Genral Flashcards
What is the treatment used in medical abortion and what are the time frames for doing so?
Up to 9 weeks: 200mg mifepristone orally followed by 800mcg misoprostol vaginally/sublingually.
Over 9 up to 13+6: 200mg mifepristone orally followed by 800mcg misoprostol vaginally/sublingually, then 400mcg every 3 hours until abortion occurs.
Always offer analgesia
What surgical abortion methods are used. When are they used? What are the risks?
Vacuum aspiration with large bore cannulae or dilation and evacuation.
Used greater than 14 weeks.
Uterine rupture Bleeding requiring transfusion Cervical damage. Future scarring and infertility. Infection - UTI give you some antibiotics - doxycycline
Reasons for termination of pregnancy.
A - risk to mothers life.
B - prevent grave permanent injury to mothers physical or mental health.
C - prevent risk of injury to physical or mental health of mother (24wk)
D - prevent risk to existing child(ren) of the family.(24wk)
E - child born would suffer from handicap
F - emergency save mothers life.
G - emergency prevent grave danger
Recommended dose of aspirin for PIH
75mg OD low dose aspirin. FROM 12weeks. Until birth
Risk factors : t2DM, CKD, hypertensive disease in previous preg, autoimmune disorders.
Greater than 140 s or 90 d or increase above booking of 30 s or 15 d
3 anti emetics used in pregnancy
Cyclizine
Metoclopramide
Prochlorperazine
Safest anti- epileptics in pregnancy
Lamotrigene
Carbimazepine
Valproate is causes neural tube and craniofacial defects.
Hyperthyroidism treated with?
Propylthiouracil is preferred to carbimazole as less likely to cross placenta
Which antihypertensives should not be used in pregnancy? Why?
Ace inhibitors as causes renal dysgenesis and craniofacial abnormalities
When shouldn’t certain UTI antibiotics be used?
Don’t use trimethoprim in first trimester due to being a folic acid antagonist
Don’t use nitrofurantoin in third trimester due to neonatal haemolysis
what is the cut off for anaemia in pregnancy
1st T: 110
2nd/3rd T: 105
post: 100
When would you consider giving parenteral iron
when oral iron is not tolerated or there is no time before delivery.
Do you need bleeding to diagnose abruption
no - oly 80 percent of cases
What are the risk factors for abruption
age(increasing) smoking cocaine or other drug use maternal hypertension trauma previous abruption
How do you manage PID
Test for chlamydia and gonnorhoea
treat with antibiotics - empirically if severe and suspicions are high
remove intrauterine devices unless very mild.
what are the main complications with PID?
10-20% after single episode. chronic pelvic pain ectopic fitz hugh curtis syndrome peritonitis reactive arthiritis
What is the cutoff for antepartum haemorrhage?
after 24 weeks is classes as APH
when can you get placenta praevia
only in 3rd trimester?
What is the management of uterine fibroids
1st - IUS
2nd Tranexamic acid
3rd OCP
4th myomectomy/ hysteroscopic endometrial ablation
GnRh agonist may be used in the short term to shrink fibroids - typically before surgery
When in hyperemesis most common
8 - 12 weeks but may be upto 20 weeks
What are the associations of HG
nulliparity obesity multip trophoblastic disease hyperthyroidism
What are the treatment options for HG
antihistamine - promethazine or cyclazine(also anticholinergic)
can advise p6 pressure point - but little evidence.
admission for IV hydration
What are the complications of HG
Wernickes encephalopathy - hence giving pabrinex Mallory weiss tear central pontine myelinolysis ATN small for dates
What is the management in primary genital herpes infection within 6 weeks of delivery.
oral acyclovir should be given to any infection after 36 weeks and any primary infection within 6 weeks of delivery.
c section should be for anyone with primary infection over 28 weeks
what is the treatment for BV
oral metronidazole
trichomonas vaginalis treatment (TV)
Oral metronidazle
what do you see on BV histology
clue cells and stippled vaginal epithelial cells
TV symptoms
green/yellow frothy discharge vulvovaginitis strawberry cervix (rare)
gonnorhoea treatment
IM ceftriaxone + oral azithromycin
What is the difference betweena complex and a simple ovarian cyst?
simple - unilocular - usually benign
complex - multilocular (
What are the 4 causes of PPH
Tone - atony 90%
Tissue - retained products
Trauma - tears
Thrombin - coagualtion
How much blood counts as PPh
> 500ml
What is the management of primary PPH
ABC
IV syntocinon 10 units or ergometrine 500micrograms
IM carboprost
stitchign and ligation
what is a rokitansky nodule
outgrowth of contents of a mature terratoma - dermoid cyst.
What is the natural course of a corpus luteal cyst in pregnancy
involute in second trimester
at how many weeks does the blood pressure trough during pregnancy
20-24
how long does it take PIH to resolve?
around 1 month
What are the high risk groups which require aspirin in pregnancy? what does should be given?
75mg OD from 12 weeks Diabetes previous PIH or preecalmpspia CKD autoimmune disease such as SLE
At what age is menopausal symptoms with elevated gonadotrophins considered premature ovarian failure
before 40
Quantify the breast cancer risk with HRT
~1.25x @5 years
breast cancer higher if progestogen added
risk declines and return to normal after 5 years when stopped taking and is equal to someone who did not take HRT
test for chlamydia
first void urine sample for NAAT
What are the risk factors for placenta praevia
previous praevia
previous c section (implantation on lower segement scar
multiple pregnancy
multiparity
danazol usage
used to treat endometriosis
is an ethisterone derivative but will not prevent implantation.
can also be used in fibrocystic change of the breast
why wont the COCP help someone after UPSI
because it prevents ovulation rather than implantation
upto how many hours is leveonogestrel lisenced?
72 hours but work upto 120 unlicensed.
What is the pearl index?
The Pearl Index is the most common technique used to describe the efficacy of a method of contraception. The Pearl Index describes the number of pregnancies that would be seen if one hundred women were to use the contraceptive method in question for one year. Therefore in the question, assuming the Pearl Index is 0.2 and the medication is adhered to perfectly, we would expect to see 0.2 pregnancies for every hundred women using the pill for one year - or 2 for every thousand.
When should you give Magnesium sulphate
rarely required to stop current fit as usually resolve. howver if a decision has been made to deliver the foetus then it should be given with:
Loading dose: Magnesium Sulphate 4 grams
8mls of MgSO4 (50%) diluted with 12mls Normal Saline (0.9%) = Total 20mls
Give IV over 20 minutes using syringe driver rate of 60 mls/hour
Maintenance dose: Magnesium Sulphate 1 gram per hour
20mls MgSO4 (10 gms) diluted with 30mls Normal Saline (0.9%) = Total
50mls
Give IV using syringe driver at rate of 5mls/hour
Recurrent seizures whilst on Magnesium Sulphate
Further bolus of 4mls MgSO4 (2 gms) diluted with 6mls Normal Saline
(0.9%) Give IV over 5 minutes
If possible take blood for Magnesium levels before bolus
Notify Obstetric and Anaesthetic Consultants
is trimethoprim safe in pregnancy
yes
What is the normal dose of folic acid
400mcg
What is the high risk dose of folic acid, when shoulkd it be taken until, and who needs to take it?
5mg taken upto 12th week risk factors: them or partner or family history of NTD have coeliac, diabetes, thalasaemia, taking antiepileptics Obese - >30kg/m2
When should contraception be stopped in menopause
after 1 year of no periods with women over 50, and after 2 years in those under 50
Which contraceptives must be withdrawn at 50
oestrogen containing
depot provera
use of contraception with beginning HRT
POP cannot be relied upon to protect the uterus from cancer risk with HRT unless HRT contains a progestogen component too. The IUS however does provide this protection.
define a late deceleration
Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction
Indicates fetal distress e.g. asphyxia or placental insufficiency
define variable decelleration
Independent of contractions
May indicate cord compression
What is the usual dose of levonogestrel for emergancy contraception
1.5mg. repeat dose if vomiting within 2 hours
what are the anatomical sections of the fallopian tube? which is most likely to be the site of an ectopic? same as fertilisation place
fimbriae 10%
infundibulum
ampulla 65%
isthmus 11%
most common POP complaint/side effect?
Women should be advised about the likelihood and types of bleeding patterns expected with POP use. As a general guide:
20% of women will be amenorrhoeic
40% will bleed regularly
40% will have erratic bleeding.
Between 10% and 25% of women using a POP will discontinue this method within 1 year as a result of these bleeding patterns.
What is the management of shoulder dystocia
mcroberts
episiotomy
manual manipulatin and manoevres including mood screw
syphisiotomy
What is an amniotic fluid embolism and how does it present:
amniotic fluid embolism usually occur during or within 30 minutes of labour.
Respiratory distress, hypoxia, and hypotension
is a diagnosis of exclusion - can be differentiated from intracranial haemorrhage by lack of headache.
it should be managed in ITU
Who should be traced in a chlamydial infection
partners in the last 6 months or most recent partner - they should be offered treatment beofer getting test results.
Causes of secondary post partum haemorrhage
endometritis
retained products of concenption
occurs 24hrs - 12 weeks (recent change from 6)
what are the causes of puerperal pyrexia
endometritis UTI wound infection (tears or csection) mastitis VTE
what is the management of endometritis
Hospital for IVabx - clindamycin and Gent
Are steroids safe in breastfeeding
yes
How do yo umanage breech
upto 36 weeks nothing
then ECV offered to nulliparous at 36 weeks and multiparous at 37 weeks
most opt for c sectin if still breech
What should be done at birth of a baby to a rhesus negative mother
Cord blood taken FBC Blood group Coombs test kleihauer test
What are the sensitising events of rhesus disease?
delivery of a Rh +ve infant, whether live or stillborn
any termination of pregnancy
miscarriage if gestation is > 12 weeks
ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
external cephalic version
antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling
what percentage of mothers are rhesus negative
15%
when are normal doses of anti D given
either single at 28 or double at 28 and 34
What is the contraindication to IUD
suspected PID - those at high risk should be screened first for infection. The IUD may cause PID
what is ashermans syndrome
Adhesions and fibrosis of the endometrium - often a complication of ERPC or curretage
What are the causes of secondary amenhorrhoea
Pregnancy Hypothalamic - stress and exercise Premature ovarian failure thyroid dysfunction sheehans prolactinoma PCOS ashermans
What are the risk factors for POM (premature ovarian failure)
family history of POM
Chemo/radiation
autoimmune disease
Who gets fibroids
20% white and 50% black women after menopause
Rare before puberty as they are a response to oestrogen
what is microgynon 30
COCP
How long does it take for each contraceptive to become effective?
Instant: IUD
2Days: POP
7 Days: COCP, IUS, implant, injection.
Unless on first day of cycle.
When should you start the COCP
ideally in the first 5 days of the period and it will be effective instantly. if not then 7 days are required till it is effective.
which antibiotics can reduce the efficacy of COCP?
only enzyme inducing antibiotics
how should a UTI be treated the first trimester
NOT with trimethoprim. use nitrofurantoin (not in third trimester - neonatal haemolysis)
What is a missed miscarriage
gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
cervical os is closed
when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
what is the difference between in inevitable and incomplete miscarriage
idea that incomplete, the body is unable to expel the remaining content and will require erpc.
symptoms of a hydatiform mole
high hcg causing HG
thyrotoxicosis due to stimulation of TSH R
usually large for dates
bleeding in 1st or early 2nd trimester
what percentage of hydatiform moles go on to become choriocarcinoma
2-3%
what is the management of a hydatiform mole
referral to specialist centre for removal
contraception for 1 year - do not get preggerz
What percentage of CIN3 becomes cancer
31%
What is a nexplanon
implant
what are the common side effects of progestogens
headache
nausea
breast pain
Which UKMEC levels should you worry about
4 - DO NOT use
3 - not worth the risk
2 - small risk but usually safe
When is the implant contraindicated
ACTIVE BREAST CA
previous breast ca, liver cirrhosis, heart disease or stroke.
antiphospholipid antibodies
What place does MRI have in endometriosis
can help with diagnosis if bowel symptoms and rectal involvement
What do you measure to test a womans fertility
day 21 progesterone.
the corpus luteum should have produced a day 21 surge in progesterone. telling you that the patient has ovulated.
How should you NOT manage an ectopic
do not palpate for adnexal mass as increases risk of rupture
what are the absolute contraindications to VBAC
classical scar and previous uterine rupture.
How do you define recurrent miscarriages and what are the most common causes?
anyone with 3 spontaneous miscarriages
Antiphospholipid antibodies 15% Poorly controlled endocrine disorders e.g DM, PCOS, thyroid Uterine abnormality e.g septum parental gene abnormality smoking
what is antiphospholipid syndrome
causes increased clotting risk - antibodies to fat
What stage of disease do endometrial cancers usually present with?
stage 1 - treated with a hysterectomy and bilateral salpingo-oophorectomy. Radiotherapy is often used more than chemo. and routine removal of lymph nodes is not helpful
ovarian FIGO
Stage 1 Tumour confined to ovary
Stage 2 Tumour outside ovary but within pelvis
Stage 3 Tumour outside pelvic but within abdomen
Stage 4 Distant metastasis
what diabetic drugs are safe in pregnancy
metformin and insulin and then second line instead of metformin you can use glibenclamide.
you cannot use gliclazide or liraglutide.
Who needs to undergo peak monitoring of LMWH levels?
under 50kg and over 90kg women. Monitor anti Xa activity
VTE prophylaxis in pregnancy
Age > 35
Body mass index > 30
Parity > 3
Smoker
Gross varicose veins
Current pre-eclampsia
Immobility
Family history of unprovoked VTE
Low risk thrombophilia
Multiple pregnancy
IVF pregnancy
Four or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal. If a woman has three risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
Low molecular weight heparin is the treatment of choice for VTE prophylaxis in pregnancy.
What is klaxons syndrome
failure to produce GnRH - primary amenorrhoea
what is primary amenhorrhoea defined as
failure to start menses by age of 16 - HOWEVER you should start workup if there is no change by 13.
secondary must have had 6 months of periods before stopping to count
What are the symptoms of imperforate hymen
blue bulging membrane with cyclical pain and no bleeding
what is mullerian agenesis
absence of internal female organs. only external genitalia
When can you identify twin to twin transfusion syndrome
monochorionic twins
shared placenta means there is blood flow between the twins. can be fatal to one or both.
polyhydramnios and oligohydramnios
it is identified between 16 and 24 weeks. after this time you are scanning for IUGR
Management of PCOS in conception
weight loss
clomiphene
metformin
ovarian drilling then try above again
What is the difference between a complete and partial hydatidiform mole
Complete: 46 chromasomes all from the father
Partial: 69 chromasomes XXX or XXY
What is the treatment for urge incontinence
bladder retraining for atlas 6 weeks
medical management including antimuscarinics oxybutinin(avoid in older frail) or tolterodine
What is the surgery of stress incontinence
retropubic mid urethral tape procedures
what is the most common cause of postcoital bleeding
ectropian
how many antenatal visits should a woman have
10 if first and 7 if more (uncomplicated)
Which children are at risk of vitamin k deficient bleesing
BREASTFED. need vit k at birth.
How does chorioamnionitis present
brown fould smell9ing discharge with fever, tachy etc, may have raised fetal heart rate
when does red degeneration usually happen?
1st or second trimester and presents with fever pain and maybe vomiting
management of chorioamnionitis
IV abx and delivery
When are you in second stage of labour
when the cervix is fully dilated - this process will take about an hour and is associated with transient foetal bradycardia
what is lochia
Lochia may be defined as the vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth.
Lochia typically takes the course of fresh bleeding, which undergoes colour changes before finally stopping. The patient can be reassured and advice should be given to her regarding lochia. Specifically, she should be told that if this begins to smell badly, its volume increases or it doesn’t stop, she should seek medical help
which blood products need to be crossmatched
all except platelets
what is cryoprecipitate
essentially clotting factors
What is the management of DIC
Clotting studies and a platelet count should be urgently requested and advice from a haematologist sought. Up to 4 units of FFP and 10 units of cryoprecipitate may be given whilst awaiting the results of the coagulation studies.’
What is in SAG-M blood
When plasma taken out it is replaced by saline, mannitol, glucose and adenine. upto 4 units of this can be given before whole blood is preferable.
What are the layers cut through to get to the uterus in a c section
Superficial fascia Deep fascia Anterior rectus sheath Rectus abdominis muscle Transversalis fascia Extraperitoneal connective tissue Peritoneum Uterus
what are the risks of prematurity
Risk of prematurity increased mortality depends on gestation respiratory distress syndrome intraventricular haemorrhage necrotizing enterocolitis chronic lung disease, hypothermia, feeding problems, infection, jaundice retinopathy of newborn, hearing problems
what drugs should be used in peurperal depression and why?
paroxitine because it has low availibility in the breast milk
Fluoxetine should be avoided as it has a long half life
CBT is th first line treatment still as this disease is likely to peak at 3 months
braxton higgs
occur in the last 4 weeks, irregular and may be spaced at 20 mins
What are the risk factors for cord prolapse
prematurity multiparity polyhydramnios twin pregnancy cephalopelvic disproportion abnormal presentations e.g. Breech, transverse lie placenta praevia long umbilical cord high fetal station
How should a cord prolapse be managed
push presenting part back into the uterus
administer tocolytics
patient to get on all fours
c section
1 in 500 births but reduced as breech is usually c sectioned now.
can deliver a cord prolapse with forceps but requires skill
When should you get a mec baby seen by a doc
low threshold for abnormalities respiratory rate above 60 per minute the presence of grunting heart rate below 100 or above 160 beats/minute capillary refill time above 3 seconds temperature of 38°C or above, or 37.5°C on 2 occasions 30 minutes apart oxygen saturation below 95% presence of central cyanosis
what drugs can be used to help with smoking cessation
varenicline and bupropion (neither should be used in pregnancy - NRT)
which hepatitis is screening for in pregnancy
hep b
what is the target range for blood pressure in pre eclampsia or PIH
<150 systolic and 80-100 diastolic
Ace inhibitors - okay in preganancy?
no fetotoxic
contraindications to ergometrine
hypertension - use oxytocin
What does a bishops score of 5 or less
labour is unlikely to progess without induction
at how many weeks should an uncomplicated pregnancy be offered induction
41-42 weeks
at how many weeks should diabetic mother be induced
38
How should you manage a PPROM
admit for 48 hours, and give antibiotics and steroids
safety net with regular temperature reading s and signs of chorio. ABX = erythro for 10 days
at 34 weeks consider induction as likely that risk of infection outweighs risk of delivery
What drug is used in the management of OC
ursodeoxycholic acid
what are the risks of OC
IUD - induced at 37
prem babies
What is one of the most severe risks of an instrumental delivery
Femoral nerve Weakness in knee extension, loss of the patella reflex, numbness of the thigh
Lumbosacral trunk Weakness in ankle dorsiflexion, numbness of the calf and foot
Sciatic nerve Weakness in knee flexion and foot movements, pain and numbness from gluteal region to ankle
Obturator nerve Weakness in hip adduction, numbness over the medial thigh
most recover within 6 week sbut some are permanent
contraindications to epidural
Coagulopathy: APTT ratio or INR >1.4 Platelet count < 100 Low molecular weight heparin (e.g. Enoxaparin, Clexane) given within last 12 hours if on prophylactic dosing (20 or 40mg) or within last 24 hours if on therapeutic dosing (>40mg) Clopidogrel given within the last 7 days
Local sepsis
what vaccinations should be offered in pregnancy and when?
Influenza - to all pregnant in the flu season regardless of trimester (october to january)
pertussus - ideally given at 28-32 but can be given upto 38. it should be given in every pregancy
there is no individual pertussus vaccine so it is given with diptheria, polio and tetanus.
rubella should be offered if the individual is not immune. - it is not a live vaccine
Late decellerations should be investigated how?
fetal blood sampling to measure a pH - >7.2
What is placenta accreta? what are the risk factors?
Attachment of the placenta TO the myometrium due to a defective decidua basalis. (hence why the normal is called placenta decidua)
there is a risk of PPH due to improper detachment
previous c section or praevia?
what are the other placental attachment abnormalities?
17% Increta - IN the myometrium
5% Percreta - PAST the myometrium into uterine serosa and can attach to other organs
What measures ofSFH are there?
20 weeks at umbilicus
36 weeks at xiphisternum
is nifedipine contraindicated in breastfeding
no
epidural anaesthesia reduced blood pressure and therefore is helpful in pre eclampsia
same day delivery of pre eclampsia is an option from 34 weeks - just as with PPROM etc
what is johnsons manoevre
used for inversion of the uterus - slow manual replacement of the uterus.
tocolytics can be used to help relax the uterus but this may aggrevate bledding
how often do type 1 diabeteics need to measure blood sugard in pregnancy
daily fasting, pre meal, 1 hour post meal, and bed time
different types of grade 3 tear
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: IAS torn
fourth degree: injury to perineum involving the anal sphincter complex (EAS and
IAS) and rectal mucosa
what is the presentation of chorioamnionitis in the absence of ruptured membranes? what organism causes it?
associated with the genital mycoplasma bacteria
foul smelling, maternal signs of infection
First steps in managing postnatal depression
Edinburgh score
IVF is a risk factor for what
most things
praevia
which antibiotic should be used in UTI when breastfeeding
trimethoprim - nitro is bad - causes G6PD
Guidelines for foetal monitoring in uncomplicated 1st stage
For foetal monitoring: carry out intermittent auscultation immediately after a contraction for at least 1 minute, at least every 15 minutes, and record it as a single rate.
Palpate the woman’s pulse every 15 minutes to differentiate between the two heart rates.
Contraction monitoring every 15 minutes. Strength; during a contraction, you shouldn’t be able to indent the uterus with your fingers. Duration; usually 3 or 4 per 10 mins, lasting <1 min each.
What are the risks for a child and mother with shoulder dystocia?
Baby: Erbs palsy or other brachial plexus injuries, HIE
Mother:3rd degree tear is not episiotomy, PPH, risk recurrence
what are the risk factors for a breech presentation?
prematurity Praevia fibroids previous breech oligo/polyhydramnios fetal anomalies multiple pregnancy
What are the benefits of VBAC
decreased risk of foetal respiratory difficulties and decreased maternal fever. can allow better chance of further vaginal deliveries.
things which worsen chance of VBAC?
previous c section for shoulder dystocia. Baby >4kg, increasing maternal age and BMI, induction.
What are the chances of succesful VBA in someone with 1 single c section? and then also one SVD
75%
85-90%
what is the risk of uterine rupture? what are the oother risks?
1 in 200
increased risk of needing transfusion.
HIE 8 in 10,000
absolute contraindications to VBAC
classical c section incision
Relative contraindications to VBAC
myomectomy or hysterotomy
What is the management of HG?
USS for reassurance Fluids - plasma-lyte/NACL with KCL20mmol Anti emetics - cyclizine50mgTDS, metoclopramide10mgTDS, Ondansetron4-8mgTDS Vitamins - Pabrinex 1+2, folic acid Stomach protection - ranitidine VTE prophylaxis - enoxaparin 40unitsOD
what are the indications for admission of HG?
2+ ketones
clinical evidence of dehydration
intolerance to food and fluid
weight loss?
What are the complications of HG?
Psychological/ emotional - can effect bonding with baby and have mental health repercussions
Wernickes
Hyponataemia - seizures respiratory arrest, central pontine myelinolysis
mallory weiss tear
DVT
fetal - SGA, preterm
What is the difference between exomphalos and gastroschisis
free loops in gastro and whole protrusion in exomphalos
What does glucocorticoid reduce the risk of antenataly?
RDS IVH mortality
What 3 markers are used in the triple test
oestroil bHCG AFP
what markers are used in the combined test
Age NT b hcg PAPP-a
what is the main difference between amnio and chorionic villous sampling
time at which is can be done. chorio at 13 vs amnio from 16. slightly greater risk of 1-2% miscarriage with chorio.
what is the treatment for genitourinary prolapse.
Physio - pelvic floor exercises
Pessary lasts 6-12 months fir biggest that isnt uncomforatble - support or space occupying
surgery - sacrohysteropexy, sacrocolpopexy
Why do spetic children often need FFP
to treat the DIC as is evidenced by their non blanching rash
What contraception can be used in breast cancer
IUD. no hormonal contraception is allowed
Upto what day do you not need emergancy contraception after child birth
21
you cannot insert the coil until after 28 days anyway due to perf risk
What 3(of4) things are needed for diagnosis of BV
AMSEL's criteria clue cells ph>4.5 possitive whiff test (additon of potassium hydroxide produced fish smell) thin white homogenous discharge
mx oral met for 5-7 days and washing advice
relapse rates are high with >50% in 3 months
how long after birth should a woman wait to have her cervical smear
atleast 12 weeks
When should you do a smear test during pregnancy
if there has been a previous abnormal smear then can be done by a specialist as long as there is no praevia
how do you diagnose a suspected praevia
abdominal uss
What should be done if a pravia is found on the 16-2 week anomaly scan
rescan at 34 weeks until which time they do not need to limit activity unless they bleed
if at 34 there is still grade1/2 then recheck in 2 weeks
if there c section should be given for grades 3 and 4
grade 1 is Vaginal delivery
Which HRT should be used in the perimenopause
CYCLICAL as this allows for withdrawal bleeds.
topical creams and pessaries are only useful to prevent vaginal symptoms
What is the management in OHSS
fluid replacement and thromboprophylaxis
What causes OHSS
hcg, gonadotrophin and clomiphene
tranexamic acid and mefanamic acid are safe to use in women trying for children?
yes - they must be started on the first day of the period and are taken for 3-4 days
What are the chances that a salpingotomy will become a salpingectomy
1 in 5
How often can emergancy contraception be used?
once per cycle - can use different type to get around this
What things increase the chance of ectropian
higher oestrogen levels:
pregnancy, COCP, ovulatory phase of cycle) they may result in features of increased discharge and post coital bleeding
can be managed with cold coagulation but only if really causing an issue
What is the management of dysmenorrhoea
mefanamic acid
What produced hcg
first by the embryo and then by the placental trophoblast
levels peak at around 8-10 weeks gestation
What is the second line treatment for chlamydia
doxy 100mg BD 1/52
What is the colour difference of blood in abruption and in praevia
bright red in praevia and dark red in abruption
What is the difference between a simple and complex cyst
simple - fluid filled
complex - solid
At what level of 21-day progesterone would you repeat the test and confirm ovulation?
upto 30 repeat, over means ovulation
if lower than 16 likely to need refferal
What are the precipitants of thrush
recent antibiotic use
immunosuppression
it causes a non offensive discharge
what is the management of thrush
pessary of clotrimazole500mg OR oral fluconazole 150mg PO stat OR oral itracnazole 200mgbd 1day
Oral agents are not for use in pregnancy
consider a maintenance dose each week if the infection is chronic
Whirlpool sign
volvulus and ovarian torsion
What would dopplers show of a torted ovary
no venous flow with absent or reversed diastolic flow
What is associated with a low and high AFP in pregancny
Low = downs High = NT defects
Treatment for PMS
OCP and SSRI aswell as lifestyle factors such as sleep hygeine, healthy diet, weight and exercise, reduction of stress.
What is wertheims hysterectomy
I think it is the same as a radical hysterectomy i.e everything including the upper third of the vagina
BUT with resection of pelvic nodes added on.
used for stage 2b
What is the difference between a subtotal, total, and radical hyseterectomy
subtotal doesnt take the cervix.
total takes the cervix
Radical takes the surrounding tissue aswell. including parametrium and upper third of the vagina.
It hink this may include the ovaries and tubes too?
what is the management for lichen sclerosus
Topical steroids and emollient and regular checkup due to increased risk of vulval cancer.
NOTE: a biopsy should only be taken if there is clinical uncertaintly or there is a poor response to treatment
what are the coplications of a hysterectomy
vault prolapse and enterocele
may get urinary retention post op for a bit
How does a degenerating fibroid present and what is the management?
low grade fever, pain and vomiting with reassuring signs of the foetus
offer analgesia and rest and it should resolve witin a week.
What is the triad of symptoms seen in vasa praevia
rupture of membranes with continuous blood but no pain with foetal bradycardai.
no risk to the mother but HIGH to the child
Which is worse for bleedign risk prolonged ventouse or a forceps?
ventouse
What are the risk factors for a placenta praevia?
previous c sections and multiparity
What is the management for hepatitis B in pregnancy?
They may have a vaginal birth as there is no evidence to duggest there is a reduction in vertical transmission with a c section.
The child should be given HBIg and a hep b vaccine within 12 hours of birth and then further vaccine at 1-2 months and 6 months.
What are the normal changes heard on cardiovascular examination in pregnancy?
an ejection systolic murmur is heard in 96% of women and 84% have a third heart sound. Forceful apex beat is not a cause for concern provided it is still within 2cm of the mid-clavicular line
uterus may block blood return to the heart - i.e when lying supine
What are the physiological changes in pregnancy affecting the lungs?
tidal volume increases 40%
o2 requirement goes up 20% along with BMR of 15%
What are the physiological changes in pregnancy affecting the blood?
Factor 7,8 and 10 and fibrinogen rise.
blood volume up 30% - 20% red cell rise and 50% plasma rise
platelets fall
WCC and ESR rise
What are the physiological changes in pregnancy affecting the urinary system?
blood flow increases by 30% and so GFR goes up 30-60%
retention of salt increases due to sex steroids and there is some increase in protein loss
What are the physiological changes in pregnancy affecting the liver?
ALP rises by 50%
albumin levels fall
hepatic flow doesnt change
What is the weight of the uterus?
100g up to 1100g
What are the biochemical changes happening during pregnancy?
calcium requirement goes up and even more so once lactation begins. serum levels of calcium fall due to increased demand and active transport accross the placenta.
increases in 1-25 hydroxy vitamin D cause huge increases in gut absorption of calcium.
What size of ectopic can be treated medically?
<35mm, it must have no heartbeat and they must have a hcg of less than 1500. stable without pain.
they must be willing to attend for follow up.
what does a hydatidiform mole look like on USS?
On ultrasound, the mole appears as a solid collection of echoes with numerous small anechoic spaces which resembles a bunch of grapes (also known as ‘snow-storm’ appearanc
what is the riskiest form of breech presentation?
footling due to high risk of cord prolapse
When would you give abx for mastitis?
when you suspect the cause is infective:
no improvement with expression in 12-24 hours
there is an infected nipple fissure
there is a positive culture
hyperechogenic bowel on USS
CF
downs
CMV infection
Name the 5 tumour markers and what they indicate?
CA 125 Ovarian cancer
CA 19-9 Pancreatic cancer
CEA Bowel cancer
AFP Liver cancer and germ cell tumours (e.g. testicular)
What are the long term complications of PCOS
Subfertility Diabetes mellitus Stroke & transient ischaemic attack Coronary artery disease Obstructive sleep apnoea Endometrial cancer
What are the causes of oligohydramnios
premature rupture of membranes fetal renal problems e.g. renal agenesis/pckd/urethral obstruction intrauterine growth restriction post-term gestation pre-eclampsia
What is an overactive bladder
due to an increase in detrussor activity
What is mixed incontinence?
mixture of stress and urge
What is overflow incontincenc
likely due to outflow obstruction
from how many weeks gestation does gestaionally induced hypertension present?
- cannot develop before this.
What is the treatment for group b strep colonisation?
intrapartum IV ben pen
treatment of choice for stage 1 and 2 endometrial cancer?
total abdominal hysterectomy with bilateral salpingo-oophorectomy
What is the major risk factor for cord prolapse
although not a risk factor per say artificial rupture of membranses is when the majority happen.
To manage it one should place the hand into the vagina to elevate the presenting part. use of tocolytics
Management for uterine atony?
5 units of syto then ergo then sytno infucion carboprost miso 1000 PR
Is vaginal bleeding pre 12 weeks a sensitisation event?
no as long as bleeding is not really heavy or continupous or painful.
What is oxybutinin
anti muscarinic for detrussor overactivity
What might make you suspect vesicovaginal fistulae? what is the way to diagnose it?
continuous dribbling incontinence - dye studeies should be done to diagnose
When should urodynamic studies be done?
when there is a degree of clinical uncertainty as to the cause of incontinence
How big does a uterine fibroid need to be before one would opt for surgical intervention rather than medical?
3cm
What is the treatment of twin to twin transfusion syndrome?
indomethacin - NSAID inhibits prostaglandin synthesis
How often should HIV sufferers have smears?
annually
What is miegs syndrome
benign ovarian ymour
ascites
pleural effusion
What are the 3 things associated with an increased nuchal translucency?
downs
congenital heart defects
abnormalities of the abdominal wall
What are alternatives to HRT
tibolone is a synthetic androgen
SSRI
clonadine and gabapentin are niche
progestogens such as norethisterone
When does a kleihaur test need to be done?
in any sensitizing event after 20 weeks. (given with anti D)
In whom should fgm be reported to the police
anyone under 18. it does not need to be reported if you can identify that another professional has made the report.
What is the management for someone with FGM
if under 18 reported to the police and social cervices.
anyone must have fgm documented in notes, and their details submitted to a register owned by the HSCIS (health and social care information centre)
They should be given advice to make them aware that it is a criminal offence which can gain them upto 14 years in prison (7 for not stopping)
de - infibulation must be offered.
What are the 4 types of FGM
1 - partial or total removal of the clitoris/and or the hood
2 plus minora (with or without majora excision)
3 - narrowing of the oriface i.e sewing up
4 - all others eg piercings and pricking scraping
When should a mother be checked for anaemia and red cell alloantibodies?
8-12 and then 28
why cant you do a smear in pregnanc
difficult to interpret results
When should oxybutinin not be used?
frail elderly due to increased risk of falls.
solifenacin or tolteradine should be used instead
What are the causes of polyhydramnios
Maternal DM
fetal abnormalities such as duodenal atresia or tracheooesophageal fistula.
what grip must not be used in assesment of foetal lie if possible?
pawlicks grip
treatment of candidiasiss in pregnancy?
imidazole PV
What are wilsons criteria?
the condition should be an important health problem
the natural history of the condition should be understood
there should be a recognisable latent or early symptomatic stage
there should be a test that is easy to perform and interpret, acceptable, accurate, reliable, sensitive and specific
there should be an accepted treatment recognised for the disease
treatment should be more effective if started early
there should be a policy on who should be treated
diagnosis and treatment should be cost-effective
case-finding should be a continuous process
Where are LH and FSH produced
anterior pituitary
what is the role of LH
to form and maintain the corpus luteum as well as thinning og the graffian follicle membrane
What does oestrogen do in the follicular phase
thins cervical mucous and thickens the endometrium
When are you most fertile in the cycle?
5 days before and 2 days after ovulation. (sperm remains in for a long time
What does progesterone do?
stimulates oestrogen production
initiates the secretory phase
increases basal body temperature
inhibits LH and FSH production
What are the phases of the menstrual cycle?
menstrual
follicular
luteal
How do you know if someone is about to ovulate?
thinning of cervical mucous due to oestrogen surge and rise in body temperature due to LH surge.
How much of the endometrium is shed suring the menstural phase
basal layer remains intact and the rest is shed by contraction of the myometrium
At how many weeks would you expect a woman to start kicking?
18-20 if not had a baby before
15-18 if they have
How many weeks does the 3rd trimester start at?
29 weeks?
first one ends at 12
when does the first stage of labour begin
when the effaced cervix is at 3cm dilation
how do you estimate the due date
add 9months and 1 week to the first day of the LMP
What are the potential complications of induction
uterine hyper stimulation uterine rupture c section prolapsed cord prolonged labour if induced too early
What is the MOA of tranexamic acid?
it is an antifibrinolytic and reduces losses by around 50%
What should be done before endometrial ablation?
biopsy to check tissue as it will be burnt
What should be done before endometrial ablation?
biopsy to check tissue as it will be burnt
What causes pain during menstruation?
high prostaglandin levels often cause large contraction and uterine ischemia
How do you define precocious puberty in a girl
secondary sex characteristics before 8 or menstruation before 10
What is the treatment for MCune albright syndrome
cyproterone acetate
What is thought to cause PMS
progetogens - PMS in luteal phase
What is the management for PMS
SSRI in second half of cycle or contnuous
OCP
oestrogen HRT can be useful
What are the main differences in the male and female pelvis
larger pelvic inlet
u shaped pubic arch rather than a ‘v’
When should you give gnrh pretreatment for fibroid shrinking
when doing open. not lap.
injection of vasopressin reduces blood loss
What are the symptoms of adenomyosis
painful, heavy irregular periods
what is a haematomaetra
collection of blood in the uterus - rare - caused by wlling off of the cervix after endometrial resection
OR by an imperforate hymen
What are uterine polyps
uaually arise from endometrial tissue and are mostly benign however can have potential for dysplasia.
commonly found in 40+
often found in women on tamoxifen
what is a nabolthian follicle
overgrowth of squamous cells over the top of gladular
CIN1 vs 3
cells only in lower 1/3 vs whole thickness(carcinoma in situ)
1/3 of women with CIN3 develop cancer in 10 years
at what age does screening for cervical cancer become 5 yealy
49
What are the complications of the LLETZ
haemorhage
premature birth
When doe sa functional cyst become worrying?
over 5cm and been there for more than a couple of months
measure ca125 - cutoff is >35 for scan
What markers should you measure in women under 40 if you suspect a malignancy?
AFP and hCG as germ cell tumours are more common in these age groups and produce these hormones
Where does the lymph drainage go?
inguinal
femoral
external iliac
What is the difference between plichen planus
simplex
sclerosus
planus - purple/red
simplex - majora mainly affected inflamed and thickened
sclerosus - pink white, loss of collagen thinning
What is the function of the bartholian gland
to secrete lubricatng mucus for coitus
infection would rsult in large painful tender swollen nodules
insicion and rainage with marsupialsation
What is the difference between small for gestational age and small for dates(or IUGR)
lower than the 10th centile for their weight is small for GE
wheras growth restriction or small for dates means the SFH is smaller than expected.
IUGR is when there is faltering growth and they are falling off the centiles
What are the symetrical causes of IUGR?
congenital abnormality
infection
normal small
poor nutrition
What are the asymetrical causes of IUGR?
Placental insufficiency Pre eclampsia (hypertension) diabetes smoking placental factors such as abruption maternal chronic disease
What are the sequlae of IUGR?
Higher levels of morbidity and mortality overall with many long term dequelae. They may be:
Cerebral palsy learning disability short stature IUD prematurity - all sequalae of that. NEC
What does bakers hypothesis suggest?
can cause fetal programming which leads to increased risk of what we would consider diseases of the aged such as CHD, hypertension, diabetes dyslipidaemia.
What is the management for a patient with IUGR.
immediate referral to obstetric team who will need to do:
close observation and monitoring
dopplers
scans
may indicate amniocentesis to test for congential abnormalities or infection
May need to consider early delivery if risks outweigh benefits
increased risk of emergancy c section
will need to have corticosteroids at some point to reduce risk of surfactant deficinecy and IVH.
How long should follow up smear be in CIN2
6 moths
What do you do if you find moderate dyskaryosis
refer for colposcopy REGARDLESS of hpv status
How much crystalloid can you give before you need to give blood products
3.5l and so you can wait for blood products
how do you confirm small for dates
uSS - no need for doppler
how do POPs work?
thickens cervical mucous
At what age is the OCP become ukmec2
40 and then should be stopped at 50
At what age does injectable become UKMEC 2
45
how do you manage delayed speach and language
hearing test and SALT
