Hard to recall O&G Flashcards
What syndrome do anti-epileptics during pregnancy cause?
Fetal Hydantoin Syndrome: IUGR Microcephaly Cleft palate Mental retardation Hypoplastic fingernail defects Distal limb deformities
Causes of omphalocele?
Trisomy 13
Trisomy 18
Exomphalos-macroglossia-gigantism syndrome
Most likely cause for DIC in a pregnant woman?
Placental abruption
4 features of isoimmunisation in a fetus?
- Erythroblastosis fetalis with haemolytic anaemia and erythroblasts on blood film
- Jaundice and hepatosplenomegaly
- Kernicterus
- Hydrops fetalis
What structures are at risk of damage following sacrospinous fixation for Tx of vaginal vault prolapse?
Sciatic nerves
Pudendal vessels
What nerve can be damaged by the lithotomy position and in abdomino-pelvic surgery?
Femoral nerve
When is pregnancy does breast enlargement and darkening occur?
12 weeks
Fetal indications for IOL?
Post-due date Fetal growth restriction Certain diabetic pregnancies Deteriorating haemolytic disease Deteriorating fetal abnormalities
Maternal indications for IOL?
Pre-eclampsia
Deteriorating medical conditions
If Tx for malignancy needed
Why does shoulder tip pain occur?
Free intraperitoneal fluid irritating diaphragm
What kind of incontinence can alpha-adrenergic blockers cause?
Stress incontinence
Symptoms of PMS?
- Psychological: depression, anxiety, mood swings
- Behavioural: aggression
- Physical: breast tenderness, abdo bloating
Causes of hypogonadotrophic hypogonadism?
Kallman syndrome
Clinical features of Kallman syndrome
Absent/delayed puberty Hyposmia/anosmia Colour blind Unilateral kidney agenesis Cleft lip Bimanual synkinesia Primary amenorrhoea Cryptorchidism
Hormone profile in Kallman syndrome?
Low GnRH
Low FSH
Low LH
Low oestradiol
Causes of primary hypogonadism?
Klinefelter’s
Turner’s syndrome
Hormone profile in primary hypogonadism?
High GnRH
High FSH
High LH
Low oestradiol
Hormone profile in secondary hypogonadism?
High GnRH
Low FSH
Low LH
Low oestradiol
What does incomplete fusion of the paramesonephric ducts result in?
Bicornuate or septate uterus
When should HIV+ve women not on ART start meds while pregnant?
Start combined ART by 24 weeks and continue life long
First line Mx of severe allergic rhinitis in pregnancy?
Oral loratadine
During pregnancy what happens to tidal volume and minute ventilation?
They both increase
Features on congenital rubella syndrome?
Sensorineural deafness Congenital heart defects - paten ductus arteriosus Congenital glaucoma Cataracts Microcephaly Hepatosplenomegaly and jaundice
Definition of polyhydramnios?
AFI >95th centile (2-3L or 25cm of amniotic fluid)
Deepest vertical pool >8cm
What type of cysts do molar pregnancies cause?
Bilateral theca lutein cysts
Pathogenesis of ovarian stromal hyperthecosis?
Hyperplasia of ovarian stroma with clusters of luteinising cells within
Features of ovarian stromal hyperthecosis?
Increased androstenedione and testosterone = virilism and hirsutism
Conversion of androgen to oestrogen in peripheries = endometrial hyperplasia and AUB
Tx for ovarian stromal hyperthecosis?
Pre-menopausal: COCP + lifestyle measures
Post-menopausal: bilateral oophorectomy
What is the histological appearance of fibroids?
Smooth muscle bundles in a whorled appearance
Define true intersex
Individual who carries both male and female gonads
Define pseudointersex
Individual has phenotype and secondary sexual characteristics different to what is defined by their karyotype and gonads. Can be male or female intersex
Explain male intersex, it’s most common cause and how it would present
46XY and testes
Phenotypically female
Presents with primary amenorrhoea
Most common cause is complete androgen insensitivity
Explain female intersex, it’s most common cause and how it would present
46XX and ovaries
Phenotypically male
Most common cause is congenital adrenal hyperplasia
Features of fragile X syndrome
Narrow face Large ears Large testicles Mental retardation Developmental delay
Inheritance of fragile X syndrome?
X-linked dominant
What syndrome does warfarin use in 1st trimester cause?
Conradi-Hunermann syndrome
Clinical features of Conradi syndrome (warfarin in 1st trimester)?
Saddle nose Frontal bossing Short stature Epiphyseal stippling Optic atrophy Cataracts
Which trimester is warfarin safe in?
2nd
What does warfarin increase risk of in 3rd trimester?
fetal or neonatal haemorrhage
Monitoring for diabetes in PCOS
If OGTT shows impaired glucose tolerance: Annual OGTT
If OGTT normal: Annual random fasting glucose
Another name for leydig cell tumour?
Hilus cell tumour
Features of leydig cell tumours?
Virilisation
Features of McCune-Albright syndrome?
Bone and ovarian cysts
Cafe au lait spots
Precocious puberty
Tx for McCune-Albright syndrome?
Cyproterone acetate (anti-androgenic progestogen)
What enzyme is deficient in congenital adrenal hyperplasia?
21-hydroxylase
Explain 46XY gonadal dysgenesis and how it might present
Phenotypically female
Mullerian structures present but gonad may remain a streak
Delayed puberty as gonads do not function
Explain 5-alpha reductase deficiency
XY Mutation in SDR5A2 gene Testes but cannot virilise Fetus has ambiguous genitalia Infertile
What karyotype is Turner’s syndrome?
46XO
Clinical features of Turner’s syndrome?
- Poor growth
- Short stature
- Webbing of the neck
- Wide carrying angle due to in-turned elbows
- Short fourth metacarpals or metatarsals
- Delayed/absent pubertal development
- Primary amenorrhoea
What medical conditions are associated with Turner’s syndrome?
o Coarctation of the aorta o Inflammatory bowel disease o Sensorineural and conduction deafness o Renal anomalies o Endocrine dysfunction e.g. thyroid disease
What effect does 21-hydroxylase deficiency on the hormone pathway?
No cortisol and aldosterone
Increased adrenal androgens
Tx of nipple thrush?
2% miconazole cream for 14 days
Can put in infants mouth if >4 months old
Examination findings of tongue tie?
Limited tongue movements - not past lips or up and down
A heart-shaped notch forms when you try to lift tongue
In posterior tongue tie the frenulum is not visible
UTI Tx in pregnancy?
Nitrofurantoin 100mg modified release BD for 7 days (avoid at term - neonatal haemolysis)
Alternative amoxicillin or cephalexin
When to offer ELCS to women with HIV? Indications?
38 weeks
HIV co-infection with Hep C
Zidovudine monotherapy
Women on HAART with viral load >50copies/ml
Why is aspirin contra-indicated in breast-feeding?
Risk of Reye’s disease in newborn
What does the progesterone challenge test involve and show?
Medroxyprogesterone acetate 5mg TDS for 5/7
Positive = vaginal bleeding –> functioning endometrium and outflow tract
Oral tx for acne and hirsuitism in PCOS?
Topical tx for hirsutism?
PO Cyproterone acetate
Topical eflornithine cream
What percentage of complete molar pregnancies go on to become invasive?
15%
How long does vulvodynia need to have lasted for by definition?
3 months
Which subset of menopausal women is fluoxetine contra-indicated in?
Breast cancer CURRENTLY receiving tamoxifen
Molar pregnancies are strongly associated with dysfunction of which gland?
Thyroid
Describe the path of the pudendal nerve
- Leaves pelvis through greater sciatic foramen between piriformis and coccygeus
- Crosses ischial spine
- Re-enters pelvis via lesser sciatic foramen
- Enters Alcock’s canal on lateral wall of ischiorectal fossa with internal pudendal vessels
How to locate the pudendal nerve trunk?
1cm below and medial to ischial spine
How long can you wait for the placenta to deliver?
1 hour
Give adjuncts of IM syntocinon and breastfeeding to stimulate its expulsion
WHO breastfeeding recommendations?
Initiate in first hour of infant’s life (in babies born to mothers with DM should be within 30 mins)
Exclusive breastfeeding for 6 months
Combination of foods and breastfeeding up to 2 years and beyond
What is used to induce multiple ovulatory events in an IVF cycle?
Human menopausal gonadotrophin + clomiphene citrate
Adjunct: FSH
Thyroxine recommendations in pregnant women with hypothyroidism?
Increase levothyroxine by 25mcg asap even if euthyroid
Check TFTs in 2 weeks
Histology of condylomata?
HPV 6 and 11
Basilar hyperplasia
Binucleated and multinucleated cells
The most common type of incontinence in women?
Stress
When do women who have had Tx in colposcopy need to be reassessed?
Test of cure in 6 months
If normal - recalled in 3 years regardless of age
In complete androgen insensitivity syndrome why do the uterine structures not develop?
The undescended testes produce anti-Mullerian hormone
Karyotype of Klinefelter’s?
47,XXY
Features of Klinefelter’s?
Tall stature Hypogonadism - infertility Gynaecomastia Sparse facial/axillary/pubic hair Delayed motor and language development
What do Klinefelter’s phenotypically present with genitalia wise?
Normal male external genitalia
What is the role of 5-alpha reductase?
Converts testosterone to more potent dihydrotestosterone which drives sexual development
What Tx should babies born to mothers with HIV receive?
First dose of ART within 4 hours of birth
Continue until 4-6 weeks
When should babies born to mothers with HIV have blood PCR tests?
Within 2 days of birth At discharge 6 weeks 12 weeks 18 months
What is the most common cause of neonatal metabolic disorder?
Hypoglycaemia
When should BMs be checked in infants born to mothers with diabetes?
2-4 hours after birth
Where does each invasive cancer first metastasise to?
- Cervical
- Ovarian
- Vulval
- Endometrial
- Pelvic lymph nodes along the iliac arteries
- Para-aortic lymph nodes
- Superficial inguinal lymph nodes
- Iliac artery lymph nodes
What test is diagnostic of antiphospholipid syndrome?
Lupus anticoagulant +/- anti-cardiolipin antibody
Features of antiphospholipid syndrome?
Recurrent or atypical venous thrombosis Arterial thrombosis Recurrent miscarriage/late fetal loss Pre-eclampsia IUGR Thrombocytopenia
Anticoagulation during pregnancy with antiphospholipid syndrome?
Low dose aspirin + LMWH
Define unprovoked vulvodynia
Chronic vulvovaginal pain lasting at least 3 months
1st line Tx of unprovoked vulvodynia?
Amitryptyline
Define uterine hyperstimulation syndrome
> 6 contractions every 10 mins
<60s between contractions
Where do the gonads descend from during embryological life?
T10 vertebral level
Where does pain from ovaries or testes get referred to?
T10 - umbilicus
How does Addison’s disease cause premature menopause?
Steroid cell auto-antibodies cross-react with theca interna/granulosa layers of ovarian follicles
Number of miscarriages and % chance or successful subsequent pregnancy
1: 85%
2: 75%
3: 60%
How does lichen planus present?
Purple/red plaques usually on labia with central erosion
Overlying lacy, white, striated patch
What is a krukenburg tumour?
Gastric carcinoma which has metastasised to ovary
Histology of krukenburg tumour?
Signet ring cells
Most common ovarian tumour in over 50 year olds?
In 20-50 year olds?
Serous adenocarcinoma
Mucinous cystadenoma
When do Hep B vaccinations for infants born to mothers with hep B occur?
Birth
4 weeks
8 weeks
1 year
Indications for ELCS?
HIV Primary genital herpes in 3rd trimester Placenta praevia major Twin pregnancy where first baby is breech Singleton breech at term after ECV fails
What is normal baseline fetal heart rate?
110-160bpm
Causes of fetal tachycardia?
Hypoxia Anaemia (fetal) Fetal distress Maternal pyrexia Chorioamnionitis Exogenous beta-agonist use
Cause of baseline fetal bradycardia?
Severe fetal distress - secondary to abruption or rupture Hypotension Maternal sedation Post-dates OP or transverse position Hypoxia
What is normal variability?
5-25bpm
How many accelerations would you expect to see normally antenatally?
At least 2 accelerations every 15 mins
Define an acceleration
Increase in fetal HR by 15bpm for at least 15sec
What do variable decelerations suggest?
Cord compression
What do late decelerations suggest?
Causes?
Fetal distress - asphyxia, hypoxia, placental insufficiency Causes: - maternal hypotension - pre-eclampsia - uterine hyperstimulation
Describe a sinusoidal trace and what it indicates
10mins of smooth wave baseline with no variability
Suggests fetal anaemia/hypoxia
How can you tell if a fetus is OP?
Anterior - diamond shaped fontanelle
Posterior - Y shaped fontanelle
In which anatomical location does fertilisation occur?
Ampulla of fallopian tube
What is the max dose of prostaglandin for IOL?
6mg/day
Complications of IOL + augmentation of labour?
Failure of induction Uterine hyperstimulation Nausea, vomiting and diarrhoea Water intoxication Uterine rupture
Which measurement is most reliable indicator of gestational age in first trimester? When should you switch to head circumference?
Crown-rump length
Once it is above 84mm
Which measurement is used to calculate gestational age after 14 weeks
Bi-parietal diameter or head circumference
Cytologically describe features of dyskaryotic cells in CIN
Anaplasia
Increased nuclear:cytoplasmic ratio
Hyperchromatism
Multinucleation
Symptoms of listeria infection in pregnancy?
Fever Headache Malaise Back ache Abdo pain Pharyngitis Conjunctivitis
Sequelae of listeria infection in pregnancy?
Miscarriage
Still birth
Preterm delivery
Neonatal listeriosis (50% mortality)
Tx of listeria infection?
High dose penicillin
Risk of parvovirus in 2nd trimester?
Hydrops fetalis
Define engagement
When less than 2/5ths of the head can be palpated abdominally
What is the maximum number of contractions associated with traction that should be used in instrumental delivery before EMCS
3
Which forceps can be used if fetus is OP
Kielland’s forceps
when can chorionic villus sampling take place?
11-14 weeks
What are the most common type of twins?
Dizygotic dichorionic diamniotic
What is the most common type of monozygotic twin?
Monozygotic monochorionic diamniotic
Requirements for twin-to-twin transfusion syndrome?
Must be monochorionic
When does twin-to-twin transfusion syndrome most commonly occur?
Monozygotic monochorionic diamniotic
What is the main hormone produced by the corpus luteum?
Progesterone
Infectious causes of miscarriage? (TORCH)
Toxoplasmosis Other infection Rubella CMV HIV
Main causative pathogens of chorioamnionitis?
E coli
Streptococcus
Enterococcus faecalis
Which term describes transition from left occipitotransverse position to OA position as head passes through pelvis?
Internal rotation
Define gravida
Number of times woman has been pregnant regardless of gestation at delivery
Define parity
Number of deliveries including all live births (even <24 weeks) and stillbirths after 24 weeks
1st number: any birth after 24 weeks
2nd number: all pregnancies up to 24 weeks which did not result in live birth
What is the gold standard test for tubal patency?
Diagnostic laparoscopy and dye test
What does a fundal placenta increase risk of?
Uterine inversion
What is the by-product of female gametogenesis?
polar body
What does T sign indicate?
Monochorionic twins
What does lambda sign indicate?
Dichorionic twins
Explain Naegele’s rule
LMP + 7days + 9 months
Components of APGAR score?
Appearance Pulse Grimace Activity Respiration
What does obstetric cholestasis increase risk of?
Preterm birth
Respiratory distress syndrome - meconium aspiration
Fetal death
Define the 4 categories of C-section
- Immediate threat to life of woman or fetus (30 mins)
- Maternal/fetal compromise but not immediately life threatening (30-75 mins)
- No maternal/fetal compromise but requires early delivery
- At a time to suit woman and health care services
What does being able to ballot the fundus and a heartbeat above the umbilicus suggest?
Breech position
Which movement occurs during crowning of the head?
Extension
Down’s syndrome screening - what is considered a positive result?
risk above 1:250
List 2 frequent risks of C-section
- Persistent wound and abdo discomfort
2. Increased risk of c-section in later pregnancies
How long does spermatogenesis take?
64 days
Explain the 5 steps of spermatogenesis.
- Primordial germ cells into spermatagonia
- Spermatagonia into primary spermatocytes (46 chromosomes)
- Primary spermatocytes into secondary spermatocytes (23 double stranded chromosomes)
- Secondary spermatocytes into spermatids (23 single chromosomes)
- Spermatids into spermatozoa (mature)
Define asthenospermia
Poorly motile sperm
Define azoospermia
Complete absence of sperm
Define oligospermia
Low sperm count
Define teratospermia
Morphologically defective
Define leucospermia
Infection in sperm
What does VBAC increase risk of?
Uterine rupture (risk increases if oxytocin used)
Most common cause of secondary PPH? Time frame for secondary PPH?
Infection followed by retained products
24 hours - 12 weeks
Which hormone promotes proliferation of glandular and stromal elements of the endometrium?
Oestradiol
Where is oestradiol secreted?
Ovary
Which type of ovarian tumours cause pseudomyxoma perotonei?
Mucinous
When should labour be induced in each of:
MCMA
MCDA
DCDA?
MCMA: 32 - 33+6 weeks
MCDA: 36 - 36+6 weeks
DCDA: 37 - 37+6 weeks
Which vaccinations are offered in pregnancy?
Whooping cough
Seasonal flu/influenza
How many cycles of IVF should women <40 be offered under NICE guidelines?
3
Criteria for IVF <40 under NICE guidelines?
- Unable to get pregnant through regular unprotected sex for 2 years
- Unable to get pregnant after 12 cycles of artificial insemination
How many cycles of IVF should women aged 40-42 be offered under NICE guidelines?
1
Criteria for IVF aged 40-42 under NICE guidelines?
- Unable to get pregnant through regular unprotected sex for 2 years
- Unable to get pregnant after 12 cycles of artificial insemination
- Never had IVF before
- No evidence of low ovarian reserve
- They’ve been informed of the additional implications of IVF and pregnancy at this age
Is it safe to breastfeed with Hep B?
Yes
Causes of oligohydramnios?
premature rupture of membranes fetal renal problems e.g. renal agenesis intrauterine growth restriction post-term gestation pre-eclampsia
What does the combined test for Downs involve?
Nuchal translucency (>6mm)
PAPPA A
beta hcg
What does the quadruple test involve? When is it applicable?
Unconjugated oestradiol hCG AFP Inhibin A 15-20 weeks
What are obese women recommended to take?
5mg folic acid
10mg Vit D
Routine antenatal screening for which 3 diseases?
Hep B
Syphilis
HIV
How much does stroke volume increase by in pregnancy?
30%
In HIV pregnant women what should be avoided?
Forceps
Amniocentesis
Fetal blood sampling
With herpes infection of genitalia - how many weeks are required between infection to clear and vaginal delivery to be possible rather than caesarean?
6 weeks
Absolute contraindications to ECV?
Multiple pregnancy
APH
Major uterine abnormality
Ruptured membranes
What does SLE in pregnancy increase risk of?
Spontaneous miscarriage Fetal death Pre-eclampsia Preterm delivery Fetal growth restriction
Features of Pruritic urticarial papules and plaques of pregnancy (PUPPP)? AKA polymorphic eruption of pregnancy
Itchy rash which appears on stretch marks late in pregnancy
Spares umbilicus
Can extend to buttocks and limbs and lesions often become confluent
Features of Pemphigoid gestationis?
blistering condition that starts in the umbilicus and spreads
Features of Prurigo gestationis?
excoriated papulitic rash of the trunk and extensor surfaces of upper limbs and shoulders with abdominal sparing.
Features of Impetigo herpetiformis?
blistering condition that always presents with a febrile illness and if not treated early can lead to maternal and fetal death
In pregnancy what are the blood glucose targets before and after eating in a diabetic?
before every meal the blood sugar should
be less than 5.5μmol/L
1 hour after a meal less than 7.8μmol/L.
What is another term for a blighted ovum and what would you see on USS?
Anembryonic pregnancy
USS:
gestational sac with no developing embryonic pole or yolk sac development
By 6 weeks what should you see on USS?
Fetal pole and fetal heart
If at 6 weeks you see a yolk sac what does it suggest and what is the next step?
Pregnancy of unknown viability
Repeat TVUS in 10-14 days
What does a pseudosac represent and what dx is it suggestive of?
decidualized reactive tissue
Suggests ectopic pregnancy
What is the risk of bladder injury in c section?
1 in 1000
What type of cancer are patients with pcos at higher risk of?
Endometrial
When is risk of VTE highest in people on HRT?
In first year
Chance of ovarian cancer with RMI <50?
3% –> watchful waiting advised
What is triptorelin?
a gonadotrapin-releasing hormone agonist that creates a temporary artificial menopause by reducing the FSH and LH levels.
When is it useful to use triptorelin and how long for
Before laparoscopy for 6 months in patients with severe endometriosis
What is the main function of progesterone?
enhance endometrial receptivity
Tx for severe PMS?
SSRIs Vit B6 Improved diet and exercise CBT Combined OCP
Tissues cut through during episiotomy?
Vaginal membrane
Perineal membrane
Bulbospongiosus
Superficial transverse perineii (STP)
CTG sensitivity and specificity
high sensitivity
low specificity
Absolute contraindications to epidural?
Uncontrolled hypotension Allergies to anaesthetics Systemic infection Skin infection over epidural site Coagulopathy
Branches of the pudendal nerve?
inferior anal nerve inferior haemorrhoidal nerve perineal nerve dorsal nerve of clitoris posterior labial nerve
Findings in DIC?
increased PT increased APTT decreased platelets increased bleeding time active haemorrhage
Complications of toxoplasmosis in pregnancy for neonate?
Classic triad: intracranial calcifications, chorioretinitis, hydrocephaly
macro- or microcephal
convulsions
long-term neurodevelopmental delay
Which procedure carries the greatest risk of haemorrhage in the newborn?
Prolonged ventouse delivery
What is looked at in semen analysis and what are the normal ranges?
- Volume 1.5 - 6mL
- pH 7.2 - 8
- Morphology normal >4%
- Motility normal >50%
- Count >15 million/mL
Markers of pelvic outlet?
inferior margin of the pubic symphysis (pubic arch)
ischial tuberosities (left and right, sometimes
called the ischial spines)
tip of coccyx
What nerve supplies the labia majora?
Posterior labial artery from internal pudendal artery
How to calculate RMI?
USS x menopause x CA125
USS (1 point out of 5 for each concerning feature)
post-menopause x3
What drug is used to reverse magnesium sulphate induced respiratory depression?
Calcium gluconate
Factors increasing risk of miscarriage?
Increased maternal age Smoking in pregnancy Consuming alcohol Recreational drug use High caffeine intake Obesity Infections and food poisoning Health conditions, e.g. thyroid problems, severe hypertension, uncontrolled diabetes Medicines, such as ibuprofen, methotrexate and retinoids Unusual shape or structure of womb Cervical incompetence
When should LMWH Tx for DVT in pregnancy be monitored and using which test?
Women at extremes of body weight
Co-morbidities e.g. renal impairment
Test used: Anti-Xa activity
When should prophylactic VTE therapy be recommended?
4+ risk factors = immediate prophylaxis
3 risk factors = from 28 weeks
List some of the risk factors for VTE prophylaxis
Age > 35 Body mass index > 30 Parity > 3 Smoker Gross varicose veins Current pre-eclampsia Immobility Family history of unprovoked VTE Low risk thrombophilia Multiple pregnancy IVF pregnancy
When is a Kleihauer test required?
Any sensitisation event after 20 weeks
Swift’s mnemonics to remember Down’s, Edward’s and Patau’s?
Down’s is “HIgh” (↑hCG ↑inhibin)
Edwards - “HE is low” (↓hCG ↓estriol)
Patau is high (↑AFP)
Causes of increased AFP?
Patau
Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy
Causes of decreased AFP?
Down’s syndrome
Trisomy 18
Maternal diabetes mellitus
Suspected endometritis Tx and what to do?
Admit
IV clindamycin and gentamicin until afebrile for >24hours
What are the glucose targets for self-monitoring pregnant women with gestational or pre-existing diabetes?
Fasting: 5.3mmol/L
1 hour after meal: 7.8mmol/L
2 hours after meal: 6.4mmol/L
What are some symptoms of TTTS a mother should look out for and why might they occur?
Any sudden increases in the size of their abdomen and/or any breathlessness, which may be the result of polyhydramnios affecting the recipient twin
Causes of increased nuchal translucency?
Down’s
Congenital heart defects
Abdominal wall defects
long term complications of hysterectomy with anterior posterior repair?
enterocele
vaginal vault prolapse
When is continuous CTG monitoring in labour warranted?
Suspected chorioamnionitis/sepsis or temp of 38+
Severe HTN 160/110+
Oxytocin use
Presence of significant meconium
Fresh vaginal bleeding that develops during labour
Which scan allows you to determine gender of a baby?
Fetal anomaly scan
Indications for fetal echocardiography in second trimester?
Mother with congenital heart disease
Mother with T1DM
Mother with epilepsy on certain meds
Previous child with congenital heart defect that required surgical correction
Inadequate/abnormal view of heart on routine second trimester scan
High-risk NT result
What feature is seen on CTG during fetal sleep?
Reduced variability
In fetal blood sampling what pH is considered normal and can allow labour to continue?
pH >7.25
What is a borderline result in fetal blood sampling and what does it mean in terms of management?
pH 7.2 - 7.25
Repeat pH needed in 30-60mins
What is an abnormal result in fetal blood sampling and what does it mean in terms of management?
pH <7.2 confirms fetal compromise
Immediate delivery
Use of what drug in preterm labour is associated with necrotising enterocolitis?
Co-amoxiclav
What happens to RR during pregnancy?
Stays the same
What happens to renal blood flow during pregnancy?
Increases
What happens to albumin during pregnancy?
Decreases
What must the bishop score be minimum to consider ARM?
5
Features of fetal varicella syndrome?
Skin scarring
Neuro defects
Eye defects
Limb hypoplasia
What is the venous drainage of the right ovary?
IVC
What are the 3 parts of the broad ligament?
Uterus: mesometrium
Uterine tube: mesosalpinx
Ovary: mesovarium
Which morning after pill does not interact with the progesterone only pill?
Levonorgestrel (Levonelle)
During labour, what is required for easy passage into mid-cavity of the pelvis?
Flexion
What stage of labour is when the levator ani muscles help the head move into the OP position?
Internal rotation
What term describes when the head moves into alignment with the shoulders before they are delivered?
External rotation (restitution)
How does cancer of the fallopian tube present?
Intermittent abdo pain relieved by sudden watery discharge
What does a posterior chin on delivery mean?
Emergency C section - can’t deliver vaginally due to large occiput
What drug is preferred in tx of hyperthyroidism when breastfeeding?
Propylthiouracil
What hormone is produced in peripheral adipose tissue?
Oestrone
If division of the embryo occurs at <3 days after fertilisation what type of twins are produced?
Monozygotic dichorionic diamniotic
If division of the embryo occurs at 4-8 days after fertilisation what type of twins are produced?
What type are produced after 8 days?
Monozygotic monochorionic diamniotic
Monochorionic monoamniotic
What measurement can provide info regarding fetal neurological status and tone?
Biophysical profile
RFs for vulval cancer?
Lichen sclerosus
HPV (16)
Smoking
Immunosuppression
Most common type of vulval cancer and what is it associated with?
Squamous cell carcinoma - lichen sclerosus
RF for vaginal cancer?
DES (diethyltilbestrol use in maternal pregnancy)
What kind of vaginal cancer do teenagers get and why?
Clear cell adenocarcinoma due to DES
What kind of vaginal cancer do older women get?
Squamous cell carcinoma
Which syndromes is PAPP-A low in?
Down’s
Edward’s
Patau’s
Which type of contraception is least affected by enzyme inducers?
Depo-provera
What are we specifically looking for in PET bloods?
FBC - low platelets
LFTs - high ALT
U&Es - high creatinine
What % of shoulder dystocia is corrected with McRobert’s?
90%
NICE cut offs for oral iron supplementation in pregnancy?
Booking visit <11g/dL
28 weeks <10.5g/dL
Who is intracytoplasmic sperm injection suitable for?
Low sperm count (oligospermia)
Problems maintaining erection/ejaculation
Who is intrauterine insemination suitable for?
Azoospermia (no sperm)
If a partner has an infectious disease e.g. HIV
If there is high risk of transmitting a genetic disorder
Same sex couples
If a woman develops chicken pox during pregnancy when should she be referred to fetal medicine?
5 weeks after infection
Which emergency contraception requires a doubling of dose in patients >70kg or BMI >26?
Levonorgestrel
When to offer ECV?
At 36 weeks for nulliparous women
At 37 weeks for multips
When does red degeneration typically present?
Mid second trimester
Risk factors for vasa praevia?
Multiple pregnancy
IVF
1st line tx for endometrial hyperplasia without atypia?
LNG-IUS
If a patient with an IUD requires tx for PID when should they be reviewed?
After 72 hours - if symptoms have not improved consider removing IUD
If previous GDM when to have ogtt?
OGTT asap after booking visit
If no GDM at booking then another OGTT at 24-28 weeks
Ix for women with pre-existing T1 or T2DM in pregnancy?
HbA1c at booking
Renal and retinal assessment
Features of listeria infection in pregnancy?
Spontaneous abortion
Premature
Pustular skin lesions
Neonatal meningitis and sepsis
When is rubella most likely to undergo vertical transmission?
8-10 weeks (90%)
Features of rubella infection in a pregnant woman?
Rash
Fever
Lymphadenopathy
Features of congenital CMV?
IUGR Chorioretinitis Periventricular calcifications Sensorineural deafness Microcephaly
Time frame for vacuum aspiration?
10-14 weeks
Time frame for dilatation and evacuation?
After 14 weeks
Risks of NSAIDs in pregnancy?
PPHN
Premature ductus arteriosus closure
Oligohydramnios
Which USS findings contribute to RMI?
Multiloculated cysts Solid areas Bilateral lesions Ascites Intra-abdominal mets
Next step for patients with a high RMI?
CT or MRI for staging
Steps in managing major PPH?
- IV/IM syntocinon
- IM carboprost
- Balloon tamponade
- B-lynch suture
- Hysterectomy
Features of congenital syphilis?
Skeletal abnormalities
Hepatosplenomegaly
Rhinitis
Tx of syphilis in pregnancy?
IM benzathine penicillin
Indications for tx for lactational mastitis and how long/what is tx for?
Persistent symptoms after 12-24hrs of effective milk removal
Nipple fissures
Systemically unwell
10-14 days of flucloxacillin
What are Call-Exner bodies and what are they pathognomonic of?
Eosinophilic fluid filled spaces between granulosa cells
Granulosa cell tumours
Who do granulosa cell tumours usually present in and symptoms?
Pre-pubertal girls - precocious puberty
Post-menopausal women - PMB
Most common type of malignant germ cell tumour and features?
Dysgerminoma
Young girls
Associated with hypercalcaemia and excess beta-hCG
Alternative to metformin in GDM if not tolerated?
Glibenclamide
Risks of polyhydramnios?
Preterm delivery
Cord prolapse
Placental abruption
Malpresentation
Definition of oligohydramnios?
AFI <5cm
Risks of oligohydramnios?
Stillbirth
Limb contractures
Incomplete lung maturation
Indications for planned C-section?
Breech at term Multiple pregnancy Placenta praevia Suspected morbidly adherent placenta Women with HIV not on ART or viral load >400copies/mL Women with HIV and Hep C Women with primary HSV in 3rd trimester
What is a severe obstetric cholestasis classed as? When should they be delivered?
Bile acids >40micromol/L
36 weeks
RFs for endometritis?
Prolonged rupture of membranes
Prolonged labour
C section
PPH
Surgical mx for urge incontinence?
Botox injections
Percutaneous tibial nerve stimulation
Sacral nerve stimulation
Augmentation cystoplasty
Define prolonged second stage of labour
Active second stage of more than 1 hour in multips and more than 2 hours in nullips
Requirements for delivery with neville barnes forceps? (FORCEPS)
Fully dilated OA position Ruptured membranes Cephalic presentation Engaged presenting part Pain relief adequate Sphincter (empty bladder)
Which instruments can be used to rotate a baby in OP position? Which is most successful?
Ventouse
Kielland forceps - most successful
How low does gestational thrombocytopenia platelet count usually go? And when does it usually occur?
70x10(9)/L
3rd trimester
When does ITP usually occur in pregnancy? What is the risk? Tx?
1st trimester
Risk = neonatal thrombocytopenia - intracranial haemorrhage
Tx = steroids or IVIG
Minimum platelet count for epidural?
Minimal platelet count for safe delivery?
Epidural = 70x10(9)/L
Safe delivery = 50x10(9)/L
After what beta-hCG level are intrauterine pregnancies usually visible? How many weeks is this?
1000 - 1500IU/L
What BMI during pregnancy warrants referral to obstetric anaesthetist?
> 40kg/m(2)
How often should women with monochorionic twin pregnancy have USS scans?
USS every 2 weeks from 16 weeks onwards
How often should women with dichorionic twin pregnancy have USS scans?
USS every 4 weeks from 20 weeks onwards
How can TTTS before 26 weeks be treated?
Fetoscopic laser ablation of communicating vessels
What problem occurs only in monochorionic twins?
TTTS
Selective growth restriction
When should GBS swabs be done if indicated?
35-37 weeks or 3-5 weeks before elective delivery
What is the bladder neck anchored to in colposuspension?
Cooper’s ligament
Triad in amniotic fluid embolism?
Acute hypoxia
Hypotension
Coagulopathy
RFs for amniotic fluid embolism?
C section
Advanced maternal age
Multiple pregnancy
APH
Dosing regimen for antenatal steroids?
2 doses of 12mg IM betamethasone 24 hours apart
Features of magnesium sulphate toxicity?
Decreased RR
Arrhythmia
Loss of deep tendon reflexes
Stages of endometrial cancer?
- In uterus only
- Connective tissue of cervix but not outside uterus
- Beyond uterus and cervix but not beyond pelvis
- Beyond pelvis
In primary genital herpes during pregnancy what is the tx?
1st/2nd trimester: PO aciclovir from 36 weeks and expectant vaginal delivery
3rd trimester: PO aciclovir from 36 weeks and c section
Within 6 weeks of due date: Start PO aciclovir immediately
RFs for prolapse?
Childbirth Old age Obesity Long term constipation Heavy lifting
Clauses of abortion act?
A: Risk to mother’s life
B: Termination will prevent serious injury to physical/mental health of mother
C: <24 weeks and continuing is risk to physical/mental health of mother
D: <24 weeks and risk to existing children/family
E: Child would be handicapped
F: Save mother’s life
What is BV in pregnancy associated with?
Preterm labour
Chorioamnionitis
Appearance of endometrioma on TVUSS?
CA125?
Echogenic “ground glass” appearance
Often raised
Advice for women on whether they are experiencing reduced fetal movements?
Lie on left side
Count movements for 2 hours
If <10 then contact maternity unit asap
When is planned vaginal delivery possible in HIV patients?
Viral load <50 copies/mL at 36 weeks
Where should medical termination be done at 12+ weeks gestation?
Clinical setting
MOA of misoprostol?
Cervical ripening
Uterine contractions
MOA of mifepristone?
Breakdown of endometrium
CIN1 where are the dysplastic cells?
Within lower 1/3rd of epithelium
When should LLETZ be offered?
Patients with CIN2, CIN3 and CGIN
Why are GnRH agonists e.g. goserelin acetate limited to 3 months of use?
They cause a significant reduction in bone mineral density
Alternative to GnRH agonist but what is the main side effect?
Ulipristal acetate (progesterone antagonist) Liver damage
Major RFs for pre-eclampsia?
CKD HTN in previous pregnancy Autoimmune disease - SLE, APS DM Chronic HTN
Moderate RFs for pre-eclampsia?
Primip Multip MAternal age >40 Pregnancy interval >10 years BMI >35 FH of pre-eclampsia
How is dx of premature ovarian insufficiency diagnosed?
2x FSH >30IU/L taken 4-6 weeks apart
PCOS hormone findings?
Elevated LH and FSH
LH:FSH ratio >1
Elevated testosterone
Reduced SHBG
4 parameters used to calculate estimated fetal weight?
Abdo circumference
Head circumference
Femur length
Biparietal diameter
Tx for molar pregnancy?
Suction curettage followed by serial beta-hCG measurements
Thyroxine requirements in first trimester/planning to get pregnant people on replacement?
Increase levothyroxine by 25mcg per day
Tx for ovarian cyst accident/rupture?
Admit for observation and analgesia
Pain should settle in 4-6 hours
Repeat TVUSS if ongoing bleeding
Twins gravidity and parity?
Counts as 1 gravidity (single pregnancy even if 2 fetuses)
Counts as 2 parity (2 babies are born)
How do RFs for VTE influence prophylaxis?
4+ = immediate LMWH until 6 weeks post partum 3 = LMWH from 28 weeks until 6 weeks post partum
Main counselling point for women taking progestogens as part of HRT?
Increased risk of breast cancer and VTE
Main SE of Nexplanon? (Implant)
Irregular menstrual bleeding
What is the most effective form of contraception?
Nexplanon
What is a beads on string sign on USS suggestive of?
chronic salpingitis, with mural nodules appearing as ‘beads’ and the relatively-thin wall appearing as ‘string’
Components of Bishop score?
Cervical position Cervical consistency Cervical effacement Cervical dilation Fetal station
Describe the normal stage 1 of labour (2 parts)
latent phase = 0-3 cm dilation, normally takes 6 hours
active phase = 3-10 cm dilation, normally 1cm/hr
Complications of hyperemesis?
Wernicke's encephalopathy Mallory-Weiss tear central pontine myelinolysis acute tubular necrosis fetal: small for gestational age, pre-term birth
Effect of smoking on hyperemesis?
Associated with decreased incidence
Life threatening complications of OHSS?
Hypovolaemic shock
Acute renal failure
Venous or arterial thromboembolism
Presentation of OHSS?
ascites
vomiting and diarrhoea
high haematocrit
Which fertility medication is most associated with OHSS?
GnRH agonists
SEs of clomiphene?
hot flushes (30%) abdominal distention and pain (5%) nausea and vomiting (2%)
Definition and Tx for recurrent vaginal candidiasis?
4+ episodes in a year
induction-maintenance regime of oral fluconazole
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
How should bleeding with no pain a woman who is <6 weeks pregnant be managed?
Expectantly
These women should be advised:
to return if bleeding continues or pain develops
to repeat a urine pregnancy test after 7–10 days and to return if it is positive
a negative pregnancy test means that the pregnancy has miscarried
Time periods for colposcopy referral?
When abnormal cytology is high-grade dyskaryosis (moderate or severe), women should be offered colposcopy within 2 weeks
If inadequate results, borderline results, or low-grade dyskaryosis (mild), they should receive an appointment within 6 weeks
When should Negative hrHPV not return to normal recall?
the test of cure for individuals who treated for CIN1, CIN2, or CIN3 (6 months)
Untreated CIN1
follow-up for incompletely excised CGIN/stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
follow-up for borderline changes in endocervical cells
Tx for ovarian cancers which are stage 2-4?
Primary: Surgical excision
Secondary: Chemo
Positive pregnancy test after TOP - when to refer?
4 weeks after TOP indicates incomplete abortion or persistent trophoblast
Safer alternative to oxybutynin in elderly women at risk of falls?
solifenacin
tolterodine
mirabegron
How long is the mirena licensed for in use as contraception in HRT?
4 years
What is placenta praevia associated with?
high presenting part or abnormal lie as a direct consequence of the low lying placenta
Ovarian cancer ix? Exception?
- CA125
- If raised - urgent USS
- Referral to gynae
Exception = abdo mass palpable - refer to gynae urgently
Normal additional HS in pregnancy?
3rd HS
Ejection systolic murmur
Forceful apex
Criteria for diagnosing a miscarriage on TVUSS?
crown-rump length greater than 7mm with no cardiac activity
Recurrence rate of postnatal psychosis?
25-50%
RFs for cord prolapse?
prematurity multiparity polyhydramnios twin pregnancy cephalopelvic disproportion abnormal presentations e.g. Breech, transverse lie placenta praevia long umbilical cord high fetal station ARM - MOST COMMON
Tx for gonorrhoea?
IM ceftriaxone
If sensitivity known give PO ciprofloxacin 500mg
Tx for chlamydia?
PO doxycycline 100mg bd
Fundal height growth normal range?
<24 weeks = 2cm a week
>24 weeks = 1cm a week
Antidepressant of choice if breastfeeding?
Sertraline or paroxetine
Indications for fetal blood sampling?
pathological CTG in labour (cervix dilated >3 cm)
suspected acidosis in labour (cervix dilated >3 cm)
Contraindications to fetal blood sampling?
Maternal infection (HIV, hepatitis, HSV)
Fetal bleeding disorders (haemophilia)
Prematurity (<34 weeks of gestation)
Acute fetal compromise (prolonged fetal bradycardia of >3 minutes)
Acute event (cord prolapse/abruption/uterine rupture)
Clinical picture suggests birth should be expedited
Interpretation of fetal blood sampling results?
pH:
- ≥7.25: Normal FBS result. Repeat after 1 hour if CTG remains the same
- 7.21–7.24: Borderline FBS result. Repeat after 30 minutes
- ≤7.20: Abnormal FBS result. Consider delivery
Lactate:
- normal: <4.1mmol/L
- borderline: 4.2-4.8mmol/L
- abnormal: >4.9mmol/L
Which stages of cervical cancer can you offer radical hysterectomy and removal of pelvic lymph nodes?
Stage IB to IIA
Technically for earlier stages too
first-line non-hormonal treatment for menorrhagia?
Tranexamic acid
Most common benign ovarian tumour in women under the age of 25 years?
Dermoid cyst
Post partum thyroiditis mx?
Beta blockers not anti thyroid drugs
Time frame for primary PPH?
<24 hours
What structures would you see week by week on TVUSS to confirm a pregnancy/determine PUL?
4 weeks - gestational sac 5 weeks - gestational sac + yolk sac 6 weeks - fetal pole with heart beat 7 weeks - amniotic membrane 8 weeks - brain structure, limb buds
What tests should be done for all pre-menopausal women with complex ovarian cysts?
serum CA-125, LDH, αFP and βHCG
Measurements in routine 2nd trimester fetal biometry?
BPD
head circumference (HC)
AC
femur length (FL)
When is the Fetal biophysical profile score assessed and what are the components? Number the abnormal findings
Fetal breathing:
- absent
- no breathing for ≥20 seconds within 30 mins
Fetal tone:
- slow extension with return to partial flexion
- absent fetal movement
Fetal movement:
1. <2 episodes of body/limb movements within 30 mins
Amniotic fluid volume:
1. abnormal if the largest pocket is <2x2 cm
CTG:
- <2 accelerations
- acceleration <15bpm in 20 mins
What is an abnormal Fetal biophysical profile score?
4/10
6/10 is borderline and must be repeated to exclude fetus being asleep as the cause
8-10 is normal
List women who should take 5mg dose of folic acid
Previous child with NTD Diabetes mellitus Women on antiepileptic Obese (body mass index >30kg/m²) HIV +ve taking co-trimoxazole Sickle cell
What to do if 1 COCP missed at any point in cycle
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
What to do if 2 COCP missed in week 1 (day 1-7)
Take last pill (even if 2 on one day)
Emergency contraception if sex in pill free interval or week 1
What to do if 2 COCP missed in week 2 (day 8-14)
Take last pill (even if 2 on one day)
Don’t need emergency contraception
What to do if 2 COCP missed in week 3 (day 15-21)
Take last pill (even if 2 on one day)
Finish pills in current pack
Omit pill free break and start new pack next day
Definition of PPH? What constitutes major PPH?
The loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby
Major = >1000ml blood loss
Layers cut through in a c section?
Superficial fascia Deep fascia Anterior rectus sheath Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba) Transversalis fascia Extraperitoneal connective tissue Peritoneum Uterus
Which cells secrete bHCG? What is its role?
syncytiotrophoblasts
acts to maintain the production of progesterone by the corpus luteum in early pregnancy
when do women experience an earlier urge to push - in OP or OA?
OP
When to follow up ovarian cysts?
Simple ovarian cyst 50-70mm in diameter - yearly USS
Larger simple cyst - MRI or surgery
Define primary amenorrhoea
No periods by 15yrs with normal secondary sexual characteristics
No periods by 13yrs with no secondary sexual characteristics
Window for taking desogestrel?
12 hours
Interpretation of serum progestogen in fertility testing?
<16nmol/l: Repeat, if consistently low refer to specialist
16-30nmol/l: Repeat
>30nmol/l: Indicates ovulation
When to consider early referral to fertility services?
Female:
- Age >35
- Amenorrhoea
- Previous pelvic surgery
- Previous STI
- Abnormal genital examination
Male:
- Previous genital surgery
- Previous STI
- Varicocele
- Significant illness
- Abnormal genital examination
What tx can you not give trans patients on testosterone therapy?
Oestrogen
Which patients should receive a special cardiac scan and when does it happen?
18-23 weeks FH of congenital abnormalities Maternal DM or connective tissue disease Antiepileptics/antidepressants Increased nuchal translucency Multiple pregnancy
What are the 4 purposes of the fetal anomaly scan?
Reproductive choice (TOP)
Prepare parents (disability/non-viability)
Manage birth in specialist centre
Intrauterine therapy
SCD screening in high risk vs low risk areas?
High risk: blood test
Low risk: family origin questionnaire
Thalassaemia screening?
All pregnant women
When are fathers offered screening of SCD/thalassaemia?
If pregnant woman is a carrier
What can be offered before fetal blood sampling if pathological CTG?
Fetal scalp stimulation - should see accelerations in response
When to measure fetal HR in labour?
Low risk: Immediately after a contraction for 1 minute every 15 mins
Rule of 3 for fetal brady on CTG?
- 3 minutes: call for help
- 6 minutes: move to theatre
- 9 minutes: prepare for assisted delivery
- 12 minutes: aim to deliver baby
Causes of prolonged brady on CTG?
cord compression cord prolapse epidural and spinal anaesthesia maternal seizure rapid fetal descent
What is the most useful predictor of fetal wellbeing in SGA foetuses ?
Fetal heart rate variation
Monitoring with epidural?
Continuous CTG for 30 mins after establishment/bolus
BP every 5 mins for 15 mins after establishment/bolus
Assess sensory block hourly
Max time after full dilation a woman with an epidural can be in labour for before giving birth?
4 hours
How long should pushing be delayed for with an epidural?
1 hour
What does active mx of 3rd stage of labour mean?
routine use of uterotonic drugs - 10IU oxytocin
deferred clamping and cutting of the cord (1-5mins)
controlled cord traction after signs of separation of the placenta
When to advise change from physiological to active mx of 3rd stage?
haemorrhage
the placenta is not delivered within 1 hour of the birth of the baby
Complications of IUGR?
still birth
PTL
intrapartum foetal distress - birth asphyxia, meconium aspiration
post-natal hypoglycaemia
neurodevelopmental delay
risk type 2 diabetes and HTN in adult life
Major RFs for IUGR?
Maternal age >40 Smoker >11cigs/day Cocaine Daily vigorous exercise Previous SGA baby Chronic HTN DM Renal impairment Antiphospholipid syndrome Low PAPPA
Which contraceptives can be given to women on enzyme inducers?
Depot medroxyprogesterone acetate
LNG-IUS
Copper IUD
Lamotrigine and COCP interaction?
May reduce seizure control
RFs for breech presentation?
Uterine malformation Placenta praevia Polyhydramnios/oligohydramnios Fetal abnormality (chromosomal/CNS malformation) Prematurity
What abx are given intraoperatively during a TAH?
IV Co-amoxiclav
When do women first feel fetal movements?
Primip 20 weeks
Multip 16-18 weeks
Most common cause of excess clear non-itchy discharge?
Ectropion
How is progress in labour after ARM assessed?
Vaginal exam 2 hours later
Thresholds for considering early birth in pre-eclampsia?
inability to control maternal BP despite using 3 or more classes of antiHTNs
maternal pulse oximetry <90%
progressive deterioration in liver function, renal function, haemolysis, or platelet count
ongoing neurological features, such as severe intractable headache, repeated visual scotomata, or eclampsia
placental abruption
reversed end-diastolic flow in the umbilical artery doppler velocimetry, a non-reassuring cardiotocograph, or stillbirth
Mild, moderate and severe pre-eclampsia classifications?
Mild: 140-149/90-99mmHg
Moderate: 150-159/100-109mmHg
Severe: >160/>110
When should mothers with diabetes deliver?
37-38+6 weeks
Retinal scans in mothers with diabetes - when?
Booking
Normal: Repeat at 28 weeks
Abnormal: Repeat at 16-20 weeks
Extra scans for serial growth measurement and amniotic fluid measurement in diabetes?
28 weeks 32 weeks 36 weeks If don't deliver between 37 and 38+6 weeks: 38 weeks 39 weeks
How can you differentiate between PCOS and CAH since both have ovarian cysts?
CAH has high serum 17-hydroxyprogesterone
What is a luteoma of pregnancy and how does it present?
Benign solid ovarian tumour
Arises only in pregnancy & disappears after delivery
Virilisation
When is surgical mx of TOP first line?
After 14 weeks
If preferred by the woman
Medical TOP failed
When should BP be checked again if a woman in antenatal clinic is found to have a high bp?
In 20 mins
If elevated - 2 further readings 4hrs apart
If still high admit for monitoring
What gestation can amniocentesis take place from?
15 weeks
Risk of miscarriage amniocentesis vs CVS?
Amniocentesis: 1%
CVS: 1.5-2%
ECTOPIC mnemonic for RFs for ectopic?
Endometriosis/previous ectopic Contraception - IUD/POP/implant Tubal surgery Other abdo surgery PID Infertility Tx Can't find cause (50%)
When should women with GDM have their glucose checked after pregnancy?
6-13 weeks fasting blood glucose
What is haematometra?
retention of blood in the uterus
Lichen sclerosis tx?
Emollients
High potency steroid ointments (clobetasol propionate)
Topical Calcineurin inhibitors (Tacrolimus)
Which increases risk of vulval cancer - lichen sclerosis or planus? When would you biopsy?
Lichen sclerosis
If not responding to tx
Lichen planus tx?
Topical steroids (clobetasol)
Oral steroids
Consider ciclosporin
Most likely cause of azoospermia?
Varicocoele
Normal dose of folic acid in pregnancy?
400mcg
Indications for intrauterine fetal transfusion?
Severe fetal anaemia usually due to red cell immunisation and parvovirus B19 infection in pregnancy
When can the ureters be damaged during gynae surgery/Csection?
When the uterine pedicle is being tied off
How much does IUI increase chances of pregnancy?
10 to 20 percent chance of getting pregnant with each IUI cycle
First investigations for hyperprolactinaemia?
First:
TFTs for hypothyroidism
Chronic renal failure
Pregnancy
Second: MRI for pituitary adenoma
Which hormone increases the most in pregnancy?
Oestriol
What is a common side effect of laparoscopy that women should be warned about?
Shoulder tip pain due to CO2 inflation
RCOG classification of OHSS?
Mild: abdo pain + bloating
Moderate: + N&V + ascites on USS
Severe: + clinical ascites + oliguria + Hct>45% + hypoproteinaemia
Severe: + VTE + ARDS + anuria + tense ascites
Normal and abnormal apgar score?
5-minute Apgar score:
7–10 = reassuring
4–6 = moderately abnormal
0–3 = low
Which organs are involved in fetal blood production?
<20 weeks: liver
>20 weeks: bone
Rotterdam criteria for PCOS?
- Oligo/amenorrhoea
- Clinical/biochemical signs of hyperandrogenism
- PCOS on USS: at least 12 follicles in 1 ovary measuring 2-9mm in diameter/ovarian volume >10ml
Trichomoniasis Ix findings?
High vaginal pH
Ovoid mobile parasites on wet saline mount
3 CTG categories?
Reassuring: all features normal
Suspicious: 1 non-reassuring feature
Pathological: 2+ non-reassuring/1+ abnormal
4Ts of PPH?
- Tissue (retained products)
- Tone (uterine atony)
- Trauma (episiotomy/perineal tears)
- Thrombin (DIC)
Which patients should get baseline TFTs in pregnancy?
Current thyroid disease Previous thyroid disease FH of first degree relative with thyroid disease Autoimmune - coeliac T1DM and T2DM
POPQ stages for urogenital prolapse?
Stage 1: cervix prolapses >1cm above hymen (within vagina)
Stage 2: cervix prolapses between 1cm above and below hymen (to introitus)
Stage 3: prolapse >1cm below hymen but no further than 2cm less than total vagina length
Stage 4: complete eversion of vagina outside introitus
Procidentia: Uterus and cervix protrude from introitus and ulceration!
Causes of secondary dysmenorrhea?
o endometriosis o adenomyosis o PID o intrauterine devices o fibroids
Contra-indications to expectant management of miscarriage?
- Increased Haemorrhage risk - late in 1st trimester
- Adverse trauma with previous pregnancy
- Coagulopathy
- Infection
When to scan during expectant mx of miscarriage?
If after 7-14 days there is no bleeding or continued bleeding
If after 3 weeks pregnancy test still positive
1st and 2nd line analgesia in pregnancy?
1st line = paracetamol
2nd line = codeine phosphate
1st and 2nd line Tx of prolactinoma?
1st line = dopamine agonist (cabergoline/bromocriptine)
2nd line = trans-sphenoidal surgery
Tx of Women with Hb <100g/l in the postpartum period?
100–200mg elemental iron for 3 months
Tx of anaemia in pregnancy?
Trial oral iron supplements for 2 weeks
Once Hb is in the normal range supplementation should continue for 3 months and at least until 6 weeks postpartum to replenish iron stores
What ferritin level in pregnancy indicates oral iron supplementation?
<30μg/l
Tx for UTI in pregnancy?
1st line = nitrofurantoin
2nd line = amoxicillin/cefalexin
Can use these all for asymptomatic bacteriuria
Tx for pyelonephritis in pregnancy?
1st line oral = PO cefalexin
1st line IV = cefuroxime
Indications for magnesium sulphate tx?
Consider the need for magnesium sulfate treatment, if 1 or more of the following features of severe pre-eclampsia is present:
ongoing or recurring severe headaches
visual scotomata
nausea or vomiting
epigastric pain
oliguria and severe hypertension
progressive deterioration in laboratory blood tests (such as rising creatinine or liver transaminases, or falling platelet count).
Surgical mx of stress incontinence?
Colposuspension (open or laparoscopic)
Autologous rectus fascial sling
Retro-pubic mid-urethral mesh sling (don’t offer first line)
Intramural bulking agents
What does a bagel sign suggest?
Ectopic pregnancy
FSH in PCOS?
Normal
Define a prolonged second stage of labour in a nullip with an epidural
3 hours
Types of breech?
Frank – the legs are extended up to head, the buttocks are the presenting part
Complete – the hips and knees are flexed, buttocks are the presenting part
Incomplete – one or both hips are extended, knee or foot is the presenting part
Footling (single/double) – one or both legs are fully extended, foot/feet is the presenting part
What do NICE recommend in the event with unstable bipolar on lithium becomes pregnant?
Switch meds gradually to an atypical antipsychotic
When to offer an ogtt in pregnancy?
BMI >30 Previous macrosomic baby Previous GDM First degree relative with DM Ethnic origin with high DM risk
What is clear fluid followed immediate vaginal bleeding suggestive of?
Vasa praevia
RFs for pre-term labour?
overstretching of the uterus: Multiple pregnancy, polyhydramnios
Conditions where foetus is at risk: Pre-eclampsia, IUGR, placental abruption
Problems with the uterus or cervix: Fibroids, congenital uterine malformation, short or weak cervix, previous uterine or cervical surgery
Infection: chorioamnionitis, maternal or neonatal sepsis, bacterial vaginosis, trichomoniasis, Group B Streptococcus, STIs and recurrent urinary tract infections
Maternal co-morbidity (for example: Hypertension, diabetes, renal failure, thyroid disease etc.)
When can you give an epidural?
Once a woman is in the active first stage of labour
Opiate analgesia in labour?
PO codeine phosphate
IM/IV diamorphine
What to give neonate if mother is Hep B positive just before labour?
HBV IgG
HBV vaccine
Both within 24 hours of birth
IM anti-emetic in hyperemesis?
IM prochlorperazine
Mx of FGM type III in labour?
anterior episiotomy during the second stage of labour under local anaesthetic or regional block
Why is CVS performed between 11-14 weeks?
Risk of fetal limb abnormalities if performed before
What are the Bishop’s score modifiers?
1 point is added to the score for each of the following:
Presence of pre-eclampsia
Each previous vaginal delivery
1 point is subtracted for each of the following:
Post-dates pregnancy
No previous vaginal deliveries
Premature pre-term rupture of membranes
Complete vs partial mole
Complete mole: 1 sperm and an empty egg with no genetic material - no fetal tissue
Partial mole: 2 sperm + 1 egg - fetal tissue
What is Potter’s syndrome?
Constellation of signs due to oligohydramnios Pulmonary hypoplasia Clubbed feet Facial deformity Congenital hip dysplasia
Contraindications to tocolysis?
Greater than 34 weeks gestation
Non-reassuring CTG, fatal foetal anomaly or intrauterine death
IUGR or placental insufficiency
Cervical dilation >4cm
Chorioamnionitis
Maternal factors: pre-eclampsia, APH, haemodynamic instability
Classifiaction of 3rd degree tears?
3a: less than 50% of the thickness of the external anal sphincter is torn
3b: more than 50% of the thickness of the external anal sphincter is torn, but the internal anal sphincter is intact
3c: external and internal anal sphincters are torn, but anal mucosa is intact
3 criteria for lactational amenorrhoea to be effective?
- Complete amenorrhoea
- > 85% of feeds are breast
- <6 months since birth of baby
Which cancer is smoking thought to reduce the risk of?
Endometiral (reduces oestrogen levels)
How long does spinal anaesthesia last? Who do we therefore give it to?
1-2 hours
Multips (primips need epidural for longer pain relief)
Highest risk of ABO incompatibility?
If mother is O negative
Cause of neonatal hydrocephalus?
Maternal rubella infection
Causes aqueductal stenosis
What is non-invasive prenatal testing for Down’s?
Maternal blood test looking at cell free foetal DNA
Being rolled out in the NHS now (fully by June 2021) as a screening tool for Down’s, Edward’s and Patau’s and some can also tell the baby’s sex (you can pay for it privately)
MORE accurate than combined test
Normal ECG changes in pregnancy?
Flat or inverted T Wave in leads III, V1 and V2
Q Waves in leads III and aVF
Risk of needing emergency c section if trialling vaginal breech delivery? Absolute contraindication to this?
40% risk of needing an emergency C-section
Footling breech
Steps in vaginal breech delivery?
- Delivery of buttocks - if handling needed put thumbs on the sacrum and fingers on ASIS of baby
- Delivery of legs and lower body - if extended use Pinard’s manoeuvre
- Delivery of shoulders - Lovset’s manoeuvre
- Delivery of head - Mauriceau- Smellie-Veit Manoeuvre
What is the least common malpresentation? How do you deliver them?
Brow
C section
When is planned C section done for breech babies?
39 weeks
Mx of uterine inversion?
summon help, discontinue uterotonic drugs, administer crystalloid aggressively and blood products (as needed), and attempt to manually reposition the uterus by pushing the fundus cephalad along the long axis of the vagina.
1st line Tx of PMS?
Exercise
CBT
Vit B6
Combined new generation pill (cyclical or continuous)
Continuous or low dose luteal phase low dose SSRIs
Tx for chlamydia in pregnancy?
Azithromycin 1g PO for one day and then 500mg OD for 2 days
UKMEC 4 to cocp?
<6 weeks post-partum and breastfeeding Age >35 and smoking >15/day Poorly controlled HTN Vascular disease Current or past history of IDH or stroke/TIA History of VTE Immobilisation due to surgery Known thrombogenic coagulopathy or positive for antiphospholipid antibodies Certain cardiac disease Migraine with aura Active breast Ca Severe liver disease or liver Ca
UKMEC 3 to cocp?
Age <35 and smoking <15/day BMI>35 Multiple RF’s for CVD Well-controlled HTN FH of VTE Immobilisation not due to surgery Migraine without aura Known carrier or gene mutations associated with breast CA Undiagnosed breast mass Past Breast Ca Diabetes with vascular disease Current gallbladder disease
UKMEC 4 to coils?
Post-partum or post-abortion sepsis
Endometrial or cervical cancer, gestational trophoblastic disease
Undiagnosed vaginal bleeding
Active PID or active chlamydia or gonorrhoea
Pregnancy
Active breast Ca (for IUS only)
UKMEC 3 to coils?
Between 48 hrs and 4weeks post-partum
Previous ectopic pregnancy
Uterine fibroids with distortion of uterine cavity
HIV with low CD4
Which method of emergency of contraception makes the POP less effective for 5 days?
Levonelle
Causes of oligo/azoospermia?
Idiopathic
Drug exposure
Varicocele
Anti-sperm antibodies – may occur after vasectomy reversal
Infection
Anatomical – congenital absence of vas deferens
Cystic fibrosis – causes obstruction
Hypothalamic hypogonadism
Kallmann’s syndrome – hypogonadotrophic hypogonadism
Hyperprolactinaemia
How is IVF carried out?
- Ovulation and Egg collection
- Single injection of LH or hCG given 34-38 hours before eggs collected - Fertilisation and culture
- Eggs and sperm incubated and transferred to growth medium
- Grown for 6 days before transfer to uterus
- Leftover embryos can be frozen - Embryo transfer
- Single or double embryo transfer
- Can give luteal phase support with progesterone of hCG until 4-8 weeks
Risk of miscarriage in threatened miscarriage?
25%
Chance of successful VBAC? How does that change if previous successful VBAC?
75%
Increases to 85-80%
Largest diameter of fetal skull?
Occipito-frontal – 11cm
Suboccipito-bregmatic – 9.5cm
Submento-bregmatic – 9.5cm
Vertomental – 13cm (brow presentation - too large for vaginal birth) – The pelvic mid-cavity diameters are 11cm in transverse and AP, the pelvic outlet diameters are 11cm transverse and 12.5cm AP (inlet diameters are 13cm T and 11cm AP)
Ix if PPROM suspected but no amniotic fluid visualised on speculum?
consider IGFBP-1 (insulin like growth factor binding protein -1) or PAMG-1 (placental alpha microglobulin -1)test
Tx of toxoplasmosis in pregnancy? What is added if congenital infection suspected?
Spiramycin
+sulfadiazine and pyrimethamine
