Obs and Gynae Flashcards
(109 cards)
1
Q
What are the 3 stages of the first stage of labour?
A
- Latent: 0-3cm dilation and 0.5cm per hour progress. Contractions are irregular
- Active: 3-7cm dilation and progresses at 1cm per hour. Contractions are regular
- Transition: 7-10cm dilation and progresses at 1cm per hour. Contractions are strong and regular
2
Q
what are Braxton Hicks contractions?
A
- occasional irregular contractions of the uterus felt in the 2nd and 3rd trimester
- experience tightening or mild cramping in the abdomen
- they don’t progress or become regular
- staying hydrated and resting can help these
3
Q
what genetic syndrome can also be associated with a reduced or absent sense of smell?
A
Kallman syndrome (genetic condition causing hypogonadotrophic hypogonadism)
4
Q
what is congenital adrenal hyperplasia?
A
- caused by a congenital deficiency of the 21 hydroxylase enzyme
- this causes underproduction of cortisol and aldosterone and over production of androgens
5
Q
what effect does primary ovarian failure and PCOS have of FSH and LH?
A
- high FSH in primary ovarian failure
- high LH (high LH:FSH) in PCOS
6
Q
management for prolactin adenoma?
A
dopamine agonists eg. bromocriptine to reduce prolactin production
7
Q
what do high prolactin levels do?
A
- act on the hypothalamus to prevent the release of GnRH
- no release of LH or FSH -> hypogonadotrophic hypogonadism
8
Q
management of menorrhagia if a patient doesn’t want to use contraceptives?
A
- tranexamic acid if experiencing no pain
- mefenamic acid if associated pain
9
Q
if the patient does want contraception to manage menorrhagia, what can be offered?
A
- mirena coil
- COCP
- cyclical oral progesterones
10
Q
what does the RCOG green top guideline recommend for medical management of PMS?
A
COCPs containing drospirenone (eg. Yasmin)
11
Q
what medications can be used to reduce the size of fibroids before surgery?
A
GnRH agonists eg. goserelin - these work by inducing a menopause like state
12
Q
what is red degeneration of fibroids?
A
- ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply
- fibroid rapidly enlarges during pregnancy and outgrows its blood supply, becoming ischaemic (haemorrhagic infarction)
- more likely to occur in fibroids >5cm, during the 2nd and 3rd trimester
- may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy
13
Q
what does localised bleeding and inflammation due to endometriosis lead to + how do they present?
A
leads to adhesions as inflammation causes damage and development of scar tissue which binds the organs together
- can lead to chronic, non cyclical pain that can be sharp, stabbing or pulling & associated with nausea
14
Q
what is the staging system for endometriosis?
A
American society of reproductive medicine (ASRM)
- stage 1: small, superficial lesions
- stage 2: mild, but deeper lesions than 1
- stage 3: deeper lesions, with lesions on ovary and mild adhesions
- stage 4: deep and large lesions affecting the ovaries with extensive adhesions
15
Q
surgical management for endometriosis?
A
- Laparascopic: excise or ablation of endometrial tissue and remove adhesions
- Hysterectomy
16
Q
what is seen on examination of adenomyosis?
A
enlarged and tender uterus, which will be softer than fibroids
17
Q
what causes menopause?
A
lack of ovarian follicular function => changes in sex hormones: low oestrogen and progesterone and high LH and FSH (due to negative feedback)
18
Q
what are the better COCP options for women over 40?
A
- norethisterone
- levenorgestrel
- lower risk of VTE
19
Q
management of perimenopause?
A
- HRT
- tibolone (synthetic steroid which acts as continuous combined HRT)
- CBT and SSRI antidepressants
- vaginal oestrogen and moisturisers
20
Q
what is premature ovarian insufficiency?
A
menopause before the age of 40 due to a decline in normal activity of the ovaries at an early age - presents with early onset of typical symptoms of menopause
21
Q
what does high levels of insulin contribute to?
A
halting the development of follicles in the ovaries, leading to annovulation
22
Q
an transvaginal USS shows a ‘string of pearls’ appearance, what is this?
A
PCOS
- follicles arranged around the periphery of the ovary
23
Q
what is the diagnostic criteria you look for on transvaginal USS?
A
- 12 or more developing follicles in one ovary
- ovarian volume of more than 10cm3
24
Q
what can improve symptoms of hirsuitism?
A
- co-cyprindiol COCP (dianette) - has anti-androgenic effects, contraception and regulates periods
- topical eflornithine (takes 6-8 weeks to work and will return after 2 months of stopping)
25
what is asherman's syndrome?
Where adhesions form in the uterus, following damage to the uterus -> pregnancy related dilation and curettage, after uterine surgery or pelvic infection (endometritis)
26
what is cervical ectropion and managment?
where columnar epithelium of the endocervix, extends out to the ectocervix due to high oestrogen levels
- if problematic symptoms can cauterise with silver nitrate or **cold coagulation** in colposcopy
27
management of preterm rupture of membranes?
- **prophylactic antibiotics** to prevent **chorioamnionitis**: **erythromycin** 250mg 4x/day for 10 days or until labour is established if within 10 days
- induction of labour from **34 weeks**
28
what do you have to monitor in mothers who have been given IV magnesium sulphate?
Monitor 4 hourly for magnesium toxicity
- reduced RR
- reduced BP
- absent reflexes
29
what is used to induce labour when intrauterine fetal death has occurred?
Oral mifepristone (anti-progesterone) and misoprostol
30
how do you manage uterine hyperstimulation due to vaginal prostaglandins (in induction of labour) & what can it cause?
- remove the vaginal prostaglandine or stop oxytocin infusion
- tocolysis with terbutaline
- can cause fetal distress (hypoxia and acidosis, elective CS and uterine rupture)
31
how to vaginal prostaglandins induce labour?
- given as gel, tablet or pessary and inserted in the vagina where they slowly release prostaglandin over 24 hours
- stimulate the cervix and uterus to cause onset of labour
32
what defines failure to progress in the first stage of labour?
- less than 2 cm cervical dilation in 4 hours
- slow progression in a multiparous woman
33
what is recorded on a partogram?
Anatomy
- **Cervical dilatation** (**4 hourly** vaginal exam)
- **Status of membranes**
Baby
- **Descent of fetal head**
- **Fetal heart rate**
Mother
- Maternal **pulse, blood pressure, temperature & urine output**
- **Frequency of contractions**
- **Drugs & fluids** which have **been given**
34
What on the partogram indicates that labour is not progressing?
- Two lines called **‘alert’ & ‘action’**
- When it takes **too long for the cervix to dilate**, the readings will cross to the **right** of the alert and action lines
- If it crosses the **alert** line, it is an indication for **amniotomy** (artificially rupturing the membranes) and a **repeat exam in 2 hours**
- If it crosses the **action** line, the care needs to be **escalated to obstetric lead care**
35
what opioid medications can be used in labour?
- IM pethidine and diamorpine to help with anxiety and distress
36
what is patient controlled analgesia?
**Remifentanil** - patient presses a button at the start of a contraction to administer a bolus of short acting opioid
37
LA options for epidural?
Levobupivacaine or bupivacaine usually mixed with fentanyl
37
management option for shoulder dystocia?
- Episiotomy
- McRobert's manoeuvre
- Pressure to the anterior shoulder - pressing on the suprapubic region of the abdomen to put pressure on the posterior part of the baby's anterior shoulder to encourage it down and under the pubic symphysis
- Rubin's manoeuvre
- Woods screw manoeuvre
- Zacanelli manoeuvre
38
what is the McRobert's manoeuvre?
hyperflexion of the mother at the hip which provides posterior pelvic tilt, lifting the pubic symphysis up and out of the way
39
what is recommended after instrumental delivery to reduce the chance of infection?
co-amoxiclav
40
Indications of instrumental delivery?
- failure to progress
- fetal distress
- maternal exhaustion
41
what is active management of the third stage?
midwife or doctor assists in delivering the placenta -> dose of IM oxytocin to help uterus contract -> careful traction to the umbilical cord to guide the placenta out of the uterus and vagina, while pressing the uterus upwards to prevent uterine prolapse
42
what are the 2 possible incisions for caesarian?
- Pfannenstiel incision - curved incision 2 fingers width above pubic symphysis
- Joel-cohen incision - straight incision which is slightly higher
43
surgical options for PPH?
- intrauterine balloon tamponade - balloon inserted and inflated in uterus to press against the bleed
- B Lynch suture - around uterus to compress it
- Uterine artery ligation
- Hysterectomy
44
management of maternal sepsis?
- continuous fetal and maternal monitoring
- emergency c section via general anaesthetic, not spinal
- strong IV antibiotics
45
what is amniotic fluid embolism?
- where amniotic fluid passes into the mothers blood stream, just prior to or during delivery and labour
- amniotic fluid contains fetal cells/tissue so this causes an immune reaction from the mother (similar to anaphylaxis)
46
what is uterine inversion?
a rare complication where the fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out
47
what is lochia?
vaginal bleeding that occurs after delivery as the endometrium initially breaks down before returning to normal -> this is a mix of **blood, endometrial tissue and mucus = lochia**
48
a post partum patient presents with foul smelling discharge, lower abdominal pain, temperature of 37.9, and bleeding which isn't improving over time. What does she have?
post partum endometritis
49
treatment for post partum anaemia?
- <100g/l loss: oral iron
- <90: consider iron infusion in addition to oral iron
- <70: iron infusion and oral iron
50
contraindication to iron infusion?
active infection as the pathogen can 'feed' on the iron, causing it to proliferate and worsening infection, so have to wait for the infection to pass
51
stages of postpartum thyroiditis?
- thyrotoxicosis: within 3 months
- hypothyroidism: 3-6 months
- return of normal thyroid function, usually within a year
52
management of postpartum thyroiditis?
- hyperthyroidism/thyrotoxicosis: propanolol (symptomatic)
- hypothyroidism: levothyroxine
53
what is sheehan's syndrome and how does it present?
- a rare complication of PPH, where the drop in circulating blood volume, leads to avascular necrosis of the pituitary gland, due to low perfusion
-**Reduced lactation- lack of prolactin**
- **Amenorrhea- lack of LH & FSH**
- **Adrenal insufficiency & adrenal crisis**- lack of **ACTH** so low cortisol
- **Hypothyroidism**- lack of TSH so low thyroid hormones
54
what is antiphospholipid syndrome?
- associated with antiphospholipid antibodies which cause the blood to clot more easy.
- The patient is in a hypercoagulable state
- one of the causes of recurrent miscarriage
- may have a history of DVTs
55
what investigations are done for recurrent miscarriage?
- antiphospholipid antibodies
- testing for hereditary thrombophilias
- pelvic USS
- genetic testing of the products of conception from 3rd or future pregnancies
- genetic testing on parents
56
what are the surgical options for abortion/TOP?
- cervical dilation and suction of the contents of the uterus (upto 14 weeks)
- cervical dilation and evacuation using forceps (between 14 and 24 weeks)
57
what is a molar pregnancy and how does it present?
= a type of tumour that grows like a pregnancy in the uterus.
- complete mole has no fetal material in it and a partial mole has some fetal material in it
- will behave like a normal pregnancy, periods will stop and hormone changes of pregnancy
- more severe morning sickness
- vaginal bleeding
- increased enlargement of the uterus
- abnormally high HCG
- thyrotoxicosis (HCG can mimic TSH and stimulate the thyroid gland)
58
what vitamins should be taken during pregnancy?
- folic acid 400mcg from before pregnancy to 12 weeks
- vitamin D daily
(avoid vitamin A tablets as teratogenic)
59
characteristics of fetal alcohol syndrome?
- microcephaly
- thin upper lip
- small flat philtrum
- short palpebral fissure
- learning disability
- behavioural difficulties
- hearing and vision problems
- cerebral palsy
60
when are babies defined as LGA?
- >.4.5kg at birth
- during pregnancy, estimated fetal weight is above the 90th percentile
61
why and when do nitrofurantoin and trimethoprim need to be avoided in pregnancy?
- nitrofurantoin needs to be avoided in the 3rd trimester due to risk of neonatal haemolysis
- trimethoprim needs to be avoided in the first trimester as it's a folate antagonist, so in early pregnancy it can cause congenital malformations, especially neural tube defects
62
what is obstetric cholestasis and presenation?
- reduced outflow of bile acids from the liver which resolves after delivery of the baby
- builds up in the blood leading to pruritis esp in the palms of hands and soles of the feet
- fatigue
- dark urine, pale stools
- jaundice
63
what are the risk factors for VTE in pregnancy?
- smoking
- parity over 3
- age >35
- BMI >30
- multiple pregnancy
- family history
- IVF pregnancy
64
when is prophylaxis started?
(RCOG)
- 28 weeks if there are 3 RFs
- 1st trimester if there are 4 or more RFs
65
management for massive PE and haemodynamic instability?
- unfractionated heparin
- thrombolysis
- surgical embolectomy
66
what is still birth and causes?
- the birth of a dead fetus after 24 weeks gestation as a result of intrauterine fetal death
- unexplained
- pre-eclampsia
- placental abruption, vasa praevia
- obstetric cholestasis
- maternal infection
- diabetes and thyroid disease
- genetic abnormalities
- cord prolapse
67
risk factors for still birth?
- FGR/SGA
- smoking and alcohol
- increased maternal age
- sleeping on back
- maternal obesity
- twins
68
what is breech presentation and the different types?
where the presenting part of the fetus is the legs and bottom, opposed to cephalic presentation
- complete, incomplete, extended, footling
69
management of breech?
1. if before 36 weeks, often turns spontaneously
2. ECV can be used at term 37 weeks
3. if ECV fails, woman given option of vaginal or CS delivery
70
what is ECV?
technique to attempt to turn a fetus from breech to cephalic position by putting pressure on the abdomen
(tried at 36 weeks for nulliparous and 37 weeks for those who have previously given birth
71
at how many weeks are the combined test, triple test and quadruple test carried out?
- combined = 11-14 weeks
- triple and quadruple = 14-20 weeks
72
a nuchal translucency greater than 6mm indicates what and what test includes this measurement?
- downs
- combined test
73
what results of the combined test will suggest Downs?
- BHCG raised
- PAPP-A lower
74
what results of the triple and quadruple test indicate down's
- beta BCG higher
- AFP - lower
- serum oestriol - lower
- (quadruple test - inhibin A higher)
75
what is involved in invasive testing for down's?
- **chronic villus sampling**: USS guided biopsy of the placental tissue, used when testing is done earlier in pregnancy (15 weeks)
- **amniocentesis**: USS guided biopsy of amniotic fluid using a needle and syringe, used later in pregnancy once there's enough amniotic fluid to make it safe to take a sample
76
what multiple pregnancy would have the best outcome?
dichorionic (2 seperate placentas) , diamniotic (2 seperate amniotic sacs) pregnancy as each fetus would have its own nutrient supply
77
how can you tell if you have dichorionic diamniotic twins and monochorionic diamniotic twins on scan?
DD: membrane between the twins with a lambda sign or twin peak sign
MD: membrane between the twins with a T sign
78
what are the risks to the fetus and mother in a twin pregnancy?
Mother
- anaemia, polyhdraminos, spontaneous preterm birth, instrumental or C section, PPH
Fetus
- miscarriage, stillbirth, FGR, prematurity, twin to twin transfusion syndrome, twin anaemia polycythaemia syndrome
79
what type of birth is required in monoamniotic and diamniotic twins?
**monoamniotic** - elective C section between 32 and 33+6 weeks
**diamniotic** - vaginal if first baby cephalic presenting and then CS potentially for second. Elective CS when presenting twin isn't cephalic
80
what are the normal ranges of Hb during pregnancy?
- Booking bloods >110
- 28 weeks >105
- post partum >10g/l
81
management for low B12?
- test for pernicious anaemia (checking for IF antibodies
- IM hydroxycobalamic injections
- oral cyanocobalamin
82
why are you likely to get anaemia in pregnancy?
during pregnancy, plasma volume increases, resulting in reduction in Hb concentration - blood is diluted
83
risk factors for gestational diabetes?
- previous gestational diabetes
- previous macrosomic baby
- BMI > 30
- ethnic origin
- family history of diabetes
- unexplained still birth in a previous pregnancy
84
normal results of OGTT?
- fasting <5.6
- at 2 hours <7.8mmol/l
**anything higher = gestational diabetes**
85
management of GDM?
- **<7mmol/l** = diet and exercise for 1-2 weeks -> metformin -> insulin
- **>7mmol/l** = insulin +/- metformin
- **>6mmol/l & macrosomia** = insulin +/- metformin
86
what sulfonylurea can be used for women who decline insulin or can't tolerate metformin?
Glibenclamide
87
what are babies of mothers with diabetes at risk of?
- neonatal hypoglycaemia
- polycythaemia
- jaundice
- congenital heart disease
- cardiomyopathy
88
how is neonatal hypoglycaemia managed?
- if their blood sugar is **<2mmol/l**
- IV dextrose of NG feed
89
how is placenta praevia graded?
- **minor praevia/grade I** - the placenta is in the lower uterus but not reaching the internal cervical os
- **margina; praevia/grade II** - the placenta is reaching the internal os but not covering it
- **partial praevia/grade III** - the placenta is partially covering the internal cervical os
- **complete praevia/grade IV** - the placenta is completely covering the internal os
90
what is vasa praevia?
- where the **fetal vessels** are exposed, outside the protection of the umbilical cord and placenta and **pass through the chorioamniotic membranes** and then **travel across the cervical os**
- the exposed vessels are prone to bleeding, particularly when the membranes are ruptures in labour, which can lead to fetal blood loss and death
91
what are the 2 types of vasa praevia?
1. type 1 - velamentous umbilical cord: the umbilical cord inserts into the CA membranes and the fetal vessels travel unprotected through the membranes before joining the placenta
2. type 2 - an accessory lobe of the placenta is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes
92
triad of symptoms seen in vasa praevia?
- painless vaginal bleeding
- fetal bradycardia
- rupture of membranes
93
management of vasa praevia in asymptomatic women in pregnancy?
- corticosteroids given from 32 weeks to mature fetal lungs
- elective CS planned for 24-36 weeks
94
what is placental abruption and what are the risk factors?
obstetric emergency where the placenta separates from the uterus wall and the site of attachment can extensively bleeds, leading to PPH
- previous abruption
- pre-eclampsia
- smoking and amphetamine
- trauma - DV
- bleeding in early pregnancy
- multiple pregnancy
95
how does placental abruption present?
- sudden painful abdominal pain
- constant
- vaginal bleed
- shock (out of keeping with amount of blood)
- fetal distress on CTG
- 'woody' abdomen on palpation, suggesting a large haemorrhage
- tender and tense uterus
96
what is placenta accreta, superficial accreta, increta and percreta?
- placenta accreta: the placenta implants deeper and past the endometrium, making it difficult to separate the placenta after delivery of the baby
- superficial accreta: placenta implants in the surface of the myometrium
- increta: implants deeply into the myometrium
- percreta: invades past the myometrium and perimetrium, potentially reaching other organs like the bladder
97
when can you refer for infertility?
after the couple has been trying for 12 months or 6 months if the woman is >35
98
what imaging is done when investigating infertility
- **USS of pelvis** - polycystic ovaries
- **hysterosalpingogram**- patency of fallopian tubes - Small tube is inserted into cervix and a contrast medium is injected through the tube and fills the uterine cavity and fallopian tubes - x-rays taken
- **laproscopy & dye test**- patency of fallopian tubes - Pt is admitted for laparoscopy and during the procedure dye is injected into the uterus and should be seen entering the fallopian tubes- won’t be seen in tubal obstruction
99
management options if infertility due to anovulation?
- weight loss
- clomifene (anti-oestrogen that stops negative feedback of oestrogen on the hypothalamus so there's more GnRH and therefore FSH and LH released
- gonadtropins
- ovarian drilling (pcos)
- metforming
100
Management of uterine factors?
Surgery can be used to correct polyps, adhesions or structural abnormalities
101
How do you manage a blockage along vas deferens which can stop sperm from reaching ejaculated semen?
- **Surgical sperm retrieval** where a **needle & syringe** is used to **collect sperm** directly **from** the **epididymis**
- **Surgical correction of obstruction**
102
What is intracystoplasmic sperm injection?
Where sperm is injected directly into the cytoplasm of an egg and the fertilised eggs are injected into the uterus of the woman
103
what can lead to testicular damage?
- mumps
- undescended testes
- radio or chemotherapy
- trauma
- caner
104
what testicular damage can lead to infertility?
- damage to testicle or vas def from trauma, surgery or cancer
- ejaculatory duct obstruction
- retrograde ejaculation
- scarring from epididymitis
- absent vas def
105
management of male infertility?
- surgical sperm retrieval
- surgical correction of obstruction
- intra uterine insemination
- ICSI
- donor insemination
106
what is a nabothian cyst and how does it form?
a fluid filled cyst on the surface of the cervix
- the columnar epithelium of the endocervix produces mucus, when the squamous epithelium of the ectocervix slightly covers this mucus producing epithelium, it can trap the mucus, forming a cyst
107
how do nabothian cysts present?
- asymptomatic
- often found incidentally on speculum exam
- smooth rounded bump on cervix, usually near os, have a whitish or yellow appearance
108
how does atrophic vaginitis present?
- itching
- dryness
- dyspareunia
- bleeding due to localised inflammation
