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Year 4 revision > GOSH revision > Flashcards

GOSH revision Flashcards

1
Q

normal variation in a CTG

A

5bpm or more

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2
Q

3 steps to assess contractions

A
  • frequency (count number in 10 minute period)
  • duration: how long do they last
  • intensity (NOT from CTG - palpate the uterus)
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3
Q

5 causes of foetal tachycardia (>160)

A
  • foetal hypoxia
  • chorioamnionitis
  • hyperthyroidism
  • foetal/maternal anaemia
  • foetal tachyarrhythmia
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4
Q

5 causes of foetal bradycardia (<100)

A
  • prolonged cord compression
  • cord prolapse
  • epidural/spinal anaesthesia
  • maternal seizure
  • rapid foetal descent
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5
Q

what indicates severe hypoxia in a foetus

A

severe prolonged bradycardia (80bpm for >3 mins)

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6
Q

non-reassuring variability is

A
  • <5bpm for 30-50 mins

- >25bpm for 15-25 mins

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7
Q

abnormal variability is

A
  • <5bpm for >50 mins

- >25bpm for >25 mins

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8
Q

5 causes of reduced variability

A
  • sleeping (<40 mins)
  • foetal acidosis due to hypoxia - more likely if late decelerations
  • drugs (opiates, benzos, methyldopa, mag sulphate)
  • prematurity
  • congenital heart abnormalities
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9
Q

typical vs atypical deceleration

A

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

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10
Q

3 causes of late decelerations

A
  • maternal hypotension
  • pre-eclampsia
  • uterine hyperstimulation

hypoxic and acidotic :(

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11
Q

what does a sinusoidal pattern indicate

A

severe foetal hypoxia/severe foetal anaemia/foetal or maternal haemorrhage

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12
Q

5 things to do if worried about CTG

A
  • 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
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13
Q

when should foetal blood sample be done

A

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

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14
Q

difference between parity a and parity b

A
  • parity a = number of pregnancies where foetus reaches 24 weeks (includes stillbirths)
  • parity b = number of pregnancy losses before 24 weeks
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15
Q

advice given in the booking visit

A
  • FA supplementation for 12 weeks
  • food hygiene (no raw milk/cheese)
  • stop smoking, alcohol,. drugs, do exercise, healthy diet
  • antenatal screening advice
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16
Q

purpose of dating scan

A
  • 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
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17
Q

when is combined test carried out

A

11-13+6 weeks (at same time as dating scan)

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18
Q

3 results of combined test indicating Down’s syndrome

A
  • thickened nuchal fold (>35mm) - scan
  • raised hCG - blood test
  • lowered PAPP-A - blood test
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19
Q

when and what does the quadruple test

A

14-17 weeks if too late to do combined test

  • AFP
  • hCG
  • oestriol
  • inhibin A
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20
Q

what is a positive result of combined/quadruple and what to do after

A

> 1/150 chance

CVS at 11-14 weeks
amniocentesis at 15 weeks

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21
Q

3 possible NIPT test results a woman could get

A
  • positive = invasive test needed to confirm
  • negative = v likely not
  • inconclusive (4%) = test repeated
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22
Q

how is gestational age measured at 10-12 weeks at dating scan

A

if BEFORE 13 WEEKS = foetal CRL

after 13 weeks = biparietal diameter, head circumference, femur length

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23
Q

what can raised AFP indicate

A
  • open NTD
  • exomphalos
  • posterior urethral valves
  • GI obstruction
  • teratomas

IUGR, preterm, placental abruption, 3rd trimester death

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24
Q

what is PAPP-A and what do low levels indicate

A

glycoprotein made by placenta - low levels in 1st trimester indicate:

  • trisomy 13/18/21
  • pre-eclampsia
  • IUGR
  • preterm delivery
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25
Q

foods advised not to eat in pregnancy

A
  • 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?)
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26
Q

when does N+V usually occur in pregnancy

A

4-7th week and resolves by 20 weeks

if persists after the first trimester, think about hyperemesis

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27
Q

ABG result in hyperemesis gravidarum

A

hypokalaemic, hypochloremic metabolic alkalosis

also might have ketonemia, ketonuria, hyponatraemia

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28
Q

2 risks of hyperemesis

A
  • Wernicke’s encephalopathy

- increased risk VTE

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29
Q

1st line antiemetics for hyperemesis if lifestyle advice doesn’t work

A

antihistamine: cyclizine/promethazine /prochlorperazine

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30
Q

2nd line antiemetics for hyperemesis

A

metoclopramide/ ondansetron but don’t prescribe longer than 5 days

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31
Q

how are varicose veins managed in pregnancy

A

reassurance - normal and due to pressure on lower legs (no harm) - but can give compression stockings

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32
Q

1st line meds if lifestyle advice doesn’t help with heartburn

A

antacids/alginates (GAVISCON?) (magnesium and aluminium combinations on PRN basis)

calcium combinations short-term/occasional use (a.g. Alka-Seltzer)

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33
Q

what can be used if heartburn symptoms are severe/persist

A

PPI (omeprazole or lansoprazole)

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34
Q

when are haemorrhoids more common in pregnancy

A

after 1st trimester - so topical haemorrhoid cream is less likely to harm baby

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35
Q

triad of HG symptoms

A
  • > 5% pre-pregnancy weight loss
  • dehydration
  • electrolyte imbalance

from rise in hCG/rise in progesterone (decrease in gastric motility)

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36
Q

scoring system used to classify severity of HG

A

PUQE (pregnancy- unique quantification of emesis index)

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37
Q

3rd line antiemetics used in HG

A

corticosteroids - hydrocortisone at first the convert to prednisolone and taper down to lowest dose at which symptoms are controlled

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38
Q

definition of SGA

A

<10th centile

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39
Q

how is SGA or foetal growth assessed

A

ask about foetal movements (over 26 weeks)

estimated foetal weight and measurements via Stan

symphysis-fundal height

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40
Q

what can be measured to identify the ‘brain-sparing’ effect - baby undergoing hypoxia so blood is shunted to head to protect brain

A

if HC is much larger than AC

Doppler studies

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41
Q

what might larger AC than HC indicate

A

maternal diabetes - affects liver and fat stores

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42
Q

when should foetal movements be asked about

A

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

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43
Q

what should women unsure about reduction in foetal movements be advised to do

A

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

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44
Q

differences between symmetrical and asymmetrical growth restriction

A
  • symmetrical = early onset, asymmetrical = late onset

- symmetrical = associated with less catch up growth in first year vs asymmetrical (more catch up growth)

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45
Q

how can IUGR be prevented/monitored

A
  • 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
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46
Q

antenatal care aspects of twin pregnancies

A
  • 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
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47
Q

when to offer induction or C/S for multiple pregnancy

A

37-38 weeks

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48
Q

when might TTTS occur

A

monochorionic pregnancy (same placenta)

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49
Q

how to monitor and treat TTTS

A

monitor = USS every 2 weeks from 16/24 weeks to delivery

treatment = laser ablation of placental anastomoses, selective foeticide by cord occlusion :(

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50
Q

how would vaginal birth be managed in twins

A
  • 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
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51
Q

symptoms of pre-eclampsia

A
  • headache
  • visual disturbance
  • cerebral oedema
  • hyperreflexia
  • sustained clonus
  • stroke
  • seizures (eclampsia)
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52
Q

why does HELLP syndrome occur after pre-eclampsia

A

increased pressure in vessels = leaky

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53
Q

how are liver and kidneys affected by pre-eclampsia

A
  • liver - vasoconstriction of blood vessels decreases supply to liver = pain, raised ALT/AST >70
  • kidneys - reduced blood supply = proteinuria
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54
Q

strong risk factors for pre-eclampsia

A
  • history in previous pregnancy
  • CKD
  • SLE, APS
  • diabetes
  • chronic HTN
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55
Q

what is used in later pregnancy and for how long to reduce risk of pre-eclampsia

A

75-150mg aspirin from 12 weeks until delivery

If they have 1 high risk factor or 2 moderate risk factors

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56
Q

moderate risk factors for pre-eclampsia

A
  • first pregnancy
  • age 40+
  • preg interval 10+ years
  • BMI 35+
  • FH pre-eclampsia
  • multiple pregnancy
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57
Q

what level is low PAPP-A

A

0.4 MoM or below at combined screening test

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58
Q

what should be offered if PAPP-A is low

A

aspirin 75mg and growth USS at 30 and 36 weeks

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59
Q

how is mild gestational HTN managed

A

BP measured once a week and do urine dip

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60
Q

how is moderate gestational HTN managed (150/100-159/109)

A

oral labetalol
BP measured twice a week and protein dip

bloods

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61
Q

how is severe HTN managed (160/110 or higher)

A

ADMIT TO HOSPITAL until bp under this

  • oral labetalol until below 150/100
  • BP QDS
  • daily protein dip
  • bloods at presentation then weekly
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62
Q

how should a woman with pre-eclampsia be managed from 37 weeks

A
  • oral labetalol
  • admit for induction
  • 4 hourly BP
  • fluid balance
  • minimum BD CTG
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63
Q

loading dose of magnesium sulphate for eclampsia

A

IV over 25 mins of 25ml of 20% 60ml/hour

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64
Q

dose of maintenance magnesium sulphate for eclampsia

A

1g/hour of 20% at 5mls hourly

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65
Q

classification system for AUB

A

FIGO system for non-gravid women of reproductive age

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66
Q

what type of bleeding do polyps cause

A

light IMB

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67
Q

type of bleeding with adenomyosis

A

heavy bleeding with pain

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68
Q

findings of adenomyosis on examination

A

bulky (6 week pregnant size) uterus - soft and doughy

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69
Q

symptoms of intramural fibroids (grow into myometrium)

A

heavy bleeding and pain (similar to adenomyosis)

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70
Q

symptoms of sub-serous fibroids (growth outside of uterus)

A

pressure on surrounding organs - urgency, frequency, constipation, pelvic pain

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71
Q

symptoms of sub-mucosal fibroids (protrude into uterus)

A

spotting to heavy bleeding

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72
Q

complex endometrial hyperplasia is

A

hyperplasia - non-equal ratio of glands to stroma

30% chance will progress to malignancy within 10 years

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73
Q

bloods to do in heavy menstrual bleeding

A

FBC
TFTs
clotting

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74
Q

histology of cervical ectropion

A

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

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75
Q

how can you treat cervical ectropion

A

silver nitrate

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76
Q

how does tamoxifen affect risk of endometrial cancer in post-menopausal vs pre-menopausal women

A

pre-menopausal = protective and inhibits endometrial growth

post-menopausal = stimulates uncontrolled growth = adenocarcinoma?

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77
Q

post-menopausal cut off for size of endometrium

A

4.5mm thick

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78
Q

how to manage endometrial hyperplasia if wanting to retain fertility

A

progesterone treatment with regular follow up

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79
Q

red flag features needing referral to gynae

A

PCB, PMB, IMB

uterus >10 week size or uterine cavity >10cm length

FBC indicating anaemia

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80
Q

what can hep B cause in pregnancy

A

hepatic cirrhosis of the neonate - neonate immunised after birth

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81
Q

what is a thick nuchal translucency indicating increased probability of having Down’s syndrome

A

> 3.5mm

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82
Q

when is the anatomy scan done

A

18-20+6 - also determines location of placenta

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83
Q

when are anti-D injections given if mother is Rh -ve and foetus is +ve

A

28 and/or 34 weeks

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84
Q

is twins 1 or 2 parity

A

1

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85
Q

what is Goodell’s sign

A

softening of the cervix (4-6 weeks pregnant)

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86
Q

What is Chadwick’s sign

A

blue discolouration of cervix and vagina due to engorgement of pelvic vasculature - 6 weeks

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87
Q

what is Hegar’s sign

A

softening of the isthmus - 6-8 weeks

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88
Q

what can be seen via TV USS and when

A

5 weeks = gestational sac visible

6 weeks = foetal pole

7/8 weeks = foetal heartbeat

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89
Q

when can pregnancy be seen via abdominal USS

A

6-8 weeks

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90
Q

how much do leukocytes increase in pregnancy

A

5000-12000/uL in pregnancy and up to 25000/uL in labour/postpartum

often means there is an improvement in autoimmune conditions

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91
Q

when should gestational thrombocytopenia normalise

A

2-12 weeks post delivery

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92
Q

why is some glycosuria normal in pregnancy

A

increased GFR by 50% = glucose reabsorption can be surpassed

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93
Q

levels of oestrogen and progesterone in pregnancy

A

both increased - progesterone produced by corpus luteum for the first 7 weeks then switches to placenta

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94
Q

cortisol levels in pregnancy

A

raised (total and free)

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95
Q

what is prolactin stimulated by

A

increasing oestrogen during pregnancy

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96
Q

when do APH occur

A

from 20 weeks until birth

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97
Q

what can a large pressure in uterus due to blood (placental abruption) lead to

A

blood extension into myometrium (couvelaire uterus) leading to internal rupture, contraction and postpartum haemorrhage

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98
Q

sign of placental abruption

A
  • PV bleeding
  • constant abdo pain
  • uterine tenderness/woody
  • maternal shock signs
  • DIC (bleeding from drip sites and bruising)
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99
Q

investigations for placental abruption

A
  • FBC, U&E, LFT
  • group and save + cross match 4-6 units of blood
  • coagulation screen
  • fibrinogen levels (depressed = severe coagulopathy?)
  • Kleinbauer-Betke test
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100
Q

what level of fibrinogen suggests severe placental abruption

A

<200mg/dl (2g/l)

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101
Q

what does Kleihauer-Betke test do

A

detects percentage of foetal blood in maternal circulation = shows correct dose of anti-D for Rh-ve mothers

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102
Q

causes of placental abruption

A
  • FA deficiency
  • smoking and cocaine
  • gestational HTN and eclampsia
  • thrombophilia
  • PROM
  • multiple pregnancy
  • trauma
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103
Q

when can placenta praevia develop and where is the normal position of the placental edge

A

> 16 weeks

20mm or more from internal os

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104
Q

risk factors for placenta praevia (detected at foetal anomaly USS)

A
  • older mothers
  • smoking
  • previous C/S (adhesion to scar)
  • artificial reproduction
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105
Q

what is done if placenta is low-lying

A

follow up USS with TVS at 32 weeks to diagnose persistent low-lying/PP

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106
Q

use of cervical length measurement in PP

A

asymptomatic women with PP - if short lengths (<25mm) BEFORE 34 weeks = risk of preterm, emergency delivery and haemorrhage during C/S

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107
Q

bleeding in PP is

A

PAINLESS and bright red (oxygenated)

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108
Q

management of PP

A

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

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109
Q

order of invasiveness of placenta accreta

A
  1. placenta accreta
  2. placenta increta (deeper into myometrum)
  3. placenta percreta (through myometrium up to serosa and out of uterus)
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110
Q

how is placenta accreta managed

A

elective admission 34+ weeks with maternal steroids

C/S

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111
Q

risk of hysterectomy if PA and had a previous C/S

A

27/100

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112
Q

type 1 vasa praevia is

A

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)

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113
Q

what increases risk of vasa praevia

A

IVF

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114
Q

management of vasa praevia

A

30-32 weeks = hospitalisation

steroids from 32 weeks

C/S from 32/36 weeks

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115
Q

risk of scar rupture (uterine rupture) after 1 C/S with spontaneous births (VBAC)

A

1/200

but this increases 2-3x with induction and augmentation of labour

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116
Q

what happens if the mother has syphilis

A

needs to have received full treatment 4 weeks prior to delivery otherwise newborn will undergo IV therapy

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117
Q

what happens if the mother has hep B

A

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

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118
Q

how to use diaphragm

A

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)

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119
Q

when can’t the diaphragm be used

A

<6 weeks postpartum
when menstruating
Hx of TSS

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120
Q

disadvantages of diaphragm

A
  • user dependent
  • doesn’t provide reliable STI protection
  • can predispose to cystitis
  • weight gain, loss and postpartum can alter size and fit
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121
Q

at what level is bHCG positive

A

> =25IU/ml

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122
Q

role of HCG

A

maintains corpus luteum so can produce progesterone and oestrogen - decreases after 8-10 weeks gestation as placenta takes over production of oestrogen and progesterone

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123
Q

when to give anti-D after a complete miscarriage

A

if Rh-ve and over 12 weeks

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124
Q

medical management for miscarriage

A

mifepristone (anti progesterone) then misoprostol (prostaglandin) 24-48 hours later

= cervical ripening and myometrial contractions

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125
Q

complications of medical management for miscarriage

A

heavy bleeding
pain/nausea
5% chance retained POC/failure

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126
Q

2 types of surgical management for miscarriage and when to do them

A
  • less than 12 weeks = MVA with LA

- >12 weeks = usually under GA

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127
Q

investigations into suspected ectopic pregnancy

A
  • pregnancy test - negative test excludes ectopic

- TVUS - to confirm IUP

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128
Q

HCG levels in miscarriage vs ectopic

A 
miscarriage = rapidly falling (halves every 48 hours)
ectopic = slowly falling
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129
Q

bHCG levels in ectopic and outcomes

A

> 1500IU + no preg on TVUS = offered laparoscopy

<1500IU + no preg on TVUS and stable = another bHCG in 48 hours

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130
Q

medical management for ectopic

A

IM methotrexate + serum bHCG checked regularly and should then decrease by 15% over 4-5 days (if hasn’t, give dose again)

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131
Q

how to work out date of ovulation

A

total cycle length - 14 days

this is because the luteal (second) phase is always 14 days long but the follicular phase can vary

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132
Q

when would EC be needed for missed pills

A

2 or more missed pills in 1 week of a packet

UPSI in pill-free week or week 1

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133
Q

when should ullipristal acetate (EllaOne) be avoided in relation to progesterone containing pills

A

avoid UPA if progesterone containing hormone in past 7 days - use levonorgestrel of copper IUD

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134
Q

when is levonorgestrel less effective

A

when UPSI occurs around the time of ovulation - because it inhibits ovulation

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135
Q

when should dose of levonorgestrel be repeated / doubled

A

repeated if vomits within 2 hours of dose

double if BMI >26 or >70kg of patient on enzyme inducing drug

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136
Q

which pill EC is more effective around ovulation

A

UPA (EllaOne)

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137
Q

when should UPA EllaOne NOT be used

A

can’t use with enzyme inducers (but can use levonorgestrel but double dose)

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138
Q

how long should breastfeeding be avoided for after using UPA

A

a week after taking

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139
Q

when can UPA effectiveness be altered in relation to progesterone

A

can be reduced if progesterone is taken 7 days before UPA and 5 days after UPA

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140
Q

when does oral EC become ineffective

A

after ovulation

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141
Q

when can hormonal contraception be started after levonorgestrel/UPA

A 
levonorgestrel = immediately 
UPA = 5 days
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142
Q

what is the decidua

A

thick layer of modified mucous membrane that lines the uterus during pregnancy and is shed in the afterbirth (part of endometrium)

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143
Q

when does bHCG reach 25IU/ml in urine (when preg test is positive)

A

4 weeks after LMP

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144
Q

at which week does placenta take over perfusion (from corpus luteum)

A

12 weeks

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145
Q

how is the biophysical profile of the foetus scored

A

+2 points for good breathing (does some practice breaths), good movements, foetal tone and normal amniotic fluid volume

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146
Q

how can placental insufficiency cause less amniotic fluid

A

less blood to kidney of baby = wee less

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147
Q

2 things umbilical dopplers measure

A

waves on USS screen to form:

  • pulsatility index (PI)
  • resistance index (RI)
148
Q

when can PI and RI be high in doppler

A

pre-eclampsia - because placenta isn’t anchored well to uterine wall so increases BP to get through sieve

149
Q

what does it mean if there is blood reversal to baby during diastole shown on the doppler

A

very concerning and baby needs to be delivered

150
Q

pH and bacteria in normal vagina vs in bacterial vaginosis (BV)

A
  • normal pH <=4.5, BV pH >4.5

- normal = lactobacilli predominant, BV = anaerobes dominant (fewer lactobacilli)

151
Q

risk factors for BV (50% asymptomatic)

A
  • vaginal douching
  • receptive cunnilingus
  • smoking
  • black ethnicity
  • STI or PID
  • recent change sexual partner
152
Q

3 complications of BV in pregnancy

A
  • endometritis after birth
  • PROM, preterm birth
  • late miscarriage
153
Q

advice for BV management

A

avoid douching and use of antiseptics

metronidazole 500mg BD for 5-7/7

154
Q

treatment for BV in pregnancy

A

topical antibiotics

155
Q

things to ask about in thrush history

A
  • itching, soreness
  • thick white vaginal discharge
  • superficial dyspareunia
  • erythema/fissuring of skin
156
Q

advice for candida infections

A
  • use soap substitute
  • avoid tight clothes
  • avoid local irritants
157
Q

treatment for candida in pregnancy

A

clotrimazole 500mg pessary - CAN’T USE FLUCONAZOLE - CONTRAINDICATED

158
Q

signs of trichomoniasis

A
  • frothy yellow discharge 10-30%
  • vulvitis and vaginitis
  • strawberry cervix (2%)
159
Q

general advice for TV infection

A

avoid sex for 1 week and until partners have completed treatment (metronidazole)

160
Q

symptoms of chlamydia in females

A
  • 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)

161
Q

2 rarer complications of chlamydia

A

sexually acquired reactive arthritis (SARA)

perihepatitis

162
Q

treatment for chlamydia if pregnant or breastfeeding (doxy contraindicated)

A

azithromycin: 1g PO stat and 500mg OD for 2 days after

163
Q

general management of gonorrhoea infection

A
  • always do a culture
  • avoid sex for 1 week until self and partners have treatment
  • test of cure done at 2 weeks after treatment
164
Q

swabs for gonorrhoea in MSM

A

triple swab:

  • urethral swab and urine
  • throat swab
  • rectal swab
165
Q

symptoms of gonorrhoea in males

A

urethritis +/- yellow discharge in 80%

166
Q

complications of gonorrhoea in males

A
  • epididymo-orchitis
  • proctitis
  • disseminated gonorrhoea
167
Q

3 physical treatments for genital warts

A

cryotherapy
excision
electrocautery

168
Q

2 topical treatments for genital warts

A

podophyllotoxin

imiquimod

169
Q

local and systemic symptoms of genital herpes

A

local = painful ulceration, dysuria, vaginal/urethral discharge

systemic = fever and myalgia

170
Q

how is genital herpes diagnosed

A

viral PCR from active lesions

171
Q

treatment of genital herpes

A

acyclovir

172
Q

how is syphilis diagnosed

A

PCR
serology
dark ground microscopy

173
Q

incubation period for primary syphilis

A

21 days (9-90 days)

174
Q

signs of primary syphilis

A
  • chancre: painful ulceration from single papule

- anogenital lesion: single, painless and indurated with clean base (non-purulent)

175
Q

how long does it take for primary syphilis to resolve

A

3-8 weeks

176
Q

secondary syphilis is

A

multi-system complication - 4-10 weeks after initial chancre

25% of untreated primary syphilis will develop this

177
Q

type of rash in secondary syphilis

A

condylomata lata - highly infectious on perineum and anus

widespread, can be itchy, can affect palms and soles of feet

178
Q

systemic effects of secondary syphilis

A
  • hepatitis
  • splenomegaly
  • glomerulonephritis
  • neurological complications: acute meningitis, cranial nerve palsies, uveitis, optic neuropathy, interstitial keratitis, retinal problems
179
Q

early vs late latent syphilis

A 
early = <2 years
late = >2 years
180
Q

how are primary, secondary and early latent syphilis treated

A

benzathine penicillin 2.4 MU in IM single dose

doxycycline if penicillin allergic

181
Q

how is late latent, cardiovascular or gummatous syphilis treated

A

benzathine penicillin 2.3 MU IM weekly for 3 weeks in 3 doses

longer treatments for neurosyphilis/ophthalmic syphilis

182
Q

main cause of balanoposthitis (inflammation of glans penis and prepuce)

A

candida infection

183
Q

how are vulvar conditions/balanitis investigated

A
  • swab for candida/bacterial culture
  • HSV/syphilis PCR
  • STI screen
  • biopsy if still uncertain
184
Q

when should OGTT be offered to a pregnant woman with previous GDM

A

ASAP after booking visit and again at 24-28 weeks if comes back as normal

185
Q

diagnostic cut offs for fasting glucose and OGTT (GDM)

A
  • fasting glucose >= 5.6mmol/L

- OGTT >= 7.8mmol/L

186
Q

management of GDM if fasting glucose 5.6-7

A

diabetes appointment within a week, diet advice, self-monitoring

next = diet + exercise + METFORMIN

187
Q

what should be done for GDM if glucose targets are still not within range 1-2 weeks after starting metformin

A

insulin - NB: start insulin STRAIGHT AWAY if fasting glucose >=7 or even if glucose is lower but evidence of macrosomia/polyhydramnios

188
Q

can you use oral hypos in pregnant patients with pre-existing diabetes

A

no - only metformin/insulin

189
Q

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

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

190
Q

How should women be managed with severe GHTN (>160/110mmHg)

A
  1. ADMISSION: for monitoring and antihypertensive until BP is lower than 160/110mmHg
  2. Aim for BP 135/85mmHg
  3. Offer antihypertensive to all women
  4. BP measured every 15-30 minutes until less than 160/110mmHg
  5. Urine dip daily whilst admitted
  6. Bloods: on admission and weekly
  7. CTG at diagnosis and then if clinically indicated
191
Q

How are women who have had GHTN managed after birth

A
  1. Measure BP daily for first 2 days after birth
    - Once between days 3 and 5 postpartum
  2. Continue hypertensive if needed- switch off methyldopar
  3. Follow up with GP 2 weeks post birht
  4. Write up a care plan:
    - Who will follow up
    - Who and when might Anti HTN stop
    - how regular BP will be monitored
192
Q

target BP for pregnant women with chronic hypertension

A

135/85

offer aspirin 75-150mg daily from 12 weeks gestation - also for those with pre-eclampsia

193
Q

why should methyldopa be stopped postnatally (3rd line med for GHTN)

A

higher risk of postnatal depression

194
Q

when are dopplers usually done for pre-eclampsia

A

34 and 36 weeks

195
Q

How are women with BP <160/110 managed with pre-eclampsia

A
  • 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

196
Q

How are women with BP >160/110 managed with pre-eclampsia

A
  • 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

197
Q

what investigation not to forget in eclampsia

A

blood glucose - differential/reversible cause

198
Q

dose of magnesium sulphate for bolus and then maintenance - for eclampsia

A

bolus = 4g in 100ml of 0.9% saline

maintenance = 1g hourly for 24 hours

199
Q

common complication of pre-eclampsia

A

placental abruption

200
Q

how is stillbirth managed in future pregnancies

A

woman induced a week BEFORE previous stillbirth occurred

201
Q

management of stillbirth

A
  1. Labour induced using prostaglandins +/- oxytocin
    - Occasionally C/s of unwell
  2. Can choose to continue pregnancy- 30% will spontaneously deliver within 3 weeks
  3. Ecouraged to hold baby:
    - Make footprints, handprints
  4. Cabergoline to suppress lactation
  5. Community follow up: GP
    - Parent groups: SANDS
    - follow up with consultant
202
Q

what should be done by week 4 of intrauterine death

A

platelets measured: 1 in 4 risk of developing coagulopathy

203
Q

investigations for recurrent miscarriages

A
  • Karyotyping of both partners
  • USS of uterus
  • high vaginal swab - BV?
  • antiphospholipid antibodies assay
  • Kleihauer test
  • post partum examination of foetus
204
Q

risk of emergency C/S in VBAC

A

25% - also increased risk of infection and 1 in 200 chance of uterine scar rupture

205
Q

what antibiotic is given for PPROM

A

erythromycin 250mg QDS 10 day course or until labour

206
Q

when are corticosteroid injections given in PPROM

A

24-33+6 weeks (consider up to 35+6)

dexamethasone 12mg every 12 hours

207
Q

what is administered if PPROM occurs and woman is going into labour

A

IV MgSO4 - neuroprotective for foetus

208
Q

what is done I asymptomatic bacteriuria is found in pregnancy

A

send repeat sample

if still positive = 7 day course amoxicillin

209
Q

when can trimethoprim and nitrofurantoin not be used in pregnancy

A

1st trimester = trimethoprim

3rd trimester = nitrofurantoin (neonatal haemolysis)

210
Q

antibiotics used for chorioamnionitis

A

cefuroxime and metronidazole

211
Q

what antibiotic is used for GBS prophylaxis

A

intrapartum IV pen V (benzylpenicillin) 3g loading dose then 1.5g every 4 hours until delivery

cefuroxime or vancomycin if penicillin allergic

212
Q

what is important to ask patients when screening for HIV

A

have they had any blood transfusions

213
Q

what might a HIV antibody-antigen test reveal in the acute period (2-6 weeks after infected)

A

p24 Ag positive but antibody negative = VERY INFECTIOUS DURING THIS PERIOD

214
Q

how long does the chronic/asymptomatic HIV stage last

A

often 5-10 years

215
Q

non-specific symptoms of advanced HIV

A
  • fevers
  • lymphadenopathy
  • fatigue
  • weight loss
  • diarrhoea
216
Q

3 advanced-HIV defining illnesses

A
  • pneumocystitis pneumonia
  • Kaposi’s sarcoma
  • candida oesophagi’s
217
Q

which cancer is more common in advanced HIV

A

B cell lymphoma

218
Q

aim of HAART

A

undetectable viral load

219
Q

which drugs can interact with HIV therapy

A
  • steroids
  • statins
  • anti-anxiety/sedatives
  • anticoagulants
  • chemo drugs
  • anti-TB drugs
  • recreational drugs
  • antacids and multivitamins
220
Q

when can the p24 antigen be detected vs HIV antibody

A

p24 antigen = 2-4 weeks post-exposure

HIV antibody = 4-8 weeks post-exposure

221
Q

3rd vs 4th generation HIV tests

A

3rd generation = antibody test - can detect after 12 weeks

4th generation = Ab/Ag test - can detect after 4 weeks

222
Q

rapid care HIV test vs HIV test II

A

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

223
Q

when can patients on HAART be virally suppressed enough that the risk of transmission is zero

A
  • stay on treatments 1-6 months

- stay on another 6 months

224
Q

when is PrEP given

A

to HIV-negative people

before, during and after sex

225
Q

what is PEPSE (PEP)

A

HIV meds taken after high risk sex/esposure - within 72 hours (ideally 24 hours)

take for 28 days

226
Q

how can HIV be prevented in mother-child transmission

A
  • routine antenatal screening
  • PEP for baby 4 weeks post birth
  • formula feeding
227
Q

contraindications to HRT

A
  • Any undiagnosed vaginal bleeding
  • Current/past breast cancer
  • Any oestrogen sensitive cancer
  • Untreated endometrial hyperplasia
228
Q

3 things which can treat vasomotor symptoms of menopause

A

duloxetine
venlafaxine
citalopram

229
Q

4 RELATIVE contraindications to IoL

A
  • previous C/S
  • breech presentation
  • prematurity
  • high parity
230
Q

when would membrane sweep be offered - nulliparous vs multiparous women

A

nulliparous = 40 and 41 week appointment

multiparous = 41 week appointment

231
Q

3 types of prostaglandin pessaries

A
  • Propess: dinoprostone 10mg over 24 hours
  • prostin gel: dinoprostone 1mg/2mg over 6 hours
  • prostin tablet: dinoprostone 3mg over 6 hours
232
Q

where is oxytocin secreted from

A

posterior pituitary gland - causes myometrial muscle contractions of the uterus

233
Q

exogenous oxytocin used to induce labour

A

syntocinon - can cause hyper stimulation of uterus = can compress placenta/cord leading to foetal hypoxia and distress

234
Q

what can be used to reduce the rate of uterine contractions

A

tocolytic e.g. terbutaline

235
Q

how to maintain confidentiality whilst contact tracing for STIs

A

no requirement to give name, address or GP details

can use number rather than name on patient samples in some services/clinics

236
Q

standard ST screening tests

A
  • chlamydia and gonorrhoea: NAAT
  • urine vs vulvovaginal swab
  • HIV
  • syphilis
237
Q

tailored screen for MSM

A

standard tests plus:

  • 3 site testing for chlamydia and gonorrhoea: in urine, rectum and pharynx
  • hep B and C serology screening
238
Q

when can CHC (COCP, patch, ring) be commenced postpartum but not breastfeeding vs breastfeeding

A

not breastfeeding = day 21

breastfeeding = 6 weeks

239
Q

which drugs can CHC interact with

A

enzyme inducing drugs:

  • carbamazepine
  • phenytoin
  • rifampicin
  • St John’s wort
  • antiretroviral medication

use additional contraception while taking and 4 weeks after

240
Q

pros and cons of Nuvaring

A
  • low incidence of breakthrough bleeds
  • avoidance of first pass metabolism = fewer reactions
  • vaginitis
  • vaginal discharge in 5%
241
Q

what is there a higher risk of if the woman is high parity and has low interpregnancy intervals

A

PPH (poorer contractions)

242
Q

1st and 2nd degree tear

A
  • 1st degree = tear of vaginal wall

- 2nd degree = tear of vaginal wall and perineal muscles

243
Q

3a, b and c degree tear

A
  • 3a = less than 50% of external anal sphincter
  • 3b = more than 50% of external anal sphincter
  • 3c = internal anal sphincter involved
244
Q

4th degree tear

A

involves anal mucosa

245
Q

how are pregnant women with high BMI advised to control weight

A

stay at same weight - shouldn’t try to lose weight during pregnancy

246
Q

can you fit an IUD/IUS into someone with long QT syndrome

A

no - could worsen arrhythmia during fitting

247
Q

when can the IUD/IUS be fitted

A

Once excluding implanted pregnancy:

  • If menstruating
  • no sex since menstruation
  • Using another reliable method
  • No sex in last 3 weeks and pregnancy test negative
248
Q

what must be done if a woman becomes pregnant whilst using an IUD

A
  • 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)
249
Q

4 contraindications for nexplanon

A
  • current breast cancer
  • current enzyme inducers
  • post CVA (Stroke/TIA)
  • severe cirrhosis, hepatoma
250
Q

is the contraceptive injection affected by enzyme inducers

A

NO

251
Q

how often is depo proverb vs sayana press given

A

depo provera = 12 weekly IM

sayana press = 13 weekly SC self injection

both effective for 14 weeks

252
Q

definition of a maternal death

A

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

253
Q

what is a coincidental/ fortuitous maternal death

A

death from unrelated cause during pregnancy e.g. RTA

254
Q

what effect does an underlying thrombophilia have on pregnancy

A
  • increased risk PE/DVT
  • increased risk pre-eclampsia (little clots in placenta)
  • increased risk miscarriage (clots in placenta)
255
Q

how are thrombophilias managed during pregnancy

A

LMWH up until 6 weeks postpartum

BUT can’t have a dose within 12 hours of epidural or spinal anaesthesia!!

256
Q

effects of congenital bicuspid aortic valve disease on pregnancy

A
  • 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
257
Q

how can risks of congenital bicuspid aortic valve in pregnancy be mitigated

A
  • 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
258
Q

impact of beta blockers in pregnancy

A

neonatal hypoglycaemia and IUGR risks

259
Q

how is epilepsy managed during pregnancy

A

preconceptual folic acid 5mg daily

260
Q

latent vs active 1st stage of labour

A
  • latent 1st stage = onset of mild irregular contractions to 3-4cm dilation
  • active 1st stage = 3-4cm dilated to full dilation (!0cm)
261
Q

when does labour become prolonged

A

if stage 2 is greater than 2-3 hours

262
Q

how long is prolonged labour in nulliparous women

A

> 2 hours active pushing

263
Q

how long is prolonged labour in multiparous women

A

> 1 hour active pushing

264
Q

lie of baby in normal labour

A

longitudinal

also cephalic, occipitoanterior

265
Q

what is vertex presentation

A

cephalic presentation - head sharply flexed and chin touching chest (normal)

266
Q

what is military presentation

A

cephalic presentation - foetus looking straight ahead, chin not tucked touching chest

267
Q

what is brow presentation

A

cephalic presentation - foetus head extended rather than flexed = oedema and bruising of face

268
Q

what is face presentation

A

cephalic presentation - neck sharply extended and back of head is arched to foetal back

269
Q

what does an increase in oestrogen towards end of pregnancy lead to

A

increased prostaglandins = labour (myometrial stimulation and cervical ripening)

also helps make more oxytocin receptors = myometrium more sensitive to oxytocin

270
Q

what drug can be used in 3rd stage of labour

A

syntometrine

271
Q

2 non-pharmacological managements used in active 3rd stage of labour

A
  • 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
272
Q

definition of an antepartum haemorrhage

A

bleeding from genital tract AFTER 24 WEEKS - before = threatened miscarriage

273
Q

how to optimise airway in obstetric emergencies

A

LL position

high flow oxygen

274
Q

how should foetus be assessed in an APH

A
  • look at 20 week scan for any placenta praevia or abnormalities
  • CTG
  • bloods
275
Q

what is important to note about hypotension in post/antepartum haemorrhage

A

young women will compensate well - hypotension is a LATE sign (often after losing 2000ml of blood)

276
Q

when would vasa praevia present

A

spontaneous/artificial rupture of membranes - accompanied by painless fresh vaginal bleeding (placenta praevia is also painless)

277
Q

4 Ts of PPH

A
  • tone
  • trauma
  • tissues (RPOC)
  • thrombin
278
Q

how is an atonic uterus managed

A
  • ergometrine: IV bolus
  • syntocinon infusion
  • consider prostaglandins if no response
  • laparotomy?!
279
Q

what liver enzymes are elevated in HELLP syndrome

A

ALT and AST

not ALP - also produced by placenta

280
Q

do you give fluids in eclampsia

A

NO- stroke risk?

281
Q

antidote for magnesium sulphate (eclampsia)

A

calcium glutinate

282
Q

3 initial VTE investigations in pregnancy

A
  • ABG
  • CXR
  • ECG (tachycardia)
283
Q

2 definitive investigations for VTE in pregnancy

A
  • compression doppler
  • V/Q scan

don’t do D-dimer - raised anyway

284
Q

treatment of PE in pregnancy

A
  • LMWH - tinzaparin BD in 2 doses according to weight

- collapse? = thrombolysis with alteplase

285
Q

what is often seen on CTG with uterine rupture

A

sudden bradycardia

286
Q

how is uterine inversion managed

A
  • attempt manual replacement

- O sulliven technique - fill uterus via vagina with warm saline

287
Q

which contraceptives take 7 days to work

A

IUS (mirena)
COCP
depo provera
nexplanon

288
Q

when are the 1st and 2nd doses of anti-D given to rhesus negative women

A

28 and 34 weeks

289
Q

what investigations should be carried out for suspected PID

A
  • 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
290
Q

5 complications of PID

A
  1. Tubal factor infertility
  2. Chronic dyspareunia, pelvic pain in 18%
  3. Ectopic pregnancy
  4. Peri-hepatitis (Fitz High Curtis syndrome)
  5. Tubo-ovarian abscess
291
Q

explaining PID to a patient

A
  • 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
292
Q

what Abx would also cover mycoplasma genitalium in PID

A

moxifloxacin 400mg OD for 14 days

293
Q

what should partner of PID patient be treated with

A

doxycycline 100mg BD for 7 days

294
Q

findings of endometriosis on USS

A

endometriomas (not common) so need to do laparoscopy

295
Q

management of chronic pelvic pain (6+ months duration)

A
  1. Transvaginal scan
  2. Trial of OCP/GnRH analogues for 3-6 months or IUD mirena
  3. Antispasmoics (buscopan), analgesia, referral to pain clinic
  4. Laparoscopy: 50% are negative so consider implications
296
Q

why is warfarin (usually) not safe in pregnancy and breastfeeding

A
  • stillbirth
  • premature birth
  • haemorrhage
  • ocular defects

foetal warfarin syndrome

297
Q

features of foetal warfarin syndrome

A
  • nasal hypoplasia
  • hypoplasia of extremities
  • developmental delay
298
Q

standard dose of syntocinon (synthetic oxytocin) for PPH

A

bolus of 5 units IV
given as infusion
IM if there is no IV access

299
Q

what is syntometrine and what is the dose

A

3rd stage management

combination of oxytocin 5 units and ergometrine 500mcg IM bolus

300
Q

which medications can cause a chemical menopause

A

GnRH analogues - Prostap, Gonapeptyl

301
Q

why should NSAIDs be avoided in pregnancy

A

1st trimester = miscarriage and malformation

3rd trimester = premature closure of ductus arterioles

302
Q

2 Abx used in chorioamnionitis

A
  • cefuroxime 1.5g TDS IV

- metronidazole 500mg TDS IV

303
Q

antibiotics used in endometritis (including penicillin allergy)

A

co-amoxiclav

clindamycin + metronidazole

304
Q

why can’t ARBs and ACEis be used in pregnancy

A

foetal renal damage in 2nd and 3rd trimester

305
Q

what is involution

A

fundus of uterus goes below umbilicus immediately after birth and then is no longer palpable after 2 weeks

306
Q

at what level Hb would oral iron vs blood transfusion be given postnatally

A

80-100 = oral

<80 and symptomatic = blood transfusion

NB: if symptomatic but Hb not low enough for transfusion = IV iron?

307
Q

what is endometritis (postnatal)

A

infection within uterus - from day 2-10

  • fever, headache, pain
  • secondary PPH
  • offensive lochia
308
Q

why is USS not used at first for postnatal endometritis

A

hard to tell difference between blood clots and placental tissue

309
Q

most common organism causing endometritis

A

group A strep

310
Q

antibiotics given for endometritis

A

co-amoxiclav OR

cefuroxime + metronidazole

311
Q

where do 90% of DVTs in pregnancy occur and why

A

LEFT LEG above knee

because right common iliac goes over left vein and is more compressed by arteries as well as uterine compression

312
Q

how common is baby blues vs PND

A

baby blues = 75%
PND = 10-15%
puerperal psychosis = 1 in 500

313
Q

how to work out fertile window

A

subtract 19 and 11 days from cycle length - period between

variable cycle length = 11 days off longest cycle and 19 days off shortest cycle

314
Q

how much vit D to take daily preconception

A

10mcg

315
Q

normal LH and FSH levels

A 
FSH = <8
LH = <10
316
Q

what does sex-binding globulin do

A

carries testosterone around the body

317
Q

what is anti-mullerian hormone a measure of

A

ovarian reserve - number of follicles left

318
Q

in which 2 groups of women is anti-mullerian hormone v high

A

PCOS

younger women

319
Q

what is Kallman syndrome

A

children born without neurones needed to secrete GnRH = group I anovulation

also often have loss of taste and smell (neurones develop from olfactory nerve)

320
Q

cyst characteristics in PCOS

A

must be under 9 cysts each 2-9mm

321
Q

type of cancer increased in PCOS

A

endometrial cancer

322
Q

fertility treatment in PCOS if ovulation is detected

A

await natural conception - IVF if no pregnancy after 6-9 months

323
Q

fertility treatment in PCOS if ovulation is NOT detected

A
  1. assessment, lifestyle advice if overweight
  2. clomiphene or letrozole given in pulses
  3. gonadotrophins OR clomiphene + metformin OR laparoscopic ovarian diathermy
324
Q

2 diagnostic criteria for premature ovarian insufficiency (group III ovulation disorder)

A
  • oligo/amenorrhoea 4+ months

- elevated FSH level >25IU/L on 2 occasions >4 weeks apart

325
Q

2 genetic causes of group III ovulation disorder

A

turner syndrome

fragile X

326
Q

what size fibroids can lead to sub fertility

A

> 4cm

327
Q

3 investigations into pelvic pathology for subfertility

A
  • hysterosalpingography
  • hysterosalpingo-contract ultrasonography (HyCoSy)
  • laparoscopy
328
Q

how are sperm assessed

A

sample counts of 2, 2-3 days apart first thing in morning

329
Q

lower limits of normal for different sperm factors

A

total sperm number = 39 million

concentration = 15 million/ml

vitality = 58%

progressive motility = 32%

total motility = 40%

normal morphology = 4%

330
Q

questions to ask in a male fertility assessment

A
  • 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
331
Q

what drug can cause (often irreversible) male infertility

A

anabolic steroids - synthetic testosterone inhibits endogenous testosterone and therefore sperm production

332
Q

when is IVF recommended if infertility remains unexplained

A

after 2 years trying

333
Q

what medications are given during IVF

A
  • exogenous high dose gonadotrophins = multi follicular recruitment
  • GnRH analogues - to prevent premature endogenous LH surge
334
Q

symptoms of mild ovarian hyperstimulation syndrome (OHSS)

A
  • mild abdo pain and bloating

- ovarian size <8cm

335
Q

symptoms of moderate OHSS

A
  • abdo pain
  • N+V
  • USS = ascites
  • ovarian size 8-12cm
336
Q

symptoms of severe OHSS

A
  • clinical ascites +/- hydrothorax
  • oliguria
  • haematocrit >0.45
  • hyponatraemia, hyperkalaemia
  • hypoproteinaemia
  • ovarian size >12cm
337
Q

symptoms of critical OHSS

A
  • tense ascites, large hydrothorax
  • haematocrit >0.55
  • WCC >25,000
  • oliguria/anuria
  • thromboembolism
  • ARDS
338
Q

enzyme enducers which interact with combined hormonal contraceptives

A
  1. Some antiepileptics: carbamazepine, phenytoin, phenobarbitone
  2. Rifampicin
  3. Some antiretrovirals used in HIV: ritonavir
  4. St john’s wort
339
Q

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

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

340
Q

at how many weeks is dilation and evacuation used for TOP

A

over 14 weeks = needs continuous US guidance

341
Q

how is the cervix prepared before 14 weeks gestation (TOP)

A

misoprostol 400mcg PV 3 hours prior to surgery or sublingually 2-3 hours before

342
Q

how is the cervix prepared after 14 weeks gestation (TOP)

A

osmotic dilators

but can still give misoprostol up to 18 weeks as an alternative

343
Q

anaesthesia for TOP

A
  • LA (cervical block)
  • conscious sedation: fentanyl + midazolam
  • GA
344
Q

medical abortion <=49 days

A

200mg oral mifepristone followed by 400mcg oral misoprostol 24-48 hours later

345
Q

medical abortion <=63 days

A

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

346
Q

Abx prophylaxis recommended for surgical and medical abortions

A

1g azithromycin + 800mg metronidazole

347
Q

why do FSH and LH levels increase in menopause

A

falling levels of oestrogen due to ovarian failure = anterior pituitary releases more FSH and LH in an attempt to raise oestrogen

348
Q

for which type of HRT must the woman be post-menopausal (age >54 or amenorrhoea >1 year)

A

continuous combined HRT - no bleed

349
Q

when is tibolone useful as HRT

A

women with low libido

350
Q

3 conditions HRT helps reduce the risk of

A
  • osteoporosis (fragility fractures by 30%)
  • dementia
  • colorectal cancer
351
Q

which combined HRT increases endometrial cancer risk

A

sequential combined (not continuous combined)

352
Q

what can vaginal atrophy in postmenopausal women cause

A

urinary frequency and STIs

353
Q

physiotherapy for urge/stress incontinence

A

pelvic floor exercises - 8+ contractions 3 times a day for 3 months

354
Q

what should be done after physiotherapy for urge incontinence

A

bladder diary 3+ days
bladder drills
oxybutynin?

355
Q

what is important to do when suffering from urge incontinence

A

sufficient water intake - more concentrated urine will cause bladder to be even more irritated

356
Q

why can menopause lead to greater risk of urge and stress incontinence

A
  • 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
357
Q

3 side effects of anticholinergics (e.g. oxybutynin)

A
  • dry mouth
  • constipation
  • blurred vision
358
Q

after 3 month follow up for stress incontinence what can be done

A

urodynamic study: 1 in 10 will actually have urge incontinence

359
Q

4 treatments for urge incontinence (after oxybutynin etc doesn’t work)

A
  • cystoscopy + botox (reduce detrursor activity)
  • percutaneous sacral nerve stimulation
  • augmentation cystoplast
  • urinary diversion
360
Q

how are pelvic organ prolapses graded

A

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)

361
Q

3 downsides of pessaries

A
  • have to come into fit
  • can’t have sex
  • low adherence: ulceration
362
Q

what does a score of 4+ in VTE assessment merit

A

tinzaparin (LMWH) from 1st trimester and consider after post-natal assessment for 6 weeks postpartum

363
Q

what does a score of 3 in VTE assessment merit

A

LMWH from 28 weeks

364
Q

what should be considered if there is a VTE score of 2 postnatally

A

LMWH for at least 10 days

365
Q

contraindications/cautions to LMWH use in pregnancy

A
  • 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

Year 4 revision (5 decks)

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