SAQs Knowledge Flashcards
1
Q
Presentation of ovarian torsion
A
- Acute onset
- Unimproving pain
- May cause inflammatory response and raised CRP
- Leukocytes within normal range
2
Q
What can transabdominal USS often not visualise?
A
Appendix
3
Q
5 VTE facts about HRT
A
- Risk of VTE is highest in the 1st year
- Thrombophilia screening is not routine (may be indicated with family hx)
- No evidence of continued VTE risk on stopping HRT
- Cannot take oral HRT with a VTE risk
- Stop HRT immediately if VTE develops
4
Q
What are the safest blood transfusion products to offer?
A
- Fully cross-matched blood (takes 45 mins to mix patient and donor blood products to test for haemolytic reaction)
- Group specific blood (takes 15 mins to test the patient’s blood group and select compatible blood)
- O negative blood (only used in emergencies, no tests are completed against recipient blood)
If the patient is haemodynamically stable, use fully cross-matched blood
5
Q
What are the risks of developing ovarian cancer at each RMI value?
A
- <50 3%
- 50-250 20%
- > 250 75%
6
Q
What are the concerning features of ovarian cyst on ultrasound?
A
- Bilateral
- Multiloculated
- Solid components
- Ascites
- Metastases
- > 5cm
7
Q
What is the management for simple ovarian cysts <5cm?
A
Conservative (NSAIDs)
FU: TVUSS and CA125 every 4 months for one year
8
Q
What are the most important differentials to exclude with PMB?
A
- Endometrial cancer
- Ovarian cancer (much less likely)
9
Q
What investigation should be offered before HRT?
A
TVUSS to ensure endometrial thickness is <4mm
10
Q
What is the main function of progesterone?
A
Enhances endometrial reciptivity, once there’s a successful implantation BHCG is produced to maintain corpus luteum function
11
Q
What blood test should not be carried out for HMB?
A
Female hormone testing
12
Q
When is USS offered for HMB?
A
- Uterus is palpable abdominally
- Hx or examination suggests mass
- Examination is difficult or inconclusive eg. obesity
13
Q
What are the treatments for HMB?
A
- Levonogestrel IUS
If IUS is declined or contraindicated
2. Txa &/or NSAIDs
3. COCP/ cyclical oral progesterone
14
Q
When is IUS contraindicated?
A
- Active infection
- Active pregnancy
- Fibroids >3cm
- Fibroids distorting uterine cavity
15
Q
What is the management for PMS?
A
All women
- Conservative
Moderate
- COCP (Yasmin best evidence base, cyclical or continous, better evidence for continuous)
Severe
- Referral for CBT
- SSRI trail for 3 months (can be continuous or just during luteal phase)
16
Q
What is severe PMS?
A
Withdrawal from social and professional activities and prevents normal functioning
17
Q
Which patients are oestrogen alone HRT used for?
A
Post hysterectomy OR in-situ LNG-IUS
Ellesete Solo
BMI >30 give as a transdermal patch (increased VTE risk with oral)
18
Q
What is combined oestrogen and progesterone HRT brand name?
A
Ellesete Duet
19
Q
When is cyclical Ellesete Duet prescribed?
A
Peri-menopausal women
Monthly
- Oestrogen every day of the month + progesterone for last 14 days
Three monthly
- Oestrogen every day for 3 months + progesterone for last 14 days
Withdrawal bleeds when taking progesterone
20
Q
When is continuous Ellesete Duet taken?
A
Post-menopausal women
- Oestrogen and progesterone daily
21
Q
What are the routes of HRT?
A
- Oral (low VTE risk)
- Transdermal (high VTE risk)
- Vaginal creams/ gels (if predominantly vaginal sx)
22
Q
What are the side effects of oestrogenic HRT?
A
- Breast tenderness
- Nausea
- Headaches
23
Q
What are the side effects of progestogenic HRT?
A
- Fluid retention
- Mood swings
- Depression
24
Q
What are the risks of HRT?
A
- Breast cancer
- Cardiovascular disease
- VTE
- Ovarian cancer
25
What are the contraindications for hormonal HRT?
- Pregnancy
- Current or present breast cancer
- Endometrial cancer
- Uncontrolled hypertension
- Current VTE
- Current thrombophilia
- Undiagnosed vaginal bleeding
- Severe liver disease
- Untreated endometrial hyperplasia
26
Which component of HRT is most effective at reducing hot flushes?
Oestrogen
27
What is done if a woman has breakthrough bleeding within the first 6 months of combined continuous HRT?
Pelvic USS and biopsy
28
What are the non-hormonal treatments of menopause?
- Alpha agonists (clonidine)
- Beta-blockers (propranolol)
- SSRIs (vasomotor symptoms)
- Symptomatic: lubricants, osteoporosis treatments etc
29
What is the managment pathway for endometriosis?
1. Analgesia (NO opiates, can worsen co-existing IBS)
2. COCP
3. Progestogens (if COCP contraindicated)
4. GnRH agonists
5. Surgical tx (fertility sparing: laparoscopy, non-sparing: hypsterectomy & oophorectomy, may not necessarily cure symptoms or disease)
30
What is the function of COCP in endometriosis?
Symptomatic relief
31
How is COCP taken for endometriosis?
Most effective: tricycle packets (3 packets back to back)
Can be taken for 21 days with 7 day pill-free interval
Can also be taken without a break to induce amenorrhea
32
What is the function of progestogens in endometriosis?
Induce amenorrhea
33
Progestogen options for endometriosis?
- Depot medroxyprogesterone acetate
- Levonogestrel IUS
- POP
- Implant (nexplanon)
34
What is the function of GnRH agonists in endometriosis?
Effective at relieving the severity and syptoms of endometriosis
- Usually administered as slow-release depot formulations (lasting 1 month)
- Can be taken as intranasal sprays (daily)
35
Why should GnRH agonists not be used for more than 6 months?
Risk of osteoporosis
36
What is the preferred management for endometriosis if fertility is a priority?
Laparoscopic excision or ablation of endometriosis plus adhesiolysis
3 months of GnRH prior to surgery for deep endometriosis involving the bowel, bladder or ureter
Risk of recurrence 30% so start medical therapy immediately after surgery
37
When is referral to specialist endometriosis service indicated?
Suspected/ confirmed endometriosis involving bladder, bowel or ureter
38
When is follow up indicated for endometriosis?
- Deep endometriosis involving bowel, bladder or ureter
- 1 or more endometrioma >3cm
39
Pathological features of CTG
BRA
- <100bpm or >180bpm
V
- <5bpm >50mins
- >25bpm >25mins
A
- Absent (uncertain significance)
D
- Repetitive variable decelerations with concerning characteristics >30 mins
- Repetitive late decelerations >30 mins
- Single prolonged deceleration >3 mins
- Acute bradycardia (3 mins = call for help, 6 mins = move to theatre, if persists beyond 9 minutes, expedite delivery, deliver by 15 mins)
O
- Pathological = 1 pathological feature or >= 2 non-reassuring features
40
What is the managment of suspicious and pathological CTGs?
Suspicious
- Involve senior midwife/ obstetrician
- Conservative management: mobilise patient/ left lateral position, maternal obs, fluids, hold oxytocin
Pathological
- Involve senior midwife and obstetrician
- Conservative management
41
When is ARM avoided?
If presenting part is mobile or high OR if cord is felt below presenting part on vaginal examination
42
Management of cord prolapse
- Call for senior help, CTG, theatre for immediate delivery
- Elevate presenting part (manual or fill bladder with 500ml saline)
- Reposition mother: all fours, knee-to-chest, left lateral position head down
- Consider tocolytics when preparing for c-section if there are still foetal heart abnormalities
- ASAP DELIVERY QUICKEST ROUTE (eg. if dilated and vaginal is quickest, expedite vaginal delivery)
43
What are the absolute contraindications for epidural?
- Patient refusal
- Allergies to anaesthesia
- Systemic infection
- Skin infection over site
- Bleeding disorders
- Platelets <80 000/ml
- Uncontrolled hypotension
44
Which position can woman be put in to increase venous return?
Left lateral tilt
45
What are the risk factors for LMWH prophylaxis?
- Age >35
- BMI >30
- Family hx DVT
- Smoker
- Immobile
- Mild thrombophilia
- P>3
- Gross varicose veins
- PET
- Multiple pregnancy
- IVF pregnancy (high levels of oestrogen = procoagulatory)
>=4 commence on LMWH immediately until 6 weeks post partum
3 commence on LMWH from 28 weeks to 6 weeks post partum
2 commence on LMWH for 10 days post partum
46
When are DVT risk assessments taken for pregnant women?
- Early pregnancy
- When they're admitted to hospital for any reason
- Intra or post partum
47
LMWH with DVT in pregnancy
Commence LMWH immediately until 6 weeks post partum, or they've had 3 months of treatment
(Whichever is longer)
48
What is the foetal surveillance for parvovirus B19 in pregnancy?
Fortnightly monitoring with Doppler USS of Middle Cerebral Artery (monitors for anaemia)
49
What is an elevated Ca125?
>35IU/ml
50
What is the risk of malignancy index?
RMI = Ca125 x M x U
M= pre or post menopausal (1 or 3 pts)
U= USS features, 0=0, 1=1, >1=3
51
What are the USS features for RMI?
- Multiloculated cysts
- Bilateral cysts
- Solid components
- Mets
- Ascites
52
What HbA1c would cause a doctor to advise against pregnancy?
>= 86mmol/mol (10%)
53
What is the criteria for hyperemesis gravidarum?
- Significant dehydration
- Weight loss >5% pre-pregnancy body weight
- Electrolyte disturbance
54
What is the score to assess hyperemesis gravidarum?
Pregnancy-Unique Quantification of Emesis score
55
What are the foetal risks of pregnancy in hypothyroidism?
- Miscarriage
- Preterm delivery
- Intellectual impairment in the neonate
56
How often are thyroid levels checked for hypothyroidism in pregnancy?
Every 2-4 weeks
Thyroxine requirements may increase in the first trimester due to increased oestrogen binding to thyroid binding globulin
57
What are the increased maternal risks with hypothyroidism in pregnancy?
Pre-eclampsia, especially with antithyroid antibodies
58
What is the ROM plus test and what is it used for?
Tests for: insulin-like growth factor binding protein 1 and alpha-macroglobulin 1
Used when PPROM is suspected but there is no pooling of liquor in the posterior vaginal space
59
What is an early miscarriage?
Losing a pregnancy within 12 weeks
60
What is the most common cause of early miscarriages?
Genetic/ chromosomal abnormalities eg. balanced chromosomal translocations
After the first miscarriage, products of conception sent to the lab for cytogenic analysis. If balanced chromosomal translocation found, karyotype performed on both parents
61
When do miscarriages occur in anti-phospholipid syndrome?
After the first trimester (>14 weeks)
62
Which antibodies are present in anti-phospholipid syndrome?
Anti-cardiolipin and lupus anticoagulant antibodies
63
What reduces the risk of miscarriage in anti-phosopholipid syndrome?
Aspirin and LMWH (low dose)
64
When do miscarriages occur with cervical weakness?
After 20 weeks
65
Which types of fibroids are most likely to cause miscarriages?
Submucosal fibroids
If pregnancy occurs, miscarriage most likely to occur in the 2nd trimester
66
When is screening for anaemia performed in pregnancy?
Booking and 28 weeks
67
When are neural tube defects screened for?
- Booking
- Anomaly scan
68
What is the combined screening test?
11-13+6 (offer to all pregnant women)
- Nuchal translucency (>6mm DS)
- hCG (high DS)
- PAPP-A (low DS)
69
What is the quadruple test?
14+2-20 (those who've missed the combined test)
- hCG
- Inihibin A
- AFP
- Unconjucated oestriol (uE3)
70
When is the quadruple test offered?
- Late presentation
- Nuchal translucency can't be obtained
- CRL >84mm and head circumference between 101-172mm during USS
71
What is the most important surveillance tool for monitoring SGA?
Umbilical artery Doppler
Can predict foetal acidaemia which enables prompt delivery of the baby with avoid IU death and end organ damage
72
What is the biophysical profile?
- Breathing movements
- Gross body movements
- CTG
- Amniotic fluid volumes
Each variable graded as 2 (normal) or 0 (abnormal)
73
When should SFH be monitored?
Every antenatal appointment from 24 weeks
74
What is an antepartum haemorrhage?
Bleeding after 24 weeks
75
What are the doppler USS findings that would predict foetal anaemia?
Elevated peak systolic velocity through the middle cerebral artery
76
What is the timeline for puerperal sepsis?
Occurs within 6 weeks of childbirth
77
How does peurperal sepsis present?
Commonly with severe abdominal pain that's not responsive to pain relief in the post partum period
+ tachycardia, tachypnea, +- hypotension
78
What is the most common pathogen indicated in peurperal sepsis?
Group A strep (strep pyogenes)
79
What is the anti-D prophylaxis for a Rh-ve woman <20 weeks with a sensitising event?
250 IU anti-D IgG wtihin 72 hours
80
What is the anti-D prophylaxis for a Rh-ve woman >20 weeks with a sensitising event?
500 IU anti-D within 72 hours and a Kleinhauer test
81
What does Kleinhauer test measure?
Degree of fetomaternal haemorrhage, significant may warrant more doses of anti-D
82
What is routinely offered to all Rh -ve women?
1500IU anti-D IgG at 28 weeks
Either one dose at 28 weeks or 2 doses at 28 and 34 weeks
83
What is the protocol for RhD negative women once babies are born?
Cord blood taken and tested for FBC, blood group and indirect Coomb's test
If baby RhD+ve, mother offered 500IU anti-D IgG within 72 hours and a Kleinhauer test performed
84
What is the aim of the booking USS?
- Detect multiple pregnancies
- Determine gestational age (based on CRL, if >84mm head circumference used instead)
- Measure nuchal translucency
85
When is CRL no longer useful to estimate gestational age?
- Beyond 13+6 weeks
- >84mm
In these cases other variables eg:
- Femur length
- Abdominal circumference
Used
86
When is CVS offered?
Between 11-13+6 weeks (transabdominal or transcervical approach)
87
When is amniocentesis offered?
15-20 weeks
88
What is the most common cause of secondary PPH?
Endometritis (occurring between 24 hrs to 12 weeks of birth)
89
What is the most common cause of primary PPH?
Uterine atony (occuring within 24 hours of birth)
90
How is endometritis investigated?
High vaginal swabs and treated with abx
91
What are the typical sx of uterine rupture?
- Abdo pain
- Vaginal bleeding
- Change in the pattern of contractions
- Haemodynamic instability (mother)
- Non-reassuring foetal heart rate tract (usually bradycardia)
92
What is the time requirement for category 3 c-sections?
Within 24 hours
93
When is vaginal delivery appropriate in patients with uterine rupture?
When delivery is imminent
94
What are the requirements for foreceps delivery?
Cervix fully dilated and effaced and baby's head is engaged (aligned with ischial spines)
95
When is ventouse not used?
When giving birth <36 weeks (baby's head is too soft), absolute contraindication <32 weeks
Higher rate of failure in general than foreceps
Aim to deliver within 3 pulls
Discontinue with 2 pop offs, seek support for less experienced opperaters with 1 pop off
96
When is mediolateral episiotomy performed?
Discussed as part of preparation for assisted birth
- Cut should be 60 defrees initiated when the head is distending the perineum
97
What abx prophylaxis is given following assisted vaginal birth?
Single prophylactic dose of IV amoxicillin and clavulanic acid
98
When is a trial assisted birth attempted?
Higher risk of failure
Non-rotational low-pelvic and lift out assisted vaginal births have low probability of failure
99
What are the thresholds for anaemia in pregnancy?
1st trimester: <110g/l
2nd trimester: <105g/l
3rd trimester: <100g/l
Women <100g/l at delivery under consultant led care
100
What is the most common cause of anaemia in pregnancy?
Iron deficiency
101
When should FBC be taken in multiple pregnancies?
- Booking
- 20-24 weeks
- 28 weeks
102
What is the management of IDA in pregnancy?
- Oral iron
- If that fails IV irone or blood transfusions
