Women's Flashcards
(38 cards)
1
Q
What are the 4Ps for young gynaecology case? (teens-mid 40s), What are the 4Ds?
A
-
Pregnancy:
- Gravidity
- have you ever been pregnant?
- how many times?
- any miscarriages/ectopics/terminations
- Parity:
- how many children do you have
- current plans
- Gravidity
-
Period:
- regular or not?
- volume?
- heavy - QOL
- abnormal
- post-coital (cervical dysplasia)
- intermenstrual bleeding (structural issue with uterus)
-
Pain: 4Ds
- dysmenorrhoea:
- primary (pain, Mittleschmerz)
- secondary (endometriosis)
- dysparenunia
- superficial (vulval, psychological, lubrication)
- deep (endometriosis)
- Dyschezia: (pain on defecation)
- same as period pain?
- advnaced endometriosis
- Dysuria
- dysmenorrhoea:
-
Pap Smear
- Up to date?
- last one?
- normal?
2
Q
Whats an extra questions you should always ask in a young gynae history?
A
- Contraception:
- what contraception
- what barrier
- brief relationship history
- Surgical
- previous CS
- PMHx, Meds, FHx
- SHx - what they do for work
3
Q
What history questions do you ask in old gynaecology? (4Ps?)
A
MenoPause
- when did your periods stop
- have you had any bleeding since
- post-menopausal bleeding (early symptoms of endometrial cancer)
- did you need HRT
- Holistic questions:
- vasomotor symptoms (hot flushes, night sweats)
- urogenital (dryness, reduced libido)
- bones
- Other - mood, sleep disturbance
- SHx - smoking diet
Prolapse:
- dragging/heavy sensation
- lump (showering)
- incontinence
- stress (leakage when coughing) - physical interventions
- urge (rush, frequency, nocturia) - medications
- how do you control it? (pads)
- who noticed it?
PAP smears
Pregnancy:
- brief
Others:
- breast screen
- PMHx, Surgical Hx, Meds, FHx, SHx, Lifestyle
- Holistic
4
Q
What questions do you ask for the Antenatal period in an obstetric history?
A
- Gestation
- early pregnancy - can’t let them go home with something bad
- US yet?
- Beta-HCG - 1500-2000 should see on US
- use the wheel
- early pregnancy - can’t let them go home with something bad
- 10 weeks
- routine blood tests? Blood group (Rh-? Hep? HIV? syphilus?)
- screening for DS? (normal, NIPS)
- 20 weeks
- morphology
- 26 weeks
- GTT
- 36 weeks
- GBS
General:
- baby movements
- BP
- vaginal discharge
5
Q
What do you do for an Obstetric history? How do you structure it?
A
- Gravidity
- been pregnant?
- how many times?
- Any miscarriages?
- gestation?
- recurrent?
- how were you treated? (curretage? meds?)
- ectopic pregnancy?
- surgery - laparoscopic salpingectomy
- methotrexate IM dose
- Parity
- how many children do you have?
- Previous pregnancies:
- mode of delivery
- CS (more you’ve had more placenta imbeds - accreta)
- born at gestation
- changes chance of low/high risk
- complications
- what was it?
- mode of delivery
- Antenatal period
- Gynae problems (PMHx, Surgical Hx, Pap Smear)
- Meds (treatment/allergies)
6
Q
What should you use as a structure for a Post partum Bleeding History?
A
- Delivery:
- mode of delivery
- placenta delivered complete and intact
- Breast-feeding
- Mood
- screen for PND
- Contraceptive plans
- Pap smears
- Bleeding
- still bleeding
- starting to change colour
- continues
- DDx:
- infection
- retained products
- Ix:
- blood group
- FBE
- Group and hold
- vaginal swabs
- US
- DDx:
- Fever - DDx - infection, mastitis, UTI
7
Q
What are the 6Ls in preparation for a PAP smear?
A
- Lump (pillow)
- Loo (emptied bladder)
- Lubricant
- Label
- Light
- Look
- (warm speculum/wash hands)
8
Q
What should you say to consent a patient before a PAP smear?
A
- explain the procedure
- undress down to waist
- instrument placed in vagina
- paddle to scrape cells from cervix
- sent off to lab which will take time to come back
- side effects:
- cramping
- spotting
- someone else in the room?
- stop signal
- do you understand? Questions?
9
Q
What is the diagnostic criteria of PCOS? What is the Management?
A
Diagnostic Criteria:
- Rotterdam = >2 of
- hyperandrogenism (clinical or biochemic (increased Free Androgen Index))
- PCO (>12 peripheral antral follicles)
- Irregular cycles (<21 or >35 days or <9 periods/yr, oligo/anovulation)
10
Q
What is the treatment of PCOS?
A
- 1st line (lifestyle modification)
- reduce weight
- stop smoking
- diet + exercise
- Andogenic effects:
- acne
- Hirsutism
- COCP (takes 6-12mths)
- spironolactone
- Menstrual:
- COCP
- progesogen therapies
- metformin
- fertility:
- LOW = if BMI >25
- metformin
- climiphene
11
Q
What is a way to structure the women’s histories?
A
- SMOG:
- Sexual history (5Ps)
- partners
- practice/libido
- protection
- past history STIs/PID
- prevention (contraception)
- Menstrual history
- age of menarche
- LNMP
- menstruation duration/volume,
- pain
- Obstetric Hx
- Past pregnancies
- complications
- methods
- Gynaecological Hx:
- PAP smear
- gynae surg
- Sexual history (5Ps)
12
Q
Decreased fetal movements history, what are your differentials?
A
- gestation? singleton?
- characterise nature? (#in 12 hrs) context?
- <10 in 2 hours is problematic
- stimulate? (cold/hot water or eating)
- OHx/Gynae - IUGR, miscarriage, PHx reduced?
Maternal:
- HTN - PET symptoms (headaches, visual changes, swelling, frothy urine, RUQ pain)
- chronic disease
- smoking/toxins - drugs (alcohol, benzos, opioids)
- thrombophilia - APLS, SLE
- malnutrition/exercise
Placental
- Abruption - bleeding, abdo pain
- multiple pregnancy
Fetal:
- Infection (TORCH) - immunity
- structural? (20week scan)
- Chromosomal (FTCS, NIPT, FHx)
- hemolytic disease
13
Q
What examinations and investigations would you perform for decreased fetal movements?
A
- Examination:
- SFH and maternal weight
- palpate abdomen + measure BP
- Investigations:
- hand held doppler
- CTG (non-reassuring)
- US (BPP, AFI, morphology, Doppler MCA/UA)
- consider Kleihauer
- FBE, coag, anticardiolipin, lupus anticoag
14
Q
What are menopausal symptoms you should ask about?
A
- vasomotor symptoms (hot flushes and night sweats)
- atrophic vaginitis (dryness, bleeding, dyspareuria)
- mood changes
- OP
- libido
- sleeping, memory, muscle aches
15
Q
What are menopausal medical screening questions you should ask?
A
- ABCDE, LMS
- Age >60
- Breast Ca, AUB
- CVD (cholestrol, HTN, AMI), cerebrovascular (stroke)
- DVT/PE
- Endometrial cancer (hysterectomy)
- Liver Disease
- Migraine (focal)
- Smoking, screening (mammogram/PAP smear)
16
Q
What are some advantages and disadvantages of HRT? What are some other therapies?
A
- Advantages:
- symptom relief (improves hot flushes, atrophic vaginitis, improve psychological)
- maintains or improves bone density, reduces risk
- small decrease in CVD and colon cancer
- Disadvantages:
- breakthrough bleeding, nausea, breast tenderness, bloating
- increased risk of VTE, breast cancer (>5 years), increased endometrial cancer with unopposed oestrogen
- Ix before HRT:
- mammogram/PAP smear
- lipid profile and OGTT
- vitamin D and DEXA (if indicated)
Other treatments
- nothing - diet and exercise, quit smoking, mammogram/OP
- flushes - cool clothing, wearing layers, cool drinks, fans
- vaginitis - lubricants
- CBT
- SSRI
- Gabapentin
17
Q
What are some causes of postpartum fever?
A
- endometritis
- tender painful lower abdomen
- PPH from RPOC
- foul smelling discharge
- mastitis or breast abscess
- red, hot, swollen, hard, tender
- nipple rauma
- flu-like - headache, myalgia, nausea
- feeding Hx - are you? troubles? missed feeds?
- DVT
- hot swollen tender leg
- SOB
- Infection
- URTI
- UTI
- wound infection (4-5days post)
18
Q
What is the management of mastitis?
A
- conservative:
- educate and reassure to continue
- rest, adequate fluids, nutrition, avoid bra
- frequent breast emptying (massage, express after)
- apply heat packs before, cold packs after feeds
- refer
- Medical:
- analgesia
- antibiotics (fluclox) - if severe with no improvement
19
Q
A patient presents with pelvic pain, what are your differentials?
A
- primary dysmenorrhea (Diagnosis of exclusion)
- Endometriosis:
- cyclical,
- deep dyspareunia
- menstrual disturbance
- Adenomyosis
- history of CS
- menorrhagia
- tender bulky uterus
- PID
- bilateral pelvic pain,
- discharge
- dyspareunia
- IMB
- STI Hx
- intracavity mass
- fibroids/IUD
- Asherman’s syndrome (surg/DNC Hx)
- consider chronic (GU/GIT/musculoskeletal, psychosocial)
20
Q
Counsel a women about dysmenorrhoea, what treatments are available?
A
Womb contracts to shed the lining every month, in some women the prostaglandins are higher and it contracts harder to shed the lining. This can reduce blood flow, making pain worse.
Treatments:
- menstrual diary
- Non-pharm - hot water bottle, smoking stop, Vit E, Magnesium
- NSAIDs - ponstan taken before pain.
- COCP - limited evidence can commense if NSAID not working
21
Q
What are some things you should ask for PET?
A
- preeclampsia symptoms:
- BP - urine tests
- neurological
- headache
- visual disturbance (scintillating scotomata, blurred)
- clonus
- renal
- peripheral oedema
- pulmonary oedema (SOB)
- frothy urine
- HELLP
- jaundice
- RUQ pain
- bruising
- bleeding
- nausea/vomiting
- eclampsia - seizure?
- general signs (fever, sweats, chills)
- Others (migraine, ICP - trauma, meningitis)
- RFs:
- HTN
- DM
- renal, thrombophilia, autoimmune disease
- SHx:
- 1st conception with partner, smoking, BMI
- FHx of PET
22
Q
What is the management of PET?
A
- Investigate
- FBE (platelets low)
- LFTs (increased ALT, AST)
- renal function
- urinalysis (ACR>30)
- severe - inpatient, mod - antenatal ward, mild - monitor
- Admit and stabilise (ABC)
- control BP (labetalol if urgent, methyldopa if mild)
- seizure prophylaxis (MgSO4)
- analgesia (epidural)
- strict fluid balance
- continous fetal monitoring and frequent vitals/reflexes
- delivery:
- immediate after 37weeks, HELLP, BP>170
- consider deferring if <34weeks
- continue MgSO4 24 hours postpartum (nifedipine or labetalol postpartum)
- follow-up
23
Q
Talk through some points to mention for twin pregnancy counselling.
A
- Explain:
- monozygotic vs dizygotic
- MA and MC vs DA and DC - confirm on US
- Risks to mum:
- PET
- GDM
- Growth problems (IUGR)
- anaemia
- APH (placental mass)
- Preterm
- PPH
- Risks to baby:
- MC
- TTTS,
- TOPS (amniotic fluid)
- TAPS (RBCs)
- discordant growth
- complications (NEC, IVH, increased mortality)
- MC
- depression higher
- Advice:
- energy needs higher
- protein, folate, calcium and iron supplements
- all appointments with Obstetrician
- increased USS (especially in 2nd/3rd trimesters)
- Delivery:
- MCMA 32-34weeks (cord entanglement)
- MCDA 36-38weeks
- DCDA elective delivery 37-38weeks
- mode:
- DA - no difference
- MA - do CS
- congratulate.
24
Q
What are some differentials for amenorrhoea?
A
- Pregnancy
- Hypothalamic
- excessive exercise
- low weight
- stress
- chronic illness
- Pituitary
- prolactinoma (headache, changes in vision, bumping into things, hypoestrogenism, galactorrhoea)
- Drugs (antipsychotics, metoclopramide)
- Sheehan’s syndrome (PPH)
- thyroid - high/low
- Ovarian:
- ovarian failure (chemo/radio)
- early menopause
- PCOS (hirsutism, acne, obesity, weight gain)
- Uterine
- asherman’s
- cervical canal stenosis
25
What are the investigations and treatment for urge incontinence?
* urinalysis + urine MCS
* bladder diary
* post-residual volume (bladder scan or catheter)
* urodynamic studies (if blood, cystourethroscopy)
Management:
* avoid diuretics and fluid intake
* if stress component:
* weight loss
* pelvic floor exercises (physio)
* pessary
* pads
* tension-free vaginal tape
* urge component (detrusor instability)
* bladder retraining
* phamacological
* oxybutinin/solifenacin
* hydrodistension with cystoscopy
26
Counsel a women wanting to start the OCP.
Medical Screen: ABCD LMS
* Age \>35 (obesity or smoking), AUB
* Breast cancer
* CVD or cerebrovascular disease
* DVT
* liver disease
* migraine with aura
* smoking
How it works:
* similar to the bodies hormones, stops release of egg, thickens cervical mucus.
How to take:
* starting today - unless unprotected intercourse LMNP \>5 days ago
* otherwise start sugar pills 1st day of menstrual period
* use backup contraception for 14 days.
* 7 day rule (if \<24 hrs late take pill, if more than 24hrs use backup contraception, if \<7 days since last placebo consider LNG-EC if sex within 5 days)
* treat gastro and antibiotics (macrolides) as missed pills
Advantages:
* regulates periods, reduces pain/bleeding, decreased incidence of Breast/ovarian/colon cancer
Side effects:
* breakthrough bleeding
* breast tenderness
* nausa
* mood changes and libido
* weight gain
* bloating
uncommon - clotting, AMI, stroke, cervical Ca
27
What are some complications of Post-date babies?
* bigger baby - obstructed and shoulder dystocia is higher (brachial plexus injury and intracerebral hemorrhage)
* placenta fails - fetal death
* induction can reduce mortality
28
What are some ways we can induce women who are post dates?
* consider it when due date +10-14days
* come in the night before, have CTG
1. prostaglandin (prostin E2) or balloon catheter to soften and dilate cervix (if Bishops is bad)
2. ARM - small plastic hook used to rupture membranes
3. Syntocinon (oxytocin) via IV infusion stimulates contractions
Side effects:
* hyperstimulation - fetal distress, precipitate labour, uterine rupture
* IV - nausea, vomiting, hyponatremia
* cord prolapse if presenting part poorly applied
* increased risk of emergency CS and PPH
29
What is the Bishops score? Why is it useful for Induction?
* Bishops 1-13 (SCaLPeD)
* statin
* consistency of cervix
* length (effacement)
* position
* diameter
* \<5 use prostin gel or foley catheter
* \>7 use ARM + oxytocin
30
What investigations would you perform for infertility?
* Semen analysis
* Hormones - FSH (high/low), AMH, PCOS
* Genetics - karyotype, CF
* Imaging - Pelvic US and hysterosalpingography (improves)
* screening - STIs, infections
31
What are some male causes of infertility?
* testicular
* trauma
* torsion
* undescended
* varicocoele
* vasectomy
* CF/mumps
* chronic disease, genetic, chromosomal
* environmental factors
32
What are some differentials for a pelvic mass?
* pregnancy + ectopic (LMNP and symptoms)
* leiomyoma (menorrhagia, nulliparity, dysmenorrhoea, pressure symptoms)
* adenomyosis (menorrhagia, multiparous, uterine surgery, dysmenorrhoea)
* endometriosis (IUD, post-childbirth, post-abortion)
* ovarian cancer (Fhx breast/gynae, BRCA, HNPCC, estrogen exposure)
* colorectal cancer (diarrhoea, constipation, PR bleeds, constitutional)
33
What are some tests you would do for a pelvic mass?
* FBE
* βHCG
* CA125/TVUS (ovarian)
34
What are some differentials for menorrhagia? What investigations would you order?
PALM COEIN:
* polyps
* adenomyosis
* leiomyoma
* malignancy
* coagulopathy
* ovulatory dysfunction
* endocrine (endometrial - DUB)
* iatrogenic
* not yet classified/never forget pregnancy
Investigations:
* βHCG
* FBE (anaemia)
* Iron studies (decreased iron/ferritin)
* TFT (thyroid)
* consider TVUS
* consider PCOS screen
35
What is the management of a women presenting with heavy menstrual bleeding?
* hemodynamically unstable:
* resuscitate with IV fluids (sometimes transfuse)
* treat underlying cause
* medical treatment:
* nonhormonal (ponstan and TXA)
* hormonal (COCP, progestagens - Mirena/depot provera, GnRH analogues)
* procedural (mirena)
36
What are the effects of diabetes on pregnancy?
* Fetus:
* malformations (NTD, cardiac, kidneys)
* macrosomia, IUGR
* still birth
* PET
* Labour:
* Preterm labour
* shoulder dystocia
* birth trauma
* Neonate:
* jaundice
* delayed lung maturity
* hypoglycemia
* Long term:
* T2DM 50% within 15 years for mother, and T2DM increases in the child.
37
What is the advice on glycemic control for a pregnant women? What is the management of a diabetic women?
* advice:
* dietary modification
* exercise 30mins 4x a week cease smoking
* monitor BSLs 4x a day (target 5mmol/L fasting, 6.7 post-prandial (2hrs post)) HbA1c \<6%
* at least 1 basal bolus/day
* complications;
* hypoglycemia (adrenergic - sweating, tachy, hunger, neuro - lethargy, headache, mood changes, visual)
* Frequency of visits:
* opthalmologist each trimester if DM before pregnancy, 3weekly visits until 28, 2weekly until 34. GDM only fortnightly until 38 no insulin, insulin weekly after 36.
* Ultrasounds:
* morph, 28-30, 34-36 (macrosomia/IUGR) before preg
* GDM - 32-34weeks
* CTG - weekly from 36 before preg, 40 weeks after preg
* delivery:
* pre-preg diabetes - 38-40weeks if CS then 38-39weeks (deliver 37 if complications)
* OGTT 6-8weeks post delivery
* GDM - deliver at 38weeks if IUGR/hyperglycemic. otherwise same as normal.
38
What is the management of post-partum haemorrhage?
* Resuscitate (ABC)
* airway - check
* breathing - RR, O2 sat, WOB
* circulation
* IV access - fluid resus
* alert blood bank
* bloods (FBE, LFTs, Coags, U&Es, Blood group and cross match)
* Summon help
* reassure
* massage uterus
* IV ergometrine
* controlled traction and clamping of cord
* 3rd stage drug management:
* repeat ergometrine 0.25mg or IV syntocinon 10U or misoprostol (5tabs)
* and syntocin 40U
* consider cause (POC - check placenta, trauma - assess episiotomy, repair tears)
* insert IDC
* continues bleeding
* ABC - fluid resus, analgesia
* Transfer to operating theatre
* bimanual uterine compression/aortic compression
* thorough VE under anaesthetic
* surgical suction/curette
* repeat misoprostol up to 5mg
