Obs and Gynae Flashcards
(132 cards)
1
Q
What is Lichen Sclerosis and how does it present?
A
- Benign skin condition.
- Any age (usually post menopausal)
- Thin skin
- White (leukoplakia), Red (inflammation)
- Perineum/perianal- atrophy in figure of 8 pattern
- Anatomical shrinkage/ adhesions
- Extragenital plaques- trunk, back
2
Q
Investigations and management of Lichen Sclerosis
A
- Ix: Swabs, vulval biopsy
- Tx: Emollient creams, shor course steroids, surgery if micturition affected
3
Q
Presentation of Bartholin cyst
A
- Cyst/ abscess in posterior forchette.
- Vulval pain esp walking/sitting
- Dyspareunia
- ?Sepsis
4
Q
Investigations at booking appointment
A
- Booking = 8-12w
- Bedside- urine dip, BP, glucose if DM RF
- Bloods- Type, Rh, haemoglobinopathies, anaemia, RBC autoAb, HIV, HepB, syphilis, rubella
- Sickle cell and thallaesemia <10w
- DM eye screening at 1st appointment
5
Q
What is looked at in dating scan?
A
- Dating scan= 12w.
- Looking at:
- ?Single, viable, intrauterine foetus
- Crown-rump length. ?Gestation and EDD
- Nuchal translucency <12w risk of abnormality
6
Q
When is the anomaly scan and what are you looking for?
A
- 18-20w
- Structural abnormalities - anencephaly, open spina bifida, cleft lip, diaphragmatic hernia, gastroschisis, emophalmos, cardiac abnormalities, renal agenesis, skeletal dysplasia
- Trisomies
- Low lying placenta –> transvaginal USS
7
Q
Pre-conception care
A
- Multivitamins, folic acid (400 micrograms) until 12w
- Lifestyle- stop smoking, no alcohol, optimise BMI, pelvic floor exercises
- Vit D once preg - 10 micrograms OD in preg
8
Q
Indications for 5mg Folic Acid
A
- DM
- High BMI
- Coeliac / Malabsorption
- Sickle cell
- Epilepsy
- Prev. FHx NTD
- Multiple Preg
9
Q
Indications for growth scans. What are you looking for in growth scans?
A
- >28w, every month in complicated
- Hx of IUGR
- HTN or PMH
- DM
- Epilepsy
- Smoking/ substance misuse
- BMI >35
- Multiple Preg
- Growth - head, abdo circumference, femur length
- Amniotic fluid
- Blood flow- umbilical artery (deoxygenated blood from baby to mum). End diastolic flow.
10
Q
Down’s Screening
A
- 1st Trimester- Combined test. Nuchal translucency, PAPa (low), betaHCG (high). If risk >1 in 250 –> ?amniocentesis/ chorionic villus sampling
- 2nd Trimester - Quadruple test. AFP, unconjugated estradiol, betaHCG, Inhibin A, maternal age
- CVS- 10-13w. Sample of placenta. Complications- miscarriage, amniotic fluid leak, sepsis
- Amniocentesis- >15w. Complications- miscarriage, amniotic fluid leak, uterine bleeding, maternal Rh sensitisation, sepsis. More accurate + safer
11
Q
What is term and what are the 3 stages of labour?
A
- Term= 37-42w
- Stage 1= 4-10cm. Reg painful contractions. Start partogram. Progress 0.5cm every hour. FHR every 15mins.
- Stage 2= 10cm - birth. Passive 1-2h –> active. FHR every 5mins.
- Stage 3= Birth - expulsion of placenta
12
Q
High risks births that would require continuous monitoring
A
- Pre-eclampsia
- Macrosomia
- IUGR
- Premature
- DM
- Breech
- Prev. C-section
- APH
- Oxytocin
- Epidural
- Meconium
13
Q
What are you looking at to interpret a CTG?
A
DR C BRVADO
- Define Risk
- Contractions - rate, duration, rhythm, strength
- Basline RAte (norm 110-160)
- Variability >10-15 bpm
- Accelerations- early/variable/late (?hypoxia)
- Decelerations
- Overall assessment and plan
14
Q
Causes of Non-Progressive Labour
A
- Powers:
- Aim 4-5 contractions/10 mins lasting 1 min.
- Ineffective contractions or hyperactive (oxytocin)
- Tx- Inefficient –> amniotomy, augmentation, oxytocin. Hyperactive –> reduce oxytocin
- Passage- Cephalo-pelvic disproportion. Pelvis 13cm at inlet, 11cm at outlet. Tx: assisted, c-sec
- Passenger:
- Malpresentation- face, brow (urgent C-sec), breech
- Unstable lie –> cord prolapse?
15
Q
What is APH and what might cause it?
A
- APH= any leed after 24w upto labour
- Uterine causes:
- Placenta previa
- Placental abruption
- Vasa previa
- Circumvallate placenta
- Lower genital tract causes:
- Ectropion
- Cervical polyp
- Cervical carcinoma
- Cervicitis
16
Q
Ix and Tx of APH
A
- Ix:
- DO NOT DO PV/ SPECULUM EXAM
- Bedside- CTG, urinalysis
- Bloods- Hb, G+S/ Cross-match, Rh status, U+Es, LFTs
- Imaging- USS
- Tx:
- ABCDE + Anti-D
- ?Transfusion
- ?C-section
17
Q
What is placenta previa? RF, Presentation, Tx and complications
A
- = Low lying placenta in 20w scan, PP Dx at 3rd trimester via TVUSS
- Minor/ major
- RF: Infection, multiple preg, fertility, smoking, parity, fibroids, prev. PP, age, trauma, abdo surg
- Presentation:
- Painless bleeding. Bright red.
- SNT abdo
- Displaced presenting part eg transverse lie
- Tx:
- Anti-D
- Manage bleed - ?transfusion
- Minor >2cm away from os. Vaginal.
- Major- C-section
- Complications: PPH, placenta accreta, preterm labour, malpresentation
18
Q
Vasa previa - presentation, Ix, Tx
A
- Foetal BVs cross os –> membrane rupture –> BVs rupture
- Presentation - Membrane rupture w/ painless bleeding
- Ix- Kleihaeur test - ?foetal blood
- Tx- Urgent C-section
19
Q
What is placenta accreta?
A
- Placenta attached to myometrium –> gets left behind.
- RF: Prev. c-section
20
Q
Placental abruption - RF, presentation, Ix, Tx, complications
A
- = Placenta separates from uterus whilst baby still in womb.
- RF: ECV, trauma, pre-eclampsia, parity, smoking, prev PA, anatomy, IUGR, multiple preg, AI, alcohol, drug s
- Presentation:
- Any stage of preg.
- Painful APH. Dark blood.
- Signs of shock - inconsistent w/ blood loss
- Concealed/ revealed
- Tender, contracting ‘woody’ uterus
- Ix- USS to rule out previa
- Tx:
- ABCDE, resus, CTG, anti-D
- Foetal distress –> urgent c-sec
- No foetal distress- expectant management and induction at 37w
- Complications: Foetal death, haemorrhage, DIC, renal failure, maternal death, PPH, Sheehan’s (pituitary necrosis secondary to hypovolaemic shock)
21
Q
Tx of Pre-existing HTN in pregnancy
A
- = HTN <20w
- Aim <150/100
- Stop ACEi/ ARBs
- Aspirin 75mg
- Test for proteinuria reg
- Growth scans 28 + 32w
22
Q
What is pregnancy induced hypertension, it’s stages and their management
A
= After 20w with no significant proteinuria. Resolves 6w post-partum
- Mild (<150/100)- no Tx, BP measurement weekly, urine dip each visit, routine bloods only
- Mod (<160/110)- oral labetalol, BP measurement 2x/w, urine dip each visit, bloods at presentation - U+Es, LFTs, FBC
- Severe (>160/110)- admission, oral labetalol, BP measurement QDS, urine dip daily. Bloods Presentation + weekly
23
Q
Pre-eclampsia, Presentation, Ix, Tx
A
- = >20w with HTN and proteinuria
- Presentation:
- HTN
- Headahce
- RUQ pain/ vomiting
- Blurred vision
- Hyper-reflexia/ Clonus
- Swelling
- Fundoscopy- papilloedema
- Ix:
- Bedside- urine PCR or 24h urine collection for ?proteinuria, CTG
- Bloods- U+Es, FBC (platelets), clotting, urate (??DIC)
- Imaging- growth scan
- Tx:
- Antihypertensives: labetalol, nifedipine, methyldopa
- Cure= deliver placenta. Indications to deliver- Term, IUGR, foetal distress, refractory HTN with 3 drugs at highest dose, changes in bloods, eclampsia, HELLP, DIC
24
Q
RF for pre-eclapmsia
A
- High risk: (any one –> 75mg Aspirin 12w)
- Prev. Pre-eclampsia or PIH
- DM
- Pre-existing HTN
- CKD
- SLE/ antiphospholipid
- Moderate risk (any 2 –> aspirin)
- Age >40y
- BMI >35
- Multiple preg
- Preg interval >10y
- 1st preg/ 1st preg w/ new partner
25
Key features of HELLP syndrome
* = Haemolysis, Elevated Liver Enzymes, Low Platelets
* Haemolysis - **LDH**. Blood film= gold standard
* Liver enzymes- LFTs
* Platelets - FBC
26
Complications of Pre-eclampsia
* Intracerebral haemorrhage
* Liver rupture
* HELLP/ DIC
* Eclampsia
* Renal failure
* Placental abruption
* IUGR
27
Key features of eclampsia
* = Seizures
* Can fit after delivery - don't discharge until \>36 hours post-delivery. Reg BP and fluid restriction.
* Tx:
* 1. BP control
* 2. Magnesium sulfate IV --\> diazepam --\> lorazepam --\> intubation
* Magnesium sulfate toxicity- reduced reflexes/ UO/ RR. Tingling around mouth. Antidote= sodium gluconate
28
Complications of DM in pregnancy
**Maternal**
* Infections, UTIs
* Pre-eclampsia
* C-section
* Retinopathy
* Nephropathy
**Foetal**
* Miscarriage, IUD
* Macrosomia/ IUGR
* Congenital abnormalities
* Neonatal hypoglycaemia
* NTD
* Heart disease
* Polyhydramnios
* Miscarriage
* Risk DM later in life
* Shoulder distocia
* Pre-term
29
Management of Pre-existign DM in pregnancy
* MDT!!!
* Pre-conception:
* HbA1c \<43
* Baseline kidney function, eye check, BP
* Stop sulfonylureas, statins, ACEi
* 5mg Folic Acid
* Antenatal care:
* Booking by 8w. DM antenatal clinic every 2w.
* Cardiac scan 24w, growth scans from 28w
* Glucose monitoring. Increase insulin 2/3?. Aim BM \<6.0mmol
* 75mg Aspirin \>12w
* Intrapartum care:
* Delivery \<29w
* C-section if est weight \>4kg
* Glucose/Insulin/K+ sliding scale. Aim 4-7mmol/L. Measure every hour
* Post-partum:
* Baby- risk of hypo --\> feed within 1h
* Insulin back to normal
* 6w check - HbA1c, OGTT, FBC
30
RF for GDM
* Prev. GDM (screen 18w)
* Prev. foetus \>4.5kg
* Prev. unexplained still birth
* \>35y
* FDR with DM
* BMI \>30
* PCOS
* Race- SE Asia, Caribbean, middle east
* Polyhydramnios
* Persistent glycosuria
* --\> OGTT at 24-28w. Fasting --\> bloods --\> 75g glucose --\> bloods 2h later
31
Treatment of GDM
1. Diet control
2. Oral hypoglycaemics eg metformin
3. Insulin
* Growth scans
* Delivert 38-41w
* Do fasting HbA1c at 6w. Annual testing - 40% T2DM later in life
32
Key features of obstetric cholestasis
* Abnormal sensitivity to oestrogen --\> cholestasis
* Genetic - FHx, S Asia esp
* Presentation:
* \>28w
* ITCH - palms and soles, ++ night, excoriations, no rash
* Jaundice
* Ix:
* Monitor CTG.
* Elevated LFTs (ALP, GGT, Bile acids) --\> measure weekly.
* Tx:
* 6w follow up. Should have resolved.
* Induce at 37w (risk still birth)
* Med- ursodeoxycholic acid, chlorphenamine, Vit K from 36w
* Cons- topical emollients
33
Classification of obesity in pregnancy and complications
* BMI 30-34.9= Obese, 35-39.9= Severely obese, BMI \>40= Morbidly obese
**Maternal**
**Baby**
Difficulty palpating foetus
Macrosomia/ IUGR
Spont + recurrent miscarriages
Foetal/ infant death
Pre-eclampsia
CVD
GDM
T1DM/T2DM
VTE
Cancer
Infections eg wound
Asthma
PPH
Congenital abnormalities
C-section + complications
34
What is Rhesus Isoimmunisation and Mechanism?
1. Rh -ve mother concieves a Rh +ve foetus (D-antigen)
2. Sensitising event --\> foetal cells can enter maternal blood stream --\> maternal antibody response (sensitisation)
3. Not a prob in 1st pregnancy (IgM can't cross placenta) --\> NEXT PREG --\> IgG can cross placenta
4. Immunodestruction of foetal RBCs --\> Rh Haemolytic disease of newborn - RBC destruction, jaundice.
35
Rhesus sensitising events
* DELIVERY
* Miscarriage
* Trauma
* Placental insufficiency
* TOP
* Invasive AN testing eg amniocentesis
* APH
* ECV
* Blood transfusion
36
How does Anti-D work and when should it be given?
* Immunoglobulin injected into mother --\> binds to D antigen on foetal RBCs --\> cannot mount IgG response. No sensitisation.
* Given at 28w, 34w and \<72h after potential sensitising event.
* Kleihauer test - how much foetal blood in maternal bloodstream = how much anti-D is needed
37
Signs of foetal anaemia in Rh isoimmunisation
* Ix: Do Doppler of foetal MCA, foetal blood sampling if anaemia likely
* Polyhydramnios
* Cardiomegaly
* Ascites/ pericardial effusion
* Variability on CTG
* Hyperdynamic circulation
* Hydrops and foetal death in severe
* --\> Tx= foetal blood transfusion/ delivery if \>36w
38
Management of Rh Isoimmunisation
* ID risk - determine foetal blood type (paternal blood), Ab testing every 2w (if increased --\> look for signs of foetal anaemia)
* Assess severity - doppler foetal MCA 2 weekly. Anaemia likely --\> foetal blood sample
* Tx:
* Anti-D to prevent sensitisation
* Transfuse blood if foetus anaemic. Deliver if \>36w
* Post-natal check - FBC, Bili, Rh status
39
Causes of maternal collapse and management
* Pregnancy specific - Amniotic fluid embolism, APH, PPH, eclampsia
* Non-Pregnancy specific - Sepsis, VTE, PE, haemorrhage, drug-induced, hypoglycaemia, MI, arrhythmia
* Tx:
* MEOWS \>7= senior r/v ASAP
* ABCDE (don't lie flat)
* No response to CPR in 4 mins in \>20mins --\> perimortem C-section
40
Key features of sepsis in pregnancy
* Signs and symptoms may be less distinctive. Most common post-natal
* Commonest cause= GBS
* Tx: sepsis 6, continuous EFM
41
Key features of post-partum pyrexia
* Maternal fever \>38 in 1st 14d
* Common sites of infection- UTI, LRTI, mastitis, perineal, c-section wound --\> O/E: abdo, breast, IV access sites, chest, legs
* Pathogens: GBS, staph, E. Coli
* Ix: Blood, urine, high vaginal and foetal swabs
* Tx: Sepsis 6. Broad spec ABx
42
Key features of chorioamnionitis
* = Infection within the womb --\> PPROM
* Common cause: E.Coli, GBS, STI, UTI
* Presentation:
* Fever
* ++ HR and foetal HR
* Foul smelling vaginal discharge
* Abdo pain
* Leukocytosis (high WCC)
* PPROM
* Ix and Tx: Sepsis 6. Swabs.
43
Key features of amniotic fluid embolism
* Defect in amniotic sac --\> pressure --\> fluid into maternal blood stream --\> embolises into pulm. circulation --\> blockage of vessels and immunological/ inflammatory reaction --\> DIC, foetal hypoxia, still birth
* Can happen PP (upto 30 mins after delivery)
* RF: TOP, amniocentesis, placental abruption, trauma, c-section
* Tx= supportive
44
Why are pregnant women at increased risk of VTE and how are they risk assessed?
* VTE 10x more common in preg:
* Change in clotting factors - less factor 11,13 and platelets, more fibrinogen
* More venous stasis - obstruction and reduced mobility
* High mortality antenatally, higher risk post-partum
* All pregnant women assessed for VTE risk at booking, admission, labour and post-natal:
* 3 or more --\> prophylaxis over 28w
* 4 or more --\> Tx throughout preg
* Postnatal 2 or more --\> prophylaxis
* Risk assessment based on: Prev VTE or FHx in 1st degree relative, co-morbidities, known high risk of thrombophilia, \>35y, obesity, parity\>2, smoker, gross varicose veins
45
Presentation, Ix, and Tx of VTE in preg/post-partum
* Presentation- PE, DVT
* Ix:
* Bedside- obs, urine dip, measure calves, CTG
* Bloods- clotting, FBC (platelets), PT, U+Es, LFTs. NOT D-DIMER
* Imaging - Doppler USS, PE - CXR/ V/Q scan, growth scan
* Tx:
* Cons- compression stockings
* LMWH (based on risk or presentation). Tx - continue 6-8w post partum
* Prev VTE --\> IV heparin
* Stop anti-coagulation 24h before labour
46
RF, classification, and presentation of multiple pregnancy
* RF: IVF, FHx, maternal age, W African
* Presention:
* ++ Preg Sx, large
* \>1 heart beat (\>10bpm)
* Labda sign on USS
* Classification:
* Dizygotic- non-identical.
* Monosyzgot- single egg splits --\> timing determines chorionicity (placentas) and amnionicity (sacs)
47
Complications of Multiple Pregnancy
Mother
* Miscarriage
* Anaemia
* Pre-eclampsia
* DM
* APH/PPH
Baby
* Stillbirth
* Pre-term labour
* Malpresentation
* IUGR
* Foeto-foetal transfusion syndrome à HF in recipient
* Congenital abnormalities
* Cord entanglement/ prolapse
* Development/social consequences
* Polyhydramnios
48
Antenatal care and intrapartum care of multiple pregnancy
* High dose folic acid
* Aspirin 75mg
* ?Iron if anaemia
* 1st trimester scan to determine chorionicity and amnionicity
* Mono --\> 2 weekly scans from 16w
* Di --\> 4 weekly scans from 20w
* Intrapartum;
* IV syntocin drop
* C-section if mono, non-cephalic prsentation of 1st twin, triplets, other RF
49
Different types of breech presentation
50
Management of Breech presentation
* ECV:
* \>36w (\>37 if multiparous)
* NB prophylactic Anti-D
* Tocolytic meds + analagesia --\> ECV
* Contraindications- labour, prev c-sec, APH, abnormal uterus, abnormal CTG, multiple preg
* Risks- placental abruption, cord damage, uterine rupture, PPROM
* Spon Breech delivery:
* Trained staff. Lying down on back with manoevers
* Risks: Anoxia due to prolapsed cord, traumatic injury to aftercomign head, fracture spine/ arm
* Continuous CTG
* C-Section:
* Indications- footling, large, small, narrow pelvis, no trained professionals
51
Definition of IUGR and classification
* = Estimated weight/ abdo circumference \<10th centile of customised growth chart (weight, height, ethnicity, parity, Hx past pregs)
* Classification:
* Constitutionally small eg short mum
* Non-placenta mediated growth restriction - structural/ chromosome abnormality, inborn errors of metabolism
* Symmetrical - early preg
* Mixed
* Asymmetrical- late. Head/ femur length diff
52
RF for IUGR
* \>35y
* Infection
* Nulliparity
* Pre-eclampsia
* Prev SGA/ still birth
* Malnutrition
* Medical condtion affecting BF eg antiphospholipid, AI, renal, BP, DM
* Smoking/ substances
* Low/high BMI
* DM
53
Complications of IUGR
**Early**
* Perinatal asphyxia
* Meconium aspiration
* Hypothermia
* Hyperglycaemia
**Late**
* Neurobehavioural
* FTT
* Risk of obesity, metabolic syn, T2DM, CVS
* Jaundice
* Feeding probs
54
Management of IUGR
* Consultant led
* 75mg aspirin \<16w
* Serial growth scans - USS and doppler every 2w
* Serial measurements of fundal height
* CTG daily 34-36w
* C-section/ induction at 37w
55
Definition of macrosomia, RF, Tx and complications
* = \>90th centile or \>9lb 15oz
* RF: Maternal obesity, DM, ABx, genetics, gestation\>40w, hydrops foetalis
* Tx:
* Monitor- USS, BMI, fundus
* Induce 38w latest
* Screen GDM
* Risks: cephalo-pelvic disproportion, shoulder, distocia, hypo
56
Definition of pre-term labour and causes
* = Delivery \<37w (++ risks \<34w)
* Causes:
* PPROM
* Incompetent cervix eg LLETZ
* Infection- chorioamnionitis, UTI, GBS
* Over-distended uterus - multiple, polyhydraminos
* Maternal systemic disease - heart, kidney, DM, stress
* Foetal abnormalities
* Uterine abnormalities
* Iatrogenic - DM, IUGR, Pre-eclampsia
* Preg complications - placental abruption, placental previa, PIH
57
RF for pre-term labour
* Stressful event
* Cocaine/ drugs
* \>35y
* Smking
* UTI
* Uterine abnormality
* Maternal illness
* Multiple preg
58
Complications of Pre-term labour
**Early**
* Death
* Hypothermia
* Infection
* Feeding difficulty
* Hypoglycaemia
* Brain haemorrhage
Late
* Hearing loss
* Cerebral palsy
* Chronic breathing probs
* Retinopathy and blindness
* Resp distress
* Necrotising enterocolitis
59
Ix and management of Pre-term labour
* Ix:
* USS
* Sterile speculum
* Foetal fibronectin - swab - protein released when membranes start to separate from uterine wall
* Amnisure test - ?amniotic fluid
* Tx:
* Corticosteroids- lung maturity. 2x12mg betamethasone given 24h apart. \<35+6
* Nifedepine - tocolysis. \<33+6 (CI- infection, abruption)
* Magnesium sulphat - foetal neuroprotection (\<30w)
* Prophylacitc ABx
* Emergency cervical cerclage - \<28w. CI if contracting.
* Delivery - C-section \<34w. Involve Paeds
* Prevention - scan and monitor future preg. Progesterone pessary if cervix shortens. Cervical cerclage.
60
What is PPROM? Ix + Tx
* = Waters break \<37w
* Present: gush of clear fluid
* O/E: Speculum - pool of clear fluid in post. fornix. Avoid VE
* ???Chorioamnionitis???
* Ix:
* Bedside- steriel speculum, swabs (high vaginal, foetal fibronectin)
* ?Bloods
* Tx:
* Monitor
* Med: ABx (erythromycin), corticosteroids, magnesium sulphate (neuroprotection), delivery \>34w
61
When is labour induced and what are the indications? + Contraindications
* 37w if medical indication or \>42w (post-term)
* Indications:
* Chrioamnionitis
* IUD
* Pelvic girdle pain
* Post-date \>42w
* PPROM
* HTN
* SGA/ IUG
* Oligohydramnios
* Placental abruption
* Non-medical eg social request
* Contra-indications- anything that CI vaginal delivery eg foetal distress, transverse lie, HIV etc
62
Procedure of induction of labour
1. Assess Bishop's score (consistency, effacement, dilatation, station)
2. ARM (amniotomy) or Cervical ripening
* Prostaglandins- gel/ tape
* Hydroscopic dilators
* Balloon catheter
3. CTG
4. Oxytocin infusion 0.3-9.6ml/h. Infusion pump.
5. IVT, G+S
6. Failed induction --\> repeat cycle once --\> c-section
63
Complications of induction of labour
* Foetal distress
* Amniotic fluid embolism
* PPH
* Cord prolapse
* Hyperstimulation
* Chorioamnionitis
64
Effect of Epilepsy on Pregnancy and visa versa
* Epilepsy control - most stay same.
* Epilepsy usually not damaging in pregnancy until status epilepticus.
* Some anti-epileptics can cross placenta --\> cardiotoxic, NTD, cleft lip. Esp sodium valproate
65
Management of Epilepsy in Pregnancy
* Pre-conception- swap from sodium valproate to lamotrigine/ carbamazepine. 5mg folic acid.
* Antenatal- NB 20w anomaly scan, cardiac scan at 24w, growth scans \>28w. Vit K injections every day in 3rd trimester w/ carbamazepine (enzyme inducers)
* Intrapartum- Ensure good pain relief
* Post-partum- pill might not work with enzyme inducers --\> coil/ depo
66
What is an episiotomy and its indications?
* Indications: foetal distress, head is not passing over the perineum depite maternal effort or a large tear is likely.
* Method: inject local anaesthetic, 3-5cm cut made with scissors from the centre of the fourchette at 45 degree angle
67
Classification of perineal trauma
1. Injury to skin only
2. Involves perineal muscles (+ episotomy)
3. Involves anal sphincter complex
4. Involves anal sphincter and anal epithelium
68
Assisted delivery: Aim, indications, methods, complications
* Aim= reduced time of second stage of labour
* Indications:
* Maternal exhaustion
* Foetal distress (confirmed by FSE)
* HTN, cardiac disease
* Breech for aftercoming head
* Methods:
* Ventouse - rule of 3s (\<30m)
* Forceps - Keillands. Less maternal effort.
* Complications: Shoulder dystocia, trauma, haemorrhage, infection, bladder damage, neonatal jaundice
69
Indications of C-Section
* Mum- prev. C-Section
* Baby- IUGR, cord prolapse, foetal distress
* Both:
* Abnormal progress
* Malpresentation
* Placenta previa/ abruption
* Severe APH
* Pre-eclampsia
* Other medical conditions
70
Categories of C-Section
1. \<30mins - life threatening
2. \<60 mins - Maternal/foetal compromise
3. By end of day - avoid complications
4. Elective
71
C-section procedure
* Analgesia- spinal block/ epidural/ GA (emergency
* 2 types of incision:
* Classical (vertical) - extreme prematurity, need large incision
* Transverse lower segment
* Cut through all layers --\> delivery baby and placenta --\> stop bleeding --\> inspect area --\> close
72
Complications of C-Section
* Bleeding and VTE
* Infection
* Organ/ bladder damage
* Scar dehiscence
* Baby- resp distress, low APGAR
73
What is VBAC and what complications does it bear?
* = Vaginal Birth After C-section
* Risk = 1 in 200 of scar dehiscence
* Contraindications- classical incision, prev rupture
74
What is shoulder dystocia, RF and management
* = When normal downward contraction fails to deliver shoulders once head isi delivered --\> excessive traction on neck can damage brachial plexus (Erb's)
* RF: baby \>4kg, Prev SD, induction of labour, BMI and DM, instrumental delivery
* Tx:
* GET HELP ASAP!
* Gentle downward traction, legs hyperextended onto abdo wall (McRobert's Manoever)
* --\> Wood screw manoever. Episiotomy + internatl manoever
* Last resort= symphysiotomy, replacement of head and c-section
75
Post-Partum Haemorrhage classification
* Primary= \<24h of delivery
* Secondary= \>24h-6w. Cuases- endometriosis, retained placenta, gynae pathology
* Minor= 500-1000mL (\>1000mL after c-section)
* Mod= 1000-2000mL
* Severe= \>2000mL
76
RF for PPH
* **APH**
* Prev PPH
* Prev C-section
* Instrumental delivery
* Coagulation defect
* Uterine eg fibroise
* Prolonged induction of labour
* Multiple Preg
77
Causes of PPH
* **Trauma** - Perineal, vaginal, instrumental delivery, c-section, uterine rupture.
* **Tone** - BMI \>35, multiparity, maternal age \>40y, P. Previa, macrosomia, shoulder distocia, uterine abnormalities, prolonged labour, polyhydramnios/ over-distention
* **Tissue** - P. Previa, retained placenta, morbidly adherent placent, p abruption
* **Thrombin** - DIC, sepsis, anticoagulants, coagulopathies
78
Management of PPH
* Aim= stop bleeding!
* ABCDE + resus. Including cross-match
* Tone- ergometrine, misoprostol
* Trauma - examine + suture
* Tissue - examine placenta, manual removal \<60mins. IV oxytocin.
* Thrombin - check clotting and correct
* Laparotomy + hysterectomy may be needed.
79
When do you treat iron deficiency anaemia in preg?
Hb \<11 g/dL
80
Oligohydramnios - causes, Ix, Tx, complications
* Causes:
* Leakage of amniotic fluid - SROM, PPROM
* Reduced foetal urine production - IUGR, renal abnormalities, post-dates
* Obstruction to foetal UO - poor urtheral valves
* Ix: USS + doppler, speculum, ?SROM - bloods + vaginal swabs
* Tx the cause
* Complications related to cause/ reduced vol - lung hypoplasia, limb abnormalities
81
Polyhydramnios - Causes, Tx, complications
* Causes:
* Increased foetal UO - maternal DM, FFTS, foetal hydrops
* Inability to swallow/ absorb amniotic fluid- GI obstruction eg duodenal atresia (Down's), neuromuscular abnormalities, facial obstruction
* Tx- Cause. Severe- amnioreduction/ NSAIDs
* Complications- pre-term labour, malpersentation, maternal discomfort
82
Differentials for vaginal discharge, their presentation and Tx + Ix
* Chlamydia - ++ mucopurulent and yellow, pelvic pain, bleeding. Tx= Azithromycin
* Gonorrhoea - ++ Mucopurulent, thick, white. Dysuria, pelvic pain, friable cervix. Tx= Ceftriaxone + azithromicin
* Bacterial vaginosis - thin, watery, white/grey. FISH. Tx= Metronidazole
* Candida- itchy, white, curd like. Vulval soreness/ pain. pH \<4.5. Tx= clotrimazole/ fluconazole
* Trichomonas (STI)- frothy, offensice yellow/green. Fish. Strawberry cervix. Tx= Metronidazole + partner Tx
* Ix: Speculum, high vaginal and endocervical swabs, pelvic USS, MSU, biopsy
83
What is Fitz-Hugh Curtis syndrome?
STI --\> PID --\> liver capsule inflammation
84
Key features of cervical ectropion
* Columnar epithelium of endocervix visible as red area around the os
* Normal in preg, puberty, OCP
* Presentation- ASx, discharge, PCB, prone to Inf
* Ix- smear, colp
* Tx- cryotherapy
85
Key features of cervical polyps
* = benign tumours of endocervical epithelium. Usally \>40y
* Presentation- ASx, IMB, PCB, PMB
* Tx- avulsion + surg removal
86
What are fibroids, their types and RF
* = Leiomyomata. Benign growth of uterine muscle. Growth dependent on oestrogen and progesterone.
* RF:
* Oestrogen exposure (reduced risk COCP)
* Obesity
* Black
* FHx
* Age
* Types:
* Intramural
* Submucosal (into cavity) ++ bleeding
* Subserosal - just outside the uterus
87
Presentation of fibroids
* 'Dragging' sensation
* IMB
* Pelvic pain
* Menorrhagia
* Bloating/ distention
* Infertility
* Acute pain - torsion, degeneration
* Dyspareunia/ dysmenorrhoea
* ?Feel on bimanual
* Sx of pressure on other organs - urinary/bowel
* ASx?
88
Ix and Tx of fibroids
* Ix:
* Bedside- clinical examination, urine
* Bloods- FBC
* Imaging - USS +/- TV
* Tx:
* Sx + \<3cm:
* Mirena coil, POP
* NSAIDs
* Tranexamic acid, mefanamic acid
* Progesterone days 5-26 of cycle
* GnRH agonists --\> artifical menopause to shrink fibroids. \<6m pre-surg.
* Large fibroids, Sx/ not responding:
* Myomectomy (preserve feritlity)
* Hysterectomy
* USS to ablate
* Embolisation
* Ablation
89
When is cervical cancer screening carried and what do the results mean?
* 25-49 = 3yearly
* 50-64 = 5 yearly
* \>65y if haven't had smear since 50y
* Results = cellular abnormalities- dyskaryosis mild, mod, severe (risk of CIN)
* Mild --\> HPV testing --\> +ve high strain to colp, rest back to 3/5 yearly screening
* Mod - Colp
* Severe - urgent colp
* Colposcopy --\> stain with 5% acetic acid --\> grades of CIN. 1-3 based on thickness of epithelium. Dx on biopsy
* CIN= pre-malignant change. CIN II/III excised - LLETZ (risk haemorrhage, pre-term labour)
90
Cervical cancer - RF, presentation, Ix, Tx, complications
* = Squamous cell carcinoma. More common 25-29y.
* RF= Smoking, ++ sexual intercourse/ multiple partners, immunosuppression, HPV (16, 18) --\> vaccinate against HPV.
* Presentation:
* IMB/ PCB/ PMB
* Dyspareunia
* Offensive discharge
* Constipation
* Incontinence/ haematuria
* Bone pain
* Fever, lethargy
* Tx: Radiotherapy, chemotherapy, surgery
* Complications - bone pain, kidney failure, PE/ DVT
91
Pelvic pain DDx
* Pregnancy - Miscarriage, ectopic, abruption,
* Abdo- appendicitis, UTI, IBS/IBD, strangulated tumour, constipation
* Gynae:
* Endometriosis
* PID
* Fibroids
* Adenomyositis (endometrial tissue in myometrium)
* Chronic pelvic pain
* Mittleschmertz (ovulation)
* Menstruation
* Ovarian cyst - rupture/ torsion
92
What is PID, cause and RF
* = Inflammation of pelvis/ upper genital tract with source of infection
* Cause- infection esp chlamydia, gonorrhoea, (E. Coli)
* RF:
* \<25y
* Sexually active
* Hx STI
* Recent new partner
* Multiple sexual partners
93
Ix and Tx of PID + complications
* Ix:
* Bedside - urine dip, preg test, endocervical swabs (NAATS)
* Bloods- ESR, CRP, WCC
* Imaging - USS if not responding to ABx ?abscess
* Tx:
* Cons- take out coil - ??source of infection. Not if sex in last 7 days. STI screen
* Med- analgesia, empirical braod spec ABx
* Complications- ectopic, chronic pelvic pain, adhesions, tubal infertility
94
Endometriosis - RF, Signs + Sx
* = Growth of endometrial tissue outside uterine cavity (oestrogen dependent). Usually 20s.
* Tissue undergoes menstrual cycle --\> bleeding --\> inflammation --\> adhesions
* RF:
* FHx
* Obstruction to vaginal outflow - FGM, defects in uterus/ tubes
* Prolonged oestrogen exposure
* Presentation:
* Dysmenorrhoea, dyspareunia
* Chronic pelvic pain
* IMB
* Bloating
* Constipation
* Rectal bleeding / haematuria
* Fixed retroverted uterus
* Adnexal masses
95
Ix and Tx of endometriosis
* Ix: (rule out ddx)
* Bedside - urine, cervical swabs, preg test
* Bloods- FBC, CRP, Ca-125
* Imaging - USS, MRI
* Tx: ??preserve fertility
* Medical
* Suppression of oestrogen for 6m - COCP, GnRH agonists (not pulsatile --\> temp menopause).
* Reduce inflamm - NSAIDs
* Surgical- laparoscopic removal of tissue/ diathermy, hysterectomy
96
Ectopic pregnancy - key features, RF, presentation, Ix and Tx
* = Implantation of fertilised egg outside uterine cavity.
* Locations - **Tubal**, abdominal, ovarian, cervical, c-section scar
* RF: IUD, PID, endometrititis, PMH ectopic
* Presentation:
* Lower abdo pain
* PV bleed
* Shoulder tip pain
* Collapse
* Peritonism
* Adnexal tenderness
* Cervical excitation
* Ix:
* Blood- high beta HcG, low progesterone
* Imaging- TVUSS
* Special - laparoscopy
* Tx:
* ABCDE
* 1. expectant
* 2. IM methotrexate if betaHcg \<5000mIU/mL
* 3. Surg- laparotomy
97
Definition of miscarriage and types + RF
* = Expulsion of foetus when incompatible with life \<24w
* RF: infection, STI, SLE, \>45y, NSAIDs, methotrexate, fibroids, HTN, PCOS, smoking/ alcohol, DM, obesity
* Types:
* Delayed/ missed - on scan
* Threatened - bleed, os closed
* Inevitable - os open
* Complete
* Incomplete
98
Presentation, Ix and Tx of miscarriage
* Presentation: Pain, Bleeding, contractions
* Ix:
* Bedside- urine, preg test, NEWS
* Bloods - hCG, progesterone (down)
* Imaging - TVUSS
* Tx:
1. Expectant - \<6w
2. Medical - prostaglandin pessary/ tablet
3. Surgery- ERCP, MVA
4. Psych support
* Ix recurrent - Antiphospholipid Ab, karyotyping of foetus, pelvic USS
99
Key features of molar pregnancy
* Trophoblastic cells- villi in lining of uterus --\> develops into placenta
* = Slow growing tumour. Villi swollen with fluid --\> clusters that look like **grapes**. Tumour grows instead of foetus
* Benign but can develop into malignant GTD --\> **invasive mole** (in muscle layer)
* Causes:
* **Complete** mole - sperm fertilises empty egg
* **Partial** mole - 2 sperms fertilise egg
* Presentation - Often no Sx. PV bleeding, ++ morning sickness --\> picked up on scan
* Ix:
* Bloods- ++ **hCG** levels
* USS - grape like appearance. No foetus.
* Tx- surgical removal.
100
Key features of hyperemesis gravidarum
* = Excessive morning sickness
* RF: multiple or molar preg - ++hCG
* Complications
* Mum- weight loss, dehydration, electrolyte imbalance, renal failure, muscle wasting
* Baby- IUGR
* Ix:
* Urine - ketones, MSU
* Bloods- FBC, U+Es, LFTs
* USS
* Tx:
* Admit --\> IVT, daily U+Es
* --\> anti-emetics --\> corticosteroids
101
Types and presentation of ovarian cyst
* Types:
* Simple - follicle cont to grow after egg released. May resolve months.
* Endometrioma - chocolate cyst. Endometriosis
* Dermoid - hair/ fat. may be v. large
* Presentation:
* Usually Asx - incidental
* Abdo/ pelvic pain
* Dyspareunia
* Dysmenorrhoea/ change in cycle
* Frequency/ urgency
* Acute- rupture/ torsion
* Abdo distention
* Loss of appetitie/ early satiety
102
Ix and Tx of ovarian cyst
* Ix:
* Bedside- Urine dip, abdo/pelvic exam
* Bloods- Ca-125
* USS
* Tx:
* \<5cm - watchful waiting
* 5-7cm - USS 1 year
* \>7cm --\> further Tx ?surgery
103
What is PCOS and what causes it?
* PCOS= Polycystic ovary syndrome = Hyperandronic anovulation.
* Pathophysiology:
* Inappropriate signalling between hypothalamus, pituitary and ovary
* More peripheral oestogen + GnRH
* **High LH, low FSH**
* More **androgens**
104
Presentation of PCOS
* Presentation:
* Oligomenorrhoea
* Hirsutism
* Obesity
* Infertility
* Weight gain
* Acne
* Thin hair
* Acanthosis nigricans
* HAIR-AN syndrome= hyperandrogenism, insulin resistance, acanothosis nigricans
105
Ix, Dx and Tx of PCOS
* Ix:
* Bedside- bimanual - enlarged ovaries
* Bloods - DHEAS = hyperandrogenisms, fasting lipids, glucose
* Imaging - pelvic USS
* Dx= 2/3 of:
* Oligo-ovulation
* Excess androgen activity
* USS - polycystic ovaries
* Tx:
* Diet + exercise + weight loss
* OCP (lowers LH) - aim 3-4 monthly bleeds to reduce risk of endometrial Ca
* Insulin sensitising agens
* Clomiphene citrate - ovulation induction
* Surg - ovarian drilling - reduce steroid production
106
Long term consequences of PCOS
* Endometrial hyperplasia / adenocarcinoma
* T2DM
* HTN/ CVS disease
* Stroke
* Obesity
107
Key features of ovarian torsion
* = Twisting of ovary aruond its ligamentous supoprt --\> loss of blood supply to ovary + fallopian tube
* Presentation:
* Abdo pain/ tenderness. IF --\> loin/groin/back
* N+V
* Low grade fever
* Peritonitic signs
* Cervical motion tenderness
* Plapable adnexal mass
* Ix:
* Bedside- urine, preg test
* Bloods - FBC
* Imaging - Abdo/ TV USS, CT abdo/pelvis
* Tx: Surgical. Untwist + fix
108
Most common ovarian cancer and RF
* 90% epithelial
* RF:
* High oestrogen exposure
* Infertility
* PMH breast cancer
* FHx BRCA1/2
* Protective - low ostrogen, parity, OCP, NSAIDs
109
Presentation of ovarian cancer
* VERY VAGUE
* IBS type Sx - change in bladder/ bowel
* Abdo pain
* Ascites/ bloating
* Loss of appetite and weight. Early satiety.
* Indigestion
* Nausea
* Omental cake - hard and craggy
* Fatigue
110
Ix and Risk of Malignancy Index for ovarian Ca
* Ix:
* Urine - dip, preg test
* Bloods - Ca-125
* Imaging - USS --\> CT for staging
* RMI= A x B x C. \>200 --\> MDT, \<200= Tx in unit
* A- USS - solid areas, bilateral, ascites (0-3)
* B Ca-125 \>35
* C- menopausal status - pre-menopausal= 1, post-menopausal= 3
* Other causes of raised Ca-125: Preg, endometriosis, fibroids, malignancy, menstruation
111
Tx of ovarian cancer
* Combo of surgery (debulking) + chemo (carboplatin, paclitaxel)
* Follow up 3 monthly for 2y, 6 monthly for 2y, 1y --\> discharge
112
Ovarian cancer 2 ww
* 2ww - Asictes or pelvic/ abdo mass
* Tests in GP if:
* Abdo distention
* Early satiety
* Pelvic/ abdo pain
* Urgency/ frequency
* Weight loss
* Change in bowel habit
* New onset IBS \>50y
* --\> Ca-125 \>35 IU/ml --\> USS
113
Most common type of endometrial cancer, RF and presentation
* Pre-malig= hyperplasia
* Most common= adenocarcinoma
* RF: Post-menopausal, \>45y, high oestrogen exposure, PCOS, tamoxifen, diet. (Smoking protective)
* Presentation:
* **PMB**
* Pelvic/ abdo pain
* Discharge
* Polymenorrhoea
114
Endometrial cancer 2ww referral criteria
* \>55y with PMB (? if \<55y)
* Direct access to USS if \>55y with:
* Unexplained PV discharge + thrombocytosis/ haematuria
* Visible haematuria + low hb, high glucose
115
Ix and Tx of endometrial cancer
* Ix:
* Pipelle biopsy if \>5cm
* TVUSS
* Hysterectomy + washings --\> histology
* Tx:
* Radio/ chemo
* Hysterectomy
* Progesterone - PO/ coil. Sx control
116
Definition of primary and secondary amenorrhoea and causes
* Primary amenorrhoea= never had a period. \>16y with no periods of secondary sexual characteristics. Causes:
* Constitutional delay
* Kallmann's syndrome - x puberty and smell. Hypogonadotrophic hypogonadism
* Prolactinoma
* Anorexia
* Athletes
* Secondary amenorrhoea= no period for \>6m. Causes:
* Pregnancy, lactation, ovarian insufficiency, low BMI, hyperthyroid, pituitary tumour, **PCOS** (oligomenorrhoea)
* Ix- preg test, BMI, TFTs, LH + FSH, USS, MRI
* Tx- lifestyle, Tx cause, progesteogens
117
Intermenstrual bleeding - causes, Ix and Tx
* Causes= polyps, STI, ectropion, ovulation, endometrial/ cervical cancer, trauma
* Ix:
* Bedside- swabs, bimanual/ speculum, smear
* Imaging- USS
* Special - pipelle, colposcopy
* Tx: Based on cause
118
Menorrhagia - definition, causes, Ix and Tx
* = Subjective. An amount that a woman considers to be excessive
* Causes:
* Younger - IUD, endometriosis, bleeding disorder, polyps, PCOS, hypothyroid
* Older (\>35y)- Hypothryoid, fibroids, malignancy, polyps, IUD
* Ix:
* Bedside- Hx and exam
* Bloods- clotting, Hb
* Imaging- USS, hysteroscopy
* Special- pipelle
* Tx:
* Conservative- Symptomatic
* Medical- Mirena, NSAIDs, tranexamic acid, OCP
* Surgical- ablation, hysterectomy
119
Definition of menopause and presentation
* = 12 months consecutive amenorrhoea. Peak 51-52y
* Early menopause= **40-45y**
* Premature ovarian failure = **\<40y**. Causes: Primary= genetic, AI, enzyme deficiency. Secondary= chemo, radio, inf, hysterectomy
* Presentation:
* Vasomotor - hot flushes/ night sweats
* Anxiety, low mood
* Osteoporosis (1/3)
* CVS disease
* Vaginal dryness
* Urinary
* Palpitations
* Less sleep and palpitations
* Low libido/ dyspareunia
* Thin hair, brittle nails
* Myalgia
120
Ix and Tx of menopause
* Ix= Usually clinical.
* High **FSH**/ LH, low oestrogen/ progesterone - primary ovarian failure
* Rule out DDx: Preg, PCOS, thyroid, TB, malignancy, infection
* Tx:
* Cons- lifestyle- less caffeine and alcohol, smoking cessation, weight loss
* Med:
* Non-hormonal
* Dryness - lubricants
* OP- caclium, vit d, bisphosphonates
* SSRI for vasomotor - venlafaxine/ clonidine
* HRT:
* No-uterus- Oestrogen only cont.
* Uterus - Oestrogen + progesterone. Cyclical or continuous (no period for 1y or 2y if younger)
* Topical creams/ pessaries
* Patch if high VTE risk
121
HRT - risks, benefits, contraindications, when to stop
* Risks: breast Ca, endometrial Ca, VTE, GB disease, Sx after stop
* Benefits: Less Sx, protective against OP/ CVS disease/ colorectal disease. Muscle bulk and strength
* CI: Prev breast/ ovarian Ca, undiagnosed vaginal bleeding, ,HTN, endometrial hyperplasia
* Stop: Annual r/v. \>70y Risks \> Benefits
122
Options of Contraception
* Family planning - rhythm, ovulation, coitus interruptus
* Barrier - condom, diaphragm. Less STIs
* IUD/ IUS
* OCP
* Injectable hormonal contraception - Depo = progesterone, implant= ethongestrel, patch
* Sterilisation - female= interruption of fallopian tubes, male= vasectomy. NB councelling
123
Key features of intrauterine devices for contraception
* IUS= Mirena: Lasts 5y
* Progestagen- endometrial atrophy, thick mucus. Highly effective. Useful when oestrogen CI.
* Reversible.
* SE: PV bleeding, amenorrhoea, hormonal (nausea, bloating, headache, breast) - usually settle 6m
* IUD= Copper coild. Lasts 8-10y
* Foreign body - prevents implantation.
* Can be used as emergency
* SE: PV bleed, inf, IUD expulsion, dysmenorrhea
* Complications:
* PID
* Perforation
* Ectopic
* Heamorrhage
* Infection
124
Key features of OCP
* COCP:
* Oestrodiol + progestoagen --\> prevent ovulation, thicker cervical mucus, thin endometrium
* SE: spotting, hormonal
* Risks: VTE, stroke, CVS disease, breast/ cervical Ca
* CI: Smoker \>35y, hemiplegic migraine, bruit \>40y, VTE, stroke, HTN, inherited thrombophilia, current breast Ca
* POP:
* Norethisterone/ levongestrel - prevents ovulation, thin endometrium, thick mucus
* SE: menstrual disturbance, hormonal Sx
125
Emergency contraception options
* Levongestrel PO - within 72h. SE: N+V, erratic PV bleed
* Ulipristal - 120h after sex
* Copper IUD
126
Definition of subfertility and male/ female factors
* = After 2 years with regular unprotected sex and no known reproductive pathology
* Female factors:
* Age
* Systemic illness eg rubella
* Poor nutrition/ ++ exercise
* Stress
* Tubal- congenital, IBD, PID, chlamydia
* Uterine - fibroids, endometriosis
* Cervical - infection
* Disorders of ovulation - Kallman's, PCOS, premature ovarian failure, pituitary adenoma
* Male factors:
* Semen - Azospermia, test. cancer, alcohol, smoking, genetics
* BMI
* Idiopathic
* Infection
* Mechanics
* Retrograde ejaculation
* Azopermia - steroids, Kallman's, pituitary adenoma, vasectomy, orchitis, chemo/radio, chlamydia, gonorrhoea
* Heat
* Tight underwear
127
Male and female investigations of subfertility
* Female:
* Ovulation- hormone levels, cervical mucus, USS
* Ovarian reserve- USS antral follicle count
* Tubal patency - STI screening, hystero-salpingography, USS hystero-contrast, hysteroscopy
* Male:
* Semen analysis after 3d abstinence
* Sperm DNA
* Auto-Ab testing
128
Subfertility Tx
* Anovulation- clomiphene 2-6d of cycle for 6m. Risk of ovarian hyperstimulation (abdo pain, D+V, distention, weight gain)
* Hypotrophic hypogonadism - GnRH
* Tubal- surgery/ IVF
* IVF:
* Eligability: \<40y= 3 cycle, \>40y= 1 cycle. Must have been trying 2y, BMI \<30, no children already, non-smokers
* Intrauterine insemination
* IVF + embryotransfer + ICSI
* Male infertility rarely treatable
129
Prolapse - Definition, types, RF, causes
* = Bulging \>1 pelvic organs
* Types:
* Cystolcoele (front vaginal wall)
* Rectocoele (back vaginal wall)
* Uterine (stage 1-4)
* Procidenture
* RF: Age, chronic cough/ constipation, heavy lifting, obesity, childbirth
* Causes= weak pelvic floor:
* Multiple vaginal deliveries/ big babies
* Obesity
* Smoking
* Gynae syrg
* FHx
* Chronic cough/ COPD
* Hypermobility/ Marfan's
* Fibroids
130
Presentation of prolapse + Ix
* Vaginal:
* Dragging sensation, bulge
* Difficulty retaining tampons
* Spotting, discharge
* Difficulty with intercourse - pain, flatus
* Urinary:
* Incontinence/ frequency/ urgency
* Incomplete voiding/ weak stream
* Manual reduction before voiding
* Recurrent UTIs
* Bowel:
* Constipation/ straining
* Urgency, incontinence
* Flatus
* Incomplete evaculation
* Manual reduction
* O/E with **Sims** speculum
131
Tx of prolapse
* Cons - watch and wait, X smoking, weight loss, physio, Tx cough/ constipation
* Pessary - ring/ gellhorn. Replace every 6m
* Med- topical oestrogen
* Surg:
* Bladder- colposuspension
* Uterine - hysterectomy/ fixation
* Rectocoele - post. colporrhaphy
* Pelvic floor repair
132
Methods of TOP + complications
* Medical (\<13w)
* **Mifepristone + Prostaglandin**
* Mifepristone= antiprogesterone --\> contractions and bleeding
* **Misoprostol**= Prostaglandin E1 analogue --\> contractions
* Gemeprost- softens cervix
* Surgical
* **7-13w**= Suction
* **\>13w**= dilatation + evacuation
* Misoprostol/ mifepristone/ gemeprost prior to surgery
* Management:
* Before:
* **Councelling**
* Bloods- Hb, blood group, Abs
* USS- gestation
* After: Anti-D, follow up 2w
* Complications- bleeding, infection, uterine perforation, cervical trauma, failed, retained products, N+V, diarrhoea, psychological
