Clinical management Flashcards
How is GDM diagnosed?
75g OGTT with 2h glucose
Diagnose gestational diabetes if the woman has either:
- a fasting plasma glucose level of 5.6 mmol/litre or above or
- a 2‑hour plasma glucose level of 7.8 mmol/litre or above.
Who should be offered a OGTT?
Those with risk factors for GDM:
- BMI above 30 kg/m2
- previous macrosomic baby weighing 4.5 kg or more
- previous gestational diabetes
- family history of diabetes (first‑degree relative with diabetes)
- an ethnicity with a high prevalence of diabetes
- glycosuria of 2+ or more on 1 occasion or glycosuria of 1+ on 2 or more occasions
Testing at 24-28 weeks
If previous GDM, offer OGTT ASAP after booking and again at 24-28 weeks if normal.
Suture materials/ techniques for repairing anal mucosa/ IAS/ EAS
AM: continuous or interrupted, 3-0 polyglactin (Vicryl)
IAS: interrupted/ mattress. Monofilament e.g. 3-0 PDS, or 2-0 polyglactin (vicryl).
Sutures must not overlap, end to end only.
EAS: end to end monofilament e.g. 3-0 PDS or 2-0 polyglactin (vicryl)
Sutures can be overlapping or end-to end.
For partial thickness, end to end should be used.
Incidence of OASIS in UK
Prognosis
6.1% for primip
1.7% for multip
60-80% of women asymptomatic 12 months post delivery and EAS repair
Incidence of obstetric cholestasis in UK
OC monitoring
OC implications
0.7%
Itching in general affects 23% of pregnancies
Itching can occur before biochemical changes.
If LFTs normal, but itching continues LFTs should be repeated in 1-2 weeks & consider testing for other causes of itch
If LFTs deranged, should be monitored every 1-2 weeks throughout pregnancy and at least 10 days post natally
OC linked with increased incidence of passage of meconium, premature delivery, fetal distress, stillbirth, delivery by CS and PPH
Different criteria’s used to diagnose BV
Amsels criteria:
3/4 criteria required for confirmation of BV
1. Thin, white, homogeneous discharge
2. Clue cells on microscopy of wet mount
3. pH of vaginal fluid >4.5
4. Release of a fishy odour on adding alkali (10% KOH)
The Nugent score:
Estimates the relative proportions of bacterial morphotypes to give a score between 0 and 10
<4 = normal
4-6 = intermediate
>6 = BV
The Hay/Ison criteria:
- Grade 1 (Normal): Lactobacillus morphotypes predominate
- Grade 2 (Intermediate): Mixed flora with some Lactobacilli present, but Gardnerella or Mobiluncus morphotypes also present
- Grade 3 (BV): Predominantly Gardnerella and/or Mobiluncus morphotypes. Few or absent Lactobacilli
OSOM BVblue is a commercially available kit that BASHH advises performs adequately compared with Amsel criteria.
Detection of gardnella vaginalis on swab does not confirm BV, as bacteria can be present in up to 50% of women without BV
% of pregnant vs non-pregnant women asymptomatically colonised with candida
Pregnant 40%
Non-pregnant 20%
Uterotonics
Oxytocin:
- Nanopeptide primarily synthezised in the hypothalamus (supraoptic and paraventricular nuclei)
- The oxytocin receptor is a G-protein-coupled receptor requiring Mg2+ and cholesterol.
Prostaglandins
- Misoprostal (Synthetic Prostaglandin E1 analogue) half-life 40 minutes
- Dinoprostone (Naturally occurring Prostaglandin E2)
- Dinoprost (Naturally occurring Prostaglandin F2 Alpha)
- Carboprost (Synthetic Prostaglandin F2 Alpha analogue)
Ergometrine
- Ergot Alkaloid
- Stimulates 5HT2, dopamine and alpha adrenergic receptors but smooth muscle contraction mechanism of action not fully understood.
- Often used as combined preparation with Oxytocin (syntometrine)
- Should not be used in HTN
Medication regimes for medical abortion depending on gestation
All gestations, begin with Mifepristone 200mg PO
<7 weeks days:
24-48h later: 400mcg PO misoprostol
7-8 weeks:
24-48h later: 400mcg PO misoprostol + 2nd dose 400mcg PV or PO if no abortion 4h later
<9 weekss:
24-48h later: 800mcg misoprostol (PV/ buccal/ sublingual)
9-13 weeks:
36-48h later: 800mcg misoprostol PV. Up to 4 further doses of 400mcg misoprostol (PO/PV) at 3 hourly intervals
13-24 weeks:
- 36-48h later: 800mcg misoprostol PV. Up to 4 further doses of 400mcg misoprostol (PO/PV) at 3 hourly intervals.
- If abortion has not occurred, mifepristone can be repeated 3h after the last misoprostol followed by misoprostol 12 hours after that.
Who should be given anti-D in cases of abortion?
Rhesus Anti-D IgG should be given, by injection into the deltoid muscle, to women who are rhesus D negative and are having an abortion after 10+0 weeks’ gestation.
Anti-D prophylaxis should not be given to women who are having a medical abortion up to and including 10+0 weeks’ gestation.
Anti-D prophylaxis should be considered for women who are rhesus D negative and are having a surgical abortion up to and including 10+0 weeks’ gestation.
Prophylactic Abx regimes for surgical abortions
Doxycycline 100mg BD for 3 days
Metronidazole 1g PR or 800mg PO if tested negative for chlamydia
When to restart COCP following abortion/ miscarriage
Immediately
Risk factors for GDM
- Increasing age
- Certain ethnic groups (Asian, African Americans, Hispanic/Latino Americans and Pima Indians)
- High BMI before pregnancy (three-fold risk for obese women compared to non-obese women)
- Smoking doubles the risk of GDM
- Change in weight between pregnancies - an inter-pregnancy gain of more than three units (of BMI) doubles the risk of GDM
- Short interval between pregnancies
- Previous unexplained stillbirth
- Previous macrosomia
- Family history of type 2 diabetes or GDM - more relevant in nulliparous than parous women
Blood test monitoring on methotrexate
FBC/ U&E/ LTF every 1-2 weeks when initiating treatment.
Once established, every 2-3 months.
Risk of blood dyscradias (myelosuppression) and liver cirrhosis
Risk of complications with laparoscopy
Overall risk of ‘serious complications’ is 2/1000
Risk of bowel injury 0.4/1000
Risk of vascular injury 0.2/1000
Risk of death is 0.05 in 1000
Women must be informed of the risks and potential complications associated with laparoscopy. This should include discussion of the risks of the entry technique used: specifically, injury to the bowel, urinary tract and major blood vessels, and later complications associated with the entry ports: specifically, hernia formation.
No significant safety advantage to open (Hasson)/ closed entry techniques
Reduced risk of uterine injury in Hasson compared to verses
Management of sub fertility in WHO group I ovulation disorders
Group I: hypothalamic pituitary failure (stress, anorexia, exercise induced)
Increase BMI if <19
Reduce exercise if high levels
Pulsatile GnRH or gonadotropins with LH activity to induce ovulation
Management of sub fertility in WHO group II ovulation disorders
WHO group II: hypothalamic-pituitary-ovarian dysfunction
Weight reduction if BMI >30
Clomiphene (1st line)
Metformin (1st line)
Clomiphene & metformin (1st/2nd line)
Laparoscopic drilling (2nd line)
Gonadotrophins (2nd line)
Management of sub fertility in WHO group III ovulation disorders
Consider IVF with donor eggs
Management of hyperprolactinaemia
Investigate cause e.g. MRI head (?pituitary adenoma) medication review (some antipsychotic medications for example can cause prolactin rise)
Dopamine agonist (Bromocriptine advised by NICE as 1st line)
What should be given/ avoided in hyperemesis to reduce the risk of Wernicke’s encephalopathy?
Avoid dextrose: can exacerbate Wernickes.
Give IV pabrinex (10ml solution in 100ml saline)
Rotterdam criteria for diagnosing PCOS
Two of the three following criteria are diagnostic of the condition:
- Polycystic ovaries (either 12 or more peripheral follicles or increased ovarian volume (greater than 10 cm3)
- Oligo-ovulation or anovulation
- Clinical and/or biochemical signs of hyperandrogenism
Typical Biochemistry
- Elevated LH
- FSH normal or low
- LH:FSH >2 (normal is 1:1 ratio, PCOS is often 3:1)
- Testosterone, oestrogen, prolactin all typically normal or elevated
- SHBG normal or reduced
Associated Endocrine Disorders
- Diabetes
- Hypothyroidism
Recommendation regarding periods in PCOS
Oligo- or amenorrhoea in women with PCOS may predispose to endometrial hyperplasia and later carcinoma.
It is good practice to recommend treatment with gestogens to induce a withdrawal bleed at least every 3 to 4 months
Changes to reproductive system following delivery
Afterpains may continue for 2-3 days
Uterine involution takes 4-6 weeks
Lochia flow 3-6 weeks
Cervical constriction takes up to 7 days
Vaginal contraction and return of tone takes 4-6 weeks
Amniotic fluid volume- peak gestation and volume
Peaks at 35 weeks, then decreases until term
Fetal contributions to amniotic fluid
Fetal Urine
- First fetal urine produced at 8-11 weeks
- By term fetus produces approximately 800ml urine per day
Fetal Swallowing
- Fetus starts swallowing 12 weeks
- 250ml swallowed per day
Fetal Lung Secretions
- 300ml/day by 2nd trimester
Erb’s palsy following shoulder dystocia- which nerve roots are affected?
C5 & C6
Which uterotonic is most associated with coronary artery spasm?
Ergometrine
Stages of syphilis, time from primary infection and symptoms
Primary: 3-90 days: chancre, lymphadenopathy
Secondary: 4-10 weeks: widespread rash typically affecting hands and soles of feet. Wart lesions (condyloma latum) of mucus membranes
Latent: early <1yr after secondary stage, late >2 year after secondary stage: asymptomatic.
Tertiary: 3+ years after primary infection. Gummas (mass of dead and swollen giber-like tissue- most often seen on liver) OR neurosyphilis OR cardiovascular syphilis
Management of trichomoniasis in HIV positive patients vs other patient groups
HIV positive: 500mg BD metronidazole for 7 days
Others: 400mg BD for 5-7 days
Radiation risk to breast tissue/ fetus of CTPA
Radiation risks to the fetus is low - 0.1mGy
Radiation to breast tissue is considerable: 10- 20 mGy.
Delivery of 10mGy of radiation to a woman’s breast has been estimated to increase her lifetime risk of developing breast ca. by 13.6%. Background risk =12%.
Relative and absolute risk of VTE in pregnancy & incidence in UK
Relative risk of VTE in pregnancy is increased 4 to 6 fold compared to non-pregnancy
Absolute risk of VTE in pregnancy and the puerperium is 1-2/1000 pregnancies
Incidence of Pulmonary Embolism in the UK is 1.3/10,000 maternities
10-20% of VTEs are PE’s. The majority are DVT
Inherited Thrombophilia is present in approximately 40% of women with pregnancy associated VTE
Cut off risk for CVS/ amniocentesis following pre-natal screening for Down’s syndrome
1 in 150
CVS should not be performed before 10 (10+0) completed weeks of gestation
Histopathology features specific to serous and mucinous ovarian tumour types
Serous tumours = Psammoma bodies
Mucinous tumours = Mucin vacoules
Management of menorrhagia
1st Line
Levonorgestrel-releasing intrauterine system (IUS eg Mirena)
2nd Line
Tranexamic Acid, NSAIDs (eg Mefenamic Acid), COCP
3rd Line
Norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens
Prelabour Rupture of Membranes (PROM)
Risk of serious neonatal infection
1% (vs 0.5% with intact membranes)
Prelabour Rupture of Membranes (PROM)
How any go into labour in first 24h?
60%
Prelabour Rupture of Membranes (PROM)
When to induce?
Induction appropriate if >34 weeks gestation and >24 hours post rupture and patients labour hasn’t started.
If <34 weeks induction of labour should not be carried out unless there are additional obstetric indications e.g. infection
Endometrial cancer
Stages and 5 year survival
Stage 1: confined to uterus
1A <1/2 depth of myometrium
1B >1/2 depth myometrium
85-90% 5 year survival
Stage 2: cervical stormal invasion, not beyond uterus. 65% 5 year survival
Stage 3: Extension beyond uterus
3A: invades serosa or adnexa
3B: Vaginal and/ or parametrial invasion
3C1: Pelvic nodal involvement
3C2: Para aortic nodal involvement
45-60% 5 year survival
Stage 4: distant metastasis
4A Tumor invasion bladder and/or bowel mucosa
4B Distant metastases including abdominal metastases and/or inguinal lymph nodes
15% 5 year survival
What is the risk of chlamydia infection following intercourse with an asymptomatic chlamydia positive partner?
65%
What percentage of men and women are asymptomatic of chlamydia following initial infection?
> 50% men and 80% of women asymptomatic after initial infection
FIGO staging of vulval ca
Stage 1: Confined to vulva
1A Lesions <=2cm with <1mm stromal invasion
1B Lesions > 2 cm in size or with stromal invasion > 1 mm confined to the vulva or perineum
Stage 2: Tumour of any size with extension to adjacent perineal structures (lower 1/3 urethra; lower 1/3 vagina; anus) with negative nodes
Stage 3: Tumour of any size with or without extension to adjacent perineal structures (lower 1/3 urethra; lower 1/3 vagina; anus) with positive inguinofemoral nodes
3A (I) With 1 lymph node metastasis ( ≥5 mm)
OR (II) 1 to 2 lymph node metastasis(es) (< 5 mm)
3B (I) With 2 or more lymph node metastases ( ≥5 mm)
OR (II) 3 or more lymph node metastases (< 5 mm)
3C Positive nodes with extra capsular spread
Stage 4: Tumour invades other regional (upper 2/3 urethra; 2/3 vagina) or distant structures
Tumour invades any of the following:
4A (I) Upper urethral and/or vaginal mucosa; bladder mucosa; rectal mucosa or fixed to pelvic bone
OR (II) Fixed or ulcerated inguinofemoral lymph nodes
4B Any distant metastasis including pelvic lymph nodes
FIGO classification of cervical cancer
Stage IA: Invasive carcinoma diagnosed only by microscopy with maximum depth of
invasion <5mm
IA1: Stromal invasion ≤3 mm deep
IA2: Stromal invasion >3 mm and ≤5 mm deep
Stage IB: Invasive carcinoma with measured deepest invasion >5 mm, lesion limited to the cervix:
IB1: Invasive carcinoma >/= 5 mm depth of stromal invasion, and <2 cm in greatest dimension
IB2: Invasive carcinoma >/= 2 cm and < 4 cm in greatest dimension
IB3: Invasive carcinoma >/= 4 cm in greatest dimension
Stage IIA: Involvement limited to the upper two-thirds of the vagina without parametrial involvement:
IIA1: Invasive carcinoma < 4cm in greatest dimension
IIA2: Invasive carcinoma >/= 4 cm in greatest dimension
Stage IIB: With parametrial involvement but not up to the pelvic wall
Stage IIIA: Carcinoma involves the lower third of the vagina with no extension to the pelvic wall
Stage IIIB: Extension to the pelvic wall and and/or causes hydronephrosis or non-functioning kidney
Stage IIIC: Involvement of pelvic and/or para-aortic lymph nodes:
IIIC1: Pelvic lymph node metastasis only
IIIC2: Para-aortic lymph node metastasis
Stage IVA: Spread to adjacent pelvic organs
Stage IVB: Spread to distant organs
Incidence of molar pregnancy in the UK
1 in 600- 1 in 2000
What is the luteo-placental shift and when does it happen?
When the placenta takes over from the corpus luteum for production of oestrogen and progesterone
6-8 weeks
Strong cytochrome P450 inducers (can reduce contraceptive effect of some hormonal forms of contraception)
Carbemazepine
Phenytoin
Phenobarbital
Esclicarbazepine
Oxcarbazepine
Primidone
St John’s Wort
Topiramate
Rifampicin
Placenta accreta/ increta/ percreta
Risk factors for placenta accreta
Incidence of placenta accrete (including intreat and percreta)
Accreta: chorionic villi attached to myometrium rather than decidua basalis
(76% cases)
Increta: chorionic villi invade into the myometrium
(17% cases)
Percreta: chorionic villi invade through the myometrium & serosa
(7% cases)
Previous CS increases risk of placenta accreta with each CS: 1st (3%), 2nd (11%), 3rd (40%), 4th (61%), 5th (67%)
Other risk factors: maternal age, multiparity, other uterine surgery, prior uterine curettage, uterine irradiation, endometrial ablation, Asherman syndrome, uterine leiomyomata, uterine anomalies, hypertensive disorders of pregnancy, smoking.
Incidence: 1.7 per 10,000 deliveries in the UK
Acute Fatty Liver of Pregnancy
- Presentation
- Risk factors
- Prevalence
- Mortality
- Cause
- Presentation
Abdo pain, lethargy/ malaise, jaundice, deranged LFTs, coagulopathy, hypoglycaemia/ hyperuricaemia - Risk factors
Primp, male fetus, multiple pregnancy, obesity - Prevalence
1 in 10,000-20,000 - Mortality
Fetal & maternal mortality around 20% - Cause
Fetal deficiency of long chain 3 hydroxyl-CoA dehydrogenase (LCHAD)
Delay in second stage of labour in nulliparous vs multiparous
Nulliparous:
- Suspect delay if progress inadequate after 1h
- Diagnose delay if progress inadequate after 2h
Multiparous
- Suspect delay if inadequate progress after 30 minutes
- Diagnose delay if progress in adequate after 1h
If delay suspected- offer amniotomy if waters in tact
If delay diagnosed, prepare for CS
According to green top guidelines- when should CVS be performed/ not be performed?
It should be performed from 11+0 weeks as it is technically difficult before then (and some suggest risk of limb and mandibular defects increased)
It should NOT be performed before 10+weeks
In practice CVS is usually performed between 11+0 and 13+6 weeks
Hyperemesis gravidarum occurs in what percentage of pregnancies?
1.5%
Definition of hyperemesis gravidarum
Severe nausea and vomiting associated with weight loss >5% of pre-pregnancy weight with metabolic disturbance (typically dehydration and/or ketosis).
Lactogenesis at term is stimulated by which hormone
Prolactin
What is required for oxytocin to bind to its receptor?
Magnesium and cholesterol
What percentage of women with gonorrhoea will develop PID?
15%
Cervical screening: what is the incidence of the following results?
- Negative
- Borderline changes
- Mild dyskaryosis
- Moderate dyskaryosis
- Severe dyskaryosis
- Inadequate sample
- Negative: 93.8%
- Borderline changes: 2.5%
- Mild dyskaryosis: 2.4%
- Moderate dyskaryosis: 0.5%
- Severe dyskaryosis: 0.7%
- Inadequate sample: 2.7%
Most common form of fibroid degeneration?
Hyaline degeneration (60%), except during pregnancy, when red (carneous) degeneration is more common
Histological features of lichen sclerosis vs lichen simplex vs VIN
Lichen sclerosis:
- Epidermal atrophy/ thinning
- Hydronic degeneration of the basal layer (sub-epidermal hyalinisation)
- Dermal inflammation
Lichen simplex:
- Epithelial thickening
- Increased mitosis in basal and prickle layers
VIN:
- Epithelial nuclear atypia
- Loss of surface differentiation
- Increased mitosis
Klinefelters syndrome
47XXY
Azoospermia & infertility, small testicles
Male phenotype
Use of EPO in anaemia in pregnancy
Currently, used in end-stage renal anaemia only
No evidence to suggest harm to mother/ fetus or neonate
Management of hyperthyroidism in pregnancy
Propylthiouracil is 1st choice- crosses placenta less readily than carbimazole
Radioiodine is contra-indicated
COCP use impact on bloods (FSH/ LH/ E2)
Decreases all
AMH not significantly changed
COCPs work by both progesterone and oestrogen negative feedback- resulting in decreasing the frequency of GnRH release and a subsequent drop in FSH and LH. Decreased follicle development from a lower FSH results in reduced E2 production.
Causes reduction in ovarian and adrenal androgen synthesis. Elevates SHBG.
Risk of developing endometrial cancer with endometrial hyperplasia
EH without atypia (overall) <5%
Simple EH without atypia 1%
Complex EH without atypia 4%
EH with atypia 40%
Risks of abdominal hysterectomy
Overall risk of serious complication 4%
Haemorrhage requiring blood transfusion 2.3%
Bladder and/ or ureter injury and/ or long term disturbance of bladder function 0.7%
Return to theatre 0.7% (e.g. bleeding/ wound dehiscence)
VTE 0.4%
Pelvic abscess/ infection 0.2%
Bowel injury 0.04% (4 in 10,000)
Death within 6 weeks 0.03%
What increases the risk of ureteral injury in abdominal surgery?
Previous surgery, adhesions, past cancer treatment, endometriosis
What does NICE advise pregnant diabetic women should keep their HbA1c below?
6.5% or 48mmol/ mol
When to use tocolytics (TPTL) and 1st/2nd line
Use of tocolytic drugs is not associated with a clear reduction in perinatal or neonatal mortality, or neonatal morbidity.
Women most likely to benefit are those in very pre-term labour, those needing transfer to a hospital which can provide neonatal intensive care and those who have not yet completed a full course of corticosteroids
1st line: Nifedipine (unlicensed)
2nd: Oxytocin receptor antagonists e.g. atosiban
Ritodrine and atosiban are licensed for treatment of threatened pre-term labour
Management of OAB
Bladder training
Treat vaginal atrophy and nocturne with topical oestrogen & desmopressin
Consider catheterisation is chronic retention
Medications
First line:
1. Oxybutynin (immediate release) - don’t offer to elderly frail patients
2. Tolterodine
3. Darifenacin
2nd line:
Consider transdermal anticholinergic
Mirabegron
Appropriate entry techniques according to BMI
Normal BMI- no preferential method
Morbid obesity (BMI >40): hasson technique or entry at Palmer’s point is preferred.
Varess needle: difficult penetration
Very thin: bassoon technique or insertion at Palmer’s point. Higher risk of vascular injury
Type of COCP best suited for acne management
Marvelon can be used for acne.
Dianette’s licence is for use in severe acne that has failed to respond to oral antibacterials and for moderately severe hirsutism.
Yasmin contains drosperinone which has antiandrogenic effects so would also be a reasonable choice but is not licensed for acne.
Definition of anaemia 1st trimester/ 2nd & 3rd, post partum
1st: Hb <110
2nd & 3rd: Hb <105
Post partum: Hb <100
Typical pattern of FM
First perceived at 18-20 weeks & increase until 32 weeks, then plateau
By term, average number of generalised movements per hour is 31
If RFM and >28 weeks, should undergo CTG +/- USS if RFM persist despite normal CTG
Typical breast milk composition (fat/ protein/ sugar)
Fat 4%, protein 1%, sugar 7%
Prevalance of fibroids
Occur in 20-50% of women holder than 30
Lifetime prevalence is 30%
Peak incidence in 40s
Nearly 70% of white women and >80% black women have at least 1 fibroid by the age of 50
40% of white women and 60% of black women have had fibroids by the age of 35 years
Process of cervical ripening in labour
Overall process = type 1 collagen breakdown by collagenase
Increased activity of metalloproteinases 2 & 9 that degrade extracellular matrix proteins
Cervical collagenase and elastase also increase and degradation of collagen increases, leading to decreased collagen content in the cervix
Increased oestrogen leads to increased collagenase activity- increase COX2 causing increased PGE2 in the cervix.
PGE2 leads to:
- increase in collagen degradation
- increase in hyaluronic acid, - increase in chemotaxis for leukocytes, which causes increased collagen degradation
- increase in stimulation of IL 8 release
- Prostaglandin F2-alpha is also involved in the process via its ability to stimulate an increase in glycosaminoglycans
Incidence of PPH in the UK
13.8% (HSCIC data)
AEDs: strong/moderate inducers and those with no effect
Strong inducers:
Carbamazepine, Eslicarbazepine, Oxcarbazepine,
Phenobarbital, Phenytoin, Primidone
Moderate:
Rufinamide
Topiramate
No effect:
BDZ, ethosuximide, gabapentin, lamotrigine, levetiracetam, pregabalin, sodium valproate
COCP and lamotrigine
May reduce levels of lamotrigine and increase risk of seizures
POP is safe. Oestrogen component is what reduces lamotrigine levels
Incidence of hyperthyroidism in molar pregnancy? Cause?
3%
Cause = excessive hCG
How often does brachial plexus injury occur in shoulder dystocia?
2.3-16%
> 90% cases, no permanent neurological disability
Shoulder dystocia is most common cause of era’s palsy
Regimes for management of chlamydia in pregnancy
Erythromycin 500mg QDS for 7 days or BD for 14 days
Amoxicillin 500mg TDS for 7 days
Azithromycin 1g stat
Contact tracing for chlamydia infection
Sexual partners in last 4 weeks for symptomatic males
Sexual partners in last 6 months for asymptomatic men and all females (or last partner if >6 months)
Most common cause of abnormal PV discharge in women of childbearing age
BV
How much do prophylactic oxytocics used for active 3rd stage reduce risk of PPH
60%
Stages of endometriosis
1: superficial lesions & filmy adhesions
2: deep lesions at cul de sac
3: as above & ovarian endometriomas
4: as above & extensive adhesions
Mortality rate of severe sepsis/ septic shock
Severe sepsis with acute organ dysfunction: 20-40%
Septic shock (persistence of hypo perfusion despite adequate fluid replacement): 60%
Presentation of ureteral injury
What % of ureteral injuries are discovered post-operatively?
Flank pain
Haematuria
Ileus
Fever
Urine discharge vaginally or via wound
HTN
Elevated serum creatinine levels
70% of unilateral ureteral injuries are discovered post-operatively
Types of metastatic spread and cancers that typically spread in that fashion
Lymphatic:
- carcinoma
Haematogenous:
- sarcoma
- RCC
- choriocarcinoma
Transcoelomic:
- ovarian
Implantation/ transplantation:
- movement of malignant cells during biopsy/ surgery/ procedure
Risk of VTE for: general population, factor V Leiden heterozygotes & homozygotes
General population: 1 in 1000
Heterozygotes: 4-8 in 1000
Homozygotes: 80 in 1000
Tocolytic drugs can prolong pregnancy for how long?
Up to 7 days
Anti-microbials for puerperal sepsis
Tazocin or a carbapenem plus clindamycin
Most common cause of puerperal sepsis
Endometritis
Prelabour rupture of membranes (PROM)
- What percentage will go into labour within 24h
- When is induction appropriate
60%
Induction appropriate >34 weeks and >24h post rupture and labour hasn’t started yet
If <34 weeks, only start induction if other obstetric indications e.g. infection
Infectious diseases routinely screened for antenatally?
HIV
Hep B
Syphilis
Which COCP is licensed for use for hirsutism
Dianette (Co-cyprindiol)
Should be stopped 3-4 months after resolution of hirsutism
NICE advised consider switching to Yasmin (unlicensed) if relapse occurs when DIanette is stopped
Note patients should be counselled about increased VTE risk with Dianette and Yasmin compared to other COCPs
What is the infertility rate in endometriosis
40%
Risks for diagnostic hysteroscopy
Serious complication 0.2%
Uterine perforation 0.13% (0.76% for therapeutic hysteroscopy)
Death (under GA) 3-8 per 100,000
LFT monitoring in OC
Monitor every 1-2 weeks during pregnancy and at least 10 days post natally
Risks at CS
Persistent wound and abdominal discomfort in the first few months after surgery, 9 per 100 (common)
Increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies, 1 in 4 (very common)
Readmission to hospital, 5 per 100 (common)
Haemorrhage, 5 per 1000 (uncommon)
Infection, 6 per 100 (common).
Emergency hysterectomy, 7-8 per 1000 (uncommon)
Need for further surgery at a later date, 5 per 1000 (uncommon)
ITU admission, 9 per 1000 (uncommon)
Thromboembolic disease, 4 to 16 women in every 10,000 (rare)
Bladder injury, 1 per 1000 (rare)
Ureteric injury, 3 per 10 000 (rare)
Death 1 per 12 000 (very rare)
Risk fetal laceration 2%
Interpretation of FBS
> 7.25 = Normal
Repeat in 1h if CTG remains abnormal
7.21-7.24 = borderline
Repeat in 30 mins
<7.2 = Abnormal
Consider delivery
Indications/ Contraindications for FBS
Indications:
- Pathological CTG in labour
- Suspected acidosis in labour
Contraindications
- Maternal infection e.g. HIV, HSV, hepatitis
- Known fetal coagulopathy
- Prematurity (<34 weeks)
- Acute fetal compromise
Significant proteinuria
Urinary protein:creatinine ratio >30mg/mmol
OR
24h urine collection >300mg protein
NICE fertility testing
2 tests for all women who haven’t conceived:
- Chlamydia screen
- Mid luteal phase progesterone (take 7 days before the expected period)
FH and LH are advised in patients with irregular periods, an ovulation or oligo-ovulation
Prolactin testing is advised for those with an ovulatory disorder, galactorrhea or a pituitary tumour
TFTs are advised if they have S&S of thyroid disease
USS appearance of the following benign ovarian cysts:
- Functional cysts
- Endometriomas
- Serous cystadenoma
- Mucinous cystadenoma
- Mature teratoma
- Functional cysts: simple cyst, thin walled and unilocular. Must be >3cm diameter (if <3cm = follicle), anechoic, no colour flow or solid components.
- Endometriomas: avascular unilocular cyst containing low-level, homogenous ‘ground glass’ like internal echoes
- Serous cystadenoma: usually unilocular cystic/ anechoic adnexal lesion, papillary projections are absent, no flow on colour doppler
- Mucinous cystadenoma: tend to be larger than serous cystadenomas, bilaterally is rare (2-5%). Multilocular with numerous thin separations. Loculations may contain low level internal echogenicity due to increased mucin content (different locules may contain various degrees of echogenicity)
- Mature teratoma (account for 10-20% of all ovarian neoplasms, tend to be in young women): Diffusely or partially echogenic mass with posterior sound attenuation owing to sebaceous maternal and hair within the cavity, echogenic, shadowing calcific or dental components, free fluid levels, dot-dash pattern, no internal vascularity. Mixed echoes
Normal arterial pH range for cord blood
7.26-7.30
Threshold for adverse neurological outcomes is 7.1
Normal progesterone conducive with ovulation
16-28 mol/L
Normal ranges for semen analysis
Volume: >=1.5ml
pH >=7.2
Concentration >=15 million/ ml
Total sperm number: >= 39 million per ejaculate
Total motility: 40% or more motile or 32% or more with progressive motility
Vitality: 58% or more live spermatozoa
Sperm morphology (percentage of normal forms): >4%
Other points from NICE:
- Do not screen for anti-sperm antibodies
- If sperm count abnormal, repeat in 3 months (or sooner if azoospermia or severe oliogozoospermia (<5million sperm/ml)
Management of simple cysts
50-70mm, yearly USS follow up.
Larger = consider further imaging (MRI) or surgical intervention
A serum ca 125 doesn’t need to be taken in all premenopausal women when an USS diagnosis of simple ovarian cyst has been made
Polymorphic eruption of pregnancy rash- management and associations
Benign, managed with emollients +/- topical steroids/ antihistamines. Severe cases may require oral steroids
Associated with multiple gestation pregnancies, excessive maternal weight, Rh neg blood type
Most common cause of PPH
Uterine atony
Risk factors for PET (moderate/ high)
Moderate:
- 1st pregnancy
- Age >=40
- Pregnancy interval >10 years
- BMI >= 35
- FHx PET
- Multiple pregnancy
High
- Hypertensive disease during previous pregnancy
- CKD
- AI disease like SLE/ APLS
- T1 or T2DM
- Chronic HTN
If two or more moderate risk factors or one high risk factor
Aspirin from 12 weeks until birth
What is the most reliable way of assessing risk of convulsion in PET
Clonus
What percentage of eclampsia occurs post-natal?
44%
Treatment for magnesium toxicity
10ml 10% calcium gluconate IV
Signs of magnesium toxicity
Moderte: loss of tendon reflexes (4h checks), resp depression
Severe: Hypotension, arrhythmia, coma, drowsiness, confusion, renal failure.
Naegele’s rule
LMP + 9 m and 7 days if regular 28 day cycle.
Add extra days for every day over 28d cycle.
