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Clinical school: 100 cases > 100 Cases in Obstetrics & Gynaecology > Flashcards

100 Cases in Obstetrics & Gynaecology Flashcards

1
Q

What are the differentials for intrauterine bleeding?

A
  • Cervical malignancy
  • Cervical ectropion
  • Endocervical polyp
  • Atrophic vaginitis
  • Pregnancy
  • Irregular bleeding related to contraceptive pill
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2
Q

What are the common causes of hyperprolacinaemia?

A
  • Physiological (pregnancy, breastfeeding, stress)
  • Tumours
  • Idiopathic hypersecretion
  • Drugs
  • Hypothyroidism
  • Ectopic prolactin secretion
  • Chronic renal failure
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3
Q

Which drugs are associated with hyperprolactinaemia (due to DA antagonistic effects)?

A
  • Metoclopramide
  • Phenothiazines (e.g. chlorpromazine, prochlorperazine, thioridazine)
  • Reserpine
  • Methyldopa
  • Omeprazole, ranitidine, bendrofluazide (rare associations)
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4
Q

What investigations should be carried out when investigating infertility?

A
  1. Day 21 progesterone
  2. Semen analysis
  3. Tubal patency testing (laparoscopy and dye test, hysterosalpingogram or hysterosalpingoconstrastsonography [hyCoSy])
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5
Q

What are the causes of secondary amenorrhoea?

A

Hypothalamic:

  • Chronic illness
  • Anorexia
  • Excess exercise
  • Stress

Pituitary:

  • Hyperprolactinaemia
  • Hypothyroidism
  • Breast-feeding

Ovarian:

  • Polycystic ovarian syndrome
  • Premature ovarian failure
  • Iatrogenic (e.g. chemotherapy, radiotherapy, oophorectomy)
  • Long-acting progresterone contraception

Uterine:

  • Pregnancy
  • Asherman’s syndrome
  • Cervical stenosis
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6
Q

What are the causes of post-menopausal bleeding?

A
  • Endometrial cancer (should be default suspected diagnosis until proven otherwise)
  • Endometrial/endocervical polyp
  • Endometrial hyperplasia
  • Atrophic vaginitis
  • Iatrogenic (e.g. anticoagulants, intrauterine device, hormone replacement therapy)
  • Infective (e.g. vaginal candidiasis)
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7
Q

What are the causes of dysmenorrhoea?

A
  • Idiopathic
  • Premenstral syndrome (PMS)
  • Pelvic inflammatory disease
  • Endometriosis
  • Adenomyosis
  • Submucosal peduculated fibroids
  • Iatrogenic (e.g. intrauterine contraceptive device [IUCD] or cervical stenosis after large-loop excision of the transformation zone [LLETZ])
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8
Q

What are the causes of post-coital bleeding in young women?

A
  • Cervical ectropion
  • Chlamydia or other STIs
  • Cervical malignancy
  • Complication of COCP
  • Endocervical polyp
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9
Q

What does an STI screen consist of?

A
  • Endocervical swab for chlamydia
  • Endocervical swab for gonorrhoea
  • High vaginal swab for trichomonas
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10
Q

What are the causes of recurrent miscarriages?

A
  • Parental chromosomal abnormalities (e.g. balanced translocation)
  • Antiphospholipid syndrome
  • Other forms of thrombophilia (e.g. activated protein C)
  • Uterine abnormality (intracavity fibroids, uterine septum)
  • Uncontrollable diabetes or hypothyroidism
  • Bacterial vaginosis (usually associated with pregnancy loss in 2nd trimester)
  • Cervical weakness (associated with 2nd trimester loss)
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11
Q

What hormonal tests should be performed when investigating female ovarian cycle integrity?

A
  • Day 2-5 LH - Normal range 1-11 IU/L
  • Day 2-5 FSH - Normal range 0.5-14.5 IU/L
  • Day 21 progesterone - Normal range >30 nmol/L
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12
Q

How should fluid overload secondary to transcervical resection procedures be managed?

A
  1. Monitor electrolytes and blood gases closely
  2. Fluid restriction
  3. Potassium supplementation if hypokalaemic
  4. ECG monitoring
  5. Diuretics
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13
Q

Under which social circumstances could an individual/couple regret a previous decision for sterilisation and thus should be discussed in detail?

A
  • Death of a child
  • Break-up of current relationship and desire to have children with a new partner
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14
Q

What technical aspects of female sterilisation needs to be considered before the procedure is carried out?

A
  • Sterilisation should be considered a permanent procedure. Success rate of reversal is <60%
  • Up to 10% of women who have been sterilised later regret their decision
  • Failure rate of laparoscopic sterilisation procedure is 2%
  • If there is pregnancy following sterilisation, there is significantly increased risk of ectopic
  • Complications associated with the procedure itself include: Bleeding, infection, injury to bowel or blad- der or blood vessels (3 in 1000 risk of significant harm), thrombosis and anaesthetic complications
  • There is a chance laparoscopic sterilisation may be technically impossible during operation, in which case it would need to be converted to open operation
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15
Q

What alternatives are there to laparoscopic female sterilisation?

A

Transcervical hysterscopically performed sterilisation involves insertion of flexible inserts into fallopian tube hysteroscopically, which induce fibrotic reactions that block the tubes within 3 months (need confirmation by hysterosalpingography)

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16
Q

What are the complications associated with insertion of IUD?

A
  • Uterine perforation
  • Device migration into peritoneal cavity
  • Pelvic inflammatory disease
  • Expulsion of device (usually with next period)
17
Q

What are the differentials for lost IUS thread?

A
  • Migration of device into peritoneal cavity
  • Expulsion of device
  • Initial misplacement if the device
18
Q

What are the causes of pelvic pain in early pregnancy?

A
  • Corpus luteum
  • Ectopic pregnancy
  • Miscarriage
  • Ovarian cyst
  • Urinary tract infection
  • Renal tract calculus
  • Constipation
  • Appendicitis
  • Unexplained pain
19
Q

In early pregnancy, what is the normal rate of hCG rise?

A

>66% every 48hrs

20
Q

What are the risks associated with using crack cocaine during pregnancy?

A

Crack cocaine use is associated with placental abruption and hence increased risk of perinatal death or prematurity. It is also known to cause intrauter- ine growth restriction by way of arterial vasoconstriction

21
Q

What are the risks associated with use of heroin in pregnancy?

A

Opiates are not teratogenic but are associated with intrauterine growth restric- tion and premature delivery.

22
Q

What are the risks associated with use of cannabis during pregnancy?

A

Cannabis is not known to have specific risks in pregnancy, but the tobacco use associated and the possibility of other associated drug use makes it an important risk factor.

23
Q

What are the risks associated with use of tobacco during pregnancy?

A

Tobacco use is associated with fetal growth restriction and low birth weight. There is also the risk of respiratory disease in the infant from passive smoking

24
Q

What are the components of the combined screening for Down’s syndrome?

A
  • Pregnancy-associated plasma protein-A (PAPP-A) - Decreased in Down’s
  • Nucal translucency - Increased in Down’s
  • Free beta human chorionic gonadotropin (hCG) - Increased in Down’s
25
Q

What are the diagnostic tests used for Down’s syndrome in-utero?

A

Chorionic villous sampling:

  • Performed 11 to 14 weeks’ gestation
  • Ultrasound guidance
  • Sample of placental tissue collected generally using needle inserted through the abdominal wall
  • Small risk of miscarriage (about 1 per cent) associated with the procedure
  • Inconclusive result in 1 per cent of cases (so amniocentesis then required)

Amniocentesis:

  • Performed any time from 15 to 16 weeks’ gestation
  • Ultrasound guidance
  • Sample of amniotic fluid collected using needle inserted through the abdominal wall
  • Small risk of miscarriage (about 1 per cent)

Cell-free fetal DNA:

  • This recently developed non-invasive diagnostic test detects cell-free fetal DNA in a sample of maternal blood from 10 weeks’ gestation. It is used to identify the common trisomies (21, 18, 13) and fetal gender
26
Q

What are the possible consequences of anaemia in pregnancy?

A

Fetal:

  • Low birth weight
  • Neonatal anaemia
  • Cognitive impairment

Maternal:

  • Antenatal symptoms (fatigue, fainting, dizziness)
  • Peripartum complications (haemodynamic compromise from extensive blood loss)
27
Q

What are the common causes of antepartum haemorrhage at term?

A

Maternal blood:

  • Bloody show (blood-stained cervical mucous from ruptured cervical vessels)
  • Bleeding placenta previa
  • Placental abruption
  • Cervical ectropion
  • Infection (e.g. candida)

Fetal blood:

  • Vasa previa
28
Q

What are the advantages of caesarean section compared to natural vaginal birth?

A
  • Predictable timing of delivery (unless labour occurs prior to the planned date of caesarean)
  • Avoidance of the need for an emergency caesarean, which has higher complication rates
  • Avoidance of the possibility of birth trauma to the baby, although the studies do not show a difference in incidence of hypoxic ischaemic encephalopathy or intra- cranial haemorrhage
  • Reduction in the chance of pelvic floor weakness (although this occurs in part due to pregnancy itself and therefore incontinence and prolapse are not completely avoided by caesarean section)
  • Lower rate of immediate postpartum haemorrhage
  • Lower rate of injury to the vagina and perineum
29
Q

What are the disadvantages of caesarean section compared to natural vaginal birth?

A
  • Increased rate of admission of baby to neonatal care unit
  • Greater pain following abdominal surgery
  • Possibility of intraperitoneal trauma to bowel or bladder at surgery
  • Increased risk of wound infection
  • Possibility of thrombosis (although this is minimized by the use of heparin prophylaxis)
  • Longer hospital admission
  • Increased likelihood of needing caesarean section in a subsequent pregnancy
  • Very small increase in chance of hysterectomy for postpartum haemorrhage or of cardiac arrest
30
Q

What do recent guidelines state about offering caesarean section without medical grounds?

A
  • Women who do not want to give birth naturally due to mental health or anxiety problems should be referred to specialist for support and counselling
  • If despite support and counselling the woman still insists on caesarean section, it may be offered
31
Q

What are causes of stillbirths/intrauterine death?

A

Maternal:

  • Diabetes
  • Infection (e.g. parvovirus, listeria)
  • Thrombophilia (e.g.antiphospholipidsyndrome)

Fetal:

  • Chromosomal abnormality (e.g.trisomy)
  • Other genetic abnormality (e.g. Gaucher’s disease)
  • Haemolytic disease
  • Cord incident (e.g. ‘knot’ in cord)

Placental:

  • Placental abruption
  • Uteroplacental insufficiency (e.g. secondary to pre-eclampsia)
  • Postmaturity

Unexplained

32
Q

What is the definition of fetal bradycardia as seen in CTG and what are the possible causes?

A
  • Fetal bradycardia on CTG is defined as fetal heart rate dropping <100/min
  • Though in many cases the cause is unknown, common causes include:
  1. Placental abruption
  2. Uterine rupture
  3. Maternal hypotension (e.g. after epidural insertion)
  4. Bleeding vasa praevia
33
Q

How should sudden decelerations seen on CTG be managed?

A

Rule of 3:

  1. If the deceleration has not recovered at 3 min call for help.
  2. If the deceleration has not recovered at 6 min transfer to theatre and prepare for immediate delivery.
  3. If the deceleration has not recovered at 9 min deliver immediately by category one (‘crash’) caesarean section (if immediate instrumental vaginal delivery is not pos- sible). This will usually involve general anaesthetic unless an effective spinal anaesthetic is achievable by an experienced anaesthetist in a similar time.
34
Q

What are the advantages and disadvantages of inducing labour when a fetus is overdue?

A

Advantages:

  • Reduced risk of stillbirth associated with prolonged pregnancy – the relative risk of stillbirth from induction of labour after 41 weeks (versus expectant management) is 0.30.
  • Some women express the wish to deliver soon after 40 weeks because of discomfort, anxiety or social reasons.

Disadvantages:

  • Uterine hyperstimulation (1–5 percent).
  • Failed induction (15 percent) – may require repeat induction process or caesar- ean section.
  • Induction of labour can be a prolonged process – sometimes taking more than 24 h for labour to be established.
  • Approximately 500 women need to undergo induction of labour to prevent one baby death.
  • There is some evidence that induced labour is associated with greater analgesia requirement than spontaneous labour.
35
Q

How should urate levels be interpreted?

A

Urate levels (in mmol/L) should be no higher than the current gestational week

36
Q

What are long-acting reversible contraception methods?

A
  • Copper coil
  • Contraceptive vaginal ring
  • Contraceptive implant
  • Contraceptive depot injection
  • Levonorgestrel-containing intrauterine system (IUS)
37
Q

In a woman on the COCP who experiences breakthrough bleeding, what important information from the history needs to be obtained?

A
  • Has she been missing any pills?
  • Has she taken any other medication which might interfere with the COCP (e.g. anti- biotics, enzyme inducers)?
  • Has she had any intercurrent illnesses causing diarrhoea or vomiting?
  • Has she ever had any sexually transmitted infections, or been investigated for this?
  • How many sexual partners has she had in the last 3 months?
  • Has she recently changed the COCP that she uses?
38
Q

What are the differentials for breakthrough bleeding in women on the COCP?

A

COCP-related causes:

  • Poor compliance
  • Intercurrent infection causing poor pill absorption
  • Drug interactions, reducing the COCP efficacy
  • Inadequate oestrogen component for that woman
  • Pregnancy

Unrelated causes:

  • Cervical ectropion
  • Cervical carcinoma
  • Sexually transmitted infection – chlamydia, gonorrhoea, trichomonas
  • Candidal vaginitis
  • Cervical or endometrial polyp
  • Bleeding disorder (rare)

Clinical school: 100 cases (3 decks)

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