OBS AND GYNAE Flashcards
(285 cards)
1
Q
how should medical abortion before 10 weeks be conducted?
A
- interval treatment (usually 24 to 48 hours) with mifepristone and misoprostol
- For women who are having a medical abortion up to and including 9+0 weeks’ gestation, give them the choice of having mifepristone and vaginal misoprostol
2
Q
how should medical abortion between 10+1 and 23+6 weeks be conducted?
A
-200 mg mifepristome, offer an initial dose (36 to 48 hours after the mifepristone) of:
-800 micrograms of misoprostol given vaginally, or
600 micrograms of misoprostol, given sublingually, for women who decline vaginal misoprostol.
-Follow the initial dose with 400 microgram doses of misoprostol (vaginal, sublingual or buccal), given every 3 hours until expulsion.
3
Q
how should medical abortion after 23+6 weeks be conducted?
A
- between 24+0 and 25+0 weeks’ gestation, consider 200 mg oral mifepristone, followed by 400 micrograms misoprostol (vaginal, buccal or sublingual) every 3 hours until delivery.
- between 25+1 and 28+0 weeks’ gestation, consider 200 mg oral mifepristone, followed by 200 micrograms misoprostol (vaginal, buccal or sublingual) every 4 hours until delivery.
- after 28+0 weeks’ gestation, consider 200 mg oral mifepristone, followed by 100 micrograms misoprostol (vaginal, buccal or sublingual) every 6 hours until delivery.
4
Q
what are the clinical features of adenomyosis?
A
-painful, regular, heavy menstruation
5
Q
what investigations should be conducted to diagnose adenomyosis?
A
- TVS
- MRI
6
Q
how is adenomyosis treated?
A
- Consider an LNG-IUS as the first treatment
- tranexamic acid
- NSAIDs
- combined hormonal contraception
- cyclical oral progestogens.
- second-generation endometrial ablation
- hysterectomy.
7
Q
define primary amenorrhoea
A
- the failure to establish menstruation
- by 15 years of age in girls with normal secondary sexual characteristics (such as breast development)
- by 13 years of age in girls with no secondary sexual characteristics.
8
Q
what are the causes of primary amenorrhoea with normal secondary sexual characteristics?
A
- physiological causes
- genito-urinary malformations (such as imperforate hymen, transverse septum, and absent vagina or uterus)
- endocrine disorders (such as hypothyroidism, hyperthyroidism, hyperprolactinaemia, and Cushing’s syndrome).
9
Q
what are the causes of primary amenorrhoea with no secondary sexual characteristics?
A
- primary ovarian insufficiency (POI) due to chromosomal irregularities (for example, Turner’s syndrome)
- hypothalamic-pituitary dysfunction (for example, due to stress, weight loss, and/or excessive exercise [functional hypothalamic amenorrhoea]).
10
Q
how is primary amenorrhoea caused by functional hypothalamic-pituitary dysfunction managed?
A
- For weight-related amenorrhoea, encourage weight gain and refer to a dietician if necessary.
- For exercise-related amenorrhoea, advise reducing exercise, increasing calorie intake, and weight gain.
- For stress-related amenorrhoea, consider measures to manage stress and improve coping strategies, such as cognitive behavioural therapy.
11
Q
define secondary amenorrhoea
A
- the cessation of menstruation for 3–6 months in women with previously normal and regular menses, or for 6–12 months in women with previous oligomenorrhoea.
12
Q
what are the causes of secondary amenorrhoea?
A
- pregnancy, lactation and menopause
- hypothalamic dysfunction
- ovarian insufficiency
- PCOS
- cushings
- CAH
- androgen secreting tumours
13
Q
what are the clinical features of placenta praaevia?
A
-intermittent painless bleeds
14
Q
what are the clinical features of placenta percreta?
A
- haematuria
- blood PR
15
Q
how is placenta praaevia diagnosed?
A
-TVS
16
Q
how is placenta praaevia managed?
A
- Late preterm (34+0 to 36+6 weeks of gestation) delivery should be considered for women presenting with placenta praevia or a low‐lying placenta and a history of vaginal bleeding or other associated risk factors for preterm delivery
- For women presenting with uncomplicated placenta praevia, delivery should be considered between 36+0 and 37+0 weeks of gestation.
- In the absence of risk factors for preterm delivery in women with placenta accreta spectrum, planned delivery at 35+0 to 36+6 weeks of gestation provides the best balance between fetal maturity and the risk of unscheduled delivery
- delivery must be by c-section
17
Q
how is haemorrhage associated with placenta praaevia managed?
A
- pharmacological measures
- intrauterine tamponade and/or surgical haemostatic techniques
- Interventional radiological techniques should also be urgently employed where possible.
- Early recourse to hysterectomy is recommended if conservative medical and surgical interventions prove ineffective.
18
Q
what are the clinical features of endometriosis?
A
- Dysmenorrhoea
- Chronic or cycling pelvic pain
- Dyspareunia
- Subfertility
- Uterosacral ligament nodularity
- Fixed retroverted uterus
- Dysuria, flank pain and haematuria
- Dyschezia and haematochezia
19
Q
how is endometriosis diagnosed?
A
- TVS
- gold standard is diagnostic laparascopy
20
Q
what is the medical management of endometriosis?
A
- NSAIDs and paracetamol
- COC in tricycling regime
- POP on a cyclical or continuous basis or mirena coil
- GnRH agonists
21
Q
what is the surgical management of endometriosis?
A
- see and treat during diagnostic lap
- removal of endometriomas
- hysterectomy with bilateral salpingo-oophorectomy
22
Q
What increase in HCG in a pregnancy of unknown location is suggestive of developing intrauterine pregnancy?
A
63%
23
Q
what are the clinical features of an ectopic pregnancy?
A
- Abdominal pain
- Amenorrhoea
- Scanty, dark vaginal bleeding
- Collapse
- Shoulder tip pain
- Tachycardia and haemodynamic instability
- Rebound tenderness
- Cervical motion tenderness
24
Q
how is ectopic pregnancy diagnosed?
A
- TVS
- Serum hCG: >1000 and not visible on USS, and hCG will plateau or decrease
25
Which patients can have expectant management for ectopic pregnancy?
- clinically stable and pain free
- tubal ectopic pregnancy measuring less than 35 mm with no visible heartbeat on transvaginal ultrasound scan,
- serum hCG levels of 1,000 IU/L or less
- able to return for follow-up.
- repeat hCG levels on days 2, 4 and 7 after the original test
26
what is the medical management for ectopic and who should it be offered to?
- systemic methotrexate
- no significant pain
- an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat
- a serum hCG level less than 1500 IU/litre
- do not have an intrauterine pregnancy (as confirmed on an ultrasound scan)
- able to return for follow-up.
27
who should be offered surgical management of an ectopic pregnancy?
- significant pain
- adnexal mass 35mm or larger
- fetal heartbeat on USS
- hCG >5000
28
what are the risk factors for placental abruption?
- IUGR
- Pre-eclampsia
- autoimmune disease
- maternal smoking
- cocaine
- Previous history
- multiple pregnancy
- non-vertex presentations
- polyhydramnios
- advanced maternal age
- low BMI
- assisted reproductive techniques
- intrauterine infection
- high parity
29
what are the clinical features of placental abruption?
- painful, dark bleeding
- tachycardia
- woody hard uterus
- fetal distress
30
how is placental abruption managed?
- manage APH
- if foetal compromise, c-section
- ergometrine-oxytocin in third stage of labour
31
how is vasa praaevia managed?
- if confirmed, elective c-section prior to onset of labour
- if VP with PROM, c-section
- if asymptomatic, planned c-section at 34-36 weeks gestation
32
what is primary dysmenorrhoea?
-painful menstruation occurs in the absence of any identifiable underlying pelvic pathology.
33
what is secondary dysmenorrhoea?
-painful menstruation caused by pelvic pathology
34
what are the clinical features of primary dysmenorrhoea?
- onset 6-12 months after menarche
- Pain, usually cramping in nature, occurs in the lower abdomen but may radiate to the back and inner thigh.
- Pain starts shortly before the onset of menstruation and lasts for up to 72 hours, improving as the menses progresses.
- Non-gynaecological symptoms, such as nausea, vomiting, diarrhoea, fatigue, irritability, dizziness, bloating, headache, lower back pain, and emotional symptoms, are present.
35
what are the clinical features of secondary dysmenorrhoea?
- Pain starts after several years of painless periods.
- Pain is not consistently related to menstruation alone but is exacerbated by menstruation.
- Other gynaecological symptoms, such as dyspareunia, vaginal discharge, menorrhagia, intermenstrual bleeding, and postcoital bleeding.
- Non-gynaecological symptoms, such as rectal pain and bleeding (which may be associated with endometriosis).
36
how is primary dysmenorrhoea managed?
- NSAIDs and paracetamol
- COC pill, POP, P injection or IUS
- heat and TENS
37
how is a breech presentation managed?
- ECV from 37 weeks
- c-section
- vaginal breech birth
38
what are the contraindications to ECV?
- foetal compromise
- other contraindications to vaginal delivery
- twins
- ruptured membranes
- recent APH
39
what are the risk factors for hyperemesis gravidarum?
- Family or previous personal history
- Multiple gestation
- Gestational trophoblastic disease
- Thyroid disease
40
what is seen on investigation in hyperemesis gravidarum?
- ketonuria
- dehydration
- hypo/hyperkalaemia
- hyponatraemia
41
how is hyperemesis gravidarum managed?
- IV rehydration with NaCl and KCl
- anti-emetics such as cyclizine, promethazine or prochlorperazine
- ondansetron and metoclopramide are second line
- thiamine supplementation
- corticosteroids if severe
42
what are the clinical features of gestational trophoblastic disease?
- Large uterus
- Heavy vaginal bleeding
- Exacerbated symptoms of pregnancy
- Hypertension
- Pelvic pain
- Hyperemesis
- Early pre-eclampsia and hyperthyroidism may occur.
43
what is seen on TVS in a complete molar pregnancy?
-snowstorm’ appearance of the swollen villi
44
how is gestational trophoblastic disease managed?
- ERPC
- Chemotherapy according to the FIGO 2000 system:
---6 or less, IM MTX with folowinic acid
---7 or more IV MTX, dactinomycin, etoposide, cyclophosphamide and vincristine
45
define miscarriage
foetus dies or delivers dead before 24 completed weeks of pregnancy.
46
define threatened miscarriage
-There is bleeding but the foetus is still alive, the uterus is the size expected from the dates and the os is closed.
47
define inevitable miscarriage
- Bleeding is usually heavier
| - Although the foetus may still be alive, the cervical os is open
48
define incomplete miscarriage
-Some foetal parts have been passed, but the os is usually open
49
define complete miscarriage
- All foetal tissue has been passed.
- Bleeding has diminished
- the uterus is no longer enlarged
- the cervical os is closed.
50
define septic miscarriage
- The contents of the uterus are infected, causing endometritis.
- Loss is usually offensive, the uterus is tender, but a fever can be absent.
- If pelvic infection occurs there is abdominal pain and peritonism.
51
define missed miscarriage
The foetus has not developed or died in utero, but this is not recognized until bleeding occurs or ultrasound is performed
52
how is a miscarriage diagnosed?
- failure of hCG to increase by >66% in 48h
| - no foetal heartbeat and crown-rump length of <7mm
53
what is the medical management of miscarriage?
- vaginal misoprostol for missed or incomplete miscarriage.
- with an incomplete miscarriage, use a single dose of 600 micrograms misoprostol.
- For women with a missed miscarriage, use a single dose of 800 micrograms of misoprostol.
54
what are the clinical features of vulval carcinoma?
- Pruritus
- Bleeding
- Discharge
- A mass
- Vulval Pain
55
how is vulval carcinoma managed?
- For Stage 1a disease, wide local excision is adequate, without inguinal lymphadenectomy.
- For other stages, wide local excision and groin lymphadenectomy through separate ‘skin sparing’ incisions is performed—so-called triple incision radical vulvectomy.
- If the tumour does not extend to within 2cm of the mid-line, unilateral excision and lymphadenectomy only are used.
56
define recurrent miscarriage
three or more miscarriages occur in succession
57
what are the causes of recurrent miscarriage?
- APS
- Chromosomal defects
- anatomical factors
- cervical incompetence
58
how is recurrent miscarriage managed?
- APS: aspirin and LMWH
- karyotyping
- cervical cerclage for cervical incompetence
59
when should a cervical smear not be taken?
- menstruating.
- less than 12 weeks postnatal.
- less 12 weeks after a termination of pregnancy, or miscarriage.
- vaginal discharge or pelvic infection
60
how should HPV positive results be managed?
- negative cytology: repeat in 12 months, of this remains then a further repeat at 12 months, before return to routine recall if normal
- if becomes positive, refer to colposcopy
61
how is inadequate cytology on cervical screening managed?
- repeat in 3 months unless on 24 month repeat for HPV positive (refer to colposcopy)
- 2 consecutive, refer to colposcopy
62
what are the clinical features of cervical cancer?
- Postcoital bleeding
- Offensive vaginal discharge
- IMB or postmenopausal bleeding (PMB)
- Pain is not an early feature.
- In the later stages of the disease, involvement of ureters, bladder, rectum and nerves causes uraemia, haematuria, rectal bleeding and pain, respectively.
- An ulcer or mass may be visible or palpable on the cervix.
- With early disease, the cervix may appear normal to the naked eye.
63
what are the risk factors for cervical cancer development?
- HPV infection
- HIV
- Early onset sexual activity with multiple partners
- Cigarette smoking
- Immunosuppression
64
how is stage 1A2-2A cervical cancer managed?
- For tumours 4 cm or less, radical hysterectomy with lymphadenectomy is preferred to chemoradiation.
- For tumours larger than 4 cm, chemoradiation is preferred.
- If the woman wishes to preserve her fertility, then depending on the stage and whether lymphatic-vascular space invasion is present, radical trachelectomy and lymphadenectomy may be considered instead of radical hysterectomy for tumours smaller than 2 cm.
65
how is stage IIB-IVA cervical cancer managed?
-chemoradiation
66
how is stage IVB cervical cancer managed?
- Combination chemotherapy is the treatment of choice.
| - Alternatively, single agent therapy and palliative care may be suitable.
67
what are the risk factors for endometrial carcinoma?
- Overweight and obesity
- Age >50
- Unopposed endogenous oestrogen (anovulation, low parity, early menarche, late menopause, granulosa cell tumours and obesity)
- Unopposed exogenous oestrogen (HRT)
- Tamoxifen use
- Family history of endometrial, breast or ovarian cancer
- HNPCC or PTEN syndromes
- PCOS
- Radiotherapy
68
how is endometrial hyperplasia with atypia managed?
- The discovery of atypia is unusual in women of reproductive age, but if the uterus must be preserved, progestogens
- Review intervals should be every 3 months until two consecutive negative biopsies are obtained, followed by biopsy every 6-12 months
- Otherwise hysterectomy is indicated, with bilateral salpingo-oophorectomy in post-menopausal women
69
what are the clinical features of endometrial cancer?
- Postmenopausal bleeding
- Premenopausal patients have irregular or intermenstrual bleeding (IMB), or, occasionally, only recent-onset menorrhagia.
- Uterine mass or fixed uterus
- Pain
- Weight loss
- Vaginal discharge
- Haematuria (with high blood glucose, low haemoglobin, thrombocytosis and vaginal dischare)
- The pelvis often appears normal and atrophic vaginitis may coexist.
70
how is stage 1a endometrial cancer managed?
- total hysterectomy with bilateral salpingo-oophorectomy and lymphadenectomy
- adjuvant vaginal brachytherapy
- if requiring fertility preservation, offer megestrol therapy with aggressive monitoring
71
how is stage 1b-2 endometrial cancer managed?
- total hysterectomy with bilateral salpingo-oophorectomy and lymphadenectomy
- If high-intermediate risk, offer vaginal brachytherapy and chemotherapy with paclitaxel and carboplatin
- If high risk, offer chemotherapy with paclitaxel and carboplatin and external beam radiotherapy
72
how is stage 3-4 endometrial cancer managed?
- total hysterectomy with bilateral salpingo-oophorectomy and lymphadenectomy
- chemotherapy with paclitaxel and carboplatin and external beam radiotherapy
73
what are the clinical features of ovarian cysts?
- Pelvic pain
- Bloating and early satiety
- Palpable adnexal mass
74
what are the risk factors for ovarian cysts?
- Pre-menopausal
- Early menarche
- First trimester of pregnancy
- Personal history of infertility of PCOS
- Tamoxifen
- Endometriosis
75
what tumour markers in germ cell tumours?
- lactate dehydrogenase
- alpha fetoprotein
- hCG
76
how are ovarian cysts managed in pre-menopausal women?
- Women with small (less than 50 mm diameter) simple ovarian cysts generally do not require follow-up
- Women with simple ovarian cysts of 50–70 mm in diameter should have yearly ultrasound follow-up and those with larger simple cysts should be considered for either further imaging (MRI) or surgical intervention.
- Ovarian cysts that persist or increase in size are unlikely to be functional and may warrant surgical management: Aspiration of ovarian cysts, either vaginally or laparoscopically
77
how are ovarian cysts managed in post-menopausal women?
- Asymptomatic, simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, in the presence of normal serum CA125 levels, these cysts can be managed conservatively, with a repeat evaluation in 4–6 months.
- All ovarian cysts that are suspicious of malignancy in a postmenopausal woman, as indicated by a RMI I greater than or equal to 200, CT findings, clinical assessment or findings at laparoscopy, require a full laparotomy and staging procedure.
78
what are the clinical features of ovarian torsion?
- Acute lower abdominal pain
- Nausea, vomiting or diarrhoea
- Abdominal and pelvic tenderness
- Palpable adnexal mass
- Rebound tenderness and guarding
79
how is ovarian torsion diagnosed?
-Perform TVS with doppler: enlarged ovary; diminished or absent blood flow to the ovary
80
how is ovarian torsion managed?
- Perform urgent surgical detorsion with salpingo-oophorectomy if ovary is no longer viable or there is suspected malignancy
- Among adolescents and women of reproductive age, oophoropexy may reduce recurrence
- Ovarian cystectomy is recommended if a cyst is present
81
define polycystic ovary
- characteristic transvaginal ultrasound appearance
- multiple (12 or more)
- small (2–8 mm) follicles
- enlarged (>10 mL volume) ovary.
82
how is PCOS diagnosed?
- 2/3 rotterdam criteria
- raised testosterone
- low/normal SHBG
- USS of ovaries: PCO
83
what are the clinical features of PCOS?
- acne
- hirsutism
- oligomenorrhoea or amenorrhoea
84
how is oligo/amenorrhoea in PCOS managed?
- Prescribe a cyclical progestogen (such as medroxyprogesterone 10 mg daily for 14 days) to induce a withdrawal bleed
- TVS for endometrial thickness, if normal:
- --A cyclical progestogen, such as medroxyprogesterone 10 mg daily for 14 days every 1–3 months.
- --A low-dose combined oral contraceptive (COC).
- --The levonorgestrel-releasing intrauterine system (LNG-IUS).
85
how is acne managed in PCOS?
- COC
- topical Abx or retinoids
- oral Abx
86
how is ovulation induced in PCOS?
- Clomifene
| - metformin
87
what are the clinical features of fibroids?
- Asymptomatic
- Menorrhagia
- Irregular, firm, central pelvic mass
- Pelvic pain
- Pelvic pressure
- Dysmenorrhoea
- Bloating
- Infertility
- Urinary frequency and retention
88
what is the medical management of fibroids?
- TXA, NSAIDs for menorrhagia
- IUS (levonorgestrel)
- GnRH agonists with add back HRT
89
what is the surgical management of fibroids?
- myomectomy
- hysterectomy
- uterine artery embolisation
90
define chronic pelvic pain
- intermittent or constant pain in the lower abdomen or pelvis
- of at least 6 months’ duration
- not occurring exclusively with menstruation or intercourse.
91
what are the clinical features of chronic pelvic pain?
- Dysuria
- Dyspareunia
- Dysmenorrhoea
- Abdominal trigger points
- Levator ani tenderness
- Cervical motion tenderness with upper pelvic organ involvement
- Uterine and abdominal tenderness
- Abdominal pain
- Incomplete voiding
92
what are the risk factors for chronic pelvic pain?
- sexual abuse
- PID
- Anxiety or depression
- Drug or alcohol abuse
- Pregnancy
- Polymenorrhoea
- Previous c-section
- Endometriosis
- Adhesions from pelvic surgery
93
define urethrocele
- prolapse of the lower anterior vaginal wall
| - involving the urethra only.
94
define cystocoele
- prolapse of the upper anterior vaginal wall
| - involving the bladder
95
define apical prolapse
prolapse of the uterus, cervix and upper vagina
96
define enterocoele
prolapse of the upper posterior wall of the vagina
97
define rectocele
- prolapse of the lower posterior wall of the vagina
| - involving the anterior wall of the rectum
98
what are the clinical features of a prolapse?
- Asymptomatic
- Dragging sensation
- Sensation of a lump
- Back pain
- Bleeding and discharge
- Urinary frequency and incomplete bladder emptying with cystourethrocoele
- Difficulty in defaecating with rectocoele
99
how is a prolapse managed?
- lifestyle advice
- pelvic floor muscle training
- vaginal pessary
- surgery
100
what is a 1st degree tear?
-minor damage to the fourchette
101
what is a 2nd degree tear?
involve perineal muscle.
102
what is a 3rd degree tear?
- 3a: Less than 50% of external anal sphincter thickness torn
- 3b: More than 50% of EAS torn
- 3c: Both EAD and IAS torn
103
what is a 4th degree tear?
-involve the anal mucosa.
104
what are the risk factors for a perineal tear?
- Asian ethnicity
- Nulliparity
- Birthweight greater than 4kg
- Shoulder dystocia
- Occipito-posterior position
- Prolonged second stage of labour
- Instrumental delivery
105
how can perineal injury be prevented?
- mediolateral episiotomy
- perineal protection at crowning
- warm compression
106
what are the causes of PID?
- STIs
| - uterine instrumentation
107
what are the clinical features of PID?
- Uterine tenderness
- Cervical motion tenderness
- Adnexal tenderness
- Bilateral lower abdominal pain
- Mucopurulent discharge or vaginal bleeding
- Fever
- Nausea and vomiting
- Deep dyspareunia
108
how is PID treated?
- analgesia
- low gonorrhoea risk: ceftriaxone and ofloxacin plus metronidazole
- high gonorrhoea risk: ceftriaxone, doxycycline and metronidazole
- remove IUS or IUD if no symptom resolution after 48 hours
109
what are the clinical features of vulval eczema?
- vulval itch
- soreness
- erythema
- lichenification and excoriation
- fissuring
110
how is vulval eczema managed?
- emollient soap substitute
| - topical corticosteroid
111
what are the clinical features of lichen simplex?
- vulval itch
- soreness
- Lichenification i.e. thickened, slightly scaly, pale or earthy-coloured skin with accentuated markings, maybe more marked on the side opposite the dominant hand.
- Erosions and fissuring.
- Excoriations as a result of scratching may be seen
- The pubic hair is often lost in the area of scratching
112
how is lichen simplex managed?
- emollient soap
- topical corticosteroid (potent in lichenified areas)
- hydoxyzine or doxepine at night for itch
113
what are the clinical features of vulval psoriasis?
- Vulval itch
- Soreness
- Burning sensation
- Well demarcated brightly erythematous plaques
- Often symmetrical
- Frequently affects natal cleft
- Usually lacks scaling due to maceration
- Fissuring
114
how is vulval psoriasis managed?
- emollient
- topical corticosteroid (weak to moderate)
- coal tar preparations
- Talcalcitol
115
what are the clinical features of vulvodynia?
- vulval pain
| - Focal tenderness elicited by gentle application of a cotton wool tip bud at the introitus or around the clitoris
116
how is vulvodynia managed?
- emollients
- topical local anaesthetics
- pelvic floor muscle biofeedback, TENS, Vaginal trainers
- amitriptyline
- modified vestibulectomy
117
what are the clinical features of vulval lichen planus?
- Itch / irritation
- Soreness
- Dyspareunia
- Urinary symptoms
- Vaginal discharge
- Can be asymptomatic
- papules will be found on the keratinised anogenital skin, with or without striae on the inner aspect of the vulva
118
how is lichen plans managed?
- ultrapotent topical steroids
| - vaginal corticosteroids
119
define foetal distress
-hypoxia that might result in foetal damage or death if not reversed or the foetus delivered urgently
120
what is the combined test?
- USS for nuchal translucency
- maternal PAPP-A
- At 11-13+6 weeks
121
what is the quadruple test?
- a-fetoprotein
- unconjugated oestradiol
- hCG
- Inhibin A
122
what are the maternal risk factors for IUGR?
- Maternal age (less than 16 years or more than 35 years).
- Low socio-economic status.
- Parity (none or more than five births).
- Inter-pregnancy interval less than 6 months or an interval of 120 months or more).
- Previous delivery of an SGA newborn.
- Maternal substance abuse (smoking, alcohol, illicit drugs such as marijuana or cocaine).
- Maternal medication (eg, warfarin, steroids, anticonvulsants, antineoplastic, antimetabolite, and folic acid antagonists).
- Maternal pre-pregnancy BMI less than 20, weight less than 45 kg or more than 75 kg.
- Assisted reproductive technologies.
- Pregnancy: moderate to heavy physical work, severe maternal starvation, poor weight gain, high-altitude and maternal hypoxia, poor medical care.
- Maternal medical disorders
- Maternal infection and parasite infestations
123
what are the foetal risk factors for IUGR?
- Chromosomal abnormalities - eg, trisomies 13, 18, or 21, autosomal deletions, triploidy, ring chromosomes and uniparental disomy.
- Genetic syndromes - eg, Russell-Silver syndrome, Rubinstein-Taybi syndrome, Dubowitz's syndrome, Seckel's syndrome, Fanconi's syndrome.
- Major congenital anomalies - eg, tracheo-oesophageal fistula, congenital heart disease, congenital diaphragmatic hernia, abdominal wall defects (omphalocele or gastroschisis), neural tube defect (eg, anencephaly), anorectal malformation.
- Multiple gestation.
- Congenital infections (TORCH syndrome, malaria, congenital HIV infection, syphilis).
- Metabolic disorders - eg, congenital lipodystrophy, galactosaemia, generalised gangliosidosis type I, hypophosphatasia, foetal phenylketonuria.
124
what is symmetrical IUGR?
-head circumference, abdominal circumference, biparietal diameter and foetal length all proportionally reduced.
125
what is asymmetrical IUGR?
- abdominal circumference decreased
| - biparietal diameter, head circumference and femur length all normal.
126
how is SGA diagnosed?
-Foetal abdominal circumference (AC) or estimated foetal weight (EFW) <10th centile
127
how should SGA foetus be delivered?
- delivery by 37 weeks with induction or c-section
| - if umbilical artery AREDV, delivery by c-section
128
what are the clinical features of vulval lichen sclerosis?
- itch and soreness
- dyspareunia
- urinary symptoms
- pale, white atrophic areas of vulva
- purpura
- fissuring
- erosions
- hyperkeratosis
129
how is vulval lichen sclerosis managed?
-ultrapotent topical steroids
130
what are the clinical features of primary invasive breast cancer?
- Unilateral nipple discharge
- Breast lump
- Axillary lymphadeopathy
- Skin thickening or discolouration
- Retraction or scaling of the nipple
131
what are the clinical features of locally advanced breast cancer?
- Ulceration
- Peau d’orange, (mammary skin oedema)
- Inflammatory breast cancer
- Fixed to chest wall
- Fixed, matted axillary lymph nodes
132
what are the clinical features of Paget's disease of the breast?
- Eczematous change of the nipple
- Does not resolve with 2 weeks of antifungal cream
- Associated mass
133
what are the risk factors for breast cancer?
- Increasing age
- Family history
- Benign breast disease
- BRCA1/2 gene
- Li-Fraumeni syndrome
- Cowden syndrome
- Peutz-Jeghers Syndrome
- Klinefelter’s syndrome
- Older age at menopause
- Older age at first full term pregnancy
- Nulliparity
- Low physical activity
- Ataxia telangiectasia
- Early menarche
- Exogenous oestrogen exposure e.g. HRT and hormonal contraception
- Radiotherapy
134
what is a luminal A breast cancer?
- ER/PR positive
- HER2 negative
- low Ki67
135
what is a luminal B breast cancer?
- ER/PR positive
- HER2 positive or negative
- High Ki67
136
what is a HER2 enriched breast cancer?
- ER/PR negative
| - HER2 positive
137
how is ER negative breast cancer treated?
- neoadjuvant chemo
- breast conserving surgery/mastectomy with SLNB
- whole-breast radiotherapy to women with invasive breast cancer who have had breast-conserving surgery with clear margins.
- partial breast radiotherapy (as an alternative to whole-breast radiotherapy) for women who have had breast-conserving surgery for invasive cancer (excluding lobular type) with clear margins
138
how is HER2 positive breast cancer treated?
- neoadjuvant chemo, with trastuzumab and pertuzumab
- breast conserving surgery/mastectomy with SLNB
- whole-breast radiotherapy to women with invasive breast cancer who have had breast-conserving surgery with clear margins.
- partial breast radiotherapy (as an alternative to whole-breast radiotherapy) for women who have had breast-conserving surgery for invasive cancer (excluding lobular type) with clear margins
139
how is ER positive breast cancer treated?
- neoadjuvant chemo
- neoadjuvant endocrine therapy for post menopausal women
- breast conserving surgery/mastectomy with SLNB
- adjuvant transtuzumab
- whole-breast radiotherapy to women with invasive breast cancer who have had breast-conserving surgery with clear margins.
- partial breast radiotherapy (as an alternative to whole-breast radiotherapy) for women who have had breast-conserving surgery for invasive cancer (excluding lobular type) with clear margins
- tamoxifen (premenopausal) or aromatase inhibitor (postmenopause) therapy
140
how is triple negative breast cancer treated?
- neoadjuvant chemo with a platinum and anthracycline
- breast conserving surgery/mastectomy with SLNB
- whole-breast radiotherapy to women with invasive breast cancer who have had breast-conserving surgery with clear margins.
- partial breast radiotherapy (as an alternative to whole-breast radiotherapy) for women who have had breast-conserving surgery for invasive cancer (excluding lobular type) with clear margins
141
what are the clinical features of a Bartholin's cyst?
- vulval/perineal mass
- vulval pressure or fullness
- pain during sitting or walking
- fever
- dyspareunia
- vulval erythema and induration
142
how is a bartholin's cyst managed?
-Offer incision, drainage and marsupialisation with broad spectrum antibiotics such as co-amoxiclav and clindamycin
143
what are the clinical features of vaginal thrush?
- Vulval itching
- Vulval soreness and irritation.
- Vaginal discharge (usually white, 'cheese-like', and non-malodorous).
- Superficial dyspareunia.
- Dysuria (pain or discomfort during urination).
- Signs of severe vulvovaginal candidiasis include:
- --Erythema
- --Vaginal fissuring and/or oedema.
- --Excoriation of the vulva.
- --Satellite lesions (rare; may indicate other fungal conditions or herpes simplex virus).
144
how is uncomplicated vaginal thrush managed?
- prescribe an initial course of an intravaginal antifungal cream or pessary (clotrimazole (200mg for 3 days/500mg for 1 day), or an oral antifungal (fluconazole 150mg once or itraconazole 200mg BD for 1 day).
- women aged 60 years and older, oral antifungals may be more acceptable
- For girls aged 12–15 years, consider prescribing topical clotrimazole 1% or fenticonazole 2% (5g at night) applied 2–3 times a day
- For breastfeeding women, prescribe an initial course of intravaginal clotrimazole or miconazole, or oral fluconazole
145
how is severe vaginal thrush managed?
- prescribe two doses of oral fluconazole 150 mg (to be taken 3 days apart). If oral treatment is contraindicated or unsuitable, prescribe two doses of clotrimazole vaginal pessaries 500 mg (to be used 3 days apart).
- For girls aged 12–15 years, refer or seek specialist advice.
- For breastfeeding women, prescribe two doses of clotrimazole vaginal pessaries 500 mg (to be used 3 days apart).
146
how is recurrent vaginal thrush managed?
- prescribe an induction course of three doses of oral fluconazole 150 mg (to be taken 3 days apart) or an intravaginal antifungal for 10–14 days (according to response).
- Give a prescription for 'treatment as required' or a maintenance of 6 months of oral or intravaginal clotrimazole
147
how is vaginal thrush managed in diabetic/immunocompromised patients?
- prescribe an extended course of an intravaginal antifungal (clotrimazole 100mg for 12 nights or 200mg for 6 nights, or econazole 150mg for 6 nights) or oral antifungal (fluconazole 100mg for 7 days or itraconazole 200mg for 7 days).
- For girls aged 12–15 years, refer or seek specialist advice.
- For breastfeeding women, consider treating with an extended course of intravaginal miconazole (2%, 5g for 10-14 days)
148
what are the clinical features of pseudomembranous oral candidiasis?
- patches of curd-like, white or yellowish plaques that can occur anywhere in the mouth, especially the cheeks, gums, palate, and tongue.
- burning and itching sensation
- dysphagia
- chest pains.
149
what are the clinical features of acute erythematous oral candidiasis?
- marked soreness and erythema, particularly on the palate and dorsum of the tongue.
- The filiform papillae disappear
- Dorsal surface of the tongue appears smooth.
- mild burning and itching sensation.
150
how is oral candida managed in children?
- miconazole oral gel first-line for children aged 4 months and over
- oral nystatin suspension
151
how is oral candida managed in adults?
- If the infection is mild and localized, prescribe topical antifungal treatment for 7 days.
- --Offer miconazole oral gel first-line.
- --If miconazole is unsuitable, offer nystatin suspension.
- If the infection is extensive or severe infection, consider one of the following:
- --Prescribe oral fluconazole 50 mg a day for 7 days.
152
how are patients on steroids or DMARDS with oral thrush managed?
- Offer miconazole oral gel first-line.
- If miconazole is unsuitable, offer nystatin suspension.
- If the infection is extensive or severe, consider one of the following options:
- --Prescribe oral fluconazole 50–100 mg a day for 7 days
153
how are patients with HIV with oral thrush managed?
-Prescribe oral fluconazole 100 mg for 7 days provided the person is otherwise well and is not taking prophylactic antimycotic treatment.
154
what are the risk factors for developing bacterial vaginosis?
- Being sexually active
- The use of douches, deodorant, and vaginal washes; menstruation; and presence of semen in the vagina.
- Copper intrauterine device.
- Smoking.
155
what are the clinical features of bacterial vaginosis?
- Fishy smelling discharge
- Thin grey-white discharge
- No associated soreness or itching
156
how is bacterial vaginosis managed in a non-pregnant woman?
- oral metronidazole 400mg BD for 5-7 days, or single oral 2g dose
- intravaginal metronidazole gel 0.75% for 5 days or intravaginal clindamycin cream 2% OD for 7 days
157
how is bacterial vaginosis managed in a pregnant woman?
- oral metronidazole 400mg BD for 5-7 days
| - intravaginal metronidazole gel 0.75% for 5 days or intravaginal clindamycin cream 2% OD for 7 days
158
define gestational hypertension
-new hypertension (a blood pressure of 140/90 mmHg or more) after 20 weeks’ gestation without significant proteinuria or other features of pre-eclampsia.
159
what are the risk factors for gestational hypertension?
- Primigravidity
- Multiple pregnancy.
- Black ethnicity.
- Maternal obesity.
- Maternal type 1 diabetes.
- Renal disease
- Young
160
how is gestational hypertension diagnosed?
- Systolic BP greater than 140 mmHg and/or diastolic BP greater than 90 mmHg on a minimum of two occasions.
- Measurements must be taken at least 4 hours apart after 20 weeks’ gestation.
- Women are normotensive prior to both pregnancy and 20 weeks’ gestation.
161
how is gestational hypertension managed?
- lifestyle interventions
- oral labetalol
- IV labetalol if >160/110
- if >37 weeks gestation, give IV labetalol and induce labour
162
what are the causes of post menopausal bleeding?
- endometrial cancer, hyperplasia or atypia
- cervical cancer
- atrophic vaginitis
- cervicitis
- ovarian carcinoma
- cervical polyps
163
what investigations should be performed for post menopausal bleeding?
- TVS for endometrial thickness
| - Hysteroscopy with biopsy if endometrial thickness >4mm
164
what are the clinical features of PMS?
- cyclical
- tension
- irritability
- aggression
- depression
- loss of control
- bloatedness
- minor GI upset
- breast pain
165
how is PMS managed?
- lifestyle advice
- Paracetamol or NSAIDs
- COC e.g. Yasmin continuously
- CBT
- If severe: SSRI during luteal phase
166
what are the symptoms of menopause?
- Hot flushes
- Sweating
- MSK symptoms – joint and muscle pain
- Low mood
- Sexual difficulties
- Vaginal dryness
- Irritability
- Loss of memory
- Lack of concentration
- Lack of energy
- Dyspareunia
- Recurrent UTIs
- Post menopausal bleeding
- Osteoporosis
- Increased risk of cardiovascular disease
167
what are the benefits of HRT?
- Reduced menopausal symptoms
- reduces osteoporosis
- reduces risk of colorectal cancer
168
what are the risks of HRT?
- breast cancer
- endometrial cancer
- VTE
169
what are the contraindications to VTE?
- Undiagnosed abnormal PV bleeding
- Breast lump
- Acute liver disease
- Caution: fibroids, uncontrolled BP, migraine, epilepsy, endometriosis, VTE family history
170
what HRT regimen should be used in women after hysterectomy?
-oestrogen only
171
what HRT regimen should be used in women with a uterus?
-oestrogen and progesterone
172
define premature ovarian failure
-cessation of menses for more than 1 year before 40 years of age secondary to loss of ovarian function
173
what are the causes of premature ovarian failure?
- genetic disorders
- autoimmune disorders
- infections
- toxic causes (including chemotherapy or radiation)
- galactosaemia
- idiopathic.
174
what are the clinical features of primary ovarian insufficiency?
- menstrual irregularities
- Sleep disturbance
- Irritability
- Vaginal dryness
- Infertility
- Vaginal atrophy
- Small uterus with non-palpable ovaries
175
how is premature ovarian insufficiency diagnosed?
- menopausal symptoms, including no or infrequent periods (taking into account whether the woman has a uterus)
- elevated follicle-stimulating hormone levels on 2 blood samples taken 4–6 weeks apart.
- There will also be elevated LH and reduced oestrogen
176
how is premature ovarian insufficiency managed?
-Offer sex steroid replacement with a choice of HRT or a combined hormonal contraceptive, unless contraindicated
177
what are the investigations needed for irregular menstrual bleeding?
- USS over 35 years
| - hysteroscopy with biopsy
178
what are the medical treatments for IMB?
- IUS or COC
| - progestogens
179
what are the causes of menorrhagia?
- fibroids
- adenomyosis
- endometriosis
- thyroid disease
- haemostatic disorders
- anticoagulant therapy
180
how is menorrhagia with no pathology, fibroids <3cm or adenomyosis managed?
- LNG-IUD
- TXA or NSAIDs
- COC or oral progestogens
181
define pre-eclampsia
- new onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic)
- after 20 weeks of pregnancy
- in addition to the coexistence of new onset-proteinuria or other maternal organ dysfunction.
182
what are the risk factors for developing pre-eclampsia?
- History of hypertension during a previous pregnancy.
- Chronic kidney disease.
- Autoimmune disease, including systemic lupus erythematosus and antiphospholipid syndrome.
- Diabetes.
- Chronic hypertension.
- Age 40 years or older.
183
what are the clinical features of pre-eclampsia?
- Hyperreflexia is the most specific sign of pre-eclampsia.
- Severe headaches.
- Visual problems.
- Persistent new epigastric pain or RUQ pain.
- Rapid weight gain
- Vomiting.
- Breathlessness.
- Oedema.
- Papilloedema or retinal vasospasm on fundoscopy
- Haematuria in HELLP syndrome (rare).
184
how is pre-eclampsia managed?
- aspirin 75mg from 12 weeks gestation in high risk
- delivery is the only cure, preferably with epidural to reduce BP in absence of thrombocytopenia
- IV labetalol or oral nifedipine
- IV magnesium sulfate
185
what are the indications for delivery in pre-eclampsia?
- Gestational age 38 weeks.
- Symptomatic pre-eclampsia.
- HELLP syndrome.
- Suspected placental abruption.
- Progressive deterioration in liver or renal function
- Suspected placental abruption
- Severe IUGR
- Non-reassuring foetal testing
- Oligohydramnios
186
how is gestational diabetes diagnosed?
- risk based testing
- 75g 2hour OGTT with risk factors at 24 to 28 weeks
- should done at booking and 28 weeks if previous gestational diabetes
- a fasting plasma glucose level of 5.6 mmol/litre or above or
- a 2-hour plasma glucose level of 7.8 mmol/litre or above.
187
how is gestational diabetes managed?
- diet and exercise advice and referral to dietitian
- FG<7, diet and exercise
- if persistent, metformin
- if persistent, insulin
- >7 at diagnosis, insulin, metformin and diet and exercise
- 6-6.9 with complications, insulin, metformin and diet
188
what are the clinical features of obstetric cholestasis?
- Pruritus sparing the face
- Pruritus that involves the palms and soles of the feet
- Excoriations without rash
- Mild jaundice
189
what are the risk factors for developing obstetric cholestasis?
- Previous Hx intrahepatic cholestasis of pregnancy
- History of hepatitis C
- FHx of intrahepatic cholestasis of pregnancy
- Age >35 years
190
how is obstetric cholestasis managed?
- Induction of labour after 37 weeks of gestation to reduce the risk of stillbirth
- Topical emollients such as diprobase, calamine lotion and aqueous cream with menthol for symptomatic relief of pruritus
- Ursodeoxycholic should be given to improve itching and liver function
- Where prothrombin time is prolonged, use water-soluble vitamin K in doses of 5-10mg daily
191
when is planned VBAC contraindicated?
- previous uterine rupture
- classical c-section scar
- other contraindications to vaginal birth e.g. placenta praaevia
192
what are the clinical features of vaginitis?
- Vaginal discharge
- Dysuria
- Discharge adherent to vaginal mucosa
- Pruritus
- Vulvodynia
- Dyspareunia
- Erythema
193
what are the risk factors for VTE in pregnancy?
- Previous VTE
- Thrombophilia
- Medical co-morbidities
- Age >35
- Obesity
- Parity >3
- Smoking
- Gross varicose veins
- Paraplegia
- Multiple pregnancy
- Pre-eclampsia
- C-section
- Prolonged labour
- Stillbirth
- Preterm birth
- PPH
- Surgical procedure in pregnancy
- Hyperemesis and dehydration
- Ovarian hyperstimulation syndrome
- Admission or immobility
- Infection
- long distance travel
194
what investigations are needed in suspected VTE in pregnancy?
- Perform compression duplex scanning for DVT
- Perform an ECG (T wave inversions, S1Q3T3 and RBBB) and chest x-ray for a suspected PE
- In women with suspected PE without symptoms and signs of DVT, a ventilation/perfusion (V/Q) lung scan or a computerised tomography pulmonary angiogram (CTPA) should be performed.
- When the chest X-ray is abnormal and there is a clinical suspicion of PE, CTPA should be performed in preference to a V/Q scan.
195
how is VTE in pregnancy managed?
- LMWH
- IV unfractionated heparin in massive PE with cardiovascular compromise
- thrombolysis
- 3 months of SC LMWH or fondaparinux
196
what are the causes of PPH?
- Retained placenta
- Uterine atony
- Perineal tear or episiotomy
- Cervical tears
- Congenital disorders, anticoagulant therapy or disseminated intravascular coagulation
197
what are the risk factors for PPH?
- Multiple pregnancy
- Previous PPH
- Pre-eclampsia
- Fetal macrosomia
- Failure to progress in second stage
- Retained placenta
- Placenta accreta
- Episiotomy
- Perineal laceration
- General anaesthesia
198
how can blood loss at delivery be reduced?
- For women without risk factors for PPH delivering vaginally, oxytocin (10 iu by intramuscular injection) for prophylaxis in the third stage of labour.
- For women delivering by caesarean section, oxytocin (5 iu by slow intravenous injection) should be used
=Clinicians should consider the use of intravenous tranexamic acid (0.5–1.0 g), in addition to oxytocin, at caesarean section to reduce blood loss in women at increased risk of PPH.
199
how is uterine atony as a cause of PPH managed?
- rub the fundus
- empty bladder
- oxytocin IV
- ergometrine IV or IM
- oxytocin infusion
- carboprost IM
- misoprostol
200
define primary PPH
-the loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby.
201
define secondary PPH
-abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally
202
how is secondary PPH managed?
-ERPC
203
What are the risk factors for umbilical cord prolapse?
- Multiparity
- Low birthweight
- Preterm labour
- Fetal congenital anomalies
- Breech
- Transverse, oblique and unstable lie
- Second twin
- Polyhydramnios
- Unengaged presenting part
- Low lying placenta
- ARM with high presenting part
- Vaginal manipulation of the fetus with ruptured membranes
- External cephalic version
- Internal podalic version
- Stabilising induction of labour
- Insertion of intrauterine pressure transduced
- Large balloon catheter induction of labour
204
when should cord prolapse be suspected?
-abnormal fetal heart rate pattern after membrane rupture
205
how is cord prolapse managed?
- fill urinary bladder and adopt knee-chest or left lateral to prevent compression
- tocolysis
- c-section
206
what are the indications for induction of labour?
- Prolonged pregnancy (>42 weeks gestation)
- Suspected growth restriction
- Prelabour term rupture of membranes
- Pre-eclampsia
- Medical disease
- Antepartum haemorrhage
- In utero death
207
what are the contraindications to induction of labour?
- Acute foetal compromise
- Abnormal lie
- Placenta praevia
- Pelvic obstruction
- Pelvic deformity
- Multiple C-sections
208
how is labour induced?
- vaginal PGE2 up to 2 doses
| - amniotomy with oxytocin
209
what is shoulder dystocia?
-a vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the fetus
210
what are the risk factors for shoulder dystocia?
- Macrosomia
- Previous shoulder dystocia
- Increased maternal body mass index
- Labour induction
- Low height
- Maternal diabetes
- Instrumental delivery
- Prolonged first and second stage of labour
211
how is shoulder dystocia managed?
- McRoberts' manoeuvre
- all fours position
- Wood's manoeuvre
- foetal cleidotomy
- symphysiotomy
- zavanelli manoeuvre
212
what are the clinical features of Erb's palsy?
- Paralysis of the arm
- Abnormal arm posture: held at the side with the shoulder internally rotated, elbow extended, wrist flexed and fingers flexed (Waiter’s tip)
213
what are the risk factors for uterine rupture?
- Labour with scarred uterus
- Neglected obstructed labour
- Congenital uterine abnormalities
214
what is the management of uterine rupture?
- Maternal resuscitation with intravenous fluid and blood is required.
- Blood is taken for clotting, haemoglobin and cross-match.
- Blood loss may be faster than can be replaced and urgent laparotomy for delivery of the foetus and cessation of maternal bleeding by repair or removal of the uterus is indicated.
215
what are the risk factors for early onset GBS in pregnancy?
- having a previous baby with GBS disease
- discovery of maternal GBS carriage through bacteriological investigation during pregnancy
- preterm birth
- prolonged rupture of membranes
- suspected maternal intrapartum infection, including suspected chorioamnionitis
- pyrexia.
216
when should intrapartum prophylactic antibiotics?
- Women with a previous baby with early or late onset GBS disease
- Women with GBS bacteriuria during the current pregnancy
- Not required for women undergoing C-section in the absence of labour and with intact membranes
- Women in confirmed preterm labour
- Benzylpenicillin should be administered and given regularly until delivery
- In penicillin allergy, use either cefuroxime or vancomycin (if penicillin allergy is severe)
217
how is cyclical breast pain managed?
- supportive (well fitting bra, NSAIDs and paracetamol)
| - danazol, goserelin and tamoxifen can be given by specialists
218
what are the risk factors for maternal sepsis?
- Obesity
- Diabetes
- Impaired immunity/immunosuppressant medication
- Anaemia
- Vaginal discharge
- History of pelvic infection
- History of group B Strep infection
- Amniocentesis and other invasive procedures
- Cervical cerclage
- Prolonged spontaneous rupture of membranes
- Group A Strep infection in close contacts / family members
- BAME women
219
what are the signs of maternal sepsis?
- Pyrexia
- Hypothermia
- Tachycardia
- Tachypnoea
- Hypoxia
- Hypotension
- Oliguria
- Impaired consciousness
- Failure to respond to treatment
220
what are the symptoms of maternal sepsis?
- Fever and rigors
- Diarrhoea and vomiting
- Breast engorgement and redness
- Rash (generalised maculopapular)
- Abdominal/pelvic pain and tenderness
- Wound infection
- Offensive vaginal discharge
- Productive cough
- Urinary symptoms
- Delay in uterine involution and heavy lochia
221
how is maternal sepsis managed?
- The Sepsis 6 Bundle should be performed within 1 hour of recognition of sepsis: blood cultures, give broad spectrum antibiotics, measure lactate, give fluids or vasopressors, give oxygen and measure fluid balance
- A combination of piperacillin/tazobactam or a carbapenem plus clindamycin is one of the broadest ranges for severe sepsis
- If MRSA is suspected, substitute clindamycin for vancomycin or teicoplanin
- IVIG is recommended for severe invasive strep or staph infection if other therapies have failed
- Antibiotic prophylaxis should be given to the neonate
222
what are the clinical features of trichomoniasis in women?
- Vaginal discharge
- Vulval itching
- Dysuria
- Offensive odour
- Frothy, yellow green discharge
- Lower abdominal pain
- Dysuria
- Vulval soreness and ulceration
223
what are the clinical features of trichomoniasis in men?
- Urethral discharge
- Dysuria
- Urinary frequency
224
how is trichomoniasis treated in men and women that are not pregnant or breast feeding?
- Prescribe oral metronidazole 400–500 mg twice a day for 5–7 days,
- or metronidazole 2 g as a single oral dose,
- or tinidazole 2 g as a single oral dose.
225
how is trichomoniasis treated in women that are pregnant or breast feeding?
-Prescribe oral metronidazole 400–500 mg twice a day for 5–7 days.
226
how is trichomoniasis treated in HIV?
-Prescribe oral metronidazole 500 mg twice a day for 7 days.
227
what are the clinical features of fibrocystic breasts?
- Mastalgia
- Diffuse symmetrical lumpiness through both breasts
- Nipple discharge
228
how are fibrocystic breasts managed?
- Ensure the women is wearing a correctly fitted and supportive bra
- Offer regular analgesia with paracetamol and ibuprofen
- Refer to secondary care for consideration or hormonal therapy with danazol or tamoxifen
229
what is PPROM?
-The membranes rupture before labour prior to 36+6 weeks
230
how is PPROM managed?
- Erythromycin should be given for 10 days following the diagnosis of PPROM or until the woman is in established labour
- from 24+0 weeks, antenatal corticosteroids should be offered up to 33+6 weeks, and considered beyond 34+0 weeks
- PPROM in established labour, or having a planned preterm birth within 24 hours, IV magnesium sulfate should be offered between 24+0 and 29+6 weeks of gestation
- Women whose pregnancy is complicated by PPROM after 24 +0 weeks’ gestation and who have no contraindications to continuing the pregnancy should be offered expectant management until 37 +0 weeks
231
what are the clinical features of ovarian cancer?
- Symptoms are often initially vague and/or absent and 70% of patients present with Stage 3–4 disease.
- persistent abdominal distension (‘bloating’)
- feeling full (early satiety)
- loss of appetite
- pelvic or abdominal pain
- increased urinary urgency and/or frequency
- Many of the symptoms are similar to those of irritable bowel syndrome (IBS) but since this rarely presents for the first time in older women then ovarian cancer must be excluded.
- Examination may reveal cachexia, an abdominal or pelvic mass and ascites.
232
how is ovarian cancer diagnosed?
- raised CA125
- USS: multilocular cysts, solid areas, ascites
- women under 40: AFP and hCG raised in germ cell tumours
- calculate risk of malignancy index: CA125 x menopausal status x USS score
233
how is stage 1 ovarian cancer managed?
- Hysterectomy, BSO and partial omentectomy
- retroperitoneal/peritoneal node sampling
- adjuvant chemo with 6 cycles of carboplatin if grade 3 or stage Ic
234
how is stage II-IV ovarian cancer managed?
- Hysterectomy, BSO and partial omentectomy
- retroperitoneal/peritoneal node sampling
- chemo with paclitaxel and cisplatin/carboplatin if advanced disease
235
what are the causes of multiple pregnancy?
- Assisted conception
- Genetic factors
- Increasing maternal age and parity
- in vitro fertilization (IVF)
- clomifene-assisted conceptions
236
how does USS appear with dichorionic twins?
-dividing membrane is thicker as it meets the placentas (Lambda sign)
237
how does USS appear in monochromic twins?
-thin (T sign) and perpendicular to the shared placenta.
238
how should DCDA or MCDA twins be delivered?
- C-section if first twin not cephalic
| - otherwise both planned c-section and vaginal birth are safe
239
how should MCMA twins be delivered?
-c-section between 32 and 33+6 weeks
240
how should triplets be delivered?
-C-section at 35 weeks
241
what are the indications for a vaginal instrumental delivery?
- prolonged second stage
- exhausted mother
- foetal distress
- to prevent pushing in women with medical problems
- breech delivery
242
what are the contraindications to instrumental vaginal delivery?
- Suspected foetal bleeding disorders (relative)
- Predisposition to fracture (relative)
- Blood borne viral infections (relative)
- Ventouse should be avoided below 32 weeks gestation
243
what are the indications for emergency C-section?
- prolonged first stage
| - foetal distress
244
what are the indications for elective C-section?
- placenta praaevia
- severe antenatal foetal compromise
- uncorrectable abnormal lie
- previous vertical c-section
- gross pelvic deformity
245
which HIV positive women should be given c-section deliveries?
- are not receiving any anti-retroviral therapy
| - are receiving any anti-retroviral therapy and have a viral load of 400 copies per ml or more.
246
categorise CTG foetal heart rate into reassuring, non-reassuring and abnormal
- reassuring: 110 to 160 beats/minute
- non-reassuring: 100 to 109 beats/minute or 161 to 180 beats/minute
- abnormal: below 100 beats/minute or above 180 beats/minute.
247
categorise CTG baseline variability into reassuring, non-reassuring and abnormal
- reassuring: 5 to 25 beats/minute
- non-reassuring: less than 5 beats/minute for 30 to 50 minutes or more than 25 beats/minute for 15 to 25 minutes
- abnormal: less than 5 beats/minute for more than 50 minutes or more than 25 beats/minute for more than 25 minutes or sinusoidal.
248
what are the concerning characteristics of variable decelerations?
- lasting more than 60 seconds
- reduced baseline variability within the deceleration
- failure to return to baseline
- biphasic (W) shape
- no shouldering.
249
how is a pathological CTG managed?
- exclude acute events
- correct underlying cause
- start one or more conservative measures (mobilise, IV fluids, reduce or stop oxytocin and offer a tocolytic such as SC terbutaline)
250
what are the clinical features of breast cancer in situ?
- Unilateral nipple discharge
- Breast lump
- Eczema like rash on breast
- Ulceration
- Asymptomatic and detected during screening
251
how is breast cancer in situ managed?
- Offer wide local excision and breast conserving surgery
- Offer further excision or mastectomy after breast conserving surgery where DCIS is present at the radial margins
- Consider adjuvant radiotherapy for women with DCIS following breast-conserving surgery with clear margins
- Offer endocrine therapy after breast conserving surgery for women with ER-positive DCIS where radiotherapy is recommended but not received
252
what are the clinical features of fibroadenoma?
-large mobile tumour
253
how is fibroadenoma treated?
-surgical removal or vacuum-assisted mammotomy if symptomatic
254
what are the risk factors for ovarian hyperstimulation syndrome?
- gonadotrophin stimulation
- age <35 years
- previous OHSS
- ovaries of polycystic morphology on ultrasound scan.
255
how is ovarian hyperstimulation syndrome prevented?
- use of the lowest effective gonadotrophin doses
- ultrasound monitoring of follicular growth and, if this is excessive, ‘coasting’ (withdrawing gonadotrophins for a few days) or cancellation of IVF cycle (withholding hCG injection).
256
what are the clinical features of ovarian hyperstimulation syndrome?
- Hypovolaemia
- Electrolyte disturbances
- Ascites
- Thromboembolism
- Pulmonary oedema
257
how is ovarian hyperstimulation syndrome managed as an outpatient?
- good fluid intake and output monitoring
- LMWH
- outpatient paracentesis
258
how is ovarian hyperstimulation syndrome managed in hospital?
- analgesia
- antiemesis
- fluid replacement
- paracentesis
259
what is mastitis?
-inflammation of the breast with or without infection.
260
what are the clinical features of breast infection?
- Fever
- Decreased milk outflow
- Breast warmth
- Breast tenderness
- Breast firmness
- Breast swelling
- Breast erythema
- Flu-like symptoms, malaise and myalgia
- Breast pain
- Yellow, green, thick nipple discharge in duct ectasia
261
what are the risk factors for breast infection?
- Female >30 years
- Poor breastfeeding technique
- Lactation
- Milk stasis
- Nipple injury
- Previous mastitis
- Shaving or plucking areola hair
- Anatomical breast defect
- Underlying breast condition
- Nipple piercing
- Skin infection
- Immunosuppresion
262
how is lactational breast infection managed?
- paracetamol or ibuprofen
- continue breast feeding
- prescribe flucloxacillin or erythromycin or clarithromycin
- co-amoxiclav second line
263
how is non-lactational breast infection managed?
-prescribe co-amoxiclav or erythromycin/clarithromycin plus metronidazole
264
how is a breast abscess managed?
-incision and drainage
265
what are the risk factors for premature labour?
- Infection and inflammation, particularly at early gestations.
- Previous preterm delivery.
- Social disadvantage and with lifestyle
- Domestic violence
- Cervical trauma such as iatrogenic dilation of the cervix or previous treatment for cervical intra-epithelial neoplasia
- Women with a history of induced abortion
- A short cervical length (<2 cm) and a positive fetal fibronectin test
- Low maternal weight
- Preterm premature rupture of membranes (PPROM)
- Multiple (multi-fetal) pregnancies
- Fetal abnormalities and polyhydramnios.
266
how is preterm labour managed?
- nifedipine for tocolysis between 24 and 34 weeks
- maternal corticosteroids if before 36 weeks
- IV magnesium sulfate for neuroprotection if 23-34 weeks
267
define subfertility
-conception has not occurred after a year of regular unprotected intercourse.
268
what are the hypothalamic causes of subfertility?
- hypothalamic hypogonadism
| - Kallmann's syndrome
269
what are the pituitary causes of subfertility?
- hyperprolactinaemia
- pituitary damage
- sheehan's syndrome
270
what are the ovarian causes of subfertility?
- PCOS
- premature ovarian failure
- gonadal dysgenesis (Turner;s syndrome)
271
what are the causes of abnormal or absent sperm release?
- idiopathic
- drugs: alcohol, smoking, sulfasalazine, anabolic steroids, industrial chemical exposure, solvents
- varicocele
- antisperm antibodies after vasectomy reversal
- epididymitis
- mumps orchitis
- Klinefelter's
- CF
- retrograde ejaculation
272
what are the clinical features of advanced and metastatic breast cancer?
- Clinical features of breast cancer
- Bone pain
- Pleural effusion
- Shortness of breath
- Anorexia
- Weight loss
- Neurological pain, weakness, headaches and seizures
273
how is metastatic breast cancer diagnosed/
- CT and MRI of bones
| - elevated alkaline phosphatase, deranged LFTs and elevated calcium
274
how is hormone receptor and HER2 positive metastatic breast cancer managed?
- endocrine therapy (tamoxifen or aromatase inhibitor)
- chemo with docetaxel, capecitabine or vinoreline
- trastuzumab
275
how is hormone receptor positive and HER2 negative metastatic breast cancer managed?
- endocrine therapy (tamoxifen or aromatase inhibitor)
| - chemo with docetaxel, capecitabine or vinoreline
276
how is hormone receptor negative and HER2 positive metastatic breast cancer managed?
- chemo with docetaxel, capecitabine or vinoreline
| - trastuzumab
277
how is triple negative metastatic breast cancer managed?
-chemo with docetaxel, capecitabine or vinoreline
278
how is rhesus incompatibility identified?
- Unsensitized women are screened for antibodies at booking and at 28 weeks’ gestation.
- If anti-D levels are <10 IU/mL, a significant foetal problem is very unlikely and levels are subsequently checked every 2–4 weeks.
- When anti-D levels are above 10IU/ml, further investigation is indicated.
279
how is rhesus incompatibility managed?
- Where anti D antibodies are detected, levels should be measured every 4 weeks up to 28 weeks and then every 3 weeks until delivery
- Anti-D (1500IU) should be given to all women who are rhesus negative at 28 weeks and within 72h of any sensitizing event.
- Kleihauer test is performed postnatally to determine need for more anti-D
280
what are the indications for mammography?
- Clinically suspicious lump in patients >40 years
- Breast cancer where mammography not previously performed
- Residual lump after cyst aspiration
- Single duct blood stained nipple discharge
- Nipple skin change
- Triennial mammograms between ages 47 and 73 as part of the National Breast Screening Programme.
- Women at increased familial risk between ages 40 and 50 (annual screening)
- Histology on a breast biopsy indicative of increased risk of subsequent cancer development - atypical ductal hyperplasia or lobular carcinoma in situ
- Breast cancer and DCIS follow up
281
what are the contra-indications to mammography?
- breast pain without a lump
- symmetrical thickening
- before commencing HRT
- women under 40 years unless diagnosed with previous breast cancer.
282
what are the indications for mastectomy?
- patient choice
- large tumour relative to the patient’s breast such that breast conservation surgery would remove more than 20% of the breast volume,
- Multi-focal or multicentric disease
- Sub-areolar tumour
- Contra-indication to radiotherapy,
- failed conservation surgery
- Very strong family history in a young patient with breast cancer
- Bilateral prophylactic mastectomy in breast cancer gene carriers.
- Local recurrence after wide local excision
- Inflammatory breast cancer
283
what are the indications for breast conservation?
- patient choice
- operable unifocal primary tumour where resection is less then 20% volume
- tumour at a favourable site for conservation
- suitable for radiotherapy
284
what are the indications for radiotherapy in breast cancer?
- Always given to the remaining breast after wide local excision
- After some mastectomies for poor prognosis, high risk tumours
- To palliate a large or inoperable primary cancer
- To treat symptomatic bone metastases where it may cause disease regression and reduces bone pain after a few weeks
-To treat the axilla in women who cannot have axillary clearance surgery
It reduces local recurrence rates, whatever the indication, by about 2/3rds.
285
what are the clinical features of sexual dysfunction in women?
- Sexual symptoms leading to distress
- Absent/reduced sexual/erotic thoughts or fantasies
- Absent or reduced sexual excitement/pleasure during sexual activity
- No subjective arousal
- No awareness of genital response
- No initiation of sexual activity
- Orgasm absent
- Spontaneous, intrusive, unpleasant genital congestion and feeling of impending orgasm
- Negative emotions during sex
- Absent or reduced interest in sex
- Minimal changes in temperature, muscle tension, heart rate during sex
- Vulvovaginal atrophy
