Obs and Gynae Flashcards
Hyperemesis Gravidarum is most pronounced in the ____ trimester (____ weeks). It can be distinguished from normal/physiological vomiting during pregnancy by 3 specific criteria:
____
____
____
1st trimester
0-13 weeks
>5% weight loss pre-pregancy
Clinical dehydration
Electrolyte Imbalance
Hyperemesis Gravidarum can lead to complications including:
Severe Dehydration
Anaemia
Malnutrition
Depression
Venous Thromboembolsim
Electrolyte imbalance (e.g hyponatraemia or wernicke’s encephalopathy)
Mallory-Weiss tear
Management of Hyperemesis Gravidarum includes:
1st line: Cyclizine / Promethazine / Prochlorperazine (dopamine antagonists)
2nd line: Metaclopramide (dopamine and 5HT antagonist)
3rd line: Odansetron (to be given with caution as can cause cleft palate if given in first trimester)- 5HT antagonist.
*can also giver ginger supplements and acupuncture to help vomiting*
If patients are severely dehydrated, have ketonuria (+3) and/or severe electrolyte imbalance – Admit to hospital.
Always consider psychological effects Hypermesis Gravidarum (i.e vomiting 10 times daily) could have on patient.
Misscarriage: Spontaneous death of foetus in utero before ____ gestation.
5 Types:
24 weeks - abdo pain and bleeding
OS open: I+I
Inevitable - Open cervical OS. Likely to dispel pregnancy without medical intervention. POC not seen.
Incomplete - Same as above but POC can be seen in vaginal canal
OS closed: TMC
Threatened - Abdo pain and vaginal bleeding but gestational sac and foetal heartbeat seen on TV ultrasound.
Missed - Patients didnt realise they were pregnant and present with Abdo pain and vaginal bleeding. The uterus still contains foetal tissue, but the foetus is no longer alive (i.e no foetal heartbeat on TV ultrasound). Cervical os closed.
Complete - Abdo pain and vaginal bleeding but the patient has passed foetal tissue. Cervical os is closed and no heartbeat or sac on TV ultrasound. No POC visible.
Septic - Abdo pain and vaginal bleeding but also gestational sac becomes infected. Patients likely to show systemic signs of sepsis.
Screening for down syndrome is done at weeks ___ and uses an algorithm that includes 4 main components. Name them.
10-14
Nuchal Translucency (> 6mm indicates possible down syndrome)
B-HCG (Very High in DS)
PAPP-A (low)
Maternal age
If patients miss their original Down Syndrome screening (i.e combined test 10-13 weeks), they can do another test (quad test) from ____ weeks which includes 3/4 components. Name them.
______ (up to 15 weeks only) and ______ (16+ weeks) are two tests that can be offered to confirm diagnosis if tests above indicate a high risk of DS.
14-20 Weeks
B-HCG -very high
Unconjugated Oestriol - low
Alpha FetoProtein (AFP) - low
+/- Inhibin A - low
NIPT - Non Invasive Prenatal Testing is now also an option and more accurate than the quad and combined test. But suspicion of trisomy 21 needs to be high to qualify for this test.
Chorionic Villous Sampling (up to 15 weeks only)
Amniocentesis (16+ weeks)
*both carry risk of misscarriage* (CVS higher risk)
Gestational Hypertension
Defined as blood pressure **_____** with no concomitant ____ after 20 weeks’ gestation in a woman with no PMH of hypertension.
Remember a blood pressure > _____ requires treatment, whilst a blood pressure >____ requires admission to hospital.
Management:
1st line:
2nd line:
>140/90 mmHg
Proteinuria
>150/100 mmHg
> 160/110 mmHg
Labetalol (b-blocker and thus contrindicated in asthma)
Nifedipine (ca channel blocker)
Gold standard investigation for Endometriosis:
Diagnostic Laporoscopy
3 types of emergency contraception:
Levonorgestrel (Progestogen) - must be taken no later than 72 hours post sexual intercourse.
EllaOne (Ulipristal acetate) - Preferred in patients with a high BMI. Must be within 5 days.
*both these oral forms work by inhibiting ovulation* - (if ovulation has already occured then they are not effective)
Gold standard is actually Copper IUD - spermicidal and causes endometritis. Must be within 5 days. *Only method that works after ovulation*. NB - not to be used if patient is pregnant Urine B-HCG.
Downsides - Permanent and invasive
______ hormone: Produced by granulosa cells of ovary. Good marker of ovarian reserve
Anti-Mullerian
Menopause < 40 yo can be investigated by checking which hormone?
FSH
*oestrogen low and so FSH not inhibited at pituitary*
Syphilis
STI caused by _______ bacteria
Primary syphilis – Painless ulcer (_____) and regional lymphadenopathy (inguinal)
Secondary syphillis - _____ involvement and _____ (attached)
Tertiary syphilis – Neurosyphilis, Cardiovascular , _____ syphilis (_____ lesions with centre of necrotic tissue)
*also important to note that syphillis has an older demographic to Chlamydia/Gonorrhoea, primarily affecting men between the ages of ____ , much like mycoplasma genitalium.
Treponema Pallidum
Chancre
Multisystem
Condylomata
Gummatous / Granulomatous
25-40
Classically, syphilitic aneurysms occur in 90% of cases on the thoracic aorta, and in 10% in the abdominal aorta
Post- menopausal bleeding is often benign (ex. _____ ) however a significant proportion of cases can be endometrial cancer and so further investigation with _____ is necessary
If TV ultrasound shows endometrial thickness > ____ then a ___ is needed to determine whether thickness is due to endometrial hyperplasia or endometrial cancer
Biopsy with no ____ indicates hyperplasia with a very low risk of associated cancer and so patient can be treated with ____ (ex. Oral or IUD ______ ) to reduce endometrial thickness. Patient should be reviewed in ____ with TV ultrasound and further biopsy.
Biopsy with ____ suggests high risk of progressing to endometrial cancer and 1st line management in post- menopausal women is a ____ . Endometrial ___ is also an option.
However, in younger reproductive females who would like to preserve fertility (ex. ____ patient more likely to get endometrial cancer), conservative management with ____ can be considered with patient reviewed (i.e TV ultrasound and biopsy every ____ )
Atrophic vaginitis
Transvaginal ultrasound
>4mm
biopsy
atypia
progestogens
levonorgestrel
6 months
Atypia
Total hysterectomy
Ablation
PCOS
Progestogens
3 months
_____ , _____ and _____ can all increase the risk of endometrial cancer as they provide unopposed levels of oestrogen stimulation to the endometrium.
COOP
Obesity
Type 2 Diabetes Mellitus
Itching of the hands and soles of feet (particularly) at night with no rash is a common presentation of obstetric cholestasis (i.e blocking of the biliary tree). This leads to high levels of circulating ____ which causes itching to the skin.
If rash is present it suggests a ______.
Due to obstruction in the biliary tree, there is also a higher level of circulating bilirubin and this leads to____ , _____ and ____.
Low levels of bile salts in the intestine also reduces the ability of the intestine to absorb ____ soluble vitamins such as ____ , and thus may lead to a _____ - Dangerous in the event of a bleed.
Bile salts
Polymorphic eruption of pregnancy - no blisters / pemphigoid gestationis - blisters (autoimmune skin eruption - more common in people with graves etc.)
Jaundice, pale stools, and dark urine
Fat soluble
Vitamin K
Coagulopathy (High INR/high PT)
- Obstetric cholestasis is associated with an increased risk of ____, ____, and _____.
Pre-mature birth, **stillbirth** and meconium passage.
In obstetric cholestasis remember that patients will have deranged ____ and increased levels of circulating bile salts on blood investigation.
**Remember** it is normal for ___ to rise in pregnancy as the ____ produces it. Thus an isolated rise in ___ is normal in pregnancy and not indicative of pathology
LFTs
ALP
Placenta
ALP
Management in obstetric cholestasis includes:
_____ improves LFTs, bile salts and symptoms.
_____ and _____ can also provide symptomatic relief.
Condition resolves after _____.
Ursodeoxycholic acid
Emollients and anti-histamines
Delivery
Pelvic Inflammatory disease can lead to____, ___ and ____ and so should be treated immediately.
Subfertility, ectopic pregnancy and chronic pelvic pain
Treatment of Pelvic Inflammatory Disease in the non septic patient is with oral _______ therapy.
Triple antibiotic therapy (Ceftriaxone / Doxycycline and Metronidazole) and review within 3 days.
Treatment of PID in the septic patient needs IV antibiotic therapy.
An important differential in PID to consider is a ____ . This is a late complication of PID and is life threatening condition if ruptures as can cause sepsis. _____ used to rule this out.
**Tubo-ovarian abcess **
TV Ultrasound
Patients who have previously suffered from gestational diabetes during pregnancy should have a ______ as soon as possible after ____ booking visit. If glucose tolerance is ok at this point, they should be retested at 24 weeks.
Patients that have an increased preponderance to develop GD (____, _____, _____) and ethnicities such as should also have a _____ at ____ weeks.
Patients with pre-existing Type 1 and 2 DM should have their Hba1c tested at booking visit. Check _____ and fundoscopy for retinopathy as in general, Insulin resistance is ____ during pregnancy.
2hr Oral Glucose Tolerance Test (OGTT)
9/10 week
2hr OGTT
(Obesity, Macrosomic baby, Familial history of GDM)
Afro-Caribbeans, South Asians, and middle easterns
24 weeks
Renal function
Increased
Stress incontinence risk factors:
Age
Obesity
Multiparity
Traumatic delivery
Gynae surgery
Treatment for stress incontinence:
1st line: Pelvic floor exercises (3-month with physiotherapist)
2nd line: Duloxetine (SNRI)
3rd line: Surgery
All TORCH congenital infections can present with non-specific symptoms such as:
Petechiae and purpura
Hepatosplenomegaly
Jaundice
Seizures
Small for gestational age (SGA)
Haemolytic anaemia
Toxiplasmosis Gondii causes a classic triad of symptoms:
It also presents with a ____ rash.
- Intracranial calcifications (diffuse as opposed to CMV which are paraventricular)
- Hydrocephalus (vs. microcephalus in CMV)
- Chorioretinitis (also in CMV)
Blueberry muffin
Toxiplasmosis gondii is a ____ that can be picked up from ___, ____, _____, and _____ .
Usually the mother is asymptomatic, and the earlier the infection in pregnancy the lower the risk of transmission to the foetus. Highest transmission is in the ____ trimester.
Increases risk of _____, _____, and _____ .
Parasite
Raw vegetables, Uncooked meats, Unpasteurised goat’s milk, and Cat faeces.
3rd Trimester.
Misscarriage, stillbirth and preterm.
In toxiplasmosis gondii, only ___ % are symptomatic at birth. Patients can go on to develop ___, ___, ___, and ___.
25%
Developmental delay
Epilepsy
Blindness
Deafness
Bacteria Listeria Monocytogenes can be passed from mother to foetus via ingestion of _____.
Defining characteristics include:
**soft cheese**
Spontaneous abortion
Pustular lesions
Neonatal meningitis
Sepsis
Rubella (aka german measles) is Viral infection caused by the rubella virus that occurs in unvaccinated mothers who present with ___, ____ and ___.
Unvaccinated
Non-specific rash
Fever
Lymphadenopathy
Rubella infection in the mother is most dangerous in the first ___ weeks, as beyond this point it is unlikely to be transmitted to the foetus.
16 weeks (90% of infections are transmitted to foetus in the 8-10 weeks of pregnancy)
The classic triad of rubella infection in the newborn is:
Cardiac abnormalities (ex. PDA - continuous “machine like” murmur)
Cataracts
Deafness
Cytomegalovirus (CMV) :
- Only ___ symptomatic at birth, causes long-term complications such as:
10%
- Intrauterine growth restriction (like rubella)
- Chorioretinitis (like toxiplasmosis)
- Periventricular calcifications
- Microcephaly
- Sensorineural deafness (like rubella)
**Remember C for Cephalus/Chorioretinitis/Calcifications M for Micro and V for periVentricular calcifications.**
The average age of the natural menopause is ____ years, but can occur much earlier or later. Menopause occurring before the age of 45 is called ______ and before the age of 40 is ____ .
51
Early menopause
Premature menopause
*Generally, women having an early or premature menopause are advised to take HRT until approximately the average age of the menopause, for both symptom control and bone protective effect*
Risks associated with HRT (X6):
Endometrial Cancer (reduced by giving progestogen)
VTE (not with patch)
CVD/Stroke (only if started in women >60/ stroke not increased w/ patch)
Breast Cancer (risk goes up slightly - no increase in mortality - because patients have hormone receptors and thus wide range of therapies available)
Very small increased risk of ovarian cancer after 5yrs of therapy and >50yrs old. (1 more per 1000)
Gallbladder disease (increased in all HRT)
_____ phase is always 14 days long in the menstrual cycle.
Luteal
Contraceptions that stop bleeding/menstruation (i.e amenorrhoea)
IUS (progestogen)
POP
DMPA (depot-medroxyprogesterone acetate) - depot - most effective at causing amenorrhoea - 45% after 12 months.
*any of the progestogen only contraceptives*
Vaginal atrophy/vaginal dryness treatment
Topical Lubricants
Local Oestrogen pessary/cream
A woman is considered potentially fertile for:
- _____ yrs after her last menstrual period if she is less than 50 yrs.
- ____ yrs after last period if > 50 yrs.
2 yrs
1 yr
Premature ovarian failure needs to be identified and treated due to risk of:
CVD
Stroke
Osteoporosis
Cognitive impairment
Dementia
Parkinsonism
*Premature ovarian insufficiency is defined as menopause before the age of 40 years*
https://zerotofinals.com/obgyn/gynaecology/prematureovarianinsufficiency/
Which HRT method does not confer an increased risk of VTE?
Transdermal Patch
Diagnosis of premature ovarian failure:
Based on a combination of oligomenorrhoea / amenorrhoea of more than ____ duration associated with elevated gonadotropins (____ >___ iu/l) on at least ___ occasions measured ___ weeks apart in women under the age of 40.
4 months’
40
Two
4-6
Menopause can be diagnosed clinically diagnosed clinically after ___ months of amenorrhoea in a woman aged over ___ yrs.
12 months
45 yrs
Non-pharmacological treatment of menopause?
Lifestyle:
Stop Smoking
Stop Alcohol
Stop Caffeine
Sleeping in cold room / wear lighter clothes/ Sleep hygiene
Exercise (bone and CVS health)
CBT
Weight loss (reduces breast cancer risk)
Symptoms of menopause:
Vasomotor - Hot flushes/Night Sweats/Palpitations
Psychological - Low mood / Anxiety / Reduced libido
Local - Vaginal dryness/ Atrophy / Itchiness
/ Urinary incontinence / dysparunia / UTI’s
Non-hormonal pharmacological treatment of menopause?
SSRI/SNRI (Fluoxetine / citalopram/ Venlafaxine)
Vaginal lubricant
Clonidine (for vasomotor symptoms)
Gabapentin (hot flushes)
Complimentary symptoms (ex isoflavones/ red clover/ black cohosh)
Pharmacological treatment of menopause?
HRT (oestrogen +/- progesterone)
*Women with a uterus - give progesterone to negate increased risk of endometrial cancer with unoppossed oestrogen exposure*
*Women without a uterus can have oestrogen only therapy*
Mirena coil (IUS w/ progestogen) :
Length of action for contraception ____ yrs.
Length of action for HRT ____ yrs.
5 yrs
4 yrs
If you remember one thing about HRT for your exams, remember the basics of choosing the HRT regime.
Women with a uterus require endometrial protection with _____, whereas women without a uterus can have oestrogen-only HRT.
Women that still have periods should go on ___ HRT, with cyclical progesterone and regular breakthrough bleeds.
Postmenopausal women with a uterus and more than ___ months without periods should go on continuous combined HRT
Progesterone
Cyclical
12
There are some essential contraindications to consider in patients wanting to start HRT:
Undiagnosed abnormal bleeding
Endometrial hyperplasia or cancer
Breast cancer
Uncontrolled hypertension
Venous thromboembolism
Liver disease
Active angina or myocardial infarction
Pregnancy
To follow the ____ Guidelines, the young person must:
- The young person ____ the professional’s advice. U
- The young person cannot be____ to inform their parents or let the healthcare professional discuss it. P
- The young person is likely to begin, or to continue having, _____ with or without contraceptive treatment.S
- Unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to ____ S
- The young person’s best _____ require them to receive contraceptive advice or treatment with or without parental consent. I
UPSSI
Fraser Guidelines
Understands
Persuaded
Sexual intercourse
Suffer.
Interests
During a consultation it is intergral to assess for coercion or pressure to take contraception (from an older partner for example) as this may raise safeguarding concerns.
Injection/ depot
Pros:
Cons:
Pros:
Amenorrhoea (>45%)
Can be used in breast feeding
Doesn’t require daily adherence
Cons:
Permanent
Fertility (at least 12 months to return)
Weight gain
BMD (shouldnt be given to <20 yr olds)
No protection from STI
Implant
Pros:
Cons:
Pros:
3yrs
Cons:
Irregular bleeding
Bruising/Painful/ Surgical incision to take out/ Can migrate/ Scar
IUD (copper coil)
Pros:
Emergency Contraception
Long Acting (5-10 yrs)
No Hormones
Cons:
HMB
Pain
Invasive
Fitting issues (Can be expelled/ can cause uterine perforation/ hypotensive shock)
Ectopic (slight increase)
IUS (mirena/jaydess)
Pros:
Cons:
Pros:
Amenorrhoea
Regulates menorrhagia (1st line)
Local effect only
Fertility returns straight away once removed
Cons:
Invasive
Which class of medications is important to ask about when assessing suitability for contraception?
Anti-epileptics (ex. lamotrigine and carbamezapine - CYP450).
Women ovulate __ days before last mentrual period. This is why its important to know cycle length.
14 days.
For example 21 days cycle (ovulate at 8 days)
28 day cycle (ovulate at 14 days)
30 day cycle (ovulate at 16 days)
*Luteal phase is always 14 days*
Female fertility can be checked by measuring the level of _____ 7 days before menstruation because this is when its at its peak (mid luteal phase), and indicates that _____ has occurred.
Progesterone
Ovulation
Tubal patency can be observed using ____ and ____ .
Ultrasound
Xray
(surgery also possible)
Termination of pregnancy
- < 10 weeks a _____ or medical termination with ____and ____
- 10- ___ weeks a _____ surgery is recommended. Sometimes misoprostol is used in addition to soften the cervix.
- 14- 24 weeks a ______ and _____ technique - aspiration, forceps and ultrasound.
- If Ectopic use _____.
Vaccum aspiration
Mifepristone and Misoprostol
14 weeks
Vacuum aspiration
Dilatation and evacuation
Methotrexate
What is the 1st line analgesic that is safe to use in pregancy?
Paracetamol is safe throughout pregnancy.
NSAIDs are teratogenic: increased risk of _____ if used in early pregnancy.
If used after ____ weeks NSAIDs can close ductus arteriosus and can also cause ______ of the newborn and _____.
Codeine: not generally recommended during pregnancy, especially in 3rd trimester as cause _____ and ____ syndrome.
Misscarriage
30
Persistent pulmonary hypertension
Oligohydramnious.
Respiratory distress
Neonatal withdrawal
Change in bowel habit / bloating / early satiety / fullness / loss of appetite / weight loss / vaginal bleeding / Pelvic or abdominal pain/ polyuria are all important symptoms to rule out in a post-menopausal woman as they may indicate ovarian cancer.
**_____ and _____ are signs of late stage disease. **
Polyruia
Change in bowel habit
RMI - _____
Includes 3 factors
_____ x _____ x_____
If RMI gives a high score - ___/___ imaging determines extent of disease. This determines type of surgery and whether patient needs (Neo) adjuvant chemotherapy.
RISK MALIGNANCY INDEX (RMI):
Menopause status x Ca125 x TV ultrasound
MRI/CT
___Obesity_ , ____ , _____ , ____, and _____ further compounds the already increased risk of a VTE in pregnancy.
Treatment: _____ (i.e _____) for at least ____ months and up to ___ weeks post-partum.
Investigation: **_____ **.
Unless patient is exhibiting signs of a PE (breathlessness/Tachycardic/Tachypnoiec/chest pain/dizziness/palpitations) - ECG/Chest x-ray/ VQ scan/ CTPA
Obesity
Multiple pregnancies (i.e twins)
Assisted reproductive technology (i.e IVF)
Age (>35 yo)
Family history
Low molecular weight heparin
Enoxaparin
3 months
6 weeks
Duplex-ultrasound (Doppler + Normal ultrasound)
HRT
Reduces the risk of (X2):
Osteoporosis
Colon cancer (up to X 1/3)
Cardiotocography (CTG)
*Remember – DR C BRVADO
Define Risk : why is the patient on a CTG monitor?
Contractions - can have up to 5 in 10 minutes
Baseline Rate: 110-160 bpm
Accelerations: Rise of 15 bpm for 15 seconds or more. Usually have 2 every 15 minutes and are close to the contractions.
Variabilty: 5-25 bpm
Decelerations: Reduction of 15bpm for 15 seconds or more
Overall Impression
Cardiotocography (CTG):
Baseline bradycardia:____, ____, or ____.
Baseline Tachycardia:____, ____, or ______.
Reduced Baseline Variability: _____ or _____.
Early Deceleration: _____.
Late deceleration: ____ (e.g ____).
Variable deceleration: _____.
Baseline bradycardia: Cord prolapse, epidural/spinal anaesthesia, rapid foetal descent.
Baseline Tachycardia: Mother usually pyrexic, baby is hypoxic, or prematurity
Reduced Baseline Variability: Hypoxic, premature
Early Deceleration: Benign sign that baby’s head is compressed during descent.
Late deceleration: Fœtal distress (ex.asphyxia)
Variable deceleration: Cord compression
Cervical ectropion
Exposure and migration of ____ (columnar epithelium) to ____ (squamous epithelium) caused by high levels of _____ exposure. (Ex. ___, ____, _____) and exposure to more ____ environment of vagina.
Diagnosis of exclusion as need to exclude cervical cancer with a smear.
Endocervix
Ectocervix
Oestrogen
(ex. COOP, Puberty, Pregnancy)
acidic
May cause visible erythematous ring (differential cervical cancer/dysplasia), post-coital vaginal bleeding and mucous discharge but most often is symptomless.
Contact Trauma from sexual intercourse also an important differential.
Induction of labour steps (4X)
- _____ (___hrs)
- _____ (every ___hrs)
- _____ (w/ ____)
- _____ (IV/IM)
Syntocinon infusion needs to be judiciously titrated with _____ as it can cause ____ and ____.
- Prostaglandin Pessary (24hrs)
- Prostaglandin gel (every 6 hrs)
- Artificial Rupture of Membranes (AROM - w/ Amnihook)
- Syntocinon (IV/IM)
Frequency of contractions
Uterine hyperstimulation
Foetal distress
Missed Oral Contraception
- COOP: Take last missed pill, prescribe emergency contraception, and advise against sexual intercourse/additional contraceptive measures for ___ days.
- POP: Take last missed pill, avoid sexual intercourse/use additional contraceptive measures for next ___ hrs. If patient has sex in this period prescribe emergency contraception (i.e levonorgestrel, ulipristal)
7 days
48 hrs
Loss of >___ ml blood is considered a Post Partum Haemorrhage (PPH). Loss of ____ is considered a major PPH
500 ml
1000 ml/1L
PPH Management:
- ____
- ____
- ____
- ____
- ____
**Can also use ______ instead of syntocinon, but contraindicated with patients w/ ____ or ____ during pregnancy as they raise blood pressure.**
- Syntocinon (IV/IM)
- Carboprost (prostaglandin)
- Balloon Tamponade
- B-Lynch Suture
- Hysterectomy
ergometrine/syntometrine (uterine smooth muscle stimulants)
hypertension
pre-eclampsia
**Syntocinon: is an ____ analogue and works by ______.
**Carboprost (Prostaglandin E2 receptor causes _____ ) needs to be carefully monitored in ____ as it can cause _____ **.
increasing the intracellular level of Ca2+.
myometrial contraction
asthmatics
bronchoconstriction
Bartholin’s Cyst.
Common benign lesion caused by _____ and subsequent dilatation of ____.
- Usually affects women of _____ years.
- Often painless, but patients (often recurrent) can also present with erythematous, tender lump called bartholin’s abcess, which can give systemic symptoms (i.e fever).
- Bartholin’s cyst can be treated with____ and ____.
- Bartholin’s abcess needs_____ and either ____ for ____weeks, or ____.
obstruction
bartholin’s gland
reproductive (20-30)
Bartholin’s cyst: warm baths and simple analgesia.
broad spectrum antibiotics
balloon catheterization for 4-6 weeks
Marsupialisation
- ____ is a normal bleeding process that occurs in the ___ weeks after delivery.
- ____ may make the condition worse.
- ____ should be avoided in this period as they pose a serious infection risk.
Lochia
4-6 weeks
- Consists of blood, mucous, products of conception and so can be quite clotty and red at first and relatively heavy. This later (over a number of weeks) becomes brown and lighter.
- Breastfeeding may make the condition worse as it activates a neuroendocrine reflex arc that stimulates the uterus to contract.
- Patients should avoid using tampons as this presents a serious risk of infection.
Endometritis: Inflammation of the endometrium that often occurs ___.
- Usually caused by ____ and gram negative microbes.
- Presentation: 2-3 days of _______, period cramps, ____, uterine tenderness and fever.
- Treatment: _____.
after delivery
Group B strep
foul-smelling bloody discharge
lower abdominal pain
co-amoxiclav (amoxicillin/clavulanic acid)
Urge Incontinence/OAB
- Treated usually with ____ of bladder training.
- If this is not successful then anticholinergics ( **antimuscarinics**) such as ____, _____, and ____ can be added.
- However, remember antimuscarinics are contra-indicated in ____. In these patients a _____ can be used.
Antimuscarinics: oxybutynin, tolterodine and darifenacin
Elderly patients as they can increase likelihood of having a fall.
B3-agonist - mirabegron
Indications for forceps delivery.
FORCEPS :
Fully Dilated
Occipito-anterior position
Ruptured Membranes
Cephalic presentation
Engaged presenting part (*remember 3/5 or 2/5 suggests baby is engaged within pelvis)
Pain relief adequate
Sphincter (empty bladder)
Vulvovaginal Candidiasis
- Caused by ____
- Presents with « ____ and ____ »
Treated with intra-vaginal ____ antifungal ___ containing ____.
Candida albicans
Itching and white curd-like discharge
Pessary/cream
Clotrimazole
Anaemia in pregnancy is very common due to an ____. This gives a concomittant low _____ . ____ however is expected to increase.
Increased plasma volume
Haemoglobin concentration
MCV
Idiopathic thrombocytopaenia purpura (ITP) is a condition in which autoantibodies attack the ____ present on ___ cells. This leads to a dramatic loss of circulating platelets in the ____ trimester.
Important to pick up ITP as it can cause neonatal thrombocytopaenia and thus increases the risk of _____ in the fœtus
Antigens
Platelet
1st
intracranial haemorrhage
What are the 1st and 2nd line treatments for Idiopathic Thrombocytopaenia in pregnancy?
- 1st line: Steroids
- 2nd Line: IVIG
Platelet count at term is important as >70X109 needed for ____ and >50X109 is needed for ____.
epidural
safe delivery
Gestational thrombocytopaenia is a most often asymmptomatic drop in platelet count that occurs in most pregnancies (drop of ~ 10%) It is unlikely to lead to a platelet number below 70X109/L. Most often occurs in the *___ trimester*.
3rd
Pregnancy of unknown location (PUL)
- B-HCG < ____ unlikely to see pregnancy on ultrasound.
- B-HCG >____ should be able to see prenancy on ultrasound.
- If B-HCG ____ in ____hrs this indicates a Intra-Uterine Pregnancy.
- If B-HCG ____ in 48hrs, this indicated a Miscarriage.
- If B-HCG is in between these two windows, this indicated an ___.
1000 IU/L
1500 IU/L
increases by >63% in 48 hrs - Intruterine pregnancy
decreases by >50% in 48hrs - Miscarriage.
Ectopic Pregnancy.
A ___ is taken at booking visit (____ weeks) to identify any clinically relevant asymptomatic bacteria (ex E.coli).
This is because asymptomatic bacteriuria (UTI) is associated with ___ and ____ during pregnancy.
Midstream urine sample (MUS)
8-10 weeks
Preterm
Pyelonephritis
What is the 1st line treatment for a UTI in pregnancy?
Nitrofurantoin
Which antibiotics are contraindicated in pregancy?
Trimethoprim (causes folate deficiency and thus neural tube defects)
Doxycycline (teratogenic and also must be avoided in children)
Cervical smear screening:
Age _____ : Every ____ years.
Age ____ : Every ___ years.
25-50
3 yrs
50-65
5 yrs
Grades of CIN or _____, are determined by how many layers of the _____ are affected by ____ and how severely the dyskarytotic the cells are. (i.e abnormal ____:_____ ratio).
Cervical Intraepithelial Neoplasia
Squamous Epithelium
Dyskaryosis
Cytoplasmic : Nucleus
Pelvic Floor Prolapse Risk Factors:
Child birth (multiparous)
Traumatic/Forceps/Episiotomy
High BMI
Gynaelogical/Pelvic organ surgery
Menopause (lack of oestrogen causes reproductive organ atrophy)
Connective Tissue Disorder (Ehlers-Danlos syndrome)
Complications of an epidural:
Urinary retention
Hypotension
Spinal Headache
Respiratory Depression of Foetus due to opioid.
Epidural complications :
- **Urinary retention** as neural output to bladder is blocked
- **Hypotension** as anaesthetic can block sympathetic output and thus cause widespread vasodilation (thus always monitor BP during epidural)
- **Spinal headache** as accidental penetration of subarachnoid space causes leakage of CSF
- **Opioid** as could reach the baby and cause respiratory depression.
Monochorionic pregnancies need to be monitored every __ weeks from ___ weeks of gestation to scan for abnormalities.
Whereas
Dichorionic pregnancies need to be scanned every ___ weeks from ___ weeks gestation
2
16
4
20
Causes of Pathological/Abnormal Uterine Bleeding:
Remember “PALM COIEN”
PALM (Structural Causes)
Polyp
Adenomyosis
Leiomyoma (Fibroids/leiomyomata)
Malignancy
COEIN (Non-structural causes)
Coagulopathy (ex. Leukaemia -low platelet count / Drugs - warfarin or heparin / Von Willebrand Disease)
Ovulatory (PCOS these patients more at risk of endometrial cancer due to unopposed oestrogen action). When ovulation fails, the corpus luteum does not form and progesterone is not produced. The endometrium then continues to proliferate in the second half of the cycle as well as in the first half (due to unopposed oestrogen produced from follicles in the ovaries). This leads to a bulky endometrium. This is eventually shed and results in heavy and prolonged bleeding often occurring at a longer interval than the normal cycle.
Endometrial (endometritis secondary to chlamydia infection / Endocrine)
Iatrogenic (COCP/Progestogens/Implants/IUD) à wait 3 months to see if it settles and if not use NSAID or Anti-fibrinolytic (tranexamic acid)
Not otherwise classified (arterio-venous malformation / uterine isthmocoele or C-section scar defect)
Fetal squamous cells in maternal blood vessels is confirmatory for ____.
Amniotic Fluid Embolism
The risk of fetal and maternal blood mixing is highest during the 3rd trimester and delivery. Foetal cells act as thrombogenic factors. While this condition is rare, it carries a very high mortality and even those who survive tend to have severe deficits including neurological defects.
Acute shortness of breath, tachycardia, and tachypnoea, wedge-shaped infarction on chest x-ray.
The resultant hypoventilation is causing the hypoxia.
Our maon differential at this stage is PE as pregnancy is a hypercoagulable state and there is an increased risk of thrombus formation, thereby increased risk of embolisation.
Somatic innervation to the bladder is via the ___, ___, and ___ nerves. Autonomic nerves travel in these nerve fibres too.
Bladder filling leads to detrusor relaxation (____) coupled with sphincter contraction.
The _____ nervous system causes detrusor contraction and sphincter relaxation. Overall control of micturition is centrally mediated via centres in the ____.
Pudendal, Hypogastric and Pelvic
Sympathetic
Parasympathetic
Pons
Pre-Eclampisa:
De Novo ___ after ___ weeks pregnancy and ______.
Aetiology unclear but due to increased ____ in the ____ arteries supplying the placenta, release of ____ , and ____ dysfunction.
Hypertension
20
Proteinuria
vascular resistance
spiral arteries
inflammatory cytokines
endothelial
Risk factors for pre-eclampsia:
Biggest risk factor is Chronic disease:
Diabetes (Type 1 and 2) /Chronic Hypertension or Hypertension in previous pregnancy/CKD/Autoimmune disease: Antiphospholipid syndrome + SLE
Lower risk factors:
- FH (If you have 1st degree relative you are 25% more likely)
- Obese
- Multiple pregnancies (twins etc)
- Older mother
- 1st time mother
- 10 yr pregancy interval
Common presenting features of PCOS.
Oligomenorrhoea
Subfertility
Acne
Hirsuitism
Obesity
Mood swings/depression/anxiety
Male pattern baldness
Acanthosis nigricans (secondary to insulin resistance)
Which criteria is used to diagnose PCOS?
Rotterdam diagnostic criteria
Assuming that other causes have been excluded, PCOS can be diagnosed if two of the following are present:
Polycystic ovaries (>12 cysts seen on imaging or ovarian volume >10 cubic cm)
Oligo-/anovulation
Clinical or biochemical features of hyperandrogenism
What investigations can be done in someone you suspect has PCOS?
Bloods:
LH:FSH ratio: Increased (>2). This is also helpful in excluding menopause where the ratio is normal. (FSH often normal)
Total testosterone: normal/slightly raised
Fasting and oral glucose tolerance tests: helps diagnose insulin resistance.
Other tests that might be indicated if other pathologies are suspected include:
_TFTs (_thyroid dysfunction)
17-hydroxyprogesterone levels (CAH)
Prolactin (hyperprolactinaemia)
DHEA-S and free androgen index (androgen secreting tumours)
24-hour urinary cortisol (Cushing’s syndrome)
Imaging:
Transabdominal and transvaginal ultrasound: Shows increased ovarian volume and multiple cysts.
Management of PCOS:
Conservative:
Weight loss and exercise control
Education about increased cardiovascular, diabetes and endometrial cancer risks.
Pharmacological treatment for women not planning pregnancy:
Co-cyprindrol - Useful for reducing hirsutism and inducing regular menstruation.
Combined Oral Contraceptive Pill (COCP) - Used to reduce irregular bleeding and protects against endometrial cancer.
Metformin - Helps with menstrual regularity, hirsutism and acne.
Pharmacological treatment for women wishing to conceive
Clomiphene - Induces ovulation and improves conception rates.
Metformin - Can be used with/out clomiphene to increase the chances of a pregnancy.
Ovarian drilling - is a 2nd line laparoscopic surgical procedure where diathermy or laser is used to damage the hormone producing cells of the ovary.
Gonadotrophins - Can induce ovulation if clomiphene and metformin have failed.
What happens at the booking appointment (10 weeks)?
Comprehensive History
Baseline Blood tests
Urinalysis
Blood pressure
BMI
Ultrasound
Contraindications to vaginal delivery after C section:
Previous Classical (vertical scar) C-section
Previous Uterine Rupture
Usual contraindications to vaginal delivery (placenta praevia)
*VBAC usually has a success rate of around 60-80%. Thus, there is still a risk of having to perform an emergency Caesarean section. Risk is increased with increasing number of prior Caesarean deliveries.
*VBAC usually has a success rate of around ___ . *
*VBAC usually has a success rate of around 60-80%. Thus, there is still a risk of having to perform an emergency Caesarean section. Risk is increased with increasing number of prior Caesarean deliveries. *
Risk Factors for ectopic pregnancy.
Pelvic inflammatory disease
Pelvic surgery
IUS/IUD
Assisted reproduction e.g. IVF
*Anything that slows the ovum’s passage through the fallopian tube to the uterus is a risk factor for developing an ectopic pregnancy*
Indications for a caesarian section:
Abnormal presentation (breech or transverse)
Twins (if first twin is not cephalic)
HIV positive mother
Primary Genital Herpes in first trimester (recurrent herpes is safe to deliver vaginally)
Placenta Praevia
Anatomical Reasons
First Stage of Labour:
____ phase: ____ cm cervical dilation w/ irregular contractions and dilation of ___cm/hr
___ phase: ___ cm cervical dilation w/ regular contractions and dilation of ___ cm/hr
___ phase: ___ cm cervical dilation w/ regular strong contractions and dilation of ___ cm/hr
The first stage of labour is from the onset of labour (true contractions) until the cervix is fully dilated to 10cm. It involves cervical dilation (opening up) and effacement (getting thinner). The “show” refers to the mucus plug in the cervix, which prevents bacteria from entering the uterus during pregnancy, falling out and creating space for the baby to pass through.
The first stage has three phases:
Latent phase – from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
Active phase – from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
Transition phase – from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.
Prolonged rupture of membranes (PROM) : Amniotic sac ruptures more than ___hrs before delivery.
18hrs
Tocolysis involves using medications to stop uterine contractions. ____ is the medication of choice for tocolysis.
_____ is an oxytocin receptor antagonist that can be used as an alternative when nifedipine is contraindicated.
Nifedipine, a calcium channel blocker.
Atosiban
Induction of labour can be used where patients go over the due date. IOL is offered between ____ weeks gestation.
41 and 42 weeks
The ____ score is a scoring system used to determine whether to induce labour.
Five things are assessed and given a score based on different criteria:
A score of ___ or more predicts a succesful induction of labour.
The Bishop score is a scoring system used to determine whether to induce labour.
Five things are assessed and given a score based on different criteria (minimum score is 0 and maximum is 13):
Pregnancy Can Enlarge Dainty Stomachs!
- Position
- Consistency
- Effacement
- Dilation
- Station - Fetal station refers to where the presenting part is in your pelvis
*A score of 9 or more predicts a successful induction of labour and a likely vaginal delivery. A score below this suggests cervical ripening may be required to prepare the cervix.*
1 point is added to the score for each of the following:
Presence of pre-eclampsia
Each previous vaginal delivery
1 point is subtracted for each of the following:
Post-dates pregnancy
No previous vaginal deliveries
Premature pre-term rupture of membranes
200mg ___ Mifepristone followed by ___ micrograms Misoprostol vaginally ___ hours later can be given to terminate pregnancies from weeks 10-24.
Oral
800mg misoprostol
36-48
Terbutaline is a ____. It is used for ___ in uterine hyperstimulation.
Beta 2 (adrenergic) agonist
Tocolysis
Carboprost is a ____ analogue. It is given as a deep ____ injection in postpartum haemorrhage when ergometrine and oxytocin have failed. Crucially it needs to be used with extreme caution in patients who have _____ , as it can cause a life threatening exacerbation.
Prostaglandin
Intramuscular
Asthma
Tranexamic acid is a ____ . It binds to ___ preventing its breakdown to the enzyme ____. This enzyme breaks down blood clots.
antifibrinolytic
fibrinogen
plasmin
What is the most significant risk factor for an umbilical cord prolapse?
How does this present?
What is the management of this condition?
Abnormal lie (i.e unstable/transverse/oblique) after 37 weeks
Foetal distress on the CTG/Vaginal or speculum examnination can confirm
Emergency C-section
_____ involves hyperfelxion of the mother at the hip (bringing knees to abdomen). This provides a posterior pelvic tilt, lifting the pubic symphisis up and out of the way.
McRoberts Manoevre (1st line management in shoulder dystocia)
_____ manoevre involves reaching into the vagina and putting pressure on the posterior aspect of the baby’s anterior shoulder to force it down and under the pubic symphysis.
Rubin’s Manoevre
____ maneouvre involves pushing the baby’s head back into the vagina so that it can be delivered by emergency C-section
Zavanelli
The key complications of shoulder dystocia are:
Foetal hypoxia
Erb’s plasy (brachial plexus injury - C5-C6)
Perineal tears
Post-partum haemorrhage
A single/stat dose of ____ is used after _____ delivery to reduced the risk of maternal infection.
Co-amoxiclav
Instrumental
Epidural carries an increased risk of ____ delivery.
Instrumental
The key risks to the baby to remember in instrumental delivery are:
Cephalohaematoma (ventouse)
Facial Nerve Palsy (forceps)
Instrumental dleivery can cause damage to which two nerves in the mother. This usually resolves over 6-8 weeks.
Obturator
Femoral
Classification of perineal tears.
1st degree:
2nd degree:
3rd degree:
4th degree:
1st degree: Junction between frenulum of labia minora and superficial skin
2nd degree: Perineal muscles (not including anal sphincter)
3rd degree: Anal sphincters
A: < 50% External anal sphincter
B: >50% External anal sphincter
C: Both external and internal anal sphincter affected
4th degree: Mucosa
What are the advantages of active management of the 3rd stage of labour?
Name the two measures that consitute active management.
Shortens 3rd stage (~half an hour)
Reduces the risk of bleeding or post-partum haemorrhage
Intramuscular dose of oxytocin
Umbilical cord traction (during uterine contractions)
Post-partum haemorrrhage classifications
500ml after vaginal delivery
1000ml after caesarian
Minor <1000mls
Major >1000mls
Moderate 1000-2000mls
Severe >2000mls
4 causes of PPH can be remembered with a mnemonic:
Which one is the most common?
PPH
4Ts
Tone (atony most common cause)
Trauma (e.g perineal tear)
Tissue (retained placenta/POC- endometritis)
Thrombin (bleeding disorder)
Intravenous infusion of oxytocin is given as ___units in ___ mls.
40 units
500mls
Primary post-partum haemorrhage is bleeding within ___ hrs.
Secondary post-partum haemorrhage is bleeding within ___ hrs to ___ wks.
24 hrs
24hrs -12 weeks
There are four categories of emergency caesarean section:
Category 1: There is an immediate threat to the life of the mother or baby. Decision to delivery time is ___minutes.
Category 2: There is not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Decision to delivery time is ___ minutes.
Category 3: Delivery is required, but mother and baby are stable.
Category 4: This is an elective caesarean, as described above.
There are four categories of emergency caesarean section:
Category 1: There is an immediate threat to the life of the mother or baby. Decision to delivery time is 30 minutes.
Category 2: There is not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Decision to delivery time is 75 minutes.
Category 3: Delivery is required, but mother and baby are stable.
Category 4: This is an elective caesarean, as described above.
The most commonly used skin incision is a transverse lower uterine segment incision. There are two possible incisions:
____ is a curved incision two fingers width above the pubic symphysis
_______ is a straight incision that is slightly higher (this is the recommended incision)
The most commonly used skin incision is a transverse lower uterine segment incision. There are two possible incisions:
Pfannenstiel incision is a curved incision two fingers width above the pubic symphysis
Joel-cohen incision is a straight incision that is slightly higher (this is the recommended incision)
Contraindications to vaginal birth after C- section (VBAC).
Previous uterine rupture
Previous classical/longitudinal scar c-section
Other reasons for not having a vaginal delivery (ex. placenta praevia)
Two key causes of sepsis in pregnancy are:
____
and
____.
Two key causes of sepsis in pregnancy are:
Chorioamnionitis
Urinary tract infections
All patients admitted to maternity inpatient units, such as at the antenatal ward and labour ward, will have monitoring on a MEOWS chart. MEOWS stands for ______. This includes monitoring their physical observations to identify signs of sepsis.
MEOWS - Maternity early obstetric warning system.
3 options for treating a uterine inversion:
Johnson Manoevre (manually pushing the uterus back into position. held in place for several minutes with concomitant oxytocin infusion)
Hydrostatic methods (inflating the uterus with fluid)
Surgery (laporotomy and uterus pulled back to normal position)
Management of GBS infection
Intrapartum antibiotics
Penicillin
Vancomycin (if penicillin is contraindicated)
HPV promotes the development of cancer by inhibiting tumour suppressor genes ___ and ___.
HPV produces two proteins that inhibit these tumour suppressor genes - ___ and ___.
p53 and pRb. (pat rabbit)
E6 suppresses p53
E7 suppresses pRb.
2/3 of multiple pregancies are ____ whilst a 1/3 are Monozygotic.
Of these monozygotic pregnancies
30% are _____
70% are ____
1% are ____
and
0.1% are ____.
Dizygotic
30% are DCDA - dichorionic (2 placentas) diamniotic (2 amniotic sacs)
70% are MCDA - Monochorionic (one placenta) Diamniotic (2 amniotic sacs)
1% are MCMA - Monochorionic Monoamniotic
and
0.1% are conjoined twins.
Remember that ____ on microscopy mean bacterial vaginosis.
Clue cells
Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.
For uncomplicated gonorrhoeal infection 1st line therapy is:
____ if sensitivities are not known.
____ if sensitivites are known.
Ceftriaxone (IM) if not known
Ciprofloxacin (Oral)if known
Trichomonas vaginalis is a type of ____ spread through sexual intercourse. Trichomonas is classed as a protozoan, and is a single-celled organism with flagella. Flagella are appendages stretching from the body, similar to limbs. Trichomonas has four flagella at the front and a single flagellum at the back, giving a characteristic appearance to the organism
Examination of the cervix can reveal a characteristic “______ ” (also called colpitis macularis).
Treatment is with _____.
Parasite
Strawberry cervix
Metronidazole
The herpes simplex virus can also cause aphthous ulcers (small painful oral sores in the mouth), ____ (inflammation of the cornea in the eye) and _____ (a painful skin lesion on a finger or thumb).
herpes keratitis
herpetic whitlow
HSV-1 is most associated with ____.
HSV-2 typically causes ____.
Cold Sores (Most common cause of genital herpes via oro-genital sex)
Genital Herpes (HSV-2 is usally a cause of re-infection (i.e reactivation of a previous infection )
Incubation - few days to 3 weeks
But this is not a hard rule and either strain can cause either cold sores or gential herpes.
Treatment of genital herpes is with ___ .
Aciclovir (400mg TDS for 5-10 days)
Alternatives are valaciclovir/famciclovir
Non-Pharmacological:
Analgesia
Saline Bathing
Local anaesthetic gel - Lidocaine 5% medicated plaster (Versatis®)* is licensed for the symptomatic relief of neuropathic pain
Warm water urination (in shower)
Counsel on risk of infection to others
Counsel on pregnancy
*Refractive/recurrent disease can be treated with long term aciclovir - 3-12 months*
What is the treatment of uncomplicated Gonorrhoea?
** Most regimes give IM Ceftriaxone 1 g if sensitivities are NOT known**
Oral Ciprofloxacin (500mg) if sensitivites are known
(azithromycin covers potential chlamydia infection)
The ___ sign is pathognomic of LGV (Lymphogranuloma Venereum)
“Groove” Sign
LGV (subtype of chlamydia infection) begins with a painless ulcer which progresses to form painful inguinal buboes, causing the characteristic “groove” sign.
This may be accompanied by fever and malaise.
Men who have sex with men (MSM) are at higher risk of LGV.
Changes to maternal physiology to consider when prescribing
This can also be described as pharmacokinetics as this is what the body does to the drug during pregnancy.
i.e
Absorption
Distribution
Metabolism
Excretion
Pharmacokinetics can be described as ____
whilst
Pharmacodynamics can be described as ____
Pharmacokinetics - what the body does to the drug
Pharmacodynamics - what the drug does to the body
Pharmacokinetics during pregnancy
Note that not only is metabolism altered during pregnancy, but renal clearance is also increased dramatically due to the increased circulating blood flow and thus GFR.
To summarize in pregnancy:
Reduced/Slowed Absorption
Increased Volume of Distribution (remember increased circulating blood volume and Fat:Water ratio) Metabolism and Excretion
What are the main CYP450 enzymes
Percentage of drugs metabolised by these CYP450 subtypes:
CYP3A4 - 55%
CYP2D6 - 30%
* Concentrations of both these CYP450 enzymes increases during pregnancy leading to increased metabolism and thus renal clearance. This leads to a suboptimal concentration of the drug and thus therapeutic benefit*
CYP2D9 (10%)
CYP1A2 (3%) - *Note this enzyme decreases during pregnancy and thus can lead to toxicity of drugs administered that are also induced by CYP450*
Medications to avoid during pregnancy (teratogens)
ACEIs - Renal dysfunction, skull ossification.
Aminoglycosides - Deafness, vestibular damage.
Cytotoxic drugs - Multiple defects, abortion.
Anti-thyroid drugs - Foetal goitre.
Carbamazepine - Neural tube defects.
Diethylstilboestrol - Vaginal carcinoma.
Lithium - CVS defects (Ebstein anomaly - abnormal tricuspid valve_)_
Phenytoin- Foetal hydantoin syndrome.
Retinoids - Craniofacial, cardiac & CNS defects.
Sodium valproate - Neural tube defects.
Warfarin - Foetal warfarin syndrome.
Drugs to avoid in 3rd trimester
•Tetracyclines: Tooth discolouration.
•Warfarin: Foetal intracranial haemorrhage.
•Androgens: Masculinisation of female foetus.
•NSAIDs: Closure of foetal ductus arteriosus.
•Opioids: Withdrawal effects in neonate.
•Theophylline: Neonatal irritability.
•SSRIs: Neonatal irritability.
___ and ___ are the anti-epileptics considered to be safe in pregnancy (usual maintenance dose).
Soldium valproate can only be used if there is a _____ but is generally contraindicated unless prescribed under the guidance of a specialist due to its teratogenic effects.
Lamotrigine (more evidence) > Levetiracetam
Valproate pregnancy prevention programme in place
What is the diagnostic test of choice for soemone suspected of having Chlamydia infection?
NAAT
(Nucleic acid amplification test)
___ sign is when an inguinal lymphoadenopathy (AKA a BUBO) is split by poubarts ligament and is pathognomonic of ____ infection.
Groove Sign
Lymphogranuloma Venereum
How do we investigate a patient with suspected gonorrhoea?
NAAT
Microscopy is possible unlike chlamydia and you may see gram negative diplococci however whilst microscopy is 90% sesistive in men with discharge it is only 50% sensitive for women.
- Anyone with a positive NAAT needs to be swabbed in an areas of sexual contact for culture.
Complications of STI’s (Chlamydia and Gonorrhoea)
PID (sepsis - subfertility - Ectopic risk)
Epididymo-Orchitis (EO)
SARA (Sexually Acquired Reactive Arthritis)
Perihepatitis (Fitz-Hugh-Curtis syndrome)
HIV risk
Gonorrhoea can also cause a disseminated rash.
Untreated gonorrhoea can lead to major complications, such as:
Infertility in women: Gonorrhoea can spread into the uterus and fallopian tubes, causing pelvic inflammatory disease (PID). PID can result in scarring of the tubes, greater risk of pregnancy complications and infertility.
Infertility in men: Gonorrhoea can cause a small, coiled tube in the rear portion of the testicles where the sperm ducts are located (epididymis) to become inflamed (epididymitis). Untreated epididymitis can lead to infertility.
Infection that spreads to the joints and other areas of the body: The bacterium that causes gonorrhoea can spread through the bloodstream and infect other parts of your body, including your joints. Fever, rash, skin sores, joint pain, swelling and stiffness are possible results.
Increased risk of HIV/AIDS: Having gonorrhoea makes you more susceptible to infection with human immunodeficiency virus (HIV), the virus that leads to AIDS. People who have both gonorrhoea and HIV are able to pass both diseases more readily to their partners.
_____ is a tiny bacteria that can cause a non specific urethritis and can present similarly to other STI’s like gonorrhoea and chlaymdia. However it is often asymptomatic.
Can be tested for using ____ and is treated similarly to chlamydia in uncomplicated infection with ____.
However Complicated infection needs to be managed with a different antibiotic called ____
Mycoplasma Genitalium
NAAT
Doxycyline + Azithromycin
**Moxifloxacin** (14 days OD)
Primary syphillis often present around ___ weeks after initial infection with a ____.
3 weeks
Chancre
*often described as single painless indurated*
Secondary syphillis most commonly presents around ____ after initial infection.
Most common symptom is a _____ (75%)
Wart like lesions called _____
Mucocutaneous lesions (6-30%)
Generalised lymphadenopathy (50-86%)
Multi-system involvement- Sore throat, malaise, weight loss, fever, musculoskeletal.
3 months
Maculopapular Rash
**Condylomata lata**
Multisystem involvement can also lead to nephritis/hepatitis etc and often can cause neurological symptoms (tinnitus/ocular syphillis/stroke)
Tertiary Syphillis leads to:
Cardiovascular (____ yrs after initial infeciton)
- Symptomatic/complicated in 10%
- Ascending aorta: dilatation & aortic regurgitation
- Rarely: coronary ostial stenosis, saccular aneurysm
_____ (2-15 years after inital infection)
• ____ lesions with central necrosis
10-30
Gummatous
Granulomatous
Syphillis follow up:
Primary Syphilis
• All partners in last ____
Secondary and Early latent Syphilis
• All partners in last ___
Late Latent and Tertiary Syphilis
• Guided by previous serology but potentially all previous partners
*Serology is monitored for 12 months whilst on treatment to see that levels of bacteria are falling appropriately*
3 months
2 years
Clinical Features of HSV
Genital ulcers (painful)
Dysuria
Mouth ulcers
Prodromal illness (fever flu like symptoms)
Vaginal or Penile discharge
Lymphadenopathy (first episode bilateral - recurrent infection - unilateral)
Extragenital manifestations of HSV?
Neurological:
Meningitis
Encephalitis
Dermatological:
*dermatitis herpetiformis*
*herpetic whitlow*
Ophthamological:
Herpetic eye disease (dendritic corneal ulcers)
HPV
_____ (low risk strains often cause benign neoplasia ex. condylomata)
___ (high risk strains often cause Intraepithelial Neoplasia in the vulva, cervix, anus etc)
6 and 11
16 and 18 (McCarthy and Schneiderlinn)
Cervarix (bivalent) immunises against two types: 16 and 18.
Gardasil: protects against 6, 11, 16 and 18
Management of HPV (genital)?
Cryotherapy (irritates and stimulates surrounding skin mounting immune response)
Topical Agents (Imiquimod)
Electro-cautery
Surgery
Nothing (30% wil disappear)
*Gynae referral if suspect Intraepithelial Neoplasia*
All acute hepatitis infections are notifiable illnesses for public health.
Hepatitis B Serology Interpretation:
Surface antigen (HBsAg) – _____
E antigen (HBeAg) – _____
Core antibodies (HBcAb) – ____ (acute infection antibody ___ Chronic infection antibody ___)
Surface antibody (HBsAb) – _____
Hepatitis B virus DNA (HBV DNA) – _____
Surface antigen (HBsAg) – active infection
Envelope antigen (HBeAg) – marker of viral replication and implies high infectivity
Envelope antibody (HBeAb) - stopped replicating
Core antibodies (HBcAb) – implies past or current infection (IgM high in acute infection / IgG high in chronic or cleared infection )
Surface antibody (HBsAb) – implies vaccination or past or current infection
Hepatitis B virus DNA (HBV DNA) – this is a direct count of the viral load
*remember Hep B is only DNA virus*
Management of Hepatitis B
Antivirals
1st line: Peginterferon
2nd line: Tenofovir or entecavir
Also screen for co-infection of Hep D
and
Refer to Hepatology
Management of Misscarriage
Most common site of ecotpic pregnancy?
Ampulla of fallopian tube
Clinical presentation of Ectopic
Remember blood is usually brown due to decidua breaking down
Management of Ectopic Pregnancy
Medical Management:
1st line (unless patient very unwell) - one-off dose of methotrexate.
(The woman is required to come to a follow-up appointment)
If the initial dose of methotrexate has failed to treat the ectopic they will require either a second dose of methotrexate or surgical management.
Surgical Management:
Surgical management is recommended if the patient would be unable to attend follow-up or if the ectopic is advanced. An advanced ectopic is indicated if any of the following are present:
The patient is in a significant amount of pain
There is an adnexal mass of size ≥35mm
B-hCG levels are ≥5000IU/L (consult local guidelines)
Ultrasound identifies a foetal heartbeat
Surgical management is often in the form of a salpingectomy where the Fallopian tube containing the ectopic is removed, unless only one functioning Fallopian tube, and they wish to remain fertile, a salpingotomy may be done where only the ectopic is removed.
Salpingotomy carries the risk that not all the tissue may have been removed and so serial serum B-hCG measurements are done to exclude any trophoblastic tissue still within the Fallopian tube.
Classic presentation of Placental abruption
Remember often much more painful than placenta praevia
- Can be concealed and thus get no blood
- Woody as in hard because of uterine spasms (contracted muscle)
Risk factors for placenta praevia
Main one is Previous C-Section
Management of pre-eclampsia
1st line: Labetalol (contraindicated in asthma)
- Nifedipine/Methyldopa
Delivery
Biggest risk factor for Uterine rupture? (occurs during delivery - no contractions/pain)
Vaginal delivery after previous C-Section
Management of a Uterine Rupture?
Emergency Laporotomy
What is the main differential for a amniotic fluid embolism?
PE
*Remember Amniotic Fluid Embolism is extremely rare*
Management: Delivery (Category 1 C-Section) and Resus mother
What is the management of Shoulder Dystocia?
Call for help
Ask mother to stop pushing
1st line - McRoberts Manoevre (90% successful)
2nd line:
All-fours position
Internal rotational manoeuvres:
Woods’ screw manoeuvre: anterior shoulder is pushed towards the foetal chest and the posterior shoulder is pushed towards the foetal back.
Rubin manoeuvre II: rotation of the anterior shoulder towards the foetal chest.
If External Cephalic Version (ECV) at 37 weeks is declined, what risk is the pregancy at?
Umbilical Cord Prolapse
High risk of fetal mortality as placental blood supply is compromised (often bradycardia on ECG)
