General OBGYN - SJS Flashcards
Briefly discuss the pathophysiology of the different signs/symptoms of pre-eclampsia
What are the diagnostic criteria of pre-eclampsia
What are the risk factors for pre-eclampsia?
What are the symptoms of pre-eclampsia?
WHat is the management of eclampsia?
What is the clinical picture of HELLP?
What do we learn from the 12 week USS?
Identifies viability of the foetus
Estimates gestation and date of delivery
Identifies and characterizes multiple gestation
Identifies risk factors for Down Syndrome as part of 1st trimester screening.
Identifies major fetal abnormalities like anencephaly
What is the amnion and the chorion?
The chorion is the placenta
The amnion is the fluid sack of foetal urine
What can we tell from the 20 week scan?
Morphology scan –> head to toe check for anatomical abnormalities
Growth (4 measurements)
Locates the placenta (5% of women will have a low lying placenta)
Amniotic fluid volume
May also perform umbilical artery doppler and/or cervical length if indicated
What % of women have a low lying placenta at their 20 week ultrasound scan?
What is the management?
What % of women have placenta previa?
5%
Follow up ultrasound at 34 weeks, explain to mother that it’s like blowing up a baloon so the placenta is likely to move to a safe spot
0.5% go on to have placenta previa
What is the cut off amniotic fluid index for oligo and polyhydramnios?
Polyhydramnios - AFI >25
Oligohydramnios - AFI < 5 - 10
What are the causes of oligo and polyhydramnios?
What is Potter’s sequence?
A triad of consequences of oligohydramnios (regardless of the cause)
Clubbed feet
Pulmonary hypoplasia
Cranial anomalies
Why is general anaesthetic avoided in pregnant women?
Higher risk of aspiration
The uterus is pushing up on the abdominal cavity + progesterone relaxes the lower oesophageal sphincter
What are you looking for on foetal artery doppler?
Two things:
1) In suspected RhD, the flow velocity of the middle cerebral artery can be used to quantify foetal anaemia. This is the equivalent of listening for a flow murmur in an anaemic adult
2) diastolic flow patterns in the umbilical artery can demonstrate high resistance in the placenta vasculature and assess the risk for pre-eclampsia, IUGR and abruption
What are some indications for foetal growth and wellbeing studies in later pregnancy?
GDM
Gestational HTN
Suspected IUGR (uterus too small)
Decreased fetal movements felt (FMF)
History of pregnancy loss or complication in late pregnancy
What can you do to assess foetal wellbeing in later pregnancy?
SAM BLACK
What are the causes of a long or short symphysiofundal height?
At what gestational age is the foetal heart beat usually detectable on USS?
Often at 6 weeks
in 80% of cases at 12 weeks
90% at 13 weeks
At what gestational age do women typically start feeling foetal movements?
What can delay this?
Foetal movements begin to be felt between weeks 15 and 25
They can be masked by an anterior lying placenta
Why are babies of mums with GDM big?
GDM –> hyperglycaemia –> increased release of insulin and insulin like growth factor from the foetus –> hepatomegaly and increased growth
What are the components of the APGAR?
How do you interpret a CTG?
DR C BRaVADO
What causes Braxton Hicks contractions?
Around week 37 progesterone levels start to drop, but oestrogen levels remain high. This higher ratio of oestrogen to progesterone causes the uterus to be more sensitive to other hormones (notably oxytocin released from the anterior pituitary) which stimulate contractions. This effect can cause some women to experience some weak contractions in late pregnancy, either called “false labour contractions” or “Braxton-Hicks contractions”.
What do you know about bloody show?
What other causes of bleeding must you differentiate bloody show from and how would you know the difference?
Bloody show (a small amount of blood with mucous discharge from the cervix) may precede onset of labor by as much as 72 hours. It is the mucus plug that sits in the cervix during pregnancy falling out.
Bloody show can be differentiated from abnormal 3rd-trimester vaginal bleeding because the amount is small, typically mixed with mucus and the pain due to abruptio placentae is absent. In most pregnant women, previous ultrasonography has been done and ruled out placenta previa. However, if ultrasonography has not ruled out placenta previa and vaginal bleeding occurs, placenta previa is assumed to be present until it is ruled out. Digital vaginal examination is contraindicated, and ultrasonography is done as soon as possible.
What are the 3 stages of labour?
First: from the onset of labour to full dilatation (commonly lasts 8-12 hours in a first labour, 3-8 hours in subsequent labours)
Second: from full dilatation of the cervix to delivery of the baby (commonly lasts 1-2 hours in a first labour, 0.5-1 hour in subsequent labours)
Third: from delivery of the baby to the delivery of the placenta (commonly lasts up to an hour if physiological, 5-15 minutes if actively managed)
What are the causes of foetal tachy or brady cardia?
What is a “normal” or “healthy” amount of variability of a foetal HR on CTG?
RWH defines normal as between 5-25, other sources say >10
Don’t forget that if the baby is in REM sleep, variability can be reduced for up to 40mins.
What is the criteria for an acceleration on CTG?
How would you interpret accelerations?
Defined as elevation in foetal HR >15 bpm above baseline for longer than 15 seconds.
>2 every 20 minutes is a good sign (hypoxic foetuses rarely have accelerations) but their absence is probably insignificant
What is the criteria for a deceleration on CTG?
HR falls below baseline by >15 bpm for >15 secs
What are the five different types of deceleration and what do they typically mean?
Early –> Normal
Variable –> (rapid onset, variable offset, usually a/w contractions) –> cord compression. If overall trace is good don’t worry, if overall trace is bad then worry
Late –> (starts in middle of contraction) uteroplacental insufficiency. Be hesitant to call a late decel in the absence of other concerning features.
Prolonged –> (15 bpm decel for longer than 90 seconds but less than 5 minutes). uteroplacental insufficiency, urgent Mx may be required. Often caused by prolonged contractions, maternal hypotension or hyperstimulation
Sinusoidal pattern –> Suggests severe hypoxia. Urgent C/S. Outcome is poor
How do you make your overall assessment of the CTG?
Normal = a CTG trace where all four features are rated as reassuring.
Suspicious = a CTG trace where one feature falls into the non-reassuring category.
Pathological = when two or more features fall into the non-reassuring category, or one feature falls into the abnormal category.
What % of pregnancies are affected by Term Prom?
What % of these will go in to labour within 24 hours?
10%
90%
What % of pregnancies will be affected by premature pre-term rupture of membranes?
What % of these will deliver within 24 hours?
1-3%
50% within 24 hours, 80% within 7 days
What are the risks of term prom and pre-term prom?
Maternal infection
Neonatal infection
Cord prolapse
Cord compression
Placental abruption
Plus in PPROM additional risk of premature birth
How can you tell in PV fluid is amniotic?
Nitrazine paper testing (alkaline amniotic fluid will turn yellow paper blue)
Fern slide
Amnisure
What will USS show in women with PROM?
Low AFI in 50-70% of women (doesn’t always happen)
If mild oligohydramnios then need to investigate for other causes (cf: causes of oligohydramnios)
If major oligohydramnios –> most likely from PROM
What are the risks of expectant management vs active management of PROM?
Expectant
Placental abruption
Cord prolapse
Maternal infection
Foetal infection
Active
Theoretical increased risk of need for instrument delivery or C-section but research shows no increased risk
In practice you usually blend the two by waiting 24 hours after PROM and if labour hasn’t started switch to IOL
What are the requirments for expectant management of PROM?
Term baby
Engaged with cephalic presentation
NO PV exams
CTG normal
Mother in a facility able to properly monitor her
Maternal vitals normal
GBS negative
What is the FULL management of term PROM?
Basics
- Health of Mother
- Vital signs
- Abdominal examination)
- FBE / CRP
- Health of Baby
- SAM BLACK
- DO NOT DO PV EXAMS
Place and person
Depends on definitive Mx
Ix and confirm diagnosis
- Confirm gestational age (are they definitely term?)
- Confirm not in labour with CTG
- Sterile speculum exam to assess for liquour
- If unsure:
- Nitrazine paper test
- Amnisure
- Fern test
Definitive
Expectant vs active management
Long term
- Monitor until labour
- Indication for CTG during labour
- Paediatric review after birth
What is the management of pre-term PROM?
Basics
- Health of Mother
- Vital signs
- Abdominal examination
- FBE / CRP
- Health of Baby
- SAM BLACK
- DO NOT DO PV EXAMS
Place and person
Depends on definitive Mx
Ix and confirm diagnosis
- Confirm gestational age (are they definitely term?)
- Confirm not in labour with CTG
- Sterile speculum exam to assess for liquour
- Collect MCS swabs for chlamydia and gonorrheoa
- Collect swab for GBS
- If unsure:
- Nitrazine paper test
- Amnisure
- Fern test
Definitive
Give antenatal steroids
Give erythromycin (reduces neonatal lung dz, cerebral haemorrhage and death)
Expectant vs active management
Long term
- Monitor until labour
- Indication for CTG during labour
- Paediatric review after birth
What are the indications for IOL?
MOTHER PIG
Maternal medical issues (heart/renal/autoimmune dz)
Obstetric cholestasis
Too long (>41 weeks)
Haematological/hypertension (pre-eclampsia)
Endocrine (GDM –> macrosomia)
ROM early or Request
Planned neonatal surgery
Intrauterine death
Growth restriction
What are the risks of IOL?
PATH / ROAD
Prolapsed umbilical cord
Abruption of placenta
Tachysystole
Hyponatraemia/haemorrhage
Rupture of uterus
Oedema/fluid retention
Atonic uterus
Didn’t work (failure leading to C section)
What are the relative contraindications to IOL?
CAMP HI
C Section previously (uterine scar –> uterine rupture)
Act quickly! (need for non-elective C-section)
Malpresentation (non-cephalic presentation)
Placenta Previa (risk of haemorrhage)
High Parity (increased risk of uterine rupture)
Infections (active genital herpes, HIV)
How do we induce labour?
What is VBAC?
What are the risks?
VBAC (pronounced veeback) stands for vaginal birth after caesarean section.
The major risk if uterine rupture at the site of the previous LUCS scar - affects 1 in 200 women trying for a VBAC.
What are the main considerations when choosing bw low and high dose oxytocin infusions for IOL?
How do you decide what approach to take in induction of labour?
In term PROM you can jump straight to oxytocin. In pre-term PROM use Modified bishop score
“Favourable Cervix” with Modified Bishop Score >8
IOL likely to be successful
ARM +/- oxytocin infusion
“Unfavourable Cervix” with a Modified Bishop Score of 8 or less (this number varies between sources!)
Cervix needs ripening
Use prostaglandin
The Bishop’s Score is a clinical tool used to gauge the favourability of the cervix for labour and induction of labour. Six is a commonly used cut off. The most important component ins the dilation of the cervix. Dilation <3cm or a score <6 will usually preclude ARM. In women with a favourable cervix, ARM ± syntocinon is a common choice.
What are the two major risk factoras/causes of shoulder dystocia?
Macrosomia (BW = >2500g)
Instrumental delivery
What manouvres/procedures should you do for shoulder dystocia?
HELPERR
Help
Evaluate for episiotomy
Legs (McRoberts Manouvre)
Pressure - suprapubic
Enter - rotational manouvres
Remove the posterior arm
Roll onto hands and knees
Explain the screening/diagnostic algorithm for Down Syndrome
What is the effect of epidural anasthesia on the 2nd stage of labour?
Slows it down, becaused reduced sensation of need to push
Increases time of second stage from 1-2 hours in multigrad, 2-3 hours in primigrad
At what rate should the cervix dilate in the first stage of labour?
The cervix should dilate >1cm per hour of labour.
In multigravidas, this figure is probably closer to >2cm.
What is generally considered the point of no return in vaginal labour? Ie: the point at which you’re better off continuing with vaginal birth rather than switching to C section.
The head is at the ischial spines (station = 0.)
What do you need to check before performing ARM (artificial rupture of membranes)?
1) That the foetal head is engaged. If it’s not, when you rupture the membranes the cord could fall out and then the baby will compress it when it’s head enters the pelvis, this could be fatal for the baby!
2) need to confirm that placenta previa has been ruled out by USS.
What are the risks and benefits of artificial rupture of membranes?
Risks
Cord prolapse
Placental abruption
Ascending infection
Failure –> may not trigger good labour
Benefits
May shorten labour
Reduces rate of dystocias
Enables fetal scalp sampling and electrodes
In the event of cord prolapse during labour, what do you do?
The most immediate management Is to place mum in the Trendelenburg position and push the presenting part back into the pelvis.
Try not to touch the cord as this can induce vasospasm.
What are the risks of using syntocinon?
- Uterine hyperstimulation
- Powerful contractions may distress foetus (use intrapartum CTG)
- Especially concerned if baby is IUGR
- Can also lead to placental abruption
- Hyponatraemia (ADH-activity)
- Hypotension
- Nausea/Vomiting
- (Rarely) arrythmias and anaphactoid reactions
What are the diagnostic criteria for uterine hyperstimulation?
What are the different administration options of prostaglandins to ripen the cervix for labour?
What are the considerations of using each type?
When would you prefer to use a non-hormonal method of cervical dilation?
An intravaginal gel can be used
Cannot administer syntocinon for 6 hours after application
A continuous release pessary also exists
Can be removed in the event of spontaneous labour, sROM or significant side effects in mum or baby
Smaller chance of hyperstimulation
Once removed, cannot adminster syntocinon for 30 mins
When to go for a non-hormonal option
- The catheter tends to be more uncomfortable, but is a good alternative to the PGE2 when…
- There is a history of hyperstimulation
- There is an already compromised foetus
- There is a history of uterine surgery (PGE2 can cause uterine rupture)
What are the indications of episiostomy?
- Foetal distress
- Short/inelastic perineum
- Shoulder dystocia
- Foetal malposition e.g. occipito-posterior
- Intrusmental delivery (especially forceps)
- Breech delivery
- Previous pelvic floor surgery
How common are instrumental deliveries in Australia?
Forceps and vacuum assisted deliveries account for 11% of deliveries in Australia.
What are the contraindications to instrument assisted delivery?
Face presentation
Bleeding from scalp
Delivery before 34 weeks
What are the pre-requisites for forceps delivery?
What history/exam would you perform before proceeding with forceps delivery?
History
- Has the patient receive syntocinon (should try first)
- How long has the labour been?
- What is the mother’s BMI? Baby’s estimated weight?
- Gestational diabetes?
- Osteogenesis imperfecta (absolute contraindication)
Examination
- Palpate abdomen for foetal size and engagement
- Perform VE –> is the head at or below spines?
- Is there a ‘face’ presentation?
FORCEPS
What are the potential complications of forceps delivery?
What are the potential complications of vaccum assisted delivery?
What is the management of facial nerve palsies caused by forceps deliveries?
In one series, patients recovered on average in 24 days
No treatment required
Beware the eye! Tape and protective gel can be used
A woman who has previously LUCS has her 20 week ultrasound and is found to have an anteriorly low lying placenta, what do you think?
sAnterior low lying placentas may be in the old scar from the previous LUSCS. This is a placenta accreta until proven otherwise and may need very senior care in tertiary settings.
What are the advantages and disadvantages of vaginal birth (vs LUCS)?
Advantages
- Mum
- Shorter hospital stay
- Less analgesia required
- Often felt to be ‘more satisifying’
- Baby
- Less likely to have TTN
- More easily cared for by mum, who is physically well sooner
Disadvantages
- Mum
- Instrumental birth
- Bleeding
- Tears
- Emergency Caesarean (30%)
- Hysterectomy (rare, PPH)
- Rupture of scar (1 in a 100)
What are the 10 Ps of every women’s station?
- Periods or any other bleeding (IMB, PCB, PMB)
- Pain (with periods, sex or other times)
- Partners
- Parents (maternal menopause), plus own menopause and HRT
- Pissing/pooing?
- Pap smears and breast checks
- PCOS
- Pelvic inflammatory disease
- Protection
- Pregnancy
What are the causes of menorrhagia?
BITCHFACE
B – Bleeding disorder
I – Iatrogenic (IUDs and drugs)
T – Thyroid dysfunction (especially hypo)
C – Cancer (Endometrial, cervical)
H – Hyperplasia
F – Fibroids and polyps
A – Adenomyosis and endometriosis
C – Chlamydia, gonorrhea and STIs
E – Ectopics and miscarriage
What are the (generic) causes of post-op fever?
WATER, WIND, WIZZ, WALK, WOUND, & WEIRD DRUGS
WATER = IV site infections WIND = pneumonia
WIZZ = UTI
WALK = deep vein thrombosis
WOUND = surgucal wound infection
WEIRD DRUGS = drug induced fever
What time frame is considered to be puerperium?
What is the clinical significance of this time?
From delivery to 6 weeks
After the puerperium any maternal complications of pregnancy (like GDM or gestational HTN) should have resolved. If they haven’t treat like normal DM/HTN.
Describe the normal pattern of lochia….
Red (approx day 3 to 5 post delivery)
Pink (approx day 5 to 10 post delivery)
Serous (approx day 10 to 35 post delivery)
After birth the flow of lochia is equivalent to a heavy menstrual period
What might delay uterine involution after labour?
Intra-uterine causes
- Fibroids
- Infection
- Retained products
Extra-uterine causes
- Full bladder
- Full rectum
- Broad ligament haematoma
A woman has red lochia at day 7 post delivery. What are the differentials? What is the management?
DDx
May indicate infection (endometritis) or retained products
Management
Endometritis
Oral Augmentin and Azithromycin (mild)
IV amoxy, gent and metro (severe)
Retained products
Evacuation + antibiotics
What is the typical causes of pain post partum?
What is the management?
Causes
- Perineal pain and ‘after-pain’ (uterine contractions) are common in the first 3 days of peurperium.
- It is preferable to avoid opioid analgesia because it can slow resumption of normal bowel function.
Management
- Regular paracetamol
- Topical lignocaine
- Diclofenac (voltaren) suppositories at birth and 12 hours postpartum (best evidence for perineal pain)
- Laxatives to avoid straining on perineal tear
What are the grades of perineal tears?
VBAC
- Grade 1: Skin of vagina torn
- Grade 2: Involves perineal (bulbocavernosus) muscle
- Grade 3: To the anal sphincters
- A) <50% of external sphincter
- B) >50% of external sphincter
- C) Internal sphincter
- Grade 4: Tear to anal canal
What are the risk factors for perineal tearing?
- Nulliparity
- Precipitous labour (<3 hours)
- Birth weight >4kg
- Occipito-posterior position
- Shoulder dystocia
- Induction of labour
- Epidural analgesia
- Assisted delivery (forceps)
What do you know about “the blues” post delivery?
What other mental health complications can arise after delivery? How common are they?
The blues
- Affects 80% of women
- Emotional lability, fatigue, sleeping difficulty and lower mood.
- Should resolve spontaneously in 10-14 days.
What is the management of mastitis?
- Abscesses will require aspiration
- eTG recommends flucloxacillin
- Analgesia
- Cold lettuce leaves are a common, anecdotal therapy for pain relief
What are the relative and absolute contraindications to hormonal contraception?
HOMESICK
Headache / Hypertension
Obesity
Medications (some antivirals/ABx)
Embolism / Thrombus / Clotting disorders
Smoking
IHD
Cancer (Breast, Endometrial)
Kids (ie. parity) / Breastfeeding
What are the side effects of oestrogen?
Mastalgia
Nausea
Fluid retention
Abdominal bloating
Headaches
Chloasma
What are the symptoms of oestrogen deficiency (menopause)?
- General
- Fatigue
- Headaches
- Muscle/joint pains
- Vasomotor
- Hot flushes
- Night sweats
- Psychological
- Depression/anxiety
- Sleep disturbance
- Poor memory and concentration
- Urogenital
- Vaginal itching, dryness and dyspareunia
- Urinary frequency and urgency
What are the serious medical side effects of oestrogen deficiency (menopause)?
- Metabolic and cardiovascular
- Central abdominal fat deposition
- Insulin resistance/T2DM
- Increased cholesterol
- Skeletal
- Osteoporosis
- Urogenital
- Atrophic vaginitis
- More frequent UTIs
What is the role of hormonal testing in suspected menopause?
Hormone measurement may be useful for:
- Women with subtle/fluctuating symptoms, for example predominant mood change and few vasomotor symptoms where it be valuable to increase the index of suspicion of menopause
- Women with amenorrheoa <45 years old
A 44yo woman presents with amenorrheoa for 3 months. What investigations would you perform to diagnose the cause?
- Pregnancy test
- Prolactin levels (hyperprolactinaemia causing amenorrheoa?)
- TSH (thyroid disease as a cause)
- If hormonal testing indicated:
- FSH
- E2 estradiol
- on two readings at least a month apart
A 47yo woman presents complaining of low mood, tiredness and concentration problems. She also has some mild vaginal dryness. What investigations would you order to determine the cause of her symptoms?
- K10/DASS for depression
- TSH for hypothyroidism
- FBE/Fe studies for anaemia
- Fasting BGL for diabetes
- Consider hormonal testing
- High FSH and low E2 on two readings at least a month apart
What is the relationship between HRT and VTE?
Oral estrogen is associated with an increased risk of DVT/PE although the absolute risk is small for women <60 years old. The risk appears to be lower/not at all with transdermal estrogen. Therefore transdermal estrogen is preferred for women at increased risk, i.e. smokers and obese women.
What are the pros and cons of HRT?
For women who have premature or early menopause, when should they be prescribed HRT?
For women with premature (age <40 years) or early (<45 years) menopause, current guidelines recommend HRT until aged 50 for the treatment of vasomotor symptoms and bone preservation.
What is the only real indication for HRT?
Everyday symptoms of menopause.
- Hot flushes
- Night sweats
- Muscle aches
- Low mood
- Headaches
- Fatigue
- Difficulty concentrating
- Vaginal dryness
- Urinary frequency
Although HRT may have other added benefit, they are not indications for commencing treatment. For example, it reduces osteoporotic fracture risk, but this is NOT long tem (ie. the benefit ceases after cessation of HRT). And since women do not take HRT after 60 years, it is likely to really be of benefit. It may also reduce the risk of colorectal cancer, but this on its own is not an indication for HRT.
What are the contraindications of HRT?
Although there are no real absolute contraindications for HRT there are the following considerations:
ABC, EIOU
Age <60
Breast cancer history
Clotting problems (DVT/PE/stroke)
Endometrial cancer (FHx?)
I is a bone. Osteoporosis risk
O is a gallstone. Can cause cholelithiasis
Uterus - does she still have one? Will need combined HRT if so
What are the different types/formulations of HRT?
Unopposed oestrogen:
- used only in women who have had a hysterectomy - otherwise risk of endometrial Ca from unopposed oestrogen.
Combined HRT (Progesterone + Oestrogen)
- If a uterus is present then progesterone therapy needs to be administered for at least 10 days each month.
- Options include:
- Cyclical – taking oestrogen every day, and adding progesterone 10-14days each month (second half of cycle). The disadvantage of this option is that a withdrawal bleed will occur with the cessation of progesterone treatment.
- Continuous (daily oestrogen and progesterone) – Much less likely to have bleeding. Prescribed for women who have had no period for at least 1yr.
What are the side effects of progesterone?
HAIL M
H - Hirsuitism
A - Acne & Apetite/Weight Increase
I - Insomnia
L - Loss of libido
M - Mood swings
What do you know about the physiology of glucose metabolism in pregnancy?
- Early pregnancy – food intake is commonly decreased because of nausea and vomiting. It this stage, the insulin demands decrease
- The most notable hormone which has major effect on glucose metabolism is human placental lactogen (hPL), which is produced in abundance in the enlarging placenta
- hPL promotes lipolysis with increased levels of circulating free fatty acid and causes a decrease in glucose uptake. In this sense it is thought of as an anti-insulin.
- The increasing production of hPL as pregnancy progresses generally requires an increase in insulin requirement.
- hPL promotes lipolysis with increased levels of circulating free fatty acid and causes a decrease in glucose uptake. In this sense it is thought of as an anti-insulin.
- Oestrogen and progesterone also interfere with the insulin-glucose relationship, and insulinase which is produced by the placenta and degrades insulin to a limited extent
- With increased renal blood flow, the simple diffusion of glucose in the glomerulus increases beyond the ability of tubular reabsorption, resulting in the normal glycosuria of pregnancy. In patients with diabetes, this glucosuria may be much greater.
What is the typical presentation of gestational diabetes?
GDM generally develops and is diagnosed in the late second or early third trimester of the pregnancy.
It is usually asymptomatic.
Explain the recommended screening for GDM in pregnancy?
In Australia, all pregnant women should be screened for GDM between 26 and 28 weeks gestation. (Note that U.K. guidelines and old Australian guidelines suggest screening only in women with risk factors).
The recommended screening regimen is a 75 gram two-hour Pregnancy Oral Glucose Tolerance Test (POGTT).
Fasting test- fast from 2200
Fasting blood sugar (drink 75gm glucose load)
Blood sugar level at 1hr
Blood sugar level at 2 hrs
What is the (full) management of GDM?
Basics
Education RE: GDM
Causes – explain pathophysiology and risk factors
Symptoms – explain the woman is usually asymptomatic
Complications – to mother and to foetus
Place and person
Referral to a dietician for diet modification
Investigate and confirm diagnosis
Pregnancy oral glucose tolerance test
Regular BSLs
Screen for urinary infections at the first sign of symptoms – more common in women with diabetes
Non-invasive management
Diet and exercise
Definitive management
Lifestyle interventions
Metformin
Insulin
Not oral hypoglycaemic agents (sulphynureas and biguandides) – as they cross the placenta and cause foetal hypoglycaemia.
Long term
- Women who were diagnosed with GDM or Diabetes Mellitus in Pregnancy should have a repeat 75gram OGTT performed 6 to 12 weeks after delivery
- The result of the test should be evaluated according to standard WHO criteria for the non-pregnant state.
- Women who do not have diabetes mellitus at this time should still be regarded as at risk of developing diabetes mellitus later in life and should be screened every two to three years.
A woman with T1DM comes to see you because she’s considering trying for a baby. She wants to know what risks are involved for her and the baby because of her DM. What do you say?
- Increased miscarriage risk
- High risk of DKA due to the increased insulin resistance
- Hypoglycaemia may also occur periodically especially in early pregnancy when nausea and vomiting interfere with caloric intake
- 2 fold increased risk of pre-eclampsia
- Diabetic retinopathy and diabetic nephropathy both worsen with pregnancy
You have decided to commence a woman on HRT. What are the options and when do you use each?
What are the different routes of administration?
Unopposed oestrogen:
used only in women who have had a hysterectomy - otherwise risk of endometrial Ca from unopposed oestrogen.
Combined HRT (Progesterone + Oestrogen)
If a uterus is present then progesterone therapy needs to be administered for at least 10 days each month.
Options include:
- Cyclical – taking oestrogen every day, and adding progesterone 10-14days each month (second half of cycle). The disadvantage of this option is that a withdrawal bleed will occur with the cessation of progesterone treatment.
- Continuous (daily oestrogen and progesterone) – Much less likely to have bleeding. Prescribed for women who have had no period for at least 1yr.
Other
High dose progesterone alone - for women who have had breast Ca
Testosterone - sometimes used for loss of libido
Tibolone - acts as oestrogen in some parts of body and progesterone in others
Routes
Oestrogen Only:
- Oral: commonest and most convenient, compliance can be an issue
- Transdermal patches and gel: doesn’t pass through portal circulation, change every 3-7 days, compliance better
- Implants: pellets inserted into abdo wall under fascia lata, sometimes given with testosterone, progesterone should be given orally in second half of cycle
- Vaginally: large dose steroids needed to get into circulation, good if vaginal dryness main problem
Combined:
Oral only
In taking a history about contraception, what are the things to consider?
Past - what methods have they used, why did they change?
Present - do they have ideas about what they might want to use?
Future - do they want more kids?
The go on to HOMESICK
H - Headache / Hypertension
O - Obesity
M - Medication (some ABx / anti-epileptics)
E - Embolsim (PE / DVT / Stroke)
S - Smoking status
I - IHD
C - Cancer / Increased CV risk (hyperlipidaemia)
K - Kids – breast feeding? (no oestrogen), primigravid? want more kids?
Susan has come to you wanting to start the COCP, you’ve confirmed that this is the best contraceptive method for her. What do you discuss with her whilst your writing the prescription?
Once you’ve selected a contraceptive option you need to SMERBB:
Explain how to START the medication
Explain what to do about MISSED pills.
Explain how to use EMERGENCY contraception if it’s ever needed
Explain the RISKS AND SIDE EFFECTS of the medication
Discuss BREAKTHROUGH bleeding
Measure the BP (and weight)
What are the risks of IUDs?
Pelvic infection
Perforation of the uterus on insertion
IUD dislodgement
Increased vaginal discharge (particularly mirena)
Heavier painful periods (Copper IUD)
Ectopic pregnancy
What investigations do you need before and after inserting an IUD?
Prior to insertion, the following is required:
- Non-pregnant proven by B HCG
- Negative for chlamydia (high vaginal swab or first pass urine)
- Up to date, normal pap smear
If used for contraceptive purposes
- U/S 2-3 months post-insertion to ensure correct position
What are the causes of IUGR?
Foetal
Chromosomal disorders
Congenital anomalies
Multiple gestation
TORCH infection
Placental
Uteroplacental insufficiency
Abnormal implantation
Placental abruption
Maternal
Chronic illness
Pre-eclampsia
Early or advanced age
Malnutrition
Substance abuse (e.g. cigarettes, alcohol, narcotics, cocaine)
Medications (e.g. warfarin, anticonvulsants)
A pregnant mum and her baby have been diagnosed with Rhesus disease.
What is the effect of this on the foetus?
Will it get kernicterus?
How is this situation managed? Explain.
Rh disease will cause haemolysis and anaemia in the foetus, which if untreated will lead to hydrops fetalis.
This occurs because the anaemia promotes extramedullary haematopoesis causing hepatosplenomegaly. The liver reverts the liver to producing blood rather than albumin in an attempt to compensate for the anaemia. Hypoalbuminaemia causes low oncotic pressure which leads to massive oedema/hydrops.
The foetus will not get kernicterus because the placenta will efficiently filter the bilirubin. BUT when the baby is born and no longer has the placenta it WILL be at high risk of kernicterus. This is because it will not only have high bili but also low albumin. Low albumin means that there is less protein for the bili to bind to and more is free to cross the BBB.
The management is in utero blood transfusion at a tertiary centre.
An A+ mum has a baby with B+ blood. Is there a risk of ABO blood incompatibility problems when the baby is born?
(Remember that ABO IgG doesn’t cross the placenta so there’s no problems in utero).
No, it’s only a problem if mum is O. I don’t think anyone knows why this is.
You are the intern on night cover in Sale hospital. A midwife calls you to urgently review a baby who was born 3 hours ago and seemed fine but is now in respiratory distress. What do you do?
- ABCD
- Give oxygen
- LFNP, HFNP, CPAP or ETT
- Bring to special care nursery
- Monitoring
- ECG
- SpO2 on right hand
- Bloods
- FBE/UEC/LFT
- Blood cultures
- CRP
- ABG
- CXR
- Hyperoxia test
- Consider empirical antibiotics (low threshold)
- IV access and commence fluids including dextrose
- Manage temperature
- Consider prostaglandins if not improving on oxygen, murmur or cardiomegaly on CXR
- Consider caffeine if premature
- Consider DDx
- MAS
- RDS
- Sepsis
- TTN
- Pneumothorax
- Diaphragmatic hernia
What % of deliveries will have mec stained liqour?
How common is MAS?
10%
1.5 in 1000
What are the clinical features of MAS?
- MAS is characterised by early onset of respiratory distress (within 2 hours) in a meconium-stained infant.
- Tachypnoea, cyanosis and variable hyperinflation are the main clinical findings.
- Ausculation reveals widespread ‘wet’ inspiratory crackles, occasionally with expiratory noises suggesting ball-valve airway obstruction.
- Radiologically the typical progression is from global atelectasis in early X-rays to a widespread patchy opacification accompanied by areas of hyperinflation and/or atelectasis.
- Blood gas analysis invariably shows hypoxaemia accompanied by hypercarbia in those infants with significant airway obstruction or severe respiratory failure.
What do you know about transient tachypneoa of the newborn?
Transient tachypnea of the newborn is a respiratory problem that can be seen in the newborn shortly after delivery. Amongst causes of respiratory distress in term neonates, it is the most common. It consists of a period of rapid breathing (higher than the normal range of 40-60 times per minute). It is likely due to retained lung fluid. It is most often seen in 35+ week gestation babies who are delivered by caesarian section without labor. Usually, this condition resolves over 24–48 hours. Treatment is supportive and may include supplemental oxygen and antibiotics. The chest x-ray shows hyperinflation of the lungs including prominent pulmonary vascular markings, flattening of the diaphragm, and fluid in the horizontal fissure of the right lung.
A midwife pages you to let you know that a baby on the postnatal ward who was born yesterday has become tachycardic.
Bloods (FBE and CRP) taken 2 hours ago were normal.
Even though you’re reassured by the bloods, you know that it’s important to have a low threshold for empirical antibiotics in newborns. You ask the midwife if there are any risk factors for sepsis. What are these?
- PROM
- Mec liquour
- +ve GBS status, GBS unknown
- Premature birth
- Low birth weight
- Maternal infection/fever
- Difficult birth
What are the different possible forms/appearances of the hymen?
What is Hematocolpos?
Hematocolpos is a medical condition in which the vagina fills with menstrual blood. It is often caused by the combination of menstruation with an imperforate hymen.
Anatomically and histologically, what is the transformation zone of the cervix?
- The transformation zone is a dynamic area, usually located on the ectocervix.
- The transformation zone, by definition, is the area between the original squamocolumnar junction and the current squamocolumnar junction.
- The transformation zone is that portion of the cervix that originally was columnar epithelium and through a process of squamous metaplasia is now squamous epithelium.
- At puberty, rising oestrogen levels cause the cervix to evert. The columnar tissue lining the cervical canal is everted onto the surface of the surface. This area of columnar tissue in the centre of the cervix is known as an ectopy or ectropion.
- Squamous metaplasia is a normal physiological process, caused by the acid conditions in the vagina, which causes columnar cells to transform into squamous cells.
- The area where this occurs is called the transformation zone. Squamous metaplasia is an ongoing process, occurring over many years.
- If oncogenic HPV affects the transformation zone, CIN may form instead of normal squamous tissue.
You perform a speculum examination and note that a woman’s cervix looks inflammed. You mention this and the woman asks what this means and if it’s bad. What do you say?
Inflammation of the cervix is extremely common. Chronic inflammation is present in the cervix of almost every sexually active woman.
Other causes of non-infectious cervicitis include chemical irritation (eg, deodorants, douching), local trauma from foreign bodies (eg, tampons, pessaries, IUDs), surgical instrumentation, and therapeutic intervention. Clinically, the cervix is swollen, erythematous, and friable, and an associated purulent discharge may be present.
What are the causes and risk factors for cervical cancer?
99.7% of cases are caused by HPV
- Most common causes are 16 and 18
- 31, 33, 35, 39, 45, 51, 52, 56 and 58 also cause cancer
Important risk factors!
- Smoking
- HIV infection or other immunocompromised state
- COCP
What do you find on history and exam of a patient with cervical cancer?
History
- Postcoital bleeding
- Instermenstrual bleeding
- Postmenopausal bleeding
- Persistent, offensive, bloodstained discharge
- Pain (late disease) – lateral direct spread may obstruct the ureter, causing loin pain due to hydronephrosis. It may affect the sciatic nerve, causing pain in the buttock and back of the leg
Examination
- Speculum
- Squamous carcinomas present as exophytic, friable lesions
- Hard barrel shaped cervix – more common with adenocarcinoma
- Cervix may be fixed in advanced disease
- PR
- Hard, irregular mass palpable anteriorly
What are the different types of hysterectomy?
(as in, the different options for how much is removed)
Wertheim’s is also called “radical” hysterectomy
A woman has cervical cancer, but you don’t yet know what stage. She is very keen to know what the management will be, what are the options dependent on what stage cancer she has?
Stage Ia1 (limited to cervix, less than 3mmx7mm)
Large loop excision of the transformation zone (LLETZ)
Cone biopsy
Stage Ia2 (limited to cervix, 5mmx7mm)
-
Surgical candidate:
- Hysterectomy and pelvic lymphadenectomy
- plus consider adjunctive postoperative chemoradiation
-
Non surgical candidate
- Chemoradiation
-
Trying to maintain fertility
- Repeat cone biopsy with laparoscopic pelvic node dissection
Stage Ib1 (Macroscopic lesion <4cm diameter)
-
Surgical candidate:
- Radical (Wertheim’s) hysterectomy and pelvic lymphadenectomy
- plus consider adjunctive postoperative chemoradiation
-
Non surgical candidate
- Chemoradiation
-
Trying to maintain fertility
- Radical trachelectomy + laparoscopic pelvic node dissection
Stage Ib2 to IVa (Macroscopic lesion >4cm up to anything without distant mets)
Chemoradiation
Stage IVb (distant mets)
Palliate
What are the different histopathological types of cervical cancer? How common is each type?
These do not alter staging but do alter prognosis and may alter treatment:
- Squamous (80%)
- Adenocarcinomas (15%)
- Adenosquamous (3% to 5%): poorest outcome of common cell types
- Rare: transitional cell, neuroendocrine, small cell, adenoid cystic, mesonephric, adenoma malignum, lymphoma, sarcoma.
What are the risk factors for endometrial cancer?
- Obesity
- Menstrual factors
- Early menarche
- Late menopause
- Low parity
- Anovulatory amenorrhoea e.g. PCOS
- Unopposed oestrogen HRT
- Oestrogen-secreting ovarian tumours
- Tamoxifen
- Family history of colorectal cancer, endometrial cancer, breast cancer (Hereditary non-polyposis colorectal cancers - HNPCC)
What are the histopathological types of endometrial cancer? How common is each type?
- Adenocarcinoma is the commonest carcinoma (95%)
- Majority are endometrial type
- Adenosquamous carcinoma are less common
Where does endometrial cancer spread to?
- *Direct spread**: cervical stroma, Fallopian tubes and ovaries
- *Lymphatic spread**: Pelvic and para-aortic lymph nodes
Haematological spread: Liver and lungs
What do you find on history and exam of a patient with endometrial cancer?
History
- Postmenopausal bleeding
- Premenopausal women may present with irregular, heavy or intermenstrual bleeding
- Menstrual irregularities in women >40 years require investigation
Examination
- Speculum
- To exclude other causes
- Bimanual
- Fixed or bulky uterus with advanced disease.
What is the management of endometrial hyperplasia?
Basics
Nil
Place and person
Gynacology referral
Investigate and confirm diagnosis
- Transvaginal ultrasound
- Hysteroscopy and biopsy
Non-invasive management
LOW to reduce oestrogen
Definitive management
- Simple and complex hyperplasia*
- Progestogens
- Mirena IUD or POP
- Follow up with repeat biopsy
- Atypical hyperplasia*
- High risk
- TAH and BSO recommended
- Regular surveillance is indicated if TAH declined
- Success of high-dose progestogens is controversial
- High risk
Simple = no cytological atypia
Complex = Atypical glandular picture with proliferation, irregular outlines and obvious structural complexity
Atypical = Glands have atypical nuclei. Severe cases are indistinguishable from cancer
Who should have pap smears?
When should they start, how often should they have them? when should they finish?
Who
Women who have ever had sex and still have an intact cervix should undergo Pap test screening.
Women who have never had genital-skin to genital-skin contact with anyone do not require Pap tests.
When to start
Pap test screening is recommended every 2 years for women who have ever had sex and have an intact cervix, commencing from age 18–20 years (or 1-2 years after first having sexual intercourse, whichever is later).
Women under the age of 18 usually will not require a Pap smear, even if they have had sexual intercourse. Cervical cancer is very slowly progressing, and therefore any abnormalities detected on screening will only be due to acute HPV infection.
How frequently should one continue Pap smears?
Routine screening with Pap tests should be carried out every 2 years for women who have no symptoms or history suggestive of cervical pathology.
When should one stop Pap smears?
Pap tests may cease at age 70 years for women who have had two normal Pap tests within the last 5 years.
A woman tells you she doesn’t want a pap smear because she’s had the HPV vaccine so should be immune from cervical cancer. What do you say?
The introduction of the HPV vaccine as part of the National Immunisation Program 2007 may reduce the future incidence of cervical cancer, but is not a substitute for a continuing screening program.
If the woman has had the HPV vaccine, she should still continue to have regular Pap tests. The vaccine only protects against some HPV types (type 16 and 18) which leads to 70 per cent of cervical cancer. There are several other HPV types that can cause cervical cancer that are not covered by the vaccine. The woman may have been exposed to these via sexual activity. Additionally, the woman may have been exposed to HPV types before she had the vaccine.
A woman gets an abnormal pap smear result and is very worried. How can you easily explain the development of cervical cancer to her?
What is the clinical definition of menorrhagia?
Heavy menstrual bleeding (menorrhagia) may be defined by:
- blood loss of > 80 mL per menstrual cycle
- bleeding that persists > 7 days, or
- bleeding that is unacceptable to the woman
An expectant mother is Rh - and her partner is Rh +. When should she receive Anti-D?
According to RANZCOG, all women who are rhesus negative (and who have not already formed their own rhesus antibodies ie. have a negative antibody screen) should receive anti-D / Rho-GAM at the following time periods:
- 28 weeks gestation
- 34 weeks gestation
- 72 hours after delivery
They should also be offered anti-D after the following events:
- In the first trimester
- CVS
- Miscarriage
- Termination of pregnancy
- Ectopic pregnancy
- In the second trimester
- Obstetric haemorrhage
- Amniocentesis, cordocentesis
- External cephalic version of breech presentation (whether successful or not)
- Abdominal trauma
What is the The Kleihauer test?
The Kleihauer test is a blood test used to measure the amount of fetal hemoglobin transferred from a fetus to a mother’s bloodstream. It is usually performed on Rhesus-negative mothers to determine the required dose of Rho(D) immune globulin(RhIg) to inhibit formation of Rh antibodies in the mother and prevent Rh disease in future Rh-positive children
What is the likely bug in this case?
A 55-year-old lady presents with a non-offensive, white vaginal discharge. She also describes polyuria for the last three months with nocturia. Her BMI is 36, and the pH of the vaginal discharge is 4.5.
This woman is showing symptoms of candidiasis. She has a high BMI and polyuria indicating that she may suffer with diabetes which puts a person at a greater risk of developing infection with Candida albicans.
What is the likely bug in this case?
A 26-year-old lady presents to antenatal clinic with a thin vaginal discharge. The discharge has a pH of 4.7 and microscopy reveals epithelial cells covered with bacteria.
Gardnerella infection
This woman is suffering with a condition known as bacterial vaginosis. The exact cause is unknown but typically a bacterial imbalance causes the symptoms. The epithelial cells covered by bacteria are known as ‘clue cells’ and are diagnostic when seen on microscopy. Metronidazole is the treatment of choice.
A 48-year-old woman presents with an acute onset of left breast pain. On examination there is thrombophlebitis of the superficial veins of the breast.
What is the diagnosis and management?
Mondor’s disease
Mondor’s disease is thrombophlebitis of the superficial veins of the breast causing tender subcutaneous cords. It is self-limiting and like other causes of thrombophlebitis it is treated with non-steroidal anti-inflammatory drugs (NSAIDs).
Which of the following statements is true and which false regarding twin pregnancy?
- Is associated with an increased risk of congenital malformation
- Is more common with increasing maternal age
- Is usually dizygous
- Prophylactic tocolytic drugs are of proven value
- Should be managed in hospital from 28 weeks
-
Is associated with an increased risk of congenital malformation
- Abnormality rates as high as 10% have been quoted, mainly heart and intestinal defects and anencephaly.
- If second trimester miscarriages are included with perinatal mortality figures, overall losses of around 10% occur.
- Is more common with increasing maternal age
-
Is usually dizygous
- Twins usually arise from completely independent fertilisation and development of two eggs - hence most are dizygous.
- Prophylactic tocolytic drugs are of proven value
- Should be managed in hospital from 28 weeks
A 48-year-old woman presents with an acute onset of left breast pain. On examination there is thrombophlebitis of the superficial veins of the breast.
What is the diagnosis and management?
Mondor’s disease
Mondor’s disease is thrombophlebitis of the superficial veins of the breast causing tender subcutaneous cords. It is self-limiting and like other causes of thrombophlebitis it is treated with non-steroidal anti-inflammatory drugs (NSAIDs).
What discrepancy is considered significant in symphysis fundal height?
What are the possible causes of a discrepancy?
+/- 2 cm
However this is really only valid between 20-34 weeks
Possible causes:
- fetus is small/large for gestational age
- multiple pregnancy
- inaccurate EDD
- molar pregnancies
- polyhydramnios/oligohydramnios
- oblique or transverse lie
A woman who is 11 weeks pregnant presents to ED in shock. What could have caused this?
- *Hypovolaemic** shock – due to a ruptured ectopic
- *Neurogenic** (cervical) shock – products of conception in cervix (causes an increase parasympathetic drive and bradycardia)
- *Septic** shock – miscarriage with infection
What is a heterotopic pregnancy?
When two eggs are fertilized; one implants at an intra-uterine site, another at an extra-uterine site.
Often associated with induced ovulation (IVF) (1:11,000). Otherwise rare (1:40,000)
When a woman presents with bleeding in early pregnancy, what are you thinking in terms of the probability of each of the possible outcomes?
60% will have an ongoing pregnancy
30% will have pregnancy loss
- 5% will have an ectopic pregnancy
- 5% will have another diagnosis.
Investigations to order for bleeding in early pregnancy?
Bedside
Pregnancy test, urine dipstick
Bloods
FBE
HCG
Blood group and hold
Blood cultures if febrile or suspect sepsis
Imaging
Transvaginal ultrasound
Special
none
In women at high risk or pre-eclampsia/eclampsia, what preventative measures are taken during pregnancy?
low dose aspirin 75‐150mg/day
Calcium 1g/day
THIS IS ONLY VALUABLE IF COMMENCED BEFORE 16 WEEKS
At what gestational age to ectopic pregnancies tend to rupture?
10 weeks
The average gestational age of maternal symptoms of ectopic pregnancy is 7 weeks
What % of ectopic pregnancies have an identifiable risk factor?
What are the risk factors?
50%
Risk factors all relate to factors which would make the uterus less hospitable for implanation
- Previous ectopic
- Previous PID
- Smoking (impairs ciliary activity)
- Previous tubal surgery
- History of infertility (esp if IVF)
- Advanced maternal age
- IUDs, progesterone-only pills, tubal ligation
How do you calculate gestational age/estimated due date?
The estimated due date (EDD) is the date that spontaneous onset of labor is expected to occur.
By menstruation
The due date may be estimated by adding 280 days (9 months and 7 days) to the first day of the last menstrual period (LMP). This is the method used by “pregnancy wheels”.
The accuracy of the EDD derived by this method depends on accurate recall by the mother, assumes regular 28 day cycles, and that conception occurs on day 14 of the cycle. This method may overestimate the duration of the pregnancy, and can be subject to an error of more than 2 weeks.
When you know
In cases where the date of conception is known precisely, such as with IVF, the EDD is calculated by adding 266 days to the date of conception.
By ultrasound
Ultrasound uses the size of the fetus to determine the gestational age (the time elapsed since the the first day of the last menstrual period). The accuracy of the ultrasound estimate of the gestational age varies and is highest in the first trimester.
How would you advise an anxious expectant mother to avoid miscarriage?
In the healthy, first-time pregnant woman there is no known strategy to prevent a miscarriage.
Even in women who have a significant medical or surgical disorder the concept of prevention of miscarriage is difficult to define. There is insufficient evidence on the intake of vitamins or bed rest in early pregnancy to help prevent miscarriage, stillbirth, or other maternal and infant outcomes.
At what BHCG should a yolk sak be visible on transvaginal USS?
A B-HCG >1,500 IU/L indicates that a normal intra-uterine pregnancy should be visible on vaginal ultrasound.
If uterus is empty at this reading, then the pregnancy is either ectopic or miscarried.
What is the most common cause of miscarriage in
a) first trimester
b) second trimester
first trimester = foetal chromosomal abnormality
second trimester = ascending infection from the lower urinary tract
What is a blighted ovum?
Also known as an ‘anembryonic pregnancy’
When a gestational sac forms but no embryo develops.
The woman may experience the normal symptoms of pregnancy or some PV bleeding.
Diagnosed on ultrasound.
Treatment options are the same for other miscarriages.
What symptoms/features of clinical picture can miscarriage present with?
PV bleeding, clots and crampy pain in early pregnancy
Disappearance of normal symptoms of pregnancy (loss of urinary frequency, nausea)
Hypotension, bradycardia – cervical shock due to products of conception in cervix
What are the risk factors for miscarriage?
- advanced maternal age
- Asymptomatic bacterial vaginosis
- IVF
- Alcohol intake during pregnancy
- Smoking during pregnancy
- Overweight/obese mother
What is the management/prognosis of subchrorionic haemorrhage?
Fetal outcome is dependent on size of the haematoma, maternal age, and gestational age. In most cases the haematoma gradually decreases in size on follow-up.
However, a large hematoma that has caused 30 to 40 percent of the sac surrounding the embryo to separate from the wall of the uterus may continue to get larger, causing the gestational sac to become compressed and membranes to burst, which will ultimately abort the pregnancy.
How would you interpret a low beta-HCG?
How would you interpret a high beta-HCG?
(Remember that the normal range is enormous)
Low beta-HCG either means ectopic pregnancy or miscarriage.
The level will continuously drop in miscarriage but plateu in ectopic
High b-HCG could be trophoblastic disease
Once you detect a foetal heartbeat (either because you’ve done an USS because something has caused you to worry, or just because it’s time for the routine 12 week USS), what is the risk of miscarriage after that point?
2%
That is, you start out with a risk of 50%, but once the baby has a detectable heartbeat your chance of miscarriage drops to 2%
What should you see on serial measurements of bHCG in a normal pregnancy?
Doubling every 48 hours
Considered slow if it doesnt rise by at least 50% in 48 hours
A woman’s EDD is different when calculated based on her LMP versus on her dating ultrasound. How do you decide which estimate to use?
For ultrasound performed between 6 and 13 weeks pregnancy — if the two dates differ by 5 days or less, use the LMP estimate; if the dates differ by more than 5 days, use the ultrasound estimate.
For ultrasound performed between 13 and 24 weeks pregnancy — if the two dates differ by 10 days or less, use the LMP estimate; if the dates differ by more than 10 days, use the ultrasound estimate.
What are the components of the “triple test”, when are they performed and what can they detect?
Maternal Serum Screen (at 10 weeks)
Free beta-HCG
PAPPA-A
Ultrasound (at 12 weeks)
Nuchal fold thickness
Can detect Trisomy 18 and Trisomy 21
A pregnant woman comes to see you for a checkup at the start of the 3rd trimester. She has had gold standard antenatal care up until now. What investigations should you order for her at this visit? What medication should you prescribe?
2 hour Pregnancy Oral Glucose Tolerance Test (POGT)
Rhesus antibodies
Irregular antibodies - if they are rhesus negative they should be given Rho-GAM at 28 weeks (even if no suspicion of foetomaternal haemorrhage)
FBE/Ferritin
Women receive Boostrix (dTpa - diptheria, tetanus, pertussis) vaccine at this point (and partners if they haven’t had a vaccine in the last 10 years)
A woman is identified as GBS positive. What antibiotics do you prescribe and when?
Benzylpenicillin during labour or at PROM
How much post partum bleeding/haemorrhage is normal? When do you start to really worry?
<500ml is normal
>1000ml you really worry
What are the cardinal movements of childbirth?
Delicate Females in China Eat Rice In Early Labour
Descent
Flexion
Internal rotation (turn neck to occipital-anterior orientation)
Crowning (this is when the contractions are no longer 3 steps forward 1 step back, the head stays in the perineum)
Extension
Restitution (also called external rotation, neck turns 45deg to once again be in line with shoulders)
Internal rotation of shoulders
External rotation (as evidenced by external rotation, shoulders rotate to AP orientation)
Lateral flexion
A woman who is 37+5 weeks pregnant has ROM. When do you expect her to go in to labour?
About 80 to 90% of women with ROM at term go into labor spontaneously within 24 h. If membranes rupture at term but labor does not start within several hours, labor is typically induced to lower risk of maternal and fetal infection.
A woman at 33+5 weeks pregnancy has ROM. When do you expect her to go in to labour?
50% of women with PROM preterm go into labor spontaneously within 24 h.
> 90% of women with PROM go into labor within 2 wk. The earlier the membranes rupture before 37 wk, the longer the delay between rupture and labor onset.
What are the most common causes of pre-term labour?
- Chorioamnionitis
- Overdistension (due to multiple gestation or polyhydramnios)
- Bleeding/placentral abruption
- Serious Illness such as pyelonephritis, appendicitis and pneumonia
- abnormal placentation/fibroids/ cervical weakness
- Idiopathic
A pregnant woman deemed to be at risk of preterm labour is recommended to have steroids to help the babies lung development. What are the contraindications for doing this?
Should be used with caution in the woman who has systemic infection including TB or sepsis, as steroids suppress the immune system.
Diabetes mellitus or impaired glucose tolerance is not a contraindication, but BGL monitoring is recommended for women with these conditions who receive antenatal steroids.
What is the dosing regime recommended for antenatal steroids?
Two doses of 12 mg IM betamethasone, given 24 hours apart
OR
Four doses of 6mg IM dexamethasone, given 12 hours apart
Note: weekly repeats are not recommended – although they do reduce the severity of neonatal respiratory distress they are also associated with a reduction in weight and head circumference.
What are the risks of PROM and Pre-term PROM?
PROM
- Maternal infection
- Neonatal infection
- Cord prolapse
- Cord compression
- Placental abruption
PPROM
All of the above plus premature birth
What are the two main contraindications to digital vaginal exams during pregnancy?
PROM (infection risk)
Proven or unknown placenta previa
A pregnant woman has had PPROM at 30+1. This was 3 days ago and it doesn’t look like she’s about to go in to labour. For the wellbeing of the fetus the obstetrician doesn’t want to induce labour just yet. What should you do?
Why should you do this?
Commence steroids in case of early labour
Check BGS status
Erythromycin (250mg po 6 hourly for 10 days)
Why erythromycin?
Reduces the chance of delivery within seven days, reduces the need for neonatal surfactant, reduces the incidence of neonatal lung disease, major cerebral haemorrhage on ultrasound and death.
At what gestational ages would you consider conservative or active management of PPROM?
Is there a role for tocolytics?
Is there a role for tocolysis to delay the onset of labour?
No. In fact it might be dangerous. Only short term tocolysis is indicated; for the purposes of finishing a course of antenatal steroids or for transfer to facility with NICU
A pregnant woman at 37+4 has come in for an IOL. She has an unfavourable Bishop score and is 2-3 cm dilated, would you perform stretch and sweep? What are the risks of doing so?
No
Only done if post term (not prior to 40 weeks)
Involves a digital VE and stretching of the cervix to reach the internal os, and performing a cyclical ‘sweeping’ 360 degree motion. This causes the release of natural prostaglandins.
Risks: Discomfort and bleeding (does NOT increase risk of infection)
A pregnant woman who is having a trial of VBAC has an unfavourable bishop score. How would you encourage cervical dilation/ripening?
Transcervical Foley Catheter
Catheter is passed into the cervix, blown up and left for 24 hours.
Stretches the cervix and causes natural release of prostaglandins.
Risks: infection and discomfort
Preferred method for VBAC patient with a cervix requiring ripening (don’t use prostaglandins in women who have had a C-section).
You have given a woman undergoing IOL prostaglandins to ripen her cervix. When can you start oxytocin?
6h after gel
30mins after removal of pessary
What are the complications of shoulder dystocia?
- Post-partum haemorrhage
- Rectovaginal fistula
- Perineal tearing
- Uterine rupture
- Clavicle fracture
- Brachial plexus injury
- Fetal hypoxia/death
What are the signs of shoulder dystocia?
- Turtle Sign: when the fetal head emerges and then retracts against the perineum
- Difficulty delivering the head and chin
- There is no restitution
- The shoulders fail to descend (and you can still palpate the anterior shoulder abdominally)
What is the sensitivity/specificity of CTG for a sick fetus?
Sensitivity 97+%, the problem is that specificity is 50-60%
HOWEVER, the CTG is less likely to be incorrect in higher risk pregnancies, (pre-term, bleeding etc)
What are the causes of decreased variability on CTG?
- Deep fetal sleep (20mins at a time)
- Important, if decreased variability for 10 mins the baby might just be asleep!
- Drugs (epidural, morphine etc)
- Prematurity
- Less symp/parasymp drive so may be normal. If lots of accelerations in preterm baby be reassured
- Hypoxia
- Congenital abnormalities
What is the first line medication for tachysystole?
subcutaneous terbutaline 0.25 mg
What are the causes of fetal tachycardia on CTG?
- High inherent rate (premmie!)
- Maternal tachy (UTI/pyelonephritis?)
- Maternal fever
- Fetal tachyarrythmia (SVT, Aflutter)
- Drugs – b agonist for tocolysis
- Hypoxia
- Chorioamnionitis
- Dehydration
You see a sinusoidal decelleration on CTG. What are the possible causes?
Only 2 things that cause this
1) foetal anaemia (due to isoimmunisation or something
2) baby is sucking their thumb
What is the risk of uterine rupture in VBAC?
0.5%
What is the reference ranges of fetal heart rate on CTG?
Reassuring = 110 - 160 beats per minute.
Non-reassuring = 100-109
Abnormal is <100 or >160
How much does the body’s temperature go up in the luteal phase of the menstrual cycle and why is this?
0.5 degrees
Because progesterone is thermogenic
Until what age should women continue taking contraception?
55
(Mini pill from age 50)
What do you need to check before inserting an IUD?
1) normal, current pap
2) high vaginal swab chlamydia screen
3) not pregnant proven by b-HCG
What are the steps you need to take in a consultation to commence a woman on a contraceptive pill?
Once you’ve selected a contraceptive option you need to SMERBB:
Explain how to START the medication
Explain what to do about MISSED pills.
Explain how to use EMERGENCY contraception if it’s ever needed
Explain the RISKS AND SIDE EFFECTS of the medication
Discuss BREAKTHROUGH bleeding
Measure the BP (and weight)
What is the most important treatable cause of recurrent miscarriages?
Anti-phospholipid syndrome
What antibodies do you screen for to diagnose antiphospholipid syndrome?
Lupus anticoagulant
Anticardiolipin antibodies
Anti-B2 glycoprotein-I antibodies
What is the management of a woman who has had multiple miscarriages due to antiphospholipid syndrome?
low-dose aspirin plus heparin
This treatment combination significantly reduces the miscarriage rate by 54%
No adverse fetal outcomes reported in meta-analyses
Heparin does not cross the placenta
Corticosteroids IVIg therapy do NOT improve the live birth rate of women with recurrent miscarriage associated with antiphospholipid antibodies.
At what stage through the pregnancy does pre-eclampsia tend to occur?
After 20 weeks gestation, when the trophoblasts would normally have done their thing
What are the investigations for pre-eclampsia?
Bedside
Urine dipstick
Bloods and urine
FBE
UEC
Urinalysis
LFTs
Coagulation studies
Imaging
Foetal USS/CTG –> IUGR?
Amniotic fluid assessment
Maternal and foetal dopplers
What is the management of mild pre-eclampsia?
BP 140/90 - 150/100
What is the management of moderate pre-eclampsia?
150/100 - 160/110
What is the management of severe pre-eclampsia?
>160/110
What are the complications of pre-eclampsia?
IUGR
Oedema/Pulmonary oedema
Placental abruption
Renal failure
DIC
Stillbirth
CVA
Eclampsia
HELLP
How long to eclamptic seizures typically last and what causes them?
Eclamptic seizures are almost always self-limiting and seldom last longer than three to four minutes (usual duration 60 to 75 seconds).
Exact mechanism is unknown. It is likely due to vasospasm of the cerebral arteries (caused by the persistent hypertension) causing temporary neural ischaemia and oedema.
What is the management of eclampsia?
What are the diagnostic criteria for HELLP?
What are the cysts in PCOS?
The cysts are harmless egg-containing follicles, which have improperly developed due to the hormone imbalance in PCOS. As a result, the egg from the improperly developed follicles cannot be released during ovulation and anovulation results. This is one of the main causes of subfertility.
What are the SIGNS and SYMPTOMS of PCOS?
What are the diagnostic criteria for PCOS?
Diagnostic criteria for Rotterdam diagnosis of polycystic ovary syndrome
Two of the following three criteria are required:
- oligo/anovulation
- hyperandrogenism
- clinical (hirsutism or less commonly male pattern alopecia) or
- biochemical (raised FAI or free testosterone)
- polycystic ovaries on ultrasound
Other aetiologies must be excluded such as
- congenital adrenal hyperplasia,
- androgen secreting tumours,
- Cushing syndrome,
- thyroid dysfunction and
- hyperprolactinaemia
What is the most common feature of hyperandrogenism in women with PCOS?
Hirsuitism –> 65-75%
Menstrual disturbance: commonly oligomenorrhoea and amenorrhoea –> 60-85%
How does PCOS cause infertility?
- Incr intra-ovarian androgen inhibits follicular maturation.
- Incr ovarian follicles produce inhibin B levels that inhibit FSH.
- FSH not fully suppressed therefore continuous recruitment and stimulation of follicles that don’t mature or ovulate
- Incr follicles produce incr oestrogen which stimulates an increase in prolactin
Do all women with PCOS have polycystic ovaries?
What are the three different phenotypes of PCOS?
No
8-25% of non PCOS women also have ultrasonographic features of PCO. PCO is also seen in hypothalamic amenorrhoea, pubertal development and hyperprolactinemia.
What are the ultrasound criteria for polycystic ovaries in PCOS?
Defined as the presence of 12 or more follicles in either ovary measuring 2-9mm in diameter and/or increased ovarian volume greater than 10mL
What are the risks/complications of PCOS?
- Psychological
- Anxiety
- Depression
- Poor self esteem
- Metabolic
- 40% chance of metabolic syndrome
- hypercholesterolaemia, HTN, central obesity, insulin resistance
- 5-10x risk of T2DM
- High risk of GDM
- 40% chance of metabolic syndrome
- Reproducitve
- Infertility
- 3x risk of endometrial cancer
What are the differential diagnoses for PCOS?
- Constitutional obesity
- Idiopathic hirsutism
- Cushing’s syndrome
- Hypothyroidism
- Prolactinoma
- Cushings disease/syndrome
- Always rule out other androgen excess disorders
- Congenital adrenal hyperplasia
- Androgen producing tumours
What investigations would you order for suspected PCOS?
Bedside
BGL
Bloods and urine
Serum total and free testosterone
Serum DHEA
Serum 17-hydroxyprogesterone (if elevated suggests congenital adrenal hyperplasia due to 21-hydroxylase-deficiency)
Serum prolactin (to exclude hyperprolactinaemia, which may present with oligo- or anovulation)
Early morning cortisol (exclude Cushings)
TSH (Active thyroid dysfunction may present with oligo- or anovulation, or menometrorrhagia.)
OGTT
Fasting lipids
Serum LH/FSH
Imaging
Pelvic ultrasound of ovaries
What is the management of PCOS?
NB: Treatment of hirsuitism takes several months to show effect because of length of hair growth cycle
Notes on below flowchart:
Choice of OCP: Yaz
Newer, less-androgenic progestogens include desogestrel or norgestimate. Drospirenone is a spironolactone analogue with anti-androgenic and anti-mineralocorticoid properties. Pills with these newer, lower-androgenicity progestins may, however, confer a higher risk of venous thromboembolism than older pills.
How does metformin work?
Metformin is associated with decreased testosterone levels and increased sex hormone binding globulin (SHBG) levels, with limited evidence of improvement in hirsutism. Thus, for the specific goal of treating hyper-androgenism, it is best suited as add-on therapy to OCPs, anti-androgens, or OCPs plus anti-androgens.
How does clomifene work?
Clomifene is a non-steroidal anti-oestrogen that inhibits oestrogen negative feedback on the hypothalamus/pituitary, which in turn leads to an increase in FSH secretion that may allow follicular maturation and ovulation.
What is the definition of infertility?
The absence of conception after one (some sources say two) year of regular, unprotected intercourse.
Fine to start investigating after one year.
In women >35yo fine to start investigation after 6 months.
How common is infertility?
15% of couples are infertile
70% of these couples have primary infertility
30% of these couples have secondary infertility
A couple is trying to get pregnant. They are having a lot of sex but ask you when the best time to have sex is to maximise their chances of getting pregnant, what do you tell them?
We’re talking about the days in a woman’s menstrual cycle when pregnancy is possible. Pregnancy is technically only possible during the five days before ovulation through to the day of ovulation.
These six days are the ‘fertile window’ in a woman’s cycle, and reflect the lifespan of sperm (5 days) and the lifespan of the ovum (24 hours).
Instructions
- Work out the length of your average menstrual cycle. Day one is the first day of the menstrual period and the last day is the day before the next period begins.
- Ovulation happens about two weeks before the next expected period. So if your average menstrual cycle is 28 days, you ovulate around day 14.
- Remember the ‘fertile window’ is the six days leading up to and including ovulation.
- The three days leading up to and including ovulation are the most fertile. Depending on your cycle length the most fertile days in the cycle varies:
- If you have 28 days between periods ovulation typically happens on day 14, and the most fertile days are days 12, 13, and 14.
- If you have longer cycles, say 35 days between periods, ovulation happens on day 21 and the most fertile days are days 19, 20, and 21.
- If you have shorter cycles, say 21 days between periods, ovulation happens on day 7 and the most fertile days are days 5, 6, and 7.
Refer them to this website for a great calculator: http://yourfertility.org.au/for-women/timing-and-conception
What is the best established pharmacotherapy for inducing ovulation?
Clomiphene
Given days 2-5 to 6-9
Ovulation occurs 5-10 days after last tablet
Ovulation rates vary from 40-85%
What are the causes of infertility?
USEMOAT or UNEXPLAINED
U - Uterine & Cervical causes
S - Sex
E - Endometriosis
M - Male
O - Ovulatory causes
A - Age
T - Tubal causes
Or UNEXPLAINED
Full list see here –>
- Uterine
- Scarring post infection (endometritis) or trauma (D&C)
- Asherman’s syndrome
- Fibroids
- Congenital abnormalities
- Sex
- Erectile dysfn (EtOH, smoking etc)
- Psychological
- Hypospadius
- Vaginismus
- Timing
- Endometriosis
- Adhesions/scarring
- Male
- Hypospermatogenesis (most common)
- Trauma/torsion
- Infection - mumps orchitis
- Congenital microdeletions on Y chromosome
- Obstructive problem
- Congenital absence of the vas
- Vasectomy
- Autoimmune
- Anti-sperm antibodies
- Endocrine
- Hypogonadism
- Hypergonadotrophic
- Hypogonadotrophic
- Hyperprolactinaemia –> importence
- Hypospermatogenesis (most common)
- Ovulatory
- PCOS
- Hypogonadism
- Hypergonadotrophic
- Premature ovarian failure
- Hypogonadotrophic
- Over/under weight
- Sheehan syndrome
- Pituatary surgery
- Hypergonadotrophic
- Hyperprolactinaemia
- Hypothyroidism
- Age
- Tubal
- Infection/STI
- UNEXPLAINED (40%)
What are the investigations for infertility?
- Hormonal
- Ovarian reserve
- Day 2-4 FSH/LH + oestradiol concentration
- AMH
- Mid luteal progesterone
- TFTs
- Serum prolactin
- Ovarian reserve
- Infectious
- First pass urine PCR
- Structural
- Pelvic Ultrasound
- Hysterosalpingo contrast sonography
- Hystero-salpingography
- Hysteroscopy
- Laparoscopy
- Other
- Rubella immunity status
- Varicella immunity status
- Sperm
- Semen Analysis
- Immuno Bead Test (IBT) for anti-sperm antibodies
What is Sheehan’s syndrome?
How does it occur?
What are the features/effects of symptomatic Sheehan’s syndrome?
Hypopituitarism caused by ischemic necrosis due to blood loss and hypovolemic shock during and after childbirth.
A common presentation is the failure of lactation when a mother is trying to breastfeed.
How does it occur?
Hypertrophy and hyperplasia of lactotrophs during pregnancy results in the enlargement of the anterior pituitary, without a corresponding increase in blood supply.
Secondly, the anterior pituitary is supplied by a low pressure portal venous system.
These vulnerabilities, when affected by major hemorrhage or hypotension during the peripartum period, can result in ischaemia of the affected pituitary regions leading to necrosis.
The posterior pituitary is usually not affected due to its direct arterial supply.
Features/effects –> see pic
You see a couple who are trying to conceieve in clinic. The woman has given up smoking to improve her chances of falling pregnant but the man still smokes (outside, away from the woman). What do you tell him?
Children of fathers who smoked during conception have an up to 4x risk of developing cancer later in life than children who’se father’s did not smoke.
Roughly how much does one round of IVF cost? How much does medicare pay?
$11k
Medicare pays around $5k
In endometriosis, where is endometrial tissue MOST COMMONLY deposited?
on the ovaries or on the uterosacral ligaments.
What is this?
“Chocolate cyst”
accumulated blood and endometrial tissue on the ovary
Which demographic group is most commonly affected by endometriosis?
Most common in nulliparous women of higher socioeconomic class.
What do you find on HISTORY and EXAM of endometriosis?
History
- Pelvic pain
- May be cyclical OR CHRONIC
- Often described as a sharp, shooting pain up the rectum during defecation when menstruating
- Secondary dysmenorrhea
- Deep dyspareunia (especially if endometrial tissue is in the pouch of Douglas)
- Subfertility
- Rectal bleeding (if bowel endometriosis)
- Haematuria (if urinary tract endometriosis)
- May also be asymptomatic
Examination
- Usually unremarkable
- Speculum examination may reveal bluish discolouration of the cervix or vagina
- Bimanual examination may be painful, and may reveal nodules or a thickened pouch of Douglas
What are the investigations for endometriosis?
Bedside tests
Transvaginal or transabominal ultrasound
Imaging
MRI pelvis
Special tests
Diagnostic laparoscopy – gold standard
What is the management of endometriosis?
Basics
Control pain with NSAIDs
Place and person
Refer to O&G
Investigate and confirm diagnosis
Bedside tests
Transvaginal or transabominal ultrasound
Imaging
MRI pelvis
Special tests
Diagnostic laparoscopy – gold standard
Definitive management
Conservative –> simple analgesia
COCP
Progesterones - Mirena IUD, Depot Provera
GnRH agonists - Goserelin
Surgical
Laparoscopic ablation and excision
What do LSIL and HSIL stand for?
Low grade Squamous Intra-epithelial lesion (LSIL)
High grade Squamous Intra-epithelial lesion(HSIL)
What strains of HPV are high risk for causing cervical cancer?
16 & 18
together cause 70% of Squamous Cell Carcinoma of the cervix
What strains of HPV cause genital warts?
90% caused by 6 & 11
Jane is a 32yo woman. She has had a pap smear with a CIN1/LSIL result. What do you recommend happens now?
If doesn’t have a clear pap smear in the past 3 years repeat in 6 months. Otherwise repeat in 12 months.
From lecture slides:
IF WOMAN IS 30+ YRS, AND HAS NO NEGATIVE CYTOLOGY IN PREVIOUS 2-3 YRS, COLPOSCOPY OR REPEAT SMEAR IN 6 MONTHS
Margot is a 45 year old woman, who had a HSIL treated back when she was 32 y.o.
She has been having annual smears since then - all normal.
When can she stop having annual pap smears and return to the routine 2 yearly schedule?
A woman with treated HSIL should have HPV test and colposcopy at 4-6 months after treatment. She should then have HPV and pap testing at 12 months and 24 months.
After ALL FOUR of these tests (ie: 2x paps and 2x HPV) are normal she can return to normal screening.
What strains of HPV does Gardasil cover?
The vaccine is effective against HPV types 16 and 18 which cause approximately 70% of cervical cancers, and against HPV types 6 and 11 which cause approximately 90% of genital warts.
Gardasil is expected to prevent up to 70% of cervical cancers, because they are due to HPVtypes against which the vaccine is directed.
From 2017 what cervical cancer screening protocols will be in place?
What is the protocol for a positive test?
5 yearly HPV screening
Start age 25, finish age 75
If symptomatic can screen at any time
If positive test
- HPV 16/18
- colposcopy, if okay repeat HPV at 1 year
- HPV not strain 16 or 18
- repeat HPV screen in 1 year, if clear return to 5 year screening
Who should receive chlamydia screening and how?
Who?
All women under 30 should have yearly tests
Women with a new partner
Sexually active women
How?
Asymptomatic women can have a first pass urine for NAAT PCR
Symptomatic women should have a vaginal swab
What is the tumour marker for ovarian/endometrial cancer? What else can cause it to be elevated?
CA125
- Epithelial ovarian cancer
- Endometrial cancer
- Benign ovarian masses
- Endometriosis
- Fibroids
- Menstruation
- PID
- Ovarian hyperstimulation syndrome (OHSS)
- Colon and breast cancer
- Peritoneal irritation
Do pap smears screen for adenocarcinoma of the cervix?
No
There is no screening test for adenocarcinoma of the cervix, although abnormal glandular cells can be identified on Pap smear.
HOW do you stage cervical cancer?
What are the stages?
Examination under anasthesia
MRI
PET
Stages (5 year survival in brackets)
Stage 0 - Carcinoma in situ (100%)
Stage 1 - Confined to cervix (85%)
Stage 2 - Beyond cervix but NOT to pelvic wall or lower 3rd of vagina (65%)
Stage 3 - To pelvic wall or lower 3rd of vagina (35%)
Stage 4 - Invades rectum, bladder or other mets (7%)
What is the lifetime risk of ovarian cancer?
1%
What is the most deadly gynae cancer?
Ovarian cancer
Mainly because majority are diagnosed late
Symptoms are vague
What is the most common ovarian germ cell tumour?
What is the management?
Most common ovarian germ cell tumour is ovarian dermoid cyst (mature cystic ovarian teratoma) which is benign
Ovarian dermoid cyst and mature cystic ovarian teratoma are terms often used interchangeably to refer to the most common ovarian neoplasm. These slow-growing tumours contain elements from multiple germ cell layers and are best assessed with ultrasound.
They are composed of well-differentiated derivations from at least two of the three germ cell layers (i.e. ectoderm, mesoderm, and endoderm). They therefore contain developmentally mature skin complete with hair follicles and sweat glands, sometimes luxuriant clumps of long hair, and often pockets of sebum, blood, fat, bone, nails, teeth, eyes, cartilage, and thyroid tissue.
Management
Mature ovarian teratomas are slow growing (1-2 mm a year) and, therefore, some advocate nonsurgical management. Larger lesions are often surgically removed. Many recommend annual follow up for lesions <7 cm to monitor growth, beyond which a resection is advised.
What instruments would you use for what kind of woman when taking a pap smear?
Pre-menopausal women –> Cervix broom alone in transformational zone easily seen
Non-pregnant women who are peri or post menopausal or in whom the transformation zone is endocervical –> Endocervical brush PLUS either the broom or spatula
What do you know about vulval cancer?
- Uncommon
- Results from HPV-related infection or chronic inflammation (eg. lichen sclerosis)
- Has pre-invasive (VIN) development akin to cervical cancer
- Tumours should be excised aiming for a 1cm clear margin
- Groin node dissection also needs to be performed for all but superficially invasive squamous tumours
What do you know about vaginal cancer?
- Rare (1-2% all gynaecological cancers)
- 85% squamous in origin
- Women within-utero DES exposure are associated with increased risk of clear-cell adenocarcinoma of the vagina
- Similarities to vulval and cervical cancer
- Depth of invasion, spread to surrounding tissue and regional lymph nodes is important for planning Rx
- Surgery is reserved for early stage disease, otherwise RT
What is DES?
What medical conditions are associated with DES exposure?
DES
- Diethylstilbestrol (DES), a synthetic form of the female hormone oestrogen was prescribed in Australia in the late 1940s and 1950s, less often in the 1960s and 1970s
- DES was primarily given to prevent miscarriage and other pregnancy complications, such as tubal pregnancy and early delivery.
- Other therapeutic uses included suppression of lactation and post menopausal syndrome.
- Separately it was later used as a growth promoter in chicken, sheep and cattle.
Associations with medical conditions?
Women exposed to DES in utero (DES daughters) are at increased risk for clear cell adenocarcinoma of the vagina/cervix, structural abnormalities in the reproductive tract, miscarriage, tubal (ectopic) pregnancy, infertility and premature birth. Women over 40 years of age who were exposed to DES in utero are at increased risk of breast cancer
Routine Pap testing is not an adequate gynaecological cancer screening test for DES daughters. An annual DES-specific pelvic examination is required
What do you know about choriocarcinoma?
- Malignant subtype of gestational trophoblastic disease
- GTD is a uncommon complication of pregnancy
- Syncytiotrophoblasts cause elevated bHCG serum levels (tumour marker)
- Commonly presents with heavy abnormal PV bleeding
- Metastasises widely – lungs, pelvic organs and brain
- Exquisitely sensitive to chemotherapy – MTX/EMACO
What are the risk factors for endometrial cancer?
- Obesity
- Factors related to increased exposure to estrogen
- Early menarche
- Late menopause
- Low parity
- Anovulatory amenorrhoea e.g. PCOS
- No corpus luteum –> high E but low P
- Unopposed oestrogen HRT
- Tamoxifen
- Family history of colorectal cancer, endometrial cancer, breast cancer (Hereditary non-polyposis colorectal cancers - HNPCC)
What is the pathophysiology/aetiology of endometrial cancer?
Cancer of the endometrial lining of the uterus is caused by stimulation of the endometrium by oestrogen without the protective effect of progesterone. Obesity is related to this because subcutaneous fat produces oestrogen postmenopausally owing to aromatization of adrenal steroids.
Endometrial hyperplasia
Long periods of unopposed oestrogen lead to hyperplasia which predisposes to cytological atypia. Atypical hyperplasia is precancerous and develops into invasive cancer in 10-50% cumulatively over 20 years. Clinical identification is not possible.
What are the phases of development of endometrial cancer?
Simple hyperplasia
Most common form
Often presents at either end of the reproductive life
Glands are enlarged and may be pleiomorphic; mitoses are present but there is no cytological atypia
Complex hyperplasia
Atypical glandular picture with proliferation, irregular outlines and obvious structural complexity
Atypical hyperplasia
Glands have atypical nuclei
Severe cases are indistinguishable from cancer
Persistent untreated atypical hyperplasia has the highest rate of progression to malignancy
Endometrial carcinoma
Adenocarcinoma is the commonest carcinoma (95%)
Majority are endometrial type
Adenosquamous carcinoma are less common
Sarcomatous elements may be present alongside the glandular adenocarcinoma – a mixed Mullerian tumour. This is a much more aggressive type.
Spread
The myometrium may act as a barrier
- Direct spread: through the myometrium and down to the cervical stroma, or to the Fallopian tubes and ovaries
- Lymphatic spread: Typically follows the uterine blood vessels to the pelvic lymph nodes. The para-aortic and rarely the inguinal nodes may be involved
- Haematological spread: To liver and lungs
What do you find on history/exam of endometrial cancer?
History
- Postmenopausal bleeding
- Premenopausal women may present with irregular, heavy or intermenstrual bleeding
- Menstrual irregularities in women >40 years require investigation
Examination
- Speculum
- To exclude other causes
- Bimanual
- Fixed or bulky uterus with advanced disease.
What is the prognosis of endometrial cancer?
If recurrences occur, these tend to be early; 50% are within the first year and 90% are within 5 years.
Prognosis depends on the stage of the disease, with significantly worse outcomes in those that have lymphatic involvement. If the para-aortic nodes are involved, survival rates drastically decline.
What is the management of the different stages of endometrial cancer?
Simple and complex hyperplasia
Progestogens –> Mirena IUD or POP
Follow up with repeat biopsy
Atypical hyperplasia
High risk
TAH and BSO recommended
Regular surveillance is indicated if TAH declined
Success of high-dose progestogens is controversial
Endometrial carcinoma
Primarily surgical: TAH, BSO, peritoneal washings +/- pelvic lymphadenectomy
Post-operative RT does not improve overall survival but does reduce rates of local recurrence
What determines whether monozygotic twins will be mono/dichorionic and mono/diamniotic?
At what time the zygote splits. The earlier the more independent the two foetuses will be, the later the more coinjoined –> all the way up to Siamese
What are the types of twin to twin transfusion syndrome?
Which types are more dangerous?
A-V : unidirectional flow
A-A or VV: bidirectional flow
Bidirectional anastomosis can assist in regulating unbalanced flow and are protective against TTS.
What are the effects of twin to twin transfusion syndrome on the fetuses?
Donor fetus
- Anaemia
- Hypotension
- Oliguria/oligohydramnios
- Growth restriction
- Renal failure
- Fetal demise
Recipient fetus
- Polycythaemia
- Hypertension
- Polyuria/polyhydramnios
- Hydrops/heart failure
- Fetal demise
What are the most common maternal complications from carrying twins?
- Hyperemesis gravidarum
- High levels of Hormones cause N&V
- Anemia
- Greater haemodilution
- Iron and folic acid supplementation recommended
- Greater haemodilution
- Gestational Diabetes
- Post Partum Hemorrhage
- Larger placental surface area, Uterine over distension,
- Higher rates of operative birth
- Postnatal depression
- Maternal mortality – Two fold higher in twin pregnancies.
A pregnant woman carrying twins asks you if she will need a C section. What do you say?
It depends on how the twins are lying?
If both twins have a vertex presentation they can be delivered normally.
If twin A has a non-vertex presentation they will both need to be born via C section.
If Twin A is vertex but Twin B is non-vertex then twin A can be delivered vaginally and for twin B it depends on their birthweight whether you attempt a breech or a c section.
In medically well pregnancies where twin A has a vertex presentation, it has been proven to be safe to delay the decision about the how to deliver the babies until labour.
What do you know about the basics of blood sugar metabolism in pregnancy?
What causes insulin resistance?
GDM is a condition of failure of the pancreatic islet β-cells to compensate for insulin resistance that is highly predictive of Type 2 diabetes in later life
The metabolism of the mother changes during pregnancy to facilitate the energy supply of the fetus.
These factors modify the insulin requirements of ALL pregnant women.
The insulin requirement of a woman DOUBLES during pregnancy. If it’s a young healthy mum the pancreas is liklely to have enough physiological reserve to cope with this, but if it can’t double it’s output (or the woman was already insulin resistant so needs even more than double baseline secretion) then GDM occurs.
What causes insulin resistance?
The diabetogenic potency of placental hormones. The most notable hormone which has major effect on glucose metabolism is human placental lactogen (hPL), which is produced in abundance in the enlarging placenta. hPL promotes lipolysis with increased levels of circulating free fatty acid and causes a decrease in glucose uptake. In this sense it is thought of as an anti-insulin.
What are the normal ranges for a pregnancy 2 hour OGTT?
What are the acceptable ranges for women who have an established diagnosis of GDM and are now taking random blood glucose levels at home?
Diagnostic test
Fasting < 5.1
1 hour <10
2 hour normal < 8.5, GDM = 8.5-11.0, DM in pregnancy >11
Monitoring test
Women should take their BSL 4 times per day. Before breakfast and then either 1 or 2 hours after each of their three daily meals. Acceptable readings are:
<5.1 fasting
<7.4 at 1 hour
<6.7 at 2 hours
If a woman has 2 or more breaches of these limits in any one week she should be put on insulin immediately (or have her insulin dose increased if she is already on insulin).
A pregnant woman with type 1 diabetes comes to see you for an antenatal consult. She is extremely health conscious, does everything right and has exemplary control of her BGLs. She is very worried about the risks her baby is at because of her diabetes. What do you say?
Miscarriage increased risk is probably small with HbA1c <8, but with higher HbA1cs the chance of miscarriage increases.
Chromosomal/physical abnormalities - The risk falls from 8% to 4% with good BSL control
There is an increased chance of spina bifida –> take 5mg folic acid per day rather than the standard 0.4mg per day
There is also a risk of IUGR which can be masked by macrosomia. More regular ultrasound scans.
What meds can you try to increase breast milk production?
Domperidone (Motilium) and Metaclopromide (Maxalon) may be used to try to increase supply
When does GDM typically develop? What are the symptoms?
GDM generally develops and is diagnosed in the late second or early third trimester of the pregnancy.
It is usually asymptomatic.
What screening tests should pregnant women get for GDM?
If she tests positive, what monitoring tests should she have?
In Australia, all pregnant women should be screened for GDM between 26 and 28 weeks gestation. (Note that U.K. guidelines and old Australian guidelines suggest screening only in women with risk factors).
The RANZCOG guidelines also suggest that earlier testing may be performed in women at particularly high risk of GDM (e.g. GDM in a previous pregnancy or current obesity) and then repeated at 26-28 weeks gestation, if a negative result is obtained at the earlier testing time point.
The recommended screening regimen is a 75 gram two-hour Pregnancy Oral Glucose Tolerance Test (POGTT).
Fasting test- fast from 2200
Fasting blood sugar (drink 75gm glucose load)
Blood sugar level at 1hr
Blood sugar level at 2 hrs
Diagnostic test
Fasting < 5.1
1 hour <10
2 hour normal < 8.5, GDM = 8.5-11.0, DM in pregnancy >11
Monitoring test
Women should take their BSL 4 times per day. Before breakfast and then either 1 or 2 hours after each of their three daily meals. Acceptable readings are:
<5.1 fasting
<7.4 at 1 hour
<6.7 at 2 hours
If a woman has 2 or more breaches of these limits in any one week she should be put on insulin immediately (or have her insulin dose increased if she is already on insulin).
A fetus with a diabetic mum is at higher risk of…..
- Foetal macrosomia which can mask IUGR (weight greater than 4500g)
- Spontaneous abortion and stillbirth
- Neonatal morbidity
- Respiratory distress
- Hypoglycaemia
- Jaundice
- Electrolyte disturbance (Mg/Ca)
- Polyhydramnios
- Consequently increased risk of placental abruption and preterm labour
- Congenital abnormality – infants of mothers with diabetes are at a sixfold increase in risk
- Neural tube defects –> take 5mg rather than .4mg of folic acid
- Cardiac abnormalities
- Renal abnormalities
What is the FULL management of GDM?
Basics
Education RE: GDM
- Causes* – explain pathophysiology and risk factors
- Symptoms* – explain the woman is usually asymptomatic
- Complications* – to mother and to foetus
Place and person
Referral to a dietician for diet modification
Investigate and confirm diagnosis
Continue to monitor glycaemic control (Self blood glucose monitoring)
Screen for urinary infections at the first sign of symptoms – more common in women with diabetes
Non-invasive management
Diet and exercise
Definitive management
Metformin
Insulin
Not oral hypoglycaemic agents (sulphynureas and biguandides) – as they cross the placenta and cause foetal hypoglycaemia.
Long term
Women who were diagnosed with GDM or Diabetes Mellitus in Pregnancy should have a repeat 75gram OGTT performed 6 to 12 weeks after delivery. The result of the test should be evaluated according to standard WHO criteria for the non-pregnant state.
Women who do not have diabetes mellitus at this time should still be regarded as at risk of developing diabetes mellitus later in life and should be screened every two to three years.
Post Partum
As there is a rapid loss of insulin resistance post delivery
USE pre-pregnancy insulin dose soon after delivery
- GDM – NO insulin
- T2DM/T1DM – rapid reduction
Why are babies of diabetetic mums often polycythaemic?
No-one really knows
How do you diagnose menopause in a hysterectomised woman?
Based on symptoms, or if diagnostic ambiguity (like in the case of primarily psychological symptoms), you can do hormonal testing. But remember the accuracy of these is very dubious
Are hot flushes associated with fever?
No
What is the biggest predictor of which women will lose bone mineral density after menopause?
BMI
Slimmer women will lose more
What % of women who have a minimal trauma fracture have normal bone mineral density?
33%
Does menopause cause weight gain?
No but it causes redistrobution of fat to the abdomen, like a male pattern
Do phytoestrogens for menopausal symptoms work?
Nope, not at all
What are the signs/symptoms of oestrogen deficiency in menopause?
- General
- Fatigue
- Headaches
- Muscle/joint aches
- Cognitive
- Depression
- Memory loss
- Difficulty concentrating
- Vasomotor
- Hot flushes
- Night sweats
- Urogenital
- Vaginal dryness/itching
- Urinary frequency/urgency
And importantly, metabolic syndrome and osteoporosis
In what situations might you consider investigations for menopause?
What tests (and their respective results) would suggest menopause
- Women with subtle/fluctuating symptoms, for example predominant mood change and few vasomotor symptoms where it be valuable to increase the index of suspicion of menopause (rather than say, depression)
- AND
- Women with amenorrheoa <45 years old
What tests?
Low oestrogen and HIGH FSH
How would you approach taking a menopause history?
- Diagnose the menopause
- LNMP
- Hysterectomy?
- OCP or HRT?
- Screen for signs/sx of menopause
- General (headaches, muscle aches, fatigue)
- Cognitive (depression, anxiety, difficulty concentrating)
- Vasomotor (night sweats, hot flushes)
- Vaginal atrophy, UTI sx
- Screen for factors related to potential HRT use
- Breast cancer –> contraindication
- DVT/PE
- Smoker?
- Cardio or cerebrovascular disease
If there is primary psych symptoms consider anaemia, thyroid dz, depression or DM
If amenorrheoa consider pregnancy, hyperprolactinaemia and thyroid dz
Describe the management of menopause
- Educate
- Not a disease
- Lack of oestrogen
- Prevention
- Mammo, Pap, FOBT
- CV checkup –> BP, lipids, FBGL
- Non-pharm
- General strategies for managing menopausal symptoms
- SNAP - Lifestyle modifications make a huge difference
- Natural therapies
- Soy
- Black cohosh
- HRT
- Pros and cons
What are the pros and cons of HRT and who is it suitable for?
In women aged <60 (or within 10 years of LMP) with no cancer risk, you can use HRT for up to 5 years with minimal risks
What is the clinical triad of endometriosis?
dysmenorrheoa, dyspareunia and infertility
Dating scans for new pregnancies are not universally done. Which women would you recommend it for? When would you recommend it happen?
High risk women
This is to allow for fully informed decision making if complications arise again with a confident estimate of the gestational age
Around 7 weeks
A woman presents with thrush. What do you tell her? What do you prescribe?
- This is a very common condition.
- Most cases (80% to 90%) of vulvovaginal candidiasis are uncomplicated, sporadic or infrequent episodes in a healthy host and due to Candida albicans.
Many effective intravaginal preparations are available (imidazoles [eg clotrimazole, miconazole], nystatin). The following have been shown to be effective in at least 80% of women. Occasionally topical therapy may itself cause irritation. Nystatin, although less effective, is generally better tolerated than the imidazoles. Use:
- a vaginal imidazole (eg clotrimazole 10% vaginal cream 1 applicatorful intravaginally, as a single dose at night)
- nystatin 100 000 units/5 g vaginal cream 1 applicatorful intravaginally, 12-hourly for 7 days.
If the patient is intolerant of topical therapy or would prefer to use oral therapy, and the patient is not pregnant, use:
- fluconazole 150 mg orally, as a single dose.
What % of women with PID are symptomatic?
60% of PID is asymptomatic, 4% severe symptoms, the rest mild-moderate symptoms
What antibiotics do you give for PID?
If thought to be STI related:
Ceftriaxone IM/IV
Azithromycin PO/IV
Metronidazole PO/IV
If not thought to be STI related (for example, an older woman post-op) and MILD
Augmentin PO
Doxycycline PO
Duration 14 days
If not thought to be STI related (for example, an older woman post-op) and SEVERE
Amoxycillin
Gentamicin
Metronidazole
All IV
What are the symptoms of vulvovaginal candidiasis?
What are the risk factors?
Symptoms
- Vuval pruritis most common symptom
- thick, white, curdy vaginal discharge (cottage cheese like)
- Erythema
- Irritation
- Satellite lesions
- Dysuria
- Dyspareunia
Risk factors
- Antibiotic use
- Use of steroids
- Immunosuppression
How do you take a sexual history?
The 5 P’s
- Partners
- How many?
- Male/female/both?
- Regular or random?
- Practices
- Frottage/oral/vaginal/anal?
- Drugs used?
- Previous STIs
- Prevention of STIs
- Prevention of Pregnancy
A pregnant woman is found to be Rh negative.
Do you test the Dad?
When do you give Anti-D?
What monitoring do you do during the pregnancy?
No don’t test the dad because you can’t know if he is REALLY the dad
Anti D given at 28 and 34 weeks and within 72 hours of birth if baby found to be Rh +
Follow the maternal antibody titres, check MCA flow and umbilical doppler for foetal anaemia
What are the systems questions/symptoms of PCOS?
HATE BODI
H - Hirsuitism
A - Acne / amenorrhea
T - Thyroid (hypo as a DDx)
E - Endocrine (Cushing’s and late onset CAH as a DDx)
B - Balding (male pattern)
O - Obesity
D - Diabetes (associated with PCOS)
I - Infertility
A women is having an antepartum haemorrhage in ED. What questions do you ask her?
TIP: BE CALM
T - Trauma
I - Investigations to date (eg. position of placenta on 20 week scan)
P - Pain
B - Blood group
E - Eat of drink today?
C - Contractions
A - Anaesthetic previously?
L - Liqour / ROM
M - Movements (foetal)
What are the causes of pelvic/lower abdo pain in a teenage girl?
PAP ME
P - Pregnant (inc ectopic, miscarriage)
A - Appendix
P - Primary dysmenorrhea
M - Mullerian obstruction (a rare, congenital cause of obstructed menstruation)
E - Endometriosis
P - PID
What are the causes of amenorrheoa?
These are also the causes of ovulatory infertility
HEAPS POACHED
H - Head injury [reduced GnRH]
E - Excessive exercise [reduced GnRH]
A - Anorexia [reduced GnRH]
P - Prolactinoma [PRL inhibits GnRH]
S - Sheehans syndrome [reduced FHS/LH]
P - PCOS / premature ovarian failure [reduced response of ovaries to FSH/LH]
O - Obesity [oestrgen++ inhibits FHS/LH secretion]
A - Asherman’s Syndrome (typically after D&C) [blocks exit of menses]
C - Cervical stenosis [blocks exit of menses] and late onset CAH
H - Hypothyroidism
E - Endocrine [DM and cushings]
D - Drugs [DA antagonsitis and progesterone]
What are the complications of using illegal opiods in pregnancy?
Before birth
- When you have withdrawal, you baby does to
- Heroin withdrawal in the infant increases the risk of miscarriage, premature labour and stillbirth.
- Injecting heroin increases the risk of blood borne viruses (HBV, HCV, HIV) which can affect the baby
- Heroin is often mixed with other chemicals, the safety of these chemicals for the baby cannot be known
- Methadone stabilistion of opioid use is recommended and safe
After birth
- heroin can enter the breastmilk; breast feeding is not recommended
- The child may have withdrawal after birth (neonatal abstinence syndrome) and will need to be admitted and monitored for 7 days
- The risk of SIDS is increased
What are the risk factors for post partum haemorrhage?
PIG FIT CUPPA
P - PPH (Hx of)
I - Infection
G - Grand multip
F - Fibroids
I - Instrumental delivery
T - Trauma
C - Clotting abnormalities
U - Uterine overdistension (polyhydramnios, macrosomia, multiple pregnancy)
P - Pronlonged labour
P - Precitipitous labour
A - APH (PMHx of)
What are the investigations for menorrhagia?
Bedside tests
Pregnancy test
Bloods and urine
FBE
Coagulation studies
Iron studies
TSH
Imaging
If indicated: transvaginal USS
Special tests
Pap smear
If indicated: hysteroscopy
An endometrial biopsy to exclude endometrial hyperplasia may be considered in women:
- whose bleeding does not respond to medical therapy
- whose endometrium is thickened (12mm or more)
- who have intermenstrual bleeding.
Describe your management approach to acute severe menorrhagia…
Occasionally, acute heavy menstrual bleeding may cause severe anaemia and hypotension à pregnancy-related haemorrhage must be excluded.
- Manage hypovolaemia with IV replacement
- Consider transfusion if really severe
- tranexamic acid
- 10 mg/kg IV, every 8 hours until bleeding stops
- Occasionally if the bleeding doesn’t stop, high dose oestrogen may be required
- ethinyloestradiol 50 micrograms combined oral contraceptive pill every six hours
There is also the option of using high dose OCPs.
Caution is advised with high doses of oestrogen and progestin in women at risk of venous thromboembolism. An antiemetic is recommended with hormonal therapy.
The Mirena has a “triple liscence” in Australia. What three things are you allowed to use it for on the PBS?
- to manage meonorrhagia
- to provide endometrial protection for women who require hormone replacement therapy (HRT)
- contraception
What is the management of menorrhagia?
What are the causes of menorrhagia?
BITCHFACE
B - Bleeding disorders
I - Iatrogenic
T – Thyroid (especially hypo)
C - Cancer (cervical, endometrial, uterine)
H – Hyperplasia of the endometrium from anovulation due to PCOS, puberty or menopause
F - Fibroids & Polyps
A - Adenomyosis & endometriosis
C - Chlamydia/STIs/PID
E - Ectopic
M - Miscarriage
P - Pregnancy
Mrs Smith had an emergency LUSCS due to abnormal CTG 3 days ago. Baby and her are both now doing well. You are the resident on the ward and go to see Mrs Smith to confirm that she is ready for discharge and provide the appropriate information/counselling. What do you ask/tell Mrs. Smith?
- Any ongoing pain? (some mild pain controlled by analgesia is okay)
- Any ongoing PV bleeding? (up to what you’d expect with a heavy period is okay)
- Does she have any calf pain? Is she up and walking? Using TED stockings or clexane?
- Is the catheter out and has she passed urine?
- Has she had a bowel motion?
- Is she breastfeeding, how is this going?
Advice/counselling
- Give the woman a “going home after cesarian” pamphlet
- The dressing on the wound should be removed on day 5
- She should shower twice per day and keep the wound clean and dry
- Organise contraception. Explain that after a LUSCs she should use birth control for at least 18 months to minimise the risk of uterine rupture
Ms Brown is at 38+1 weeks gestation and her baby is found to be in a breech position. She asks you what the options are, what do you say?
Three options:
- Consider breech vaginal birth by senior consultant with paediatrician on hand
- Cesarian
- Trial external cephalic version
- 50% success rate in primigravid
- 75% success rate in multigravid
- 1 in 200 risk of foetal distress requiring emergency cesarian
For women with a breech baby at full term (37- 41 weeks) it has been shown that an elective caesarean section birth is safer for the baby than a vaginal breech birth. However, a caesarean section is a surgical operation and so is associated with increased risks of maternal complications such as bleeding and infection. Having a caesarean section also has implications for a woman’s future pregnancies and birth.
What/when should women expect to feel fetal movements throughout her pregnancy?
First perceive FM at 20 weeks gestation**
Frequency of FM increases after this
Frequency of FM plateaus at 32 weeks, but should definitely not reduce
**The foetal movements have a clear diurnal pattern. The afternoon and evening periods are periods of peak activity. Foetal movements are usually absent during fetal ‘sleep’ cycles, which occur regularly throughout the day and night and usually last for 20–40 minutes. These sleep cycles rarely exceed 90 minutes in the normal, healthy foetus.
Reduction in fetal movements is often a worrying sign that can indicate serious fetal distress. Aside from this though, what else can account for decreased fetal movements?
- Maternal factors
- Maternal position (the most FM felt lying down, fewer in sitting, fewest whilst standing)
- Mother busy or not concentrating
- Placental positional factors
- Prior to 28 weeks, an anteriorly placed placenta may decrease a woman’s perception of FM
- Foetal positional factors
- When the spine is anterior this may reduce maternal perception of FM
- Drugs
- Sedating drugs which cross the placenta (eg. ETOH, benzos, methadone and other opiods) can have a transient effect on FM
- Corticosteroids (given to enhance foetal lung maturation) have also been shown to reduce FM
What is the management of hyperemesis gravidarum?
Basics
- DRABC + fluid resuscitation if severe
- Commence fluid monitoring if severe
Place and Person
- Admit if severe
Investigate and Confirm Diagnosis
Bedside Tests
- Urine dipstick
- BGL
Blood Tests
- FBE
- UEC
- LFT
- TFT
- BHCG [to screen for molar pregnancy]
- Urine MC&S
Definitive Management
Non-Pharmacological
- Ginger
- Dietary strategies
- Avoid provoking foods
- Small frequent meals
- Elevate bed head
Pharmacological
- H2 antagonists
- Anti-emetic (metaclopromide / ondansetron)
- If severe - steroids
Prevention / Future Care / Prophylaxis
Vitamin B1 and B6 supplementation
DVT prophylaxis [as the woman is dehydrated + often not mobile!]
Is abortion legal in Victoria?
In Victoria, abortion can be performed by a medical practitioner with no other conditions up to 24 weeks.
If >24 weeks, it can still be performed however two doctors must consider it appropriate in all the circumstances which include physical, psychological, and social circumstances.
Talk through how you would consent a woman for surgical termination of pregnancy,…..
What is the procedure?
Day procedure
Twilight sedation
5-10 minute surgical procedure to remove the pregnancy tissue via the vagina
Why do we do it normally?
Termination of pregnancy from 7-12 weeks gestation
Why are we doing it in this case?
Termination of pregnancy
Pre-op
Blood tests and swab to decrease chance of rhesus or GBS infection
You will need to fast for 6 hours before the procedure
3 hours before the procedure the doctor will insert a misoprostrol pessary to help ripon the cervix.
Anaesthetic, off to sleep
Intra op
The doctor will dilate your cervix and remove the pregnancy tissue
You will then be given some synthetic oxytocin to help contract the uterus and pass any remaining products of conception.
Post-op
You will wake up in the recovery room and spend a few hours resting and recovering from the procedure
You will be given some antibiotics called doxycycline to reduce any infection risk
Risks
Anaesthetic complications
Anaphylaxis
Very rarely, infection or uterine rupture
Asherman’s syndrome
Failure of the procedure/retained products (it’s blind) –> can use MTX, wait to pass or go back in
Vacuum aspiration in 1st trimester has no association with later infertility or ectopic
Contraindications
Ectopic pregnancy
Some serious medical comorbidities
Alternatives
Medical abortion
Expectant management
Questions and obtain written consent
Talk through how you would consent a woman for a medical termination of pregnancy…
What is the procedure?
Generally use a combination of two medications to induce the uterus to pass the pregnancy tissue.
MIFEPRISTONE (Antiprogesterone and antiglucocorticoid)
And
MISOPROSTOL (prostaglandin analogue)
Why do we do it normally?
Termination of pregnancy
Why are we doing it in this case?
Termination of pregnancy
Pre-op
Blood tests and swab to decrease chance of rhesus or GBS infection
Intra op
Visit a clinic that is authorised to prescribe the medication
During the consultation with the doctor you will take the Mifepristone tablet. You will then need to take the misoprostol at home 24-48 hours later. Usually within 4 hours of taking the second medication you will experience vaginal bleeding, cramps and you will pass some pregnancy tissue.
Post-op
You will need to come back to the clinic two weeks after for a final assessment and to ensure the abortion is complete. This is very important.
Risks
Nausea, vomiting
Diarrhoea
Headache, dizziness, Fatigue
Abdominal pain and cramps
Prolonged vaginal bleeding
Failure of the procedure - 95% success rate (5% will need curettage, 1% will fail, 1% will require transfusion)
Contraindications
IUD
Ectopic pregnancy
Some serious medical comorbidities
Alternatives
Surgical abortion
Expectant management
Questions and obtain written consent
Up to what gestational age would you consider medical termination of pregnancy?
7 - 9 weeks
What is the circulating blood volume of a fetus?
80–100 ml/kg
Where do ectopic pregnancies occur?
Fallopian tubes (95%)
Ovaries (3%)
Peritoneum (1%)
What are the risk factors for ectopic pregnancy?
Anything that obstructs the passage of the fertilised ovum through the fallopian tubes is a risk factor
- Previous ectopic
- Previous PID
- Smoking (impairs ciliary activity)
- Previous tubal surgery
- History of infertility (esp if IVF)
- Advanced maternal age
- IUDs, progesterone-only pills, tubal ligation
Broadly speaking, what would be your management of a woman with an ectopic pregnancy who is currently stable and opting for medical management?
The mainstay of medical treatment is a single dose of 50mg/m2 of IM methotrexate.
B-HCG levels are checked on day 4 and 7, and should fall by 15%. If not, give a second dose.
15% of women will need a second dose. 7% will need subsequent surgery.
What is the surgical management of an ectopic pregnancy?
Laparoscopy is generally preferred. Laparotomy is usually required in emergency, heamodynamically unstable patients.
Ruptured and bleeding ectopics often require salpingectomy (removal of affected tube). However, if future fertility is desired and removal is not critical, salpingotomy is recommended.
What are the different definitions of the types of miscarriages….
Threatened miscarriage – bleeding in the first 20 weeks of gestation (a presentation, not a diagnosis)
Inevitable miscarriage – when the cervix has dilated, but products of conception are still intra-uterine
Incomplete miscarriage – some products of conception have been expelled, but not all
Complete miscarriage – the uterus is empty, the cervix is closed. Symptoms have often resolved.
Missed miscarriage – asymptomatic fetal demise. Diagnosed retrospectively on U/S because the fetus is too small for gestational age, reflecting cessation of growth at an early gestation e.g. absence of fetal heart and 9 week sized foetus on 12 week U/S
Septic miscarriage – miscarriage complicated by infection – can lead to PID, sepsis and death
Ms. Green had a miscarriage 2 days ago and has had a D&C as a day case this morning. She is now ready for discharge. What do you tell her before she goes home?
- Light bleeding may continue for up to 2 weeks
- Watch out for prolonged bleeding, infection, failure of menses –> this may suggested persistent trophoblast and require further treatment
- Consider referral to grief counselling
- Reassure that miscarriage is a common event in normal women, and that the next pregnancy is likely to be successful. After 3 sequential early pregnancy losses, further investigation is required
A women who has had a missed miscarriage would like to opt for expectant/conservative management. What is the liklihood of this being successful?
Incomplete miscarriage (cervical os open, some products expelled) has a high success rate with expectant management (94%)
Missed miscarriages are less likely to resolve spontaneously (28%)
Louise has just fallen pregnant. She tells you that she knows she can’t drink or smoke during pregnancy, but wants to know if there’s anything else she should avoid. What do you say?
Toxoplasmosis: avoid cat litter, garden soil, raw/undercooked meat and unpasteurised milk products, and wash all fruit and vegetables.
Cytomegalovirus, parvovirus B19 (fifth disease): discuss importance of frequent handwashing, and child and healthcare workers further reducing risk by using gloves when changing nappies.
Listeriosis: avoid paté, soft cheeses (feta, brie, blue vein), pre-packaged salads, deli meats and chilled/smoked seafood. Wash all fruit and vegetables before eating.
Fish: limit fish containing high levels of mercury.
What is the management of pelvic prolapse?
Basics
ABx for UTI if indicated
Place and person
Refer to gynaecologist (ED if acute urinary retention)
Investigate and confirm diagnosis
Post-void residual volume + urinalysis
Non-invasive management
N/A
Definitive management
There are a number of different treatment options depending on the severity of symptoms:
Describe the normal appearance of lochia in the post partum period…
Red (approx day 3 to 5 post delivery)
Pink (approx day 5 to 10 post delivery)
Serous (approx day 10 to 35 post delivery)
In a sentence, what is endometritis
Can think of it as a non-STI pelvic inflammatory disease that can occur postpartum.
If thought to be related to an STI Treat with the same antibiotics as PID –> Ceftriaxone, Metronidazole and Azythromycin
If not thought to be due to an STI treat with augmentin and azithromycin
You are asked to review Mrs. White who gave birth to baby Sarah yesterday. What things will you cover in your assessment of Mrs. White?
Pain
Normal for around 3 days. Consider paracetemol, topical lignocaine and/or diclofenac suppositories
PE/DVT
Are they up and mobilizing? Did they use TEDS or clexane?
Perineum
Tears
Pyrexia
Intrauterine infection, mastitis
Pulse
PPH?
Pre-eclampsia
80% of deaths occur post-partum
Pooing
Should resume in 3 days. Laxatives can help.
Pissing
Beware retention, especially if epidural
Psych
Post-natal depression
Protection
Should commence non-hormonal or progesterone only birth control within 3 weeks if intending to be sexually active
What are the stepwise options for definitive management of post partum haemorrhage?
MASSAGE ME MSIS PM + the 5 Bs
Massage - the fundus
Metrine – Ergo (250mcg, diluted to 5mL in normal saline, IV)
Metrine – Synto (1mL IM)
Infusion of
Syntocin (40 IU in 1L of Hartman’s over 4 hours)
Prostaglandin
Misoprostol
Bimanual compression
Balloon tamponade
B lynch suture
Bilateral uterine artery ligation
Bail –> hysterectomy
What are the system review questions for rapid evaluation of post partum haemorrhage?
EMBLEMS GCP
E - Estimated blood loss
M - Medical history of the mother? Bleeding disorders?
B - Birth weight (of baby – macrosomia can cause uterine atony)
L - Labour - How did the labour go? Prolonged? (Uterine atony?)
E - Epidural given? (cause of poor uterine tone)
M - Mode of delivery → Cesarian, instrumental, normal (trauma or cause of poor tone)
S - Symptoms of shock (conscious state, shoulder pain, light headed)
G - Gs and Ps (grand multiparity risk factor for poor uterine tone)
C - Cesarian in the past? (Uterine rupture risk)
P - Placenta – has it passed and been inspected? (retained products)
What are the types of placenta previa?
Major – covers os
Minor – close to but doesn’t cover os
morbidity proportional to how much of the placenta is placed centrally over os
How common is placenta previa?
What are the risk factors?
1 in 200 pregnancies
Age
Multiparity
Large placental area e.g. Multiple pregnancy
Uterine scar/previous c-sec
What are the differences between placenta previa and placental abruption?
Previa
- Painless
- Bleeding in proportion to degree of shock
- Bright blood
- Uterus soft
- Ongoing/repeated episodes of bleeding
- Associated with malpresentation/high presenting part
Abruption
- Painful (abdo or back)
- Often single instance of bleeding
- Bleeding may be out of proportion to degree of maternal shock if concealed
- Often dark blood/clots
- Uterus hard/tender
- Not associated with malpresentation/high presenting part
What are the risks/potential complications of shoulder dystocia?
Baby:
- Death,
- hypoxia,
- trauma/fractures,
- brachial plexus injury
Mum:
- PPH
- perineal trauma (3rd & 4th degree tears)
- uterine rupture
- PTSD
What constitutes active management of the 3rd stage of labour?
Syntocin 10U IM with delivery of anterior shoulder
Cut cord
Controlled cord traction with guarding of the fundus
What do you know about amniotic fluid embolus?
Classic triad: hypoxia, DIC, haemodynamic collapse
Probably due to anaphylaxtic reaction to fetal tissue
Buzzword: Fetal squames in the mother’s lungs at autopsy
What are the generic risk factors for obstetric complications?
Generic risk factors for any obstetric complication
BAGPIPE COMBO
(think the bagpipe is a loud warning, and when >1 of these factors are present in combination you should consider referring the woman to a specialist obstetrician for management)
B - Bleeding disorders
A - Age – maternal
G - Grand multiparity
P - Previous obstetric complications – APH, PPH, infertility
I - Infections – GBS, PID
P - PROM
E - External cephalic version
C - Congenital abnormalities
O - Obesity/Metabolic syndrome/Diabetes
M - Multiple gestation
B - Breech, transverse or oblique lie
O - Other maternal medical conditions
What are the causes of abnormal uterine bleeding?
PALM COEIN
P - Polyp
A - Adenomyosis (endometriosis in the myometrium)
L - Leiomyoma (submucosal or otherwise)
M - Malignancy (endometrial hyperplasia or carcinoma, or uterine sarcoma)
C - Coagulopathy
O - Ovulatory dysfunction
E - Endometrial
I - Infection (PID/endometritis) and Iatrogenic (anticoagulants, contraceptives, IUDs)
N - Not yet classified
What things would you discuss with a mother when consenting her for amniocentesis or chorionic villus sampling?
- Procedure
- Takes less than 30 mins
- Doctor will numb your abdomen, pass a needle in and remove fluid/cells of the placenta. May (rarely) pass tube through vagina to perform CVS
- Afterwards
- May have some spotting or pain for 24 hours
- Can be exhausting: get someone to pick you up and rest for next few days
- Results may take 2 weeks. Some people find keeping busy during this time helpful to reduce anxiety
How common is placental abruption?
1% of pregnancies
What are the risk factors for placental abruption?
Vascular Dysfunction
- IUGR
- Pre-eclampsia
- Smoking
- Hypertension
- Crack Cocaine
- Thrombophilia
Rapid pressure release
- Rupture of membranes of Polyhydramnios
- Between births of multiple pregnancies
Shearing trauma
- MVA
- Abdominal trauma
- External cephalic version
Infection
- Chorioamnionitis
What are the clinical features of placental abruption?
-
Abruption Itself
- Pain: abdominal, back
- PV bleeding
- Tender, ‘woody’ uterus
- Pre-term labour – contractions, cervical dilatation
-
Haemorrhage
- Hypotension and shock
- Renal failure
- DIC
- Fetal distress or death
Should women with abruption be cared for as inpatients or outpatients?
All women will need to be initially admitted and assessed. If mum and baby are both stable they can be monitored as outpatients.
After trauma, pregnant women need 4 hours of inpatient surveillance minimum, due to the risk of abruption
Is vaginal delivery absolutely contraindicated by the presence of abruption?
No.
C/S will always be used in emergencies, but stable cases can consider vaginal birth. Continuous monitoring (CTG) is strongly recommended. Prepare blood products in case of massive haemorrhage.
What do you do if a woman has a placental abruption and the baby dies in utero?
Get that baby out. Can progress to DIC.
If stable, induced labour. If unstable, emergency Caesarean.
What are the consequences/complications of placenta previa?
When should you start taking an OCP? How long until it’s effective?
Immediate protection if begin active pills in the first 5 days of menstrual cycle (‘day one’ = first day of bleeding)
For COCP
If start active pills after this time, need alternate contraception until 7 active pills are taken for 7 consecutive days
For POP
If start active pills after this time, need alternate contraception until 3 active pills are taken for 3 consecutive days
You have just started a women on the OCP. You need to explain to her the missed pill rules, what are these?
Take pill as soon as you remember
Take next pill at usual time
> 24 hours late taking an active pill (or vomiting or severe diarrhoea >24 hours)
Take pill as soon as you remember
Take next pill at usual time
Condoms or abstain from sex until have taken active pills for 7 days in a row
If a pill is missed (>24 hrs late) in last 7 days of active pills (days 15-21)
Finish active pills in current pack and start active pills in new pack without any break, ie skip the sugar pills so no break between active pills
If a pill is missed in first 7 days of active pills (days 1-7)
Consider emergency contraception if there has been unprotected intercourse in the previous 5 days.
AND restart COCP within 24 hrs
AND condoms or abstain from sex next 7 days
If >4 consecutive pills are missed ie >120 hours since last pill
Emergency contraception
Start from scratch
A woman has presented with breakthrough bleeding whilst on the OCP. What do you think of?
- Common in first few months of starting the OCP
- In presence of daily pill taking does not imply lack of contraceptive effect
- Check if patient is tri-cycling or longer ie skipping inactive section for ≥3 cycles
- Exclude possible causes: missed pills, vomiting or diarrhoea or concurrent medication, pregnancy, cervical or other pathology eg STIs, especially chlamydia
What are the systems review questions for a patient with diabetes?
SHOELACE FARM
S – Specialist? Do you see an endocrinologist or diabetic educator, when did you see them last?
H – Hypos. Have you ever had a hypo? How often?
O – other autoimmune problems? Thyroid, coeliac?
E – Eyes. When was your last review?
L – Levels. What is your current HbA1c? What readings do you get on your random BGLs?
A – Age at diagnosis
C – Compliance. Do you ever miss your medications or BGL readings?
E – Event at diagnosis (DKA/HHS)
F – Feet. When was your last podiatry review?
A – Assess cardiovascular risk factors. Hypertension, obesity etc.
R – Renal. Any renal problems?
M – What medications are you on, what have you been on previously?
Describe your full management of post partum haemorrhage…
“As this is an emergency my assessment and immediate management would be simultaneous”
Clinical Assessment
EMBLEMS GCP
E - Estimated blood loss
M - Medical history of the mother? Bleeding disorders?
B - Birth weight (of baby – macrosomia can cause uterine atony)
L - Labour - How did the labour go? Prolonged? (Uterine atony?)
E - Epidural given? (cause of poor uterine tone)
M - Mode of delivery → Cesarian, instrumental, normal (trauma or cause of poor tone)
S - Symptoms of shock (conscious state, shoulder pain, light headed)
G - Gs and Ps (grand multiparity risk factor for poor uterine tone)
C - Cesarian in the past? (Uterine rupture risk)
P - Placenta – has it passed and been inspected? (retained products)
Resuscitation
D: Look for slip hazards, put on gloves.
R:
S: Send for help:
- 2 x midwives
- O&G consultant
- Anaethetist
Assign roles:
- Someone to scribe
- Someone to support patient
- Someone to start intensive vitals chart (every 10-15 minutes)
- Someone to get drugs and blood products etc.
- Someone to be the “runner”
Contact theatre
A:
B: administer O2 10L via HM
C:
- 2 x wide bore (16 guage) cannulae
- IV colloids / O negative blood / X-matched blood: mark as urgent
- Send off blood for cross match / FBE / coags & fibrinogen
Assess for underlying cause
- Tone: palpate tonicity of uterus and position of fundus
- Tissue: ask about placental completeness and active third stage
- Trauma: inspect perineum for tears and vagina/cervix with speculum
- Technique to inspect for cervical tears is “walking” with sponge forceps – this is very painful and should be done with epidural
- Thrombin: ask about PMHx and await coags and fibrinogen –> if you suspect this involve HAMEATOLOGIST
- Theatre: contact if haven’t already!
Management
MASSAGE ME MSIS PM
Fundal massage + urinary catheter
Metrine – Ergo (250mcg, diluted to 5mL in normal saline, IV) – don’t give if history of HT/PET!
Metrine – Synto (1mL IM)
Infusion of
Syntocin (40 IU in 1L of Hartman’s over 4 hours)
Prostaglandin F2 alpha (injections into uterus through abdomen)
Misoprostol (tablets in the rectum or vagina)
Surgical: 5Bs
Bimanual compression
Balloon tamponade
B lynch suture
Bilateral uterine artery (or internal iliac) ligation
Bail à hysterectomy
Post-PPH Care
Baby check
Debriefing with mum (& dad) and screen for post-natal depression
Debriefing with all staff involved
Discuss at M&M (morbidity & mortality) meeting – can things be done better next time?
Most low lying placenta’s detected at 20 weeks will migrate further up the uterus as it expands. What factors make this even more likely to happen (thus less likely to be a problem) than normal?
Anterior placenta
Primigravid
What dose of folate supplementation are mothers recommended to take before/during pregnancy?
The recommended dose of folic acid is at least 0.4mg daily to aid the prevention of neural tube defects (NTD).
Where there is a known increased risk of NTD or a risk of malabsorption, a 5mg daily dose is recommended.
What dose of iodine are pregnant mothers recommended to take each day?
150 micrograms each day
List all the vitamins/minerals that it may be important to supplement for a mother during pregnancy…
Important supplements include folic acid (0.4 or 5mg per day) and iodine (150mcg/day).
plus in some women consider
vitamins B12, D, and K,
iron
calcium
omega-3 fatty acids
For a pregnant woman with diabetes, how long would you allow the pregnancy to continue before you recommended IOL or LUSCS?
Varies from woman to woman
Monitor the baby for macrosomia and assess maternal pelvis
Generally do not go beyond 40 weeks
At what gestational ages would you order a triple test or a quad test?
What is involved in each test at and what gestational ages?
What can each of these tests screen for?
No ultrasound in quad test, just four serum biomarkers.
The quad test is free in Victoria, but less sensitive with a 5% false positive rate.
At what gestational ages can you order CVS versus amniocentesis?
What are the risks to both mum and bubs of twin pregnancies?
Risks to fetuses
- PROM and Pre-term birth (PTB)
- PTB is the biggest cause of multi fetal M&M
- PTB at 24-32 weeks affects:
- 1% of singletons
- 5% DC twins
- 10% MC twins
- Cord Prolapse
- Polyhydramnios, PPROM and malpresentation can lead to cord prolapse
- Congenital malformations
- IUGR
- Twin-twin transfusion syndrome (TTTS)
- 10-15% of all monochorionic gestations
- If untreated, severe early-onset TTTS is associated with a perinatal mortality rate of over 90%.
Maternal complications
- Hyperemesis gravidarum
- More severe pregancy symptoms like GORD, back ache
- Anemia (greater haemodilution)
- Iron and folic acid supplementation recommended
- Gestational Diabetes
- Gestational hypertension/Pre-eclampsia
- Antepartum and post partum hemorrhage
- Higher rates of instrumental birth
- Higher rates of operative birth
- Postnatal depression
- Maternal mortality – Two fold higher in twin pregnancies.
What are the antenatal and postnatal effects of smoking?
Antenatal
- Infertlity/sub-fertility (also if partner smokes or passive smoking)
- Risk of preterm birth
- Placentral abruption
- Miscarriage
- Ectopic pregnancy
- Lower birth weight
Postnatal
- Infant lung disease/infections
- Increased risk of infant brain tumours
- 2-3x risk of SIDS
Also earlier menopause in smokers by 1-4 years
Can nicotine replacement therapy be used in pregnancy?
Yes, it’s safer than smoking
A woman presents after having unprotected sex and wanting emergency contraception. What are her options, their effectiveness and side effects?
What else should you talk to the woman about?
Levonogestrel oral tablet
- 2x 0.75mg stat dose
- 95% effective if taken within 24 hours of unprotected sex. Within 25 to 48 hours, the effectiveness falls to 85%, and within 49 to 72 hours it is only 58% effective.
- Side effects include spotting, nausea and mastalgia
- Double the dose to 3mg if on enzyme enhancing drugs
Copper IUD
- Effective for up to five days
- 99% effective
- Standard risks of IUD –> PID, dislodgement, heavy bleeding, ectopic pregnancy,
Mifepristone
It can be used up to 120 hours after unprotected sex but may delay the onset of the next menses.
Specialist prescriber
Other things
Counselling about TOP should method fail
STI screening and treatment
Pap smear
Ongoing contraception options
What are the things you have to check/confirm before proceeding with an instrumental birth?
- Fully dilated cervix
- Cephalic presentation
- Station below ischial spines
- No part of the fetal head palpable above the symphisis pubis
- Must be sure of correct position of the head
- No obvious cephalo-pelvic disproportion
- Empty bladder
- Adequate analgesia (in this situation, either pudendal nerve block, or epidural/spinal)
- Episiostomy
- Paediatrician at birth
What are the major parts of a set of forceps?
Neville Barnes are for normal vaginal exam
Wrigley’s are for cesarians
K one is rarely used, for when you need to rotate the baby
What are the different types of forceps deliveries?
- Outlet forceps delivery is forceps-assisted delivery performed when the baby’s scalp is visible at the vaginal opening. This type of assisted delivery is performed only when the baby’s head is in a straight OA or OP position or in slight rotation (less than 45 degrees to the right or left) from one of these positions.
- Low forceps delivery is forceps-assisted delivery performed when the baby’s head is at +2 station or lower. There is no restriction on rotation for this type of delivery.
- Midforceps delivery station 0 to +2
- High forceps delivery Station less than 0. We don’t do these anymore
What are the different types of forceps and when do you use each type?
Neville Barnes –> NVD
Wrigleys –> Caesarian
A consultant asks you to examine a woman with suspected PCOS. What are you looking for on exam?
- BP
- BMI
- Deep voice
- Cardiovascular examination
- Visual fields for pituitary adenoma
- Hirsuitism and male pattern baldness
- Acne
- Acanthosis nigricans
- Increased muscle mass, breast atrophy
- Abdominal masses (?androgen secreting tumours)
- Pelvic exam and pap smear
A woman on the wards is at 30weeks gestation and has had PPROM. What features would make you suspect chorioamnionitis?
- Fever
- Pain
- Tender uterus/abdomen
- Change in colour of liquour
- Raised WCC
- Raised CRP
- Fetal tachycardia on CTG
What are the two most common types of speculum and who do you use them for?
Pederson -> narrow/flat for nulliparous
Graves –> broader, curved for multiparous
What are the clinical features of twin-twin transfusion syndrome?
What investigations are indicated to monitor twins?
- Rapid abdominal/uterine distension (due to polyhydramnios in receptive twin)
- Reduced ability to palpate foetal parts (due to polyhydramnios in receptive twin)
- Can only occur in monochorionic twins
Testing
Fortnightly ultrasound from 24 weeks
Ideally care provided by multiple pregnancy team
What conditions would have to be in place for you to be happy to deliver twins vaginally?
- Twins should have no foetal compromise/distress
- Should be near term
- At least first twin must be cephalic
- Delivery in hospital with obstetrician, anaethestist and paediatrician
- Epidural/spinal anasthesia
- IV access
- Continuous CTG monitoring
How common is twin twin transfusion syndrome?
15-20% of monochorionic twin pregnancies
How do you tell is a twin pregnancy is mono or dichorionic?
First trimester ultrasound scan
After that the placentas fuse and you can’t tell
What investigations would you order after a fetal death in utero (FDIU)?
Remember that it is completely up to the mothers discretion if any/all of these tests are performed. You can just give her the option that the tests could possibly show up a cause of the death which could potentially be treated for future pregnancies.
Maternal
- Blood group and antibodies (in case of isoimmunisation)
- FBE (if low, may be disseminated intravascdar coagulation)
- APTT/INR
- Kleihauer test (if positive, may be concealed abruption)
- Serologv screening for possible infections (toxoplasma, listeria, CMV, rubella serology)
- HbA1c
- TSH
- Antiphospholipid, anticariolipin, anti lupus anticoagulant
- ANA
Placenta/cord
- Send for histology after delivery
- Swab for MCS
- Examine for knots
Fetus
- Autopsy
- Xray
- Karyotype from skin biopsy
- Surface swabs and gastric aspirate for MCS
What are the various options for TOP and different gestational ages?
Medical
7 - 12 weeks –> Dilation and Aspiration
>12 weeks –> Dilation and evacuation
You are called to neonatal code blue. A baby has just been born with no respirations or muscle tone. Describe your actions.
- Call for senior help/call code
- Don PPE/gloves
- History
- Gestational age
- mec stained liquour
- mothers GBS status
- maternal fever
- complications in labour?
- Stimulate the baby for 30 secs, check HR and RR with stethoscope
- If inadequate resps commence IPPV on room air whilst attaching Spo2 and telemetry
- PIP (30 cmH2O for a term infant or 20 - 25 cmH2O for a preterm infant), PEEP 5cm
- If no response after 30 seconds and HR
- At this stage consider intubation, adrenaline and 10ml/kg normal saline through umblical artery
- Titrate oxygen to time of life
A woman has had a miscarriage in the past and is now trying for a baby, what can you counsel her about to maximise her chances of success?
Preventing miscarriage advice
SAFER
S – Smoking
A – Alcohol
F – Folate and iodine supplementation
E – exercise, diet and weight loss
R – Rubella vaccination
What are the causes of bleeding in early pregnancy (BEP)?
What system questions would you ask a woman with BEP?
Causes bleeding in early pregnancy
EMETIC-H
(Women are often emetic in early pregnancy and a dodgy H)
E - Ectopic
M - Miscarriage
E - Ectropion (?post coital bleeding)
T - Trophoblastic disease
I - Infection – STI/PID
C - Cancer – cervical, endometrial
H - Heterotopic pregnancy
PISSED CC
P – Pap smear
I – IVF?
S – sex, was the bleeding post coital?
S – symptoms of pregnancy? Nausea? Has it gone away?
E – Eat and drink last?
D – Discharge?
C – clots or POC passed?
C – cramps/contractions?
What are the causes of antepartum haemorrhage?
PAV
P - Placenta previa
A – Abruption
V – Vasa previa
You’ve been asked to pop your head in to check on a woman who is in labour on the birth suite. What do you ask?
Quick assessment of labour
VAGAL BIC
V – vital signs and CTG
A – Antenatal complications? GDM, pre-eclampsia, bleeding?
G – GBS status
A – Analgesia?
L – Liqour colour and amount
B – Blood group
I – Induced or spontaneous?
C – Contractions – frequency, intensity
Apart from contraception, what are the benefits of the COCP?
What are the risks?
Benefits
- Periods lighter and less painful, less likely to become anaemic
- Less ovarian functional cysts
- Decreased risk of
- ovarian cancer
- endometrial cancer
- bacterial STIs
- Fibroids and endometriosis
Risks
- DVT
- Gall bladder disease
- Probably no increase in breast cancer
- Small increase in cervical cancer
What is BRCA?
What percentage of cancers are caused by BRCA mutations?
How much does having a BRCA1 or BRCA2 gene mutation increase a woman’s risk of breast and ovarian cancer?
What is BRCA?
BRCA are tumour suppressor genes. When they are miscoded and the tumor suppressor protein is not expressed the risk of cancer is higher.
Men with BRCA 1 or 2 mutations are at higher risk of breast, prostate and pancreatic cancer.
What percentage of cancers are caused by BRCA mutations?
Specific inherited mutations in BRCA1 and BRCA2 increase the risk of female breast and ovarian cancers, and they have been associated with increased risks of several additional types of cancer.
Together, BRCA1 and BRCA2 mutations account for about 20 to 25% of hereditary breast cancers and about 5 to 10% of all breast cancers.
In addition, mutations in BRCA1 and BRCA2 account for around 15 percent of ovarian cancers overall
How much does having a BRCA1 or BRCA2 gene mutation increase a woman’s risk of breast and ovarian cancer?
55 to 65 percent of women who inherit a BRCA1 mutation and around 45 percent of women who inherit a harmful BRCA2 mutation will develop breast cancer by age 70 years.
39 percent of women who inherit a harmful BRCA1 mutation and 11 to 17 percent of women who inherit a harmful BRCA2 mutation will develop ovarian cancer by age 70 years.
What are the investigations and management options for premenstrual syndrome (PMS)?
Additional things to talk about:
- poorly understood causes
- extremely common - 2% disabling symptoms, up to 60% moderate symptoms
- can refer for psych support/mindfulness
- if associated with menorrhagia treat that too
What do you check/assess in a vaginal exam during labour?
- Dilation
- Effacement
- Cervical length
- Cervical consistency
- Cervical position (anteverted, retroverted)
- Presentation - cephalic/breech?
- Station
- Position - OA?
- Liquor seen?
- Caput?
- Moulding
- Pelvic adequacy
A woman who has just fallen pregnant says, “oh doc, I had an ultrasound a few years back and they found I had fibroids. I’ve had no problems with them but will it be a problem for my pregnancy?” What do you say?
As long as they’re not huge then they shouldn’t cause any problems
Rarely fibroids can grow rapidly in response to the high oestrogen levels of pregnancy, if this happens there is a risk of “red degeneration of a leiomyoma” which is where bleeding/necrosis within the centre of the fibroid occurs as the tumour has grown faster than it’s blood supply. This can cause pain (especially back pain), usually in the second trimester but is just managed conservatively. Red degeneration can be very painful, usually requires treatment with strong painkillers, but nearly always settles down without causing serious problems or needing specific treatment.
At what point in gestation is hyperglycaemia most dangerous? Why is this?
The first trimester
Fetuses don’t make their own insulin until 14 weeks so hyperglycaemia before this is teratogenic
What antibiotics would you give for chorioamnionitis?
Ampicillin
Gentamycin
Metronidazole
What are the two valid indications for tocolysis?
To allow completion of a course of steroids for fetal lung development
To facilitate transfer to a tertiary centre
Can a woman with premature pre-term ROM be managed as an outpatient?
Only after 3 days of stability as an inpatient and after review of a consultant obstetrician
A woman has had pPROM at 33 weeks gestation as confirmed by amnisure.
What are the next steps?
How would this be different if the pPROM was at 31 weeks?
How would this be different if the pPROM was at 27 weeks?
- Admit to hospital
- Avoid digital vaginal examination.
- Investigate for infection:
- maternal pulse and temperature –> every 6 hours
- FBE, CRP, urine MCS, high vaginal swab for GBS –> twice per week
- Blood cultures if febrile
- Cervical suture (consider removal after antibiotics and corticosteroids administered)
- Fetal monitoring with CTG
- Erythromycin
- Steroids
- Tocolysis acceptable only if indicated to complete steroids or facilitate transfer to tertiary hospital
- Try and get to at least 34 weeks
If before 32 weeks
IV ampicillin and amoxycillin instead of erythromycin (risk/benefit changes)
Try and get to at least 34 weeks
If before 28 weeks
Fetal monitoring via biophysical profile rather than CTG
Only consider steroids from 24 to 34 weeks gestation, before that the fetus is not viable, after that the fetus doesn’t need it.
Between what gestational ages is a ventouse delivery an option?
The ventouse is not appropriate prior to 34 weeks and is used with caution between 34 to 36 weeks.
A woman elects to have expectant management of a miscarriage at 13 weeks gestation. Before you send her off home she asks how much bleeding is okay, and how much should make her come back in.
If any more than a full maternity pad an hour for 3 hours come to ED
What options for termination of pregnancy are available based on gestational age?
Before 7 weeks = medical only
7-14 weeks = Either surgical (dilation and aspiration) or medical
14 weeks onwards - Depends on Dr, younger obstetricians will only offer medical management, some older doctors will offer dilation and evacuation because they are comfortable performing this procedure
Which STIs/infections are associated with pre-term labour and pPROM?
Chlamydia
Bacterial Vaginosis
What drugs can you use for hyperemesis gravidarum?
Metoclopramide
Ondansetron
Antihistamines
Prochlorperizine
Pyridoxine (Vitamin B6)
Corticosteroids if VERY severe
What are the criteria to proceed with medical management of an ectopic pregnancy?
Medical management
Methotrexate, given as intramuscular injection or ultrasound guided intra-amniotic injection, is commonly used in treating unruptured ectopic pregnancies.
Methotrexate is an anti-metabolite that inhibits DNA and RNA synthesis, stopping production of new cells. Methotrexate also kills the rapidly dividing cells at the fallopian tube implantation site. The body should then reabsorb the remaining products of conception and blood clot that made up the ectopic pregnancy.
To be appropriate for medical management patients must:
- Must meet the set criteria (minimal pain and bleeding, no live ectopic, ßhCG less than 5000mIU/ml, adnexal mass less than 4.0cm in diameter.)
- Must be motivated and compliant (due to need for multiple follow-up appointments)
- Must have easy access to emergency care
- Must not want to conceive in next three months
- Have no contraindications to methotrexate
What are the criteria for expectant management of an ectopic?
Around 70% of ectopic pregnancies with βhCG levels <1000mIU/mL resolve spontaneously, or ‘expectantly’. This basically just means that the foetus dies and is resorbed into the body. The best indicator of spontaneous resolution is βhCG levels that are falling by 15-25% every 48hours.
If spontaneous resolution is suspected, the patient will be monitored with 48hourly bloods looking for a continuous decline in βhCG of at least 15% each two days. If this rate stops declining or βhCG levels start to rise then medical or surgical treatment should be considered.
To be appropriate for expectant treatment patients must:
- Minimal or no pain
- Vaginal bleeding not excessive
- βhCG less than 1000mIU/ml
- Progesterone less than 60nmol/l
- Willing to undertake repeat follow-up visits
A woman has had a miscarriage at 8 weeks gestation. She asks when she can try to conceive again, what do you say?
Wait until you have had at least one period after your miscarriage before trying again, as this makes it easier to calculate the dates in the next pregnancy.
What medications other than labetalol can you use for hypertension in pre-eclampsia?
*Alternatives to labetalol are the following, but only offer if considering side-effect profiles for woman and foetus
- Methyldopa – centrally acting antihypertensive (oral) takes 24 hours to work
- Nifedipine (rapid) - can cause worsening headache
- In severe pre-eclampsia or imminent eclampsia - Hydralazine/MgSO4 (IV)
A woman presents in spontaneous labour at 38+3. She has a history of moderate pre-eclampsia in this pregnancy. The midwives are preparing a room, what medication should you instruct them to give the woman?
At the time of labour - prescribe ranitidine. This is to reduce the risk of aspiration.
What is pediculosis pubis and what is the management?
Pubic lice/nits
Standard therapy
Permethrin 1% cream rinse topical from chest to knees washed off after 10 minutes with repeated treatment 1 week later (B2)
Note the following:
- Permethrin should be applied to clean and cool skin. The patient should not take a hot bath or shower prior to treatment
- apply to infected and adjacent hairy areas
- nits should be removed with a fine toothed comb
- sex partners should be treated concurrently
- clothing and bed linen contaminated by the patient within the past 2 days should be washed and dried by machine (hot cycle) or dry cleaned.
In what female STIs is vaginal PH increased?
Bacterial vaginosis and trichomoniasis
What is the pH of the vagina in candida infection?
Lowered, less than 4.5
What do the following terms mean?
Oligospermia
Azoospermia
Teratospermia
Asthenozoospermia
Oligospermia –> semen with low concetration of sperm
Azoospermia –> no sperm in semen
Teratospermia –> sperm with abnormal morphology that affects fertility in males
Asthenozoospermia –> reduced sperm motility
What is the presentation of cholestasis of pregnancy?
Pruritis which spares the face
Jaundice is rare
Pruritus in pregnancy is common, affecting 23% of pregnancies, of which a small proportion will have obstetric cholestasis.1 The pruritus of obstetric cholestasis is typically worse at night, is often widespread and may involve the palms of the hands and/or the soles of the feet
What investigations should you order for suspected cholestasis of pregnancy?
- Bile acids
- LFTs
- Coags –> prothrombin time may be prolonged in rare cases when vitamin K has been depleted from liver dysfunction
- Cholesterol –> may be markedly elevated
- Hep C serology
Liver biochemistry may be normal at first, but eventually reveals elevated transaminases (up to 20 times normal) in most patients, with elevated gamma-glutamyl transferase in 30% and elevated bilirubin in 10%. Diagnosis is based on raised serum bile acid concentrations (more than 10 micromoles/L).
What is the management of cholestasis of pregnancy?
- topical emollients e.g. calamine lotion may provide temporary relief
- Offer advice to decrease skin irritation - wear cool loose cotton clothing, keep skin moisturised, cool baths/showers for comfort, use of cotton material where possible (e.g. bed linen).
- Encourage a low fat diet, and advise women to increase their water intake
- Offer anti-histamines at night (beneficial for their sedative effect).
- Offer Ursodeoxycholic acid (UDCA or URAO).
- Dexamethasone last line
- Consider delivery after 37 weeks
- MONITOR THE BABY
What are the causes of menorrhagia?
BITCHFACE
B - Bleeding disorders
I - Iatrogenic
T – Thyroid (especially hypo)
C - Cancer (cervical, endometrial, uterine)
H – Hyperplasia of the endometrium from anovulation due to PCOS, hyperprolactinaemia or menopause
F - Fibroids & Polyps
A - Adenomyosis
C - Chlamydia/STIs/PID
E - Endometriosis
What is the management of menorrhagia?
Try OCP!
What are the investigations for menorrhagia?
Bedside tests
Pregnancy test
Bloods and urine
FBE
Coagulation studies
Iron studies
TSH
Serum prolactin
PCOS Ix: DHEA/Testosterone/Day 21 Progesterone
Imaging
If indicated: transvaginal USS
Special tests
Pap smear
If indicated: hysteroscopy
An endometrial biopsy to exclude endometrial hyperplasia may be considered in women:
whose bleeding does not respond to medical therapy
whose endometrium is thickened (12mm or more)
•who have intermenstrual bleeding.
What are the main uses for goserelin?
Endometriosis
Uterine fibroids
Endometrial thinning before endometrial ablation
What are the major side effects of misoprostol?
Diarrheoa and GI symptoms
Fever
What are the management options for endometriosis?
Conservative –> Simple analgesia
COCP
Progesterones –> Mirena IUD, Depot Provera
GnRH agonists –> Goserelin
Laparoscopic ablation and excision
Adenomyosis
What is the epidemiology?
What is the classic presentation?
What do you find on exm?
Epidemiology
Adenomyosis typically affects women of reproductive age. In general, affected women are multiparous, and the condition is seen with higher frequency in woman with a history of surgical uterine procedures (e.g. Caesarian section, dilatation and curettage).
Clinical presentation
Most patients with adenomyosis are symptomatic and typically present withmenorrhagia and dysmenorrhea. They may present with chronic pelvic pain and/or deep dyspareunia.
On exam
The ectopic endometrial tissue appears to induce hypertrophy and hyperplasia of the surrounding myometrium, which results in a diffusely enlarged uterus. However, some women have a normal sized uterus while others develop nodules (termed adenomyomas), which clinically resemble leiomyomas.
What are the alternative terms for cervical excitation?
What does it suggest when present?
Cervical motion tenderness/Chandelier sign
PID, ectopic pregnancy, ovarian cyst
Describe the RMI (risk of malignancy index).
Score >200 needs gynae oncologist
What are the causes of post menopausal bleeding?
Vaginal/uterine atrophy
Endometrial cancer
Cervical cancer
Endometrial hyperplasia
Polyps
What is a normal CA125 level?
<35
Where are Bartholin’s glands?
The glands are located bilaterally at the base of the labia minora and drain through 2- to 2.5-cm–long ducts that empty into the vestibule at about the 4 o’clock and 8 o’clock positions
What can go wrong with Bartholin glands?
Obstruction of the distal Bartholin’s duct may result in the retention of secretions, with resultant dilation of the duct and formation of a cyst. The cyst may become infected, and an abscess may develop in the gland. A Bartholin’s duct cyst does not necessarily have to be present before a gland abscess develops
What is the management of a Bartholin cyst or abcess?
Symptomatic Bartholin’s duct cysts and gland abscesses require drainage. Unless spontaneous rupture occurs, an abscess rarely resolves on its own.
Although incision and drainage is a relatively quick and easy procedure that provides almost immediate relief to the patient, this approach should be discouraged because there is a tendency for the cyst or abscess to recur.
- Analgesia
- Broad spectrum ABx if infection present (Augmentin)
- Marsupialisation (if cyst only, not for abcess)
- Catheter drainage with Word catheter (for cyst or abcess)
- To allow epithelialization of the surgically created tract, the Word catheter is left in place for four to six weeks
What is the other name for a Bartholin gland?
greater vestibular glands
How do you diagnose missed miscarriage on US?
If the crown rump length (CRL) is >7mm and there is no foetal heart beat
If the gestational sac / mean sac diameter is >25mm and there is no foetal pole (i.e. it is empty)
A woman has come in for routine antenatal appointments at 36 and 38 weeks of gestation. Each time the baby has been 5 fifths palpable above the pelvic brim. What are your differentials?
Placental
Placenta previa
Nuchal cord
Foetal
Hypotonia/neuromuscular disorder
Thyroid or sternocleidomastoid tumour preventing head flexion
Maternal
Grand multi –> poor uterine tone
How often is CTG monitoring required for mothers with GDM?
Twice weekly from 36 weeks if on insulin
Weekly from 36 weeks if on diet or metformin
A woman has been diagnosed with pre-eclampsia. What foetal monitoring is indicated from this point on?
All women with pre-eclampsia
CTG twice weekly
US for fetal growth/AFI/Doppler at diagnosis - Repeat every 2-3 weeks
If IUGR is noted
Weekly AFI and Dopplers should be performed with fortnightly growth scans.
A woman is 29 weeks pregnant and has moderate-severe pre-eclampsia. She has started to have contractions and birth appears imminent. You initiate a course of betamethasone. What else should you prescribe?
Magnesium sulfate for fetal neuroprotection should be considered for all women less than 30 weeks gestation in whom birth is imminent within the proceeding 24 hours.
A woman is admitted for severe pre-eclampsia. You, the intern, ask if it is okay to start her on a normal saline drip. What might the consultant say?
Yes but…
Careful maternal fluid balance is required in all women with pre-eclampsia. In severe pre-eclampsia maternal fluid retention can lead to severe APO. Strict fluid balance is imperative to avoid risk of fluid overload. Fluid input should be restricted to normal requirements, which is usually about 80 mL/hr or 1 mL/kg/hr. Urine output should be measured and recorded every hour, via an indwelling urinary catheter (IDC) with an hourly urometer. Where urine output is < 80 mLs in total over 4 consecutive hours, medical review is necessary to assess renal function.
What analgesia should be offered to women post caesarean?
Immediately post CS
1g paracetamol oral or rectal strictly every 6 hours
50-100 mg diclofenac oral or rectal strictly every 8 hours
Slow release oxycodone (OxyContin®) 10 mg orally, may be given immediately unless morphine was given via epidural, in which case wait 12 hours from the last dose of morphine
Slow release oxycodone (OxyContin®) 10 mg SR orally every 12 hours for 3 days (72 hours).
For breakthrough pain
oxycodone (Endone®) 5-10 mg orally 4 hourly PRN
After a maximum of how many days after abdominal surgery should a patient have had a bowel motion?
(Ie: after this you’d be thinking they have a post operative ileus)
3 days max
What are the SYMPTOMS and SIGNS of post operative ileus?
Symptoms
Abdominal distention, bloating, and “gassiness”
Diffuse, persistent abdominal pain
Nausea and/or vomiting
Delayed passage of or inability to pass flatus
Inability to tolerate an oral diet
Signs
Physical examination typically reveals abdominal distention and tympany, a variable reduction of bowel sounds, and often some degree of mild diffuse tenderness.
In what circumstances would you use misoprostol for post partum haemorrhage?
What are the precautions and side effects?
It’s given PR and takes 30 minutes to work. It’s therefore given if you think there is going to be late bleeding / or a slow drible of PPH.
It is not to be given to asthmatics. It also always causes a fever.
When would you give prostaglandin F2 alpha for PPH?
PG F2 alpha is to be given ONLY IN THEATRE by a specialist.
It’s the last line of all utertonics.
It’s given via injection into 4 quadrants of the uterus.
A woman presents with likely vaginal prolapse, what questions do you ask her?
What examination do you perform?
History
- Can you feel a lump or fullness in the vagina?
- How long for?
- Can/do you push the lump back in?
- Any UTI symptoms - dysuria, frequency, foul smelling urine?
- Any constipation/diarrheoa?
- Any stress or urge incontinence?
- Assess severity.
- How often?
- How much does it affect your life?
- What do you do about it? Pads?
- Coffee and alcohol intake?
- Parity?
- Sex life? - current and desired
- Other medical history
- PMHx, meds, allergies
- Pap smears, mammograms
Examination
Vitals
BMI
Abdo for masses
Vulva
Speculum
Cardiorespiratory to assess suitability for surgery
Mr. Brown has just had abdominal surgery. You are the intern. What post operative orders must you make for the ward staff for the next 24 hours of Mr. Brown’s care?
Post Operative Orders
AAA! FIDO Leg Pain
A – Analgesia
A – Antibiotics
A – Antiemetic
F - Fluid balance charts including urine output and surgical drain volume
I – IV fluids (usually two salts and a sugar)
D – Diet (NBM, free fluids, clear fluids)
O – Frequency of obs (including special ones like BGL, neuro obs)
L – Legs à clexane and TEDs
P – Pathology requests
A woman presents at 30 weeks with some moderate-strong contractions. She has had some fluid leak but it’s unclear if this was sROM. Obviously, you’re worried. How can you tell if she’s likely to go into labour in the next two weeks?
Clinical PV exam for cervical dilation
Fetal fibronectin test on fluid from posterior fornix of vagina.
What is the definition of primary and secondary amenorrheoa?
Primary = Amenorreheoa in the prescence of the development of normal secondary sexual characteristics
Secondary = Amenorrheoa for >6 months in a woman who has previously menstruated
Describe the typical LH/FSH cycle in women with PCOS….
At the beginning of the cycle, LH and FSH levels usually range between about 5-20 mlU/ml. Most women have about equal amounts of LH and FSH during the early part of their cycle. However, there is a LH surge in which the amount of LH increases to about 25-40 mlU/ml 24 hours before ovulation occurs. Once the egg is released by the ovary, the LH levels goes back down.
While many women with PCOS still have LH and FSH still within the 5-20 mlU/ml range, their LH level is often two or three times that of the FSH level. For example, it is typical for women with PCOS to have an LH level of about 18 mlU/ml and a FSH level of about 6 mlU/ml (notice that both levels fall within the normal range of 5-20 mlU/ml). This situation is called an elevated LH to FSH ratio or a ratio of 3:1. This change in the LH to FSH ratio is enough to disrupt ovulation. While this used to be considered an important aspect in diagnosing PCOS, it is now considered less useful in diagnosing PCOS, but is still helpful when looking at the overall picture.
You have been asked to consent a woman for a LUSCS. What are the risks you inform her about?
Serious risks:
- Emergency hysterectomy, 7–8 women in every 1000 (uncommon)
- Need for further surgery at a later date, 5 women in every 1000 (uncommon)
- Admission to intensive care unit, 9 women in every 1000 (uncommon)
- Increased risk of a tear in the womb in future pregnancies, 2–7 women in every 1000 (uncommon)
- Developing a blood clot, 4–16 women in every 10 000 (rare)
- Stillbirth in future pregnancies, 1–4 women in every 1000 (uncommon)
- In a future pregnancy, the placenta covers the entrance to the womb (placenta praevia), 4–8 women in every 1000 (uncommon)
- Injury to the urinary system, 1 woman in every 1000 (rare)
- Death, approximately 1 woman in every 12 000 (very rare)
Frequent risks:
Common:
- persistent wound and abdominal discomfort,
- repeat caesarean section in subsequent pregnancies,
- readmission to hospital,
- minor cuts to the baby’s skin
Uncommon:
- haemorrhage
- infection
What are the ingredients of the COCPs which are deemed first line for most women?
The pills containing levonorgestrel or norethisterone in combination with ethinyloestradiol at doses equal to or below 35 microgram are considered first-line due to their possible lower risk of venous thromboembolism and their PBS listing.
What progesterone is best for acne/hirsuitism?
Cyproterone acetate
Or possibly drospirenone
What are the relative contraindications to COCP?
HOMESICKL
H - Headache / Migraine / Hypertension
O - Obesity
M - Medication (some ABx / anti-epileptics)
E - Embolsim (PE / DVT)
S - Stroke
I - Informed consent (especially if minor)
C - Cancer / Increased CV risk (eg. smoking, hyperlipidaemia)
K - Kids – breast feeding? (no oestrogen), primigravid? (less frequently have IUDs)
L - Liver disorders?
What are the treatment options for PCOS?
NB: Treatment of hirsuitism takes several months to show effect because of length of hair growth cycle
What are the ten Ps of a womens history?
Pain
Periods
Parental (and own) menopause?
Partners
Pregnancy
Protection
PID
PCOS
Piss/Poo
Pap and mammogram
What are the various evidence based management options for vasomotor symptoms of menopause?
- HRT (cyclical or continuous)
- Venlafaxine
- Clonidine (alpha blocker)
- Gabapentin/pregabalin (neuropathic pain meds)
- Hypnosis
- CBT
- Weight loss for obese women
Define pre-eclampsia vs gestational hypertension vs chronic hypertension…
1. Pre-eclampsia
HTN >20W with proteinuria, +/- renal or liver upset, neurological problems, haematological disturbance, IUGR
2. Gestational Hypertension
HTN alone >20W
3. Chronic Hypertension
HTN preconception or in early pregnancy
Essential (90%); secondary (10%)
4. Pre-eclampsia superimposed on chronic HT
What are the risk factors for pre-eclampsia?
- Family history (RR = 3)
-
Immunological dysfunction
- primigravid or new sexual partner
- reduced length of sexual co-habitation
- barrier contraception use
- sperm and oocyte donation.
-
Maternal vascular disease
- Age
- Obesity
- Diabetes
- Hypertension
- Renal disease
- Hereditary and acquired thrombophilia
-
Excessive placental size
- Multiple pregnancy
- Advancing weeks
- Hydrops
What are the effects/complications/signs/symptoms of pre-eclampsia?
Helen’s CaRe PlaN
Hepatic/Haematological
Cardiovascular
Renal
Placental
Neurological
- Hepatic
- HELLP, Abdo pain, Raised LFTs
- Haematological
- DIC
- Cardiovascular
- Heart failure, pulmonary oedema
- Renal
- Proteinuria, oedema, oliguric renal failure
- Placental
- IUGR, abruption, fetal distress, FDIU
- Neurological
- Visual disturbances, headaches, seizures, CVA
In what circumstances would you start an antihypertensive in a pregnant woman?
Severe hypertension > 160/105
OR
Pre-eclampsia*
*Pre-eclampsia = two BP readings at least 4 hours apart of >140/90 plus either
- >300mg protein in 24 hours
- 3+ protein on dipstick or
- spot Albumin Creatinine Ratio >30 mg/ mmol
You diagnose a woman with gestational hypetension at 24 weeks gestation. What monitoring is now required?
- Assess for proteinuria at each visit.
- Perform bloods for pre-eclampsia screen 4 weekly
- US for fetal growth/AFI/Doppler at time of diagnosis and every 4 weeks
Write out the FULL management of pre-eclampsia…
Basics
NA
Ix and confirm
Bedside
4 hourly BPs, recommend home BP monitor
Daily urine dipstick
If inpatient strict fluid balance chart with IDC
Bloods and Urine
FBE/UEC/LFTs
Spot Protein:Creatinin ratio (PCR)
24 hour urine collection and urinalysis
Coags
Uric acid levels
Imaging/Special
Weekly CTG >28 weeks gestation
Ultrasound
- Fetal growth
- Biophysical profile
- AFI
- Dopplers including MCA, umbilical artery and ductus venosus
Place and person
Admit if SBP >150
Obstetrician care
Delivery at tertiary hospital
Definitive
Consider induction >37 weeks or earlier if severe
Betamethasone if <37 weeks
MgSO4 if seizure or risk of seizure
If BP > 150/100 commence labetalol (2nd line = nifedipine, methydopa, hydralazine)
Aim for a sustained and gradual reduction to <150/100
Follow up
Monitor closely post delivery until diuresis occurs
Counselling about future risk of recurrence in subsequent
pregnancies, as well as hypertension and cardiovascular disease risks in later life.
If asked to perform a physical exam on a woman with pre-eclampsia, what would you do?
- General inspection and mental state
- Vital signs, BP
- Abdo palp
- SFH
- Lie
- Presentation
- Engagement/5ths above
- Liqour volume
- Tenderness
- Tightenings
- Auscultate foetal heart rate
- Neuro
- Cranial nerves
- Tone
- Reflexes
- Clonus
- Listen to lungs for APO
- Check for oedema
What are the types of breech presentation, which is the most common type?
- Complete (10%)
- Incomplete
- Frank (65%)
- Footling
You are a GP.
A woman presents for pre-conceptual counselling. What do you need to cover off with her?
everyone DRAMATISES Food
D – Dental care (see dentist before getting pregnant)
R – Rubella and varicella immunity checks
A – Animals (no new pets, stay away from poo)
M – Medication review
A – Alcohol
T – Travel (flying safest during second trimester, if car accident come to ED)
I – Immunisations up to date
S – Smoking
E – Exercise (no contact sports)
S – Supplemetation with folate, iodine +/- iron
Food
- No cold pre-cooked meats (like from deli)
- No soft cheese
- Uncooked or ready to eat seafood (like from deli)
- Pre-prepared salad (like from deli)
- Soft serve ice cream or yoghurt
What things do you need to check in a postpartum woman before discharge?
4,4,4, ABCD
4 urgent
- PE / DVT (+ walking + clexane)
- PPH
- Pre-Eclampsia
- Pyrexia
4 less urgent
- Pain
- Perineum
- Pissing (+ drinking)
- Pooing (+ eating)
4 always forget:
- Psych
- Protection
- Pap Smears
- Pelvic floor exercises
AntiD
Breastfeeding
Check Rubella immunology from antenatal visits
Diabetes (GDM)
Describe the staging for ovarian cancer…
Describe the staging of endometrial cancer…
Describe the staging of cervical cancer…
What non-foetal measurement is taken on the 20 week US, and why?
Cervical length
Cervical shortening in those who are already at risk of preterm birth have an even greater risk of preterm birth.
What is the most midely used “cut off” for a short cervix?
≤20mm at 18-22 weeks gestation
(3 centres)
What is cervical insiffuciency?
Why is it significant?
A congenital or acquired (e.g. by previous surgery) structural weakness of the cervix.
[The term “cervical incompetence” is considered pejorative and insensitive]
Cervical insufficiency is associated with an increased risk of mid-trimester pregnancy loss or preterm birth.
What are the risk factors for preterm birth?
- previous preterm birth
- preterm rupture of membranes
- multiple pregnancy
- antepartum haemorrhage
- systemic infections
- genital tract infections
- cervical insufficiency
- shortened cervix*
- congenital uterine abnormalities
*While there is an association between a shortened cervix and preterm labour and birth, most women with a short cervix do not experience a preterm birth and most preterm births are not related to a cervical problem. Look at other risk factors
What are the options for treatment of a short cervix?
- Conservative management
- do nothing, especially if no other risk factors
- Cervical surveillance
- ongoing monitoring of cervical length
- Progesterone
- vaginal progesterone
- Cervical cerclage / cervical stitch
What are the indications for / types of cervical cerclage?
When are each performed?
The terms “emergency, therapeutic and prophylactic” are no longer used.
History-indicated cerclage
- Insertion of a cerclage based on history / increased risk factors
- performed as a prophylactic measure in an asymptomatic woman and normally inserted electively at 12–14 weeks of gestation
Ultrasound-indicated cerclage
- Insertion of a cerclage as a therapeutic measure in cases of cervical length shortening seen on transvaginal ultrasound.
- Performed on asymptomatic women who do not have exposed fetal membranes in the vagina.
- Sonographic assessment of the cervix is usually performed between 14 and 24 weeks of gestation.
Rescue Cerclage
- Insertion of cerclage as a salvage measure in the case of premature cervical dilatation with exposed fetal membranes in the vagina.
- May be discovered by ultrasound examination of the cervix or as a result of a speculum/physical examination performed for symptoms such as vaginal discharge, bleeding or ‘sensation of pressure’.
What can be said about the two types of cerclage techniques; Shirodkar and McDonald?
What route are these inserted?
No evidence that one is better than the other
Usually inserted transvagibally but can be inserted transabdominally
Is there any evidence for bed rest with cervical shortening?
No
What is recommended as treatment for low risk women with a short cervix, in preventing preterm labour?
- If cervix is >25mm - it isn’t short, do nothing.
- If cervix is 20-25mm - cervial surveillance every 1-2 weeks
- If cervix is
- If cervix is
What is recommended for high risk women with a short cervix?
Cervical cerclage is more readilly recommended.
The situation in which the short cervix is found (history, U/S or symptoms) dictates which type of cerclage should be inserted and when (history-indicated, U/S-indicated or redscue cerlage)
What does a “washed out” vagina mean and what is it’s significance?
An absence of leucorrhoea which you would normally see on spec exam of a pregnant woman.
Supportive of PPROM / PROM
What can be used for tocolysis?
nifedipine (oral) - watch BP
tebutaline (SC)
salbutamol
GTN patch (often used in C section)
NSAIDs also work well - but care of foetal heart!
How do you write up an order for tocolysis for transfer?
And what is done for maintenance once the woman arrives at the tertiary centre?
20mg nifedipine stat
Repeat 20 minutes later
Repeat 20 minutes after that
For maintenance: 20mg nifedipine 8 hourly, until second dose of steroid has been administered
What is the dosage of benzylpenicillin that should be given in GBS+ or GBS unknown women with risk factors?
3g IV loading dose
1.8g IV q4h until birth
What should be given for GBS prevention if a woman is allergic to benpen with no Hx of anaphylaxis?
cephazolin
What is given to GBS+ women or GBS unknown women with risk factors, who are allergic to benpen with a history of anyphylaxis?
Vancomycin or clindamycin
What are the terms:
Zygosity
Chorionicty
Amnionicity
What does the result of each depend on, in a twin pregnancy?
Zygosity = number of eggs
Chorionicity = number of placentas
Amniocity = number of sacs
The number of placentas & sacs depends on the timing of when monozygotic twins split.
What increases your risk of having a twin pregnancy?
Increasing age
Obesity
IVF
(not because we impant two eggs, because we don’t anymore, but because clomifene and FSH stumulation cause a number of eggs to mature)
What are the complications of twin pregnancy?
- The risk of everything is increased!*
- Think of everything that can go wrong in a timeline, and say it!*
- First Trimester
- minor Cx of pregnancy: back pain, stress incontinence
- Hyperemesis gravidarum
- Miscarriage
- Malformations
- Second Trimester
- PET
- GDM
- IUGR
- APH
- FDIU
- Third Trimester
- Prematurity (PTL, PPROM)
- IOL
- C/S
- Instrumental birth
- Post Partum
- PPH
- Depression
- Breast feeding difficulty
- Financial strain
Specific to monochorionic twins: twin to twin transfusion syndrome
What are the hx questions for PPH?
EMBLEMS GCP
E - Estimated blood loss
M - Medical history of the mother? Bleeding disorders?
B - Birth weight (of baby – macrosomia can cause uterine atony)
L - Labour - How did the labour go? Prolonged? (Uterine atony?)
E - Epidural given? (cause of poor uterine tone)
M - Mode of delivery → Cesarian, instrumental, normal (trauma or cause of poor tone)
S - Symptoms of shock (conscious state, shoulder pain, light headed)
G - Gs and Ps (grand multiparity risk factor for poor uterine tone)
C - Cesarian in the past? (Uterine rupture risk)
P - Placenta – has it passed and been inspected? (retained products)
What are the OSCE steps for managing an obstetric emergency?
What are the causes of abnormal uterine bleeding?
PALM COEIN
P - Polyp
A - Adenomyosis (endometriosis in the myometrium)
L - Leiomyoma (submucosal or otherwise)
M - Malignancy (endometrial hyperplasia or carcinoma, or uterine sarcoma)
C - Coagulopathy
O - Ovulatory dysfunction
E - Endometrial
I - Infection (PID/endometritis) and Iatrogenic (anticoagulants)
N - Not yet explained
What questions would you ask when you pop your head in for a quick assessment of a woman in labour?
VAGAL BIC
V – vital signs and CTG
A – Antenatal complications? GDM, pre-eclampsia, bleeding?
G – GBS status
A – Analgesia?
L – Liqour colour and amount
B – Blood group
I – Induced or spontaneous?
C – Contractions – frequency, intensity
What are the risks of smoking in pregnancy?
(need 6)
- Decreased fertility
- Earlier menopause
- Miscarriage
- Ectopic pregnancy
- Placental abruption
- Placenta previa
- Premature delivery
- Low birth weight
- Brain tumours in the baby
- SIDS
- respiratory illness
What are the risks of alcohol in pregnancy?
(Need 5)
- IUGR
- Fetal alcohol syndrome
- Cardiac defects
- Intellectual disability
- Characteristic facial features
What are the systems questions for APH?
TIP: BE CALM
T - Trauma
I - Investigations to date (eg. position of placenta on 20 week scan)
P - Pain
B - Blood group
E - Eat or drink today?
C – Contractions (bleeding can irritate uterus inducing labour)
A - Anaesthetic previously?
L - Liqour / ROM
M - Movements (foetal)
