Obstetrics and Gynecology Flashcards
(181 cards)
1
Q
What is the recommended folic acid regimen for women planning for pregnancy?
Prepregnancy planning
A
Low risk: 0.5mg daily
At risk: 5mg daily
At risk includes women with a past or family history of neural tube defect, anticonvulsant drugs, or prepregancy diabetes.
2
Q
How can gestational age be measured?
A
From the 1st day of last normal menstrual period (LMNP)
Ultrasound measuring the crown-rump length (CRL) is the most accurate from 6-12 weeks gestation.
3
Q
How is EDC usually calculated? Under what condition?
A
LMNP + 40 weeks
This assumes regular period every 28 days
4
Q
What investigations should be performed in early pregnancy
A
- FBE: assess for thalassemia and anemia
- Blood group and screen: screen for Rh isoimmunization
- CST: assess for any cervical pathology
- Urine MCS: assess for asymptomatic bacteremia
- Serology: screen for syphilis, rubella, varicella, Hep B/C, HIV, etc.
- Ultrasound scan:
- 12 weeks: screen for fetal aneuploidy, identify multiple pregnancy
- 19 weeks: screen structural defects, placental localisation
5
Q
Typical antenatal visit schedule
A
- Initial visit: 8-10w
- Follow-up: 12-14w
- Every 4 weeks: 20-28w
- Every 2 weeks: 28-36w
- Every week: 36w - delivery
6
Q
What do you do if a pregant mother has no immunity to varicella, rubella? Or infected with syphilis, Hep B, C, HIV?
A
Live vaccines (e.g. rubella, varicella) can’t be given to mothers. Treat mothers in puerperineum.
Syphilis can be treated during pregnancy, with penicillin with aims to cure.
Steps could be taken to reduce vertical transmission for Hep B/C and HIV, such as administering antiviral medications and avoid fetal contact with mother’s blood.
7
Q
What vaccinations should be taken during pregnancy? At what weeks?
A
Pertussis (Tdap): between 20-32 weeks
Influenza and COVID-19: anytime
8
Q
When can fetal movement usually be felt? How can a mother assess them?
A
> 17w in multigravida, >19w in first pregnancy
- Check with meals: movements usually happen 30min-1h after meals
- Count to 10: if less than 10 movements per day, contact hospital
- Usual pattern: subjective, if baby much quieter than usual
9
Q
What should be assessed during a typical antenatal visit in an uncomplicated pregnancy?
A
- Maternal weight
- Blood pressure
- Abdominal examination: fundal height, fetal lie, presentation, station, etc
- Measure fetal heart rate
- Urinalysis: proteinuria and glycosuria
Preeclampsia may present with proteinuria before the onset of hypertension.
10
Q
Further antenatal testing after the first trimester
A
- Glucose tolerance test: at 28 weeks
- Repeat blood group antibody screen (for Rh- patients): at 28 weeks
- GBS swab: at 36 weeks
11
Q
Prevention of red cell isoimmunisation (D antigen)
A
Anti-D immunoglobulin is given to Rh negative mothers to prevent any recognition of fetal antigen D and the production of anti-D antibodies by the mother’s immune system (which could cause fetal hemolysis in future pregnancies)
**Usually given in 3rd trimester (28 and 34 weeks). **
Could also be given when there is:
1. Bleeding in pregnancy (msicarriage, abortion, antepartum hemorrhage)
2. Trauma (amniocentesis, CVS, MVA, etc)
3. Pueperineum (after testing neonate for Rh status)
12
Q
What management can be done if a mother tested positive for GBS?
A
Intrapartum IV antibiotics (usually penicillin)
Cephazolin can be used instead for cases of penicillin allergy.
13
Q
Weight gain targets during pregnancy
A
14
Q
Conditions at increased risk with higher maternal BMI
A
HTN in pregnancy, GDM, C-section, perinatal mortality, preterm birth
15
Q
Define hyperemesis gravidarum
A
severe, persistent nausea and vomiting leading to a loss of >5% of pre-pregnancy weight and ketonuria with no other identifiable cause
16
Q
Medications to treat N/V in early pregnancy
A
- Vitamin B6 (Pyridoxine): first line
- Consider adding doxylamine or metoclopramide
- Last resort: corticosteroids
17
Q
Treatment of hyperemesis gravidarum
A
-
Acute Management (for moderate-severe cases)
- Hospitalization
- Intravenous Fluids: correct dehydration and maintain electrolyte balance.
-
Pharmacological Interventions:
-
Antiemetic Medications:
- Vitamin B6 (Pyridoxine): first line if tolerates oral intake
- For severe cases: IV metoclopramide or ondansetron
- Vitamin B1 replacement
-
Antiemetic Medications:
- Other
- Referral to dietician
- Consider enteral feeding for severe cases
- Discharge as patient tolerates light diet and fluids
18
Q
Differential diagnoses for bleeding in early pregnancy
A
- Not pregnant and normal menstrual period
- Intrauterine pregnancy: viable or non-viable
- Ectopic pregnancy
- Incidental: cervical polyps/cancer, other genitourinary causes
19
Q
Management for early bleeding for early pregnancy
A
- Perform TVUS
- Confirmed intrauterine pregnancy: assess fetal viability
- Confirmed ectopic pregnancy: manage accordingly
- Unlocalised: measure b-hCG levels:
- If<1500 IU/L: early intrauterine vs ectopic
- Consider admission and repeat b-hCG levels in 48h
- > 1500 IU/L: ectopic pregnancy
- Consult senior obstetrician
- If<1500 IU/L: early intrauterine vs ectopic
20
Q
Clinical features of a miscarriage.
A
- Vaginal bleeding
- Abdominal pain: Cramping or abdominal pain
- Tissue passing: In some cases, women may pass clots or tissue from the vagina.
- Loss of pregnancy symptoms: If miscarriage occurs in early pregnancy, there may be a sudden loss of pregnancy symptoms, such as breast tenderness or morning sickness.
21
Q
Classification of miscarriage
A
22
Q
Management of miscarriage based on types
A
- Threatened miscarriage:
- Expectant management
- Avoid strenous physical activity
- Repeat US in one week
- Complete miscarriage: no intervention needed
- Inevitable, incomplete, missed miscarriage
- Expectant management
- Pharmacological: misoprostol - cervical ripening for expulsion of conception products
- Surgical: dilation and curettage
Anti-D immunoglobulin for Rh(D)-negative patients
23
Q
Diagnosis of miscarriage
A
- TVUS: Findings consistent with a spontaneous abortion may include:
- Absence of fetal cardiac activity
- Gestational sac ≥ 25 mm without an embryo
- Previously visualized IUP not observed (empty uterus)
- Downtrending b-hCG levels
24
Q
Three possible outcomes of tubal pregnancy
A
- Tubal abortion: accompanied by colicky pain and bleeding; conceptus is extruded out the fimbrial end
- Tubal rupture: associated with severe intraperitoneal bleed and acute abdo pain
- Missed tubal abortion: embryo dies and absorbed
25
Diagnosis of ectopic pregnancy
* TVUS visualisation
* If not visualised through US: b-hCG levels>1500 indicates EP
26
Management of ectopic pregnancy
- Acute intervention:
- IV access
- Pain relief
- Fluid replacement
- Blood group typing and antibody screen
- Serial b-hCG monitoring
- Medical management:
- IM Methotrexate
- Assess renal and liver function - before and after giving MTX
- Surgical management (laparoscopic vs laparostomy)
- Salphingectomy
- Salphigostomy
27
Clinical features of ectopic pregnancy
* Vaginal bleeding
* Abdominal pain or cramping
* PV discharge
* Enlarged or tender uterus
* Pregnancy symptoms (N/V, amenorrhea, etc)
28
Management of ruptured ectopic pregnancy
- Acute stabilization
- IV access and flui
29
Screening and diagnostic tests for aneuploidy
- Screening tests
- Combined first trimester screening: 11-13 weeks
- Nuchal translucency
- Maternal serum tests: b-hCG, AFP
- NIPS (non-invasive prenatal screening) using cell-free DNA: from 10 weeks
- 2nd trimester:
- Maternal serum tests: AFP, oestriol, inhibin
- Morphology ultrasound
- Diagnostic test
- Chorionic villous sampling: from 11 weeks (higher risk)
- Amniocentesis: from 15 weeks
30
Advantage and disadvantage of CVS and amniocentesis
- CVS: Offers earlier results, but a slightly higher risk of miscarriage.
- Amniocentesis: Lower risk of miscarriage, but results take longer to obtain
31
Define antepartum hemorrhage
Vaginal bleed >20mL occuring after 20 weeks gestation
32
Initial management of antepartum hemorrhage
* IV access and fluid replacement therapy
* Blood group typing and antibody screen
* Monitor maternal and fetal vitals
- CTG and ultrasound for fetal wellbeing
33
Possible causes of APH
Placenta previa, vasa previa, placental abruption, cervical polyp, uterine rupture
34
Can a digital vaginal examination be performed in APH assessment?
Only after placenta has been localised and placenta previa has been ruled out
35
Define placenta previa
Occurs when the placental location in the lower uterine segment either partially or completely occludes internal os
36
Clinical features of placenta previa
* painless vaginal bleeding usually happens in the 2nd-3rd trimester
* soft, non-tender uterus
* in severe cases, signs of shock
37
Diagnosis of placenta previa
TVUS - usually identified at the 19-20 weeks scan
Follow-up US at 32-34 weeks to confirm persistence of placenta previa, and exclude vasa previa and placenta accreta
38
Management of placenta previa
- Asymptomatic:
- avoid sexual intercourse
- repeat US at 32-34 weeks
- if persistent - consider planned C-section at 37-38 weeks
- Symptomatic
- Initial management for APH
- >37 weeks: IOL
- <37 weeks: preterm delivery or expectant management
- Tocolytics to postpone labour if <34w
- MgSO4 for neuroprotection if <30w
- Corticosteroid for lung maturity if <34w and not imminent
39
Define vasa previa
Presence of fetal vessels trasnversing over the internal os
40
Clinical features of vasa previa
- painless vaginal bleed
- usually occurs during labour, often with the rupture of membranes
- fetal distress and still birth
41
Diagnosis and management of vasa previa
Diagnosed antenatally with US or incidentally during ROM
Management:
- Early detection => planning for C-section delivery at around 36-37 weeks
- If preterm delivery expected, consider corticosteroids for fetal lung maturity
- In cases of incidental finding during labour:
- Emergency C-section delivery
- Blood group and screen - blood transfusion as needed
42
Define placental abruption
Partial or complete detachment of placenta from placental/decidual interface prior to labour
43
Risk factors for placental abruption
- HTN in pregnancy
- smoking, cocaine use
- trauma
44
Clinical feature of placental abruption
- Painful vaginal bleeding
- Acute abdominal or back pain
- Uterine tenderness and contractions
- Fetal distress and/or maternal hemodynamic compromise in severe cases
45
Management of placental abruption
- Mild abruption:
- hospital admission and expectant management
- serial US and anticipate expedited delivery
- Moderate abruption:
- IV access and blood group and screen
- Fluid replacement therapy and blood transfusion as needed
- Fetal monitoring with CTG
- Emergency or planned C-section delivery based on fetal and maternal wellbeing
- MgSO4 if <30w, Corticosteroid if <34w
- Severe abruption
- Fetal death in utero - vaginal or C-section to expel fetal remains
- Correct hypovolemia and hematological disturbances
46
Clinical features of uterine rupture
- Severe abdominal pain
- Fetal distress
- Sudden pause in contractions
- Vaginal bleeding
- Signs of shock
## Footnote
Uterine rupture generally occurs during active labor.
47
Signs of fetal distress in CTG
* Bradycardia: <110 bpm
* Tachycardia: >160 bpm
* Absent or minimal beat-to-beat variability: <6 or >25 bpm
* Late decelerations: A drop in the fetal heart rate that occurs after the peak of a uterine contraction.
* Prolonged Decelerations: A significant drop in the fetal heart rate that lasts longer than usual
* Variable decelerations: Abrupt drops in the fetal heart rate that may not correlate directly with uterine contractions, sometimes associated with cord compression.
48
Management of uterine rupture
- Initial stabilisation
- IV access and fluid replacement therapy
- Pain relief
- Avoid uterotonic agent (e.g. oxytocin, prostaglandin)
- Blood group and screen
- Surgical management
- Emergency laparotomy and C-section delivery
- Hysterectomy in uterus severely damaged
49
What tests can be performed to diagnose SGA or FGR?
Fundal height and ultrasound biometry (head and abdo circumference, femur length)
50
Define FGR and SGA
* Small for gestational age describes babies where the birth weight is less than the 10th percentile for gestation.
* Fetal growth restriction refers to babies that have faield to reach their optimal growth potential
51
Risk factors for FGR
Maternal hypertension, diabetes, smoking, obesity, and advanced maternal age
52
Management of SGA baby.
- General: serial US monitoring and referral to specialised fetal medicine or perinatal unit
- Labour:
- Delivery around 37-38 weeks
- Use of continous electronic fetal monitoring during labour
- Use of mechanical, rather than prostaglandin-based, method of cervical ripening
53
Define preterm labour and preterm birth.
- Preterm labour is defined as labour occurring prior to 37 weeks of gestation.
- Preterm birth is delivery of a baby prior to 37 completed weeks of gestation
54
Aetiology for preterm delivery
* SROM
* Infection
* Antepartum hemorrhage
* Multiple pregnancy
* Cervical insufficiency/trauma
* Uterine malformation
55
What is the earliest gestational age where neonatal survival is considered possible?
23 weeks
56
Management of women in active preterm labour
- **Steroids** to be given to all women <34 weeks' gestation (2 doses 24h apart)
- **Transfer** to a hospital with appropriate level of neonatal care
- **Antibiotics** (usually ampicillin or amoxycillin) given to prolong pregnancy, reduced risk of maternal and neonatal infection (such as GBS and genital mycoplasma)
- **Tocolytics** given to women <34 weeks' gestation at least **48h prior to delivery** - allow adequate time for steroids to be given
- Infection surveillance
- Neuroprotection and neonatal review: give MgSO4 if <30 weeks gestation
## Footnote
Remember STATIN
57
Mention examples of tocolytics
CCBs: nifedipine
Beta-mimetics: terbutaline, salbutamol
Others: Glyceryl nitrate
58
Define PPROM
Preterm premature rupture of membranes (PPROM) is the spontaneous prelabour rupture of membranes before the onset of labour, prior to 37 weeks’ gestation
59
What is the most common symptom of PPROM?
The most common symptom of PPROM is a gush of clear fluid from the vagina.
60
What is the management approach for a woman with PPROM at less than 34 weeks of gestation?
For PPROM before 34 weeks, corticosteroids are administered to promote fetal lung maturity, and the woman is usually admitted to the hospital for close monitoring and possible administration of antibiotics to reduce the risk of infection.
61
What is the term used to describe PPROM that occurs after 37 weeks of gestation?
PPROM that occurs after 37 weeks is referred to as Term PROM (Premature Rupture of Membranes).
62
What is the management approach for a woman with PROM at term gestation (after 37 weeks)?
In term PROM, labor induction is usually recommended to avoid potential risks associated with prolonged rupture of membranes.
63
Define cervical insufficiency
Painless dilatation of the cervix leading to recurrent second-trimester pregnancy loss.
64
What are the risk factors for cervical insufficiency?
* History of previous cervical procedures (e.g., cone biopsy, cervical conization)
* previous preterm birth due to cervical insufficiency
* uterine anomalies
* history of multiple pregnancy losses in the second trimester.
65
What is a strong predictor of preterm birth on ultrasound?
Short cervical length prior to 28 weeks' gestation
66
What is the management approach for cervical insufficiency?
Placement of a **cervical cerclage** (a stitch placed around the cervix) to provide mechanical support and prevent further cervical dilation.
**Progesterone supplementation** may also be considered - thought to supress smooth muscle activity adn reduce prostaglandin sythesis
67
At what gestational age is cervical cerclage typically performed?
Cervical cerclage is usually performed between 12 and 14 weeks of gestation, to reduce the risk of any miscarriages and allow time for the 12 weeks' aneuploidy screen.
68
How do you assess suitability for labour?
Bishop's score assessment
69
The main concern with PROM
Increased risk of maternal or neonetal infection with increased latency between time of ROM and birth
70
Management of PROM
Depends on GBS status, infection risk, fetal wellbeing, maternal preference
**Early induction of labour**, compared to **waiting for spontaneous labour**, has been associated with lower risk of neonatal infection and maternal chorioamnionitis in mothers who are GBS positive.
71
Define prolonged ROM and how to manage it.
ROM that occurs >18h before onset of uterine contractions in term or preterm pregnancies
Patients with prolonged ROM are given IV antibiotics due to the increased risk of maternal and neonatal infections.
72
Types of monozygotic twins based on cleavage timing
- Before Day 4: dichorionic diamniotic
- Day 4-8: monochorionic diamniotic
- Day 8-12: monochorionic monoamniotic
- After Day 12: conjoined twins
73
How is a multiple pregnancy diagnosed?
1st trimester ultrasound
## Footnote
Beyond 1 trimester, dichorionicity can only be determined through sex
74
What interventions are used to prevent preterm birth in multiple pregnancies?
In some cases, healthcare providers may recommend cervical cerclage (stitching the cervix) or the use of progesterone supplementation to help prevent preterm birth in multiple pregnancies.
75
Define preeclampsia
Preeclampsia is a hypertensive disorder of pregnancy characterized by high blood pressure (≥140/90 mmHg) and the presence of proteinuria (excess protein in the urine) or end-orgna dysfunction after 20 weeks of gestation.
76
What is the difference between preeclampsia and eclampsia?
Preeclampsia is the condition of high blood pressure and proteinuria in pregnancy. Eclampsia is a severe complication of preeclampsia, **characterized by the occurrence of seizures or convulsions** in addition to high blood pressure and proteinuria.
77
What is HELLP syndrome?
HELLP syndrome is a severe variant of preeclampsia characterized by Hemolysis (breakdown of red blood cells), Elevated Liver enzymes, and Low Platelet count.
78
How is gestational hypertension managed during pregnancy?
* Regular monitoring of BP and symptoms
* Evaluate fetal wellbeing
* Antihypertensives: labetalol, methyldopa, nifedipine
79
What is the primary treatment for preeclampsia?
**Delivery of the baby** is the primary treatment for preeclampsia. If preeclampsia occurs before term, medications may be used to control blood pressure and prevent complications until delivery can be safely accomplished.
80
How does chronic hypertension differ from gestational hypertension?
Chronic hypertension is high blood pressure that existed before pregnancy or is diagnosed before 20 weeks of gestation. Gestational hypertension develops after 20 weeks in a woman with previously normal blood pressure.
81
What should be given as preeclampsia prophylaxis for mothers at risk?
Low dose aspirin (100-150g/day)
82
Management of preeclampsia with severe features (inc. eclampsia, HELLP)
- Monitor for vitals, BP, oxygenation, and urine output
- Treat any complication:
- Urgent BP control: IV labetalol or hydralazine
- Eclamptic seizures: MgSO4, diazepam or clonazepam
- HELLP syndrome: administer blood products (platelets, PRBCs, FFP)
- Assess need for immediate delivery
- Immediate: if eclampsia, signs of fetal distress, etc
- Based on gestational age:
- >34 weeks: deliver
- 24-34 weeks: expectant management and prepare for preterm delivery
- <24 weeks: termination of pregnancy
- Post-delivery: Follow-up after 6 weeks - reassess symptoms and blood test results
83
Investigations in woman with pre-eclampsia and potential findings
- Urinalysis: screen for proteinuria (urine protein:creatinine>0.3)
- Serum uric acid: usually elevated
- LFTs: possibly elevated
- FBE: possible thrombocytopenia
- Coagulation profile: possible prolonged PT and aPTT (in cases of DIC, rare)
84
Antihypertensives commonly used in pregnancy
Labetalol, nifedipine, methyldopa
85
Principles of stabilisation of preeclampsia/eclampsia prior to delivery
1. **Seizure prophylaxis**: MgSO4 - continued until 12-24h post-delivery
2. **Urgent BP control** (>160/110mmHg): IV hydralazine or labetalol
3. **Fluid assessment and replacement as required**: assess JVP and urine ouput
86
Clinical feature of eclampsia
* Severe headache
* Visual disturbance
* Eclamptic seizures (tonic-clonic)
87
Management of eclamptic seizures
* Position patient in a semiprone position to maintain patent airway and minimise aspiration risk
* Assess airway and maintain oxygenation
* Anticonvulsant - MgSO4 + clonazepam/diazepam
* Transport to hospital
* Exclude other intracranial pathology
88
Possible presentation of preeclampsia
- **CV**: generalised edema (feet, hands, face)
- **Renal**: increased serum uric acid and urinary protein
- **Hematology**: thrombocytopenia
- **Hepatic**: epigastric pain, elevated transaminases/bilirubin
- **Neurological**: visual blurring, headaches, hyperreflexia, convulsions
89
Treatment of thromboembolism during pregnancy
Administed LMWH (initially at therapeutic dose before continuing at a reduced prophylactic dose until puerperium)
Discontinued during labour (at least 12h before planned delivery)
90
Define chorioamnionitis
An intrauterine infection of the fetal membranes and amniotic fluid caused by bacteria ascending from the vagina.
91
Clinical features of chorioamnionitis
* Maternal fever
* Uternine contractions and tenderness
* Foul-smelling vaginal discharge
* Fetal tachycardia on CTG
92
Investigation and possible diagnostic results for chorioamnionitis
* Leukocytosis and left-shift
* Elevated CRP
* Fetal tachycardia on CTG
* Amniocentesis or GBS cervicovaginal swab
93
Management of chorioamnionitis
* Established chorioamnionitis requires immediate delivery
* Acute management:
* IV antibiotics: ampicillin + gentamicin + metronidazole
* Supportive: IV fluids and continous fetal monitoring
94
Risk factor for postpartum endometritis
* C-section
* Prolonged labour
* GBS colonization
* Retained placenta
95
Define mastitis
Mastitis is defined as inflammation of the breast, with or without infection.
96
Most common cause of infectious mastitis
S. aureus
97
Most common cause of infectious mastitis
S. aureus
98
Management of mastitis
* Symptomatic treatment: NSAIDs and warm compress
* Broad-spectrum antibiotics if no improvement after 12-24h
* Supportive treatment: continous breastfeeding and ensure proper breastfeeding technique
99
Clinical features of mastitis
- Fever
- Flu-like symptoms: fatigue, malaise, etc
- Breast tenderness and swelling (generally unilateral)
- Pain during breastfeeding
100
Investigations for mastitis
Diagnosis is usually clinical.
If poor response to empiric antibiotics, may consider doing a breast milk MCS and imaging (rule out breast abscess)
Consider other diagnoses such as inflammatory breast cancer.
101
Recommended STI screening tests for asymptomatic and high-risk women.
- Asymptomatic: endocervical swab or first-catch urine
- Chlamydia PCR swab
- Hep B, HIV, and syphilis serology
- High-risk: add the following
- Gonorrheal PCR swab
- Hep C if there is history of IV drug
102
Investigations for the presentation of subfertility/infertility
- FSH and LH in day 2
- Mid-luteal progesterone
- Sperm analysis
- Rubella and varicella serology
103
Clinical feature of endometriosis
- Common: dysmenorrhea, dysapareunia, subfertility
- Bladder: frequency, urgency, hematuria
- Intestinal: dyschezia, bowel changes
- Endometrioma: irregular menses and intermenstrual bleed
104
Investigation for endometriosis
- **Transvaginal ultrasound**: Ultrasound may be used to visualize the pelvic organs and detect the presence of endometrial cysts (endometriomas).
- **Pelvic MRI:** for deep infiltrating endometriosis
- **Laparoscopy**: The definitive diagnosis of endometriosis is made through laparoscopic surgery, during which the surgeon can visualize and biopsy endometrial implants.
105
Management of endometriosis
- Symptomatic management:
- NSAIDs: pain relief and prostaglandin inhibition
- Hormonal therapy:
- COP, progesterone-only pill, GnRH agonists
- supresses ovulatio and growth of endometrial tissue
- Surgical management:
- Laparoscopy
- Involvement of rectosigmoid or bladder require collaboration with urologist or colorectal team
- Other:
- Fertility treatments: such as IVF
106
Classification method for endometriosis
107
Differential diagnosis of acute pelvic pain
108
Differential diagnoses for chronic pelvic pain
109
Normal menstrual cycle length and duration of bleeding
21-35 days
2-8 days of bleeding
110
Menstruation occurs in response to (?) withdrawal in the presence of endometrium primed by (?).
Menstruation occurs in response to progesterone withdrawal in the presence of endometrium primed by estrogen.
111
Explain the etiology of primary dysmenorrhea
Excess endometrial prostaglandin ⇒ increased uterine muscle tone and contraction ⇒ high uterine pressure => uterine pressure > arterial pressure => ischemia and accumulation of anaerobic products ⇒ stimulates type C pain fibres
112
Management of dymenorrhea
- First-line: NSAIDs - reduce prostaglandin synthesis
- Others: naproxen, ibuprofen
- Hormonal therapy: combine OCP or progesterone-only contraceptive (e.g. Implanon, Mirena, POP)
- If pain persists, exclude secondary causes of dysmenorrhea (e.g. endometriosis)
113
Common causes of abnormal uterine bleeding
* Polyps
* Adenomyosis
* Leiomyoma
* Malignancy
* Coagulopathy
* Ovulatory dysfunction
* Endometrial
* Iatrogenic
114
Investigation for abnormal uterine bleeding
* FBE: assess anemia
* Platelet, PT, PTT: screen bleeding disorders
* Iron studies
* Imaging:
* Pelvic US: screen for structural abnormalities
* Hysteroscopy
* Invasive: endometrial biopsy (if endometrial thickness>4mm)
* Others:
* Cervical swab: screen for STI-caused cervicitis
* Cervical screening tests: rule out cervical malignancy
* b-hCG: rule out pregnancy
* TFTs
115
Management of AUB
- General measure: correct any hemodynamic instability (e.g fluid resuscitation, blood transfusion)
- Pharmacological:
- Tranexamic acid: anti-fibrinolytic agent
- NSAIDs: reduce prostaglandin
- **Hormomal treatment**:
- Progesterone-only contraception: POP, Mirena, Implanon
- Combined OCP: avoid in women >40y due to increased thrombotic risk
- Surgical
- Hysteroscopy
- Uterine D&C: diagnostic and therapeutic
- Resection: for polyps
- Uterine artery embolization: for fibroids
- Hysterectomy or endometrial ablation: does not preserve fertility (last option)
- Treat organic causes to the bleed
116
Define polyps and management.
- Overgrowth of localized benign endometrial tissue
- Features: painless bleeding (post-coital and intermenstrual as well)
- Management:
- Hysteroscopic resection
- Control reoccurrence: progesterone-only contraception
117
Differentiate between adenomyosis and polyps.
Polyps usually presents as painless bledding.
Adenomyosis usually presents as bleeding with pain.
118
Define adenomyosis and its management.
* Overgrowth of endometrial tissue within the myometrium
* Management:
* Hormonal therapy: e.g. progestin
* Hysterectomy
119
Define fibroids and their management.
- Benign growths that arise from the myometrium
- Management:
- Hormonal therapy
- Surgical: myomectomy, hysterectomy
120
Recall the classification of leiomyomas
- Subserosal leiomyoma: located in the outer uterine wall beneath the peritoneal surface
- Intramural leiomyoma (most common): growing from within the myometrium wall
- Submucosal leiomyoma: located directly below the endometrial layer (uterine mucosa)
- Cervical leiomyoma: located in the cervix
121
Rule of thumb for TVUS finding of endometrial hyperplasia.
- >5mm in menopausal woman
- >15mm in reproductive-aged woman
122
Diagnosis of endometrial cancer and management.
- TVUS:
- >5mm for menopausal women
- > 15mm for reproductive-aged women
- Uterine dilation and curretage or biopsy
- **Management: hysterectomy with bilateral oopherectomy and salphingectomy**
123
Possible causes of post-menopausal bleeding
- Common: genital tract atrophy (vaginal, vulva, endometrium)
- Others:
- Polyps
- Fibroids
- Malignancy
- Endometrial hyperplasia
- HRT treatment
124
Investigations for post-menopausal bleeding
- TVUS: assess endometrial thickness
- high risk patients = endometrial thickness >4mm
- Hysteroscopy and D&C or biopsy (for high risk patients)
125
Define infertility
Failure to concieve after 1 year of timed, regular intercouse without contraception
126
Investigations for infertility
- Women
- Mid-luteal progesterone; tests ovulation
- Day 3 FSH and LH: tests ovarian function or reserve
- AMH: low in suspected diminished ovarian reserve
- TVUS - screen for anatomical abnormality
- Men: semen analysis
127
When is the fertile window?
The fertile window typically spans a few days before ovulation and the day of ovulation itself.
128
When is the fertile window?
The fertile window typically spans a few days before ovulation and the day of ovulation itself.
129
Factors causing male infertility
* Hypothalamo-pituitary dysfunction: e.g. hypogonadotrophic hypogonadism
* Testicular failure: congenital or acquired (testicular trauma, torsion, orchitis)
* Obstructive disorder: previous trauma or inflammation (e.g. epididymitis)
130
Pathalogical classification of anovulation
- Hypothalamic dysfunction:
- Stress, overexercise, weight loss
- Hyper/hypothyroidism
- PCOS
- Pituitary dysfunction
- Prolactinoma
- Pituitary trauma, radiation, necrosis (Sheehan's hemorrhage)
- Ovarian failure (raised FSH/LH)
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Most common cause of tubal dysfunction
Pelvic inflammatory disease (usually caused by C. trachomatis or N. gonorrhoea)
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What are the principle casues of anemia in pregnancy?
* Iron deficiency
* Folate deficiency
* Hemoglobinopathies
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Classification of hemoglobinopathies
- Thalassemia: quantitative defects
- Hemoglobin variants (e.g. sickle cell): qualitative defects
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How to screen and diagnose thalassemia in pregnancy?
FBE might show hypochromic microcytic anemia.
To differentiate from iron-deficiency anemia, a Hb electrophoresis can be performed
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Causes of thrombocytopenia in pregnancy
- Gestational thrombocytopenia
- HELLP (form of pre-eclampsia)
- ITP
- TTP
- DIC
- Infections
- Malignancies
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Treatment for ITP
Prednisolone +/- immunoglobulin infusion
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Management of TTP
Plasmapheresis +/- corticosteroids
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How do you diagnose DIC?
Thrombocytopenia, elevated D-dimer, increased PT and aPTT, and low fibrinogen should immediately raise suspicion for DIC.
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Management of DIC
- **Treat the Underlying Cause**: The primary approach is to identify and treat the underlying condition that triggered DIC.
- Consult specialist - obstetricians and hematologist
- **Supportive Care**:
- Initiate clinical and serial laboratory monitoring to assess response to treatment
- Blood products as needed
- Vitamin K supplementation if needed
- **Anticoagulants**: not usually indicated in obstetric DIC
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Causes of DIC in pregnancy
1. **Obstetric Complications**: Certain obstetric conditions can predispose pregnant women to DIC. These include:
- **Placental abruption**
- **Amniotic Fluid Embolism**
- **Severe Preeclampsia or Eclampsia**
- **Postpartum hemorrhage**
2. **Infections**: Certain infections during pregnancy can lead to sepsis, triggering DIC. These infections may include:
- **Chorioamnionitis**
- **Urinary Tract Infections**
3. **Trauma**: Severe trauma or injuries during pregnancy can trigger DIC
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Pathophysiology of DIC (brief)
DIC is a disorder characterized by systemic activation of the clotting cascade and subsequent exhaustion of all clotting factors, leading to systemic bleeding.
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From what gestational age can CVS and amniocentesis be performed?
- Chorionic villous sampling: from 11 weeks
- Amniocentesis: from 15 weeks
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In Victoria, abortions can be perform up to how many weeks of pregnancy, without further workup by a medical practitioner?
24
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Methods of abortion based on gestational age
- Medication: up to 9 weeks
- Surgical:
- Dilation and curretage: 9-14 weeks
- Dilation and evacuation: 14-24 weeks
- Medication: >24 weeks
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Two medications used for abortion and how do they work
- Mifepristone: anti-progestin - primes uterus to receive prostaglandin
- Misoprostol: prostaglandin analogue, given 24-48h after
- cause the uterus to contract and expel the pregnancy.
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Why is an ultrasound indicated prior to abortions?
* Rule out ectopics
* Dating of fetus
* Screen for possible miscarriage already
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Contraindications of medication-induced abortions
* Ectopics
* Intrauterine device (IUD)
* >9 weeks gestational age
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Investigations of thrombocytopenia in pregnancy
- FBE: platelet levels, screen for anemia
- Peripheral blood smear: presence of schistocytes
- Coagulations studies: APTT, PT, fibrinogen levels
- ADAMTS13 activity: screen for TTP
- Other tests of organ function: depending on clinical picture
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How does the position of appendix change with pregnancy?
It elevates as gestation advances.
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Diagnosis for cholestasis of pregnancy.
Pruritus with elevated serum bile acid levels - typically manifesting during 2nd or 3rd trimester
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Treatment of cholestasis of pregnancy
Ursodeoxycholic acid
Induction of labour indicated at 37-38 weeks
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How do you differentiate acute fatty liver of pregnancy from conditions, such as HELLP?
**Renal failure, hyperuricemia, and hypoglycemia** are more common and severe in AFLP than in HELLP and severe preeclampsia.
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Treatment of AFLP
- **Supportive Care**: Supportive measures include intravenous fluids, correction of clotting abnormalities, and management of other symptoms.
- **Delivery**: **Immediate delivery** of the baby is the main treatment for AFLP. This is often done via induction of labor or cesarean section, depending on the mother's condition and the gestational age of the baby.
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Investigation for AFLP and possible results
* FBE: leukocytosis
* LFT: raised AST, ALT, normal GGT
* UEC: hypoglycaemia, raised urea and creatinine
* Ultrasound imaging: liver enlargement and fatty infiltration
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Should you treat asymptomatic bacteriuria in pregnancy?
Yes. A course of amoxicillin is usually indicated (unless urine MCS indicates otherwise). Another urine specimen needed after the completion of antibiotic course to check for recurrence.
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Diagnostic criteria for GDM based on OGTT results.
One of the following:
- Fasting glucose ≥ 5.1mmol/L
- 1-hour value ≥ 10mmol/L
- 2-hour value ≥ 8.5mmol/L
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Conditions at increased risk due to GDM
- Pre-eclampsia
- Polyhydramnios
- Preterm labour
- Infection (UTI, vaginal candidiasis)
- Macrosomia
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Aim of HbA1c level for pregnant women and normal population.
A target HbA1c of less than 7.0% is recommended for most adults with type 2 diabetes.
The target HbA1c level for pregnant women with diabetes is generally lower, aiming for less than 6.0% to reduce the risk of birth complications.
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What additional antenatal investigations should be performed on a GDM pregnant women?
- More frequent antenatal visits
- Fetal surveillance during 3rd trimester to screen for placental insufficiency
- Ultrasound at 28 and 34 weeks to assess fetal growth (screen for macrosomia or placental insufficiency)
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Timing of birth in women with GDM or pregestational diabetes
Pregestational diabetes: 38-39 weeks
GDM with no evidence of macrosomia: 40 weeks (postdates not recommended)
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Diabetes management postpartum
Pregestational diabetes: cease any insulin, revert back to prepregnancy dose of insulin, fine tune glycaemic control after lactation
GDM: cease insulin after delivery, monitor blood glucose levels for 48h, if still high - report to an endocrinologist
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What is the role of measuring fetal fibronectin in obstetrics?
A negative fetal fibronectin test result (absence of detectable levels) in women with symptoms of preterm labor can help identify those who are at low risk of delivering within the next two weeks.
It is most valuable when combined with clinical assessment and other diagnostic tests. Fetal fibronectin testing is typically recommended for women with symptoms of preterm labor, such as uterine contractions, pelvic pressure, or cervical changes.
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Main differences between postpartum blues and postpartum depression
Women with postpartum blues may experience mood swings, tearfulness, irritability, anxiety, and feelings of sadness or overwhelm. Symptoms of postpartum blues typically **arise within the first week after childbirth and tend to resolve on their own within a few days to two weeks**.
Postpartum depression (PPD) is a more severe and persistent mood disorder that **develops within 4 weeks following delivery. Symptoms must be present for at least 2 weeks to confirm the diagnosis.**
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Criteria of the onset of true labour
1. Ryhtmic, regular contractions that increases in amplitude and frequency - discomforting to the woman
2. 'Show' of blood and mucus - indicates the cervical canal is opening
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Describe the first stage of labour
Latent phase starts from the start of contraction until the cervix is at least 3cm dilated and fully effaced. This phase could last many hours or days.
Active phase starts where the latent phase ends until the cervix is 10cm dilated.
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Mechanics of childbirth
- Engagement, descent, and head flexion
- Internal roation: fetal head rotates 90 degrees - from transverse to anterior-posterior position
- Head extension: as the head exits the pelvic canal
- Restitution and external rotation: fetal head and shoulders rotate until head is in original transverse position
- Expulsion: delivery of head, anterior shoulder, followed by posterior shoulder, and the body
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When can a woman start "pushing"?
When the cervix is fully dilated (verified by vaginal examination)
If pushing is attempted before this, there is increased risk of cervical tears and swelling.
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Why is fetal compromise common during the second stage of labour?
With every uterine contraction, there is a reduction in placental blood flow due to higher uterine pressures leading to reduced oxygenation of the fetus.
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When is the third stage of labour?
The period after birth of baby until the removal of placenta and membranes.
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Indications for prophylactic antibiotic during labour
- GBS positive
- prolonged ROM (>18h)
- chorioamnionitis (fever in labour)
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Active management of the third stage of labour
* Palpate uterus to exclude a second twin
* Administer oxytocic agent (oxytoxin, ergometrine, etc)
* Await uterine contraction, before drawing upon the placental cord
* Placental separation, descent, and delivery through **controlled cord traction**
* Inspect placenta - if there is any missing section, exploration of uterus should be made
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Induction vs augmentation of labour
1. Induction of Labor: refers to the process of initiating labor artificially when it hasn't started spontaneously. It involves using medical interventions, such as medications or mechanical methods, to stimulate uterine contractions and initiate the progress of labor.
2. Augmentation of Labor: involves enhancing or strengthening existing labor contractions when they are deemed insufficient or not progressing adequately. The goal of augmentation is to promote more effective contractions, leading to cervical dilation and descent of the baby, thereby advancing the labor process.
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Indications of IOL
- Prolonged pregnancy
- Post-term pregnancy
- PPROM >34 weeks or PROM at term
- Diabetes
- HTN in pregnancy
- FGR
- Macrosomia
- Multiple pregnancy
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Approach to induction of labour
- **Pre-induction tests**: CTG or ultrasound to assess fetal wellbeing
- If cervix is still unfavorable (Bishop's score less than 6): **cervical ripening method**
- Mechanical: transcervical balloon catheter
- Medication: prostaglandin analogues (e.g. misoprostol)
- **Artificial membrane rupture**: indicated in some cases
- **Maternal oxytocin infusion** - increase uterine contraction
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Risk of prostaglandin for IOL
Increased risk of uterine rupture due to uterine hyperstimulation
Managed by acute tocolysis (e.g. salbutamol, terbutaline, etc)
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Advantages and disadvantages of forceps delivery
- Advantages:
- Precise control over the baby's position and descent during delivery.
- Less failure rate compared to vacuum
- Disadvantages:
- higher risk of maternal perineal tears, lacerations, and pelvic floor injuries during forceps delivery.
- higher risk of neonatal facial bruising, scalp lacerations, or temporary facial nerve injury.
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Indications of instrumental births
* Prolonged second stage of labour
* Fetal compromise
* Maternal inability to push
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Advantage and disadvantage of vacuum delivery
- Advantages:
1. Lower Risk of Maternal Trauma
2. Less Neonatal Facial Trauma
3. Easier Application
- Disadvantages:
1. Lower Success Rates: higher failure rate compared to forceps, requiring a switch to other delivery methods, such as cesarean section.
2. Potential for Scalp Injuries: such as cephalohematoma (a collection of blood between the skull and scalp) or caput succedaneum
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Common indications of cesarian section
- Malpresentation
- Fetal distress
- Maternal exhaustion
- Inadequate progress in labour
- Previous C-sections
- Preeclampsia
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Two types of caesarian sections
Classical (midline)
Low transverse
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Options of future deliveries after a C-section
- Trial of labor after cesarean (TOLAC):
- Results in either vaginal birth after cesarean (VBAC) or repeat cesarean if unsuccessful
- Contraindicated in patients with a history of >2 prior low transverse cesarean or previous classic cesarean
- Planned repeat cesarean birth
