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Clinical Years / Progress Test > Obs & Gynae > Flashcards

Obs & Gynae Flashcards

1
Q

Information to know from woman before pregnancy

A

Age
PMH
Medications and allergies
Smoking and alcohol
previous pregnancies?
periods?
any problems having sex
FHx of any conditions or problems in pregnancy

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2
Q

Supplements for conception

A

everyone should be taking folic acid
higher dose if raised BMI, previous history or family history of NTD or taking antiepileptic medication, diabetes or other medical problems

some women should be taking vitamin D

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3
Q

booking visit

A

once woman knows she is pregnant

appt with the midwife to discuss pregnancy and assess risks in pregnancy

health screen (PMH etc)+ dip urine, BP, + bloods for Hb, platelets, infections, blood group +rhesus, sickle cell/thalaassaemia if high risk

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4
Q

12 week scan

A

dating the pregnancy
taking measurements including nuchal thickness (part of Down syndrome screening)

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5
Q

how does b-HCG change during pregnancy

A

rises after conception to peak at about 3 months then declines slowly. keeps the CL alive so it can produce oestrogen and progesterone

doubles every 48 hours until peak (>53% increase okay)
produced by the placenta
higher in multiple pregnancies and can be higher in a Down’s syndrome pregnancy

declines steadily in failing pregnancy

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6
Q

how do oestrogen and progesterone levels change during pregnancy

A

initially produced by the ovaries (corpus luteum)
placenta then takes over after about 3 months

oestrogen and progesterone levels steadily increase throughout pregnancy

drop just before labour which allows for delivery

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7
Q

what does rising oestrogen levels do to the uterus

A

prepares for delivery by increasing oxytocin receptors in the uterus

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8
Q

what is progesterones role in pregnancy

A

smooth muscle relaxant (can lead to reflux, constipation and urethral relaxation) and maintains uterus lining

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9
Q

normal physiological changes in pregnancy

A

initially BP decreases due to increased stroke volume and decreased peripheral resistance

oedema is physiological due to increased plasma volume

anaemia - increased plasma volume and increased RBC volume

hyper coagulability - increased clotting factors

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10
Q

changes to female reproductive system during pregnancy

A

breast enlargement under oestrogen and progesterone and areolar pigmentation

development of cervical mucus plug under oestrogen effect
vaginal proliferation of lactobacilli lowering pH

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11
Q

risk factors for a high risk pregnancy

A
  • older age
  • some ethnicities at higher risk
  • previous pregnancy complications; premature labour, growth restriction, haemorrhage, pre eclampsia, gestational diabetes, tears, still birth, miscarriage
  • medical or mental health conditions
  • FHx
  • social history; abuse, financial difficulty
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12
Q

20 week scan

A

anomaly scan where anatomy of foetus is assessed for any abnormalities

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13
Q

Down syndrome screening

A

Nuchal thickness at dating scan; increased thickness higher risk
Blood test for Pregnancy associated plasma protein - A (PAPP-A) and HCG
Describes combined test

These combined with mothers age give predicted risk

If high risk or nuchal thickness unmeasurable then quad test; blood test for AFP, Inhibin A, Oestriol and Beta-HCG. between 14 and 20 weeks of pregnancy

Diagnostic tests; chorionic villous sampling or an amniocentesis

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14
Q

screening for gestational diabetes

A

at booking appointment midwife assesses for risk factors
- BMI >30
- Indian or black ethnicity
- FHx of FDG with DM
- PCOS
- previous macrosomic baby
- previous gestational diabetes

if any risk factors OGTT at 26-28 weeks

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15
Q

Anti-D in pregnancy

A

any woman who is found to be Rhesus -ve is at risk of Rhesus disease of the newborn
‘prophylactic Anti-D’, a 1500iu dose, is given at 28 weeks
The baby’s blood is tested at birth, and if it is also Rh-ve, then the risk is very low

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16
Q

what is rhesus disease of the newborn

A

If a fetus is Rh+ve and the mother Rh-ve, the maternal antibodies and fetal antibodies can react and have potentially serious consequences

Mothers are counselled to report potential ‘sensitising events’ which may increase passage of fetal blood cells into the maternal circulation, where a reaction may take place

Sensitising events can include spontaneous miscarriage, termination of pregnancy, invasive procedures, traumatic events, placental abruption, fetomaternal haemorrhage, blood transfusions

May not affect current pregnancy but once sensitised can be severe in next pregnancy

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17
Q

growth assessment in pregnancy

A

in low risk pregnancy midwife monitors using symphisis-fundus height
plotted on growth charts
if any change can be referred

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18
Q

pre-existing disorders with a risk of foetal abnormality

A

diabetes, epilepsy, obesity

diabetes can also cause excessive growth and stillbirth risk
HTN risk factor for poor growth

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19
Q

pre-existing disorders and maternal risk

A

risks of pre-eclampsia; HTN, diabetes, renal disease, SLE

risks of gestational diabetes; obesity, steroid use

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20
Q

what diseases can worsen or improve in pregnancy

A

worse; renal and cardiac disease and diabetes

improve; autoimmune disorders such as RA and MS but relapse often follows delivery

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21
Q

target ranges for glucose monitoring during pregnancy

A

avoid hypos. minimum 4

fasting <5.3

1 hour post meal 7.8

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22
Q

common drugs contraindicated or cautioned in pregnancy

A

Contraindicated: NSAIDs, ramipril in 2nd and 3rd trimester, isotretinoin, sodium valproate, trimethoprim in 1st trimester, statins, nitrofurantoin near term, warfarin, methotrexate

Caution: Carbimazole & Propylthiouracil (don’t use after 1st trimester), lamotrigine, , SSRIs discuss with woman; these drugs are often still used as they are safer to the alternatives

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23
Q

risks to foetus of gestational diabetes

A

Macrosomia, Polyhydramnios, Shoulder Dystocia, Stillbirth, Neonatal Hypoglycaemia and Expedited delivery

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24
Q

risks of raised maternal BMI in pregnancy

A

Pre-eclampsia, VTE risk, difficulties intrapartum including monitoring of fetus and anaesthetic risk, and postpartum risks including PPH, and infection and VTE

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25
Q

treatment of gestational diabetes/diabetes in pregnancy

A

met form up to max dose
then add insulin

diet and exercise for everyone

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26
Q

timing of lower segment Caesarean section

A

diabetic patients on insulin by 38/40

non-diabetic patients at >39/40

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27
Q

steroids in deliveries at <39/40

issues in diabetic mothers

A

all mothers planned to deliver before 39 weeks should be given steroids to mature foetal lungs

this can worsen diabetic control so take caution and supplementary insulin may be required

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28
Q

how does gestational diabetes develop

A

hormonal influences of human placenta lactogen, cortisol, growth hormone and progesterone increase maternal glucose levels whilst also increasing insulin resistance

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29
Q

what anticoagulant should be used in pregnancy

A

LMWH

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30
Q

pre-conception for women with pre-existing diabetes

A

aim for BMI<30 and HbA1C <48 (if >86 advise against pregnancy as v high risk)

medications should be switched to metformin +/- insulin

folic acid 5mg

screening for retinopathy and neuropathy (more likely in pregnancy)

refer to nephrology if urine ACR >30mg/mmol or eGFR <45

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31
Q

antenatal care pre-existing diabetes

A

aspirin 75mg od to reduce risk of pre-eclampsia started at 12 weeks

monitoring of Bus fasting, pre and post meal

regular contact with member of MDT

retinal assessment at first appointment and 28/40

renal assessment at first appt

serial growth scans

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32
Q

intra-partum care diabetes

A

offer elective delivery for uncomplicated T1 or T2 DM at 37-38+6 weeks by induction or caesarean
offer earlier if any complications

offer delivery by 40+6 for GDM but monitor for macrosomia/complications earlier and caesarean if macrosomic

T1 diabetics may need sliding insulin scale during delivery

breast feeding encouraged

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33
Q

post partum care diabetes

A

Post delivery insulin requirement rapidly fall

Women with Pre-existing diabetes should restart their pre-pregnancy dose (reduced by 25-40% if they are breastfeeding)

Women with GDM usually stop all glucose reducing agents immediately after delivery

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34
Q

GDM and risk of T2DM

A

Women who are overweight and who have had diabetes in pregnancy have a 50-75% chance of developing Type II diabetes
Test at post natal appointments usually 6 weeks after delivery

Counsel for risk of GDM in further pregnancies

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35
Q

thresholds for caesarean regarding risk of shoulder dystocia

A

women with diabetes and estimated foetal weight >4.5kg

non-diabetic mothers + weight >5kg

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36
Q

feeding baby born to diabetic mother and blood glucose check

A

feed within 30 minutes of birth and check BM at 2-4 hours - risk of neonatal hypoglycaemia

if no symptoms but hypoglycaemic just monitor

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37
Q

treating existing HTN in pregnancy

A

ACEi, ARB and diuretics should be avoided

use labetalol or nifedipine and offer aspirin from 12 weeks
(same for gestational HTN)

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38
Q

management of anaemia in pregnancy

A

iron replacement therapy

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39
Q

what is small for gestational age

A

birth weight less than 10th centile
usually constitutional but can be due to foetal growth restriction

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40
Q

what is foetal growth restriction

A

failure of foetus to reach pre-determined growth potential; evidence of growth faltering and crossing centiles

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41
Q

types of foetal growth restriction

A

symmetrical - head and abdomen in proportion. usually due to insult early in pregnancy, infection or maternal alcohol use

asymmetrical - insult later in pregnancy means blood in redirected to head. e..g pre-eclampsia, essential HTN and maternal smoking

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42
Q

major risk factors for SGA

A

maternal age >40
paternal or maternal SGA
smoker >11 per day
cocaine use
previous stillbirth or SGA
chronic HTN
diabetes with vascular disease
renal impairment
anti phospholipid syndrome
heavy bleeding pv
low PAPP-A
foetal echogenic bowel

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43
Q

screening for SGA/ growth restriction

A

3 or more minor risk factors uterine artery doppler
if normal single scan at 36 weeks
if abnormal serial scans from 28 weeks

1 or more major risk factor serial scans from 28 weeks

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44
Q

aetiology of SGA/ growth restriction

A
  1. impaired gas exchange and transfer across placenta
    - impaired maternal oxygen carrying
    - impaired oxygen delivery
    - placental damage
  2. intrinsic problems within the foetus
    - chromosomal abnormalities
    - congenital e.g. cardiac
    - intrauterine infections
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45
Q

short and long term implications for babies SGA/FGR

A

short term
-premature birth and associated complications
-low Apgar score
-hypoglycaemia/hypocalcaemia
-hypothermia
-polycythaemia and hyperbilirubinaemia

long term
-learning difficulties
-short stature
-failure to thrive
-cerebral palsy
- HTN, T2DM, heart disease

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46
Q

what measurements are taken on a growth scan

A

abdominal circumference, head circumference, femur length; combined to give estimated weight

umbilical artery doppler and liquor volume

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47
Q

management of early onset FGR <32 weeks

A

may suggest infection of chromosomal abnormality
detailed USS for structural abnormality
offer amniocentesis for chromosomal abnormality
steroids for foetal lung maturity
intensive monitoring

consider delivery if reversed end diastolic flow on umbilical artery doppler

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48
Q

management of late onset FGR >32 weeks

A

surveillance
steroids if <36 weeks
delivery is likely better option if end diastolic flow is revered on doppler

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49
Q

prevention of FGR

A

smoking cessation
identify women high risk
aspirin for women at risk of pre-eclampsia

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50
Q

APGAR score domains

A

Appearance
0 - blue/pale
1 - pink centrally but blue peripherally
2 - normal

Pulse
0 - no heartbeat
1 - <100
2 - >100

Grimace
0 - absent
1 - feeble
2 - strong cry

Activity
0 - absent
1 - some flexion
2 - full movement

Respiration
0 - no respiratory effort
1 - weak/irregular respiration
2 - strong respiratory effort

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51
Q

when are APGAR scores measured

A

always at 1 and 5 minutes

measure again if 7 or less at 5 minutes
<3 indicates neurological damage will be present

10 is best score

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52
Q

pharmacological management of postpartum haemorrhage

A

Syntocinon, syntometrine, ergometrine, misoprostol, carboprost, Transexamic Acid

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53
Q

uterine fibroids in pregnancy

A

oestrogen dependent so enlarge in pregnancy leading to large for dates

may also cause diffuse pain and firm tender uterus
treatment is bed rest and analgesia

complications include malpresentation, obstructed delivery, haemorrhage and need for caesarean section

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54
Q

in normal pregnancy what remodelling happens to uterine vessels

A

become high capacitance low resistance

this failing to happen can contribute to development of pre-eclampsia

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55
Q

history of abnormal vaginal bleeding

A
  • age
  • is bleeding regular
  • cycle length and how long periods last
  • other symptoms associated with fibroids; pelvic heaviness/pain, urinary symptoms, previous scans
  • bleeding disorders? thyroid dysfunction? anticoagulants? other PMH and DH
  • contraception?
  • FHx of coagulation or bleeding disorders
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56
Q

red flags vaginal bleeding

A
  • Age >45yrs
  • intermenstrual bleeding
  • postcoital bleeding
  • postmenopausal bleeding
  • abnormal examination fidnings eg pelvic mass or lesion on cervix
  • treatment failure after 3 months.
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57
Q

what is hysteroscopy

A

narrow lumen camera which is passed through the cervical os to enable visualisation of the uterine cavity. It is also used to take biopsies of the endometrium and any suspicious areas

can also be used for treatment of some conditions such as small fibroids and polyps

58
Q

indications for hysteroscopy

A
  • sterility
  • infertility
  • menstrual disorder
  • suspicious USS findings
  • check ups after interventions/treatment
  • lost IUD
59
Q

causes of abnormal uterine bleeding

A

Polyps
Adenomyosis
Leiomyoma- fibroids
Malignancy
Coagulopathy (VWD)
Ovulatory dysfunction (adolescence, PCOS, menopause)
Endometrial processes
Iatrogenic
Not classified

60
Q

early pregnancy bleeding

A
  • can be normal
  • may indicate miscarriage if larger amounts and symptoms such as pain, tachycardia

take full history of LMP, pregnancy tests, bleeding, pain and examine obs, abdominal, speculum and digital vaginal

61
Q

diagnosing miscarriage

A
  1. crown rump length 7mm or more with no foetal heart beat
  2. mean gestational sac diameter of 25mm with no yolk sac or embryo
62
Q

threatened miscarriage

A

anyone pregnant presenting with vaginal bleeding

63
Q

inevitable miscarriage

A

cervix open on examination

64
Q

delayed miscarriage

A

pregnancy stopped growing/foetal heartbeat absent but no signs of bleeding

65
Q

investigations in miscarriage/early pregnancy bleeding

A

depends on gestation; if very early often not needed
possible investigations; FBC, group and save if severe, serum HCG if early gestation, USS if >7 weeks

66
Q

what happens if +ve HPV status on smear

A

samples are examined by cytology

if cytology abnormal then refer for colposcopy

if cytology normal then repeat next at 12 months
- if now -ve then return to normal recall
- if still +ve then test again in 12 months

if inadequate sample repeat in 3 months

67
Q

treatment for cervical intraepithelial neoplasia

A

Large loop excision of transformation zone (LLETZ) is most commonly used. can be done at colposcopy appointment or at later date

cryotherapy is another option

68
Q

what is colposcopy (explanation)

A

use a speculum to open vagina

stain cervix with acetic acid and iodine to look for abnormalities

microscope is inserted to look in detail

69
Q

who is offered cervical screening

A

women aged 25-49 every 3 years
age 50-64 every 5 years

trans men with a cervix are eligible but not invited if registered as male with GP

70
Q

what is dyskaryosis

what are the different grades

A

describes abnormal looking cells on the cervix - it is not cancer
described as low grade, high grade moderate, or high grade severe

low grade - dyskaryotic cells with a nuclear: cytoplasmic diameter ratio of <50%
high grade moderate - 50-75%
high grade severe - ratio >75%

hard to distinguish between moderate and severe. these correspond to CIN 1-3 but CIN cannot be diagnosed from smear

abnormal cells often return to normal but can develop to cancer if untreated especially at higher grade

71
Q

follow up after treated for CIN 1, 2 or 3 changes

A

repeat smear in 6 months

if normal return to routine recall

72
Q

early labour hormonal changes (foetus and mother)

A
  1. foetal stress causes release of corticotropin hormone (ACTH) by foetal anterior pituitary gland
  2. this stimulates their adrenal glands to produce cortisol
  3. cortisol acts on the placenta to
    - decrease progesterone and oestrogen production
    - increase prostaglandin production
  4. prostaglandin causes uterus to start to contract
  5. causes foetus to start to stimulate stretch receptors/oxytocin receptors
  6. oxytocin produced by mother
73
Q

what does oxytocin do in labour

A

causes uterus to contract causing a positive feedback cycle where more contraction causes more oxytocin to be released
stimulates production of more prostaglandins which also causes uterus to contract

cervical effacement and thinning starts then dilation begins

foetus further stimulates cervical stretch receptors - more dilation
- more hormones released
- contractions become more regular and longer

this describes stage 1 of labour

74
Q

stage 1 of labour latent and active phases

A

latent is up to 3 or 4 cm dilated where the positive feedback of oxytocin and prostaglandins is causing uterine contraction and cervical dilatation
increased uterine pressure causes the amniotic sac to rupture before/during the first stage

the active phase of stage 1 of labour is regular, painful contractions and further dilation until the cervix is 10cm /fully dilated and the baby head can be seen (crowning) - unless breech position

75
Q

stage 2 of labour

A

describes the progress from full cervical dilatation to delivery of the baby

76
Q

stage 3 of labour

A

delivery of the placenta by slow detachment from uterine lining
uterus is still contracting
mothers are usually given injection of oxytocin to speed up process (active management - lower risk of PPH)

77
Q

artificial rupture of membranes

A

if labour is slow progressing/not started but amniotic sac not ruptured then amniotomy can be done - artificially rupture to speed up/induce labour to progress

contraindications
- breech position
- placenta praevia

78
Q

premature rupture of membranes

A

before 37 weeks

79
Q

failure to progress in stage 1 of labour

A

nulliparous woman if initial phase of stage 1 >20 hours
active phase should progress at >1.2cm per hour

multiparous woman if initial phase >14 hours
active phase should progress at >1.5 cm/hour

80
Q

Causes of post partum haemorrhage

A

Tone - lack of uterine tone causing slow and steady loss of blood

Trauma - caesarean incision, trauma from vaginal delivery, medical instruments. Can cause haematoma

Tissue - retention of placenta

Thrombin - blood clotting condition either genetic e.g. VWD or obstetric e.g. pre eclampsia

81
Q

management of ongoing post partum haemorrhage

A
  1. Head
    - A-E; airway, breathing etc
    - lie flat. monitor obs. give oxygen if needed/if massive haemorrhage
  2. Arm
    - Large bore IV access; give ergomerine or syntococin bolus
    - group and save
    - restore circulating volume

if continuing consider moving to theatre and get more input +…

  1. Leg
    - IM drugs to stop bleeding
    - Consider IV tranexamic acid
  2. Uterus
    - if bladder full catheterise
    - examine uterus
    - consider cell salvage
    - consider hysterectomy
82
Q

order of cardinal movements of labour

A

Engagement, descent, flexion, internal rotation, extension, external rotation, expulsion

83
Q

what does active management of the third stage of labour involve

A

intramuscular oxytocin, cutting of the umbilical cord and controlled cord traction

84
Q

when is low lying placenta usually discovered? what is done at this stage

A

on anomaly scan at 20 weeks

at this stage advise what it is and complications including possibility of bleeding and then rescan at 32 and 36 weeks
if not moved then plan for caesarean section

85
Q

obstetric causes of abdominal pain in pregnancy

A
  • pre term labour
  • placental abruption
  • choriamnionitis
  • acute fatty liver of pregnancy
  • epigastric pain associated with pre-eclampsia
  • torsion of pregnant uterus
    (+ miscarriage and ectopic)

other causes are GI + other causes such as trauma, respiraotry disease, gynaecological

86
Q

late pregnancy causes of abdominal pain

A

torsion of fibroid

Placental abruption

Uterine rupture

HELLP syndrome

87
Q

tests that can indicate pre term labour likely

A

fetal fibronectin in cervical secretions and increased IGFBP-1 can both indicate preterm labour

88
Q

management of likely preterm labour

A

2 doses of betamethasone 24 hours apart

can delay with tocolysis; nifedipine, atosiban and indomethacin

magnesum sulphate can be given for fetal neurological protection

89
Q

risk factors for uterine rupture

A

previous C section

trial of vaginal delivery after CS - risk of 7/1000

increased risk in induction of labour

90
Q

uterine rupture signs and symptoms

A
  • abdo pain
  • hypovolaemic shock
  • ctg abnormalities
  • uterine contractions may stop
  • palpation of foetus outside uterus
91
Q

appendicitis in pregnancy

A

most common non-obstetric cause of abdo pain

note pain moves with trimester
first - RLQ pain
second - umbilicus pain
third - diffuse of RUG pain

higher liklihood of perforation

92
Q

ovarian torsion in pregnancy

A

increased risk compared to not pregnant

caused by ovary twisting resulting in impaired blood flow

sudden onset unilateral severe pain
N&V
low grade fever
may palpate mass

USS to diagnose

93
Q

what does a CTG show

A

fetal heartbeat

fetal movements

fetal movement detected by mother

uterine contractions

94
Q

causes/origins of antepartum bleeding

A
  1. bleeding from lower ano-genital tract inlcuidng cervix
  2. bleeding from placenta
    - abruption
    - placenta praevia
    - vasa praevia
  3. bleeding of unknown origin
95
Q

what is vasa praevia

A

when cord fails to insert into middle of placental body
cord inserts peripherally then large vessels move to rest of placenta

rare but hard to detect
causes catastrophic bleeding

96
Q

treatment of secondary PPH due to retained products/infection

A

1st line treat with broad spec Abx such as co-amoxiclav

if fails anaesthetise and surgically remove retained product

if no retained products on exploration then likely dysfunctional uterine bleeding - start on COCP if not breastfeeding

97
Q

what is the cut off for distance from internal os to edge of placenta for vaginal delivery

A

should be distance of 2cm or more in third trimester to attempt vaginal delivery

98
Q

what is Kleihauer test

A

detects the presence of fetal red cells in the maternal circulation

99
Q

risk factors for need for instrumental vaginal delivery

A
  • primiparous women
  • epidural anaesthesia
  • supine and lithotomy positions
100
Q

Steps for assessing a CTG

A

DR C BRAVADO

Define Risk

Contractions

Baseline RAte (fetal heart)

Variability

Accelerations

Decelerations

Overall impression

101
Q

indications for operative vaginal delivery

A

presumed fetal compromise

maternal - to shorten and reduce effects of second stage of labour on medical conditions

inadequate progress in nulliparous women for 3 hours and in mutliparous women for 2 hours
or maternal fatigue/exhaustion

102
Q

when should attempt at operative vaginal delivery be abandoned

A

no evidence of progressive descent with moderate traction during each contraction
or where delivery is not imminent following three contractions of a correctly applied instrument by an experienced operator

103
Q

when is operative vaginal delivery more likely to fail

A

Maternal body mass index over 30
Estimated Foetal Weight over 4000 g or clinically big baby
Occipitoposterior position
Mid-cavity delivery or when 1/5th of the head palpable per abdomen.

104
Q

complications of Caesarean section in the second stage of labour

A

Maternal morbidity: uterine/cervical/high vaginal injury, postpartum haemorrhage, blood transfusion, sepsis, admission to intensive care, and length of stay.

Neonatal morbidity: admission to neonatal intensive care

105
Q

methods for foetal head disimpaction from the pelvis in caesarean

A

fetal pillow most commonly used

other methods; use of non-dominant hand, vaginal disimpaction, tocolytics, reverse breech extraction

106
Q

normal movements of the fetal head in labour

A
  1. Engagement - fetal head enters pelvis in occipitotransverse position
  2. Descent and flexion of head
  3. Internal rotation - head rotates to occipitoanterior position
  4. Further descent
  5. Extension and delivery

following delivery of the head routes back to OT position then traction is applied to allow delivery of the shoulders one by one

107
Q

in terms of risks associated how does ventuose delivery compare to forceps

A

ventuose is more likely fail
more likely to be associated with cephalohaematoma and retinal haemorrhage
less likely to be associated with tears

108
Q

what two main methods of instrumental delivery

A

forceps and ventuose suction

109
Q

key risks to baby of forceps and ventuose delivery

A

forceps - facial nerve palsy

ventuose - cephalohaematoma

110
Q

definition of sub fertility

A

unwanted delay of 2 years in achieving conception despite regular unprotected sexual intercourse

111
Q

when should further assessments be offered to people struggling to conceive

A

after 1 year of unprotected intercourse

112
Q

investigations for fertility problems

A

semen analysis; volume, pH, concentration, total number, motility, vitality, morphology

female; basic testing is progesterone levels 7 days before next expected period >30 indicates ovulation
ovarian reserve testing ; use total antral follicle count, anti-mullerian hormone or FSH
AMH best predictor of oocyte reserve - can be measured any time of cycle

113
Q

FSH/LH levels for absent/irregular periods

A

low - problem at hypothalamus/pituitary level

normal - problem in folliculogenesis but oocytes are present

high - low number/absence of oocytes; or ovarian failure

114
Q

low FSH, LH and oestrodial

A

hypothalamic or pituitary dysfunction

115
Q

normal FSH and normal oestrodial

A

problem at final stage of oogenesis must likely polycystic ovarian disease

116
Q

when should FSH be measured if using as a marker of ovarian reserve

A

day 2-5 of cycle when oestrogen low because oestrogen would suppress FSH

high FSH is linked to low ovarian reserve

117
Q

antral follicle count as a measure of ovarian reserve

A

uses USS to look for follicles
can be anytime of cycle

118
Q

full set of female investigations infertility
- regular periods
- irregular/amennhorea
- all women

A

regular periods
- FSH, LH, oestradiol
- progesterone; 7 days before menses

irregular/amennorrhoea
- FSH, LH
- oestrogen
- prolactin, free testosterone; exploring causes

all women
- rubella serology
- anti-mullerian hormone
- cervical smear
- transvaginal USS

119
Q

main factors other than ovulation/ovarian reserve and sperm that affect conception

A

female age

uterine function

duration of trying

smoking and alcohol

weight

medical history

have they had a successful previous pregnancy

120
Q

tubal factors in infertility

A

tubal reduced patency e.g. from previous sexually transmitted infections can reduce fertility or from endometriosis
Previous surgery can also affect tubes

can check tubal patency by an X-ray after injecting radio-opaque dye – known as a hysterosalpingogram or HSG

if tubes not patent then best chance of conception is by IVF

121
Q

what medication can be used to induce ovulation

A

clomiphene citrate taken for 5 days from day 2-6 of cycle
measure mid-luteal progesterone and if low can increase dose of clomiphene

often used in women with PCOS

if this fails injections of FSH can be tried

122
Q

next steps once medications tried to induce ovulation

A

can try ovarian “drilling” where holes are made in ovaries which encourages ovulation

if both clomiphene and FSH or drilling tried and failed then move on to IVF

123
Q

distribution of causes of subfertility

A

ovulatory problems 20-30%

tubal problems 20-30%

Male factor 25-40%

Unexplained 10-20%

Endometriosis 5-10%

Other problems (e.g. fibroids) 4%

124
Q

possible causes for unexplained sub fertility

A
  • subtle abnormalities in sperm or oocyte function
  • defective endometrial receptivity
  • subclinical endometriosis
  • nutritional factors
  • undiagnosed/untreated coeliac disease
  • immunological factors
125
Q

features of ovarian USS that raise concern

A

cysts that are large, bilateral, appear “complex” (i.e. have both solid and cystic areas) should be treated as suspicious

126
Q

genetic testing in ovarian cancer

A

women with high grade serous ovarian cancer are offered genetic testing for BRCA genes amongst others

About 15% of high grade serous ovarian cancer is associated with a germline mutation in either BRCA1 or BRCA2

BRCA associated cancers can respond better to certain treatments such as PARP inhibitors

127
Q

what is the Risk of Malignancy Index (RMI) in ovarian cancer

A

used to assess the risk associated following the finding of an ovarian cyst

combines 3 pre-surgical features
- CA-125
- Menopause
- USS findings

Menopause is scored 1 for pre-menopausal and 3 for post-menopausal
USS score is 2-5 based on features seen; multi ocular cysts, solid areas, metastases, ascites, and bilateral lesions

a higher overall score of CA-125 x M x U gives a higher risk of malignancy

128
Q

red flags in urogynaecology

A

visible haematuria - may indicate bladder cancer

pain associated with bladder filling - may indicate bladder cancer

abdominal swelling - may indicate pelvic mass

129
Q

symptom tracking/assessment pelvic floor symptoms

A

keep a bladder diary

ICI-Q short form questionnaire (a validated symptom questionnaire which evaluates which pelvic floor symptoms

130
Q

examination for prolapse

A

Pelvis Organ Prolapse Quantification (POP-Q) examination
measures distance from cervix/bottom of prolapse to hymen

stages 1 -5

131
Q

urodynamics

A

other aspect of assessment or urogynaecological issues

evaluates bladder function; storing and releasing urine

looks at speed and pattern of micturition and post-void volume first without a catheter

then catheter studies are done using pressure catheters

ossible diagnoses from urodynamic studies include urodynamic stress incontinence (USI), detrusor overactivity (DO) and voiding dysfunction

132
Q

surgical interventions (after pelvic floor exercises) for stress urinary incontinence

A
  • colposuspension; uses sutures to elevate neck of bladder and support urethra
    risks include prolapse
  • urethral bulking; less invasive option but lower success rate
  • fascial sling; strip of fascia taken from patient
  • mid-urethral sling; tension free tapes made of mesh. current controversy about their use
133
Q

what is Bishop score

A

scoring system used to decide whether to induce labour
max score 13

5 things assessed and given a score

fetal station 0-3
cervical position 0-2
cervical dilatation 0-3
cervical effacement 0-3
cervical consistency 0-2

score of 8 or more predicts successful induction

134
Q

options for induction of labour

A

membrane sweep; more of an assistance. used from 40 weeks

vaginal prostaglandin E2; gel, tablet or pessary into vagina

cervical ripening balloon; where prostaglandins not preferred

artificial rupture of membranes with oxytocin infusion; only where above contraindicated or already tried

oral mifepristone + misopristol if intra-uterine death has occurred

135
Q

main complication of induction of labour with vaginal prostaglandins

A

frequent and prolonged contractions causing foetal distress and compromise

can lead to need for c section and uterine rupture

manage by removing prostaglandins and if needed tocolysis

136
Q

booking bloods

A

Haemoglobin level
Platelets level
Infections; HIV, syphilis, Hepatitis B
Blood group and antibody status
Sickle Cell and Thalassaemia if high risk from the family origin questionnaire

137
Q

risk factors to offer screening for GDM

A

BMI>30
Certain ethnic origins e.g. Black African, Indian
Family history of a first degree relative with Diabetes Mellitus
Polycystic Ovarian Syndrome
Previous baby >4.5kg at delivery
Previous Gestational Diabetes

138
Q

obstetric risks associated with high maternal BMI

A

miscarriage, congenital malformations, PET, GDM and macrosomia and VTE. Intrapartum complications such as monitoring of their baby during labour (may require FSE), anaesthetic difficulties in siting regional anaesthetics and with General anaesthetic. Postpartum complications include PPH, wound infections and VTE

139
Q

aspirin in mothers with diabetes

A

all should take aspirin 75mg od from 12 weeks

140
Q

growth scans all diabetic mothers

A

serial every 4 weeks from 28/40

141
Q

what signs associated with bleeding warrant 2ww

A

Age >45yrs

intermenstrual bleeding

postcoital bleeding

postmenopausal bleeding

abnormal examination fidnings eg pelvic mass or lesion on cervix

treatment failure after 3 months

142
Q

endometrial ablation

A

non-hormonal, surgical treatment that works by destroying the endometrium using heat

daycase procedure under a short anaesthetic or as an outpatient procedure under local anaesthesia

reduced heavy periods in 90% of patients and in about 50% it will stop them from having periods completely

Main risks 1% uterine perforation and infection

Clinical Years / Progress Test (24 decks)

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