Obs & Gynae Flashcards
(142 cards)
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
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
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
4
Q
12 week scan
A
dating the pregnancy
taking measurements including nuchal thickness (part of Down syndrome screening)
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
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
7
Q
what does rising oestrogen levels do to the uterus
A
prepares for delivery by increasing oxytocin receptors in the uterus
8
Q
what is progesterones role in pregnancy
A
smooth muscle relaxant (can lead to reflux, constipation and urethral relaxation) and maintains uterus lining
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
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
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
12
Q
20 week scan
A
anomaly scan where anatomy of foetus is assessed for any abnormalities
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
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
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
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
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
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
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
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
21
Q
target ranges for glucose monitoring during pregnancy
A
avoid hypos. minimum 4
fasting <5.3
1 hour post meal 7.8
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
23
Q
risks to foetus of gestational diabetes
A
Macrosomia, Polyhydramnios, Shoulder Dystocia, Stillbirth, Neonatal Hypoglycaemia and Expedited delivery
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
25
treatment of gestational diabetes/diabetes in pregnancy
met form up to max dose
then add insulin
diet and exercise for everyone
26
timing of lower segment Caesarean section
diabetic patients on insulin by 38/40
non-diabetic patients at >39/40
27
steroids in deliveries at <39/40
issues in diabetic mothers
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
28
how does gestational diabetes develop
hormonal influences of human placenta lactogen, cortisol, growth hormone and progesterone increase maternal glucose levels whilst also increasing insulin resistance
29
what anticoagulant should be used in pregnancy
LMWH
30
pre-conception for women with pre-existing diabetes
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
31
antenatal care pre-existing diabetes
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
32
intra-partum care diabetes
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
33
post partum care diabetes
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
34
GDM and risk of T2DM
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
35
thresholds for caesarean regarding risk of shoulder dystocia
women with diabetes and estimated foetal weight >4.5kg
non-diabetic mothers + weight >5kg
36
feeding baby born to diabetic mother and blood glucose check
feed within 30 minutes of birth and check BM at 2-4 hours - risk of neonatal hypoglycaemia
if no symptoms but hypoglycaemic just monitor
37
treating existing HTN in pregnancy
ACEi, ARB and diuretics should be avoided
use labetalol or nifedipine and offer aspirin from 12 weeks
(same for gestational HTN)
38
management of anaemia in pregnancy
iron replacement therapy
39
what is small for gestational age
birth weight less than 10th centile
usually constitutional but can be due to foetal growth restriction
40
what is foetal growth restriction
failure of foetus to reach pre-determined growth potential; evidence of growth faltering and crossing centiles
41
types of foetal growth restriction
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
42
major risk factors for SGA
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
43
screening for SGA/ growth restriction
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
44
aetiology of SGA/ growth restriction
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
45
short and long term implications for babies SGA/FGR
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
46
what measurements are taken on a growth scan
abdominal circumference, head circumference, femur length; combined to give estimated weight
umbilical artery doppler and liquor volume
47
management of early onset FGR <32 weeks
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
48
management of late onset FGR >32 weeks
surveillance
steroids if <36 weeks
delivery is likely better option if end diastolic flow is revered on doppler
49
prevention of FGR
smoking cessation
identify women high risk
aspirin for women at risk of pre-eclampsia
50
APGAR score domains
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
51
when are APGAR scores measured
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
52
pharmacological management of postpartum haemorrhage
Syntocinon, syntometrine, ergometrine, misoprostol, carboprost, Transexamic Acid
53
uterine fibroids in pregnancy
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
54
in normal pregnancy what remodelling happens to uterine vessels
become high capacitance low resistance
this failing to happen can contribute to development of pre-eclampsia
55
history of abnormal vaginal bleeding
- 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
56
red flags vaginal bleeding
- Age >45yrs
- intermenstrual bleeding
- postcoital bleeding
- postmenopausal bleeding
- abnormal examination fidnings eg pelvic mass or lesion on cervix
- treatment failure after 3 months.
57
what is hysteroscopy
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
indications for hysteroscopy
- sterility
- infertility
- menstrual disorder
- suspicious USS findings
- check ups after interventions/treatment
- lost IUD
59
causes of abnormal uterine bleeding
Polyps
Adenomyosis
Leiomyoma- fibroids
Malignancy
Coagulopathy (VWD)
Ovulatory dysfunction (adolescence, PCOS, menopause)
Endometrial processes
Iatrogenic
Not classified
60
early pregnancy bleeding
- 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
diagnosing miscarriage
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
threatened miscarriage
anyone pregnant presenting with vaginal bleeding
63
inevitable miscarriage
cervix open on examination
64
delayed miscarriage
pregnancy stopped growing/foetal heartbeat absent but no signs of bleeding
65
investigations in miscarriage/early pregnancy bleeding
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
what happens if +ve HPV status on smear
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
treatment for cervical intraepithelial neoplasia
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
what is colposcopy (explanation)
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
who is offered cervical screening
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
what is dyskaryosis
what are the different grades
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
follow up after treated for CIN 1, 2 or 3 changes
repeat smear in 6 months
if normal return to routine recall
72
early labour hormonal changes (foetus and mother)
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
what does oxytocin do in labour
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
stage 1 of labour latent and active phases
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
stage 2 of labour
describes the progress from full cervical dilatation to delivery of the baby
76
stage 3 of labour
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
artificial rupture of membranes
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
premature rupture of membranes
before 37 weeks
79
failure to progress in stage 1 of labour
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
Causes of post partum haemorrhage
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
management of ongoing post partum haemorrhage
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 +...
3. Leg
- IM drugs to stop bleeding
- Consider IV tranexamic acid
2. Uterus
- if bladder full catheterise
- examine uterus
- consider cell salvage
- consider hysterectomy
82
order of cardinal movements of labour
Engagement, descent, flexion, internal rotation, extension, external rotation, expulsion
83
what does active management of the third stage of labour involve
intramuscular oxytocin, cutting of the umbilical cord and controlled cord traction
84
when is low lying placenta usually discovered? what is done at this stage
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
obstetric causes of abdominal pain in pregnancy
- 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
late pregnancy causes of abdominal pain
torsion of fibroid
Placental abruption
Uterine rupture
HELLP syndrome
87
tests that can indicate pre term labour likely
fetal fibronectin in cervical secretions and increased IGFBP-1 can both indicate preterm labour
88
management of likely preterm labour
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
risk factors for uterine rupture
previous C section
trial of vaginal delivery after CS - risk of 7/1000
increased risk in induction of labour
90
uterine rupture signs and symptoms
- abdo pain
- hypovolaemic shock
- ctg abnormalities
- uterine contractions may stop
- palpation of foetus outside uterus
91
appendicitis in pregnancy
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
ovarian torsion in pregnancy
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
what does a CTG show
fetal heartbeat
fetal movements
fetal movement detected by mother
uterine contractions
94
causes/origins of antepartum bleeding
1. bleeding from lower ano-genital tract inlcuidng cervix
2. bleeding from placenta
- abruption
- placenta praevia
- vasa praevia
3. bleeding of unknown origin
95
what is vasa praevia
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
treatment of secondary PPH due to retained products/infection
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
what is the cut off for distance from internal os to edge of placenta for vaginal delivery
should be distance of 2cm or more in third trimester to attempt vaginal delivery
98
what is Kleihauer test
detects the presence of fetal red cells in the maternal circulation
99
risk factors for need for instrumental vaginal delivery
- primiparous women
- epidural anaesthesia
- supine and lithotomy positions
100
Steps for assessing a CTG
DR C BRAVADO
Define Risk
Contractions
Baseline RAte (fetal heart)
Variability
Accelerations
Decelerations
Overall impression
101
indications for operative vaginal delivery
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
when should attempt at operative vaginal delivery be abandoned
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
when is operative vaginal delivery more likely to fail
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
complications of Caesarean section in the second stage of labour
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
methods for foetal head disimpaction from the pelvis in caesarean
fetal pillow most commonly used
other methods; use of non-dominant hand, vaginal disimpaction, tocolytics, reverse breech extraction
106
normal movements of the fetal head in labour
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
in terms of risks associated how does ventuose delivery compare to forceps
ventuose is more likely fail
more likely to be associated with cephalohaematoma and retinal haemorrhage
less likely to be associated with tears
108
what two main methods of instrumental delivery
forceps and ventuose suction
109
key risks to baby of forceps and ventuose delivery
forceps - facial nerve palsy
ventuose - cephalohaematoma
110
definition of sub fertility
unwanted delay of 2 years in achieving conception despite regular unprotected sexual intercourse
111
when should further assessments be offered to people struggling to conceive
after 1 year of unprotected intercourse
112
investigations for fertility problems
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
FSH/LH levels for absent/irregular periods
low - problem at hypothalamus/pituitary level
normal - problem in folliculogenesis but oocytes are present
high - low number/absence of oocytes; or ovarian failure
114
low FSH, LH and oestrodial
hypothalamic or pituitary dysfunction
115
normal FSH and normal oestrodial
problem at final stage of oogenesis must likely polycystic ovarian disease
116
when should FSH be measured if using as a marker of ovarian reserve
day 2-5 of cycle when oestrogen low because oestrogen would suppress FSH
high FSH is linked to low ovarian reserve
117
antral follicle count as a measure of ovarian reserve
uses USS to look for follicles
can be anytime of cycle
118
full set of female investigations infertility
- regular periods
- irregular/amennhorea
- all women
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
main factors other than ovulation/ovarian reserve and sperm that affect conception
female age
uterine function
duration of trying
smoking and alcohol
weight
medical history
have they had a successful previous pregnancy
120
tubal factors in infertility
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
what medication can be used to induce ovulation
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
next steps once medications tried to induce ovulation
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
distribution of causes of subfertility
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
possible causes for unexplained sub fertility
- subtle abnormalities in sperm or oocyte function
- defective endometrial receptivity
- subclinical endometriosis
- nutritional factors
- undiagnosed/untreated coeliac disease
- immunological factors
125
features of ovarian USS that raise concern
cysts that are large, bilateral, appear “complex” (i.e. have both solid and cystic areas) should be treated as suspicious
126
genetic testing in ovarian cancer
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
what is the Risk of Malignancy Index (RMI) in ovarian cancer
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
red flags in urogynaecology
visible haematuria - may indicate bladder cancer
pain associated with bladder filling - may indicate bladder cancer
abdominal swelling - may indicate pelvic mass
129
symptom tracking/assessment pelvic floor symptoms
keep a bladder diary
ICI-Q short form questionnaire (a validated symptom questionnaire which evaluates which pelvic floor symptoms
130
examination for prolapse
Pelvis Organ Prolapse Quantification (POP-Q) examination
measures distance from cervix/bottom of prolapse to hymen
stages 1 -5
131
urodynamics
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
surgical interventions (after pelvic floor exercises) for stress urinary incontinence
- 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
what is Bishop score
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
options for induction of labour
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
main complication of induction of labour with vaginal prostaglandins
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
booking bloods
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
risk factors to offer screening for GDM
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
obstetric risks associated with high maternal BMI
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
aspirin in mothers with diabetes
all should take aspirin 75mg od from 12 weeks
140
growth scans all diabetic mothers
serial every 4 weeks from 28/40
141
what signs associated with bleeding warrant 2ww
Age >45yrs
intermenstrual bleeding
postcoital bleeding
postmenopausal bleeding
abnormal examination fidnings eg pelvic mass or lesion on cervix
treatment failure after 3 months
142
endometrial ablation
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
