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Flashcards in O&G Deck (101):
1

Pain in Pregnancy

Early
Ectopic
Miscarriage

Late (LAPUS)
Labour
Abruption
Pre-eclampsia (HELLP)
Uterine rupture
Symphysis pubis dysfunction

Any time
UTI
Appendicitis

2

Causes of a Raised and Decreased AFP

Increased (MAN)
Neural Tube Defects (meningocele, myelomeningocele, anencephaly)
Abdominal wall defects (gastroschisis, omphalocele)
Multiple pregnancy

Decreased (MED)
Down Syndrome
Edward's
Maternal diabetes mellitus

3

Causes of Amenorrhoea

Primary Amenorrhoea
Causes:
Outflow abnormalities Müllerian agenesis; transverse vaginal septum; androgen insensitivity, imperforate hymen
Ovarian disorders PCOS; gonadal dysgenesis, e.g. Turner’s syndrome— gonads may have malignant potential
Pitutary disorders: Prolactinoma
Hypothalamic disorders: Kallman’s syndrome (congenital GnRH deficiency associated with anosmia)

2Ts and 2Cs
Turner's
Testicular feminisation
Congenital adrenal hyerplasia
Congenital genital tract ,malformation

Secondary
PHHAST
Premature ovarian failure
Hypothalamic (stress, low BMI)
Hyperprolactinaemia
Asherman's syndrome
Sheehan's syndrome
Thyrotoxicosis

4

Antenatal Supplements

Folic Acid: 400 micrograms/day (unless taking anti-epileptics)

Vitamin D: 10 micrograms/day

Both Folic Acid and Vit D are in the "Healthy Start Vit"

Iron not routine

Vitamin A supplementation (intake above 700 micrograms) might be tetragenic. Liver is high in vitamin A so consumption should be avoided

5

Antenatal Screening

Anaemia
Bacteriuria
Blood group, Rhesus status and anti-red cell antibodies
Down's syndrome
Fetal anomalies
Hepatitis B
HIV
Neural tube defects
Risk factors for pre-eclampsia
Rubella immunity
Syphilis

The following should be offered depending on the history:
Placenta praevia
Psychiatric illness
Sickle cell disease
Tay-Sachs disease
Thalassaemia

6

Amsel's Criteria

3 of the 4 = bacterial vaginosis

White, thin homogenous discharge

Clue cells on microscopy

pH >4.5

Positive Whiff test (addition of potassium hydroxide --> fishy odour)

Management: Metronidazole for 5-7 days

7

Breast Cancer Risk Factors

Genetics
BRCA gene - 40% life-time risk
1st degree premenopausal relative developing breast cancer
p53 gene mutations

Pregnancy associated
Nulliparity
1st Pregnancy >30 years (<25 years protective)

Hormone associated
Early menarche, late menopause
COCP use
HRT use (1.023 / year of use)

Past breast cancer
Not breast feeding
Ionising radiation
Obesity
Previous surgery for benign disease (?more follow-up, scar hides lump)

8

Contraindications to Breastfeeding

Non-Drug
Galactosaemia
Viral Infections

Drug
Antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
Psychiatric drugs: lithium, benzodiazepines
Aspirin
Carbimazole
Sulphonylureas
Cytotoxic drugs
Amiodarone

9

Cervical Cancer

80% squamous cell
20% adenocarcinoma

Abnormal vaginal bleeding
post-coital bleeding
inter-menstrual bleeding

HPV 16, 18, and 33

10

Cervical screening

25-49 years: 3-yearly screening

50-64 years: 5-yearly screening


Mild dyskaryosis and HPV +ve --> refer for colp

Moderate dyskaryosis --> refer for colp

Severe dyskaryosis --> refer urgently (two week wait)

Suspected invasive cancer --> refer urgently (two week wait)

Inadequate --> repeat, if 3 consistent inadequate --> refer for colp

11

Cervical Ectropion

Larger area of columar epithelial at transition zone

Elevated oestrogen (ovulatory phase, pregnancy, COCP) --> increased columnar area

Vaginal discharge
Post-coital bleeding


Ablative treatment (for example 'cold coagulation') is only used for troublesome symptoms

12

Chickenpox exposure in pregnancy

Chickenpox = primary infection with varicella zoster
Varicella zoster is human herpesvirus 3 (HHV-3)

During pregnancy:
Increased risk to mother: 5x risk of pneumonitis
Increased risk to fetus: Varicella syndrome

Management of chickenpox exposure
Maternal blood should be urgently checked for varicella antibodies

Not immune --> varicella zoster immunoglobulin (VZIG) as soon as possible, effective up to 10 days post exposure

Oral aciclovir should be given if pregnant women with chickenpox present within 24 hours of onset of the rash

13

Fetal Varicella Syndrome

Fetal varicella syndrome (FVS)

Risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation

Very small number of cases occurring between 20-28 weeks gestation

None following 28 weeks

Features of FVS
Skin scarring
Eye defects (microphthalmia)
Limb hypoplasia,
Microcephaly
Learning disabilities


Other risks to the fetus
Shingles in infancy: 1-2% risk if maternal exposure in the second or third trimester

Severe neonatal varicella: if mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

14

COCP Advantages and Disadvantages

Advantages
Failure rate <1 per 100 women years
Make periods lighter and less painful
Reduced risk of ovarian, endometrial and colorectal cancer
May protect against pelvic inflammatory disease
May reduce ovarian cysts, benign breast disease, acne vulgaris

Disadvantages
People may forget to take it
Offers no protection against sexually transmitted infections
Increased risk of VTE
Increased risk of breast and cervical cancer
Increased risk of stroke and ischaemic heart disease (especially in smokers)
Temporary side-effects such as headache, nausea, breast tenderness may be seen

15

COCP Contraindications

Examples of UKMEC 3 conditions include
>35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
Family history of thromboembolic disease in first degree relatives < 45 years
Controlled hypertension
Immobility e.g. wheel chair use
Carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)


Examples of UKMEC 4 conditions include
>35 years old and smoking more than 15 cigarettes/day
Migraine with aura
History of thromboembolic disease or thrombogenic mutation
History of stroke or ischaemic heart disease
Breast feeding < 6 weeks post-partum
Uncontrolled hypertension
Current breast cancer
Major surgery with prolonged immobilisation

16

COCP Counselling

Benefits
>99% effective if taking as prescribed
Lower risk of some cancer

Risks
Small increase in clots
Very small increase risk of stroke and heart attacks
Small increase in breast and cervical cancer

Contraceptive Advice
if started <5 days of cycle --> no further contraception needed
If after day 5 --> additional contraception for 7 days
Should be taken at the same time everyday
taken for 21 days then stopped for 7 days - similar uterine bleeding to menstruation
Advice that intercourse during the pill-free period is only safe if the next pack is started on time

Discussion on situations here efficacy may be reduced*
If vomiting within 2 hours of taking COC pill
If taking liver enzyme inducing drugs
Don't worry about antibiotics unless rifampicin

Other information
Discussion on STIs

If 1 pill is missed (at any time in the cycle)
Take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
No additional contraceptive protection needed


If 2 or more pills missed
Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
The women should use condoms or abstain from sex until she has taken pills for 7 days in a row.

IF missed pills in day 1-7: emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1

IF pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

17

Contraception for women aged > 40 years

Combined oral contraceptive pill (COCP)
COCP use in the perimenopausal period may help to maintain bone mineral density
COCP use may help reduce menopausal symptoms
Pill containing < 30 µg ethinylestradiol may be more suitable for women > 40 years
STOP at 50

Depo-Provera
Women should be advised there may be a delay in the return of fertility of up to 1 year for women > 40 years
Use is associated with a small loss in bone mineral density which is usually recovered after discontinuation
STOP at 50

IUS and POP can be used >50 years!

IUS can be used as progesterone part of HRT

POP cannot

18

Causes of Delayed Puberty

Delayed puberty with short stature
Turner's syndrome
Prader-Willi syndrome
Noonan's syndrome


Delayed puberty with normal stature
polycystic ovarian syndrome
androgen insensitivity
Kallman's syndrome
Klinefelter's syndrome

19

Klinefelter's Syndrom

Klinefelter's syndrome is associated with karyotype 47, XXY

Features
often taller than average
lack of secondary sexual characteristics
small, firm testes
infertile
gynaecomastia - increased incidence of breast cancer
elevated gonadotrophin levels

Diagnosis is by chromosomal analysis

20

Kallman's Syndrome

Kallman's syndrome is a recognised cause of delayed puberty secondary to hypogonadotrophic hypogonadism

It is usually inherited as an X-linked recessive trait.

Kallman's syndrome is thought to be caused by failure of GnRH-secreting neurons to migrate to the hypothalamus.

The clue given in many questions is lack of smell (anosmia) in a boy with delayed puberty

Features
'delayed puberty'
Hypogonadism, cryptorchidism (absence or one or both testes from scrotum)
Anosmia
Sex hormone levels are low
LH, FSH levels are inappropriately low/normal
Patients are typically of normal or above average height

Cleft lip/palate and visual/hearing defects are also seen in some patie

21

Androgen Insensitivity Syndrome

X-linked recessive condition
End-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype
Complete androgen insensitivity syndrome is the new term for testicular feminisation syndrome

Features
'primary amennorhoea'
undescended testes causing groin swellings
breast development may occur as a result of conversion of testosterone to oestradiol


Diagnosis
buccal smear or chromosomal analysis to reveal 46XY genotype


Management
counselling - raise child as female
bilateral orchidectomy (increased risk of testicular cancer due to undescended testes)
oestrogen therapy

22

Down Syndrome Screening

Combined test is now standard:
Nuchal translucency Measurement
Serum B-HCG
Pregnancy associated plasma protein A

These tests should be done between 11 - 13+6 weeks


IF women book later in pregnancy either the triple* or quadruple test** should be offered between 15 - 20 weeks

Triple Test
Alpha-fetoprotein
Unconjugated oestriol
Human chorionic gonadotrophin

Quad Test
Alpha-fetoprotein
Unconjugated oestriol,
Human chorionic gonadotrophin
Inhibin-A

23

Secondary dysmenorrhoea

Causes include:
Endometriosis
Adenomyosis
Pelvic inflammatory disease
Copper coil
Fibroids

24

Magnesium Sulfate Treatment for Pre-eclampsia

Guidelines on its use suggest the following:
Should be given once a decision to deliver has been made
In eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour

Urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment

Treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)


Other important aspects of treating severe pre-eclampsia/eclampsia include fluid restriction to avoid the potentially serious consequences of fluid overload



25

Risk Factors for Ectopic

Anything slowing the ovum's passage to the uterus

Damage to tubes (salpingitis, surgery)
Previous ectopic
Endometriosis
IUCD
Progesterone only pill
IVF (3% of pregnancies are ectopic)

26

Eisenmenger's Syndrome

Reversal of a left-to-right shunt in a congenital heart defect due to pulmonary hypertension.

An uncorrected left-to-right leads to remodeling of the pulmonary microvasculature, eventually causing obstruction to pulmonary blood and pulmonary hypertension.

Associated with
ventricular septal defect
atrial septal defect
patent ductus arteriosus


Features
original murmur may disappear
cyanosis
clubbing
right ventricular failure
haemoptysis, embolism


Management
heart-lung transplantation is required

27

Emergency Contraception

Levonorgestrel
Should be taken as soon as possible - efficacy decreases with time
Must be taken within 72 hrs
Single dose of levonorgestrel 1.5mg (a progesterone)
If vomiting occurs within 2 hours then the dose should be repeated
Can be used more than once in a menstrual cycle

Ulipristal
Progesterone receptor modulator (EllaOne)
Inhibition of ovulation
30mg oral dose taken as soon as possible
No later than 120 hours after intercourse
Ulipristal may reduce the effectiveness of hormonal contraception
Contraception with the pill, patch or ring should be started, or restarted, 5 days after
Caution should be exercised in patients with severe asthma
Breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel

IUD
Within 5 days, or within 5 days of supposed ovulation date

28

Endometrial Cancer

Endometrial cancer
post-menopausal women

The risk factors for endometrial cancer are as follows*:
Obesity
Nulliparity
Early menarche
Late menopause
Unopposed oestrogen.
Diabetes mellitus
Tamoxifen
Polycystic ovarian syndrome


Features
post-menopausal bleeding is the classic symptom
pre-menopausal women may have a change intermenstrual bleeding
pain and discharge are unusual features


Investigation
first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm in post-menopausal, <10mm pre-men) has a high negative predictive value
Hysteroscopy with endometrial biopsy (Pipelle)


Management
Localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy
progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery

29

Endometriosis

Growth of ectopic endometrial tissue outside of the uterine cavity
Up to 10-15% of women have a degree of endometriosis

Clinical features
chronic pelvic pain
dysmenorrhoea - pain often starts days before bleeding
deep dyspareunia
subfertility


Less common features
urinary symptoms e.g. dysuria, urgency
dyschezia (painful bowel movements)


Investigation
Laparoscopy is the gold-standard investigation



Management depends on clinical features - there is poor correlation between laparoscopic findings and severity of symptoms

NSAIDs and other analgesia for symptomatic relief

Combined oral contraceptive pill

Progestogens e.g. medroxyprogesterone acetate

Gonadotrophin-releasing hormone (GnRH) analogues - said to induce a 'pseudomenopause' due to the low oestrogen levels

Intrauterine system (Mirena)

Drug therapy unfortunately does not seem to have a significant impact on fertility rates


Surgery
Some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility

30

Genital warts

Genital warts (also known as condylomata accuminata)

They are caused by the many varieties of the human papilloma virus HPV
especially types 6 & 11.

It is now well established that HPV (primarily types 16,18 & 33) predisposes to cervical cancer.

Features
Small (2 - 5 mm) fleshy protuberances which are slightly pigmented
May bleed or itch


Management
Topical podophyllum or cryotherapy

2nd line: imiquimod is a topical cream

Genital warts are often resistant to treatment and recurrence is common although the majority of anogenital infections with HPV clear without intervention within 1-2 years

31

Gestational Trophoblastic Disease

Describes a spectrum of disorders originating from the placental trophoblast:
-Complete hydatidiform mole
-Partial hydatidiform mole
-Choriocarcinoma


Complete hydatidiform mole
Benign tumour of trophoblastic material
Empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin

Features
Bleeding in first or early second trimester
Exaggerated symptoms of pregnancy e.g. hyperemesis
Uterus large for dates
Very high serum levels of human chorionic gonadotropin (hCG)
Hypertension and hyperthyroidism


Management
Urgent referral to specialist centre - evacuation of the uterus is performed
Effective contraception is recommended to avoid pregnancy in the next 12 months

Around 2-3% go on to develop choriocarcinoma

Partial Mole
Normal haploid egg may be fertilized by:
Two sperms,
OR
One sperm with duplication of the paternal chromosomes

Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen

32

Gynaecological Causes of Abdominal Pain

Causes:
Mittelschmerz
Endometriosis (adenomyosis)
Ovarian torsion
Ectopic pregnancy
PID

33

Fitz-Hugh Curtis Syndrome

Peri-hepatic inflammation secondary to chlamydia

Secondary to PID

RUQ abdominal pain aggravated by breathing, coughing or laughing, which may be referred to the right shoulder.

34

Herpes Simplex Infection

HSV-1: oral herpes

HSV-2: genital herpes

(Although overlap)

Management
Gingivostomatitis: oral aciclovir, chlorhexidine mouthwash

Cold sores: topical aciclovir although the evidence base for this is modest

Genital herpes: oral aciclovir. Some patients with frequent exacerbations may benefit from longer term aciclovir


Pregnancy
Elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation

Women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low

35

HIV in Pregnancy

Factors decreasing vertical transmission:
Maternal ART
Method of delivery
Neonatal ART
Bottle feeding decreases transmission

Mode of Delivery
IF maternal viral load <50 at 36 weeks --> vaginal delivery recommended
IF >50 --> caesarean section with Zidovudine transfusion starting 4 hours pre section

Neonatal ART
IF maternal viral load <50 --> Oral Zidovudine
IF >50 --> Triple ART for 4-6 weeks

36

Hormone Replacement Therapy

Complications
Cancer-associated
Increased breast cancer (duration-dependent increase)
Increase endometrial cancer (risk reduced with continuous progesterone)

Vascular-associated
Increased VTE
Increased Stroke
Increased ischaemic heart disease if given >10 years after menopause

Side Effects
Nausea
Breast tenderness
Fluid retention and weight gain

37

hCG

Produced by the embryo and later by the placental trophoblast (syncytiotrophoblasts specifically)

Main role is to prevent the disintegration of the corpus luteum

hCG levels double approximately every 48 hours in the first few weeks of pregnancy

Levels peak at around 8-10 weeks gestation.

38

Human papilloma virus vaccination

HPV 6 & 11: causes genital warts
HPV 16, 18, and 31: linked to a variety of cancers, most notably cervical cancer

HPV infection is linked to:
over 99.7% of cervical cancers
around 85% of anal cancers
around 50% of vulval and vaginal cancers
around 20-30% of mouth and throat cancers

VACCINE: Gardasil protects against HPV 6, 11, 16 & 18.

Girls aged 12-13 years are offered the vaccine in the UK
The vaccine is normally given in school
Information given to parents and available on the NHS website make it clear that the daughter may receive the vaccine against parental wishes
Given as 2 doses - girls have the second dose between 6-24 months after the first, depending on local policy


Injection site reactions are particularly common with HPV vaccines.

39

Hyperemesis Gravidarum

Associations
Multiple pregnancies
Trophoblastic disease
Hyperthyroidism
Nulliparity
Obesity

Management
Antihistamines should be used first-line (BNF suggests promethazine as first-line)
Ginger and P6 (wrist) acupressure

Admission may be needed for IV hydration

Complications
Wernicke's encephalopathy
Mallory-Weiss tear
Central pontine myelinolysis
Acute tubular necrosis
Fetal: small for gestational age, pre-term birth

40

Pre-existing hypertension

A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg BEFORE 20 weeks gestation

No proteinuria, no oedema

Occurs in 3-5% of pregnancies and is more common in older women

41

Pregnancy-induced hypertension
(PIH, also known as gestational hypertension)

Hypertension (as defined above) occurring in the second half of pregnancy (i.e. AFTER 20 weeks)

No proteinuria, no oedema

Occurs in around 5-7% of pregnancies

Resolves following birth (typically after one month)

Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life

42

Pre-eclampsia

Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)

Oedema may occur but is now less commonly used as a criteria

Occurs in around 5% of pregnancies

Grading severity:
MILD
Proteinuria
Mild/Moderate HTN
140/90 - 149/99 mmHg

MODERATE
Proteinuria
Severe HTN
No maternal complications
150/100-159/109 mmHg

SEVERE
Proteinuria
Any HTN <34 weeks
Maternal complications present
BP: >160/110 mmHg

43

Hypothyroidism in Pregnancy

Increase levothyroxine by at least 25-50 micrograms

44

Induction of Labour

Indications
Prolonged pregnancy, e.g. > 12 days after estimated date of delivery
Prelabour premature rupture of the membranes, where labour does not start
Diabetic mother > 38 weeks
Rhesus incompatibility


Method
membrane sweep
intravaginal prostaglandins
breaking of waters
oxytocin

45

Measuring Ovulation

Serum progesterone 7 days before menstruation

i.e. day 21 of a 28 day cycle
BUT day 27 of a 34 day cycle

>30nmom/L --> Ovulation
16-30nmol/L --> Repeat
<16nmol/L on 2 occasions --> Refer

46

Infertility

Causes
male factor 30%
unexplained 20%
ovulation failure 20%
tubal damage 15%
other causes 15%


Basic investigations
semen analysis
serum progesterone 7 days prior to expected next period

Secondary Care Investigations
Hysterosalpingography
Investigates the shape of the uterine cavity and the shape and patency of the fallopian tubes
Diagnoses uterine malformations, intrauterine adhesions (Asherman's syndrome) and tubal patency

Key counselling points
folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice

47

Criteria for Methotrexate in Ectopic

Asymptomatic
<35mm
Unruptured
No heart beat
b-hCG <1500
Willing to attend follow up

48

Management of PPH

ABCD
Fluids should be initiated while waiting for appropriate cross-matched blood.

Non-pharmacological intervention
Bimanual uterine compression should be employed Catheter inserted to ensure an empty bladder

Pharmacological
Syntocinon 5 Units by slow IV injection.
THEN
Ergometrine (contraindicated in hypertension)
THEN
Syntocinon infusion
THEN
Carboprost (contraindicated in asthma)
THEN
Misoprostol 1000 micrograms rectally

If pharmacological management fails then surgical haemostasis should be initiated

Primary post-partum haemorrhage (PPH) is the loss of greater than 500 ml of blood within 24 hours of delivery.
Minor PPH is a loss of 500-1000 ml of blood.
Major PPH is over 1000 ml of blood.

The causes of a primary PPH can be divided into the 4 T's:
Tone - problems with uterine contraction
Tissue - retained products of conception
Trauma
Thrombin

The most common cause of primary PPH is due to uterine atony.

49

Sensitising Events in Pregnancy (RhD)

Potentially sensitising events in pregnancy:
- Ectopic pregnancy
- Evacuation of retained products of conception and molar pregnancy
- Vaginal bleeding < 12 weeks, only if painful, heavy or persistent
- Vaginal bleeding > 12 weeks
- Chorionic villus sampling and amniocentesis
- Antepartum haemorrhage
- Abdominal trauma
- External cephalic version
- Intra-uterine death
- Post-delivery (if baby is RhD-positive)

50

Cervical Smears

3-yearly from 25–49y

5-yearly from 50–64y

51

Other Abnormalities seen on Cervical Smear

Dyskaryotic glandular cells—refer for colposcopy

Atrophic—common in peri-/postmenopausal women. No action

Endometrial cells—may be normal if IUCD in situ, hormonal treatment, or first half of 28d cycle. Otherwise, discuss with laboratory. Refer if reported as abnormal

Inflammatory changes—common finding. Take chlamydial, endocervical, and high vaginal swabs. Treat as necessary

Trichomonas, candida or changes associated with HSV infection—treat trichomonas or candida. Discuss any new diagnosis of HSV with the patient

• Actinomyces—associated with IUCDs

52

Small for gestational age

= <10th centile

Severe SGA = <3rd

53

Fraser Criteria

• The young person understands the practitioner's advice.
The young person cannot be persuaded to inform parents

The young person is likely to begin/continue having intercourse with or without contraceptive treatment.

Unless receives contraceptive advice/treatment, physical or mental health (or both) are likely to suffer.

The young person's best interest requires the practitioner to give contraceptive advice/treatment (or both) without parental consent.

54

Nagle's Law

Subtract 3 months from last period

Add 1 year and 7 days = EDD

Add number of days if cycle >28 days and subtract number of <28

55

Large for Dates

Incorrect dates

Full bladder

Multiple pregnancy

Uterine fibroids

Pelvic mass

Molar pregnancy

56

Symphisis - Fundal height

After 24 weeks = gestational age in weeks +/- 2cm

57

1 minute APGAR

Correlates with need to be resuscitated

58

5 minute APGAR

Correlates with long-term neurological condition

59

Booking bloods for pregnacy

FBC

Anti-D

Syphilis

Rubella

HIV

Hep B

Sickle cell

Thalassaemia

Urinalysis

Urine MC&S

60

No of antenatal appointments in uncomplicated pregnancy

10 Appointments

16 weeks

18-21 weeks

25 weeks

28 weeks

31 weeks

34 weeks

36 weeks

38 weeks

40 weeks

41 weeks

61

Candida infection during pregnancy

Imidazole pessaries

62

Solid or cystic chest masses in neonate

Congenital cystic adenomatous malformation & Pulmonary sequestration

63

Non-immune fetal hydrops

Chromosomal abnormalities: T21

Structural abnormalities: pleural effusion

Cardiac abnormalities or arrhythmias

Anaemia: Parvovirus B19, Fetomaternal haemorrhage, fetal alpha thalassaemia

Twin-twin transfusion syndrome

64

Immune fetal hydrops

ABO incompatibility

Rhesus disease

65

CMV Infection during pregnancy

40% vertical transmission

Symptomatic at birth

IUGR

Pneumonia

Thrombocytopenia

Neurological sequelae: hearing, visual and mental impairment

Dx: USS intracranial calcifications and hepatic calcification
CMV titres IgM vs IgG
Amniocentesis 6 weeks post maternal infection

Mx:
Close surveillance with USS
Fetal blood sampling at 32 weeks for platelets

Offer TOP

66

Herpes simplex during pregnancy

Not teratogenic

Neonatal infection --> disseminated

C-section if primary within 6 weeks delivery

Daily acyclovir

If neonate exposed --> aciclovir

67

Rubella in pregnancy

Infection in early pregnancy
Deafness
Cardiac defects
Eye problems
Mental retardation

90% at 9 weeks

>16 weeks gestation --> very low risk

TOP offered if rubella <16 weeks

Live vaccine contraindicated in pregnancy --> identify need to have it after pregnancy

68

Toxoplasmosis in pregnancy

Protozoa: Toxoplasmosis Gondii

Fetal transmission <50%

Earlier infection = worse outcome

Mental retardation
Convulsions
Spasticities
Visual impairment

USS: hydrops fetalis

Mx: Spiramycin started as soon as maternal infection is diagnosed

+ additional combination therapy

69

Varicella during Pregnancy

Bad if earlier on <28 weeks
FVS
Cutaenous scars
Limb defects
CNS abnormalities

>20 weeks little risk

Bad if within 4 weeks of delivery
Worst: within 5 days after delivery or two days before

70

Protein in PET

Protein:creatinine ratio >30mg/nmol

= 0.3g/24hr protein

71

Treatment of Hyperthyroidism in Pregnancy

Propylthiouracil


(not carbimazole)

72

Tocolytics

Nifedipine

Atosiban (oxytocin receptor antagonist)

73

PTL

If FFN +ve OR Cervical shortening --> steroids and tocolytics

+ mag sulphate

Intra-partum antibiotics

74

Preterm Prelabour Rupture of Membranes

Membranes rupture

Before labour

Before 37 weeks

PTD follows within 48 hours in 50%

Admit
Give steroids

Give prophylactic daily erythromycin

75

ROM

= pool of fluid in posterior fornix (diagnostic)

76

Persistent fetal tachycardia

Chorioamnionitis

77

Massive obstetric haemorrhage

>1000ml

ABC approach

Oxygen by mask 10-15L/min

2x 14-gauge cannula --> take bloods (x-match etc.)

Left lateral tilt

Up to 2L of crystalloid (Hartman)

Up to 1-2L of colloid

Cross-matched blood (if unavailable --> O rh-)

For every 6 units of blood, give 4 units FFP (also give FFP if PT and aPTT 1.5x raised)

Platelets

Cryoprecipitate

78

Lambda sign

Dichorionic

79

T sign

Monochorionic

80

Rotational forceps

Occipito-posterior

Occipito-transverse

81

First stage Active Labour

>3cm dilated

1cm/hr for nullips

2cm/hr for multips

Should be less than 12hr

82

Second Stage Activate Labour

40 mins for nullips

20 mins for multips

If > 1 hr --> SVD unlikely

83

Third Stage of Labour

15 minutes

Normal blood loss = 500 ml

84

Brow and face presentation

---> CS

85

Absence of menstruation for 6 months

Secondary Amenorrhoea

86

>10mm endometrial thickness or polyp in woman >40 years old with recent onset menorrhagia or IMB

Endometrial biopsy

87

When to do an endometrial biopsy (pipelle or hysteroscopy)

1. Endometrial thickness >10mm in premenopausal; >4mm in postmenopausal

2. Age >40 years

3. Menorrhagia with IMB

4. US suggests polyp

5. Before insertion of IUS if cycle irregular

6. Prior to endometrial ablation/diathermy as tissue will not be available for biopsy

7. Abnormal uterine bleeding --> acute admission\

88

Precocious puberty

Polyorstotic fibrous dysplasia

Cafe au lait spots

McCune Albright Syndrome


Mx: Cyproterone acetate

89

cervical glandular intraepithelia neoplasia on Smear

Endometrial cancer

90

Endometrial cancer staging

Stage 1 Lesions confined to uterus
1a <1/2 myometrial invasion
1b >1/2 myometrial invasion

Stage 2 As above but in cervix also
2 Cervical stromal invasion, not beyond
uterus

Stage 3 Tumour invades through uterus
3a Invades serosa
or adnexae
3b Vaginal and/or parametrial
involvement
3c i Pelvic node involvement
3c ii Para-aortic node involvement

Stage 4 Further Spread
4a In bowel/bladder
4b Distant metastases

91

‘inflammatory’ smear

Cervicitis (STI)

92

Non-familial cancer

Cervical cancer

93

Wertheim’s hysterectomy

LN clearance, hysterectomy and removal of parametrium and upper 1/3 vagina

Tx of Cervical cancer above stage 1a

94

Krukenberg tumours

Signet ring cells

Ovarian secondary carcinoma from gut

95

Ca125 of >35IU/ml

USS of pelvis and abdomen

96

Diagnosing Ovarian Cancer

Ca125 + USS
Women under 40: measure AFP and hCG (both raised in germ cell tumours)

Calculate risk of malignancy index (RMI)
RMI = U x M x Ca125 level
U = USS Score
1 point for each of the following characteristics:
Multilocular cysts
Solid areas
Metastases
Ascites
Bilateral lesions
1 point, U =3; 2-5 points (max score) U=3

M = menopausal status
1 = premenopausal
3 = postmenopausal

All women with RMI >250 referred to specialist MDT
CT abdo-pelvis is performed for initial assessment of extent of disease

97

Differentiated Type VIN

Rarer
Associated with Lichen Sclerosis
Older women
Higher risk of progression

Unifocal
Ulcer or plaque

Keratinising squamous cell carcinoma of the vulva

98

Usual Type VIN

Accounts for nearly all VIN
Women aged 35-55
HPV (HPV 16 especially)
Associated with CIN
Smoker
Chronic immunosuppression

Warty
Basaloid
Mixed

Multifocal
Appearances vary widely: Red, white or pigmented Plaques, papules or patches
Erosions
Nodules, Warty
Hyperkeratosis

Associated with warty or basaloid squamous cell carcinoma

99

Vulval Cancer Staging

Stage 1a
Tumour confined to vulva/perineum
<2cm in size with stromal invasion <1mm
Negative nodes

Stage 1b
Tumour confined to vulva/perineum
>2cm in size with stromal invasion >1mm
Negative nodes

Stage 2
Tumour of any size with adjacent spread (lower
urethra/vagina or anus)
Negative nodes

Stage 3
Tumour of any size with positive inguinofemoral
nodes

Stage 4
Tumour invades upper urethra/vagina, rectum,
bladder, bone (4a) or distant metastases (4b)

100

Clear Cell Adenocarcinoma of the Vagina

Daughters of women who had taken DES to prevent miscarriage in late 1950searly
1970s

101

Duloextine

SNRI

Enhances urethral striated sphincter activity via centrally mediated pathway

Stress incontinence

Other sfx: dyspepsia, dry mouth, dizziness, insomnia or drowsiness