Obs and gynae Flashcards

Question

Treatment for breast cancer?

Answer 1

radio and pre-op chemo (small tumour); mastectomy for large relative to breast size and position (medial more dangerous – can shrink with radio/chemo first) but more likely to recur, reconstruction; axillary surgery if glands involved (full clearance but partial if glands found to be normal), with glands removed may cause arm oedema as lymph no longer there to drain

Answer 2

young age, ER-ve, HER-2+ve, high grade, node positive, Ki67 +ve, tumour size, high oncotype DX recurrence score

Answer 3

flushes, nausea, vaginal bleeding

Answer 4

better than tamoxifen, inhibit aromatase enzyme for making androgens to oestrogen; no DVT or endometrial cancer risk like tamoxifen

Answer 5

high rate of capsule formation, skin viability risk, wound healing, loss of elasticity, fat necrosis, fibrosis, implant extrusion

Answer 6

either implants or autologous (latissimus dorsi, gluteal muscle – but can interfere with physical activity/job); stick on nipples, nipple tattoos, new nipples constructed from skin

Answer 7

hormonal treatments, bisphosphonates, densoumab, chemo (CMF, doxorubicin, taxanes, Herceptin)

Answer 8

benign breast change (puberty to menopause, tender and painful, cyclical variation, rubbery feel, leave and reassure), fibroadenoma (usually puberty, smooth, mobile, non-tender, leave unless enlarging/tender/atypical), cyst (35-55yrs, usually multiple, feel cystic usually, aspirate), sebaceous cyst, papilloma (dilated ductal system, usually benign yet remove, multiple means breast cancer risk), fat necrosis, mastitis/abscess (breast sepsis, pyrexia and flu-like, respond to abx, staph aureus; if chronic and periductal then excise duct), cancer, sarcoma/lymphoma/mets, implant related, duct ectasia (asymptomatic, nipple discharge, bloody discharge, nipple inversion, menopause; breast duct becomes blocked from duct narrowing and breast widening), can get benign cyclical breast pain (record diary; management = reassure, NSAIDs PRN, low fat, correct fitting bra)

Answer 9

malignant cells infiltrate epidermis via mammary duct epithelium; thickened skin results

Answer 10

unilateral usually, usually nipple, eczematous change, itching, erythema, scales, erosions, discharge, bleeding; can indicate breast cancer

Answer 11

treat as cancer but can be more conservative if need be

Answer 12

investigate if none by 16 or no signs by 14yrs; first start of puberty is growth spurt; controlled by hypothalamic-pituitary-ovarian axis; pulsatile gonadotrophin-releasing hormone get Pituitary to release FSH and LH which stimulate ovaries to make oestrogen and progesterone that -ve feedback; <16yrs, >45yrs menopause, <8 days, blood loss <80mL, cycle length 23-35 days, no intermenstrual bleeding; monthly bleeding from hormonal changes, length = start of one to start of other

Answer 13

menstruation; cycle lengths vary; soon after menarche and menopause will be irregular (also HRT)

Answer 14

GnRH pulses increase levels of LH and FSH which stimulate development of primary follicle in ovary; follicle makes oestradiol and inhibin which suppress FSH secretion in -ve feedback so only one egg and follicle matures; oestradiol rises and +ve feedback to cause LH secretion and surge (36 hours after ovulation occurs); oestradiol also develops endometrium (endometrial proliferation), cervical mucous receptive to sperm, mucous stringy and white

Answer 15

oestrogen level high enough to stimulate LH and ovulation; primary follicle then forms corpus luteum and produces progesterone and endometrium ready for implantation (secretory phase); cervical mucous hostile to sperm; corpus luteum broken down so hormones low, spiral arteries constrict, endometrium sloughs off (normal loss 20-80mL over 2-7 days)

Answer 16

ovaries don’t develop follicles; no -ve feedback so gonadotrophin levels rise and so periods stop

Answer 17

use norethisterone 3 days before period or take 2 packets combined pill consecutively without break

Answer 18

periods stop >6 months

Answer 19

duration, cycle, heaviness (clots, protection, flooding); pain, premenstrual tension, infertility worries and details, cancer phobia, interference with QOL, duration and relation to cycle; social and work

Answer 20

sclera, palms, gingiva, thyroid, abdo; specific = vulva, vaginal, cervix, uterus (fibroids and adenomyosis), adnexae

Answer 21

thyroid disease (temp intolerance, hair consistency, lethargy), clotting disorder, anti-clotting/blood thinning drugs

Answer 22

bleeding clearly between cycles and menses; fall in oestrogen levels; other causes = cervical polyps, ectropion (columnar epithelium migrating to front of os), carcinoma, cervicitis, HRT, IUCD, chlamydia, pregnancy

Answer 23

continuous high oestrogen (obesity) can make it hyperplastic and can cause irregular heavy bleeding; treat = address cause, Mirena coil, can lead to endometrial carcinoma

Answer 24

uterus distended by pus from salpingitis; drain uterus and treat cause

Answer 25

uterus filled with blood from obstruction; rare (imperforate hymen, carcinoma, stenosis

Answer 26

rare; blood borne and affects fallopians first; menstrual pain and disorders if active, salpingitis; exclude lung disease; check up scans and RIPE treatment

Answer 27

abnormal in vol, regularity, timing, non-menstrual (PCB, IMB, PMB)

Answer 28

excessive bleeding in normal cycle (80mL

Answer 29

endometrial haemostasis (balance between fibrin deposition and platelet aggregation with platelet inhibition and fibrinolysis), uterine prostaglandin levels, uterine polyps, fibroids (irregular enlargement of uterus), chronic pelvic infection, ovarian tumours, malignancy, adenomyosis (endometrium breaks through to myometrium – 40yrs, with endometriosis and fibroids)

Answer 30

absent, painful, reg, heavy menstruation, uterus can be enlarged and tender

Answer 31

Hb, coagulation, TFT, transvaginal US, endometrial biopsy (if endometrium thicker >10mm, polyps, women >40 with recent menorrhagia to exclude malignancy), not responding to treatment use hysteroscope, smear hx, STI screen

Answer 32

first line progesterone IUD (too much = amenorrhoea), second = antifibrinolytics (tranexamic acid – inhibits plasminogen activator), NSAIDs (mefenamic acid – inhibits COX and blocks PGE2 receptors), combined OC (all reduce blood loss) or IUD, others are IM/oral progesterone like norethisterone (least effective in luteal phase so use 5-25 day, best for anovulatory and chaotic bleeding), gonadotrophin-releasing hormones (danazol – stops sex steroid production); polyps resected under anaesthesia, endometrial ablation for older women (reduces fertility; if heavy, not expecting amenorrhoea, completed family, uterus less than 12 wks size), transcervical resection of endometrium/fibroid; myomectomy = removal of fibroids from myometrium; hysterectomy = last resort for abnormal uterine bleeding; uterine artery embolization for menorrhagia from fibroids who want to keep uterus

Answer 33

anovulatory cycles (absence of ovulation and luteal phase and varying menstruation), pelvic pathology (fibroids, uterine/cervical polyps, adenomyosis, ovarian cysts, chronic infection)

Answer 34

menorrhagia?, Hb, malignancy?, US for women >35 and where treatment failed, biopsy if endometrium thickened

Answer 35

drugs (IUS, combined OC pill), cervical polyp excised and surgery same as menorrhagia but ablative less useful

Answer 36

primary = not occurred by 16yrs; oligomenorrhoea = occurs every 35 days-6 months

Answer 37

pregnancy, menopause, pathological with hypothalamus, pituitary, thyroid (hypo/hyper), adrenals (congenital adrenal hyperplasia), ovary (ovarian insufficiency), uterus, outflow tract, drugs causing = progestogens, GnRH analogues, antipsychotics, Turner’s; secondary causes = premature menopause, polycystic ovary syndrome (PCOS), hyperprolactinaemia, hypothalamic-pituitary-ovarian (delayed from stress etc), pregnancy, Asherman’s syndrome (uterine adhesions)

Answer 38

pituitary hyperplasia, benign adenomas (use bromocriptine or surgery), tumours and Sheehan’s syndrome, thyroid, premature menopause, Turner’s syndrome, imperforate hymen (membrane partially covering vagina) and transverse vaginal septum obstruct menstrual flow (accumulates in vagina/uterus – surgery), also cervical stenosis (stops blood from uterus)

Answer 39

pregnancy test, serum free androgen index (high in PCOS), FSH/LH low for hypothalamic-pituitary-ovarian, prolactin, TFT, testosterone (secreting tumour)

Answer 40

HRT for ovarian failure; diet, stress management and psych and some drugs

Answer 41

cervical ectropions (glandular cells inside cervix present on outside from eversion – discharge, postcoital bleeding and aka cervical erosion, columnar epithelium around os of endocervix = red), benign polyps, invasive CC

Answer 42

cervix and smear

Answer 43

ectropion frozen with cryotherapy, colposcopy used

Answer 44

high prostaglandins in endometrium, from contraction/uterine ischaemia, painful periods and can have N+V; primary with no organic cause

Answer 45

pain use NSAIDs (mefenamic acid) or ovulation suppression (combined pill), pelvic pathology if this doesn’t work (secondary)

Answer 46

deep dyspareunia (pain on intercourse/penetration) and menorrhagia, pelvic US, fibroids, adenomyosis, endometriosis, pelvic inflammatory disease, ovarian tumours

Answer 47

menstruation <10yrs; rare and usually no pathology; stop sexual development

Answer 48

= meningitis, CNS tumours, hydrocephaly, ovarian, adrenal tumours

Answer 49

GnRH agonists

Answer 50

bone and ovarian cysts, café-au-lait spots and precocious puberty

Answer 51

congenital adrenal hyperplasia (AR inherited); ACTH gives high androgen production (enlarged clitoris, amenorrhoea)

Answer 52

cortisol and mineralcorticoid replacement

Answer 53

95% have psych, behavioural, physical symptoms and 5% debilitating before menstruation; behaviour = irritable, aggressive, depressed; others = bloated, minor GI upset, breast pain, headache

Answer 54

SSRIs, 100mcg oestrogen HRT, GnRH agonists, sometimes CBT, diet, exercise; total hysterectomy may be indicated

Answer 55

>1yr after last period

Answer 56

endometrial carcinoma, vaginitis, foreign bodies, carcinoma of cervix/vagina, endometrial/cervical polyps, oestrogen withdrawal; consider bleeding from other areas

Answer 57

unexpected bleeding patterns with HRT, over 45yrs and PMB

Answer 58

benign tumours of myometrium, whorls of smooth muscle cells with collagen

Answer 59

menopause, Afro-caribbean, FH (reduce with OC pill); types = intramural, subserosal, submucosal; growth = oestrogen dependent (stop growing after menopause and can be slow), 50% asymptomatic and more from site than size

Answer 60

menorrhagia, dysmenorrhoea, frequency and retention (large and on bladder), fertility reduced (tubal ostia blocked), pedunculated fibroids (grows on stalk-like growth – peduncle) can have torsion (pain); may be felt abdo, press on bladder (urinary retention), veins (varicose)

Answer 61

pain, tenderness, haemorrhage, necrosis, common in pregnancy and can cause severe pain, N+V; premature labour, malpresentations and obstructed labour; thrombosis of capsular veins leading to engorgement and inflammation

Answer 62

fibroid soft and partly liquefied

Answer 63

MRI diagnostic, hysteroscopy/hysterosalpingogram for uterine cavity distortion, Hb low (bleeding) or high (high EPO); size

Answer 64

don’t use HRT (can increase size); asymptomatic nothing needed; GnRH (max 6 months – temporary amenorrhoea and fibroid shrinkage; goserelin), ulipristal acetate (induces amenorrhoea and is a selective progesterone receptor modulator; only for a few months to shrink them) small resected (myomectomy – treat failed but reproductive function needed), adhesions in surgery reduce fertility, hysterectomy (only cure), uterine artery embolization to reduce fibroids

Answer 65

secondary to STI, complication of surgery, foreign material in IUD, malignancy; uterus tender

Answer 66

abx and evacuation of retained products of conception

Answer 67

benign tumours in uterus (disordered apoptosis and regrowth of endometrium); most endometrial but some submucosal; 40-50yrs, in post-menopause = tamoxifen

Answer 68

menorrhagia and IMB

Answer 69

US or hysteroscopy

Answer 70

Resection of polyp

Answer 71

menstrual blood in uterus from outflow obstruction; from fibrosis, cone biopsy or carcinoma of cervical canal

Answer 72

; Mullerian ducts don’t fuse at 9 wks (total = 2 uteruses), renal problems, malpresentations, preterm labour, recurrent miscarriage, retained placenta

Answer 73

most common genital tract cancer (mostly adenocarcinoma of columnar endometrial gland cells); 60yrs

Answer 74

oestrogen:progesterone ratio, HT, DM, obesity, PCOS, nulliparity (never done a pregnancy past 20wks), late menopause, ovarian granulosa cell tumours, tamoxifen

Answer 75

oestrogen causes cystic hyperplasia/menstrual abnormalities or PMB, irregular/IMB in premenopausal, atrophic vaginitis (post-menopausal bleeding)

Answer 76

surgical staging; US (thickness >4mm), endometrial biopsy, hysteroscopy, FBC, renal function, glucose, ECG, most are stage 1

Answer 77

high age/stage, deep, myometrial spread, higher grade, adenosquamous pathology

Answer 78

uterus preserved then progestogens and 6 monthly endometrial biopsy, otherwise hysterectomy and bilateral salpingo-oophorectomy, vaginal vault when bad prognosis, can use adjuvant radio

Answer 79

leiomyosarcomas (malignant fibroids), endometrial stromal tumours (perimenopausal women) and mixed Mullerian tumours (with PMB)

Answer 80

cervical ectropion (red ring around os as endocervix epithelium migrated to ectocervix; from puberty, combined pill and pregnancy, prone to bleeding, excess mucous and infection, no treatment but can stop pill or diathermy), acute cervicitis (rare from STI), chronic cervicitis = usually ectropion, discharge, cryotherapy with/out abx, can mask neoplastic change on smear; cervical polyps (>40yrs, asymptomatic or cause IMB/PCB; if small avulse, endocervical epithelium; hysteroscopy to exclude IU polyps); Nabothian follicles (squamous epithelium over endocervical cells, treatment not needed unless symptoms)

Answer 81

atypical cells in squamous epithelium, pre-invasive stage of cancer; 1-3 grade, histology diagnose (dyskaryosis – high false +ves and -ves); 1 = atypical cells in low 1/3rd of lower epithelium, 2 = 2/3rds, 3 = full thickness; peak age = 25-29

Answer 82

HPV, more sexual contacts, virus proteins inactivate tumour suppressor genes, smoking, immunocompromise; refer for colposcopy if risk (visualise cervix and paint with acetic acid to see dense white areas of risk and take biopsies; abnormal looking vessels indicate invasive carcinoma); grade 2/3 = excision with cutting diathermy (large loop excision of the transition zone [LLETZ], usually during colposcopy high cure rate

Answer 83

HPV vaccination (only protects against some strains)

Answer 84

visualise with speculum; suspicious areas identified and scrape off squamo-columnar transitional zone of cervix for chlamydia and HPV; 3 yearly 25-50yrs, 5yearly until 64yrs

Answer 85

PCB, offensive vaginal discharge, IMB/PMB and later stages uraemia, haematuria, rectal bleeding, pain, ulcer/mass visible, altered bowel habit (blood borne spread = late feature); tumour spread to parametrium, vagina and pelvic side wall, cervical smear +ve, weight loss, ureteric obstruction, vesicovaginal fistula

Answer 86

bimanual examination (cervix rough and hard, cervix fixed), tumour biopsy, staging from vaginal and rectal exam, cystoscopy (bowel), MRI/PET for tumour size and mets, bloods; colposcopy

Answer 87

stage 1a with cone biopsy, up to stage 2 with surgery/chemo/radio, sometimes radical abdo hysterectomy (pelvic node clearance, parametrium, upper vagina) or radical trachelectomy (keep fertility), palliative radio for bone pain/haemorrhage; death usually uraemia from ureteric obstruction

Answer 88

offered at 12yrs to kids; for prevention only mainly against HPV 6 and 11; don’t prevent all cancers; HPV strong cervical cancer risk

Answer 89

• Silent masses and detected when large (>5cm); rupture of cyst = peritonitis; epithelial tumours mostly in postmenopause, histology of borderline malignancy

Answer 90

cystadenoma/adenocarcinoma (mucinous cystadenoma v large and less common), exclude pseudomyxoma peritonei and appendiceal tumour; also endometrial carcinoma and clear cell carcinoma (rarer but poorer prognosis – associated with endometriosis)

Answer 91

asymptomatic, chronic pain, dyspareunia, cyclical pain, acute pain (torsion [rare] and bleeding), irregular bleeding, abdo swelling, hormonal effects, discharge

Answer 92

common benign in premenopausal women, bilateral, large and asymptomatic

Answer 93

most common ovarian malignant; granulosa cell tumours malignant but slow in postmenopausal, lots of oestrogen and inhibin; ovary common mets site for breast and GI

Answer 94

blood-filled cysts in ovaries; OC pill prevents follicular and lutein cysts

Answer 95

low 5yr survival; most >50yrs and most are epithelial carcinomas

Answer 96

early menarche, late menopause, nulliparity, smoking, obesity, asbestos, BRCA1/2 or HNPCC (offered yearly transvaginal US and CA 125 screening)

Answer 97

pregnancy, lactation and OC pill

Answer 98

mostly absent/vague (70% stage 3/4), persistent abdo distension, early satiety, loss of appetite, pelvic/abdo pain, increased urinary frequency, IBS, cachexia, abdo/pelvic mass, ascites, weight loss, bloating

Answer 99

breasts palpated, staging surgical and histology, CA125 levels in >50 with symptoms, US abdo/pelvis, <40yrs alpha fetoprotein and hCG, CT/MRI staging, FBC, TVS

Answer 100

total hysterectomy, bilateral salpingo-oopherectomy, partial omentectomy, carboplatin for 1c and above, radio only for dysgerminomas, chemo post-op

Answer 101

later stage, poorly differentiated, clear cell tumours, slow chemo response

Answer 102

60% with advanced; from opiates, metabolic causes, vagal stimulation, psych; use = anticholinergics, antihistamines, dopamine agonists, 5HT-3 agonists (ondansetron)

Answer 103

metoclopramide, stool softeners, enemas, cyclizine (total obstruction), hyoscine (spasm)

Answer 104

important for arousal, plateau, orgasm, resolution; also emotional, physical, biological, psychological, sexual stimuli and drive all important too

Answer 105

loss of libido and sexual desire, affects personal relationships and causes distress; mainly from psychosexual

Answer 106

menopause, depression, chemo, radio

Answer 107

start?, normal sexual function?, different to partner’s beliefs?, relationship problems?

Answer 108

testosterone and psychosexual counselling

Answer 109

superficial = infections, skin conditions (lichen sclerosis); can be deep; treat the cause (lubricants, local anaesthetic gel); if don’t treat can become fearful and avoid

Answer 110

difficult for woman to be penetrated even if want to

Answer 111

contraction of the thigh adductors and pelvic floor muscles; exclude vaginal septae (anatomical); treatment = vaginal dilators, relaxation techniques and her own fingers

Answer 112

burning pain in absence of visible findings or neuro disorder

Answer 113

physio, psychosexual, pain management, first-line = pelvic floor exercises, internal and external perineal massage, topical anaesthetic; can use tricyclic antidepressants and gabapentin

Answer 114

fibrous scar tissue on penis causing painful, curved erections; non-cancerous

Answer 115

verapamil oral, interferon injections (breaks down fibrous tissue)

Answer 116

congenital and urethral meatus not at tip but along shaft instead

Answer 117

lack of semen when ejaculating or antegrade ejaculation; associated with infertility

Answer 118

hormonal level change, infection, spinal cord injury, diabetes, anti-hypertensives, alcohol, radiation, chemo, congenital

Answer 119

either treat cause (infection) or offer artificial conception (ICSI/IVF etc)

Answer 120

– inability to ejaculate semen (orgasmic/anorgasmic); prostate and seminal ducts fail to release semen

Answer 121

Artificial insemination

Answer 122

itching, soreness, burning, superficial dyspareunia

Answer 123

may be general or localised; local = infection, vaginal discharge, allergies to washing powder, vulval dystrophy; obesity and incontinence exacerbate, autoimmune?

Answer 124

smear, examination, vaginal and vulval swabs, diabetes and thyroid disease?, biopsy, vulval dermatitis = ferritin

Answer 125

treat cause, avoid sensitizers, usually not successful, topical steroids

Answer 126

chronic inflammatory skin with severe intractable pruritus (mainly night)

Answer 127

labia majora inflamed and thickened, stress, low iron; vulval biopsy, avoid irritants and antihistamines

Answer 128

affect mucosa of mouth and GU tract (flat, papular, purple lesions); autoimmune; treat = potent steroid creams

Answer 129

vulval epithelium thin and collagen loss; autoimmune; discomfort, pain, dyspareunia, carcinoma in 5%; use ultra-potent topical steroids

Answer 130

white patches due to skin thickening and hypertrophy; itchy and analysed to see if pre-malignant

Answer 131

topical corticosteroids, psoralens with UV phototherapy, methotrexate and ciclosporin

Answer 132

unknown cause, inflammatory; shiny erythematous patches with/out petechiae; intravaginal clindamycin cream and hydrocortisone to vulva

Answer 133

inflammation from infection (candida, herpes, chemicals) and often with discharge

Answer 134

provoked or spontaneous (burning pain more common in older); associated = PMH of GU infections, previous OC, psychosexual

Answer 135

Amitriptyline or gabapentin

Answer 136

herpes simplex, vulval warts, syphilis, donovanosis can affect vulva; candidiasis (diabetics, obese, immunocompromised, pregnant), may need antifungals

Answer 137

blockage and infection with staph or E coli (glands under labia minora and make lubricant during sexual excitement); painful red with large tender swelling, can get vaginal cysts

Answer 138

incision and drainage by marsupialisation

Answer 139

columnar epithelium in squamous of the vagina, can resolve spontaneously or into clear cell carcinoma

Answer 140

usually warty, basaloid, mixed, 35-55yrs, reddening, whitening, pigmentation, plaques, papules, erosions, nodules, hyperkeratosis; associated = HPV, CIN, smoking, immunosuppression, warty/basaloid squamous cell carcinoma; differentiated type rare and with lichen sclerosis, risk of progression is higher, pruritus and pain

Answer 141

local excision

Answer 142

>60yrs; most squamous cell (others are melanomas/basal cell); association = lichen sclerosis, immunosuppression, smoking, Paget’s disease of vulva

Answer 143

pruritus, bleeding, discharge, mass, large inguinal lymph nodes; staging surgically and histology

Answer 144

stage 1 is wide local excision, others are that with groin lymphadenectomy, may use pre-op radiotherapy

Answer 145

secondary malignancy from cervix, endometrium and vulva (primary rare); older women and squamous; bleeding, discharge, mass

Answer 146

intravaginal radio/radical surgery; survival 50% for 5 yrs

Answer 147

very rare if primary; most squamous and older women and upper 1/3rd; associated with CIN, pelvic radio, long-term inflammation (pessaries/procidentia = complete uterus prolapse)

Answer 148

S+Ss = bleeding; treat = radio, poor prognosis

Answer 149

lower anterior vaginal wall and urethra

Answer 150

upper anterior vaginal wall and bladder

Answer 151

uterus, cervix and upper vagina

Answer 152

upper posterior wall of vagina

Answer 153

lower posterior wall of vagina and anterior wall of rectum; these are all the areas involved in the prolapse (vagina/uterus beyond anatomical confines from weakness from support)

Answer 154

vaginal delivery, pregnancy, Ehlers-Danlos, menopause, obesity, chronic cough, constipation, heavy lifting, pelvic mass/surgery

Answer 155

first = prolapse halfway to introitus, second = to introitus, third = outside of vagina

Answer 156

usually asymptomatic, dragging sensation/lump, worse at end of day/standing, severe = interferes with sex, ulcerates, bleeds, cystourethrocele can cause urinary frequency, stress incontinence, back ache, tenesmus

Answer 157

examine abdo, exclude polyps and masses, vaginal cysts, pelvic US, urodynamic testing if incontinent, Sims speculum

Answer 158

pelvic floor exercises, avoidance of excessive long 2nd stage, weight reduction, stop smoking, physio

Answer 159

pessaries (women unfit for surgery – artificial pelvic floor, ring most common and changed 6-9months, can cause urinary retention, pain or infection); vaginal hysterectomy for uterovaginal prolapse; hysteropexy (resuspension of prolapsed uterus) for uterine prolapse; sacrocolpopexy (lifts the vagina up using metal mesh) for vaginal vault prolapse; hysterectomy best treatment if severe and untreatable but can leave vault (where cervix was) and this can prolapse

Answer 160

transvaginal is best, homogeneity, low intensity echoes, linear central shadow = normal; 20mm endometrium = investigated, tamoxifen thickens it

Answer 161

overactive bladder (increase in detrusor) or increased intra-abdo pressure (stress incontinence)

Answer 162

daytime voids (4-7), nocturia, nocturnal enuresis, urgency and voiding difficulties, incomplete emptying, bladder pain, dysuria, haematuria, UTI, prolapse, bowel movement abnormal, ADLs

Answer 163

Urethral sphincter weakness

Answer 164

pregnancy, prolonged labour, forceps delivery, obesity, age

Answer 165

frequency, urgency, urge incontinence, faecal incontinence, cysto/urethrocele

Answer 166

urine dipstick, cystometry, test pelvic floor strength, urinalysis, imaging (US), urodynamics, cystoscopy, MSU

Answer 167

lose weight, pelvic floor exercises for 3 months, vaginal cones/sponges, duloxetine for moderate/severe, surgery after everything else (tension-free vaginal tape/trans-obturator tape)

Answer 168

urgency without incontinence (can be urge urinary incontinence too), frequency, nocturia without infection, leak at orgasm, childhood enuresis

Answer 169

detrusor overactivity, idiopathic, MS, spinal cord injury, postmenopause

Answer 170

reduce fluid, avoid caffeine, bladder training (education, timed voiding and positive reinforcement), anticholinergics (suppress detrusor), oestrogen, Botox (weakens muscle), neuromodulation/sacral nerve stimulation

Answer 171

childbirth, surgery, drugs (anticholinergics), retroverted gravid uterus, pelvic masses and neuro; mimics stress incontinence, leaking from bladder overflow

Answer 172

US or catheter after micturition

Answer 173

catheter for 48hrs, ISC (intermittent self catheterisation)

Answer 174

suprapubic pain from bladder filling, frequency with no UTI; interstitial cystitis from painful bladder filling with cystoscopic and histological

Answer 175

diet changes, bladder training, TCAs, analgesics, intravesical infusion of drugs, surgery

Answer 176

• Presence/growth of endometrium tissue out of uterus, driven by oestrogen; 30-45yrs and nulliparous

Answer 177

pelvis/ovaries, inflammation, progressive fibrosis, adhesions with pain, dysuria, dysmenorrhoea before menstruation, deep dyspareunia, subfertility, pain on defecation (dyschezia), menstrual problems, tenderness/thickening behind uterus, bleeding at area of tissue, cyclical pain

Answer 178

Retrograde menstruation?

Answer 179

laparoscopy with biopsy (active/red lesions on peritoneum, if white/brown then less active, extensive adhesions means more severe), transvaginal US, MRI (excludes adenomyosis), American fertility society grading system, bimanual exam = fixed retroverted uterus, tender nodes over uterosacral ligaments

Answer 180

asymptomatic don’t need treating, analgesia (NSAIDs), OC pill (without break) or GnRH analogues (danazol – temporary menopause so bone demineralisation so <6months, mirena), IUS (less pain and dysmenorrhoea), scissors, laser or bipolar diathermy for lesions, surgery to dissect lesions, hysterectomy last resort; problems post-op = chronic pain (difficult to treat and need a specialist), consider other non-gynae problems (IBS etc), analgesia to treat (GnRH analogues, opiates, gabapentin if neuropathic)

Answer 181

• Intermittent/chronic pain in lower abdo/pelvis >6months; not just menstruation/intercourse

Answer 182

psych evaluation, tansvaginal US, MRI, laparoscopy

Answer 183

IBS/interstitial cystitis (endometriosis/adenomyosis), depression, sleep disorder

Answer 184

cyclical pain with OC pill/GnRH analogue, counselling, psychotherapy, amitriptyline, gabapentin

Answer 185

pregnant, diabetes, abx, steroids

Answer 186

non-offensive discharge, vulval irritation, itching, superficial dyspareunia, dysuria; diagnose = culture

Answer 187

imidazoles (clotrimazole) or oral fluconazole

Answer 188

normal lactobacilli replaced by anaerobes and Gardnerella

Answer 189

grey-white discharge, fishy odour, regular sex partners, concurrent STIs, child sexual abuse; diagnose = high pH, clue cells

Answer 190

metronidazole or clindamycin cream

Answer 191

preterm labour, intra-amniotic infection, post-termination sepsis, HIV susceptible

Answer 192

usually asymptomatic, urethritis, vaginal discharge, pelvic infection (subfertility/chronic pelvic pain/PID), Reiter’s syndrome

Answer 193

nucleic acid amplification

Answer 194

azithromycin/doxycycline

Answer 195

asymptomatic, vaginal discharge, urethritis, bartholinitis, cervicitis, bacteraemia, monoseptic arthritis, PID

Answer 196

culture, endocervical swabs; treat = ceftriaxone

Answer 197

from HSV2; virus dormant in dorsal root ganglia

Answer 198

multiple small painful vesicles and ulcers around introitus, vulvitis, lymphadenopathy, dysuria, systemic flu symptoms, attacks = less painful with tingling before

Answer 199

examination and viral swabs; treat = acyclovir for severe, strong analgesia

Answer 200

solitary painless vulval ulcer (first), then wks after rash, flu symptoms, warty genital growth, tertiary rare but AR, dementia, tabes dorsalis

Answer 201

syphilis EIA; treat = parenteral penicillin

Answer 202

offensive grey-green fishy discharge, vulval irritation, superficial dyspareunia, asymptomatic

Answer 203

wet film microscopy; treat = metronidazole

Answer 204

untreated can spread to pelvis, fallopians and ovaries; from complication of pregnancy/instrumentation of uterus (C-section, miscarriage, abortion); chlamydia and gonococcus

Answer 205

heavy vaginal bleeding and offensive discharge, lower abdo pain, tender uterus

Answer 206

swabs and FBC; treat = broad-spectrum abx, evacuation of retained products of conception

Answer 207

– upper genital tract infection with dense pelvic adhesions and obstructed fallopian tubes if persists

Answer 208

ascending infection from endocervix (STI, uterine instrument, post-partum) or from descent (appendix)

Answer 209

chronic lower abdo pain, dysmenorrhoea, deep dyspareunia, heavy/irregular menstruation, chronic vaginal discharge, subfertility, similar to endometriosis, fever

Answer 210

= laparoscopy (diagnosis uncertain), MC+S, endocervical swabs for chlamydia/gonorrhoea, FBC, CRP, blood cultures, TVS if abscess suspected

Answer 211

analgesics, abx (ceftriaxone +/- doxycycline if high risk), salpingectomy, contact tracing

Answer 212

tubo-ovarian abscess, Fitz-Hugh-Curtis syndrome, recurrent PID, ectopic, subfertility

Answer 213

increases in ovulation, pregnancy and OC pill

Answer 214

exposure of columnar epithelium in adenomyosis and ectropion, bacterial vaginosis and candidiasis, foreign body (offensive), cervical carcinoma (bloody), fallopian tube carcinoma (watery)

Answer 215

low oestrogen and before menarche, during lactation and after menopause, treat with oestrogen cream, HRT

Answer 216

notify sexual partners of individual diagnosed with HIV/AIDS; public health duty and should be anonymous/confidential of who the sexual partner is

Answer 217

for symptomatic; endocervical NAAT swab, a high-vaginal charcoal media swab and an endocervical charcoal media swab

Answer 218

conception not happened after 1yr unprotected sex (either primary or secondary [had a previous terminage/miscarriage])

Answer 219

anovulation, inadequate sperm, fallopian tube damage, defective implantation, unexplained, endometriosis, male causes, >35yrs predisoposes; regular cycles = ovulatory (higher serum progesterone in mid-luteal phase means ovulation)

Answer 220

Both partners have fertility problems

Answer 221

age, duration of subfertility; previous pregnancies/children; menstrual hx; pelvic pain; STI hx; previous surgery; smoking; drinking; medical hx; sex hx and problems during; male = undescended testes, mumps, drugs, smoking, alcohol

Answer 222

BMI, endocrine disorder signs, exclude pelvic pathology, cervical smear; invest = chlamydia, hormonal profiling, TSH, prolactin, testosterone, MMR vaccine, semen analysis, mid-luteal progesterone (ovulation); TVS, hysterosalpingogram (and with contrast), laparoscopy and dye = gold standard for tube patency

Answer 223

transvag US with multiple small follicles in enlarged ovary (12+); most cases of anovulatory infertility

Answer 224

irregular periods, hirsutism (acne/more body hair/raised testosterone), disordered LH, peripheral insulin resistance, more androgens, obese, oligo/amenorrhoea, anovulation

Answer 225

FSH, prolactin, TSH (all for anovulation), testosterone (hirsutism), LH, US, screening for diabetes and lipids

Answer 226

DM2, gestational diabetes, endometrial cancer (rf for this = obesity, HT, DM, PCOS, tamoxifen, late menopause)

Answer 227

diet, weight loss, exercise, OC pill (to menstruate to protect endometrium), cyproterone acetate (hirsutism), eflornithine (for facial hirsutism), clomifene (first line ovulation induction - <6months, blocks oestrogen receptors in hypothalamus and pituitary, assess with transvag US for ovarian response and endometrial thickness), metformin, laparoscopic ovarian diathermy and gonadotrophins are all good 2nd line ovulation treatments (increases perinatal complication rates), cyproterone for anti-androgen

Answer 228

GDM, T2DM, CVD, endometrial cancer

Answer 229

low GnRH causing amenorrhoea

Answer 230

anorexia, diets, athletes, stress, benign tumours or hyperplasia of pituitary cells, PCOS, hypothyroidism, psychotropics

Answer 231

increase weight, CT, bromocriptine/cabergoline (dopamine inhibits prolactin that reduces GnRH)

Answer 232

anovulation so donor eggs needed for pregnancy; hyper/hypothyroid can reduce fertility

Answer 233

health advice, risk of multiple pregnancy with ovulation induction and folic acid, normal weight, no smoking

Answer 234

gonadotrophins overstimulate follicles (large and painful); common in IVF

Answer 235

gonadotrophin stimulation, <35yrs, previous OHSS, polycystic ovaries

Answer 236

= low gonadotrophin dose, US monitoring

Answer 237

hypovolaemia, electrolyte disturbance, ascites, thromboembolism, pulmonary oedema

Answer 238

idiopathic oligospermia, asthenozoospermia, alcohol, smoking, drugs, industrial chemicals, varicocele, infections, mumps, orchitis, testicular abnormalities, obstruction to delivery, hypothalamic problems, hyperprolactinaemia, retrograde ejaculation

Answer 239

body form, gynaecomastia, orchidometer (orchitis), rectal exam

Answer 240

semen analysis repeated 12wks later if abnormal, high FSH and LH with low testosterone means primary testicular failure, azoospermia and no vas deferens check for CF, testosterone and FSH for androgen deficiency

Answer 241

lifestyle changes, loose clothing and testicular cooling, hypogonadotrophic hypogonadism (2x FSH and LH 6-12 months), may need intrauterine insemination

Answer 242

pelvic inflammatory disease most common form of tubal damage (hx pelvic pain, vaginal discharge, abnormal menstruation, asymptomatic), endometriosis, pelvic surgery (adhesions), sometimes cervical cancer and sexual problems

Answer 243

Usually asymptomatic

Answer 244

laparoscopy and dye test for fallopians, hysteroscopy, hysterosalpingogram (shape of uterus and patency of fallopians); ovarian reserve testing (FSH, antral follicle count, antimullerian hormone); use IVF and ICSI

Answer 245

washed sperm injected into uterus after gonadotrophin ovulation induction, for unexplained subfertility, cervical, sexual and male factors, tubes should be patent

Answer 246

weight loss/gain; clomifene citrate (50mg 2-6days of cycle; anti-oestrogen; menopause symptoms; only for 6-12 cycles; follicular monitoring for hyperstimulation); laparoscopic ovarian drilling (PCOS only; aim to reduce LH and increase -ve feedback); gonadotrophins (if clomifene resistance; injected; expensive); metformin (PCOS, not licensed)

Answer 247

success higher in <36, need normal ovarian reserve (no ovarian failure – test with antimullerian hormone), get multiple follicular development with 2wks daily FSH+LH (GnRH analogue to stop LH surge and stop premature ovulation), eggs collected under IV sedation with US and incubated with washed sperm to growth medium until cleavage/blastocyst, progesterone 4-8wks in gestation

Answer 248

for male subfertility but can be surgically retrieved; inject sperm into egg cytoplasm; preimplantation genetic diagnosis to test for defects; surrogate?

Answer 249

superovulation and higher ectopic rates

Answer 250

male can’t donate sperm (azoospermia), high risk genetic disorder, HIV transmission

Answer 251

mild male subfertility, coital difficulties, unexplained, same-sex couples; can be combined with ovarian stimulation

Answer 252

immature eggs collected from ovaries and matured before ICSI; reduces risk of ovulation stimulation drugs and hyperstimulation (PCOS)

Answer 253

– 2 mothers; one for nucleus and other for mtDNA and cytoplasm

Answer 254

small bowel disease and malabsorption for oral, IBD higher osteoporosis (<18yrs), breast feeding (98% stops pregnancy), women <50 advised to continue contraception up to 2yrs after last period; non-compliance

Answer 255

venous disease/heart disease RF; arterial disease; liver disease; cancer; previous pregnancy complications; hepatic enzyme-inducing drugs; avoid if migraines as risk of ischaemic strokes (especially if with aura)

Answer 256

• Important to have sex education in schools, condoms (don’t use oil based lubes), femidom, cap over cervix, cervical sponges, spermicide used with a barrier; aim to not have sex 6 days prior to ovulation to 2 days after (cervical mucous should be clear and slippery before ovulation and then sticky and tacky – no sex when slippery to 3 days after tacky); Persona use urine sticks measure oestorgen-3-gluconoride + LH, give her a green/amber/red light when not ovulating and can have sex, use 8 times per cycle and v effective

Answer 257

ve feedback on gonadotrophin release and inhibits ovulation; thin endometrium and thicken cervical mucous, 1 tablet daily for 3ks then stop for a week, vaginal bleeding at end of each packet (determined by progesterone used), some contain ethinyloestradiol (same O+P dose) or oestradiol valerate (natural O and synthetic P – 26 pill days then 2 free)

Answer 258

menarche-menopause, stop recurrent simple ovarian cysts

Answer 259

diarrhoea (reduced absorption), vomits 2hrs after taking take another, broad spectrum abx use condoms as well, liver enzyme inducing drugs use more oestrogen, forgotten pill taken asap, pill stopped 4wk before major surgery

Answer 260

nausea, headaches, breast tenderness

Answer 261

releases ethinyloestradiol then norelgestromin (progestogen); new patch weekly for 3wks then week break

Answer 262

daily ethinyloestradiol and etonogestrel; same rule as patch; don’t remove during intercourse

Answer 263

levonorgestrel or norethisterone; every day without a break at same time; makes cervical mucous hostile to sperm and inhibits ovulation in 50%, not affected by broad-spectrum

Answer 264

vaginal spotting, weight gain, mastalgia, pre-menstrual symptoms

Answer 265

medroxyprogesterone acetate IM 3 months

Answer 266

irregular bleeding in 1st wks then amenorrhoea, bone density increases, noristerat as short-term interim

Answer 267

40mm rod of etonogestrel into upper arm and lasts 3yrs

Answer 268

levonelle has levonorgestrel (take in 24hrs), affects sperm and endometrial receptivity; ulipristal is selective progesterone receptor modulator prevents/delays ovulation, if IUD inserted then stops implantation and can be inserted 5 days after sex

Answer 269

diaphragms and caps before sex and 6hours after; also use with spermicide (nonoxynol-9)

Answer 270

screen for STD/prophylactic abx before; use immediately after TOP/miscarriage for 4wks

Answer 271

copper (prevent fertilisation; more ectopic/PID risk) or progesterone like Mirena/Jaydess (change cervical mucous and uterotubal fluid so no sperm migration, can be used for menorrhagia and dysmenorrhoea)

Answer 272

low failure and SEs; can perforate uterus, be expelled, PID association, dysmenorrhoea/menorrhagia

Answer 273

use of clips and applied laparoscopically; other is transcervical sterilisation (microinserts into proximal tubal lumen); confirm 3months later by hysertosalpingogram

Answer 274

more effective and ligation and removal of small section of vas deferens (confirm by azoospermia in 2 sperm samples up to 6months)

Answer 275

failure, infection and chronic pain; make sure consent properly and that they know it’s permanent and won’t regret later (reversibility 50% effective and not on NHS)

Answer 276

from corpus luteum til 35 days post-conception then by placenta causes smooth muscle excitability, raises body temp

Answer 277

increase breast and nipple growth, water retention and protein synthesis

Answer 278

increase thyroid from more colloid made

Answer 279

from pituitary increases

Answer 280

late in pregnancy cervical collagen reduces and vaginal discharge from cervical ectopy, cell desquamation, more mucous

Answer 281

increased stroke volume and pulse rate; bp mainly diastolic falls in 2nd trimester; increased venous pressure so may get varicose from venous dilation (increase in renin and angiotensin)

Answer 282

from uterus when on back which reduces CO significantly; put woman on her left side tilting 15 degrees on side

Answer 283

ventilation increases, gut motility decreases, micturition frequently common, palmar erythema, spider naevi, striae

Answer 284

amenorrhoea, nausea, vomiting, bladder irritability, breasts engorge, nipples large, Montgomery’s tubercles prominent, increased vulval vascularity, cervix softens, uterine globular, temp rises (37.8)

Answer 285

Headaches, palpitations and fainting – dilated peripheral circ; stand slowly and drink; Urinary frequency – exclude UTI, fetal head pressure on bladder, GFR increases; abdo pain; SOB; constipation – gut motility low, fluid and fibre, avoid stimulant laxatives, piles common, rest with feet up and stockings; GORD – pyloric sphincter relaxation from progesterone, foetus pressing on GI, pillows, other GORD treatment; MSK – symphysis pubis dysfunction, analgesia and physio; carpal tunnel syndrome – from fluid retention; itchy/rashes – common (pruritic eruption of pregnancy/PEP), 35wks+, emollients and weak topical steroids; ankle oedema – very common, measure BP, check protein (pre-eclampsia) and DVT usually harmless and elevate feet; leg cramps – raise foot 20cm in bed, sometimes restless leg syndrome harder to treat; chloasma – dark pigmentation on face; nausea/vomiting – starts by 4wks and usually declines, small meals, low stress

Answer 286

• Persistent vomiting causing weight loss and ketosis in pregnancy; v rare; higher in multiple, molar pregnancy, previous HG

Answer 287

can’t keep F+D down, weight low, nutritional deficiency, dehydration, hypovolaemia, tachycardia, postural hypotension, electrolyte disturbance with hypokalaemia, hyponatraemic shock, polyneuritis, behaviour disorder, haematemesis (Mallory-Weiss), ptyalism (can’t swallow saliva), spitting

Answer 288

urine dip (ketones and UTI), U+Es, FBC (raised haematocrit), albumin low, transaminases abnormal, TFTs abnormal

Answer 289

hospital if oral anti-emetics not working; fluid replacement; don’t use glucose (wernicke’s encephalopathy – use folic acid and thiamine), daily U+Es; anti-emetics (promethazine, cyclizine, metoclopramide and ondansetron if these fail) use corticosteroids if these fail; high risk of VTE so stockings and thromboprophylaxis

Answer 290

pregnancy worsens anaemia (crises and acute chest syndrome increased); advise on cold intolerance, hypoxia, dehydration

Answer 291

genetic counselling for child and test partner; echo to exclude pulmonary hypertension, bp, urinalysis, U+Es, LFTs, retinal screening, iron overload screening

Answer 292

daily penicillin, update vaccines (more at risk to infections), 5mg folic acid OD; prenatal testing and tell medical team before so they can prepare; 12wks give aspirin 75mg OD so no pre-eclampsia, TEDs in hosp; regular testing as seen above at visits

Answer 293

fever, severe pain, chest pain, SOB; fluids, opiates and O2; delivery 38-40wks, monitor foetus and maternal sats, 7 days thromboprophylaxis after (progesterone contraception)

Answer 294

risk increased from pulmonary hypertension, effect on haemodynamics, NHYA functional class I-IV and cyanosis present, arrhythmias, TIA, HF, left tract outflow tract obstruction, low EF

Answer 295

25-40% mortality, advise against pregnancy, Eisenmenger’s etc

Answer 296

uncorrected can mean IUGR (intrauterine growth restriction), get foetal echo

Answer 297

risk of aortic dissection, offer root replacement pre-pregnancy

Answer 298

dyspnoea, orthopnoea, PND risks and treat AF and pulmonary oedema

Answer 299

exclude anaemia and hyperthyroidism, SVT treat with adenosine

Answer 300

warfarin can harm foetus and heparin could mean valve thrombosis, can have LMWH

Answer 301

diuretics, vasodilators, B-blockers and inotropes then ACEI once delivered

Answer 302

prevent anaemia, obesity, smoking, treat hypertension, echo, HF = admission; O2 and drugs to hand for labour, vaginal delivery aim for, epidurals safe if no hypotension, avoid fluids and ergometrine (use oxytocin)

Answer 303

avoid paroxetine, fluoxetine and citalopram but SSRIs fine (same for ante/postnatal depression); try to avoid valproate as mood stabiliser (lamotrigine and carbamazepine have lower chance of NTD); lithium is teratogenic, deffo stop it during labour, don’t breastfeed; higher incidence of foetal abnormalities in schizophrenic; avoid benzos for foetal withdrawal and cleft lip/palate

Answer 304

can increase risk of postpartum haemorrhage (PPH – when uterus cannot tense from muscle fibres to restrict in size post-birth and knot itself and cervix cuts off), infection, HF severity

Answer 305

<150g/L and steepest decline in 20wks

Answer 306

Hb at 1st and 28wks, malaria, SCT, FBC (MCV), iron and ferritin (main cause is deficiency), check folate too; iron deficiency = need way more iron if pregnant so can give oral/parenteral iron; thalassaemias = don’t give iron, alpha more likely to mean anaemic foetus

Answer 307

increased risk of foetus contracting from vaginal birth, membrane rupture >4hrs and increased viral load

Answer 308

antiretroviral use, C-section, bottle feeding

Answer 309

HIV test, if +ve MDT and monitor viral load and drugs, check for hep B, C, varicella zoster, measles and toxoplasmosis and offer vaccines, give HAART if women needs or if not then must take at 24wks

Answer 310

if membrane ruptures <34wks give steroids, erythromycin, HAART and decide if needs delivered or not; if >34wks deliver baby

Answer 311

intrapartum = vaginal <50 copies/mL, HAART, limit trauma to foetus; C-section at 38wks; postpartum = avoid breastfeeding and give cabergoline within 24hrs to stop lactation, newborns given zidovudine in 4hrs or HAART if high risk, test babies, co-trimoxazole prophylaxis given to babies high risk of transmission

Answer 312

plan pregnancy, HbA1c <43mmol/L, 5mg folic acid OD before, stop ACEI and hypoglycaemics other than metformin, don’t if severe nephropathy and screen retinopathy

Answer 313

maternal: pre-eclampsia, infection, C-section; foetus: miscarriage, malformation, macroscopic (shoulder dystocia, IUGR), polyhydramnios, preterm

Answer 314

anomaly scan and foetal echo 18-20wks, aim for normoglycaemia, review insulin regularly (needs increase through pregnancy), aim for fasting 3.5-5.9mmol/L, assess renal function (best to be <120umol/L creatinine), monitor foetal growth, metformin used

Answer 315

elective delivery at 38wks, corticosteroids for preterm for lung maturity, aim for glucose 4-7mmol/L (if above give sliding scale insulin and take off immediately after birth and return to normal regimen, should have to reduce dose through delivery), avoid hypers, monitor foetus

Answer 316

encourage breastfeeding (should be fine with regimen), prepregnancy counselling before next baby

Answer 317

OGTT >7.8mmol/L

Answer 318

screen if FH, previous baby >4.5kg, ethnicity, BMI >30, previous GDM

Answer 319

only give hypoglycaemics (metformin/glibenclamide) if can’t control levels without; 50% develop T2DM (screen postpartum)

Answer 320

• Stop smoking; weight loss (BMI 18.5-30); exercise; folic acid to stop neural tube defects and cleft lip until 13wks; vit D for those at risk; no alcohol and drugs to stop Foetal alcohol syndrome; change medication if teratogenic and monitor if have chronic disease; age (higher miscarriage); genetic counselling

Answer 321

• For respiration, nutrition and excretion; immune foetal protection; endocrine

Answer 322

• Placental villi functional units of the placenta; on maternal surface is syncytiotrophoblast (direct contact to maternal blood), then cytotrophoblast, then basement membrane then mesenchymal stroma then basement membrane of the foetal vessels

Answer 323

uteroplacental circ = maternal blood through intervillous spaces, if this becomes high resistance and low flow then IUGR and pre-eclampsia; fetoplacental circ = 2 umbilical arteries, divide and feed to chorionic villus where is oxygenated and picks up nutrients then drains to umbilical vein; maternal and foetal vessels occur in countercurrent and never mix

Answer 324

look for blood abnormalities (pH, clotting, Hb, Coombs, LFTs, blood group, infection)

Answer 325

• Detect disease in mother; help promote fetal welfare, prepare for birth, monitor trends (bp most important for pre-eclampsia)

Answer 326

full obs hx; risk assess for pre-eclampsia/venous thromboembolism; any diseases; gestational diabetes (glucose tolerance at 28wks for at risk [high BMI, heavy baby, FH]); past psych; tropical diseases if out of UK; social care for women unsupported/domestic violence; EXAMINATION (heart, lungs, bp, weight, abdo, smear, varicose veins, genetically cut?; TESTS = mainly blood (Hb, group, abs, syphilis/rubella, serology, HIV, serology, MSU, genetic

Answer 327

identify the eligible, provide info, inform about test, document the decision, perform test, communicate the results, have follow-up and treatment for those positive, optimise health outcomes

Answer 328

sickle cell, thalassaemia, infectious diseases screening, Down’s, Edward’s, Patau’s, foetal anomalies, diabetic eye screening, newborn infant physical exam, newborn hearing screen, newborn blood spot

Answer 329

beta = less B chains made and alpha = less A chains made in Hb (imbalance of alpha and beta chains leads to precursor deaths); BETA = more Hb delta and Hb gamma (lots of Hb which cannot be used), categories = MINOR [heterozygous, asymptomatic, anaemia mild/absent, hypochromic and microcytic, iron stores normal]; INTERMEDIA [symptomatic with moderate anaemia but not regular transfusions, splenomegaly, bone deformities, leg ulcers, gallstones, infections – blood = not carrying enough oxygen so tissues can die causing things like infections etc]; MAJOR [in 1 year olds; can’t thrive and bacterial infections; severe anaemia; transfusions needed; hypertrophy of bone marrow; microcytic; homozygous; need iron-chelating so no iron overload as big problem; ascorbic acid to increase urinary iron exctretement]; ALPHA = FOUR GENE DELTION [no alpha chain synthesis and only Hb Barts present (4 gamma chains and cannot carry O2), infants stillborn or die after birth]; THREE GENE DELETION [severe reduction in alpha chain synthesis, HbH disease and has 4 beta chains; moderate anaemia and splenomegaly]; TWO GENE DELETION [microcytosis with/without anaemia]; ONE GENE DELETION [normal blood usually]

Answer 330

Hb is insoluble and polymerises when deoxygenated and flexibility of cells decreased and become rigid and sickled; SEE PAGE 24 FOR MORE STUFF ON ITS PATHOGENESIS; sickling means shorter RBC survival and obstruction of microcirculation = tissue infarction and pain; HbS releases O2 easier than normal Hb; HETEROZYGOUS [symptom free unless hypoxic and can offer protection against falciparum anopheles (malaria)];

Answer 331

HOMOZYGOUS [vaso-occlusive crises (acute pain in hands and feet and avascular necrosis of bone marrow in children and in long bones of adults for same reasons {SEE WHICH ARE LONG BONES FROM PHASE 1} – blockage due to cells taking up small vessels; can have CNS infarction in kids); acute chest syndrome (occlusion in pulmonary vessels; mortality most common with pulmonary hypertension and chronic lung disease; infection, fat embolism from bad bone marrow or occlusion can cause this); pulmonary hypertension (mean pulmonary artery pressure greater than 25mmHg by right heart catheterisation; usually from repeated chest crises); anaemia (chronic haemolysis; cell can get trapped in spleen and cause splenomegaly and then acute haemolysis and can lead to non-functioning spleen); BONE MARROW APLASIA

Answer 332

Hb = 60-80g/L, raised reticulocytes, sickled erythrocytes and Hb electrophoresis confirms diagnosis

Answer 333

keep well (no infections etc); folic acid if have haemolysis; IV fluids, pain killers and oxygen for attacks (common sense)

Answer 334

offered to all at 8-10wks; family origin questionnaire with bloods; test biological father; offered termination if affected foetus

Answer 335

<11wks for location, viability, dating of pregnancy; dating a pregnancy

Answer 336

11-13wks for viability, dates, multiple, chorionicity, most with genetic abnormalities detected; chromosomal using nuchal folds and blood test; also if high nuchal translucency then can mean fetal heart failure

Answer 337

18-22wks for structural abnormalities (lethal = anencephaly, bilateral renal agenesis, major cardiac, trisomies 13/18); soft markers (choroid plexus cysts, echogenic bowel [higher chromosome abnormality, congenital infection, CF, bowel obstruction], 2 vessel umbilical cord, mild renal pelvic dilation); info and specialist help if abnormality found

Answer 338

* Fetal echo – for at risk of fetal cardiac abnormalities (drugs, history) * Fetal growth scans – need accurate gestational age; head circ, abdo circ, liquor vol, at least 2wks apart * Doppler US – uterus, placenta and foetus blood flow

Answer 339

trisomy 21 (Down’s) = increased rate of miscarriage and increased age increases incidence, can have cardiac abnormalities (VSD/ASD), most common aneuploidy

Answer 340

trisomy 18 = Edward’s, most don’t survive after 1yr (VSD, rocker-bottom feet and small chin, LD, resp problems and other organs)

Answer 341

trisomy 13 = Patau’s and very rare and most children die (microcephaly, exomphalos [umbilical hernia from thin abdo wall), cleft palate, holoprosencephaly [brain development abnormal]); can test in 1st trimester with combined test with NT scan

Answer 342

• Alpha fetoprotein – 10% can have a foetal defect with high AFP • Pregnancy associated plasma protein A – secreted mainly by placenta so low means poor early placentation; can mean trisomies or even predict pre-eclampsia • Invasive testing – increased genetic disease risk; chorionic villus = 10-13wks, transabdo/transcervical using US, can mean 1-2% miscarriage and introduce blood-borne virus; amniocentesis = 16+wks, transabdo to take fluid that has foetal cells shed in it • Cell free foetal DNA – non-invasive for prenatal chromosome abnormalities; used to guide anti-D use in Rh-ve women • Diabetic eye screening – over 6wks pregnant; existing diabetics, tested at least 2x in pregnancy, early appt and scan • Newborn infant physical – within 72 hours then 6-8wks; identify defects; screen eyes, heart, hips, testes and refer to specialist if needed • Newborn hearing And newborn bloodspot

Answer 343

identify permanent deafness and severity; helps develop communication if found early

Answer 344

screened within 4wks birth; use automated otoacoustic emission test (AOAE – clicking in ear and ear response recorded) and sometimes also automated auditory brainstem response test (AABR – sensors on head, neck and shoulder and clicking sounds played)

Answer 345

SCD, CF, congenital hypothyroidism, 6 inherited metabolic disorders, PKU, medium-chain acyl CoA dehydrogenase deficiency, maple syrup urine disease, isovaleric acidaemia, glutaric aciduria type 1, homocystinuria

Answer 346

Early cleavage stage embryos are ‘totipotent’ – the nuclei of individual blastomeres are each capable of forming an entire fetus; keep embryos past day 3 so can tell it’s gonna have a normal stage of development

Answer 347

Cells flatten; • Maximise intracellular contacts • Tight junctions form • Polarisation of outer cells

Answer 348

Tight junctions between outer cells – forms the trophectoderm • Fluid filled cavity expands (blastocyst) • Blastocyst stage - >80 cells (50-66% comprise trophectoderm, rest the ICM) • Day 5/6 – cavity expands and diameter increases and ZP thins (in uterine cavity) • Day 6+ (hatching) - Blastocyst expansion and enzymatic factors cause the embryo to hatch from the ZP

Answer 349

* Maturing of egg begins in fallopian tubes and called the in vivo stage (nutrients supplied by cumulus cells, fallopian tube secretions and uterine secretions); give growth factors and cytokines (IGF-I and IGF-II and LIF) * Early implantation – mainly pyruvate used and not metabolically active but after this needs more glucose and more energy in blastocyst stage (in uterine cavity for blastocyst stage)

Answer 350

unstable adhesion to uterine lining; always attaches by embryonic pole (bit closest to egg sac) to receptive endometrium (day 19-22 must implant in this window)

Answer 351

stronger and more stable adhesion; trophoblast forms protrusions into endometrium also interaction by receptor-ligand; apical surfaces of endometrium express adhesion molecules and trophoblastic cells do; integrins join

Answer 352

trophoblast erodes endometrium into blood vessels and makes contact with maternal blood to give chorionic villi by enzymes (synctiotrophoblast)

Answer 353

progesterone primed endometrial stromal cells next o blastocyst differentiate into secretory cells/decidual cells; endometrial glands enlarge and local uterine wall = very vascularised; more secretions to help blastocyst implant; however this is not a requirement as can have ectopic pregnancies

Answer 354

alpha made in committed cytotrophoblast cells; beta made in synctiotrophoblast cells and is limiting and these rising indicates starting implantation in day 7-8; makes sure corpus lutem continues to make progesterone in first trimester of pregnancy; essential to early pregnancy; interacts with endometrium with specific receptors; immunosuppressive; doubling of HCG in 1.3 days in 10-12 days of pregnancy

Answer 355

spontaneous in onset, low risk at start if labour and remaining so in labour and delivery; infant born spontaneously in vertex position 37-42wks, then after both mother and baby in good condition, in 24 hours of first contractions; no induction of labour; spinal, epidural, analgesia used forceps or ventouse, C-section or episiotomy used; feed baby after birthing

Answer 356

latent (long + painful and contractions vary and irregular, mucoid plug seen, cervix starts to efface and dilate to 4cm, 2-3 days; harder in primiparous women [first baby]), first stage = established (stronger contractions, cervix effaces and dilates to 10cm [good dilation is 1/2cm per hour], assess strength and freq of contractions and temp of mother, urinary bladder, vaginal exam 4hours for dilatation and head position, liquor state, foetal heart)

Answer 357

(full dilation to birth of foetus, 2-3 hours longest but can be 5 minutes, woman pushing with abdo and valsalva manoeuvre to birth, same measurements as above but offer oxytocin if contractions wane; can be a passive hour after dilatation then active stage, use syntometrine as anterior shoulder exposed to reduce chance of PPH and reduce 3rd stage time unless has heart/pulse problems)

Answer 358

birth of foetus to expulsion of the placenta, retroplacental haemorrhage aids, less than an hour

Answer 359

most will be cephalic (head down), small amount will be breech (bum down) and transverse (back down); best of all is left occipitoanterior (LOA)

Answer 360

starts in fundus (pacemaker); retraction of muscle fibres; build in amplitude as labour progresses; foetus forced down putting pressure on cervix

Answer 361

cervical ripening is where cervix softens and thins (usually long 4cm bottleneck and during pregnancy tight closed and mucous plug)

Answer 362

opening of cervix from retraction of muscles and pressure of baby on cervix; full = 10cm, done by vaginal exam

Answer 363

frontal, parietal and temporal bones; not fully formed and 3 bones are separate; allows baby to navigate through cervix

Answer 364

when mucous plug dislodges from cervix; in early labour when starts to dilate

Answer 365

into pelvis 37wks onwards, from increased abdo muscle tone and increased strength and freq of contractions

Answer 366

(uterine contractions uterine contractions exert force on foetal spine and forces the occiput to meet the pelvic floor, then the foetal neck flexes so the foetal skull has a smaller diameter for birthing, more successful if foetus back to mother’s front

Answer 367

each contraction pushes foetal head onto pelvic floor and after each contraction small rebound means slight rotation each time until head is 90 degrees rotated

Answer 368

foetal occiput slips beneath suprapubic arch allowing head to extend, foetal head now born facing the mother’s back

Answer 369

foetus my naturally align head with shoulders [restitution], shoulders have to negotiate pelvic outlet and may have to externally rotate

Answer 370

gentle downward traction with foetal spine, helped by midwife to deliver shoulder then upwards traction to deliver posterior shoulder, too much force can damage brachial plexus

Answer 371

group of measurements from vaginal exam (station, dilation, effacement, position, consistency of cervix) that determine if cervix ripe for spontaneous labour; out of 8

Answer 372

release the amniotic fluid surrounding and cushioning the baby; the foetus can swallow amniotic fluid and helps creates urine and meconium; sometimes baby born in amniotic sac (en caul)

Answer 373

not immediately clamp cord but allowed at least 1 minute to transfuse blood to baby; good for pre-term babies; allows time for baby to transition, increase in RBCs, iron and stem cells, less need for inotropic support

Answer 374

management is active (give oxytocin to uterine contract and birth the placenta, not too much force or snap the cord or invert uterus) or physiological (without intervention)

Answer 375

ideally meant to be upright (increases diameter of pelvic outlet, less risk of compressing aorta, stronger and longer contractions); encourage women to have strong sighs and concentrate on out-breaths to less thought on the pain and not hyperventilating; in water bath as well

Answer 376

water immersion (below 37.5 degrees), aromatherapy, massage, hypnobirthing (breathing techniques), TENS machine (transcutaneous electrical nerve stimulation); non-invasive, partner can be involved, no risk, some work better than others

Answer 377

Entonox (fast-acting and short half-life and use alongside other analgesia but can cause nausea and drowsiness), paracetamol and condeine; opioids (diamorphine, pethidine, remifentanil – given by midwife, doesn’t slow labour, sleep between contractions, given with anti-emetic, can cross the placenta to baby so be careful and can cause resp depression in mother and foetus); pudendal nerve block using lidocaine into sacrum, not good enough for forceps; lidocaine into perineum before episiotomy; epidurals (mix of bupivacaine and fentanyl, administered by pump through spine [T10-S5] and works completely in 90% but can slow labour, takes hour to work and may need urinary catheter, CTG monitoring, can cause hypotension [good for pre-eclampsia], headache and nerve damage; can be topped up when needed); combined spinal epidural (used to cover a C-section taking longer); spinal anaesthesisa (used mainly for LSCS, single injection)

Answer 378

must be low risk; reasons = more relaxed, hosp fear, midwife continuous care, family support, avoid intervention; could mean a worse outcome if problems (maternal mortality same but perinatal worse)

Answer 379

``` o Consent and explain o 1/5th or less head felt in abdo o ROM o Adequate analgesia o Adequate contractions o Empty bladder o Fully dilated cervix o Check position of head and presentation o Check instrument o Have neonatal specialist there ```

Answer 380

o Maternal = prolonged second stage, maternal exhaustion, medical avoidance or can’t of pushing (cardiac, tetraplegic) o Foetal = suspected distress, for the head when breech presentation

Answer 381

assisted breech/face presentation, <34wks, some C-sections, suspected coagulopathy/thrombocytopenia, cord prolapse, general anaesthesia, significant caput (foetal head swelling from labour); abandon if 3 pulls from forceps doesn’t help

Answer 382

head on perineum to lift out baby; can be used in LSCS

Answer 383

only used when sagittal suture lies in AP direction; blades put in between contractions

Answer 384

for rotating by experienced doctors

Answer 385

suction to get foetal scalp into a ventouse cup; creates an artificial caput on the head called a chignon that takes 24-48hrs to resolve

Answer 386

o More likely for foetal trauma but must be >34wks and no maternal coagulopathy; more likely to fail; metal cup, soft cup, Kiwi OmniCup (single use) • Complications – maternal GU trauma, spiral vaginal tears, foetal injuries (haemorrhages, fx, nerve palsies), most common for foetal is with ventouse causing cephalhaematoma (others = scalp lacerations and retinal haemorrhage), obstetric brachial plexus injury (can also be from large weight and shoulder dystocia)

Answer 387

no descent with each pull and after 3 pulls; go to emergency LSCS

Answer 388

vit K, analgesia, document time and vol of 1st urine (catheterise if spinal/epidural), thromboprophylaxis needed?, future deliveries discussed

Answer 389

loss of >500ml in first 24hours post birth; causes = tone (uterine atony = most common), tissue (retained products of conception), trauma (genital tract), thrombin clotting disorders

Answer 390

excessive blood loss after 24 hours (5-12days); from placental tissue retained and can be with infection, uterine involution can be incomplete

Answer 391

antenatal = previous, BMI over 35, maternal Hb >85 at labour, APH, over 35yrs, >4 kids, uterine malformation, large/low placenta, overdistended uterus, abruption; labour = prolonged, induced, oxytocin use, C-section

Answer 392

call for emergency help; high flow O2 and may need to intubate; do bloods (all the normal ones); IV fluids; catheterise and monitor urine output; try to deliver placenta and stimulate contractions; repair tears

Answer 393

syntometrine, oxytocin, ergometrine, misoprostol, carboprost

Answer 394

if drugs don’t stop it; consider laparotomy; Rusch balloon, B-lynch suture, internal iliac/uterine artery ligation; hysterectomy if necessary

Answer 395

not complete by 30 mins with active management, by 60 mins with physiological 3rd stage; won’t deliver spontaneously; danger of PPH

Answer 396

if doesn’t separate from uterus then not too much cord traction as may snap or uterus invert; check placenta not in vagina, palpate abdo, rub up contraction, put baby to breast to stimulate oxytocin (may give oxytocin too), proximally cord clamp, empty bladder; after 30 mins examine to see if need manual removal

Answer 397

lithotomy position; one hand on abdo to stabilise uterus and other hand into uterus; manually separate and then pull out and give oxytocin and abx after

Answer 398

immediately push fundus back through cervix; crossmatch blood and take to theatre (tocolytics, manual push up and if this doesn’t work then laparotomy)

Answer 399

umbilical vessels in membrane before placenta insertion

Answer 400

separate lobe away from placenta that may not separate normally (PPH)

Answer 401

foetal vessels from velamentous insertion more likely to damage and haemorrhage (C-section)

Answer 402

thin placenta surrounds baby (may fail to separate and APH risk

Answer 403

abnormal adherence to uterus (increta = to myometrium and percreta if to serosa); PPH risk; need hysterectomy; RF = previous C-section; diagnose prenatally by Doppler

Answer 404

placenta lies in lower uterine segment (over the cervix); advise against penetrative sex and digital examination; transvaginal US to diagnose and speculum to check for cervical cancer, CTG

Answer 405

C-section (placenta can attach to scar), multiparity and twins, old mother (>35yrs), assisted conception, fibroids, manual removal of placenta

Answer 406

APH, abnormal foetal lie, obstruction during labour, accrete, intermittent bleeding usually only after 20wks with no pain;

Answer 407

advise for C-section but minor normal vaginal birth; o Delivery – want baby out by 39 weeks but aim for 37

Answer 408

secondary to procoagulant substance release in mother for any reason (pre-eclampsia, dead foetus etc)

Answer 409

= Kaolin and clotting factors

Answer 410

give fluids and blood, plasma and calcium gluconate and remove source

Answer 411

IgG abs formed and 10% can cross the placenta causing thrombocytopenia in foetus as well as mother; consider HIV and SLE

Answer 412

give steroids if platelets too low; aim for non-traumatic delivery with no instruments used if possible; cord blood at delivery and may have to give baby IVI at birth if platelets low

Answer 413

dyspnoea, chest pain, resp arrest, hypotension, foetal distress, seizures, low consciousness, cardiac arrest

Answer 414

prevent resp death (O2 and IVI if develop DIC), resus, monitor foetus, if mother has cardiac arrest deliver baby by C-section, correct hypotension

Answer 415

natural and is where skull pieces move over each other to allow birth by reducing diameter; slight moulding is where bones touch, extreme is where bones overlap and can’t be reduced

Answer 416

subperiostal swelling and may be absorbed over time but can contribute to jaundice

Answer 417

oedematous swelling over presenting part of head from venous collection from where presenting part squeezed by pelvis; disappears over 1-2 days

Answer 418

from shoulder dystocia and unable to move arm; most resolve in 6 months with physio

Answer 419

associated with ventouse; can cause anaemia/jaundice

Answer 420

difficult, fast labour, instrumental and breech deliveries; check babies platelets; anoxia can cause intravertebral haemorrhage and asphyxia can cause intracerebral haemorrhage; supportive treatment

Answer 421

1st and 2nd affect perineal skin and or muscle; 3rd = part or all of anal sphincter and 4th = into mucosa

Answer 422

repair can help alleviate incontinence but may not; greatest risk after 1st vaginal birth and if it happens then subsequent births also for pudendal nerve injury

Answer 423

abx, anal US, specialist physio, laxatives

Answer 424

bladder to vagina leading to incontinence; obstructed labour (mainly those younger and smaller pelvises and malnourished) = head compresses against tissues of vagina, bladder and rectum causing ischaemia of these and foetal asphyxiation, 2 days after foetus died is soft enough to expel vaginally, then 3 days later expels sloughed ischaemic tissue leaving a fistula, fibrosis healing and vagina and rectum stenose and become incontinent

Answer 425

urinary catheter and surgery; monitor those at risk

Answer 426

delivery through incision in abdo wall

Answer 427

failure to progress, foetal distress, breech

Answer 428

support in labour, induction at 41wks, consultant involvement, foetal blood sampling, 4hour partogram (maternal and foetal key data on graph during labour against time; cervical dilation, foetal HR, labour duration and vitals)

Answer 429

o Lower uterine segment incision – 3cm above pubis symphysis to reduce blood loss; transverse incision in lower segment for less adhesions formed, lower blood loss, less scarring o Classical CS – vertical incision on uterus and transverse or vertical on skin; rarely used; some reasons why: very premature, foetus lies transverse, maternal cardiac arrest; more likely to have adhesions and infection

Answer 430

repeat CS, foetal compromise (bradycardia), malpresentation, failure to progress, severe pre-eclampsia, IUGR, placenta praevia

Answer 431

1 = immediate threat to life, within 30mins (abruption/foetal bradycardia); 2 = maternal or foetal compromise; 3 = semi-elective (pre-eclampsia); 4 = elective (carried out after 39wks, give corticosteroids for foetal lung maturity if before this)

Answer 432

blood loss >1L, uterine lacerations, blood transfusion, bladder laceration, bowel injury, ureteral injury, hysterectomy, haemorrhage more likely with praevia/abruption; post-op = infections, endometritis, UTI, VTE (have LMWH prophylaxis); long-term = praevia, uterine rupture and accreta risk

Answer 433

1-1 support; skin to skin contact; check: pulse, resps, BP and sedation every 30 mins; use MEOWS (modified early obstetric warning score chart); remove catheters after 12 hours epidural; mobilise early; remove wound dressing after 24hours; analgesia; can be discharged after 24hours if well

Answer 434

perineal; labial (common, painful, heal quickly but if both labia then stitch to stop fusion); first-degree (superficial and just skin); second-degree (involve perineal muscle – common repair to episiotomy); third-degree (involve anal sphincter; 3a = less than 50% sphincter, 3b = more than 50%, 3c = anal internal and external); fourth-degree (also mucosa)

Answer 435

abx after surgery, lactulose, high fibre diet, pelvic floor exercises and follow-up

Answer 436

to prevent 3rd degree and over tears and make larger opening (instrumental, distressed baby)

Answer 437

vaginal epithelium, perineal skin, bulbocavernous muscle, superficial and deep transverse perineal muscles; use lidocaine; repair go deep from mucosa stitched first, then muscle, then skin

Answer 438

• 6 weeks after delivery; uterus involutes form 1kg to 100g; afterpains as uterus contracts; cervix firm over 3 days; internal os closes over 3 days and external over 6; lochia (sloughed endometrium, red cells etc) passed is (rubra – blood cervical discharge, foetal membrane, vernix, meconium) then yellow to day 10 (serosa – cervical mucous, exudate, foetal membrane, micro-organisms, WBCs) then white to 6 weeks (alba – cholesterol, epithelial cells, fat, micro-organisms, mucous, leucocytes); breasts make milky white and colostrum from last trimester then tender and engorge 3-4 days after birth

Answer 439

thromboprophylaxis?, anti-D?, check temp, bp, breasts, legs, lochia (if red then could be endometritis), fundal height, pelvic floor exercises, vaccinate against rubella, HT may need drugs, check Hb, contraception

Answer 440

temp over 38 in first 2wks; examine fully; culture MSU, high vaginal swabs, blood, sputum; 90% urinary genital tract

Answer 441

lower abdo pain, offensive lochia, tender uterus, urgent abx (also for breast infection to stop abscess)

Answer 442

different to mild depression; high suicidal drive, severe depression, mania, schizophrenic behaviour with delusions; exclude infection causing delirium; will see by 3 months; sudden onset and rapid deteriorate; some mothers may also develop postnatal depression; refer to specialist psych ward

Answer 443

due to sudden hormonal and chemical changes in body and may seem like postnatal depression

Answer 444

feeling emotional, irritable, low mood, restless; not as severe as postnatal depression (lose interest in baby and withdraw etc)

Answer 445

see how mother related to baby; bp and weight; FBC if anaemic; cervical smear; contraception plans; ask about depression, incontinence, backache; intercourse? (gentle recommended so no air embolism); sexual problems common; dyspareunia complaints

Answer 446

breastfeeding delays ovulation (contraception); does this by decreasing freq and amount of gonadtrophin surges; lasts 6 months; contraceptive decrease if: breastfeeding decreases, periods start, night feeding stops, separation from baby, ill baby, baby gets supplements; when this happens give contraception

Answer 447

– can start at any time and no effect on baby; some can leak into breast milk; precautions if started after 21 days

Answer 448

start at 3 weeks if not breastfeeding; not recommended if breastfeeding til 6 months and affect early milk production

Answer 449

not recommended in those breastfeeding as can cause problems with liver and sex steroids

Answer 450

not recommended until 6wks in those breastfeeding; 21-28 wks in those breastfeeding

Answer 451

either within 48hrs or after 4wks to minimise uterine perforation

Answer 452

wait significant amount of time as need time to process if want it and more likely to fail

Answer 453

usually due to dehiscence (wound reopens) of CS scars

Answer 454

obstructed labour in multiparous, previous surgery, high forceps delivery, internal version, breech extraction

Answer 455

successful in 3/4s; less risk of neonatal resp problems; more risk of: endometritis, blood transfusion, uterine rupture, perinatal death; use CTG in labour

Answer 456

usually in labour; pain variable; vaginal bleeding variable; unexplained maternal tachycardia, sudden maternal shock, cessation of contractions, disappearance of presenting part, foetal distress; postpartum = PPH if uterus well-contracted, bleeding continuing after vaginal repair, shock

Answer 457

suspected = category 1 CS; O2 at 15L/min; IVI; crossmatch blood; repair if rupture small; may need hysterectomy; post-op abx cover

Answer 458

cyanosis, bronchospasm, pulmonary oedema, tachycardia when inhale gastric acid in general anaesthesia

Answer 459

preop H2 antagonists, sodium citrate, gastric emptying, cricoid pressure, endotracheal tubes, pre-extubation of stomach

Answer 460

tilt pt head down; aspirate pharynx; aminophylline and hydrocortisone; aspirate bronchial tree; abx prevent pneumonia; ventilation

Answer 461

FH, older mother, induced ovulation, IVF (more likely to also have: older mother, genetic defects, low birthweight, prematurity and vasa praevia), Nigerian

Answer 462

* Monochorionic – share placenta | * Monoamniotic – share amniotic sac

Answer 463

uterus large for gestational dates, hyperemesis, polyhydramnios, >2 poles felt, multiple foetal parts, 2 foetal hearts detected, US confirms, 11-13wks confirms mono/dichorionic

Answer 464

polyhydramnios, pre-eclampsia, anaemia, APH, abruption, placental praevia, GDM, PPH, malpresentation, vasa praevia rupture, cord prolapse and entanglement

Answer 465

higher mortality, prematurity (37 wks for twins and 33 for triplets), IUGR, malformation, placental vascular anastomoses (one twin donor and other recipient so one gets bigger than other, stopped by laser coagulation in utero)

Answer 466

US at 11-13 wks (viability, chorionicity, malformations, NT), consultant led; educate about preterm labour and more antenatal visits; more support and offer elective birth; selective reduction at 12wks from triplet to twins; identify risk of preterm by cervical length US

Answer 467

* Polyhydramnios – too much amniotic fluid; S+Ss = SOB, heartburn, constipation, swollen ankles; over 8cm in single deepest pocket * Oligohydramnios – too little amniotic fluid; IUGR and increased perinatal mortality risks; less than 500ml at 32-36wks; under 2cm in single deepest pocket

Answer 468

* Born dead after 24 weeks; mother may feel guilty, labour seem futile, sad * Macerated = skin has peeled in utero and looks different to fresh stillbirth

Answer 469

unknown, placental, ante-intrapartum haemorrhage, congenital abnormality, maternal disease, IUGR, mechanical; multiple, smoking, socioeconomic, higher age, IVF, obesity

Answer 470

absent foetal movements; no foetal HS on US; offer to call companion if alone; repeat US if mother requests

Answer 471

Rh-ve give anti-D; Kleihauer to see if fetomaternal haemorrhage; check temp, BP, proteinuria, blood clotting screen; advise delivery if complications (pre-eclampsia); allow home to reflect; check coagulopathy 2x weekly if not induced in 48hrs; use mifepristone oral to induce and prostaglandin vaginally; offer comfort and locks of hair and photos if she wants them; funeral etc; discuss future pregnancy at follow-up and cause if known; bereavement counsellor assigned; screen for depression

Answer 472

maternal = Kleihauer, FBC, CRP, LFT, HbA1c, cultures, viral screen (TORCH), thrombophilia, abs, MSU; foetal = swabs and placental, lithium heparin tube for cord blood infection, examine, post-mortem discussed with parents (if refused MRI, cytogenetics, tissue samples)

Answer 473

• Give 250u before 20 wks and 500u after; at 20 wks do Kleihauer test to check if feto-maternal haemorrhage; don’t give anti-D if know they are sensitised to them (abs present); if Rh-ve woman then give abs unless child is Rh-ve too; given in deltoid and also if big bleed

Answer 474

surgery, infections, AI, chemo, ovarian dysgenesis, metabolic diseases

Answer 475

vasomotor symptoms and menstrual irregularity (hot flushes, mood swings, urogenital atrophy [dyspareunia, recurrent UTIs, PMB], joint and muscle pain, low libido, irritable, low mood, loss of memory and conc, headaches, lethargy, loss of confidence); ends 12 months after last period

Answer 476

exclude cancer of endometrium and cervix

Answer 477

poorly oestrogenised vag wall, diverticular abscess

Answer 478

bimanual and speculum, cervical smear, transvaginal sonography (thick endometrium and fluid filled cavity = malignancy risk, hysteroscopy if >4mm, single bleeding episode)

Answer 479

mainly hot flushes and night sweats, vaginal atrophy, urinary problems (both from low oestrogen), dyspareunia/painful sex, itching, burning and dryness, loss of interest in sex and arousal from it; lower bone density and quality leading to fx (Colle’s, hip and spine), CVD risk, dementia increase, risks = parental hx, early menopause, use of corticosteroids, immobile, previous fx

Answer 480

FSH levels for ovarian reserve (higher = less eggs), vary daily in perimenopause so check in days 2-5; also antimullerian hormone; TFTs for HRT response; low progesterone = inovulation; DEXA

Answer 481

diet, exercise, HRT = oestrogen (oestradiol, oestrone, oestriol) for peeps with hysterectomy or progesterone (levonorgestrel and norethisterone) if not; topical on vag; tibolone = post-menopause for wanting amenorrhoea and vasomotor, psych and libido problems; testosterone for libido; progestogens with oestrogens so no endometrial hyperplasia (this is useful for perimenopause with menorrhagia or need contraception); oestrogen for hot flushes or progestogens, clonidine and SSRIs; HRT lowers risk spine, hip fx, colorectal cancer, increases risk breast cancer (oestrogen and progesterone), VTE, gallbladder disease, stroke, CVD; use for 5 yrs and evaluate and should use until median age of menopause; aim for lowest effective dose; try to avoid transdermal as worse risks (uses: gastric upset, migraine, epilepsy, high VTE risk)

Answer 482

alpha adrenergic receptor antagonist (clonidine), SSRI/SNRI, anti-epileptics (gabapentin), vit D, lubricants for vaginal dryness

Answer 483

2 years if menopause <50, 1 year if menopause >50yrs

Answer 484

If can get finger in os

Answer 485

uterus bleeding but foetus still alive

Answer 486

– fallopian tube the most common, then ampullary; consider when empty uterus but positive pregnancy test; usually static or slowly rising BcHG levels; can do salpingotomy (open up fallopian tube) to remove embryo; can treat with methotrexate if healthy woman

Answer 487

Ht, diabetes, epilepsy, RA, asthma, ITP, gastro, any disease, complications in current pregnancy, complications in previous pregnancy (3rd or 4th degree tear etc), issues with woman (high/low BMI, smoking, alcohol, drugs, old/young)

Answer 488

growth (head circ, abdo, full length and estimated weight), liquor volume (fluid around baby from urine), umbilical artery dopplers (look for placental insufficiency)

Answer 489

takes into acc symphysis fundal height, BMI, estimated foetal weight (form US) and plots this on graph to see what centile the woman is in

Answer 490

doppler US after each contraction in low risk women; every 15 mins in 1st stage and 5 mins in 2nd; can use a pinard stethoscope

Answer 491

5 things to check a baby’s health 1-5min of birth (appearance [body pink = 2], pulse [100bpm = 2], grimace [grimace/cough/cry = 2], activity [active motion = 2] and respiration [good cries = 2]); scored 0-2 for each

Answer 492

if risk of foetal compromise in labour; sensitive other than finding foetal hypoxia; either foetal scalp electrode (screw in direct contact with the foetus and much more accurate but need to rupture membranes; gold standard but rarely used) or abdo probe; indications = post-maturity, induction of labour, maternal cardiac problems, pre-eclampsia, prolonged ROM, dematurity, diabetes, haemorrhage, oligohydramnios, small, multiple, pyrexia etc

Answer 493

average foetal HR (100-160 = normal),

Answer 494

bandwidth of the baseline (>5 = normal)

Answer 495

upward spikes >15bpm for >15 secs (deceleration = opposite); how to correct = get weight off maternal vessels if lying supine, IV fluids if hypotensive, reduce oxytocin if too many contractions/bradycardia

Answer 496

use foetal blood sampling from scalp and analyse in blood gas machine, woman should be dilated 4cm and ROM, don’t do if suspected blood viruses, if it fails deliver asap; also looks at frequency of contractions

Answer 497

– define risk; contractions (bottom trace), baseline rate, variability (how squiggly bottom line is), accelerations, decelerations (timing based off when contraction occurs; early = usually head compression which is fine; variable = vary in shape and time and often cord compression; late = concerning as could be hypoxia), overall assessment

Answer 498

dies or delivers dead before 24wks; high rate when older mother

Answer 499

bleeding heavier and os open

Answer 500

some foetal parts passed and os open

Answer 501

= bleeding stopped, uterus not enlarged and os closed

Answer 502

uterus contents infected so endometritis (abdo pain and peritonism)

Answer 503

foetus not developed but not known until bleeding happens (how much, haemodynamically shock?, pain/bleeding worse than period, uterine size correct, what’s cause?)

Answer 504

US for >66% HCG with viable intrauterine pregnancy

Answer 505

IM ergometrine for bleeding, anti-D for rhesus -ve treated surgically, for non-viable use prostaglandin with oral mifepristone; surgery = ERCP with vacuum aspiration

Answer 506

haemolysis occurring; RBCs from rhesus positive foetus cross placenta in pregnancy and delivery to rhesus negative maternal blood circ; stimulate maternal abs

Answer 507

small foetal-maternal haemorrhage unrecognised; can get foetal anaemia in subsequent pregnancies as the abs go back into foetal circulation via placenta and haemolyse their Hb; excess bilirubin processed by placenta until birth and then stops so can cause jaundice at birth (high levels = brain damage);

Answer 508

hydrops fetalis and polyhydramnios in severe cases

Answer 509

O-ve blood transfusion, anti-d prophylaxis and ABO and RhD blood typing done

Answer 510

>3 in a row

Answer 511

antiphospholipid abs, chromosome defects, cervical incompetence, uterine abnormalities, obesity, smoking, PCOS, excess caffeine, older, infection (bacterial vaginosis);

Answer 512

thrombosis in uteroplacental with aspirin and low dose LMW heparin, few treatments, refer to specialist

Answer 513

legal limit (abortion act and human fertilisation and embryology act) 24wks but past this if grave risk of life to woman, severe foetal abnormality, injury risk; 2 doctors must sign

Answer 514

counselling, support, consent, abx prophylaxis; tests = hb, blood groups, rhesus, haemogoblinopathies, chlamydia

Answer 515

suction curettage 7-13wks; above 13 wks = dilation and evacuation, abx; <7wks = mifepristone with prostaglandin

Answer 516

haemorrhage, infection, uterine perforation, cervical trauma, failure

Answer 517

anti-D?, contraception, info on symptoms, refer if emotional/MH risk

Answer 518

older, lower socioeconomic, PID, previous ectopic, smoking, assisted conception, surgery, endometriosis, IUCD; mainly fallopians but also cervix, cornu, ovary, abdo; can rupture if thin-walled when trophoblastic invasion

Answer 519

abdo/vag bleeding, pain (colicky to constant), collapse, shoulder pain, intraperitoneal blood loss, pain of pelvis/uterus, closed os, amenorrhoea, diarrhoea, dizziness, collapse, normal sized uterus, peritonism

Answer 520

US not useful, serum hCG (slow rising levels), FBC, group and save, serum progesterone

Answer 521

blood cross matched, anti-D if needed, salpingectomy to remove tube or salpingostomy to take ectopic out of tube, methotrexate if no rupture and <3000IU/ml hCG; SEs = conjunctivitis, stomatitis, diarrhoea, abdo pain

Answer 522

severe N+V so severe dehydration, weight loss or electrolyte disturbance; more common in multiparous, won’t past 14wks

Answer 523

IV rehydration until can have oral then small regular meals, 1st line metoclopramide and cyclizine, if these fail ondansetron, sometimes steroids and psych

Answer 524

= premalignant hydatidiform mole, malignant conditions of choriocarcinoma, rare is placental site trophoblastic tumour (slow growing and after chemo is excised); sperm fertilises an empty ovum and proliferates without maternal DNA (there is mtDNA present) and aggressive proliferation of chorionic villi, hCG secreted; localised non-invasive = hydatidiform mole, complete is sperm fertilises empty oocyte (diploid), partial is 2 sperms into 1 oocyte (triploid or more – less malignant); only malignant if in uterus or metastasis

Answer 525

heavy, frequent vag bleeding, severe vomiting, early pregnancy failure, severe morning sickness; use US for snowstorm appearance and histology

Answer 526

older, Asian and previous mole

Answer 527

= can get huge theca-lutein cysts that can rupture and tort, hyperthyroidism

Answer 528

suction curettage of molar tissue; lower risk = methotrexate and folic acid, higher risk = combination chemo, avoid pregnancy and give anti-D if Rh-ve

Answer 529

years after pregnancy can be, malaise, uterine bleeding, mets, nodules on CXR, pulmonary artery obstruction from emboli causing PAH

Answer 530

combo chemo and specialist team, good outcome if no mets

Answer 531

primigravidity, young female, blacks, multifetal, hypertension, renal disease, collagen vascular disease

Answer 532

rise in bp (140/90 or higher) and proteinuria (0.3g/24hour or more or 2+ on urine dipstick; oliguria, 5+ proteinuria, impaired LFTs, thrombocytopenia, oedema all can mean severe), don’t necessarily need oedema; superimposed if new onset proteinuria after 20wks but already have HT; mild/moderate if without severe HT; early <34wks

Answer 533

the spiral artery to the endometrium/arcuate artery does not become dilated and low resistance so ischaemia, vasoconstriction, damage, less renal perfusion so increase in bp

Answer 534

maternal = death, CVA, elevated LFTs and low platelet count (HELLP), DIC, liver failure, renal failure, pulmonary oedema; child = IUGR, preterm, oligohydramnios, intrauterine foetal death

Answer 535

(usually only seen in severe) = visual, migraine, epigastric pain, maybe oedema and weight gain; physical = RUQ tenderness, retinal vasospasm/oedema, brisk reflexes, ankle clonus

Answer 536

FBC (platelets/Hb), serum uric acid, LFTs, protein, dipstick; not much antepartum management other than little activity

Answer 537

; cure = delivery but can harm the baby if premature; treatment = control bp and monitor 4 hourly (aspirin; severe = hydralazine and labetalol but avoid in asthma and CHF, oral nifedipine used with care), fluid balance, monitor foetus, anticonvulsants to prevent eclampsia (parenteral magnesium sulfate), deliver if >34wks if severe; delivery = vaginal preferable, epidural, spinal are advantageous, use hydralazine/labetalol to reduce HT

Answer 538

new HT 20wks after gestation; little/no proteinuria; ¼ develop pre-eclampsia; over 140/90 (increase each by 10mm/Hg each time for severity); check urine for proteinuria and give labetalol checking bp and urine 2x weekly; similar advice to chronic HT

Answer 539

have pre-eclampsia with generalised tonic-clonic seizures

Answer 540

use magnesium sulfate to prevent and treat and DR ABC (use calcium gluconate if toxicity); repeated seizures use diazepam; catheterise; monitor with CTG

Answer 541

before 20wk, increased risk of IUGR, pre-eclampsia, placental abruption (placenta comes away from walls of uterus before birth meaning O2 and nutrient deprivation); change ACEI, A2A blockers and thiazides to labetalol/methyldopa preconception

Answer 542

aim for bp <150/90, 75mg aspirin until birth, foetal US every 4wks from 28wks, arrange cardiotocography if abnormal (CTG – measures foetal heartbeat and uterine contractions)

Answer 543

monitor bp hourly, if severe and not controlled operative delivery and oxytocin only at 3rd labour stage

Answer 544

change methyldopa to other antihypertensive as risk post-natal depression, check bp for few days after, avoid diuretics if breastfeeding

Answer 545

haemolysis, elevated liver enzymes, low platelets

Answer 546

RUQ pain, N+V, dark urine; treat same as eclampsia

Answer 547

before 37wks, 259 days from LMP; low birth weight below 2500gm, very low 1500 and extremely low 1000

Answer 548

largest cause of perinatal death of normal foetuses, developmental delay, visual impairment, other diseases; improvements from: steroids, artificial surfactant, ventilation, nutrition, abx

Answer 549

spontaneous (cervical weakness, amnionitis, premature ROM) sometimes induced from medical disorders; multiple births and polyhydramnios increasing the stretch, any problems (abruption, infection, pre-eclampsia etc), uterine abnormalities, malignancy, UTIs

Answer 550

antepartum haemorrhage/vaginal bleeding, multiple babies, recurrent (race, previous preterm, genital infection [UTI, pyelonephritis, appendicitis], cervical weakness, socioeconomics), smoking, funnel present at cervix found on US

Answer 551

primary (stop smoking, prevent multiple, planned pregnancy), secondary (screening high risk), tertiary (quick dx, tocolysis (anti-contraction medication) and abx, corticosteroids)

Answer 552

persistent uterine activity, change in cervical dilatation and/or effacement; foetal fibronectin = protein found in choriodecidual interface, abnormal finding after 20wks, if found early could mean high chance of labour in 2wks but high false +ve rate

Answer 553

progesterone, cervical cerclage (stitch put in cervix to make opening smaller), manage RFs; management = assess symptoms, vaginal swabs and speculum (infections), gestational duration, cervical examination and US if less than 3cm dilated; find best delivery method; glucocorticoids for helping foetal surfactant production (betamethasone); magnesium sulfate (neuroprotective effect and help prevent cerebral palsy)

Answer 554

26degree temp, heat, food wrap bag and not dry; if older in towels, use cord delay clamping (3mins) to give more O2 and nutrients

Answer 555

treat cause; give corticosteroids; nifedipine only drug to show foetal benefit not tocolytics; check breech presentation, rule out PROM, foetal fibronectin and IV abx to stop infection

Answer 556

Cis = heart conditions, chorioamnionitis, foetal death, lethal abnormality condition needing immediate delivery or any other reason for allowing preterm birth; nifedipine is best for woman and less likely to affect foetus (resp depression)

Answer 557

low bp, headache, flushing, high pulse and risk of MI

Answer 558

rule out chorioamnionitis (expedite delivery if this is it) and sepsis; take temp, MSU and HVS (high vaginal swab); management = corticosteroids and erythromycin for foetal lung maturity; rupture usually starts labour but if not then monitor and don’t allow intercourse, swimming, tampons to prevent infection; if infection takes hold then IV abx and expedite

Answer 559

infection, preterm, pulmonary hypoplasia and limb contractures

Answer 560

chart using SFH and maternal age, parity, BMI, ethnicity, birthweights of previous children; doppler at 20-24wks if risk high

Answer 561

maternal age >40yrs; smoker; drugs; previous SGA; diabetes; hypertension; renal impairment; antepartum bleeding; pre-eclampsia; placental factors = abnormal trophoblast invasion (pre-eclampsia, infarction, abruption); foetal = genetic and congenital abnormalities, infections and multiple

Answer 562

intrapartum foetal distress, meconium aspiration, emergency C-section

Answer 563

estimated foetal weight or abdo circ <10th centile for gestational age

Answer 564

umbilical artery dopplers good then growth scans 2-3wks and if normal aim for IOL 37wks; if abnormal consider C-section; warm welcome for baby, feed within 2hrs birth

Answer 565

hypertension, coronary artery disease, T2DM, autoimmune thyroid disease

Answer 566

above 95 centile; obesity major cause; risk of shoulder dystocia, hypoglycaemia, hypocalcaemia, left colon disease (similar to Hirschsprung’s and gives temporary bowel obstruction)

Answer 567

• >42wks pregnancy

Answer 568

intrapartum death, early neonate death, placental insufficiency, induction of labour, macrosomia, shoulder dystocia, foetal injury, less mouldable skull (more ossified), more meconium passage, C-section

Answer 569

membrane sweep (get as much from vaginal exam when finger in cervix to stimulate natural prostaglandins and can stimulate natural labour), offer induction after 41wks but if refused monitor CTG 2x weekly

Answer 570

• DR ABC immediately (CPR in left lateral position); prioritise mother

Answer 571

FBC, U+Es, LFTs, coagulation, uric acid, group and save, ABG, CXR, ECG etc

Answer 572

* Obs causes – massive haemorrhage, eclampsia, intracranial haemorrhage, amniotic fluid embolism, uterine inversion causing neurogenic shock, severe sepsis, peripartum cardiomyopathy * Others – massive PE, pre-exisiting cardiac, anaphylaxis, stroke, meningitis, OD, DKA, malaria (abroad)

Answer 573

* Ask about domestic violence (can harm foetus and mother) * Causes – DANGEOUS = abruption, placenta praevia, vasa praevia (foetus can bleed out), UTERINE = circumvallate placenta, placental sinuses, LOWER GI = cervical polyps, erosions, carcinoma, cervicitis, vaginitis, vulval varicosities

Answer 574

part of placenta detaches from uterus; depends on detachment and blood loss

Answer 575

pre-eclampsia, smoking, IUGR, PROM, multiple etc; can cause placental insufficiency (foetal anoxia/death), blood constriction reduces contraction force, PPH

Answer 576

backache, abdo tenderness, uterine hypercontractility, DIC, renal failure, Sheehans, foetal heart abnormal, coagulation problems, pain, shock more than blood loss appears, tense uterus

Answer 577

placenta attaches in lower part of uterus that can cover cervix

Answer 578

no pain, shock in proportion to blood loss, uterus non-tender, small bleeds then large, abnormal lie, foetal heart normal, coagulation usually normal

Answer 579

IV infusion, bloods (clotting) and raise legs if severe; O2; catheterise; C-section for praevia and beware PPH; milder = IV, crossmatch, coagulation, U+Es, pulse, BP, blood loss check

Answer 580

• 37wks + rupture before labour

Answer 581

mostly unknown, lower GI infection, polyhydramnios, multiple, malpresentation

Answer 582

serious infection, chorioamnionitis, endometritis

Answer 583

conservative if up to 24hrs: liquor clear, mother well, foetus well; take temp reg and avoid sex; report abnormal changes to labour ward

Answer 584

not spontaneous within 24hours; • Usually for hypertension, pre-eclampsia, prolonged pregnancy or rhesus disease

Answer 585

use vaginal prostaglandin for 6 hours then oxytocin if no contractions; only use IV abx if infection found (HVS, MSU and cultures); monitor foetal heart if this declined

Answer 586

= group B strep carriers, HIV for vaginal delivery, chorioamnionitis, foetal movement concerns, herpes simplex, meconium-stained liquor

Answer 587

every hour up to 10; well-being, chest, nasal flare, cap refill, feeding, muscle tone, temp, resps, HR; monitor for sepsis

Answer 588

wrap baby to mum to: keep warm, stabilise HR and reduce stress

Answer 589

malpresentations, foetal distress, placental praevia, cord presentation, vasa previa, pelvic tumour

Answer 590

first pregnancy

Answer 591

cervical dilatation, length of cervix, station of head, cervical consistency, position of cervix; higher score = more favourable (>5 at least)

Answer 592

idiopathic, uterine abnormalities, premature, placenta praevia, oligohydramnios, foetal abnormalities

Answer 593

extended (flexed at hips but extended at knees), flexed (hips and knees flexed so presenting is buttocks and genitals), footling (greatest risk of cord prolapse)

Answer 594

usually during labour; pain under ribs, no head felt in pelvis and balloted at fundus; by US

Answer 595

manoeuvring breech into forward somersault but only do this if planned vaginal delivery after 36-37wks

Answer 596

placenta praevia, multiple, APH, ROM, IUGR, abnormal CTG, foetal abnormality, scarring uterine, pre-eclampsia/hypertension

Answer 597

try not to interfere til scapula present and keep spine anterior if you can; Mauriceau-Smellie-Veit manoeuvre to get out head or use forceps

Answer 598

mother has long anthropoid pelvis (50%) which is felt by palpation; labour prolonged because of degree of rotation needed (hydration and analgesia); most have normal vaginal delivery but some require forceps and C-section; feel posterior fontanelles in posterior of pelvis

Answer 599

from anencephaly, tumour of or shortened foetal neck muscles; head extends rather than flexes at breech; most rotate so chin behind symphysis and born by flexing; if chin rotates to sacrum then C-section; feel eyes and nose in early vaginal exam before oedema

Answer 600

diagnosed in early labour; halfway between flexion and extension; if persists then LSCS; feel anterior fontanelle and supraorbital ridges on vaginal exam

Answer 601

diagnosis = uterus wider than sides, lower pole empty, head in 1 flank, foetal heart heard various places; only feel ribs/shoulder/hand if ROM; if persists then C-section; risk of cord prolapse

Answer 602

• Cord through cervix after ROM before presenting part; emergency = cord compression and vasospasm means foetal asphyxia

Answer 603

2nd twin, footling breech, premature, polyhydramnios, unengaged head, transverse lie; carry out C-section

Answer 604

obvious if happened; vaginal exam; foetal bradycardia or heart decelerations

Answer 605

senior help and keep cord in vagina; stop presenting part occluding cord; either deliver by LSCS or instrumental if fully dilated; tocolytics like terbutaline o Steps – push up presenting part back in vagina during contractions; knee to chest position; 500mL saline into bladder and catheterise; tocolysis to reduce contractions o Delivery – best to do by ventouse/forceps/breech presentation if under 15mins; take pH and base excess from cord after

Answer 606

need obs manoeuvres to release shoulders in birth when gentle downward traction failed; high rate of foetal mortality and morbidity; risk of PPH, 4th degree perineal tears, brachial plexus injuries

Answer 607

large foetus, BMI>30, induction, oxytocin use, prolonged 1st/2nd stage, assisted vaginal delivery, previous hx, DM

Answer 608

speed to reduce asphyxiation risk (cord squashed); prompt shoulder dystocia drills; help (MDT), episiotomy (space for internal movements), legs (in McRoberts position so that each thigh touches abdomen to straighten sacrum, 90% effective), suprapubic pressure (apply steady rocking/traction to foetal head from mother’s sacrum to let anterior shoulder enter pelvis), enter the pelvis (help with rotating shoulders to oblique diameter; if fails switch posterior shoulder to anterior), roll (mother onto all fours if fails) o Other manoeuvres – maternal symphysiotomy, push baby back up by head to flexed occipito-anterior position and C-section (Zavanelli – usually severely acidotic baby at this stage); cleidotomy (cut through clavicles if baby dead before birth)

Answer 609

Erb’s palsy and fractured clavicles to baby

Answer 610

* Late pregnancy baby can pass some meconium staining amniotic dull green (insignificant); • During labour – fresh meconium passed (dark green, sticky, lumpy); may be a response to stress of normal labour (CTG and consultant-led care) * PROM with meconium stained – immediate induction and neonate support care

Answer 611

• Less than 2cm dilatation per 4 hours in 1st stage

Answer 612

review notes, examine abdo and contractions, foetal heart monitoring and amniotic colour, vaginal assessment, analgesia/rehydration, previous C-section (have to be careful with oxytocin for scars)

Answer 613

oxytocin and reassess in 4hours if ROM (offer epidural); consider LSCS if not working

Answer 614

non-infectious or infectious; maculopapular = rubella and parvovirus B19; also think of streptococcus, meningococcus, EBV, syphilis • In general – earlier the infection more likely to affect foetus

Answer 615

severe encephalitis and pneumonia in pregnancy; RNA paramyxovirus, droplet, v infectious; infectious 2-5 days before and after rash; S+Ss = fever, generalised maculopapular erythematous rash, Koplik’s spots, cough, coryza, conjunctivitis and corneal scarring

Answer 616

foetal loss and preterm; if rash 6 days before/after birth then give baby human normal globulin to stop neonatal subacute sclerosing panenecephalitis

Answer 617

childhood vaccination; spread by droplet and half asymptomatic; most dangerous to foetus in 1st 12wks; foetus features = cataracts, deafness, cardiac lesions, purpura, jaundice, hepatosplenomegaly, thrombocytopenia, cerebral palsy, microcephaly, foetal death

Answer 618

give TOP if found in 1st trimester

Answer 619

more motor and cognitive impairment; impairments = IUGR, microcephaly, hepatosplenomegaly, thrombocytopenia, jaundice

Answer 620

similar symptoms to glandular fever; S+Ss = fever, rash, eosinophilia; complications to foetus = similar to above

Answer 621

spiramycin in mothers and pyrimethamine if foetus is infected, prednisolone in baby if infected; prevention = avoid raw meat, cat litter and sheep

Answer 622

droplet; S+Ss = slapped cheek rash, maculopapular rash, fever, arthralgia; complications = foetal erythropoiesis and cardiac toxicity (cardiac failure and foetal hydrops);

Answer 623

monitor for anaemia and treat

Answer 624

neonate S+Ss = rhinitis, snuffles, rash, hepatosplenomegaly, jaundice, ascites, hydrops, nephrosis, deaf, meningitis

Answer 625

benzylpenicillin

Answer 626

S+Ss = fever, shivering, myalgia, headache, sore throat, vomiting, cough, diarrhoea, vaginitis, miscarriage and stillbirth; infection from milk and soft cheese

Answer 627

bloods, meconium, blood cultures

Answer 628

ampicillin and gentamicin

Answer 629

leucopenia, rashes, fever, conjunctivitis, fits, resp distress

Answer 630

neonates get chronic infection and hepatocellular cancer risk

Answer 631

give immunoglobulin and vaccinate

Answer 632

complications = blindness, LD, epilepsy, jaundice, resp distress, DIC; if in last trimester give acyclovir/valaciclovir and elective C-section; foetus = conjunctival lesions and pustules on area of trauma from birth

Answer 633

give baby varicella immune immunoglobulin and deliver baby after 7 days if get near due date; if before then give oral acyclovir; test all women not had chickenpox before

Answer 634

low birthweight, premature membrane rupture, death, pneumonitis, pharyngitis, conjunctivitis

Answer 635

cleanse eye and erythromycin and same to mother

Answer 636

lid swelling, purulent discharge, corneal rupture

Answer 637

cefotaxime, chloramphenicol eye drops

Answer 638

pneumonia, meningitis and septicaemia in newborn

Answer 639

in labour give abx = high GBS vaginal swab, previous GBS baby, gestation <37wks, any fever; treat = benzylpenicillin and clindamycin if allergic

Answer 640

give phototherapy as can break up the bilirubin (baby cannot do this themselves)

Answer 641

* Big cause of maternal death and mainly strep A; better survival if found early * Sepsis – infection plus systemic infection manifestations; severe = sepsis with organ dysfunction or tissue ischaemia; shock = persistent tissue ischaemia with fluids

Answer 642

obesity, diabetes, immunosuppressed, anaemia, vaginal discharge, invasive procedures, cervical cerclage, ethnicity, prolonged ROM

Answer 643

fever, rigors, diarrhoea, vomiting, rash (maculopapular), abdo/pelvic pain, offensive vaginal discharge, cough, urinary symptoms

Answer 644

>38degrees or <36; tachypnoea, systolic hypotension, confusion, significant oedema, hyperglycaemia, raised WCC, raised lactate • SEPSIS 6

Answer 645

Iv broad spectrum abx; fluids; vasopressors to combat hypotension; oxygen; immunoglobulin against strep; can mean preterm labour so notify neonatal; avoid epidural/spinal anaesthesia, pyrexia means foetus degree hotter and tachycardia

Answer 646

period 6wks after birth where mother returns to prepregnant state; if sepsis here then investigate and genital tract, uterus leading to endometritis may be or mastitis and breast abscess; features = fever, rigors, diarrhoea, breast engorgement, abdo pain, offensive vaginal discharge, cough, urinary symptoms, lethargy, reduced appetite

Answer 647

triad of abdo pain, uterine rigidity and vaginal bleeding; painful bleeding (dark blood), shock in proportion to blood loss, uterus tender and contracting (filled with blood so woody uterus)

Answer 648

uterus rotates >90degrees, abdo pain, shock, tense uterus and urinary retention

Answer 649

Abruption, uterine rupture, fibroids, torsion, appendicitis, cholecystitis (commoner as biliary stasis and more cholesterol; subcostal pain, nausea, vomiting; only surgery in complicated), pancreatitis, UTI, gastroenteritis (common and can be severe; manage at home if can; rehydration and rest)

Answer 650

gestational hypertension, pre-eclampsia, GDM, VTE, miscarriage, stillbirth and others

Answer 651

5mg folic acid 1month before conception and first trimester; give vit D, glucose tolerance test, mobilise; if over 40 then heparin and TED stockings

Answer 652

• Every woman should have VTE risk assessment at booking; avoid immobility and dehydration

Answer 653

venous stasis, trauma to pelvic veins at delivery, procoagulant changes (high fibrinogen and factors 10 and 9, less anticoagulation) and these changes from 1st trimester til 6wks postpartum

Answer 654

LMWH drug of choice and given until 6wks postpartum and depends on bodyweight

Answer 655

hx of VTE, antithrombin 3 deficiency

Answer 656

thrombophilia, medical comorbidities (cancer, inflammatory, resp), over 35yrs, obesity, parity 3+, smoker, varicose, current infection, pre-eclampsia, immobility, dehydration, multiple, assisted reproduction

Answer 657

tendency to increased clotting

Answer 658

factor 5 leiden, protein c deficiency, protein s deficiency, antithrombin 3 deficiency, acquired thrombophilia; screen women who’ve had previous VTE or FH

Answer 659

leg swelling, pain, redness, tenderness, pyrexia, erythema, oedema, WBC can be raised

Answer 660

SOB, chest pain, haemoptysis, collapsed, raised JVP, DVT S+Ss, raised resp, hypoxic, severe = low resp and cardiac arrest

Answer 661

FBC, U+Es, LFTs, clotting screen, ABG, ECG, CXR, compression/duplex US and -ve = LMWH and do V/Q scan, D-dimers less effective but if low not likely to be VTE

Answer 662

massive PE in pregnancy use thrombolysis or percutaneous catheter thrombus fragmentation, embolectomy only can be done in certain specialist areas, LMWH (enoxaparin/dalteparin BD) safer but may have to use unfractionated heparin afterwards, continue this 6months and then 6wks postpartum or switch to warfarin; if in labour LMWH stopped (avoid anaesthesia til 12 hours after last dose), may have to use unfractionated heparin if high risk

Answer 663

cutting diathermy, glycine irrigation

Answer 664

macroscopic pelvic disease, dysmenorrhoea, infertility, ectopics assessments or to sterilise, remove adhesions or remove ectopics

Answer 665

– for menstrual disorders, fibroids, endometriosis, chronic PID, prolapse, pelvic malignancy; involves removing uterus and cervix in total but keep cervix in subtotal; vaginal for prolapse; radical for 1a-2a cervical carcinoma (parametrium, upper third vagina, pelvic lymph nodes)

Answer 666

sudden onset unilateral lower abdo pain from exercise and also N+V/adnexal mass

Answer 667

unilateral dull ache and worse on sex

Answer 668

BMI 20-25, folic acid, sex 2-3x per week, quit smoking/drinking

Answer 669

pain halfway through ovulation cycle

Answer 670

adhesions/fibrosis of endometrium, associated with dilation and curettage of uterus

Answer 671

hypopituitarism from ischaemic necrosis from blood loss/hypovolaemia in or after childbirth

Answer 672

ascites, pleural effusion, ovarian fibroma

Answer 673

onset at 30, asymptomatic and bilateral; mucinous cystadenoma can mean pseudomyxoma peritonei if rupture

Answer 674

any procedure that partially or fully removes or injures female external genitalia, interferes with natural function of women’s bodies

Answer 675

* Type 1 – partial/total removal of clitoris (clitoridectimy) * Type 2 – partial/total removal of clitoris and labia minora (excision) * Type 3 – narrowing of vaginal orifice by cutting and positioning labia minora and/or majora with/without clitoris excision (infibulation) * Type 4 – other if not medical or cosmetic (pricking, piercing [if under 18yrs], incision, scraping, cauterising)

Answer 676

status and respect, keeps chastity, upholds family honour, tradition rather than religion, social acceptance and belonging to community; mainly in African (central and eastern countries), Middle East and South-East Asian countries

Answer 677

illegal to perform and assist FGM and take child overseas to do this; recording mandatory requirement (if found in a pt, reported to safeguarding only if over 18yrs and must report to police if under 18 the next day)

Answer 678

dyspareunia, sexual dysfunction (anorgasmia or androgen insensitivity syndrome [genetically male but genitals may be female or somewhere between, doesn’t respond to testosterone efficiently]), chronic pain, keloid scar formation, dysmenorrhoea, urinary outflow obstruction, PTSD, difficulty conceiving, blood loss, sepsis, tetanus, hepatitis, HIV

Answer 679

childbirth fear, C-section needed, PPH risk, episiotomy needed, vaginal lacerations and vaginal fistula, long hosp stay, difficulty performing vaginal exams, difficulty for FSE, difficulty for foetal blood sampling, difficulty catheterising

Answer 680

• Reversal of infibulation – ideally preconception; use a small dilator and cut fused labia with diathermy then suture edges; may need episiotomy if have to reverse infibulate during labour (wait until crowning to do this procedure); can offer epidural

Answer 681

4 every 10-15 mins

Answer 682

Extended breech

Answer 683

need power of contractions, passenger to be right size and passage to be large enough

Answer 684

IV infusion of oxytocin

Answer 685

• Meconium is the newborn’s first poo made of bile, cells etc (better to poo outside uterus than in)

Answer 686

bdominal shape: this may give an initial indication of the fetal lie. Fetal movements: these are typically visible from 24 weeks gestation. Surgical scars: may provide clues regarding previous abdominal surgery (e.g. caesarian section). Linea nigra: a dark line running vertically down the middle of the abdomen (a normal finding in pregnancy). Striae gravidarum: reddish or purple lesions that develop due to overstretching of the abdominal skin as the gravid uterus expands (commonly referred to as stretch marks). Striae albicans: mature stretch marks which appear silver-like in colour and are less pronounced.

Answer 687

12 weeks gestation: pubic symphysis 20 weeks gestation: umbilicus 36 weeks gestation: the xiphoid process of the sternum

Answer 688

Longitudinal lie: the head and buttocks are palpable at each end of the uterus. Oblique lie: the head and buttocks are palpable in one of the iliac fossae. Transverse lie: the fetus is lying directly across the uterus.

Answer 689

The fetal head is divided into fifths when assessing engagement: If you are able to feel the entire head in the abdomen, it is five fifths palpable (i.e. not engaged). If you are not able to feel the head at all abdominally, it is zero fifths palpable (i.e. fully engaged).

Answer 690

distance between the fundus and the upper border of the pubic symphysis. After 20 weeks gestation, the symphyseal-fundal height should correlate with the gestational age of the fetus in weeks (+/- 2cm).

Answer 691

Ulcers: typically associated with genital herpes. Abnormal vaginal discharge: causes include candidiasis, bacterial vaginosis, chlamydia and gonorrhoea. Scarring: may relate to previous surgery (e.g. episiotomy) or lichen sclerosus (destructive scarring with associated adhesions). Vaginal atrophy: most commonly occurs in postmenopausal women. White lesions: may be patchy or in a figure of eight distribution around the vulva and anus, associated with lichen sclerosus. Masses: causes include Bartholin’s cyst and vulval malignancy. Varicosities: varicose veins secondary to chronic venous disease or obstruction in the pelvis (e.g. pelvic malignancy).

Answer 692

Position (e.g. anterior or posterior) Consistency (e.g. irregular, smooth) Cervical motion tenderness: involves severe pain on palpation of the cervix and may suggest pelvic inflammatory disease or ectopic pregnancy.

Answer 693

Size: the uterus should be approximately orange-sized in an average female. Shape: may be distorted by masses such as large fibroids. Position: the uterus may be anteverted or retroverted. Surface characteristics: note if the uterus feels smooth or nodular. Tenderness: may suggest inflammation (e.g. pelvic inflammatory disease, ectopic pregnancy).

Answer 694

Day 21 of menarche

Answer 695

premenopausal oestrogen 15-350 pg/mL, progesterone while ovulating (luteal stage of cycl) = 2–25 ng/mL, testosterone = 15 to 70 nanograms per deciliter (ng/dL), Mid-cycle peak = FSH is 4 – 25 and LH is 10 - 75

Answer 696

haemolysis, elevated LFTs and low platelet count

Answer 697

Placental insufficiency

Answer 698

Sytocinon, tranexamic acid and misoprostol

Answer 699

Stromal cells grow, glands swell, blood supply increases in endometrium

Answer 700

23-35 days

Answer 701

decrease in placental hormones (human placental lactogen, hcg, oestrogen, progesterone) and increase in prolactin

Answer 702

in colostrum more, regulates iron absorption in intestines and delivery or iron to cells; protection against bacterial infection, some viruses, fungi; helps regulate bone marrow function; boosts immune system

Answer 703

minor = infection, PPH, fatigue, anaemia, backache, mastitis, stress incontinence, haemorrhoids, constipation, the blues; major = sepsis, severe PPH, pre-eclampsia, thrombosis, uterine prolapse, incontinence, post-dural puncture headache, breast abscess, depression/psychosis

Answer 704

obesity, diabetes, anaemia, amniocentesis, prolonged ROM, vaginal trauma, BAME

Answer 705

endometritis, skin/soft tissue infection, mastitis, UTI, pneumonia, gastroenteritis, pharyngitis, infection from epidural/spinal

Answer 706

<36/38< temp, HR >90bpm, resp rate >20bpm, WCC >12/<4 x 10^9/l, hyperglycaemia >7.7mmol/L

Answer 707

BUFALO (Bloods culture, Urine output, Fluid resus, Abx, Lactate, Oxygen) plus delivery (ERCP) and VTE prophylaxis

Answer 708

With clinical shock or 1500+mls

Answer 709

Headache, neck stiffness, photophobia, recent epidural/spinal

Answer 710

Lie flat, simple analgesia

Answer 711

abrupt onset/aching or not of able to micturate needing catheter 12hours after birth or not able to spontaneously void within 6hours of vaginal delivery

Answer 712

Mood and suicide

Answer 713

Seen on MRI and painful and menorrhagia

Answer 714

Usually hysterectomy but can manage with HRT/GnRH

Answer 715

Torsion of the pedicles (also have pain)

Answer 716

o -1 next to the parity number is a stillborn after 24 wks | o For twins would be G1P2

Answer 717

Cusco and Sims (for prolapse)

Answer 718

placental problem; normally spiral arteries dilate 10x at 20wks so more perfusion to baby; pre-eclampsia incomplete trophoblastic invasion of spiral arteries so arteries become fibrous and narrow, less placental perfusion so placenta releases pro-inflammatory proteins which go into mum’s circ that causes vasoconstriction and endothelial damage, vasospasm leads to glomerular damage leading to proteinuria (hypertension with proteinuria)

Answer 719

hypertension and endothelial damage leads to liver swelling and damage causing capsule to stetch causing pain (RUQ pain)

Answer 720

endothelial damage causing platelets used up to adhere to damage, haemolysis from clotting and RBC death at sites of damage, elevated liver enzymes from liver damage

Answer 721

from endothelial damage so tissue fluid leaks out to hands and feet and face

Answer 722

170/110 bp or proteinuria above 30

Answer 723

complete = over the os, partial = partially over the os, marginal = 2cm of the os (but at least 4cm for vaginal delivery)

Answer 724

Syntometrine and fundal pressure to stimulate uterine involution

Answer 725

tissue [bit of placenta left], trauma [during birth], tone [not complete uterine involution], thrombin [clotting disorders]

Answer 726

parasympathetic for voiding and sympathetic prevent it

Answer 727

Overflow and fistula formation

Answer 728

12+ hours of no micturition

Answer 729

detrusor inactivity or urethral obstruction

Answer 730

Chocolate-coloured and can be painful if ruptured

Answer 731

Adhesiolysis

Answer 732

menstrual disorder, previous PID/STI, previous abdo surgery, abnormal pelvic surgery, >35yrs

Answer 733

Folic acid, stop smoking and drinking alcohol, have medical condition under control, BMI under 35, avoid contact with toxic substances, up to date with vaccinations and discuss current medications

Answer 734

may have vaginal spotting, more discharge, pelvic pain, cervical mucous usually acellular and ‘fern’ on a dry slide, body temp drops; LH surge tester kits and high serum progesterone

Answer 735

Increased free serum androgens

Answer 736

multiple pregnancy, ovarian hyperstimulation syndrome and ovarian/breast carcinoma

Answer 737

Superovulation and pregnancy complications

Answer 738

risk of pregnancy per 100 women years using a contraceptive

Answer 739

before age of 40; can be due to infections, surgery, AI, ovarian dysgenesis and metabolic diseases

Answer 740

bisphosphonates (alendronate), strontium ranelate for hip fx, raloxifene for prevention spinal fx, parathyroid hormone peptides prevention vertebral fx, denosumab reduces osteoclast activity and for CI in bisphosphonates and stops fx, calcium and vit D

Answer 741

Head more than 2/5ths palpable

Answer 742

110-160bpm

Answer 743

50mls+ blood loss

Answer 744

12wks gestation

Answer 745

maternal levels of alpha fetoprotein often raised

Answer 746

chorionic gonadotrophin beta subunit (B-hCG), pregnancy-associated plasma protein A (PAPP-A), AFP, oestriol, inhibin A

Answer 747

the space between skin and soft tissue over the cervical spine (larger = more likely to have structural damage)

Answer 748

free loops of bowel in amniotic cavity, more common in young mother

Answer 749

extra fluid accumulates in 2 or more areas of foetus

Answer 750

abs causing anaemia, chromosomal abnormalities, structural abnormalities, cardiac abnormalities, anaemia, twin-twin transfusion syndrome

Answer 751

CMV IgM blood test

Answer 752

chorioamnionitis with abdo pain diarrhoea, severe sepsis all in puerperium

Answer 753

Before 16wks

Answer 754

ACEi and warfarin

Answer 755

Foetal RBCs enter maternal bloodstream and mother's abs attack and destroy them (rhesus disease of the newborn)

Answer 756

[positive feedback from presenting part onto cervix stimulating more oxytocin], longitudinal fibres down the uterus when contracts pulls fundus to cervix causing it to efface and dilate

Answer 757

progress of labour measured by ischial spines which is 0 and if below is +cms and above is -cms

Answer 758

Bits between skull bones, occiput and bregma

Answer 759

occiput posterior or occiput anterior (best one) or occiput transverse (worst one)

Answer 760

Metronidazole

Answer 761

CTG, foetal fibronectin, transvaginal scanning for cervical length, vaginal swabs for infection and CRP

Answer 762

bleeding from genital tract >24wks gestation

Answer 763

CTG and US for foetus; FBC, coagulation, group and save, catheterisation with urine output, U+Es, CVP monitoring for mother

Answer 764

IV fluids with steroids if preterm, anti-D, opiate analgesia sometimes, C-section if distress, monitor with CTG and amniotomy if after 37wks

Answer 765

chronic and situation where conditions for foetus are not optimal (poor nutrient transfer, IUGR etc)

Answer 766

Bhcg produced preventing sloughing off of endometrium, eventually the Bhcg is produced by placenta to take over it’s role

Answer 767

limb movements, tone, breathing movements, liquor volume

Answer 768

Caucasians, obese, low liquor volume

Answer 769

division in monozygotic twins after day 3 of fertilisation

Answer 770

after day 9

Answer 771

incomplete division (after day 13)

Answer 772

unequal blood distribution in shared placenta so donor develops anameia, IUGR, oligohydramnios; recipient polycythaemia, cardiac failure, polyhydramnios

Answer 773

inlet is transverse and passenger needs to transverse, mid-cavity is round and needs to be cephalic, outlet is round but in a different plane and foetus head needs to rotate to 90 degrees

Answer 774

head has occiput, vertex and then bregma from posterior to anterior

Answer 775

pink/white mucous plug

Answer 776

outlet too small for the head; retrospective diagnosis usually; no inadequate uterine contractions, no malpresentation

Answer 777

pH of <7.2 on foetal scalp

Answer 778

or meconium stained liquor [pea-soup], abnormal HR patterns from pinard/hand-held doppler, CTG, foetal blood sampling for pH

Answer 779

>5 per 10 mins

Answer 780

Postpartum thyroiditis

Answer 781

within 7 days of delivery

Answer 782

within 28 days of delivery

Answer 783

death during pregnancy or within 42 days of cessation, late can be when until a year after

Answer 784

if mental capacity can consent under 16yr old child to contraception without parents involvement if asked them to involve parents, danger to themselves and would keep having sex

Answer 785

is the same as fraser but for general medical procedures

Answer 786

Na+; 30-50% more plasma (1-2L), increase in renin-angiotensin aldosterone system; not fully understood why increases; lower threshold for thirst

Answer 787

lower plasma osmolality and lower plasma oncotic pressure (oedema in ankles etc)

Answer 788

compression of ureters as dilate (hydronephrosis and urinary stasis)

Answer 789

polyp, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory, endometrial, iatrogenic, not classified

Answer 790

Pruritus (palms, soles, abdo), raised bilirubin and jaundice in 20%; 37-38wks induction of labour, vit K, ursodeoxycholic acid

Answer 791

OC pill and smoking

Answer 792

Pyrimethamine and sulphadiazine

Answer 793

Metronidazole

Answer 794

Clarithromycin

Obs and gynae Flashcards

(827 cards)