Obstetrics and Gynaecology Flashcards
(275 cards)
1
Q
Examination of the Pregnant abdomen:
Obeservation
A
- Distension (does she look pregnant)
- Linea nigra
- Striae gravidarum
- Surgical scars
- Foetal movement
2
Q
Examination of the Pregnant abdomen:
Palpation
A
- Symphasis-fundal height
- Foetal lie
- Foetal position
- Foetal engagement
- Foetal heartbeat
- Foetal movement
3
Q
What can you measure on CTG?
A
- Contractions
- Variation
- Acceleration
- Deceleration
- Heartbeat
- Foetal movement
4
Q
How to auscultate a foetal heart sound on pregnant abdomen?
A
This is best heard over the baby’s shoulder. If you have correctly identified the lie you should roughly know where this is. Put either your Doppler ultrasound or Pinard stethoscope over this area and listen. Always palpate maternal pulse at the same time to ensure you are not incorrectly hearing the transmission of mum’s, remember her’s will be slower).
5
Q
Examining the pregnant abdomen
A
- Obervation
- Palpation
- Ausultation
- Inform your examiner that for completeness you would like to check her blood pressure, and also perform urinalysis. If you have any concerns regarding the baby’s heart rate you should suggest that a CTG should also
6
Q
Vaginal/vulval presentation:
Ulcers
A
typically associated with genital herpes.
7
Q
Vaginal/vulval presentation:
Abnormal vaginal discharge
A
There are several causes of abnormal vaginal discharge including:
- Bacterial vaginosis: a thin, profuse fishy-smelling discharge without pruritis or inflammation.
- Candidiasis: a curd-like (“cottage cheese”), non-offensive discharge with associated pruritis and inflammation.
- Chlamydia and gonorrhoea (symptomatic): a purulent vaginal discharge with or without associated inflammation.
- Trichomoniasis: an offensive yellow, frothy vaginal discharge with associated pruritis and inflammation.
8
Q
Vaginal/vulval presentation:
Scarring
A
may relate to previous surgery (e.g. episiotomy) or lichen sclerosus (destructive scarring with associated adhesions).
9
Q
Vaginal/vulval presentation:
Vaginal atrophy
A
most commonly occurs in postmenopausal women.
10
Q
Vaginal/vulval presentation:
White lesions
A
may be patchy or in a figure of eight distribution around the vulva and anus, associated with lichen sclerosus.
11
Q
Vaginal/vulval presentation:
Masses
A
causes include: *Bartholin’s cyst - obstruction of the Bartholin glands, located on both sides of the vaginal opening. The cyst is a painless lump. COMPLICATIONS: abscess. MANAGEMENT drainage/Abx
*vulval malignancy
12
Q
Vaginal/vulval presentation:
Varicosities
A
varicose veins secondary to chronic venous disease or obstruction in the pelvis (e.g. pelvic malignancy).
13
Q
Vaginal/vulval presentation:
Female genital mutilation
A
total or partial removal of the clitoris and/or labia and/or narrowing of the vaginal introitus.
14
Q
Inspection of the vulva
A
- Scars
- Erythema
- Masses
- Discharge/Bleeding
- Rash/Vesicles
- Prolapse (cough relfex)
15
Q
Female genital mutilation
A
Female genital mutilation (FGM) is defined by the WHO as all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.7 Over 140 million girls and women worldwide have undergone FGM.8 Women attending maternity, family planning, gynaecology, and urology clinics (among others) should be asked routinely about the practice of FGM.9 Cases of FGM in girls under the age of 18 should be reported to the police.10
16
Q
Bartholin’s cyst
A
Bartholin’s glands are responsible for producing secretions which maintain vaginal moisture and are typically located at 4 and 8 o’clock in relation to the vaginal introitus. These glands can become blocked and/or infected, resulting in cyst formation. Typical findings on clinical examination include a unilateral, fluctuant mass, which may or may not be tender.
17
Q
Lichen sclerosus
A
Lichen sclerosus is a chronic inflammatory dermatological condition that can affect the anogenital region in women. It presents with pruritis and clinical examination typically reveals white thickened patches. Destructive scarring and adhesions develop causing distortion of the normal vaginal architecture (shrinking of the labia, narrowing of the introitus, obscuration of the clitoris).
18
Q
Inspection of the cervix:
Identify the cervical os
A
if open, this may indicate an inevitable or incomplete miscarriage.
19
Q
Inspection of the cervix:
Inspect for erosions around the os
A
most commonly associated with ectropion however early cervical cancer can have similar appearances.
20
Q
Inspection of the cervix:
Cervical masses
A
typically associated with cervical malignancy.
21
Q
Inspection of the cervix:
Ulceration
A
most commonly associated with genital herpes.
22
Q
Inspection of the cervix:
Abnormal discharge
A
several possible causes including bacterial vaginosis, vaginal candidiasis, trichomonas, chlamydia and gonorrhoea.
23
Q
Cervical ectropion
A
Cervical ectropion is a condition in which the columnar epithelial cells which are normally located inside the cervical canal are present on the outside of the vaginal cervix (normally the only cells on the outside of the vaginal cervix are squamous epithelial cells). The areas of columnar epithelial cells appear red against the normal pink colour of the cervix and are often located around the external os. They are more prone to bleeding, due to the presence of a network of delicate fine blood vessels, and as a result, patients often present with post-coital bleeding.
24
Q
Cervical cancer
A
Cervical cancer is caused by persistent infection with human papillomavirus (HPV). Prior to the development of cervical cancer, the cells of the cervix can become dysplastic, a condition that is known as cervical intraepithelial neoplasia (CIN). Cervical screening can identify patients infected with HPV who have CIN, allowing early treatment to prevent progression to invasive cervical cancer. Many women do not have symptoms in the early stages of cervical cancer, but symptoms can include:
- vaginal bleeding (intermenstrual, post-coital)
- increased vaginal discharge
- vaginal discomfort.
Clinical examination typically reveals
- white or red patches on the cervix in early disease
- cervical ulcer or tumour in more advanced disease.
25
Completing a speculum exam/smear test:
* Urinalysis: including β-HCG to rule out pregnancy (e.g. ectopic pregnancy).
* Vaginal swabs/endocervical swabs: if there are concerns about infection (bacterial/viral).
* Bimanual vaginal examination: to assess the uterus and adnexa for masses.
* Complete abdominal examination: if there are concerns about intraabdominal pathology (e.g. appendicitis).
* Ultrasound abdomen and pelvis: to further investigate pelvic pathology.
* HPV testing: can be performed on the same cervical screening sample if using liquid-based cytology (no extra swabs required).
26
Assessing the uterus
* Size: the uterus should be approximately orange-sized in an average female.
* Shape: may be distorted by masses such as large fibroids.
* Position: the uterus may be anteverted or retroverted.
* Surface characteristics: note if the uterus feels smooth or nodular.
* Tenderness: may suggest inflammation (e.g. pelvic inflammatory disease, ectopic pregnancy).
27
Uterine Position
The position of the uterus can be described as:
* Anteverted: the uterus is orientated forwards towards the bladder. This is the most common position of the uterus.
* Retroverted: the uterus is orientated posteriorly, towards the spine. This is a less common uterine position present in approximately 1 in 5 women.
28
Double vs triple swabs
* Double swabs: a NAAT swab (endocervical or vulvovaginal) and a high vaginal charcoal media swab.
* Triple swabs: a NAAT swab (endocervical or vulvovaginal), a high-vaginal charcoal media swab and an endocervical charcoal media swab.
29
Where is the NAAT (nucleic acid amplification test) swab taken from and what does it test for?
Endocervical/Vulvovaginal.
Chlamydia and gonorrhoea
30
Where is the High vaginal charcoal media swab taken from and what does it test for?
Posterior fornix of the cervix
Bacterial vaginosis, trichomonas, vaginalis, candida and Group B streptococcus.
31
Where is the Endocervical charcoal media swab taken from and what does it test for?
Cervical os
MCS for gonorrhoea (only after gonorrhoea detected on NAAT)
32
How is type 1 diabetes managed in pregnancy?
Insulin Pump therapy
33
Is gestational diabetes due to insulin resistance or insulin insufficiency?
Insulin resistance
| Placental hormones counteract the effects of insulin, thus when baby is delivered, diabetes resolves
34
Maternal risk factors for GDM
* BMI >30
* previous baby >4.5kg (10lb)
* Previous history of GDM
* Child/sibling with DM
* Ethnicity (Afro-caribbean/South Asian/Middle Eastern)
35
What are the screening parameters for GDM?
If someone has >1 risk factor then they should be screened
* starts at wk 8-12
1. OGTT which takes about 2 hours
- Fasting <5.6
- 2hr glucose >7.8
2. Test urine at every antenatal visit
3. Blood glucose at booking and 24-28 wks
36
Management of GDM?
* Diet/exercise
* Metformin
* Insulin therapy
37
What are the factors to consider before starting insulin in GDM?
* Can't tolerate metformin
* uncontrolled blood sugar
* very large foetus
38
How do you manage bleeding disorders in pregnancy?
1. Tranexamic acid, if stable
| 2. G+S, XM for transfusion
39
What are the symptoms of pre-eclempsia?
* Mother:
- headache
- seeing flashing lights/spots
- chest pain
- oedema
* Foetus
- Reduced growth
- Reduced foetal movement
40
How do you monitor/diagnose eclampsia?
- BP monitoring (3 consecutive readings)
- Urinalysis (dip and PCR)
* Measuring for proteinuria*
41
How do you manage HTN/eclampsia?
- Monitoring (BP/symptoms)
- Diet and lifestyle
- Labetolol (beta-blocker) +/- nifedipine (CCB)
- Aspirin prophylaxis (stroke risk)
42
What should you consider when premature rupture of membranes?
- Group B strep/chorioamnionitis (bacterial infection that occurs before or during labor)
43
How to take a smear Hx?
1. When was your last smear?
| 2. What was found?
44
How much blood is supplied to the uterus at term?
600ml/min
45
How much blood is supplied to the uterus at labour?
800ml/min
46
What are the 4Ts of PPH?
Tone, Tissue, Trauma, Thrombin
1. Tone
The uterus must contract down to clamp down in the arteries.
2. Tissue
Placental tissue left in uterus may prevent uterine contraction
3. Trauma
Bleeding tears e.g. episiotomy, high vaginal walls, labial tears, parautheral etc.
4. Thrombin (clotting)
clotting disorders can increase bleeding.
47
How do you manage poor uterine tone after delivery?
1. Uterotonics
e. g. Synthotocin/Synthometrine
2. 'Rub up' uterus
stimulates contraction
48
How long can you wait for placental delivery?
30 mins
49
What are the symptoms of obstetric cholestasis?
**Widespread itching (without rash)**
occasional jaundice
50
How to read a CTG?
DR C BRAVADO
DR: Define Risk
C: Contractions
```
BR: Baseline rate
A: Accelerations
VA: variability
D: Decelerations
O: Overall impression
```
51
How is obstetric cholestasis diagnosed?
clinical (itching w/ no rash)
+ LFTs/bile studies
52
What scans will all pregnant women have?
2 scans: Dating scan, Anomaly scan
```
Dating scan (12+0 - 13+6)
Anomaly scan (18+0 - 12 +0)
```
53
What do you include in an Obstetric history?
1. Presenting complaint (PC)
2. Hx of PC
3. Hx of current pregnancy
4. Obstetric Hx
5. Past gynaecological Hx
6. PMHx
7. PSHx
8. Drug Hx + allergies
9. Family Hx
10. Social Hx
11. Summary
54
How do you calculate Estimated Date of delivery (EDD?
Due date = 40 weeks from LMP
OR
Naegle's rule = LMP - [3 months] + [1 year +7 days]
(LMP + 9month, 7 days)
55
What are the gestational ages for the trimesters?
1st: <12/40
2nd: 12-28/40
3rd: 28-42/40
56
What are some teratogenic drugs that should not be used in pregnancy?
1. Sodium valproate:
- Anti-epileptic
- mood stabiliser
2. ACEi
- Hypertension
- Mood stabiliser
3. Methotrexate
- cytotoxic drug (chemottherapy)
- Crohn's
- Rheumatoid arthritis
4. Warfarin
- anti-coagulant/blood thinner
5. Retinoids
- Acne vulgaris
6. Diuretics (esp. thiazide)
7. Statins
8. Lithium
9. Vitamin A supplementation
57
What are the key components of a gynae Hx?
1. Menstrual Hx
2. Pain Hx
3. Discharge
4. Sexual Hx
5. Contraception Hx
6. Urogynaecology Hx
7. Menopause
58
How do you take a Menstrual Hx?
1. Menarche and menopause
2. LMP
3. Cycle length
4. Length of bleeding
5. Abnormal bleeding
- heavy bleeding and Sx of anaemia
- Painful bleeding (dysmenotthoea)
- intermenstrual bleeding
- post-coital bleeding
- post-menopausal bleeding
59
How do you take a pain Hx?
SOCRATES
60
How do take a discharge Hx?
1. Amount
2. Colour
3. Smell
4. Itchy
5. Blood
61
How do you take a sexual Hx?
1. Sexual active?
- regular/casual partner
2. Sexual health screen
- positive tests and treatments
3. Problems
- Post coital bleeding
- Dyspareunia
* superficial
* deep
62
How do you take a contraception Hx?
1. Current method
- duration
- problems?
- compliance e.g. missed pills
2. Previous methods
3. Plans for family
63
How do you take a urogynaecology Hx?
1. Incontinence?
- stress
- urge
- contant
2. Urinary symptoms
3. Prolapse
- lumps
- bowel symptoms
64
How do you take a menopausal Hx?
1. Age of menopause?
2. Symptoms
- vasomotor
- psychological
3. HRT and other meds
4. Vulval symptoms
- itching
- bleeding
- lumps
65
What should be included in your systemic review in a gynae Hx?
1. FLAWS
2. GI symptoms
3. GU symptoms
66
What should be included in a past gynae Hx?
1. Smears
- last smear timing
- abnormal smears and treatments
* colposcopy
2. Gynaecological investigations
3. Gynaecological procedures/surgeries
- complications
4. Oestrogen exposure
- menarche and menopause
- COCP/HRT/Tamoxifen
- Obesity
67
What should be included in a past obstetric Hx?
1. Previous TOP/Miscarriage/Ectopic/Stillbirth
2. Previous live pregnancies
- method of conception
- delivery methods
- delivery date: pre/at/post-term
- birth weight
- complications and post-natal perios
68
What should be included in a gynae FHx?
1. Gynaecological cancers
2. Benign gynae conditions:
- Fibroids
- Endometriosis
- Premature ovarian failure
3. Thrombosis
69
What is the DDx for menorrhagia?
* fibroids
* adenomyosis
* dsyfunctional uterine bleeding
* STI
* endometrial polyp
* malignancy
70
What is the DDx of lower abdominal pain?
* ectopic pregnancy
* PID
* Ovarian torsion
* Endometriosis
* Non-gynaecological
- pancreatitis
- renal pathology
71
What is the DDx of post-menopausal bleeding?
* atrophic vaginitis
* endometrial cancer/endometrial hyperplasia
* cervial/endometrial polyp
72
What happens at the booking appointment (8-12 weeks)
- Clinical Hx
- Lifestyle advice
- Booking BMI and BP
- Medications
* 10mcg Vit D + 400mcg Folic acid (Prengnacare)
- Urine dip and culture
- Booking blood tests
- Screening for clinical conditions in the mother and baby
- Ask about social support and domestic violence
73
When is a high dose of folic acid (5mg) required?
* Coeliac disease
* Diabetes
* Taking anti-epileptics
* BMI >30
* Sickle cell
* Previous pregnancy w/ neural tube defect
74
Why do we take an MSU @ booking?
To detect asymptomatic bacteriuria
This leads to an increased risk of:
- pyelonephritis
- preterm labour
- perinatal mortality
Tx: Abx
75
What bloods are checked @ Booking?
1. FBC
2. Haemoglobinopathies
3. Blood group and Rhesus status
4. HIV/HBV/Syphillis
76
What is checked @ Dating Scan (10-14 wks)?
- gestational age
| - detect multiple pregnancy
77
What is checked @ Anomaly scan (18-21 wks)?
- Detect any foetal strucural abnormalities
- look for placental position
- amniotic fluid volume
78
What are the screening tests for aneuploidy?
1. Combined test
2. Quadruple test
3. Integrated test
4. Free fetal DNA test
Threshold for offering Dx tests: 1 in 150
79
When is the Combined Test performed and what does it measure?
11-14 wks
1. PAPP-A
2. beta-HCG
80
When is the Quadruple Test performed and what does it measure?
14-20 wks
1. Alpha-fetoprotein (AFP)
2. beta-HCG
3. Inhibin A
4. Unconjugated Estriol
81
When is the Integrated Test performed and what does it measure?
14-20 wks
1. Quadruple test
- AFP
- beta-HCG
- inhibin A
- Unconjugated Estriol
2. Nuchal transluceny
3. PAPP-A
82
When can Chorionic Villous sampling be done and what are the risks?
11-14 wks
1% miscarriage
Mosaicism
83
When can Amniocentesis be done and what are the risks?
15-18 weeks
1% miscarriage
Fetal talipes if done earlier
84
What conditions are tested for in the foetal Dx tests?
Aneuploidies
- Down's syndrome
- Edward/s syndrome
- Patau's syndrome
Genetic conditions
- Cystic Fibrosis
- Sickle Cell Disease
- Thalassaemia
- Duchenne's Muscular Dystophy
85
At what wks are the routineAN appointments?
* All women: 28, 34, 36, 38, 41, 42 wks
* Nulliparous only: 25, 31 and 40
What do you measure:
1. Measure SFH
2. Check BP
3. Perform Urine Dipstick
4. Discuss concerns and birth plan
86
When do you give Anti-D to a rhesus-neg mother?
@28 weeks gestation
87
What vaccinations are given to pregnant women?
1, Whooping cough @ 16-32wks
| 2. Influenza (flu season only) @ any gestation
88
What is labour?
Process in which foetus and placenta are expelled by the uterus
Defined from the onset of regular uterine activity associated with effacement and dilatation of the cervix, and descent of the presenting part
89
What is the first stage of labour?
Onset of painful contractions with cervical dilatation to 10cm
* LATENT PHASE: Onset of painful
contractions until cervix is fully effaced up to 4cm dilation
* ACTIVE PHASE: Fully effaced cervix dilates beyond 4cm
90
What is the 2nd stage of labour?
From full dilatation of the cervix to delivery of the
baby.
```
There are 2 stages:
o Descent of head to pelvic floor (passive)
o Pushing (active)
```
91
According to the NICE guidelines, when do we consider the 2nd stage of labour to be prolonged?
o Prolonged if >3 hours (regional anaesthesia) or 2 hours without
– nulliparous
o Prolonged if >2 hours (regional anaesthesia) or 1 hour without - multiparous
92
What is the 3rd stage of labour?
From delivery of the baby to delivery of the placenta
- Physiological
- Active management with uterotonics e.g.
synthometrine/syntocinon
93
When is the third stage of labour considered to be prolonged?
> 30 mins
94
What are the three P's of successful labour?
1. Power
- uterine contractions
2. Passage
- pelvic inlet and outlet
3. Passenger
- foetal position
95
What are the movements of the foetal head in PV labour.?
1. Engagement on the occipito-transverse (OT) position)
2. Descent and flexion
3. Rotation 90 degrees to the occiput anterior (OA position)
4. Extension to deliver
5. Restitution and delivery of the shoulder
96
What is the foetal lie?
relationship between the long axis of the foetus with respect to the long axis of the mother
- longitudinal
- oblique
- transverse
97
What is the foetal presentation?
The part of the foetus that lies over the inlet. The three main presentations are:
- cephalic (head first)
- breech (pelvis first)
- shoulder
98
What is foetal engagement?
Descent of the foetal head into the maternal pelvis, occurs when ≤ 2/5 palpable per abdomen
99
What is the foetal attitude?
Relationship of foetal parts to each other. The basic attitudes are flexion and extension.
The foetal head is in flexion when the chin approaches the chest and in extension when the occiput nears the back.
The typical foetal attitude in the uterus is flexion, with the head bent in front of the chest, the arms and legs folded in front of the body, and the back curved forward slightly.
100
What is the foetal station?
Relationship of the presenting part (head/buttocks/feet) to the ischial spines (assessed vaginally)
101
What is caput succedaneum?
Diffuse swelling of the scalp caused by the pressure of the scalp against the dilating cervix
Graded subjectively from 0 (none) to +3 (marked)
102
What is moulding?
The bones of the foetal head move closer together or overlap to help the head fit through the pelvis.
Moulding can decrease the biparietal diameter by ~1 cm.
103
How many sutures does the anterior fontanelle have and what shape is it?
4, diamond
104
How many sutures does the anterior fontanelle have and what shape is it?
3, triangle
105
What factors can affect the cervical effacement and dilation?
1. Contractions
2. The pressure of the foetal head on the cervix
3. Ability of the cervix to soften and allow distension
106
What is an episiotomy?
When the perineal body is cut
This is to allow for the passage of the head though the perineum
NB: prophylactic episiotomies not done in the UK
107
What factors can affect the passage of the head through the pelvis?
1. Attitude or flexion
2. Position
3. Size of the head
108
What is considered a delay in first labour?
* < 2 cm in 4 hours for nulliparous
| * < 2 cm in 4 hours or a slowing in the progress of labour for multiparous
109
How do you manage inefficient uterine action?
1. ARM: if membranes still in tact
| 2. Oxytocin = syntocinon
110
What is cephalopelvic disproportion?
Implies pelvis too small to allow head to pass through (both passage and passenger!)
retrospective diagnosis when unable to deliver despite adequate uterine activity and absence of malposition or presentation.
111
What is a brow presentation and how is it managed?
* Very deflexed head (extended)
* Presentng diameter 13.5cm
CS: delivery if stlll brow at level of spines
112
What is malposition in labour?
Disorder of rotation often combined with some extension of foetal head
This can lead to longer more painful labour – backache and early desire to push
113
What are the causes of delay in the first stage of labour?
* Inefficient uterine activity (power)
* Malposition, malpresentation or large baby (passenger) • Inadequate pelvis (passage)
* Combination of two or more
114
What are the causes of delay in the second stage of labour?
* Inefficient uterine activity (power)
* Malposition, malpresentation or large baby (passenger) • Inadequate pelvis (passage)
* Combination of two or more
115
How do we manage delay in the 2nd stage of labour?
1. syntocinon
| 2. instrumental delivery
116
What does the partogram record?
1. frequency and strength of contractions
2. descent of the head in fifths palpable
3. station of the head
4. amount and colour of amniotic fluid
5. basic obs: BP/HR/Temp
6. Urine: ketones and protein
117
What are the indications for using Low cavity forceps (Wrigley’s)?
Used mainly at CS for delivery of head
118
What are the indications for using Mid cavity non-rotational forceps (Neville-Barnes, Simpson)?
* Used when in direct OA position (can be used in direct OP)
| * Can manually rotate from OT or OP to direct OA before use
119
What are the indications for using Mid cavity rotational forceps (Keilland’s)?
• Reduced pelvic curve on the blades allows rotation about the
axis of the handle
• Helps correct asynclitism and malposition
• Must only be attempted by experienced operator.
120
What are the indications for operative vaginal delivery?
MATERNAL:
1. Exhaustion
2. Delay in 2nd stage of labour
3. Maternal conditions that require short second stage or avoidance of valsalva
- NYHA Class III or IV of heart disease
- msyathenia gravis
FOETAL:
foetal compromise
121
What are the maternal risks for operative vaginal delivery?
vaginal and sphincter trauma (especially forceps)
122
What are the foetal risks for forceps delivery?
* facial nerve palsy
* skull fractures
* orbital injury
* Intracranial haemorrhage
123
What are the foetal risks for ventouse delivery?
* scalp lacerations and avulsions
* Cephalohaematoma
* retinal haemorrhage
* Subgaleal and or intracranial haemorrhage
124
What are the benefits of ventouse delivery (over forceps)?
1. kinder to mother
2. less need for analgesia
3. less need for episiotomy
125
What are the contraindications for ventouse delivery?
* <34 weeks
* foetal bleeding disorders
* face presentation
* maternal infection (relative CI)
126
What are the benefits of forceps delivery (over ventouse)
1. Kinder to the baby
2. Less likely to fail
3. Don't require much maternal effort
4. Position must be direct OP/OA
127
What is the average age of menarche?
10-15 years old
12 (UK average)
128
What is the average age of menopause?
45-55 years old
51 (UK average)
129
What does the ovarian follicle consist of?
1. Oocyte/ovum
2. Surrounding cell layers that contribute into steroid production
* granulosa cells (inner most and facing the antrum)
* theca cells (inner and externa)
130
What are the steroid hormones in menstruation?
* Oestrogens (oestradiol, oestrone, oestriol)
* Progesterone
* Testosterone
131
What are the precursors to oestradiol synthesis?
Androgens
132
What drives conversion of androgens to oestradiol?
FSH
133
Where is oestradiol produced?
Granulosa cells only
134
Where are androgens produced?
Theca cells
driven by LH receptor binding
135
What are the precursors to androgens?
Cholesterol molecules
136
What is the Hypothalamus-Pituitary-Gonadal Axis
```
Hypothalamus
| GnRH +
Anterior Pituitary
| FSH, LH +
Ovary --- Estradiol -
```
[Estradiol places negative feedback on the anterior pituitary and the hypothalamus]
137
What is the Follicular/Proliferative Phase?
Onset of menstruation to the day of ovulation
Variable length of 14-21 days average
138
What is the Luteal/Secretory Phase?
Ovulation to the onset of the next menses
Fixed length of 14 days
139
What are the stages of the Follicular/Proliferative Phase?
* Follicles are dependent on FSH for growth
* FSH allows selection of the dominant follicle, the other 4-6 follicles die from atresia
* Dominant follicle increases in size, increasing the amount of oestrogen being produced
* Once level of oestrogen is about 300nmol for 2-3 days, negative feedback switches to positive, triggering the LH surge
140
What are the stages of ovulation?
* Ovulation occurs 24-36 hours after the LH surge, releasing the egg from the follicle
* The corpus luteum forms from the follicle
* The corpus luteum produces progesterone and is the only source of significant levels of progesterone during the cycle.
* Progesterone has negative feedback on FSH and LH, preventing subsequent follicle development
141
What is the function of the corpus luteum?
The corpus luteum produces progesterone and is the only source of significant levels of progesterone during the cycle.
142
What are the stages of the luteal phase?
* cells of the corpus luteum die 14 days after ovulation
* This results in a fall in progesterone, leading to shedding of the endometrium and menstruation
* falls of steroids results in the loss of negative feedback on the hypothalamus and pituitary, allowing FSH to rise again
**NB: in pregnancy, the corpus luteum is maintained due to HCG production, so continues to produce progesterone
143
What is the source of progesterone in pregnancy?
corpus luteum
This is maintained by beta-HCG
144
What is menses composed of?
desquamated endometrial tissue, red blood cells, inflammatory exudates and proteolytic enzymes
145
What is the impact of progesterone withdrawal on the menstrual cycle?
1. increase coiling and constriction of the spiral arterioles
2. reduced blood supply to the superficial endometrial layers and lead to tissue ischeemia
146
What is released by the endometrium after loss of progesteron?
prostaglandin
147
What is the impact of prostaglandin release in menstruation?
* contract the uterine smooth muscles and sloughing of the degraded endometrial tissue
* aid endometrial necrosis and bleeding
148
What are the changes in the endometrium during the Follicular/Proliferative Phase?
increased mitosis, tubular glands
149
What are the changes in the endometrium during the Luteal/Secretory Phase?
Stromal oedema, decidiualisaton (no mitoses,
| increased vessel tortuosity)
150
What are the changes in the endometrium during menstruation?
Vasoconstriction of spiral arterioles, stromal
| haemorrhage and disintegration of the endometrium
151
What are the effects of oestrogen on the endometrium?
thickening of the endometrium
152
What are the effects of progesterone on the endometrium?
* causes pre-thickened endometrium to become more suitable for implantation through remodelling
* balances and negatively regulated proliferative effect of oestrogen
* prevents further endometrial growth by inhibiting mitotic activity
153
What happens to the cervix in the follicular phase?
increased vascularity, leading to oedema and watery mucous. This aides the passage of sperm
154
What happens to the cervix in the luteal phase?
the mucous thickens, preventing sperm entry
155
How does a urinary pregnancy test work?
Detects urinary beta-HCG >25
This is produced by syncytiotrophoblast D6-7 post fertilization
156
How does beta-HCG maintain the corpus luteum?
binds to LH receptors
This prevents the endometrium from breaking down
157
When do beta-HCG levels peak?
12 weeks gestattion
158
What is the Luteal-placental shift and when does it take place?
8-12 wks in pregnancy => the feto-placental unit takes over production of progesterone
159
What is the main hormone of the follicular phase?
Oestrogen
160
What is the main hormone of the luteal phase?
Progesterone
161
What causes ovulation?
LH surge
162
What hormone thickens the endometrium?
Oestrogen
163
What hormone opposes the effect of oestrogen and makes the endometrium suitable for implantation?
Progesterone
164
What are the clinical features of PCOS?
* oligomenorrhoea/amenorrhoea
* hirsutism
* acne
* infertility
165
What are the metabolic features?
* obesity
| * insulin resistance
166
What are the long-term risks?
* endometrial cancer
* cardiovascular disease
* diabetes inc. GDM
167
How do we Dx PCOS?
Rotterdam Critera (2 out of 3)
* oligomenorrhoea/amenorrhoea
* clinical or biochemical evidence of hyperandrogenism
* Evidence of polycystic ovaries on USS
*Excluding other aetiologies
168
What investigations do we do for PCOS?
* LH - raised
* FSH - normal to low
* LH:FSH ratio, 3:1
* SHBG - low
* testosterone - raised
169
What is PCOS?
Complex syndrome of ovarian dysfunction with features of hyperandrogenism and PCO morphology
170
What are the main features of PCOS pathophysiology?
1. Excess testosterone
= XS LH, and not enough FSH to convert to oestrogen
2. Constantly in the follicular phase
= follicles arrested in development, and endometrial lining thickens in response to oestrogen (no progesterone to balance)
3. Follicles do not mature to become ovulated
= due to low FSH
4. Annovulation causes
= no LH surge due to persistently high LH
171
What is the management of subfertility in PCOS?
1st line: Clomiphene
- Selective oestrogen receptor modulator acting on the hypothalamus
- block negative feedback from oestrogen
- increases gonadotrophin levels
2nd line: *Metformin and Clomifene
- helps with wt loss
* Laparoscopic Ovarian drilling
- stimulates ovulation
3rd line: IVF
172
What is the management of oligo/amenorrhoea in PCOS?
* Withdrawal bleeds protect the endometrium from thickening
* COCP with withdrawal bleed (at least 3 per year(
* Progestogens
* IUS
173
What is the management of hyperandrogenism in PCOS?
* Weight loss
* Anti-androgenic COCP containing cyproterone acetate
==> Dianette
==> Increases risk of VTE
* Eflomithine cream
* Laser hair removal
* Anti-androgen medication
- Spironolactone
- Finasteride
- Cyproterone acetate
174
What are the types of emergency contraception?
OVULATION DEPENDENT:
1. Levonelle (Levonorgestrel)
2. EllaOne (Ullipristal)
NON-OVULATION DEPENDENT:
3. Copper Coil
175
What is the time window for Levonelle?
72h
176
What is the time window for EllaOne?
120h
177
What is the time window for the copper coil?
120h
178
Which form of emergency contraception's efficacy is decreased by BMI?
Levonelle
179
What advice should you give for Levonelle/EllaOne?
Advice to give:
• Take as soon as possible as efficacy decreases with time from UPSI
• If vomits within 3 hours, must take repeat dose
• May alter next menstrual period-heavy/longer/shorter bleeding
• Take pregnancy test if next menstrual period is delayed by a week
180
How does the emergency pill work?
inhibits ovulation
NB: pills are not very effective after ovulation
181
When can an IUD be used as emergency contraception?
any time in the cycle.
They are NOT ovulation dependent.
182
What is the most effective method of emergency contraception?
IUD
183
What is antepartum haemorrhage (APH)?
Bleeding from or into the genital tract occuring from 24+0 weeks of pregnancy and prior to the birth of the baby
NB: leading cause of perinatal and maternal mortality worldwide
184
What is spotting?
staining, streaking or blood spotting noted on underwear or sanitary protection
185
What is a minor APH?
<50 ml blood loss that has settled
186
What is a major APH?
50-1000ml blood loss
| * no signs of clinical shock
187
What is a massive APH?
>1000ml blood loss
| and/or signs of clinical shock
188
What are the causes of APH?
* Placenta praevia (+ vasa praevia)
* Uterine rupture
* Bloody show/cervical change
* Cervical pathology
- ectropian
- polyp
- infection
* Placental abruption
189
What is placenta praevia?
Placenta covering the internal os
190
What is a 'low lying placenta' from 16/40
placenta within 20mm from internal os
191
What are the clinical features of placenta praevia?
* identified on scan
| * Painless PV
192
What is the management of placenta praevia?
* cannot deliver vaginally, require C/S
| * NEVER do a VE in these pt
193
What are the risk factors for placenta praevia?
* previous placenta praevia
* previous C/S
* previous termination of pregnancy
* multiparity
* advanced maternal age
* multiple pregnancy
* smoking
* deficient endometrium
* assisted conception
194
What is vasa praevia?
rare condition where the foetal vessels run through the free membranes
195
What is placental abruption?
the premature separation of a normally located placenta from the uterine wall that occurs before the delivery of the foetus
196
What are the risk factors for placental abruption?
* maternal age
* abdominal trauma
* non-vertex presentations
* IUGR
* multiparity
* PET
* low BMI
* assisted reproduction
* PROM
* Polyhydramnios
* Infection
* multiple pregnancy
* smoking + recreational drug use
197
What are the clinical features of placental abruption?
* * woody abdomen**
* abdominal pain
* bleeding
* sudden foetal distress (deceleration/bradycardia
198
How do you Dx placental abruption?
clinically and @ delivery
199
What is cervical ectropian?
columnar, glandular encocervival cells wisible on ectocervix
200
What are the causes of blood stained show following a membrane sweep?
* cervical changes - effacement, softening in early about
| * mucous plug
201
What is uterine rupture?
disruption of the uterine muscle extending to and involving the uterine serosa, or disruption of the uterine muscle with extension to the bladder or broad ligament
202
What are the clinical features of uterine rupture?
* abdominal pain
* foetal distress
* rise in presenting part
203
What are the risks of uterine rupture?
intra-abdominal haemorrhage:
* foetal demise
* maternal collapse
204
What are the risk factors of uterine rupture?
* ** previous major uterine surgery e.g. CS ***
* AMA
* malformation of the uterus
* ECV
* uterine hyperstimulation
* obstructed labour
* transverse lie in labour
* >41/40
* >4kg birthweight
* manouvres for shoulder dystocia
* internal podalic version + breech extraction
* rotational forceps
* manual exploration of the uterus
205
How do you take a Hx of PV bleeding in pregnancy?
1. Colour
2. TImeline
3. How much bleeding? Quantify (# of pads)
4. Signs of anaemia: DIzziness, SOB, fatigue
5. Foetal movements normal?
6. Associated symptoms: pain? SROM?
7. Any previous episodes?
8. Precipitating factors? Post-coital?
206
What Ix should you do when PV bleeding in pregnancy?
1. USS - Placental location
2. Bloods - Rhesus status
3. Smear history
207
How do you manage Rhesus negative mothers in pregnancy?
Give Anti-D @28/40
208
How do you test foetal rhesus status in pregnancy?
cell free foetal DNA (in maternal circulation)
209
What is the Kleihauer-Betke Test?
measures the amount of foetal Hb transferred for a foetus to a mother's bloodstream:
* post-natally
* determines dose of Anti-D
210
What is the definition of primary PPH?
blood loss of 500mls or more from genital tract within 24hr of birth
211
What is the definition of secondary PPH?
blood loss of 500mls or more, from 24hr - 12wk post-partum
212
What is the definition of a minor PPH?
500 - 1000mls blood loss
213
What is the definition of a major PPH?
> 1000mls
* moderate 1001-2000mls
* severe >2000 mls
214
What are the risk factors for PPH?
* previous PPH
* Multiparity
* Foetal macrosomia/polyhydramnios
* PET
* High BMI
* Multiple pregnancy
* Underlying clotting disorder
* Prolonged 2nd/3rd stage of labour
215
What are the 4 T's causes of PPH?
Tone, Tissue, Trauma and Thrombin
1. Tone - uterine atony
2. Tissue - retained placenta
3. Trauma - lacerations
4. Thrombin (clotting) - coagulation
216
How do you manage post-partum uterine atony?
1. syntocinon/syntometrine for active management of 3rd stage in high risk individuals
NB: physiological 3rd stage uses naturally produced oxytocin
2. uterine rubbing
**these allow the uterus to contract and clamp arteries.
217
How do you manage retained tissue in the uterus and why is it important?
retained tissue (e.g. fragments of the placenta) prevents uterine contraction - risk of PPH
Mx:
manual removal placenta/fragments:
- if placenta not delivered within 30 mins/evidence of tissue on bedside USS
218
What are the degrees of perineal tears?
1*: vaginal mucosa torn
2*: perineal muscles torn
3*: anal sphincter torn
4*: rectum torn
219
How do you investigate clotting risk for PPH?
1. Underlying clotting disorders - what needs replacing?
2. Anti-coagulated as high risk VTE?
3. Liver pathology, PER, risk of going into DIC once clotting factors exhausted?
220
How do you manage Major Obstetric Haemorrhage?
1. Call 2222 (emergency buzzer)
2. ABCDE assessment
3. * Oxygen
* Large bore cannulae x 2
* Bloods: FBC, U&E, LFT, clotting, VBG, G&S, XM
* IV fluids
* Catheter
4. Consider cause of bleeding - 4 Ts!
221
What medications can be used to manage Major Obstetric Haemorrhage?
* syntocinon/syntometrine IM
* 40 units syntocinon
* tranexamic acid 1g IV
* Misoprostal 1mg PR
* Haemobate (Carboprost) 250mcg IM
Move to HDU/ITU
Document, debrief and Datix
222
What is the surgical management of Major Obstetric Haemorrhage?
Consider moving to theatre:
1. Examination under anaesthesia
2. Insertion of intra-uterine balloon tamponade?
3. B-Lynch suture?
4. Interventional radiology - artery embolization/ligation?
5. Hysterectomy?
Move to HDU/ITU
Document, debrief and Datix
223
How do you manage consent for blood transfusion?
i.e. Jehovah's Witnesses?
1. Advanced Directive - confirm which products acceptable
2. Antenatal optimisation of anaemia
3. Delivery:
- active management of third stage
- senior clinician input
- confirm pt wishes
- cell salvage?
- fluid managament
224
What is abnormal uterine bleeding (AUB)?
any menstrual bleeding from the uterus is either abnormal in volume (XS duration or heavy), regularity, timing (delayed or frequent) or is non-menstrual (intermenstrual - IMB, post-coital - PCB, post-menopausal - PMB)
225
What is heavy menstrual bleeding (HMB)?
XS menstrual blood loss leading to interference with the physical, emotional, social and material quality of life of a woman
- can occur alone or in combination w/ other symptoms
226
What is inter-menstrual bleeding (IMB)?
uterine bleeding that occurs between clearly defined cyclic and predictable mense
227
What are the clinical features of HMB?
* blood clots
* flooding (soaking through pads)
* signs of anaemia (dizziness, SOB, fatigue)
228
What are the pathological causes of HMB include?
1. uterine fibroids (20-30%)
2. uterine polyps (5-10%)
3. ademomyosis (5%)
= infiltration of endometrial tissue into the muscular (myometrium) of the uterus
4. endometriosis rarely presents as AUB, but is identified in <5% cases of AUB
229
What is the FIGO classification of AUB?
PALM COEIN
1. Polyp
2. Adenomyosis
3. Leiomyoma (fibroid): submucosal, other
4. Malignancy & hyperplasia
5. Coagulopathy
6. Ovulatory dysfunction
7. Endometrial
8. Iatrogenic
9. Not yet classified
230
What are the malignancy of the genital?
cervical, endometrial, ovarian, vaginal, vulval, sarcoma of endometrium or myometrium)
231
What are the disorders of ovulatory function?
1. PCOS
2. Congenital adrenal hyperplasia
3. Hypothyroidism
4. Cushing's disease
5. Hyperprolactinaemia
232
What are the iatrogenic causes?
* exogenous sex steroid administration:
- combined oral contraceptives
- progestins
- tamoxifen
* intrauterine contraceptive device
* traumatic uterine perforation
233
What is the definition of post-menopausal bleeding (PMB)?
genital tract bleeding that recurs in a menopausal woman at least one year after cessation of cycles
234
What are the causes of vaginal bleeding in post-menopausal women?
1. Polyps: 30%
2. Submucosal fibroids: 20%
3. Endometrial atrophy: 30%
4. Hyperplasia: 8-15%
5. ** Endometrial carcinoma**: 8-10%
6. Ovarian, tubal, cervical malignancy: 2%
235
What are some of the clinical features of fibroids?
1. Period problems
- menorrhagia
- dymenorrhoea
2. Anaemia
3. Pain and pressure symptoms
* bladder problems:
- frequency and nocturia
- urgency
- incontinence
* bowel problems (bloating, constipation)
236
What are the potential reproductive complications of fibroids?
* infertility
* early miscarriage
* late miscarriage
* premature birth
* labour complications
237
What are the potential complications of pelvic masses?
1. PE
2. DVT
Risk factors:
* age
* weight
* long-haul air travel
* FH
* Oral contaceptive use
238
What imaging can you use to visualise pelvic masses?
1. USS (most readily available)
| 2. MRI
239
What are the main issues to consider when managing fibroids?
1. QoL
2. Fertility
3. Cultural wishes
240
What hormones are fibroids linked to?
Oestrogen
241
What are the medical treatment options for Uterine fibroids?
1. Drugs
- Tranexamic acid
- Mefanamic acid
- Norehisterone
2. IUD: Mirena Coil (secretes progesterone)
3. Gonadotrophin releasing hormone agonists "Zoladex" (Tryptorelin)
- reduce fibroid size and vascularity before surgery
242
What are the SEs of Gonadotopin releasing hormone agonists (GnRHa)?
can cause a number of menopause-like SE including:
- hot flushes
- increased sweating
- muscle stiffness
- vaginal dryness
- osteoporosis
243
What are the SEs of Levonorgestrel intrauterine system (LNG-IUS)?
* irregular bleeding that may last >6 months
* acne
* headaches
* breast tenderness
244
What are the surgical treatment options for uterine fibroids?
1. Uterine artery embolisation
2. MRgFUS
3. Surgical resection
- TRCF
- Myomectomy: open/laproscopic
- Hysterectomy
245
Who is suitable for transcervical resection of fibroids (TCRF)?
women with small fibroids on the inside of their womb
Details:
* usually day-case
* good recovery
* minimal damage to womb
* improved fertility
NB: requires GA
246
What is Uterine Fibroid Embolisation?
intentional blockade of the blood supply to the uterus = leads to shrinkage of the fibroids
Details:
* minimally invasive technique
* local anaesthetic
* 5 day recovery
* Good results w/ up to 5 year follow up
247
What are the legal criteria for abortion in the UK?
1. 2 medical practitioners agree to it
2. 5 grounds:
a. risk of life to the woman
b. prevent permanent physical/mental injury to the woman
c. pregnancy <24/40, risk to the physical/mental health of woman
d. pregnancy <24/40, risk of physical/mental health to the children of pregnant woman
e. substantial risk that is child born, it would suffer from physical/mental abnormalities as to be seriously handicapped
248
Up to which week of gestation can a termination normally be performed?
24 (23+6)
249
What is conscientious objection?
A clinical can choose not to be involved with the provision of TOP services if they have a moral or conscientious objection.
** They must facilitate a consultation with a colleague who does not object i.e. they cannot obstruct provision of treatment **
250
How do women obtain a TOP?
1. Speak to a GP
- refer/suggest self-referral to a provider
2. Directly approach a provider
251
Which TOPs are treated in NHS hospitals?
if medical/surgical co-morbidity and independent provider cannot treat, they refer to NHS
252
What should you do when a woman presents for an abortion?
1. Find out why she is planning this?
2. Be non-judgemental
- choice of free will?
- understand the alternative options
- explain legality
3. Find out medical/surgical obstetric Hx
4. Discuss social Hx (safeguarding)
5. Discuss contraception
253
What is an early medical TOP and how is it performed?
up to 9+6/40
* Mifepristone oral tablet, then misoprostol @ home 24-48 hr later
254
How are surgical TOPs performed?
* Local anaestethic (MVA) <10/40
| * Surgical under GA/sedation up to 23+6/40
255
What is a late medical TOP and how is it performed?
>10/40
* misoprostol in hospital
* feticide >22/40
256
When is the uterus palpable?
12/40
257
What is the management of hyperemesis gravidarum?
1. Fluids (+ correction of electrolytes)
2. Pabrinex
3. Anti-emetics:
1*: cyclozine, promethazine
2*: metoclopramide
3*: steroids (hydrocortisone)
4: VTE prophylaxis (due to admission to hospital)
258
What is the scoring system for hyperemesis gravidarum?
PUQE (Pregnancy-Unique Quantification of Emesis and Nausea)
* 3Q: how often nausea, how often vomiting, how often retching/dry heaves
* out of 15:
- mild: up to 6
- moderate: 7-12
- severe: >12
259
What is the management of endometrial hyperplasia w/out atypia?
1. POP
| 2. marina coil (w/ progesterone) + 3/12 follow-up
260
What is the management of endometrial hyperplasia with atypia?
hysterectomy?
NB: progression to endometrial cancer is 25%
261
What is the normal thickness for the endometrium post-menopause?
5mm
262
What is the management of migraines in pregnancy?
1. Aspirin (75mg - low dose)
2. Metaclopramide (dopamine receptor agonist
3. Amitriptyline (TCA)
263
What is the mechanism of action for the copper coil?
aseptic inflammation
* copper = spermicidal
* physical barrier
264
What are the SE of the copper coil?
* perforation and infection
* heavy bleeding (esp. after insertion)
* expulsion (due to clots)
265
What are the CI for copper coil?
fibroids, esp. around the cervical os
266
What are some of the uses of the Mirena Coil?
1. contraception
2. fibroids
3. PCOS
4. endometrial hyperplasia
5. endometriosis
267
What advice should you give after administering oral contraception?
1. if the pt takes it and vomits within 2 hr, then take another pill
2. period can be early/late up to a wk
3. If period delayed more than one wk, see practitioner
**NB: all progesterone contraception can cause spotting/bleeding**
**NB: small risk of pregnancy""
268
What is Depo Provera and what are the factors to be considered?
an injection
* only contraception that is not immediately reversible
* avoid in extremes (young and old)
* can cause weight gain
* lasts 8wks/12wks
269
What is the Combined Oral Contraceptive pill and how is it adminstered?
oestrogen and progesterone = no fluctuation in hormone levels
* 3 wks on + 1 week off (withdrawal bleed)
* *NB: not effective after D + V**
* *NB: Not effective after Abx for 1wk**
270
How is the contraceptive diaphragm used?
spermicidal cream is added to the diaphragm 2hr before + after sex
271
What is the benefits of using condoms as contraception?
only contraception that offers protection from STIs
272
What are the indications for doppler studies?
to check for:
1. Uterine artery resistance
2. Umbilical artery resistance
273
What are the signs of ectopic pregnancy?
1. PV bleeding
2. Abdominal pain
3. Shoulder tip pain
4. Pain when pooing/weeing
274
What are the options for female sterilisation?
1. tubal occlusion
2. salpingectomy
3. hysterectomy
275
What are the options for HRT?
1. patches
- applies below waist
- oestrogen OR oestrogen + progesterone
2. HRT tablets
- oestrogen OR oestrogen + progesterone
3. HRT gel
- oestrogen ONLY
4. Vaginal oestrogen (local HRT)
- deal w/ vaginal dryness and urinary symptoms.
- do not improve systemic symptoms
