O+G 8 Flashcards
What monitoring should be done in labour?
- FHR monitored every 15min (or continuously via CTG)
- Contractions assessed every 30min
- Maternal pulse rate assessed every 60min
- Maternal BP and temp should be checked every 4 hours
- VE should be offered every 4 hours to check progression of labour
- Maternal urine should be checked for ketones and protein every 4 hours
When and to whom does anti-D need to be given?
Within 72 hours
- delivery of a Rh +ve infant, whether live or stillborn
- any termination of pregnancy
- miscarriage if gestation is > 12 weeks
- ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
- external cephalic version
- antepartum haemorrhage
- amniocentesis, chorionic villus sampling, fetal blood sampling
Pelvic inflammatory disease is an absolute contraindication for which contraception?
IUD
Which of the following medications is not safe to use during the first trimester of pregnancy?
Lamotrigine Nitrofurantoin Trimethoprim Salbutamol inhaler Prednisolone
Trimethoprim
What are the risks of HRT?
- Venous thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
- Stroke: slightly increased risk with oral oestrogen HRT.
- Coronary heart disease: combined HRT may be associated with a slight increase in risk.
- Breast cancer: there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised.
- Ovarian cancer: increased risk with all HRT.
A 35-year-old woman comes to see you in clinic with a 12 month history of heavy periods with clots and flooding. She does not experience any pelvic pain.
On examination she has a palpable bulky uterus.
You book her in for a transvaginal ultrasound scan and decide to start her on some treatment in the interim.
What is the most appropriate first line management?
In this scenario, this lady most likely has uterine fibroids and is therefore appropriately being sent for transvaginal ultrasound for further assessment.
NICE Clinical Knowledge Summaries dictate that tranexamic acid or NSAIDs are the most suitable 1st line agents to use to manage symptoms while awaiting results of investigations. Since the patient does not have pelvic pain, tranexamic acid is most appropriate.
It would not be appropriate to insert a levonorgestrel releasing IUS before delineating the anatomy in someone whom you’re suspicious of fibroids.
A 36-year-old woman who used to inject heroin has recently been diagnosed HIV positive. She is offered a cervical smear during one of her first visits to the HIV clinic. How should she be followed-up as part of the cervical screening program?
Women with HIV should be offered cervical cytology at diagnosis. Cervical cytology should then be offered annually for screening.
Which one of the following is the most common cause of recurrent first trimester spontaneous miscarriage?
Factor V Leiden gene mutation Polycystic ovarian syndrome Hyperprolactinaemia Antithrombin III deficiency Antiphospholipid syndrome
Antiphospholipid antibodies (aPL) are present in 15% of women with recurrent miscarriage, but in comparison, the prevalence of aPL in women with a low risk obstetric history is less than 2%
What is recurrent miscarriage and what proportion of women are affected?
Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions.
It occurs in around 1% of women
What are the causes of recurrent miscarriage?
- antiphospholipid syndrome
- endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
- uterine abnormality: e.g. uterine septum
- parental chromosomal abnormalities
- smoking
A 24-year-old female has an abdominal ultrasound performed as she has had repeat urinary tract infections in the past 12 months. It is reported as follows:
Both kidneys are normal size. No abnormality of the urinary tract is noted.
Liver, spleen, pancreas are normal
Right ovary and uterus normal.
4cm simple ovarian cyst noted on left ovary
End of report.
What is the most appropriate action?
If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
However, any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment.
What causes menorrhagia?
- dysfunctional uterine bleeding: this describes menorrhagia in the absence of underlying pathology. This accounts for approximately half of patients
- anovulatory cycles: these are more common at the extremes of a women’s reproductive life
- uterine fibroids
- hypothyroidism
- intrauterine devices (copper coil)
- pelvic inflammatory disease
- bleeding disorders, e.g. von Willebrand disease
A 24-year-old woman with a past history of polycystic ovarian syndrome (PCOS) attends your clinic. She is receiving optimum medical therapy for her condition and is still finding it difficult to conceive. Herself and her husband have now been trying to conceive for 2 years. Given her history, you believe that she may be a suitable candidate for in-vitro fertilisation (IVF) therapy. What are women with PCOS at particular risk of when undergoing IVF?
Ovarian hyperstimulation syndrome
A 29-year-old woman who is known to have HIV visits her general practitioner (GP) to discuss becoming pregnant. At present she is not on any antiretroviral (ARV) medications because her CD4 count is sufficiently high and viral load low. What advice should the GP give her about what treatment she may need in pregnancy or post-partum? When is a c-section indicated?
She will need to begin ARV treatment and may require a caesarean section.
Although this woman’s viral load is low at present she should begin combination antiretroviral therapy (cART) in early pregnancy to ensure that it remains as low as possible, minimising the risk of transmission to the fetus. Viral load is measured again in the third trimester and caesarean section at 38 weeks is recommended for women with HIV RNA levels > 1000 copies/ml at this time.
A 50-year-old woman comes to see you in clinic complaining of hot flushes which are keeping her up at night. She is still having periods, although they are lighter and not every month.
You counsel her about hormone replacement therapy (HRT) and she decides she would like to try it. She has not had a hysterectomy.
Which of the following HRT regimes would be most appropriate?
Systemic combined cyclical HRT
In order to find the correct HRT regime, there are 3 main areas to address - whether there is a uterus or not, whether the patient is perimenopausal or menopausal and whether a systemic or local effect is required.
This patient can be classed as perimenopausal as she is still having periods (menopause is defined as 12 months after the last menstrual period).
Therefore the correct answer is: combined oestrogen and progestogen cyclical HRT.
Cyclical HRT is recommended in perimenopausal women because it produces predictable withdrawal bleeding, whereas continuous regimens often cause unpredictable bleeding.
Which risk factors that increase the womans likelihood of developing VTE and are assessed at the booking appointment? (11)
What treatment should be initiated?
- Age > 35
- Body mass index > 30
- Current pre-eclampsia
- Family history of unprovoked VTE
- Gross varicose veins
- Immobility
- IVF pregnancy
- Low risk thrombophilia
- Multiple pregnancy
- Parity > 3
- Smoker
Four or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal.
If a woman has three risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.
A 63-year-old nulliparous lady presents to her general practitioner with symptoms of abdominal bloating and diarrhoea. She has a family history of irritable bowel syndrome. On examination, the abdomen is soft and non-tender with a palpable pelvic mass. Which one of the following is the most suitable next step ?
Measure CA125 and refer her urgently to gynaecology.
If suspicion of ovarian cancer but there is an abdominal or pelvic mass, CA125 and US test can be bypassed and the patient directly referred to gynaecology.
What are the long term complications of PCOS?
- Subfertility
- Diabetes mellitus
- Stroke & transient ischaemic attack
- Coronary artery disease
- Obstructive sleep apnoea
- Endometrial cancer
When are decelerations on CTG concerning?
- variable decelerations for over 30 minutes since starting conservative measures to improve, occuring with over 50% of contractions
- late decelerations present for over 30 minutes not improving with conservative measures, occurring with over 50% of contractions
- bradycardia or a single prolonged deceleration lasting 3 minutes or more
When is a lack of variability concerning?
Less than 5 for over 90 minutes
What are the most common sites for an ectopic pregnancy to occur?
Tubal ectopic: 93-97%
- ampullary ectopic: most common ~70% of tubal ectopics and ~65% of all ectopics
- isthmal ectopic: ~12% of tubal ectopics and ~11% of all ectopics
- fimbrial ectopic: ~11% of tubal ectopics and ~10% of all ectopics
- interstitial ectopic/cornual ectopic: 3-4%; also essentially a type of tubal ectopic
Abdominal ectopic: rare; ~1.4%
Cervical ectopic/cervical pregnancy; rare <1%
Ovarian ectopic/ovarian pregnancy; 0.5-1%
Scar ectopic: site of previous Caesarian section scar; rare
How is postpartum thyroiditis diagnosed?
based on three criteria:
1) Patient is within 12 months of giving birth
2) Clinical manifestations are suggestive of hypothyroidism
3) Thyroid function tests support diagnosis
What are the 3 stages of postpartum thyroiditis?
- Thyrotoxicosis
- Hypothyroidism
- Normal thyroid function (but high recurrence rate in future pregnancies)
How do you manage postpartum thyroiditis?
- the thyrotoxic phase is not usually treated with anti-thyroid drugs as the thyroid is not overactive. Propranolol is typically used for symptom control
- the hypothyroid phase is usually treated with thyroxine
The uncontrollable and convulsive urge to push is usually associated with…
occiput posterior fetus
What’s the condition?
fever (and tachycardia), malaise, uterine enlargement and tenderness, and foul-smelling lochia
Endometritis
A 27 year-old lady is day 1 post emergency caesarean section for failure to progress in the first stage. She has been complaining of pain and heavy vaginal bleeding since delivery and in the morning was noted to have heavy, offensive lochia and a boggy poorly contracted uterus above the umbilicus. What is the most appropriate treatment?
Examination under anaesthesia. IV antibiotic also needed by need examination for source control.
This is a typical history of retained products, which can happen after caesarean section if care is not taken to make sure that all the placental membranes are removed. The uterus does not contract down well as the products are still in the cavity, and the discharge is offensive suggesting that the products have become infected.
This lady needs and urgent examination under anaesthesia to remove the products. The products often pass by themselves without the need for anaesthesia, however after day 1 this is unlikely so intervention is needed.
