Random Flashcards
(78 cards)
1
Q
What are the hypothalamic causes of amenorrhoea?
A
psychological weight loss, stress, exercise endocrine hyperandrogenism (including PCOS) hyperthyroidism hyperprolactinaemia increased oestrogen/progesterone - e.g. hormonal, pregnancy drugs anti psychotics congenital kellman’s syndrome - anosmia with hypothalamic dysfunction
2
Q
What are the pituitary causes of amenorrhoea?
A
tumour adenoma prolactinoma cushing's acromegaly non hormonal secreting tumour infection basal meningitis - TB vascular pituitary apoplexy sheehan’s syndrome - hypoperfusion of pituitary after PPH trauma previous surgery or radiation infiltration haemochromatosis
3
Q
What are the ovarian causes of amenorrhoea?
A
premature ovarian failure - familial surgery/radiation bilateral torsion ovarian agenesis turner’s syndrome chemotherapy storage diseases mumps
4
Q
What investigations should you order for amenorrhoea?
A
LH, FSH, TFT, prolactin, androgens, beta hCG
US if not sexually active
MRI of the pituitary
5
Q
What are risk factors for placental abruption?
A
prior history of abruption trauma smoking hypertensive disorders of pregnancy polyhydramnios PPROM first trimester bleeding FGR maternal thrombophilias cocaine/amphetamines
6
Q
History questions for APH
A
past obstetric history previous abruptions hypertension previous FGR past gynaecological history pap smears ?cervical ca past medical history hypertension bleeding tendency trauma? MVA domestic violence smoking antenatal investigations 20 week scan - low lying placenta? HOPC what happened what were you doing at the time of the bleed > intercourse? how much blood loss any pain associated with the bleed? contractions? fetal movements felt? ruptured membranes?
7
Q
Examination for APH
A
assess for maternal compromise haemodynamic compromise is an obstetric emergency vital signs assess for fetal compromise abdominal palpation tenderness tense > indicates significant abruption uterine contractions symphysis fundal height presentation and lie speculum examination > do not do a VE until praevia has been excluded cervical dilatation visualise a lower genital tract cause
8
Q
Investigations for APH
A
FBE coags group and hold UEC LFT kleihauer test US CTG MCA doppler
9
Q
Management of APH
A
stabilise
assess conscious state and presence of shock
put in an IV line and take off FBE, group and hold, coags and a kleihauer
continuous CTG - for 4 hours post bleed
transfer
admit
all women with APH heavier than spotting and women with ongoing bleeding should be admitted - at least until bleeding has stopped
corticosteroids for fetal lung maturation if between 24 and 34 weeks gestation
tocolytics
should not be used if patient is haemodynamically unstable or if there is fetal compromise
possibly indicated if needs transfer, if very preterm or if have not had steroids
contraindicated in placental abruption
dont use nifedepine due to risk of maternal hypotension
antenatal care
becomes high risk
perform serial ultra sound for fetal growth
delivery
APH + maternal or fetal compromise > deliver immediately - usually CS unless established labour
delivery is likely necessary if significant abruption
women in labour with active bleeding require continuous electronic fetal monitoring
early elective delivery by CS for women with placenta praevia or vasa praevia
should receive active management of the third stage
give anti D if rhesus negative
10
Q
Complications of C/S
A
anaesthesia related aspiration syndrome hypotension spinal headache haemorrhage uterine atony placenta praevia/accreta lacerations urinary tract and gastrointestinal injuries general post op complications ileus atelectasis/pneumonia UTI thromboembolism endomyometritis wound infection increased risk of placenta praevia, accreta, increta, percreta in future pregnancies hysterectomy
11
Q
When to refer to colposcopy
A
refer to colposcopy if 2 x LSIL HSIL smear reported as invasive carcinoma, glandular neoplasia, adenocarcinoma suspicious symptoms cervix suspicious of invasive disease
12
Q
Indications for a cone biopsy
A
failure to visualise the upper limit of the transition zone in a woman referred with HSIL
suspicion of early invasive cancer on cytology, biopsy or colposcopic assessment
suspected presence of additional significant glandular abnormality on cytology or biopsy (i.e. a mixed lesion)
13
Q
What antibiotics are given for chorioamnionitis?
A
ampicillin
gentamicin
metronidozole
14
Q
What are the contraindications for the OCP?
A
undiagnosed vaginal bleeding
CV disease, stroke, TIA
? previous VTE
focal migraines - risk of stroke - dont want to add oestrogen
active liver disease
hormone dependent cancer
drug interaction - enzyme inducing drugs chew up hormones - e.g. carbamazepine
if breastfeeding is not well established can make it drop off
15
Q
Things to counsel a patient on before starting OCP
A
- things that interfere with efficacy
vomiting and diarrhoea
treat as a missed pill
missing a pill
if not taken in 12 hours of forgetting need to use condoms for next 7 days of active pills
if you’ve just finished seven day break and now missed it - consider morning after pill if unprotected sex - if less than 7 days left then skip placebos
antibiotics
use condoms for 7 days after finishing course - adverse effects
serious - thrombosis - extremely uncommon - increased risk with smoking and weight
common
breast tenderness
nausea
breakthrough bleeding
headaches
mood changes
generally improves after a few weeks but if it continues come back and try a different pill - how to take it
take it every day at the same time
must be taken daily
start in the red section - with your period
definitiely ok not to take the sugar pills and to take active pills continuously - need to use a condom
doesn’t protect against STDs
16
Q
Benefits of the OCP
A
contraception less acne less hirsuitism regular periods lighter periods less painful periods timed periods no periods if you wish reduced endometrial cancer, polyps, fibromyomas reduces endometriosis prevents ectopic pregnancy (unlike IUD) reduces ovarian cysts reduces ovarian cancer no change in breast cancer - does not increase the risk with the dose of oestrogen reduces benign breast disease reduces pre menstrual syndrome (progestogen withrdrawl)
17
Q
Causes of dysmenorrhoea
A
primary dysmenorrhoea - absence of any organic pelvic pathology - caused by excess endometrial prostaglandins endometriosis adenomyosis intracavity mass - polyp, fibroid cervical stenosis imperforate hymen non communicating uterine horn post endometrial ablation
18
Q
Management for primary dysmenorrhoea
A
analgesia NSAIDs e.g. naproxen - inhibit prostaglandin synthesis so are more effective than paracetamol hormonal OCP- thins the endometrium so reduces the amount of arachidonic acid - can also skip periods progestins GnRH analogues surgery hysterecomty acupuncture nifedipine/GTN/buscopan
19
Q
Management of an ectopic
A
medical - methotrexate IM 50mg per metre squared of body surface area
surgery - salpingostomy
20
Q
Indications for surgical management of an ectopic
A
haemodynamically unstable free fluid on US beta hCG >3000 adnexal mass >3cm fetal heart beat seen on US live far away contraindications to methotrexate
21
Q
Risk factors for endometrial cancer
A
oestrogens (exogenous and endogenous) delayed menopause early menarche PCOS obesity tamoxifen oestrogen only HRT smoking Lynch syndrome - may require prophylactic hysterectomy hypertension diabetes (insulin is a trophic growth factor and endometrium has a receptor) family history - bowel cancer, endometrial cancer, ovarian cancer
22
Q
Management of endometriosis
A
analgesia NSAIDs reduces prostaglandin production suppress hormonal activity OCP- Suppresses ovulation, reduces growth of endometrial tissue, down-regulates cell proliferation, increases apoptosis of ectopic endometrium.Suppresses ovulation, reduces growth of endometrial tissue, down-regulates cell proliferation, increases apoptosis of ectopic endometrium can be helpful to skip periods progestins- particularly if high cardiovascular risk factors or other contraindications to the OCP - inhibit endometriotic tissue growth, causes decidulisation and atrophy oral primolut (norethisterone) dienogest injectable depot implant implanon IUD mirena hypo oestrogen therapy GnRH analogues down regulates the pituitary-ovarian axis danazol suppresses the pituitary-ovarian axis surgery ablation hysterectomy, oophorectomy etc
23
Q
Management of fibroids
A
conservative
nothing if asymptomatic and less than 8cm
medical
non hormonal
NSAIDs for pain relief
tranexamic acid to reduce blood loss
hormonal treatment
OCP, depo provera, implanon
GnRH analogues (to shrink the fibroid pre surgery)
partial progesterone receptor agonist - ulapristil acetate
procedural
embolisation of vessel supplying the fibroid/ablation - contraindicated in women who want children
resection - hysteroscopic
myomectomy - preserves fertility
hysterectomy
24
Q
Things to do in first antenatal visit
A
- confirm pregnancy
- confirm gestational age
- screening for any problems
- management of any problems
- general advice
- booking
25
What antenatal investigations do all women get?
```
FBE
blood group and antibody screen
rubella
varicella
syphillis
hep B
hep C
HIV
MSU
pap smear
aneuploidy screening if they want it
20 week morph scan
consider: vitamin D, ferritin, TSH
```
26
What general advice should you give to all pregnant women?
1. diet
nutritious diet
don’t need to eat for two - increased caloric intake is equivalent to an apple and a slice of bread
avoid undercooked chicken, mayonnaise, seafood, soft cheese for risk of listeria causing septic abortion before 20 weeks and chorioamniotis after 20 weeks
avoid undercooked meat for risk of toxo
2. toxoplasma risk
don’t change cat litter
wear gloves when gardening
3. vitamins and minerals
all pregnant women should take folate and iodine
if deficient - supplement vitamin D and iron
4. travel
domestic flights until 36 weeks, international flights until 32 weeks
avoid dangerous/low resource areas - no Zika areas
test woman and partner if they have been in a zika zone
hydrate well, wear compression stockings, mobilise
5. exercise
only moderate exercise
no contact sports from second trimester
6. no smoking
7. no alcohol
8. sex is fine
unless bleeding
9. work
most cease work at 34 weeks unless advised to cease work earlier
10. medication
fine to take paracetamol
use maxalon for nausea
penicillin and ampicillin are ok
all other medication seek advice
27
What should be done at the 28 week antenatal visit?
FBE
OGTT
Rh antibodies and anti D administration if mother is rhesus negative (repeat screen to see if antibodies have developed during pregnancy)
28
What should be done at the 32 week antenatal visit?
boostrix
29
What should be done at the 36 week antenatal visit?
FBE
GBS swab
anti D administration if rhesus negative
30
What should be done at every antenatal visit?
```
Hx
general well being
fetal movements
oedema
tightenings/pain
leakage/blood loss
Ex
weight gain
blood pressure
fundal height
lie and presentation
auscultation
urinalysis
```
31
How often should antenatal visits be?
36 weeks visit weekly
32
What is the diagnostic criteria for GDM?
```
fasting blood glucose
>5.1 = GDM
1 hour blood glucose
>10 = GDM
2 hour blood glucose
> 8.5 = GDM
```
33
Investigations for HMB?
```
FBE
iron studies
TFTs - ?hypothyroidism
beta hCG
coags
VWF
FSH
LH
estradiol
androgen screen- ?PCOS
transvaginal ultrasound
saline sonohysterogram
endometrial sampling
```
34
Management for HMB?
```
treat the underlying cause
medical therapy
non hormonal
prostaglandin inhibitors (ponstan)
anti fibrinolytics (tranexamic acid)
iron supplementation if iron deficient
hormonal
OCP
contraindicated if high cardiovascular risk
progesterone only therapy
depot, implanon, mirena
hypo-oestrogenic therapy
use if failed other treatments
danazol
side effects of androgens: weight gain, acne, hirsuitism, voice change
GnRH analogues
side effects of hypo oestrogenism: vasomotor symptoms, urogenital atrophy, osteoporosis, adverse lipid profile
surgical
endometrial ablation
not compatible for future pregnancy so effective contraception must be used
myomectomy
polypectomy
hysterectomy
```
35
Management of HSV in pregnancy
Management of First Episode of HSV in Pregnancy
if first or second trimester - treat with aciclovir
if third trimester - treat with aciclovir and deliver via C/S
Management of Recurrent HSV in Pregnancy
supportive treatment alone if before 36 weeks
aciclovir if after 36 weeks gestation
vaginal delivery in absence of other obstetric indications for C/S
36
Management of hyperemesis gravidarum
```
admit to hospital
fluid resuscitation
non pharmacological
ginger
small frequent meals
avoid triggers
psychological support
pharmacological
vitamin B6
antihistamines
motility drugs
maxalon
ondanestron
thiamine
?TPN
```
37
Causes of FGR
```
fetal
congenital
chromsomal
trisomy 13, 18, 21
turner’s syndrome
UPD (two chromosomes from one parent)
paternal growth genes are switched on in life
2 from dad - tiny baby
single gene defects
structural anomalies
gastroschesis
cardiac anomalies
familial (small parents)
infections
CMV
1 in 1000
toxoplasmosis
other TORCH infections
parvovirus
maternal
vascular disease
HTN
renal disease
diabetes
connective tissue disease
thrombophilia
acquired
malignancy
smoking
stasis
congenital
protein S, protein C, antithrombin III
factor V leiden, prothrombin gene, MTHFR
anti phospholipid syndrome
toxins
smoking
alcohol (only one that is a clear teratogen)
cocaine
narcotic
cardiac disease
anaemia
hypoxia
malnutrition
respiratory disease
placental
multiple pregnancy
abruption
placenta separates before birth
uncommon
usually in associated with vascular disease
placental abnormalities
placental insufficiency
PET
```
38
Adverse effects of HRT
thrombotic risk (stroke, thromboembolism, cardiovascular disease)
particularly significant if HRT is started in older women (over 60) when atheroma is already present
if HRT is started at a younger age before atheroma develops then it may have a beneficial effect on cardiovascular risk
risk of VTE is increased further by obesity, factor V leiden, increasing age
breast cancer
decreased risk if oestrogen alone (only possible if have previously had a hysterectomy)
39
Benefits of HRT
decreases risk of endometrial cancer (if it contains oestrogen and progesterone)
decreases risk of colorectal cancer
decreased cardiovascular risk in younger women
decreases vasomotor symptoms
decreases urogenital atrophy
decreases osteoporosis
40
Treatments for vasomotor symptoms of menopause
gabapentin
SSRI/SNRI
clonidine
41
Types of miscarriage
threatened miscarriage
pregnancy complicated by vaginal bleeding prior to 20th week
cervix is closed
inevitable miscarriage
vaginal bleeding and pain, non viable pregnancy on US, open os
no products of conception passed yet
incomplete miscarriage
non viable pregnancy
pain and bleeding associated by the passage of some products of conception
complete miscarriage
bleeding, pain, passage of all products of conception, then reduction in bleeding, closure of cervix, empty uterus on scan
missed miscarriage
fetus has died, but is retained in the uterus
no bleeding, closed cervix, no POC passed
42
History for miscarriage
```
bleeding
how much
colour
symptoms of hypovolaemia
pain
passage of products of conception
was the pregnancy planned?
date of last normal menstrual period
do you still feel pregnant? > breast tenderness, nausea and vomiting
past medical/obs/gynae history
last meal
allergies
social - where do they live > implications for management
```
43
Examination for miscarriage
blood pressure
pulse
bradycardia is a sign of cervical shock > need to remove products of conception
size of uterus
speculum examination > cervix open or closed, amount of blood, presence of POC
adnexal tenderness or mass
signs of peritonism
44
Investigations for miscarriage
```
blood group and rhesus status
FBE
group and save
beta hCG
ultrasound
```
45
Management for miscarriage
manage shock if present
emergency D&C if required
definitive treatment
expectant
allowing the natural process of expulsion of uterine POC to occur without intervention -> for inevitable/incomplete miscarriages
cannot predict when this will happen, involves passage of POC -> heavier than a normal period +/- clots and tissue, cramping. Usually settles within 1-2 hours, with days-weeks of PV bleeding but not as heavier
clinical review in 1-2 weeks or can do an ultrasound to confirm if complete or incomplete
2/3rds will have a complete miscarriage, 1/3rd will have an incomplete miscarriage and need further treatment to avoid retained products
HCG follow up if no period in 4-6 weeks following miscarriage
medical
Misoprostol 800mg -> sublingual, per vaginal or oral -> use if any POC in uterus -> complete miscarriage usually occurs within 3-4 days
expect patient to have heavy bleeding, passing of POC and pain (more than expectant) -> lasts 1-2 hours then settles, bleeding afterwards is less than with expectant
review 1-2 weeks -> clinical review or ultrasound
15% will have incomplete miscarriage
surgical
dilatation and suction curettage
if any POC left
done under GA
risk of perforation, damage to other viscera, infection, Asherman’s syndrome (adhesions inside uterus and cervix -> front and back of uterus stick together)
pain is better (been anaesthetised), few days of bleeding
reassure patient
anti D if necessary
46
Causes of neonatal respiratory distress in a term infant
```
pneumonia (most worrying)
group B strep
gram negative bacilli
wet lung (most common)
meconium aspiration
more common post term
pneumothorax
diaphragmatic hernia
cardiac anomalies e.g. TGA, TOF
```
47
Causes of neonatal respiratory distress in a preterm infant
HMD (most common)
pneumonia
wet lung
48
Newborn exam
```
general inspection - colour, dysmorphism, movement, breathing, alertness
measurement - height, weight, hc
head - eyes, fontanelles, ears, nose, mouth
skin
hands, feet and limbs
neck
chest
abdomen
genitals
femoral pulses
hips
back
primitive reflexes
```
49
Which tumour marker is raised in mucinous epithelial tumours?
CEA
50
What is the rotterdam criteria for PCOS?
oligomenorrhoea/amenorrhoea
| irregular cycle >35 days or 10cc
51
Management for PCOS
```
lifestyle modification
low caloric diet
exercise
weight loss should be first line treatment for PCOS
non hormonal treatment for menorrhagia
tranexamic acid
NSAIDs
? iron supplementation
hormonal
OCP
reduces hirsuitism
protection from endometrial hyperplasia
progestogen only
treatment for hirsuitism
spironolactone
ciproterone acetate (in some COCP such as Diane and Brenda)
monitor for complications
2 yearly HbA1c or OGTT
check lipids 2 yearly
monitor BP
screen for depression
endometrial biopsy to screen for endometrial cancer
fertility
clomiphine
```
52
Management for PID
analgesia
IV access/fluids if required
antibiotics
IV if severe
azithromycin 1g IV
ceftriaxone 1g IV
metronidazole 500mg IV 12 hours
give until afebrile for 24 hours and can change to oral antis - still give metronidazole for 2 weeks, second dose azithro one week later
oral if mild - moderate
azithromycin 1g oral stat + ceftriaxone 500mg IM + metronidazole 400mg oral bd 14 days
avoid intercourse until treatment has been completed
53
Risk factors for placenta praevia
```
prior placenta praevia
prior CS
prior TOP
multiparity
multiple pregnancy
advanced maternal age
ART
```
54
Management for asymptomatic placenta praevia
optimise haemoglobin
no digital vaginal examination (speculum is safe)
no intercourse
remain an outpatient until 34 weeks and then become an inpatient
plan for elective C/S at or around 37 weeks - early to avoid risk of haemorrhage if cervix starts to efface - can be 38 weeks if minor praevia
55
Management for symptomatic placenta praevia
resuscitation
IV access
IV fluid
blood transfusion if indicated
initial investigations
FBE
group and hold
coags
CTG
treatment
corticosteroids if before 34 weeks
magnesium sulphate if before 30 weeks
tocolysis may be used if bleeding is minor and labour has been initiated
delivery if:
any bleeding and gestation is >36/37 weeks
moderate ongoing blood loss gestation > 34 weeks
heavy bleeding with maternal haemodynamic compromise or unremitting bleeding at any gestation
location
generally remain an inpatient until delivery
56
Risk factors for PPH
```
prolonged labour
over distension of the uterus e.g. polyhydramnios, multiple pregnancy
antepartum haemorrhage
operative delivery
deep general anaesthesia
previous PPH
chorioamnionitis
```
57
Management of PPH
```
summon assistance
resuscitation
put in an IV line and give fluids
contract uterus
uterine massage
give an oxytocic
ergometrine
syntocinon
misoprostol
prostaglandin F2alpha
check placenta is intact
check the lower birth canal
prepare for theatre if bleeding is ongoing and perform the following steps as required
explore the uterus
further oxytocics
balloon tamponade
compression sutures
internal iliac ligation or placental site radiological embolisation
hysterectomy
may require blood transfusion
take blood and check for coagulation defects
```
58
Risk factors for PPROM
```
past history of PPROM or preterm delivery
urogenital tract infection
APH
cigarrette smoking
past cervical surgery
amniocentesis in current pregnancy
positive fetal fibronectin
connective tissue disorders
nutritional deficiencies?
lean maternal bodymass
multiple pregnancy/polyhydramnios
```
59
What is the antibiotic treatment for PPROM?
erythromycin - for 10 days or until delivery
60
Management of PPROM
admit/transfer to appropriate hospital
antenatal steroids (celestone) if before 34 weeks
erythromycin - for 10 days or until delivery
tocolytics
to allow for transfer and administration of steroids
only if no infection, vaginal bleeding or fetal distress
immediate delivery if fetal distress or evidence of infection or 37 weeks
serial US to assess fluid volume
fetal heart rate monitoring
infection surveillance
assess vital signs
abdominal palpation
assess amniotic fluid colour and quality
serial blood tests
high vaginal swabs
may discharge home on a case by case basis
61
What is the blood pressure cut off for pre eclampsia?
140/90 or 30/15 above baseline
62
What is the proteinuria cut off for pre eclampsia?
300mg/24hr
63
What are the features of severe pre eclampsia?
severe hypertension not controlled with medication
renal insufficiency - heavy proteinuria > 5g/24 hours
hepatocellular enzymes markedly elevated or jaundice
severe thrombocytopaenia/DIC
neurological sequalae - stroke/convulsions
pulmonary oedema
64
Risk factors for pre eclampsia
```
family history
previous pre eclampsia
age extremities
immune factors
first pregnancy
new paternity
short period of sexual cohabitation
barrier protection
assisted reproduction
maternal vascular disease
chronic hypertension
renal disease
diabetes
autoimmune disease
thrombophilias
excessive placental size
multiple pregnancy
gestational diabetes
GTD
hydrops fetalis
advancing gestation
```
65
History for pre eclampsia
```
headache
visual disturbances
RUQ pain
facial itching
generalised oedema
fetal movements
```
66
Examination for pre eclampsia
```
hypertension
if high - re check again in 10 minutes, ensuring correct cuff size and that patient is sitting
proteinuria
hyper reflexia
symphysis fundal height - check for FGR
```
67
Investigations for pre eclampsia
```
maternal
haematological parameters
platelet count
renal function
uric acid
urine protein creatinine ratio
hepatic function
LFTs
fetal
CTG
US
estimate fetal weight
amniotic fluid volume
fetal activity
umbilical artery doppler
```
68
Blood pressure control for pre eclampsia
```
aim for blood pressure of 150/90 - antihypertensive drugs are indicated for a blood pressure of systolic > 160 and diastolic > 100
methyldopa
labetalol
nifedipine
hydralazine
diazoxide
```
69
Seizure prophylaxis for pre eclampsia
```
definitely indicated if hyper reflexia is present, if not always
magnesium sulphate (IV)
monitor for respiratory depression
antidote is IV calcium
continue for at least 12-24 hours after delivery
```
70
Principles of management for pre eclampsia
stabilise: blood pressure control, seizure prophylaxis, fluid balance, monitor for and treat deranged LFTs, renal function or platelets, fetal welfare surveillance (including corticosteroids)
deliver
71
Indications for vaginal delivery in pre eclampsia
```
multiparous mother
stable blood pressure
cerebral stability
ripe cervix
mature fetus
cephalic presentation
normally grown fetus
good fetal welfare
```
72
Indications for C section in pre eclampsia
```
primiparous mother
unstable blood pressure
cerebral irritability
unripe cervix
immature fetus
breech presentation
FGR
abnormal CTG
```
73
Causes of pre term labour
```
premature rupture of membranes
cervical incompetence
multiple pregnancies
polyhydramnios
antepartum haemorrhage
uterine anomalies
infection
induction
idiopathic
```
74
Management of pre term labour
```
steroids
transfer and admission
antibiotics
tocolytics
intrapartum care
neuroprotection
```
75
Risk factors for prolapse
```
parity (even if C section)
vaginal delivery
long labour/long second stage
big baby
vaginal delivery with forceps damaging pudendal nerve
age (low oestrogen)
menopause (low oestrogen)
previous surgery to correct pelvic organ defects
hysterectomy - if ligaments have not been fixed to apex of vagina
congenital defects
ehlers danlos
marfan syndrome
hypermobility
spina bifida
bladder exstrophy
increased abdominal pressure
high impact activities
heavy lifting
chronic cough
constipation
obesity
smoking
diabetes
```
76
Investigations for recurrent miscarriage
```
chromosomal anomaly
chromosomal analysis of products of conception
investigate parental chromosomes (balanced robertsonian translocation)
anatomical
saline hysterosonography
MRI
maternal disease
diabetes
HbA1c
thyroid
TFTs
prolactin, androgens
autoimmunity
SLE
ANA
anti ds DNA
antiphospholipid syndrome
antiphospholipid antibodies
thrombophilias
factor V leiden
factor II gene mutation
protein S
```
77
Management for Shoulder Dystocia
McRoberts
suprapubic pressure
delivery of the posterior arm
rotation of shoulders
78
Aetiology of Urge Incontinence
```
idiopathic
psychosomatic
train yourself to have a hyper sensitive bladder - can be as an outcome of bladder neck weakness and trying to keep bladder empty
neuropathic
stroke
parkinson's
multiple sclerosis
spinal cord injury
a complication of incontinence surgery
outflow obstruction
bladder pathology - stones, cancer, interstitial cystitis
```
