Obs and Gynae Flashcards
(310 cards)
1
Q
Explain the hypothalamic-pituitary-gonadal axis
A
- Hypothalamus releases GnRH
- GnRH stimulates the pituitary to produce LH and FSH
- LH and FSH stimulate the development of the follicles in the ovaries
- Theca granulosa cells around the follicles secrete oestrogen which then has a negative feedback on the hypothalamus and the anterior pituitary, which then suppresses GnRH, LH and FSH
1
Q
What are the actions of oestrogen?
A
- breast tissue development
- growth and development of the female sex organs at puberty
- blood vessel development in the uterus
- development of the endometrium
2
Q
When is progesterone produced/what by?
A
- corpus luteum
- after ovulation
- when pregnancy occurs it is produced by the placenta from 10 weeks onwards
3
Q
What is the role of progesterone?
A
- thicken and maintain the endometrium
- thicken the cervical mucus
- increase the body temperature
4
Q
What is the follicular phase?
A
start of menstruation to the moment of ovulation
5
Q
What is the luteal phase?
A
moment of ovulation to the start of menstruation
6
Q
At what point do follicles develop FSH receptors?
A
When they reach secondary follicle stage
7
Q
Describe what happens in the follicular phase
A
- FSH stimulates development of secondary follicles
- Granulosa cells around the follicles secrete increasing amounts of oestrogen (making the cervical mucus more permeable)
- oestradiol has a negative. feedback effect on the hypothalamus which then reduces LH and FSH
- one follicle develops and becomes the dominant follicle which then releases an ovum when LH spikes
8
Q
Describe the luteal phase of the menstrual cycle
A
- follicle that released the ovum collapses ->corpus luteum
- corpus luteum secretes progesterone (and a small amount of oestrogen)
- if fertilised, the embryo secretes HCG which maintains the corpus luteum, without it will degenerate
- if no fertilisation occurs then the progesterone and oestrogen drops and causes the endometrium to break down and menstruation to occur
9
Q
What is the definition of menorrhagia?
A
Whatever the woman considers to be excessive and impacting on quality of life
10
Q
What are the uterine causes of heavy menstrual bleeding?
A
- fibroids
- endometrial polyps
- adenomyosis
- pelvic infection
- endometrial malignancy
11
Q
What medical disorders can cause heavy menstrual bleeding?
A
clotting disorders
12
Q
Investigations for heavy menstrual bleeding
A
- coagulation disorders
- serum ferritin
- thyroid testing if other symptoms
- consider biopsy to exclude endometrial cancer or atypical hyperplasia
- transvaginal USS if suspected structural or histological abnormality
13
Q
Explain the management of heavy menstrual bleeding
A
- no contraception needed/wanted: mefenamic acid or tranexamic acid (take during menses)
- contraceptive: IUS firstline, COCP, progestogens
14
Q
What is primary amenorrhoea?
A
- failure to mensturate by age 15
- may be associated with normal or delayed/absent development of secondary sexual characteristics
15
Q
What is secondary amenorrhoea?
A
- established menses stop for ≥6 months in the absence of pregnancy
16
Q
What is the definition of oligomenorrhoea?
A
- cycle persistently greater than 35 days in length
17
Q
Investigations for primary amenorrhoea
A
- plasma FSH, LH, oestrodiol, prolactin, TFT
- karyotype
- X ray for bone age
- cranial imaging
18
Q
Explain the causes of primary amenorrhoea in someone with secondary sexual characteristics, and a present uterus on USS
A
- Outflow tract obstruction: imperforate hymen or transverse vaginal septum
- normal anatomy: hormone profile
19
Q
What are the physiological causes of secondary amenorrhoea?
A
- pregnancy
- lactation
- menopause
20
Q
What are the hypothalamic causes of secondary amenorrhoea?
A
- weight loss/anorexia
- heavy exercise
- stress
21
Q
What are the ovarian causes of secondary amenorrhoea?
A
- PCOS
- premature ovarian failure
22
Q
What is the rotterdam criteria?
A
- Clinical or biochemical evidence of hyperandrogenism (high free androgen index)
- Oligomenorrhoea/amenorrhoea
- USS features of PCOS
23
Q
What are the consequences of PCOS?
A
- reduced fertility
- insulin resistance and diabetes
- hypertension
- endometrial cancer due to unopposed oestrogen
- depression and mood swings
- snoring and daytime drowsiness
24
What is the management of PCOS?
- education
- weight loss and exercise
- endometrial protection
- fertility assistance
- lifetime awareness ± screening for complications
25
What is primary dysmenorrhoea
- begins with onset of ovulatory cycels
- typically within first 2 years of menarche
- pain is most severe on the day of or the day prior to start of menstruation
26
What is the treatment of dysmenorrhoea?
- prostaglandin synthesis inhibitors (NSAIDs)
- COC
- depot progestogens
- levonorgestrel-releasing intrauterine system
27
What is secondary dysmenorrhoea?
- associated with pelvic pathology
- endometriosis, adenomyosis, pelvic infection and fibroids
28
What is the definition of post menopausal bleeding?
Bleeding occurring >12 months after LMP
29
Cells of ectocervix
Squamous
30
Cells of the endocervix
columnar epithelium/glandular epithelium
31
What is the most common cancer of the ectocervix?
Squamous cell cancer
32
What is the most common cancer of the endocervix?
Adenocarcinoma
33
What is the transformation zone of the cervix?
Area at the junction of the ectocervix and endocervix (squamo-columnar junction)
34
Describe the NHS cervical screening programme
Age group 25-64
- those age 25-49 every 3 years
- those 50-64 every 5 years
- anyone who has a cervix
35
What are the 3 types of results from smear test?
- HPV negative, return to routine screening
- HPV positive wiht no abnormal cells -> repeat HPV test in one year
- HPV positive with cell changes -> refer to colposcopy
36
Which HPV viruses are the most common causes of cervical cancer?
- 16
- 18
37
What are the preventative measures for HPV infection
- barrier contraception
- HPV vaccine (6,11, 16, 18)
38
What are the risk factors for cervical cancer?
- HPV (16, 18, 33)
- smoking
- HIV
- early first intercourse, many sexual partners
- high parity
- lower socioeconomic status
- COCP use
39
For how long should cervical screening be delayed in pregnant women?
until 3 months post partum
40
What happens if a cervical smear sample is inadequate?
- repeat sample in 3 months time
- if two consecutive samples are inadequate then refer to colposcopy
41
Treatment of CIN
Large loop excision of the transformation zone
42
CIN 1
mild dysplasia, affecting 1/3 the thickness of the epithelial, likely to return to normal without treatment
43
CIN 2
moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
44
CIN 3
Severe dysplasia, very likely to progress to cancer if untreated
45
What are the possible cytology results
- inadequate
- normal
- borderline changes
- low grade dyskaryosis
- high grade dyskaryosis moderate or severe
- possible invasive squamous cell carcinoma
- possible glandular neoplasia
46
Role of acetic acid in colposcopy
- abnormal cells appear white
- CIN and cancer cells
47
Iodine in colposcopy
- stains healthy cells brown
48
What is endometriosis?
Chronic condition, growth of ectopic endometrial tissue outside of the uterine cavity
49
What are the clinical features of endometriosis?
- chronic pelvic pain
- secondary dysmenorrhoea (pain often starts days before bleeding)
- deep dyspareunia
- subfertility
- can have urinary symptoms or painful bowel movements
50
Endometriosis signs on pelvic examination
- reduced organ mobility
- tender nodularity in the posterior vaginal fornix
- visible vaginal endometriotic lesions may be seen
51
Investigation for endometriosis
Laparoscopy is the gold standard
52
Management of endometriosis
- NSAIDs and/or paracetamol
- COCP or progestogens if analgesia doesn't help
53
What are the secondary treatments of endometriosis
- DnRH analogues
- surgery: laparoscopic exciison or ablation of endometriosis plus adhesiolysis
54
What is pelvic inflammatory disease?
Describes infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and surrounding peritoneum
55
What is the most common cause of PID?
Chlamydia trachomatis
56
What are the causes of pelvic inflammatory disease?
- chlamydia trachomatis
- neisseria gonorrhoeae
- mycloplasma genitalium
- mycoplasma hominis
57
What are the features of PID?
- lower abdominal pain
- fever
- deep dyspareunia
- dysuria and mentrual irregularities
- vaginal or cervical discharge
- cervical excitation
58
Investigations for PID
- pregnancy test to exclude ectopic pregnancy
- high vaginal swab
- screen for chlamydia and gonorrhoea
59
What is the management of PID?
- oral doxycycline
- oral metronidazole
- intramuscular ceftriaxone
60
What are the complications of PID?
- perihepatitis: right upper quadrant pain
- Infertility
- chronic pelvic pain
- ectopic pain
61
What hormone are fibroids sensitive to?
Oestrogen (so can grow during pregnancy)
62
Fibroid degeneration symtpoms
Often occurs during pregnancy
- low grade fever
- pain
- vomiting
63
What are fibroids?
Benign smooth muscle tumours of the uterus
64
What are the symptoms of fibroids?
- may be asymptomatic
- menorrhagia
- lower abdominal pain: cramping
- bloating
- urinary symptoms
- sub-fertility
65
Investigation for fibroids
transvaginal USS
66
Management of fibroids
- symtpomatic management with levonorgestrel releasing intrauterine system
- GnRH may reduce size
- myomectomy, hysteroscopic endometrial ablation, hysterectomy
67
What are the physiological cysts?
- follicular cysts: due to non rupture of the dominant follicle
- corpus luteum cyst: corpus luteum fails to break down
68
What are the benign germ cell tumours?
Dermoid cysts
69
What are the benign epithelial tumours?
- serous cystadenoma
- mucinous cystadenoma
70
What cyst is most common with torsion?
Dermoid
71
What is the most common benign tumour in women under 30?
Dermoid cysts
72
What is ovarian torsion?
- partial or complete torsion of the ovary on its supporting ligament
- this may compromise blood supply
73
What are the risk factors of ovarian torsion?
- ovarian mass
- being of reproductive age
- pregnancy
- ovarian hyperstimulation syndrome
74
What are the features of ovarian torsion
- sudden onset, deep colicky abdominal pain
- vomiting and distress
- fever in minority
- vaginal exam may demonstrate adnexial tenderness
75
USS of ovarian torsion
may show free fluid or whirlpool sign
76
What is the management of ovarian torsion?
Surgical detorsion (laparascopically) or salpingo-oophorectomy
77
Who should be referred to gynaecology in relation to ovarian cysts?
- any postmenopausal woman with any cyst
- premenopausal women with a simple cyst can be referred if persists after 8-12 weeks
- complex cysts should be biopsied
78
What is infertility?
The inability of a heterosexual couple to conceive in 12 months of regular unprotected intercourse
79
What is primary infertility?
Never conceived
80
What is secondary infertility?
at least one previous pregnancy
81
What are the factors that can affect fertility?
- age (mostly female)
- weight
- timing of intercourse, sperm needs to be deposited before ovulation due to progesterone
- duration of sub-fertility
82
Directions on sample for semen analysis
- 3-5 days of abstaining
- then give sample
83
What is assessed in a semen analysis?
- volume
- concentration
- total motility
- progressive motility
- normal forms
- vitality
84
What further testing should be carried out if semen analysis demonstrates oligospremia or azoospermia
- karyotype
- Y microdeletions
- CF status
- FSH
85
What options can be considered if oligospermia?
- Surgical sperm retrieval
- ICSI (intracytoplasmic sperm injection)
86
What are the types of azoospermia?
- obstructive (normal spermatogenesis but unable to leave)
- non-obstructive(testicular failure, high FSH)
87
What are the causes of obstructive azoospermia?
- congenital absence of vas deferens (test CF)
- blockage of the epididymis or vas deferens
88
Group 1 no or irregular cycle
- primary or secondary amenorrhoea
- low levels of endogenous gonadotropins
- negligable levels of endogenous oestrogen activity
- low FSH, LH, E2
- normal/increased prolactin
89
Group 2 no or irregular cycle
- anovulation with a varitey of menstrual disorders
- endogenous oestrogen activity
- normal urinary gonadotropins
90
Group 3 no or irregular period
- primary or secondary amenorrhoea
- primary ovarian failure
- low endogenous oestrogen activity
- pathologically high gonadotropin levels
91
What are the causes of group 3 amenorrhoea/oligomenorrhoea
- Idiopatihic
- Chemo/XRT
- Surgical removal of ovaries
- Autoimmune
- Chromosomal
- Turners (45XO)/ Turners mosaic
- Pure gonadal dysgenesis
- Androgen insensitivity (46XY)
- Fragile X
92
How do you assess tubal patency?
- hysterosalpingogram
- laparoscopy and dye test
- Hysterosalpingo-contrast-ultrasonography
93
What is the NHS scotland criteria for fertility treatment?
- woman must be under 43 by the time treatment is complete and under 42 by the time screening is carried out
- womans BMI must be under 30 and over 18.5
- both must have stopped smoking for a period of at least 3 months
- couple must have been in a cohabiting stable relationship for 2 years
- neither person sterilised
- at least one of the couple must not have a biological child
94
What are the assisted conception techniques?
- intrauterine insemination ± ovulation induction
- In vitro fertilisation (IVF)
- Intracytoplasmic sperm injection (ICSI)
95
What is ovarian hyperstimulation syndrome?
- Ovaries ‘over respond’ to gonadotrphin injections
- Systemic disease resulting from release of vasoactive products from hyperstimulated ovaries
- higher risk in PCOS
96
Symptoms of menopause
- change in periods: length change, dysfunctional bleeding
- vasomotor symptoms: hot flushes, night sweats
- urogenital changes: vaginal dryness and atrophy, urinary frequency
- psychological: anxiety, depression, short term memory impairment
- longer term: osteoporosis, increased risk of ischaemic heart disease
97
What are the types of HRT?
- combined
- cyclical
- continuous
- oestrogen only
- patch/gell/tablet
98
Who should not receive oestrogen only HRT and why?
- any woman with a uterus
- increases endometrial cancer risk
99
when would you give continuous vs cyclical hrt?
- continuous if no period for 12 months
- cyclical if still getting a period
100
What are the cons of HRT?
- Increased breast cancer risk in combined
- increased VTE/stroke risk if tablet
- Side effects: nausea, breast tenderness, fluid retention and weight gain
101
What are the pros of HRT?
- relieves menopausal symptoms
- prevents osteoporosis
- maintains muscle strength
102
What are the non hormonal options to help with menopausal symtpoms?
- lifestyle changes: exercise, diet, stop smoking, reduce alcohol and caffeine consumption
- CBT
- clonidine for vasomotor symptoms
- SSRI
- gabapentin
103
What are the causes of post menopausal bleeding?
- vaginal atrophy
- HRT
- endometrial hyperplasia
- endometrial cancer
- cervical cancer
- vaginal cancer
- ovarian cancer
- trauma
- bleeding disorders
104
When to refer for PMB
- women over 55
- 2 week USS
105
Acceptable depth of endometrial lining in post menopausal women
<5mm
106
What is the most common cause of PMB?
Vaginal atrophy
107
Treatment of vaginal atrophy
topical oestrogens, lubricants
108
Risk factors for endometrial hyperplasia
- obesity
- unopposed oestrogen
- tamoxifen use
- diabetes
- PCOS
109
Treatment of endometrial hyperplasia
dilatation and curettage
110
Cystocele
Anterior vaginal wall defect, bladder prolapses in to vagina
111
Rectocele
Posterior vaginal wall defect, rectum prolapses into the vagina. Can result in faecal loading causing constipation
112
Vault prolapse
In women with a hysterectomy and no uterus the top of the vagina (vault) descends into the vagina
113
What are the risk factors for urogenital prolapse?
- multiple vaginal deliveries
- traumatic delivery
- increasing age and postmenopausal
- obesity
- chronic resp condition resulting in cough
- chronic constipation resulting in straining
114
What are the treatments for urogenital prolapse?
- conservative: physio, weight loss, lifestyle changes, vaginal oestrogen
- vaginal pessary
- surgery
115
enterocele
prolapse of the upper posterior vaginal wal (posterior fornix) and pouch of douglas, usually contains loops of small bowel
116
What provides support to the uterus?
- vaginal walls
- transverse cervical ligaments
- round and broad ligaments
- indirect support from pelvic floor
117
What supports the cervix and upper 1/3 vagina?
- transverse cervical ligament
- uterosacral ligaments
118
Symptoms of prolapse
- sensation of heaviness/dragging/pressure
- sensation of bulge
- bleeding/discharge
- backache
- dyspareunia
- urinary incontinence/frequency/urgency
- constipation/straining
- faecal incontinence or urgency of stool
119
Stage 0 prolapse
No prolapse
120
Stage 1 prolapse
more than 1cm above hymenal ring
121
stage 2 prolapse
prolapse extends from 1cm above to 1cm below hymenal ring
122
Stage 3 prolapse
Prolapse extends 1cm or more below the hymenal ring, no vaginal eversion
123
Stage 4 prolapse
Vagina completely everted
124
What is the most common prolapse?
cystocele
125
Where is a pessary placed?
Between the posterior aspect of the symphysis pubis and posterior fornix
126
What are the complications of pessaries?
- interference with sex
- ulceration
- infection
- difficulty and discomfort during removal
- fistula if neglected
127
Surgery for anterior compartment defect
anterior colporrhaphy
128
surgery for posterior compartment defect
posterior colporrhaphy
129
Explain the micturition cycle
- bladder fills: detrusor relaxes, urethral sphincter and pelvic floor contracts
- first sensation to void: bladder half full, urination is voluntarily inhibited until appropriate time
- normal desire to void
- micturition: detrusor contracts, pelvic floor relaxes
130
What maintains continence?
- brain
- spinal cord and nerves: pelvic and pudendal
- bladder
- urethral sphincter
- pelvic floor
131
What are the types of urinary incontinence?
- Urgency incontinence
- mixed
- stress incontinence
132
What is urge incontinence?
Leakage of urine in repsonse to an involuntary contraction of the detrusor muscle
133
Overactive bladder
symptoms of urgency with or without urge incontinence, usually with frequency and nocturia
134
What is stress incontinence?
Leakage occurs with a rise in intra-abdominal pressure without a detrusor contraction
135
Investigations in suspected urinary incontinence
- urine dip and culture
- bladder diary: minimum 3 days
- cystoscopy and renal tract imaging : recurrent uti or haematuria
- urodynamic testing
136
What is the medical management of overactive bladder?
- anticholinergic drugs: oxybutynin, tolterodine, solfenacin
137
What is the surgical management of over active bladder?
- botox to detrusor muscle
- percutaneous sacral nerve stimulation
- augmentaton cystoplasty
138
missed miscarriage
Fetus is no longer alive
139
Threatened miscarriage
Vaginal bleeding with a closed cervix and fetus that is alive
140
Inevitable miscarriage
vaginal bleeding with an open cervix
141
complete miscarriage
a full miscarriage has occurred and there are no products of conception left in the uterus
142
early miscarriage
before 12 weeks
143
Late miscarriage
Between 12 and 14 weeks
144
investigation to diagnose miscarriage
USS
145
Management of miscarriage
- less than 6 weeks: expectant (await and do urine pregnancy test after 7-10 days)
- More than 6: referral to early pregnancy unity, USS then: expectant, medical, or surgical
146
What is the medical management of miscarriage?
- misoprostol
- vaginal suppository or oral dose
147
What is the surgical management of miscarriage?
- manual vacuum aspiration undler local anaesthetic
- electric vacuum aspiration under general anaesthetic
- give misoprostol before to soften the cervix
148
What is the management of incomplete miscarriage?
- medical (misoprostol)
- Surgical (evacuation of retained products of conception)
149
What are the causes of miscarriage?
- idiopathic
- antiphospholipid syndrome
- hereditary thromophilias
- uterine abnormalities
- genetic factors in parents
- chronic histiocytic intervillositis
- chronic diseases e.g. diabetes, untreated thyroid disease, SLE
150
What is antiphospholipid syndrome?
- antiphospholipid antibodies
- blood becomes prone to clotting: hypercoagulable state
151
Investigations for recurrent miscarriage
- antiphospholipid antibodies
- test for hereditary thrombophilias
- pelvic USS
- genetic tesitng of products of conception from third or future miscarriages
- genetic testing on parents
152
Most common site of ectopic
Fallopian tube
153
What are the risk factors for ectopic pregnancy?
- previous ectopic
- previous pelvic inflammatory disease
- previous surgery to the fallopian tubes
- intrauterine devices
- older age
- smoking
154
Presentation of ectopic pregnancy
- constant lower abdo pain in iliac fossas
- vaginal bleeding
- lower abdominal pain or tenderness
- cervical motion tenderness on bimanual examination
- should tip pain due to peritonitis
155
Management of pregnancy of unknown location
- Track the serum hCG
- intrauterine pregnancy hCG will rise above 63% every 48 hours, if this is the case then repeat the uss in one - two weeks
- a rise of less than 63% indicates potential ectopic pregnancy
- fall of more than 50% indicates miscarriage
156
What is the management of ectopic pregnancy?
- expectant (await miscarriage)
- medical with methotrexate
- surgical (salpingectomy or salpingotomy)
157
Criteria for expectant management of ectopic pregnancy
- follow up must ensure successful termination
- must be unruptured
- adnexal mass <35mm
- no visible heart rate
- no significant pain
- HCG <1500
158
Criteria for medical management of ectopic pregnancy
- follow up must ensure successful termination
- must be unruptured
- adnexal mass <35mm
- no visible heart rate
- no significant pain
- HCG <5000
- confirmed absence of intrauterine pregnancy on ultrasound
159
How long should a woman treated with methotrexate for ectopic wait until conceiving?
3 months
160
What are the common side effects of methotrexate for ectopic?
- vaginal bleeding
- nausea and vomiting
- abdominal pain
- stomatitis
161
What happens in a medical abortion?
- mifepristone is given
- misoprostol is given 1-2 days later
162
Who should get anti-D for termination?
Rhesus negative women with a gestational age over 10 weeks
163
Diagnosis of hyperemesis gravidarum
- more than 5% weight loss compared with before pregnancy
- dehydration
- electrolyte imbalance
164
How can you assess severity of emesis in pregnancy
- PUQE score
- <7 mild
- 7-12 moderate
- >12 severe
165
Order of preference of antiemetics for pregnancy
- prochlorperazine
- cyclizine
- ondasetron
- metoclopramide
166
When should you consider admission for hyperemesis gravidarum?
- unable to tolerate oral antiemetics or keep fluids down
- more than 5% weight loss compared with pre pregnancy
- ketones in urine
167
complete mole
two sperm fertilise an ovum that contains no genetic material. No foetal material forms
168
partial mole
two sperm cells fertilise a normal ovum so it has three sets of chromosomes. Some foetal material forms
169
Symptoms of molar pregnancy
- more severe morning sickness
- vaginal bleeding
170
Signs of a molar pregnancy
- increased enlargement of the uterus
- abnormally high hCG
- thyrotoxicosis
- USS showing snowstorm appearance
171
Gravida
How many pregnancies a woman has had
172
para
Number of times a woman has given birth after 24 weeks regardless of if fetus is alive or not
173
When is a dating scan?
Between 10 and 13+6 weeks
174
What happens at a dating scan?
An accurate gestational age is calculated from the crown rump length and multiple pregnancies are identified
175
When does the anomaly scan take place?
Between 18 and 20+6 weeks
176
When does OGTT take place
24-28 weeks gestation
177
When do rhesus negative women get anti d (in normal pregnancy)
28 and 34 weeks
178
What vaccines are recommended for all pregnant women?
- whooping cough
- influenza
179
At what point in pregnancy is flying not recommended?
- 37 weeks in a single
- 32 weeks in a twin pregnancy
180
When does the combined test occur?
between 11 and 14 weeks gestation
181
combined test result indicating downs
- nuchal trnaslucency greater than 6mm
- low Pregnancy associated plasma protein A (PAPPA)
- high beta hCG
182
when does triple test occur
14 to 20 weeks
183
triple test result suggestive of downs
- high beta hcg
- low alpha fetoprotein
- low serum oestriol
184
What happens when risk score for downs syndrome is greater than 1 in 150?
Offered:
- chorionic villus sampling if before 15 weeks
- amniocentesis
- may be offerened NIPT
185
sodium valporate in pregnancy
Avoided as causes neural tube defects and developmental delay
186
Phenytoin in pregnancy
causes cleft lip and palate
187
What are the drugs safe for pregnancy for rheumatoid
- hydroxychloroquine
- sulfasalazine
188
When may sensitisation in rhesus occur?
- antepartum haemorrhage
- amniocentesis procedures
- abdominal trauma
189
What are the causes of placenta mediated growth restriction?
- idiopathic
- pre-eclampsia
- maternal smoking
- anaemia
- malnutrition
- infection
- maternal health conditions
190
What are the causes of non placenta mediated growth restriction
- genetic abnormalities
- structural abnormalities
- fetal infection
- errors of metabolism
191
What is large for gestational age
- Over 4.5kg at birth
- over 90th percentile during pregnancy
192
What are the causes of macrosomia?
-constitutional
- maternal
- previous macrosomia
- maternal obesity or rapid weight gain
- overdue
- male baby
193
What are the risks of macrosomia
- failure to progress
- perineal tears
- instrumental delivery or caesarean
- postpartum haemorrhage
- uterine rupture
- shoulder dystocia
- birth injury (e.g. erbs palsy, clavicle fracture)
- neonatal hypoglycaemia
- obesity in childhood and later life
- type 2 diabetes in adulthood
194
What is pre eclampsia?
- hypertension
- end organ dysfunction: proteinuria
- after 20 weeks gestation
- oedema
195
What are the high risk factors for pre exlampsia?
- pre existing hypertension
- previous hypertension in pregnancy
- existing autoimmune condiitons
- diabetes
- chronic kidney disease
196
Prophylaxis for pre eclampsia
aspirin from 12 weeks
197
What are the symptoms of pre-eclampsia?
- headache
- visual disturbance or blurriness
- nausea and vomiting
- upper abdominal or epigastric pain
- oedema
- reduced urine output
- brisk reflexes
198
Diagnosis of pre eclampsia
- systolic above 140, distolic above 90
any one of:
- proteinuria
- organ dysfunction e.g. raised creatinine or liver enzymes, seizures, thrombocytopenia)
- placental dysfunction e.g. fetal growth restriction
199
What is the management of pre-eclampsia?
- labetalol 1st line, nifedipine 2nd
- intravenous hydralazine in critical care
- IV magnesium sulfate during labour and 24 hours afterwards
- switch to enalapril afterwards
200
What is HELLP syndrome?
- haemolysis
- elevated liver enzymes
- low platelets
201
When should you do OGTT for women (risk factors)
- previous gestational diabetes
- previous macrosomic baby
- BMI >30
- ethnic origin, black caribbean, middle eastern, south asian
- family history of diabetes
202
OGTT fasting less than 7
Diet and exercise for 1-2 weeks then metformin then insulin
203
OGTT fasting glucose above 7
insulin ± metformin
204
fasting glucose above 6 with macrosomia
insulin ± metformin
205
What are the targets for gestational diabetes?
- fasting 5.3
- 1 hour post meal 7.8
- 2 hours post meal 6.4
- avoiding levels of 4 or below
206
what is the risk to the baby whose mums have diabetes?
- neonatal hypoglycaemia
- macrosomia
- polycythaemia
- jaundice
- congenital heart disease
- cardiomyopathy
207
symptoms of obstetric cholestasis
- itching (particularly palms of the hands and soles of the feet)
- fatigue
- dark urine
- pale, greasy stools
- jaundice
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Investigations obstetric cholestasis
- abnormal liver function tests: ALT, AST, GGT
- raised bile acids
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What liver function test is normally raised in pregnancy and why
ALP produced by placenta
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Management of obstetric cholestasis
- ursodeoxycholic acid
- emollients
- antihistamines
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presentation of acute fatty liver of pregnancy
- general malaise and fatigue
- nausea and vomiting
- jaundice
- abdo pain
- anorexia
- ascites
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What is placenta praevia?
Placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus (over the internal cervical os)
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What are the risks of placenta praevia?
- antepartum haemorrhage
- emergency caesarean
- emergency hysterectomy
- maternal anaemia and transfusions
- preterm birth and low birth weight
- stillbirth
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What are the risk factors for placenta praevia?
- previous caesarean
- previous placenta praevia
- older maternal age
- maternal smoking
- structural uterine abnormalities
- assisted reproduction (e.g. IVF)
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What are the risk factors for placental abruption?
- previous placental abruption
- pre-eclampsia
- bleeding early in pregnancy
- trauma
- multiple pregnancy
- fetal growth restriction
- multigravida
- increasing maternal age
- smoking
- cocaine or amphetamine use
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Presentation of placental abruption
- sudden onset severe abdo pain
- vaginal bleeding
- shock
- CTG abnormalities indicating distress
- woody abdomen
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What is the management of placental abruption?
- If <36 weeks and fetal distress then immediate caesarean
- If <36 weeks and no fetal distress then observe and steroids
- If >36 weeks then vaginal birth if no distress, if there is distress then caesarean
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What is placenta accreta?
The placenta embeds past the endometrium into the myometrium and beyond.
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Placenta increta
Myometrium
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Placenta percenta
Myometrium, perimetrium, may reach other organs.
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Risk factors for placenta accreta
- previous placenta accreta
- previous endometrial curettage
- previous caesarean
- multigravida
- increased maternal age
- low lying placenta or placenta praevia
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Delivery time for placenta accreta
35 to 36+6 weeks
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What is the management of placenta accreta?
- caesaran at 35 to 36+6
- hysterectomy is recommended
- uterus saving surgery
- expectant: allow time for the placenta to be absorbed by the body
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Complete breech
hips and knees fully flexed,
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Incomplete breech
one leg flexed at the hip and extended at the knee
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Extended breech
Both legs flexed at the hip and extended at the knee
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Footling breech
Foot presenting through the cervix with the leg extended
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Management of breech
- external cephalic version at 36 weeks if nulliparous, 37 weeks if had children before (give tocolysis to soften uterus)
- vaginal or caesarean
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What is the first stage of labour?
From onset of labour until 10cm dilatation
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Second stage of labour
from 10cm dilation to delivery of baby
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third stage of labour
from delivery of baby until delivery of placenta
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What are braxton hicks contractions?
- occasional irregular contractions of the uterus
- do not progress or become regular
- normally felt between the second and third trimester
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What are the signs of labour?
- show from mucus plug
- rupture of membranes
- regular painful contractions
- dilating cervix on examination
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latent phase of first stage
from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
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active phase of first stage
from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
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transition phase of first stage
from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.
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Rupture of membranes
Amniotic sac has ruptured
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Preterm prelabour rupture of membranes
The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation
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prophylaxis for preterm labour
- vaginal progesterone if cervical length less than 25mm between 16 and 24 weeks gestation
- cervical cerclage (stitch in the cervix) if less than 25mm between 16 and 24 weeks, or if previous premature birth or cervical trauma
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What is the management of preterm prelabour rupture of the membranes?
- prophylactic antibiotics to prevent chorioaminonitis (erythromycin)
- induction of labour from 34 weeks
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What is the management of preterm labour?
- fetal monitoring
- tocolysis with nifedipine
- maternal corticosteroid before 35 weeks gestation
- IV magnesium sulphate if before 24 weeks
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What are the options for managing failure to progress?
- amniotomy (artificial rupture of the membranes)
- oxytocin infusion
- instrumental delivery
- caesarean section
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What is cord prolapse?
When the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes
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What is the management of cord prolapse?
- emergency caesarean section. The cord should be kept warm and wet and have minimal handling whilst waiting for delivery
- if baby is compressing a prolapsed cord then the presenting part can be pushed upwards (mum in left lateral position or on all fours)
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What is shoulder dystocia?
baby becomes stuck behind the pubic symphysis after the head has been delivered
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What is the turtle neck sign?
head is delivered but then retracts back into the vagina (shoulder dystocia)
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What is the management of shoulder dystocia?
- should call anaesthetics and paediatrics
- episiotomy
- mcroberts manoeuvre (press on the suprapubic region of the abdomen)
- rubins manoeuvre (reach into the vagina and put pressure on the posterior aspect of the baby's anterior shoulder)
- Wood screw manoeuvre (during rubins manoeuvre)
- zavanelli manoeuvre
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McRoberts manoeuvre
Hyperflexion of the mother at the hip (knees to abdomen)
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Rubins manouvre
Reaching in to the vagina and putting pressure on the posterior aspect of the baby's anterior shoulder. Can then do a wood's screw manouvre to rotate the baby
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Zavanelli manoeuvre
Pushing the baby's head back into the vagina so the baby can be delivered by emergency c section
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What are the complications of shoulder dystocia?
- fetal hypoxia and subsequent cerebral palsy
- brachial plexus injury and erb's palsy
- perineal tears
- postpartum haemorrhage
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What are the indications of an instrumental delivery?
- failure to progress
- fetal distress
- maternal exhaustion
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What are the risks to the mother during instrumental delivery?
- postpartum haemorrhage
- episiotomy
- perineal tears
- injury to the anal sphincter
- incontinence of the bladder or bowel
- nerve injury (obturator or femoral)
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What are the risks to the baby of instrumental delivery?
- cephalohaematoma with ventouse
- facial nerve palsy with forceps
rarely:
- subgaleal haemorrhage
- intracranial haemorrhage
- skull fracture
- spinal cord injury
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What is venotuse
Suction cup on a cord, the suction cup goes onto the baby's head
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Femoral nerve injury symptoms
- weakness of knee extension
- loss of the patella reflex
- numbness of the anterior thigh and medial lower leg
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Obturator nerve injury
- weakness of hip adduction and rotation
- numbness of the medial thigh
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First degree perineal tear
injury is limited to the frenulum of the labia minora and superficial skin
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Second degree perineal tear
injury to the frenulum of the labia minora and the perineal muscles but not the anal sphincter
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Third degree perineal tear
- labia minora
- perineal muscles
- anal sphincter but not affecting the rectal mucosa
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Fourth degree perineal tear
- labia minora
- perineal muscles
- anal sphincter
- rectal mucosa
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What are the complications of a perineal tear?
- pain
- infection
- bleeding
- wound dehiscence or breakdown
Lasting complications
- urinary incontinence
- anal incontinence and altered bowel habit
- fistula between bowel and vagina
- sexual dysfunction and dyspareunia
- psychological and mental health consequences
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What are the options for management of the third stage of labour?
- physiological management: placenta delivered by maternal effort without medication or cord traction
- active management: oxytocin, traction to the umbilical cord
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What volume of blood loss is required to be considered a post partum haemorrhage?
- 500ml after vaignal
- 1000ml after caesarean
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minor Post Partum Haemorrhage
under 1000ml blood loss
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major post partum haemorrhage
over 1000ml
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What are the causes of post partum haemorrhage?
- tone: uterine atony (most common)
- trauma e.g. perineal tear
- tissue: retained placenta
- Thrombin: bleeding disorder
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What are the risk factors for post partum haemorrhage
- previous PPH
- multiple pregnancy
- obesity
- large baby
- failure to progress in second stage
- prolonged third stage
- pre-eclampsia
- placenta accreta
- instrumental delivery
- general anaesthesia
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What is the management of post partum haemorrhage?
- ABCDE
- lie woman flat
- 2x large bore cannnula
- FBC, U+Es, clotting screen
- group and cross match 4 units
- warmed IV fluid and blood resuscitation as required
- oxygen
- fresh frozen plasma
- stop bleeding: mechanical/medical/surgical
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Mechanical treatment of PPH
- rubbing the uterus through the abdomen to stimulate a uterine contraction
- catheterisation (bladder distension prevents the uterus from contracting)
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Medical treatment of PPH
- oxytocin
- ergometrine
- carboprost
- misoprostol
- tranexamic acid
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Surgical management of PPH
- intrauterine baloon tamponade
- B lynch suture (suture around the uterus to compress it)
- Uterine artery ligation : ligation to one or more of the arteries supplying the uterus to reduce the blood flow
- hysterectomy as a last resort
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What is the most common cause of secondary postpartum haemorrhage?
Retained products of conception or infection e.g. endometritis
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What is the definition of secondary postpartum haemorrhage?
- ultrasound for retained products of conception
- antibiotics for infection
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Category 1 caesarean section
- immediate threat to the life of mother or baby
- decision to delivery time is 30 minutes
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Category 2 caesarean section
- not imminent threat to life
- required urgently due to compromise of the mother or baby
- decision to delivery time is 75 minutes
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Category 3 caesarean section
- delivery is required
- mother and baby are stable
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Category 4 caesarean section
Elective caesarean
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What are the layers of the abdomen that need to be dissected during a caesarean?
- skin
- subcutaneous tissue
- fascia/rectus sheath
- rectus abdominis muscle
- peritoneum
- vesicouterine peritoneum
- uterus
- amniotic sac
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Risk factors of amniotic fluid embolism
- increasing maternal age
- induction of labour
- caesarean
- multiple pregnancy
281
Presentation of amniotic fluid embolism
- shortness of breath
- hypoxia
- hypotension
- coagulopathy
- haemorrhage
- tachycardia
- confusion
- seizure
- cardiac arrest
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What are the risk factors for uterine rupture?
- vaginal birth after caesarean
- previous uterine surgery
- increased bmi
- high patiry
- increased age
- induction of labour
- use of oxytocin
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What is the presentation of uterine rupture?
- abdominal pain
- vaginal bleeding
- ceasing of uterine contractions
- hypotension
- tahcycardia
- collapse
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Presentation of endometritis
- foul smelling discharge or lochia
- bleeidng that gets heavier or doesnt improve with time
- lower abdominal or pelvic pain
- fever
- sepsis
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investigations for endometritis
- vaginal swab
- urine culture and sensitivities
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Presentation of retained products of conception
- vaginal bleeding that gets heavier or is not improving with time
- abnormal vaginal discharge
- lower abdominal or pelvic pain
- fever if infection occurs
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diagnosis of retained products of conception
USS
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Management of retained products of conception
Evacuation of retained products of conception under general anaesthetic
- vacuum, aspiration and curettage
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What are the complications of dilatation and curettage?
- endometritis
- asherman's syndrome (adhesions form within the uterus
290
Management of post partum anaemia
- Hb under 100g/l start oral iron
- Hb under 90 g/l consider an iron infusion in addition to oral iron
- Hb under 70g/l blood transfusion in addition to oral iron
291
What score can you use to assess postnatal depression?
Edinburgh postnatal depression scale. Score of 10 or more suggests postnatal depression
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Presentation of mastitis
- breast pain and tenderness (unilateral)
- erythema in a focal area of breast tissue
- local warmth and inflammation
- nipple discharge
- fever
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Management of mastitis
- continue breastfeeding, expressing milk and breast massage
- if not effective or infection suspected then flucloxacillin
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Management of postpartum thyroiditis
- thyrotoxicosis: symptomatic control such as propranolol
- hypothyroidism: levothyroxine
295
What is sheehan's syndrome?
Complication of psot partum haemorrhage where drop in circulating blood leads to avascular necrosis of the pituitary gland
Only affects the anterior pituitary gland
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What hormones does the anteiror pituitary release?
- thyroid stimulating hormone
- adrenocorticotropic hormone
- follicle stimulating hormone
- luteinising hormone
- growth hormone
- prolactin
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Presentation of sheehans
- reduced lactation
- amenorrhoea
- adrenal insufficiency and adrenal crisis due to lack of cortisol
- hypothyroidism with low thyroid hormones
298
Management of sheehans
- oestrogen and progesterone as HRT
- hydrocortisone
- levothyroxine
- growth hormone
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What is the management of a complex ovarian cyst in pre-menopausal women?
- serum CA125
- alpha fetoprotein
- beta HCG
- book for an elective cystectomy
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Edward's syndrome quadruple test result
- low AFP
- low oestriol
- low hCG
- normal inhibin A
301
In pre-eclampsia, how long should you continue magnesium sulfate?
for 24 hours after delivery or last seizure
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When is the booking visit?
8-12 weeks (ideally less than 10)
303
Early scan to confirm dates
10-13+6
304
Down's sydrome screening including nuchal scan
11-13+6
305
Anomaly scan
18-20+6 weeks
306
First step in PPH
Uterine massage and catheter
THEN oxytocin
307
How long should someone who is taking methotrxate for RA wait to conceive?
6 months (both partners)
307
What position should be adopted in cord prolapse?
All fours
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