JLS O&G Flashcards

Question

If you are inducing someone at 36 weeks, do you give steroids?

Answer 1

Not according to guidelines

Answer 2

dysfunctional uterine bleeding | (\>80% of all primary menorrhagia)

Answer 3

Primary - since menarche Secondary - later onset Secondary menorrhagia is more likely to have an underlying cause (and not just be DUB).

Answer 4

CA 125 (ovarian. sensitivie but not specific) HE4 AFP LDH B-HCG CEA CA 19.9

Answer 5

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

Answer 6

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

Answer 7

"thickening of the junctional zone" "venetian blind" pattern of accoustic shadowing

Answer 8

Non-Hormonal * Mefenamic acid (Ponstan) * Tranexamic acid * Paracetamol Hormonal * Mirena * COCP Surgical * Laparoscopic ablation * Laparoscopic excision * TAH & BSO

Answer 9

generally enlarged

Answer 10

The adnexa of uterus (or uterine appendages) are the structures most closely related structurally and functionally to the uterus.

Answer 11

Painful manipulation of the cervix Helps to differentiate between pathology of the reproductive tract vs of the GI or urinary system

Answer 12

PID endometriosis tubo-ovarian abcsess

Answer 13

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.

Answer 14

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

Answer 15

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

Answer 16

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

Answer 17

**Titre** **(Immunity can wane)**

Answer 18

Viral load LFT R UQ US Referral to ID

Answer 19

1/3 risk of pyelonephritis due to Compression of urteres Progesterone (slows down bowel and bladder) Treat and continue to treat throughout pregnancy

Answer 20

CMV | (but a lot are asymptomatic)

Answer 21

sticky toddlers

Answer 22

100IU of IgG GIven in *opposite thighs*

Answer 23

F/U of LFTs and look out for HCC Screen others in family Follow up baby

Answer 24

MCA peak systolic velocity (low viscoty of blood - travels faster) MCA pulsatility index (shunting blood to the brain)

Answer 25

snuffles saddle nose sabre shins Hutchinson's trid: notched incisors, keratitis, 8th nerve defects

Answer 26

dermatomal scarring contratures

Answer 27

contractions which dause cervical change

Answer 28

in the third trimester (before this, it's a low lying placenta)

Answer 29

preeclampsia (but if you do get it and you smoke, it is likely to be worse!)

Answer 30

cervical length If it is short ( also for cervical surveillance

Answer 31

Because the reason for it is probably infection 10 days qid (because the ORACLE trial only studied it for 10 days!)

Answer 32

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

Answer 33

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

Answer 34

straight to colposcopy

Answer 35

Repeat in 6-12 weeks (enough time for cervical cells to re-grow)

Answer 36

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

Answer 37

The Bethesda System (Cytology) HSIL / LSIL

Answer 38

CIN I - III / Histopathology

Answer 39

That SGA babies are at a higher risk of metabolic syndrome as adults

Answer 40

**_SGA =_** A. more than 2SD below the mean, or B. less than the 10th percentile The issue with this term is that 1. some babies are constitutionally small and not IUGR 2. some babies are IUGR and not SGA (ie. not

Answer 41

IUGR increases the risk of still birth x 4

Answer 42

+/- 10% This increases later on in the pregnancy because as the head engages it can't be measured

Answer 43

BPD (Bi Parietal Diameter) HC (Head Circumference) AC (Abdom circumference) FL (femur length) The most sensitive = AC

Answer 44

**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

Answer 45

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

Answer 46

a normal antenatal CTG with accelerations

Answer 47

Non-stress test / antenatal CTG Tone Breathing movements Gross movements AFI (each component is given a 2 or a 0, no 1s)

Answer 48

Head compression

Answer 49

**Cervical length** Cervical shortening *in those who are already at risk of preterm birth* have an even greater risk of preterm birth.

Answer 50

≤20mm at 18-22 weeks gestation | (3 centres)

Answer 51

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.

Answer 52

* 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***

Answer 53

* Conservative management * do nothing, especially if no other risk factors * Cervical surveillance * ongoing monitoring of cervical length * Progesterone * vaginal progesterone * Cervical cerclage / cervical stitch

Answer 54

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’.

Answer 55

No evidence that one is better than the other Usually inserted transvagibally but can be inserted transabdominally

Answer 56

* 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

Answer 57

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)

Answer 58

An absence of leucorrhoea which you would normally see on spec exam of a pregnant woman. Supportive of PPROM / PROM

Answer 59

nifedipine (oral) - watch BP tebutaline (SC) salbutamol GTN patch (often used in C section) NSAIDs also work well - but care of foetal heart!

Answer 60

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

Answer 61

\>34 weeks : active 24 - 34 : expectant

Answer 62

Clexane Ted stockings always (if they are spending more time resting in bed than mobilising)

Answer 63

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

Answer 64

250mg po 6 hourly for 10 days

Answer 65

3g IV loading dose 1.8g IV q4h until birth

Answer 66

cephazolin

Answer 67

Vancomycin or clindamycin

Answer 68

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.

Answer 69

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)

Answer 70

24 weeks Ask the woman to empty her bladder beforehand Use the tape measure face down

Answer 71

wrong dates! macrosomia polyhydramnios twins molar pregnancy mass / fibroids obesity

Answer 72

* 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

Answer 73

Twin reversed arterial perfusion (TRAP)

Answer 74

When there is a discordance of growth between twins of \>25% This discordance may be due to: * Placental insufficiency * Infection * Genetics * Structure (TTTS)

Answer 75

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!)

Answer 76

* 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

Answer 77

When the babies hips are flexed and knees extended

Answer 78

When the baby's hips and knees are flexed

Answer 79

When the hip & knee joints are extendted on one or both sides

Answer 80

An umbrella term for footling and kneeling presentations

Answer 81

When the hip is extended and the knee is flexed on one or both sides

Answer 82

Quintero System Laser Photocoagulation

Answer 83

1. Frank 2. Complete 3. Incomplete (footling / kneeling)

Answer 84

**Maternal / Uterus** Fibroids Uterine malformations Polyhydramnios Placenta Praevia **Foetal** Prematurity Twin pregnancy CNS malformations neck masses aneuploidy

Answer 85

ECV is (generally) performed AFTER 37 weeks, to avoid the baby flipping back over again before labour.

Answer 86

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

Answer 87

The reference range of CA 125 is 0-35 units/mL

Answer 88

endometriosis other cancer vaginal atrophy fibroid polyp

Answer 89

Analgaesia Anti-emetics ABx Fluid Balance IV fluids Diet - NMB Obs Legs - PE Pathology

Answer 90

**\> 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

Answer 91

**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)

Answer 92

SNAP Pets & Sex Work & Travel Drugs & Dental Immunisations & Investigation

Answer 93

* 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

Answer 94

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.

Answer 95

OK unless placenta praevia or PROM. Advise doctor if bleeding post intercourse.

Answer 96

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.

Answer 97

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.

Answer 98

**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.

Answer 99

Ask if they received all their childhood vaccinations? Ask if they have had chicken pox?

Answer 100

*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

Answer 101

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

Answer 102

achondroplasia

Answer 103

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

Answer 104

Potter's Sequence Clubbed feet Pulmonary hypoplasia Potter facies * low set ears * flattened nose * wrinkled skin * micrognathia IUGR

Answer 105

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.

Answer 106

Congenital abnormalities Twin-Twin Transfusion Post term pregnancy PROM **Renal** Bilateral renal agenesis Posterior utherthral valve ACE inhibitors PG inhibitors

Answer 107

pruritis without a rash abnormal LFTs resolution post partum ?due to increasesd sensitivity of the increased cholestatic effect of oestrogens

Answer 108

Increased risk of the following to the foetus * stillbirth * increased risk of premature labour To mother: * lack of sleep * pruritis * PPH

Answer 109

At 37-38 weeks

Answer 110

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

Answer 111

Discuss Risks Consider using non-oral oestrogen and specific type of P and reduce other risk factors eg. obesity Not absolutely contraindicated!

Answer 112

Not for only 5 years! At least until the average age of menopause!

Answer 113

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.

Answer 114

because the overies still secrete testosterone

Answer 115

pearl index continuation rate [doctor driven]

Answer 116

Always ethinyl estradiol | (the progesterone changes)

Answer 117

* Brenda* * Dianne* Cyptotenerone Acetate

Answer 118

***_'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

Answer 119

**CRAM + Post-PPH Care** ## Footnote Clinical Assessment Ressuss Assess for Underlying Cause Management Post-PPH Care

Answer 120

***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

Answer 121

**_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!

Answer 122

**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!

Answer 123

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?

Answer 124

decrease the oestrogen dose for any side effect (mastalgia, nausea, weight gain, bloating) but increase the oestrogen dose for breakthrough bleeding

Answer 125

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

Answer 126

* FBE * Blood film * LDH * LFTs (AST, bilirubin especially) * UEC (uric acid) * Spot Protein:Creatnine Ratio

Answer 127

asthenozoospermia

Answer 128

azoospermia? (hypospermia and oligospermia are more than this)

Answer 129

Miscarriage Ectopic + TITCH Trauma Infection Trophoblastic Disease Cervical polyps / Ca / ectropion Heterotropic pregnancy

Answer 130

Anything \>1:300

Answer 131

CVS = 11-14 weeks (ie. remember end of first trimester) Amnio \>15 weeks

Answer 132

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%)

Answer 133

**_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_**

Answer 134

**_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_**

Answer 135

CRL \> 7 OR Sac \>25mm WITHOUT FOETAL HR

Answer 136

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)

Answer 137

Immediate induction No option for expectant management

Answer 138

Peripheral conversion of oestrogen

Answer 139

BP check regularly 2hOGTT / HbA1c 2 yearly lipid profile 2 yearly OCP to reduce endometrial Ca risk cease smoking

Answer 140

HT First Pregnancy Novel sperm! / New Partner

Answer 141

The next 24 hours Keep the MgSO4 going for 24 hours Continue to monitor BP

Answer 142

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?

Answer 143

TEN ELEVEN ## Footnote Term Engaged (cephalic presentation) No VE or cervical sutures EFM (CTG) normal Logistics for ongoing Evaluatiuon Vitals normal Exit Portal should have No GBS

Answer 144

\>35 days without mensturating

Answer 145

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

Answer 146

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.

Answer 147

FORCEPS ## Footnote 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

Answer 148

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)

Answer 149

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.

Answer 150

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

Answer 151

Nicotine replacement therapy is OK But wear the patch for 16h not 24h CAN'T USE CHAMPIX

Answer 152

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

Answer 153

endocervical swab is the best high vaginal swab (self-collected) is also good! first pass urine if not symptomatic or if decline swab

Answer 154

STIs Rather than a need to change the pill (tricycling, and increasin oestrogen)

Answer 155

IM ceftriaxone 500mg (not 250mg anymore) There is supergohnorrhea (resistant) in the north of england now!

Answer 156

1g azithromycin stat and another dose a week later **OR** doxy for 14 days (slightly higher cure rate)

Answer 157

uterotonic agents, controlled cord traction, and uterine massage

Answer 158

FBE LFT coags UEC Protein:Creatnine Ratio

Answer 159

**Early Jaundice** ETOH, viral hepatitis, gall stones **Late Jaundice** Obstetric cholestasis, acute fatty liver of pregnancy, HELLP syndrome

Answer 160

After one month if you're ready

Answer 161

After 3 miscarriages If it occurs in the 2nd trimester

Answer 162

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)

Answer 163

Extra folate Lose weight prior to pregnancy if possible will require care at a tertiary centre if over a certain BMI

Answer 164

**Conservative** Simple analgesia COCP Progesterones: Mirena IUD, Depot Provera GnRH agonists: Goserelin **Surgical** Laparoscopic ablation and excision

Answer 165

flame lesions chocolate cysts cigarette burn lesions

Answer 166

Wound Wind Water Walk Whiz Wonder Drugs Mastitis Genital Tract Sepsis

Answer 167

**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

Answer 168

Monochromnic twins

Answer 169

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.*

Answer 170

15-20% of monochromionic twins

Answer 171

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)

Answer 172

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

Answer 173

\>30 AND no normal smear in the last two years: Either colposcopy OR repeat in 6/12

Answer 174

Not pregnant after 12/12 of unprotected sex Not pregnant after 6/12 of protected sex

Answer 175

1 in 6 (there is a campaign in USA called 1 in 6)

Answer 176

Ovarian cancer

Answer 177

1. Engagement (usually LOA) 2. Descent 3. Flexion 4. IR 5. Extension 6. ER / restitution 7. Expulsion

Answer 178

**Maternal** PPH 3rd or 4th degree tear Rectovaginal fistula Uterine rupture **Baby** Erbs palsy (C56) Klumpkes palsy (C78T1) Clavicular # Foetal hypoxia

Answer 179

**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)

Answer 180

**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.

Answer 181

the chorion is the outer layer amnion is the inner layer

Answer 182

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'.

Answer 183

A – appearance (colour) P – pulse (HR) G – grimace (reflex irritability – the response to nasal suction) A – activity (tone) R – respiraton (cry)

Answer 184

# 1. call for help 2. knee-chest face-down position / steep trendelenberg 3. Wrap cord in damp, warm cloth 4. Elevate the presenting part (foetal head) off cord 5. Fill the bladder with catheter 6. Tocolysis 7. Emergcency ceaser Don't put cord back in as this may cause vasoconstriction.

Answer 185

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.

Answer 186

Give her the MMR vaccine before she is discharged fom hospital post birth (is a live vaccine, can't give it whilst pregnant)

Answer 187

You might still use prostin over an oxytocin infusion

Answer 188

The cervical os 'admitted' one finger/two fingers etc

Answer 189

***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

Answer 190

Hep C TFTs

Answer 191

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)

Answer 192

HEAPS POACHED ## Footnote 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]

Answer 193

USE MOAT ## Footnote Uterine & Cervical (tend to cause more miscarriage) Sex Endometriois Male (hypospermatogenesis, obstruction, endocrinological, drugs, radiation, heat) Ovaries: HEAPS POACHED Age \>30 Tubal

Answer 194

No safe level

Answer 195

placental abruption

Answer 196

Foetal alcohol syndrome Intellectual disablity Congenital cardiac defects Brain and spine defects

Answer 197

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

Answer 198

need to keep having Pap smears

Answer 199

If you can't see the squamo-epithelial junction (but usually you use LLETZ)

Answer 200

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

Answer 201

PAP ME Pregnancy Appenix Primary dysmenorrhea / PID Mullerian obstruction Endometriosis + bladder / bowel causes (eg. UTI, IBS)

Answer 202

laparoscopy is the gold standard diagnostic test for endometriosis

Answer 203

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

Answer 204

unexplained infertility

Answer 205

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

Answer 206

**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]

Answer 207

clear cell (it's an endometrial cancer which acts like a ovarian cancer in that's its spread is transcoelomic)

Answer 208

sinusoidal represents severe hypoxia

Answer 209

**TIP: BE CALM** ## Footnote 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)

Answer 210

painful = uterine rupture (rare) or placental abruption painless = placenta praevia or vasa praevia

Answer 211

**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

Answer 212

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

Answer 213

**4Ss** Sleep Stress Sedation Small baby

Answer 214

on a Rh -ve mother who may have experienced foetomaternal haemorrhage the degree of feto-maternal haemorrhage

Answer 215

**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

Answer 216

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

Answer 217

MENOPAUSE ## Footnote 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

Answer 218

ABCEIOU ## Footnote Age \>60 Breast Ca, BP Clots (DVT / PE / stroke) Endometrial cancer I = OP O = gallstones + liver disease Uterus or not?

Answer 219

_Ix and CONFIRM DIAGNOSIS_ * Can do AMH - but not necessary * DEXA scan * FRAX score * Lipid profile, OGTT * HBA1C * CV risk _DEFINITIVE MANAGEMENT_ **Lifestyle Modifications** * Cut down smoking * Healthy diet + exercise to reduce BMI *AND TO SLOW ONSET OF OP* * Cut down ETOH * Dress in layers * Carry a small fan **Complementary** * Phyto-oestrogens (soy isoflavones, black coshosh) **Non-Hormonal** * For urogenital symptoms - cranberry juice, lubricants * For other symptoms - SSRI, SNRI, gabapentin, clonidine **Hormonal** * HRT * Tibolone _PREVENTATIVE OPPORTUNITIES_ * Pap smear * Mammography * FOBT

Answer 220

Other causes of amenorrhea = HEAPS POACHED Also = Fragile X syndrome (?), Turner's moasicism

Answer 221

1. Oligo/amenorrhea 2. Clinic and/or biochemical signs of hyperandrogenism * Hirsutisim * Acne * Androgenic alopecia (male pattern balding) * Raised levels of testosterone, free testosterone index or dehydroepiandrosteronesulphate (DHEAS) 3. Polycystic ovarian morphology on US * Defined as the presence of 12 or more follicles in either ovary measuring 2-9mm in diameter and/or increased ovarian volume greater than 10mL CAN'T BE CAUSED BY ANYTHING ELSE

Answer 222

HATE BODI ## Footnote Hirsuitism Acne Thyroid (hypo as a DDx) Endocrine (as a DDx - cushings and late onset CAH) Balding (male pattern) Obesity Diabetes (Associated with PCOS) Infertility

Answer 223

T2 DM Gestational diabetes Hypertension and increased cardiovascular risk Infertility Endometrial hyperplasia and carcinoma

Answer 224

***_Depends on problem_*** **First line treatment for any problem is diet + exercise** **Obesity** * referral to dietician to help the primary issue but also to aid with menstural disturbance **Menstural Disturbance** * COCP * Particularly newer ones, less-androgenic progestogens such as Yaz * Metformin * If planning a family **Infertility** * Clomifene * Metformin * GnRH analogues (ovulation induction) * Ovarian drilling of this fails * IVF **Acne & Hirsuitism** * OCP * sprinolactone

Answer 225

**To diagnose PCOS** * U/S showing 12+ follicles in either ovary [more specific criteria than this exists] * Increased serum testosterone & DHEA * Decreased sex hormone binding globulin * Increased LH:FSH ratio [\>2:1] (although this isn’t formally part of criteria) **To DDx other conditions** * TFTs – to rule out hypothyroidism * Morning cortisol – Cushing’s * Morning 17-hydroxyprogesterone – to rule out late-onset CAH * Pregnancy test – to rule out physiological amenorrhea **To work out complications of PCOS** * Serum lipid profile * HBA1C * 2hOGTT * U/S endometrial tissue thickness

Answer 226

The placenta produces **insulin antagonists** (human placental lactogen / HPL, progesterone and HCG) as well as **cortisol**, all of which increase glucose production. * The reason why the placenta produces these hormones + cortisol is because the foetus primarily uses glucose for energy (this is why you suspect GDM with a macrosomic foetus). If the pancreatic B-cells are unable to produce sufficient insulin to balance this, or if there is maternal insulin resistance, a state of hyperglycaemia develops.

Answer 227

* Overweight / obese * Increased waist circumference * PMHx of GDM * Previous macrosomic baby (\>4.5kg) * Family history of T2DM * Ethnic origin with high prevalence of DM - asian

Answer 228

PIH / PE T2DM in later life Foetal macrosomia leading to increased rate of C section, obstructed labour, perineal tears

Answer 229

Foetal macrosomia Increased risk of fetal death in utero Respiratory distress Hypoglycaemia Jaundice Electrolyte disturbance (Mg/Ca) Polyhydramnios Congenital abnormality, especially cardiac Packaging problems eg. talipes

Answer 230

hypoglycaemia respiratory distress Klumpkes / Erbs Palsy Clavical Fracture Packaging problems eg. positional talipes Jaundice Electrolyte disturbance (Mg/Ca) Polyhydramnios Congenital abnormality, especially cardiac

Answer 231

The inheritance of PCOS is poorly understood, but appears to be multifactorial. Whilst there is a familial trend, a PCOS gene has not been identified.

Answer 232

Population studies have shown that Caucasian women have a **20–25 %** incidence of PCO. In women from the Indian and Asian subcontinents, the incidence can be as high as 50 %.

Answer 233

Fifty percent of women with PCO have no symptoms or signs. The presence of signs / symptoms.

Answer 234

Pathogenesis appears to commence with an **excess of LH secretion** and **excess insulin secretion** (leading to insulin resistance) plus **reduced sex hormone binding globulin** This results in **hyperandrogenism**.

Answer 235

Diet & Exercise (Will help with infertility, oligomenorrhea/amenorrhea, acne, hirsuitism and obesity)

Answer 236

It releases GnRH in a pulsatile fashion which stimulates the anterior pituitary to release FSH and LH

Answer 237

The ovary secretes oestrogen, progesterone, testosterone and inhibin (and AMH). The inhibin acts as negative feedback to the pituitary.

Answer 238

The follicular phase starts on D1 of menses (when progesterone levels are low). FSH causes the follicule to begin to mature. The maturing follicle secretes increasingly higher amounts of oestrogen, which acts as positive feedback and causes more of a release of GnRH and therefore FSH/LH. This then causes an LH surge which stimulates ovulation one day later - when the phase ends. The length of this stage / phase is variable.

Answer 239

LH surge (which is caused by an increasingly higher amount of oestrogen secreted by the follicle)

Answer 240

It is the left over follicular tissue after the follicle has "burst" and the woman has ovulated. It secretes OESTROGEN, PROGESTERONE AND INHIBIN, as it is stimulated by LH. The combination of oestrogen + progesterone causes NEGATIVE feedback to the hypothalamus and blocks the seceretion of GnRH (and therefore of FSH / LH by the pituitary).

Answer 241

Starts after ovulation (afer the lH surge) Ends when the CL disintegrates (caused by cessation in FSH/LH secretion) and the endometrial lining sheds (D1 of period) This equates to 14 days.

Answer 242

14 days (if egg not fertilised) The significance of this is that the luteal phase is always 14 days

Answer 243

When you take oestrogen + progesterone, you are ingesting what your ovaries/follicles/CL would normally be secreting. Therefore the hypothalamus does not secrete GnRH and the pituitary does not secrete FSH or LH (the **progesterone + oestrogen** inhibits the secretion of GnRH, FSH and LH, as it would normally in the luteal phase). Therefore **you do not ovulate**. Although you do not ovulate, **you still build your endometrial lining**. When you take the sugar pills and you no longer take progesterone, you get a withdrawal bleed.

Answer 244

Within 10 weeks of conception

Answer 245

BP BMI Urine dipstick

Answer 246

BMI urine dipstick BP fundal palpation intermittent auscultation of foetal heart

Answer 247

BMI BP urine dipstick fundal palpation intermittent auscultation of the foetal heart ask about foetal movements

Answer 248

BP BMI urine dipstick auscultate foetal heart fundal palpation ask about foetal movements SFH palpation of lie and presentation

Answer 249

***_Routine Investigations_*** * Naegel's rule * FBE (+ ferritin) * Blood group * Antibodies * SaRAH * Syphillus serology * Rubella serology * Asymptomatic bacuria * HIV & Hep B * EPNDS ***_Consider the Following Investigations_*** 2G, 3T, 4C * Gohnorrhea * GDM * Trichomoniasis * Toxoplasmosis * TFTs * Chlamydia * Hep C * CMV * Cervical abnormalities - Pap smear

Answer 250

* 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!

Answer 251

2G, 3T, 4C? ## Footnote Gonorrhea - previous STI, unknown partner, infrequent condom use GDM - overweight, previous history of GDM Trichomoniasis - if have symptoms Toxplasmosis - if have symptoms or pets / work wth animals Thyroid - previous history of thyroid disease, symptoms of thyroid disease Chlamydia - as for gohnorrhea CMV - work with children? Cervical abnormalities - pap smear up to date? Hep C - tattoos, piercings, IVDU

Answer 252

**8-14 weeks** (usually called "12 week scan" and done with first trimester screening) CRL (in mm) + 6.5 = approximate gestational age in weeks If the CRL is above 84 mm, estimate the gestational age using head circumference The crown rump length is used to measure GA, because all foetuses grow at roughly the same rate at this time.

Answer 253

At 12 weeks: dating scan At 20 weeks: morphology scan + position of the placenta At 26 weeks: 2hOGTT, FBE & antibody screen At 37 weeks: GBS

Answer 254

* Advanced maternal age is the only known risk factor for downs syndorme (as well as perhaps previous baby with down syndrome) * HOWEVER most babies with DS are born to mothers

Answer 255

* **What is the screening for?** * Screening for trisomy 18 (Edwards Syndrome) * Screening for trisomy 21 (Downs Syndrome) * Screening for NTD (but these are better picked up on the 20 week scan) * **Why people might want to screen?** * People should only screen if they would consider termination of pregnancy if it was to show that their child had trisomy 18, 21 or a NTD. * **Explain that it is a** **two part process** * The first part ascertains your **risk _but is not diagnostic_** * If in the first trimester involes a blood test at 10 weeks + USS at 12 weeks [combined screening test / triple test / first trimester screening] * If in the second semester involves a blood test only * A third option is "percept" or NIPS. This is more sensitive but is not yet covered by medicare. * The second part is diagnostic, you only have it if the first part has shown you to be _high risk_. WOMEN WHO ARE \>37 YEARS OLD AND ARE AT A MUCH HIGHER INCREASED RISK, CAN OPT TO GO STRAIGHT TO THIS STEP * CVS is performed at the end of the first trimester * in which a sample of pre-placental tissue is removed with a needle through the abdomen under US guidance * Amniocentesis is performed after 15/40 * In which a sample of amniotic fluid is sampled via the same process * These samples are sent to the lab, and looked at under a microscope, to see if the foetal cells have an abnormality

Answer 256

CVS 1% above background amnio 0.5% above background

Answer 257

**CVS = 99.9%** CVS has a 0.1% rate of failure to detect a pregnancy with a chromosomal anomaly, due to the occasions when there is an abnormal karyotype in the baby, but not in the placenta. **Amnio = 100%**

Answer 258

* PAPP-A * free B-HCG reduction in free B-HCG and increase in PAPP-A is suggestive of Trisomy 21 Reduction in both is suggestive of Trisomy 18

Answer 259

* inhibin * B-HCG * AFP * unconjugated estradiol Trisomy 21: increased B-HCG and inhibin and decreased in the others Trisomy 18: decrease in all NTDs: increase in AFP

Answer 260

Smoking * Cease * Nicotine replacement therapy is OK Nutrition * Folate supplementation (0.4mg/day or 5mg/day) from one month prior to conception * Iodine supplementation from conception * Iron supplementation if deficient Alcohol * No known safe level of alcohol in pregnancy Physical activity * Advise against contact sports * But not contraindictaed Pets * Do you have pets? Sex * Not contraindicated unless placenta previa / PROM? Drugs * Taking any medication, need to change? Dental * In need of any major dental work? Work Travel Vaccinations * Measles * Mumps * Rubella * Varicella Zoster – this is new! Most women won’t have had it * Diphtheria * Tetanus * Pertussis Investiagtions * FBE * Syphillus * Rubella * HIV * Hep C And, if indicated * gohnorrhea, GDM, TFTs, toxo, trichomoniasis, Hep C, chlamydia, CMV and Pap smear

Answer 261

Influenza vaccine Whooping cough vaccine at 26 weeks Rhogam at 26 and 34 weeks if Rh negative

Answer 262

Obesity - increased peripheral conversion of oestrogen

Answer 263

1. Menses 2. Proliferative 3. Secretory

Answer 264

Chain of pearls / ring of pearls

Answer 265

twice / week If more than twice - step up Rx from lifestyle --\> insulin --\> metformin

Answer 266

* FBE, UEC (anaemia and pre-renal renal failure) * LFTs, CXR, ECG (anaesthetic work up) * Pelvic U/S (preferably transvaginal, * Pipelle sampler * Diagnostic hysteroscopy + D&C * Mammogram if \>40 (ovarian Ca / breast Ca)

Answer 267

Those with PHx of GDM, FHx of GDM and who are overweight. Plus if they have glycosuria. Don't do it until AFTER 14 weeks

Answer 268

Unstable lie Cord prolapse

Answer 269

If they are being treated by lifestyle --\> can go to 42 If on insulin --\> can't go past 40

Answer 270

Cyclical - if the woman is still having her periods (want a progesterone withdrawal to shed the rest of the lining - if gave cyclical would spot). Continuous - if the woman hasn't had periods for \>1 year

Answer 271

* Hysterectomy (TAH) * Consider bilateral salpingectomy and oopherectomy (BSO)! * Staging of the pelvic lymph nodes

Answer 272

General insepection of the vulva and perineum As well as check pads for blood / liqour

Answer 273

At 20 years old your risk is 1/1,500 At 40 years old your risk is 1/100 Anything more than 1/300 is considered "high risk" (which is the equivalent of the risk of a 36 year old) This is why women \>36 years old can be offered to skip straight to diagnostic testing!

Answer 274

1st is more sensitive 85-90% 2nd is less sensitive 70-75%

Answer 275

DIAGNOSTIC TESTING CVS - performed earlier (12-14 weeks) - higher risk of miscarriage (1%) - less sensitive (99.9%\*) \* CVS has a 0.1% rate of failure to detect a pregnancy with a chromosomal anomaly, due to the occasions when there is an abnormal karyotype in the baby, but not in the placenta. Amniocentesis - Performed later (15-18 weeks) - lower risk of miscarriage (0.5%) - More sensitive (100%)

Answer 276

BIG CAPUT ## Footnote Bloody show Infection Giant haemorrhoids Cancer Abruptio placentae Praevia - placenta or vasa Uterine rupture Trauma

Answer 277

PPROM / PROM Placenta Praevia

Answer 278

Praevia / previa = uterus is soft Abruption = uterus is tender and hard

Answer 279

praevia = bright red, often ongoing abruption = dark red, often single instance

Answer 280

Vasa praevia

Answer 281

Basics * DRABC Place & Person * Call for help * **_INPATIENT BED REST UNTIL DELIVERY_** * **Consider calling PIPER for transfer** Ex & Ix & Confirm Diagnosis *Examination* * Abdominal palpation * SFH * Auscultate foetal heart * Sterile speculum examination * NO VAGINAL EXAM *Investigations* * FBE, UEC, LFT * Blood group * Cross match * Kleihauer if Rhesus negative * U/S to confirm position of placenta & blood flow * CTG *Defitiive Management* * * Steroids * **_C cection at 37 weeks_**: discuss with mother *Follow Up* * NO SEX OR ANYTHING IN THE VAGINA * CONSIDER RISK OF Placenta Accreta - may need hysterectomy * O&G, Paeds at delivery * Counsel mother after birth

Answer 282

APPEASED (Think: you have to appease everyone) A – Age, gestational (this with maternal health guides your definitive management) P – Paediatrics & Anaesthetics referral for delivery **OR** PIPER for transfer out of a rural setting P – Penicillin if GBS+ve and vaginal delivery E – Erythromycin for 10 days if PPROM A – Anti-D ready for after birth if Rh– (although can give within 72 hours) S – Steroids if E – Evaluate: Expectant or Active Management D – Discuss with mother (Woman-Centered Care)

Answer 283

DEFINITIELY GIVE * If at risk of delivery and * If elective C section between 37-39 weeks (NB: C sections are normally performed after 39 weeks) * If IUGR and at risk of delivery CONSIDER * If not IUGR and at risk of delivery

Answer 284

Betamethasone: 2 x 12mg, 24 hours apart Dexamethsone: 4 x 6mg, 12 hours apart

Answer 285

Antenatal steroids are associated with a significant reduction in rates of * Neonatal death * Neonatal Respiratory Distress Syndrome * Neonatal intraventricular haemorrhage

Answer 286

**UNOPPOSED OESTROGEN** Obese (peripheral conversion) Nulliparous (because pregnancy is a progestogenic state, and because when you breast feed you don't ovulate) Increasing age Late menopause Oestrogen only HRT Tamoixfien (anti-oestrogen at the breast but por-oestrogen at the endometrial tissue)

Answer 287

COCP Mirena Smkoing (causes earlier menopause, anti-oestrogen ffect)

Answer 288

Just after period when endometrium is at its thinnest

Answer 289

Leiomyosarcoma!

Answer 290

older woman with vague pain + plus "abdominal swelling" (ascites)

Answer 291

\>5cm Multicystic Solid area Ascites Bilateral Increased blood flow

Answer 292

CA125 sensitivity 81% specificity 75%

Answer 293

Much more aggressive than endometrial cancer\ ## Footnote AGGRESIVE SURGERY + chemo infracolic omentectomy washings biopsies of noes appendicectomy! + chemo

Answer 294

Can't see transitional zone Galandular change (as this can be skip lesions) \*LLETZ is a form of biosy and treatment (get a specimen - not in ablation)

Answer 295

Lazer ablation - less risk of cervical incompetence but don't get a sample LLETZ - good because get a specimen Cone biopsy - get a specimen but increased risk of vercial incompetence

Answer 296

Because HCG is similar in structure to TSH

Answer 297

More of a clinical presentation *"PV bleeding in a pregnant women* PV bleeding in early pregnancy Cervical os is closed Can still visualise a heart / normal growth on US

Answer 298

PV bleeding cervical os open gestational sac + foetal pole is present on U/S

Answer 299

PV bleeding in Cervical os is open Some of the products of conception are in utero on U/S, but not all

Answer 300

Hx of PV bleeding Cervical os is closed No products on conception on ultrasound / nothing on ultrasound A DDx from this would be an ectopic pregnancy or "pregnancy of unknown location". Would need serial BHCG to DDx.

Answer 301

No PV bleeding Cervix is closed Foetal pole / sac is small for dates OR no heart beat. An anembyronic pregnancy / blighted ovum is the same thing!

Answer 302

Threatened miscarriage

Answer 303

Inevitable miscarriage

Answer 304

incomplete

Answer 305

Complete miscarriage

Answer 306

Missed miscarriage Asymptomatic foetal demise

Answer 307

\>3 miscarriages ie. "recurrent miscarriage"

Answer 308

SLEIGH ## Footnote **Structural** - submucosal fibroids, cervical incompetence, uterine septum, bicornuate uterus **Lifestyle** - smoking, alcohol, cocaine, **Endocrine** - poorly controlled DM, graves disease, hyperprolactinaema **Infectious** / **Immunological** - bacterial vaginosis, Rh disease **Genetic** - chromosomal abnormalities **Haematological** - Antiphospholipid syndrome, thrombophilias

Answer 309

NORMALISE CAUSE SYMPTOMS COMPLICATIONS NORMALISE * 1 in 5 women pregnancies, unfortunately, result in a miscarriage * Very difficult and very sad CAUSES * It is important to realise that this is not your fault, there is nothing you have done wrong. You did not cause this. You should not feel guilty. * This foetus, from when it was conceived, had something wrong with it and it was not going to survive in your uterus, and not in the outside world. * There are some factors which increase your risk of miscarriage, **smoking** is one of them (if they smoke) - ***but this is unlikely to be the sole cause of the miscarriage*** SYMPTOMS * This is why you've experienced this pain and bleeding (if relevant) Complications * Your risk of future miscarriages is not increased. * If you have two miscarriages, your future risk is only slightly increased * We only start investigating for possible miscarriage after you've had three miscarriages

Answer 310

**Basics** **Place & Person** **Ex, Ix and CD** - speculum examination - pelvic ultrasound - serum BHCG **Definitive Management** \*\*Anti-D if Rhesus Negative\*\* * Expectant Management* * Medical Management* * Misoprostol (unless has ASTHMA) + mifepristone * Surgical Management* * Suction D&C **Follow Up** BHCG / urine pregnancy test post management to ensure no longer pregnant, to ensure no molar or ectopic pregnancy Counselling, reassurance Ix if recurrent miscarriages

Answer 311

Miscarriage Ectopics STITCH Subchorionic haemorrhage Trauma Infection Trophoblastic Cervical cancer, polys or ectropion Heterotropic pregnancy

Answer 312

If the gestational sac meaures \> 25mm and NO foetal pole is visualised, this is diagnostic of a miscarriage. If the CRL is \> 7mm and no foetal heart beat is visualised

Answer 313

Hydatitaform mole

Answer 314

Complete = "snow storm" appearnce

Answer 315

***_6Bs_*** ## Footnote Bladder – insert a urinary catheter! Bimanual compression (not technically surgical) Balloon Tamponade B-Lynch Suture Bilateral uterine artery ligation Bail! – Hysterectomy

Answer 316

BEP APH IPH PPH

Answer 317

Bleeding within the first 24 hours post partum \>500mL loss in NVD \>750mL loss in C section

Answer 318

Tone Tissue Trauma Thrombin

Answer 319

The two main causes are: 1. Infection 2. Tissue - retained products of conception 3. Trophoblastic disease But you need to consider lochia and a period (especially if it's been approximately 4 weeks since birth, and she isn't exclusively breast feeding and is not on any form of contraception!)

Answer 320

Hypovolaemic shock + end organ damage Anaemia AKI Sheehan's syndrome Lactation failure or delay

Answer 321

PIG FIT CUPPA ## Footnote PHx PPH Infection Grand multiparity (although age is a confounding factor in studies) Fibroids Instrumental Trauma Coagulopathy Uterine overdistension - multiple pregnancy, macrosomia, polyhydraminios Precipitous labour Prolonged labour APH

Answer 322

Ferritin (Don't do full iron studies because iron handling changes)

Answer 323

1. immediate administration of prophylactic uterotonics 2. early cord clamping 3. controlled cord traction It is emplyed to reduce the risk of PPH

Answer 324

ME MSIS PM ## Footnote _First Line_ Ergometrine 250mcg (IM or IV) - don't give if Hx of HT; **OR** Syntometrine (1mL IM) _Second Line_ Infusion of syntocinon (40 IU in 1L of NaCl or Hartmans, administered over 4 hours) _Last Lines_ Prostaglandin F2 alpha (in theatre) Misoprostol (in theatre)

Answer 325

Misoprostol = asthma Ergometrine = HT / PIH / PET

Answer 326

Position + BIM + ME MSIS PM + 4Bs ## Footnote *Mechanical* Position - head down + wedge to left side lie Bimanual compression (if epidural) IDC Massage *Medical* Ergometrine (250mcg IV / IM) - not in HT Syntometrine (1mL IM) Infusion of syntocinon (40u in 1L NaCl over 4 hours) Prostaglandin F2 alpha (in theatre) Misoprostol (in theatre) *Surgical* B Lynch Suture Balloon tamponade Bilateral uterine (or internal iliac) artery ligation Bail! Hysterectomy

Answer 327

Can stay in for \>24 hours Have to be on a broad spectrum ABx

Answer 328

PPH Management *“As this is an emergency my assessment and immediate management would be simultaneous”* **Clinical Assessment** * Take a brief history: * : name, age, time of delivery, health of baby / babies * : “any significant medical conditions?” * : “any ante-partum complications?” * *The labour*: how it started, duration, pain relief eg. epidural, type of delivery, episiotomy or tears, active management of third stage * *Post partum*: estimated blood loss, haemodynamic stability of the woman, placenta **Resuscitation** **D**: Look for slip hazards, put on gloves. **R**: **S**: *Send for help:* * 2 x midwives * O&G consultant * *Assign roles:* * Someone to scribe * Someone to support patient * Someone to start intensive vitals chart (every 10-15 minutes) * Someone to get drugs and blood products etc. * Someone to be the “runner” *Contact theatre* **A:** **B:** administer O2 10L via HM **C:** * 2 x wide bore (16 guage) cannulae * Send off blood for cross match / FBE / coags & fibrinogen * IV colloids / O negative blood / X-matched blood: mark as *urgent* **Assess for underlying cause** * 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 à if you suspect this involve HAMEATOLOGIST * Theatre: contact if haven’t already! **Management** *_Mechanical_*_:_ Think Julia has a POSITION at BIM Position: Head down + wedge to roll on to left side + keep warm Bimanual compression (if has epidural) *- this is in earlier because if you can get your hand in early (soon after epidural) you can also fish around and pull out any retained placental products* IDC Massage - the fundus _Medical_: ME MSIS PM Metrine – Ergo (250mcg, diluted to 5mL in normal saline, IV) *– don’t give if history of HT/PET!* Metrine – Synto (1mL IM) Infusion of Syntocin (40 IU in 1L of Hartman’s over 4 hours) Prostaglandin F2 alpha (injections into uterus through abdomen) Misoprostol (tablets in the rectum or vagina) *_Surgical_*_:_ 4Bs Balloon tamponade B lynch suture Bilateral uterine artery (or internal iliac) ligation Bail à hysterectomy **_Post-PPH Care_** 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?

Answer 329

FBE LFT Coags UEC Uric acid FWT for proteinuria

Answer 330

Benzylpenicillin If hypersensitive: Cephazolin If immediately hypersensitive: Clindamycin If resistant to clindamycin or suspecptibility testing unavailable: Vancomycin

Answer 331

**Basics** DRABC + fluid resuscitation if severe Commence fluid monitoring if severe **Place and Person** Admit if severe **Investigate and Confirm Diagnosis** *_Bedside Tests_* Urine dipstick BGL *_Blood Tests_* FBE UEC LFT TFT BHCG [to screen for molar pregnancy] Urine MC&S **Definitive Management** *_Non-Pharmacological_* Ginger Dietary strategies Avoid provoking foods Small frequent meals Elevate bed head *_Pharmacological_* H2 antagonists Anti-emetic (metaclopromide / ondansetron) If severe - steroids *_Prevention / Future Care / Prophylaxis_* Vitamin B1 and B6 supplementation DVT prophylaxis [as the woman is dehydrated + often not mobile!]

Answer 332

foetal death after 20 weeks gestation

Answer 333

**Current Risks** Bleeding / blood loss Infection Pain Scar DVT Damage to bladder or bowel Foetal laceration Neonatal respiratory morbidity **Future Risks** Increased risk of uterine rupture with future vaginal births Placenta previa Placenta accrete Adehesions

Answer 334

**_Foetus_** *Elective* * Macrosomia / Cephalopelvic disproportion * Breech (not always) * Twins *Non-Elective* * Signs of foetal compromise / demise, which need to be managed more quickly than with IOL * Shoulder dystocia **_Mother_** *Elective* * Maternal wishes * Maternal medical condition which hinders her from maternal effort (eg. aortic stenosis) * Placenta previa * Previous C section *Non-Elective* * Failure to progress * Failed IOL * Medical illness which requires urgent delivery

Answer 335

PIG FIT CUPPA ## Footnote PPH PHx Infection Grand multiparity Fibroids Instrumental delivery Trauma Clotting abnormalities Uterine overdistension (polyhydramnios, macrosomia, multiple gestation) Prolonged labour Precipitous labour APH (PMHx of) "Couvelaire uterus"

Answer 336

Pain Perineum Pissing Pooing Pyrexia Psyche PPH PE + **GDM** Protection + **Pap Smear** PE / DVT **Rhesus status** **Rubella immunity**

Answer 337

Call for help before/after each step! C Clinical Evaluation Hx, Ex and vitals R Resuscitate Standard shock management A Assess the underlying cause Investigate the four T’s M Manage the cause Medical and Surgical

Answer 338

A loss of \>500mL of blood after pregnancy Primary * In the first 24 hours Secondary * 24h - 6 weeks

Answer 339

**Tone** [uterine atony] **Tissue** [Retained products (placenta or membranes)] **Thrombin** [DIC, coagulopathy] **Trauma** [Laceration to the cervix, vaginal, perineum and (rarely) uterine rupture]

Answer 340

Abortion is legal up until 2nd STAGE OF LABOUR It was decriminalised in 2008 THERE IS NO UPPER LIMIT (After this is infanticide) But after 24 weeks need 2 doctors approval / it goes to an ethics committtee at southern health

Answer 341

Up until 9 weeks (The woman can choose between surgical / medical TOP) Mifepristone (RU486) is taken orally Vaginal misoprostol is then adminstered 1-3 days later

Answer 342

An ultrasound to confirm - GA (only until 9 weeks) - to ensure it is intrauterine (can't use it ectopic pregnancy)

Answer 343

Repeat 6-12 weeks Not before 6 weeks because want cells to recover

Answer 344

Dilation, suction and curretage / vacuum extraction

Answer 345

Prepare the cervix with misoprostol inserted vaginally Dilation with graduated rods Suction Scrape with curette IV Oxytocin is given during this Give doxycycline prophylactically afterward (because at risk of chlamydia) - NB you don;t give this in miscarriage

Answer 346

Mifepristone / RU486 orally + Misopristol (vaginally or orally) 48 hours later!

Answer 347

Azythromycin 1g as a single dose OR Doxycycline 100mg BD for 7 days

Answer 348

Chlamydia is MUCH mor common If a patient had urethral discharge, even though chlamydia is usually asymptomatic, you would suspect chlamydia over gohnorrhea because it is so much more common

Answer 349

Basics - Reportable disease: DHS - Advise to avoid sexual contact for 7 days during and after treatment Ix and Confirm Diagnosis - First pass urine: NAAT - Screen for gohnorrhea, syphillus, HIV, Hep B Defitive Management - 1g azithromycin OR 7 days of doxycylcine - advise to abstain from sexual intercourse for 7 days during and after treatment Prevention - education RE condom use - contact tracing: encourage patient to do so, using the "let them know" website. Explain to them the options of doing so anonymously. There is no legislation requiring contact tracing Australian Medical Association believe that doctors do have a professional responsibility to contact trace

Answer 350

**_Report_**: Should report to DH&S **_Contact Tracing_**: There is no legislation requiring contact tracing Australian Medical Association believe that doctors do have a professional responsibility to **contact trace**. Respect privacy, but encourgae and show them options such as letthemknow.org.au

Answer 351

PID Infertility Ectopic pregnancy Epididymitis Reactive arthritis

Answer 352

Screening recommended for under 25’s and those at risk: * past history of chlamydia or other STI * new or multiple sexual partners * inconsistent condom use. Done through self collected vaginal swab or first-voided urine (the latter being much more common).

Answer 353

Chlamydia Gohnorrhea

Answer 354

Asymptomatic! They may be infertile before they get symptoms!

Answer 355

Gohnorrhea

Answer 356

Man: copious uretheral discharge Woman: usually asymptomatic Infections of the cervix, anus and throat usually cause no symptoms.

Answer 357

Ceftriaxone: 250mg IM as a single dose + azithromycin: 1 g orally as a single dose Because gohnorrhea often comes with chlamydia (not vice versa) and chlamydia is much more common

Answer 358

Screening recommended for under 25’s and those at risk- * past history of chlamydia or other STI * new or multiple sexual partners * inconsistent condom use (Same as chlamydia)

Answer 359

urine (mid stream) endocervical specimen MC&S culuture of discharge (if symptomatic)

Answer 360

Basics * Advise to abstain from sex until after treatment Ix and confirm diagnosis * Ix for gohnorrhea with MSU / swab & culture * Screen for chlamydia, syphillus, HIV, Hep B Defitive Management * IM ceftriaxone Ongoing * Notify DHS within 5 days * Encourage partner notification / contact tracing. Direct patient to the "let them know" website. Doctors are not legally required to perform contact tracing but are considered ethically required to do so * Advise abstience for 7 days after treatment * Education RE condom use in the future

Answer 361

A painLESS genital ulcer caused by syphillus

Answer 362

A painless geintal ulcer caused by primary syphillus. Also comes with local lymphadenopathy

Answer 363

benzathine penicillin 1.8 g IM, as a single dose

Answer 364

Chlamydia: 1 dose of azithromycin (or x 7 of doxycyline) Gohnorrhea: IM ceftriaxone (+ azithromycin for chlamydia) Syphillus: IM benzathine penicillin

Answer 365

Genital herpes = HSV Genital warts = caused by HPV types 6 and 11

Answer 366

HSV 1 HSV 2

Answer 367

People who are infected by the HSV virus usually have the infection for the rest of their lives. It intermittently manifests as a cold sore (HSV 1) or a genital bliser (HSV 2). In some people, however, it never manifests. If one member of a couple has diagnosed HSV, and they are having ongoing unprotected intercourse you can be certain the other member has it - even if it isn't diagnosed.

Answer 368

Acyclovir Protected sex whilst there is active lesions

Answer 369

Call for help

Answer 370

breech malpresentation multiple gestation grand multiparity preterm labour abnormal placentation polyhydramnios **all to do with more space in utero / head not plugging the os**

Answer 371

complete incomplete - this one is bad frank

Answer 372

cord presentation = intact membranes cord prolapse = ruptured membranes, cord doesn't necessarily have to be external

Answer 373

VE Palpate for the head. If there is a soft, pulsatile structure it could be cord presentation or vasa previa

Answer 374

epidural doesn't cover it

Answer 375

Either intra-rater error OR uterine rupture

Answer 376

The posterior aspect of the shoulder

Answer 377

only at autopsy foetal squames in patient lungs

Answer 378

\>500mL loss 24/24-6/52 post birth

Answer 379

perforation bleeding asherman's syndrome

Answer 380

6 weeks 12 weeks

Answer 381

That their lochia has stopped and that they don't have PPH because can get heavy bleeding

Answer 382

Start: 18-20 years OR 2 years after first had sex (whichever is later) Frequency: every 2 years Stop: age 70 (for women who have had two normal Pap tests within the last 5 years)

Answer 383

Start: 25 years Frequency: Every 5 years Stop: Between 70 and 74 years Actual test will be for HPV as well as liquid based cytology

Answer 384

Avoid during menstruation, obvious vaginal infection, within 24 hours of intercourse (incrased risk of UNSATISFACTORY SMEAR)

Answer 385

condylomata acuminata

Answer 386

Three broad strokes of management. * **ablative options** [fertility sparing] - such as lazer * **excisional options** [fertility sparing] - such as LLETZ or cone biopsy * **definitive options** [not fertility sparing] - hysterectomy

Answer 387

1 hour in multis 2 hours in primis 3 hours if epidural should take no longer than 3 hours!

Answer 388

Oxytocin / Syntocinon Yes, this should be given even in women having a C section? Reduces risk of PPH by 50-60% Preferred route = IM; 10IU Sometimes give it IV; 5-10 IU (see relevant hospital guidelines)

Answer 389

***_Non-Surgical_*** Think of a creepy prime minister intructing his wife to massage him ***"Massage ME MSIS PM***" **Massage** **M**etrine-**E**rgo **M**etrine-**S**ynto **I**nfusion of **S**yntocinon **P**rostaglandins **M**isoprostol ***_Surigcal_*** The 4Bs Balloon Tamponade B-Lynch Suture Bilateral urerine artery ligation Bail! - Hysterectomy

Answer 390

Cervical ectroption

Answer 391

Obseity (fat produces oestrogen) Nulligravid (?) Older age (anovulation, unopposed oestrogen) PCOS + infertility (anovulation, unopposed oestrogen) Unopposed oestrogen increases risk of endometrial cancer

Answer 392

PPH due to endometritis Usually caused by retained products Febrile women, approx 1-2 weeks post birth with lower abdominal pain and vaginal bleeding

Answer 393

Tenderness of the cervix on movement Can signify pelvic inflammatory disease (PID), ectopic pregnancy Used to DDx from appendicitis or gastrointestinal pathology

Answer 394

When the gestational sec is 16mm in diameter, a foetal pole should be able to be visualised. If the gestational sac measures 16-24mm and NO foetal pole is visualised, you should be suspicious of a miscarriage. If the gestational sac meaures \>25mm and NO foetal pole is visualised, this is diagnostic of a miscarriage.

Answer 395

"Postinor" / Levonorgesterol Within 72hours 1-2%

Answer 396

Oetrogen + LNG (administered with an anti-emetic) Has to be prescribed by a GP Has to be used within 72 hours Failure rate = 2-3%

Answer 397

Up to 5 days post intercourse Advantage is that it can be used for ongoing contraception Contraindication = possible STI Relative contraindication = nulligravid Failure rate = 2-3%

Answer 398

=RU486 Up to five days post intercourse It is more effective than the Yupze method Can only be prescribed by registered prescribers It might delay their period - can cause anxiety Advantage is that it is better tolerated than LNG

Answer 399

**SMERBB** ## Footnote Explain how to START the medication Explain what to do about MISSED pills. Explain how to use EMERGENCY contraception if it’s ever needed Explain the RISKS AND SIDE EFFECTS of the medication Discuss BREAKTHROUGH bleeding Measure the BP (and weight)

Answer 400

Follicular phase Luteal phase

Answer 401

The hypothalamus secretes GnRH , the anterior pituitary, in turn, secretes LH and FSH which stimulates a follicale to grow

Answer 402

The growing follicale secretes oestrogen, which causes more secretion of GnRH, which in turn causes more secretion of FSH/LH - causing a surge!

Answer 403

The LH/FSH surge (preceedes it by one day)

Answer 404

It's length of time is variable - it ends at ovulation. It is approximately 14 days long

Answer 405

The corpus luteum secretes oestrogen, progesterone and inhibin - these in combination inhibit the release on GnRH and thereby FSH/LH, stopping other follicules from growing

Answer 406

The corpus luteum dicintegrates, so no more O/P/inhibin so no more inhibitiion of GnRH/FSH/LH

Answer 407

menstural flow proliferative phase

Answer 408

secretory phase

Answer 409

intermenstural bleeding post-coital bleeding

Answer 410

Leiomyoma Composed of myometrial tissue They can be located within the myometrium, sub mucosal, sub-serosal or pedunculated

Answer 411

fibroids are made of myometrial tissue polyps are made of entometrial tissue

Answer 412

* asymptomatic (50% of fibroids are asymptomatic) * menorrhagia (+/- symptoms of anaemia) * dysmenorrhea (but rare, unless complications occur) * pressure effects * urinary frequency * urinary retention, symptoms of UTI * tenesmus * constipation

Answer 413

* General examination - look for signs of anaemia * Abdominal examination * Speculum examination * Bimanual examination

Answer 414

Bedside Tests * First pass urine for chlamydia * Urine sample for gohnorrhea * Pap smear / HPV tetsing Labratory Tests * FBE * UEC (if unstable) * Coags * Thyroid Function Tests * CA125 / CEA may aid differential diagnosis eg. from ovarian mass) Imaging * Pelvic ultrasound Invasive * Hysteroscopy * Biopsy * Diagnostic laproscopy (espeically if mass is intraperitoneal, may need to DDx it from ovarian pathology

Answer 415

BITCHFACE ## Footnote Bleeding disorders Iatrogenic (Copper IUD, drugs, surgical) Thyroid (hypo) Cancer (endometrial, cervical) Hyperplasia of the endometrium Fibroids (leiomyoma) and polyps Adenomyosis & endometriosis Chlamydia & Gohnorrhea Ectopic pregnancy, miscarriage or other causes of bleeding in early pregnancy

Answer 416

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 * Pharmacological * Tranexamic acid * NSAIDs * OCP * Surgical * Mirena * Endometrial ablation / rescection * Mymectomy (fibroids) * Hysterectomy

Answer 417

Tranexamic acid OCP & NSAIDS - can cease when trying to get pregnant Mirena - can remove when trying to get pregnant Myomectomy (for fibroids)

Answer 418

Endometrial resection or ablation Hysterectomy

Answer 419

Everyone! (The guidelines used to say only those with risk factors). Between 26-28 weeks but on the first antenatal visit if they have risk factors.

Answer 420

75g 2 hour POGTT Women should fast overnight. They should then have a fasting BSL, and then a BSL at one and two hours. It is not uncommon for women to vomit during this test, before the two hour mark. If this is the case, you can still consider the 1h result but it is best to do an HbA1c too

Answer 421

TFTs (if not done already). They should have a repeat 75g OGTT 6-12 weeks post pregnancy (using non-pregnant parameters). If they have had GDM they are at an increased risk of developing TIIDM in the future so they should have ongoing monitoring every 2-3 years.

Answer 422

GDM: 0 hours = 5.5 - 7 1 hour = \> 10 2 hours = 8.5 - 11 Can't diagnose DM in pregnancy

Answer 423

* **pregnant women from 28 weeks gestation during every pregnancy** * partners of women who are at least 28 weeks pregnant if the partner has not received a pertussis booster in the last ten years * parents/guardians of babies under six months of age and they have not received a pertussis booster in the last ten years.

Answer 424

From 25 weeks. Symphysiofundal height may be the GA+/-2cm The measurement **should start from the** **variable point; the fundus**, while both hands are available for palpation. From there, the tape is run along the longitudinal axis of the uterus to the top of the symphysis – a fixed point, and the more easily identified landmark.

Answer 425

18-20 weeks normally

Answer 426

iodine (iFolic is a good option) The developed world is becoming more iodine deficient and there is increased iodine requirements in pregnnancy due to increased thyroid activity

Answer 427

* Colic * GOR * Cleft palate * Cleft lip * Tongue tie (ankyglossia) * Poor suck/swallow reflex eg. when premature * Sick baby for another reason (eg. sepsis) so they are tiring at the breast, unable to suck * Respiratory illnesses (eg. RDS) – it is difficult to suck and breathe at the same time – anyway!

Answer 428

Nipple Issues * Nipple variation (inverted, short, long) making it hard for the baby to suck * Infection of nipple / inflammation of nipple making it painful for the mother to feed Breast Issues * Infection/inflammation making it painful to breastfeed (mastitis, abcess, galactocele) Issues with supply * Oversupply / engorgement – can eventually cause poor supply. Can also cause breasts to be painful. * Poor supply Issues with milk * If mother has infection which may transfer to child (eg. HIV, Hep B if bleeding / cracked nipples) Perinatal / Postnatal Depression * Low mood, lack of motivation to breast feed

Answer 429

ABCDEFGH ## Footnote Allergy and atopy reduced Bones (protective against OP) Close relationship & contraception Developmental / IQ benefits Economical Figure: quicker return to pre-pregnancy weight GIT (NEC, IBD and gastroenteritis) Haemorrharge (post partum) reduced

Answer 430

Galactagogues Domperidone (Motilium) and Metaclopromide (Maxalon)

Answer 431

Tests for chlamydia Pregnancy test

Answer 432

How to collect a 'first pass urine' specimen for chlamydia testing * This test works best if you haven't been to the toilet to pass urine in the past hour. If it is less than 1 hour since you passed urine, this test may not be accurate. Let your doctor know if this is the case * You do not need to clean or wipe yourself before this test * You need to collect the very first part of your urine stream. This means first passing urine straight into the container, not into the toilet * Once the container is about a quarter full, pass the rest of your urine into the toilet

Answer 433

Yearly in all sexually active young people aged 15–29 years

Answer 434

Nucleic acid amplification test (NAAT) most commonly by PCR

Answer 435

Locally secretes a high dose of progesterone: 1. makes the mucous thicker - a barrier to sperm entry 2. thins the endometrium so the egg can't implant 3. the mirena itself acts as a barrier to sperm

Answer 436

Non-stress test Gross body movements Foetal breathing Muscle tone Amniotic fluid index

Answer 437

The permanent cessation of menstruation in non-hysterectomied women.

Answer 438

The time from the onset of cycle irregularity through until 12 months after the menstrual period.

Answer 439

When the cessation of ovarian function occurs before the age of 40 years (ie. cessation of menstruation before age 40)

Answer 440

Breast tenderness Menorrhagia Migraine Nausea Shorter cycle length and a shorter follicular phase

Answer 441

General: * Fatigue * Headaches * Muscle/joint aches Cognitive: * Depression * Memory loss * Difficulty concentrating Vasomotor: * Hot flushes * Night sweats * Urogenital Vaginal dryness/itching * Urinary frequency/urgency

Answer 442

Metabolic syndrome Osteoporosis Vaginitis

Answer 443

Head injury Excessive exercise Anorexia Prolactinoma Sheehan’s Syndrome PCOS / Premature ovarian failure / PREGNANCY?! Obesity Asherman’s syndrome Cx stenosis and late-onset CAH Hypothyroidism Endocrine Drugs (DA antagonists à hyperprolcatinaemia or progesterone)

Answer 444

Remember: **ABCEIOU** (see summary) Breast cancer DVT / PE Stroke Endometrial cancer Cholecystitis

Answer 445

A clinical diagnosis. If a woman is \> 45 years old and had been amenorrheic for 12 months you can diagnose menopause. You don't need to perform any investiagtions (althugh if you did they would have low oestrogen, AMH and inhibin and a high FSH.

Answer 446

ABC,EIOU ## Footnote Age ( Blood Pressure & Breast Cancer Clotting: DVT / PE & **_Cardiovascular Risk_** Endometrial cancer & Everyday symptoms I (bone) – OP O – cholecystitis Uterus? ie. Hysterectomy?

Answer 447

1. Continuous Use - oestrogen and progesterone both daily. Have to have had cessation of period for one year or greater before commencing. 2. Cyclycal Use - oestrogen daily and progesterone for 10-14 days of teh cycle. May have withdrawl bleed upon cessation of progesterone.

Answer 448

Signs of oestrogen excess (headache, breast tenderness, nausea)

Answer 449

***The 10 Ps*** Periods: * First period (age of mecarche) * Regularity * Volume * Last normal menstrual period / age of menopause Pain (with periods, sex or other times) Partners + sexual activity * Number of partners * Sex of partners * Type of relations Protection * Contraception * Screen for Domestic Violence Parents (maternal menopause) Pissing/pooing? * Dysuria * Nocturia * Polyuria * Urgency * Incontinence Pap smears and breast checks PCOS Pelvic inflammatory disease * Vaginal discharge? (colour, quantity, odour) Pregnancy

Answer 450

Lifestyle Modifications * Cut down smoking * Healthy diet + exercise to reduce BMI * Cut down ETOH * Dress in layers * Carry a small fan Complementary * Phyto-oestrogens (soy isoflavones, black coshosh) Non-Hormonal * For vasomotor symptoms - SSRI, SNRI, gabapentin * For urogenital symptoms - cranberry juice, lubricants Hormonal * HRT

Answer 451

spontaneous pregnancy loss early pregnancy failure

Answer 452

20% of recognised pregnancies will end in pregnancy loss

Answer 453

* 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

Answer 454

15-20% of women will experience BEP

Answer 455

* FBE * Blood group and **antibodies** * Consider cross-match is patient is likely to need a transfusion * B-HCG - may consider serial B-HCG * U/S - transvaginal vs abdominal * Kleihauer if Rh -ve * urine test for chlamydia in women

Answer 456

transvaginal u/s are most reliable when the B-HCG is \>1,500 U/L a transabdominal u/s is most reliable when the B-HCG is \>3,500 U/L

Answer 457

5.5 weeks gestation detection of heart beat also rules out non-viable pregnancy

Answer 458

should double every 48 hours * Too quickly - molar pregnancy.* * A molar pregnancy is an abnormal form of pregnancy in which a non-viable fertilized egg implants in the uterus and will fail to come to term. A molar pregnancy is a gestational trophoblastic disease which grows into a mass in the uterus that has swollen chorionic villi. The word mole is used to denote simply a clump of growing tissue, or a growth. It is often caused by a sperm combining with an egg which has lost its DNA). * Too slowly -* non-viable pregnancy: ectopic or miscarriage * Fluctuating B-HCG* - ectopic pregnancy

Answer 459

* Hypovolaemic shock – due to a ruptured ectopic * Neurogenic (cervical) shock – products of conception in cervix (causes an increase parasympathetic drive and bradycardia) * Septic shock – miscarriage with infection

Answer 460

1. fallopian tube (95%) 2. ovaries (3%) 3. peritoneum (1%)

Answer 461

Heterotopic pregnancy when two eggs are fertilized; one implants at an intra-uterine site, another at an extra-uterine site. Often associated with induced ovulation (IVF) (1:11,000). Otherwise rare (1:40,000)

Answer 462

1. amenorrhea 2. irregular bleeding 3. lower abdominal pain if more severe: 1. hypotension 2. tacchycardia 3. shoulder tip pain

Answer 463

* FBE * Blood group and antibodies * Consider group and hold * Consider Kleinhauer test if Rh -ve * B-HCG - consider serial BHCG (levels may be fluctating) * Transvaginal / abdominal U/S * if the uterus is empty --\> either ectopic por misscarried **NB**: In haemodynamically unstable patients in whom ectopic pregancies are the most likely diagnosis, U/S investiagations can be bypassed for diagnosis and treatment at laparoscopy.

Answer 464

expectant management surgical management medical management Regardless of treatment option, RCOG recommends anti-D for all non-isoimmunised Rhesus negative mothers.

Answer 465

* Single dose of 50mg/m2 of IM methotrexate. * B-HCG levels are checked on day 4 and 7, and should fall by 15%. If not, give a second dose. * 15% of women will need a second dose. 7% will need subsequent surgery.

Answer 466

Removal of fallopian tube. In a ruptured / bleeding ectopic pregnancy.

Answer 467

laparoscopy (preferred) laparotomy (required in an emergency) Monitor B-HCG afterward - it should fall rapidly. If it is \>65% of original level 48 hours post op OR \> 10% of original level 10 days post op --\> think: persistent trophoblast

Answer 468

3 or more pregnancy losses

Answer 469

spontaenous loss of pregnancy before 20 weeks

Answer 470

spontaneous pregnancy loss before five weeks gestation (so called because B-HCG is elevated but a gestational sac cannot be viewed on ultrasound) When a gesttaional sac can be viewed on ultrasound, this is called a clinical pregnency (not really the opposite - because this is a viable pregnancy)

Answer 471

after 5 weeks

Answer 472

***Complete miscarriage***: The uterus is empty - all of the products of conception have been expelled. The cervix is closed. Symptoms have often resolved. ***Incomplete miscarriage***: some products of conception have been expelled, but not all.

Answer 473

When the cervix has dilated, but products of conception are still intra-uterine. An inevitable miscarriage will either progress to an incomplete or a complete miscarriage.

Answer 474

***Threatened miscarriage*** - bleeding in the first 20 weeks of gestation (a presentation, not a diagnosis). ***Missed miscarriage -*** In this situation what happens is that the embryo fails to develop fully and, instead of being passed out of the womb in a miscarriage situation, it is retained inside. ie. "*_asymptomatic fetal demise_*". Diagnosed retrospectively on U/S because the fetus is too small for gestational age, reflecting cessation of growth at an early gestation e.g. absence of fetal heart and 9 week sized foetus on 12 week U/S

Answer 475

A miscarriage complicated by infection – can lead to PID, sepsis and death

Answer 476

**"Blighted ovum"** When a gestational sac forms but no embryo develops.

Answer 477

In women without a previous Hx of miscarriage, once the foetal heart is detected, the risk of miscarriage is 2%. This statistic is 18% for women with a Hx of miscarriage.

Answer 478

with B-HCG Falling levels or failure to rise 50% in 48 hours suggests an abnormal pregnancy.

Answer 479

Expectant OR Medical OR Surgical

Answer 480

Dilatation and suction curettage

Answer 481

* That they may experience light bleeding for a few weels * That they should abstain from sexual intercourse and avoid using tampons for a few weeks, to reduce the risk of infection * That their period may not occur at the usual time, because the uterus has to build new lining

Answer 482

***_Mifepristone_*** (RU486) - Mifepristone acts to block the hormone progesterone --\> starves the embryo of nourishment. Also causes softening and opening of the cervix (an oral medication). ***_Misoprostol_***: This is a prostaglandin E1 analogue which causes strong uterine contractions in an attempt to expel the embryo from the woman’s body. It is taken 24-48 hours following the mifepristone (can be oral or vaginal)

Answer 483

It is a prostaglandin E1 analogue --\> causes strong uterine contractions

Answer 484

Progesterone antagonsist. Used to "prime" the uterus before misoprostol. Causes the embryo to detach and ripens the cervix.

Answer 485

**_Basics_** * ****Anti-D for rhesus negative women **_Place and Person_** **_Investigate & Confirm Diagnosis_** * Confirm non-viable intra-uterine pregnancy with B-HCG or ultrasound * High vaginal swab / serology for chlamydia if opting for surgical management * Culture of genital discharge to screen for gonhorrea prior to surgical management * Vaginal swab for bacterial vaginosis prior to surgical management **_Definitive Management_** * Medical or surgical management **_Prophylaxis / Ongoing Rx_** * Psychological support * Contraceptive advice - all hormonal and implantable methods of contraceotion can be performed at the time of D&C

Answer 486

Only investiagte after 3 miscarriages

Answer 487

* Blood group --\> anti-D given to rhesus negative women * B-HCG / U/S to confirm viable, intra-uterine pregnancy * high vaginal swab / serology to rule out chlamydia * culture of genital discharge to rule out gohnorrhea * vaginal swab to rule out bacterial vaginosis

Answer 488

Incomplete miscarriage. This process can take several weeks (75% success rate at 6 weeks) This option is usually only made available to women in the 1st trimester.

Answer 489

A spectrum of placental tumours that arise from genetically abnormal embryos. GTD may be benign (most commonly) or rarely malignant.

Answer 490

1 hour in multigravid women 2 hours in primigravid women 3 hours if having epidural no longer than three hours

Answer 491

No longer than 30 minutes

Answer 492

After the anterior shoulder is delivered

Answer 493

1cm/hour during in multiparous women 2cm/hour in nuliparous women

Answer 494

No longer than 8 hours in multiparous women No longer than 12 hours in nulliparous women

Answer 495

MOTHER AND PIG Medical issues (heart dz, chronic renal dz, auto-immune) Obstetric cholestasis (controversial) Too long! (\>41 weeks) Haematological (Rh isoimmunisation) / Hypertension (preeclampsia, eclampsia) Endocrine (GDM) – at 38-39 weeks (due to foetal macrosomia) ROM early / Request (maternal psychosocial issues) Planned neonatal surgery In Utero Demise (IUD) or Intrauterine death Growth restriction

Answer 496

PATH and ROAD? Prolapsed umbilical cord Abruption of placenta Tachysystole / Hyperstimulation Hyponatraemia & Haemorrhage Rupture of uterus Oedema / fluid retention Atonic uterus Didn’t work (failure of induction) à then need CS / operative vaginal delivery

Answer 497

CAMP HI C Section previously (uterine scar à uterine rupture) Act quickly! (need for non-elective C-section) Malpresentation (non-cephalic presentation) Placenta Previa (risk of haemorrhage) High Parity (increased risk of uterine rupture) Infections (active genital herpes, HIV) / IUGR * (IUGR babies are often delivered by C section b/c they don’t have a good enough blood supply to cope with vaginal delivery.

Answer 498

PGE2 Transcervical catheter Stretch and sweep

Answer 499

post dates ie. \> 40 weeks

Answer 500

Transcervical foley catheter

Answer 501

**_The Bishops Score_** Dilation of cervix Lenth of cervix Consistency of cervix Station Position A score of 6-8 is the cut-off (Dilation of the cervix is the most important component) A score greater than 6-8 indicates a favourable cervix A score of less than 6-8 an unfavourable cervix

Answer 502

Favourable cervix Most likely AROM + syntocin

Answer 503

Unfavourable cervix. Most likely PGE2 or transcervical catheter (the latter if VBAC)

Answer 504

“In term PROM or PPROM, either PGE2 or an oxytocin infusion are acceptable, regardless of cervical status, as they are equally effective”

Answer 505

Push and hold the cord back into the pelvis, and put mother into the trendelenberg position

Answer 506

\>6 hours post

Answer 507

the baby's head must be fixed and engaged, otherwise may --\> cord prolapse

Answer 508

If you need to take scalp lactate

Answer 509

hyponatraemia and oedema (because oxytocin is similar in structure to ADH)

Answer 510

tachysystole and uterine rupture if previous uterine surgery

Answer 511

episiotomy

Answer 512

Face presentation Bleeding from skull

Answer 513

2 or 3 C-sections * 1 C section is NOT a contraindication * 2 C sections is a contraindications for some O&Gs * 3 C sections is a contraindication for some O&Gs * No one would really even perform a VBAC if the woman had had more than 3 C sections

Answer 514

**Fully Diated Cervix** Fully dilated cervix OA position (ideal) Ruptured membranes Contractions/catheter Episiotomy and epidural Presentation: cephalic Station: Spines or below (0 or

Answer 515

amniorrhexis

Answer 516

It occurs in 10% of all pregnancies

Answer 517

when a woman doesn't go in to labour before 24 hours after her membranes have ruptutred

Answer 518

occurs in 1-3% of all pregnancies

Answer 519

* Confirm gestation * Confirm that they are definitely not in labour - CTG * Perform a **sterile speculum examination** (NOT a vaginal exam) * Look for liqour in the posterior fornix - can ask woman to cough to see it trickle down * If unsure, can do: * Nitrazine * Amnisure * Fern test

Answer 520

maternal infection foetal infection cord prolapse placental abruption

Answer 521

**Basics** * Health of mother * Vitals * Abdominal examination * FBE / CRP * Health of baby * SAM BLACK * Symphysiofundal height * Auscultate foetal heart * Ask RE foetal movements * Biophysical profile * Lengths on US * Amniotic fluid index * CTG * Kinks in U/S **Place and Person** **Investigate and confirm diagnosis** * Confirm gestation * CTG - ensure they're not in labour * sterile speculum examination * DO NOT PERFORM VAGINAL EXAM **Definitive Management** * Expectant versus Active Management * Don't forget to consider GBS status before inducing labour **Ongoing management** * CTG during labour * Paediatric review after birth?

Answer 522

* Collect cervico-vaginal swabs for microscopy and culture (Chlamydia trachomatis and Neisseria gonorrhoeae) * Collect low vaginal and ano-rectal swabs for GBS

Answer 523

Give antenatal steroids Erythromycin should be given for (250mg po 6 hourly for 10 days) following the diagnosis of PPROM

Answer 524

* * consider termination OR expectant management * 24-34 weeks gestation * expectant management (unless complication for foetus or mother) * 34 weeks gestation * active management

Answer 525

No. In fact it might be dangerous. Only short term tocolysis is indicated; for the purposes of finishing a course of antenatal steroids or for transfer to facility with NICU

Answer 526

1. placenta previa 2. placental abruption 3. vasa previa

Answer 527

1/200 (half of that of CVS)

Answer 528

10-14 weeks

Answer 529

\> 15 weeks

Answer 530

1. *maternal blood pressure -* Gestational HT (increased blood volume, no drop in perippheral vascular resitance due to uterine artery dilation) 2. *endothelial dysfunction of* *materal kidneys -* Pre-eclampsia (proteinuria, oedema) 3. *endothelial dysfunction of* *maternal liver -* HELLP syndrome 4. *endothelial dysfunction of maternal brain* - liver **5. placental abruption** **6. IUGR**

Answer 531

Mother can lose large amounts of blood + The bleeding can be concealed (may not have PV bleeding)

Answer 532

2/3 1/3 of women don't have any PV bleeding! The bleeding is concealed and they are bleeding into their uterus.

Answer 533

- placenta previa and abruption - maternal blood loss - vasa previa - foetal blood loss

Answer 534

aka 'triple test' as it involves maternal serum screening (looking for PAPP-A and free B-HCG) + an ultrasound which looks for nuchal translucency.

Answer 535

aka the 'quad test' involves only maternal serum screening but screens for four markers (alpha feto protein / AFP, unconjugated estriol, B-HCG and inhibin A)

Answer 536

1. Trisomy 21 (Downs Syndrome) and Trisomy 18 (Edwards Syndrome) 2. As above + neural tube defects - however the 20 week ultrasound is more reliable for this, anyway

Answer 537

* Free B-HCG is increased in trisomy 21, whereas PAPP-A is decreased * Both free B-HCG and PAPP-A are decreased in trisomy 18 * Nuchal translucency is thicker in trisomy 21 (plus there may be an absent nasal bone and polyhydramnios)

Answer 538

Trisomy 21 - Increased B-HCG and inhibin, reduced estriol and AFP Trisomy 18 - reduced all of them NTDs - increased AFP

Answer 539

**First Trimester Screening Advnatages** * Earlier - more options in terms of CVS / amniocentesis and more options for TOP? * More sensitive for Trisomy 21 and 18 **Second Trimester Screening Advantges** * Is free (versus first timester which costs money) * AFP protein levels can be used to screen for NTDs (although the 20 week ultrasound is more reliable)

Answer 540

Non Invasive Perinatal Screening (NIPS) aka “percept” A blood test looking at foetal cells in the maternal circulation Newer test - expensive (over $400 AUD)

Answer 541

Maternal Serum Screening - 10/40 U/S - 12/40

Answer 542

14 - 20 weeks

Answer 543

15/40 or later

Answer 544

12-13 / 40

Answer 545

APH = bleeding after 20 weeks BEP = bleeding before 20 weeks

Answer 546

1. miscarriage, ectopic pregnancy 2. placental abruption, placenta previa, vasa previa 3. uterine atony

Answer 547

Antenatal Presentation * PV bleeding after 20 weeks (or not!) * Pain (or not!) * CV risk factors * Signs of shock * Tender, woody-hard uterus Perinatal Presentation * CV risk factors * Uterine tachysystole * Blood stained liqor * Signs of shock * Foetal compromise on CTG

Answer 548

CV risk factors (HT, DM, hyperlipidaemia) Trauma Sudden uterine decompression - following ROM or delivery of the first twin Chorionamnitis

Answer 549

usually a clinical diagnosis (painful PV bleeding) in pregnancy \> 20 weeks +/- symptoms of shock Can perform transvaginal U/S - but wouldn't do so if patient is unstable!

Answer 550

placenta previa is usally painless PV bleeding, placental aburption is painful

Answer 551

***_CRAM_*** **Clinical Assessment** Mother * vitals * peripheral signs of shock * abdominal examination * ask her blood group * when she had her last meal (readiness for surgery) * previous surgeries involving GA - women with placental abruption may have DIC, epidural is contraindicated in DIC and so these women will need a GA Baby * Choose some of SAM BLACK **Recussitation (if mother is unstable)** * Airway * Breathing * Circulation - 2 x wide bore canulae * Take blood off for group and hold / cross-match * Anti-D if rhesus negative **Assess for underlying cause of APH** * FBE * Coags including fibrinogen (DIC is a complication of placental abruption) * Kleihaur Test if to assess for extent of fetomaternal haemorrhage if rhesus negative * Transvaginal U/S in non-emergent cases **Management** * Consider risks versus benefit of expedited delivery versus premature delivery

Answer 552

* hypovolaemic shock * Pre-renal renal failure * foetal compromise * DIC (occurs in up to 35% of cases - as thromboplastims are released from damaged placental tissue) * PPH (poor myometrial contraction following placental abruption) * Fetomaternal haemorrhage

Answer 553

Two doses of 12 mg IM betamethasone, given 24 hours apart OR Four doses of 6mg IM dexamethasone, given 12 hours apart

Answer 554

major = covering the os minor = within 2-3 cm of the os

Answer 555

at the 20 week scan you can usually see that a woman has a "low lying placenta" If it is low lying, in a lot of cases it will migrate

Answer 556

* PV bleeding after 20 weeks especially if associated with: * abnormal lie * high presenting part

Answer 557

5% 0.5% (most migrate)

Answer 558

5% of pregnancies have a low lying placenta. Most migrate so only 0.5% of pregnancies end up with placenta previa. Be aware of any vaginal bleeding, and present to hospital immediately. Depending on how much of the cervical os the placenta is covering (and whether the baby is engaged or not), you may have to have a C section, rather than a NVD. In the mean time, avoid penetrative sex and warn any doctors or midwives that you hve placenta previa, as they should not perform a VE if you are bleeding

Answer 559

**Placenta Previa** * Painless bleeding * Abdo SNT * Patient not distressed * CTG may be NAD * Abnormal lie / presentation * Not associated with CV risk factors or preeclampsia * Clotting abnormalities unusual **Placental Abruption** * Painful bleeidng * Woody hard uterus * Patient distressed * CTG may be abnormal * Normal lie / presentation * Associated with CV risk factors and preeclampsia * may develop clotting abnormaliites early

Answer 560

Basics * education RE: * penetrative sex and VE * what to do if experiences PV bleeding * prognosis Place and Person Ix and Confirm Diagnosis * *Repeat U/S at 34 weeks* * Placenta previa? Major or minor * Make decision about delivery method Definitive Management * Ensure blood is available at delivery Prognosis

Answer 561

***accreta*** - abnormal adherence of the placenta to the uterine wall ***increta*** - occurs when the placenta invades deeply in to the myometrium ***pancreta*** - when the placenta invates through the uterus to reach the serosa These are dangerous because they mean that the placenta can't be fully delivered, so the uterus cannot contrcat down enough to cause cessation of bleeding (therefore increased risk of PPH). They are diagnosed cliically, in the third stage of labour! Usually you check the placenta to see if it is complete, and it isn't.

Answer 562

* Pain * Perineum * Pissing * Pooing * PPH * PreEclampsia / GDM * PE / DVT * Pyrexia (mastitis, endometritis) * Psych * Protection

Answer 563

Causes of Post-Op Fever * Wound * Wind (atelectasis) * Water (IV lines) * Walking (DVT / PE) * Wonder drugs * Whizz (UTI) Pregnancy Specific * Mastitis * Endometritis

Answer 564

FBE U&Es High vaginal swab Pelvic ultrasound for retained products

Answer 565

**Good Choices** * Progesterone only pill * Barrier protection * IUDs * Injectable progesterones **Bad Choices** * Breast feeding as exclusive contraception * Combined OCP (as oestrogen affects milk supply) * Tubal ligation

Answer 566

***Primary*** •Occurs in the first 24 hours after delivery ***Secondary*** •Occurs after 24hrs and before 6 weeks after pregnancy (end of post-partum period)

Answer 567

1. Tone (uterine atony) 2. Trauma (uterine rupture, laceration) 3. Tissue (retained products) 4. Thrombin (coagulopathy)

Answer 568

***_Medical Management_*** **First insert a catheter and massage the uterus to stimulate contractions.** ***1st Line:*** Ergometrine Syntometrine (ergometrine + syntocinon) ***2nd Line:*** IV syntocin infusion ***3rd Line:*** Misoprostol Prostaglandin F2α ***_Surgical Management_*** If medical management is unsuccessful. * Without laparotomy * Examination under anaesthetic – allows for more thorough search for lacerations and retained products * Prostaglandin F2α injection into uterus from abdomen * Backri balloon – inflated within uterus to provide tamponade * With lapartomy * Manual pressure on uterus * B lynch suture – a suture generated clamping of the uterus that may preserve future fertility * Bilateral uterine artery ligation and internal iliac artery ligation * Last line - hysterectomy

Answer 569

**_Reversible_** * Male sterilisation - vescetomy * Female sterilisation - tubal ligation or essure **_Non Reversible_** * Long acting * Implanon * Depot provera * IUD * hormonal IUD * copper IUD * Short acting * Oestrogen + Proggesterone * Nuvaring * COCP * Progesterone * minipill * Emergency * Mifepristol (RU486) * Copper IUD * Levonorgestrel

Answer 570

high dose progesterone (Etonogestrel) it is 99.95% effective 1/3 of women experience amenorrhea, 1/3 experience light bleeding and 1/3 experience heacy bleeding (consider removal) it can stay in for 3 years you should perform a B-HCG prior to insertion

Answer 571

HOMESICKL Headache / hypertension Obesity Medications (some anti-convulsants, some ABx) Embolism / Thrombus / Clotting disorders Stroke IHD / Informed consent / Gillick competent (for minors Cancer (breast, cervical), Cardiovascular Risk Kids (nulliparous women & myrena), pregnant (progesterone only pill) and breast feeding (no oestrogen) Liver disorders

Answer 572

Breast Cancer But use with caution and explain all possible risks to patients with "HOMESICKL"

Answer 573

**HAIL M** ## Footnote Hirsuitism Acne + Apetite Increase / Weight Gain Irregular bleeding Loss of libido Mood swings (Think: progesterone is a hormone of pregnancy)

Answer 574

1. pap semar normal and up to date 2. chlamydia screen negative 3. B HCG negative Can be left in for 5 years Yes, it can be used but usually requires insertion by specialist in Australia

Answer 575

**Risks of all IUDs** * Pelvic infection - first 3 weeks following insertion * Perforation of the uterus during insertion * IUD moving from its position after insertion * Ectopic pregnancy * Some intermentsural bleeding for 6 months (but then reduces by 90% and usually amennorheic) **Risks of Myrena** * Risks of progesterons (although local, so very unlikely) * Hirsuitism * Apetite increase / weight gain / acne * Irregular bleedining * Loss of libido * Mood change **Risks of Copper IUD** * Heavy bleeding

Answer 576

every 3 months

Answer 577

Contraception Acne Dysmenorrhea Menorrhagia Endometriosis

Answer 578

IBD (CD & UC) Gastroenteritis (Diarrhoea & Vomitting)

Answer 579

**Yuzpe method** (ethinyl estradiol / LNG) * Oldest method, not available in a lot of countries * 2 doses given 12 hours apart * Failure rate = 2-3% * 72 hours * AE = N&V: often simultaneously prescribed with an anti-emetic **Levonorgestrel** (LNG - a progesterone) * Method of choice * Available OTC * Less adverse effects * Failure rate = 1-2% * Can be taken within 72 hours, but preferable within 24 hours **Copper IUD** * Can be taken up to five days post unprotected intercourse * Failure rate = 2-3% * Should not be used in those at risk of STIs or PIDs **Mifepristone (RU486)** * progesterone antagonist * Faiure rate = 1-2% * Few side effects * Can delay menses, which can cause anxiety * Can be used up to five days after unprotected intercourse

Answer 580

1. Counselling RE adequate, ongoing contraception 2. Offer an STI screen, education if required RE barrier protection from STIs 3. Ascertain if the sex was consensual-non consensual 4. Discuss pap smears 5. Abortion if emergency contraception fails

Answer 581

Copper IUD Mifepristone RU486

Answer 582

LNG Yupze Method (although less effective than levonorgesterl) Copper IUD RU486

Answer 583

**Intro / HOPC Definition** * What is the OCP? * How does it work? **Indications: General and Specific** * Contraception * Acne * Dysmennorhea * Menorrhagia * Endometriosis **Experience of the patient: pre, during and post** * Start the pill - preferably on day 1-5 of menstural cycle * Can start at another time if it is certain the woman is not pregnant * Need to take the pill for seven days before it will be efficious. Use condoms for these seven days and consider the use of EC if have unprotected sex until then * If miss one pill, retake is as soon as you remember * If it is missed but retaken within 24 hours, can continue sexual practises as normal * If missed but retaken after 24 hours, use condoms or abstain from sex until have taken 7 active pills in a row**.** Consider EC if have unprotected sex. * If miss three or more pills, use condoms or abstain from sex for the next seven days. If have unprtected sex, use EC. * If you miss pills in the last week and need to take seven active ones, skip the inactive ones so you can take seven in a row * If you become unwell with diarrhoea or vomitting, also take seven pills in a row * Consult with your doctor if you start on ABx or Anti-epilepsy medication **Benefit** * see indications **Risk** * Oestrogen: * Mastalgia * Nausea * Fluid retention * Abdominal bloating * Headaches * Chloasma * Progesterone * Hirsuitism * Apetite changes / weight gain, Acne * Irregular bleeding * Loss of libido * Mood changes **Contraindications** * Headache / Hypertension * Obesity * Medication (ABx, anti-convulsants) * Embolsim / Thrombus / FHx of thrombophillia * Stroke * IHD * Caner - breast / endometrial? * Kids / Breast feeding * Liver disease * Gillick competenet? **Alternatives** * Irreversible * Reversible * Long acting * implanon * depot provera * IUD - copper or hormonal * Short Acting * Mini-Pill * Other formulations of COCP **Conclusion: Check understanding, offer written information, gain informed consent**

Answer 584

molar pregnancy

Answer 585

Gestational trophoblastic disease (GTD) is a group of rare diseases in which abnormal trophoblast cells grow inside the uterus after conception. Hydatidiform mole (HM) is the most common type of GTD.

Answer 586

RUPTURED ECTOPIC PREGNANCY UNTIL PROVEN OTHERWISE don't waste time, straight to Rx May not get time for all Ix