ObGyn Flashcards
1
Q
Definition of subfertility?
A
Inability to conceive after 12mnths of regular sex
35yo and above, after 6/12
Regular sex as 2-3x weekly
1 in 7 couples experience delayed conception after regular sex for 12mths
2
Q
How is insulin homeogenesis affected during pregnancy?
A
Placental hormones have diabetogenic properties.
They affect pancreatic b-cell function and peripheral tissue sensitivity to insulin.
Insulin sensitivity falls by 50-70%
Insulin demand rises to maintain GLC homeostasis
3
Q
Does mum’s hypergly lead to fetal hypergly?
A
yes. By facilitated diffusion.
This causes fetal pancreatic b-cell hyperplasia -> fetal hyperinsulinemia
4
Q
when does GDM manifest?
A
2nd and 3rd trimester.
2! to rising levels of insulin-antagonistic placental hormones
1-14% prevalence rate
5
Q
Obstetric complications of DM?
A
Infection
PIH
Macrosomia
Polyhydramnios
Sudden intrauterine death
6
Q
How does fetal hyperinsulinemia affect baby?
A
Promotes growth of insulin-sensitive tissue (adipose tissue, muscle, liver)
Disproportionately big size of trunk and shoulders
7
Q
Complications of fetal hyperinsulinemia?
A
Prolonged labour
CPD
Operative delivery
Shoulder dystocia
Birth asphysixa
Birth trauma
8
Q
Strong RF for intrauterine death
A
Poor glycemic control
DKA
Macrosomia
Polyhydramnios
Pre-eclampsia
Maternal vascular disease
9
Q
Risk of IUD in diabetics vs non-diabetics?
A
4 times higher in GDM
10
Q
What is neonatal hypogly a result of?
A
Result of hyperinsulinemia from b-cell hyperplasia 2! to maternal hypergly
3/4 of IDM and 1/4 of infants of GDM
11
Q
How does DM of mum cause respiratory distress syndrome of neonates?
A
Hyperinsulinemia affects pulmonary surfactant prod, delaying pulmonary maturation
Risk of RDS not increased in well-controlled diabetics delivered at term
RDS 6x risk in IDM
12
Q
Why screen for GDM?
A
GDM raises perinatal morbidity
High risk of GLC intolerance and obesity in babies
13
Q
Risk of GDM mothers becoming diabetic later?
A
50% become diabetic in 15 yrs after pregnancy
75% risk of recurrence in subsequent pregnancy
14
Q
Universal screening of GLC tolerance for pregnants?
A
Screening by OGTT at 26-28 weeks
GDM = fasting 5.1-6.9
1hr >= 10.0
2hr 8.5 -11.0
Possible pre-existing DM
Fasting >= 7.0
2hr >= 11.1
15
Q
Criteria for GDM
A
Symptomatic:
Random BSL on 2 separate occasions >11.1
15
Q
Nutritional therapy for GDM?
A
Limit CHO intake to 35-45%
Protein to 20-25%
Fat 35-40% of total Calories
Encourage complex CHO, high fibre diet
16
Q
Change in insulin requirement as pregnancy progresses?
A
Rise by up to 75% at term.
Falls abruptly after delivery
This aggravates diabetic complications!!
16
Q
Metabolic surveillance of GDM?
A
Glucometer
Self GLC monitoring
7-point blood sugar profile
17
Q
What does diabetic nephropathy raise risk of?
A
Pre-eclampsia
Intrauterine growth restriction
Preterm delivery
18
Q
Proliferative diabetic retinopathy in GDM?
A
May progress despite strict diabetic control
Will require close monitoring after PRP
19
Q
Components of Pre-gestational DM clinic visit?
A
- Convert OHA to insulin
- Blood sugar monitoring
- self-GLC monitoring
- Renal function
- Eye check
- US scan for fetal viability + date the pregnancy
20
Q
Components of Fetal surveillance in GDM?
A
- dating scan
- Early Fetal anomaly scan at 17-18 wks for diagnosed DM
- Fetal anomaly scan at 21-22wks
- Serial growth scans
- Monitoring of fetal well-being
- Fetal movement chart
21
Q
Risks of maternal hypergly during delivery?
A
- High risk of neonatal hypogly
- Fetal hypoxia risk
22
Q
ICD-10 definition of perinatal period?
A
Start at wk 22 completed, till 7 days post-birthh
23
Clinical features of Turner's syndrome?
Short stature
Poor breast development
Shield chest
24
Imaging/test findings in Turner's syndrome
Karyotype 45, XO
FSH high = ovarian failure
Ultrasound = no follicles in ovary
25
Causes of primary amenorrhea?
Chromosomal 43% (Turner's)
Outflow tract problem 15% (imperforate hymen)
Delayed menarche/sever illness 14%
Single gene disorders/other syndromes
26
Symptoms of imperforate hymen?
in puberty
Monthly abdominal pains
No menses (primary amenorrhea)
Suprapubic mass
27
Definition of oligomenorrhea?
Less than 9 menstrual cycles yearly or cycle length >34 days
28
Causes of secondary amenorrhea/Oligomenorrhea?
Hypothalamic 35% = stress, weight loss/gain,
Drugs (OCP, Psych meds)
Pituitary 17% = prolactinoma
Ovarian disorder = Premature menopause, PCOS
Uterus = Intrauterine adhesions (Ashermann)
29
Clinical characteristics of PCOS?
Infrequent masses + oligo-anovulation
Polycystic ovarian morphology
High androgens
Obesity
Insulin resistance
T2DM (5-7x higher)
30
Criteria for PCOS diagnosis?
Oligomenorrhea/amenorrhea
Polycystic ovarian morphology
Hyperandrogenism
2/3 enough for diagnosis
31
Amenorrhea screen components?
FSH
LH
Estradiol
Prolactin
TTT
KIV Karyotype
KIV MRI brain
32
Symptoms of hyperprolactinemia?
Galactorrhea
Visual disturbances
Headaches
A/w pregnancy
33
Invx for hyperprolactinemia?
Prolactin >500IU/L (repeat)
Presence of pituitary adenoma
34
Mx of PCOS?
1. Lower risk of endometrial hyperplasia / infrequent menses. Induce menses with cyclical progesterones / OCP
2. Induce ovulation when fertility desired
3. Cosmetic measures/drugs for hirsutism
35
Immediate mx of abruptio placenta?
Immediate delivery preferred, dont delay unlike previa.
No warning bleeds - unpredictable massive bleeding could follow
Vaginal delivery preferred. This is possible as placenta is not blocking exit.
## Footnote
If u want CSec, ensure there is no DIVC
36
Conditions for expectant mx of abruptio placenta?
Aim is to prolong pregnancy with hope of improving fetal maturity and survival.
Only in mild AP happening <37wks
Continue close fetal surveillance
## Footnote
Still, timing of delivery depends on many other factors e.g. further APH, fetal state etc.
37
Comp of abruptio placenta mx?
- Haemorrhagic shock
- DIVC (in CSec)
- Ischemic necrosis of distal organs e.g. kidneys, pituitary
- PPH
- Rhesus sensitization
38
Complications of too small baby in short term?
Respi distress syndrome
Hypogly
Neonatal jaundice
Sepsis
Prolonged NICU stay
39
Long term complications of too small baby?
'Barker' hypothesis -> higher risk of metabolic disease in later life
40
criteria for early FGR?
## Footnote
<32 weeks
AC / EFW <3rd centile
OR
AC / EFW <10th centile AND any of:
1. UtA-PI >95th centile
2. UA-PI >95th centile
41
Criteria for late FGR?
## Footnote
>32 weeks
AC or EFW <3rd centile
OR 2/3 of:
AC/EFW <10th centile
AC/EFW crossing >2 quartiles on growth centiles
CPR <5th centile UA-PI >95th centile
42
What does liquor volume show?
Its a reflection of baby's urine output and hence renal function.
43
Causes of oligohydramnios?
- Severe IUGR (reduced renal perfusion)
- Lower urinary tract obstruction
- PROM
- Maternal use of NSAIDs e.g. indomethacin
44
Causes of Polyhydramnios ?
| amniotic fluid index >20cm
- Poorly controlled DM
- Bowel atresia
- Tracheal-esophageal fistula
- Neuromuscular disorders
- twin-twin transfusion syndrome
45
Polyhydramnios + macrosomia points to?
Maternal DM until proven otherwise
46
Steps to approach reduced fetal movements
1. Hx + stillbirth risk evaluation
2. Fetal HR on CTG if >28w GA, for min 20min
3. Bedside liquor volume assessment OR formal scan for growth/liquor+dopplers if persistent/RF
47
Mx of IUGR/SGA pregnancy
1. Bi-weekly AFI + Doppler
2. Growth scan every 3 weeks
3. FM chart
4. Hospital STAT if reduced FM again
5. Risk factors reduction
48
What does Mumps infection cause in males?
Aspermia
49
Symptoms of endometriosis
Chronic pelvic/back/uterosacral pain
Infertility
Dysmenorrhea
Pre- or post-menstrual bleeding
Dyspareunia
Urinary incontinence
| higher risk of ectopic pregnancy + miscarriage
50
Invx for endometriosis?
PE = adnexal mass, lateral displacement of cervix
Transvaginal US is best initial imaging = Chocolate cysts in uterosacrum, fixed retroverted uterus
Laparoscopy (confirmatory)
51
Preconception screening for females?
1. FBC, thalassemia
2. Hep B, HIV, syphillis
3. Rubella, Varicella IgG
4. Blood group
5. HPV/pap smear
6. Chlamydia/Gonorrhea
52
Subfertility invx for males?
Preconception screening = Hep B, HIV, syphilis
Fertility invx = semen analysis
53
Mx options for getting pregnant?
1. Timing the sex with/wo ovulation induction
2. Intrauterine insemination
3. IVF (30%)
## Footnote
Induce ovulation with Clomiphene, Letrozole or Gonadotrophins like FSH or LH. Give at D2-D6 of menses
54
# fmf
How to do intrauterine insemination?
Give ovulation meds if anovulatroy at D2-D5 of menses.
Attend for US to track follicle growth at D12 of cycle.
Once follicle reaches 17-18mm, give HCG injection to trigger maturation and release of oocyte
Return 36 hrs later for intrauterine insemination.
54
How to do timing ovulation with sex?
Give ovulation meds if anovulatory at D2-D5 of menses.
Attend for US to track ovarian follicle growth at D12.
Once follicles reach 17-18mm = fertile, have sex!
54
How to do IVF?
- Pituitary downregulation (GnRH agonist/antagonist)
- Controlled ovarian stimulation
- Oocyte retrieval
- Sperm recovery
- Fertilization
- Embryo replacement (OT)
55
Causes of early menopause?
Surgical removal of ovaries
Cancer treatment = RT, chemo
Idiopathic
56
Acute symptoms of menopause?
Vasomotor symptoms = hot flushes, night sweats
PSychological = mood swings, concentration difficulty, poor verbal memory, depression
Headaches
57
Medium term symptoms of menopause?
| 5-10 years in
- Vaginal issues = dryness, dyspareunia, higher vaginal pH
- Loss of libido
- Stress and urge urinary incontinence
- Skin thinning, brittle hair due to collagen loss
- Generalized aches, pains
58
Long term implications of menopause??
CVS = HTN, IHD, Atherosclerosis, 뱃살
Osteoporosis
Dementia
Depression
59
How does estrogen affect CVS system?
1. Protect against CVS disease
2. Beneficial effect on CRL
3. REduce plaque formation risk in arteries
60
Aim of hormone replacement therapy?
Relieve symptoms a/w estrogen deficiency e.g. hot flushes, vaginal dryness, osteoporosis
## Footnote
Estrogen also prevents Alzheimer's and lowers risk of CRC by 1/3
61
Risks of HRT?
CVS Disease
Stroke
Venous thromboembolism
Breast cancer
62
How does age of starting HRT affect risk/benefit ratio?
If HRT is started before 60 and within 10 years of menopause, benefits usu outweigh risks.
In early menopause, HRT can help reduce the risks of osteoporosis, CVS disease, stroke, dementia
63
Risks/benefits of transdermal estrogen administration?
## Footnote
Transdermal, Oral, SubQ, Vaginal
- more physiological than oral
- Avoids liver and gut first-pass effect
- Does not affect lipoprotein profile
- Risks of sensitivity to patch or gel
64
Risks/benefits of oral estrogen administration?
- Cost effective
- Raises TG, raises HDL, lowers LDL and CRL
- High doses needed to achieve required blood levels
65
Risks/benefits of SubQ estrogen administration?
- 6 month intervals
- Risk of tachyphylaxis, needs surgical procedure to remove
66
Risks/benefits of vaginal estrogen administration?
- indicated for genitourinary symptoms e.g. vaginal dryness, dyspareunia, urgency, recurrent cystitis
- Minimal estrogen reaches systemic circulation, avoiding potential ADR
67
Indications for first line transdermal estrogen?
1. personal preference
2. Migraine
3. DM
4. Controlled HTN
5. Existing Gallbladder disease
6. hyperlipidemia
7. Obesity, smoking
8. Prev venous thromboembolism
9. Varicose veins
68
How to classify prematurity by date?
Mildly preterm = 34-36 /52
Moderate = 32-33 /52
Very preterm = 28-31 /52
Extremely = <28 /52
Borderline viability = 22-25 /52
69
How does preterm birth cause respi distress syndrome in neonates?
- Due to surfactant deficiency
- Antenatal steroids stimulate fetal surfactant prod. Given to mum if anticipated delivery <34/52
- antenatal steroids reduce RDS, intraventricular haem and mortality
70
Asymmetrical vs symmetrical IUGR?
Asymmetrical = placental insufficiency late in pregnancy with sparing of brain growth
Symmetrical = Prolonged period of poor growth in early pregnancy
71
Causes of asymmetrical IUGR?
Pre-eclampsia
Multiple pregnancies
Maternal smoking
72
Causes of symmetrical IUGR?
Small and normal
Chromosomal disorder
Congenital infection
Maternal drug or alcohol use
Maternal chronic medical conditions
73
Problems of SGA and IUGR infants in perinatal period?
Fetal death
Perinatal asphyxia
74
Mx of SGA and IUGR infants in perinatal period?
Monitor for
1. Reduced growth abdo circumference
2. Oligohydramnios
3. Absent or reduced EDF in umbilical artery
4. Reduced flow to brain
5. Abnormal CTG
75
Potential problems of SGA / IUGR babies at birth?
1. Perinatal hypoxia (need neonatal resusc)
2. Respi distress (may be premature baby)
3. Meconium aspiration (hx of fetal distress)
4. Hypothermia (may be premature or IUGR baby)
76
What is neonatal sepsis?
systemic bacteremia in first 28D of life.
Early onset = <72hrs of birth
Late onset = >72hrs from birth
## Footnote
Some viral infection can have sepsis-like presentation in neonates
77
Commonest pathogens for early onset neonatal sepsis?
GBS
E. coli
Listeria
78
Transmission in early onset vs Late onset neonatal sepsis?
Early onset = intra-partum
Late onset = Intra-partum horizontal (nosocomial)
79
Risk factors for early onset sepsis?
1. Premature birth >37wks
2. PROM >18hrs
3. Maternal peripartum infection
4. Prev infant with invasive GBS disease
80
Invx for neonatal sepsis?
1. WBC <5000/ml or very high
2. Absolute NC <1000/ml
3. Immature : Total neutrophil ratio >0.2
4. CRP ESR raised
5. Maternal high vaginal swab, placental swab culture
6. CXR
7. Blood culture
81
Note on CRP levels in Neonatal sepsis?
CRP may take 12-24 hrs to rise.
2 consecutive normal values taken 24 hrs apart have high negative predictive value
82
What abx in early onset sepsis?
## Footnote
Empirical!
Penicillin/Ampicillin for Gram pos coverage
Gentamicin for Gram neg coverage
Change abx based on culture and sensitivity results
## Footnote
Discontinue abx if baby remains well and invx are normal
83
How to prevent GBS in neonatal sepsis?
Intrapartum abx prophylaxis (IAP)
- IV ampicillin 2 grams loading dose, 1 gram every 4 hourly until delivery
- Adequate IAP = min 1 dose 4 hrs prior to delivery
84
How does HSV-1 or HSV-2 infection happen in perinatal infection?
Contact with maternal genital ulcers during vaginal birth
85
How does Varicella infection happen in perinatal infection?
Airborne exposure to mother's varicella lesions or during incubation period
86
How does Hep B or HIV infection happen in perinatal infection?
baby exposed to maternal blood and fluids during birth
87
How to prevent perinatal Hep B infection?
Screen all pregnant women.
If positive -> Hep B immune globulin+ Hep B vaxx to newborn within 12 hours of birth
88
Tell me about venous thrombolism in ADR of OCP?
| Mainly estrogen based OCP
Limited to current users, unrelated to duration.
Stop COC 4 weeks before major surgery.
89
Absolute contraindications to COC?
| Combined oral contraceptive
1. Thrombotic disorders
2. Cerebrovascular accidents
3. CAD
4. Impaired liver function
5. Breast / endometrial cancer (dependent on estrogen)
6. Pregnnacy
7. Any undiagnosed irregular genital tract bleeding
90
Contraindications to Progesterone only injectables?
1. Breast cancer
2. Pregnancy
3. Thromboembolic disorders or cerebrovascular disease
4. Sever liver impairment
5. Undiagnosed PV bleed
91
Where do ovarian cancers arise from?
Skin (epithelium) = 90% of ovarian cancers, 9% borderline tumours.
- Germ cell 1%
- Sex cords/stroma <1%
92
invx for ovarian cancer?
Blood =
CA-125
FNC
RP
LFT
US pelvis
CT TAP
93
FIGO staging for ovarian cancer?
1 = confined to ovary
2 = pelvis
3 = abdo/retroperitoneal nodes
4 = above diaphragm / stroma of soft tissue organs in abdo
94
Features that point to <1% risk of malignancy regardless of menopausal status or cyst size?
- Unilocular, thin-walled sonolucent cysts
- Smooth regular borders
95
Features of ovarian endometrioma on US?
Round + homogeneous cysts
Low level echoes
96
US features of mature teratomas? (Dermoid cysts)
1. Hypo-echoic attenuating component
2. Multiple small homogeneous interfaces
97
US features of hydrosalpinges?
Tubular shaped sonolucent cysts
98
Why is aspiration of non-unilocular cyst fluid banned in post-menopausal women?
1. Diagnostic cytology has poor sensitivity to detect malignany.
2. Aspiration of malignant mass may induce spillage
99
What are borderline ovarian neoplasms?
NEoplasms that did not display overt malignant features, but occasionally had intraperitoneal spread.
Most commonly serous subtype, then mucinous, then endometrioid.
## Footnote
14-15% of all primary ovarian neoplasms
100
FIGO Staging of cervical cancer?
1. Strictly confined to cervix
2. Invade beyond uterus, but limited to upper 2/3 of vagina and/or with parametrial involvement (but not up to pelvic wall)
3. Involves lower 1/3 of vagina and/or extend to pelvic
100
What makes up majority of persistent adnexal masses above 5cm?
Dermoids
| but consider germ cell tumours and borderline ovarian tumours
101
Prognosis of borderline ovarian neoplasms?
| 10 year survival
Stage 1 = 97%
Stage 4 = 69%
102
Treatment of cervical cancer?
Stage 1 - 2A = Surgery OR pelvic radiation
Stage 2b - 4 = Pelvic radiation + concurrent chemo
103
Surgical options for cervical cancer?
Microinvasive ca = simple hysterectomy
Early stage = radical hysterectomy + pelvic lymphadenectomy
Fertility preservation in selected cases = radical trachelectomy + pelvic lymphadenectomy
104
1st line mx of endometriosis?
Progestins - Visanne.
Induced decidualization followed by endometrial atrophy. Suppresses matrix metalloproteinases and angiogenesis.
## Footnote
NSAIDs manage pain but do NOT treat disease
105
ADR of Dienogest (Visanne)
Irregular bleeding
Weight gain
Headache
Mood change
Libido effect
| No detrimental effect on subsequent infertility
106
Characteristic symptoms of endometriosis?
Dyspareunia
Infertility
Chronic pelvic pain
Fatigue/anaemia
## Footnote
Others are Dysmenorrhea, dysuria, PID
107
Features of macrosomia?
- Excess fat deposits in: chest, abdo, scapula
- Weight >90% for gestational age, >4kg at birth
- Normal length and head circumference
108
What is the clinical significance of macrosomia?
Marker of severity and predicts other complications in DM
109
Complications of macrosomia?
1. Obstructed labour - shoulder dystocia
2. Birth injuries - frac, brachial plexus injury
3. Birth asphyxia
110
Symptoms of hypogly in newborn?
## Footnote
Due to mother's DM
Jiterriness
Sweating
Respi distress
Apnea
Seizures
Agitation
111
Symptoms of hypoCa and hypoMg in newborn?
## Footnote
Due to mum's DM
Jitteriness
Sweating
Seizures
Respi distress
Apnea
Agitation
| Same as hypogly
112
Symptoms and risks of polycythemia in newborn?
## Footnote
due to mum's DM
Plethoric, sluggish and lethargic
There is high viscosity -> tissue hypoperfusion, thrombosis, stroke
113
Impact of hyperBRB in neonate due to maternal DM?
Polycythemia
Low hepatic function
Poor feeding
114
Risk factors for preterm birth?
1. Previous preterm birth strongest
2. Cervical trauma/surgery (cervical insufficiency)
3. Uterine abnormalities e.g. didelphys
4. Social e.g. smoking, age etc
115
What is normal vaginal pH and amniotic fluid pH?
Vaginal pH 4.5-6.0
Amniotic fluid 7-7.5
116
How to TRO imminent delivery in preterm labour?
Actim partus, a simple cervical swab.
Very high negative predictive value of 98% - can return home and overtreatment is avoided.
Positive predictive value only 50%
117
Clinical significance of cervical length in suspected preterm labour?
TVUS to decide likelihood of birth within 48hrs in those past 30wks.
<15mm = initiate treatment. Shortened cervix indicates high likelihood of preterm birth.
118
Treatment options for preterm labour?
Antenatal steroids
MgSO4
Tocolysis
Decision on time and mode of delivery
## Footnote
same as PPROM
119
Treatment options for PPROM?
Antenatal steroids
MgSO4
Tocolysis
Decision on time and mode of delivery
| same as preterm labour
120
2 indications for tocolysis?
1. Delay of birth by 48hrs is necessary to administer ANS
2. In-utero transfer
121
Benefits of tocolysis?
its just buying time.
It provides symptomatic relief but does not treat underlying cause, hence they do not delay delivery further or confer any long term benefit.
## Footnote
Dont use in PPROM - chorioamnionitis
122
Main tocolytic agents?
Nifedipine is main.
MgSO4 and Atosiban (IV) used as well.
## Footnote
Atosiban is a direct oxytocin receptor
Salbutamol not used anymore cuz of reported maternal mortality
123
Abx for PPROM?
Erythromycin for 10d after PPROM reduces risk of chorioamnionitis
Prolongs latency of pregnancy
Improves neonatal outcomes
124
When to deliver in PPROM?
Expectant mx until 37W, in dicussion with mum and ongoing clinical assessment.
No diff btw early birth and expectant mx in terms of neonatal sepsis or overall perinatal mortality.
BUT early delivery raises risk of RDS and need for ventilation
125
Exclusion criteria for expectant mx in PPROM?
1. Active labour
2. Chorioamnionitis
3. Concerns about fetal wellbeing
4. Monochorionic multiple pregnancy
5. Hypertensive disorder
6. Other contraindications to continuing pregnancy
126
Prevention plan of preterm birth / PPROM?
1. Modifiable RFs e.g. smoking
2. Screen for infection e.g. UTI, STI, BV
3. Cervical length screening - TVUS
4. Vaginal progesterone suppository
5. Cervical cerclage
## Footnote
The last 3 are most effective and done in clinics
127
Definition of short cervix in TVUS in preterm birth / PPROM?
<25mm before Gestation age 24wks
128
Is smoking protective in pre-eclampsia?
yes
129
Prophylaxis of pre-eclampsia?
1. Low dose aspirin in high-risk cases
- start 12-16wks for optimal effects
- promotes normal placentation
- postulated anti-inflamm + anti-platelet effects
2. Calcium supplement 1.5-2.0g daily
## Footnote
high risk = 1 strong RF or 2 moderate RFs
130
Criteria for pre-eclampsia?
BP 140/90 on 2 occasions 4hr apart
OR 160/110 on 1 occasion
Proteinuria 0.3g/24h OR spot urine protein:Cr ratio 30mg/mmol
OR dipstick proteinuria ++ or higher
131
What is eclampsia
Tonic-clonic seizure activity and/or unexplained coma in a woman with signs/symptoms of pre-eclampsia, due to cerebral vasoconstriction
132
Pathophysio of pre-eclampsia?
Placental hypoxia -> release vasoactive factors -> vascular hypersensitivity + endothelial dysfunction -> HTN + end organ dysfunction
133
Lochia Rubra vs Serosa vs Alba?
Rubra = 0-4D postpartum, dark-red colour
Serosa = 4-10D, pinkish brown colour
Alba = 10-28D, whitish yellow
134
Uterine size post delivery?
Immediate post-delivery = umbilical level
2 weeks post-delivery = just below pubic symphysis
135
How fast do menses return after delivery?
By 6 weeks or soon after if not breastfeeding
136
Side effects of urinary tract in puerperium?
Bladder = bladder trauma & relative insensitivity. Prone to incomplete emptying + retention
Ureter = Dilated ureters & renal pelvis may take up to 3/12 to return to pre-pregnant state
137
Causes of puerperal pyrexia / sepsis?
Breast engorgement & mastitis
UTI
Genital tract infection
Wound infection
DVT
Pneumonia
Other infections
138
Common organisms in Puerperal sepsis?
GAS
E. Coli
Staph aureus
Strep pneumo
MRSA
Clostridium septicum, Morganella morganii
139
When to induce labour?
On diet control = 40-41 wks
On treatment = 37-38 wks
Severe IUGR = 37wks if doppler normal/reduced
140
Factors that increase risk of uterine rupture?
Prev 2 CSec
Prev uterine rupture
Prev classical CSec or extension into upper uterine segment
Known connective tissue disorder
Myomectomies that perforate
141
When is vaginal delivery contraindicated?
Placenta previa
Non vertex presentations
Severe life threatening maternal/fetal conditions
142
How does Prostaglandin work as pharmacological IOL?
Act on cervical collagen -> encourage cervix to soften and stretch -> cervical ripening
PGE can also stimulate uterine contractions
## Footnote
T1/2 6-12 hours, hard to reverse hyperstimulation
143
Causes of fetal tachycardia on CTG?
1. Fetal hypoxia
2. Maternal pyrexia
3. fetal/maternal hyperT
4. fetal/maternal anaemia
5. Fetal/maternal acidosis
6. Fetal tachyarrythmias e.g. SVT
| Fetal tachy is a compensatory mechanism for fetal stress
144
How to diff btw TVUS and trans-abdo US?
Small semi-circle at top of US in TVUS
145
Frequency of clinic appt for weekly visits?
## Footnote
For normal healthy pregnancy
Every 4 weeks until 28
Every 2 weeks until 36
Every week from 36
146
ADR of MgSO4?
Respi depression
Pulm edema
Loss of deep tendon reflexes - check reflexes 2hrly
Heart block
Renally excreted, so can cause AKI. Do strict I/O charting
147
Normal Hb in pregnancy?
1st trimester = 11
2nd, 3rd trimester = 10.5
Post-partum = below 10 is abnormal
148
Cutoff for thrombocytopenia in pregnancY?
Below 150k
149
Why does Cr go down in pregnancy?
Blood volume rises. Renal blood flow rises.
Higher bloodflow -> Higher GFR -> Cr falls
Above 70 Cr is abnormal in pregnancy
150
Indications for stopping breastfeeding? What med to stop?
Stillbirth
Chemo
HIV +ve
Stop with Carbegoline
## Footnote
Cabergoline is dopamine agonist, but lowers prolactin as well.
151
4 meds for gestational HTN? (not pre-eclampsia)
Nifedipine
Labetalol
Hydralazine
Methyldopa
| Methyldopa is slowest-acting. Hydralazine not rly used
## Footnote
Labetalol preferred cuz it brings down BP more gradually, which lowers chance of fetal distress.
152
Gold standard for proteinuria diagnosis in pregnancy?
Urine PCR.
Dont use total urine protein!
153
When is BP lowest in pregnancY?
BP is usu lowest in 2nd trimester. Blood volumes are changing, hence BP falls
154
Cutoff for papp in 1st trimester screening?
Below 0.4 means higher risk for IUGR and pre-eclampsia
## Footnote
Start aspirin + screening for fetal growth scan
155
Examples of vaxx CI in pregnancy?
Rubella
Chickenpox
Hep B
## Footnote
High risk of fetal abnormalities
156
Types of vaginal swabs and target organism?
High vaginal swab = GBS, trichomonas
Low vaginal swab = GBS
Endocervical swab = Pap smear, HPV, chlamydia
157
MEdical mx of adenomyosis?
Non-hormonal = tranexamic acid
Hormonal = COCPs, Prostogens
| Surgical = hysterectomy
158
Treatment for hyperplasia without atypia?
## Footnote
Risk of malignancy in 25 years = <5%
Conservative
- Progestogens = Norethisterone or Medroxyprogesterone daily
- Levonogestrel intrauterine system / Mirena
## Footnote
If got atypia must do hysterectomy
159
US of fibroids show?
Solid, round, well-defined, hypoechoic, heterogenous lesion within myomterium.
Often acoustic shadowing at the edge
160
Target hba1c in pregnancy?
6.5% and below
161
Fetal anomaly most specific to infants of diabetic mums?
Sacral agenesis
162
What is colpocleisis?
| Vaginal closure
a surgical treatment option for pelvic organ prolapse in which the length of the vaginal canal is shortened. It is performed through the vagina and does not require any abdominal incisions.
USED FOR VAGINAL PROLAPSE
163
Pharm mx for menopause?
Analgesia = ponstan, NSAIDs
Heavy uterine bleed = TXA
For cycle control and bleed = progestogens
Anxiety & depression = SSRI, SNRI
Hot flushes = gabapentin, pregabalin
HRT in another slide!
164
HRT for menopause?
Estrogen + Progesterone.
2 types - Sequential vs Continuous combined.
In sequential, PGT higher dose for 15days, stop for 2d then bleed comes.
Continuous combined has both hormones.
| Name is Tibolone (Livial)
165
# ftr
How do COCPs work?
1. Feedback loop to cause anovulation
2. Thicken mucus to prevent motility of sperm up into tube
3. Make endometrium thin and unsuitable for ovum implantation
166
At what GA is aspirin treatment generally stopped?
36 weeks
167
Endometrioma vs Ovarian cyst?
Endometrioma is much more painful
168
What is partogram?
composite graphical record of key data (maternal and fetal) during labour entered against time on a single sheet of paper.
169
Commonest kind of male infertility?
Oligoasthenoteratozoospermia
(OAT)
170
How to diagnose urinary stress incontinence and detrusor overactivity?
Urodynamic studies
171
Components of Bishop's score
Consistency
Shortening
Position
Station
Dilatation
172
When to give Tdap vaxx?
try to give before 28 weeks
