What is pelvic inflammatory disease?
Inflammation and infection arising from the endocervix leading to endometritis, salpingitis, oophoritis, pelvic peritonitis, and subsequently formation of tube-ovarian and pelvic abscesses
How does pelvic inflammatory disease cause ectopic pregnancy?
Inflammation of the mucosal lining of the Fallopian tubes -> destruction of cilia -> scarring in the tube lumen -> pocketing in the lumen with partial obstruction predisposing to ectopics
What causes adhesion formation in pelvic inflammatory disease?
Mucopurulent discharge exuding through the fimbrial end of the Fallopian tubes causing peritoneal inflammation, which leads to scarring and adhesion formation.
What is Fitz-Hugh-Curtis syndrome?
'Violin string' appearance of adhesions between the liver and peritoneal surface, caused by perihepatitis due to chlamydia and gonorrhoea infection in pelvic inflammatory disease
What are the signs and symptoms of pelvic inflammatory disease?
-Abdominal, pelvic pain and dyspareunia -Mucopurulent vaginal discharge -Pyrexia (>38 degrees) -Heavy/intermenstrual bleeding -Pelvic tenderness/cervical excitation at examination -Tender adnexal or palpable pelvic mass -Generalised sepsis in severe and systemic infection -Tubal damage leading to tubal occlusion, abscess and hydrosalpinx
What is the gold standard for diagnosis of pelvic inflammatory disease?
Laparoscopy, but not always obvious in mild cases
Which clinical features give a diagnosis of pelvic inflammatory disease?
-Raised WCC - neutrophilia suggestive of acute inflammatory process -Reduced WCC - neutropenia in severe infections -Raised CRP + ESR -Adnexal masses on ultrasound
What are the components of the combined test for Down's syndrome?
-Nuchal translucency -PAPP-A -Beta hCG
What are the components of the quadruple test for Down's syndrome?
-Uconjugated oestradiol -Total hCG -AFP -Inhibin A
What is the downside of the quadruple test compared to the combined test for Down's?
It has a 4.4 per cent false positive rate compared with 2.2.% for the combined test and 1% for the integrated test
What is the integrated test for Down's risk?
The combined test AND the quadruple test together
Is tamoxifen safe in pregnancy and breastfeeding?
No, neither - risk of teratogenicity
Can you do radiotherapy in pregnancy?
No, unless it is a life saving option
When can you use chemotherapy in pregnancy?
All is potentially teratogenic in the first trimester but you can use it in the mid and third trimesters
How should you time birth with chemotherapy ideally speaking?
Ideally birth should be 2-3 weeks after the most recent chemotherapy session to allow bone marrow regeneration
What are the risk factors for gestational diabetes?
High BMI, previous macrocosmic baby, previous history of GDM, family history of diabetes and ethnicity
What is the WHO definition of gestational diabetes?
Impaired glucose tolerance (2 hour glucose greater than or equal to 7.0 umol/L) or diabetes (random glucose greater than or equal to 7.0umol/L or 2 hour glucose greater than or equal to 7.8 mol/L)
What infections does NICE recommend screening for at booking?
Syphilis, HIV, hepatitis B, rubella
What is placenta praaevia?
Where the placenta attaches to the uterine wall close to or overlying the ccervical opening
What is placenta accrete?
Firm adhesion of the placenta to the uterine wall without extending through the full myometrium
What is placenta percreta?
Where the placenta invades the full thickness of the myometrium and beyond it
What are the risk factors for placenta accreta/increta/percreta?
Presence of uterine scar tissues (Asherman's), possible thin decide (uterine cavity lining in pregnancy which is formed under the influence of progesterone)
What is the preferred investigation for pulmonary embolism in pregnant women?
V/Q scan - better than CTPA because it is a definitive test but much lower radiation dose
How do clotting factors change in pregnancy?
Factors VII, X and XII and fibrinogen increase markedly throughout pregnancy
How does stroke volume change in pregnancy?
Increases from the first trimester and is over 30% higher than the non pregnant state by the third trimester
What causes a reduction in haemoglobin concentration in a normal pregnancy?
Haemodilution caused by a relative increase in the plasma volume compared to the red cell mass
How should you manage a soft systolic flow murmur in pregnancy? What causes it?
Don't need to do anything - it's normal. Due to dilatation across the tricuspid valve causing mild regurgitant flow
Can you use warfarin in pregnancy?
No - teratogen and is contraindicated
What is foetal warfarin syndrome?
Use of warfarin in the first trimester causes a constellation of symptoms including nasal hypoplasia, vertebral calcinosis and brachydactyly
What are the risks of using warfarin in the mid and third trimesters?
Risk of teratogenicity is reduced but could be a chance of cerebral malformation s and ophthalmic disorders
How do you treat pulmonary embolism in pregnancy?
Enoxaparin and fondaparinux could technically be used by evidence for efficacy an safety in pregnancy only exists for enoxaparin
What are the risk factors for placental abruption?
Previous abruption, smoking, a growth restricted baby and hypertension
What is the classical presentation for placental abruption?
Painful vaginal bleed
What is a common risk factor for placenta accrete?
Previous caesarean section scar (But can be present in an unscarred uterus)
What is the purpose of giving magnesium sulphate in a pre eclamptic fit?
Cerebral membrane stabiliser
What are the features of HELLP syndrome?
Variant of pre-eclampsia - haemolysis, elevated liver enzymes and low platelets
What are the advantages of using UDCA in obstetric cholestasis?
Helps to treat the pruritus and reduce bile acid level but no data to suggest it helps reduce stillbirths
Is the level of bile acids predictive of outcome of the pregnancy in obstetric cholestasis?
What are the characteristic features of obstetric cholestasis?
Itching and deranged liver function, especially an elevated bile acid level (above 20 mol/L)
How should you manage obstetric cholestasis?
Check liver function weekly. UDCA is unlicensed but may help reduce itching and bile acid level. Induce patients between 37 and 38 weeks gestation as main concern is stillbirth
What history features suggest chorioamnionitis?
Possible ruptured membranes, offensive vaginal discharge, abdominal pain, temperature
How should you manage chorioamnionitis in early pregnancy?
Antibiotics and induce (pregnancy is the nidus of infection)
When is CVS performed?
At what gestation is CVS not performed and why?
9-11 weeks; risk of foetal limb abnormalities
What is the risk of miscarriage with CVS?
How long do results take in CVS?
Why might there be an inconclusive result from CVS?
Other than placental mosaicism, what is a cause of false negative results with CVS?
What must you know about a mother when doing CVS?
Rhesus status - so she can have anti-D if she's negative
What does the first trimester ultrasounds can tell you?
Foetal viability Gestation Defects in gross anatomy Chronicity and amnionicity of multiple pregnancies
What does the second trimester ultrasound tell you?
Abnormalities in structural anatomy Foetal growth Locates placenta Foetal sex with 99% Accuracy
How long do results from amniocentesis take?
Up to 3 weeks for a full karyotype but faster for PCR/FISH tests e.g. for trisomies, triploidy and Turner's syndrome
When is Amniocentesis performed and why?
From 15 weeks - increased risk of miscarriage and talipes if done earlier
What is the risk of miscarriage with amniocentesis?
What can amniocentesis be used for?
Chromosomal analysis e.g. Down's DNA analysis for genetic diseases Enzyme assays for inborn errors of metabolism Diagnosis of foetal infection Information about rhesus isoimmunisation
What do you need to know about the mother before doing amniocentesis?
Rhesus status - she needs anti D if she's negative
What does the serum 'triple test' look for?
Down's syndrome and spina bifida
When (gestation) is triple testing available?
14 to 20 weeks, optimal is 15-16 weeks
How long do the results from the triple test take?
What triple test results are associated with Down's syndrome?
High bHCG, low AFP, low oestriol
What is the face positive rate from the serum triple test?
What is a 'positive' triple test result (what risk)?
1 in 250
What happens if you get a 'positive' triple test result?
Offer CVS or amnio
What triple test results are associated with spina bifida and anencephaly?
Raised AFP alone - associated with a break in foetal skin which can be neural tube defect e.g. spina bifida or anencephaly
What should you do if the triple test suggests spina bifida?
Further testing (imaging) - large overlap with the normal and abnormal levels of AFP
When is foetal echocardiography done?
In the second trimester if there's a high risk of foetal cardiac abnormalities
What are the indications for doing foetal echocardiography?
Mothers with congenital heart disease Diabetes Epilepsy Previous child with congenital heart disease Anormal or inadequate views of the heart at routine second trimester scans High risk nuchal translucency result
When is nuchal translucency done?
11-14 weeks with the crown rump length is 45-84mm
What is the false positive rate with nuchal translucency?
Other than Down's, when is increased nuchal translucency seen?
Cardiac defects Other chromosomal abnormalities e.g. trisomy 18 and 13 and Turner's syndrome
What does it mean if there's increased nuchal translucency but no chromosomal abnormality?
Associated with multiple structural abnormalities e.g. congenital heart disease, exomphalos, diaphragmatic hernia and skeletal defects
What is uterine artery doppler ultrasound used for and when?
20-24 weeks - if high resistance then there is a high chance of pre-eclampsia, abruption and growth restriction )so more careful monitoring is needed)
Where are you trying to sample blood from in antenatal foetal blood sampling?
Umbilical cord (cordocentesis) Fetal intrahepatic vessels Fetal heart
When is antenatal foetal blood sampling used and why?
Only where blood is the only source of information required as the risk of miscarriage is much higher than other invasive tests: In utero transfusion in haemolytic disease Alloimmune thrombocytopenia Investigation of foetal infection e.g. parvovirus Investigation of foetal hydrops
What do you need to know about the mother before doing antenatal foetal blood sampling?
Rhesus status - she needs anti D if she's negative
When is foetal tissue sampling used?
Rarely - to diagnose uncommon conditions that specifically require histological examination of the skin or assay of the enzymes restricted to the liver
A painful inflammatory condition where functioning endometrial tissue grows outside the uterine cavity. Response to cyclical hormonal changes and bleeds at menstruation, forming abdominal adhesions
What are the common sites of endometriosis deposition?
Ovaries Uterosacral ligaments Ovarian fosse Can be found further afield - bladder, rectum, lung
What age group is endometriosis most common in?
25-35 year olds (1%)
What are the presenting features of endometriosis?
Cyclical abdominal pain due to bleeding at affected sites with menstruation Dyspareunia Secondary dysmenorrhoea Subfertility
What might be the findings on examination in endometriosis?
Uterosacral nodules Endometriomas Uterine or ovarian enlargement Adnexal tenderness In advanced cases the uterus is retroverted, retroflexed and immobile with thickening of the cardinal or uterosacral ligaments
How is endometriosis diagnosed?
At laparoscopy - brown spots ('powder burn'), adhesions and endometriomas ('chocolate cysts').
What is the treatment for endometriosis?
Medical: analgesia, COCP, progestogens, GnRH analogues, anti androgens Medical treatment doesn't improve underlying sub fertility - this requires surgery
What is chronic PID?
Recurrent or untreated episodes of acute pelvic infection which result in chronic inflammation of the pelvic organs and multiple adhesions, causing abdominal pain, dyspareunia and subfertility
How does renal calculus present?
Spasmodic 'loin to groin' pain and haematuria
What conditions is secondary dysmenorrhoea associated with?
Endometriosis PID Fibroids Iatrogenic (IUCD, cervical stenosis after LLETZ)
What are the features of a 'low risk' ovarian cyst?
Normal CA125 Ultrasound findings: simple, unilateral, unilocular cyst
How should you manage a low risk ovarian cyst?
Follow up in 3-4 months 50% will resolve spontaneously but if symptomatic might need surgical excision
What are the features of a 'high risk' ovarian cyst?
Elevated CA125 Ultrasound findings: complex, bilateral, multi nodular cyst >5cm
How should you manage a high risk ovarian cyst?
How is fibroid degeneration managed?
Conservatively initially: analgesia, fluids, antibiotics May need surgery if pain is persistent or recurrent
What is a normal foetal baseline on CTG?
When is sustained tachycardia seen on a CTG?
Prematurity (rate slows physiologically with advancing gestational age) Hypoxia Foetal distress Maternal pyrexia Use of exogenous beta agonists e.g. salbutamol
What are the indications for CTG monitoring?
Maternal: previous caesarean section, pre eclampsia, diabetes, APH Foetal: IUGR, prematurity, oligohydramnios, multiple pregnancy or breech Intrapartum: oxytocin use, epidural use, induction of labour
From what gestational age can CTG be used confidently to monitor foetal condition?
What might baseline bradycardia on a CTG suggest?
Commonly: hypotension, maternal sedation, post maturity, hypoxia Less commonly: severe foetal distress due to placental abruption, uterine rupture
What foetal heart rate on CTG suggests impending foetal demise?
What produces variability on a CTG?
Balance between sympathetic and parasympathetic nervous systems
At what rate do minor fluctuations in the baseline foetal heart rate occur?
What is normal variability on a CTG?
Between 5 and 25 beats per minute
What is variability an indicator of on a CTG?
Foetal well being
When is reduced variability seen on CTG?
Most commonly: phases of foetal sleep which can safely last up to 40 minutes Early gestation (nervous system develops later in pregnancy) Certain drugs: opiates or benzos especially Prolonged reduced variability suggests acute foetal distress
How are accelerations defined on CTG?
Rise in foetal heart rate of at least 15 beats/min for at least 15 secs
How many accelerations should you expect antenatally and in labour on CTG?
Antenatally: at least 2 accelerations every 15 minutes Often seen with contractions but absence in advanced labour isn't uncommon
Define decelerations on CTG
Fall in foetal heart rate of at least 15 beats per minute for more than 15 seconds
When are early decelerations seen and what do they mean?
Occur with contractions and return to normal by the end of the contraction; probably physiological and thought to reflect increased vagal tone when foetal intracranial pressure increases during a contraction. Uniform in depth, length and shape
When are late decelerations seen and what do they mean?
Occur during a contraction and return to baseline only after the contraction. They suggest foetal distress and are more worrying if they are shallow and late
What do variable decelerations look like and what do they mean?
Vary in timing and shape in relation to uterine contraction. Suggest cord compression especially in oligohydramnios. 'Shouldering' suggests foetus is coping well with compression - this is where there is a small acceleration before and after the deceleration. May resolve if mother's position is changed.
What does a sinusoidal trace look like on CTG?
Smooth undulating sine-wave-like baseline with no variability - pattern lasts over 10 minutes with an amplitude of 5-15 beats per minute
What might a sinusoidal CTG trace suggest?
Can be physiological or can represent foetal anaemia/hypoxia, but has to be considered serious until proven otherwise
What are pseudo sinusoidal CTG traces and how do they differ from sinusoidal CTG traces?
Benign, uniform, long term pattern. Less regular in shape and amplitude when compared to sinusoidal traces
What are the feature of Reiter's syndrome?
Can's see, can't pee, can't climb a tree - triad of urethritis, seronegative arthritis and conjunctivitis
What are the associated features of Reiter's syndrome?
Circinate balanitis (erythematous lesions on the penis), keratoderma blenorrhagicum (hard nodules on the soles of the feet that are clinically and histologically indistinguisha le from plantar psoriasis)
What are the two main subtypes of Reiter's syndrome?
Genitourinary infection: chlamydial infection or gonorrhoea GI infection: Salmonella, shigella, Yersinia, Campylobacter
Is Reiter's commoner in males or females?
What are the features of genital candidiasis?
Vulval pruritus Burning Swelling Dyspareunia White discharge and plaques in the vagina with redness of the vulva and labia minora
What are the causative organisms of genital candidacies?
Yeasts - particularly Candida albicans and C. glabrata
In which situations is genital candidiasis more common?
Pregnancy, tissue maceration, diabetes mellitus, HIV infection, use of antimicrobial agents and immunosuppressive drugs
How do you treat genital candidiasis?
Antifungals - topical imidazole (Canesten) or oral fluconazole
What is lymphogranuloma veneruem?
An STI caused by servers L1, L2 and L3 of Chlamydia trachomatis mainly found in the tropics
What are the features of lymphogranuloma venereum?
Between 3 and 21 days after infection, 1/3 of people develop a small painless papule which ulcerates and heals after days. The patients then develop lymphadenopathy which is unilateral in 2/3. Inguinal abscesses (buboes) may form and develop a sinus. Acute ulcerative proctitis ma develop when infection takes place via the rectal mucosa.
What causes syphilis and how is it spread?
Treponema pallidum Spread by sexual contact or congenital
What are the features of primary syphilis?
10-90 days post infection Dull, red papule on the external genitalia Forms a single, well demarcated, painless ulcer associated with bilateral inguinal lymph node enlargement Lesion heals within 8 weeks
What are the features of secondary syphilis?
Develops 7-10 weeks after primary infection Malaise, mild fever, headache, pruritic skin rash, hoarseness, swollen lymph nodes, patchy or diffuse hair loss, bone pain and arthralgia
What are the features of latent syphilis?
No clinical evidence of disease but can detect with serological testing
What are the features of gummatous syphilis?
Late stage of infection where the host resistance to the infection begins to fail. Areas of syphilitic granulation tissue develop on the scalp, upper aspect of the leg or sternoclavicular region. The 'gummatous' lesions are copper in colour. Granulation can also occur internally e..g on heart valves and bone. Still good response to treatment
What are the features of neurosyphilis?
Disease is detectable in CSF. Headache, cranial nerve palsies, general paralysis of the insane (psychosis with muscular reflex abnormality, dementia, seizures), tabes dorsals (degeneration of the dorsal column of the spinal cord, resulting in poor coordination), trophic ulcers, Charcot's joints (peripheral neuropathy resulting in excessive trauma to distal joints with subsequent bony destruction) and Argyll Robertson pupils (bilateral small, irregular pupils that do accommodate but don't react to light)
What is the cause of Trichomoniasis?
Flagellated protozoan Trichomonas vaginalis
Where does trichomonas invade?
Superficial epithelial cells of the vagina, urethra, glad penis, prostate and seminal vesicles
What are the features of trichomoniasis?
Females: offensive greens-grey discharge, vulval soreness, dyspareunia, dysuria, vaginitis vulvitis, strawberry cervix Males: mostly asymptomatic
How do you treat trichomoniasis?
What causes granuloma inguinale (donovanosis)?
What are the features of granuloma inguinale (donovanosis)?
Flat topped papule develops on the genitalia days to months post infection and then degenerates into a painless ulcer. The ulcer spreads along skinfolds and heals with scarring
What are the features of gonorrhoea in females?
Mostly asymptomatic in females but may have vaginal discharge and urethritis
What are the complications of gonorrhoea in females?
Bartholin's abscess and gonococcal salpingitis with irreversible tube damage
What are the features of gonorrhoea in males?
Dysuria, frequency, and/or mucopurulent discharge after 3-5 days, coupled with urethritis and mental oedema
What are the complications of gonorrhoea in males?
Disseminated gonococcal infection in
What are the presenting features of HELLP syndrome?
Nausea and vomiting with epigastric pain/RUQ pain due to haemorrhage, with stretching of the liver capsule
Which other condition is HELLP Syndrome related to?
Pre eclampsia - but it can begin suddenly without any previous indication of pre eclampsia
What are the biochemical findings in HELLP syndrome?
Haemolysis, elevated liver enzymes and low platelets
What are the risks associated with HELLP syndrome?
High mortality and morbidity - often progresses to acute renal failure, disseminated intravascular coagulation and increased risk of abruption
How should HELLP syndrome be managed?
Haematological and biochemical monitoring and treatment of hypertension. Delivery is the only cure but can still deteriorate 48 hours after delivery
Why is cholecystitis more common in pregnancy?
Because biliary stasis in pregnancy means gallstones grow rapidly
What is the incidence of cholecystitis during pregnancy?
1 in 1000
How should cholecystitis be treated in pregnancy?
Antibiotics, analgesia, fluids Cholecystectomy is generally postponed until after delivery
Why are ascending UTIs more common in pregnancy?
Because of dilatation of the urinary system by progesterone and obstructive uropathy with urinary stasis
How common are ascending UTIs in pregnancy?
Seen in 1-2% of pregnancies
How are ascending UTIs treated in pregnancy?
Analgesia, fluids, intravenous antibiotics
What is the risk with severe UTI and bacteraemia?
Risk of preterm labour. Patient may report uterine tightenings but don't confuse these with contractions
Which antibiotics are used to treat UTI in pregnancy?
Oral cephradine or amoxicillin
What is the most likely organism to cause a UTI in pregnancy?
What are the features of chorioamnionitis?
Abdominal pain, uterine tenderness, maternal pyrexia with raised CP and white cell count, meconium stained or foul smelling liquor and foetal tachycardia. Usually preceded by pre labour rupture of membranes but can be present without membrane rupture
When is chorioamnionitis more likely?
If there is proven UTI or vaginal infection
What is the risk with chorionamnionitis?
Overwhelming neonatal or maternal infectoin
How common is acute fatty liver of pregnancy?
Not very. 1 in 10,000-15,000 pregnancies in the 3rd trimester
How does acute fatty liver of pregnancy present?
Similar to cholecystitis - sudden onset epigastric abdominal pain, anorexia, malaise, nausea, vomiting and diarrhoea, with distinguishing features of jaundice, mild hypertension, proteinuria and fulminant liver failure
What are the biochemical features of acute fatty liver of pregnancy?
Raised bilirubin with abnormal liver enzymes Leukocytosis Thrombocytopenia Hypoglycaemia Coagulation defects
How can you distinguish acute fatty liver of pregnancy from HELLP?
Hypoglycaemia and high uric acid
What investigations are needed in acute fatty liver of pregnancy?
Diagnosis is clinical but you may need CT or MRI or liver biopsy
How is acute fatty liver of pregnancy treated?
Correction of fluid balance, coagulation, and electrolyte disturbances with hasty delivery May need admission to a specialist liver unit or intensive care unit
What is the maternal mortality rate in acute fatty liver of pregnancy?
What gestation does obstetric cholestasis occur after?
How does obstetric cholestasis present?
Severe pruritus of limbs, trunk, palms and feet but no abdominal pain
How do you confirm a diagnosis of obstetric cholestasis?
Increased serum total bile acid concentration
What are the risks of obstetric cholestasis?
PREterm labour, intracranial haemorrhage, foetal distress and intrauterine foetal death
When should you ideal deliver in obstetric cholestasis and why?
Delivery at 37-38 weeks reduces risk of intrauterine death
How is obstetric cholestasis managed?
Chlorphenamine for symptomatic relief of itching Ursodeoxycholic acid to reduce serum bile acids in more severe cases
What are the features of symphysis pubis dysfunction?
Pain and discomfort in the pelvic area which can radiate to the upper thighs or perineum. Pain is rose on walking and may be severe enough to limit mobility
How do you diagnose symphysis pubis dysfunction?
Clinically - but can confirm by increased pain on pressure over the symphysis pubis or compression of the pelvis
How do you treat symphysis pubis dysfunction?
Supportive - analgesia, pelvic support braces and crutches
What is the most preferable position of presentation?
What do the fontanelles feel like?
Anterior fontanelle is diamond shaped Posterior fontanelle is Y shaped or triangular
What are the underlying causes of a transverse or oblique lie?
Multiparty Structural uterine abnormality Pelvic tumours Foetal prematurity Multiple pregnancy Foetal abnormality Placenta praaevia Fundal placenta
What is the least common presentation?
Brow - 1 in 2000 labours
What is the problem with brow presentation?
For the brow to be presenting the neck must be extended, which means the largest diameter of the foetal head is presenting (chin to occiput); this is often too large to pass through the pelvis and can cause delay in the second stage of labour if it persists
What causes face presentation?
Full extension of the head
How common is face presentation?
1 in 500 cases
What is the problem with face presentation?
Can delay engagement and progress, possibly because facial bones do not mould, and the babies are at risk of facial oedema
What are the examination indicators of breech presentation?
Ballotatabe head at the funds Heart above the umbilicus High presenting part due to failure to engage
When does breech presentation become a concern?
37 weeks (except in preterm labour)
What is the incidence of breech presentation at term in singleton pregnancies?
What are the risk factors for breech presentation?
Grand multiparty Bony pelvic abnormalities Uterine abnormalities Foetal prematurity (insufficient time to rotate) Multiple pregnancy Foetal abnormality Extended legs Oligo/polyhydramnios Placenta praevia
What are the 3 types of breech presentation from most to least common?
Extended (feet extended near head) Flexed (feet next to bottom) Footling (foot presents at cervix)
When is external cephalic version more difficult?
Primps with firm abdominal muscles Overweight women Those with fibroids When the breech is engaged with the cervix
How commonly is ECV successful?
2/3 when done by a senior obstetrician provided no contraindications
What are the contraindications to ECV?
Previous caesarean section History of antepartum haemorrhage Multiple pregnancy Oligo/poly hydramnios Placenta praevia
What are the complications of ECV?
Placental abruption Transplacental haemorrhage (possibly requiring anti D in rhesus negative women) Foetal bradycardia PROM
What % of pregnancies are complicated by diabetes and what proportion of these are gestational, type 1 or type 2?
2-5% of pregnancies are in diabetic women. 65% of these have GDM, 25% type 1 and 10% type 2
What % of babies born to diabetic mothers are over the 50th percentile in weight?
What are the risks to the mother of poorly controlled diabetes?
Miscarriage Pre eclampsia Stillbirth Preterm labour
What are the risks to the baby of poorly controlled diabetes in the mother?
Congenital malformations: cardiac, neural tube, askeletal defects Large for gestational age: increased risk of birth injuries and increased likelihood of induction of labour, operative delivery and caesarean section Perinatal mortality and morbidity requiring admission to neonatology, e.g. neonatal hypoglycaemia
Failure to conceive after regular unprotected sexual intercourse for 2 years in the absence of known reproductive pathology (irregular periods etc included in this!)
How common is infertility?
Overall prevalence about 15% - related to age of female partner and related to history of STIs
What is the probability of pregnancy in the 1st and 2nd years?
84% in first year 92% in second year
When does a woman's fertility start to decline rapidly?
About age 38
What has an inverse relationship to infertility?
Risk of spontaneous miscarriage
What general advice can you give for infertility?
Sexual intercourse every 2-3 days Stop smoking and reduce caffeine intake over 3 espressos per tay Minimal alcohol Folic acid Don't be overweight
In how many infertile couples is it the result of a male problem?
What would make you see someone in infertility clinic sooner?
Over 35, irregular periods or no periods, significant history e.g. PID, ectopic For the man: testicular trauma or torsion, history of mumps as a child
What are the WHO criteria for normal sperm?
count >20 million/ml Motility >50% Morphology >50% normal
How do you determine on which day someone is ovulating?
Always 14 days before the end of the cycle
How many antral follicles should you see in each ovary?
What is a drug to induce ovulation and how successful is it?
Clomid - successful in 70%. Also letrozole, FSH
What is laparoscopic ovarian diathermy?
Procedure which basically drills holes into the ovary. Seems to work in 70% after 3 months.
What are the indications of IVF?
Tubal damage, severe male factor, severe endometriosis, unexplained infertility (if prolonged or older woman), failure of simple treatment, can also screen embryos for abnormalities
Restrictions for IVF?
Age 23-40, BMI 20-30, non smoker, no children in current or previous relationship, no sterilisation either partner, not poor ovarian reserve
How many embryos can you implant in IVF?
Should just be one but legally allowed to do up to 3 e.g. if embryo quality is lower, older mother etc
What is the risk of recurrence in ectopic?
What questions should you ask about bleeding in early pregnancy?
What colour is the blood? Is it more or less than your period?
What questions should you ask about pain in early pregnancy?
Crampy or sharp? Unilateral or generalised? Shoulder tip pain?
At what gestation, roughly, should you use a TA ultrasound as opposed to TV?
10 weeks - but depends on body habitus of the woman amongst other factors
How should the bladder be when scanning?
TV - empty bladder TA - full bladder
What is the % risk of major congenital malformation if the first HbA1c result is >10%?
How should you counsel a diabetic woman wishing to become pregnant regarding her diabetic control?
Monthly HbA1c should be done in those wishing to conceive and contraception strongly recommended whilst it's >10% - HbA1c of
What are the risk factors for gestational diabetes?
Maternal BMI >30 Previous baby >4.5 kg Previous gestational diabetes Family history of diabetes in a first degree relative South Asia, Afro-Caribbean, Chinese
When is the OGTT done?
What extra monitoring of the foetus is done in gestational diabetes?
Detailed USS of heart chambers and outflow tracts with the foetal normality scan at 18-20 weeks Foetal growth and amniotic fluid volume checked regularly at 28, 32 and 36 weeks
When should the baby be delivered in gestational diabetes?
If indications for induction, e.g. macrosomia, plan this from 36 weeks. If normally growing, offer induction or elective C section after 38 weeks
How should you manage a woman with diabetes in labour?
Monitor blood sugars hourly and maintain control between 4 and 7 mmol/L; may need an insulin/dextrose sliding scale to do so
What must you assess a baby born to a diabetic mother for?
Hypoglycaemia, respiratory distress, cardiac failure/dysfunction and jaundice
How common is recurrence of gestational diabetes?
At least 60%
What is the management for women with gestational diabetes after pregnancy?
Follow up with fasting glucose at 6 weeks At greater risk of recurrence so offer an early OGTT at 16-18 weeks in next pregnancy; if normal, repeat at 28 weeks
What ist he risk of developing T2DM in the next 10 years after having gestational diabetes?
What HRT is recommended for women with a uterus who have bled in the last year?
Low dose cyclical HRT
What are the advantages/disadvantages of cyclical HRT?
Gives progesterone on 12 of 28 days Results in a regular post-progesterone bleed which protects the endometrium Prolonged use increases risk of endometrial cancer so should be given for a max of 5 years
At what point should a patient be transferred to continuous combined HRT?
When she has been amenorrhoeic for 1 year or reaches age 54, whichever happens first
What HRT is recommended for women with a uterus who have not bled for 1 year?
Low dose continuous combined HRT
How effective is low dose continuous combined HRT for symptom relief in menopause?
Effective in 90%
What are the features of continuous combined HRT?
Combined preparation causes endometrial atrophy so should have no bleeding Protects the endometrium from hyperplasia and reduces risk of endometrial cancer Unwanted side effects of progesterone: withdrawal bleeds and premenstrual like symptoms
What HRT is recommended for women who have had a hysterectomy and why?
Oestrogen only - don't require progesterone as they are not at risk of unopposed oestrogen induced endometrial hyperplasia
What are the indications for HRT?
Menopausal related symptoms, early menopause, prevention of osteoporosis
What are the contraindications to oestrogen replacement therapy?
Carcinoma of the endometrium Liver disease e.g. active hepatitis Suspected pregnancy Inherited thrombophilias
What are the relative contraindications to HRT?
Hypertension Previous personal or family history of thromboembolism or breast cancer
What are the indications for specialist referral when considering HRT?
History of thromboembolism or breast cancer Menopause before the age of 40 Confirmed risk of osteoporosis High risk or a personal history of oestrogen dependent cancers e.g. breast or endometrium Abnormal bleeding before the start of HRT, while using cyclical HRT, or more than 6 months after the start of continuous combined HRT
What is the mechanism of action of bisphosphonates?
Inhibit osteoclast mediated bone resorption
What is Tibolone?
A synthetic steroid that has oestrogenic, progestognenic and some androgenic effects
What are the side effects of tibolone and what important side effect does it not have?
Doesn't cause endometrial proliferation Still can cause irregular bleeding in the first few months
What class is Raloxifine and what does it do?
Selective oestrogen receptor modulator Selectively stimulates oestrogen receptors so can prevent osteoporosis and have a beneficial effect on lipid profile but doesn't relieve menopausal symptoms of oestrogen deficiency
What are the benefits of HRT?
50% reduction in osteoporosis May delay onset of Alzheimer's but no effect on established disease
What are the risks of HRT?
Positive association with breast cancer and 3x risk of VTE Recent data says there might be an increased risk of cardiovascular disease with combined HRT
How should you follow up women on HRT?
Every 6 months to assess symptomatic improvement and adverse effects - postmenopausal bleeding will need immediate referral for endometrial biopsy
Define premature delivery
Delivery before 37 weeks' gestation
When is premature delivery really a concern (gestational age)?
34 weeks - majority of morbidity and mortality is when delivery is before this
How common is preterm labour?
5-10% of pregnancies
What % of perinatal deaths is preterm labour the cause of?
What are the risk factors for preterm delivery?
Previous preterm delivery Maternal age
When are tocolytics likely to be beneficial?
Very preterm cases so that you can get time for steroids and transfer to specialist unit
What do tocolytics not seem to improve according to evidence?
What is the most widely evaluated tocolytic?
Ritodrine - beta-agonist
Why is ritodrine being phased out somewhat?
Poor side effect profile: tachycardia, headache, palpitations, impaired glucose tolerance
In whom should you avoid using ritodrine?
Cardiac disease and diabetics
What is atosiban?
Oxytocin inhibitor - tocolytic
What are the plus points of atosiban?
Reduces delivery within a 48 hour period Preferable side effect profile compared with ritodrine
What is nifedipine useful for in preterm labour?
Tocolytic - not yet licensed in UK thought
What are the common tocolytics?
Ritodrine, atosiban, nifedipine, magnesium sulphate, indometacin
What are the relative contraindications to tocolysis?
Rupture of membranes, foetal distress, intrauterine infection
What is the sequence of pubertal changes in women?
- Breast development 2 or 3 years before menarche
- Then pubic and axillary hair growth
- Growth spurt
- Onset of menstruation - mean age 12.8 years
- May take 3 years or more for cycle to establish a regular pattern
How is premenstrual syndrome manageD?
- First line: lifestyle modification, COCP, SSRIs, CBT
- Second line: Oestradiol patches plus oral progesterone/Mirena, SSRIs (higher dose)
- Third line: GnRH analogues + add back HRT (continuous combined oestrogen and progesterone)
- Fourth line: TAH and BSO + HRT (including testosterone)
What do inhibin and activin do and where are they produced?
- Peptide hormones produced by granulosa cells
- Inhibin inhibits pitutiary FSH secretion
- Activin stimulates it
Define priamry and secondary amenorrhoea
- Primary: failing to menstruate by 16 years of age
- Secondary: absence of menstruation for >6 months in a normal female of reproductive age that is not due to pregnancy, lactation or the menopause
What is the problem in Kallman's syndrome?
X linked recessive condition resulting in deficiency in GnRH causing underdeveloped genitalia
Define heavy menstrual bleeding
What are some of the medical options for treatment of heavy menstrual bleeding and how effective are they?
- Mefenamic acid and other NSAIDs - 20-25% reduction in blood loss
- Tranexamic acid - 50% reduction
- Norethisterone (cyclical progesterone day 6-26, not contraceptive)
- Levonogestrel IUS - 95% reduction
- GnRH agonists for short term
What are the success rates of clomifene citrate, IUI, and IVF?
- Clomifene - 70% ovulate, pregnancy rate 15-20%
- IUI - 15-20% in top units
- IVF - ~30% for women under 35
What are the features of ovarian hyperstimulation syndrome?
- Ascites, hugely enlarged multifollicular ovaries, pulmonary oedema
- Risk of multiorgan failure and coagulopathy
- Need admission and care under specialist team
What are the normal parameters for semen analysis?
- Volume >2mL
- pH > 7.2
- Sperm concentration >20 million per mL
- Total sperm number >40 million per ejaculate
- Motility >50% grade a and b
- Morphology >30% normal forms
What does the anti mullerian hormone represent?
Quality of ovarian follicle pool - useful marker of ovarian reserve, decreases with age and undetectable after menopause
What are the contraindications to IUS?
- Current STI or PID, including post abortion and following childbirth
- Malignant trophoblastic disease
- Unexplained vaginal bleeding
- Endometrial and cervical cancer until assessed and treated
- Known malformation of the uterus or distortion of the cavity e.g. with fibroids
- Copper allergy (but could use MIrena)
What are the risks with COCP use?
- VTE (3-5x risk)
- Arterial disease
- Breast cancer (slightly increased risk)
- Drug interactions
What are the absolute contraindications to COCP?
- Breastfeeding <6 weeks post partum
- Smoking ≥15 cigarettes per day and age ≥35
- Multiple CVS risk factors
- Hypertension ≥160/100 (either)
- Current or history of DVT or PE
- Major surgery with prolonged immobilisation
- Known thrombogenic mutations
- Current or history of ischaemic heart disease
- Current or history of stroke
- Complicated valvular heart disease
- Migraine with aura
- Migraine without aura with age ≥35
- Current breast cancer
- Diabetes for ≥20 years with severe vascular disease or with severe nephropathy, retinopathy or neuropathy
- Acute viral hepatitis
- Severe cirrhosis
- Benign or malignant liver tumours
What are the relative contraindications to COCP use?
- Multiple risk factors for arterial disease
- HYpertension: systolic 140-159 or diastolic 90-99 or adequately treated to below 140/90
- Some known hyperlipidaemias
- Diabetes mellitus with vascular disease
- Smoking (<15 cigarettes per day) and age ≥35
- Breast cancer with >5 years without recurrence
- Breastfeeding until 6 months postpartum
- Postpartum and not breastfeeding until 21 days after childbirth
- Currently or medically treated gallbladder disease
- History of cholestasis related to combined oral contraceptives
- Mild cirrhosis
- Taking rifampicin or certain anticonvulsants
What do you do if you miss a COCP?
If one or two (or one lower dose), take missed pill ASAP, continue remaining pills daily at usual time. Don't need additional contraceptive protection or emergency contraception.
If 3 or more pills (2 if lower dose) take most recent missed pill ASAP, continue taking remaining pills daily at usual time, extra protection until taken pills 7 days in a row. If missed in week 1, consider emergency contraception if unprotected sex during pill free interval or in week one. If missed in week 3, finish current pack and start a new pack on the next day.
What are the hormonal options for emergency contraception?
- Levonelle - levonorgestrel single 1.5mg dose
- Within 72 h (earlier the better)
- No real contraindiations
- PRevents 3/4 pregnancies that would have occurred
- EllaOne - progesterone receptor modulator (ulipristal 30mg)
- Up to 120 hours after UPSI
- Needs prescription unlike levonelle
- Within 72 h (earlier the better)
- No real contraindiations
- PRevents 3/4 pregnancies that would have occurred
- Up to 120 hours after UPSI
- Needs prescription unlike levonelle
How long after UPSI can copper coil be given for emergency contraception?
What medications are given for medical termination?
600mg oral mifepristone + 1mg gemeprost vaginal pessary 48h later (if first trimester)
If later pessary is given every 3-6 hours