Gynaecology Flashcards
(139 cards)
1
Q
Ectocervix
A
Portion projecting into the vagina Lined by stratified squamous non-keratinised epithelium
2
Q
Endocervix
A
Proximal and inner part of cervix Lined by mucus secreting simple columnar epithelium Endocervix ends at internal os
3
Q
Layers cut in lower segment of Caesarian section
A
Superficial fascia Deep fascia Anterior rictus sheath Rectus abdominus Transversals fascia Extraperitoneal connective tissue Peritoneum Uterus
4
Q
supply and drainage of cervix
A
Supply = uterine artery (from internal iliac) Drain = plexus in broad ligament to uterine vein Lymph= iliac, sacral, aortic and inguinal nodes
5
Q
What is the isthmus
A
Junctional zone between the cervix and the body of uterus
6
Q
3rd trimester scan - growth checks
A
Fetal measurement
- Bipaparietal diameter
- occipitofrontal diameter
- head circumference
- abdominal circumference
- femur length
- est fetal weight (Hadlock)
Baby wellbeing
- heart activity
- presentation
- amniotic fluid inc index
- placenta structure and location
- Doppler - umbilical artery - PI, RI, end diastolic flow - R MCA - PI, Ri, Vmax, end diastolic flow
7
Q
Alcohol in pregnancy
A
Complete abstinence is advised. Alcohol is not harmful in small amounts (less than one drink per day) Binge drinking is associated with fetal alcohol syndrome
8
Q
Anetanatal test diagnostic of Down syndrome
A
Trisomy 21 on amniocentesis - chorionic villous sampling Low PAPP-A and high b-HCG = increased risk (NOT diagnostic)
9
Q
Blood glucose frequency in T1DM during pregnancy
A
Daily fasting, pre-meal, post meal 1hr, bedtime
10
Q
Calculation of EDD
A
Taking date of last LMP, counting forward by nine months and adding 7 days If cycles longer than 28 days then add the difference between cycle length and 28 days
11
Q
Management of contact with chickenpox
A
Only VZIG If rash present - then acyclovir
12
Q
Components of early pregnancy scan
A
In 1st trimester
- Gestational sac
- Yolk sac
- Corpus luteal cyst
- Crown rump length
- Subchorionic haematoma
- Uterus ante/retroverted
- Retained products of conception
13
Q
What is knife cone biopsy associated with
A
Increased risk of cervical incompetence (weakness) and stenosis (leading to preterm delivery and dystocia)
14
Q
What is maternal diabetes linked with
A
Macrosomia, FGR, congenital abnormality, pre-eclapmsia, still birth, neonatal hypoglycaemia
15
Q
What is maternal epilepsy associated with
A
Increased fit frequency, congenital abnormality
16
Q
Fetal Dopplers
A
- Umbilical artery
- Middle cerebral artery
- Venous = ductus venosus
- Umbilical artery = placental circulation - in disease resistance increases and end-diastolic flow reverses
- MCA = hypoxaemia - flow redirected
- Ductus venous Doppler’s = cardiac compliance and afterload - increases with disease state affecting placenta so assess wellbeing
17
Q
Fetal MCA Doppler’s
A
Normally = high resistance flow - minimal antegrade flow Pathological = low resistance flow due to fetal head sparing theory Some situations such as severe cerebral odema - the flow reverts back to high resistance pattern —> poor prognostic sign Crebroplacental ratio >1:1 normal and <1:1 is abnormal
18
Q
What is maternal HIV associated with
A
Risk of mother to child transfer
19
Q
What is maternal hypertension associated with
A
Pre-eclampsia
20
Q
What is LLETZ associated with
A
LLETZ (large loop excision of the transformation zone) Is associated with a small increase in risk of preterm birth More than one excision = shorter cervix, which does increase the risk of second and third trimester delivery
21
Q
What is myasthenia Travis/myotonic dystrophy associated with
A
Fetal neurological effect, increase maternal muscular fatigue in labour
22
Q
What is maternal renal disease associated with
A
Worsening renal disease, pre-eclampsia, FGR, preterm delivery
23
Q
A 30-year-old woman who is 26 weeks pregnant is admitted to the maternity unit with heavy vaginal bleeding. She is Rhesus negative. What is the most appropriate management for prophylaxis of Rhesus sensitisation?
A
One dose of Anti-D immunoglobulin followed by Kleihauer test - to detect fetal cell in maternal circulation (required post 20 weeks) check Australia guidelines
24
Q
Routine pregnancy scan
A
- Dating scan
- Nuchal translucency scan
- Morphology scan
- Growth scan
25
What is included in antenatal screening in Australia
? Down syndrome Fetal anomaly - via u/s Haemoglobinopathies Rubella HIV/Hep B Tay-Sach’s in high risk
26
What would you do a speculum exam in pregnancy
1. Excessive or offensive discharge
2. Vaginal bleeding (in absence of placental praevia)
3. To perform cervical smear
4. To confirm potential rupture of membrane
27
What is used for ultrasound dating of pregnancy
Crown-rump length up to 13 weeks + 6 days Head circumference from 14-20 weeks
28
Contraindications to digital exam in pregnancy
1. Known placenta praevia,
2. vaginal bleeding when the placental site in unknown and the presenting part unengaged
3. Prelabour rupture of membranes (increased risk of ascending infection)
29
what is venous thromboembolic disease associated with
Increased risk during pregnancy, thrombophilia, increased thromboembolism risk and increased risk of pre-eclampsia and FGR
30
Adhesions and fibrosis of endometrial cavity due to dilation and curettage
Asherman’s syndrome
31
Braxton Hicks
* Uterine contraction
* Painless contraction
* Allow pacemaker activity of uterine fundus to promote the coordinated, fundal-dominant contraction
32
Cervical ectropion
* Elevated estrogen levels results in a larger area of columnar epithelium being present - cervical ectropion
* Transformation zone - stratified squamous (vaginal) meet columnar epithelium (cervical).
* **Clinical presentation** : vaginal discharge, post coital bleeding
* **Protective factors**: OCP More common in pregnancy.
* **Treatment** = ablative - cold coagulation
33
Meiosis I and Meiosis II
Meiosis I is arrested in prOphase 1 for years until Ovulation Meiosis II is arrested in METaphase II until fertilisation “An egg MET a sperm”
34
What are the components of morula
Trophoblast - cytotrophoblast + synctiotrphoblast Embryoblast - epiblast (ectoderm) + hypoblast (endoderm) —\> amniotic cavity and yolk sac
35
What is a morula
Morula is a 8-16 cell cluster with two layers trophoblast (outer cell mass) and embryoblast (inner cell mass)
36
Toxoplasmosis in pregnancy + congenital
Transmission- mother = raw meat, cat faeces, unpasteurised milk (goat) Fetus = transplacental transmission 70% in third and 15% in first trimester Triad of toxoplasmosis : chorioretinitis, diffuse intracranial calcification and hydrocephalus The 4 C’s = cerebral calcification, chorioretinitis, hydroCephalus and convulsions Other cool features = blueberry muffin rash can also lead to epilepsy, intellectual disability or visual disabilities Diagnostic - PCR for T. Gondii DNA in amniotic fluid Newborn = CT/MRI- intracranial calcification, hydrocephalus, ring enhancing lesions, IgM antibiotics T-gondii PCR for T-gondii and opthamalological evaluation - chorioretinitis Treatment Mother - immediate admistration of spiramycin Fetus - when confirmed or highly suspected - pyrimethamine, sulfadiazine and folinic acid Newborn- pyrimethamine, sulfadiazine and folinic acid
37
Congenital CMV infection
Pathogen - cytomegalovirus herpesvirus Transmission Mother Fetus- transplacental Newborn- birth and breastmilk Clinical features- IUGR, periventricular calcification, hearing loss, chorioretinitis, blueberry mufffin rash, Diagnosis CMV IgM antibodies Viral culture or PCR for CMV DNA (urine or saliva) for fetus use amniotic fluid) Treatment Fetus - intrauterine blood or platelet transfusion for severe anemia and thrombocytopenia Newborn Antivirals, Prevention - freq hand washing, avoid food sharing, kissing CMV similar to toxoplasmosis
38
Congenital listeriosis
Listeria monocytogenes Transmission Mother- raw milk products, Fetus - transplacental transmission, direct from infected vaginal secretion and/or blood during delivery Clinical features Diagnosis - culture from blood or CSF (pleocytosis) Treatment - IV ampicillin or gentamicin Prevention - soft cheese, avoidance of contaminated water and food Nationally notifiable condition
39
Congenital parovirus B19 infection
Parovirus B19 Transmission Mother - via aerosols, hemtogenous transmisison, fifth disease Fetus - transplacental transmission Clinical feature Severe anemia, fetal hydrops (fluid in 2 compartment - plural effusion, pericardial effusion, skin, ascites) Miscarriages and stillbirth Most intrauterine infection
40
What are TORCH infection
T = toxoplasma Gondi O = others - listeria, varicella and parvovirus R = rubella C = cytomegalovirus H = herpes and HIV
41
Congenital rubella infection
Rare because of vaccination Rubella virus Transmission Mother Fetus - transplacental (congenital rubella syndrome esp in first trimester) 1-11 weeks = 90% risk Clinical features CCC- cataracts, cochlear defects (bilateral deafness), cardiac feats (patent ductus arteriosis, pulmonary artery stenosis) Diagnosis PCR for rubella (throat), serology, viral culture In fetus IgM antibodies serology , PCR for rubella RNA (chorionic villi, amniotic fluid) Treatment Intrauterine before 16 weeks = counsel regarding termination \>16 reassurance - supportive and survallence (u/s)
42
Congenital rubella syndrome
Transmission: airborne, transplacental from infected mother. In first trimester 1-11 90% transmission Triad = CCC Cataract - eye manifestation: salt and pepper retinopathy, glaucoma Cochlear defects - bilateral sensoneural hearing loss Cardiac defect - patent ductus arteriosis, pulmonary artery stenosis Early \<16 weeks: termination counselling \>16 weeks: reassurance Supportive care and survelliance - late term management Other clinical features: hepatosplemegaly, jaundice, haemolytic anemia, petechia
43
Congenital syphillis
Caused by treponema pallidum TRANSMISSION Mother - sexual contact Fetus - transplacental transmission : increased with recent sypillis infection risk of transmission increases with age Neonate - perinatal transmission during birth CLINICAL FEATURES Hutchinson triad= interstitial keratitis, senosorineural hearing loss and Hutchinson teeth Early vs late Early = hepatomegly, rhinorrhea, maculopapular rash and skeletal abnormalities Late = facial (saddle nose, frontal bossing, short maxilla. Dental (Hutchinson’s teeth (notched, widely spaced teeth), mulberry molar) Eyes and ears: interstitial keratitis, sensorineural hearing loss Skin: Rhayader (perioral fissure) gummas Skeletal : saber skins (ant bowing of tibia) Dx Newborn and mother - PRP or VDRL (serum) Confirm with dark field microscopy or PCR Fetus- repeat ultrasound exam - placentomegaly, hepatomegly, ascites and/or hydros fetalis TREATMENT 14 days IV penicillin G for pregnancy women and newborn Notifiable disease
44
Congenital varicella infection
Varicella-zoster virus Transmission Mother - airborne droplet, vesicles fluid, deactivation Fetus - transplacental transmission from infected mother Clinical features Congenital varicella syndrome - hypertrophic scar, limb defects, ocular defects, CNS defects (cortical atrophy) Neonatal varicella - mild infection (\>5 days), severe infection (\<5 days) Diagnosis Newborn and baby - skin lesions, PCR from blister or CSF, Fetus- PCR for VZV DNA and ultrasound for fetal abnormalities Treatment Acyclovir IgG antibodies symptoms \<5 days Cesarean section - lesions area present at delivery Breastfeeding encouraged Immnunisation NO NO during pregnancy Immunisation before pregnancy for seroneg women Notifiable disease
45
Insertion of nexplanon (etonogestrel)
Subdermal- non dominant hand
IMPLANON
46
Post-Partum contraception
Needed 21 days after birth Can use progesterone only pill - anytime after 21 days IUD 0 within 48 hours of childbirth or after 4 weeks
47
When is contraception effective immediately?
If inserted up to and including day 5 of mensturation
48
Absolute contraindications for OCP
* More than 35 yo and smoking more than 15 cig/day
* Migraine with aura
* History of thromboembolic disease of thrombogenic mutation
* History of stroke or IHD
* Breastfeeding \<6 week post-partum
* Uncontrolled hypertension
* Current breast cancer
* Major surgery with prolonged immobilisation
49
Acceleration and deceleration
* Acceleration are increase of HR by \>15 beats for \>15 second - reassuring!
* If spontaneous they indicate pH \>7.25
* decelerations are \>15BPM for less than \>15 sec - can be early, late, variable and prolonged -
* early: repetitive between contraction and always return to baseline after contraction
* Late: repetitive from one to next (3+) recovery to baseline is late
* Variable can be typical or atypical
* Prolonged - FHR fall for \>3 min and are usually associated with an acute episode in the mother
50
Early deceleration causes
Early deceleration = repetitive between contraction and always return to baseline after contraction
* Vagal nerve stimulation
* Bowl-like appearance, mirror to contraction
Causes
* Head compression during contraction
* Reduced blood flow and hypoxia
* hypercapnia also which leads to HTN
* bradycardia from parasympathetic
* NS NOT FETAL COMPROMISE
51
Heart rate on CTG
* Bradycardia (100-110) or abnormal bradycardia (\<100) is rare in labour - sudden - prolonged deceleration
* Prolonged - are you monitoring maternal HR
* Tachycardia (161-180) or abnormal (\>180)
* Causes : maternal dehydration, prematurity, maternal fevers either maternal or fetal stress, chorioamniotis
* Early sign of fetal compensation with reduced O2 supply
* Variable deceleration —\> cord compression/prolapse
* Early decelerations —\> head compression
* Acceleration —\> Ok
* Late deceleration —\> placental insuffiency/problem
52
CTG interpretation mnemonic
DR C BRaVODA
* Dr- determine risk
* C- contractions
* BRa- baseline rate
* V- variability
* A- acceleration
* D- deceleration
* O- overall assessment and plan
53
Late deceleration causeas
* Repetitive from one to next
* recovery to baseline is later
Causes
* Change in placental adequacy, may signify hypoxia and acidosis
* Often signals fetal decompensation
* Hypoxia —\> chemoreceptors simulated —\> SA node activated, HR down —\> myocardium deoxygenated and HR slows further —\> takes ages to deoxygenation
54
Late decelerations on CTG
* Pathological sign - fetal distress (asphyxia or placental insufficiency)
* Blood sampling for featl hypoxia - urgent delivery if acidosis
55
CTG: Variability in CTG
* Baseline variabilty - change in FHR over a one minute period
* Should be \>5 but \<25 BPM
* Increased variability - often following acute hypoxic event and should settle after about 10 mins
* Reduced variability - medication (morphine, pethidine), fetal hypoxia, CNS anomalies in the baby and fetal cardiac arrhythmia
56
Rokitansky’s protuberance
Teratoma (dermoid cyst)
57
Indications for expectant management of ectopic pregnancy
* An unruptured embryo \<30 mm in size
* Have no heartbeat
* Be asymptomatic
* Have a B-HcG levels of \<2000U/L and declining
58
Common location for ectopic pregnancy
Most common = ampulla
most likely to rupture: isthmus
59
Ectopic locations
Ampulla = main
60
Cell differentiation of ecto, meso and endoderm
Ectoderm = nervous system + skin Mesoderm = muscle, bone, cartilage , lining and connective tissue Endoderm = primitive gut + organs
61
Endometrial hyperplasia
Irregular proliferation of endometrial glands Simple Complex, Simple atypical Complex atypical Protective factors: OCP
62
Drug associated with endometrial hyperplasia
Tamoxifen - estrogen without progesterone
63
Investigation for suspected endometriosis
Laparoscopy
64
Causes of FGR
* Fetal
* genetic: chromosomes 13 (Palau syndrome), 18 (Edward’s syndrome) and trisomy 21 (Down syndrome)- trisomy 21 = less severe
* infection: rubella, cytomegalovirus, toxoplasma and syphilis
* Maternal
* physiological: maternal height, weight, age and ethnicity
* behavioural : smoking, alcohol and drug use.
* Smoking (CO or vascular effects on uteroplacental circulation)
* alcohol crosses placenta
* chronic disease: restricts fetal growth, hypertension (placental infarction), lung or cardiac conditions
* Placenta
* infarction
65
What is the organism that causes GBS disease
* Streptococcus agalacticae
* Cocci in chains
* Can cause pneumonia and meningitis in children
66
CIN classification
CIN 1 = lower 1/3 of epithelium (LSIL low grad) CIN 2 = lower 2/3 of epithelium (HSIL high grad) CIN 3 = all layers (HSIL) Loss of stratification, abnormal mitosis, increase nuclei size
67
Origin of adenomcarcinoma in gynae
Endometrium
68
causive agent of Herpes simplex
HSV-2 and HSV-1 Transmission
69
Main components of obstertric history
* Presenting complaint
* History of current pregnancy
* Mensturation history
* Past obstetric history
* Gynaecological history - CST to date?
* Sexual and social history
* Past medicine history
* Family history
* Drug - folic acid and iron
* Allergies
70
Obstetric history
Age, date of birth, occupation, ethnicity and first pregnancy Reason for visit This pregnancy: Dating the pregnancy - from LMP - add nine month and 7 days. Antenatal care so far Ultrasound Previous obstetric history Recurrent miscarriage Preterm delivery Pre-eclampsia Abruption Congenital abnormality Macroscopic baby FGR Still birth Method of delivery Past gynae history Length of cycle, contraceptive history , PID history last cervical smear (cone biopsy), pelvic masses, history of sub-fertility Medical and surgical history : pre-existing conditions, previous surgery, psych history Drug history: over-the counter, homeopathic and herbal Allergies Family history Maternal and first degree Social history: partner, who lives at home, income, housing, plan to work during pregnancy, domestic violence Smoking, alcohol and illicit drug history
71
What is gravida and what is parity
Gravida = total number of pregnancies (regardless of end) Parity = number of live births or stillbirths after 24 weeks Twins count as 2 gravida and 2 parity
72
Hypermesis gravidarum electrolyte disturbance
Hyponatraemia, hypokalemia, hypochlorite and metabolic alkalosis Molar pregnancy and multiple pregnancy
73
Blood test for HELLP syndrome
Epigastric pain, nausea, headache and general malaise. HELLP is severe form of pre-eclampsia Characterised by H (haemolysis- low Hb raised raised LD) EL(elevated liver enzyme) and LP (low plalete)
74
Long term complications of hysterectomy
Enterocoele Vaginal vault prolapse
75
increased detrusor pressure
reduced flow rate
in bg of incontience
bladder outlet obstruction: overflow incontienency
symptoms: straining + poor flow + incomplete emptying
76
An 83-year-old lady attends with a history of falls. She has a past medical history of osteoporosis, constipation, frequent urinary tract infections, ischaemic heart disease and urge incontinence. After a thorough history and examination, you decide that these are likely multifactorial related to a combination of physical frailty, poor balance and medication burden. Which one of the following medications should you stop in the first instance?
Oxybutynin
77
Ovarian hyperstimulation syndrome
* seen with fertility treatment - gondadotropin and HcG treatment
* multiple luteining cyst in overies due to increased oestrogen, progesterone and VEGF (vascular endothelial growth factor)
* increased permiability and loss of fluid from intravascular compartment
Clinical features
* Abdo pain + bloating - ascites on u/s
* Mod = abdo pain + bloating + n/v
* severe= mod + oligouria + haemotorit \>45% + hypoprotinemia
* critical = thromboembolism + ARDS + anuria + tense ascitis
78
What are the things used to calculate a bishops score
1. Dilation of cervix in cm
2. Consistency of cervix
3. Length of cervical canal
4. Position
5. Station of presenting part (cm abnove ischial spine)
DCLPS Women dilate consistently only the length of a positioned station
79
Indications for continuous CTG during labour
* Suspected choriamionitis or sepsis or temp of 38 or above
* Severe hypertension 160/110 mmHg or above
* Oxytocin use
* The presence of significant Meconium
* Fresh vaginal bleeding that develops in labour - could be placental rupture or placental praevia
80
Risk factors indicated for intrapartum EFM (electric fetal monitoring)
Antenatal RF
* Prematurity
* Pre-eclampsia/eclampsia
* Diabetes
* Other maternal medical disease
* Antepartum Hemorrhage
* Fetal growth restriction
* Non-reassuring antenatal fetal welfare assessment
* Multiple pregnancy
* Post-term
* Oligohydramnios
* Malpresentation
Intrapartum
* Syntocinon
* Meconium
* Epidural
* Vaginal bleeding during labour
* Maternal pyrexia
* Suspicious FHR on auscultation
* Prolonged ROM (\>24 Hr)
* Previous CS
81
First stage of labour
Start: onset of regular painful contraction and cervical changes
stops when cervix reaches full dilation and effacement and is no longer palpable
82
Rupture of membranes
passage of possibly blood stained mucus from cervix - called "show"
associated with but NOT an indicator of onset of labour
delay of \>4 hours between repture of membrane and onset of painful contaction is called PROM prolonged rupture of membrane
If PROM occurs in the premature period its called preterm prelabour rupture of memebrane
83
Labour: What are the stages of labour
1. Prelabour" days-weeks
2. Rupture of membrane
3. First stage - early and active
4. Second- passive and active (pushing)
5. Third - delivery of newborn to placenta
84
What happens in prelabour
Prebour can last days-week
cervix ripens \*becomes softer, shorter and dilates
85
Transverse lie in early labour
* Early labour (\<3 cm) without rupture of membrane
* can try ECV (external cephalon version) - with the ECV do a rupture of membrane to aid labour and delivery
* Otherwise Caesarean section
86
Fetal fibronectin
* released from gestation sac
* increased risk of early labour
* therefore begin preparing for labour
1. IM steroids: bethamethasone, dexamethason (24-34 weeks)
2. tocolytics- B-Adr agonist, NSAID, Ca channel
3. Abx for GBS
Steroids in GDM: monitor closely as can result in hypoglycemia
87
Advice for post-menopausal women with atypical endometrial hyperplasia
Total hysterectomy with bilateral saplingo-oophorectomy due to malignant progression
88
Management of menopause
1. Lifestyle: exercise, weight loss and sleep hygiene
* hot flushes
* sleep disturbance
* mood
* cognition
1. HRT
* contraindications:
* current/past estrogen sensitive cancer: esp breast cancer
* undiagnosed vaginal bleeding
* endometrial hyperplasia
1. Non-HRT
* vasomotor: fluoxetiene, citalopram and venlafaxine
* dry vagina: vaginal lubrication, moisturiser
* psychological symp: selp help, CBT, antidepressants
* urogenital: strophy (vaginal oestrogen)
89
Post menopausal bleeding
Always investigate
* ultasound
* pipelle biopsy of endometrium
* hysteroscopy with d/c
endometrial hyperplasia = most common
90
What is the hormone predominant in the follicular phase of the cycle
FSH Promotes growth of follicles
91
What is microcephaly
Smaller than usual head circumference - less than 2SD or 3rd percentile Causes include- chromosomal trisomies, fetal alcohol syndrome, congenital TORCH infections, cranial anatomical abnormalities, neural tube defects Practically = 3SD
92
Missed (delayed) miscarriage
* can see gestational sac (\>25mm) with dead fetus
* no fetal actiivity
* w/o symptoms of expulsion: maybe light bleeding
* cervical os closed
* 'blighted ovum' or 'anembroyonic pregnancy'
Management
1. Expectant: \<14 wk, surgical if no response for \>4 weeks
2. Medical: misoprostol +/- pre rx w/ mifepristone
3. Surgical: d&c
4. give anti d to Rh(D) neg patients
93
Threatened Miscarriage
* Painless vaginal bleeding before 24 wk
* less than menstural
* cervical os closed
on ultrasound: vaginal bleeding with fetal activity
Management
1. Expectant: acoid acitivity, weekly ultrasound
2. give Anti D to Rh(D) neg patients
94
Measures for maternal death
MMR = number of maternal deaths in a population divided by the number of live births - shows risk of maternal death relative to number of live births MMRate (maternal mortality rate) - number of maternal death in population divided by the number of women of reproductive age, - reflecting not only the risk of maternal death per pregnancy or per birth but also the level of fertility in population
95
Causes of oligohydramoius
Fetal
* renal causes: renal agenesis, autosomal polycystic kidney disease, uretral obstruction
* torch infection
* multiple pregnancy
Maternal
* premature rupture of memnrame
* post term gestation
* pre-eclapsia
* placental insufficiency
Oligohydramious = reduced amniotic fluid
\<500 mls at 32-36 weeks (3rd trimester)
AFI \<5th percentile
96
Risk factors for ovarian cancer
Family history of BRAC1, BRAC2 gene Early menarche, late menopause an nulliparity CA125 test raised —\> ultrasound
97
Stromal cell types of ovarian cancer
Granulosa - releases inhibit, releases estogen Sertraline leading - renin release —\> HTN Gynandroblastoma
98
Types of ovarian cancer
Epithelium - Fallopian tube or ovary Germ cell - egg production cells Stromal cell - start in cell that produce estrogen and progesterone
99
Best measure of ovulation
* Day 21 progesterone in a normal 28 day cycle.
* Otherwise calculate the day to measure progesterone
* Example for a 35 day cycle lady this will be day 28
100
Blood gas and acid-base changes
Reduced PCO2 Increase PO2 pH alters little Increased bicarbonate excretion Increased oxygen availability to tissue and placenta
101
Changes in breast during pregnancy
* Deposition of fat around glandular tissue, and the number of glandular duct increases (oestrogen effect)
* Progesterone and human placental lactogen (hPL) increases number of gland alveoli
* Prolactin - imp in milk secretion - during pregnancy prolactin level increase but does not cause secretion as it is antagonised but oestrogen at alveolar receptor level
* The drop is oestrogen level 48 hr after delivery removes inhibitor
* The early suckling —\> ant and post pituitary releases prolactin oxytocin - oxytocin released from post pit causes contraction of myoepithelium cell squeezing the milk
102
Cardiovascular changes in pregnancy
1. Increase heart rate (10-20 beat)
2. Increased stroke volume (10%)
3. Increased cardiac output - 5 weeks of gestation
4. Reduced mean arterial pressure (10%)
5. Reduced pulse pressure
6. Reduced peripheral resistance (35%)
7. Palpitation + premature atrial and ventricular ectopic
103
Changes to cervix during pregnancy
Increased vascularity Hypertrophic of cervical glands producing the appearance of cervical erosion - thick mucous discharge and mucous plug Reduced collagen in 3rd trimester and accumulation of glycoaminoglycans and water leading to cervical ripening The lower section shortens and the upper segment expands
104
What causes physiological dyspnoea of pregnancy
Increase tidal volume - increases minute ventilation which is perceived a SOB which is 60-70% Resolves immediately postpartum
105
Changes to eyes during pregnancy
Corneal sensitivity decreases - returns 8 wk post partum Increased corneal thickness - odema Reduced tear production Increased curvature of crystalline lens
106
Gastrointestinal changes in pregnancy
* Oral
* gingivitis (due to vascular permeability),
* increased dental caries,
* increased tooth mobility
* Gut
* uterus displaces the stomach and intestine upwards,
* reduced LOS tone (progesterone effect ),
* increased placental gastrin production and increased gastric acidity (progesterone effect) —\> increased reflux oesophagiits and heartburn.
* Reduced gastric motility and increased stomach volume —\> increase in gastric content aspiration post 16/40
* Liver
* common to find findings of talengiectasia and palmar erythema as liver can clear increased levels of estrogen and progesterone
107
Haematological concequence of pregnancy results in increase of
Erythrocytes sedimentation rate Fibrinogen concentration Activated protein c resistance Factor VII, VIII, IX, X and XII D-dimmer Alkaline phosphatase
108
Haematological concequences of pregnancy results in decrease in
Haemoglobin concentration, haematocrit, plasma folate concentration, protein s activity, plasma protein concentration, creatinine, urea and uric acid
109
Difference in fetal and adult haemoglobin
Two beta-chains are replaced by gamma-chains 2-3, DPG binds to preferentially to beta chains therefore in fetus the oxygen-Hb dissociation curve is shifted to left relative to mother.
110
immune system in pregnancy
IgG antibodies Reduced CD8 T-cell acitivity Increase innate immunity - increase NK cells Unchanged WBC count
111
Normal laboratory findings in pregnancy
* Reduced urea
* Reduced creatinine
* Increased urinary protein
due to increased perfusion to the kidneys
112
Oxygenation during pregnancy
1. Increase in 2,3 diphosphaglycerate (2,3-DPG) concentration.
2. 2,3 DPG preferencially binds to deoxygenated Hb and promotes the release of oxygen from
3. Red cells at relatively lower levels of Hb saturation - this increases the availability of oxygen within tissues
113
Prolactin in pregnancy
* Increased by 15 fold in pregnancy by anterior pituitary
* Oestrogen = stimulators and hPL is inhibitory
* Promotes breast engorgement and alveoli distension with milk
* Receptors for prolactin are also present in trophoblast cell and within the amniotic fluid
* Prolactin many regulate insulin secretion and glucose homeostasis
114
Role of relaxin in pregnancy
1. Allows ligamentaous attachment to relax during pregnancy
2. Includes ribcage to relax increasing subcostal angle
3. Relaxin is producer by ovary and planceta and usually softens and widens the cervix
115
Changes to kidney during pregnancy
increased kidney size Dilation of calyces, renal pelvis and ureter—\> looks like obstruction
116
Functional changes in kidney during pregnancy
Increased GFR 50% Increased renal blood flow 60-75% Increase renal plasma flow Increased clearance of most substances Reduced plasma creatinine, urea and urate Glycouria is normal for
117
Sodium balance in pregnancy in kidney
Increased filteration but also increased sodium reabsorption in proximal (oncotic pressure) and distal (hormonal factors)
118
Skin changes in pregnancy
* Hyperpigmentation
* Striae gravidarum
* Hirsuitism
* Increased sebaceous gland activity
119
Affect of pregnancy on uterus
* Increased blood flow
* Hyperplasia and hypertrophy of myometrium (estrogen and prosgesterone)
* Increased weight
* Hypertrophy of uterine artery
* Lower segment = thinner, less muscle and fewer blood vessels - therefore caesarean incision here Increased intercellular gap - increased depolarisation
120
Volume homeostasis in pregnancy
* Rapid expansion of blood vol at 6-8 weeks up to 32-34 weeks of gestation
* Accounts for 8-10 kg of weight gain 6.5L to 8.5 L
* increased cardiac output
* increased renal blood flow
* physiological anemia : increased plasma volume relatively to erythrocytes volume
* lower plasma albumin concentration
* Water retention occurs from changes in osmoregulation and RAAS system —\> active sodium reabsoption in renal tubles —\> retention
* Other factors resulting in fluid retention: sodium ratio in, reduced thirst threshold, reduced plasma oncotic pressure Plasma osmolality decreased by 10 mOsmol/kg in preg
121
Consequences of fluid retention in pregnancy
Reduced haemoglobin concentration Reduced haematocrit Reduced serum albumin oncentration Increased stroke volume Increased renal blood flow
122
Thyroid function during pregnancy
HCG similar to TSH First trimester - TSH suppressed, due to reduced release to TRH After 20 week increase T3, T4 Increased GFR increased renal loss of iodised - which results in thyroid taking up too much iodide from circulation and then iodised deficiency Use free T4 and free T3 not total T3 and T4 Reduced fT4 late pregnancy, reduced TSH early pregnancy
123
PID followed by liver inflammation
Fitz-Hugh Curtis - adhesions in liver, liver capsule - Glisson’s capsule
124
Woody uterus
Placental abruption with pain
125
Definition of post-dates pregnancy
The average length of pregnancy is 280 days, or 40 weeks, counted from the first day of your LMP.
A pregnancy that lasts 41 weeks up to 42 weeks is called “late term.”
A pregnancy that lasts longer than 42 weeks (294 days) is called “postterm or post-dates"
In general terms 41+0 is what the medical interventions are used for in regards to mortality risk post-date
126
Post term: What are the complications of post-term pregnancy
1. Stillbirth
2. Macrosomia --\> shoulder dystosia and brachial nerve injury during labour
3. Postmaturity syndrome
4. Meconium in the lungs of the fetus, which can cause serious breathing problems after birth
5. Decreased amniotic fluid, which can cause the umbilical cord to pinch and restrict the flow of oxygen to the fetus
6. Other risks include an increased chance of an assisted vaginal delivery or cesarean delivery.
7. There also is a higher chance of infection and postpartum hemorrhage when your pregnancy goes past your due date.
127
What is post-maturity syndrome
Newborns born after 42 weeeks of gestation
Clinical features
* Dry, loose, peeling skin - esp hands and feet
* Absence of vernix caesosa (yellow cheese substance on skin) and lanugo (thin soft hair)
* Overgrown nails
* Large amount of hair on the head
* Visible creases on palms and soles of feet
* loss of subcutaneous fat
* Meconium staining of skin - Green, brown, or yellow
* More alert and "wide-eyed"
* Intrapartum fetal distress
* increased perinatal mortality
* increased opertative delivery rate
128
What is included in newborn screening
1. Hearing
2. Phenylketonuria
3. Congenital hypothyroidism
4. Cystic fibrosis
5. Medium chain acyl co-A dehydrogenase deficiciency
129
Causes of PPH
The 4 T’s Tone Trauma Tissue Thrombin
130
PPH mangement
1. Call for help, rapid if there is shock, do not leave the women
* Basic measures:
* lie flat
* keep warm
* monitor virals every 5 mins and temp 15 mins
2. Initial assessment: ABCD
* look for reversible causes: remove blots, massage
* Insert catheter - empty bladder (\>30ml/hr)
* IV access - FBC, coats, crossmatch 4 unit, Ca (repeat 30-60 mins)
* Give O2 10-15 L/min
3. History
4. medical management
* syntocin 2nd IV - 5 units
* synotocin infusion IV - w/ saline and hartmans 40 units over 4 hours
* ergometrine (if no HTN) - IV and IM
* contraindication: retained placenta, twin preg, hypertension, sepsis, heart disease, pvd, impaired hepatic or renal function - carbopristil IM or intramyometrial
5. Operative theatre
* MTP
* bimanual compression of the way
* uterine massage
* ballon tamponade: bakri ballon
* haemostatic brace suture
* bilateral ligation uterine artery
* bilateral ligation internal iliac
* arterial embolisation
* hysterectomy
131
Difficulty breastfeeding after PPH in delivery is caused by?
Sheehan’s syndrome: PPH—\> pituitary necrosis —\> hypopituisim (inadequate prolactin and gonodotropin stimulation)
132
Postpartum haemorrhage cause
Most common = uterine Antony the 4 t’s T = tone T = tissue (retained placenta) T = trauma T = thrombin (coagulation abnormalities)
133
First line for respiratory depression caused by MgSulphate
Calcium gluconate
134
Psychiatric disorders post pregnancy
Baby blues, postnatal depression and puerperal psychosis
Baby blue: anxious, tearful and irritable Reassure and health visitor
Postnatal depression: start within a month and peak at 3 months - reassure, CBT and SSRI (paroxetine and Sertraline)
Puerperal psychosis : severe mood swings (bipolar), disordered perception (auditory). Admission to hospital as treatment
135
Female genital tract source sepsis
Amoxicillin/ampicillin 2g IV 6 hourly Gentamicin 4-7 mh/kg IV Metronidazole 500 mg IV 12- hourly
136
Management of shoulder dystocia
1. Recognise: turtle size and failure to progress
2. Call for help - obstetrician, paediatric + Time (7 mins)
3. Simple manoeuvres -
1. McRoberts Manoeuvre
2. Suprapubic pressure : down and rotate
4. Consider episiotomy - access
5. Manoeuvre -
1. internal rotation manoeuvre ant and post -
2. deliver posterior arm
3. be on all 4’s : reverse McRoberts
6. Repeat on reverse McRoberts
7. Zavonelli’s : push head back in and cesarean
8. Symphisiotomy
137
McRobert’s manoeuvre
Supine with both hips fully flexed and abducted
138
Treatment for submucosal fibroid causing infertility
Myomectomy surgical removal of fibroid
139
VBAC: What are absolute contraindications for planned vaginal birth after caeasarean
* Previous vertical (classical) caesarean scar
* Previous episodes of uterine rupture
* Contraindications to vaginal birth - placenta Previa
