Obstetrics and Gynaecology for ISCE PDF

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ANTENATAL OF have made a series of the advice that pregnant women should antenatal visits in first pregnancy if antenatal visits in subsequent ones if acid 400 mcg should be given from until 12 weeks to reduce risk of defects higher dose if also supplement not offered vitamin A might may harm the ba...

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ANTENATAL CARE

ANTENATAL VISITS

EXPLANATION OF CARE

EXPLANATION

Guideline have made a series of recommendations regarding the advice that pregnant women should receive:

10 antenatal visits in first pregnancy if uncomplicated 7 antenatal visits in subsequent ones if uncomplicated

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• •

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Folic acid 400 mcg should be given from before conception until 12 weeks to reduce risk of neural tube defects – higher dose if also taking antiepileptic Iron supplement not offered routinely Avoid vitamin A (liver/pate) – might be teratogenic, may harm the baby and cause birth defects Vitamin D supplement 10mcg OD

ALCOHOL and SMOKING Recommend that pregnant women should not drink to keep risks to your baby to a minimum. It can lead to long term harm to the baby, with the more you drink the greater the risk Risk of smoking including low birthweight and preterm birth NRT may be used but woman must stop smoking, risk/benefits should be discussed. Do not offer varenicline or bupropion to pregnant or breastfeeding women

Week

2.

Listeriosis – avoid unpasteurised milk, ripened soft cheeses (Camembert, brie, and blue-veined chesses), pate or undercooked meat Salmonella – avoid raw or partially cooked eggs and meat especially poultry

OTHER IMPORTANT ADVICE Work • •

• •

Associated with increased risk of VTE (clots) Wearing correctly fitted compression stockings is effective at reducing risk

Prescribed meds – avoid unless benefits > risks OTC meds – use as little as possible

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Starting or continuing moderate exercise is not associated with adverse outcomes Avoid high impact sports where there is risk of abdominal trauma and scuba diving

Sexual intercourse: •

Not known to be associated with any adverse outcomes

• • • •

FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies hepatitis B, syphilis, rubella HIV test is offered to all women urine culture - asymptomatic bacteriuria

Down’s syndrome screening (sBHCG, PAPPA) + nuchal scan (not suitable for obese)

14-20

Quadruple test – AFP, bHCG, inhibin A, oestrodiol (multi preg use combined)

16

1820+6

25

Info on anomaly and bloods. If Hb /= 30 • Previously given birth to a large baby (>4.5kg) • PMHx of GDM • First degree relative with diabetes • Ethnicity – family origin is South Asian, Chinese, African-Caribbean or middle eastern. • Increase age, smoking

MATERNAL CARE • • • • • • • • • • •

Under the care of specialist team, consultant-led Obstetrician, diabetes specialist, diabetes nurse, dietician, midwife, extra antenatal care and clinics Healthy eating and exercise – may improve Monitor sugar - 7 – insulin Aspirin 75mg from week 12 – pre-eclampsia Baby monitoring – USS growth scans at 32 & 36w C-section if estimated weight >4kg Best time to deliver – 38-40w, may induced/c-section if >40+6 Insulin drip during labour and monitor fetal HR

COMPLICATIONS Maternal: • Hypoglycaemia, HTN (pre-clampsia), nephropathy, retinopathy (screening), instrumental/C-section, PPH

SYMPTOMS • • • • •

AETIOLOGY AND RISK FACTORS High risk: Aspirin 75mg from 12 weeks • HTN disease in previous pregnancy/ chronic HTN • Chronic kidney disease • Autoimmune disease • T1/T2DM Moderate risk: Aspirin if more than 1 of any: • Nulliparous – first pregnancy • Aged 40 or over • Last pregnancy more than 10 years ago • Overweight – BMI 35 or more at booking • FHx pre-eclampsia • Multiple pregnancy

INVESTIGATIONS • • • • • •

•

Pre-term labour, low lung maturity, IUGR (vasculopathy)/Macrosomia/ Polyhydramnios Still birth (>40), shoulder dystocia, fetal distress

BP(>160/110 – severe), urine at routine apt 24hr urine collection >0.3g Protein creatinine ratio >30 FBC (high Hb, low Plt), LFT (high ALT and LDH), U+E (high uric acid and Cr) USS – fetal weight and growth Umbilical artery Doppler + CTG

COMPLICATIONS Maternal: eclampsia, cerebrovascular haemorrhage, HELLP, DIC, liver subcapsular haemorrhage, renal failure, ARDS Fetal: IUGR, still births/preterm delivery, placenta abruption

MANAGEMENT • •

Delivery of baby – at about 37w or earlier – IOL or C-section, if /= 150/100 – 160/110) – urgent • •

Fetal: •

Severe headache – painkillers do not help Problems with vision – blurring/flashing lights Severe pain below ribs/heart burn with N+V Massive swelling of face, hands, feet Hyperreflexia/clonus

• • •

Lower BP – labetalol 200mg PO or nifedipine 10mg PO – reassess in 30min, no improve, another dose IV labetalol 10ml 50mg 2mins/IV hydralazine 5mg 5mg 15mins (loading dose) Magnesium sulphate – prevent & treat eclampsia. Fluid restriction, furosemide if pulmonary oedema Monitor for Mg toxicity – calcium gluconate

PLACENTA ABRUPTION

PLACENTA PRAEVIA EXPLANATION OF CONDITION

EXPLANATION OF CONDITION

The placenta develops along with the baby in the womb during pregnancy. It connects the baby with the mother’s blood system and provides the baby with its source of oxygen and nourishment. In some women, the placenta attaches low in the uterus and may cover a part or all of the cervix (neck of the womb). This attachment often shows up in early USS and we call it a low-lying placenta. Placenta praevia is when the placenta continues to lie in the lower part of the womb in the last months of pregnancy.

The placenta is your baby’s life support system which it provides oxygen and important nutrients to your baby. In a placental abruption, the placenta separates away from the wall of the uterus and disrupts the flow of nutrients and oxygen to baby. The separation also causes bleed between the placenta and the womb. It is an emergency and can be life-threatening.

SYMPTOMS • •

• •

Incidental finding/routine scan Painless bleeding after 28w (second half of pregnancy) – sudden and profuse but does not last for long Initial pain, high risk of preterm delivery No indication of fetal distress – abnormal lie

AETIOLOGY AND RISK FACTORS • • • • • • •

Previous history of PP Previous caesarean section Advanced maternal age/increase parity Smoking, cocaine use Previous spontaneous/induced abortion Deficient endometrium – endometritis/curettage Assisted conception

INVESTIGATIONS •

• • •

A low-lying placenta may be suspected during routine 20w scan – many women will not go on to have PP later in pregnancy TV USS – safe for baby and you (in 32/36 weeks) to confirm diagnosis and plan for delivery FBC, cross match/ G+S, fetal monitoring Speculum – safe, NO PV

SYMPTOMS • • • • •

AETIOLOGY AND RISK FACTORS • • • • • • •

Clinical diagnosis CTG – fetal distress, hypoxia Bloods – FBC (low plt), Coag screen, cross-match, U+E

MANAGEMENT • • • • •

Minor PP: • May be able to deliver vaginally • If edge 35 years, >/=3 babies • PMHx of VTE or FHx of VTE • Thrombophilia – makes blood clot more likely • Medical condition – heart disease, lung, arthritis • Severe varicose veins that are painful Lifestyle: Overweight, BMI >30, smoker, IVDU During pregnancy: • Admitted to hospital • Multiple pregnancy • Dehydrated/less mobile/infection • Long travels • Pre-eclampsia • IVF pregnancy After delivery: • Long labour >24hr, PPH, C-section

INVESTIGATIONS • • •

Examine leg, ultrasound scan CXR, CT lung, VQ scan (if suggestive of PE) All scans have radiation (pros>cons) VQ hysterectomy

INDUCTION OF LABOUR EXPLANATION An induced labour is one that’s started artificially. It is very common. Sometimes labour can be induced if your baby is overdue or there is any sort of risk to you or your baby’s health.

INDICATIONS • • • • •

Prolonged pregnancy - >12 days after EDD or more than 42 weeks Prelabour premature rupture of membranes – labour does not start Diabetic mother >38weeks Pre-eclampsia/obstetric cholestasis Rhesus incompatibility

METHOD •

• • •

Membrane sweep – sweeps their finger around the neck of your womb during an internal examination. This separate the membranes of the amniotic sac surrounding your baby from your neck of womb. This releases hormones (PG) to kick start labour – does not hurt, slight bleeding Prostaglandins (PV) – pessary or gel Artificial rupture of membrane Oxytocin

AMENORRHOEA

DYSMENORRHOEA EXPLANATION OF CONDITION

EXPLANATION OF CONDITION

Dysmenorrhoea is the medical term for painful periods. It is common for periods to be painful for teenagers and young adults. Periods tend to become less painful as you get older. Most women have some pain during periods, pain is often mild but in 1/10 women, the pain is severe enough to affect day-to-day activities. It may be so severe that they are unable to go to school or work.

Periods can stop for all sorts of reasons. Most of the time there is no worrying cause (before puberty, during pregnancy/breastfeeding, after menopause, using contraception such as POP, coil, Depro-vera, implant). As long as you are sue you are not pregnant and feel well yourself there is no need for concern. If you don’t have a period for 3-6 months, or have other symptoms, you should see a doctor. Sometimes teenage girls start their periods later than in others. Periods can also be infrequent, erratic or irregular.

Primary dysmenorrhoea – most common. No underlying problems of the womb or pelvis Secondary dysmenorrhoea – caused by a problem of the womb or pelvis. Less common and more likely to occur in women in their 30s and 40s.

SYMPTOMS • • •

Pain - just before/within few hours of period starting Suprapubic cramping pains which may radiate to the back or down the thigh Secondary – may be associated dyspareunia

AETIOLOGY AND RISK FACTORS Often not clear (primary). Thought to be that normal body chemicals (PG) build up in the lining of the womb. PG help the womb to contract and remove the lining during a period. Too much PG may cause womb to contract too hard, reduce blood supply to womb and cause pain. Secondary – Endometriosis, fibroids, PID, adenomyosis, IUD (cooper coils)

INVESTIGATIONS History – menarche, cycle length, regularity, duration of bleed, timing, location of pain, smoking history, sexually active, obstetric Hx, contraceptive Hx, features suggestive of underlying pathology (vaginal discharge, PCB, IMB, dyspareunia), dyschezia/rectal pain/bledding (endometriosis) Examination – Abdo + PV if sexually active • Adenomyosis – enlarged uterus, tender & boggy • Endometriosis – generalised tenderness in pelvis, fixed/retroverted uterus due to adhesions Additional Investigations: • Speculum exam, high vaginal swab, cervical smear • Pelvic USS/TV USS • MRI, laparoscopy, laparotomy with biopsy

MANAGEMENT General: • Lifestyle – stop smoking, TENS/locally applied heat, tea (regular, camomile, mint), abdo massage, lying supine position Medical: • •

NSAIDs – ibuprofen, mefenamic acid Hormonal Rx – COCP, POP, Depo-provera, Mirena

Primary amenorrhoea – If you never had a period by the age of 16 years Secondary amenorrhoea – Cessation of established, regular menstruation for 6m or more

PRIMARY AMENORRHOEA Secondary sexual characteristic present: • Constitutional delay – later than peers • GU malformations – imperforate hymen (uncommon) • Testicular feminisation/androgen resistance syndrome – No internal female organs, XY • Hyperprolactinaemia – caused by hypothyroidism/pituitary tumour Secondary sexual characteristics absent: • Ovarian failure – Turner’s syndrome, Mullerian agenesis • Hypothalamic failure – anorexia nervosa • Congenital adrenal hyperplasia

SECONDARY AMENORRHOEA • • • • • • • • •

INVESTIGATIONS • • •

Surgical: •

Hysterectomy if severe & completed family

Pregnancy, lactation, menopause Depot/implant/ Mirena Hypothalamic dysfunction due to – stress, eating disorder, depression, chronic systemic illness Pituitary disease – Sheehan’s syndrome (acute infarct due to PPH), hyperprolactinaemia Thyroid: Hypo/hyperthyroidism Adrenal: tumour Ovary: PCOS, premature ovarian failure 3cm in diameter) that develops on or in an ovary. A cyst can vary in size from a few centimetre to the size of a large melon. It may be thin-walled and only contain fluid – known as a simple cyst or may be more complex. Ovarian cyst are common. Most women will be unaware that they have a cyst as they often cause no symptoms.

Cancer is a disease of cells in the body. The normal process of cells grow and multiply in an orderly way goes wrong and cancer cells grow and multiply too quickly and they damage healthy tissue. The majority of ovarian cancer occur in women who have gone through the menopause and are usually aged over 50, but younger women can also be affected. The earlier the disease is found and treated, the better the survival rate. 90% are epithelial origin, mostly serous carcinoma

SYMPTOMS Simply cyst – which is usually a large follicle that has continued to grow after an egg has been released. Simple cysts are the most common cysts to occur before the menopause and most disappear within few months • Serous cystadenoma • Mucinous cystadenoma – larger, rupture may cause pseudomyxoma peritonei Endometrioma – cells of the lining of the womb found on the ovary Dermoid cyst – which develops from the cells that make eggs in the ovary, often contains substances such as hair and fat

SYMPTOMS • • • • • • • • •

Asymptomatic – diagnose by chance Lower abdominal pain/pelvic pain Painful periods/change in pattern of periods Pain during sex Pain related to bowels Feeling that want to pass urine urgently and more frequently Change in appetite or feeling full quickly Distended abdomen Difficulty in becoming pregnant – endometriosis

INVESTIGATIONS • • • • •

PV examination and abdo Pregnancy test TV USS Blood tests if complex cyst (LDH, AFP, hCG) Cancer antigen, diagnostic laparoscopy, FNAC

MANAGEMENT Simple cyst 7cm in diameter – further test such as MRI, +/- surgery (laparoscopic) • If cyst too large or suspicion of cancer – laparotomy, open operation Complications – ovarian torsion, rupture, haemorrhage, infertility

• • • • • •

Abdominal distension and bloating Abdominal and pelvic pain Urinary symptoms – urgency Early satiety Diarrhoea Fatigue, weight loss, depression

AETIOLOGY AND RISK FACTORS Family history: mutation of BRCA 1 or BRCA 2 – genetic screening • Many ovulations – early menarche, late menopause, nulliparity • Hx of ovarian cancer, breast cancer or bowel cancer • Hx of endometriosis Protective: child bearing, brest feeding, early menopause, oral contraceptive pill •

INVESTIGATIONS • • • • •

CA125 blood test Pelvic/abdo ultrasound scans CT scan/MRI Risk Malignancy Index – assess likelihood of cancer and referral to specialised MDT Diagnostic laparotomy

MANAGEMENT Staging: 1 – Limited to ovaries 2 – Involving one or both ovaries with pelvic extension 3 – With microscopically confirmed peritoneal implants outside the pelvis 4 – Distant metastasis • • •

Surgery: TAH + BSO Platinum based chemotherapy (adjuvant or neoadjuvant) Debulking in advance disease

CERVICAL CANCER

CERVICAL SCREENING EXPLANATION

EXPLANATION OF CONDITION

A cervical screening test (previously known as a smear test) is a method of detecting abnormal cells on the cervix (neck of the womb). This isn’t a test for cancer, it is a test to check the health of the cells of the neck of the womb. Most women’s test results show that everything is normal. But for around 1 in 20 women the test shows some abnormal changes in the cells of the cervix. Most changes will not lead to cervical cancer and the cells may go back to normal on their own. However, in some cases, the abnormal cells need to be removed so they cannot become cancerous.

Cervical cancer is a type of cancer that develops in a woman’s cervix – the entrance to the womb from the vagina (neck of the womb). Mostly squamous carcinoma

WHO AND WHEN

AETIOLOGY AND RISK FACTORS

All women who are registered with a GP are invited for cervical screening: Aged 25-49: every 3 years Aged 50-64: every 5 years Over 65 – only women who haven’t been screened since age of 50 or those who have recently had abnormal tests Being screened regularly means any abnormal changes in the cells of the cervix can be identified at an early stage and if necessary, treated to stop cancer developing. It is not 100% accurate and does not prevent all cases of cervical cancer. Screening is a personal choice and you have the right to choose not to attend.

WHAT HAPPENS DURING SCREENING You will receive a letter through post asking you to make an appointment for a cervical screening test. Screening is usually carried out by the practice nurse at your GP. You can ask to have a female doctor or nurse. Try to book an appointment during middle of your menstrual cycle (14d from LMP) as this can ensure a better sample of cells is taken. If you use a barrier method of contraception or lubricant jelly, you should not use these for 24 hours before the test as the chemicals may affect the test results. The cervical screening usually takes around 5 minutes to carry out. • You will be asked to undress from waist down and lie on a couch • Doctor/nurse will gently put an instrument called a speculum into your vagina – this holds the walls of vagina open so the cervix can be seen • A small soft brush will be used to gently collect some cells from the surface of your neck of womb • Some women find it uncomfortable or embarrassing but for most women it’s not painful • Try to relax as much as possible, take slow deep breaths will help • Results will be received in 2 weeks

HPV TESTING Changes in the cells of the cervix are often caused by the human papilloma virus (HPV). If it is found in your sample, you will be referred for a colposcopy for further investigation and if necessary, treatment

SYMPTOMS Cancer of the cervix often has no symptoms. • Unusual bleeding – can occur after sex, in between periods, after menopause • Detected on cervical screening

HPV – particularly serotypes 16, 18, 33 Risk factors: • Smoking • HIV • Early first intercourse, many sexual partners • High parity • Combined oral contraceptive pills • Lower socioeconomic status Prevention: using condoms offer some protection, HPV vaccine routinely offered to girls

INVESTIGATIONS • • • •

Biopsy Examination under anaesthetic + cystoscopy MRI to stage CXR, FBC, U+E

MANAGEMENT Staging: • 1 – cervix • 2 – including upper vagina • 3 – including lower vagina or pelvic wall or ureteric obstruction • 4 – into bladder or rectum or beyond pelvis 1a(I) • cone biopsy or simple hysterectomy 1a (II) – 1b(I) • Laparascopic lymphadenectomy + radical trachelectomy (preserve fertility) 1a (II) – 2a • radical hysterectomy if LN negative • if LN positive –chemo-radio therapy 2b-4 – chemo-radiotherapy

SEXUALLY TRANSMITTED INFECTIONS

PELVIC INFLAMMATORY DISEASE

EXPLANATION OF CONDITION

EXPLANATION OF CONDITION

An STI is an infection that can be passed from person to person when having sexual intercourse. It can infect the water passage, womb, neck of womb, back passage, testicles, throat or eyes. It can be passed on through: • Unprotected sex (not using a condom, whether vaginal, oral or anal) with someone has chlamydia • Fr...