Obs and Gynae Flashcards

Question

Complications of PCOS

Answer 1

- Infertility - Miscarriage - Gestational DM/ T2DM - Endometrial hyperplasia --> malignancy - HTN/CVD

Answer 2

Primary - failure to commence menses Secondary - cessation of periods for >6m excluding pregnancy Hypothalamic --> (↓ GnRH - ↓Fsh:LH ) - eating disorder; ↓/↑ T3/4 (affects LH/FSH); Kallman syn Pituitary --> prolactinoma (I.GnRH sec); pitutary tumour; Sheehans syn (post-partum necrosis); AI/ radiation affecting pit; prolonged use contraception (downreg) Ovarian - PCOS; Turners; POI; haemochromatomis (hypogonadism) Adrenal gland - CAH Genital tract abnormality - Ashermanns; Imperforate hymen; vaginal atresia; Androgen insensitivity; cryptomenorrhoea (hidden period as obstruction)

Answer 3

Intervals between cycles >35d o PCOS; Contraceptive/Hormonal treatments; Perimenopause o Thyroid disease/Diabetes o Eating disorders/excessive exercise o Medications e.g. anti-psychotics, anti-epileptics Mx - treat cause - COCP;POP

Answer 4

As corpus luteum regress - ↓ progesterone  endometrial cells release prostaglandin - Spiral artery vasospasm - leading to ischaemic necrosis and shedding of the superficial layer of the endometrium. - ↑ myometrial contractions Secondary - underlying pelvic pathology Sx Crampy lower abdominal pain, - starts at the onset of menstruation ± radiation to back/thigh. Lasts 48-72 hrs, worse at onset of menses. Other Sx: malaise, N+V diarrhoea, dizziness. ± uterine tenderness

Answer 5

RF: Early menarche; Long menstrual phase;Smoking; Nuliparity; Heavy periods (clot dysmenorrhoea – pain when endometrium expels clot) Differentials (diagnosis of exclusion) - Endometriosis (pain before period) - Adenomyosis - PID - Adhesions - IBS/IBD

Answer 6

- Stop smoking; local application of heat - treat any underlying cause 1) NSAIDs (inhibit PGs) ± paracetamol - Start few days before usual onset of pain 2) 3-6m trial of COCP/ POP/ Coil

Answer 7

- 40-60% no underlying cause (Abnormal uterine bleeding) - Other: leukaemia, IUCD, PIC, hypothyroidism, Liver disease, SLE, Ca, Progesterone contraception, most commonly fibroids Ix • Bloods --> FBC (anaemia); TFT (?↓); hormones (?PCOS); Clotting screen (vW) • USS – Detect Fibroids/ adenomyosis • Urine pregnancy test (?ectopic) • ?Hysteroscopy – biopsy pelvic masses • ?Laparoscopy –abdo masses • ?Endometrial biopsy – pathology/ inconclusive ± failure of pharm treatment

Answer 8

- Age (more likely at menarche and approaching the menopause) (>45 ↑ risk) - Obesity; - Previous caesarean section

Answer 9

Ix - Smear up to date - STI screen - USS for structural pathology - ?laparoscopy (endometriosis) 1) Mirena Coil 2) tranexamic acid/NSAID or COCP/POP 3) Endometrial ablation/ hysterectomy

Answer 10

- Pregnancy test - TFT - Hormone levels (prolactin, GnRH, LH, FSH, Oest, test) - ?Karyotyping - USS - ? progest challenge (if get withdrawal bleed adequate oest but not ovulating)

Answer 11

- sx 5-11 d before period with >1 symptom free week after - sx --> bloating, breast tenderness, headaches, tension & irritability, fatigue, forgetfulness, mood swings, sleep problems, depression, carbohydrate craving, clumsiness, libido↓ Mx - support, lifestyle change, vit B6, COCP - Bromocriptine (Da Ag)

Answer 12

MOA - Antifibrinolytic - reversibly binds to lysine R on plasminogen/ preventing plasmin binding to and degrading fibrin. SE - Headaches; Back ache; Abdominal pain

Answer 13

Zolidex (Nasal spray/ impant) MOA - Analogue which activates GnRH R -↑ LH + FSH Induces hypoestrogenic state --> amenorrhoea (due to pituitary desensitisation) SE - Menopausal like symptoms e.g. night sweats, headaches, ↓ libido, mood swings

Answer 14

Used in fibroids and emergency contraception - Selective Progesterone R modulator – acts by I. ovulation CI – breast/gynae Ca/ hepatic disorder ``` SE • Dysmenorrhoea • Hepatic failure • Pelvic pain • Breast tenderness ```

Answer 15

Gonadotrophin inhibitior – suppressing the pituitary-ovarian axis by inhibiting the release of LH + FSH SE - Androgenic effects (hirsutism, acne); Breast atrophy; Hot flushes

Answer 16

Microgynon --> Inhibits ovulation (stops LH surge), and reduces bleeding and period pain (Vaginal ring and patch work in same way) CI - BMI>35/ breastfeeding; HTN; FH breast/cervical; hx migraines ``` SE • VTE • Breast / Cervical Ca • Headaches • Mood changes ```

Answer 17

- Norethisterone - inhibit ovulation, thickening the cervical mucus SE Nausea; Headache; Bloating/ weight gain; Skin rash

Answer 18

Releases Levonorgestrel into the Uterus, preventing uterine shedding and reducing bleeding – thins endometrium and contraceptive CI – recent STI/ hx PID/ endometritis SE - Spotting; Ectopic pregnancy; Falling out

Answer 19

Medroxyprogesterone acetate- Agonist of progesterone androgen and glucocorticoid R - i. follicular development and prevent ovulation Thin endometrium + change cervical mucus SE - menstrual disturbance/ acne; headaches; bone loss; blood clots

Answer 20

Subtotal (partial) - Uterus, not cervix Total (Cervix + uterus) +/- bilateral salpoingo-oophorectomy (fallopian tubes and ovaries) Radical - Total + parametrium, vaginal cuff + part/ whole of fallopian tubes. SE - Haemorrhage requiring blood transfusion - Early menopause (change in blood supply to ovaries) - Infection/ Pain/ Adhesions - Anaesthetic risks - total vault prolapse ``` Uncommon Damage bladder/bowel wound dehiscence Pelvic abscess/ infection Vaginal prolapse VTE/ PE (early mobilisation) ```

Answer 21

* Infection * Infertility * Failure * Pain and fever post - op

Answer 22

Transcervical resection (GA) - uses diathermy Balloon ablation (LA/GA) - using heated fluids - need cervical dilation Microwave energy (LA) - <72s Bipolar mesh (LA/GA) - need cervical dilation SE • Infection • internal organ damage uterine perforation/ bowel/bladder • Haemorrhage • new adhesions • intrauterine scarring - obstructed outflow of menstrual blood - haematometra + pelvic pain • Fluid overload/ electrolyte imbalance ( transcervical) CI Only if don't want any more children - risk placenta praecia +/- accerta - Endometrial hyperplasia/ Ca

Answer 23

LA; vas deferens cut/blocked Complications - haematoma (scrotum); infection; epidymitis; sperm granuloma; testicular pain

Answer 24

Anterior - Urethrocele (Lower) --> Prolapse of Urethra into the vagina; Stress incontinence - Cystocele (Upper) --> Prolapse of Bladder into vagina; Few / no symptoms; If large may cause increased frequency, recurrent UTI Middle - Uterine prolapse --> Descent of the Uterus into the vagina 1st ° --> cervix stays in the vagina. 2nd ° --> cervix protrudes from introitus when standing/ straining. 3rd ° --> the uterine fundus lies outside the vagina. The vagina becomes keratinized and the cervix may ulcerate (bleeding ± discharge from ulcer) o Pressure, urinary incontinence, dyspareunia - Vaginal vault prolapse--> Descent of the vaginal vault after Hysterectomy; Often associated with cystocele, rectocele and enterocele' Urinary retention, distal ureteric obstruction Posterior - Rectocele (Middle) - Prolapse of the rectum into the vagina (through levator ani); Sx - Constipation, urgency or symptomless - may have to reduce herniation prior to defecation - Enterocele (Upper) --> Herniation of the Pouch of Douglas into the vagina o Usually asymptomatic

Answer 25

Weakened pelvic floor: - Post-menopause (reduced oestrogen) - Pelvic surgery - Obesity / Frequent heavy lifting - Congenital/ genetics - Loss of muscle tone / Repeated straining (chronic constipation/COPD - Childbirth >1 –? Trauma / macrosomic fetus

Answer 26

``` Stress Urge Mixed (stress and urge) Overflow - Functional Fistulae ```

Answer 27

Weakness of pelvic floor and urethral sphincter leads to passage of urine when ↑ intra-abdo P e.g coughing / laughing) RF - weak pelvic floor (childbirth; obesity; chronic cough; post-pelvic surgery; post-menopausal - prostacetectomy ; TURP; - Infection; neurological disease; age; female

Answer 28

Detrusor overactivity causing high bladder pressure leading to sudden urge/ uncontrolable bladder emptying --> Large volumes, (day and night) Causes - idiopathic (overactive bladder) - precipitated by arriving home; running water; coffee - Neurogenic (hyperreflexia): MS, PD, spinal cord injury (incl prolapsed disc/DM), stroke - Bladder outlet obstruction: prostate/ bladder/ cervical/ colon ca; BPH/stone/stricture; STI/trauma/ blood clot/ faecal impaction - UTI

Answer 29

Bladder doesn’t empty properly/ incomplete voiding; overfill --> overflow - hesitancy; terminal dribbling; poor stream Causes - bladder outflow obstruction (e.g. BPH/stricture/stone/ faecal impaction) - impaired detrusor contractility (M.S/PD)

Answer 30

``` DIAPPERS Delirium Infection (UTI) Atrophy Pharm Psych (demenita) Excess UO (↑ intake/DI) Restricted mobility Stool impaction ```

Answer 31

Predisposing - Race; FH; Anatomy/neurology abnormality Promoting - Co-morbidites; ↑ intra-abdo P; cognitive impairment; UTI; pelvic prolapse; diet (caffeine, citrus fruit juice, alcohol), meds (diurectics; anti-cholinergics; anti-dep; sedatoves; alpha blockers

Answer 32

- haematuria - prolapse beyond introitus - pelvic mass - weight loss - pain assoc micturition - >3 infections in 6m

Answer 33

- general --> BMI (heigh/weight); MMSE - CVS - signs CR disease - CNS - gait; check L1-S3 sensation and neuro exam - Abdo - surgical scars, hernias, masses, distended bladder after voiding - DRE - impaction; tone; mass (prostate in males) - Vaginal - atophy; prolapse; urethral tenderness; strength pelvic floor (oxford scale) +/- cough/strain - speculum

Answer 34

- freq/volume chart - 3 day bladder diary - urine dip +/- MC&S - Bloods - FBC (↑ WCC); U&E (↑ ca - constipated/confused); glucose (DM) Imaging - USS kidneys- post-residual vol - cystoscopy (if haematuria) - USS abdo (CRF/obstruction) - CT abdo (mass) Specialist - urodynamic studies - uroflowmetry - cystometry (get detrusor P) - video/ ambulatory urodynamics

Answer 35

Conservative - watch and wait - lifestyle modification (stop smoking, constipation mx, weight loss) - pelvic floor exercises - vaginal pessary (frail) - S.E --> Vaginal discharge (smelly), discomfort, UTI, discomfort, ulceration , interfere with sex, incontinence - topical oestrogens (if post-meno Surgery - hysterectomy - Sacrocolpopexy/ Sacrospinous fixation - to fix vaginal vault - colposuspension - strengthen pelvic floor (SE- Anaesthetic risk, infection, bleeding, DVT, voiding difficulty, urinary retention, urinary incontinence)

Answer 36

Stress - pelvic floor exercises (trial 3m) - vaginal tampon - duloxetine - vaginal tape (only if others fail - sling around urethra; SE - bladder perf; Damage to vessels/viscera; Voiding difficulties + urinary retention (short-term); Urgency and frequency; Groin/ suprapubic pain (short duration); Vaginal tape erosions. - Other --> rectus fascial sling; repair; injection of bulking agents into bladder neck Urge - bladder training (6wk) - pelvic floor+ scheduled voiding - Reduced caffeine intake, weight loss, modify fluid intake (none after 8pm) - Oxybutynin Other -->botox injection; sacral N stim; self-catheter (if neuro) Overflow - review meds/bowel/ intermittent catheter; education; rx cause Functional - mobility aids; continence aids etc

Answer 37

Inhibit pre-synaptic 5HT + NAdr in Onuf’s nucleus of sacral spinal cord ↑ [5HT+NAdr] in synaptic cleft Stronger urethral contractions and persistent sphincter tone during storage phase ``` SE • N&V; GI Sx • Insomnia • Dizzy; drowsy • Anxiety; ↓ appetite • dry mouth; palpitation • flushing; headache • vision disorders (CI in glaucoma) • sweat changes ```

Answer 38

Direct anti-spasmodic effect, acting on M1/2/3 SM R --> ↓ Detrusor activity - increase bladder capacity Modified release tablets -↓ SE ``` SE • Dry mouth; headache • Urinary retention • Constipation/ diarrhoea • Blurred vision • Nausea; abdo pain ```

Answer 39

* Sexually active/ Aged 15-24 y/o * Multiple sexual partners * Intercourse without barrier contraception * Hx of STIs/ PID * Instrumentation of cervix - gynae surgery, TOP, and insertion IUS * Retrograde menstruation * Hormonal changes – ↓ barrier from cervix (COCP ↓ risk)

Answer 40

• Infective inflammation of endometrium, uterus, fallopian tubes, ovaries + peritoneum - Acute - <6 months; Chronic >6 months - ~ 25% - Chlamydia and gonorrhoea

Answer 41

* asymptomatic * Lower abdo pain (unilateral / bilateral) * Deep dyspareunia/ Post-coital bleeding * Menstrual abnormalities (e.g menorrhagia, dysmenorrhoea or IMB) * Dysuria * Abnormal vaginal discharge (purulent ± unpleasant odour) Advanced - severe lower abdo pain, fever (>38° C), and n&v

Answer 42

Vaginal examination - tenderness of uterus/adnexae or cervical excitation - palpable mass in the lower abdomen - Speculum --> abnormal vaginal discharge noted ± cervicitis * Endocervical (gonorrhoea and chlamydia) + High vaginal swab (TV,BV)  NAAT * Full STI screen * Urine dipstick +/- MSU – to exclude UTI * Pregnancy test * ? FBC (CRP &WBC) * TV USS – severe/ diagnostic uncertainty. * ? Laparoscopy – severe

Answer 43

* Infertility - (tubal adhesion) * Ectopic pregnancy - narrowing and scarring of the fallopian tubes * Fitz-Hugh-Curtis syndrome (peri-hepatitis) -- infection of the Glissons capsule around the Liver, leading to acute RUQ pain and tenderness * Tubo-ovarian abscess (pocket of pus) * Chronic pelvic pain * Reiter syndrome Admit --> pregnant; n&v/fever; signs abscess; need IV; HIV

Answer 44

14-day Abx • Low risk of Gonococcal --> Ofloxacin + Metronidazole BD • High risk --> Ceftriaxone IM stat; then Doxycycline + Metronidazole BD Advice • Pain relief and rest • Avoid sexual intercourse until Abx course complete and partner treated • Contact tracing

Answer 45

* Sexual activity * New sexual partner * Pregnancy * Urinary/ faecal incontinence * Renal tract malformation • Use of spermicides (condoms) * ↓ oestrogen/menopause * Immunocompromised/ DM * Dehydration * Obstruction (stones/catheter)

Answer 46

``` Gynae o Endometriosis/ Adenomyosis o Chronic PID o Ovarian cysts o Post C-section o Prolpase o Fibroids o Tumours ``` ``` GI o Adhesions o Appendicitis o Constipation o Diverticular disease o IBS ``` Urinary o UTI o Calculus ``` Other o MSK o Degenerative joint disease o Low back pain o Psychological o CRPS ```

Answer 47

Endo - Chronic oestrogen-dependent condition --> growth of endometrial tissue in sites other than the uterine cavity (?retrograde menstruation), most commonly the pelvic cavity (incl. ovaries). Also includes uterosacral ligaments, the pouch of Douglas, peritoneum and lungs. Adeno - extension of endometrial tissue and stroma into the uterine myometrium, affecting ~15% of women; causing a bulky, tender uterus and dysmenorrhoea RF • Early menarche / late menopause • Delayed childbearing/ Long duration of menstrual bleeding • Short menstrual cycles • FH – 1st ° relative • HMB • Defects of uterus or fallopian tubes

Answer 48

* Dysmenorrhoea (2°) /chronic pelvic pain * Menorrhagia * Dyspareunia (↑ in menses) * cyclical GI/urinary symptoms (?pain) * infertility - with 1+ of above Present at distant sites - Haemothorax; epistaxis; rectal bleeding Symptoms ↓ in pregnancy and menopause

Answer 49

Examination – can be normal •fixed, retroverted uterus •Enlargement (tender + boggy = adenomyosis) •Tender nodularity in the posterior vaginal fornix and uterosacral ligament •Visible vaginal endometriotic lesions or Adnexal mass •Tenderness/ focal pain on examination - Pregnancy test – exclude ectopic pregnancy - Urinalysis + cervical swabs -exclude STI/PID cause of pain, - Laparoscopy(1st!) – visualise endometrial lesions >Chocolate cysts (active endometriosis); Adhesions (+scars - inactive); Peritoneal deposits - Pelvic USS –severity and demonstrate pelvic mobility ± bowel involvement MRI –visualise endometrial ectopic endometrial tissues

Answer 50

Medical 1) NSAIDs OR 2) COCP/vaginal ring - ↓ oestrogen 3) MPA OR Mirena Coil 4) Specialist - GnRH agonist (e.g. soladex) Surgical 1) Laparoscopic removal of ectopic endometrial tissue – Excision/ ablate 2) Hysterectomy with bilateral salpingo-oophorectomy (10% pain recurrence) - replace hormones until menopause age - Complications --> persistent pain; bladder/bowel injury; infection 3) Artificial insemination - ?IVF; potentially laparoscopic ablation

Answer 51

RF - Peri / post-menopausal; Sexually inexperienced; hx sexual abuse ``` Presentation • Penetration / deep pain • Tightening of the vagina on penetration • Vulvodynia (vulva pain) ?Pelvic masses/ Suprapubic tenderness ```

Answer 52

* Examination – Assess for Vaginismus, and for tenderness on palpation * Cervical swabs – To assess for PID and STIs * Urinalysis – Assess for the possibility of an UTI cause * Laparoscopy – To assess for endometriosis

Answer 53

oSex therapy - Modification of sexual technique + lubrication oCBT o Lidocaine – topically ( if pain alone the major complaint) Treat underlying cause e.g. vaginismus --> vaginal trainers and PT

Answer 54

pregnancy which is implanted at a site outside of the uterine cavity Tubal (>99%) - Ampullary (55%) - Isthmic (25%) present late and often bleed catastrophically Rare Ovary; abdo; cervical

Answer 55

PMH - Previous ectopic - PID (adhesion formation) - Endometriosis (adhesions) - tubal pathology Contraception - IUD/IUS - POP/ implant (fallopian tube ciliary dysmotility) Iatrogenic - Pelvic surgery – especially tubal surgery - Assisted reproduction i.e. embryo transfer in IVF

Answer 56

- Lower abdominal/pelvic pain ± irregular PV bleeding or hx of amernorrhoea - Vaginal discharge – brown (prune juice) -->result of decidual breakdown (as suboptimal β-HCG) - Shoulder tip pain (haemoperitoneum) Other --> Breast tenderness, GI symptoms, dizziness, fainting or syncope, urinary symptoms, passage of tissue, rectal pressure or pain on defecation

Answer 57

On examination - Abdo/ pelvic tenderness; enlarged uterus Vaginal --> - Cervical excitation +/- adnexal tenderness. - Fullness in pouch of douglas (if ruptured) If ruptured --> haemodynamically unstable o pallor, ↑ CRT, tachycardia, hypotension, shock/collapse o signs of peritonitis (abdo rebound tenderness and guarding) o Abdominal distention - Pregnancy test - if +ve  pelvic USS (+/- TV USS) - If can't see location (i) very early intrauterine pregnancy (ii) miscarriage (iii) ectopic pregnancy - serum β-HCG >1500 iU + no intrauterine --> ? ectopic --> diagnostic laparoscopy <1500 iU + pt stable --> blood test 48 hours later: • Viable pregnancy --> HCG level double every 48 hours • Miscarriage --> HCG level halve every 48 hours

Answer 58

Medical - No significant pain - Adnexal mass <35mm - No intra-uterine pregnancy on USS - Serum hCG <1500 IU/L - Not ruptured - Can attend for follow up (2 serum hCG day 4 &7; then every week until -ve) - 24h access to gynae services (+ sx rupture) Surgical - Significant pain - Adnexal mass >35mm - Fetal heart beat visible on USS - Serum hCG >5000IU/L - Ruptured - Can’t attend for follow up

Answer 59

Medical +ve - Avoids surgical complications and the patient can be at home after the injection. -ve - SE of methotrexate (abdo pain, myelosuppression, renal dysfunction, hepatitis, teratogenesis (use contraception for 3-6 m after use), treatment failure Surgical +ve: Reassurance about when the definitive treatment can be provided, high success rate. -ve: GA risk, risk of damage to bladder/ bowel/ureters, DVT/PE, haemorrhage, infection, risk treatment failure (salpingotomy - some of the pregnancy may remain within the tube), ↑ risk of recurrent ectopic in salpingotomy, need Anti-D prophylaxis

Answer 60

Conservative --> no sx/ rupture/ <3cm and hcg<1500 - sx of rupture and 24h access Medical --> Methotrexate IM Surgical --> Laproscopic salpingectomy All - Miscarriage Association; Written information / leaflets; Counselling and Support

Answer 61

``` • >35 (↑ ch. abnormalities) • Previous miscarriage (esp if ≥ 2 before) • Obesity • Ch. abnormalities (maternal or paternal) • Smoking/ caffeine • Uterine anomalies e.g. fibroids • Previous uterine surgery • Anti-phospholipid syndrome/ SLE • Coagulopathies • PCOS • Poorly controlled DM/ thyroid • Serious maternal infection – causing fever --> Rubella, CMV can cross placenta o Malaria, chlamydia, listeria,syphilis • Alcohol (esp >5 units/wk) and drug use • Folate deficiency • Methotrexate ```

Answer 62

spontaneous loss of the fetus <24/40; occurs in 1/4 pregnancies Sx - PV bleed +/- clots/POC - haemodynamically unstable - suprapubic pain - haemoperiteum - ? distended abdo - cervic open/closed - uterine tenderness/ adenxal mass/collection

Answer 63

Threatened - mild bleeding/pain; cervix closed (viable) Inevitable - heavy bleeding/pain; cervix open (?viable) Missed (silent) - on-going discharge; small for dates; asymptomatic but no fetal heart pulsation; anembryonic (empty gestation sac) Incomplete - POC partially expelled (retained POC >15mm + proof pregnancy previously); cervix open Complete - hx bleeding/clots/ POC; pain; cervix closed (previous proof and POC <15mm now) Septic - Infected POC - fever; tender uterus; bleeding; pain

Answer 64

Threatened - observe Inevitable - admit (if haemodynamiccal unstable)/ option for conservative/ med/ surgical mx Missed - rescanned by 2nd person 7-14d to confirm-conservative/ med/ surgical mx Incomplete - medical/surgical mx Complete - discharge to GP Septic - admit + sepsis 6 + remove infected tissue (med/surgically)

Answer 65

- Ectopic pregnancy - Hydatidiform mole - Cervical/uterine malignancy

Answer 66

+ve pregnancy test - send to EPAU USS (?TV) --> fetal development + heartbeat (if >6/40) - yolk sac; ovarian cysts; free fluid/ mass; position of uterus - If no heartbeat 2nd scan 1-2 weeks later Serum hCG o> 1500 and no signs of pregnancy in uterus – significant o<1500 – hCG 48 hours later ( if ↑ x 63% - intrauterine pregnancy; <63% - ?ectopic) ?FBC; blood group and Rh status; triple swaps and CRP (if pyrexic)

Answer 67

If >12 weeks ? Anti-D prophylaxis -Conservative (<12/40) - wait +ve: remain at home, no S.E. of meds/surgery, 24/7 access to gynae services -ve: Unpredictable timing (takes longer), heavy bleeding + pain during passage of POC, may require further intervention + need for transfusion. Worries about being at home. Follow-up: Repeat scan in 2/52 OR pregnancy test in 3/52. - medical (>14/40) --> Mifepristone + Misoprostol (48h later) - stimulate cervical ripening and myometrial contractions. + Analgesia + anti-emetics +ve: Can be at home, 24/7 access to gynae services, no anaesthetic/ surgical risk. -ve: S.E of meds: vom/d, heavy bleeding (up to 3/52) and pain during passage of POC, chance of requiring emergency surgical intervention. Follow-up: Pregnancy test 3 weeks later Surgical - Surgical Evacuation of Retained products of Conception (SERPC) - using suction or manual vacuum aspiration with LA if <12 weeks +ve: Planned procedure (help pt cope), unaware during the process (under GA), discharged same day -ve: Anaesthetic risk, infection (endometritis), uterine perforation, haemorrhage, Ashermen’s syndrome, bowel/ bladder damage, retained POC, damage/weakness cervix - histology on tissue

Answer 68

Loss of ≥ 3 CONSECUTIVE pregnancies with SAME partner

Answer 69

- Balanced (Robertsonian) translocations - Uterine anomalies - Antiphospholipid syndrome o I. of trophoblastic function – poor oxygenation and nutrient supply to the foetus o Complement activation and inflammatory response at the maternal/foetal interface – Leading to poor oxygenation of the fetus - IUGR, Still birth, Pre-eclampsia - Thrombophilia -->hypercoagulability - Unexplained

Answer 70

- anti-phospholipid Ab (2+ tests >12wk apart) o Mx - LMWH + lose-dose Aspirin + mx risk of DVT/PE; Stroke - Karyotype - Pelvic USS/ Hystereoscopy for uterine malformation +/- cervical weakness - thrombophilia screen - DM and hypothyroidism

Answer 71

Gestational trophoblastic disease --> Spectrum of disorders of trophoblastic development arising from abnormal ch no. in fertilisation (pregnancy related) 1) Pre-malignant conditions (more common) – such as partial(1 ovum and 2 sperm) /complete (empty egg and 1 sperm) molar pregnancy 2) Malignant conditions (rarer) - invasive mole/ choriocarcinoma (trophoblastic cells of placenta)

Answer 72

* Stage 1 – Confined to Uterus * Stage 2 – Outside uterus, but limited to genital structures * Stage 3 – Extends to the lungs * Stage 4 – Affecting any other metastatic site

Answer 73

* <20 / >35 * hx GTD/ miscarriage * Asian * oral contraceptive pill

Answer 74

* Vaginal bleeding + abdo pain in early pregnancy * Large uterus for dates (+soft/boggy) * Absence of fetal movement detected * Met signs (dyspnoea, etc) Later • Anaemia • Hyperemesis (↑ β hCG) • Hyperthyroidism (↑ β hCG stimulates thyroid)

Answer 75

* Urine + blood hCG – remain ↑ after pregnancy * Histology POC – post treatment/ non-viable pregnancies * Pelvic USS – T2 onwards - complete mole =granular/ snowstorm appearance + central heterogeneous mass and surrounding multiple cystic areas/vesicles. * Staging CT CAP – if suspect mets

Answer 76

Register with GTD centre for follow-up and future monitoring Surgical - Suction curettage –complete/partial molar pregnancy Medical - evacuation (partial mole of a greater gestation with fetal development & isn’t conducive to surgical evacuation) – urinary β -hCG after 3/52 Chemotherapy – rising hCG after surgical evacuation, evidence of mets, or histological evidence of choriocarcinoma Anti-D prophylaxis After - 2/52 serum+urine hCG until normal (+ 4/52 if complete for 6m) Advice - not to conceive until hCG levels have been normal for >6 months, and women who undergo chemotherapy are advised not to conceive for one year after completion of treatment

Answer 77

Prolonged and severe N&v of pregnancy (lasts >20/40) due to rapidly ↑ β – hCG levels o >5% pre-pregnancy weight loss o Severe dehydration o Deranged bloods (e.g.↓ K/Na) o Marked ketosis o Nutritional deficiency/ muscle wasting (risk wernickes) ? mallory weiss tear; AKI; liver failure - baby may have low birth weight/ be premature Measure using PUQE score (Pregnancy-Unique Quantification of Emesis)

Answer 78

- First pregnancy - Hx of hyperemesis gravidarum - Raised BMI - Multiple pregnancy - Hydatidiform mole - GTD

Answer 79

- Gastroenteritis - Cholecystitis - Appendicitis - Hepatitis - Pancreatitis - Chronic H. Pylori infection - Peptic ulcers - UTI or pyelonephritis - Metabolic condition --> thyrotoxicosis, Addisons, DKA - Neurological conditions - Drug-induced (Abx / iron)

Answer 80

Beside – Weight; Urine dip (ketones) Lab o MSU; FBC (anaemia, infection, haematocrit (can ↑)); Blood glucose (exclude DKA) o U&E (↓ K/Na, dehydration, renal disease) Severe causes o LFT: exclude liver disease e.g. hepatitis or gallstones, monitor malnutrition o Amylase: exclude pancreatitis o TFT: ↑/↓-thyroid o ABG: exclude metabolic disturbances, monitor severity USS -->confirm viability, confirm gestation, exclude multiple pregnancy and trophoblastic disease/ ectopic

Answer 81

Mild - Reassurance and rest +/- antiemetics (cyclizine) hydration, dietary advice Moderate (or community mx failed) – ambulatory daycare. - IV fluids, parenteral antiemetics and thiamine. Managed until ketonuria resolves. - PPI for reflux, oesophagitis or gastritis Severe – inpt mx - IV rehydration + KCL (guided by electrolytes) - IV antiemetics - Thromboprophylaxis If can’t control may need termination

Answer 82

1) Cyclizine; Promethazine; Chlorpromazine 2) Metoclopramide (max 5d due to risk EPSE); Domperidone; Ondansetron 3) Hydrocortisone IV (Once sx improve --> pred PO and wean)

Answer 83

In t1 - teratogenesis and T2/3 - affect growth Li --> Ebstein anomaly, neonatal hypothyroidism, foetal hypotonia, poor reflexes, arrhythmia – strict monitoring SSRI --> pulmonary HTN, (cardiac defects – paroxetine), miscarriage, low birth weight. o Fluoxetine safer oWithdrawal symptoms --> poor adaptation, jitteriness, irritability and poor gaze control Valproate - ↑ risk NTD (use contraception) Carbamazepine - cleft lip Lamotrigine - ↑ risk of SJS Anti-manic drugs - infants -->sedation, poor feeding, behavioural effects and developmental milestones. Olanzapine - fetal macrosomia, GDM

Answer 84

* Primary –Couples who have inability to conceive >12m of regular unprotected intercourse * Secondary – Couples who have previously been able to become pregnant, but now cannot

Answer 85

- Idiopathic - Female: ovulation disorder (PCOS, ovarian failure, hyperprolactinaemia); Anatomical anomalies (PID, STIs, sterilisation, fibroids, endometriosis); Turners - Male - disorders of sperm morphology/ vol/ concentration/ motility

Answer 86

Female Age; Methods of contraception Duration + Type of infertility 1° /2° -2° - previous birth e.g C-section/ PPH/ ectopic Menstrual cycle – ovulating? Regular/irreg; Menorrhagia/ dysmenorrhoea/ amenorrhoea Tubal surgery/ PID/ Pelvic surgery pelvic pain – endometriosis/ fibroids Taking folic acid; Smoking (↑ infertility) Chemo/RT Male - Alcohol/ smoking (↓ sperm quality) Previous surgery (urogenital) /infections (STI) Sexual dysfunction – erectile/ ejaculatory Varicocele; Cryptorchidism Ask if had semen analysis (abnormal) Chemo-RT

Answer 87

BMI Pelvic exam -structural abnormalities; Fixed/ tender uterus Mid-luteal progesterone - ? ovulating ``` Hormone levels (FSH + LH) (Day 2) o ↑↑ may suggest poor ovulatory function o High LH:FSH -?PCOS ``` Tubal patency assessment o Hysterosalpingogram o Diagnostic laparoscopy and dye Genetic testing (Turners) and presence of 2 ° sexual characteristics Additional: Pelvic USS (ovaries, uterine abnormalities); Hysteroscopy; Prolactin levels/TFTs; Testosterone/SHBG; Screen for chlamydia; Rubella status (?MMR vaccine. ? Booster)

Answer 88

Semen analysis x 2 from masturbation after >3d abstinence 3m apart ``` Hormone analysis (FSH + Testosterone) o ↑ FSH may suggest impaired spermatogenesis ``` USS Testes hx urinary sx / abnormal findings when exam testicles, Genetic testing (Kleinfelters)

Answer 89

``` o Volume (ml) - >1.5ml o Total sperm – 39 x 106 per ejaculation o pH - >7.2 o Sperm concentration – 15 x 106 per ml o Total motility ( % progressive & non‑progressive motility): > 40% motile or > 32% progressive motility o Vitality: 58% or more live spermatozoa o Morphology (normal forms) - >4% ```

Answer 90

Dependent on cause - unexplained --> IVF (>2 years not concieved) - tubal blockage --> Tubal anastomosis + reimplantation - Cervical factors - low pH (sodium bicarb douche); poor mucus quality (intra-uterine insemination) - Hypothalmic-pit failure --> lifestyles, BMI >19, pulsatile GnRH agonist (stim release FSH+LH - SE- hot flush; headache; osteoporosis) HPG axis dysfunction (PCOS) - PCOS mx + clomifene citrate (block -ve feedback of oest - SE -->hot flushes, headche, n+v, ovarian enlargement) +/- laproscopic drilling + metformin Ovarian failure --> IVF with donor egg

Answer 91

Stop drinking/smoking; lose weight; loose fitting underwear and avoid sauna (reduce scrotal temp) - low semen vol --> IVF/ intra-uterine insemination - Oligospermia - clomifene citrate / IVF etc Azoospermia - correct bloackage OR sperm extraction then injection Hypogonadism - GnRH ag Ejaculatory failure - sex therapy

Answer 92

IVF - fertilise in a lab. Fertilised egg (zygote) is cultured for 2–6 d in growth medium and then transferred back to uterus to develop Intra-uterine insemination - Placing sperm in uterus, to ↑ the no. of sperm that reach the fallopian tubes and subsequently ↑ the chance of fertilization Intracytoplasmic sperm injection (ICSI) - single sperm is injected directly into an egg after being extracted from testicles

Answer 93

- Important health problem. - Should be a treatment for the condition. - Facilities for diagnosis and treatment should be available. - A latent stage of the disease. - Test/examination for the condition. - Test should be acceptable to population. - The natural history of the disease should be adequately understood. - Agreed policy on whom to treat. - Total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.

Answer 94

- 3-yearly from 25-49, and then 5-yearly to 50-64 year olds - smear at transformation zone --> detect CIN and HPV status EITHER: - normal - routine recall - inadequate - repeat - abnormal borderline/ mild dyskaryosis but HPV -ve --> repeat smear 6-12m - Abnormal borderline/ mild dyskaryosis but HPV +ve --> Colposcopy - Mod/severe dyskaryosis --> urgent colposcopy +histology Looking for abnormal vascular pattern (mosaicism, punctation); abnormal staining of the tissue (aceto-white, brown iodine) on colposcopy

Answer 95

Cervical intra-epithelial neoplasia (CIN) - abnormal growth of the cervical mucosa at transformation zone; it is potentially pre-malignant ``` CIN 1 (Mild) - Basal 1/3 of epi CIN 2 (Mod) - Basal 2/3 of epi CIN 3 (Severe) - >2/3 of epi /full thickness --> carcinoma in situ ```

Answer 96

* Most common aged 25-35 (though can occur at any age) * Young commencing sexual activity (<18) * Giving birth <16 * Multiple sexual partners * Immunosuppression * Smoking

Answer 97

CIN1 -->ablation CIN 2+3 --> Excisional: LLETZ (large loop excision of the transformation zone) + histological analysis (under LA) o Complications – Bleeding, infection, ↑ risk of premature rupture of membranes Colposcopy after 6 m, then yearly for 10 yrs Screen for STIs Don't treat while pregnancy

Answer 98

47-73 every 3 years - mammogram (or <47 +RF; if <35 - USS) RESULTS: - normal - abnormal --> breast exam; repeat mammograph +/- breast USS of the abnormal results 1/4 have cancer

Answer 99

Precancerous prolif of endometrium --> ↑ volume of endometrial tissue --> abnormal thickening of the lining of the uterus - ↑ risk endometrial ca (hyperplasia +/- atypia) Cause--> Excess/ unopposed oestrogen o early menarche, late menopause, PCOS --> ↑ anovulatory cycle o Exogenous oestrogen therapy (e.g. HRT); Obesity; Low parity

Answer 100

SX --> AUB Ix --> TV USS - thickened endometrial stripe ↑ suspicion -Confirm diagnosis - endometrial biopsy Mx - Hyperplasia-atypia o Hormonal - Mirena and surveillance biopsy to identify progression or high dose progesterone - Atypical hyperplasia o Total hysterectomy ± bilateral salpingo-oophorectomy If CI - regular surveillance biopsies

Answer 101

1) Endometrial adenocarcinoma- related to unopposed oestrogen; Obesity; Lynch; endometrial hyperplasia and increasing age 2) Other: papillary serous; clear cell etc - oest indep Presentation AUB – intermenstrual, irregular menstruation, postmenopausal (10% risk) - Less commonly blood stained, watery, purulent vaginal discharge Abnormal cervical smear Advanced/ mets (cervix, bladder, rectum, regional LN) - Abdo pain/distention; weight loss; feeling of fullness in the abdo, abnormal bowel/ bladder function --> CT CAP

Answer 102

* Abdo exam– masses * Speculum - vulval/vaginal atrophy, or cervical lesions. * Bimanual– assess size & axis of uterus before endometrial sampling * TV USS – ix PMB- >4mm endometrial thickness need to pipelle biopsy for histology (of <4 and recurrent AUB) Hysteroscopy with biopsy - AUB, multiple RF for Ca or v. thick endometrium on USS

Answer 103

- Weight loss Stage 1) Total hysterectomy + bilateral salpingo-oophorectomy + Peritoneal washings Stage 2) Radical hysterectomy + assess & remove pelvic LN ± adjuvant radiotherapy. Stage 3) Chemo +/- RT +/- max de-bulking surgery Stage 4) RT / high dose oral prog

Answer 104

Stage 0 – carcinoma in situ Stage 1 - confined to organ of origin Stage 2 – Invasion of surrounding organs/tissues Stage 3 – Spread to distant nodes/ tissue in pelvis Stage 4 – Distant mets

Answer 105

- trauma/ bleeding from elsewhere - oestrogen-secreting ovarian tumours e.g. granulosa-thecal cell or oest from HRT - endometrial --> atrophy; polyps; hyperplasia; cancer; endometritis/PID - Cervical --> polyps; cancer; cervitis - vaginal – atrophic vaginitis, vaginal cancer - vulval pathology – dermatitis; dystrophy; cancer - systemic problem – bleeding disorders, mets cancer e.g. ovarian, CRC

Answer 106

Mainly SCC (99% caused by HPV) - developed from CIN Other - adenocarcinoma/ mixed ``` RF - • HPV infection (16 + 18) • Multiple sexual partners • Young age 1st intercourse • Exposure (no barrier contraception)/ other STIs • Immunosuppression/ HIV • Smoking • use COCP >8 years) • Non-compliance cervical screening ```

Answer 107

* Screening * AUB (+ can see ulcer on speculum) * Vaginal discharge (blood-stained, foul-smelling) * Dyspareunia * Pelvic pain * Weight loss Late symptoms - Painless haematuria, painless PR bleeding, leg oedema, altered bowel habit, loin pain, radiculopathy - ?pelvic masses. - GI–hydronephrosis, hepatomegaly, rectal bleeding, mass on PR.

Answer 108

- test for chlamydia if <50 y/o (if +ve treat) - colposcopy + biopsy Confirmed - baseline bloods and CT CAP +/- MRI pelvis

Answer 109

1a) Radical trachelectomy (preserve fertility) - removal of the cervix and upper vagina OR laparoscopic hysterectomy 1b) Radical hysterectomy +/- RT+ neoadjuvant/ adjuvant chemo 2) Radical hysterectomy +chemoradiation 3) Chemoradiation 4) Surgery/ pallative chemo Review every 4m after treatment complete for 2 years then 6m 3 years

Answer 110

Stage IA: Invasive cancer identified only microscopically. Stage IB: Gross lesions confined to the cervix or preclinical lesions greater than Stage II: extends beyond the cervix, but does not extend into the pelvic wall. The carcinoma involves the vagina, but not as far as the lower third. Stage III extended into the pelvic sidewall/ lower third of the vagina/ hydronephrosis Stage IV extended to involve the mucosa of the bladder and/or rectum/ mets

Answer 111

``` --> Surgery Infection VTE Haemorrhage Vesicovaginal fistula Bladder dysfunction Lymphocyst formation Short vagina ``` ``` --> RT Vaginal dryness Vaginal stenosis Radiation cystitis Radiation proctitis Loss of ovarian function ```

Answer 112

``` RF • Genetics (BRCA1/2 or Lynch 2 syn) • Age (>50) • Smoking • FH • Extended oestrogen exposure (early menarche, late menopause, nulliparity, Oest only HRT, Obesity) • Endometriosis ``` ``` Protective • Multiparity/ pregnancy • Breast-feeding • Sterilisation • Early menopause • COCP • Hysterectomy/ oopherectomy ```

Answer 113

``` ~60% present late (stage 3-4) • Insidious onset vague sx • Abdo discomfort / bloating • Urinary frequency / PV bleed • Ascites • Change in bowel habit/ IBS • Dyspareunia • Constitutional symptoms (fatigue, weight loss, cachexia) • Pelvic / back pain o Acute -->bleeding into the cyst, rupture or torsion (?shock) o Chronic --> due to pressure o Cyclic -->endometriosis ```

Answer 114

• Abdo exam --> pelvic masses/ ascites • Pelvic examination -->> discharge/ bleeding, adnexal masses and cervical excitation. • Bloods – FBC (chronic bleed, anaemia), U+E, LFT, and albumin oCA125 – Ovarian Ca marker (any peritoneal irritation will raise it) • Abdo and pelvic USS – To assess for masses--> risk of malignancy index Confirmed Ca - Staging CT CAP and CXR

Answer 115

Counselling (if childbearing age) - staging laparotomy (↑ RMI) + attempt to debulk the tumour. - Oophorectomy (repro age) OR Total hysterectomy with bilateral salpingo-oophrectomy Adjuvant chemotherapy – all but early, low grade F/u –clinical exam+ monitoring of CA125 level for 5 years Recurrence – palliative chemotherapy

Answer 116

o Stage 1 – Limited to ovaries o Stage 2 – Involving one/both ovaries with pelvic extension o Stage 3 – Involving one/both ovaries with microscopic peritoneal implants o Stage 4 – With distant metastases

Answer 117

``` - >50y/o who present with: > Abdo mass/ ascite OR o Abdominal distension ('bloating') o Early satiety ± loss of appetite o Pelvic / abdominal pain ```

Answer 118

Epithelial 90% --> >50 years - Serous/ mucinous cystadenocarcinoma Germ cell --> <35 y/o - presents early; may sec hcg/ AFPO Mets

Answer 119

Risk of malignancy index RMI = U x M x CA125 ``` Menopausal status (M) Pre- menopausal (1) Post- menopausal (3) ``` Ultrasound score (U) --> 1 feature = 1; >2 = 3 - Mulilocular cyst - Solid areas - Metastases - Ascites - Bilateral lesions CA125--> units/ml

Answer 120

Functional - follicular and corpus luteal Pathological - endometrioma (chocolate cyst) - PCOS - Theca lutein cyst (molar pregnancy) Benign - epi --> serous/ mucinous cystadenoma - germ cell --> mature cystic teratoma (+teeth/hait/skin/bone) - sex-cord --> fibroma/ theca cell

Answer 121

Pre-menopausal - rescan in 6 weeks - if still there--> then monitor with USS + Ca125 6m - consider cystecomy Postmenopausal - Use RMI • RMI <25 -follow up for 1 yr with USS and CA125 if less than 5cm. • RMI 25-250- bilateral oophorectomy; if Ca - staging + completion surgery of hysterectomy, omentectomy ±lymphadenectomy). • RMI >250 - referral for staging laparotomy

Answer 122

85% squamous - majority on labium majorium ``` RF • VIN • HPV infection • Lichen sclerosis/ sw cell hyperplasia • Pagets disease of the vulva ```

Answer 123

* Vulval lump * Vulval bleeding / ulceration * Vulval pruritus /pain Affecting labia majora – keratotic, warty and ulcerated lesions

Answer 124

Exam– extent + borders of lesion - Anaplastic lesions more likely to invade deeply Biopsy – To provide a histological diagnosis CT CAP – For staging (often metastasise via inguinal LN) Mx - counselling (surgery may mutilate - need reconstruction) - chemo/ RT - radical vulvectomy +/- remove LN

Answer 125

Vulval intra-epithelial neoplasia (VIN) - • A pre-malignant state of epithelium of the Vulva, no screening tests - usually related to HPV Sx - asymp or itchy/burn/pain

Answer 126

• HRT / Topical oestrogen cream Works by thickening and re-vascularising the vaginal epithelium, so improving lubrication; and reducing fissure development

Answer 127

Naegele rule | 1st day LMP + 1year -3m +7d

Answer 128

USS between 10 weeks and 13 weeks 6 days - gestational age using CRL (10 Weeks = 3cm; 12 weeks = 5cm; 13 weeks = 7cm) - fetal viability (looking at cord; skull and abdo wall) - multiple pregnancies

Answer 129

Sx - Amenorrhoea - endometrium maintained with prog from Corpus luteum - ↑ frequency of micturition, especially at night - Nausea + vomiting Mx - ginger, wrist acupressure, antihistamines - Breast - tingling of the nipples and areola, >6 weeks they enlarge Signs - Breast changes o ↑ in size and feel warm o Areolae darken o Montgomery's tubercles become prominent (sebaceous glands on the nipples) - Cervix changes -->Appears lilac red on passing a speculum - Uterus -->Enlarges as it accommodates the fetus

Answer 130

Heartburn; constipation; haemorrhoids; vaginal discharge; varicose veins (give support stockings); backache (massage, exercise in water, back care classes)

Answer 131

Resp - ↑ tidal volume; ↓ total lung capacity; ↑ oxygen consumption; ↓ pCO2 CVS - CO ↑; ↑ blood volume Urinary - ↑ GFR -->↓ plasma urea + cr/ glycosuria; ↑ urinary frequency; ↑ renal length (cellular hypertrophy) + ↑ ureter diameter Blood -↑ WBC; ↑ platelets +CF (hypercoaguble state); ↓ Hb; Metabolic - HPL --> ↑ blood sugar and insulin resistance; weight gain (~12.5kg - Fetus, uterus, breasts, ↑ blood vol and body fat) GIT - SM relax (prog) --> ↑ risk haemorrhoids + pain; GOR; constipation (↓ motility) + Displaced organs upwards Water - ↑ - softens ligaments +/- CTS Endocrine - hyperthryoid (stim hcg)

Answer 132

• smoking cessation, alcohol (non 3m than 1-2 unit/week), diet, recreational drugs folic acid supplementation + Vit D supplements Food hygiene and ↓ risk of a food-acquired infection (listeriosis and salmonella) o Drink pasteurised/ UHT milk o NOT EATING -ripened soft cheese (Camembert, Brie); pâté; uncooked/ undercooked ready‑prepared meals; raw/partially cooked eggs or food that may contain them (eg. mayo); raw or partially cooked meat, esp poultry moderate exercise (+ pelvic floor exercises) Screening: anaemia, HBV, HIV, rubella status, syphilis, chlamydia, SCD/ thalassaemia; ABO, rhesus status and any irregular RBC Ab Downs screen - Nuchal thickening can be performed until 14 weeks Info- how the baby develops; place of birth & pregnancy care pathway; breastfeeding (offer workshops); ? antenatal classes; Maternity rights and benefits; Majority are safe to continue work; Air travel - ↑ risk VTE; Mental health issues RISK ASSESSMENT + risks for pre-eclampsia, gestational diabetes etc

Answer 133

Structural anomalies - all limbs - encephaly - cleft lip - scoliosis - spina bifida - heart working - stomach - kidneys +/- gender + confirm due date

Answer 134

Week 28 and week 34 | or <72h of a sensitising event

Answer 135

RF - Nulliparity; >40 y/o; Previous/ FH hx; ↑ BMI; unaccurrate dating Complications - ↑ risk still birth - ↑ potential for placental insufficiency - ↑ risk of fetal acidaemia + meconium aspiration in labour - ↑ need for instrumental/ C-section delivery - ↓ oxygen and nutrient transfer - placental degradation can deplete fetal glycogen stores, resulting in neonatal hypoglycaemia Presentation - macrosomia/ oligohydramnios/ reduced fetal movements - meconium - dry/ flaky skin (less vernix|)

Answer 136

From T1 - uterus undergoes physiological contractions (‘practice contractions’) Common after week 36 +/- pain; occur infrequently; Cease with activity (usually); Very short duration (~30 seconds); Always have the same intensity (contractions proper increase intensity)

Answer 137

Passage (bony pelvis) Power (of contractions - progressive shortening) Passenger (moulding of cranium)

Answer 138

Expulsion of cervical mucus plus 1) dilation --> usually 1-3cm/hr (quicker in parous)- from onset of regular contractions to full dilation of cervix. 2) complete dilation --> baby born. Urge to push + valsalva maneouvre (engage - flex - descend - extend - external rotation) 3) delivery of placenta and membranes - give oxytocin (promote uterine contraction) to reduce to <5 mins - ↓PPH

Answer 139

VE - 4 hrly --> dilation +position Maternal urine - 4 hrly --> ketones + protein - (+ve ketones - 10% dextrose IV) Baseline Obs - 30 mins - ?distress CTG --> fetal heart and uterine contractions LAPPED fetus position L – Lie A – Attitude (posture, flexed / extended head) P- Presentation P – Position (part of head that exits birth canal) E – Engaging diameter D – Denominator (the presenting part, eg. Occiput, face, brow, etc)

Answer 140

- membranes not ruptured - 1st baby - inadequate uterine activity Mx - Start syntocin; DVE for process; if indicated emergency C-section

Answer 141

DR C BraVADO Define Risk (pre-eclampso; DM; preterm) Contractions - aim 4/5 in 10min); should be <1min and intensity should increase Baseline rate - Fetal HR 110-160 (every 15m 1st stage + 5m 2nd) Variability - can fluctate by 5-25bpm; FBS if <5bpm for >90mins Accelerations - >15bpm for 15sec Deceleration (<15bopm for 15s) - AFTER contraction sign of fetal hypoxia - FBS; ANYTIME - umbilical cord compression Overall impression - suspicious/ pathological --> senior help

Answer 142

Meconium ileus; abnormal fetal HR; mother pyrexial; oxytocin/ epidural use; PV bleed; PROM; APH; multiple pregnancies; DM/HTN/PRe-eclampsia; IOL; prolonged pregnancy

Answer 143

Hypoxia Hyperthyroidism Fetal / maternal anaemia Chorioamnionitis (if maternal fever present)

Answer 144

- Post-date gestation - Occiput posterior / Transverse presentation Prolonged (<80bpm for >3m) - Prolonged cord compression - Cord prolapse - Rapid foetal descent

Answer 145

o perineal pain, discomfort, stinging, offensive odour or dyspareunia (use topical cold therapy + paracetamol) o Headache - ?post epidural/ spinal; ?tension/ migraine headache o Persistent fatigue –?FBC oConstipation – assess diet and fluid intake ± gentle laxative o Haemorrhoids – if severe/ prolapsed – urgent action. o Faecal incontinence – assess severity, duration and frequency o Urinary retention (< 6 hrs of birth) – advise warm bath/shower when urinarate; ?catheter o Urinary incontinence – pelvic floor exercises o Mental health problems – ensure coping strategies and support in place and encourage to report concerns

Answer 146

↑ progesterone & oestrogen inhibit lactation before birth (↓ after) Prolactin - maintaining tight junctions of the ductal epithelium and regulating milk production Oxytocin - contracts SM in alveoli - squeeze milk into duct system

Answer 147

colostrum - ↑ WBCs + IgA, which coats the lining of the baby's immature intestines - helps to prevent pathogens from invading Over the first 2 weeks after birth, colostrum production slowly gives way to mature milk

Answer 148

To baby - ↓ infection; childhood leukaemia; cot death; T2DM To mother - ↓ breast/ovarian Ca; postnatal depression; osteoporosis; T2DM/ Obesity§

Answer 149

↑ risk - difficulty conceiving, miscarriage, gestational DM, caesarean, HTN/ pre-eclampsia, VTE, anaesthetic complications and wound infections Babies of obese mothers are ↑ risk of – stillbirth, NTD, prematurity, macrosomia, shoulder dystocia, neonatal death and obesity.

Answer 150

Smoking - : IUGR, miscarriage/stillbirth, prematurity Alcohol - fetal alcohol syndrome - growth restriction, LD, facial anomalies Cocaine - spontaneous abortion, placental abruption, premature birth, IUGR and sudden infant death syndrome

Answer 151

↑ global risks: difficulty in conceiving, ↑ risk of miscarriage, twins, fibroids, hypertension, gestational DM, labour problems and perinatal mortality with ↑ maternal age ↑ Downs syn risk - 1 in 800 at 30 yrs 1 in 100 at 40 yrs 1 in 50 or more at >45 yrs

Answer 152

Comprised of fetal urine output (main); placenta and some fetal secretions (e.g. respiratory). The fetus breathes and swallows the amniotic fluid. It gets processed, fills the bladder and is voided, and the cycle repeats.

Answer 153

amniotic fluid index < 5th centile for GA Causes - PPROM - Placental insufficiency –blood flow redistributed to fetal brain rather than the abdo + kidneys - causes poor urine output. - Renal agenesis (Potter’s syndrome) - Non-functioning fetal kidneys, e.g. bilateral multicystic dysplastic kidneys - Obstructive uropathy - Genetic/chromosomal anomalies - Viral infections

Answer 154

amniotic fluid index > 95th centile Causes - Idiopathic in 50-60% o - fetus swallowing stopped – e.g. oesophageal atresia, CNS abnormalities, muscular dystrophies, congenital diaphragmatic hernia obstructing oesophagus - Duodenal atresia – ‘double bubble’ sign on USS - Anaemia – alloimmune disorders, viral infections (TORCH) - Fetal hydrops - Twin-to-twin transfusion syndrome - ↑ lung secretions – cystic adenomatoid malformation of lung - Genetic/ ch abnormalities - Maternal DM – esp if poorly controlled - Maternal ingestion of Li – leads to fetal DI - Macrosomia – LGA produce more urine.

Answer 155

``` Group of infections that cause proboems for developing baby Toxoplasmosis Other (coxsackie, syphilis chicken pox) Rubella CMV HSV ```

Answer 156

Hx- sx of leaking fluid and feeling damp all the time Examination - S-F height; tense uterus? (poly) - ?PROM; maternal DM (GTT) Ultrasound - ↑/ ↓ amniotic fluid - Assess for liquor volume - Measure fetal size (SGA from placental insufficiency) - Fetal anatomy – structural causes, renal agenesis and obstructive uropathy - ?↑ in pulsatility index of the umbilical A Doppler in placental insufficiency. Karyotyping (if appropriate) – particularly in cases of early and unexplained/ structural abnormality Doppler – fetal anaemia (poly) OR Assses kidneys (oligo) TORCH screen

Answer 157

Premature rupture of membranes (PROM) –rupture >1 hr prior to the onset of labour, at ≥37/40 Pre-term premature rupture of membranes (P-PROM) – rupture of fetal membranes - <37/40

Answer 158

- Smoking (esp < 28/40). - Previous PROM/ pre-term delivery (predisposition) - Vaginal bleeding during pregnancy. - Lower genital tract infection (weaken fetal membrane) - Invasive procedures e.g. amniocentesis (activate normal process early) - Polyhydramnios. - Multiple pregnancy. - Cervical insufficiency

Answer 159

- Gradual leakage of watery fluid from vagina + damp underwear/pad - Speculum  Don’t do if SEE fluid draining opooling in the posterior vaginal fornix. Lay on couch for at least 30 mins. o Coughing during examination – amniotic fluid expelled - Change in colour/ consistency or lack of normal vaginal discharge (‘washed clean’) - Avoid DVE until in active labour - ↓ time between rupture & onset of labour (↑ risk asc intrauterine infection)

Answer 160

``` o Urinary incontinence. o Normal vaginal secretions of pregnancy. o ↑ sweat/ moisture around perineum. o ↑ cervical discharge (e.g. infection). o Vesicovaginal vaginal fistula. o Loss of mucus plug. ```

Answer 161

?USS (amnoiotic fluid level) Actim-PROM - IGFBP-1 level High vaginal swab (?infection) Ferning test - cervical secretion on slide

Answer 162

- majority fall into labour within 24-48 hours (if >36/40 and don't then IOL if not in 24h) - Monitor for signs of clinical chorioamnionitis and advise no sex Clindamycin/penicillin during labour if GBS isolated <36/40 give erythromycin for 10d + corticosteroids

Answer 163

* Chorioamnionitis * Oligohydramnios – if < 24/40 ↑ risk lung hypoplasia. * Neonatal death – prematurity, sepsis and pulmonary hypoplasia. * Placental abruption * Umbilical cord prolapse

Answer 164

<12/40 - Ectopic pregnancy, molar pregnancy, heavy uterine bleeding <20 /40 - Amniocentesis, CVS, miscarriage, termination of pregnancy; intrauterine death; abdo trauma >20/40 - Delivery, Intra-uterine procedures, external cephalic version, APH

Answer 165

Measure cervical ripeness - * ≥ 7 –cervix is ripe – IOL possible * <4 –labour unlikely to progress naturally and prostaglandin tablet/gel/pessary required Features - dilation; length; station (relative to ischial spines); consistency; position

Answer 166

Non-pharm - relaxation/ breathing exercises - moving - massage - music - warm bath/ shower Pharm - Entonox (50% O2; 50% NO) - Pethidine IM + metoclopramide (opiod) - epidural (indwelling plastic catheter) - ideally in 1st stage of labour - spinal (c-section/ manual removal of placenta/ instrumental) - LA (episiotomy) - Pudendal block

Answer 167

serial growth measurements every 2-4 weeks +/- umbilical A doppler (any placental resistance) modify maternal RF Corticosteroids

Answer 168

LGA Maternal - DM; obesity; ↑ age; multiparity; large stature Fetal - constitutional; male; post maturity; genetic (Beckwick wierderman -macrosomia + taller than peers during childhood -ch 11) SGA - -hx IUGR; recurrent fetal loss; previous unexplained stillbirth; T1 bleedings; infection; placental pathology (e.g. praevia); multiple pregnancies - Smoking; unexplained raised AFP; extremes of maternal age - BMI <20; poor nutrition; severe anaemia; High altitude - Smoking, alcohol, substance abuse, prescription/ OTC drugs; Domestic violence - HTN; haemoglobinopathies; anti-phospholipid syndrome; collagen vascular disease; renal disease

Answer 169

``` Maternal •Anaemia – ↑ fetal use of maternal blood • Pre-eclampsia • APH/PPH - ↑ trauma • ↑ sx hyperemesis •Maternal mortality ``` ``` Fetal • Stillbirth • Preterm birth, and associate difficulties (respiratory distress, etc) • Umbilical cord entanglement • Feto-fetal transfusion syndrome ```

Answer 170

artery-vein anastomosis between twins (usually monozygotic) --> donor becomes anaemic and may show considerable growth retardation; recipient becomes polycythaemic, hypertensive, and will also be much larger Risk of hydrops foetalis - severe anaemia causing oedema of whole body and HSM Mx - laser ablation surgery to cut anastomoses or serial amniocentesis (remove membrane so share amniotic fluid)

Answer 171

Causes Power --> Inefficient uterine activity;Mx --> Oxytocin (ONLY if 1st baby – if previous uterus can rupture) - Hypotonic or Incoordinate contractions - ? dehydration, exhaustion, ketosis --> Mx - hydration, analgesia; amniotomy, oxytocin infusion; delivery if appropriate Passenger - Cephalopelvic disproportion (relative, absolute) - Too big (e.g. macrosomia, hydrocephalus etc.) - Abnormal diameter presenting (abnormal attitude, malpresentation or malposition) Mx - C-section; ensure adequate contraction; ?instrumental delivery Passage - Abnormal bony pelvis; Cervical dystocia (Mx - C-section) OR Rigid Perineum (Mx – episiotomy)

Answer 172

Chorioamnionitis; 3-4th degree perineal tears; Uterine atony – ↑ the risk of PPH

Answer 173

Ventouse - Attaches cup to fetal skull flexion point (midline, 3cm AP fontanelle) via a vacuum - ↓ success rate. During uterine contractions, traction is applied perpendicular to the cup. Forceps - Double bladed inserted through pelvis and applied to sides of fetal head - gentle traction during uterine contractions + episiotomy

Answer 174

Maternal • Inadequate progress • Maternal exhaustion. • Maternal medical conditions - mean active pushing or prolonged exertion should be limited e.g. intracranial pathologies, some maternal congenital heart diseases and severe HTN Fetal • Suspected fetal compromise in the 2nd stage of labour, usually diagnosed by: o CTG monitoring OR Abnormal fetal blood sample • Clinical concerns e.g significant APH

Answer 175

F - Fully dilated cervix O - Occipito-anterior position (preferably) R - Ruptured membranes C - Cephalic presentation E - Engaged presenting part (head largest diameter should have passed pelvic brim) P - Pain relief, should be adequate (nerve block / epidural) S - Sphincter – Bladder empty o Mediolateral episiotomy - before instrumental delivery - ↓ risk of 3-4th ° tears

Answer 176

``` Unengaged incompletely dilated cephalo-pelvic disportion breech/face presentation preterm/ coag disorder ``` relative - acute fetal distress/ prolapsed umbilical cord

Answer 177

``` > Fetal Neonatal jaundice Scalp lacerations Cephal or sublgaleal haematoma Facial bruising Facial N damage Skull # Retinal haemorrhage ``` ``` > Maternal Vaginal tears 3rd/4th °tears (↑ in forceps) VTE Incontinence PPH Shoulder dystocia Infection ```

Answer 178

Prematurity; Multiple pregnancy; Uterine abnormalities (e.g fibroids, partial septate uterus, bicornuate uterus); Fetal abnormalities; Placenta praevia; Primiparity; smoking; DM

Answer 179

External cephalic version (ECV) ~ 36/40 - manoeuvring baby through a forward somersault to cephalic presentation from breech - some return back (more likely if oligohydramnios, etc) Complications - fetal distress, PROM, APH, placental abruption, uterine rupture, emergency C-section CI - recent APH, ruptured membranes, uterine scar/ abnormalities, previous C-section, fetal compromise, vaginal bleeding and medical conditions.

Answer 180

* Ballotable head in the fundal-area * Soft-irregular mass (buttocks) in the pelvis * Fetal heartbeat loudest above the umbilicus * Sub-costal tenderness

Answer 181

* Premature labour / Cord-prolapse * Perinatal mortality 4x ↑ ``` At delivery • fetal head entrapment • cord prolapse • intracranial haemorrhage (rapid compression head during delivery) • internal injuries – PROM ```

Answer 182

EMERGENCY - cord passes through as infront of presenting part --> ↓ blood flow - foetal hypoxia and distress Types - incomplete (alongside presenting part but not beyond) - complete - desc past presenting part)

Answer 183

* Transverse/ unstable lie * Breech * Artificial rupture of membranes * Multiple pregnancy * Polyhydramnios * Prematurity

Answer 184

HELP • Avoid handling the cord to reduce vasospasm • 4-6L oxygen to mother and stop oxytoxin infusion • Manually elevate the presenting part Lift presenting part off cord by DVE – if in community, fill the maternal bladder with 500ml of normal saline (warmed if possible) via a urinary catheter and arrange immediate hospital transfer. • Encourage into L lateral position with head down and pillow placed under left hip OR knee-chest position. This will relieve pressure off the cord from the presenting part. • ? terbutaline - stop contractions, relieving pressure off the cord. Allow time to transfer for delivery • Emergency C-section

Answer 185

* Breech (at term) * Other malpresentations – e.g. unstable (fluctuates ), transverse/ blique lie. * Twin pregnancy – when the 1st twin not a cephalic * Maternal medical conditions (e.g. cardiomyopathy) –labour dangerous for mum * Fetal compromise (e.g. early onset IUGR ± abnormal fetal Dopplers) – thought fetus wouldn’t cope with labour. * Transmissible disease (e.g. poorly controlled HIV). * 1° genital herpes (HSV) in T3 –no maternal Ab to HSV crossed placenta and protected baby. * Placenta praevia * Maternal diabetes - fetal weight >4.5 kg. * Previous major shoulder dystocia. * Previous 3rd/4th perineal tear * Maternal request – previous traumatic birth

Answer 186

- mendelson syndrome (inhale gastric acid contents --> cyanosis, bronchospasm, tachycardia and pulmonary oedema) Mx - H2RA; empty stomach before - VTE (stockings +/- LMWH) - Bladder injury - catheter - supine hypotension - L lateral tilt - Pain - epidural/spinal - Haemorrhage (PPH/ intra-abdo - G&S Other: bowel/bladder trauma; ARDA; fetal laceration; infections; fistula; subfertilit

Answer 187

HELP; 100% oxygen; Tilt head down; Turn onto left side - Aspirate pharynx; Aminophylline and hydrocortisone; ?Abx - ± ventilation; PT and rarely bronchoscopic aspiration of mucous plug

Answer 188

VBAC - If successful, shorter hospital stay and recovery - Risk of uterine rupture/ anal sphincter injury - Risk of maternal death – 4 in 100,000 If successful – good chance of successful future VBACs - 2-3% risk of transient respiratory difficulties for neonate - Risk of hypoxic ischaemic encephalopathy (HIE) to the neonate – 0.08% - Risk of stillbirth beyond 39 weeks whilst awaiting spontaneous labour – 0.1% C-section - Longer recovery - ↑ rates of: infection, pain after surgery, fertility issues and need for hysterectomy - Risk of maternal death – 13 in 100,000 - Subsequent pregnancies likely to require C- section - 4-5% risk of neonatal respiratory morbidity - <0.01% risk of neonatal HIE - risk of placental problems (including accreta and praevia), and adhesion formation

Answer 189

absolute - classical caesarean scar, previous uterine rupture, CI for vaginal birth, IOL Relative - complex uterine scars or >2 prior lower segment Caesarean sections- ↑ risk of uterine rupture

Answer 190

Utero-placental insufficiency --> inadequate oxygen / nutrient supply ``` RF • Pre-eclampsia • Oligohydramnios • Infection • Uterine hyperstimulation • Rhesus sensitisation • Smoking • IUGR • ↓ BP (?lying on back/ epidural) ```

Answer 191

* Reduced fetal movement / growth slowing * USS - Lack of growth suggests distress / poor prognosis * Oligohydramnios / polyhydramnios are associated with fetal distress * Meconium stained liquor (risk chemical pneumonitis) Ix - Dopper USS (↑ placentral resistance - CTG (late decel?)

Answer 192

- L lateral tilt - stop oxytoxics - CTG monitoring + FBS (esp if meconium) ? C-section <30mins if threat to life

Answer 193

- 40 -42/ 40 avoid the risks of fetal compromise and stillbirth - Maternal - HTN, pre-eclampsia, diabetes and obstetric cholestasis. - FGR - intrauterine fetal death -IOL offered if mother is physically well with intact membranes. - PROM >37/40 if >24 hr

Answer 194

``` >Absolute Cephalopelvic disproportion Major placenta praevia Vasa praevia Cord prolapse Transverse lie Active primary genital herpes Previous classical C- section ``` >Relative Breech presentation Triplet or higher order pregnancy 2+ previous low transverse C- sections

Answer 195

1) Vaginal PG - ripening cervix+ contract SM - monitor on CTG 2) membrane sweep (>40weeks) - aim to separate chorionic membrane from decidua - release natural PG to kick-start labour 3) Amniotomy - rupture membranes artificially using amnihook - release PG (only if cervix 'ripe')

Answer 196

* Failure of induction (15%) * Uterine hyperstimulation – contractions last too long/ frequently, leading to fetal distress - Mx =terbutaline. * Cord prolapse * Infection – risk is ↓ by using pessary vs tablet/gel, * Pain – IOL is often more painful than spontaneous labour. Often epidural analgesia is required. * ↑ rate of further intervention vs spontaneous labour * Uterine rupture (rare)

Answer 197

- bleeding from >24/40 Minor <50ml; Major -50-1000ml; massive >1000ml ``` Causes • Placental abruption • Vasa praevia • Uterine rupture • Placenta praevia • Marginal placental bleed ( not large enough to cause maternal or fetal compromise) ``` Local causes • Benign or malignant lesions – e.g. polyps, carcinoma. cervical ectropion(common) • Infections – e.g. candida, bacterial vaginosis/ chlamydia • Vaginal bleeding – trauma/ assault • Vulval bleeding – lesion/ warts/ trauma

Answer 198

Ix Bloods - - FBC (anaemia); clotting profile; G&S; Cross match (min 4 units); U&E + LFT (exclude pre-eclampsia and HELLP) - Kleihauer test (if Rhesus -ve  determine amount feto-maternal haemorrhage + anti-D required) - >26/40 - CTG - USS - Placenta praevia / abruption ?(retroplacental haematoma) Mx - ABCDE and emergency management – Mothers life takes priority - IVI + Transfusion – to resuscitate mother - Prophylactic Anti-D Ig + Corticosteroids – to prevent rhesus incompatibility or fetal RDS - Emergency C-section – if the fetus is alive

Answer 199

Benign eversion of the endocervix, exposing the columnar epithelium to the vaginal milieu. The stratified squamous cells of the ectocervix undergo metaplastic change- simple columnar epithelium (same as endocervix) that contain mucus-secreting glands Features Often asymptomatic  ↑ vaginal discharge (as↑ mucus-secreting glands)  Post-coital bleeding or intermenstrual bleeding (fine blood vessels present within the epithelium are easily broken during intercourse) Change is thought to be induced by high levels of oestrogen (so increased risk if COCP, pregnant, menstruating age)

Answer 200

Ix --> clinical diagnosis • Pregnancy test • Speculum - everted epithelium redish; usually arranged in ring around external os. • Triple swabs – if any suggestion of infection - endocervical and high vaginal swabs • Cervical smear – rule out CIN Mx - No treatment unless symptomatic 1) stop any oestrogen containing medications (e.g. COCP) 2) cryotherapy/ electrocautery = ablate columnar epithelium; SE - ↑ vaginal discharge until healing complete 3) Medication to acidify the vaginal pH has been suggested, such as boric acid pessaries.

Answer 201

o Viral hepatitis (40%) o Obstetric cholestasis (20%) - onset >20/40  Intense pruritus ± excoriation, no skin rash •Worse at night, can affect sleep •↑ AST + ALT + GGT o Acute fatty degeneration of the Liver  ↑ bilirubin, ALT + AST  vom, abdo pain, headache  Mx - immediate delivery, and treatment of liver failure Other: gallstones; EBV; CMV

Answer 202

Monitor LFTs weekly o Ursodeoxycholic acid (UDCA) – ↓ bile acid levels - ↓ pruritus + improving LFT o Vitamin K – offered if prolongation of the PT Delivery >37/40 with CTG in labour. Check LFTs after 6 weeks.

Answer 203

Bacterial infection of the fetal amnion and chorion membranes - typically ascending GBS infection (or prolonged labour) ``` Sx Maternal fever (>37.8), and >2 of the following: • Leucocytosis (>15,000 /uL) • Maternal HR >100bpm • Fetal HR >160 bpm • Uterine tenderness ```

Answer 204

Ix •Bloods – FBC, WCC, CRP, cultures – ?sepsis markers • Aspiration of Amniotic fluid – MC&S • GBS screen Mx o Empiric maternal ABx therapy - Ampicillin + Gentamicin o C-section – may be indicated to expedite delivery

Answer 205

Part/all of placenta separates from wall of uterus prematurely Blood collects between placenta and uterus --> splits placental attachment from the basal layer. Detached portion of placenta is unable to function --> rapid fetal compromise. ``` Types o Revealed (80%) – bleeding tracks down + drains through the cervix --> vaginal bleeding. o Concealed (20%)– bleeding remains in uterus (forms clot retroplacentally) --> Bleeding is not visible, can be severe enough to cause systemic shock. (usually incomplete detachment) ```

Answer 206

* Previous abruption * Multiple pregnancy * Abnormal lie e.g. transverse * Polyhydramnios * Abdominal trauma * Underlying thrombophilias * Trauma * Pre-eclampsia/ HTN * Smoking or drug use * Bleeding in t1, particularly if a haematoma is seen inside the uterus on a T1 scan.

Answer 207

Sudden unexpected painful PV bleeding Tense, tender uterus with a 'woody' feel; painful on palpation and difficult to feel fetal parts CTG – shows bradycardia / asystole (if dead)

Answer 208

Placenta is fully/ partially attached to the lower uterine segment. - Identified at 20-week USS (even if asymptomatic): a. Minor placenta praevia – placenta is low but does not cover the internal cervical os --> repeat scan 36/40 as placenta likely to have moved superiorly b. Major placenta praevia – placenta lies over the internal cervical os --> repeat scan at 32/40 and make delivery plan (as placenta may move upwards until later on in pregnancy) ``` Grades o 4 - Completely covers cervix o 3 – partially covers o 2 – reaches internal os o1 – doesn’t reach cervix but within 2cm of internal os ```

Answer 209

* Previous placenta praevia * Previous C-section (↑ as ↑ no.) * Multiple pregnancy * Hx uterine infection (endometritis) * High parity * Maternal age >40 years * Curettage to endometrium after miscarriage or termination

Answer 210

``` Most commonly: • Painless PV bleed >28/40 - Usually sudden + heavy -Spontaneous / mild trauma - Does not last for long • Associated pre-term delivery •? incidental finding on USS •Abnormal fetal lie (placenta blocks the pelvic inlet - ~10% have abdo pain ```

Answer 211

* Antenatal USS - confirmed using TV USS/ Abdo USS * Uterus should be shoft, non-tender * Bloods – Cross match, in preparation of potential APH NO vaginal exam -may exacerbate APH Mx - Minor - ?vaginal deliery - Major - C- section at 38/40 If APH --> follow that mx and consent for hysterectomy

Answer 212

Placenta is morbidly attached to the uterine wall to an ↑ degree o Chorionic villi penetrate the decidua basalis to attach to the myometrium --> Failure to deliver the placenta in the 3rd stage of labour

Answer 213

RF • Previous C-section • Placenta praevia • Advanced maternal age Ix - Ante-natal USS Mx - methotrexate after delivery (destroy tissue for expulsion - elective C-section and hysterectomy

Answer 214

Vessels run near the internal cervical os Classic triad - Membrane rupture (causes rupture of umbilical cord vessels); Painless PV bleeding; Fetal Compromise (as loss of fetal blood)

Answer 215

RF • IVF pregnancy • Multiple pregnancy • T2 placenta praevia Ix - TV Doppler ultrasound --> assess blood flow from placenta Mx - delivery at 35-36/40 (before rupture of membranes)

Answer 216

Full-thickness disruption of the uterine muscle and overlying serosa. The fetus can be extruded from the uterus, resulting in fetal hypoxia and large internal maternal haemorrhage. • Incomplete – peritoneum overlying uterus is intact. Uterine contents remain within uterus. • Complete – peritoneum also torn, uterine contents can escape into peritoneal cavity. RF • Previous C- section (↑ if vertical incision) • Previous uterine surgery – such as myomectomy. • Induction – (Esp wPG ) or augmentation of labour. • Obstruction of labour • Multiparity

Answer 217

o sudden severe abdominal pain, persists between contractions o shoulder-tip pain o± vaginal bleeding Examination o regression of presenting part o scar tenderness and palpable fetal parts. o Significant haemorrhage --> hypovolaemic shock (↑ HR and hypotension)

Answer 218

Ix - CTG (? late decel/prolonged fetal bradycardia are early indicators). o pathological CTG prompts an emergency section - ?Maternal haematuria -?USS if pre-labour o abnormal fetal lie or presentation, haemoperitoneum and absent uterine wall. Mx - A-E + give blood +/- massive haem protocol - C-section <30mins +/- hysterectomy/repair

Answer 219

- D-dimer not useful as already raised in pregnancy - TEDs - LMWH and Rivaroxaban (6-12weeks post partum)

Answer 220

Measure score using risk assesssment tool - >4 prophylaxis from T1 - >3 prophylaxis from 28/40

Answer 221

Vaginal discharge after giving birth - Starts around 3-4 days after delivery, and continues for 4-6 weeks starts red-brown - (blood and trophoblastic tissue) then changes to yellow if offensive odour/ green - infection

Answer 222

Takes >30mins to deliver: • Placenta adherens - myometrium fails to contract behind the placenta • Trapped placenta - detached placenta is trapped behind a closed cervix • Partial accreta - small area of adherent placenta preventing detachment Mx - oxytocin IM - produce contractions and expel remaining placenta; if fails --> manual removal under GA

Answer 223

Hypo-pituitarism due to anterior pituitary infarction, following PPH Dx --> ↓ Prolactin + GRH following a hx of PPH -Lack of lactation; Amenorrhoea; Hypothyroid symptom

Answer 224

Life-long hormone replacement therapy managed by endocrinology– to replace ↓ levels, may include: o Levothyroxine o LH + FSH o Corticosteroids

Answer 225

After delivery of the head, the anterior shoulder of the fetus becomes impacted on the maternal pubic symphysis, or (less commonly) the posterior shoulder becomes impacted on the sacral promontory. EMERGENCY Presentation - • Difficulty delivering the face/chin • Head retraction (turtle-neck sign) neck no longer visible • Failure of the shoulders to descend – doesn’t turn to look to side

Answer 226

``` Pre-labour •Previous hx •Macrosomia •DM (macrosomic - baby’s disproportionately bigger abdomen compared to head) •Maternal BMI > 30 •IOL ``` ``` Intrapartum •Prolonged 1st or 2nd stage of labour •2° arrest (initially good progress in labour and then progress stops, usually due to malposition of baby) • Augmentation of labour with oxytocin •Assisted vaginal delivery ```

Answer 227

Keep head in line with spine , and do not apply fundal P (↑ risk uterine rupture). SHEMSPIER • Stop pushing • HELP (senior obstetrician &midwife; paediatrician) • ? Episotomy (make access easier) – • McRoberts (knees to chest – hyperflex maternal hips) - flatten sacral promontory + ↑ lumbosacral angle + AP diameter • Suprapubic P – sustained/rocking – behind ant shoulder to disimpact it from underneath maternal symphysis • Posterior arm delivery • Internal rotation- ("corkscrew manoeuvre") - apply P simultaneously in front of one shoulder and behind the other to move baby 180 ° or into an oblique position. o All fours / repeat • Emergency - Cleidotomy – # fetal clavicle; Symphysiotomy – cutting the pubic symphysis. - Zavenelli – returning fetal head to pelvis for delivery of the baby via C- section. • Review - PR examination - exclude a 3rd ° tear -Debrief mother and birth partner(s), advise them of the risk of recurrence with any subsequent delivery. (very traumatic if no regional anaesthesia) -PT review – ↑ risk of pelvic floor weakness/3rd degree tear, MSK pain and temporary nerve damage. -Paediatric review - ? brachial plexus injury, humeral # or hypoxic brain injury.

Answer 228

Primary - Loss of blood >500ml, within 24 hours of delivery o Minor <1000 mls o Major >1000 mls Secondary - Loss of blood >500ml – 24h- 6weeks (most common 7-10 d) after delivery

Answer 229

1) Tone Uterine atony --> uterus fails to contract adequately following delivery, due to a lack of tone in the uterine muscle. 2) Tissue – Retained placenta / clots – 2nd most common cause (stops uterus contracting) 3) Trauma – uterine, cervical, or vaginal laceration during delivery (↑ risk – instrumental; episiotomy; c-section) 4) Thrombin – Coagulopathy (pre-existing e.g. vWD/ haemophilia or acquired - DIC/HELLP) and vascular abnormalities (Placental abruption, hypertension, pre-eclampsia) Also risk if anaemic at onset

Answer 230

Maternal profile: Age >40, BMI > 35, Asian ethnicity. Uterine over-distension – multiple pregnancy, polyhydramnios, fetal macrosomia. Labour – induction, prolonged (>12 hours)/ use oxytocin/ GA Placental problems – placenta praevia, placental abruption, previous PPH

Answer 231

Clinical features • Continuous PV bleeding • Fails to stop after delivery of the placenta • Dizziness, palpitations, SOB O/E - Shock (↑ HR; ↑ RR; ↓ BP, cyanosis,) - Speculum - reveal sites of local trauma causing bleeding. - Examine placenta - ensure complete (missing cotyledon/ ragged membranes could cause PPH).

Answer 232

HELP ABCDE +/- activate massive haemorrhage protocol 2222 - ? tranfuse 2L warmed crystalloid or o-ve blood - X-match 4-6 units trauma - repair laceration; rupture - repair/ hysterectomy Tissue - IV oxytoxin and manually remove placenta than prophylactic Abx Thrombin - blood products

Answer 233

Bimanual compression to stimulate uterine contraction – fist insider the ant fornix + P on abdomen at the post aspect of the uterus (ensure the bladder emptied by catheter) Pharmacological measures – ↑ uterine myometrial contractions e.g. Syntometrine ( Syntocinon + ergometrin)/ carboprost; misoprostol Surgical measures – intrauterine balloon tamponade, haemostatic suture around uterus (e.g. B-lynch), bilateral uterine or internal iliac artery ligation, hysterectomy (as a last resort).

Answer 234

MOA - Synthetic oxytocin, act on oxytocin R in the myometrium to contract uterus (short t ½ so can give as infusion). Given IV/IM. SE - N&V, headache, rapid infusion, ↓ BP, fluid retention (if large volume) CI - Hypertonic uterus; uterine spasm\rupture, severe CVS disease (↓ BP/ reflex ↑ HR)

Answer 235

MOA - Multiple receptor sites action – contracts uterus and small blood vessels. Given IV/IM. SE - HTN, nausea, bradycardia CI - HTN, eclampsia, vascular disease, glaucoma

Answer 236

MOA -. Prostaglandin analogue (up to 8 doses x 20ml IM) SE - Bronchospasm, pulmonary oedema, HTN, pulmonary HTN (multiple doses), CV collapse CI - Cardiac disease, pulmonary disease i.e. asthma, untreated PID

Answer 237

(PR/Oral) Prostaglandin analogue (v. cheap and don’t keep in fridge) Diarrhoea, malignant hyperthermia (if >1g given)

Answer 238

Causes: o Retained placenta o Infection (endometritis) RF - C- section, PROM and long labour o Abnormal involution of the placental site (inadequate closure and sloughing of the spiral A at the placental attachment site). o Trophoblastic disease (v. rare) Clinical features o Excessive vaginal bleeding  spotting on-and-off for days after her delivery, occasional gush of fresh blood. OR  Haemodynamically unstable/ massive bleed  HELP AND RESUSCITATION  ? Open os – obstetric exploration o Additional features depend on underlying cause  Endometriosis --> fever/rigors, lower abdominal pain or foul smelling lochia (the normal discharge from the uterus following childbirth). o Abdominal examination --> lower abdominal tenderness (? endometritis), or the uterus may still be high (? retained placenta). o Speculum examination (amount bleeding) + high vaginal swab

Answer 239

Ix - Bloods --> FBC; U&E; CRP; Coagulation profile; G&S; Blood cultures (if pyrexial) - Imaging --> Pelvic USS (?retained placental tissue- good -ve predictive value) - High vaginal swab? Mx - IV Tazocin ± metronidazole o + Gentamicin if endomyometritis (tender uterus) or overt sepsis. - Uterotonics – same 1° PPH ( + ?syntometrine (oxytocin+ ergometrine)) Surgical - if excessive/ continuing bleeding (irrespective of USS findings) -? balloon catheter o Evacuation of retained POC  ↑ risk of uterine perforation (uterus softer and thinner post-partum)

Answer 240

Haemolysis, Elevated Liver enzymes and Low Platelets 1) AST↑ 2) LDH ↑ 3) blood film – burr cells and polychromasia (haemolysis - MIHA) • Platelets <100 x 109/L due to activation and ↑ consumption * 70% of cases present before delivery, peaking at 27-37 weeks of gestation * Usually non-specific symptoms – headache, visual symptoms, fatigue, RUQ / epigastric, pain, N&v

Answer 241

Delivery if >34/40 Transfusion of red cells, platelets, FFP and cryoprecipitate or fibrinogen concentrate are required as indicated clinically and by blood tests

Answer 242

Amniotic fluid embolism - Multiple pregnancy - Increasing maternal age - Induction of labour - Uterine rupture - Placenta praevia - Placental abruption - Cervical laceration - Eclampsia - Polyhydramnios - C- section / instrumental delivery - Disruption of vessels supplying uterus - Strong uterine contractions (prevent with IV β – adrenergic drugs /magnesium sulphate)

Answer 243

``` Sudden onset of: • Hypoxia/respiratory arrest --> ARDS • Hypotension • Fetal distress • Seizures • Shock • Confusion • Cardiac arrest • DIC (may be 1st sign – all within 4 hours) • Acute renal failure • Uterine atony (uterus fails to contract --> PPH) ```

Answer 244

PE; anaphylaxis; sepsis; eclampsia; MI

Answer 245

ABCDE  high flow oxygen -  IV access & fluids  ± FFP/ platelets Early MDT involvement o Anaesthetics --> ITU  Measure pulmonary artery wedge pressures oHaematology - Manage DIC Continuous fetal monitoring o if pt stable -->delivery o if cardiac arrest/ maternal compromise--> perimortem section and CPR of mother If uterine atony - oxytocics Ix • Bloods – FBC, U&E, calcium and magnesium, clotting studies, ABG • ECG (ischaemic changes) • CXR (shows pulm oedema) Definitive diagnosis = Post mortem - fetal squamous cells along with debris in the pulmonary vasculature.

Answer 246

Call 2222: If >4 units red cells <1hour >1500ml blood loss in pregnancy/ labour or following birth of baby Losing blood >150ml/min

Answer 247

Lamotrigine safest + vitmain K for last 4 weeks of pregnancy + 5mg of folic acid per day from before conception until 12 weeks of pregnancy to reduce the risk of NTDs

Answer 248

1) NNRT throughout pregnancy and delivery 2) C-section delivery if detectable viral load 3) No breastfeeding 4) NRTI to baby for 4-6 weeks (Zidovudine)

Answer 249

Ideally keep HBA1C <8% +/- metformin Insulin requirements increase - need regular sugar checks - may need to + / ↑ insulin. Increases risk of hypos and can lose hypo-awareness Ketones can cross placenta - don't deliver manage mother and baby to reduce risk Put on growth scan pathway (macrosomia) in labour - variable insulin rate infusion - check gluc regulaley Encourage breast feeding

Answer 250

miscarriage, congenital malformation, stillbirth, neonatal death, IUGR, pre-eclampsia, prematurity

Answer 251

o Gestational hypertension - pregnancy-induced HTN (PIH) which develops >20 weeks o Pre-existing hypertension - defined as chronic HTN, either pre-pregnancy/ at booking, <20/40– without proteinuria ``` RF • Previous / pre-existing hypertension • CKD • AI disease (SLE, etc) • Diabetes • Hx pre-eclampsia • BMI >35 ```

Answer 252

Dx - dBP >90 mmHg, on ≥2 occasions, ≥4 hours apart, or a single dBP >110 mmHg Ix - BP and Urine dip – monitor regularly • Bloods – FBC, U+E, LFTs – monitor regularly in moderate-severe disease, moderate as a one-off and severe as a weekly test • Fetal USS - fetal growth and amniotic fluid vol and Doppler velocimetry of umbilical arteries

Answer 253

Aspirin 75mg OD – indicated after 12 weeks in women with RF to prevent pre-eclampsia Rest and exercise Treatment – o Labetalol --> if BP >140/90 Monitor BP 2 x week (+ urine dip if >150/100) If >160/110 - admit --> BP QDS + urine daily +bloods alternative = Methyldopa / Nifedipine

Answer 254

1) HTN (sBP >140 or dBP >90) – x2 at least 4 hrs apart Or dBP >110 2) Significant proteinuria o 2+ protein on urinalysis – prompt a urinary protein:cr o >30 mg/mmol urinary protein:cr – prompt 24 hr o ≥ 300 mg protein in a 24-hr urine sample 3) In a woman >20/40

Answer 255

Generalized convulsions during pregnancy, labour or ≤ 7 days postpartum & not caused by epilepsy/ other neurological disorder such as epilepsy or metabolic causes o ≥1 convulsions superimposed on pre-eclampsia o Last~ 60 to 75 secs, followed by a variable lasting post-ictal phase. oMaternal convulsions may cause fetal distress; bradycardia and neurological damage induced by hypoxia

Answer 256

``` Moderate • Nuliparity. • Maternal age ≥ 40 years. • Maternal BMI ≥ 35 at initial presentation. • FH of pre-eclampsia. • Pregnancy interval > 10 years. • Multiple pregnancy ``` High • Chronic hypertension • HTN, pre-eclampsia or eclampsia in previous pregnancy. • Pre-existing CKD • Diabetes Mellitus • AI disease (e.g. SLE, antiphospholipid)

Answer 257

* Hew onset HTN >20/40 * New onset proteinuria * Headache (frontal) * New oedema (face, hands, feet) (due to ↓ oncotic P) * Agitation * Hyperreflexia/ clonus * Epigastric pain (due to hepatic capsule distention ± vomiting * IUGR on ante-natal USS * HELLP syndrome * Visual disturbances e.g. blurred or double vision, halos, flashing lights --> Retinal oedema, haemorrhage or papilloedema

Answer 258

Regular BP monitoring Urinalysis - MC&S 24hr urine collection Fetal USS +Doppler of umbilical A Monitor for signs of organ dysfunction/ HELLP/ reversible causes: FBC (↓ Hb, ↓ platelets); U&E: (↑ urea, creatinine, urate, ↓ urine output);LFT (↑ ALT & AST); Clotting studies (?DIC); Blood glucose (reversible cause of eclampsia)

Answer 259

CT/MRI head o HTN/ pre-eclampsia who has focal neurology; not recovered from seizure o Hx head trauma; Seizure onset in T1 Abdominal USS – estimate gestation age and rule out placental abruption; CTG monitoring – evidence fetal distress/ bradycardia

Answer 260

Maternal • HELLP syndrome • fibrin deposit in hepatic sinusoids/ Hepatic rupture • DIC • Glomerular damage leading to proteinuria, hyperproteinaemia + ↓ oncotic pressure (which exacerbates hypovolaemia). ?AKI ± cortical necrosis • ARDS/ Pulmonary oedema • Cerebrovascular haemorrhage -CNS thrombosis and fibrinoid necrosis of cerebral A --> Permanent CNS damage/ oedema ± cortical blindness • Hypertension • Death Fetal Complications • IUGR ( impaired uteroplacental circulation); Intrauterine fetal death. • Prematurity (iatrogenic and idiopathic) • Infant respiratory distress syndrome; Placental abruption

Answer 261

Admit if any sign of proteinuria - limit fluids to 80ml/hour - control BP - Magnesium sulfate (reduce risk eclampsia) - delivery of fetus (c-section if severe)

Answer 262

ABCDE assessment and intervention as appropriate. Pt lie in the left lateral position, with secured airway and oxygen therapy. Magnesium sulphate; + continued 24h after delivery OR last seizure (whichever later)- stop seizure and prevent - assess for signs of ↑ Mg (hyper-reflexia, respiratory depression), and the fetus monitored via continuous CTG. IV labetalol + hydralazine. A target MAP of <120mmHg. - continuous CTG during and for 30 minutes after Delivery of Baby and Placenta (definitive treatment) – ideally C-section ASAP Mother - seizures controlled, severe HTN treated and hypoxia corrected before HDU/ ITU at least 24hours after until - well controlled BP (<150/100), adequate UO and discontinuation of MgSO4 Monitor fluid balance monitoring - prevent pulmonary oedema and detect AKI. After 72h measure FBC, LFT and creatinine. Monitor BP (daily 2 weeks) for 6 weeks after. + check bloods and urine at 6 weeks.

Answer 263

``` Hypoglycaemia. Medication-induced. Pre-existing epilepsy. Brain tumour. Head trauma. Cerebral aneurysm. Haemorrhagic stroke. Septic shock. Meningitis. Ischaemic stroke. ```

Answer 264

Β-blocker. SE --> Postural hypotension, fatigue, headache, nausea and vomiting, epigastric pain. CI- asthma; T1DM; pheo

Answer 265

Trophoblasts fail to invade spiral arteries - remodelling of spiral arteries incomlete leading to a high resistance, low-flow uteroplacental circulation --> ↑ BP, hypoxia and oxidative stress

Answer 266

Glucose intolerance with onset during pregnancy - usually T3 (if in T1 - DM) Fasting glucose > 5.6mmol/L 2hrs postprandial glucose > 7.8mmol/L Mx - Diet control ± metformin ± insulin

Answer 267

- BMI >30 - Asian ethnicity - Previous hx - 1st degree relative DM - PCOS - Previous macrosomic baby - Polyhydramnios - Multiple pregnancies - Unexplained still birth

Answer 268

- < 16 y/o - Unrealistic ideas of motherhood - Pre-existing MH e.g. schizophrenia, OCD, bipolar - FH (1st ° relative) of MH - Volatile or Absent family relationships - Social Isolation - Lack of positive supportive partner - Poor or inadequate antenatal care - Pregnancy Complications ``` Social problems • Hx substance misuse • Migrant, asylum seeker or refugee • Difficultly speaking English • Experienced domestic abuse • Homeless ```

Answer 269

Depressive episode within the first 12 months postpartum

Answer 270

Onset often <3m of delivery - Appear confused and distracted/restless - Quiet and withdrawn OR agitated/irritable and distressed - Express bizarre ideas – paranoid/grandiose delusions, report/respond to auditory hallucinations. - Appear manic- talking rapidly and being more active. - Sleep disturbance

Answer 271

Prompt assessment by specialist MH services o Risk assessment - risk to mother and child  suicidal ideation, thoughts of harm to or bizarre ideas about the baby, self-neglect and ability to provide care for the baby Most treated as inpatient – specialist mother and baby units OR general psychiatric ward  Anti-psychotics e.g. olanzapine ± mood stabiliser (lithium); ?ECT in severe Close monitoring during future pregnancies and after delivery

Answer 272

- minority ethnic groups - low socio-economic status - poor education - unemployed people - multiple of sexual partners - age at first sexual intercourse - concurrent partners - sexual orientation - non-barrier contraception - Co-infection with another STI - +ve sexual partner - Men who have sex with men (MSM).

Answer 273

Symptoms - Pruritus (itchy) vulvae–can extend to perineal region - Vaginal discharge - white, cottage cheese – like and non-offensive Dysuria (superficial dysuria) Signs - Erythema and swelling of the vulva - Satellite lesions - Red, pustular lesions with superficial white/creamy pseudomembranous plaques that can be scraped off.

Answer 274

* Pregnancy (↑ glycogen production - more favourable environment for mo ) * Abx (broad spectrum – alter vaginal micro-biota) • Diabetes * Immunodeficiency (HIV/Ca) * Steroids Caused by candida albicans

Answer 275

OTC --> - Clotrimazole (via applicator) --> esp in pregnancy - PO fluconazole -50mg OD for 2/52 ± Topical imidazole (address vulval symptoms) – ?weaken latex condoms Children - nystatin If fail to clear in 1-2 weeks - measure vaginal Ph and swab. Mx RF. Advice - soap substitutes; avoid cleaning vaginal area >1/day; avoid potential irritants (e.g. shower gels, vaginal deodorants, douches) and tight fitting underwear/tights.

Answer 276

Normal vaginal flora disturbed -->↓ no lactobacilli (produce H2O2 -keep pH vagina <4.5 - inhibiting the growth of other mo) subsequent ↑ in vaginal pH – growth other mo (Gardnerella vaginalis, anaerobes and mycoplasmas) Risk factors - IUD, vaginal douching, smoking, recent abx, presence STI

Answer 277

50% asymptomatic | Smelly, thin, white-fishy discharge (Most common cause of abnormal vaginal discharge in childbearing age.)

Answer 278

High vaginal smear: - clue cells - ↓ no. lactobacilli - Absence of pus cells Swab for STI +/- Vaginal pH >4.5 ± KOH (potassium hydroxide) whiff test – + KOH to discharge - strong fishy odour

Answer 279

Metronidazole PO – 400 BD for 5-7/7 – or 2g stat dose OR Clindamycin 2% cream – ON for 7/7 Advice - avoid vaginal douching, scented shower gels, antiseptic agents and shampoos in the bath, Removal of an IUD. Can recur (>50% in <3m)

Answer 280

Caused by Chlamydia trachomatis an obligate intracellular gram -ve bacterium - invades the cells of the endocervix, urethra, fallopian tubes, rectum, and conjunctivae . Transmitted -. unprotected vaginal, anal or oral sex Highly infectious, and infects in >50% of exposures – incubation period 7-21d Commonly associated with Gonorrhoea

Answer 281

``` Males ~50% asymptomatic Symptoms o Urethritis --> Dysuria; Urethral discharge o Epididymo-orchitis o Testicular pain (prostatitis) ``` Signs o Epididymal tenderness o Mucopurulent discharge

Answer 282

``` Females ~70% asymptomatic Symptoms o Dysuria o Abnormal vaginal discharge o Intermenstrual/ postcoital bleeding o Deep dyspareunia/ Lower abdominal pain o Salpingitis Signs o Cervicitis +/- contact bleeding o Mucopurulent endocervical discharge o Pelvic tenderness/ Cervical excitation ```

Answer 283

Women: Vulvo-vaginal swab (1st ) or endocervical swab - NAAT Men: first catch urine sample (first choice) or urethral swab - NAAT Swabs from rectum, eye, throat too +/- PCR

Answer 284

``` Males • Epididymitis/ epididymo-orchitis • Infertility • Proctitis • Reiters disease ``` ``` Females • PID (infertility) • Salpingitis ± endometriosis • Perihepatitis • Ectopic pregnancy Pregnancy --> premature, low birth weight, miscarriage, stillbirth, transfer to neonate in delivery causing conjunctivitis/ pneumonia) ```

Answer 285

Doxycycline – 100mg BD 7/7 (CI in pregnancy) OR Azithromycin – 1g one-off Erythromycin in neonates Repeat testing recommended in 3m.

Answer 286

Neisseria gonorrhoeae- Gram--ve diplococcus bacterium. • 2-14d incubation, sx~2-5 days after infection Transmission- unprotected vaginal/oral/anal sex + Vertical Strong affinity for mucous membranes - Uterus, urethra, cervix, fallopian tubes, ovaries, testicles, rectum, pharynx and conjunctiva Pili that attach -> endocytosed into cell -> acute inflammation. Surface proteins -> bind R of immune cells + prevent immune response

Answer 287

``` Males - 10% asymptomatic  Urethritis – Mucopurulent urethral discharge  Dysuria  Proctitis (MSM)  Epididymal tenderness ``` Females - 50% asymp  Altered/↑ vaginal discharge (thin, watery, green or yellow)  Dysuria; Dyspareunia; Lower abdominal pain  Rare – intermenstrual ± post-coital bleeding  Easily induced cervical bleeding  Pelvic tenderness Rectal - ? anal discharge +/- pain/discomfoty

Answer 288

Males • Epididymitis • Prostatitis Females • Bartholins abscess – severe unilateral labial pain • Fitz-Hugh-Curtis syndrome • Endocervivitis, urethritis, salpingitis • PID - chronic pain, infertility and ectopic pregnancy Both - Disseminated gonococcal infection - malaise, joint pain, fever, rash Pregnancy - Perinatal mortality, spontaneous abortion, premature labour, early fetal membrane rupture. Vertically transmission during delivery - neonatal gonococcal conjunctivitis

Answer 289

Ceftriaxone 500 mg IM stat + Azithromycin 1 g orally stat Culture should be performed at 72 hours, as test of cure

Answer 290

HSV-1 - Cold sores (lasts 7-10 days) ± genital herpes (oral sex) HSV-2 - genital herpes. Spread - via skin-to-skin contact - travels up the nearest nerve to ganglion and remains - dormant (can’t be reached by immune system) - During reactivation - travels back down the nerve onto the surface of the genitals once again to cause a symptomatic outbreak. Asymptomatic shedding - can transmit (may be unaware have infection)

Answer 291

Primary infection may be asymptomatic 1° infection - Painful small red blisters around genitals, can form open sores o penis/vulva/clitoris, anus, buttocks and thighs o Vaginal or penile discharge ± itch o Flu-like symptoms, fever, muscle aches, dysuria, Inguinal lymphadenopathy After around 20 days the lesions crust and heal. 2°/recurrent - outbreaks often shorter and less severe over time (as Ab ↑ recognition of the virus and ↑ the effectiveness of response) -↑ if HIV - Painful red blisters; Burning & itching around the genitals o Viral shredding only occurs with these lesions and ulcerations If contract in T3 no Ab cross placenta so high risk of child getting.

Answer 292

Swab ulcer - PCR / serology Mx - no cure; avoid sex in outbreak; contact trace; painkillers; ice packs ?Aciclovir 400 mg TDS – within 5d of sx - ↓ severity and duration (if recurrent take as soon as get sx) >6 outbreaks/year – take prophylactically

Answer 293

Skin, eyes and mouth (SEM) herpes --> antivirals Disseminated (DIS) herpes  internal organs (↑ mortality) CNS  encephalitis (↑ mortality)

Answer 294

Treponema pallidum - Spirochete gram-ve bacterium – replicates slowly Enters through a break in the skin or through intact mucous membranes Can be transmitted through infected blood products Commonly occurs with HIV

Answer 295

1° lesion - papule will appear before ulcerating into a chancre (infectious hard painless, surrounded by bright-red margin) develop at site of contact 2 ° stage ~6 wks after 1° lesion - pathogen disseminates - highly infectious o Fever/ Myalgia/ malaise/ arthralgia; Sore throat; Headache o Skin rash (hands & soles of the feet – not itchy/painful) o Weight loss o Condylomata lata- elevated plaques like warts at moist areas of skin e.g. inner thighs, anogenital region, axillae o Painless lymphadenopathy o Silvery-gray mucous membrane lesions - oral, pharyngeal, genital Latent period  patient can remain asymptomatic for months to years

Answer 296

- obliterating arteritis Gummatous syphilis – locally destructive inflammatory nodules - Granulomas - bone, skin, mucous membranes of upper resp tract, mouth and viscera or CT e.g. lung, liver, testis. Neurosyphilis: - Tabes dorsalis; Dementia; Meningovascular complications (CN palsies, stroke, cerebral gummas); Argyll Robertson pupil – pupil is constricted and unreactive to light, but reacts to accommodation Cardiovascular syphilis: - AR due to aortic valvulitis + aortic root dilatation; Angina (stenosis of the coronary ostia); Dilation and calcification of the ascending aorta.

Answer 297

Dark field microscopy of chancre fluid- detects spirochaete in 1° syphilis • PCR testing of swab from active lesion • Serology: o Treponemal tests – assess for exposure to treponemes  Treponemal ELISA (IgG/IgM) – +ve for life  TPPA or TPHA –+ve for life o Non-treponemal tests - RPR/VDRL: ↑ in early disease; ↓ titres indicate successful treatment or progression to late disease. False +ve - inflammatory conditions/ pregnancy. Lumbar puncture: CSF antibody tests in neurosyphilis

Answer 298

1st line - PenV IM STAT (early – 1 dose); late (weekly) (neuro – IV) 2nd line - Azithromycin stat - Tertirary --> oral steroids prior to abx (↓risk of an acute localised inflammatory reaction) - risk of Jarisch Herxheimer reaction - inflammatory response 2° to death of treponemes, and results in a flu-like illness within 24 hrs of treatment - Supportive measures Follow-up serology to determine response to treatment

Answer 299

Potential cross placenta/ infect during delivery (congenital) - treat - ↓ risk of miscarriage, stillbirth, pre-term labour or congenital syphilis. Congenital syphilis - severe + debilitating - saddle nose, rashes, fever, failure to gain weight.

Answer 300

Anaerobic flagellated protozoan spread by vaginal sexual intercourse Replicates via binary fission

Answer 301

Male - Usually asymptomatic • Urethritis - Urethral discharge & Dysuria • Urinary frequency • Pain/ itch around foreskin • Balanoposthitis – inflammation of the glans penis (rare) • prostatitis Female • ~70% have vaginal discharge (smelly, frothy, yellow-green-ish) • Itchy/ sore vulva; Vulvitis; Vaginitis • Dyspareunia; Dysuria; • Strawberry cervix (cervicitis)– punctate and papilliform appearance (due to small petechial haemorrhages) pregnancy --> Premature labour; low birth-weight; predispose to maternal postpartum sepsis.

Answer 302

Female: - High vaginal or Self-administered vaginal swab Males: Urethral swab or first void urine sample Swabs --> NAAT +/- MCS Bloods - if systemic features of infection.

Answer 303

Metronidazole 2g PO stat, OR 400mg BD for 5-7/7 (no alcohol) Avoid breastfeeding 24h.

Answer 304

Many asymptomatic Warts - penis, scrotum, vulva, inside vagina or anus, cervix, perianal skin (speculum) Usually painless, fleshy growths that can be soft/hard & singular/ multiple Occasionally warts may cause irritation or become inflamed. Extra-genital lesions - oral cavity, larynx, conjunctivae and nasal cavity

Answer 305

Watch and wait – 1/3 regress spontaneously within 6 months Soft non-keratinised lesions – Podophyllotoxin 0.15% cream BD for 3/7 then 4d rest, repeated for 5 wks (CI - pregnancy, breastfeeding, weakens condoms) Hard keratinised lesions – Imiquimod 5% cream – apply 3/7 and wash off after 6-10 hours - max of 16 weeks Resistant/recurrent/ in pregnancy– Ablation, Cryotherapy or excision should be used Screen for other STIs

Answer 306

HIV --> CD4 R on Th --> penetrates --> combines host dna --> makes viral protein and virus assembles --> disseminates to secondary lymphoid tissue --> damaged

Answer 307

Sero-conversion (start to produce anti-HIV ab) - 1-6wk - lymphadenopathy/ glandular fever like, myalgia, pharyngitis, headache, diarrhoea, neuralgia, neuropathy, fever, malaise, macpap rash Asymptomatic infection - m-years Persistent generalised lymph-adenopathy (PGL) - nodes >1 cm at 2 extra-inguinal sites, last >3m Symptomatic infection - fever, night sweats, diarrhoea, weight loss +/- opportunistic - HZV, candida, HSV, tinea - lasts years AIDS - severe immunodef --> CD4 count <200 x 109 /L - life threatening infection/tumours- p. jiroveci, non-Hodgkin’s lymphoma, and TB

Answer 308

ELISA (serum/saliva) - HIV ab and p24Ag --> +ve 4-6 weeks after exposure - produce IgG+IgM after 3m Contact tracing STI screen Baseline CXR Pregnancy test Monitor --> CD4 count; HIV viral load (Viral Ag & HIV RNA) - aim HIV RNA <20 /mL FBC (?pancytopenia); U&Es; Urinalysis; ALT, AST and bilirubin

Answer 309

- counselling - sexual health advice - High activity anti-retroviral therapy (HAART) >3 drugs starting ASAP - NRTI/ NNRTI/ inSTI/ PI e.g. Atripla: tenofovir (NRTI) + emtricitabine (NRTI) + efavirenz (NNRTI) SE NRTI and PI- myalgia, neuropathy, pancreatitis NNRTi - hepatitis, dizzy

Answer 310

Has/ suspects been exposed to the virus within the last 72 hours to ↓ risk of becoming infected. A PEP course lasts for a month: Truvada (one tablet daily) + Raltegravir (one tablet twice daily) Check patient risk – related to donor CD4 + HIV RNA levels Needle-stick injury transmission <0.5% (bloods at 3, 6 + 8m to test for seroconversion)

Answer 311

- Suspected ectopic pregnancy - Medical problems Severe asthma or COPD; CVD/prosthesis; hepatic failure (risk of bleeding); chronic renal failure (mifepristone can cause electrolyte imbalance); Haemorrhagic disorders and treatment with anticoagulants; Long-term steriod therapy Known allergy to Mifepristone

Answer 312

``` Haemorrhage Uterine perforation Cervical Tears: RF - Young < 18 yr/higher gestation (multipara) Failure (continuing pregnancy) Post abortion Sepsis Psychological Trauma ```

Answer 313

- women's life in danger - prevent mental/physical injury - risk child born serious physical/ mental disability

Answer 314

- Anti-D - Metronidazole + doxycycline - advise about complications - no sex/tampons for 2 weeks - future contraceptive plans - where to go for counselling - VTE risk +/- STI screen

Obs and Gynae Flashcards

(338 cards)