O&G PACES Flashcards
(190 cards)
1
Q
What investigations are routinely given and offered in the booking visit?
A
1) USS - 11-13 (+6) weeks - date using CRL, detect multiple pregnancy
2) Combined test - beta-hCG, PAPPA + nuchal translucency measurement (NTM) - screening for Down’s syndrome
3) Bloods: FBC, serum antibodies (e.g. anti-D), Syphilis, Rubella immunity, HIV/Hep B offered, haemaglobin electrophoresis if at risk, GTT if at risk.
4) Urine dip, microscopy and culture - protein, nitrites, glucose, screen for bacteruria
2
Q
How can you work out the estimated due date (EDD) (3 ways)
A
- Naegle’s rule –> date of LMP + 12 months - 3 months + 7 days
- 280 day wheel (often gives a slightly different date)
- USS measurements
3
Q
What are Korotkoff sounds, describe accurately what they are and how they are identified
A
When measuring blood pressure, you aim to get the systolic and the diastolic pressures. Normally the blood is being pumped along the brachial artery in a smooth line - laminar flow, doesn’t make a noise. When you inflate the cuff to the same as the systolic pressure, the artery becomes occluded, preventing flow of blood. Then pressure is released down again, and at the point of systolic pressure blood is squeezed through the arm past the cuff during systole, creating turbulent flow which is audible - this is the first Korotkoff sound. As pressure is slowly dropped in the cuff, thumping sounds are heard, until eventually they become muffled and then silent - because less restriction means that blood flow is able to become laminar again, which doesn’t produce sounds.
4
Q
What are the symptoms and signs of pre-eclampsia
A
Headache, flashing lights, oedema, hyper-reflexia
5
Q
what is the preinvasive stage of cervical cancer?
A
CIN - cervical intraepithelial neoplasia
6
Q
What is the cause of CIN and cervical cancer?
A
HPV - human pappilomavirus
7
Q
Which subtypes of HPV cause the majority (70%) of invasive cancers
A
16, 18 - are the types which are vaccinated against
31, 33 also
8
Q
wen is the smear recommended and how often should it be repeated?
A
between 25-64
3 yearly between 25-49, and then 5 yearly from 50-64
then can stop at age 65 providing the last 3 previous smears have been negative
9
Q
which part of the cervix should cells be taken from in a smear test?
A
the transformation zone
10
Q
what 4 groups can cytology report the cervical cells from a smear?
A
- BNC - borderline nuclear changes
- mild dyskaryosis
- moderate dyskaryosis
- severe dyskaryosis
11
Q
Why can’t a diagnosis of CIN - cervical intraepithelial neoplasm or cancer be made from a smear test? What’s the point of it then
A
it’s a cytological test, and the diagnosis can only be made histologically –> however the degree of dyskaryosis corresponds to the grade of CIN
12
Q
What should be done immediately if moerate or severe dyskaryosis is found on a smear?
A
refer to colposcopy clinic
13
Q
what is a colposcope
A
binocular microscope which allows a close examination of the vaginal and cervical epithelium. This allows the clinician to better assess the cervix and obtain a tissue sample in order to make a firm diagnosis
14
Q
Which types of epithelium covers the ectocervix and endocervix?
A
ecto- squamous epithelium
endo - columnar epithelium
15
Q
where is the position of the squamcolumnar junction? (SCJ)
A
it is not fixed - changes throughout life under the influence of oestrogen.
16
Q
in younger women, where does the scj tend to be visible?
A
On the ectocervix: can see red columnar epithelium area near to the cervical os and then the paler squamous epithelium surrounding it
17
Q
Why does columnar epithelium on the cervx appear more red than squamous epithelium?
A
Because it consists of a single layer of cells and so the blood vssels are nearer the surface
18
Q
What is a visible area of columnar cells seen on the surface of the cervix called?
A
an ectropion
19
Q
Which subtypes of HPV are associated with genital warts?
A
6 and 11
20
Q
What % of CIN3 will progress to invasive cancer if untreated?
A
50%
21
Q
What can invasive cancer of the cervix present with
A
- post coital bleeding
- post menopausal bleeding
- intermestrual bleeding
- abnormal vaginal discharge
22
Q
What is the appropriate management of CIN2 or 3?
A
loop excision of the transition zone - which is performed with a diathermy loop in the colposcopy clinic using local anaesthetic. Can be under GA if it’s a large area or if patient cannot tolerate. Tissue removed and sent to histology, only takes about 10 mins.
23
Q
What is the TZ (transition zone) of the cervix?
A
area between the old squamo-columnar junction and the new one - area where dysplasia is most commonly seen due to all the squamous metaplasia going on.
24
Q
What is the cure rate of LETZ (loop excision or the transition zone)
A
95% cure, 5% need a second LETZ which will then be curative in most cases.
25
what are the 2 main aetiological causes of PID?
1. transmission - usually sexual related
| 2. iatrogenic
26
give 4 iatrogenic causes of PID
1. IUD insertion
2. hysterosalpingography
3. endometrial biopsy
4. uterine cutterage
27
What is a common investigation in a woman with abnormal bleeding where it is difficult to gain much info from a speculum/
endometrial pipelle sample / biopsy
28
What are the 3 most common organisms causing infection in PID?
1. chlamydia trachomitis
2. N gonorrhoea
3. mycoplasma hominis
29
what are some risk factors for PID
- multiple sexual partners
- menstruating teens
- previous Hx of PID
- STIs
- non use of barrier contraceptive
30
give some differentials for PID
- ectopic pregnancy
- appendicitis
- ovarian cyst rupture
- ovarian torsion
- endometriosis
- UTI
31
What kind of pain is seen in PID?
severe recent onset bilateral lower abdominal pain
32
What investigations should you consider to confirm suspicion of PID?
- bHCG
- bloods: FBC, WCC. CRP, U+E, LFTs
- triple swabs: lack of infection doesn't exclude PID
- urine dip and MSU
- TV USS pelvis
- CT abdo/pelvis - if suspecting abcess or ovarian cyst
- ? endometrial biopsy
- ?laparoscopy/hysteroscopy
33
what is the outpatient reginmen of antibiotics for a PID patient
cef + doxy + metro
| 500mg single dose IM ceftriaxone, then oral doxy 100mg bd and metronidaxole 400mg BD for 14 days
34
What advice should you give to patient regarding sex with partner after Tx for PID?
- avoid unprotected sex until patient and partner have completed follow up - finished course of Abx.
- partner hsould be offered broad spec Abx e.g. single dose azithromycin
- contact tracing within 6 months of symptoms
35
What are the complications of PID?
- Fitz Hugh curtis syndrome (rare - liver capsule inflammation & adhesions)
- infertility
- ectopic pregnancy (x6 more common)
- chronic pelvic pain
- Reiter's syndrome
- preterm delivery
36
How many couples are affected by infertility?
15%
37
what is the syndrome in which males have more than one X chromosome - aka 47XXY
Kleinfelter syndrome
38
what are the 4 aetiological categories for infertility?
1. anovulation
2. male factor
3. Fertilisation disorder
4. implantation defect
39
What investigations should you consider in a couple presenting with primary infertility?
Male - semen analysis (motility, morphology, sperm count)
Female
- LH, FSH, day 3-5
- mid luteal progesterone (day 21)
- rubella
- TFTs (hyper/hypo thyroid can cause decreased feritlity and menstrual disturbances)
prolactin
- USS if thinking PCOS
- hysterosalpingogram
- laparoscopy and dye (looks for blocked tubes, adhestions, cysts, fibroids, infection)
- ovarian reserve testing
40
what is a normal male sperm count
40-300 million per ml is the normal range
| anything <15 million/ml is considered a low sperm count
41
How does a mirena IUS prevent pregnancy?
Releases a progestogen hormone which is similar to progesterone - natural hormone produced by the ovaries.
Progestogen thickens the mucus from the cervix (opening of the womb), making it harder for sperm to move through it and reach an egg. It also causes the womb lining to become thinner and less likely to accept a fertilised egg. In some women, the IUS also stops the ovaries from releasing an egg (ovulation), but most women will continue to ovulate.
42
`in pregnancy, why does the corpues luteum not degenerate as it does in normal mensturation?
because in pregnancy hCg levels rise, which functions in a smilar way to LH which means that the corpus lutteum remains viable, therefore continues to produce progesterone. (In menstruation, LH and FSH become suppressed due to negative feedback from oestrogen and inhibin and so corpus luteum degenrates).
43
What actually causes the endometrium to shed in a period?
the corpus luteum degenerates due to low FSH and LH
this means progesterone production is suppressed
- this causes spiral arteries of the functional endometrium to contract, causing ischaemia - which is shed
44
What is the window of fertility?
5 days before ovulation, to 1-2 days after
| normally ovulate on day 14 of cycle
45
Wha are the Rotterdam criteria for PCOS?
1. polycystic ovaries (12+ on transvaginal ultrasound)
2. oligomenorrhoea/amenorrhoea - (>35 days apart)
3. hyperandrogenism (clinical / biochemical signs, or elevated testosterone)
46
what should you consider in the management of PCOS?
amen/oligomenorrhoea - mirena coil, COCP
insulin - metformin
hirsutism - weight loss, hair removal, eflornithine cream, anti-androgens e.g. yasmin
weight loss - orlistat, diet and exercise advice
infertility - SERMs e.g. clomifene citrate
47
What is the first line drug for infertility in PCOS
clomifene citrate - (SERM) -
48
How does clomifene citrate help fertility in PCOS
selective estrogen receptor modulator - so it inhibits oestrogen's negative feedback suppression of LH and FSH, therefore high levels and high oestrogen help follicle maturation at the beginning of the cycle.
49
How long can you have clomifene for and what are the risks of long term use?
6 months, no more thna 1 year - risk of endometrial cancer
50
What must you warn patients about with the use of clomifene
- should not use for more than a year, risk of endometrial cancer
- higher risk of multiple pregnancy as more follicles may mature
- risk of ovarian overstimulation syndrome
51
What surgery can be offered to treat tubal damage infertility as a result of PID?
laprascopic adhesiolysis and salpingostomy
52
what methods of assisted conception are there?
1. intrauterine insemination
2. IVF
3. intracytoplasmic sperm injection
4. oocyte donation
5. preimplantation genetic diagnosis
5. surrogacy
53
what is the live birth rate after IVF treatment in a) ,35s and b) <40?
a) 35%
| b) <10%
54
How do you help fertility in patients with cervical causes of fertility disorder, such as antisperm antibody production or cone biopsy?
intrauterine insemination (IUI)
55
What does CGIN mean?
cervical glandular intraepithelial neoplasm - abnormal glandular cells in the endocervix. Similar pre-cancer to CIN but rarer.
56
What blood test should you do to asess ovarian reserve
antimullerian hormone
57
What is the main solution to male factor infertility due to poor motility?
intracytoplasmic sperm injection
58
What is the chance of CINIII developing to cancer in 8-15 years?
30%
59
What % of cervical smear results are normal?
92%
60
What should be done if the cervical smear test is inadequate?>
should repeat within 6 months. If 3 tests are inadequate then should refer to colposcopy
61
What is the management for PPROM?
preterm premature rupture of membranes - admit, monitor closely infection markers and temperature to screen for sepsis (chorioamnionitis). Give prophylactic antibiotics - erythromycin for 10 days. Can give tocolytics to prevent labour and allow time to give corticosteroids to prevent fetal respiratory distress syndrome and NEC.
62
`what is the management of a DVT in pregnancy?
Depends on clinical suspicion of a PE... do a doppler ultrasound to look for the clot, can give LMWH --> clexane or enoxaparin usually. Warfarin is contraindicated as its teratogenic, and thrombolytics are dangerous as risk of maternal haemorrhage.
63
what is the management when you see Borderline dyskaryosis (HPV negative) on a cervical smear?
nothing - just repeat smear in 3 years
64
A 19-year-old woman at ten weeks gestation presents to her general practitioner with intermittent vaginal bleeding over the previous month and hyperemesis. Obstetric examination reveals a non-tender, large-for-dates uterus. These symptoms are strongly suggestive of which condition?
Molar pregnancy
65
What organisms most commonly causes bacterial vaginosis?
Gardnerella vaginalis
66
How do you diagnose bacterial vaginosis?
1. clinical features of thin, 'fishy' grey discharge
2. on microscopy clue cells - stippled vaginal epithelial cells
3. vaginal pH >4.5
4. positive whiff test (add potassium hydroxide - fishy odour)
67
What is the treatment of BV?
oral metronidazole for 5-7 days
68
What are the risks of BV in pregnancy?
- chorioamnionitis
- preterm labour
- low birth weight
- late miscarriage
69
On a CTG, what can reduced variability be caused by?
- foetal sleeping is the most common cause, should not be more than 40 mins
- foetal acidosis (and hypoxia)
- foetal tachycardia
- drugs - opiates/benzos/methyldopa
- prematurity
- congenital heart problems
70
what is defined as an acceleration on a CTG?
abrupt increase in baseline HR of >15 bpm for >15 seconds
71
what is defined as a deceleraton on a CG?
decrease of >15bpm for >15 seconds
72
what are early decelerations on a CTG and why do they happen?
- deceleration of >15bpm for >15seconds starting at the beginning of a contraction and recovering when the contraction stops - due to increased ICP due to squashing of the baby's head which increase vagal tone
73
What is variable deceleration?
SHOULDERING - When decels occur unrelated to contractions, and vary in duration. Often seen in patients with decreased amniotic fluid volume, and often caused by cord compression
74
how can variable decelerations sometimes be resolved?
if the mum changes position - which can relieve the cord compression.
75
what are late decelerations and what do they indicate?
decels that begin at the peak of contractions and only recover after contractions have finished - indicates insufficient blood flow to the uterus and placenta and therefore potentially foetal hypoxia and acidosis
76
what can reduced utero-placental flow be caused by?
maternal hypotension
pre-eclampsia
uterine hyperstimulation
77
What should be the next investigation if late decelerations are seen on a CTG?
foetal blood sampling for pH
78
What are the 3 wats you can report your overall impression of a CTG?
- reassuring
- pathological (2+ abnormal features)
- suspicious (if there is 1 feature which is non-reassuring)
79
What are the main risk factors for vaginal prolapse?
obesity, increasing age and increasing parity
80
By how many fold does the risk of vaginal prolapse increase following a second birth?
8 fold
81
what conservative treatment options are available for vaginal prolapse?
vaginal pessary - silicome structure used to hold the pelvic organs up.
pelvic floor exercises
82
what is the characteristic pain of a ruptured ovarian cyst?
suden onset unilateral lower quadrant pain, typically sharp and focal, moderate/severe intensity, may increase shortly after onset. can be precipitated by strenuous activity like sexual intercours. may get shoulder pain (Kehr's sign) or upper abdo pain due to blood in the peritoneal cavity irritating the diaphragm when lying down.
83
Where do the majority of ectopics occur? and where can other rare ones occur?
98% in the fallopian tube
| cervical, hysterotomy scar, intramural, ovarian, abdomina
84
what is the difference between salpingostomy and salpingectomy?
salpingostomy = inscising the tube to remove ectopic but leaving tube intact
salpingectomy = removal of the whole fallopian tube
85
What should you monitor in a woman who has received methotrexate therapy for n ectopic pregnancy
serum bHCG - twice in the first week and then once a week following that until the levels have become neative
86
What is the standard surgical management of an ectopic?
Salpingectomy - removal of the tube, unless there is risk factors for infertility such as damage to the contralateral tube where you might consider a salpingostomy
87
Which types of fibroids can be removed with a laparoscopic myomectomy?
Intramural and subserosal (in the wall and on the outside of the cavity- look at a diagram for a reminder)
88
what type of surgery would need to be conducted to remove submucosal fibroids
hysteroscopic myomectomy
89
Draw a diagram showing theanatomical location of the different types of fibroids: subserosal, intra mural, submucosal, pedunculated
https://www.google.co.uk/search?q=types+of+fibroids&rlz=1C5CHFA_enGB702GB704&source=lnms&tbm=isch&sa=X&ved=0ahUKEwj6tuWd-6HUAhXLL8AKHRZFDJAQ_AUICigB&biw=1199&bih=585#imgrc=XrGGE_-cNAESPM:
90
What is the most common types of incontinence in women?
```
Stress (50%)
Overactive Bladder (35%)
Mixed (10%)
Unknown (4%)
Overflow incontinence (1%)
Fistula (0.3%)
```
91
What are the risk factors for stress incontinence?
Pregnancy, multparity, vaginal delivery, prolonged labour, forceps, obesity, age , postmenopause, maybe hysterectomy
92
What is the stepwise management of stress incontinence?
- make sure they have made it clear which aspect of incontinence is the most troublesome e.g. is it definitely stress? or urge? could suggest a urinary diary to keep track of intake and frequency of output.
1. Lifestyle: lose weight if obese and sop smoking if chronic cough triggers leaking
2. Conservative: Pelvic floor exercises - with a physiotherapist. Also V cones help 50% patients!
3. Medical - Duloxetine is a SNRI which is licenced for USI - most useful wen used in conjunction with pelvic floor exercises
4. Surgery: TVT or TOT which are highly successful procedures involving a mid urethral sling, allowing surgeon to adjust tension enough to prevent leaks. Cure rate up to 90%
93
What investigations should you consider for stress incontinence?
-consider a urinary diary if unsure if it's a mixed picture with OAB
- urine dipstick to exclude infection - if so send of for MCS
- general inspection - sims speculum - palpate bladder to see if distended
- Cystometry - using catheters to look at the pressure differences in bladder/abdomen and whether leaking is linked to this or detrusor muscle overactivity
94
What are the management steps in OAB patients?
1. suggest a urinary diary - to monitor intake of fluids/caffeinated drinks and frequency of output
2. Lifestyle - reduce fluid intake if excessive and cut down on caffeine - can have a huge impact.
Bladder re-training - basically start a 6 week reigeme where patient must resist the urges and stick to a timetable - idea is to have systematic delays to try and train the bladder.
3. meds: antimuscarinics are commonly used. Mirabegron - antispasmodic which has no antimusc side effects but be careful of NTN. Oestrogens, Botox.
95
Which type of incontinence is Mirabegron sometimes used for and what must you be careful to monitor when prescribing?
- overactive bladder - good as doesn't have the side effects that antimuscarinics have. Associated with HTN so must monitor.
96
What blood tests should you order when investigating PCOS?
anovulation
FSH (normal in PCOS - ruling out ovarian insufficiency n which it would be v high)
AMH (raised)
Prolactin
Serum testosterone - Hirsutism
- LH (ften raised but not diagnostic)
97
Management of PCOS
conservative - diet and exercise - weight reduction will improve symptoms
COCP - will control periods and hirsutism / acne
Metformin - will keep insulin levels down so reduce androgens
Clomifene - first line for fertilisation (antioestrogen)
98
What is Kallman's syndrome?
Where the GnRh secreting neurones fail to develop so results in infertility and primary amenorrhoea
99
drug treatment for hyperprolactinaemia causing amenorrhoea?
Dompamine agonist such as bromocriptine - as it inhibits prolactin
100
What investigations are useful when suspecting premature ovarian failure?
- LH and FSH (will be very HIGH due to low oestrogen)
- oestrogen (low)
- AMH - LOW
- Prolactin
- serum androgens
- antral follicle count on ultrasound
101
What are the commnon causes of anovulation?
- PCOS
- Hypothalamic hypogonadism
- Thyroid disease
- Hyperprolactinaemia
- premature ovarian insufficiency
102
What are the treatment options to induce ovulation in PCOS
1. clomifene (anti-oestrogen so stimulates more LH+FSH which enable follicle maturation)
2. metformin (insulin sensitiser)
103
Give 2 examples of drugs which are YP450 inducers, meaning you must be careful with doses of oestrogen in oral contraception
Anticonvulsants e.g. carbamezapine and phenytoin
104
WHat is the downside of clomifene which may explain the relatively low birth rate of 40% (compared to ovulation rate of 70%)?
it's an anti-oestrogen so causes thinning of the endometrium - must monitor it with TVUS.
105
how do you test fallopian tube patency?
methylene blue insufflaton
106
What surgical option is there for patients suffering with anovulation infertility due to PCOS?
Laporoscopic ovarian diathermy - wjere several holes are drilled into one or both ovaries, and can result in normal ovulation cycles for years afterwards
107
what are the main complications of ovulation induction treatments?
Multiple pregnancy - esp in gonadotrophin treatments as more than one follicle are allowed to develop. Results in increased perinatal compicication rates.
Ovarian hyperstimulation syndrome (OHSS) - follicles get very big and painful, but can get must more severe where hypovolaemia, electrolyte disturbances, ascitesd, thromboembolism and pulmonary oedema - can be fatal!! `
108
Which cells in the testis produce testosterone?
Leydig cells
109
How long does it take for sperm cells to develop fully?
70 days
110
WHat are the roles of FSH and LH in sperm production?
LH - involved in production of testosterone from the Leydig cells in the testis
FSH --> controls the Sertoli cells (along with testosterone) which synthesize and transport sperm
111
What is a normal volume and sperm count in a semen analysis?
vol >1.5ml
| sperm count >15 million/ml
112
Why should depo-provera be avoided in teenagers?
Causes decrease in bone density, so not ideal in teenagers who have not reached their peak bone mass yet.
113
What are the figures for oligospermia and severe oligospermia?
oligo - <15million/ml
| severe = <5 million/ml
114
Whqat blood tests should be done if aszoospermia is found on a semen anamysis?
```
FSH
LH
Testosterone
TSH
Prolactin
May consider karyotye/genetic studies to look for genetic cause e.g. Klinefelters syndrome (XXY) or chromosomal translocations
```
115
What are the management options for azoospermia?
1. lifestyle - counselling on drugs and alcohol abstinence and keeping testicles cool, avoid tight clothing
2. drugs - if the cause is hypothalamic hypogonadism then can have injections of FSH and LH 3x a week which should restore spermatogenesis and androgen production back to normal.
3. intrauterine insemination may help
4. surgical sperm retrieval - surgically taken out and then can be used for ICSI-IVF
5. assisted conception - IVF / ICSI
6. sperm DONATION
- remember that education and counselling/couple therapy should be offered as it can be very emotional and stressful time e.g. the fertility network
116
What is the most common cause of tubal damage leading to infertility?
PID due to chlamydia infection resulting in adhesions in/around the tubes
117
What should be the management in a lady who's fallopian tubes are shown to be 'clubbed' at the fimrial ends?
laporoscopic adhesiolysis OR a salpingostomy (hole made_
118
What is hydrosalpinx commonly caused by
PID
119
how is success of assisted conception techniques measured?
live birth rates
120
what are the indications for assisted conception?
- unexplained infertility
- all other methods have failed e.g. medication
- tube blockage
- endometriosis
- male factor infertility (requiring ICSI-IVF for example)
- genetic disorders
121
What are the different options for IUI?
Natural - i.e. normal ovulatory cycle - check with urine tests for LH
Stimulated - with GnRh induction
122
What is the live birth rate per cycle for stimulated |UI?
5-10%
123
What is the live birth rate per cycle of IVF?
35% for women <35, and <10% for women in 40s.
124
How is ovarian reserve measured?
AMH - direct measurement
FSH - indirect (not as good as AMH)
TVUS - antral follicle count - number of resting small follicles in the ovaries.
125
In IVF - what is injected to stimulate late maturation of follicles once it has been confirmed that there are good mature size follicles available?
hCG or LH
126
What sized follicles means they are mature?
15-20mm
127
Causes of postmenopausal bleeding
- MUST consider endometrial cancer
- endometrial hyperplasia
- cervical cancer
- atrophic vaginitis
- cervical polyps
- cervicitis
- ovarian cancer
128
What should be the next investigation if a TV ultrasound shows endometrium >4mm thick
endometrial biopsy (pipelle) +/- hysteroscopy - can both be outpatients under paracervical LA, or if complicated/anxious then day case GA.
129
How can atrophic vaginitis be treated?
Topical oestrogen or oral ospemifene (a selective oestrogen receptor modulator)
130
what is the T score threshold for osteoporosis?
a T score of -2.5 or lower - in other words bone mineral density greater than or equal to 2.5 s.d. from the yuoung adult mean
131
What are the most common osteoporotic fractures
Wrist - Colles
Hip - NOF
spine
132
What are the Risks of taking HRT?
- increased risk of breast cancer with combined therapy, but risk disappears 5 years after stoppping back to normal risk
- increased risk of endometrial cancer in oestrogen only (which is why you should give progesterone combined to women with a uterus still)
- increased risk of VTE
- increased risk of gallbladder disease
-
133
What are the advantaged of HRT?
- oestrogen helps the symptoms of hot flushes and vaginal dryness, dyspareunia, libido,
- Also helps with urinary symptoms like frequency and urgency
- reduces osteoporotic fractures like hip and wrist
- reduces risk of colorectal cancer by 1/3
134
What age is endometriosis most common?
30-45 years
135
How common is chronic pelvic pain in women
15% women get it
136
What are differentials for endometriosis?
```
Adenomyosis
Chronic PID
CHronic pelvic pain
Pelvic Masses
IBS
```
137
What contraception should be used in women with IBD and why?
IBD small bowel disease causes malabsorption and can therefore lead to decreased efficacy of oral contraception - use alternatives like patches, progesterone only injections and implants, IUD and vaginal methods.
AVOID depot-provera as IBD increases risk of osteoporosis
138
which contraeptives are considered after pregnancy?
- if breastfeeding then 98% safe up to 6 months postpartum (stops ovulation)
- oral combined pill affects milk volume so avoid defs before 6 weeks and probs between 6 weeks-6 months
- Progesterone only pill is fine in first 6 weeks and after
- IUD can be put in from 4 weeks
139
What is the synthetic oestogen used in most combined oral contraceptives?
ethinyloestrodiol
140
what is the standard dose of combined oral contraceptives?
30-35ug
141
What is the advice for missed COCP?
if normal dose - 1 or 2 missed pills is fine, take the missed one ASAp and then continue
If low dose only 1 missed is okay
If more, keep taking + use condoms for 7 days
If <7 pills left in pack, continue straight onto next packet without break
vomiting within 2h of taking pill counts as a missed pill
142
What are the absolute contraindications for staring the oral contraceptive pill?
```
BMI >40 or age >35 and smokes >15/day
History of VTE
Hx of cerebrovascular accident, IHD, HTN
Migraine with aura
Active breast/endometrial ca
inherited thrombophilia
pregnancy
Diabetes with vascular problems
Active/chronic liver disease
```
143
what is the risk of non fatal VTE in women using the COCP, and in smokers using it?
5 in 100,000 per year in normal
| 60 in 100,000 p/y in smokers
144
what is the efficacy of the combined oral contraceptive pill if taken properly?
PI 0.2 so 0.2 in 100 women in a year
145
efficacy of the POP?
1 in 100
146
How does the progesterone only pill work?
- makes cervical mucus hostile to sperm
| - stops ovulation in 50% women
147
What should you do if you miss a progesterone only pill by more than 3 hours?
Take it ASAP and use condoms for 2 days following
148
Why should depo-provera be avoided in teenagers?
Causes decrease in bone density, so not ideal in teenagers who have not reached their peak bone mass yet.
149
Which type of rhesus blood type are we worried about in pregnancy?
If the mum is Rhesus D negative
150
Give examples of sensitising events which can result in fetal blood entering maternal circulation
- ectopic pregnancy
- delivery
- termination of pregnancy or evacuation of retained products of conception (ERPC) after a miscarriage
- vaginal bleeding >12 weeks or <12 weeks if heavy
- external cephalic version
- invasive uterine procedure e.g. amniocentesis or chorionic villus sampling
- intrauterine death
151
When would you give a rhesus negative woman anti-D?
- at 28 weeks
- at any bleeding or sensitising event
After delivery if the baby is Rh+ (and you didnt know before)
152
What are the consequences of Rhesus disease (ie if mum is Rh- and baby is Rh+ and left untreated?
1. mild = neonatal jaundice
2. mod = neonatal anaemia / haemolytic diisease of the newborn
severe = hydrops, aascites, cardiac failure
153
How do you test for fetal anaemia in pregnancies at risk of rhesus disease?
uLTRASOUND - DOPPLER OF PEAK VELOCITY IN SYSTOLE (psv) of the middle cerebral artery - high sensitivity
154
What do you need to do if maternal anti-D antibodies are found on routine testing?
Test the dad's genotype - if he is homozygous dd then he is also anti D and so the baby will be dd - absolutely fine. If he is Dd then the baby will either be Dd or dd so must check maternal blod for free fetal DNA to work out fetal rhesus status
155
what other major antibodies which can cause haemolysis in fetus apart from anti-D
anti- C
anti E
anti- kell
156
How do you determine fetal blood genotype?
Paternal blood +/- free fetal DNA in maternal blood
157
what is the management if severe fetal anaemia <5g/dL is detected?>
Blood transfusions in utero - through umbilical artery (blood must be Rh -!!)
then postnatally check fetal FBC, bilirubin and blood film
may need to do top up transfusions / exchange transfusions
158
A 21-year-old female presents for review. She is 14 weeks pregnant and has been seen by the midwives for her booking visit. There have been no pregnancy related problems to date. Tests taken revealed the following: rhesus negative
what is the most appropriate management
give anti-D at 28 weeks
159
What are the main 2 things measured on ultrasound when assessing fetal growth?
Head and abdomen circumference
160
What findingd on doppler measurement of umbilical artery waveform might indicate severe placental dysfuction?
- high end diastolic flow >95th centile
- absent end diastolic flow (AEDF)
- reversed end diastolic flow (REDF)
161
How does velocity of middle cerebral artery blood flow change in fetal anaemia?
Velocity INCREASES
162
What investigations should you consider to investigate IURG
Ultrasound - measure fetal head and abdomen circumference. If growth velocity of the abdomen has reduced by >30% it's indicative of IUGR
umbilical artery velocity
if >34 weeks also mid cerebral artery velocity to calculate the ratio - look for placental dysfunction
163
What are major risk factors for SGA?
```
heavy smoking
cocaine
heavy daily exercise
maternal illness e.g. diabetes
previous Hx of SGA or stillbirth
parental SGA
```
164
at hwat gestation and fetal weight is it theoretically possible to deliver a viable baby?
>500g and 25-26 weeks gestation
165
If IUGR is detected at 37+3 what should be the management?
Its >37 weeks so should deliver - either induce or if CTG is abnormal then C section
166
How ocmmon are stillbirths in the UK?
1 in 200 pregnancies
167
What are the aetiological factors for stillbirths?
```
IUGR - esp smoking/multiple pregnancy
fetal/chromosomal abnormalities
maternal medical problems
maternal pregnancy related illness e.g. pre-eclampsia
Infection
Placental abruption
Intrapartum - hypoxia
vasa previa
```
168
What is the difference between SGA (small for gestational age) and IUGR (intra-uterine growth restriction)?
SGA = smaller than the 10th centile for the gestation
IUGR = small compared to genetic determination and compromised.
169
What should be your differentials for bleeding in the 1st 2nd and 3rd trimesters?
1st = ectropion, spontaneous abortion, ectopic, hydatidiform mole
2nd (13-27 weeks)
= cervical ectropion, spontaneous abortion, placental abruption, hydatidiform mole
3rd (28 weeks-40)
= ectropion, bloody show, placental abruption, placenta or vasa previa
170
When is abortion allowed after 24 weeks gestation?
- if there is risk to the pregnant woman's life
- evidence of severe fetal handicap
- risk of grave physical/mental injury to the woman
171
What tests should be done on the woman before carrying out a TOP
- haemaglobin
- blood group
Rhesus status
172
What should happen if a woman is found to be rhesus negative before having a TOP?
MUST GIVE ANTI-d WITHIN 72 HOURS OF THE PROCEDURE
173
What is the medical method of TOP?
Mifepristone (an anti-progesterone) + prosaglandin: misoprostol
Mife and Miso
174
When is surgical cutterage generally carried out for TOPs?
>7 weeks to about 14 weeks - either side you usually d omedical management
175
What are the surgical options for TOP?
1. suction and cutterage (usualyl 7-14 weeks)
| 2. dilatation and evacuation - safe any time really
176
Complications of TOP
- haemorrhage
- infection
- perforation of uterus
- cervical injury
- failure
177
When do the majority of miscarriages occur?
Before 12 weeks
178
What drug should you give intra-muscularly in an incomplete miscarriage where bleeding is quite profuse
Ergometrine - contracts uterus
179
What are the main causes of recurrant miscarriages?
- antiphospholipid syndrome
- parental chromosomal defects
- maternal age
- thyroid - esp. autoantibodies
- uterine anatomy (although more likely in later miscarriages)
-
180
What might you expect to see on ultrasound with a complete hydatidiform mole pregnancy?
snowstorm appearance of swollen chorionic villi
181
What can relieve itching in intrahepatic cholestasis of pregnancy?
ursodeoxycholic acid (UDCA)
182
What seems to be the cause of intrahepatic cholestasis of pregnancy?
Increased sensitivity to the cholestatic effects of oestrogens
183
by how much does pregnancy increase the risk of VTE
6 fold
184
how would you diagnose PE in a pregnant woman
History of chest pain, dyspnoea,
signs: tachycardia, raised RR, raised JVP, chest abnormalities
- CXR, ABG and CT to ocnfirm
185
how frequent are depot-provera injections given?
IM injection every 3 months
186
whta is the success rate of the levonelle morning after pill at a) 24h and b) 72h?
```
24h = 95%
72h = 58%
```
187
what are the 2 types of emergency morning after pills?
1. levonelle (single dose levonorgestrel)
| 2. ellaOne - selective progesterone receptor modulator
188
How long after unprotected sex can you use ellaOne?
up to 120 hours after
189
When can an IUD be inserted with assurance that it will be effective emergency contraception?
5 days after unprotected sex OR 5 days after ovulation
190
What are the absolute contraindications for the intrauterine device?
- undiagnosed vagina bleeding
- active endometrial/cervical ca
- ctive/recent pelvic infection
- breast cancer (for mirena)
- pregnancy
