Gynaecology + Obstetrics Flashcards
HPV cercial cancer types (1)
other RF (5)
Human papillomavirus infection (particularly 16,18 & 33) is by far the most important risk factor
Mechanism of HPV causing cervical cancer
HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
E6 inhibits the p53 tumour suppressor gene
E7 inhibits RB suppressor gene
Other RF:
smoking, HIV, parity, low SES, COCP
widely spaced nipples and primary amenorrhoea
Turner’s syndrome
(X)
hormonal changes characteristic with turners
raised gonadotrophin levels (FSH/LH)
decreased levels of oestrogen and progesterone due to gonadal dysgenesis resulting in a compensatory increase in serum FSH and LH.
Gonadal dysgenesis causes an increase in FSH/LH by the negative feedback cycle to try to compensate for the lack of oestrogen and progesterone produced by the ovaries.
Increased serum androgen levels
polycystic ovarian syndrome. This will present a history of oligomenorrhoea, obesity, acne and hirsutism.
most common cause of primary amenorrhoea
gonadal dysgenesis (e.g. turners)
other causes:
testicular feminisation
congenital malformations of the genital tract
functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
congenital adrenal hyperplasia
imperforate hymen
secondary amenorrheoa
hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
amenorrheoa- what do the gonatorohins show us
FSH/LH tell us:
low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
raised if gonadal dysgenesis (e.g. Turner’s syndrome)
secondary amenorrhoea + raised FSH/LH + lw oestradiol
POremature ovarian insufficiency (<40 years)
Gonadotropin-producing pituitary adenoma: hormones
elevated FSH and LH levels alongside normal or high oestradiol levels
- mass effect on surrounding structures, such as headaches or visual disturbances.
diagnostic test for POI
FSH level
Ectopic:
when can you do expectant:
hCG (1)
size (1)
<35mm
unruptured
asymptomatic
no fetal heartbead
hCG <1000
(involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed.)
Ectopic:
when can you do medical management:
hCG (1)
size (1)
<35mm
no significant pain
no heart beat
hCG < 1,500
medical management ectopic
methotrexate
pt has to be willing to attend follow up
Ectopic:
when can you do surgical management:
hCG (1)
size (1)
> 35mm
hCG >5000
heart beat
pain
Salpingectomy is first-line for women with no other risk factors for infertility
Salpingotomy should be considered for women with risk factors for infertility such as contralateral tube damage (around 1/5 require further methotrexate/ salpingostomy)
Infertility in PCOS - first line treatment
2nd line?
1st= clomifene
2nd line= metformin
(weight reduction)
uterine fibroids short term treatment to reduce size
GnRH agonists
typically used more for short-term treatment due to side-effects such as menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density
uterine fibroid surgical management
myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically
hysteroscopic endometrial ablation
hysterectomy
uterine artery embolization
Benign ovarian cyst management:
premenopausal
postmenopausal
PREMENOPAUSAL
a conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
POSTMENOPAUSAL
by definition physiological cysts are unlikely
any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment
gestational sac containing a dead fetus before 20 weeks without the symptoms of expulsion
missed misscarriage
threatened vs inevitable miscarroage
Inevitable miscarriage would have symptoms of imminent expulsion such as abdominal pain and vaginal bleeding with an open cervical os.
Threatened miscarriage would have vaginal bleeding with or without abdominal pain, with a closed cervical os.
HIV and cervical cancer screening
Women with HIV should be offered cervical cytology at diagnosis.. Cervical cytology should then be offered annually for screening.
Even those women who are effectively treated with antiretrovirals have a high risk of abnormal cytology and an increased risk of false-negative cytology.
bacterial vaginosis and Trichomonas vaginalis treatment
metronidazole
thrust treatment options (2)
if pregnant (1)
oral fluconazole 150 mg as a single dose first-line
clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
hormonal changes in menopause
The menopause can either be a natural or iatrogenic process that results in the cessation of oestradiol and progesterone production in the ovaries. Due to this decrease, FSH and LH levels will often increase.
temperature during period
Rises following ovulation in response to higher progesterone levels
Progesterone also highest in luteal (secretory) 15-28 days, as it is secreted by the egg
Urge incontinence management (2)
examples of the meds (3)
- bladder retraining
- anti muscarinic antagonist
NICE recommend oxybutynin (immediate release),
tolterodine (immediate release) or
darifenacin (once daily preparation)
who to not give oxybutynin to
Immediate release oxybutynin should, however, be avoided in ‘frail older women’
duloxetine MOA
mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction
duloxetine may be offered to women if they decline surgical procedures
STRESS INCONTINENCE
Amels’s criteria;
what cells? (1)
what pH (1)
Amsel’s criteria for diagnosis of bacterial vaginosis - 3 of the following 4 points should be present:
thin, white homogenous discharge
clue cells on microscopy: stippled vaginal epithelial cells
vaginal pH > 4.5
positive whiff test (addition of potassium hydroxide results in fishy odour)
Treatment for BV and trichomonads vaginalis
Oral metronidazole
recurrent candida - how to treat
if 4+ / year
–> check compliance
–> check for other causes e.g. diabetes
–> consider lichen sclerosis
TREAT with induction-maintenance regimen
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
Most common benign ovarian tumour in women under the age of 25 years
Dermoid cyst (teratoma)
also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
most common benign ovarian tumour in woman under the age of 30 years
median age of diagnosis is 30 years old
bilateral in 10-20%
usually asymptomatic. Torsion is more likely than with other ovarian tumours
commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
commonly regress after several menstrual cycles
Follicular cysts
sample “inadequate” in cervical smear
repeat in 3 months
if 2x samples inadequate in cervical smear
colposcopy
HPV +ve by cytology normal (i.e NO borderline changes) –> repeat in 12 months.
if repeat:
normal? (1)
+ve? (1)
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
(Cervical cancer screening: if 2nd repeat smear at 24 months is still hrHPV +ve → colposcopy)
progesterone surge in cycle
day 21
fertility: what hormone to test for
progesterone
management endometrial cancer
localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy
patients with high-risk disease may have postoperative radiotherapy
Progestogen therapy is sometimes used in frail elderly women not considered suitable for surgery.
when to investigate infertility
> 35 = 6 months
<35= 12 months
VWD
Von Willebrand’s disease is the most common inherited bleeding disorder. The majority of cases are inherited in an autosomal dominant fashion* and characteristically behaves like a platelet disorder i.e. epistaxis and menorrhagia are common whilst haemoarthroses and muscle haematomas are rare
Investigation
prolonged bleeding time
APTT may be prolonged
factor VIII levels may be moderately reduced
defective platelet aggregation with ristocetin
ovarian hyperstimulaton syndrome
Whilst it is rarely seen with clomifene therapy is more likely to be seen following gonadotropin or hCG treatment. Up to one third of women who are having IVF may experience a mild form of OHSS
severe;
* As for moderate
* Clinical evidence of ascites
* Oliguria
* Haematocrit > 45%
* Hypoproteinaemia
critical’ As for severe
* Thromboembolism
* Acute respiratory distress syndrome
* Anuria
* Tense ascites
secondary dysmenorrhoea in the GP
referred to gynaecology for investigation
Hypothyroidism impact on menstrual cycle
menorrhagia NOT dysmenorrahia
(heavier longer periods not really more painful)
Adenomyosis
endometrium grows in myometrium of the uterus (endometriosis in the womb)
ages cervical cancer screening
Cervical cancer screening
25-49 years: 3-yearly
50-64 years: 5-yearly
First line treatment for:
dysmenorrahgia
menorrhagia
DYSmenorrhagia - NSAID
Menorrhagia - intrauterine system (Mirena) is first-line
what hormone causes ovulation
LH surge causes ovulation
Most common type of ovarian pathology associated with Meigs’ syndrome (1)
what else Sx associated? (2)
fibroma
associated with ascites and pleural effusion
corpus luteum cyst
during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
more likely to present with intraperitoneal bleeding than follicular cysts
Benign epithelial tumours:
serous cystadeoma
mutinous cystaedoma
Serous cystadenoma (The most common type of epithelial cell tumour)
the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
bilateral in around 20%
Mucinous cystadenoma
second most common benign epithelial tumour
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei
–> SEROUS CARCINOMA IS MOST COMMMON TYPE OF OVARIAN CANCER
normal HR for fetus
100-160
fetal HR < 100 causes
Increased fetal vagal tone, maternal beta-blocker use
fetal HR > 160
Maternal pyrexia, chorioamnionitis, hypoxia, prematurity
what type of decelerations in foetus is normal
EARLY is normal
variable decelerations in fetal HR
May indicate cord compression
how many weeks into gestation is pre eclampsia
new-onset hypertension after 20 weeks’ gestation with proteinuria (≥0.3g/24h) or other maternal organ dysfunction.
preterm prelabour rupture of membranes PPROM management
10/7 erythromycin
aspirin and breastfeeding
AVOID (Reye syndrome)
breastfeeding and epilepsy
Breast feeding is acceptable with nearly all anti-epileptic drugs
epilepsy drugs and pregnancy
aim for monotherapy
there is no indication to monitor antiepileptic drug levels
sodium valproate: associated with neural tube defects
carbamazepine: often considered the least teratogenic of the older antiepileptics
phenytoin: associated with cleft palate
lamotrigine: studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy
RFM when to refer
24 weeks
(Generally women can feel their babies move around 18-20 weeks)
how long to take folic acid for in pregnancy
until 12 week
Pregnant women ≥ 20 weeks who develop chickenpox .. treat with
oral acyclovir if they have the rash
if severe –> hospital for IV acyclovir
Magnesium sulphate - what to monitor
monitor reflexes + respiratory rate
breast candid infection -
treat mum and beat ad continue breastfeeding
women with a previous baby with early- or late-onset GBS disease - what to do
ntrapartum antibiotic prophylaxis (IAP), either benzylpenicillin or ampicillin.
Antibiotics should only be administered to the child if they present signs and symptoms of neonatal sepsis.
IAP should be offered to women in preterm labour regardless of their GBS status
women with a pyrexia during labour (>38ºC) should also be given IAP
benzylpenicillin is the antibiotic of choice for GBS prophylaxis
perineal tears - 1st
2nd
3rd
4th
1st = SUPERFICIAL
2nd= MUSCLE BUT NO ANAL S{PINTER (repeat on ward)
3rd= INVOLVING ANAL SPINCTER (repeat in theatre)
4th= ANAL SPINTER COMPLEX and rectal mucosa
anomaly scan
18 - 20+6 weeks
downs syndrome screening/ nuchal scan
11 - 13+6 weeks
what medications or diseases –> folic acid 5mg (4)
DIABETES
antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
methotrexate and pregnancy
Methotrexate: must be stopped at least 6 months before conception in both men and women
breastfeeding avoid these drugs
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone
Can have these in breastfeeding
antibiotics: penicillins, cephalosporins, trimethoprim
endocrine: glucocorticoids (avoid high doses), levothyroxine*
epilepsy: sodium valproate, carbamazepine
asthma: salbutamol, theophyllines
psychiatric drugs: tricyclic antidepressants, antipsychotics**
hypertension: beta-blockers, hydralazine
anticoagulants: warfarin, heparin
digoxin
UTI and pregnant treatment
trimethoprim
multiparty or nulliparity associated with placental abruption
MULTIparity
when to do OGTT for women at risk of gestational diabetes
ASAP after booking
OGTT number
fasting glucose >= 5.6 mmol/L
2-hour glucose >=7.8 mmol/L
Amiodarone and breastfeeding
AVOID
sodium valproate and breastfeeding
SAFE
when does gestational diabetes usually start
2nd or 3rd trimester
Psychological changes in pregnancy
increased SV, CO, HR, plasma volume
rudimentary digits, limb hypoplasia and microcephaly
Varicella zoster
cerebral calcification, microcephaly and sensorineural deafness
cytomegalovirus
deafness, congenital cataracts and cardiac complications
rubella
smoking in pregnancy increased risk of..
Increased risk of pre-term labour
(and IUGR
stillbirth
miscarriage)
Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations:
delivery of a Rh +ve infant, whether live or stillborn
any termination of pregnancy
miscarriage if gestation is > 12 weeks
ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
external cephalic version
antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling
abdominal trauma
when to give anti-D
28 and 34 weeks
Booking visit and bloods
8-12 weeks
Booking visit
general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
BP, urine dipstick, check BMI
Booking bloods/urine
FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
hepatitis B, syphilis
HIV test is offered to all women
urine culture to detect asymptomatic bacteriuria
OP vs OA : urge to push
5: Generally, women will experience an earlier urge to push in OP than OA.
oligohydramnios
less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile.
premature rupture of membranes
Potter sequence
bilateral renal agenesis + pulmonary hypoplasia
intrauterine growth restriction
post-term gestation
pre-eclampsia
renal agenesis
pregnancy 10 - 13+6 weeks
early scan to determine dates
A 19-year-old woman presents with a two day history of central lower abdominal pain and one day history of vaginal bleeding. Her last period was 8 weeks ago. On examination her cervix is tender to touch
ectopic - miscarriage NOT usually painful cervix
Anomaly scan
18 - 20+6 weeks
HIV and breastfeeding
All mothers known to be HIV positive, regardless of antiretroviral therapy, and infant PEP,
should be advised to exclusively formula feed from birth.
factors which reduce HIV transmission to baby
maternal antiretroviral therapy
mode of delivery (caesarean section)
neonatal antiretroviral therapy
infant feeding (bottle feeding)
baby prophylaxis for HIV
zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.
when to deliver baby with gestational hypertension
mild or moderate gestational hypertension, are more than 37 week pregnant, and are showing signs of pre-eclampsia, should be recommended to give birth within 24 - 48 hours.
Downs syndrome
↑ HCG, ↓ PAPP-A, thickened nuchal translucency
what do you assess before induction of labour
Bishops score
Cervical position (posterior/intermediate/anterior)
Cervical consistency (firm/intermediate/soft)
Cervical effacement (0-30%/40-50%/60-70%/80%)
Cervical dilation (<1 cm/1-2 cm/3-4 cm/>5 cm)
Foetal station (-3/-2/-1, 0/+1,+2)
anyone with secondary dynmenorrhagia presenting for first time to GP should..
All patients with secondary dysmenorrhoea need to be referred to gynaecology for investigation
Most common beingn epithelial tumor (ovarian) AKA The most common type of epithelial cell tumour (1)
what is most common ovarian cancer? (1)
SEROUS Cystadenoma –> SEROUS CARCINOMA (most common ovarian cancer - Around 90% of ovarian cancers are epithelial in origin)
If ruptures may cause pseudomyxoma peritonei (1)
Ruptures–>pseudomyxoma peritonei = Mucinous cystadenoma
Risk factors ectopic pregnancy
damage to tubes (pelvic inflammatory disease, surgery)
previous ectopic
endometriosis
IUCD
progesterone only pill
IVF (3% of pregnancies are ectopic)
stopping HRT
When stopping HRT it is important to tell women that gradually reducing HRT is effective at limiting recurrence only in the short term. In the long term, there is no difference in symptom control.
Although menopausal symptoms can be managed mainly in primary care, there are some instances when a woman should be referred to secondary care. She should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects or if there is unexplained bleeding.
3rd stage labour bleed management
IV oxytocin
obstetric cholestasis management
induction of labour at 37-38 weeks is common practice but may not be evidence based
ursodeoxycholic acid - again widely used but evidence base not clear
vitamin K supplementation
medication of choice in suppressing lactation when breastfeeding cessation is indicated
Cabergoline
management PID
due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment
first-line: stat IM ceftriaxone + followed by 14 days of oral doxycycline + oral metronidazole - this now considered first-line due to the desire to avoid systemic fluoroquinolones where possible
second-line: oral ofloxacin + oral metronidazole
RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in. The more recent BASHH guidelines suggest that the evidence is limited but that ‘ Removal of the IUD should be considered and may be associated with better short term clinical outcomes’
complications PID
perihepatitis (Fitz-Hugh Curtis Syndrome)
occurs in around 10% of cases
it is characterised by right upper quadrant pain and may be confused with cholecystitis
infertility - the risk may be as high as 10-20% after a single episode
chronic pelvic pain
ectopic pregnancy
Mg sulphate in pre eclampsia
- should be given once a decision to deliver has been made
- in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
- urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression - treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
Premature ovarian insufficiency - how long to treat for
until 51 years
(with HRT/. combined therapy)
Wertheim’s radical hysterectomy
includes removal of lymph nodes and is used to treat stage IIB endometrial carcinoma.
complications hyperemesis
acute kidney injury
Wernicke’s encephalopathy
oesophagitis, Mallory-Weiss tear
venous thromboembolism
fetal outcome
studies generally show little evidence of adverse outcomes for birth weight/other markers for mild-moderate symptoms
severe NVP resulting in multiple admissions and failure to ‘catch-up’ weight gain may be linked to a small increase in preterm birth and low birth weight
Androgen insensitivity syndrome
X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype. Complete androgen insensitivity syndrome is the new term for testicular feminisation syndrome
Features
‘primary amenorrhoea’
little or no axillary and pubic hair
undescended testes causing groin swellings
breast development may occur as a result of the conversion of testosterone to oestradiol
Presence of a foetal heartbeat on ultrasound in the context of an ectopic pregnancy
indication for surgical management
when to manage miscarriage surgically/medically
increased risk of haemorrhage
she is in the late first trimester
if she has coagulopathies or is unable to have a blood transfusion
previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
evidence of infection
medical management miscarriage:
missed miscarriage
incomplete miscarriage
missed miscarriage
oral mifepristone. Mifepristone is a progesterone receptor antagonist → weakening of attachment to the endometrial wall + cervical softening and dilation + induction of uterine contractions
48 hours later, misoprostol (vaginal, oral or sublingual) unless the gestational sac has already been passed. Misoprostol is a prostaglandin analogue, binds to myometrial cells → strong myometrial contractions → expulsion of products of conception
if bleeding has not started within 48 hours after misoprostol treatment, they should contact their healthcare professional
incomplete miscarriage
a single dose of misoprostol (vaginal, oral or sublingual)
a pregnancy test should be performed at 3 weeks
HELLP syndrome
severe form of pre-eclampsia whose features include: Haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). A typical patient might present with malaise, nausea, vomiting, and headache. Hypertension with proteinuria is a common finding, as well as epigastric and/or upper abdominal pain.
To confirm ovulation what should you check
serum progesterone level 7 days prior to the expected next period
endometriosis treatment
The COCP is the first line option and can be used back-to-back with no pill-free interval. Second line treatments include progesterone only methods, such as POP, implant or injection (again they work by inhibiting ovulation). In addition, the Mirena coil can be used as it will reduce bleeding, resulting in less retrograde menstruation. The copper intrauterine device can make menstrual cycles longer and more painful and would not be a suitable option.
If the above methods fail to improve a patient’s symptoms, then GnRH analogues may be used.
If analgesia/hormonal treatment does not improve symptoms, or if fertility is a priority, the patient should be referred to secondary care. Secondary treatments include:
GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
drug therapy unfortunately does not seem to have a significant impact on fertility rates
surgery
this may be an option for women who have not responded to conventional medical treatment
for women who are trying to conceive, NICE recommend laparoscopic excision or ablation of endometriosis plus adhesiolysis as this has been shown to improve the chances of conception. Ovarian cystectomy (for endometriomas) is also recommended
Premature ovarian failure definition
The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years’
how to manage placenta prevue
If low-lying placenta at the 20-week scan:
rescan at 32 weeks
no need to limit activity or intercourse unless they bleed
if still present at 32 weeks and grade I/II then scan every 2 weeks
final ultrasound at 36-37 weeks to determine the method of delivery
elective caesarean section for grades III/IV between 37-38 weeks
if grade I then a trial of vaginal delivery may be offered
if a woman with known placenta praevia goes into labour prior to the elective caesarean section an emergency caesarean section should be performed due to the risk of post-partum haemorrhage
major cause of death in women with placenta praevia is now PPH
when to do ECV ?
what contraindications?
36 weeks
where caesarean delivery is required
antepartum haemorrhage within the last 7 days
abnormal cardiotocography
major uterine anomaly
ruptured membranes
multiple pregnancy
diabetic pregnancy complications
Maternal complications
polyhydramnios - 25%, possibly due to fetal polyuria
preterm labour - 15%, associated with polyhydramnios
Neonatal complications
macrosomia (although diabetes may also cause small for gestational age babies)
hypoglycaemia (secondary to beta cell hyperplasia)
respiratory distress syndrome: surfactant production is delayed
polycythaemia: therefore more neonatal jaundice
malformation rates increase 3-4 fold e.g. sacral agenesis, CNS and CVS malformations (hypertrophic cardiomyopathy)
stillbirth
hypomagnesaemia
hypocalcaemia
shoulder dystocia (may cause Erb’s palsy)
Earlier referral for inferlitily
Female
>35 yr
amenorrhoea
previous pelvic surgery
prev STI
abnormal genitalia
Male:
prev surgery on genitalia
prev STI
varicocele
significant systemic illness
abnormal genitalia
continuous CTG in pregnancy for
suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
severe hypertension 160/110 mmHg or above
oxytocin use
the presence of significant meconium
fresh vaginal bleeding that develops in labour - this was a new point added to the guidelines in 2014
when to start insulin in gestational diabetes
fasting glucose is >= 7 mmol/l. Aspirin should also be considered given the increased risk of pre-eclampsia.
