OBS + GYN Flashcards

Question

What are the 4 main types of incontinence; what are they, what are the main causes and management -what are the 2 other subtypes

Answer 1

* *1. stress** - urine loss with exertion or straining (coughing, laughing, exercise) - due to failure of normal anatomic supports of the urethrovesical junction or failure of the bladder neck to close sufficiently - due to vaginal births, chronic constipation, obesity - Mx; strengthen the muscles (kegel's), occlusive pessaries, localised oestrogen (engorgement of periurethral blood supply causes thickening of the urethrl mucosa), surgical suburethral sling * *2. urge - **sensory incontinence (urine irritates bladder and causes frequency) and motor incontinence (detrusor hyperactivity- urge to micturate before bladder is full) - caused by acute/chronic UTI's, bladder cancer/stones, interstitial cystitis, can be secondary to an obstruction - mx with CBT or oxybutynin * *3. mixed - **involuntary leakage of urine associated with a combinatino of urge and stress symptoms * *4. overflow** - frequent or constant dribbling and difficulty voiding (associated with overdistension of bladder)--\> caused by MND, outlet obstruction (pelvic organ prolapse), diabetic neuropathy, radical pelvic surgery - Other types include anatomical and functional

Answer 2

-Mid stream urine; dipstick and analysis (looking for UTI) ## Footnote - Urinary diary; track input, output, frequency of voiding and incontinence - If conservative treatment options fail then can investigate with urodynamic studies--\> looks at urine flow rates, residual volume measurement, intrinsic detrusor pressure measurement

Answer 3

- Conservative; treat UTI's, weight loss, manage chest conditions (to decrease cough), limit water intake, manage medications (decrease diuretic dose), limit caffiene, bladder training - Medical; anticholinergics (oxybutinin- decreases detrusor stimulation), botox injections, pessaries - Surgical; polypopylene tension free vaginal tape

Answer 4

* *INDICATIONS;** - Symptomatic - post-coital bleeding, dyspareunia, discharge etc. - HPV 16 or 18 identified on screening - LSIL - \<30 & still present at 12 month re-test OR \>30 with no history of negative test in past 2 years - Any HSIL - Any glandular abnormality/adenocarcinoma * *PROCESS;** - Inspection of the cervix-\> need to identify the SCJ (border between pink ecto and red endocervix) and also the transformation zone (velvety red patch) - Apply acetic acid--\> ectropions, CIN and cervical cancer will all turn white--\> biopsy these portions - Apply iodine--\> dysplastic/cancer will turn yellow whilst normal tissue will turn dark brown--\> biopsy these areas - abnormal areas will have irregular margins, punctuation and mosaicism - Biopsy the most abnormal areas-\> if biopsy shows dysplastic cells in only upper 1/3rd of epithelium= LSIL (CIN1), if biopsy shows dysplastic cells spanning 2/3rd of whole depth of epithelium= HSIL (CIN 2/3) - LSIL and HSIL can spontaneously clear but can also progress to cancer--\> NEED TO COUNSEL THAT THIS IS NOT CANCER BUT A PRECURSOR AND THAT HSIL REQUIRES TREATMENT BUT LSIL DOES NOT

Answer 5

- LLETZ procedure; large loop excision of the transformation zone--\> can be done in clinic or under general anaesthetic - Cone biopsy; indicated if cancer is very likely or there are suspected glandular abnormalities--\> has to be done under general as large portion of tissue is taken * *Follow-up** - Will have testing after the procedure at 3,6 and 12 months - colposcopy and HPV

Answer 6

- Presenting features; vulval lesions, itch/discharge - RF; 90% are SCC, linked to HPV, smoking, chronic vulval irritation or inflammation, lichen sclerosis, smokers, immunosuppression -Mx; surgical excision and LN resection if \>1mm invasion, may also need chemo/radiation depending on stage

Answer 7

- Presenting features; pelvic/abdominal pain, abdo discomfort/bloating, ascites, back/leg pain, weight loss, nausea, anorexia, ovarian torsion, virilisation/increased oestrogen, upper abdo mass, pleural effusion (meegs syndrome) - RF; nulliparity, infertility, fam hx, BRCA 1/2 - Sex cord stromal tumours; arise from granulosa/thecal/stromal cells in the ovaries; become fibroma, thecoma, sertoli cell tumour - Germ cell tumour; arise from ova; teratoma, dysgerminoma, emrbyonal cancer --\> majority are malignant and release AFP/B-HCG **Staging;** 1; confined to one ovary 2; beyond ovary within pelvis 3; peritoneal implants of LN 4; distant mets (pleural effusion) * *Management;** - all managed surgically - oopherectomy for stage 1 - hysterectomy + BSO (bilateral salpingo-oopherectomy) + cytology washings + peritoneal biopsies - chemotherapy

Answer 8

- Presents as vaginal mass, discomfort, vaginal discharge, post-coital bleeding, lesion seen on VE - RF; 1-3% of gynae cancers, all same RF as cervical cancer-\> smokers, COCP, immunosuppression, STI's - Mx; surgical excision/radiation

Answer 9

-Occurs when there is abnormal proliferation of trophoblastic tissue (placental) triggered by 2 sperm fertilising 1 egg -4 main types; Complete mole; empty ova with 2 sperm Partial mole; ova with 2 sperm, can form fetal parts Invasive mole; invades the myometrium and can cause haemorrhage Choriocarcinoma; trophoblastic tissue spreads and is highly malignant, can spread to lungs -Presents with extreme symptoms of pregnancy; hyperemesis gravidarum, abnormal bleeding, high BHCG, can present due to missed periods -Managed by D+C, monitor BHCG afterwards until negative, COCP after toe nsure no early pregnancies, if BHCG not dropping then may need to use chemotherapy to eradicate tissue (esp. choriocarcinoma)

Answer 10

- Pregnancy outside of the uterine cavity--\> embryo most commonly will impant in the fallopian tubes but can also be found in the ovaries, peritoneal cavity, cervix - RF; previous ectopic, IUD, IVF, PID, tubal ligation - Haemorrhage can occur when the trophoblastic cells invade the walls of the fallopian tubes and erode into BV - Present as missed menses, abdo pain (initiailly unilateral and then becoming generalised peritonitis, PV bleeding (early spotting developing ot haemorrhage), shoulder tip pain, syncope Ix; BHCG, FBC (anaemia), G+H, UEC/LFT (before giving methotrexate), coags, TVUS (IUP will be visible by 5-6 weeks, if no IUP visible but high BHCG suspect ectopic) -Features of ectopic on USS; absent IUP, tubal pregnancy visualised in adnexa (uncommon), free fluid in pouch of douglas (if peritoneal implantation)

Answer 11

Expectant; aka conservative management (done if found incidentally, if the patient is haemodynamically stable, if BHCG is falling and theres no signs of rupture)--\> is the woman's preference, need to educate woman on need for follow up if ongoing pain/bleeding and need for BHCG testing every 2 days until level begins to fall Medical; Unruptured & haemodynamically stable, small \<3cm, no active bleeding, BHCG \<5000, routine bloods normal (FBC/UECs/LFTs)--\> use methotrexate (inhibits DNA synthesis) and perform follow up BHCG and then USS at 1 week AND advise to delay imminent pregnancy due to teratogenicity Surgical; done if preferred or evidence of rupture, unstable, excessive bleeding--\> salpingectomy (removal of tube) or salpingotomy (removal of ectopic with conservation of tube) Supportive care; IDC & monitor U/O - if severe NBM IVFs Analgesia & anti-emetics Anti-D Ig - give to Rh -ve women to prevent the formation of RhD Abs -Give info about management option chosen, what side effects to expect (N/V, abdominal pain, PV bleeding), and access to services (psychological support)

Answer 12

- Multiple pregnancy - Cervical insufficiency - Pre-eclampsia - Placental abruption - IVF - Poor maternal nutrition, limited antenatal care, low SES, prior abortions

Answer 13

**Can be based on appearance; Erythematous;**dermatitis, candidiasis, psoriasis, tinea, vulval intraepithelial neoplasia **Pallor;** lichen sclerosus, lichen simplex, vulval intraepithelial lesion **Erosions;** apthous ulcers, lichen planus, herpes **Itchy vaginal discharge;** candidiasis, bacterial vaginosis, trichomoniasis, STI, foreign body **OR can be based on cause;** Infection; candidiasis, trichomoniasis, HSV Dermatoses; dermatitis, warts, psoriasis, tinea cruris, lichen planus/sclerosus Local irritation; atrophic vaginitis, hari removal, lubricants, condoms, tight clothing, sanitary wear

Answer 14

Vasomotor; hot flushes, night sweats, insomnia--\> due to rapid decrease in oestrogen causing relief of inhibition of hypothalamus= release of adrenaline and serotonin Urogenital; -there is decreased vascularity and epithelial lining= atrophy and irritation -decreased glycogen and lactic acid= alkaline state= infection -laxity of ligaments in the pelvic floor= incontinence and prolapse Breast; dense tissue is replaced by fat= sag Bone; decreased oestrogen causes relief of inhibition of RANK= osteoclastic action and bone resorption=osteoporosis CVS; oestrogen causes high HDL/low LDL= high CVS risk Skin; decreased collagen causing thinning and drieness Psych; anxiety, irritability, forgetfullness (limited evidence)

Answer 15

Lifestyle changes; -Stress reduction (CBT, mindfullness), Regular exercise--\> resistance aids in bone strength, healthy diet, optimal weight, avoid smoking, decrease caffiene and alcohol Vasomotor symptoms; avoid trigers, sleep in cool room Address bone density; vitamin D + calcium, exercise and weight training Non-hormonal options; -Address vasomotor symptoms; SSRI/SNRI (venlaxafine- reduce hot flash), clonidine, gabapentin HRT; - recommended in women with distressing menopausal vasomotor symptoms, those with primary ovarian insufficiency (used until normal age of menopause) - CI; CVD, CVA, VTE, BrCa, AUB, smokers, active SLE, abnormal LFT - Can cause breast tenderness, fluid retention, menstrual spotting, increased risk of VTE - Women with a uterus require both oestrogen and progesterone for HRT

Answer 16

- Synthetic oestrogen and progesterone causes inhibition of ovulation, decreases receptivitity of endometrium to implantation, increases cervical mucous production to prevent entry of sperm - Also used for acne (hormonal), endometriosis, dysmenorrhoea/menorrhagia - Adverse effects; nausea, breakthrough bleeding (due to thinning of endometrium), decreased libido, mood change, HTN, altered lipid profiles, VTE Need to counsel patient to; - Begin the pill on the first day of your period (or within 5 days), the placebo tablets allow for a withdrawal bleed (pregnancy should be suspected if withdrawal bleed is missed twice), continue taking pill everyday and if one pill is missed take it the next day (can double up and still be protected if they have been taking the pill for 7 consecutive days), if more than one pill is missed take most recent pill and then continue taking pill for next 7 days whilst also using barrier contraception (as won't be protected) - This goes for vomiting and antibiotics- continue taking pill but use barrier contraception for 7 days after - Advise to seek help urgently if suffering from chest pain, leg pain, severe headache - Follow up in 4-6 months to assess side effects and check BP

Answer 17

COCP; - reduce risk of endometrial and ovarian cancer - window to take pill - aids in acne, dysmenorhea, menorrhagia, endometriosis, contraception - Risk of breast and cervical cancer, risk of VTE - CI in those over 35/obese/smokers/clotting history/breast feeding Minipill; - has to be taken at same time every day (only lasts 24 hours) - can be taken in those with thrombophilia or past VTE, those who are breastfeeding & can be used any time after pregnancy (although nothing required for first 3 weeks), can be taken by smokers \>35 and other contraindications to COCP (those with clotting disorders)

Answer 18

- MOA; IUD releases levonorgestrel (synthetic progesterone) and prevents implantation in endometrium, thickens cervical mucus, can suppress ovulation in some women (hence why some get amenorrhea) - Caution with anatomically disorted or fixed retroverted uterus due to difficulty with implantation and also risk of perforation, CI in pregnancy/breast cancer/SLE - Safe to use with breastfeeding Adverse effects; -Post insertion pain or cramps, prolonged or irregular bleeding (settles after 3-6 months), reduced menstrual flow, expulsion of devise, depression, acne, uterine perforation, risk of pregnancy Counsel; - Periods may be irregular and prolonged, may have spotting, may have amenorrhea - See your doctor if you have signs of infection; fever, abdo pain, discharge - Regularly check for presence of the strings - Replace every 5 years

Answer 19

- Is progestin that can be given orally or IM for contraception (IM), HMB or secondary amenorrhea (oral), endometriosis, HRT - CI; breast cancer, current VTE, SLE, surg (basically anyting promoting clotting), SAFE FOR BREAST FEEDING - Adverse effects; 50% become amenorrhoic, delayed return of periods, loss of BMD, weight gain, menstrual irregularity, prolonge dbleeding, acne, decreased BMD, decreased libido, androgenic effects, cholestatic jaundice - Injections given every 12 weeks for contraception, injections can be given within 2 week window of the next date

Answer 20

- Laparoscopic; involved using titanium clips to clamp off each fallopian tube - Caeserean section; done after delivery and uterine closure, the fallopian tibes are tied and cut, this method is irreversible - Hysteroscopic; given GA, cervix is dilated and a hysteroscope is inserted through the cervix, once the tubal ostia (opening) is visualised a coil is placed to obstruct it; need post op imaging to ensure correct placement -Other methods women needs to be informed about for contraception are COCP/Mirena/Depo/Implanon/minipill and also male vasectomy (which is a shorter procedure with less risk) Risks and complications; -Unsatisfactory placement of device leading to failure, bowel/bladder/vessel damage during procedure, may need to convert to open if unable to do it laparoscopically, all other general risks (NV, bleeding, reaction to gas, aetlectasis, DVT), increased risk of ectopic, pregnancy (1 in 250) adhesions, hernias, menorrhagia or oligomenorrhoea, REGRET contraindications; not 100% definite on decision, suspected or confirmed preg, active or recent pelvic infection, untreated acute cervicitis, unexplained or severe vaginal bleeding -Need to inform patient to use contraception until the procedure as the procedure can't be done if a blastocyst has already implanted, also need to use contraception until next menses after sterilisation to ensure adequacy

Answer 21

- Vasectomy - 99% effective and have a better success rate than bilateral tubal ligation in female (33x more effective than the pill) - CI; coercion or unsure about decision, large hydroceles or varicoceles, scrotal infection - Conventional vasectomy involves incising the scrotal skin and surgically separating the vas from surrounding structures and then tying and cutting the ends--\> takes longer and has more pain/recovery time - Non-scalpel vasectomy; vas is located on palpation and small incision is made, vas is brought out and clipped, placed back in scrotum and bandaid used for incision--\> quicker, less pain and recovery time Risks; -scrotal bruise, testicular/epididymal cyst, ejaculate may never clear of sperm, spontaneous recanalisation and re-anastamosis of vas deferens, epididymitis, granuloma formation leading to pain on ejaculation, chronic testicular pain, fistula formation, general surgical risks -Still need to use contraception for 6-10wks until semen analysis is done and can confirm no presence of sperm Pre-op; don't eat or drink for 3-6 hrs, bring scrotal support (jock strap), shave hair around area Post-op; can't driv immediately after, avoid exertion, use analgesia, avoid sexual intercourse for 1 week and refrain from ejaculating for 1 wk

Answer 22

RF; high maternal age, previous miscarriage, hx of STI/PID, smoking, alochol, high BMI, fever -Majority occur within the first 2-3 months of conception, rarely after 15wks Causes; -Chromosomal abnormalities; responsible for 50% -Congenital abnormalities; genetic, secondary to extrinsic factors, teratogens -Amniocentesis -Abdo trauma; fall, mva, domestic violence -Infections; TORCH -Maternal conditions; hyperthyroism, DM, PCOS -Hypercoagulable state

Answer 23

Presentation; cramping pelvic pain, PV bleeding or dark d/c, amenorrhoea, loss of pregnancy symptoms, cervical shock (retained products may irritate vagal nerve and cause low HR/BP) IX; -FBC, serum bHCG (if under 51 means not preg), group and hold + Rh status (if bleeding lots, or may need anti-d for future preg), TVUSS Mx; 1. Expectant- done if non-viable pregnancy and the patient is educated, need to be haemodynamically stable and have access to ED; need review after 7-10 days (is basically doing nothing and waiting for contents to be excreted) 2. Medical- done if small RPOC and early foetal demise and if incomplete miscarriage; given PV misoprostal and wait for contents to be excreted; need to be educated that it will be painful and have sig. bleeding and need USS in 2-3 wks to confirm no RPOC 3. Surgical- done if women prefers, if the products are infected, having heavy bleeding and unstable haemodynamically, will undergo dilation and curettage Dilation and curettage; -Prime cervix with misoprostal (also increass frequency of uterine contractions) --\> dilate and enter uterus and remove lining with curette Risks; infection, retained products, adhesions, perforation, injury to surrounding organs Counsel; menses should return in 1-2 months, attempt to conceive again in 3 months (or 2 normal periods), recieve USS early in next pregnancy

Answer 24

**Medical (MTOP)** -Give mifepristone at day 1 (progesterone antagonist that causes women to reject conceptus and cause vasoconstriction) and on day 3 give misoprostal (prostaglandin that causes uterus to contract and expel contents) Benefits; -Does not need a hospital, a surgeon, an anaesthetic, or any instrumentation --\> needs phone access to doctor -Takes 1-2 hours to expel after taking misoprostol -Cheaper - $500 -Gives the woman more privacy, and some degree of control Limitations; - More likely to fail at 2.5% - More likely to be incomplete at 5% - Carries a very slightly greater risk of infection and bleeding - CI in adrenal failure, coagulopathy, more than 9 wks preg * *Surgical abortion (STOP)** - Use D/C Benefits; - Completed in 30 painless minutes - Avoids what might be an unpleasant experience - Less likely to fail (0.2%) - More likely to be complete (1% for STOP) - Can be more easily combined with on-going contraception Limitations; - More expensive - $1000 - Risk of haemorrhage, trauma, sepsis, cervical stenosis, incompetence, Asherman’s syndrome, uterine rupture Follow up in 2 weeks to make sure; bleeding has stopped, no risk of infection, do USS to make sure no RCOP

Answer 25

- Past pre-eclampsia - Fam hx of pre-eclampsia - Antiphospholipid syndrome - Maternal age above 40 - High BMI - DM, HTN, Renal disease - Multiple pregnancy (ie twins/triplets), primigravida (first time preg) Effects; PROTEINURIA, HTN, OEDEMA Renal; proteinuria, oliguria (due to reduced GFR) Liver; elevated LFT, severe epigastric/RUQ pain Neuro; headaches, hyperreflexia/clonus, persistant visual disturbances, convulsions, stroke Haem; low platelets, MAHA, haemolysis, DIC--\> due to endothelial activation Lungs; pulmonary oedema Foetus; growth restriction -Can develop HELLP syndrome; Haemolysis, elevated LFT, low platelet count--\> causes DIC and placenta abruption

Answer 26

Prevention; in mod-high risk pt recommend aspirin daily from 12wks till birth; also need to assess mother with BP/urine dip at every visit Woman with HTN/pre-eclampsia; - antihypertensive medication is initiated or continued due reduce risk of intracerebral bleed - If the woman did not have pre-existing HTN then her HTN is likely to disappear by week 12 - Considered if HTN mod but started if HTN severe (above 160/110)--\> first line medication include methyldopa, labetalol, hydralazine - She will recieve regular monitoring of her BP, urine (for PCR), CTG and USS (for foetal growth) - If concerned about pre-eclampsia; order FBC/coag studies/LFT/UEC - Recommend delivery at 37 weeks - If her pre-eclampsia leads to organ dysfunction she may require early delivery of the baby CI; ACE-I, diuretics, ARB, atenolol

Answer 27

-Is pre-eclampsia that is then complicated by generalised tonic-clonic seizures -Eclampsia is imminent if the patient has 2 or more of the following symptoms--\> frontal headache, visual disturbance, altered LOC, hyperreflexia, epigastric tenderness -Caused by cerebral oedema caused by pre-eclampsia Mx; -DRABCD -Order FBC/UEC/LFT/Coag/G+H -Give MgSO4 (if actively seizing whilst prepping MgS04 then give benzo) -Give IV anti-htn (like labetalol) -Once stable- deliver baby -Send mother to HDU/ICU

Answer 28

- ACE-I, ARBS, warfarin (switch to LMWH as does not cross placenta), antiepileptics, lithium, isoretinoin (like roaccutane), methotrexate, NSAIDS (foetal renal impairment, premature closure of ductus arteriosus, increased risk of miscarriage) - High risk preg; extremes of age, high BMI, prev high risk pregnancy, hx of alcoholism/smoking (that have not yet ceased), hx of medical conditions (HTN, DM, epilepsy), multiparous (leads to weakening of the uterine wall causing increased risk of rupture)

Answer 29

Screening; 1. CFTS (combined first trimester screening); done at 11-14 weeks and is the triple test looking at BHCG, PAPPA, USS nuchal translucency 2. 2nd trimester scan; is the quadruple test- BHCG, UE3, AFP, Inhibin A 3. NIPT- noninvasive pre-natal testing; can detect aneuploidy but is not covered by government - If any screening indicates an abnormality the patient goes for a diagnostic test Diagnostic tests; - Chorionic villi sampling; biopsy of the placenta, done in first trimester - Amniocentesis; 2nd trimester; detects chromosomal/neural tube/genetic defects- 1% chance of spontaneous foetal loss USS scans; - Dating scan; confirms pregnancy and viability - Nuchal translucency scan; 11-14 weeks; used to detect CVS abnormalities - Morphology scan; 18-20 weeks; assess viability and looks at the anatomical structures

Answer 30

-DR C BRAVADO DR; define risk; normal pregnant women in labour don't generally get a CTG (reserved for those at high risk- maternal medical condition, multiple pregnancy, IUGR, pre-eclampsia, PPROM/PROM/Premature labour) C; contractions; should occur every 2-3 mins and last around 45s-1 min BRA; baseline fetal HR; should be 100-160 bpm V; variability; measured by the fluctuations around the fetal HR- should be 5-25 A; acceleration; need at least 2 for CTG to be normal, is 15 beats above the baseline lasting for 15s D; decelerations (should be 0) O; outcome; normal CTG? Record the; - baseline rates - baseline variability - accelerations - decelerations - management

Answer 31

Early; due to fetal head compressing on cervix and causing 'high ICP'--\> triggers baroreceptors and causes bradycardia; occurs at start of contraction and ceases with contraction; NORMAL Variable; looks like a V; the babys HR is responding at different times to the contractions and has no continuity; due to cord compression and can spontaneously resolve when the uterus stops contracting and the cord moves; however can be pathological if coupled with tachy Late; BAD SIGN; baby HR doesn't respond to contractions until after the contraction has ended; due to uteroplacental insufficiency (hypoxia); causes a 'U' shape; due to decreased BF to fetus causing decreased O2 delivery and myocardial depression; when the contraction stops and BF returns the fetal HR will increase again Prolonged; lasts longer than 90s but under 5 mins; caused by hypoxia but significance depends on clinical picture

Answer 32

- Increased insulin resistance by the mother due to increased human placental lactogen/cortisol/thyroid hormone/glucagon--\> causes an insulin resistant state--\> triggers mothers placenta to increase insulin production--\> if the mother is unable to increase her insulin production= GDM - Insulin does not cross the placenta, but glucose does--\> insulin resistance acts to increase glucose available for the foetus--\> once glucose is removed (post-birth) the fetus is at risk of developing hypoglycaemia RF; - ATSI/Asian/Indian/Islander - Past GDM or macrosomic birth - High BMI/AGE -Multiple births - Fam hx of GDM/pmhx of PCOS

Answer 33

Maternal; complications from delivery of macrosomic baby (PPH), 50% develop T2DM within 20 yrs, miscarriage, infection, preeclampsia, complications of DM (retinopathy, nephropathy) Fetal; macrosomia+complications (shoulder dystocia), RDS (hyperglycaemia reduces surfactant production), IUGR (placental insuffiency), polyhydramnios, increased risk of obesity/T2DM later in life Screening; all women do a OGTT at 24-28 weeks (if high risk the test is done in the first trimester and again at 24-28wk) Diagnosed; if the OGTT has a 2hr BSL of greater than 8.5 the pt has GDM (or a fasting above 5.1) -only need one elevated level

Answer 34

Non-pharm; Diet- refer to dietician and reduce carbohydrate intake Exercise- 20-30min a day, referal to exercise physiologist if need Pharm; Metformin; if BSL not resolving after 2 wks; crosses placental barrier but no teratogenic effects; start at 500mg OD and can increase upt to 3g; may exacerbate N/V Insulin; started if still not controlled on metformin (can be used in conjunction with metformin); if fasting glucose is high then put on long acting, if post-prandial glucose is high then do rapid acting before meals; need to check BSL at clinic every 3 days to ensure level correction -Both ceased post partum + Start aspirin to prevent PTE + folate/iodine Monitoring- 4daily BSL checks; before meals and 2hrs post prandial; aim for fasting below 5 and 2hr post below 6.7 Increased ante-natal care; referal to high risk ante-natal clinic, testing for preeclampsia, discuss GWG (if normal BMI only want to increase weight by 11-16kg), regular USS from 24wks to assess foetal growth+doppler of cord to assess placental insuffiency, regular urinalysis Birth; if greater than 4500g recommended caesar Spontaenous birth is recommended if no complications Need to consider risks of shoulder dystocia/PPH if macrosomic Post partum; - feed within 30-60min of birth - regular BSL monitoring of baby and mother; monitor for 24hr - perform OGTT at 6wks to ensure not still hyperglycaemic; if still high BSL then pt has T2DM

Answer 35

- Delivery of the placenta - indicated by a large gush of blood and then lengthening of the cord - normally lasts 5-10 min if been given syntometrine, or 30-60 if no syntometrine - need to place controlled cord contraction when the uterus contracts ## Footnote Complications; - post partum haemorrhage - retained placenta - inversion of uterus

Answer 36

- PV exam scoring system to determine if labour is likely to commence spontaneously or if induction will be required - assesses; cervical dilation, consistency, length and position plus station of presenting part

Answer 37

- Maternal; BP, HR, RR, BSL and temp - FHR, amniotic fluid (blood, meconium, not perf) - Abdo palpation findings - Cervicograph (dilation and descent of cervix) - If oxytocin has been given - Ix performed - Results of the VE; caput, moulding, station, position, presentation - Bishops score

Answer 38

Caput succedaneum= occurs when the foetal head is compressed by the dilating cervix and causes diffuse swelling of the scalp Moulding; bones of fetal head can overlap (as the fissures and sutures havent closed yet) and allow the diameter of the fetal head to reduce, allowing it to pass through the pelvis

Answer 39

- Rupture of maternal vessels in the decidua basalis where it interfaces with the anchoring villi of the placenta - The accumulating blood splits the decidua and separates the thin layer of the decidua with its placental attachement--\> the bleed can be small or dissect through the placental decidual interface - Can be complete (whole placenta detached), incomplete (part of the placenta is detached), concealed (no PV bleeding), apparant (PV bleeding) RF; - Previous placental abruption - Early preg - Pre-eclampsia - Abdominal trauma - Smoking, drug misuse - PROM, IU infection, low BMI, polyhydramnios Presentation; - dark vaginal bleeding, abdominal pain, uterine irritability/contractility, uterine hypercontractile, uterine hypercontractile state (woody feel), back pain, foetal distress, foetal demise, BUT CAN PRESENT ASYMPTOMATICALLY - need to consider aburption in mother \<20wks with sudden onset abdo pain without sign. bleeding Ix; - CTG-\> might show high freq and low amplitude, elevated baseline tone - Foetal HR-\> recurrent late or variable decelerations - FBC, G&H, antibodies, kleihauer test (measures fetal Hb in maternal blood) Mx; - ABC/RESUS/STABILISE - Give RhD Ig + give steroids if gestational age between 24-34 wks - If stable; continue to IOL - If fetal distress; straight to emergency c/s - If significant bleeding may require MTP - If mild bleeding; - Less than 37 wks; CTG, haematocrit, USS to monitor bleeding-\> continue until baby mature or continual bleeding - Over 37 weeks; stabalise and deliver (iol or c/s)

Answer 40

-Placenta previa is when the palcenta is insterted partly or wholly into the lower segment of the uterus in the third trimester of pregnancy Classified into; Major- placenta overlies the internal os Minor- placenta doesn't overly the internal os but is in the lower segment -Graded based on how much it covers the os (grade 1= lower segment but doesn't cover os, grade 4- placenta completely covers and surrounds os) RF; -previous placenta previa, previous C/S, previous TOP, multiparity, multi-pregnancy, advanced maternal age, smoking, IVF, endometritis Presentation; - Can be asymptomatic ans just picked up on USS - Can present as painless antepartum haemorrhage, maternal aneamia, foetal malpresentation Diagnosis; - Made with transvaginal USS (better than transabdo as there will be no fetus to obstruct the view) - picked up on 18wk morphology scan Mx; - If identified on 18wk scan, redo scan in 32nd week (high grade) or 36th wk (low grade) - counsel on risk of haemorrhage, may need hysterectomy or tubal ligation - give corticosteroids (if delivering before/at 37 weeks, replace iron/blood) - perform caeser at 37 wks (ideally 39 but will have higher risk of bleeding - grade 1 may be able to deliver vaginally at 36 wks Complications; fetal hypoxia, IUGR, prematurity, vasa previa, APH, PPROM

Answer 41

Vasa previa is when unprotected/unsupported foetal umbilical vessels pass over the cervical os RF; twins, low lying placenta, placenta prevua, bilobate placenta Presents; - on 3rd trimester as painless vaginal bleeding with foetal distress - VE may be able to palpate foetal vessels - Causes severe foetal distress and abnormalities in foetal HR during labour Management; - elective C/S before onset of labour- consider 35/36 wks - potential neonatal resus

Answer 42

\>500ml blood loss via vaginal birth, \>1L via caeser (if over 1L= major bleed)- leading cause of maternal morbidity 1. Tone; uterine atony is most common cause (70%) and can be due to overdistended uterus (macrosomia, mulitple pregnancy), uterine exhaustion (prolonged labour, anaesthetic use), uterine distortion (fibroids, placentra previa), intra-amniotic infection, iatrogenic (MgS04-given for preeclampsia) 2. Tissue; retained placental products (accreta), retained blood clots in atonic uterus, abnormal placentation 3. Trauma; laceration (of uterus, cervix, vagina, perineum), episiotomy tear, uterine rupture, uterine inversion (when too much traction is placed on cord without stabilising uterus) 4. Thrombin; coagulopathy- acquired (DIC,TTP, Preeclampsia) or pre-existing (haemophilia), anticoagulants Prevention; - Antenatal; correct anaemia, determine site of placenta - Labour; birht in a tertiary unit, G+H with available blood products, active third stage management (give oxytocin, controlled cord traction, placental massage, delayed cord clamping) Ix; VBG, Clotting - point of care ROTEM if available, FBC (Hb, PLTs), UECs, G&H and cross-match (2 units pRBCs), coagulation, CMP, LFTs Mx; -Resus; ABCDE-\> -apply bimanual compression TONE-\> massage fundus and give oxytocin (can also give ergometrine, misoprostol, carboprost if not responding), check placenta and membranes are complete and the bladder is empty TRAUMA-\> inspect all sites and clamp obvious bleeders TISSUE-\> DON'T MASSAGE FUNDUS AS MAY DISLODGE MORE TISSUE-\> apply controlled cord traction and attempt delivery, give oxytocin, transfer to OT is the placenta is adhered or has parts missing THROMBIN-\> activate MTP and avoid acidosis/hypothermia, give TXA2 + platelets + clotting factors THEATRE; -Ligation of arteries, hysterectomy -Tone; hysterectomy, balloon tamponade -Tissue; manual removal of products -Trauma; tissue repair

Answer 43

McRoberts; flexion and abduction of maternal hips and flexing knees so her thighs are on her abdomen; aids in straightening the lumbosacral angle and rotating maternal pelvis to increase to diameter of the pelvis Rubins 1 manouvre; suprapubic pressure applied along with the McRoberts manouvre to reduce the foetal bisacromial dimaeter and rotate the shoulders Rubin 2; hand inserted into the posterior aspect of the vagina and pressure applied to the to the posterior aspect of the anterior shoulder; rotates the shoulder towards the oblique diameter; anticlockwise Woods manouvre; only done if rubin 2 unsuccessful; introduce second hand and rotate baby Zavanelli manouvre; vaginal replacement of the head and then delivery via C/S

Answer 44

Non-pharm; psychoprohylaxis (breathing and relaxation techniques), upright positioning, activation of peripheral sensory receptors (TENS, water immersion, massage) Pharm; use a pyramid scheme - Paracetamol; early preg only - Morphine or pethidine; used if birth not expected within 4hrs (DO NOT GIVE WITHIN 2 HOURS OF DELIVERY AS CAN CAUSE FETAL RESP DEPRESSION) - Inhaled nitrous oxide; used in early labour, gives mother control but can cause confusion and disorientation - Regional analgesia; - -\> Epidural; spinal cord terminates at L1/L2, insert needle into epidural space between L3/L4 or L4/L5 and insert catheter--\>inject opiods and local anaesthetic to numb from below hips - -\>Spinal block; Needle penetrates the dura and injected into the spinal CSF encasing the spinal cord --\> used for C/S

Answer 45

-Foetal death after 20wks or over 400g birthweight, prior to complete extraction or expulsion from the mother Causes; congenital abnormality, haemorrhage, placenta issues (insufficiency or abruption), pre-eclampsia, obstetric complications (spontaneous premature labour, PROM, polyhydramnios, oligohydramnios, intrapartum asphyxia, birth trauma), cord prolapse, IUGR, liver disease, DM, infections during preg RF; IUGR, previous still birth, congenital foetal anomaly, nulliparity, smoking, maternal obesity, advancing maternal age, pre-existing DM, thrombophilia, APH DX; Intrauterine- assess wit USS to show lack of foetal heart activity At birth- no signs of life; nil beating heart, pulsating umbilical cord, definite voluntary muscle movements Mx; - SPIKES - Educate on delivery; vaginal + active 3rd stage management - If \<28wks= misoprostol per vaginum x 8 doses, if \>28wks= oxytocin infusion + ARM once labour initiated - If the death was after 20wks gestation or birthweight above 400g then the death needs to be reported to perinatal data collection and death certificate + burial needed

Answer 46

PROM; term (greater than 37wk) ROM at least 4hrs before contractions commence PPROM; premature (below 37wk) RF; multiple gestations, congenital anomoly, cervical laxity, previous self/fam hx of PROM, infection, multiparity Complications; infection (chorioamnionitis, neonatal sepsis, maternal sepsis, endometritis), abruption, cord prolapse Diagnosis made; history (when did it occur, volume, colour/smell (blood stained, clear etc), presence of contractions, gestaitonal age, obs hx) + sterile speculum exam revealing pooling of amniotic fluid in vagina (can test with nitrazine paper or amniosure (looks at alpha-1microglobulin) and can look for oligohydramniosis with USS

Answer 47

PROM - need to determine whether managing expectant or active - Expectant--\> done if GBS-ve, quick access to hosp, understands the risks and benefits, normal CTG--\> D/C home with advice to continue observations, have daily CTG use/4hrly temps/reg pad checks - Active--\> manage as pre-term labour; commence tocolysis (nifedipine), commence prophylactic Abx (penicillin), start steroids (betamethasone- 2 doses apart), MgSO4 (if less than 34 wks)--\> if tocolysis has failed or is CI then prepare for labour with oxytocin infusion PPROM - Suspected but not confirmed; admit for pad checks - Confirmed + signs of pre-term labour; suppress labour (tocolysis), obeserve and offer analgesia, give steroids, give proph Abx--\> if still no labour start PO erythromycin and d/c home w twice weekly CTG and weekly high vaginal swab - Confirmed and active labour--\> steroids + proph Abx + MGSO4, continuous CTG, aim for vaginal delivery - No evidence of labour; d/c home

Answer 48

-VBAC is successful in 60-80% of cases Indicated; maternal choice, when only one caeser has occurred, when the mother wants to maintain normal antomy and wants another vaginal delivery CI; if more than 3 caesers, previous uterine rupture or incision other than a low transverse, prev hysterotomy or myomectomy Risks; uterine rupture (esp if multiple preg, macrosomia or multiple C/S), need for blood transfusion, hypoxic ischaemic encephalopathy, PPH, episiotomy tear, death Benefits; shorter inpatient stay, low risk of DVT/PE, improves maternal bonding due to immediate skin to skin, decrease neonatal resp distress Counsel; - ask about the birth plan she wants, does she want another caeser? - ask about past c/s hx--\> when (CI VBAC if in last 18months), why (emergency or planned), type (only low transverse can have VBAC), complications after, issues with the baby? - PMHX/PSHX/SOCIAL/FMHX/MED/ALLERGIES - BRABAD--\> counsel on risks and benefits - provide time for pt to think, arrange follow up with obs/gyn - provide ways to increase VBAC success (lose weight) - If decide to book caeser; advise to come to hospital as soon as contractions start, take FBC/GH/CROSS/put on CTG, perform 4hrly VE

Answer 49

Contraception; OCP is not effective with AED that interfere with liver enzymes (ie. phenytoin, carbimazole)-\> if wanting contraception better to go for progesterone only pill or the bar/mirena Conception; -need to involve neurologist -aim to have seizures under ontrol 6 months before conception and aim to either cease AED or be on the lowest dose -switch from sodium valproate to phenytoin/carbimazole/phenobarbitone (as teratogenic) -encourage **5mg folic acid use -**if needs to continue AED, explain need for continual use as skipping medication can put mother and baby at risk -monitoring plasma levels for AED levels regularly (1-2monthly) -reduce triggers; sleep and eat well Preg/post-partum; - need to have oral Vit K in last 4 weeks of preg (as AED reduces synthesis) and also IMI of Vit K post partum (fetus and mother) - if already on AED, continue throughout labour and post partum - encourage breast feeding (low dosage of AED will pass into breast milk but monitor baby for drowsiness) - encourage not to bath baby alone, to feed baby on ground or whilst sitting, minimise carrying of baby

Answer 50

* *Primary herpes;** get serology and typing done from genital lesions - If in 1st or 2nd timester then suppress with aciclovir until 36 weeks (if labour begins less than 6 wks after tx, perform C/S, if over 6wks the vaginal delivery) - If in 3rd timester deliver via C/S and tx with aciclovir for 5days * *Recurrent herpes**; suppress mother from 36wk then do vaginal delivery if no active lesions * *Neonatal herpes;** - SEM; skin eyes mouth; pustular lesions, vesicular lesions, buccal lesions, keratitis/conjunctivitis (can cause blindness) - CNS; tremors, seizures, fatigue, bulging fontanelles, high icp - Systemic; DIC, hepatomegaly (high LFT, low platelet), respiratory, sepsis * *MX of neonatal; - **collect swabs, collect urine (HSV PCR), FBC, LFT, HSV PCR, coag, +/- LP for CSF analysis and PCR - start IV acyclovir - reassess for hearing/vision problems, recurrence and CNS impairment

Answer 51

Monozygotic; 1 single ova and 1 single sperm combine and then the conceptus splits= identical twins -are all monochorionic but can be di or monoamniotic Dizygotic= 2 ova and 2 sperm= genetically different, 50% both sexes, 25% unisex Complications of pregnancy; -exaggerated symptoms of N/V, GORD, weight gain, oedema, anaemia, IUGR (high risk in monochorionic), GDM, PET, miscarriage, APH, preterm labour, PROM Complications of the labour; -cord entanglement, asphyxiation of twin B if placental separation occurs, labour obstruction -Consider IOL at 38/39 weeks, only do vaginal birth if twin A cephalic

Answer 52

SGA; \<10th percentile - Parameters; head circumference, abdo circumference, foetal length - IUGR is SGA caused by a pathological process; can be asymmetrical or symmetrical - RF; old or young maternal age, anaemia, chronic health conditions, pre-natal drug use, congenital or chromosomal abnormalities, TORCH infection, twin;twin transfusion, multipreg, small placenta, placenta accreta/abruption/infarction Symmetrical; small parents, asian, IUGR from early age (chromosomal abnormalities) Asymmetrical; late onset pathology Ix for IUGR; - assess mother for PET and infections - offer amniocentesis--\> look for chromosomal abnormalities - foetal USS surveillance (if growth plateus or stops; indication for caeser), CTG, refer to high risk clinic

Answer 53

- Mothers with a hx of GBS, febrile mothers (in labour), PPROM over 18h, preterm labour under 37wks - give IV penicillin (or ampicillin) during labour

OBS + GYN Flashcards

(77 cards)