Obstetrics & Gynaecology

Obstetrics & Gynaecology

Obstetrics & Gynaecology

🤰🏼 Obstetrics

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🤰 Antenatal
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Timetable
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When is the booking visit?
  • 8-12 weeks
    • ‣
    What bedside investigations are done?
    • BP
    • Urinalysis
    • BMI
    ‣
    What bloods are done to screen the Mother?
    • FBC, blood group, Rh status, red cell alloantibodies
    • Hepatitis B, syphilis, rubella
    • Offer HIV test
    • Urine culture - Asymptomatic bacteruria
      • ‣
      Why is it important to treat asymptomatic bacteruria in Mother?
      • Can cause pyelonephritis and preterm labour.
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Folate: When does folate supplementation begin & stop? What are the doses, in normal and high risk pregnancies?
  • Start: On conception OR 1 month before conception in obesity or other high risk cases
  • Stop: 12 weeks
  • Doses:
    • 400mcg - Normal pregnancy
    • 5mg - High risk pregnancy (obesity, smoking, FH)
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Nuchal scan: When is it? Name 3 causes of ↑ nuchal translucency.
  • 10 weeks
  • Causes:
    • Down's syndrome
    • Congenital heart disease
    • Abdominal wall defects
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Down's syndrome:
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All have a nuchal translucency, what do these tests involve:
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Combined (11-13W)
  1. PAPP-A: ↓
  2. β-hCG: ↑
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Quadruple (> 13W)
  1. β-hCG: ↑
  2. Inhibin-A: ↑
  3. AFP: ↓
  4. Oestriol (uE3): ↓
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What can be done for definitive diagnosis?
  1. Non-invasive prenatal testing (NIPT)
  2. CVS (< 15W)
  3. Amniocentesis (> 15W)
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Name 2 reasons that non-invasive prenatal testing (NIPT) might be done.
  • Rh status of foetus
  • Down's syndrome screening (optional - patient may not want to know)
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What does routine care consist of and when does it begin?
  • SFH, BP, urinalysis
  • Begins: 24 weeks
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When are the 2 doses of anti-D given if needed?
  1. 28 weeks
  2. 34 weeks
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Physiology of pregnancy
‣
What produces β-hCG in pregnancy and what is its role?
  • Producers: Embryo & syncytiotrophoblast
  • Role: Prevent disintegration of corpus luteum

How does pregnancy affect the following:

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Cardiac output & BP
  • Cardiac output: ↑
  • BP:
    • ↔︎ Systolic
    • Diastolic: ↓ in first 2 trimesters, ↔︎ in 3rd trimester
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FBC
  • ↓ Hb
  • ↑ WCC & ESR
  • ↓ Platelets
  • ↑ Coagulation (Body preparing for placental delivery)
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Urine
  • Proteinuria
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LFTs
  • ↓ Albumin
  • ↑ ALP
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What should the normal fetal HR be on CTG?
  • 100-160 bpm

Key antenatal conditions:

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Rhesus status
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Describe the pathophysiology of sensitisation.
  1. Mother Rh -, fetus Rh +
  2. Fetal cells enter mother's blood stream → Mother forms antibodies against fetal RBCs → Doesn't affect this pregnancy
  3. Next pregnancy: Mother's antibodies pass into fetal blood stream → Fetal haemolysis
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Describe the screening process.
  • Booking: Mother Rh status
  • NIPT: Fetal Rh status
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Name 8 potential sensitisation events.
  1. Maternal abdominal trauma
  2. Ectopic (if managed surgically)
  3. Termination
  4. APH
  5. Miscarriage
  6. Amniocentesis / CVS
  7. ECV
  8. Delivery - Vaginal / CS
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If a feto-maternal haemorrhage is suspected, what test can confirm it?
  • Kleihauer test: Maternal blood exposed to acid and this kills all HbA, HbF is then left and volume can be measured
  • Determines the dose of anti-D needed to mop up all of the HbF
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Describe the management.
  • Give mother anti-D (mops up fetal RBCs before mother sensitises) at week 28 & 34
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Hypertension

Define the following terms in relation to pregnancy:

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Chronic HTN
  • Hypertension present ≤ 20 weeks gestation
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Gestational HTN
  • Hypertension without proteinuria > 20 weeks gestation
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Pre-eclampsia
  • Hypertension & proteinuria > 20 weeks gestation
    • ‣
    Basics
    ‣
    Briefly describe the pathophysiology.
    • ↑ Placental spiral artery diameter → Syncytiotrophoblast infiltration → ↓ Vascular resistance → Hypoperfusion of the placenta → IUGR & placental GF release → ↑ CO & microvascular damage in kidneys, liver & brain
    ‣
    Name 5 RFs.
    1. Nulliparity
    2. Previous history / FH
    3. Mother > 40 years
    4. HTN, DM, CKD, autoimmune disease
    5. Obesity
    6. Large placenta: Multiple pregnancy, molar pregnancy
    ‣
    Name 5 features.
    1. Proteinuria
    2. HTN. Typically > 170/110mmHg
    3. Hyperreflexia
    4. Epigastric pain
    5. Headache (+/- visual disturbance/papilloedema)
    ‣
    Investigations
    ‣
    How do you investigate to confirm the diagnosis?
    • Urinary protein : creatinine > 30mg/mmol → Confirmed
    ‣
    In severe pre-eclampsia, what bloods do you do and why?

    HELLP syndrome:

    • FBC: ↓ Hb & platelets
    • LFT: ↑ ALT/AST
    ‣
    Management
    ‣
    What prophylaxis is given?
    • 75mg aspirin from 12 weeks until birth
    ‣
    What therapeutic drugs can be given?
    1. PO/IV Labetalol
    2. Asthmatics: PO nifedipine → Methyldopa (if CCB inadequate)
    ‣
    What is the definitive management?
    • Delivery
    ‣
    Complications
    ‣
    How does it affect the fetus?
    • IUGR
    • Prematurity
    ‣
    Why are they predisposed to haemorrhage & what haemorrhages may occur?
    • ↓ platelets & HTN
    • Placental abruption, intra-abdominal/cerebral
    ‣
    Pregnant lady with pre-eclampsia has seizures, headache and papilloedema. What is this and how is it managed?
    • Eclampsia
    • IV magnesium sulphate & fetus delivery
      • If OD: Give calcium gluconate
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Bleeding
‣
Name differentials for PV bleeding at the following times:
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1-12W
  1. Ectopic
  2. Molar pregnancy
  3. Miscarriage
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13-26W
  1. Spontaneous abortion (miscarriage)
  2. Molar pregnancy
  3. Placental abruption
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27W-End
  1. Placental abruption
  2. Placenta previa
  3. Bloody show
  4. Vasa praevia
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What is the difference between miscarriage and antepartum haemorrhage?
  • Miscarriage < 24 weeks
  • APH ≥ 24 weeks
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Miscarriage:

Define the following:

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Threatened miscarriage
  • Painless PV bleeding < 24 weeks with closed cervical os (USS heart present)
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Missed (delayed) miscarriage, management?
  • Dead fetus still present in the uterus < 20 weeks with a closed cervical os
    • Management: Expectant (wait 7-14 days), medical (vaginal misoprostol), surgical (manual vacuum evacuation)
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Inevitable miscarriage
  • Open cervical os with clots and pain
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Incomplete miscarriage
  • Open cervical os with retained fetal products causing pain and bleeding

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What is the management of all miscarriages after 13W?
  • Medical: Misoprostol (PO/vaginal) as risk of retained products
    • < 13W: Expectant management if cervical os is open
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Antepartum haemorrhage:
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How do you differentiate between placental abruption and placenta praevia?

Placental abruption:

  1. Shock out of proportion with PV blood loss
  2. Constant pain with tender, tense uterus
  3. Normal lie/presentation
  4. Absent or distressed fetal heart

Placenta previa:

  1. Shock in proportion with PV bleeding
  2. No pain
  3. Non-tender abdominal palpation
  4. Fetal heart usually normal
Blausen.com

Types:

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Placental abruption
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What is placental abruption?
  • Occurs when the placenta partly or completely separates from the inner wall of the uterus before delivery.
Bonnie Urquhart Gruenberg, CC BY-SA 4.0
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What are the RFs for placental abruption?
  1. Maternal trauma
  2. Pre-eclampsia/HTN
  3. Multiparity
  4. Polyhydramnios
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What is placenta praevia?
  • Placental location in the lower 1/3 of the uterus
OpenStax College, CC BY 3.0
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What are placenta accreta, increta & percreta?
  1. Accreta: Adherence of the placenta to myometrium, without penetration
  2. Increta: Villi invade into but not through the myometrium
  3. Percreta: Villi invade through the myometrium into the serosa
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What is the triad of vasa previa?
  1. Painless vaginal bleeding
  2. Rupture of membranes
  3. Fetal bradycardia (or resulting fetal death) < 100 bpm

Investigating & managing:

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How do you investigate it?
  1. Routine 20W abdominal USS
  2. Abdominal palpation: High presenting part
  3. TV USS
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How is APH managed?
  1. Conservatively at first: Re-scan at 34W
  2. Still low? Re-scan every 2W to check
  3. High presenting part/abnormal lie at 37W → C-section
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What are they at high risk of?
  • APH & PPH
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Foetal complications
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Molar pregnancy
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What is a complete hyatidiform mole?
  • An empty egg is fertilised by a single sperm that duplicates its DNA
  • USS: "Snowstorm appearance" - Not fetal tissue
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What is a partial hyatidiform mole?
  • A normal egg is fertilised by a single sperm that duplicates its DNA or 2 separate sperm
  • USS: Some fetal tissue present in uterus
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What features may be seen?
  • Uterus large for dates
  • Very ↑ β-hCG
  • PV bleeding in first 12 weeks gestation
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How do you investigate these and what results are seen?
  • USS - 'Snow-storm appearance'/'Bunch of grapes'
  • Bloods:
    • ↑ β-hCG
    • ↓ TSH & ↑ T4 - β-hCG mimics TSH stimulating the thyroid gland → Primary hyperthyroidism picture
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How does it affect the thyroid gland?
  • Hyperthyroidism: hCG mimics TSH → ↑ T4 → ↓ TSH
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How is it managed? (Short & long-ish term)
  • Short: Uterus evacuation
  • Long: Contraception for next 12 months
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Hydramnios
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Name the 2 types.
  1. Polyhydramnios
    2. ‣
    Typical presentation?
    1. SFH large for dates
    2. Tense abdomen - "Difficult to feel fetal parts"
    ‣
    Causes?
    • GDM
    • Fetal swallowing problem
    • Fetal infections
    ‣
    Management?
    • Amnioreduction
    • NSAIDs → ↓ Fetal renal output
    ‣
    Complications?
    1. Maternal SOB / respiratory problems
    2. Cord prolapse
    3. PROM/pre-term labour
    4. Breech presentation
    5. Placental abruption
  2. Oligohydramnios
    3. ‣
    Typical presentation?
    1. Small for dates
    2. "Fetal parts feel abnormally prominent"
    ‣
    Causes?
    1. Premature membrane rupture
    2. Fetal renal tract abnormality
    3. IUGR
    4. Smoking
    ‣
    Complications?

    Potter's syndrome:

    1. Fetal pulmonary hypoplasia (Swallowing amniotic fluid → Lung development)
    2. Clubbed feet
    3. Congenital hip dysplasia
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How do you investigate them?
  • USS
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Foetal loss - Between what ages are the following foetal losses?
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Spontaneous abortion
  • 0-24 weeks
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Stillbirth
  • 24 weeks - Delivery
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Perinatal death
  • 24 weeks to 7 days after delivery
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Neonatal death
  • Within 28 days of delivery
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Infant death
  • In first year of life
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Post-neonatal death
  • 28 days - 1 year of life
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Multiple pregnancy
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How do you classify multiple pregnancies?
  1. Zygosity - How many ova?
    • Mono: 1 ovum has divided into 2 separate embryos
    • Di: 2 separate ova are fertilised
  2. Chorionicity - How many placentae?
  3. Amniosity - How many amniotic sacs?
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Name the main RFs for dizygotic twins.
  1. Previous twins
  2. FH
  3. ↑ maternal age
  4. IVF
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Name 3 antenatal, fetal and perinatal complications.
  • Antenatal
    1. Polyhydramnios
    2. Anaemia
    3. APH (placenta praevia)
  • Fetal
    1. Prematurity
    2. ↑ Perinatal mortality
    3. Light-for dates
  • Perinatal
    1. PPH (2X risk)
    2. Malpresentation
    3. Cord prolapse
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What is twin-twin transfusion syndrome, and what type of twins are at risk? How can you manage this?
  • Monochorionic diamniotic twins (monozygotic)- when they share a chorion.
  • One twin gains at the others expense- there is unequal blood and nutrient distribution.
  • One twin will be- anaemia, hypovolaemic and oligohydramniotic. The other twin will be- polycythaemic, hypervolaemic and polyhydramniotic.
  • Manage with Septostomy- make a hole in membrane between.
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Other maternal complications
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Diabetes
‣
Name 4 RFs.
  1. BMI > 30
  2. Previous macrosomic baby ≥ 4.5 kg
  3. Previous GDM
  4. FH (First-degree relative)
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How is gestational diabetes screened for? (Inc. Key values to look for)
  • OGTT at 24-28 weeks, diabetes values:
    • Fasting ≥ 5.6
    • 2 hours ≥ 7.8
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How are the following managed:
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Fasting BM < 7

3 lines to work through:

  1. Lifestyle
  2. Metformin
  3. Insulin
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Fasting BM ≥ 7
  • Straight to insulin: High risk
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What fetal complications can occur?
  1. Macrosomia
  2. Preterm delivery
  3. Neonatal hypoglycaemia → Seizures
    • ↑ BM → ↑ Insulin → Hypoglycaemia after delivery
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Infection
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Lady presents with preterm premature rupture of membranes, she has a fever and is deteriorating quickly. What is this likely to be? (Follow-on Qs)
  • Chorioamnionitis
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How does this usually occur?
  • Ascending infection of the amniotic fluid from the vagina
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How do you manage this?
  • IV antibiotics & prompt delivery (CS if necessary)
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Neonate is found to have SN deafness, cataracts, PDA and growth retardation. What antenatal infection did they contract? (Follow-on Qs)
  • Rubella
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At what time in gestation does rubella infection cause the most damage?
  • < 8 weeks
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How do you investigate a mother that thinks she may have been exposed and isn't vaccinated?
  • Check her IgM - Will be raised if currently infected
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For non-vaccinated mother's, when should the MMR vaccination be given?
  • After delivery
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Lady presents due to her 3 year old son having chickenpox, she has not had it before or been immunised. She is asympomatic. How do you investigate and manage this?
  • Check maternal blood for antibodies
    • No antibodies - Give varicella zoster immunoglobulin (VZIG)
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If she was symptomatic, what would you give immediately?
  • PO aciclovir
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How do you manage a patient with vaginal candidiasis in pregnancy?
  • Clotrimazole pessary
    • PO fluconazole is CI
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Jaundice
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Lady presents with severe pruritus, jaundice and she has a raised bilirubin but all other LFTs are normal. What is this?
  • Obstetric cholestasis

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Management?
  1. Chlorphenamine → Itching symptoms. Vitamin K → Reduce bleeding risk
  2. Induction at 37 weeks
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Lady presents with abdominal pain and jaundice. Her bilirubin is raised alongside her ALT and WCC. What is this?
  • Acute fatty liver of pregnancy
  • Management: Supportive & delivery
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Name 2 other differentials of jaundice in pregnancy.
  1. Gilbert’s syndrome
  2. Haemolysis - HELLP
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VTE
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Name 5 RFs.
  1. Previous VTE
  2. Blood disorder - thrombophilia (anti-phospholipid)
  3. Obesity
  4. Multiple pregnancy
  5. Smoking
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If you suspect a DVT, what immediate steps need to be made?
  • LMWH therapeutic dose then investigate
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How is antiphospohlipid syndrome managed in pregnancy? (2)
  1. Aspirin 75mg
  2. LMWH
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How do you investigate it?
  • Compression duplex USS
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When does management stop?
  • Re-assess/stop after 6 weeks postnatal
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Hyperemesis gravidarum
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What is this and what is the biochemical cause?
  • Severe N&V in early pregnancy
  • Very ↑ β-hCG
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What is the triad for diagnosis?
  1. WL ≥ 5% pre-pregnancy
  2. Dehydration
  3. Electrolyte imbalance
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How do you assess the severity of this?
  • Pregnancy-Unique Quantification of Emesis (PUQE)
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Name 5 associations.
  1. Multiple pregnancy
  2. Molar pregnancy
  3. Hyperthyroidism
  4. Nulliparity
  5. Obesity (macrosomia)
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What are the 3 steps in the management plan?
  1. IV NaCl (add potassium if needed)
  2. Cyclizine / promethazine
    • Ondansetron / metoclopramide if severe
  3. Thiamine & folate
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Name 3 potential complications.
  1. Mallory-Weiss tear
  2. Wernicke's encephalopathy
  3. Central pontine myelinolysis
  4. Acute tubular necrosis
  5. Hypochloraemic metabolic alkalosis
  6. Arrhythmias (K+)
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👧 Labour & Delivery
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Assessment
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Prematurity
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Delivery in what time period is defined as premature?
  • > 20 weeks, < 37 weeks
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What women need prophylactic steps to delay birth?
  • History of preterm birth
  • USS demonstrating a cervical length of ≤ 25mm before 24 weeks
image
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What prophylactic steps can be taken to prevent preterm birth?
  1. Prophylactic vaginal progesterone
  2. Prophylactic cervical cerclage - Suture the cervix shut
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When preterm labour is suspected/confirmed, what are the management steps?
  1. Tocolysis (labour suppression) with PO nifedipine
  2. Maternal cortocosteroids - PO Dexamethasone (between 24-34W)
  3. Prophylactic erythromycin (or IV Abx if GBS confirmed)
  4. IV magnesium sulphate - Neuroprotection of baby
  5. Delayed cord clamping after birth - Increased blood volume & Hb in baby
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Lie & Presentation
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Name the 3 types of lie. (Follow-on Q)
  1. Longitudinal
  2. Oblique
  3. Transverse
    4. ‣
    Name 2 complications of transverse lie.
    1. Cord prolapse
    2. Preterm rupture of membranes
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Name the 3 types of breech presentation.
  1. Frank (most common): Knees extended
  2. Complete: Knees flexed
  3. Footling
‣
Which breech has higher perinatal morbidity?
  • Footling
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Name 5 RFs for breech presentation.
  1. Poly/oligo-hydramnios
  2. Placenta praevia
  3. Fibroids
  4. Fetal abnormality (e.g. Down's)
  5. Prematurity (↑ incidence in earlier gestation)
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How is it managed at different stages of gestation? (Follow-on Q)
  1. < 36 weeks: Watch & wait
  2. ECV (50% success rate): 36 weeks ina a primip, 37 weeks in a multip
    3. ‣
    When is ECV contraindicated?
    1. Multiple pregnancy
    2. APH
    3. Fibroids
    4. Abnormal CTG
    5. Ruptured membranes
  3. Planned delivery / Elective C-section
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Delivery
‣
Induction
‣
When does a mother need to be considered for induction?
  1. Normal pregnancy > 12 days after EDD
  2. Diabetic mother > 38W (due to macrosomia)
  3. Rupture of membranes but labour doesn't start within 24h
‣
What does the Bishop Score assess? Name the factors it takes into account.
  • Cervical favourability for delivery
  • Cervical dilation, effacement, station (relation of head to pelvic outlet), position, consistency
    • ‣
    What is the importance of Bishops score with regards to induction of labour?
    • Score <5 suggests labour won't start spontaneously and cervix is not 'ripened'
      • Low bishop score: Prostaglandins
      • High bishop score: Move straight to artificial rupture of membranes with amniotomy
‣
Name the 4 stages of induction.
  1. Membrane sweep
  2. Vaginal prostaglandins
  3. AROM/Amniotomy - Artificial breaking of waters
  4. Oxytocin
‣
Labour
‣
What makes up each stage of labour?
  1. First stage: Onset of true labour to full cervical dilation
    • Latent phase: 0-3cm dilated
    • Active phase: 3-10cm dilated
  2. Second stage: Full cervical dilation to delivery of fetus
  3. Third stage: Delivery of fetus to delivery of placenta
    • Physiological: Natural delivery
    • Active: IM oxytocin & apply cord traction
‣
What are the signs that someone has entered true labour? How long is the first stage typically?
  • Signs:
    • Show (mucus plug shedding)
    • Membrane rupture
    • Regular, painful uterine contractions
  • 6-10 hours in primip. Can be shorter in multip.
‣
If the woman is failing to progress, how is it managed?
  1. Failing to progress: < 2cm dilation in 4h
  2. Management: Amniotomy (artificial membrane rupture), consider oxytocin infusion in primip
‣
Describe the movement of the fetus/mechanisms of labour in 7 stages:

*This is assuming a cephalic presentation with longitudinal lie (commonest presentation).

  1. Engagement: Head descends in OT position (transverse wider than AP here)
  2. Descent and flexion of the head
  3. Internal rotation by 90 degrees OA (allows head to pass through AP outlet)
  4. Crowning. Rotation complete, further descent and perineum distends
  5. Extension of the head and head delivery as the fetus leaves the vagina.
  6. Restitution via external rotation 90 degrees
  7. Delivery of the shoulders: Lateral flexion to deliver anterior shoulder, then posterior shoulder and finally rest of body.
‣
Name 2 tools that could be useful in aiding vaginal delivery, and why they might be needed?
  • May be needed in: Fetal/maternal distress, failure to progress within second stage
    • Ventouse (Crudely a vaccuum to suck out fetus)
    • Forceps
‣
Caesarian Section
‣
What are the categories & indications for each?
  • Category 1: Clinical suspicion of acute fetal compromise, immediate threat to life. C-section required within 30 minutes.
  • Category 2: No imminent threat to life but Mother or baby compromised. C-section required within 75 minutes.
  • Category 3: Delivery required but Mother and baby are stable.
  • Category 4: Elective C-section.
‣
Name the different types of incision.
image
‣
What is a VBAC? Is this possible?
  • Vaginal birth after C-section. You can trial a vaginal delivery in your second pregnancy if there was no contraindication before. You cannot trial a vaginal delivery after two C-sections because the risk of uterine rupture is too high.
‣
Complications
‣
Name the 4 types of perineal tear.
  1. Superficial
  2. Perineal muscle & subcutaneous tissue
  3. Anal sphincter (AS) affected
    • 3a: < 50% EAS. 3b: >50% of EAS. 3c: IAS affected
  4. Anal mucosa affected
‣
Shoulder dystocia
‣
What is the anatomy of this?
  • Anterior shoulder of the fetus impacted on the pubic symphysis
‣
Name the main RF and factors that may contribute to this.
  • Macrosomic baby
    • Metabolic syndrome
    • GDM/DM
  • Prolonged labour
‣
Name your initial management step and then options to help deliver the child.
  • Call for additional help
    1. McRobert's manoeuvre
    2. Episiotomy
‣
Name 4 complications of this.
  1. Maternal perineal tear
  2. Maternal PPH
  3. Brachial plexus injury → Erbs palsy
  4. Neonatal death
‣
Amniotic fluid embolism
‣
What is the pathophysiology of this?
  • Amniotic fluid enters maternal circulation → Immune reaction → Shock (↓ BP, ↑ HR, bronchospasm) → MI
‣
When does it often occur?
  • During labour
‣
How is it managed?
  • MDT supportive management - Poor prognosis
‣
Group B streptococci infection
‣
What organism causes this?
  • Streptococcus agalactiae: GP cocci
‣
Is there screening?
  • No
‣
When will the fetus be at risk of exposure?
  • During vaginal delivery
‣
How & when is it tested for?
  • How: Vaginal swab
  • When: 35-37 weeks
‣
How is it managed?
  • Intrapartum IV antibiotics
    1. Benzylpenicillin
    2. Allergic: Vancomycin
  • Given to all premature deliveries
‣
When is the neonate likely to develop sepsis if exposed?
  • Early onset: < 48 hours after birth
‣
Preterm rupture of membranes (PROM)
‣
Name 1 maternal and 2 fetal complications.
  • Maternal: Chorioamnionitis
  • Fetal:
    • Infection
    • Prematurity → Pulmonary hypoplasia
‣
How is it investigated & what are you looking for?
  • Sterile speculum examination
  • USS - Oligohydramnios
  • CTG - Fetal heartbeat
‣
How are the complications managed, respectively?
  • Chorioamnionitis: IV antibiotics & delivery
  • Pulmonary hypoplasia: Antenatal dexamethasone
‣
Cord prolapse
‣
If this is left untreated, what can occur?
  • Fetal compression of cord → Hypoxia → Death
‣
Name 5 RFs.
  1. Prematurity
  2. Polyhydramnios
  3. Multiple pregnancy
  4. Breech presentation/transverse lie
  5. Long umbilical cord
‣
What is the immediate & definitive management of these patients?
  • Immediate: Patient on 'all 4s' & push fetal presenting part up to prevent compression of cord
    • Tocolytics: Prevent contraction of uterus - nifedipine/terbutaline
  • Definitive: CS
‣
🍼 Postnatal
‣
Post-partum haemorrhage

PV bleeding of > 500ml within 12 weeks of delivery.

‣
Name 4 RFs for it.
  1. Uterine atonia - Long labour, multiple pregnancy, polyhydramnios, macrosomia
  2. Placenta praevia/accreta
  3. Pre-eclampsia (HELLP: ↓ platelets)
  4. Previous PPH
‣
How do you differentiate between primary & secondary?
  • Primary: Within 24 hours
    • ‣
    Name 4 causes of this. (Ts)
    1. Tone - Atony → Inability of the placenta to contract and stop bleeding
    2. Tissue - Retained
    3. Trauma - CS, instrumental
    4. Thrombin - Placenta praevia/accreta
    ‣
    Which is the most common?
    • Atony
  • Secondary: 24 hours - 12 weeks
    • ‣
    Name 2 causes of this.
    1. Endometritis - PPH with offensive discharge
    2. Retained tissue
‣
Name the 3 steps of medical management of a patient having a PPH.
  1. Get help, ABCDE - Stabilise patient, 2 peripheral cannulae, IV fluids, blood transfusion
  2. IV syntocinon/ergometrine - Stimulates uterine contraction
  3. IM carboprost
‣
What is the first step in management of uterine inversion?
  • Immediate replacement of the uterus through the cervix with the palm of the hand
‣
What surgical options are available?
  • Balloon tamponade if due to atony
  • Ligate supplying arteries
  • Hysterectomy
‣
What is Sheehan's syndrome?
  • Severe PPH → Pituitary hypoperfusion & necrosis → ↓ Milk production & amenorrhoea
‣
Puerperal pyrexia
‣
How is this defined?
  • Temperature > 38°C within 14 days of delivery
‣
What is the most likely cause and 3 differentials?
  1. Endometritis
  2. UTI
  3. Wound infections (perineal tear/CS)
  4. Mastitis
‣
How is it managed?
  • Endometritis → IV clindamycin & gentamicin
‣
Breastfeeding
‣
Patient has nipple pain when breastfeeding, what are your differentials and what management is needed?
  • Blocked duct. Continue feeding
  • Poor latch
‣
What is the management of nipple candidiasis?
  • Stop breastfeeding
  • Maternal miconazole cream, fetal nystatin fluid
‣
How is mastitis managed?
  • Continue breastfeeding if possible, if too painful continue expressing milk
  • Maternal PO flucloxacillin if no improvement in 24h or systemic upset
‣
What is a differential for a breast abscess and why does it happen?
  • Galactocele - Painless & no infection signs
    • Woman stops breastfeeding → Milk build up & cyst creation
‣
Name 5 key drugs that are able to be used in breastfeeding women.
  1. Antibiotics: Penicillins, trimethoprim
  2. Sodium valproate
  3. Glucocorticoids
  4. ACEi / ARB
  5. Beta-blockers
‣
Name 4 drugs that should be avoided in breastfeeding women.
  1. Antibiotics: Ciprofloxacin, tetracyclines
  2. Lithium
  3. NSAIDs: Aspirin
  4. Methotrexate
‣
What drug can be used to suppress lactation?
  • Cabergoline: Dopamine agonist → ↓ Prolactin
‣
Mental health
‣
What 3 psychiatric conditions related to mood must you consider in women perinatally, in order of severity?

How do you distinguish between them? How do you manage them?

‣
① Baby blues
  • Affects 80% women
  • Onset 2-3 days postpartum, lasts <10 days
  • Features: Tearful, not feeling like yourself, anxiety, delayed bonding.
  • Manage: Monitor
‣
② Postpartum depression
  • Affects 5-8% women
  • Onset within first month usually, lasts >2 weeks
  • Features: Same as depression. May have suicide ideation.
  • Manage: CBT, antidepressants
‣
③ Postpartum psychosis
  • Affects 0.2% women
  • Onset within first two weeks
  • Features: Elated, labile, occasionally low mood. Agitation, emotional distance, hallucinations, mania, delusions, insomnia. Suicide ideation in 5%.
  • Manage: Consider admission, antipsychotics. Involve senior.

Case examples:

‣
Patient presents with low mood, anhedonia and fatigue 2 months after giving birth. Diagnosis?
  • Postnatal depression
    • ‣
    What scale can be used to screen for depression in these individuals?
    • Edinburgh depression scale
    ‣
    Management?
    • CBT & SSRI (sertraline/paroxetine if severe)
‣
4 days after giving birth a lady presents anxious and tearful. Diagnosis? Management?
  • 'Baby blues'
    • ‣
    Management?
    • Reassurance & support
‣
2 weeks after giving birth a patient presents with severe mood swings and auditory hallucinations. Diagnosis?
  • Puerperal psychosis
    • ‣
    Management?
    • Hospital admission required

🧘🏽‍♀️ Gynaecology

‣
🤬 Pelvic Pain Cases

What’s the diagnosis based on the following presentations:

‣
6-8 weeks of amenorrhoea presenting with right-sided lower abdominal pain and vaginal bleeding. On examination she is found to have cervical excitation.
  • Ectopic pregnancy
‣
Central abdominal pain initially followed by localisation to the right iliac fossa (RIF). Also has tachycardia and low grade pyrexia, on palpation of the LIF the RIF is more painful.
  • Appendicitis
‣
Patient presents with chronic pelvic pain worse around the menstrual cycle. They are struggling to conceive and have dyspareunia.
  • Endometriosis
‣
22 year old has sudden onset RIF pain whilst playing netball. There is an adenexal mass on examination & USS shows "whirlpool sign".
  • Ovarian torsion secondary to cyst
    • Differential: Ovarian cyst rupture
‣
Patient presents with bloating, abdominal pain and a change in bowel habit. All sinister diagnoses are excluded.
  • Irritable bowel syndrome (IBS)
‣
Patient presents with severe abdominal pain, on a background of unilateral, intermittent dull ache worse during intercourse.
  • Ovarian cyst (can rupture during exercise or sex)
‣
Patient presents with fever, deep dyspareunia and vaginal discharge. On examination there is cervical excitation.
  • Pelvic inflammatory disease (may have STI history but may not have positive tests now)
‣
🧚🏼‍♀️ Vulva/Vagina
‣
Discharge

What’s the diagnosis based on the following presentations:

‣
Thick white discharge with no odour.
  • Vaginal candidiasis
    • ‣
    How would you manage them?
    • Oral fluconazole (not if pregnant) or clotrimazole pessary.
‣
Thin, fishy white discharge.
  • Bacterial vaginosis
    • ‣
    Name of criteria for BV?
    • Amsels criteria- need 3 out of 4 for diagnosis.
      • Thin white discharge
      • Clue cells on microscopy
      • Vaginal pH >4.5
      • Positive whiff test (add KOH —> Fishy odour)
    ‣
    How would you manage them?
    • Metronidazole
‣
Yellow/green frothy discharge. Strawberry cervix.
  • Trichomonas vaginalis.
    • ‣
    How would you manage them?
    • Metronidazole
‣
Lichen sclerosus
‣
What is it?
  • Inflammation causing atrophy of the epidermis of the vulva with white plaques forming and a prominent itch
‣
How is it managed?
  • Topical steroids (clobetasole propionate)
  • Emollients
‣
Female Genital Mutilation
‣
What are the 4 types of FGM?
  1. Removal of the clitoris
  2. Removal of the clitoris and labia minora +/- labia majora
  3. Infibulation - Cutting and joining the labia minora +/- majora creating a cover over the vaginal orifice
  4. All other FGM including cauterisation, piercing, incising and scraping of tissue
‣
🍓 Cervix
‣
Cervical Cancer
‣
What are the risk factors for cervical cancer?
  • HPV
    • ‣
    What is the vaccination schedule?
    1. First dose given to girls & boys aged 12-13 years
    2. Second dose 6-24 months after the first
    ‣
    Name both the carcinogenic and common strains of HPV.
    • Carcinogenic: 16, 18, 33
    • Common: 6, 11
  • Early first intercourse, many sexual partners
  • Smoking
  • HIV
  • High parity
  • Low socioeconomic status
‣
Cervical screening:
‣
Who requires cervical screening & how often does this need to be done?
  • Cervical smear for all women between 25-64 years
    • 25-49 years: 3 yearly
    • 50-64 years: 5 yearly
‣
How does screening differ in HIV patients & why?
  • Annual cervical cytology due to high risk of CIN
‣
What action is required with the following smear results:
‣
Mild dyskaryosis
  • HPV screen. And if that is positive → Colposcopy.
‣
Inadequate results in 3 samples
  • Colposcopy
‣
Moderate/severe dyskaryosis/suspected cancer
  • 2WW - Colposcopy
‣
What cell types could the cancer be?
  • Squamous cell carcinoma (80%)
  • Adenocarcinoma (20%)
‣
How would you investigate?
  • Bloods
    • FBC, U&E, LFT
  • Colposcopy
    • ‣
    What position and dyes are used in colposcopy?
    • Lithotomy position
    • Acetic acid and Lugol's iodine dyes
    ‣
    What can colposcopy show you, and what do these stages mean?

    Whether a patient has CIN I, II or III (histological grading):

    • CIN I: 1/3 thickness is abnormal.
    • CIN II: 2/3 thickness is abnormal.
    • CIN III: Full thickness- classified as carcinoma in situ.
  • Cervical biopsy
  • Radiology
    • MRI pelvis to help plan treatment
    • CT thorax, abdo, pelvis: Metastases
  • Clinical staging: Cystoscopy and sigmoidoscopy
‣
How are they staged?

Using the International Federation of Gynaecology and Obstetrics (FIGO) staging system, that is as follows:

  1. Stage 1: Confined to the cervix
  2. Stage 2: Invades the uterus or upper 2/3 of the vagina
  3. Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
  4. Stage 4: Invades the bladder, rectum or beyond the pelvis
‣
How do you manage CIN I, II and III?
  • CIN I: Nothing or cold coagulation. Can revert back to normal in 1-2 years.
  • CIN II or III: LLETZ (large loop excision of transformation zone). If you want to spare fertility can do a cone biopsy.
‣
How would you manage?

General guidelines, but management depends on FIGO staging at time of presentation, the individual and whether they want to spare fertility.:

  1. 1/1a: LLETZ or cone biopsy
  2. 1-2: Radical/Wertheims hysterectomy
  3. Late 2: Chemo and radiotherapy alone.
    • Once grown out of the cervix and uterus, surgery is unlikely to be curative.
‣
Cervical Ectropion
‣
What is the pathophysiology of cervical ectropion?
  • ↑ Oestrogen → Migration of the columnar epithelium from inside the cervix downwards → Vaginal discharge & post-coital bleeding
‣
What are the causes?
  • Physiological: Ovulation
  • Pregnancy
  • Combined oral contraceptive pill
‣
What is the management?
  • Ablation (cold coagulation)
‣
🥩 Uterus
‣
Endometrial Cancer
‣
Name 6 risk factors for this.
  1. Obesity
  2. Early menarche
  3. Late menopause
  4. Nulliparity
  5. PCOS
  6. Unopposed oestrogen - Tamoxifen (ER+ breast Ca)
‣
Name 2 protective factors.
  1. COCP
  2. Smoking
‣
What features need to be present to refer under the 2WW rule?
  • Post-menopausal bleeding in a lady ≥ 55 years
‣
When referred, how are these patients investigated and what results are significant?
  1. TV USS assessing endometrial thickness
    • > 4 mm is significant
  2. Hysteroscopy with endometrial biopsy
‣
What is the main management?
  • Hysterectomy with bilateral salpingo-oophorectomy
‣
Abnormal Bleeding
‣
Menorrhagia
‣
How do you determine what is excessive menstrual bleeding?
  • Ask what is normal for that individual and assess from there
‣
How do you investigate menorrhagia?
  • FBC
  • TV USS (if structural abnormality is suspected)
‣
What do you need to ask about when deciding the management plan? (Follow-on Qs)

Do they require contraception?

‣
What are the options if they don't require contraception?
  1. Mefanemic/tranexamic acid
  2. Endometrial ablation
‣
What are the options if they require contraception?
  • Mirena coil
  • COCP
  • Long-acting progestogens
‣
Amenorrhoea
‣
How do you divide this?
‣
Primary - Name 3 causes?

Failure to undergo menarche by 16 years.

  1. Turner's
  2. Congenital genital malformations - Obstructing menstrual flow
  3. Congenital adrenal hyperplasia
‣
Secondary - What are the causes and how do you investigate each?

Stopping of regular established menstruation for ≥ 6 months:

  1. Pregnancy - Urine β-hCG
  2. Menopause - Serum FSH, LH & oestrogen. Day 21 progesterone concentration (> 30)
  3. Premature ovarian failure - Serum FSH, LH & oestrogen. Day 21 progesterone concentration (> 30)
  4. PCOS - Androgens
  5. Hypothalamic amenorrhoea - Gonadotropins, oestradiol
    • Excessive exercise/anorexia nervosa/stress
  6. Hyperprolactinaemia - Prolactin
  7. Hypothyroidism/thyrotoxicosis - TFTs
‣
Dysmenorrhoea
‣
A 15 year old girl presents with suprapubic cramping pain within a few hours of the period starting. Likely diagnosis? Pathophysiology? Management?
  • Diagnosis: Primary dysmenorrhoea (Mittelschmerz)
  • Pathophysiology: Overproduction of endometrial prostaglandins
  • Management:
    1. Mefanemic acid
    2. COCP
‣
A 35 year old lady presents with pain 3-4 days before the onset of her period. Name 4 differentials?
  1. Endometriosis
  2. Fibroids
  3. PID
  4. Adenomyosis
‣
Fibroids
‣
What is the main cause of fibroid growth?
  • Oestrogen
‣
Name 4 potential symptoms.
  1. Fertility problems
  2. Menorrhagia
  3. Lower abdominal pain/dysmenorrhoea
  4. Urinary frequency
‣
How is it investigated?
  • TV USS
‣
Name the 4 management options and when they are used.
  1. IUS (Mirena) - Anatomy dependent
  2. Tranexamic acid/COCP/progesterone
  3. GnRH analogues - Relieves symptoms whilst waiting for myomectomy
  4. Myomectomy - Definitive management that maintains fertility
  5. Hysterectomy - If family is completed
‣
Endometriosis
‣
Name 5 features that may be present in a patient with endometriosis.
  1. Pain:
    1. Chronic abdominal pain
    2. Dysmenorrhoea
    3. Deep dyspareunia
  2. Subfertility problems
  3. Urinary symptoms
‣
How do you investigate for this?
  • Laparoscopy
‣
A woman with endometriosis presents with acute abdominal pain and free fluid in the pelvis 1 week after her LMP. What is this?
  • Ruptured endometrioma - Cyst filled with menstruation bursts
image
‣
How is it managed in both primary and secondary care?
  1. Primary care:
    • NSAIDs +/- paracetamol
    • COCP/progestogens
  2. Secondary care:
    • GnRH analogues
    • Laparoscopic excision of tissue
‣
Adenomyosis
‣
What is this?
  • Migration of the endometrial tissue into the myometrium
‣
What is the gold standard investigation?
  • MRI
‣
How is it managed?
  • GnRH analogues
  • Hysterectomy
‣
🍒 Ovaries
‣
Ectopic Pregnancy
‣
Key features of the presentation?
  1. Period of amenorrhoea (6-8 weeks)
  2. Lower abdominal pain (unilateral, acute)
  3. PV bleeding (later on usually)
  4. Cervical excitation
  5. If severe can present with shoulder tip pain (indicates irritated diaphragm) and collapse —> So any collapse in women of childbearing age do a pregnancy test!
‣
Where is an ectopic most commonly found?
  • Ampulla of fallopian tube
image
‣
What investigations are needed?
  1. TV USS (although will not show unless 6-7 weeks gestation. So if under this just do serial β-hCG).
  2. Serial serum β-hCG - In pregnancy of unknown location
    • Doubles in 48h → Likely intrauterine pregnancy
‣
How does size, symptoms, fetal heartbeat & the investigation above affect the management of an ectopic? What are the options?
  • Conservative - Monitor over 48 hours
    • Size < 30 mm
    • β-hCG < 200
    • Asymptomatic
    • No fetal heartbeat
  • Medical - Methotrexate
    • Size < 35 mm
    • β-hCG ≤ 1500
    • No pain
    • No fetal heartbeat
  • Surgical - Salpingotomy/ectomy
    • Size > 35mm
    • β-hCG > 1500
    • Pain
    • Fetal heatbeat may be present
‣
Ovarian Cancer
‣
What are the types?
  1. Epithelial (90%): Commonly in post-menopausal women
  2. Germ-cell (5%): Young woman with rapidly growing mass
  3. Sex cord stromal (5%): Connective tissue
‣
A patient has a benign ovarian tumour, ascites and a right pleural effusion. What syndrome do they have?
  • Meig's
‣
Name 4 risk factors and 2 protective factors.

RFs:

  1. BRCA 1/2
  2. Early menarche
  3. Late menopause
  4. Nulliparity

Protective:

  1. COCP
  2. Pregnancy
‣
Name 3 investigations.
  1. CA125 > 35
  2. Abdomen/pelvis USS
  3. Laparotomy
‣
How does staging work? (1-4)
  1. Confined to ovary
  2. Outside of the ovary but within the pelvis
  3. Outside the ovary but within the abdomen
  4. Distant metastases
‣
What is the management?
  • Surgery - Remove all macroscopic disease. Explorative laparotomy for staging and debulking with TAH and BSO (total abdominal hysterectomy with bilateral salpingo-oophorectomy)
  • Platinum-based chemotherapy
  • *Ovarian cancer management differs to cervical in that you don't always do surgery in cervical if advanced but with ovarian you always do some form of debulking surgery.
‣
Ovarian Cyst
‣
When does a cyst need to be biopsied to exclude malignancy?
  • Multi-loculated cyst on USS
‣
What cyst forms when:
‣
A dominant follicle doesn't rupture or a non-dominant follicle doesn't undergo atresia? Management?
  • Follicular cyst
  • Conservative management - Regress over time
‣
The corpus luteum doesn't break down in pregnancy?
  • Corpus luteal cyst
‣
What cyst is lined by epithelial tissue? What does this result in? Who is this common in?
  • Dermoid cyst (teratoma)
  • Growing of teeth, hair, eyes, etc.
  • Young women (≤ 30 years)
‣
What are the 2 types of cystadenoma?
  1. Serous
  2. Mucinous
‣
Polycystic Ovary Syndrome
‣
What is the triad of PCOS?

Diagnosis requires 2/3:

  1. Oligo-ovulation or anovulation
  2. Hyperandrogenism (↑ LH): Hirsutism/acne
  3. USS: "String of pearls" (cysts - these are corpus lutea), ovarian volume > 10cm³
‣
Name 5 features present in PCOS.
  1. Obesity
  2. Oligo/amenorrhoea
  3. Subfertility/infertility
  4. Hirsutism - Male hair growth
  5. Acanthosis nigricans - Hyperpigmentation of skin around creases
‣
How would you investigate this?
  • OGTT
  • Bloods: Testosterone, gonadotropins, TSH, prolactin
    • Raised LH, normal FSH
    • Raised LH : FSH
  • Radiology: Abdominal USS
‣
What would be your options for management of infertility?
  1. WL - Lifestyle
    • Add metformin
  2. Clomifene - Good for infertility management in these patients, first line if normal BMI
    • Add metformin
  3. Laparoscopic ovarian drilling
  4. Gonadotrophins - FSH & LH
‣
What is the most important reason to manage anovulation in PCOS? Why does this occur? How do you manage this?
  • To prevent endometrial cancer. Low progesterone means there is never a drop in progesterone cause endometrium to shed —> It continues proliferating —> Endometrial hyperplasia and cancer.
    • ‣
    Management?
    • COCP or Mirena coil.
‣
Complications of PCOS?
  1. Endometrial cancer
  2. Infertility
  3. Increased risk of T2DM and cardiovascular disease
‣
Menopause
‣
How is this defined?
  • Cessation of menstrual periods for ≥ 12 months
‣
Name 5 typical menopausal symptoms.
  1. Hot flushes
  2. Night sweats
  3. Vaginal dryness
  4. Loss of libido
  5. Low mood
‣
What are the 3 broad management headings? (Follow-on Qs)
  1. Lifestyle
  2. HRT
    3. ‣
    When is HRT contraindicated?
    • Endometrial/ovarian/breast cancer current Ca / high risk
    ‣
    How does management differ between a patient with a uterus and without?
    • With: Combined HRT
    • Without: Unopposed oestrogen HRT
    ‣
    Name 3 risks associated with HRT.
    1. Breast cancer
    2. Ovarian cancer
    3. Thrombosis: VTE, stroke, CHD
  3. Non-HRT
    4. ‣
    How are vasomotor symptoms managed?
    • SSRIs: Fluoxetine
‣
Premature Ovarian Failure
‣
How is this defined?
  • Onset of the menopause < 40 years
‣
Name 3 potential causes of this.
  • Idiopathic
  • Chemotherapy/radiation
  • Autoimmunity
  • Abdominal surgery
‣
🍆 Contraception
‣
Prophylaxis
‣
What is the MOA/mode of action of the following contraceptives:
‣
COCP
  • Negative feedback on pituitary → ↓ FSH & LH → No ovulation
‣
POP
  • Thickens cervical mucus
‣
Injection/implant/cerazette
  • Primary: Inhibits ovulation
  • Thickens cervical mucous
‣
IUD
  • Spermatocidal & prevents implantation
‣
IUS
  • Endometrial thinning & thickens cervical mucous
‣
Between what time-period are hormonal contraceptives immediately effective when started? (Follow-on Qs)
  • Day 1-5 of menstrual cycle

If taken after 5 days, what medications take the following durations to work:

‣
2 days
  • POP
‣
7 days
  • COCP
  • Implant / injection
  • Mirena
‣
What are the risks associated with the COCP?
  • VTE - ↑ Clotting
  • Stroke (if experienced migraine with aura)
  • Breast & cervical cancer (protective: ovarian & endometrial)
    • ‣
    A patient on the COCP presents with trigeminal neuralgia, what do you need to consider when deciding the management plan?
    • Carbamazepine is first line - CYP450 inducer
    • Will reduce effectiveness of COCP so cannot be used together
‣
A patient is on the COCP and misses 1 pill in the third week of her cycle. How is this managed? Does management differ if in week 1/2?
  1. Take missed pill ASAP and today's, no barrier or emergency contraceptive needed
  2. No
‣
Patient on the COCP misses 3 pills on the third week of her cycle. How is this managed? Would this management differ if in week 1/2?
  1. If UPSI in last week then consider emergency contraception +/- pregnancy test
  2. Barrier contraception/abstain for 7 days
  3. Take 2 pills today, miss the pill-free interval next week & continue as normal after

Week 1/2:

  • No need to miss pill-free interval but all other steps are the same
‣
Patient taking the POP took her pill 5 hours late today. What is your advice? Would this differ if the pill was 2 hours late? What is the anomaly?
  • > 3 hours late: Take pill ASAP, barrier contraception for 48 hours
  • < 3 hours late: Take pill ASAP, no other precautions needed
  • Anomaly: Cerazette (desogestrel) has a 12 hour window instead of 3 hours - Much better for compliance
‣
How long does depo provera last? What key advice do you need to give regarding adverse effects of this?
  • Progesterone injection - 3 months
  • SE:
    1. Common: Abnormal PV bleeding
    2. May not reach full fertility until up to 12 months after stopping the injection
‣
How long does the Nexplanon implant last? Where is it situated?
  • 3 years
  • Non-dominant arm, subdermal implant above the triceps
‣
Contraception indication cases:
‣
A 47 year old comes in asking for contraception. Her LMP was 12 months ago. What advice do you give her?
  • Cu IUD needed as she is under 50 years
‣
Patient on the COCP is booked for an elective cholecystectomy in 8 weeks. How do you manage this?
  • Stop COCP 4 weeks before and restart 2 weeks after due to VTE risk
‣
A patient is 7 weeks post-partum and is breastfeeding, do they need contraception? What can be given?
  • Yes they need contraception from day 21 onwards
  • POP if < 6 weeks postpartum but here COCP can be considered too
    • < 6 weeks postpartum is an absolute CI for COCP
‣
Emergency
‣
When considering giving this, what key questions need to be asked?
  1. When was the UPSI (unprotected sexual intercourse)?
  2. When was your LMP? How long is your normal cycle?
‣
What are the three options for EC and when can you use each of them?
  1. IUD
    2. ‣
    When is this effective?
    • Up to 5 days after UPSI OR 5 days post ovulation
    • *It is the only one effective form of emergency contraception available post-ovulation, given that the other two work to inhibit ovulation
    • *Therefore if 6 days after UPSI and 6 days post ovulation, cannot use any form of emergency contraception, unlikely to work!
    ‣
    What is the MOA?
    • Spermicidal effect
    • Obstructs/prevents implantation
  2. Ulipristal acetate - STAT
      3. ‣
      When is this effective?
      • Up to 5 days after UPSI
      • Before ovulation (< 14 days into cycle)
      ‣
      What is the MOA?
      • Prevents ovulation
    1. Contraindicated in Liver disease and asthma!
  3. Levonorgestrel - STAT
    4. ‣
    When is this effective?
    • Up to 3 days (72h) after UPSI. How to remember- L for effective LESS time after UPSI.
    • Before ovulation (< 14 days into cycle)
    ‣
    What is the MOA?
    • Prevents ovulation
    ‣
    Why do you need to check the patients weight?
    • Double dose if patient ≥ 70 kg
‣
If a patient is on day 20 of their cycle, can you give them PO EC?
  • Yes, still recommended to give it to them, may be less effective due to ovulation already occuring
‣
Ethics & Law
‣
How do you assess for competence in < 16 year olds and what is this competence called?
  • Fraser guidelines- refers specifically to sexual health and contraception
  • Gillick competence- all medical advice.
    • If they are deemed Gillick competent- they can consent but not dissent to treatment ie cannot refuse treatment.
‣
Before giving contraception to someone under 16 what conditions must you follow?
  • Must have intelligence to understand
  • Can't be persuaded to tell parents
  • Likely to continue having sex anyway
  • Physical or mental health likely to suffer if you don't help
  • Treatment is in their best interests
‣
When are children deemed completely unable to consent to intercourse, so you therefore must involve safeguarding ASAP?
  • < 13 years
‣
What contraceptive is recommended for them?
  • Nexplanon implant: Long acting reversible contraceptive (LARC)
  • Longest effect
‣
🧐 Other
‣
Pelvic Inflammatory Disease (PID)
‣
What is this?
  • Infection/inflammation of the female pelvic organs
‣
Name 2 common causes.
  1. Chlamydia
  2. Gonorrhoea
‣
Name 5 potential features.
  1. PV discharge
  2. Cervical excitation
  3. Fever
  4. Abdominal pain
  5. Dyspareunia/post-coital bleeding
‣
Why may they develop RUQ pain? What is this called?
  • Perihepatitis (adhesions on liver USS)
  • Fitz-Hugh Curtis syndrome
‣
How is it investigated?
  • Speculum examination - Swabs for MC&S & cervical excitation
  • Blood test for gonorrhoea
  • USS - Tubal inflammation
‣
What are the complications?
  • Infertility
  • Ectopic pregnancy
  • Chronic pelvic pain
‣
Infertility
‣
What is the difference between primary and secondary infertility?
  • Primary: No children
  • Secondary: Previous children
‣
Name 5 potential infertility causes.
  1. Anovulation
    2. ‣
    How is this classified?
    1. Primary - Ovarian problem
      • Premature ovarian failure
      • Surgery
      • Chemotherapy/immunosuppressants
      • Turner's
    2. Secondary - Hypothalamic/pituitary problem
      • Excessive WL/exercise
      • Hypopituitarism, Kallmann's, prolactinoma
    3. Combined
      • PCOS
  2. Male factor
    3. ‣
    What are the 3 reasons for this?
    1. Semen abnormality - Idiopathic, cancer, varicocele, alcohol
    2. Azoospermia - Semen contains no sperm
      • Pre-testicular: Steroids, Kallmann's
      • Non-obstructive testicular: Cryptorchidism, orchitis (mumps), Klinefelter's
      • Obstructive: Absence of vas deferens, vasectomy, gonorrhoea
    3. Immunological
    4. Coital dysfunction
      5. ‣
      What can cause this?
      1. Erectile dysfunction
      2. Hypospadias
      3. Phimosis
  3. Structural - Fallopian tube damage/fibroids/PID
  4. Endometriosis
  5. Unexplained
‣
When should investigations begin for infertility?
  • After 12 months of regular (every 2-3 days) unprotected intercourse
‣
What investigations should be done in primary & secondary care?
  • Primary:
    • Vaginal examination & speculum - PID, ovarian masses, fibroids (large uterus), contraceptives
    • Bloods:
      • Hormonal profile: FSH, LH, oestradiol, TSH, prolactin
      • Mid-luteal progesterone level
        • Normal > 30
          • ‣
          When do you do this?
          • 7 days before the end of the cycle.
            • 28d cycle: Day 21
            • 35d cycle: Day 28
      • Semen analysis - Volume, pH, concentration, total sperm, motility
  • Secondary:
    1. TV USS - Fibroids, ovarian abnormalities
    2. Hystersalpingogram - Contrast XR for tubal patency
    3. Blue dye laparoscopy (gold standard) - Fallopian tube patency
‣
Name 6 management options.
  • Lifestyle advice:
    • Stop smoking, lose weight, intercourse every 2-3 days
  • Inducing ovulation:
    • Metformin - WL
    • Clomifene
    • Laparoscopic ovarian drilling - Reduces LH negative feedback
    • Gonadotrophins
  • Surgical:
    • Tubal catheter
    • Endometriosis removal
    • Intrauterine adhesions
  • IVF
    • Indications: Fallopian tube disease, male factor, endometriosis, refractory anovulation
    • Other options: Intrauterine insemination
    • Egg donation
‣
Lady presents with known infertility during IVF with weight gain, oliguria and N&V. What is the likely problem?
  • Ovarian hyperstimulation syndrome (OHSS)
    • ↑ Oestrogen & VEGF → ↑ Membrane permeability
‣
Urinary Incontinence
‣
Case examples:
‣
Patient presents due to incontinence that can occur at any time of day. She is unable to hold her bladder when trying to get to the toilet. Diagnosis?
  • Urge incontinence: Overactive bladder
    • ‣
    Pathophysiology?
    • Detrusor overactivity
    ‣
    Management?
    1. Lifestyle - Bladder retraining
      • Bladder diary for 6 weeks, reduce fluid intake to < 2L
    2. Medications:
      1. Antimuscarinics: Oxybutynin/tolterodine
      2. β₃-agonists (e.g. Mirabegron) if no response to 2 antimuscarinics
    3. Surgery:
      1. Intravesical botox
      2. Posterior tibial nerve stimulation (PTNS)
‣
Patient presents after pregnancy with small amounts of leaking urine when coughing or laughing. Diagnosis?
  • Diagnosis: Stress incontinence
    • ‣
    Management?
    1. Pelvic floor physiotherapy (3 months)
      • RF modification: Less caffeine, stop smoking, weight loss
    2. Surgical: Tension free vaginal tape/sling
    3. Medical: Duloxetine (rarely used unless unsuitable for surgery)
‣
Patient presents with a feeling of incomplete emptying after urination and she went to the toilet before coming in yet her bladder is still palpable. Diagnosis?
  • Overflow incontinence due to obstruction
‣
Name 3 investigations you may like to do in patients with urinary incontinence:
  1. Bladder diary
  2. Vaginal exam: Rule out prolapse and pelvic floor tone
  3. Urinalysis: UTI & DM
  4. Urodynamics
‣
Termination of Pregnancy
‣
Who needs to be present for this?
  • 2 registered medical practitioners
‣
How does management differ depending on gestation?
  1. < 9 weeks: Mifepristone (antiprogestogen) → 48h later give misoprostol to stimulate uterine contraction
  2. < 13 weeks: Dilation & suction
  3. > 15 weeks: Dilation & evacuation
‣
A patient presents 3 weeks after termination with a positive pregnancy test. Did the termination fail? What do you advise?
  • Can expect β-hCG to still be raised up to 4 weeks after termination
  • Come back if still raised next week

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