AMCQ OG.docx

7/30/2019 AMCQ OG.docx

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OC Pill** Usually recommended (1stchoice) a preparation containing 20-30g ethinyl oestradiol(monophasic pill) Pt with extensive fluidretention best to use preparation containing drospirenone (yasmin)

(Drospirenone analogue of the diuretic spironolactone) Pt with suspected PCOS best with preparation containing cyproteroneacetate(Brenda-35

ED,Diane-35 ED)

(cyproterone is less androgenic) Pt with migraine with aura or neurological deficit OCP containing oestrogen and progesterone are

contraindicateduse barrier method of contraception, POP

(levonorgestrel,norethisterone) Implanon is contraindicated in obese pt Pt with acne less androgenic progestogen(eg Diane-35 ED, Marvelon) Pt with epilepsy COC with high oestrogen (eg 50g)(Nordette 50, Microgynon 50)

Missed pillsSeven-day rule

Take the forgotten pill as soon as possible and take the next pill at the usual time and finish course If forget for >12hrs a/f the usually time, there is an increased risk of pregnancy, so use another

contraceptive methods (s/as condoms) for 7days If these 7days run beyond the last hormone pill in yr packet, then miss out on inactive pill (or 7day gap)

and proceed directly to the first pill on next packet You may miss a period (at least 7 hormone tablets should be taken)

Other rules Two for twenty or three for thirty

Two or more 20g EO pill Three or more 30-35g EO pill

take the most recent missed pill ASAP continue taking remaining pills use condoms or abstinence until pill is taken for 7consecutive days if missed pills are in week three omit the pillfree interval (7days)

HRT for menopause cyclical hormone therapy(daily oestrogen with medroxy progesterone acetate (MPA))

use in perimenopause with irregular cycle(has preditable periods which commences abt 2days afterprogetogen course has been completed )

continuous therapy with oestrogen and MPA best not given within 1-2yrs of the last periodbecause of high risk of breakthrough bleeding

oestrogen alone should not be given to a woman who still have a uterus( for pt with nouterus(hysterectomy))

progestogen alone should not be given unless contraindicated to oestrogenfor menorrhagia give progestogen continuously daily Medroxyprogesterone or norethisterone

HRT and AD(Alzheimer d/s) HRT given at the time of menopause reduce the decline in cognitive function (early manifestation of

AD) HRT given at 60-65yrs increased AD incidence HRT does not reduce the rate of progression of AD or make advanced d/s less severe

Most common primary site for 2 CA ovary CA breast in underdeveloped countries (lack of mamograpy screening) CA stomach in Japan (high incidence) CA colon in Australia (do colonoscopy for dx)

LH level


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Mildly elevated in PCOS rarely exceed 30mIU/ml Mid-cycle elevation 100-150mIU/ml Pregnancy >200mIU/ml

Pregnancy Serum prolactin upper normal range (early pregnancy) FSH low normal range

Ascites(250ml to detect)

On examination central resonance(gas containing bowel float to centre) peripheral dull(d/tfluid)

For ovariancyst central dull peripheral resonance (d/t displaced bowel to peripheral)Rupture ovarion cyst **

Cyst tend to rupture pirior to ovulation or following coitus Pt usu 15-25yrs Sudden onset of pain in one or other iliac fossa(deeppain)

pain shift from lateral to central heavy feeling in pelvic

May be N & V Pain usually settles within a few hrs Signs tenderness and guarding within a few hrs PR tenderness in rectovaginal pouch InVx US +/_ colour Droppler M/Mx

Explain and reassurance Conservative simple cyst


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Avoid various drugs(eg diuretics, psychotropics, alcohol) Wt reduction if obese It is important to exclude UTI and define exact cause of the incontinence by urodynamic

studies b/4 embarking on Sx Tx of any asso: prolapsed or medical tx of possible urgeincontinence

Infertility Semen analysis Normal : volume >2ml

Concentration >20million sperm/ml

Motility > 50% after 2hrs

Normal forms >20%

Osteoporosis**T score

0 to -1 normal -1 to -2.5 osteopenia(risk of later osteoporotic fracture, offer lifestyle advice) < -2.5 osteoporosis (i.e > +2.5 SD) -2 4time increased risk of fracture

-2.5 5time incrased risk of fractureBld InVx Ca, PO4 and alk phos are normal

Tx 1st line biphosphonate (alendronate)Prevention?(GP)

use oestrogen only therapy for women without a uterus if uterus is present, combined oestrogen-progestogen therapy (cyclical or continuous) avoid giving progestogen in the presence of continuing ovarian activity Ca supplement is ineffective without oestrogen supplement therapy Need 1-1.5g for post-menopause *HRT is no longer liscensed for the prevention of osteoporosis, consider raloxifene(a selective

oestrogen r/c modulator)(which decrease breast CA; it is related to tamoxifen) or bisphosphonate.

(fr; OXfD sp)?Vaginal bleeding before 20 wks of gestationAbortion pregnancy vaginal blding ut:cramping Cx dilatation M/MxMissed nonviable _ _ _ D&C,wait,Misoprostol

Threatened viable + _ + Observe

Inevitable nonviable + + +(no POC) Ex suction D&C

Incomplete nonviable + + +(part of POC) Ex suction D&CComplete nonviable + + +(all POC) Conservative, serial

hCG

Most appropriate next step Vaginal US (to differentiate)A/f 20wks fetal demise

A/f onset of labour still birth

Ectopic pregnancy** Amenorrhoea Abdominal pain Vaginal bleeding Cx closed and uterine size is smaller than expected C/F may absent and may present only with diarrhoea and vomiting or nausea and dizziness Almost certainly have become evident prior to 15wks of gestation (except abdominal ectopic and

interstitial pregnancy)

Cervical incompetence


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Cx is opened Uterine size would be as expected for pregnancy

Antepartum Haemorrhage (>24wks of gestation)Placental abruption** placental previaShock out of keeping with visible loss shock in proportion to visible lossPain constant No pain

Tender,tense uterus Uterus not tenderNormal lie and presentation Both may be abnormal

Fetal HR: absent/distressed Fetal HR usually normal

Coagulation problems Coagulation problems rare

Beware pre-eclampsia,DIC,anuria small bleeds before large

M/Mx of placenta abruption

When the baby is dead, CS is rarely performed in Australia and appropriate tx is to expedite delivery.

Tx the shock and exclude (or tx) any coagulation d/o

Amniotomy is all that requiredSpontaneous labor almost always follows the amniotomy.

M/Mx for PROM (at 26wks)

1 Cervical swab to exclude infection and prophylactic Antibiotics2 Glucocorticoid Tx for 48hrs, to improve fetal lung maturity and to reduce intracranial blding3 Transfer to the tertiary centre4 Assessment ofWCC and CRP every 2-3 days looking for evidence of intrauterine infection5 CTG assessment of fetal HR every 2-3days6 Contraction-inhibiting drugs s/as salbutamol or nifedipine if uterine contraction occur beforethe glucocorticoid tx is completed, rarely used after that time. In the absence of infection,

prolonging the pregnancy and delaying the delivery is the objective

GBS infection in pregnancy

About 15-20% of women Most are asymptomatic Give the antibiotics to all screened positive women in labour(parenteralpenicillin given six-hrly) and tx

the baby as well if any signs of possible infection +

Most babies do not require antibiotics txPremature delivery

Risk factor Increased uterine size (fetal macrosomia, polyhydraminos and multiple pregnancy) Shorted cervix (esp: < 1.5cm in length)


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Open cervix (esp: when internal os is opened) Evidence of Bacteria vaginosis Previous premature delivery

When fetal fibronectin test is positive, even when the cervix is closed, risk of premature delivery ismarkedly increased

It is the confirmatory test , -ve predictive value 100% Candida or BV infection + other factors(past h/o or Cx open)

Down $ screening

Definitive dx can be obtained by CVS Amniocentesis Cordocentesis

Lowest risk of miscarriage is Amniocentesis performed at 16wks of gestation CVS is at least twice risk Cordocentesis is rarely done and even higher risk

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AMCQ OG.docx