (may be concealed)
Fetal distress
Firm tender uterus
```
Hypertension!
Blunt trauma
Cocaine use
Multiparity
Smoking
```
Placental Abruption is the No1 cause of late pregnancy bleeding and painful bleeding!
57
What CTG changes present in placental abruption?
Bradycardia
+
Late Decelerations (always seen in placental problems due to lack of blood flow to the fetus)
58
What are the complications of placental abruptions?
DIC! (prolonged PT and PTT, Thrombocytopaenia, schistocytes and helmet cells on film)
Preterm delivery
Maternal and/or fetal shock (resulting in renal failure)
Death
59
What is uterine rupture and what is the most common risk factors?
Complete separation of the wall of uterus
Classical (Vertical) C-Section
therefore uterine scarring as a result is a huge risk factor
60
What are the symptoms of uterine rupture?
How do you manage uterine rupture?
TEARING uterine pain
Popping sensation (significant pressure within uterus relieved on rupture which feels like pop)
Most reliable symptom is Fetal Distress (late decelerations)
Mx: Emergency C-Section
61
How may vasa-previa present?
artificial rupture of membrane > painLESS fresh pink blood > emergency c section
Vasa vessels covering cervical os. These vessels supply fetus. On artificial rupture, without knowing if vasa-previa, can result in massive bleeding.
62
What is the initial symptom of placenta-previa?
PainLESS uterine bleeding
63
Name three obstetric causes of late pregnancy painLESS bleeding?
Placenta Previa
Vasa Previa
Abnormal placentation
64
Name two obstetric causes of late pregnancy PAINFUL bleeding?
Placental Abruption
| Uterine Rupture
65
What is endometriosis? How does it differ to adenomyosis?
What are the characteristic symptoms and signs of endometriosis?
Endometrial glands and stroma OUTSIDE NORMAL LOCATION.
Adenomyosis is where the glands are in the myometrium
1. Cyclical pelvic pain* (not always but very indicative)
2. Uterosacral nodularity
-----------------------------------------------------------------
*Most common presenting complaint is chronic pelvic pain
Also a differential for subfertility / infertility
Chiefly affects reproductive-aged women
66
What are some risk factors for endometriosis?
Family history: Increased incident if 1st degree relatives also affected
Anatomical: anything causing Outflow Obstruction
Environmental: TCDD, caffeine, alcohol
*protective factors: smoking, exercise
67
What is the treatment for primary dysmenorrhoea?
NSAIDs
| COCP
68
What are the symptoms of endometriosis?
Pain Symptoms
- Secondary Dysmenorrhoea (not responsive to NSAIDS or COCP)
- Dysparenuia (endometrial implants on uterosacral ligament which is moved during sexual intercourse)
- Dysuria (implants in the urethra)
- Defecatory pain (implants in the rectum)
Infertility / Subfertility (implants in the tubes / ovaries)
Intestinal obstruction (will appear like malignancy on CT, need to do laparoscopy to diagnose properly)
Urethral obstruction (increased frequency, urgency, retention, leading to renal failure, consult urologist)
69
What may you see, in endometriosis, on physical exam?
Visual inspection?
Speculum?
Bimanual?
Visual: Normal
Speculum: Usually normal, maybe blue/red lesions that easily burn
Bimanual:
UTEROSACRAL NODULARITY & TENDERNESS
FIXED RETROVERTED UTERUS (should be anteroverted)
Cystic adnexal mass
70
What is the management of endometriosis?
Conservative: Watch and wait
Medical: NSAIDs and COCP >>> GnRH Agonist (gonadorelin)
Surgical: ablation, resection, hysterectomy (make sure they dont want children, these patients are young and often want children!)
71
What are some differentials of endometriosis?
Gynecological
- PID (fever)
- Haemorrhagic ovarian cyst (no uterosacral nodularity)
- Ovarian torsion (acute pain, not chronic)
- Primary dysmenorrhea (younger, no other findings)
- Ectopic (dx with B-hCG)
Non-Gyne
- Chronic UTI (extensive hx)
- Interstitial cystitis (UA)
- Renal calculi (hx of kidney stones)
- GI: IBD, IBS, Diverticulitis (not common in young ppl)
- MSK:
72
What is a normal and abnormal frequency for voiding?
Every 4h is considered normal
Voiding more than 6x per day, or more frequent than every 2h is abnormal.
73
What is nocturia?
Interruption of sleep >1x per night to void
74
What questions may you ask in the urinary history of someone coming in complaining of incontinence?
OFNAUSPA
```
Onset
Frequency
Nocturnal
Amount
Urge (Sudden? Make it in time?)
Stress (Staining, coughing, walking?)
Pads (How many, types?)
Access (to lavatories)
```
75
What is the conservative, medical and surgical treatment for stress incontinence?
Conservative
- Pelvic floor exercises
Medical
- Pseudoephedrine / Duloxetine
Surgical
- Colposuspension (elevation of bladder neck)
76
What are the different causes of urge incontinence that you should question about during a history?
BPH / Prostatic Carcinoma
- Elderly male
- Sx, from start to end, of hesitancy, intermittency, weak stream, terminal dribbling and feelings of incomplete voiding
- Metastatic sx include bone pain, weight loss, jaundice
Autonomic Neuropathy
- MS, PD, DM
- Other neurological symptoms present
UTI
- Fever, flank/groin/back pain, dysuria, haematuria, confusion, N&V
Stool impaction
- Constipation
Also consider Post Menopausal Atrophic Changes of the Bladder which is seen in post-menopausal women who have not / never undergone HRT
77
What clinical examination would you perform in a patient presenting with incontinence?
Performed with comfortably full bladder to demonstrate incontinence with cough
Signs of estrogen deficiency on inspection of genitalia
Uterovaginal descent on straining
Pelvic exam - pelvic mass which may be causing symptoms from pressure effects
Neurological disease, assess S2, S3, S4 dermatomes
78
What is the conservative, medical and surgical management of urge incontinence?
Conservative
- Involve incontinence advisory service
- Fluid intake habits altered
- Bladder training for detrusor instability
Medical
- HRT
- Abx for UTI
- Antimuscarinics (oxybutynin / tolterodine)
Surgical
- None
79
What are some common side effects of anticholinergics / antimuscarinics?
dry mouth
blurred vision
constipation
80
What investigations should be performed in a patient presenting with incontinence?
MSU - To exclude UTI
Urodynamic studies - Stress incontinence will be normal, detrusor instability will produce anomalies
81
How may you examine a patient presenting with symptoms congruent with a prolapse?
Record bodyweight, height, and fitness for surgery if indicated.
Inspect for masses, atrophy of genitalia, obvious prolapses.
Ask to cough, look for stress incontinence/prolapse. Describe prolapse.
Use Sim's Speculum to assess prolapses.
Use bimanual to exclude masses.
82
What is the conservative, medical and surgical management of prolapses?
Conservative
- Stop smoking
- Loose weight
- Pelvic floor exercises
- Pessaries
Medical
- Vaginal estrogen cream
- HRT
Surgical
- Repair of prolapse
- Hysterectomy
83
How may you explain stress vs urge incontinence?
Stress
- Weak support
- Gives in to stress
- Unable to hold urine when pressure increases
Urge
- Bladder sensitive
- Urges to go ever if very little volume
- detrusor instability, sensitivity
84
How may you counsel a surgically-unfit patient on managing her procidentia?
Ensure to patient that it is not harmful although it is progressive.
Advise estrogen cream to prevent excoriation and dryness of the vagina. Alternatively, HRT can be prescribed.
Pessaries can be inserted. Intially ring pessaries, then move onto shelf pessaries. 6 monthly replacements, risks of ulcers and excoriations, where if occurring will be remedied with estrogen creams for 2-4 weeks.
Risk of urinary incontinence and fecal impaction with pessaries.
85
What are the causes of post-coital bleeding?
Cervical carcinoma
Cervical polyp
Cervical ectropion
Chlamydia
86
What factors should you question the woman about for a couple presenting with sub-fertility?
Miscarriages
PCOS
STIs / PID
Cancers
87
What general questions should you ask about a couples sexual relationship who have come in with sub-fertility?
Regularity
Problems with sex (pain, erectile dysfunction)
How long trying for?
Previous pregnancies together or with other partners?
88
What factors should you question a man about for a couple presenting with sub-fertility?
```
Undecended testes
Torsion or trauma
Mumps as an adult
STIs (chlamydia)
Cancer
```
89
What questions should you ask about in the SH of sub-fertility?
Drinking, smoking, drugs
Employment? Tiredness?
Long time spent away from each other?
90
What questions should you ask the woman in DH for sub-fertility?
Current medications
Allergies
Have you tried medicines to help with fertility
History of contraception use in the past (take full history)
91
What are the female causes of subfertility?
Age
Weight
Unhealthy habits
Systemic conditions (SLE)
Iatrogenic - Surgery / Chemotherapy
Ovulatory disorders
- PCOS
- hyperprolactinaemia
- thyroid
- premature menopause
Tubular pathology
- PID
- Endometriosis
Uterine pathology
- fibroids
92
What are the male causes of subfertility?
```
V - systemic conditions (SLE)
I - Gonorrhoea, Chlamydia, Mumps
T - Trauma
A - SLE?
M -
I - chemotherapy, vasectomy
N - testicular cancer, prostate cancer
C - undecended testes
D -
E -
F -
K - downs
```
93
What medication can be given to stimulate ovulation?
clomiphene
94
What method of conception may be offered where there is a problem with the fallopian tubes or sperm quality?
IVF
95
What are the causes of pelvic pain?
Gyne
- PID
- Ectopic pregnancy
- Ovarian cyst / rupture / torsion / haemorrhage
- Endometriosis
- Ovulation pain
Urological
- Pyelonephritis
- Renal colic
GI
- Appendicitis
- Diverticulitis
- IBS / IBD
96
Symptoms of PID
```
BILATERAL pelvic pain
PV Discharge
Dyspareunia and Dysmenorrhoea
Fever
Bleeding post-coital / intermenstrual
Unprotected sex with multiple / new partners
```
97
Symptoms of ectopic
Unilateral pain + spotting + amenorrhoea
Trying to get pregnant / unprotected sex
Usually occurs at 5-9 weeks gestation
In tubal rupture >>> collapse and shoulder tip pain
98
Symptoms of ovarian pathology (cyst/rupture/torsion/haemorrhoage)
SUDDEN UNILATERAL pelvic pain
| Fever & Vomitting
99
Symptoms of endometriosis
CYCLICAL pelvic pain
DEEP dyspareunia
Dysmenorrhoea
Menstrual disturbance
100
Symptoms of pyelonpehritis
Fever, chills, rigors
Loin pain
Urinary frequency and Dysuria
101
Symptoms of appendicitis
Pain periumbilical >>> RIF
Anorexia
Young
102
Symptoms of diverticulitis
Elderly
LIF
Pyrexic
103
Symptoms of IBD/IBS
Change in bowel habits
Lower abdominal pain
IBD: Blood / Mucus PR
104
What are the causes of menorrhagia PV bleeding?
DUB (most cases)
Fibroids
Endometriosis
105
What are the causes of inter-menstrual PV bleeding?
```
Normal spotting at middle of cycle
Breakthrough bleed from contraception
Polyps (cervical or endometrial)
Ectropion
Ectopic
Infection / STI / PID
```
106
What are the causes of post-coital PV bleeding?
Cervical Trauma
Cervical Cancer
Cervical Ectropion
Cervical Polyp
107
What are the causes of post-menopausal PV bleeding?
```
Cervical Cancer (until proven otherwise!)
Atrophic Vaginitis (90% of cases)
```
108
What categories of questions should you ask in PV bleeding?
Type (menorrhagia/inter/post-coital or menopausal)
Timing (onset, duration, progression, frequency)
Bleeding (pattern, amount, pain)
Anaemia sx (tiredness, breathlessness on exertion)
Thyroid sx (hypothyroidism)
109
What question should you always ask in a PV bleed systems review?
Weight loss, night sweats, fatigue
For cervical / endometrial cancer
110
List the possible causes of amenorrhoea / oligomenorrhoea?
Gyne
- Primary amenorrhoea
- Pregnant
- PCOS
- Menopause
Endocrine
- Hyperthyroidism
- Hyperprolactinaemia
- Hypogonadotrophic Hypogonadism
- Cushings
Other
-Progesterone pill
111
What is primary amenorrhoea?
What are the causes?
Menarche not reached by the age of 16
Most commonly constitutional delay
- Mother and siblings may also have a late start
Other causes
- Testicular feminisation
- PCOS
112
What are the symptoms of PCOS? What causes these symptoms?
How is it investigated and managed?
Oligomenorrhoea more commonly than amenorrhoea
Hiristuism
Acne
Obesity
Subfertility
Sx due to excessive androgen hormones
Investigated by
- USS
- Blood glucose may show diabetes (insuline resistance)
Manage by
- Weight loss
- Diet
- COCP for hirustism and irregular periods
- Metformin for insulin resistance
- Laparoscopic ovarian drilling
113
What are the common causes of hypogonadotrophic hypogonadism?
What changes to FSH and LH does this cause?
```
Anorexia
Anxiety
Excessive exercise
Stress
Depression
Starvation
```
Low FSH and LH levels
114
How is menopause defined?
How is premature menopause defined?
What symptoms may a woman experience during the perimenopause phase (the change)?
Menopause: Periods absent for 12 consecutive months
Premature menopause: Menopause before the age of 40
The change: Hot flushes, profuse sweating, loss of libido, vaginal atrophy, irregular periods
115
How is menopause investigated?
How are the symptoms of menopause managed?
PV exam - vaginal atropy
Managed
- Topical: lubrican / cream / estrogen for atrophy
- HRT
116
What are the symptoms of hyperprolactinaemia?
What are the causes?
How is it investigated?
How is it managed?
Galactorrhoea, oligo/amenorrhoea, subfertility, (bitemporal hemianopsia if macroprolactinoma)
Antipsychotic use
Macroprolactinomas (will press on optic nerve)
Pregnancy, breast feeding
Stress
MRI head if visual disturbances
Managed
- bromocriptine (DA agonist)
- surgery if visual defect present
117
What are some obstetric causes of PV Bleeding?
```
Miscarriage
Ectopic
Braxton Hicks
Labour
Pre-eclampsia
Placental abruption
Uterine rupture
Acute fatty liver of pregnancy
```
118
What are the symptoms of a miscarriage?
PV bleeding
Products of conception may be present
Pelvic pain
<24 wks
119
What are the absolute contraindications of the COCP?
```
Smoker >35 years
<6/52 post-partum
Breastfeeding
Hypertension
Current or past DVT Hx
Migraine with aura
CVD
Current breast cancer
Liver cirrhosis
```
120
How does the COCP work and prevent conception?
Stops ovulation
Thickens cervical mucus
Thins endothelium
121
What formulations of the COCP are available and how is each taken?
Pill
- daily
- 3 weeks on 1 week off
Patch
- weekly
- 3 weeks on 1 week off
Ring
- changed after 3 week
- 1 week break between taking out and putting in
122
What are the SE of the COCP?
Hormonal SE: acne, headaches, weight gain
Blood clots
Increased risk of Breast and Cervical ca
Local irritation with the patch
Pain during intercourse with ring (can be taken out but only for maximum of 3 hours)
123
What are some benefits of the COCP?
Controls periods, pain and bleeding
124
What is the rule for missed doses of COCP?
Take ASAP even if with next dose.
If next dose on time then fine.
If missed second dose, take a pill immediately + condom for 7 days
125
What is the treatment course for the minipill?
What are some of the side effects?
What are some of the pros and cons of it?
What should you do if you miss a dose?
Take everyday, at exactly the same time
SE: hormonal, irregular bleeding
-ve: needs taking at exactly the same time
Missed: take immediately (even with next one). If more than >3h late then use condom for next 2 days. Use emergency contraception if had unprotected sex 2-3 days before or after missed pill.
126
What are the contraindications for the progesterone only pill?
Forgetfulness
Breast cancer
Liver disease
Undiagnosed PV bleeding
127
What cancers can the COCP protect against?
Ovarian and endometrial
Hint: COCP protects O and E
128
How does the copper coil work?
Copper is a spermicide
| Causes uterine inflammation
129
Compare the risks of the copper coil with marina coil
Both carry coil insertion risks: infection in first 3 weeks, bleeding, perforation
Copper - may cause heavier periods (think increased uterine inflammation resulting in more bleeding)
Marina - may cause spotting in first 6 months after which periods will be very light / stop
130
What are the contraindications for both the copper and marina coil?
Both
- pelvic infection
- PID <3 months ago
- Gyne ca
- Small uterine cavity
- undiagnosed PV bleeding
For Copper IUD
- copper allergy
131
What are the contraindications for progesterone implant / injection?
liver / genital / breast ca
Liver disease
Undiagnosed PV bleeding
132
How long does the Prog Implant last for?
What are the SE?
What are the + and -?
How is it implanted?
3 years
SE: Hormonal, periods spotting / light / stop
+ can forget about it
- some continue to experience spotting
Placed on inner upper arm
Around 4 cm
Under local anaesthetic
Can feel it after procedure
133
What checks need doing before and during the insertion of a coil?
When during the cycle can it be fitted in?
STI check prior
Check string present every month
If not had sex since period then can fit any time, or within first 5 days of periods starting
134
Side effects of prog implant
Hormonal
Periods > stop/ irregular / longer
Weight gain
Time for fertility to return
Osteoporosis (>2y consider, >5y stop)
135
Drawbacks of prog implant?
- must remember to come back every 3 months
- time for fertility to return
- cannot remove so side effects may last 3 months
136
How is a vasectomy performed? How long does the procedure take?
What is the failure rate?
What are some side effects and complications of the procedure?
Vas deferens cut and tied by forceps
Local anaesthetics
20 minutes procedure
1/2000 fail
Bleeding bruising infection
Scrotal swelling for first few days
Chronic testicular pain (1-3%)
Irreversible (50%)
137
After a vasectomy...
How long until intercourse?
When sperm free?
When sperm tests?
Condom sex - whenever you feel ready
May take up to 3 months for all of sperm to be used up
Sperm count test at 8 weeks and then 2-4 weeks later (both must be -ve)
138
How is tubal ligation performed?
What is the failure rate?
What risks are involved?
Clipping of fallopian tubes under GA
1/200
Surgical risks
Anaesthetic risks
139
What are some draw backs of condoms as a method of contraception?
Latex allergies
May slip off / break
New one every time
Oil based products may damage latex
140
Screening tests for what two genetic conditions are done at 10 weeks or earlier?
Sickle Cell
| Beta Thalassaemia
141
Between 8-12 weeks, a screening test for which three infectious diseases is performed?
HIV
Hep B
Syphilis
142
What additional screening test should be performed on a diabetic pregnant patient?
Eye screening
143
What is the combined test and when is it performed? What does it screen for?
Nuchal scanning + Blood test for PaPP and BHCG
11-14 weeks
Pataus
Edawards
Downs
144
When are the newborn checks done and what does it check for?
Within 72 hours of being born
Screens for problems with eyes, heart, hips, genetalia (+testes)
145
What is the blood spot test and when is it performed?
@5 days old
Screens for rare but serious conditions such as
- CF
- Congenital hypothyroidism
- Sickle cell
- Inherited metabolic diseases
146
What are the risk factors for miscarriage?
```
old age
uterine malformation
bacterial vaginosis
thrombophilia
chromosomal anomaly
```
147
How may an USS differentiate a miscarriage from an ectopic?
Products of conception would be visualised in an USS if a miscarriage. Uterus would be empty if it was an ectopic.
148
What investigations should you order in the suspected miscarriage patient?
Urine B-HCG to confirm pregnancy
FBC for blood loss
Blood group for rhesus status (if negative, give anti D)
Cross match in case of shock
USS to visualise products vs empty (ectopic)
Serum B-HCG as doubling of levels within 48h indicates a viable intrauterine pregnancy
149
What is the conservative, medical and surgical management of a miscarriage?
Conservative
- Analgaesia
- Anti-D
- Wait for expulsion
Medical
- Analgaesia
- Misoprostol (pg) for severe vaginal bleeding
- Mifepristone (anti-prog) induces evacuation of uterus
- Anti-D
Surgical
- Suction evacuation
- GA
- Analgaesia
- Oxytocics to facilitate uterine evacuation
- Mifepristone to facilitate uterine evacuation
- Anti-D
150
When may methotrexate be appropriate in the management of an ectopic pregnancy?
If
- Haemodynamically stable
- hCG <5000
- Unruptured ectopic of <3-4cm
151
What is the surgical management of an ectopic?
Salpingotomy/salpingostomy - incision made and ectopic removed
Salpingectomy - removal of ectopic WITH fallopian tube
PLUS methotrexate in either case, prevents failure rate in salpingostomies.
152
What tests should be done after a salpingostomy and a salpingectomy?
B-hCG should be measured after both
153
What risk factors, if present, require a hospital birth only?
Previous births
- C section
- Six children
- Serious PPH
Current baby
- Twins / multiple
- Breech
- Previa
- Problems with baby
Maternal factors
- Anaemia
- GDM
- Pre-eclampsia
- Age >40yrs
- Obesity
