Obs-Gyn-Conditions Flashcards

Question

Summarise the prognosis for patients with Asherman’s syndrome

Answer 1

Recurrence 1/3-2/3

Answer 2

Asthma is a chronic inflammatory airway disease characterised by intermittent airway obstruction and hyper-reactivity. Many cellular components are involved in the asthmatic pathway, including mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells. On insult, in susceptible people, inflammation causes increased bronchial hyper-responsiveness and recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, which are usually associated with widespread but variable airway obstruction that is reversible either spontaneously or with treatment.

Answer 3

Asthma is a complex disease with underlying multi-gene association interacting with environmental exposure. The genes associated with the disease include, but are not limited to, ADAM 33, dipeptidyl peptidase 10, PHD finger protein 11, prostanoid DP1 receptor, chromosome 12q, and polymorphisms in tumour necrosis factor (TNF). Patients' genetic make-up may predispose them to hyper-responsiveness to environmental aetiological triggers. Those triggers include viral infections (e.g., rhinovirus, respiratory syncytial virus, human metapneumovirus, and influenza virus), bacterial infections ( Mycoplasma pneumoniae or Chlamydia pneumoniae ), allergen exposure (e.g., tree, grass, or weed pollen; fungi; or indoor allergens), occupational exposures (e.g., animal or chemical), food additives and chemicals (e.g., metabisulfites), irritants, or aspirin in predisposed people.

Answer 4

Asthma is one of the most common medical conditions encountered during pregnancy, occurring in 3 to 8 percent of pregnant women

Answer 5

``` presence of risk factors recent upper respiratory tract infection dyspnoea cough expiratory wheezes nasal polyposis ``` RFs FHx allergens atopic history nasal polyposis obesity gastro-oesophageal reflux

Answer 6

``` FEV1/FVC ratio FEV1 peak expiratory flow rate (PEFR) CXR FBC ``` bronchial challenge test immunoassay for allergen-specific IgE skin prick allergy testing

Answer 7

Normal Rx except: - Caution with systemic glucocorticoids - Methylxanthines, chromoglycates NOT USED - Terbutaline = parenteral B agonist of choice - Budesonide/salmeterol/albuterol used - Immunoglobulins seem safe Maternal positioning – In general, pregnant patients with acute asthma should rest in a seated or lateral position, rather than supine, particularly in the third trimester, to avoid aortocaval compression by the gravid uteru Albuterol is recommended as the short-acting beta agonist of choice. Budesonide has been the preferred inhaled glucocorticoid for use during pregnancy Salmeterol/formoterol has been recommended as the inhaled long-acting beta agonist of choice Montelukast or zafirlukast could be considered as alternative but NOT preferred therapy for mild persistent asthma or as add-on therapy to inhaled glucocorticoids

Answer 8

Possible gastrochisis, cardiac defects, autism with B agonists. Several potential areas of concern have been raised with systemic glucocorticoids: congenital malformations (primarily cleft palate [12th week]), preeclampsia, gestational diabetes, low birth weight, and neonatal adrenal insufficiency.

Answer 9

Acute asthma exacerbations are common during pregnancy and increase the risk of pre-eclampsia, gestational diabetes, placental abruption and placenta previa

Answer 10

Vulvovaginal atrophy (also referred to as vaginal atrophy, urogenital atrophy, or atrophic vaginitis) results from estrogen loss and is often associated with vulvovaginal complaints (eg, dryness, burning, dyspareunia) in menopausal women [1]. Urinary frequency and recurrent bladder infections may also occur.

Answer 11

An estimated 40% of woman post-menopause Chemotherapy and radiotherapy Prescription drugs and medicines that have anti-estrogen effects Disorders/conditions affecting the function of ovaries, surgical removal of ovarian cysts The period after childbirth; mothers who are lactating Reduced incidence of sexual activity (intercourse) in adult women Deficient production of the hormone estrogen due to cigarette smoking, physiological factors, vaginal changes, depression or intensive stress

Answer 12

An estimated 10 to 40 percent of postmenopausal women have symptoms of atrophic vaginitis

Answer 13

thinning of the vaginal walls shortening and tightening of the vaginal canal lack of vaginal moisture (vaginal dryness) vaginal burning (inflammation) spotting after intercourse discomfort or pain during intercourse pain or burning with urination more frequent urinary tract infections urinary incontinence (involuntary leakage)

Answer 14

Vaginial moisturisers / lubricants Inc sex reduces symptoms Vaginal dilators VAGINAL ESTROGEN THERAPY — Estrogen is the most effective treatment for moderate to severe symptoms of vaginal atrophy. (EDependent tumour = contra) vaginal > systemic - dec risk of thrombosis/breast cancer Ring — A silastic ring impregnated with estradiol Estradiol cream Use of an opposing progestin — A progestin is probably not necessary to protect against endometrial hyperplasia or cancer in women treated for vaginal atrophy with low-dose preparations OSPEMIFENE — Ospemifene (SERM)

Answer 15

Adverse effects — Adverse effects of vaginal estrogen therapy are uncommon. Women may complain of vaginal irritation, vaginal bleeding, or breast tenderness. Women who dislike the messiness of cream may use the insert or ring.

Answer 16

Vaginitis is inflammation of the vagina due to changes in the composition of the vaginal micro-environment from infection, irritants, or from hormonal deficiency (e.g., atrophic vaginitis). Bacterial vaginosis, trichomoniasis, and candidiasis are types of infections that cause vaginitis.

Answer 17

An overgrowth of bacterial organisms such as Gardnerella vaginalis , Mobiluncus species, Mycoplasma hominis , Escherichia coli , group B streptococci, and Peptostreptococcus species are proven to be the main cause of bacterial vaginosis. ``` douching poor or excessive hygiene antibiotic use change in feminine hygiene products and/or soap HIV infection diabetes black women IUD oral contraceptive pill use latex condom/diaphragm reproductive age menopause multiple or new sex partners tobacco increased frequency of intercourse pregnancy ```

Answer 18

Vaginitis is the most common gynaecological diagnosis in the primary care setting. [2] Women presenting with vaginal discharge account for approximately 10 million clinic visits each year. In approximately 90% of affected patients in the US, this condition develops secondary to bacterial vaginosis, candidiasis, or trichomoniasis, of which bacterial vaginosis is the most common. [3]

Answer 19

``` presence of risk factors vaginal discharge dysuria discharge adherent to vaginal mucosa prior episodes pruritus vulvodynia vaginal dryness dyspareunia erythema pale epithelium shiny epithelium decreased elasticity friable epithelium fever vaginal bleeding abdominal pain strawberry cervix ```

Answer 20

vaginal pH amine 'whiff' test of vaginal secretions wet mount microscopy of vaginal secretions Gram stain of vaginal secretions - reduced lactobacilli HIV test nucleic acid amplification test (NAAT) = chlam/gonorrhoea VDRL = syphilis serum rapid plasma reagin (RPR) test = syphilis culture of vaginal secretions = trichomoniasis 3 day growth

Answer 21

``` non-pregnant: isolated acute episode bacterial vaginosis 1st line –  metronidazole bacterial vaginosis – 1st line –  clindamycin: intravaginal cream bacterial vaginosis – 2nd line –  clindamycin: oral preparations or intravaginal ovules bacterial vaginosis – 2nd line –  tinidazole trichomoniasis – 1st line –  nitroimidazole therapy uncomplicated vulvovaginal candidiasis – 1st line –  antifungal therapy complicated vulvovaginal candidiasis ```

Answer 22

Preterm birth Preterm membranes rupture Low birth weight Inc STI risk

Answer 23

Overall, with the proper treatment, the prognosis is very good for all types of vaginitis.

Answer 24

A Bartholin's duct cyst is a non-infectious occlusion of the distal Bartholin's duct, with resultant retention of secretions. The paired Bartholin's ducts are located at the posterior vestibule and provide a conduit for secretions from the Bartholin's glands. A Bartholin's duct cyst may be asymptomatic if the cyst is small. It typically presents as a medially protruding mass at the inferior aspect of the labia majora, in the posterior introitus, and is crossed by the labium minus. Duct cysts and gland cysts are indistinguishable, and the terms are used interchangeably. A Bartholin's duct abscess may be primary (from bartholinitis) or secondary (from infection of Bartholin's cyst).

Answer 25

Bartholin's cysts arise in the duct system of the Bartholin's gland and are typically the result of occlusion of the main duct into the vestibule. The glands are believed to provide a lubricating function during sexual intercourse and a moisturising effect on the vulval surfaces. While ductal obstruction is an essential aetiological factor, the cause of obstruction is typically obscure. It may occur secondary to mucus or trauma, or from infection and oedema compressing the duct. A Bartholin's abscess more commonly results from polymicrobial non-gonorrhoeal infection of the cyst fluid rather than primary infection of the gland or duct. Common isolates from Bartholin's gland abscesses include: ``` Staphylococcus aureus Staphylococcus epidermidis Streptococcus faecalis Group B streptococci Enterococcus species Escherichia coli Pseudomonas aeruginosa Bacteroides fragilis Clostridium perfringens Peptostreptococcus species Fusobacterium species Coliforms Neisseria gonorrhoeae (no cases reported in most recent case series) Chlamydia trachomatis (no cases reported in most recent case series). ``` ``` RFs: Reproductive age Hx Bartholins Sex Trauma/surgery ```

Answer 26

2-3% Approximately 3% of women who underwent pelvic MRI (serving as controls as part of research studies) were noted to have Bartholin's gland cysts identified. Bartholin's cysts typically occur in sexually active women of reproductive age.

Answer 27

``` Vulval/perineal mass (common) • Classically a medially protruding cystic structure at the inferior aspect of the labia majora in the 5 or 7 o'clock position. Vulval pressure or fullness (common) Fever (common) Dyspareunia (common) Vulval erythema and induration (common) Spontaneous rupture (uncommon) ```

Answer 28

Microscopy and culture of abscess material - Polymicrobial growth Biopsy of vulval lesion - non-malignant cells

Answer 29

``` Asymptomatic <40 = leave alone Symptomatic: Marsupialisation Catheter Drainage Excision - not preferred due to recurrence/infection/loss of function Aspiration Silver nitrate cauterisation Alcohol sclerotherapy +BS ABx ```

Answer 30

Bartholins abscess Dyspareunia Bartholin's-rectal fistula

Answer 31

85% Rx success | May get vaginal dryness/dyspareunia

Answer 32

Bartholins cyst

Answer 33

Bartholin's cyst

Answer 34

Cervical cancer is a human papillomavirus-related malignancy of the uterine cervical mucosa.

Answer 35

Human papillomavirus (HPV) is the most important aetiological factor, with most (99.7%) tumours containing HPV DNA. HPV-16 and 18 are the 2 most common high-risk types detected in more than 70% of malignancies. Peak infection incidence is in the late teens and early 20s, but in 80% of patients, the infection resolves within 12 to 18 months with a median duration of infection of roughly 8 months * Squamous (80%) * Adenocarcinomas (15%) * Adenosquamous (3% to 5%)

Answer 36

Cervical cancer is the fourth most common malignancy in women worldwide with an estimated 530,000 new cases and 270,000 deaths in 2012. Effective screening with the Pap smear in developed countries has reduced the incidence and mortality by 75% in the last 50 years. Human papillomavirus is the most important aetiological factor. Incidence of cervical cancer correlates with early onset of sexual activity, multiple sexual partners, cigarette smoking, low socioeconomic status, poor nutrition, oral contraceptive use, and immunosuppression.

Answer 37

``` Vaginal bleeding Postcoital bleeding Pelvic pain, dyspareunia Cervical Mass Cervical bleeding Mucoid/purulent discharge Bladder / renal / bowel OB Bone pain ```

Answer 38

Vaginal or speculum examination Colposcopy - white change/+vascular Biopsy HPV testing ``` CONSIDER FBC LFT RFT CxR Renal USS CT/PET +/- contrast ```

Answer 39

Stage 1a - Local excision+LN dissection +/- hysterectomy Stage 1a-b - radical hysterectomy + lymphadenectomy +/- chemoradiation Stage 2b-4a - chemoradiation Metastatic - combined chemo +/- local ablative therapy

Answer 40

``` Bleeding Bladder instability Radiation comps: vaginal stenosis/atrophy/fibrosis Long term Sex Dys Post radio lyphoedema Preterm birth Bowel/bladder fistula ```

Answer 41

Most recurrence happens within 2 years. The tumour may spread locally; to the lymphatics (pelvic or paraaortic 11%, supraclavicular 7%); haematogenously (lungs 21%, bone 16%, liver, adrenals, brain); or transcelomically to the ovary or bowel (more common in adenocarcinomas but still very rare, <2%). The 5- year survival depends on the stage of the tumour: • Stage IA1: 100% • Stage IB2-IIB: 50% to 70% • Stage III: 30% to 50% • Stage IV: 5% to 15%.

Answer 42

``` STRONG Human papillomavirus (HPV) infection Age group HIV Multiple sexual partners Cigarette smoking Immunosuppression WEAK STDs Oral Contraceptive High Parity Uncircumcised male partner Micronutrient malnutrition Low folate Low Vit C Alcohol abuse Low socioeconomic ```

Answer 43

Cervical cancer

Answer 44

Cervical cancer

Answer 45

Urogenital chlamydia infection is a common STD worldwide. The causative organism is Chlamydia trachomatis. Infection is usually asymptomatic in both men and women.

Answer 46

Infections are caused by the bacterium Chlamydia trachomatis , which is almost always transmitted by sexual contact, and it is one of the most commonly reported sexually transmitted infections. The bacterium may cause symptoms, but in most people the infection is asymptomatic.

Answer 47

Genital chlamydia is the most common bacterial STD in resource-rich countries. A total of 202,546 chlamydia diagnoses were made in England in 2016, predominantly in departments of genitourinary medicine, where it accounts for 49% of all new STD diagnoses.

Answer 48

presence of risk factors asymptomatic cervical discharge friable cervix abnormal vaginal bleeding penile discharge

Answer 49

nucleic acid amplification test (NAAT) direct immunofluorescence enzyme immunoassay nucleic acid hybridisation tests cell culture

Answer 50

age under 25 years, sexually active new sex partner or multiple sex partners sexual activity with infected partner condoms not used

Answer 51

1g single dose azithromycin Doxycycline Erythromycin

Answer 52

``` Epididymitis Reactive Arthritis Opthalmia Neonatorium Chlamidya Pneumonia Ectopic Pregnancy Infertility Cervical cancer Pelvic Inflammatory Disease ```

Answer 53

Nearly all patients are cured with the current recommended antibiotic therapy. Potential complications in women for untreated or inadequately treated infections include PID and infertility. Men can develop prostatitis, epididymitis, and urethral strictures if not treated. Occasionally, a reactive arthritis may occur.

Answer 54

Genital tract chlamydia infection

Answer 55

Genital tract chlamydia infection

Answer 56

Genital warts are the most prevalent form of viral genital mucosal lesions and are caused by infection with several types of human papillomavirus (HPV). The infection manifests as verrucous fleshy papules that may coalesce into plaques. Lesion size ranges from a few millimetres to several centimetres. The warts may be located anywhere in the anogenital or genital area, including on mucosal surfaces. The colour can vary from whitish to flesh-coloured to hyperpigmented to erythematous. They are generally asymptomatic, but may be painful, friable, or pruritic.

Answer 57

intercourse at an early age increasing number of lifetime sexual partners increasing number of partner's lifetime sexual partners immunocompromise

Answer 58

In the UK, the estimated prevalence of detected human papillomavirus (HPV) among women aged 16 to 25 years undergoing routine cervical screening is 42%. [8] This rate decreases with increasing age. [8]

Answer 59

presence of risk factors female aged 19-22 male aged 22-26 sessile exophytic papillomas asymptomatic pruritus bleeding pain

Answer 60

Clinical Investigations to consider: biopsy anoscopy urethroscopy

Answer 61

``` Cryotherapy Trichloroacetic acid Podophyllotoxin topical Surgical removal CO2 laser ablation ```

Answer 62

Bleeding/scarring/infection from Rx SCC / adenocarcinoma Persistent hyperpigmentation Rx related hypertrophic scarring

Answer 63

There is no cure for genital warts, and recurrence is not uncommon. The goal of treatment is to eliminate visible lesions. There is no evidence showing that treatment affects the natural course of human papillomavirus infection. If left untreated, 10% to 30% of genital warts will resolve spontaneously within 3 months.

Answer 64

Gestational diabetes mellitus (GDM) has traditionally been defined as any degree of glucose intolerance with onset or first recognition during pregnancy. However, the criteria for diagnosis are controversial, and some authorities now define it as diabetes diagnosed in the second or third trimester of pregnancy that is clearly not overt diabetes. It is usually recognised at 24 to 28 weeks of gestation on the basis of abnormal glucose tolerance testing.

Answer 65

Women who develop GDM have deficits in beta-cell response leading to insufficient insulin secretion to compensate for the increased insulin demands. Risk is increased by: Age: due to age-related decreased pancreatic beta-cell reserve Obesity: leads to increased insulin resistance, which is further compounded by pregnancy Smoking: increases insulin resistance and decreases insulin secretion Polycystic ovarian syndrome: associated with insulin resistance and obesity Non-white ancestry Family history of type 2 diabetes Low-fibre and high-glycaemic index diet Weight gain as a young adult: correlates with risk Lack of physical activity: exercise increases insulin sensitivity and may impact body weight Prior GDM: GDM recurs in as many as 80% of subsequent pregnancies.

Answer 66

NICE suggests that the prevalence of GDM in England and Wales is approximately 3.5% of all pregnancies.

Answer 67

presence of risk factors elevated BMI fetal macrosomia polyuria polydipsia glycosuria UTIs

Answer 68

ORAL GLUCOSE TOLERANCE TEST one-step test option: 75-gram oral glucose tolerance test (OGTT) - Glucose level: ≥5.1 mmol/L (≥92 mg/dL) fasting; or ≥10.0 mmol/L (≥180 mg/dL) at 1 hour; or ≥8.5 mmol/L (≥153 mg/dL) at 2 hours two-step test option: 1-hour 50-gram glucose load test (GLT), followed by 3-hour 100-gram OGTT - ≥5.8 mmol/L (≥105 mg/dL) fasting; ≥10.6 mmol/L (≥190 mg/dL) at 1 hour; ≥9.2 mmol/L (≥165 mg/dL) at 2 hours; ≥8.0 mmol/L (≥145 mg/dL) at 3 hours. ``` fasting blood (plasma) glucose >7.0mmol/L random blood (plasma) glucose >11.1mmol/L ```

Answer 69

PREGNANT: Diet, exercise, metformin, glucose monitoring Add insulin if uncontrolled 32-34 weeks = fetal monitoring LABOUR Best to avoid hyperglycaemia in pregnancy: INSULIN

Answer 70

``` Maternal HTN C-Section Fetal macrosomia Neonatal hypoglycaemia Neonatal polycythaemia Neonatal jaundice Neonatal hypocalcaemia Birth injuries - shoulder dystocia Neonatal death Hypoglycaemia (insulin) Recurrent GDM T2DM ```

Answer 71

GDM recurs in 30% to 84% of subsequent pregnancies. Risk factors for GDM recurrence are older age, increased BMI, and higher weight gain between pregnancies. Eventually the majority of women with GDM develop type 2 diabetes. - metformin/exercise reduces Ten-year risk approximates 50%

Answer 72

``` advanced maternal age (>40 years) elevated BMI polycystic ovarian syndrome (PCOS) non-white ancestry Hx Smoking Dec exercise FH Low fibre/high glycemic index ```

Answer 73

Dysfunctional uterine bleeding (DUB) is a common disorder of excessive uterine bleeding affecting pre-menopausal women that is not due to pregnancy or any recognisable uterine or systemic diseases. The underlying pathophysiology is believed to be due to ovarian hormonal dysfunction. However, the exact mechanisms remain unknown. DUB usually presents as heavy, prolonged, or frequent bleeding of uterine origin.

Answer 74

age (years after puberty and before menopause) - women at both ends of their reproductive age period polycystic ovary syndrome (PCOS) other anovulatory disorders endocrine disorders - hypothyroidism and hyperprolactinaemia, are frequently associated with DUB. obesity

Answer 75

Abnormal uterine bleeding (AUB) that is not related to pregnancy is believed to occur in more than half of all women at least once during their reproductive age period. DUB is a diagnosis of exclusion that is encountered in almost half of the occasions of AUB.

Answer 76

``` uterine bleeding use of hormone therapy menstrual irregularity anaemia premenstrual molimina - Breast fullness and tenderness, weight gain, and mild mood swings are associated with ovulation. ``` Absence of these symptoms is suggestive of anovulatory DUB. hirsutism, acne, acanthosis nigricans

Answer 77

``` Pregnancy test, neg FBC - anaemia Coag profile - N Low progesterone Prolactin - hyperprolactinaemia TSH (hypo/hyperthyroid) Androgen levels - PCOS 17a hydroxyprogesterone - high in congenital adrenal hyperplasia Endometrial thickness - N NSAIDS Ovulation induction agents GnRH analogue ```

Answer 78

Progestogens - medroxyprogesterone/norethisterone | Intrauterine progesterone device

Answer 79

Endometrial hyperplasia/carcinoma possible | ID anaemia

Answer 80

In younger patients suffering from DUB due to anovulation during the first few years following menarche, the prognosis is usually excellent once regular ovulatory menstrual cycles are attained. In peri-menopausal women, DUB has also excellent prognosis after medical treatment. The problem disappears upon reaching the menopause.

Answer 81

A fertilised ovum implanting and maturing outside of the uterine endometrial cavity, with the most common site being the fallopian tube (97%), followed by the ovary (3.2%) and the abdomen (1.3%). [1] If undiagnosed or untreated, it may lead to maternal death due to rupture of the implantation site and intraperitoneal haemorrhage.

Answer 82

Two broad categories of conditions lead to ectopic pregnancy: 1) conditions that hamper the transport of a fertilised oocyte to the uterine cavity, and 2) conditions that predispose the embryo to premature implantation. However, more than half of diagnosed ectopic pregnancies are not associated with any known risk factors. Pelvic infection can increase risk by distorting fallopian tube anatomy. Factors associated with increased risk of ectopic pregnancy include smoking, multiple sexual partners, use of IUD, prior fallopian tube surgery, in utero diethylstilbestrol (DES) exposure, infertility and in vitro fertilisation, age <18 at first sexual intercourse, black race, and age >35 at presentation.

Answer 83

``` STRONG previous ectopic pregnancy previous tubal sterilisation surgery in utero diethylstilbestrol exposure of the mother intrauterine device (IUD) use previous genital infections chronic salpingitis salpingitis isthmica nodosa infertility multiple sexual partners smoking ``` ``` WEAK assisted reproductive technology (ART) first sexual encounter <18 years maternal age >35 years tubal reconstruction surgery ```

Answer 84

Global rates of ectopic pregnancy are 1.1% in the UK, 1.49% in Norway, and 1.62% in Australia.

Answer 85

abdominal pain - Typically unilateral lower abdominal pain; however, patient may present with generalised or upper abdominal pain. - Pain with vomiting may be indicative of tubal rupture. amenorrhoea - 6-8 weeks vaginal bleeding abdominal tenderness - Typically lower quadrant with voluntary guarding. - If involuntary guarding, rebound, or other acute abdomen findings present, could be warning sign of rupture. adnexal tenderness or mass blood in vaginal vault UNCOMMON haemodynamic instability, orthostatic hypotension cervical motion tenderness urge to defecate referred shoulder pain - Bleeding from Fallopian tube -> irritates diaphragm

Answer 86

Preg test - Positive TVUS - determines location - "Donut" sign OR "Ring of fire" - increased blood flow with doppler AbdoUSS - Less sensitivity that TVUS Serum HCG - <53% increase in level over 48 hours or plateau of level Uterine aspiration - intrauterine chorionic villi absent

Answer 87

Tubal Low risk - Expectant management Mod/high - methotrexate + surgery + anti-D immunoglobulin +/- post surgical methotrexate

Answer 88

Methotrexate SEs - hepato/nephrotoxicity, myelosuppression Persistent trophoblast - 4% to 15% Iatrogenic damage

Answer 89

With proper patient selection, expectant, medical, and surgical treatments are 82%, 90%, and 92% successful, respectively. The rate of recurrent ectopic pregnancy is 5% to 20%, but it rises to >30% in women with two consecutive ectopic pregnancies. The future fertility and tubal patency rates in laparoscopically treated patients are similar to those in the medically managed group. In women with a normal contralateral tube, salpingostomy does not appear to improve fertility prospects compared with salpingectomy. Neither methotrexate nor salpingectomy affect subsequent ovarian response and pregnancy with IVF in women treated for ectopic pregnancy resulting from IVF.

Answer 90

An epithelial malignancy of the uterine corpus mucosa, usually an adenocarcinoma.

Answer 91

Endometrial hyperplasia • Endometrial hyperplasia commonly results from chronic oestrogen stimulation unopposed by the counterbalancing effects of progesterone. • Complex hyperplasia with cytological atypia has been termed 'intra-epithelial endometrial neoplasia' (IEN). Unopposed endogenous oestrogenic stimulation of the endometrium • Seen in chronic anovulation, which is a feature of polycystic ovary syndrome. • In post-menopausal women, continued ovarian secretion of estradiol or conversion of the androgens androstenedione and testosterone to oestrone and estradiol occurs, by aromatase in adipocytes. • In obese women, high levels of endogenous oestrogen are due to the conversion of androstenedione to oestrone and the aromatisation of androgens to estradiol in adipose tissue. • Sex cord stromal tumours of the ovary, such as granulosa cell tumours, are also a source of endogenous estradiol. Unopposed exogenous oestrogenic stimulation of the endometrium • Exogenous oestrogen therapy (e.g., HRT) in pre-menopausal and post-menopausal women is associated with endometrial hyperplasia. Familial cancer syndromes • Family history of endometrial, ovarian, breast, or colon cancer. • Hereditary non-polyposis colon cancer (HNPCC) or Lynch syndrome. • Cowden's syndrome, related to mutation in the PTEN (phosphatase and tensin homologue protein gene) tumour suppressor gene. Carriers have an increased risk for endometrial, breast, thyroid, colorectal, and renal cancer.

Answer 92

``` STRONG Obesity - BMI over 30 triples risk Age >50 Endometrial Hyperplasia Unopposed exogenous oestrogen Tamoxifen FHx endometrial/breast/ovarian Fix PTEN syndromes PCOS Radiotherapy ``` ``` WEAK Inactivity Insulin resistance (DM 3x risk) Nulliparity / Infertility White ethnicity ```

Answer 93

Endometrial cancer is the most common gynaecological tumour in the developed world, with approximately 320,000 new cases each year. It is the sixth most common cancer overall in women. The incidence in Western countries is 10 times higher than in the developing world because of the increasing obesity epidemic.

Answer 94

PM bleeding - 5-10% will have endometrial cancer Uterine mass / adnexal Abnormal menstruation

Answer 95

Pelvic TVUSS - Thickening >5mm Endometrial biopsy + histopathology - show adenocarcinoma Hysteroscopy + histopathology Pap smear - NOT a screening test - but can identify abnormalities further up the genital tract in 50% FBC - anaemia Serum CA-125 <35 units ``` Consider: LFTs - ALP increased if liver involvement CT for initial staging CxR MRI PET scan ```

Answer 96

1. Staging surgery +/- vaginal brachytherapy 2. (stage 2+) +/- Pelvic radiation 3. +/- Chemotherapy IF ER/PR positive then add hormonal therapy plus aromatase inhibitor

Answer 97

``` Bladder instability post surgery Vaginal stenosis, atrophy, fibrosis post radio Long term sexual dysfunction Local/distant spread Lymphoedema Chemo toxicity Bowel/bladder fistulae ```

Answer 98

The 5-year survival rate for all types and grades of endometrial adenocarcinoma, following treatment, is:[163] • 75%to95%forstageI • 70% for stage II • 50% to 60% for stage III • 5% to 15% for stage IV. Because endometrial cancer is usually diagnosed in the early stages (70% to 75% of cases are in stage I at diagnosis; 10% to 15% in stage II; 10% to 15% in stage III or IV), there is a better probable outcome from endometrial cancer than from other types of gynaecological cancers such as cervical or ovarian cancer. Of cases that recur, 85% of cases of endometrial adenocarcinoma recur within the first 2 years. Recurrences for early stage disease occur at the vaginal cuff and pelvis.

Answer 99

Endometrial carcinoma

Answer 100

Endometriosis is defined as the presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature. Surgical appearance varies significantly from superficial blebs to infiltrating fibrosis. Direct visualisation confirmed by histological examination remains essential for diagnosis.

Answer 101

Low-end estimates of prevalence are 1% to 7% for women undergoing gynaecological surgery, including tubal sterilisation. The prevalence is thought to be higher in white women and in those with a lower body mass index.

Answer 102

``` STRONG Reproductive age group FHx Nulliparity Mullerian abnormalities ``` ``` WEAK White Low BMI AI Disease Late 1st sequel encounters ```

Answer 103

Dysmenorrhoea Chronic/cyclic pelvic pain Dyspareunia Sub-fertility Uterosacral ligament nodularity - rectovaginal palmpation reveals "guitar string" ligament + potential pain on palpation Pelvic mass Fixed retroverted uterus Depression Dysuria/flank pain/haematuria if bladders involved Dyschezia/haematochezia if colon involved

Answer 104

TVUS Rectal US Hysterosalpingography MRI

Answer 105

1. COCP - NSAID throughout - +ve feedback of PG synthesis 2. Progestogen 3. GnRH agonist 4. Androgen 5. Hysterectomy with bilateral salpingooophorectomy + excision of pelvic disease - Will need HRT

Answer 106

Ovarian failure post surgery | Adhesion formation post surgery

Answer 107

Often long period before diagnosis | Positive association with 2+3rd trimester complications

Answer 108

Endometriosis

Answer 109

Hydatidiform moles are chromosomally abnormal pregnancies that have the potential to become malignant (gestational trophoblastic neoplasia). Gestational trophoblastic disease includes tumours of fetal tissues, including hydatidiform moles, arising from placental trophoblasts. Syncytiotrophoblasts secrete human chorionic gonadotrophin and, therefore, this hormonal product is used as a tumour marker for the disease.

Answer 110

Not fully understood. An important component is the presence of excess paternal chromosomes. There is a greater risk for malignant transformation in the presence of a Y chromosome, suggesting a genetic component for the more aggressive form of the disease. Classified as: Benign trophoblastic tumours Hydatidiform moles Gestational trophoblastic neoplasia = malignant possibilities

Answer 111

STRONG Extremes of maternal age Prior GTD (10x risk) WEAK

Answer 112

1 in 1000 to 1200 pregnancies Patients with a previous diagnosis of hydatidiform mole have a 1% to 2% chance of molar gestation in subsequent pregnancies. Among women over 35 years of age, there is a significantly higher chance of GTD, which increases progressively as maternal age advances

Answer 113

``` COMMON Presentation in 1st trimester. Missed period Vaginal bleeding Unusually large uterus for gestational age ``` ``` UNCOMMON Headache / photophobia - exacerbated pre-eclampsia symptoms - due to high HcG SOB - anaemia Nausea / emesis - high HCG Thyrotoxicosis signs - HCG can cross react with TSH HTN Uterine bleeding Pelvic pain ```

Answer 114

Serum HCG - ABNORMALLY high for gestational age FBC - anaemia TSH - N - DO blood typing Pelvic USS - MASS CxR - high output cardiac failure (kerley B lines, fluid, alveolar infiltrates, interstitial markings)

Answer 115

DESIRING FERTILITY - Dilation and evacuation - Contraception = add antiemetic if hyper-E-Grav = add Bblocker if thyrotoxicity = add magnesium sulphate and anti-hypertensives with pre-eclampsia = caution bleeding NOT DESIRING FERTILITY - hysterectomy

Answer 116

Preeclampsia - usually asymptomatic Invasive gestational trophoblastic neoplasia - ie invasion of hydatidiform mole - CHECK HCG has gone down Choriocarcinoma Trophoblastic tumours in placenta / epithelioid Post-evacuation resp distress Ashermans syndrome Metastases

Answer 117

The risk for recurrent gestational trophoblastic disease in a future pregnancy is 1% (or about 10 times the baseline risk). Patients should be followed closely in subsequent pregnancies. Among patients with complete molar pregnancy, about 20% develop malignant gestational trophoblastic neoplasia (GTN). About 5% of patients with partial molar pregnancies will develop malignant GTN. The rate of cure for these conditions exceeds 95%.

Answer 118

Molar pregnancy

Answer 119

Molar pregnancy

Answer 120

Molar pregnancy

Answer 121

Precocious puberty STDs Childhood genital malignancy of the vagina DUB

Answer 122

``` Uterine fibroids Hypotheroidism Endometritis DUB - exclusion PCOS Cervical/endometrial carcinoma/polyp Leiomyomas (fibroid) Cervicitis Adenomyosis ``` POST COITAL - Cancers / polyps / ectropion SYSTEMIC - liver disease - RF - Clotting disorders Pharmacological/iatrogenic

Answer 123

Ectopic Miscarriage (before 22w) 2/3rd TRIMESTER Placenta praevia (placenta overlying the cervical os) Placental abruption - (premature separation of the placenta from the uterus)

Answer 124

Malignancies | Atrophic vaginitis = usually associated with intercourse

Answer 125

Uterine fibroids (leiomyomata) are benign tumours of the uterus primarily composed of smooth muscle and fibrous connective tissue. They range in size from seedlings to large uterine tumours. Grossly, these tumours are round, firm, and well-circumscribed nodules located just under the uterine serosa (subserosal), within the myometrium (intramural) or just below the endometrium (submucosal). There are often multiple tumours in a single uterine specimen. Microscopically, these nodules are made up of spindle-shaped cells with no mitotic activity or remarkable nuclear atypia.

Answer 126

STRONG Increased BMI Increased age Black ethnicity ``` WEAK HTN Dietary intake high in red meat Sex hormone exposure Nulliparous ```

Answer 127

The exact aetiology of uterine fibroids is not completely understood. There is good evidence that uterine fibroids grow from a single mutated uterine smooth muscle cell and are thereby monoclonal tumours. Initiation and promotion of abnormal growth of this single myometrial cell, however, is less well-understood. Chromosomal rearrangements including specific translocations have been identified in some specimens, which may be responsible for the initiation and proliferation of uterine fibroids. Multiple leiomyomas develop de novo rather than through a metastatic mechanism.

Answer 128

Incidence increases with age during the reproductive years such that cases occur in 20% to 50% of women older than 30 years. In another study, the estimated cumulative incidence by age 50 was >80% for black women and approaching 70% for white women. Uterine fibroids represent the most common solid tumours of the female pelvis and are the leading cause for hysterectomy.

Answer 129

``` Menorrhagia Irregular firm pelvic mass Pelvic pain Pelvic pressure Dysmenorrhoea Bloating Infertility Urinary complaints Constipation Enlarged uterus (more commonly adenomysosis than fibroids) ```

Answer 130

USS Endometrial biopsy - N ``` Consider Sonohysterography Hysteroscopy MRI Laparoscopy ```

Answer 131

FERTILITY DESIRED Myomectomy + anti-progestogen ie leuprorelin/mifepristone OR mirena OR naproxen 500mg orally ``` FERTILITY NOT DESIRED Uterine artery embolisation Myomectomy (same medical Rx post surgery) IF uterine preservation not desired = hysterectomy ```

Answer 132

``` Recurrence Labour + delivery complications: - Inc risk breach, dysfunctional labour, bleeding, inc CS risk Acute torsion Haemorrhage / anaemia Severe infection Infertility "Degenerative fibroid changes" Pregnancy loss ```

Answer 133

On cessation of medical therapy, regrowth of fibroids to pretreatment size occurs relatively quickly (within 12 weeks in the case of GnRH agonists, for example) and symptoms return. Uterine-sparing surgeries such as myomectomy and uterine artery embolisation have been shown to be effective in treating fibroid-related symptoms such as menorrhagia and those related to uterine bulk. In a collection of 5 studies involving 285 patients undergoing myomectomy for menorrhagia, 81% showed reduction or complete resolution of heavy bleeding following surgery. Unfortunately, there is some risk of recurrence of fibroids (up to 25%), which does not vary by type of surgery.

Answer 134

Blood loss >80mls per month during menses

Answer 135

In the UK, 20% of women have a hysterectomy by the age of 60, mainly for heavy bleeding, despite the fact that 40% have a normal uterus on histological examination.

Answer 136

Thinning of the vascular smooth muscle cell layer of the spiral arterioles, shifts in prostaglandin secretion towards vasodilatory prostaglandins, and disturbances in the endometrial coagulation mechanisms are often found in women with heavy menstrual bleeding.

Answer 137

Anovulatory bleeding

Answer 138

``` Endocrine Structural Pregnancy complication Infectious Haematological Physiological Iatrogenic Systemic disease ```

Answer 139

``` PCOS Hyperprolactinaemia Hypothyroidism Dysfunction of the hypothalamo-pituitary-ovarian axis Dysfunctional corpus luteum ```

Answer 140

Fibroids Polyps Adenomyosis (endometrial gland growth into myometrium)

Answer 141

Miscarriage GTD (choriocarcinoma) Ectopic

Answer 142

Endometritis Salpingitis PID

Answer 143

Coagulation disorders

Answer 144

IUD Anticoagulant therapies Tamoxifen Herbal supplements - ginseng

Answer 145

Chronic renal and liver disease

Answer 146

Transient or permanent absence of menstrual flow and may be subdivided into primary / secondary, relative to menarche.

Answer 147

Lack of menses by age 15 years in a patient with appropriate development of secondary sexual characteristics, or absent menses by age 13 years and no other pubertal maturation.

Answer 148

Lack of menses in a non-pregnant female for at least 3 cycles of her previous interval, or lack of menses for 6 months in a patient who was previously menstruating.

Answer 149

Primary ovarian failure (dysfunctional/agenesis) PCOS Mullerian anomalies HP dysfunction

Answer 150

Group I: low oestrogen, low FSH, and no hypothalamic-pituitary pathology, leading to a diagnosis of hypogonadotrophic hypogonadism. Group II: normal oestrogen, normal FSH, and normal prolactin, leading to a diagnosis of polycystic ovary syndrome. Group III: low oestrogen and high FSH, leading to a diagnosis of gonadal failure.

Answer 151

Galactorrhoea: Hyperprolactinaemia is more commonly associated with secondary amenorrhoea. History of a traumatic head injury or infection: a remote history may be elicited from the patient or parents. Headache/visual field changes: suggest a CNS tumour (e.g., craniopharyngioma). Anosmia: suggests Kallman syndrome or a complete congenital gonadotrophin-releasing hormone (GnRH) deficiency. Poor nutritional status due to systemic illness, an eating disorder, and/or low body fat: may result in hypothalamic dysfunction. Extreme athleticism, especially with low BMI, may result in a similar phenomenon. An inquiry into a patient's health status, eating habits, and body image is necessary. Emotional stress: can impair hypothalamic function, resulting in hypogonadotrophic hypogonadism. Chronic systemic illness: may present with fatigue, malaise, anorexia, and weight loss. Family history: height should be documented and compared with that of other family members. Short stature is suggestive of Turner syndrome or hypothalamic-pituitary disease. A history of familial delayed puberty, in addition to onset of menarche in the patient's mother and female siblings, should be elicited.

Answer 152

Follicle-stimulating hormone (FSH): in concert with estradiol levels, gonadotrophins help determine if amenorrhoea is due to gonadal failure, hypothalamic dysfunction, or systemic or functional causes. Serum estradiol: low levels are suggestive of either primary ovarian failure (along with elevated FSH) or suppressed hypothalamic function (low FSH). Serum prolactin: elevated levels of circulating prolactin (hyperprolactinaemia), whether idiopathic or due to a pituitary adenoma, result in hypogonadotrophic hypogonadism. For persistently elevated levels, neuroimaging is indicated to rule out intracranial neoplasm. [12] Thyroid-stimulating hormone (TSH): is indicated to rule out (primary) hypothyroidism, more commonly associated with secondary amenorrhoea. Mild or sub-clinical hypothyroidism is unlikely to result in menstrual irregularities. [17] It is proposed that elevated thyrotrophin-releasing hormone (TRH) stimulates prolactin secretion from the pituitary, suppressing FSH production. [18] Serum androgens: done for signs of hyperandrogenism. Levels such as dehydroepiandrosterone sulphate (DHEAS) and free testosterone will be elevated in patients with polycystic ovary syndrome, [19] but might be significantly higher in patients with androgen-producing tumours. Karyotype: helps to identify patients at risk for gonadal tumours, such as those with premature ovarian failure (usually secondary amenorrhoea) younger than 30 years, androgen insensitivity syndrome, or gonadal dysgenesis. [5] Cranial MRI - prolactinoma TVUSS - tumours / endometrial thickness

Answer 153

``` COMMON Eating disorders / athlete Emotional/physical stress Post contraception with depot medroxyprogesterone Hyperprolactinaemia PCOS Idiopathic premature ovarian failure Post chemoradiation ovarian failure Fragile X carrier Turner's syndrome mosaic (fewer manifestations than turners) Non-classic congenital adrenal hyperplasia (presents later) Hypothyroidism ``` UNCOMMON Malnutrition / chronic disease Empty sella syndrome Sheehans syndrome (postPart pituitary necrosis( Post-encephalitis Androgen producing ovarian/adrenal tumour A/I prem ovarian failure Cushing's syndrome Ashermans syndrome Drug induced - ie antipsychotics cause galactorrhea

Answer 154

Nausea and vomiting in pregnancy (NVP), commonly referred to as morning sickness, typically begins between the fourth and seventh week after the last menstrual period. It is characterised by nausea and vomiting that occur more frequently during the morning hours, and typically resolves in the second trimester. Hyperemesis gravidarum is the most severe form of NVP and is characterised by persistent vomiting, volume depletion, ketosis, electrolyte disturbances, and weight loss.

Answer 155

Nausea and vomiting in pregnancy (NVP) occurs in up to 75% of pregnant women. Hyperemesis gravidarum occurs in 1 in 200 pregnancies and is a severe form of NVP.[5] Its incidence is increased with multiple gestation, gestational trophoblastic disease, triploidy, trisomy 21, and hydrops fetalis.[1]

Answer 156

Progesterone has been shown to decrease gastric motility and cause nausea and vomiting in non-pregnant women. Some studies have shown that NVP is associated with elevated human chorionic gonadotrophin (hCG) levels. Other studies have shown that NVP is more common in women with high oestrogen levels and less common in those with lower oestrogen levels. Finally, a recent systematic review demonstrated an association between the presence of Helicobacter pylori and hyperemesis gravidarum.

Answer 157

``` STRONG FHx Hx Multiple gestation / increased placental size GTD Trisomy 21/18 ``` WEAK Female fetus Hx motion sickness Hx migraine

Answer 158

``` RFs 1st trimester WL >5% Absence of thyroid enlargement Absence of CNS signs Dry Mucous Membranes Dizziness Tachycardia Hypotension Ketotic breath ```

Answer 159

FBC - N Metabolic panel - may show hypernatraemia + hypochloraemia LFTs - N Serum urea and Creatinine - Increased in hyperemesis Serum TSH - may be decreased with hyperemesis Urinalysis - ketonuria Fetal USS - multiple gestation ``` Consider: Urine culture - N - to exclude pyelonephritis Serum amylase and lipase - N RUQ USS - N exclude gallstones etc Renal USS - N ```

Answer 160

``` Euvolaemic = conservative - Ginger is good FAILED - Pyridoxine (B6) OR Antiemetics eg: Meclozine Metoclopramide Chlorpromazine Prochlorperazine Promethazine Domperidone ``` HYPEREMESIS - Corticosteroids eg prednisolone

Answer 161

Uncomplicated = resolves by 20w Furthermore, women who experience NVP have been shown to have improved pregnancy outcomes. These include a decrease in miscarriages, pre-term deliveries, and stillbirths. In addition, there is a lower prevalence for reduced fetal birth weight, fetal growth restriction, and fetal mortality. Hyperemesis: In contrast with uncomplicated NVP, hyperemesis gravidarum is associated with an increase in maternal morbidity, and also increased fetal morbidity and mortality.

Answer 162

``` Mallory Weisss Pre-eclampsia Splenic avulsion Oesophageal rupture FGR Fetal mortality Wernickes Encephalopathy ```

Answer 163

Hyperemesis G / morning

Answer 164

Hyperemesis Gravidarum

Answer 165

A hypertensive syndrome that occurs in pregnant women after 20 weeks' gestation, consisting of new-onset, persistent hypertension (defined as a BP ≥140 mmHg systolic and/or ≥90 mmHg diastolic, based on at least 2 measurements taken at least 4 hours apart) with one or more of the following: 1) proteinuria (defined as urinary excretion of ≥0.3 g/24 hours of protein); 2) evidence of systemic involvement, such as renal insufficiency (elevated creatinine), liver involvement (elevated transaminases and/or right upper quadrant pain), neurological complications, haematological complications; 3) fetal growth restriction.

Answer 166

Pre-eclampsia is associated with a failure of normal invasion of trophoblast cells leading to maladaptation of maternal spiral arterioles, and is associated with hyperplacentation disorders such as diabetes, hydatidiform mole, and multiple pregnancy. The systemic maternal response results in vasoconstriction and capillary leaking, leading to hypertension and complications such as: • cerebral vascular dysregulation and oedema; • liver vascular dysregulation and oedema; and • pulmonary oedema.

Answer 167

``` Primiparity Hx FHx BMI >30 Maternal age > 35 Twin pregnancy Sub-fertility Gestational HT PCOS A/I disease Renal disease Chronic HTN ``` WEAK Interval of 10ys since last pregnancy High altitude

Answer 168

While the exact incidence is unknown, pre-eclampsia has been reported to occur in about 4% of all pregnancies in the US. When figures include patients who develop pre-eclampsia postpartum, the incidence is between 2% and 8% of all pregnancies worldwide.

Answer 169

* Headache: usually frontal; occurs in around 40% of patients with severe disease, and is one the few symptoms that predict an increased risk of eclampsia. * Upper abdominal pain: usually right upper quadrant pain; occurs in around 16% of patients with severe disease, and is a clinical symptom of HELLP syndrome. HELLP syndrome is a subtype of severe pre-eclampsia characterised by haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). * Visual disturbances: for example, photopsia (perceived flashing lights in the visual fields), scotomata, retinal vasospasm; are relatively rare but predict an increased risk of eclampsia. Cortical blindness should alert a clinician to underlying cerebral oedema. * Breathlessness: due to pulmonary oedema and may complicate pre-eclampsia. If it occurs after delivery, it is one of the main causes of maternal mortality. * Seizures: mandates admission to intensive care unit, stabilisation, and delivery. * Oliguria. ``` HTN Reduced metal movement FGR Oedema Hyperreflexia ```

Answer 170

Urinalysis - 1+ protein OR >0.3g/24hrs OR PCR >30mg/mmol Fetal USS Fetal CTG Umbilical doppler - absence of end-diastolic flow is a sign that delivery needs to occur soon. Amniotic fluid assessment - deepest vertical pocket <2cm = bad FBC - may reveal low platelets LFTs may be up Serum creatinine - may be elevated

Answer 171

ALL WOMEN ADMITTED UNTIL BIRTH unless v low risk. DEFINITIVE Rx = Delivery <32 weeks - prolonging gestation is beneficial for fetes 34-37 weeks = early delivery increases risk of fetal respiratory distress syndrome BUT earlier delivery safer for mother GIVE antenatal corticosteroids before 34 weeks if early delivery to mature fetal lungs Delivery >36 weeks = optimum ANTI-HTN - Labetalol - Nifedipine - Methyldopa - Hydralazine SEIZURE COVER - Magnesium sulfate ASPIRIN

Answer 172

``` IUGR Eclampsia Pulmonary Oedema Pregnancy-related stroke Placental Abruption Renal Failure Still-birth ```

Answer 173

Pre-eclampsia is a self-limiting condition of pregnancy that usually resolves once the placenta has been delivered, although it may persist for a few days post delivery. There are few long-term sequelae; however, there are some long-term disease associations. Women with pre-eclampsia have an increased long-term risk of type 2 diabetes, cardiovascular disease, including hypertension and stroke.

Answer 174

Pre-eclampsia

Answer 175

Pre-eclampsia

Answer 176

Miscarriage is an involuntary, spontaneous loss of a pregnancy before 24 completed weeks. After 24, the loss would be defined as a stillbirth. Miscarriage is associated with unprovoked vaginal bleeding with or without suprapubic pain.

Answer 177

Embryonic factors: - Primary embryonic disease/disorder/damage - 80% chromosomally abnormal - Particularly CNS malformation Maternal factors: - 2nd trimester Ms due to ascending infection from genital tract - Exposure to chemo/irradiation/toxicity - Asymptomatic Bacterial vaginosis (2nd T) - Large submucosal fibroids - Antiphospholipid syndrome - Cervical incompetence, insufficiency, or weakness account for most recurrent second-trimester miscarriages. - Ovulation induction, fetuses with high nuchal translucency, and in women with pre-existing diabetes mellitus In practice, the most common causes of second-trimester miscarriage are cervical incompetence, weakness, or insufficiency following invasive fetal diagnostic procedures; trans-placental fetal viral infection; trans- placental fetal bacterial infection; severe rhesus isoimmunisation

Answer 178

The main symptom of miscarriage is vaginal bleeding, and up to 30% of all pregnancies may end in miscarriage. The majority of miscarriages occur in the first trimester and <3% occur in the second trimester.

Answer 179

Miscarriage

Answer 180

Miscarriage

Answer 181

``` STRONG Older age Uterine malformation Bacterial vaginosis (2nd trimester) Thrombophilia [hyperhomocysteinaemia//antiphosp] Parental chromosomal anomaly ``` ``` WEAK Hx Infertility NSAIDs Caffeine Alcohol Smoking BMI high DM Thyroid dysfunction ```

Answer 182

``` RFs PV bleed +/- clots Suprapubic pain/crampy Low-back pain Recent post-coital bleed Uterine structural abnormality eg fibroids ```

Answer 183

Urine PREG test FBC - check Hb RhD - must assess Serum B-hCG titres - falling indicates failing pregnancy TVUS - confirms viability Serum progesterone - low titres = non-viable preg Lupus anticoagulant/cardiolipin antibodies Cytogenetic analysis of products of conception OR parental karyotyping - chromosomal abnormalities Vaginal swab - bacterial vaginosis

Answer 184

``` Manual evacuation Misoprostol 800mcg IVag AntiD immunoglobulin OR conservative (follow up 2w) Suction evacuation of the uterus + ABx Counselling ```

Answer 185

``` Incomplete evacuation of the uterus Post evacuation uterine bleeding Sepsis Uterine/cervix perforation Recurrence Ashermans syndrome Psychological dysfunction PV bleeding ```

Answer 186

Recurrent miscarriage of pregnancies with the same partner affects 1% to 2% of otherwise healthy women. These patients will require a complete assessment to identify the cause. Persistence of vaginal bleeding or spotting should raise the possibility of gestational trophoblastic disease Psychological upset after a miscarriage event is not uncommon, but the severity varies.

Answer 187

Onset of the menopause is heralded by the cessation of menses for at least 12 consecutive months, without some other reason for amenorrhoea (such as pregnancy, hormone therapy, or other medical condition). Permanent cessation of ovarian function may occur surgically by removal of both ovaries (surgical menopause) or medically, usually due to chemotherapy or radiotherapy (treatment-induced menopause) The perimenopause includes the years before and after the cessation of menses in an ovulating woman and is marked by irregular menses and menopausal symptoms. Management of menopause symptoms requires individualisation based on each woman’s clinical circumstance.

Answer 188

Av age: 51 Hot flushes (vasomotor symptoms [VMS]) are the most common menopausal symptom: moderate to severe hot flushes were reported by 24% of women aged 50 to 54 years. Prevalence decreased rapidly with age, from 15% in women aged 55 to 59 years to 6% in the 60- to 69-year age group, and to only 3% in women aged >70 years.

Answer 189

Women are born with a set number of oocytes. As this supply of oocytes becomes depleted during their early 40s, ovarian production of progesterone, estradiol, and testosterone begins to decline. Fertility also significantly declines. Before the menopause, estradiol is the predominant oestrogen. Serum estradiol levels vary throughout the menstrual cycle but average about 367 picomol/L (100 picograms/mL). After the menopause, oestrone, which is derived from estradiol metabolism in the liver and peripheral conversion of androstenedione in adipose tissue, becomes the dominant oestrogen. Serum oestrone levels average about 110 to 184 picomol/L (30-50 picograms/mL). Symptoms of the menopause, such as hot flushes and urogenital atrophy, are closely related to decreasing estradiol levels.

Answer 190

Age 40-60 Cancer Rx (chemo/radio destroy ovarian follicles) Smoking Ovarian surgery Mothers age - not a strong predictor but weak

Answer 191

``` Amenorrhoea Irregular cycle in 40s marks perimenopause Hot flushes + night sweats (7.4y duration) Vag dryness, itching Dyspareunia Pale/dry looking Decreased vag rugae Irritability + mood swings Sleep disturbance Mild memory impairment Sleep disturbance Mild memory impairment ```

Answer 192

Preg test - neg FSH - elevated >30 IU/L (>30 mIU/mL) Serum estradiol <110 -picomol/L (<30 picograms/mL) (low because estrone becomes principle oestrogen)

Answer 193

Lifestyle changes - diet, WL, reducing stress ``` HRT - Oestrogen + Progestin SERMs SSRIs - treat vasomotor symptoms Gabapentin Clonidine ``` Can give vag oestrogen-androgen combination in Vag symptoms only

Answer 194

``` Hormone-therapy related SEs: Vaginal bleeding Breast tenderness VTE Breast cancer Stroke ``` UTIs?

Answer 195

The endocrine changes are permanent, but hot flushes usually resolve in most women within 5 to 10 years. Urogenital atrophy may stay the same or worsen.

Answer 196

Pelvic inflammatory disease (PID) comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. Sexually transmitted organisms, especially Neisseria gonorrhoeae and Chlamydia trachomatis , are implicated in many cases; however, micro-organisms that comprise the vaginal flora (e.g., anaerobes, Gardnerella vaginalis , Haemophilus influenzae , enteric gram-negative rods, and Streptococcus agalactiae ) have also been associated with PID. In addition, cytomegalovirus (CMV), Mycoplasma hominis , Mycoplasma genitalium , and Ureaplasma urealyticum might be associated with some cases of PID. Symptoms include fever, vomiting, back pain, dyspareunia, and bilateral lower abdominal pain, as well as symptoms of lower genital tract infection such as abnormal vaginal odour, itching, bleeding, or discharge. In some instances, symptoms are mild or even absent.

Answer 197

Pelvic inflammatory disease (PID) is most often seen in young, single, sexually active women with a history of sexually transmitted diseases. The exact incidence is unknown because it is difficult to diagnose definitively based on clinical signs and symptoms. PID peaks in women aged 20 to 24 years.

Answer 198

``` STRONG Prev chalmidya / gonorrhoea Young age at onset of sexual activity Unprotected intercourse with multiple partners Hx PID IUD use ``` ``` WEAK Smoking Low socioeconomic status Vaginal douching Intercourse during menstruation ```

Answer 199

PID is a polymicrobial infection. Sexually transmitted organisms, especially Neisseria gonorrhoeae and Chlamydia trachomatis , are implicated in many cases; however, micro-organisms that comprise the vaginal flora (e.g., anaerobes, Gardnerella vaginalis , Haemophilus influenzae , enteric gram-negative rods, and Streptococcus agalactiae ) also have been associated with PID. In addition, cytomegalovirus (CMV), Mycoplasma hominis , Mycoplasma genitalium , and Ureaplasma urealyticum might be the aetiological agents in some cases of PID.

Answer 200

MINIMUM CRITERIA FOR DIAGNOSIS: A young, sexually active woman is presumed to have PID if she has pelvic or lower abdomen pain, no other cause for illness, and one or more of the following minimum criteria on pelvic examination: - Adnexal tenderness - Uterine tenderness - Cervical motion tenderness. ``` OTHER: Lower abdominal pain - May be associated with dysuria, dyspareunia, or uterine bleeding. Abnormal discharge Fever N+V ```

Answer 201

WCC - High Vaginal secretion PMNs - High PMNs on smean (polymorphnucs) ESR - elevated N.Gonorrhoea/Ctracho in Vag secretions ``` CONSIDER TVUSS - increased tubal wall thickness/tubo-ovarian abscess/cogwheel tubal wall MRI/CT Laparoscopy Endometrial Biopsy ```

Answer 202

1. Parenteral cephalosporin + doxycycline +/- metronidazole +/- IUD removal 2. Fluoroquinolone IF severe: IV

Answer 203

``` Tuboovarian abscess Infertility Chronic pelvic pain Ectopic Fitz-Hugh-Curtis syndrome - Comprises right upper quadrant abdominal pain associated with perihepatitis. Characterised by 'violin string' perihepatic adhesions seen at laparoscopy. Treatment is the same as for PID. ```

Answer 204

Prognosis for complete recovery is good in patients treated within 3 days of symptom onset and who are able to complete the full course of therapy. Clinical and microbiological cure rates of 88% to 100% have been reported after oral antibiotic treatment. The risks of tubal occlusion and infertility depend on severity of infection before treatment. Clinical improvement may not translate into improved fertility. Patients who have co-existent conditions (HIV infection, pregnancy, IUD, prior PID or tubo-ovarian abscess) require close observation and may require hospitalisation.

Answer 205

Ovarian cyst is a surgical, imaging, or examination finding of an enlarged, fluid-filled ovary or portion of ovarian tissue. Ovarian cysts imply a pathophysiological process involving the ovary itself.

Answer 206

Worldwide, about 7% of women have an ovarian cyst at some point in their lives. A large European screening trial revealed a 21.2% incidence of ovarian cysts among healthy post-menopausal women.

Answer 207

Physiological: cyst development as an exaggerated response to normal physiological processes; includes follicular, endometriotic, corpus luteum, and theca lutein cysts Infectious: an abscess or cystic collection of cellular debris Benign neoplastic: excessive growth of normal ovarian tissue types without dysplasia; includes serous cystadenoma, mucinous cystadenoma, adenofibroma, fibroma, thecoma, mature cystic teratoma (dermoid cyst), and Brenner's tumour Malignant neoplastic: includes serous cystadenocarcinoma, mucinous cystadenocarcinoma, endometrioid carcinoma, and immature teratoma Metastatic: invasion and growth of neoplastic tissue from another malignant source, most commonly ovarian, endometrial, colonic, or gastric cancers.

Answer 208

``` STRONG Premenopausal Early Menarche 1st Trimester PHx infertility / PCOS (due to GnRH Rx) Tamoxifen Hx / FHx endometriosis ``` WEAK Smoking

Answer 209

Pelvic pain Bloating / early satiety Palpable adnexal mass Mass features consistent with malignancy include irregularity, solid consistency, fixed mobility, nodularity, and presence of ascites.

Answer 210

TVUS - enlarged ovary or portion of ovarian tissue; may be cystic, solid, or mixed Serum CA-125 - elevated in malignancy (Levels >35 U/mL in PM women, or >200 U/mL in pre-menopausal) Doppler - penetrating vessels into solid, papillary, or central areas of malignant tumour MRI/CT Laparoscopy + histology

Answer 211

Non-malignant = serial USS Suspicious: Laparoscopy + histopathology Gynae oncology referral Acutely unwell: Laparoscopy / otomy + resus/haemodynamic support/ABx

Answer 212

``` Cyst spillage (may contain malignant cells( Cyst rupture Ovarian torsion Dyspareunia Ovarian cancer ```

Answer 213

The majority of ovarian cysts resolve spontaneously in all patient groups. Without strong supporting evidence for malignancy, management hinges on determining the likelihood of natural resolution. Surgery provides an immediate solution, but each patient group heralds different risks for recurrence. Pregnancy related: 70-100% regress

Answer 214

Ovarian cyst

Answer 215

Ovarian Cyst

Answer 216

Breech presentation in pregnancy occurs when a baby presents with the buttocks or feet rather than the head first (cephalic presentation) and is associated with increased morbidity and mortality for both the mother and the baby. There is good current evidence regarding effective management of breech presentation in late pregnancy using external cephalic version and/or planned caesarean section.

Answer 217

Breech presentation is common in early pregnancy and decreases with advancing gestational age, as most babies turn spontaneously to a cephalic presentation before birth. The prevalence at term in singleton pregnancies is 3% to 4% of all births. The prevalence prior to term at various gestations is as follows: 33% of births less than 28 weeks' gestation 14% of births at 29 to 32 weeks' gestation 9% of births at 33 to 36 weeks' gestation 6% of births at 37 to 40 weeks' gestation.

Answer 218

``` STRONG Premature fetus (can turn easily) LBW Nulliparity Fetal congenital abnormalities Hx Breech Uterine abnormalities Female (54%) ``` WEAK Abnormal amniotic fluid volume (oligo/poly) Placental abnormalities (praevia)

Answer 219

Aetiology is largely unknown. Factors that predispose pregnancies to breech presentation include preterm delivery, small for gestational age fetus, primiparity, congenital anomalies in the fetus, abnormal amniotic fluid volume, placental and uterine anomalies, and previous breech delivery. All these factors are associated with increased infant morbidity and mortality. Frank Baby's buttocks lead the way into the birth canal Hips are flexed, knees are extended, and the feet are in close proximity to the 65% to 70% of breech babies are in this Complete Baby presents with buttocks Both the hips and the knees are flexed; the baby may be sitting cross-legged. Incomplete or footling One or both of the baby's feet lie below the breech so that the foot or knee is lowermost in the birth This is rare at term but relatively common with premature fetuses.

Answer 220

COMMON Buttocks or feet presenting part Fetal head under costal margin Fetal HR above maternal umbilicus UNCOMMON Subcostal tenderness Pelvic/bladder pain

Answer 221

Transabdo USS | TVUSS

Answer 222

<37w = specialist >37w 1) external cephalic version - Contraindications include multiple pregnancy (except after delivery of a first twin), ruptured membranes, current or recent (<1 week) vaginal bleeding, rhesus isoimmunisation, other indications for caesarean section (e.g., placenta praevia or uterine malformation), or abnormal electronic fetal monitoring. 2) Tocolytic - salbutamol / terbutaline, ritodrine + Anti D 3) UNSUCCESSFUL = C section 4) No imminent delivery needed = vaginal breech delivery

Answer 223

Compared with cephalic presentation, persistent breech presentation has increased frequency of cord prolapse, abruptio placentae, pre-labour rupture of membranes, perinatal mortality, fetal distress (heart rate <100 bpm), preterm delivery, lower fetal weight. ``` C section complications: PE Bleeding Infection Iatrogenic damage to bladder/bowel ``` LONG TERM - repeat c section Placenta praevia, uterine rupture, emergency hysterectomy etc...

Answer 224

No differences at 2 years postnatal were found between planned caesarean section and planned vaginal birth in maternal outcomes of breastfeeding; relationship with child or partner; pain; subsequent pregnancy; incontinence; depression; urinary, menstrual, or sexual problems; fatigue; or distressing memories of the birth experience. However, planned caesarean section was associated with a higher risk of constipation. Adult intellectual performance at 18 years of age was not affected by mode of delivery. There was also no difference in the risk of death or neurodevelopmental delay.

Answer 225

Epithelial ovarian cancer is a relatively uncommon gynaecological cancer occurring when there is malignant transformation of the ovarian capsule epithelium. [1] The epithelium covering the ovary consists of the same epithelial cells that line the peritoneal cavity. Thus, epithelial ovarian cancer and primary peritoneal cancer occur via the same pathophysiology and are treated with the same basic principles. Sub-types of ovarian cancer include epithelial, germ cell, and sex-cord stromal tumours. The primary focus of this monograph will be the epithelial ovarian sub-type.

Answer 226

In the UK there are approximately 7100 new cases of ovarian cancer per year and 4300 deaths from the disease each year. The median age of patients with ovarian cancer is 60 years, with an estimated lifetime risk of 1 in 70. Although the overall 5-year survival rate is relatively low (46%), it varies by age: women younger than 45 years of age are far more likely to survive (77%) than women aged 75 years and older (20%). W>B

Answer 227

The aetiology of ovarian cancer is poorly understood at present, and further studies are warranted. There are promising data implicating genetic causes in specific populations, such as breast ovarian cancer gene 1 (BRCA1) and breast ovarian cancer gene 2 (BRCA2). Also, in patients with hereditary non-polyposis colon cancer, mutations MSH2 and MLH1 can be associated with ovarian cancer.

Answer 228

``` STRONG BRCA1 mutation (AD inheritance) BRCA2 mutation Increased Age FHx breast/ovarian Never used OCP Lynch II syndrome ``` WEAK Nulliparity Obesity HRT

Answer 229

COMMON ``` Pelvic mass (adnexal) GI - abdominal bloating, nausea, dyspepsia, early satiety, diarrhoea, and constipation Symptom duration 3 months Ascites Distention ``` UNCOMMON Pleural effusion

Answer 230

Pelvic USS - presence of solid, complex, septated, multi-loculated mass; high blood flow CT scan - peritoneal thickening, enlarged lymph nodes, ascites, omental thickening, liver metastases CA-125 - >35 units (>65 in PM = usually cancer) Histopathology - infiltrative destructive growth best demonstrated by clusters of disorganised cells, usually with desmoplasia CONSIDER PET

Answer 231

Grade 1/2 - comprehensive surgical staging Grade 3 - chemotherapy (carboplatin + docetaxel) Stage 2/3/4 - just chemotherapy

Answer 232

``` Chemotherapy SEs Blood loss/infection from surgery Neutropaenic sepsis/fever Bowel obstruction BM suppression ```

Answer 233

The majority of patients (70% to 80%) will achieve a complete clinical remission after first-line therapy for ovarian cancer (debulking surgery followed by chemotherapy). When patients relapse, the most important prognostic factor is the treatment-free interval or time from completion of first-line therapy to diagnosis of recurrence. For patients with platinum-resistant or refractory disease, the overall prognosis is grim, as the likelihood of responding to second-line agents is estimated between 15% to 20%. For patients who have recurrent disease that is platinum sensitive, response rates for second-line therapy improve as the treatment-free interval increases.

Answer 234

Ovarian cancer

Answer 235

Placenta praevia (PP) is defined as the placenta overlying the cervical os. It can be complete, partial, marginal, or low-lying. Partial, marginal, and low-lying PP may resolve as pregnancy progresses. In women with a scarred uterus (most commonly from a prior caesarean section), PP may be associated with an abnormally adherent placenta, where the placenta attaches to the myometrial layer of the uterus. Vasa praevia, where the fetal vessels lie over the internal cervical os, is an associated condition.

Answer 236

Occurs in 0.3% to 0.5% of pregnancies worldwide. The condition is uncommon in first pregnancies. One caesarean section increases the incidence in the next pregnancy to about 0.6%. Subsequent caesarean sections increase the risk only slightly compared with one procedure.

Answer 237

Advanced maternal age, [12] multiple pregnancies, and tobacco use increase the risk of placenta praevia (PP), but the mechanisms are uncertain. With the exception of the risk factor of previous uterine scarring, it is likely that multiple risk factors contribute together to the occurrence of the condition.

Answer 238

STRONG ``` Uterine scarring (prior C) - do mid trimester USS Infertility Rxs (2% risk) Hx ``` WEAK ``` Increased age Multiparity Smoking Induced abortion Placental abnormalities Short interpregnancy intervals Illicit drug use ```

Answer 239

Painless PV bleeding 2/3 trimester - {{{Digital vaginal examination should not be performed on women with active vaginal bleeding until the position of the placenta is known with certainty.}}} Absence of cervical/vaginal causes of bleeding on speculum Lack of uterine tenderness Low BP / tachycardia - haemorrhage

Answer 240

Uterine USS + doppler - position of placenta FBC - potential anaemia G+S + crossmatch CONSIDER MRI placenta INR/PTT fibrinogen - possible DIC Kleihauer-Betke test - if Rh+

Answer 241

- If needing to deliver <34 weeks -> CORTICOSTEROIDS - Potential tocolytics if preterm labour - Labour desirable -> C section

Answer 242

``` Anaemia C-section complications Preterm birth Abnormally adherent placenta DIC IUGR Fetal death Sudden infant death syndrome ```

Answer 243

About 85% of placentas that are praevia at about 15 to 20 weeks and about one third that are praevia at 20 to 23 weeks will no longer be praevia at the onset of labour. Prognosis may be worse in complete versus partial placenta praevia.

Answer 244

Low-lying placenta seen in early pregnancy that has migrated away from the cervical os

Answer 245

Where the umbilical cord inserts upon the chorioamniotic fetal membranes instead of the placental mass

Answer 246

Where the placenta has 1 or more accessory lobes

Answer 247

Where the placenta has 1 or more accessory lobes

Answer 248

The premature separation of a normally located placenta from the uterine wall that occurs before delivery of the fetus. Abruption may be revealed, when blood escapes through the vagina, or concealed, when the bleeding occurs behind the placenta, with no evidence of bleeding from the vagina. [1] Abruption may be partial, affecting only part of the placenta, or total, involving the entire placenta. Abnormal uterine artery Doppler velocimetry at 23 to 24 weeks of gestation may carry an increased risk of abruption later in pregnancy

Answer 249

Placental abruption complicates about 0.3% to 1% of births. The incidence has risen more in black women than in white women.

Answer 250

Direct abdominal trauma may cause separation of the placenta. Indirect trauma may shear the placenta off the uterine wall. Cocaine use causes vasospasm that may lead to placental separation.

Answer 251

Placenta praevia

Answer 252

STRONG ``` Chronic HTN Pre-eclampsia Smoking Cocaine use Trauma Chorioamnionitis Uterine malformations Hx Oligohydramnios ``` WEAK ``` Prev C-S Preterm ROM Multiparity Inc age Polyhydramnios Multiple pregnancy Uterine Fibroids Thrombophilias ```

Answer 253

PV bleed (bleeding associated with abdominal pain, as compared with the painless bleeding of placenta praevia) Abdo pain Uterine contractions Uterine tenderness - may feel hard, with the consistency of wood. UNCOMMON Lower back pain Fetal death - common if 50% has detached

Answer 254

Fetal CTG - abnormalities in the tracing that suggest an abruption: late decelerations, loss of variability, variable decelerations, a sinusoidal fetal heart rate tracing, and fetal bradycardia, defined as a persistent fetal heart rate below 110 beats per minute Hb + Hct - N/L Coag studies - abnormal K-B test for Rh+ USS - retroplacental haematoma (hyperechoic, isoechoic, hypoechoic); pre-placental haematoma (jiggling appearance with a shimmering effect of the chorionic plate with fetal movement); increased placental thickness and echogenicity; sub-chorionic collection or marginal collection

Answer 255

Unstable fetus / mother - Deliver - Corticosteroids if <34w - Post op uterotonic - haemostatic preparations post op

Answer 256

``` Hypovolaemic shock DIC Surgical/anaesthetic risks IUGR Neurological infant impairment Preterm birth Perinatal death Acute RF ```

Answer 257

The maternal prognosis is linked primarily to the severity of the abruption, particularly to the amount of blood lost and to the presence or absence of associated coagulopathy. For the fetus, the prognosis depends primarily on the gestational age at which the abruption occurs, and on the degree of the abruption. Abruption is also an important cause of indicated preterm birth and is associated with an increased risk of perinatal asphyxia and long-term neurodevelopmental handicap.

Answer 258

Placenta praevia

Answer 259

Placental abruption

Answer 260

Placental abruption

Answer 261

Defined by BP ≥140/90 mmHg on 2 occasions during pregnancy after 20 weeks' gestation in a previously normotensive patient, without the presence of proteinuria (<300 mg in 24 hours).

Answer 262

Hypertension is the most frequently identified medical problem during pregnancy. Hypertensive disorders are a common cause of morbidity and mortality during pregnancy, contributing to poor maternal and neonatal outcomes if not adequately managed. In the UK, gestational hypertension and pre-eclampsia complicate around 5% to 6% of pregnancies. Healthy nulliparous women may experience higher rates of gestational hypertension (6% to 17%) compared with multiparous women (2% to 4%). African-American women may be at greater risk than white women. Gestational hypertension occurs more often in twin pregnancies than in singleton pregnancies.

Answer 263

The exact aetiology of gestational hypertension remains unknown. It is thought that insulin resistance may mediate the clinical onset of hypertension in pregnancy.

Answer 264

STRONG Nulligravity WEAK ``` Black/hispanic Multiparity Obesity Small mother at gestation T1DM Migraine ```

Answer 265

Previously normotensive BP 140/90mmHG after 2 readings 6+hrs apart Measurement of diastolic BP during pregnancy should include K5 or the disappearance of the Korotkoff sound as opposed to K4 or the muffling of this sound.

Answer 266

<37w 1) Lifestyle modification 2) Methyldopa 250mg BD Oral 3) Labetalol 100mg BD orally 4) Nifedipine 30-60mg orally OD >37w - induce labour if mild/mod - REDUCE BP if >160/110mmHg

Answer 267

Pre-eclampsia CVD for mother later in life Fetal/neonatal complications - increases the risk of macrosomia, caesarean delivery, and admission of the neonate to the intensive care unit. Mean gestational age and mean birth weight tend to be lower.

Answer 268

gestational HTN

Answer 269

gestational HTN

Answer 270

Rh incompatibility is caused by destruction of fetal erythrocytes from transplacental passage of maternally derived IgG antibodies. IgG antibodies are produced by the maternal immune system, usually against the rhesus D (RhD) antigen. These antibodies can freely cross the placenta, binding to and destroying RBCs. More than 50 known RBC antibodies potentially cause Rh incompatibility. The consequence is progressive fetal anaemia, which, untreated, may ultimately lead to hydrops fetalis (collection of fluid in serous compartments) and death.

Answer 271

About 15% of the white population has an RhD-negative blood type. In the UK, about 16% of the white population is RhD negative. In 2005, it was estimated that about 65,000 RhD-positive babies were born in the UK to women who were RhD-negative (accounting for 10% of all births).

Answer 272

Exposure of an RhD-negative mother to RhD-positive fetal RBCs results in the generation of B lymphocyte clones that recognise the foreign RBC antigen, and promote production of IgG. Memory B lymphocytes await the reappearance of RBCs containing the respective antigen in a subsequent pregnancy. When challenged by these antigenic erythrocytes, the lymphocytes differentiate into plasma cells and produce IgG. Maternal IgG crosses the placenta and attaches to fetal erythrocytes that have expressed the antigen. These RBCs are then sequestered by macrophages in the fetal spleen, where extravascular haemolysis occurs, producing fetal anaemia. The fetus attempts to compensate by increasing extramedullary haematopoiesis. This results in hepatosplenomegaly, portal hypertension, cardiac compromise, tissue hypoxia, hypoviscosity, and increased brain perfusion. Extreme fetal haemoglobin deficits of 70 g/L (7 g/dL) or greater can ultimately lead to hydrops fetalis (collection of fluid in serous compartments) and intrauterine fetal death, unless corrected by intrauterine fetal transfusion or neonatal exchange transfusion following delivery.

Answer 273

STRONG ``` Maternal RhD negative status Maternal sensitisation to RhS Invasive fetal procedures Placental trauma Abortion Multiparity Previous Hydrops (Rh incompatibility) ``` WEAK External cephalic version Molar pregnancy Ectopic pregnancy

Answer 274

Maternal blood type - Rh -ve Maternal serum AB Rh screen - +ve Consider fetal/paternal blood typing Consider USS - may show subcutaneous oedema, ascites, pleural effusion, or pericardial effusion if untreated Doppler in MCA can predict anaemia in fetus if elevated ≥1.5 MoM

Answer 275

Anti-D immunoglobulin Specialist: intravascular intrauterine blood transfusions

Answer 276

Hyperbilirubinaemia and kernicterus Transfusion related fetal bradycardia Fetal / neonatal hydrops Neonatal anaemia - when haemoglobin falls <8 g/dL

Answer 277

RhD alloimmunisation is a disease that will usually progress during the pregnancy and in future pregnancies. Therefore, follow-up of these patients is required through antibody titres and fetal middle cerebral artery Doppler ultrasound during subsequent pregnancies.

Answer 278

Rh incompatibility

Answer 279

Rh incompatibility

Answer 280

PMS is characterised by cyclical, physical, and behavioural symptoms occurring in the luteal phase of the normal menstrual cycle (the time between ovulation and onset of menstruation). Symptoms must not be present at other times through the cycle, must also cause significant impairment, and must not represent an exacerbation of another disorder, and at least one symptom-free week must be present.

Answer 281

Clinically significant PMS is thought to affect 3% to 8% of women, with a point prevalence of 20% to 30% in some studies. Rates of PMDD are estimated to be between 1.2% and 10%. W>B

Answer 282

PMS and PMDD occur in women with ovulatory cycles, and they do not occur before puberty or after menopause. This association implies a role of gonadal steroid hormones. Absence of PMS/PMDD during pregnancy (in addition to supporting evidence) suggests that changing levels of gonadal steroid hormones play a role in PMS/PMDD.

Answer 283

STRONG Post-pubescant/Premenopausal ``` WEAK FHx Mood disorders Cigarette smoking White women Sexual abuse/trauma ```

Answer 284

COMMON - ALL resolve post menstruation ``` Abdo bloat Fatigue Breast tenderness Headaches Labile mood Adverse effects on life Increased appetite Difficulty concentrating ``` UNCOMMON Insomnia/hypersomnia GI upset Palpitations Hot flushes

Answer 285

Symptom diary - predominance in luteal phase TFTs - rule out - N FSH - rule out Meno - N Depression screen

Answer 286

``` MILD Lifestyle mod CBT NSAID B6/12 + calcium carbonate COC ``` ``` SEVERE COC SSRI GnRH agonist Surgical oophorectomy ```

Answer 287

There are no reports documenting spontaneous remission before the menopause. It is difficult to define spontaneous remission, because women could remit during pregnancy only for symptoms to return subsequent to pregnancy. Women with PMS/PMDD tend to suffer throughout their reproductive life.

Answer 288

Premenstrual syndrome

Answer 289

Syphilis is a sexually transmitted infection caused by the spirochaetal bacterium Treponema pallidum , subspecies pallidum . It is found only in human hosts. Acquired infection is transmitted through direct person-to-person sexual contact with an individual with early syphilis. Vertical transmission from mother to baby causes a congenital infection. Most sexual transmission of syphilis probably occurs from the genital and mucous membrane lesions of primary and secondary syphilis. Syphilis has often been described as the great imitator because many of the symptoms and signs are difficult to distinguish from other diseases.

Answer 290

Syphilis is a common, worldwide STD, with approximately 10.6 million new cases reported in 2005 and 2008, according to the World Health Organization (WHO). In 2014, 61% of cases of primary and secondary syphilis occurred in MSM.

Answer 291

Syphilis is caused by Treponema pallidum subspecies pallidum , a motile spirochaete bacterium. Although often described as spiral or coiled, high-resolution time-lapse microscopy has confirmed earlier reports that T pallidum has a flat-wave morphology. Humans are its only natural host. In-vitro culture is not possible. Entry of T pallidum probably occurs via the lesions of primary and secondary syphilis through areas of minor abrasion as a result of sexual intercourse at genital and mucous membrane sites. Oro-genital sex is an important route of transmission and, therefore, transmission can occur despite the use of condoms for penetrative sex. Other modes of transmission are blood transfusion and transplacental transmission from mother to fetus.

Answer 292

``` Sexual contact with infected MSM Drug use Commercial sex Multiple partners HIV/other STDs Syphillis during pregnancy ```

Answer 293

COMMON Genital ulcer - initially a macule, then develops into a papule, then ulcerates. Usually indurated, solitary, and painless 14-21 days after exposure. Lymphadenopathy Diffuse rash - Symmetrical macular, papular, or maculopapular rash in secondary syphilis. Usually non-itchy, over the trunk, palms, soles, and scalp. ``` Constitutional symptoms Mouth ulcer Asymptomatic (latent syphilis) Tremor Headache Meningismus Eye pain Hearing loss Seizures Peripheral oedema Jaundice Peripheral neuropathy Areflexia Angina Dyspnoea Organomegaly ``` UNCOMMON ``` Patchy alopecia Condylomata lata - Oval papules in genitalia (2ndary syphilis) Memory impairment/dementia Visual disturbance Argyll-robertson pupils (small irregular pupils non-constricting to light, but do to accommodation) Loss of vibration sense Ataxia Loss of anal/bladder sphincter control +ve rombergs sign Diastolic murmur ``` ``` CONGENITAL Sx Rhinitis (can be bloody) Hepatosplenomegaly Miscarriage/stillbirth Premature labour/IUGR Neonatal skin rash Tibial bowling Craniofacial malformation (frontal bossing) Tooth abnormalities Necrotising funisitis ```

Answer 294

Dark field microscopy of lesion swab - coiled spirochaete bacterium viewed Serum treponemal enzyme immune assay (EIA) - +ve serum T pallidum particle agglutination (TPPA) - +ve serum T pallidum haemagglutination (TPHA) - +ve serum Venereal Disease Research Laboratory (VDRL) test - +ve Lumbar puncture - WCC >10, Protein >50mg/dL, VDRL +ve, TPHA/TPPA/FTA-ABS +ve ``` CxR Echo MRI/CT brain HIV test Fetal USS FBC LFTs Audiometry ```

Answer 295

1) IM benzathine benzylpenicillin + Prednisolone PENICILLIN ALLERGY = Oral Doxycyclone

Answer 296

Jarisch-Herxheimer reaction - acute reaction to ABx therapy to treponemes Allergic reaction to penicillin Iatrogenic procaine reaction - occurs when IM benzylpenicillin is administered IV HIV infection Asymptomatic progression of disease

Answer 297

Natural course of infection Treatment is curative once antibiotic treatment is completed. However, re-infection may occur if there is further exposure to syphilis. The natural course of organ-specific involvement is determined by the stage of syphilis at diagnosis and whether appropriate treatment has been administered. Follow-up of organ-specific complications requires specialist opinion (e.g., cardiology assessment of aortic regurgitation; neurology assessment of tabes dorsalis).

Answer 298

Toxic shock syndrome (TSS) is an exotoxin-mediated illness caused by bacterial infection. Organisms commonly responsible include group A streptococcus ( Streptococcus pyogenes ), or methicillin-sensitive (MSSA) or methicillin-resistant (MRSA) Staphylococcus aureus . Although the presenting signs and symptoms can be non-specific (e.g., fever, chills, myalgias, headache), the course of the disease is precipitous, and shock and multi-organ system failure occur early in the course of the disease. Staphylococcal TSS can be split into 2 groups: menstrual TSS, which occurs in women during menstruation with extended use of a single tampon or, historically, with highly absorbable tampons; and non-menstrual TSS, which can result from a variety of staphylococcal post-partum vaginal and caesarean wound infections.

Answer 299

Invasive infection complicates about one third of group A streptococcal infections, and it is estimated that there are 3.5 cases per 100,000 people. People of all ages are affected and most do not have underlying diseases. [25] About 85% of invasive infections occur sporadically in the community, 10% are hospital acquired, 4% occur in residents of long-term care facilities, and 1% occur after contact with an infected person. Most cases of staphylococcal TSS are due to methicillin-sensitive (MSSA) Staphylococcus aureus. Non-menstrual cases now account for about 55% of all staphylococcal TSS.

Answer 300

Menstrual TSS occurs in women during menstruation with extended use of a single tampon or, historically, with highly absorbable tampons. Non-menstrual TSS can result from a variety of staphylococcal postpartum vaginal and caesarean wound infections, including mastitis, therapeutical abortions, episiotomy infections, endometritis, and infected abdominal wounds. Sinusitis, septorhinoplasty, osteomyelitis, arthritis, burns, cutaneous infections, soft-tissue infections, enterocolitis, endovascular infections, visceral abscesses, and post-influenza respiratory infections have also been implicated.

Answer 301

``` STRONG DM Alcoholism Minor trauma/injuries with bruising Surgical procedures Single tampon use Highly absorbent tampons ``` WEAK NSAID Contraceptive sponges Untreated strep throat

Answer 302

``` Severe diffuse/localised pain in an extremity (streptococcal) Fever Localised swelling/erythema Desquamating rash Hypotension ``` ``` UNCOMMON Diffuse erythematous rash Influenza-like symptoms Muscle tenderness/weakness Abdominal pain/tenderness Myocarditis features Hypothermia (shock) ```

Answer 303

Microscopy and culture - blood, wound, fluid, tissue - +ve for group A strep / staph A FBC - Inc WCC, thrombocytopenia, left shift, anaemia PT/APTT - increased if DIC + staphylococcal infection Serum urea + creatinine - increased Urinalysis - haemoglobinuria precedes hypotension with streptococcal disease LFTs - increased transaminases + bilirubin CK - increased in new fasciitis Calcium + albumin - low in streptococcal Lactic acid - increased in sepsis

Answer 304

SUSPECTED Supportive - fluids, vasopressor, source control, etc Empirical therapy - clindamycin + vancomycin CONFIRMED STREP Clindamycin + benzylpenicillin or vancomycin Potential IVIG CONFIRMED STAPHY Clindamycin + oxacillin or vancomycin

Answer 305

``` Bacteraemia ARDS DIC RF Wound sequela Neuropsychiatric sequelae ```

Answer 306

Mortality ranging from 30% to 85% has been reported for streptococcal toxic shock syndrome (TSS), despite prompt antibiotic therapy. Shock is the most important predictor of death. Advanced age, hypotension, and multi-organ system failure are significantly associated with increased mortality. Mortality for menstrual cases is now 1.8% compared with 6% mortality associated with non-menstrual cases.

Answer 307

Toxic shock syndrome

Answer 308

Postnatal depression refers to the development of a depressive illness following childbirth and may form part of a bipolar or, more usually, a unipolar illness. Postnatal depression is not recognised by current classification systems as a condition in its own right, but the onset of a depressive episode within 4 weeks of childbirth can be recorded via the perinatal-onset specifier in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Answer 309

The overall prevalence of clinically significant postnatal depressive symptoms is estimated to be 7% to 19%, although estimates vary.

Answer 310

STRONG ``` Hx depression, anxiety Stress Poor social support Discontinuation of anti-depressants Sleep deprivation Genetic susceptibility Domestic violence ``` WEAK ``` Postnatal hypomania Personality disorder Birth complications Poor socioeconomic status Age <16 ```

Answer 311

The aetiology is poorly understood but is likely to involve an interaction between psychological, social, and biological factors.

Answer 312

``` Depressed mood Anhedonia Decreased energy Decreased concentration Appetite change Feelings of guilt Loss of confidence Sleep disturbance Obsessive thoughts Suicidal ideation ``` OTHER Self harm FHx Psychotic symptoms

Answer 313

Depression screen questions TFTs - rule out hypothyroid FBC - anaemia exclusion Urine drug screen - N Brain CT/MRI - in case structural abnormality

Answer 314

Facilitated self help. Lifestyle Antidepressants - Sertraline / paroxetine

Answer 315

Impaired bonding with baby Neglect of baby Suicide Bipolar Disorder

Answer 316

Episodes of postnatal depression last 3 to 6 months on average, but a few women remain depressed at 1 year Women with a first episode of postnatal depression have a higher risk of subsequent postnatal depression (41% versus 18%) but a lower risk of non-postnatal depression (38% versus 62%). Approximately 14% of women with first-time psychiatric contacts during the first postnatal month converted to a bipolar diagnosis within the follow-up period, compared with only 4% of women with a first psychiatric contact unrelated to childbirth.

Answer 317

There is no internationally recognised definition of premature labour. Preterm birth occurs between 24 and 37 weeks' gestation. In two-thirds of cases it occurs following spontaneous onset of labour. Only a minority of women who present with preterm contractions known as threatened premature labour (TPTL) progress to actual labour and delivery. The remainder of preterm birth is due to iatrogenic delivery, most commonly because of pre-eclampsia and intrauterine growth restriction. Preterm premature rupture of membranes (PPROM) is defined as the rupture of membranes at <37 weeks' gestation and prior to the onset of labour.

Answer 318

In the UK in 2014, the percentage of births before 37 weeks’ gestation ranged from 6.4% to 9.9% of live births, depending on ethnicity. Only 1% of all births occur below 32 weeks' gestation. Mortality and serious morbidity are uncommon above 32 weeks' gestation, although more subtle long-term effects, such as behavioural problems during childhood, still occur with later gestations. The economic and psychological burdens on society are considerable. The estimated cost to the US is $26.2 billion per year.

Answer 319

STRONG ``` Hx premature labour Hx cervical trauma Hx induced abortion Maternal infections Multifetal pregnancies (av 3w before) Short cervical length Positive fetal fibronectin (1/3-1/2 of women have a +ve FFN at 23 weeks deliver before 30weeks) PROM ``` WEAK ``` Fetal abnormalities Smoking BMI <19 Social factors and ethnicity Polyhydramnios Domestic violence Poor dental hygeine ```

Answer 320

COMMON Uterine contractions PROM Advanced cervical dilation Cervical length <2cm UNCOMMON Increased maternal/fetal HR Non-specific lower abdominal or back pain Fever Vaginal bleeding

Answer 321

Cardiotocogram Tocography - >1 in 10 TVUS Cervico-vaginal swab for fetal fibronectin - +ve FBC - check Hb + WCC CRP - infection Urine dip/microscropy High vaginal/rectal swab - may be positive for group B strep

Answer 322

Maternal evaluation + assessment of fetal viability CORTICOSTEROIDS - beclametasone /dexamethasone sodium phosphate IM Consider induced delivery ABx for group B strep -> clindamycin / benzylpenicillin sodium

Answer 323

Neonatal morbidity and mortality | Maternal adverse effects to Beta agonists

Answer 324

Risk of recurrence of spontaneous premature labour and birth are well defined, and remarkably consistent in spite of the varied aetiology. Only if women have recurrent preterm births at early gestations do they tend to have a future risk of >50%. Even in women who have major risk factors, such as extensive cervical surgery, it is rare not to achieve a viable pregnancy with appropriate management. These cases may be more amenable to intervention such as cervical cerclage.

Answer 325

A seizure is defined as "a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain". Epilepsy is considered to be a disease of the brain defined by any of the following conditions: At least 2 unprovoked (or reflex) seizures occurring more than 24 hours apart One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after 2 unprovoked seizures, occurring over the next 10 years Diagnosis of an epilepsy syndrome. Epileptic seizures may be classified as focal, generalised, or unknown onset, with subcategories of motor, non-motor (absence), with retained or impaired awareness for focal seizures.

Answer 326

1 in 200 women of childbearing age

Answer 327

``` febrile seizure head trauma CNS infection stroke brain tumour mental retardation (MR) and/or cerebral palsy dementia FHx of seizures vascular malformations ```

Answer 328

Aim is to have the lowest possible dose of antiepileptic medication

Answer 329

EEG - defines whether generalsed or focal Blood Glucose - extreme hypo/hyper can cause provoked generalised tonic-clonic seizures FBC - CNS/systemic infection can cause seizures Electrolytes - hypo/hypernatraemia or uraemia can cause Toxicology screen - drugs can cause Prolactin - >2x baseline indicates a generalised tonic-clonic seizure CK - >200mU/mL (questionable reliability but high levels 2hrs after insult can suggest tonic-clonic seizure) MRI brain - structural lesion can cause

Answer 330

Aim is to have the lowest possible dose of antiepileptic medication Sodium valproate - PARTICULARLY teratogenic - therefore CAUTION (consider swapping another medication) Lamotrigine - SAFEST Carbamazepine Lacosamide

Answer 331

``` Rx can cause: Orofacial clefts Neural tube defects Congenital heart disease Haemorrhage disease of the newborn ```

Answer 332

Neisseria gonorrhoeae is a gram-negative diplococcus bacterium that is closely related to other human Neisseria species. Gonorrhoea is any manifestation of infection by N gonorrhoeae . Aside from causing infection in the lower genital tract, it can also cause conjunctivitis and severe disseminated infections, especially if acquired congenitally. The pathogen is almost exclusively sexually transmitted and can be found in the genital tract, pharynx, and rectum.

Answer 333

2nd most common WW Global rate 9/1000 F 24/1000 M M>F

Answer 334

``` STRONG Age 15-29 MSM Black ancestry Current prior Hx of STI Multiple recent sexual partners Inconsistent condom use RFs of partner Hx sexual/physical abuse ``` WEAK Substance use Past incarceration

Answer 335

urethral/urine/cervical/vaginal NAAT - +VE Culture - +ve chocolate agar culture - can culture Urethral, endocervical, rectal, pharyngeal, blood, synovial fluid, CSF, or conjunctival specimen Urinalysis - +ve leukocyte esterase Gram-stain urine/discharge DO HIV / SYPHILIS TEST TOO

Answer 336

Non-Pregnant - DUAL ABx therapy Ceftriaxone + azithromycin Hx of sexual abuse - include metronidazole Pregnancy = ceftriaxone + azithromycin Neonate - just ceftriaxone

Answer 337

``` Ectopic - PID Infertility in women - PID Infertility in men Blindness PID Fitz-hugh-curtis syndrome ```

Answer 338

Appropriate treatment with recommended antibiotics should resolve gonorrhoeal infections. The key related morbidity in women is infertility, ectopic pregnancy, and chronic pelvic pain secondary to pelvic inflammatory disease. In men, treatment will help prevent ascending infection to the prostate, epididymis, and testis. Death is rare but can be the result of disseminated infection.

Answer 339

``` COMMON Urethral discharge in men Pelvic pain in women Tenderness/swelling of epididymus Micropurulent exudate at endocervix ``` OTHER Urethral irriation Dysuria ``` UNCOMMON Orchitis Swollen prostate Anal pruritus Micropurulent discharge from anus Rectal pain Tenesmus Vaginal discharge Cervical friability Uterine/adnexal/cervical motion tenderness - PID Uterine mass - PID ``` ``` OTHERS Conjunctivitis - gonococcal infection Fever - disseminated infection Cutaneous lesions - due to disseminated infection Polyarthritis ``` ``` Meningitis signs: Purpuric rash - gonococcal meningitis Positive brudzinski / kernig Seizures Focal cerebral ``` Murmur - gonococcal endocarditis Opthalma neonatorum - Preg complication to neonate = neonatal conjunctivitis Infantile Rhinitis Infantile urethritis

Answer 340

Urinary incontinence is a complaint of involuntary loss of urine. It can have devastating effects on the patient, detrimentally affecting her level of activity and psychosocial state, leading to depression and withdrawal from social settings. Characterisation of the type of incontinence can help to elucidate the underlying aetiology and help to guide management.

Answer 341

Prevalence increases with age 1 in 4 seek consultation Women in long term institutions - 43-65%

Answer 342

Stress incontinence - involuntary leakage on effort, exertion, sneezing, or coughing Urge incontinence - involuntary leakage accompanied by or immediately preceded by urgency Overactive bladder (detrusor overactivity) - urgency with or without urge incontinence; usually with frequency and nocturia in the absence of an underlying metabolic or pathological condition Mixed incontinence - combination of stress and urge incontinence symptoms Nocturnal enuresis - involuntary loss of urine occurring during sleep Continuous incontinence - continuous loss of urine Overflow incontinence - urinary leakage from an over-distended bladder; terminology is no longer widely used Other - involuntary leakage during situations not encompassed by other classifications (i.e., during sexual activity or change in body position).

Answer 343

STRONG ``` Increasing age Pregnancy - parity, vag delivery, episiotomy Obesity LUTsymptoms Long term care facility residence Dementia Constipation - straining Faecal incontinence High impact physical activity Pelvic organ prolapse Stroke Parkinsons MS Diuretic use Caffeine ``` WEAK ``` White PM-Women Functional impairment FHx Childhood enuresis DM - neurogenic - overflow Depression Chronic heart failure Smoking Genitourinary and pelvic surgery Radiation exposure Alcohol Antihistamine use Sedative use Hypnotic use Anticholinergic use Antidepressants CCBs Alpha adrenergic agonist ```

Answer 344

COMMON Involuntary incontinence on effort/sneezing etc - stress incontinence Involuntary incontinence preceded by urgency Frequency Bladder diary Vaginal bulge/pressure - prolapse - stress incontinence Urogenital atrophy UNCOMMON Hx cognitive impairment Back injury Dysuria Urethral discharge or tenderness

Answer 345

Empty supine stress test - urine leakage Urinalysis - normal or may show WBCs, nitrites, RBCs with underlying infection, or malignancy Post-void residual measurement - elevated if >100mL or >50% voided volume Cough stress test - leakage Urodynamic testing - The bladder is filled with sterile fluid. Changes such as first sensation, desire to void, and bladder capacity are recorded electronically during the filling and storage phase. Urinary loss from the urethra during provocative manoeuvres, such as coughing, is documented. Cystourethroscopy - may reveal fistula, foreign body, tumour, or interstitial cystitis

Answer 346

STRESS Lifestyle - pelvic muscle exercises, WL, fluid management, smoking cessation etc STRESS with urethral sphincter insufficiency - Pseudoephedrine Imipramine Duloxetine Oestrogen -> estradiol or conjugated oestrogens IF PM Urethral bulking injection Surgery URGE INCONTINENCE Anticholinergics: Oxybutynin Mirabegron - (adrenergic) Fesoterodine Neuromodulation - implant in sacral spine, inhibits micturition reflex - 60-70% works Botox Rx - makes bladder more compliant. Less firing of afferent, and less ability to contract. 6-12months. MIXED = use aspects of both

Answer 347

``` Surgery related: Retention UTI Perforation of bladder Haemorrhage Bowel injury Voiding disorders Wound complications ```

Answer 348

This disorder has a significant impact on a patient's quality of life, including loss of self-esteem and decreased ability to exercise, socialise, and maintain independence. As the condition worsens, dependence on carers increases, leading to restriction on social interaction. Treatment is directed at improving quality of life and should be individualised according to impact severity. No treatment is fully curative, and combination therapy may be beneficial.

Answer 349

Whereby there is a vilamentous insertion of the cord. Vessels lie on the membranes that cover the internal os. When the membranes rupture, vessels can be torn and PV bleeding/haemorrhage occurs. HOWEVER this is foetal blood - therefore delivery must be prompt

Answer 350

1 in 2000-6000 pregnancies

Answer 351

Bloodloss >500-1L after delivery

Answer 352

Incidence 5% deliveries in developed world | <38% in developing countries - maj cause maternal mortality

Answer 353

``` Uterine atony Trauma Retained placenta / placenta accrete Coagulation disorders Uterine inversion Uterine rupture ```

Answer 354

Retained products Endometritis Persistent molar / choriocarcinoma

Answer 355

``` Multiple pregnancy Grand multiparity Fetal macrosomia Polyhydramnios Fibroid uterus Prolonged labour Previous PPH Antepartum haemorrhage ```

Answer 356

Use of an oxytotic drug (reduces incidence by 30-40%) IE Syntometrine Contolled cord traction to deliver placenta (Brandt-andrews) Clamping and cutting the cord

Answer 357

``` ABC Blood loss quantification Pulse BP Urine output Uterine contraction - if fully contracted it makes trauma/retained placenta likely cause Fundal height Placenta/membranes complete Genital tract trauma ```

Answer 358

``` Establish IV access Send blood haemoglobin, platelets, clotting factors Cross-match blood Check U+Es Full blood count - secondary USS - check if retained products/molar B-HCG - if molar round - CxR + LFTs ```

Answer 359

Basic ABC + resus IV access Replace blood / factors etc as needed / u+e Atony - give syntocinon, IM/PR prostaglandins (carboprost), SURGERY - bilateral uterine artery embolisation Genital tract trauma - repair Retained placenta - controlled cord traction delivery + ABx Accrete

Answer 360

A common benign polyp or tumour of the surface of the cervical canal

Answer 361

Believed to be due to inflammation of the cervix May be due to raised oestrogen or clogged cervical blood vessels

Answer 362

Post-menarche Pre-menopausal Pregnancy

Answer 363

Pelvic examination + speculum - Generally bright red, spongy texture, may be pedunculated (attached by a stalk) Generally <1cm Biopsy

Answer 364

Removal by ring forceps Laser or cauterisation Abx if infected

Answer 365

1% progress to cancer | Unlikely to regrow

Answer 366

``` Irregular menstrual bleeding IMB PMB PC bleed Thick white/yellow discharge Asymptomatic ```

Answer 367

Mass in the inner lining of the uterus May be sessile or pedunculated

Answer 368

Pedunculated > sessile 40s-50s peak 10% of women Present in 25% of women with abnormal bleeding

Answer 369

``` Obesity High BP Hx cervical polyps HRT Tamoxifen Mirena REDUCES incidence in women on tamoxifen ```

Answer 370

Appear to grow in response to oestrogen

Answer 371

``` Usually none Irregular MB IMB Menorrhagia PMB If polyp protrudes through cervix -> dispareunia/dysmenorrhoa ```

Answer 372

Vag USS - may be difficult Hysteroscopy Dilation + curettage 1mm-3cm usually Same red/brown of the endometrium Larger = darker red Sessile or Pedunculated

Answer 373

Hysteroscopy + curettage / forceps | Histology

Answer 374

0.5% contain adenocarcinoma cells Frequently re-occur (NB cervical usually don't) Untreated small polyps may regress Increase the risk of miscarriage in IVF May cause infertility if near Fallopian tubes

Answer 375

0.5% contain adenocarcinoma cells Frequently re-occur (NB cervical usually don't) Untreated small polyps may regress Increase the risk of miscarriage in IVF May cause infertility if near Fallopian tubes

Answer 376

1. Oxygen 2. Blood cultures 3. IV ABx 4. IV Fluids 5. Serial lactates (>4 = critical care) 6. Measure UO ``` POST SEPSIS SIX IF PT HAS: SystBP <90 Reduced consciousness despite resus RR >25 Lactate not reducing ``` CRITICAL CARE OUTREACH

Answer 377

Excision of lesion using electrocautical loop Cervical transformation zone and lesion excised 4-5mm beyond lesion Usually histological specimens taken.

Answer 378

High grade cervical dysplasia CIN2/3

Answer 379

``` Infection Haemorrhage Risk of infertility/sub Slight risk of miscarriage Increased risk of preterm births with multiple Rx ```

Answer 380

Breakage of the amniotic sac prior to labor | < 37w = PPROM

Answer 381

8% pregnancies at term 30% of premature births <24weeks 1% PPROMs account for 5% of all PROMs

Answer 382

``` Infection of amniotic fluid PROM Hx Bleeding PV in pregnancy Smoking Low BMI Polyhydramnios Multiple gestation Invasive procedures Cervical insufficiency ```

Answer 383

Infection Weakness of membranes - poor collagenation, cell death, breakdown by MMPs Lower levels of TIMPs

Answer 384

``` Painless gush PV Steady leakage PV Absence of contractions More palpable baby Decreased uterine size Meconium ``` ``` Examination: Pooling of amniotic fluid in fornixes Leakage on valsalva Nitrazine test - HIGHER pH (7.1-7.3) than acidic vaginal fluid. (turns nitrazine paper from orange to blue) Fibronectin + AFP blood tests ```

Answer 385

Symptoms Speculum Testing of fluid

Answer 386

If at term - induce labour. 34-36weeks - treat like term 24-34weeks - steroids, watchful waiting, tocolytics, magnesium sulphate, ABx to prevent group B strep transmission in all <24 weeks previable. Usually watchful waiting or induction of labor

Answer 387

``` Premature birth Cord compression Infection Placental abruption PP endometritis Chorioamnionitis ``` ``` Fetus: <37w: Necrotising enterocolitis Resp distress Brain injury Death ``` <24w: Fetal deformity Contractures Pulmonary hypoplasia

Answer 388

Medical procedure allowing visualisation of the cervix and tissues of the vulva and vagina using a camera. Illuminated and magnified view. 3% Acetic acid solution and iodine solution (Lugol's or Schiller's) are applied to the surface to improve visualization of abnormal areas. Areas of acetowhiteness correlate with higher nuclear density. A cervical punch biopsy [punch forceps] is when a small piece of tissue is taken from the cervix. Endocervical curettage to collect tissue. Silver nitrate to coagulate blood. Dorsal lithotomy position

Answer 389

Normally for abnormal Pap smear Other indications: - Immunosuppression - HIV - Sexual assault forensic examination

Answer 390

Bleeding | Infection

Answer 391

Endometrial ablation is an outpatient medical procedure that is used to remove (ablate) or destroy the endometrial lining of the uterus in women who have heavy menstrual bleeding. Endometrial ablation should never be performed on women who wish to have children. Endometrial Ablation procedure is primarily performed while patients are under local and/or light sedative anesthesia, or if necessary, general or spinal anesthesia. Ablation using cauterisation - minerva. Pt usually leaves 1hr post procedure. Progestogen Rx prior to therapy reduces endothelial thickness.

Answer 392

Heavy menstrual bleeding IN THE CONTEXT OF NOT WANTING CHILDREN. IE DUB / Adenomyosis Alternative to hysterectomy.

Answer 393

Perforation of the uterus Burns to the uterus (beyond the endometrial lining) Pulmonary edema or embolism Bowel burn leading to death Post-ablation tubal sterilization syndrome Placenta accreta may occur if the patient becomes pregnant after endometrial ablation, so birth control is necessary.

Answer 394

The endometrial biopsy is a medical procedure that involves taking a tissue sample of the lining of the uterus. Sent to histology.

Answer 395

Chronic anovulation -> eg PCOS -> increased risk for endometrial hyperplasia/neoplasia. To rule out endometrial hyperplasia/neoplasia Suspected uterine cancer (biopsy may discover cells in endometrium) TVUS usually done BEFORE. If endometrial thickness <4cm then biopsy is RARELY performed Pipelle used to obtain sample.

Answer 396

Cramps / pelvic pain | RARE uterine perforation/infection

Answer 397

A method of abortion as well as a therapeutic procedure used after miscarriage to prevent infection by ensuring that the uterus is fully evacuated. ___________ The first step in the procedure itself is dilation of the cervix. The second step is insertion of a vacuum curette through the cervix. Under ultrasound, the tip of that curette is placed up against the fetal chest or abdomen. The suction is turned on. Amniotic fluid is removed and the fetus dies instantly due to removal of the fetal heart, lungs, and abdominal contents. This leaves the fetal cranium and skeleton with soft tissue to be removed. The thorax, pelvis, cranium, and each arm and leg are removed separately using surgical instruments. The fetal cranium will usually have to be crushed in order to be extracted. Use of ultrasound greatly facilitates this part of the procedure although it may be done safely without ultrasound guidance. In the absence of ultrasound, the tissue will be carefully inspected to insure all fetal tissue is removed. It is important to recognize that this is the removal of dead tissue to protect the patient from bleeding and infection well after the fetus died instantly. Under no circumstances is the fetus being dismembered alive. After removal of all fetal tissue, the uterine cavity is thoroughly curetted to insure that all placental tissue, blood, and membranes are removed. The uterus will then be massaged to insure it is firmly contracted to minimize post operative bleeding. The entire procedure usually takes less than 30 minutes and is well tolerated.

Answer 398

Second trimester abortion Post miscarriage

Answer 399

Rare: damage to uterine lining or cervix, perforation of the uterus, infection, and blood clots

Answer 400

External cephalic version (ECV) is a process by which a breech baby can sometimes be turned from buttocks or foot first to head first. Practitioner experience, maternal weight, obstetric factors such as uterine relaxation, a palpable fetal head, a non-engaged breech, non-anterior placenta, and an amniotic fluid index above 7–10 cm, are all factors which can be associated with higher success rates. Contraindications: antepartum haemorrhage, placenta praevia, abnormal fetal monitoring, ruptured membranes, multiple pregnancy, pre-eclampsia, reduced amniotic fluid and some other abnormalities of the uterus or baby

Answer 401

Breech presentation after 36/37 weeks.

Answer 402

Typical risks include umbilical cord entanglement, abruption of placenta, preterm labor, premature rupture of the membranes (PROM) and severe maternal discomfort.

Answer 403

Cardiotocography (CTG) is a technical means of recording the fetal heartbeat and the uterine contractions during pregnancy. Continuous or intermittent. Heart rate (A) is calculated from fetal heart motion determined by ultrasound, and uterine contractions are measured by a tocodynamometer (B) Abnormal baseline is termed bradycardia when the baseline FHR is less than 110 bpm; it is termed tachycardia when the baseline FHR is greater than 160 bpm. Contractions: Normal- less than or equal to 5 contractions in 10 minutes, averaged over a 30-minute window Tachysystole- more than 5 contractions in 10 minutes, averaged over a 30-minute window Using this definition, the baseline FHR variability is categorized by the quantitated amplitude as: Absent- undetectable Minimal- greater than undetectable, but less than or equal to 5 beats per minute Moderate- 6-25 beats per minute Marked- greater than 25 beats per minute Moderate = low chance of academia / hypoxic injury. An abrupt increase is defined as an increase from the onset of acceleration to the peak in less than or equal to 30 seconds. To be called an acceleration, the peak must be greater than or equal to 15 bpm, and the acceleration must last greater than or equal to 15 seconds from the onset to return to baseline.[12] A prolonged acceleration is greater than or equal to 2 minutes but less than 10 minutes in duration. Early Decelerations are a result of increased vagal tone due to compression of the fetal head during contractions. Early decelerations begin and end at approximately the same time as contractions, and the low point of the fetal heart rate occurs at the peak of the contraction. Late Decelerations are a result of placental insufficiency, which can result in fetal distress. In contrast to early deceleration, the low point of fetal heart rate occurs after the peak of the contraction, and returns to baseline after the contraction is complete. Variable Decelerations are generally a result of umbilical cord compression, and contractions may further compress a cord when it is trapped around the neck or under the shoulder of the fetus. When variable decelerations are associated with uterine contractions, their onset, depth, and duration commonly vary with successive uterine contractions. Prolonged Deceleration: Decrease in FHR from baseline greater than or equal to 15 bpm, lasting greater than or equal to 2 minutes, but less than 10 minutes. A deceleration greater than or equal to 10 minutes is a baseline change. Internal cardiotocography uses an electronic transducer connected directly to the fetal scalp

Answer 404

Labour Problems in pregnancy Monitoring in high risk.

Answer 405

First stage of labor Divided into a latent phase and an active phase Begins with regular uterine contractions and ends with complete cervical dilatation at 10 cm The latent phase begins with mild, irregular uterine contractions that soften and shorten the cervix Contractions become progressively more rhythmic and stronger The active phase usually begins at about 3-4 cm of cervical dilation and is characterized by rapid cervical dilation and descent of the presenting fetal part Second stage of labor Begins with complete cervical dilatation and ends with the delivery of the fetus In nulliparous women, the second stage should be considered prolonged if it exceeds 3 hours if regional anesthesia is administered or 2 hours in the absence of regional anesthesia In multiparous women, the second stage should be considered prolonged if it exceeds 2 hours with regional anesthesia or 1 hour without it. Third stage of labor The period between the delivery of the fetus and the delivery of the placenta and fetal membranes Delivery of the placenta often takes less than 10 minutes, but the third stage may last as long as 30 minutes Expectant management involves spontaneous delivery of the placenta The third stage of labor is considered prolonged after 30 minutes, and active intervention is commonly considered. Active management often involves prophylactic administration of oxytocin or other uterotonics (prostaglandins or ergot alkaloids), cord clamping/cutting, and controlled traction of the umbilical cord

Answer 406

First stage of labor Divided into a latent phase and an active phase Begins with regular uterine contractions and ends with complete cervical dilatation at 10 cm The latent phase begins with mild, irregular uterine contractions that soften and shorten the cervix Contractions become progressively more rhythmic and stronger The active phase usually begins at about 3-4 cm of cervical dilation and is characterized by rapid cervical dilation and descent of the presenting fetal part

Answer 407

Second stage of labor Begins with complete cervical dilatation and ends with the delivery of the fetus In nulliparous women, the second stage should be considered prolonged if it exceeds 3 hours if regional anesthesia is administered or 2 hours in the absence of regional anesthesia In multiparous women, the second stage should be considered prolonged if it exceeds 2 hours with regional anesthesia or 1 hour without it.

Answer 408

Third stage of labor The period between the delivery of the fetus and the delivery of the placenta and fetal membranes Delivery of the placenta often takes less than 10 minutes, but the third stage may last as long as 30 minutes Expectant management involves spontaneous delivery of the placenta The third stage of labor is considered prolonged after 30 minutes, and active intervention is commonly considered. Active management often involves prophylactic administration of oxytocin or other uterotonics (prostaglandins or ergot alkaloids), cord clamping/cutting, and controlled traction of the umbilical cord

Answer 409

``` Baby engages....then Do Frogs In Canada Ride In A Pink Limo Descent Flexion Internal rotation of head Crowning Restitution Internal rotation of shoulders Anterior shoulder Posterior shoulder Lateral flexion ```

Answer 410

Frequency and time of onset of contractions Status of the amniotic membranes (whether spontaneous rupture of the membranes has occurred, and if so, whether the amniotic fluid is clear or meconium stained) Fetal movements Presence or absence of vaginal bleeding. Braxton-Hicks contractions must be differentiated from true contractions. Typical features of Braxton-Hicks contractions are as follows: Usually occur no more often than once or twice per hour, and often just a few times per day Irregular and do not increase in frequency with increasing intensity Resolve with ambulation or a change in activity Contractions that lead to labor have the following characteristics: May start as infrequently as every 10-15 minutes, but usually accelerate over time, increasing to contractions that occur every 2-3 minutes Tend to last longer and are more intense than Braxton-Hicks contractions Lead to cervical change The physical examination should include documentation of the following: Maternal vital signs Fetal presentation Assessment of fetal well-being Frequency, duration, and intensity of uterine contractions Abdominal examination with Leopold maneuvers Pelvic examination with sterile gloves Digital examination allows the clinician to determine the following aspects of the cervix: Degree of dilatation, which ranges from 0 cm (closed or fingertip) to 10 cm (complete or fully dilated) Effacement (assessment of the cervical length, which can be reported as a percentage of the normal 3- to 4-cm–long cervix or described as the actual cervical length) Position (ie, anterior or posterior) Consistency (ie, soft or firm) Fatal heart rate assessed constantly via CTG

Answer 411

Supine with her knees bent (ie, dorsal lithotomy position; the usual choice) Lateral (Sims) position Partial sitting or squatting position On her hands and knees

Answer 412

Pain control Agents given in intermittent doses for systemic pain control include the following [4] : Meperidine, 25-50 mg IV every 1-2 hours or 50-100 mg IM every 2-4 hours Fentanyl, 50-100 mcg IV every hour Nalbuphine, 10 mg IV or IM every 3 hours Butorphanol, 1-2 mg IV or IM every 4 hours Morphine, 2-5 mg IV or 10 mg IM every 4 hours As an alternative, regional anesthesia may be given. Anesthesia options include the following: Epidural Spinal Combined spinal-epidural

Answer 413

Labor is a physiologic process during which the products of conception (ie, the fetus, membranes, umbilical cord, and placenta) are expelled outside of the uterus. Labor is achieved with changes in the biochemical connective tissue and with gradual effacement and dilatation of the uterine cervix as a result of rhythmic uterine contractions of sufficient frequency, intensity, and duration. Labor is a clinical diagnosis. The onset of labor is defined as regular, painful uterine contractions resulting in progressive cervical effacement and dilatation. Cervical dilatation in the absence of uterine contraction suggests cervical insufficiency, whereas uterine contraction without cervical change does not meet the definition of labor.

Answer 414

Most women experience onset of labor without premature rupture of the membranes (PROM); however, approximately 8% of term pregnancies is complicated by PROM. Spontaneous onset of labor usually follows PROM such that 50% of women with PROM who were expectantly managed delivered within 5 hours, and 95% gave birth within 28 hours of PROM. Group B streptococcal prophylaxis be given based on prior culture results or risk factors of cultures not available. On admission to the Labor and Delivery suite, a woman having normal labor should be encouraged to assume the position that she finds most comfortable. Possibilities including walking, lying supine, sitting, or resting in a left lateral decubitus position. Of note, ambulating during labor did not change the progression of labor in a large randomized controlled study of >1000 women in active labor. The patient and her family or support team should be consulted regarding the risks and benefits of various interventions, such as the augmentation of labor using oxytocin, artificial rupture of the membranes, methods and pharmacologic agents for pain control, and operative vaginal delivery (including forceps or vacuum-assisted vaginal deliveries) or cesarean delivery. They should be actively involved, and their preferences should be considered in the management decisions made during labor and delivery. The frequency and strength of uterine contractions and changes in cervix and in the fetus' station and position should be assessed periodically to evaluate the progression of labor. Although progression must be monitored, vaginal examinations should be performed only when necessary to minimize the risk of chorioamnionitis, particularly in women whose amniotic membrane has ruptured. During the first stage of labor, fetal well-being can be assessed by monitoring the fetal heart rate at least every 15 minutes, particularly during and immediately after uterine contractions. In most labor and delivery units, the fetal heart rate is assessed continuously. Two methods of augmenting labor have been established. The traditional method involves the use of low doses of oxytocin with long intervals between dose increments. For example, low-dose infusion of oxytocin is started at 1 mili IU/min and increased by 1-2 mili IU/min every 20-30 minutes until adequate uterine contraction is obtained. The second method, or active management of labor, involves a protocol of clinical management that aims to optimize uterine contractions and shorten labor. This protocol includes strict criteria for admission to the labor and delivery unit, early amniotomy, hourly cervical examinations, early diagnosis of inefficient uterine activity (if the cervical dilation rate is < 1.0 cm/h), and high-dose oxytocin infusion if uterine activity is inefficient. Oxytocin infusion starts at 4 mili IU/min (or even 6 mili IU/min) and increases by 4 mili IU/min (or 6 mili IU/min) every 15 minutes until a rate of 7 contractions per 15 minutes is achieved or until the maximum infusion rate of 36 mili IU/min is reached.

Answer 415

When the woman enters the second stage of labor with complete cervical dilatation, the fetal heart rate should be monitored or auscultated at least every 5 minutes and after each contraction during the second stage. Although the parturient may be encouraged to actively push in concordance with the contractions during the second stage, many women with epidural anesthesia who do not feel the urge to push may allow the fetus to descend passively, with a period of rest before active pushing begins. When a prolonged second stage of labor is encountered, clinical assessment of the parturient, the fetus, and the expulsive forces is warranted.

Answer 416

The labor process has now entered the third stage, ie, delivery of the placenta. Three classic signs indicate that the placenta has separated from the uterus: (1) The uterus contracts and rises, (2) the cord suddenly lengthens, and (3) a gush of blood occurs. Delivery of the placenta usually happens within 5-10 minutes after delivery of the fetus, but it is considered normal up to 30 minutes after delivery of the fetus. Excessive traction should not be applied to the cord to avoid inverting the uterus, which can cause severe postpartum hemorrhage and is an obstetric emergency. The placenta can also be manually separated by passing a hand between the placenta and uterine wall. After the placenta is delivered, inspect it for completeness and for the presence of 1 umbilical vein and 2 umbilical arteries. Oxytocin can be administered throughout the third stage to facilitate placental separation by inducing uterine contractions and to decrease bleeding. Expectant management of the third stage involves allowing the placenta to deliver spontaneously, whereas active management involves administration of uterotonic agent (usually oxytocin, an ergot alkaloid, or prostaglandins) before the placenta is delivered. This is done with early clamping and cutting of the cord and with controlled traction on the cord while placental separation and delivery are awaited. A review of 5 randomized trials comparing active versus expectant management of the third stage demonstrated that active management was associated with lowered risks of maternal blood loss, postpartum hemorrhage, and prolongation of the third stage, but it increased maternal nausea, vomiting, and blood pressure (when ergometrine was used). After the placenta is delivered, the labor and delivery period is complete. Palpate the patient's abdomen to confirm reduction in the size of the uterus and its firmness. Ongoing blood loss and a boggy uterus suggest uterine atony. A thorough examination of the birth canal, including the cervix and the vagina, the perineum, and the distal rectum, is warranted, and repair of episiotomy or perineal/vaginal lacerations should be carried out.

Answer 417

The labor process has now entered the third stage, ie, delivery of the placenta. Three classic signs indicate that the placenta has separated from the uterus: (1) The uterus contracts and rises, (2) the cord suddenly lengthens, and (3) a gush of blood occurs. Delivery of the placenta usually happens within 5-10 minutes after delivery of the fetus, but it is considered normal up to 30 minutes after delivery of the fetus. Excessive traction should not be applied to the cord to avoid inverting the uterus, which can cause severe postpartum hemorrhage and is an obstetric emergency. The placenta can also be manually separated by passing a hand between the placenta and uterine wall. After the placenta is delivered, inspect it for completeness and for the presence of 1 umbilical vein and 2 umbilical arteries. Oxytocin can be administered throughout the third stage to facilitate placental separation by inducing uterine contractions and to decrease bleeding. Expectant management of the third stage involves allowing the placenta to deliver spontaneously, whereas active management involves administration of uterotonic agent (usually oxytocin, an ergot alkaloid, or prostaglandins) before the placenta is delivered. This is done with early clamping and cutting of the cord and with controlled traction on the cord while placental separation and delivery are awaited. A review of 5 randomized trials comparing active versus expectant management of the third stage demonstrated that active management was associated with lowered risks of maternal blood loss, postpartum hemorrhage, and prolongation of the third stage, but it increased maternal nausea, vomiting, and blood pressure (when ergometrine was used). After the placenta is delivered, the labor and delivery period is complete. Palpate the patient's abdomen to confirm reduction in the size of the uterus and its firmness. Ongoing blood loss and a boggy uterus suggest uterine atony. A thorough examination of the birth canal, including the cervix and the vagina, the perineum, and the distal rectum, is warranted, and repair of episiotomy or perineal/vaginal lacerations should be carried out.

Answer 418

To define abnormal labor, a definition of normal labor must be understood and accepted. Normal labor is defined as uterine contractions that result in progressive dilation and effacement of the cervix. By following thousands of labors resulting in uncomplicated vaginal deliveries, time limits and progress milestones have been identified that define normal labor. Failure to meet these milestones defines abnormal labor, which suggests an increased risk of an unfavorable outcome. Thus, abnormal labor alerts the obstetrician to consider alternative methods for a successful delivery that minimize risks to both the mother and the infant. Dystocia of labor is defined as difficult labor or abnormally slow progress of labor. Other terms that are often used interchangeably with dystocia are dysfunctional labor, failure to progress (lack of progressive cervical dilatation or lack of descent), and cephalopelvic disproportion (CPD). Abnormal labor constitutes any findings that fall outside the accepted normal labor curve.

Answer 419

According to Friedman et al., latent stage considered to be prolonged if takes >20 hours for nulliparous women and >14 hours for multiparous women. However, prolonged latent phase does not usually lead to any clinically significant adverse events for mother or the infant. Therefore, diagnosis of abnormal labor during the latent phase is uncommon and is not relevant for clinical practice.

Answer 420

>6cm dilation with ruptured membranes and one of the following: 4 hours or more of adequate contractions (>200 MVU) or 6 hours or more of inadequate contractions and no cervical change.

Answer 421

NULLIPAROUS 2. 8 hours w/o regional anaesthesia 3. 6 hours with MULTIP 2hours w/o regional 1 hour with One study found that if nulliparous women delivered after prolonged second stage, they were twice as likely to have operative vaginal delivery, three times as likely to develop chorioamnionitis, have higher odds of having episiotomy and 3rd or 4th degree lacerations, and one day longer median hospital stay.

Answer 422

Traditionally 30 mins BUT 90% of placentas are delivered within 10 minutes and the risk of postpartum hemorrhage almost doubles by the time the duration of third stage reaches twenty minutes.

Answer 423

Passenger (infant size, fetal presentation [occiput anterior, posterior, or transverse]) - Macrosomia most common Pelvis or passage (size, shape, and adequacy of the pelvis) - mechanical dystocia Power (uterine contractility) - Surgical scars - Fibroids - Atony

Answer 424

Of all cephalic deliveries, 8-11% are complicated by an abnormal first stage of labor. Dystocia occurs in 12% of deliveries in women without a history of prior cesarean delivery. Dystocia may account for as many as 60% of cesarean deliveries.

Answer 425

Syntocinon Dinoprostone and misoprostol are prostaglandin analogs used to stimulate cervical dilation and uterine contractions; they are pharmacologic alternatives to using laminaria or placing a Foley bulb in the cervix. Using prostaglandin analogs with a scarred uterus (eg, from prior cesarean or myomectomy) for labor induction is absolutely contraindicated due to the significant risk for uterine rupture. Propranolol can be given

Answer 426

Intrahepatic cholestasis of pregnancy (ICP) is a pruritic condition during pregnancy caused by impaired bile flow allowing bile salts to be deposited in the skin and the placenta. The cause is a combination of hormonal, genetic, and environmental factors. ICP may predispose mothers to vitamin K deficiency and the fetus to adverse pregnancy outcomes that may include prematurity, intra-uterine fetal demise, and respiratory distress syndrome. May be associated with an increased risk of adverse pregnancy outcomes, including premature birth, intra-uterine fetal demise, and placental abruption in severe disease. There is an increased risk of respiratory distress syndrome in neonates, owing to meconium aspiration syndrome, which is unpredictable by available methods of surveillance. The only definitive cure is delivery of the baby. The condition is associated with a history of hepatitis C and there may be an association with long-term liver disease. Mild disease with bile acid levels <40 micromol/L or mild itching can be treated with bile-sequestering agents and antihistamines, such as colestyramine and hydroxyzine. However, if tolerated no treatment is necessary. Severe disease with bile acid levels >40 micromol/L or severe pruritus remote from term can be treated effectively with ursodeoxycholic acid. Close fetal surveillance with delivery near term can be expected with premature delivery reserved for those with severe, worsening disease despite treatment.

Answer 427

The aetiology is most likely multi-factorial with mutations in the canalicular phospholipid export pump MDR3 A large number of hepatobiliary disorders have been linked to these mutations, including familial intrahepatic cholestasis, adult biliary cirrhosis, and familial cholelithiasis. Intrahepatic cholestasis caused by MDR3 mutations is typically associated with elevated gamma-glutamyl transferase (GGT) levels, which are encountered in up to 30% of pregnancies complicated by the disorder.

Answer 428

``` STRONG Hx of prev Hx Hep C FHx Age >35 ``` WEAK Multiple pregnancy

Answer 429

0.7% prevalence 1-1.5% of Indian-Asian and Pakistani-Asian Scandinavian (2%) or Chilean descent (14%), with 4.7% of Chilean singletons and 20.9% of Chilean twin gestations affected.

Answer 430

COMMON RF presence Pruritus, sparing face Excoriations BUT NO RASH OTHER Mild jaundice

Answer 431

Bile acids - >11 micromol/L and <40 micromol/L (mild); >40 micromol/L (severe) LFTs - transaminases elevated up to 300 units/L in more severe disease; alk phos 5- to 10-fold normal; direct bilirubin elevated in some, not usually >85.5 micromol/L (>5 mg/dL) Coagulation - prothrombin time may be prolonged in rare cases when vitamin K has been depleted from liver dysfunction Fasting serum cholesterol - total cholesterol and triglycerides are elevated above the 2- to 3-fold increase usually seen in pregnancy Hep C serology - positive in hepatitis C infection

Answer 432

TREATMENT DEPENDS ON SEVERITY MILD: <40micromol bile acids Anti-Histamines - eg dipenhydramine Ursodeoxycholic acid Colestyramine Phytomenadione (vit k) SEVERE: >40micromol bile acids Ursodeoxycholic acid Phenobarbital (induces microsomal enzymes) FETAL SURVEILLANCE IS REQUIRED Steroids - systemic reduce itchiness, IM gven to mature metal lung Colestyramine Phytomenadione (vit k) Anti-Histamines - eg dipenhydramine NB do not give phenobarbital if used within 2 hours of colestyramine. Pathological CTG - DELIVER There is increased risk of pre-term delivery and intra-uterine fetal demise in those with intrahepatic cholestasis of pregnancy. Almost half will have meconium and up to 25% will develop non-reassuring fetal status in labour. The overall perinatal mortality is between 3% and 20%.

Answer 433

Mild disease Prognosis is excellent. Most patients can attain a term delivery and complete resolution occurs within 24 to 48 hours in many cases. If prolonged >1 week, the patient should be evaluated for a retained placenta. Recurrence is expected in future pregnancies or with the use of oral contraceptives. All patients should be evaluated for hepatitis C if not already done. Although morbidity can be seen with mild disease, it is rare and no strategy to prevent fetal adverse outcome has been identified. Severe disease Most patients will attain gestational age 37 to 38 weeks as fetal demise or compromise is rare prior to term. Less than 10% will require premature delivery.

Answer 434

Resp distress in pre-term Vit K deficiency Premature labour Intrauterine fetal demise

Answer 435

obstetric cholestasis

Answer 436

obstetric cholestasis

Answer 437

Acute fatty liver of pregnancy (AFLP) is a serious complication unique to pregnancy, characterized by microvesicular steatosis in the liver. The foremost cause of AFLP is thought to be due to a mitochondrial dysfunction in the oxidation of fatty acids leading to an accumulation in hepatocytes. The infiltration of fatty acids causes acute liver insufficiency, which leads to most of the symptoms that present in this condition. If not diagnosed and treated promptly, AFLP can result in high maternal and neonatal morbidity and mortality.

Answer 438

AFLP affects 1 in 7000 to 1 in 16,000 deliveries. There is a predilection for nulliparous women and women with multiple gestations.

Answer 439

The foremost cause of AFLP is thought to be due to a mitochondrial dysfunction in the oxidation of fatty acids leading to an accumulation in hepatocytes. The infiltration of fatty acids causes acute liver insufficiency, which leads to most of the symptoms that present in this condition. If not diagnosed and treated promptly, AFLP can result in high maternal and neonatal morbidity and mortality.

Answer 440

There is a predilection for nulliparous women and women with multiple gestations.

Answer 441

Malaise Nausea and vomiting (70%); this may present for the first time in the third trimester Right upper-quadrant and epigastric pain (50-80%) Upper gastrointestinal hemorrhage Acute renal failure Infection Pancreatitis Hypoglycemia Fulminant liver failure with hepatic encephalopathy Hypertension Bleeding Confusion and altered mental status Jaundice: Hyperbilirubinemia resulting in jaundice is rarely encountered in patients with severe preeclampsia. When jaundice is present in pregnancy, AFLP should be high on the differential.

Answer 442

``` LFTs - elevated AST ALT Blood glucose - decreased Serum ammonia - increased Coagulation assessment - prolongation of prothrombin time, low fibrinogen, and low antithrombin levels (decreased production by the damaged liver) Bilirubin - high ``` IF pancreatitis too - increased serum amylase/lipase IF kidneys affected - creatinine + uric acid increased (met acidosis seen) Imaging rarely needed

Answer 443

Monitor fetal wellbeing closely and counsel mother on emergency deliveries 5% dextrose - prevent + Rx hypoglycaemia Monitor fluid balance closely Plasmapheresis/plasma exchange has improved outcomes if - severe encephalopathy, on ventilator support, or with severe liver or renal insufficiency who failed to respond to conventional management Consult anaesthetist regarding the anaesthetics that can be used

Answer 444

The prognosis for women who develop AFLP is excellent, assuming they survive the acute event. However, a case of chronic pancreatitis has been described, occurring about 3 months after recovery and discharge from the hospital.

Answer 445

LGA is often defined as a weight, length, or head circumference that lies above the 90th percentile for that gestational age.

Answer 446

1 out of 10 women | 1 in 3 Americans

Answer 447

``` Poorly controlled GDM / T2DM (NB T1DM is associated with microsomia) Obesity Gestational age past 40w Male Multiparity Hydrops fetalis Congenital anomalies causing hydros fetalis Amoxicillin Some links to polyhydramnios ```

Answer 448

``` Poorly controlled GDM / T2DM (NB T1DM is associated with microsomia) Obesity Gestational age past 40w Male Multiparity Hydrops fetalis Congenital anomalies causing hydros fetalis Amoxicillin Some links to polyhydramnios ```

Answer 449

Common risks in LGA babies include shoulder dystocia, hypoglycemia, metatarsus adductus, hip subluxation and talipes calcaneovalgus due to intrauterine deformation. ``` Poorly controlled GDM / T2DM (NB T1DM is associated with microsomia) Obesity Gestational age past 40w Male Multiparity Hydrops fetalis Congenital anomalies causing hydros fetalis Amoxicillin Some links to polyhydramnios ```

Answer 450

USS to assess liquor volume and fetal size using haddock formulas (AC/HC/FL)

Answer 451

Induction of labour for women with a baby with suspected macrosomia leads to babies being born at a lower birth weight, with fewer bone fractures and less shoulder dystocia, but could increase the number of women with perineal tears. Predicting a baby’s weight can be inaccurate and women could be worried unnecessarily, and request their labour to be induced for no reason. Doctors disagree whether women should be induced for suspected macrosomia and more research is needed to find out what this is best for women and their babies.

Answer 452

Common risks in LGA babies include shoulder dystocia, hypoglycemia, metatarsus adductus, hip subluxation and talipes calcaneovalgus due to intrauterine deformation. Big babies are at higher risk of hypoglycemia in the neonatal period, independent of whether the mother has diabetes. Complications were most often due to C-sections and included bleeding (hemorrhage), wound infection, wound separation, fever, and need for antibiotics.

Answer 453

Amniotic fluid index [AFI] >24 cm It cushions the fetus from physical trauma, permits fetal lung growth, and provides a barrier against infection. Normal amniotic fluid volume varies. The average volume increases with gestational age, peaking at 800-1000 mL, which coincides with 36-37 weeks' gestation. An abnormally high level of amniotic fluid, polyhydramnios, alerts the clinician to possible fetal anomalies. An inadequate volume of amniotic fluid, oligohydramnios , results in poor development of the lung tissue and can lead to fetal death.

Answer 454

1% pregnancies In pregnancies affected by polyhydramnios, approximately 20% of neonates are born with a congenital anomaly of some type; therefore, the delivery of these newborns in a tertiary care setting is preferred.

Answer 455

Fetal swallowing, which occurs physiologically, reduces the amount of fluid, and an absence of swallowing or a blockage of the fetus's gastrointestinal tract can lead to polyhydramnios. A near term fetus produces 500-1200 mL of urine and swallows between 210 and 790 mL of amniotic fluid per day. IDIOPATHIC Twin/multiple gestation TTTS Oesophageal atresia (usually associated with a tracheoesophageal fistula), tracheal agenesis, duodenal atresia, and other intestinal atresias CNS problems preventing swallowing Hydrops associated Chromosomal abnormalities, most commonly trisomy 21, followed by trisomy 18 and trisomy 13.

Answer 456

IDIOPATHIC Twin/multiple gestation TTTS Oesophageal atresia (usually associated with a tracheoesophageal fistula), tracheal agenesis, duodenal atresia, and other intestinal atresias CNS problems preventing swallowing Hydrops associated Chromosomal abnormalities, most commonly trisomy 21, followed by trisomy 18 and trisomy 13.

Answer 457

LGA Multiple pregnancy Fetal abnormalities associated with polyhydramnios include neonatal macrosomia, fetal or neonatal hydrops with anasarca, ascites, pleural or pericardial effusions, and gastrointestinal tract obstruction (eg, duodenal atresia, tracheoesophageal fistula). Skeletal malformations can also occur, including congenital hip dislocation, clubfoot, and limb reduction defect. Abnormalities in fetal movement are suggestive of primary neurologic abnormalities or may be in association with a genetic syndrome, such as polyploidy.

Answer 458

US measured AFI >24 or SINGLE pocket of 8cm depth containing >2000ml Chromosome testing, testing for evidence of congenital infection, ultrasonography of the genitourinary tract, and appropriate radiologic evaluation of the gastrointestinal tract. Electrocardiography and echocardiography may also be indicated. Histologic examination of the placenta may be helpful in determining the cause of the polyhydramnios or oligohydramnios. If premature delivery is anticipated with either oligohydramnios or polyhydramnios, the amniotic fluid lamellar body count, lecithin-sphingomyelin (L:S) ratio, and phosphatidylglycerol (PG) concentration are helpful in determining the maturity of the fetal lungs and, therefore, in assessing the likelihood of respiratory distress syndrome. If fetal hydrops is present, immunologic and fetal infection need to be investigated. This should include screening for maternal antibodies to D, C, Kell, Duffy, and Kidd antigens to determine maternal antibody production against the fetal red blood cells. Infections of the fetus include cytomegalovirus (CMV), toxoplasmosis, syphilis, and parvovirus B19. The investigation should include the following studies: Venereal Disease Research Laboratories (VDRL) test to screen for syphilis Immunoglobulin G (IgG) and IgM titers to evaluate for exposure to rubella, CMV, toxoplasmosis, and parvovirus A test for congenital viruses in the amniotic fluid using polymerase chain reaction (PCR) Kleihauer-Betke test to evaluate fetal-maternal hemorrhage Hemoglobin Bart in patients of Asian descent (who may be heterozygous for alpha-thalassemia) Fetal karyotyping for trisomy 21, 13, and 18

Answer 459

Most cases of polyhydramnios respond in the first week of treatment with indomethacin. This approach appears to be highly effective (90-100% in some studies), provided that the cause is not hydrocephalus or a neuromuscular disorder that alters fetal swallowing. _________________ Reductive amniocentesis may be performed and has contributed to prolonged pregnancy in patients who are severely affected by hydramnios. This procedure can reduce the risk of preterm labor, premature rupture of the membrane (PROM), umbilical cord prolapse, and placental abruption. However, if too much fluid is removed, placental abruption may occur. Other risks of the procedure include infection, bleeding, and trauma to the fetus. Laser ablation of placental vessels may be effective in cases of twin-to-twin transfusion syndrome, performed at highly specialized centers. Patients with polyhydramnios tend to have a higher incidence of preterm labor secondary to overdistention of the uterus. Schedule weekly or twice weekly perinatal visits and cervical examinations.

Answer 460

If polyhydramnios is not associated with any other findings, the prognosis is usually good. Polyhydramnios (amniotic fluid index [AFI] >24 cm) is associated with an increased rate of fetal malformations, genetic syndromes, neurologic disorders, and developmental delay, conditions that may only be diagnosed postnatally. Perinatal Mortality Rate = 4.12 deaths per 1000 patients with polyhydramnios and 56.5 deaths per 1000 patients with oligohydramnios.

Answer 461

Polyhydramnios (amniotic fluid index [AFI] >24 cm) is associated with an increased rate of fetal malformations, genetic syndromes, neurologic disorders, and developmental delay, conditions that may only be diagnosed postnatally. Other complications include premature rupture of the membranes (PROM), abruptio placenta, malpresentation, and postpartum hemorrhage 20% of cases of polyhydramnios involved associated fetal anomalies, including problems of the gastrointestinal system (40%), central nervous system (26%), cardiovascular system (22%), or genitourinary system (13%). Risks and complications of amnioinfusion include amniotic fluid embolism, maternal respiratory distress, increased maternal uterine tone, and transient fetal respiratory distress. An increase in the risk of maternal or fetal infection is not substantiated. Risks of amniocentesis include fetal loss (1-2%). Other complications are placental abruption, preterm labor, fetal-maternal hemorrhage, maternal Rh sensitization, and fetal pneumothorax. The risk of fetal infection is slightly increased.

Answer 462

The amniotic fluid that bathes the fetus is necessary for its proper growth and development. It cushions the fetus from physical trauma, permits fetal lung growth, and provides a barrier against infection. Normal amniotic fluid volume varies. The average volume increases with gestational age, peaking at 800-1000 mL, which coincides with 36-37 weeks' gestation. An abnormally high level of amniotic fluid, polyhydramnios, alerts the clinician to possible fetal anomalies. An inadequate volume of amniotic fluid, oligohydramnios , results in poor development of the lung tissue and can lead to fetal death.

Answer 463

11% pregnancies

Answer 464

Rupture of the membranes is the most common cause of oligohydramnios. However, because the amniotic fluid is primarily fetal urine in the latter half of the pregnancy, the absence of fetal urine production or a blockage in the fetus's urinary tract can also result in oligohydramnios. A near term fetus produces 500-1200 mL of urine and swallows between 210 and 790 mL of amniotic fluid per day.

Answer 465

Foetal urinary abnormalities - renal genesis, PKD, obstructive lesion PROM Chorioamnionitis Placental insufficiency (T1DM, maternal Gest-HTN) Maternal use of prostaglandin synthase inhibitors or angiotensin-converting enzyme

Answer 466

Marked deformation of foetus if real agenesis Oligohydramnios adversely affects fetal lung development, resulting in pulmonary hypoplasia that typically leads to death from severe respiratory insufficiency. Other fetal deformations include bowed legs, clubbed feet, a single umbilical artery, gastrointestinal atresias, and a narrow chest secondary to external compression. Infants are typically small for their stated gestational age (SGA)

Answer 467

Oligohydramnios is ultrasonographically defined as an AFI less than 7 cm or the absence of a fluid pocket 2-3 cm in depth. Premature rupture of membrane (PROM) is the most common cause of oligohydramnios; therefore, obtain available tests to confirm or exclude this condition. Maternal substance abuse and certain medications (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], angiotensin-converting enzyme inhibitors [ACEI]) can also cause oligohydramnios. Test for systemic lupus erythematosus (SLE), which causes immune-mediated infarcts in the placenta as well as placental insufficiency. Evaluate for pregnancy-induced hypertension (PIH) and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Test for elevated blood pressure, proteinuria, elevated uric acid levels, increased liver function test results, and low platelet count.

Answer 468

The transabdominal instillation of indigo carmine may be used to evaluate for PROM. The transcervical instillation of isotonic sodium chloride solution (ie, amnioinfusion) at the time of delivery reduces the risk of cord compression, fetal distress, and meconium dilution. It also reduces the potential need for cesarean delivery. Maternal bed rest and hydration promote the production of amniotic fluid by increasing the maternal intravascular space. Bed rest may also help when pregnancy-induced hypertension (PIH) is present, allowing prolongation of the pregnancy. Studies show that oral hydration, by having the women drink 2 liters of water, increases the AFI by 30%.

Answer 469

Perinatal Mortality Rate = 4.12 deaths per 1000 patients with polyhydramnios and 56.5 deaths per 1000 patients with oligohydramnios. The mortality rate in oligohydramnios is high. The lack of amniotic fluid allows compression of the fetal abdomen, which limits movement of its diaphragm. In addition to chest wall fixation, the lack of amniotic fluid flowing in and out of the fetal lung leads to pulmonary hypoplasia. Oligohydramnios is also associated with meconium staining of the amniotic fluid, fetal heart conduction abnormalities, umbilical cord compression, poor tolerance of labor, lower Apgar scores, and fetal acidosis. In cases of intrauterine growth restriction (IUGR), the degree of oligohydramnios is often proportional to growth restriction, is frequently reflective of the extent of placental dysfunction, and is associated with a corresponding increase in the PMR.

Answer 470

In the setting of oligohydramnios with renal agenesis, mortality is 100%. Milder forms of renal dysplasia or obstructive uropathy can be associated with a mild to severe degree of pulmonary hypoplasia and long-term renal failure. In cases of pulmonary hypoplasia, the effectiveness of many treatments such as the administration of surfactant, high-frequency ventilation, and nitric oxide has not been established. The prognosis in these cases is related to the volume of amniotic fluid and the gestational age at which oligohydramnios develops. The mortality rate in oligohydramnios is high. The lack of amniotic fluid allows compression of the fetal abdomen, which limits movement of its diaphragm. In addition to chest wall fixation, the lack of amniotic fluid flowing in and out of the fetal lung leads to pulmonary hypoplasia. Oligohydramnios is also associated with meconium staining of the amniotic fluid, fetal heart conduction abnormalities, umbilical cord compression, poor tolerance of labor, lower Apgar scores, and fetal acidosis. In cases of intrauterine growth restriction (IUGR), the degree of oligohydramnios is often proportional to growth restriction, is frequently reflective of the extent of placental dysfunction, and is associated with a corresponding increase in the PMR The primary complications of oligohydramnios are those related to fetal distress before or during labor. The risk of fetal infection is increased in the presence of prolonged rupture of the membranes.

Answer 471

Carcinoma of the vulva HPV related = young Non- HPV = old - associated with VIN or lichen sclerosis 85% squamous 5% melanoma

Answer 472

10 per 100k incidence | 1000 per year in UK

Answer 473

Squamous cell cancers of skin Femoral+inguinal LN involvement eventually -> before lung / liver HPV related = young Non- HPV = old - associated with VIN or lichen sclerosis

Answer 474

``` Age HPV Lichen sclerosis Smoking Impaired immunity Hx of VIN ```

Answer 475

``` Vulval lump Pruritus / irritation Pain (some tumours ulcerating) PM bleed Asymptomatic "cauliflower type growths" Skin thickening Most commonly labiamajora / clitoris Inguinal-femoral LNs Can be multifocal ```

Answer 476

Biopsy | Staging

Answer 477

Excision of primary sites + LNs Clear margins of 1-2cm Positive modes -> radiotherapy +/- chemotherapy May need radical vulvectomy

Answer 478

5yr survival 75% Prognosis poor if >4cm, sphincter involvement, groin mets ``` Wound breakdown/infection Thromboemolic disease Secondary haemorrhage Chronic leg oedema Parasthesia over leg Impaired sexual function ```

Answer 479

Herniation of the genital tract through the pelvic diaphragm Caused by deficiency pelvic fascia, or weakness of the ligaments, muscles, blood or nerves that supply the pelvic organs. ANTERIOR VAGINAL WALL Urethrocele Cystocele Cystourethrocele POSTERIOR VAGINAL WALL Rectocele Enterocele APICAL WALL Uterovaginal Vaginal vault

Answer 480

41-50% over 40 | 10% risk of needing an operation for prolapse

Answer 481

Connective tissue defects Levator ani + intact nerve supply required for function Damaged through: birth, aging, Congenital weaknesses (ie 2% of nulliparous still get) Hysterectomy - with VVault Anything causing raised intra-abdominal pressure - IE coughing/constipation

Answer 482

Birth, aging Congenital weaknesses (ie 2% of nulliparous still get) Hysterectomy - with VVault Anything causing raised intra-abdominal pressure - IE coughing/constipation

Answer 483

``` "Baring down" Lump Discomfort Backache Bleeding Dyspareunia Renal failure - if urethral kinking ``` SPECIFIC Cysto-urthral - urinary freq/urgency/UTI/Stress incontinence Rectocele - incomplete bowel emptying, digitation, splinting, anal incontinence

Answer 484

Clinical Potential UTI screen

Answer 485

MILD SYMPTOMS: Pelvic floor physio Silicon rubber pessaries ``` Severe: SURGERY - Colporrhaphy UTERINE PRESERVING: Hysterosacropexy Manchester repair Mesh repair ``` NON PRESERVING Vaginal hysterectomy Total abdominal hysterectomy + sacrocolplexy Subtotal abdominal hysterectomy + sacrocervicoplexy

Answer 486

Stress incontinence Dyspareunia Recurrence

Answer 487

Colonisation + infection of the vagina by trichomonas vaginalis, a protozoan organism. Infests the vagina and urethra Single celled organism with 4 flagella and an undulating membrane Acquired via sexual intercourse

Answer 488

18% of female population

Answer 489

Multiple partners | Disuse of barrier contraceptives

Answer 490

Colonisation + infection of the vagina by trichomonas vaginalis, a protozoan organism. Infests the vagina and urethra Single celled organism with 4 flagella and an undulating membrane Acquired via sexual intercourse

Answer 491

``` Acute phase: Vaginal pain + tenderness acutely Irritant discharge Inflamed vaginal walls Strawberry vaginitis Copious frothy, offensive discharge Burning sensation Pruritus Dysuria Dyspareunia Latet-dormant phase - no symptoms ```

Answer 492

Smear + microscopy - observation of trichomonas | Culture of smear

Answer 493

Metronidazole 200mg TD for a week OR one dose of 2g (and avoidance of alcohol) Short courses more likely to produce gastritis but may be good if non-adherent patient Recheck smear after Rx

Answer 494

Infection of the urinary tract. Asymptomatic bacteria = most common Ranges from cystitis -> pyelonephritis Pyelonephritis is the most common serious medical complication of pregnancy

Answer 495

Asymptomatic bacteria = 5-6% non-pregnant women, more common in diabetics. Usually detected at antenatal clinics. Must be Rx. 25% will develop Sx in pregnancy. Pyelonephritis is the most common serious medical complication of pregnancy. 15-20% have bacteraemia. 3.5% antepartum admissions for UTIs

Answer 496

``` E coli Kelbsiella Enterobacter Proteus GBS Staph A ```

Answer 497

Urinary stasis DM/GDM Vesicouteric reflux Puerperal RFs: Bladder sensitivity reduced post surgery Discomfort from haematomas / episiotomy lines Cathetisation to relieve retention

Answer 498

``` Asymptomatic Suprapubic dyscomfort Fever Dysuria Freq urination + urgency Foul smelling urine ``` Haematuria, flank pain, shivering, anorexia, N+V Pyelonephritis = unilateral and RS in 50% - May cause ARDS NB

Answer 499

Urine dip - +ve nitrites, leucocytes, +/- blood Urine culture USS if pyelonephritis / blood cultures

Answer 500

Asymptomatic - nitrofurantoin / trimethoprim (can do single dose/3 days/ten days) Pyelonephritis: Prompt antimicrobials: Ampicillin + Gentamicin OR ceftriaxone (until afebrile for 24hr) IV hydration = cornerstone of Rx NB 30-40% of pyelos relapse -> consider longer Rx 7-10days nitrofurantoin

Answer 501

The majority of long-term sequelae are due to complications associated with septic shock, respiratory failure, and hypotensive hypoxia (ie, extremity gangrene). ARDS Untreated upper UTIs are associated with low birth weight, prematurity, premature labor, hypertension, preeclampsia, maternal anemia, and amnionitis

Answer 502

Vasa previa is an uncommon obstetrical complication that poses a high risk of fetal demise if not recognized before rupture of membranes. It is vital that providers recognize risk factors for vasa previa and diagnose this condition before the onset of labor so that fetal shock or demise is prevented. Neither the umbilical cord nor the placenta supports the vessels. Vasa previa presents with painless vaginal bleeding at the time of spontaneous rupture of membranes or amniotomy (AROM). Fetal shock or demise can occur rapidly. Fetal mortality for cases not recognized before the onset of labor is reported to range between 22.5% and 100%.

Answer 503

Vasa previa occurs when the fetal vessels in the membrane are situated in front of the presenting part of the fetus. This may occur because of a velamentous insertion of the cord or with vessels running between the placenta and a succenturiate lobe. Vasa previa may also exist over the dividing membrane when a second twin has a velamentous insertion of the umbilical cord.

Answer 504

Vasa previa may be associated with low-lying placenta, placenta with accessory lobes, and with multiple pregnancies.

Answer 505

Vasa previa is diagnosed prenatally with an average sensitivity of 93% and a specificity of 99%. AT DELIVERY: PV bleed Sinusoidal fetal heart pattern, fetal bradycardia, or fetal heart rate decelerations during labor may all indicate a ruptured vasa previa

Answer 506

Vasa previa is diagnosed prenatally with an average sensitivity of 93% and a specificity of 99%. US scan Consider endovaginal color flow Doppler ultrasonography to rule out vasa previa for patients with a known succenturiate lobe or velamentous insertion of the cord.

Answer 507

Cesarean delivery is the preferred mode of delivery for known vasa previa and is mandatory if significant vaginal bleeding occurs.

Answer 508

Fetal mortality for cases not recognized before the onset of labor is reported to range between 22.5% and 100%.

Answer 509

Increased TBG, increase t3/t4, Serum TSH decreases in early pregnancy (-ve feedback from weak stimulation by BHCG). Thus TRH also reduced (typically undetectable). Maternal thyroxine important for normal fatal development. Fetal thyroid begins producing thyroxine from 12 weeks. Maternal sources still contribute to 30% at term. 15% of pregnant women have TPO antibodies

Answer 510

Throtoxicosis / hyperthyroid = 2-17% of pregancies Graves = most common. Hashimotos = most common hypo 2-10 per 1000 pregnancies = hypothyroid

Answer 511

Graves most common hyper | Hashimotos = most common hypo

Answer 512

Hyper: Often difficult to detect due to normal t4 excess in pregnancy: SX Tachycardia, thryomegaly, exophthalmos, failure to gain weight Hypo: Fatigue, constipation, cold intolerance, muscle cramps, weight gain. Oedema, dry skin, hair loss, def deep tendon reflexes

Answer 513

HYPER: Markedly depressed TSH, elevated t4, sometime t3. Graves: anti-TSH receptor antibodies May be associated with GTD/Hyperemesis G HYPO: High TSH, Low t4 Anti-TPO antibodies

Answer 514

Thyrotoxicosis: PTU - propylthiouracil is safest drug (least crosses placenta). Recommended to switch to Methimazole in 2nd trimester (PTU associated with hepatotoxicity) THYROID ABLATION + RADIOACTIVE IODINE Rx IS CONTRAINDICATED IN PREGNANCY Hypo: Levothyroxine 1-2ug/kg/day. Survey 4-6 weekly, increase dose by 25ug until normal t4.

Answer 515

HYPER RELATED Pre-eclampsia, HF, IUGR, preterm delivery, stillbirth, thyrotoxocosis, goitre HYPER RELATED DRUGs: Hepatotoxicity Fetal malformations if methimazole is used in 1st trimester transient leukopenia ``` HYPO RELATED COMPLICATIONS: Pre-eclampsia Placental abruption Cardiac dysfunction LBW Stillbirth Fetal hypothyroidism HTN possible Congenital hypothyroidism Cretinism ```

Answer 516

Uterus compresses pelvic veins + inferior vena cava. Increases stasis. Stasis Trauma Hypercoagulability ``` Obstetrical: CS DM Haemorrhage/anaemia Hyperemesis Immobility Multiple gestation Multiparity Pre-eclampsia Puerperal infection ``` ``` General: >35yo Cancer Connective tissue disease Dehydration Immobility Infection/inflammatory disease Nephrotic syndrome Obesity Oral contraceptivo use Orthopedic surgery Paraplegia Hx of VTE SCD Smoking Thrombophilia ```

Answer 517

Risk of DVT/PE highest during pregnancy (in healthy women). 1 in 1000 pregnancies DVT 1 in 7000 pregnancies PE 10% of maternal deaths = PE

Answer 518

Stasis Trauma Hypercoagulability ``` Obstetrical: CS DM Haemorrhage/anaemia Hyperemesis Immobility Multiple gestation Multiparity Pre-eclampsia Puerperal infection ``` ``` General: >35yo Cancer Connective tissue disease Dehydration Immobility Infection/inflammatory disease Nephrotic syndrome Obesity Oral contraceptivo use Orthopedic surgery Paraplegia Hx of VTE SCD Smoking Thrombophilia ```

Answer 519

DVT: 70% iliofemoral Pain, oedema, swelling, pain on dorsiflexion, erythema. NB 30-60% of women with lower extremity DVT have an asymptomatic PE ``` PE: Dyspnoea Pleuritic chest pain Cough Syncope Haemoptysis ``` Tachypnoea Tachycardia Apprehension RAD, S1q3t3 May be atelectasis Haemodynamic instability - saddle emboli

Answer 520

Compression US with doppler D dimer often raised anyway in pregnancy BUT a negative d dimer is reassuring. MRI if pelvic/iliofemoral suspected..often not seen on US doppler PE: CTPA is most sensitive but increased radio dose so: Ventilation -perfusion scan = preferable Can do MR-angiography

Answer 521

DVT: LMWH (better bioavailability than unfractionated). Converted to unfractionated during the last month of pregnancy. (less bleeding from epi/spinal) Unfractionated heparin can be reversed with Protamine Sulfate. PE: If needing to undergo CS soon: Vena cava filter Risk of death lower if given Alteplase BUT increased risk of fatal bleeding episode. Case-by-case decision. WILL ALL NEED THROMBOPROPHYLAXIS POST CS UNLESS NO RISK FACTORS 6 week Rx NB warfarin can be given as thromboprophylaxis postnatally.

Answer 522

``` Haemorrhage thrombocytopenia Osteoporosis Death RVH/F PHTN ```

Answer 523

Elective termination of pregnancy The law: (a) that the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or (b) that the termination of the pregnancy is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or (c) that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated (d) that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.

Answer 524

1.7% of US women 15-44 per year Half have had at least one prior abortion. 89% of abortions occur less than 12 weeks gestation Globally, abortion mortality accounts for at least 13% of all maternal mortality. New estimates are that 50 million induced abortions are performed each year in developing countries, with approximately 20 million of these performed unsafely because of conditions or lack of provider training. 1 in 100k mortality with 1st trimester abortions BUT always safer for abortion than continuation Women in their 20s account for more than half of all abortions.

Answer 525

Few absolute conrtaindications for pregnancy. Cardiac conditions that still carry maternal mortality rates of 5-15% include severe mitral stenosis, coarctation of the aorta, uncorrected tetralogy of Fallot, aortic stenosis, history of myocardial infarction, and the presence of artificial heart valves. Higher mortality rates have been reported in women with coarctation of the aorta with vascular involvement, pulmonary hypertension, Marfan syndrome with aortic involvement, and myocardial infarction in pregnancy. The most common fetal anomalies encountered in abortion counseling include most fetal cardiac anomalies; trisomy 21; open and closed neural tube defects; limb, face, or cleft abnormalities; esophageal or duodenal atresia; chest and abdominal wall defects; cystic kidneys or hydronephrosis; intracranial calcifications suggestive of viral disease; or diaphragmatic defects. Fetal conditions that are incompatible with life include anencephaly, trisomy 13, trisomy 18, renal agenesis, thanatophoric dysplasia, alobar holoprosencephaly, and some hydrocephalic cases. Medical abortion is contraindicated in patients with clotting disorders, severe liver disease, renal disease, cardiac disease, and chronic steroid use. Medical abortion is also contraindicated in women with no access to emergency services and no partners or family to be with the patient during the heaviest bleeding times. Surgical abortion is contraindicated in patients with hemodynamic instability, profound anemia, and/or profound thrombocytopenia. The conditions should be managed and the context of pregnancy continuation must be considered. The rare instance of placenta accreta and percreta in the second trimester may necessitate laparotomy with hysterotomy or hysterectomy.

Answer 526

Most abortion counseling focuses on the decision-making process, the options for continuing the pregnancy, medical issues of the pregnancy, information regarding the pregnancy itself, full disclosure of the risks of continuing to term, information and options for the technique of the abortion procedure, and, finally, information regarding a contraceptive decision. The risks and benefits of both medical and surgical abortions should be reviewed. The counseling process is aimed primarily at the woman herself but may also include other persons she chooses to be involved. Studies indicate that males are involved in more than 40% of the decisions, but only scant research has been performed on male involvement in the process. Some women can reach a decision quickly; others take longer to decide. The counseling process should include referrals for those who need ongoing support. Of utmost importance is to ensure that the patient has had enough time to consider her options and that she is not being coerced into her decision. In actual US Supreme Court reference materials there are statements that women may experience "regret...depression...loss of esteem"; however, most research fails to substantiate this, and, in fact, postabortion mental health benefits have been shown. Some studies show significant negative mental health effects of bearing an unwanted child, which others argue should be placed into the counseling context, although it seldom is. Most women experiencing depression postabortion experienced significant preabortion depression. [18] Many strategies can be used in the counseling session. Open-ended questions bring out issues that are pertinent to the woman and encourage meaningful exchange of dialogue. The patient's emotions should be validated, and the counselor should encourage the client to explore her feelings in more depth. Health care providers and counselors may not have the time or expertise to devote themselves to lengthy sessions, and not all women are able to complete the process in a day if these issues need to be explored before the abortion procedure.

Answer 527

Pregnancy test FBC + haematinics Rhesus typing STI screen May perform Coagulation studies, RFTs, LFTs Post operative HCG may be performed - Titer resolution is different between surgical and medical abortions. The titer should decrease to approximately 64% of its preabortion value within 24 hours of misoprostol being administered in medical abortion protocols. By 2 weeks, the titers should have dropped 99%. US scan may be performed - establish gestation

Answer 528

MEDICAL: Mifepristone + Buccal misoprostone - <9weeks - Mifepristone administered there + then, misoprostal administered at home 24-48hrs after misoprostol. - Most women deliver 2-24hr post misoprostol. The package inserts for the medical regimen are critical to review with the patient and send home with her. They cover side effects, expected progress, and symptoms very completely. Follow up appointment - 7-14 days later. OR Methrotrexate injection, misoprostol on days 6-7 ``` SURGICAL: Manual vacuum aspiration - 4-10w Suction curettage - 6-14w Dilation and evacuation - 14-24w Hysterotomy - 12-24w (if large fibroids) ``` Surgical: Often sedation only used. Laminaria japonicas are small sticks of presterilized seaweed that can be inserted preoperatively to dilate the cervix. May give vag/oral misoprotol to prepare cervix May give local lidocaine to cervix Agents useful to control bleeding include oxytocin, methylergonovine, or prostaglandins. A surgical abortion is usually performed under local anesthesia. For those modestly tolerant of pain, either intravenous sedation or a preoperative antianxiolytic agent can be administered. Nonsteroidal anti-inflammatory drugs (NSAIDs) have also been used for preoperative preparation. Narcotics can be used for pain control but are usually not necessary. Most antibiotics are used prophylactically to prevent postoperative endometritis. Some institutions have used dosages that would cover chlamydia and gonorrhea because patients often cannot be contacted after an abortion.

Answer 529

Medical abortions can provide some measure of safety in that they eliminate the risk of cervical lacerations and uterine perforations. Medical: can cause bleeding A rare and serious infection of Clostridium sordellii is related to medical abortions.

Answer 530

Safer to terminate than continue pregnancy Contraindications to mifepristone include serious medical problems, such as cerebrovascular or cardiovascular disease, severe liver, kidney or pulmonary disease, preoperative anemia (< 10 mg/dL), undiagnosed ectopic pregnancy, allergies, contraindications to prostaglandin use, active uterine bleeding, or large uterine leiomyomata. Of all methods of second trimester abortion, the safest procedure (using mortality surveillance data) is dilation and extraction. Labor induction with prostaglandins and passive dilators has a higher risk than dilation and extraction due to the risk of retained placenta.

Answer 531

Intrauterine growth restriction (IUGR) refers to a condition in which a fetus is unable to achieve its genetically determined potential size. This functional definition seeks to identify a population of fetuses at risk for modifiable but otherwise poor outcomes. This definition intentionally excludes of fetuses that are small for gestational age (SGA) but are not pathologically small. SGA is defined as growth at the 10th or less percentile for weight of all fetuses at that gestational age. Not all fetuses that are SGA are pathologically growth restricted and, in fact, may be constitutionally small. Similarly, not all fetuses that have not met their genetic growth potential are in less than the 10th percentile for estimated fetal weight (EFW).

Answer 532

Maternal causes of IUGR include the following: ``` Chronic hypertension Pregnancy-associated hypertension Cyanotic heart disease Class F or higher diabetes Hemoglobinopathies Autoimmune disease Protein-calorie malnutrition Smoking Substance abuse Uterine malformations Thrombophilias Prolonged high-altitude exposure ``` Placental or umbilical cord causes of IUGR include the following: ``` Twin-to-twin transfusion syndrome Placental abnormalities Chronic abruption Placenta previa Abnormal cord insertion Cord anomalies Multiple gestations ```

Answer 533

Maternal causes of IUGR include the following: ``` Chronic hypertension Pregnancy-associated hypertension Cyanotic heart disease Class F or higher diabetes Hemoglobinopathies Autoimmune disease Protein-calorie malnutrition Smoking Substance abuse Uterine malformations Thrombophilias Prolonged high-altitude exposure ``` Placental or umbilical cord causes of IUGR include the following: ``` Twin-to-twin transfusion syndrome Placental abnormalities Chronic abruption Placenta previa Abnormal cord insertion Cord anomalies Multiple gestations ```

Answer 534

For most purposes, an EFW at or below the 10th percentile is used to identify fetuses at risk. Importantly, however, understand that this is not a definitive cutoff for uteroplacental insufficiency. A certain number of fetuses at or below the 10th percentile may be constitutionally small. In these cases, short maternal or paternal height, the neonate's ability to maintain growth along a standardized curve, and a lack of other signs of uteroplacental insufficiency (eg, oligohydramnios, abnormal Doppler findings) can be reassuring to the clinician and parents. Customized growth curves for ethnicity, parental size, and gender are in development so as to improve sensitivity and specificity of diagnosing IUGR.

Answer 535

SFH US estimated gestation: Measures FL, AC, HC Hadlock 1 used FL, AC Often uterine + umbilical arteries measured. MCA doppler performed - abnormal MCA study results had earlier deliveries, lower birth weights, fewer vaginal deliveries, and increased admissions to neonatal ICUs 3D US can be performed in some places

Answer 536

This should include steroid administration when at all feasible, based on the monitoring and delivery strategies Case by case. Some need immediate delivery, some benefit from delayed: Situation 1 See the list below: Test results – AC less than fifth percentile, low AC growth rate, high ratio of head circumference to AC; BPS greater than or equal to 8 and AFV normal; abnormal UV and/or cerebroplacental ratio; normal MCA Interpretation – IUGR diagnosed, asphyxia extremely rare, increased risk for intrapartum distress Recommended management – Intervention for obstetric or maternal factors only, weekly BPS, multivessel Doppler every 2 weeks Situation 2 See the list below: Test results – IUGR criteria met, BPS greater than or equal to 8, AFV normal, UA with absent or reversed end-diastolic velocities, decreased MCA Interpretation – IUGR with brain sparing, hypoxemia possible and asphyxia rare, at risk for intrapartum distress Recommended management – Intervention for obstetric or maternal factors only; BPS 3 times a week; weekly UA, MCA, and venous Doppler Situation 3 See the list below: Test results – IUGR with low MCA PI; oligohydramnios; BPS greater than or equal to 6; normal IVC, DV, and UV flow Interpretation – IUGR with significant brain sparing, onset of fetal compromise, hypoxemia common, acidemia/asphyxia possible Recommended management – If at more than 34 weeks' gestation, deliver (route determined by obstetric factors). If at less than 34 weeks' gestation, administer steroids to achieve lung maturity and repeat all testing in 24 hours. Situation 4 See the list below: Test results – IUGR with brain sparing, oligohydramnios, BPS greater than or equal to 6, increased IVC and DV indices, UV flow normal Interpretation – IUGR with brain sparing, proven fetal compromise, hypoxemia common, acidemia/asphyxia likely Recommended management – If at more than 34 weeks' gestation, deliver (route determined by obstetric factors and oxytocin challenge test [OCT] results). If at less than 34 weeks' gestation, individualize treatment with admission, continuous cardiotocography, steroids, maternal oxygen, and/or amnioinfusion and then repeat all testing up to 3 times a day depending on status. Situation 5 See the list below: Test results – IUGR with accelerating compromise, BPS less than or equal to 6, abnormal IVC and DV indices, pulsatile UV flow Interpretation – IUGR with decompensation, cardiovascular instability, hypoxemia certain, acidemia/asphyxia common, high perinatal mortality, death imminent Recommended management – If fetus is considered viable by size, deliver as soon as possible at tertiary center. Route determined by obstetric factors and OCT results. Fetus requires highest level of natal ICU care.

Answer 537

Relative risks associated with IUGR using morbidity and mortality parameters, from the study by Bernstein et al, are as follows: Relative risk of death, 2.77; 95% confidence interval (CI), 2.31-3.33 Relative risk of respiratory distress syndrome, 1.19; 95% CI, 1.03-1.29 Relative risk of intraventricular hemorrhage, 1.13; 95% CI, 0.99-1.29 Relative risk of severe intravascular hemorrhage, 1.27; 95% CI, 0.98-1.59 Relative risk of necrotizing enterocolitis, 1.27; 95% CI, 1.05-1.53

Answer 538

Increasingly, data support the idea that long-term consequences of IUGR last well into adulthood. Several authors have noted that these individuals have a greater predisposition to develop a metabolic syndrome later in life, manifesting as obesity, hypertension, hypercholesterolemia, cardiovascular disease, and type 2 diabetes.

Answer 539

The use and abuse of illicit or harmful drugs during pregnancy

Answer 540

Neonatal withdrawal = 1-40 per 10k The prevalence of prenatally exposed newborns to one or more illicit drugs averages approximately 5.5%, with a range of 1.3-50% 14.8% of pregnant women consumed alcohol

Answer 541

``` FHx Closer relatives = higher risk Hx sexual abuse Psychiatric comorbidity Teenage years + other RFs ```

Answer 542

Alcohol withdrawal: Signs of alcohol withdrawal may include hyperactivity, crying, irritability, poor sucking, tremors, seizures, poor sleeping patterns, hyperphagia, and diaphoresis. Signs usually appear at birth and may continue until age 18 months. Withdrawal typically appears within 3-12 hours after delivery. Barbiturate withdrawal: Signs may include irritability, severe tremors, hyperacusis, excessive crying, vasomotor instability, diarrhea, restlessness, increased tone, hyperphagia, vomiting, and disturbed sleep. Marijuana withdrawal: For marijuana, a mild opiatelike withdrawal syndrome has been observed. Signs may include fine tremors, hyperacusis, and a prominent Moro reflex; however, these symptoms rarely require treatment. Nicotine withdrawal: Mild signs are observed, including fine tremors and variations in tone; recent data have shown that maternal smoking was associated with subtle neonatal behaviors, such as poor self-regulation and an increased need for handling. Methadone withdrawal: Symptoms typically appear within 48-72 hours but may not start until the infant is aged 3 weeks. This is particularly true for infants whose mothers took excessively higher doses. Opiate withdrawal: Signs of NAS include hyperirritability, gastrointestinal dysfunction, respiratory distress, and vague autonomic symptoms (eg, yawning, sneezing, mottling, fever). Tremors and jittery movements, high-pitched cries, increased muscle tone, and irritability are common. Normal reflexes may be exaggerated. Loose stools are common, leading to possible electrolyte imbalances and diaper dermatitis. Long-term symptoms have been difficult to study, but evidence supports that these children show hyperphagia, increased oral drive, sweating, hyperacusis, irregular sleep patterns, poor tolerance to environmental changes, and continued loose stools. NAS appears to be less severe if the mother has used opiates longer than one week prior to delivery. Cocaine: Acute signs such as tremors, high-pitched cry, irritability, excess suck, hyperalertness, apnea, and tachycardia can be seen with the first 72 hours of life.

Answer 543

The following studies are indicated when assessing perinatal drug abuse and neonatal drug withdrawal: Obtain a serum glucose level. Obtain a serum calcium level. Perform a CBC count with differential and platelets. Consider blood culture and other cultures to rule out newborn sepsis. Confirm maternal hepatitis status and treat accordingly. Confirm human immunodeficiency virus (HIV) status. A urine toxicological screen may be helpful in determining drug use. A urine screen only signifies recent use or heavy use of drugs. In general, the length of time that a drug is present in urine after use is as follows: Marijuana: 7 days to 1 month in an adult, perhaps even longer in an infant Cocaine: 24-28 hours in an adult, 72-96 hours in an infant Heroin: 24 hours in an adult, 24-48 hours in an infant Methadone: Up to 10 days in an infant

Answer 544

Opiates - naloxone Other drugs - no specific Rx yet determined Non-opiate withdrawal - can be Rx with barbiturates: (phenobarbital) 1. The newborn with a nonopiate withdrawal 2. The newborn with a known polydrug withdrawal 3. The newborn with abstinence-related seizures 4. The newborn who has already received the maximum safe level of deodorized tincture of opium (DTO) All medically treated newborns should constantly be monitored for cardiovascular, respiratory, and oxygen saturation changes (see Medication). Increased caloric intake The child's comfort is paramount. Being a newborn is extremely stressful in the first few weeks of life because every external stimulus is entirely new to the infant. Add the stress of the internal stimuli from drug withdrawal, and the usefulness of environmental control can be understood. With this in mind, consider that 40% of all withdrawing newborns can be treated symptomatically (without medication). Involve general paeds follow up Early intervention and developmental pediatrics Social services

Answer 545

Neonatal withdrawal syndrome occurs in 60% of all fetuses exposed to drugs.

Answer 546

Neonatal withdrawal syndrome occurs in 60% of all fetuses exposed to drugs. In particular, the incidence of premature delivery, abruptio placentae, breech presentation, and intrauterine growth retardation are significantly increased in mothers who are dependent on drugs. In particular, cocaine use, with its vasoconstrictive properties, has been associated with an increase in vaginal bleeding, abruptio placentae, placenta previa, premature rupture of membranes, abortion, pneumothorax, pneumonia, malnutrition, and seizures. Opioid use has been shown to increase the rate of premature labor, premature rupture of membranes, breech presentation, antepartum hemorrhage, toxemia, anemia, uterine irritability, and infection (eg, HIV, hepatitis, syphilis). Alcohol use has been associated with an increased rate of abruptio placentae. Complications for mothers who drink alcohol heavily can include increased spontaneous abortions and premature placental separation. Cognitive and developmental defects for most

Answer 547

Destructive inflammatory condition affecting the anogenital area in women

Answer 548

1 in 300 | 15% have involvement elsewhere on body

Answer 549

A/I | Inflammation in the subnormal layers resulting in hyalinisation of the skin

Answer 550

Other A/I conditions: Thyroid disease Pernicious anaemia

Answer 551

``` Itchiness Soreness Splitting of skin (from itching) White parchment paper appearance Fissuring possible ```

Answer 552

Biopsy can confirm but usually clinical

Answer 553

Good skin care - cleaning and moisturising afterwards Steroid cream eg dermovate

Answer 554

Associated with vulval cancer, but not a cause Many presenting with vulval cancer have lichen sclerosis Thought 3-5% of lichen sclerosis sufferers will develop vulval cancer

Answer 555

Normally pigmented areas become more so - IE nipples, external genitalia, anal region Fresh pigmentation on face = normal called CHLOASMA / MELASMA GRAVIDARUM Fresh pigmentation also seen on linea alba line - called LINEA NIGRA Thought to be due to excess melanin in pregnancy - Melanocyte-stimulating hormone is elevated early in pregnancy NORMAL to see striae - STRIAE GRAVIDARUM Seen on thighs, abdomen, breast Persistent striae are called STRIAE ALBICANTES May be associated with increased ACTH Increased glands in breasts - glands of Montgomery Rectus abdominus may separate in middle - diastisis recti Angiomas/vascular spiders also appear = normal Palmar erythema also normal

Answer 556

``` Candida Lichen sclerosis Eczema VIN Contact dermatitis ``` Vulva irritation can be caused by any moisture left on the skin. This moisture may be perspiration, urine, vaginal discharge or small amounts of stool. It may be caused by vaginal infections, vulvitis, HPV (human papilloma virus) infection, anal incontinence, Bowen's disease, or dietary irritants (caffeine, potatoes, chilli, capsicum, tomatoes, and peanuts). Patch testing may be useful for diagnosis

Answer 557

The obstetric population is generally fit and healthy, with a small proportion having pre-existing cardiac disease. Pre-existing: ensure patient is counselled prior to pregnancy Either way the job of the obstetrician is to involve the MDT

Answer 558

Between 1997-9 only 35 deaths in UK from heart disease 10 from congenital 25 from acquired 1/3 of congenital were PHTN 7/25 of acquired were from puerperal cardiomyopathy Older motherhood and lifestyle habits -> increasing IHD in pregnancy

Answer 559

Sharp rise in CO during 1st trimester, followed by gradual 40% increase above normal by 2nd trimester CO rises even more during labour during contractions, and delivery of placentae Can cause myocardial compromise Cardiac failure can occur gradually in the pregnancy as the heart fails to meet the demand on the circulation. LHF presents early in pregnancy if mod-severe disease More commonly acute HF occurs as tachycardia >110 due to reduced ventricular filling In mitral valve disease -> 2nd trimester + birth are dangerous -> increases in circulatory volumes EISENMENGER = CONTRAINDICATION TO PREGNANCY

Answer 560

``` Aggregating factors: Anaemia Respiratory infection Febrile illness Excessive exercise Emotional upset -> all cause tachycardias ```

Answer 561

LVF -> pulmonary oedema, leg oedema | RVF -> JVP, fluid retention, orthopnoea, coughing, wheezing

Answer 562

Pre-pregnancy counselling: - assessment of cardiac status - eisenmenger = contraindication to pregnancy Booking: Haemic systolic murmurs are common in pregnancy Assessment by cardiologist should be performed Patients with known lesions should be supervised jointly by a cardiologist and obstetrician

Answer 563

TOP: - If eisenmenger - Tetraology of fallot = 1% mortality risk AFTER 12 weeks the risk of termination is as great as continuing the pregnancy Minor lesions such as uncomplicated septal defects + PDA rarely justify surgical Rx during pregnancy Any infections = Rx rigorously. Chest infection = admission to hospital + expert cardiology opinion Anaemia should be avoided and Rx Good dental care + dental surgery should be Rx with Abs (endocarditis) Conversion to IV heparin may be considered if on warfarin CS may be indicated as labour can be tumultuous LABOUR Rx Patient should be propped up. Lithotomy position should be avoided (increases venous return) Analgesia must be OPTIMUM to reduce tachycardia. Epidurals are good -> provided hypotension is avoided IM ampicillin and gentamicin given IF ANY evidence of structural lesions (to prevent endocarditis) During stage 2 labour: Patient should not be made to make substantial expulsive efforts Vacuum/forceps should be used readily Stage 3: Allow time for circulatory adjustment. Do not rush. The risk of atonic PPH must be balanced with the effects of oxytocin (tachycardia and hypotension) ``` IF ACUTE PULMONARY OEDEMA: Sit up Hang legs over bed O2 via face mask Morphine IM Frusemide 20-40mg Seek cardiology ```

Answer 564

Severe HD: Preterm labour, IUGR Cyanosis of mother = severe risk

Answer 565

Pregnancy in an obese patient | AKA BMI >30

Answer 566

Increased risk of GDM, GHTN, Preclampsia

Answer 567

US scans are more difficult Anaesthesia Spinal/epi challenges Higher incidence of post-partum depression Oralcontraception is more likely to fail

Answer 568

Behavioural, pharmacological and surgical methods Very difficult Weight reduction not advisable during pregnancy Should LIMIT weight gain to 5-9kg (lifestyle interventions and physical activity) Be diligent at picking up GHTN / Pre-Eclampsia

Answer 569

Early pregnancy loss Subfertility (increased insulin resistance + loss of gonadotrophin pulses) Recurrent loss Preterm delivery Baby will have: Increased rates of mortality, morbidity and obesity ``` General obesity: T2DM HTN CAD Cardiomyopathy Sleep apnoea Gallbladder disease NAFLD/NASH Osteoarthritis Subfertility Cancers (endometrium, breast, colon) DVT Poor wound healing Carpal Tunnel ```

Answer 570

Polycystic ovary syndrome (PCOS) includes symptoms of hyper-androgenism, presence of hyper-androgenaemia, oligo-/anovulation, and polycystic ovarian morphology on ultrasound.

Answer 571

6-8% of women PCOS accounts for 80% to 90% of cases of hyper-androgenism in women

Answer 572

The aetiology of PCOS is unknown. It is a syndrome wherein multiple systems are affected and the site of the primary defect is unclear. Various lines of evidence have supported primary defects in the hypothalamic-pituitary axis, postulating increased amplitude and frequency of pulses of LH, or defects involving the ovaries through an intrinsic problem leading to androgen over-production. Some theories postulate defects in insulin sensitivity with insulin resistance leading to compensatory hyper-insulinaemia.

Answer 573

STRONG FHx Premature adrenarche ``` WEAK LBW Fetal androgen exposure Obesity Environmental endocrine disruptors ```

Answer 574

``` COMMON Reproductive age female Irregular menstruation (oligo/an) <21 >35 days Infertility Hirsituism Hirsutism is the presence of terminal hairs (thick, pigmented) in androgen-dependent areas (upper lip, chin, chest, back, upper arm, shoulders, linea alba, peri-umbilical region, thigh, buttocks). Acne Overweight/obese HTN ``` UNCOMMON Scalp hairloss Oily skin / excessive sweating Acanthosis nigricans

Answer 575

Serum total + free testosterone - High DHEAS - High Serum 17-hydroxyprogesterone - NORMAL (performed to rule out adult onset adrenal hyperplasia) Serum prolactin - NORMAL (rule out prolactinoma) Serum TSH - NORMAL (if high think hypothyroidism) Check glucose tolerance Fasting lipid panel - Dyslipidaemia frequently seen in PCOS LH/FSH ratio >3 suggests PCOS Pelvic USS - ≥12 follicles in each ovary measuring 2 to 9 mm in diameter, and/or increased ovarian volume (>10 mL) in either or both ovaries; endometrial lining >5 to 7 mm in thickness indicates endometrial thickening

Answer 576

Fertility Weight loss Metformin if insulin resistance 1) Clomifene - Clomifene is a non-steroidal anti-oestrogen that inhibits oestrogen negative feedback on the hypothalamus/pituitary, which in turn leads to an increase in follicle-stimulating hormone secretion that may allow follicular maturation and ovulation. 2) Dexamethasone can be given if Clomifene. fails - surpasses androgen production 3) follitropin alfa/beta - Gonadotrophins (human menopausal gonadotrophins [hMG]: luteinising hormone + follicle-stimulating hormone [FSH]) directly act on the ovary, stimulating follicular recruitment and maturation. (risk of multiple gestation / ovarian hyper stimulation syndrome) 4) IVF 5) Ovarian drilling NOT REQUIRING FERTILITY 1) COCP 2) Spironolactone / finasteride 3) long acting GnRH 4) Cyclic progesterone

Answer 577

``` Infertility Spontaneous pregnancy loss T2DM NAFLD CVD Endometrial hyperplasia/cancer Metabolic syndrome Dyslipidaemia Psychological complications OSA ```

Answer 578

PCOS is a chronic condition. There is no cure. Thus, management options are targeted at alleviating the signs and symptoms to reduce morbidity. Another goal of treatment is to prevent the development of complications such as type 2 diabetes. There have been no clinical trials demonstrating the efficacy of any agent in terms of preventing complications. Many experts believe that weight loss and metformin may prevent diabetes and atherosclerosis. In PCOS, therapy is generally continued throughout the reproductive years. If treatments are stopped during that time, symptoms generally recur. Once a women with PCOS reaches menopause, hyper-androgenic manifestations may improve as ovarian function declines, allowing withdrawal of therapies directed against hyper-androgenism.

Answer 579

Normally clinical PH - normal in candidiasis Swab + microscopy - Candidiasis: hyphae and budding yeast are better seen with the KOH preparation microscopy.

Answer 580

1. topical anti fungal eg clotrimazole 2. fluconazole: 150 mg/dose orally as a single dose COMPLICATED thrush Complicated candidiasis refers to: non-albicans candidiasis, more than 4 episodes a year, and women with uncontrolled diabetes, debilitation, or immunosuppression. 1) fluconazole: 150 mg orally every 3 days for a total of 3 doses

Answer 581

Female genital cutting, also known as female circumcision or genital mutilation, is a culturally determined practice, predominantly performed in parts of Africa and Asia and affecting more than 125 million women and girls worldwide ●Type I consists of excision of the prepuce, with or without excision of part or all of the clitoris. ●Type II involves clitoridectomy and partial or total excision of the labia minora. ●Type III, or infibulation, includes removing part or all of the external genitalia and reapproximation of the remnant labia majora, leaving a small neointroitus. Type IV involves other forms of injuries to the genital region including pricking, piercing, stretching, burning, scraping, or any other manipulation of external genitalia.

Answer 582

over 125 million women and girls in the 29 countries in Africa and the Middle East where the procedure is mainly practiced

Answer 583

Africa and the Middle East

Answer 584

●Type I consists of excision of the prepuce, with or without excision of part or all of the clitoris. ●Type II involves clitoridectomy and partial or total excision of the labia minora. ●Type III, or infibulation, includes removing part or all of the external genitalia and reapproximation of the remnant labia majora, leaving a small neointroitus. Type IV involves other forms of injuries to the genital region including pricking, piercing, stretching, burning, scraping, or any other manipulation of external genitalia. Women seek defibulation because they are pregnant or planning pregnancy, or because of apareunia/dyspareunia, dysmenorrhea, or difficulty urinating

Answer 585

Defibulation We suggest defibulation prior to coitus to prevent dyspareunia or prior to pregnancy to prevent problems with vaginal delivery

Answer 586

Early post-procedure complications thus include hemorrhage, infection, oliguria, and sepsis The most common long-term complications are dysmenorrhea, dyspareunia, and chronic vaginal infections. Other complications are related to voiding

Answer 587

The term multifetal gestation includes twins, triplets, and higher-order multiples. Twins can be classified as monozygotic, originating from the fertilization and subsequent division of one egg, or dizygotic, originating from the fertilization and development of two eggs. Twins can be further classified by their chorionicity. Dizygotic twins are almost always dichorionic, diamniotic. The chronicity of monozygotic twins depends on the timing of division of the fertilized egg. Dichorionic, diamniotic twins result if the fertilized egg splits 0-3 days after fertilization. This is thought to occur in approximately 20-30% of monozygotic twins. Monochorionic, diamniotic twins occur at days 4-8 after fertilization and account for approximately 70% of monozygotic twins. Monochorionic, monoamniotic twins are rare (1-5% of monozygotic twins) and result secondary to division 8-12 days postfertilization. Conjoined twins occur with division 13 days or later; this is extremely rare.

Answer 588

1 in 80 = spontaneous

Answer 589

The etiology of monozygotic twinning is unknown. Dizygotic twins are thought to result from the ovulation of multiple follicles caused by elevations in serum gonadotropin levels. Hence, advanced maternal age is associated with an increased prevalence of twin birth. The availability of assisted reproductive technology has contributed to the increase in multiple gestations seen over the past 20 years. During ovulation induction treatment, the ovaries are stimulated to produce several follicles, thus increasing the risk of multiple eggs being released and subsequently fertilized. The risk of multiple gestations during in-vitro fertilization is directly related to maternal age and number of embryos transferred.

Answer 590

Increased age IVF ?FHx

Answer 591

Women carrying multiple gestations may be initially asymptomatic or may have normal signs and symptoms of pregnancy (eg, breast tenderness, fatigue, nausea, vomiting). Multiple gestations may be suspected in the setting of hyperemesis gravidarum or in a patient who has undergone assisted reproductive technology. A complete history, including a family history, should be taken in every woman suspected to have multiples. Large for dates

Answer 592

USS (establish chorionicity)

Answer 593

Multifetal reduction possible (postassium chloride injected into selected fetus) - Multifetal reduction in a monochorionic twin setting is typically not recommended due to unknown effects on the remaining twin. Increased nutrition needed. Monochorionic - US scans every 2w to detect TTTS Dichorionic - 4-6weekly Uncomplicated dichorionic, diamniotic twin gestation- 38 weeks Uncomplicated monochorionic, diamniotic twin gestation- between 34-37 6/7 weeks Uncomplicated monochorionic, monoamniotic twin gestations- 32-34 weeks Trial labour allowed Breeched second baby > ECV Dependent on confidence of obstetrician

Answer 594

``` FOETAL Preterm delivery (increases with number of gestations) TTTS (monochorionic) 3x risk cerebral palsy Stillbirth 7x risk of neonatal death Congenital anomalies IUGR ``` ``` MATERNAL Preterm leabour PROM Pre-eclampsia GHTN GDM Placental abruption PE PPH Polyhydramnios VTE AFLP Malpresentation ```

Answer 595

Mastitis is inflammation of the breast with or without infection. Mastitis with infection may be lactational (puerperal) or non-lactational (e.g., duct ectasia). Non-infectious mastitis includes idiopathic granulomatous inflammation and other inflammatory conditions (e.g., foreign body reaction). A breast abscess is a localised area of infection with a walled-off collection of pus. It may or may not be associated with mastitis. Breast infection (including infectious mastitis and breast abscess) more commonly affects women aged 15-45 years, especially those who are lactating. Mastitis and breast abscess can occur at any age. Staphylococcus aureus is the most frequent pathogen isolated. Prompt and appropriate management of mastitis usually leads to a timely resolution and prevents complications, such as a breast abscess. Treatment of infectious and non-infectious mastitis includes antibiotic therapy and effective milk removal if lactating. Breast abscess requires removal of pus and antibiotic therapy. Surgical interventions can include aspiration and incision and drainage. It is imperative to identify and treat any underlying co-existent causes of infection and to exclude breast carcinoma.

Answer 596

1-10% of lactating women Duct ectasia occurs in 5-9% of non-lactating women Breast abscess 3-11% of women with mastitis, and 0.1-3% of breastfeeding women Approximately 50% of infants with neonatal mastitis will develop a breast abscess Mammary fistula occurs in 1% to 2% of women

Answer 597

Mastitis may occur with or without infection. Infectious mastitis and breast abscess are usually caused by bacteria colonising the skin. Cases due to Staphylococcus aureus are by far the most common, followed by those due to coagulase-negative staphylococci. Methicillin-resistant S aureus is a growing problem and has been increasingly found in cases of mastitis and breast abscesses. Non-infectious mastitis may result from underlying duct ectasia (peri-ductal mastitis or plasma cell mastitis) and infrequently foreign material (e.g., nipple piercing, breast implant, or silicone). In lactational mastitis, milk stasis or milk overproduction, coupled with infection from bacteria entering the breast via a traumatised nipple (e.g., cracked or fissured) and/or from the infant's mouth, can lead to mastitis. In duct ectasia (dilated ducts associated with inflammation), the mammary duct-associated inflammatory disease sequence involves squamous metaplasia of lactiferous ducts. This causes blockage (obstructive mastopathy) with peri-ductal inflammation and possible duct rupture. Left untreated, mastitis may cause tissue destruction resulting in an abscess. NB tubercular possible

Answer 598

``` STRONG Female >30yo Poor breastfeeding technique Lactation Milk stasis Nippleinjury Hx Hx abscess Nipple piercing Shaving nipples Anatomical breast defect Breast cancer Foreign body Skin infection Staph A carrier Immunosuppression ``` ``` WEAK Hx admission Trauma to breast Primiparity Overabundant milk supply Post maturity Complications of delivery Maternal fatigue Tight clothing Antifungal nipple cream Fibrocystic breast disease Smoking Poor nutrition Anti-retroviral therapy ```

Answer 599

``` COMMON Fever - mastitis or asbscess Flu-like symptoms, myalgia, malaise Breast pain (when breast feeding) Decreased milk outflow Breast warmth - Lactational mastitis tends to involve more peripheral wedge-shaped areas. Tenderness Breast firmness Breast swelling Erythema ``` ``` UNCOMMON Mass - abscess Fistula - may be associated with abscess Discharge Lymphadenopathy (axillae) Extra-mammary lesions ```

Answer 600

Breast US - if any pointer to abscess Needle aspiration - purulent fluid indicates a breast abscess Cytology of FNA Milk, aspirate, discharge, or biopsy tissue for culture and sensitivity - +ve culture indicates infection CAN DO PUNCH BIOPSY IF FEAR TB If indication of systemic infection - perform blood cultures + FBC

Answer 601

In an early stage, when signs and symptoms of mastitis have not been present for more than 12-24 hours, it may be possible to manage the condition without antibiotics. However, antibiotics are required if the pain becomes severe or lasts more than 12-24 hours, if milk or blood culture is positive, or if there are any signs of systemic infection. Breastfeeding should continue frequently (e.g., breastfeeding 8-12 times per day) to promote effective milk removal. Breast pumping on the affected side if indicated and/or massage, if tolerated, may also be used. The patient should be advised to increase her fluid intake, try warm and/or cold compresses, and have bed rest. _________________ Antibiotics are indicated for patients with acute pain, severe symptoms, or symptoms lasting more than 12-24 hours; fever or any other signs of systemic infection; or positive microbiology studies. Flucloxacillin / cefalexin / clindamycin 10-14 days NB NO IMPROVEMENT IN 24 HRS = give vancomycin IV _________________ Needle aspiration (18- to 19-gauge needle) with local anaesthesia, with or without ultrasound guidance, can be used to drain an abscess.

Answer 602

``` Cessation of breast feeding Abscess Sepsis Scarring Functional mastectomy Nec-fasc Extramammary skin infection Fistula ```

Answer 603

When treated promptly and appropriately, most breast infections, including abscess, will resolve without serious complications. Resolution of mastitis after 2-3 days of appropriate antibiotic therapy is expected among most patients. Lactational abscesses tend to be easier to treat than non-lactational abscesses because their aetiology and pathology is better understood. Non-lactational abscesses can be multifactorial and have a greater risk of becoming chronic. HIV-infected mothers To completely prevent HIV transmission via human milk, the US American Academy of Pediatrics recommends that HIV-infected mothers do not breastfeed their infants. Mastitis may recur with delayed therapy, inappropriate therapy, uncorrected poor breastfeeding technique, nipple candidiasis, an underlying breast condition, and in Staphylococcus carriers. Recurrent mastitis or persistence of a mass after therapy may be due to a breast abscess or underlying breast lesion. Granulomatous mastitis has a high (up to 50%) recurrence rate.

Answer 604

Infectious mastitis

Answer 605

Breast abscess

Answer 606

The diminished ability of a couple to conceive a child. This may result from a definable cause (e.g., ovulatory, tubal, or sperm problem), or may be unexplained failure to conceive over a 2-year period. Can be due to ovulatory dysfunction, tubal or other anatomical disorders, endometriosis, or unknown causes. Workup requires evaluation of reproductive anatomy and physiology; even in the absence of diagnosis, a couple is considered to be subfertile after 2 years of regular unprotected sexual intercourse without pregnancy. Timing and type of treatment are diagnosis-dependent, but may include medical therapy, surgical therapy, or IVF. Prognosis is dependent on patient age, infertility diagnosis, and treatment plan.

Answer 607

Infertility is a major disease worldwide. The primary cause of infertility worldwide is tubal disease due to infection, including gonorrhoea, chlamydia infection, and tuberculosis. In their 2015 Assisted Reproductive Technology (ART) report, the Centers for Disease Control and Prevention identified female factors in 13% (tubal), 15% (ovulatory dysfunction), 31% (diminished ovarian reserve), 8% (endometriosis), and 6% (uterine) of ART cycles. Male factors were detected in 33% of cases and unknown factors in 13% of cases.

Answer 608

Female infertility aetiologies include cervical/uterine abnormalities, tubal disease, ovulatory dysfunction, and unexplained infertility. The most common aetiology is ovarian dysfunction. Polycystic ovarian syndrome, which is estimated to affect 5% of women, is also a major contributor to ovulatory infertility. The primary cause of infertility worldwide is tubal disease due to infection, including gonorrhoea, chlamydia infection, and tuberculosis. Cigarette smoking High/low body fat Decreased body mass Endometriosis Uterine - bicornuate, fibroids, ashermans, uterine septum

Answer 609

``` STRONG Age >35 Hx sexually transmitted disease Very high body fat Very low body fat Cigarette smoking ``` ``` WEAK A/I disease Hx appendicitis Psychiatric disease Substance abuse Alcohol consumption Caffeine consumption Stress ```

Answer 610

``` RFs Hx pelvic surgery Irregular cycles Hirsituism ACNE Palpable uterine abnormalities Adnexal abnormalities ``` UNCOMMON Galactorrhoea Dyspareunia - could indicate adhesions/endometriosis Cul-de-sac abnormalities

Answer 611

Semen analysis Luteal phase progesterone - <9.5 = anovulatory Urinary LH - a positive test kit result indicates imminent ovulation Transvaginal USS - may demonstrate follicular development, polycystic appearance of ovaries, presence of significant cysts (including endometriomas), abnormal uterine structure (e.g., with congenital abnormalities), presence of fibroids, endometrial polyps, hydrosalpinges Hysterosalpingogram - performed between cycle days 7 and 11 - fallopian tubes: patent or blocked, with free spill of dye and normal tubal pattern; uterus: normal or abnormal contour, presence or absence of filling defects Consider basal FSH measurement - hypogonadotophism Serum LH - hypogonadotophism Check serum testosterone, prolactin, TSH Can do 3d US Karyotyping - may demonstrate chromosomal abnormality (e.g., with Turner’s syndrome)

Answer 612

Manage any underlying medical conditions All women need to be counselled. The process cam be stressful and evidence is emerging that stress can be associated with treatment failure. ANOVULATORY - Gonadotrophin stimulation - menotrophin / follitrophin - HCG - IVF PCOS - WL - Metformin - Clomifene / GnRH stimulation - Ovarian drilling - IVF TUBAL - IVF - Can do tubal reconstruction ENDOMETRIOSIS - Clomifene / GnRH stimulation - IVF - Surgical ablation of endometriosis AGE RELATED - Oocyte donation - Can try ovarian stimulation -> Clomifene / GnRH UNEXPLAINED - Try ovarian stimulation - Intra-uterine insemination possible (evidence suggests no more successful than timed intercourse) - IVF DAMAGED UTERUS - Surrogacy

Answer 613

Clomifene induced hypo-oestrogenism Multiple gestation Ovarian cancer Ovarian hyper-stimulation syndrome: Symptoms range from mild to severe. Mild OHSS manifests as bloating and abdominal discomfort. As the abdominal fluid collection continues it restricts diaphragmatic activity with resultant shortness of breath. Increased abdominal pressure can also restrict the inferior vena cava and reduce pre-load. A reduced intravascular volume decreases glomerular filtration rate and may result in renal failure. As intravascular depletion continues, the rising haematocrit can increase the risk of blood clotting. This risk is further increased by the high level of estradiol. Third spacing can occur in other tissues including the lungs and the brain. Treatment is supportive. Paracentesis can improve respiratory effort and cardiac output. OHSS occurs in approximately 20% of all IVF cases but is only severe in <5%. Symptoms last approximately 1 week, but will continue longer when conception occurs.

Answer 614

Clomifene - 36% probability of pregnancy, 10% of pregnancies twins GnRH - 20-22% probability of pregnancy, 30% of pregnancies twins NB twins increase with age IVF is the most successful treatment for infertility, regardless of diagnosis: 54.4% live births in women under 35 years of age. This declined with age: 42% for women aged 35 to 37 years; 26.6% for women aged 38 to 40 years; 13.3% for women aged 41 to 42 years; and only 3.9% in women aged over 42 years.

Answer 615

Infertility in women

Answer 616

Infertility in women

Answer 617

Ovarian hyper-stimulation syndrome: Symptoms range from mild to severe. Mild OHSS manifests as bloating and abdominal discomfort. As the abdominal fluid collection continues it restricts diaphragmatic activity with resultant shortness of breath. Increased abdominal pressure can also restrict the inferior vena cava and reduce pre-load. A reduced intravascular volume decreases glomerular filtration rate and may result in renal failure. As intravascular depletion continues, the rising haematocrit can increase the risk of blood clotting. This risk is further increased by the high level of estradiol. Third spacing can occur in other tissues including the lungs and the brain. Treatment is supportive. Paracentesis can improve respiratory effort and cardiac output. OHSS occurs in approximately 20% of all IVF cases but is only severe in <5%. Symptoms last approximately 1 week, but will continue longer when conception occurs.

Answer 618

The clinical definition of male factor infertility is the presence of abnormal semen parameters in the male partner of a couple unable to achieve conception after 1 year of unprotected intercourse. The World Health Organization defines male factor infertility as the presence of ≥1 abnormalities in the semen analysis or the presence of inadequate sexual or ejaculatory function. Presence of abnormal semen parameters in the male partner of a couple unable to achieve conception after 1 year of unprotected intercourse. Male factor alone contributes to 20% of cases of infertile couples and to an additional 30% to 40% in combination with other factors. Most cases are of unknown aetiology. Diagnosed if abnormal semen parameters in 2 semen analyses separated by 1 month. Sperm functional assays, endocrine tests, genetic testing, and imaging can be helpful. Treatment should be targeted to the aetiological factors whenever possible. Assisted reproductive techniques are often the fastest and most effective method to achieve pregnancy regardless of the aetiology

Answer 619

It is estimated that 1 in 6 couples will have difficulty conceiving. Male factor alone is responsible for 20% of those cases. In an additional 30% to 40% of couples, male factor is present in combination with other factors including anovulation, tubal factor, increased maternal age, and endometriosis.

Answer 620

There is no formal classification of male infertility. It may be categorised according to aetiology: Primary spermatic failure Genetic disorders of infertility Obstructive azoospermia Varicocele Hypogonadism Cryptorchidism Idiopathic Male contraception Male accessory gland infections Germ cell malignancies and testicular microcalcifications Disorders of ejaculation. Factors that alter spermatogenesis through low testosterone levels include obesity, endocrinopathies, and exposure to medicine or environmental toxins. Other factors that have a direct deleterious effect on spermatogenesis include varicocele, increased scrotal heat, systemic diseases, smoking, history of undescended testicles, and alcohol intake.

Answer 621

``` STRONG Varicocele Cryptochidism Prior chemo/radio Current medications - sulfsalazine/antifungals CF Congenital absence of the vas deferens Y chromosome abnormalities - Kleinfelters - 47XXY Hyperprolactinaemia Kallmanns Hx infertility ``` ``` WEAK Genital tract infection Erectile dysfunction Retrograde ejaculation - Prostatic surgery, diabetes, and some medications, such as psychiatric agents (thioridazine, chlorpromazine, and amitriptyline) Obesity Testicular torsion Smoking Alcohol Age >55 (affects sperm motility sometimes) Environmental toxin exposure CAD DM Hot tub use Hx STD ```

Answer 622

``` Inability to conceive Vasectomy Palpable and dilated testicular veins ED Dec libido TEstis atrophy Body habitus, abnormal hair distribution, and gynaecomastia - KLEINFELTERS Absent vasa/epididymus ``` OTHER UNCOMMON Headaches/galactorrhoea/visual disturbance -> prolactinoma Anosmia - kallmans Frequent resp infections - immotile cilia syndrome - PCD Pain, blood or pus with ejaculation - prostatitis or epididymitis

Answer 623

Sperm concentration <15 million per ML Sperm motility - <40% motile spermatozoa Sperm morphology - <4% normal forms Seminal fluid parameters - poor liquefaction; low ejaculate volume (<1.5 ml); decreased seminal pH; presence of fructose; increased leukocyte count ____________ Consider sperm viability testing - >42% sperm necrosis Sperm membrane function - >40% reacted sperms Measure FSH, LH, free and total testosterone, estradiol, sex hormone-binding globulin, and prolactin levels. MRI - prolactinoma Colour Flow doppler - varicocele

Answer 624

KALLMANS - Give GnRH / HCG HYPERPROLACTINOMA Cabergoline/bromocriptine VARICOCELE varicocelectomy UNEXPLAINED - GnRH / HCG / CLOMIFENE / Tanoxifen NB Clomifene = nonsteroidal SERM ALL ELSE FAILS Intrauterine insemination - better than timed sex if male factor infertility IVF

Answer 625

Testicular cancer

Answer 626

The patient's prognosis depends on the initial diagnosis. Some reversible causes of male infertility are curable. However, for most conditions, the value of medical and surgical care remains controversial. Artificial reproductive technologies remain an effective option for the infertile man. Chromosomal defects may be passed on to offspring if intracytoplasmic sperm injection is used. Men with severe oligospermia should be offered karyotypic evaluation and advised of this risk.

Answer 627

Male factor infertility

Answer 628

Male factor infertility

Answer 629

Pregnancy of unknown location (PUL) is the term used for a pregnancy where there is a positive pregnancy test but no pregnancy has been visualized using transvaginal ultrasonography The true nature of the pregnancy can be an ongoing viable intrauterine pregnancy, a failed pregnancy, an ectopic pregnancy or rarely a persisting PUL.

Answer 630

8% and 10% of women attending for an ultrasound assessment in early pregnancy will be classified as having a PUL

Answer 631

The true nature of the pregnancy can be an ongoing viable intrauterine pregnancy, a failed pregnancy, an ectopic pregnancy or rarely a persisting PUL. Definite ectopic pregnancy Extrauterine gestational sac with yolk sac or embryo (with or without cardiac activity). Pregnancy of unknown location – probable ectopic pregnancy Inhomogeneous adnexal mass or extrauterine sac-like structure. "True" pregnancy of unknown location No signs of intrauterine nor extrauterine pregnancy on transvaginal ultrasonography. Pregnancy of unknown location – probable intrauterine pregnancy Intrauterine gestational sac-like structure. Definite intrauterine pregnancy Intrauterine gestational sac with yolk sac or embryo (with or without cardiac activity).

Answer 632

Sx of pregnancy | Bleeding

Answer 633

USS: Definite ectopic pregnancy Extrauterine gestational sac with yolk sac or embryo (with or without cardiac activity). Pregnancy of unknown location – probable ectopic pregnancy Inhomogeneous adnexal mass or extrauterine sac-like structure. "True" pregnancy of unknown location No signs of intrauterine nor extrauterine pregnancy on transvaginal ultrasonography. Pregnancy of unknown location – probable intrauterine pregnancy Intrauterine gestational sac-like structure. Definite intrauterine pregnancy Intrauterine gestational sac with yolk sac or embryo (with or without cardiac activity).

Answer 634

Treatment should only be considered when a potentially viable intrauterine pregnancy has been definitively excluded A treated persistent PUL is defined as one managed medically (generally with methotrexate) without confirmation of the location of the pregnancy such as by ultrasound, laparoscopy or uterine evacuation A resolved persistent PUL is defined as serum hCG reaching a non-pregnant value (generally less than 5 IU/l) after expectant management, or after uterine evacuation without evidence of chorionic villi on histopathological examination

Answer 635

Between 6% and 20% have an ectopic pregnancy Between 30% and 47% of women with pregnancy of unknown location are ultimately diagnosed with an ongoing intrauterine pregnancy, whereof the majority (50–70%) will be found to have failing pregnancies where the location is never confirmed Persisting PUL is where the hCG level does not spontaneously decline and no intrauterine or ectopic pregnancy is identified on follow-up transvaginal ultrasonography

Obs-Gyn-Conditions Flashcards

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