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Obstetrics & Gynaecology
π€°πΌ Obstetrics
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- 8-12 weeks
- BP
- Urinalysis
- BMI
- FBC, blood group, Rh status, red cell alloantibodies
- Hepatitis B, syphilis, rubella
- Offer HIV test
- Urine culture - Asymptomatic bacteruria
- Can cause pyelonephritis and preterm labour.
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- 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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- 10 weeks
- Causes:
- Down's syndrome
- Congenital heart disease
- Abdominal wall defects
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- PAPP-A: β
- Ξ²-hCG: β
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- Ξ²-hCG: β
- Inhibin-A: β
- AFP: β
- Oestriol (uE3): β
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- Non-invasive prenatal testing (NIPT)
- CVS (< 15W)
- Amniocentesis (> 15W)
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- Rh status of foetus
- Down's syndrome screening (optional - patient may not want to know)
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- SFH, BP, urinalysis
- Begins: 24 weeks
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- 28 weeks
- 34 weeks
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- Producers: Embryo & syncytiotrophoblast
- Role: Prevent disintegration of corpus luteum
How does pregnancy affect the following:
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- Cardiac output: β
- BP:
- βοΈ Systolic
- Diastolic: β in first 2 trimesters, βοΈ in 3rd trimester
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- β Hb
- β WCC & ESR
- β Platelets
- β Coagulation (Body preparing for placental delivery)
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- Proteinuria
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- β Albumin
- β ALP
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- 100-160 bpm
Key antenatal conditions:
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- Mother Rh -, fetus Rh +
- Fetal cells enter mother's blood stream β Mother forms antibodies against fetal RBCs β Doesn't affect this pregnancy
- Next pregnancy: Mother's antibodies pass into fetal blood stream β Fetal haemolysis
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- Booking: Mother Rh status
- NIPT: Fetal Rh status
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- Maternal abdominal trauma
- Ectopic (if managed surgically)
- Termination
- APH
- Miscarriage
- Amniocentesis / CVS
- ECV
- Delivery - Vaginal / CS
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- 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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- Give mother anti-D (mops up fetal RBCs before mother sensitises) at week 28 & 34
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Define the following terms in relation to pregnancy:
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- Hypertension present β€ 20 weeks gestation
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- Hypertension without proteinuria > 20 weeks gestation
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- Hypertension & proteinuria > 20 weeks gestation
- β Placental spiral artery diameter β Syncytiotrophoblast infiltration β β Vascular resistance β Hypoperfusion of the placenta β IUGR & placental GF release β β CO & microvascular damage in kidneys, liver & brain
- Nulliparity
- Previous history / FH
- Mother > 40 years
- HTN, DM, CKD, autoimmune disease
- Obesity
- Large placenta: Multiple pregnancy, molar pregnancy
- Proteinuria
- HTN. Typically > 170/110mmHg
- Hyperreflexia
- Epigastric pain
- Headache (+/- visual disturbance/papilloedema)
- Urinary protein : creatinine > 30mg/mmol β Confirmed
- FBC: β Hb & platelets
- LFT: β ALT/AST
- 75mg aspirin from 12 weeks until birth
- PO/IV Labetalol
- Asthmatics: PO nifedipine β Methyldopa (if CCB inadequate)
- Delivery
- IUGR
- Prematurity
- β platelets & HTN
- Placental abruption, intra-abdominal/cerebral
- Eclampsia
- IV magnesium sulphate & fetus delivery
- If OD: Give calcium gluconate
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HELLP syndrome:
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- Ectopic
- Molar pregnancy
- Miscarriage
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- Spontaneous abortion (miscarriage)
- Molar pregnancy
- Placental abruption
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- Placental abruption
- Placenta previa
- Bloody show
- Vasa praevia
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- Miscarriage < 24 weeks
- APH β₯ 24 weeks
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Define the following:
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- Painless PV bleeding < 24 weeks with closed cervical os (USS heart present)
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- 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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- Open cervical os with clots and pain
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- Open cervical os with retained fetal products causing pain and bleeding
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- Medical: Misoprostol (PO/vaginal) as risk of retained products
- < 13W: Expectant management if cervical os is open
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Placental abruption:
- Shock out of proportion with PV blood loss
- Constant pain with tender, tense uterus
- Normal lie/presentation
- Absent or distressed fetal heart
Placenta previa:
- Shock in proportion with PV bleeding
- No pain
- Non-tender abdominal palpation
- Fetal heart usually normal
Types:
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- Occurs when the placenta partly or completely separates from the inner wall of the uterus before delivery.
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- Maternal trauma
- Pre-eclampsia/HTN
- Multiparity
- Polyhydramnios
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- Placental location in the lower 1/3 of the uterus
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- Accreta: Adherence of the placenta to myometrium, without penetration
- Increta: Villi invade into but not through the myometrium
- Percreta: Villi invade through the myometrium into the serosa
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- Painless vaginal bleeding
- Rupture of membranes
- Fetal bradycardia (or resulting fetal death) < 100 bpm
Investigating & managing:
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- Routine 20W abdominal USS
- Abdominal palpation: High presenting part
- TV USS
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- Conservatively at first: Re-scan at 34W
- Still low? Re-scan every 2W to check
- High presenting part/abnormal lie at 37W β C-section
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- APH & PPH
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- An empty egg is fertilised by a single sperm that duplicates its DNA
- USS: "Snowstorm appearance" - Not fetal tissue
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- 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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- Uterus large for dates
- Very β Ξ²-hCG
- PV bleeding in first 12 weeks gestation
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- USS - 'Snow-storm appearance'/'Bunch of grapes'
- Bloods:
- β Ξ²-hCG
- β TSH & β T4 - Ξ²-hCG mimics TSH stimulating the thyroid gland β Primary hyperthyroidism picture
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- Hyperthyroidism: hCG mimics TSH β β T4 β β TSH
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- Short: Uterus evacuation
- Long: Contraception for next 12 months
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- Polyhydramnios
- SFH large for dates
- Tense abdomen - "Difficult to feel fetal parts"
- GDM
- Fetal swallowing problem
- Fetal infections
- Amnioreduction
- NSAIDs β β Fetal renal output
- Maternal SOB / respiratory problems
- Cord prolapse
- PROM/pre-term labour
- Breech presentation
- Placental abruption
- Oligohydramnios
- Small for dates
- "Fetal parts feel abnormally prominent"
- Premature membrane rupture
- Fetal renal tract abnormality
- IUGR
- Smoking
- Fetal pulmonary hypoplasia (Swallowing amniotic fluid β Lung development)
- Clubbed feet
- Congenital hip dysplasia
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Potter's syndrome:
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- USS
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- 0-24 weeks
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- 24 weeks - Delivery
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- 24 weeks to 7 days after delivery
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- Within 28 days of delivery
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- In first year of life
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- 28 days - 1 year of life
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- Zygosity - How many ova?
- Mono: 1 ovum has divided into 2 separate embryos
- Di: 2 separate ova are fertilised
- Chorionicity - How many placentae?
- Amniosity - How many amniotic sacs?
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- Previous twins
- FH
- β maternal age
- IVF
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- Antenatal
- Polyhydramnios
- Anaemia
- APH (placenta praevia)
- Fetal
- Prematurity
- β Perinatal mortality
- Light-for dates
- Perinatal
- PPH (2X risk)
- Malpresentation
- Cord prolapse
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- 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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- BMI > 30
- Previous macrosomic baby β₯ 4.5 kg
- Previous GDM
- FH (First-degree relative)
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- OGTT at 24-28 weeks, diabetes values:
- Fasting β₯ 5.6
- 2 hours β₯ 7.8
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3 lines to work through:
- Lifestyle
- Metformin
- Insulin
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- Straight to insulin: High risk
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- Macrosomia
- Preterm delivery
- Neonatal hypoglycaemia β Seizures
- β BM β β Insulin β Hypoglycaemia after delivery
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- Chorioamnionitis
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- Ascending infection of the amniotic fluid from the vagina
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- IV antibiotics & prompt delivery (CS if necessary)
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- Rubella
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- < 8 weeks
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- Check her IgM - Will be raised if currently infected
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- After delivery
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- Check maternal blood for antibodies
- No antibodies - Give varicella zoster immunoglobulin (VZIG)
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- PO aciclovir
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- Clotrimazole pessary
- PO fluconazole is CI
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- Obstetric cholestasis
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- Chlorphenamine β Itching symptoms. Vitamin K β Reduce bleeding risk
- Induction at 37 weeks
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- Acute fatty liver of pregnancy
- Management: Supportive & delivery
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- Gilbertβs syndrome
- Haemolysis - HELLP
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- Previous VTE
- Blood disorder - thrombophilia (anti-phospholipid)
- Obesity
- Multiple pregnancy
- Smoking
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- LMWH therapeutic dose then investigate
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- Aspirin 75mg
- LMWH
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- Compression duplex USS
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- Re-assess/stop after 6 weeks postnatal
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- Severe N&V in early pregnancy
- Very β Ξ²-hCG
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- WL β₯ 5% pre-pregnancy
- Dehydration
- Electrolyte imbalance
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- Pregnancy-Unique Quantification of Emesis (PUQE)
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- Multiple pregnancy
- Molar pregnancy
- Hyperthyroidism
- Nulliparity
- Obesity (macrosomia)
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- IV NaCl (add potassium if needed)
- Cyclizine / promethazine
- Ondansetron / metoclopramide if severe
- Thiamine & folate
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- Mallory-Weiss tear
- Wernicke's encephalopathy
- Central pontine myelinolysis
- Acute tubular necrosis
- Hypochloraemic metabolic alkalosis
- Arrhythmias (K+)
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- > 20 weeks, < 37 weeks
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- History of preterm birth
- USS demonstrating a cervical length of β€ 25mm before 24 weeks
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- Prophylactic vaginal progesterone
- Prophylactic cervical cerclage - Suture the cervix shut
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- Tocolysis (labour suppression) with PO nifedipine
- Maternal cortocosteroids - PO Dexamethasone (between 24-34W)
- Prophylactic erythromycin (or IV Abx if GBS confirmed)
- IV magnesium sulphate - Neuroprotection of baby
- Delayed cord clamping after birth - Increased blood volume & Hb in baby
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- Longitudinal
- Oblique
- Transverse
- Cord prolapse
- Preterm rupture of membranes
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- Frank (most common) - Knees extended
- Complete - Knees flexed
- Footling
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- Footling
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- Poly/oligo-hydramnios
- Placenta praevia
- Fibroids
- Fetal abnormality (e.g. Down's)
- Prematurity (β incidence in earlier gestation)
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- < 36 weeks: Watch & wait
- ECV (50% success rate)
- 36 weeks in primip
- 37 weeks in multip
- Multiple pregnancy
- APH
- Fibroids
- Abnormal CTG
- Ruptured membranes
- Planned delivery / Elective C-section
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- Normal pregnancy > 12 days after EDD
- Diabetic mother > 38W (due to macrosomia)
- Rupture of membranes but labour doesn't start within 24h
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- Cervical favourability for delivery
- Cervical dilation, effacement, station (relation of head to pelvic outlet), position, consistency
- 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
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- Membrane sweep
- Vaginal prostaglandins
- AROM/Amniotomy - Artificial breaking of waters
- Oxytocin
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- First stage: Onset of true labour to full cervical dilation
- Latent phase: 0-3cm dilated
- Active phase: 3-10cm dilated
- Second stage: Full cervical dilation to delivery of fetus
- Third stage: Delivery of fetus to delivery of placenta
- Physiological: Natural delivery
- Active: IM oxytocin & apply cord traction
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- Signs:
- Show (mucus plug shedding)
- Membrane rupture
- Regular, painful uterine contractions
- 6-10 hours in primip. Can be shorter in multip.
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- Failing to progress: < 2cm dilation in 4h
- Management: Amniotomy (artificial membrane rupture), consider oxytocin infusion in primip
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*This is assuming a cephalic presentation with longitudinal lie (commonest presentation).
- Engagement: Head descends in OT position (transverse wider than AP here)
- Descent and flexion of the head
- Internal rotation by 90 degrees OA (allows head to pass through AP outlet)
- Crowning. Rotation complete, further descent and perineum distends
- Extension of the head and head delivery as the fetus leaves the vagina.
- Restitution via external rotation 90 degrees
- Delivery of the shoulders: Lateral flexion to deliver anterior shoulder, then posterior shoulder and finally rest of body.
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- May be needed in: Fetal/maternal distress, failure to progress within second stage
- Ventouse (Crudely a vaccuum to suck out fetus)
- Forceps
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- 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.
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- 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.
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- Superficial
- Perineal muscle & subcutaneous tissue
- Anal sphincter (AS) affected
- 3a: < 50% EAS. 3b: >50% of EAS. 3c: IAS affected
- Anal mucosa affected
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- Anterior shoulder of the fetus impacted on the pubic symphysis
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- Macrosomic baby
- Metabolic syndrome
- GDM/DM
- Prolonged labour
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- Call for additional help
- McRobert's manoeuvre
- Episiotomy
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- Maternal perineal tear
- Maternal PPH
- Brachial plexus injury β Erbs palsy
- Neonatal death
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- Amniotic fluid enters maternal circulation β Immune reaction β Shock (β BP, β HR, bronchospasm) β MI
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- During labour
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- MDT supportive management - Poor prognosis
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- Streptococcus agalactiae: GP cocci
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- No
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- During vaginal delivery
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- How: Vaginal swab
- When: 35-37 weeks
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- Intrapartum IV antibiotics
- Benzylpenicillin
- Allergic: Vancomycin
- Given to all premature deliveries
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- Early onset: < 48 hours after birth
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- Maternal: Chorioamnionitis
- Fetal:
- Infection
- Prematurity β Pulmonary hypoplasia
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- Sterile speculum examination
- USS - Oligohydramnios
- CTG - Fetal heartbeat
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- Chorioamnionitis: IV antibiotics & delivery
- Pulmonary hypoplasia: Antenatal dexamethasone
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- Fetal compression of cord β Hypoxia β Death
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- Prematurity
- Polyhydramnios
- Multiple pregnancy
- Breech presentation/transverse lie
- Long umbilical cord
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- Immediate: Patient on 'all 4s' & push fetal presenting part up to prevent compression of cord
- Tocolytics: Prevent contraction of uterus - nifedipine/terbutaline
- Definitive: CS
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PV bleeding of > 500ml within 12 weeks of delivery.
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- Uterine atonia - Long labour, multiple pregnancy, polyhydramnios, macrosomia
- Placenta praevia/accreta
- Pre-eclampsia (HELLP: β platelets)
- Previous PPH
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- Primary: Within 24 hours
- Tone - Atony β Inability of the placenta to contract and stop bleeding
- Tissue - Retained
- Trauma - CS, instrumental
- Thrombin - Placenta praevia/accreta
- Atony
- Secondary: 24 hours - 12 weeks
- Endometritis - PPH with offensive discharge
- Retained tissue
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- Get help, ABCDE - Stabilise patient, 2 peripheral cannulae, IV fluids, blood transfusion
- IV syntocinon/ergometrine - Stimulates uterine contraction
- IM carboprost
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- Immediate replacement of the uterus through the cervix with the palm of the hand
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- Balloon tamponade if due to atony
- Ligate supplying arteries
- Hysterectomy
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- Severe PPH β Pituitary hypoperfusion & necrosis β β Milk production & amenorrhoea
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- Temperature > 38Β°C within 14 days of delivery
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- Endometritis
- UTI
- Wound infections (perineal tear/CS)
- Mastitis
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- Endometritis β IV clindamycin & gentamicin
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- Blocked duct. Continue feeding
- Poor latch
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- Stop breastfeeding
- Maternal miconazole cream, fetal nystatin fluid
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- Continue breastfeeding if possible, if too painful continue expressing milk
- Maternal PO flucloxacillin if no improvement in 24h or systemic upset
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- Galactocele - Painless & no infection signs
- Woman stops breastfeeding β Milk build up & cyst creation
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- Antibiotics: Penicillins, trimethoprim
- Sodium valproate
- Glucocorticoids
- ACEi / ARB
- Beta-blockers
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- Antibiotics: Ciprofloxacin, tetracyclines
- Lithium
- NSAIDs: Aspirin
- Methotrexate
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- Cabergoline: Dopamine agonist β β Prolactin
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How do you distinguish between them? How do you manage them?
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- Affects 80% women
- Onset 2-3 days postpartum, lasts <10 days
- Features: Tearful, not feeling like yourself, anxiety, delayed bonding.
- Manage: Monitor
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- Affects 5-8% women
- Onset within first month usually, lasts >2 weeks
- Features: Same as depression. May have suicide ideation.
- Manage: CBT, antidepressants
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- 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:
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- Postnatal depression
- Edinburgh depression scale
- CBT & SSRI (sertraline/paroxetine if severe)
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- 'Baby blues'
- Reassurance & support
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- Puerperal psychosis
- Hospital admission required
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π§π½ββοΈ Gynaecology
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- Ectopic pregnancy
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- Appendicitis
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- Endometriosis
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- Ovarian torsion secondary to cyst
- Differential: Ovarian cyst rupture
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- IBS
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- Ovarian cyst (can rupture during exercise or sex)
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- PID (may have STI history but are not always positive now)
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- Abdominal USS
- Differentials: Miscarriage, molar pregnancy, ectopic
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- Removal of the clitoris
- Removal of the clitoris and labia minora +/- labia majora
- Infibulation - Cutting and joining the labia minora +/- majora creating a cover over the vaginal orifice
- All other FGM including cauterisation, piercing, incising and scraping of tissue
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- Vaginal candidiasis. Oral fluconazole (not if pregnant) or clotrimazole pessary.
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- Bacterial vaginosis. Metronidazole.
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- 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 β> Fishy odour)
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- Trichomonas vaginalis. Metronidazole.
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- Inflammation causing atrophy of the epidermis of the vulva with white plaques forming and a prominent itch
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- Topical steroids (clobetasole propionate)
- Emollients
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- HPV
- First dose given to girls & boys aged 12-13 years
- Second dose 6-24 months after the first
- Carcinogenic: 16, 18, 33
- Common: 6, 11
- Early first intercourse, many sexual partners
- Smoking
- HIV
- High parity
- Low socioeconomic status
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- Cervical smear for all women between 25-64 years
- 25-49 years: 3 yearly
- 50-64 years: 5 yearly
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- Annual cervical cytology due to high risk of CIN
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- HPV screen. And if that is positive β Colposcopy.
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- Colposcopy
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- 2WW - Colposcopy
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- SCC (80%)
- Adenocarcinoma (20%)
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- Lithotomy position
- Acetic acid and Lugol's iodine dyes
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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.
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- 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 want to spare fertility can do a cone biopsy.
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- Colposcopy, cervical biopsy
- Bloods:
- FBC, U&E, LFT
- Radiology:
- MRI pelvis to help plan treatment
- CT thorax, abdo, pelvis: Metastases
- Clinical staging: Cystoscopy and sigmoidoscopy
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General guidelines:
- 1/1a: Cone biopsy or simple hysterectomy
- 1-2: Radical/Wertheims hysterectomy. Can do laparoscopy hysterectomy and lymphadenopathy.
- Late 2: Chemo and radiotherapy alone.
- Once grown out of cervix and uterus, surgery unlikely to be curative.
*Depends on FIGO staging at time of presentation, the individual and whether they want to spare fertility.
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- β Oestrogen β Migration of the columnar epithelium from inside the cervix downwards β Vaginal discharge & post-coital bleeding
- Physiological - Ovulation
- Pregnancy
- COCP
- Ablation (cold coagulation)
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- Obesity
- Early menarche
- Late menopause
- Nulliparity
- PCOS
- Unopposed oestrogen - Tamoxifen (ER+ breast Ca)
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- COCP
- Smoking
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- Post-menopausal bleeding in a lady β₯ 55 years
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- TV USS assessing endometrial thickness
- > 4 mm is significant
- Hysteroscopy with endometrial biopsy
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- Hysterectomy with bilateral salpingo-oophorectomy
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- Ask what is normal for that individual and assess from there
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- FBC
- TV USS (if structural abnormality is suspected)
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Do they require contraception?
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- Mefanemic/tranexamic acid
- Endometrial ablation
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- Mirena coil
- COCP
- Long-acting progestogens
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Failure to undergo menarche by 16 years.
- Turner's
- Congenital genital malformations - Obstructing menstrual flow
- Congenital adrenal hyperplasia
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Stopping of regular established menstruation for β₯ 6 months:
- Pregnancy - Urine Ξ²-hCG
- Menopause - Serum FSH, LH & oestrogen. Day 21 progesterone concentration (> 30)
- Premature ovarian failure - Serum FSH, LH & oestrogen. Day 21 progesterone concentration (> 30)
- PCOS - Androgens
- Hypothalamic amenorrhoea - Gonadotropins, oestradiol
- Excessive exercise/anorexia nervosa/stress
- Hyperprolactinaemia - Prolactin
- Hypothyroidism/thyrotoxicosis - TFTs
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- Diagnosis: Primary dysmenorrhoea (Mittelschmerz)
- Pathophysiology: Overproduction of endometrial prostaglandins
- Management:
- Mefanemic acid
- COCP
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- Endometriosis
- Fibroids
- PID
- Adenomyosis
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- Oestrogen
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- Fertility problems
- Menorrhagia
- Lower abdominal pain/dysmenorrhoea
- Urinary frequency
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- TV USS
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- IUS (Mirena) - Anatomy dependent
- Tranexamic acid/COCP/progesterone
- GnRH analogues - Relieves symptoms whilst waiting for myomectomy
- Myomectomy - Definitive management that maintains fertility
- Hysterectomy - If family is completed
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- Pain:
- Chronic abdominal pain
- Dysmenorrhoea
- Deep dyspareunia
- Subfertility problems
- Urinary symptoms
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- Laparoscopy
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- Ruptured endometrioma - Cyst filled with menstruation bursts
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- Primary care:
- NSAIDs +/- paracetamol
- COCP/progestogens
- Secondary care:
- GnRH analogues
- Laparoscopic excision of tissue
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- Migration of the endometrial tissue into the myometrium
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- MRI
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- GnRH analogues
- Hysterectomy
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- Period of amenorrhoea (6-8 weeks)
- Lower abdominal pain (unilateral, acute)
- PV bleeding (later on usually)
- Cervical excitation
- If severe can present with shoulder tip pain (indicates irritated diaphragm) and collapse β> So any collapse in women of childbearing age do a pregnancy test!
β£
- Ampulla of fallopian tube
β£
- TV USS (although will not show unless 6-7 weeks gestation. So if under this just do serial Ξ²-hCG).
- Serial serum Ξ²-hCG - In pregnancy of unknown location
- Doubles in 48h β Likely intrauterine pregnancy
β£
- Conservative - Monitor over 48 hours
- Size < 30 mm
- Ξ²-hCG < 200
- Asymptomatic
- No fetal heartbeat
- Medical - Methotrexate
- Size < 35 mm
- Ξ²-hCG β€ 1500
- No pain
- No fetal heartbeat
- Surgical - Salpingotomy/ectomy
- Size > 35mm
- Ξ²-hCG > 1500
- Pain
- Fetal heatbeat may be present
β£
β£
- Epithelial (90%): Commonly in post-menopausal women
- Germ-cell (5%): Young woman with rapidly growing mass
- Sex cord stromal (5%): Connective tissue
β£
- Meig's
β£
RFs:
- BRCA 1/2
- Early menarche
- Late menopause
- Nulliparity
Protective:
- COCP
- Pregnancy
β£
- CA125 > 35
- Abdomen/pelvis USS
- Laparotomy
β£
- Confined to ovary
- Outside of the ovary but within the pelvis
- Outside the ovary but within the abdomen
- Distant metastases
β£
- 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.
β£
β£
- Multi-loculated cyst on USS
β£
β£
- Follicular cyst
- Conservative management - Regress over time
β£
- Corpus luteal cyst
β£
- Dermoid cyst (teratoma)
- Growing of teeth, hair, eyes, etc.
- Young women (β€ 30 years)
β£
- Serous
- Mucinous
β£
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Diagnosis requires 2/3:
- Oligo-ovulationΒ orΒ anovulation
- Hyperandrogenism (β LH): Hirsutism/acne
- USS: "String of pearls" (cysts - these are corpus lutea), ovarian volume > 10cmΒ³
β£
- Obesity
- Oligo/amenorrhoea
- Subfertility/infertility
- Hirsutism - Male hair growth
- Acanthosis nigricans - Hyperpigmentation of skin around creases
β£
- OGTT
- Bloods: Testosterone, gonadotropins, TSH, prolactin
- Raised LH, normal FSH
- Raised LH : FSH
- Radiology: Abdominal USS
β£
- WL - Lifestyle
- Add metformin
- Clomifene - Good for infertility management in these patients, first line if normal BMI
- Add metformin
- Laparoscopic ovarian drilling
- Gonadotrophins - FSH & LH
β£
- To prevent endometrial cancer. Low progesterone means there is never a drop in progesterone cause endometrium to shed β> It continues proliferating β> Endometrial hyperplasia and cancer.
- COCP or Mirena coil.
β£
β£
- Endometrial cancer
- Infertility
- Increased risk of T2DM and cardiovascular disease
β£
β£
- Cessation of menstrual periods for β₯ 12 months
β£
- Hot flushes
- Night sweats
- Vaginal dryness
- Loss of libido
- Low mood
β£
- Lifestyle
- HRT
- Endometrial/ovarian/breast cancer current Ca / high risk
- With: Combined HRT
- Without: Unopposed oestrogen HRT
- Breast cancer
- Ovarian cancer
- Thrombosis: VTE, stroke, CHD
- Non-HRT
- SSRIs: Fluoxetine
β£
β£
β£
β£
β£
β£
- Onset of the menopause < 40 years
β£
- Idiopathic
- Chemotherapy/radiation
- Autoimmunity
- Abdominal surgery
β£
β£
β£
β£
- Negative feedback on pituitary β β FSH & LH β No ovulation
β£
- Thickens cervical mucus
β£
- Primary: Inhibits ovulation
- Thickens cervical mucous
β£
- Spermatocidal & prevents implantation
β£
- Endometrial thinning & thickens cervical mucous
β£
- Day 1-5 of menstrual cycle
If taken after 5 days, what medications take the following durations to work:
β£
- POP
β£
- COCP
- Implant / injection
- Mirena
β£
- VTE - β Clotting
- Stroke (if experienced migraine with aura)
- Breast & cervical cancer (protective: ovarian & endometrial)
- Carbamazepine is first line - CYP450 inducer
- Will reduce effectiveness of COCP so cannot be used together
β£
β£
- Take missed pill ASAP and today's, no barrier or emergency contraceptive needed
- No
β£
- If UPSI in last week then consider emergency contraception +/- pregnancy test
- Barrier contraception/abstain for 7 days
- 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
β£
- > 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
β£
- Progesterone injection - 3 months
- SE:
- Common: Abnormal PV bleeding
- May not reach full fertility until up to 12 months after stopping the injection
β£
- 3 years
- Non-dominant arm, subdermal implant above the triceps
β£
β£
- Cu IUD needed as she is under 50 years
β£
- Stop COCP 4 weeks before and restart 2 weeks after due to VTE risk
β£
- 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
β£
β£
- When was the UPSI (unprotected sexual intercourse)?
- When was your LMP? How long is your normal cycle?
β£
- IUD
- 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!
- Spermicidal effect
- Obstructs/prevents implantation
- Ulipristal acetate - STAT
- Up to 5 days after UPSI
- Before ovulation (< 14 days into cycle)
- Prevents ovulation
- Contraindicated in Liver disease and asthma!
- Levonorgestrel - STAT
- Up to 3 days (72h) after UPSI. How to remember- L for effective LESS time after UPSI.
- Before ovulation (< 14 days into cycle)
- Prevents ovulation
- Double dose if patient β₯ 70 kg
β£
β£
β£
β£
β£
β£
β£
β£
- Yes, still recommended to give it to them, may be less effective due to ovulation already occuring
β£
β£
- 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.
β£
- 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
β£
- < 13 years
β£
- Nexplanon implant: Long acting reversible contraceptive (LARC)
- Longest effect
β£
β£
β£
- Infection/inflammation of the female pelvic organs
β£
- Chlamydia
- Gonorrhoea
β£
- PV discharge
- Cervical excitation
- Fever
- Abdominal pain
- Dyspareunia/post-coital bleeding
β£
- Perihepatitis (adhesions on liver USS)
- Fitz-Hugh Curtis syndrome
β£
- Speculum examination - Swabs for MC&S & cervical excitation
- Blood test for gonorrhoea
- USS - Tubal inflammation
β£
- Infertility
- Ectopic pregnancy
- Chronic pelvic pain
β£
β£
- Primary: No children
- Secondary: Previous children
β£
- Anovulation
- Primary - Ovarian problem
- Premature ovarian failure
- Surgery
- Chemotherapy/immunosuppressants
- Turner's
- Secondary - Hypothalamic/pituitary problem
- Excessive WL/exercise
- Hypopituitarism, Kallmann's, prolactinoma
- Combined
- PCOS
- Male factor
- Semen abnormality - Idiopathic, cancer, varicocele, alcohol
- 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
- Immunological
- Coital dysfunction
- Erectile dysfunction
- Hypospadias
- Phimosis
- Structural - Fallopian tube damage/fibroids/PID
- Endometriosis
- Unexplained
β£
β£
β£
β£
- After 12 months of regular (every 2-3 days) unprotected intercourse
β£
- 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
- 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:
- TV USS - Fibroids, ovarian abnormalities
- Hystersalpingogram - Contrast XR for tubal patency
- Blue dye laparoscopy (gold standard) - Fallopian tube patency
β£
β£
- 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
β£
- Ovarian hyperstimulation syndrome (OHSS)
- β Oestrogen & VEGF β β Membrane permeability
β£
β£
β£
- Urge incontinence: Overactive bladder
- Detrusor overactivity
- Lifestyle - Bladder retraining
- Bladder diary for 6 weeks, reduce fluid intake to < 2L
- Medications:
- Antimuscarinics: Oxybutynin/tolterodine
- Ξ²β-agonists (e.g. Mirabegron) if no response to 2 antimuscarinics
- Surgery:
- Intravesical botox
- Posterior tibial nerve stimulation (PTNS)
β£
β£
β£
- Diagnosis: Stress incontinence
- Pelvic floor physiotherapy (3 months)
- RF modification: Less caffeine, stop smoking, weight loss
- Surgical: Tension free vaginal tape/sling
- Medical: Duloxetine (rarely used unless unsuitable for surgery)
β£
β£
- Overflow incontinence due to obstruction
β£
- Bladder diary
- Vaginal exam: Rule out prolapse and pelvic floor tone
- Urinalysis: UTI & DM
- Urodynamics
β£
β£
- 2 registered medical practitioners
β£
- < 9 weeks: Mifepristone (antiprogestogen) β 48h later give misoprostol to stimulate uterine contraction
- < 13 weeks: Dilation & suction
- > 15 weeks: Dilation & evacuation
β£
- Can expect Ξ²-hCG to still be raised up to 4 weeks after termination
- Come back if still raised next week
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