Flashcards in Obstetrics and Gynaecology 1 Deck (50):
List some symptoms of pregnancy
- A missed or light period
- Nausea, especially in the morning
- Breast tenderness
- Passing urine more frequently (especially at night)
- Feeling tired
- Possible period type pains/cramps
- Being constipated
- An increased vaginal discharge without any soreness or irritation
- Having a strange taste in the mouth: many women describe it as metallic
- Going off things: tea, coffee, tobacco smoke or fatty foods etc
When is the normal peak in bhCG?
Around the 12 week mark, reaching between 25k to 180k mIU/ml
What can cause a false positive pregnancy test?
- Recent first trimester miscarriage
- hCG secreting tumours
- Gestational trophoblastic disease
- some medications
What is an early miscarriage?
Early miscarriage occurs in the first 12 weeks of pregnancy
women can present with vaginal bleeding and pain
Miscarriage occurs in 15-20% of clinical pregnancies and most are "one off" events
How common are ectopic pregnancies?
what are the symptoms
- Pain in the lower abdomen with may be unilateral
- vaginal bleeding may occur though not always
- feeling faint
- shoulder-tip pain
- Occasionally there are no symptoms and women may collapse due to sudden heavy bleeding
In England, Scotland and Wales on what grounds can two medical practitioners confirm need for abortion? (5)
1) To save the women's life (any gestation)
2) To prevent grave permanent injury to the women's physical or mental health (any gestation)
3) under 24 weeks to avoid injury to the physical or mental health of the woman
4) under 24 weeks to avoid injury to the physical or mental health of the child(ren)
5) if the child was likely to be severely physically or mentally handicapped (any gestation)
What medical management is used for abortions? (2)
Early abortion - at or up to 63 days of gestation
- mifepristone 200 mg orally, followed 24-48 hours by misoprostol 800 mcg vaginal, buccal or sublingual.
From 64 days to 13 weeks and 6 days
- mifepistone 00 mg orally followed 24-48 hours by misoprostol 800 mcg as above, followed by misoprostol 400 mcg every 3 hours until abortion occurs
mifepristone 200 mg orally, followed 12-48 hours by misoprostol 800 mcg vaginally, followed by 400 mcg every 3 hours.
what are the options for surgical abortion?
Early suction aspiration using an electrical or manual suction under GA or local
Late up to 24 weeks dilation and evacuation - rare
what should all ladies under going abortion who're non sensitized have?
What are the complications of abortion?
Severe haemorrhage; less than 1 in 1000 in early procedures, 4 in 1000 beyond 20 weeks' gestation
Uterine perforation following surgical abortion (1-4 in 1000)
Cervical trauma following surgical abortion. Damage to external os is less than 1 in 100
Abortion may fail in fewer than 1 in 100 procedures
Retained products will require a further evacuation either surgically or medically.
Uterine rupture can occur in medical abortion at late gestation. The risk is less than 1 in 100..
What regime of ABX is recommended for abortion?
Azithromycin 1 g orally on the day of abortion, plus metronidazole 1 g rectally or 800 mg orally prior to or at the time of abortion
Doxycycline 100 mg orally twice daily for 7 days, starting on the day of the abortion, plus metronidazole 1 g rectally or 800mg orally prior to or at the time of the abortion
Metronidazole 1 g rectally or 800 mg orally prior to or at the time of abortion for women who have tested negative for C. trachomatis infection
How long do Drs have to refer for abortion?
How long does assessment to procedure take?
5 days each
10 days from initial interview with abortion provider to the procedure
Contraception! Long acting reversible methods should be discussed and ideally initiated at the centre
When is the pregnant uterus palpable?
12 weeks gestation
What are the normal ranges of BMI for underweight, normal weight, overweight and obese?
Normal weight 18.5-25
What is the average length of a menstrual cycle?
When is an egg released during the menstrual cycle? How can you calculate the average?
How long does the egg survive?
10-16 days (14) before the end of the cycle. 28-14 = day 14 would be when ovulation is expected.
The egg survives for 48 hours
What are the main indicators of fertility?
How effective is natural family planning?
Body temperature (waking, before getting out of bed) _ the fertile period ends when you have recorded 3 days in a row which are all higher than the previous six days - 0.2 C
the length of the menstrual cycle
up to 99% when used effectively (1/100 per year)
What is the Lactational Amenorrhoea Method? (LAM)
Fully breastfeeding - not giving the baby any other liquid or solid food or
mainly breastfeeding your baby and infrequently giving liquids and baby being <6 months and no periods.
Can be up to 98% effective.
What is the Intrauterine system?
Given an example
Mode of action
When can it be fitted?
For how long
A plastic T which fits into uterus and releases levonorgestrel - Mirena is licensed for contraception, idiopathic menorrhagia and for those receiving oestrogen hormone replacement.
Jaydess is licensed for contraception only
Mode of action: suppressant effect on the endometrium, preventing implantation: within one month endometrial atrophy, changes in the stroma.
Decreased sperm penetration of cervical mucus and impaired sperm migration
Most women continue to ovulation
Lasts for 5 years
Women over 45 can retain it until menopause
It can be fitted any time of the cycle - though is only immediately effective when fitted up to day 5 of the cycle. Otherwise a 7 day abstinence is required.
Failure rate as always depends on sexual activity, age and parity - <1-2% over 5 years. (some say perfect use 0.2%)
Expulsion <1/20, Displacement
Initial menstrual irregularities (3-6 months) can become amenorrhoeic
reduced menstrual loses
acne, headaches, breast tenderness and nausea.
STI to pelvic infection
Procedure - examination + insertion via speculum
What is the Intrauterine Device?
Given an example
Mode of action
When can it be fitted?
For how long
T shaped or frameless with a coil of copper.
Nova T-380A (5 year) (Cu280)
primary mode of action through cytotoxic inflammatory reaction in the endometrium with is spermicidal.
The cooper concentration in the cervical mucus is substantial and inhibits sperm motility
Implantation may be prevented
can be fitted any time in the cycle if it is certain they're not pregnant - effective immediately.
For emergency contraception: within 5 days of ovulation or within 5 days sex if no previous UPSI.
Thelarche - the development of secondary sexual characteritics or beginning of breast development at age 9-11
Adrenarche or growth of pubic hair (dependent on adrenal activity)
starts at 11-12
Menarche the onset of menstruation in a west the average age of 13
What are the different stages of a women's reproductive life?
Reproductive years 13-45
Menopause 50 (51) +
Post menopause 51+
Describe the phases/physiology of the menstrual cycle
Day 1-4: menstruation
The endometrium is shed as hormonal support: progesterone falls. Myometrial contractions occur with can be painful.
Day 5- 13: proliferative phase
Pulses of GnRH from the hpothalamus stimulate LH and FSH the latter causes follicular growth, the follicules produce oestradiol and inhibin which suppress FSH via negative feedback, such that only one follicle (the largest with the most FSH-R) and therefor oocyte mature. Estradiol levels continue to rise and reach their maxium causing positive feedback and a rapid peak in LH and ovulation follows 36 hours after. the E2 causes the endometrium to reform and proliferate, driving stromal cells.
Day 14-28: luteal/secretory phase
The follicle from which the egg was released becomes the corpus luteum, which produces E2 and P4 which peak a week later at day 21. The progesterone induces secretory changes in the endometrium, enlarging the stromal cells, glandular swelling and increased blood supply. Towards the end of the luteal phase the corpus lutem fails if the egg is not fertilized, causing E2 and P4 levels to fall and menstruation follows.
Give a definition of abnormal uterine bleeding
Any variation from the normal menstrual cycle and includes changes in regularity and frequency of menses, duration of flow, or in amount of blood loss
Menorrhagia is the most common complaint
What is the acronym by FIGO for abnormal uterine bleeding?
PALM = structural abnormalities that can be evaluated and diagnosed by imaging and/or biopsy
ADENOMYOSIS (Endometrial tissue in the myometrium)
LEIOMYOMAS (fibroids - submucosal/other)
MALIGNANCY and hyperplasia
COEIN = consideration of underlying medical disturbances
COAGULOPATHY -haemophilia, von willebrand's
ENDOMETRIAL (primary disorder of mechanisms regulating local endometrial haemostasis)
NOT YET SPECIFIED /Not known
What is the definition of heavy menstrual bleeding?
excessive blood loss which interferes with the women's physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms.
>80 mL of blood loss in an otherwise normal menstrual cycle. - This corresponds to the normal amount a woman can lose per cycle without becoming iron deficient.
1/3 women suffer heavy periods
o/e What does irregular enlargement of the uterus suggest?
o/e what does tenderness with or without enlargement suggest?
What investigations should a woman with Heavy Menstrual Bleeding have?
A Full Blood Count should be carried out on all women with HMB and should be done in paralell with any HMB treatment
If the history suggests Heavy Menstrual Bleeding without a structural or histological cause what can you do?
HMB w/o a structural cause (Polyps, Adenomyosis, Leiomyomas, Malignancy) then pharmaceutical treatment can be started without physical exam or initial investigation. unless the treatement is LNG-IUS
When should a biopsy be performed in Heavy Menstrual Bleeding?
Women 45+ (?40)
persistent intermenstrual bleeding
treatment failure or ineffective treatment
When should a lady with heavy menstrual bleeding be imaged?
What is the first line diagnostic tool for structural abnormalities?
What if USS Is inconclusive?
A abdominally palpable uterus
Vaginal examination reveals a pelvic mass of uncertain origin
Pharmaceutical treatment fails
USS is first line
Hysteroscopy can be used as a diagnostic tool when USS is inconclusive to determine location of nature of an abnormality
When can pharmaceutical treatment be considered for Heavy Menstrual Bleeding?
Pharmaceutical treatment can be considered where no structural or histological abnormality is present, or for fibroids < 3cm diameter causing no distortion of the uterine cavity
What are the first, second and third line pharmaceutical treatments for heavy menstrual bleeding?
What is important to consider before giving a contraceptive agent for HMB?
What is another important factor in managing HMB?
1) Levonorgestrel-releasing IUS provided long term 12 mo + expected)
2) traexamic acid (antifibrinolytic) or NSAIDs or combined oral contraceptives (though COCP not for use in older population due to VTE risk)
3) norethisterone (POP) daily from day 5 to 26 of the cycle or injected long acting progestogens
Whether the woman wants to conceive - tranexamic acid or NSAIDs can be used.
Counsel the patient on losing weight, in obesity the excess oestrogens formed by the aromatase in the fat can be reduced by losing weight.
What should a lady be counselled on if they start the first line pharmaceutical treatment for heavy menstrual bleeding?
Women need to know that the LNG-IUS (mirena) can cause changes in bleeding pattern, particularly int he first few cycles and maybe lasting longer than 6 months. They need to persevere for at least 6 cycles to see the benefits of the treatment.
If a lady has heavy menstrual bleeding and dysmenorrhoea
what is the best pharmaceutical agent?
NSAIDs over traexamic acid
In ladies with leiomyomas - uterine fibroids over 3 cm or more what pharmaceutical agent can you offer? what else needs to be a factor?
Ulipristal acetate 5 mg (up to 4 courses) to women with heavy menstrual bleeding and 3 cm + fibroids. Ladies should have a Hb of 102 g/L or less
But it can be considered in those above this
When can endometrial ablation be considered for heavy menstrual bleeding?
What counselling is needed?
When bleeding is having a severe impact on the woman's quality of life, and she does not want to conceive in the future
You need to prevent pregnancy following ablation.
When can you considered Uterine Artery Embolisation or Surgery as first line in heavy menstrual bleeding?
Uterine Artery Embolisation, myomectomy or hysterectomy should be considered when large fibroids (greater than 3 cm in diameter) are present and bleeding is having a severe impact on quality of life
What is the normal variation in endometrial thickeness?
Endometrium varies from
4 mm in the follicular phase up to
16 mm in the luteal phase
What risk factors for young women may indicate the need for a Pipelle biopsy?
For young women:
FMHx of Non-polyposis colorectcal cancer: HNPCC
In the treatment of heavy menstrual bleeding, how long are Gondaotrophin-releasing hormone agonists licensed for?
BNF: Leuprorelin/ gonadorelin analogues
How is postmenopausal bleeding defined?
What is the initial investigation?
PMB is defined as bleeding 12 + months after the last menstrual period
TV USS then history, examination +/- endometrial biopsy. If <4 mm and normal no biopsy needed
if > 4 mm then biopsy needed.
The examination should aim to exclude vulvovaginal diesease.
What should all people who have a cancer diagnosis have?
Discussion at the MDT!
What drug can increase the risk of endometrial cancer?
SERM tamoxifen if take for longer than 5 years
When is the prevalence highest for endometrial CA?
What are the reversible causes of cardiac arrest?
4 H's and 4 T's
What is amenorrhoea?
Amenorrhoea is pathological with failure to menstruate for at least 6 months (or 6 cycles) during normal reproductive life in the absence of pregnancy
What are the causes of amenorrhoea?
Primary amenorrhoea: menses have not occurred by the time of the expected menarche (age 14) in the absence of secondary sexual characteristics
Where menstruation has previously occurred but it has stopped - usually with an absence of 6 months or 6 cycles. (consider 3 months)
Olgiomenorrhoea is menstruation with 35 days to 6 months between menses