RHCN Flashcards
(154 cards)
1
Q
what are the leading causes of maternal mortality worldwide
A
postpartum haemorrhage syntocinon etc can cause postpartum haemorrhage - pushing out uterus can’t contract afterwards as too tired
2
Q
what is the most common cause of PPH (post party haemorrhage)
A
uterine atony (uterine failing to contract after delivery 4 T’s - causes of PPH: - tone - atony - trauma - tissue retained - thrombin clotting abnormalities
3
Q
what is the leading cause of maternal mortality in the uk?
A
cardiac disease
4
Q
what is the first line medication for an eclamptic seizure
A
first line: IV magnesium sulphate will prevent further seizure activity IV labetalol for managing HTN
5
Q
risk factors for gestational diabetes
A
- PCOS (polycystic ovarian syndrome) - BAME ethnicities - older age - high BMI - previous big baby >4kg
6
Q
what test do pregnant women need when high risk for gestational diabetes
A
GTT between 26 and 28 weeks gestational diabetes diagnosis: - fasting glucose > 5.6 - post sugar > 7.8 refer to gestational diabetes clinic
7
Q
when choosing VBAC (virginal birth after Caesarean section) what is the risk of uterine rupture in spontaneous labour?
A
1/200 - best chance with spontaneous labour if induced with prostaglandin 1/50
8
Q
a manoeuvre to aid delivery at shoulder dystocia
A
McRobert’s bed flat and knees up to chest
9
Q
what is shoulder dystocia
A
anterior shoulder stuck behind pubic symphysis EMERGENCY delivery of head and then with the next push the baby should come out so if it doesn’t = shoulder dystocia
10
Q
what injury is common with shoulder dystocia
A
brachial plexus injury
11
Q
risk factors for shoulder dystocia
A
- macrosomia (big baby) - diabetes -maternal high BMI - previous shoulder dystocia
12
Q
what is the upper limit of normal for the post-menopausal endometrium?
A
4mm
13
Q
post manopausal bleeding investigations
A
- speculum and bimanual examination - transvaginal USS to look at endometrial thickening - normal <4mm if >4mm: - pipette endometrial biopsy/ hysteroscopy
14
Q
a women presents with with postcoital bleeding and you see a mass on her cervix, what should you do
A
refer for urgent colposcopy
15
Q
cervical smear
A
for people that are asymptotic screening checks for changes in cells
16
Q
a 54yr old woman has USS, a complex ovarian cyst is seen, which blood test should be done
A
Ca125 - ovarian cancer USS
17
Q
complex ovarian cyst in pre-menopausal woman which blood tests?
A
Ca125 AFP hCG CEA
18
Q
what is recommended to all low risk women planning pregnancy and in the 1st trimester
A
folic acid 400mcg OD
19
Q
who should get 500mcg folic acid during 1st trimester
A
high risk epilepsy previous fatal anomaly diabetes high BMI
20
Q
what is the normal scan schedule in a low risk pregnancy
A
12 - dating scan - due date, screening offered here 20 weeks - anatomy scan
21
Q
what is the scan schedule in a high risk pregnancy
A
12,20, 28, 36
22
Q
how far away from the internal OS must the placenta be to allow vaginal birth
A
20mm
23
Q
what is the UK gestational age viability
A
24 weeks
24
Q
a 14yr old girl attends to ask for the pill, you deem her Fraser competent, what should you do
A
give her the pill, encourage her to discuss with her parents
25
what is the biggest risk factor for ectopic pregnancy + other risk factors
1. tubal damage (ie from chlamydia) - endometriosis - previous surgery - conceiving while on the pill
26
a woman presents to the GP with shortness of breath 5 days post emergency CS, what should you do?
refer to hospital for investigation of PE commence LMWH if +ve
27
when is anti D prophylaxis required?
Rh -ve mother Rh +ve predicted fetus prophylaxis dose at 28 weeks then after delivery and at any desensitising events (eg bleed) Rh status checked at 16 weeks
28
what is a contraindication to fetal blood sampling
any maternal blood borne infection e.g.maternal HIV baby with predicted abnormal clotting mother been warfarinised (crosses placenta)
29
fatal blood sampling
look at pH of blood to see if baby is getting enough O2 to continue with labour need to be at least 3 cm dilated don't do if under 36 weeks gestation
30
potential causes of polyhydramnios
too much fluid around baby - weeing too much or can't wee it out - check for diabetes - check if they've had contact for acute CMV in pregnancy (cytomegalovirus) - foetal medicine to check for abnormalities
31
what is a normal FBS result?
pH \> 7.25 if \<7.20 - deliver within 30 mins 7.20 - 7.25: boarderline- repeat in 1hr
32
the different category Caesarean sections and how quickly they need to be carried out
cat 4: elective cat 3: no time limit but e.g.if they spontaneously rupture & so have to move elective CS forward cat 2: concern but not life threatening:\<75mins cat 1: \<30mins
33
what is the name for forceps
Keillands: rotational wrigleys: small Andersons and neville barnes: direct traction, straight delivery
34
a post menopausal woman has a multilocular ovarian cyst, her Ca125 is 100 what is the RMI (risk of malignancy index)?
RMI = Ca125 x ultrasound score x menopause status (RMI = Ca125 x U x M) ultrasound features: 1 point for: - multilocular cyst - solid areas - metasteses - ascites - bilateral lesions 0 points = U0 1 point = U1 2-5 points = U3 menopausal status: pre-menopausal = M1 post menopausal = M3 menopausal: woman with no period for 1yr or \>50 with hysterectomy for this example: RMI = 100 x 1 x 3 = 300
35
which are the high risk strains of HPV
16 & 18
36
which surgical procedure should be performed for stage 1a endometrial cancer
1a: confined to the uterus total laparoscopic hysterectomy
37
how many sets of chromosomes are in a partial molar pregnancy
3 (69 total) two paternal + egg (3 sets)
38
molar/ partial molar pregnancy
abnormal pregnancy - molar and partial molar potential to cause malignancy - gestational trophoblastic disease
39
how many sets of chromosomes are in a molar pregnancy
2 (46) no maternal + 2 paternal
40
management for a partial/ molar pregnancy
evacuation of pregnancy and refer mother to specialist to get hCG to normalise
41
what is the most common site for an ectopic pregnancy
ampulla of the Fallopian tube (main length) - due to damage of cilia from things like chlamydia
42
what classifies as HTN in pregnancy?
two episodes \>20mins apart \> 140/90 beyond 20th week of pregnancy severe HTN: \>160/100 without proteinuria: pregnancy induced HTN with proteinuria: pre-eclampsia
43
most common cause of post-menopausal bleeding
atrophic vaginitis endometrial atrophy
44
chocolate cyst diagnosis?
endometriosis
45
investigations and management for endometriosis
investigations: - pelvic examination - transvaginal USS if persistent/ pelvic signs - serum Ca125 - MRI for assessing other organ damage - diagnostic LAPAROSCOPY management: - first line= analgesia - NSAIDs & PARACETAMOL - COCP - IUS - mirena - excision or ablation - hysterectomy
46
endometriosis presentation
chronic pelvic pain - period related pain - deep pain during or after sexual intercourse - painful bowel movements - urinary symptoms
47
20yrs contraceptive advice UPSI four days ago most appropriate method of contraception
copper-containing intrauterine device acts as emergency contraception for up to 5 days after UPSI
48
movement of the fatal head from occipital-transverse to occipital-anterior position during labour. what is the most appropriate term for this
internal rotation the occiput leads and meets the pelvic floor first and rotates anteriorly 1/8th of the circle to come under the pubic symphysis. the anteroposterior diameter of the head now lies in the anteroposterior diameter of the pelvic outlet
49
newborn baby weight 3.8kg not moving left arm after difficult forceps delivery left arm is floppy, reflexes absent, hand in backward position. right arm moves normally which anatomical structure is most likely to have been damaged?
brachial plexus complete brachial plexus palsy: lies with arm held limp at side deep tendon reflexes in affected arm absent moro response is asymmetrical no active abduction of ipsilateral arm
50
48yrs regular periods till 45y now more frequent, bleeding twice a month and heavier. sweating, severe hot flushes, decreased libido single best management choice
take endometrial biopsy histological diagnosis in patients \> 45yrs
51
descent of labour
due to forceful uterine contraction and retraction, rupture of membranes, complete cervical dilatation and maternal efforts
52
flexion of labour
flexion increased throughout labour. when head meets resistance of pelvic floor flexion is increased. this decreases the presenting diameter to a smaller diameter (9.5cm). the occiput becomes the leading part
53
mechanism of labour order
- flexion - internal rotation of head - crowning - extension of head - restitution
54
crowning in labour
- occiput slips beneath the subpubic arch - crowning occurs when the head no longer recedes back btwn contractions - widest transverse diameter (biparietal) is born
55
extension of head in labour
fatal head pivots around the pubic bone while the sinciput, face and chin sweep the perineum and head is born by the movement of extension
56
restitution in labour
the twist in the neck of the foetus that resulted from internal rotation is now corrected by a slight untwisting movement. the occiput moves 1/8th of a circle towards the side from which it started
57
antiphospholipid syndrome =
recurrent miscarriages + thrombocytopenia can be secondary to SLE
58
antiphospholipid syndrome ix
increased APTT antiphospholipid antibodies: anti-cardiolipin lupus anticoagulant antibodies
59
antiphospholipid mx in pregnancy
aspirin (after confirmation on urine testing) + LMWH (after seen on USS) during pregnancy for preventing arterial and venous thromboembolisms
60
why is warfarin teratogenic
crosses placenta
61
risk factors for endometrial cancer
obesity nulliparity early menarche late menopause unopposed oestrogen diabetes mellitus tamoxifen polycystic ovarian syndrome HNPCC
62
risks of COCP
heart attack stroke breast cancer cervical cancer
63
ix for polycystic ovarian syndrome
pelvic USS
check for impaired glucose tolerance
hyperinsulinaemia
high LH (high LH:FSH ratio)
64
endometriosis features
chronic pelvic pain dysmenorrhoea dyspeunia subfertility urinary symptoms and painful bowel movements
65
gold standard ix for endometriosis
laparoscopy
66
most common organism for pelvic inflammatory disease
chlamydia trachomatis
67
features of PID
lower abdo pain fever deep dyspareunia dysuria menstrual irregularities vaginal or cervical discharge cervical excitation
68
ix for PID
exclude ectopic pregnancy screen for chlamydia and gonorrhoea high vaginal swab
69
mx for PID
abx oral ofloxacin + oral metronidazole or IM ceftriaxone + oral doxy + oral metronidazole
70
complications of PID
perihepatitis (Fitz-Hugh Curtis syndrome) - RUQ pain infertility chronic pelvic pain ectopic pregnancy
71
risk factors for ovarian cancer
BRCA1 or BRCA2 mutations early menarche late menopause nulliparity
72
ix for ovarian cancer
CA125 USS diagnosis: laparotomy
73
bHCG \>1,500
points towards ectopic pregnancy
74
risk factors for cervical cancer
HPV 16,18, 33 smoking HIV early first intercourse many sexual partners high parity lower socioeconomic status COCP
75
drugs to avoid during breast feeding
76
placenta accreta
attachment of placenta to the myometrium
as the placenta does not properly separate during labour there is a risk of post partum haemorrhage
risk factors:
previous caesarean section
placenta praevia
77
HPV screening
tested for HrHPV
- negative = return to normal recall
- positive = cytology
cytology abnormal = colposcopy
cytology normal = test repeated at 12 months
if repeat test -ve = return to normal recall
if repeat test hrHPV still +ve and cytology normal = further repeat in 12 months
if hrHPV -ve at 24months = return to normal recall
if hrHPV +ve at 24 months = colposcopy
if cytology sample inadequate = repeat within 3 months
if two consecutive inadequate samples = colposcopy
78
how often do you get the injectable contraceptive (depo provera)
every 12 weeks
79
contraindication of injectable contraceptives
breast cancer
80
\< 40yrs
secondary ammenorrhoea
raised FSH, LH
infertility
hot flushes, night sweats
premature ovarian failure
- simialr to normal menopause symptoms but in earlier age
81
mode of action of contraceptive
82
which contraceptive can be relied upon immediately
copper coil
all others take 7 days to be relied upon
83
teenage girl
primary amenorrhoea
undescended testes causing groin swelling
breast development
diagnosis
androgen insensitivity syndrome
x-linked recessive
resistance to testosterone causing genotypically male children (46XY) to have a female phenotype
84
how long does the progesterone only pill take to become effective
after 2 days
if commenced on or before day 5 of cycle it provides immediate protection
85
missed pill \>3hrs for POP
if \> 3hrs late: take missed pill as soon as possible, continue with rest of pack, extra precautions for 48hrs
86
87
booking visit and bookking bloods when?
8-12 weeks (ideally \<10)
88
anomaly scan time
18-20+6 weeks
89
first dose of anti-D prophylaxis to rhesus neg women
28 weeks
90
dating scan
10-13+6 week
91
10 weeks pregnant
vaginal bleeding
USS - snowstorm appearance, no fetus
B-hCG markedly elevated
hydatidiform mole
- happens when sperm fertilises empty egg so doubles its own DNA
- usually bleeding if first or early second trimester
- exaggerated symptoms of pregnancy
high hCG
92
pregnant
vaginal bleeding but haemodynamically stable
placenta praevia
= low lying placenta
usually picked up on 20wk abdo USS
do transvaginal USS to locate placenta
risk factors:
multiple pregnancies
previous caesarian
93
hydatidiform mole mx
urgent referral for evacuation of uterus
contraception to avoid pregnancy in next 12 months
risk of choriocarcinoma (cancer of uterus)
94
partial hydatidiform mole
normal haploid egg may be fertilised by two sperms or by one sperm with duplication of paternal chromosomes e.g. 69XXX or 69XXY
95
complete vs partial hydatidiform mole
complete: 46 2 paternal
partial: 69 XXX or XXY (2 paternal, 1 maternal)
fetal parts may be seen
96
down syndrome screening including nuchal scan
11-13+6 weeks (one week after dating scan)
97
early pregnancy ovarian cyst
usually physiological - corpus luteum - usually resolve from second trimester
98
first line mx for eclampsia
magnesium sulphate
- for preventing seizures in severe pre eclampsia and stopping them once developed
given once a decision to deliver has been made
should be continued 24hrs after last seizure or delivery
99
first line mx for magnesium sulphate induced respiratory depression
calcium gluconate
magnesium sulphate given for eclampsia
100
what weeks for antenal
first blood tests
urine culture to detect asymptomatic bacteriuria
booking visit
8-12 weeks
101
at how many weeks do you offer external cephalic version (to turn baby in to cephalic lie)
36 wks
102
pre-eclampsia presentation
after 20wks
pregnancy induced HTN
proteinuria (\>0.3g/24hrs)
features of severe pre-eclampsia:
- HTN \>170/110
proteiunuria ++/+++
headache
visual disturbance
papilloedema
RUQ/ epigastric pain
hyperreflexia
platelet count low
103
mx of pre-eclampsia
women at moderate/ high risk of pre-eclampsia = aspirin 75mg from 12 weeks until birth
treat BP \>160/110 = oral labetalol
delivery of baby
104
risk factors for pre-eclampsia
105
36 wks pregnant
vaginal bleeding
shock out of keeping with visible loss
pain constant
tender, tense uterus
normal lie and presentation
fetal heart absent/ distressed
placental abruption
maternal haemorrhage
vaginal bleeding but shock out of keeping with visible loss
106
anti D propylaxis dates
anti D given to rhesus negative women
28 weeks
34 weeks
107
baby born with:
blunted upper incisor teeth
keratitis
saber shins
saddle nose
deafness
congenital syphilis
108
baby born with
sensorineural deafness
congenital cataracts
patent ductus arteriosus
purpuric skin lesions
'salt and pepper' chorioretinitis
congenital rubella syndrome
classic triad of:
- cataract
- cardiac abnormalities - PDA
- deafness
purpuric skin lesions
'salt and pepper' chorioretinitis - on fundoscopy - grainy appearance
caused by togavirus
109
mx of rubella in pregnancy
Igm raised
should also be checked for parovirus B19
suspected cases discussed with **local health protection unit**
non-immune mothers should be offered MMR **vaccination in post-natal** period - should not be administered to women known to be pregnant or attempting to become pregnant
110
what type of contraceptive is nexplanon
implant
111
safest form of contraception for suspected/ personal hx of breast cancer or confirmed BRCA mutation
copper coil - category 1 on UKMEC
COCP is 3 - shouldnt be given
all others are 2
copper coil can also be given in current or past breast cancer but is the only one
112
UK Medical Eligibility Criteria for Contraceptive Use (UKMEC)
contraception should only be offered in primary care if it is considered category 1 or 2
113
routine recall for cervical smear
25-49: every 3yrs
50+: every 5yrs
114
tearing pelvic pain
vaginal bledding
haemodynamically unstable
ectopic pregnancy
USS shows no intra uterine pregnancy but bHCG is elevated
115
RUQ pain
fever
white vaginal discharge
pelvic pain and dyspareunia
pelvic inflammatory disease
RUQ pain --\> Fitz Hugh Curtis syndrome - perihepatic inflammation occurs
116
usually mid cycle mild supra pubic pain
sharp onset
no systemic disturbance
Mittelschmerz
mid cycle pain due to small amount of fluid released during ovulation
inflammatory markers normal
FBC normal
USS - small quantity free fluid
usually subsides over 24-48hrs
117
sudden onset deep seated colicky abdo pain
vomiting and distress
vaginal examination - adnexial tenderness
ovarian torsion
- laparoscopy
118
119
mx for ectopic
laparoscopy or laparotomy if haemodynamically unstable
salphingectomy is usually performed
120
anti D should be given immediately in which scenarios
delivery of a Rh +ve infant, whether live or stillborn
any termination of pregnancy
miscarriage if gestation is \> 12 weeks
ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
external cephalic version
antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling
abdominal trauma
121
mx for the affected foetus from rhesus neg mother
transfusions and UV phototherapy
can result in hydrops fetalis
122
coombs test: direct vs indirect
Direct Coombs: Is a investigation used to look for autoimmune haemolytic anaemia
Indirect: Used antenatally to detect antibodies in the maternal blood that can cross the placenta and result in haemolytic disease of the newborn.
123
pregnant woman in third trimester
pruritis in soles of hands and feet
deranged LFTs
obstetric cholestasis
pruritis
raised bilirubin
124
first line medical mx for obstetric cholestasis
ursodeoxycholic acid
increased risk of still birth - induction of labour at 37-38wks
125
at what stage do most people present with endometrial cancer - mx
most people present in stage 1
treated with hysterectomy + bilateral salpingo- oophorectomy
126
rupture of membranes followed by painless vaginal bleeding
fetal bradycardia
vasa praevia
classic triad
significant risk to fetus but no risk to mother
127
types of spontaneous abortion
threatened miscarriage: painless vaginal bleeding typically around 6-9 wks
missed (delayed) miscarriage: light vaginal bleeding and symptoms of pregnancy disappear
inevitable misscarriage: complete or incomplete
complete: all fetal and placental tissue expelled : little bleeding
incomplete: not all tissue expelled: heacy bleeing and crampy lower abdo pain
128
cardiotocography normal fetal heart rate
100-160
bradycardia: \<100
tachycardia: \> 160
129
decelerations in tocography
a single prolonged deceleration lasting 3 mins or more is abnormal
early decelerations: deceleration of heart rate which commences with contraction and returns to normal on completion of contraction
- head compression
late decelerations: lags behind onset of contraction
- fetal distress e.g. asphyxia or placental insufficiency
variable decelerations: independent of contractions
- cord compression
130
normal features of cardiotocography
100-160 beats/min heart rate
baseline variability of 5 or more beats/min
fetal heart rate accelerations
131
need for contraception after menopause
contraception after menopause:
\>50: 12months after last period
\<50: 24months after last period
132
why is the injectable contraceptive not advised in high BMI women
causes weight gain
133
contraceptive of choice for patient on epilepsy drug (carbamazepine)
**copper coil** - prefered (only one for lamotrigine)
progesterone injection
mirena intrauterine system
if taking others then they need to also use barrier protection - COCP and POP is UKMEC 3 so not recommended
134
down's antenatal screening
nuchal translucency - thickened
+ bHCG - increased
+ pregnancy associated plasma protein A (PAPP-A) - decreased
can also assess for edwards and pataus - PAPP-A lower
135
taking COCP
post-coital bleeding
cervical smear negative
cervical ectropion
- elevated oestrogen levels leads to larger transformation zone on cervix --\> post coital bleeding and vaginal discharge
136
breast lump after recent cessation from breast feeding
painless
no systemic symptoms
galactocele
can be differentiated from breast abscess with hx and ex so no further investigation necessary
- breast abscess more likely painful, fever
137
medical mx of ectopic pregnancy
methotrexate
for unruptured ectopic with no significant pain
138
expectant mx for ectopic pregnancy when?
if \<35mm
unruptured
asymptomatic
no fetal heart beat
serum bHCG \< 1000
139
visible fetal heart beat on ectopic pregnancy - mx
surgical mx
- salpingectomy (tubes removed) or salpingotomy (tubes preserved)
140
ix of choice for ectopic
141
cervical screening programme for HIV positive women
offered cytology at diagnosis
then offered cervical cytology annually
at increased risk of cervical cancer
142
first line mx for menorrhagia
requires contraception: intra-uterine system (mirena)
does not require contraception: tranexamic acid or NSAIDs (e.g mefenamic acid)
143
most common cause of early onset infection of baby in neonatal period
group B streptococcus
risk factors:
prematurity
prolonged rupture of the membranes
previous sibling GBS infection
maternal pyrexia e.g. secondary to chorioamnionitis
144
mx of GBS +ve mother during pregnancy
women with GBS detected in previous pregnancy:
- intrapartum antibiotic prophylaxis (IAP) or testing in late pregnancy and then abx if still +ve
previous baby with early or late onset GBS disease: IAP
preterm labour regardless of GBS status: IAP
women with pyrexia during labour (\>38) = IAP
IAP = **benzylpenicillin**
145
chickenpox exposure in pregnancy \>20 wks (if not immune)
antivirals (acyclovir) of VZIG (varicella zoster immunoglobulins IM) given at days 7-14 post-exposure, not immediately
if theyre not sure if theyre immune (had it before): urgent bloods for varicella antibodies - if -ve then not immune
146
chicken pox exposure in pregnancy \<20 weeks
varicella zoster immunoglobulin ASAP
effective up to 10 days post exposure
147
mx chickenpox in pregnancy
if presenting within 24hrs and \>20 wks = oral acyclovir
if \<20 weeks should be considered with caution
148
medical mx to shrink fibroid size
GnRH agonists
- short term shrinkage
eg before sugery
149
mx for large fibroids causing problems with fertility and woman wishes to conceive in future
myomectomy
150
bladder still palpable after urination
retention with urinary overflow incontinence
151
mx of PCOS symptoms
**weight loss + smoking cessation** - first line
contraception: COCP
hirsutism: COCP
infertility: **c****lomifene** or metformin
152
appropriate next step for postmenopausal women with ovarian cyst
referred to gynae for assessment regardless of nature or size - less likely physiological
153
next step of ovarian cyst in premenopausal women
if simple small (\<5cm) cyst on USS: repeat USS in 8-12 wks and referral considered if it persists
154
stages of labour
stage 1: from the onset of true labour to when the cervix is fully dilated
latent phase: 0-3cm
active phase 3-10cm
stage 2: from full dilation to delivery of the fetus
stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered
false labour: in last 4 weeks of pregnancy. contractions in lower abdo, irregular, no cervical changes
