OBGYN Flashcards
1
Q
Topics covered at the booking appointment
A
- Folic acid until 12 weeks
- Smoking
- Dietary advice
- Alcohol advice
- Recreational drug advice
- Physical activity and exercise
- Screening options
2
Q
Risks of maternal smoking during pregnancy
A
- Infertility
- Miscarriage
- Preterm birth
- IUGR
- Neonatal RDS
- Cot death
- Club foot
- Palate defects
- Childhood asthma and ear infections
- Increased hospital admissions in first year of life
3
Q
Dietary advice given to pregnant women
A
- Do not eat raw eggs
- Wash all fruits and veg
- Cook meat and shellfish thoroughly
- Avoid large quantities of liver and pate
- Avoid soft cheese
- Eat foods high in folic acid
- Take a vit D supplement
- AVOID vit A supplements
4
Q
Factors which should be assessed at each 2nd trimester appointment
A
- Maternal physical and emotional wellbeing
- Maternal social situation
- Maternal BP
- Maternal urinalysis
- Pain/weight loss
- Auscultation of foetal heart from 18 weeks
5
Q
Additional factors to include in 3rd trimester appointments
A
- Abdominal exam
- Assessment of foetal presentation
- Evaluation of foetal growth with SFH
- Enquiry about foetal movements
- CTG and US to identify foetal heart rate and movements
- Hypertension/preeclampsia screen
- FBC
- Red cell antibody screen at 28 weeks
6
Q
What is included in the Dating scan
A
- History
- Examination
- Abdo exam
- BMI
- Obs
- Urinalysis
- FBC
- Blood group
- Antibody screen
- Rubella, Hep B, Hep C status
- Hb electrophoresis
- Syphillis and HIV screen
- Blood glucose
- Abdo US
- STI screen in <25s
- U&Es in hyperemesis
7
Q
Aims of the dating scan
A
- Identify risk factors
- Screen for illness/abnormalities
- Screen for symptoms
- Confirm pregnancy viability
- Confirm number of babies and chorionicity/amnionicity
- Detect gross foetal anomalies
- Establish gestational age
- Trisomy screening
8
Q
Components of the Down syndrome screen offered after 14 weeks
A
- AFP
- B-hCG
- Oestriol
- Inhibin A
9
Q
Aims of the foetal anomaly scan
A
- Identify structural abnormalities
- identify foetal gender
10
Q
Indications for maternal Rhesus Anti-D in a Rhesus negative mother
A
Dose given as soon as possible after the event, within 72 hours
- Routinely given at 28 and 34 weeks
- CVS/Amniocentesis
- Miscarriage management
- Threatened miscarriage after 12 weeks gestation
- Ectopic pregnancy
- After birth if baby is Rhesus positive
- ECV
- Abdominal trauma
- Antepartum haemorrhage
- TOP
- Delivery
- Stillbirth
11
Q
Features of amniocentesis
A
- Performed after 15 weeks
- Miscarriage risk: 1%
12
Q
Features of CVS
A
- Performed after 10 weeks
- Miscarriage risk: 1.5-2%
13
Q
Risk factors for foetal anomalies
A
- Maternal age
- FH
- Consanguinity
- Maternal pre-existing diabetes or epilepsy
14
Q
Contra-indications for the COCP
A
- Current or previous VTE
- FH of VTE
- Major surgery with prolonged immobilisation
- Immobility
- Thombogenic mutations
- Smokers age >35
- Current or previous vascular disease
- Liver disease
- Migraine with aura
- Postpartum breastfeeding
15
Q
Side effects of COCP
A
- Increased risk of VTE and vascular disease
- Small increase in risk of breast and cervical cancer
- Interacts with anti-epileptics, antiretrovirals, some antibiotics, St johns wort
16
Q
Benefits of the COCP
A
- Reduced risk of ovarian, endometrial and colorectal cancer
17
Q
Side effects of POP
A
- Irregular bleeding
- Abdo bloating
- Weight changes
- Acne
- Headache
- Mood changes
- Interacts with anti-epileptics, antiretrovirals, some antibiotics, St johns wort
18
Q
Side effects of progesterone injection
A
- WEIGHT GAIN
- Unpredictable bleeding then amenorrhoea
- DELAY IN RETURN OF FERTILITY for up to 1 year
- REVERSIBLY LOSS OF BONE MINERAL DENSITY
19
Q
How long does the progesterone injection last?
A
12 weeks
20
Q
How long does the progesterone implant last?
A
3 years
21
Q
Side effects of the progesterone implant
A
- Changes in bleeding pattern
- Risk of deep insertion
22
Q
How long does the progesterone IUS last?
A
3-5 years
23
Q
Contraindications to the IUS
A
- 48 hours-4 weeks postpartum
- Organ transplant
- Post-abortion sepsis
- Long QT syndrome
- Unexplained vaginal bleeding
- HIV with CD4 <200
- Gestational trophoblastic neoplasia
- Cervical or endometrial cancer
- Radical trachelectomy
- Current STI/PID
- Known pelvic TB
- Structural uterine anomalies
- Postpartum sepsis
- Current/previous breast cancer
- Severe decompensated liver cirrhosis
- HCC
24
Q
Side effects of IUS/IUD
A
- Discomfort
- Irregular bleeding - HEAVIER BLEEDING IN IUD
- Uterine perforation
- Expulsion
- Lost threads
- Pelvic infection
- Increased risk of ectopic pregnancy
25
Contraindications to IUD
- 48 hours-4 weeks postpartum
- Organ transplant
- Post-abortion sepsis
- Long QT syndrome
- Unexplained vaginal bleeding
- HIV with CD4 <200
- Gestational trophoblastic neoplasia
- Cervical or endometrial cancer
- Radical trachelectomy
- Current STI/PID
- Known pelvic TB
- Structural uterine anomalies
- Postpartum sepsis
26
How long after unprotected sex can levonorgestrel be used?
72 hours (PRIOR to ovulation)
27
How long after unprotected sex can ulipristal acetate be used?
5 days after unprotected intercourse or 5 days after earliest likely date of ovulation
28
Contraindications for ulipristal acetate
- Liver enzyme-inducing drugs
- Severe asthma controlled by oral steroids
- Breast-feeding women: discard milk for 1 weeks after taking
29
How long after taking ulipristal acetate must a woman wait to start using hormonal contraception?
5 days
30
How long after unprotected sex can the copper IUD be used?
5 days after unprotected intercourse or 5 days after earliest likely date of ovulation
31
Causes of high hCG/hyperemesis gravidarum
- Multiple pregnancy
- Molar pregnancy
- Germ cell tumours
32
Prevalence of miscarraige
1 in 4
33
Risk factors for miscarriage
- Obesity
- Age >35
- History of IUD, Ashermann's
- Maternal illness
- CVS or amniocentesis
- Uterine malformation
- Bac vag
- Thrombophilia
- Smoking
- Alcohol
34
Clinical features of miscarriage
- PV bleeding
- Suprapubic pain
- Recent post-coital bleed
- Asymptomatic
35
Investigations for suspected miscarriage
- Urine pregnancy test
- FBC and blood group
- Serum BhCG
- Transvaginal US
36
Management of a miscarraige
- Watchful waiting
- Medical management: single dose vaginal misoprostol
- Surgical evacuation
37
Follow up after a miscarriage
- Pregnancy test in 3 weeks - if this is positive, US scan to confirm uterus is empty
38
Prevalence of recurrent miscarraige
1%
39
Define recurrent miscarriage
3 or more consecutive miscarriages
40
Causes for recurrent miscarriage
- Parental genetic anomaly
- Uterine abnormality
- PCOS
- Antiphospholipid syndrome
- Thrombophilia defects
- Cervical incompetence
- Bac vag
41
Prevalence of ectopic pregnancy
1%
42
Define an ectopic pregnancy
A pregnancy which has implanted outside the uterine cavity, most commonly in the ampulla of the Fallopian tube
43
Sites of ectopic pregnancy
- Cervix
- Fallopian tubes
- Ovary
- C-section scar
- Intra-abdominally
44
Risk factors for ectopic pregnancy
- PID
- Previous ectopic
- Tubal surgery
- Peritonitis
- Previous pelvis surgery
- IUD in situ
- IVF/infertility
- Endometriosis
- POP
- In utero exposure of mother to diethylsillboestrol
- Smoking
45
Clinical features of ectopic pregnancy
- Abdo pain
- Shoulder tip pain
- Amenorrhoea
- Vaginal bleeding
- Bowel upset
- Adnexal tenderness/mass
- Blood in vaginal vault
- Circulatory shock/collapse
46
Investigations in ectopic pregnancy
- Urine/serum hCG (lower than expected)
- High resolution TVUS: 'donut sign' or 'ring of fire'
- TAUS
- Laparoscopy
47
Management options for ectopic pregnancy
- Watchful waiting
- Methotrexate IM or direct injection
- Surgery: salpingectomy, salpingotomy
48
Indications for watchful waiting in ectopic pregnancy
- hCG <1500 and falling
- No foetal heartbeat
- Reliable patient
- Minimal symptoms
49
Indications for methotrexate in ectopic pregnancy
- Tube intact
- Mass <3.5cm
- hCG <1500
50
Side effects of methotrexate management of an ectopic
- Can't conceive for 3 months
- Bone marrow suppression (CI in active infection)
- Stomatitis
- Requires follow up with FBC, LFTs, u&Es, hCG on day 1 and 4
51
Indications for surgical management in ectopic pregnancy
- Significant pain
- Mass >3.5cm
- Foetal heartbeat on US
- hCG >5000
- Failed medical management
- Haemodynamically unstable
- Significant free fluid
52
Follow up required after management of an ectopic pregnancy
- Serial B-hCG levels
| - Urine pregnancy test at 3 weeks
53
Prevalence of molar pregnancies
1 in 1000
54
Clinical features of a molar pregnancy
- Early PV bleeding
- Vaginal discharge
- Abdo pain
- Hyperemesis gravidarum
- Large for dates uterus
55
Investigations for a molar pregnancy
- US scan: 'bunch of grapes'
- Histopathology
- Serum hCG (very high)
56
Management of molar pregnancy
Surgical uterine evacuation
57
Follow up for molar pregnancy
- 2-weekly serum BhCG for 6 months after evacuation or from first normal hCG level
- If levels rise or plateau, methotrexate must be started
58
Define SGA
A foetus whose estimated weight or birth weight is below the 10th centile
59
Define FGR
A foetus which fails to reach it's genetic growth potential
60
Risk factors for SGA/FGR babies
- Maternal age >40
- Smoking >10/day
- Cocaine
- Previous SGA baby
- Previous stillborn baby
- Chronic hypertension
- Diabetes with vascular disease
- Renal impairment
- Antiphospholipid syndrome
- Threatened miscarriage
- Preeclampsia
- Placental abruption
- Unexplained antepartum haemorrhage
- Abnormal uterine artery Doppler
- Low PAPP-A
- Hyperechogenic foetal bowel
- Foetal chromosomal or structural anomalies
- Maternal malnutrition
61
Screening for mothers with ?SGA babies
Serial US foetal biometry from 26-28 weeks onward
62
Normal SFH
Approximately equal to gestational age +/- 2cm
63
Management of ?SGA/FGR babies
- Screening by serial US scans
- US confirmation
- Exclusion of foetal anomaly
- Doppler studies
- Monitor as appropriate
- Deliver if foetal demise is anticipated
64
Complications of FGR
- Stillbirth
- Birth hypoxia
- Operative delivery
- Neonatal complications
- Impaired neurodevelopment
- T2DM and coronary artery disease in adult life
65
Risk factors for bacterial vaginosis
- excessive washing/douching
- sexual activity
- recent change in sexual partner, frequent changes, multiple regular partners
- no condom use
- history of STIs
- smoking
- IUD
- Afro-Caribbean ethnicity
- Prolonged/heavy periods
- Hormonal changes
- Recent use of antibiotics
66
Clinical features of BV
- Watery grey fishy discharge, particularly after sex or after a period
- painless, no itch
- dyspareunia
- vaginal pH >4.5
- Vaginal discharge swab: clue cells
67
Management of BV
7 days PO metronidazole
68
Complications of BV
- Vaginal vault infection following hysterectomy
- postpartum endometritis following C-section
- PID after surgical TOP
- HIV infection
69
Risk factors for thrush
- Pregnancy
- Hormonal contraception
- Diabetes
- Immunosuppression
- Recent antibiotics
- Vulval irritation/trauma
70
Clinical features of candida infection
- Vaginal itching or pain
- Dyspareunia
- Dysuria
- Thick white cottage cheese discharge
71
Diagnosis of candida
- Clinical
| - Vaginal discharge swab
72
Management of candida
- Clotrimazole pessary + cream
| - PO Fluconazole + clotrimazole cream
73
Risk factors for chlamydia
- Age <25
- Sexual activity with infected partner
- New sexual partner
- Multiple sexual partners
- History of STIs
- No condoms
74
Clinical features of chlamydia
- Asymptomatic
- Cervical cloudy yellow discharge
- Friable cervix
- Abnormal vaginal bleeding
- penile/vaginal discharge: odourless mucoid or mucopurulent
- Dysuria
- Scrotal pain
- lower abdo pain
- Dyspareunia
75
Diagnosis of chlamydia
- Vaginal swab/first void urine for NAAT
76
Management of chlamydia
10 days PO doxycycline (azithromycin in pregnancy)
77
Complications of chlamydia
- PID/tubal infertility
- Chronic pain
- Epididymitis
- Prostatitis
- Reactive arthritis
- Skene's and Bartholin's abscesses
- Endometritis/salpingitis/peripherpatitis
- Miscarriage
- Preterm birth
- Postpartum infection
- Neonatal ocular and respiratory infection
78
Risk factors for gonorrhoea
- Age 15-24
- Black ancestry
- Current/past history of STIs
- Multiple recent sexual partners
- Inconsistent condom use
- MSM
- Partners with risk factors
- History of physical or sexual abuse
79
Clinical features of gonorrhoea
- Asymptomatic
- Mucopurulent discharge
- Friable cervix
- Pelvic pain
- Post-coital/inter-menstrual bleeding
- Lower abdo pain
- Urethral irritation/dysuria
- Rectal bleeding
- Pharyngitis
80
Diagnosis of gonorrhoea
- Vaginal swab/first void urine for NAAT
81
Management of gonorrhoea
IM ceftriaxone + oral azithromycin
82
Complications of gonorrhoea
- PID
- Chronic pelvic pain
- Male infertility
- Prostatitis
- Bartholinitis
83
Risk factors for herpes
- HIV
- Immunosuppression
- High risk sexual behaviour
84
Clinical features of herpes
- Asymptomatic
- Painful genital ulcers
- dysuria
- Painful inguinal lymphadenopathy
- Tingling sensation
- Oral ulcers
- Systemic upset
85
Investigations in herpes
- HSV PCR or viral culture from lesions
| - Glycoprotein G1 and 2: useful to assess risk in asymptomatic pregnant women
86
Management of herpes
- Oral Aciclovir for 5 days within 3 days of symptom onset (10 days and higher doses for immunosuppression)
- PO Aciclovir for 3 days in recurrent episodes
87
Risk factors for HIV
- IVDU
- Unprotected sexual intercourse, especially MSM
- Tattoos, piercing
- Blood transfusion
88
Clinical features of HIV
- Fevers/night sweats
- Unexplained weight loss
- Skin rashes and post-inflammatory scars
- Mouth ulcers, angular chellitis, oral thrush, oral hairy leukoplakia
- Diarrhoea
- Wasting syndrome
- Changes in mental state or neuropsychiatric function
- Generalised lymphadenopathy
89
Investigations for HIV
- Serum HIV rapid test: may be falsely negative in first month
- CD4+ cell count
- Serum viral load
- Other BBV testing
90
Management of HIV
3 antiretrovirals
91
Indications for PrEP
- Regular partner with detectable HIV load
- MSM and transgender women who have had unprotected anal sex with more than one partner in the last year
- Rectal STIs
- Anyone else at equivalent risk
92
When can PEPSE be used?
For up to 72 hours post-exposure to HIV
93
Cause of genital warts
HPV 6 and 11
94
Clinical features of genital warts
- Asymptomatic warts round vaginal or penile opening
| - Itching, bleeding or pain
95
Diagnosis of genital warts
- Clinical
| - Biopsies if lesions bleed, are ulcerated or indurated
96
Management of genital warts
1) Topical podophyllotoxin or imiquimod
| 2) Cryotherapy or surgical excision
97
Complications of genital warts
- Anogenital cancer
- Head and neck cancer
- Scarring after treatment
98
Risk factors for syphilis
- Sexual contact with an infected person
- MSM
- IVDU
- Commercial sex workers
- Multiple sexual partners
- HV
- Other STIs
99
Clinical features of syphilis
1) Indurated PAINLESS anogenital ulcer
2) Widespread symmetrical non-pruritic maculopapular rash involving palms and soles, alopecia, condylomata lata, generalised lymphadenaopthy, oral snail-track lesions, systemic upset
3) Neurosyphilis: tabes dorsalis, general paresis, stroke
Cardiovascular syphilis: aortitis, aortic aneurysms
Granulomatous syphilis: formation on granulomas on bone, skin and mucosa
100
Investigations in syphilis
- Serum treponemal serology
- Serum rapid plasma reagin or VDRL test
- Syphilis PCR from swab from lesion
- Dark-field microscopy of swab from lesion
101
Management of syphilis
Single dose IM benzathine Benzylpenicillin and PO prednisolone for 3 days
102
Complications of syphilis
- Jarisch-Herxheimer reaction
| - HIV
103
Clinical features of trichomoniasis
- Thin, frothy, yellow fishy smelling discharge
- Vulval pruritus
- Dysuria
- Dyspareunia
- Balanitis
104
Investigations in trichomoniasis
- Vaginal pH: >5
- High vaginal swab and wet mount microscopy
- Culture of vaginal discharge
- Urethral swab/first void urine
105
Management of trichomoniasis
Single dose PO metronidazole OR 5-7 days metronidazole
106
Complications of trichomoniasis
- PID
- Altered vaginal flora
- Prostatitis
- PROM and preterm birth
- LBW
- HIV
107
Risk factors for PID
- Age <25
- Single
- Young at first sexual intercourse
- High frequency of sexual intercourse
- Multiple sexual partners
- Past history of STI
- Past history of PID
- Recent uterine instrumentation
- Use of IUD
108
Causes of PID
- Chlamydia
- Gonorrhoea
- Mycoplasma genitalium
- Gardnerella vaginalis
109
Clinical features of PID
- Bilateral pelvic/lower abdo pain
- Deep dyspareunia
- Dysmenorrhoea
- Increased vaginal discharge
- Fever
- Asymptomatic
- Infertility
110
Diagnostic criteria of PID
At least 3 of:
- Temp >37.5
- Abdo tenderness
- Purulent vaginal discharge
- Cervical excitation
- Adnexal tenderness
- Adnexal swelling
111
Investigations for PID
- Bloods
- Blood cultures
- STI screen
- Pregnancy test
- US
- Laparoscopy (gold standard)
112
Management of PID
14 days PO doxycycline and metronidazole
113
Complications of PID
- Pelvic abscess
- Sepsis
- Infertility
- Ectopic pregnancy
- Chronic pelvic pain
- Dyspareunia
- Menstrual disturbances
- Psychological effects
- Fitz-Hugh-Curtis syndrome
114
Risk factors for a high risk pregnancy
- Extremes of maternal age
- >6 previous births
- High or low BMI
- Smoking, drugs, alcohol
- Social difficulties
- First pregnancy
- Infertility/IVF
- FH of high risk pregnancies
- Miscarriage, stillbirth or neonatal death
- Medical conditions
- Recurrent miscarriage
- Pelvic surgery
- Maternal mental illness
- Previous preterm birth
- Previous SGA baby
- Previous pregnancy-related disease
- IOL
- Operative delivery
- PPH
115
Risk factors for gestational diabetes
- FH of diabetes
- BMI >30
- Previous baby >4.5kg
- Previous GDM
- Ethnic minorities
116
Screening for gestational diabetes
OGTT at 24-28 weeks
117
Diagnostic criteria for gestational diabetes
- Fasting glucose >5.6
| - OGTT >7.8
118
Management of gestational diabetes
1) Dietary advice and weight loss
2) Metformin
3) Insulin
119
Delivery in women with diabetes
IOL between 37 and 39 weeks
120
Delivery in women with gestational diabetes
IOL by 41 weeks if no complications
121
Complications of diabetes in pregnancy
- Foetal congenital abnormalities e.g. cardiac defects, neural tube defects, renal anomalies
- Preeclampsia
- maternal infection
- Polyhydramnios
- Macrosomia with organomegaly
- Neonatal polycythaemia
- Unexplained intrauterine death
- Shoulder dystocia
- Neonatal hypoglycaemia
- Hyaline membrane disease/RDS
- Development of diabetes
- Recurrent GDM in future pregnancies
122
Define preeclampsia
Hypertension developing after 20 weeks gestation with one or more of:
- Proteinuria
- Maternal organ dysfunction
- Foetal growth restriction
123
Define eclampsia
Neurological involvement (generalised tonic clonic seizures) in a woman with preeclampsia, when seizures can not be attributed to another cause
124
Prevalence of preeclampsia
<5%
125
Risk factors for gestational hypertension and preeclampsia
- First pregnancy
- FH
- Extremes of maternal age
- New sexual partner
- Obesity
- Medical conditions e.g. hypertension, renal disease, thrombophilia, connective tissue disease, diabetes, autoimmune disease
- Multiple pregnancy
- History of preeclampsia
- Complete molar pregnancy
- Triploidy
- Hydrops fetalis
- Inter-pregnancy interval of >10 years
- Donor insemination
126
Symptoms of preeclampsia
- Severe headache
- Severe RUQ/epigastric pain
- Sudden swelling of hands/feet/face
- Visual disturbance
- Vomiting
- Restlessness/agitation
- Hyperreflexia
- Clonus
127
Investigations in women with preeclampsia
- BP: raised
- Urinalysis: proteinuria
- 24 hour urinary collection
- FBC: haemolytic anaemia, decreased platelets
- U&Es: raised creatinine and urea
- LFTs: elevated
- Coagulation screen
- Fundoscopy
- SFH
- Growth scan US
- Umbilical artery Doppler
- Uterine artery doppler velocimetry
128
Management of preeclampsia
- Daily aspirin 75mg from 12 weeks gestation for high risk women
- Admit for assessment and initial diagnosis
- Antihypertensives to reduce BP <150/100
1) Labetaolol (CI in asthma)
2) Nifedipine
- Monitoring of maternal fluid input and output
- Monitor O2 sats, U&Es, LFTs, Hb, haematocrit, platelets, coagulation
- MgSo4 to prevent seizures
- Elective delivery at 37 weeks
- Continued monitoring postpartum
129
Management of gestational hypertension without proteinuria
- Repeat BP measurement if BP is elevated
- BP and urinalysis 2x weekly
- Serum biochemistry and haematology 1x weekly
- Advise to return to hospital if she feels unwell
- Antihypertensives if BP consistently >150/100
130
Indications for immediate delivery in preeclampsia
- Gestation >37 weeks
- Uncontrolled hypertension
- Deteriorating liver/renal function
- progressive fall in platelets
- Neurological complications
- Deteriorating foetal condition
- Abnormal foetal HR
- HELLP syndrome
131
Complications of preeclampsia
- FGR
- Foetal hypoxia and neurological deficits
- Intrauterine death
- Premature birth
- Longterm foetal cardiovascular morbidity
- Placental rupture
- DIC
- HELLP syndrome
- Pulmonary oedema
- Aspiration
- Eclampsia
- Liver failure
- Hemorrhagic stroke
- Long term maternal cardiovascular morbidity
- Maternal death
132
Management of eclampsia
- Turn patient to left hand side
- Secure airway
- High flow oxygen
- IV MgSO4 followed by IV infusion for at least 24 hours following delivery or last seizure
- Urgent delivery
- Paralysis and ventilation in prolonged recurrent seizures
133
Risk factors for VTE in pregnancy
- Age >35
- BMI >30
- Para 3+
- Gross varicose veins
- Current infection
- Preeclampsia
- Immobility
- Major current illness
- C-section
- Extended major pelvic or abdominal surgery
- Personal or family history
- Antiphospholipid syndrome
- Paralysis of lower limbs
- Smoking
- Multiple pregnancy
- IVF
134
Clinical features of VTE
- Calf tenderness
- Calf swelling
- Breathlessness
- Chest pain
- Abdo pain
- Groin pain
135
Thromboprophylaxis used in pregnancy
LMWH
136
Investigations in VTE
- Duplex Doppler US
- X-ray venography
- V/Q scan
- CTPA
137
Effects on foetus of chickenpox in pregnancy
- Limb deformity
- Skin scarring
- Eye abnormalities
- Neurological abnormalities
- Hydrops fetalis
- Microcephaly
- IUGR
138
Management of chickenpox in pregnancy
- Check immunisation status
- Give varicella IgG if mum is exposed
- Neonatal IgG if delivery occurs within 5 days of maternal infection or mother develops chickenpox within 2 days of birth
- Neonatal infection: Acyclovir
139
Effects on foetus of rubella in pregnancy
- Miscarriage
- IUGR
- Low platelets
- Hepatosplenomegaly
- Jaundice
- Sensorineural deafness
- Congenital heart disease
- Neurodevelopmental disorders
- Cataracts
- Microphthalmia
- Microcephaly
- CP
- Pulmonary stenosis
140
Management of rubella in pregnancy
- Consider TOP if <12 weeks
| - Postnatal maternal vaccination
141
Effects on foetus of toxoplasmosis in pregnancy
- Hydrocephalus
- Chorioretinitis
- Intracranial calcification
142
Management of toxoplasmosis in pregnancy
Consider TOP if primary infection <20 weeks
143
Effects on foetus of CMV in pregnancy
- Hepatosplenomegaly
- Low platelets
- IUGR
- Microcephaly
- Sensorineural deafness
- Chorioretinitis
- Hydrops fetalis
- Exomphalos
- CP
144
Delivery of women with HSV
- Primary herpes should be treated with Acyclovir, continued to delivery if >28 weeks
- Vaginal delivery encouraged if >6 weeks after primary infection
- Elective C-section if >28 weeks with primary infection
- Acyclovir from 34 weeks in recurrent episodes
145
Complications of twin pregnancies
- Hyperemesis
- Anemia
- Preeclampsia
- Antepartum haemorrhage
- VTE
- Gestational diabetes
- General discomfort
- Varicose veins
- Dependent oedema
- Delivery trauma
- C-section
- PPH
- Psychological disorders
- Breastfeeding and parenting challenges
- Chromosomal abnormalities
- Structural defects
- Preterm birth
- FGR
- Twins with one foetal death
146
Antenatal complications specific to monochorionic twin pregnancies
- Twin to twin transfusion syndrome
- Twin anaemia polycythaemia sequence
- Severe selective IUGR
- Cord entanglement
- Twin reversed arterial perfusion sequence
147
Delivery in twin pregnancies
At 37 weeks in dichorionic twins
| At 36 weeks in monochorionic twins
148
Indications for a C-section in a twin pregnancy
- Significant growth discordance
- Concern about foetal wellbeing
- <34 weeks gestation
- Previous C-section
- Twin II is transverse
149
Prevalence of polyhydramnios
0.5-2%
150
Risk factors for polyhydramnios
- Maternal diabetes
| - Congenital foetal anomaly
151
Define polyhydramnios
- A single pool of amniotic fluid >8cm in depth AND/OR
| - Amniotic fluid index >90th centile for gestational age
152
Complications of polyhydramnios
- Placental abruption
- Malpresentation
- Cord prolapse
- LGA
- C-section
- PPH
- Premature birth
- Perinatal death
153
Management of polyhydramnios
- Increased foetal surveillance
- Exclusion of gestational diabetes
- Examination of neonate for congenital anomalies e.g. oesophageal atresia
154
Prevalence of oligohydramnios
1-3%
155
Define oligohydramnios
- AFI <5 cm OR
| - Single cord-free pool of amniotic fluid <2cm
156
Complications of oligohydramnios
- Prolonged pregnancy
- Rupture of membranes
- IUGR
- Fetal renal anomalies
- Fetal hypoxia due to cord compression
157
Prevalence of prolonged pregnancies
10%
158
Define prolonged pregnancy
Pregnancy continuing beyond 42 weeks
159
Management of prolonged pregnancy
- Membrane sweeps and IOL offered between 41 and 42 weeks
| - If declined, offer a 2x weekly CTG and US estimation of amniotic fluid volume
160
Prevalence of infertility
1 in 6
161
Risk factors for infertility
- Smoking
- Previous pelvic infection
- Previous pelvic surgery
- Regular NSAIDs
- Cannabis
- Ashermann's syndrome
162
Causes of male factor infertility
- Genetic causes
- Acute illness
- Alcohol binge
- Drugs
- Vasectomy
- Obstructive disease
163
- Low LH
- Low FSH
- Low oestrogen
- Normal/low testosterone
- Normal prolactin
- Normal TFTs
Hypogonadotrophic hypogonadism:
- Low BMI
- Pre-pubertal
- Stress
- Systemic illness
- Sheehan's syndrome
164
Management options for hypogonadotrophic hypogonadism
- Lifestyle modification: weight gain, stress management
| - GnRH pulses or LH/FSH injections
165
- Low LH
- Low FSH
- Low oestrogen
- Normal/low testosterone
- HIGH prolactin
- Normal TFTs
Hyperprolactinaemia
- Breast feeding
- Prolactinoma
166
Management options for hyperprolactinaemia
- Dopamine agonists
- Cessation of implemented drugs
- Surgical removal of prolactinoma
167
- HIGH LH
- HIGH FSH
- Low oestrogen
- Normal/low testosterone
- Normal prolactin
- Normal TFTs
Premature ovarian failure:
- Turner syndrome
- Chemotherapy
168
Management of premature ovarian failure
- Donor egg
169
- HIGH LH
- HIGH FSH
- Normal oestrogen
- HIGH testosterone
- Normal prolactin
- Normal TFTs
PCOS
170
Management of PCOS
1) Lifestyle modification
2) Metformin
3) COCP
4) Clomifene citrate for 5 days at start of cycle
171
Management of tubal infertility
IVF
172
Investigations for infertility
- BMI
- Signs of PCOS
- Secondary sexual characteristics
- Vaginal examination
- Testicular examination
- STI screen
- Evidence of MMR immunisation
- 21 day progesterone
- Sex hormones
- Semen analysis: 2 samples 12 weeks apart after 3 days abstinence from ejaculation
- TVUS
- HSG or lap and dye or hysterosalpingo contrast sonography
- Serial US or hysteroscopy
173
Clinical features of OHSS
- Abdominal distention
- Nausea and vomiting
- Abdominal discomfort
- Ascites
- Pleural effusion
- Hepatorenal failure
- ARDS
- Thromboembolism
174
Stages of labour
1) From onset until full cervical dilatation:
a) Latent: cervical effacement and dilatation to 4cm
b) Active/established: regular, longer stronger contractions and dilatation from 4-10cm
2) From full cervical dilatation until delivery of the baby
a) Propulsive: from full dilatation until head descends onto pelvis floor
b) Expulsive: from time mother has irresistible urge to push to delivery
3) From birth of baby to delivery of placenta
175
Diagnosis of labour
- Regular contractions and a fully effaced cervix
OR
- Regular contractions + a show or spontaneous membrane rupture
176
Monitoring during labour
- Baseline BP, pulse, temp, urinalysis
- Baseline assessment of length, strength, frequency and contractions
- Confirm if membranes have ruptured or not, colour and volume of amniotic fluid
- Assessment of contractions using abdo palpation
- 4 hourly VE
- Intermittent FHR: for 1 min before and after contractions, at least every 15 mins in first stage and 5 mins in second stage
177
Indications for CTG monitoring in labour
- High risk pregnancy
- Abnormal intermittent auscultation
- Abnormal maternal obs
- PV bleeding/antepartum haemorrhage
- Thick meconium-stained amniotic fluid
- Oxytocin use
- Hypertonus
- Tachysystole
- Epidural
- FGR or SGA
- Preeclampsia/hypertension
- Precipitate labour
- Preterm labour
- Prolonged labour
- IOL or augmentation with Syntocinon
- Previous C-section
178
Define a suspicious CTG
- One non reassuring and two reassuring features
179
Define a pathological CTG
- One abnormal feature OR
| - Two non reassuring features
180
CI to FBS
- Risk of infection transmitted from the mother
- Foetal bleeding disease
- <34 weeks gestation
- Acute even necessitating immediate delivery
181
Action if FBS pH is 7.2107.25
Repeat in 30-60 mins if not delivered
182
Action if FBS pH is <7.2
Instrumental delivery or C-section
183
Grades of perineal tears
1) Injury to vaginal epithelium and vulval skin
2) Injury to perineal muscles but not anal sphincter
3) Injury to perineum involving the anal sphincter complex
4) Injury to the perineum involving the anal sphincter and anal/rectal muscle
184
Indications for episiotomy
- Instrumental delivery
- Fetal distress
- Extensive scarring
- Rigid perineum which is preventing delivery
- Large tear is suspected
- Shoulder dystocia
185
Complications of episiotomy
- Extension
- Bleeding
- Pain
- Infection
- Scarring
- Dyspareunia
- Fistula
186
Active management of the third stage of labour
- Oxytocin IM (+/- Ergometrine)
- Double clamping of the cord after delayed cord clamping
- Observe for signs of separation of the placenta
- Stabilise the uterus during controlled cord traction
- Empty bladder
- Massage fundus to ensure it is well contracted
187
Risk factors for PPH
- Age of mother
- Previous PPH
- Large baby
- Placental abruption
- Preeclampsia
- Long labour
- Multiple pregnancy
188
Non-pharmacological methods of pain management in labour
- Massage
- Heat pads
- Mobilisation
- Birthing pool/immersion in warm water
- Breathing exercises
- Creation of a calm environment
- 1:1 midwifery care
- TENS machine
- Acupuncture
189
Analgesics for use in labour
- Paracetamol
- Dihydrocodeine
- Entonox
- IM Diamorphine OR pethidine + antiemetic
- IV remifentanil
- Sterile water injections
- Pudendal nerve block
- Epidural
- Spinal
190
Side effects of entonox
- Nausea
- Vomiting
- Drowsiness
- Lightheadedness
191
CI for IM diamorphine in labour
- Delivery expected within 4 hours
192
Side effects of diamorphine
- Nausea
- Vomitnig
- Drowsiness
- Short term respiratory distress and drowsiness in the neonate
193
Advantages and disadvantages/side effects of an epidural
- Effective
- Fast
- Reduces adrenaline
- Can be topped up
- Non-drowsy
- No neonatal effects
- Incomplete block
- Hypotension
- Reduced mobility
- Tenderness over insertion site
- Dural puncture headache
- Respiratory distress if migrates into subarachnoid space
- Abscess
- Haematoma
- Needs secure IV access and continuous CTG monitoring
- Needs regular BP monitoring
- Increased risk of prolonged second stage and instrumental delivery
194
Indications for an epidual
- Maternal request
- Expectation of operative delivery
- Maternal cardiac or respiratory distress
- Preeclampsia
- Trial of labour after previous LUCS
- Neurological disease
- Obstetric disease
- Breech delivery
- Multiple pregnancy
- GA contraindicated
- Intrauterine death
195
CI to an epidural
- Overlying skin infection
- Hypotension
- Coagulation disorders
- Sepsis during labour
- Maternal refusal
- Uncontrolled hypovolaemia or haemorrhage
- Expectation of significant haemorrhage or manual removal of placenta
- Certain spine surgery and spinal abnormalities
- Lack of trained staff available
196
Complications of epidural
- Severe headache
- Temporary or permanent nerve damage
- Infection
- Meningitis
- Epidural blood clot
197
Indications for a spinal
C-section
198
Advantages of a spinal
- Easier than epidurals
- Allows bonding with baby
- Reliable
199
Disadvantages of a spin
- Severe hypotension
- Can wear off
- Risk of conversion to GA
200
Indications for induction of labour
- Prolonged pregnancy
- Maternal age >40
- Maternal diabetes
- Twin pregnancy
- PROM
- FGR and suspected foetal compromise
- Hypertensive disorders of pregnancy
- Deteriorating maternal medical condition
- Maternal request
201
Contra-indications for IOL
- Placenta previa
- Transverse lie
- Previous C-section or uterine surgery
- Previous history of precipitate labour
202
IOL if Bishop score <6
Vaginal prostaglandin +/- membrane sweep
203
IOL if Bishop score >6
Vaginal prostaglandins or ARM +/- Syntocinon
204
Complications of IOL
Uterine hyperstimulation
205
Incidence of breech presentation
3-4%
206
Risk factors for breech delivery
- Placenta previa
- Multiple pregnancy
- Bicornuate uterus
- Fibroids
- Polyhydramnios/oligohydramnios
- Foetal anomalies
207
Management options for breech presentation
- ECV at 36-37 weeks
- C-section
- Vaginal breech birth
208
Contraindications/cautions for ECV
- Multiple pregnancy
- C-section indications
- Abnormal uterine anatomy
- Abnormal CTG
- Ruptured membranes
- Antepartum haemorrhage in last 7 days
- IUGR
- Oligohydramnios
- Pre-eclampsia
- Nuchal cord
- Major foetal anomalies
- Hyperextended foetal head
- Morbid maternal obesity
209
Risks of vaginal breech delivery
- Intracranial injury
- Widespread bruising
- Damage to internal organs
- Spinal cord transection
- Cord prolapse
- Hypoxia
- Head entrapment
210
Risk factors for transverse/oblique lie
- Multiparity
- Multiple pregnancy
- Preterm labour
- Polyhydramnios
- Placenta previa
- Congenital uterine anomalies
- Lower uterine fibroids
- Pelvic masses
211
Management of oblique/transverse lie
- ECV
| - C-section
212
Prevalence of face presentation
1 in 500
213
Risk factors for face presentation
- Prematurity
- Foetal neck tumours
- Loops of cord around foetal neck
- Foetal macrosomia
- Anencephaly
214
Complications of malposition
- Longer first and second stages of labour
- Back pain
- Increased frequency of epidural
- Obstructed labour
- More likely to require augmentation with Syntoncinon
- More likely to require instrumental delivery or C-section
- Increased risk of 3rd and 4th degree perineal tears
215
Define precipitate labour
Expulsion of the foetus within 2-3 hours from onset of contractions
216
Management of precipitate labour
- Cessation of oxytocin infusions
- Turn woman to left lateral position
- Administration of a tocolytic e.g. SC terbutaline or GTN spray
- Delivery via instrumental delivery or C-section if foetal distress
217
Complications of precipitate labour
- Cervical and perineal tears
- Retained placenta
- PPH
- Need for blood transfusion
218
NICE definition of delayed labour
First stage
- <1cm dilation in 4 hours in primiparous women
- <2cm dilation in 4 hours OR slowing in progress for multiparous women
Second stage
- Baby not delivered after 3 hours of active second stage in primiparous women
- Baby not delivered after 2 hours in parous women
Third stage
- Failure to pass placenta within 30 mins with active management
- Failure to pass placenta within 60 mins with passive management
219
Causes of delayed labour
- Idiopathic inadequate contractions
- Obstructed labour
- Maternal dehydration
- Maternal obesity
- Maternal age
- CPD
- Malpresentation
- Malposition
220
Complications of slow labour
- Maternal fatigue
- Maternal anxiety/loss of moral
- Pelvic floor dysfunction or obstetric fistula
- Uterine rupture
- Maternal/foetal sepsis
- PPH
- Fetal hypoxia
- Instrumental delivery or C-section
221
Management of inadequate contractions in labour
- Fluids
- Mobilisation
- Pain management
- ARM
- Syntocinon infusion
222
CIs/cautions for syntocinon infusion in labour
- Obstructed labour
- Previous C-section
- Multiparous women
223
Management of true CPD in labour
C-section
224
Indications for operative vaginal delivery
- Suspected foetal compromise
- Maternal exhaustion
- Fetal malposition
- CPD
225
Criteria for a operative vaginal delivery
- Consent obtained
- Cervix is fully dilated with membranes ruptured
- Head is fully engaged and at or below ischial spines, with no head palpable abdominally
- Position of the head is known
- Bladder is empty
- Satisfactory analgesia
226
Complications of instrumental delivery
- Failure resulting in C-section
- Low APGAR scores
- Foetal acidosis
- Cerebral trauma
- Cerebral haemorrhage
- Brachial plexus injuries
- Fracture
- Perineal tears
- PPH
- Perineal infection
- Urinary/bowel incontinence
- Dyspareunia
- Fear of childbirth
227
Increased risks with ventouse (compared to forceps) of...
- Failure
- Neonatal cephalohaematoma
- Retinal haemorrhage
- Low APGAR score at 5mins
228
CI for ventouse
- Face presentation
| - Risk of foetal bleeding disorder
229
Indications for a vertical incision in C-section
- Transverse fetal lie
- Placenta previa
- Very preterm birth
- Lower uterine segment fibroids
230
Preparation for a C-section
- Consent
- IV access
- Group and save +/- crossmatch
- Sodium citrate +/- ranitidine
- Appropriate thromboprophylaxis
- Antibiotics prophylaxis
- Anaesthesia
- Catheterisation
231
Incision used in most C-sections
Pfennenstiel incision
232
Layers to cut through in a C-section
- Skin
- SC fat
- Rectus sheath
- Peritoneum
233
Complications of a C-section
- Infection
- PPH
- VTE
- Bowel/bladder injury
- TTP
234
Define menopause
Absence of menstrual periods for 12 months in a woman with a uterus who is not pregnant or taking hormones that may induce amenorrhoea
235
Clinical features of menopause
- Hot flushes/night sweat
- Headaches
- Palpitations
- Insomnia
- Irritability
- Poor concentration and short-term memory
- Depression/low mood
- Lethargy
- Decreased self confidence
- Decreased libido
- Dyspareunia
- Joint aches
- Irregular periods
- Atrophic vaginitis
- Vaginal dryness
- Urethral symptoms
- Urge incontinence or urinary frequency
236
Adverse effects of menopause on long-term health
- Cardiovascular disease
- Cerebrovascular disease
- Osteoporosis
237
Clinical diagnosis of menopause
FSH >30 with irregular or absent menses
238
Marker of ovarian reserve
AMH
239
Risks and side effects of HRT
- Nausea
- Breast tenderness
- Uterine bleeding
- Endometrial cancer (unopposed oestrogen therapy)
- Breast cancer
- VTE
240
CIs for HRT
- Pregnancy
- Current or previous VTE
- Liver disease
- Undiagnosed vaginal bleeding
- Breast carcinoma
- Advanced endometrial carcinoma
241
Define neonatal encephalopathy
Clinically define syndrome of disturbed neurological function occurring in the first week of birth, characterised by difficulty with initiating and maintaining respiration, depression of tone and reflexes, altered consciousness level and seizures
242
Risk factors for haemolytic disease of the newborn
- Miscarriage
- Ectopic pregnancy
- Invasive intrauterine procedures
- ECV
- Abdominal trauma
- Antepartum haemorrhage
- Labour and delivery
243
Clinical features of haemolytic disease of the newborn
- Reduced/absent foetal movement
- FGR
- Anaemia
- Hydrops fetalis
- Polyhydramnios
- Unreactive pattern or decelerations on CTG
- Sinusoidal fetal HR pattern
- Postnatal jaundice and kernicterus
244
Features of hydrops fetalis
- Hypoxia
- Acidosis
- Hepatic dysfunction
- Cardiac dysfunction
- Generalised skin oedema
- Ascites
- Pericardial effusions
- Pleural effusions
245
Investigation for haemolytic disease of the newborn
Foetal MCA Doppler velocity
246
Management of haemolytic disease of the newborn
- Intrauterine transfusion
247
Complications of intrauterine transfusion
- Cord haematoma
- Foetal bradycardia
- Intrauterine death
- Further sensitisation of the mother
248
Delivery of babies with haemolytic disease of the newborn
- Delivery in a NICU hospital
- Term delivery if US normal and antibody level is low
- Vaginal delivery in mild anaemia or those successfully treated with intrauterine transfusion
- C-section in hydrops fetalis
- Induction at 35 weeks in those being managed with intrauterine transfusion
- Kleihauer testing of foetal cord blood
249
Complications of haemolytic disease of the newborn
- CP
- Abnormal development
- Hearing problems
250
Causes of abnormal uterine bleeding
- Polyps
- Adenomyosis
- Leiomyoma/fibroids
- Malignancy/premalignant conditions
- Coagulopathy
- Ovulatory dysfunction
- Endometrial causes
- Iatrogenic
- Not-otherwise classified
251
Causes of amenorrhoea
- CNS disorders
- Gonadal dysfunction
- Genital tract disorders
- Endocrine disorders
- Drug therapy
252
Define primary amenorrhoea
Lack of menstruation after age 16
253
Investigations in secondary amenorrhoea
- Pregnancy test
- TFTs
- Blood glucose
- Serum gonadotrophins
- Serum androgens
- Serum prolactin
- Pelvic US
- Lateral skull X-ray/CT
254
Definition of menorrhagia
- Technically defined as >80ml per period
- Clinically defined as excessive menstrual blood loss which interferes with the woman's physical, emotional, social and material quality of life
255
Causes of menorrhagia
- Thyroid disease
- Clotting disorders
- Fibroids
- Endometrial polyps
- Endometrial carcinoma
- Endometriosis/adenomyosis
- PID
- Dysfunctional uterine bleeding
- IUCD
- Oral anticoagulants
256
Investigations in menorrhagia
- Subjective assessment
- Pictorial blood loss assessment chart
- FBC
- TFTs
- Coagulation studies
- Laparoscopy
257
Management for menorrhagia
1) NSAIDs e.g. mefenamic acid
2) Fibrinolytics e.g. tranexamic acid
3) COCP or POP
4) IUS
5) Endometrial ablation
6) Hysterectomy
258
Define PMB
Vaginal bleeding occurring >6 months after the menopause
259
Causes of PMB
- Endometrial hyperplasia/carcinoma
- Atrophic vaginitis
- Endometrial polyps
- Fibroids
- Cervical malignancy
- Ovarian carcinoma
- Oestrogen-secreting tumour
260
Investigations for PMB
- TVUS
- Pipelle biopsy (4-10mm)
- Hysteroscopy and biopsy (>10mm)
261
Risk factors for fibroids
- African-Caribbean
- Increasing age
- Nulligravida
- Obesity
262
Protective factors for fibroids
- Smoking
- COCP
- Pregnancy
263
Clinical features of fibroids
- Asymptomatic
- Menorrhagia
- Intermenstrual/post-coital/continuous vaginal bleeding
- Dysmenorrhoea
- Abdo/pelvic pain
- Abdo/pelvic mass
- Pressure symptoms
- Bloating
264
Investigations for fibroids
- Clinical examination: firm irregular uterus, moves with fibroid movement
- Pelvic US: characteristic diffuse changes
- Hysteroscopy + Pipelle biopsy: normal
265
Management for fibroids
1) Leuprelin or Mifepristone OR IUS
2) Myomectomy
3) Uterine artery embolisation
4) Hysterectomy
266
Complications of fibroids
- Subfertility/infertility
- Miscarriage
- Preterm labour
- Malpresentation
- Obstructed labour
- PPH
- Acute abdomen due to torsion
- Urinary retention
- Hyaline, cystic or calcific degeneration
- Malignant transformation (rare)
267
Risk factors for endometriosis
- Reproductive age
- FH
- Nulliparity
- Mullerian abnormalities
268
Clinical features of endometriosis
- Secondary dysmenorrhoea (cyclical)
- Deep dyspaurenia
- Pelvic pain
- Infertility
269
Investigations for endometriosis
- Clinical examination: tender, retroverted, retroflexed fixed uterus with thickening of cardinal or uterosacral ligaments, endometriotic nodules, pain on moving cervix anteriorly
- Diagnostic laparoscopy: gun powder lesions
270
Management of endometriosis
1) COCP/POP +/- NSAIDs
2) GnRH agonist
3) Diathermy treatment of lesions
4) TAHBSO
271
Risk factors for shoulder dystocia
- Macrosomia
- Current or past diabetes
- Postdates gestation
- Obese mother
- High parity
- Male foetus
- Prolonged first stage of labour
- Secondary arrest >8cm
- Mid-cavity arrest
- Instrumental delivery
- Difficulty delivering chin
272
Management of shoulder dystocia
Try each manoeuvre for 30 secs
- Call for help
- Episiotomy
- McRoberts position
- Suprapubic pressure
- Woodscrew/reverse woodscrew manoeuvre
- Roll over
- Removal of posterior arm
- Symphisiotomy
- Clavicle/humerus fracture
- Zavanelli manoeuvre
273
Complications of shoulder dystocia
- Erb's palsy
- Klumpke's palsy
- Maternal genital tract trauma
- Atonic PPH
274
Risk factors for cord prolapse
- Breech presentation
- Malposition
- Preterm labour
- Polyhydramnios
- FGR
- Placenta previa
- Long umbilical cord
- ARM
- Second twin
275
CTG features of cord prolapse
- Deep variable decelerations
| - Single prolonged deceleration
276
Management of cord prolapse
- Woman moved into knees to chest position
- Hand placed in vagina to lift presenting part off cord
- Tocolytic
- Immediate delivery by C-section or instrumental delivery
277
Prevalence of APH
3-5%
278
Grading of placenta previa
1) Enroaches the lower uterine segment
2) Reaches the internal os
3) Covers part of the internal os
4) Completely covers internal os
279
Delivery in placenta previa
Elective C-section at 38-39 weeks recommended in placentas <2cm away from the internal os
280
Clinical features of placenta previa
- Vaginal bleeding
- PAINLESS
- Soft uterus
- Presenting foetal part is free and foetal heartbeat usually present
281
Clinical features of placental abruption
- Vaginal bleeding
- PAINFUL
- Hard, tender uterus
- Contractions
- Foetal heartbeat may be absent
- Suspicious/pathological CTG
282
Management of APH
Minor haemorrhage with soft uterus and normal CTG:
- US scan for placental site
- Speculum examination (CI in placenta previa)
- Admission to hospital until bleeding stops
- Anti-D prophylaxis
- Delivery by C-section: placenta previa in 37+ weeks gestation
Minor/major haemorrhage with a hard tender uterus:
- Maternal resus
- Assessment of foetal condition with CTG
- Prompt delivery
Haemorrhage requiring maternal resus:
- Prompt delivery
283
Causes of intrapartum haemorrhage
- Placental abruption
- Placenta previa
- Uterine rupture
- Vasa previa
284
Define a primary PPH
Blood loss >500ml within 24 hours of delivery
285
Define a secondary PPH
Any significant blood loss between 24 hours and 12 weeks postpartum
286
Risk factors for PPH
- 4+ deliveries
- Age >35
- BMI >35
- Multiple pregnancy
- Fibroids
- Placenta previa
- Long labour
- Instrumental delivery
- Previous PPH or APH
287
Causes of primary PPH
- Uterine atony/poor contractility
- Trauma
- Coagulopathy e.g. DIC
- Retained placental tissue
288
Management of primary PPH
- IM Oxytocin in 3rd stage
- Reassurance
- 2222 call
- Estimation of blood loss
- Measure pulse and BP
- Assess size and tone of uterus
- Abdominal massage/bimanual compression
- IV access with 2 widebore cannulas
- Take FBC, clotting and cross-match
- IV bolus of Syntocinon followed by infusion
- IV fluids stat
- Insertion of urinary catheter
- Encourage delivery of placenta with cord traction
- Arterial line insertion
- Blood transfusion +/- FFP +/- cryoprecipitate
- 1g IV tranexamic acid
- Brace suture
- Intrauterine balloon insertion
- Internal iliac artery ligation
- Hysterectomy
289
Causes of secondary PPH
- Endometritis
- Retained products of conception
- Trophoblastic disease
290
Assessment in secondary PPH
- Pulse, BP, temp
- Uterine palpation
- Endocervical and vaginal swabs for culture
- US scan
291
Management of secondary PPH
- Antibiotics
| - Evacuation of retained products with fingers (in first week) or instrumentation
292
Causes of prolapse
- Childbirth, especially prolonged second stage of labour with a large baby and instrumental delivery
- Chronic constipation
- menopause
- Gynae surgery
- Genetic factors
293
Clinical features of prolapse
- Asymptomatic
- Discomfort
- Dragging sensation
- Feeling a lump
- Coital problems
- Vaginal bleeding or discharge
- Associated urinary problems: stress incontinence, poor bladder emptying, urinary frequency, UTI
- Associated bowel problems: pressure, backache, difficulty emptying bowels
294
Staging of prolapse
0) none
1) Most distal part is more than 1 cm above hymen
2) Most distal part is 1cm or less proximal or distal to hymen
3) Most distal part is more than 1cm below hymen but protrudes no further than 2cm less than total vaginal length
4) Complete eversion of total length of lower genital tract
295
Management of prolapse
- No treatment
- Lifestyle advice: smoking cessation, weight reduction, fluid and dietary advice
- Pelvic floor exercises
- Vaginal pessaries changed every 4-6 months
- Vaginal oestrogen
- Surgery: pelvic floor repair e.g. colporrhaphy, vaginal hysterectomy
296
Side effects of pessaries
- Urinary symptoms
- Vaginal discharge
- Bleeding
- Fistula formation (rare)
297
Side effects of pelvic floor repair
- Infection
- Bleeding
- Organ damage
- Chronic pain
- Vaginal scarring
- Prolapse recurrence
298
Risk factors for stillbirth
- Maternal age
- Obesity
- Social deprivation
- Smoking
- Non-white ethnicity
- Domestic violence
299
Causes of stillbirth
- Lethal congenital anomaly
- FGR
- Infection
- Anaemia
- Fetomaternal haemorrhage
- Twin to twin transfusion syndrome
- Cord obstruction
- Maternal metabolic disturbance
- Reduced maternal oxygen states e.g. CF
- Maternal antibody production e.g. rhesus disease
- Diabetes
- Preeclampsia
- Antiphospholipid syndrome
- Thrombophilia
- Smoking
- Cocaine
- Uterine abnormality
- Uterine rupture
- Placenta previa
- Vasa previa
- Intrapartum asphyxia
300
Clinical features of stillbirth
- Reduced foetal movements
- Vaginal bleeding
- Abdo pain
301
Management of stillbirth
- Offer to call someone to support the mother
- Assessment for underlying conditions that might threaten maternal wellbeing
- Vaginal birth via IOL
- Psychological support
- Suppression of lactation with dopamine agonists
302
Investigations that can be done to investigate the cause of stillbirth
- Haematology and biochemistry
- Coagulation studies
- Kleihauer test
- Bacteriology
- Serology
- Random blood glucose, HbA1c
- TFTs
- Anti red cell antibody
- Parental karyotype
- Foetal and placental microbiology
- Foetal and placenta karyotype
- Postmortem
303
Stillbirths must be registered within 21 days (T/F)
True
304
Causes of neonatal death
- Complications after birth
- Congenital anomalies
- Premature birth and complications
- Infection
- Complications pre-labour
- Intrapartum complications
- Placental issues
305
Criteria for a legal abortion in the first 24 weeks of pregnancy in the UK
- Treatment must be carried out in a hospital/licensed clinic
- Two doctors must agree that abortion would cause less risk to a woman's health than continuing with the pregnancy, meeting one of the following 5 reasons:
a) continuance of the pregnancy would involve risk to the life of the pregnant women
b) termination is necessary to prevent grave permanent injury to the physical or mental health of the woman
c) continuance of the pregnancy would involve risk of injury to the physical or mental health of the woman
d) continuance of the pregnancy would involve risk of injury to the physical or mental health of any existing children of the family of the woman
e) substantial risk that the child would be born with physical or mental abnormalities which would render it seriously handicapped
306
Criteria for legal abortion over 24 weeks gestation in UK
Only one doctor needs to consent to an abortion in an emergency
- Necessary to save woman's life
- To prevent grave permanent injury to the physical or mental health of the pregnant woman
- Substantial risk that the child would be born with serious physical or mental disabilities
307
Medical management of a miscarriage
1) Oral mifepristone +/- antibiotic prophylaxis
2) Vaginal/buccal/sublingual misoprostol 1-2 days later
- Can be taken at same time as mifepristone in <9+1 weeks
- Can be taken at home in <10+1 weeks
- Needs to be taken in hospital if >10+0 weeks, age <16, needs a translator, lives a long way from home, hyperemesis
308
Side effects of mifepristone
- Nausea
- Vomiting
- Diarrhoea
309
Side effects of misoprostol
- Bleeding
- Cramping
- Passage of blood clots
310
Advantages of medical management of TOP
- Can be used at any gestation
- Avoidance of surgery
- Can go home same day
311
Disadvantages/complications of medical management of TOP
- Woman is awake and aware of process
- May see pregnancy pass
- Bleeding
- Infection
- RPOC
- Failure of abortion (<1 in 100)
- Need for second procedure (<5 in 100)
- Uterine rupture (<1 in 1000)
312
Surgical management of TOP
- Misoprostol 1-3 hours before operation
| - Insertion of suction tube/vacuum aspiration into uterus under GA
313
Benefits of surgical management of TOP
- Avoids seeing pregnancy pass
314
Disadvantages of surgical management of TOP
- Can only be done up to 14 weeks gestation
- Needs accompanying adult if sedation/anaesthetic used
- Inpatient stay may be necessary
- Severe bleeding
- Infection/sepsis
- RPOC
- Failure of abortion (<1 in 100)
- Need for second procedure (<5 in 100)
- Uterine perforation (<1 in 1000)
- Cervical trauma (rare)
315
Clinical features of urethral caruncle
- Commonly seen after menopause
- Asymptomatic
- Dysuria
- Frequency
- Urgency
- Focal tenderness
- Soft, red, smooth tissue
316
Clinical features of Bartholin's cyst
- Tense, retention cyst in the lower third of the labia majora
317
Management of Bartholin's cyst
Marsupilisation
| balloon catheterisation is a non-surgical alternative
318
Clinical features of lichen sclerosus
- More common in older women
- Associated with other autoimmune disease
- Itch
- Dyspaurenia and pain
- Skin appears white, thin and crinkly or thickened and keratotic
- Clitoral and labial atrophy
319
Diagnosis of lichen sclerosus
- Usually clinical
| - Can be confirmed on biopsy
320
Management of lichen sclerosus
- Potent topical corticosteroids e.g. dermovate reducing to a milder preparation +/- emollient
- Avoidance of soaps, perfumed products or washing powder,
321
Management of VIN
- Surgical excision with clear margins
- Imiquimod
- Laser ablation
- Close follow up
322
Risk factors for stress incontinence
- Pregnancy and vaginal delivery
- Prolapse
- Menopause
- Collagen disorders
- Obesity
323
Risk factors for overactive bladder
- Neurological conditions
| - Psychological conditions
324
Clinical features of stress incontinence
- Involuntary loss of small amounts of urine on effort or physical exertion in the absence of detrusor contraction
- No urgency, frequency or nocturia
- Able to reach the toilet in time
325
Clinical features of overactive bladder
- Sudden compelling desire to pass urine which is difficult to defer
- No leakage during physical activity
- Large amounts of urine leakage
- Often can't reach the toilet in time
- Day time frequency and nocturia
- Enuresis
326
Risk factors for voiding difficulties
- Previous surgery
- Ageing
- Pregnancy
- Childbirth
- Neurological disease
327
Clinical features of incontinence
- Frequency
- Urgency
- Nocturia
- Incontinence on exertion or constant urinary leakage
- Hesitancy
- Straining to avoid
- Poor or intermittent urinary stream
- Post-micturition dribbling
- Sensation of incomplete emptying
- Prolapse symptoms
- Associated bowel symptoms
328
Red flag symptoms in urinary incontinence
- Haematuria
- Persistent bladder or urethral pain
- Recurrent UTI
329
Investigations for women with urinary incontinence
- Urinalysis
- Frequency-volume chart/bladder diary
- Urodynamic studies
- Post-void residual volume US
- QOL questionnaires
- Cystoscopy and upper renal tract US
330
Management of stress incontinence
1) Pelvic floor exercises for at least 3 months
2) Duloxetine +/- vaginal oestrogen
3) Mid-urethral sling OR colposuspension OR autologous fascial sling OR bladder neck injection
331
Management of an overactive bladder
1) Lifestyle advice
2) Bladder retraining
3) Anticholinergics
4) Beta 3 agonists
5) Intravesical botox injection OR sacral nerve root stimulation
332
Management of voiding difficulties
Clean intermittent self-catheterisation OR indwelling catheter
333
Management of a GU fistula
- Contrast studies
- Indwelling catheter
- Surgery
334
Prevalence of preterm birth
10%
335
Risk factors for preterm labour
- Previous preterm labour
- BMI <18
- Low social class
- Lack of support
- Afro-Caribbean
- Extremes of reproductive age
- Smoking
- BV
- Chronic medical conditions
- Multiple pregnancy
- Bleeding in 1st or 2nd trimester
- APH
- FGR
- Placenta previa
- Intrauterine infection
- PPROM
- Congenital foetal anomaly
- Polyhydramnios
- Congenital uterine anomaly
- Preeclampsia
- UTI and asymptomatic bacteriuria
- Physiological stress e.g. domestic violence
336
Causes of preterm labour
- Infection
- Uteroplacental ischaemic e.g. abruption
- Uterine overdistention
- Cervical incompetence
- Foetal anomaly
- PPROM
- Iatrogenic
337
Investigations in suspected preterm labour
- Haemodynamic assessment
- Assessment for precipitants e.g. bloods, MSU, high vaginal and endocervical swabs
- VE
- Foetal monitoring with CTG
- US scan
- TVUS to examine cervical length
- Maternal cervical secretion fibronectin levels
- Clinical risk scoring based on risk factors
338
Management in preterm labour
- Close monitoring of foetus
- Maternal IM corticosteroid injections (CI in active sepsis)
- Antibiotics as indicated: 10 days of PO erythromycin following PPROM, intrapartum penicillin/clindamycin in GBS
- IV Mag sulphate
- IV beta-agonists
339
Side effects of IV magnesium sulphate
- Blurred vision
- Loss of tendon reflexes
- Arrhythmias
- Reduced foetal HR variability
- Hypotonia
- Neonatal respiratory depression
- Perinatal mortality
340
Complications of preterm labour
- Risk of recurrence in future pregnancies
- Perinatal mortality
- Intrapartum complications e.g. abnormal lie, cord prolapse, abruption, infection
- CP
- Chronic lung disease
- Visual and hearing difficulties
- Learning difficulties
341
Prevalence of PPROM
2-3%
342
Risk factors for PPROM
- Polyhydramnios
- Multiple pregnancy
- Vaginal infection
343
Complications of PPROm
- Secondary pulmonary hypoplasia
- Severe skeletal deformities
- Preterm delivery
- Intrauterine infection/chorioamnionitis
- Cord prolapse
344
Clinical features of chorioamnionitis
- Maternal pyrexia
- Maternal and foetal tachycardia
- Abdo pain
- Uterine tenderness
- Offensive smelling liquor
- Raised inflammatory markers
345
Management of PPROM
- Regular foetal monitoring
- Advise to report if feeling unwell or pyrexia detected
- Aim for delivery around 34-36 weeks
- Corticosteroids and Antibiotics if PPROm occurs <35 weeks
346
Risk factors for cervical cancer
- Young age at first sexual intercourse
- High number of sexual partners
- Smoking
- HPV
- Lower SES
- Partner with prostate or penile cancer
347
Most common type of cervical cancer
Squamous cell carcinoma
348
Clinical features of cervical cancer
- Postcoital/intermenstrual/postmenopausal bleeding
| - Offensive vaginal discharge
349
Investigations for cervical cancer
- Smear
- Colposcopy
- Cone biopsy
- CXR
- IV urogram
- Cystoscopy and sigmoidoscopy or MRI
350
Indications for colopscopy
- 3 unsatisfactory smears
- 2 borderlines or 2 mild dyskaryosis
- One moderate or severe dyskaryosis
- Clinical suspicion of cancer
- Glandular smear
351
Red flag features at colposcopy
- Intense acetowhite staining or pale iodine staining
- Mosaicism and punctuation
- Raised or ulcerated surface
352
Management of CIN
- LLETZ with local anaesthetic
- Needle excision of transformation zone
- Cone biopsy
- Follow up with a smear test and HPV screen in 6 months as proof of cure - if this is negative they can return to routine screening, if it is positive they should have a repeat colposcopy
353
Management of cervical cancer
Stage I:
- Extended hysterectomy or radical trachelectomy
Stage II:
- Radiotherapy and chemotherapy
Stage III or IV: radical radiotherapy and chemotherapy
354
Screening for cervical cancer
- Smears every 3 years from 25-64
| - Every 5 years from 65 over
355
Risk factors for endometrial cancer
- Age
- Obesity
- Nulliparity
- Late menopause/early menarche
- PCOS
- Unopposed oestrogen HRT
- Tamoxifen
- Diabetes
- Personal or family history of breast or colon cancer
356
Cancer type of endometrial cancer
Adenocarcinoma
357
Clinical features of endometrial cancer
- PMB
- Pain
- Vaginal discharge
358
Investigation for endometrial cancer
- TVUS
- Pipelle biopsy
- Hysteroscopy and biopsy
- MRI for staging
359
Management of endometrial cancer
Stage I:
- TAHBSO +/- radiotherapy
Stage II:
- TAHBSO + radiotherapy
Stage III:
- Debulking surgery + radiotherapy
Stage IV:
- Palliative care
360
Risk factors for ovarian cancer
- Nulliparity
- Treatment with ovulation-induction drugs
- Caucasian
- Blood group A
- higher SES
- Late age at first conception
- Family history
361
Protective factors for ovarian cancer
- Multiparity
- COCP
- Black/Asian
- Blood group O
362
Clinical features of ovarian cancer
- Abdominal pain
- Abdominal distention
- Urinary frequency
- GI upset
363
Investigation of ovarian cancer
- US (+ liver US if cancer suspected to look for mets)
| - Ca125
364
Ovarian risk of malignancy index features
- US appearance
- Ca125
- Menopausal status
365
Red flag signs for ovarian cancer on US
- Solid mass or cyst containing septae
- Mass >5cm
- Presence of ascites
- Bilateral tumours
366
Causes of a raised Ca125
- Ovarian cancer
- Fibroids
- Diverticular disease
- Pregnancy
367
Management of ovarian cancer
Stage I:
- Surgery
Stage II and III:
- Surgery + chemotherapy (cyclopshophamide + carboplatin)
Stage IV:
- Palliative care
368
Side effects of chemotherapy for ovarian cancer
- Myelosuppression
- GI upset
- Peripheral neuropathy
- Alopecia
- Renal toxicity
- Ototoxicity
- Eye toxicity
369
Risk factors for vaginal tumours
- CIN
- HPV
- History of a gynae malignancy
370
Clinical features of a vaginal cancer
Abnormal bleeding
371
Investigation of vaginal tumours
- Biopsy
- Exploration under anaesthetic
- Bladder/rectum assessment (at surgery or on MRI
- CXR
372
Management of vaginal cancer
- External beam and intravaginal radiotherapy
373
Risk factors for vulval tumours
- Age
- Smoking
- Immunosuppression
- Vulvar mutation disorders e.g. lichen sclerosus
- History of CIN, VIN or HPV
374
Clinical features of a vulval carcinoma
- Pruritus
- Lump/ulcer on vulva
- Bleeding
- Pain
- Urinary symptoms
- Unusual discharge
375
Investigations for vulval cancer
- Biopsy
- CT/MRI
- Examination under anaesthesia
376
Management of vulval cancer
Microinvasive disease:
- Cone biopsy
- TAH
Early stage:
- Radical hysterectomy + pelvic lymphadenectomy +/- radical radiotherapy
OR radical radiotherapy alone
Stage IIb to IVa:
- Radical radiotherapy
Distant metasasis:
- Palliative care
