Obstetrics/Gynaecology (NEW) Flashcards

Question

Operative delivery

Answer 1

- operative delivery indications - >maternal exhaustion/prolonged second stage - >engaged/position known/cephalic/adequate anaesthesia - >consider for maternal/fetal compromise - operative delivery containdications - >three prior attempts - >extremely premature - >bone or bleeding disorder - >face or brow presentation/unengaged/unknown - >cephalopelvic disproportion

Answer 2

Epidemiology -approx 10% of women of reproductive age Aetiology - unknown - heritability = approx 75% - >multiple genes contributing small risk - environmental - >obesity and hyperinsulinaemia - >congenital adrenal hyperplasia and androgenism Pathophys - Functional ovarian hyperandrogenism - >dysregulated LH driven thecal androgen production - >causes hirsutism - >high androgens = increased primary follicle recruitment - >increased synergism with FSH = premature luteinization - >increased recruitment + premature luteinization = PCOM + oligo-anovulation - Insulin resistant hyperinsulinism - >causes and worsened by obesity - >sensitises theca cells to LH = increased androgens - High LH - >androgen excess disturbs sex steroid inhibition of LH - >high insulin decreases SHBG by liver - Excess adrenal androgens - >enhanced responsiveness to ACTH - >similar action to ovarian androgens

Answer 3

Hx - often presents in puberty - hirsutism/acne/alopecia - oligo-anovulation - >primary amenorrhoea (no menarche by 15) - >secondary amenorrhoea (no menses for three cycles) - >oligomenorrhoea = <9 menses/year (less during puberty) - >AUB = menses <21 apart/ >7 days long/ very heavy - weight gain - infertility - medications associated with hirsutism? Exam - HTN - hyperandrogenism - >male hair growth/loss - >acne - >deep voice/clitoromegaly/increased muscle mass - obesity - acanthosis nigricans - abdo exam - >adrenal tumour - pelvic exam - >ovarian tumour Investigations - Androgens (day 3 follicular phase) - >total and free (SHBG) testosterone - >dehydroepiandrosterone sulfate (DHEA-S) - >androstenedione (A4) - 17 hydroxyprogesterone - >early morning during (day 3 follicular phase ) - >anytime if amenorrhea - >low rules out non classic congenital adrenal hyperplasia - Luteal phase (7 days before menses) progesterone - >high levels = ovulation - Rule out other causes oligomenorrhoea/anovulation - >b HCG = pregnancy - >prolactin = prolactinoma - >TSH = hypothyroidism - >LH:FSH = >3 in PCOS, low in hypothalamic disease - Tranvaginal ultrasound (if criteria not already met) - >PCOM = ovarian volume >10mL/12 follicles in either - Additional tests - >GTT - >lipids Diagnosis - 2/3 (all three for puberty) of Rotterdam criteria - >oligo/an-ovulation (present for 2yrs if pubertal) - >PCOM - >clinical or biochemical hyperandrogenism - exclude other causes

Answer 4

PCOS + CODEIN - Cushings - >disease (corticotroph adenoma) - >syndrome (adrenocortical tumour) - Ovarian tumour - >sertoli-leydig - >theca-granulosa - Endocrine - >hypothyroidims - >prolactinoma - >acromegaly - Idiopathic - Non classical congenital adrenal hyperplasia

Answer 5

Epidemiology -<0.1% Aetiology - Hypothalamus - >constitutionally delayed growth and puberty - >idiopathic hypogonadotropic hypogonadism - >Kallman's syndrome - Pituitary - >prolactinoma - Ovaries - >PCOS - >primary hypogonadism (Turner's/injury/insult) - >androgen insensitivity syndrome - Uterus/cervix/vagina - >mullerian agenesis - >transverse vaginal septae - >imperforate hymen - Adrenal - >NCCAH - Thyroid - >hypothyroidism - Systemic (functional hypothalamic amenorrhoea) - >anorexia nervosa - >excessive weight gain/loss - >stress - >female athlete triad

Answer 6

Epidemiology - average is 51yrs - >5% <45 - >5% >55 Aetiology - family history of age - smoker = earlier - hysterectomy with persevered ovaries = earlier Pathophys - several million oocytes present by approx GA 15 - primary follicles form at this time - continuous follicular atresia - >begins in utero - >steady decline in oocytes over lifespan - late reproductive (40's) - >lower inhibin and progesterone - >declining fertility - >ovulatory cycles with shorter follicular phase - perimenopause - >significant depletion of oocytes - >variable length (yrs) - >high FSH/low inhibin/low AMH - >highly variable estrogen and low luteal progesterone - >irregular/anovulatory periods - menopause - >process continues until 12 months of amenorrhea - post menopause

Answer 7

Clinical manifestations - late productive - >infertility - perimenopause - >irregular menses - >prolonged time between cycles - >occasionally heavier bleeding - hot flash (most common symptom) - >can begin in late reproductive - >most common late peri/early post - poor sleep - >often due to hot flushes or anxiety/depression - depression - >mostly perimenopausal - vaginal atrophy - >dryness - >irritation - >dyspareunia - dyspareunia - >decreased lubrication - >vagina is shorter, narrower and less elastic Complications of oestrogen withdrawal - cardiovascular disease - >increase in LDL - bone health - >decreased BMD and increased osteoporosis - decreased collagen content in skin - impaired balance - central adiposity ``` bHCG Consider -FSH -TSH -prolactin ```

Answer 8

Hx - no menarche by age 15 +/- pubarche - Hypothalamus - >pubertal development (constitutional delay) - >stress/weight gain and loss/eating/ exercise - >anosmia - Pituitary - >headaches - >blurred/loss vision or diplopia - >galactorrhea - Ovaries - >stature relative to family (Turners) - >hirsutism/acne/weight (PCOS) - Uterus - >cyclical pelvic pain (anatomical abnormality) - Adrenals - >neonatal crisis (NCCAH) - Additional - >family hx of delayed puberty (constitutional) - >medications Exam - height/weight/BMI - inspect - >acne/hirsutism/pigmentation/virilisation - >syndromic features - >pubertal development - >outflow tract abnormalities - consider - >neuro exam for pituitary mass - >bi manual for outflow tract abnormalities bHCG TSH prolactin FSH and estradiol -high FSH/low estradiol = primary ovarian failure (Turners) -low FSH/low estradiol = hypothalamic failure Ultrasound pelvis -presence/absence of uterus/ovaries/cervix Consider - Karyotyping - >if uterus present/high FSH = Turners - >if uterus absent = 46 XX (genesis)/46XY (androgen insensitivity syndrome) - Androgens (PCOS) - >presence of hirsutism/acne/virilisation - MRI brain (sellar mass) - >if uterus present/low FSH/no breast development - >no mass = constitutional/functional hypothalamic/idiopathic hypogonadotropic hypogonadism

Answer 9

Epidemiology -approx 3% Aetiology - Hypothalamus - >weight loss/athlete triad/anorexia - Pituitary - >prolactinoma (inhibits GnRH) - Thyroid - >hypothyroid (high TRH increase prolactin release) - Ovaries - >PCOS - >premature ovarian failure (radiation/chemo/fragile X/autoimmunity) - Uterus - >pregnancy - >ashermans Hx - pregnancy risk/symptoms - hypothalamus - >stress/eating/exercise - >medications (COCP/antipsychotics/metaclopramide) - pituitary - >headache/vision changes/galactorrhoea - ovaries - >hirsutism/acne/virilisation - >menopause symptoms - uterus - >bleeding/infection/curretage Exam - height/weight/BMI - inspect - >virilisation/pigmentation - >galactorrhoea - >vaginal atrophy ``` bHCG FSH and estradiol ->both low = hypothalamus/pituitary disease ->FSH high/estradiol low = POI prolactin TSH ``` Consider - PCOS testing - karyotyping if FSH high - MRI brain if FSH/estradiol low - progestin challenge if normal labs - >10mg medroxyprogesterone for 10 days - >absence of bleeding supports ashermans

Answer 10

Desiring fertility - weight loss - >ovulation in approx 80% - >may take 6-9 months - metformin - >500mg TDS titrated over 4-6wks - >1500-2000mg once daily extended release - >take with food - >may take 6-9 months to worse - >may be less effective in overweight/obese - fertility pharm - IVF - laparoscopic drilling - >pregnancy in approx 50% - >similar efficacy to fertility pharm/less multiple pregancy - >no evidence for POI Not desiring fertility/hyper-androgenism - weight loss - >less effective - COCP - >anything but levonorgestrel - Eflornithine cream BD - >effective in about 1/4 by 2 months - >can cause local reactions/acne - Spirinolactone (anti-androgen) - >50-100mg BD - >combine with OCP (teratogenic) - Consider adding metformin to OCP/spirinolactone Not desiring fertility/oligo-amenorrhoea - weight loss - >returns ovulation in up to 80% - >may take 6-9 months - OCP - >progestogen protects endometrium - >avoid levonorgestrel - progesterone (protect endometrium) - >mini pill - >Mirena

Answer 11

Epidemiology - 10-20% colonisation of vagina/rectum - >neonatal colonisation rate = 40-50% - >early infection rate = 0.5-0.05% Aetiology - Risk factors - >prematurity - >prolonged rupture of membranes (>18hrs) - >maternal fever - >heavy maternal colonisation - >low level maternal/fetal serotype specific Ig - >previous infant with early GBS disease - Neonatal infection - >intra-amniotic infection (with intact membranes) - >passage through birth canal - >contact with outside environment Pathophys - early onset <24hrs - >sepsis (most common) - >pneumonia - >meningitis - late onset <90 days - >fever/bacteraemia (most common) - >meningitis - >septic arthritis/osteomyelitis - >cellulitis - mortality - >overall = 3% - >pre-term early = 30% - morbidity - >CP - >ID - >seizures - >hearing/vision loss

Answer 12

Screening - rectovaginal swap/culture for all women - >false negative approx 5% - timing - >general = 35-37wks - >high risk for preterm = 3-5wks prior to EDD - exceptions - >GBS bacteruria/previous infant GBS = empiric rx Labour management - Intrapartum antibiotics - >IV penicillin G or ampicillin - >at least 4hrs prior to delivery - >reduces risk of early disease by 80% - >risk of late onset unchanged - Indication for intrapartum antibiotics - >GBS+/GBS bacteruria - >previous early GBS disease - >unknown status + preterm labour/PPROM/prolonged rupture of membranes/intrapartum maternal fever Scenarios - Caesarian - >not indicated for GBS+ - >abx not indicated for caesarian with intact membranes - Intrapartum procedures - >no indication for change in practice if intrapartum abx - PROM at term - >GBS+ = induction + intrapartum antibiotics - >GBS unknown = culture and risk assessment - Preterm labour GBS unknown - >intrapartum antibiotics until culture -ive - PPROM GBS unknown - >consider 48hrs of antibiotics - >take cultures - >intrapartum antibiotics - PPROM GBS+ - >if >34wks = induction + intrapartum antibiotics - >if <34wks = normal PPROM management

Answer 13

Compared to normal vaginal delivery - Positives - >delivery date known - >avoids post-term neonatal mortality increase - >avoids risk of emergency caesarian - >lower rate urinary and bowel incontinence - >lower rate pelvic organ prolapse/perineal tear - >lower rate HIE/birth injury/asphyxia - >less vertical transmission HIV/HSV - Negatives - >higher rate TTN/RDS (only if <39 weeks) - >higher neonatal mortality - >longer hospitalisation/recovery time - Same - maternal mortality rate - post partum sexual function - pain 4 months post partum Complications (HOISTED) - Haemorrhage - >approx 1L - >less than 5% need transfusion - Obstructed bowel (ileus) - >15% - Infection - >2% - Surgical error (rare) - >bowel/bladder perforation - >laceration to baby - Thrombosis (stroke/MI/VTE) - >3x vaginal delivery risk - >0.25% for VTE - Endometritis - Death - >less than 0.1% Anaesthetic risk - neuraxial - general Long term risk - abnormal placentation - >placenta accreta/previa/abruption - adhesions - hernias - nerve pain around scar VBAC - uterine rupture - >TOLAC = 0.5% (< if previous successful delivery) - >twice as high as risk with repeat caesar - outcome of rupture - >1/3rd hysterectomy - >neonatal death <3% - neonatal - >mortality 2-3x higher with TOLAC (very low) - >resus 2x higher with TOLAC

Answer 14

Categories - 1 = immediate threat to maternal/fetal life (30mins) - 2 = compromise with no threat to life (1hr) - 3 = earlier than planned without compromise - 4 = maternal request - >possible if harm/benefit understood by patient Timing of planned/maternal request - before 39 wks - >increased risk of blood transfusion - >higher rates RDS/TTN - >higher neonatal mortality - at 39 wks - >approx 10% will require emergency CD prior to 39wks - >emergency has 2x risk of complications - after 39 wks - >increase perinatal mortality - >macrosomia - >dysmaturity syndrome

Answer 15

Epidemiology -approx 10% births Aetiology - Fetal - >genetic abnormality - >TORCH infections - Placenta - >pre-eclampsia - >abruption - Maternal (ACHINGS) - >age (extremes of) - >CKD - >HTN - >Insulin resistance - >nutritional deficiency - >genetics (previous SGA or personally SGA) - >SLE - Exposures - >teratogenic meds - >alcohol/smoking/cocaine/heroin/marujuana Pathophys - Foetal response to compromised nutrient supply - >redirect blood flow to brain/heart/adrenals - >reduces overall size/fat/BMD/glycogen stores - >reduces renal blood flow and oligohydramnios - >preserve brain growth - >accelerate lung maturation - >increased RBCs - >decrease - Symmetric - >proportional reduction of body components - >chromosomal or infection - >occurs early in gestation - Asymmetric (majority) - >weight/abdominal size reduced more than length/HC - >adaptation to pathological stressor - >occurs later in gestation

Answer 16

Hx - PC - >unwell lately? - >headaches/vision changes - >loss of blood or fluid - >pain? - >fetal movements - This pregnancy - >any complications - >scans (morph + aneuploidy) + serology - Past obstetric - >G/P - >G/A and route - >small babies - >HTN/diabetes - Past medical - >any chronic illnesses - Allergies - Medications - Supplements and food avoidance - Social - >Smoking/drinking/drugs - >contact with children - >proximity for follow Exam - Height/weight/BMI - BP - Abdo palp - Fundal height - Doppler Confirm diagnosis with ultrasound - Urgent CTG - SGA - >weight below 10th centile in second trimester - >may be constitutional or restricted growth - >consider AC/AFI/growth velocity Determine cause - Fetal survey - >doppler (umbilical/uterine/middle cerebral arteries) - >BPP - Anatomy scan - >if abnormal, consider cell free DNA for aneuploidy - >if negative, consider amniocentesis for microarray - Infection workup - >maternal CMV/rubella/varicella seropositivity

Answer 17

Monitoring - Usually monitored as outpatients - Weight - >review every 2 weeks if concerned - >consider velocity (normal in constitutional) - US doppler - >umbilical artery most useful - >review every 2 weeks if first two are normal - >review weekly if abnormal or concerned - >reduced/absent end-diastolic flow = consider delivery - BPP or NST with AFI - >not needed if mild - >twice weekly if severe - >daily if abnormal doppler Delivery consideration - Issue - >pre term delivery has high mortality/morbidity - >each day in utero between 26-29wks increases survival up to 2% - >mortality in IUGR rises sharply at time (placental insufficiency) - GRIT trial - >randomised to immediate or delayed delivery - >when obstetrician was uncertain - >immediate group = fewer stillbirths/more neonatal deaths - >long term neurodevelopment outcome similar - DIGITAT trial - >randomised to spontaneous/expectant at term - >spontaneous had lower birth weight - >same adverse events/same caesarian rate/long term developmental outcomes - Consider - >dopplers/BPP/NST/risk factors - >gestational age - >patient preference - >need for caesarian delivery if poor dopplers - >corticosteroids and magnesium sulfate Intrapartum - Issues - >intrapartum heart rate abnormalities - >birth asphyxia/HIE - >meconium aspiration - >polycythaemia - >hypothermia - >hypoglycaemia - Approach - >continuous fetal heart monitoring - >low threshold for emergency caesarian - >neontal support present - >umbilical blood gas and glucose at birth Long term - catch up growth - CVD/diabetes/renal disease/neurodevelopment

Answer 18

Epidemiology - approx 1% of all pregnancies - up to 15% of first trimester bleeding Aetiology - risk factors (ASEPTIC) - >age (older) - >smoking - >ectopic pregnancy in previous pregnancy - >PID - >tubal abnormalities - >infertility and IVF - >contraception failure (IUD/COP) Pathophys - anatomic sites - >fallopian tubes (more than 95%) - >ovarian - >interstitial - >abdominal - >cervical - >hysterectomy scar - >intramural - >heterotopic

Answer 19

Hx - onset of symptoms usually after 8 weeks gestation - vaginal bleeding - lower abdo pain - >sharp or dull (not crampy) - >diffuse or localised - pregnancy related symptoms - rupture - >acute severe pain - >severe bleeding - >syncope - >shoulder tip pain - >tenesmus = blood in pouch of douglas - review risk factors - review surgical/medical fitness Exam - often unremarkable - vitals - >assess for shock - >postural hypotension - abdo - >tenderness - >acute abdomen in rupture - speculum - >source of bleeding - pelvic - >adnexal mass/tenderness - >cervical motion tenderness with rupture Investigations - unstable - >FAST scan for intraperitoneal haemorrhage - b HCG (urine or serum) - >confirms pregnancy - FBC - >anaemia - >baseline for methotrexate - blood group and antibodies - >hold if significant bleeding - >sensitising event (anti D) - EUCs and LFTs - >methotrexate baseline - Transvaginal ultrasound Transvaginal ultrasound - Confirms ectopic - >gestational sac with yolk sac/embryo at ectopic site - >adnexal mass/empty uterus/free fluid - Suggests ectopic - >pseudosac - >complex extra ovarian adnexal mass - >tubal donut sign - >adnexa ring of fire sign on doppler - >consider heterotopic - Suggests rupture - >fluid in morrisons or douglas' pouch - Absence of findings - >follow PUL protocol

Answer 20

Indications - >patient preference - >stable - >b HCG <5000 - >no cardiac tones / ectopic mass <3-4cm Contraindications - >unstable - >evidence of threatened rupture - >viable IUP/heterotopic - >liver/renal/pulmonary disease - >immunosuppression or peptic ulcers - >abnormal FBC, EUCs, LFTs - >breastfeeding Risks - approx 1/3 experience side effects - >stomatitis - >conjunctivitis - treatment failure approx 20% Benefits - >avoids surgical complications - >similar efficacy to surgery when adequate doses given - >similar fertility outcomes to surgery - >similar risk as surgery of further ectopic pregnancies Procedure -IM single dose Monitoring - b HCG on days 4 and 7 - b HCG weekly until 0 - inadequate decrease - >repeat dose (no more than three total) Advice - >avoid conception for 4 months - >avoid folic acid supplements and NSAIDs - >avoid sunlight - >mild pain at 1 week is common - >severe pain needs to be investigated

Answer 21

Indications - any b HCG level - unstable - rupture or impending rupture - heterotopic ectopic - methotrexate contraindications - methotrexate failure Contraindications -no absolute Risks -surgical and anaesthetic risks Procedure - salpingectomy vs salpingostomy - >similar rate of future fertility - > salpingostomy = higher rate of retained/future ectopics - laparoscopic vs laparotomy - >laparoscopic preferred - >laparoscopic = less blood loss, faster operation, recovery and discharge - >consider laparotomy for interstitial or unstable Follow up - salpingostomy - >GP 3 weeks post op - >weekly b HCG until negative - >insufficient b HCG decrease = methotrexate - salpingectomy - >post op b HCG unnecessary if histopath confirmed - future conception - >no solid data - >0-3 months common

Answer 22

Indications - asymptomatic - no TVU findings of ectopic pregnancy - low (<1500) and decreasing b HCG - aware of risks - access to emergency treatment and close follow up Contraindications -any of indications absent Risks -rupture can occur with low and falling b HCG Benefits - similar success rate (80%) to medical management - similar treatment time as medical management Procedure - b HCG every 48hrs for 8 days - >then weekly until negative - abandon expectant management if - >any symptoms - >b HCG not decreasing - avoid conception until sonographic resolution

Answer 23

Epidemiology - Rh -ive - >15% of caucasians - >7% africans - incompatibility in 10% pregnancies Aetiology - Rh -ive mother - Rh +ive baby - >inherited from father Pathophys - sensitising event - >occurs in majority of pregnancies - >fetomaternal haemorrhage (most placental insults) - >passage of fetal cells across placenta - formation of maternal anti-D Ig - >formation of memory B lymphocytes - >future challenge leads to plasma cell Ig production - haemolytic disease of the new born - >maternal Ig cross placenta attache to fetal RBC - >RBCs sequestered in spleen and destroyed - >extramedullary haematopoeisis - >hepatosplenomegaly/pHTN/HF/cerebral hypoxia - >hydrops fetalis/intrauterine death Screening for incompatibility - blood group, Rh status, antibodies - >first antenatal visit - >Rh -ive repeated at 24-28wks - >after any sensitising event Diagnosing incompatibility - if mother Rh antibody +ive - >paternal blood group - Paternal zygosity if Rh +ive (PCR for RHD genes) - >if homozygous = fetus Rh +ive - >if heterozygous = 50% chance fetus Rh +ive - Amiocentesis (>15wks) or cfDNA (>10wks) if heterozygous Monitoring incompatability - Baby Rh +ive - >serial (monthly) maternal indirect coombs - If antibody titre rises above critical threshold - >doppler MCA for severe anaemia ever 1-2wks - If suspected sensitising event - >rosette test = presence of fetal RBC in maternal blood Sensitisation prevention - Rh incompatibility diagnosed - >maternal Ig present = no benefit of anti-D - >routine prophylaxis = anti-D at 28wks - >fetomaternal haemorrhage = anti-D - >sensitising procedure = anti-D 72hrs prior - >delivery = additional anti-D 72hrs prior - Dosage - >Kleihauer test/flow cytometry = %fetal RBC

Answer 24

Epidemiology - GD = approx 10% pregnancies - pre-existing = 2% pregnancies Aetiology - pre-existing - GD risk factors - >older age - >personal hx - >family hx - >obesity - >physical inactivity - >high GI/low fibre diet - >smoking - >PCOS Pathophys GD - relative insulin resistance normal part of pregnancy - >ensures adequate glucose delivery to fetus - >most marked resistance in 3rd trimester - diabetogenic hormones released by placenta - >growth hormone - >prolactin - >lactogen - >progesterone - GD develops when maternal beta cells are overwhelmed Shared complications - short term - >LGA = preterm/caesarian/instrumental/dystocia/injury - >polyhydramnios = BPD/preterm/malposition - >pre-eclampsia - >neonate = hypoglycaemia/jaundice/CMP/cardiac/resp - long term - >increased risk of T2DM - >child = obesity/metabolic syndrome/diabetes Pre-existing complications - Congenital defects - >2-4%x base (incidence apex 5%) - >CCHD/neural tube defects - IUGR - Pre-eclampsia/HTN - Miscarriage - Aggravates underlying micro/macrovascular disease - DKA more common - >occurs at higher BGL - >more lethal for mother (fetal demise also common)

Answer 25

Screening - first antenatal visit - >all women - >low risk GD = BGL/high risk GD = GTT - >pre-existing = HbA1c/UACR/GFR/TSH/fundoscopy - 24-28wks - >all women GTT Diagnosis - GTT - >NBM for 8hrs prior - >fasting glucose - >75g glucose - >glucose at 1 hr - >glucose at 2hrs - GDM criteria - >fasting = >5.1 - >1hr = >10.0 - >2hr = >8.5 - pre-existing diabetes - >if diagnostic criteria met <1st trimester 1st trimester - Pre-existing - >cease ACEI/ARB - >low dose aspirin after 12wks - >higher folic acid supplementation 2nd trimester -morph/neural tube scan at 20wks 3rd trimester - GD and good control/lifestyle only - >fetal movements may be sufficient - >growth scans close to term - Poor control/pre-existing - >NST/ST/BPP from 32 wks - >serial growth scans from 32 wks - >increase insulin if steroids given Labour - Timing - >consider induction after 39/before 40wks - Route - >consider delivery at term for macrosomia - >consider caesarian for macrosomia >4.5kg - Intrapartum - >maternal glucose monitoring (fetal hypoglycaemia) - >continuous FHR - Post partum - >neonatal glucose monitoring - >loss of insulin resistance with placental delivery - >monitor glucose for 24-72hrs (unrecognised T2DM)

Answer 26

Diet - referral to dietician - >caloric needs individualised - >determined by baseline and GA - best evidence for low GI diet (vs low carb/calorie restricted) - >less insulin requirements - >lower birth weights - some evidence for increasing folic acid supplementation Exercise - moderate intensity exercise - >increased muscle mass = increased insulin sensitivity - >lower blood glucose levels - >less insulin requirements Insulin therapy - after lifestyle trial for 2-4wks - trial intermediate acting basal insulin at bedtime - >approx 6 units - assess fasting BGL over week - >more than 3 > 5 = increase by 2 units - >more than 3 > 6 = increase by 4 units - >more than 3 > 8 = increase by 6 units - avoid prolonged fasting at night - >paradoxically raises morning fasting levels - consider adding pre-prandial rapid acting bolus - >split approx 50% of total daily dose across meals Glucose self monitoring - 4x daily - >fasting/waking - >post prandial (1-2hrs) - log in book Glucose targets - fasting <5.3 - 1hr post prandial <7.8 - 2hr post prandial <6.7

Answer 27

Infectious - endocervix - >chlamydia (most common overall) - >gonorrhoea - ectocervix - >HSV - >trichomonas - other - >tuberculosis - >mycoplasma genitalium - >GAS Non infectious - mechanical - >condoms/diaphragms/tampons - >surgical instrumentation - chemical - >latex - >douching - >spermicides - systemic disease - >bechets - >lichen planus

Answer 28

Hx - mucopurulent discharge - abnormal bleeding - >post coital - >intermenstrual - dyspareunia - vulvovaginal irritation/pruritis/burning - with concomitant urethritis - >dysuria - absence - >abdo/pelvic pain - >fever - presence of risk factors Exam - abdo - >tenderness? - speculum - >erythematous/oedematous vulva (may be normal) - >erythematous/tender vagina - >oedematous/erythematous/friable cervix with discharge - typical lesions - >strawberry cervix = trichomoniasis - >ulcerations/vesicles = HSV - bimanual to exclude PID - >cervical motion/uterine/adnexal tenderness? Investigations - b HCG - NAAT - >men = first catch urine/urethral swab - >women = first catch urine/self swab/endocervical swab - Culture (gonorrhoea sensitivity) - >thayer martin/charcoal enriched swab - >male = clinician urethral - >female = endocervical - Gram stain (provisional dx from gram -ive diplococci) - >male urethritis only (clinician collected) - Consider if typical lesions - >HSV serology - Consider if high risk/STI confirmed - >HIV - >syphilis - >Hep B/C Empiric management - if concern for PID in high risk - >empiric PID treatment - if high risk - >consider empiric chlamydia treatment Gonorrhoea management - targeted antibiotics - >ceftriaxone 500mg IM single dose - test of cure unnecessary - contact tracing/prophylactic treatment - >sexual partners for past 2 months - avoid sex for 7 days - >post treatment of index patient and partner Chlamydia management - targeted antibiotics - >azithromycin 1g oral single dose - >doxycycline 100mg oral BD 1 week - test of cure at 3 weeks - >pregnant - >PID - contact tracing/prophylactic treatment - >sexual partners for past 6 months - avoid sex for 7 days - >post treatment of index patient and partner

Answer 29

Epidemiology - most common gynaecological reason for hospitalisation - risk factors - >under 25 - >multiple partners/new partner - >infrequent condom use - >previous STD/partner with STD Aetiology - majority - >chlamydia - >gonorrhoea - occassionaly - >mycoplasma genitalium - >gram negative enterics - >haemophilus influenzae Pathophys - infection of cervix with chlamydia/gonorrhoea - >disruption of protective barrier - >ascent of micro-organisms - complications - >recurrence - >chronic pain - >tuba-ovarian abscess - >hydro-salpinx - >ectopic pregnancy - >infertility (<20%) - >fitz-hugh curtis syndrome

Answer 30

Hx - may be asymptomatic - lower abdo pain - >often bilateral - >worse with jarring movements - >may have RUQ pain - nausea/vomiting - abnormal vaginal bleeding - >intermenstrual - >post-coital - >menorrhagia - mucopurulent discharge Exam - fever - abdo - >tenderness (bilateral) - >rebound tenderness/bowel sounds? - speculum - >discharge at endocervix - bi-manual - >cervical motion tenderness - >uterine tenderness - >adnexal tenderness - Beta HCG - Vaginal discharge wet mount - >absence of WCC has negative predictive value - Endocervical swab - >NAAT for gonorrhoea/chlamydia - >culture for gonorrhoea - FBC - CRP/ESR - Consider - >blood cultures - >US of fallopian tubes/ovaries/endometrium (severe) - >CT (peritonitis/equivocal US) - >laparoscopy (complicated/resistant/ddx suspected) - If high risk - >HIV/HBV/HCV/syphilis

Answer 31

Empiric management - criteria - >high risk - >lower abdo pain/positive bi-manual - regime - >cetriaxone 500mg IM single dose - >azithromycin 1g oral single dose - >metronidazole 500mg BD for 10 days Additional - Analgesia - Patient education - >causes/risks/prevention - >prognosis/complications - >avoid intercourse for 7 days post treatment - Insufficient evidence for removal of IUD - Disposition - >generally outpatient - >inpatient if resistant/severe/complications - Safety net - >reassess in 24-48hrs - >present to hospital if its gets worse - Contact tracing - >any partner within 60 days = investigation - >no partner within 60 days = last partner - >consider empiric treatment - Test of cure - >repeat chlamydia/gonorrhoea within 3 months

Answer 32

Opportunity for general health check - cst - mammogram - smoking/alcohol advice - cvd risk factors - weight control Non pharm - exercise and weight loss - >CVD risk - avoid alcohol/caffeine/spicy foods - >VMS - layered clothes/cool water/sprays - >VMS Intact uterus (including post-ablation) HRT - Perimenopausal (need contraception) - >low dose OCP - >Mirena + oestrogen - >cyclical HRT + barrier - 1-5 years post menopause - >continuous combined HRT - >Mirena + oestrogen - >Tibolone (no progestogen needed) - Over 5 years post menopause - >continuous very dose combined HRT - >Mirena + very low dose oestrogen - >caution with Tibolone - >vaginal oestrogen alone for genitourinary No uterus HRT - Under 5 years amenorrhoea - >oestogen alone - >tibolone - Over 5 years - >low dose oestrogen alone - >caution with tibolone - Hx endometriosis - >consider adding progestogen (poor evidence) Non hormonal - Indication - >HRT contraindicated - >significant mood component - >personal choice - Effect - >significant reduction of VMS (less than HRT) - Options - >paroxitine - >venlafaxine - >clonidine Urogenital symptoms only

Answer 33

Epidemiology - fecundability - >85% over 12 months regular unprotected sex - >25% in first 3 months, then decreases Aetiology - Risk factors - >age >35 - >obesity/low BMI - >smoking - >previous STD Pathogenesis - Female factors (1/3rd) - >diminished ovarian reserve with age (majority) - >oligo/anovulation (PCOS/prolactin/hypogonadism/hypothalamus) - >tubal (post infection/endometriosis/pelvic adhesions) - >uterine (adhesions/mullerian abnormalities) - >smoking/obesity - Male factors (10%) - >oligo/azoospermia (majority idiopathic) - >primary/secondary hypogonadotrophinism - >congenital testicular disorder (klinefelter/cryptochordism) - >acquired testicular disorder (infection/drugs/exposure) - Combined factors (1/3rd) - Idiopathic 5%

Answer 34

Hx - Menstrual hx - >regular menses/moliminal symptoms = ovulatory - >long = anovulation - >short = anovulation/endometrial dysfunction - Sexual hx - >timing and regularity - >dyspareunia (PID/endometriosis/adhesions/uterine abnormality) - Hypothalamus - >stress/weight loss/exercise - >anosmia - Pituitary - >headache/vision changes/nipple discharge - Ovaries - >acne/hirsuitism/overweight/irregular periods - >SLE/UC - Tubes - >pelvic surgery/STD - >endometriosis/pelvic pain/menorrhagia/dysmenorrhea - Uterus - >procedures/instrumentation - Social - >smoking - >alcohol and substances - >stress/mood/psychiatric disorders - >occupational exposure Exam - height/weight/BMI - inspection - >hirsutism/acne - >galactorrhea - >secondary sex characteristics/syndromic features - pelvic - >abnormal shape uterus - >nodular pouch of douglas (endometriosis) - >adnexal mass/tenderness Assess ovulation - serum progesterone - >7 days before menses - >ovulation if high - urine LH sticks - >serial assessments at home - >predicts ovulation approx 24hrs in advance - serial ultrasounds - >usually restricted to during treatment - if anovulatory - >FSH/LH (hyper/hypogonadotrophic hypogonadism) - >androgens (PCOS) - >TSH - >prolactin - >karyotyping Anatomical assessment - Imaging - >transvaginal ultrasound (uterine/tubal/ovarian morph) - >hysterosalpingography (uterine/tubal path) - >saline infusion sonography (uterine path) - >MRI (uterine path pre-op planning) - Surgical - >laparoscopy (endometriosis/adhesions) with chromotubation (tubal patency) - >hysteroscopy (uterine path) Ovarian reserve testing - Basal FSH on day 3 - >less than 2 = hypogonadotrophinism - >greater than 10 = possible reduced ovarian reserve - >greater than 30 = menopausal/ovulatory surge - Antral follicle count on day 3 - >transvagianl ultrsound - >less than 4 indicates diminished reserve - AMH on any day - >less than 1 ng/mL indicates diminished reserve

Answer 35

Non pharm - Diet - >limited evidence - >beneficial for future pregnancy - Weight loss - >high BMI or PCOS - Weight gain - >athlete/low BMI/anorexia - Reduce smoking/drinking/substances - Psychology support - >high stress associated with infertility - >stress/psychological morbidity risk factor for infertility Ovarian stimulation - Clomiphene - >indicated for normogonodotrophic ovulatory dysfunction - >ineffective in hypogonadotrophic hypogonadism - Letrozole - >indicated for normogonadotrophic ovulatory dysfunction - Gonadotrophin therapy - >failed first line treatment - >hypogonadotrophic hypogonadism Tubal abnormalities - IVF - >failed ovulation treatment - >tubal abnormality - >male infertility - >uterine abnormalities with surrogate - Tubal patency improving procedures - >distal occlusion may be treated/proximal should not - >fimbrioplasty (lysis of adhesions/dilation of strictures) - >neosalpingostomy (new tubal opening) Uterine abnormalities - Setate - >some evidence for surgical intervention - Fibroids - >consider surgery if other treatments failed - >best evidence for submucosal - Polyps - >polypectomy for large endometrial polyps Specific aetiologies - Endometriosis - >first line = IVF - >surgical ablation of impants/adhesiolysis - PCOS additional treatments - >ovarian stimulation - >metformin - >ovarian drilling - Hyperprolactinaemia - >bromocriptine

Obstetrics/Gynaecology (NEW) Flashcards

(59 cards)