Qs and content to learn Flashcards
What are the two types of vasa praevia
In Type 1, there is a velamentous insertion with vessels running over the cervix. In Type 2, unprotected vessels run between lobes of a bilobed or succenturiate lobed placenta.
What are the ADIPS cut-offs for GDM?
Fasting glucose ≥ 5.1mmol/L
1‐hr glucose ≥ 10.0mmol/L
2‐hr glucose ≥ 8.5mmol/L
What is the Rubella serology cut-off for postnatal MMR?
<30
What is a normal ET for a pre-menopausal woman?
- during menstruation: 2-4 mm 1,4
- early proliferative phase (day 6-14): 5-7 mm
- late proliferative / preovulatory phase: up to 11 mm
- secretory phase: 7-16 mm
What is a normal ET for a post-menopausal woman?
vaginal bleeding (and not on tamoxifen): suggested upper limit of normal is <5 mm no history of vaginal bleeding: the acceptable range of endometrial thickness is less well established in this group, cut-off values of 8-11 mm have been suggested
What is Type 1 FGM?
Type I — Partial or total removal of the clitoris and/or the prepuce.
Type Ia, removal of the clitoral hood or prepuce only;
Type Ib, removal of the clitoris with the prepuce.
What is Type 2 FGM?
Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Type IIa, removal of the labia minora only;
Type IIb, partial or total removal of the clitoris and the labia minora;
Type IIc, partial or total removal of the clitoris, the labia minora and the labia majora.
What is Type 3 FGM?
Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
Type IIIa, removal and apposition of the labia minora;
Type IIIb, removal and apposition of the labia majora.
What is Type 4 FGM?
All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.
What is the risk of NTD recurrence?
~5%
What is the preferred form of contraception in Epilepsy and why?
LARC, Depot - Some anti-epileptics induce liver enzymes that increase OCP metabolism.
Leveteracitem, Lamotrigine are examples of what?
Non-enzyme inducing anti-epileptics. However, OCPs decrease Lamotrigine concentrations. They also have lower teratogenicity.
Name 8 risk factors for SGA.
- Low BMI
- Nullip
- Prev SGA
- Ethnicity
- Smoking
- Drugs
- Maternal age
- Maternal medical disease
In an SGA baby with abnormal dopplers and AEDF, when do you repeat the dopplers?
Daily.
In an SGAbaby with abnormal dopplers but present EDF, when do you repeat dopplers?
Twice weekly.
What is the physiological cause of abnormal DV doppler?
The Ductus venosus (DV) Doppler flow velocity pattern reflects atrial pressure-volume changes during the cardiac cycle. As FGR worsens velocity reduces in the DV a-wave owing to increased afterload and preload, as well as increased end-diastolic pressure, resulting from the directs effects of hypoxia/acidaemia and increased adrenergic drive.
What is the physiological cause of abnormal MCA doppler?
Cerebral vasodilatation is a manifestation of the increase in diastolic flow, a sign of the ‘brain-sparing effect’ of chronic hypoxia, and results in decreases in Doppler indices of the middle cerebral artery (MCA) such as the PI. Reduced MCA PI or MCA PI/umbilical artery PI (cerebroplacental ratio) is therefore an early sign of fetal hypoxia in SGA fetuses.
Name 8 risk factors for placental abruption
- Prev PA
- Low BMI
- HTN
- PET
- AMA
- Multiparity
- Smoking and drugs
- Abdominal trauma
What are the three tests for APLS?
- Lupus anti-coagulant
- Anti-cardiolipin antibodies, IgG/IgM
- Anti-beta-2 glycoprotein 1
What is the global maternal mortality rate?
Global estimates from the World Health Organization (WHO) show that the maternal mortality ratio (MMR) fell from 385 per 100,000 women giving birth in 1990 to 216 per
100,000 women giving birth in 201
What is the Australian maternal mortality rate?
This led to a maternal mortality ratio of 6.8 deaths per 100,000 women giving birth. The remaining 10 deaths were classified as incidental to the pregnancy.
In 2015 the MMR for developed
countries, which includes Australia, New Zealand, the United Kingdom and the United States
of America, was 12 per 100,000 women giving birth, which is lower than in regions such as
Oceania (MMR estimate 187 per 100,000 women giving birth), South-East Asia (110 per
100,000 women giving birth) and Sub-Saharan Africa (546 per 100,000 women giving birth).
What are the most common causes of maternal death in Australia?
The most common causes of the Australian maternal deaths from 2012-2014 were non-obstetric haemorrhage, cardiovascular conditions and thromboembolism. Maternal
suicide was less prominent in this period than in the 2006-2010 and 2008-2012 reports
(AIHW: Johnson et al. 2014b; AIHW: Humphrey et al. 2015)
How much higher in the maternal mortality rate for indigenous Australians?
3x
How many of the maternal deaths are thought to have been avoidable?
Exploration of contributory factors to these deaths suggests that up to one-third may be avoidable.
Define ‘direct’ maternal deaths.
Those resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium) from interventions, omissions, incorrect treatment or from
a chain of events resulting from any of the above
Define ‘indirect’ maternal deaths.
Those resulting from previous existing diseases or diseases that developed during pregnancy, and which were not due to a direct obstetric cause, but were
aggravated by the physiologic effects of pregnancy
Define late maternal death.
Late maternal deaths are deaths that occur between 43 and 365 days after pregnancy ends and and
result from obstetric complications of the pregnancy or previous existing diseases or
diseases that developed during pregnancy.
Between 2012 and 2014, were direct or indirect causes of maternal death more common?
Direct (51% vs 46%)
How does age affect maternal mortality?
More dangerous at extremes of age.
How does parity affect maternal mortality?
3 or more is bad.
in 2012-2014, name the top 4 causes of maternal death.
- Non-obstetric haemmorhage
- Cardiovascular
- VTE
- Obstetric haemmorhage
Define the three levels of preterm birth.
- Extremely preterm (less than 28 weeks)
- Very preterm (28 to 32 weeks)
- Moderate to late preterm (32 to 37 weeks).
Define neonatal mortality.
A neonatal death is defined as a death during the first 28 days of life (0-27 days).
Define perinatal mortality.
The World Health Organization defines perinatal mortality as the “number of stillbirths and deaths in the first week of life per 1,000 total births, the perinatal period commences at 22 completed weeks (154 days) of gestation, and ends seven completed days after birth.
Define infant mortality.
It is measured by the infant mortality rate (IMR), which is the number of deaths of children under one year of age per 1000 live births. The under-five mortality rate is also an important statistic, considering the infant mortality rate focuses only on children under one year of age.
Define low birthweight.
Low birth weight (LBW) is defined by the World Health Organization as a birth weight of a infant of 2,499 g or less, regardless of gestational age. … Normal weight at term delivery is 2500-4200 g
Define standard deviation.
a quantity expressing by how much the members of a group differ from the mean value for the group.
Define standard error.
a measure of the statistical accuracy of an estimate, equal to the standard deviation of the theoretical distribution of a large population of such estimates.
Define confidence interval.
A confidence interval is an interval that will contain a population parameter a specified proportion of the time. The confidence interval can take any number of probabilities, with the most common being 95% or 99%.
How is sample size calculated?
The sample size is an important feature of any empirical study in which the goal is to make inferences about a population from a sample. In practice, the sample size used in a study is determined based on the expense of data collection, and the need to have sufficient statistical power.
Define prevalence.
Prevalence in epidemiology is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seat-belt use).
Define incidence.
Incidence in epidemiology is a measure of the probability of occurrence of a given medical condition in a population within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate[1] with a denominator.
Define cumulative incidence.
Cumulative incidence is defined as the probability that a particular event, such as occurrence of a particular disease, has occurred before a given time.[2] It is equivalent to the incidence, calculated using a period of time during which all of the individuals in the population are considered to be at risk for the outcome. It is sometimes also referred to as the incidence proportion.
Define relative risk.
In statistics and epidemiology, relative risk or risk ratio (RR) is the ratio of the probability of an event occurring (for example, developing a disease, being injured) in an exposed group to the probability of the event occurring in a comparison, non-exposed group.
Define odds ratio.
An odds ratio (OR) is a measure of association between an exposure and an outcome. The OR represents the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure.
Define attributable risk.
In epidemiology, attributable risk or excess risk is the difference in rate of a condition between an exposed population and an unexposed population. Attributable risk is mostly calculated in cohort studies, where individuals are assembled on exposure status and followed over a period of time.
Define number needed to treat.
The NNT is the average number of patients who need to be treated to prevent one additional bad outcome (e.g. the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial). It is defined as the inverse of the absolute risk reduction.
Define an RCT.
Randomized controlled trial: (RCT) A study in which people are allocated at random (by chance alone) to receive one of several clinical interventions. One of these interventions is the standard of comparison or control.
Define a cohort study.
A study design where one or more samples (called cohorts) are followed prospectively and subsequent status evaluations with respect to a disease or outcome are conducted to determine which initial participants exposure characteristics (risk factors) are associated with it.
Define a case-control study.
A study that compares patients who have a disease or outcome of interest (cases) with patients who do not have the disease or outcome (controls), and looks back retrospectively to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor.
Define a cross-sectional study.
In medical research and social science, a cross-sectional study (also known as a cross-sectional analysis, transverse study, prevalence study) is a type of observational study that analyzes data from a population, or a representative subset, at a specific point in time—that is, cross-sectional data.
What is Level 1 evidence?
Level I
Evidence obtained from a systematic review of all relevant randomised controlled trials.
What is Level 2 evidence?
Level II
Evidence obtained from at least one properly designed randomised controlled trial.
What is Level 3 evidence?
Level III-1
Evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation or some other method).
Level III-2
Evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies), case control studies, or interrupted time series with a control group.
Level III-3
Evidence obtained from comparative studies with historical control, two or more single-arm studies, or interrupted time series without a parallel control group.
What is Level 4 evidence?
Level IV
Evidence obtained from case series, either post-test or pre-test and post-test.
Define selection bias.
Selection bias is the bias introduced by the selection of individuals, groups or data for analysis in such a way that proper randomization is not achieved, thereby ensuring that the sample obtained is not representative of the population intended to be analyzed.
Define measurement bias.
Measurement bias results from poorly measuring the outcome you are measuring. For example: The survey interviewers asking about deaths were poorly trained and included deaths which occurred before the time period of interest.
Define confounding.
In statistics, a confounder (also confounding variable, confounding factor or lurking variable) is a variable that influences both the dependent variable and independent variable causing a spurious association.
Define heard immunity.
the resistance to the spread of a contagious disease within a population that results if a sufficiently high proportion of individuals are immune to the disease, especially through vaccination.
Following post-hysterectomy prolapse, what three outcomes is ASC better than SSF?
- Dyspareunia
- Post-op SUI
- Recurrent vault prolapse
What are the 5 reasons for surgical management in endometrial hyperplasia without atypia?
(i) progression to atypical hyperplasia occurs during follow-up, or (ii) there is no histological regression of hyperplasia
despite 12 months of treatment, or (iii) there is relapse of endometrial hyperplasia after completing
progestogen treatment, or (iv) there is persistence of bleeding symptoms, or (v) the woman declines
to undergo endometrial surveillance or comply with medical treatment.
How should endometrial hyperplasia be managed in women wishing to conceive?
Disease regression should be achieved on at least one endometrial sample before women attempt to conceive.
What are risk factors for ectopic pregnancy?
Risk factors for ectopic pregnancy include tubal damage following surgery or infection, smoking and in vitrofertilisation
What is the intradecidual sign?
Theintradecidual sign is described as a fluid collection with an echogenic rim located ‘within a markedly thickened decidua on one side of the uterine cavity’
What is the double decidual sign?
The double decidual sign is described as anintrauterine fluid collection surrounded by ‘two concentric echogenic rings’
What ultrasound findings are characteristic of cervical ectopic?
an empty uterus, a barrel-shaped cervix, a gestational sac present below the level of theinternal cervical os, the absence of the ‘sliding sign’ and blood flow around the gestational sacusing colour Doppler.
What are the criteria for a Caesarean Scar ectopic?
- Empty uterine cavity. Gestational sac or solid mass of trophoblast located anteriorly at the level of the internal os embedded at the site of the previous lower uterine segment caesarean section scar. Thin or absent layer of myometrium between the gestational sac and the bladder. Evidence of prominent trophoblastic/placental circulation on Doppler examination. Empty endocervical canal.
What are the ultrasound features of an interstitial pregnancy?
- Empty uterine cavity.2. Products of conception/gestational sac located later ally in the interstitial (intramural) part of the tube and surrounded by less than 5 mm of myometrium in all imaging planes.3. The ‘interstitial line sign’, which is a thin echogenic line extending from the central uterine cavity echo to the periphery of the interstitial sac. The ‘interstitial line sign’ has been shown to have a sensitivity of 80% and a specificity of 98% for the diagnosis of interstitial ectopic pregnancy.
What is the dose of Methotrexate for ectopic pregnancy?
50mg/m2
Name four predictors of success with Methotrexate treatment for ectopic pregnancy?
- Initial HCG of ~1000
- Ultrasound appearance of the ectopic pregnancy
- Pretreatment changes in serum b -hCG levels - The smaller the increase in b-hCG level prior to administration of methotrexate, the higher the chance of successful medical management.
- Decrease in b-hCG levels from day 1 to day 4 after methotrexate
What should women avoid during treatment for ectopic pregnancy?
During treatment with methotrexate women should be advised to avoid alcohol and folate-co ntaining vitamins.
Name 6 characteristics that would make a woman a good candidate for Methotrexate treatment”
haemodynamic stability
low serum b-hCG, ideally less than 1500 iu/l but can be up to 5000 iu/l
no fetal cardiac activity seen on ultrasound scan
certainty that there is no intrauterine pregnancy
willingness to attend for follow-up
no known sensitivity to methotrexate.
What are the four elements that NICE recommend as first line Methotrexate treatment for ectopic
no significant pain
an unruptured ectopic pregnancy with a mass smaller than 35 mm with no visible heartbeat
a serum b-hCG between 1500 and 5000 iu/l
no intrauterine pregnancy (as confirmed on ultrasound scan).
What are the selection criteria for expectant management of ectopic pregnancy?
Selection criteria for expectant management were clinical stabi lity with noabdominal pain, no evidence of significant haem operitoneum on ultrasound scan, an ectopic pregnancymeasuring less than 30 mm in mean diameter with no evidence of embryonic cardiac activity, a serumb-hCG level of less than 1500 iu/l and the woman’s consent.
What is the treatment of cervical ectopic?
Interestingly, surgical is not first line given risk of bleeding.
How long after methotrexate should women wait before getting pregnant?
3 months
Describe the time course of Parvovirus infection?
Viraemia is typically present six days after exposure and lasts for around a week. As people are contagious before they are symptomatic, containing the spread of disease is not easily done. The development of rash marks the end of the infectious period, usually one-to-two weeks after infection.
What is the vertical transmission rate of Parvovirus infection?
The risk of vertical transmission is 50 per cent. Infection between eight and 20 weeks poses the greatest risk to the fetus.
What is the model of ultrasound monitoring of Parvovirus?
This monitoring should start four weeks post conversion/infection and continue for up to 12 weeks, as this is the window of greatest risk to the fetus.
At what MSV do you worry about fetal anemia?
Diagnosis of fetal anaemia should be suspected when assessment of the middle cerebral artery Doppler peak systolic velocity (MCA PSV) is greater than 1.5MoM (multiples of the mean).
What is the pathophysiology of fetal anaemia with Parvovirus?
Parvovirus is cytotoxic to fetal haemoglobin precursors.
When is the cFTS carried out?
This is carried out between 11+0 and 13+6
When is CVS done?
This can be carried out between 11 and 14 weeks of gestation by chorionic villous sampling (CVS) of placental tissue.
What is the false positive rate of the cFTS?
Using the cFTS, a detection rate of approximately 85-90% can be achieved for trisomy 21, 18 and 13, at a false positive rate of 4-5%.
What is normal vaginal pH?
They maintain the normal vaginal pH between 3.8 and 4.4.
What is the treatment for bacterial vaginosis?
Metronidazole
Name four non-infective causes of vaginal discharge?
Physiological
Cervical ectopy
Foreign bodies, such as retained tampon
Vulval dermatitis
NAme two non-sexually transmitted infections that can cause vaginal discharge.
Bacterial vaginosis
Candida infection
What are the vaginal pHs of Candida and BV?
Bacterial vaginosis (pH ≥4.5) and vulvovaginal candidiasis (pH <4.5)
What are the antibiotics for chlamydia
Doxycycline 100 mg twice daily for seven days (contraindicated in pregnancy), azithromycin 1 g orally in a single dose (WHO recommends azithromycin in pregnancy but the British National Formulary advises against its use unless no alternatives are available)
What are the antibiotics for gonorrhea
Cefixime 400 mg as a single oral dose or ceftriaxone 250 mg intramuscularly as a single dose
What is the treatment for trichomonas?
Metronidazole 2 g orally in a single dose or metronidazole 400-500 mg twice daily for five to seven days
What is the Amsel criteria for BV?
Amsel criteria for diagnosis of BV (at least three criteria must be present):
Vaginal pH >4.5.
●Homogeneous, thin, grayish-white discharge that smoothly coats the vaginal walls.
●Vaginal pH >4.5.
●Positive whiff-amine test, defined as the presence of a fishy odor when a drop of 10 percent potassium hydroxide (KOH) is added to a sample of vaginal discharge.
●Clue cells on saline wet mount. Clue cells are vaginal epithelial cells studded with adherent coccobacilli that are best appreciated at the edge of the cell. For a positive result, at least 20 percent of the epithelial cells on wet mount should be clue cells. The presence of clue cells diagnosed by an experienced microscopist is the single most reliable predictor of BV
For what group is HRT recommended?
This continued decline occurred in spite of reassuring data that the benefits of MHT outweigh the risks for most young menopausal women (within 10 years of menopause or under age 60 years).
What are the risks of HRT?
- Coronary heart disease (CHD) - 2.5 additional cases
- Invasive breast cancer - 3 additional cases
- Stroke - 2.5 additional cases
- Pulmonary embolism - 3 additional cases
- Colorectal cancer - 0.5 fewer cases
- Endometrial cancer - no difference
- Hip fracture - 1.5 fewer cases
- All-cause mortality - 5 fewer events
What effect does HRT have on VTE?
Combined oral estrogen plus progestin has been shown to increase the relative risk of VTE twofold.
What effect does HRT have on breast cancer?
The attributable risk is small and decreases when treatment is stopped. Cumulative long term follow up of the
Women’s Health Initiative RCT11 found no increase in risk for women receiving estrogen only therapy but an
increased risk for those receiving combined therapy amounting to approximately 0.1%.
What is the difference between cyclical and continuous HRT?
For women with an intact uterus MHT may be prescribed as estrogen plus a progestogen for 14 days per month (cyclical therapy) or every day (continuous combined therapy).
What is the follow-up plan for someone on HRT?
All women using MHT should be reviewed after 6 months therapy. This should include a general health check, a breast check and a mammogram every two years, Bone densitometry should be performed where
indicated18 and any unexpected vaginal bleeding after 6 months therapy requires appropriate investigation.
The need for ongoing MHT should be reviewed regularly.
Which HRT risks are related to length of treatment?
Consider the potential impact of recurrent symptoms on quality of life. The risks of HRT may be related to duration of HRT use - for example, the risk of venous thromboembolism is greatest in
the first year of use, but the risk of breast cancer increases with duration of use.
What is an alternative to HRT?
Several serotonin-norepinephrine reuptake inhibitors (venlafaxine and desvenlafaxine) and selective serotonin reuptake inhibitors (paroxetine, citalopram, and escitalopram) have been shown in short-term trials
to alleviate VMS but to a lesser degree than MHT.
Gabapentin is the only non-hormonal product shown to be equally effective as low dose estrogen for
vasomotor symptoms.
What is the average age of menopause?
The menopause transition commonly starts around 47 years and the average age of natural menopause is 51 years.
What are the first line measures for perimenopausal symptoms?
Women seeking relief from menopausal symptoms should first be offered advice on life style
changes including stress reduction, regular exercise, optimal weight management, appropriate diet and
avoidance of smoking and excessive alcohol and caffeine intake should also be addressed.
Recent high
quality evidence suggests that mindfulness training and cognitive behaviour therapy may reduce both
the impact and severity of vasomotor symptoms
What can you do to protect bone in women who have contraindications to HRT?
Evidence-based non-hormonal options should first be considered (e.g. bisphosphonates or SERMs for osteoporosis, cholesterol lowering agents and aspirin for cardiovascular disease). Some
individual menopausal symptoms may be ameliorated with individual selected therapies eg
venlafaxine, desvenlafaxine, escitalopram, citalopram and paroxetine, clonidine and gabapentin for
vasomotor symptoms, vaginal lubricants for superficial dyspareunia, and anticholinergics for urinary
urgency. Please note that paroxetine and tamoxifen should not be prescribed together.
What organisms are usually isolated from a TOA?
Common organisms include Escherichia coli, aerobic streptococci, Bacteroides fragilis, Prevotella, and other anaerobes, such as Peptostreptococcus.
Not Chlamydia/Gonorrhoea!
What are the organisms identified from BV?
The major bacteria detected in women with BV are Gardnerella vaginalis, Prevotella species, Porphyromonas species, Bacteroides species, Peptostreptococcus species, Mycoplasma hominis, and Ureaplasma urealyticum, as well as Mobiluncus, Megasphaera, Sneathia, and Clostridiales species. Fusobacterium species and Atopobium vaginae are also common.
When do you start MCVs for a non-Kell Ab?
24 weeks
When do you start MCVs for Kell ABs?
18 weeks
What are the critical levels for antibody titires?
> 8 for Kell, >16 for non-Kell
What is the prevalence of red cell antibodies/
A Netherlands found that red cell antibodies were detected in 1.2% of pregnancies,
while the prevalence of clinically significant antibodies was placed at 0.4%
When can you clear a woman with epilepsy?
Women who have remained seizure-free for at least 10 years (with the last 5 years off AEDs) and those with a childhood epilepsy syndrome who have reached adulthood seizure- and
treatment-free are considered no longer to have epilepsy
What are the congenital abnormalities caused by AEDs?
The most common major congenital malformations associated with AEDs are neural tube defects, congenital heart disorders, urinary tract and skeletal abnormalities and cleft
palate.
Sodium valproate is associated with neural tube defects, facial cleft and
hypospadias; phenobarbital and phenytoin with cardiac malformations; and phenytoin and
carbamazepine with cleft palate in the fetus.
What is the risk of a woman with epilepsy relapsing during pregnancy?
The majority of women (67%) do not experience a seizure in pregnancy. The seizure-free
duration is the most important factor in assessing the risk of seizure deterioration.
In women who were seizure free for at least 9 months to 1 year prior to pregnancy, 74-92%
continued to be seizure free in pregnancy.
What do you need to ask an epileptic woman antenatally?
In the antenatal period, WWE should be regularly assessed for the following: risk factors for seizures, such as sleep deprivation and stress; adherence to AEDs; and seizure type and frequency
What do you give to babies of epileptic mums?
All babies born to WWE taking enzyme-inducing AEDs should be offered 1 mg of intramuscular vitamin K to prevent haemorrhagic disease of the newborn.
Postnatal care of an epileptic mum?
Women should ensure that they take their AEDs as prescribed in the postnatal period. Nausea and
vomiting should be treated and if there is no oral intake, consideration should be given to parenteral
administration of AEDs. Sleep deprivation-related seizures could be reduced by arranging help for the
mother, especially for night-time feeds.If the mother breastfeeds, storage of breast milk and pumped during
the day might be beneficial. Reviewing the daily activities of the mother and identifying high-risk
situations can reduce the risks to the mother and baby due to seizures.
If the AED dose was increased in pregnancy, it should be reviewed within 10 days of delivery to avoid
postpartum toxicity.
WWE should be screened for depressive disorder in the puerperium. Mothers should be informed about
the symptoms and provided with contact details for any assistance
How does APS cause procoagulation?
2GPI antibodies disrupt normal coagulation mechanisms in several ways: direct cellular effects
caused by bound 2GPI-antibody complexes,
activating platelets, endothelial cells and
monocytes, hence inducing tissue factor
expression; interference with haemostatic factors;
resistance to activated protein C; and reduction in
fibrinolysis.
pre-pregnancy planning forAPS?
https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1576/toag.13.1.15.27636
what is the prevalence of mesh erosion?
Erosion occurs as a complication of between 1-2% of operations where a midurethral sling is placed, and up to 10-12% of operations where transvaginal mesh is used for prolapse.
What are contraindications to VBAC? Risk factors?
Classical, prev rupture. Factors that potentially increase the risk of uterine rupture include short inter-delivery interval
(less than 12 months since last delivery), post-date pregnancy, maternal age of 40 years or
more, obesity, lower prelabour Bishop score, macrosomia and decreased ultrasonographic
lower segment myometrial thickness.
What happens with synto on a VBAC?
2-3x risk of UR
1.5x risk of CS
What other autoimmune conditions are associated with lichen sclerosis?
The most common autoimmune conditions in women with lichen sclerosus are thyroid disorders,alopecia areata,pernicious anaemia,type 1 diabetes and vitiligo.
The reported prevalence of autoimmune conditions in first-degree relatives is around 30%
Why do you check Ferritin in vulval conditions?
Correction of iron-deficiency anaemia or low serum ferritin can relieve vulval symptoms.In a case series of 38 women with vulval dermatitis, 20% were found to have iron-deficiency anaemia.
What is second line medication for lichen sclerosis?
Approximately 4-10% of women with anogenital lichen sclerosus will have symptoms that do not improve with topical ultrapotent steroids (steroid-resistant disease). The recommended second-line treatment
is topical tacrolimus under the supervision of a specialist clinic.
What are the side effects of Imiquimod?
Adverse effects include pain, erythema and swelling and can result in non-compliance
Which HPV is vin associated with?
Nearly all VIN is of usual type: warty, basaloid and mixed (warty and basaloid). Usual type VIN is more common in women aged 35-55.It is associated with HPV (especially HPV-16)
Describe the use of clobetasol for lichen?
Once daily for 1 month then on alternate days for 1 month
then twice a week for 1 month
then once a week for 1 month
then gradually reduce this until you can use it occasionally or not at all
What is the next step for a woman positive for HPB 16/18?
Colposcopy
What has the entry age for cervical screening increased?
Research shows that beginning cervical screening at age 25 years is safe.
Cervical cancer in people under the age of 25 is rare.
After more than 20 years of screening women under 25 years of age, the incidence of cervical cancer in this age group has not reduced.
Most women and men under 25 years of age have been vaccinated for HPV and people under the age of 25 have robust immune systems that will usually clear the infection quickly and without treatment.
Commencing screening at age 25 will reduce the investigation and treatment of common cervical abnormalities that would usually resolve by themselves in women under the age of 25. This is because it usually takes 10 to 15 years for a persistent HPV infection to develop into cervical cancer.
What should you do with a woman who has non 16/18 oncogenic type and low grade?
Women with a positive oncogenic HPV (not 16/18) test result, with a LBC report of negative or prediction of pLSIL/LSIL, should have a repeat HPV test in 12 months.
Referral of women with a positive oncogenic HPV (not 16/18) test result and LBC prediction of pHSIL, HSIL or any glandular abnormality
Women with a positive oncogenic HPV (not 16/18) test result, with a LBC prediction of pHSIL/HSIL or any glandular abnormality, should be referred for colposcopic assessment at the earliest opportunity, ideally within 8 weeks.
Management after repeat HPV test at 12 months, following initial positive oncogenic HPV (not 16/18) test result
At repeat HPV testing 12 months after a positive oncogenic HPV (not 16/18) test result with reflex LBC negative or pLSIL/LSIL: if a woman has a positive oncogenic HPV (any type) test result, reflex LBC will be performed and she should be referred for colposcopic assessment
if oncogenic HPV is not detected, the woman should be advised to return to routine 5-yearly screening
What do you do with a ‘Women with a positive oncogenic HPV (not 16/18) test result (self-collected sample)’
Women who have undergone HPV testing on a self-collected sample and who have a positive oncogenic HPV (not 16/18) test result should be advised to visit their GP or healthcare professional to obtain a cervical sample for LBC:
If the LBC test result is negative or pLSIL/LSIL, HPV testing should be repeated in 12 months, preferably by a healthcare professional.
If the LBC test result is pHSIL/HSIL or any glandular abnormality the woman should be referred for colposcopy at the earliest opportunity, ideally within 8 weeks.
What do you do with a ‘Women aged 75 years or older who request screening’
Women who are 75 years or older who have never had a cervical screening test, or have not had one in the previous five years, may request a test and can be screened.
Repeat LBC usually not necessary at time of colposcopy, unless:
Delay in attending for colposcopy > 3 months after referral LBC is unsatisfactory
referral LBC is negative but lacks an endocervical component
prior LBC is not available because the HPV test was performed on a self-collected sample
the woman has developed symptoms suggestive of cervical cancer since undergoing her screening test.
What happens when: For women who have had a colposcopy with significant discordance between the histopathology and the referral cytology?
Both specimens should be reviewed by a pathologist from at least one of the reporting laboratories who should then convey the results of the review to the colposcopist in order to inform the management plan
When should you send for tertiary referral
Adenocarcinoma in situ
Abnormalities in pregnancy
Immune-deficient women
Women with multifocal lower genital tract disease.
For cervical disease, Ablative therapy should be reserved for :
Women intending to have children, and when the following conditions have all been met:
TZ is completely visible (Type 1 or Type 2).
There is no evidence of invasive or glandular disease.
A biopsy has been performed prior to treatment.
HSIL (CIN2/3) has been histologically confirmed.
There is no significant discordance between the histopathology and referral cytology results.
Do not treat at first visit with a LBC report of a low-grade lesion. Is this true?
Women who have a LBC prediction of pLSIL/LSIL should not be treated at the first visit.
Repeat excision not necessarily required for incomplete excision of high-grade lesions. Is this true? Why?
Women who have incomplete excision of HSIL (CIN2/3) with positive endocervical or stromal margins do not necessarily require immediate repeat excision and could be offered test of cure (HPV and LBC) surveillance, with the exception of:
women aged 50 years or over
women who may not be compliant with recommended follow-up
women in whom subsequent adequate colposcopy and follow-up cytology cannot be guaranteed.
Describe the pathway of: Normal colposcopy following LBC prediction of negative or pLSIL/LSIL?
For women with a positive oncogenic HPV (any type) test result, a LBC report of negative or pLSIL/LSIL, and normal colposcopy, the HPV test should be repeated in 12 months:
If HPV is not detected at 12 months, the woman should return to routine 5-yearly HPV screening.
If the woman has a positive oncogenic HPV (not 16/18) test result at 12 months and a LBC report of negative or pLSIL/LSIL, the HPV test should be repeated in another 12 months.
If the woman has a positive oncogenic HPV ( any type) test at the 24 month HPV test, she should be referred directly for colposcopic assessment, which will be informed by the result of the reflex LBC.
If the woman has a positive oncogenic HPV (not 16/18) test result at 12 months and a LBC prediction of pHSIL/HSIL or any glandular abnormality, she should be referred for colposcopic assessment at the earliest opportunity, ideally within 8 weeks.
If the woman has a positive oncogenic HPV (16/18) test result at 12 months, she should be referred directly for colposcopic assessment at the earliest opportunity, ideally within 8 weeks, and the reflex LBC result will inform the colposcopy.
Normal colposcopy following LBC prediction of HSIL: diagnostic excision of TZ
For women who have a positive oncogenic HPV (any type) test result, normal colposcopy, and a LBC prediction of HSIL on cytopathology review, diagnostic excision of the TZ should be performed.
What should you do in the case of: Type 3 TZ colposcopy and referral LBC negative or pLSIL/LSIL
For women who have a positive oncogenic HPV (any type) test result with a LBC report of negative or pLSIL/LSIL, and colposcopy is reported as Type 3 TZ,† the HPV test should be repeated in 12 months:
If oncogenic HPV is not detected at 12 months, the HPV test should be repeated 12 months later.
If oncogenic HPV is not detected again at the second repeat HPV test, the woman should be advised to return to routine 5-yearly screening.
If the woman has a positive oncogenic HPV (any type) test result at 12 months, she should be referred directly for colposcopic assessment, with the LBC report available to inform the assessment.
Diagnostic excision of the TZ should not be performed if there is no cytological or histological evidence of a high-grade lesion after Type 3 TZ colposcopy. Why?
For asymptomatic women who have a positive oncogenic HPV (any type) test result, Type 3 TZ† colposcopy, and no cytological, colposcopic or histological evidence of a high-grade lesion, further diagnostic procedures (such as diagnostic excision of the transformation zone) should not routinely be performed.
Women who have a positive oncogenic HPV (any type) test result with a LBC report of either negative or pLSIL/LSIL, and histologically confirmed ≤ CIN1 on biopsy
should have a repeat HPV test 12 months later:
If oncogenic HPV is not detected at the repeat HPV test, the woman should return to routine 5 yearly screening.
If the repeat test is positive for oncogenic HPV (not 16/18) and the LBC report is negative or pLSIL/LSIL, the woman should have a further repeat HPV test in 12 months.
If the second follow-up HPV test is negative the woman should return to routine 5-yearly screening.
If the second follow-up test is HPV positive, the woman should be referred for colposcopic assessment informed by reflex LBC.
If the repeat test is positive for oncogenic HPV (not 16/18) and the LBC report is pHSIL/HSIL, the woman should be referred for colposcopic assessment.
If the repeat test is positive for oncogenic HPV (16/18), the woman should be referred for colposcopic assessment informed by the reflex LBC
Is there an option for observation following cytological prediction of pHSIL?
REC9.4: Option for observation following cytological prediction of pHSIL.
Women who have a positive oncogenic HPV (any type) test result with a LBC prediction of pHSIL (confirmed after cytopathology review), and who have undergone colposcopy and have a histologically confirmed LSIL (≤ CIN1), could be offered diagnostic excision of the TZ.
If the colposcopist considers a period of observation is preferable to treatment, or the woman with these findings wishes to defer diagnostic excision, she can be offered observation with a HPV test and colposcopy at 6-12 months.
Women should not be offered observation unless the colposcopic assessment meets all the following conditions:
Colposcopy is adequate.
TZ is completely visualised (Type 1 or 2 TZ^).
LSIL (≤ CIN1) has been confirmed on histopathological review
HSIL (CIN2) and observation
In some circumstances, it may be acceptable to offer a period of observation (generally 6-12 months) to women who have a histological diagnosis of HSIL (CIN2), and this would usually be supervised by an experienced colposcopist or at a tertiary centre. Observation may be considered for:
women who have not completed childbearing
women with discordant histology and LBC prediction of pLSIL/LSIL
women with focal minor changes on colposcopy and HSIL (CIN2) on histology
women recently treated for HSIL (CIN2).
How do you Test of Cure after treatment for HSIL (CIN2/3)?
A woman who has been treated for HSIL (CIN2/3) should have a co-test† performed at 12 months after treatment, and annually thereafter, until she receives a negative co-test on two consecutive occasions, when she can return to routine 5 yearly screening.
Any abnormal finding goes to colp
What is the cervical screening for ladies who had Total hysterectomy for benign disease
Women with a normal cervical screening history, who have undergone hysterectomy for benign disease (e.g. menorrhagia, uterine fibroids or utero-vaginal prolapse), and have no cervical pathology at the time of hysterectomy, do not require further screening or follow up.
What is the cervical screening for ladies who had Total hysterectomy after adenocarcinoma in situ (AIS)?
Women who have had a total hysterectomy, have been treated for AIS, and are under surveillance, should have a co-test on a specimen from the vaginal vault at 12 months and annually thereafter, indefinitely.
The implantation of any foreign body generates a host response that is characterised by seven stages:
Injury, protein absorption, acute inflammation, chronic inflammation, foreign body reaction, granulation tissue formation and tissue encapsulation.
How many cells in the morula?
32
How many days after fertilisation is implantation?
5-8 days
What three hormones affect fetal growht?
Glucocorticords, insulin, thyroid
What are the two most important fetal growth factors?
IGF-I, IGF-III
What are the radiological definitions of oligo and poly?
Poly - AFI 25 or above, or DVP >8.
Oligo - AFI <5, DVP <2
When CVS done?
9-12 weeks
