General OBGYN - SJS Flashcards
Briefly discuss the pathophysiology of the different signs/symptoms of pre-eclampsia
What are the diagnostic criteria of pre-eclampsia
What are the risk factors for pre-eclampsia?
What are the symptoms of pre-eclampsia?
WHat is the management of eclampsia?
What is the clinical picture of HELLP?
What do we learn from the 12 week USS?
Identifies viability of the foetus
Estimates gestation and date of delivery
Identifies and characterizes multiple gestation
Identifies risk factors for Down Syndrome as part of 1st trimester screening.
Identifies major fetal abnormalities like anencephaly
What is the amnion and the chorion?
The chorion is the placenta
The amnion is the fluid sack of foetal urine
What can we tell from the 20 week scan?
Morphology scan –> head to toe check for anatomical abnormalities
Growth (4 measurements)
Locates the placenta (5% of women will have a low lying placenta)
Amniotic fluid volume
May also perform umbilical artery doppler and/or cervical length if indicated
What % of women have a low lying placenta at their 20 week ultrasound scan?
What is the management?
What % of women have placenta previa?
5%
Follow up ultrasound at 34 weeks, explain to mother that it’s like blowing up a baloon so the placenta is likely to move to a safe spot
0.5% go on to have placenta previa
What is the cut off amniotic fluid index for oligo and polyhydramnios?
Polyhydramnios - AFI >25
Oligohydramnios - AFI < 5 - 10
What are the causes of oligo and polyhydramnios?
What is Potter’s sequence?
A triad of consequences of oligohydramnios (regardless of the cause)
Clubbed feet
Pulmonary hypoplasia
Cranial anomalies
Why is general anaesthetic avoided in pregnant women?
Higher risk of aspiration
The uterus is pushing up on the abdominal cavity + progesterone relaxes the lower oesophageal sphincter
What are you looking for on foetal artery doppler?
Two things:
1) In suspected RhD, the flow velocity of the middle cerebral artery can be used to quantify foetal anaemia. This is the equivalent of listening for a flow murmur in an anaemic adult
2) diastolic flow patterns in the umbilical artery can demonstrate high resistance in the placenta vasculature and assess the risk for pre-eclampsia, IUGR and abruption
What are some indications for foetal growth and wellbeing studies in later pregnancy?
GDM
Gestational HTN
Suspected IUGR (uterus too small)
Decreased fetal movements felt (FMF)
History of pregnancy loss or complication in late pregnancy
What can you do to assess foetal wellbeing in later pregnancy?
SAM BLACK
What are the causes of a long or short symphysiofundal height?
At what gestational age is the foetal heart beat usually detectable on USS?
Often at 6 weeks
in 80% of cases at 12 weeks
90% at 13 weeks
At what gestational age do women typically start feeling foetal movements?
What can delay this?
Foetal movements begin to be felt between weeks 15 and 25
They can be masked by an anterior lying placenta
Why are babies of mums with GDM big?
GDM –> hyperglycaemia –> increased release of insulin and insulin like growth factor from the foetus –> hepatomegaly and increased growth
What are the components of the APGAR?
How do you interpret a CTG?
DR C BRaVADO
What causes Braxton Hicks contractions?
Around week 37 progesterone levels start to drop, but oestrogen levels remain high. This higher ratio of oestrogen to progesterone causes the uterus to be more sensitive to other hormones (notably oxytocin released from the anterior pituitary) which stimulate contractions. This effect can cause some women to experience some weak contractions in late pregnancy, either called “false labour contractions” or “Braxton-Hicks contractions”.
What do you know about bloody show?
What other causes of bleeding must you differentiate bloody show from and how would you know the difference?
Bloody show (a small amount of blood with mucous discharge from the cervix) may precede onset of labor by as much as 72 hours. It is the mucus plug that sits in the cervix during pregnancy falling out.
Bloody show can be differentiated from abnormal 3rd-trimester vaginal bleeding because the amount is small, typically mixed with mucus and the pain due to abruptio placentae is absent. In most pregnant women, previous ultrasonography has been done and ruled out placenta previa. However, if ultrasonography has not ruled out placenta previa and vaginal bleeding occurs, placenta previa is assumed to be present until it is ruled out. Digital vaginal examination is contraindicated, and ultrasonography is done as soon as possible.
What are the 3 stages of labour?
First: from the onset of labour to full dilatation (commonly lasts 8-12 hours in a first labour, 3-8 hours in subsequent labours)
Second: from full dilatation of the cervix to delivery of the baby (commonly lasts 1-2 hours in a first labour, 0.5-1 hour in subsequent labours)
Third: from delivery of the baby to the delivery of the placenta (commonly lasts up to an hour if physiological, 5-15 minutes if actively managed)
What are the causes of foetal tachy or brady cardia?
What is a “normal” or “healthy” amount of variability of a foetal HR on CTG?
RWH defines normal as between 5-25, other sources say >10
Don’t forget that if the baby is in REM sleep, variability can be reduced for up to 40mins.
What is the criteria for an acceleration on CTG?
How would you interpret accelerations?
Defined as elevation in foetal HR >15 bpm above baseline for longer than 15 seconds.
>2 every 20 minutes is a good sign (hypoxic foetuses rarely have accelerations) but their absence is probably insignificant
What is the criteria for a deceleration on CTG?
HR falls below baseline by >15 bpm for >15 secs
What are the five different types of deceleration and what do they typically mean?
Early –> Normal
Variable –> (rapid onset, variable offset, usually a/w contractions) –> cord compression. If overall trace is good don’t worry, if overall trace is bad then worry
Late –> (starts in middle of contraction) uteroplacental insufficiency. Be hesitant to call a late decel in the absence of other concerning features.
Prolonged –> (15 bpm decel for longer than 90 seconds but less than 5 minutes). uteroplacental insufficiency, urgent Mx may be required. Often caused by prolonged contractions, maternal hypotension or hyperstimulation
Sinusoidal pattern –> Suggests severe hypoxia. Urgent C/S. Outcome is poor
How do you make your overall assessment of the CTG?
Normal = a CTG trace where all four features are rated as reassuring.
Suspicious = a CTG trace where one feature falls into the non-reassuring category.
Pathological = when two or more features fall into the non-reassuring category, or one feature falls into the abnormal category.
What % of pregnancies are affected by Term Prom?
What % of these will go in to labour within 24 hours?
10%
90%
What % of pregnancies will be affected by premature pre-term rupture of membranes?
What % of these will deliver within 24 hours?
1-3%
50% within 24 hours, 80% within 7 days
What are the risks of term prom and pre-term prom?
Maternal infection
Neonatal infection
Cord prolapse
Cord compression
Placental abruption
Plus in PPROM additional risk of premature birth
How can you tell in PV fluid is amniotic?
Nitrazine paper testing (alkaline amniotic fluid will turn yellow paper blue)
Fern slide
Amnisure
What will USS show in women with PROM?
Low AFI in 50-70% of women (doesn’t always happen)
If mild oligohydramnios then need to investigate for other causes (cf: causes of oligohydramnios)
If major oligohydramnios –> most likely from PROM
What are the risks of expectant management vs active management of PROM?
Expectant
Placental abruption
Cord prolapse
Maternal infection
Foetal infection
Active
Theoretical increased risk of need for instrument delivery or C-section but research shows no increased risk
In practice you usually blend the two by waiting 24 hours after PROM and if labour hasn’t started switch to IOL
What are the requirments for expectant management of PROM?
Term baby
Engaged with cephalic presentation
NO PV exams
CTG normal
Mother in a facility able to properly monitor her
Maternal vitals normal
GBS negative
What is the FULL management of term PROM?
Basics
- Health of Mother
- Vital signs
- Abdominal examination)
- FBE / CRP
- Health of Baby
- SAM BLACK
- DO NOT DO PV EXAMS
Place and person
Depends on definitive Mx
Ix and confirm diagnosis
- Confirm gestational age (are they definitely term?)
- Confirm not in labour with CTG
- Sterile speculum exam to assess for liquour
- If unsure:
- Nitrazine paper test
- Amnisure
- Fern test
Definitive
Expectant vs active management
Long term
- Monitor until labour
- Indication for CTG during labour
- Paediatric review after birth
What is the management of pre-term PROM?
Basics
- Health of Mother
- Vital signs
- Abdominal examination
- FBE / CRP
- Health of Baby
- SAM BLACK
- DO NOT DO PV EXAMS
Place and person
Depends on definitive Mx
Ix and confirm diagnosis
- Confirm gestational age (are they definitely term?)
- Confirm not in labour with CTG
- Sterile speculum exam to assess for liquour
- Collect MCS swabs for chlamydia and gonorrheoa
- Collect swab for GBS
- If unsure:
- Nitrazine paper test
- Amnisure
- Fern test
Definitive
Give antenatal steroids
Give erythromycin (reduces neonatal lung dz, cerebral haemorrhage and death)
Expectant vs active management
Long term
- Monitor until labour
- Indication for CTG during labour
- Paediatric review after birth
What are the indications for IOL?
MOTHER PIG
Maternal medical issues (heart/renal/autoimmune dz)
Obstetric cholestasis
Too long (>41 weeks)
Haematological/hypertension (pre-eclampsia)
Endocrine (GDM –> macrosomia)
ROM early or Request
Planned neonatal surgery
Intrauterine death
Growth restriction
What are the risks of IOL?
PATH / ROAD
Prolapsed umbilical cord
Abruption of placenta
Tachysystole
Hyponatraemia/haemorrhage
Rupture of uterus
Oedema/fluid retention
Atonic uterus
Didn’t work (failure leading to C section)
What are the relative contraindications to IOL?
CAMP HI
C Section previously (uterine scar –> uterine rupture)
Act quickly! (need for non-elective C-section)
Malpresentation (non-cephalic presentation)
Placenta Previa (risk of haemorrhage)
High Parity (increased risk of uterine rupture)
Infections (active genital herpes, HIV)
How do we induce labour?
What is VBAC?
What are the risks?
VBAC (pronounced veeback) stands for vaginal birth after caesarean section.
The major risk if uterine rupture at the site of the previous LUCS scar - affects 1 in 200 women trying for a VBAC.
What are the main considerations when choosing bw low and high dose oxytocin infusions for IOL?
How do you decide what approach to take in induction of labour?
In term PROM you can jump straight to oxytocin. In pre-term PROM use Modified bishop score
“Favourable Cervix” with Modified Bishop Score >8
IOL likely to be successful
ARM +/- oxytocin infusion
“Unfavourable Cervix” with a Modified Bishop Score of 8 or less (this number varies between sources!)
Cervix needs ripening
Use prostaglandin
The Bishop’s Score is a clinical tool used to gauge the favourability of the cervix for labour and induction of labour. Six is a commonly used cut off. The most important component ins the dilation of the cervix. Dilation <3cm or a score <6 will usually preclude ARM. In women with a favourable cervix, ARM ± syntocinon is a common choice.
What are the two major risk factoras/causes of shoulder dystocia?
Macrosomia (BW = >2500g)
Instrumental delivery
What manouvres/procedures should you do for shoulder dystocia?
HELPERR
Help
Evaluate for episiotomy
Legs (McRoberts Manouvre)
Pressure - suprapubic
Enter - rotational manouvres
Remove the posterior arm
Roll onto hands and knees
Explain the screening/diagnostic algorithm for Down Syndrome
What is the effect of epidural anasthesia on the 2nd stage of labour?
Slows it down, becaused reduced sensation of need to push
Increases time of second stage from 1-2 hours in multigrad, 2-3 hours in primigrad
At what rate should the cervix dilate in the first stage of labour?
The cervix should dilate >1cm per hour of labour.
In multigravidas, this figure is probably closer to >2cm.
What is generally considered the point of no return in vaginal labour? Ie: the point at which you’re better off continuing with vaginal birth rather than switching to C section.
The head is at the ischial spines (station = 0.)
What do you need to check before performing ARM (artificial rupture of membranes)?
1) That the foetal head is engaged. If it’s not, when you rupture the membranes the cord could fall out and then the baby will compress it when it’s head enters the pelvis, this could be fatal for the baby!
2) need to confirm that placenta previa has been ruled out by USS.
What are the risks and benefits of artificial rupture of membranes?
Risks
Cord prolapse
Placental abruption
Ascending infection
Failure –> may not trigger good labour
Benefits
May shorten labour
Reduces rate of dystocias
Enables fetal scalp sampling and electrodes
In the event of cord prolapse during labour, what do you do?
The most immediate management Is to place mum in the Trendelenburg position and push the presenting part back into the pelvis.
Try not to touch the cord as this can induce vasospasm.
What are the risks of using syntocinon?
- Uterine hyperstimulation
- Powerful contractions may distress foetus (use intrapartum CTG)
- Especially concerned if baby is IUGR
- Can also lead to placental abruption
- Hyponatraemia (ADH-activity)
- Hypotension
- Nausea/Vomiting
- (Rarely) arrythmias and anaphactoid reactions
What are the diagnostic criteria for uterine hyperstimulation?
What are the different administration options of prostaglandins to ripen the cervix for labour?
What are the considerations of using each type?
When would you prefer to use a non-hormonal method of cervical dilation?
An intravaginal gel can be used
Cannot administer syntocinon for 6 hours after application
A continuous release pessary also exists
Can be removed in the event of spontaneous labour, sROM or significant side effects in mum or baby
Smaller chance of hyperstimulation
Once removed, cannot adminster syntocinon for 30 mins
When to go for a non-hormonal option
- The catheter tends to be more uncomfortable, but is a good alternative to the PGE2 when…
- There is a history of hyperstimulation
- There is an already compromised foetus
- There is a history of uterine surgery (PGE2 can cause uterine rupture)
What are the indications of episiostomy?
- Foetal distress
- Short/inelastic perineum
- Shoulder dystocia
- Foetal malposition e.g. occipito-posterior
- Intrusmental delivery (especially forceps)
- Breech delivery
- Previous pelvic floor surgery
How common are instrumental deliveries in Australia?
Forceps and vacuum assisted deliveries account for 11% of deliveries in Australia.
What are the contraindications to instrument assisted delivery?
Face presentation
Bleeding from scalp
Delivery before 34 weeks
What are the pre-requisites for forceps delivery?
What history/exam would you perform before proceeding with forceps delivery?
History
- Has the patient receive syntocinon (should try first)
- How long has the labour been?
- What is the mother’s BMI? Baby’s estimated weight?
- Gestational diabetes?
- Osteogenesis imperfecta (absolute contraindication)
Examination
- Palpate abdomen for foetal size and engagement
- Perform VE –> is the head at or below spines?
- Is there a ‘face’ presentation?
FORCEPS
What are the potential complications of forceps delivery?
What are the potential complications of vaccum assisted delivery?
What is the management of facial nerve palsies caused by forceps deliveries?
In one series, patients recovered on average in 24 days
No treatment required
Beware the eye! Tape and protective gel can be used
A woman who has previously LUCS has her 20 week ultrasound and is found to have an anteriorly low lying placenta, what do you think?
sAnterior low lying placentas may be in the old scar from the previous LUSCS. This is a placenta accreta until proven otherwise and may need very senior care in tertiary settings.
What are the advantages and disadvantages of vaginal birth (vs LUCS)?
Advantages
- Mum
- Shorter hospital stay
- Less analgesia required
- Often felt to be ‘more satisifying’
- Baby
- Less likely to have TTN
- More easily cared for by mum, who is physically well sooner
Disadvantages
- Mum
- Instrumental birth
- Bleeding
- Tears
- Emergency Caesarean (30%)
- Hysterectomy (rare, PPH)
- Rupture of scar (1 in a 100)
What are the 10 Ps of every women’s station?
- Periods or any other bleeding (IMB, PCB, PMB)
- Pain (with periods, sex or other times)
- Partners
- Parents (maternal menopause), plus own menopause and HRT
- Pissing/pooing?
- Pap smears and breast checks
- PCOS
- Pelvic inflammatory disease
- Protection
- Pregnancy
What are the causes of menorrhagia?
BITCHFACE
B – Bleeding disorder
I – Iatrogenic (IUDs and drugs)
T – Thyroid dysfunction (especially hypo)
C – Cancer (Endometrial, cervical)
H – Hyperplasia
F – Fibroids and polyps
A – Adenomyosis and endometriosis
C – Chlamydia, gonorrhea and STIs
E – Ectopics and miscarriage
What are the (generic) causes of post-op fever?
WATER, WIND, WIZZ, WALK, WOUND, & WEIRD DRUGS
WATER = IV site infections WIND = pneumonia
WIZZ = UTI
WALK = deep vein thrombosis
WOUND = surgucal wound infection
WEIRD DRUGS = drug induced fever
What time frame is considered to be puerperium?
What is the clinical significance of this time?
From delivery to 6 weeks
After the puerperium any maternal complications of pregnancy (like GDM or gestational HTN) should have resolved. If they haven’t treat like normal DM/HTN.
Describe the normal pattern of lochia….
Red (approx day 3 to 5 post delivery)
Pink (approx day 5 to 10 post delivery)
Serous (approx day 10 to 35 post delivery)
After birth the flow of lochia is equivalent to a heavy menstrual period
What might delay uterine involution after labour?
Intra-uterine causes
- Fibroids
- Infection
- Retained products
Extra-uterine causes
- Full bladder
- Full rectum
- Broad ligament haematoma
A woman has red lochia at day 7 post delivery. What are the differentials? What is the management?
DDx
May indicate infection (endometritis) or retained products
Management
Endometritis
Oral Augmentin and Azithromycin (mild)
IV amoxy, gent and metro (severe)
Retained products
Evacuation + antibiotics
What is the typical causes of pain post partum?
What is the management?
Causes
- Perineal pain and ‘after-pain’ (uterine contractions) are common in the first 3 days of peurperium.
- It is preferable to avoid opioid analgesia because it can slow resumption of normal bowel function.
Management
- Regular paracetamol
- Topical lignocaine
- Diclofenac (voltaren) suppositories at birth and 12 hours postpartum (best evidence for perineal pain)
- Laxatives to avoid straining on perineal tear
What are the grades of perineal tears?
VBAC
- Grade 1: Skin of vagina torn
- Grade 2: Involves perineal (bulbocavernosus) muscle
- Grade 3: To the anal sphincters
- A) <50% of external sphincter
- B) >50% of external sphincter
- C) Internal sphincter
- Grade 4: Tear to anal canal
What are the risk factors for perineal tearing?
- Nulliparity
- Precipitous labour (<3 hours)
- Birth weight >4kg
- Occipito-posterior position
- Shoulder dystocia
- Induction of labour
- Epidural analgesia
- Assisted delivery (forceps)
What do you know about “the blues” post delivery?
What other mental health complications can arise after delivery? How common are they?
The blues
- Affects 80% of women
- Emotional lability, fatigue, sleeping difficulty and lower mood.
- Should resolve spontaneously in 10-14 days.
What is the management of mastitis?
- Abscesses will require aspiration
- eTG recommends flucloxacillin
- Analgesia
- Cold lettuce leaves are a common, anecdotal therapy for pain relief
What are the relative and absolute contraindications to hormonal contraception?
HOMESICK
Headache / Hypertension
Obesity
Medications (some antivirals/ABx)
Embolism / Thrombus / Clotting disorders
Smoking
IHD
Cancer (Breast, Endometrial)
Kids (ie. parity) / Breastfeeding
What are the side effects of oestrogen?
Mastalgia
Nausea
Fluid retention
Abdominal bloating
Headaches
Chloasma
What are the symptoms of oestrogen deficiency (menopause)?
- General
- Fatigue
- Headaches
- Muscle/joint pains
- Vasomotor
- Hot flushes
- Night sweats
- Psychological
- Depression/anxiety
- Sleep disturbance
- Poor memory and concentration
- Urogenital
- Vaginal itching, dryness and dyspareunia
- Urinary frequency and urgency
What are the serious medical side effects of oestrogen deficiency (menopause)?
- Metabolic and cardiovascular
- Central abdominal fat deposition
- Insulin resistance/T2DM
- Increased cholesterol
- Skeletal
- Osteoporosis
- Urogenital
- Atrophic vaginitis
- More frequent UTIs
What is the role of hormonal testing in suspected menopause?
Hormone measurement may be useful for:
- Women with subtle/fluctuating symptoms, for example predominant mood change and few vasomotor symptoms where it be valuable to increase the index of suspicion of menopause
- Women with amenorrheoa <45 years old
A 44yo woman presents with amenorrheoa for 3 months. What investigations would you perform to diagnose the cause?
- Pregnancy test
- Prolactin levels (hyperprolactinaemia causing amenorrheoa?)
- TSH (thyroid disease as a cause)
- If hormonal testing indicated:
- FSH
- E2 estradiol
- on two readings at least a month apart
A 47yo woman presents complaining of low mood, tiredness and concentration problems. She also has some mild vaginal dryness. What investigations would you order to determine the cause of her symptoms?
- K10/DASS for depression
- TSH for hypothyroidism
- FBE/Fe studies for anaemia
- Fasting BGL for diabetes
- Consider hormonal testing
- High FSH and low E2 on two readings at least a month apart
What is the relationship between HRT and VTE?
Oral estrogen is associated with an increased risk of DVT/PE although the absolute risk is small for women <60 years old. The risk appears to be lower/not at all with transdermal estrogen. Therefore transdermal estrogen is preferred for women at increased risk, i.e. smokers and obese women.
What are the pros and cons of HRT?
For women who have premature or early menopause, when should they be prescribed HRT?
For women with premature (age <40 years) or early (<45 years) menopause, current guidelines recommend HRT until aged 50 for the treatment of vasomotor symptoms and bone preservation.
What is the only real indication for HRT?
Everyday symptoms of menopause.
- Hot flushes
- Night sweats
- Muscle aches
- Low mood
- Headaches
- Fatigue
- Difficulty concentrating
- Vaginal dryness
- Urinary frequency
Although HRT may have other added benefit, they are not indications for commencing treatment. For example, it reduces osteoporotic fracture risk, but this is NOT long tem (ie. the benefit ceases after cessation of HRT). And since women do not take HRT after 60 years, it is likely to really be of benefit. It may also reduce the risk of colorectal cancer, but this on its own is not an indication for HRT.
What are the contraindications of HRT?
Although there are no real absolute contraindications for HRT there are the following considerations:
ABC, EIOU
Age <60
Breast cancer history
Clotting problems (DVT/PE/stroke)
Endometrial cancer (FHx?)
I is a bone. Osteoporosis risk
O is a gallstone. Can cause cholelithiasis
Uterus - does she still have one? Will need combined HRT if so
What are the different types/formulations of HRT?
Unopposed oestrogen:
- used only in women who have had a hysterectomy - otherwise risk of endometrial Ca from unopposed oestrogen.
Combined HRT (Progesterone + Oestrogen)
- If a uterus is present then progesterone therapy needs to be administered for at least 10 days each month.
- Options include:
- Cyclical – taking oestrogen every day, and adding progesterone 10-14days each month (second half of cycle). The disadvantage of this option is that a withdrawal bleed will occur with the cessation of progesterone treatment.
- Continuous (daily oestrogen and progesterone) – Much less likely to have bleeding. Prescribed for women who have had no period for at least 1yr.
What are the side effects of progesterone?
HAIL M
H - Hirsuitism
A - Acne & Apetite/Weight Increase
I - Insomnia
L - Loss of libido
M - Mood swings
What do you know about the physiology of glucose metabolism in pregnancy?
- Early pregnancy – food intake is commonly decreased because of nausea and vomiting. It this stage, the insulin demands decrease
- The most notable hormone which has major effect on glucose metabolism is human placental lactogen (hPL), which is produced in abundance in the enlarging placenta
- hPL promotes lipolysis with increased levels of circulating free fatty acid and causes a decrease in glucose uptake. In this sense it is thought of as an anti-insulin.
- The increasing production of hPL as pregnancy progresses generally requires an increase in insulin requirement.
- hPL promotes lipolysis with increased levels of circulating free fatty acid and causes a decrease in glucose uptake. In this sense it is thought of as an anti-insulin.
- Oestrogen and progesterone also interfere with the insulin-glucose relationship, and insulinase which is produced by the placenta and degrades insulin to a limited extent
- With increased renal blood flow, the simple diffusion of glucose in the glomerulus increases beyond the ability of tubular reabsorption, resulting in the normal glycosuria of pregnancy. In patients with diabetes, this glucosuria may be much greater.
What is the typical presentation of gestational diabetes?
GDM generally develops and is diagnosed in the late second or early third trimester of the pregnancy.
It is usually asymptomatic.
Explain the recommended screening for GDM in pregnancy?
In Australia, all pregnant women should be screened for GDM between 26 and 28 weeks gestation. (Note that U.K. guidelines and old Australian guidelines suggest screening only in women with risk factors).
The recommended screening regimen is a 75 gram two-hour Pregnancy Oral Glucose Tolerance Test (POGTT).
Fasting test- fast from 2200
Fasting blood sugar (drink 75gm glucose load)
Blood sugar level at 1hr
Blood sugar level at 2 hrs
What is the (full) management of GDM?
Basics
Education RE: GDM
Causes – explain pathophysiology and risk factors
Symptoms – explain the woman is usually asymptomatic
Complications – to mother and to foetus
Place and person
Referral to a dietician for diet modification
Investigate and confirm diagnosis
Pregnancy oral glucose tolerance test
Regular BSLs
Screen for urinary infections at the first sign of symptoms – more common in women with diabetes
Non-invasive management
Diet and exercise
Definitive management
Lifestyle interventions
Metformin
Insulin
Not oral hypoglycaemic agents (sulphynureas and biguandides) – as they cross the placenta and cause foetal hypoglycaemia.
Long term
- Women who were diagnosed with GDM or Diabetes Mellitus in Pregnancy should have a repeat 75gram OGTT performed 6 to 12 weeks after delivery
- The result of the test should be evaluated according to standard WHO criteria for the non-pregnant state.
- Women who do not have diabetes mellitus at this time should still be regarded as at risk of developing diabetes mellitus later in life and should be screened every two to three years.
A woman with T1DM comes to see you because she’s considering trying for a baby. She wants to know what risks are involved for her and the baby because of her DM. What do you say?
- Increased miscarriage risk
- High risk of DKA due to the increased insulin resistance
- Hypoglycaemia may also occur periodically especially in early pregnancy when nausea and vomiting interfere with caloric intake
- 2 fold increased risk of pre-eclampsia
- Diabetic retinopathy and diabetic nephropathy both worsen with pregnancy
You have decided to commence a woman on HRT. What are the options and when do you use each?
What are the different routes of administration?
Unopposed oestrogen:
used only in women who have had a hysterectomy - otherwise risk of endometrial Ca from unopposed oestrogen.
Combined HRT (Progesterone + Oestrogen)
If a uterus is present then progesterone therapy needs to be administered for at least 10 days each month.
Options include:
- Cyclical – taking oestrogen every day, and adding progesterone 10-14days each month (second half of cycle). The disadvantage of this option is that a withdrawal bleed will occur with the cessation of progesterone treatment.
- Continuous (daily oestrogen and progesterone) – Much less likely to have bleeding. Prescribed for women who have had no period for at least 1yr.
Other
High dose progesterone alone - for women who have had breast Ca
Testosterone - sometimes used for loss of libido
Tibolone - acts as oestrogen in some parts of body and progesterone in others
Routes
Oestrogen Only:
- Oral: commonest and most convenient, compliance can be an issue
- Transdermal patches and gel: doesn’t pass through portal circulation, change every 3-7 days, compliance better
- Implants: pellets inserted into abdo wall under fascia lata, sometimes given with testosterone, progesterone should be given orally in second half of cycle
- Vaginally: large dose steroids needed to get into circulation, good if vaginal dryness main problem
Combined:
Oral only
In taking a history about contraception, what are the things to consider?
Past - what methods have they used, why did they change?
Present - do they have ideas about what they might want to use?
Future - do they want more kids?
The go on to HOMESICK
H - Headache / Hypertension
O - Obesity
M - Medication (some ABx / anti-epileptics)
E - Embolsim (PE / DVT / Stroke)
S - Smoking status
I - IHD
C - Cancer / Increased CV risk (hyperlipidaemia)
K - Kids – breast feeding? (no oestrogen), primigravid? want more kids?
Susan has come to you wanting to start the COCP, you’ve confirmed that this is the best contraceptive method for her. What do you discuss with her whilst your writing the prescription?
Once you’ve selected a contraceptive option you need to SMERBB:
Explain how to START the medication
Explain what to do about MISSED pills.
Explain how to use EMERGENCY contraception if it’s ever needed
Explain the RISKS AND SIDE EFFECTS of the medication
Discuss BREAKTHROUGH bleeding
Measure the BP (and weight)
What are the risks of IUDs?
Pelvic infection
Perforation of the uterus on insertion
IUD dislodgement
Increased vaginal discharge (particularly mirena)
Heavier painful periods (Copper IUD)
Ectopic pregnancy
What investigations do you need before and after inserting an IUD?
Prior to insertion, the following is required:
- Non-pregnant proven by B HCG
- Negative for chlamydia (high vaginal swab or first pass urine)
- Up to date, normal pap smear
If used for contraceptive purposes
- U/S 2-3 months post-insertion to ensure correct position
What are the causes of IUGR?
Foetal
Chromosomal disorders
Congenital anomalies
Multiple gestation
TORCH infection
Placental
Uteroplacental insufficiency
Abnormal implantation
Placental abruption
Maternal
Chronic illness
Pre-eclampsia
Early or advanced age
Malnutrition
Substance abuse (e.g. cigarettes, alcohol, narcotics, cocaine)
Medications (e.g. warfarin, anticonvulsants)
A pregnant mum and her baby have been diagnosed with Rhesus disease.
What is the effect of this on the foetus?
Will it get kernicterus?
How is this situation managed? Explain.
Rh disease will cause haemolysis and anaemia in the foetus, which if untreated will lead to hydrops fetalis.
This occurs because the anaemia promotes extramedullary haematopoesis causing hepatosplenomegaly. The liver reverts the liver to producing blood rather than albumin in an attempt to compensate for the anaemia. Hypoalbuminaemia causes low oncotic pressure which leads to massive oedema/hydrops.
The foetus will not get kernicterus because the placenta will efficiently filter the bilirubin. BUT when the baby is born and no longer has the placenta it WILL be at high risk of kernicterus. This is because it will not only have high bili but also low albumin. Low albumin means that there is less protein for the bili to bind to and more is free to cross the BBB.
The management is in utero blood transfusion at a tertiary centre.
An A+ mum has a baby with B+ blood. Is there a risk of ABO blood incompatibility problems when the baby is born?
(Remember that ABO IgG doesn’t cross the placenta so there’s no problems in utero).
No, it’s only a problem if mum is O. I don’t think anyone knows why this is.
You are the intern on night cover in Sale hospital. A midwife calls you to urgently review a baby who was born 3 hours ago and seemed fine but is now in respiratory distress. What do you do?
- ABCD
- Give oxygen
- LFNP, HFNP, CPAP or ETT
- Bring to special care nursery
- Monitoring
- ECG
- SpO2 on right hand
- Bloods
- FBE/UEC/LFT
- Blood cultures
- CRP
- ABG
- CXR
- Hyperoxia test
- Consider empirical antibiotics (low threshold)
- IV access and commence fluids including dextrose
- Manage temperature
- Consider prostaglandins if not improving on oxygen, murmur or cardiomegaly on CXR
- Consider caffeine if premature
- Consider DDx
- MAS
- RDS
- Sepsis
- TTN
- Pneumothorax
- Diaphragmatic hernia
What % of deliveries will have mec stained liqour?
How common is MAS?
10%
1.5 in 1000
What are the clinical features of MAS?
- MAS is characterised by early onset of respiratory distress (within 2 hours) in a meconium-stained infant.
- Tachypnoea, cyanosis and variable hyperinflation are the main clinical findings.
- Ausculation reveals widespread ‘wet’ inspiratory crackles, occasionally with expiratory noises suggesting ball-valve airway obstruction.
- Radiologically the typical progression is from global atelectasis in early X-rays to a widespread patchy opacification accompanied by areas of hyperinflation and/or atelectasis.
- Blood gas analysis invariably shows hypoxaemia accompanied by hypercarbia in those infants with significant airway obstruction or severe respiratory failure.
What do you know about transient tachypneoa of the newborn?
Transient tachypnea of the newborn is a respiratory problem that can be seen in the newborn shortly after delivery. Amongst causes of respiratory distress in term neonates, it is the most common. It consists of a period of rapid breathing (higher than the normal range of 40-60 times per minute). It is likely due to retained lung fluid. It is most often seen in 35+ week gestation babies who are delivered by caesarian section without labor. Usually, this condition resolves over 24–48 hours. Treatment is supportive and may include supplemental oxygen and antibiotics. The chest x-ray shows hyperinflation of the lungs including prominent pulmonary vascular markings, flattening of the diaphragm, and fluid in the horizontal fissure of the right lung.
A midwife pages you to let you know that a baby on the postnatal ward who was born yesterday has become tachycardic.
Bloods (FBE and CRP) taken 2 hours ago were normal.
Even though you’re reassured by the bloods, you know that it’s important to have a low threshold for empirical antibiotics in newborns. You ask the midwife if there are any risk factors for sepsis. What are these?
- PROM
- Mec liquour
- +ve GBS status, GBS unknown
- Premature birth
- Low birth weight
- Maternal infection/fever
- Difficult birth
What are the different possible forms/appearances of the hymen?
What is Hematocolpos?
Hematocolpos is a medical condition in which the vagina fills with menstrual blood. It is often caused by the combination of menstruation with an imperforate hymen.
Anatomically and histologically, what is the transformation zone of the cervix?
- The transformation zone is a dynamic area, usually located on the ectocervix.
- The transformation zone, by definition, is the area between the original squamocolumnar junction and the current squamocolumnar junction.
- The transformation zone is that portion of the cervix that originally was columnar epithelium and through a process of squamous metaplasia is now squamous epithelium.
- At puberty, rising oestrogen levels cause the cervix to evert. The columnar tissue lining the cervical canal is everted onto the surface of the surface. This area of columnar tissue in the centre of the cervix is known as an ectopy or ectropion.
- Squamous metaplasia is a normal physiological process, caused by the acid conditions in the vagina, which causes columnar cells to transform into squamous cells.
- The area where this occurs is called the transformation zone. Squamous metaplasia is an ongoing process, occurring over many years.
- If oncogenic HPV affects the transformation zone, CIN may form instead of normal squamous tissue.
You perform a speculum examination and note that a woman’s cervix looks inflammed. You mention this and the woman asks what this means and if it’s bad. What do you say?
Inflammation of the cervix is extremely common. Chronic inflammation is present in the cervix of almost every sexually active woman.
Other causes of non-infectious cervicitis include chemical irritation (eg, deodorants, douching), local trauma from foreign bodies (eg, tampons, pessaries, IUDs), surgical instrumentation, and therapeutic intervention. Clinically, the cervix is swollen, erythematous, and friable, and an associated purulent discharge may be present.
What are the causes and risk factors for cervical cancer?
99.7% of cases are caused by HPV
- Most common causes are 16 and 18
- 31, 33, 35, 39, 45, 51, 52, 56 and 58 also cause cancer
Important risk factors!
- Smoking
- HIV infection or other immunocompromised state
- COCP
What do you find on history and exam of a patient with cervical cancer?
History
- Postcoital bleeding
- Instermenstrual bleeding
- Postmenopausal bleeding
- Persistent, offensive, bloodstained discharge
- Pain (late disease) – lateral direct spread may obstruct the ureter, causing loin pain due to hydronephrosis. It may affect the sciatic nerve, causing pain in the buttock and back of the leg
Examination
- Speculum
- Squamous carcinomas present as exophytic, friable lesions
- Hard barrel shaped cervix – more common with adenocarcinoma
- Cervix may be fixed in advanced disease
- PR
- Hard, irregular mass palpable anteriorly
What are the different types of hysterectomy?
(as in, the different options for how much is removed)
Wertheim’s is also called “radical” hysterectomy
A woman has cervical cancer, but you don’t yet know what stage. She is very keen to know what the management will be, what are the options dependent on what stage cancer she has?
Stage Ia1 (limited to cervix, less than 3mmx7mm)
Large loop excision of the transformation zone (LLETZ)
Cone biopsy
Stage Ia2 (limited to cervix, 5mmx7mm)
-
Surgical candidate:
- Hysterectomy and pelvic lymphadenectomy
- plus consider adjunctive postoperative chemoradiation
-
Non surgical candidate
- Chemoradiation
-
Trying to maintain fertility
- Repeat cone biopsy with laparoscopic pelvic node dissection
Stage Ib1 (Macroscopic lesion <4cm diameter)
-
Surgical candidate:
- Radical (Wertheim’s) hysterectomy and pelvic lymphadenectomy
- plus consider adjunctive postoperative chemoradiation
-
Non surgical candidate
- Chemoradiation
-
Trying to maintain fertility
- Radical trachelectomy + laparoscopic pelvic node dissection
Stage Ib2 to IVa (Macroscopic lesion >4cm up to anything without distant mets)
Chemoradiation
Stage IVb (distant mets)
Palliate
What are the different histopathological types of cervical cancer? How common is each type?
These do not alter staging but do alter prognosis and may alter treatment:
- Squamous (80%)
- Adenocarcinomas (15%)
- Adenosquamous (3% to 5%): poorest outcome of common cell types
- Rare: transitional cell, neuroendocrine, small cell, adenoid cystic, mesonephric, adenoma malignum, lymphoma, sarcoma.
What are the risk factors for endometrial cancer?
- Obesity
- Menstrual factors
- Early menarche
- Late menopause
- Low parity
- Anovulatory amenorrhoea e.g. PCOS
- Unopposed oestrogen HRT
- Oestrogen-secreting ovarian tumours
- Tamoxifen
- Family history of colorectal cancer, endometrial cancer, breast cancer (Hereditary non-polyposis colorectal cancers - HNPCC)
What are the histopathological types of endometrial cancer? How common is each type?
- Adenocarcinoma is the commonest carcinoma (95%)
- Majority are endometrial type
- Adenosquamous carcinoma are less common
Where does endometrial cancer spread to?
- *Direct spread**: cervical stroma, Fallopian tubes and ovaries
- *Lymphatic spread**: Pelvic and para-aortic lymph nodes
Haematological spread: Liver and lungs
What do you find on history and exam of a patient with endometrial cancer?
History
- Postmenopausal bleeding
- Premenopausal women may present with irregular, heavy or intermenstrual bleeding
- Menstrual irregularities in women >40 years require investigation
Examination
- Speculum
- To exclude other causes
- Bimanual
- Fixed or bulky uterus with advanced disease.
What is the management of endometrial hyperplasia?
Basics
Nil
Place and person
Gynacology referral
Investigate and confirm diagnosis
- Transvaginal ultrasound
- Hysteroscopy and biopsy
Non-invasive management
LOW to reduce oestrogen
Definitive management
- Simple and complex hyperplasia*
- Progestogens
- Mirena IUD or POP
- Follow up with repeat biopsy
- Atypical hyperplasia*
- High risk
- TAH and BSO recommended
- Regular surveillance is indicated if TAH declined
- Success of high-dose progestogens is controversial
- High risk
Simple = no cytological atypia
Complex = Atypical glandular picture with proliferation, irregular outlines and obvious structural complexity
Atypical = Glands have atypical nuclei. Severe cases are indistinguishable from cancer
Who should have pap smears?
When should they start, how often should they have them? when should they finish?
Who
Women who have ever had sex and still have an intact cervix should undergo Pap test screening.
Women who have never had genital-skin to genital-skin contact with anyone do not require Pap tests.
When to start
Pap test screening is recommended every 2 years for women who have ever had sex and have an intact cervix, commencing from age 18–20 years (or 1-2 years after first having sexual intercourse, whichever is later).
Women under the age of 18 usually will not require a Pap smear, even if they have had sexual intercourse. Cervical cancer is very slowly progressing, and therefore any abnormalities detected on screening will only be due to acute HPV infection.
How frequently should one continue Pap smears?
Routine screening with Pap tests should be carried out every 2 years for women who have no symptoms or history suggestive of cervical pathology.
When should one stop Pap smears?
Pap tests may cease at age 70 years for women who have had two normal Pap tests within the last 5 years.
A woman tells you she doesn’t want a pap smear because she’s had the HPV vaccine so should be immune from cervical cancer. What do you say?
The introduction of the HPV vaccine as part of the National Immunisation Program 2007 may reduce the future incidence of cervical cancer, but is not a substitute for a continuing screening program.
If the woman has had the HPV vaccine, she should still continue to have regular Pap tests. The vaccine only protects against some HPV types (type 16 and 18) which leads to 70 per cent of cervical cancer. There are several other HPV types that can cause cervical cancer that are not covered by the vaccine. The woman may have been exposed to these via sexual activity. Additionally, the woman may have been exposed to HPV types before she had the vaccine.
A woman gets an abnormal pap smear result and is very worried. How can you easily explain the development of cervical cancer to her?
What is the clinical definition of menorrhagia?
Heavy menstrual bleeding (menorrhagia) may be defined by:
- blood loss of > 80 mL per menstrual cycle
- bleeding that persists > 7 days, or
- bleeding that is unacceptable to the woman
An expectant mother is Rh - and her partner is Rh +. When should she receive Anti-D?
According to RANZCOG, all women who are rhesus negative (and who have not already formed their own rhesus antibodies ie. have a negative antibody screen) should receive anti-D / Rho-GAM at the following time periods:
- 28 weeks gestation
- 34 weeks gestation
- 72 hours after delivery
They should also be offered anti-D after the following events:
- In the first trimester
- CVS
- Miscarriage
- Termination of pregnancy
- Ectopic pregnancy
- In the second trimester
- Obstetric haemorrhage
- Amniocentesis, cordocentesis
- External cephalic version of breech presentation (whether successful or not)
- Abdominal trauma
What is the The Kleihauer test?
The Kleihauer test is a blood test used to measure the amount of fetal hemoglobin transferred from a fetus to a mother’s bloodstream. It is usually performed on Rhesus-negative mothers to determine the required dose of Rho(D) immune globulin(RhIg) to inhibit formation of Rh antibodies in the mother and prevent Rh disease in future Rh-positive children
What is the likely bug in this case?
A 55-year-old lady presents with a non-offensive, white vaginal discharge. She also describes polyuria for the last three months with nocturia. Her BMI is 36, and the pH of the vaginal discharge is 4.5.
This woman is showing symptoms of candidiasis. She has a high BMI and polyuria indicating that she may suffer with diabetes which puts a person at a greater risk of developing infection with Candida albicans.
What is the likely bug in this case?
A 26-year-old lady presents to antenatal clinic with a thin vaginal discharge. The discharge has a pH of 4.7 and microscopy reveals epithelial cells covered with bacteria.
Gardnerella infection
This woman is suffering with a condition known as bacterial vaginosis. The exact cause is unknown but typically a bacterial imbalance causes the symptoms. The epithelial cells covered by bacteria are known as ‘clue cells’ and are diagnostic when seen on microscopy. Metronidazole is the treatment of choice.
A 48-year-old woman presents with an acute onset of left breast pain. On examination there is thrombophlebitis of the superficial veins of the breast.
What is the diagnosis and management?
Mondor’s disease
Mondor’s disease is thrombophlebitis of the superficial veins of the breast causing tender subcutaneous cords. It is self-limiting and like other causes of thrombophlebitis it is treated with non-steroidal anti-inflammatory drugs (NSAIDs).
Which of the following statements is true and which false regarding twin pregnancy?
- Is associated with an increased risk of congenital malformation
- Is more common with increasing maternal age
- Is usually dizygous
- Prophylactic tocolytic drugs are of proven value
- Should be managed in hospital from 28 weeks
-
Is associated with an increased risk of congenital malformation
- Abnormality rates as high as 10% have been quoted, mainly heart and intestinal defects and anencephaly.
- If second trimester miscarriages are included with perinatal mortality figures, overall losses of around 10% occur.
- Is more common with increasing maternal age
-
Is usually dizygous
- Twins usually arise from completely independent fertilisation and development of two eggs - hence most are dizygous.
- Prophylactic tocolytic drugs are of proven value
- Should be managed in hospital from 28 weeks
A 48-year-old woman presents with an acute onset of left breast pain. On examination there is thrombophlebitis of the superficial veins of the breast.
What is the diagnosis and management?
Mondor’s disease
Mondor’s disease is thrombophlebitis of the superficial veins of the breast causing tender subcutaneous cords. It is self-limiting and like other causes of thrombophlebitis it is treated with non-steroidal anti-inflammatory drugs (NSAIDs).
What discrepancy is considered significant in symphysis fundal height?
What are the possible causes of a discrepancy?
+/- 2 cm
However this is really only valid between 20-34 weeks
Possible causes:
- fetus is small/large for gestational age
- multiple pregnancy
- inaccurate EDD
- molar pregnancies
- polyhydramnios/oligohydramnios
- oblique or transverse lie
A woman who is 11 weeks pregnant presents to ED in shock. What could have caused this?
- *Hypovolaemic** shock – due to a ruptured ectopic
- *Neurogenic** (cervical) shock – products of conception in cervix (causes an increase parasympathetic drive and bradycardia)
- *Septic** shock – miscarriage with infection
What is a heterotopic pregnancy?
When two eggs are fertilized; one implants at an intra-uterine site, another at an extra-uterine site.
Often associated with induced ovulation (IVF) (1:11,000). Otherwise rare (1:40,000)
When a woman presents with bleeding in early pregnancy, what are you thinking in terms of the probability of each of the possible outcomes?
60% will have an ongoing pregnancy
30% will have pregnancy loss
- 5% will have an ectopic pregnancy
- 5% will have another diagnosis.
Investigations to order for bleeding in early pregnancy?
Bedside
Pregnancy test, urine dipstick
Bloods
FBE
HCG
Blood group and hold
Blood cultures if febrile or suspect sepsis
Imaging
Transvaginal ultrasound
Special
none
In women at high risk or pre-eclampsia/eclampsia, what preventative measures are taken during pregnancy?
low dose aspirin 75‐150mg/day
Calcium 1g/day
THIS IS ONLY VALUABLE IF COMMENCED BEFORE 16 WEEKS
At what gestational age to ectopic pregnancies tend to rupture?
10 weeks
The average gestational age of maternal symptoms of ectopic pregnancy is 7 weeks
What % of ectopic pregnancies have an identifiable risk factor?
What are the risk factors?
50%
Risk factors all relate to factors which would make the uterus less hospitable for implanation
- Previous ectopic
- Previous PID
- Smoking (impairs ciliary activity)
- Previous tubal surgery
- History of infertility (esp if IVF)
- Advanced maternal age
- IUDs, progesterone-only pills, tubal ligation
How do you calculate gestational age/estimated due date?
The estimated due date (EDD) is the date that spontaneous onset of labor is expected to occur.
By menstruation
The due date may be estimated by adding 280 days (9 months and 7 days) to the first day of the last menstrual period (LMP). This is the method used by “pregnancy wheels”.
The accuracy of the EDD derived by this method depends on accurate recall by the mother, assumes regular 28 day cycles, and that conception occurs on day 14 of the cycle. This method may overestimate the duration of the pregnancy, and can be subject to an error of more than 2 weeks.
When you know
In cases where the date of conception is known precisely, such as with IVF, the EDD is calculated by adding 266 days to the date of conception.
By ultrasound
Ultrasound uses the size of the fetus to determine the gestational age (the time elapsed since the the first day of the last menstrual period). The accuracy of the ultrasound estimate of the gestational age varies and is highest in the first trimester.
How would you advise an anxious expectant mother to avoid miscarriage?
In the healthy, first-time pregnant woman there is no known strategy to prevent a miscarriage.
Even in women who have a significant medical or surgical disorder the concept of prevention of miscarriage is difficult to define. There is insufficient evidence on the intake of vitamins or bed rest in early pregnancy to help prevent miscarriage, stillbirth, or other maternal and infant outcomes.
At what BHCG should a yolk sak be visible on transvaginal USS?
A B-HCG >1,500 IU/L indicates that a normal intra-uterine pregnancy should be visible on vaginal ultrasound.
If uterus is empty at this reading, then the pregnancy is either ectopic or miscarried.
What is the most common cause of miscarriage in
a) first trimester
b) second trimester
first trimester = foetal chromosomal abnormality
second trimester = ascending infection from the lower urinary tract
What is a blighted ovum?
Also known as an ‘anembryonic pregnancy’
When a gestational sac forms but no embryo develops.
The woman may experience the normal symptoms of pregnancy or some PV bleeding.
Diagnosed on ultrasound.
Treatment options are the same for other miscarriages.
What symptoms/features of clinical picture can miscarriage present with?
PV bleeding, clots and crampy pain in early pregnancy
Disappearance of normal symptoms of pregnancy (loss of urinary frequency, nausea)
Hypotension, bradycardia – cervical shock due to products of conception in cervix
What are the risk factors for miscarriage?
- advanced maternal age
- Asymptomatic bacterial vaginosis
- IVF
- Alcohol intake during pregnancy
- Smoking during pregnancy
- Overweight/obese mother
What is the management/prognosis of subchrorionic haemorrhage?
Fetal outcome is dependent on size of the haematoma, maternal age, and gestational age. In most cases the haematoma gradually decreases in size on follow-up.
However, a large hematoma that has caused 30 to 40 percent of the sac surrounding the embryo to separate from the wall of the uterus may continue to get larger, causing the gestational sac to become compressed and membranes to burst, which will ultimately abort the pregnancy.
How would you interpret a low beta-HCG?
How would you interpret a high beta-HCG?
(Remember that the normal range is enormous)
Low beta-HCG either means ectopic pregnancy or miscarriage.
The level will continuously drop in miscarriage but plateu in ectopic
High b-HCG could be trophoblastic disease
Once you detect a foetal heartbeat (either because you’ve done an USS because something has caused you to worry, or just because it’s time for the routine 12 week USS), what is the risk of miscarriage after that point?
2%
That is, you start out with a risk of 50%, but once the baby has a detectable heartbeat your chance of miscarriage drops to 2%
What should you see on serial measurements of bHCG in a normal pregnancy?
Doubling every 48 hours
Considered slow if it doesnt rise by at least 50% in 48 hours
A woman’s EDD is different when calculated based on her LMP versus on her dating ultrasound. How do you decide which estimate to use?
For ultrasound performed between 6 and 13 weeks pregnancy — if the two dates differ by 5 days or less, use the LMP estimate; if the dates differ by more than 5 days, use the ultrasound estimate.
For ultrasound performed between 13 and 24 weeks pregnancy — if the two dates differ by 10 days or less, use the LMP estimate; if the dates differ by more than 10 days, use the ultrasound estimate.
What are the components of the “triple test”, when are they performed and what can they detect?
Maternal Serum Screen (at 10 weeks)
Free beta-HCG
PAPPA-A
Ultrasound (at 12 weeks)
Nuchal fold thickness
Can detect Trisomy 18 and Trisomy 21
A pregnant woman comes to see you for a checkup at the start of the 3rd trimester. She has had gold standard antenatal care up until now. What investigations should you order for her at this visit? What medication should you prescribe?
2 hour Pregnancy Oral Glucose Tolerance Test (POGT)
Rhesus antibodies
Irregular antibodies - if they are rhesus negative they should be given Rho-GAM at 28 weeks (even if no suspicion of foetomaternal haemorrhage)
FBE/Ferritin
Women receive Boostrix (dTpa - diptheria, tetanus, pertussis) vaccine at this point (and partners if they haven’t had a vaccine in the last 10 years)
A woman is identified as GBS positive. What antibiotics do you prescribe and when?
Benzylpenicillin during labour or at PROM
How much post partum bleeding/haemorrhage is normal? When do you start to really worry?
<500ml is normal
>1000ml you really worry
What are the cardinal movements of childbirth?
Delicate Females in China Eat Rice In Early Labour
Descent
Flexion
Internal rotation (turn neck to occipital-anterior orientation)
Crowning (this is when the contractions are no longer 3 steps forward 1 step back, the head stays in the perineum)
Extension
Restitution (also called external rotation, neck turns 45deg to once again be in line with shoulders)
Internal rotation of shoulders
External rotation (as evidenced by external rotation, shoulders rotate to AP orientation)
Lateral flexion
A woman who is 37+5 weeks pregnant has ROM. When do you expect her to go in to labour?
About 80 to 90% of women with ROM at term go into labor spontaneously within 24 h. If membranes rupture at term but labor does not start within several hours, labor is typically induced to lower risk of maternal and fetal infection.
A woman at 33+5 weeks pregnancy has ROM. When do you expect her to go in to labour?
50% of women with PROM preterm go into labor spontaneously within 24 h.
> 90% of women with PROM go into labor within 2 wk. The earlier the membranes rupture before 37 wk, the longer the delay between rupture and labor onset.
What are the most common causes of pre-term labour?
- Chorioamnionitis
- Overdistension (due to multiple gestation or polyhydramnios)
- Bleeding/placentral abruption
- Serious Illness such as pyelonephritis, appendicitis and pneumonia
- abnormal placentation/fibroids/ cervical weakness
- Idiopathic
A pregnant woman deemed to be at risk of preterm labour is recommended to have steroids to help the babies lung development. What are the contraindications for doing this?
Should be used with caution in the woman who has systemic infection including TB or sepsis, as steroids suppress the immune system.
Diabetes mellitus or impaired glucose tolerance is not a contraindication, but BGL monitoring is recommended for women with these conditions who receive antenatal steroids.
What is the dosing regime recommended for antenatal steroids?
Two doses of 12 mg IM betamethasone, given 24 hours apart
OR
Four doses of 6mg IM dexamethasone, given 12 hours apart
Note: weekly repeats are not recommended – although they do reduce the severity of neonatal respiratory distress they are also associated with a reduction in weight and head circumference.
What are the risks of PROM and Pre-term PROM?
PROM
- Maternal infection
- Neonatal infection
- Cord prolapse
- Cord compression
- Placental abruption
PPROM
All of the above plus premature birth
What are the two main contraindications to digital vaginal exams during pregnancy?
PROM (infection risk)
Proven or unknown placenta previa
A pregnant woman has had PPROM at 30+1. This was 3 days ago and it doesn’t look like she’s about to go in to labour. For the wellbeing of the fetus the obstetrician doesn’t want to induce labour just yet. What should you do?
Why should you do this?
Commence steroids in case of early labour
Check BGS status
Erythromycin (250mg po 6 hourly for 10 days)
Why erythromycin?
Reduces the chance of delivery within seven days, reduces the need for neonatal surfactant, reduces the incidence of neonatal lung disease, major cerebral haemorrhage on ultrasound and death.
At what gestational ages would you consider conservative or active management of PPROM?
Is there a role for tocolytics?
Is there a role for tocolysis to delay the onset of labour?
No. In fact it might be dangerous. Only short term tocolysis is indicated; for the purposes of finishing a course of antenatal steroids or for transfer to facility with NICU
A pregnant woman at 37+4 has come in for an IOL. She has an unfavourable Bishop score and is 2-3 cm dilated, would you perform stretch and sweep? What are the risks of doing so?
No
Only done if post term (not prior to 40 weeks)
Involves a digital VE and stretching of the cervix to reach the internal os, and performing a cyclical ‘sweeping’ 360 degree motion. This causes the release of natural prostaglandins.
Risks: Discomfort and bleeding (does NOT increase risk of infection)
A pregnant woman who is having a trial of VBAC has an unfavourable bishop score. How would you encourage cervical dilation/ripening?
Transcervical Foley Catheter
Catheter is passed into the cervix, blown up and left for 24 hours.
Stretches the cervix and causes natural release of prostaglandins.
Risks: infection and discomfort
Preferred method for VBAC patient with a cervix requiring ripening (don’t use prostaglandins in women who have had a C-section).
You have given a woman undergoing IOL prostaglandins to ripen her cervix. When can you start oxytocin?
6h after gel
30mins after removal of pessary
What are the complications of shoulder dystocia?
- Post-partum haemorrhage
- Rectovaginal fistula
- Perineal tearing
- Uterine rupture
- Clavicle fracture
- Brachial plexus injury
- Fetal hypoxia/death
What are the signs of shoulder dystocia?
- Turtle Sign: when the fetal head emerges and then retracts against the perineum
- Difficulty delivering the head and chin
- There is no restitution
- The shoulders fail to descend (and you can still palpate the anterior shoulder abdominally)
What is the sensitivity/specificity of CTG for a sick fetus?
Sensitivity 97+%, the problem is that specificity is 50-60%
HOWEVER, the CTG is less likely to be incorrect in higher risk pregnancies, (pre-term, bleeding etc)
What are the causes of decreased variability on CTG?
- Deep fetal sleep (20mins at a time)
- Important, if decreased variability for 10 mins the baby might just be asleep!
- Drugs (epidural, morphine etc)
- Prematurity
- Less symp/parasymp drive so may be normal. If lots of accelerations in preterm baby be reassured
- Hypoxia
- Congenital abnormalities
What is the first line medication for tachysystole?
subcutaneous terbutaline 0.25 mg
What are the causes of fetal tachycardia on CTG?
- High inherent rate (premmie!)
- Maternal tachy (UTI/pyelonephritis?)
- Maternal fever
- Fetal tachyarrythmia (SVT, Aflutter)
- Drugs – b agonist for tocolysis
- Hypoxia
- Chorioamnionitis
- Dehydration
You see a sinusoidal decelleration on CTG. What are the possible causes?
Only 2 things that cause this
1) foetal anaemia (due to isoimmunisation or something
2) baby is sucking their thumb
What is the risk of uterine rupture in VBAC?
0.5%
What is the reference ranges of fetal heart rate on CTG?
Reassuring = 110 - 160 beats per minute.
Non-reassuring = 100-109
Abnormal is <100 or >160
How much does the body’s temperature go up in the luteal phase of the menstrual cycle and why is this?
0.5 degrees
Because progesterone is thermogenic
Until what age should women continue taking contraception?
55
(Mini pill from age 50)
What do you need to check before inserting an IUD?
1) normal, current pap
2) high vaginal swab chlamydia screen
3) not pregnant proven by b-HCG
What are the steps you need to take in a consultation to commence a woman on a contraceptive pill?
Once you’ve selected a contraceptive option you need to SMERBB:
Explain how to START the medication
Explain what to do about MISSED pills.
Explain how to use EMERGENCY contraception if it’s ever needed
Explain the RISKS AND SIDE EFFECTS of the medication
Discuss BREAKTHROUGH bleeding
Measure the BP (and weight)
What is the most important treatable cause of recurrent miscarriages?
Anti-phospholipid syndrome
What antibodies do you screen for to diagnose antiphospholipid syndrome?
Lupus anticoagulant
Anticardiolipin antibodies
Anti-B2 glycoprotein-I antibodies
What is the management of mild pre-eclampsia?
BP 140/90 - 150/100
What is the management of moderate pre-eclampsia?
150/100 - 160/110
What is the management of severe pre-eclampsia?
>160/110
What is the management of eclampsia?
What are the diagnostic criteria for HELLP?
What are the SIGNS and SYMPTOMS of PCOS?
Do all women with PCOS have polycystic ovaries?
What are the three different phenotypes of PCOS?
No
8-25% of non PCOS women also have ultrasonographic features of PCO. PCO is also seen in hypothalamic amenorrhoea, pubertal development and hyperprolactinemia.
What is the management of PCOS?
NB: Treatment of hirsuitism takes several months to show effect because of length of hair growth cycle
Notes on below flowchart:
Choice of OCP: Yaz
Newer, less-androgenic progestogens include desogestrel or norgestimate. Drospirenone is a spironolactone analogue with anti-androgenic and anti-mineralocorticoid properties. Pills with these newer, lower-androgenicity progestins may, however, confer a higher risk of venous thromboembolism than older pills.
How does metformin work?
Metformin is associated with decreased testosterone levels and increased sex hormone binding globulin (SHBG) levels, with limited evidence of improvement in hirsutism. Thus, for the specific goal of treating hyper-androgenism, it is best suited as add-on therapy to OCPs, anti-androgens, or OCPs plus anti-androgens.
How does clomifene work?
Clomifene is a non-steroidal anti-oestrogen that inhibits oestrogen negative feedback on the hypothalamus/pituitary, which in turn leads to an increase in FSH secretion that may allow follicular maturation and ovulation.
A couple is trying to get pregnant. They are having a lot of sex but ask you when the best time to have sex is to maximise their chances of getting pregnant, what do you tell them?
We’re talking about the days in a woman’s menstrual cycle when pregnancy is possible. Pregnancy is technically only possible during the five days before ovulation through to the day of ovulation.
These six days are the ‘fertile window’ in a woman’s cycle, and reflect the lifespan of sperm (5 days) and the lifespan of the ovum (24 hours).
Instructions
- Work out the length of your average menstrual cycle. Day one is the first day of the menstrual period and the last day is the day before the next period begins.
- Ovulation happens about two weeks before the next expected period. So if your average menstrual cycle is 28 days, you ovulate around day 14.
- Remember the ‘fertile window’ is the six days leading up to and including ovulation.
- The three days leading up to and including ovulation are the most fertile. Depending on your cycle length the most fertile days in the cycle varies:
- If you have 28 days between periods ovulation typically happens on day 14, and the most fertile days are days 12, 13, and 14.
- If you have longer cycles, say 35 days between periods, ovulation happens on day 21 and the most fertile days are days 19, 20, and 21.
- If you have shorter cycles, say 21 days between periods, ovulation happens on day 7 and the most fertile days are days 5, 6, and 7.
Refer them to this website for a great calculator: http://yourfertility.org.au/for-women/timing-and-conception
What are the causes of infertility?
USEMOAT or UNEXPLAINED
U - Uterine & Cervical causes
S - Sex
E - Endometriosis
M - Male
O - Ovulatory causes
A - Age
T - Tubal causes
Or UNEXPLAINED
Full list see here –>
- Uterine
- Scarring post infection (endometritis) or trauma (D&C)
- Asherman’s syndrome
- Fibroids
- Congenital abnormalities
- Sex
- Erectile dysfn (EtOH, smoking etc)
- Psychological
- Hypospadius
- Vaginismus
- Timing
- Endometriosis
- Adhesions/scarring
- Male
- Hypospermatogenesis (most common)
- Trauma/torsion
- Infection - mumps orchitis
- Congenital microdeletions on Y chromosome
- Obstructive problem
- Congenital absence of the vas
- Vasectomy
- Autoimmune
- Anti-sperm antibodies
- Endocrine
- Hypogonadism
- Hypergonadotrophic
- Hypogonadotrophic
- Hyperprolactinaemia –> importence
- Hypospermatogenesis (most common)
- Ovulatory
- PCOS
- Hypogonadism
- Hypergonadotrophic
- Premature ovarian failure
- Hypogonadotrophic
- Over/under weight
- Sheehan syndrome
- Pituatary surgery
- Hypergonadotrophic
- Hyperprolactinaemia
- Hypothyroidism
- Age
- Tubal
- Infection/STI
- UNEXPLAINED (40%)
What are the investigations for infertility?
- Hormonal
- Ovarian reserve
- Day 2-4 FSH/LH + oestradiol concentration
- AMH
- Mid luteal progesterone
- TFTs
- Serum prolactin
- Ovarian reserve
- Infectious
- First pass urine PCR
- Structural
- Pelvic Ultrasound
- Hysterosalpingo contrast sonography
- Hystero-salpingography
- Hysteroscopy
- Laparoscopy
- Other
- Rubella immunity status
- Varicella immunity status
- Sperm
- Semen Analysis
- Immuno Bead Test (IBT) for anti-sperm antibodies
What is Sheehan’s syndrome?
How does it occur?
What are the features/effects of symptomatic Sheehan’s syndrome?
Hypopituitarism caused by ischemic necrosis due to blood loss and hypovolemic shock during and after childbirth.
A common presentation is the failure of lactation when a mother is trying to breastfeed.
How does it occur?
Hypertrophy and hyperplasia of lactotrophs during pregnancy results in the enlargement of the anterior pituitary, without a corresponding increase in blood supply.
Secondly, the anterior pituitary is supplied by a low pressure portal venous system.
These vulnerabilities, when affected by major hemorrhage or hypotension during the peripartum period, can result in ischaemia of the affected pituitary regions leading to necrosis.
The posterior pituitary is usually not affected due to its direct arterial supply.
Features/effects –> see pic
What is this?
“Chocolate cyst”
accumulated blood and endometrial tissue on the ovary
Jane is a 32yo woman. She has had a pap smear with a CIN1/LSIL result. What do you recommend happens now?
If doesn’t have a clear pap smear in the past 3 years repeat in 6 months. Otherwise repeat in 12 months.
From lecture slides:
IF WOMAN IS 30+ YRS, AND HAS NO NEGATIVE CYTOLOGY IN PREVIOUS 2-3 YRS, COLPOSCOPY OR REPEAT SMEAR IN 6 MONTHS
Margot is a 45 year old woman, who had a HSIL treated back when she was 32 y.o.
She has been having annual smears since then - all normal.
When can she stop having annual pap smears and return to the routine 2 yearly schedule?
A woman with treated HSIL should have HPV test and colposcopy at 4-6 months after treatment. She should then have HPV and pap testing at 12 months and 24 months.
After ALL FOUR of these tests (ie: 2x paps and 2x HPV) are normal she can return to normal screening.
What do you know about vulval cancer?
- Uncommon
- Results from HPV-related infection or chronic inflammation (eg. lichen sclerosis)
- Has pre-invasive (VIN) development akin to cervical cancer
- Tumours should be excised aiming for a 1cm clear margin
- Groin node dissection also needs to be performed for all but superficially invasive squamous tumours
What is the prognosis of endometrial cancer?
If recurrences occur, these tend to be early; 50% are within the first year and 90% are within 5 years.
Prognosis depends on the stage of the disease, with significantly worse outcomes in those that have lymphatic involvement. If the para-aortic nodes are involved, survival rates drastically decline.
What determines whether monozygotic twins will be mono/dichorionic and mono/diamniotic?
At what time the zygote splits. The earlier the more independent the two foetuses will be, the later the more coinjoined –> all the way up to Siamese
What are the effects of twin to twin transfusion syndrome on the fetuses?
Donor fetus
- Anaemia
- Hypotension
- Oliguria/oligohydramnios
- Growth restriction
- Renal failure
- Fetal demise
Recipient fetus
- Polycythaemia
- Hypertension
- Polyuria/polyhydramnios
- Hydrops/heart failure
- Fetal demise
What do you know about the basics of blood sugar metabolism in pregnancy?
What causes insulin resistance?
GDM is a condition of failure of the pancreatic islet β-cells to compensate for insulin resistance that is highly predictive of Type 2 diabetes in later life
The metabolism of the mother changes during pregnancy to facilitate the energy supply of the fetus.
These factors modify the insulin requirements of ALL pregnant women.
The insulin requirement of a woman DOUBLES during pregnancy. If it’s a young healthy mum the pancreas is liklely to have enough physiological reserve to cope with this, but if it can’t double it’s output (or the woman was already insulin resistant so needs even more than double baseline secretion) then GDM occurs.
What causes insulin resistance?
The diabetogenic potency of placental hormones. The most notable hormone which has major effect on glucose metabolism is human placental lactogen (hPL), which is produced in abundance in the enlarging placenta. hPL promotes lipolysis with increased levels of circulating free fatty acid and causes a decrease in glucose uptake. In this sense it is thought of as an anti-insulin.
How would you approach taking a menopause history?
- Diagnose the menopause
- LNMP
- Hysterectomy?
- OCP or HRT?
- Screen for signs/sx of menopause
- General (headaches, muscle aches, fatigue)
- Cognitive (depression, anxiety, difficulty concentrating)
- Vasomotor (night sweats, hot flushes)
- Vaginal atrophy, UTI sx
- Screen for factors related to potential HRT use
- Breast cancer –> contraindication
- DVT/PE
- Smoker?
- Cardio or cerebrovascular disease
If there is primary psych symptoms consider anaemia, thyroid dz, depression or DM
If amenorrheoa consider pregnancy, hyperprolactinaemia and thyroid dz
Describe the management of menopause
- Educate
- Not a disease
- Lack of oestrogen
- Prevention
- Mammo, Pap, FOBT
- CV checkup –> BP, lipids, FBGL
- Non-pharm
- General strategies for managing menopausal symptoms
- SNAP - Lifestyle modifications make a huge difference
- Natural therapies
- Soy
- Black cohosh
- HRT
- Pros and cons
What are the pros and cons of HRT and who is it suitable for?
In women aged <60 (or within 10 years of LMP) with no cancer risk, you can use HRT for up to 5 years with minimal risks
What are the systems questions/symptoms of PCOS?
HATE BODI
H - Hirsuitism
A - Acne / amenorrhea
T - Thyroid (hypo as a DDx)
E - Endocrine (Cushing’s and late onset CAH as a DDx)
B - Balding (male pattern)
O - Obesity
D - Diabetes (associated with PCOS)
I - Infertility
What is the management of menorrhagia?
What is the management of pelvic prolapse?
Basics
ABx for UTI if indicated
Place and person
Refer to gynaecologist (ED if acute urinary retention)
Investigate and confirm diagnosis
Post-void residual volume + urinalysis
Non-invasive management
N/A
Definitive management
There are a number of different treatment options depending on the severity of symptoms:
You are asked to review Mrs. White who gave birth to baby Sarah yesterday. What things will you cover in your assessment of Mrs. White?
Pain
Normal for around 3 days. Consider paracetemol, topical lignocaine and/or diclofenac suppositories
PE/DVT
Are they up and mobilizing? Did they use TEDS or clexane?
Perineum
Tears
Pyrexia
Intrauterine infection, mastitis
Pulse
PPH?
Pre-eclampsia
80% of deaths occur post-partum
Pooing
Should resume in 3 days. Laxatives can help.
Pissing
Beware retention, especially if epidural
Psych
Post-natal depression
Protection
Should commence non-hormonal or progesterone only birth control within 3 weeks if intending to be sexually active
What are the differences between placenta previa and placental abruption?
Previa
- Painless
- Bleeding in proportion to degree of shock
- Bright blood
- Uterus soft
- Ongoing/repeated episodes of bleeding
- Associated with malpresentation/high presenting part
Abruption
- Painful (abdo or back)
- Often single instance of bleeding
- Bleeding may be out of proportion to degree of maternal shock if concealed
- Often dark blood/clots
- Uterus hard/tender
- Not associated with malpresentation/high presenting part
What are the consequences/complications of placenta previa?
At what gestational ages would you order a triple test or a quad test?
What is involved in each test at and what gestational ages?
What can each of these tests screen for?
No ultrasound in quad test, just four serum biomarkers.
The quad test is free in Victoria, but less sensitive with a 5% false positive rate.
At what gestational ages can you order CVS versus amniocentesis?
What are the major parts of a set of forceps?
Neville Barnes are for normal vaginal exam
Wrigley’s are for cesarians
K one is rarely used, for when you need to rotate the baby
What are the different types of forceps and when do you use each type?
Neville Barnes –> NVD
Wrigleys –> Caesarian
You are called to neonatal code blue. A baby has just been born with no respirations or muscle tone. Describe your actions.
- Call for senior help/call code
- Don PPE/gloves
- History
- Gestational age
- mec stained liquour
- mothers GBS status
- maternal fever
- complications in labour?
- Stimulate the baby for 30 secs, check HR and RR with stethoscope
- If inadequate resps commence IPPV on room air whilst attaching Spo2 and telemetry
- PIP (30 cmH2O for a term infant or 20 - 25 cmH2O for a preterm infant), PEEP 5cm
- If no response after 30 seconds and HR
- At this stage consider intubation, adrenaline and 10ml/kg normal saline through umblical artery
- Titrate oxygen to time of life
What are the investigations and management options for premenstrual syndrome (PMS)?
Additional things to talk about:
- poorly understood causes
- extremely common - 2% disabling symptoms, up to 60% moderate symptoms
- can refer for psych support/mindfulness
- if associated with menorrhagia treat that too
What is pediculosis pubis and what is the management?
Pubic lice/nits
Standard therapy
Permethrin 1% cream rinse topical from chest to knees washed off after 10 minutes with repeated treatment 1 week later (B2)
Note the following:
- Permethrin should be applied to clean and cool skin. The patient should not take a hot bath or shower prior to treatment
- apply to infected and adjacent hairy areas
- nits should be removed with a fine toothed comb
- sex partners should be treated concurrently
- clothing and bed linen contaminated by the patient within the past 2 days should be washed and dried by machine (hot cycle) or dry cleaned.
What is the management of menorrhagia?
Try OCP!
Describe the RMI (risk of malignancy index).
Score >200 needs gynae oncologist
Where are Bartholin’s glands?
The glands are located bilaterally at the base of the labia minora and drain through 2- to 2.5-cm–long ducts that empty into the vestibule at about the 4 o’clock and 8 o’clock positions
What can go wrong with Bartholin glands?
Obstruction of the distal Bartholin’s duct may result in the retention of secretions, with resultant dilation of the duct and formation of a cyst. The cyst may become infected, and an abscess may develop in the gland. A Bartholin’s duct cyst does not necessarily have to be present before a gland abscess develops
What is the management of a Bartholin cyst or abcess?
Symptomatic Bartholin’s duct cysts and gland abscesses require drainage. Unless spontaneous rupture occurs, an abscess rarely resolves on its own.
Although incision and drainage is a relatively quick and easy procedure that provides almost immediate relief to the patient, this approach should be discouraged because there is a tendency for the cyst or abscess to recur.
- Analgesia
- Broad spectrum ABx if infection present (Augmentin)
- Marsupialisation (if cyst only, not for abcess)
- Catheter drainage with Word catheter (for cyst or abcess)
- To allow epithelialization of the surgically created tract, the Word catheter is left in place for four to six weeks
How do you diagnose missed miscarriage on US?
If the crown rump length (CRL) is >7mm and there is no foetal heart beat
If the gestational sac / mean sac diameter is >25mm and there is no foetal pole (i.e. it is empty)
Mr. Brown has just had abdominal surgery. You are the intern. What post operative orders must you make for the ward staff for the next 24 hours of Mr. Brown’s care?
Post Operative Orders
AAA! FIDO Leg Pain
A – Analgesia
A – Antibiotics
A – Antiemetic
F - Fluid balance charts including urine output and surgical drain volume
I – IV fluids (usually two salts and a sugar)
D – Diet (NBM, free fluids, clear fluids)
O – Frequency of obs (including special ones like BGL, neuro obs)
L – Legs à clexane and TEDs
P – Pathology requests
Describe the typical LH/FSH cycle in women with PCOS….
At the beginning of the cycle, LH and FSH levels usually range between about 5-20 mlU/ml. Most women have about equal amounts of LH and FSH during the early part of their cycle. However, there is a LH surge in which the amount of LH increases to about 25-40 mlU/ml 24 hours before ovulation occurs. Once the egg is released by the ovary, the LH levels goes back down.
While many women with PCOS still have LH and FSH still within the 5-20 mlU/ml range, their LH level is often two or three times that of the FSH level. For example, it is typical for women with PCOS to have an LH level of about 18 mlU/ml and a FSH level of about 6 mlU/ml (notice that both levels fall within the normal range of 5-20 mlU/ml). This situation is called an elevated LH to FSH ratio or a ratio of 3:1. This change in the LH to FSH ratio is enough to disrupt ovulation. While this used to be considered an important aspect in diagnosing PCOS, it is now considered less useful in diagnosing PCOS, but is still helpful when looking at the overall picture.
What are the treatment options for PCOS?
NB: Treatment of hirsuitism takes several months to show effect because of length of hair growth cycle
Write out the FULL management of pre-eclampsia…
Basics
NA
Ix and confirm
Bedside
4 hourly BPs, recommend home BP monitor
Daily urine dipstick
If inpatient strict fluid balance chart with IDC
Bloods and Urine
FBE/UEC/LFTs
Spot Protein:Creatinin ratio (PCR)
24 hour urine collection and urinalysis
Coags
Uric acid levels
Imaging/Special
Weekly CTG >28 weeks gestation
Ultrasound
- Fetal growth
- Biophysical profile
- AFI
- Dopplers including MCA, umbilical artery and ductus venosus
Place and person
Admit if SBP >150
Obstetrician care
Delivery at tertiary hospital
Definitive
Consider induction >37 weeks or earlier if severe
Betamethasone if <37 weeks
MgSO4 if seizure or risk of seizure
If BP > 150/100 commence labetalol (2nd line = nifedipine, methydopa, hydralazine)
Aim for a sustained and gradual reduction to <150/100
Follow up
Monitor closely post delivery until diuresis occurs
Counselling about future risk of recurrence in subsequent
pregnancies, as well as hypertension and cardiovascular disease risks in later life.
What are the types of breech presentation, which is the most common type?
- Complete (10%)
- Incomplete
- Frank (65%)
- Footling
Describe the staging for ovarian cancer…
Describe the staging of endometrial cancer…
Describe the staging of cervical cancer…
What are the OSCE steps for managing an obstetric emergency?
