obs and gynae Flashcards

Question

Types of miscarriage and management Most common cause - chromosomal abnormalities Investigate recurrent miscarriages if >3 in a row - antiphospholipid syndrome - anti-cardiolipin

Answer 1

Is a miscarriage if loss of pregnancy before 24 weeks Threatened - PV bleeding but baby alive, closed cervix Inevitable - baby alive or dead, more blood, open cervix, pain common Missed - cervix closed, often no blood or pain, baby dead (no heart beat) Incomplete - cervix open, some products of conception remaining, PV blood, pain - remove with sponge forceps Complete - Cervix closed, bleeding/ pain settled, empty uterus Investigations - speculum and pelvic exam - TVUS to identify heartbeat/ foetal pole, if not there repeat in 7-14d, if still not present = miscarriage - serial hcg to see if cont pregnancy, >63 rise ongoing pregnancy = ectopic, >50 fall failed pregnancy = miscarriage - progesterone - confirm failed pregnancy if low - if bleeding heavily go to hosp for FBC, U&E, crossmatch, GC&S, coag, rhesus d Treatment: If threatened, mother wants pregnancy start on progesterone 400mg BD if bleeding and had previous miscarriage - reduces rate of miscarriage 1st line: expectant (trialed for 7-14 days for missed/ incomplete) - do if stable, bleeding light - let occur naturally, take 2-8 week, repeat pregnancy test at 3w to check for retained products For incomplete/ missed: medical - < 12w - give PV or PO misoprostol, pain relief and anti-emetic as needed, - >12w give PO mifepristone + PV misoprostol - repeat pregnancy test in 3w - speeds up process Surgical - Do if haemorrhage, unstable, persistent bleeding/pain, trophoblastic disease, infection - manual vacuum aspiration under LA or surgical curettage under GA, less pain and blood loss, give anti-D - Psychosocial wellbeing

Answer 2

Headaches, vomiting, constipation and heartburn due to progesterone, swelling, carpal tunnel, tiredness, increased frequency of urination due to pressure effects, breast tenderness, foetal movements, backache, symphysis pubis dysfunction and pain, varicose veins, vaginal discharge, haemorrhoids in 3rd trimester

Answer 3

normal - 400mcg folic acid from preconception to 12w high risk - 5mg folic acid from preconception to 12w vit D 400 IU OD throughout Avoid excessive vit A Those at risk of pre-eclampsia take aspirin from 12w onwards

Answer 4

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

Answer 5

- Wrong dates - Oligohydraminos - IUGR, SGA - Presenting part deep in the pelvis - Abnormal lie of the fetus

Answer 6

2 years of amenorrhoea if <50, 1 year if >50

Answer 7

Occurs after 20w Raised BP >140/90 plus either proteinuria >0.3g/24hr/ 2+ / ACR >8, protein creatinine ratio (PCR) > 30, maternal organ dysfunction or uteroplacental dysfunction severe if BP >160/110 <34w = early onset >34w = late onset Present with headache, visual disturbance, sudden swelling of hands/feet/face, severe abdo pain and vomiting. Also clonus, foetal distress, altered mental status, hyperreflexia Investigations - bedside do BP, urine dipstick + culture, ACR, vitals - FBC (HELLP - low platelets), U+E, LFT, Coag, urate (indicates worsening disease) - USS to assess foetal development - umbilical artery doppler, CTG - MRI/CT if suspect intracranial haemorrhage monitoring mild - bp 4x daily, bloods 2x weekly, US every 2w mod - same but 3x weekly bloods severe - bp > 4x daily, 3x weekly bloods, US every 2w Management If high risk: - prevention = 75mg aspirin OD from 12w to birth - consultant led care - healthy lifestyle advice Severe = DBP of at least 110 or SBP of at least 160, and/or symptoms, and/or biochemical and/or haematological impairment Mild - (140/90 - 150/100) manage conservatively until 34w, give antihypertensive to keep BP <140/90 - Labetalol first line, nifedipine 2nd, methyldopa 3rd. Home BP monitoring every 2 days, bloods every 2w Severe (>160/110) - antihypertensives (as above, in very severe consider hydralazine) - Consider additional corticosteroids - monitor BP every 15 mins until <160/110 then 4x daily, bloods 3x weekly - magnesium sulphate if seizure or high risk of seizure (also give prior to delivery) - fluid restriction to reduce oedema (1ml/kg/hr) Delivery: 34-36w if high risk - cant control BP, HELLP, O2 < 90%, neuro sx, placental abruption or worrying CTG. Give mg sulphate and corticosteroids 37w if low risk - induce within 24-48 hours During delivery - constant BP and CTG, consider VTE prophylaxis and in 3rd stage give 5units syntocinon ``` Post birth: Keep in as risk of eclamptic seizures Monitor bloods at 48-72 hrs Monitor BP every 1-2 days for 2 weeks Do urine dip at 6w Lower antihypertensives to match drop in BP 1st line post pregnancy = enalapril ```

Answer 8

Defined as severe N+V in combination with dehydration, electrolyte imbalance, 5% pre-pregnancy weight loss Usually starts at 4-7w, peak at 9w, gone by 16-20w Investigations - Obs, BM, urine dip for ketones, MSU, examine for dehydration - FBC, U&E (low K+), LFT, amylase, TFT, bone profile, Mg - US - identify multiple pregnancy or trophoblastic disease Risk stratify with PUQE-24 - how long felt sick, how many times been sick, how many times dry heaved - low 3-12 -> outpatient - med >12 -> ambulatory care - high (failed amb care, cant keep down liquids, weight loss/ketonuria despite oral therapies, complications) -> inpatient Management - outpatient -> oral antiemetics, rehydration, healthy diet - amb care -> IV antiemetics, IV fluids +K, pabrinex, psychosocial support - inpatient -> same as amb care + LMWH. severe cases termination Antiemetic - 1st line = cyclizine, prochlorperazine, chlorpromazine - 2nd line = metoclopramide, domperidone - 3rd line = corticosteroids (IV hydro then oral pred)

Answer 9

It is the occurrence of a tonic clonic seizure superimposed on a diagnosis of pre-eclampsia 24 hours post birth most common period for seizure, can be up to 6w Presents with - tonic clonic seizure - Epigastric or RUQ pain - N+V - Tea coloured urine due to haemolysis - Headache, oedema, hyper-reflexia etc Investigations: - rule out hellp, DIC with FBC, LFT - do BM for hypoglycaemia - do U&E, coag - check on baby with abdo US and CTG - rule out neuro if suspected using MRI/CT Management - AtoE - lie in left lat, secure airway, IV access - Mg sulfate - 4g over 5-15mins, then 1g/hr for 24hr. if more fits give 2g bolus. 2nd line diazepam - control BP - IV labetalol or hydralazine - reduce oedema with fluid restriction - monitor obs every 15min, urine 60min, CTG continuous - deliver once mother stable

Answer 10

Presentation - facial features - small eyeballs, flat groove under nose, thin upper lip, cleft lip/palate, post rotation of ears - learning disabilities, cognitive impairment, behavioural issues - IUGR facial features improve into adulthood but have short stature, microcephaly and learning issues

Answer 11

What know about types of contraception What do you already know about the pill Do you have any concerns about taking the pill What are you hoping the pill will do for you There are 3 main types of pill - monophasic - all same lvl hormone, 21d, 7d break - phasic - different hormone lvl, have to take in order 21d, 7d break - everyday pill - 21 normal pill, 7 placebo - take continuously everyday oestrogen and progesterone Works to prevent ovulation, thicken cervical mucus, thin endometrium to prevent implantation 99% effective at perfect use, may be less than this if not take at same time every day or miss days Pros - can improve acne - can reduce PMS - can reduce bleeding/ menorrhagia - not as strict as POP - non-invasive - effective - can control timings of periods - do up to 3 packs back to back - reduce ovarian, uterine, colon cancer risk Cons - headache, nausea, mood changes, breast tenderness - breakthrough bleeding in first few months - need to remember to take each day - not protect from STI - increase risk of vte, breast, cervical cancer - increase risk of cholestasis in PBC, cervical ectropion Cannot take if - pregnant - >35 and smoke - BMI > 35 - migraine with aura - fix of breast cancer - vte risk factors Can start at any point during period - if start day 1-5, is effective immediately, if start other times need 7 day barrier take for 21 days then 7 day break or can take for 3x21 then break if miss a pill take asap even if means taking 2 in one day. If miss 2 days then need 7 day barrier, if had sex in last 7 days need emergency contraception if miss 2 pill and >7 left in pack cont then break as normal if miss 2 pill and <7 then go straight to next pack and dont break If sick within 2 hours of taking take another if feeling better If severe diarrhoea >24hrs take pill as though missed one Epilepsy meds, HIV meds and St Johns wart can reduce the efficacy of the pill If want to become pregnant stop taking the pill and wait until after their first natural period to begin trying and start folic acid 400mcg, stop smoking Any Q's Give website link/ leaflet encourage use of condoms

Answer 12

Can abort up to 24w if - Reduces risk to M life - Reduces risk M physical or mental health - Reduces risk to physical or mental health of her existing children - Baby at risk of being physically or mentally handicapped Can abort after 24w if - Risk to the M life - Risk of grave, permanent injury to M physical/mental health - Substantial risk that, if the child were born, it would have such physical or mental abnormalities as to be seriously handicapped Ix: - pregnancy test to confirm - US if suspect ectopic - STI especially chlamydia - Contraceptive counselling - Rhesus status - VTE risk - Smear test if not had Surgical - antibiotic prophylaxis with 1g metro then 100mg doxy BD for 7d - Anti D, LMWH if needed - up to 14 w - vacuum aspiration LA or GA - after 14-24w - dilation and evacuation with forceps, sedation or GA Medical - Anti-D only if after 10w - NSAID pain relief if needed - use pads nor tampon for blood - <9w - 200mg PO mifepristone then 800mcg buccal/lingual/vaginal misoprostol after 24-48hrs - 9-24w - 200mg PO mifepristone then 800mcg buccal/lingual/vaginal misoprostol after 36-48hrs, additional 400mcg misoprostol can be given up to 4x sx: headache, nausea, sweating, diarrhoea, pain, cramp Advise to re-perform pregnancy test after 4w - if still positive may be incomplete TOP or persistent trophoblastic pregnancy

Answer 13

Any level of glucose intolerance with first onset in gestation Often asymptomatic may have polyuria, polydipsia, fatigue Diagnosis: Fasting > 5.6 Two-hour 75g OGTT > 7.8 Also do HbA1c at time of diagnosis to identify if pre-existing diabetes Management Monitoring - Fetal growth scan every 4w from 28-36w - Also check amniotic fluid volume Complications - macrosomia - preterm - organomegaly, polycythemia - Polyhydramnios - neonatal hypoglycaemia - NRDS Management - 1st line lifestyle + monitor BMs - 2nd line metformin if lifestyle not effective within 1-2w - 3rd line or if >7 fasting or 6-6.9 with complication - Insulin basal + bolus. Council for hypo, what to do if not eat/ vomit. - 4 weekly growth scans For insulin aim for 5.3 fasting, 7.8 1hr post, 6.4 2hr post Measure BM pre meal fasting, 1 hr post meal and bedtime Birth: - 40+6 - induce or caesarean beyond this - if type 1 or complications aim 37-38w birth - During labour monitor BMs hourly, if 2x raised then put on sliding scale Post birth: - Monitor babys BMs - stop all meds - if macrosomia give prophylactic oxytocin to prevent uterine atony Do fasting glucose at 6-13 weeks <6 - lifestlyle 6-6.9 - high risk, preventative measures >7 - repeat test for diagnosis Yearly HbA1c

Answer 14

Screen at 24-28w - BMI >30 - Previous macrosomic baby ≥4.5kg or more - Previous GDM - First-degree relative with diabetes - Family origin – S Asian, black and Middle Eastern

Answer 15

Increases risk of postnatal depression

Answer 16

Placental growth factor (PIGF) testing

Answer 17

<110g/L at booking <105g/L in the second and third trimester <100g/L postpartum

Answer 18

IDA | Treat with 100-200mg iron daily + increase dietary Vit C

Answer 19

``` Folate deficiency 400mcg/day from pre-conception for all 5mg/day from pre-conception if high risk o On anticonvulsants o Previous child affected with a neural tube defect o With demonstrated deficiency o With diabetes o With a BMI >30 o With sickle cell disease ```

Answer 20

1st line conservative 2nd alginates and antacids 3rd ranitidine or omeprazole

Answer 21

Presents in late 2nd or 3rd trimester with pruritus and excoriation particularly on palms and soles. Have elevated LFTs, bile acids and sometimes bilirubin. May develop pale stools/dark urine/jaundice and RUQ pain. Increases risk of foetal distress, preterm birth and stillbirth Investigations: - bile acid levels - weekly LFTs - cholestatic picture - Abdominal US to exclude other causes - rule out pre-eclampsia Management - Ursodeoxycholic acid but no improvement in foetal outcomes - cholestyramine or rifampicin if refractory - Vit K if prolonged PT or steatorrhoea Birth - if very high bile acid lvls consider birth before 37w due to high risk of stillbirth, induce - if normal or slightly elevated then deliver between 37-40

Answer 22

Investigations - AtoE - compression doppler for DVT - CXR for PE, V/Q mismatch or CTPA if -ve - FBC, U&E, LFT, Coag Management - Massive PE: AtoE, IV unfractionated heparin 5000IU bolus then 1000-2000/hr. monitor APTT from 6hrs post bolus. If repeated consider caval filter. If life/ limb threatening consider surgical embolectomy, thrombolytic therapy - Non massive PE: 1.5mg/kg OD LMWH (clexane) - DVT: LMWH, elevate leg, compression stockings, mobilise - Maintenance: LMWH subcut as outpatient - Labour: let ward take over, switch to unfractionated heparin. Can induce/ cesarean 12 hr post stopping LMWH prophylactic dose, 24 post therapeutic dose - Post birth cont. for 6-12 w with LMWH or Warfarin then reassess

Answer 23

carbamazepine and lamotrigine for breastfeeding can use any apart from barbiturates

Answer 24

artificially rupture membranes and give syntocinon

Answer 25

= bleeding between 24w and term minor <50 major 50-1000, no shock massive >1000 or shock Investigations - Obs to look for shock - bloods to assess blood loss etc. FBC, G&S, crossmatch, LFT, U&Em COAG - US look for placenta previa/abruption/ vasa praevia (associated with waters breaking = vasa praevia) - speculum exam to look for external causes of bleeding - Swabs for infection - assess foetus with us or ctg Treatment - minor, no foetal issues then discharge - major or some sign of foetal distress admit for 24hrs and monitor - if unstable consider c-section, stable induction - massive - AtoE, cannula, fluid resus, bloods (G&S, crossmatch), blood products, CTG, escalate. If M/Baby unstable consider caesarean, if stable consider induction. If before 34+6 give steroids. Do active 3rd stage and continuous ctg For all assess rhesus -ve and give anti d within 72hrs

Answer 26

Present with triad of membrane rupture, painless bleeding and foetal bradycardia Treat with emergency c-section - due to risk of foetal compromise

Answer 27

Placenta praevia

Answer 28

minor - close to os major - covering os investigations - abdo US, confirm with TVUS - bloods - FBC, U&E, LFT, G&S, crossmatch - Maternal obs - Speculum - look for external causes of bleeding - CTG once mother stable - rhesus status - high vaginal swabs for infection Present with painless bleeding - fresh red blood Management - usually identified at 20w scan. minor repeat at 36w, major at 32 Grade 1 - encroaches on OS but not reach it Grade 2 - reaches but not cover OS Grade 3 - partially covers OS Grade 4 - completely covers OS AtoE Resus, wide bore cannula, blood products, fluids Anti D if needed If major or massive bleed consider emergency c-section - steroids if 34-35+6w CTG once mother stable Grade 1 - consider vaginal birth Grade 2 - clinicians assessment Grade 3/4 - elective cesarian at 38w Minor - Scan at 36w. if >2cm from os vaginal, if <2cm then c-section Major - admit to hosp from 34w onwards if had bleed - US to confirm at 32w - always do c-section. Aim for 38w or 36-37 if accreta - no penetrative sex

Answer 29

accreta - just into myometrium increta - deep into myometrium/ serosa percreta - through peritoneum Main risk factors are previous c-section and placenta praevia. Also increasing maternal age, IVF, fibroids Diagnosis - trans abdo US - confirm depth with MRI - often not know full extent until surgery Management - AtoE and resus for any bleeding - aim for birth at 35-37 weeks via c-section - Post birth either deal with placenta conservatively and leave to pass with or without UAE, iliac vessel ligation or methotrexate (no evidence). Or perform elective hysterectomy - if partial loss off placenta after conservative management can consider partial myomectomy

Answer 30

2 types: Revealed - blood tracks down between membranes and presents as sudden onset painful PV bleeding Concealed - blood trapped between myometrium and placenta, presents as pain and shock Uterus tense, hard, tender and painful on exam Often in labour with contractions Dark, red blood Investigations - clinical diagnosis - can do TVUS to rule out praevia - normal in abruption - FBC, U&E, LFT, Kleihauer, clotting, G&S, crossmatch - speculum and PV - CTG - uterine artery doppler - high vaginal swabs if bleeding minimal Management Acute bleed - AtoE, left lateral position, O2, IV access, G&S, crossmatch, resus with bloods or Hartmans, anti D If foetal distress on CTG - emergency c-section If no foetal distress and signif bleed <37w keep in for 24hr, do foetal growth scan As abruption increases risk of pre-term birth give steroids if before 35w If no foetal distress, >37w - induce labour with artificial membrane break and syntocinon if foetus dead induce vaginal delivery

Answer 31

Praevia - painless, fresh red, can see on US, no abdo tenderness Abruption - panful, dark red or no blood, cant see on US, hard woody uterus, very tender

Answer 32

Present with sudden onset tearing abdo pain, pain radiating to tip of shoulder, cessation of contractions, vaginal haemorrhage, tachycardia and shock Do US and CTG (fetal bradycardia) Manage by resus, uterine repair +/- c-section May need hysterectomy

Answer 33

18 weeks onwards, max at 32 Reduced if - foetal distress (hypoxia) - obesity - Posture - Distraction due to maternal stress - Oligo and polyhydramnios - Anterior placenta can reduce foetal movements - Alcohol and benzos - Anterior foetal position - SGA If past 28w 1st do foetal heartbeat using doppler - if no heartbeat do immediate US - if heartbeat do CTG for at least 20 mins to monitor HR - if still concerned despite normal CTG do US - assess abdo circumference, weight and look for poly/oligohydramnios

Answer 34

Fibroid degeneration

Answer 35

Both are the rupture of of membranes at least 1 hour before onset of labour PROM - >37w P-PROM - <37w - preterm labour is before 36+6 Risk factors = - Smoking (especially < 28 weeks gestation). - Previous PROM/ pre-term delivery. - Vaginal bleeding during pregnancy. - Lower genital tract infection. - Invasive procedures e.g. amniocentesis. - Polyhydramnios. - Multiple pregnancy. - Cervical insufficiency. Painless popping sensation following by a gush of fluid Investigate with speculum, get woman to lie down for 30 mins prior - look for pooling of amniotic fluid. Can ask to cough, might see fluid expelled. - do high vaginal swab, temp, FBC/CRP if suspect infection - Ferning or Nitrazine test - identify if amniotic fluid - US if doubt - CTG if foetal distress Do not do digital vaginal exam as can expedite labour and increase risk of infection Differentials = urinary incontinence, increased sweat and moisture, vesicovaginal fistula, loss of mucus plug Management - most spont start labour in 24-48hrs so admit to hosp If not: - <34w - monitor for chorioamnionitis, avoid sex, erythromycin, steroids, expectant management until 34w - 34-36 - monitor for signs of chorioamnionitis, avoid sexual intercourse, prophylactic erythromycin 250 mg QDS for 10 days, steroids if 34-34+6w, induction of labour - >36 - induce after 24-48hrs, monitor for signs of chorioamnionitis, clindamycin/penicillin during labour if GBS isolated Erythromycin prophylaxis for all between 24- 29+6 give IV mag sulph to prevent cerebral palsy Steroids given up to 33+6, consider up to 35+6 If chorioamnionitis detected give IV betamethasone, broad spectrum Abx e.g. benpen and deliver baby Complications - chorioamnionitis, Placental abruption Umbilical cord prolapse, Neonatal death, oligohydramnios (can cause lung hypoplasia)

Answer 36

Fever, malaise, abdo pain (tender on exam), purulent vaginal discharge, foetal tachycardia

Answer 37

= onset of contractions and cervical changes (effacement/dilation) of cervix before 37w RF: - Multiple pregnancy, infections, smoking, previous preterm, diabetes, placental dysfunction Increases risk of: PDA, NEC, NRDS, IVH, cerebral palsy, infection/ sepsis Ix - Make sure both contractions and cervical changes - Perform PV to examine for dilation and effacement of cervix - Speculum to look for membrane rupture, can also swab for STI and GBS screen, also perform fibronectin test - TVUS to assess placenta - Bloods for rhesus status and infection screen Management - Abx cover for GBS - Steroids if before 35+6 (dexamethasone) - give tocolysis (nifedipine) for 48hrs to allow steroids to work (only use if membrane intact) - IV mag sulphate to protect against cerebral palsy if <29+6 - cervical cerclage if 16-34w with dilated cervix and unruptured membrane Progesterone can be used to prevent preterm birth if prev late miscarriage or preterm or if low risk woman with shirt cervix.

Answer 38

>42w - induce at 41w

Answer 39

Reduces aorto-caval compression

Answer 40

4H's - hypoxia - hypo/hyperkalaemia - haemorrhage - hypothermia - + hypoglycaemia 4T's - Thromboembolism - Toxicity - mg, anaphylaxis, LA - Tension pneumothorax - Tamponade + in pregnancy - pre-eclampsia, intracranial haemorrhage Management A - secure immediately with intubation B - O2, bag and mask until intubated C - if no breathing start chest compressions, defibrillate as normal, insert 2x cannulas, adrenaline every 3-5mins Give fluid, blood products as needed Treat cause If no response with 4mins of CPR do emergency c-section whilst continuing resus

Answer 41

Reduction in progesterone -> increase in prostaglandins -> contractility -> oxytocin release get mucous plug/ bloody show, uterine contractions and spontaneous rupture of membranes

Answer 42

1st - latent - irregular contractions from 0cm dilated to 3/4 - active - regular contractions from 3/4cm to 10cm. aim for 0.5cm/hr in nulliparous, 1cm/hr in multiparous listen to babies heart for 1min every 15 If delay examine for problem, Amniotomy if not ruptured membranes, do Bishop score to identify obstruction, if none give oxytocin. 2nd - 10cm dilated to delivery - Delayed if last >2 hours in nulliparous or >1 in multiparous - consider amniotomy, oxytocin, instrumental or c-section listen to baby heart every 5min or after each contraction 3rd - delivery to passage of placenta and membranes - physiological/ expectant - aim for 1hr - active (syntocinon IM 10U, pull on cord) - aim for 30min

Answer 43

Massage, relaxation TENS machines - level can be increased throughout labour - feels like a tingling, numb sensation - have a boost button for extra painful periods Entonox - not for >24hrs - can feel dizzy or sick - are in full control, can decide to start and stop using at any point Opiates e.g. pethidine - only in early labour, can make feel sick, drowsy - given anti-emetic at same time Remifentanil - PCA, need to be on delivery suite with O2 sats and nasal specs Epidural - PCA, stops pain altogether, started during active 1st stage, topped up every 2hrs. can drop BP so insert cannula. Requires constant foetal monitoring every 30 mins

Answer 44

Foetal heart rate - every 15 mins for 1min from 3-10cm - every contraction or 5 mins (whichever most frequent) when fully dilated Maternal BP and HR every 2 hours , temp 4hrly Do urinalysis on admission Contractions every 30 mins (record rate in number per 10 mins, strength /10, regularity) - If not happy with contractions give and record oxytocin PV exam every 4 hours, hourly once fully dilated – dilation of cervix and descent of head with 0 being level with ischial spines Assess moulding (growth plates of scalp), liquor (amniotic membrane) in tact (I), clear (C) or stained with meconium (M) or blood (B) Drugs and fluid given should be recorded

Answer 45

Increases risk of instrumental or c-section delivery through false positives no improvement in maternal or foetal outcomes

Answer 46

DR C BRAVADO 1. define risk 2. contraction regularity, length, intensity 3. base heart rate (normal = 110-160) 4. variability 5. accelerations >15bpm increase for >15s 6. decelerations >15bpm decrease for >15s 7. opinion reassuring - hr, variability, acceleration, deacceleration normal suspicious - one non reassuring pathological - 2 or more reassuring, 1 or more abnormal

Answer 47

Hypoxia, anaemia, hyperthyroid, chorioamnionitis

Answer 48

Foetal acidosis (due to hypoxia), which can be assessed by a capillary blood sample for foetal scalp pH Foetal tachycardia Maternal drugs – opiates, benzodiazepines, magnesium sulphate, methyldopa Prematurity <28w – variability is reduced at earlier gestation Congenital heart abnormality

Answer 49

Early contraction- normal Variable - cord compression often if low amniotic fluid Late contraction - reduced utero-placental flow often indicate foetal hypoxia and acidosis Prolonged - >3min Sinusoidal - severe hypoxia, anaemia or maternal haemorrhage - emergency c-section

Answer 50

stimulation of contractions before spontaneous onset with or without a ruptured membrane Do CTG before inducing 3 methods: 1- prostaglandins (repeat every 24hrs) - gel/tablet - 1 dose, second at 6hrs - pessary - 1 dose over 24hrs 2 - amniotomy - use amnihook to rupture membranes - do bishops score to ensure cervix ripe beforehand - may give syntocinon alongside - often use if delay in active 1st stage labour 3- membrane sweep - cervix needs to slightly dilated to allow finger - run finger along membrane separating from decidua Bishops = 0-13 Bishops >8 - cervix ripe, spont labour likely Bishops <5 - labour unlikely to start without induction - includes cervical dilation length/ effacement, consistency, position, station If hyper stimulation of uterus causing foetal distress consider giving tocolytics e.g. terbutaline or nifedipine often more painful than spont labour, may need epidural

Answer 51

Amniotic fluid embolus

Answer 52

- prolonged 2nd stage - malpositioned baby - maternal conditions that cause exhaustion or reduce ability to push e.g. hypertension, - multiple pregnancies - foetal distress

Answer 53

- Maternal choice - foetal distress on doppler or CTG - placenta praevia - maternal emergency e.g. eclampsia, APH, collapse - Maternal disease that prohibits labour - Macrosomia in diabetic - previous 3rd or 4th degree tear - previous shoulder dystocia - foetal malposition - multiple pregnancies if first baby not cephalic - primary genital herpes or HIV in 3rd trimester aim for >39w

Answer 54

Previous uterine rupture Placenta praevia Classical vertical c-section scar

Answer 55

Overt - descent of cord in front of leading part of foetus Occult - descent of cord alongside leading part of foetus Funic - cord in between foetal descending part and chorionic membrane Risk of cord compression/ arterial vasospasm and foetal hypoxia Suspect if bradycardia/ variable decelerations on CTG and absent membranes Confirm with VE - poorly engaged or ill fitting presenting part, may feel pulsatile cord Management - place in left lat position with pillow under hip or knee chest position - lift foetal presenting part to relieve pressure on cord, or fill bladder with saline - give tocolysis to relieve contractions (terbutaline) if delivery not imminent - emergency c-section, vaginal if fully dilated and imminent

Answer 56

When babies head retracts back into the vagina, is a sign of shoulder dystocia

Answer 57

Advise woman to stop pushing, get help and avoid downward traction on babies head 1st line - McRoberts - hyper flex and abduct maternal hips and place pressure suprapubically 2nd line - consider episiotomy + - deliver post shoulder - Rubins - put pressure on post shoulder to ease passage of anterior - Wood's screw - rotate baby 180 degrees turning anterior shoulder to posterior position

Answer 58

1st - just perineal skin (vaginal mucosa) 2nd - perineal skin + muscle 3rd - external anal sphincter 4th - internal and external anal sphincter, rectal mucosa torn

Answer 59

if <36w leave, may turn on own If >36w nulliparous or >37w multiparous then offer ECV - turn baby externally - offer tocolytics e.g. salbutamol/ terbutaline - can make easier - dont do if APH in last 7 days, abnormal CTG, ruptured membrane or multiple pregnancy - can cause foetal bradycardia and placental abruption If unsuccessful - c-section - vaginal delivery

Answer 60

Tone - uterine atony - polyhydramnios, multiple pregnancy, macrosomia, multiparty, chorioamnionitis Trauma - tears, episiotomy, uterine rupture Thrombin - von willebrands, clotting issues e.g. haemophilia or HELLP/ DIC Tissue - retained placenta General exam shows: haemodynamic instability, tachycardia/pnoea, hypotension, long cap refill Minor <1000 (commonly more than 500ml) Major >1000 Massive >1500 have continuous bleeding that fails to stop with delivery of placenta Management - Escalate - alert obs, anaesthetic, major haemorrhage protocol, haem consultant - AtoE - G&S, Crossmatch 4-6U, FBC, LFT, U&E, coag - Blood asap, in mean time 2L warmed hartmanns uterine atony - Empty bladder with catheter - Bimanual external compression - 1st line 5U syntocinon IV - 2nd line add Ergometrine 0.5mg IV or IM - Then tranexamic acid 1g -> syntocinon infusion -> carboprost 250 mcg -> misoprostol 800mcg - Surgery if above not effective: Balloon tamponade, haemostat suture, uterine or iliac artery ligation, hysterectomy If retained placenta - IV Oxytocin, - Manual removal of placenta with regional or general anaesthetic - Prophylactic antibiotics in theatre if trauma - compress and suture Thrombin - call haem

Answer 61

occurs between 24hrs post pregnancy and 12w Main causes are endometritis and retained products of conception presents with vaginal bleeding and associated symptoms of fever/ tachycardia, abdominal pain etc Investigations - do bloods including blood cultures and high vaginal swabs is suspect infection - US to identified retained products of conception Management - If infection then treat with IV tazocin, if less severe can give oral co-amoxiclav and metronidazole - If RPOC - consider giving uterotonics e.g. oxytocin or performing manual evacuation via curettage (cover with Abx)

Answer 62

RPOC If within 6w might consider infection; puerperal pyrexia

Answer 63

oestrogen - increases duct size and number progesterone - increases alveolar cells These two block effects of prolactin until levels fall after birth, prevents milk production during pregnancy when not needed. hPL - increases acinar cells, glands prolactin - stimulates milk production in alveoli oxytocin - let down reflex when nipples sucked - contracts myoepithelial cells

Answer 64

Bromocriptine, cabergoline - dopamine agonists that stop prolactin production

Answer 65

Puerperal pyrexia - do high vaginal swab, MSU, FBC, blood culture, US scan to rule out RPOC, sputum culture

Answer 66

Present with pyrexia, tachycardia, hypotension, abdo pain, foul smelling lochia, dysuria, abnormal bleeding Do - FBC - high vaginal swabs - MSU - Blood culture For general endometritis give clindamycin and gentamicin if severe sepsis - IV tazocin

Answer 67

ant - cystocoele or urethrocoele Mid - uterine prolapse or enterocoele (pouch of Douglas) Post - rectocele Present with pressure, fullness, bulge sensation, spotting, issues placing tampon, urinary/ bowel symptoms, dyspareunia, loss of vaginal sensation, vaginal flatus, loss of arousal. Treat with conservative measures like pelvic floor exercises, weight loss, avoid straining, reduce caffeine and fluids, physical activity Vaginal pessary - ring pessary often 1st choice, however makes sexual intercourse difficult - vaginal oestrogen creams - oestrogen secreting rings surgery - colposuspension commonly done for urethral sphincter incontinence, Sacrospinous ligament fixation for uterine prolapse big issue with prolapse surgery is recurrence

Answer 68

Do urine dipstick, U&E to assess renal function, bladder diary, post-void residual volume can show overflow incontinence, urodynamics can identify stress incontinence Stress - conservative - fluid intake, reduce caffeine, treat constipation or cough, loose weight - 12w pelvic floor exercises - duloxetine - colposuspension Urge - conservative same as above - 6w pelvic floor exercises - oxybutynin 1st line - mirobegron if antimuscarinic contraindicated - botulinum injection or sacral nerve stimulation - augmentation cystoplasty

Answer 69

post partum blues - negative and joyous emotions starting within a few days of birth and lasting max of 2w. Treat with emotional support, sleep hygiene post partum depression - symptoms of low mood and loss of interest lasting longer than 2w and occurring any time up to one year post birth. - assess using screening questionnaire e.g. PHQ-9 - if mild to moderate - self help and support - if mild and prev severe depression - antidepressant - if moderate or severe - CBT first line, antidepressant if mother accepts risks or if CBT not suitable/ effective - if very severe and suicidal - may need to be admitted to mother and baby unit First line in breast feeding = sertraline

Answer 70

Tubal dmg - PID causing stricture , endometritis causing adhesions, ectopic, ruptured appendix - Mid luteal progesterone >3 (ovulating as normal) - Investigate with HSG (Hysterosalpingography) - Surgery to open fallopian tube or IVF - Proximal blocks - tubal catheterisation (salpingostomy) - Distal blocks - laparoscopic surgery Uterine issues - US - vaginal septum, adhesions, polyp, fibroid - surgery for polyp, endometritis, fibroid Cervical issues - bypass with intrauterine insemination Premature ovarian failure - Mid luteal progesterone <3 (7 days before period) - FSH high day 2-5 - low ovarian reserve - Low AMH (high number shows high ovarian preserve) - Egg donation Hypothalamic - stress, excessive exercise, low BMI or pituitary e.g. Sheehans and pituitary adenoma - check FSH, LH, Oestrogen levels - hCG, 2nd line GnRH - Hyperprolactin (galactorrhea, amenorrhoea, reduced libido, headache) - do MRI - cabergoline, bromocriptine PCOS - facial hair, acne, irregular periods, obesity - LH, androgens high - Confirm with US - weight loss - 1st line letrozole, 2nd line clomiphene, 3rd line hCG, FSH - laparoscopic ovarian drilling - IVF prev chemo/radiotherapy

Answer 71

Sperm production issues - hormonal -> hypothalamic/pituitary issues, anabolic steroids - antipsychotics can increase prolactin level - testicular abnormalities -> cryptorchidism, kleinfelters, trauma, tumour, varicocele - Hx of mumps - orchitis Sperm transport issues - obstructed vas def/ epididymus due to infection, trauma, vasectomy, cancer, surgery, CF - Retrograde ejaculation, ejaculatory problems - SSRI can effect erection Do semen analysis, hormone levels Normal semen = conc >15m/ml, motility >40%, morphology >4%, ejaculate volume >1.5ml Management: - obstructive - surgical correction or surgical sperm retrieval - oligozoopsermia/ non obstructive azoospermia - ICSI, if hypothalamic or pituitary give IM hCG to boost testosterone, cabergoline/ bromocriptine for prolactinoma - low motility, concentration, morphology - ICSI - Absolute azoospermia - sperm donation - retrograde ejac - sympathomimetics or ICSI/IVF

Answer 72

Cysts on US (>12 follicles or increase in size >10cm3) Anovulation Clinical or biochem signs of hyperandrogegism Present with irregular periods, acne, hirsutism and inability to conceive Often get associated insulin resistance Ix - US - Free and total testosterone - SHBG - sex hormone binding globulin - LH high, FSH normal, LH:FSH >2 - BM, OGTT, TSH, Cortisol lvl, prolactin Management - conservative: weight loss - COCP and metformin can be used to treat sx of the condition - ensure have withdrawal bleed to reduce risk of endometrial cancer - spironolactone can be used to reduce androgen level - try and restart ovulation with lotrimazole 1st line then clomiphene 2nd line, metformin and Laparoscopic ovarian drilling or gonadotrophins can also help

Answer 73

Prolactin, TFT, random FSH/LH/Estradiol, US to look for PCOS, sperm test

Answer 74

2-5 day FSH/LH/Estradiol, mid cycle progesterone, US of pelvis (fibroids, polyps, swollen tubal), semen test

Answer 75

Imperforate hymen

Answer 76

Absent periods for 2-3 months in prev regular menses | Absent periods for 6-12 months in prev oligomenorrhoea

Answer 77

risk factors are pregnancy, adolescence and combined oral contraceptive presents with intermenstrual and post coital bleeding as well as discharge from columnar cell secretions, may also be dyspareunia Investigations: Pregnancy test Do speculum - see red ring around cervical opening Do smear and take endocervical/ high vaginal swabs Management - no need if asymptomatic - stop COCP - Can do cryo-ablation - boric acid pessary

Answer 78

``` Infection- STI Malignancy Benign polyps Cervical ectropion Trauma Vaginal atrophy ```

Answer 79

Heavy bleeding >80ml, affecting woman's QOL, have to use 2x types of sanitary products often have passage of clots Management - hormonal: IUS (mirena), COCP, POP, progestogens e.g. oral norethisterone. If not effective try GnRH analogues - non hormonal - if want to get pregnant - mefanamic acid, tranexamic acid, - surgery - uterine artery embolisation, hysterectomy, endometrial ablation

Answer 80

``` unopposed exogenous oestrogen HNPCC obesity tamoxifen Oestrogen secreting ovarian tumour Age PCOS Chronic anovulation Nulliparity ``` Do TVUS, if >4mm thick take biopsy to confirm

Answer 81

Abnormal vaginal bleeding - heavy, intermenstrual, post menopausal can do US to assess endometrial thickness - in post menopausal >4mm indicative, take biopsy - less helpful in pre-menopausal For definitive diagnosis do hysteroscopy with biopsy Management: If atypical - hysterectomy - if post menopausal remove Fallopian tubes and ovaries aswell If not atypical - reassure - lifestyle, address risk factors - reduce exposure to unopposed oestrogen - place on progesterone - 1st line IUS mirena, second line is continuous oral progesterone - take endometrial biopsies every 6m until 2x -ve - hysterectomy if woman wants, not get better within 1 year

Answer 82

Primary dysmenorrhoea

Answer 83

Is presence of endometrial tissue outside the uterus Present with dysmenorrhea, dyspareunia, infertility, irregular menses, cyclical pain and chronic stabbing pain due to adhesions. May have bladder or bowel symptoms - pain when passing stool or change in bowel habit initially dull cyclical pain due to endometrial tissue then develop chronic sharp stabbing pain due to adhesions Investigations - Hx and exam - may see endometrial deposits in vagina on speculum, bimanual may show fixed uterus/ cervix (due to adhesions), adnexal tenderness/mass, post fornix nodule/ tenderness - gold standard = laparotomy (laparoscopic) - 1st line = TVUS - can see endometrioma (chocolate cyst) - MRI can help with deep endometriosis with bowel, bladder or ureter involvement Management: Medical - pain relief with etc analgesics, NSAID (mefanamic acid), paracetamol - hormone treatments including Mirena, COCP, POP, implant or depot-provera injection - progesterone tablets e.g. norethisterone - Danazol can be used (cause masculinisation) - if unsuccessful refer to secondary care for GnRH Surgical - laparotomy with cauterisation or excision - ablation/ cauterisation/ excision - Ovarian cystectomy for endometrioma - Adhesiolysis - Hysterectomy if recurrences For poor fertility do laparoscopic surgery, remove endometrioma, if not help do IVF

Answer 84

Present with menorrhagia, dysmenorrhea, dyspareunia, enlarging uterus that can give fullness sensation/ dragging sensation are older, multiparous as pregnancy and injury to uterus e.g. c-section increases risk Investigations - full exam and hx - Can perform TVUS, MRI - Often confirmed by biopsy post hysterectomy Management - Pain relief - Tranexamic acid and mefanamic acid for blood loss - 1st line hormonal = Mirena, COCP, POP, injection etc - 2nd line GnRH analogues - Danazol can also be used - surgical management includes uterine artery ablation, endometrial ablation, adenomyomectom, hysterectomy is definitive

Answer 85

IM ceftriaxone single dose followed by 100mg doxy and 400mg metro 2x daily for 14 days do high vaginal swab present with - Lower abdominal pain - Fever - Deep dyspareunia - Dysuria and menstrual irregularities may occur - Vaginal or cervical discharge - Cervical excitation Diagnosis - clinical in most cases - FSH lvl raised - Do TFT, BM to exclude other cause - Do cholesterol, triglycerides to assess CVD risk

Answer 86

Menopause = when not had a period in last 12m ``` early = <45yo premature = <40yo ``` Symptoms - irregular periods, vasomotor (hot flushes, night sweats), urogenital sx (vaginal atrophy, UTI, dyspareunia), anxiety, low libido, sleep disturbance, MSK issues, skin thinning, hair loss etc. Management: All premature/ early menopause need HRT, otherwise is based on patient sx and preference Conservative - light baggy clothing, sleep in cool room, healthy lifestyle, reduce BMI, caffeine, alcohol If uterus give combined oestrogen + progesterone If no uterus give just oestrogen If also no ovaries may also give testosterone If post menopausal or >54 give continuous If still bleeding give monthly or 3 monthly cycles. Take oestrogen throughout and progesterone for 12-14 days at end Transdermal patch (combined) or gel (oestrogen only) first line. Progesterone given by IUS mirena or pill. Combined pill 2nd line and implant if refractory. Testosterone gel used if low libido, no ovaries Vaginal oestrogen cream/tablets can be used for vaginal atrophy/ dryness Alternative if very mild hot flushes: SSRI e.g. venlafaxine, clonidine, gabapentin or oxybutynin risks: Combined increases risk of breast cancer Increased risk of ovarian cancer Oestrogen alone increases risk of endometrial ca Increased risk of VTE, not with transdermal Oral oestrogen can increase risk of stroke but transdermal does not

Answer 87

<50 - 2 years | >50 - 1 year

Answer 88

LARC - implant (nexplanon), can stay in for 3yrs, inhibits ovulation

Answer 89

Why want the pill Brief sexual history ICE Clarify not have any bleeding disorders, not have migraines Contains both oestrogen and progesterone Inhibits ovulation, thickens cervical mucus and thins the endometrium 99% effective with perfect use AV: non invasive, effective, can make periods more regular, lighter and more pain free, can take back to back, improves acne, reduced premenstrual tension, reduce risk of ovarian, uterine, colon cancer DV: Headache, nausea, breast tenderness, mood changes, breakthrough bleeding, not protect from UTI, user dependant Increases risk of breast and cervical cancer, also VTE Clarify not pregnant, smoker, migraine w. aura, family hx of breast cancer, CV risk factors, high BMI Can start the pill at any point as long as your not pregnant, if within first 5 days of onset of bleeding you are covered if otherwise need to take another form of contraception for 7 days Take at same time everyday, most people just before bed Take for 21 days then break for 7 within which you will have a period. Are covered for these 7 days however any longer and you won't be. If miss one day then take as soon as remember If miss 2 days then take last one as soon as remember but need to use another method of contraception for next 7 days. If >7 pills left in a pack then break as normal, if <7 then back to back If two pills are missed, between days 8-14 of the cycle, no emergency contraception is required, as long as the previous 7 days of COCP have been taken correctly

Answer 90

Progesterone only injections e.g. depo-provera

Answer 91

Ask about why need, when last time had sex Ask about if it was consensual, whether feel safe and supported in their relationship 3 types IUCD - can be inserted up to 5 days post sex, or up to 5 days after the earliest estimated date of ovulation. Works by inhibiting fertilisation and implantation. AV - most effective, can stay in place for 10 years, no hormones, no effect on other meds Dv - Irregular bleeding for few days after, heavier periods, requires a procedure to insert, contraindicated if STI Complications - can form hole in womb, can fall out (check monthly), infection, ectopic Ellaone - one pill - effective up to 5 days post sex. Stops implantation and ovulation. contraindicated if severe asthma. AV - very few SE, no procedure DV - N+V, changes to next period, have to wait 5 days to start contraception Levonelle - effective up to 3 days post sex. Works same as ellaone. AV - same as ellaone, can start contraception immediately DV - Same as ellaone + shorter window, needs double dose if over 70kg or BMI >26 Confirm not pregnant with pregnancy test or period - inform woman may be early or late, return if >7d late Can take multiple pills during one cycle but must be the same type

Answer 92

Ectopic bleeding often less heavy, darker and is associated cervical excitation tenderness Do TVUS - may be able to identify tubal mass/inflammation Do repeat Pregnancy tests 48hrs apart - >63% rise = ectopic as continued pregnancy - >50% fall = miscarriage as failed pregnancy

Answer 93

Antiphospholipid syndrome - give heparin and low dose aspirin Other causes = thrombophilia, Abnormal uterus

Answer 94

Present with: - irregular vaginal bleeding - Large for dates, soft boggy uterus - - increased HCG can lead to ovarian cysts and hyperemesis gravidarum - Hyperthyroidism - Pre-eclampsia complete - empty egg, 2 sperm or 1 divided sperm partial - egg and 2 sperm can progress to choriocarcinoma (cont bleeding after molar pregnancy, spread beyond uterus), invasive molar pregnancy or placental site trophoblastic tumour investigations - high betaHCG - histology post evacuation for definitive diagnosis - US may show grape appearance for complete, viable foetus with anomalies for partial - CT/MRI is suspect metastasis Management - register to GTD centre - may end on own as spont miscarriage - Surgical evacuation via suction curettage for complete moles and all non viable partial moles - if partial mole, greater gestation may consider medical with mifepristone and misopostel - Anti D - if betaHCG still raised 4w post evacuation, symptoms not improving, evidence of metastasis or histology of choriocarcinoma commence chemotherapy long term hcg monitoring - not get pregnant until normal for 6m or 1yr post chemo - not start on hormonal contraception

Answer 95

Presents with: - Abdominal pain and vaginal bleeding - amenorrhoea - positive pregnancy test - N+V - Urinary/ bowel sx - signs of peritonism, shoulder pain, shock - cervical motion tenderness RF = prev ectopic, copper coil, IVF, PID, STI, endometriosis, Fallopian tube or other abdo surgery Investigations - examination for tenderness, cervical excitation - Serial hcg 48hr apart - will be raised, stay high unlike >50% drop seen in miscarriage, >63% rise in viable pregnancy - progesterone <5 is an indicator of a non-viable pregnancy - TVUS - can confirm tubal ectopic, abdo US 2nd line - MRI - can be used to confirm, good if cervical scar or interstitial ectopic If one off BHCG >1500 - most likely intrauterine Management: Counselling and Anti-D If ruptured - AtoE - Wide bore cannula - Fluid resus - Cross match and G&S - 4-6 units - straight to theatre for salpingectomy Expectant management - monitor for 48hrs: If no sx, stable, hcg <1500 up to 5000, no foetal heart beat, size <35mm, unruptured, intrauterine pregnancy Medical management - IM methotrexate If limited sx/ pain, hcg <1500 up to 5000, no foetal heart rate, no intrauterine pregnancy, unruptured, <35mm - monitor hcg at 4,7 days if <15% fall give second dose - put on contraceptive for 6m Surgical management: Laparoscopic salpingectomy If severe sx/ pain, hcg >5000, foetal heart rate, intrauterine pregnancy, ruptured or >35mm - If other tube healthy salpingectomy - if other tube damaged or fertility issues salpingotomy

Answer 96

Unable to conceive after one year of regular unprotected intercourse primary - no prior pregnancies secondary - prior pregnancy (miscarriage, stillbirth etc)

Answer 97

GnRH analogues to inhibit pituitary Clomiphene or Lotrazole given to suppress oestrogen FSH levels rise causing follicle maturation hcg given to induce ovulation for IVF dont give clomiphene or lotrazole instead give exogenous FSH Need to give luteal support (progesterone) during pregnancy as no corpus luteum

Answer 98

Ovarian hyper-stimulation syndrome

Answer 99

1st line =. TVUS >4mm thickness - biopsy <4mm - discharge and return if continued bleeding <4mm and had tamoxifen - biopsy Biopsy via hysteroscopy

Answer 100

Adenocarcinoma most common Can be endometrioid (type1) or non-endometrioid (type 2) Presents with post menstrual bleeding, weight loss, anorexia, lethargy - can present earlier with irregular periods, abnormal bleeding Risk factors = oestrogen exposure. e.g. obesity, tamoxifen, nulliparity, oestrogen only HRT, endometrial hyperplasia, early menarche, late menopause Investigations: - 1st TVUS - >4mm thickness do biopsy - pipelle biopsy or hysteroscopy with biopsy Management - Stage 1 (in uterus) - hysterectomy with bilateral sapling-ophrectomy - Stage 2 (cervical stroma) - same + LN clearance - Stage 3 (Regional spread/LN) - maximal debulking surgery +/- radio/chemo - stage 4 (spread to bowel, bladder, liver) - same

Answer 101

Presents in post menopausal with itching, vaginal bleeding and vulval mass/ulceration squamous cell carcinoma HPV is a risk factor Diagnose with exam and biopsy - extent of spread with CT/MRI, cystoscopy and proctoscopy Stages: - 1 - in vulva - 2 - in perineum (lower 1/3 of rectum or urethra) - 3 - nodal spread - 4 - Invade other region or metastasis Management - wide local excision or radical local excision with sentinel LN biopsy or groin LN dissection - Radiotherapy +/- chemo for late stage

Answer 102

Abdominal distension, Early satiety, weight loss, change in bowel habit, abnormal bleeding, pelvic pain, urinary symptoms, pelvic mass Do CA 125, USS, menopausal status - calculate risk of malignancy score Then do CT Can do image guided percutaneous biopsy or take sample as part of laparoscopic surgery Stage 1 - within ovary Stage 2 - within pelvis, spread to uterus, Fallopian tube Stage 3 - Spread outside pelvis Stage 4 - metastasised to liver or lungs Treatment - surgery to diagnose, debulk and stage (remove as much as possible) - in later stage disease may give adjuvant chemotherapy using carboplatin +/- neoadjuvant

Answer 103

Intermenstrual, post sex, post menopausal bleeding. Malodorous discharge, pelvic pain, pain on sex. Refer via 2ww for cervical screening if abnormal looking cervix or unexplained symptoms, post or premenopausal bleeding screening = HPV testing, if liquid based cytology - 25-49 every 3 years, 50-64 every 5 years Stage Stage 1a – Diagnosed only by microscopy, <5mm depth Stage 1b – Depth >5mm, only in cervix Stage 2 upper 2/3 of vagina (a) or parametrium (b) Stage 3 cancer has spread throughout the vagina (a) or to the pelvic sidewall (b) Stage 4 - metastatic Management Stage 1a (micro-invasive) - large loop excision of transformation zone or cone biopsy 1b-2a (Early stage) - radical hysterectomy + lymphadenectomy, or if >4cm chemoradiation 2b- 4a (locally advanced/ metastatic consider) chemoradiation

Answer 104

Cervical screening - first invited at age 25, 25-49 every 3 years and 50-65 every 5 years. Only screen over 65 if not had a test since 50 or if recent abnormal test Insert speculum, use brush and rotate 5 times against squamocolumnar junction = liquid based cytology Results are - 1st look at if +ve for high risk HPV - if not return to normal screening pathway - if yes do cytology - For cytology - if negative repeat in 12m - if still HPV +ve/ cytology negative repeat again in 12m - if still then refer for colposcopy - If dyskaryosis refer for colposcopy Negative - return to screening Inadequate - repeat Borderline - some changes, very unlikely to progress Mild dyskaryosis - Cancer very unlikely, most revert to normal smears Moderate dyskaryosis - Intermediate probability of developing into cancer Severe dyskaryosis - high risk of cancer, some may show changes suggestive of cancer Glandular neoplasia - adenocarcinoma If 2x inadequate samples in a row send for colposcopy Treat CIN with: - large loop excision of the transformation zone (LLETZ) - Cryotherapy - Laser treatment

Answer 105

Present with abdominal pain, dyspareunia, pressure symptoms, palpable mass Torsion - acute onset after heavy exercise, severe pain with fever, N+V. unilateral tender adnexal mass - See whirlpool sign on US Rupture - acute onset pain often after heavy lifting or sex. Signs of peritonism and shock. N+V Investigations - TVUS first line - hCG, LDH, AFP if <40 - germ cell tumour - CA125 if post menopausal - Calculate risk of malignancy index - CT/ MRI if needed Management For simple small cysts <5cm most will go away on own within 3 menstrual cycles so no need for treatment For larger cysts 5-7cm observe and monitor for malignancy For >7cm consider MRI followed by surgical removal by either cystectomy or oophrectomy For all torsions/ ruptures - TVUS, CT/MRI and immediate surgery - uncoiling and oophoropexy in torsion - oophractomy or salpingo-oophrxectomy in rupture or haemorrhage - give broad spectrum abx

Answer 106

1. APGAR - appearance, pulse, grimace, activity and respiration - do at 1,5 mins post birth - <3 is low, 4-6 is fairly low, 7-10 is normal 2. physical check - done my midwife within 72hrs of birth - Height, weight, head circumference - check eyes for cataract, ears for patency, mouth for suckling reflex, check hands and limb movement, assess pulses, HR and RR, check umbilical stump for hernia or infection, look for descent of testes, check back for spina bifida, assess Barlow and ortolani for congenital hip dysplasia 3. Heel prick - done on day 5-8 - detects 9 conditions most notably: sickle cell, PKU, CF, congenital hypothyroid 4. Hearing test - at 4-5w - automated otoacoustic emission test can detect if cochlear working normally - if abnormal refer for automated auditory brainstem response where sounds are produced and response recorded by electrodes on the brainstem

Answer 107

SGA - baby smaller than 10th centile IUGR - babies growth slows or ceases whilst in utero due to genetic or environmental factors - occurs over 2 measurements

Answer 108

Aspirin from12-16w until 36w for those at high risk of pre-eclampsia Progesterone therapy for prevention of preterm birth consider karyotyping, serological screening for infection If single measurement <10th centile or slowing/stopped growth over 2 -> US If SGA detected on scan or midterm do umbilical artery doppler If major risk factor - Regular US monitoring and umbilical artery doppler at 26-28w If >3 minor risk factors - umbilical artery doppler at 20-24w

Answer 109

Placental issues e.g. pre-eclampsia, praevia, abruption, accreta

Answer 110

2 weekly US from 28w - head, abdo circumference, femur length - uterine artery doppler - Liquour volume - Sometimes CTG - if severe consider karyotyping (if symmetrical, early in pregnancy)

Answer 111

Oral vitamin K

Answer 112

``` Placental issues - abruption, eclampsia Uterine issues - rupture, perforation Maternal issues - shock, hypovolaemia Cord failure - prolapse Failure of cardioresp adaptation at birth ```

Answer 113

Therapeutic hypothermia Resuscitation as needed Is commonest cause of neonatal seizures

Answer 114

Coughing/ cyanosis when feeding - entering trachea Polyhydramnios Dribbling, excess salivation at birth Perform xray and try to pass radio-opaque tube into stomach - won't reach Treat with surgery

Answer 115

Transient tachypnoea of newborn Often occurs in term baby (SGA or macrosomia) following c-section, arises within first day post birth and resolves after 24-72 hours CXR shows fluid filled fissures within the lungs Observe, give O2 as required, supportive care If patchy infiltrates on CXR - think meconium aspiration

Answer 116

Investigations - Bloods - Urine toxicology - Blood glucose - CSF - EEG - Neuroimaging - cranial US, CT/MRI if needed - Metabolic screen Treat if desaturating, haemodynamic instability, lasting >5 mins or > 3 per hour Give IV phenobarbital 1st line, phenytoin second line Treat cause e.g. give glucose or calcium etc

Answer 117

Persistent pulmonary hypertension - treat with ventilation, NO (dilates vessels), inhaled vasodilator e.g. Sildenafil - Abx if signs of infection on CXR

Answer 118

RF - prematurity, C section, maternal diabetes, hypothermia, meconium aspiration Prevention - give steroids in expected preterm labour e.g. PROM, can also use tocolytics to delay labour Management - Surfactant replacement therapy via endotracheal tube, give O2, prevent hypothermia, monitor glucose and electrolytes

Answer 119

``` T- toxoplasmosis Other - VZV, HIV, hepatitis, chlamydia, gonorrhoea, GBS, syphilis R - Rubella C - CMV H - Herpes ``` GBS presents with newborn resp distress and meningitis - treat with IV benzylpenicillin

Answer 120

Important to check blood for antibodies if any ambiguity about previous infection If not immune, exposed: - Give immediate immunoglobulin (effective up to 10 days post exposure) If contract infection - r antivirals 7-14 days post exposure if present within 24hrs of rash

Answer 121

RDS - Episodes of apnoea, bradycardia, and desaturation - gentle physical stimulation - oxygenation with CPAP or ET tube - surfactant therapy Hypothermia - Place baby in plastic bag, give hat - Place in humidified incubator Nutrition, hypoglycaemia - IV 10% dextrose or breastmilk - May give extra phosphate and protein Infection - take blood cultures, FBC, CRP - if any suspicion of risk of infection start prophylactic Abx with IV benpen and gent Also council parents on what will happen, what to expect

Answer 122

Present with shock, collapse, respiratory distress, tachycardia, febrile Most common causes are GBS and E.Coli Investigations: - Blood culture - Full blood examination - CRP for monitoring - Blood gases - look for acidosis and lactate - Urine microscopy, culture and sensitivity - Lumbar puncture - meningitis - CXR - exclude pneumonia as cause Treatment - Give IV benzylpenicillin and gentamicin - start before results of cultures - continue for approx 10 days or as needed - if culture negative and repeat CRP <10 can stop after 48hrs

Answer 123

1. Dry the baby, warm and start clock 2. Assess the baby’s heart rate (auscultation), chest movement, colour, and tone 3. If not breathing by 90s give 5 inflation breaths 4. Re-assess heart rate, chest movement, colour, and tone 5. If chest not moving consider suction, reposition mask and give 5 more breaths 6. Reassess 7. If heart rate undetectable for <60 after 30s ventilation start chest compressions. 3 to 1 breath. Also consider intubation

Answer 124

pathological if <24hrs, last >14 days or 21 if preterm, total bilirubin >225 or rising by >85 per day <24hrs - haemolysis, ABO/Rhesus D incompatibility, infection (sepsis), G6PD - if rapidly rising post birth think haemolysis >24hrs - 2w - breast feeding/ breast milk jaundice, pathological, infection, dehydration, haemolysis >2w - - unconjugated - breast milk, infection, hypothyroidism, haemolytic, physiological - conjugated - bile duct obstruction, hepatitis, biliary atresia, sepsis, CF Investigations: - Transcutaneous bilirubinometer if >35w and after 24hrs - if >250 or otherwise do total and conjugated bilirubin - hb (if low suspect haematoma, if normal haemolysis), hb electrophoresis, reticulocytes will also be high in hemolysis - LDH - if high haemolysis - U&E for dehydration, TFT - LFTs, US + biopsy if suspect hepatic/cholestatic cause - infection screen - urine dip + culture - capillary blood gas - blood type and rhesus or mother and baby Management: - plot bilirubin levels on treatment threshold graph - lower line = phototherapy - repeat bilirubin every 6 hr, stop when >50 below - higher line = plasma exchange - iv immunoglobulin can be given as adjunct if haemolysis Complication = Kernicterus (lethargy, poor feeding, irritability and increased tone), billirubin-induced brain dysfunction - if >450 bilirubin

Answer 125

- anxiety - stress - fatigue - mood swings 1st line = lifestyle 2nd line = COCP 3rd line = sertraline

Answer 126

Sudden onset abdominal pain, N+V, palpable mass Do TVUS Laparoscopic surgery, fix in place

Answer 127

Short history • Ask what understand about downs syndrome • Explain is most common congenital abnormality, occurs due to additional genetic material, usually occurs without any particular cause/ is not inherited. It is a lifelong condition without cure, majority of people can live independently and have happy and fulfilling lives but may need some additional help and care. Life expectancy is 58, most causes of earlier deaths is heart problems. Can suffer from other problems such as learning difficulties, asthma, and GI conditions • Explain risk is higher if previous DS baby or older maternal age • Ask on opinions of having a downs syndrome baby Tests If 10-14w: Combined test - Raised beta HCG and low pappa-a - Nuchal translucency scanning - 11 weeks + 2 days and 14 weeks + 1 day gestation - Results from combined test are added to maternal age, weight, family origin and gestation. If risk > 1in150 women are offered diagnostic testing If 15-20w: Quadruple test - Beta-hCG - high - AFP - low - Inhibin A - high - Unconjugated estriol - low Diagnostic testing - Warn about risk of miscarriage - Bleeding, watery discharge, flu like symptoms (infective miscarriage) - Minimise using aseptic technique, US guidance, regular practice, auditing miscarriage rates - If twins: Need to test both even if monozygotic, Can inject one baby with feticide Chorionic villous sampling – 11-14 weeks - Cells removed from placenta through abdomen via needle or cervix using small tube - Give LA - Takes about 10 mins, uncomfortable - Screens for other genetic anomalies such as Edwards, Patau’s, CF - 1-2% risk of miscarriage, infection - Take 3 days for results Amniocentesis – 15 weeks (later so less time for decision) - Long thin needle via abdomen with US - No need for LA - 0.5-1% risk of miscarriage/ infection, easier to perform - Takes 10 mins, described as period pain - Take 3 days for results Foetal blood sample for later gestations - NIPT – foetal DNA in mothers’ blood - Use if high risk and mother doesn’t want CVS or amniocentesis - Not as accurate - Reassuring if -ve If baby does have downs important do post-natal screening for complications, management requires multidisciplinary approach - do foetal echo to look for heart defects - Regular growth scans from 28w - Feeding support - Ask if want to see neonatal team before pregnancy or before deciding on TOP

Answer 128

Meconium aspiration - Often a sign of foetal distress/ intra-uterine hypoxia - meconium stained amniotic fluid, patchy infiltrates on CXR, term or late babies, treat with abx, NO, O2, airway suctioning Transient tachypnoea of newborn - Term babies, often SGA or macrosomia, post C section - Fissures filled with fluid on Xray - Due to failure to expel amniotic fluid from lungs - Starts on first day post birth often after a couple of hours, resolves quickly with supportive care Persistent pulmonary hypertension - Term baby - Can be caused by any other resp/ cardio issues - diagnose with echo/ CXR - give O2, NO to dilate vessels, inhaled sildenafil NRDS - Preterm baby, C-section, maternal diabetes are RF - Due to lack of surfactant, collapsed lungs on CXR, ground glass appearance - Presents with cyanosis often minutes to hours post birth - Treat with surfactant, steroids, ventilatory support

Answer 129

ICE - Can still have pregnancy - most people with diabetes have a problem free pregnancy with healthy child - At increased risk of macrosomia, miscarriage, NRDS, heart problems, still birth, neuro defects - Managing blood sugars well can reduce these risks - Before trying to get pregnant important to get blood sugar lvls stable, <48 HbA1c - monthly tests, continue contraception until told to stop - take 5mg folic acid daily till 12w - may need to switch medication to metformin or insulin injectables during pregnancy - Measure blood glucose regularly throughout the day, aim to keep within normal range. Due to N+V there is as increased risk of hypos - these are not harmful to the baby but make sure yourself and partner know how to deal with them - will receive eye screening during pregnancy - recommended give birth at a consultant let facility - May consider early induction as increased risks to yourself and baby if pregnancy goes on too long, if baby is found to be large they may also consider performing a c-section - your blood glucose will be measured regularly, at least hourly during labour and you might need a drip with insulin/ glucose if there are issues - important to try and feed baby within 30mins post birth, a heel prick test will be performed to measure babys blood glucose level and if needed support from the neonatal team will be provided - following birth can return to pre-pregnancy insulin/ metformin levels - follow up in GP

Answer 130

Ask about - Bleeding - when, how much - Discharge - appearance, smell, how much - Pain - during sexual intercourse, pelvic, abdominal? - Skin changes - Abdominal masses - Mental health - Bladder/bowel - Systemic sx - weight loss, fever, fatigue, abdo distension If suspect STI - number sexual partners in last 12m, 3m - assess risk - use of condoms, anal sex, oral sex ICE Mestrual hx - duration - frequency - regular - heaviness - pain - LMP? - age at menarche Contraception - current type - adherence - previous Family planning - planning for any children in near future? Past gynae hx Prev surgery Cervical screening Obs hx - gravida and parra - age of prev children - method of delivery - any issues - currently breastfeeding? DHx + allergies FHX SHX

Answer 131

https://oscestop.com/Pelvic_exam.pdf

Answer 132

24-38 days +/- 4 days 8 days max <80ml

Answer 133

Vaginal atrophy = thinning, drying and inflammation of vaginal walls - dyspareunia, post coital bleeding, reduced sexual desire, burning or itching. Treat with vaginal lubricants, moisturisers, vaginal oestrogen or HRT Cervical or endometrial polyp - visible on speculum, biopsy and remove Fibroids - enlarged uterus on bimanual, do US to confirm Endometrial hyperplasia/ Endometrial cancer - TVUS, if >4mm thick biopsy, <4mm monitor unless clinical suspicion is high - treat with weight loss, systemic progesterone/ mirena coil Cervical cancer - speculum, take biopsy/ liquid based cytology Vaginal cancer - observe/ feel on vaginal exam, take biopsy Bleeding from elsewhere

Answer 134

``` Ovarian cyst Ovarian torsion ectopic pregnancy Endometriosis PID STI Vaginal trauma Fibroid Ovarian or cervical cancer IBS UTI Appendicitis ```

Answer 135

Introduce Brief hx - sx, periods, pmh (VTE, oestrogen sensitive cancers), age, smoking, uterus Ask what understand by menopause, what understand of HRT, any worries or concerns Explain what menopause is, what happens Explain the function of HRT Pros of HRT - improve vasomotor sx - improve vaginal dryness - improve mood, anxiety - reduce risk of osteoporosis and coronary artery disease Cons - increased risk of VTE - increased risk of breast, endometrial, ovarian cancer - not a form of contraception - side effects of oestrogen: nausea, GI upset, breast tenderness, cramps, - side effects of progesterone: pre-menstrual syndrome Can be taken in a variety of forms including tablet form, patches, gels, implants - topical vaginal gel, pessary can also be used Start on cyclical if periods within last year, otherwise continuous Is not set length of time to remain on HRT is tailored to a woman's risks vs benefits Will need to continue on contraception until >1 year no periods after 50 or >2yrs no periods if <50 Discuss alternatives - mood - CBT, counselling, SSRI - vasomotor - SSRI, sleep with window open, baggy clothes, SNRI, clonidine - vaginal dryness - lubricants, moisturisors - irregular periods - mirena coil

Answer 136

Early - miscarriage, implantation bleed, gynae causes, ectopic pregnancy Mid to late - miscarriage, placenta praevia/ accreta/ abruption,, vasa praevia

Answer 137

Length Amniotic fluid Heart rate Umbilical artery doppler

Answer 138

Ectopic, implantation bleed, cervical polyp, gestational trophoblastic disease, miscarriage

Answer 139

Can continue all meds as normal - discuss with Drs

Answer 140

``` Cord prolapse Sustained fetal bradycardia Fetal hypoxia (scalp pH < 7.20) Placental abruption Uterine rupture Vasa praevia Eclampsia ```

Answer 141

- a twin or multiple pregnancy - diabetes in the mother – including diabetes caused by pregnancy (gestational diabetes) - a blockage in the baby's gut (gut atresia) - an infection during pregnancy - the baby's blood cells being attacked by the mother's blood cells (rhesus disease) - your baby having a genetic condition Usually no issues but is some increased risk of: - giving birth prematurely (before 37 weeks) - your waters breaking early - a problem with the position of the umbilical cord (prolapsed umbilical cord) - heavy bleeding after your baby is born because your womb has stretched - your baby having a health condition ``` Can cause breathlessness heartburn constipation swollen ankles and feet ```

Answer 142

LCHAD +ve | Emergency delivery

obs and gynae Flashcards

(168 cards)