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YEAR 4 study collated > Women's > Flashcards

Women's Flashcards

1
Q

What are the most common sites of implantation in an extrauterine pregnancy?

A
  1. fallopian tube (95%)
  2. ovaries (3%)
  3. peritoneum (1%)
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2
Q

How many C-sections may a woman have previously had, whilst still being able to have a VBAC?

A

2 or 3 C-sections

  • 1 C section is NOT a contraindication
  • 2 C sections is a contraindications for some O&Gs
  • 3 C sections is a contraindication for some O&Gs
  • No one would really even perform a VBAC if the woman had had more than 3 C sections
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3
Q

What are the possible immediate side effects of HRT?

A

Signs of oestrogen excess (headache, breast tenderness, nausea)

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3
Q

what is a major clinical difference in terms of symptoms between placenta previa and placental abruption?

A

placenta previa is usally painless PV bleeding, placental aburption is painful

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4
Q

What are the different administration options of prostaglandins during induction of labour? What are the considerations of using each type?

A

An intravaginal gel can be used
Cannot administer syntocinon for 6 hours

A continuous release pessary also exists
Can be removed in the event of spontaneous labour, sROM or significant side effects in mum or baby
Smaller chance of hyperstimulation
Once removed, cannot adminster syntocinon for 30 mins

  • The catheter tends to be more uncomfortable, but is a good alternative to the PGE2 when…
  • There is a history of hyperstimulation
  • There is an already compromised foetus
  • There is a history of uterine surgery (PGE2 can cause uterine rupture)
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4
Q

at what GA can you perform amniocentesis?

A

> 15 weeks

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4
Q

how do you organise your thoughts around the types of contraception?

A

Reversible

  • Male sterilisation - vescetomy
  • Female sterilisation - tubal ligation or essure

Non Reversible

  • Long acting
    • Implanon
    • Depot provera
    • IUD
      • hormonal IUD
      • copper IUD
  • Short acting
    • Oestrogen + Proggesterone
      • Nuvaring
      • COCP
    • Progesterone
      • minipill
  • Emergency
    • Mifepristol (RU486)
    • Copper IUD
    • Levonorgestrel
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5
Q

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

A
  1. Latent: cervical effacement and early dilation
  2. Active: SLope of cervical dilation increases; usually begins when the cervix is 3 to 4 cm cilated and contractions are regular
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5
Q

Briefly discuss the pathophysiology of the different signs/symptoms of pre-eclampsia

A
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5
Q

What are the 10 Ps of every women’s station?

A
  1. Periods
  2. Pain (with periods, sex or other times)
  3. Partners
  4. Parents (maternal menopause)
  5. Pissing/pooing?
  6. Pap smears and breast checks
  7. PCOS
  8. Pelvic inflammatory disease
  9. Protection
  10. Pregnancy
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5
Q

What are the stages of normal uterine involution after labour?

A

Uterus should be below the umbilicus (4cm) immediately after delivery
Within 2 weeks, it should no longer be palpable above the pubic symphysis

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5
Q

define prolonged rupture of membranes

A

when a woman doesn’t go in to labour before 24 hours after her membranes have ruptutred

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5
Q

what is the risk of miscarriage in CVS?

A

1/100

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5
Q

what are some reasons concerning the mother why breast feeding may not be an option?

A

Nipple Issues

  • Nipple variation (inverted, short, long) making it hard for the baby to suck
  • Infection of nipple / inflammation of nipple making it painful for the mother to feed

Breast Issues

  • Infection/inflammation making it painful to breastfeed (mastitis, abcess, galactocele)

Issues with supply

  • Oversupply / engorgement – can eventually cause poor supply. Can also cause breasts to be painful.
  • Poor supply

Issues with milk

  • If mother has infection which may transfer to child (eg. HIV, Hep B if bleeding / cracked nipples)

Perinatal / Postnatal Depression

  • Low mood, lack of motivation to breast feed
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6
Q

how do you diagnose miscarriage in someone >5.5 weeks gestation?

A

TVUS

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7
Q

What is the criteria for an acceleration on CTG?

How would you interpret accelerations?

A

Defined as elevation in foetal HR >15 bpm above baseline for longer than 15 seconds.

>2 every 20 minutes is a good sign (hypoxic foetuses rarely have accelerations) but their absence is probably insignificant

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7
Q

What is the definitive management of post-partum haemorrhage?

A

Simple measures

  • Insert a catheter
  • Fundal massage (massage up!) to stimulate contractions
  • Bimanual compression (if still bleeding heavily)

Medical Measures
See image

Surgical Measures

  • Prostaglandin F2α injection into uterus from abdomen
  • Backri balloon – inflated within uterus to provide tamponade
  • With laparotomy
    • Manual pressure on uterus
    • B lynch suture – a suture generated clamping of the uterus that may preserve future fertility
    • Bilateral uterine artery ligation and internal iliac artery ligation
    • Last line - hysterectomy
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8
Q

What are your differentials for post-partum fever?

A

Causes of Post-Op Fever

  • Wound
  • Wind (atelectasis)
  • Water (IV lines)
  • Walking (DVT / PE)
  • Wonder drugs
  • Whizz (UTI)

Pregnancy Specific

  • Mastitis
  • Endometritis
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9
Q

what are some reasons as to why a newborn may have difficulty breast feeding?

A
  • Colic
  • GOR
  • Cleft palate
  • Cleft lip
  • Tongue tie (ankyglossia)
  • Poor suck/swallow reflex eg. when premature
  • Sick baby for another reason (eg. sepsis) so they are tiring at the breast, unable to suck
  • Respiratory illnesses (eg. RDS) – it is difficult to suck and breathe at the same time – anyway!
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10
Q

What are the signs and symptoms of severe pre-eclampsia?

A
  • SYMPTOMS
    • Frontal headache
    • Visual distubance (blurred vision and flashing lights)
    • Epigastric pain
    • General malaise and nausea
    • Restlessness
  • SIGNS
    • Agitation
    • Hyper-reflexia and clonus
    • Facial (especially periorbital) oedema
    • Right upper quadrant tenderness
    • Poor urine output
    • Papilloedema
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10
Q

What do you know about “the blues” post delivery?

What other mental health complications can arise after delivery? How common are they?

A

The blues

  • Affects 80% of women
  • Emotional lability, fatigue, sleeping difficulty and lower mood.
  • Should resolve spontaneously in 10-14 days.
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10
Q

What is menopause?

A

The permanent cessation of menstruation in non-hysterectomied women.

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11
Q

Describe the normal pattern of lochia….

A

Red (approx day 3 to 5 post delivery)
Pink (approx day 5 to 10 post delivery)
Serous (approx day 10 to 35 post delivery)

After birth the flow of lochia is equivalent to a heavy menstrual period

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11
Q

what are the differential diagnoses for primary ovary insufficiency? ie. what are causes of secondary amenorrhea?

A
  • hypothyroid disease
  • pregnancy
  • hyperprolactinaemia
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12
Q

how common are miscarriages?

A

20% of recognised pregnancies will end in pregnancy loss

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12
Q

In the first trimester screening, what results would increase the risk of trisomy 21? what results would increase the risk of trisomy 18?

A
  • Free B-HCG is increased in trisomy 21, whereas PAPP-A is decreased
  • Both free B-HCG and PAPP-A are decreased in trisomy 18
  • Nuchal translucency is thicker in trisomy 21 (plus there may be an absent nasal bone and polyhydramnios)
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13
Q

At what B-HCG should you be able to detect a gestational sac on ultrasound?

A

1500mlU/mL on a transvaginal ultrasound

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13
Q

What is an anembryonic pregnancy and what is it’s other name?

A

“Blighted ovum”

When a gestational sac forms but no embryo develops.

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14
Q

How do we induce labour?

A
  • Stretch and sweep
  • Prostagladins
  • Oxytocin
  • Balloon catheter
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15
Q

what proportion of pregnancies have a low lying placenta?

what proportion have placenta previa?

A

5%

0.5%

(most migrate)

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16
Q

What are the normal and values for interventions for foetal scalp lactates?

A
  • Normal
  • 4.2-4.8 repeat 30 mins ( pH 7.21 - 7.24)
  • 4.8 - 5.0 Expedite delivery ( pH
  • >5.0 urgent delivery (pH
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16
Q

what is involved in the first trimester screeing?

A

aka ‘triple test’ as it involves maternal serum screening (looking for PAPP-A and free B-HCG) + an ultrasound which looks for nuchal translucency.

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17
Q

What manouvres/procedures should you do for shoulder dystocia?

A

HELPERR

Help

Evaluate for episiotomy

Legs (McRoberts Manouvre)

Pressure - suprapubic

Enter - rotational manouvres

Remove the posterior arm

Roll onto hands and knees

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18
Q

What should also be discussed if a patient attends a clinic for emergency contraception?

A
  1. Counselling RE adequate, ongoing contraception
  2. Offer an STI screen, education if required RE barrier protection from STIs
  3. Ascertain if the sex was consensual-non consensual
  4. Discuss pap smears
  5. Abortion if emergency contraception fails
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19
Q

What are the risks of IUDs?

A

Risks of all IUDs

  • Pelvic infection - first 3 weeks following insertion
  • Perforation of the uterus during insertion
  • IUD moving from its position after insertion
  • Ectopic pregnancy
  • Some intermentsural bleeding for 6 months (but then reduces by 90% and usually amennorheic)

Risks of Myrena

  • Risks of progesterons (although local, so very unlikely)
    • Hirsuitism
    • Apetite increase / weight gain / acne
    • Irregular bleedining
    • Loss of libido
    • Mood change

Risks of Copper IUD

  • Heavy bleeding
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20
Q

What is the management for shoulder dystocia?

A

HELPERR Mnemonic

H – Call for help

  • senior obstetric, midwifery and paediatric assistance
  • Ask patient to stop pushing
  • Move patient into position to facilitate manoeuves: flat on back/bottom of bed

E – Evaluate for episiotomy

  • should be considered to make room for rotation maneouvres
  • episiotomy alone will not release the shoulder
  • aids in access for internal manoevres

L – Legs ( McRoberts maneouver)

  • Flexing and abducting the maternal hips, positioning the maternal thighs up into the maternal abdomen
    • This flattens the sacral promontory and results in a cephalad rotation of the pubic symphysis

P – Suprapubic pressure

  • Assistant hand should be placed suprapubically over the fetal anterior shoulder, applying pressure in a CPR style in a downwards motion
  • Aims to decrease the fetal bisacromial diameter or rotate fetus into oblique plane

E – Enter maneuvers ( internal rotation)

  • Attempting to rotate the anterior shoulder into an oblique plane and under the maternal symphysis

R – Remove the posterior arm

  • Apply pressure to the antecubital fossa to flex the elbow in front of the body and grasp the posterior hand to sweep the arm across the chest and deliver the arm
  • Rotate fetus into oblique plane and deliver

R – Roll the patient

  • Rolling onto all-fours may dislodge the shoulder.
  • Opens pelvis in A-P plane
  • Apply gentle downward traction to disimpact posterior shoulder from sacral promontory
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20
Q

What can we tell from the 20 week scan?

A

Morphology scan –> head to toe check for anatomical abnormalities
Growth (4 measurements)
Locates the placenta (5% of women will have a low lying placenta)
Amniotic fluid volume

May also perform umbilical artery doppler and/or cervical length if indicated

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20
Q

What are the causes of menorrhagia?

A

BITCHFACE

B – Bleeding disorder

I – Iatrogenic (IUDs and drugs)
T – Thyroid dysfunction (especially hypo)
C – Cancer (Endometrial, cervical)
H – Hyperplasia
F – Fibroids and polyps
A – Adenomyosis and endometriosis
C – Chlamydia, gonorrhea and STIs
E – Ectopics and miscarriage

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21
Q

What are the diagnostic criteria for uterine hyperstimulation?

A
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21
Q

what is placenta accreta, increta and perceta?

Why are these potentially dangerous?

When are they diagnosed?

A

accreta - abnormal adherence of the placenta to the uterine wall

increta - occurs when the placenta invades deeply in to the myometrium

pancreta - when the placenta invates through the uterus to reach the serosa

These are dangerous because they mean that the placenta can’t be fully delivered, so the uterus cannot contrcat down enough to cause cessation of bleeding (therefore increased risk of PPH).

They are diagnosed cliically, in the third stage of labour! Usually you check the placenta to see if it is complete, and it isn’t.

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21
Q

Describe how you would counsel someone who wanted to start the OCP?

A

Intro / HOPC
Definition

  • What is the OCP?
  • How does it work?

Indications: General and Specific

  • Contraception
  • Acne
  • Dysmennorhea
  • Menorrhagia
  • Endometriosis

Experience of the patient: pre, during and post

  • Start the pill - preferably on day 1-5 of menstural cycle
  • Can start at another time if it is certain the woman is not pregnant
  • Need to take the pill for seven days before it will be efficious. Use condoms for these seven days and consider the use of EC if have unprotected sex until then
  • If miss one pill, retake is as soon as you remember
    • If it is missed but retaken within 24 hours, can continue sexual practises as normal
    • If missed but retaken after 24 hours, use condoms or abstain from sex until have taken 7 active pills in a row. Consider EC if have unprotected sex.
  • If miss three or more pills, use condoms or abstain from sex for the next seven days. If have unprtected sex, use EC.
  • If you miss pills in the last week and need to take seven active ones, skip the inactive ones so you can take seven in a row
  • If you become unwell with diarrhoea or vomitting, also take seven pills in a row
  • Consult with your doctor if you start on ABx or Anti-epilepsy medication

Benefit

  • see indications

Risk

  • Oestrogen:
    • Mastalgia
    • Nausea
    • Fluid retention
    • Abdominal bloating
    • Headaches
    • Chloasma
  • Progesterone
    • Hirsuitism
    • Apetite changes / weight gain, Acne
    • Irregular bleeding
    • Loss of libido
    • Mood changes

Contraindications

  • Headache / Hypertension
  • Obesity
  • Medication (ABx, anti-convulsants)
  • Embolsim / Thrombus / FHx of thrombophillia
  • Stroke
  • IHD
  • Caner - breast / endometrial?
  • Kids / Breast feeding
  • Liver disease
  • Gillick competenet?

Alternatives

  • Irreversible
  • Reversible
    • Long acting
      • implanon
      • depot provera
      • IUD - copper or hormonal
    • Short Acting
      • Mini-Pill
      • Other formulations of COCP

Conclusion: Check understanding, offer written information, gain informed consent

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21
Q

What physical examination findings are suggestive of endometriosis?

A
  • Tenderness on bimanual examination
  • Tenderness or nodularity on the posterior vaginal fornix
  • Uterosacral ligament tenderness or nodularity
  • Cystic ovarian enlargement
  • Fixation of adnexal structures
  • Retroflexed uterus
  • Episotomy or cesarean section scar implants
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22
Q

What is the management of pre-term PROM?

A

Basics

  • Health of Mother
    • Vital signs
    • Abdominal examination
    • FBE / CRP
  • Health of Baby
    • SAM BLACK
  • DO NOT DO PV EXAMS

Place and person

Depends on definitive Mx

Ix and confirm diagnosis

  • Confirm gestational age (are they definitely term?)
  • Confirm not in labour with CTG
  • Sterile speculum exam to assess for liquour
    • Collect MCS swabs for chlamydia and gonorrheoa
    • Collect swab for GBS
    • If unsure:
      • Nitrazine paper test
      • Amnisure
      • Fern test

Definitive

Give antenatal steroids

Give erythromycin (reduces neonatal lung dz, cerebral haemorrhage and death)

Expectant vs active management

Long term

  • Monitor until labour
  • Indication for CTG during labour
  • Paediatric review after birth
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22
Q

what is a heterotopic pregnancy and when is it most common?

A

Heterotopic pregnancy when two eggs are fertilized; one implants at an intra-uterine site, another at an extra-uterine site. Often associated with induced ovulation (IVF) (1:11,000). Otherwise rare (1:40,000)

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23
Q

What is a salpingectomy and when may it be required?

A

Removal of fallopian tube.

In a ruptured / bleeding ectopic pregnancy.

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25
Q

How long does the latent phase of labour last?

A

Primigravids: up to 20 hours

Multiparas: up to 14 hours

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26
Q

At what gestational age is the foetal heart beat usually detectable on USS?

A

Can be heard in 80% of cases at 12 weeks, 90% at 13 weeks

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26
Q

What are the main considerations when choosing bw low and high dose oxytocin infusions for IOL?

A
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26
Q

what does first trimester screening screen for?

what does second timester screening screen for?

A
  1. Trisomy 21 (Downs Syndrome) and Trisomy 18 (Edwards Syndrome)
  2. As above + neural tube defects - however the 20 week ultrasound is more reliable for this, anyway
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26
Q

What are the potential complications of a caesarian section?

A
  • 4-6x risk of maternal death as compared to NVD
  • Haemorrhage
  • Injury to surrounding structures such as bowel, bladder, blood vessels, nerves and ureters
  • Postoperative
    • Thromboembolic events
    • Pain
    • Prolonged hospitalisation
    • Postop infection involving the urterus, wound, bladder, lung and IV site
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27
Q

what are the 10 Ps of post natal complications?

A
  • Pain
  • Perineum
  • Pissing
  • Pooing
  • PPH
  • PreEclampsia / GDM
  • PE / DVT
  • Pyrexia (mastitis, endometritis)
  • Psych
  • Protection
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27
Q

What is the gold standard test for GDM? How is this test performed and measured?What else can be performed if this test cannot be done.

A

75g 2 hour POGTTWomen should fast overnight.They should then have a fasting BSL, and then a BSL at one and two hours.It is not uncommon for women to vomit during this test, before the two hour mark. If this is the case, you can still consider the 1h result but it is best to do an HbA1c too

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28
Q

If a woman had unprotected sex 12 hours ago and is seeking emergency contraception, what could be offered?

A

LNG

Yupze Method (although less effective than levonorgesterl)

Copper IUD

RU486

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28
Q

What are causes of a prolonged latent stage of labour?

A
  • Hypertonic uterine contractions that do not lead to effective cervical dilatation
  • Hypotonic uterine contractions
  • Premature or excessive use of sedatives or analgesics
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29
Q

describe the medical management of ectopic pregnancy?

A
  • Single dose of 50mg/m2 of IM methotrexate.
  • B-HCG levels are checked on day 4 and 7, and should fall by 15%. If not, give a second dose.
  • 15% of women will need a second dose. 7% will need subsequent surgery.
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30
Q

What are the causes of oligo and polyhydramnios?

A
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31
Q

What are the risks of pregnancy with pregestational diabetes?

A
  • Increased miscarriage risk
  • High risk of DKA due to the increased insulin resistance and therefore increased fat break down
  • Hypoglycaemia may also occur periodically especially in early pregnancy when nausea and vomiting interfere with caloric intake
  • 2 fold increased risk of pre-eclampsia
  • Diabetic retinopathy and diabetic nephropathy both worsen with pregnancy
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32
Q

What is the mechanism of action of misoprostol?

A

It is a prostaglandin E1 analogue –> causes strong uterine contractions

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33
Q

Is there a role for tocolysis to delay the onset of labour, in the case of PROM?

A

No. In fact it might be dangerous. Only short term tocolysis is indicated; for the purposes of finishing a course of antenatal steroids or for transfer to facility with NICU

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34
Q

What is the risk of miscarriage in women with a negative history, once the foetal heart is detected?

How about if they have a history of miscarriage?

A

In women without a previous Hx of miscarriage, once the foetal heart is detected, the risk of miscarriage is 2%. This statistic is 18% for women with a Hx of miscarriage.

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35
Q

What happens to the management of preexisting diabetes during pregnancy?

A
  • For these patients, management ideally begins before conception, with the goal of optimal glucose control before and during pregnancy
  • Insulin requirements will increase during pregnancy, most markedly between 28 and 32 weeks of gestation
  • Patients may need to be seen every 1 to 2 weeks during the first two trimesters, and weekly afterwards
  • Post Partum - immediately reduce dose to pre-pregnancy doses as there is a rapid loss of insulin resistance post delivery
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36
Q

What is the mechanism of action of mifepristone?

A

Progesterone antagonsist. Used to “prime” the uterus before misoprostol. Causes the embryo to detach and ripens the cervix.

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36
Q

Describe the differing definitive management of PPROM depending on GA?

A
    • consider termination OR expectant management
  • 24-34 weeks gestation
  • expectant management (unless complication for foetus or mother)
  • 34 weeks gestation
  • active management
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37
Q

What are the causes of primary post-partum haemorrhage?

What are the risk factors associated with each?

A

Causes

  1. Tone (uterine atony)
  2. Tissue (retained products)
  3. Trauma
  4. Thrombin (DIC, coagulopathy)

Risk factors

  • Tone (uterine atony)
    • prolonged/dysfunctional labour
    • polyhydramnios
    • macrosomia
    • fibroids
    • intrauterine infection
    • MgSO4, general anaesthetic, tocolytics
  • Tissue (retained products)
    • abnormal placenta
  • Trauma
    • operative or instrumental delivery
  • Thrombin (DIC, coagulopathy)
    • HELLP/pre-eclampsia
    • Family or personal history of bleeding disorder
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38
Q

what else is usually done in the case of instrumental delivery?

A

episiotomy

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39
Q

If a woman had unprotected sex 4 days ago and is seeking emergency contraception, what can be offered?

A

Copper IUD

Mifepristone RU486

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40
Q

what is used in the Rx of uterine atony?

A

Medical Management

First insert a catheter and massage the uterus to stimulate contractions.

1st Line:

Ergometrine

Syntometrine (ergometrine + syntocinon)

2nd Line:

IV syntocin infusion

3rd Line:

Misoprostol

Prostaglandin F2α

Surgical Management

If medical management is unsuccessful.

  • Without laparotomy
    • Examination under anaesthetic – allows for more thorough search for lacerations and retained products
    • Prostaglandin F2α injection into uterus from abdomen
    • Backri balloon – inflated within uterus to provide tamponade
  • With lapartomy
    • Manual pressure on uterus
    • B lynch suture – a suture generated clamping of the uterus that may preserve future fertility
    • Bilateral uterine artery ligation and internal iliac artery ligation
    • Last line - hysterectomy
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41
Q

What are the potential complications of forceps delivery?

A
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42
Q

what is an alternative screening option to first and second trimester screening?

A

Non Invasive Perinatal Screening (NIPS) aka “percept”

A blood test looking at foetal cells in the maternal circulation

Newer test - expensive (over $400 AUD)

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43
Q

Where is endometriosis most commonly found?

A
  • In or on the ovaries
  • Posterior cul-de-sacc
  • Uterosacral ligaments
  • Broad ligament
  • Anterior cul-de-sac
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43
Q

What are the most common symptoms of endometriosis?

A
  • Pelvic pain
    • Secondary dysmenorrhea
    • Deep dyspareunia
    • Low sacral backache
    • Diffuse pelvic pain
    • Disease severity does not predict the degree of pain
  • Infertility
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45
Q

What are the indications for a cesarean section?

A
  • Maternal/fetal
    • Dystocia
    • Cephaloelvic disproportion
  • Maternal
    • Maternal disease
      • Eclampsia/severe preeclampsia
      • Diabtes
      • Cervical cancer
      • Active herpetic outbreak
      • Ovarian tumour
    • Previous uterine surgery
    • Obstruction in birth canal
    • Fibroids
  • Fetal
    • Fetal distress
    • Cord prolapse
    • Fetal malpresentation
    • Macrosomia
    • Higher order multiple gestation
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46
Q

What investigations would you order for someone with bleeding in early pregnancy?

A
  • FBE
  • Blood group and antibodies
    • Consider cross-match is patient is likely to need a transfusion
  • B-HCG - may consider serial B-HCG
  • U/S - transvaginal vs abdominal
  • urine test or high vaginal swab for chlamydia in women
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47
Q

What are the risk factors for endometriosis?

A
  • Nulliparity
  • Infertility
  • Reproductive age (usually late teens to forties)
  • A first-degree relative with endometriosis
  • Regular menstrual cycle
  • Prolonged menses of 8 or more days
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49
Q

What are the risk factors for hyperemesis gravidarum?

A
  • Multiple gestation
  • Gestational trophoblastic disease
  • Triploidy
  • Trisomy 21
  • Hydrops fetalis
  • H pylori
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49
Q

What are the contraindications for a foetal scalp lactate?

A
  • Severe comprompse -> ->DELIVERY
  • Fetal bleeding disorders suspected
  • Face presentation
  • Maternal Infection eg hepatitis, HIV
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50
Q

at what GA is a transvaginal U/S usually 100% sensitive, for intra-uterine pregnancy?

ie. how early can you reliable tell if there is an intra-uterine preganncy?

A

5.5 weeks gestation

detection of heart beat also rules out non-viable pregnancy

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51
Q

what are the medically concerning physiological effects of oestrogen deficiency?

A

Metabolic syndromeOsteoporosisVaginitis

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53
Q

Which foods should a pregnant woman avoid as they are prone to listeriosis?

A
  • Soft cheeses
  • Precooked/ pre-prepared cold foods not to be reheated eg. Salads, deli meals
  • Undercooked meat, chilled pre-cooked meats, pate, meat spread
  • Raw seafood
  • Unpasteurised foods
  • Pre-prepared/ packaged cut fruit and vegetables
  • Soft serve ice cream
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55
Q

What are the five types of decelerations?

A
  • Early Decelerations
    • Decrease in HR with slow onset early in the contraction and return to baseline by the end of a contraction
    • Usually a normal finding
    • Indicative of head compression
  • Variable decelerations
    • V shaped due to rapid onset and recovery
    • Drop of >15bpm for >15secs
    • Are considered non-reassuring
  • Late decelerations
    • A uniform repetitive decreasing of foetal HR with an onset mid to end of the contraction and ends after the cessation of the contraction
    • Indicates uteroplacental insufficiency
  • Prolonged decelerations
    • Decrease >15bpm for >90secs but
    • Can indicate maternal hypotension or hyperstimulation
  • Complicated variable decelerations
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57
Q

What is the term for painful intercourse?

A

Dyspareunia

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58
Q

What are the three major causes of antepartum haemorrhage?

A
  1. placenta previa
  2. placental abruption
  3. vasa previa
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60
Q

What are the causes of dystocia?

A
  • Ineffective uterine expulsive forces
  • Abnormal presentation, position or foetal structure
  • Disproportion between the size of the foetus and the maternal pelvis
  • Obstruction of the birth canal
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61
Q

what are the outcomes to mother and foetus of failure of trophoblastic invasion (at 20 weeks which usually causes vasdilation of uterine arteries)?

A
  1. maternal blood pressure - Gestational HT (increased blood volume, no drop in perippheral vascular resitance due to uterine artery dilation)
  2. endothelial dysfunction of materal kidneys - Pre-eclampsia (proteinuria, oedema)
  3. endothelial dysfunction of maternal liver - HELLP syndrome
  4. endothelial dysfunction of​ maternal brain - liver

5. placental abruption

6. IUGR

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62
Q

Which infectious organisms are routinely screened for during pregnancy?

A

SARaH

Syphillus

Asymptomatic bacturia

Rubella and

HIV & Hepatitis B

Group B Strep is recommended to all women at week 37

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62
Q

how do you define chemical pregnancy?

what is the “opposite” of chemical pregnancy?

A

spontaneous pregnancy loss before five weeks gestation (so called because B-HCG is elevated but a gestational sac cannot be viewed on ultrasound)

When a gesttaional sac can be viewed on ultrasound, this is called a clinical pregnency (not really the opposite - because this is a viable pregnancy)

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63
Q

describe the prerequsites of expectant management of ectopic pregnancy

A
  • Candidates must:
  • Be haemodynamically stable
  • Have minimal symptoms
  • Have an initial B-HCG
  • Have a U/S confirmed ectopic pregnancy
  • Be available for twice weekly B-HCG and weekly transvaginal U/S
  • Be informed of the risk of tubal rupture, haemorrhage and emergency surgery
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63
Q

what proportion of women in term PROM spontaneously go into labour in 24 hours?

A

90%

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65
Q

What are the symptoms of pre-eclampsia?

A
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66
Q

What is perimenopause?

A

The time from the onset of cycle irregularity through until 12 months after the menstrual period.

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68
Q

What is turtleneck sign?

A
  • A sign of shoulder dystocia
  • The head appears to be pulled back by the perineum - the vulva remains tightly applied to the head
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69
Q

how do you define early pregnancy loss?

A

spontaenous loss of pregnancy before 20 weeks

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70
Q

What does a small or large SFH mean?

A

A small SFH could represent

  • FGR
  • Oligohydramnios

A large SFH could represent

  • Macrosomia
  • Multiple pregnancy (rarely missed on ultrasound)
  • Polyhydramnios
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71
Q

How do you screen for gestational diabetes?

A

In Australia, all pregnant women should be screened for GDM between 26 and 28 weeks gestation.

The recommended screening regimen is a 75 gram two-hour Pregnancy Oral Glucose Tolerance Test (POGTT).

  • Fasting test- fast from 2200
    • Fasting blood sugar (drink 75gm glucose load)

Diagnostic criteria

2 hour OGTT

  • Normal
  • GDM = 8.5-11.0
  • DM in pregnancy >11

Notes – when normally diagnosing DM (not gestational), can’t use 1h GTT. But can in GDM.

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71
Q

What % of pregnancies are affected by Term Prom?

What % of these will go in to labour within 24 hours?

A

10%

90%

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72
Q

In a woman who is only experiecing urogenital symptoms, what route of HRT would you consider?

A

Vaginal

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73
Q

what are the indications for IOL?

A

MOTHER AND PIG

Medical issues (heart dz, chronic renal dz, auto-immune)

Obstetric cholestasis (controversial)

Too long! (>41 weeks)

Haematological (Rh isoimmunisation) / Hypertension (preeclampsia, eclampsia)

Endocrine (GDM) – at 38-39 weeks (due to foetal macrosomia)

ROM early / Request (maternal psychosocial issues)

Planned neonatal surgery

In Utero Demise (IUD) or Intrauterine death

Growth restriction

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73
Q

when can you undergo second trimester screening?

A

14 - 20 weeks

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74
Q

what are the risk factors for placental abruption?

A

CV risk factors (HT, DM, hyperlipidaemia)

Trauma

Sudden uterine decompression - following ROM or delivery of the first twin

Chorionamnitis

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75
Q

What is the management of mastitis?

A
  • Abscesses will require aspiration
  • eTG recommends flucloxacillin
  • Analgesia
  • Cold lettuce leaves are a common, anecdotal therapy for pain relief
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76
Q

A woman wants to have a vaginal birth but has had C-sections in the past. How many C-sections would she be able to have had before you’d say that it would be too risky to have a vaginal birth?

A

2 or 3

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76
Q

What are the effects of menopause?

A

HOTFLUSH

H – heart disease risk increased

O - osteoporosis

T – tired, teary and Thrombus risk (if HRT)
F – Friction (atrophic vaginitis)

L – Libido change

U – Urinary

S – Strange cycles

H - Headaches

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76
Q

what drug is implanon?

how effective is it?

what is it’s effects on menses?

how long can it stay in for?

what tests should be performed prior to insertion?

A

high dose progesterone (Etonogestrel)

it is 99.95% effective

1/3 of women experience amenorrhea, 1/3 experience light bleeding and 1/3 experience heacy bleeding (consider removal)

it can stay in for 3 years

you should perform a B-HCG prior to insertion

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77
Q

How long should labour take, overall?

A

No longer than 8 hours in multiparous women

No longer than 12 hours in nulliparous women

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78
Q

what are some indications for the COCP?

A

Contraception

Acne

Dysmenorrhea

Menorrhagia

Endometriosis

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79
Q

What are the pre-requisites for forceps delivery?

What history/exam would you perform before proceeding with forceps delivery?

A

History

  • Has the patient receive syntocinon (should try first)
  • How long has the labour been?
  • What is the mother’s BMI? Baby’s estimated weight?
  • Gestational diabetes?
  • Osteogenesis imperfecta (absolute contraindication)

Examination

  • Palpate abdomen for foetal size and engagement
  • Perform VE –> is the head at or below spines?
  • Is there a ‘face’ presentation?

FORCEPS

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80
Q

What might delay uterine involution after labour?

A

Intra-uterine causes

  • Fibroids
  • Infection
  • Retained products

Extra-uterine causes

  • Full bladder
  • Full rectum
  • Broad ligament haematoma
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80
Q

On the wards day 1 post-delivery, the midwives ask you to see Mrs Jones, who has been having some trouble. What possible problems cross your mind?

A

The Ten P’s of Early Post-Partum

  • Pain
  • PE/DVT
  • Perineum
  • Pyrexia (WWWWWWs or intrauterine infection or mastitis)
  • Pulse (PPH?)
  • Pre-eclampsia
  • Pooing - should resume in 3 days
  • Pissing
  • Psyche
  • Protection
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80
Q

in broad brushstrokes, what are the types of management for miscarriage?

A

Expectant

OR

Medical

OR

Surgical

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80
Q

What are the requirements if a women who has term PROM wishes for expectant manageement?

A

TEN ELEVEN

Term

Engaged (cephalic presentation)

No VE or cervical sutures

EFM (CTG) normal

Logistics for ongoing Evaluatiuon

Vitals normal

Exit Portal should have

No GBS

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82
Q

What is the amnion and the chorion?

A

The chorion is the placenta

The amnion is the fluid sack of foetal urine

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84
Q

What is the typical presentation of endometriosis?

A

Pelvic pain which is worse prior to menses and is eased with menses (secondary dysmenorhea). May also have subfertility, dyspareunia, rectal bleeding (endometrial tissue in colon) or haematuria (endometrial tissue in urinary tract). Examination is usually unremarkable.

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85
Q

when can you perform CVS?

A

12-13 / 40

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86
Q

what are the porential risks of HRT

A

Remember: ABCEIOU (see summary)

Breast cancer

DVT / PE

Stroke

Endometrial cancer

Cholecystitis

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87
Q

Regardless of the type of management for miscarriage (medical, surgical, expectant), what else needs to be done in terms of management?

A

Basics

  • ​Anti-D for rhesus negative women

Place and Person

Investigate & Confirm Diagnosis

  • Confirm non-viable intra-uterine pregnancy with B-HCG or ultrasound
  • High vaginal swab / serology for chlamydia if opting for surgical management
  • Culture of genital discharge to screen for gonhorrea prior to surgical management
  • Vaginal swab for bacterial vaginosis prior to surgical management

Definitive Management

  • Medical or surgical management

Prophylaxis / Ongoing Rx

  • Psychological support
  • Contraceptive advice - all hormonal and implantable methods of contraceotion can be performed at the time of D&C
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88
Q

what is a complete miscarriage?

what is an incomplete miscarriage?

A

Complete miscarriage: The uterus is empty - all of the products of conception have been expelled. The cervix is closed. Symptoms have often resolved.

Incomplete miscarriage: some products of conception have been expelled, but not all.

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89
Q

What pharmacological tehrapy may be used to increase breast milk supply?

A

Galactagogues

Domperidone (Motilium) and Metaclopromide (Maxalon)

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90
Q

What are the gynae systems questions?

A

The 10 Ps

Periods:

  • First period (age of mecarche)
  • Regularity
  • Volume
  • Last normal menstrual period / age of menopause

Pain (with periods, sex or other times)

Partners + sexual activity

  • Number of partners
  • Sex of partners
  • Type of relations

Protection

  • Contraception
  • Screen for Domestic Violence

Parents (maternal menopause)

Pissing/pooing?

  • Dysuria
  • Nocturia
  • Polyuria
  • Urgency
  • Incontinence

Pap smears and breast checks

PCOS

Pelvic inflammatory disease

  • Vaginal discharge? (colour, quantity, odour)

Pregnancy

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92
Q

What are the cardinal movements of labour?

A
  • Engagement (usually before the true onset of labour)
  • Descent
  • Flexion
  • Internal rotation
  • Extension
  • Restitiution and external rotation
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94
Q

At what rate should the cervix dilate in the first stage of labour?

A

The cervix should dilate >1cm per hour of labour.
In multigravidas, this figure is probably closer to >2cm.

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95
Q

What are the two major risk factoras/causes of shoulder dystocia?

A

Macrosomia (BW = >2500g)

Instrumental delivery

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96
Q

What is foetal macrosomia?

A

>4.5kg

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97
Q

When does the placenta separate from the uterine wall?

A
  • Within 5 to 10 minutes of the end of the second stage?
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97
Q

what is the surgical management of miscarriage?

A

Dilatation and suction curettage

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97
Q

What are the risks of IOL?

A

PATH and ROAD?

Prolapsed umbilical cord

Abruption of placenta

Tachysystole / Hyperstimulation

Hyponatraemia & Haemorrhage

Rupture of uterus

Oedema / fluid retention

Atonic uterus

Didn’t work (failure of induction) à then need CS / operative vaginal delivery

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97
Q

What are the prerequisites for the use of forceps?

A

Fully Diated Cervix

Fully dilated cervix

OA position (ideal)

Ruptured membranes

Contractions/catheter

Episiotomy and epidural

Presentation: cephalic

Station: Spines or below (0 or

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98
Q

What are the grades of perineal tears?

A

VBAC

  • Grade 1: Skin of vagina torn
  • Grade 2: Involves perineal (bulbocavernosus) muscle
  • Grade 3: To the anal sphincters
    • A)
    • B) >50% of external sphincter
    • C) Internal sphincter
  • Grade 4: Tear to anal canal
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99
Q

how would you proceed with IOL in a woman with a modified bishops score of 4?

A

Unfavourable cervix.

Most likely PGE2 or transcervical catheter (the latter if VBAC)

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100
Q

What are the causes of a long or short symphysiofundal height?

A
100
Q

Describe the management of Term PROM?

A

Basics

  • Health of mother
    • Vitals
    • Abdominal examination
    • FBE / CRP
  • Health of baby
    • SAM BLACK
      • Symphysiofundal height
      • Auscultate foetal heart
      • Ask RE foetal movements
      • Biophysical profile
      • Lengths on US
      • Amniotic fluid index
      • CTG
      • Kinks in U/S

Place and Person

Investigate and confirm diagnosis

  • Confirm gestation
  • CTG - ensure they’re not in labour
  • sterile speculum examination
  • DO NOT PERFORM VAGINAL EXAM

Definitive Management

  • Expectant versus Active Management
  • Don’t forget to consider GBS status before inducing labour

Ongoing management

  • CTG during labour
  • Paediatric review after birth?
101
Q

What is Gestational Trophoblastic Disease?

A

A spectrum of placental tumours that arise from genetically abnormal embryos. GTD may be benign (most commonly) or rarely malignant.

103
Q

How do you make your overall assessment of the CTG?

A

Normal = a CTG trace where all four features are rated as reassuring.

Suspicious = a CTG trace where one feature falls into the non-reassuring category.

Pathological = when two or more features fall into the non-reassuring category, or one feature falls into the abnormal category.

103
Q

What are the causes of post-menopausal bleeding?

A

PATCH

P – Polyps (cervical, endometrial)

A – Atrophic vaginitis (80%)

T – Therapy (cyclical HRT or HRT withdrawal)

C – Cancer (cervical, endometrial, rarely ovarian)

H – Hyperplasia (typical or atypical)

104
Q

What is a septic miscarriage?

A

A miscarriage complicated by infection – can lead to PID, sepsis and death

105
Q

What are the options for combined HRT? And what are the advantages / indications for each?

A
  1. Continuous Use - oestrogen and progesterone both daily. Have to have had cessation of period for one year or greater before commencing.
  2. Cyclycal Use - oestrogen daily and progesterone for 10-14 days of teh cycle. May have withdrawl bleed upon cessation of progesterone.
105
Q

what is the dosage of antenatal steroids which should be given?

A

Two doses of 12 mg IM betamethasone, given 24 hours apart

OR

Four doses of 6mg IM dexamethasone, given 12 hours apart

106
Q

What are the risk factors for perineal tearing?

A
  • Nulliparity
  • Precipitous labour (
  • Birth weight >4kg
  • Occipito-posterior position
  • Shoulder dystocia
  • Induction of labour
  • Epidural analgesia
  • Assisted delivery (forceps)
107
Q

Why are babies of mums with GDM big?

A

GDM –> hyperglycaemia –> increased release of insulin and insulin like growth factor from the foetus –> hepatomegaly and increased growth

108
Q

What are the steps taken to interpret CTG?

A

“DR C BRAVADO”

  • Determine risk
  • Contractions
  • Baseline
    • Must be taken with the absence of foetal movements or uterine contractions
    • Normal 110-160
  • Variability
    • May not be present when foetus is sleeping
    • 5-25bpm
  • Accelerations
    • >15bpm for >15secs
  • Decelerations
    • Typically >15bpm for >15secs
  • Overall assessment
110
Q

What are the complications of shoulder dystocia?

A

Maternal

  • PPH (most common)
  • Rectovaginal fistula
  • Pubic symphysis separation
  • Episiotomy /tear
  • Uterine rupture

Fetal

  • Brachial plexus palsy ( common)
  • Clavicle #
  • Fetal hypoxia/death
  • Humeral #
111
Q

what is the classic triad of the signs/symptoms ectopic pregnancy?

… and if it is more severe?

A
  1. amenorrhea
  2. irregular bleeding
  3. lower abdominal pain

if more severe:

  1. hypotension
  2. tacchycardia
  3. shoulder tip pain
112
Q

What are the causes of primary PPH?

A
  1. Tone (uterine atony)
  2. Trauma (uterine rupture, laceration)
  3. Tissue (retained products)
  4. Thrombin (coagulopathy)
114
Q

What are the advantages and disadvantages of LUCS (compared to vaginal birth)?

A

Advantages

  • Mum
    • Planned
    • No tears
    • Less risky than emergency Caesarean

Disadvantages

  • Mum
    • Anesthesia
    • Catheter + UTIs
    • Surgery
    • Bleeding, infection, DVT/PE
    • Adhesions
    • Hysterectomy
  • Baby
    • Possible TTN and need for special care (1%)
    • Delayed to time with mum
115
Q

What tests should one have before the insertion of a myrena?

A

Tests for chlamydia

Pregnancy test

116
Q

How do you diagnose menopause?

A

A clinical diagnosis.

If a woman is > 45 years old and had been amenorrheic for 12 months you can diagnose menopause.

You don’t need to perform any investiagtions (althugh if you did they would have low oestrogen, AMH and inhibin and a high FSH.

117
Q

How long should the third stage of labour take?

A

No longer than 30 minutes

118
Q

How do you instruct someone to collect a urine specimen for chlamydia testing?

A

How to collect a ‘first pass urine’ specimen for chlamydia testing

  • This test works best if you haven’t been to the toilet to pass urine in the past hour. If it is less than 1 hour since you passed urine, this test may not be accurate. Let your doctor know if this is the case
  • You do not need to clean or wipe yourself before this test
  • You need to collect the very first part of your urine stream. This means first passing urine straight into the container, not into the toilet
  • Once the container is about a quarter full, pass the rest of your urine into the toilet
120
Q

What is the sensitivity of the 20 week scan for disabling or lethal abnormalities

A

70-80%

121
Q

What are the indications for a classical cesarian section?

A
  • Preterm breech fetus or in any preterm delivery with under deceloped lower uterine segment
  • Fetus in a transverse lie with back down
  • Restricted access to the lower uterine segment secondary to fibroids or dense adhesions
  • When a hysterectomy is to follow the delivery of the fetus
  • Presence of an invasive cervical cancer
  • Postmortum C/S to remove a live fetus
123
Q

What are the advantages and disadvantages of vaginal birth (vs LUCS)?

A

Advantages

  • Mum
    • Shorter hospital stay
    • Less analgesia required
    • Often felt to be ‘more satisifying’
  • Baby
    • Less likely to have TTN
    • More easily cared for by mum, who is physically well sooner

Disadvantages

  • Mum
    • Instrumental birth
    • Bleeding
    • Tears
    • Emergency Caesarean (30%)
    • Hysterectomy (rare, PPH)
    • Rupture of scar (1 in a 100)
123
Q

What is the overall definitive management of menopause?

A

Lifestyle Modifications

  • Cut down smoking
  • Healthy diet + exercise to reduce BMI
  • Cut down ETOH
  • Dress in layers
  • Carry a small fan

Complementary

  • Phyto-oestrogens (soy isoflavones, black coshosh)

Non-Hormonal

  • For vasomotor symptoms - SSRI, SNRI, gabapentin
  • For urogenital symptoms - cranberry juice, lubricants

Hormonal

  • HRT
125
Q

What are the investigations for endometriosis?

A

Gold standard = laparoscopyCan also perform U/S or MRI.

125
Q

what is the other medical term for rupture of membranes?

A

amniorrhexis

126
Q

at what gestational age can the gestational sac be viewed on ultrasound?

A

after 5 weeks

128
Q

What are the characteristics of hyperemesis gravidarum?

A
  • Persistent vomiting
  • Volume depletion
  • Ketosis
  • Electrolyte disturbances
  • Weight loss
129
Q

What is threatened and missed miscarriage?

A

Threatened miscarriage - bleeding in the first 20 weeks of gestation (a presentation, not a diagnosis).

Missed miscarriage - In this situation what happens is that the embryo fails to develop fully and, instead of being passed out of the womb in a miscarriage situation, it is retained inside. ie. “asymptomatic fetal demise”. Diagnosed retrospectively on U/S because the fetus is too small for gestational age, reflecting cessation of growth at an early gestation e.g. absence of fetal heart and 9 week sized foetus on 12 week U/S

130
Q

of the causes of antepartum haemorrhage, which are maternal blood loss and which are foetal blood loss?

A
  • placenta previa and abruption - maternal blood loss
  • vasa previa - foetal blood loss
132
Q

What types of lacerations are there after vaginal delivery?

A
  • 1st degree: involves the vaginal mucosa or perineal skin
  • 2nd degree: extends intot he submucosal tissue of the vagina or perineum with or without involvement of the muscles of the perineal body
  • 3rd degree: involves the anal sphincter
  • 4th degree: involves the rectal mucosa
133
Q

what should you warn women post D&C?

A
  • That they may experience light bleeding for a few weels
  • That they should abstain from sexual intercourse and avoid using tampons for a few weeks, to reduce the risk of infection
  • That their period may not occur at the usual time, because the uterus has to build new lining
135
Q

What are the considerations required before starting HRT?

A
137
Q

What % of pregnancies will be affected by premature pre-term rupture of membranes?

What % of these will deliver within 24 hours?

A

1-3%

50% within 24 hours, 80% within 7 days

138
Q

when can you give syntocinon after prostaglandins?

A

>6 hours post

139
Q

In a woman who has never had a hysterectomy, what sprt of HRT would you prescribe?

A

Oe + P

140
Q

What is the management of facial nerve palsies caused by forceps deliveries?

A

In one series, patients recovered on average in 24 days
No treatment required
Beware the eye! Tape and protective gel can be used

141
Q

Define primary and secondary post partum haemorrhage?

A

Primary
•Occurs in the first 24 hours after delivery

Secondary
•Occurs after 24hrs and before 6 weeks after pregnancy (end of post-partum period)

142
Q

if a woman’s membranes are intact, what is required prior to the administration of syntocinon?

A

AROM

143
Q

how do you “Investigate and confirm a diagnosis” of PROM (either pre-term or term)?

What shouldn’t you do?

And what can you do it you’re uncertain?

A
  • Confirm gestation
  • Confirm that they are definitely not in labour - CTG
  • Perform a sterile speculum examination (NOT a vaginal exam)
    • Look for liqour in the posterior fornix - can ask woman to cough to see it trickle down
  • If unsure, can do:
    • Nitrazine
    • Amnisure
    • Fern test
145
Q

How do you decide what approach to take in induction of labour?

A

In term PROM you can jump straight to oxytocin. In pre-term PROM use Modified bishop score

“Favourable Cervix” with Modified Bishop Score >8

IOL likely to be successful

ARM +/- oxytocin infusion

“Unfavourable Cervix” with a Modified Bishop Score of 8 or less (this number varies between sources!)

Cervix needs ripening

Use prostaglandin

The Bishop’s Score is a clinical tool used to gauge the favourability of the cervix for labour and induction of labour. Six is a commonly used cut off. The most important component ins the dilation of the cervix. Dilation

147
Q

A woman has red lochia at day 7 post delivery. What are the differentials? What is the management?

A

DDx

May indicate infection (endometritis) or retained products

Management

Endometritis

Oral Augmentin and Azithromycin (mild)

IV amoxy, gent and metro (severe)

Retained products

Evacuation + antibiotics

148
Q

how does the mirena work?

A

Locally secretes a high dose of progesterone:

  1. makes the mucous thicker - a barrier to sperm entry
  2. thins the endometrium so the egg can’t implant
  3. the mirena itself acts as a barrier to sperm
149
Q

what is the risk of miscarriage with amniocentesis?

A

1/200 (half of that of CVS)

150
Q

How often do you have to have the depot-provera?

A

every 3 months

151
Q

how common is PPROM?

A

occurs in 1-3% of all pregnancies

152
Q

If a woman has GDM, what other testing should be done?

A

TFTs (if not done already).They should have a repeat 75g OGTT 6-12 weeks post pregnancy (using non-pregnant parameters).If they have had GDM they are at an increased risk of developing TIIDM in the future so they should have ongoing monitoring every 2-3 years.

153
Q

what are the risks of prelabour rupture of membranes?

A

maternal infection

foetal infection

cord prolapse

placental abruption

154
Q

at what GA week can you perform CVS?

A

10-14 weeks

155
Q

How common is term PROM?

A

It occurs in 10% of all pregnancies

156
Q

What is VBAC?

What are the risks?

A

VBAC (pronounced veeback) stands for vaginal birth after caesarean section.

The major risk if uterine rupture at the site of the previous LUCS scar - affects 1 in 200 women trying for a VBAC.

157
Q

What time frame is considered to be puerperium?

What is the clinical significance of this time?

A

From delivery to 6 weeks

After the puerperium any maternal complications of pregnancy (like GDM or gestational HTN) should have resolved. If they haven’t treat like normal DM/HTN.

158
Q

What are the outcomes of bleeding in early pregnancy?

A
  • 60% have ongoing pregnancy
  • 30% have early pregnancy loss
  • 9.5% have ectopic pregnancy
  • 0.5% other

What is the other 0.5%?

159
Q

What causes Braxton Hicks contractions?

A

Around week 37 progesterone levels start to drop, but oestrogen levels remain high. This higher ratio of oestrogen to progesterone causes the uterus to be more sensitive to other hormones (notably oxytocin released from the anterior pituitary) which stimulate contractions. This effect can cause some women to experience some weak contractions in late pregnancy, either called “false labour contractions” or “Braxton-Hicks contractions”.

161
Q

What is the management of term PROM?

A

Basics

  • Health of Mother
    • Vital signs
    • Abdominal examination)
    • FBE / CRP
  • Health of Baby
    • SAM BLACK
  • DO NOT DO PV EXAMS

Place and person

Depends on definitive Mx

Ix and confirm diagnosis

  • Confirm gestational age (are they definitely term?)
  • Confirm not in labour with CTG
  • Sterile speculum exam to assess for liquour
    • If unsure:
    • Nitrazine paper test
    • Amnisure
    • Fern test

Definitive

Expectant vs active management

Long term

  • Monitor until labour
  • Indication for CTG during labour
  • Paediatric review after birth
162
Q

What results would you expect on the second trimester screening test for the abnormailites which it is testing for?

A

Trisomy 21 - Increased B-HCG and inhibin, reduced estriol and AFP

Trisomy 18 - reduced all of them

NTDs - increased AFP

163
Q

What is the general management of all antepartum haemorrhage?

A

CRAM

Clinical Assessment

Mother

  • vitals
  • peripheral signs of shock
  • abdominal examination
  • ask her blood group
  • when she had her last meal (readiness for surgery)
  • previous surgeries involving GA - women with placental abruption may have DIC, epidural is contraindicated in DIC and so these women will need a GA

Baby

  • Choose some of SAM BLACK

Recussitation (if mother is unstable)

  • Airway
  • Breathing
  • Circulation - 2 x wide bore canulae
    • Take blood off for group and hold / cross-match
    • Anti-D if rhesus negative

Assess for underlying cause of APH

  • FBE
  • Coags including fibrinogen (DIC is a complication of placental abruption)
  • Kleihaur Test if to assess for extent of fetomaternal haemorrhage if rhesus negative
  • Transvaginal U/S in non-emergent cases

Management

  • Consider risks versus benefit of expedited delivery versus premature delivery
165
Q

What are the risks of using syntocinon?

A
  • Uterine hyperstimulation
    • Powerful contractions may distress foetus (use intrapartum CTG)
    • Especially concerned if baby is IUGR
    • Can also lead to placental abruption
  • Hyponatraemia (ADH-activity)
  • Hypotension
  • Nausea/Vomiting
  • (Rarely) arrythmias and anaphactoid reactions
166
Q

When should women receive testing for GDM, and who should receive this screening?

A

Everyone! (The guidelines used to say only those with risk factors).Between 26-28 weeks but on the first antenatal visit if they have risk factors.

167
Q

How would you proceed with IOL in a woman who has a Bishop’s Score of 10?

A

Favourable cervix

Most likely AROM + syntocin

168
Q

What is Potter’s sequence?

A

A triad of consequences of oligohydramnios (regardless of the cause)

Clubbed feet

Pulmonary hypoplasia

Cranial anomalies

169
Q

What is the specific test for chalmydia?

A

Nucleic acid amplification test (NAAT) most commonly by PCR

171
Q

What investigations should be ordered at the first antenatal appointment?

A
  • FBE
  • Blood group and red cell antibodies
  • MSU for asmptomatic bacteriuria
  • Rubella serology
  • Hep B serology
  • HIV screen
  • Syphilis screen
  • Haemoglobin studies
171
Q

when can you have amniocentesis?

A

15/40 or later

172
Q

What are the components of the biophysical profile?

A

Non-stress test

Gross body movements

Foetal breathing

Muscle tone

Amniotic fluid index

174
Q

What are Braxton Kicks contractions?

A

Contractions that occur with variable frequency and do not cause progressive cervical dilatation and effacement, can begin as early as the second trimester

176
Q

What are the options for the surgical management of ectopic pregnancy? What do you need to monitor afterward? And what is a potential complication of this type of management?

A

laparoscopy (preferred)

laparotomy (required in an emergency)

Monitor B-HCG afterward - it should fall rapidly.

If it is >65% of original level 48 hours post op OR

> 10% of original level 10 days post op –>

think: persistent trophoblast

177
Q

What are the causes of IUGR?

What can you do about them?

A
179
Q

what is the medical management of miscarriage?

A

Mifepristone (RU486) - Mifepristone acts to block the hormone progesterone –> starves the embryo of nourishment. Also causes softening and opening of the cervix (an oral medication).

Misoprostol: This is a prostaglandin E1 analogue which causes strong uterine contractions in an attempt to expel the embryo from the woman’s body. It is taken 24-48 hours following the mifepristone (can be oral or vaginal)

180
Q

what needs to be done prior to mirena insertion?

how long can it be left in for?

can it be used in nulliparous women?

A
  1. pap semar normal and up to date
  2. chlamydia screen negative
  3. B HCG negative

Can be left in for 5 years

Yes, it can be used but usually requires insertion by specialist in Australia

181
Q

what are the complications of placental abruption?

A
  • hypovolaemic shock
  • DIC (occurs in up to 35% of cases - as thromboplastims are released from damaged placental tissue)
  • Pre-renal renal failure
  • PPH (poor myometrial contraction following placental abruption)
  • Fetomaternal haemorrhage
182
Q

What questions should be asked in the history of the preterm labour patient?

A

Does the patient have:

  • A history of preterm birth?
  • A history of cystitis or pyelonephritis?
  • A known multiple gestation?
  • A known placenta previa?
  • A known fetal anomaly?
  • A known uterine anomaly?
  • Good fetal movements?
  • Untreated infections?
  • Cigarette or cocaine use?
  • An accurate last menstural period LMP or dating ultrasound?
183
Q

What else is required other than folate supplementation in pregnancy?

A

iodine

(iFolic is a good option)

The developed world is becoming more iodine deficient and there is increased iodine requirements in pregnnancy due to increased thyroid activity

185
Q

What are the contraindications to instrument assisted delivery?

A

Face presentation
Bleeding from scalp
Delivery before 34 weeks

186
Q

What are the risks and benefits of artificial rupture of membranes?

A

Risks
Cord prolapse
Ascending infection
Failure à may not trigger good labour

Benefits
Shortens labour
Reduces rate of dystocias

Enables fetal scalp sampling and electrodes

187
Q

what extra investgations do you need to do if you suspect PPROM?

A
  • Collect cervico-vaginal swabs for microscopy and culture (Chlamydia trachomatis and Neisseria gonorrhoeae)
  • Collect low vaginal and ano-rectal swabs for GBS
188
Q

What proportion of women in PPROM go in to spontaneous labour in 24 hours?

A

50%

190
Q

In what type of miscarriage will expectant management be most successful?

How long might the process take?

When is expectant management no longer offered?

A

Incomplete miscarriage.

This process can take several weeks (75% success rate at 6 weeks)

This option is usually only made available to women in the 1st trimester.

191
Q

What is an inevitable miscarrigae?

A

When the cervix has dilated, but products of conception are still intra-uterine. An inevitable miscarriage will either progress to an incomplete or a complete miscarriage.

192
Q

How do you measure the SFH?

A
  1. Find the fundus - may not at the midline
  2. With a tape which is not elastic, lay it face down and run it to the top of the pubic symphasis
  3. Turn the tape over and record the measurement to the nearest 0.5
  4. Roughly - gestational age in weeks = SFH +/- 2cm - should be plotted on chart
193
Q

What are the components of the APGAR?

A
193
Q

what are the artifical ways in which we can “ripen” the cervix?

A

PGE2

Transcervical catheter

Stretch and sweep

193
Q

What are the benefits of breast feeding?

A

ABCDEFGH

Allergy and atopy reduced

Bones (protective against OP)

Close relationship & contraception

Developmental / IQ benefits

Economical

Figure: quicker return to pre-pregnancy weight

GIT (NEC, IBD and gastroenteritis)

Haemorrharge (post partum) reduced

195
Q

What is Naegele’s Rule?

A

Estimated Due date = first day of LNMP + 1 year-3months-7 days (for a 28 day cycle)

196
Q

What are the five different types of deceleration and what do they typically mean?

A

Early –> Normal

Variable –> (rapid onset, variable offset, usually a/w contractions) –> cord compression. If overall trace is good don’t worry, if overall trace is bad then worry

Late –> (starts in middle of contraction) uteroplacental insufficiency. Be hesitant to call a late decel in the absence of other concerning features.

Prolonged –> (15 bpm decel for longer than 90 seconds but less than 5 minutes). uteroplacental insufficiency, urgent Mx may be required. Often caused by prolonged contractions, maternal hypotension or hyperstimulation

Sinusoidal pattern –> Suggests severe hypoxia. Urgent C/S. Outcome is poor

197
Q

What are the indications for IOL?

A

MOTHER PIG

Maternal medical issues (heart/renal/autoimmune dz)

Obstetric cholestasis

Too long (>41 weeks)

Haematological/hypertension (pre-eclampsia)

Endocrine (GDM –> macrosomia)

ROM early or Request

Planned neonatal surgery

Intrauterine death

Growth restriction

199
Q

What is the Brandth-Andrews maneuver?

A

Exertion of traction on the umbilical cord with one hand while the uterus is lifted out of the pelvis by suprapubic pressure on the uterus with the other hand: pressure on the uterus is stopped as the placenta passes through the introitus

200
Q

What Ix would you perform for endometritis / post-partum genital-tract sepsis?

A

FBE

U&Es

High vaginal swab

Pelvic ultrasound for retained products

200
Q

From what GA does the symphysio-fundal height become accurate?

And what is “normal”?

How do you measure it?

A

From 25 weeks.

Symphysiofundal height may be the GA+/-2cm

The measurement should start from the variable point; the fundus, while both hands are available for palpation. From there, the tape is run along the longitudinal axis of the uterus to the top of the symphysis – a fixed point, and the more easily identified landmark.

201
Q

What is a specific indication for ARM, other than the other indications for IOL?

A

If you need to take scalp lactate

202
Q

What are the options of emergency contraception, and their efficacy?

Briefly describe their AE?

At what time frames can each be used?

A

Yuzpe method (ethinyl estradiol / LNG)

  • Oldest method, not available in a lot of countries
  • 2 doses given 12 hours apart
  • Failure rate = 2-3%
  • 72 hours
  • AE = N&V: often simultaneously prescribed with an anti-emetic

Levonorgestrel (LNG - a progesterone)

  • Method of choice
  • Available OTC
  • Less adverse effects
  • Failure rate = 1-2%
  • Can be taken within 72 hours, but preferable within 24 hours

Copper IUD

  • Can be taken up to five days post unprotected intercourse
  • Failure rate = 2-3%
  • Should not be used in those at risk of STIs or PIDs

Mifepristone (RU486)

  • progesterone antagonist
  • Faiure rate = 1-2%
  • Few side effects
  • Can delay menses, which can cause anxiety
  • Can be used up to five days after unprotected intercourse
204
Q

What do you need to check before performing ARM (artificial rupture of membranes)?

A

That the foetal head is engaged. If it’s not, when you rupture the membranes the cord could fall out and then the baby will compress it when it’s head enters the pelvis, this could be fatal for the baby!

206
Q

what is the preferred method of cervical ripening in a woman requiring / requesting a VBAC?

A

Transcervical foley catheter

207
Q

compare and contrast first and second trimester screening tests?

A

First Trimester Screening Advnatages

  • Earlier - more options in terms of CVS / amniocentesis and more options for TOP?
  • More sensitive for Trisomy 21 and 18

Second Trimester Screening Advantges

  • Is free (versus first timester which costs money)
  • AFP protein levels can be used to screen for NTDs (although the 20 week ultrasound is more reliable)
207
Q

What are the best choices of contraception post-partum?

What are not good choices?

A

Good Choices

  • Progesterone only pill
  • Barrier protection
  • IUDs
  • Injectable progesterones

Bad Choices

  • Breast feeding as exclusive contraception
  • Combined OCP (as oestrogen affects milk supply)
  • Tubal ligation
208
Q

what is a normal AFI?

A

5-25cm

209
Q

What are the signs of oestrogen deficiency?

A

General:

  • Fatigue
  • Headaches
  • Muscle/joint aches

Cognitive:

  • Depression
  • Memory loss
  • Difficulty concentrating

Vasomotor:

  • Hot flushes
  • Night sweats
  • Urogenital Vaginal dryness/itching
  • Urinary frequency/urgency
210
Q

what are the major causes of -

  1. bleeding in early pregnancy
  2. antepartum haemorrhage
  3. post partum haemorrhage
A
  1. miscarriage, ectopic pregnancy
  2. placental abruption, placenta previa, vasa previa
  3. uterine atony
211
Q

What are the management options for a prolonged latent stage of labour?

A

Hypertonic uterine activity: therapeutic rest with morphine sulfate

Hypotonic uterine contractions: IV oxytocin in a continuous infusion increased incrementally; artificial rupture of membranes

212
Q

how would you define recurrent miscarriage?

A

3 or more pregnancy losses

214
Q

What fetal abnormalities are screened for antenatally and how is this done?

A
  • Down syndrome
    • Ultrasound nuchal translucency
    • First trimester serum screening - free beta human chorionic gonadotrophin and pregnancy-associated plasma protein A
    • Chorionic villus sampling (at 12-14 weeks) or amniocentesis (at 15-18 weeks)
    • New test (not yet covered by the PBS) - free foetal DNA
  • Cystic fibroris or thalassaemia
    • CVB or amniocentesis
  • Neural tube defect
    • Ultrasound diagnosis
215
Q

how do you diagnose placental abruption?

A

usually a clinical diagnosis (painful PV bleeding) in pregnancy > 20 weeks +/- symptoms of shock

Can perform transvaginal U/S - but wouldn’t do so if patient is unstable!

217
Q

What are the three broad strokes of management for extopic pregnancies?

what might be required in ALL of these management options?

A

expectant management

surgical management

medical management

Regardless of treatment option, RCOG recommends anti-D for all non-isoimmunised Rhesus negative mothers.

218
Q

What are the parameters for diagnosing GDM and DM in pregnancy?

A

GDM:

0 hours = 5.5 - 7

1 hour = > 10

2 hours = 8.5 - 11

DM:

0 hours = > 7

2 hours = >11

220
Q

What are the risks of expectant management vs active management of PROM?

A

Expectant

Placental abruption

Cord prolapse

Maternal infection

Foetal infection

Active

Theoretical increased risk of need for instrument delivery or C-section but research shows no increased risk

In practice you usually blend the two by waiting 24 hours after PROM and if labour hasn’t started switch to IOL

221
Q

Why is placental abruption dangerous?

A

Mother can lose large amounts of blood

+

The bleeding can be concealed (may not have PV bleeding)

223
Q

When would you choose forceps instead of vaccuum delivery?

A

Face presentation

Bleeding from skull

224
Q

What are the (generic) causes of post-op fever?

A

WATER, WIND, WIZZ, WALK, WOUND, & WEIRD DRUGS

WATER = IV site infections
WIND = pneumonia

WIZZ = UTI
WALK = deep vein thrombosis
WOUND = surgucal wound infection
WEIRD DRUGS = drug induced fever

225
Q

What is generally considered the point of no return in vaginal labour? Ie: the point at which you’re better off continuing with vaginal birth rather than switching to C section.

A

The head is at the ischial spines (station = 0.)

226
Q

what are some specific risks of PGE2

A

tachysystole and uterine rupture if previous uterine surgery

227
Q

How can you tell in PV fluid is amniotic?

A

Nitrazine paper testing (alkaline amniotic fluid will turn yellow paper blue)

Fern slide

Amnisure

228
Q

what are the progesteronic side effects?

A

HAIL M

Hirsuitism

Acne + Apetite Increase / Weight Gain

Irregular bleeding

Loss of libido

Mood swings

(Think: progesterone is a hormone of pregnancy)

229
Q

what are some specific medical conditions in which the COCP will not be efficacious?

A

IBD (CD & UC)

Gastroenteritis (Diarrhoea & Vomitting)

231
Q

In the event of cord prolapse during labour, what do you do?

A

The most immediate management Is to place mum in the Trendelenburg position and push the presenting part back into the pelvis.

232
Q

How long should labour take, overall?

A

sOverall, labour should take no longer than 12 hours for primis and 8 hours for multis.

233
Q

What are the potential complications of vaccum assisted delivery?

A
234
Q

What action should be taken in the case of cord prolapse?

A

Push and hold the cord back into the pelvis, and put mother into the trendelenberg position

235
Q

As well as history and examination, what are the important components of each antenatal visit?

A

Blood pressure

Weight

Urine dipstick

AUscultation of foetal heart - from 12 weeks onwards

Ask about foetal movements - from 18-20 weeks

Fundal height measureennts and abdominal palpation - from 24 weeks

236
Q

When should you start to ask about foetal movements?

A

18-20 weeks normally

237
Q

What clinical findings (signs or symptoms) may be evident in a woman with placental abruption?

A

Antenatal Presentation

  • PV bleeding after 20 weeks (or not!)
  • Pain (or not!)
  • CV risk factors
  • Signs of shock
  • Tender, woody-hard uterus

Perinatal Presentation

  • CV risk factors
  • Uterine tachysystole
  • Blood stained liqor
  • Signs of shock
  • Foetal compromise on CTG
239
Q

What is the management of eclampsia?

A

Maternal condition is the priority – it is important not to deliver an unstable patient

  • Seizure first aid First aid
  • Roll into recovery position
  • O2 8lpm via hudson mask
  • Mx seizure
  • 4mg MgSO4
  • Treat HTN
  • Labetelol
  • Nifedipine
  • If fits continue
  • 5-10mg IV diazepam

Once the patient is stable:

URGENT DELIVERY IS THE ONLY DEFINITIVE MANAGEMENT

241
Q

How common are instrumental deliveries in Australia?

A

Forceps and vacuum assisted deliveries account for 11% of deliveries in Australia.

242
Q

A woman who has previously LUCS has her 20 week ultrasound and is found to have an anteriorly low lying placenta, what do you think?

A

sAnterior low lying placentas may be in the old scar from the previous LUSCS. This is a placenta accreta until proven otherwise and may need very senior care in tertiary settings.

244
Q

At what gestational age do women typically start feeling foetal movements?

What can delay this?

A

Foetal movements begin to be felt between weeks 15 and 25

They can be masked by an anterior lying placenta

246
Q

What tool is used to assess how “ripe” the cervix is? What are it’s components?

What do the scores indicate?

A

The Bishops Score

Dilation of cervix

Lenth of cervix

Consistency of cervix

Station

Position

A score of 6-8 is the cut-off

(Dilation of the cervix is the most important component)

A score greater than 6-8 indicates a favourable cervix

A score of less than 6-8 an unfavourable cervix

247
Q

What will USS show in women with PROM?

A

Low AFI in 50-70% of women (doesn’t always happen)

If mild oligohydramnios then need to investigate for other causes (cf: causes of oligohydramnios)

If major oligohydramnios –> most likely from PROM

248
Q

Majority of women with placenta previa will have been diagnosed with a low lying placenta at the 20 week scan.

When else should placenta previa be investigated for / excluded, irrespective of U/S reuslts?

A
  • PV bleeding after 20 weeks especially if associated with:
    • abnormal lie
    • high presenting part
249
Q

What are the relative contraindications to contraception?

A

HOMESICKL

Headache / hypertension

Obesity

Medications (some anti-convulsants, some ABx)

Embolism / Thrombus / Clotting disorders

Stroke

IHD

Cancer (breast, cervical)

Kids (nulliparous) and breast feeding

Informed consent / Gillick competent (for minors)

Liver disorders

251
Q

How quickly should the cervix dilate in the first stage of labour?

A

1cm/hour during in multiparous women

2cm/hour in nuliparous women

253
Q

What are the types of shock associated with bleeding in early pregnancy?

A
  • Hypovolaemic shock – due to a ruptured ectopic
  • Neurogenic (cervical) shock – products of conception in cervix (causes an increase parasympathetic drive and bradycardia)
  • Septic shock – miscarriage with infection
254
Q

what are some specific risks of syntocinon?

A

hyponatraemia and oedema (because oxytocin is similar in structure to ADH)

255
Q

What are the important vitamins/minerals to consume during pregnancy?

A
  • Folic acid
  • Iron - the developing foetus iron’s source for the first 5 to 6 months of life is the mother
  • Iodine
257
Q

what are the signs of oestrogen excess?

A

Breast tendernessMenorrhagiaMigraineNauseaShorter cycle length and a shorter follicular phase

258
Q

What extra compnonents of definitive management apply for PPROM (compared to just term PROM)?

A

Give antenatal steroids

Erythromycin should be given for (250mg po 6 hourly for 10 days) following the diagnosis of PPROM

259
Q

When is syntocin administered during normal labour?

A

After the anterior shoulder is delivered

260
Q

What do we learn from the 12 week USS?

A

Identifies viability of the foetus
Estimates gestation and date of delivery
Identifies and characterizes multiple gestation
Identifies risk factors for Down Syndrome as part of 1st trimester screening.
Identifies major fetal abnormalities like anencephaly

261
Q

What are the indications of episiostomy?

A
  • Foetal distress
  • Short/inelastic perineum
  • Shoulder dystocia
  • Foetal malposition e.g. occipito-posterior
  • Intrusmental delivery (especially forceps)
  • Breech delivery
  • Previous pelvic floor surgery
262
Q

What are the signs on CTG which are associated with significant foetal compromise and require immediate delivery, which may include urgent delivery?

A
  • Prolonged bradycardia (5 minutes).
  • Absent baseline variability (
  • Sinusoidal pattern.
  • Complicated variable decelerations with reduced or absent baseline variability.
  • Late decelerations with reduced or absent baseline variability.
263
Q

What are the relative contraindications of IOL?

A

CAMP HI

C Section previously (uterine scar à uterine rupture)

Act quickly! (need for non-elective C-section)

Malpresentation (non-cephalic presentation)

Placenta Previa (risk of haemorrhage)

High Parity (increased risk of uterine rupture)

Infections (active genital herpes, HIV) / IUGR

  • (IUGR babies are often delivered by C section b/c they don’t have a good enough blood supply to cope with vaginal delivery.
264
Q

How do you interpret a CTG?

A

DR C BRaVADO

265
Q

What are the relative and absolute contraindications to hormonal contraception?

A

HOMESICK

Headache / Hypertension
Obesity
Medications (some antivirals/ABx)
Embolism / Thrombus / Clotting disorders
Stroke
IHD
Cancer (Breast, Endometrial)
Kids (ie. parity) / Breastfeeding

266
Q

How do you diagnose miscarriage in someone

A

with B-HCG

Falling levels or failure to rise 50% in 48 hours suggests an abnormal pregnancy.

266
Q

What investigations are required prior to the surgical method of miscarriage?

A
  • Blood group –> anti-D given to rhesus negative women
  • B-HCG / U/S to confirm viable, intra-uterine pregnancy
  • high vaginal swab / serology to rule out chlamydia
  • culture of genital discharge to rule out gohnorrhea
  • vaginal swab to rule out bacterial vaginosis
267
Q

when can you undergo first trimester screening?

A

Maternal Serum Screening - 10/40

U/S - 12/40

268
Q

What are the diagnostic criteria of pre-eclampsia

A
269
Q

when is a tranvaginal ultrasound most reliable?

when is a transabdominal ultrasound most reliable?

A

transvaginal u/s are most reliable when the B-HCG is >1,500 U/L

a transabdominal u/s is most reliable when the B-HCG is >3,500 U/L

270
Q

Define a major versus a minor placenta previa?

A

major = covering the os

minor = within 2-3 cm of the os

271
Q

WHat is the management of eclampsia?

A
272
Q

compare and contrast the clinical and examination findings of placenta previa and placental abruption?

A

Placenta Previa

  • Painless bleeding
  • Abdo SNT
  • Patient not distressed
  • CTG may be NAD
  • Abnormal lie / presentation
  • Not associated with CV risk factors or preeclampsia
  • Clotting abnormalities unusual

Placental Abruption

  • Painful bleeidng
  • Woody hard uterus
  • Patient distressed
  • CTG may be abnormal
  • Normal lie / presentation
  • Associated with CV risk factors and preeclampsia
  • may develop clotting abnormaliites early
274
Q

What infectious diseases are screened for in high-risk women?

A

Think 1G 3T 4C

Gonorrhea

Trichomoniasis, Toxoplasmosis, Thyroid function

Chlamydia, Hep C, CMV and cervical abnormalities

275
Q

who is eligible for the free boostrix vaccine?

A
  • pregnant women from 28 weeks gestation during every pregnancy
  • partners of women who are at least 28 weeks pregnant if the partner has not received a pertussis booster in the last ten years
  • parents/guardians of babies under six months of age and they have not received a pertussis booster in the last ten years.
276
Q

How would you investigate for a suspected ectopic pregnancy?

A
  • FBE
  • Blood group and antibodies
    • Consider group and hold
  • B-HCG - consider serial BHCG (levels may be fluctating)
  • Transvaginal / abdominal U/S
    • if the uterus is empty –> either ectopic por misscarried

NB: In haemodynamically unstable patients in whom ectopic pregancies are the most likely diagnosis, U/S investiagations can be bypassed for diagnosis and treatment at laparoscopy.

278
Q

what should you tell a woman who has been diagnosed with a low lying placenta?

A

5% of pregnancies have a low lying placenta. Most migrate so only 0.5% of pregnancies end up with placenta previa.

Be aware of any vaginal bleeding, and present to hospital immediately.

Depending on how much of the cervical os the placenta is covering (and whether the baby is engaged or not), you may have to have a C section, rather than a NVD.

In the mean time, avoid penetrative sex and warn any doctors or midwives that you hve placenta previa, as they should not perform a VE if you are bleeding

279
Q

if a woman is diagnosed with a low lying placenta at 20 weeks, what is the management?

A

Basics

  • education RE:
    • penetrative sex and VE
    • what to do if experiences PV bleeding
    • prognosis

Place and Person

Ix and Confirm Diagnosis

  • Repeat U/S at 34 weeks
    • Placenta previa? Major or minor
  • Make decision about delivery method

Definitive Management

  • Ensure blood is available at delivery

Prognosis

280
Q

What are the causes of foetal tachy or brady cardia?

A
281
Q

What are some indications for foetal growth and wellbeing studies in later pregnancy?

A

GDM
Gestational HTN
Suspected IUGR (uterus too small)
Decreased fetal movements felt (FMF)
History of pregnancy loss or complication in late pregnancy

281
Q

What is primary ovarian insufficiency?

A

When the cessation of ovarian function occurs before the age of 40 years (ie. cessation of menstruation before age 40)

282
Q

What can you do to assess foetal wellbeing in later pregnancy?

A

SAM BLACK

283
Q

how quickly does the B-HCG increase in a normal, viable, intra-uterine pregnancy (which you would use when requesting serial B-HCG)?

What might be a reason for the B-HCG increasing too quickly?

What might be a reason for the B-HCG not increasing quickly enough?

What might be a reason for fluctuating B-HCG?

A

should double every 48 hours

  • Too quickly - molar pregnancy.*
  • A molar pregnancy is an abnormal form of pregnancy in which a non-viable fertilized egg implants in the uterus and will fail to come to term. A molar pregnancy is a gestational trophoblastic disease which grows into a mass in the uterus that has swollen chorionic villi. The word mole is used to denote simply a clump of growing tissue, or a growth. It is often caused by a sperm combining with an egg which has lost its DNA).
  • Too slowly -* non-viable pregnancy: ectopic or miscarriage
  • Fluctuating B-HCG* - ectopic pregnancy
284
Q

What is the clinical picture of HELLP?

A
286
Q

How common is bleeding in early pregnancy??

A

15-20% of women will experience BEP

287
Q

How long should the second stage of labour take?

A

1 hour in multigravid women

2 hours in primigravid women

3 hours if having epidural

no longer than three hours

288
Q

What do you know about bloody show?

A

Bloody show (a small amount of blood with mucous discharge from the cervix) may precede onset of labor by as much as 72 hours.

Bloody show can be differentiated from abnormal 3rd-trimester vaginal bleeding because the amount is small, typically mixed with mucus and the pain due to abruptio placentae is absent. In most pregnant women, previous ultrasonography has been done and ruled out placenta previa. However, if ultrasonography has not ruled out placenta previa and vaginal bleeding occurs, placenta previa is assumed to be present until it is ruled out. Digital vaginal examination is contraindicated, and ultrasonography is done as soon as possible.

290
Q

When is implanon contraindication?

A

Breast Cancer

But use with caution and explain all possible risks to patients with “HOMESICKL”

291
Q

what is involved in second trimester screening?

A

aka the ‘quad test’

involves only maternal serum screening but screens for four markers (alpha feto protein / AFP, unconjugated estriol, B-HCG and inhibin A)

292
Q

What are the requirments for expectant management of PROM?

A

Term baby

Engaged with cephalic presentation

NO PV exams

CTG normal

Mother in a facility able to properly monitor her

Maternal vitals normal

GBS negative

293
Q

What is the cut off amniotic fluid index for oligo and polyhydramnios?

A

Polyhydramnios - AFI >25

Oligohydramnios - AFI

294
Q

What proprortion of mothers with placental abruption present with PV bleeding?

A

2/3

1/3 of women don’t have any PV bleeding! The bleeding is concealed and they are bleeding into their uterus.

295
Q

when is placenta previa usually diagnosed?

A

at the 20 week scan you can usually see that a woman has a “low lying placenta”

If it is low lying, in a lot of cases it will migrate

296
Q

What is the typical causes of pain post partum?

What is the management?

A

Causes

  • Perineal pain and ‘after-pain’ (uterine contractions) are common in the first 3 days of peurperium.
  • It is preferable to avoid opioid analgesia because it can slow resumption of normal bowel function.

Management

  • Regular paracetamol
  • Topical lignocaine
  • Diclofenac (voltaren) suppositories at birth and 12 hours postpartum (best evidence for perineal pain)
  • Laxatives to avoid straining on perineal tear
297
Q

When can a stretch and sweep be performed?

A

post dates ie. > 40 weeks

298
Q

What are the other, “non-emotional” names for abortion and miscarriage?

A

spontaneous pregnancy loss

early pregnancy failure

299
Q

What are the risks of IOL?

A

PATH / ROAD

Prolapsed umbilical cord

Abruption of placenta

Tachysystole

Hyponatraemia/haemorrhage

Rupture of uterus

Oedema/fluid retention

Atonic uterus

Didn’t work (failure leading to C section)

300
Q

What % of women have a low lying placenta at their 20 week ultrasound scan?

What is the management?

What % of women have placenta previa?

A

5%

Follow up ultrasound at 34 weeks, explain to mother that it’s like blowing up a baloon so the placenta is likely to move to a safe spot

0.5% go on to have placenta previa

301
Q

If a woman has had PROM or PPROM and you are inducing labour, what do you use?

A

“In term PROM or PPROM, either PGE2 or an oxytocin infusion are acceptable, regardless of cervical status, as they are equally effective”

302
Q

What are the risk factors for pre-eclampsia?

A
303
Q

What is the criteria for a deceleration on CTG?

A

HR falls below baseline by >15 bpm for >15 secs

304
Q

What is a “normal” or “healthy” amount of variability of a foetal HR on CTG?

A

RWH defines normal as between 5-25, other sources say >10

If baby is in REM sleep, variability can be

305
Q

What are the signs of placental separation?

A
  • The uterus becomes firm and globular
  • A gush of blood flows from the vagina
  • The umbilical cord lengthens outside the vulva
  • The uterine fundus rises in the abdomen
306
Q

What are the risk factors for shoulder dystocia?

A

Maternal

  • Abnormal pelvic anatomy
  • Diabetes
  • Post dates prePnancy
  • Previous shoulder dystocia
  • Short stature
  • Obesity

Fetal

  • Macrosomia
  • Postmsyutity

Intrapartum

  • Long first stage of labour
  • Long second stage of labour
  • Instrumental delivery
  • Induction of labour
  • Use of oxytocin
307
Q

what is a definite prerequisiute before you perform AROM and why?

A

the baby’s head must be fixed and engaged, otherwise may

–> cord prolapse

308
Q

What things would lead you to consider or proceed with instrument assisted delivery?

A
  • Apparent or likely foetal compromise in the second stage
    • Delay in the second stage (>1 hour for multi, >2 to primi à epidural ads an extra hour to each)
  • Maternal effort contraindicated (cannot strain)
    • Cerebral aneursym
    • Aortic dissection
    • Severe HTN
309
Q

Why is general anaesthetic avoided in pregnant women?

A

Higher risk of aspiration

The uterus is pushing up on the abdominal cavity + progesterone relaxes the lower oesophageal sphincter

310
Q

How often and at what aged should one be screened for chlamydia?

A

Yearly in all sexually active young people aged 15–29 years

311
Q

What are the risks of term prom and pre-term prom?

A

Maternal infection
Neonatal infection
Cord prolapse
Cord compression
Placental abruption

Plus in PPROM additional risk of premature birth

312
Q

What are you looking for on foetal artery doppler?

A

Two things:

1) In suspected RhD, the flow velocity of the middle cerebral artery can be used to quantify foetal anaemia. This is the equivalent of listening for a flow murmur in an anaemic adult
2) diastolic flow patterns in the umbilical artery can demonstrate high resistance in the placenta vasculature and assess the risk for pre-eclampsia, IUGR and abruption

313
Q

What are the possible causes of recurrent miscarraige?

A

Only investiagte after 3 miscarriages

314
Q

What are the requirments for a forceps delivery?

A
  • The foetal vertex must be engaged
  • The position of the foetal vertex myst be certain
  • Membranes must be ruptured
  • Uterine contractions must be present
  • The cervix must be fully dilated
  • The bladder should be emptied
  • Adequate anesthesia is optimal
315
Q

What are the 3 stages of labour?

A

First: from the onset of labour to full dilatation (commonly lasts 8-12 hours in a first labour, 3-8 hours in subsequent labours)

Second: from full dilatation of the cervix to delivery of the baby (commonly lasts 1-2 hours in a first labour, 0.5-1 hour in subsequent labours)

Third: from delivery of the baby to the delivery of the placenta (commonly lasts up to an hour if physiological, 5-15 minutes if actively managed)

316
Q

When should vaginal examinations be performed in the first stage of labour?

A
  • On initial presentation of patient with contractions
  • Latent phase: sparingly if membranes have ruptured
  • Active phase: approximately every 2 hours
  • If the patient reports the urge to push of FHR decelerates
317
Q

What are the relative contraindications to IOL?

A

CAMP HI

C Section previously (uterine scar –> uterine rupture)

Act quickly! (need for non-elective C-section)

Malpresentation (non-cephalic presentation)

Placenta Previa (risk of haemorrhage)

High Parity (increased risk of uterine rupture)

Infections (active genital herpes, HIV)

318
Q

how do you define antepartum haemorrhage (versus bleeding in eraly pregnancy)?

A

APH = bleeding after 20 weeks

BEP = bleeding before 20 weeks

320
Q

What is the effect of epidural anasthesia on the 2nd stage of labour?

A

Slows it down, becaused reduced sensation of need to push

Increases time of second stage from 1-2 hours in multigrad, 2-3 hours in primigrad

321
Q

What are endometriomas?

A

Invasive

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