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MBBS V > Obs & Gynae > Flashcards

Obs & Gynae Flashcards

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1
Q

Management of pre-eclampsia ?

A

CTG fetal monitoring. Call obsetrician for advice.

Asymptomatic, incidental finding, no severe features: Close outpatient monitoring. Labetalol. IOL at 37 weeks

If rural, send to Adelaide for monitoring

Symptomatic or any features of HELLP: hospitalisaion and IOL

Future pregnancies need prophylacic aspirin

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2
Q

Invetigation for suspected polyhydramnios?

A

AFI (Amniotic Fluid Index) >24 cm

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3
Q

Risk factors for preterm labour?

A

Smoking, alcohol use, illicit drug use

Previous preterm labour

Twins

Previous cervical surgery

Chorioamnionitis

Preeclampsia + placental abruption

Placenta previa

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4
Q

Management of PCOS?

A

Non med: weight loss, mx metabolic syndrome (lipids, glucose, HTN)

If not concerned about infertility:

Med: OCP (or Metformin if OCP contraindicated)

If concorned about infertility:

Med: Ovulation induction wth clomiphene

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5
Q

Pre-menopausal bleeding, clots, open oss. Ix, Dx, Mx?

A

Doppler US + transvaginal USS

Incomplete abortion

Expectant management +/- misprostol (prostagladin) + Anti-D (625 IU)

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6
Q

Investigation (2) and Mx (1) of prolactinoma?

A

Visual fields

MRI head

Dopamine agonists (cabergoline)

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7
Q

Clinical features pre-eclampsia (8)?

A

High BP + proteinuria

RUQ Abdominal pain (vasospasm to liver)

Blurred vision (raised ICP and vasospasm to retinal artery)

Peripheral swelling (d/t proteinuria)

SOB (pulmonary oedeam d/t proteinuria)

Headaches (raised ICP from cerebral oedema amd HTN)

Hyperreflexia + Clonus

Eventually cerebral oedema (from severe proteinuria) causes seizures

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8
Q

Screening tests in 3rd trimester?

A

Morphology scan 20 weeks

Oral GTT 24 weeks

GBS swab 36 weeks

(Give Anti-D at 28 and 34 weeks for Rh- mother)

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9
Q

Normal CTG (cardiotocography)?

A

HR normal range is 110-160 bpm

Variability of HR is normal (5-25 bpm)

Accelerations (>15bpm for 10 minutes) reflects fetal movement

Early deceleration (decline of >15 bpm) during contractions

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10
Q

When can you have vaginal birth after C section ? When contraindicated? Risk of what?

A

Indicated: After low transverse incision C section

Contraindicated: Classical (vertical) incision, multiple gestation

Risk of uterine rupture

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11
Q

Features of HELLP syndrome?

A

Hemolysis (H)

Haemolysis: low Hb, low haptoglobin, high LDH, high unconjugated bilirubin

Elevated Liver (EL) enzymes

Low Platelet (LP) count

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12
Q

Late deaccelerations reflect what?

A

Deaccelerations after contraction curve

Reflect placental inufficiency and hypoxia. Problem!

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13
Q

How’s this CTG? What does it represent?

A

Late deaccelerations during labour. Low variability, deaccelerations occur after contraction finish. Indicates Placental insufficiency, hypoxia + Problem!

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14
Q

Chlamydia mx?

A

Doxycycline 100mg PO, BD 7 days

OR

Azithromycin 1g PO, stat

Contact tracing back 6 months. Notifiable

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15
Q

When to use tocolytics?

A

Tocolytics (nifidipine/calcium channel blocker)

Indicated in pre-term labour when wanting to allow steroids to work (<34 weeks) or transfer to tertiary hospital

Contraindicated:

Haemodynamic instability in abuptio placentae

Cervical dilation > 4cm

Chorioamnionitis

Nonreassuring fetal signs

Cord prolapse

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16
Q

Uncomplicated genital gonorrhoea mx?

A

STAT IM ceftriaxone and oral azithromycin

Contact tracing back two months. Notifable

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17
Q

Main mechanism of action for progesterone implant?

A

Inhibits ovulation

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18
Q

Investigation of bleeding during pregnancy?

A

Resuscitate if needed

Abdominal examination: SFH, fetal lie

Bloods – CBE, group and save, Kleihauer, coagulation studies

CTG for fetal distress

Tranvaginal USS to assess position of placenta

NO digital vaginal exam

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19
Q

Mx of placenta previa ?

A

If Rh-ve give Anti-D

If bleeding stopped and HD stable –

Lives <20 minutes from hospital and have supports can go home

Lives >20 minutes stay in hospital until no bleeding for 24 hours

If still bleeding and HD stable –

Admit and monitor, send for group and hold

Conider steroids if <34 weeks

Will ultimately need C-section when mature fetus

If not stable -> emergency C-section

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20
Q

Investigations for suspected molar pregnancy? Mx?

A

B-HCG ++++++

USS: snowstorm

Chest CXR + LFTs to check for haematogenous spread of invasive disease (or choriocarcinoma)

Dilation and curettage. Normal reproduction after, higher risk of molar pregnancy

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21
Q

New onset rash in pregnancy. Diff Dx (4)?

A

Pruritic urticarial papules and plaques of pregnancy (PUPPP)/ Polymorphic eruption of pregnancy (PEP)

Atopic eruption of pregnancy

Potentially harmful to fetus:

Pemphigoid gestationis (self limiting)

Obsetetric cholestasis (very itchy on hands and feet) (IOL or ursodeoxycholic acid)

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22
Q

Risk factor for ovarian cancer (1)?

A

HPV 16/18

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23
Q

How to establish labour?

A

Regular contractions (3 every 10 minutes) and cervical dilitation

Can test for premature labour with fetal fibronectin if <35 weeks

Cervical USS to see if effacement if occuring (normal >3cm)

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24
Q

When should a pregnant lady be offered high dose folate supplementation (6)?

A

BMI >35

On anti-epileptics

On methotrexate

Diabetes

Inflammatory bowel disease

Family history of neural tube defects

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25
Risk factors for endometrial cancer? (3)
Unopposd oestrogen exposure Tamoxifen (oestrogen stimulator in endometrium, inhibits in breast) PCOS
26
Mx of preterm labour?
Admit and consider transfer to tertiary centre with NICU Steroids if \<34 weeks – betamethasone Tocolysis (nifedipine) unless contraindicated (infection or bleeding) to delay labour for 48 hours to allow steroids to work MgSO4 for neuro protection (reduce risk of cerebral palsy) \<32 weeks ABx prophylaxis for GBS penicillin G Treat chorioamnionitis (Ampicillin + Gentamicin + Metronidazole) or abruption (Fluid resuscitation and blood transfusion)
27
Free fluid in Pouch of Douglas? (2)
Ruptured Ovarian cyst PID
28
Missed OCP today, last OCP taken 2 days ago. Had unprotected sex last night. At start of active pills (ended start sugar pills 2 days ago). How to manage?
Take missed pill now (2 in one day). As \>48 hours since last pill, use condoms for 7 days As just finished sugar pills, consider emergency conaception.
29
Gonorrhoea dx?
Men: first pas urine NAAT Women: endocervical swab NAAT
30
Post menopausal bleeding differential diagnosis (3)?
Endometrial cancer Endometrial polyp or hyperplasia Atrophic vaginitis
31
Clamydia dx?
First pass urine NAAT
32
Screening tests in 2nd trimester?
2nd trismester chromosomal abnormality screen (if missed first): HCG + Alpha fetoprotein + estriol + inhibin A) (14-20 weeks) Asymptomatic bacteuria screen (12 weeks)
33
Pre-menopausal bleeding, no clots, closed oss. Ix, Dx, Mx?
Doppler US + transvaginal USS Threatened abortion Reversible, watch and wait. Anti-D (625 IU)
34
What is the best test for ovulation?
Progesterone 7 days before expected menstruation
35
Contraindications to OCP (4)
Women over 35 who smoke Previous VTE Migraines with aura Previous stroke, CVD
36
Pre-exising HTN vs Gestational HTN vs Pre-eclampsia?
Pre-existing HTN (\>140/90) prior to 20 wk GA, persisting \>7 wk postpartum Gestational HTN: sBP \>140 or dBP \>90 developing after 20th wk GA in a woman known to be normotensive before pregnancy Preeclampsia: pre-existing or gestational hypertension with new onset proteinuria
37
Pre-menopausal bleeding, no clots, open oss. Ix, Dx, Mx?
Doppler US + transvaginal USS Inevidable abortion Expectant management +/- misprostol (prostagladin) + Anti-D (625 IU)
38
Investigation of urge incontinence? (2)
Bladder diary Urodynamic testing
39
Differentials for SGA fetus?
Symmetrical (small head=body): Chromosomal, TORCH infection Asymmetrical (big head\>\>body): Placental dysfunction: abruption, infarction, previa, chorioamnionitis, matenal issue leading to insufficient nutrients or O2, smoking, alcohol
40
Complications of pre-eclampsia? (9)
Maternal: ARDS, placental abruption, cerebral heamorrhage Fetal: IUGR, pre-term birth Long term: HTN, ischemic heart disease, stroke, venous thromboembolism
41
In developing females, what order of changes during puberty? (4)
Boobs, Pubes, Grow & Flow Breasts (8) Axillary hair (9) Growth spurt (10) Menache (11)
42
Hyperemesis gravidarum dx?
Loss of weight Ketouria
43
Routine screening at start of pregnancy? (5)
Blood type (for Rh- and APO incompatability, may need blood transfusion in future) CBE (anaemia) and iron studies Viral immunology (esp. Rubella) Viral serology (HIV, Hep C, Hep B, Syphillis, TORCH infections, STIs) Cervical screen
44
Main mechanism of action for intrauterine progestrrone device?
Prevents endometrial proliferation
45
When is the OCP effective?
If taken in first 5 day of menstrual cycle (from first day of bleed) -\> effective immediately If not, takes 7 days
46
Test for premature ovarian failure?
FSH/LH (will be increased), FSH:LH ratio \>1.0 CVD screen Bone density screen
47
Causes of polyhydramnios + investigations
Twins Maternal diabetes Reduce fetal swallowing (oesophagial atresia, duodental atresia) Amniotic Fluid Index \>25cm Fetal wellbeing CTG, Morphology USS
48
Ectopic pregnancy haemodynamicaly unstable. Mx? (2)
Rupture: salpingectomy (tube removal) If contralateral fallopian tube not viable: salpinostomy (tube preserving) (+ Rh- mothers need Anti-D 625 IU)
49
When does cervical screening start? What tests does it involve (2)? Pathways?
At age of 25 years or 2 years after the last pap smear (whatever is later) HPV testing If 16/18 deteced -\> Liquid Based Cytology + referral (colposcopy) If 16/18 not detected -\> Liquid Based Cytology High grade lesion -\> referral (colposcopy) Low grade lesion or negative LBC -\> repeat HPV testing in 12 months If after 12 months had repeated positive HPV (any type) -\> referral (colposcopy)
50
Investigations for preeclampsia?
Urine dipstick. urinalysis + 24 urine collection + urine protein-creatine ratio EUC for renal function CBE – haemolysis bloods, anaemia, platelets (HELLP) LFTs (HELLP) US – foetal growth restriction (complication)
51
Milky fishy odor discharge from vagina. Dx, Mx?
Bacterial vaginosis Metronidazole
52
Dysmenorrhea differential dx (3)?
PID Endometrisosis Adenomyosis
53
What is Kleihauer test used for?
The amoutn of maternal-fetal blood expure during a pregnancy bleed Helps determine how much Anti-D is needed.
54
Big fundal height compared to gestational weeks + bHCG++++. Next investigation, dx?
Transvaginal USS (snowstorm appearance) Molar pregnancy
55
Bishop's score cut offs?
\<5 needs cervical ripening (misoprostol or sweeping of membranes) \<6 not ready for vaginal birth (not ready for IOL)
56
Variable deaccelerations reflect what?
Reflect cord compression: change maternal position
57
Colicky lower abdominal pain during pregnancy differentials?
Preterm labour Braxton Hicks contractions Placental abruption UTI, appendicitis
58
Diff dx of bleeding during pregnancy?
Placental abruption Placenta previa Preterm labour Miscarriage Cervical pathology – cancer, ectropion, STI
59
Diagnosis of PCOS?
Needs 2/3: Clinical or lab evidence of hyperadrogenism (increased testosterone, 3:1 LH:FSH) Anovulation Polycystic ovaries on USS
60
Contraindications for HRT (4)?
\>60 or \>10 years since LMP Established cardiovascular disease Previous VTE Suspicion for endometrial cancer or breast cancer
61
Which are cancerous HPV strains?
16 and 18
62
Atrophic vaginitis mx (1)?
Topical oestrogen
63
Risk factors for umbilical cord prolapse (5)?
Breech Multiple pregnancies Premature birth Polyhydramnios
64
What is the Rh- protocol?
For Rh- mothers (assuming Rh+ infants): Anti-D given routinely at 28, 34 and post birth Any bleeding during 2nd and 3rd trimesters Any surgical intervention (ie miscarriage, ectopic pregnancy, D&C, termination)
65
HPV 16/18 came up on cervical screening. Next step?
LBC and referral for colpscopy
66
Follow up of Molar pregnancy?
Esure no invasive disease (CXR) Serum BHCG 48 hours after surgery, every 1–2 weeks while this value is elevated, and then monthly for 6 months.
67
Mx of urge incontinence (2)?
Referral to incontinence nurse Anticholingergics (oxybutynin)
68
Investigations for SGA fetus?
Serial USS + plot growth Amniotic fluid index (AFI \<5 Oligohydramnios) Umbilical artery doppler MCA doppler Waveform TORCH screen Karyotyping
69
Calculating estimated date of delivery: What do you need to know? How to do it?
Need to know: 1) LMP? 2) Regular cycle? 3) How long is cycle? Calculate using Naegele's rule: Date of LMP + 7 days (+ x days) - 3 months + 1 year 'x' days is amount over normal 28 day cycle. Ie if 35 day cycle: Date of LMP + 14 days - 3 months + 1 year. If LMP not known or irregular cycle: need US scan between 7-14 (8-11) weeks (max growth time so most accurate results).If more than 5 day discrepency, use USS
70
Thick, white, adherent non offensive vaginal discharge in diabetic, post Abx steroid user. Dx? Mx?
Candidal vulvovaginitis Topcial antifngal (clotrimazole, miconazole)
71
Causes and mx of post partum haemorrhage?
Tone (uterine atony) Trauma (perineal tears) Tissue (retained placenta, placenta accreta) Thrombin (coagulation disorders) Turned inside out (uterine eversion) ALS and Fluid resuscitation -\> Check cause (high SFH for uterine atony, trauma of vagina) Bimanual uterine massage + ocytocin + tranexamic acid -\> intrauterine balloon tamponade -\> Uterine artery Embolisation
72
Contraception options if on anticonvulsant?
Use Mirena, Copper IUD or barrier All hormonal mehtods interacts with anticonvulsants
73
Mx of normal vomiting in pregnancy?
Dietary changes: small frequent meals + avoid spicy, odorous, high-fat, and acidic foods Ginger +/- pyridoxine (B6) +/- doxylamine (H1-receptor antagonist)
74
TORCH infections?
Toxoplasmosis Others (including Syphillis, Listeria, Varicella Zoster, Parvovirus B19), Rubella virus Cytomegalovirus (CMV) Herpes simplex virus (HSV)
75
Complication of PCOS?
Higher risk of endometrial cancer Infertility Metabolic syndrome: T2DM, CVD OSA
76
Causes of menorrhagia or abnormal uterine bleeding (9)?
Menorrhagia = heavy bleeding PALM (structural) COEIN (physiological) Polyps Adenomyosis Leiomyoma (fibroids) Malignancy (endometrial cancer) Coagulopathy Ovulation dysfunction Endometrisosi Iatrogenic Not classified
77
Complaints about prolapse (7)?
ADD B2 + S2 Asymptomatic Discomfort (dragging) Dysfunction (Bladder + Bowel) Sexual issue pSychiatric concerns (afriad of cancer)
78
What are the screening tests for chromosomal abnormalities ?
First trimester: Pregnancy Associated Plasma Protein (PAPP-A) + b-hCG + nucheal translucency USS Second trimester: Alpha feto-protein + HCG + ucongugated estriol Confirm with CVS or amniocentesis
79
Copious thin white, discharge with fishy odour. \>4.5 pH. Dx? Ix? Mx?
Bacteial vaginosis Clue cells on wet prep from vaginal swab Metronidazole
80
Karyotype of Turner's syndrome + other features (5)
45XO Widely space nipples Webbed neck Hypergonadotropic hypogonadism (low oestrogen, low androgens, high FSH/LH) + Primary amenorrhoea Coarctation of aorta Short stature
81
Indications for induction of labour (6)
_Matenal:_ Mild preclampsia after 37 weeks (severe at any time, consider steroid before 34 weeks) Maternal request Gestational diabetes at 39 weeks (reduce risk of shoulder dystocia) _Fetal:_ Post term pregnancy Prelabour prterm rupture of membranes Chorioamnionitis
82
Benefits to HRT? (3)
Reduce menopausal symptoms Cadioprotective (if no current CVD) Protects against osteoporosis
83
What contraception contraindicated with carbemazapine?
Systemic hormonal (COCP, implanon, POP)
84
Main mechanism of action for COCP?
Inhibits ovulation
85
Post coital bleeding young women differential dx? (4)
Cervical ectropian (new OCOP use) STI Hormonal contraception Cervical malignancy
86
Missed OCP today, last OCP taken 24 hours ago. Had unprotected sex last night. How to manage?
As \<48 hours since last pill, the pill is still working. Take missed pill now (2 in one day) and continue regular cycle
87
A 57-year old post-menopausal woman is referred to the gynaecology clinic by her general practitioner following the incidental discovery of an ovarian cyst on ultrasound. She is otherwise completely well. The ultrasound report describes "a 5cm left sided ovarian cyst with solid components. Right ovary normal." She has had bloods performed and her CA-125 level is 25. Management?
3 for post menopausal x 1 for one US finding x 25 CA-125 level RMI: 75 (3 x 1 x 25) Moderate risk of RMI (25-200) -\> laparoscopic salpingo-oophorectomy High risk (\>200) -\> staging laparotomy
88
Mx of PID?
Ceftriaxone, metronidazole, doxycycline
89
Complicatons of PID (3)?
Infertility Ectopic pegnancy Fitz-Hugh-Curtis syndrome: adhesions that cause chronic pain
90
How's this CTG? What does it represent?
Norml CTG showing early deaccelerations during labour (head compression)
91
Which HPV strains cause warts?
6 and 11
92
Goals of therapy in PCOS? (4 +1)
Reduce irregular menses (OCP, Metformin) Reduce endometrial hyperplasia + risk of endometrial cancer from unopposed oestrogen (OCP) Reduce androgen production (OCP) Control metabolic syndome (weight loss, metformin) Induce ovulation if wanting pregnancy: letrozole
93
How's this CTG? What does it represent?
Variable deaccelerations. Demonstrates cord compression.
94
Pre-menopausal bleeding, no clot, closed oss. No fetal heart beat, Dx, Mx?
Missed abortion Misprostol (prostagladin) + Anti-D (625 IU)
95
Mx of Hyperemesis gravidum? (7)
Urine dipstick (for ketones). EUC to check for AKI. Urine MCS for pyelonephritis Ultrasound on admission -\> higher risk of IUGR IV Fluids. consider thiamine + glucose for prolonged vomiting (prevent Wenicke's encephalopathy) Pharmacological: 1st line: Metoclopramide or doxylamine 2nd line: Ondansetron for severe hyperemesis gravidarum
96
Features of endometriosis (4)?
Dysmenorrhoea Dyspareunia Pelvic pain Infertility
97
Posterior vaginal labial swelling differentials (2) and mx?
Bartholin gland cyst or abscess Abscess: I&D Cyst: Marsupialisation
98
Screening tests in 1st trimester?
Dating USS 8-12 weeks Serology screen (HIV, Hep B, Hep C, Syphillis, TORCH) Blood type 1st trimester chromosomal abnormalities screen: b-HCG, PAPP-A + nuchal translucency scan (11-14 weeks)
99
Risk factors for ovarian cancer?
BRCA + Lynch syndrome Factors that lead to increased number of ovulation cycles: Nulliparity Early menarche, late menopause COCP adds protective effect!
100
Previous cervical screening 12 months ago showed LSIL. Now HPV testing shows HPV11. Mx?
LBC and referral for colpscopy
101
Thin, frothy, yellow, malodourous, strawberry cervix, \>4.5 pH. Dx, Mx?
Trichomonas vaginalis Single dose 2g tinidazole or 2g metronidazole
102
Approximate fundal heights per gestational week (3)?
12 weeks palpable above pubic bone 20 weeks palpable at umbilicus 36 weeks palpable at sternum
103
Investigations for suspected pre-term labour?
Abdominal palpation CTG Do not perform vaginal examination (infection risk, unsure if low lying placenta) US for cervical length (ie start of cervical effacement). If \<3cm, high risk of delivery in next 7 days. Needs hospitalisation GBS status CBE and CRP to check for infection Midstream urine High and low cervical swab Amnistick or ferning Fetal fibronectin test (if \<35 weeks)
104
Missed OCP today, last OCP taken 2 days ago. Had unprotected sex last night. At end of active pills (about to start sugar pills tomorrow). How to manage?
Take missed pills now (2 in one day). As \>48 hours since last pill, use condoms for 7 days As about to start sugar pills, change to new cycle and start active pills
105
Mx of shoulder dystopia?
Ask for help Perform McRobert's manoeuvre (flex and abduct hips) Apply suprapubic pressure Attempt to manually rotate the anterior shoulder (Rubin manoeuvre)
106
Pre-menopausal bleeding, clots, closed oss. Ix, Dx, Mx?
Doppler US + transvaginal USS Complete abortion Anti-D (625 IU)
107
Complications of IUD insertion? (4)
Device expulsion (usually next period) PID Device migration to peritoneal cavity Uterine perforation
108
Ectopic pregnancy haemodynamicaly stable. Mx?
Methotrexate (+ Rh- mothers need Anti-D 625 IU)
109
Causes of oligohydramnios (3) + investigations? (2)
Placental insufficiency (dugs use, smoking, placental abruption) Decreased fetal urination: renal agenesis, posterior urethral valves Amniotic Fluid Index \<5cm Fetal CTG, Fetal morphology US
110
Risk factors ovarian cancer (2)?
BRCA mutations Lynch syndrome (CEO = colorectal, endometrial, ovarian)
111
Causes of increased SFH compared to gestational age?
Wrong gestational age/ EDD Multiple pregnancies (twins) Polyhydramnios: Fetal abnormality (structural causing difficulty swallowing), TORCH infection LGA (from gestational diabetes) If early in pregnancy with no USS -\> Gonadotrophic hyadid/Molar pregnancy
112
Is warfarin safe in breast feeding? Does it cross the plaenta?
Yes and yes (not safe in pregnancy)
113
Risks to HRT ? (3)
Breast cancer risk if for more than 4-5 years (needs oestogen+progesterone) Endometrial cancer risk if uterus + oesotrogen alone Stroke and ischemic heart disease if established VTE or coronary artery disease
114
Previous cervical screening 12 months ago showed LSIL. Now negative HPV. Mx?
Back to 5 yearly screen
115
How's this CTG? What does it represent?
Normal CTG during labour. Normal HR,normal variability, normal accelerations associated with contractions.
116
Post menopausal bleeding investigation (3)?
Transvaginal USS (\>4mm has high risk) Endometrial biopsy Hystoscopy
117
What pathogen are we worried about in gastroenteritis in pregnancy? What's more common (2)?
Listeria More common: rotavirus + norovirus
118
Causes of seconday ammenorrhoea? (7)
Pregnancy Meds: **Anti-psychotics + metoclopramide** (dopamine antagonists -\> nothing opposes prolactin -\> inhibits GnRH) Hypothalamus issue: **Physiological stress, anorexia, excssive exercise** Pituitary issue: **Hypothryoidism** (TRH+++ stimulates prolactin -\> inhibits GnRH), **Prolactinaemia** (prolactin inhibits GnRH), Sheehan's syndrome Ovarian issue: **PCOS, premature menopause** Endometrial issue: **Ashemann's syndrome** post procedure
119
Contraindication to Neagles rule? (2) Alternative?
Irregular cycle, hormonal contraception in last 12 weeks. Crown-rump ratio by USS 7-14 weeks
120
Milky fishy odour with alkalotic pH, smear shows clute cells. Dx and Mx?
Bacterial Vaginosis Metronidazole, must be treated in pregnancy, higher risk of fetal complicaitons (miscarriage, preterm labour)

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