JLS O&G Flashcards
What is mild, moderate and severe hypertension in pregnancy?
Mild = 140/90-150/100
Moderate = 150/100-160/110
Severe = >160/110
What tests should be ordered in suspected pre-eclampsia (and what components of the test are you specifically looking for)?
FBE
- looking at red cell count
- looking at platelets
Blood film
- Shistocytes
LDH
LFTs
- Particularly looking at AST
UEC / uric acid
Urine dipstick
Spot urine:creatnine ratio
Which component of LFTs is naturally elevated in pregnancy?
ALP (there are ALPs of placental origin)
What are some features that make nausea & vomitting in pregnancy more likely to be hyperemesis gravidarum rather than just simple morning sickness?
- persistent vomiting
- volume depletion
- ketosis
- electrolyte disturbances
- weight loss
What is the definition of azoospermia?
absenze of sperm cells in semen
What is the definition of asthenozoospermia?
Reduced sperm motility
(Same as asthenospermia)
Think: your tongue has to be motile to say that word
What is the definition of asthenospermia?
Reduced sperm motility
(Same as asthenozoospermia)
Think: need to have a mobile tongue to pronounce this word.
What is aspermia?
A complete lack of semen
What is the term used to secribe abnormal morphology of sperm?
Teratozoospermia
What is alendronate?
A bisphonphonate
(Alendronic acid)
What terms are used to describe separate CTG features?
What terms are used overall CTG assessment?
Separate CTG features =
Reassuring, Non-Reassuring, Abnormal
Overall Assessment =
Normal, Suspicious, Pathological
(Think: separate features are just reassuring or not… got to have the whole picture to call it normal)
What are the parameters for baseline rate on CTG?
Reassuring = 110 - 160
Non-Reassuring = 100-110
Abnormal = 160
What are the parameters for variability on CTG?
Ressuring = 5-25bpm
Non-reassuring = 3-5bpm
Abnormal =
What are the criteria for sleep phase?
Variability
How do you diagnose missed miscarriage on US?
If the crown rump length (CRL) is >7mm and there is no foetal heart beat
If the gestational sac / mean sac diameter is >25mm and there is no foetal pole (i.e. it is empty)
What do you do if you get a HSIL on a Pap smear?
Refer immediately for colposcopy, regardless of age
On what day do you measure progesterone to check for ovulation?
What values indicate ovulation / anovulation?
Day 7 of luteal phase (day 21 of 28 day cycle)
>30 = ovulated
Who am I (Contraception):
The prime mechanism of action is inhibition of ovulation but also causes thickening of cervical mucus. This treatment also decreases the risk of endometrial and ovarian carcinoma.
COCP
A 25-year-old patient, who has been trying to get pregnant, presents to the GP with a small amount of vaginal bleeding with vague lower abdominal cramping. Her LMP was 4 weeks ago. On examination her heart rate is 70 and BP 120/80. Her other observations are normal. Her bHCG is 400 IU/L. Her pelvic ultrasound shows an empty uterus and a 20 mm cystic structure in her left ovary with peripheral vascularity. Your next step is?
Repeat BHCG in 48 hours
What is the biggest risk in premature delivery?
Previous premature delivery
What is the biggest risk factor for having pre eclampsia?
previous pre ecmlampsia
What types of steroids do you give for prematurity and at what frequency?
Two doses of 12 mg IM betamethasone, given 24 hours apart
OR
Four doses of 6mg IM dexamethasone, given 12 hours apart
When do you give steroids?
- For any C section (which is usually less than 39 weeks)
- For vaginal delivery between 24 and 35 weeks (consider under 24 weeks
If you are inducing someone at 36 weeks, do you give steroids?
Not according to guidelines
What is the most common cause of menorrhagia?
dysfunctional uterine bleeding
(>80% of all primary menorrhagia)
What is the difference between primary and secondary menorrhagia?
Why is this distinction clinically useful?
Primary - since menarche
Secondary - later onset
Secondary menorrhagia is more likely to have an underlying cause (and not just be DUB).
What tumor markers would you order if you suspected a cancer?
(NOTE: in reality you would be HESITANT and VERY CAREFUL to order these markers)
CA 125 (ovarian. sensitivie but not specific)
HE4
AFP
LDH
B-HCG
CEA
CA 19.9
Tests (such as tumor markers) alone are not sufficient to diagnose ovarian cancer.
What tools can help you?
Risk stratifictaion tools
The risk of malignancy index (RMI)
The Risk of of Malignancy Algorithm (ROMA)
Uses a number of factors such as CA-125, menopasual status, U/S findings to calculate risk
What are the risks for shoulder dystoicia?
You can’t predict shoulder dystocia!
The strongest predictive factor is previous shoulder dystocia!
Pre-Labour
- Previous shoulder dystocia
- Increased BMI
- Macrosomia
- GDM
Labour - but these could be correlative, not causative!
- Prolonged first stage
- Prolonged second stage
- Instrumental delivery
- IOL
What are the US findings of adenomyosis?
“thickening of the junctional zone”
“venetian blind” pattern of accoustic shadowing
What is the Mx of Adenomyosis / Endometriosis?
Non-Hormonal
- Mefenamic acid (Ponstan)
- Tranexamic acid
- Paracetamol
Hormonal
- Mirena
- COCP
Surgical
- Laparoscopic ablation
- Laparoscopic excision
- TAH & BSO
What does a “bulky uterus” mean on by manual palpation?
generally enlarged
What are the adnexa?
The adnexa of uterus (or uterine appendages) are the structures most closely related structurally and functionally to the uterus.
What is cervical excitation (cervical motion tenderness) and it’s significance?
Painful manipulation of the cervix
Helps to differentiate between pathology of the reproductive tract vs of the GI or urinary system
What are the possible causes of hydrosalpinx?
PID
endometriosis
tubo-ovarian abcsess
What are the components of the RMI?
What is it for?
RMI combines three pre-surgical features
Ultrasound score (U) Menopausal status (M) Serum CA-125 level (IU/ml)
RMI score = U x M x CA 125 value.
Score ≥200 = high risk of malignancy.
What is included in a partogram?
Four Domains
- Maternal well-being
- Maternal vitals (to be measured 4 hoursly, maternal HR to be measured hourly)
- Urine (to be measured 4 hourly)
- Foetal Well-Being
- Foetal HR (measure every 15 minutes during stage one, then during every contraction - for one minute)
- Amniotic fluid (a VE is done four hourly)
- Moulding
- Progress of labour (a VE is done four hourly)
- Palpable fifths
- Station (compare with alert & action lines)
- Dilation (compare with alert & action lines)
- Length / effacement
- Consistency
- Contractions (measured every 30 minutes)
- Interventions
- Syntocinon
- Drugs
- Fluids
What are the symptoms of menopause?
Muscle aches
Energy levels reduced
Night sweats
Osteoporosis – pathological fracture
Psych – [depression, headache, reduced concentration & memory]
Aretries = vasomotor symptoms (hot flushes & night sweats)
Urogenital symptoms – increased frequency, urgency, UTIs, prolapse
Sex – loss of libido
Extra risk of CV disease and osteoporosis
what is an oulet, low and mid operative vaginal delivery?
Outlet
- Fetal scalp visible without separating the labia
- Fetal skull has reached the pelvic floor
Low
- Leading point of the skull (not caput) is at station plus 2 cm or more and not on the pelvic floor
Mid
- Fetal head is no more than 1/5th palpable per abdomen
- Leading point of the skull is above station plus 2 cm but not above the ischial spines
NB High is not included in the classification as operative vaginal delivery is not recommended in this situation where the head is 2/5th or more palpable abdominally and the presenting part is above the level of the ischial spines
How do you screen for rubella?
Titre
(Immunity can wane)
If someone is Hep B +ve what do you do?
Viral load
LFT
R UQ US
Referral to ID
Why do you test for asymptomatic bacturia?
How do you treat it?
1/3 risk of pyelonephritis due to
Compression of urteres
Progesterone (slows down bowel and bladder)
Treat and continue to treat throughout pregnancy
WHat is the most common cause of congental deafness?
CMV
(but a lot are asymptomatic)
Who carries CMV?
sticky toddlers
What is the dose of IgG you give to a child born to an Hep B + mother and how?
100IU of IgG
GIven in opposite thighs
What follow up is required for a pregnant woman with Hep B?
F/U of LFTs and look out for HCC
Screen others in family
Follow up baby
how can you test for foetal anaemia?
how can you test for foetal IUGR?
MCA peak systolic velocity (low viscoty of blood - travels faster)
MCA pulsatility index (shunting blood to the brain)
At what IgG level do you ensure a woman has a rubella vaccine post partum?
congenital syphillus looks like?
snuffles
saddle nose
sabre shins
Hutchinson’s trid: notched incisors, keratitis, 8th nerve defects
what does congenital varicella look like?
dermatomal scarring
contratures
what is the magic number for antivirals in varicella?
96 hours
what is the definition of labour?
contractions which dause cervical change
when can you call a placenta praevia a praevia?
in the third trimester
(before this, it’s a low lying placenta)
smoking is a risk factor for everything in pregnancy except for one this, what?
preeclampsia
(but if you do get it and you smoke, it is likely to be worse!)
What else should be measured on a mid trimester screen?
in what other context is this useful?
cervical length
If it is short (
also for cervical surveillance
why do you give erythro in PPROM?
how long do you give it for and how much?
Because the reason for it is probably infection
10 days qid (because the ORACLE trial only studied it for 10 days!)
If you are
You repeat the Pap smear in 12 months
If normal: repeat in another 12 months, and then if normal again, back to two yearly.
If the (any of the) repeat(s) is(are) LSIL or HSIL –> colposcopy
If you are >30, and you have a LSIL on Pap smear, what is recommended?
If you have had a normal smear in the previous 2-3 years, repeat in 12 months
If you haven’t had a normal smear in the previous 2-3 years EITHER do a colp OR re-do smear in 6/12
If a woman has a HSIL on pap smear, what should be done next?
straight to colposcopy
What should you do if you receive an unsatisfactory smear?
Repeat in 6-12 weeks (enough time for cervical cells to re-grow)
After you have had treatment for a HSIL, what is required?
You will need six normal tests before returning to two yearly Pap smears.
These are:
- Pap smear & colposcopy 4-6 months post Rx
- Pap smear & HPV 12 months post Rx
- Pap smear & HPV 24 months post Rx
in what nomencutalture / grading system is a Pap smear usually reported?
The Bethesda System
(Cytology)
HSIL / LSIL
In what nomenculature / system is a cervical biopsy usually reported?
CIN I - III / Histopathology
What is the DOHaD Barker hypothesis?
That SGA babies are at a higher risk of metabolic syndrome as adults
What is the definition of SGA?
What is the issue with this term?
SGA =
A. more than 2SD below the mean, or
B. less than the 10th percentile
The issue with this term is that
- some babies are constitutionally small and not IUGR
- some babies are IUGR and not SGA (ie. not
Why are we so worried about IUGR?
IUGR increases the risk of still birth x 4
What is the margin of error for EFW?
+/- 10%
This increases later on in the pregnancy because as the head engages it can’t be measured
What parameters are used to calculate EFW on US?
Which is the most sensitive of all the parameters to IUGR?
BPD (Bi Parietal Diameter)
HC (Head Circumference)
AC (Abdom circumference)
FL (femur length)
The most sensitive = AC
How do you measure and monitor foetal well-being in IUGR on ultrasound?
To identify IUGR
- Measure growth (AC, HC, BPD, FL)
- Plot on graph
Once IUGR is identified
- Doppler Umbilllical Artery Systolic:Diastolic Ration (UASDR)
- forward flow (normal)
- absent flow
- reversed flow
- Amniotic Fluid Index
- Middle Cerebral Artery Pulsatile Index (MCPAI)
- PI reduced with foetal compromsie
- (NB: flow in the MCA increases in anaemia)
- Ductus Venosus Flow
- Increase flow in foetal compromsie
- Pre-terminally: reduced flow. If you see this the baby will die in the next few days
- Biophysical profile
How are the umbillical vessels named?
Of which is there two and which one?
as per the foetus
ie. two x arteries from the illiac arteries going to the placenta (away from the foetal heart)
one x umbillical vein
What does a ‘recative’ CTG really mean?
a normal antenatal CTG with accelerations
What are the components of the biophysical profile?
How is it scored?
Non-stress test / antenatal CTG
Tone
Breathing movements
Gross movements
AFI
(each component is given a 2 or a 0, no 1s)
What do early deccels indicate?
Head compression
What non-foetal measurement is taken on the 20 week US, and why?
Cervical length
Cervical shortening in those who are already at risk of preterm birth have an even greater risk of preterm birth.
What is the most midely used “cut off” for a short cervix?
≤20mm at 18-22 weeks gestation
(3 centres)
What is cervical insiffuciency?
Why is it significant?
A congenital or acquired (e.g. by previous surgery) structural weakness of the cervix.
[The term “cervical incompetence” is considered pejorative and insensitive]
Cervical insufficiency is associated with an increased risk of mid-trimester pregnancy loss or preterm birth.
What are the risk factors for preterm birth?
- previous preterm birth
- preterm rupture of membranes
- multiple pregnancy
- antepartum haemorrhage
- systemic infections
- genital tract infections
- cervical insufficiency
- shortened cervix*
- congenital uterine abnormalities
*While there is an association between a shortened cervix and preterm labour and birth, most women with a short cervix do not experience a preterm birth and most preterm births are not related to a cervical problem. Look at other risk factors
What are the options for treatment of a short cervix?
- Conservative management
- do nothing, especially if no other risk factors
- Cervical surveillance
- ongoing monitoring of cervical length
- Progesterone
- vaginal progesterone
- Cervical cerclage / cervical stitch
What are the indications for / types of cervical cerclage?
When are each performed?
The terms “emergency, therapeutic and prophylactic” are no longer used.
History-indicated cerclage
- Insertion of a cerclage based on history / increased risk factors
- performed as a prophylactic measure in an asymptomatic woman and normally inserted electively at 12–14 weeks of gestation
Ultrasound-indicated cerclage
- Insertion of a cerclage as a therapeutic measure in cases of cervical length shortening seen on transvaginal ultrasound.
- Performed on asymptomatic women who do not have exposed fetal membranes in the vagina.
- Sonographic assessment of the cervix is usually performed between 14 and 24 weeks of gestation.
Rescue Cerclage
- Insertion of cerclage as a salvage measure in the case of premature cervical dilatation with exposed fetal membranes in the vagina.
- May be discovered by ultrasound examination of the cervix or as a result of a speculum/physical examination performed for symptoms such as vaginal discharge, bleeding or ‘sensation of pressure’.
What can be said about the two types of cerclage techniques; Shirodkar and McDonald?
What route are these inserted?
No evidence that one is better than the other
Usually inserted transvagibally but can be inserted transabdominally
Is there any evidence for bed rest with cervical shortening?
No
What is recommended as treatment for low risk women with a short cervix, in preventing preterm labour?
- If cervix is >25mm - it isn’t short, do nothing.
- If cervix is 20-25mm - cervial surveillance every 1-2 weeks
- If cervix is
- If cervix is
What is recommended for high risk women with a short cervix?
Cervical cerclage is more readilly recommended.
The situation in which the short cervix is found (history, U/S or symptoms) dictates which type of cerclage should be inserted and when (history-indicated, U/S-indicated or redscue cerlage)
What does a “washed out” vagina mean and what is it’s significance?
An absence of leucorrhoea which you would normally see on spec exam of a pregnant woman.
Supportive of PPROM / PROM
What can be used for tocolysis?
nifedipine (oral) - watch BP
tebutaline (SC)
salbutamol
GTN patch (often used in C section)
NSAIDs also work well - but care of foetal heart!
How do you write up an order for tocolysis for transfer?
And what is done for maintenance once the woman arrives at the tertiary centre?
20mg nifedipine stat
Repeat 20 minutes later
Repeat 20 minutes after that
For maintenance: 20mg nifedipine 8 hourly, until second dose of steroid has been administered
At what GA do you conisder active management in PPROM?
At what GA do you consider expectant management?
At what GA do you consider termination?
>34 weeks : active
24 - 34 : expectant
What should you consider on every antenatal inpatient admission, except if they are admitted with BEP or APH?
Clexane
Ted stockings always (if they are spending more time resting in bed than mobilising)
You have admitted a woman with PPROM who is staying there for expectant management (at least for the first few days). What should you assess regularly?
Health of Mother
- Vital signs
- Abdominal palpation
- FBE
- CRP
- High vaginal swab weekly
Health of Foetus
- Foetal HR daily
- Ask colour of liqour
- CTG
- US for AFI
What is the erythromycin dose which should be given in PPROM?
250mg po 6 hourly for 10 days
What is the dosage of benzylpenicillin that should be given in GBS+ or GBS unknown women with risk factors?
3g IV loading dose
1.8g IV q4h until birth
What should be given for GBS prevention if a woman is allergic to benpen with no Hx of anaphylaxis?
cephazolin
What is given to GBS+ women or GBS unknown women with risk factors, who are allergic to benpen with a history of anyphylaxis?
Vancomycin or clindamycin
What are the terms:
Zygosity
Chorionicty
Amnionicity
What does the result of each depend on, in a twin pregnancy?
Zygosity = number of eggs
Chorionicity = number of placentas
Amniocity = number of sacs
The number of placentas & sacs depends on the timing of when monozygotic twins split.
What increases your risk of having a twin pregnancy?
Increasing age
Obesity
IVF
(not because we impant two eggs, because we don’t anymore, but because clomifene and FSH stumulation cause a number of eggs to mature)
From what gestation can you measure SFH?
What should you do to measure it?
24 weeks
Ask the woman to empty her bladder beforehand
Use the tape measure face down
What are the DDx for an increased SFH?
wrong dates!
macrosomia
polyhydramnios
twins
molar pregnancy
mass / fibroids
obesity
What are the complications of twin pregnancy?
- The risk of everything is increased!*
- Think of everything that can go wrong in a timeline, and say it!*
- First Trimester
- minor Cx of pregnancy: back pain, stress incontinence
- Hyperemesis gravidarum
- Miscarriage
- Malformations
- Second Trimester
- PET
- GDM
- IUGR
- APH
- FDIU
- Third Trimester
- Prematurity (PTL, PPROM)
- IOL
- C/S
- Instrumental birth
- Post Partum
- PPH
- Depression
- Breast feeding difficulty
- Financial strain
Specific to monochorionic twins: twin to twin transfusion syndrome
What is a similar, rarer condition like TTTS?
Twin reversed arterial perfusion (TRAP)
When do you start to worry about TTTS?
What are the DDx of TTTS?
When there is a discordance of growth between twins of >25%
This discordance may be due to:
- Placental insufficiency
- Infection
- Genetics
- Structure (TTTS)
What should be considered in the antenatal care of a twin pregnancy?
Need to determine chorionicity at 8-12 weeks!
Increased folate and iodine
Consider aspirin (as risk of PET)
More frequent US
Note that aneuploidy screening is less sensitive (and there is usually a higher risk!)
What are the requirements for a vaginal birth in a twin pregnancy?
- Near term
- Twin 1 should have cephalic presentation
- Not > 25% growth discordance
- Because if T1 is smaller, T1 might still experience shoulder dystocia
- Because if T2 is smaller, it is at greater risk of demise while waiting to come out (T2 is at higher risk, always)
- Continuous CTG
- FSE for T2
- External for T1
- Experienced accoucher
- U/S close by in the room
- IV access (PPH risk)
- Epidural - controversial. Good to do because might require internal vaginal breech extraction
- Paediatric and anaesthetic staff present
- Twin-Twin delivery interval
What is a frank breech?
When the babies hips are flexed and knees extended
What is a complete breech?
When the baby’s hips and knees are flexed
What is a footling breech?
When the hip & knee joints are extendted on one or both sides
What is an incomplete breech?
An umbrella term for footling and kneeling presentations
What is a kneeling breech?
When the hip is extended and the knee is flexed on one or both sides
How is TTTS scored and how is it treated?
Quintero System
Laser Photocoagulation
What are the three types of breech presentation?
- Frank
- Complete
- Incomplete (footling / kneeling)
What are the maternal and fetal risk factors for breech presentation?
Maternal / Uterus
Fibroids
Uterine malformations
Polyhydramnios
Placenta Praevia
Foetal
Prematurity
Twin pregnancy
CNS malformations
neck masses
aneuploidy
When is ECV performed?
ECV is (generally) performed AFTER 37 weeks, to avoid the baby flipping back over again before labour.
How should intermittent auscultation be performed?
Should commence toward the end of a contraction and should continue for 30-60 seconds after the contraction is finished
Should be udertaken every 15-30 minutes in the active phase of the first stage labour.
Should be undertaken after each contraction or at least every 5 minutes during the active second stage of labour
What is the reference range of CA 125?
The reference range of CA 125 is 0-35 units/mL
What are the causes of PMB?
endometriosis
other cancer
vaginal atrophy
fibroid
polyp
AAA FIDO LEG PAIN
Analgaesia
Anti-emetics
ABx
Fluid Balance
IV fluids
Diet - NMB
Obs
Legs - PE
Pathology
What cut-off score of CA-125 is used to be almost diagnostic of ovarian cancer?
> 200
(But
This is because the RMI is calculated as:
Findings on US X menopausal status X CA-125
And if it is >200 = ovarian cancer
What are the risks of T1DM in pregnancy?
Risks to the mother
- Hypos in the first trimester (N&V)
- Hypers in the second and third trimester (because placenta produces insulin antagonsists)
- Macrosomia & complications to mother of this
- insturmental delivery
- shoulder dystocial
- perineal tears
- Worsening retinopathy and nephropathy
- Pre-eclampsia
- Placental abruption
Risk Factors for Foetus
- cardiac defects
- NTDs especially spina bifida
- hypos after birth
- IUGR (which can be masked by macrosomia)
About what should you counsel in pre-conceptual care?
SNAP
Pets & Sex
Work & Travel
Drugs & Dental
Immunisations & Investigation
What should you discuss in terms of SNAP in preconceptual counselling?
- Smoking
- encourage quitting, nicotine replacement therapy is safe.
- Nutrition
- Folic acid & iodine supplementation
- Iron supplementation if deficient
- Avoid soft cheeses and pre-perpared salad with meat: listeriosis –> premature birth / miscarriage / stillborn
- Mercury in fish: know levels ensure it is safe
- Alcohol:
- No known safe level of ETOH during pregnancy. Advise to stop drinking
- Physical activity:
- Safe
- Remeber that joints are more lax later on in pregnancy –> more prone to injury
- Avoid contact sports
- Stop exercise if notice severe SOB, H/A, PV bleeding or anything abnormal
What should you discuss RE pets in pre-conceptual care?
Advise not to get a new pet, young animals have accidents and it is often their faeces which carry pathogens which may harm the baby.
Don’t clean up poo, leave this task to someone else.
Also be wary of bites and scratches.
Beware of Lymphocytic choriomeningitis virus (LCMV) in rodents which can cause severe birth defects and miscarriage.
What should you discuss about sex if preconceptual care?
OK unless placenta praevia or PROM.
Advise doctor if bleeding post intercourse.
What should you advise about drugs in pre-conceptual care
Please inform your GP & obstetrician as to what drugs you are taking.
Some may cross the placenta and harm your baby, it is important to discuss this before taking any medictaion.
Paracetamol is OK, NSAIDs are not.
Recreational drugs are not.
Cocaine causes placental abruption.
What should you discuss about dental care in pre-conceptual care?
If you have any major dental work needing to be done, consider seeing a dentist prior to falling pregnant.
You may not be able to have a GA for dental work whilst pregnant, and furthermore it may be uncomfortable to sit in a dental chair!
There is an associating between periodontal disease and preterm birth, ensure you keep your teeth and gums healthy.
What should you discuss in regard to work and travel in preconceptual counselling?
Ask what they do for work.
Work with radiation / chemicals?
Work is not contraindicated unless complications
occur such as pre-eclampsia
Ask if they plan to travel.
Discuss DVT/PE prophylaxis and airline requirements.
What should you discuss in regard to vaccinations in pre-conceptual care?
Ask if they received all their childhood vaccinations?
Ask if they have had chicken pox?
What pre-conceptual investigations can you order?
For which investigations should you wait until they are pregnant?
Definitely perform
FBE
Syphillus
Rubella
HIV
Hep B
Consider
TFTs
Trichomoniasis
Toxoplasmosis
Gohnorrhea
Chlamydia
Hep C
CMV
Pap smear
Wait until pregnant before testing
Blood group (unless already knwon)
Antibodies
Asymptomatic bacturia
If risk factors for GDM - do this at 14 weeks
What is triploidy syndrome and how does it present?
A rare chromosomal anomaly
Three of every chromosome, i.e. a total of 69 rather than the normal 26 chromosomes.
Very rare
Usually miscarries, but if survives can cause early PET or thyrotoxicosis
What is the most common cause of non-lethal dwarfism?
achondroplasia
What should you do if you find one congenital anomaly on a newborn exam?
Look for associaed congenital anomolies.
VACTERL
V Vertebral dysgenesis
A Anal atresia (imperforate anus) ± fistula
C Cardiac anomalies
T-E TracheoEsophageal fistula ± esophageal atresia
R Renal anomalies
L Limb anomalies
What are the consequences of oligohydramnios?
Potter’s Sequence
Clubbed feet
Pulmonary hypoplasia
Potter facies
- low set ears
- flattened nose
- wrinkled skin
- micrognathia
IUGR
What is Potter’s sequence?
A collection of anomolies due to oligohydramnios including pulmonary hypoplasia, clubbed feet, Potter’s facies and IUGR.
It was originally used to describe these anomolies with oligohydramnios due to bilateral renal agenesis, but it is since used to describe these anomolies due to any cause of oligohydramnios.
What are the causes of oligohydramnios?
Congenital abnormalities
Twin-Twin Transfusion
Post term pregnancy
PROM
Renal
Bilateral renal agenesis
Posterior utherthral valve
ACE inhibitors
PG inhibitors
What is the defitintion of obstetric cholestasis?
What is the hypothesized pathophysiology?
pruritis without a rash
abnormal LFTs
resolution post partum
?due to increasesd sensitivity of the increased cholestatic effect of oestrogens
What are the risks of obstetric cholestasis?
Increased risk of the following to the foetus
- stillbirth
- increased risk of premature labour
To mother:
- lack of sleep
- pruritis
- PPH
When should you plan to deliver in a woman with obstetric cholestasis?
At 37-38 weeks
What is the evidence RE breast cancer and HRT?
What is the implications for this?
Increased risk of breast cancer with Oe + P if use for >5 years (but increase is only minimal.
If using Oe only risk is not increased.
Therefore should do a mammogram and careful clinical assessment prior to commencing
What do you do for a woman who wants to continue to use for longer than 5 years?
Discuss Risks
Consider using non-oral oestrogen and specific type of P and reduce other risk factors eg. obesity
Not absolutely contraindicated!
For how long should women who have primary ovarian insufficiency be taking HRT?
Not for only 5 years!
At least until the average age of menopause!
How should you manage someone with HRT?
Annual review.
CV risk + other risk Ax.
Recommended to trial coming off it once a year to see if it’s still needed [do this in winter]. Might reduce the dose if they want to go back on it.
why shouldn’t you do an oopherectomy in a post-menopausal woman if you can help it?
because the overies still secrete testosterone
What are the factors impacting on the efficacy of contrapection?
pearl index
continuation rate [doctor driven]
What is the oestrogen in the OCP?
Always ethinyl estradiol
(the progesterone changes)
which of the OCP are best for acne and what progesterone do they contain?
- Brenda*
- Dianne*
Cyptotenerone Acetate
What should you ask in regard to ‘clinical assessment’ for PPH?
‘BPALP’
“As this is an emergency my assessment and immediate management would be simultaneous”
Basics
- Name, age, number of babies, health of baby
- BLOOD GROUP
- Gs & Ps
- PHx of PPH
PMHx
- Any medical conditions including bleeding disorders?
Antepartum Hx
- Any complications during the pregnancy?
Labour
- Onset of labour? eg. induced?
- How long?
- Type of birth?
- Pain relief in labour?
- Episiotomy or tears?
Post Partum
- Haemodynamic stability of mother [VITALS]**
- Estimated blood loss**
- Completeness of placenta
- Active management of third stage?
- Medication already eg. syntocinon?
**start with these first, and then CALL FOR HELP
What are the broad strokes of management of PPH?
CRAM + Post-PPH Care
Clinical Assessment
Ressuss
Assess for Underlying Cause
Management
Post-PPH Care
What resus is required in terms of PPH?
DRS ABC
Danger: put on gloves
Response: GCS / assess conscious state
Send for help & assign tasks:
- 2 midwives
- O&G consultant
- anaethetist
- assign roles including a scribe and someone to take obs every 15 minutes
- ask someone to contact theatre
Airway: -
Breathing: Apply Hudson Mask and adminster 10L O2
Circulation:
- move bed into head down position
- 2 large wide bore (16 guage) cannulae
- take off blood for x match / coags / FBE / fibrinogen MARKED AS URGENT
- start IV colloids and switch to O neg blood if X matched blood not available
What is involved in “Assess for Underlying Cause” in PPH?
5Ts
- Tone: palpate tonicity of uterus and position of fundus
- Tissue: ask about placental completeness and active third stage
- Trauma: inspect perineum for tears and vagina/cervix with speculum
- Technique to inspect for cervical tears is “walking” with sponge forceps – this is very painful and should be done with epidural
- Thrombin: ask about PMHx and await coags and fibrinogen - if you suspect this involve HAMEATOLOGIST
- Theatre: contact if haven’t already!
What is involved in management of PPH?
Mechanical: Position BIM
- Position: head down, wedge under left side, keep warm
- Bimanual compression (if has epidural)
- IDC
- Massage the fundus
Medical: ME MSIS PM
- ergometrine (250mcg, diluted to 5mL in normal saline, IV UNLESS HAS HISTORY OF PE OR PIH)
- syntometrine (1mL IM)
- Infusion of syntocinon (40 IU in 1L of Hartman’s over 4 hours)
- Prostaglandin F2 alpha (injections into uterus through abdomen IN THEATRE)
- Misoprostol (tablets in the rectum or vagina iN THEATRE)
Surgical 4BS
- Baloon Tamponade
- B-lynch suture
- Bilateral uterine artery ligation (or internal iliac ligation)
- Bail - hysterectomy!
What should be done post a PPH?
Baby check
Debriefing with mum (& dad) and screen for post-natal depression
Debriefing with all staff involved
Discuss at M&M (morbidity & mortality) meeting – can things be done better next time?
How do you adjust the OCP according to side effects?
decrease the oestrogen dose for any side effect (mastalgia, nausea, weight gain, bloating)
but increase the oestrogen dose for breakthrough bleeding
What are the risks of IUDs?
Pelvic infection - first 3 weeks following insertion
Perforation of the uterus during insertion
IUD moving from its position after insertion
IUD may come out during menses
Very small risk of ectopic pregnancy
Increased vaginal discharge
Heavier, painful periods (Cu)
+ side effects of progesterone:
Hirsuitism
Acne
Irregular bleeding & spotting / increased apetite & weight gain
Loss of libido
Mood changes
What investigations are required for preeclampsia?
- FBE
- Blood film
- LDH
- LFTs (AST, bilirubin especially)
- UEC (uric acid)
- Spot Protein:Creatnine Ratio
What word is used to describe reduced sperm motility?
asthenozoospermia
What word is used to describe no semen in the ejaculate?
azoospermia?
(hypospermia and oligospermia are more than this)
What word is used to describe a complete lack of semen?
aspermia
If an STI has been treated appropriately does it cause PID?
no
What are the causes of bleeding in early pregnancy?
Miscarriage
Ectopic
+ TITCH
Trauma
Infection
Trophoblastic Disease
Cervical polyps / Ca / ectropion
Heterotropic pregnancy
What is considered high risk in aneuploidy screening?
Anything >1:300
When can CVS be performed?
When can amniocentesis be performed?
CVS = 11-14 weeks (ie. remember end of first trimester)
Amnio >15 weeks
What are the pros / cons of CVS / Amniscentesis?
CVS: Less sensitive (99%) and increased risk of miscarriage (1%)
- ABORTION IS SAFEST IN THE FIRST TRIMESTER
- Can have medical TOP 7-12 weeks?
Amniocentesis: more senstivie (100%) and reduced risk of miscarriage (0.5%)
How do you consent a woman for a medical termination of pregnancy?
What is the procedure?
- Generally use a combination of two medications to induce the uterus to pass the pregnancy tissue.
- MIFEPRISTONE; AND
- MISOPROSTOL (prostaglandin analogue)
Why do we do it normally?
Termination of pregnancy
Mifepristone is also used for miscarriage.
Misoprostol is also used to ripen cervix in labour.
Why are we doing it in this case?
Termination of pregnancy
Pre-op
- Screen for STIs and treat (given unprotected sex)
Intra op
- Visit a clinic that is authorised to prescribe the medication
- During the consultation with the doctor you will take the Mifepristone tablet.
- You will then need to take the misoprostol at home 24-48 hours later. Usually within 4 hours of taking the second medication you will experience vaginal bleeding, cramps and you will pass some pregnancy tissue.
Post-op
- Return to clinic for repeat BHCG
- Discuss contraception!
- OFFER PSYCHOLOGICAL SUPPORT
Risks
- Nausea, vomiting
- Diarrhoea
- Headache, dizziness, Fatigue
- Abdominal pain and cramps
- Prolonged vaginal bleeding
- Failure of the procedure - 95% success rate (5% will need curettage, 1% will fail, 1% will require transfusion)
Contraindications
- IUD
- Ectopic pregnancy
- Some serious medical comorbidities
Alternatives
- Surgical abortion
- Expectant management
Questions and obtain written consent
How do you consent a woman for surgical TOP?
What is the procedure?
- Day procedure
- Twilight sedation
- 5-10 minute surgical procedure to remove the pregnancy tissue via the vagina
Why do we do it normally?
- Termination of pregnancy from 7-12 weeks gestation
Why are we doing it in this case?
Termination of pregnancy
Pre-op
- SCREEN FOR STIs and treat
- Blood group and Anti D if Rhesus negative
- Fast before the procedure
- 3 hours before the procedure the doctor will insert a misoprostrol pessary to help ripon the cervix.
- Anaesthetic, off to sleep
Intra op
- The doctor will dilate your cervix and remove the pregnancy tissue
- You will then be given some synthetic oxytocin to help contract the uterus and pass any remaining products of conception.
Post-op
- recovery room
- home that day
- doxycycline to reduce any infection risk
- OFFER PSYCHOLOGICAL SUPPORT
- DISCUSS CONTRACEPTION
Risks
- Anaesthetic complications
- Anaphylaxis
- Very rarely, infection or uterine rupture
- Asherman’s syndrome
- Failure of the procedure/retained products (it’s blind) –> can use MTX, wait to pass or go back in
- Vacuum aspiration in 1st trimester has no association with later infertility or ectopic
Contraindications
- Ectopic pregnancy
- Some serious medical comorbidities
Alternatives
- Medical abortion
- Expectant management
Questions and obtain written consent
How do you diagnose missed miscarriage on U/S?
CRL > 7 OR Sac >25mm
WITHOUT FOETAL HR
How do you differentiate between missed and threated miscarriage, according to DS?
They are really the same (missed miscarriage can have bleeding). But the CRL is >7, sac is >25,, and there is a foetal hr in threatened (no hr in missed)
What would you do in PROM in a women who was GBS +ve?
Immediate induction
No option for expectant management
How much weight do you have to lose to improve ovulation in an overweight woman who is anovulatory?
5-10%
Where does the exessive oestrogen come from in PCOS, given that it is a state of hyperandrogenism (and hyperinsulinsm)?
Peripheral conversion of oestrogen
What should you conisder in PCOS management, that isn’t necessarily directly managing the PCOS symptoms?
BP check regularly
2hOGTT / HbA1c 2 yearly
lipid profile 2 yearly
OCP to reduce endometrial Ca risk
cease smoking
What are some risks of Preeclampsia?
HT
First Pregnancy
Novel sperm! / New Partner
Is someone has PE during pregnancy and then they deliver, for how long are at risk of eclampsia?
The next 24 hours
Keep the MgSO4 going for 24 hours
Continue to monitor BP
What is the dosage of intrapartum antibiotics you give in pregnancy for GBS+ve women (or women with risk factors of GBS)?
What is the minimum amount they require?
Benzylpenicillin
3g IV loading dose
1.8g IV q 4h thereafter
They need two doses at least
If they don’t - monitor bub post pregnancy; give Bub antibiotics?
What are the requirements for expectant management of PROM?
TEN ELEVEN
Term
Engaged (cephalic presentation)
No VE or cervical sutures
EFM (CTG) normal
Logistics for ongoing Evaluatiuon
Vitals normal
Exit Portal should have
No GBS
What is the definition of oligomenorrhea?
>35 days without mensturating
How may a woman with PCOS and oligomenorrhea still have infrequent heavy periods?
Oligomenorrhea can be defined as >35 days without a period
It may be heavy because it is not a true period but the endometrial lining simply becoming friable / sheddding / spotting
How do you use clomifene to induce ovulation?
First you have to take high dose progesterone for approx 7 days, then stop.
This causes withdrawal bleed.
Then on day 5 after period you take the clomifene on days 5, 6, 7, 8 & 9
And then you check the day 21 progesterone to see if you have ovulated.
What are the requirements for a forceps delivery?
FORCEPS
Fully dilated
OA position or known position so can apply to forceps correctly
Ruptured membranes
Catheter and contractions
Episiotomy and epidural
Ppresentation: cephalic
Spines or below with none of the head palpable above the pubic symphisis
Plus no obvious cephalopelvic disproproportion
What is the ‘Place and Person’ managment for PPROM (in GA >34 weeks)?
Keep them in for 72 hours (because will likely go in to labour). Can discharge after this. Teach them to monitor for signs of infection (febrile, changed colour of liqour, reduced foetal movements)
If placenta praevia is diagnosed at the 20 week scan, what can you tell the patient?
What do you do to follow up?
No sex.
But 95% will move up as the lower segment of the uterus appears at 26-28 weeks.
Rescan at 36 weeks. It should have moved up. Even if it hasn’t it might still move up, rescan 2 weeks later.
If doesn’t move up - C section.
What is the FIRST LINE management of miscarriage?
How should you counsel the woman?
Expectant management
It’s nOT YOUR FAULT
1/5 pregnancies - miscarriage
Give them oral and written information about what to expect
Pain relief
Tell them when to seek medical advice - if pain/bleeding never stop or is increasing repeat BHCG and repeat scan
Bleeding and in 1-2 weeks the tissue should pass naturally
What can / you can’t use for smoking cessation in pregnancy?
Nicotine replacement therapy is OK
But wear the patch for 16h not 24h
CAN’T USE CHAMPIX
How do you use the BHCG to diagnose ectopic pregnancy
If BHCG is >1,500 and rising should be able to see the foetal heart on transvagainal US
If it is this and can’t see it - ectopic
How do you screen someone for gohnorrhea who is possibly symptomatic?
endocervical swab is the best
high vaginal swab (self-collected) is also good!
first pass urine if not symptomatic or if decline swab
A girl starts on the pill and gets IMB / PCB, what is the most common cause of it?
STIs
Rather than a need to change the pill (tricycling, and increasin oestrogen)
What is the definitive managment of gohnorrhea?
IM ceftriaxone 500mg (not 250mg anymore)
There is supergohnorrhea (resistant) in the north of england now!
What is the management of chlamydia?
1g azithromycin stat and another dose a week later
OR
doxy for 14 days (slightly higher cure rate)
What is the active management of the third stage of labour?
uterotonic agents, controlled cord traction, and uterine massage
What is required for “preeclampsia bloods”
FBE
LFT
coags
UEC
Protein:Creatnine Ratio
What are the causes of jaundice in pregnancy?
Early Jaundice
ETOH, viral hepatitis, gall stones
Late Jaundice
Obstetric cholestasis, acute fatty liver of pregnancy, HELLP syndrome
When after a miscarriage can you try for another baby?
After one month if you’re ready
When do you investigate for miscarriage?
After 3 miscarriages
If it occurs in the 2nd trimester
What are the proven benefits of the cervical cancer vaccine?
So far it’s been proved to reduce the rate of high grade lesions but not the rate of cervical cancer (as it hasn’t been around all that long and cervical cancer takes 10 years to develop)
What are preconceptual considerations for an overweight women?
Extra folate
Lose weight prior to pregnancy if possible
will require care at a tertiary centre if over a certain BMI
what is the management of endometriosis?
Conservative
Simple analgesia
COCP
Progesterones: Mirena IUD, Depot Provera
GnRH agonists: Goserelin
Surgical
Laparoscopic ablation and excision
What are the lesions in endometriosis?
flame lesions
chocolate cysts
cigarette burn lesions
What are the causes of post partum fever?
Wound
Wind
Water
Walk
Whiz
Wonder Drugs
Mastitis
Genital Tract Sepsis
What are the risk of a multiple gestation pregnancy?
Antenatal - Maternal
- Hyperemesis gravidarum
- Fe defficiency
- GOR
- Back pain
- APH
- Miscarriage
- GDM
- PIH
- PE
- PROM
- Premature delivery (due to PROM or foetal/maternal wellbeing)
Antenatal - Foetal
- Congenital anomolies
- IUGR
- Growth discordance
- Perinatal mortality rate
Intrapartum
- Increased risk of instrumental delivery
- Increased risk of C section
Postpartum
- PPH
- Financial difficulties
- Feeding difficulties
- Post natal depression
What sort of twins might suffer from TTTS?
Monochromnic twins
What is the pathophysiology behind twin to twin transfusion syndrome?
Twin-to-twin transfusion syndrome occurs in monochorionic twins and is due to arteriovenous anastomosis in the shared placenta.
The donor twin is small and anemic.
The recipient twin is polycythemic, large, and at risk for high-output cardiac failure.
Both twins are at risk and can die.
What is the epidemiology of TTTS?
15-20% of monochromionic twins
What are the clinical signs of TTTS?
How do you monitor for it?
Rapid abdominal/uterine distension
Reduced ability to palpate foetal parts
(i.e. massive polyhydramnios)
Monitor with regular US from 24-28/40 gestation looking for:
growth discordance between twins
polyhydramnios (recpient twin)
oligo/anhydramnios (donor twin)
What are the criteria to have a NVD of twins?
Should be near term
Presentation of first twin should be cephalic
Continuous CTG monitoring
No foetal compromise or distress
Epidural / spinal (because might have to perform internal cephalic version of second twin or breech extraction!)
Delivery by obstetrician, paediatrician and anaethetist
IV access
What do you do if you get an unsatisfactory smear?
repeat it
What do you do if you get a LSIL…
If the girl is
If the girl is >30?
>30 AND no normal smear in the last two years:
Either colposcopy
OR repeat in 6/12
What is the definition of primary infertility?
In someone
In someone >35?
Not pregnant after 12/12 of unprotected sex
Not pregnant after 6/12 of protected sex
How common is infertility?
1 in 6
(there is a campaign in USA called 1 in 6)
What is infertility associated with?
Ovarian cancer
What are the seven cardinal movements of childbirth?
- Engagement (usually LOA)
- Descent
- Flexion
- IR
- Extension
- ER / restitution
- Expulsion
What are the complications of shoulder dystocia?
Maternal
PPH
3rd or 4th degree tear
Rectovaginal fistula
Uterine rupture
Baby
Erbs palsy (C56)
Klumpkes palsy (C78T1)
Clavicular #
Foetal hypoxia
Describe the management of shoulder dystocia
HELPERR
H - call for help
- 2 x midwives
- anaethetist
- paediatrician
- more senior O&G
Evaluate for Episiotomy
- note that this will only really provide more room for internal manoevers: shoulder dystocia is due to BONY impaction, not soft tissue
Legs - Elevate the Legs
- McRoberts Manoeuvre
Pressure - suprapubic pressure
- A downward and lateral motion onto the posterior aspect of the foetus’ anterior shoulder
- Can be continuous and rocking (similar technique and force to CPR)
- Can be performed in combination with McRobertson manoeuvre
Enter - rotational manouvers
- Rubin II
- Rubin II + woods corkscrew
- Reverse woods cork screw
Remove the posterior arm
Roll patient on to hands and kness (Gaskin manoevre)
Describe the two phases of the second (2nd) stage of labour
Latent / Passive / Descent Phase
when the cervix is found to be fully dilated prior to, or in the absence of involuntary expulsive contractions.
(During this phase the fetal head progressively descends
through the maternal pelvis, and internal rotation and flexion occurs.)
Active / Pelvic Floor Phase
The onset of the active phase of second stage labour is recognised when:
- the fetal presenting part is visible
- there are expulsive contractions with a finding of full dilatation of the cervix and other signs indicating full dilatation.
- there is active maternal effort following confirmation of full dilatation of the cervix in the absence of expulsive contractions.
what is the chorion and what is the amnion?
the chorion is the outer layer
amnion is the inner layer
Discuss routine ABx in C section
For caesarean section: there is evidence that antibiotics are beneficial for prophylaxis of wound sepsis as well as endometritis for all caesarean sections, elective or non-elective.
use: cephazolin 1g (adult 80kg or more: 2g) IV
Administration after the cord is clamped has been common practice to avoid exposing the neonate to antibiotics, and to avoid compromise to the fetus in the event of maternal anaphylaxis. These considerations need to be weighed against lower maternal infection rates if prophylaxis is administered before skin incision.
NB - low risk to foetus - so I think most places administer prior to ‘knife to skin’.
What is assessed in Apgars?
A – appearance (colour)
P – pulse (HR)
G – grimace (reflex irritability – the response to nasal suction)
A – activity (tone)
R – respiraton (cry)
What is the management of cord prolapse?
1. call for help
- knee-chest face-down position / steep trendelenberg
- Wrap cord in damp, warm cloth
- Elevate the presenting part (foetal head) off cord
- Fill the bladder with catheter
- Tocolysis
- Emergcency ceaser
Don’t put cord back in as this may cause vasoconstriction.
Describe how IOL is initiated with PGs?
CTG for one hour prior to prostin / cervidil
Ask woman to empty her bladder (as she will have to lie still for one hour prior)
Insert prostin or cervadil
Put on CTG for one hour (woman has to lie still)
Usually do this at about 5pm. May be enough to induce labour but may require another dose the next morning.
Wat should you do if a woman is weakly immune to rubella in her antenatal Ix?
Give her the MMR vaccine before she is discharged fom hospital post birth
(is a live vaccine, can’t give it whilst pregnant)
If the cervix is favourable, what might you use to induce labour in a primip?
You might still use prostin over an oxytocin infusion
How do you describe cervical dilation in terms of fingers, not cms?
The cervical os ‘admitted’ one finger/two fingers etc
What levels are acceptable in BGL monitoring with GDM?
Compare this to diagnostic levels?
BGL monitoring
Fasting capillary blood glucose (BG): ≤ 5.0mmol/L
[1 hour BG after commencing meal: ≤ 7.4mmol/L]
2 hour BG after commencing meal: ≤ 6.7mmol/L
GDM diagnosis
Fasting
1 hour post meals
2 hours post meals
The diagnosis levels are higher because they have 75g of glucose + they sit still for two hours. We encourage women already with GDM to have a healthy diet + stay active
What two antenatal screening tests are considered optional by RANZCOG but are almost always done?
Hep C
TFTs
When can you use date of LNMP for EDD?
when the woman has not been on the OCP for 3/12 prior
When she has had 3 normal periods
When the dates from the U/S do not differ by more than 3 days (when scanned prior to 13 weeks) or by more than 10 days (when scanned after >13 weeks weeks)
What are the causes of amenorrhea?
HEAPS POACHED
Head injury [reduced GnRH]
Excessive exercuse [reduced GnRH]
Annorexia [reduced GnRH]
Prolactinoma [PRL inhibits GnRH]
Sheehans syndrome [reduced FHS/LH]
PCOS / premature ovarian failure [reduced response of ovaries to FSH/LH]
Obesity [oestrgen++ inhibits FHS/LH secretion]
Asherman’s Syndrome [blocks exit of period]
Cervical stenosis [blocks exit of period] and late onset CAH
Hypothyroidism
Endocrine [DM and cushings]
Drugs [DA antagonsitis and progesterone]
What are the causes of infertility?
USE MOAT
Uterine & Cervical (tend to cause more miscarriage)
Sex
Endometriois
Male (hypospermatogenesis, obstruction, endocrinological, drugs, radiation, heat)
Ovaries: HEAPS POACHED
Age >30
Tubal
What is a safe ETOH level in pregnancy?
No safe level
What is cocaine use in pregnancy associated with?
placental abruption
What are the risks of alcohol to an unborn / newborn child?
Foetal alcohol syndrome
Intellectual disablity
Congenital cardiac defects
Brain and spine defects
Causes of menorrhagia?
Bleeding disorder
Iatrogenic (IUDs and drugs)
Thyroid dysfunction (especially hypo)
Cancer (Endometrial, cervical)
Hyperplasia of the endometrium
Fibroids (leiomyomata) and polyps
Adenomyosis and endometriosis
Chlamydia, gonorrhea and STIs
Ectopics, miscarriage, pregnancy
what do you need to consider in a sub-total hysterectomy?
need to keep having Pap smears
When do you use a cone biopsy over LLETZ?
If you can’t see the squamo-epithelial junction (but usually you use LLETZ)
what is cervical incompetence?
Cervical incompetence (or cervical insufficiency) is a medical condition in which a pregnant woman’s cervix begins to dilate (widen) and efface (thin) before her pregnancy has reached term –> MISCARRIAGES
What are the causes of pelvic pain in an adolescent?
PAP ME
Pregnancy
Appenix
Primary dysmenorrhea / PID
Mullerian obstruction
Endometriosis
+ bladder / bowel causes (eg. UTI, IBS)
What Ix should you order in suspected endometriosis?
laparoscopy is the gold standard diagnostic test for endometriosis
What Ix are required for infertility, itially?
MALE
- Semen analysis and IBT
HORMONAL - FEMALE
- Ovarian Reserve
- Day 2-4 FHS/LH + oestrogen
- AMH
- Mid luteal progesterone
- TFTs
- Serum Prolactin
STRUCTURAL - FEMALE
- US
- dye studies
- hysteroscopy
- laparoscopy
OTHER - FEMALE
- Rubella immunity status
- Varicella immunity status
what is the most common cause of infertility?
unexplained infertility
What needs to be considered prior to contraception?
Headache / hypertension
Obesity / Osteoporosis / Old [>35 years old]
Medications (some anti-convulsants, some ABx)
Embolism / Thrombus / Clotting disorders
Stroke
Infective endocarditis / Informed consent / Gillick competent (for minors)
Cancer (breast, cervical), Cardiovascular Risk
Kids (nulliparous women & myrena) breast feeding (no oestrogen)
Liver disorders
What contraceptive option is associated with increased risk of OP?
depot
Which canger is associated with an increased CA125?
ovarian
What is the management of menorrhagia?
Basics
- DRABC: resuss if anaemic
- Iron supplementation if iron deficient
Place & Person
Ix and confirm Diagnosis
Examination:
- general
- abdominal
- speculum
- bimanual
Investigations:
- Urine for chlamydia/gohnorrhea
- FBE
- UEC
- Coags
- TFTs
- Hysteroscopy
- Biopsy
- Diagnostic labaroscopy
Defninitive Management
FIRST TREAT UNDERLYING CAUSE eg. Mymectomy (fibroids)
Pharmacological
- Tranexamic acid
- NSAIDs
- OCP
Surgical
- Mirena
- Endometrial ablation / rescection [can’t get pregnant afterward]
- eg. NOVASURE
- Hysterectomy [can’t get pregnant afterward]
which type of ENDOMETRIAL cancer carries the worst prognosis and accounts for 10% of all ENDOMETRIAL cancers?
clear cell
(it’s an endometrial cancer which acts like a ovarian cancer in that’s its spread is transcoelomic)
What is the most concerning type of trace and what does it represent on CTG?
sinusoidal
represents severe hypoxia
What “systems” questions should you ask in an APH history?
TIP: BE CALM
Trauma
Investigations to date (eg. position of placenta on 20 week scan)
Pain
Blood group
Eat of drink today?
Contractions
Anaesthetic previously?
Liqour / ROM
Movements (foetal)
what is the name of a lobule of the placenta?
cotyledon
what are the causes of painless APH?
what are the causes of painful APH?
painful = uterine rupture (rare) or placental abruption
painless = placenta praevia or vasa praevia
What are the grades of perineal tear?
Grade 1: epithelium of vagina torn
Grade 2: Involves perineal muscle
Grade 3: To the anal sphincters
- A)*
- B) >50% of external sphincter*
- C) Internal sphincter*
Grade 4: Tear to anal epithelium
What is the defitive management options for ectopic pregnancy?
Medical
- IM methotrexate
- Re-check B-HCG levels 4 and 7 days later
- Should fall by 15%
- If not - give second dose
Surgical
- laparoscopy
- might do salpingectomy if it’s in the tube
- might to oopherectomy if it’s in the sac
- laparotomy (required in emergency) to remove products of conception
- Recheck B HCG: should fall rapidly
- should be less than 65% the original level 48 hours post hop
- should be less than 10% the original level 10 days post op
- if not –> consider persistent trophoblast
- Recheck B HCG: should fall rapidly
What are the causes of reduced variability on CTG?
4Ss
Sleep
Stress
Sedation
Small baby
With whom should you order a kleihauer test?
What does it actually test?
on a Rh -ve mother who may have experienced foetomaternal haemorrhage
the degree of feto-maternal haemorrhage
When would you administer anti-D / rhogam?
In a Rh -ve mother at
28 weeks
34 weeks
72 hours post delivery (IF bub is Rh +ve)
PLUS if you suspect foetomaternal haemorrhage
At what day of the cycle is mid-luteal progesterone taken (in a 28 day cycle)?
What does it indicate?
The level is taken on day 7 of the luteal phase
(= day 21 of a 28 day cycle)
A level of >30 indicates the woman HAS ovulated
A level of
What are the symptoms of menopause?
MENOPAUSE
Muscle aches
Energy levels reduced
Night sweats
Osteoporosis – pathological fracture
Psych – [depression, headache, reduced concentration & memory]
Aretries = vasomotor symptoms (hot flushes & night sweats)
Urogenital symptoms – increased frequency, urgency, UTIs, prolapse
Sex – loss of libido
Extra risk of CV disease and osteoporosis
What are the screening questions one should ask prior to HRT?
ABCEIOU
Age >60
Breast Ca, BP
Clots (DVT / PE / stroke)
Endometrial cancer
I = OP
O = gallstones + liver disease
Uterus or not?
When is USS commonly performed in pregnancy?
(not neccessarily routinely)
- Can do one in early pregnancy
- Dating scan @ 12 weeks (and aneuploidy risk)
- Scan at 20 weeks to see position of placenta + foetal morphology
- Third trimester scans can depict planetal function & EFW
Only the middle two are routine!
Describe what should occur is a LSIL is found on cervical screening?
What are the parameters for diagnosing GDM and DM in pregnancy?
GDM:
0 hours = 5.5 - 7
1 hour = > 10
2 hours = 8.5 - 11
Can’t diagnose DM in pregnancy
What are the considerations required before starting HRT?
ABC,EIOU
Age (
Blood Pressure & Breast Cancer
Clotting: DVT / PE & Cardiovascular Risk
Endometrial cancer & Everyday symptoms
I (bone) – OP
O – cholecystitis
Uterus? ie. Hysterectomy?
What are the outcomes of bleeding in early pregnancy?
- 60% have ongoing pregnancy
- 30% have early pregnancy loss
- 9.5% have ectopic pregnancy
- 0.5% other
What is the other 0.5%?
S – subchorionic haemorrhage
T – trauma (vaginal)
I – Infection (STI/PID)
T – trophoblastic disease
C – cervical polyps or cancer
H – heterotopic pregnancy
Placenta – previa
What are the possible causes of recurrent miscarraige?
Only investiagte after 3 miscarriages
