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obs and gynae > ILA revision > Flashcards

ILA revision Flashcards

1
Q

what does tender lt iliac fossa make you think..?

and what other symtpoms / features would make you suspect it … even more…

A

ectopic?

sexually active woman
abdo pain
fainting
bleeding 
especially in early preganncy 
d&v
(no guarding, no rebound tenderness, no masses)
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2
Q

how to differentiate between an ectopic and an intrauterine pregnancy

A

TVS + P-USS
bloods - (bHCG rasied in both - but prog <5 rules out intrauterine pregnancy- ie failing pregnancy)
(-ve serum B-hCG excludes ectopic 99%)
FBC, clotting, group and save
ectopic - OE - may be shocked / hupotensive / tachy / peritonitic

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3
Q

how to manage an ectopic:
(and when expectant…?)
what drug for medical
what surgical procedures…

A

2 large bore cannulae
fluids - crystalloids then colloids
may be suitable for expectant if:
- aSx / mild / hCG <3000 / <3cm / no haemoperitoneum
medical - MTX
surgical:
1. salpingectomy - removing the tube if the contralateral is healthy
2. salpingotomy - tubal incision to remove ectopic if the other tube is not healthy…. increases risk of another ectopic..
laparotomy if unstable..

Expectant Medical Surgical
Size <30mm Size <35mm Size >35mm
Unruptured Unruptured Can be ruptured
Asymptomatic No pain Severe pain
No fetal heartbeat Visible fetal heartbeat

Exp:B-hCG <200IU/L and declining
MedL: serum B-hCG <1500IU/L
Surg: serum B-hCG >1500IU/L

Not medical if another intrauterine pregnancy

Expectant management involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed.

Medical management involves giving the patient methotrexate and can only be done if the patient is willing to attend follow up.

Surgical management can involve salpingectomy or salpingotomy

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4
Q

what is the finding of endometrioisis on bimanual palpation

A

fixed retroverterted uterus

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5
Q

what hormones are released from the ant and post pit

A 
ant: GAF TPM
GH
ACTH (salt stress sex) 
FSH
TSH
Prolactin 
Melanocyte stimulating hormone

post: OA
oxytocin
adh

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6
Q

what do the following blood pictures make you think?

a. raised LH:FSH ration (3;1)
b. raised FSH (>40)
c. low fsh and low lh

A

a. PCOS
b. ovarian failure..
c. hypothalamic failure

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7
Q

what is it important to exclude in recurrent PCB?

A

cervical cancer

with or without IMB

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8
Q

what are some common causes of IMB?
define IMB
what is it important to exclude?

A

breakthrough bleeding with hormonal contraception
IMB - bleeding occuring between clearly defined cyclical and regular menses
EXCLUDE:
pregancy
infection ( esp chlamydia infection of cervix / vagina)

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9
Q

what is it important to exclude in PMB?

what are other causes?

A

uterine Ca
Ix: TVS - if endometrium <3mm then endometerial path unlikely
endometrial biopsy - diagnostic hysteroscopy
other causes:
- other GU tract tumours
- stimualtion of endometrium (exogenous oestrogen eg HRT / oestrogens from ovarian tumours)
-infection
-post meno atrophic vaginitis

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10
Q

list the structural and non-structural causes of abnormal uterine bleeding…

A

PALM-COEIN (polyp [5-10%]; adenomyosis5%; leiomyoma 20-30%; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified)

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11
Q

what investigations might you order in menorrhagia

A

EXCLUDE ANAEMIA / LOCAL CAUSES / MALIGNANCY / SYSTEMIC CAUSE
if PCB / IMB - investigate further

FBC - ?anaemia
TVS - ?structural abnormalities
TSH - ?hypo/hyperthyroid
endometrial biopsy if ?uterine malignancy
hysteroscopy if unresponsive to treatment

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12
Q

how would you manage / treat menorhagia?

A
  1. provide information on menorrhagia and its management** put this for lots of stuff….**

no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis:

if tryong to conceive:
Non-hormonal: tranexamic acid or a non steroidal anti-inflammatory drug (NSAID) eg. mefanamic acid..

if not trying to conceive:

  1. Mirena IUS is first line - may see changes in bleeding pattern
  2. then COCP
  3. cyclical oral progestogen (such as oral norethisterone - P-only contraception can suppress menstruation) / Depot-provera

other options (surgical):
Uterine artery embolization (UAE)
UAE involves cannulating the femoral artery and identifying the uterine arteries before injecting an embolic agent into them to impair the blood supply to the uterus and fibroids (if present).
Women should be informed that UAE may potentially allow them to retain their fertility.
Myomectomy
Women should be informed that myomectomy may potentially allow them to retain their fertility.
Myomectomy may increase pregnancy rates compared with UAE in women with fibroids who wish to retain fertility.
Hysterectomy
The route of hysterectomy can be vaginal, abdominal, or laparoscopic. It may include removal or preservation of the ovaries, and/or removal or preservation of the cervix.
Women should be informed:
About the increased risk of serious complications (such as intraoperative haemorrhage or damage to other abdominal organs) associated with hysterectomy when uterine fibroids are present.
About the risk of possible loss of ovarian function and its consequences, even if their ovaries are retained during hysterectomy.
In all women who are considering hysterectomy, a full discussion should be had about the implications of surgery before a decision is made. The discussion should include:
Psychological impact.
Alternative surgery.
The woman’s expectations.
Treatment complications.
Need for further treatment.
Bladder function.
Impact on fertility.
Endometrial ablation
Endometrial ablation involves destroying the endometrium (lining) and the superficial myometrium (muscle) of the uterus.
Women should be informed to avoid subsequent pregnancy and use effective contraception, if needed, after endometrial ablation.

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13
Q

describe the differentiating features of placenta praevia and placental abruption..

A

PP:
painless, non-tender uterus, unstable lie, normal tone of uterus, BLOOD LOSS RELATES TO MATERNAL CONDITION

PA: constant pain / tender tense uterus / longitudinal lie / hypertonic uterus / blood loss incongruous with maternal condition

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14
Q

when should vasa praevia be diagnosed? (and when is this..)

A

colour USS at fetal anatomy scan

18-20 weeks

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15
Q

describe the risk factors for uterine rupture and its presentation

A 
labour stops
uterus hard
blood 
fetal distress
more likely with previous CS and grand MP women (obvs.. easier for it to split)
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16
Q

how would you investigate suspected APH in primary care>

full investigations:

A
  1. DO NOT DO A VAGINAL EXAMINATION IN PRIMARY CARE FOR SUSPECTED APH - WOMEN WITH PLACENTA PRAEVIA MAY HAEMORRHAGE
  2. stabilise if necessary
  3. transfer to a hospital maternity unit with facilities for resuscitation (such as anaesthetic support and blood transfusion resources) and performing emergency operative delivery.

Do BP + HR
O/E - abdominal palpation- tender/woody in abruption
no vaginal exam.
Speculum exam may be done as well - safe in placenta praevia
Rhesus D-negative
TV-USS - can Dx praevia BUT not exclude abruption
CTG monitoring begun

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17
Q

what are the DDxs for APH in primary care?

A

placental abruption
placenta praevia
vasa praevia
smaller - cervical ectropions etc..

18
Q

what is the management of a primary PPH

A

Management:

A and B – assess airway and breathing
A high concentration of oxygen (10–15 litres/minute) via a facemask should be administered.
● C – evaluate circulation
Establish two 14-gauge intravenous lines; a 20 ml blood sample should be taken and sent for diagnostic tests,
including full blood count and assessment of FMH if RhD-negative, coagulation screen, urea and electrolytes
and cross match (4 units)

call for help - senior midwife, obstetrics registrar, anaesthetics registrar on call. alert blood transfusion labs and porters.
Push IV fluids, send blood for crossmatch and group and save
catheterise
deliver placenta, empty uterus, massage
Drugs to contract the uterus:
IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
IM carboprost (up to 2 doses)

if medical options failure to control the bleeding then surgical options will need to be urgently considered
the RCOG state that the intrauterine Rusch balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage

other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries

if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

19
Q

deifne 1y and 2y pph
define major 1y

when does 2y usually occur?

A

1y - blood loss of >500mls that may be primary or secondary
major - >1L

2y - occurs between 24 hours - 12 weeks**
due to retained placental tissue or endometritis
USUALLY 5-12 days post due to retained tissue or clot - often concurrent infection needing ABx tx

20
Q

what are the causes of 1y pph (the 4ts)

A

tone (poor tone causes 90%)
tissue - retained products of conception
trauma - g tract trauma
thrombin - 3%

21
Q

what is labour defined as?

4 criteria

A
  1. regular uterine contractions
  2. up to 2.5 mins each
  3. with 30s rest in between
  4. dilatation of cervix
22
Q

how can you interpret a CTG?

describe the features of decelerations. which are reassuring, which are non-reassuring, which are abnormal

what are decelerations?

Decelerations are an abrupt decrease in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds.

A

How to read a CTG
To interpret a CTG you need a structured method of assessing its various characteristics.

The most popular structure can be remembered using the acronym DR C BRAVADO

DR – Define Risk

C – Contractions

BRa – Baseline Rate

V – Variability

A – Accelerations

D – Decelerations

O – Overall impression

early - fine - reassuring. physiological - foetus HR is dropping during the contraction

variable - usually seen in labour, usually caused by umbilical cord compression: ¹
Accelerations before and after a variable deceleration are known as the “shoulders of deceleration”.
Their presence indicates the fetus is not yet hypoxic and is adapting to the reduced blood flow.

Late deceleration
Late decelerations begin at the peak of the uterine contraction and recover after the contraction ends.
This type of deceleration indicates there is insufficient blood flow to the uterus and placenta.
As a result, blood flow to the fetus is significantly reduced causing fetal hypoxia and acidosis.

Reduced uteroplacental blood flow can occur due to: ¹

Maternal hypotension
Pre-eclampsia
Uterine hyperstimulation

Prolonged deceleration
A prolonged deceleration is defined as a deceleration that lasts more than 3 minutes.
If it lasts between 2-3 minutes it is classed as non-reassuring.
If it lasts longer than 3 minutes it is immediately classed as abnormal.

Sinusoidal - BAD

23
Q

what is syntocinon?

what are the indications…

A

Syntocinon is a synthetic version of oxytocin that is used in the active management of third stage of labour. It stimulates the contraction of the uterus reducing the risk of postpartum haemorrhage. It is also used to induce labour.

24
Q

what is ergometrine?

what is the mechanism?

what are the ADRs?

A

Ergometrine is an ergot alkaloid which is used as an alternative to oxytocin in the active management of third stage of labour. By constricting vascular smooth muscle of the uterus it can decrease blood loss.

Mechanism of action
stimulates alpha-adrenergic, dopaminergic and serotonergic receptors

Adverse effects
coronary artery spasm

25
Q

what is mifepristone?

what is the indication?

what is the mechanism of action?

what are the ADRs?

A

Mifepristone is used in combination with misoprostol to terminate pregnancies. Misoprostol is a prostaglandin analog that causes uterine contractions.

Mechanism of action
competitive progesterone receptor antagonist

Adverse effects
menorrhagia

26
Q

define early, late miscarriage and APH

A

early: <12 wks
late: 12-24 wks
APH: any bleeding post 24wks

27
Q

describe the presentation of hydatiform moles

A

irregular vaginal bleeding
hyperemesis
XS uterine enlargement
EARLY FAILED PREGANCY

28
Q

describe the diagnosis of hydatiform moles

A

USS

Definitive - histology of products of conception post evacuation

29
Q

decribe the tx of hydatiform moles

and what do you need to be aware of when conducting this…

A

evacuation
THYROTOXIC STORM MAY OCCUR AT EVACUATION
HCG produced by the mole imitates TSH

30
Q

what does GDM increase the risk of in:

  1. mum
  2. baby
A
  1. increased risk of LSCS, increased risk of preeclampsia and infection, 7x risk of DM2 in later life
  2. miscarriage / increased malformation rates / (sacral agenesis pathognomic)
    macrosomia (which then increases risk of shoulder dystocia)
31
Q

outline the screening crieria for gdm

A 
1st degree relative with gdm
previous macrosomic baby
bmi >30
ethnicity
prev gdm
32
Q

outline the 4 main causes of early pregancy problems:

A
  1. thyroid disease (hyper - mental development of baby at risk)..
  2. uncontrolled GDM - sacral agenesis
  3. teratogenic medications - ACEis / warfarin in wks 6-9
  4. folic acid deficiency - neural tube defects - early pregnancy
33
Q

MISCARRIAGE:

list the types of miscarriage, and say whether the cervical os is open or closed…

A
  1. threatened - os closed (mild Sx of painless bleeding pre 24wks - 1/4 of all pregnancies - often OK)
  2. inevitable - os open (very heavy bleeding but baby still alive - v distressing)
  3. complete - os (re)closed (Hx of recent confimed IU pregnancy - may Px with recent Hx of heavy bleeding and clots)
  4. incomplete - os open (pain + PV bleeding, some fetus parts passed)
  5. Missed / delayed / silent - os closed (finding of non-viable foetus / empty uterine sac at 24wks)
34
Q

define miscarriage

A

baby dies or is delivered dead before 24 completed weeks of pregancny

35
Q

RFs for miscarriage?

A 
age
prev miscarriage 
infections
smoking 
antiphospholipid Antibodies / other clotting disorder
uterine abnormalities - esp fibroids
36
Q

Ix of suspected miscarrigae?

A
  1. srrum bHCG (rise of 66% over 48hrs = viable preganncy)
  2. TVUSS
  3. FBC / group and save / Rh blood group (post 10weeks - give anti-D)

may also want to do:
pelvic uss
parent karyotyping
autoantibodies

37
Q

management of miscarriage

3 methods, and some extra bits..

A

Expectant:
haemodynamically stable
wait and observe 7-14 days ->repeat TVUSS

Medical:
offer to ALL women
oral / vaginal misoprostol (PG analogue)
Re test in 3 weeks (B-hCG)

Surgical:
if haemodynamically iunstable / ongoing symptoms post expectant and medical
ERCP - evac of retained products of conception

additional?
Anti-D - post 12weeks (late miscarriage)
counselling

38
Q

vaginal bleeding, abdo pain, fever. vaginal discharge, foul odour. SHOCKED. what do you suspect?

A 
septic miscarriage
associate with incomplete miscarriage
can lead to endometritis 
ABCDE 
bufalo
surgery
39
Q

what do you need to investigate the possibility of in all persistent post pregnancy PV bleeding?

A

CHORIOCARCINOMA

responds well to combination chemotherapy based on MTX

40
Q

when is Anti-D given in Rh-ve mothers?

A

SENSITISING EVENTS:
late miscarriage(post 12wks)
abdominal trauma
bleeding

ROUTINE:
28 weeks
if baby’s blood group (from umb cord) is rh+ve - give to mum

IT’S PROPHYLAXIS - no use giving it days post sensitisation

41
Q

what is eclampsia and how would you manage it?

A

eclampsia is preeclampsia +

obs and gynae (4 decks)

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