Obs + Gynae II Flashcards
(119 cards)
1
Q
Crown rump length required for diagnosis of miscarriage
A
> 7mm
At <7mm, may be too early to tell if pregnancy is viable but very early, or if it is non-viable
Foetal heartbeat expected once CRL >7mm
2
Q
Repeat USS in potential miscarriage
A
If CRL <7mm without foetal heartbeat, scan repeated at least one week later to ensure heartbeat develops
CRL >7mm, without a foetal heartbeat, scan repeated one week later to confirm a non-viable pregnancy
If mean gestational sac diameter >25mm without a foetal pole, scan repeated after one week to confirm an anembryonic pregnancy
3
Q
Measurements relevant in miscarriages
A
CRL = 7mm, foetal heartbeat expected once CRL >7mm
Mean gestational sac diameter = 25mm, foetal pole expected once diameter >25mm
4
Q
Investigation/management in miscarriage <6 weeks
A
USS not useful, perform repeat urine pregnancy test after 7-10 days. Negative –> confirms miscarriage
Expectant management, unless bleeding continues, or pain occurs, or risk factors e.g. previous ectopic
5
Q
Follow-up for low-grade cervical intraepithelial neoplasia (CIN 1)
A
Screen again at 12 months in the community
6
Q
Most common type of vaginal cancer
A
Overall = secondary (metastatic cancer), usually from cervix, ovary or endometrium
Prumary cancer = squamous cell carcinoma
7
Q
Features of vaginal cancer
A
Post-coital bleeding is common
May be followed by an offensive watery discharge
8
Q
Follicular phase of menstrual cycle
A
Granulosa cells surround oocytes –> follicles
FSH stimulation –> further development of follicles
Granulosa cells secrete oestrogen as follicles grow –> negative feedback –> reduced FSH/LH secretion
Oestrogen –> cervical mucus is more permeable
Dominant follicle forms
LH surge –> dominant follicle release ovum
9
Q
Luteal phase of menstrual cycle
A
After ovulation, follicle collapses –> corpus luteum –> secretes progesterone –> maintains endometrial lining, thickens cervical mucus
Also secretes some oestrogen
10
Q
What happens to the corpus luteum when fertilisation occurs
A
Syncitiotrophoblast of the embryo secretes hCG –> maintain corpus luteum –> produces progesterone + oestrogen
11
Q
What happens if no fertilisation occurs in menstrual cycle
A
No hCG production –> corpus luteum degenerates –> stops producing oestrogen + progesterone
This causes endometrium to break down + menstruation occurs
Stromal cells of endometrium release prostaglandins –> encourage breakdown of uterus + contraction
LH + FSH levels rise
12
Q
Process of foetal descent through birth canal
A
Descent
Engagement (<2/5 palpable)
Flexion
Internal rotation
Crowning
Extension of presenting part
External rotation of head
Delivery (of shoulders and rest of body)
13
Q
Management of asymptomatic bacteriuria in pregnancy
A
Confirm presence of bacteria with second culture (contamination of first sample possible)
Offer an immediate antibiotic prescription, taking into account urine culture + susceptibility
e.g. Nitrofurantoin (avoided at term), amoxicillin (if results available + susceptible), cefalexin
14
Q
Diagnosis of polyhdramnios
A
Amniotic fluid index >24cm (or 2000ml+)
AFI >95th centile for gestational age
15
Q
Diagnosis of oligohydramnios
A
Amniotic fluid index <5cm (or <200ml)
AFI <5th centle for gestational age
16
Q
Timings of amniotic fluid
A
Increases steadily until 33 weeks gestation
Plateaus from 33-38 weeks
Declines –> approx 500ml at term
17
Q
Causes of polyhdramnios
A
Idiopathic = 50-60% cases
Conditions preventing foetus from swallowing
Duodenal atresia
Anaemia
Foetal hydrops
Twin-to-twin transfusion syndrome
Genetic or chromosomal abnormalities
Macrosomia
Maternal diabetes
Maternal use of lithium
Viral infections
18
Q
Management of polyhydramnios
A
No medical intervention required for majority
Aminoreduction if severe maternal symptoms (risk of infection + placental abruption)
Indomethacin –> enhance water retention –> reduce foetal output (premature closure of PDA so not used beyond 32 weeks)
Examine baby if idiopathic
19
Q
Risks of polyhydramnios
A
Malpresentation
–> higher risk of cord prolapse
Postpartum haemorrhage
20
Q
Causes of oligohydramnios
A
Preterm prelabour rupture of membranes
Placental insufficiency (blood flow to brain –> reduced foetal urine output)
Renal agenesis (Potter’s syndrome)
Non-functioning foetal kidneys
Obstructive uropathy
Genetic/chromosomal abnormalities
Viral infections
21
Q
Management of oligohydramnios
A
Depends on underlying cause
P-PROM –> induction of labour if relevant, steroids for foetal lung development, antibiotics for infection
Placental insufficiency –> deliver before 36-37 weeks
22
Q
Complication of oligohydramnios
A
Foetal muscle contractures due to inability to move limbs in utero
23
Q
Points to remember for epilepsy in pregnancy
A
Risk of uncontrolled epilepsy > risk to foetus
Take 5mg folic acid per day prior to conception –> 12 weeks (risk of neural tube defects)
Aim for monotherapy
24
Q
Epilepsy medications in pregnancy
A
Avoid sodium valproate (NTD)
Carbamazepine is least teratogenic of older antiepileptics
Phenytoin –> risk of cleft palate, given vitamin K in last month of pregnancy to prevent clotting disorders in newborn
Lamotrigine –> seems safe, may need increased dose
Most anti-epileptics safe in breastfeeding
25
Blood tests for hypothalamic/pituitary causes of secondary amenorrhoea
Low levels of gonadotrophins (FSH + LH)
Low levels of oestradiol (from ovaries)
FSH + LH should rise in response to low oestrogen --> hypothalamic dysfunction
26
What is postpartum thyroiditis
Changes in thyroid function within 12 months of delivery
Affects women without a history of thyroid disease
Can be hyper/hypothyroidism, or both
27
Typical pattern of postpartum thyroiditis
1. Thyrotoxicosis (usually in first three months)
2. Hypothyroid (usually from 3-6 months)
3. Thyroid function gradually returns to normal (usually within 1 year)
28
Blood tests in postpartum thyroiditis
Thyrotoxicosis: Raised T3/T4, low TSH
Hypothyroidism: Low T3/T4, raised TSH
Thyroid peroxidase antibodies found in 90% patients
29
Management of thyrotoxic phase of postpartum thyroiditis
Propanolol for symptom control
Not usually treated with anti-thyroid drugs
Annual monitoring of TFTs
30
Management of hypothyroid phase of postpartum thyroiditis
Levothyroxine
Annual monitoring of TFTs
31
Risk factors for GDM
BMI >30
Previous macrosomic baby weighing 4.5kg+
Previous GDM
First degree relative with diabetes
Family origin with a high prevalence of diabetes e.g. South Asian
32
Indications for GDM screening
Any risk factor present
Large for dates foetus
Polyhydramnios
Glucose on urine dipstick
33
Cut-offs for GDM on OGTT
Fasting = 5.6 mmol/L
2 hours = 7.8 mmol/L
5, 6, 7, 8
34
Management of GDM
Fasting glucose <7: diet + exercise for 1-2 weeks, then metformin, then insulin
Fasting glucose >7: start insulin +/- metformin
Fasting glucose >6 + macrosomia/other complications: start insulin +/- metofmrin
Glibenclamide (sulfonylurea) can be used if decline insulin/cannot target metformin
35
Blood glucose targets for women with GDM
Fasting: 5.3 mmol/L
1-hour post-meal: 7.8 mmol/L
2 hours post-meal: 6.4 mmol/L
Avoid 4mmol/L or below
36
Management of pre-existing diabetes in pregnancy
Take 5mg folic acid from preconception to 12 weeks gestation
Weight loss for women with BMI >27
Stop oral hypoglycaemic agents (apart from metformin) and commence insulin
Retinopathy screening
Planned delivery 37-38+6 weeks gestation
37
Insulin use in labour
Sliding-scale insulin regime for T1DM
Dextrose + insulin infusion titrated to blood usgar levels
Also considered for women with GDM or T2DM with poorly controlled blood sugars
38
Postnatal care for GDM
Can stop diabetic medications immediately after birth
Test fasting glucose at least 6 weeks later
Regular BG checks for neonatal hypoglycaemia - aim >2mmol/L
39
Postnatal care for women with existing diabetes
Insulin sensitivity increases after birth, and with breastfeeding --> lower insulin doses + be aware of hypoglycaemia
40
Complications of diabetes in pregnancy
Neonatal hypoglycaemia
Polycythaemia
Jaundice
Congenital heart disease
Cardiomyopathy
41
Investigation for placenta praevia
Gold standard = transvaginal ultrasound, can be used to determine position of the placenta
Avoid digital vaginal examination as may provoke a severe haemorrhage
42
Contraception use in women who are menopausal (even if using HRT)
<50 years old: 2 years after last menstrual period
>50 years old: 1 year after last menstrual period
Appropriate methods: barrier, IUD/IUS, POP, Progesterone implant, sterilisation, depot injection (if <45)
- Depot can cause weight gain and reduce bone mineral density
NB: COCP can be used up to age of 50
43
Contraindications to HRT
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Endometrial hyperplasia or cancer
Uncontrolled hypertension
VTE
Liver disease
Acive angina or MI
Pregnancy
44
Principles of HRT to reduce risks
Progesterone required in women who have a uterus, to avvoid endometrial hyperplasia and cancer associated with unopposed oestrogen
Patches > pills to avoid VTE risk
45
Non-hormonal treatments for menopausal symptoms
Lifestyle changes e.g. diet, exercise, weight loss, smoking cessation, alcohol/stress/caffeine reduction
CBT
Clonidine: lowers BP + reduces HR. Useful for vasomotor symptoms
SSRIs
Venlafaxine
Gabapentin
46
Indications for HRT
Premature ovarian insufficiency, even without symptoms
Reducing vasomotor symptoms
Improving symptoms e.g. low mood, decreased libido, poor sleep + joint pain
Reducing risk of osteoporosis in women <60
47
Risks of HRT
Increased risk of breast cancer (esp with combined HRT)
Endometrial cancer
VTE
Stroke + coronary artery disease (with long term use in older women)
48
Considerations when choosing HRT formulation
Local symptoms --> topical treatment
Systemic symptoms --> systemic management -->
No uterus --> oestrogen-only HRT
Uterus --> combined HRT -->
Perimenopausal --> cyclical combined HRT
Postmenopausal (>12 months since last menstruation) --> continuous combined HRT
49
Options for oestrogen delivery in HRT
Oral (tablets)
Transdermal (patches or gels)
- Patches mroe suitable for women with poor control on oral treatment, higher risk of VTE/CVD/headaches
50
Options for progesterone delivery in HRT
Women with period in past 12 months --> cylical progesterone for 10-14 days per month
No period --> continuous progesterone
- Last 24 months if <50
- Last 12 months if >50
Oral
Transdermal
IUS (e.g. Mirena) --> licensed for 4 years
51
Progesterone vs Progestogens vs Progestins
Progesterone = hormone naturally produced in body
Progestogens = any chemical that targets and stimulates progesterone receptors
Progestins = synthetic progestogens
52
Types of progesterone used in HRT
C19 progestogens - derived from testosterone e.g. norethisterone, levonorgestrel, desogestrel
- May be helpful for women with reduced libido
C21 progestogens - derived from progesterone (more female in effects) e.g. progesterone, dydrogesterone, medroxyprogesterone
- May be helpful for women with side effects such as depressed mood or acne
53
Description of primary dysmenorrhoea
No underlying pelvic pathology
Usually appears within 1-2 years of menarche
Pain typically starts just before or within a few hours of period starting
Suprapubic cramping pains - may radiate to the back or down the thigh
54
Management of primary dysmenorrhoea
NSAIDs e.g. mefenamic acid + ibuprofen (inhibit prostaglandin production)
COCP used as 2nd line
55
Description of secondary dysmenorrhoea
Result of underlying pelvic pathology
Typically develops many years after menarche
Pain usually starts 3-4 days before onset of period
Causes:
- Endometriosis
- Adenomyosis
- PID
- Intrauterine device
- Fibroids
56
Management of secondary dysmennorhoea
Referral to gynaecology for investigation
Use analgesia in the meantime
57
Management of rhesus incompatibility in pregnancy
Prevention of sensitisation - give IM anti-D injections
Routinely given:
- 28 weeks gestation (may also give at 34 weeks)
- Birth (if baby's blood group is found to be rhesus-positive)
Also given if sensitisation may occur
Given within 72 hours of a sensitisation events
500IU if >20GW, 250IU if <20GW
58
Situations that may lead to sensitisation in Rhesus -ve women (and therefore Anti-D given)
Antepartum haemorrhage
Amniocentesis procedures/chorionic villus sampling/foetal blood sampling
Abdominal trauma
Delivery of Rh +ve infant
Termination of pregnancy (if >10 GW)
Miscarriage >12 GW
Ectopic pregnancy (if managed surgically)
External cephalic version
59
Investigation to detect feto-maternal haemorrhage in a suspected sensitising event in Rhesus -ve mothers
Kleihauer test - used to detect amounts of foetal haemoglobin in the mothers bloodstream
Used to determine if the correct amount of Anti-D has been given
60
Management of eclampsia
1st line: magnesium sulphate
- Treats seizures
- Neuroprotection for foetus
Fluid restriction to avoid fluid overload
61
Contraception in active breast cancer
Injectable progesterone UKMEC4 contraindicated (e.g. depo-provera)
Recommended to use barrier methods or IUD, as progesterone is contra-indicated
62
Investigations for reduced foetal movements
If past 28 weeks gestation:
- Initially handheld Doppler to confirm foetal heartbeat
- If no heartbeat detectable --> immediate ultrasound
- If heartbeat present --> CTG should be used for at least 20 minutes
24-28 weeks:
- Handheld doppler to confirm foetal heartbeat
<24 weeks + previous movements felt
- Handheld doppler
Not felt by 24 weeks --> referral to maternal-foetal medicine unit
63
Management of P-PROM at 24-33 weeks
Monitor for signs of chorioamnionitis
Advise avoid sexual intercourse
Prophylactic erythromycin 250mg QDS 10 days
Corticosteroids (as less than 34+6)
Aim expectant until 34 weeks
64
Management of P-PROM at 34-36 weeks
Monitor for signs of chorioamnionitis
Advise avoid sexual intercourse
Prophylactic erythromycin 250mg QDS 10 days
65
Missed pill rules - COCP
If 1 pill missed - take ASAP, even if taking two in same day, no additional contraception needed
If 2+ pills missed -
- Take last pill ASAP, leave any other missed pills
- Use condoms/abstain from sex until taken pills for 7 days in a row
- If pills missed in week 1: consider emergency contraception if UPSI in pill-free interval, or in week 1
- If pills missed in week 2: no need for emergency, as 7 days consecutively have been taken
- If pills missed week 3: finish current pack, and omit pill-free interval
66
Management of bleeding <6 weeks gestation
Important to rule out ectopic pregnancy
If no pain/risk factors -->
- Return if bleeding continues, or pain develops
- Repeat urine pregnancy test after 7-10 days and return if it is positive (negative means miscarriage)
67
Drugs to avoid whilst breastfeeding
Antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
Psychiatrics: lithium, benzodiazepines
Aspirin
Carbimazole
Methotrexate
Sulfonylureas
Cytotoxic dugs
Amiodarone
68
Cervical screening in pregnancy
Usually delayed until 3 months post-partum unless missed screening, or previous abnormal smears
69
HRT in women with history of migraine with aura
HRT not contraindicated
Topical > oral
70
HRT in women with family history of DVT
HRT not contraindicated
Topical > oral
71
When to suspect a vesicovaginal fistula
Continuous dribbling incontinence
After prolonged labour
From an area with limited obstetric services
72
COCP and surgery
Preferably should be discontinuted 4 weeks before major elective surgery, and all surgery to legs or surgery which involves prolonged immbolisation of lower limbs
Progesterone-only contraceptive may be offered as an alternative
Oestrogen-containing contraceptive can be restarted after mobilisation
73
Pregnancy tests after pregnancy termination
Urinary pregnancy test often remains positive for up to 4 wees following termination
+ve test beyond 4 weeks indicates incomplete abortion, or persistent trophoblast
74
Risk factors for Group B Streptococcus infection
Prematurity
Prolonged rupture of membranes
Previous sibling GBS infection
Maternal pyrexia e.g. secondary to chorioamnionitis
75
Management of group B streptococcus
Benzylpenicillin = GBS prophylaxis
Offered to:
- Women with GBS in previous pregnancy (50% chance recurrence) (or testing late in pregnancy, then abx)
- Previous baby with early, or late-onset GBS disease
- Preterm labour
- Pyrexia >38 during labour
76
Contraception postpartum
Women only require contraception 21 days from giving birth
77
What is hydrops foetalis
Occurs when extra fluid accumulates in two or more areas in the foetus including ascites, pleural effusion, pericardial effusion, and skin oedema
78
Immune cause of hydrops foetalis
Blood group incompatibility (e.g. rhesus status) between mother and foetus --> anaemia + haemolysis
79
Non-immune causes of hydrops foetalis
Chromosomal abnormalities e.g. trisomy 13, 18 or 21, Turner's: most common in early pregnancy
Structural abnormalities
Cardiac abnormalities or arrhythmias
Anaemia - congenital parovirus B19 infection, alpha thalassaemia major, massive materno-feto haemorrhage
Infection - toxoplasmosis, rubella, CMV, varicella
Twin-twin transfusion syndrome (in recipient twin)
Chorioangioma
80
Investigation of foetal hydrops
US assessment: including echocardiography + assessment of middle cerebral artery
Maternal blood tested: Kleihauer and parovirus, CMV and toxoplasmosis IgM testing
Foetal blood tested if anaemia suspected
Blood testing and/or amniocentesis for karyotyping
81
Management of foetal hydrops
Cure only possible when anaemia (transfusion) or compression by fluid collection such as pleural effusions (vesicoamniotic shunting) have caused hydrops
82
What factors are considered in BISHOP score
Foetal station (0-3)
Cervical position (0-2)
Cervical dilatation (0-3)
Cervical effacement (0-3)
Cervical consistency (0-2)
83
Score used to determine whether to induce labour
Bishop score (0-13)
Score of 7+ predicts successful induction
Score <4 suggests cervical ripening may be required to prepare the cervix
84
Indications for induction of labour
Prolonged gestation: offered at 40+0 to 40+14 in women with uncomplicated pregnancies
Premature rupture of membranes >37 weeks (or expectant management for max 24 hours)
If <37 weeks, consider on a risk vs benefits
Maternal health problems e.g. pre-eclampsia, diabetes
Foetal growth restriction
Intrauterine foetal death
85
Contraindications for induction of labour
Relative:
- Breech presentation
- Triplet or higher order pregnancy
- 2+ previous low transverse C-sections
Absolute:
- Cephalopelvic disproportion
- Major placenta praevia
- Vasa praevia
- Cord prolapse
- Transverse lie
- Active primary genital herpes
- Previous classical C-section
86
Methods of induction of labour
Vaginal prostaglandins - ripen the cervix, and have a role in contraction of smooth muscle of the uterus
- Tablet/gel: 1st dose, plus 2nd dose if labour not started 6 hours later
- Pessary: 1 dose over 24 hours
Amniotomy: articificial rupture of membranes using amnihook (Bishop score calculated first) --> syntocinon infusion
Membrane sweep at 40 and 41GW to nulliparous women, and 41 to multiparous women: adjunct to IOL as increases likelihood of spontaneous delivery
87
Complications of induction + augmentation of labour
Failure of induction --> operative delivery
Uterine hyperstimulation
Nausea, vomiting + diarrhoea (due to prostaglandins)
Uterine rupture
88
Features of foetal alcohol syndrome
Baby may show symptoms of alcohol withdrawal at birth e.g. irritable, hypotonic, tremors
Short palpebral fissure
Hypoplastic upper lip
Smooth/absent filtrum
Learning difficulties
Microcephaly
Growth retardation
Epicanthic folds
Cardiac malformations
89
Criteria for termination of pregnancy
1. <24 weeks
2. Continuation will involve more risk to life of pregnant woman, or existing children in the family, than termination
3. Prevent permanent injury to physical/mental health of mother
4. Mother's life at risk if continued
5. Risk of severe/physical abnormalities
90
Legal requirements for abortion
Two registered medical practitioners must sign to agree abortion is indicated (cannot be FY1)
Must be carried out by a registered medical practitioner in an NHS hospital or approved premise
91
Medical abortion
Mifepristone (anti-progestogen) --> halts pregnancy + relaxes cerviz
Misoprostol (prostaglandin analogue): 1-2 days later --> softens cervix + stimulates uterine contractions
- From 10 GW, additional misoprostol doses (e.g. every 3 hours) required until expulsion
Anti-D if >10GW
92
Surgical abortion
Can be performed at any gestional age
Medications for cervical priming: misoprostol, mifepristone or osmotic dilators
<14GW: cervical dilatation + suction of contents of the uterus
14-24GW: cervical dilatation and evacuation using forceps
Anti-D prophylaxis (considered if <10GW)
93
Moulding
Degree of overlap of foetal skull bones
94
Caput
Localised swelling found on baby's head due to pressure from cervix or pelvic inlet
Capit succedaneum = diffuse swelling of the scalp, unlike cephalohaematoma (which does not cross suture lines)
95
Risk of artificial rupture of membranes
Cord prolapse
Especially possible if there is a high head/presenting part/malpresentation, polyhydramnios or foetal growth restriction
If there is --> may be prudent to perform ARM in theatre
96
Measuring size of foetus
<14GW: Crown-rump length is the most reliable method
If CRL >84mm (correlates to >14GW) --> head circumference becomes a more reliable indicator
97
Estimated delivery date
Can be calculated from date of last menstrual period (LMP)
40 weeks after first day of LMP (not date of conception)
Only true if cycle is 28 days and regular - if shorter or longer, days can be added or subtracted
98
Complications of rubella infection in pregnancy
Teratogenic effects worse + higher chance of passing on infection to foetus at earlier gestations
Sensorineural deafness
Cataracts
Congenital heart disease - patent ductus arteriosus
Glaucoma
Growth retardation
Purpuric skin lesions
'Salt and pepper' Chorioretinitis
Hepatosplenomegaly
Microphthalmia
Cerebral palsy
99
Complications of cytomegalovirus infection in pregnancy
Low birth weight
Purpuric skin lesions
Sensorineural deafness
Microcephaly
Visual impairment
Learning disability
Encephalitis/seizures
Pneumonitis
Hepatosplenomegaly
Anaemia
Jaundice
Cerebral palsy
100
Complications of toxoplasmosis infection in pregnancy
Cerebral calcification
Chorioretinitis
Hydrocephalus
Anaemia
Hepatosplenomegaly
Cerebral palsy
101
What is twin-to-twin transfusion
Anastomosis of vessels in single placenta of monochorionic twin pregnancies --> one gains at the others expense
102
Consequences of twin-to-twin transfusion
One twin: anaemic, hypovolaemic, oligohydramnios + growth-restricted
Other twin: polycythaemia, hypercolaemia, polyuria + polyhydramnios
103
First degree perineal tear
Injury to skin only
No need for routine suturing unless haemostasis is an issue
104
Second degree perineal tear
Injury to perineum involving perineal muscles
No involvement of anal sphincter
Can be sutured on the ward
105
Third degree perineal tear
Injury to perineum involving anal sphincter complex
Must be sutured in theatre with adequate analgesia
3a - <50% external anal sphincter thickness torn
3b - >50% external anal sphincter torn
3c - both EAS and internal anal sphincter torn
106
Fourth degree perineal tear
Involves anal sphincter complex + anal/rectal epithelium
Must be repaired in theatre
107
Beta-hCG level required to visualise gestational sac on TVUS
>1000IU
(>3500IU for abdominal scan)
108
Differentials of positive pregnancy test with empty uterus
Complete miscarriage (fall in hCG)
Very early intrauterine pregnancy (increase in hCG)
Ectopic pregnancy (normally plateau hCG)
--> use serial beta-hCG measurements
109
Uterine inversion
Rare complication of birth
Fundus of uterus drops down through uterine cavity + cervix
Incomplete = descends, but not as far as the introitus
Complete = descends to the introitus
110
Presentation of uterine inversion
Large postpartum haemorrhage
Maternal shock/collapse (shock out of proportion with haemorrhage due to vagal stimulation)
May be felt with manual vaginal examination or seen at the introitus
111
Management of uterine inversion
Johnson manoeuvre: use hand to push back up + then oxytocin to cause contraction
Hydrostatic methods: fill vagina with fluid to 'inflate' uterus back to normal position. Requires tight seal at entrance of vagin
Surgery
112
Risk factors for uterine inversion
Uterine atony
Previous uterine inversion
Fundal placenta - especially if too much traction put on cord during delivery of placenta
113
Management of atrophic vaginitis
Lubricants + moisturisers
Topical oestrogen cream may also be considered
114
Symptoms of atrophic vaginitis
Dryness of vagina
Local irritation i.e. pruritus, pressure + burning pain
Painful intercourse
Vaginal bleeding e.g. haematuria, or post-coital bleeding
Urinary symptoms
Vaginal discharge: usually white or yellow, sometimes malodorous
115
Examination findings of atrophic vaginitis
Reduced pubic hair
Loss of labial fat pad
Narrowing of vaginal introitus
Thinning of labia minora
Smooth, shiny vaginal mucosa with loss of skin folds
Dryness of mucosa
Loss of vaginal muscle tone
Erythema or bleeding
116
When does acute fatty liver of pregnancy occur
Rare complication
May occur in third trimester or in the period immediately following delivery
117
Features of acute fatty liver of pregnancy
Abdominal pain
Nausea + vomiting
Headache
Jaundice
Hypoglycaemia
Severe disease may result in pre-eclampsia
118
Investigations in acute fatty liver of pregnancy
LFTs: ALT typically elevated (hepatic derangement)
USS: Steatosis
119
Management of acute fatty liver of pregnancy
Supportive care
Once stablised, delivery is the definitive management
