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Women’s health Flashcards

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1
Q

Long term Complications of hysterectomy with anterioposterior repair

A

Enterocoele and vaginal vault prolapse

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2
Q

3 criteria for diagnosis of post partum thyroiditis

A

Within 12 months of giving birth
Clinical manifestations of hypothyroidism
Thyroid function tests

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3
Q

PCOS diagnosis

A

2/3 of:
1 infrequent or no ovulation
Clinical or biochemical signs of hyperandrogenism or elevated free or total testosterone
Polycystic ovaries on USS or increased ovary volume

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4
Q

Causes of spontaneous miscarriage in first trimester

A 
Antiphospholipid syndrome
Uterine abn eg septum
Endocrine - thyroid, diabetes badly controlled, pcoS
Parental chromosomal abnormalities
Smoking
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5
Q

Immediate medications in premature early stage labour

A

Tocolytics and steroids

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6
Q

Risks of prematurity

A 
Chronic lung disease
Retinopathy 
Intraventricular haemorrhage
Jaundice
Respiratory distress syndrome
NEC
Hypothermia
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7
Q

Indications for continuous combined HRT

A

LMP over 1y ago
Or 2y iif under 40
Cyclic for 1y

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8
Q

HRt if hysterectomy

A

Continuous oestrogen

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9
Q

Features of endometriosis and diagnosis

A 
Chronic pelvic pain
Deep dysparaunia
Dysmenorrhea 
Sub fertility 
Urine sx and painful bowel movements
Exam - tender nodularity in post fornix, reduced organ motility, endometriosis lesions
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10
Q

Manage endometriosis

A

NSAIDs
COCP, progestogens
GnRH analogues to induce pseudo menopause due to low oestrogen
Laparoscopic/laser removal of cysts for fertility

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11
Q

What to do if missed POP

A

Under 3h - take and continue as normal

Over 3h - take as soon as possible but use condkms until pills used for 48h as normal

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12
Q

In what situations does POP provide immediate protection

A

Start on Up to day 5 of cycle

Start after day 21 exactly from COCP

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13
Q

What antibiotic to be cautious with for POP

A

Rifampicin

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14
Q

drug for magnesium sulphate-caused respiratory depression

A

Calcium gluconate

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15
Q

Drug for benzo OD

A

Flumazenil

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16
Q

How do the main contraceptives work (primary action)

A

COCP - inhibit ovulation
POP (not desorgestrel) - thicken cervical mucus
Desorgestrel pill, prog inject or implant - inhibit ovulation
Copper device - inhibit implantation

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17
Q

Sign that hyperemesis requires hospital admission

A

Ketonuria, weight loss, oral antiemetics not controlling sx

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18
Q

Most common causes of PPH

A

1) uterine stony (80-90%)

Coagulopathy, retained placenta, trauma

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19
Q

Risk factors for PPH

A 
Maternal age
Pre-eclampsia
Polyhydramnios
Macrosomia
Placenta praevia/accreta
Previous PPH
Prolonged labour
Emergency c section
B2 adrenergic receptor agonist for tocolysis
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20
Q

Manage PPH

A

Syntocin (oxytocin) IV or ergometrine
IM carboprost
Surgical - balloon tamponade, ligation of uterine or int iliac arteric

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21
Q

Muscarinic antagonists for incontinence

A

Tolterodine, oxybutynin

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22
Q

What is lochia and how long does it last

A

Blood mucus and uterine tissue up to 4-6w post partum

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23
Q

What is rokitansky protuberance

A

Where dermis, bone and teeth come from in mature teratoma

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24
Q

Types of functional ovarian cysts

A

Follicular - non rupture of dominant follicle

Corpus luteum cyst - blood or fluid, with intraperitoneal bleeding

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25
Epidemiology of benign dermoid cyst/teratoma of ovary
Most common benign ovarian tumour in under 30s, commonest at 30y, Bilateral in 10-20%
26
Types of benign epithelial tumours
Serous cystadenoma most common | Mucinous cystadenoma - large, causes pseudomyxoma peritonei if rupture
27
3 categories of benign ovarian cyst
Physiological/functional Epithelial Germ cell/dermoid
28
2 manoeuvres for shoulder dystocia
Woodscrew - put hand in vagina and turn baby 180 | McRoberts - hyperflex legs and apply suprapubic pressure
29
Medical management for ectopic pregnancy, adv and disadv
IM methotrexate - must attend follow up - bHCG on day 4 and 7, repeat if fallen <15% +: can go home, avoid surgery -: diarrhoea and abdo pain; hepatitis, renal impairment, myelosuppression, teratogenic (contraception for 3m)
30
Surgical management for ectopic pregnancy and adv and disadv
Salpingectomy or salpingotomy + = definitive, high success rate - = damage to adjacent structures eg ureters, GA risk, DVT/PE, infertility, infection + anti-D prophylaxis if >12w or known rh-ve
31
Indications for surgical management ectopic
``` >35mm Intrauterine pregnancy as well Visible foetal heart beat Serum bhCG high Can be ruptured Severe pain ```
32
Indications for medical management of ectopic
``` <3.5cm and no heartbeat Asymptomatic or mild No haemoperitoneum on TVUS BhCG not high Not suitable if intrauterine pregnancy as well ```
33
Expectant management for ectopic and its indications
<30mm Asymotomaic, no foetal heart beat, hCG low and getting lower Compatible with intrauterine pregnancy Monitor every 48h until confirmed fall then weekly
34
Risk factors for cord prolapse
``` Artificial rupture of membranes Multi parity Prematurity Polyhydramnios Twins Breech or transverse Placenta praevia Long cord High foetal station ```
35
Hyperemesis severity scoring system
Pregnancy Unique Quantificatoin of Emesis score
36
Steroid used in lung maturation
Dexamethasone
37
Suppression of lactation medication
Cabergoline - dopamine receptor agonist
38
Sx of abruption
``` Continuous Pain Woody firm uterus/spasm Shock disproportionate to blood loss visible Foetus hard to feel Heart hard to auscultate ```
39
Features of Sheehan syndrome
Agalactorrhoea Amenorrhoea Hypothyroid sx Hypoadrenalism sx
40
What are molar pregnancies and features including on USS
Imbalance of chromosomes - non viable Causes early bleeding and large uterus for dates Hyperemesis gravidRum and thyrotoxicosis from excessive hCG (mimics TSH) “from abnormal trophoblastic tissue Solid collection of echos with anenchoic spaces -bunch of grapes
41
3 disorders of gestational trophoblastic disease
Complete hydatiform mole - sperm duplicates it’s own DNA so all 46 chromosomes of parental origin Partial hydatiform mole - 2 sperms or 1 sperm that duplicates, so 69XXX or 69XXY, maternal and paternal ChoriocArcinoma
42
When to stop COCP before surgery and what to do instead
4w before, use progestogen only instead
43
Cause of macrocytic anaemia in pregnancy
Folate deficiency
44
Causes of folic acid deficiency
Pregnancy Alcohol Phenytoin Methotrexate
45
When should folic acid be taken in pregnancy and what are indications for the higher dose?
``` Up to 12w History of neural tube defects - personal or family Antiepileptics Diabetes, coeliac, thalassaemia Obese ```
46
Initial management of labour not starting a 41w
Membrane sweep | Vaginal prostaglandin gel
47
When to give anti-d to rhesus negative mother
``` Not yet sensitised, family history Rhesus positive baby born Miscarriage over 12w Termination Amniocentesis, chorionic villus sampling Antepartum haemorrjage External cephalic version ```
48
Features of foetus affected by rhesus disease
Oedematous (albumin not produced due to over production of RBC from liver), hydrops fetalis Jaundice, anaemia, hepatosplenomegaly Heart failure Kernicterus
49
Surgical management of tubal ectopic
Salpingectomy
50
Indications for induction of labour
Diabetic >38w Rhesus incompatibility Over 12d after estimated DD PPROM without labour
51
Methods of induction
Membrane sweep Intravaginal prostaglandins Break waters Oxytocin
52
Who can authorise and perform abortion?
2 registered medical professionals sign, registered medical practitioner in NHS hospital or licensed premise perform
53
Method for termination at different ages
<9w = mifepristone (anti-progesterone) then prostaglandins after 48h to stimulate uterine contractions <13w - surgical dilation and suction of uterine contents >15w - surgical dilation and evacuation or late medical abortion (mini labour)
54
4 Requirements of abortion act
Not exceeded 24tth week and continuance is more risk than termination Needed to prevent permanent injury to health of woman Risk life of woman Risk of child having severe handicap
55
How much does hCG decrease after termination
Half every 2 days, can stay positive for 4w
56
Features of vasa praevia
Foetal vessels inserted into membranes | Painless vaginal bleeding, foetal bradycardia, membrane rupture
57
Risk factors for placenta praevia
Multiparity Multiple pregnancy Lower segment scar from previous c section
58
Grades of placenta praevia
1 - lower segment but not internal os 2 - reaches os but doesn’t cover 3 - covers os but not when dilated 4 - completely coversf os
59
How much fundal height growth
2cm a week until 24w then 1cm a week
60
What does IUD and IUS do to periods
IUD - Heavier, longer, more painful | IUS - initial frequent bleeding and spotting for 6m then light/amenorrhoea
61
Requirements for instrumental delivery
``` FORCEPS: Fully dilated cervix and second stage+ OA position preferable and location of head known Ruptured membranes Cephalic presentation Engaged presenting part (at or below ischial spines and not palpable abdominally) Pain relief Sphincter (bladdeR) empty ```
62
Indications for forceps
Foetal distress Maternal exhaustion Not progressing in 2nd stage Contnrol head if breech
63
Smears for women with hiv
Annual cytology
64
Biggest risk of TOP
10% Infection
65
antiepileptics safest in pregnancy
Lamotrigine, carbamazepine, levtiricitam
66
Definition of PPH
500ml loss from genital tract within 24h of birth
67
Cause of secondary PPH
Retained placental tissue or endometritis
68
Which contraceptive causes the biggest delay in fertility returning
Depot provera IM injectable every 12w - for up to a year
69
Condition that includes benign ovarian tumour and the triad
Meig’s syndrome: Benign fibroma ovarian tumour, Pleural effusion, ascites
70
What makes pregnancy induced hypertension pre eclampsia?
Proteinuria
71
Complications of PPROM for mum and baby
Mum - chorioamnionitis | Baby - premature, infection, pulmonary hypoplasia
72
Abx for PPROM
Erythromycin 10d PO
73
Test for complications of rhesus incompatability and when
Kleihauer test for foetomaternal haemorrhage to detect foetal cells in maternal circulation and volume to calculate additional anti - d ig needed Any sensitising event after 20w
74
Most common cardiac abnormality in pregnant women
Mitral stenosis
75
Sudden onset chest pain in 3rd trimester and high bp
Aortic dissection, can block right coronary artery and cause MI
76
Treat aortic dissection in pregnancy
<28w = repair 28-32 depends on foetal condition >32w = c section then repair
77
Anticoagulation for PE in pregnancy
LMWH throughout and 4-6w after birth
78
Treat vaginal vault prolapse
Sacrocolpoplexy - suspends vaginal apex to sacral promontory by uterosacral ligaments
79
Features of chorioamnionitis
Infection ascending into amniotic fluid, membranes or placenta. Uterine tenderness and foul smelling discharge, baseline foetal tachycardia
80
Contraceptives time until effective
Instant IUD 2 days POP 7 days COCP, injection, implant, IUS
81
When can pre eclampsia be diagnosed and how to prevent if high risk
From 20w | Aspirin 75mg OD from 12w
82
High risk for pre eclampsia
Hypertensive in previous pregnancy CKD AI - SLE, antiphospholipid DM1 or 2
83
What infections are screened for in pregnancy
``` HIV Syphilis Rubella Asymptomatic bacteriuria Hep b ```
84
4 most common causes of premature ovarian failure
Idiopathic Chemo AI Radiation
85
4 ADRs of depo provera
Weight gain Infertility for 1y Osteoporosis Irregular bleeding
86
Proven contraceptive to cause weight gain
Depo provera
87
First line antihypertensive if asthma and prenant
Nifedipine
88
CVS changes in pregnancy
SV 30% HR 15% CO 40%
89
Resp changes in pregnancy
pulmonary ventilation 40%, tidal volume to 700ml, o2 requirements increase by 20% so pCO2 can decrease Bmr up to 15%
90
When is twin transfusion syndrome diagnosed
US 16-24
91
Medication prior to surgery for fibroid removal
GnRH agonist to shrink and reduce post op blood loss
92
Why is footling presentation dangerous
Risk of cord prolapse
93
5 causes of oligohydramnios
``` Renal problems Premature rupture of membranes iugr Post term gestation Pre eclampsia ```
94
What is a galactocoele
Benign collection of milk from blocked lactiferous duct
95
Treat GBS identified early in pregnancy
intrapartum Iv benzylpenicillin to reduce neonatal transmission
96
RF for ectopic
``` Previous ectopic Tube damage - PID, surgery Endometriosis IUCD, POP, IVF Smoking ```
97
Symptoms and signs of ectopic and why bleed
Bleed as sub-optimal BHCG means endometrial lining isn’t maintained and starts to shed Amenorrhoea, pain (unilateral), bleeding Diarrhoea, loose stools, vomiting Shoulder tip pain from diaphragmatic irritation from haemoperitoneum Signs: collapse Cervical excitation +- adnexal tenderness Peritonism
98
Most common sites for ectopic
Tubal - ampulla = 1 | 2 = isthmus (narrow, inextensible, presents early and higher risk of rupture )
99
Inv ectopic pregnancy
``` FBC, G&S (6u) Serum progesterone BHCG TVUS Laparoscopy if unknown location ```
100
Definition of pregnancy of unknown location and causes
Pos pregnancy test or bHCG >5 but no signs f intrauterine or ectopic pregnancy or retained products of conception Eaarly intrauterine pregnancy Complete miscarriage Ectopic Failing PUL which wil resolve on its own
101
Inv pregnancy of unknown location
Based on symptoms Pain and haemoperitoneum = laparoscopy Well - repeat 48h later scan, prog and bHCG and follow up - prog will fall (failed pregnancy), HCG will increase a lot (pregnancy) or plateau (ectopic?)
102
How much does HCG normally increase
>66% in 48h in early pregnancy
103
What is a miscarriage
expulsion of pregnancy whe its incapable of independent survival - all losses <24w
104
Cervical os open, bleeding/pain
Inevitable miscarriage
105
Cervical os closed, mild pain
Threatened miscarriage
106
Findings of incomplete miscarriage and management
Some retained POC, sliding sign, endometrial thickening Os open Expectant Ergometrine IM or surgery if bleeding/pain profuse
107
bleeding and smal for dates uterus with closed os and specific findings
Missed miscarriage - foetus died in utero Pain, bleeding, asymptomatic, cervix closed, small uterus Foetal pole >7m with no hr Gestational sac >25mm with no foetal pole or yolk sac
108
Manage missed miscarriage
Mifepristone - antiprogestogen - -sheds lining and removes supply to POC Mifoprostol 24-48h later - prostaglandin analogue - ripens cervix and causes expulsion by myometrial conctractions Can bleed for 3w Or suction - manual under LA <13w or under GA - if patient chooses of bleeding after 2w ++
109
What is septic misscarriaghe
complete or incomplete, os open or closed | Inf
110
complete miscarriage signs
No endometrial thickening, no RPOC, os closed
111
RF for mischarriage
``` Previous miscarriage Age Foetal chromosome abnormalities Maternal uterine abnormalities or cervical weakness Infection or illness eg SLE Ssmoking Obestiy Antiphospholipid syndrome ```
112
Sx of miscarriage
Bleeding , clots, POC Suprapubic cramping pain Dizzy, SOB
113
Manage antiphospholipid syndrome in pregnancy ad risks other than. Miscarriage
Aspirin 75mg from day of pos pregnancy test Pre eclampsia Severe growth restriction PReterm birth
114
causes of recurrent miscarriage
Endocrine - thyroid, DM - badly controlled Uterine abnormality Infection - bv in 2nd trimester Parental chromosome abnormality Antiphospholipid syndrome - 1st trimester Thrombophilia
115
Test for antiphospholipid syndrome
2 tests 12 weeks apart - test all women
116
What to do before TOP
``` Counselling USS screen to confirm gestation and no other viable foetus Metronidazole and Azithromycin STI screen Anti-D if neg Discuss contraception ```
117
Methods of TOP
Medical - mifepristone and misoprostol + nsaid | Surgical + misoprostol to dilate cervix. Vacuum 7-14w, dilatation and evacuation 13-24w
118
RF for heavy bleeding - 3
1) age - menarche, pre menopause 2) obesity 3) c section - adenomyosis
119
Wha is heavy bleeding
Interfering with qol >80 Fatigue, sob
120
Findings on exam for heavy bleeding
Mass - smooth/irregular Vaginal tumour Cervix - polyp, tumour, inflammation Tender/excitation - adenomyosis, endometriosis
121
Causes of heavy bleeding
1 = DUB - no other abn, vessel contraction abn Med problem - SLE, hypothyroid, liver disease, cancer FIGO classification : PALM-COEIN Polyp - endom, cervical. Intermenstrual or postcoital, no pain Adenomyosis - dyuria , bulky tender uterus Leiomyoma - mass, heavy bleed, shrink after meno Malignancy or hyperplasia - vaginal, endometrial or cervical Coagulopathy - vwf, anticoagulants, thrombocytopoenia, leukaemia Ovarian - pcos Endometriosis Iatrogenic - contraception, IUCD Not known - dub
122
Investaigiaons for heavy bleeding
Pregnancy FBC, clotting and vwf, hormones (PCOS), TFT Smear, swabs TVUS if mass, pharm failed, risk factors Endometrial pipelle biopsy if >45yo and persistent Hysteroscopy and biopsy if pathological or inconclusive US
123
MAnage heavy bleeding and ADRs - medical
1 - levonorgestrel releasing IUS: shrinks fibroid, thins endom, 5yy, contraceptive - ADR - progesterone ADRs, 6m of irregular bleeding 2 - antiifibrinoltics inhibit tPA so less plasminogen activation and less fibrinolysis - clot stabilissied - tranexamic acid CI VTE, ADR tinnitus, rash, nausea - mefanamic acid (also NSAID) CI ulcer, ADR GI, headache - COCP - decrease gonadotrophins 3 - progesterone - norethisterone (short term), depo or implant
124
Surgical management of heavy bleeding
1 - endometrial thermal ablation - but can burn through to bladder and can regrow 2 - hysterectomy 3 - myomectomy or uterine artery emoblisation if >3cm fibroid and want to stay fertile
125
Signs and symptoms of fibroids other than heavy bleedin
Asymmetrical enlarged uterus Lower abdo pain Dysuria
126
Sx of adenomyosis other than bleedin
Symmetrically enlarged boggy uterus Chronic pain Dysuria Older women
127
Sx of PID other than bleedin
Tender on exam Discharge Fever New onset
128
Polyps sx as well as bleeding
Not usually painful Intermenstrual Post coital if cervical
129
Gold standard investigation for endometriosis
Diagnostic/explorative laparoscopy
130
7 RF for endometrial cancer
``` Too much oestrogen: - nulliparity - early menarche - late menopause - pcos Obesity Family history of breast ovarian or colon cancer Diabetes ```
131
Cancer most linked to endometrial
Colon - HNPCC
132
Why are BMI and PCOS risk factors for endometrial cancer
Obese - increased peripheral aromatisation of androgens to oestrogens. 2x risk >25, 3x risk >30 PCOS - loner anovulation so less progesterone to counteract oestrogen
133
Staging of endometrial cancer
``` FIGO staging: 1 - uterine body 2 - uterine body and cervix 3 - outside uterus but in pelvis 4 - local/regional spread of tumour (bowel, bladder etc) ```
134
Inv endometrial cancer
TVUS for thickness >4mm Biopsy with hysteroscopy (visualise) or as outpatient bedside CT/MRI for staging
135
Surgery for endometrial cancer
TAHBSO RT as adjuvant to prevent recurrence or external beam to control bleeding if unfit for surgery High dose progesterone for bleeding in palliation
136
4 types of fibroid
Subserosal (visceral) Intramural Submucosal (under endometrium) Pedunculated
137
RF for fibroid
Age Afrocaribbean FHx Oestrogen - pregnancy and COCP
138
Presentation of fibroids - 4
Menorrhagia - heavy and pronged, not intermenstrual Pain - from pedunculated torsion or red degeneration (thrombus) Mass effect - pressure on bladder Infertility - distort cavity nd prevent implantation
139
Manage fibroids
None if symptoms not too bad Med - GnRH analogue or ullipristal acetate (selective progesterone receptor modulator) for 3-6m before surgery to shrink and induce amenorrhoea. Ullipristal acetate needs regular LFTs and FBCs Surg - uterine artery embolisation (v painful post op, can cause infected necrotic uterus) - myomectomy (hysteroscopy or laparotomy) - best for future pregnancy but will need c section if uterus breached - hystorectomy
140
Fibroids in pregnancy
Red degeneration: 2nd trimester - grow, can get thrombus of vessels, causing venous engorgement and inflammation = abdo pain, vomiting, low grade fever and localised tenderness Will resolve in 4-7d with rest and analgesia
141
Fibroid after menopause
Most regress | Can become sarcoma = pain, malaise, bleeding, grow
142
Causes of intermenstrual bleeding
Cervical polyp, cancer of ectropion | Trauma or abrasion - post coital
143
Causes of post menopause bleedin
endometrial - polyp, cancer, hyperplasia Cervical - polyp, cancer Vulval cancer
144
What is endometriosis nd adenomyosis
Endo - endometrial tissue outside uterus | Adeno - endometrial tissue in myometrium
145
3 causes of endometriosis
Retrograde menstruation - adherence, invasion and growth Impaired immunity Metalasia of mesothelium cells
146
Inv endometriosis
TVUS for ovarian cysts MRI if bowel symptoms to map extent Diag - laparoscopy with biopsy - deep infiltrating lesions, do 3m after stopping hormones
147
Cells in cervix
Endocervix canal = mucous columnar epithelium Vaginal cervix = squamous epithelium Junction = transitional zone = predisposed to malig
148
What is ectropion and treatment
Extension of mucous columnar endocervix epithelium into ectocervix - prone to bleed, infection, mucous Extends under hormones - puberty, pregnancy, COCP No treatment necessary but can treat by removing hormonal contraception or diathermy
149
Manage cervical polyps
Post coital bleeding/discharge If young, avulsed Older - TVUS +- hysteroscopy to exclude interuterne polyp
150
Caus of cervicitis
Follicular or mucopurulent | Chlamydia, gonococci or herpes
151
What is CIN and different stages and management
Dyskaryosis of cervical tissue - pre-invasive CIN1 - lower 1/3 - most will regress spontaneously CIN2 <2/3 CIN3 >2/3 - less likely to regress, more likely to progress to invasive squamous cell cancer and quickly in younger women Smear : CIN2-3: Inflammatory - repeat in 6m, do swab, colposcopy if 3x abnormal Borderline dyskaryosis = HPV test. If pos = 6 monthly colposcopy, LLETZ if persistent If neg = 3y screening If mod or severe dyskaryosis = colposcopy + LLETZ, then smear and HPV test in 6m. Pos = colp again Suspected invasion or abnormal glandular cells (adenocarcinoma of cervix) = urgent colposcopy Colposcopy = visualise transformation zone, give acetic acid which is taken up by neoplastic cells = white = abnormal, then do punch biopsy. Also look for microinvaion - vascular abnormalities
152
Inv CIN in pregnancy
Colp but no LLETZ | - definitive treatment 12w postpartum
153
Complications of Lletz
Haemorrhage Infection Vasovagal, anxiety Cervical stenosis
154
What is related to CIN but not cancer
Cervical glandular intraepithelial neoplasia Also HPV risk Less visible, has skip lesions LLETZ or cone biopsy or hysterectomy
155
Different HPVs vaccinated against
6 and 11 = anogenial warts | 16 and 18 = cancer
156
cervical cancer bimanual exam - 4
rough and hard cervix Loss of fornices and fixed cervix Irregular mass on speculum may bleed on contact
157
Inv cervical cancer and staging
``` FBC UE LFT Punch biopsy for histology - LLETZ will bleed heavily CT abdo pelvis for staging MRI pelvis for staging and nodes (EUA - cystoscopy, hysteroscopy, PV/PR) ``` Stage 1 - cervix, 1a microscopic 1b macroscopic 2 - upper 2/3 vagina, 2b - parametria 3 - a = lower 1/3 vagina, b = pelvic wall 4 - rectum or bladder 4b distant organs
158
Treat cervical cancer and ADRs
1a - Local excision or hysterectomy >2b = combined crt 4b - palliative radio for bleeding Hysterectomy ADR - bleeding, infection, VTE, ureteric fistula, bladder dysfunction, lymphodedma RT - bowel and bladder dysfunction - tenesmus, bleeding, ulceration, strictures
159
Rf for cervical cancer
``` HPV16 and 18 STD High parity Long term COCP Non-barrier contraception Smoking ```
160
CIs to cervical screening
Not had sex Pregnancy or <12w post partum Hysterectomy Previous radio to cervix
161
% of CIN that will progress to cervical cancer
20-30%
162
Cancers linked to HPV
Cervical Anal Head and neck
163
When is cervical cancer diagnosed
Half <47yo | Peak in 20-30 and 70s
164
Sx of cervical cancer
``` Abn bleeding- PCB, IMB, postmenopause Vaginal discharge Dysparunia Dysuria, pelvic pain Weight loss ```
165
Causes of dysmenorrhea and treatment
Primary - crampy, back/groin, worse in first 2 days, with anovulaory cycles and excess prostaglandins causing uterine contractions. Give NSAID/paracetamol. If pain with ovulation = COCP Secondary - later - adeomyosis, PID, fibroid, endometriosis - constant pain, deep dysparaunia. Treat cause, mirena coil. (IUCD usually makes dysmenorrhea worse)
166
Causes of PMB
Atrophic vaginitis Carcinoma of cervix/vulva Endometrial or cervical polyps Oestrogen withdrawal - HRT or ovarian tumour
167
Causes of amenorrhoea
Primary - structural or genetic - Turner’s, hormonal (androgen insensitivity) - look for SSC, consider tests for secondary Secondary - HPO - stress, exercise, weight loss Hyperprolactinaemia - Sheehan’s Ovarian - PCOS, ovarian insufficiency (prem menopause) Uterus - pregnancy, Asherman’s, post-pill
168
Manage HPO cause of amenorrhoea
Stress management Medroxyproesterone acetate challenge = endometrium is shed in 10d - confirms, unless severe and shut down LH, FSH, oestrogen low Clomifene will stimulate ovary release but will need GnRH for fertility if severe
169
Inv amenorrhoea
BHCG - pregnancy Prolactin - high in stress, hypothyroid, prolactinoma, drugs LH, FSH - low if HPO TFT Testosterone - androgen secreting tumour or late onset CAH
170
Sx of PMS
Psych - irritability, depression, mood swings Phys - bloating, breast tenderness, headache Improve significantly after period - do diary
171
Treat PMS
Exercise, stress, weight loss, smoking 1 - CBT, combined contraception, SSRI 2 - oestradiol patch and progestogen, high dose SSRI 3 - GnRH analogue and HRT but sx will return when ovarian activity returns, and risk of bone thinning >6m 4 - TAHBSO
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What is found on high vagina (4) and endocervical swab (2)
Endocervical - chlamydia tracomatis, neisseria gonorrhoea High vaginal - candidiasis, trichomonas vaginalis, GBS, gardnerella vaginalis
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Chlamydia treatment
Doxycline 7d or azithromycin stat | Erythromycin if pregnant - stop neonatal conjunctivitis
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Gonorrhoea treatment
Ceftriaxone IM and azithromycin - both stat | Test cure with culture 72h post abx
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Bacterial vaginalis and trichomonas treatment
PO metronidazole stat or clindamycin PV gel 7d
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Candidiasis treatment
Intravaginal clotrimazole or oral fluconazole
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RF for candida and what is the candida and inv
Candida albicans Pregnancy, COCP, immunodeficiency, steroids, antibiotic, diabetes Inv - micro for spores and culture
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Sx of trichomonas vaginalis
Vaginitis Bubbly thin fish smelling discharge Strawberry cervix Wet film - motile flagelettes, or culture
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Sx of BV and complications
10% have it, mostly asymptomatic Fishy odour, rarely itching Altered overgrowth - Gardenrella and mycoplasma Clue cells on wet film Pregnancy - preterm labour, intraamniotic inf, HIV susceptibility, post TOP sepsis
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Chlamydia sx, inv and complications
70% asymptomatic Dysuria, discharge, IMB/PCB Diag with vulvovaaginal or endocervical NAAT Complications - PID, Fitz-Hugh Curtis syndrome (perihepatitis), tubal infertility, ectopic pregnancy, Reiter’s syndrome In pregnancy - PPROM and prem delivery, neonatal conjunctivitis and pneumonia
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Gonorrhoea - gram stain, sx, complications
Gr neg diplococcus Asymptomatic, loser abdo pain, vaginal discharge, IMB Complictions - PID, Bartholin’s abscess, tubular infertility and ectopic pregnancy Disseminated - fever, pustular rash, polyarthralgia, septic arthritis NAAT - vulvovaginal, endocervical, urethra, rectal and pharyngeal swabs Then culture for sensitivity Treat with stat ceftriaxone and azithromycin. ?Abx resistance Pregnancy - risk of PROM and delivery, chorioamnionitis, neonatal conjunctivitis
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Vulval warts cause, complication and treatent
HPV6 and 11 Can be penile, vulval, perineal, vagina, cervical, anal Increase in pregnancy and immunosuppression - risk of laryngeal or respiratory papilloma to offspring Treat with cryotherapy in clinic or podophyllotoxin cream for 4-6w if vulval/anal (CI pregancy and only a few at once)
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Herpes sx and treatment
Flu-like, itching, vulvitis, pain and small vesicles on vulva Urinary retention from autonomic nerve dysfunction Relapse when stress, illness, sex, mensturation Men might be asymptomatic for years Treat with analgesia and lidocaine gel, and oral acyclovir for 5d or year of suppressant if recurrent
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Syphilis sx
Treponema pallidum - spirochaete Primary - chancre where lesion was that infection entered through - very infective Secondary 6w-6m later - rash on face, trunk, hands and feet - malaise, lymphadenopathy, fever - tonsillitis - glomerulonephritis, optic neuritis, uveitis, hepatitis Tertiary >2y - granulomas in skin, bones, joints Quaternary - aortic aneurysm, tabes dorsalis (ataxia, numb, Charcot) Inv - T pallidum assay Treat - penicillin
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What is vulvovaginitis and treatment
Desquamative inflammatory vaginitis with shiny erythematous patches and petechiae May be due to NSAID or statin - stop for 2w Intraavaginal clindamycin cream
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What is causing white vulval patches with skin thickening
Leukoplakia. Itchy and biopsy as may be pre malignant | Treat with topical steroids and phototherapy
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Very itchy red erosions on vulva
Lichen sclerosis - AI, elastic tissue turns to collagen. May be bullae and ulceration Vulva will eventually turn to white, flat and shiny. May be premalignant - biopsy Clobetasol cream
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What is VIN and treatment
HPV link White patches with surrounding inflammation Surveillance Remove if irritating but will often reoccur Treat with imiquimod - stimulates macrophages and monocytes
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Hot swollen red labia
Bartholin cyst, under labia minora, secretes thin lubricating fluid Blocked = red hot swollen and painful Treat - incise, may need permanent drainage. Check for gonorrhoea
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Cells in vulval cancer, presentation and treatment
Mostly squamous Also melanoma, basal cell, carcinoma of Bartholin gland Sx - induration ulcer, not noticed until bleeding and painful - late Generally >70yo If <2cm wide and 1mm deep, excise If larger = wide local excision and ipsilateral groin node Adjcanat RT to shrink if risk of damaging sphincter CRT if unsuitablefor surgery
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What is endometrititis
Infection of endometrium, when invaded by TOP, IUCD, childbirth, surgery, miscarriage Lower abdo pain and uterine tenderness on bimanual palpation Foul discharge Can spread to tubes High vaginal swabs and blood culture if septic Abx, remove IUCD if not working
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Normal endometrial thickness and when to do hysteroscopy
<5mm post menopause - >4 = hysteroscopy 11mm in proliferative phase, 7-16 in late cycle - >20 = hysteroscopy
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Vaginal tumours - what kind and RF and treatment
Mostly secondary from cervix, uterine, vulva Primary are mostly squamous Generally upper 1/3 vagina Related to CIN, radiation, chronic inflammation from pressure Treat with radiotherapy, poor prognosis
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Benign ovarian cyst sx
Asymptomatic Dull ache, dysparaunia, cyclic pain, mass effect Irregular bleeding Hormone effect - androgenic Abdo swelling, ascites = malignant Severe pain and bleeding if torsion - impaired blood supply - oedematous - raised WCC and CRP Cyst rupture = haemorrhic shock Exam: adnexal mass, discharge, bleeding, cervical excitation, ascites, peritonism
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Inv benign ovarian tuumour
CA125 BHCG, AFP CA19-9, CEA, LDH TVUS - malignant = multiloculated, solid area, ascites, mets, ascites MRI if >7cm
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Treat benign ovarian tumour
Unstable = laparoscopy. Stable = TVUS Pre-meno: <5cm and no sx = no treatment, rescan in 6w. >5cm or sx: laparoscopic ovarian cystectomy, don’t spill contents Post-meno: calculate risk of malignancy with TVUS, CA125 and US features every 4m for 1y then discharge if no change Mod risk = bilateral oopherectomy
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Types of ovarian tumours
Functional cyst - enlarged or persistent follicular or corpus luteum cyst. Very common, may rupture at ovulation or bleed Endometrioma - chocolate cyst Serous cystadenoma - papillary growths, may appear solid. May be bilateral or malignant Mucinous cystadenoma - very large, multilocular, most common, filled in mucinous material. May rupture and cause pseudomyxoma peritonei (thick jelly like deposits in abdo - bad prognosis) Fibroma - small solid benign fibrous tissue. Meig’s syndrome = (right sided) pleural effusion and benign ovarian fibroma and ascites Teratoma - from primitive germ cells. Benign and mature = dermoid cyst. Well differentiated eg hair. In young women
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Score for ovarian cancer
Risk of Malignancy Index: Ca125 x US findings (0-2) x menopausal (3 = post) US: multiloculaed, solid, mets, ascites, bilateral
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Ovarian cancer type and RF and protective factors
Mostly epithelial ``` RF: Early menarche late menopause Nulliparity HNPCC (Lynch 2) BRCA1 or 2 ``` Protective: pregnancy, breastfeeding, COCP, tubal ligation Borderline ovarian tumour = epithelial and not benign, in younger women, general pre-meno and confined to ovary with difficult with histological diagnosis. Better prognosis than carcinoma and only need oopherectomy
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Screening for ovarian cancer
If gene mutation - yearly TVUS and CA125 | If BRCA+ offer BSO
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Sx and inv for ovarian cancer
Bloating, fatigue, non spec abdo pain, bowel/bladder sx, weight loss, vagina bleeding ``` Inv - CA125, CA19-9 = mucinous If <40 = AFP, BHCG, LDH TVUS CXR for pleural effusion CT abdo pelvis for peritoneal, liver, omental, para-aortic nodes MRI for benign/malignant Ascites/pleural effusion cytology ```
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Staging for ovarian cancer and treatment
``` FIGO: 1 - ovary - 1c if capsule breached, on ovarian surface, or ruptured 2 - pelvis 3 - abdo and nodes 4 - distant ``` Full staging involves laparotomy, hysterectomy, BSO, omentectomy, nodes etc Can leave uterus and other ovary if want to stay fertile Neoadjuvant chemo for 2-4
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Causes of PID - 4
``` Infection of upper genital tract STI Uterine instrumentation - hysteroscopy, IUCD insertion, TOP Post-partum Descending inf eg appendicitis ``` Chlamydia and gonorrhoea, or anaerobes and endogenous bact
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RF and protective factors for Pid
RF: <25, STI hx, new/multiple partner Protective: barrier contraception, IUS, COCP
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Sx of PID
Lower abdo, bi/unilateral pain, constant or intermittent Deep dysparaunia, dysmenorrhea Discharge IMB, PCB Fever Afebrile if mild or chronic Cervical excitation on exam, +- adnexal tenderness
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Inv PID
FBC, WBC, CRP, cultures Swab - chlamydia and gonorrhoea and mc&s TVS if tubo-ovarian abscess
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Complications of PID - 5 | Chronic PID
``` Tubo-ovarian abscess Fitz-Hugh Curtis syndrome - perihepatic adhesions and liver capsule inflammation Subfertility Ectopic pregnancy Recurrent PID ``` Chronic - fibrosis and adhesions, pyosalpinx, hydrosalpinx. Chronic pain, dysparauunia, dysmenorrhoea, menorrhagia Tube masses, tenderness, fixed retroverted uterus Laparoscopy = infection vs endometriosis Pain difficult to control and abx not helpful
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Manage PID
Ceftriaxone, doxycycline, metronidazole Check for improvement in 72h Inpatient if severe, sepsis or fail to respond to abx
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Causes of chronic pelvic pain and management
Analgesia, gabapentin (pain clinic), hormonal Treat depression >6m, intermittent or constant lower abdo pain not associated exclusively with menstruation, sex or pregnancy Non-gynae: IBS, constipation, neuropathic (surgery), fibromyalgia Endometriosis, adenomyosis, adhesions - COCP may help if cyclical pain - GnRH course can predict success of hysterectomy Mitelschmerz - mid-cycle menstrual pain in teenagers and older women around time of ovulation Pelvic congestion: lax pelvic veins seen on laparoscopy get worse when standing or premenstrually. - Deep post-coital ache - Exam - most tender over ovaries, blue vagina and cervix from congestion - Look for deep leg varicosities Treat: ovarian suppression, relaxation techniques, migraine remedies. Severe - bilateral ovarian vein ligation, radiological embolisation, hysterectomy with salpingo-oopherectomy
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Causes of polycystic ovaries and RF/assoc conditions with main cause
Cushing’s Late onset adrenal hyperplasia PCOS - obesity, diabetes 2, metabolic syndrome (dyslipidaemia, htn, insulin resistance, visceral obesity), cvs risk, OSA, acanthosis nigricans from hyperinsulinaemia
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Diagnosis of PCOS
Rotterdam criteria - 2/3 of: 1. Hyperandrogenism - clinical or biochemical sx 2. Polycystic ovaries on US - >=12 follicles of >10cm^3 volume 3. Oligomenorrheoa - oligo/anovulation Exclude other causes of irreg cycles - hyperprolactinaemia, thyroid, CAH, androgen secreting tumour, Cushing’s If hyperandrogenergic and testosterone >5, check 17-hydroxyprogesterone to exclude androgen secreting tumour
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Manage PCOS and long term consequences
Weight loss and exercise improve insulin sensitivity Smoking cessation Treat dyslipidaemia, hypertension, DM2 Metformin - increases insulin sensitivity in short term, reduces disturbance of menstrual and ovulatory function. Doesn’t cause weight loss Clomifene - induces ovulation. Risk of multiple pregnancies, ovarian hypersensitivity (esp if assisted contraception) - monitor response on US for first cycle, ovarian cancer Ovarian drilling needle point diathermy - reduces hormonal production. Risk of future preterm, large babies, gestational diabetes, pre-eclampsia COCP to increase progesterone and decrease risk of endometrial cancer from unopposed oestrogen Induce regular withdrawal bleed with norethisterone (/3m) if not on COCP to reduce risk of endometrial cancer Treat hirsuitism with cyproterone anti-androgen cream Long term = endometrial cancer, gestational and type 2 diabetes, CVS disease. NO increased risk of ovarian or breast cancer
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What is ovarian hyperstimulation syndrome and RFs and sx and prevention
Vasoactive mediator production including VEGF, systemic disease In young, PCOS, low BMI, previous OHSS Sx: - ovarian enlargement - shift of fluid from intra to extracellular spaces: — haemoconcentration and hypercoagulability — fluid in pleural and peritoneal spaces Presents with abdo discomfort and nausea, vomiting, distension 3-7d after HCG, 12-17d after pregnancy ensues Prevent with lowest level of gonadotrophs, may need to cancel next cycle
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Manage OHSS
Mild and moderate - bloating, mild/mod pain, ascites on US, ovary 8-12cm: - Analgesia - paracetamol (avoid NSAIDs as encourage shift from intra to extracellular space and renal impairment) - Avoid strenuous exercise - risk of torsion - Continue progesterone luteal support and avoid HCG - See fertility team every 2-3d Severe - clinical ascites, haematocrit >45%, hypoproteinaemia, oliguria, ovary >12cm: - Admit, daily FBC/UE/LFT/albumin - Analgesia and anti-emetics - VTE - stockings and LMWH - Measure ascites, weight, legs (thrombus) - Paracentesis for sx relief +- albumin replacement - Careful fluid management and catheter Critical - tense ascites, oligo/anuria, haematocrit >55%, WCC raised, VTE, ARDS: - ITU - Drain symptomatic pleural effusion - VTE - Fluid balance, caution of hyponatraemia
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RF for uterine prolapse
Intra-abdo pressure - obese, chronic cough, constipation | Trauma from instrumental births, prolonged labour, poor perineal repair/exercises
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5 types of prolapse
Uterine - protrusion of uterus into vagina, with upper vagina and cervix Cystocoele - anterior wall of vagina and attached bladder bulge. May have residual urine = frequency, dysuria +- urethra (cystourethrocoele) Rectocoele - lower posterior wall attached to rectum pushes through weak levator ani. Patient needs to put finger in vagina or push on perineum to defacate Enterocoele - bulges of the upper posterior vaginal wall may contain loops of intestine from pouch of Douglas Vaginal vault prolapse if had hysterectomy
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Grading of prolapse
1st degree - to level of introitus 2nd - through introitus on straining 3rd - through introitus and outside vagina 4th = procidentia = uterus outside of vagina
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Symptoms of prolapse and exam
Something coming down, dysparaunia, dragging sensation, back ache Cystocoele - dysuria, frequency, incomplete emptying, urinary retention if urethra kinked Rectocoele - constipation, difficulty with defecating Exam - bimanual for pelvic mass Left lateral to look at anterior and posterior walls, for atrophy and descent No obvious prolapse = strain or stand Urodynamic studies if incontinent
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Management of prolapse
Conservative - weight loss, stop smoking, pelvic floor exercises Ring pessary + oestrogen cream for erosion: between posterior fornix of vagina and posterior symphysis pubis, change /6m, interferes with sex Surgery if severe, pessary failed, or sexually active: - debulking and support (may narrow cervix) - hysterectomy
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Symptoms of menopause - 4
12m since period, average 52yo 1. Vasomotor - flushing, sweats, palpitations 2. Atrophy of oestrogen dependent tissues - breasts, vaginal dryness, dysparaunia, bleeding, incontinence, prolapse 3. Menstrual irregularities - anovulatory cycles 4. Osteoporosis
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Basic steps in menopause management - 5
``` Ensure not hypothyroid or psychological Encourage exercise and diet Topical oestrogen for dryness Mirena IUS for menorrhagia Contraception for 1y if >50, 2y if <50 ```
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Types of HRT
No uterus = progesterone only Uterus and <12m since period - continuous oestrogen and cyclic progesterone (withdrawal bleed) Uterus and >12m since period - continuous combined Oestrogen and progesterone = oral or transdermal (gel, patch) Oestrogen - SC or topical vaginally Progesterone - IUS
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Side effects of HRT
Progesterone = mood swings, depression, acne, backache | Bloating, fluid retention, breast tenderness, nausea, headache, dyspepsia
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CI to HRT
``` Undiagnosed PV bleed Previous PE or phlebitis Raised LFTs Pregnancy or breast feeding Oestrogen dependent cancer ```
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Annual check for someone on HRT - 4
BP - stop and investigate if >160 Breasts Weight Abnormal bleeding
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Alternatives to HRT - 3
Topical oestrogen or lubricant for vaginal dryness SSRI (clomifene) for vasomotor sx Calcium, vit d, bisphosphonates, SERM for osteoporosis
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Benefits of HRT - 4
Reduced fracture risk - must be life long Reduced colon cancer by 1/3 Reduced vasomotor sx - start at 4w, peak at 3m, stay on for 1y to minimise recurrence Reduced urogenital sx - takes months for effects, use long term
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Risks of HRT - 4
Endometrial cancer from unopposed oestrogen Breast cancer - increases for each year on, back to baseline after 5y off. Esp with combined continuous. Increase of 3/1000 if started at 50yo for 5y VTE - esp if oral and older Gall stones?
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5 general advice when starting HRT
``` Exercise, diet, local > systemic Minimum dose minimum time Breasts - awareness, screening, report changes — be aware of family history Benefits and risks Start close to menopause ```
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Risks of HRT - 4
Endometrial cancer from unopposed oestrogen Breast cancer - increases for each year on, back to baseline after 5y off. Esp with combined continuous. Increase of 3/1000 if started at 50yo for 5y VTE - esp if oral and older Gall stones?
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5 general advice when starting HRT
``` Exercise, diet, local > systemic Minimum dose minimum time Breasts - awareness, screening, report changes — be aware of family history Benefits and risks Start close to menopause ```
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Features of Fraser guidelines - 4
<16yo Cannot be persuaded to tell parents Will begin or continue to have sex with or without contraception Failure to give contraception will result in physical or mental health suffering Best interests of the child are to give contraception and not tell parents
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CI to IUD
``` Pregnant, or <4w post-partum STI or pelvic infection Wilson’s disease Copper allergy Undiagnosed abn uterine bleed Distorted cavity Heavy painful periods Trophoblastic disease or gynaecological malignancy Caution if coagulopathy ```
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Problems with IUD - 4
1. May be expelled - esp if uterine distorted (fibroid) or nulliparity 2. Risk of PID up to 21d after insertion 3. Menorrhagia and dysmenorrhoea 4. Risk of ectopic pregnancy if becomes pregnant
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CI to IUD
Pregnant, or <4w post-partum STI or PID Wilson’s disease Undiagnosed PV bleed
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Insertion of IUD and removal
STI screen or give azithromycin 1g stat dose afterwards Mild analgesia before Warning of faint - vagal tone. Legs up and head down. Have atropine and AED if epilepsy Warn of mild cramping Check for strings after periods Most expulsions in 1st 3m - follow up after 1st period Removal - other contraception for 7d before
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What to do if lost threads on IUD
Extra contraception and pregnancy test US to locate X-ray if can’t
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Infection with IUD?
Treat with coil in place If removed - don’t replace for 3m If actinomyces, send strings for culture
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Pregnancy with IUD?
Remove to reduce risk of miscarriage and miscarriage with infection
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IUS levonorgestrel effect, advantages, uses
Mirena = levonorgestrel Local - prevent implantation - endometrial atrophy Lighter periods, may be amenorrhoea Good for endometriosis, adenomyosis, endometrial hyperplasia Can use in breastfeeding, obesity, CVD, hepatic enzyme-inducing drugs May have spotting/heavy bleed for 3-6m after insertion Can’t be used for emergency contraception Ectopic and PID less of a risk than IUD
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How do progesterone only contraceptives work
Inhibit implantation Thicken cervical mucus May inhibit ovulation Also reduce pelvic infection and can be used when oestrogen cannot
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CIs to progesterone only contraception
New sx of migraine with aura, IHD, stroke Breast cancer <5y ago Trophoblastic disease Liver disease - cirrhosis, tumour, hepatitis SLE with antiphospholipid antibodies Undiagnosed PV bleeding
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Progesterone only pill - time windows and ADRs
Desonorgestrel has 12h window, others have 3h window Immediate effect if day 1-5, otherwise use barrier for 2d Start >3w postpartum Efficacy affected by hepatic enzyme inducing drugs ADR - acne, mood swings, depression, menstrual irregularities higher failure rate ad ectopic pregnancy rate, functional ovarian cysts
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Depot progesterone - indication and 4 ADRs
/12w or /8w Start during first 5 days of cycle Not for adolescents Can use up to 50yo if no other rf for osteoporosis ``` ADR: Menstrual irregularities, then amenorrhoea for some ?osteoporosis Weight gain Delay in fertility after starting again ```
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Implant progesterone
Change /3y, earlier if obese | Immediate effect if day 1-5, otherwise use barrier for 7d
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Initial management for emergency contraception appointment
``` LMP, normal cycle Number of hours since unprotected sex CIs to COCP in future BP STI/HIV screen Discuss future contraception - COCP from day 1 of next cycle, or explain extra cover if going to start immediately (7d) - Follow up in 3-6w if IUD now ```
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Types of emergency contraception and requirments
IUD <5d since intercourse, or <5d since ovulation. - Toxic effect to inhibit implantation. - STI screen or 1g stat azithromycin. - No interaction with hepatic enzyme inducing drugs ``` Ullipristal acetate (progesterone receptor modulator) <5d, inhibits/delays ovulation - caution in asthma, liver disease, don’t breastfeed for 36h after ``` Levonorgestrel <3d, inhibits ovulation - suitable if focal migraine and past VTE - higher dose if enzyme inducer taken in last 28d - use contraception until next period
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Combined contraception types and CIs
COCP - 21d then 7d off for withdrawal bleed. If many progesterone SEs, use desorgestrel Patch - change on day 8 and 15, remove on day 22 Ring - remove on day 22 ``` Venous disease - avoid if VTE or hx, or sclerosing treatment to treat varicose veins. Caution in 1 of: - smoker >15d (>35d = avoid) - >35yo - BMI>30 (>35 avoid) - 1st degree rel <45yo - immobile - superficial thrombophlebitis ``` Arterial disease - avoid if valvular or congenital heart disease with complications, or CVD eg stroke, IHD, TIA, peripheral vascular disease, hypertensive retinopathy. Caution in 1 of: - smoker >15d (>35d = avoid) - >35yo - 1st degree rel <45yo - diabetes, hypertension >140/90 (avoid if >160/95) - migraine (with aura = avoid) CI: - Liver disease - hepatitis, cirrhosis, gall bladders disease - Breast cancer <5 years ago - Pregnancy complications- pruritis, choolesasis - Hepatic enzyme inducing drugs eg rifampicin - migraine with aura - smoke >35/d - BP >160/95 - BMI >35
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Features of migraine with aura - 6
Slow evolution of sx over several minutes 10-30m aura resolves in 1h Visual - bilateral homonmous hemianopia, scotoma Sensory disturbance Speech - dysphasia, dysarthria Motor
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Short term SEs of COCP
Oestrogens - bloating, breast tenderness, nausea, weight gain, discharge Progestogenic - headache, mood swings, decreased libido, acne Headaches Breakthrough bleeding for up to 6m
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Risks and benefits of COCP - 4 of each
``` Risks: VTE Breast and cervical cancer Mood changes Ischaemic stoke ``` ``` Benefits: Reduced ovarian, endometrial and bowel cancer Dysmenorrhoea and menorrhagia Menopause sx Improvement in acne ```
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Starting COCP, what to do if missed one
If after day 5, barrier for 7d Start 21d postpartum, 14d post surgery Don’t take if breastfeeding (take POP) Missed one - 7d condoms, start new pack with no break if at end of pack
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Warnings to stop taking pill
``` Breathless, chest pain, calf swelling Prolonged headache or vision loss, dysphasia, motor/sensoriloss Severe stomach pain Hepatitis, jaundice, hepatomegaly SBP >160 4w before major surgery ```
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Why does COCP make VTE more likely
Increase resistance to activated protein c | Thrombosis risk increases if antithrombin, protein c/s, factor 5 Leiden deficiency
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When to take emergency contraception with COCP or POP
COCP if 2+ pills missed in first 7 days, and had sex in those days or in pill free week POP if 1+ missed and sex in 2 days since
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Female vs male sterilisation
Female - GA, laparoscopic tube ligation - ADR = heavy bleeding - pregnancy test before - remove IUCD after next period as may have fertilised ovum - 1:200 failure Male - LA, vasectomy (vas def ligated and excised) - ADR = bruising, haematoma, chronic testicular pain - takes 3m for sperm stores to be used up - can test ejaculates to be neg at 8 and 12w post op before stopping other contraception - failure 1:2000
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Questions to ask in sterilisation - 6
``` Other methods Consent of both partners Who Irreversible Failure Side effects ```
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HPO in menstruation
Hypothalamus has pulsatile release of GnRH which stimulates ant pituitary to release gonadotrophs LH and FSH These stimulate ovary to release oestrogen and progesterone which have negative feedback on hypothalamus and pituitary
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Process of menstruation
Day 1 = first day of menstruation. FSH levels high for 4 days, stimulating primary follicle to develop. This then make oestrogen which stimulates glandular proliferative endometrium and cervical mucus receptive to sperm (clear and stringy) and controls release of LH and FSH By 14 days before end of cycle, oestrogen high enough to stimulate LH surge which stimulates ovulation. Primary follicle then becomes corpus luteum which secretes progesterone, preparing endometrium for implantation - convoluted glands in excretory phase, and makes mucus viscid hostile to sperm If it doesn’t get fertilised in 14d, corpus luteum breaks down and hormone levels drop, stimulating spiral arteries in lining to constrict and shed lining If it is fertilised = high levels of chorionic gonadotropin and embroil embeds in decidua
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How to delay ovulation
Norethisterone from 3d before bleeding due until to acceptable level Or 2 packets of COCP with no break
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Normal menarche
From 10yo, average 12.7. Breast buds - pubic hair - axillary hair - menses 14yo with no SSC 16yo with no menses
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When to investigate subfertility
>=1y of regular sex (84% conceive within 1y, 92% in 2) Earlier if woman >=35yo, a/oligomenorrhoea, previous PID, previous cancer treatment to either partner or undescended testes
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Causes of subfertility in order - 5
``` [UMATE] Unexplained Male factor Anovulation Tubal Endometriosis ```
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History and exam for subfertility
``` Women: - menstrual - pain, sti - surgery Men: - undescended testes - mumps - ed Both: - smoking - alcohol - children ``` Exam: - BMI - reduced fertility and cannot get trt - evidence of endocrine eg pcos - evidence of pelvic pathology eg endometriosis or fibroids - cervical smear if due, STI screen
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Investigate subfertility - primary and secondary care
Primary care: - baseline hormone profile - FSH and LH at start of cycle - progesterone surge 7d before menses (midluteal) - TSH, prolactin, testosterone - rubella - chlamydia - semen analysis - lifestyle changes and vit c supplements then reanalyse in 3m Secondary care: - TVUS for adnexal mass, submucosal fibroid, endometrial polyp, PCOS - laparoscopy and dye test for tubal patency - hysterosalpingogram with contrast and x-ray or sonogram with TVUS - dye into cervix for uterine and tubal abn — chlamydia screen first and stat azithromycin
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Lifestyle modification for subfertility management
Alcohol, smoking | Sex 2-3x/w, not timed
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Management of subfertility in woman
Clomifene citrate - antioestrogen, increases FSH by negative feedback to pituitary SE: ?multiple pregnancy, ovarian hyperstimulation - monitor with US, SE - labile mood, flushing - 6-12 cycles (?ovarian cancer link) Laparoscopic ovarian drilling for PCOS reduces LH and restores feedback mechanisms Gonadotrophins if clomifene resistant or low oestrogen wth normal FSH Metformin may stimulate ovulation in PCOS Surgery: tubal catetherisation of hysteroscopic cannulation, but high rates of ectopic. Treat endometriosis, adhesions (adhesiolysis)
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Indications and good prognosis signs for IVF
IVF if: - tubal disease - male factor - clomifene failure and anovulation - >2y of unexplained, or old Prognosis good if: - AMH not too low - smoking, BMI - age, duration of trying Screen for HIV, HepB and C Ovaries stimulated, ova collected, fertilised and 1 embryo put in 3-5d later Luteal support with progestogens Pregnancy test 2w later
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Hormone production in men
In seminiferous tubules. Undifferentiated diploid germ cells (spermatogonia) multiple and become haploid spermatozoa - takes 74d LH - leydig cells - testosterone Testosterone and FSH - sertolli cells - substances for metabolic support of germ cells and spermatogenesis
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Spermatozoa anatomy and how much | Normal semen analysis
Motile tail, head with haploid chromosome, covered with acrosome granule with enzymes for fertilisation Seminal fluid = 90% of ejaculate volume, alkaline to buffer vaginal acidity 1. Volume >1.5ml 2. Concentration 15 x 10^6/ml 3. Progressive motility 32% 4. Motility 40% 5. Normal forms = 4%
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Male causes of subfertility - 4 categories
Semen abnormality - testicular cancer, drugs (alcohol), varicocoele Azoospermia: - pretesticular - hypogonadotrophic hypogonadism, kalman’s syndrome, anabolic steriods - non obstructive - cryptorchidism, kleinefelters, chemo - obstructive - vasectomy, chlamydia, gonorrhoea Immunological - idiopathic, infective Coital dysfunction: - ED (b blockers, antidepressants) - phimosis, hypospadias, disability - ejactulatory failure (MS)
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Examination, tests and treatment for subfertilty in men
Exam: SSC, gynaecomastia, testicular volume (15-35ml = normal), rectal exam for prostatitis Inv: - Plasma FSH in testicular failure - Testosterone and LH if suspect androgen deficiency - Karyotype if suspect 47XXY - CF screen for absent vas def Treat: - vitamins and lifestyle changes then check again in 3m - intracytoplasmic sperm injection - sperm from epididymis or testes
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Where is uterus felt at 16w, 20-24w and 36w and growth rate
``` 16w = halfway between pubic symphysis and umbilicus 20-24w = umbilicus 36w = ribs ``` ``` 16-26w = SFH = weeks 26-36cm = SFH +-2 >36w = SFH +-3 ```
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Reasons for discrepancy between fundal height and dates - 6
``` Inaccurate menstural history Fibroid or adnexal mass Multiple pregnancy Polyhydramnios Hydatiform mole Maternal size ```
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What to note on abdo inspection for pregnancy
Size, asymmetry Foetal movements Linea nigra Striae gravidarum - purple new, silver old C section or lap scars
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Abdo palpation in pregnancy and when difficult
1. Palpate size if <20w, measure SFH from 20w 2. Number of foetuses 3. Foetal lie - longitudinal, oblique, transverse - presentation = occipitoposterior, occipitoanterior or occipitotransverse 4. Presentation - cephalic, breach 5. Head engagement - /5 with Pawlik’s grip between lower pole of uterus Watch patient’s face for pain Difficult if: polyhydramnios, maternal size, tense abdo muscles
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When and where to listen for foetal heart
Doppler US on anterior shoulder of foetus | From 12w
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When are foetal movements felt and inv if stop
From 18-20w, increase until 32w Reduced >28w = CTG - if RF for IUGR, still birth or still reduced movements= US for growth, liquor volume and umbilical artery Doppler
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Effect of hormones in pregnancy on woman
Progesterone reduce smooth muscle excitability, relaxing gut, ureters and uterus. Also raises temperature Oestrogen increases breast and nipple growth and fluid retention Thyroid growth from colloid production Prolactin increases throughout pregnancy
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Genital changes in pregnant woman
Discharge is more towards end of pregnancy Uterus hypertrophies until 20w then stretches Cervix may develop ectropion
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Blood result changes in pregnancy
Plasma volume increases Red cell volume increases - dilution anaemia WCC, platelets, ESR, cholesterol, fibrinogen raised Albumin, urea and creatinine fall
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CVS changes in pregnancy
CO increases from increase in SV and HR Peripheral resistance falls from hormonal changes Aorta-caval compression can reduce CO BP (diastolic) decreases in 2nd trimester then back to normal by 3rd Varicose veins Vasodilation and hypotension = renin and angiotensin release for BP regulation
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Resp, GI, renal and skin changes in pregnancy
SOB, ventilation increases, maternal pCO2 lower to allow removal of foetal CO2 GI reduced motility so constipation and delayed emptying, and lower oesophageal sphincter relaxes = heart burn GFR increases early and mass puts pressure on bladder = increased frequency Skin pigmentation - linea nigra, spider naevi, palmar erythema, striae
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Pregnancy testing
From 9 days after conception | BHCG
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What should be checked antenatal booking visit
12w Obestetric hx and fhx of twins, DM, BP, foetal abnormality PMH Mental health VTE risk Gestational diabetes risk and 75g OGTT: - screen at 16+28w if previous GDM - screen at 28w if BMI >30, first degree relative diabetic, previous baby >4.5kg, family origin from high diabetes prevalence Risk of haemoglobinopathy, viruses, cardiac disease Support, substance abuse, vitamins Folic acid - from 4w before pregnancy until 13w. Give higher dose if AED, HIV, obesity, history of NTD Examine: Heart, lungs, BP, weight, abdo, ?cervical smear ``` Inv: Hb, blood group, antibody screen Syphilis, HbsAg, HIV MSU Consider Mantoux and CXR if TB endemic Offer screening for chr/structural abnormalities ``` Advice: smoking, alcohol, diet, vitamins, antenatal classes, seatbelts, benefits, dentist
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When to have antenatal visits and what for
10-12w booking Later - discuss screening results and treat anaemia or UTI Each appointment = BP, proteinuria, fundal height Visits at: 12, 16, 25, 28, 31, 34, 36, 38, 40, 41 (primip) 28 - Hb and Rh autoantibodies and Anti-D if needed 34 - labour and birth plan, pain relief 36 - breastfeeding, neonatal vit k and postnatal care, postnatal depression 40 - discuss post dates pregnancy management 41 - membrane sweep, offer induction by 42w
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When to test Rh and when to give anti-D
Test at booking visit Give to everyone if TOP or miscarriage before this (12w), or if Rh-ve before procedures eg ECV, uterine procedures, intra uterine death. Bigger dose after 20w If haemorrhage, test for concentration of foetal RBC in blood with Kleinhauer test, to see how much is needed After birth, give to Rh-ve mum if cannot determine baby blood group within 72h
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Antenatal scans and what’s done at each
``` 11-14: Dating - 1st trimester, use crown rump length - after 14w, biparietal best (until 34w) - head circumference - then abdo circumference, femur length If first present in 3rd trimester, do 2 scans 2w apart to estimate gestation Umbilical artery Doppler if SGA ``` At 11-14w: nuchal translucency and combined test (fold measurement and blood test). NT = exclude miscarriage, heart failure, dates pregnancy. 18-22w: anomalies - cardiac, renal, neural tube - skull shape and interior, spine, abdo, heart, arms and legs, face and lips - fatal abnormalities are bilateral renal agenesis, some cardiac, some trisomy 18/13 Echo if high risk of cardiac abn eg hx, suspected abnormality, drugs, monochorionic twins Invasive testing if combined test = high risk (<1:150): CVS from 10w Amniocentesis from 15w Extras: Early <11w if pain, hyperemesis, bleeding - exclude molar or twins Uterine artery Doppler at 23w if high risk pre-eclampsia If placenta over cervical os, rescan at 32w for placenta praevia
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Trisomy tests
11-14w: Combined test - NT - PAPP-A - hCG - maternal age 15-20w: Quadruple test - dating scan - AFP - unconjugated oestradiol - inhibit-A - bhCG - maternal age Integrated: - NT - PAPP-A - quadruple test AFP = released from liver. Increased in abnormalities - exomphalos, nephrosis, open neural tube defect, Turner’s syndrome PAPP-A = released by placenta. Low = pre-eclampsia, IUGR, trisomy 18/21 Chorionic villus sampling - 10-13w. Karyotyping in 2d, full analysis in 3. - CI = dichorionic twins - ADR = BBV, miscarriage Amniocentesis - >16w. Can detect CMV. Less risk of miscarriage than CVS Cell free foetal DNA - non-invasive prenatal testing, cells from 1st trimester. For specific purposes eg Rh-ve. - fewer cells available if dichorionic, obese, <10w
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RF for hyperemesis gravidarum
Molar pregnancy Multiple pregnancy Previous hyperemesis gravidarum
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Presentation of hyperemesis gravidarum and tests
``` Dehydration, hypovolaemia, hypotension Cannot eat, malnutrition, polyneuritis Hyponatraemia Hyperthyroid Mallory-Weiss tear, liver, renal failure ``` Urine dip for ketones and UTI (MSU) FBC - raised haematocrit U&E - hypokalaemia, hyponatraemia Abn transaminases and low albumin US for multiple pregancy and mole
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treat HG
Oral antiemetic - cyclizine, metaclopramide PO/IV/IM Admit and rehydration if not better - NaCl and K Prednisolone if intractable Thiamine and folic acid to prevent Wernicke’s encephalopathy Enoxiparin and stockings if VTE risk
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Risks of hypertension in pregnancy and what might be causing it
Pre-eclampsia IUGR Placental abruption Exclude: Conn’s, Cushing’ s, coarctation of aorta, renal artery stenosis, renal disease, phaeochromocytoma
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Manage chronic high bp throughout pregancy
Prenatal: change ACEi/ARB to labetalol or methyldopa Antenatal: keep bp <150/90 (140 if end organ damage), keeping diastolic >80. >160/110 = admit - aspirin 75mg OD from day of conception to birth - US /4w from 28w for growth restriction, amniotic fluid volume, umbilical artery Doppler. Abn activity = CTG Intrapartum: monitor /h if <159/109, continuously if >160/100 - operative delivery if intractable - no ergometrine as will cause severe htn Postpartum: day 1, 2, 3-5 and 2w. Change methyldopa (postnatal depression). Likely to fall then increase by day 5
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Manage pregnancy induced htn
Usually 2nd half, >140/90, no proteinuria or signs of preeclampsia Increased risk of pre-eclampsia Mild 140/90-149/99 = monitor bp and urine (PCR) weekly. US/4w 150/100-159/109 = labetolol and monitor twice a week >160/110 = admit, monitor bp 4x/d, urine daily, FBC/UE/LFT/bilirubin at presentation and weekly Deliver at 37w Continue antihypertensives during labour and monitor hourly or continuously if >160/110
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What is pre-eclampsia, what can it cause
Htn and proteinuria Failure of trophoblastic invasion of spiral arteries so stay vasoactive - BP increases to compensate. Also affects renal, liver and coagulation After 20w, resolves 6w after birth Causes: - fatal - cerebral haemrrrhage, multi-organ failure, ARDS, iatrogenic prematurity - liver involvement = DIC - micro-aneurysms if >180/140 = DIC - renal failure - HELLP with placental infarcts - eclampsia - sudden oedema - iugr - increased peripheral resistance, decreased plasma volume
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Risk factors for pre-eclampsia
High: - previous severe or early onset pre-eclampsia, chronic htn/htn of pregnancy - CKD, DM - AI (SLE-antiphospholipid) Mod: - fhx of pre-eclampsia - multiple pregnancy - 1st preg >40yo or >10y gap - BMI >=30 - low PAPP-A If 1 high or 2 mod, give aspirin from 12w
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Presentation of pre-eclampsia and inv
``` Asymptomatic Headache, flashing lights, swollen hands/face RUQ/epigastric pain Nausea, vomiting Fits ``` Exam: RUQ tenderness Clonus, brisk reflexes IUGR, abruption, still birth Inv: PCR of urine Thrombocytopoenia, increased clotting time Transaminases raised Urate and creatinine high Anaemia if haemolysis - and raised LDH Oligohydramnios, foetal growth restriction, notching of uterine arteries, abn umbilical arteries on Doppler
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Manage pre-eclampsia
Mild - BP/4h, FBC/UE/LFT 2x/w, growth scans every 2w Moderate - same but bloods 3x/w, CTG 2x/d Severe (>160/110 or sx or evidence of end organ damage) - contact obstetrics, anaesthetics, midwife. - nifedipine PO - IV labetolol - magnesium sulphate prophylaxis - catheter, maintain fluid balance - steroids - deliver if >34w - if <34w, deliver within 48h under senior advice
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What is eclampsia and management
Pre-eclampsia and tonic clonic seizure. Pre, intra or post-partum IV magnesium sulphate - 4g IV / 5-10mins then 1g/h for 24h, and future 2g boluses in seizures - monitor for low rr, loss of reflexes or urine output - may need Calcium Gluconate if toxic effects Catheterise, fluid restrict (unless haemorrhage) Diazepam for repeated seizures Monitor foetal hr with CTG Deliver once stable - c section for speed - oxytocin for 3rd stage
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What is HELLP syndrome
Haemolysis Elevated liver enzymes (first to present) Low platelets = RUQ pain, nv, dark urine No regional anaesthesia if platelets <80. Transfuse if <50 annd need surgery
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RF for preterm labour
``` Previous preterm birth Multiple pregnancy Uterine abnormalities Medial conditions Previous cervical surgery eg LLETZ Pre-eclampsia IUGR ```
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Preterm rupture of membranes management
Admit for 48h, 80% will deliver If don’t, discharge, the weekly follow up with FBC and CRP Report change in discharge (offensive smell) or reduced movements Avoid sex Give steroids and erythromycin Induction of labour >34w Deliver immediately if evidence of chorioamnionitis - temp, high vaginal swab, MSU, tender uterus, maternal or foetal tachycardia Or bleeding, foetal compromise or active labour
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Manage preterm labour
50% contractions will stop spontaneously Treat cause eg glomerulonephritis Can use nifedipine tocolytic but minimal evidence FBC, CRP, MSU, HVS Speculum for PROM. If not ruptured, assess dilation. Take foetal fibronectin (predictive of preterm labour. Shouldn’t’ be in discharge from 22-36w) Give abx IV if in labour
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Contraindications for tocolytics and advantages
Nifedipine. Reduces RDS and ITU admission CI: chorioamnionitis, foetal death, condition requirement immediate delivery - relative = pre eclampsia, praevia, abrupation, cervix >4cm
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When to give steroids to pregnant mother - 4 - and what monitoring
- Risk of delivery <35w, or <36w if iugr - ?35-36w if pre-eclampsia so expedited delivery - ?20-24w - <39w if elective c section 2nd dose if 1st <26w and new indication arises Monitor glucose if diabetic mother
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Delivery of premature babies
<28w - deliver at 26 degrees, don’t dry, put into plastic bag, place under heat, don’t cut cord for 3m, hold 20cm below introitus to increase haematocrit and reduces oxygen requirements and IVH but increases phototherapy need
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Definition of onset of labour
Contractions become regular and cervical effacement and dilatation become progressive 1 - onset of contractions 2 - cervical effacement and dilatation 3 - rupture of membranes 4 - descent of presenting part through birth canal
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Stages of labour
First - latent = irregular painful contractions, cervix effacing and dilates up to 4cm. Established = regular contractions from 4-10cm (0.5cm/h). Takes 8-18h for primip, 5-12h for nullip Monitor: - foetal hr /15m - contractions /30m - should be 3-4/10m, 1m each - pulse /h - assess dilatation and position of head /4h - urine for ketones/protein /4h - bp and temp /4h Second - passive (if epidural, to reduce chance of instrumental delivery). Complete dilatation but no pushing. - active - pushing with abdo muscles and Valhalla manoeuvre. Use oxytocin if plateau. Should deliver within 3h of active phase starting - contractions /30m - pulse and bp /h - temp /4h Third - placental delivery (1h), uterus contracts to <24w. Signs = lengthening of cord, rush of blood, uterus rises. Can give ergometrine and oxytocin (syntometrin) once ant shoulder delivered - decreases PPH, need for transfusion and postnatal anaemia - can cause MI, dont use in htn, pre eclampsia, liver or renal disease - SE nv, headache
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Sequence of passage of baby
1. Engage and decent in occipitotransverse 2. Internal rotation to occipitoanterior at level of ischial spines 3. Crowning - extend head, extending peritoneum until delivered 4. Realign head with spine 5. External rotation of shoulders 6. Anterior shoulder 7. Posterior shoulder
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When to induce labour
Uteroplacental insufficiency, iugr, oligo/anhydramnios, intrauterine foetal death Htn/pre-eclampsia, diabetes, rhesus disease, abruption Prolonged prenancy, PROM >37w Bishops score 4-5
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What is in Bishops score and what is it for
Check before and durin induction. = cervix: Position, consistency, effacement, dilation, station >9 likely to begin spontaneously >7 can artificial rupture membranes <5 will need induction <4 induction unlikely to be useful. If notripened = long labour, foetal distress, c section
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CI to induction
``` Placenta praevia Vasa praevia transverse Cord prolapse Previous classical section Active primary genital herpes ``` Relative CI: breech,2previous sections, triplets
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Methods of induction of labour
Membrane sweep - separate decidua from chorionic membrane to encourage pg release and start labour. Can titrate until 4 contractions /10m Pg gel or tablet or pessary to constrict sm and ripen cervix. Monitor on CTG before and for 30m after. SE- nv, bronchospasm, maternal pyrexia Amniotic hook - artificial rupture of membranes and encourage pg release and labour onset. Only once cervix ripened. Can give with oxytocin to increase strength and frequency Oxytocin - increase cervical pg, titrate up . Continuous CTG
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Complications of induction
``` Failure Uterine hyperstimulation - can counteract with tocolytics terbutaline Cord prolapse Infection Pain Rupture uterus Increased rate of intervention ```
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When to monitor foetus during labour and 2 types
Monitoring I uncomplicated pregnancy: intermittent auscultation - for 60s /15m in 1st stage and /5m in 2nd stage CTG or foetal electrode scalp monitoring
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Indications for CTG | Features of CTG and causes of each
Records hr and uterine activity Foetal: iugr, prem, oligohydramnios, twins, breech Maternal: pre-eclampsia, diabetes, antiparticle haemorrhage, previous csection Intrapartum: bleeding, oxytocin, econium staining, epidural Baseline rate = FHR mean. <110 = hypoxia >160 = foetal distress, maternal tachycardia Baseline variability excluding accelerations and decelerations - 5-25 <5 = hypoxia, CNS/cardiac malformations, drugs (GA, methydopa), severe prematurity Accelerations = 15bpm for 15s + Decelerations = 15bpm for 15s + - variable - early decelerations = peak coincides with peak of contraction - late = peak 15s after peak of contraction = acidosis
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Indications for foetal scalp electrode monitoring
When membranes ruptured, cervix 2-3cm dilated and other monitoring unsatisfactory
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Signs of foetal distress
Cannot calculate baseline heart rate Hr <110 (hypoxia) or >160 (Distressor maternal pyrexia) Variability <5bpm (cardiac/CNS malformation, extreme prem, hypoxia, drugs (GA, methydopa) Late decelerations (>15bpm >15s after contraction peak) -acidosis
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Who should be treated with VTE prophylaxis in pregnancy and how long for?
Give LMWH High risk - 1 of: unprovoked or oestrogen-proved VTE, thrombophilia (factor 5 Leiden, protein c/s def), antithrombin 3 deficiency Moderate risk - consider if 1 of: thrombophilia but no VTE, single provoked VTE, medical comorbidities (CVS or resp disease, SLE, sickle cell, nephrotic), PWID If 3 of: obese, BMI >35, smoker, immobile, multiple parity, multiple pregnancy, pre-eclampsia, varicose veins Intrapartum: instrumental, PPH or transfusion Give for 7d after c section or 6w after vaginal delivery Start asap, as long as >4h since epidural and no more PPH
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Inv PE/DVT in pregnancy and treat
PE - ABG, ECG, CXR - if normal = duplex us of deep veins, if DVT assume PE. If normal = VQ mismatch DVT - duplex US - if normal, give LMWH and repeat in a week Massive PE = PCI, thrombolysis, embolectomy, UFH, aim for INR1.5-2.5 LMWH for 6m and 6w postpartum, including throughout next preg and 6w postpartum Stop LMWH during labour. Don’t give regional anaesthesia for 12h post prophylactic dose and 24h post therapeutic dose Don’t give LMWH until 4h after epidural catheter removed Don’t remove catheter until 12h after dose
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Risks of measles in pregnancy and management
Risk of preterm delivery and foetal loss | Treat with immunoglobulin if rash appears 6d before or after delivery, to prevent subacute sclerosing panencephalitis
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MMR vaccine and pregnancy
AVoid pregnancy for >4w after MMR as live vaccine
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Rubella complications in pregnancy
Worse <16w gestation: - miscarriage and stillbirth - sensorineural loss, cataracts - cardiac lesions - jaundice, hepatosplenomegaly - purpura, thrombocytopoenia - cerebral palsy, microcephaly Take antibody levels 10d apart and check for antibody 4-5w from date of contact
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CMV sx and complications in pregnancy
Maternal: mild, rash, lymphadenopathy, raised temperature Foetal outcome worse if presents with sx at birth Early: - IUGR, microcephaly - thrombocytopoenia, jaundice, hepatosplenomegaly Late: - motor and cognitive impairment - sensorineural loss
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How to avoid toxoplasmosis
Avoid raw meat Wear gloves if gardening or cat urine Avoid sheep during lambing
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Compicatiotns of parvovirus in pregancy
Maternal haemolysis if not immune | Foetal suppressed erythropoiesis and cardiotoxicitty - cardiac failure and hydrops fatalis
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Intrauterine syphilis sx and treatment
Neonatal - rhinitis, rash, jaundice, nephrosis, keratitis | Give benzylpenicillin to mum and baby
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Listeria complications in pregnacny
Recurrent foetal loss Premature labour Stillbirth Resp distress from pneumonia, conjunctivitis
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Hep b transmission and results in pregnancy | Screening and
Very high level transmitted, mostly at birth but some transplacental Screen all mothers, Give immunoglobulin and vaccinate babies of carriers and infected mothers at birth Check immunisation status at 12-15m old. Protected if anti-HBs present and HBsAg neg Will cause chronic infection, hepatocellular cancer and cirrhosis
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hep e in pregnancy
Maternal fulminant hepatic failure after delivery and coma, massive PPH annd death 30-50% of babies infected No vaccine yet
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Manage hep c in pregnancy
Elective c section only if HIV and not on HAART as well | Check for HCV RNA at 2-3m and again at 12m. Refer if positive
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Herpes simplex in pregnancy
Secondary inf recurrence not normally problem as maternal antibodies If develop primary (first ever) genital herpes during pregnancy, refer to GUM to screen for other inf to ensure primary inf 3rd trimester = oral acyclovir and encourage CS if within 6w of delivery date If labour and active lesions, give maternal IVI and newborn high dose acyclovir, and do baby PCR at birth Avoid foetal blood sampling, scalp electrode and instrumental delivery If baby infected, presents at 5-21d with vesicles/pustular rash on red base on traumatised area +- periocular/conjunctival Can cause blindness, epilepsy, reduced IQ, jaundice, RDS, DIC, death
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Manage varicella zoster in pregnancy
Oral acyclovir to mum, varicella immune Ig at birth to baby and monitor for 28d, give azyclovir if chicken pox
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Causes of ophthalmia neonatorum
Chlamydia, herpes, staph, strep, pneumonococci, E. coli
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Treat chlamydia and gonorroehoa in newbord
Chlamydia - erythromycin | Gonorrhoea - cefotaxime and chloramphenicol eye drops, and benzylpenicillin
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Risks of GBS | Who to treat for GBS and what is it
Severe early onset infection - pneumonia, meningitis, septicaemia - 20% death Treat if: - pos high vaginal swab or urine at any point in pregnancy - previous baby with GBS - 50% of infection this time, have prophylactic abx or test later on then have abx - intrapartum fever - <37w - prolonged rupture of membranes for >18h Give benzylpenicillin IV
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What is GBS and diagnoses
Strep agalactiae Common bowel/vagina commensal Swab loser vaginal annd perianal
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HIV risks in pregna
Transmission during labour or breast feeding Spontaneous abortion Postpartum endometritis
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Factors that increase risk of HIV complications in pregnancy
``` Primary infection during pregnancy Low CD4 HIV core antigens Other STDs Chorioamnionitis Rupture of membranes Premature Invasive procedures Vaginal delivery ```
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Management of HIV in pregnancy
Screen at 12w and 28w HAART, or ART if advanced, and start after 1st trimester Elective CS - can have vaginal delivery if CD4 is high and viral load low Discourage breast feeding Consider confidentiality, housing, other children testing
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TORCH screen
``` Toxoplasma Rubella CMV Herpes, HIV Syphilis [ToRCHHS] ```
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Pain relief in labour
Non-pharm: breathing, partner, water, TENS (short) ``` Pharm: NO - CI = pneumothorax - SI = NV, fainting Narcotic - pethidine and cyclizine - SI to mum = drowsy, nv - SI to baby = temporary resp distress, drowsy Pudendal nerve block - L2-4 - lidocaine Lidocaine for repairing perineum ``` Regional: Spinal 2h CS. No sensorimotor function - ADR: profound hypotension Epidural anywhere: 25-30m onset, large amount of fluid but leave in cannula so can increase /30m. Sensation loss but function maintained. Monitor BP/5m for 20m - SE: failure to place, patchy, hypotension, accidentally puncture dura, headache if puncture dura
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What layers does spinal and epidural go through
Spinal - through dura into subdural space = CSF | Epidural - just through lig flavum into epidural space
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Indications for episiotomy and where | Repair and ADR
Foetal distress Complicated labour - shoulder dystocia, instrumental Perineum scarred from poor previous repair or FGM Mediolateral Repair: lidocaine, suture vaginal wall, perineal muscle then perineum wall - check in rectum for no sutures Risks: pain, infection, prolapse
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Instrumental delivery - when, general risks and requirements
If: - malposition of foetus - maternal tiring - abnormal CTG Risks: - genital tract trauma - infection or haemorrhage Requirements: - adequate analgesia - engagement 0/5 or 1/5 - head at or past ischial spines - fullly dilated cervix
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Ventouse indications and ADR
``` >34w Requires mother effort and contractions Can rotate baby Better for mother Less successful that forceps ``` ADR: scalp oedema, cephalohaematoma (between periosteum and skull)
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Forcesps indications and ADR
``` <34w Bladder must be empty Mum unable to push Face forward Baby has bleeding disorder Slow down head delivery with breech ``` ADR: - bruising - nerve palsy - skull depression or fracture - genital damage
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Indications for cs
Breech or malpresentation Multiple pregnancy Foetal compromise - abn CTG, umbilical artery Doppler or scalp sample Transmissible infection incl herpes Maternal request Previous 3/4th degree tear, previous shoulder dysocia Maternal diabetes, maternal conditions
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Categories of CS
1 - immediate threat to life, within 30m 2 - some foetal/maternal compromise but not immediately life threatening, within 75m 3 - needs early delivery but no compromise 4 - elective
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Types of CS
Lower uterine incision and blunt dissection - horizontal line above pubic symphysis Classical - vertical line above umbilicus. If 1) very premature, 2) transverse with membrane rupture, 3) fibroids
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VBAC advantages, risks, indications for better outcome and CI
``` 3/4 women can have VBAC Less time in hospital Early skin to skin Reduced foetal distress No operative complications ``` ``` Risks: May need instruments Uterine rupture - 1:200 1/4 will need emergency CS - worse outcomes than elective CS, but 1/5 general pop need emergency CS anyway More likely to need transfusion May tear ``` Better outcome if: Previous labour BMI<30 <41w and spontaneous labour ``` CI: 3+ CS Previous uterine rupture Classical CS Other indications for CS ```
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Causes of PROM -5
``` Unknown Infection Polyhydramnios Malpresentation Multiple prenancy ```
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Sx of PROM
``` Gush of fluid Look for evidence of fluid on speculum Nitrazine test: swab fluid - amniotic pH 7.1-7.3 instead of vaginal 4.5-6 Fibronectin and AFP Temp, pulse, BP CTG ```
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Signs of chorioamnionitis in PROM and complications of PROM
``` Foetus or maternal tachy Raised temp Raised CRP or leukocytes Pyrexia Irritable/tender uterus ``` Risks: - maternal endometritis postpartum or intra-amniotic infection - need for cs - premature
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Degrees of tear in labour and management
First - perineum skin only. Heals without stitches in a few days, can sting on urination Second - includes perineum muscle and may extend into vagina. Will need stitches, heal in a few weeks Third - extends to anal sphincter. Needs repair with anaesthesia, may cause faecal incontinence and painful sex Fourth - extends to rectal mucosa, likely to need more specialised repair. Cause faecal incontinence and painful sex Management: Ice, warm water, sit on cushion Laxatives, numbing spray Tell doctor if persisting, severe or getting worse
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Diagnosis of transverse lie
``` Wide abdomen Low fundus Foetal pole not felt in pelvis Hr more inferior Foetal head palpable to one side DO NOT do vaginal exam until excluded praevia ```
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Causes of transverse/breech lie and complications and management
``` Premature Multiparity Praevia Uterine abnormalities - fibroid Foetal abnormality - hypotonia, hydrocephalus ``` Cord prolapse = spontaneous rupture of membranes Prematurity Birth trauma - soft tissue injury, IVH ECV if membranes intact, not advancing labour and no foetal distress - at 37w - give medication to relax uterus then turn - anti-D - 50% effective, may return - ADR: pain, abruption, PROM - CI: antipartum haemorrhage, pelvic mass, praevia Transverse may turn in uterine contractions in labour Elective CS
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Cause of face/brow presentation and management
Neck tumour or anencephaly Face: face can turn oedematous on delivery Can try to turn with forceps Likely to need CS Brow: membranes rupture early, high risk of cord prolapse. Too wide for canal = CS
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Retained placenta - causes and management
Delayed 3rd stage - >30m to deliver 1. Placenta adherens - myometrium doesn’t contract behind it 2. Trapped placenta - trapped behind closed cervix 3. Partial accretion - still embedded If had rush of blood and lengthening of cord, rub uterus up and pull and twist cord IV oxytocin if bleeding May need surgical removal Risks: infection, PPH
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2 types of shoulder dystocia and risk factors
Anterior - against pubic symphysis = most Posterior - against sacral promontory ``` RF: Pre-partum: - Macrosomia >4.5kg - DM = macrosomia - BMI >30 - previous shoulder dystocia - induced Intrapartum - prolonged 1st or 2nd stage - secondary arrest - oxytocin - instrumental vaginal delivery ```
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Features of shoulder dystocia and dangers
Failure of restitution - stays occipito-anterior Head/chin stuck ‘Turtle neck’ - withdraws Baby - death, hypoxic injury, brachial plexus injury, humerus/clavicle fracture Mum - 3/4th degree tears
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Manage shoulder dystocia
1. Help 2. Stop pushing 3. ?episiotomy McRobert’s procedure with suprapubic pressure Posterior arm or internal rotation to oblique Postpartum: Manage 3rd stage to minimise PPH Paediatrics review for fractures, nerve injury or hypoxia Check PR for tear Physio review for pelvic floor weakness, nerve injury, MSK pain
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Causes of primary postpartum haemorrhage and management and prevention
500-1000ml - minor >1000 - major In 1st 24h since birth Prevent: oxytocin IM if vaginal, IV if cs Tone - RF: multiple pregancy, polyhydramnios, previous pregnancies, previous PPH, praevia, abruption, >35BMI, Asian, >40yo, prolonged labour - bimanual massage (ant adnexa and abdoment) to increase uterine contraction - oxytocin IV, syntometrine IM, ergometrine IV/IM, misoprostol PR, carboprost - EUA, balloon tamponade, Lynch suture around uterus, uterine or int iliac artery ligation, hysterectomy Trauma - RF: instrumental delivery, epidisiotomy - repair Tissue - retained placenta = uterus can’t contract - RF = age, parity, uterine surgery, premature, induction - examine placenta after birth - manual removal, oxytocin Thrombin - thrombophilia, vwf, ITP, DIC - vasc - pre-eclampsia, hypertension 2222 massive haemorrhage Rhneg O blood RBC, FFP, hartmann’s
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Causes of secondary postpartum haemorrhage
24h-6w after birth 1) retained placenta - high uterus — placenta adherens - myometrium not contracted behind — partial accreta - still attached — trapped placenta behind cervical os 2) endometritis - give ampicillin, metronidazole (and gentamicin if septic) - foul selling lochia, rigor, fever, tender uterus 3) thromboplastic 4) abnormal involution of placenta - inadequate closure and slough of spiral arteries Sx - spotting, bleeding Inv - FBC, UE, CRP, coag, G&S, culture, US pelvis Treat - oxytocin, ergometrine, surgery
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5 causes of APH and inv
FBC, UE, LFT, CRP, coag, G&S, cross match 6u, TVUS, CTG - sinusoidal = maternofoetal haemorrhage - mild bleed - admit, do inv, high risk serial scans then CS at 37-38w - big bleed - raise legs, fluids, blood transfusion, CS, maintain UO Placenta praevia - placenta in lower segment of uterus, covering os - major or minor - normally diagnosed at 20w scan. Scan again at 32w if major, 36w if minor — can vaginal deliver if mild or >2cm from os, otherwise CS - DO NOT do vaginal exam - soft and non tender uterus, painless bleed, can be heavy - assoc with smoking, iugr, polyhydramnios, maternal age, fibroids, D&C - if foetal head engaged = not praevia Placenta abruption - placenta partially/completely separates from uterus before labour - painful, woody uterus, with contractions - foetal hr absent or distressed, normal lie - concealed or revealed, shock out of keeping with visible blood - DIC from thromboplastin release - assoc with pre-eclampsia and htn - CS if signs of distress Vasa praevia - foetal vessels near/over os and can rupture Genital tract trauma Infection
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Types of placenta
Accreta: abnormal adherence of placenta to uterus, also increta = myometrium, percreta = serosa Membranacea - thin placenta all round baby Succenturia - one lobe separate Velematous - umbilical vessels in membrane before placental insertion Vasa praevia
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Causes of preterm labour and drug management
``` Infection Ischaemia eg abruption Cervical incompetence Multiple pregnancy or polyhydramnios Iatrogenic eg for IUGR ``` Check foetal lie, presentation and hr Abx if infection Steroids - 2 IM inj 12h apart Consider tocolytics for a few days: oxytocin receptor antagonist or nifedipine
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RF for uterine rupture, sx and management
RF: - previous CS, esp classical, or uterine surgery (endometritis, neonatal death, transfusion, rupture more likely with VBAC) - obstructed labour in multiparity esp with oxytocin - breech - internal version - high use of forceps - polyhydramnios Sx: - loads or minimal blood - shock - tachycardia, abdo very/mild pain - cessation of contractions - loss of presenting part in pelvis - foetal distress Manage: O2, blood transfusion, CS and investigation, may need hysterectomy if cervix or vagina involved Cefuroxime and metronidazole
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Risks of prolonged pregnancy and management
Mum - instrumental delivery, genital tract trauma - PPH - obstructed Baby - meconium aspiration - macrosomia - shoulder dystocia, birth injury, prolonged labour - placental insufficiency = acidosis, encephalopathy, seizures - IUGR - stillbirth Manage: membrane sweep at 41w, IOL at 42w
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Sx of obstetric cholestasis, risks and management
``` 3rd trimester Pruritis esp at night and on trunk and limbs Anorexia, malaise Epigastric discomfort Dark urine and steatthoroea ``` Inv: LFT 2-3x raised, bile acids, clotting screen, viral serology and AI screen, US Risks: still birth, meconium aspiration, prem, vit K def for mum Manage: - water soluble vit K - topical emollients - ursodeoxycholic acid - deliver at 37w if very high bile acids as increased risk of still birth
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Differentials of 1st seizure in pregnancy
``` Vascular abn Eclampsia Encephalitis, meningitis SOL Electrolyte disturbance Epilepsy ```
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Risks of AED in pregnancy
All: teratogenicity, neonatal withdrawal, baby vit K def, behavioural/developmental difficulty Phenytoin: cardiac and cleft lip/palate defect Carbamazepine: also neutral tube defects Valproate: also GUM defect (hypospadias)
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Manage epilepsy in pregnancy
If already pregnant, no point changing drug as already had teratogenic effect Before pregnancy: lamotrigine, minimal dose, folic acid 5mg OD 12w before pregnancy Vit K 4w before birth Advice: no bathing or sleep deprivation, once born don’t stand and hold baby Detailed foetal anomaly scan, consider echo, AFP Intrapartum: vaginal delivery, benzos, neonatal vit K, breastfeeding
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Manage diabetes in pregnancy and risks
Stop all drugs except metformin, start insulin Lose weight if BMI>27 Tight glycaemic control - HBA1c <6.1% Monitor retinopathy as can worsen Folic acid from before conceptiotn to 12w Detailed anomaly scan at 20w Intrapartum: insulin sliding scale for 24h after giving steroids, and during birth Insulin - will need to double in pregnancy Stop insulin at birth if not previously on it Risk: infection, macrosomia, CS, hypoglycaemia unawareness, pre-eclampsia, malformation, IUGR, neonatal reflex hypoglycaemia
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Gestational diabetes RF and management
OGTT >=7.8 or fasting >=5.6mmol/l - check at 24-28w ``` RF: Previous GDM or baby >4.5kg BMI >30 1st degree relative diabetes Family origin ``` Diet and exercise (30m/d) for 2w then metformin, then insulin 4w scans from 28w BM 4x/d Aim for 7.8 1h, 6.4 2h, 5.3 fasting Check BM 6w postpartum, 50% will go on to develop DM2 - advice
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Complications of Grave’s in pregnancy and treatment
Foetal thyrotoxicosis - foetal tachycardia, prem delivery Carbimazole Propylthiouracil - less crosses placenta and into breast milk Partial thyroidectomy in 2nd trimester Check neonatal TFT
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Postnatal depression sx, RF and managemen
Anxiety, tiredness, irritability, lack of bonding 2-3m, resolve by 6-12m RF: previous psych illness, sleep deprivation, stress including around birth Edinburgh postnatal depression score Treat: CBT, SSRI, ECT/admission
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Puerperual psychosis RF , sx and treatment
10-14d after birth Sx - mania, depression, confusion, paranoia, hallucinations, delusions RF: previous psych illness, primip Treat: lithium, hospitalisation, ECT
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Gestational trophoblastic disease, types, sx and treatment
1) Hydatiform mole - unfertilised ovum implants into uterus and forms mass, benign 2) Choriocarinoma - trophoblastic cells tumour, can be complete (no foetal tissue) or partial (some foetal tissue but usually not viable). Can develop when mole doesn’t regress after surgery Sx - sign features of pregnancy early, from v v high bHCG = vomiting, uterus large for dates USS = bunch of grapes echogenic Treat - surgery to remove, and ensure bHCG levels falling in following weeks - fortnightly, then monthly urine for HCG to see if reactivation to choriocarcinoma Choriocarcinoma = chemotherapy
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Rf for multiple preganncy
Age Family history of dichorionic twins Ethnicity IVF/assisted reproduction
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Complications during pregnancy of multiple pregnancy and manage during and at labour
``` Polyhydramnios 1 sac = entanglement 1 placenta = twin to twin transfusion Worse hyperemesis Gestational diabetes Pre-eclampsia Placena praevia/accreta as bigger placenta APH PPH ``` Foetus: asphyxia (esp second twin), premature, malformation Labour: malpresentation, vasa praevia, abruption, cord prolapse, cord entanglement, PPH Plan to deliver at 37w for dichorionic, 36 for monochorionic and 35 for triplets. Most go into spontaneous labour before this At delivery, have IV access, anaesthetist and 1 paediatrician for each baby See on scan at 11-14w, scan monthly from 20w, every 2w if monochorionic FBC monthly Discordant growth >25% = refer to tertiary centre Weekly visits from 30w Tell mother what to do if spontaneous labour Aspirin from 12w if other indications for pre-eclampsia
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RF for cord prolapse, sx and management
2nd twin, footling, transverse or unstable lie Not engaged head Premature, polyhydramnios Sx: may see cord, or foetal brady/late deceleration Manage: if before membrane rupture, CS immediately Deliver with CS or forceps if fully dilated Don’t touch cord as will spasm Get help 1. Keep presenting part away from compressing cord - push head during contraction 2. Knees to chest to keep head lower than pelvis 3. Saline into bladder 4. Tocolysis After birth, check cord pH and bicarb to exclude hypoxic injury
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Severely oedematous baby, 8 RFs and management
``` Hydrops fetalis - oedematous with stiff oedematous lungs RF: - pre-eclampsia - diabetes - infection - toxoplasmosis, syphilis, parvovirus - thalassaemia - isoimmunisaton - anaemia = CCF = oedema - twin to twin transfusion - hypoproteinaemia ``` At birth: get help and take cord blood for: - hb, mcv, blood group, Coombs - bilirubin, protein, LFT - infection screen - high pressure ventilation - vit K - correct anaemia - drain pleural effusion and ascites if impairing breathing - furosemide if CCF - fluid restriction - monitor glucose and treat
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Cause of hydrops fetalis in rhesus disease
``` Anaemia = CCF = oedema Anaemia = hypoproteinaemia = oedema ```
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Causes of oligohydramnios
<500ml at 32-36w Renal abnormalities - agenesis, cystic dysplasia Reduced flow to kidneys - chronic hypoxia causes blood to divert to other organs - IUGR - Placental insufficiency Post-term PROM RF: Foetal: - chromosomal or congenital - IUGR, post-term, foetal demise Maternal: - pre eclampsia - diabetes - hypertension - hypoxia - dehydration Placental: - twin-twin transfusion - abruption Drugs - ACEi, indomethacin
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Diagnosing and manage oligohydramnios
Discrepancy in SFH measurements, foetus easily palpated US - also check for placenta, IUGR and Doppler umbilical arteries Speculum and nitrazine for ROM Maternal causes including SLE Pre-term: expectant management. Amniotic transfusion. If uropathy, can do vesico-amniotic shunt At term: deliver, continuous hr monitoring during labour Complications: - pulmonary hypoplasia - amniotic band syndrome - foetal compromise - infection if ROM
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Causes of polyhydramnios
``` Reduced swallowing - oesophageal atresia Increased urine output - anaemia causing increased CO, twin-twin transfusion receiver produces a lot of urine Other defects - neural tube, CVS, renal Chromosomal Hydrops fatalis Maternal: diabetes, multiple pregnancy ```
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Diagnose polyhydramnios and treat and complications
Rule out other causes eg choriocarcinoma or multiple pregnancy Present: large for dates, SOB, PROM, cord prolapse Measure on scan - amniotic fluid index Check for renal/GI abnormalities Maternal screen for infections, diabetes, antibodies (?hydrops), chromosomes Expectant if mild, or deliver if foetal compromise Aspirate amniotic fluid Indomethecin to reduce perfusion to foetal kidneys Independent factor for low birth weight and death Cord prolapse, PROM, premature, malpresentation, PPH Maternal UTI as increased pressure on bladder

Finals (13 decks)

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