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camilledubuisson
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Created on 31 January 2024

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presentation of pre-eclampsia

headache, vision changes, vomiting,

epigastric pain, swelling of
hands/feet/face, proteinuria and
BP>140/90

Mx pre-eclampsia

risks of pre-eclmpsia

refer to specialist <24 hours.

Stop ACEi, ARBs, thiazide diuretics

those with HTN from previous pregs ->

aspirin 75mg from week 12

CKD, DM, AID, HTN

first line for pre-eclampsia

140/90 or higher

2nd

labetolol hydrochloride 100mg BD

2nd: nifedipine 10mg? if asthmatic

BP >160/110 in preg

emergency Tx with oral or IV labetolol

OR hydralazine hyrochloride or oral

nifedipine

preg women who have

previously had a eclamptic
fit/sebere pre eclampsia

magnesium sulfate IV 4g over 5-15 mins ->

1g/hour over 24 hours

Tx of fit same as above

post natal hypertension

enalapril maleate 5mg OD

hypertension Tx in breastfeeding

enalapril maleate 5mg OD PO BUT

monitor renal func and K

african caribbean pts: nifedipine 10mg

menstruation cycle

follicular phase (day 1-14, menstruation is

day 1-7), ovulation (day 14), luteal phase
(14 to 28)

oestrogen causes endometrial growth,

progesterone maintains it, LH causes
ovulation and FSH causes growth of egg

best measure of ovulation

serum progesterone 7 days after ovulation

(or 7 days before the end of the cycle),
therefore in a normal 28 day cycle, this will
be on day 21

ie in 35 day cycle, this will be day 28

Presentation of endometriosis

subfertility, dyspareunia (pain with sex),

dysmenorrhea, chronic pelvic pain. May
have GI/urinary symptoms: dysuria,
urgency, haematuria

**Usually have chronic pain with this

condition

Ix endometriosos

laparoscopy is gold standard

Mx of endometriosis

suppressing ovarian function

pain: paracetamol and NSAID 1st line ->

pain ladder

hormonal Tx for COC or progesterone

fertility a priority -> 2ary care for GnRH

analogues -> surgery

surgery to remove ectopic

tissues

laparoscopic excision or ablation,

hysterectomy

Presentation of PCOS

Oligomenorrhoea or amenorrhoea
subfertility
Obesity (in about 70% of patients with
PCOS)
Hirsutism
Acne
Hair loss in a male pattern
insulinaemia, raised LH

Ix PCOS

pelvic USS, FSH, LH, prolactin, TSH,

testosterone

raised LH:FSH is feature

prolactin/testosterone may be raised

glucose tolerance

how to diagnose PCOS

Rotterdam criteria
2/3 of following criteria are met
-infrequent/no ovulation
(oligomenorrhoea)
-clinical/biochem signs of
hyperandrogenism
-polycystic ovaries on USS

Mx of PCOS

COCP for acne, hirsutism, menstrual irreg

metformin by specialist: impaired glucose

tolerance

hypothalamic pituitary ovarian

axis

- hypothalamus releases GnRH which

stimulates anterior pituitary to release FSH
and LH
- FSH stimulates ovarian estrogen
production, whereas LH stimulates
ovulation
- estrogens stimulate proliferation of
endometrium
- progesterone (produced by corpus
luteum) stimulates endometrial secretion
and prepares uterine lining for embryonic
implantation

ovary produces oestrogen (-ve feedback

effect) and progesterone

testosterone?

converted to oestrogen by aromatose in

fat cells

-> overweight = heavy periods and

endometrial cancer

mentrual cycle

preperation of the uterus for pergnacy

which part of the menstrual

cycle is variable

proliferative phase, luteal phase is usually

set at 14 days

what causes ovulation

what does oestrogen do

what does progesterone do

what happens during menses

LH surge

builds lining

maintains lining

progesterone stops (corpus luteum gone)

What does a pregnancy test

detect?

HCG (human chorionic gonadotropin)

mechanism of menstruation

spasm of spiral aterioles -> extravasation

and endometrial shedding -> fibrinolysis
spills fibrinogen preventing clotting

when does division occur in the

oocyte

1st meiotic division: time of ovulation

(becoming 2ary oocytes)
2nd: after fertilization

what causes menopausal

symptoms

decreased oestrogen

causes of delayed menarche

imperforate hymen
-may lead to build up of blood in vagina
(haematocolpos)

vaginal agenesis
-no development of vagaina
-intermittent abdo pain
-palpable swelling
-bulging bluish membrane at lower end of
vagina

testicular feminisation/androgen
insensitivity
-XX, XY
-testes present

delayed puberty causes

hypothalamic/pituitary failure

gonadal dysgenesis

turner's syndrome

2ary amenorrhoea

causes

periods have started but stop for some

reason

pregnancy/lactation, contraceptives,
PCOS, 1ary ovarian insufficiency, changes
of weight, stress, hypothyroidism,
iatrogenic (chemo), hypothalamic/pituitary
tumour (prolactinoma)

abnormal uterine bleeding

PALM-COEIN

structural causes: Polyp, Adenomyosis,

Leiomyoma, Malig/hyperplasia

non-structural: Coagulopathy, Ovarian

dysfunction, Endometrial, Iatrogenic, Not
classified??

types of abnormal bleeding

heavy, intermenstrual, post coital,

postmenopausal

Causes of post-coital bleeding

Cervical polyps
Ectropion
Cervical/endometrial cancer
Cervicitis
Atrophic vaginitis

What is an ectropion?

columnar epithelium that has not yet

undergone squamous metaplasia on
cervix

definition of heavy menstrual

bleeding

excessive menstrual blood loss which

interferes with women's
physical/social/emotional/QoF

HMB History

regular cycle? -> not fully understood,

disorder of prostoglandin receptors?
failure of artery constriction

irregular: hormonal cause

-increased BMI
-failure of ovulation (unruptured follicle)
-excessive oestrogen production
-endometrial hyperplasia
-usually seen in early or late puberty

Ix of HMB

FBC, transvaginal USS if

intermenstrual/post coital bleed, pelvic
pain/pressure, pelvic examination

Mx HMB

doesn't require contraception: mefanamic

acid (pain) or tranexamic acid 1g TDS,
started on first day of period

contraception:
-1st line: mirena coil
-COCP
-progesterones

endometrial polyps

outgrowth of endometrial tissue, usually

benign, subfertility, IMB

presentation of endometrial
polyp

Mx

abnormal uterine bleeding

surgery

fibroids aka leiomyoma

arise from underlying muscle layer

(myometrium)

most common benign tumour in women

types of fibroids

features

intramural (type 3/4), submucosal (type 0-

2), subserosal (type 6/7)

enlarged uterus, heavier periods, pressure

symptoms (bladder/bowel)

submucosal fibroids features

inside womb, stretch endometrium,

increased surface area, heavy bleeding,
subfertility/miscarriage

complications of fibroids

hyaline degeneration (calcium), malignant

change, tortion of pedunculated fubroid,
subfertility, bleeding

Mx fibroids

myomectomy/uterine artery embol (for

those who wish not to go to surgery)
where >3cm

GnRH agonist for short term Mx (shrink

fibroids)

anaemia managed

uterine artery embolization

minimally invasive procedure used to treat

fibroids of the uterus by blocking arteries
that supply blood to the fibroids ->
ischaemic degen

unknown impact of fertility

adenomyosis

deposits of endometrial tissue in

myometrium

heavy painful periods, dyspanurea, can be

concurrent with endometriosis, tender and
bulky uterus

1ary dysmenorrhea

physiological, pain from uterus due to

contraction of uterine muscle
(prostoglandins)

nulliparous women

prior to menstruation, relieved once

period starts

can be associated with colicky abdo pain,

N&V

Mx with NSAIDs

2ary dysmen

pain present throughout menses and often

after (assoc with
adenomyosis/endometriosis)

Mittelschmerz

abdominal pain that occurs midway

between the menstrual periods at
ovulation

non cyclical 2ary dysmen

ovarian cyst, PID, tubo ovarian abscess,