Obstetrics Flashcards
1
Q
When are children competent to consent?
A
When they can understand the nature and consequences of treatment
2
Q
4 reasons why you can breech confidentiality for children
A
too immature to understand/ consent (see Frazer guidelines)
force or threat of force dangerous to health
drugs/ alcohol used to influence them
known to police as having abusive relationships with children/young people
3
Q
How old is a child when they are presumed competent to consent to treatment
A
16-18 years
4
Q
When can a child refuse treatment
A
If they are over 18
5
Q
What happens if a competent child refuses treatment
A
A parent/court might allow management in their best interest
6
Q
What is the difference between the frazer guidelines and gillick competence?
A
Frazer guidelines: If under 16 for contraceptives
Gillick competence: General issues around consent
7
Q
5 points for frazer guidelines
A
understand advice cannot inform parents dangerous to their health unless they get contraception have sex anyway in their best interest
8
Q
What 3 acts are used for consent in people with learning difficulties?
A
learning disability, sex and the law (2005)
sexual offences act (2003)
mental capacity act
9
Q
What do people with learning difficulties need in order to consent to sex ?
A
They need capacity to know the mechanisms and the consequences of sex
10
Q
What would you do if a patient came to you after a rape
A
Refer to sexual assault referral centre (SARC) where a forensic physician does Hx and examination
Checks for pregnancy, HIV, Hep B, suicidal ideation and safeguarding
11
Q
how can you assess the quality of NHS services
A
Number of processes (referral/smears) and Outcome (mortality/morbidity, STI, unplanned pregnancy)
12
Q
4 issues with NHS services
A
societal (less services), cultural (language, modesty), economic (access), political (e.g. law regarding abortion)
13
Q
4 sexual health services
A
GP
Family planning clinics (STI, unplanned pregnancy)
Pharmacies
SARC
14
Q
3 GU services
A
GUM clinic
GP
A&E
15
Q
2 gynae services
A
Gynaecologist
GP
16
Q
4 midwife/obstetric services
A
Hospital Antenatal services Community midwife GP Early assessment unit
17
Q
Define stillbirth
A
A baby delivered after 24 weeks with no signs of life
1/200
18
Q
Defineneonatal death
A
Death of a LIVE BORN infant within 28 days (3/1000)
19
Q
Define early neonatal health
A
Within 7 days
20
Q
Define post-neonatal death
A
From 28 days to 1 year (1/1000)
21
Q
Define stillbirth rate
A
Number of stillbirths per 1000
4/1000
22
Q
Define perinatal mortality rate
A
Number of stillbirths + early neonatal deaths per 1000 total
(7/1000)
23
Q
Define infant mortality rate
A
Number of deaths in first year per 1000 live births (4/1000)
24
Q
Define maternal mortality rate
A
Within 42 days of TOP/whilst pregnant
9/100,000
25
What recent campaign has reduced infant mortality rate in the UK
Sleep campaign
26
8 risk factors for stillbirth in the UK
Foetal growth restriction (biggest cause)
Congenital abnormality
Multiple birth
Maternal age (<25 or >40), ethnicity (black/Asian have 50% increased risk), poverty, substances, obstetric complications.
27
5 causes of stillbirth in the UK
4 causes worldwide
1 key fact about worldwide stillbirths
- 92% occur before onset of labour
- 54% are unexplained
- 25% due to asphyxia/ trauma e.g. cord prolapse/ abruption
- 15% due to congenital abnormalities
- 10% due to infections
Worldwide, 50% of deaths occur during labour, maternal infections inc malaria, syph and HIV, post term pregnancy and poorly controlled maternal health conditions e.g. NTH, DM
(most are preventable)
28
4 biggest causes of neonatal death in the UK and 1 worldwide
- prematurity is biggest killer (resp. disorders followed by neurological disorders)
- congenital abnormalities (heart, NTD, etc)
- obstetric complications e.g. shoulder dystocia
- infections
Globally, majority are due to infections
29
What global percentage of stillbirths occur in low/middle income countries
98%
| 75% in ssa
30
8 strategies for prevention of stillbirth in the UK
Vit D, folate and iron
Stop smoking (SIDS/ neonatal breathing difficulties), alcohol, medication
Certain foods (raw meat, soft chesses, liver)
Screen for diseases
Breastfeeding
CTG training
31
5 ways to reduce perinatal deaths
- thermal protection, dry the goddam baby
- hygiene
- breastfeeding
- assessment
- prevention (vit K, Hep B and BCG if necessary)
32
First down syndrome screening
11-14 weeks
Combined test
Increased nuchal BHCG; low PAPP-A
33
Second down syndrome screening
15-20 weeks
Quadruple test
High inhibin A and BHCG, low AFP and low unconjugated oestriol
34
What happens if there is a low and high chance of downs syndrome
and what are the cut offs?
1/150 is cut off
| Go for amniocentesis
35
2 benefits of screening for downs syndrome
Allows the parents to prepare and plan
| Gives them an informed choice if they want to terminate
36
3 arguments against screening for downs syndrome
Risk of false positive and negatives
Spontaneous abortion with diagnostic testing (1%)
Suggesting Down’s syndrome life is less important
37
When should you seek fertility help
After 1 year of trying (6 months if over 35 years)
38
First line for infertility
Lifestyle change
39
Epidemiology of fertility
Affects 1/7 couples
| 84% should conceive within 1 year
40
5 causes of infertility and %
```
30% male factor
20% ovulation failure
15% tubal damage
20% unexplained
15% other
```
41
Investigations for infertility
Semen analysis
Serum progesterone 7 days prior to next period
Oestrogen
FSH/LH
42
Medication used for infertility where the cause is known
Clomifene (SERM, increases HPG axis)
43
How long do you wait after investigations before IVF is considered
1 year
44
How many cycles of Intrauterine Insemination (IUI)?
| 3 criteria
Up to 6 cycles
If unable to have vaginal intercourse (e.g. disability)
Condition that means need help to conceive (e.g. STI)
Same sex relationship
45
How many cycles of IVF if below 43 years
Up to 3 cycles on the NHS if:
Below 43 years and 2 years of trying with 12 cycles of artificial insemination
Between 23 and 39 AND there is a fertility problem OR infertile for more than 3 years
46
Does any previous self-funded count towards 3 funded by NHS
Yes
47
How many cycles of IVF if aged 40-42 years
1 cycle of IVF if after 2 years of regular sex or 12 cycles of insemination
- never had IVF
- no evidence of fertility problems
- risks have been discussed
48
2 lifestyle criteria for IVF
Non smoking
| Healthy BMI
49
Epidemiology of assisted reproduction
2% of all babies in the UK
| 25% success rate
50
What are the 5 stages of IVF?
```
Ovarian hyperstimulation
Oocyte recovery
Insemination
Embryo culture and transfer
Luteal phase support
```
51
What happens during ovarian hyperstimulation?
GnRH agonist given to cause pituitary downregulation to prevent premature ovulation (increased then decreased oestrogen)
jMG, LH, FAH and hCG to stimulate folliculogenesis
52
When does oocyte recovery occur?
34-36 hours after hCG infections
| US for transvaginal oocyte recovery
53
Percentage of sperm which fertilise during insemination
Put sperm in petri dish with oocytes
| 50-70% fertilise
54
What happens during embryo culture and transfer
Fertilised oocytes examined, selected and inserted into the uterus
55
What happens during luteal phase support
Progesterone supplementation to support the pregnancy until 10 weeks (when placenta begins to make progesterone)
56
What is intrauterine insemination (IUI)
Separate healthy sperm and inject them into the uterus
57
Benefits and drawbacks of IUI
Good for male infertility
If you can't have sex, same sex or HIV
Cheaper
Worse outcomes
58
What happens during intracytoplasmic sperm injection (ICSI)
Same as IVF but sperm are INJECTED into oocytes instead of left to mix in a petri dish
59
2 indications for ICSI
Indicated when quality of sperm is poor/low sperm count or when pregnancy has failed in the past
60
What happens during pre-implantation genetic diagnosis (PIGD)
Single cell removed from the blastocyst and screened for diseases
61
3 things people can donate
Who uses it?
Ethics?
Oocyte, Sperm or Embryo
Same-sex
Ethics of anonymity
62
When would you use surrogacy
When the mother can no-longer carry the foetus
63
Legality of surrogacy
Surrogate is the legal mother and cannot hand over legal responsibility until 6w postnatal
64
6 risks of IVF to mother
ectopic, OVHS, multiple gestation GD, anaemia, pre-eclampsia, miscarriage
65
3 risks of IVF to the foetus
Prematurity (and consequences), IUGR, Miscarriage
66
What does the court/adoption agency consider in regards to the child's welfare in subfertility
Effect on child on not being a member or original family
Harm (children’s act 1989) child has suffered or is at risk of suffering
In adoption, child’s religious, racial, cultural and linguistic background
67
3 arguments for IVF
Procreative autonomy: respect patient choices, minimalize state interference
Infertility can affect mental health
Welfare interest of future child
68
2 arguments against IVF
Embryos have moral status (destruction of embryos)
| Harm to those conceive (OHSS, multiple, ectopics)
69
Positive and Negative right of IVF
- Positive rights: no obligation to provide parents with means to have children
- Negative right: obligation not to interfere with peoples decision to have children
70
What does the HFEA Act 1990 State?
no treatment unless welfare of child has been taken into account (including need for a father)
- changed to 2008 to remove father and just supportive parenting
71
Epidemiology of TOP
30% of pregnancies terminated
| 92% before 13 weeks
72
What does the Abortion Act (1990) state about the foetus?
Foetus holds no legal status until birth
73
When was the abortion act amended from 28 weeks to 24 weeks
1990
74
2 laws regarding medical practitioners in termination
Done by a medical practitioner in NHS hospital or licenced premise
Two medical practitioners signs HSA1 agree unless it is an emergency (HSA2)
75
5 key points for TOP
A: continuing pregnancy involves greater risk of life to pregnant women than if terminated
B: Termination is necessary to prevent permanent injury to physical/mental health of mum
C: pregnancy < 24w and continuing pregnancy means greater risk than if terminated to physical/mental of pregnant woman
D: < 24w and continuing pregnancy means greater risk to physical/mental heath of existing children of pregnant woman
E: if child was born it would suffer physical or mental abnormalities > seriously handicapped.
76
i. e. > 24w, threatens mums life, permanent injury to mum, child has serious handicap (A,B,E)
i. e. < 24w risk>benefit of preg vs TOP to physical/mental health of mum or her children (C,D)
?
77
When can you continue with a TOP in under 16 year olds
If Gillick competent AND
- Girl understands all aspects and implications
- Cant persuade her to tell her parents/ allow us to tell them
- Physical/mental health is likely to suffer unless they receive treatment
- In the best interest of the young person to receive treatment without parents
78
3 routes to get an abortion
Contact advisor e.g. British pregnancy advisory service (BPAS), Marie Stopes
GP for referral to abortion service
Visit contraception clinic/ family planning clinic/ sexual health clinic/ Gum for referral
79
Length of time from initial appointment to abortion
2 weeks
80
Can a doctor refuse
Yes, unless it is an emergency
| They need to refer quickly to another person
81
5 things to do prior to TOP
```
Screen for STO
Discuss contraception
Check smear
Give ABX prophylaxis
Give Anti-D if needed after procedure
```
82
What infection can you get?
Post-operative salpingitis
83
TOP procedure if less than 9 weeks
use mifepristone (anti-progesterone – cervix easier to open) followed by misoprostol (prostaglandins) 48h later to stimulate uterine contractions
84
TOP procedure if less than 13 weeks
Misoprostol 3h before surgery – reduce cervical trauma
| Surgical dilation and suction of uterine contents
85
TOP if more than 15 weeks
Surgical dilation and evacuation of uterine contents or late medical abortion (mini-labour)
86
TOP procedure if more than 22 weeks
Feticide is performed by using KCL in umbilical vein or foetal heart.
87
4 complications of TOP
Infection (10%)
Cervical trauma (1%)
Failed TOP (1%)
Haemorrhage 1/1000)
88
6 arguments for TOP
- respects mothers autonomy
- prevents harm to mothers health
- prevents harm to foetus’ health
- may be due to crime e.g. rape
- may not be able to cope with a child
- more backstreet abortions
89
4 arguments against TOP
- Pro-life: ends life of fetus with moral status of a person (their rights)
- religions reasons
- abortions for Down’s syndrome – suggest they have a lower moral status than other children
- subjects more parents to unnecessary procedures.
90
What are the four types of FGM?
Type 1: patrial/total removal of clitoris
Type 2: Removal of clitoris and labia minora
Type 3: Narrowing vaginal oriface by cutting labina minora/majora
Type 4: All other harmful procedures
91
?Where is FGM most common and why?
Africa, Middle East, Malaysia, Indoesia
Preservation of virginity, promoting hygiene, cultural norms and religion
92
Consequences of FGM for girl
Infection, pain, dyspareunia, self-harm, depression
93
Suspect FGM
Illegal
| Call police
