Obs & Gynae Flashcards
(635 cards)
1
Q
how does oestrogen act in the follicular phase
A
- stimulate fallopian tube function
- thicken endometrium
- growth and motility of myometrium
- thin alkaline cervical mucus
- vaginal changes
2
Q
how does progesterone act in the luteal phase
A
- acts on oestrogen-primed cells to cause further thickening of endometrium
- thickening of myometrium with reduced motility
- thick acidic cervical mucus
- changes in mammary tissue
3
Q
describe the HPG axis at the beginning of the cycle
A
- follicles part-developed therefore very little steroid or inhibin production
- low inhibition at hypothal and pituitary therefore fsh and lh levels rise
- fsh binds to granulosa cells to stimulate development
- lh acts on theca interna cells to produce oestrogen
4
Q
describe the HPG axis around the time of ovulation
A
- rising oestrogen levels causes hpg axis to swtich to positive - increase in oestrogen
- lh carries on rising
- fsh rises, but not to same extent due to inhibin production
- inhibin also means no new follicles can develop
- lh surge causes ovulation
5
Q
describe the HPG axis at the end of the cycle
A
- after ovulation, corpus luteum forms,
- steroid levels rise - oestrogen + progesterone
- oestrogen suppresses fsh, progesterone suppresses lh
- fast drop in hormone and progesterone levels due to lack of fertilisation causes menses
6
Q
what is the normal range for the ovarian cycle
A
24-32 days
7
Q
list some of the common causes for menorrhagia
A
- abnormal clotting: VWF disease, thrombocytopenia, coag disorders, leukaemia etc
- pathology: fibroids, adenomyosis, endometriosis, polyps etc
- medical disorders: hypo/hyperthyroid, liver disease, sle, cancer
- DUB: primary menorrhagia - heavy bleeding with no recognisable pelvic pathology/bleeding disorder
8
Q
list some of the factors affecting menstrual loss
A
- age: 4th decade
- hereditary
- parity
- uterina pathology
- cycle-cycle vaiability
9
Q
list some of the ways to investigate menorrhagia
A
- FBC: Hb, platelets, clotting factors as necessary
- TFTs
- coagulation
- USS/TVUS
- hysteroscopy
- biopsy
- (colposcopy)
- (smear)
10
Q
list some of the treatments for managing menorrhagia
A
- progestogens e.g. norethisterone, depot
- Mefenamic acid/ other NSAIDs
- tranexamic acid - antifibrinolytic
- IUCD - Mirena (progesterone-impregnated), not copper coil
- cocp
- surgical: endometrial ablation, cold coag treatment, laser; hysterectomy as last result
11
Q
what is the mechanism of action of tranexamic acid
A
antifibrinolytic - inhibits plasminogen activation into plasmin. plasmin usually causes fibrin degradation - therefore TXA inhibits fibrin breakdown
12
Q
what is PCOS
A
endocrine disorder of unknown aetiology, which can be hereditary.
accounts for majority of causes of amenorrhoea
13
Q
what are the pathological features of PCOS
A
- ovarian hypersecretion of andorgens
- increased pulsatile secretion of LH
- ovarian theca cell hyperplasia leading to ovarian enlargement
- anovulation
- insulin resistance
14
Q
what are the clinical features of PCOS
A
- oligo/amenorrhoea
- DUB
- obesity
- hirsuitism
- acne
- ‘string of pearls’ appearance of ovaries on USS
15
Q
what are the biochemical features of PCOS
A
- increased LH:FSH ratio
- decreased sex hormone binding globulin
- increased free androgen index
- increased serum insulin
16
Q
what are the differentials for PCOS
A
- anovulatory cycles
- congenital adrenal hyperplasia
- androgen secreting tumours
- cushings syndrome
17
Q
what are the long-term health complications of PCOS
A
- miscarriage
- gestational diabetes
- NIDDM
- HTN
- cardiovasc disease
- endometrial hyperplasia/carcinoma
18
Q
what is the management for PCOS
A
- weight loss
- metformin
- COCP
- cyproterone acetate (antiandrogen)
- ovulation induction in infertility
- ovarian drilling
- cyclical progestogen
19
Q
what is the definition of menopause
A
permanent cessation of menstruation due to loss of ovarian follicular activity - 12 months since LMP
20
Q
what is LMP
A
last menstrual period - calculated as the first day of the last period a woman has had
21
Q
what are the symptoms of the menopause
A
- hot flushes and night sweats
- irritability, mood changes, lack of concentration, depression
- reduced libido
22
Q
what is hrt for
A
oestrogen replacement therapy (combined with progestogens if uterus intact)
used to manage symptoms of menopause
23
Q
list some of the risks associated with hrt
A
- effects of unapposed oestrogen: increased endometrial/ovarian/breast cancer risk
- increased IHD/stroke; adverse effect on lipid profile
- increased risk of vte; adverse effect on thrombophilia profile
24
Q
what are the different modes of administration of hrt
A
- po
- transdermal
- implant
- transvaginal
- nasal
- local
25
what drugs may be given to prevent osteoporosis in postmenopausal women
- bisphosphanates (inhibit osteoclasts)
- calcium + vit D
- raloxifene (SERM)
- exercise
26
define amenorrhoea
primary: no menses by age 14, or no menses by 16 despite presence of secondary sexual characteristics
secondary: previous menstrual cycles, but now without menses for 6 months
27
list the points in the history that should be asked about when taking an amenorrhoea history
- duration of amenorrhoea
- contraception
- vasomotor syndrome
- galactorrhoea
- exercise habits
- stress
- meds
- pmhx
28
list some of the causes of primary amenorrhoea without ssc's
- constitutional delay
- GU malformation e.g. imperforate hymen
- testicular feminisation (XY - female external appearance, but gonads are testes, no ovaries)
- hyperprolactinaemia e.g. pituitary tumour
- pregnancy must always be considered
29
list some of the causes of primary amenorrhoea with ssc's present
- ovarian failure e.g. chemo, turner syndrome
- hypothalamic failure e.f. chronic illness, exercise, stress
- HPG - tumours, head injury, Kallman's synd etc
30
list some of the causes of secondary amenorrhoea
- pregnancy
- PCOS
- Cushings
- adrenal/ovarian ca
- primary ovarian insufficiency
- hypothalamic amenorrhoea
- hyperprolactinaemia
- thyroid disease
- sheehan's synd following pregnancy
- iatrogenic, 'post pill amenorrhoea'
31
what would you look for when performing an examination of someone with amenorrhoea
- bmi
- signs of excessive androgens
- thyroid disease/cushings
- ssc's
- vaginal/external genital/pelvic examination
- masses e.g. large ovarian cyst
32
list some of the investigations you would do on someone presenting with amenorrhoea
- pregnancy test
- fsh/lh levels
- prolactin
- total testosterone/sex hormone-binding globulin
- tft's
- pelvic uss e.g. pcos, anatomy
- additional: karyotype, mri, ct, hysteroscopy
33
what is the management of amenorrhoea
depends on cause
- reassure if constitutional
- structural abnormalities: surgery
- hrt if premature ovarian failure
- medical review if prolactin increased due to medicines
- gh for short stature in turner's syndrome
- testicular feminisation - surgical removal of testes
- fertility clinic referral
34
list some of the causes of irregular menstrual bleeding
- more common in extremes of age
- anovulatory cycles
- pelvic pathology e.g. fibroids, polyps, adenomyosis, ovarian cysts, chronic pelvic infection
- cancer
35
what investigations would you perform on a woman presenting with irregular bleeding
- hb level
- exclude malignancy - smear/hysteroscopy/pipelle(older women especially)/biopsy/colposcopy
- uss
36
what is the management for irregular menstrual bleeding
if no anatomical defect: Mirena, COCP, progestogens (however these cause withdrawal bleed)
exclude cancer first: pipelle exclusion required in older women before inserting coil
37
what is the definition of oligomenorrhoea
bleeding every 35 days - 6months
38
what are the hypothalamic reasons for amenorrhoea
- psychological
- stress
- low weight/anorexia nervosa
- excessive exercise
- tumours
39
what are the pituitary reasons for amenorrhoea
- hyperprolactinaemia usually due to tumour, or pituitary hyperplasia
- sheehan's syndrome
40
what is the treatment for hyperprolactinaemia
bromocriptine - dopoamine agonist
41
what are the ovarian reasons for amenorrhoea
- pcos
- premature ovarian failure
- tumours
- turners syndrome
42
what is the general rule in management of post coital bleeding
always abnormal except after first intercourse. must always exclude cancer
43
what is the aetiology of PCB
usually due to the cervix not being covered in healthy squamous epithelium - more likely to bleed after trauma
- ectropions
- polyps
- cervical cancer
- cervicitis and vaginitis
- atrophic vagina
44
what is the management of PCB
- check smear history
- careful inspection of cervix +/- smear
- ectropions -> cryotherapy freezing
- polyps -> removed and sent for histology
- colposcopy to exclude malignant cause
45
what is the treatment for precocious puberty (<10 y/o or ssc's before 8)
gnrh agonists to inhibit sex hormone secretion if no pathological cause found - helps growth as you dont want the femoral epiphysis to fuse too early
cryproterone acetate to act as anti-androgen
46
what are the causes of dysmenorrhoea
primary or secondary
- primary: no organic cause found
- secondary: pathology - fibroids, adenomyosis, endometriosis, PID, ovarian tumours
47
what is the management of dysmenorrhoea
- if primary: NSAIDs, COCP, reassurance as tends to get better with time
- if secondary: treat underlying cause if possible, NSAIDs, COCP/POP, GnRH analogues,
48
what is Premenstrual syndrome and the management for it
psychological, behavioural and physical symptoms experienced regularly during luteal phase. often resolve by end of cycle. SSRIs may help, COCP, may do a trial of GnRH analogues
49
list some of the pathological causes of precocious puberty
- central: increased GnRH due to menigitis, encephalitis, tumours, hydrocepahlus etc
- ovarian/adrenal: hormone-producing tumours or cysts,
50
list some of the cases of post menopausal bleeding
- endometrial cancer
- endometrial hyperplasia +/- atypia
- polyps
- cervical cancer
- cervicitis
- ovarian cancer
- cervical polyps
51
what is the management of PMB
all these women should undergo bimanual and speculum examination
TVUS should be performed in all to assess endometrial thickness - if over 5mm, requires hysteroscopy + pipelle or polyp biopsy etc
52
describe some of the effects that menopause has on the vagina
atrophy, urinary symptoms
atrophy can cause dyspareunia, itching, dryness
urinary symptoms can cause urgency, nocturia, frequency, recurrent infection
53
which hormones may be tested for changes in menopause
- FSH (decreases as oocytes decrease)
- antimullerian hormone - low levels consistent with ovarian failure as AMH is produced by follicles
- TFT
- catecholamines (phaeo)
- LH, oestrogen, progesterone
54
list the hromonal and non-hormonal treatments for post-menopausal women
- hrt
- tibolone: synthetic steroid activated by metabolism
- andorgens
- lubricants and moisturisers/oestrogen creams in atrophy
- bisphosphanates, strontium ranolate, raloxifene, PTH peptides, denusomab, adcal for osteoporosis
55
what are the benefits of hrt
symptom control of flushes, sweats, mood swings etc
56
what are the risks of hrt
- increased risk of certain cancers
| - increased risk of vte
57
what is the difference between infertility and infundicity
infertility - inability for a couple to concieve after one year of unprotected intercourse (6 months for women > 35yo)
infundicity - inability for a couple to produce a live birth
58
list the categories of causes of infertility
- ovulation defects
- tubal disease
- endometriosis
- uterine factor
- unexplained
- male factor
- other e.g. anovulatory cycles
59
what is evaluated and males and females in couples who are infertile
females: ovary, tubes, corpus, cervix, peritoneum
males: sperm count and function, ejaculate characteristics, anatomic anomalies
60
what is examined in a female presenting with infertiltiy
- bmi
- body hair distribution
- galactorrhoea
- ssc
- pelvic abnormalities, fixed/tender uterus
61
list some of the important points in the history of a female presenting with infertility
- age
- duration of infertility
- type of infertility
- menstrual cycle, ovulation
- previous surgery, especially pelvic
- menorrhagia, dysmenorrhoea, pelvic pain
- PID
62
list some of the important points in the history of a male presenting with infertility
- general health, diabetes?
- alcohol intake/smoking
- previous infections
- sexual dysfunction - erectile/ejaculatory
63
list the baseline investigations of a female with infertility
- follicular phase fsh/lh day 2
- luteal phase day 12 lh/fsh
- tft, prolactin, testosterone, steroid hormone binding globulin
- rubella status
- tests of tubal patency
- pelvic uss
- hysteroscopy
64
what are the different tests for tubal patency
- hysterosalpingography (injection of radioopaque material into uterus)
- hycosy aka tubal patency test (contrast sonoggraphy - TVUS + contrast)
- diagnostic laparoscopy + dye (blue dye injected and laparoscopy looks for leakage of dye into abdomen if tubes are patent)
65
how would you examine a male presenting with infertility
- testicle size
- testicular position
- scrotum - varicocoele
- prostate for chronic infection
66
what are the tests done for males presenting with infertility
semen analysis
| - volume, concentration and initial foward motility, morphology
67
what is the normal volume and conc of sperm in ejaculate
> 1.5ml
| > 15x10^6/ml
68
except for semen analysis, what other tests could you perform in a male presenting with infertility
- antisperm antibody
- fsh/lh/testosterone
- uss - seminal vesicles, prostate
69
what is the treatment for anovulation
- clomiphene citrate (SERM) - upgrade hpg axis
- gonadotrophins/pulsatile lhrh
- dopamine agonists e.g. bromocriptine in hyperprolactinaemia
- weight loss/gain
70
what is the treatment for infertility due to tubal disease
surgery
| ivf
71
what is the treatment for male factor infertility
```
ivi
ivf
intracytoplasmic sperm injection
donor insemination
donor sperm
```
72
what is endometriosis
condition where there is tissue resembling the endometrium lying outside the endometrial cavity - predominantly in pelvis
these respond to cyclical hormone changes and bleeds at menstruation
73
what is adenomyosis
presence of endometrial tissue within the myometrium
74
how is adenomyosis diagnosed
biopsy
75
what may be some of the signs found on examination of a patient with endometriosis, if any
- fixed uterus
- uterine/ovarian enlargement
- uterine fornix tender
76
what are the difference ways in which endometriosis presents
secondary dysmenorrhoea
heavy periods
dyspareunia
lower abdo pain
epistaxis/rectal bleeding (tissue in extra-pelvic places)
infertility can be found alongside endometriosis
77
how is endometriosis diagnosed/investigated
laparoscopy + biopsy gives diagnosis
78
what signs are present with endometriosis on laparoscopy
if active - powder burn spots and chocolate cysts
| scars if inactive; peritoneal defects
79
what is the management of endometriosis
```
mefenamic acid
tranexamic acid
cocp
continuous progesterone therapy
gnrh analogues +/- hrt
surgical - lap, diathermy, tah + bso (hysterectomy), removal of adhesions
```
80
what happens to endometriosis with pregnancy/menopause
regress
81
what are the symptoms of endometriosis
```
often asymptomatic
chronic pelvic pain, usually cyclical
dysmenorrhoea
deep dyspareunia
subfertility
```
82
list some of the differentials of endometriosis
- adenomyosis
- chronic pelvic inflammatory disease
- chronic pelvic pain
- other pelvic masses
- ibs
83
what are the side effects of progestogens
fluid retention, weight gain, erratic bleeding, pms
84
how to gnrh analogues work
induce a temporary menopausal state - overstimulation of the pituitary gland leads to down-regulation of gnrh receptors
85
why is treatment with gnrh analogues limited only to 6 months
reversible bone demineralisation occurs
86
define chronic pelvic pain
intermittent or constant pain in lower abdomen or pelvis for at least 6 months' duration, not occuring exclusively with menstruation or intercourse
87
list some of the investigations that may be performed in chronic pelvic pain
TVUS
MRI
Laparoscopy
ca125?
88
list some of the possible causes of chronic pelvic pain
```
endometriosis
adenomyosis
malignancy
ibs
intermittent cystitis
```
89
list four common causes of anovulation
1) pcos
2) hypothalamic hypogonadism
3) hyperprolactinaemia
4) thyroid disease
90
at which steps can fertilisation fail
- ovaries: anovulation
- sperm release: inadequate
- reaching egg: path may be blocked
- implantation: may fail
91
what is the treatment of pcos
- advice on diet and exercise
- cocp to regulate menstruation and treat hiruitism
- metformin to increase peripheral sensitivity to insulin
- clomiphene - antioestrogen to reduce negative feedback ad increase lh/fsh
- lapaorscopic ovarian diathermy
- gonadotrophins (lh and fsh) if clomiphene has failed
92
describe the pathological processes in the hypothalamus that can cause anovulation
reduced GnRH release
usually with anorexia nervosa, extreme diet/exercise stress
kallman's syndrome -> GnRH-secreting hormones fail to develop
93
how may hypothalamic anovulation be managed
weight gain, reducing stressor factors
exogenous gonadotrophins
gnrh pump
bone protection if gnrh low
94
describe the pathological processes in pituitary causes of anovulation
increased prolactin causes decreased GnRH release
usually due to adenomas or hyperplasia of pituitary gland
also can be due to trauma, sheehan's syndrome after pregnancy
95
what are the other possible symptoms of anovulation due to pituitary cause (increased prolactin)
```
amenorrhoea
galactorrhoea
headaches
bitemporal hemionopia
increased prolactin levels on biochem
```
96
what is the treatment for hyperprolactinaemia
ct to exclude tumour
dopamine agonist e.g. bromocriptine to inhibit prolactin release
surgery
97
what are the options is semen analysis shows mild oligospermia
intrauterine insemination
98
what are the options if semen analysis shows mod-sev oligospermia
ivf +/- intracytoplasmic sperm injection
99
what investigations should be done is semen analysis is azoospermic
examine for presence of vas deferens
karyotype: CF
hormones
may try surgical sperm retrieval
100
what bloods can be performed in males with abnormal sperm analysis
serum fsh, lh, prolactin, testosterone, tsh, karyotype, cf blood test
antisperm antibodies
101
what are the common causes of abnormal/absent sperm release
- idiopathic
- drug exposure e.g. alcohol, smoking, anabolic steroids, industrial chemicals etc
- varicocoele, structural abnormalities, obstruction
- antisperm antibodies
- genetic
- hyperprolactinaemia
- infections
- kallmann's syndrome
- retrograde ejaculation
102
what is the management of male infertility
- lifestyle chanegs e.g. stopping smoking, reducing alcohol
- subcut fsh/lh if hypogonadotrophic
- assisted conception e.g. IUI, IVF, Intracystoplasmic sperm injection, donor sperm, surgical sperm retrieval
103
what are some of the factors that may make it impossible for sperm to reach egg in order to fertilise it
- sexual problems e.g. psychological
- cervical problems
- tubal damage e.g. infection, pid, adhesions from previous surgery etc
104
what are the indications for assisted conception
other methods have failed, or unexplained cause.
male subfertility identified
tubal blockage, endometriosis or genetic factoes
105
what are the steps in inducing ovulation in patients with pcos
- weight loss/lifestyle changes
- clomifene
- if fails add metformin
- gonadotrophins
- ovarian diathermy
- finally if no success - ivf
106
what are some of the side effects of induction of ovulation
- multiple pregnancy
| - ovarian hyperstimulation syndrome where follicles get very large and painful
107
what is the gestation limit for termination of pregnancy
24 weeks, unless foetal abnormality
108
what are the current medical methods of termination of pregnancy
```
mifepristone (antiprogestogen)
given with prostacyclin - different types:
- IM suprostone
- PV metenoprost
- PV gemeprost
- PV/PO misoprostol
```
109
what is the regimen for medical termination of pregnancy
day1: mifepristone
day3: prostaglandins every few hours (depending on which one used)
day14: follow up
110
what are the contraindications for TOP
- pregnancy 64 days of gestation or over
- suspected ectopic
- chronic hepatic/renal failure
- haemorrhagic disorders
111
list some of the complications of abortion
- haemorrhage
- uterine perforation
- scar dehisence
- cervical tears
- failure
- post abortion sepsis
- psychological trauma
112
list the different types of emergency contraception
```
hormonal - high dose oestrogen/progesterone 2 tablets 12 hours apart
- levonelle
- ellaOne
works within 72 hours of unprotected sex
iud - within 5 days of unprotected sex
- copper
- mirena
- mifepristone iud
```
113
what should be ruled out before inserting iud emergency contraception
pelvic infection
114
list some of the "special groups" of patients who may need adjustment to their contraceptive routine - suggest optimal management for each
1) adolescents: encourage barrier to prevent sti's
2) IBD: redcued absorption - patches, injectibles, implants, IUD, vaginal
3) breastfeeding: not effective on its own - progesterone or IUD 4/52 pp. not oestrogen as affects milk production
4) later life: encourage contraception for at least 2 years after LMP
115
how does the cocp work
exert negative feedback on hpg axis to inhibit lh/fsh release and therefore ovulation
also thins the endometrium and thickens cervical mucus
116
what is the failure rate of cocp
0.2/100 woman-years
117
what changes with each generation of cocp
type of progesterone used
| each generation may also have a different oestrogen conc used
118
what are some of the other useful effects of cocp
treating acne/hirsuitism
menstrual cycle regulation
managing dysmenorrhoea
ovarian cysts
119
what are the common se of progestogens
depression, bleeding, amenorrhoea, acne, breast discomfort, weight gain, reduced libido
120
what are the common se of oestrogens
nausea, headache, mucus, fluid retention, weight gain, htn, breast tenderness, bleeding
121
list some of the factors which may affect cocp absorption
diarrhoea, vomiting, some PO abx
122
how would you advise a women who has vomited and is on the pill
if vomited within 2 hours, take another pill or follow "missed pill rules"
123
how would you advise a woman who has diarrhoea and is on the pill
follow "missed pill rules" for every day of the illness
124
how would you advise a woman who is on antibiotics and the pill
carry on taking the pill but also use condoms while being treated with antibiotics, for 7 days
125
how would you advise a woman on the pill who is going for surgery?
stop pill for 4 weeks prior surgery and use condoms/other cover in meanwhile
126
what are the major complications of cocp
vte
mi
this is increased by smoking, age, obesity
also: migraines, htn, cervical/endometrial/breast ca
127
what are the absolute ci's for cocp
```
bmi>40
>35 yo
smoking >15/day
hx of vte/mi/cva
thrombophilia
active breast/endometrial/ovarian ca
pregnancy
chronic liver disease
```
128
list the benefits of cocp
very effective and acceptable
regular, lighter, less painful periods
manages ovarian/breast cysts, fibroids, endometriosis
129
what is the regimen for the contraceptive patch
applied weekly for 3 consecutive weeks then replaced, followed by patch-free week
130
what is the combined vaginal ring regimen
contraception - releases daily dose of hormones to inhibit ovulation. inserted into vagina, worn for 3 weeks and then removed to allow bleed for 7days
new ring then inserted
131
what is the mechanism of pop
make cervical mucus hostile to sperm, may prevent ovulation, maintains thin endometrium to reduce chance of implantation
132
what should a woman be advised to do if they miss a pop pill
take another asap if within 3 hours and condoms used for a following 2 days
133
is pop contraception affected by broad spec abx
no
134
what is the regimen for depo-provera
im every 3/12
135
why is depo-provera avoided in younger patients
reduced bone density risk
136
what is nexplanon/implant contraception
single progestogen-containing rod is inserted into upper arm under LA
137
what is the failure rate of nexplanon
<0.1/100 woman-years
138
what is in levonelle
levonogestrel
139
what type of drug is the emergency contraceptive ellaOne
selective progesterone receptor modulator
140
what is the failure rate of condoms
2-15/100 woman years - similar for male and female condoms
141
what is the failure rate of diaphragm/cap
<5/100 woman years
142
how are spermicides used
in conjunction with barrier methods - jelly/cream/pessary
143
how do copper iud's work
prevent fertilisation as copper ion is toxic to sperm
| also blocks implantation
144
are copper iud's recommended in those with heavy periods
no -can in fact increase menstrual loss
| mirena coil used instead as it is much more useful
145
how does the mirena coil work
is progestogen-containing, and releases small doses locally
| changes cervical mucus and endometrium
146
what are some of the complications of iud use
- pain or cervical shock on insertion
- expulsion of device
- movement into abdomen or lodging into endometrium
- if pregnancy occurs, it is more likely to be ectopic
147
if a patient cannot feel the strings of her iud, what should you do
pelvic uss to look for iud in the uterus
| if no present - axr
148
what are the absolute ci's to iud
```
endometrial/cervical ca
undiagnosed pv bleeding
active/recent pelvic infection
current breast ca
pregnancy
```
149
what advice should be given to women put on iud
check strings after each period
| inform doctor if imb, pelvic pain, vaginal dc, feels may be pregnant
150
describe female sterilisation
interruption of fallopian tubes
- clips to occlude tubes
- placement of microinserts to expand and cause fibrosis and occlusion of tubes
151
what is the failure rate of female sterilisation
1/200
152
how would you counsel a woman asking for sterilisation
explain surgical risks, that they and their partner must be certain, tat failure risk is 1/200
discuss alternatives
reversal is not always successful and NOT on the NHS
153
what is the failure rate of vasectomy (ligation and removal of small section of vas deferens)
1/2000
154
how is vasectomy confirmed to have worked
azoospermia confirmed by two negative semen analyses
155
what is the usual histology type of vulval and vaginal cancer
squamous cell ca
156
what are the main causes of vulval and vaginal cancers
hpv/chronic skin disease
157
what are the main treatments for vulval and vaginal cancers
surgery, radio, chemo
158
what is the peak incidence of endometrial cancer
64-74 yo
159
list the risk factors for endometrial cancer
1) obesity
2) nulliparity
3) early menarche, late menopause
4) unapposed oestrogen
5) tamoxifen
6) oestrogen-producing tumours
7) diabetes
8) pcos
9) hnpcc
160
what is the premalignant stage to endometrial cancer
endometrial hyperplasia - can be simple, complex, atypical
161
how is endometrial hyperplasia treated
progestogens
| surgery
162
what is type 1 and what is type 2 endometrial cancer
type 1: adenocarcinoma
| type2: serous, clear cell, carcinosarcoma
163
what is the treatment for endometrial cancer
medical: progestagens PO/IV, Mirena
surgical: TAH + BSO, peritoneal washings, lap/open TAH, pelvic node disection
if advanced: chemo/radio, hormones, palliative
164
how is endometrial cancer diagnosed
hysteroscopy +
sample - pipelle or less commonly d&c
TVUS - useful for PMB
165
what is the cut off for thickness of the endometrium before it becomes a concern
5mm or more
166
what are the early signs of endometrial cancer
abnormal bleeding - imb/irregular
167
what are the late signs of endometrial cancer
pmb, blood stained vaginal dc
168
list the different cell lines from which endometrial cancer can arise
- surface epithelium
- stroma
- germ cells
- mets/misc
169
what are the different types of surface epithelium carcinoma
- serous
- mucinous
- endometrioid
- clear cell
- brenner
170
what are the different types of germ cell tumours
- choriocarcinoma
- dysgerminoma
- teratoma
- yolk sac
171
what are the different types of stroma/cord cell tumour
granulosa
theca
sertoli-leydig
172
what are the risk factors for ovarian tumours
- BRCA 1/2
- hnpcc
- nulliparity
- infertility
- early menarche
- late menopause
- unapposed oestrogen
- hrt
173
what is the peak age for ovarian cancer
70-74
174
list some of the factors that decrease risk of ovarian cancer
- cocp
- pregnancy
- breastfeeding
- hysterectomy
- oopherectomy
- sterilisation
175
list the stages of ovarian cancer
1) limited to ovary/ies
2) spread to pelvic organs
3) spread to rest of peritoneal cavity
4) distant mets/liver parenchyma/lung
176
how may ovarian cancer present, if symptomatic
```
abdo swelling
pain
anorexia, n&v, weight loss
vaginal bleeding
changes in bowel habit
```
177
what are the diagnostic investigations for ovarian cancer
```
pelvic examination
fbc/U&E/LFT
CA125
transvaginal ultrasound
ct to assess peritoneal, omental and retroperitoneal disease
cytology of ascitic tap
surgical exploration
histopathology
cxr
```
178
what is the treatment for ovarian epithelial ca
surgery + chemo (cisplatin and paclitaxel)
| staging lap/TAH/BSO, debulking
179
what is the treatment for non-epithelial ovarian ca
chemo +/- conservative surgery
| palliative
180
what are the peak ages of incidence of cervical carcinoma
30's and 80's
181
what are the histological types of cervical carcinoma
2/3 ssc
| 15% adenocarcinoma
182
what are the risk factors for cervical ca
- hpv 16/18
- sti's
- young age at first intercourse
- multiple sexual partners
- smoking
- long term use of cocp
- immunosuppression/hiv
183
what is CIN
premalignant condition to cervical cancer, occuring at the transformation zone
it is asymptomatic
184
what is the current UK cervical screening programme
first invitation at 25
then 3-yearly until 50
50-65 : 5-yearly
after 65 : selected patients only
185
what is the process for analysing a cervical smear
liquid-based cytology - looking at morphology under microscope
dyskaryosis detected, if borderline/mild: further tests for HPV. If +ve - colposcopy in 8/52
if mod/severe - straight to colptoscopy in 4/52
if suspected invasive ca: colposcopy in 2/52
can perform direct biopsy from here which will give a histological diagnoses of CIN invasion
186
list some of the ways in which cervical ca can present
- IMB
- PMB
- PCB
- blood-stained vaginal dc
if very advanced: fistulae, renal failure, nerve root pain, lymphoedema
187
what are the clinical stages for cervical ca
1) confined to cervix
2) cervix + upper 1/3 of vagina/parametrium
3) pelvic spread, side wall, lower 1/3 vagina
4) distant spread - invade adjacent organs, distant sites
188
what are the treatments for cervical ca according to stage
```
1a) tissue-cone biopsy
1b-2a)radical hysterectomy, chemo/radio
beyond 2a) chemoradiotherapy
post op radiotherapy
lymph node disection
```
189
list some of the side effects of radiotherapy for patients with cervical cancer
vaginal dryness, stenosis
radiation cystitis, proctitis
loss of ovarian function
190
which HPV strains are important in cervical cancer
16, 18, 31, 33, 45
191
what levels do the sympathetic and parasymapthetic nerves that supply the bladder come from
sympathetic: t12-l2
parasymp: s2-s4
( somatic: s2-s4)
192
what is classed as nocturia
voiding >2 times/night
193
what gynae history shouldl be taken in a patient presenting with incontinence
- previous births
- birthweight
- forceps delivery?
- episiotomy
- perineal trauma - grade
194
what should be examined in a patient presenting with incontinence
- obesity
- scars
- abdo/pelvic mass
- visible incontinence
- prolapse
- pelvic floor tone
- cns
195
what are some of the quantitative tools that can be done in a patient with incontinence
- urinalysis
- diaries
- pad tests
- uss/iv pyelogram (for renal tract abnormalities)
- postmicturition uss or catheterisation for residual volume measurement
- cystoscopy, urodynamics/cystometry
- axr for calculi
- methylene dye test for fistulas
- CT + contrast in some cases to look at integrity of ureter
196
what parameters can you assess from cystometry
bladder capacity, flow rate, voiding function
| inserting bladder and PR catheters can measure the difference between abdominal and bladder pressure
197
list some general advice you can give to someone with incontinence
moderate fluid intake, 1,500-2,500ml/day
tea/coffee/alcohol should be reduced/stopped
pelvic floor exercises
commodes/downstairs toilets/bedpans/pads in some
198
list the treatment options for someone with urodynamic stress incontinence
- pelvic floor exercises with physiotherapy
- meds e.g. duloxetine
- urethral injections e.g. collagen, silicone
- surgery; Burch colposspension; tension free vaginal tape
199
list the treatment options for someone with detrusor overactivity incontinence
- drugs: anticholinergics, antidepressants e.g. imipramine, oxybutinin, tolterodine (specific for detrusor muscle muscarinic receptors), solifenacin, trospium
- botulinum toxin injection
- surgery as last resort e.g. urinary diversion
200
list the predisposing factors for prolapse
- age
- menopause
- parity
- obesity
- connective tissue disease
- smoking
201
give the symptoms that someone with prolapse can get
feeling of "something coming down", backache or lower abdo pain,
urinary/faecal incontinence, difficulty with micturition
bleeding/discharge
apareunia
202
what are the treatment options for prolapse
if asymptomatic, may choose to do nothing "watchful waiting"
lifestyle: cough management, stop smoking, constipation, weight loss, avoiding heavy lifting
pelvic floor exercises with physio
pessaries to reduce prolapse
surgery (anterior/posterior/anterior and posterior repair depending on type of prolapse)
203
list some of the complications of surgery for prolapse
```
recurrence
haemorrhage, vault haematoma
vault infection
dvt
new incontinence
uterine and bladder injury
```
204
which structures usually support the pelvic organs
levator eni muscles and endopelvic fascia
205
describe the different types of prolapse
- anterior compartment: urethrocoele, cystocoele, cystourethrocoele
- middle compartment: uterine prolapse, vaginal vault prolapse, enterocoele (herniation of pouch of douglas)
- posterior compartment: rectum prolapses into vagina
206
how would you examine someone with prolapse
speculum + pv when lying down; ask them to cough/strain while slowly removing the speculum
both standing and in left lateral position
determine degree of prolapse
pr may be required to check for rectal prolapse
207
what other problems may prolapse be associated with
bowel: constipation, straining, urgency, incontinence, incomplete evacuation
bladder: incontinence, frequency, urgency, incomplete bladder emptying
208
which procedure is done in bladder/urethral prolapse
colposuspension
209
which procedure is done in uterine prolapse
hysterectomy, sacrohysteroplexy, sacrospinous fixation
210
which procedure is done in recto/enterocoele
colporrhaphy
211
what are some of the complications of a prolapse
recurrence despite treatment
ulceration
uti
retention, incontinence (overflow)
212
define overactive bladder incontinence
involuntary urine leakage due to uncontroleed increases in detrusor pressure, increasinf pressure beyond that of the normal urethra
213
define stress incontinence
involuntary leakage of urine due to intraabdominal pressure beyond that of urethre
214
what does a urinary diary involve
patient keeps record of the time and volume of fluid intake and micturition over a week. gives info on drinking habits, frequency and bladder capacity
215
what do urodynamic tests show in overactive bladder and stress incontinence
- overactive bladder: involuntary detrusor contractions detected on cystometry, causing urine flow
- stress: increased abdo pressure causes increased bladder pressure and causes urine flow
216
what is the management for overactive bladder
- lifestyle modifications
- review drugs affecting bladder
- bladder training - regularity
- drugs: anticholinergics/antimuscarinics
- if postmenopausal, can give oestrogens to reduce effects of atrophy
- botulinum toxin (blocks neuromuscular transmission)
- surgery rarely
217
what is the management of mixed incontinence
management according to whether stress inconctinence or overactive bladder symptoms are most bothersome
218
how can bladder retention cause incontinence
chronic retention of urine in the bladder can increase pressures to the level that it eventually cannot be held any longer and causes overflow
(intermittent self catheterisation often required)
219
what receptors are found in the bladder that are associated with voiding and filling
M3 - parasymp - contraction of detrusor muscle: holding
B3 - symp - relaxation of detrusor muscle: filling
a1 : contraction, filling phase; voluntary skeletal muscle
220
what are the risk factors for candidiasis
pregnancy, diabetes, abx, recently, immunocompromise
221
what are the symptoms of candidiasis
"cottage cheese" dc with vulval irritation and itching. superficial dyspareunia and dysuria may occur
vagina/vulva inflamed and red
222
how is candidiasis diagnosed
culture
223
what is the treatment of candidiasis
clotrimazole (canesten) or floconazole
224
what is the pathophys for bacterial vaginosis (i.e. gardnerella)
when normal lactobacilli are overgrown by a mixed flora including anaerobes, gardnerella and mycoplasma hominis
225
what are the symptoms of bacterial vaginosis
grey-white dc but vagina not red or itchy
| characteristic "fishy odour"
226
how is bacterial vaginosis diagnosed
increased vaginal pH, typical dc, positive Whiff test (KOH), "clue cells" on microscopy
227
what are the complications of chlamydia
as it is often asymptomatic - can cause chronic pelvic infection with tubal dmaage, subfertility and chronic pelvic pain
228
what is reiter's syndrome
chalmydia-associated: urethritis, uveitis and arthralgia
229
what is the diagnostic test for chlamydia
NAAT (nucelic acid amplification test - PCR)
| urine sample for screening
230
which antibiotics are used to treat chalmydia
7/10 Doxycyline +
| 1g stat Azithromycin
231
if there are any symptoms, which symptoms may occur with chalmydia
urethritis, vaginal dc
232
is n. gonorrhoea gram +ve or -ve
-ve
233
what symptoms may occur with gonorrhoea in women
commonly asymptomatic, but may have vaginal dc, bartholinitis, urethritis, cervicitis,
234
what symptoms do men with gonorrhoea develop
urethritis, and can cause bacteraemia, monoaticular septic arthritis too systemically
235
what is the treatment of vaginal warts
podylophillin topically or imiquimod cream
alternatively, cryotherapy or electrocautery if resistent
(HPV vaccine may prevent)
236
which hsv type is most common cause of genital herpes
hsv2
237
what is the presentation of genital herpes
multiple small painful vesicles and ulcers around the introitus
local lymphadenopathy, dysuria, systemic symptoms
238
what type of organism is trichomonas
flagellate protozoan
239
what are the symptoms of trichomoniasis
offensive grey-green dc
vulval irritation
superficial dyspareunia
240
what may the cervix look like on examination of someone with trichomoniasis
punctuate, erythematous - "strawberry"
241
what is the diagnosis of gonorrhoea
culture of endocervical swabs ( + sensitivities), NAAT
242
what is the diagnosis of trichomoniasis
wet film, staining, culture of vaginal swabs
243
what is the treatment for trichomoniasis
metronidazole
244
how does endometritis present
can be post pregnancy, sti, TOP, miscarriage, vaginal instrumentation etc
and symptoms include persistent and often heavy vaginal bleeding, pain, tender uterus, os commonly open, may be offensive smelling dc
+/- septicaemia, fever, dc
245
what is the diagnosis of endomteritis
vaginal/cervical swabs
fbc
uss
246
what is the management of endometritis
broad spec abx
| erpc
247
what is the causative organism for syphillis
treponema pallidum spirochete
248
what are the typical symptoms of primary syphillis
solitary painless ulcer
249
what are the typical symptoms of secondary syphillis (untreated)
weeks later, often with rash, influenza-like symptoms, condylomata (warty growths), variety of systemic symptoms
250
what are the typical symptoms of latent syphillis
many years later - aortic regurg, dementia, tabes dorsalisskin gummata
251
what is the diagnosis of syphillis
enzyme immunoassay (syphilis EIA)
VDRL test
syphillis serology
test from active lesion
252
what is the treatment for any stage of syphillis infection
penicillin
253
what are the risk factors for hiv
multiple partners, unprotected sex
migration from high-prevalence countries (esp subsaharan africa)
ivdu
msm contact
254
what are the symptoms of hiv seroconversion if any
influenza-like illness, with rash
255
what is the definition of AIDS
development of opportunistic infections or malignancy due to much-reduced CD4+ count (<200 cells/mm^3)
256
what is the aetiology of PID
ascending infection of bacteria in the vagina and cervix
can be provoked by instrumentation, TOP, ERPC, , miscarriage. mostly chlamydia/gonorrhoea
(can also occur from descending infections e.g. appendix)
257
what surrounding structures can be affected by PID
endometrium (endometritis), salpingitis, parametritis, fitx hugh curtis
258
what are some of the symptoms of PID, if symptomatic
subfertility, menstrual problems, chronic pelvic pain, deep dyspareunia is a hallmark, abnromal vaginal bleeding/dc
259
what are some of the signs on examination of PID
lower abdo peritonitic signs
adnexal tenderness
"cervical excitation"/"cervical motion tenderness": painful
abscess may even be palpated pv
260
what is the treatment for PID
analgesia: parenteral cephalosporin e.g. IM ceftriaxone, followed by doxycycline or metronidazole
261
what is the treatment for bacterial vaginosis
metronidazole and clindamycin cream
262
what is the treatment for gonorrhoea
IM Ceftriaxone + 1g stat Azithromycin if suspected
| 7-day follow-up
263
list some of the complications of PID
- abscess
- pyosalpinx
- tubal onbstruction
- infertility
- ectopic pregnancy risk increased
264
what happens in chronic PID
perisisting untreated infection causing dense pelvic adhesions, obstruction to fallopian tubes, dilation with fluid (hydrosalpinx), pyosalpinx
265
what are the symptoms of chronic PID
chronic pelvic pain, dysmenorrhoea, deep dyspareunia, heavy irregular mesntruation, chronic vaginal dc, subfertility
266
how is chronic PID diagnosed
TVUS reveals fluid collections in fallopian tubes or surrounding adhesions
laparoscopy is best tool
swabs taken
267
what is the treatment for chronic PID
analgesics and abx if active infection (IM ceftriaxone + PO metronidazole)
adhesiolysis and salpingectomy may be required
268
which drug is given as candidiasis prophylaxis
fluconazole
269
what are some of the precipitants of bacterial vaginosis
- unprotected sexual intercourse
- receptive OI
- perfumed bath products, douching
- menstruation
NOT an STI
270
list the examinations for vaginal dc
- examination
- vaginal ph
- high vaginal swab (culture, wet mount, gram stain)
- endocervical swab (NAAT, culture)
- HSV PCR
271
how can you try and reduce transmission of herpes
condoms, avoid sex when lesions present/prodrome, infrom partners if risk, suprressive aciclover, advise to inform partners, avoid oral sex if oral herpes
272
list the treponemal blood tests for syphillis
- EIA - IgG (screening test)
- TPPA/TPHA (stay positive once exposed)
- IgM - marker of acute infection
273
what is the follow test for syphillis
VDRL
274
list some non-infective causes of ulceration
crohn's
behcet's
apthous ulcers
275
list the steps in which the HIV DNA replicates
```
1- HIV attaches to CD4
2- fusion
3- genomic RNA (reverse transcriptase)
4- replication and budding of mature HIV virion
5- nucleic acid detection : RNA/NA
6- EIA
7- HIV genotype
```
276
discuss some of th einfections more common in patients with AIDS
- bacterial e.g. TB
- fungal e.g. candidia, pneumocystis
- viral: HSV, CMV
- protozoa: toxoplasmossi
- CNS: encephalopathy
- malignancy: kaposi sarcoma, cervical
277
list the different virology tests for HIV
1) antigen detection (Ag)
2) IgM - first response, transient
3) IgG - subsequent response, may persist
278
how may someone with HIV present
- concerned patient after risky event
- acute seroconversion illness
- routine testing - antenatal, AMU, GUM, occy health
- opportunistic infections/AIDS
279
list some of the features of acute seroconversion illness in HIV infection
- fever
- malaise
- arthralgia
- headache
- sore throat
- lymphadenopathy
- rash
280
how is HIV managed
1) HAART
2) HIV monitoring : viral load, CD4 count, genotyping
3) testing for other conditions e.g. Hep B/C
4) treat/prevent opportunistic infections
5) PEP - try to prevent integration of HIV DNA into host DNA
281
what are the different classes of mechanism of action of HAART
- fusion/entry inhibitors
- protease inhibitors
- integrase inhibitoes
- reverse transcriptase inhibitors
(each affect different parts of HIV replication cycle)
triple therapy - combines 3 drugs from two different classes to prevent resistance
282
list the symptoms of acute hepatitis B
fever, RUQ pain, jaundice
malaise, anorexia/nausea,
dark urine/pale stools
fulminant (transplant)
283
what are the features of the hepatitis virus
enveloped, partially dsDNA
284
what does chronic hepatitis B cause
cirrhosis of the liver, HCC
285
describe how the hep B antigens/antibody levels vary according to time
HBsAg - increases over 4-24 weeks (acute)
total anti-HBc if ever been infected
IgM anti-HBc increases from 4-32 weeks
anti-HBs increases after 32 weeks (immunity)
HBe Ag (marker of infectivity)
286
what is the prevention for Hep B
risk factor modification
vaccine 0,1,6 months
neonates: 0/1/2/12 months
post exposure: needlestick, neonates to infected mothers
287
what is the management of Hep B
admit if unwell, refer to infectious diseases/hepatology/GUM
notify prevention of infectious disease
full serology testing
baseline liver tests
288
what advice would you give to someone diagnosed with hep B
risk of transmission
avoid alcohol
breastfeeding okay if baby immunised
antivirals and referral
289
what is the structure of Hep C
enveloped ssRNA
290
what are the clinical features of Hep C
usually asymptomatic
20% clear infection
80% have chronic infection - cirrhosis, hcc
291
what are the serology tests for Hep C
1- anti-HCV (total) for initial screening
2- Ag
3- Ab
4- HCV RNA (if present: infectious, infected)
292
what is the management of Hep C
advice: lose wieght, avoid alcohol, stop smoking
vaccines: hep a/b
if acute: monitor for 3 months to see if it clears itself
drug therapy depends on genotype e.g. interferon and ribavirin is old regime. now, there are many new targeted drugs e.g. sofobuvir, daclatasvir
293
list some of the risk factors for hep a and e
travel - africa, asia, south america
msm
ivdu
294
explain the importance of contact tracing in GUM
course of infection should be traced in order to treat past contacts and break chain of disease. used for most GU diseases except HIV, providing an anonymous and confidential method of contacting sexual contacts of affected patient.
295
how would you investigate a patient with suspected PID
```
urine dipstick, msu
pregnancy test
swab
sti screen: NAAT, ELISA
bloods: FBC/U+E/ESR
uss
laparoscopy
mri/endometrial biopsy/doppler flow studies
```
296
what is the normal frequency of antenatal visits
- for uncomplicated nulliparous: 10
- for uncomplicated parous: 7
incorporate routine tests into visits
297
what tests/investigations are done at each antenatal visit
- bp and urine dip
- from 24 weeks: fundal-symphysis height
- from 36 weeks: check foetal presentation
- routine ctg
-
298
describe the foetal anomaly screening in antenatal care
normally between 18+0 - 20+6
| which allows option to terminate pregnancy, parents to prepare for treatment, specialist care, intrauterine therapy
299
describe screening for down's syndrome
done by end of first trimester (13+6) - combined test of bHCG, PAPPA, nuchal translucency
quadruple test from 14+2 - 20+0: hCG, afp, inhibin A, UE3
cut off of 1/150 for further testing
300
what symptoms would you advise a woman to look out for for preeclampsia
- severe headache
- visual disturbance
- severe pain just below ribs
- vomiting
- sudden swelling of hands
301
around which week are US anomaly scans done in antenatal care
20 weeks
302
what antenatal information is given at the first antenatal visit - booking visit (10 weeks)
- folic acid supplements (400 mcg)
- nutrition, diet, vit d, food hygiène
- pelvic floor exercises
- pregnancy care pathway and place of birth
- breastfeeding workshops
- antenatal classes
- discussion of mental health issues
303
what is examined for at the booking visit of anc
height, weight,
bloods taken
rule out hx of fgm
signs of domestic violence
304
which bloods are taken at booking visit of anc
hb, rhesus status
ab's, syphillis, hep b, hiv, rubella
sickle cell/thalassaemias Ihigh risk ethnicities)
gtt if at high risk of diabetes
305
when is a dating scan done
between 8 and 14 weeks
306
list the risk factors for gestational diabetes
- bmi>30
- prev macrosomic baby >4.5kg
- fhx of diabetes 1st deg relative
- high risk ethnicity groups
- htn, preeclapmsia hx
307
what is offered for hep B positive pregnant women
post natal intervention for baby
308
at which week/s is anti-D given
28 and 34(?)
309
what information is given to woman at 36week anc visit
```
breastfeeding information
birth plan review
recognition of active labour
care of new baby
newborn screening tests
vit K prophylaxis
post natal self care
awareness of PND
```
310
list some of the common symptoms of pregnancy
- nausea and vomiting
- heartburn
- constipation
- haemorrhoids
- vaginal discharge
- varicose veins
- backache
- tiredness
311
how is pregnancy after 41 weeks managed
membrane sweep
induction of labour
ctg monitoring
312
what advice is given to women postnatally
advice about physical and emotional wellbeing
coping strategies and support
experiencing common health problems
encourage to report concerns
313
what steps can be taken to look after women preconceptually
```
rubella check +/- vaccine
manage chronic disease
meds review
routine preconceptual daily folic acid
advice on smoking/drinking/drugs
```
314
what happens at the booking visit (10 weeks) in anc
history and examination, risk assessed
LMP
past obstetric - stillbirth, preeclampsia, gestational diabetes
past gynae - smear, subfertility, prev surgery
examination: bmi, bp, abdo exmination, heart auscultation
decisions made about type and frequency of care
315
at how many week's gestation is the uterus usually palpable
12 weeks
316
what is assessed for women 11+0 - 13+6 weeks antenatally
crown rump length
uss - detect multiple pregnancy, chromosomal abnormalities, nuchal translucency scan in conjunction with combined test: Bhcg, PAPPA
317
list the medical conditions it is important to ask about in anc
```
htn, diabetes, cvs disease
vte, autoimmune disease, haemoglobinopathy
renal disease
depression/mental health
(+ any medications they are on)
```
318
who is advised for vit D administration in anc
bmi > 30
certain ethnicities: south asian, afrocaribbean descent
those found to be vit d deficient
319
what lifestyle advice would you give to a pregnancy woman
- stop smoking/alcohol/elicit drug use
- well balanced diet (around 2500 kcal)
- coitus not CI unless rupture of membranes or placenta preavia
- only use pasteurised milk, avoid soft and blue cheeses, well cooked food
- avoid contact sports
- seat belt worn above the bump
320
what is the preparation for the run up to birth in antenatal care
- antenatal classes
- informed choice about intrapartum and postpartum care
- intrapartum techniques for posture, breathing, and pushing
321
what week is gtt done in patients with increased risk of gestational diabetes in anc
28
322
how is VTE prophylaxis managed in pregnant women
weight and risk factors taken into account - if 3 or more (?) present, put on prophylactic sc lmwh injections
prophylactic dose calculated acocrding to booking weight
323
when do pregnant women on vte prophylaxis stop taking it
24 hours prior to c-section
| onset of labour
324
how long is vte prophylaxis continued post partum
up to 6 weeks
325
at how many weeks are results of antenatal screening tests reviewed
16
326
if the antenatal downs screening test is missed, what are the women offered
triple/quadruple test
327
what happens at the 28 weeks antenatal visit
fundal height is measured, fbc and antibodies checked
gtt if indicated
anti-D given in Rh-ve women
328
what is checked at 31 week anc
blood results from 28 week appointment
329
what is done in 36, 38 and 40 week anc
fundal height measured, lie of foetus, presentation checked, (referred for ecv if breech)
330
what is done at 41 week anc
fundal height measured, foetal lie and presentation checked,
membrane sweep offered, and induction of labour offered at 42 weeks
331
what vaccines may be offered to women during pregnancy
- flu vaccine
| - whooping cough (pertussis) during weeks 28 and 38 of pregnancy
332
outline the antenatal care management of women with diabetes in pregnancy
(+ve urine dip for glucose or gtt may alert you)
- refer to diabetes and antenatal clinic
- assessment of blood glucose control every 1-2 weeks
- offer retinal assessment at 16 weeks
- 20 week anomaly scan
- 36 week advice about birth
(advise that they may be at higher risk of developing diabetes later in life)
333
what advice can be given to a woman preconceptually
explain importance of establishing good glycaemic control
offer self-monitoring of glucose levels
dietary advice, weight loss,
folic acid to prevent ntd's
334
list some of the ways in which gestational diabetes is managed
```
regular monitoring
dietary changes
metformin
(isophane) insulin
discontinue any other glucose lowering drugs
```
335
what parameters are used to diagnose gestational diabetes
- fasting plasma glucose 7mmol/l or more
| - 2-hr plasma glucose 7.8mmol/l or more
336
what is the risk associated with gestational diabetes during labour
shoulder dystocia
337
what can congential abnromalities be due to
inherited defects
chromosomal abnormalities
intrauterine infection
drug exposure, teratogens
338
what marker is raised in ntd's
afp
339
which trisomies are screened for antenatally
21, 13, 18
340
describe amniocentesis
a diagnostic test, where there is removal of amniotic fluid with the use of a fine guage needle under us-guideance.
it enables prenatal diagnosis of congenital abnormalities
341
what is the miscarriage risk in women undergoing amniocentesis
1%
342
describe chorionic villous sampling
biopsy of trophoblast by passign a fine-guage needle through abdo all or cervix into the placenta after 11 weeks
used to diagnose chromosomal problems,
343
list the risk factors for down's syndrome
- high maternal age
- prev affected baby
- thickened nuchal tranparency. structural abnormalities, shortened nasal bone, tricuspid regurg on uss
344
what is the pathophysiology of ntd's
failure of closure of neural tube - causes neural tube tissue to often be exposed, causing degeneration
spina bifida and anencepahly are most well known forms
345
what is the normal dose of folic acid given to pregnant women in first trimester/preconceptually in order to prevent ntd's
0.4mg/daily
346
what is the in utero treatment for babies with arrhythmias
flecainide, digoxin
347
what can diaphragmatic hernias in babies cause as a consequence
pulomnary hypoplasia
348
list some gi defects that can occur in foetuses
- gastroschisis, exomphalmos
- oesophageal atresia and tracheooesophageal fistula
- duodenal atresia (double bubble sign)
- lower gut atresia (dilated bowel)
349
list the causes for foetal hydrops
1) immune - anaemia, haemolysis (rh disease)
2) chromosomal abnormalities e.g. trisomy
3) pleural effusions/other structural abnormlaities
4) cardiac - abnormlaities, cardiac failure
5) twin-twin transfusion syndrome
350
how is foetal hydrops investigated
```
uss, echo
mca assessment
maternal blood for kleihauer test
foetal blood sampling
amniocentesis for karyotyping
```
351
when is a baby considered small for date/small for gestational age
<10th centile
352
what is foetal distress
acute situation such as hypoxia, in which normal growth and development are not optimal
353
what is foetal compromise
chronic situation when conditions of normal growth and development are not normal
354
what is placental dysfunction
poor nutrient transfer across placenta - commonly there is iugr
355
list some of the methods of foetal surveillance
1) symphysis-fundal height
2) uss
3) doppler umbilical waveform
4) doppler waveform of foetal circulation looking at major foetal vessels e.g. mca
5) hfr, ctg
6) ask if kicking/movements are normal
356
list some of the causes of sga/iugr
```
consitiutional
preexisting maternal disease, maternal pregnancy complication e.g. preeclampsia, multiple pregnancy
smoking, durgs, alcohol
infections e.g. cmv
malnutrition
```
357
how is sga investigated
```
uss
doppler umbilical artery
mca blood flow
ctg
oligohydraminos?
```
358
how is sga managed
- if small but consistently-gorwing with normal investigations, leave alone
- if abnormal investigations at term - c section or induction
- if preterm and abnormalities - admit and monitor, give steroids, deliver beyond 34 weeks
359
when is a pregnancy classed as "prolonged"
42 weeks or more
360
what is the risk of prolonged gestation
increased risk of stillbirth, foetal distress
361
list some of the risk factors that may prompt you to give vte prophylaxis antenatally and for 7 days after delivery
(3 or more risk factors)
```
age > 35
mbi >30
parity >4
varicose veins
immobility
certain medical disorders
dehydration/excessive blood loss
surgery in pregnancy
long haul travel
preeclampsia
midcavity instrumental delivery
prolonged labour
```
362
list the risk factors that would prompt you to give vte prophylaxis antenatally and for 6 weeks after delivery
- prev vte
- lupus
- protein c/s deficiency
- factor v leiden, or prothrombin gene
- antithrombin deficiency
363
list some of the symptoms that may be found in the history of someone with ectopic pregnancy
- rif/lif pain
- irregular pv spotting/bleeding
- fainting, dizziness
- shoulder tip pain
364
list the risk factors for ectopic pregnancy
- previous ectopic pregnancy
- tubal surgery
- tubal pathology
- prev pid/endometriosis
- iucd, pop if fails
365
list some of the site, apart from tubal ,where an ectopic pregnancy can implant
ovarian, abdominal, uterine scar
366
what is the management of ectopic pregnancy
- methotrexate if criteria met
| - surgery if medical criteria not met/ clinically unwell: laparoscopy/laparotomy -> salpingectomy/otomy
367
what is the definition of recurrent miscarriage?
loss of 3 or more consecutive pregnancies
368
list some of the causes for recurrent miscarriage
- chromosomal abnormalities
- genetic defects
- antiphospholipid syndrome, other rheum conditions
369
what is the management of miscarriage
conservative, medical or surgical
conservative: waiting for products of conception to pass naturally, with 24 hr access to gynae service
medical: day 1 mifepristone and day 3 misoprostol
surgical: evacuation of retained products of conception (erpc) - use of suction curette to empty uterus; alternatively dilation and curettage
370
what are the adv and disadv of conservative management of miscarriage
adv: avoids risk of surgery/medication
disadv: pain and bleeding can be unpredictable, takes longer, may be unsuccessful
371
what are the adv and disadv of medical management fo ectopic pregnancy
adv: avoids surgical complications and high patient satisfaction if successful. can be done as outpatient
disadv; pain and bleeding may be unpleasant
372
what are the adv and disadv of surgical managment of ectopic pregnancy
adv: provides closure, planned procedure
| disadv; surgical/anaesthetic, perforation, bowel/bladder/cervix damage, asherman's, cervical weakness
373
what is a threatened miscarriage
bleeding and pain up to 24 weeks with a viable ongoing pregnancy. cervical os closed
374
what is an inevitable miscarriage
cervical os open
| poc have not yet been passed, but they inevitably will
375
what is an incomplete miscarriage
com poc have been passed, but some clots and tissues remain within the uterus
cervical os open
(if infected -> septic)
376
what is a complete miscarriage
all products of conception have been passed, and bleeding and pain start reducing. cervix is now closed (uss shows empty cavity)
377
what is the aetiology for miscarriage
most cases cause is not established
chromosomal abnormalities, congenital abnormalities
maternal disease, uterine abnormalities, acute illness/infection, poorly controlled diabetes, thrombophilia/antiphospholipid synd
378
what are the risk factors for miscarriage
```
advanced maternal age
previous miscarriage
smoking, alcohol, drugs
folate deficiency
consanguinity
```
379
what is trophoblastic disease
spectrum disorders arising from disorders of trophoblastic development arising from abnormal implantation
380
what is the presentation for trophoblastic disease
- bleeding/haemorrhage
- severe nausea and vomiting
- uterus large for dates
381
what is the risk associated with trophoblastic disease
potentially premalignant - molar pregnancy, hydatidiform mole, complete mole -> can become invasive mole/choriocarcinoma
382
what is the management of trophoblastic disease
surgical erpc
| register with one of the three national gestational trophoblastic disease centres
383
how can you manage the psychological implications of miscarriage
give info/leaflets
encourage discussion
counselling and support
384
what are the features of true hyperemesis gravidarum
severe dehydration, deranged bloods, marked ketosis
| weight loss and nutritional deficiency may be a feature
385
at which weeks of gestation does hyperemesis gravidarum usually occur
6-20
386
what investigations would you order in a patient with hyperemesis gravidarum
- urine: pt/ketones/uti
- fbc: haematocrit
- U+E: K+ especially
- lft/amylase
- tft
- uss to exclude trophoblastic disease, multiple pregnancy
387
what is the management for hyperemesis gravidarum
- rehydration - not with glucose
- thiamine replacement
- antiemetics parenterally
- ranitidine
- thromboprophylaxis
- rarely: steroids
388
list the different types of miscarriage
- threatened
- inevitable
- incomplete
- complete
- septic
- missed
389
what is a missed miscarriage
foetus has not developed, or has died in utero. this si not recognised however by the body, and it carries on "thinking it's pregnant". os closed
390
how are missed miscarriaged picked up
uss, bleeding occuring eventually
391
what investigations are carried out in miscarriage
- uss to show foetus in uterus or not, and if viable
- hcg blood levels (increases in viable pregnancy, then plateus once very high)
- fbc and rhesus group
392
what can be given to prevent bleeding in miscarriage
ergometrine
393
what is done with a viable foetus with threatened miscarriage
no intervention proven to prevent miscarriage
394
what are the complications of miscarriage
heavy pv bleeding
shock - causes multisystem failure
ashermans syndrome
395
how should you counsel a patient who has had a miscarriage
tell them that the miscarriage is not a result of something they did or didnt do
could not have been pregnant
reassure that there is a high chance of successful further pregnancies
referral to support group e.g. miscarriage association
only further investigations if recurrent
396
list some of the grounds for which a termination of pregnancy is acceptable
continuance of pregnancy would be a risk to life of pregnant woman, would cause permanent physical or mental health problems
pregnancy not exceeded 24 weeks and continuance would involve risk
substantial risk that is child were born it would suffer from physical and mental abnormalities
397
what are the methods of TOP
bloods: taken for hb, blood group, rhesus status, haemoglobinopathy
medical: mifepristone + misoprostol/gemeprost
surgical: curettage, dilatation and evacuation (with antibiotic cover)
398
what is the mechanism of action of mifepristone
antiprogesterone
399
what is the mechanism of action of misoprostol
prostaglandin
400
what are the complications of TOP
haemorrhage, infection, uterine perforation, cervical trauma, failure, psychological sequelae
401
what may be found on examination of a woman with ectopic pregnancy
- tachy
- hypotension
- collapse
- usually abdo and often rebound tenderness
- movement of cervix o/e can cause pain
- adnexa may be tender
402
what investigations would you do in someone with suspected ectopic
- pregnancy test - urine hcg
- uss (preferably tvus) may or may not be able to visualise the pregancy, can show free fluid in the abdomen
- quantitative serum hcg: slower-rising or lower levels in ectopic compared to viable
- laparoscopy
403
how do you monitor if treatment for ectopic pregnancy has worked
hcg levels should fall
404
can you treat a ruptured ectopic with medical management
no
405
which antiemetics are given in hyperemesis gravidarum
- cyclizine
- metoclopramide
- ondansetron
406
how is herpes zoster managed in affected pregnant women
immediate po acicolovir
| chicken pox can be teratogenic
407
what can parvovirus in utero cause
suppressed erythropoeisis: anaemia
408
what are the risks of group B strep in pregnancy
neonate can become infected after membrane rupture, especially if preterm
409
what is given to prevent vertical transmission of group B strep in pregnancy
iv pencilllin
410
which infections are screened for in TORCH screen
- toxoplasmosis
- rubella
- cmv
- herpes simplex
411
what can result from infection of a pregnant woman with cmv
childhood handicap, deafness
412
what is the management for herpes simplex in pregnancy
referral to gum clinic
woman needs aciclovir in late pregnancy
neonate may require aciclovir if exposed
c-section recommended if attack delivery within 6 weeks of attack
413
what are the complications of rubella in pregnancy for the baby
deafness, cardiac disease, eye problems (cataracts)
414
what is the management of rubella in pregnancy
mother offered termination if infected early in pregnancy
| screening at booking
415
what is the causative organism for toxoplasmosis
protozoa toxoplasma gondii
416
what are the effects of toxoplasmosis in pregnancy for the baby
mental retardation, convulsions, spasticities, visual impairment
417
what is the management for toxoplasmosis in pregnancy
education to avoid infection
| spiramycin
418
what is the definition of gestational hypertension
new hypertension, bp > 140/90, after 20 weeks of gestation
419
what is the definition of preeclampsia
hypertension and proteinuria appearing in second half od pregnancy, with/without oedema
420
what is the definition of preexisting hypertension in pregnancy
high bp either before pregnancy, or before 20 weeks gestation, or woman already on antihypertensive medicine
421
what is the only cure for preeclampsia
delivery
422
what is preeclampsia thought to be due to
increased vascular resistance causing htn
increased vascular permeability causing proteinuria
reduced cerebral perfusion -> eclampsia
423
what are the principal risk factors for preeclampsia
1) nulliparity
2) previous hx
3) fhs
4) older maternal age
5) chronic hypertension
6) diabetes
7) twin pregnancies
8) autoimmune disease
9) renal disease
10) obesity
424
how is preeclampsia investigated, apart from bp
- urine dip
- protein:creatinine ratio
- 24 hour collection of urine
- bloods (hellp): fbc, U+e, lfts, platelet count, clotting
- ctg, doppler umbilical artery
425
how may preeclampsa present
usually asymptomatic - but headaches, drowsiness, visual disturbance, nausea, vomiting, epigastric pain at later stage
426
what may be found on examination of a patient with preeclampsia
increased bp
oedema
epigastric tenderness
urine dipstick for positive proteins
427
what are the maternal complications for preeclampsia
```
grand mal seizures (eclampsia)
cerebrovascular haemorrhage
HELLP syndrome (liver and coagulation problems)
renal failure
pulmonary oedema
```
428
how are gran mal seizures from eclampsia treated
magnesium sulphate, intensive surveillance
429
what are the foetal complications of preeclampsia
- increased morbidity and mortality
- iugr if 34 weeks
- placental abruption
- preterm birth
- hypoxia/distress
430
what are the components of HELLP syndrome, which can result as a complication of preeclampsia
- haemolysis
- elevated liver enzymes
- low platelet count
431
what can occur as a result of HELLP syndrome
dic
liver rupture
liver failure
432
what can be given to women at risk of preeclampsia
aspirin to help placental function, from 16 weeks gestation
433
what warrants admission in preeclamptic women
- symptomatic
- 2+ protein on dip
- bp >160/110 (severe preeclampsia)
- suspected foetal compromise
434
which antihypertensive drugs can be given to women with preeclampsia
- labetolol
- methyldopa
- nifedipine
(magnesium sulfate for treatment/prevention of eclapmsia)
- steroids may be given if baby <37 weeks?
435
when is labetolol contraindicated for preeclampsia
if woman has asthma
436
what are the rules for monitoring, admitting or delivery for preeclampsia
- if just htn - monitor for foetal compromise and induce by 40 weeks
- mild preeclampsia - deliver at 37
- severe preeclampsia - steroids if <37, admission and surveillance, ctg, fluid balance, frequent blood testing
- if severe preeclampsia + complications/foetal distress - deloivery whatever the gestation
437
describe the postnatal care that should be given to women with preeclampsia
- may worsen during this time
- monitor liver enzymes, platelets, and renal function closely (low platelets usually return to normal within a few days)
- fluid balance monitoring essential
- cvp monitoring may be required
- bp maintained at around 140/90
- b blockers, nifedipine, acei postpartum
- bp monitoring after dc
438
list some of the complications after eclampsia for the foetus
- placental abruption
- stillbirth
- iugr
- miscarriage
439
list some of the foetal complications of gestational diabetes
- increased risk of congenital abnormalities, and cardiac defects
- preterm labour
- macrosomia
- polyhydramnios
- dystocia and birth trauma
- foetal compromise, distress, sudden death
440
what are the maternal consequences of gestational diabetes
- increased preeclampsia risk
- retinopathy often worsens
- hypos/dka if not well controlled
- infections more likely after delivery
441
what is the monitoring for gestational diabetes
uss to monitor foetal growth and size
umbilical artery doppler if preeclampsia
retina screen, renal function screen
apsirin daily to reduce risk of preeclampsia
442
what is advised in terms of delivery for gestational diabetes
- deliver by 39 weeks
| - if > 4kg, c section
443
what may be the complications of a neonate born to a mother who had gestational diabetes
- hypoglycaemia
| - respiratory distress
444
how is gestational diabetes detected
at 28 weeks with gtt, if risk factors present
445
what are the risk factors for developing gestational diabetes
- high bmi
- previous large baby
- first degree relative with diabetes
- unexplained stillbirth
- certain ethnicites e.g. afrocaribbean, south asian, middle eastern
446
is warfarin given in pregnancy
no -teratogenic
447
how should pregnant women with epilepsy be managed
antiepileptic drug review - ideally preconceptually
avoid sodium valproate
lamotrigine and carbamazepine and (keppra?) are safe in pregnancy
folic acid supplements
448
how should a pregnant woman with thyroid problems be managed
replacement with thyroxine
ptu for hyperthyroidism kept at lowest possible dose as it crosses the placenta
post partum thyroiditis can increase risk of pnd
449
what are the obstetric complications of antiphospholipid syndrome
- placental thrombosis
- recurrent miscarriage
- iugr
- early preeclampsia
450
how are pregnant women with antiphsopholipid syndrome managed
aspirin and lmwh
serial uss
elective induction of labour at term
postnatal anticoag to prevent vte
451
list some prothrombotic diseases that can affect pregnancy
protein c/s deficiency
factor v leiden
(both treated like antiphospholipid syndrome, especially inportant to anticoagulate)
452
how is renal disease in pregnancy managed
screening for uti's
uss foetal growth
measure renal function
control htn
453
how soon after delivery can postpartum thromboprophylaxis be started
24 hours if not haemorrhaginf
454
which conditions does high bmi predispose to in pregnancy
vte
gestational diabetes
preeclampsia
macrosomia, miscarriage, prematurity
455
what is the management of high bmi pregnancies
- high dose preconceptual folic acid
- vit d recommended
- thromboprophylaxis considerations
456
what may be considered in pregnant women who are using illegal drugs
mdt, social support
| care order in some
457
what are the types of anaemia in pregnancy
- physiological/dilutional
- iron deficiency
- folic acid and b12 deficiency
- sickle cell disease
- thalassaemia
458
how are hiv-infected pregnant women managed
```
referral to specialist regional centre
haart - especially zidovudine
c section instead of vaginal birth
do not breastfeed
intrauterine events e.g. ecv are avoided
```
459
what is the definition of preterm delivery
if it occur between 24-37 weeks gestation
460
list the complications of preterm delivery
- prematurity and its complications for the baby
- infection
- endometriosis
461
list the aetiology behind preterm delivery
- factors within the placenta e.g. multiple pregnancy, preeclampsia, polyhydramnios
- iugr
- infection
- structural problems e.g. uterine abnormalities, fibroids, congenital abnormalities
- cervical weakness/ "incompetence"
462
what does antenatal infection cause
- offensive liqour, chorioamnionitis
- neonatal sepsis
- endometritis
463
what are the risk factors for antenatal infection
bacerial vaginosis
| group b strep infection
464
how may preterm delivery be prevented
- cervical suture insertion if cervical incompetence
- progesterone suppositories
- screening and treatment of stis and infections
- amnioreduction for polyhydramnios
465
what investigations would you order in a patient with preterm delivery
- ctg
- tvus of cervical length
- high vaginal swabs to look for infection with sterile speculum (be careful as passing speculum is not always indicated)
466
what is the management of preterm delivery
- steroids before 34 weeks
- delivery - vaginal prefered, c section if obstruction
- forceps rather than ventouse detected
- abx for delivery
467
what is the definition of preterm rupture of membranes
membrane rupture <37 weeks gestation
468
list the complications of PPROM
- preterm delivery
- infection of foetus or placenta (chorioamnionitis, endometritis, sepsis)
- prolapse of umbilical cord
469
why should you avoid a pv/speculum examination in a patient with PPROM
avoid introducing infection
470
what are the symptoms/signs of chorioamnionitis
contractions, abdo pain, fever, tachy, uterine tenderness, coloured or offensive liquor
471
what are the investigations you would do on someown with pprom
- baby monitoring: ctg, fhr, uss doppler
- high vaginal swab - fbc, crp
- amniocentesis for chorioamnionitis
- DO NOT perform pv examination as you could introduce infection
- sterile speculum examination in some cases
- look for amniotic fluid draining
472
what is the management for pprom
balance of risk of preterm delivery
admission onto ward, close maternal and foetal surveillance
give steroids
prophylactic erythromycin
if chorioamnionitis - give imediate iv abx and deliver
473
list the risk factors for pprom
```
smoking, ilicit drug use
previous preterm delivery
pv bleeding any time during pregnancy
lower genital tract infection
multiple gestation
cord prolapse, abruption
```
474
why is group b strep infection important in pregnancy
significant cause of severe early onset infection in newborns
475
is there screening for gbs in pregnancy
no - not proved effective
| however if detected on high vaginal swab/ previous infection in pregnancy, can give abx in later stages of pregnancy
476
what is the treatment of gbs in pregnancy if positive
benzylpenicillin
477
what are the complications of pprom
- prematurity
- sepsis
- umbilical cord prolpase
- stillbirth
- placental abruption
- pph/haemorrhage
- infection
478
what are the different types of chrionicity and zygosity
dizygotic: different oocytes, different sperm
monozyogtic: mitotic division of zygote into identical twins
dichorionic diamniotic: two separate placentas and amnions
monochorionic diamniotic: shared placenta, separate amniotic sacs
monochorionic monoamniotic: shared placenta and shared amniotic sac
479
what are the antipartum complications associated with multiple pregnancy
maternal: gestational diabetes, preeclampsia, anaemia
foetal: mortality, longer term handicap risk, preterm delivery, iugr, miscarriage, co-twin death
480
describe what twin twin transfusion syndrome is
only in monochorionic diamniotic twins - results from unequal distribution of blood through anastomoses of shared placenta
the "donor" is volume deplete and develops iugr, whereas "recipient" gets volume overload
481
what are the more common intrapartum risks in twin pregnancies
malpresentation
foetal distress
pph
482
what is the antepartum management of twin pregnancy
pregnancy considered high risk
- iron and folic acid
- screening for chromosomal abnormalities
483
what is the intrapartum management of twin pregnancy
c-section offered or induction at 37-38 weeks
foetal monitoring with ctg
ecv can be performed in second twin if not in longitudinal lie
after delivery, propylactic oxytocin due to risk of pph
484
what is propess
prostaglandin pessary given to help induce labour
485
what are the complications with twin pregnancy in first trimester
- hyperemesis, increased miscarriage risk, anaemia
486
what are the complications of twin pregnancy in second trimester
- iugr, tts, gestational htn, diabetes, anomalies, preeclampsia, oligo/polyhydramnios, cord entalngement
487
what are the complications of twin pregnancy during / peri-delivery
aph/pph
stillbirth
preterm delivery, preterm labour
abruption
488
what is the definition of antepartum haemorrhage
bleeding from genital tract after 24 week's gestation
489
what are the main causes of aph
- unknown
- placenta preavia
- placental abruption
490
describe placenta praevia
occurs when the placenta is implanted in the lower segment of the uterus
(classified by proximity of placenta to cervical os)
491
what are the complications of placenta praevia
aph
pph
obstruction of foetal head engagement therefore needing c section
492
what is associated with placenta praevia
- intermittent painless bleeds
- breech presentation
- abnormal lie
- foetal head not engaged
493
should you attempt a pv in someone with placenta praevia
no -can cause bleeding
494
what are the investigations for placenta praevia
- fbc, clotting, x match
- ctg
- uss
495
what is the management for placenta praevia causing aph
- admission due to risk of massive haemorrhage
- anti D if rh-ve
- have appropriate bloods on the ready for transfusion if needed
- steroids if < 34 weeks
- c section delivery if term/emergency
496
describe what placental abruption is
part or all of the placenta separates before delivery of the foetus
significant maternal haemorrhage can occur behind the placenta
497
is bleeding always obvious in placental abruption
no - because some of it can clot behind where the placenta separates therefore does not always present with pv bleeding
498
what are the presenting features of placental abruption
painful bleeding
bear in mind bleeding not always seen
tachy/other signs suggesting shock
uterus tender and often contracting "woody"
499
what are the risk factors for placental abruption
```
prev hx
iugr
preeclampsia
htn
maternal smoking
```
500
how is placental abruption usually diagnosed
on clinical grounds
| uss may not detect the placenta praevia and can blood clot be mistaken for placenta
501
what is the management for placental abruption causing aph
- resuscitation
- blood transfusion considered
- anti d if rh-ve
c-section if foetal distress
if no foetal distress and over 37 weeks - induction
steroids if <34 weeks and no foetal distress, with minimal abruption
502
what is the definition of foetal lie
relationship of ofetal long axis to the long axis of the uterus
503
what are the different presentations of a foetus
cephalic, breech, other body part
504
list some causes of frequently-changing foetal lie
polyhydramnios
multiparity - lax uterus
associated with placenta praevia
505
what are the complications of abnormal lie
if head or breech cannot enter the pelvis, labour cannot deliver the foetus.
an arm or umbilical cord may prolapse when the membranes rupture - and can cause uterine rupture eventually
506
what is the management of abnormal lie
if <37 weeks, no management unless woman is in labour
if in labour, admit
if >37 weeks, usually admitted to hospital in case membranes rupture - will need to be monitored and need medical input to deliver
the abnormal lie may stabilise itself, and ecv usually doesnt work
507
how is abnormal lie and breech investigated
head usually palpated at fundus, or elsewhere not in lower uterus
uss confirms position of baby
uss to look for placenta praevia
508
what are the complications of breech presentation
```
will often require c-section
head entrapment can cause foetal death
fetal abnormalities more common
cord prolapse
intracranial haemorrhage, internal injuries
```
509
describe external cephalic version
attempt made to turn baby to cephalic presentation, with about 50% success rate
performed in hospital under uss guidance, with a ctg straight after
cannot be done if memrbanes have already ruptured
510
what is given when ecv is performed
anti d if rh-ve
511
is ecv usually safe
yes - very few will require emergency c section
| those who are rh-ve will reuiqre anti-d as a precaution
512
when is ecv contraindicated
compromised foetus, membranes ruptured, aph, where vaginal delivery is contraindicated
513
how is breech managed
ecv may be tried, but if this fails/is ci'd then you can deliver by c-section
very few delivered vaginally
514
why is it important to catheterise a woman whom you are going to perform a c-section on
must empty the bladder first - ensure that it is small and less likely to be damaged during a csection
also if they are under spinal/epidural they are less likely to feel the sensation of needing to void
515
what is the definition of labour
progressive effacement and dilatation of the cervix
516
what is "show" in labour
cervical mucus plug - white or pinkish in colour
517
what is the 1st 2nd and 3rd stage of labour
1st: onset of labour to full dilatation
2nd: full dilatation to delivery of foetus
3rd: delivery of foetus to explusion of placenta
518
how long should the 3rd stage of labour be
up to 30 mins
519
which factors affect labour in women
- passage: bony and soft tissues
- powers: contraction rhythm and strength
- passenger: size, lie, attitude
520
what is the "attitude" in which a baby presents during labour
relation of foetal head to trunk (e.g. flexed, indifferent, deflexed)
521
what is the "position" in which a baby presents during labour
relation of foetal "denominator" e.g occiput, mentum, etc, to the maternal pelvis
e.g. - occipito-anterior, occipitoposterior, occipitotransverse position
522
what is the "presentation" of a foetus
part of the foetus lowermost in the uterus e.g. cephalic, vertex, brow, face, breech, shoulder etc
523
what are the steps in the mechanism of labour
- engagement
- flexion
- descent
- internal rotation
- extension
- external rotation
524
what is the monitoring you would undertake in labour
maternal: obs, hydration status, pain, bladder, position
progression: contractions, dilatation, descent of presenting part
3rd stage: bleeding
foetal: heart monitoring, colour of liqour
525
what is the management of 3rd stage of labour
oxytocics, ergometrine
controlled cord traction
perineum
526
list the common problems occurring in labour
- failure to progress
- malpresentation/malposition
- suspected foetal compromise
- vbac
- operate delivery
- shoulder dystocia
527
what are the "powers"-related causes of failure of progression of labour
- insufficient uterine activity/tone
- hypotonic ocntraction
- incoordinate contractions
- exhaustion, dehydration
528
what are the "passage"-related causes of failure of progression of labour
- abnormal bony pelvis
- cervical dystocia
- rigid perineum
529
what are the "passenger"-related causes of failure of progression of labour
- macrosomia
- abnormal attitude, presentation or position
(occipitoposterior malpositioning)
530
what is the management for 'powers'- related failure to progress
hydration, analgesia,
amniotomy
oxytocin infusion
delivery by other means if appropriate
531
what is the management of "passage"- related failure to progress
c-section
| episiotomy if perineum rigid
532
what is the management of 'passenger'-related failure to progress
c-section
| instrumental delivery
533
what are the ways in which to induce labour
1) membrane sweep
2) prostaglandin e2 (propess) - slow release prostaglandin pessary
3) amniotomy (arom)
4) syntocin (oxytocin)
5) if miscarriage - mifepristone + misoprostol
534
what signs/investigation findings would alert you to foetal compromise
- passage of meconium
- non-reassuring ctg
- foetal scalp bloods showing acidosis to confirm
535
what are the features of a non-reassuring ctg
- baseline tachy/brady
- decreased beat to beat variability
- absence of acceleration
- presence of decelerations (below baseline, take a long time to pick up etc)
536
list the causes of foetal compromise in labour
- uterine hyperstimulation e.g. iatrogenic
- hypotension
- poor foetal tolerance of labour e.g. iugr
- cord compression
- infection
- maternal disease
537
what is the management for foetal compromise in labour
rectify possible causes e.g if maternal hypotension, can put her in left lateral position
stop oxytocics
foetal blood scalp sample
deliver by speediest route if unable to correct acidosis
538
what is the overall success rate of successful vaginal birth after c section
70%
539
what are the risks associated with vbac
- need to convert to c section
| - uterine scar dehiscence/rupture
540
what are the precaution steps/ investigations done for vbac patients
- iv access, g+s
- continuous electrical foetal monitoring
- avoid prolonged labour
- senior should make decision about whether augmentation/induction needed
541
what are the different types of operative vaginal delivery
forceps, ventouse
542
what are the indications for forceps/ventouse delivery
- failure to progress to second stage
- foetal distress in second stage
- maternal reasons e.g. tired
543
what are the prerequisistes for forceps/ventouse delivery
full diltatation
cephalic presentation
presenting part engaged
544
what are the complications of forceps/ventouse delivery
- failure
- maternal/foetal trauma
- postpartum haemorrhage
- urinary retention
545
list the risks of c section
- anaesthetic risks
- infection
- bleeding, may reuqire transfusion
- vte
- accidentally cutting baby
- damage to surrounding tissues (needs cath)
546
what are the indications for c section
- failure to progress
- foetal distress
- maternal reasons
- malpresentation/malposition
- failed instrument delivery
547
what is the definition of shoulder dystocia
inability to deliver shoulder after delivery of head
| anterior shoulder does not enter pelvic inlet
548
what are the complications of shoulder dystocia
foetal asphyxia
foetal death
birth trauma e.g. erb's palsy, fractures (esp. clavicle)
maternal trauma
549
which pregnancies are at risk of shoulder dystocia
macrosmoic foetus
foetus of diabetes mother
rotational instrumental delivery
550
what is the management of shoulder dystocia
- episiotomy
- mcroberts position with suprapubic pressure
- other obstetric manoeuvres
- symphisiotomy last resort
551
what are the different modes for intrapartum foetal monitoring
- fhr
- ctg
- foetal blood sampling (tests ph and lactate)
552
list the different types of intrapartum analgesia
- entonox
- im opiates (pethidine)
- remifentanil pca
- epidural
- combined spinal-epidural
- local
553
what is the success rate for epidural in labour
95%
554
what are the side effects of epidurals in labour
```
dizziness, transient hypotension
dural tap (accidentally going through dura), causing headache
```
555
what is the bishop score in labour
quantifies ripeness of cervix, station, effacement, dilatation, position of uterus
556
how is foetal station evaluated in labour
compare head of foetus to position of ischial spines (pelvic inlet)
0 = at ischial spines, with range of -3 to +3 (from far away from ischial spines to degree of how much the head is past the ischial spines)
557
what is the definition of cord prolapse
umbilical cord descends below presenting part when the membranes have ruptured.
558
what happens with untreated cord prolapse
cord becomes compressed or goes into spasm, causing foetus to rapidly become hypoxic
559
what are the risk factors for cord prolapse
- preterm labour
- preterm rupture of membranes
- breech
- polyhydramnios
- abnormal lie
- twin pregnancy
560
how is cord prolapse diagnosed
cord palpated pv, or seen in introitus
| fhr reduced, abnormal
561
how is cord prolapse managed
the presenting part may be pushed back in to prevent compression of cord
tocolytics such as terbutaline
emergnecy c section
562
what is the definition of uterine rupture
uterus tears de novo/old scar ruptures, causing haemorrhage
563
how may uterine rupture present
constant lower abdo pain, pv bleeding
cessation of contractions
maternal collapse
fhr abnormalities
564
what are the risk factors for uterine rupture
labour with scarred uterus (previous c section)
| congenital uterine abnormalities
565
how is uterine rupture prevented
avoid induction
caution when using oxytocin in women with previous c sections
elective c section for woemn with scars not in the lower segment
566
what is the management of uterine rupture
maternal resus with iv fluids and blood
blood taken for clotting, hb and x match
urgent laparotomy for delivery, repair, stop bleeding
hysterectomy in some cases
567
why is ctpa avoided in pregnancies with ?pe
xrays affect foetus
| v/q instead
568
define the peuperium
6 week period following delivery, when the body returns to its prepregnant state
569
what is lochia
discharge from uterus in the peuperium - can be blood stained at first, but after that is white
570
explain general postnatal care for women
mother and baby should not be separated
early mobilisation
pelvic floor exercises
counselling and practical help with breastfeeding
daily check for uterine involution, temp, hr, bp, perineal/c section wound check
advice regarding contraception
mental health
571
what is the advice for contraception postnatally
usually started 4 weeks post delivery
cocp ci in breastfeeding due to inhibiting mild production
pop or iud (once screened for infection)
572
which hormones is lactation dependent on
prolactin and oxytocin
| oestrogen and progesterone inhibit prolactin
573
what is the definition of primary post partum haemorrhage
over 500 ml blood loss within 24 hours of delivery or over 1000 ml after c section
574
what are the causes for pph
4 t's
1) tone - uterine atony
2) trauma - injury to birth canal e.g. perineal tear, vaginal tear etc
3) tissue - retention from placenta or foetus
4) thrombin: bleeding disorder/coagulopathy/dic
575
how may pph be prevented
routine use of oxytocin in 3rd stage of labour or ergometrine, or both in combination to help contract the uterus
576
what are the side effects of ergometrine
headaches, vomiting
577
what is the management of primary pph
```
resus, lie flat, iv access
get senior help
x match 6 units
volume restoration
manual removal of placenta if delayed explusion
pv to look for uterine inversion
iv oxytocin/ergometrine
bimanual compression of uterus
myometrium prostaglandin injection
surgery, balloon tamponade, brace suture
hysterectomy
```
578
what is the definition of secondary pph
excessive blood loss between 24 hours and 6 weeks postpartum
579
what are the causes of secondary pph
endometritis +/- retained placental tissue
| incidental gynae pathology or gestational trophoblastic disease
580
what are the investigations for secondary pph
bloods: fbc, clotting, U+E, Xmatch
vaginal swab
uss - though hard to differentiate between clots and retained placental tissues
581
what is the management of secondary pph
antibiotics
erpc may be required
histological examination for tissues for ?trophoblastic disease
582
what is the definition of postpartum pyrexia
temp > 38 deg in the first 2 weeks pp
583
what is the management of postpartum pyrexia
prophylactic antibiotics given to reduce the risk of sepsis
blood, urine, foetal, vaginal cultures taken
swabs for important pathogens e.g. group a strep, e coli, staph
584
what are the most common causes of postpartum pyrexia
uti, chest infection, mastitis, perineal and wound infection
585
does dvt cause pyrexia
yes - low grade
586
in which women is pnd more common
socially and emotionally isolated
previous history
pregnancy complications
587
what is the management of mental health problems in pregnancy/pp
drug review ideally preconceptually
risk assessment
if high risk, antidepressants continued in pregnancy
ssri's preferred to fluoxetine
psychiatric review before delivery if hx of mental health problems
588
what is peuperal psychosis
abrupt onset of psychotic symptoms, leading to psychiatric admission and drug therapy
589
what are some of the medical problems that can result postpartum
- dvt
- hypertensiive complications take 24 hours to resolve
- urinary retention
- utis
- incontinence
- perineal trauma
- bowel problems e.g. constipation, haemorrhoids
590
list the complications of pph
- hypovolaemic shock
- dic
- renal failure
- liver failure
- ards
591
describe dic
widespread activation and consumption of clotting factors
592
what is the management of dic
transfuse platelets, plasma,
ffp, ptcc, cryoprecipitate
protein c
593
how is dic investigated
pt
aptt
platelet counts
fibrinogen levels
594
what are the neuro conditions associated with prematurity
- aponea of prematurity
- hypoxic ischaemic encephalopathy
- retinopathy
- developmental disability
- brain damage
595
what are the cardioresp complications of prematurity
pda
| rds
596
what are the gi complications of prematurity
hypoglycaemia
| nec
597
what are the haem complications of prematurity
anaemia of prematurity
hyperbilirubinaemia
thrombocytopenia
598
what are the infective complications of prematurity
due to underdeveloped immune system: sepsis, uti's, pneumonias
599
list the steps in examining a post partum woman
1) palpate abdomen, examine scars
2) bp
3) pv: tears, bleeding, episotomy, incontinence
4) smear in some
5) weight
6) hb, glucose tolerance in past gestational diabetes
7) breast examination
600
what is the management of mastitis
- rest, analgesia, fluids, massage
- warm cloth compress
- express milk
- abx if likely due to infection (flucloxacillin for staph)
601
list the different degrees of perineal tear
```
1st = fourchette
2nd = perineum
3rd = anal sphincter
4th = anal mucosa torn
```
602
what is a partogram
chart used to record progress of dilatation of the cervix, plotted against time
603
what is the treatment for neonatal group b strep infection
iv penicillin
604
what does meconium aspiration cause in the newborn
severe pneumonitis
605
what are the different signs/symtpoms that indicate foetal distress
ph <7.2 in foetal scalp blood sample
meconium stained amniotic fluid
fhr abnormal when auscultated with hand held doppler
ctg abnormalities detected
606
what is the drcbravado abbreviation for ctg
```
dr = define risk
c = contractions (less or more than expected)
br = baseline rate
v = variability
a = acceleration
d = deceleration
o = overall assessment
```
607
what should normal ctg baseline rate be, and what can cause it to be increased
110-160
| infection, fever, hypoxia
608
list the steps in diagnosing foetal distress
- fhr -> abnormal, meconium, high risk
- ctg -> abnormal
- fbs -> abnormal
- delivery by quickest route
609
what are the contraindications for epidural
```
sepsis
coagulopathy/anticoagulant use
neuro disease
spinal abnormalities
hypovolaemia
```
610
what is assessed when a woman presents in labour, after taking hx and obs
pv examination to check cervical effacement - cofnirms labour
degree of descent assessed
colour of any leaking liqour assessed
fhr, ctg
611
what is considered slow progress of labour
cervical dilatation at rate of less than 1cm per hour after latent phase
612
how long do doctors usually wait for the cervix to fully dilate before putting lady in for c section
12 hours
613
what is the problem with epidurals and labour
woman may not feel contractions so are encouraged to contract 3 times for 10 seconds each time. if after 1 hour delivery not imminent -> instrumental/c section
614
how is the placenta examined once it is delivered
check the cord - 2 arteries and vein
check cotyledons if ant missing
the amniotic sac is examined
615
what are the indications for induction of labour
```
prolonged pregnancy
iugr
compromise
aph
prom
maternofoetal indications e.g. preeclapmsia
```
616
what are the absolute contraindications for induction of labour
acute foetal compromise
abnormal lie
placenta praevia
pelvic obstruction - causing cephalopelvic disproportion
617
what are the complications of induction of labour
```
unsuccessful
risk of instrumental delivery/c section
overactivity of uterus-hypercontractility
aph/pph
pp infection
```
618
list some of the physiological changes in pregnancy to the cardiovascular system
- increased hb mass
- increased plasma volume
- fall in hb in 2nd trimester
- physiological anaeamia of pregnancy
- mild increase in wcc
- fall in platelet count
619
what hb level is considered anaemia in pregnancy
less than 104 g/L
620
what ar ethe different types of aneamia in pregnancy
- physiological
- iron deficiency
- folate deficiency
- b12 deficiency
- haemoglobinpathies
- chronic disease, drugs etc
621
what are the causes of iron deficiency anaemia in pregnancy
- increased red cell mass
- foetus and placenta demand
- increased basal maternal requirements
- blood loss at delivery
622
what should be avoided with iron supplements
- bran, oats, rye, fibre
- tannins in tea
- some veg
- dietary calcium content increase
623
list some of the causes for folate deficiency
- malabsorption
- haemolysis
- haemoglobinopathies
- myeloproliferative disease
- anticonvulsants
624
why are d-dimers not useful in ?pe for in pregnancy
raised in pregnancy anyway
625
describe the concept of rhesus alloimmunisation
if mother rhesus negative and baby rhesus positive, mother can become exposed to the RhD antigen during pregnancy after release of foetal cells into maternal circulation. mother therefore produces IgM antibodies against RhD which do not cross placenta, however on reexposure to RhD (usually subsequent pregnancy), the mothe rproduces IgG antibodies against RhD which can cross placenta and cause haemolysis of foetal blood
626
list some sensitising events for rhesus alloimmune reaction
- threatened miscarriage
- abdo trauma
- cvs, amniocentesis, ecv
- antepartum haemorrhage
- delivery
- blood trasnfusions
- some sensitisation throughout normal pregnancy
627
what is the main haemoglobin type in foetuses, found in minute quantities in adults
HbF (2 alpha and 2 gamma chains)
628
what is the pathophysiology of sickle cell disease
single base change glutamic acid -> valine
| HbS causes sickling and shape changes
629
how are babies with haemolytic disease monitored and treated
ab levels
mca doppler uss
iv transfusion
exchange/topup transfusion after delivery
630
how is sickle cell diagnosed
- hb low
- sickle cells on film
- howell jolly bodies
- nrbc
- sickle solubility test/electrophoresis
631
how can sickle cell disease affect pregnancy
- mother: reduced hb, infection, crises increased
| - foetus: miscarriage, iugr, stillbirth, prematurity
632
what is the pathophysiology of thalassaemia
heterogenous group of disorders where there is reduced rate of synthesis of alpha or beta globin chains
633
what are the clinical features of thalassaemia
severe anaemia
hepatospleomegaly
bm hyperplasia
634
what is the treatment for thalassaemia
regular blood transfusions
| folic acid, iron, vit c, splenectomy
635
what is the process of ideintifying women at increased risk of having baby with haemoglobinopathies
- booking visists and bloods
- partner testing
- increased risk couple is identified and counselled
