GOSH revision Flashcards
normal variation in a CTG
5bpm or more
3 steps to assess contractions
- frequency (count number in 10 minute period)
- duration: how long do they last
- intensity (NOT from CTG - palpate the uterus)
5 causes of foetal tachycardia (>160)
- foetal hypoxia
- chorioamnionitis
- hyperthyroidism
- foetal/maternal anaemia
- foetal tachyarrhythmia
5 causes of foetal bradycardia (<100)
- prolonged cord compression
- cord prolapse
- epidural/spinal anaesthesia
- maternal seizure
- rapid foetal descent
what indicates severe hypoxia in a foetus
severe prolonged bradycardia (80bpm for >3 mins)
non-reassuring variability is
- <5bpm for 30-50 mins
- >25bpm for 15-25 mins
abnormal variability is
- <5bpm for >50 mins
- >25bpm for >25 mins
5 causes of reduced variability
- sleeping (<40 mins)
- foetal acidosis due to hypoxia - more likely if late decelerations
- drugs (opiates, benzos, methyldopa, mag sulphate)
- prematurity
- congenital heart abnormalities
typical vs atypical deceleration
typical = <60 seconds for <60bpm - typical ones also have shouldering (good - foetus is adapting to reduced blood flow and is not yet hypoxic)
atypical = >60 seconds OR >60bpm drop in HR
3 causes of late decelerations
- maternal hypotension
- pre-eclampsia
- uterine hyperstimulation
hypoxic and acidotic :(
what does a sinusoidal pattern indicate
severe foetal hypoxia/severe foetal anaemia/foetal or maternal haemorrhage
5 things to do if worried about CTG
- change maternal position to left lateral (increase CO)
- give fluids if dehydrated
- foetal scalp electrode - if increases HR = good
- foetal blood sample for pH testing
- delivery
when should foetal blood sample be done
if worried about CTG and delivery not imminent - must be >3cm dilated and should take 2 samples
pH normal = >7.25, <7.2 = v bad and needs delivery
difference between parity a and parity b
- parity a = number of pregnancies where foetus reaches 24 weeks (includes stillbirths)
- parity b = number of pregnancy losses before 24 weeks
advice given in the booking visit
- FA supplementation for 12 weeks
- food hygiene (no raw milk/cheese)
- stop smoking, alcohol,. drugs, do exercise, healthy diet
- antenatal screening advice
purpose of dating scan
- confirm viability of pregnancy
- ensure gestational age is correct and reduce need for IOL
- aid detection of lethal abnormalities
- detect multiple pregnancies and assess chorionicity
when is combined test carried out
11-13+6 weeks (at same time as dating scan)
3 results of combined test indicating Down’s syndrome
- thickened nuchal fold (>35mm) - scan
- raised hCG - blood test
- lowered PAPP-A - blood test
when and what does the quadruple test
14-17 weeks if too late to do combined test
- AFP
- hCG
- oestriol
- inhibin A
what is a positive result of combined/quadruple and what to do after
> 1/150 chance
CVS at 11-14 weeks
amniocentesis at 15 weeks
3 possible NIPT test results a woman could get
- positive = invasive test needed to confirm
- negative = v likely not
- inconclusive (4%) = test repeated
how is gestational age measured at 10-12 weeks at dating scan
if BEFORE 13 WEEKS = foetal CRL
after 13 weeks = biparietal diameter, head circumference, femur length
what can raised AFP indicate
- open NTD
- exomphalos
- posterior urethral valves
- GI obstruction
- teratomas
IUGR, preterm, placental abruption, 3rd trimester death
what is PAPP-A and what do low levels indicate
glycoprotein made by placenta - low levels in 1st trimester indicate:
- trisomy 13/18/21
- pre-eclampsia
- IUGR
- preterm delivery
foods advised not to eat in pregnancy
- unpasteurised cheese and milk (listeria, salmonella, toxoplasmosis)
- pate and poorly cooked meat
- shellfish and raw fish
- caffeine
- liver (high levels of vitamin A = congenital abnormalities?)
when does N+V usually occur in pregnancy
4-7th week and resolves by 20 weeks
if persists after the first trimester, think about hyperemesis
ABG result in hyperemesis gravidarum
hypokalaemic, hypochloremic metabolic alkalosis
also might have ketonemia, ketonuria, hyponatraemia
2 risks of hyperemesis
- Wernicke’s encephalopathy
- increased risk VTE
1st line antiemetics for hyperemesis if lifestyle advice doesn’t work
antihistamine: cyclizine/promethazine /prochlorperazine
2nd line antiemetics for hyperemesis
metoclopramide/ ondansetron but don’t prescribe longer than 5 days
how are varicose veins managed in pregnancy
reassurance - normal and due to pressure on lower legs (no harm) - but can give compression stockings
1st line meds if lifestyle advice doesn’t help with heartburn
antacids/alginates (GAVISCON?) (magnesium and aluminium combinations on PRN basis)
calcium combinations short-term/occasional use (a.g. Alka-Seltzer)
what can be used if heartburn symptoms are severe/persist
PPI (omeprazole or lansoprazole)
when are haemorrhoids more common in pregnancy
after 1st trimester - so topical haemorrhoid cream is less likely to harm baby
triad of HG symptoms
- > 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
from rise in hCG/rise in progesterone (decrease in gastric motility)
scoring system used to classify severity of HG
PUQE (pregnancy- unique quantification of emesis index)
3rd line antiemetics used in HG
corticosteroids - hydrocortisone at first the convert to prednisolone and taper down to lowest dose at which symptoms are controlled
definition of SGA
<10th centile
how is SGA or foetal growth assessed
ask about foetal movements (over 26 weeks)
estimated foetal weight and measurements via Stan
symphysis-fundal height
what can be measured to identify the ‘brain-sparing’ effect - baby undergoing hypoxia so blood is shunted to head to protect brain
if HC is much larger than AC
Doppler studies
what might larger AC than HC indicate
maternal diabetes - affects liver and fat stores
when should foetal movements be asked about
after 26 weeks - but most women become aware of them around 18-20 weeks (nulliparous women can be a bit later)
plateau 32 weeks onwards but should NOT reduce
what should women unsure about reduction in foetal movements be advised to do
lie on LL side and focus on movements for 2 hours - if don’t feel 10+ should come to MAC immediately
MAC will confirm heart activity and do CTG within 2 hours of assessment
differences between symmetrical and asymmetrical growth restriction
- symmetrical = early onset, asymmetrical = late onset
- symmetrical = associated with less catch up growth in first year vs asymmetrical (more catch up growth)
how can IUGR be prevented/monitored
- serial dopplers and scans from 20-28 weeks
- pre-eclampsia = aspirin from 12 weeks to birth
- stop smoking, no drugs, no alcohol
- correction of anaemia with iron supplements
- optimisation and management of chronic conditions before conception e.g. renal disease, blood clotting disorder
antenatal care aspects of twin pregnancies
- routine iron and folic acid
- aspirin 75mg daily if risk factors for pre-eclampsia (because multiple pregnancy increases the risk)
- serial growth scans for DC: 28, 32 and 36 weeks
- discuss mode and date of delivery
- establish presentation of leading twin by 34 weeks
when to offer induction or C/S for multiple pregnancy
37-38 weeks
when might TTTS occur
monochorionic pregnancy (same placenta)
how to monitor and treat TTTS
monitor = USS every 2 weeks from 16/24 weeks to delivery
treatment = laser ablation of placental anastomoses, selective foeticide by cord occlusion :(
how would vaginal birth be managed in twins
- leading twin must be cephalic
- induced at 38 weeks
- IV access (group and save)
- continuous CTG
- 2nd twin must be stable and at correct presentation before delivery
- oxytocin if contractions diminish after 1st
symptoms of pre-eclampsia
- headache
- visual disturbance
- cerebral oedema
- hyperreflexia
- sustained clonus
- stroke
- seizures (eclampsia)
why does HELLP syndrome occur after pre-eclampsia
increased pressure in vessels = leaky
how are liver and kidneys affected by pre-eclampsia
- liver - vasoconstriction of blood vessels decreases supply to liver = pain, raised ALT/AST >70
- kidneys - reduced blood supply = proteinuria
strong risk factors for pre-eclampsia
- history in previous pregnancy
- CKD
- SLE, APS
- diabetes
- chronic HTN
what is used in later pregnancy and for how long to reduce risk of pre-eclampsia
75-150mg aspirin from 12 weeks until delivery
If they have 1 high risk factor or 2 moderate risk factors
moderate risk factors for pre-eclampsia
- first pregnancy
- age 40+
- preg interval 10+ years
- BMI 35+
- FH pre-eclampsia
- multiple pregnancy
what level is low PAPP-A
0.4 MoM or below at combined screening test
what should be offered if PAPP-A is low
aspirin 75mg and growth USS at 30 and 36 weeks
how is mild gestational HTN managed
BP measured once a week and do urine dip
how is moderate gestational HTN managed (150/100-159/109)
oral labetalol
BP measured twice a week and protein dip
bloods
how is severe HTN managed (160/110 or higher)
ADMIT TO HOSPITAL until bp under this
- oral labetalol until below 150/100
- BP QDS
- daily protein dip
- bloods at presentation then weekly
how should a woman with pre-eclampsia be managed from 37 weeks
- oral labetalol
- admit for induction
- 4 hourly BP
- fluid balance
- minimum BD CTG
loading dose of magnesium sulphate for eclampsia
IV over 25 mins of 25ml of 20% 60ml/hour
dose of maintenance magnesium sulphate for eclampsia
1g/hour of 20% at 5mls hourly
classification system for AUB
FIGO system for non-gravid women of reproductive age
what type of bleeding do polyps cause
light IMB
type of bleeding with adenomyosis
heavy bleeding with pain
findings of adenomyosis on examination
bulky (6 week pregnant size) uterus - soft and doughy
symptoms of intramural fibroids (grow into myometrium)
heavy bleeding and pain (similar to adenomyosis)
symptoms of sub-serous fibroids (growth outside of uterus)
pressure on surrounding organs - urgency, frequency, constipation, pelvic pain
symptoms of sub-mucosal fibroids (protrude into uterus)
spotting to heavy bleeding
complex endometrial hyperplasia is
hyperplasia - non-equal ratio of glands to stroma
30% chance will progress to malignancy within 10 years
bloods to do in heavy menstrual bleeding
FBC
TFTs
clotting
histology of cervical ectropion
columnar epithelium of endocervix protrudes out through external os to vaginal portion of cervix and undergoes squamous metaplasia - transforms to stratified squamous epithelium
indistinguishable from cervical cancer so further testing is required
how can you treat cervical ectropion
silver nitrate
how does tamoxifen affect risk of endometrial cancer in post-menopausal vs pre-menopausal women
pre-menopausal = protective and inhibits endometrial growth
post-menopausal = stimulates uncontrolled growth = adenocarcinoma?
post-menopausal cut off for size of endometrium
4.5mm thick
how to manage endometrial hyperplasia if wanting to retain fertility
progesterone treatment with regular follow up
red flag features needing referral to gynae
PCB, PMB, IMB
uterus >10 week size or uterine cavity >10cm length
FBC indicating anaemia
what can hep B cause in pregnancy
hepatic cirrhosis of the neonate - neonate immunised after birth
what is a thick nuchal translucency indicating increased probability of having Down’s syndrome
> 3.5mm
when is the anatomy scan done
18-20+6 - also determines location of placenta
when are anti-D injections given if mother is Rh -ve and foetus is +ve
28 and/or 34 weeks
is twins 1 or 2 parity
1
what is Goodell’s sign
softening of the cervix (4-6 weeks pregnant)
What is Chadwick’s sign
blue discolouration of cervix and vagina due to engorgement of pelvic vasculature - 6 weeks
what is Hegar’s sign
softening of the isthmus - 6-8 weeks
what can be seen via TV USS and when
5 weeks = gestational sac visible
6 weeks = foetal pole
7/8 weeks = foetal heartbeat
when can pregnancy be seen via abdominal USS
6-8 weeks
how much do leukocytes increase in pregnancy
5000-12000/uL in pregnancy and up to 25000/uL in labour/postpartum
often means there is an improvement in autoimmune conditions
when should gestational thrombocytopenia normalise
2-12 weeks post delivery
why is some glycosuria normal in pregnancy
increased GFR by 50% = glucose reabsorption can be surpassed
levels of oestrogen and progesterone in pregnancy
both increased - progesterone produced by corpus luteum for the first 7 weeks then switches to placenta
cortisol levels in pregnancy
raised (total and free)
what is prolactin stimulated by
increasing oestrogen during pregnancy
when do APH occur
from 20 weeks until birth
what can a large pressure in uterus due to blood (placental abruption) lead to
blood extension into myometrium (couvelaire uterus) leading to internal rupture, contraction and postpartum haemorrhage
sign of placental abruption
- PV bleeding
- constant abdo pain
- uterine tenderness/woody
- maternal shock signs
- DIC (bleeding from drip sites and bruising)
investigations for placental abruption
- FBC, U&E, LFT
- group and save + cross match 4-6 units of blood
- coagulation screen
- fibrinogen levels (depressed = severe coagulopathy?)
- Kleinbauer-Betke test
what level of fibrinogen suggests severe placental abruption
<200mg/dl (2g/l)
what does Kleihauer-Betke test do
detects percentage of foetal blood in maternal circulation = shows correct dose of anti-D for Rh-ve mothers
causes of placental abruption
- FA deficiency
- smoking and cocaine
- gestational HTN and eclampsia
- thrombophilia
- PROM
- multiple pregnancy
- trauma
when can placenta praevia develop and where is the normal position of the placental edge
> 16 weeks
20mm or more from internal os
risk factors for placenta praevia (detected at foetal anomaly USS)
- older mothers
- smoking
- previous C/S (adhesion to scar)
- artificial reproduction
what is done if placenta is low-lying
follow up USS with TVS at 32 weeks to diagnose persistent low-lying/PP
use of cervical length measurement in PP
asymptomatic women with PP - if short lengths (<25mm) BEFORE 34 weeks = risk of preterm, emergency delivery and haemorrhage during C/S
bleeding in PP is
PAINLESS and bright red (oxygenated)
management of PP
steroids between 34+0 and 35+6 weeks
between 36-37 weeks can consider vaginal delivery if minor and head below leading edge
otherwise do C/S
order of invasiveness of placenta accreta
- placenta accreta
- placenta increta (deeper into myometrum)
- placenta percreta (through myometrium up to serosa and out of uterus)
how is placenta accreta managed
elective admission 34+ weeks with maternal steroids
C/S
risk of hysterectomy if PA and had a previous C/S
27/100
type 1 vasa praevia is
most common (90%) - abnormal insertion of umbilical cord into edge of placenta
type 2 (10%) is when foetal vessels connect lobes of placenta (succenturiate lobe)
what increases risk of vasa praevia
IVF
management of vasa praevia
30-32 weeks = hospitalisation
steroids from 32 weeks
C/S from 32/36 weeks
risk of scar rupture (uterine rupture) after 1 C/S with spontaneous births (VBAC)
1/200
but this increases 2-3x with induction and augmentation of labour
what happens if the mother has syphilis
needs to have received full treatment 4 weeks prior to delivery otherwise newborn will undergo IV therapy
what happens if the mother has hep B
notifiable, newborn has 5 doses vaccine
Hep Be antibody - / Be antigen + are at higher risk and newborn will require a dose of immunoglobulin at birth
how to use diaphragm
must be used with spermicide and left in for at least 6 hours after sex
can be inserted before sex as long as spermicide is applied at most 3 hours before sex (latex free)
when can’t the diaphragm be used
<6 weeks postpartum
when menstruating
Hx of TSS
disadvantages of diaphragm
- user dependent
- doesn’t provide reliable STI protection
- can predispose to cystitis
- weight gain, loss and postpartum can alter size and fit
at what level is bHCG positive
> =25IU/ml
role of HCG
maintains corpus luteum so can produce progesterone and oestrogen - decreases after 8-10 weeks gestation as placenta takes over production of oestrogen and progesterone
when to give anti-D after a complete miscarriage
if Rh-ve and over 12 weeks
medical management for miscarriage
mifepristone (anti progesterone) then misoprostol (prostaglandin) 24-48 hours later
= cervical ripening and myometrial contractions
complications of medical management for miscarriage
heavy bleeding
pain/nausea
5% chance retained POC/failure
2 types of surgical management for miscarriage and when to do them
- less than 12 weeks = MVA with LA
- >12 weeks = usually under GA
investigations into suspected ectopic pregnancy
- pregnancy test - negative test excludes ectopic
- TVUS - to confirm IUP
HCG levels in miscarriage vs ectopic
miscarriage = rapidly falling (halves every 48 hours) ectopic = slowly falling
bHCG levels in ectopic and outcomes
> 1500IU + no preg on TVUS = offered laparoscopy
<1500IU + no preg on TVUS and stable = another bHCG in 48 hours
medical management for ectopic
IM methotrexate + serum bHCG checked regularly and should then decrease by 15% over 4-5 days (if hasn’t, give dose again)
how to work out date of ovulation
total cycle length - 14 days
this is because the luteal (second) phase is always 14 days long but the follicular phase can vary
when would EC be needed for missed pills
2 or more missed pills in 1 week of a packet
UPSI in pill-free week or week 1
when should ullipristal acetate (EllaOne) be avoided in relation to progesterone containing pills
avoid UPA if progesterone containing hormone in past 7 days - use levonorgestrel of copper IUD
when is levonorgestrel less effective
when UPSI occurs around the time of ovulation - because it inhibits ovulation
when should dose of levonorgestrel be repeated / doubled
repeated if vomits within 2 hours of dose
double if BMI >26 or >70kg of patient on enzyme inducing drug
which pill EC is more effective around ovulation
UPA (EllaOne)
when should UPA EllaOne NOT be used
can’t use with enzyme inducers (but can use levonorgestrel but double dose)
how long should breastfeeding be avoided for after using UPA
a week after taking
when can UPA effectiveness be altered in relation to progesterone
can be reduced if progesterone is taken 7 days before UPA and 5 days after UPA
when does oral EC become ineffective
after ovulation
when can hormonal contraception be started after levonorgestrel/UPA
levonorgestrel = immediately UPA = 5 days
what is the decidua
thick layer of modified mucous membrane that lines the uterus during pregnancy and is shed in the afterbirth (part of endometrium)
when does bHCG reach 25IU/ml in urine (when preg test is positive)
4 weeks after LMP
at which week does placenta take over perfusion (from corpus luteum)
12 weeks
how is the biophysical profile of the foetus scored
+2 points for good breathing (does some practice breaths), good movements, foetal tone and normal amniotic fluid volume
how can placental insufficiency cause less amniotic fluid
less blood to kidney of baby = wee less
2 things umbilical dopplers measure
waves on USS screen to form:
- pulsatility index (PI)
- resistance index (RI)
when can PI and RI be high in doppler
pre-eclampsia - because placenta isn’t anchored well to uterine wall so increases BP to get through sieve
what does it mean if there is blood reversal to baby during diastole shown on the doppler
very concerning and baby needs to be delivered
pH and bacteria in normal vagina vs in bacterial vaginosis (BV)
- normal pH <=4.5, BV pH >4.5
- normal = lactobacilli predominant, BV = anaerobes dominant (fewer lactobacilli)
risk factors for BV (50% asymptomatic)
- vaginal douching
- receptive cunnilingus
- smoking
- black ethnicity
- STI or PID
- recent change sexual partner
3 complications of BV in pregnancy
- endometritis after birth
- PROM, preterm birth
- late miscarriage
advice for BV management
avoid douching and use of antiseptics
metronidazole 500mg BD for 5-7/7
treatment for BV in pregnancy
topical antibiotics
things to ask about in thrush history
- itching, soreness
- thick white vaginal discharge
- superficial dyspareunia
- erythema/fissuring of skin
advice for candida infections
- use soap substitute
- avoid tight clothes
- avoid local irritants
treatment for candida in pregnancy
clotrimazole 500mg pessary - CAN’T USE FLUCONAZOLE - CONTRAINDICATED
signs of trichomoniasis
- frothy yellow discharge 10-30%
- vulvitis and vaginitis
- strawberry cervix (2%)
general advice for TV infection
avoid sex for 1 week and until partners have completed treatment (metronidazole)
symptoms of chlamydia in females
- mostly asymptomatic
- dysuria
- PCB, IMB
- deep dyspareunia
- lower abdo pain
- mucopurulent cervix/discharge
NB: similar symptoms to gonorrhoea (but might be green discharge in gonorrhoea)
2 rarer complications of chlamydia
sexually acquired reactive arthritis (SARA)
perihepatitis
treatment for chlamydia if pregnant or breastfeeding (doxy contraindicated)
azithromycin: 1g PO stat and 500mg OD for 2 days after
general management of gonorrhoea infection
- always do a culture
- avoid sex for 1 week until self and partners have treatment
- test of cure done at 2 weeks after treatment
swabs for gonorrhoea in MSM
triple swab:
- urethral swab and urine
- throat swab
- rectal swab
symptoms of gonorrhoea in males
urethritis +/- yellow discharge in 80%
complications of gonorrhoea in males
- epididymo-orchitis
- proctitis
- disseminated gonorrhoea
3 physical treatments for genital warts
cryotherapy
excision
electrocautery
2 topical treatments for genital warts
podophyllotoxin
imiquimod
local and systemic symptoms of genital herpes
local = painful ulceration, dysuria, vaginal/urethral discharge
systemic = fever and myalgia
how is genital herpes diagnosed
viral PCR from active lesions
treatment of genital herpes
acyclovir
how is syphilis diagnosed
PCR
serology
dark ground microscopy
incubation period for primary syphilis
21 days (9-90 days)
signs of primary syphilis
- chancre: painful ulceration from single papule
- anogenital lesion: single, painless and indurated with clean base (non-purulent)
how long does it take for primary syphilis to resolve
3-8 weeks
secondary syphilis is
multi-system complication - 4-10 weeks after initial chancre
25% of untreated primary syphilis will develop this
type of rash in secondary syphilis
condylomata lata - highly infectious on perineum and anus
widespread, can be itchy, can affect palms and soles of feet
systemic effects of secondary syphilis
- hepatitis
- splenomegaly
- glomerulonephritis
- neurological complications: acute meningitis, cranial nerve palsies, uveitis, optic neuropathy, interstitial keratitis, retinal problems
early vs late latent syphilis
early = <2 years late = >2 years
how are primary, secondary and early latent syphilis treated
benzathine penicillin 2.4 MU in IM single dose
doxycycline if penicillin allergic
how is late latent, cardiovascular or gummatous syphilis treated
benzathine penicillin 2.3 MU IM weekly for 3 weeks in 3 doses
longer treatments for neurosyphilis/ophthalmic syphilis
main cause of balanoposthitis (inflammation of glans penis and prepuce)
candida infection
how are vulvar conditions/balanitis investigated
- swab for candida/bacterial culture
- HSV/syphilis PCR
- STI screen
- biopsy if still uncertain
when should OGTT be offered to a pregnant woman with previous GDM
ASAP after booking visit and again at 24-28 weeks if comes back as normal
diagnostic cut offs for fasting glucose and OGTT (GDM)
- fasting glucose >= 5.6mmol/L
- OGTT >= 7.8mmol/L
management of GDM if fasting glucose 5.6-7
diabetes appointment within a week, diet advice, self-monitoring
next = diet + exercise + METFORMIN
what should be done for GDM if glucose targets are still not within range 1-2 weeks after starting metformin
insulin - NB: start insulin STRAIGHT AWAY if fasting glucose >=7 or even if glucose is lower but evidence of macrosomia/polyhydramnios
can you use oral hypos in pregnant patients with pre-existing diabetes
no - only metformin/insulin
What should be done in terms of management of women with GHTN at 140-159 BP?
a) . Admission
b) . Antihypertensives
c) . Target BP once on hypertensives
d) . How often BP and urine dip is done
a) . No admission needed
b) . If BP remains above 140/90 then prescribe antihypertensive
c) . Target BP is 135/85 mmhg
d) . BP and urine dip done once to twice weekly until below 135/85mmHg
How should women be managed with severe GHTN (>160/110mmHg)
- ADMISSION: for monitoring and antihypertensive until BP is lower than 160/110mmHg
- Aim for BP 135/85mmHg
- Offer antihypertensive to all women
- BP measured every 15-30 minutes until less than 160/110mmHg
- Urine dip daily whilst admitted
- Bloods: on admission and weekly
- CTG at diagnosis and then if clinically indicated
How are women who have had GHTN managed after birth
- Measure BP daily for first 2 days after birth
- Once between days 3 and 5 postpartum - Continue hypertensive if needed- switch off methyldopar
- Follow up with GP 2 weeks post birht
- Write up a care plan:
- Who will follow up
- Who and when might Anti HTN stop
- how regular BP will be monitored
target BP for pregnant women with chronic hypertension
135/85
offer aspirin 75-150mg daily from 12 weeks gestation - also for those with pre-eclampsia
why should methyldopa be stopped postnatally (3rd line med for GHTN)
higher risk of postnatal depression
when are dopplers usually done for pre-eclampsia
34 and 36 weeks
How are women with BP <160/110 managed with pre-eclampsia
- Usually outpatient
- BP every 48 hours in ANDU
- Bloods: FBC, LFT’s and renal function 2/7 in ANDU
- Don’t need to dip urine regularly unless change of symptoms
- Safety netting advice: symptoms develop
- Repeat ultrasounds every 2 weeks
- Anti hypertensive: Labetalol
usually induction at 37 weeks
How are women with BP >160/110 managed with pre-eclampsia
- ADMITTED
- BP every 15-30 minutes until BP is lowered
- Labetalol
- Bloods: FBC, renal function + LFT’s: 3/7
- Ultrasound every 2 weeks
usually induction at 37 weeks
what investigation not to forget in eclampsia
blood glucose - differential/reversible cause
dose of magnesium sulphate for bolus and then maintenance - for eclampsia
bolus = 4g in 100ml of 0.9% saline
maintenance = 1g hourly for 24 hours
common complication of pre-eclampsia
placental abruption
how is stillbirth managed in future pregnancies
woman induced a week BEFORE previous stillbirth occurred
management of stillbirth
- Labour induced using prostaglandins +/- oxytocin
- Occasionally C/s of unwell - Can choose to continue pregnancy- 30% will spontaneously deliver within 3 weeks
- Ecouraged to hold baby:
- Make footprints, handprints - Cabergoline to suppress lactation
- Community follow up: GP
- Parent groups: SANDS
- follow up with consultant
what should be done by week 4 of intrauterine death
platelets measured: 1 in 4 risk of developing coagulopathy
investigations for recurrent miscarriages
- Karyotyping of both partners
- USS of uterus
- high vaginal swab - BV?
- antiphospholipid antibodies assay
- Kleihauer test
- post partum examination of foetus
risk of emergency C/S in VBAC
25% - also increased risk of infection and 1 in 200 chance of uterine scar rupture
what antibiotic is given for PPROM
erythromycin 250mg QDS 10 day course or until labour
when are corticosteroid injections given in PPROM
24-33+6 weeks (consider up to 35+6)
dexamethasone 12mg every 12 hours
what is administered if PPROM occurs and woman is going into labour
IV MgSO4 - neuroprotective for foetus
what is done I asymptomatic bacteriuria is found in pregnancy
send repeat sample
if still positive = 7 day course amoxicillin
when can trimethoprim and nitrofurantoin not be used in pregnancy
1st trimester = trimethoprim
3rd trimester = nitrofurantoin (neonatal haemolysis)
antibiotics used for chorioamnionitis
cefuroxime and metronidazole
what antibiotic is used for GBS prophylaxis
intrapartum IV pen V (benzylpenicillin) 3g loading dose then 1.5g every 4 hours until delivery
cefuroxime or vancomycin if penicillin allergic
what is important to ask patients when screening for HIV
have they had any blood transfusions
what might a HIV antibody-antigen test reveal in the acute period (2-6 weeks after infected)
p24 Ag positive but antibody negative = VERY INFECTIOUS DURING THIS PERIOD
how long does the chronic/asymptomatic HIV stage last
often 5-10 years
non-specific symptoms of advanced HIV
- fevers
- lymphadenopathy
- fatigue
- weight loss
- diarrhoea
3 advanced-HIV defining illnesses
- pneumocystitis pneumonia
- Kaposi’s sarcoma
- candida oesophagi’s
which cancer is more common in advanced HIV
B cell lymphoma
aim of HAART
undetectable viral load
which drugs can interact with HIV therapy
- steroids
- statins
- anti-anxiety/sedatives
- anticoagulants
- chemo drugs
- anti-TB drugs
- recreational drugs
- antacids and multivitamins
when can the p24 antigen be detected vs HIV antibody
p24 antigen = 2-4 weeks post-exposure
HIV antibody = 4-8 weeks post-exposure
3rd vs 4th generation HIV tests
3rd generation = antibody test - can detect after 12 weeks
4th generation = Ab/Ag test - can detect after 4 weeks
rapid care HIV test vs HIV test II
rapid care = bedside, no needle, result available immediately, but some 3rd gen = only work after 12 weeks, need to confirm if comes back positive
HIV test II = venous blood sample, result not instant, 4th gen test (4 weeks), positive result = can tell patient
when can patients on HAART be virally suppressed enough that the risk of transmission is zero
- stay on treatments 1-6 months
- stay on another 6 months
when is PrEP given
to HIV-negative people
before, during and after sex
what is PEPSE (PEP)
HIV meds taken after high risk sex/esposure - within 72 hours (ideally 24 hours)
take for 28 days
how can HIV be prevented in mother-child transmission
- routine antenatal screening
- PEP for baby 4 weeks post birth
- formula feeding
contraindications to HRT
- Any undiagnosed vaginal bleeding
- Current/past breast cancer
- Any oestrogen sensitive cancer
- Untreated endometrial hyperplasia
3 things which can treat vasomotor symptoms of menopause
duloxetine
venlafaxine
citalopram
4 RELATIVE contraindications to IoL
- previous C/S
- breech presentation
- prematurity
- high parity
when would membrane sweep be offered - nulliparous vs multiparous women
nulliparous = 40 and 41 week appointment
multiparous = 41 week appointment
3 types of prostaglandin pessaries
- Propess: dinoprostone 10mg over 24 hours
- prostin gel: dinoprostone 1mg/2mg over 6 hours
- prostin tablet: dinoprostone 3mg over 6 hours
where is oxytocin secreted from
posterior pituitary gland - causes myometrial muscle contractions of the uterus
exogenous oxytocin used to induce labour
syntocinon - can cause hyper stimulation of uterus = can compress placenta/cord leading to foetal hypoxia and distress
what can be used to reduce the rate of uterine contractions
tocolytic e.g. terbutaline
how to maintain confidentiality whilst contact tracing for STIs
no requirement to give name, address or GP details
can use number rather than name on patient samples in some services/clinics
standard ST screening tests
- chlamydia and gonorrhoea: NAAT
- urine vs vulvovaginal swab
- HIV
- syphilis
tailored screen for MSM
standard tests plus:
- 3 site testing for chlamydia and gonorrhoea: in urine, rectum and pharynx
- hep B and C serology screening
when can CHC (COCP, patch, ring) be commenced postpartum but not breastfeeding vs breastfeeding
not breastfeeding = day 21
breastfeeding = 6 weeks
which drugs can CHC interact with
enzyme inducing drugs:
- carbamazepine
- phenytoin
- rifampicin
- St John’s wort
- antiretroviral medication
use additional contraception while taking and 4 weeks after
pros and cons of Nuvaring
- low incidence of breakthrough bleeds
- avoidance of first pass metabolism = fewer reactions
- vaginitis
- vaginal discharge in 5%
what is there a higher risk of if the woman is high parity and has low interpregnancy intervals
PPH (poorer contractions)
1st and 2nd degree tear
- 1st degree = tear of vaginal wall
- 2nd degree = tear of vaginal wall and perineal muscles
3a, b and c degree tear
- 3a = less than 50% of external anal sphincter
- 3b = more than 50% of external anal sphincter
- 3c = internal anal sphincter involved
4th degree tear
involves anal mucosa
how are pregnant women with high BMI advised to control weight
stay at same weight - shouldn’t try to lose weight during pregnancy
can you fit an IUD/IUS into someone with long QT syndrome
no - could worsen arrhythmia during fitting
when can the IUD/IUS be fitted
Once excluding implanted pregnancy:
- If menstruating
- no sex since menstruation
- Using another reliable method
- No sex in last 3 weeks and pregnancy test negative
what must be done if a woman becomes pregnant whilst using an IUD
- assess whether ectopic (1 in 20 if IUD)
- can continue with pregnancy but higher miscarriage rate
- remove device if before 12 weeks if threads can be seen (reduce miscarriage)
4 contraindications for nexplanon
- current breast cancer
- current enzyme inducers
- post CVA (Stroke/TIA)
- severe cirrhosis, hepatoma
is the contraceptive injection affected by enzyme inducers
NO
how often is depo proverb vs sayana press given
depo provera = 12 weekly IM
sayana press = 13 weekly SC self injection
both effective for 14 weeks
definition of a maternal death
Death of woman whilst pregnancy or within 42 days of end of pregnancy (including birth, ectopic, termination, miscarriage) from any cause related to or aggravated by pregnancy/management
BUT not from accidental or incidental cause
late maternal death = between 42 days and 1 year after end of pregnancy
what is a coincidental/ fortuitous maternal death
death from unrelated cause during pregnancy e.g. RTA
what effect does an underlying thrombophilia have on pregnancy
- increased risk PE/DVT
- increased risk pre-eclampsia (little clots in placenta)
- increased risk miscarriage (clots in placenta)
how are thrombophilias managed during pregnancy
LMWH up until 6 weeks postpartum
BUT can’t have a dose within 12 hours of epidural or spinal anaesthesia!!
effects of congenital bicuspid aortic valve disease on pregnancy
- no ability to increase SV (normal in pregnancy) so can only increase CO by increasing HR
- high risk of decompensation and HF
- labour and contractions = increased CO and lots of exertion - dangerous
- in 3rd stage = auto transfusion of blood in uterus back into circulation - causes fluid shift = dangerous
how can risks of congenital bicuspid aortic valve in pregnancy be mitigated
- regular cardiology review with echo
- early epidural to reduce pain = HR stays down
- avoid large fluid boluses
- shorten 2nd stage of labour - forceps after 15/20 mins
impact of beta blockers in pregnancy
neonatal hypoglycaemia and IUGR risks
how is epilepsy managed during pregnancy
preconceptual folic acid 5mg daily
latent vs active 1st stage of labour
- latent 1st stage = onset of mild irregular contractions to 3-4cm dilation
- active 1st stage = 3-4cm dilated to full dilation (!0cm)
when does labour become prolonged
if stage 2 is greater than 2-3 hours
how long is prolonged labour in nulliparous women
> 2 hours active pushing
how long is prolonged labour in multiparous women
> 1 hour active pushing
lie of baby in normal labour
longitudinal
also cephalic, occipitoanterior
what is vertex presentation
cephalic presentation - head sharply flexed and chin touching chest (normal)
what is military presentation
cephalic presentation - foetus looking straight ahead, chin not tucked touching chest
what is brow presentation
cephalic presentation - foetus head extended rather than flexed = oedema and bruising of face
what is face presentation
cephalic presentation - neck sharply extended and back of head is arched to foetal back
what does an increase in oestrogen towards end of pregnancy lead to
increased prostaglandins = labour (myometrial stimulation and cervical ripening)
also helps make more oxytocin receptors = myometrium more sensitive to oxytocin
what drug can be used in 3rd stage of labour
syntometrine
2 non-pharmacological managements used in active 3rd stage of labour
- deferred clamping and cutting of cord (reduced risk of neonatal anaemia) >1 minute
- controlled cord traction - gentle traction of cord whilst counter pressure above pubic bone to guard uterus
definition of an antepartum haemorrhage
bleeding from genital tract AFTER 24 WEEKS - before = threatened miscarriage
how to optimise airway in obstetric emergencies
LL position
high flow oxygen
how should foetus be assessed in an APH
- look at 20 week scan for any placenta praevia or abnormalities
- CTG
- bloods
what is important to note about hypotension in post/antepartum haemorrhage
young women will compensate well - hypotension is a LATE sign (often after losing 2000ml of blood)
when would vasa praevia present
spontaneous/artificial rupture of membranes - accompanied by painless fresh vaginal bleeding (placenta praevia is also painless)
4 Ts of PPH
- tone
- trauma
- tissues (RPOC)
- thrombin
how is an atonic uterus managed
- ergometrine: IV bolus
- syntocinon infusion
- consider prostaglandins if no response
- laparotomy?!
what liver enzymes are elevated in HELLP syndrome
ALT and AST
not ALP - also produced by placenta
do you give fluids in eclampsia
NO- stroke risk?
antidote for magnesium sulphate (eclampsia)
calcium glutinate
3 initial VTE investigations in pregnancy
- ABG
- CXR
- ECG (tachycardia)
2 definitive investigations for VTE in pregnancy
- compression doppler
- V/Q scan
don’t do D-dimer - raised anyway
treatment of PE in pregnancy
- LMWH - tinzaparin BD in 2 doses according to weight
- collapse? = thrombolysis with alteplase
what is often seen on CTG with uterine rupture
sudden bradycardia
how is uterine inversion managed
- attempt manual replacement
- O sulliven technique - fill uterus via vagina with warm saline
which contraceptives take 7 days to work
IUS (mirena)
COCP
depo provera
nexplanon
when are the 1st and 2nd doses of anti-D given to rhesus negative women
28 and 34 weeks
what investigations should be carried out for suspected PID
- preg test
- urine dipstick + MSU
- temp
- NAAT from vulvovaginal swab for chlamydia, gonorrhoea and trichomonas
- endocervical swab for gonorrhoea culture
- bloods for HIV and syphilis
- consider FBC, ESR/CRP, LFTs
5 complications of PID
- Tubal factor infertility
- Chronic dyspareunia, pelvic pain in 18%
- Ectopic pregnancy
- Peri-hepatitis (Fitz High Curtis syndrome)
- Tubo-ovarian abscess
explaining PID to a patient
- 25% from STI - no STI doesn’t rule it out
- easy to treat but can have serious problems if untreated
- most can go on to become pregnant
- NO SEX until they and partner have completed treatment
what Abx would also cover mycoplasma genitalium in PID
moxifloxacin 400mg OD for 14 days
what should partner of PID patient be treated with
doxycycline 100mg BD for 7 days
findings of endometriosis on USS
endometriomas (not common) so need to do laparoscopy
management of chronic pelvic pain (6+ months duration)
- Transvaginal scan
- Trial of OCP/GnRH analogues for 3-6 months or IUD mirena
- Antispasmoics (buscopan), analgesia, referral to pain clinic
- Laparoscopy: 50% are negative so consider implications
why is warfarin (usually) not safe in pregnancy and breastfeeding
- stillbirth
- premature birth
- haemorrhage
- ocular defects
foetal warfarin syndrome
features of foetal warfarin syndrome
- nasal hypoplasia
- hypoplasia of extremities
- developmental delay
standard dose of syntocinon (synthetic oxytocin) for PPH
bolus of 5 units IV
given as infusion
IM if there is no IV access
what is syntometrine and what is the dose
3rd stage management
combination of oxytocin 5 units and ergometrine 500mcg IM bolus
which medications can cause a chemical menopause
GnRH analogues - Prostap, Gonapeptyl
why should NSAIDs be avoided in pregnancy
1st trimester = miscarriage and malformation
3rd trimester = premature closure of ductus arterioles
2 Abx used in chorioamnionitis
- cefuroxime 1.5g TDS IV
- metronidazole 500mg TDS IV
antibiotics used in endometritis (including penicillin allergy)
co-amoxiclav
clindamycin + metronidazole
why can’t ARBs and ACEis be used in pregnancy
foetal renal damage in 2nd and 3rd trimester
what is involution
fundus of uterus goes below umbilicus immediately after birth and then is no longer palpable after 2 weeks
at what level Hb would oral iron vs blood transfusion be given postnatally
80-100 = oral
<80 and symptomatic = blood transfusion
NB: if symptomatic but Hb not low enough for transfusion = IV iron?
what is endometritis (postnatal)
infection within uterus - from day 2-10
- fever, headache, pain
- secondary PPH
- offensive lochia
why is USS not used at first for postnatal endometritis
hard to tell difference between blood clots and placental tissue
most common organism causing endometritis
group A strep
antibiotics given for endometritis
co-amoxiclav OR
cefuroxime + metronidazole
where do 90% of DVTs in pregnancy occur and why
LEFT LEG above knee
because right common iliac goes over left vein and is more compressed by arteries as well as uterine compression
how common is baby blues vs PND
baby blues = 75%
PND = 10-15%
puerperal psychosis = 1 in 500
how to work out fertile window
subtract 19 and 11 days from cycle length - period between
variable cycle length = 11 days off longest cycle and 19 days off shortest cycle
how much vit D to take daily preconception
10mcg
normal LH and FSH levels
FSH = <8 LH = <10
what does sex-binding globulin do
carries testosterone around the body
what is anti-mullerian hormone a measure of
ovarian reserve - number of follicles left
in which 2 groups of women is anti-mullerian hormone v high
PCOS
younger women
what is Kallman syndrome
children born without neurones needed to secrete GnRH = group I anovulation
also often have loss of taste and smell (neurones develop from olfactory nerve)
cyst characteristics in PCOS
must be under 9 cysts each 2-9mm
type of cancer increased in PCOS
endometrial cancer
fertility treatment in PCOS if ovulation is detected
await natural conception - IVF if no pregnancy after 6-9 months
fertility treatment in PCOS if ovulation is NOT detected
- assessment, lifestyle advice if overweight
- clomiphene or letrozole given in pulses
- gonadotrophins OR clomiphene + metformin OR laparoscopic ovarian diathermy
2 diagnostic criteria for premature ovarian insufficiency (group III ovulation disorder)
- oligo/amenorrhoea 4+ months
- elevated FSH level >25IU/L on 2 occasions >4 weeks apart
2 genetic causes of group III ovulation disorder
turner syndrome
fragile X
what size fibroids can lead to sub fertility
> 4cm
3 investigations into pelvic pathology for subfertility
- hysterosalpingography
- hysterosalpingo-contract ultrasonography (HyCoSy)
- laparoscopy
how are sperm assessed
sample counts of 2, 2-3 days apart first thing in morning
lower limits of normal for different sperm factors
total sperm number = 39 million
concentration = 15 million/ml
vitality = 58%
progressive motility = 32%
total motility = 40%
normal morphology = 4%
questions to ask in a male fertility assessment
- History of surgery to testes or hernia repairs
- History of mumps orchitis
- Any swelling of testes
- Any history of STI’s
- Any history of chemo/radiotherapy
- Any history of vasectomy/reversal
- General health: sarcoidosis, TB, DM, Obesity, CF
- Drugs: prescribed and non-prescribed
- Lifestyle occupation, smoking and alcohol
what drug can cause (often irreversible) male infertility
anabolic steroids - synthetic testosterone inhibits endogenous testosterone and therefore sperm production
when is IVF recommended if infertility remains unexplained
after 2 years trying
what medications are given during IVF
- exogenous high dose gonadotrophins = multi follicular recruitment
- GnRH analogues - to prevent premature endogenous LH surge
symptoms of mild ovarian hyperstimulation syndrome (OHSS)
- mild abdo pain and bloating
- ovarian size <8cm
symptoms of moderate OHSS
- abdo pain
- N+V
- USS = ascites
- ovarian size 8-12cm
symptoms of severe OHSS
- clinical ascites +/- hydrothorax
- oliguria
- haematocrit >0.45
- hyponatraemia, hyperkalaemia
- hypoproteinaemia
- ovarian size >12cm
symptoms of critical OHSS
- tense ascites, large hydrothorax
- haematocrit >0.55
- WCC >25,000
- oliguria/anuria
- thromboembolism
- ARDS
enzyme enducers which interact with combined hormonal contraceptives
- Some antiepileptics: carbamazepine, phenytoin, phenobarbitone
- Rifampicin
- Some antiretrovirals used in HIV: ritonavir
- St john’s wort
TOP - manual vacuum aspiration:
a) . When can it take place
b) . When does examination of aspirate need to be done
c) . How can it be done between 14-16 weeks
a) . Can take place up to 14 weeks
b) . Needs examination of aspirate when under 7 weeks to confirm complete abortion
c) . Between 14-16 can be done with large-bore cannula and suction tubing
at how many weeks is dilation and evacuation used for TOP
over 14 weeks = needs continuous US guidance
how is the cervix prepared before 14 weeks gestation (TOP)
misoprostol 400mcg PV 3 hours prior to surgery or sublingually 2-3 hours before
how is the cervix prepared after 14 weeks gestation (TOP)
osmotic dilators
but can still give misoprostol up to 18 weeks as an alternative
anaesthesia for TOP
- LA (cervical block)
- conscious sedation: fentanyl + midazolam
- GA
medical abortion <=49 days
200mg oral mifepristone followed by 400mcg oral misoprostol 24-48 hours later
medical abortion <=63 days
200mg oral mifepristone followed by 800mcg PV/buccal/sublingual misoprostol 24-48 hours later
might need second misoprostol 400mg dose PV/PO if no abortion after 4 hours of misoprostol
Abx prophylaxis recommended for surgical and medical abortions
1g azithromycin + 800mg metronidazole
why do FSH and LH levels increase in menopause
falling levels of oestrogen due to ovarian failure = anterior pituitary releases more FSH and LH in an attempt to raise oestrogen
for which type of HRT must the woman be post-menopausal (age >54 or amenorrhoea >1 year)
continuous combined HRT - no bleed
when is tibolone useful as HRT
women with low libido
3 conditions HRT helps reduce the risk of
- osteoporosis (fragility fractures by 30%)
- dementia
- colorectal cancer
which combined HRT increases endometrial cancer risk
sequential combined (not continuous combined)
what can vaginal atrophy in postmenopausal women cause
urinary frequency and STIs
physiotherapy for urge/stress incontinence
pelvic floor exercises - 8+ contractions 3 times a day for 3 months
what should be done after physiotherapy for urge incontinence
bladder diary 3+ days
bladder drills
oxybutynin?
what is important to do when suffering from urge incontinence
sufficient water intake - more concentrated urine will cause bladder to be even more irritated
why can menopause lead to greater risk of urge and stress incontinence
- urge - lack of oestrogen = bladder and vaginal atrophy = more at risk of overactive bladder and UTIs
- stress - reduction in oestrogen and collagen = weaker pelvic floor
3 side effects of anticholinergics (e.g. oxybutynin)
- dry mouth
- constipation
- blurred vision
after 3 month follow up for stress incontinence what can be done
urodynamic study: 1 in 10 will actually have urge incontinence
4 treatments for urge incontinence (after oxybutynin etc doesn’t work)
- cystoscopy + botox (reduce detrursor activity)
- percutaneous sacral nerve stimulation
- augmentation cystoplast
- urinary diversion
how are pelvic organ prolapses graded
Baden-walked systm
0: normal position
1: Descent half way to hymen
2. Descent to the hymen
3rd: Descent halfway past hymen
4th: Maximum descent possible (procidentia)
3 downsides of pessaries
- have to come into fit
- can’t have sex
- low adherence: ulceration
what does a score of 4+ in VTE assessment merit
tinzaparin (LMWH) from 1st trimester and consider after post-natal assessment for 6 weeks postpartum
what does a score of 3 in VTE assessment merit
LMWH from 28 weeks
what should be considered if there is a VTE score of 2 postnatally
LMWH for at least 10 days
contraindications/cautions to LMWH use in pregnancy
- Known active bleeding disorder: haemophilia, vWd, acquired coagulopathy
- Active antenatal/postnatal bleeding
- Women at increased risk of major haemorrhage: placenta praevia
- Acute stroke in previous 4 weeks: haemorrhagic or ischaemic
- Severe renal disease (eGFR <30)
- Severe liver disease
- Uncontrolled HTN: BP >200/120 mmHg
