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obs and gynae > obs and gynae 3a > Flashcards

obs and gynae 3a Flashcards

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1
Q

detail the steps in the menstrual cycle (hormones)

A

hypothalamus–>GnRH–> anterior pituitary gland–>Fsh and LH

1) FSH stimulates follicule maturation
2) Oestrogen produced by maturing follicule
3) At low oestrogen levels oestrogen inhibits LH (negative feedback on anterior pituitary)
4) FSH secreted at low oestrogen levels (rise in oestrogen=fall in FSH)
5) Oestrogen levels rise and stimulate LH secretion
6) LH triggers ovulation
7) corpus luteum secretes oestrogen, inhibin and progesterone–> negative feedback inhibiting secretion of FSH (preventing further follicule maturation).
8) Porgesterone stimulates endometrial growth and inhibits GnRH production
9) Corpus luteum degenerates. Fall in progesterone (endometrium shed)–> GnRH not inhibited–> stimulates new cylcle (FSH and LH)

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2
Q

Describe the hormonal changes that occur to allow labour to commence

A

progesterone and oestrogen DROP
prostaglans RISE- causes uterus to contract

progesterone and oestrogen initially produced by corpus luteum in first trimester, then by placenta

progesterone is a smooth muscle and so inhibits uterine contraction

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3
Q

what is the metabolic disturbance seen in hyperemesis gravidarum

A

Hypochroraemic alkalosis

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4
Q

management of gestational diabetes melitus

A

Aim for BM <7.8 post prandial

1) diet and exercise
2) metformin
3) insulin
4) detailed anomaly scan and monitor growth (risk of preterm delivery, miscarriage, cardiac malformations, polyhydramnios, macrosomia, IUGR
5) increased risk of developing T2DM after delivery- screen annually

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5
Q

define pre-eclampsia

A

raised blood pressure >140/90 AFTER 20 weeks

proteinuria >0.3g/24 hrs

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6
Q

management of pregnancy induced hypertension

A

=hypertension occurring AFTER 20 weeks
if >150/100- labetalol
weekly BP and urine- excluse Pre-eclampsia
regular growth scans- increased risk of fetal growth restriction

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7
Q

risk factors for pre-eclampsia

A 
PROF CANT DO
*Personal history*
Renal disease
Older
Family history
*Chronic hypertension*
*Autoimmune disease*
Nuliparity
Twin pregnancies
*Diabetes*
Obesity
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8
Q

investigations of pre-eclampsia

A

urine dip- raised proteins
protein-creatinine ratio
fetal US- look for fetal grwoth restriciton
Bloods- U+Ez, LFTs, FBC, GFR- Exclude HELLP

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9
Q

Define HELLP

A

severe variant of pre-eclampsia
H-Haemolysis
EL- elevated liver enzymes
LP- low platelets

Symptoms: epigastric/ RUQ pain, N+V, dark urine (haemolysis), raised BP, hepatomegaly, bruising

Risk of DIC, placental abruption, renal failure

Deliver is 34 weeks+

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10
Q

Define eclampsia + management

A

Tonic-clonic seizures and pre-ecampsia- can occur before, during or after pregnancy

ABCDE
magnesium sulfate
O2
Iv labetalol
Delivery by C section once mother stable
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11
Q

What is part of the antenatal screening programme?

A

1) <10 weeks- sickle cell and thalasaemia blood test
2) Early pregnancy- syphilis, Hep B, HIV blood test
3) 10-14 weeks- combined test for downs, edwards and pataus (nuchal translucency and serum markers
4) 14-20 weeks- quadruple test- If combined test not possible- blood test screens for Downs
5) 18-21 weeks major abnormalities scanned for

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12
Q

If a fetus is small for dates at two dates 2 weeks apart, what does this indicate and what further investigations should be carried out

A

Fetal Growth Restriction

Ultrasound measurement of amniotic fluid—> if low–>uterine and umbilical artery doppler–indicates placental dysfunction

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13
Q

Management of fetal growth restriction

A

1) grwoth scans every 2-3 eeks + doppler
2) give corticosteroids for fetal lung maturityup to 35+6 weeks
3) plan birth- normal dopplers induce at 37 weeks/ abnormal dopplers concider LSCS

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14
Q

presentation of ectopic pregnancy

A

Pain (unilateral, sudden onset), amenorrhoea 6-8 weeks, bleeding, D+V, dizziness and syncope

cervical excitation and adnexal tenderness, abdo distension, rebound tenderness

Serum hCG and urine pregnancy test positive

Transvaginal ultrasound- uterus empty

history of ectopic, PID, previous uterine surgery, IVF, chlamydia, pregnancy despite IUD

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15
Q

management of ectopic pregnancy

A

1) stabilise patient
2) if asymptomatic/ hCG<3000/ ectopic <3cm on scan/ no fetal heart beat–> MEDICAL MANAGEMENT- IM methotrexate
3) if significant pain/ opossite of above–> SURGICAL MANAGEMENT- Laproscopic salpingectomy

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16
Q

presentation of molar pregnancy

A

Significantly raised hCG
exaggerated pregnancy symptoms- severe morning sickness and pre-eclampsia

most present with early pregnancy failure- heavy bleeding, molar tissue looks like frogspawn

US- snowstorm effect/ grapes

Management: Terminate pregancy

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17
Q

Management of a missed abortion

A

1) medical- mifepristone (antiprogesterone- allows contractions) and misoprostol (prostaglandin- brings on contractions)
2) Surgical- evacuation of retained products of conception
3) expectant- rarely

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18
Q

In general, what is the likely diagnosis of an antepartum haemorrhage

1) PAINFUL
2) PAINLESS

A

1) pain- abruption

2) painless- preavia

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19
Q

What is the name for placenta lying in lower uterine segment?

A

placenta preavia

diagnosed on ultasound scan

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20
Q

management of placenta preavia

A

if minor= placental edge >2cm from os
stay at home until 37 weeks as long as mum can get in quickly, deliver at 39 weeks

if major= placental edge <2cm from os
delivery by C section at 39 weeks
Give steroids 24-34 weeks

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21
Q

Placental abruption definition

A

Part of placenta becomes detached from uterus before dilvery- can be significant maternal bleeding behind

concealed (80%)- blood goes directly into myometrium, blood loss amount easily underestimated

revealed- dark bleeding

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22
Q

placental abruption presentation

A

PAIN
woody hard uterus
Tender contracting uterus, tachycardia, hypotemsion, fetal distress, poor urine output

complications- fetal death due to placental insufficiency

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23
Q

Name 3 clinical features of normal labour

A

1) contractions
2) cervical effacement and dilation
3) show- plug of cervical mucus and blood

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24
Q

outline the 3 stages of labour

A

FIRST STAGE
initiation of contractions–>full cervical effacement and dilation
latent- irregular contractions, dilation up to 4cm
established- regular contractions, dilation up to 10cm

SECOND STAGE
full cervical dilation–> delivery of baby
passive- head decending to pelvic floor- takes up to 2 hours
active- pushing- up to 3 hours

THIRD STAGE
delivery of fetus to delivery of placenta
<500mls blood loss normal

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25
what is given to aid the 3rd stage of labour?
Syntometrine- oxytocin and ergometrine | contaction of uterus and decreased bleeding
26
what is used in induction of labour
if ruptured membraines but not progressing to spontaneous labour give vaginal prostaglandin and oxytocin infusion
27
what biomarker indicates an increased risk of prematurity
fetal fibronectin
28
what can be given to supress premature labour?
Tocolytics- atositiban/ nifedipine
29
define primary and secondary post partum haemorrhage
``` Primary= >500mls blood lost in first 24 hours secondary= excessive blood loss 24hrs- 6 weeks after delivery ```
30
What are the causes of a primary post partum haemorrhage?
tone- uterine atony (not contracting well)- 90% tissue- retained POC Trauma- genital tract trauma Thrombin- clotting disorders
31
what are the causes of a secondary PPH
most commonly endometritis +/- retained placental tissue also C section, prolonged rupture of membranes, manual removal of placenta, extreme of mothers age, lower socioeconomic status
32
explain the difference between baby blues, post natal depression and puerperal psychosis
BABY BLUES Seen in around 60-70% of women Typically seen 3-7 days following birth and is more common in primips Mothers are characteristically anxious, tearful and irritable Reassurance and support, the health visitor has a key role POST NATAL DEPRESSION Affects around 10% of women Most cases start within a month and typically peaks at 3 months Features are similar to depression seen in other circumstances Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe** - whilst they are secreted in breast milk it is not thought to be harmful to the infant PUERPERAL PSYCHOSIS Affects approximately 0.2% of women Onset usually within the first 2-3 weeks following birth Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations) Admission to hospital is usually required There is around a 20% risk of recurrence following future pregnancies
33
what are the main risk factors for shoulder dystocia?
fetal macrosomia maternal high BMI Diabetes mellitus prolonged labour
34
first line anti-hypertensive for pre-eclampsia in women with severe asthma
nifedipine
35
what blood markers are measured in the combined and quadruple antenatal screening test for Downs
Combined- B hCG (raised) and PAPP-A (pregnancy associated plasma protein )(low) quadruple- AFP (alpha fetoprotein) (low), unconjugated oestrodial (low), beta hCG (high) inhibin A (high)
36
List some lifestyle advice to give to a couple who are struggling to conceive
``` regular intercourse folic acid supplements smoking cessation lose weight and healthy diet decreased alcohol consumption exercise manage any pre-existing medical conditions ```
37
List some likely causes of infertility due to disorders in ovulation
HYPOTHALMIC hypothalmic gonadism- anorexia, stress, exercise Kallman's syndrome PITUITARY hyperprolactinaemia pituitary damage psychotropics OVARIAN *PCOS* premature ovarian failure OTHER hypo/hyperthyroidism androgen secreting tumour
38
When investigating infertility, at what day would progesterone be measured and what would indicate ovulation had occured
Day 21 progresterone | >30 suggests ovulation has occured
39
what is the most common cause of infertility in women?+ symptoms
PCOS weight gain, hirsutism, irregular periods, polycyctic ovaries on ultrasound scan
40
Management of PCOS infertility +side effects
Clomifine citrate = antioestrogen-->increases indogenous FSH-->stimulates follicule mauration increased risk of multiple pregnancies hot flushes, labile mood, pelvic pain also manage with metformin, laproscopic ovarian drilling, gonadotrophins, weight loss
41
If tubular damage is the suspected reason for infertilty, what are the likely causes, how to investigate, and management
1) Infection- PID, STIs- do chlamydia screen and high vaginal swab 2) Previous surgery- salpingostomy and adhesions - from previous ectopic/ other disease- Tx: tubual catheterisation 3) endometriosis- laproscopic surgery to remove endometriosis lesions
42
List the common causes of menorrhagia
``` dysfunctional uterine bleeding fibroids polyps chronic pelvic infection ovarian tumour cervical (post coital bleeding) and endometrial malignancy (post menopausal bleeding) ```
43
Symptomatic management of menorrhagia
1) Mirena IUD- decreases bleeding- local release of progesterone- endometrial atrophy 2) Antifibrinolytics- transexamic acid- decreases blood loss 3) NSAIDS- mefanamic acid 4) progestens 5) GnRH agonists 6) Surgery- endometrial ablation, hysterectomy
44
Typical presentation of endometrial cancer Plus management
POST MENOPAUSAL BLEEDING obese, diabetes, nuliparity, early/late menopause, HRT, Breast cancer treated with tamoxifen, PCOS -->all high oestrogen:progesterone COCP and pregnancy protective- increased progesterone exposure Management: totaly hysterectomy with bilateral salpingo-oophrectomy Adjuvant radiotherapy Progesterone therapy- in advance disease- palliation of symptoms
45
Investigation of endometrial cancer
Transvaginal ultrasound- thickness >4mm endometrial biopsy hysteroscopy
46
presentation of cervical cancer Typical patient and risk factors
POST COITAL BLEEDING watery vaginal dischage, IMB/PMB, menorrhagia, weight loss, bowel disturbance in late disease or incidental finding on cervical smear/ CIN treatment RISK FACTORS HPV infection, aged 25-34, multiple sexual partners, smoking, lower social class, developing countries, previous CIN, oral contraceptive pill, immuno-suppression, non-attendance at cervical screening
47
Investigations for cervical cancer
examination- irregular cervical surface, irregular massess that bleed on contact Biopsy- 70% squamous cell carcinoma CT abdo+ pelvis, MRI pelvis for staging
48
Ovarian tumour presentation Investigations
LATE presentation aged 75-84 vague symptoms (ovarian=overall)- systemic presentation: abdo distenstion, weight loss, PV bleeding, urinary symptoms risk factors: BRCA1 and BRCA2 gene increased ovulations: early menarche, late menopause, nuliparity Investigations Ca125 raised ultrasound abdo and pelvis
49
presentation of firbroids risk factors
Menorrhagia infertility pain mass- can press on bladder--> frequency/ press on veins--> oedematous legs and varicose veins RISK FACTORS age, family history, afrocaribbean, oestrogen(enlarge in pregnancy, COCP, atrophy after menopause)
50
management of fibroids
1) hyerectomy- definitive cure, but not if fertility preservation important 2) myomectomy 3) GnRH agonist- shrinks fibroid via down regulation of oestrogen- desensitises anterioir pituriary to GnRH, so less FSH and LH so less oestrogen
51
common causes of secondary dysmenorrhoea
Secondary= due to pelvic pathology Endometriosis, PID, Adenomyosis, fibroids Pain precedes period and may be relieved by end of period (Primary= no organic cause, pain starts with menstruation- treat with NSAIDS and COCP)
52
Presentation of endometriosis
Cyclical pelvic pain, gets better after periods Chronic pelvic pain Deep Dyspareunia Subfertility Woman of reproductive age, early menarche and low parity
53
Investigations of endometriosis
Endometrial laproscopy and biopsy- chocolate cysts? | Transvaginal ultrasound- cysts, thick walls, blood inside
54
Management of endometriosis
1) MEDICAL- ovarian suppression - COCP - GnRH analogue - Mirena IUD 2) SURGICAL - lesion ablation laproscopically - hysterectomu
55
Definition of adenomyosis
``` Endometrium in myometrium PAIN, regular heavy menstruation enlarged boggy uterus It is more common in multiparous women towards the end of their reproductive years. diagnose with MRI ```
56
Causes and risk factors of pelvic inflammatory disease
CAUSES - ascending endocervical infection- chalmydia, ghonorrhoea, uterine instrumentation - descending abdo infection- appendicitis RISKS <25, previous STIs, multiple sexual partners
57
Presentation of PID Treatment
constant/ intermittent pelvic PAIN bleeding- irregular periods, IMB, PCB, vaginal discharge (due to vaginal infection) fever (sometimes) Antibiotics- ceftriaxone
58
what investigations should be carried out for a) acute pelvic pain b) chronic pelvic pain
ACUTE - urine analysis/ MSU - pregnancy test - FBC- infection - urgent ultrasound- miscarriage/ectopic - high vaginal swab CHRONIC - sexually active- screen for chlamydia and gonorrhoea - Ca125- ovarian cancer? - transvaginal ultrasound- endometriosis, ovarian cysts, fibroids - MRI- adenomyosis - laproscopy
59
list some causes of primary amenorrhoea
structural- malformation of genital tract genetic- Turners, kallmans low body weight mullarian agenesis
60
List some causes of secondary amenorrhoea
hypothalamic-pituitary-ovarian disorders - stress, exercise, weight loss, athletes - Hyperprolactinaemia - Hyper/hypothyroid - PCOS, ovarian failure - Pregnancy - Ashermans- excessive scarring in uterine cavity, often after multiple dilatation and curettage procedures or post TB/ schistosomiasis infection - drugs- contraceptive pill, antipsychotics, GnRH analogues
61
what is the classic hormonal imbalance in PCOS?
LH>FSH (Usually FSH>LH)
62
Presentation of PCOS
Oligomenorrhoea hypergonadism polycystic ovaries on US- >12 Subfertility Typical patient: obese, childbearing age, high BP, Type 2 diabetes, insulin resistance,
63
Investigations for PCOS
raised free androgen/ testosterone raised LH/FSH ratio ultrasound
64
Management of PCOS
``` Weight loss COCP Clomifine/ tamoxifen metformin ovarian diathermy ```
65
``` Which STI? asymptomatic or white discharge, dysuria, bleeding PID gram -ve cocci ``` Investigations Treatment
Chlamydia Investigations: NAAT/ PCR treatment: azithromycin Stat
66
Which STI? asymptomatic or urethetis, vaginal discharge, cervicitis, dysuria, increased risk of premature labour or miscarriage Investigations Treatment
Gonorrhoea Investigations NAAT Treatment: Azithromycin + IM ceftriaxone
67
Which STI? Multiple painful ulcers fever, myalgia, discharge and dysuria investigation treatment
Herpes investigations: viral swabs Treatment: Acyclovir
68
Which STI Single painful ulcer= chancre Later serious systemic symptoms treatment
Syphilis treatment IM Penicillin
69
Which infection cottage cheese discharge itchy/ inflamed vulva and superficial dyspareunia Treatment
Thrush Fluconazole
70
which infection? grey/yellow, fishy, thin discharge clue cells alkaline pH treatment
bacterial vaginosis metronidazole
71
which STI? offensive green/grey frothy discharge, vulval irriation, superficial dyspareunia strawberry lesions on cervix
Trichomonias metronidazole
72
Presentation of menopause
hot flushes, insomnia, psychological | breast atrophy, hair loss, atrophic vaginitis, prolapse, urinary symptoms, osteoporosis
73
investigations of menopause
Low antimularian hormone | raised FSH
74
Diagnostic test of premature menopause management
< 40 yo raised FSH 4 weeks apart HRT until 50 fertility support androgen replacement
75
side effects of combined oral contraceptive pill
- increased risk of breast cancer and cervical cancer (protective of endometrial and ovarian) - thromboembolic risk - contraindicated in migraine, stroke, IHD, uncontrolled hypertension
76
what makes up the triple assessment in the diagnosis of breast cancer?
1) clinical score - palpable lump, physical changes in breast (eg pau d'orange, nipple indrawing, discharge etc), secondary symtoms eg bone pain, back pain, pathological fracture 2) Imaging score- mammography/ ultrasound 3) Tissue biopsy
77
possible complications of amniocentesis what should be given at time
- discomfort and cramping - vaginal bleeding - maternal rhesus sensitisation - amnionitis - miscarriage 1% risk - amniotic fluid leakage give rhesus prophylaxis if appropriate
78
complications of hyperemesis gravidarum
wernickes encephalopathy korsakoffs syndrome mallory weiss tear--> haematemesis
79
why is it important to date pregnancies
timing of downs syndrome screening knowing viability of preterm births timing of induction of labout if post term births
80
Long term risk of molar pregnancy
chroiocarcinoma- follow up closely
81
4 complications of IUD insertertion
PID uterine perforation device migrating through peritoneal cavity expulsion of device

obs and gynae (1 decks)

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