2020CQS Flashcards
Criteria for a diagnosis of primary ovarian insufficiency
Age less than 40
Oligo/amenohorroea for 4 months
2 x FSH in menopausal range at least 4 weeks apart
4 conditions that present with vulval itch and a rash
Lichen scelrosis Psoriasis Chronic vulvovaginal candidiasis Tinea cruris Lichen simplex chronicus Vulval dermatitis
Medical management of vulval dermatitis
Potent steroid ointment up to 4 weeks e.g. Avantan
Polonged treatment with weak steroid e.g. 1% hydrocortisone
Treat superinfection if present
Review back and consider alternate diagnosis
Consider antihistamine for itch
When to remove IUD PID
No response to treatment 48-72 hours
Patient choice
Swabs grew actinomyses
IUD malpositioned on USS
Long term sequalae to PID
Fitz Hugh Curtis syndrome RUQ pain and perihepatitis
Infertility 10% more likely chlamydia and delay in treatment
Chronic pelvic pain 1/3
Ectopic pregnancy 7.8%
Define primary dysmenorrhoea
Cramping and lower abdominal pain associated with menses and no evidence of pelvic disease
Define secondary dysmenorrhoea
Cramping pain associated with menses due to disease e.g. Endometriosis
Stage 4 endometriosis
Complete obliteration of pouch of Douglas
Deep peritoneal endometriosis >3cm
Endometerioma >3cm
Dense adhesions to >2/3rds ovary and tube
Bladder/bowel involvement
Increased risk of recurrence in BOT
Macropapillary or serous subtype
Stroma invasion
Evidence of peritoneal/extra ovarian implants
How to calculate an RMI
USS features × menopausal status (1 pre 3 post) x CA125 USS 1 feature = 1 & 2+ features = 3 Multiloculated Solid areas Bilateral lesions Ascites Intra-abdominal mets RMI >200 requires further investigation 75% chance of having a cancer
Risk of ovarian cancer
1.2% in general population 3% 1 1st degree relative 44% BRCA 1 17% BRCA 2 15% Lynch
Risk of ovarian cancer
1.2% in general population 3% 1 1st degree relative 44% BRCA 1 17% BRCA 2 15% Lynch
Balloon vs prostaglandins for induction
No difference in NVD in 24 hours
Reduced risk of hyperstimulation
Reduced serious neonatal morbidity and perinatal death
Slight reduction in NICU
How to collect GBS swab
Anorectal and vaginal rectal increases detection by 10%
Cultured in an enriched median so state GBS prophylaxis otherwise 50% false negative
Take 35-37 weeks ie 3-5 weeks before birth as GBS carriage can fluctuate
Sensitivities should be requested for penecillin allergy to avoid unnecessary vancomycin use.
How much can EOGBS be reduced by IAP
80%
What is EOGBS
Neonatal sepsis due to group B streptococcus with onset in the first 7 days following delivery
In shoulder dystocia when should you perform an episiotomy
To enable access of the operator’s hand for internal manoeuvres
What to avoid doing to reduce brachial plexus injury
Excessive downward or lateral traction on the fetal head
Rapidly applied jerking motion on fetal head
Fundal pressure
Common genetic conditions and their carrier frequencies
Cystic fibrosis 1:25-35
Fragile X premutation 1:332
Spinal muscular dystrophy 1:50
Genetic basis for cystic fibrosis inheritance
CF is caused by one of over 1000 mutations to the cystic fibrosis transmembrane conductance regulator gene.
This gene is inherited in an autosomal recessive manner. This means in order to have an affected child both parents need to be carriers.
For such a couple their risk of an affected child is 25% and risk of their child being a carrier is 50%.
Delancey levels of support (soft tissue structures which provide structural integrity to the cervix and vagina to prevent pelvic organ prolapse).
Level 1 - utero-sacral and cardinal ligaments
Level 2 - Endopelvic fascia
Level 3 - The perineal membrane and urogenital diaphragm
Level 1 is the most relevance when performing a vaginal hysterectomy as they provide elevation of uterus which needs to be dissected in order to allow sufficient descent and access to the other pedicles.
Contraindications to vaginal hysterectomy
Suspected or confirmed malignancy
Lack of descent of uterus and cervix
Inadequate access e.g. increased BMI, narrow pelvis
Large uterus fibroids, adenomyosis
Mullerian abnormality could be ureter anomaly too
History of severe endometriosis
History of severe pelvic infection
History of multiple pelvic surgeries
Requirement for concurrent adnexal procedure
Anatomical location of injury to the ureter at hysterectomy
Distal ureter at level of uterines when taking pedicle
IP ligament particularly when taking tubes and ovaries
Vaginal cuff closure at the point where ureters enter bladder
When reflecting the anterior leaf of broad ligament as ureter passes deep in posterior leaf (laparoscopic)
Principles of repair of cystotomy
Identify location and extent of injury +/- ask urology
Communicate to OT team
If injury >1cm surgically manage: 2 layer closure with absorbable suture e.g. Vicryl, non locked and tension free.
Check integrity: Backfill with methyline blue
Consider cystoscopy +/- indigo carmine: if suspicion of ureter damage e.g. posterior bladder near trigone.
IDC 7-14 days: allows ustures to heal without being distended
Consider abx: If had prophylaxis likely not needed but check local policy
CT Urigram prior to TROC: ensure bladder has healed.
Drugs which increase NTDs
Valproate
Carbemazepine
Trimethoprim
recurrence of NTD in subsequent pregnancy 1 child affected
2-4% vs 1:1000 background risk
USS features of spina bifida
Lateral displacement of spinal pedicles
Lemon head
Banana cerebellum
Separation of posterior ossification centres in transverse plane with skin defect and exposure of neural contents
Type 1 FGM
Partial or total removal of the clitorus
Type 2 FGM
Partial or total removal of clitorus and labia minora +/- labia majora excision
Type 3 FGM
Narrowing of vaginal orifice with a covering seal by cutting or apopositioning of the labia +/- removal of clitorus
Obstetric and non obstetric causes of collapse
Obstetric: Eclampsia, peripartum cardiomyopathy, uterine rupture, uterine inversion.
Non-obstetric: Vasovagal, MI and anaphylaxis
Pathophysiology of AFE
Dyspnoea and hypoxia - Amniotic fluid enters maternal lung circulation causing pulmonary congestion.
Hypotensive shock - Decreased coronary perfusion leads to decreased cardiac output adding to it pulmonary congestion.
DIC - amniotic fluid entering maternal circulation leading to thromboplastin release.
Physiological effect of pregnancy on thyroid
- HCG and TSH structurally similar therefore HCG has a weak thyroid stimulating effect. Increasing T3 + T4 which then suppress TSH.
- Circulating thyroid binding globulin increase more than hormone level therefore slight fall in free hormone number.
Iodine supplementation supplementation importance
Iodine is a constituent of thyroid hormones and fetus is dependent on maternal thyroid hormones for first 12 weeks.
After this they rely on maternal iodine to synthesize their own.
Pregnancy is a state of iodine deficiency as an increase in eGFR increases excretion as well as increase in demand from fetus.
Hypothyroid effects on fetus
Low birth weight
Low IQ
Stillbirth
Fetal goitre
Hypothyroid effects on pregnancy
PET
Abruption
Anaemia
PPH
Evidence for oxytocin for slow progress
No difference in c-section rate
No adverse effects to mum or baby
Reduction in time to delivery by 2 hours
Does not increase vaginal delivery rate
WHO recommends pregnancy interval of 24-36 months why?
Reduction in congenital anomalies Reduction in SGA Reduction in PTB Reduction in stillbirth Possible association with autism
Major components of semen analysis and parameters
Insure sample was taken with 3 days of abstinence and sent to lab within 1 hour
Volume >1.5ml
Concentration 15million/ml
Total sperm count >39 million per ejaculate
Normal morphology 4%
Total motility 40%
Progressive forward motility 32%
If abnormal repeat 3 months 50% of repeats are normal.
When should pregnant women start suppressive HSV therapy
From 36 weeks valaciclovir 500mg PO, Aciclovir 400mg PO TDS Cat B
Vertical transmission of HSV 95% comes from direct exposure, 5% transplacental explain risk of transmission with primary and secondary infections
Primary 25-50% (higher if acquired within 6 weeks of delivery) perform c-section within 4 hours of SROM
Secondary no lesion 0.1%
Secondary active lesions 1-3%
15% of women with presumed primary actually have secondary.
What is the evidence for progesterone and unexplained recurrent pregnancy loss
Cochrane review - supports use with a RR of 0.73 for pregnancy loss & RR 1.07 for live birth. Both confidence intervals touched 1 therefore possibly no improvement.
PROMISE looked at livebirth >24 weeks did not find a difference.
No studies have found any harm with using progesterone.
Criteria for referral for GTN
Plateau +/- 10% that lasts for 4 measurements over a period of 3+ weeks
Rise in HCG on 3 consecutive weekly measurements
HCG >20,000 >4weeks after ERPOC
Evidence of mets brain, liver, GI tract or >2cm on chest x-ray
What percentage of stage 3 ovarian high grade serous carcinomas are sensitive to chemotherapy
80%
Antiphospholipid syndrome clinical criteria
Vascular thrombosis
Pregnancy morbidity:
- 1+ unexplained death of morphologically normal fetus after 10 weeks
- 1 premature birth <34 weeks due to PET, abruption
- 3+ unexplained consecutive miscarriages
Antiphospholipid laboratory criteria:
Present on 2 occasions 12 weeks apart
- Lupus anticoagulant
- Anticardiolipin antibody
- Anti B2 glycoprotein 1 antibody
Why is CA125 not a good screening tool
Numerous benign conditions which cause it to rise giving false positives e.g. TOA giving sensitivity and specificity.
It is only risen in 50% of early stage high grade serous epithelial cancers and 80% of advanced stage cancer.
Only risen in serous epithelial cancers therefore can’t identify mucinous, germ cell or sex cord stromal.
Cancer genetics and risk of ovarian CA
BRCA 1 44%
BRCA 2 17%
Lynch 10-15%
Ovarian cancer and subtypes
High grade serous 70% Clear cell 10% Endometroid 10% Mucinous 3% Low grade serous <5%
Placitexal for ovarian cancer MOA & side effects
Taxane chemo - suppress microtuble detachment in M phase.
Shared side effects: bone marrow suppression causing anaemia and SOB.
Neutropenia which can increase susceptibility to infections.
Specific side effect - peripheral neuropathy causing paresthesia
Cisplatin for ovarian cancer MOA & side effects
Platinum chemo - crosslinking DNA strands
Shared side effects: bone marrow suppression causing anaemia and SOB.
Neutropenia which can increase susceptibility to infections.
Specific side effect: hearing loss and tinnitus
Long term management of ovarian cancer post surgery and chemo
Frequency - 3 monthly for 2 years, 6 monthly for 3 years, annual after.
MDT - GONC, nurse + psychologist
Recurrence - identify symptoms e.g. abdo pain, nausea, bloating and TVUSS + Ca125 6 monthly. IF rising Ca125 CT-CAP.
Side effects from chemo
Genetic screening
General health promotion - breast CA, cervical CA + CVS risk
RANZCOG stance on alcohol during pregnancy & why
ABSTINENCE
Passes through placenta freely and fetus cannot metabolise it
Alcohol can damage fetal cells and impair placental blood flow, leading to hypoxia.
There is no safe threshold known
What is fetal alcohol syndrome?
Characteristic facial features: short palpebral folds, thin vermillion, smooth philtrum.
Growth retardation
CNS structural or functional abnormalities
Confirmed or suspected prenatal alcohol exposure
Why routinely screen all women for mental health
Reduces stigma
Early identification of at risk women to allow increased supports and early treatment
Maternal suicide is number 1 causes of maternal death in NZ 26% (2017)
What is baby blues
During first 3-10 days
Low mood mild, self limiting
Typically lasting 48 hours
Diagnostic criteria of PND
Must exhibit >5 symptoms for >2 weeks and have impact on their capacity to function. Must have 1 of these 2: Depressed mood Anhedonia Others: significant change in weight/appeptite sleep disturbance fatigue or loss of energy feelings of worthlessness and guilt Reduced concentration Recurrent thoughts of death or suicide
What is the Edinburgh post-natal depression score
10 point self reported questionnaire about mood and self perception over the last 7 days.
Identifies women who require further assessment, not diagnostic
Cut >/= 13 has +ve predictive value 57% and -ve predictive value of 99%
If Q10 +ve RE:suicide take action
Puerperal psychosis risk factors
1-2:1000 background risk
Past hx 50%
Bipolar 2%
Puerperal psychosis onset and symptoms
50% by day 7, 75% by day 16 and 95% by day 90
Kaleidoscope presentation - first insomnia, agitation and odd behaviour then rapid progression to hallucinations and usually manic symptoms..
Benefits of continuing SSRIs in pregnancy e.g. Sertraline and Escitalopram
Category C - reversible fetal harm, no anomaly risk
- Reduces psychosis
- Reduces suicide
- Reduces perinatal depression
SSRIs in pregnancy e.g. Sertraline and Escitalopram
Category C - reversible fetal harm, no anomaly risk
Further safety profile in pregnancy
increased miscarriage risk within 20 weeks
Neonatal risk of convulsions, persistent pulmonary hypertension, RDS and abstinence syndrome.
Maternal PPH
Breastfeeding low levels in breastmilk safe to continue
Pregnancy effects of Tricyclic antidepressants e.g. Nortriptyline
No increase in structural anomalies Increased risk of HTN and PET Neonatal withdrawal PPH risk Low levels in breastmilk safe
Lithium in pregnancy
Ebstein’s anomaly (abnormal tricuspid valve)
Lithium toxicity especially PP signs are blurred vision, GI disturbance, muscle weakness, tremor, convulsions
Monitor blood levels likely increase dose
Lithium and breastfeeding
DO NOT BREASTFEED
Can cause kidney and thyroid problems to the neonate
Venlafaxine in pregnancy SNRI
Poor neonatal adjustment Persistent pulmonary hypertension BP disorders maternal PPH Breastfeeding dose transferred high monitor fetus for sedation and poor weight gain
When does the zygote split in twin pregnancies
DCDA dizygotic or monozygotic splits within 3 days
MCDA monozygotic splits day 3 - 8
MCMA monozygotic splits day 9 - 12
When is best time to determine chorionicity
First trimester ~10 weeks
Sensitivity and specificity 98-100%
What signs can you look for to determine chorionicity
DC - Lambda sign
Two seperate placental masses
Thick septal edge
MC - T sign
Wispy thin membrane
No intervening layer of chorion
When to deliver twins
MCDA 36-37 weeks
DCDA 37-38 weeks
What is twin-to-twin transfusion (occur in 10-15%)
One twin receives more blood due to unidirectional flow along large AV anastamoses.
Donor - oligo, IUGR and abnormal UAPI.
Recipient - Poly, cardiac dysfunction +/- failure
What is twin-anaemia-polycythemia syndrome (5%)
Small AV anastamoses unidirectional flow but very slowly. Leaving one twin anaemic and one twin polycytheamic.
What is twin reversal arterial perfusion sequence <5%
PResence of live twin and acardiac twin. The live twin pumps blood through both twins an leads to high output cardiac failure.
What is selective IUGR in MC twins
Unequal placental sharing with fetal weight discordance >20%
What additional scans would you perform for monochorionic twins
Early anatomy 18 weeks +/- echo: aneuploidy screening is less sensitive and increased risk of congenital heart disease.
Scan for MCA PSV from 20 weeks to look for fetal anaemia TAPs
Fortnightly growth scans from 16 weeks to look for growth discordance and LV, bladder and stomach filling (TTS) and both babies UAPI (TTS)
Antihospholipid prevelance in recurrent miscarriage
10-20% vs 2% general population
Why would karyotype be performed in recurrent miscarriage?
Peripheral blood karyoptype of both partners for any unbalanced chromosomal abnormalities present in 2-5% of couples.
If one were identified it can be addressed with PGD, adoption, donor gametes.
If not present couple can be reassured more likely to have success with next pregnancy.
Tests to distinguish MRKH and CAIS
Karyotye 46XY in CAIS, 46 XX MRKH
LH - levels very high CAIS
Testosterone - high CAIS
Medical issues associated with CAIS
Germ cell tumours Gender dysmorphia Infertility Short vaginal length CVD and reduced bone density once gonads removed
Histological factors that increase recurrence in BOT
Serous
Macropapipillary
Peritoneal or extra ovarian depositis
Stroma microinvasion
Describe the act of voiding
Stretch receptors reach critical level and pass information to pontine micturition centre.
Once PMC activated sends parasympathetic signals which release actelycholine and cause detrouser contraction.
Inhibitory signals to straited muscle of the urethra and bladder smooth muscle causing them to relax.
Detrouser is then inhibited by sympathetic system and release of norepinephrine/epinephrine.
Do Urodynamics for stress incontinence in the following circumstances
Mixed type or type unclear
Symptoms suggestive of voiding dysfunction
Anterior or apical prolapse
A history of previous surgery for stress incontinence
6 elements of Urodynamics
Uroflowmetry Post void residual residual LEak point pressure Pressure flow study Urethral pressure profilometry Cystometrogram
How to calculate detrouser pressure
Pressure catheter in bladder = Pves
Pressure catheter in rectum = Pabd
Pdet = Pves - Pabd
Laparoscopic risk of complication
Any 1%
Major 0.5%
Describe cutting waveform in electrosurgery
Wave is simple and continuous when switched on
Lower voltage
Describe coagulation waveform in electrosurgery
Modulated current. Sinusoidal non-continuous 5%:95% modulated
Pulses of current flow alternate with peroids of no flow causing a heating effect
Higher voltage
Types of injury from electrosurgery
Iatrogenic
Lateral thermal spread
Insulation failure
Direct coupling - active electrode and another instrument that acts as a conductor
Return electrode - of poorly applied local burns
Capacitive coupling - electric current is transferred from one conductor through intact insulation into adjacent conductive materials with direct contact.
USS features of adhenomyosis
Sensitive 53-89%
Specific 50-99%
Venetian blind Nodules which extend from endometrium to myometrium Irregular myometrial junction Tiny echoic myometrial cysts Increased vascularity on doppler
MRI in adenomyosis
Thickening of the transition zone >12mm
Can diagnose co-existing pathology e.g. fibroids or endometriosis
Sensitivity 77-88%
Specificity 89-93%
4 proven clinical benefits of HRT
Reduction in symptoms of vulvovaginal atrophy
Reduction in vasomotor symptoms
Reduction in osteoporotic fractures and osteoporosis
Reduction in CVD (if started <60 and within 10 years of menopause)
Components of normal vaginal discharge
Vaginal flora
Epithelial cells
Mucinous secretions
Sweat
Amsel’s criteria for BV diagnosis must have 3 out of 4
Homogenous vaginal discharge
+ve whiff test
Clue cells on wet mount
pH >4.5
What strains of HPV does Gardisil 9 protect against
6, 11, 16, 18, 31, 33, 45, 52, 58
Benefits of Gardisil 9
Potentially prevents 95% of cervical cancer
95-100 efficacy against strains in the vaccine and therefore increased potential for cancer prevention (cervix, vulva, vagina, anal, oropharynx, penile)
Reduction in under 30s being diagnosed with high grade by 75%
Safe 1-3 per million chance of anaphylaxis
Limitations Gardisil 9
Is not a treatment - effective against strains of HPV that woman has not been exposed to.
Requires multiple dose <15yo x2, >15yo x3
59% reduction in genital warts
ECG changes in pregnancy
Sinus tachycardia
Left axis deviation
Atrial and ventricular ectopic beats
Q wave inverted/flattened T wave in lead III
What is New York Heart Association Classification
Classification of functional impairment
Class I No limitation on physical activity
Class II Slight limitation
Class III marked limitation but asymptomatic at rest
Class IV symptomatic at rest
What is CARPEG II
Points based scale for risk prediction for a significant cardiac event in pregnancy. Score 1 = 5%, 3 = 15% and 5+ = 41% Biggest predictors: Prior cardiac event or arrhythmia Baseline NYHA 3-4 or cyanosis Mechanical valve
What heart conditions are WHO class I No detectable increased risk
Uncomplicated PDA
MV prolapse
Repaired simple lesions e.g. ASD, VSD, PDA
Isolated atrial or ventricular ectopic beats
What conditions are in WHO Class IV
Extremely high risk pregnancy contraindicated
Severe mitral stenosis Symptomatic severe aortic stenosis Bicuspid aortic valve with ascending aortic diameter >5cm Marfan's syndrome with aorta >4.5cm Ventricular dysfunction LVEF <30% NYHA III - IV Fontan circulation Signifcant pulmonary arterial HTN
Effects of warfarin in pregnancy
Nasal hypoplasia
Skeletal abnormalities including short limbs and digits
IUGR
Cardiac anomalies
What heart conditions should be anticoagulated
Metal heart valves Pulmonary hypertension Eisenmenger's syndrome Caridomyopathy Arrhythmias Coronary artery disease
Outline mitral stenosis management in pregnancy
B-blockers Anticoagulant ~10% get AF Avoid syntometrine Short second stage +/- forceps Early epidural Strict fluid balance IV frusemide if needed in 2nd stage
Define placenta acreta, increta, percreta
acreta - partial or complete absence of decidua, placenta adherent to superficial myometrium
Increta villi invade into myometrium but not through
Percreta - villi invade through full thickness of myometrium and serosa.
Features of morbidly adherent placenta on USS
Loss of clear zone Bridging vessels Sub placenta hypervascularity Loss of visualisation of myometrium increased placenta lacunae MRI 24-28 weeks for invasion
how to calculate BMI
BMI = kg/m2
Height and weight from booking visit
Obesity risk and quantifications
Hypertension 10%
GDM 7%
C-section 52%
VTE 10 times
Chicken pox maternal sequalae
Hepatitis Encephalitis Pneumonia 4-13% mortality if primary infection in pregnancy <96 hours VZIG for mother Alsways give Aciclovir
Transmission rate of chicken pox VZV
<12 weeks 0.55%
12-28 weeks 1.5%
>28 weeks 0%
Significant exposure is same house, face to face 5 mins or same room 1 hour.
Define fetal hydrops
Extravascular fluid accumulation The diagnosis requires 2 or more: Ascites Polyhydramnios Subcutaneous oedema Pericardial effusion Hepatosplenomegaly
6 causes of fetal hydrops
HDFN Twin-to-twin transfusion Parvovirus Structural anomalies cardiac Chromosomal anomalies T18, T13 & Turner's Metabolic Pyruvate kinase deficiency Arrhythmia heart block thyrotoxicosis
Effect of pregnancy on diabetes
Hypoglycemia
Increase in insulin requirements particularly week 28-32
DKA - give meter
Retinopathy progression 2 fold 1st appointment & 28 weeks screen
Nephropathy progression in pregnancy
PET 30% increase risk
Obstetric intervention 24% SVD
Effect of diabetes on fetus
Miscarriages’
Inheritance T1DM 6%, T2DM 10-15%
Congenital anomalies aim HbA1c <48 and give high dose folic acid
Macrosomia - post parandials >6.7
Preterm labour - twice as likely
Perinatal morbidity 30% risk of NICU admission vs 10%
Still birth - chronic hypoxia caused by fetal hyper-insulinaemia causing macrosomia as it is a growth factor and therefore increased O2 requirements add to this placental vasculopathy and insufficiency particularly towards the end of pregnancy the demand cannot be met causing stillbirth.
Why is Rubella vaccine not safe in pregnancy
Live attenuate vaccination
Theoretically cross the placenta and cause infection in the fetus.
Maternal shift away from TH1 cell mediated immunity therefore increasing the risk of acquiring this infection through the vaccine in pregnancy.
Avoid pregnancy for 28 days flowing the vaccine.
When to give whooping cough vaccine
From 28-34 weeks in each pregnancy protects neonate for 6 weeks until their own vaccine.
Importance and benefits of flu vaccine in pregnancy
50-80% risk reduction in influenza
40% risk reduction in hopsital admission
Pregnant women 5 times more likely to end up in ICU and if have underlying co-morbidities 5% die.
Can have fetal impacts birth defects, miscarriages, SGA, PTB or IUFD.
Name 2 obstetric and 2 anaesthetic interventions to reduce the risk of instrumental birth with epidural
Positioning in second stage - upright or lateral to enhance descent and rotation of the fetal head.
Passive descent - decreased duration of pushing and increased rates of SVD.
Patient controlled epidural
Combination LA/opiate - reduces motor block
Transmission of pain
1st stage via spinal nerves T10-L1
2nd stage via pudendal nerves S2-S4
In MC twins incidence of 1 twin dying and consequences
1% chance Consequences - fetal demise 15% - Preterm birth 70% - Neurological impairment 30% Offer MFM and MRI 6 weeks after event cannot prevent by delivery.
Ace-i effects on fetus
Oligohydramnios, renal impairment, premature closure of the ductus in fetus. Oligo is a/w limb contractures and lung hypoplasia
What is a cephaloheamatoma
Collection of blood underneath periosteum limited to that specific bone (does not cross suture line). Caused by rupture of vessels beneath periosteum.
What is subgaleal heamatoma
Emissary veins are sheared or severed. Blood accumulates in the space betwee periosteum of the skull and aponeurosis. No boundaries to contain blood loss. MAssive blood volumes can be lost. Diffuse fluctuant swelling of head that may shift with movement.
Technical aspects of instrumental which increase risk of SGH
Cup placement too anterior <3cm from anterior fontanelle
Cup placement too lateral
Application of traction without contraction
Prolonged contractions >3 contractions
Prolonged cup application >20 mins
>2 cup pop offs
LMWH vs UFH
LMWH allows once daily dosing and less likely to need routine anti Xa assays
Lower risk of osteoporosis and fractures
Lower incidence thrombocytopenia
V/Q scan benefits in pregnancy
Less maternal radiation exposure Better for distal PE High -ve predictive value Fewer non diagnostic scans in pregnancy 3-24% Should have CXR and leg USS prior
Evidence based ways to reduce infection post c-section
Pre-op abx 1st generation cephlasporin 30-60 mins prior to skin incision. RR 0.5 for post-op maternal infections.
Vaginal cleansing - 10% povidine iodine for 30 seconds RR 0.5 for PP endometritis, fever and infection - Cochrane 2018.
Avoid MROP associated with increase in infection Cochrane 2018.
Closure of subcutaneous layer >2cm to reduce hematoma and seroma and subsequent infection
Major risk factors for SGA
Age >40 Previous SGA (x3) Previous stillbirth (x6.4) Maternal SGA Smoker >11/day Hypertension APLS Renal disease Diabetes with vascular disease
Dopplers and usefulness in timing of delivery
Umbilical artery:
Useful for all infants including preterm
AEDV deliver by 34 weeks C-section
Predictive of fetal acideamia and death
Middle cerebral artery:
Timing of delivery for term infants
Good risk stratification in woman with normal UAPI
Plan delivery by 38 weeks not useful in preterm decisions
Limited accuracy in predicting acideamia
Ductus venosus:
Delivery preterm <32 weeks
Equates well with survival free of neurological impairment as per TRUFFLE
Is last doppler to change
Has moderate predictive value in acideamia
4 maternal risks with renal transplant and pregnancy
No averse outcomes if Cr<100
Chance of graft rejection 2%
VTE if nephrotic range PCR >300
Pre-eclampsia
GDM consider early screening if on steroid
3 effects on renal transplant has on pregnancy
IUGR (25% if mild, 60% severe)
Pre-term birth (30% mild, 90% severe)
Stillbirth
Mild Cr <125 Severe >180
5 intra-op complications of fully c-section
Fetal skull fracture Fetal intraventricular hemorrhage Tears in lower uterus Hemorrhage Urinary tract injury
5 interventions at fully c-section to minimise complication
Senior obstetrician present - a technically difficult delivery is anticipated
Elevation of fetal head with fetal pillow also reduces uterine angle extensions
Steady elevation of the fetal head by an experienced assistant
Tocolysis to relax uterus allowing more space to accommodate displacing the fetus upwards
Consider Trendelenburg for gravity to assist with disimpaction
Complications from abruption
DIC Acute renal failure Fetomaternal hemorrhage Fetal anaemia IUFD Maternal death
2 clinical end points associated with mortality in puerperal sepsis
Lactate >2mmol/L
Hypotension requiring vasopressors to maintain MAP >65mmHg
Define shock and list maternal signs
Inadequate tissue perfusion with reduced tissue perfusion with reduced oxygenation which can lead to cell death. HR >120 RR >30 BP <100 Urine <20ml/hr Confusion/agitation Sweaty, cold, clammy
Group A Strep Antibiotics
Gram +ve cocci of B-heamolytic streptococci group
Sensitive to penecillin e.g. BenPEn +/- Clindamycin
Penecillin allergy Cefazolin or Vancomycin
Sequential hormonal and ovarian physiology to produce ovulation
Follicular phase (Day 0-13)
Slowing rising levels of FSH & LH causes a growth of follicles.
As follicles grow they begin releasing oestrogens and a low level of progesterone.
Ovulation Day 14
High levels of oestrogen causes FSH and LH to rise rapidly then fall. Especially spike in LH causes ovulation of most mature follicle.
Premenstrual disorder characteristics
Content - mood (depression, anxiety) and somatic (bloating and lethargy)
Cyclicity - Symptom onset prior to menses nd resolve several days after (luteal phase)
Severity - Significant distress
Chronicity - Multiple menstrual cycles within past year
Treatments for Pre-menstrual disorder
SSRIs
COCP with drosperinone for ovulation suppression
GnRH analogues
Possible evidence for COCP without drosperinone, excercise and vitex agnus castus
Pharmacological MOA of Clomiphene
Selective estrogen receptor modulator
Blocks receptors in hypothalamus, interrupting negative feedback causing increase in FSH
Pharmacological MOA of Letrazole
Aromatase inhibitor
Works at ovarian level reducing oestrogen secretion. Meaning FSH is released by pituitary via negative feedback.
What is Ferriman-Gallway Score
Scoring system for hirsuitism
Density scored 1-4 at 11 different sites: upper lip, chin, chest, arm, upper back, lower back, thighs, pubic, stomach
0 - absence 4 - extensive
Normal score <15
When is expectant management for an ectopic appropriate
Clinically stable
Decreasing B-HCG initially less than 1500
A good candidate for methotrexate for ectopic have the following
Dose is calculated 50mg per m2 IM
Heamodynamically stable Low HCG <1500 but no more than 5000 No fetal cardiac activity Certainty no IUP Willingness to attend follow up No known sensitivity to Methotrexate (chronic liver disease, breastfeeding, immunodeficient, peptic ulcer disease) Mass <3.5cm
Hyperplasia no atypia progression to CA
<5% over 20 years
Needs 6 monthly sample till x2 -ve
Hyperplasia atypia progression to CA
8% after 4 years
TAH & BSO gold standard 43% have co-existent cancer on histology
Mirena causes regression ~90%
5 management principles for PPH
Recognition e.g. weigh loss Communication e.g. Call for help Resuscitation e.g. ABCs Monitoring and investigation e.g. Obs Management e.g. early transfer to OT if still bleeding.
FIGO exam recommendations for staging cervical cancer
Colposcopy EUA Endocervical curettage Hysteroscopy Cystoscopy Proctoscopy IV Urogram X-ray exam of lungs and skeleton Developed countries MRI, CT-TAP, CT-PET
Late complications of radiotherapy 3 months post
Urinary - Bladder fibrosis, UV & VV fistulas
GI - Chronic enteropathy, dysmotility
Vaginal - Sexual dysfuction, adhesions
Ovaries - Premature ovarian insufficiency
Bone and bone marrow - Insufficiency fractures
Skin - hyperpigmentation, telengectasia
Define puerperal sepsis
Dysregulated host response to infection resulting in organ dysfunction with onset within first 6 weeks postpartum
5 pathologies for anaemia in pregnancy
Nutritional deficiencies: Iron, B12, Folate Heamolysis: PET, HELLP, TTP Blood loss: APH, Heamorrhoids Underlying chronic illness: Renal, autoimmune Heamoglobinopathies Thalasseamia, sickle cell
Poor prognostic factors in uterine cancer
- Significant co-morbidities
- High stage >1b
- Increase myometrial invasion
- Vascular infiltration
- Tumour extension beyond the fundus
- Tumour >2cm
- Distant metastases
- High grade
- DNA aneuploidy
- Serous or clear cell histology
- Increasing age
How do you identify Lynch syndrome
3/2/1 principle
3 or more relatives with histological verified lynch cancers
2 generations
1 diagnosed under 50
Lynch common cancers are colon, endometrial, ovary, stomach
Define overactive bladder
A symptom complex of urgency +/- incontinence usually with frequency and nocturia in the absence of UTI or other obvious pathology.
Define urge incontinence
Involuntary leakage of urine accompanied by or immediately preceded by an urge to void which is unable to be deferred.
List possible complications with dermoid cysts
Torsion 10%
Rupture 4%
Malignancy 1%
Chemical peritonitis 0.2%
3 USS features of torsion
Ovary may be enlarged and appear heterogenous compared to contralateral ovary due to engorgement, oedema and/or heamorrhage.
Unilateral R>L
Absent doppler flow
Free fluid
Ovary anterior to uterus rather than lateral or posterior
Short term risks of endometrial ablation
Failed procedure 10% Heamorrhage 1-2% Infection 1-2% PErforation - 0.3% Thermal injury 0.01% Air embolism Cervical trauma 14% still need hysterectomy in next 5 years
What is clinical governance - 7 pillars
Involves 7 pillars PIRATES
Patient and public involvement
Service provided suits patients and public. Feedback increase quality.
Information and IT
Ensuring patient data is accurate and up to date, confidentiality is respected, appropriate use of data is assessed
Risk management
Systems in place to monitor and minimise risks for patient and staff
Reporting adverse outcomes e.g. incident forms
Audit
Assessing current practice against a gold standard
Training and education
courses, regular assessments and appraisals
Effectiveness in clinical care and research
everything you do is designed to provide the best outcome for patients
Staffing and staff management
Appropriate recruitment and management of staff. Providing good working condition
Parvovirus who is most likely to be infected and symptoms
40% childbearing women are susceptible Highest risk at home - 20% chance Occupational 2-12% Highest risk people - Childcare workers - Teachers - Mothers of infected children
How to diagnose Parvovirus
Maternal serology:
IgM + IgG both recent +ve infection
If IgG negative repeat in 2-4 weeks
Still uncertain do parvo serology on booking bloods
Risks to fetus of Parvovirus
Only relevant if infected in first 20 weeks
10% excess of fetal loss
3% hydrops (33% resolves, 33% IUT & 33% die)
<1% congenital abnormalities
Asymptomatic fetal infection most likely.
USS weekly for MCA PSV
How much more common in pregnancy is Listeria and how to diagnose it
13 times more likely as cell mediated immunity is primary host defence against listeria.
Diagnosis Blood culture, gram stain and cultures of genital tract and stool culture.
Food safety advice to avoid listeria
- Wash fruit and veg
- Avoid raw, deli meats and soft cheese
- Have pasteurized milk
- Do not reheat leftovers
Fetal sequalae of Listeria
Transmission highest in 3rd trimester
- Preterm birth
- Meningitis neonatal
- IUFD 50%
Who is at risk of CMV
Early childhood teachers (~12.5%)
Parent with a childcare in daycare (~23%)
1st trimester neonatal risk of infection and sequalae is 10%
Passed through contact with salvia from children under 3 years old.
How to diagnose CMV
Maternal IgM + IgG and IgG avidity
Avidity low recent primary
Intermediate possible test 1st antenatal bloods
High PAst infection/non-primary infection
In fetus amnio if >21 weeks and performed 6 weeks after infection
Ongoing imaging in CMV
MRI at 28 + 32 weeks USS features: Microcephaly IUGR Oligo/Poly Abdominal or intracranial calcification Hydrocephalus Hyperechogenic bowel
Prevention of Toxoplasmosis
Avoid raw uncooked meat
Wash hands after gardening
Wash raw veggies
Minimize contact with cat litter
Risk of transmission and fetal damage at each trimester
1st trimester 4-15% but high risk of damage
2md trimester 25-44% 33% chance of fetal damage
3rd trimester 35-75% but low risk of damage
How to test for toxoplasmosis
Mother serology if IgM present indicates recent infection could be months or up to a year
Rising IgG or low IgG avidity is recent
Fetal T. gondii PCR from amnio at 18-20 weeks or >4 weeks since infection
Treatment for toxoplasmosis
Spiramycin if no USS features
Pyrimethasine, sulfadiazene and folinic acid if >18 weeks and positive PCR
4 weekly USS scans - ventriculomegaly, thickened placenta, IUGR
Fetus needs hearing and occular exams and treatment for up to 12 months
How does primary syphilis effect mum and baby
Normally 21 days after primary infection lasts 2-6 weeks painless chancre.
70% chance of fetal transmission.
Fetus stillbirth, IUGR and PTB
Congenital syphilis syndrome - jaundice, anaemia, rash, neurological/occular.
70-100% of children born to untreated mothers will be effected vs 1-2% if treated.
Management of pregnancy with maternal syphilis
Treatment with Benzylpenecillin
Monitor Jarisch-Herxheimer reaction Fever, headache, myalgia and uterine activity
Growth scans
Monitor fetal movements
COVID 19 in pregnancy
Majority of pregnant women experience mild to moderate cold flu symptoms
Are at increased risk of complications due to reduced lung function, increased O2 demand and altered immunity.
Risk of preterm birth spontaneous or iatrogenic
COVID 19 vaccine in pregnancy
Offer as doesn’t contain live virus
Global data has not shown any significant safety concerns
Evidence of antibod in cord blood and in breastmilk may offer passive immunity to infants
Name 5 normal changes to the skin in pregnancy and their aetiology
DARKENING OF AEROLA, NIPPLE AND LINEA NIGRA Oestrogen causes increased production of melanin
SKIN TAGS increased weight gain, friction and hormones
VARICOSE VEINS increased intra-abdominal pressure, direct pressure on iliac veins and hormonal changes to valvues and veins increasing malleability.
STRIAE GRAVIDARUM Dermal collagen is damaged and blood vessels dilate secondary to uterine enlargement.
PALMER ERYTHEMA Vascular changes secondary to oestrogen and vasomotor instability.
Polymorphic eruption of pregnancy incidence and obstetric implications
1:160
Rarely baby born with mild rash but soon fades
Pemphigoid gestationis incidence and obstetric implications
1:50,000
Premature delivery, IUGR and Stillbirth
Transient blistering on the infant that resolves with clearance of antibodies 10%
Appearance of PEP
Itchy bumpy red rash that starts in stretch marks, spares umbilicus.
Normally occurs in last 3 months of pregnancy then clears with delivery
Appearance of Pemphigoid gestationis
Itchy rash that goes into blisters normally in 2nd and 3rd trimesters.
Starts around the umbilicus then spreads
Spares face, scalp, pals, soles and mucus membranes
Incidence and risk factors for acute fatty liver of pregnancy
Incidence 5-30 per 100,000 2% maternal mortality, 1% fetal mortality
Risk factors:
P0
Twins
Male fetus
Fetus has mutation in fatty oxygenation gene
Pathogenesis of AFLP
Defect in fatty acid metabolism causes microvascular fatty infiltrate of liver causing damage and then failure. Variant of PET & HELLP
Signs and symptoms of AFLP
HYPOGLYCEAMIA, POLYURIA & POLYDIPSIA Diabetes inspidius
BP AND RASIED UPCR 20-40% have co-existing HELLP
HEPATIC FLAP - acute encephalopathy
JAUNDICE, ASCITES - acute liver failure
COAGULOPATHY
Women presents with Obs Cholestasis how do you proceed
Bile acids and LFT
If LFTs raised check for other causes of hepatic impairment
Consider PET, HELLP
Consider UCS=DA 500mg BD (PITCHES suggests no benefit mother or fetus)
BA + LFTs weekly till delivery
If <100 could have IOL at 39 weeks
If >100 consider delivery earlier 37 weeks
As per meta-analysis of cholestasis with biochemical markers Ovadia 2019
Differentials for vomiting epigastric pain and jaundice in pregnancy, clinical exam and lab finding unique to each
GALLSTONES - Murphy’s sign RUQ pain - increased bilirubin
AFLP - Encephalopathy flap - low glucose
HELLP - High BP - Proteinuria
HEPATITIS - Fever - Serology IgG and IgM +ve
PANCREATITIS - Epigastric pain - Amylase >1000
POP specific hormone compound and dose, time to return to fertility and failure rate
30mcg of levenogesterol per tablet.
Immediate 7% typical use 0.5% perfect use
Implanon specific hormone compound and dose, time to return to fertility and failure rate
68mg of Levonogestrol: released at 60mcg/day (first year) then 30-35mcg/day
Immediate
0.1%
Mirena: specific hormone compound and dose, time to return to fertility and failure rate
52mg levonogesterol releasing IUD
Immediate
0.1-0.4%
Depot: specific hormone compound and dose, time to return to fertility and failure rate
150mg of depot medroxyprogesterone acetate IM
Up to 1 year
6% typical use 0.2% perfect use
Contraindications to COCP
Breastfeeding - under 6 weeks PP
Smoking - aged >35 and smoking >15 per day
Obesity - BMI >40
CVD - multiple risk factors
HTN - BP >160/95
VTE - current or past history
Known thrombogenic mutations (Factor V Leiden, Prothrombin mutation, Protein S, Protein C and Antithrombin deficiencies)
Stroke
Migraine with aura
Valvular and congenital heart disease
Current breast cancer or history within last 5 years or carry BRACA mutation
Viral hepatitis
Cirrhosis
Diabetes - severe with complications e.g. Retinopathy or diagnosed for >20 years
MOA for COCP and failure rate
• Inhibit ovulation
• Alters cervical mucus to reduce sperm penetration
• Alters the endometrium, making it atrophic and unreceptive to implantation
Perfect use 99.7%, and for typical use 91%.
Important history points in relation to fertility preservation
Review of cancer:
- Diagnosis, stage, grade of disease and prognosis
- Treatment plan – surgery, chemotherapy and radiotherapy
- Time available until start of treatment and indication of urgency
Family cancer history:
- Risk of miss match repair gene mutation
- Lynch syndrome is associated with risk of colorectal cancer but also endometrial and ovarian cancer any may influence future fertility following fertility preserving treatment
Obstetric and gynae history:
- Previous pregnancies and any existing children?
- Subfertility? PCOS, endometriosis or tubal disease that may impact fertility preserving treatment
Medical and surgical history:
- Any medical conditions that may impact fertility preserving treatment
- Previous abdominal or pelvic surgery?
- Smoking, alcohol or substance abuse
- BMI
Future fertility wishes:
- Relationship status – single or partnered?
What are options related to fertility preservation
- Frozen oocyte
- Ovarian tissue cryopreservation
- Frozen embryo (with partner or donor sperm)
- Ovarian transposition (oophoropexy and transfixing ovaries outside field of radiation)
- Donor oocyte or donor embryo
- Surrogacy or adoption
Risk associated with egg retrieval
Risk associated with egg retrieval:
- Pelvic infection
- Injury to viscera (bowel, bladder)
- Anaesthetic risk
- Failure for egg retrieval
What are the risks of not performing or discussing fertility preservation
Chemotherapy and radiotherapy are associated with high risk of gonadotoxicity
Risk of compromising future fertility, having a family and producing a biological child
Psychological implications of infertility
- Depression, anxiety, regret and negative impact on quality of life
Pregnancy after cancer and the risk of pregnancy complications (not as a result of fertility preservation therapy):
- Low spontaneous pregnancy rate
- Lower success rates of ART (compromised ovarian reserve)
- Risk of miscarriage, preterm birth and low birth weight
- Fetal risks following chemotherapy radiotherapy – potential risk of chromosomal abnormalities and congenital malformations
- Potential risk of childhood cancer in offspring
Medico-legal
Anti-D dose and how does it work
1st trimester 250IU
2nd and 3rd trimester 625IU
Give within 72 hours but can have benefit up to a week do not repeat <2 weeks
Anti-D destroys the fetal red cells in the circulation so mother’s immune system does not produce antibodies
Additional risk of T21 if first pregnancy is effected
1%
Benefit of NIPT vs MSS1
Lower false +ves <1% NIPT vs 5% MSS1
Higher sensitivity >99% NIPT vs 85-90% MSS1
Malformations associated with Lamotrigine and/or other anticonvulsants
Cleft palate (all AEDs)
Neural tube defects (Valporate and Carbemazepine)
Cardiovascular (phenytoin, valproate, carbemazepine)
Fetal anticonvulsant drug syndrome
Neonatal vitamin K deficiency
Neurophyschological abnormalities or decreased cognitive skills
Name and justify 6 tests to order in secondary amennorrhoea
HCG PROLACTIN - exclude hyperprolactinoma AMH & OESTRODIAOL - confirm hypogonadism USS - antral follicle count and ovarian volume KARYOTYPE - 45XO TSH, T4, ANTITPO ANTIBODIES - hypothyroidism FMR1 MUTATION - Fragile X carrier DEXA SCAN - bone density
4 causes of benign ovarian cyst
Cystadenoma
Corpus luteal cyst
Mature teratoma
Endometrioma
Describe international ovarian tumour analysis group scoring system
Sensitivity 95% specificity 91% for classifying as benign or malignant
B signs:
Unilocular, smooth multinodular, <10cm, acoustic shadowing, solid components <7mm, avascular
M signs:
Irregular solid lesions, irregular multiloculated, >10cm, ascities, at least 4 papillary structures, abundant flow
History and exam in Lichen Planus
Extra genital Present pain Perimenopausal women 40-60 Lesions erosive raw and red Symmetrical distribution at vaginal introitus
History and exam in lichen sclerosis
Risk of SCC 2-6% screen annually
Postmenopausal presents itch Autoimmune association Family history Affects vulval and perianal area Figure 8 distribution White sclerotic plaques Loss of architecture
Usual type VIN
Multifocal
Associated with HPV 16+18
Young women 35-49
Malignancy potential 4-6%
Differentiated VIN
less common <5%
unifocal ulcer or plaque
a/w lichen sclerosis or planus
Higher malignancy potential
Peripartum cardiomyopathy if LV function does not return to normal future pregnancy risk
Recurrence 50%
Risks of worsening HF 50%
Death 25%
If recovered 25% chance of recurrence
Effects of epilepsy on fetus
IUGR x2
MALFORMATIONS 10%
INHERITENCE 4% vs 0.5% gen pop
FETAL LOSS secondary to miscarriage, APH
Anti D titre and risk of HDFN
<4 unlikely
4-15 moderate
> 16 high
Measure 4 weekly till 28 weeks and then 2 weekly
Embryology of the female reproductive tract
Development of the gonads is separate from development of uterus and vagina
Formation of reproductive tract is closely linked to urinary tract
Two mullerian ducts fuse to form uterus and vagina
Ovaries from mesoderm within urogenital ridges absence of SRY gene leads to female differentation to ovary
Histopathology of chorio
Can effect any layer of chorionic plate, umbilcal cord and fetus
If findings on decidual aspect more likely heamatogenous spread from mother.
Fusitis, chorionic villitis, white cell infiltrate
Define vasa preavia and 2 types
Exposed fetal vessels within amniotic membranes which cover or are within 20m of the internal os.
Type 1 velamentous cord
Type 2 succinturiate lobe
Fetal survival in vasa preavia
Depends on antenatal detection 97% vs 44%
Reduces need for neonatal blood transfusion
Admit 32-34 weeks
Deliver 34-36 weeks
