Obs + Gynae - Misc Flashcards by Hugh Brookes

Name the 5 criteria for a screening programme

) The condition - should be an important health problem
) The test - simple, safe, precise, validated, accepted by population
) The intervention - effective intervention with evidence of better outcomes
) Screening programme - RCT evidence + clinically, socially, ethically acceptable
) Implementation criteria - quality standards, adequately trained staff

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Between which vertebrae is epidural given?

L3/4

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The APGAR score is used to assess health of newborns. What does APGAR stand for?

Appearance (skin colour)
Pulse
Grimace (reflex irritability)
Activity (muscle tone)
Respiration
=>A score of 0-3 is very low score, between 4-6 is moderate low and between 7 - 10 means the baby is in a good state

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A 28-year-old woman is admitted to the labour ward at 38+4 weeks gestation. This is her first pregnancy and she tells you that contractions started around 10 hours ago. On examination, her cervix is positioned anteriorly, is soft, and is effaced at around 60-70%. Cervical dilatation is estimated at around 3-4cm and the fetal head is located at the level of the ischial spines. She has had no interventions performed as of yet.

What is her Bishop’s score?

Cervical position - Anterior = +2
Cervical consistency - Soft = +2
Cervical effacement - 60-70% = +2
Cervical dilation - 3-4cm = +2
Fetal station - 0 = +2
Overall = 10 (A Bishop's score of ≥ 8 indicates that the cervix is ripe, or 'favourable' - there is a high chance of spontaneous labour, or response to interventions made to induce labour)

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Name one risk and one benefit of using HRT for menopause

risks: breast cancer, VTE, CVS disease, stroke
benefits: relief of Sx, bone mineral density, prevents long term mobidity

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When is the first, second and third stage of labour?

The first stage is from the onset of labour (true contractions) until 10cm cervical dilatation.
The second stage is from 10cm cervical dilatation to delivery of the baby.
The third stage is from delivery of the baby to delivery of the placenta.

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What are the seven cardinal movements of labour?

Descent
Engagement
Flexion
Internal Rotation
Extension
Restitution and external rotation
Expulsion

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What are the three phases of the first stage of labour?

Latent phase: From 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
Active phase: From 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
Transition phase: From 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.

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After giving birth, women require contraception after what day?

Day 21

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Adverse effects and one contraindication of injectable contraception (Depo-provera)

Adverse effects

irregular bleeding
weight gain
may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable
not quickly reversible and fertility may return after a varying time

Contraindications
- breast cancer: current breast cancer is UKMEC 4, past breast cancer is UKMEC 3

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Intrauterine device must be inserted how long after last unprotected sexual intercourse?

within 5 days of UPSI, or

- within 5 days after the likely ovulation date if a women presents after more than 5 days after last UPSI

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Levonorgestrel must be taken how long after last unprotected sexual intercourse?

(asap) within 72 hours after last UPSI

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Ulipristal must be taken how long after last unprotected sexual intercourse?

(asap) within 120 hours after last UPSI

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The intrauterine device or intrauterine system can be inserted how long after childbirth?

48 hours after childbirth or after 4 weeks

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Oestrogen-containing contraceptives should preferably be discontinued 4 weeks before major elective surgery and all surgery to the legs or surgery which involves prolonged immobilisation of a lower limb.

What may be offered as an alternative while the oestrogen-containing contraceptive can be restarted after mobilisation?

Progesterone-only pill

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Why should the COCP not be used in the first 21 days postpartum?

risk of VTE

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Which form of contraception works by inhibiting ovulation?

COCP

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Women need to use effective contraception for how long after their last menstrual period?

Two years after the last menstrual period in women under 50
One year after the last menstrual period in women over 50

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What are good contraceptive options (UKMEC 1, meaning no restrictions) for women approaching the menopause?

Barrier methods
Mirena or copper coil
Progesterone only pill
Progesterone implant
Progesterone depot injection (under 45 years)
Sterilisation

(The combined oral contraceptive pill is UKMEC 2 (advantages generally outweigh the risks) after aged 40, and can be used up to age 50 years if there are no other contraindications)

TIP: It is worth making a note and remembering two key side effects of the progesterone depot injection (e.g. Depo-Provera): weight gain and reduced bone mineral density (osteoporosis). These side effects are unique to the depot and do not occur with other forms of contraception. Reduced bone mineral density makes the depot unsuitable for women over 45 years.

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Name some contraindications for the COCP

Examples of UKMEC 3 conditions (disadvantages outweigh advantages):

more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
current gallbladder disease

Examples of UKMEC 4 conditions (unacceptable health risk):

more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation

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The combined oral contraceptive pill (COCP) contains a combination of which hormones?

Oestrogen and progesterone

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COCP is licensed up to what age?

50 years

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What is ‘withdrawal bleeding’ and ‘breakthrough bleeding’?

When the pill is stopped the lining of the uterus breaks down and sheds. This leads to a “withdrawal bleed“. This is not classed as a menstrual period as it is not part of the natural menstrual cycle.
“Breakthrough bleeding” can occur with extended use without a pill-free period.

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Name a regime for taking COCP

21 days on and 7 days off
63 days on (three packs) and 7 days off (“tricycling“)
Continuous use without a pill-free period

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Side effects and risks of COCP

- Unscheduled bleeding is common in the first three months and should then settle with time - Breast pain and tenderness - Mood changes and depression - Headaches - Hypertension - Venous thromboembolism (the risk is much lower for the pill than pregnancy) - Small increased risk of breast and cervical cancer, returning to normal ten years after stopping - Small increased risk of myocardial infarction and stroke

COCP reduces risk of which cancers?

Reduced risk of endometrial, ovarian and colon cancer

What do you need if you start COCP after day 5 of the menstrual cycle?

``` Extra contraception (i.e. condoms) for the first 7 days of consistent pill use before they are protected from pregnancy (Ensure the woman is not already pregnant before starting the pill) ```

Should there be a pill-free period between switching COCPs?

When switching between COCPs, finish one pack, then immediately start the new pill pack without the pill-free period.

How long after last COCP pill was taken to be classified as a 'missed pill'?

48 hours since last pill taken (Missing one pill is when the pill is more than 24 hours late)

What to do if one pill is missed (less than 72 hours since the last pill was taken)?

- Take the missed pill as soon as possible (even if this means taking two pills on the same day) - No extra protection is required provided other pills before and after are taken correctly

What to do if one pill is missed (more than 72 hours since the last pill was taken)?

- Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day) - Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight - If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex - If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required - If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period.

How long should you stop taking COCP before major operation?

4 weeks

What is the only UKMEC 4 criteria for the POP?

active breast cancer.

Traditional vs Desogestrel - How long after last pill was taken to be classified as a 'missed pill'?

- Traditional progestogen-only pill cannot be delayed by more than 3 hours. Taking the pill more than 3 hours late is considered a “missed pill”. - Desogestrel-only pill can be taken up to 12 hours late and still be effective. Taking the pill more than 12 hours late is considered a “missed pill”.

When in menstrual cycle should POP be started and how long is additional contraception required?

- Day 1 to 5 of menstrual cycle | - Additional contraception is required for 48 hours

How long after starting COCP is a woman protected from pregnancy?

7 days

Should there be a pill-free period or additional contraception between switching POPs?

No, POPs can be switched immediately without any need for extra contraception.

How long after last POP pill was taken to be classified as a 'missed pill'? (+ what to do if late?)

A pill is classed as “missed” if it is: - More than 3 hours late for a traditional POP (more than 26 hours after the last pill) - More than 12 hours late for the desogestrel-POP (more than 36 hours after the last pill) - The instructions are to take a pill as soon as possible, continue with the next pill at the usual time (even if this means taking two in 24 hours) and use extra contraception for the next 48 hours of regular use. Emergency contraception is required if they have had sex since missing the pill or within 48 hours of restarting the regular pills.

How does Progestogen-Only Injection inhibit ovulation?

inhibits FSH secretion by the pituitary gland, preventing the development of follicles in the ovaries.

How often is the Progestogen-Only Injection required?

Women need to have injections every 12 – 13 weeks

Starting Progestogen-Only Injection after day 5 of the menstrual cycle requires extra contraception (e.g. condoms) for how long before the injection becomes reliably effective?

seven days

Progestogen-Only Injection side effects and risks

- Irregular/abnormal bleeding - Weight gain - Acne - Reduced libido - Mood changes - Headaches - Flushes - Hair loss (alopecia) - Skin reactions at injection sites - Reduced bone mineral density (osteoporosis) is an important side effect of the depot injection. (Oestrogen helps maintain bone mineral density) - The depot injection may be associated with a very small increased risk of breast and cervical cancer. TIP: The two side effects that are unique to the progestogen injection are weight gain and osteoporosis

How long does the Progestogen-Only Implant last?

3 years

What is the name of the implant used in the UK?

Nexplanon

When is contraception required after implant removed or impalpable?

Immediately

Contraindications for IUD or IUS

- Pelvic inflammatory disease or infection - Immunosuppression - Pregnancy - Unexplained bleeding - Pelvic cancer - Uterine cavity distortion (e.g. by fibroids)

How long after IUS/IUD insertion are women seen to check threads?

Women need to be seen 3 to 6 weeks after insertion to check the threads. They should be taught to feel the strings to ensure the coil remains in place.

What should women avoid / for how long before the coil is removed?

Before the coil is removed, women need to abstain from sex or use condoms for 7 days, or there is a risk of pregnancy

Copper coil IUD is notably contraindicated in which disease?

Wilson’s disease (Wilson’s disease is a condition where there is excessive accumulation of copper in the body and tissues)

Copper IUD is licensed for how long after insertion?

5-10 years

Mirena is effective for how long?

5 years

LNG-IUS can be inserted up to what day of the menstrual cycle without any need for additional contraception? (+ If inserted after day 7, extra protection is required for how long?)

The LNG-IUS can be inserted up to day 7 of the menstrual cycle without any need for additional contraception. If it is inserted after day 7, pregnancy needs to be reasonably excluded, and extra protection (i.e. condoms) is required for 7 days.

What are the three options for emergency contraception? | + how long can you use each after last UPSI?

- Levonorgestrel should be taken within 72 hours of UPSI - Ulipristal should be taken within 120 hours of UPSI - Copper coil can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation

Which is the most effective type of emergency contraception?

Copper coil

What day would ovulation occur in a 31 week menstrual cycle?

day 17 (14 days before end)

There is a small increased risk of what condition after the insertion of an intrauterine device (IUD)?

PID

Side effects of Levonorgestrel vs Ulipristal

Levonorgestrel: - Spotting and changes to the next menstrual period - Diarrhoea - Breast tenderness - Dizziness - Depressed mood Ulipristal - Spotting and changes to the next menstrual period - Abdominal or pelvic pain - Back pain - Mood changes - Headache - Dizziness - Breast tenderness

Breastfeeding is avoided for how long after taking Levonorgestrel to reduce the exposure to the infant?

8 hours

How long should you wait before starting the combined pill or progestogen-only pill after taking ulipristal?

5 days

Breastfeeding is avoided for how long after taking Ulipristal to reduce the exposure to the infant?

1 week

Ulipristal should be avoided in patients with what respiratory condition?

Severe Asthma

Time untill effective for IUD, POP, IUS, COCP?

IUD - Instant POP - 2 days COCP + IUS - 7 days

What secretes hCG?

Human chorionic gonadotrophin (HCG) is secreted by the syncytiotrophoblast into the maternal bloodstream, where is acts to maintain the production of progesterone by the corpus luteum in early pregnancy

What is first-line treatment for a small (<35mm) unruptured ectopic pregnancy with no visible heartbeat, a serum B-hCG level of <1500 IU/L, no intrauterine pregnancy and no pain

Methotrexate (No Misoprostol in ectopic!)

All breech babies at or after 36 weeks gestation require what investigation after delivery?

USS for DDH screening at 6 weeks regardless of mode of delivery

Obs + Gynae - Misc Flashcards

(65 cards)