O+G

Question 1

normal fundal height and major week milestones

Answer 1

gestational age +/- 2cm

12 weeks - pubic symphysis

20 weeks - umbilicus

36 weeks - xiphisternum

Question 2

pre-eclampsia important symptoms

Answer 2

blurred vision or flashing lights (due to local vasospasm of the retina)
severe epigastric pain 
hyperreflexia 
clonus 
oedema of hands, feet, face
severe headache - usually frontal 
fetal distress- reduced fetal movements 
vomiting 
confusion / altered mental status

Question 3

when do you feel fetal movements

Answer 3

16-25 weeks - will increase until 32 weeks and then plateu

cut off to investigate is 24 weeks

Question 4

amount of vitamin D in pregnancy

Answer 4

400 IU daily

Question 5

appointment timing

Answer 5

booking - 8-12 weeks - detailed history, risk assessment (community or midwife), estimation of due date but most accurate is at dating scan with CRL, heigh, weight, BMI, urine dip for asympomatic bacteriuria, bloods (anaemia, HIV, syphilis, hepB, group and save for Rh)

dating - 8-14 weeks - determines age based on CRL, detects if twins, DS (via nuchal translucency, PAPP-a, beta hCG)

anomaly - 18-20 - take pic home, gender, major structural malformations

Question 6

how is DS confirmed

Answer 6

CVS at 11-14 weeks - 2% risk of miscarriage

amniocentesisis at 15 weeks - 1% risk of miscarriage

give anti-D in both

Question 7

TOP methods

Most women have some bleeding and cramping for several days after either
method, but these usually get better day by day

surgical can be doen under LA or LA and sedation or GA - benefit w LA is going home same day and dont have to fast
wont be able to drive following sedation

beforehand - may be offered sti testing, an US to check how many weeks, chance to speak to counsellor

Answer 7

medical - up to 24w
mifepristone pill then 24-48 hours later misoprostol (vaginal/buccal/sublingual) - dose and amount of pills depends on how far along - e.g. <9 weeks only need one bill, 9-12 need vaginal + up to 4 doses oral
pregnancy comes out via bleeding several hours after the 2nd pill. someimtes need to take extra dose of misoprostol to get it to pass

if >10w pregnany you may need to take the second tablet at hospital

surgical
vacuum aspiration up to 14w
dilation and evacuation 14-24 w under sedation or GA

done w LA, sedation or GA/deep sedation - w both can go home say day

In very limited circumstances an abortion can take place after 24 weeks – for example, if there’s a risk to life or there are problems with the baby’s development

saftey netting = get advise if pain or bleeding that does not get better in a few days - have a temp or unusual vag discharge

comps inc needing another procedure, heavy bleeding or sepsis, injury to womb

Question 8

what is needed alongside a TOP

Answer 8

anti-d prophylaxis for Rh negative after 10w gestation in every sort of TOP

consider for before 10 weeks for surgical TOP

for those that need thrombophrophylaxis, consider LMWH for at least a week after the abortion

NSAIDs for pain relief for either

use pads until bleeding stops

Question 9

who needs to take aspirin from 12w of pregnancy

Answer 9

>1 of 
-	First pregnancy
-	Aged >40
-	Previous pregnancy >10 years ago
-	BMI >35
-	Family history of pre-eclampsia
-	Multiple pregnancy
Or 1 of 
-	Hypertension or pre-eclampsia in a past pregnancy
-	CKD
-	Autoimmune disease e.g. SLE 
-	Diabetes mellitus
-	Chronic hypertension

Question 10

diabetes monitoring (with target values) and checkups in pregnancy

Answer 10

seen every 1-2 weeks by diabetes care team

type 1 and type 2 on insulin - test glucose pre-meal, one hour post meals and bedtime

type 2 on oral or conservative - same but not bedtime

target = fasting 5.3, two hours after meal 6.4 (7.8 one hour after)

Question 11

timing of birth in diabetes

Answer 11

elective birth by induction of labour or C section if indicated between 37-38+6 weeks of pregnancy

Question 12

screening for gestational diabetes + its risk factors

Answer 12

75g oral glucose tolerance test - wont eat for 8-12hrs before, then given some glucose, then blood measured at intervals after

fasting = 5.6, two hour = 7.8

if previous GDM pregnancy - done asap after booking, and again at 24-28 weeks if first was normal

any other risk factor - done at 24-28 weeks

risk factors include BMI >30, previous macrosomic baby, first degree relative with diabetes, south asian, black carribean, middle eastern

glycosuria of 2+ or above on one occasion or of 1+ or above on two or more occasions during routine antenatal care may indicate undiagnosed GDM. Consider further testing to exclude GDM

Question 13

management of gestational diabetes

Answer 13

consultant led

most treated with lifestyle modifications

offer metformin to women with GDM if targets are not met within 1-2 weeks

offer insulin instead of metformin if CI - advise tho of risk of hypo- always have a fast-acting form of glucose in case

offer insulin +metformin if target not met

offer insluin straight away with or without metformin if fasting glucose >7 at diagnosis

advise give birth no later than 40+6 weeks - offer induction or c section to those that haven’t by then (a bit earlier if on treatment - 37-38w)

discontinue treatment immediately after birth

Question 14

when to offer a fasting blood glucose test after birth for a women with GDM

Answer 14

6-13 weeks after birth

if >7 then is likely they have diabetes

Question 15

gestational hypertension vs pre-eclampsia

Answer 15

gestational hypertension = pregnancy-induced hypertension (SBP > 140 or DBP > 90 or increase above booking readings SBP >30 or DBP > 15) that develops after 20 weeks gestation - will resolve after birth

pre-eclampsia = pregnancy -induced hypertension + proteinuria (>0.3g/24hr) and/or oedema - (most cases occur after 24 weeks but definition is after 20)

Question 16

3 anti-hypertensives safe in pregnancy

Answer 16

labetolol
nifedipine
methyldopa - NB if this is use, switch back to pre-pregnancy anti-HTN regime within 2 days of delivery due to increased risk of post natal depression on this

Question 17

definition and management of severe gestational HTN

Answer 17

> 160/110

admit to hosptial

start IV labetolol to keep SBP <150 and DBP <100

CTG to check on baby

test BP 4x per day and check for proteinuria once a day

discharge one BP in target range

Question 18

management of mild and moderate gestational hypertension

Answer 18

mild - check BP and proteinuria weekly

moderate - twice weekly, and start labetalol to keep SBP <150 and DBP <100, and arrange bloods to check liver function, FBC and U+E for signs of pre-eclampsia

(nafedipine 2nd line, methyldopa 3rd line)

Question 19

HELLP syndrome

Answer 19

haemolysis, elevated liver enzymes, low platelets

Question 20

investigations for pre-eclampsia - DUCH

Answer 20

BP and urine dip (2+)
then confirm via urinalysis - MC+S (rule out UTI), then 24-hour urine collection or calculation of albumin:creatinine ratio (or protein:creatinine ratio)
FBC - low platelets and anaemia in HELLP
LFTs - raised transaminases
U+E - keep an eye on creatinine for AKI
coagulation profile - prolonged PT and APTT
high LDH in haemolysis
high urate - indicates worsening disease

USS - assess fetal growth and amniotic fluid volume
dopper of umbilical arteries**
CTG

use placental growth factor (PIGF) to test in those with pre-existing HTN and renal disease

Question 21

management of mild and moderate pre-eclampsia (not including delivery)

Answer 21

mild - proteinuria with BP 140/90-149/99
moderate - proteinuria and BP 150/100 -159/109
both same

admit if concerns for mother or baby or high risk of adverse effects suggested by fullPIERS or PREP-S
monitor BP QDS if in hospital, if not every 48 hours
twice weekly bloods
anti-HTN with labetalol
carry out US and CTG at diagnosis
repeat US 2-weekly
VTE prophylaxis if in patient

Question 22

management of severe pre-eclampsia (not including delivery)

Answer 22

severe - BP >160/110

admit
antihypertensive - labetalol oral, if not IV labetalol, or oral nifedipine, or IV hydralazine
monitor BP at least QDS (but at first, every 15-30 minutes until BP is less than 160/110)
bloods three times weekly: U&Es, FBC, LFTs
carry out CTG and US of fetus at diagnosis and if normal, repeat US every 2 weeks
repeat CTG if clinically indicated
VTE prophylaxis

Question 23

delivery for pre-eclampsia

(up to this point - patients can usually be managed conservatively until 34w as long as they’re stable - then just antihypertensives, monitor +/- admit)

Answer 23

anti-HTN oral or IV labetolol or oral nifedipine or IV hydralazine if SBP >160 or DBP >110
magnesium sulphate if seizure concern 24 hours before delivery
fluid restriction due to pulmnoary oedema being a significant cause of maternal death in pre-eclampsia
CTG throughout
BP measurement throughout
3rd stage of labour with syntocinon (not ergometrine or syntometrine)

only offer delivery <34 weeks if severe HTN refractory to treatment or complications develop like eclampsia, HELLP, reversed umbilical diastolic flow - consider steroids and mag sulph

consider <37 weeks if inability to control BP (tried >3 classes), <90% sats, HELLP, eclampsia, non-reassuring CTG - consider steroids

from 37w onwards - initiate birth within 24-48 hours

offer IV Mg sulphate and a course of antenatal corticosteroids (if <34+6) if indicated - e.g. in severe pre-eclampsia

Question 24

post-natal management for pre-eclampsia

Answer 24

important to monitor mother as still at risk of eclamptic seizures measure bloods 48-72 hours after delivery - FBC, U+Es,LFTs
monitor fluid balace
measure BP every day or other day for 2 weeks, reducing the anti-HTN gradually as it falls
urine dip at 6w to ensure no proteinuria

(anti-HTN may be needed for several weeks after birth)

Question 25

management of eclampsia

Answer 25

A-E left lateral position magnesium sulphate 4g loading dose then infusion 1st line for fits if further fits occur a further 2g can be given as bolus assessment for magnesium toxicity via testing reflexes (confusion, loss of reflexes, hypotension, respiratory distress) - if low urine output consider lowering dose as it is renally excreted anti-HTN - oral or IV fluid restrict to 80m/hr continuous CTG deliver fetus once mother is stable (vaginal is fine) manage 3rd stage with syntocinon measure obs every 15 minutes assess for magnesium toxicity (confusion, loss of reflexes, respiroaty distress, hypotension) after delivery, mother will need HDU care until stable - well controlled BP, good UO, discontinuation of magnesium sulphate - usually takes a minimum of 24 hours

Question 26

hyperemesis gravidarum triad is associated w a higher incidence of SGA, multiples and premature babies - thought to be due to rapidly increasing bhcg

Answer 26

dehydration electrolyte imbalance body weight loss of more than 5% pre-pregnancy weight (may also be ketonuria)

Question 27

grading vomiting in pregnancy

Answer 27

PUQE score - pregnancy unique qualification of emesis

Question 28

management of hyperemesis gravidarum

Answer 28

outpatient (PUQE = 3-12), ambulatory (PUQE>12), inpatient (complications/failed ambulatory care) NB PUQE = pregnancy unqieu quantification of emesis outpatient - cyclizine, promethazine, chlorpromazine or prochlorperazine with oral hydration abulatory care - IV fluids and IV anti-emetics and oral or IV thiamine/pabrinex in patient - same plus thromboprophylaxis with LMWH, nutritional support may be required, steroids if unresponsive to anti-emteics, TOP may be last option for intractable

Question 29

management of obstetric cholestasis

Answer 29

weekly LFT monitoring UDCA vitamin K if steatorrhoea or prolonged PT (small risk of neonatal haemolytic anaemia, hyperbilirubinaemia and kernicterus) induction 37w onwards as maternal morbidity and stillbirth increases form this point onwards hospital birth

Question 30

chages/monitoring if taking an AED and pregnant

Answer 30

measure maternal AED levels at each trimester to avoid fits - pregnancy can change plasma concentration increased fetal growth monitoring vitamin K oral from 34w CTG tracing 5mg folic acid

Question 31

define types of haemorrhage within APH

Answer 31

minor <50 major 50-1000 massive >1000

Question 32

triad of ruptured vasa previa

Answer 32

rupture of membranes followed by painless vaginal bleeding and fetal bradycardia

Question 33

placenta praevia vs placental abruption

Answer 33

placenta praevia = placenta covers internal cervical os - not painful, fresh red blood placental abruption = placenta separates from the uterus and blood separates them - painful, may be no blood or dark red

Question 34

causes of APH

Answer 34

``` idiopathic placenta previa placental abruption ruptured vasa previa trauma cervical ectropion poylps infection uterine rupture (although this usually happens in labour) ```

Question 35

management of APH

Answer 35

mild spotting and baby is ok can be discharged with serial growth US scans for IUGR, oligohydraminos etc (are at increased risk from APH) if more than just spotting or ongoing bleeding then should remain in hospital until the bleeding has stopped A-e cannula - take bloods FBC, U+E, LFTs, clotting, G+S, 4u crossmatched in major haemorrhage Kleihauer test if mother is Rh D negative - give anti-D prophylactically with dose according to Kleihauer fluids auscultate heart rate - if not do US US to rule out praevia (abruption is clinical diagnosis) CTG APH is a risk factor for pre-term delivery so give steroids if 24 - 34+6 weeks - BUT if small spotting which has stopped (particuarly if cause identidied like postcoital from ectropion or lower genital tract infection ) then may not need steroids tocololysis only in very preterm and not yet completed steroids - senior decision (if fetal distress dont want to delay delivery) if >37w and stable - induce vaginal with CTG monitroing fetal distress then C section 3rd stage managed actively due to risk of PPH

Question 36

specific management for placenta previa

Answer 36

A-e cannula - take bloods FBC, U+E, LFTs, clotting, G+S, 4u crossmatched in major haemorrhage Kleihauer test if mother is Rh D negative - give anti-D prophylactically with dose according to Kleihauer fluids CTG monitoring minor >2cm away from os, may be able to deliver vaginally continue scanning every 2 weeks <2cm is an indication for C section at 38 weeks (after this risk of haemorrhage increases) - early if evidence of accreta (35-37) women with major PP who have previously bled should be admitted from 34 weeks (can be remain at home if they are close to hospital, have a constant companian and understand risks) must avoid intercourse should explain the risk of hysterectomy while a c section is done note on steroisd - if bleeding is associated with pain suggestive of uterine activity or abruption then the risk of preterm birth is increased and therefore steroids may be of benefit. Women presenting with spotting that has stopped (particularly if identified cause like post-coital from a cervical ectropion or lower genital tract infection is found) and no abdominal pain, may not require steroids

Question 37

management of placenta accreta

Answer 37

delivery should take place in a specialist centre with immediate access to blood products and adult and neonatal intensive care planned c section delivery at 35-36+6 weeks (35-37 weeks) (opening of the uterus at a site distant from the placenta) can be performed with regional anaesthesia but risk of converting to GA should be discussed if the mother really wants another child, then a uterus-saving approach may be tried with or without therapeutic uterine artery embolisation, surgical internal iliac artery ligation or methotrexate therapy e.g. a partial myometrial resection but unfortunately is not often successful and can be associated with bleeding and infection and some will still need to go on to have a hysterectomy so must consent pt for both blood transfusion and a hysterectomy

Question 38

management of placental abruption

Answer 38

A-e - oxygen if needed cannula - take bloods FBC, U+E, LFTs, clotting, G+S, 4u crossmatched in major haemorrhage Kleihauer test if mother is Rh D negative - give anti-D prophylactically with dose according to Kleihauer CTG monitoring and arrange USS position in left lateral tilted position catheter + fluids - keep SBP >100 - warmed hartmanns until blood is available if required fetal distress - immediate C section no distress <37 weeks - observe, steroids, regular US for growth - i.e the conservative method - a less common presentaiton no distress >37 weeks or dead fetus - induction and labour and vaginal for all Rh neg - give anti-D within 72 hours of haemorrhage note on steroisd - if bleeding is associated with pain suggestive of uterine activity or abruption then the risk of preterm birth is increased and therefore steroids may be of benefit. Women presenting with spotting that has stopped (particularly if identified cause like post-coital from a cervical ectropion or lower genital tract infection is found) and no abdominal pain, may not require steroids

Question 39

what to do if reduced fetal movements

Answer 39

try handheld dopper if none detectable, use US if present, do CTG for next 20 minutes to monirot

Question 40

PROM vs P-PROM

Answer 40

prom = premature reupture after 37 weeks (at least an hour before onset of labour) p-prom = preterm prom, occurs <36+6

Question 41

investigations for PROM

Answer 41

speculum after woman has lied down for 30 minutes - showing amniotic fluid pooling in the vagina swab for infection can do a ferning test - place cervical secretion onto a slide and allow it to dry - will form fern-patterened crystals US will show low liquor volume temperature, MSU, bloods +/- amniocentesis to look for infection fetal monitoring with CTG do not perform PV exam as this increases risk of chorioamnionitis

Question 42

management of PROM

Answer 42

evidence of chorioamnionitis - betamethasone 12mg IM, broad spectrum antibioitc cover and deliver no evidence - then admit then depends on date <37w (P-PROM) erythromycin for 10 days (or until labour if this is sooner) and can go home after 48 hours of no labour - take temp every 4-8 hours and return if it spikes also give steroids if between 24-34+6 tocolytics are generally not recommended magnesium sulphate to prevent CP - between 24-29+6w (and consider if up to 33+6) in those in labour or a planned birth within 24 hours - bolus followed by infusion if >34 weeks, the timing of IOL depends on risk vs benefits of delaying pregnancy further >37w - expectant management for no longer than 24 hours, or induce labour straight away <37w - alert neonatal team as the preterm baby will need supprot

Question 43

when to offer someone magnesium sulphate

Answer 43

* NICE say to offer IV magnesium sulphate for neuroprotection between 24-29+6 weeks in those in established preterm labour or having a planned preterm birth within 24 hours * AND to consider the same for up to 33+6 weeks * Give a 4 g intravenous bolus of magnesium sulfate over 15 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours (whichever is sooner) * Monitor for toxicity - calcium gluconate to treat

Question 44

when should antenatal steroids be given

Answer 44

between 24 and 34+6 weeks

Question 45

define premature labour

Answer 45

contractions leading to dilation of the cervix before 37 weeks

Question 46

investigations for premature contractions without water breaking

Answer 46

TV to measure cervical length - if >15mm then unlikely she is in pre-term labour, re-evaluate 2 weeks later fetal fibronectin if TV US is unavailable or unacceptable - if positive then more likely to deliver

Question 47

management of preterm labour

Answer 47

admit if likely to be true labour i.e. TV cervical length <15mm or fibronectin assay positive steroids should be consdiered - betamethasone or dexamethasone e.g. betamethasone IM 2x doses given 24 hours apart tocolytic drugs can be consdiered to allow time for steroids to work e.g. nifedipine magnesium sulphate if between 24 and 29+6 (and consider up to 33+6) can consider emergency cervical cerclage if dilated cervix and unruptured fetal membranes delivery - IV benzylepenicillin to protect against GBS in all preterm deliveries (and if GBS postitive at term)

Question 48

prevention of preterm labour

Answer 48

treat BV - clindamicin rather than metronidazole progesterone reduces recurrence in high risk (e.g. previous history of late miscarriage or preterm birth) and in low risk with a short cervix - done via cream or pessary elective (rather than rescue) cervical cerclage/sutures

Question 49

active vs latent phase of first stage of labour

Answer 49

latent= where contractions occur at 5 and 10 minute intervals - women should go home and come back when contractions are stronger active phase - when cervix is around 4-5cm dilated and contractions are more painful and regular

Question 50

delayed first stage management

Answer 50

e.g. <2cm in 4 hours (remember than expected is 1cm an hour for multiparous and 0.5cm an hour for nuliparous) when there is a delay it is recommended to commence CTG monitoring amniotomy followed by oxytocin infusion can be offered to accelerate labour, advise the woman that this will increase pain – contractions will be stronger and more painful if membrane is broken then consider oxytocin infusion if full dilation is not imminent consider C section

Question 51

deliver within what amount of time from starting pushing

Answer 51

within 3 hours of pushing in a nulliparous (start investigating after 2) – if multiparous would expect to deliver within 2 hours but start intervening after 1

Question 52

management of second stage

Answer 52

- Half-hourly documentation of the frequency of contractions - Hourly BP - Continued 4-hourly temperature - Offer vaginal examination hourly in the second stage - Perform intermittent auscultation of the fetal heart rate immediately after a contraction for at least 1 minute, at least every 5 minutes. Palpate the woman's pulse every 15 minutes - Sufficient analgesia - Once born, the baby’s mouth and nose are suctioned, and the 1- and 5-minute Apgar scores recorded

Question 53

management of third stage of labour

Answer 53

expectant - uterus is rubbed to stimulate contraction active - rcommended. with IM syntocinon or IM syntometrine immediately after birth, followed by clamping umbilical cord after 5 minutes

Question 54

amount of dilation during first stage expected

Answer 54

want 1 cm an hour for multiparous or 0.5cm an hour for a nulliparous

Question 55

normal variability on ctg

Answer 55

10-25bpm non-reassuring is <5 for 40-90mins abnormal is <5 for >90 mins - should assess for fetal acidosis via fetal scalp capillary blood sample

Question 56

normal amount of accelerations

Answer 56

>15bpm for >15 seconds - and there should be at least 2 accelerations every 15 minutes

Question 57

3 methods of inducing labour

Answer 57

vaginal prostaglandins - either via tablet/gel or via pessary e.g. propess - max one cycle in 24 hours (60% will start labour within that 24 hours) amniotomy - membranes are ruptured using an amniohook which releases prostaglandins - only performed when cerxic is ripe syntocinon infusion is given alongside membrane sweep - insert gloved finger and rotate it against the fetal membranes to separate the chorionic membrane from the decidua

Question 58

what is the bishops score

Answer 58

an assessment of cervical ripeness uses cervical dilation, cervical effacement/length, cervical consistency (how soft), cervical position, fetal station highest score = 13 <5 = labour unlikely to start without induction >8 = labour is likely to be spontaneous / high chance of induction agents working between these values is hard to predict one way or another

Question 59

things to do before instrument delivery

Answer 59

mediolateral episiotomy pudendal nerve block - usually this is sufficient analgesia empty bladder via catheter

Question 60

pre-op for c section

Answer 60

FBC + G+S - average blood loss is around 500-1000ml H2 receptor antagonist should be prescribed e.g. ranitidine +/- metoclopramide (risk of Mendelson’s syndrome (aspiration of gastric contents into the lung), leading to a chemical pneumonitis. This is because of pressure applied by the gravid uterus on the gastric contents) risk score for VTE should be calculated - anti-thromboembolic stockings +/- low molecular weight heparin should be prescribed as appropriate anaesthesia – majority under regional, this is usually a topped-up epidural or spinal prophylactic Abx during op and oxytocin to aid delivery of placenta woman positioned with a left lateral tilt of 15 degrees

Question 61

3 types of cord prolapse and its treatment

Answer 61

overt - cord through cervix and vagina past presenting part occult - is alongside presenting part but not passed it funic - cord is between presenting fetal part and fetal membranes but has not passed the opening of the cervix treat with emergency c section

Question 62

management of shoulder dystocia

Answer 62

mcroberts - hyperflex maternal hips (knees to chest) to widen pelvic outlet suprapubic pressure - pressure behind anterior shoulder can try episotomy to make access for following manoeuvres easier posterior aim - insert hand posteriorly and grasp posterior arm internal rotation/corkscrew manoeuvre - put pressure with 2 fingers on posterior shoulder and rotate it until it becomes anterior if all fail, patient on all fours then repeat last resort = symphisiotomy, zavenelli moevre (return head and c section), fracture clavicle

Question 63

3 types of breech presentation

Answer 63

frank/extended (majority) - knees extended upwards complete - knees are flexed footling - one or both thighs are extended, feet downwards

Question 64

management of breech

Answer 64

<36w - may turn spontaneously ECV (external cephalic version) done at 36 for nulli and 37 for multi - 50% success rate (higher in muliparous) - can be increased by tocolytics like salbutamol that relax the uterus - either electively or if first attempt fails - 2-3% chance of baby turning back to breech after a succesful ECV - painful if fails/CI - planned C section has lower risks of perinatal death - however in most cases vaginal is safe with monitoring and in hospital (some women may not favour this tho e.g. large baby, previous C section...)

Question 65

CI to ECV _RAM

Answer 65

``` where C section is required APH in last 7 days abnormal CTG ruptured membranes multiple pregnancy ```

Question 66

complications of ECV

Answer 66

``` transient fetal heart abnormalities persistent fetal bradycardia DDH PROM and premature labour cord prolapse traumatic injuries like Erb palsy placental abruption ``` risk of woman needing emergency c section is 1 in 200

Question 67

4Ts in PPH

Answer 67

tone - atony - most common - where uterus fails to continue to contract after birth and clamp placental artereis shut to reduce bleeding which continues for a few weeks trauma - e.g. due to instrumentation, incision from c section, from baby itself, uterine rupture tissue - retained placenta (prevents contractions and leads to uterine atony) thrombin - pre-existing coagulopathy e.g. VWD or eclampsia leading to a DIC preventing clot formation and thus --> bleeding

Question 68

causes of uterine atony

Answer 68

multiple pregnancies, fatigue from prolonged labour, induction of labour, magnesium sulphate and nifedipine can also interfere with uterine contractions

Question 69

management of primary PPH

Answer 69

communicate and alert relevant professions resuscitae with a-e, oxygen, IV access, fluids via bolus in minor, blood transfusion in major (in meantime use 2L of warmed Hartmann's) monitor and investigate - bloods from cannula; FBC, coagulation, U+E, LFT, crossmatch 4u, monitor obs stop bleeding atony - empty bladder, fundal massage, oxytocin slow IV injection or IM ergometrine or IM syntometrine second line - IM carboprost (Hemabate), rectal misoprostol, oxytocin infusion adjuncts with IV tranexamic acid or factor VIIa surgery if medical fails - balloon tamponade, B-lynch suture, arterial ligation/embolisatio or hysterectomy last option trauma - compress and suture tears tissue - manual removal of placenta if placenta has separated. if not the exam under anaesthesia

Question 70

primary vs secondary PPH

Answer 70

``` primary = within 24 hours secondary = 24 hours - 6 weeks ```

Question 71

causes of secondary PPH

Answer 71

endometritis - risk factors include C section, PROM, meconium stained liquor, long labour with multiple exams retained products of conception - elevated fundus that feels boggy

Question 72

when can you start COCP again after giving birth - breastfeeding vs nonbreastfedding

Answer 72

non-breastfeeding >3 weeks breastfeeding >6w - same as for patch or ring nb iud is within 48 hours - if not after 4 weeks immediately after birth = any progesterone method LAM becomes unreliable when: other foods or liquids are substituted for breastmilk your baby reaches 6 months old you have a period

Question 73

contraception options for <21 days non breastfeeding or <6 months breastfeeding

Answer 73

progesterone only (POP, injection, implant) barrier IUD or IUS can be inserted within 48 hours of giving birth - if not in this time then have to wait until 4 weeks after birth

Question 74

urinary symptoms vs bowel symptoms are associated with what sort of prolapse

Answer 74

urinary with anterior compartment prolapse this includes urethrocele and cystocele bowel with posterior prolapse which includes rectocele (constipation, tenesmus, need to digitally evacuate stool, incontinence)

Question 75

management of prolapse

Answer 75

conservative - pelvic floor exercises, weight loss medical - vaginal pessary (inserted into the vagina to relieve pressure on bladder and bowel - are changed every 6m) surgical anterior vault prolapse - colporrhaphy (fixation of anterior vaginal wall) or colposuspension (fixation of bladder bass to pelvic side wall) uterine prolapse - hysterectomy, sarcospinus fiaxation (fixation of uterus to sacrospinus ligament) vaginal vault prolapse - vaginal sacrospinous fixation with sutures or with mesh to attach it to sacrum

Question 76

treatment for overactive bladder

Answer 76

conservative medical - antimuscurinics like oxybutynin, darifenacin, solifenacin, tolterodine, or beta3 agonist ; mirabegron surgery - augmentaiton cystoplasty (small piece of intestine is added to the bladder wall to increase its size) or urinary diversion (ureters are re-routed to outside the body)

Question 77

causes of overflow incontinence

Answer 77

where there is detrusor underactivity or bladder outlet obstruction resulting in retention and leakage of urine e.g. due to neurological disease, urethral obstruction, medications that decrease contractiliy e.g. ACEi, antidepressants, antimuscurinics, antihistamines, antiparkinsonian drugs, CCBs, opioids, sedatives

Question 78

causes of urge incontinence

Answer 78

idiopathic in most can be associated with neurological conditions like PD, MS or injury to pelvic/spinal nerves comorbidites like obestiy, T2DM and chronic urinary tract infection can increase urgency symptoms drugs such as antidepressants exacerbated by caffine or alcohol

Question 79

investigations for incontinence

Answer 79

LL neuro exam ask about bowel habit examine abdomen for a palpable bladder perform a pelvic exam - do bimanual and ask woman to contract her pelvic muscles ask woman to cough with full bladder and observe for urethral meatus leakage test for UTI U+E - AKI may be present if urinary obstruction is present ask patient to keep a bladder diary ask about use of pads to determine severity post-void residual volume measurement with US or catheter urodynamic studies - can measure pressures with bladder outlet behaviour during filling and voiding

Question 80

management of stress incontinence

Answer 80

conservative - reduce caffine, avoid excessive fluid intake, weight loss, stop smoking (cough), make adaptations to get to toilet quicker, at least 3 months of pelvic floor muscle training (minimum of 8 contractions performed at least 3 times a day - vaginal cones can be used to help, or electrical stimulation) surgery - colposuspension - bladder neck is lifted upwards via stiching lower part of vagina to ligament behind pelvic bone, or intramural urethral bulking agents e.g. with collagen or silicone, retropubic mid-urehtral mesh sling or rectus fascial sling medical with duloxetine (anticholinergic) if doesnt want surgery

Question 81

management of urge incontinence

Answer 81

conservative - reduce caffeine, monitor fluid (too much or too little will make it worse), offer referral for bladder training (at least 6 weeks, where you hold for 5 mins for a week after urge kicks in, then extra min the next week if you dont lose continence with 5) which can be combined with pelvic floor training if mixed medical - antimuscurinics with oxybutynin, tolterodine or darifenacin OR beta 3 agonist with mirabegron (if am is CI e.g. if concerns about frailty in elderly) - can take 4 weeks to work (SE constipation and dry mouth) if these fail - botulinum toxin into bladder, percutaneous sacral nerve stimulation, percutaneous tibial nerve stimulation, augmentation cystoplasty and urinary diversion indwelling catheter for intractable symptoms

Question 82

management of postnatal psychosis

Answer 82

- Most need to be treated in hospital – ideally in a mother and baby unit - Medication -antidepressants, antipsychotics to help with manic and psychotic symptoms like delusions and hallucinations (most antipsychotics are secreted in breastmilk but there is little evidence of it causing problems - avoid clozapine) -mood stabilizers like lithium (but should be encouraged not to breastfeed) - CBT - ECT – only rarely used. If very severe depression or mania

Question 83

3 stages of the menstrual cycle

Answer 83

proliferative phase - oestrogen stimulates repair and growth of functional layer secretory phase - once ovulation has occured, progresterone creates a more welcoming environment for embyro to implant menstrual phase - decreased progesterone due to corpus luteum degeneratio leading to breakdown of endometrial tissu

Question 84

causes of primary amenorrhoea

Answer 84

SECONDARY SEXUAL CHARACTERISTICS PRESENT constitutional pregnancy imperforate hymen - complains of intermittent abdominal pain, palpable lower abdominal swelling, bulging, bluish membrane at vagina mullerian agenesis - painless, where there is a missing uterus with variable degree of vaginal hypoplasia testicular feminisation syndrome (aka complete androgen insensitivity syndrome) - may have ambiguous genitalia high prolactin- due to pituitary tumour, hypothyroidism, medicaition (chlorpromazine antipsychotic) SECONDARY ABSENT ovarian failure - chemo, iraddiation, Turner's hypothalamic - stress, anorexia, exercise failure of hypothalamic-pituitary axis - tumour, infarction, injury, Kallmann's (anosmia, unilateral renal agenesis, cleft) congenital adrenal hyperplasia - classic severe (salt losing or not-salt losing/simple virulizing) which presents with ambigious genitalia or salt losing crisis in boys, or non-classic/late-onset form which presents with early pubarche in men or amenorrhoea or infertility in women

Question 85

causes of secondary amenorrhoea (no periods for 6 months)

Answer 85

pregnancy PCOS high prolactin - hypothyroidism, pituitary tumour, medication (chlorpromazine antiemetic/antipsychotic) primary ovarian insufficiecny aka premature ovarian failure thyroid disease hypothalamic amenorrhoea - stress, anorexia, trauma, tumour

Question 86

causes of raised FSH and LH in amenorrhoea

Answer 86

``` Turner's ovarian failure (because no oestrogen inhibiting) ```

Question 87

causes of post-coital bleeding

Answer 87

infection cervical ectropion - where the columnar epithelium from the inside of the cervix is on the outside and is weaker and prone to bleed - COC, puberty and pregnancy are risk factors so can manage by stopping COC, or if persists then cryotherapy or ablation or can go away by itself cervical or endometrial polyps malignancy in vagina or cervix trauma vaginal atrophy - usually occurs after menopause, is due to lack of oestrogen

Question 88

causes of intermenstrual bleeding

Answer 88

``` ectopic pregnancy gestational trophoblastic disease spotting may occur with ovulation vaginal adenosis - presence of glandular tissue within vagina, is benign vaginal tumours vaginitis infection ectropion polyps fibroids endometrial hyperplasia endometritis adenomyosis following smear missed COC ```

Question 89

management of menorrhagia

Answer 89

IUS second line = tranexamic acid or mefenamic acid (better tolerated), COC third line = progestogens like oral or injected, or oral norethisterone in secondary care - a 3 or 4 month course of GnRH analogue (SC every 28 days) may be offered but if using >6m then add back therapy will be needed surgery - hysterectomy if doesnt need uterus, or endometrial ablation if no desire for future fertility ideally >45 (is less effective <35 and although pregnancy is unlikely, it can be associated with life-threatening complications)

Question 90

classification of fibroids

Answer 90

intramural - within the uterine wall submucosal - in the submucosa and protrude more into the uterine cavity - these may be pedunculated subserosal - grow outwards from the uterus

Question 91

investigations for fibroids

Answer 91

pregnancy test fbc for anaemia pelvic/trans-vaginal us endometrial sampling, MRI or hysteroscopy with biopsies if leiomyosarcoma is suspected MRI may be done if myomectomy is being considered or if suspicious of adenomyosis or adenomyomas

Question 92

management of fibroids

Answer 92

medical - IUS, NSAIDs like ibuprofen or mefenamic acid taken 3x a day from first day of period until bleeding stops/mangeable level, tranexamic acid 3-4x a day for up to 4 days, COCP, GnRH agonist (max 6m), ulipristal acetate (only prescribe for occassional use if surgery/non-surgical procedures like UAE not suitable) surgical laparascopic myomectomy (+/- GnRH agonist before - goserelin injection) (2-3% recurrence rate) uterine artery embolisation (via femoral - not so much surgery - not if pregnant) hysteroscopy w myomectomy for removal for submucosa if closer to cevrix endometrial ablation (for very small fibroids in womb lining) hysterectomy MRI-guided transcutaenous US is a new treatment

Question 93

types of endometrial hyperplasia

Answer 93

hyperplasia without atypia - risk of progression to carcinoma is <5% over 20 years atypical hyperplasia - pre-malignant condition - 28% risk over 20 years

Question 94

investigations for endometrial hyperplasia

Answer 94

transvaginal US- >3-4mm then further investigations needed in postmenopausal women (in premenopausal is less useful due to cyclical changes but can be used to identify things like polyps) pipelle biopsy - definitive diagnosis is with biopsy and histology hysteroscopy and biopsy should be considered as a more accurate method of diagnosis

Question 95

management of endometrial hyperplasia

Answer 95

hyperplasia without atypia address any risk factors e.g. hormonal medication like tamoxifen or obesity in asymptomatic - watchful waiting as it may return to normal on its own progesterone treatment is the usual management - IUS first line, second is continuous progesterone treatment for 6m (everyday) with either; follow-up biopsies is an option -6montly until 2 are negative, then annually if higher risk e.g. BMI >35 hysterectomy option if women wishes, change to atypia, regression has not occured despite a year of progesterone treatment with atypia total hysterectomy with bilateral salpingo-oophorectomy in addition for postmenopausal women women who wish to preserve fertility, progestogen options may be used as above, with regular monitoring by three-monthly endometrial biopsy, and advice to have a hysterectomy as soon as potential fertility is no longer required

Question 96

tubo-ovarian abscess - what is is and what does it result in

Answer 96

late manifestation of untreated PID is a cause of secondary dysmenorrhea can result in adhesions, tubal blockage and infertility

Question 97

causes of dysmenorrhea

Answer 97

``` endometriosis adenomyosis chronic PD tubo-ovarian abscess IUD fibroids pelvic adhesions including Ashermann's syndrome where scar tissue forms due to trauma e.g. surgery to remove fibroids ovarian cysts ```

Question 98

dysmenorrhoea management

Answer 98

conservative - locally applied heat, tea (regular, chamomile or mint), massage, stop smoking, some evidence for TENS medical analgesia paritcuarly NSAIDs, mefenamic acid, COC, IUS, POP, people can become amenorrhoeic within a year of depo-provera surgery - laproscopic uterine nerve ablation (LUNA) in refractory cases - insufficient evidence hysterectomy

Question 99

management of endometriosis

Answer 99

analgesia like NSAIDs hormonal treatment like COC, depo-provera, IUS, POP, implant - all same efficacy says NHS (by stopping ovulation you decrease the amount of endometrial thickening - help w cyclical pain but may not help w adhesion pain) norethisterone danazol - not used commonly due to androgenic SEs GnRH for 6 m (cyclical pain stops w menopause - but can experience menopausal symptoms) GnRH agonists for 3m can be used before surgery (induce a temporary menopause by decreasing oestrogen secretions) surgery - ablation of endometrial lesions, adhesiolysis, ovarian cystectomy for endometriomas hysterectomy last resort - ovaries removed at same time means less chance of it coming back but will require HRT if doing this (but may not work and is quite drastic) infertility - with surgical methods above (endometrial cyst may cause infalmmation in ovary, adhesion may block egg) or IVF NB periods will stop while taking goserelin

Question 100

management of adenomyosis

Answer 100

- Can do nothing if symptoms are mild - Conservative options include yoga - Pain relief with NSAIDs if mild - Tranexamic acid and mefanamic acid can help bleeding and pain - Hormonal medications - IUS, COC, POP - GnRH agonists via injections - but only short term (SC injection every 28 days for max of 6m) - Danazol - but use is reduced due to androgenic side effects - Uterine artery embolisation– by reducing blood supply there is insufficient oxygen for the adenomyosis to grow and spread - Or endometrial ablation (only if completed childbearing) o Not used as much as although it reduces bleeding, not so much the pain - Hysterectomy is definitive treatment o Removal of ovaries as well is not necessary unless they also have endometriosis in which case removing ovaries means less chance of recurrence

Question 101

early vs premature menopause

Answer 101

``` early = before 45 premature = before 40 ```

Question 102

how long are women fertilie for after menopause

Answer 102

one year if >50, 2 if <50

Question 103

symptoms of menopause

Answer 103

``` may start while still menstruating or not until more than a year after their last period night sweats hot flushes menstrual irregulatiry leading up to it dyspareunia vaginal dryness UTIs urinary incontinece sleep disturbance mood changes- anxiety, irritability, difficulty concentrating loss of libido other - brittle nails, thinning of skin, hair loss, aches and pains ```

Question 104

investigations for menopause if in doubt

Answer 104

FSH >30iu/l TFTs - thyroid symptoms may be confused with menopause BMD if siginificant risk factors for osteoporosis

Question 105

management of menopause

Answer 105

conservative - lose weight to improve flushes, same with caffeine, light clothing HRT helps with symptoms and bone loss HRT alternatives CBT for mood symptoms, SSRIs /clonidine/gabapentin for vasomotor symptoms (night sweats and hot flushes), SERMs e.g. tibolone (if period more than 1 year ago), herbal - oestrogen derivatives found in food like nuts, soy, wholegraines, oil of primrose for breast tenderness

Question 106

CI to HRT

Answer 106

current, past or suspected breast cancer known or suspected oestrogen-sensitive cancer past VTE - unless already on anticoagulant treatment undiagnosed PV bleeding raised LFTs - any active liver disease untreated HTN pregnancy be cautious with - fibroids, migraines, epilepsy, endometriosis, starting >60, FHx breast cancer

Question 107

risks of HRT

Answer 107

VTE - 2/3x baseline risk ischaemic stroke oestrogen alone increases risk of endometrial cancer so only given to those without uterus breast cancer with combined only (1 extra case per 1000) increased risk of IHD if taken more than 10 years after menopause

Question 108

HRT preperations

Answer 108

oral patch - preferred if bowel disorder than affects absorption or lactose sensitivity - do not increase clot risk - placed on thigh - oestrogen only or combined gel - same reasons as patch - but only comes in oestrogen so need to take additional pill if wanting progesterone as welll HRT implant into abdomen or an IUS - reserved for those where nothing else has worked - oestradiol has to be monitored to avoid tachyphylaxis vaginal oestrogen cream if only problem is dryness - can use even if still have womb as does not carry extra risks testosterone gel for libido if not improving with HRT alone

Question 109

who can you give oestrogen only HRT to

Answer 109

wihtout a uterus o BUT if ovaries are removed as well, may also want to consider giving testosterone to bring up sex drive o BUT if subtotal – got to check there is no endometrial tissue left around cervical stump – so do 2 progesterone challenges – bleeding after this means positive and needs combined, no bleeding is negative and means is ok for oestrogen only

Question 110

types of combined HRT preparations

Answer 110

sequential aka cyclical - LMP within 1 year - gives a monthly bleed - monthly (take on last 14 days of cycle) or 3 monthly regimens available continuous - LMP >1 year or >54 years - gives no period - takes every day without a break

Question 111

side effects of HRT

Answer 111

``` fluid retention bloating breast tenderness leg cramps headaches vaginal bleeding - breakthrough - continuous combined, <6m indigestion cancers - encourage self examination of breasts and attendance of screening with combined ``` usually all transient – usually settle within 3-4 months – if not change preparation or dose

Question 112

when to stop HRT

Answer 112

trial withdrawal should be suggested with asymptomatic for 1-2 years or been on HRT >5 years comes down to - Patient choice - No arbitrary time limit - Main issue with combined HRT is the breast cancer risk

Question 113

time until effective - COC

Answer 113

- If you start on the 1st day of the period up to and including the 5th day then you are protected straight away - If on any other day, 7 days condoms

Question 114

cancers increased in COC

Answer 114

cervical | breast

Question 115

2 missed COC pills or start new pack 2 days late

Answer 115

take last pill you missed now use extra contraception for 7 days you may also need EC if you have missed 2 or more pills in the first week of a pack and had unprotected sex in the previous 7 days - If there are 7 or more pills left in the pack after the last missed pill – finish the pack, take your 7-day pill-free break as normal - If there are less than 7 pills left in the pack after the missed pill – finish the pack and start a new pack the next day; this means missing out the pill-free break

Question 116

time until effective POP

Answer 116

- Taken during first 5 days of period, will work straight away - If not, then need additional contraception for 2 days

Question 117

missed POP pill

Answer 117

- <3 or <12 hours - take now then take next pill at usual time - If >3 hours or >12 hours - take a pill asap - only take 1 (even if you have missed more than 1) - Then take next pill at normal time (this may mean taking 2 on the same day) - Need extra contraception for next 2 days, or do not have sex - If you have unprotected sex from the time that you miss your pill until 2 days after you start taking it reliably again, you may need emergency contraception

Question 118

types of progesterone injection

Answer 118

IM dep-provera - 12 weekly SC sayana-press - 13 weekly IM noristerate - 8 weekly max of 2 injections so only for short-term use e.g. waiting until their partners vasectomy is effective

Question 119

time until injection effective

Answer 119

if during first 5 days fine | if not then extra contraception for 7 days

Question 120

disadvantages of progesterone injection

Answer 120

delay in return of fertility - up to 1 year menstrual irregularity - nearly half with be amenorrhoeric at 1 year decreased bone mineral density - will recover once injections are stopped weight gain - up to 3kg in one year small hormonal side effects like COCP

Question 121

IUS time until effective

Answer 121

if fitted in first 7 days then protected any other time need 7 days of protection

Question 122

IUD time until effective

Answer 122

instant

Question 123

when can the IUD be used for emergency contraception

Answer 123

up to 5 days after sex OR up to 5 days after the earliest time you have ovulated (even if the UPSI was then >5 days ago) e.g. if UPSI occured 7 days ago and ovulation was 3 days ago then can be used

Question 124

when can ellone be used for EC

Answer 124

up to ovulation and 5 days after UPSI

Question 125

when can levonelle be used for EC

Answer 125

within >48 hours before ovulation and within 72 hours of UPSI

Question 126

threatened miscarriage vs inetiable miscarriage

Answer 126

threatened - bleeding and abominal pain but pregnancy still continues with fetal hr present, cervical os is closed and theres a fetal heartbeat. 25% will go on to have a miscarriage (not very much bleeding) inevtiable - cervical os is open and fetal hr present - will lead to an incomplete or complete miscarriage (heavy bleeding) (if US - fetal heartbeat may be present but a miscarriage is a bout to occu - unlike incomplete where no heartbeat usually)

Question 127

missed vs incomplete vs complete miscarrage

Answer 127

missed = fetus dead but retained and os is closed - suspect a missed miscarriage in pregnant women who do not have bleeding or pain but have resolving symptoms of pregnancy (often no bleeding at all) incomplete = partially expelled products of conception, os is open - some products still retained (bleeding still ongoing) complete = os is closed, US shows empty uterus

Question 128

differentials for bleeding in early pregnancy

Answer 128

miscarriage ectopic implantation bleed - light bleeding or spotting that occurs between 7 and 14 days after fertilisation cervical polyp or ectropion gestational trophoblastic disease - most develop bleeding in first trimester and undergo uterine evacuation at about 10w

Question 129

investigations to confirm a miscarriage NB risk increases with age - 10% in 20s to 50% in 40s other risk factors = infection, multiple preg, assissted conception, fibroids, uncontrolled diabetes

Answer 129

transvaginal ultrasound - if empty then either is an ectopic, too early to see or a complete miscarriage (if CRL <7mm and mean sac diameter <25 then could just be too early) but if a woman has had a previous scan confirmed pregnancy and is now empty - miscarriage is confirmed serum hCG if PUL on US - two tests taken 48 hours apart • ≥63% increase suggests ongoing intrauterine pregnancy (rescan in 7-14 days to determine location - ectopic isn't necessarily ruled out yet) • Fall by >50% indicates failing pregnancy and potential miscarriage (should do pregnancy test 14 days later and return if positive) • Fall <50% OR fail to rise >63% should be reviewed in EPAU to exclude ectopic rare causes of raised hCG should also be consdiered like gestational trophoblastic disease or germ cell tumour if woman is <6w, bleeding but no pain can also consider expectant - tell her to repeat pregnany test in 7-10 days and return if postive or symptoms worsen

Question 130

miscarriage management

Answer 130

complete - just support incomplete, inevitable or missed expectant - allow miscarriage to progress naturally - cant do this if increased risk of haemorrhage (e.g. pregnancy in late first trimester or coagulopathy) or has infection - should complete in 2w and in most cases resorption of fetal tissue occurs without much bleeding but this can vary, then take preg test in 21 days - if still positive then medical or surgical (saftey net - any unusal signs of infection like discharge) medical - misoprostol pessary or oral - then preg test in 21 days - can take 2-8w to resolve - can be more pain and bleeding than surgical but advantage is avoids GA w analgesia and antiemetics surgical - manual vacuum aspiraton under LA or surgically under GA - always done if haemodynamic compromise or suspected molar or GTD - offer anti-D if Rh negative - risk is uterine perforation or asherman's once miscarriage occurs, recomened to send products to lab to rule out ectopic (choiroinc vili present) and molar

Question 131

investgiations for recurrent miscarriage

Answer 131

endocrine - TFTs, HbA1c, and investigate for PCOS antiphospholipid antibodies inherited thrombophilia screen - factor V leiden, prothrombin/protein s/protein c mutation USS of uterus - fibroidsm malformed uterus, e.g. bicorunate hysteroscopy for ashermans karyotype woman and partner kartotype products of conception

Question 132

managemnet of antiphospholipid syndrome to prevent recurrent miscarriages

Answer 132

usually is warfarin but women will be switched to heparin while trying to conceive then heparin with low-dose aspirin during pregnancy

Question 133

ranges within gestational trophoblastic disease

Answer 133

ranges from molar pregnancies (benign) to malignant conditions like choriocarcinoma premalignant = hydratiform mole - complete hydatiform mole - partial hydatiform mole malignant - invasive mole - a complete mole that has invaded the myometrium - choriocarcinoma - can metastasise to lungs - most often follows a molar pregnany which is why is important to monitor these pregnanies - placental site throphoblastic trumour - epithelioid trophoblastic tuomur

Question 134

what makes a complete vs partial molar pregnancy

Answer 134

complete = all comes from father - 46 chromosomes - 2 sperm fertilising empty ovum - will be no fetal tissue - 15% go on to develop persistent gestational trophoblastic neoplasia partial = 2 sperm fetilise one ovum - 69 chromosomes - usually evidence of fetal tissue and embryo may be present at start - 0.5% go on to deveop persistent gestational trophoblastic neoplasia

Question 135

features of molar pregnancy

Answer 135

bleeding in first trimester +/- abdominal pain may end on its own by a miscarriage hyperemsis abnormal uterine enlargement (larger with soft, boggy consistency) hyperthyroidism - due to the high hCG (similar shaped to TSH) anaemia respiratory distress pre-eclampsia

Question 136

investigations for molar pregnancy

Answer 136

urine and blood hCG - excessively high US - complete looks like bunch of grapes or snowstorm - partial may be viable with signs of early growth restriction histology from conception for definitive suspicion of metastatic = pelvic US, CT, MRI

Question 137

management of molar pregnancy

Answer 137

complete - surgical evacuation via suction curettage by experienced surgeon oxytocin may be required alongisde due to haemorrhage risk but is associated with risk of tissue dissemination leading to metastasis so should be avoided until uterus is evacuated if possible chemotherapy may be required after evacuation if hCG level does not fall (is measured fortnightly) - risk of requiring chemo is 15% after complete and 0.5% after a partial partial - surgical evacuation unless v small and can do medical chemotherapy may be required after evacuation if hCG level does not fall persistant gestational trophoblastic disease - chemotherapy +/- surgery hCG levels should be checked at 6w and 10w after each subsequent preg following a normal hcg on the fortnightly tests, urine hCG is requested at 4-weekly intervals until 1yr post-evacuation, then every 3mths in the 2nd year of follow-up usually you will be advised not to become pregnant until your hCG tests have been normal for six months after a molar pregnancy, and for a year after finishing chemotherapy Indications for chemo - Serum hCG levels >20 000IU/L at 4wks after uterine evacuation - Static or rising hCG after uterine evacuation in absence of new pregnancy - Persistent symptoms, e.g. uterine bleeding and/or abdominal pain - Evidence of metastases - Histological diagnosis of choriocarcinoma

Question 138

when do ectopic pregnancies present

Answer 138

6-8 weeks after last normal period

Question 139

diagnosis of ectopic pregnancy

Answer 139

abdominal exam - if pain then admit to EPAU, if not then pelvic pelvic exam - if cervical motion tenderness or pelvic tenderness admit to EPAU, if none and >6w pregnant then refer to EPAU if no pain or anything and <6w pregnant then do expectant and advise to repeat test in 7-10 days then return if positive pregnancy test positive, do urine dip to rule out UTI, bloods include FBC, crossmatch, G+S if thinking rupture transvaginal US - if too small can look for free fluid in pouch of douglas or adnexae serum hCG - >63% suggests ongoing (rescan in 7-14 days), fall by 50% indicates failing + miscarriage (redo preg test 14 days later), fall <50% to rise <63% could mean ectopic and need clinical review

Question 140

management of ectopic pregnancy

Answer 140

expectant - stable, asymptomatic/minimal symptoms, hCG <1500 IU, no fetal activity on TV USS, mass <35mm, willingness to attend for follow-up requires serum hCG every 48 hours until repeated fall then weekly until less than 15IU medical - stable, minimal symptoms, hCG <1500IU, no fetal cardiac activity on TV USS, mass <35mm, willingness to attend follow-up methotrexate IM as a single dose hCG levels should be measured at 4 and 7 days post-methotrexate and another dose can be given if drop is <15% they will need reliable contraception for 3-6m after due to teratogenicity surgical - significant pain, adnexal pain >35mm, fetal heartbeat on US, hCG >5000IU/L, unable to return follow-up laparoscopy is preferred (laparatomy may be done if particulary unstable) laparascopic salpingectomy is commonest, if other tube not ok then salpingotomy anti-D should be given if Rh negative to those that have had surgery if haemodynamically unstable then 2 large bore IV lines and fluids, crossmatch 6u of blood then emergency laparotomy once resuscitated

Question 141

how long to wait until investigating for not being able to get pregnant

Answer 141

not concieved within 1 year can offer earlier referral for consultation to discuss other options where >35 years or where there is a known clinical cause of infertility nice advise a couple to try for a total of 2 years (which can include up to 1 year before their fertility investigations) before IVF will be considered

Question 142

everyday things that can affect fertility

Answer 142

atypical antipsychotics like chlorpromazine can increase prolactin levels NSAID use is associated with luteinized unruptured follicle syndrome antidepressants and erectile dysfunction smoking, drugs, obesity chemotherapy surgery and radiotherapy to pelvic area systemic disease can interfere with the hypothalamic-pituitary axis - SLE or rhumatoid, CKD, DM, anorexia mumps in men

Question 143

causes of female infertility in infertility station - ask about symptoms of galactorrhoea, hirsutism, weight changes, temperature, hair loss, excessive tiredness, feeling cold when others are not

Answer 143

hypothalmic amenorrhoea - low BMI, excessive, kallman's syndrome pituitary tumours sheehan's syndrome hyperprolactinaemia - high prolactin inhibits GnRH PCOS premature ovarian failure - idiopathic, chemo, autoimmune turner's testicular feminisation syndrome damage to tubes due to pid/infection significant distortion of uterine cavity by fibroids or adhesions endometrioris causing tubal infertiliy problems with cervical mucus - hostility to sperm

Question 144

investigations for female infertiliy

Answer 144

exam for signs of PCOS, bimanual for PID mid-luteal progesterone to assess if ovulation occurs as it is produced by corpus luteum so must have ovulated - done 7 days after ovulation/7 days before next anticipated period (<3ng/ml means no ovulation, if normal then points to fallopian tube obstruction or uterine abnormality - can repeat if low - may have not ovulated that month) FSH and LH - high suggests poor ovarian function and low suggests central testosterone for pcos prolactin US genital tract for abnormalities HSG for tubal patency (or laparascopy with dye test if cormorbdities like PID or endometriosis) - must do sti check beforehand ovarian reserve testing with total antral follicle count via US, AMH level (high means more reserve), FSH level on day 2-5 (high if fewer follicles)

Question 145

causes of male infertilty in infertility station - ask about symptoms of galactorrhoea, hirsutism, weight changes, temperature, hair loss, excessive tiredness, feeling cold when others are not

Answer 145

high prolactin pituitary tumour kallman syndrome hypothalamic - head trauma, radiation testicular - cryptochidism, varicoele, tumours, trauma, orchitis, radiotherapy, chemotherapy, Kleinfelter's problems with genital tract - CF (absence of vas), previous STI thats caused scarring, damage from trauma, surgery or cancer, ejaculatory dysfunction, retrograde ejection

Question 146

investigations for male infertility in infertility station - ask about symptoms of galactorrhoea, hirsutism, weight changes, temperature, hair loss, excessive tiredness, feeling cold when others are not

Answer 146

examine - look for presence of varicoele, epididymal thickening, scrotal swelling semen analysis (repeated 3m later if abnormal to complete one cycle of spermatozoa, but repeat asap if gross deficiency) (need 3 days of abstinence before) FSH and LH - low is central, high in testicular abnormalities like kleinfelters, crytochidism, normal is ejaculatory dysfunction and retrograde ejaculation testosterone prolactin genetic testing for kleinfelts US genital tract testicular biopsy to see if sperm present in men with non-obstructive azoospermia - these can then be used in treatment

Question 147

teratozoospermic

Answer 147

low sperm morphology - <4% of sperm with normal morphology

Question 148

cryptozoospermia

Answer 148

so few sperm in the ejaculate that they are identified only after concentration and centrifugation

Question 149

management of male infertility

Answer 149

obstructive azoospermia - end to end anastomosis or surgical sperm retrieval non-obstructive azoospermia - ICSI (selects sperm w best morphology and motility then injects it directly into an egg), donor sperm, if secondary to central cause than gonadotropins (hCG IM or recombinant FSH), varicocelectomy, microTESE (microsurgical testicular sperm extraction - done under GA, sample is taken from testes) or ICSI for Kleinfelters with genetic counselling beforehand motility issues - ICSI or can do intra-uterine insemination where high-quality sperm are injected into uterus but unclear as to whether this is any better than normal intercourse central - hCG via IM or gonadotrophins like recominant FSH prolactinoma - cabergoline or bromocriptine (all other benign tumours should be removed by transphenoidal resection) retrograde ejaculation - sympathomimetic meds that close bladder neck or ICSI/IVF

Question 150

management of female infertiliy In polycystic ovary syndrome, abnormal hormone levels prevent follicles from growing and maturing to release egg cells. Instead, these immature follicles accumulate in the ovaries. Affected women can have 12 or more of these follicles

Answer 150

central - avoid excessive exercie/normal BMI, hCG via IM or gonadotrophins like recominant FSH prolactinoma - cabergoline or bromocriptine (all other benign tumours should be removed by transphenoidal resection) PCOS - weight loss, then clomiphene (encourages ovulation), then ovarian induction with gonadotrophins (recombinant FSH and hCG - but mighter risk of multiple pregnancies), laparascopic ovarian drilling by laser or diathermy (destroyes the tissue that is producing androgens and has been found to increase fsh levels) metofrmin can be used to lower blood sugar levels in pcos which may help - used off liscense in uk letrozole can also be used instead of clomiphene off label ovarian failure - donor eggs tubal - surgery can be considered for adhesiolysis or salpingotomy, IVF if not

Question 151

how are ovaries stimulated

Answer 151

suppress pituitary with GnRH agonist or antagonist then give clomiphene to suppress natural oestrogen release and therefore neg feedback on the pituitary FSH will then increase (or exogenous FSH can also be given) this will increase number of mature follicles ovulation can be triggered 36 hours prior to egg harvesting via hCG

Question 152

what is gamete intrafollipian transfer (GIFT) vs ZIFT

Answer 152

egg and sperm put back into the fallopian tube via laparascopy but not fertilised yet, needs more eggs so higher risk of mlutiple = GIFT - e.g. if couple has religious reasons about not wanting to have fertilisation done outside of the body mix egg and sperm then inject fertilised egg back into the fallopian tube via laparascopy = ZIFT e.g. used in unexplained infertility after trying IUI

Question 153

relationship between tamoxifen and taking a biopsy with endometrial hyperplasia

Answer 153

even if <4mm - if the patient has taken tamoxifen in the last year then this is an indication for biopsy due to it increasing the risk of endometrial cancer

Question 154

investigations for endometrial cancer

Answer 154

speculum to rule out other causes of PMB TVUS - 4mm or around that as cut off for biopsy pipelle biopsy via vagina or hysteroscopy and biopsy (some women may require GA for this) or can do hysteroscopy with dilation and curettage under GA CT for staging in those with suspected advanced disease

Question 155

management of endometrial cancer TVUS >4mm, then pipelle or hysteroscopy and biopy or hysterosocpy w dilation and curettage under ga CT for staging

Answer 155

2 week wait referral for >55 with PMB stage 1 - total hysterectomy with bilateral salpingo-oophorectomy (if wish to preserve fertility then can be hormonal treatment with progestogens) stage 2- total hysterectomy with bilateral salpingo-oophorectomy with pelvic node clearance stage 3 and 4 - maximal debulking surgery with radiation and chemo other o Unfit for surgery - options include vaginal hysterectomy (regional anaesthesia), pelvic radiotherapy or hormonal therapy with progestogens or aromatase inhibitors o Chemoradiotherapy - may be combined with surgery - can be given before to shrink - options dependent on stage, grade and risk of recurrence o New immunotherapies and biological therapies

Question 156

commonest symptoms of cervical cancer

Answer 156

vaginal discharge post-coital bleeding intermenstrual bleeding late signs = haematuria, PR bleeding, urinary/bowel symptoms, dyspareunia signs on examination = unusual appearance of cervix on speculum, or bulky masses on bimanual PV

Question 157

investigations for cervical cancer

Answer 157

``` bloods - FBC, UE, LFTs diagnosed via biopsy at colposcopy STI screening may be done prior to this to rule out cervicitis staging via CT, PET, CXR, cystoscopy etc pelvic lymph node sampling ```

Question 158

management of cervical cancer

Answer 158

- 1A1 o Large loop excision of the transformation zone (LLETZ) or cone biopsy - simple hysterectomy can also be considered particularly if preserving fertility is not an issue - IA2 - IIA (early-stage disease) o <4cm - gold standard is radical hysterectomy +/- lymph node clearance o >4cm - chemoradiation is preferred o If wanting to preserve fertility • Depending on stage, a cone biopsy with negative margins or local excision can be performed • Or depending on exact staging and growth, cervicectomy (aka trachelectomy) - IIB - IVA (locally advanced disease) o Chemoradiation is first line - IVB (metastatic) o Combination chemotherapy is the treatment of choice o Alternatively, single agent therapy and palliative care may be suitable

Question 159

how is cervical screening performed

Answer 159

done using liquid based cytology from the squamocolumnar junction (junction of ectocervix and endocervix) (theres a move away from pap testing where the sample is smeared on a slide) HPV status and dyskaryosis status are both tested during screening

Question 160

age group for cervical screening

Answer 160

25-49 every 3 years, then 50-64 every 5 years women >65 are invited if one of 3 recent cervical cytology samples is abnormal or if they have not had a test since 50 and request one women who are HIV positive should be screened annually due to them being at increased risk of CIN if pregnant - wait until 12 weeks post partum

Question 161

outcomes of cervical screenin g

Answer 161

borderline/low grade changes - only if HPV positive mild dyskaryosis = grade 1 CIN - only if HPV positive moderate dyskaryosis = grade 2 CIN - colposcopy - will be seen quicker within 2w rather than a month severe dyskaryosis = grade 3 CIN - colposcopy negative follow up as normal indadequate - repeat sample in 3 months if HPV positive but cytologically normal, repeat in 12 months (keep doing this until 3rd test then coloposcopy if still HPV positive)

Question 162

how is colposcopy performed

Answer 162

- Speculum is inserted then a microscope is used to look at cervix - The cervix is cleaned with acetic acid followed by iodine to identify the abnormal areas (will stain them yellow) - Abnormal cells in the cervix that are identified at colposcopy are removed by large loop excision of the transformation zone in some cases treatment like diathermy, laser therapy or larger excision may be undertaken but this will generally only be after discussion of biopsy results whole things takes 20 mins fine to return to work same day - warn of small amount of blood of discharge bring pad - avoid sex and tamponds until bleeding stops biospy results usulaly avaible in a week may be an association between treatment of the cervic and preterm labouir

Question 163

treatment of CIN

Answer 163

done at same time as colposcopy but may have to wait for biopsy results (colposcopy doesnt hurt but may cause cramping - take pain killer 30mins before and bring pad to wear after in case of bleeding) most common treatment is large loop excision of the transformation zone (LLETZ) with a thin heated (with electric current) wire loop – LA is injected into cervix first cone biopsy is done less – a cone-shaped piece of tissue is cut out – done if a large area of tissue needs to be removed. Cannot be done at same time as colposcopy - done under GA other treatments include cryotherapy (only used to treat minor cell changes), laser treatment, cold coagulation, hysterectomy (if abnormal cells found more than once and dont want children) after treatment - another screening test 6m later - if HPV or cytology changes found then another colposcopy NB after a cone biopsy - generally wont affect fertility however there is a small chance or miscarriage and preterm labour (and a small chance that there will be cervical stenosis in which case sperm wont be able to get through)

Question 164

subtotoal vs total hysterectomy

Answer 164

total = removes cervix

Question 165

RMI for ovarian cancer

Answer 165

US score (number of findings on scan) x menopausal score (1= premenopausal, 3 = post) x Ca 125

Question 166

investigations for ovarian cancer

Answer 166

two-week wait referral is recommended in any woman with ascites ± pelvic mass that is not obviously fibroids baseline investigations - urine pregnancy test (exclude ectopic and uterine pregnancy as a cause of symptoms), FBC CA125 - >35 then arrange pevlic and abdominal US then consider CT of pelvis and abdomen if US is suggestive then do RMI (risk malignancy index) if RMI >200-250 then refer to MDT for laparotomy in women <40 measure AFP and hCG as well to exclude rarer tumours can also consider doing AFP, CA19-9 and CEA final diagnosis is often obtained during surgery after appropriate MDT discussion. In cases where cytotoxic chemotherapy is proposed prior to surgery a histological sample is normally attained before treatment is commenced. This is ideally by percutaneous image-guided biopsy

Question 167

management of ovarian cancer

Answer 167

standard - surgery followed by chemo - surgery is via midline incision with goal to remove as much as possible - will usually involve a hysterectomy, removal of both ovaries and fallopian tubes and the omentum the chemotherapy after surgery isn't necessarily required for very early stages at earlier stages there can be discussion of fertility preserving surgery but this has risks associated in advanced, may also have neoadjuvant chemo radiotehrapy for palliative

Question 168

investigatinos for ovarian cysts the vast majortiy of ovarian cysts are benign and may not need treatment and go away on their own folliciluar cyst is the commonest type syptmos - dull ache in abdo or back (may be intermittent or only w sex) cyclical pain suggests chocolate cysts palpable mass pressure effects on bladder or bowel ascites - meig's syndorme (ovarian tumour, ascites and effusion)

Answer 168

pregnancy test FBC - infection, haemorrhage US - simple vs complex (simple is fluid only, complex can be irregular and contain solid material, blood or have separations or vascularity) CA-125 - be aware it can be rasied in endometriosis, diverticulosis, liver cirrhosis, menstruation and pregnancy - it does not need to be done in premenopausal women who US shows simple cyst LDH, AFP and hCG for germ cell tumours calculate RMI - >200 = high risk and shoudl be discussed for staging laparotomy, 25-200 - do MRI to further evaluate CT and MRI if US not definitive diagnostic laparoscopy or fine-needle aspiration cytology may be used to gain histological evidence that a mass or cyst is benign BUT - RCOG said that aspiration of the cyst is associated with a high rate of recurrence and increased spillage into the peritoneal cavity, which may disseminate possible malignant cells - Therefore cystectomy may be preferred over aspiration

Question 169

meig's syndrome

Answer 169

triad of ovarian tumour, ascites and pleural effusion

Question 170

mangement of ovarian cysts

Answer 170

<5cm and without complications, follow up not required as is likely physiological and almost always resolves in 3 menstrual cycles if >5cm then observe with annual US to monitor for possible malignany if the cyst persists, or enlarges, either further imaging (MRI) or surgery is recommended if the cyst is >70mm or symptomatic o In children and younger women wishing to preserve maximum fertility, cystectomy may be preferable to oophorectomy

Question 171

investigations + management of complication of ovarian cysts (torsion, rupture, haemorrhage)

Answer 171

A-E cannulate, take bloods including FBC and G+S fluids as needed pregnancy test to exclude ruptured ectopic pelvic or transvaginal US (can do doppler for torsion - however doppler flow isnt always even absent in torsion) CT or MRI if diagnostic uncertainty immediate surgical intervention = usually laparascopically with uncoiling and oophoropexy for torsion and removal of the cyst salpingo-oophorectomy may be indicated if severe vascular compromise, peritonitis or tissue necrosis in cyst rupture, IV broad spectrum antibiotics

Question 172

how long do you give inflation breaths over

Answer 172

5 inflation breaths over 30 seconds

Question 173

rate of ventilation breaths

Answer 173

30-40 per minute (1-2 seconds each) (after your 5 inflation breahts, if HR increases but baby does not breath then you would now do your ventilation breaths until it breaths by itself)

Question 174

when to start compressions in neonatal rescitation

Answer 174

- If the heart rate remains slow (less than 60 beats per minute) or absent following 5 inflation breaths, despite good passive chest movement in response to your inflation efforts, start chest compression - Give 3 compressions to one inflation breath

Question 175

APGAR meaning

Answer 175

appearance - colour pulse - >100 scores 2 points grimace/reflex irritability in response to a pinch activity - muscle tone respiration - absent, weak or strong cry 7-10 is normal <3 is critically low is taken 1 and 5 minutes after birth

Question 176

timing of heel prick test

Answer 176

5-8 days

Question 177

timing and types of hearing test for neonates

Answer 177

4-5 weeks automated otoacoustic emission - probe in the ear that emits clicks and acoustic energy will be produced in response if the cholcea is normal (detects echoes) automated auditory brainstem response - done if the baby doesn't have a clear repsonse to the first - uses electrodes to detect brainstem responses babies who have spent more than 48 hours in a Neonatal Intensive Care Unit (NICU) or Special Care Baby Unit (SCBU) are regarded as high-risk and are screened using both AOAE and AABR tests

Question 178

SGA baby define

Answer 178

birth weight <10th centile or 2 standard deviations from norm (whereas IUGR described baby that hasn't reached its growth potential due to genetic or environmental factors)

Question 179

risk factors for SGA

Answer 179

``` - Minor risk factors o Maternal age ≥35 years o IVF singleton pregnancy o Nulliparity o BMI <20. o BMI 25-34.9 o Smoker - 1-10 cigarettes per day o Low fruit intake pre-pregnancy o Pregnancy interval <6 months o Pregnancy interval ≥60 months - Major risk factors o Maternal age >40 years o Smoker - ≥11 cigarettes per day o Paternal or maternal SGA o Cocaine use o Daily vigorous exercise o Previous SGA baby o Previous stillbirth o Chronic hypertension o Diabetes with vascular disease o Renal impairment o Antiphospholipid syndrome o Heavy bleeding similar to menses o Pregnancy associated plasm protein-A (PAPP-A) <0.4 multiples of the median (MOM) ```

Question 180

investigations for SGA

Answer 180

plot symphysis fundal height if <10th centile then can do US for fetal size or women with major risk factor should have serial US and umbilical artery doppler from 26-28 weeks women with 3 or minor risk facotrs should have uterine artery doppler at 20-24w - if this is abnormal (pulsitility index >95th centile) – should be referred for serial US measurement of fetal size with umbilical artery Doppler at 26-28 weeks where uterine artery doppler shows reversal or absent diastolic flow, delivery of fetus is indicated can do karyotyping is detected before 23 weeks

Question 181

some causes of IUGR

Answer 181

placenatal most common - pre-eclampsia, abruption, accreta, previa maternal - malnutrition, low BMI, substance abuse, chronic disease, hypertensive disease, anti-phospholipid syndrome, extremes of ages fetal - chromosomal abnormalities, congenital abnormalities, congenital infections, multiple pregnancy

Question 182

3 types of IUGR

Answer 182

symmetrical - mostly due to chromosomal abnormalities asymmetrical - cause of IUGR later in pregnancy, most often placental insufficiency, head circumference will be normal - but abdominal circumference will be decreased mixed - when early IUGR is affected further by placental causes in late pregnancy

Question 183

scanning when at risk of IUGR

Answer 183

every 2 weeks from 28w gestation to asses fetal head circumference, liquor volume (oligohydramnios occurs in IUGR as there is shunting of blood to the head to protect the developing brain. This deceases renal perfusion, lowering urine output) uterine artery doppler- where this shows reversal or absent diastolic flow, delivery of fetus is indicated

Question 184

when is meconium aspiration seen vs transient tachypnoea of newborn vs newborn respiratory distress syndrome

Answer 184

meconium aspiration usually seen in term or post term - will see patchy infiltrations and atelectasis on cxr transient tachypnoea usually seen in term or near term infants usually after a c section (as is due to delay in resorption of lung fluid, thought to be due to decreased levels of catecholamines from c section) - resolves fully within first day of life - HF type patten on CXR (interstital oedema and pleural effusions - but normal size heart which distinguishes it from heart issue) NRDS in premature - respiratory distress which worsens over next few days - diffuse ground glass lung with low volumes on CXR

Question 185

causes of neonatal seizures

Answer 185

most common = HIE (hypoxic ischaemic encephalopathy) - presents in first 24 hours with fetal distress, need for resuscitation at birth and decrease coscious level group b strep and e coli are commonest infective causes and present from end of 1st week onwards cerebral infarction often presents with focal seizures at 24-72 hours in an otherwise well infant remember IUGR babies are at risk of hypoglycaemia materanl substance abuse = neonatal abstinence syndrome benign neonatal sleep myoclonus – presents from 5 days with myoclonic jerks only during sleep

Question 186

management of neonatal seizure

Answer 186

- Monitor breathing – may be compromised during seizures and following anticonvulsant administration - Start an anticonvulsant if there are: prolonged desaturations, haemodynamic instability, seizure lasting >5 minutes, or brief but frequent seizures >3 per hour o First- line: phenobarbital ‘full’ loading dose (20 mg/ kg IV) - Commence antibiotics and add aciclovir if there is any suspicion of herpes infection (maternal infection, rash, abnormal LFTs)

Question 187

management of ttn

Answer 187

- Observation – if symptoms are related to TTN they will improve within mins-hours (whereas if due to pneumonia for example will get worse) - Additional oxygen may be required

Question 188

cause of meconium aspiration

Answer 188

usually secondary to fetal hypoxia which causes increased peristalsis, relaxation of anal sphincters and reflex gasping so is a sign of fetal distress

Question 189

management of meconium aspiration

Answer 189

observation over 12 hours therapeutic interventions include airway suctioning, oxygen delivery, ventilatory support surfactant replacement can be beneficial as meconium will deactivate the actvity of rsurfactant causing a rise in surface tension antibiotics if suspicious of infection prevent hypothermia with incubator if needed (hypothermia inhibits surfactant production) continuous monitoring serum electrolytes should be measured in babies with MAS because perinatal stress can lead to inappropriate antidiuretic hormone (ADH) secretion syndrome and acute kidney injury resp distress usually subsides in 2-4 days

Question 190

management of respiratory distress syndrome

Answer 190

manage in NICU surfactant replacement therapy given via endotracheal tube oxygen via a hood supportive therapy including presvention of hypothermia (may need incubator), IV nutrition antibiotics after obtaining cultures - discontinue after 3-5 days if cultures are negatiev

Question 191

antibiotic for group b strep prophylaxis

Answer 191

benzypenicillin - Maternal IV antibiotic prophylaxis should also be offered to women in preterm labour regardless of their GBS status

Question 192

when is neonatal jaundice pathological

Answer 192

``` if develops before 24 hours or if conjugated or if unconjugated and lasts >14 days or symptomatic or raised >220 ```

Question 193

causes of unconjugated hyperbilirubinaemia

Answer 193

breast milk jaundice - after 7-10 days due to substances in breast milk - should keep breastfeeind regardless breastfeeding jaundice - presents within first 7 days - due to insufficient feeding - decreased milk volume slows down GIT infection haemolytic anaemia hypothyroidism gilbert's cephalohaematoma usually not a problem, but unconjugated bilirubin is fat soluble and can cross BBB --> kernicterus

Question 194

causes of conjugated hyperbilirubinaemia

Answer 194

liver disease leading to cholestasis o Bile duct obstruction e.g. biliary atresia, choledochal cyst o Alpha-1-antitrypsin deficiency o Galactosaemia o Cystic fibrosis o Neonatal hepatitis syndrome o Intrahepatic biliary hypoplasia e.g. Alagille syndrome, Down syndrome

Question 195

investigations for neonatal jaundice

Answer 195

transcutaneous bilirubinometer if >24 hours old and >35 weeks gestation serum if <24 hours or <35w or if transcutaenous was high at >250 total and conjugated levels to decide if conjugated or not haemoglobin levels = if llow could be a collection outside vessels like cephalohaematoma LFTs for cholestatis or liver disease infection screen for TORCH look for sources of infection investigate for haemolysis - reticulocyte count, LDH, direct Coomb's (see if mothers antibodies are attacking baby's RBCs due to Rh or ABO incompatibility), blood film and red cell enzyme assay, electrophoresis US, HIDA scan for cholestatic jaundice like biliary atresia

Question 196

management of neonatal jaundice differentials include - hypothyridism, haemolytic anaemia

Answer 196

- Infants with jaundice will have their bilirubin levels plotted on a graph against age since birth, with adjustment for prematurity. The graph has two lines, marking treatment threshold - The lower line is the threshold for treatment with phototherapy (stop once >50 below treatment lines, recheck in 12-18 hours after stopping) - The higher line is the threshold for treatment with exchange transfusion - if below both lines - >50 below do nothing, <50 below then repeat level in 18-24 hours depending if baby has risk factors present or not IV immunoglobulin can be used as an adjunct to phototherapy in Rh or ABO haemollytic disease

Question 197

when should anti-D prophylaxis be given to rh negative women that have not already been sensitised

Answer 197

as two doses of anti-D immunoglobulin of at least 500 IU at 28 and 34 weeks or as a large single dose of 1500 IU at 28 weeks’ gestation

Question 198

management of breast milk jaundice - prsents in first 2 weeks of life and can persist for as long as 12 weeks can be diagnosed in a healthy thriving infant w food weight gain where haemolysis has been ruled out

Answer 198

this is the commonest form of prolonged jaundice in term infants *uncongjugated benign process no real identifiable cause and is relatively common up to 10% of breast-fed infants can remain jaundiced up to one month of age treatment depends on bilirubin levels and may include increasing number of feeds per day, interrupting feeds w formula solution or even phototherapy

Question 199

placentra previa on exam

Answer 199

soft uterus | abnormal lie

Question 200

typical age of presentation for fibroids

Answer 200

30-50

Question 201

tranexamic vs mefenamic acid

Answer 201

``` Tranexamic acid (anti-fibrinolytic) – ~50% reduction in blood loss and is used during or just before the period. Particularly effective in fibroids. 3-4x a day for up to 4 days Mefenamic acid (NSAID) – ~30% reduction in blood loss, particularly useful if dysmenorrhoea is also present. take 3x a day from first day of period until it stops/is mangeable ```

Question 202

norethisterone

Answer 202

You'll usually be prescribed 3 norethisterone tablets a day, starting 3 to 4 days before you expect your period to begin norethisterone does not act as a contraceptive when used in this way, so you could still get pregnant

Question 203

when is combined vs quadruple done

Answer 203

combined at datings scan - 8-14 weeks | quadruple at 14-20 weeks and is only for DS

Question 204

notes for DS counselling nb high bmi can make it hard to measure nuchal translucency

Answer 204

DS is most common conegnital abnormality - 1 in 1000 main cause of early mortality is congenital heart disease - despite this many will live happy and fulfilling lives risk increases to about 1 in 100 at 40 years presents w low tone, increase reflexes, intellectual disability, developmental delay, diabetes, short stature, obestiy, 50% have congenital defects (AVSD, ASD, VSD), asthma, duodenal atresia combined - 8-14 (beta hCG, PAPP-A and nuchal translucency) quadruple - 14-20 is considered positive if risk is greater than 1 in 150 and these women are offered diagnostic testing CVS - 11-14 amniocentesis - 15-18 both have infection risk and may have to be repeated both take 10 mins, results in 3 days both test for other things too will need anti-D

Question 205

termination of pregnancy investigations

Answer 205

confirm pregnancy w urine dip USS to assess pregnancy including dating - however this is no longer considered to be an essential prerequisite of abortion in all cases (an alternative would be estimation of gestation via examination) screen for STIs discuss future contraceptive needs check rhesus status determine if smear has been done within recommended time - if not should be offered within the abortion service Counsel the patient and give options and advice but also remember that RCOG guidelines state that: the earlier in pregnancy an abortion is performed, the lower the risk of complications

Question 206

meaning of twin types

Answer 206

dichorionic diamniotic = separate amniotic membranes and placenta dizygotic means 2 eggs fertilised by 2 sperm monochorionic monoamniotic = same sac and same placenta monochorionic diamniotic = different sac same placenta

Question 207

complications and diagnosis - twin pregnancy (NB identical twins dont run in fam, IVF can increase risk)

Answer 207

DIAGNOSTIC SIGNS hyperemsis gravidarum uterus larger two fetal hearts may be heard on ausculation BUT not really relied upon - mostly picked up at dating scan (twin peak or lambda sign) COMPLICATIONS MATERNAL - diabetes, pre-eclampsia, hyperemsis, APH, PPH (a hormone drip will be started after birth to reduce this), placentra previa, anaemia FETAL - pre-term (40%), miscarriage (particuarly with mono), IUGR, congenital anomalies (particuarly w mono e.g. cardia, neural tube), vanishing twin syndrome (one twin being resorbed), twin twin transfusion syndrome in mono (only occurs in twins sharing same placenta)

Question 208

precautions for a twin pregnancy

Answer 208

consultant led should all have more frequent growth scans from 20 weeks routine use of iron and folate can be considered for anaemia risk aspirin 75mg if one additional risk factor for pre-eclampsia e.g. first baby or FHx more frequent check ups due to pre-eclampsia risk offer delivery at 37-38 weeks via induction for normal birth or c section (ealier for monozygotic monochorimnotic at 32 weeks) NB dizygotic have much less risks and dont need as much scanning more than half of twins (around 60%) in uk are born by c section - will need if first twin is breech, placenta is low lying or if they share placenta if previous baby was c section then will recommend c sec NB if twins are dizygotic then you may not be able to find out for certian if identical - a third are non-identical can reduce risks of these with a healthy lifestyle - no alcohol and smoking

Question 209

presentation of fibroids

Answer 209

most are asymptomatic ``` menorrhagia local pressure effects causing abdo pain dysmenorrhoea dyspareunia 30-50 years may have palpable abdominal mass signs of anaemia enlarged, often irregular, firm, non-tender uterus palpable on bimanual pelvic examination ``` - Submucosal and intramural fibroids are linked to infertility and increased risk of miscarriage - 5% of pregnant women noted to have fibroids experience acute pain during the pregnancy, due to fibroid degeneration - red degeneration - May have urinary or bowel symptoms - Torsion of a pedunculated fibroid can present with acute abdominal pain

Question 210

endometriosis pahthohysiology

Answer 210

blood outside uterus also respond to the hormones so causes a cyclical - dull heavy or burning pain around the same time as menstruation if depsotis in bladder or bowel can lead to bleeding in stools and urine duein tmenstruation localised bleeding and inflammation can lead to adhesions - scar tissue can attach different organs together adhesions leads to non-cyclical pain - sharp, stabbing pulling in nature - pt feels quite sick when happenng

Question 211

diagnosis of endometriosis

Answer 211

histroy - cyclical pain speculum - may show deposits in vagina bimanual - fixed urterus or cervix, tender on deep, adnexa tender pelvic US may show large endoemtriomas or choc cyst - but often normal MRI useful for mapping pre-surgery and may show some deposits laparascopic surgery is gold standard NB can stage from 1-4 by severity blood tests (e.g. FBC), urinalysis and MC&S, cervical swabs (MC&S, chlamydia testing) and beta human chorionic gonadotrophin may be helpful in excluding some important differentials

Question 212

cerical ectropion notes

Answer 212

occurs when the columnar epithium of the endocerxic extends out to the ectocervix will be visible on speculum more common in younger, coc, pregnany (associated w high oestrogen levels) asymptomatic, post coital bleeding, vaginal discharge, pain in sex problematic bleeding is an indication for treatmen manage w nothing if asymptomatci stopping pill ablation w silver nitrate, cold cyrotherapy this will result in some vaginal bleeding until it is healed

Question 213

P1+1 meaning

Answer 213

+1 could be miscarriage or ectopic

Question 214

questions to ask in history

Answer 214

w bleeding - any tissue, clots any treatment to the cervix before

Question 215

counselling points w colposcopy

Answer 215

speculum is inserted, then cervix is cleaned and stained to highlight abnormal cells will then take a biopsy - most do not have LA but can if want to the biopsy taken is the size of a grain of rice wait until and bleeding or discharge stops before you have sex, swim or use tampons is generally painless but may cause cramping, discomfort and bleeding in some women your doctor may suggest taking a pain killer 30 minutes before bring a sanitary pad before to wear after in case of bleeding HPV is a common virus that 8 in 10 will get and does not cause problems in most people but in some can cause genital warts or cancer

Question 216

hyperemesis gravidarum investigations

Answer 216

``` examine for signs of dehydration obs urine dip - uti is a differential and check for ketones - can be raised due to starvation ketosis UE, LFTs blood glucose - exclude dka abg amylase tfts US to exclude multiple or molar pregnancy do PUQE score ```

Question 217

induction of labour counselling ask about allergies

Answer 217

RISKS W POST DATES BABY malnutrtiion, chest related complications and meconium aspiration INDICATIONS 1 in 5 need induction = stimulation of uterine contraction with or without a ruptured membrane should be offered between 41-42 weeks and for PROM >37w or maternal of fetal complications like obstetric cholestasis RISKS increased risk of needing c section excessive uterine contractions --> fetal distress or uterine rupture uterine atony and PPH METHODS if cervix is not favroubale: vaginal prostaglandins - ripen the cervix - either as a tablet or as a pessary called propess - 60% will go into labour after 24 hours - some will need repeat dose - may be able to go home to give it time to work if the cervix is favourable: amniotomy + oxytocin infusion - amnihook is used to rupture membranes - this releases prostaglandins to speed up labour, given w oxytocin to increase contractions - only performed if cervix is ripe adjunct: membrane sweep - insert gloved finger into cerivx and rotate it against fetal membranes to cause separation - this releases natural hormones to speed up labour - fot this there needs to be some dilation of cervix - risk of this is small amount of bleeding after and could be uncomfrtable - no risk of infection to baby if membranes ruptures - iv syntocinon BISHOPS an assessment of how ripe the cervix is and likelihood labour will start and how successful induction methods will be TESTS prior to induction of labour, a reassuring fetal heart rate must be confirmed by CTG if syntocinin/hormone drip is used then baby will need constatn monitoring w ctg

Question 218

IUGR history

Answer 218

``` any high bp - ask about med conditions previous obstetric CERVICAL SMEARS pmh of kidney disease or clotting disorders good nutrition? medication during a prior to pregnancy smoking, alcohol and substance abuse ```

Question 219

notes on rhesus counselling

Answer 219

15% are neg explains that if the newborn baby is positive - then a small amount of the babys blood may enters the mothers blood stream and because it is a different blood group - the mothers body can produce a protein known as an antibody against the babys blood cells the mums antibodies can then destroy the babys blood cells - not necessarily harm first baby but may be dangerous for subsequent explain that blood is most likely to mix during childbirth but also termination or pregnancy, miscarriages, amniocentesis the reason why it will affect the next baby is because the mothers cells will keep this memonry and produce more in future can cause haemolytic disease of newborn - baby becaomes jaundice, v ill or stillbirth to prevent this we give anti-d injection that prevents mum from making these antibodies offered at 28 and 34 weeks kleihauer test will be taken after birth anti-d is safe for the mum and baby - rarely you may have allergic reaction so may be monitored for 20 mins before going home