General OBGYN - SJS Flashcards

Question

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?

Answer 1

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.

Answer 2

**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)

Answer 3

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.**

Answer 4

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**

Answer 5

HR falls below baseline by \>15 bpm for \>15 secs

Answer 6

**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

Answer 7

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.

Answer 8

1-3% 50% within 24 hours, 80% within 7 days

Answer 9

Maternal infection Neonatal infection Cord prolapse Cord compression Placental abruption ## Footnote **Plus in PPROM additional risk of premature birth**

Answer 10

Nitrazine paper testing (alkaline amniotic fluid will turn yellow paper blue) Fern slide Amnisure

Answer 11

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

Answer 12

**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**

Answer 13

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

Answer 14

**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

Answer 15

**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

Answer 16

**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

Answer 17

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)

Answer 18

**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)

Answer 19

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.

Answer 20

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.

Answer 21

Macrosomia (BW = \>2500g) Instrumental delivery

Answer 22

**HELPERR** Help Evaluate for episiotomy Legs (McRoberts Manouvre) Pressure - suprapubic Enter - rotational manouvres Remove the posterior arm Roll onto hands and knees

Answer 23

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

Answer 24

The cervix should dilate \>1cm per hour of labour. In multigravidas, this figure is probably closer to \>2cm.

Answer 25

The head is at the ischial spines (station = 0.)

Answer 26

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.

Answer 27

**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

Answer 28

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.

Answer 29

* 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

Answer 30

**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)

Answer 31

* Foetal distress * Short/inelastic perineum * Shoulder dystocia * Foetal malposition e.g. occipito-posterior * Intrusmental delivery (especially forceps) * Breech delivery * Previous pelvic floor surgery

Answer 32

Forceps and vacuum assisted deliveries account for 11% of deliveries in Australia.

Answer 33

Face presentation Bleeding from scalp Delivery before 34 weeks

Answer 34

**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

Answer 35

In one series, patients recovered on average in 24 days No treatment required Beware the eye! Tape and protective gel can be used

Answer 36

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.

Answer 37

**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)

Answer 38

1. Periods or any other bleeding (IMB, PCB, PMB) 2. Pain (with periods, sex or other times) 3. Partners 4. Parents (maternal menopause), plus own menopause and HRT 5. Pissing/pooing? 6. Pap smears and breast checks 7. PCOS 8. Pelvic inflammatory disease 9. Protection 10. Pregnancy

Answer 39

**BITCHFACE** ## Footnote 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

Answer 40

WATER, WIND, WIZZ, WALK, WOUND, & WEIRD DRUGS ## Footnote ``` WATER = IV site infections WIND = pneumonia ``` WIZZ = UTI WALK = deep vein thrombosis WOUND = surgucal wound infection WEIRD DRUGS = drug induced fever

Answer 41

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.

Answer 42

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

Answer 43

**Intra-uterine causes** * Fibroids * Infection * Retained products **Extra-uterine causes** * Full bladder * Full rectum * Broad ligament haematoma

Answer 44

**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

Answer 45

**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

Answer 46

**VBAC** * Grade 1: Skin of **v**agina torn * Grade 2: Involves perineal (**b**ulbocavernosus) muscle * Grade 3: To the **a**nal sphincters * A) \<50% of external sphincter * B) \>50% of external sphincter * C) Internal sphincter * Grade 4: Tear to anal **c**anal

Answer 47

* Nulliparity * Precipitous labour (\<3 hours) * Birth weight \>4kg * Occipito-posterior position * Shoulder dystocia * Induction of labour * Epidural analgesia * Assisted delivery (forceps)

Answer 48

**The blues** * Affects 80% of women * Emotional lability, fatigue, sleeping difficulty and lower mood. * Should resolve spontaneously in 10-14 days.

Answer 49

* Abscesses will require aspiration * eTG recommends flucloxacillin * Analgesia * Cold lettuce leaves are a common, anecdotal therapy for pain relief

Answer 50

**HOMESICK** ## Footnote Headache / Hypertension Obesity Medications (some antivirals/ABx) Embolism / Thrombus / Clotting disorders Smoking IHD Cancer (Breast, Endometrial) Kids (ie. parity) / Breastfeeding

Answer 51

Mastalgia Nausea Fluid retention Abdominal bloating Headaches Chloasma

Answer 52

* 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

Answer 53

* Metabolic and cardiovascular * Central abdominal fat deposition * Insulin resistance/T2DM * Increased cholesterol * Skeletal * Osteoporosis * Urogenital * Atrophic vaginitis * More frequent UTIs

Answer 54

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

Answer 55

* 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

Answer 56

* 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

Answer 57

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.

Answer 58

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.

Answer 59

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.

Answer 60

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

Answer 61

**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.

Answer 62

**HAIL M** ## Footnote H - Hirsuitism A - Acne & Apetite/Weight Increase I - Insomnia L - Loss of libido M - Mood swings

Answer 63

* 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. * 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.

Answer 64

GDM generally develops and is diagnosed in the late second or early third trimester of the pregnancy. It is usually asymptomatic.

Answer 65

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

Answer 66

**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.

Answer 67

* 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

Answer 68

**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

Answer 69

**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?

Answer 70

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)

Answer 71

Pelvic infection Perforation of the uterus on insertion IUD dislodgement Increased vaginal discharge (particularly mirena) Heavier painful periods (Copper IUD) Ectopic pregnancy

Answer 72

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

Answer 73

**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)

Answer 74

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.

Answer 75

No, it's only a problem if mum is O. I don't think anyone knows why this is.

Answer 76

* 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

Answer 77

10% 1.5 in 1000

Answer 78

* 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.

Answer 79

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.

Answer 80

* PROM * Mec liquour * +ve GBS status, GBS unknown * Premature birth * Low birth weight * Maternal infection/fever * Difficult birth

Answer 81

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.

Answer 82

* 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.

Answer 83

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.

Answer 84

**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

Answer 85

**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

Answer 86

Wertheim's is also called "radical" hysterectomy

Answer 87

**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

Answer 88

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.

Answer 89

* 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)

Answer 90

* Adenocarcinoma is the commonest carcinoma (95%) * Majority are endometrial type * Adenosquamous carcinoma are less common

Answer 91

* *Direct spread**: cervical stroma, Fallopian tubes and ovaries * *Lymphatic spread**: Pelvic and para-aortic lymph nodes **Haematological spread**: Liver and lungs

Answer 92

**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.

Answer 93

**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 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

Answer 94

**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.

Answer 95

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.

Answer 96

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

Answer 97

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

Answer 98

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

Answer 99

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.

Answer 100

**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.

Answer 101

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).

Answer 102

* **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

Answer 103

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).

Answer 104

**+/- 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

Answer 105

* *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

Answer 106

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)

Answer 107

60% will have an ongoing pregnancy 30% will have pregnancy loss 9. 5% will have an ectopic pregnancy 0. 5% will have another diagnosis.

Answer 108

**Bedside** Pregnancy test, urine dipstick **Bloods** FBE HCG Blood group and hold Blood cultures if febrile or suspect sepsis **Imaging** Transvaginal ultrasound **Special** none

Answer 109

low dose aspirin 75‐150mg/day Calcium 1g/day THIS IS ONLY VALUABLE IF COMMENCED BEFORE 16 WEEKS

Answer 110

10 weeks The average gestational age of maternal symptoms of ectopic pregnancy is 7 weeks

Answer 111

**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

Answer 112

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.

Answer 113

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.

Answer 114

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.

Answer 115

first trimester = foetal chromosomal abnormality second trimester = ascending infection from the lower urinary tract

Answer 116

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.

Answer 117

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

Answer 118

* advanced maternal age * Asymptomatic bacterial vaginosis * IVF * Alcohol intake during pregnancy * Smoking during pregnancy * Overweight/obese mother

Answer 119

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.

Answer 120

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

Answer 121

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%

Answer 122

Doubling every 48 hours Considered slow if it doesnt rise by at least 50% in 48 hours

Answer 123

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.

Answer 124

**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

Answer 125

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)

Answer 126

Benzylpenicillin during labour or at PROM

Answer 127

\<500ml is normal \>1000ml you really worry

Answer 128

***Delicate Females in China Eat Rice In Early Labour*** ## Footnote 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

Answer 129

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.

Answer 130

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.

Answer 131

1. Chorioamnionitis 2. Overdistension (due to multiple gestation or polyhydramnios) 3. Bleeding/placentral abruption 4. Serious Illness such as pyelonephritis, appendicitis and pneumonia 5. abnormal placentation/fibroids/ cervical weakness 6. Idiopathic

Answer 132

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.

Answer 133

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.

Answer 134

**PROM** * Maternal infection * Neonatal infection * Cord prolapse * Cord compression * Placental abruption **PPROM** All of the above plus premature birth

Answer 135

PROM (infection risk) Proven or unknown placenta previa

Answer 136

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.

Answer 137

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

Answer 138

**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)

Answer 139

Transcervical Foley Catheter ## Footnote 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).

Answer 140

6h after gel 30mins after removal of pessary

Answer 141

* Post-partum haemorrhage * Rectovaginal fistula * Perineal tearing * Uterine rupture * Clavicle fracture * Brachial plexus injury * Fetal hypoxia/death

Answer 142

* 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)

Answer 143

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)

Answer 144

* 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

Answer 145

subcutaneous terbutaline 0.25 mg

Answer 146

* High inherent rate (premmie!) * Maternal tachy (UTI/pyelonephritis?) * Maternal fever * Fetal tachyarrythmia (SVT, Aflutter) * Drugs – b agonist for tocolysis * Hypoxia * Chorioamnionitis * Dehydration

Answer 147

Only 2 things that cause this 1) foetal anaemia (due to isoimmunisation or something 2) baby is sucking their thumb

Answer 148

Reassuring = 110 - 160 beats per minute. Non-reassuring = 100-109 Abnormal is \<100 or \>160

Answer 149

0.5 degrees Because progesterone is thermogenic

Answer 150

55 | (Mini pill from age 50)

Answer 151

1) normal, current pap 2) high vaginal swab chlamydia screen 3) not pregnant proven by b-HCG

Answer 152

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)

Answer 153

Anti-phospholipid syndrome

Answer 154

Lupus anticoagulant Anticardiolipin antibodies Anti-B2 glycoprotein-I antibodies

Answer 155

**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.

Answer 156

After 20 weeks gestation, when the trophoblasts would normally have done their thing

Answer 157

**Bedside** Urine dipstick **Bloods and urine** FBE UEC Urinalysis LFTs Coagulation studies **Imaging** Foetal USS/CTG --\> IUGR? Amniotic fluid assessment Maternal and foetal dopplers

Answer 158

BP 140/90 - 150/100

Answer 159

150/100 - 160/110

Answer 160

IUGR Oedema/Pulmonary oedema Placental abruption Renal failure DIC Stillbirth CVA Eclampsia HELLP

Answer 161

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.

Answer 162

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.

Answer 163

**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

Answer 164

Hirsuitism --\> 65-75% Menstrual disturbance: commonly oligomenorrhoea and amenorrhoea --\> 60-85%

Answer 165

* 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

Answer 166

No 8-25% of non PCOS women also have ultrasonographic features of PCO. PCO is also seen in hypothalamic amenorrhoea, pubertal development and hyperprolactinemia.

Answer 167

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

Answer 168

1. Psychological 1. Anxiety 2. Depression 3. Poor self esteem 2. Metabolic 1. 40% chance of metabolic syndrome 1. hypercholesterolaemia, HTN, central obesity, insulin resistance 2. 5-10x risk of T2DM 3. High risk of GDM 3. Reproducitve 1. Infertility 2. 3x risk of endometrial cancer

Answer 169

* 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

Answer 170

**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

Answer 171

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.

Answer 172

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.

Answer 173

15% of couples are infertile 70% of these couples have primary infertility 30% of these couples have secondary infertility

Answer 174

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

Answer 175

Clomiphene Given days 2-5 to 6-9 Ovulation occurs 5-10 days after last tablet Ovulation rates vary from 40-85%

Answer 176

**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 * Ovulatory * PCOS * Hypogonadism * Hypergonadotrophic * Premature ovarian failure * Hypogonadotrophic * Over/under weight * Sheehan syndrome * Pituatary surgery * Hyperprolactinaemia * Hypothyroidism * Age * Tubal * Infection/STI * UNEXPLAINED (40%)

Answer 177

* Hormonal * Ovarian reserve * Day 2-4 FSH/LH + oestradiol concentration * AMH * Mid luteal progesterone * TFTs * Serum prolactin * 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

Answer 178

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

Answer 179

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.

Answer 180

$11k Medicare pays around $5k

Answer 181

on the ovaries or on the uterosacral ligaments.

Answer 182

“Chocolate cyst” accumulated blood and endometrial tissue on the ovary

Answer 183

Most common in nulliparous women of higher socioeconomic class.

Answer 184

**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

Answer 185

**Bedside tests** Transvaginal or transabominal ultrasound **Imaging** MRI pelvis **Special tests** Diagnostic laparoscopy – gold standard

Answer 186

**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

Answer 187

Low grade Squamous Intra-epithelial lesion (LSIL) High grade Squamous Intra-epithelial lesion(HSIL)

Answer 188

16 & 18 together cause 70% of Squamous Cell Carcinoma of the cervix

Answer 189

90% caused by 6 & 11

Answer 190

If doesn't have a clear pap smear in the past 3 years repeat in 6 months. Otherwise repeat in 12 months. ## Footnote 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

Answer 191

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.

Answer 192

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.

Answer 193

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

Answer 194

**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

Answer 195

**CA125** * Epithelial ovarian cancer * Endometrial cancer * Benign ovarian masses * Endometriosis * Fibroids * Menstruation * PID * Ovarian hyperstimulation syndrome (OHSS) * Colon and breast cancer * Peritoneal irritation

Answer 196

No ## Footnote There is no screening test for adenocarcinoma of the cervix, although abnormal glandular cells can be identified on Pap smear.

Answer 197

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%)

Answer 198

**Ovarian cancer** Mainly because majority are diagnosed late 􏰀Symptoms are vague

Answer 199

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.

Answer 200

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

Answer 201

* 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

Answer 202

* 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

Answer 203

**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**

Answer 204

* 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

Answer 205

* 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)

Answer 206

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.

Answer 207

**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**

Answer 208

**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.

Answer 209

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.

Answer 210

**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

Answer 211

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

Answer 212

A-V : unidirectional flow A-A or VV: bidirectional flow Bidirectional anastomosis can assist in regulating unbalanced flow and are protective against TTS.

Answer 213

Donor fetus * Anaemia * Hypotension * Oliguria/oligohydramnios * Growth restriction * Renal failure * Fetal demise Recipient fetus * Polycythaemia * Hypertension * Polyuria/polyhydramnios * Hydrops/heart failure * Fetal demise

Answer 214

* Hyperemesis gravidarum * High levels of Hormones cause N&V * Anemia * Greater haemodilution * Iron and folic acid supplementation recommended * 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.

Answer 215

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.

Answer 216

*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.

Answer 217

**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).

Answer 218

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.

Answer 219

Domperidone (Motilium) and Metaclopromide (Maxalon) may be used to try to increase supply

Answer 220

GDM generally develops and is diagnosed in the late second or early third trimester of the pregnancy. It is usually asymptomatic.

Answer 221

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).

Answer 222

* 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

Answer 223

**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

Answer 224

No-one really knows

Answer 225

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

Answer 226

BMI Slimmer women will lose more

Answer 227

No but it causes redistrobution of fat to the abdomen, like a male pattern

Answer 228

Nope, not at all

Answer 229

* 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**

Answer 230

* 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

Answer 231

1. Diagnose the menopause 1. LNMP 2. Hysterectomy? 3. OCP or HRT? 2. Screen for signs/sx of menopause 1. General (headaches, muscle aches, fatigue) 2. Cognitive (depression, anxiety, difficulty concentrating) 3. Vasomotor (night sweats, hot flushes) 4. Vaginal atrophy, UTI sx 3. Screen for factors related to potential HRT use 1. Breast cancer --\> contraindication 2. DVT/PE 3. Smoker? 4. 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

Answer 232

* 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

Answer 233

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

Answer 234

dysmenorrheoa, dyspareunia and infertility

Answer 235

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

Answer 236

* 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.

Answer 237

60% of PID is asymptomatic, 4% severe symptoms, the rest mild-moderate symptoms

Answer 238

**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

Answer 239

**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

Answer 240

**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

Answer 241

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

Answer 242

**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

Answer 243

**TIP: BE CALM** ## Footnote 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)

Answer 244

**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

Answer 245

**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]

Answer 246

**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

Answer 247

**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)

Answer 248

**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.

Answer 249

Occasionally, acute heavy menstrual bleeding may cause severe anaemia and hypotension à pregnancy-related haemorrhage must be excluded. 1. Manage hypovolaemia with IV replacement 1. Consider transfusion if really severe 2. tranexamic acid 1. 10 mg/kg IV, every 8 hours until bleeding stops 3. Occasionally if the bleeding doesn't stop, high dose oestrogen may be required 1. 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.

Answer 250

1. to manage meonorrhagia 2. to provide endometrial protection for women who require hormone replacement therapy (HRT) 3. contraception

Answer 251

**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

Answer 252

* 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

Answer 253

**Three options:** 1. Consider breech vaginal birth by senior consultant with paediatrician on hand 2. Cesarian 3. Trial external cephalic version 1. 50% success rate in primigravid 2. 75% success rate in multigravid 3. 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.

Answer 254

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.

Answer 255

* 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

Answer 256

***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!]

Answer 257

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.

Answer 258

**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**

Answer 259

**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**

Answer 260

7 - 9 weeks

Answer 261

80–100 ml/kg

Answer 262

Fallopian tubes (95%) Ovaries (3%) Peritoneum (1%)

Answer 263

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

Answer 264

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.

Answer 265

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.

Answer 266

**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

Answer 267

* 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

Answer 268

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%)

Answer 269

**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.

Answer 270

**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:

Answer 271

Red (approx day 3 to 5 post delivery) Pink (approx day 5 to 10 post delivery) Serous (approx day 10 to 35 post delivery)

Answer 272

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

Answer 273

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

Answer 274

**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

Answer 275

**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)

Answer 276

Major – covers os Minor – close to but doesn’t cover os morbidity proportional to how much of the placenta is placed centrally over os

Answer 277

1 in 200 pregnancies Age Multiparity Large placental area e.g. Multiple pregnancy Uterine scar/previous c-sec

Answer 278

**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

Answer 279

**Baby**: * Death, * hypoxia, * trauma/fractures, * brachial plexus injury **Mum**: * PPH * perineal trauma (3rd & 4th degree tears) * uterine rupture * PTSD

Answer 280

Syntocin 10U IM with delivery of anterior shoulder Cut cord Controlled cord traction with guarding of the fundus

Answer 281

Classic triad: hypoxia, DIC, haemodynamic collapse Probably due to anaphylaxtic reaction to fetal tissue Buzzword: Fetal squames in the mother’s lungs at autopsy

Answer 282

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

Answer 283

**PALM COEIN** ## Footnote 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

Answer 284

* 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

Answer 285

1% of pregnancies

Answer 286

**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

Answer 287

* **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

Answer 288

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

Answer 289

**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.

Answer 290

Get that baby out. Can progress to DIC. If stable, induced labour. If unstable, emergency Caesarean.

Answer 291

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

Answer 292

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

Answer 293

* 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

Answer 294

**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?

Answer 295

*“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?

Answer 296

Anterior placenta Primigravid

Answer 297

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.

Answer 298

150 micrograms each day

Answer 299

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

Answer 300

Varies from woman to woman Monitor the baby for macrosomia and assess maternal pelvis Generally do not go beyond 40 weeks

Answer 301

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.

Answer 302

Risks to fetuses ## Footnote * 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.

Answer 303

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

Answer 304

Yes, it's safer than smoking

Answer 305

**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

Answer 306

* 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

Answer 307

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

Answer 308

* **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

Answer 309

Neville Barnes --\> NVD Wrigleys --\> Caesarian

Answer 310

* 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

Answer 311

* Fever * Pain * Tender uterus/abdomen * Change in colour of liquour * Raised WCC * Raised CRP * Fetal tachycardia on CTG

Answer 312

Pederson -\> narrow/flat for nulliparous Graves --\> broader, curved for multiparous

Answer 313

* 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

Answer 314

* 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

Answer 315

15-20% of monochorionic twin pregnancies

Answer 316

First trimester ultrasound scan After that the placentas fuse and you can't tell

Answer 317

**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

Answer 318

Medical 7 - 12 weeks --\> Dilation and Aspiration \>12 weeks --\> Dilation and evacuation

Answer 319

* 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

Answer 320

Preventing miscarriage advice **SAFER** S – Smoking A – Alcohol F – Folate and iodine supplementation E – exercise, diet and weight loss R – Rubella vaccination

Answer 321

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?

Answer 322

**PAV** P - Placenta previa A – Abruption V – Vasa previa

Answer 323

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

Answer 324

**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

Answer 325

**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.

Answer 326

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

Answer 327

* Dilation * Effacement * Cervical length * Cervical consistency * Cervical position (anteverted, retroverted) * Presentation - cephalic/breech? * Station * Position - OA? * Liquor seen? * Caput? * Moulding * Pelvic adequacy

Answer 328

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.

Answer 329

The first trimester Fetuses don't make their own insulin until 14 weeks so hyperglycaemia before this is teratogenic

Answer 330

Ampicillin Gentamycin Metronidazole

Answer 331

To allow completion of a course of steroids for fetal lung development To facilitate transfer to a tertiary centre

Answer 332

Only after 3 days of stability as an inpatient and after review of a consultant obstetrician

Answer 333

* 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.

Answer 334

The ventouse is not appropriate prior to 34 weeks and is used with caution between 34 to 36 weeks.

Answer 335

If any more than a full maternity pad an hour for 3 hours come to ED

Answer 336

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

Answer 337

Chlamydia Bacterial Vaginosis

Answer 338

Metoclopramide Ondansetron Antihistamines Prochlorperizine Pyridoxine (Vitamin B6) Corticosteroids if VERY severe

Answer 339

*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

Answer 340

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

Answer 341

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.

Answer 342

\*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)

Answer 343

At the time of labour - prescribe ranitidine. This is to reduce the risk of aspiration.

Answer 344

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.

Answer 345

Bacterial vaginosis and trichomoniasis

Answer 346

Lowered, less than 4.5

Answer 347

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

Answer 348

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

Answer 349

* 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).

Answer 350

* 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**

Answer 351

**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

Answer 352

**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.

Answer 353

Endometriosis Uterine fibroids Endometrial thinning before endometrial ablation

Answer 354

Diarrheoa and GI symptoms Fever

Answer 355

Conservative --\> Simple analgesia COCP Progesterones --\> Mirena IUD, Depot Provera GnRH agonists --\> Goserelin Laparoscopic ablation and excision

Answer 356

**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.

Answer 357

Cervical motion tenderness/Chandelier sign PID, ectopic pregnancy, ovarian cyst

Answer 358

Score \>200 needs gynae oncologist

Answer 359

Vaginal/uterine atrophy Endometrial cancer Cervical cancer Endometrial hyperplasia Polyps

Answer 360

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

Answer 361

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

Answer 362

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. 1. Analgesia 2. Broad spectrum ABx if infection present (Augmentin) 3. Marsupialisation (if cyst only, not for abcess) 4. Catheter drainage with Word catheter (for cyst or abcess) 1. To allow epithelialization of the surgically created tract, the Word catheter is left in place for four to six weeks

Answer 363

greater vestibular glands

Answer 364

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)

Answer 365

**Placental** Placenta previa Nuchal cord **Foetal** Hypotonia/neuromuscular disorder Thyroid or sternocleidomastoid tumour preventing head flexion **Maternal** Grand multi --\> poor uterine tone

Answer 366

Twice weekly from 36 weeks if on insulin Weekly from 36 weeks if on diet or metformin

Answer 367

**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.

Answer 368

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.

Answer 369

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.

Answer 370

**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

Answer 371

3 days max

Answer 372

**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.

Answer 373

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.

Answer 374

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.

Answer 375

**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

Answer 376

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

Answer 377

Clinical PV exam for cervical dilation Fetal fibronectin test on fluid from posterior fornix of vagina.

Answer 378

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

Answer 379

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.

Answer 380

**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

Answer 381

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.

Answer 382

Cyproterone acetate Or possibly drospirenone

Answer 383

**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?

Answer 384

NB: Treatment of hirsuitism takes several months to show effect because of length of hair growth cycle

Answer 385

Pain Periods Parental (and own) menopause? Partners Pregnancy Protection PID PCOS Piss/Poo Pap and mammogram

Answer 386

* HRT (cyclical or continuous) * Venlafaxine * Clonidine (alpha blocker) * Gabapentin/pregabalin (neuropathic pain meds) * Hypnosis * CBT * Weight loss for obese women

Answer 387

**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**

Answer 388

1. **Family history (RR = 3)** 2. **Immunological dysfunction** * primigravid or new sexual partner * reduced length of sexual co-habitation * barrier contraception use * sperm and oocyte donation. 3. **Maternal vascular disease** * Age * Obesity * Diabetes * Hypertension * Renal disease * Hereditary and acquired thrombophilia 4. **Excessive placental size** * Multiple pregnancy * Advancing weeks * Hydrops

Answer 389

**Helen’s CaRe PlaN** **H**epatic/Haematological **Ca**rdiovascular **Re**nal **Pla**cental **N**eurological * 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

Answer 390

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

Answer 391

1. Assess for proteinuria at each visit. 2. Perform bloods for pre-eclampsia screen 4 weekly 3. US for fetal growth/AFI/Doppler at time of diagnosis and every 4 weeks

Answer 392

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 (2^nd 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.

Answer 393

* 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

Answer 394

1. Complete (10%) 2. Incomplete 3. Frank (65%) 4. Footling

Answer 395

**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

Answer 396

**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)

Answer 397

**Cervical length** Cervical shortening *in those who are already at risk of preterm birth* have an even greater risk of preterm birth.

Answer 398

≤20mm at 18-22 weeks gestation | (3 centres)

Answer 399

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.

Answer 400

* 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***

Answer 401

* Conservative management * do nothing, especially if no other risk factors * Cervical surveillance * ongoing monitoring of cervical length * Progesterone * vaginal progesterone * Cervical cerclage / cervical stitch

Answer 402

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’.

Answer 403

No evidence that one is better than the other Usually inserted transvagibally but can be inserted transabdominally

Answer 404

* 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

Answer 405

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)

Answer 406

An absence of leucorrhoea which you would normally see on spec exam of a pregnant woman. Supportive of PPROM / PROM

Answer 407

nifedipine (oral) - watch BP tebutaline (SC) salbutamol GTN patch (often used in C section) NSAIDs also work well - but care of foetal heart!

Answer 408

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

Answer 409

3g IV loading dose 1.8g IV q4h until birth

Answer 410

cephazolin

Answer 411

Vancomycin or clindamycin

Answer 412

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.

Answer 413

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)

Answer 414

* 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

Answer 415

**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)

Answer 416

**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

Answer 417

**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

Answer 418

* Decreased fertility * Earlier menopause * Miscarriage * Ectopic pregnancy * Placental abruption * Placenta previa * Premature delivery * Low birth weight * Brain tumours in the baby * SIDS * respiratory illness

Answer 419

* IUGR * Fetal alcohol syndrome * Cardiac defects * Intellectual disability * Characteristic facial features

Answer 420

**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)