Obs&Gynae Flashcards
(124 cards)
1
Q
Take a full gynaecological history
A
Demographics - name, age, marital status, parity, occupation
Presenting complaint - impact on QoL/normal functioning
Menstrual - LMP, days of bleeding, flow, regularity of cycle, abnormal bleeding (IMB/PCB), menarche
Contraception - current method and duration, previous methods, problems
Cervical smear - last smear and result
Gynae hx - past problems, investigations, treatment, operations
Obs hx - gravidity, parity, outcomes, birth weight, mode of delivery
PMH
DHx + allergies
FH
SH - smoking, alcohol, BMI, HTN
2
Q
Take a menstrual history
A
LMP Days of bleeding Flow Regularity of cycle Abnormal bleeding (IMB/PCB) Menarche Impact on QoL/normal functioning
3
Q
List conditions associated with abnormal menstruation
A
Amenorrhoea
Dysmenorrhoea
Menorrhagia/dysfunctional uterine bleeding
4
Q
Describe causes, investigations and management of amenorrhoea
A
Causes - Turner’s syndrome, endocrine abnormality, pregnancy, lactation, menopause, iatrogenic (progesterone), stress, anorexia, PCOS
Ix - pregnancy test, FSH/LH levels, testosterone/SHBG, prolactin levels, TFTs, pelvic USS, karyotyping
Mx - guided by diagnosis and fertility wishes
5
Q
Define amenorrhoea
A
Primary - lack of menstruation by age 16 with secondary sex characteristics, 14 without secondary sex characteristics
Secondary - absence of menstruation for 3 months if regular, 9 months if irregular
6
Q
Define dysmenorrhoea
A
Painful periods
Primary - no organic cause
Secondary - due to underlying cause
7
Q
Describe clinical features, investigations and management of dysmenorrhoea
A
CFs - functional loss, pelvic pain, deep dyspareunia, PID/STI history, abdominal surgery, abdominal mass, cervical excitation, adnexal tenderness
Ix - STI screen, USS, laparoscopy
Mx - symptom control (paracetamol, mirena IUS, COCP, mefenamic acid), treat cause (COCP/progesterone/GnRH analogue, ABx), therapeutic laparoscopy
8
Q
Suggest differential diagnoses for dysmenorrhoea
A
Endometriosis Adenomyosis PID Pelvic adhesions Leiomyomata (fibroids)
9
Q
Define menorrhagia
A
Abnormally heavy or prolonged bleeding
Blood loss >80ml
10
Q
Describe clinical features, investigations and management of menorrhagia
A
CFs - clots, flooding, anaemia symptoms, disruption of life, enlarged uterus
Ix - FBC, ferritin, TFTs, clotting, STI screen, TVS USS, pipelle biopsy, hysteroscopy
Mx - mirena IUS, transexamic acid, mefanamic acid, COCP, progesterone, GnRH analogue, endometrial ablation, hysterectomy
11
Q
Suggest differential diagnoses for menorrhagia
A
Leiomyomata (fibroids) Adenomyosis Endometrial polyps Endometrial hyperplasia Endometrial cancer Hypothyroidism Coagulation disorder Dysfunctional uterine bleeding (dx of exclusion)
12
Q
Take a sexual history
A
Partners - gender, type of relationship, duration, number in last 3/12, type of sex, use of barrier contraception Sex with anyone born outside the UK? Been paid/paid for sex? MSM? Sex with bisexual men? Injected drugs? PMH FH DH + allergies Hx of STI Previous HIV tests Menstrual, obstetric, contraceptive, gynae hx
13
Q
Describe clinical features, investigations and management of acute pelvic pain
A
CFs - unknown LMP, UPSI, vaginal discharge, bowel/urinary symptoms, acute abdomen, masses, cervical excitation, adnexal tenderness
Ix - urinary/serum b-hCG, urinary MSU, triple swab, FBC, G&S, pelvic USS, diagnostic laparoscopy
Mx - analgesia, treat underlying cause
14
Q
Suggest differential diagnoses for acute pelvic pain
A
Gynae - ectopic pregnancy, miscarriage, PID, ovarian cyst rupture/torsion, abscess
Other - appendicitis, IBS, IBD, hernia strangulation, UTI, renal calculi
15
Q
Define the term chronic pelvic pain
A
= intermittent or constant pelvic pain in the lower abdomen or pelvis for >6 months, not exclusively with menstruation, intercourse or associated with pregnancy
16
Q
Suggest differential diagnoses and management of chronic pelvic pain
A
Gynae - endometriosis, adenomyosis, adhesions (trapped ovary syndrome), pelvic venous congestion
Other - IBS, constipation, hernia, interstitial cystitis, renal calculi, fibromyalgia, nerve entrapment, neuropathic pain
Mx - analgesia, COCP, progesterone, complementary therapy, support groups, GnRH analogue –> hysterectomy
17
Q
Describe risk factors, clinical features, investigations and management of endometriosis
A
= retrograde menstruation, sensitive to oestrogen
RFs - early menarche, FH, short menstrual cycles, long duration of bleeding, menorrhagia, defects in uterus/tubes
CFs - cyclical pelvic pain/chronic pelvic pain, dysmenorrhoea, dysuria, dysparaenia, dyschezia, sub fertility, fixed retroverted uterus
Ix - laparoscopy (chocolate cysts, adhesions, peritoneal deposits), pelvic USS
Mx - analgesia, COCP/mirena IUS, surgery (laser ablation)
18
Q
List different types of ovarian cyst
A
Non neoplastic:
Functional - follicular, corpus luteal
Pathological - endometrioma (chocolate cyst), polycystic ovaries, theca lutein cyst
Benign Neoplastic:
Epithelial tumour - serous cystadenoma, mucinous cystadenoma, brenner tumour
Benign germ cell tumour - mature cystic teratoma (dermoid cyst)
Sex cord stomal tumour - fibroma, sertoli-leydig cell tumour, thecoma, lipoma
19
Q
What is Meig syndrome?
A
Tumour + ascites/pleural effusion
20
Q
Describe risk factors, clinical features, investigations and management of adenomyosis
A
= endometrial stroma communicates with myometrium after uterine damage (e.g. pregnancy, childbirth, C-section, TOP), common in posterior wall, responsive to hormones
RFs - high parity, uterine surgery, previous C-section, genetic(?)
CFs - menorrhagia, dysmenorrhoea, deep dyspareunia, irregular bleeding, symmetrically enlarged tender uterus
Ix - TV USS, MRI (*diagnosis is histology after hysterectomy)
Mx - hysterectomy (=curative), NSAIDs, COCP/progesterone, uterine artery embolisation, endometrial ablation
21
Q
Describe risk factors, clinical features, investigations and management of PID
A
= infection of upper genital tract in females
RFs - sexually active, intercourse without barrier contraception, STI hx, gynae surgery, TOP, insertion of IUS/IUD
CFs - abdo pain, deep dyspareunia, menstrual disorder (PCB), abnormal vaginal discharge, fever, uterine tenderness, cervical excitation, palpable abdo mass
Ix - endocervical swab (gonorrhoea, chlamydia), high vaginal swab (trichomonas, BV), full STI screen, urine dipstick, pregnancy test, TV USS, laparoscopy
Mx - IM ceftriaxone 500mg STAT + PO doxycycline 100mg BD 14 days + PO metronidazole 400mg BD 14 days
22
Q
List complications of PID
A
Tubo-ovarian abscess Fitz-Hugh Curtis syndrome Recurrent PID Ectopic pregnancy Infertility
23
Q
List different types of urinary incontinence
A
Stress Urge Mixed Overflow Functional
24
Q
Describe risk factors, clinical features, investigations and management of stress incontinence
A
= involuntary leakage during increased intraabdominal pressure
RFs - childbirth, low oestrogen, bladder neck weakness, weak pelvic floor, chronic cough
CFs - coughing, sneezing, exercise = small leak +/- prolapse of urethra and anterior vaginal wall
Ix - urodynamic studies (normal frequency and bladder capacity)
Mx - weight loss, stop smoking, decrease caffeine intake, treat constipation/cough, PT (pelvic floor muscle training), duloxetine, bulking, tape, sling
25
Describe risk factors, clinical features, investigations and management of urge incontinence
= presence of urgency, usually with frequency and nocturia in the absence of UTI or other pathology
RFs - MS, spina bifida, UMNL, pelvic surgery
CFs - sudden sensation, triggers (running water), leak a large volume
Ix - urodynamic studies (increased frequency, nocturia)
Mx - increase fluid, decrease caffeine, PT (bladder retraining), anticholinergics, oestrogen, botox injection, sacral nerve stimulation, neuromodulation, detrusor myomectomy
26
List risk factors for prolapse
```
Pregnancy
Vaginal delivery
Large baby
Instrumental delivery (forceps)
Congenital (EDS)
Menopause (low oestrogen)
Obesity
Chronic cough
Constipation
Iatrogenic (hysterectomy, continence procedures)
```
27
Describe the different types of prolapse
Uterine - uterus prolapses down
Rectocele/posterior vaginal prolapse - bulging of the front wall of the rectum into the back wall of the vagina
Cystocele - bladder bulges into vagina anteriorly
Enterocele - herniation of the peritoneal sac containing bowel against vagina
28
Describe grading of prolapse
Grade 1 - descends halfway down to hymen
Grade 2 - extends to level of hymen
Grade 3 - through hymen, lies outside vagina
29
Describe clinical features, investigations and management of prolapse
CFs - dragging sensation, discomfort, 'lump' coming down, dyspareunia, backache, urinary symptoms (urge, frequency), bowel symptoms (constipation, requires digital assistance), worse with standing, prolapse when asking lady to bear down (using Sims speculum)
Ix - USS, urodynamic studies, ECG, CXR, FBC, U&Es (fitness for surgery)
Mx - lose weight, treat constipation/chronic cough, PT (pelvic floor muscle exercises), pessary, topical oestrogen, surgery (anterior/posterior repair, vaginal hysterectomy)
30
Define the term infertility
= a couple cannot conceive despite regular unprotected sexual intercourse for >12 months
31
List different causes of infertility
```
Primary - premature ovarian failure, genetic (Turner's syndrome), iatrogenic (tubal surgery, chemotherapy), Secondary - PCOS, excessive weight loss/exercise (low BMI), hypopituitarism (tumour, surgery), Kallmann's syndrome, hyperprolactinaemia
Ovulation disorder
Tubal factor
Male factor
Endometriosis
```
32
Take a fertility history
```
Age
Duration of trying, coital frequency
Menstrual hx - LMP, pelvic pain, dyspareunia, cervical smears
Obs hx - previous pregnancy (other partner?), ectopic
Sexual hx - STIs, PID
PMH - tubal/pelvic surgery
DH
SH - smoking, alcohol, folic acid
```
33
Describe clinical features, investigations and management of infertility
CFs - signs of an endocrine disorder (acne, hirsutism, alopecia, acanthosis nigricans), adnexal masses, uterine fibroids, endometriosis, vaginismus
Ix - STI screen, baseline (day 2-5) hormone profile (FSH, LH, FSH, TSH, prolactin, testosterone), rubella status, mid-luteal progesterone level (confirm ovulation), semen analysis, hysterosalpingography (HSG), laparoscopy and dye test, hysterosalpingo-contrast-sonography (HyCoSy)
Mx - healthy diet, stop smoking, no alcohol, exercise, folic acid, regular intercourse, ovulation induction (clomifene), pulsatile GnRH, laparascopic ovarian diathermy, insulin sensitiser, assisted contraception
34
List the WHO criteria for normal semen analysis
```
>15 million spermatozoa/ml
Sperm volume >1.5ml
>39 million spermatozoa/ejaculate
pH >7.2
Motility >40% total or >32% progressive
>58% live
>4% normal morphology
```
35
List causes for male infertility
Semen abnormality - testis cancer, drugs (alcohol, nicotine), genetic, varicocele
Azospermia - steroid abuse, Kleinefelter's syndrome, chemotherapy, cystic fibrosis, STI
Coital dysfunction - hypospadias, phimosis, retrograde ejaculation, MS
Immunological
36
Describe clinical features, investigations and management of PCOS
= raised GnRH (--> raised LH --> androgens), insulin resistance (--> low SHBG --> androgens), no LH surge (no ovulation)
RFs - diabetes, dysmenorrhoea, FH
CFs - oligo/amenorrhoea, infertility, hirsutism, obesity, chronic pelvic pain, depression, HTN
Ix - basal (day 2-5) LH (high), FSH (normal), TFTs, prolactin, testosterone (high), SHBG (low), oral GTT, pelvic USS (follicles, ovarian volume)
Mx - exercise, orlistat, COCP, progesterone, clomifene +/- metformin, laparoscopic ovarian drilling, antiandrogen
37
Explain the Rotterdam criteria
= >2/3 for a diagnosis of PCOS
1. Irregular/absent periods (cycle >42 days)
2. Clinical signs of raised androgens (acne/hirsutism/alopecia)
3. Polycystic ovaries on USS (>12 antral follicles), ovarian volume >10ml
38
List complications of PCOS
Gestational DM
| Endometrial hyperplasia
39
Suggest differential diagnoses for bleeding/pain in early pregnancy
```
Miscarriage
Ectopic pregnancy
Gestational trophoblastic disease
Hyperemesis gravidarum
Placental issues
```
40
Define the term miscarriage?
= a loss of a pregnancy <24 weeks of gestation
Early - <12-13 weeks
Late - 13-24 weeks
41
Describe the classification of miscarriage
Threatened - blood +/- pain, closed Os
Complete - symptoms cease, closed Os, empty uterus
Incomplete - blood +/- pain, possible open Os, tissue in uterus
Missed - no fetal heart activity, closed Os
Inevitable - blood +/- pain, open Os
PUL - +ve pregnancy test, empty uterus, closed Os
42
When is Anti-D prophylaxis given?
Any sensitising event:
<12 weeks - uterine evacuation, ectopic
>12 weeks - if bleeding
43
Describe clinical features, investigations and management of miscarriage
RFs - maternal age >30-35, previous miscarriage, obesity, chromosomal abnormality, smoking, uterine abnormality, antiphospholipid syndrome
CFs - PV bleed +/- clots, suprapubic, cramp pain, haemodynamic instability, distended tender abdomen, diameter of cervical os, uterine tenderness
Ix (at EPAU) - TV USS (CRL, fetal pole, mean sac diameter), serum bHCG, FBC, Rh status
Mx - anti-D prophylaxis
Conservative - repeat scan in 2/52, pregnancy test in 3/52
Medical - mifepristone + misoprostol, pregnancy test in 3/52
Surgical - manual vacuum, ERPC
44
List advantages and disadvantages of the types of miscarriage management
Conservative:
+ - home, no surgical risk
- - unpredictable timing, blood, pain, unsuccessful
Medical:
+ - home, no surgical risk
- - s/e of medication (diarrhoea, vomiting), blood, pain, unsuccessful
Surgical:
+ - planned procedure, general anaesthetic
- - anaesthetic risks, infection (endometritis), uterine perforation, bladder/bowel damage, retained POC, Asherman's syndrome (intrauterine adhesions)
45
Describe causes, investigations and management of recurrent miscarriage
= >3 consecutive pregnancies that end in miscarriage before 24 weeks gestation
Causes - antiphospholipid syndrome, genetics (parental/embryonic), endocrine (diabetes, thyroid, PCOS), anatomical (uterine malformation, cervical weakness), infective (BV), inherited thrombophilia
RFs - increased maternal age, miscarriage hx, lifestyle (smoking, alcohol, caffeine)
Ix - bloods (antiphospholipid antibody, thrombophilia screen, karyotyping), imaging
Mx - counselling, specialist miscarriage clinic, clinical geneticist, cervical cerclage, heparin, low dose aspirin
46
Describe clinical features, investigations, management and complications of ectopic pregnancy
= implantation of a conceptus outside the uterine cavity
RFs - previous ectopic, PID, endometriosis, IUD/IUS/POP/implant, tubal ligation/occlusion, pelvic surgery, assisted reproduction (IVF)
CFs - lower abdomen pain +/- blood PV, shoulder tip pain, brown vaginal discharge, abdo tenderness, cervical tenderness, adnexal tenderness, haemodynamically unstable
Ix - pregnancy test (urine hCG), pelvic USS/TV USS, serum bHCG
Mx - Anti-D, A-E if unstable
Medical - IM methotrexate (*contraception for 3 months required)
Surgical - lap. salpingectomy/salpingotomy
Conservative - monitor serum b-hCG (48hrly)
Complications - fallopian tube rupture, peritonitis, sepsis
47
Describe clinical features, investigations and management of gestational trophoblastic disease
RFs - maternal age <20 ir >35, previous disease, previous miscarriage, use of OCP
CFs - abdo pain +/- PV bleed, large for dates uterus, soft boggy uterus, hyperemesis, hyperthyroidism, anaemia
Ix - urine/blood b-hCG, USS (snowstorm/whirlpool appearance surrounding multiple cysts), MRI/CT/USS (suspected metastatic spread)
Mx - register with GTD centre, suction curettage/medical evacuation, anti-D, chemo +/- surgery
48
State the triad of gestational trophoblastic disease
>5% weight loss
Dehydration
Electrolyte disturbance
49
Suggest differential diagnoses for postmenopausal bleeding
```
= vaginal bleeding >12 months after periods have stopped
Endometrial cancer
Endometrial hyperplasia
Atrophic vaginitis/endometrial atrophy
Endometrial polyps
```
50
Describe clinical features, investigations and management of endometrial cancer
= presence of unopposed oestrogen (endogenous/exogenous)
RFs - obesity, T2DM, hypothyroidism, low progesterone production (nulliparity, PCOS, early menarche, late menopause), genetic (HNPCC/Lynch syndrome), breast cancer, HRT, tamoxifen
Protective factors - COCP, parity
CFs - PMB, menstrual disturbance (heavy, irregular), PV discharge
Ix - FBC, LFTs, U&Es, TV USS +/- biopsy, CT CAP (staging)
Mx - surgery (TAH & BSO), adjuvant radiotherapy, hormonal (high dose progesterone = palliation of bleeding symptoms), palliative radiotherapy
51
Explain the different types of HRT as well as their advantages and disadvantages
Oetrogen + progesterone/oestrogen only (if hysterectomy)
Continuous/cyclical
PO, transdermal (patch, gel), PV (cream, pessary), implant
+ - alleviate menopausal symptoms (hot flushes, vaginal dryness, night sweats)
- - increased risk of breast cancer, endometrial cancer (if oestrogen only), blood clots
52
What is CIN?
= precursor lesion for carcinoma of cervix
53
Which HPV infections are associated with the development of CIN and cervical cancer?
HPV 16, 18, 31, 33
54
List risk factors for cervical cancer
```
Persistent high risk HPV infection
Multiple partners
Smoking
Immunosuppression
COCP use
```
55
Explain the criteria for cervical screening
Sexually active women aged 25-64
3 yearly for women aged 25-50
5 yearly for women aged 50-64
56
List indications for referral to colposcopy
Smear showing borderline nuclear changes or mild dyskaryosis with high risk HPV
Smear showing moderate or severe dyskaryosis
Smear suggestive of malignancy
Smear suggestive of glandular abnormality
Three consecutive inadequate smears
Keratinizing cells
Post coital bleeding
Abnormal looking cervix
57
Describe the management of CIN
Depends on grade and patient preference
Conservative
Excision
Destruction
58
Describe the indications, benefits and complications of LLETZ excision
= large loop excision of transformation zone
Persistent low grade low grade CIN (CIN 1)
High grade CIN (>CIN 1)
+ - easy, safe, local anaesthetic, tissue available for histology/assessment of excision margins
Complications - haemorrhage, infection, vaso-vagal reaction, anxiety, cervical stenosis (dysmenorrhoea), cervical incompetence, premature delivery
59
State the % of low grade CIN that will regress
50-60% spontaneously regress within 2 years
60
State the % of high grade CIN that will progress to cancer within 10 years
CIN 2 - 3-5%
| CIN 3 - 20-30%
61
Describe the risk factors, clinical features and management of vaginal/vulval cancer
Rare (<1 in 100)
RFs - age (>60), HPV, HIV, smoking
CFs - itching, bleeding, discharge
Mx - wide local excision, vulvectomy, groin lymphadenopathy +/- radiotherapy
62
Describe the clinical features and management of lichen sclerosis
Potential to progress to SCC
CFs - itching, white atrophic patches, fusion, adhesions
Mx - topical steroids, regular follow up
63
Describe clinical features, investigations and management of cervical cancer
= persistent infection with high risk HPV, age 45-55
RFs - exposure to HPV (early first sexual experience, multiple partners, non barrier contraception), smoking, immunosuppression
CFs - detection on cervical smear, PCB, PMB, heavy bleeding PV, weight loss, fistula, roughened hard cervix +/- loss of fornices, fixed
Ix - colposcopy punch biopsy (irregular surface, abnormal vessels, dense aceto-white changes), U&Es, LFTs, FBC, CT CAP, MRI pelvis, examination under anaesthetic
Mx - (depends on stage and age), local excision/TAH, lymphadenopathy + Wertheim's hysterectomy, chemotherapy, combination chemoradiotherapy, best supportive care, palliative radio
64
List complications of cervical cancer
```
Bleeding
Infection
DVT/PE
Ureteric fistula
Lymphoedema
Acute bowel/bladder dysfunction
Vaginal stenosis
```
65
Describe the common histology of cervical cancer
SCC (85-90%)
| Adenocarcinoma (10-15%)
66
Describe clinical features, investigations and management of ovarian cancer
= irritation of ovarian surface epithelium by damage during ovulation, age 60-70
RFs - multiple ovulations, nulliparity, early menarche, late menopause, genetics (BRCA mutations, HNPCC (Lynch)
CFs - abdominal distension (bloating), urinary symptoms, change in bowel habit, abnormal PV bleeding, pelvic mass, ascites, omental mass, pleural effusion, supraclavicular lymphadenopathy
Ix - FBCs, U&Es, LFTs (albumin), Ca125, CEA, Ca19-9, AFP, hCG tumour markers. abdo/pelvic USS, CXR, CT CAP
Mx - staging laparotomy, debulking surgery, hysterectomy, BSO, omentectomy, lymph node sampling, peritoneal biopsy, pelvic wash, adjuvant chemotherapy (platinum agents)
67
Which cancers is someone with BRCA predisposed to?
Ovarian
| Breast
68
Which cancers is someone with HNPCC (Lynch II syndrome) predisposed to?
Colorectal
Uterine
Ovarian
69
List protective factors for ovarian cancer
Suppressed ovulation
COCP use
Pregnancy
70
What is the purpose of a sexual health history?
Assess clinical condition
Assess risk for STIs (including HIV) - which sites to test, when to test
Assess risk of pregnancy/need contraception
71
What is the window period for chlamydia/gonorrhoea testing?
2 weeks
72
What is the window period for HIV?
4 weeks
73
What is the window period for Hepatitis B?
12 weeks
74
What is the window period for Syphilis?
12 weeks
75
What is the window period for Hepatitis C?
6 months
76
List causes of vaginal discharge
Physiological - pregnancy, sexual arousal, menstrual cycle variation
Pathological - vaginal (candida, trichomoniasis, FB, post menopausal vaginitis), cervical (gonorrhoea, herpes, cervical ectropion, cervical neoplasm)
77
Describe clinical features, investigations and management of vulvovaginal thrush
RFs - ABx use, steroids, immunosuppression
CFs - superficial dyspareunia, itch, white curd-like discharge
Ix - satellite lesions --> candida albicans
Mx - anti fungal (PV, PO, topical)
78
Describe clinical features, investigations and management of bacterial vaginosis
CFs - thin, white/grey fishy smelling discharge
Ix - odour with KOH whiff test, clue cells on high vaginal swab (*Amsel criteria) --> gardnerella vaginalis
Mx - metronidazole PO
79
Describe clinical features, investigations and management of trichomonas vaginalis
CFs - itchy/sore, frothy offensive odour discharge, UPSI (vaginal)
Ix - strawberry cervix --> protozoan
Mx - metronidazole PO
80
List common symptoms of pregnancy
```
Nausea
Vomiting
Increased frequency of urination
Breast tenderness
Fetal quickening (first baby = 18-20, multiple = 16-18)
```
81
List components of a booking visit
```
Folic acid 400mcg daily (or 5mg), vitamin D, iron
Aspirin 75mg (pre-eclampsia risk)
Food hygeine
Lifestyle advice (smoking, drugs, alcohol)
Exercise - pelvic floor
Breastfeeding
Antenatal classes
Antenatal screening
Mental health issues
Weight/height (BMI)
Rule out FGM
Domestic violence
Haemoglobinopathy (sickle cell, B thal), anaemia
Blood group
Infection (syphillis, hepatitis, HIV, rubella)
Urine - blood, glucose, protein
```
82
List prenatal screening tests available in the UK
Fetal anomaly USS - 18+0-20+6 weeks
| Down's - 13+6
83
Describe the different Down's screening tests
12 weeks - combined test (NT, b-hCG, PAPP-A)
| <20 weeks - quadruple test (b-hCG, aFP, uE3, inhibin A)
84
State examples of confirmatory diagnostic tests for Down's and when they can be performed
Chorionic villus sampling - 10-12 weeks
| Amniocentesis - 16-18 weeks
85
State the frequency of antenatal appointments and what is monitored
Uncomplicated nulliparous = 10 with midwife
Uncomplicated parous = 7
BP, urine, symphysis-fundal height (>24 weeks), fetal presentation (>36 weeks)
86
List physiological changes of pregnancy
CVS:
BP low in T1+T2, normal in T3, high blood volume, CO, SV, HR, decreased systemic vascular resistance
Coagulation:
Prothrombotic state *VTE prophylaxis
Low flow velocity to lower limbs, increased factor 7,8 fibrinogen, vWF
Increased inhibition of fibrinolysis
87
State the most likely place for a DVT in a pregnant woman and why
Left leg
Due to compression of left iliac vessel by right iliac artery and ovarian artery which only crosses vein on left side
Ileofemoral
*if acute VTE, treat with LMWH
88
Describe clinical features, investigations and management of pre-eclampsia
= new onset HTN (>140/90) and proteinuria (>300mg/24h) in the second half of pregnancy that resolves after delivery
CFs - headache, visual disturbance, epigastric pain (RUQ), oedema, vomiting, hyperreflexia/clonus, epigastric tenderness, abnormal bloods (raised urea, creatinine, rate, ALT, low platelets)
Ix - maternal BP, proteinuria, platelet count, LFTs, fetal movements, CTG, umbilical doppler, US (fetal size, liquor volume)
Mx - check BP in T1, monthly visits (>20 weeks), fortnightly visits (>34 weeks), early intervention if BP >140/90, *admit if persistent >170/110/persistent >140/90 + proteinuria, methyldopa, labetalol, nifedipine
89
Describe the pathogenesis of pre-eclampsia
Abnormal trophoblastic invasion and adaptation of spiral arteries --> low vasodilators --> maternal plasma volume fails to expand --> placenta fails to be a low pressure system
90
List complications of pre-eclampsia
CNS - intracranial haemorrhage/cortical blindness
Renal - renal tubular necrosis
Resp - pulmonary oedema
Liver - haemorrhage, hepatic rupture, HELLP, DIC
Placenta - placental infarction/abruption
Fetus - death, IUGR, preterm, cerebral palsy
91
Describe primary and secondary prevention of pre-eclampsia
Primary - rest, exercise, diet/nutrition (vit. D, calcium), low dose aspirin
Secondary - labetalol, methyldopa, nifedipine SR, daxazocin
*in emergency --> hydrazine/labetalol/nifedipine SR
*prevent fits with magnesium
92
List contraindications for labetalol
T1DM
Asthma
Phaeochromocytoma
93
What is eclampsia?
= generalised convulsions during pregnancy, labour or <7 days post partum
Not caused by epilepsy or another neurological disorder
94
List risk factors for gestational diabetes
```
BMI >30kg/m2
Previous macrosomic baby (>4.5kg)
Previous GDM
First degree relative with diabetes
Ethnicity - south asian, black caribbean, middle eastern
Current large for dates fetus
```
95
Describe the diagnosis of gestational diabetes
Oral glucose tolerance test at 26-28 weeks (*may be repeated at 34 weeks if concerns)
75g glucose
Fasting glucose >5.6mmol/L
2h plasma glucose >7.8mmol/L
96
Describe management of gestational diabetes
MDT - obstetrician, diabetologist
Measure glucose 4-6x day (1h post prandial)
Lifestyle change (diet --> metformin --> insulin)
Fetal monitoring USS 4 weekly (from 28 weeks)
Birth planning - no later than 40+6
97
State information to give to a mother with GDM post-partum
Check glucose prior to discharge
OGTT 6 weeks post partum
50% risk of T2DM in next 25 years
98
Describe types, causes and complications of breech presentation at term
Types - extended/frank, flexed/complete, footling
Causes - idiopathic, preterm, previous breech, uterine abnormalities, placenta praaevia, metal abnormalities, multiple
Complications - fetal hypoxia, trauma at labour, preterm, C-section delivery
99
Describe indications and complications of external cephalic version
= manually turning fetus from 37 weeks
Contraindications - CS delivery already indicated, antepartum haemorrhage, fetal compromise, oligohydramnios, pre-eclampsia
100
Define zygocity
= the number of ova from which a pair of twins are derived --> monozygotic/dizygotic
101
Define chorionicity
= the number of placenta --> monochorionic/dichorionic
102
List differentials for antepartum haemorrhage
```
= bleeding >24 weeks gestation before onset of labour
Placental abruption
Placenta praevia
Polyps
Ectropion
```
103
Define primary and secondary postpartum haemorrhage
```
Primary = blood loss >500ml within 24h of delivery
Secondary = excessive loss 24h-6 weeks after delivery
```
104
List causes of primary postpartum haemorrhage
```
4Ts
Tone - uterine atony
Tissue - retention of placental tissue
Trauma - vaginal/cervical tears
Thrombin - coagulopathies and vascular abnormalities - placental abruption, HTN, pre-eclampsia, vWF, haemophilia, ITP, DIC, HELLP
```
105
Describe risk factors, clinical features, investigations and management of postpartum haemorrhage
RFs - maternal age >40, BMI >35, asian ethnicity, multiple pregnancy, fatal macrosomia, placental problems, IOL, prolonged labour, instrumental delivery, CS delivery, episiotomy
CFs - PV bleed, dizzy, SOB, palpitations, uterine rupture, missing cotylydon
Ix - FBC, X-match, coagulation profile, U&Es, LFTs
Mx - resus, treat cause, bimanual compression, balloon tamponade, haemostatic suture, hysterectomy, IV oxytocin, manual removal with anaesthetic, prophylactic ABx, repair laceration/laparotomy/hysterectomy, blood products
106
List causes of secondary postpartum haemorrhage
Uterine infection
Retained placental tissue
Abnormal involution of placental site
Trophoblastic disease
107
Describe clinical features, investigations and management of secondary postpartum haemorrhage
CFs - PV bleed, fever/rigors, lower abdomen pain/tenderness, high uterus
Ix - high vaginal swab, bloods (culture, FBC, U&Es, CRP, coagulation profile, G&S), pelvic USS
Mx - ABx, uterotonics, surgery (e.g. balloon catheter)
108
Describe clinical features, investigations and management of obstetric cholestasis
= raised in asians, trimester 3, resolves after delivery
CFs - pruritus of trunk, limbs, hands, feet without skin rash, worse at night, loss of appetite, jaundice
Ix - LFTs (high ALT, AST, GGT, ALP), clotting, raised bile acids, viral serology, autoimmune screen, USS of liver and biliary tree
Mx - consultant led care, 1-2weekly LFTs, water soluble vit. K, topical emollients, ursodeoxycholic acid, fetal surveillance (USS/CTG)
109
List risk factors of perinatal psychiatric
```
Personal MH history
Other vulnerability factors (substance misuse, domestic violence)
FH of bipolar disorder
<16 years old
Unrealistic ideas of motherhood
Pre-existing illness
FH
Volatile/absent family relationships
Social isolation
Pregnancy complications
Social problems
```
110
List screening tools for postnatal depression
Edinburgh's PND scale
GAD-2
Beck's Depression Inventory
111
Describe onset and management of postpartum blues
3-10 days post partum
Self limiting (48h-2 weeks)
Reassurance essential
112
Describe onset and management of postnatal depression
1-3 weeks post delivery or 10th-12th
NICE screening Qs/EPND scale
Mild/moderate - self help strategies
Moderate/severe - CBT, antidepressants (SSRI sertraline)
113
Describe onset and management of puerperal psychosis
Abrupt onset (1st week)
*refer to specialist perinatal service (+mother/baby unit) - increased risk of suicide, infanticide
Antipsychotics/lithium/ECT
114
Define the first stage of labour
Latent - cervix effacement +3cm dilation
| Active - cervix dilation 3-10cm
115
What is the rate of progression of the first stage of labour
Prima - 0.5cm dilation/hr
| Multi - 1cm dilation/hr
116
List monitoring recorded on partogram
```
FHR (every 15 mins/continuous)
Contractions (30 mins)
Maternal pulse (1hrly)
BP/temp (4hrly)
Vaginal examination (4hrly)
```
117
Describe the modified bishop score
```
= assess favourability for IOL (>8 = favourable cervix)
Dilation
Length of cervix
Station (relative to ischial spines)
Consistency
Position
```
118
List indications for induction of labour
Obstetric - uteroplacental insufficiency, prolonged pregnancy (41-42 weeks), IUGR, oligohydramnios, non reassuring CTG, PROM, severe pre-eclampsia, unexplained antepartum haemorrhage, chorioamniotits
Medical - severe HTN, uncontrolled diabetes, renal disease with decreased renal function
119
List methods of IOL
Amniotomy + oxytocin infusion
Vaginal PGs
Membrane sweep
120
List contraindications for IOL
```
Major placenta praaevia
Vasa praevia
Cord prolapse
Transverse lie
Active genital herpes
Previous CS delivery
```
121
List complications of IOL
```
Failure
Infection
Uterine hyperstimulation (*give terbutaline)
Pain
Cord prolapse
Increased risk of further interventions
```
122
Describe how to interpret a CTG
```
Dr C Bravado
Define Risk
Contractions /10 mins - normal <5
Baseline Rate - normal 110-160
Variability >5bpm - normal 5-25bpm
Accelerations (with movements/contractions are reassuring)
Decelerations - early/variable/ late
Overall assessment
```
123
Describe classification of CTG
Reassuring/non-reassuring/abnormal
| Normal/suspicious/pathological
124
List indications for instrumental delivery
```
FORCEPS:
Fully dilated cervix
Obstruction excluded
Ruptured membranes
Contracting uterus
Engagement of head at/below ischial spines
Presentation suitable
Severity of pain reduced (epidural)
```
