CLINICAL MANAGEMENT Flashcards
How many pregnancies get shoulder dystocia
How many get erb’s palsy?
How many have lasting neurological damage?
0.65%
2-16%
<10%
How does the COCP work? Describe the effects on LH/FSH/SHBG/ovarian and adrenal androgens
suppresses LH AND FSH
Suppresses ovarian androgen secretion because LH is low
INCREASES SHBG release from liver which reduces circulating androgens
Suppresses adrenal androgens
Prevents conversion of testosterone to dihydrotestosterone which therefore cannot bind to androgen receptors
Which are the paraneoplastic bits of SCLC
SIADH
cushing’s
Which are the paraneoplastic bits of squamous cell lung cancer
hypercalaemia
Paraneoplastic - polycythemia - which cancer?
renal (EPO)
hepatocellular (alcoholics)
Which is better for images in hysteroscopy - saline or CO2
saline
What type of hysteroscope is used for outpatients?
2.7mm minihysteroscope
Analgesia for hysteroscopy?
NSAIDs 1 hour before.
NO OPIATES routinely
Which drug classes cause raised prolactin?
Opiates
Oestrogens
Antipsychotics
SSRI
H2 antagonists
ASHOO - if you sneeze you will get a raised prolactin
How does mifepristone work?
It is an anti-progestogen. It competes for progesterone receptors
What are the risk factors for bladder cancer?
SMOKING IS BIGGEST - 4x higher
SPOF
smoking
painter
obesity
family history
Treatment of chlamydia in pregnancy
erythromycin QDS 500mg 7/7
OR BD 500mg 14/7
amoxicillin 500mg TDS
Obstetric cholestasis:
How common in UK?
How common is itch?
Investigation?
Management?
Can cause?
0.7%
23%
LFTs - repeat weekly and 10 days postnatally
Tx - anti-itch
Delivery baby
If Bile acids 19-40 - mild IOL 40 weeks
40-100 - moderate IOL 38 weeks
>100 - severe - ONLY THIS ONE HAS RISK OF STILLBIRTH - IOL 35 weeks
meconium, early delivery, neonatal distress, PPH
MEN-P
key to how methotrexate works
look for word folate!
What is this?
How many pregnancies get the this?
What is it due to?
What else can it cause?
3/4 pregnancies
melanocyte stimulating hormone from the placenta
melasma - darkening patches on the face
Stages of syphilis
Suture technique for OASIS repair of: anal mucosa, EAS, IAS
AM - PG3
EAS - end-to-end (ALL THE E’s) PDS or PG2
IAS - interrupted (ALL THE I’s) or mattress - inside your house PDS or PG2
What is PIGF and how is it interpreted
Placental growth factor.
If it is low in high risk pregnancies it indicates that preterm birth is imminent and there is a higher risk of pre-eclampsia and still birth
Management of hypertnesion in pregnancy.
Who is admitted?
What is moderate and what is severe and how are each managed?
What is the target BP?
What needs to be monitored?
Management of pre-eclampsia in pregnancy.
Who is admitted?
Who gets treated?
What is moderate and what is severe and how are each managed?
What is the target BP?
What needs to be monitored?
First column is moderate - BP <149/<109
Second column is severe >160/>110
What would prompt admission in pre-eclampsia
Renal - creatinine rise of >90
oedema - signs of pulmonary oedema
Liver - rise in ALT of >70 or twice upper limit
E - eclampsia - signs of this impending
Sustained BP >160
Fetal compromise
Platelets - fall <150
ROLES of Fetal Protection
Choice of antihypertensive for pregnant women
1st - labetalol
2nd - nifedipine
3rd - methyldopa
How do define pre-eclampsia
Hypertension - systolic>140 OR >90 diastolic
PLUS ONE OF
Renal - creatinine >90
Urine - protein:creatinine >30 mg/mmol or albumin:creatinine >8mg/mmol or 2+ protein in urine
B - blood. platelets <150, haemolysis
L - ALT >40
N - neuro - eclampsia, blindness, stroke
BURN - Like pre-eclampsia
What are 3 types of emergency contraception?
What is the drug content?
When can it be used?
Which is the most effective?
Levenorgestrel
- progesterone
- can be used up to 72h after intercourse
- give dose again if they vomit within 2 hours
- prevents ovulation/fertilisation
Ulipristal (ellaOne)
- progesterone receptor modulator
- up to 5 days
- give again if vomit in 3 hours
- works by inhibiting ovulation
IUD - copper coil
- most effective
- - can be given up to 120 hours after SI
Most common type of fibroid degeneration in prenant/non-prenant women?
PREGNANT = RED (pregnant women see red)
NON-PREGNANT = hyaline
What to do if a women who is hypertensive has +1 protein in urine on a stick
Organise protein:creatinine ratio OR albumin:creatining ratio
NOT 24h URINE ROUTINELY
What are the risks of complications in hysteroscopy: diagnostic vs therapeutic?
Risk of uterine perforation?
Risk of uterine perforation:
Diagnostic - 0.1%
Therapeutic - 0.8%
overall risk of serious complication for diagnostic = 0.2%
What is the key process causing cervical ripening
degredation of type 1 collagen
Describe the cervical Ca screening programme
Describe the pathway for the results following screening
25-49 = every 3 years
49-65 = every 5 years
When are women treated for CIN called back?
6 months
Are secondary sexual characteristics present in:
androgen resistance
turners
AR = YES
Turner’s = NO
Which vitamin deficiency leads to wernicke’s encephalopathy
B1
When is amniocentesis performed?
When is CVS performed?
What is it and what is CVS?
Amnio - No earlier than 15 weeks
Chorio - 11-13+6 weeks
COCP with lamotrigine?
Is this ok?
NO
COCP - specifically the oestrogen - can reduce lamotrigine levels and increase seizure risk
lamotrigine is NOT an enzyme inducer
Most common cause of abnormal vaginal discharge in women of childbearing age?
BV
Incidence of OASIS in primip/multip/overall?
PRIM = 6.1%
MULTI = 1.7%
OVERALL = 2.9%
What percentage of cervical cancers are due to HPV?
Almost 100%!
70% due to HPV 16/18
Most common age group for chlamydia?
20-24
What is the most common cause of sepsis in the pueperum?
What is the management?
What is the mortality rate of severe sepsis, septic shock?
Endometritis
Tazocin within 1 hour + sepsis 6
20-40%, 60%
Are unilateral ureter injuries noticed more intra-op or post-op ?
post-op = 70%
Describe the 3 groups of ovulation disorders
What are the management options for each?
What is the difference in vascular/bowel injury risk for hassan (open) vs varess (closed) techniques for insertion of the first trochar?
No real difference
Risk factors for acute fatty liver of pregnancy?
Mortality rate?
Who gets it? Those who MOP up the Munchies
Multiple pregnancy
Obesity
Primigravida
Male fetus
Fetal/maternal mortality 20%
prevalence = 1/10,000
How common is ecoptic pregnancy?
Where are most of the pregnancies?
1/100 roughly
mortality 2/1000
Tubal = 93-95%
Next most common is interstitial
WITHIN TUBE:
= 70% ampulla
then isthmus, then fimbrial, then corneal
Thrush in pregnancy.
Most common organism?
How many pregnancy women vs non-pregnant women are colonised with this?
Treatment?
Candida albicans (90%)
20% non-preg, 40% preg
Topical imidazole used in pregnancy
At what gestation does the amniotic fluid peak volume level?
35 weeks
Describe the RMI
What is the value which determines referral to the MDT as likely malignancy?
Scoring system for ovarian masses. Looks at 3 things:
- USS appearance
- Menopausal status
- Ca125 value
USS appearance looks at 5 things:
1. ascites
2. multilocular cyst
3. intrabdominal metastases
4. Solid areas
5. Bilateral lesions
As per RCOG - RMI of >200 highly sus of ovarian ca
Chlamydia.
What type of organism is this
Investigation
Management
How many people contract it if they have had sex with an asymptomatic partner
Gram negative obligate aerobic cooco-bacillus bacteria. Intracellular
NAAT
Treatment = 7/7 metronidazole
65% contract after sex with asymptomatic
Contraindications for POP MEC3
IHD
Neuro - Stroke
Breast Ca - past or cleared 5 years ago
Aura in migraine
Liver - Cirrhosis or tumour or hepatitis
GTD
A - BLING
Which antibiotics are given to women undergoing a surgical abortion?
What about a medical abortion?
100mg doxycycline BD 7 days
NONE FOR MEDICAL
Prelabour rupture of membranes.
When should induction be offered?
How many women will labour after prom in 24h?
What is the risk of serious neonatal infection with PROM vs normal?
Induction offered 24h after if still no labour if >37 weeks. If <37 weeks do not offer induction
60% will start to labour within 24h
Risk is 1% compared to 0.5% in no-PROM
Describe the endometrial Ca staging.
Group B strep.
When do you treat during pregnancy?
What happens during delivery?
You treat if they have bacteruria and symptoms. You do not treat during pregnancy if asymptomatic
If vaginal delivery patient needs intrapartum antibiotics
TSH aim for 1st, 2nd and 3rd trimester
TSH <2.5 = 1st
TSH <3 = 2nd, 3rd
Molar pregnancy.
How many pregnancies?
Symptoms?
What are the types?
USS appearances?
Treatment?
How many can cause hyperthyroidism?
How many cases of choriocarcinoma occur after molar pregnancy?
Complete 46XX = empty egg fertilised by 1 sperm which then replicates. USS = snow storm appearance - reticular shadows, bunch of grapes - villous distension
Incomplete 47XXY = egg fertilised by 2 sperm (separate sperm)
1/1000 are molar
Symptoms: hyperemesis, vaginal bleeding, large for dates
Management = methotrexate
3% can have hyperthyroidism. Caused by excessive hcg
70% of chorio occur after molar
Oxytocin.
Where does it come from?
What receptors does it act on?
What is required for it to act on receptors?
Half life?
Made in hypothalamus but stored and released by posterior pituitary
G-coupled protein receptors
Requires Mg and cholesterol
5 minute half life
Syphilis
Causative organism?
Symptoms?
Treatment?
Treponema pallidum
1 (<90 days) = chancre, lymphadenopathy
2 (<10 weeks) = hands and feet rash, wart lesions
latent = asymptomatic
tertiary (>3 years) = neurosyphilis, gumma, cardiovascular syphilis
Treatment: benzathin penicillin 2.4 IM single dose (if primary or secondary).
If teritary then for once weekly doses for 3 weeks
If neurosyphilis then for procaine penicillin as BP doesnt do well in CSF.
Alternatives: cef or doxy
Ergometrine.
What is it?
Receptors?
Half life?
Contraindications?
Ergot alkaloid
Stimulates 5HT2, dopamine receptors AGONIST
30-120 minute half life
Cant use in PET/hypertension
How many babies are exclusively breast fed at birth vs 3 months
70%
20%
Benefits of breast feeding for baby?
For mum?
Baby: increased immunity because of IgA in colostrum
Decreased rates of SIDS, childhood leukaemia, obesity, diabetes and cardiovascular disease
Mum: decreased rates of breast cancer, ovarian cancer, osteoporosis, CVD
According to greentop guidelines: what level of blood loss (without shock) can we continue ‘basic measures’ - IV access, monitoring, bloods
Up to 1000ml without shock
As per the PPH infusion/transfusion protocol, what are the triggers for platelets, cryo, FFP
Plt <75 and ongoing need for haemostasis
Cryo - fibrinogen <2 and ongoing need for haemostasis
FFP - transfused 4 units RBC and ongoing need for haemostasis OR PT/APTT ratio raised and ongoing need for haemostasis
Half life of ergometrine
30-120 minutes
How many cases of endometrial hyperplasia WITHOUT atypia turn into EC within 20 years
<5%
How many deliveries have a PPH in the UK
13.8%
What is the follow-up for endometrial hyperplasia WITHOUT atypia
Hysteroscopy and biopsy every 6 months until 2x negative biopsies
What is the management of endometrial hyperplasia WITHOUT atypia
IUD first line
If they dont want this then oral progesterone.
After this if all fails can do hysterectomy.
Ablation NOT recommended
What is the management of endometrial hyperplasia WITH atypia
Hysterectomy. As in 10 years 25-30% turn into cancer
PROM
How many patients will go into labour within 24h?
What is the risk of a serious neonatal infection?
When should induction be recommended?
60% will go into spont labour
1% risk serious neonatal infection
If >37 weeks and been ruptured for 24h
What causes endometrial hyperplasia
Unopposed oestrogen
Nulliparity
Early menarche/late menopause
Tamoxifen (acts like oestrogen in uterus and bone, blocks oestrogen in breast)
PCOS
Obesity (adipose tissue secrete oestrogen)
How many patients with recurrent miscarriages have APLS
15%
Which clotting factors reduce during pregnancy, and which rise?
REDUCE = 11 , PROTEIN S ?also 13
STAY THE SAME = 2, 5, 9
RISE = everything else (including fibrinogen)
When taking EllaOne (ulipristal) - when should you advice patient re-takes the medication if she vomits?
What about levonorgestrel
if vomited within 3 hours
Levo - if vomits within 2 hours
Dont levo it longer than 2 hours to take it again, and if you vomit after 3 hours you only need EllaOne
How many cases of choriocarcinoma occur after TOP, molar pregnancy or normal pregnancy
TOP - 20%
Molar - 70%
Normal - 10%
What is the male infertility rate in cycstic fibrosis
98%
Which hormone stimultes milk ejection?
Which hormone stimulates lactogenesis?
Ejection - oxytocin
Lactogenesis - prolactin
What is karyotype for really tall male with azoospermia and infertility from this
Kleinfelters - XXY
Which cancers are acanthosis nigricans associated with
Mostly GI - stomach is more likely accounts for 90%
What is used to treat type 1 WHO classification causes of infertility
How do they work?
This is hypothalamic pituitary disorders
- anorexia, stress
Treatment
- gain weight
- cure stress
- pulsation GNRH
Pulsation GNRH: (PREGNANCY)
- GNRH needs to be released in a pulsation fashion because this mimics how it is released naturally:
- maintains sensitivity of the pituitary GNRH receptors
Continuous GNRH (CANCER)
- GNRH receptors on the pituitary decrease in sensitivity as exposure is continuous
- therefore reduces LH and FSH and sex hormones
- used to treat sex hormone sensitive cancers eg prostate
Which nerves are involved in Erbs palsy
C5/6
Which nerve roots are involved in erbs palsy
C5/6
How common are mole pregnancies
1 in 1000
How many cases of chorio carcinoma occur after molar pregnancy, TOP, normal pregnancy
Molar - 70%
TOP - 20%
normal - 10%
What causes hyperthyroidism in early pregnancy
HCG causes increased release of t3/t4
Only happens in about 3% of cases of molar pregnancies
When is the luteo-placental phase
6-8 weeks
When placenta takes over production of progesterone and oestrogen
How many positive HPV swabs to trigger colp
On third
In between this is a 1 year recall
What percentage of smears have:
Normal
Mild dyskaryosis
Mod dyskaryosis
Severe dyskaryosis
Normal - 94%
Mild - 2.5%
Mod - 0.5%
Severe 0.7%
How common is hyperthyroidism in pregnancy
Treatment?
2:1,000
Propylthiouracil - crosses placenta less readily than carbimazole
What causes OAB?
Describe the treatment for OAB (urge incontinence)
Causes:
- neurological (Parkinson’s/dementia)
- physiological (detrusor overactivity, too little water - concentrated urine irritates bladder, too much water - increased volume and increased contraction, inflammation eg from chronic or recurrent UTI)
- anatomical (BPH - incomplete emptying —> increased contraction)
- lifestyle ( diet - caffeine/spicy, fat - pressure on the bladder)
OAB Management:
- bladder training
- topical oestrogen for atrophic vaginitis
- desmopressin for noctoria
AFTER THIS: antimuscarinic anticholinergics - reduce contraction of detrusor
- oxybutinin - antimuscarinic inhibits acetylcholine
- darifenacin - antimuscarinic inhibits acetylcholine
- tolterodine - antimuscarinic inhibits acetylcholine
2nd line - mirabegron - Beta 3 agonist (think what SABA do in lung)
Does lamotrigine interact with POP?
NO but it does interact with COCP - oestrogen reduces the seizure threshold.
What is the mechanism of action of:
Quinolones
Quinolones - DNA gyrase inhibitor
Trimethoprim - dihydrofolate reductase inhibitor
Nitrofurantoin - damaged DNA
Tetracyclines - binds to 30S ribosomes
Macrolides - peptidyltransferase inhibitor
Cephalosporins - betalactam inhibit
Penicillin - betalactam inhibit
The QUEEN GRAZES on TWO FIGS and NOT DATES because THEY ROT if MICE PICK CONSTANTLY BEFORE PIGS BITE
How long does it take for the uterus to go back to normal size after birth
4-6 weeks
How long do after pains continue for following birth
2-3 days
How long does lochia flow continue for
3-6 weeks
How long does cervical constriction take following delivery
7 days
Risk of unsuccessful VBAC
Average 25%
Risk of readmission following CS
Risk of prolonged Abdo pain following CS
Risk of infection following CS
Uncommon:
Bladder injury
Ureteric injury
Death
VTE
Common risks:
5%
9%
6%
Uncommon risks:
1 in 1000
3 in 10,000
1 in 12,000
4-16 in 10,000
RCOG guidelines for sepsis:
How much crystalloid?
If not responding to fluids what to do? What are target BPs if not responding?
If lactate over __ what do you want for central venous pressure?
20ml/kg initially
If not responding - vasopressors and aim MAP >65
Septic shock: hypotension and not responding to fluids
If not responding to fluids and lactate over 4 aim for CVP to be 8mmhg
Aim central venous sats to be 70%
What are the classes of thrombophillias?
Give examples of type 1
Type 1 - deficient in anticoagulation factors (typically congenital)
Type 2 - too much clotting factor
Type 1 - protein C deficiency, protein S deficiency, antithrombin deficiency
Type 2 - factor V leiden, prothrombin g20210A
Bacterial Vaginosis:
Which pathogen is typically associated with BV
What is the pathogenesis
Criteria ?
Definciency in which bacteria?
Treatment?
Gardnerella vaginalis
Overgrowth of anaerobic bacteria making vagina alkali
Amsel/nugent criteria
- Ph >4.5
- Clue cells >20%
- Vaginal discharge
- Positive whiff test with KOH
Deficiency in lactobacillus
Treatment:
- 7/7 metronidazole
What is the histology for lichen sclerosis?
What is the histology for VIN?
Histology for lichen planus?
Histology for lichen simplex?
Lichen sclerosis - epidermal thinning, degeneration of basal layer
Macroscopic - small introitus, loss of architecture
VIN - Atypical nuclei, loss of differentiation of surface layer , increased mitosis
Macroscopic - lumpy - white or pigmented
Lichen planus - violet plaques with white lace over the top (wickham’s striae), can have eroded layers in genital and buccal areas
Lichen simplex - lichenification (whitening), epithelial thickening, increased mitosis in basal and prikle layers
Macroscopic - erosions and excoriation
Management of simple ovarian cysts according to size?
<5cm - no follow-up (premenopausal)
5-7cm - annual follow-up with USS
> 7cm - surgery or further evaluation with MRI
NO CA125 if patient premenopausal and SIMPLE CYST
TRICHOMONAS
- Causative organism?
- Symptoms?
- How many asymptomatic?
- Investigation?
- Treatment?
Trichomonas vaginalis
Vaginal discharge (green frothy), abdo pain, dysparenunia, dysuria, itching, strawberry cervix 2%
50% asymptomatic (WOMEN)
Investigation - wet smear microscopy or PCR
Tx - 7/7 metronidazole
USS features scoring points in RMI
multilocular cyst
Bilateral lesions
Solid areas
Ascites
Intra-abdominal mets
What is most common bug causing pueperal sepsis
Group A Strep
Definition of latent phase vs first stage
Latent - contractions and dilation up to 4cm
First stage - from 4cm to fully
Define delay in the third stage with:
- Active
- Physiological
Active >30 minutes
Physiological >1 hour
FIBROIDS
What are the hormonal management options?
What are the surgical management options?
IUS - ?risk of expulsion depending on location
GNRH analongues
- limited to 6 months as risk of osteoporosis
- given with back up tibolone (small dose oestrogen to reduce SEs)
Surgical:
- UAE (some evidence can affect ovarian function). Need MRI and hysteroscopy prior to this
What are the relative contraindications for uterine artery embolisation?
Submucosal or pedunculated fibroids (location means does not work as well)
Postmenopausal women
With HMB, when is the hormonal coil most appropriate
Fibroids <3cm, adenomyosis, ovulatory cause, endometriosis
What are the outcomes of EA?
What are the criteria?
3rd of women are amenorrhoeic
90% are satisfied with results
Needs to have cavity normal size <10cm length
Normal pathology
Completed her family
Fibroids not larger than 3cm in size
Endometrial hyperplasia
Risk of progression to cancer?
Tx?
WITHOUT:
- 5% risk in 20 years
- Mirena
- Norethisterone 15mg/day
- 6 month endomtrial biopsu
- Minimum 2 negative prior to d/c
WITH:
- 12% risk in 9 years
- 43% risk of concomitant carcinoma - missed on biopsy
- HYSTERECTOMY
How do you manage VWB as cause of HMB
Ideally COC - increases fibrinogen and other factors
Can also use mirena or EA if family complete
What is the prevalence of N&V in pregnancy
What about hyperemesis?
70%
3%
what is the most common side effect of misoprostol after PPH
Diarrhoea
Fever is only 4%
What type of drugs are:
- Misoprostol
- Carboprost
- Ergometrine
Misoprostol - E1 Prostaglandin
Carboprost - F2 prostaglandin
Ergometrine - Ergot alkaloid
