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6. Obs and Gyn 3 Flashcards

1
Q

When do women require contraception after giving birth?

A

Day 21

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2
Q

What is endometrial hyperplasia and give the pathophysiology, and a risk factor.

A

Abnormal proliferation of the endometrium.

It develops due to presence of unopposed oestrogen; oestrogen stimulates endometrial growth whilst progesterone stimulates shedding of this tissue.

Tamoxifen has pro-oestrogenic effects on endometrium (though it has anti-oestrogenic effects on breast)

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3
Q

Risk factors for endometrial carcinoma (7).

A

Excess oestrogen e.g. nulliparity, late menopause, early menarche, unopposed oestrogen e.g. HRT

Metabolic syndrome e.g. obesity, DM, PCOS

Tamoxifen

HPNCC

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4
Q

Third stage of labour is measured from the birth of the baby to the expulsion of placenta and membranes. Why is active management of this stage recommended and what does it involve (3 things)?

A

Reduce PPH and need for blood transfusion post delivery.

Lasts <30 minutes, involves uterotonic drugs, deferred clamping and cutting of cord (1 min < x < 5 mins) and controlled cord traction after signs of placental separation.

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5
Q

What is an amniotic fluid embolism, and give some signs and symptoms a patient may present with.

A

Fetal cells / amniotic fluid enter the mother’s bloodstream and stimulate a reaction.

Shivering, chills, sweating, anxiety, coughing.

Cyanosis, hypotension, tachycardia, dyspnoea, arrhythmias, MI

Supportive management in a critical care setting.

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6
Q

What is the intervention used in obstetric cholestasis that prevents stillbirth, and also give 4 other management strategies for symptom relief.

A

Elective induction from 37 weeks.

Ursodeoxycholic acid
Vitamin K
Emollients
Chlorphenamine

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7
Q

What are the 3 types of oestrogen, where and when are they produced?

A

E1 = ESTRONE; post menopause, converted from androgens in peripheral tissues.

E2 = OESTRADIOL; premenopausal, from ovaries.

E3 = ESTRIOL; produced from the placenta, weakest of them all. Maintains uterine lining and supports fetal development.

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8
Q

Describe the histological types of endometrial cancer.

A

Endometrioid type = 80%. Split into mostly endometrioid adenocarcinoma, + some others inc mucinous carcinoma.

Non-endometrioid type = 20%. Split into clear cell, serous and mixed adenocarcinoma.

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9
Q

State some contraindications to HRT.

A

History of unprovoked / recurrent VTE
Oestrogen sensitive malignancy
Undiagnosed PV bleeding
Untreated hypertension
Liver dysfunction
Untreated endometrial hyperplasia

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10
Q

What is adenomyosis, and give 3 clinical features of it.

A

Endometrial tissue present in the myometrium. More common in multiparous women at the end of their reproductive years.

Dysmenorrhoea
Menorrhagia
Enlarged, boggy uterus

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11
Q

What is the first line investigation for adenomyosis?

A

TVUS

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12
Q

What specific levels are measured in the combined screening and the quadruple screening tests offered in pregnancy, and when are they offered?

A

Combined at 11-13+6 weeks. Nuchal translucency, PAPP-A, b-hCG.

Quadruple at 15-20 weeks. Inhibin A, unconjugated estriol, AFP, hCG.

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13
Q

What are the diagnostic thresholds for gestational diabetes?

A

Fasting glucose >/= 5.6 mmol/L

2-hour glucose >/= 7.8mmol/L

If <7mmol fasting at diagnosis then diet and exercise should be encouraged, if not then metformin and insulin added in later.
If >7mmol at presentation then insulin should be started. If borderline but evidence of complications such as macrosomia or polyhydramnios then offer insulin as well.

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14
Q

What is the mnemonic used to remember the process for reading a CTG?

A

DR - define risk
C - contractions
BRa - baseline rate
V - variability
A - accelerations
D - decelerations
O - overall impression

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15
Q

When should fetal movements be established by?

A

24 weeks

Quickening usually occurs between 18-20 weeks, and increase until 32 weeks and then plateaus.

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16
Q

What is considered as RFM and therefore warrants further investigation in a patient after 28 weeks?

A

<10 recognised movements in 2 hours

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17
Q

Late decelerations begin at the peak of a uterine contraction and recover after the contraction ends. What does this type of deceleration indicate, and give 3 causes.

A

Late decels indicate insufficient blood flow to uterus and placenta.

This can lead to fetal hypoxia and acidosis.

Causes:
Maternal hypotension
Pre-eclampsia
Uterine hyperstimulation

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18
Q

Early decelerations occur at the start of a uterine contraction and recover quickly once it ends. What is the physiology behind this?

A

Early decels indicate increased fetal ICP and increased vagal tone during a contraction, and quick recovery indicates return to normal ICP post contraction.

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19
Q

A sinusoidal pattern on a CTG is rare but very concerning. What does it look like and what 3 things could it indicate?

A

Smooth, regular wave pattern, around 2-5 cycles per minute.

Severe fetal hypoxia
Severe fetal anaemia
Fetal / maternal haemorrhage

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20
Q

What is a normal baseline rate for a fetal heartbeat on a CTG?

A

110-160 bpm

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21
Q

What are variable decelerations usually caused by, and give the mechanism.

A

Umbilical cord compression

Acceleration is caused by umbilical vein compression.
Rapid deceleration during artery compression.
When pressure on the cord is reduced, baseline rate returns.

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22
Q

What does the ‘shoulders of deceleration’ refer to, and what does their presence / absence indicate?

A

Occurs in variable decelerations.

Shoulders indicate fetus is not hypoxic and is adapting to reduced blood flow. Reassuring.

Absence of shoulders may indicate hypoxia.

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23
Q

What is classed as prolonged deceleration?

A

> 2 mins

Non-reassuring = 2-3 minutes

Abnormal = >3 minutes

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24
Q

Give 3 features of a CTG that would be reassuring.

A

110-160 bpm rate

Variability of 5-25 bpm

None or early decels, or variable decels with no concerning features for <90 mins

https://geekymedics.com/how-to-read-a-ctg/

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25
BV in pregnancy can increase the risk of the pregnancy; give 4 things BV can increase the risk of.
Low birth weight Pre-term labour Chorioamnionitis Late miscarriage
26
What is the treatment for BV, in symptomatic patients and in pregnancy?
Oral metronidazole 5-7 days. Asx does not require treatment unless undergoing TOP, but if pregnant should discuss with an obstetrician.
27
Which organisms are predominant in BV and what does this do to the vaginal pH?
Overgrowth of predominantly anaerobic bacteria e.g. Gardnerella vaginalis. This inhibits aerobic lactic acid-producing lactobacilli, therefore raising the vaginal pH to over 4.5.
28
What is the incubation period for chlamydia vs gonorrhoea?
Chlamydia = 7-21 days Gonorrhoea = 2-5 days
29
When should chlamydia testing be carried out and what test is first line for men vs women?
2 weeks after possible exposure Women = vulvovaginal swab Men = urine All tested via NAAT
30
First line management of chlamydia:
7 days of doxycycline Azithromycin if contraindicated (1g OD one day, 500mg OD two days) Azithromycin is first choice in pregnancy.
31
Who should be contact-traced if someone they have slept with is diagnosed with chlamydia, and what should be done for contacts?
Men with urethral symptoms must contact all sexual contacts 4 weeks prior to symptoms starting onwards. Women, and asymptomatic men, should contact all partners within the last 6 months, or most recent partner. Contacts should be treated before results are available.
32
Chlamydia is asymptomatic in 70% of women and 50% of men. Describe symptoms for each of these groups.
Women: cervicitis e.g. discharge and bleeding, dysuria Men: urethral discharge, dysuria
33
Give 7 potential complications of chlamydia.
Epididymitis Reactive arthritis PID Endometritis Increased incidence of ectopics Infertility Perihepatitis (Fitz-Hugh-Curtis syndrome = perihepatic inflammation due to chlamydia)
34
50% of cord prolapses occur at ARM. How is the diagnosis usually made?
Fetal heartrate becomes abnormal and cord is palpable vaginally, or is visible below the level of the introitus.
35
Cord prolapse is an obstetric emergency. What is the management of it?
Push fetal presenting part back in if possible to avoid cord compression. If visible past introitus, minimal handling and keep warm and moist to prevent vasospasm. All fours position whilst preparation for Cat1 CS is completed. ?Tocolytics to reduce uterine contractions ?Retrofilling the bladder
36
6 risk factors for a cord prolapse:
Multiparity Polyhydramnios Breech position Cephalopelvic disproportion Twin pregnancy Prematurity
37
10% of women of reproductive age have a degree of endometriosis. Describe some symptoms and clinical features of this condition.
Chronic pelvic pain Secondary dysmenorrhoea, pain often starting days before menses Deep dyspareunia Subfertility Examination; tender nodularity around posterior vaginal fornix, reduced organ mobility Non gynae; urinary symptoms (dysuria, urgency, haematuria), dyschezia
38
What is the gold standard investigation for endometriosis?
Laparoscopy Minimal use for investigation in GP e.g. US, should be referred for definitive dx.
39
Outline the step wise management options for endometriosis.
1. NSAIDs and paracetamol 2. COCP or progesterone e.g. POP 3. GnRH analogues. Induces 'pseudomenopause' with correlating side effects. Surgical options do exist. Laparoscopic excision or ablation of endometriosis can improve chances of conception. Ovarian cystectomy.
40
The benefit of a mother taking her antiepileptic medication during pregnancy usually outweighs the risk of uncontrolled seizures. Which medication does this NOT apply to and is contraindicated in pregnancy and why?
Sodium valproate Associated with NTD
41
Pregnant women taking phenytoin should be offered what in the last month of pregnancy, and why?
Vitamin K To prevent clotting disorders in the newborn
42
Which antiepileptic medication may require a dose increase in pregnancy?
Lamotrigine Rate of congenital malformations is low
43
Which antiepileptic medication is associated with a cleft palate?
Phenytoin
44
Women who are at high risk of developing pre-eclampsia should take what?
75 - 150 mg aspirin OD from 12 weeks until birth.
45
Hypertension in pregnancy is classed as >140 / >90, or a change above booking readings. What change is signficant?
>30 systolic change >15 diastolic change
46
Gonorrhoea is caused by a gram-negative diplococcus and can occur on any mucous membrane surface. Discuss features and how they differ between males and females.
M = urethral discharge, dysuria F = discharge Rectal and pharyngeal infection is usually asymptomatic.
47
Reinfection of gonorrhoea is common, and immunisation is not possible. What is the microbiological reason for reinfection being common?
There is antigen variation. Type IV pili proteins which adhere to surfaces, and Opa proteins that are surface proteins that bind to receptors on immune cells mean that immunity is not possible.
48
Local and systemic complications of gonorrhoea can occur. State 3 local complications.
Salpingitis, leading to infertility. Epididymitis. Urethral strictures.
49
First line treatment for gonorrhoea is 1g IM ceftriaxone as a single dose. What can be used for patients who are needle-phobic?
Oral cefixime 400mg single dose + Oral azithromycin 2g single dose
50
Disseminated gonococcal infection can occur, and it is not fully understood but is thought to be due to haematogenous spread from mucosal infection. What is the classic initial triad of symptoms of DGI? What are 3 later complications that can occur?
Tenosynovitis Migratory polyarthritis Dermatitis Later on: endocarditis, septic arthritis, perihepatitis (Fitz-Hugh-Curtis syndrome)
51
What is the recommendation for using effective contraception around menopause?
Women >50; for 12 months since LMP Women <50; for 24 months since LMP
51
Vasomotor symptoms in menopause can be particularly distressing / annoying. Give 3 medications that can be used to treat them.
Fluoxetine Citalopram Venlafaxine
51
4 contraindications for HRT:
Current or past breast cancer Any oestrogen-sensitive cancer Undiagnosed vaginal bleeding Untreated endometrial hyperplasia
52
Discuss increased risk of VTE in relation to different forms of HRT.
Slight increase in risk with all forms of oral HRT. No increased risk in transdermal.
53
What is atrophic vaginitis and what are the management options?
Vaginal dryness Dyspareunia Occasional spotting Treatment: vaginal lubricants and moisturisers. Topic oestrogen if these not working.
54
What is important to discuss with obese women who present at booking appointments with regards to their weight?
BMI >30 at booking = obese Their weight poses a risk to their health and the baby's health, however they should not try to reduce this risk by dieting whilst they are pregnant. The risk will be managed by healthcare professionals during their pregnancy. Take 5mg folic acid, rather than 400mcg. Screen for gestational diabetes.
55
Give 6 fetal risks associated with obese mothers.
Prematurity Macrosomia Obesity and metabolic disorders in childhood Congenital anomalies Stillbirth Neonatal death
56
Give 7 maternal risks to an obese mother.
Pre-eclampsia VTE GDM Dysfunction in labour or need for IOL PPH Wound infection Miscarriage
57
What is the most common causative organism of PID, and then give 3 further causative organisms.
Chlamydia trachomatis Neisseria gonorrhoeae Mycoplasma genitalium Mycoplasma hominis
58
Describe some clinical features of PID, and some potential complications.
Lower abdominal pain Fever Discharge Dysuria Menstrual irregularities Deep dyspareunia Cervical excitation Complications: 1. Perihepatitis 2. Infertility 3. Chronic pelvic pain 4. Ectopic
59
It is difficult to make an accurate diagnosis of PID, as high vaginal swabs are often negative. Due to the potential complications of untreated PID, there should be a low threshold for treatment. What are the first and second line options for PID?
First line = stat IM ceftriaxone + 14 days of oral doxycycline and metronidazole Second line = oral ofloxacin + oral metronidazole
60
Pregnancy itself is a risk factor for VTE. List some other risk factors that increase a women's risk of VTE that should be identified at the booking appointment.
>35 years old BMI >30 Parity >3 Smoker Gross varicose veins FHx unprovoked VTE Low risk thrombophilia Multiple pregnancy IVF pregnancy Current pre-eclampsia Immobility
61
Discuss VTE prophylaxis in relation to number of identified risk factors.
4 OR MORE: immediate VTE prophylaxis until 6 weeks postpartum. 3: VTE prophylaxis at 28 weeks until 6 weeks postpartum. LMWH is given in all cases.
62
A woman has had a previous VTE and presents for her booking appointment; what risk is she deemed and how is this managed?
HIGH RISK LMWH throughout antenatal period and also input from experts.
63
A pregnant woman has been exposed to chickenpox. She cannot remember if she has had it before. What should be done?
Blood test to check for varicella antibodies
64
If a pregnant woman who has not had chickenpox before requires PEP for chickenpox, what treatment is given and when?
Oral aciclovir Given day 7 to day 14 post exposure. There is a varicella vaccine, but it is live so cannot be given during pregnancy, but can be arranged afterwards.
65
What organism causes syphilis, and what is the incubation period range?
Treponema pallidum Incubation is between 9 and 90 days
66
Outline the primary and secondary features of syphilis.
Primary = painless chancre at site of sexual contact (often not seen in women as may be on cervix). Local non-tender lymphadenopathy Secondary = occur 6-10 weeks after primary infection. Fever, lymphadenopathy, rash on trunk palms and soles, buccal 'snail track' ulcers, condylomata lata (painless genital warts)
67
Give some tertiary features of syphilis.
Gummas Ascending aortic aneurysms Paralysis Tabes dorsalis (progressive degeneration of dorsal columns and dorsal roots of the spinal cord. Sensory ataxia, shooting pains, paraesthesia, bladder and sexual dysfunction) Argyll-Robertson pupil (do not react to light, react briskly to accomodation)
68
Syphilis serology can be tested using non-treponemal tests, though these are not specific to syphilis. Give some other conditions that could cause a false positive result on a non-treponemal serology test.
Pregnancy SLE / APS HIV TB Leprosy Malaria
69
A positive non-treponemal and a positive treponemal test is consistent with:
Active syphilis infection
70
A positive non-treponemal test and a negative treponemal test is consistent with:
False positive syphilis results due to e.g. pregnancy
71
Negative non-treponemal test and positive treponemal test is consistent with:
Successfully treated syphilis
72
First line management for syphilis, and if in case of allergy:
IM benzathine penicillin Doxycycline in allergic cases
73
What is the Jarisch-Herxheimer reaction?
Fever, tachycardia and rash following first dose of antibiotic in syphilis. Typically occurs within a few hours of treatment. Contrast to anaphylaxis = no wheeze or hypotension.
74
What should be measured to assess response to antibiotics in syphilis treatment?
Non-treponemal titres (RPR or VDRL) Four-fold decline e.g. 1:16 - 1:4 is considered adequate response.
75
Which STI presents with a 'strawberry cervix', and which other features may also be present?
Trichomonas vaginalis Offensive, yellow/ green, frothy discharge Vulvovaginitis pH >4.5 Men are usually asx but can cause urethritis
76
Trichomonas vaginalis is a highly motile, flagellated protozoan parasite. What would be seen on microscopy?
Motile trophozoites on a wet mount
77
Treatment of trichomonas vaginalis?
Metronidazole PO 5-7 days OR on-off 2g dose
78
What do the 'fetal vessels' consist of?
2 x umbilical arteries 1x umbilical vein
79
The umbilical cord usually contains the fetal vessels, providing them with protection until they insert directly into the placenta. Give the 2 types of vasa praevia, when the fetal vessels are not protected.
Type I = velamentous umbilical cord Type II = accessory placental lobe
80
Management of vasa praevia in a) symptomatic women and b) APH
a) Corticosteroids given from 32 weeks. Elective CS at 34-36 weeks. b) Emergency CS
81
Many women find that their migraine severity and frequency increases around menstruation. What are some management options?
Mefenamic acid OR Combination of aspirin, paracetamol and caffeine Also triptans in the acute setting
82
Can you prescribe HRT for patients with a history of migraine?
Yes it is safe, but it may make migraines worse.
83
What are the first and second line options for the management of migraine in pregnancy?
1st line: paracetamol 1g 2nd line: NSAIDs in first and second trimester only
84
Why should NSAIDs be avoided in the 3rd trimester?
Can cause oligohydramnios, fetal renal dysfunction and potentially early closure of the PDA.
85
What is the first line option for someone with menorrhagia who DOES require contraception?
IUS / Mirena coil COCP and long acting progestogens can be 2nd line options.
86
Options for menorrhagia without a need for contraception?
Tranexamic acid or mefenamic acid (useful if dysmenorrhoea is also present)
87
Which type of ovarian cyst is most likely to present with intraperitoneal bleeding?
Corpus luteum cyst
88
Which is the most common type of ovarian cyst that commonly regresses after several menstrual cycle?
Follicular cyst
89
What is the most common benign ovarian tumour in women under the age of 30?
Dermoid cyst
90
Which type of benign tumour of the ovary is most likely to present with torsion?
Dermoid cyst
91
What is the most common benign epithelial tumour, and which type of cancer does it bear resemblance to?
Serous cystadenoma Resembles serous carcinoma
92
What type of cyst can cause pseudomyxoma peritonei if it ruptures?
Mucinous cystadenoma
93
All women >=55 years presenting with post-menopausal bleeding should be referred using the suspected cancer pathway. What is the first line investigation and what result would be reassuring?
TVUS Endometrial thickness <4mm has a high negative predictive value
94
What is the treatment for endometrial hyperplasia without atypia?
High dose progestogens (can use the levonorgestrel IUS) and then repeat in 6 months.
95
What complications can occur from using heroin during pregnancy?
3rd trimester bleeding Low birth weight Withdrawal; sleep problems, irritability, seizures, tremors, feeding problems SIDS
96
When are women screened for anaemia during their pregnancy?
8-10 weeks 28 weeks
97
What cut offs are used throughout pregnancy to determine whether a woman needs iron therapy or not, and how long should it be continued for?
1st trim <110 g/L 2nd / 3rd trim <105 g/L Postpartum <100 g/L Oral ferrous sulfate or ferrous fumarate should be continued for 3 MONTHS after correction.
98
When do rhesus negative women receive their anti-D prophylaxis in pregnancy?
28 weeks and 34 weeks
99
When is Down's syndrome screening, including a nuchal scan, done?
11-13+6 weeks

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