OnG year 5 Impeys Flashcards
(630 cards)
1
Q
What is the average age of menarche?
A
13 years
2
Q
what are the different phases of the menstrual cycle?
A
Day 1-4: menstruation
day 5-13: proliferative phase
day 14-28: luteal/secretory phase
3
Q
Define abnormal uterine bleeding
A
any variation from the normal menstrual cycle. Includes: changes in regularity and frequency of menses, in duration of flow, or in amount of blood loss
4
Q
Define amenorrhea
A
No bleeding in a 6 month interval
5
Q
What is the normal frequency and duration of periods?
A
24-38 days, with 3-8 days of bleeding
6
Q
What is the subjective and objective defintion of menorrhagia?
A
Subjective: bleeding interferes with woman’s physcial, emotional, social and material quality of life.
Objective: >80mL blood loss = maximum amount a woman can lose eating a normal diet without becoming iron defecient
7
Q
what are the most common pathologies causing heavy menstrual bleeding? + rest?
A
fibroids- 30%
Polyps- 10 %
thyroid disease, haemostatic disorders such as von willebrand’s disease and anti- coagulant therapy
8
Q
What are the investigations required for a patient presenting with dismenorrhagia?
A
Haemoglobin + FBC: assess the effect of blood loss
Coagulation + thyroid: if history is suggesive of a problem
TVUS: to exclude local structural causes ( saline US improves visualisation of fibroids and polyps.)
9
Q
what is the normal range of endometrium thickness in premenopausal women?
A
4mm(follicular phase) - 16mm(luteal phase)
10
Q
What are the risk factors of endometrial cancer?
A
Obesity diabetes nulliparity history of PCOS family history of HNPCC) hereditary non polyposis colorectal cancer
11
Q
What investigations should be considered for endometrial cancer?
A
Pipelle in OP
hysteroscopy in IP
12
Q
How is HMB managed?
A
IUS- NICE first line if not trying to concieve. 2nd = COCP. 3rd= POP, GnRH agonists- limited to 6 months
Tranexamic acid or NSAIDS (mefenamic acid reduces prostaglandin synthesis) if trying to concieve
Then consider surgical management- Polyp removal endometrial ablation techniques transcervical resection of fibroids Myomectomy Uterine artery embolisation Hysteroscopy
13
Q
When should endometrial biopsy be considered?
A
Age > 40 years
HMB with IMB
risk factors for endometrial cancer present
HMB unresponsive to medical treatment
US shows polyp or focal endometrial thickening
If abnormal uterine bleeding has led to acute admission
14
Q
Which pelvic pathology can use irregular bleeding or IMB?
A
Non malignant causes: fibroids, polyps, adenomyosis, ovarian cysts and chronic pelvic infection
Malignant causes: endometrial, ovarian + cervical cancer
15
Q
What are the investigations for irregular bleeding or IMB?
A
FBC + Hb: assess effect of blood loss
cervical smear taken if required to rule our malignancy
US for >35 with irregular or IMB or if medical treatment has failed for younger women
Endometrial biopsy if the endometrium is thickened, especially if women is over 40.
16
Q
What is the management for IMB or irregular bleeding?
A
COCP makes cycle regular. IUS lightens period. - 1st line
Progestogens in high dose cause amenorrhoea
HRT may regulate erratic uterne bleeding during perimenopause
Surgery: cervical polyps can be avulsed.
17
Q
Define primary and secondary amenorrhoea.
A
Primary amenorrhoea = menstruation hasn’t started by age of 16, may be after delayed puberty- no secondary sexual characeristics by 14 years.
Secondary amenorrhoea = previously normal menstruation ceases for 3 months
18
Q
What are the most common cause of oligomenorrhoea and secondary amenorrhoea? + other causes
A
PCOS, premature menopause (1/100), hyperprolactinaemia
19
Q
What causes hypothalamic hypogonadism and how does it cause amenorrhoea?
A
Causes: psychological stress, low weight/anorexia, excessive exercise
Leads to reduced GnRH and therefore FSH, LH and oestrodial are reduced.
Oestrogen replacement required if prolonged
20
Q
How is hyperprolactinaemia managed?
A
Bromocriptine, cabergoline, transsphenoidal surgery
21
Q
How does hypothyroidsim lead to amenorrhoea?
A
Hypothyroidism leads to raised prolactin levels
22
Q
What are some congenital causes of amenorrhoea?
A
congenital adrenal hyperplasia, Turner’s syndrome, imperforate hymen, transverse vaginal septum
23
Q
What are structural causes causes secondary amenorrhoea?
A
Cervical stenosis, asherman’s syndrome- caused by excessive curettage during ERPC.
24
Q
What are the causes of postcoital bleeding?
A
Think Cervix! cervial carcinoma cervial ectropion cervical polyps cervicitis, vaginitis
25
How is postcoital bleeding managed?
Cervix inspected using a speculum, smear taken and if polyp present it is avulsed. Ectropion can be frozen with cyrotherapy. If smear is abnormal, colposcopy is undertaken to exclude a malignant cause.
26
define dysmenorrhoea?
Painful menstruation associated with high prostagalandin levels in the endometrium and due to contraction and uterine ischaemia
27
define primary dysmenorrhoea
when no organic cause is found, associated with onset of menstruation. Present in 50% of women.
pain usually responds to NSAIDs or ovulation suppression.
28
What are some causes of secondary dysmenorrhoea?
Fibroids, adenomyosis, endometriosis, PID and ovarian tumours
29
Define precocious puberty
Menstruation occurs before age of 9 years or other secondary sexual characteristics are evident before 8 years.
30
What are the causes of precocious puberty?
80% = Physiological
Central causes: meningitis, encephalitis, CNS tumours, hydrocephaly, hypothyroidism may prevent normal pubertal inhibition of hypothalamic GnRH release.
Ovarian/adrenal causes: due to increased oestrogen production. E.g = hormone producing tumours of the ovary or adrean lands. McCune Albright syndrome- bone and ovarian cysts, cafe au lait spots and precocious puberty.
31
what is the treat of McCune albright syndrome?
Cyproterone acetate- antiandrogenic prostogen
32
What are the causes of ambigious development and intersex?
Congenital adrenal hyperplasia ( recessive inheritance): 21-hydroxylase defeciency.
Androgen insensitivty syndrome- male has cell receptor insensitivity to androgens. XY female phenotype.
33
How does congenital adrenal hyperplasia present?
Condition usually present at birth with ambigious genitalia, glucocorticoid deficiency may cause addisonian crisis.
Can present in adolescent with enlarged clitoris and amenorrhoea
34
What is the management of congenital adrenal hyperplasia?
Treatment = cortisol and mineralocorticoid replacement
35
How is androgen insensitibity syndrome managed?
Rudimentary testes are present. These are removes because of possible malignant changes.
Oestrogen replacement therapy is started.
36
Define Pre menstrual syndrome (PMS)? and how common is it?
PMS encompasses psychological, behavioural and physical symptoms that are experienced on a regular basis during luteal phase of the menstrual cycle and often resolve by the end of menstruation.
95% of women experience PMS, of which 5% are severly debilitated.
37
What are the clinical feautres of PMS?
Cyclical nature.
Behaviour changes include: tension, irritablity, aggression, depression and loss of control.
Physical symptoms: sesnsation of bloatedness, minor gastrointestinal upset and breast pain
38
What is the management of PMS?
After completion of menstrual diary and psychological evaluation to exclude depression and neurosis:
SSRIs- either continously or intermittently during the second half of the cycle.
Stopping regular cycles- COCP
2nd line- GnRH agonist trial and add back oestrogen therapy to induce a pseudomenopause.
Final resort- bilateral oopherectomy however combined HRT or COCP required for bone and endometrial protection.
May also consider CBT?
39
when should endometrial biopsy be considered?
IMB
thickened or irregular endometrium
Age >40
risk factors for endometrial cancer
40
Percentage of anteverted and retroverted uterus?
```
anterverted = 80%
retro = 20%
```
41
Definition and epidemiology of fibroids.
Defintion: Leiomyomata are benign tumours of the myometrium
By age 50 70% of white women and >80% of black women have had at least one fibroid.
Risk factors:
asian and black ethniticty
early menarche
obese women
first degree relative also effected
Less common in parous women, COCP or used injectable progesterone
42
What are the different types of fibroids?
```
Subserous polyp
Subserous
intramural
submucosal
intracavity polyp
cervical
```
43
What are the clinical features of fibroids?
50% asymptomatic, discovered by physical examination or US. Symptoms = site dependant
Menorrhagia
Dysmenorrhea
IMB if submucosal or polyp
Large fibroids can have pressure symptoms: urinary frequency, urinary retention- could lead to hydronephrosis.
Fertility impaired if tubal ostia are blocked.
44
What is the chance of malignancy from a fibroid?
0.1% of fibroids = leiomyosarcomata
| Increased risk if fibroid growth in post menopausal women, rapidly enlarging or sudden onset of pain in women of any age
45
What complications arise in pregnancy due to fibroids?
premature labour, malpresentaion, transverse lie, obstructed labour and postpartum haemorrhage. Red degeneration is common in pregnancy and causes severe pain.
Fibroids should not be removed during caesarian as bleeding can be heavy.
46
What investigation are done if fibroids are suspected?
US- determine the number , size and postion of fibroids
MRI- if diagnosis is unclear or greater accuracy required to decide mode of treatment + differentiation from adenomyosis
If subfertility present- hysteroscopy, saline TVUS, hysterosalphingogram used to assess distortion of uterus
Bleeding present?- FBC + haemoglobin
also fibroids can secrete erythropoietin
47
what is the medical management of fibroids?
```
Tranexamic acid, NSAIDs, progestogens are ineffective but worth trying first line. IUS reduced efficacy + expulsion risk from submucosal fibroids.
GnRhH analogues can cause temporary amenorrhoea and fibroid shrinkage - can only be used for 6 months withour addition of HRT.
SPRMs- urlipristal acetate new class of drug used for HMB, shrink fibroids- volume reduce 50%. Can be used short term before surgery.
```
48
what is the surgical management of fibroids?
Transcervical resection of fibroid- 3cm polup or submucousal fibroid
Myomectomy- if medical management failed, can be preceded by 2-3 months gnRH analogues or urlipristal acetate to shrink and reduce vascularity of fibroid. Pre-op vasopressin injection reduces bleeding. Caesarean inidcated for large fibroid myomectomy- due to increased risk of uterine rupture.
Radical hysterectomy
Uterine artery embolization- not offered to women desiring pregnancy
49
What are the different types of benign cysts?
Simple cysts
Haemorrhagic cysts- feeding vessels haemorrhage
Endometrioma - endometriosis inside ovary respond to hormone produced therefore enlarge. Can rupture and cause infection.
Mature cystic teratoma- also called dermoid cyst
50
What factors are considered for management of ovarian cysts?
Age: pre-pubertal, reproductive, postmenopausal
Size of cysts- 3-5-7-< cm no symptom- some symptom- Pain present
Character of cyst- simple or complex
Symptoms of cyst- pain, bleeding
Co morbidity- endometriosis, sub fertility
51
What investigations are done for ovarian cysts?
Pain score, FBC, US, tumour markers, carbohydrate antigen 125, serum hCG, AFP
Ca-125 can be raised in reproductive age due to other causes: endometriosis
, PID, fibroids
52
What are the different US features of different cysts?
Simple cyst is clear
Haemorrhagic cyst slight shadow
Malignant cysts have papillary projections, solid components and also associated with Ascites.
53
What is Risk of malignancy index based on?
Postmenopausal status, CA-125, features on US
54
Management of cysts <5c simple cysts premenopausal?
Reassurance and no further action required
55
Management of 5-7cm simple asymptomatic cysts premenopausal ?
Repeat ultrasound 3-4 months, reassurance if no change, consider referral if there is an increase in size
56
Management of >7cm cysts with symptoms premenopausal ?
Referral to gynaecologist
57
Management of postmenopausal ovarian cysts seen on camera?
ca-125
58
When are postmenopausal woman referred to gynaecology for assessment ?
Some suspicious features
| >7cm grossly abnormal features and abnormal ca-125 > 30- urgent referral
59
What are the complications of ovarian cysts?
Rupture
Torsion- gynaecology emergency 6 hour rule. Managed by laparoscopic detortion. Present with acute pain but as ovarian necrosis occurs pain resolves.
Malignant change.
60
Which ligaments attach to the ovary?
Ovarian ligament attaches to uterus, infundibular pelvic ligament. These ligaments are the ligaments that get tortes !
61
Define PID and what are its causes?
Inflammation of reproductive organs- cervix, uterus, tubes and ovaries
Causes: chlamydia
Gonorrhoea
Actinomycosis, gardnerella, anaerobes, mycoplasma
62
What are the risk factors of PID?
Multiple sexual partners
Foreign body/ IUD
Douching - squirting water into vagina to clean it
63
What are the clinical features of PID?
Abdominal pain, vaginal discharge(offensive/non offensive), dyspareunia, intermenstrual bleeding
64
What investigation are used for suspected PID diagnosed?
Clinical assessment- pyrexia, abdo tenderness, possible rigidity and guarding, cervical excitation
Investigation: WCC, CRP, high vaginal swab, chlamydia/ gonorrhoea NAAT
USS- rule out abscess
Laparoscopy
65
What is the management of PID? Come back to this
Analgesia
antibiotics dependent on OP (when systematically well) or IP.
Outpatient AB regime:
IM ceftriaxone stat, oral doxycycline BD, metronidazole BD for 14 days
Inpatient difference = iv ceftriaxone daily
66
What is Fitzh Hugh Curtis syndrome?
Chronic untreated PID descended upwards causing perihepatic adhesions to peritoneal wall
67
What are the complications of PID?
Infertility
Chronic pelvic pain
Turbo ovarian abscess
Ectopic pregnancy
68
What is the function of the Bartholin gland?
Provides lubrication during intercourse
69
What causes barthoin cyst formation ?
Blockage of gland could be congenital or due to infection
70
What is the management of bartholin cyst?
Asymptomatic and small cysts can be managed conservatively
Incision and drainage and word catheter
If recurrence- incision and drainage and marsupialisation
71
Define adenomyosis and its aetiology
Presence of endometrium and its stroma within the myometrium. Associated with endometriosis and fibroids.
72
What are the clinical features of adenomyosis ?
History: symptoms maybe absent but painful, heavy, regular, menstruation is common.
In examination uterus is mildly enlarged and tender.
73
What are the investigations for adenomyosis?
Adenomyosis can be suspected on ultrasound but clearly diagnosed on MRI
74
What is the management of adenomyosis?
IUS or COCP with or without NSAIDs may control the menorrhagia and dysmenorrhea but hysterectomy often required. Trial of GnRH to see if hysterectomy will relieve symptoms many be done.
75
Define endometritis
Often occurs secondary to infections as a complication of surgery, particularly caesarean and intrauterine procedure. Other causes = IUD and retained products of conception. Infection postmenopausal woman often due to malignancy.
76
What is the aetiology of intrauterine polyps?
Usually benign tumours that grow in intrauterine cavity often endometrial in origin but some are derived from submucousal fibroids. Common in woman aged 40-50. Can also be commonly found in postmenopausal woman taking tamoxifen for breast cancer.
77
How about interuterine polyps present ?
Often cause menorrhagia, IMB, may prolapse through the cervix. Diagnosed during USS or hysterescope
78
How are interuterine polyps managed?
Resection of polyp with cutting diathermy or avulsion.
79
what is congenital uterine maformation associated with?
Increased incidence of renal anomalies.
| 25% cause preganancy related problems- preterm labour, transverse lie, recurrent miscarraige
80
When is prevalence of endometrial cancer highest?
60 years. limetime risk = 1%
81
what are the two types of endometrial cancer?
type 1- low grade endometrioid cancers- oestrogen sensitive
type 2 - high grade endometrioid, clear cell, serous or carcinosarcoma cancers- not oestrogen sensitive and more aggressive.
82
what are the risk factors of endometrial cancer?
obesty, diabetes, early onset of menarche, nulliparity, late onset menopause, older age unopposed oestrogen, tamoxifen.
Lynch type 2- HNPCC
83
What is the management for endometrial hyperplasia with atypia?
consider hysterectomy. If fertility if a conern, progestogens (IUS or continous oral) and 3-6 monthly hysteroscopy and endomertial biopsy are used and referrral to fertility specialist
84
What are the clinical features of endometrial carcinoma?
PMB = 10% risk of carcinoma with risk increasing with age. Premenopausal women might have intermenstrual bleeding.
On examination pelvis often appears normal and atrophic vaginitis may coexist
85
Which lymph nodes does endometrial carcinoma spread to ?
Internal and external iliac lymph nodes then para aortic lymph nodes.
86
what are the different stages of endometrial carcinoma?
```
Stage 1A: confined to uterus <1/2 of myometrium
1B: >1/2 of myometrium
Stage 2: cervical stromal invasion
Stage 3: tumour invades through the uterus
a- serosa/adnexa
b- vagina/ parametrial involvement
ci- pelvic node involvement
cii- prara-aortic node involvement
Stage 4:further spread
a in bowel or bladder
b distant metastases
```
Staging only done after hysterectomy
87
What investigations should be done after confirmation of endometrial carcinoma?
```
MRI to assess myometrial invasion
chest X-ray to exclude pulmonary spread
FBC
ECG
Glucose
```
88
what is the management of endometrial carcinoma?
75% present with stage 1: manged with total laparoscopic hysterectomy and bilateral salpingo-ooporectomy (BSO). Pelvic and para aortic lymphadenectomy dependant on staging.
Adjuvant therapy: external beam radiotherapy, vaginal vault radiotherapy
chemotherapy
89
What is the prognosis of endometrial carcinoma?
```
Five year survival rate
stage 1 = 90%
stage 2 = 75%
stage 3 = 60%
stage 4 = 25%
overall = 75% survival rate
```
90
How can fibroids degenerate?
Red degeneration and hyaline degeneration.
91
what is protective againsts endometrial carcinoma?
COCP and pregnancy
92
what is endocervix and ectocervix lined by?
Endocervix lined by columnar epithelium, ectocervix lined by squamous epithelium.
93
Define cervical ectoprion and its risk factors
When columnar epithelium of the endocervix is visible as a red area around the os on the surface of the cervix. Normal finding in younger women taking the pill.
94
What symptoms can a cervical ectropion cause?
Normally asymptomatic, may present with abnormal discharge and PCB
95
How is ectropion managed?
Cyrotherapy after exclusion of carcinoma with colposcopy.
96
Define chronic cervicitis.
chronic inflammation or infection of an ectropion.
97
How do cervical polyps present and how are they mananged?
IMB or PCB. Management - avulsion
98
what are nabothian follicles?
trapped secretion from columnar epitheiium where squamous epithelium has formed by metplasia over endocervical cells. Metaplasia is caused by the low vaginal pH
99
define cervical intraepithelial neoplase (CIN)
presence of atypical cells within the squamous epithelium. Dyskaryotic cells. CIN graded 1-3 starting with bottom 1/3 of epithelium.
Malignancy ensues if these abnormal cells invade the basement membrane.
100
What is the risk of CIN 2/3?
1/3 of women untreated with CIN 2/3 develop cervical cancer over the next 10 years.
101
When is the peak incidence of CIN 3?
99% of caes <45 with peak incidence at age 25-29 years.
102
What is the aetiology and risk factors of CIN?
HPV strain 16, 18, 31, 33. viral protein causes inactivity of tumour suppressor genes.
Risk factors - number of sexual contacts at an early age, smokingm oral contraceptive use, HIV and those on long term steroids
103
Which strain is in the quadstrain HPV vaccine?
6,11,16,18. 16,18 cause 75% of cervical cancers in UK
104
How often are cervical smears done normally?
25-49 every 3 years
50-64 every 5 years
from age 65 only those who haven't been screened since 50 are tested
105
How is cervical smear done?
Using a cusco's speculum a brush is gently scraped around the external os of the cervix to pick up loose cells over the transformation zone. Brush tip broken intro preservative fluid, which is centrifuged in a lab before being spread on a slide to be viewed under microscope. Process is called liquid based cytology. LBC also allows testing or HPV.
Smears identify dyskaryosis classified as borderline, low and high which is associated with different CIN levels.
106
what does the presence of abnormal columnar cells in smear test suggest?
cervical glandular intraepithelial neoplasia. Requires colposcopy, if no abnormality on colposcopy then hysteroscopy
107
what is the treatment for CIN 2/3?
if CIN 2/3 present large loop excision of transformation zone(LLETZ) done. RIsk = increased risk of preterm delivery in proportion to dept of LLETZ.
108
which cells do cervical cancers arise from?
Squamous cells = 90%
columnar cells = 10%(adenocarcinoma)
screening test better at identifying squamous cell carcinoma therefore these have a better prognosis
109
how does cervical carcinoma present?
Occult carcinoma - no symptoms
| clinical carcinoma- PCB, offensive vaginal discharge
110
what are the different staging for cervical cancer?
Stage 1 is confined to the cervix
ai: invasion <3mm lateral spread <7mm
aii: invasion 3-5mm lateral spread <7mm
bi: clinically visible lesion larger than 1aii <4cm in greatest dimension
bii: clinically visible >4cm
stage 2 = invasion into vagina but not pelvic side wall
2ai= upper 2/3 of vagina without parametrial invasion <4cm in greatest dimension
2aii >4cm
b invasion of parametrium
stage 3 : invasion of lower vagina or pelvic wall or ureteric obstruction
stage 4 : invasion of bladder or rectal mucosa or beyond the true pelvis
111
What investigation are done for cervical cancer?
Tumour biospy to stage and confirm diagnosis
Vaginal and rectal examination to assess the size of the lesion and parametrial and rectal invasion
Cystoscopy: bladder involvement?
MRI: lymph node spread? tumour size?
Assess fitness for surgery: chest X-ray, FBC, UnE
Blood crossmatched before surgery
112
How is stage 1ai cervical cancer managed?
Cone biopsy as LN invovlement = 0.5%. Simple hysterectomy preferred in older women
113
How is stage 1aii- stage 2a cancer managed?
Surgical/ chemo-radiotherapy dependent on LN involvement- confirmed using MRI and LN sampling. No srugery if LN involved
Radical hysterectomy(Wertheim's hysterectomy)- removal of uterus, parametrium, upper 1/3 of vaigna, pelvic node clearance. Ovaries left in young woman with squamous carcinoma.
Radical trachelectomy- preserve fertility removal 80% of cervix and upper vagina. LN invovlement = + chemo-radiotherapy. Approprate for stage 1aii-1bi
114
How is stage 2b+ or positive lymph node cervical cancer managed?
Treated with radiotheray and chemotherapy e.g. platinium agents.
115
what are the indication for chemo-radiotherapy in cervical cancer?
Lymph nodes positive on MRI or lymphadenectomy
Alternative to hysterectomy
Surgical resection margins not clear
Palliation for bone pain or haemorrhage
116
What is the prognosis for cervical cancer?
```
Five year surivaval rate
1a = 95%
1b = 80%
2 = 60%
3-4 = 10-30%
LN involvement = 40%
LN clear = 80%
overall = 65%
```
117
how often are patients reviewed after treatment for cervical cancer?
Patients are reviewed at 3 months and six months and then every 6 months for 5 years.
118
Which cysts and tumours of the ovaries are beign?
```
Endometriotic cysts
Follicular cysts
Lutein cysts
Brenner tumour arise from epithelium
Germ cell tumour: Dermoid cysts
Sex cord: Thecomas, Fibromas ( meig's syndrome- ascites and right pleural effusion)
```
119
which ovarian tumours can be either malignant or benign?
serous cystadenomas
mucinous cystadenomas
granulosa cell tumours`
120
which ovarian tumours are malignant?
```
Endometroid carcinoma
clear cell carcinoma
Solid teratoma
dysgerminoma
yolk sac tumours
```
121
Where do secondary malignancies of the ovaries arise from?
Breast or bowel (krukunberg tumours- present with signet ring cells)
122
Which tumours of the ovaries arise from epithelium?
serous cystadenoma, adenocarcinoma, endometroid carcinoma, clear cell carcinoma, mucinous cystadenoma or adenocarcinoma.
123
Which tumours of the ovaries arise from germ cells?
teratoma (dermoid cysts), yolk sac tumours, dysgerminoma
124
which tumours of the ovaries arise from the sex cord?
granulosa cell tumours
thecomas
fibromas
125
Number of cases/ death in UK from ovarian cancer and what is the life time risk?
4200 deaths, 7000 cases and 1/60 lifetime risk
126
What are the 4 most common type of ovarian cancer?
Serous adenocarcinoma- 75%
endometroid carcinoma- 10%
clear cell carcinoma- 10%
Mucinous adenocarcinoma- 3%
127
Which genes are associated with ovarian cancer?
BRCA1/2 HNPCC
128
What is the screening programme in UK for ovarian cancer?
Currently no screening program. Women with family history of ovarian cancer, tested for BRCA1/2 genetic mutation and offered prophylactic salpingo- oopherectomy
129
How does ovarian cancer present?
Symptoms are often vague
Abdominal bloating, early satiety, increased urinary frequency, pelvic/abdo pain. Also important to ask abut breast and gastro symptoms due to mets.
Examination may reveal cachexia
130
State the different staging of ovarian cancer
```
Stage 1: confined to ovaries
a unilateral capsule is intact
b bilateral capsule is intact
c a/b ruptured capsule
stage 2: disease extending to pelvis
stage 3: abdo disease and lymph nodes involvement
stage 4: diseae is beyong abdomen
```
131
Which investigation are done for suspected ovarian cancer in primary care?
CA125 level measured in women over 50 with abdo smptoms.
CA125 > 35iu/ml USS of abdo and pelvis arranged.
If USS scan reveals ascited and/or pelvic or abdominal mass urgent referral to secondary care.
132
Which investigation are done for suspected ovarian cancer in secondary care?
```
CA125: epithelial tumours
HCG: choriocarcinoma
S-AFP: for yolk cell tumours
LDH: for dysgerminomas
Serum inhibin: for germ cell tumour
women under 40 AFP and bhCG measured to identify germ cell tumours.
RMI calculated
RMI > 250 referred to specialist MDT
CT pelvis abdo, thorax if indicated to establish the extent of disease.
Discuss in MDT for further management
```
133
How is risk of malignancy index (RMI) calculated?
ultrasound scan score x menopausal status x CA125 level
134
How is ovarian cancer managed?
Midline laparotomy for total hysterectomy , BSO and partial omentectomy.
Lymph node biopsy/removal
Debulk all advanced tumours
Possible laparoscopy and oopherctomy for women in early stage disease looking to preserve fertility
Then chemotherpay unless borderline or low risk stage 1a/b.
135
Which memebers of the MDT team are involved in ovarian cancer?
GP, macmillan nurses, gynae onco specialist
136
Which lymph nodes does the vulval lymph fluid drain into?
Inguinal lymph nodes, which drain into the femoral and thence to the external iliac nodes
137
what are the causes of pruritis vulvae?
Infectons: candidiasis, vulval warts, public lice, scabies
Dermatological disease: eczema, psoriasis, lichen simplex, lichen sclerosus, lichen planus
Neoplasia: carcinoma, premalignant disease
138
how is lichen simplex managed?
Irritants such as soap avoided. Emollients, moderately potent steroid creams and anti histamines are used to break itch-scratch cycle.
139
how does lichen planus present?
Effects paticularly mucosal surfaces such as mouth and genital. Presents with flat, papular, purpulish lesions. Presents with itching and pain.
140
How does lichen sclerosus present?
Probable cause = Auto immune disease. Thin epithelium due to loss of collagen, thyroid disease and vitiligo coexist in postmenopausal women. Severe pruritis, may cause bleeding + dyspareunia. Vulval carcinoma develops in 5% of cases.
Apperance = pink white papules
141
How is lichen sclerosus managed?
Biopsy important to exclude carcinoma and confirm diagnosis.
| Treatment = ultrapotent steroids.
142
Which organism causes vulval donovanosis?
Klebsiella granulomatis
143
Which factors increase the risk of candidiasis?
Diabetes, obesity, pregnancy, antibiotics
144
Which organisms are commonly responsible for bartholin's cyst and abscess?
Staphylococcus or escherichia coli
145
Define vaginal adnosis and its risk factor?
Columnar epithelium found in normal squamous epithelium of vagina. Commonly occurs in mothers who recieved diethylstillboestrol (prescribed in 1970s for miscarriage and preteerm labour.) Can turn into clear cell carcinoma.
146
What are the two types on vulval intraepithelial neoplasia and how do they present?
Usaual type VIN- more common (95%). Associated with HPV(16), smoking, CIN. Warty or basaloid squamous cell carcinoma.
Differentiated type VIN: lichen sclerosis older women, unifocal lesion with keratinizing squamous cell carcinomas of the vulva. Pruritis or pain is common.
147
What is the management for VIN?
Gold standard = local surgical excision
148
State the epidemiology of vulval cancer?
1200 cases 400 death common after age 60 50% present with stage 1 disease
149
How is vulval cancer staged?
stage 1: tumour confined to vulva/perineum
1a <2cm with stromal invasion depth <1mm; negative nodes
1b >2cm >1mm negative nodes
stage 2 : adjacent spread to urethra, vagina, anus; negative nodes
stage 3: tumour any size with inguinofemoral nodes positive
stage 4:
4a-tumour invades uper uretha, vagina, rectum, blader bone
4b- distant metastases
150
What investigation are done for vulval carcinoma?
Biospy taken for histology to establish diagnosis and stage disease
Assess fitness for surgery: chest X-ray, ECG, UnE, FBC, cross match blood
151
How is vulval carcinoma treated?
1a = wide local excision
| for other stages:
152
State 3 maligancies of the vagina
secondary vaginal carcinoma due to mets from cervix, endometrium or vulva
primary carcinoma of the vagina
153
How are the three levels of the vagina supported?
level 1: cervix and the upper 1/3rd of the vagina are supported by cardinal and uterosacral ligaments.
level 2: mid portion of vagina is attached by endopelvic fascia laterally to the pelvic side walls
level 3: the lower third of the vagina are supported by the levator ani muscles and the perineal body. Levator ani + fascia = pelvic diaphragm
154
What are the different types of vaginal prolapse?
urethrocoele- prolapse of the lower anterior vaginal wall involving urethra only
cystocele- prolapse of the upper anterior vaginal wall involving the bladder. Often associated with urethral prolapse. Together called : cystourethrocoele
Apical prolapse: prolapse of uterus, cervix and upper vagina
Enterocoele: upper posterior wall involving bowel
Rectocele: lower posterior wall of vagina involving the anterior wall of the rectum
155
State the different grades in a baden- walker classification of a vaginal prolapse.
0: No descent during straining
1: leading surgace of prolapse >1cm above hymenal ring
2: 1cm above to 1cm below hymenal ring
3: prolapse extends >1cm below hymenal ring
4: complete vaginal eversion
156
How common are vaginal prolapse?
50% of parous women of which 10-20% seek medical help
157
What are the associated risk of a vaginal prolapse?
Pregnancy, large infants, prolonged second stage of labour and instrumental delivery
Congenital factors e.g ehlers danlos syndrome
Menopause
Chronic intraabdominal pressure + eg. = obesity, chronic cough, constipation, heavy lifting
Iatrogenic factors: pelvic surgery
158
How does vaginal prolapse present?
Dragging sensation or the sensation of a lump.
Cystourethrocoele: urinary frequency, incomplete bladder emptying + stress incontinence
Rectocoele: difficulty opening bowels
159
Which speculum is used to visualise a prolapse?
Sim's speculum, patient lies laterally and told to bear down on the prolapse. Tell patient to strain/cough
160
How can vaginal prolapse be prevented?
Recognition of obstructed labour and avoidance of excessively long 2nd stage.
Pelvic floor muscle exercises after childbirth encouraged
161
How is vaginal prolapse managed if surgery isn't appropriate?
Lifestyle advice: lose weight, treat chest problem, stop smoking, physiotherapy
Postmenopausal women: HRT or topical oestrogen prevent vaginal ulceration
Pessaries: ring commonly used, shelf for severe form of prolapse. Changed every 6-9 months.
162
What are the disadvantages of pessary use?
Cause pain, urinary retention, infection or may fall our
163
how is vaginal prolapse managed surgically?
Hysteropexy or vaginal hysterectomy for uterina prolapse
Anterior repair for cystocoele, posterior repair for rectocoele.
Sacrospinous fixation or sacrocolpopexy for vault prolapse.
colposuspension or tension free vaginal tape or transobturator tape or stress incontinence.
164
Describe the neural control of the bladder and urethra
Parasympathetic nerve aid voiding and symphathetic nerves prevent it
165
what is continence dependant on?
Pressure in urethra being greater than pressure in bladder.
Bladder pressure = detrusor + abdo
Urethral pressure = urethral muscle + pelvic floor + abdo pressure
166
Describe the two types of urinary incontinence
OAB- detrusor muscle overactivity
Urinary stress incontinence- due to intra abdo pressure not being transmitted to urethra because bladder neck has slipped below pelvic floor therefore increase in abdo pressure such as when coughing cause micturition.
167
What is the average number of times a woman voids bladder?
4-7 times
168
what is dysuria associated with?
UTI- also causes nitrite presence
169
What does haematuria suggest?
Calculi or carcinoma
170
How is chronic urinary retention investigated?
Post micturition catheterization or ultrasound
171
How is stress incontinence differentiated from OAB using urodynamic studies?
Cystometry measures pressure in bladder (vesical pressure) whilst bladder is filled and provoked with coughing. Pressure transducer placed in rectum or vagina to measure abdominal pressure.
Detrusor pressure = vesical pressure - abdo pressure
Detrusor pressure doesn't normally alter with filling or provacation.
Leaking without incerase in detrusor pressure = stress incontinence
Leaking with increase = detrusor overactivity
172
what is methylene dye test used for?
Leakage from other places other than urethra e.g. fistulae can be visualised
173
what examinations are done when a patient persents with stress incontinence?
Sim's speculum
leakage of urine with coughing
abdomen palpated to exclude distended bladder.
174
How is stress incontinence managed conservatively?
Obese patient encourage to lose weight
Causes of chronic cough e.g smoking addressed
reduce excessive fluid intake
Pelvic floor muscle training for 3 months taught by physiotherapist. 8 contractions 3x per day.
175
How is stress incontinence managed medically?
Duloxetine (SNRI) enhances urethral striated sphincter activity.
Sideffects: nausea, dyspepsia, drymouth, drowsiness, insomnia
176
How is stress incontinecne managed surgically?
First line= mid urethral sling e.g. = tension free vaginal tape and transobturator tape 90% cure rate
177
what is the initial investigation for suspected OAB?
urinary diary: may show frequent passage of small volumes of urine, particularly at night. High intake of caffeine containing drinks.
178
what is the conservative management for OAB?
Advice: reducing fluid intake and caffeine intake.
| Bladder retraining: education; tied voiding with systematic delay; positive reinforcement. Done for 6 weeks.
179
how is OAB medically managed?
Anticholinergics(antimuscarinics) oxybutynin. Mirabegron for elderly. - however blood pressure monitoring required.
Oestrogen may help with symptoms
Botulinum toxin A 3-12 months cure for 60-90% patients
Referral to specialist clinic if oral relaxants fail to improve symptoms after 1-2months
180
How is OAB managed surgically?
Clam augmentation ileocystoplasty
181
What are the causes of bladder urgency and frequency?
```
Urinary infection
Bladder pathology
Pelvic mass compressing bladder
OAB
stress incontinence
```
182
what are the causes of acute urianry retention?
after childbirth (paticularly with epidural)
vulval or perineal pain
Surgery
183
what causes urethrovaginal fistulae?
Obstructed labour
184
Definition and aetiology of endometriosis?
Presence and growth of tissue similar to endometrium outside the uterus. 1-2% 30-45 years. More common in nulliparous women.
185
Where can endometriosis occur?
Commonly: uterosacra ligament, ovaries
| also in : umbilicus, abdominal scars, vagina, bladder, rectum and lungs
186
what are the clinical features of endometriosis?
History: cyclical dysmenorrhoea, deep dyspareunia, subfertility, pain on passing stool(dyschezia) during menses.
Severe disease: cyclical haematuria, rectal bleeding or bleeding from umbilicus
Examination: Tenederness, thickening behind uterus/ adnexa. In advanced cases uterus retroverted and immobile
187
What is the gold standard on endometriosis diagnosis?
Laparoscopy: diagnosis only made with certainty after visualisation and biopsy.
Active lesions: red vesicles or punctuate mark
White scars or brown spots = less active
188
How is presence of adenomyosis confirmed?
Visualised in USS confirmed in MRI.
189
What grading system is used for endometriosis?
```
revised american fertility society(rev-AFS). At laporoscopy points are scored dependent on the presence and position of endometriosis deposits and adhesions.
grade 1 minimal
2 mild
3 moderate
4 severe
```
190
How is endometriosis managed medically?
```
NSAIDS - management of pain
COCP
progesterone
GnRH- 6months use can be extended to 2 years with add back HRT
IUS
```
191
how is endometriosis managed surgically?
Scissors, laser or bipolar diathermy used to destroy endometriotic lesions- improves fertility
Radical surgery: dissection of adhesions, removal of endometriomas, hysterectomy and BSO
192
How does surgical and medical management of endometriosis effect fertility?
Medical management doesn't improve fertility
Surgical management does.
IVF best option
193
what is the definition of chronic pelvic pain ?
6 months pain not occurring exclusively with menstruation or intercourse.
194
What is the pH of the vagina and which bacteria dominates the bacterial flora?
>4.5 , lactobacilli
195
Which vaginal infections are associated with vaginal discharge?
bacterial vaginosis, trichomoniasis, candidiasis
196
Which bacteria does rise in pH facilitate and what histological feature does this lead to?
Gardnerella vaginalis, atopobium vaginae.
Grey white discharge
Positive whiff test- fishy odour when KOH added.
Clue cells: epithelial cells studded with coccobacilli.
197
How is BV treated?
clindamycin or metronidazole cream
198
What are the risk factors for candida infection?
Commonly caused by candida albicans, increased risk during pregnancy, diabetes and antibiotics use.
199
how does candidiasis present?
clinical features include: cottage cheese discharge with vulval irritation and itching.
superficial dyspareunia and dysuria may occur.
Diagnosis confirmed by culture
200
How is candidiasis treated?
Topical imidazole- clotrimazole pessary- or oral fluconazole
201
what principles are considered in the management of STIs?
screening for concurrent infection as more than one STI may be present
Contact tracing
Confidentiality. partners cannot be informed about diagnosis of STI without patient's permission
Education
202
what is the most common STI and how does it present?
chlamydia trachomatis- 70% = symptom free
most common symptoms= altered vaginal discharge, IMB and PMB
Pelvic infection can lead to subfertility due to tubal damage
203
Which arthritis is chlamydia associated with?
sexually acquired reactive arthritis(SARA) characterized by triad of conjunctivitis, urethritis, and arthritis
204
how is chlamydia diagnosed and treated?
nucleic acid amplification test (NAATs) can be used on urine.
Treatment is with azithromycin or doxycycline
205
How does gonorrhoeae present and how is it diagnosed?
G- diplococcus, men develop urethritis, often asymptomatic in women.
NAAT of endocervical or vulvovaginal swabs. Positive NAAT should be followed by culture to check for AB sensitivities.
206
how is gonorrhoeae managed?
IM ceftriaxone
207
which HPV strain cause genital warts?
6 and 11
208
what is the treatment for HPV?
there is no treatment
209
How does primary HSV present?
HSV-1 often causes cold sores but can cause genital infection with oral sex. HSV-2 commonly affects genital and anal area.
1/3- experience primary infection within 4-14 days of becoming infected. Flu like symptoms- fever, tiredness and headaches. Followed by stinging or itching and vesicle appearance lasting 2-3 days which crust over.
Lymphadenopathy and dysuria are common.
210
how common is HSV recurrence?
HSV-2: 4-6 recurrence each year
HSV-1: less frequent -1 a year
recurrences are milder. tingling and mild flu like symptoms before an outbreak.
211
how is hsv managed?
aciclovir- for severe infection and reduce duration of symptoms if started early in reactivation
212
Which organism causes syphilis?
spirochaete treponema pallidum- spiral shape bacteria
213
what is the transmission history of syphilis?
syphilis is sexually transmissible up till 2 years of untreated infection.
Transmission to fetus may occur up to 10 years after the primary infection.
214
how does primary, secondary and tertiary syphilis present?
Primary: solitary painless genital ulcer (chancre)
Secondary: weeks after primary- rash, influenza like symptoms and warty genital or perioral growths (condylomata lata), systemic vasculitis + organ involvement
Tertiary: common complications include: aortic regurg, dementia, tabes dorsalis(degeneration of sensory nerve cells), gummata of skin and bone (small soft swelling)
215
which test are used to diagnose syphilis ?
enzyme immunoassay(syphilis EIA), venereal disease research laboratories (VDRL)
216
How is syphilis treated?
parenteral penicillin- usually intramuscular
217
describe the discharge produced by trichomonas vaginalis infection and the associated symptoms
Flagellate protozoan produces offensive grey green discharge.
Vulval irritation, dysuria and superficial dyspareunia.
Cherry red cervix
218
How is trichomonas diagnosed?
NAATs
219
How is trichomonas treated?
Systemic metronidazole
220
How common is cervical intraepithelial neoplasia amongst HIV + women and how frequently are they invited for smear test?
1/3, yearly
221
Can a HIV+ women give birth vaginally and is breast feeding recommended?
Yes vaginal delivery is safe if on antiretroviral therapy. Breast feeding not recommended.
222
What causes endometritis?
Result of instrumentation of uterus or retained product of conception. Causes - chlamydia and gonorrhoea
other causes = e.coli, staphylococci, clostridia
223
How does endometritis present?
heavy vaginal bleeding accompanied by pain. Uterus tender and cervical os open.
224
What investigations are done if endometritis is suspected?
USS
FBC
vaginal and cervical swab
225
How is endometritis managed?
Broad spectrum antibiotics
| ERCP is indicated on USS
226
how does PID present?
subfertility, menstrual problems, bilateral lower abdominal pain, with deep dyspareunia = hallmark
severe cases examination reveals: tachycardia, fever, bilateral adnexal tenderness, cervical excitation
227
what investigations are done for suspected PID?
endocervical swabs for chlamydia and gonorrhoea
Blood culture if there is fever
WBC and c-reactive protein(CRP) may be raised
USS- exclude abscess or ovarian cyst
Gold standard for diagnosis = laparoscopy with fimbrial biopsy and culture - not commonly performed
228
how is PID treated?
Analgesia
IM ceftriaxone, doxycycline and metronidazole
alternate: ofloxacin with metronidazole
febrile patients admitted for intravenous therapy
no improvement = perform laparoscopy as abscess may not respond to antibiotics - requires drainage USS guidance or laparoscopic
229
what are the complication of PID?
Early complication = abscess formation or pyosalpinx ( fallopian tube filled with pus).
Ectopic pregnancy = 6x more likely after pelvic infection
tubal damage chance = 12% after one episode of acute PID.
230
when does vaginal discharge increase?
increases around ovulation, during pregnancy and in women taking COCP
231
what is the definition of subfertility?
conception hasn't occurred after a year of regular unprotected intercourse. 15% of couples are` affected
232
what are the conditions for pregnancy?
ovulation - 30%
adequate sperm release- 25%
sperm must reach egg- fallopian damage will prevent this - 25%
fertilized egg must implant
233
which hormone is released by the trophoblast to maintain the corpus luteum up till 8-10 weeks gestation?
hCG - human chorionic gonadotrophin
234
what is pain during ovulation called?
MIttelschmerz pain
235
what body temperature changes occur pre and post ovulation?
body temperature drops 0.2*C preovulation and rises 0.5*C during luteal phase
236
When should progesterone be measured to get mid luteal phase level?
7 days before subsequent menstruation as luteal phase lasts 14 days
237
How can ovulation be detected?
mid luteal progesterone (21 in a 28 day cycle)- standard
USS follicular tracking
temperature charts
LH based urine predictor kit
238
what are the diagnostic criteria for PCOS?
Rotterdam criteria 2 or more out of:
Polycystic ovaries morphology on US (12+ cyst or >10ml volume)
Irregular periods 5 weeks or more apart
Hirsutism (clinical or biochemical)
239
what is the aetiology of PCOS?
Predisposed women demonstrate disordered LH production and peripheral insulin resistance. Raised LH and insulin acting on PCO causes increased androgen production + also from adrenals.
Raised insulin also reduce hepatic production of SHBG
-sex hormone binding globulin
leading to overall increase in androgen which causes anovulation and hirsutism
240
how does weight impact risk of PCOS?
increased weight = greater risk of insulin resistance and increased production of insulin. greater chance of PCOS. Woman effected with PCOS also show family history of type 2 diabetes
241
what are the clinical features of PCOS?
```
Subfertility
oligomenorrhoea or amenorrhoea
hirsutism and or acne
obesity
miscarriage
```
242
What investigation are done for is PCOS is suspected?
Anovulation investigated with: FSH, LH, AMH (high in PCOS low in ovarian failure), prolactin, TSH, Serum testosterone
TVUS to look for polycystic ovaries
Other: Fasting lipids and glucose.
Especially if woman is obese or has family history of diabetes, abnormal lipids or CVD
243
What are the complications of PCOS?
Up to 50% of women with PCOS develop type 2 diabetes.
30%- gestational diabetes
risk reduced with weight loss.
Endometrial cancer is more common
244
How is PCOS managed?
Advice regarding diet and exercise
COCP if fertility not required for regular periods- 3/4 bleeds per year spontaneous or induced required for endometrial protection. Oestrogen consider- cyproterone acetate as antiandrogenic
Spironolactone = antiandrogenic
Metformin
Eflornithine= topical anti androgen used for facial hirsutism
245
What are the hypothalamic causes of anovulation?
Anorexia nervosa
Excessive exercise
Kallmann' syndrome- exogenous GnRH required
246
what are the pituitary causes of anovulation?
Hyperprolactinaemia- prolactinoma
enlarging ones may cause headaches and bitemporal hemianopia. CT imaging indicated if prolactin levels high
Sheehan's syndrome following post partum haemorrhage
247
how is prolactinoma medically managed?
dopamine agonist- cabergoline or bromocriptine
248
What are the ovarian causes of anovulation?
premature ovarian insufficiency: lower oestradiol and inhibin levels causing FSH and LH rise. Bone protection with HRT or oral contraceptive required
Gonadal dysgenesis- present with primary amenorrhoea
249
what is Clomifene used for ?
first line ovulation induction drug for PCOS. Limited use of 6 months, results in 70% ovulation rate and 40% live birth rate.
250
How does clomifene work and what needs to be monitored when using it?
antioestrogenic effect on hypothalamus, therefore increases GnRH release consequently increasing FSH and LH level. Given on day 2-6.
Clomifene cycle monitored using TVUS to assess ovarian response and endometrial thickness.
If no follicles develop increase dose.
If 3 or more follicles develop cycle cancellation indicated to prevent multiple pregnancy.
251
how effective in metformin in treating anovulation?
More effective than clomifene in women with BMI >30 but less effective <30 BMI.
doesn't cause multiple pregnancy but needs to be taken everyday multiple times and causes GI symptoms
252
Name an oral aromatase inhibitor which if off licence use for anovulation?
letrozole
253
how can anovulation be surgically managed?
laparoscopic ovarian diathermy- in the same operation tubal patency can be tested using methylene blue and comorbidities such as endometriosis and adhesions treated.
254
what is a severe side effect of ovulation induction especially IVF and how does it present?
Ovarian hyperstimulation syndrome (OHSS) risk factors include age <35, gonadotropin stimulation, previous OHSS and polycystic ovarian morphology.
Severe case: hypovolaemia, electrolyte imbalance, ascites, thromboembolism, pulmonary oedema
255
How is OHSS prevented and managed?
Ultrasound monitoring of follicular growth, cancellation of IVF cycle or use of GnRH agonist instead of hCG injection.
Manage: IV fluid for electrolyte imbalance, analgesia, thromboprophylaxis, drainage of ascetic fluid may be necessary.
256
How many days does it take for sperm to develop?
70 days
257
During sperm analysis if the first test is abnormal when should a repeat test be done?
In 12 weeks, no delay if azoospermia
258
What are the levels of normal semen analysis volume, sperm count and progressive motility?
>1.5ml
>15million/ml
>32%
259
Define azoospermia, oligospermia, severe oligospermia, asthenospermia
No sperm present
<15million/ml
<5million/ml
absent or low motility
260
What are the common causes of abnormal semen analysis?
Sulfasalazine, anabolic steroids
varicocele
smoking/ alcohol/ inadequate local cooling
genetic factors
antisperm antibodies
epididymitis, orchitis, XXY, Kallmann's, cystic fibrosis
261
How is abnormal sperm analysis managed?
Abnormal repeat: examine the scrotum, optimise lifestyle factors, hormone profile, TFT, serum karyotype, if azoospermia test for cystic fibrosis
Oligospermia: intrauterine insemination
Moderate to severe oligospermia: IVF or intracytoplasmic sperm injection
azoospermia: examine presence of vas deferens
check karyotype, cystic fibrosis, hormone profile,
Surgical sperm retrieval can be done if no vas deferens, or blocked.
Donor insemination
262
Can children contact their sperm donor?
Yes after age 18
263
what test are used for detection of fallopian tube damage?
Laparoscopy and dye test if indication of tubal damage e.g. history of endometriosis or PID.
Hysterosalpingogram or TVUS + US opaque fluid performed on woman with no risk factors of tubal damage.
264
What is the success rate of IVF? and when is IVF not indicated?
35% <36 years of age per stimulated cycle.
<10% once above 40
doesn't help in premature ovarian insufficiency- tested using AMH which decreases if +
265
What are the stages of IVF?
Multiple follicular development-
Long protocol: GnRH started day 21 of menstrual cycle for 2-3 weeks to suppress follicular development before adding exogenous gonadotrophin to stimulate follicles.
short protocol: GnRH antagonist only added post 5 days of gonadotrophin stimulation.
Ovulation with LH/hCG injection once multiple mature ovarian follicles (15-20mm). GnRH and gonadotrophins stopped and egg collection 35-38 hours post injection.
Fertilization and culture until blastocyst formation (day 5-6)
Embryo transfer: 2 embryos used. Luteal phase support using progesterone or hCG until 4-8 weeks gestation
266
what ovarian volume seen in USS should prompt referral for assessment?
ovarian volume greater than 20ml in premenopausal woman
| greater than 10ml in postmenopausal woman
267
what is the daily fluid requirement?
```
2.5L fluid intake and out
Intake:
Metabolic-0.5l
food:0.5l
drink:1.5l
outtake-
urine:1.5l
sweat:0.5l
respiration:0.4l
faeces:0.1l
```
268
how is a fluid status examination done?
```
blood pressure and heart rate
Input and output fluid chart
ask feeling thirsty/faint?
skin turgor and cap refill
mucous membrane moisture
JVP- jugular venous pressure raised if overloaded
basal crepitation
peripheral oedema- pressure over bony prominence
```
269
What is the first step in managing dehydration?
Raise patient's leg. 300ml raise even with 20* raise
| Is also reversible
270
What are the different types of IV fluids?
Larger proteins e.g. - albumin use in liver patients + certain other specialty, Risk of anaphylaxis
Crystalloid: Smaller molecules e.g. saline
Hartmann's: used more in surgery, for insensible loses diarrhoea and vomiting. where fluid loss is electrolyte rich
5% dextrose: used in maintenance 2x salty 1x sweet if BMs are okay over 24 hours.
271
Give example of different blood products used?
blood transfusion
FFP
Plt for massive haemorrhage
272
```
When are the following fluid regime used:
Stat 500ml
Stat 250ml
1l/hr
1l/2hr
1l/4hr
1l/6hr
1l/8hr
1l/12hr?
```
Stat 500ml: acutely unwell. To test if fluid responsive?
Stat 250ml: carefully challenge if hugely overloaded- maybe consider leg raise instead?
1l/hr: needs aggressive fluid resus eg DKA
1l/2hr: following 1l/hr still needing fluid resus in AnE
1l/4hr: unwell, patient can be sent to ward
1l/6hr: more than maintenance, patient still mildly dehydrated
1l/8hr: Maintenance for Nill by mouth patient.
1l/12hr: poor oral intake, e.g. overnight
273
what urine output to aim for ?
0.5mL/kg/hr
274
Which patients are at a greater risk of fluid overload?
MI or HF as fluid overload can cause pulmonary oedema
275
How is fluid overload reversed?
furosemide 40mg IV
276
How many days postpartum can woman have sex without risk of pregnancy?
21 days
277
How effective is breast feeding as contraception?
first 6 months if no period and exclusively breast feeding >98% effective
278
why is COCP contraindicated post partum?
Affects breast milk volume, and UKMEC 4 first 6 weeks due to increased clotting risk. Can be used after 6 months postpartum
279
Can POP be used postpartum?
yes after 6 weeks as progestogen only method do not affect milk production.
280
When can IUD be inserted?
After 4 weeks postpartum
281
How long after last period should a woman continue to use contraception?
2 years if under 50, 1 year if above
282
What is another name for POP?
Mini pill
283
How does COCP work and how is it taken?
inhibits ovulation
3 weeks on and then stopped for 1 week. Pill packets can be taken continuously for up to 3 phases, to reduce frequency of bleed- irregular spotting may occur
284
What is the contraceptive efficacy of COCP?
0.2 per 100 2 out 1000 women taking the pill every year become pregnancy
285
What are the common side effects of progestogens?
Depression, premenstrual tension like symptoms, reduced libido
Irregular bleeding or amenorrhoea
Acne, breast discomfort, weight gain
286
What are the common side effects of oestrogens?
```
Nausea + headache
increased mucus, fluid retention and weight gain,
occasionally hypertension
breast tenderness and fullness
irregular bleeding
```
287
How should the patient be advised if she has missed 2 COCP?
One pill can be missed, take missed pill asap
2 pills missed use condoms for 7 days continue packet as normal.
If fewer than 7 pills remaining in packet, the next packet should be started straight after the last, avoid a pill free break.
288
How many weeks prior surgery is the pill stopped?
4 weeks prior and started 2 weeks after surgery.
289
What advised should be given before starting woman on COCP?
Risk of venous thrombosis, MI and cerebrovascular accidents. Breast and cervical carcinoma
Advice to stop smoking
See doctor if symptoms suggestive of major complications
poor absorption with antibiotic and sickness( treat as missed pill)
Leaflet on missed pills
Stress the importance of follow up and blood pressure measurement
290
What are the most common side effects of COCP?
Nausea, headaches and breast tenderness.
291
what are the advantages of COCP?
More regular, less painful and lighter menstruation
Protection from ovarian and benign breast cysts
Protects from fibroids and endometriosis
Hirsutism and acne may improve
Risk of PID reduced
Lower incidence of ovarian, endometrial and bowel cancer
292
What are the absolute contraindications for COCP?
```
history of VT, TIA/stroke, IHD, severe hypertension
Migraine with aura
active breast/endometrial cancer
inherited thrombophilia
pregnancy + up to 6 weeks postpartum
smokers> 35 years and smoking >15 cigarettes
Diabetes with vascular complications
Liver disease
BMI >40
```
293
what are the relative contraindications for COCP?
```
smokers
chronic inflammatory disease ( reduces absorption of hormones)
renal impairment, diabetes
age > 40 years
BMI 35-40
breast feeding up to 6 months postpartum
```
294
how much progesterone does standard POP contain?
350 micrograms norethisterone
295
How does POP work?
thickens cervical mucus and in 50% of women inhibits ovulation too. Effective within 2 days
296
How effective is POP?
1/100 failure rate = higher than COCP
297
Define malstalgia
Breast pain
298
What should be advised if a patient misses a POP by more than 3 hours?
take as soon as possible, condom use for 2 days
299
which type of POP inhibits ovulation?
desogestrel containing POP: cerazette and cerelle. More effective and can be taken within 12 hour window
300
What should the woman be counselled on before starting on POP?
Advice woman about irregular bleeding patterns - breakthrough bleeding
Emphasize the importance of meticulous time keeping.
301
How is depo Provera administered?
IM 150mg medroxyprogesterone acetate (150mg) every 3 months
Sayana press- self administered every 13 weeks
Noristerat- contains norethisterone instead given every 8 weeks.
302
Where is Nexplanon inserted?
40mm flexible rod containing etonogestrel inserted in upperarm with local anaesthetic.
303
How long does nexplanon last?
3 years
304
What are the disadvantages of depo provera?
decrease in bone density over the first 2-3 years and then stabilises therefore not recommended in teenagers and older women at risk of osteoporosis
305
What are the three options for emergency contraception?
Levonelle: levonorgestrel(progestogen) 1.5mg best taken within 24 hours and no longer than 72 hours. 95% success rate
Ulipristal(ellaone): selective progesterone receptor modulator. Prevents or delays ovulation. Used up to 120 hours or 5 days after unprotected intercourse. Reduces effectiveness of progesterone containing contraception therefore condom use recommended until next period
IUD: prevents implantation. Most efficacious. up to 5 days post UPS or 5 days from expected day of ovulation. Antibiotic prophylaxis given during insertion.
306
If a woman comes into clinic for emergency contraception, what else should be counselled on ?
STI screen
| long term contraception
307
Examples of barrier contraception
male condom
female condom
diaphragms and caps- fitted during intercourse and must remain in situ for at least 6 hours afterwards.
spermicides used in conjunction with barrier method
308
how often do different IUS need to be replaces?
jaydess and levosert- 3 years
MIrena- 5 years
contain levonorgestrel
309
what is the disadvantage of IUS?
Irregular light bleeding
expulsion of device
perforation of uterus
with IUD pregnancy more likely to be ectopic if it does occur
310
what are the complete contraindication of IUD?
```
endometrial or cervical cancer
undiagnosed vaginal bleeding
active/recent pelvic infection
current breast cancer- IUS
pregnancy`
```
311
what are the relative contraindication of IUD?
```
previous ectopic
excessive menstrual loss- unless IUS
multiple sexual partners
young/nulliparous
immunocomprimised
```
312
what should the women be counselled on before insertion of IUD?
advice about major risk
advice to inform her doctor if : IMB, pelvic pain or vaginal discharge or thinks she's pregnant
advice about checking strings after each period
313
How is female sterilization procedure done?
Under GA
Filshie clips, block off fallopian tube- laparoscopic placement
Trans cervical sterilisation hysteroscopic placement of micro inserts into the proximal part of each tubal lumen. Inserts expand and cause fibrosis- confirmed after 3 months with Hysterosalpingogram.
314
what is the failure rate of female sterilization?
1/200 life time failure risk
315
What should the woman be counselled on before female sterilization procedure?
```
certainty of choice
alternative contraception
1/200 lifetime risk of failure
risk of ectopic
reversal may not be possible and not available in NHS
risks of surgery and possible laparotomy
```
316
how effective is vasectomy?
1/2000 lifetime risk after two negative semen analysis.
317
what does vasectomy invovle?
ligation and removal of a small segment of vas deferens, performed under LA.
Sterility not confirmed under 2 negative semen analysis which takes up to 6 months.
318
What is the median age of menopause?
51 years
319
define menopause
12 consecutive months of amenorrhoea
320
define premature menopause
menopause before 40 years of age affects 1%
| HRT indicated until age 50
321
define postmenopausal bleeding
vaginal bleeding occurring at least 12 months after the last menstrual period
322
what are the causes of PMB?
```
endometrial carcinoma
endometrial hyperplasia +- atypia and polyps
cervical carcinoma
atrophic vaginitis
cervicitis
ovarian carcinoma
cervical polyps
```
323
How is PMB initially managed?
bimanual and speculum examination
cervical smear if one has not been taken according to national screening programme
TVUS- measure endometrial thickness + gives information on fibroids and ovarian cysts
324
when is endometrial biopsy indicated and how is it done?
endometrium thickness >4mm on US
multiple bleeds
either with pipelle suction or hysteroscopy
325
how is atrophic vaginitis managed?
topical oestrogen or oral ospemifene(SERM)
326
What are the common symptoms and consequence of menoause?
```
Increase risk of CVD
vasomotor symptoms
urogenital problem
sexual problem
osteoporosis
```
327
Define osteopenia and osteoporosis
osteopenia- BMD between -1 to -2.5 SD from the young adult mean
osteoporosis- BMD >2.5 SD from the young adult mean
328
what is the most common osteoporotic fracture?
fracture of wrist- colle's fracture
329
what are the risk factors for the development of osteoporosis?
```
history of fracture
Parental history of fracture
early menopause <45 years of age
low BMI
corticosteroid use
smoking and prolonged immobilisation
```
330
What is the FRAX tool?
developed by WHO to give the 10 year probability of fracture based on individual patient clinical factors and BMD
331
how is BMD calculated?
Using dual energy x ray absorptiometry (DEXA), measure at lumbar spine and hip
332
how can oestrogen be delivered in HRT?
orally, transdermally(patch or gel), subcutaneously(implant). Topical oestrogen vaginally
333
what different regimes are there for progesterone use in HRT?
progesterone can be given sequentially for 10-14 days every 4 weeks, 14 days every 3 weeks or taken consequentially
first causes monthly bleed
second three monthly bleed
amenorrhoea if taken continous
cyclic therapy preferred if within 12 months of last period
334
how can local vaginal oestrogen therapy be given?
cream, pessary, tablet, ring
335
which cancer does HRT increase the risk of?
Breast
336
Which HRT intake method increases the risk VTE and gallbladder disease?
oral, transdermal doesn't
337
which cancer does HRT decrease the risk of?
Colon by 1/3
338
what pharmacological interventions can be implemented to prevent osteoporosis?
```
bisphosphonates e.g. alendronate
strontium ranelate
raloxifene and bazedoxifene (SERM)
parathyroid hormone peptides
Denosumab- RANKL monoclonal antibody reduces osteoclast activity
calcium and vitamin D supplements
```
339
What is the principle side effect of bisphosphonates?
upper GI irritation
340
define miscarriage
fetus dies or delivers dead before 24 completed weeks of pregnancy. Majority occur before 12 weeks
341
what are the different types of miscarriage?
threatened: 25% miscarry, bleeding, cervical os closed, fetus still alive
inevitable: cervical os open, heavier bleeding
incomplete: some fetal parts remain, cervical os generally open
complete: all fetal tissue has passed, bleeding has diminished, cervical os is closed
septic miscarriage: contents of uterus infected, endometritis
missed: fetus has not developed or died in utero, not recognised until bleeding occurs
342
what is the aetiology of most sporadic miscarriage?
isolated non recurring chromosomal abnormality = 60% of one off or sporadic miscarriage
343
define recurrent miscarriage
three or more consecutive miscarriage
344
what investigations should be done if miscarriage is suspected?
US at early pregnancy assessment units, if doubt repeat scan week later
blood tests: hCG levels normally increase >63% in 48 hours with viable intrauterine pregnancy
+63%to -50% = ectopic
more than -50% = unviable pregnancy
FBC + rhesus group should also be checked
345
How is incomplete miscarriage managed?
Product of conception is cervical os removed using polyp forceps
IM ergometrine given to reduce bleeding by contracting uterus
if there is fever- swab for bacterial culture are taken and IV antibiotics started
Anti d for rhesus - women- if being treated surgically or medically or if there spontaneous miscarriage after 12 weeks gestation or bleeding
346
How is non viable intrauterine pregnancy managed?
expectant management success rate >80% 2-6 weeks of incomplete miscarriage and 30-70% of women with missed miscarriage
Medical management = misoprostol (vaginal or oral) >80% success with incomplete 40-90% of missed. repeat urine pregnancy test after medical management to exclude ectopic or molar pregnancy
Surgical management: evacuation of retained products of conception carried out under anaesthetic using vacuum aspiration. Suitable if woman prefers, heavy bleeding or signs of infection. Success rate >95% for both incomplete and missed.
347
How is a woman counselled after miscarriage?
Told that miscarriage was not due to result of anything they did or did not do and could not have been prevented. Reassurance as to the high chance of successful further pregnancies and referral to support group. Further investigation if 3 or more miscarriage or miscarriage after 12 weeks.
Exercise, sex or emotional trauma do not cause miscarriage
348
what are the causes of recurrent miscarriage?
Antiphospholipid antibodies- thrombosis in the uteroplacental circulation likely mechanism
Parental chromosomal defects- options = prenatal diagnosis using CVS or amniocentesis, use of donor oocyte/sperm, preimplantation genetic diagnosis of IVF embryos are alternate options
anatomical factors: uterine weakness, adhesions, cervical problems
Infection: implicated in preterm labour, late miscarriage, early treatment of bacterial vaginosis reduces the incidence of fetal loss
hormonal factors: thyroid dysfunction, PCOS
349
how is miscarriage due to antiphospholipid antibodies managed?
aspiring and low dose molecular weight heparin
350
what are the risk factors of recurrent miscarriage?
obesity, smoking, excess caffeine intake, older maternal age
351
what investigations are done following recurrent miscarriage ?
Antiphospholipid antibody screen- repeat at 6 weeks if positive
karyotyping of fetal miscarriage tissue
thyroid function
pelvic ultrasound (MRI or Hysterosalpingogram if pelvic ultrasound is abnormal)
352
what investigations and discussions should be done before TOP?
blood test should be taken for Hb, blood groups, rhesus status, screened for chlamydia and undergo risk assessment for other STI and are screened for them if appropriate. Contraception should be discussed
353
what should be given to rhesus negative women who have undergone termination of pregnancy?
receive anti D within 72 hours of TOP
354
What is the medical management of TOP?
first mifepristone given
| then misoprostol 36-48 hours later.
355
when can TOP be done medically?
Most effective method of abortion at gestation less than 7 weeks but can also be alternative to surgical termination at any gestation.
Usual and most effective method for mid trimester abortion (13-24 weeks)
356
From which week of gestation is feticide done?
22 weeks to prevent live birth. KCL injection into umbilical vein or fetal heart.
357
How is TOP performed surgically?
vacuum aspiration generally used between 7 till 14 weeks. till 14 weeks LA. till 15 weeks GA
Before 7 weeks medical abortion more effective.
Above 15 weeks - 24 weeks dilatation and evacuation done under GA.
Cervix is prepared preoperatively with vaginal misoprostol and antibiotic prophylaxis.
358
What are the complications of TOP?
Haemorrhage
infection
uterine perforation
cervical trauma
359
where can ectopic pregnancies occur?
```
tubal-95%
cornual
cervical
ovarian
abdominal
```
360
what causes an increase risk of ectopic pregnancy?
PID from STI, surgery, previous ectopic, smoking
| also rule out in pregnancy with IUD in place
361
what are the clinical features of ectopic pregnancy and how is it diagnosed?
amenorrhoea, abnormal vaginal bleeding, abdominal pain, or collapse in any women should arouse suspicion and on examination uterus is smaller than expected
urine pregnancy test should be done
ultrasound does not always confirm ectopic or intrauterine pregnancy before 5 weeks- as no heartbeat
362
what is the management of the symptomatic suspected ectopic pregnancy?
```
nil by mouth
FBC and cross match blood
pregnancy test
ultrasound
laparoscopy or consider medical management
IV access
Anti D given if rhesus negative
```
363
how is haemodynamically unstable ectopic presentation managed?
laparotomy + salpingectomy
364
how is subacute ectopic pregnancy managed surgically?
Indications include: significant pain, adnexal mass >35mm, visible heart activity or serum hCG level >5000IU/ml.
Laparoscopy salpingectomy done
salpingotomy if one tube left and fertility preservation required- however 10% chance repeat surgery for persisting ectopic required
365
How is persisting ectopic detected?
detected by failure of serum hCG to fall on follow up.
366
what is the medical management of ectopic pregnancy?
indication: patient can return for follow up, no significant pain, unruptured ectopic, adnexal mass <35mm with no fetal heart activity.
single dose methotrexate
Serial hCG monitored until <20IU/ml
second dose or surgery may be required
367
define hyperemesis gravidarum
hyperemesis gravidarum is when nausea and vomiting are so severe as to cause dehydration, weight loss or electrolyte disturbance.
368
what antiemetics can be given to manage hyperemesis gravidarum?
metoclopramide, cyclizine, even ondansetron
| thymine to prevent Wernicke's encephalopathy
369
define complete and incomplete mole
complete mole = 2 sperm genetic material in egg
| partial mole = triploid 2 sperm + egg genetic material
370
What is a choriocarcinoma?
Mole which has metastasised
371
what are the clinical features of a molar pregnancy?
uterus often large
vaginal bleeding, hyperemesis
complete mole - snowstorm appearance on US
Serum hCG high
372
How is a molar pregnancy managed?
```
suction curettage (ERPC) and the diagnosis is confirmed histologically.
thereafter serial blood or urine hCG persistent or rising levels = malignancy 15% of complete moles and 0.5% of partial moles
molar pregnancy only precedes 50% of malignancies as it also follow from miscarriage or normal pregnancy
```
373
what is the recurrence rate of molar pregnancy?
1/60
374
how is choriocarcinoma managed?
low risk- methotrexate and folic acid
high risk combination chemotherapy
good prognosis
five year survival rates approach 100 %
375
how common are miscarriage?
15% of recognized pregnancy
376
what is used to distend the cavity during hysteroscopy?
saline or carbon dioxide
377
how can the endometrium be ablated?
diathermy, roller ball diathermy, intrauterine hot balloon, laser ablation, microwave probe
378
what are the different types of hysterectomy?
total abdominal hysterectomy
vaginal hysterectomy- lower morbidity and quicker recovery than abdominal
laparoscopic hysterectomy
379
what does Wertheim's (radical) hysterectomy involve?
removal of parametrium , upper third of vagina and pelvic lymph nodes. Indication = 1aii - 2a cervical carcinoma.
380
what the risk of hysterectomy?
immediate- haemorrhage, bladder or ureteric injury
postoperative- VTE(LMWH prophylaxis), pain, infection
long term- prolapse, stress incontinence, premature menopause
381
what does hysteropexy involve?
Resuspension of the prolapse uterus using a strip of non absorbable bifurcated mesh to lift uterus and hold it in place. one end of mesh attached to the cervix and the other end to anterior longitudinal ligament over the sacrum.
382
what precautions are taken to reduce the risk of thromboembolism before gynaecological surgery?
COCP stopped 4 weeks prior, if HRT not stopped LMWH must be used.
Low risk: minor surgery or major surgery <30min, no risk factors
Moderate risk: consider anti embolus stockings or subcutaneous heparin for surgery >30mins, obesity, gross varicose veins, current infection, prior immobility, major current illness
High risk: use LMWH for 5 days or until mobile for:
cancer surgery, prolonged surgery, history of DVT. thrombophilia or more than 3 moderate risk factors
383
how is the risk of infection reduced during abdominal and vaginal surgery?
Prophylactic antibodies
384
how is the estimated day of delivery calculated?
-3 months + 7 days + 12 months from LMP
| if cycle longer than 28 days add the number of days greater than 28, reverse applies for shorter cycles
385
when is dating ultrasound done?
between 11-13+6 weeks, estimated date of delivery calculated from crown rump length at this scan
386
what are the various complications of pregnancy to ask about in obstetric history?
bleeding, hypertension, diabetes, urine infection, concerns about fetal grown, fetal movement
387
Describe the uterus size in the following weeks: 12, 20, 36
uterus palpable from 12 weeks
20 weeks at fundus
at xiphisternum at 36 weeks
388
how common is breech presentation at 28 weeks and 37 weeks?
30%-28 weeks
| 3%- 37 weeks
389
what does engagement of the head mean?
widest diameter of fetal head descended into pelvis, if only 2/5th of head palpable in abdomen, the head has engaged
390
when is the apgar score calculated?
total score = 10
calculated at 1 min after delivery to assess need for resuscitation
calculated at 5 min = correlates vaguely with neurological outcome
391
what are the 5 criteria in apgar score?
Heart rate, respiratory effort, muscle tone, colour, reflex irritability(stimulate foot)
392
How is heart rate apgar scored?
0: absent
1: <100
2: >100
393
how is respiratory effort apgar scored?
0 : absent, irregular
1 : weak
2 : strong cry
394
how is muscle tone apgar scored?
0: absent
1: limb flexion
2: active motion
395
how is reflex irritability apgar scored?
0: no response
1: grimace
2: cry
396
how is colour apgar scored?
0: all blue/pale
1: blue extremities
2: all pink
397
what is involved in the neonatal examination?
General: colour, birthmark, posture, behaviour and feeding, respiration
Measure: heart rate, temperature, head circumference, weight
Examine: primitve reflex, inspect back and spine with baby prone, heart- check all pulses equal, abdomen, genetalia, anus, look for dislocation of hip and talipes (club foot)
Investigation: serum bilirubin if jaundiced. Day 7: guthrie test for phenylketonuria and thyroid
398
Ideally when should the first booking appointment be?
before 10 weeks gestation
399
What is measured in the combined test done during the dating scan?
nuchal translucency measurement
| In blood: b-hCG, PAPPA ( pregnancy associated plasma protein A)
400
What are the routine booking investigations?
FBC
serum antibodies
glucose tolerance test
blood test for Syphilis, HIV and hepatitis B
Haemoglobin electrophoresis for high risk women - thalassaemia and sickle cell
Urine culture
401
when is 5mg folate/ per day indicated?
BMI >30, diabetes, sickle disease or malabsorption, anti epileptics
402
What is the prophylaxis for women at increased risk of pre-eclampsia?
Aspiring 75mg
403
Which immunisations are recommended during pregnancy?
influenza and pertussis ideally done between 16-32 weeks
404
how is VTE prevented is in high risk women ?
Low molecular weight heparin
405
when is FBC and antibody assessment repeated during pregnancy?
28 weeks gestation, also rechecked at 34 weeks if low
406
what are the indications for OGTT?
increased BMI, ethnicity, first degree relative with history of diabetes
407
what is the average recommended amount of antenatal visits for an uncomplicated pregnancy?
7 for multiparous women 10 for nulliparous
408
what is checked on every antenatal visit?
blood pressure and urine: protein, glucose and nitrites
409
when are the antenatal visit for nulliparous and multiparous women?
10, 13, 20, 25, 28, 31, 34, 36, 38, 40, 41
| induction of labour latest by 42 weeks
410
what are the different causes of congenital abnormalities in pregnancy?
structural deformities, chromosomal abnormality, inherited, infection, drug exposure
411
when can amniocentesis be done and what are the risks?
from 15 weeks gestation, allows diagnosis of chromosomal abnormalities + CMV, toxoplasmosis and inherited disorders e.g. sickle cell, thalassaemia and cystic fibrosis.
1% miscarriage rate
412
When can CVS be done?
after 11 weeks gestation
413
what are the risk factors of down's syndrome?
High maternal age
previous affected baby
balanced parental translocation
414
what do blood test show if the fetus has down's syndrome?
low: oestriol
low: AFP
low: PAPP-A
high: b-hCG
high: inhibin
415
when is quadruple test done and what is it composed of?
```
blood test done between 14- 22 weeks, integrates:
AFP
total hCG
inhibin
oestriol
```
416
what does NIPT stand for?
non invasive prenatal testing, near 100% sensitivity therefore negative test is reassuring but positive test prompts further invasive test
417
what syndrome does 22q11 deletion correspond with?
```
di George syndrome
Cardiac abnormality
Atypical face
Thymic hypoplasia
Cleft palate
Hypocalcaemia/hypoparathyroidism
```
418
define exomphalos
partial extrusion of the abdominal contents in a peritoneal sac. 50% = chromosomal problem therefore amniocentesis offered
419
define gastroschisis
free loops of bowel in the amniotic cavity. Postnatal surgery indicated >90% survive
420
what do diaphragmatic hernias lead to?
pulmonary hyperplasia as abdominal content herniate into the chest. severe cases- in utero tracheal occlusion. Trachea is plugged with balloon that stimulates lung growth.
421
what appearance does duodenal atresia present with in USS?
double bubble of stomach and dilated upper duodenum
422
define fetal hydrops
extra fluid accumulates in two or more areas in the fetus. 1/500
cause can be immune or non immune
423
what are the five main categories of non immune hydrops?
chromosomal abnormalities e.g. trisomy 21
structural abnormality - pleural effusion
cardiac abnormality and arrhythmias
anaemia causing cardiac failure
twin-twin transfusion in monochorionic twin
424
what investigation is done in suspected hydrops?
echocardiogram and assessment of the middle cerebral artery.
| maternal blood taken for Kleihauer and parvovirus, CMV, toxoplasmosis IgM testing
425
which causes of hydrops are curable?
Anaemia- transfusion
compression by fluid collection such as pleural effusion- vesicoamniotic shunting
twin-twin transfusion- laser ablation
426
what are the purposes of doing an USS in the first trimester?
exclusion of ectopic, assessment of pregnancy viability, estimation of gestational age, detection of multiple pregnancy, detection of retained products of conception after miscarriage or TOP
427
what are the purposes of doing an USS in the second trimester?
diagnosis of structural abnormality
Help other diagnostic or therapeutic techniques- transfusion, amniocentesis
doppler of uterine arteries for growth restriction
measurement of cervical length as screening test for preterm delievery
428
what are the purposes of doing an USS in the third trimester?
assessment of fetal growth
doppler of MCA velocity for fetal anaemia
diagnosis of placenta praevia
determining presentation in difficult cases
429
what are the causes of polyhydramnios?
maternal diabetes, renal failure
twin to twin transfusion
fetal anomaly: upper GI obstruction, inability to swallow, CNS, cardiac or renal abnormality, myotonic dystrophy
430
what is the epidemiology of CMV during pregnancy and what is its neonatal effect?
1% of women develop CMV infection in pregnancy with 40% vertical transmission rate to fetus of which 10% = symptomatic at birth
Effect: IUGR, pneumonia, thrombocytopenia. Go on to develop neurological sequelae such as hearing, visual and mental impairment.
431
How is CMV infection diagnosed in pregnancy and what is the management?
IgM for mother
Amniocentesis post 6 week maternal infection will confirm or refute vertical transmission
Management: no prenatal treatment, termination may be offered. Routine screening is not advised.
432
what is the epidemiology of herpes simplex during pregnancy and what is its neonatal effect?
HSV-2 effects genitals and vertical transmission occurs at birth following recent maternal primary infection-40% risk. High mortality rate
433
How is herpes simplex infection diagnosed in pregnancy and what is the management?
diagnosis is clinical.
Management: referral to genitourinary clinic.
Caesarean section recommended for those delivering within 6 weeks of primary attack and for those with genital lesions from primary infection at the time of delivery. Exposed neonates given acyclovir.
434
what is the epidemiology of herpes zoster during pregnancy and what is its neonatal effect?
chickenpox in pregnancy = 0.03% but causes severe maternal illness
neonatal effect: teratogenicity = 1/2%
maternal infection in the 4 weeks preceding delivery can cause severe neonatal infection
435
How is herpes zoster diagnosed in pregnancy and what is the management?
immunoglobulin used to prevent and acyclovir used to treat.
Pregnant women tested for immunity
Immunoglobulin given within 10 days of exposure,
436
what is the epidemiology of rubella during pregnancy and what is its neonatal effect?
congenital rubella very rare in UK, taken out of screening program in UK
<10 affected neonates born
causes: deafness, cardiac disease, eye problem and mental retardation. Probability and severity decreases with increase in maternal age.
at 9 weeks = 90% risk post 16 weeks very low risk
437
How is rubella diagnosed and managed during pregnancy?
non immune women develops rubella before 16 weeks gestation termination of pregnancy offered. Rubella vaccine contraindicated in pregnancy, although harm has not been recorded
438
what is the epidemiology of parvovirus and what is its neonatal effect?
0.25% of pregnant women infected. 50% immune. slapped cheek appearance is classic, but many have arthralgia or are asymptomatic.
Neonatal effect: suppresses fetal erythropoiesis causing anaemia. Variable degree of thrombocytopenia also occur. fetal death = 10% of pregnancy usually with infection before 20 weeks.
439
How is parvovirus diagnoses and managed?
Positive maternal IgM prompts fetal surveillance.
Fetal anaemia detected initially as increased blood flow velocity in the middle cerebral artery and later as oedema(fetal hydrops) from cardiac failure. Spontaneous resolution in 50%
Transfusion via umbilical artery if anaemia = severe
very severe disease sometimes associated with neurological damage
440
what is the epidemiology of hepatitis B and what is its neonatal effect?
1% of pregnant women infected during pregnancy - acute / chronic.
vertical transmission occurs at delivery with 90% being chronic carriers.
441
How is hepatitis B diagnosed and managed?
Booking bloods screening
Neonatal immunization reduced the risk of infection by >90%.
Women with high viral load- HBV DNA levels greater than 200 000 IU/mL treated with antiviral agents from 32 weeks with additional passive immunisation to the neonate.
442
what is the epidemiology of hepatitis C and what is its neonatal effect
0.5% of women in UK infected. Risk factors = drug use and sexual transmission
Vertical transmission rate = 3-5%
screening is restricted to high risk group
443
what is the epidemiology of HIV and what is its neonatal effect?
1000 pregnancies infected by HIV, 15% transmission if no treatment <1% with prophylaxis
maternal effect = increased risk of pre-eclampsia and gestational diabetes
neonatal effect= stillbirth, preeclampsia, growth restriction and prematurity risk increased.
Vertical transmission risk greatest during intrapartum and breast feeding.
25% of infected neonates develop AIDS by 1 year and 40% by 5 years.
444
How is HIV diagnosed and managed during pregnancy?
Routine screen during booking
HAART throughout pregnancy and baby for first 6 weeks.
Caesarean recommended if viral load >50copies/ml and if coexistence of hepatitis C virus.
Breastfeeding not advisable
445
How is influenza managed in pregnancy?
Preventative measure by recommendation of influenza vaccine
| If symptomatic give oseltamivir and consider admission
446
How is Zika transmitted and what are its effect on the neonates?
Aedes mosquitoes.
| CNS abnormality: intracranial calcification, ventriculomegaly and microcephaly
447
How does group A streptococcus present?
streptococcus pyogenes- most common bacterium associated with maternal death
most common symptom = sore throat
can cause chorioamnionitis with abdominal pain, diarrhoea and severe puerperal sepsis.
Reduced morality with early recognition, cultures, high dose antibiotics
448
what increases the risk of neonatal streptococcus B infection?
infection from group b streptococcus ( streptococcus agalactiae) is most common with preterm labour, labour prolonged or there is maternal fever.
449
how can vertical transmission of Streptococcus B be prevented?
high dose IV penicillin throughout the labour
450
what are the two strategies used to prevent vertical transmission of group b streptococcus?
Strategy 1: risk factors no screening
treat with IV penicillin in labour if: previous history, intrapartum fever >38, current preterm labour, rupture of membranes >18h
strategy 2: screening vaginal and rectal swab at 35-37 weeks
treat with IV penicillin if swab positive or risk factors present.
451
how is toxoplasmosis transmitted and what are its neonatal effects?
due to protozoan parasite - toxoplasma gondii
follows contact with cat faeces or eating infected meat
0.2% pregnant women affected
neonatal effect: mental handicap, convulsions, spasticity, and visual handicap
452
How is toxoplasmosis diagnoses and how is it managed?
ultrasound may show hydrocephalus, maternal infection is usually diagnosed with IgM following exposure. confirmed with amniocentesis after 20 weeks.
Spiramycin started as soon as maternal toxoplasmosis is diagnosed.
If vertical transmission confirmed add additional combination therapy: pyrimethamine and sulfadiazine with folinic acid.
Termination may be offered
453
how does TB effect and neonate ?
diagnosis in late pregnancy is associated with prematurity and IUGR. treatment with first line drugs and addition vitamin B6 but streptomycin contraindicated
454
how is malaria in pregnancy managed?
artemisin combination therapy
455
what are the neonatal effect of chlamydia and gonorrhoea in pregnancy and how are they managed?
Associated with preterm labour and with neonatal conjunctivitis.
Chlamydia treated with: azithromycin or erythromycin; tetracycline cause fetal tooth decolouration
Gonorrhoea treated with cephalosporins
456
what are the neonatal effect of bacterial vaginosis and how is it managed?
Common overgrowth of normal vaginal lactobacilli by anaerobes such as gardernella vaginalis and mycoplasma hominis.
Preterm labour and late miscarriage are common
Screening and treatment with oral clindamycin reduce the risk of preterm birth if used before 20 weeks in women with a history of preterm birth
457
define proteinuria
>0.3mg/24h
458
how much does blood pressure drop by in normal pregnancy?
-30/15mmHg minimum in second trimester
459
define gestational hypertension
blood pressure >140/90 mmHg after 20 weeks
460
define preeclampsia
Preeclampsia: >140/90 mmHg after 20 weeks + protein urea often with oedema
461
define early onset pre eclampsia
complication before 34 weeks, often causes IUGR
462
what is the mechanism of pre eclampsia?
poor trophoblastic invasion of spiral arteries causes high resistance flow in uterine arties. Oxidative inflammatory markers released. Blood vessel endothelial cell damage is systemic flow leas to vasospasm, increased capillary permeability and clotting dysfunction
463
how is pre eclampsia classified?
mild or moderate: pre-eclampsia without severe hypertension and no symptoms and no biochemical haematological impairment
severe: pre-eclampsia with severe hypertension and/or with symptoms and/or biochemical and haematological impairment
Hypertension mild: moderate: severe
140:150:160
464
what are the risk factors of preeclampsia and indication for low dose aspirin us?
```
High risk: aspirin indicated if any of the following:
1) hypertensive disease during a previous pregnancy
2) CKD
3) AI disease such as SLE or anti phospholipid syndrome
4) type 1 or 2 diabetes
5) chronic hypertension
moderate risk: aspiring if >1 of:
1) nulliparous
2) age >= 40
3) pregnancy interval more than 10 years
4) BMI >35 at booking
5) family history of pre eclampsia
6) multiple pregnancy
```
465
What is HELLP syndome?
Haemolysis(dark urine, raised LDH, anaemia), elevated liver enzymes, low platelets
466
what are the clinical features of pre eclampsia
at late stage: headache, drowsiness, visual disturbance, nausea, vomiting or epigastric pain
hypertension, oedema, urine dipstick
467
what are the maternal complications of pre eclampsia?
Indication for delivery:
1) eclampsia- treatment with magnesium sulphate IV intensive surveillance for complications
2) cerebrovascular haemorrhage
3) HELLP- magnesium sulphate prophylaxis
4) renal failure- identified by careful fluid balance monitoring and creatinine measurement.
5) Haemodialysis required in severe cases.
6) Pulmonary oedema- treated with oxygen and furosemide
468
what are the fetal complications of pre eclampsia
IUGR, preterm birth, placental abruption, hypoxia
469
what investigations are done for pre eclampsia?
```
Urine protein- PCR
FBC
LDH, LFTs,
renal function: UnEs, creatinine clearance
USS monitoring for IUGR
umbilical artery doppler and CTG
PIGF
```
470
how is preeclampsia managed?
Prevention: 75mg aspirin from 12 weeks to birth
Blood pressure and urinalysis 2x weekly and USS 2-4 weeks
Labetalol if BP 140/110mmHg with target <135/95
471
when should hospital admission be considered for pre eclampsia?
proteinuria pcr >30, severe hypertension >160/110
IUGR, abnormal CTG
blood pressure measurement every 15-30mins until below 160 then 4x daily inpatient
renal function, liver function and FBC 3x weekly afterwards
472
when is delivery recommended for pre eclamptic women?
deliver 37 weeks unless indication for early delivery.
| steroid course before delivery 37 weeks.
473
how should labour be managed in a pre eclamptic women?
continuous CTG monitoring, blood pressure and fluid balance closely observed.
Oxytocin rather than ergometrine as latter raises blood pressure.
474
what is the postnatal management of pre-eclamptic patient?
24 hours for severe disease to improve
continue LFTs, platelets and renal function
Fluid balance monitored
Blood pressure maintained 140/90
Long term management plan with GP or community midwife. Hypertension persisting past 6 weeks referred to renal or hypertension clinic
475
define pre existing hypertension in pregnancy
140/90mmHg before 20 weeks
476
what are the causes of secondary hypertension?
secondary hypertension association = obesity, diabetes, renal disease, renal artery stenosis, chronic pyelonephritis, Cushing's syndrome, coarctation of aorta
477
how is existing hypertension in pregnancy managed?
Labetalol normally used with nifedipine as a second line agent.
478
what are the various assessment of urinary protein and what do they indicate?
dipsticks(bed side): trace, (1+, >=2) significant protein urea => quantify
Protein creatinine ratio >30mg/nmol = confirmed significant proteinuria
24h collection >0.3g/24h
479
define gestational diabetes
carbohydrate intolerance which is diagnosed in pregnancy and may or may not resolve after pregnancy
480
what are the diagnostic threshold for diagnosing gestational diabetes?
fasting glucose 5.6
| 2 hour glucose 7.8
481
what are the complications of maternal diabetes in pregnancy?
complications are related to poorly controlled blood sugars:
increased risk of neural and cardiac defect
fetal lung maturity slower
Increased risk of macrosomia
polyhydramnios common
dystocia and birth trauma
fetal compromise and fetal distress in labour and sudden fetal death are more common
482
what are the maternal complications of diabetes?
Increased insulin requirement
UTI and endometrial infection more common
caesarean or instrumental delivery more common
diabetic nephropathy and retinopathy
483
how is pre existing diabetes managed preconceptually?
HbA1c <6.5% ideal >10% pregnancy not advised
| folate 5mg, antihypertensive suitable for pregnancy substituted and statins stopped
484
what is the blood glucose aim when gestational diabetes is being treated?
fasting glucose <5.3mmol/l
| one hour glucose <7.8mmol/l
485
when is the fetal growth monitored in a woman with gestational diabetes and what are the recommendation for delivery?
USS fetal growth and liquor at 32 and 36 weeks
delivery at 37-39 weeks
elective caesarean is often used when fetal weight exceeds 4kg
during labour glucose levels re maintained with a sliding scale of insulin and dextrose infusion
486
how is gestational diabetes managed if fasting levels are >7mmol/l?
metformin or insulin is started immediately
487
what murmur is heard during pregnancy due to increase in stroke volume?
ejection systolic murmur in 90% of pregnant women
| left axis shift and inverted T waves are common
488
what are the risk factors for gestational diabetes and when is it screened?
```
Previous history of gestational diabetes
1st degree relative with diabetes
previous fetus >4.5kg
BMI > 30
racial origin
polyhydramnios
persistent glycosuria
previous unexplained stillbirth
```
489
which antiepileptic drugs can be used in pregnancy?
lamotrigine, levetiracetam
| must use 5mg folate
490
how is hyperthyroidism managed in pregnancy?
propylthiouracil in first trimester than carbimazole
491
In women presenting with intrahepatic cholestasis what can help with their itching?
ursodeoxycholic acid
492
How is the increased risk of haemorrhage reduced in patient's diagnosed with intrahepatic cholestatsis?
Vitamin K is given from 36 weeks 10mg/day
also induction by 40 weeks
38 if bile acids are high
493
why does urea and creatinine decrease in pregnancy?
glomerular filtration rate increases 40%
494
why should nitrofurantoin be avoided after 36 weeks gestation?
it may produce neonatal
| haemolysis.
495
when in bacteriuria screened for during pregnancy and what complications can it lead to?
Urine cultured at booking visit. Bacteriuria may led to pyelonephritis
E.coli accounts for 75% of cases
496
what antibodies are present in antiphospholipid syndrome?
lupus anticoagulant and or anticardiolipin antibodies or anti B2 glycoprotein I antibody
measured twice 3 months apart
497
give examples of prothrombotic disorders which increase the risk of VTE
anti thrombin deficiency, protein s and c deficiency
498
how is hyperhomocysteinaemia managed?
>15 μmol/L, managed with high dose folic acid
| aspiring + LMWH
499
how does pregnancy increase the risk of VTE?
blood clotting factors are increased
| fibrinolytic activity reduced
500
how is pulmonary embolism diagnosed?
chest x-ray, arterial blood gas analysis, CTPA, VQ scan
501
how is DVT diagnosed?
doppler US or MRI used
502
how is cerebral VT diagnosed?
MRI head
503
what are the risk factors for VTE?
```
any previous VTE
High risk thrombophilia
Obesity
increasing age >35
parity >3 or equal
smoker
caesarean section in labour
surgical procedure except perineal repair
prolonged admission
family history of VTE
gross varicose veins
current systemic infection
immobility
current preeclampsia
multiple pregnancy
prolonged labour
haemorrhage
```
504
what is the management of VTE?
high risk: antenatal LMWH
continue postnatally for 6 weeks if high risk
intermediate risk: consider LMWH antenatal
LMWH postnatally for 10 days
505
what are the criteria to consider for admission to a mother and a baby unit
```
Rapidly changing mental state
suicidal idealation
pervasive guilt or hopelessness
significant estrangement from the infant
new or persistent beliefs of inadequacy as a mother
evidence of psychosis
```
506
which antipsychotic is first line in pregnancy?
haloperidol
507
what are the complications of ecstasy use during pregnancy?
cardiac defects and gastroschisis
508
what are the complication of benzodiazepine use during pregnancy?
association with facial clefts, neonatal hypotonia and withdrawal symptoms
509
what are the common side effects of oral iron supplement?
GI upset- constipation
510
what are the anaemia criteria in pregnancy?
110 in first and third
| 105 in second
511
what are the complications of sickle cell disease in pregnancy?
painful crisis, pre eclampsia and thrombosis
512
what are the different severity of alpha thalassaemia?
4 gene deletion die in utero
3 gene deletion require lifelong transfusion
2 or 1 gene deletion are carriers and usually well but mildly anaemic
513
what are the complications of beta thalassaemia major?
chronic haemolytic anaemia is present and multiple transfusion may cause iron overload
514
what are the four classifications of FGM?
type 1: clitoridectomy
type 2: excision partial or total removal of the clitoris and labia minora +- labia major
type 3: infibulation: narrowing of the vaginal opening by cutting and repositioning the labia with our without removal of the clitoris
type 4: other non medical procedure to the female genitalia
515
give examples of potentially sensitising events for rhesus d in pregnancy
```
TOP or ERPC after miscarriage
ectopic pregnancy
vaginal bleeding >12 weeks or <12 weeks if heavy
external cephalic version
Invasive uterine procedures
intrauterine death
delivery
```
516
how is sensitisation prevented in pregnancy?
anti d given week 28 if fetus rhesus positive or unknown, when mother = rhesus negative
also given within 72 hours of any sensitising event
517
how is rhesus d isoimmunisation managed?
anti d level >4IU/mL fetus investigated for anaemia, blood transfusion in utero or delivery for affected fetus
518
how is fetal anaemia assessed?
doppler ultrasound of the fetal middle cerebral artery to calculate peak systole velocity has high sensitivity for significant anaemia before 36 weeks.
very severe anaemia <5g/dL is detectable as fetal hydrops or excessive fetal fluid
519
In which veins can transfusion be given to the fetus?
umbilical vein or intrahepatic vein
| deliver if more than 36 weeks
520
what is the post natal management of a baby born to rh - mother?
check FBC, bilirubin and rhesus group
521
what percentage of deliveries are preterm?
5-8%
522
what are the complications of preterm labour?
increased mortality, cerebral palsy, chronic lung disease, blindness
523
what are the risk factors for spontaneous preterm labour?
```
previous history
lower socioeconomic class
extremes of maternal age
short interpregnancy interval
pre eclampsia
IUGR
STI
vaginal infections
previous cervical surgery
multiple pregnancy
uterine abnormalities
UTI
```
524
what are the prevention strategies for prevention of preterm of labour?
preventive strategies usually limited to high risk women who have previously delivered between 16-34 weeks.
Cervical cerclage: insertion of one or more sutures in the cervix to strengthen it and keep it closed. Either done at 12-14 weeks or scanned regularly and if only done if significant shortening
Progesterone supplementation using pessary may reduce risk but not currently recommended
525
what investigation is done if a women presents with suspected rupture of membranes?
at point of care: fetal fibronectin assay
a negative results means preterm delivery within the next week is unlikely.
TVS of cervical length: delivery unlikely if cervical length >15mm
Fetal state assessed by: CTG and ultrasound
To look for infection: high vaginal swab using a sterile speculum.
CRP and WCC may be helpful in diagnosing chorioamnionitis
526
what can be used to delay labour for steroid to be administered in preterm labour?
tocolytics: nifedipine, atosiban(oxytocin antagonist)
527
when should magnesium sulphate be given in pregnancy and what are its complications?
```
magnesium sulphate is given within 24 hours of delivery of preterm babies of less than 34 weeks gestation. It is given as a bolus, followed by an infusion for up to 24 hours or until birth
complications:
Reduced respiratory rate
Reduced blood pressure
Absent reflexes
Monitor tendon reflex, ECG if possible
```
528
how does ROM present?
gush of clear fluid is normal followed by further leaking
529
why is co-amoxiclav contraindicated in prevention of infection after ROM?
more prone to necrotising enterocolitis
| use erythromycin
530
define antepartum haemorrhage
bleeding from genital tract after 24 weeks gestation
531
what are the risk factors for placenta praevia
more common with twins, previous caesarean, high parity and age, scarred uterus.
532
what are the complications of placenta praevia?
obstructs head engagement
| haemorrhage
533
how does placenta praevia present?
intermittent painless bleeding
incidental US finding
Abnormal lie, breech presentation
534
which examination should not be performed in suspected placenta praevia?
vaginal examination
535
When is USS done in third trimester to detect ongoing placenta praevia?
32 weeks
536
how can placenta accreta be diagnosed?
3D power doppler ultrasound or MRI
537
what investigations should be done if pregnant woman presents with vaginal bleeding?
CTG, FBC, clotting studies and cross match blood
538
how is placenta praevia managed?
Admit all women with bleeding from placenta praevia
Anti d is administered to rh- women
IV access
Steroids if gestation <34 weeks IM injection
delivery by elective caesarean section at 39 weeks by most senior person available
539
define placental abruption
when part or all of the placenta separates before delivery of the fetus.
540
what are the risk factors for placental abruption?
```
IUGR
pre-eclampsia
pre-existing hypertension
maternal smoking
previous abruption
cocaine
```
541
what are the clinical features of placental abruption?
woody uterus, painful bleeding, tachycardia, hypotension, poor urine output or renal failure
542
what CTG features are seen during placental abruption?
fetal bradycardia, frequent erratic uterine activity
543
how is placental abruption initially managed?
```
admission to hospital even without vaginal bleeding if there is pain and uterine tenderness.
Resuscitation may be required
IV fluid, steroid if <34 weeks.
Opiate analgesia, anti D for rh-
early delivery if fetal distress
transfusion of blood +- blood products
```
544
what are the delivery options for placental abruption?
Depends on fetal state and gestation
Fetal distress urgent delivery by c section required
if no fetal distress but gestation is 37 weeks or more- induction of labour with amniotomy
545
how is maternal condition accessed in placental abruption?
fluid balance, renal function, FBC and clotting, urine output
546
what are the causes of perinatal mortality?
```
unexplained
preterm delivery
IUGR
congenital abnormality
intrapartum, including hypoxia
placental abruption
```
547
define SGA
<10th centile for date
548
define IUGR
describes foetuses that have failed to reach their own growth potential
549
what is the difference between fetal distress and fetal compromise?
fetal distress- acute situation.
| fetal compromise- chronic situation
550
how can PAPPA be used to asses risk?
low in chromosomal abnormality, IUGR placental abruption and still birth
551
How can maternal uterine artery doppler be used to asses risk ?
abnormal wave forms suggesting failure of development of a low resistance circulation identify 75% of pregnancies at risk of adverse neonatal outcomes: early preeclampsia, IUGR, placental abruption
552
when is ductus venous waveform useful?
Measure of cardiac function. Useful in assessing disease severity in babies with heart failure and twin to twin transfusion
553
what are the determinants of fetal size?
constitutional determinants: gender, ethnicity, low maternal height and weight, nulliparity
Pathological determinants: pre-eclampsia, smoking, drug usage, CMV, extreme exercise and malnutrition
554
what are the major risk factors for SGA at booking?
```
previous history of SGA or stillbirth
heavy smoking
cocaine use
heavy daily exercise
maternal illness: diabetes
parental SGA
```
555
how is SGA investigated?
ultrasound to determine size
check for fetal abnormalities, CMV and chromosome
Umbilical artery doppler if less than 34 weeks
if more add on middle cerebral artery doppler as well
CTG if doppler abnormal
556
defined prolonged pregnancy
>=42weeks, labour induced between 41-42 weeks
557
how is prolonged pregnancy managed?
at 40-41 week offer cervical sweep
at 41 week check patient vagina and offer induction
if no induction arrange daily CTG
if CTG abnormal caesarean
558
how is IUGR managed?
<34 weeks twice weekly umbA doppler if abnormal but not AEDF
give steroids
daily CTG if abnormal AEDF <32 weeks
deliver if abnormal AEDF >32 weeks or CTG abnormal
give magnesium prior to delivery
>34 week monitor, Cerebroplacental ratio
consider delivery anyway
>37 Weeks deliver
559
what increases the risk of abnormal lie?
```
preterm delivery
lax uterus due to multiparity
polyhydramnios
twin pregnancy
placenta praevia
uterine deformities
```
560
after how many weeks gestation is ECV done?
37 weeks
561
what are the different types of breech presentation?
extended: hip flexion, knee extension
flexed: hips flexion, knee flexion
footling: one /two foot presents below buttocks
562
when is vaginal birth contraindicated in breech?
footling breech, >3.8kg
563
what are the different types of multiple pregnancy?
DZ twins- different oocyte fertilised by different sperm
MZ division before day 3: DCDA 30%
division between 4-8: MCDA 70%
division between 9-13: MCMA rare
564
what are the risk factors for multiple pregnancy?
genetic predisposition, assisted conception (IVF, clomiphene), increasing maternal age and high parity
565
what are the complications of multiple pregnancy?
6x greater mortality rate, IUGR, preterm dlivery, malpresentation, post partum haemorrhage
preeclampsia, diabetes, anaemia
566
how is twin twin transfusion syndrome managed?
laser ablation
567
what does lambda sign and T sign in pregnancy ultrasound mean?
Lambda sign: dichorionic
| T sign: monochorionic
568
when are serial ultrasound performed in multiple pregnancies to detect IUGR?
28, 32, 36 weeks
569
how many weeks gestatation is delivery advised by in multiple pregnancy?
37 weeks for dichorionic twins and 36 weeks for uncomplicated monochoronic twins
570
how often is US surveillance performed in MC twins>
starts at 12 weeks, every 2 week until 24 weeks and every 2-3 weeks afterwards
571
when is twin to twin transfusion syndrome most commom?
16-24 week gestation
572
after how many weeks are pregnancies complicated by TTTS considered for delivery?
26 weeks
573
how is labour diagnosed?
painful contraction leading to dialatation of the cervix
574
what are the different stages of labour?
first- cervical dialatation
second- delivery of fetus
third- delivery of placenta
575
which three mechanical factors determine progress during labour?
the degree of force expelling the fetus
the dimension of pelvis and the resistance of the soft tissue
the diameters of the fetal head
576
which landmark feature is used to access progress during labour?
ischial spines, palpable vaginally
577
what are the other names for posterior and anterior fontanelle?
posterior- occiput
| anterior- bregma
578
what is meant by attitude during labour presentation and how does it effect delivery?
attitude = degree of flexion of the head on the neck. Ideal = maximal flexion smaller vertex presentation. extended head causes larger vertex presentation and can mean the fetal diameters are too large to deliver vaginally.
579
what is meant by position during presentation?
degree of rotation of the head on the neck. Ideal situation = transverse sagital suture when head enters inlet and vertical at outlet with occiput anterior
580
how does the fetal head move during second stage of labour?
transverse at inlet
descent and flexion
rotation 90* to occipito anteror at outlet
descent
extension to deliver
transverse rotation again for delivery of shoulders
581
how is first stage of labour split up?
the latent phase - cervix up to 4cm dialated slow
| active phase after 4cm- quicker dilatation
582
how long does second stage of delivery last?
40 mins nulliparous 20 mins multiparous
583
how long does third stage last on average?
15 mins
584
what obervation are made during labourand how often?
temperature and BP monitored every 4 hours, pulse every hour(first stage) pulse every 15 mins in second stage. if abnormal measurements should be more frequent
contraction frequency is recorded every 30 mins
585
which position is contraindicated during delivery?
supine
586
is drinking encouraged in labour?
yes unless high risk
587
how is pyrexia defined in labour and how is it managed?
>37.5 more common with epidural and prolonged labour. Culture of vagina, urine and blood are taken.
administer paracetamol
antibiotics IV and CTG monitor if fever reaches 38*C
588
what effect does epidural have on urination?
removes bladder sensation therefore may reduce urination
589
what is the nice guidelines definition of slow progress of labour?
<2cm dialatation in 4 hours
590
define augmentation
augmentation is the artificial strengthening of contraction in established labour
591
what are the steps in augmentation of labour
first rupture of membrane if hasn't happened yet
| oxytocin IV
592
how is OT position managed?
rotation with ventouse
593
how is OP managed?
kielland's forcep
594
how is brow presentation managed?
requires caesarean
595
how is face presentation managed?
chin anterior - vaginal possible
| chin posterior - caesarean
596
what is terbutaline used for?
stop contractions
597
what is entonox?
mix of nitrous oxide and oxygen, mild but rapid analgesia
598
what is in local anaesthetic?
opiate + local anaesthetic
| fentanyl and bupivacaine
599
where is an epidural injected?
l3/4 or l4/5 loading dose followed by intermittent low dose
600
what are the contraindications to epidural?
```
severe sepsis
coagulopathy or anticoagulant therapy unless low dose heparin
active neurological disease
some spinal abnormalities
hypovolaemia
```
601
what are complications of epidurals?
```
spinal tap
total spinal analgesia
hypotension
local anaesthetic toxicity
higher instrumental delivery rate
poor mobility
urinary retention
maternal fever
```
602
where is analgesia delivered for caesarean?
spinal anaesthesia
603
what are the criteria for home birth?
```
woman's request
low risk on basis of anetnatal or past obstetric medical complications
37-41 weeks
cephalic presentation
clear liquor
normal fetal heart rate
all maternal observations normal
```
604
how are perineal traumas classified
1: injury to skin only
2: involving perineal muscle
3: involving anal sphincter complex
a <50% external
b >50% external
c internal as well
4: involving anal epithelium as well
605
how is oxytocin administered for active management of third stage?
IM syntometrine often used : ergometrine + oxytocin
606
what are the risk factors for perineal tears?
forecep delivery, large babies, nulliparity
607
define prolonged labour
>12h duration after latent phase
608
what are the causes of prolonged labour?
power: inefficent uterine action
passenger: fetal size, disorder of rotation OT OP, disorder of flexion
passage: cephalo-pelvic disproportion
609
how is slow progress in labour managed?
Wait if natural labour waned, mobilize and provide support
Nulliparous: amniotomy + oxytocin
Multiparous: amniotomy + oxtocin if malpresentation/ malposition excluded
if this fails caesarean section if in first stage of labour and instrumental delivery if in second stage of labour
610
how common in OP?
5%
611
what are the different causes of fetal inury during labour?
hypoxia, meconium aspiration, trauma, infection/inflammation, blood loss
612
define fetal distress
hypoxia that may result in fetal damage or death if not reversed or the fetus delivered urgently
613
how is the fetus monitored during labour?
```
intermittent ascultation(IA), inspection for meconium, if IA abnormal do CTG
can do fetal blood sample if CTG abnormal
```
614
how is CTG showing bradycardia managed?
resusitate, if no improvemt caesarean or instrumental delivery - whichever quickest route
615
which score predicts successful induction of labour?
Bishop's score
616
what are the methods of inducing labour?
medical: prostagladin, oxytocin
surgical: amniotomy
617
what are the indication for induction of labour?
IUGR, prolonged pregnancy, pre eclampsia, maternal disease such as diabetes, preterm rupture of membranes
618
what are the absolute and relative contraindication for induced labour?
acute fetal comprimise, abnormal lie, placenta praevia, pelvic obstruction, previous caesarean section
619
what are the factors influencing vaginal delivery after one caesarean section?
spontaneous labour, interpregnancy interval of less than 2 years, low age and normal BMI, caucasian rave, previous vaginal delivery
620
how is prelabour term rupture of the membranes managed?
check for infection, lie/presentation, avoid vaginal examination
consider immediate induction as risks lower, or wait
advise induction and antibiotics if >18-24 hour duration
621
how common is instrumental delivery?
20% of nulliparous women and 2% of multiparous
622
when is a classical caesarean indicated?
extreme prematurity, multiple fibroids, fetus is transverse
623
what are the absolute indication for caesarean section?
placenta praevia, severe antenatal fetal comprimise, uncorrectable abnormal lie, previous vertical caesarean section and gross pelvic deformity
624
what are the relative indication for caesarean?
breech, twin, IUGR, diabetes, pre eclampsia, previous caesarean and older nulliparous patients
when delivery before 34 weeks caesarean favoured over induction
625
what are complications of caesarean section and how are they reduced?
haemorrhage, blood transfusion, infection of the uterus or wound, bowel or bladder damage, postop pain, VTE
preoperative antibiotic + thromboprophylaxis given
626
how is placenta accreta diagnosed?
3D power doppler
627
what is the name of rotational forcep?
kielland's
628
what are the two non rotational forceps?
simpson's neville-barnes
629
what is the risk of shoulder dystocia?
Erb's palsy
630
how is shoulder dystocia managed?
```
McRobert's manoeuvre
gentle pressure on anterior shoulder
episiotomy
Rubins manoeuvre
Wood’s screw manoeuvre
Zavanelli manoeuver- emergency caesarean
```
