-
Risk factors for endometrial cancer
- Nulliparity
- Obesity
- Early Menarche/Late menopause
- lack of breastfeeding
- Tamoxifen HRT
-
Diagnosis of endometrial cancer
Endometrial Biopsy during D&C
-
Treatment for endometrial Cancer
- Total hysterectomy + Bilateral Salpingoophorectomy + LN dissection
- +/- RadioT and ChemoT
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DDx for Post Menopausal Bleeding
- Atrophic Vaginitis
- Vaginal trauma
- Vaginal infectoin
- Cervical atrophy
- Cervical polyp
- Cervical cancer
- uterine polyp/fibroid
- Endometrial atrophy
- Hyperplasia
- Endometriosis
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General checklist for post-operative care
- Monitor vitals for 24hours
- Analgesia
- Fluid maintenance balance whlist NGT?
- IDC
- DVT prevention (stockings, leg physio)
- Check wound sites
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Reccurent bleeds following endometrial cancer surgery causes
- Vaginal atrophy
- vaginal infection
- Vault carcinoma recurrence
- Vault Granulation
- Bladder infection
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Investigaoins to cary out with continuous bleeds following endometrial cancer surgery
- FBC,
- urine MCS
- PEx speculum bimanual
- vaginal swab
- PR
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What is the MC cause of PMB and what is treatment
- vaginal atrophy
- loss of rugae
- increased redness, dryness
- reduced exudate
Topical Oestrogen
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Woman presents with pelvic pain to ED. What to do
- 1. ABC
- shock? BP, HR, T
- IM morphine if not contraindicated
- 2. Further history
- Nildocaaf
- Period Hx - LMP, menarche, period cycle length, spotting, pain, contraception,
- Sexual Hx - contraception, partners, dysparenuria
- Pregnancy Hx -
- Papsmear Hx -
- 3. Ix
- FBC
- biochem
- bHCG
- Urine MCS
- DNA cervical swab (Gon, CHlamyd)
- USS pelvis (uterus, adnexal masses, Doppler blood fow, Inflammatory reactors)
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Pelvic Pain DDx
- PID
- accute apendicitis
- ovarian cyst
- threatened abortion
- ectopic
unlikely - bowel issues (colic, IBS,) acute cystitis
-
MC STD?
S&S
Detection
- Chlamydia
- PCB, IMB, discharge
urine MCS, endocervical sample
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Common places for Ectopic Pregnancy
- Fallopian tube 95% (Ampulla, isthmus, fimbirae, interstitium)
- Ovaries
- Peritoneal cavity
-
RFs/Aetiology for ectopic
- Tubal diseases (PID/Chlamyd)
- previous ectopic
- previous tubal surgery
- subfertility
- IUD
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Spontaneous abortion frequency
MC cause
MC weeks to occur in
20-24%
- most likely due to chromosomal abnormlaities, however exact is unkonwn
- Most commonly in middle first trimester
-
some pain to the shoulder, previous use of IUD, has not got menstrual period as expected
possible ectopic pregancy (ruptured)
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PEx to be carried out if suspecting threatened pregnancy, miscarriage, ectopic or molar
- Obs - Shock?
- bimanual - cervical excitement, fornices pain,
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Investigations to perform if suspecting threatened pregnancy, miscarriage, ectopic or molar
- Obs - shock?
- FBC,
- Hb and group&hold
- bHCG quantitative (multiple reads)
- TVS - visible sac (@4.5weeks), HR (@5weeks), free fluid within peritoneal cavity (ruptured ectopic)
checking for high hCG against no sac/HR visible
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Management of miscarriages
- Hx
- PEx - BP, T, HR, bimanual
- Ix
- Hb + group&hold
- bHCG and quantitative hCG
- TVS - location
- expectant wait
- surgical management
- medical (misoprostol or PV gamepostrol with mifepristone Progesterone antagonist)
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Miscarriage RFs
- advanced maternal age (pooor quality eggs)
- medical/endocrine disorddres
- uterine/chromosomal abnomralities
- infections,drugs,chemicals
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Gestational Trophoblastic disease types
- Complete Hydatidiform
- Partial Hydatidiform 46XXY. XYY, XXX
- Malignant GTD
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Gestational Trophoblastic disease S&S
- usual - PV bleed, pain
- increased uterus size, very high bHCG, hyperemesis gravidarum, big theca-lutein cells
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Gestational Trophoblastic disease treatment
- suction D&C
- ?hysterectomy
- rho-Gram antibodies against Rh + blood cells from fetus
- F/U
- Contraception during treatment
- Serial bHCGs until bHCG dropping for 6/12 monthly. plateua or increasing warrants investigations
- investigations for persistent bHCG -
- full works - FBC, U+E, Cr, bHCG, TSH, LFTs
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Malignant GTN or GTD types
- invasive mole, persistent GTD
- Choriocarcionma
- placental sitaion of trophoblastic cells
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Hyperemesis Gravidarum
6-8 week mark most common
- non-pharma
- smaller, more frequent meals,
- don't mix solids and fluids
- stop prenatal vitamins apart from folic acid
- increse sleep n rest
rehydrate patient
- Pharma - Metoclopramide (class A) + Vit B6 Restivite
- Ondansetron (class b) VSDs etc
- Steroids - cleft palate
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Chlamydia First line treatment
Azithromycin 1g Stat
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Gonorrhoea 1st line treatment
Ceftriaxone 500mg IM stat in 2ml 1% lignocaine
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UTI - first line treatment
- Trimethorim 300mg daily for 14/7.
- cephalexin 500mg BD for 14/7
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PID first line treatment
- Doxycycline 100mg BD 14/7
- + Metronidazole 400mg BD for 14/7
- + azithromycin 1g stat
- + (if gonorrhea) Ceftriaxone 500mg IM stat in 2ml 1% lignocaine
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Herpes treatment 1st line
Acyclovir 400mg TDS for 5-10/7
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Essential HTN can lead to what in gestation
- Gestational HTN
- Abruptio placenta
- IGUR
- IU fetal demise (IUFD)
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Clinical evaluation of HTN in pregnancy
mother and fetus
- mother:
- body weight/BMI
- CNS - headache, visual disturbances, reflexes, irritabilty
- Bleeding, petechaie
- RUQ/epigastric hepatic pain, N + V
- UO and color
- non-dependednt oedema
Fetus:
- fetal movement
- Fetal HR
- Growth serial scans
- Biophysical profile
- Doppler studeies
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Lab evaluation of gestational HTN (think of clinical evaluation)
- bleeding - Hb, platelets, blood fild, PTT, INR, fibrinogen, D-dimer
- liver - ALT, AST, LDH, bilirubin
- kidneys - proteinuria, creatinine, uric acid
- 24 hour collection for total protein and Creatinine clearance
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Mgmt of HTN in pregnancy
not ACEi, diuretics, propanolol
- Methyldopa PO 250-500mg TDS, QDS
- or
- Labetalol 100-300 mg PO BD or TDS
- or
- Nifedipine 30-50mg PO OD
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Pre-eclampsia? what is it
- HTN (pre-existing or gestational) with NEW onset of PROTEINURIA
- continue if normal, may be delivering 34-36 mark depending on fetal size etc
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Management of Pre-eclampsia
Immediate reduction of BP
- Hyrdralazine 5-10mg IV bolus over 5min, q15-30min
- Labetalol 20-50mg IV q10min or Nifedipine 10-20mg PO q20-60min
Prevent seizure
- MgSO4
- Contineu and manage for 12-24hrs post=partum cos highest risk of seizure
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Pre-cclamspia clinical investigations checklist
check bleeding - FBC, INR, aPTT
check liver - liver enzymes, LDH, bilirubin, albumin
Check urine - Cr, Uric acid, Urine Dip collection +24hr
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Eclampsia definition
- occurence of at least 1 generalised convulsion (60-70secs) in setting of pre-eclampsia in absence of other nruo conditions
- 2-3% of severely pre-eclamptic women.
-
Eclampsia managemet
- ABC
- roll patient to LLDP
- Oxygen (hypoventilation during convulsion)
- anti HTN therapy _ Hydralazine
- MGSO4 to prevent further seizures
DEFINITIVE TREATMENT - delivery of baby, irrespective of GA, due to risk of maternal morbidity
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DDx for seizure in pregnancy
- stroke
- hypertensive disorder
- SOL in CNS
- Hypoglycaemia
- TTP
- illicit drugs
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MgSO4 toxicity
hyporeflexia, flushing, cardiorespiratory depreession, weakness, somnolence
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Why UTI more common in pregnancy?
why treat asymptomatic UTIs in preganncy
increased urinary stasis from progesterone and mehcanical factros
increased risk of progession to cystitis, pyelonephritis and increased risk of pre-term labour.
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treatment of UTI in pregancy
- uncomplicated
- 1st line - amoxcilicin 250-500mg PO
Pyelonephritis - admit and IV antibiotics.
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T1/T2 bleeding investigations
- B-hCG --> lower than expected if spontaneous abortion of ectopic
- US - confirm iuntra-uterine pregnancy and fetal viability
- FBC
- Group n hold
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Clinical features of ectopic pregnancy
- Temperature
- Tenderness - abdominal
- Tenderness - bimanual
- Tissue - palpable adnexal mass (50%)
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If ectopic pregnancy ruptures
- acute abdomen with increasing pain
- abdominal distension
- shock
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ectopic pregnancy risk factors
- Previous ectopic
- gyne causes: IUD, PID, Salpingitis, Infertility, Clomiphene citratie (used for ovulation)
- Previous procedures: ectopic removal/tubal ligation, abdo surgeries, IVF pregnancies + induction
- smoking
- abnormal uterus.
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ectopic pregnancy investigations
- serial B-hCG levels, non-doubling.
- US checking for when serum B-hCG >1500 TVUS or bHCG>6000 Transabdomial US
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Ectopic pregnancy Treatment
Conservativ, maintain haemodynamic stabilitiy
- Surgical lap
- - salpingostomy
- salpingectomy
- Monitor B-hCG for weeks until non-detectable
- consider Rhogram
MethoTreXate if small unruptured ectopic with no hepatic/renal dysfunction
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Antepartum Haemorrhage definition:
what to asks
Vaginal bleeding from 20wk to term
- how much bleeding?
- Description of colour, clotting
- Contractions/cramping present?
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DDx for antepartum haemorrhage
- Placenta praevia, Abruptio PLacentae (MC pathological)
- Vasa Praveia
Shedding of cervical mucous plug (MC normal)
- Cervical lesion
- Uterine rupture.
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What hormones could indicate the completion of menopause
- FSH (increased)
- Oestradial (decreased) - hence osteo
- Inhibin B (decreased)
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Investigations to carry out in the clinical evaluation of a menopausal woman
- FSH, oestradial,
- Serum androgens (free androgen index)
- TSH
- lipids, glucose
- chem 20
TVUS
- BMD + Hydroxy vit D
- pap
- mammogram
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Premenopausal diagnosic criter
PM is diagnosed with amenorrhea <4 months, in a less than 40 year old, with FSH readings >40 on 2 separate occasions.
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Bleeding in a patient on HRT; what to do
- reassure if within first 12 months, normal.
- however after 12 months, needs investigations for pathology.
- TVUS - uterine pathology
- +/- endometrial biopsy
again, breakthru bleeds are expected on sequential HRT>
-
on HRT,
persistent mastalgia, N+H,
what to do
- reduce oestrogen dose,
- or switch to transdermal
- or switch to tibolone
-
on HRT,
PMS type symptoms - what to do
reduce progesterone dose or switch progestogen type
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which type of HRT suits
Cause of menopause (natural vs surgical)
Urogenital symptoms are main issue
Smoking status
Hepatic or concurrent disease present
- hysterectomy - no uterus, therefore ET alone is good - ET alone is not as bad as EPT for breast cancer, CHD, VTE.
- Urogenital only - dryness, atrophy, dysparenuria, - oestrogen cream
smoking status - OCP not recommended, DVT risk
Hepatic or concurrent - patches
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Is tibolone suited best for everyone with cancers
- Tibolone - synthetic steroid with androgenic, progestogenic, oestrogenic properties, reduces cancer risks in all BUT those with previous breast cancer.
- HIgher risk of recurrence if previously treated for breast cancer c.f. control
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What are some non-hormonal alternatives for relieving vasomotor symptoms
- gabapentin
- venlaxafine
- paroxetine - caution in women with tamoxfen + breast cancer
- clonidinee
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Which weeks of T1 are highly susceptible to teratogens
weeks 2-8 post-concentpion = the embryonic periods where fetal organs are developing
weeks 0-2 (conception to 2 weeks post) there is an all-or-none survival or death mechanism.
Fetal period (K9-) fetus is less susceptible to teratogens, but drug toxicieities, behavioural teratogenicity (vision, hearing, neurodevelopment) and vascular insults (IUGR) can be caused.
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when is N+V most common
- occurs in K5-6,
- peaks at K8
- by K12 60% of vomiting has resolved
-
what is hyperemesis gravidarum
intractable vomiting resulting in dehydration, weithg loss, electrolyte imbalance
may require hospitalisation and IV fluid rehydration.
-
what hormones influence vomiting?what invesitgations should be performed
- bHCG
- hence higher in twin pregnancies, molar pregnancies
- TVUS can help.
-
what investigations would be performed for hyperemesis gravidarum
- serum electrolyes - K, Na
- FBC - Increased haematocrit concentration due to depeletded plasma volume
- LFTs - transaminase elevation, check jaundice
- TSH - only TSH lowered and T4 should be raised, not T3 and T4 and reduced TSH (true hyperthyoidism)
- US - multiple pregnancy or GTD
-
what advice to avoid vomiting
- conservative
- avoid spicy food, fatty foods, caffienes
- increase hydration
- eat small amounts, small snacks
- eating before rising
-
anti N + V medications
- Vit B6,
- ginger,
- antihistamines
- dopamine antagonists,
- phenothiazines
- metoclopramide.
-
Steroids help in refractory cases, but why not used genearlly
methylprednisolone is associated with cleft lip/palate before K10, with 3-4 fold increase
-
what would be indicatioins for hospitalisation
- significant dehydration
- inability to tolerate PO
- 2+ ketonuria in the setting of hyperemeiss.
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GORD reasoning in rpegnancy
- increased PG
- thus, reduced LOS pressure, incerased intra-gastric pressure, reduced pyloric sphincter tone
- increased gastric pressure - worsens from T1 to T3.
-
Main medication for GORD
worry in pregnancy
- antacid
- Fe needs acid for absorption - thus Fe deficiency should watch outn
- Alginates - barrier added
- H2receptor antagnosits
- Promotility - metoclopramisde
- PPIs - omperazole is B3.
-
Uterine fibroids occur in how many
20-40% of women of repro age
-
aetiolgoy of pain due to fibroids in pregnancy
- impaired fibroid perfusion
- vessel occlusion or fibroid volume too much with growth
- inflammatroy process producing CKs and Prostaglandins and thus cellular injury.
-
WHen is pubic symphisitis most common
K10-12 when the high relaxin concentrations cause widening of the symphysis pubis.
-
how common is bleeding in pregnancy
in T1- 20-40%
-
what are the serious causes of bleeding in pregnancy
- threatened
- actual M/C
- GTD
- PLacenta preavia
- Placental abruption
- Prematuer labour
TVUS done at first triage.
-
in triage with PV bleed during pregnancy, what are you hoping for
- patient stable
- no adnexal masses
- no intraperitoneal bleeing sigsn
- fetal heart sounds on TVUS or abdominal.
-
when is abstinence from coitus recommended in prengnayc
- wommen at risk for PTL
- antepartuum haemorhage because of praevia
-
why is cervical bleeding more common in pregnancy
- stromal oedema
- increased vasularity
- enlargement of glandurlar structures.
-
what organisms cause cervicitis
- Chlamdyia 50%
- N. gonorrhea
- Trichomonas vaginalins,
- HSV type 2
- HPV.
-
what is the empirical treatment(s) for cervicitis
- azithromycin or
- ceftriaxone or metronidazole
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Risk factors for Pre-term delivery
- Previous PTL delivery, or late miscarraiage
- multipregnancy
- cervical surgery
- uterine anomalies
- Pre-eclampsia and IUGR
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