JLS O&G Flashcards
What is mild, moderate and severe hypertension in pregnancy?
Mild = 140/90-150/100
Moderate = 150/100-160/110
Severe = >160/110
What tests should be ordered in suspected pre-eclampsia (and what components of the test are you specifically looking for)?
FBE
- looking at red cell count
- looking at platelets
Blood film
- Shistocytes
LDH
LFTs
- Particularly looking at AST
UEC / uric acid
Urine dipstick
Spot urine:creatnine ratio
Which component of LFTs is naturally elevated in pregnancy?
ALP (there are ALPs of placental origin)
What are some features that make nausea & vomitting in pregnancy more likely to be hyperemesis gravidarum rather than just simple morning sickness?
- persistent vomiting
- volume depletion
- ketosis
- electrolyte disturbances
- weight loss
What is the definition of azoospermia?
absenze of sperm cells in semen
What is the definition of asthenozoospermia?
Reduced sperm motility
(Same as asthenospermia)
Think: your tongue has to be motile to say that word
What is the definition of asthenospermia?
Reduced sperm motility
(Same as asthenozoospermia)
Think: need to have a mobile tongue to pronounce this word.
What is aspermia?
A complete lack of semen
What is the term used to secribe abnormal morphology of sperm?
Teratozoospermia
What is alendronate?
A bisphonphonate
(Alendronic acid)
What terms are used to describe separate CTG features?
What terms are used overall CTG assessment?
Separate CTG features =
Reassuring, Non-Reassuring, Abnormal
Overall Assessment =
Normal, Suspicious, Pathological
(Think: separate features are just reassuring or not… got to have the whole picture to call it normal)
What are the parameters for baseline rate on CTG?
Reassuring = 110 - 160
Non-Reassuring = 100-110
Abnormal = 160
What are the parameters for variability on CTG?
Ressuring = 5-25bpm
Non-reassuring = 3-5bpm
Abnormal =
What are the criteria for sleep phase?
Variability
How do you diagnose missed miscarriage on US?
If the crown rump length (CRL) is >7mm and there is no foetal heart beat
If the gestational sac / mean sac diameter is >25mm and there is no foetal pole (i.e. it is empty)
What do you do if you get a HSIL on a Pap smear?
Refer immediately for colposcopy, regardless of age
On what day do you measure progesterone to check for ovulation?
What values indicate ovulation / anovulation?
Day 7 of luteal phase (day 21 of 28 day cycle)
>30 = ovulated
Who am I (Contraception):
The prime mechanism of action is inhibition of ovulation but also causes thickening of cervical mucus. This treatment also decreases the risk of endometrial and ovarian carcinoma.
COCP
A 25-year-old patient, who has been trying to get pregnant, presents to the GP with a small amount of vaginal bleeding with vague lower abdominal cramping. Her LMP was 4 weeks ago. On examination her heart rate is 70 and BP 120/80. Her other observations are normal. Her bHCG is 400 IU/L. Her pelvic ultrasound shows an empty uterus and a 20 mm cystic structure in her left ovary with peripheral vascularity. Your next step is?
Repeat BHCG in 48 hours
What is the biggest risk in premature delivery?
Previous premature delivery
What is the biggest risk factor for having pre eclampsia?
previous pre ecmlampsia
What types of steroids do you give for prematurity and at what frequency?
Two doses of 12 mg IM betamethasone, given 24 hours apart
OR
Four doses of 6mg IM dexamethasone, given 12 hours apart
When do you give steroids?
- For any C section (which is usually less than 39 weeks)
- For vaginal delivery between 24 and 35 weeks (consider under 24 weeks
If you are inducing someone at 36 weeks, do you give steroids?
Not according to guidelines
What is the most common cause of menorrhagia?
dysfunctional uterine bleeding
(>80% of all primary menorrhagia)
What is the difference between primary and secondary menorrhagia?
Why is this distinction clinically useful?
Primary - since menarche
Secondary - later onset
Secondary menorrhagia is more likely to have an underlying cause (and not just be DUB).
What tumor markers would you order if you suspected a cancer?
(NOTE: in reality you would be HESITANT and VERY CAREFUL to order these markers)
CA 125 (ovarian. sensitivie but not specific)
HE4
AFP
LDH
B-HCG
CEA
CA 19.9
Tests (such as tumor markers) alone are not sufficient to diagnose ovarian cancer.
What tools can help you?
Risk stratifictaion tools
The risk of malignancy index (RMI)
The Risk of of Malignancy Algorithm (ROMA)
Uses a number of factors such as CA-125, menopasual status, U/S findings to calculate risk
What are the risks for shoulder dystoicia?
You can’t predict shoulder dystocia!
The strongest predictive factor is previous shoulder dystocia!
Pre-Labour
- Previous shoulder dystocia
- Increased BMI
- Macrosomia
- GDM
Labour - but these could be correlative, not causative!
- Prolonged first stage
- Prolonged second stage
- Instrumental delivery
- IOL
What are the US findings of adenomyosis?
“thickening of the junctional zone”
“venetian blind” pattern of accoustic shadowing
What is the Mx of Adenomyosis / Endometriosis?
Non-Hormonal
- Mefenamic acid (Ponstan)
- Tranexamic acid
- Paracetamol
Hormonal
- Mirena
- COCP
Surgical
- Laparoscopic ablation
- Laparoscopic excision
- TAH & BSO
What does a “bulky uterus” mean on by manual palpation?
generally enlarged
What are the adnexa?
The adnexa of uterus (or uterine appendages) are the structures most closely related structurally and functionally to the uterus.
What is cervical excitation (cervical motion tenderness) and it’s significance?
Painful manipulation of the cervix
Helps to differentiate between pathology of the reproductive tract vs of the GI or urinary system
What are the possible causes of hydrosalpinx?
PID
endometriosis
tubo-ovarian abcsess
What are the components of the RMI?
What is it for?
RMI combines three pre-surgical features
Ultrasound score (U) Menopausal status (M) Serum CA-125 level (IU/ml)
RMI score = U x M x CA 125 value.
Score ≥200 = high risk of malignancy.
What is included in a partogram?
Four Domains
- Maternal well-being
- Maternal vitals (to be measured 4 hoursly, maternal HR to be measured hourly)
- Urine (to be measured 4 hourly)
- Foetal Well-Being
- Foetal HR (measure every 15 minutes during stage one, then during every contraction - for one minute)
- Amniotic fluid (a VE is done four hourly)
- Moulding
- Progress of labour (a VE is done four hourly)
- Palpable fifths
- Station (compare with alert & action lines)
- Dilation (compare with alert & action lines)
- Length / effacement
- Consistency
- Contractions (measured every 30 minutes)
- Interventions
- Syntocinon
- Drugs
- Fluids
What are the symptoms of menopause?
Muscle aches
Energy levels reduced
Night sweats
Osteoporosis – pathological fracture
Psych – [depression, headache, reduced concentration & memory]
Aretries = vasomotor symptoms (hot flushes & night sweats)
Urogenital symptoms – increased frequency, urgency, UTIs, prolapse
Sex – loss of libido
Extra risk of CV disease and osteoporosis
what is an oulet, low and mid operative vaginal delivery?
Outlet
- Fetal scalp visible without separating the labia
- Fetal skull has reached the pelvic floor
Low
- Leading point of the skull (not caput) is at station plus 2 cm or more and not on the pelvic floor
Mid
- Fetal head is no more than 1/5th palpable per abdomen
- Leading point of the skull is above station plus 2 cm but not above the ischial spines
NB High is not included in the classification as operative vaginal delivery is not recommended in this situation where the head is 2/5th or more palpable abdominally and the presenting part is above the level of the ischial spines
How do you screen for rubella?
Titre
(Immunity can wane)
If someone is Hep B +ve what do you do?
Viral load
LFT
R UQ US
Referral to ID
Why do you test for asymptomatic bacturia?
How do you treat it?
1/3 risk of pyelonephritis due to
Compression of urteres
Progesterone (slows down bowel and bladder)
Treat and continue to treat throughout pregnancy
WHat is the most common cause of congental deafness?
CMV
(but a lot are asymptomatic)
Who carries CMV?
sticky toddlers
What is the dose of IgG you give to a child born to an Hep B + mother and how?
100IU of IgG
GIven in opposite thighs
What follow up is required for a pregnant woman with Hep B?
F/U of LFTs and look out for HCC
Screen others in family
Follow up baby
how can you test for foetal anaemia?
how can you test for foetal IUGR?
MCA peak systolic velocity (low viscoty of blood - travels faster)
MCA pulsatility index (shunting blood to the brain)
At what IgG level do you ensure a woman has a rubella vaccine post partum?
congenital syphillus looks like?
snuffles
saddle nose
sabre shins
Hutchinson’s trid: notched incisors, keratitis, 8th nerve defects
what does congenital varicella look like?
dermatomal scarring
contratures
what is the magic number for antivirals in varicella?
96 hours
what is the definition of labour?
contractions which dause cervical change
when can you call a placenta praevia a praevia?
in the third trimester
(before this, it’s a low lying placenta)
smoking is a risk factor for everything in pregnancy except for one this, what?
preeclampsia
(but if you do get it and you smoke, it is likely to be worse!)
What else should be measured on a mid trimester screen?
in what other context is this useful?
cervical length
If it is short (
also for cervical surveillance
why do you give erythro in PPROM?
how long do you give it for and how much?
Because the reason for it is probably infection
10 days qid (because the ORACLE trial only studied it for 10 days!)
If you are
You repeat the Pap smear in 12 months
If normal: repeat in another 12 months, and then if normal again, back to two yearly.
If the (any of the) repeat(s) is(are) LSIL or HSIL –> colposcopy
If you are >30, and you have a LSIL on Pap smear, what is recommended?
If you have had a normal smear in the previous 2-3 years, repeat in 12 months
If you haven’t had a normal smear in the previous 2-3 years EITHER do a colp OR re-do smear in 6/12
If a woman has a HSIL on pap smear, what should be done next?
straight to colposcopy
What should you do if you receive an unsatisfactory smear?
Repeat in 6-12 weeks (enough time for cervical cells to re-grow)
After you have had treatment for a HSIL, what is required?
You will need six normal tests before returning to two yearly Pap smears.
These are:
- Pap smear & colposcopy 4-6 months post Rx
- Pap smear & HPV 12 months post Rx
- Pap smear & HPV 24 months post Rx
in what nomencutalture / grading system is a Pap smear usually reported?
The Bethesda System
(Cytology)
HSIL / LSIL
In what nomenculature / system is a cervical biopsy usually reported?
CIN I - III / Histopathology
What is the DOHaD Barker hypothesis?
That SGA babies are at a higher risk of metabolic syndrome as adults
What is the definition of SGA?
What is the issue with this term?
SGA =
A. more than 2SD below the mean, or
B. less than the 10th percentile
The issue with this term is that
- some babies are constitutionally small and not IUGR
- some babies are IUGR and not SGA (ie. not
Why are we so worried about IUGR?
IUGR increases the risk of still birth x 4
What is the margin of error for EFW?
+/- 10%
This increases later on in the pregnancy because as the head engages it can’t be measured
What parameters are used to calculate EFW on US?
Which is the most sensitive of all the parameters to IUGR?
BPD (Bi Parietal Diameter)
HC (Head Circumference)
AC (Abdom circumference)
FL (femur length)
The most sensitive = AC
How do you measure and monitor foetal well-being in IUGR on ultrasound?
To identify IUGR
- Measure growth (AC, HC, BPD, FL)
- Plot on graph
Once IUGR is identified
- Doppler Umbilllical Artery Systolic:Diastolic Ration (UASDR)
- forward flow (normal)
- absent flow
- reversed flow
- Amniotic Fluid Index
- Middle Cerebral Artery Pulsatile Index (MCPAI)
- PI reduced with foetal compromsie
- (NB: flow in the MCA increases in anaemia)
- Ductus Venosus Flow
- Increase flow in foetal compromsie
- Pre-terminally: reduced flow. If you see this the baby will die in the next few days
- Biophysical profile
How are the umbillical vessels named?
Of which is there two and which one?
as per the foetus
ie. two x arteries from the illiac arteries going to the placenta (away from the foetal heart)
one x umbillical vein
What does a ‘recative’ CTG really mean?
a normal antenatal CTG with accelerations
What are the components of the biophysical profile?
How is it scored?
Non-stress test / antenatal CTG
Tone
Breathing movements
Gross movements
AFI
(each component is given a 2 or a 0, no 1s)
What do early deccels indicate?
Head compression
What non-foetal measurement is taken on the 20 week US, and why?
Cervical length
Cervical shortening in those who are already at risk of preterm birth have an even greater risk of preterm birth.
What is the most midely used “cut off” for a short cervix?
≤20mm at 18-22 weeks gestation
(3 centres)
What is cervical insiffuciency?
Why is it significant?
A congenital or acquired (e.g. by previous surgery) structural weakness of the cervix.
[The term “cervical incompetence” is considered pejorative and insensitive]
Cervical insufficiency is associated with an increased risk of mid-trimester pregnancy loss or preterm birth.
What are the risk factors for preterm birth?
- previous preterm birth
- preterm rupture of membranes
- multiple pregnancy
- antepartum haemorrhage
- systemic infections
- genital tract infections
- cervical insufficiency
- shortened cervix*
- congenital uterine abnormalities
*While there is an association between a shortened cervix and preterm labour and birth, most women with a short cervix do not experience a preterm birth and most preterm births are not related to a cervical problem. Look at other risk factors
What are the options for treatment of a short cervix?
- Conservative management
- do nothing, especially if no other risk factors
- Cervical surveillance
- ongoing monitoring of cervical length
- Progesterone
- vaginal progesterone
- Cervical cerclage / cervical stitch
What are the indications for / types of cervical cerclage?
When are each performed?
The terms “emergency, therapeutic and prophylactic” are no longer used.
History-indicated cerclage
- Insertion of a cerclage based on history / increased risk factors
- performed as a prophylactic measure in an asymptomatic woman and normally inserted electively at 12–14 weeks of gestation
Ultrasound-indicated cerclage
- Insertion of a cerclage as a therapeutic measure in cases of cervical length shortening seen on transvaginal ultrasound.
- Performed on asymptomatic women who do not have exposed fetal membranes in the vagina.
- Sonographic assessment of the cervix is usually performed between 14 and 24 weeks of gestation.
Rescue Cerclage
- Insertion of cerclage as a salvage measure in the case of premature cervical dilatation with exposed fetal membranes in the vagina.
- May be discovered by ultrasound examination of the cervix or as a result of a speculum/physical examination performed for symptoms such as vaginal discharge, bleeding or ‘sensation of pressure’.
What can be said about the two types of cerclage techniques; Shirodkar and McDonald?
What route are these inserted?
No evidence that one is better than the other
Usually inserted transvagibally but can be inserted transabdominally
Is there any evidence for bed rest with cervical shortening?
No
What is recommended as treatment for low risk women with a short cervix, in preventing preterm labour?
- If cervix is >25mm - it isn’t short, do nothing.
- If cervix is 20-25mm - cervial surveillance every 1-2 weeks
- If cervix is
- If cervix is
What is recommended for high risk women with a short cervix?
Cervical cerclage is more readilly recommended.
The situation in which the short cervix is found (history, U/S or symptoms) dictates which type of cerclage should be inserted and when (history-indicated, U/S-indicated or redscue cerlage)
What does a “washed out” vagina mean and what is it’s significance?
An absence of leucorrhoea which you would normally see on spec exam of a pregnant woman.
Supportive of PPROM / PROM
What can be used for tocolysis?
nifedipine (oral) - watch BP
tebutaline (SC)
salbutamol
GTN patch (often used in C section)
NSAIDs also work well - but care of foetal heart!
How do you write up an order for tocolysis for transfer?
And what is done for maintenance once the woman arrives at the tertiary centre?
20mg nifedipine stat
Repeat 20 minutes later
Repeat 20 minutes after that
For maintenance: 20mg nifedipine 8 hourly, until second dose of steroid has been administered
At what GA do you conisder active management in PPROM?
At what GA do you consider expectant management?
At what GA do you consider termination?
>34 weeks : active
24 - 34 : expectant
What should you consider on every antenatal inpatient admission, except if they are admitted with BEP or APH?
Clexane
Ted stockings always (if they are spending more time resting in bed than mobilising)
You have admitted a woman with PPROM who is staying there for expectant management (at least for the first few days). What should you assess regularly?
Health of Mother
- Vital signs
- Abdominal palpation
- FBE
- CRP
- High vaginal swab weekly
Health of Foetus
- Foetal HR daily
- Ask colour of liqour
- CTG
- US for AFI
What is the erythromycin dose which should be given in PPROM?
250mg po 6 hourly for 10 days
What is the dosage of benzylpenicillin that should be given in GBS+ or GBS unknown women with risk factors?
3g IV loading dose
1.8g IV q4h until birth
What should be given for GBS prevention if a woman is allergic to benpen with no Hx of anaphylaxis?
cephazolin
What is given to GBS+ women or GBS unknown women with risk factors, who are allergic to benpen with a history of anyphylaxis?
Vancomycin or clindamycin
What are the terms:
Zygosity
Chorionicty
Amnionicity
What does the result of each depend on, in a twin pregnancy?
Zygosity = number of eggs
Chorionicity = number of placentas
Amniocity = number of sacs
The number of placentas & sacs depends on the timing of when monozygotic twins split.
What increases your risk of having a twin pregnancy?
Increasing age
Obesity
IVF
(not because we impant two eggs, because we don’t anymore, but because clomifene and FSH stumulation cause a number of eggs to mature)
From what gestation can you measure SFH?
What should you do to measure it?
24 weeks
Ask the woman to empty her bladder beforehand
Use the tape measure face down
What are the DDx for an increased SFH?
wrong dates!
macrosomia
polyhydramnios
twins
molar pregnancy
mass / fibroids
obesity
What are the complications of twin pregnancy?
- The risk of everything is increased!*
- Think of everything that can go wrong in a timeline, and say it!*
- First Trimester
- minor Cx of pregnancy: back pain, stress incontinence
- Hyperemesis gravidarum
- Miscarriage
- Malformations
- Second Trimester
- PET
- GDM
- IUGR
- APH
- FDIU
- Third Trimester
- Prematurity (PTL, PPROM)
- IOL
- C/S
- Instrumental birth
- Post Partum
- PPH
- Depression
- Breast feeding difficulty
- Financial strain
Specific to monochorionic twins: twin to twin transfusion syndrome
What is a similar, rarer condition like TTTS?
Twin reversed arterial perfusion (TRAP)
When do you start to worry about TTTS?
What are the DDx of TTTS?
When there is a discordance of growth between twins of >25%
This discordance may be due to:
- Placental insufficiency
- Infection
- Genetics
- Structure (TTTS)
What should be considered in the antenatal care of a twin pregnancy?
Need to determine chorionicity at 8-12 weeks!
Increased folate and iodine
Consider aspirin (as risk of PET)
More frequent US
Note that aneuploidy screening is less sensitive (and there is usually a higher risk!)
What are the requirements for a vaginal birth in a twin pregnancy?
- Near term
- Twin 1 should have cephalic presentation
- Not > 25% growth discordance
- Because if T1 is smaller, T1 might still experience shoulder dystocia
- Because if T2 is smaller, it is at greater risk of demise while waiting to come out (T2 is at higher risk, always)
- Continuous CTG
- FSE for T2
- External for T1
- Experienced accoucher
- U/S close by in the room
- IV access (PPH risk)
- Epidural - controversial. Good to do because might require internal vaginal breech extraction
- Paediatric and anaesthetic staff present
- Twin-Twin delivery interval
What is a frank breech?
When the babies hips are flexed and knees extended
What is a complete breech?
When the baby’s hips and knees are flexed
What is a footling breech?
When the hip & knee joints are extendted on one or both sides
What is an incomplete breech?
An umbrella term for footling and kneeling presentations
What is a kneeling breech?
When the hip is extended and the knee is flexed on one or both sides
How is TTTS scored and how is it treated?
Quintero System
Laser Photocoagulation
What are the three types of breech presentation?
- Frank
- Complete
- Incomplete (footling / kneeling)
What are the maternal and fetal risk factors for breech presentation?
Maternal / Uterus
Fibroids
Uterine malformations
Polyhydramnios
Placenta Praevia
Foetal
Prematurity
Twin pregnancy
CNS malformations
neck masses
aneuploidy
When is ECV performed?
ECV is (generally) performed AFTER 37 weeks, to avoid the baby flipping back over again before labour.
How should intermittent auscultation be performed?
Should commence toward the end of a contraction and should continue for 30-60 seconds after the contraction is finished
Should be udertaken every 15-30 minutes in the active phase of the first stage labour.
Should be undertaken after each contraction or at least every 5 minutes during the active second stage of labour
What is the reference range of CA 125?
The reference range of CA 125 is 0-35 units/mL
What are the causes of PMB?
endometriosis
other cancer
vaginal atrophy
fibroid
polyp
AAA FIDO LEG PAIN
Analgaesia
Anti-emetics
ABx
Fluid Balance
IV fluids
Diet - NMB
Obs
Legs - PE
Pathology
What cut-off score of CA-125 is used to be almost diagnostic of ovarian cancer?
> 200
(But
This is because the RMI is calculated as:
Findings on US X menopausal status X CA-125
And if it is >200 = ovarian cancer
What are the risks of T1DM in pregnancy?
Risks to the mother
- Hypos in the first trimester (N&V)
- Hypers in the second and third trimester (because placenta produces insulin antagonsists)
- Macrosomia & complications to mother of this
- insturmental delivery
- shoulder dystocial
- perineal tears
- Worsening retinopathy and nephropathy
- Pre-eclampsia
- Placental abruption
Risk Factors for Foetus
- cardiac defects
- NTDs especially spina bifida
- hypos after birth
- IUGR (which can be masked by macrosomia)
About what should you counsel in pre-conceptual care?
SNAP
Pets & Sex
Work & Travel
Drugs & Dental
Immunisations & Investigation
What should you discuss in terms of SNAP in preconceptual counselling?
- Smoking
- encourage quitting, nicotine replacement therapy is safe.
- Nutrition
- Folic acid & iodine supplementation
- Iron supplementation if deficient
- Avoid soft cheeses and pre-perpared salad with meat: listeriosis –> premature birth / miscarriage / stillborn
- Mercury in fish: know levels ensure it is safe
- Alcohol:
- No known safe level of ETOH during pregnancy. Advise to stop drinking
- Physical activity:
- Safe
- Remeber that joints are more lax later on in pregnancy –> more prone to injury
- Avoid contact sports
- Stop exercise if notice severe SOB, H/A, PV bleeding or anything abnormal
What should you discuss RE pets in pre-conceptual care?
Advise not to get a new pet, young animals have accidents and it is often their faeces which carry pathogens which may harm the baby.
Don’t clean up poo, leave this task to someone else.
Also be wary of bites and scratches.
Beware of Lymphocytic choriomeningitis virus (LCMV) in rodents which can cause severe birth defects and miscarriage.
What should you discuss about sex if preconceptual care?
OK unless placenta praevia or PROM.
Advise doctor if bleeding post intercourse.
What should you advise about drugs in pre-conceptual care
Please inform your GP & obstetrician as to what drugs you are taking.
Some may cross the placenta and harm your baby, it is important to discuss this before taking any medictaion.
Paracetamol is OK, NSAIDs are not.
Recreational drugs are not.
Cocaine causes placental abruption.
What should you discuss about dental care in pre-conceptual care?
If you have any major dental work needing to be done, consider seeing a dentist prior to falling pregnant.
You may not be able to have a GA for dental work whilst pregnant, and furthermore it may be uncomfortable to sit in a dental chair!
There is an associating between periodontal disease and preterm birth, ensure you keep your teeth and gums healthy.
What should you discuss in regard to work and travel in preconceptual counselling?
Ask what they do for work.
Work with radiation / chemicals?
Work is not contraindicated unless complications
occur such as pre-eclampsia
Ask if they plan to travel.
Discuss DVT/PE prophylaxis and airline requirements.
What should you discuss in regard to vaccinations in pre-conceptual care?
Ask if they received all their childhood vaccinations?
Ask if they have had chicken pox?
What pre-conceptual investigations can you order?
For which investigations should you wait until they are pregnant?
Definitely perform
FBE
Syphillus
Rubella
HIV
Hep B
Consider
TFTs
Trichomoniasis
Toxoplasmosis
Gohnorrhea
Chlamydia
Hep C
CMV
Pap smear
Wait until pregnant before testing
Blood group (unless already knwon)
Antibodies
Asymptomatic bacturia
If risk factors for GDM - do this at 14 weeks
What is triploidy syndrome and how does it present?
A rare chromosomal anomaly
Three of every chromosome, i.e. a total of 69 rather than the normal 26 chromosomes.
Very rare
Usually miscarries, but if survives can cause early PET or thyrotoxicosis
What is the most common cause of non-lethal dwarfism?
achondroplasia
What should you do if you find one congenital anomaly on a newborn exam?
Look for associaed congenital anomolies.
VACTERL
V Vertebral dysgenesis
A Anal atresia (imperforate anus) ± fistula
C Cardiac anomalies
T-E TracheoEsophageal fistula ± esophageal atresia
R Renal anomalies
L Limb anomalies
What are the consequences of oligohydramnios?
Potter’s Sequence
Clubbed feet
Pulmonary hypoplasia
Potter facies
- low set ears
- flattened nose
- wrinkled skin
- micrognathia
IUGR
What is Potter’s sequence?
A collection of anomolies due to oligohydramnios including pulmonary hypoplasia, clubbed feet, Potter’s facies and IUGR.
It was originally used to describe these anomolies with oligohydramnios due to bilateral renal agenesis, but it is since used to describe these anomolies due to any cause of oligohydramnios.
What are the causes of oligohydramnios?
Congenital abnormalities
Twin-Twin Transfusion
Post term pregnancy
PROM
Renal
Bilateral renal agenesis
Posterior utherthral valve
ACE inhibitors
PG inhibitors
What is the defitintion of obstetric cholestasis?
What is the hypothesized pathophysiology?
pruritis without a rash
abnormal LFTs
resolution post partum
?due to increasesd sensitivity of the increased cholestatic effect of oestrogens
What are the risks of obstetric cholestasis?
Increased risk of the following to the foetus
- stillbirth
- increased risk of premature labour
To mother:
- lack of sleep
- pruritis
- PPH
When should you plan to deliver in a woman with obstetric cholestasis?
At 37-38 weeks
What is the evidence RE breast cancer and HRT?
What is the implications for this?
Increased risk of breast cancer with Oe + P if use for >5 years (but increase is only minimal.
If using Oe only risk is not increased.
Therefore should do a mammogram and careful clinical assessment prior to commencing
What do you do for a woman who wants to continue to use for longer than 5 years?
Discuss Risks
Consider using non-oral oestrogen and specific type of P and reduce other risk factors eg. obesity
Not absolutely contraindicated!
For how long should women who have primary ovarian insufficiency be taking HRT?
Not for only 5 years!
At least until the average age of menopause!
How should you manage someone with HRT?
Annual review.
CV risk + other risk Ax.
Recommended to trial coming off it once a year to see if it’s still needed [do this in winter]. Might reduce the dose if they want to go back on it.
why shouldn’t you do an oopherectomy in a post-menopausal woman if you can help it?
because the overies still secrete testosterone
What are the factors impacting on the efficacy of contrapection?
pearl index
continuation rate [doctor driven]
What is the oestrogen in the OCP?
Always ethinyl estradiol
(the progesterone changes)
which of the OCP are best for acne and what progesterone do they contain?
- Brenda*
- Dianne*
Cyptotenerone Acetate
What should you ask in regard to ‘clinical assessment’ for PPH?
‘BPALP’
“As this is an emergency my assessment and immediate management would be simultaneous”
Basics
- Name, age, number of babies, health of baby
- BLOOD GROUP
- Gs & Ps
- PHx of PPH
PMHx
- Any medical conditions including bleeding disorders?
Antepartum Hx
- Any complications during the pregnancy?
Labour
- Onset of labour? eg. induced?
- How long?
- Type of birth?
- Pain relief in labour?
- Episiotomy or tears?
Post Partum
- Haemodynamic stability of mother [VITALS]**
- Estimated blood loss**
- Completeness of placenta
- Active management of third stage?
- Medication already eg. syntocinon?
**start with these first, and then CALL FOR HELP
What are the broad strokes of management of PPH?
CRAM + Post-PPH Care
Clinical Assessment
Ressuss
Assess for Underlying Cause
Management
Post-PPH Care
What resus is required in terms of PPH?
DRS ABC
Danger: put on gloves
Response: GCS / assess conscious state
Send for help & assign tasks:
- 2 midwives
- O&G consultant
- anaethetist
- assign roles including a scribe and someone to take obs every 15 minutes
- ask someone to contact theatre
Airway: -
Breathing: Apply Hudson Mask and adminster 10L O2
Circulation:
- move bed into head down position
- 2 large wide bore (16 guage) cannulae
- take off blood for x match / coags / FBE / fibrinogen MARKED AS URGENT
- start IV colloids and switch to O neg blood if X matched blood not available
What is involved in “Assess for Underlying Cause” in PPH?
5Ts
- Tone: palpate tonicity of uterus and position of fundus
- Tissue: ask about placental completeness and active third stage
- Trauma: inspect perineum for tears and vagina/cervix with speculum
- Technique to inspect for cervical tears is “walking” with sponge forceps – this is very painful and should be done with epidural
- Thrombin: ask about PMHx and await coags and fibrinogen - if you suspect this involve HAMEATOLOGIST
- Theatre: contact if haven’t already!
What is involved in management of PPH?
Mechanical: Position BIM
- Position: head down, wedge under left side, keep warm
- Bimanual compression (if has epidural)
- IDC
- Massage the fundus
Medical: ME MSIS PM
- ergometrine (250mcg, diluted to 5mL in normal saline, IV UNLESS HAS HISTORY OF PE OR PIH)
- syntometrine (1mL IM)
- Infusion of syntocinon (40 IU in 1L of Hartman’s over 4 hours)
- Prostaglandin F2 alpha (injections into uterus through abdomen IN THEATRE)
- Misoprostol (tablets in the rectum or vagina iN THEATRE)
Surgical 4BS
- Baloon Tamponade
- B-lynch suture
- Bilateral uterine artery ligation (or internal iliac ligation)
- Bail - hysterectomy!
What should be done post a PPH?
Baby check
Debriefing with mum (& dad) and screen for post-natal depression
Debriefing with all staff involved
Discuss at M&M (morbidity & mortality) meeting – can things be done better next time?
How do you adjust the OCP according to side effects?
decrease the oestrogen dose for any side effect (mastalgia, nausea, weight gain, bloating)
but increase the oestrogen dose for breakthrough bleeding
What are the risks of IUDs?
Pelvic infection - first 3 weeks following insertion
Perforation of the uterus during insertion
IUD moving from its position after insertion
IUD may come out during menses
Very small risk of ectopic pregnancy
Increased vaginal discharge
Heavier, painful periods (Cu)
+ side effects of progesterone:
Hirsuitism
Acne
Irregular bleeding & spotting / increased apetite & weight gain
Loss of libido
Mood changes
What investigations are required for preeclampsia?
- FBE
- Blood film
- LDH
- LFTs (AST, bilirubin especially)
- UEC (uric acid)
- Spot Protein:Creatnine Ratio
What word is used to describe reduced sperm motility?
asthenozoospermia
What word is used to describe no semen in the ejaculate?
azoospermia?
(hypospermia and oligospermia are more than this)
What word is used to describe a complete lack of semen?
aspermia
If an STI has been treated appropriately does it cause PID?
no
What are the causes of bleeding in early pregnancy?
Miscarriage
Ectopic
+ TITCH
Trauma
Infection
Trophoblastic Disease
Cervical polyps / Ca / ectropion
Heterotropic pregnancy
What is considered high risk in aneuploidy screening?
Anything >1:300
When can CVS be performed?
When can amniocentesis be performed?
CVS = 11-14 weeks (ie. remember end of first trimester)
Amnio >15 weeks
What are the pros / cons of CVS / Amniscentesis?
CVS: Less sensitive (99%) and increased risk of miscarriage (1%)
- ABORTION IS SAFEST IN THE FIRST TRIMESTER
- Can have medical TOP 7-12 weeks?
Amniocentesis: more senstivie (100%) and reduced risk of miscarriage (0.5%)
How do you consent a woman for a medical termination of pregnancy?
What is the procedure?
- Generally use a combination of two medications to induce the uterus to pass the pregnancy tissue.
- MIFEPRISTONE; AND
- MISOPROSTOL (prostaglandin analogue)
Why do we do it normally?
Termination of pregnancy
Mifepristone is also used for miscarriage.
Misoprostol is also used to ripen cervix in labour.
Why are we doing it in this case?
Termination of pregnancy
Pre-op
- Screen for STIs and treat (given unprotected sex)
Intra op
- Visit a clinic that is authorised to prescribe the medication
- During the consultation with the doctor you will take the Mifepristone tablet.
- You will then need to take the misoprostol at home 24-48 hours later. Usually within 4 hours of taking the second medication you will experience vaginal bleeding, cramps and you will pass some pregnancy tissue.
Post-op
- Return to clinic for repeat BHCG
- Discuss contraception!
- OFFER PSYCHOLOGICAL SUPPORT
Risks
- Nausea, vomiting
- Diarrhoea
- Headache, dizziness, Fatigue
- Abdominal pain and cramps
- Prolonged vaginal bleeding
- Failure of the procedure - 95% success rate (5% will need curettage, 1% will fail, 1% will require transfusion)
Contraindications
- IUD
- Ectopic pregnancy
- Some serious medical comorbidities
Alternatives
- Surgical abortion
- Expectant management
Questions and obtain written consent
How do you consent a woman for surgical TOP?
What is the procedure?
- Day procedure
- Twilight sedation
- 5-10 minute surgical procedure to remove the pregnancy tissue via the vagina
Why do we do it normally?
- Termination of pregnancy from 7-12 weeks gestation
Why are we doing it in this case?
Termination of pregnancy
Pre-op
- SCREEN FOR STIs and treat
- Blood group and Anti D if Rhesus negative
- Fast before the procedure
- 3 hours before the procedure the doctor will insert a misoprostrol pessary to help ripon the cervix.
- Anaesthetic, off to sleep
Intra op
- The doctor will dilate your cervix and remove the pregnancy tissue
- You will then be given some synthetic oxytocin to help contract the uterus and pass any remaining products of conception.
Post-op
- recovery room
- home that day
- doxycycline to reduce any infection risk
- OFFER PSYCHOLOGICAL SUPPORT
- DISCUSS CONTRACEPTION
Risks
- Anaesthetic complications
- Anaphylaxis
- Very rarely, infection or uterine rupture
- Asherman’s syndrome
- Failure of the procedure/retained products (it’s blind) –> can use MTX, wait to pass or go back in
- Vacuum aspiration in 1st trimester has no association with later infertility or ectopic
Contraindications
- Ectopic pregnancy
- Some serious medical comorbidities
Alternatives
- Medical abortion
- Expectant management
Questions and obtain written consent
How do you diagnose missed miscarriage on U/S?
CRL > 7 OR Sac >25mm
WITHOUT FOETAL HR
How do you differentiate between missed and threated miscarriage, according to DS?
They are really the same (missed miscarriage can have bleeding). But the CRL is >7, sac is >25,, and there is a foetal hr in threatened (no hr in missed)
What would you do in PROM in a women who was GBS +ve?
Immediate induction
No option for expectant management
How much weight do you have to lose to improve ovulation in an overweight woman who is anovulatory?
5-10%
Where does the exessive oestrogen come from in PCOS, given that it is a state of hyperandrogenism (and hyperinsulinsm)?
Peripheral conversion of oestrogen
What should you conisder in PCOS management, that isn’t necessarily directly managing the PCOS symptoms?
BP check regularly
2hOGTT / HbA1c 2 yearly
lipid profile 2 yearly
OCP to reduce endometrial Ca risk
cease smoking
What are some risks of Preeclampsia?
HT
First Pregnancy
Novel sperm! / New Partner
Is someone has PE during pregnancy and then they deliver, for how long are at risk of eclampsia?
The next 24 hours
Keep the MgSO4 going for 24 hours
Continue to monitor BP
What is the dosage of intrapartum antibiotics you give in pregnancy for GBS+ve women (or women with risk factors of GBS)?
What is the minimum amount they require?
Benzylpenicillin
3g IV loading dose
1.8g IV q 4h thereafter
They need two doses at least
If they don’t - monitor bub post pregnancy; give Bub antibiotics?
What are the requirements for expectant management of PROM?
TEN ELEVEN
Term
Engaged (cephalic presentation)
No VE or cervical sutures
EFM (CTG) normal
Logistics for ongoing Evaluatiuon
Vitals normal
Exit Portal should have
No GBS
What is the definition of oligomenorrhea?
>35 days without mensturating
How may a woman with PCOS and oligomenorrhea still have infrequent heavy periods?
Oligomenorrhea can be defined as >35 days without a period
It may be heavy because it is not a true period but the endometrial lining simply becoming friable / sheddding / spotting
How do you use clomifene to induce ovulation?
First you have to take high dose progesterone for approx 7 days, then stop.
This causes withdrawal bleed.
Then on day 5 after period you take the clomifene on days 5, 6, 7, 8 & 9
And then you check the day 21 progesterone to see if you have ovulated.
What are the requirements for a forceps delivery?
FORCEPS
Fully dilated
OA position or known position so can apply to forceps correctly
Ruptured membranes
Catheter and contractions
Episiotomy and epidural
Ppresentation: cephalic
Spines or below with none of the head palpable above the pubic symphisis
Plus no obvious cephalopelvic disproproportion
What is the ‘Place and Person’ managment for PPROM (in GA >34 weeks)?
Keep them in for 72 hours (because will likely go in to labour). Can discharge after this. Teach them to monitor for signs of infection (febrile, changed colour of liqour, reduced foetal movements)
If placenta praevia is diagnosed at the 20 week scan, what can you tell the patient?
What do you do to follow up?
No sex.
But 95% will move up as the lower segment of the uterus appears at 26-28 weeks.
Rescan at 36 weeks. It should have moved up. Even if it hasn’t it might still move up, rescan 2 weeks later.
If doesn’t move up - C section.
What is the FIRST LINE management of miscarriage?
How should you counsel the woman?
Expectant management
It’s nOT YOUR FAULT
1/5 pregnancies - miscarriage
Give them oral and written information about what to expect
Pain relief
Tell them when to seek medical advice - if pain/bleeding never stop or is increasing repeat BHCG and repeat scan
Bleeding and in 1-2 weeks the tissue should pass naturally
What can / you can’t use for smoking cessation in pregnancy?
Nicotine replacement therapy is OK
But wear the patch for 16h not 24h
CAN’T USE CHAMPIX
How do you use the BHCG to diagnose ectopic pregnancy
If BHCG is >1,500 and rising should be able to see the foetal heart on transvagainal US
If it is this and can’t see it - ectopic
How do you screen someone for gohnorrhea who is possibly symptomatic?
endocervical swab is the best
high vaginal swab (self-collected) is also good!
first pass urine if not symptomatic or if decline swab
A girl starts on the pill and gets IMB / PCB, what is the most common cause of it?
STIs
Rather than a need to change the pill (tricycling, and increasin oestrogen)
What is the definitive managment of gohnorrhea?
IM ceftriaxone 500mg (not 250mg anymore)
There is supergohnorrhea (resistant) in the north of england now!
What is the management of chlamydia?
1g azithromycin stat and another dose a week later
OR
doxy for 14 days (slightly higher cure rate)
What is the active management of the third stage of labour?
uterotonic agents, controlled cord traction, and uterine massage
What is required for “preeclampsia bloods”
FBE
LFT
coags
UEC
Protein:Creatnine Ratio
What are the causes of jaundice in pregnancy?
Early Jaundice
ETOH, viral hepatitis, gall stones
Late Jaundice
Obstetric cholestasis, acute fatty liver of pregnancy, HELLP syndrome
When after a miscarriage can you try for another baby?
After one month if you’re ready
When do you investigate for miscarriage?
After 3 miscarriages
If it occurs in the 2nd trimester
What are the proven benefits of the cervical cancer vaccine?
So far it’s been proved to reduce the rate of high grade lesions but not the rate of cervical cancer (as it hasn’t been around all that long and cervical cancer takes 10 years to develop)
What are preconceptual considerations for an overweight women?
Extra folate
Lose weight prior to pregnancy if possible
will require care at a tertiary centre if over a certain BMI
what is the management of endometriosis?
Conservative
Simple analgesia
COCP
Progesterones: Mirena IUD, Depot Provera
GnRH agonists: Goserelin
Surgical
Laparoscopic ablation and excision
What are the lesions in endometriosis?
flame lesions
chocolate cysts
cigarette burn lesions
What are the causes of post partum fever?
Wound
Wind
Water
Walk
Whiz
Wonder Drugs
Mastitis
Genital Tract Sepsis
What are the risk of a multiple gestation pregnancy?
Antenatal - Maternal
- Hyperemesis gravidarum
- Fe defficiency
- GOR
- Back pain
- APH
- Miscarriage
- GDM
- PIH
- PE
- PROM
- Premature delivery (due to PROM or foetal/maternal wellbeing)
Antenatal - Foetal
- Congenital anomolies
- IUGR
- Growth discordance
- Perinatal mortality rate
Intrapartum
- Increased risk of instrumental delivery
- Increased risk of C section
Postpartum
- PPH
- Financial difficulties
- Feeding difficulties
- Post natal depression
What sort of twins might suffer from TTTS?
Monochromnic twins
What is the pathophysiology behind twin to twin transfusion syndrome?
Twin-to-twin transfusion syndrome occurs in monochorionic twins and is due to arteriovenous anastomosis in the shared placenta.
The donor twin is small and anemic.
The recipient twin is polycythemic, large, and at risk for high-output cardiac failure.
Both twins are at risk and can die.
What is the epidemiology of TTTS?
15-20% of monochromionic twins
What are the clinical signs of TTTS?
How do you monitor for it?
Rapid abdominal/uterine distension
Reduced ability to palpate foetal parts
(i.e. massive polyhydramnios)
Monitor with regular US from 24-28/40 gestation looking for:
growth discordance between twins
polyhydramnios (recpient twin)
oligo/anhydramnios (donor twin)
What are the criteria to have a NVD of twins?
Should be near term
Presentation of first twin should be cephalic
Continuous CTG monitoring
No foetal compromise or distress
Epidural / spinal (because might have to perform internal cephalic version of second twin or breech extraction!)
Delivery by obstetrician, paediatrician and anaethetist
IV access
What do you do if you get an unsatisfactory smear?
repeat it
What do you do if you get a LSIL…
If the girl is
If the girl is >30?
>30 AND no normal smear in the last two years:
Either colposcopy
OR repeat in 6/12
What is the definition of primary infertility?
In someone
In someone >35?
Not pregnant after 12/12 of unprotected sex
Not pregnant after 6/12 of protected sex
How common is infertility?
1 in 6
(there is a campaign in USA called 1 in 6)
What is infertility associated with?
Ovarian cancer
What are the seven cardinal movements of childbirth?
- Engagement (usually LOA)
- Descent
- Flexion
- IR
- Extension
- ER / restitution
- Expulsion
What are the complications of shoulder dystocia?
Maternal
PPH
3rd or 4th degree tear
Rectovaginal fistula
Uterine rupture
Baby
Erbs palsy (C56)
Klumpkes palsy (C78T1)
Clavicular #
Foetal hypoxia
Describe the management of shoulder dystocia
HELPERR
H - call for help
- 2 x midwives
- anaethetist
- paediatrician
- more senior O&G
Evaluate for Episiotomy
- note that this will only really provide more room for internal manoevers: shoulder dystocia is due to BONY impaction, not soft tissue
Legs - Elevate the Legs
- McRoberts Manoeuvre
Pressure - suprapubic pressure
- A downward and lateral motion onto the posterior aspect of the foetus’ anterior shoulder
- Can be continuous and rocking (similar technique and force to CPR)
- Can be performed in combination with McRobertson manoeuvre
Enter - rotational manouvers
- Rubin II
- Rubin II + woods corkscrew
- Reverse woods cork screw
Remove the posterior arm
Roll patient on to hands and kness (Gaskin manoevre)
Describe the two phases of the second (2nd) stage of labour
Latent / Passive / Descent Phase
when the cervix is found to be fully dilated prior to, or in the absence of involuntary expulsive contractions.
(During this phase the fetal head progressively descends
through the maternal pelvis, and internal rotation and flexion occurs.)
Active / Pelvic Floor Phase
The onset of the active phase of second stage labour is recognised when:
- the fetal presenting part is visible
- there are expulsive contractions with a finding of full dilatation of the cervix and other signs indicating full dilatation.
- there is active maternal effort following confirmation of full dilatation of the cervix in the absence of expulsive contractions.
what is the chorion and what is the amnion?
the chorion is the outer layer
amnion is the inner layer
Discuss routine ABx in C section
For caesarean section: there is evidence that antibiotics are beneficial for prophylaxis of wound sepsis as well as endometritis for all caesarean sections, elective or non-elective.
use: cephazolin 1g (adult 80kg or more: 2g) IV
Administration after the cord is clamped has been common practice to avoid exposing the neonate to antibiotics, and to avoid compromise to the fetus in the event of maternal anaphylaxis. These considerations need to be weighed against lower maternal infection rates if prophylaxis is administered before skin incision.
NB - low risk to foetus - so I think most places administer prior to ‘knife to skin’.
What is assessed in Apgars?
A – appearance (colour)
P – pulse (HR)
G – grimace (reflex irritability – the response to nasal suction)
A – activity (tone)
R – respiraton (cry)
What is the management of cord prolapse?
1. call for help
- knee-chest face-down position / steep trendelenberg
- Wrap cord in damp, warm cloth
- Elevate the presenting part (foetal head) off cord
- Fill the bladder with catheter
- Tocolysis
- Emergcency ceaser
Don’t put cord back in as this may cause vasoconstriction.
Describe how IOL is initiated with PGs?
CTG for one hour prior to prostin / cervidil
Ask woman to empty her bladder (as she will have to lie still for one hour prior)
Insert prostin or cervadil
Put on CTG for one hour (woman has to lie still)
Usually do this at about 5pm. May be enough to induce labour but may require another dose the next morning.
Wat should you do if a woman is weakly immune to rubella in her antenatal Ix?
Give her the MMR vaccine before she is discharged fom hospital post birth
(is a live vaccine, can’t give it whilst pregnant)
If the cervix is favourable, what might you use to induce labour in a primip?
You might still use prostin over an oxytocin infusion
How do you describe cervical dilation in terms of fingers, not cms?
The cervical os ‘admitted’ one finger/two fingers etc
What levels are acceptable in BGL monitoring with GDM?
Compare this to diagnostic levels?
BGL monitoring
Fasting capillary blood glucose (BG): ≤ 5.0mmol/L
[1 hour BG after commencing meal: ≤ 7.4mmol/L]
2 hour BG after commencing meal: ≤ 6.7mmol/L
GDM diagnosis
Fasting
1 hour post meals
2 hours post meals
The diagnosis levels are higher because they have 75g of glucose + they sit still for two hours. We encourage women already with GDM to have a healthy diet + stay active
What two antenatal screening tests are considered optional by RANZCOG but are almost always done?
Hep C
TFTs
When can you use date of LNMP for EDD?
when the woman has not been on the OCP for 3/12 prior
When she has had 3 normal periods
When the dates from the U/S do not differ by more than 3 days (when scanned prior to 13 weeks) or by more than 10 days (when scanned after >13 weeks weeks)
What are the causes of amenorrhea?
HEAPS POACHED
Head injury [reduced GnRH]
Excessive exercuse [reduced GnRH]
Annorexia [reduced GnRH]
Prolactinoma [PRL inhibits GnRH]
Sheehans syndrome [reduced FHS/LH]
PCOS / premature ovarian failure [reduced response of ovaries to FSH/LH]
Obesity [oestrgen++ inhibits FHS/LH secretion]
Asherman’s Syndrome [blocks exit of period]
Cervical stenosis [blocks exit of period] and late onset CAH
Hypothyroidism
Endocrine [DM and cushings]
Drugs [DA antagonsitis and progesterone]
What are the causes of infertility?
USE MOAT
Uterine & Cervical (tend to cause more miscarriage)
Sex
Endometriois
Male (hypospermatogenesis, obstruction, endocrinological, drugs, radiation, heat)
Ovaries: HEAPS POACHED
Age >30
Tubal
What is a safe ETOH level in pregnancy?
No safe level
What is cocaine use in pregnancy associated with?
placental abruption
What are the risks of alcohol to an unborn / newborn child?
Foetal alcohol syndrome
Intellectual disablity
Congenital cardiac defects
Brain and spine defects
Causes of menorrhagia?
Bleeding disorder
Iatrogenic (IUDs and drugs)
Thyroid dysfunction (especially hypo)
Cancer (Endometrial, cervical)
Hyperplasia of the endometrium
Fibroids (leiomyomata) and polyps
Adenomyosis and endometriosis
Chlamydia, gonorrhea and STIs
Ectopics, miscarriage, pregnancy
what do you need to consider in a sub-total hysterectomy?
need to keep having Pap smears
When do you use a cone biopsy over LLETZ?
If you can’t see the squamo-epithelial junction (but usually you use LLETZ)
what is cervical incompetence?
Cervical incompetence (or cervical insufficiency) is a medical condition in which a pregnant woman’s cervix begins to dilate (widen) and efface (thin) before her pregnancy has reached term –> MISCARRIAGES
What are the causes of pelvic pain in an adolescent?
PAP ME
Pregnancy
Appenix
Primary dysmenorrhea / PID
Mullerian obstruction
Endometriosis
+ bladder / bowel causes (eg. UTI, IBS)
What Ix should you order in suspected endometriosis?
laparoscopy is the gold standard diagnostic test for endometriosis
What Ix are required for infertility, itially?
MALE
- Semen analysis and IBT
HORMONAL - FEMALE
- Ovarian Reserve
- Day 2-4 FHS/LH + oestrogen
- AMH
- Mid luteal progesterone
- TFTs
- Serum Prolactin
STRUCTURAL - FEMALE
- US
- dye studies
- hysteroscopy
- laparoscopy
OTHER - FEMALE
- Rubella immunity status
- Varicella immunity status
what is the most common cause of infertility?
unexplained infertility
What needs to be considered prior to contraception?
Headache / hypertension
Obesity / Osteoporosis / Old [>35 years old]
Medications (some anti-convulsants, some ABx)
Embolism / Thrombus / Clotting disorders
Stroke
Infective endocarditis / Informed consent / Gillick competent (for minors)
Cancer (breast, cervical), Cardiovascular Risk
Kids (nulliparous women & myrena) breast feeding (no oestrogen)
Liver disorders
What contraceptive option is associated with increased risk of OP?
depot
Which canger is associated with an increased CA125?
ovarian
What is the management of menorrhagia?
Basics
- DRABC: resuss if anaemic
- Iron supplementation if iron deficient
Place & Person
Ix and confirm Diagnosis
Examination:
- general
- abdominal
- speculum
- bimanual
Investigations:
- Urine for chlamydia/gohnorrhea
- FBE
- UEC
- Coags
- TFTs
- Hysteroscopy
- Biopsy
- Diagnostic labaroscopy
Defninitive Management
FIRST TREAT UNDERLYING CAUSE eg. Mymectomy (fibroids)
Pharmacological
- Tranexamic acid
- NSAIDs
- OCP
Surgical
- Mirena
- Endometrial ablation / rescection [can’t get pregnant afterward]
- eg. NOVASURE
- Hysterectomy [can’t get pregnant afterward]
which type of ENDOMETRIAL cancer carries the worst prognosis and accounts for 10% of all ENDOMETRIAL cancers?
clear cell
(it’s an endometrial cancer which acts like a ovarian cancer in that’s its spread is transcoelomic)
What is the most concerning type of trace and what does it represent on CTG?
sinusoidal
represents severe hypoxia
What “systems” questions should you ask in an APH history?
TIP: BE CALM
Trauma
Investigations to date (eg. position of placenta on 20 week scan)
Pain
Blood group
Eat of drink today?
Contractions
Anaesthetic previously?
Liqour / ROM
Movements (foetal)
what is the name of a lobule of the placenta?
cotyledon
what are the causes of painless APH?
what are the causes of painful APH?
painful = uterine rupture (rare) or placental abruption
painless = placenta praevia or vasa praevia
What are the grades of perineal tear?
Grade 1: epithelium of vagina torn
Grade 2: Involves perineal muscle
Grade 3: To the anal sphincters
- A)*
- B) >50% of external sphincter*
- C) Internal sphincter*
Grade 4: Tear to anal epithelium
What is the defitive management options for ectopic pregnancy?
Medical
- IM methotrexate
- Re-check B-HCG levels 4 and 7 days later
- Should fall by 15%
- If not - give second dose
Surgical
- laparoscopy
- might do salpingectomy if it’s in the tube
- might to oopherectomy if it’s in the sac
- laparotomy (required in emergency) to remove products of conception
- Recheck B HCG: should fall rapidly
- should be less than 65% the original level 48 hours post hop
- should be less than 10% the original level 10 days post op
- if not –> consider persistent trophoblast
- Recheck B HCG: should fall rapidly
What are the causes of reduced variability on CTG?
4Ss
Sleep
Stress
Sedation
Small baby
With whom should you order a kleihauer test?
What does it actually test?
on a Rh -ve mother who may have experienced foetomaternal haemorrhage
the degree of feto-maternal haemorrhage
When would you administer anti-D / rhogam?
In a Rh -ve mother at
28 weeks
34 weeks
72 hours post delivery (IF bub is Rh +ve)
PLUS if you suspect foetomaternal haemorrhage
At what day of the cycle is mid-luteal progesterone taken (in a 28 day cycle)?
What does it indicate?
The level is taken on day 7 of the luteal phase
(= day 21 of a 28 day cycle)
A level of >30 indicates the woman HAS ovulated
A level of
What are the symptoms of menopause?
MENOPAUSE
Muscle aches
Energy levels reduced
Night sweats
Osteoporosis – pathological fracture
Psych – [depression, headache, reduced concentration & memory]
Aretries = vasomotor symptoms (hot flushes & night sweats)
Urogenital symptoms – increased frequency, urgency, UTIs, prolapse
Sex – loss of libido
Extra risk of CV disease and osteoporosis
What are the screening questions one should ask prior to HRT?
ABCEIOU
Age >60
Breast Ca, BP
Clots (DVT / PE / stroke)
Endometrial cancer
I = OP
O = gallstones + liver disease
Uterus or not?
What is the OVERALL management of menause?
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
What are some DDx of primary ovarian insufficiency?
Other causes of amenorrhea = HEAPS POACHED
Also = Fragile X syndrome (?), Turner’s moasicism
What are the criteria for the diagnosis of PCOS?
- Oligo/amenorrhea
- Clinic and/or biochemical signs of hyperandrogenism
- Hirsutisim
- Acne
- Androgenic alopecia (male pattern balding)
- Raised levels of testosterone, free testosterone index or dehydroepiandrosteronesulphate (DHEAS)
- 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
What are the systems questions for PCOS?
HATE BODI
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
What are the complications of PCOS?
T2 DM
Gestational diabetes
Hypertension and increased cardiovascular risk
Infertility
Endometrial hyperplasia and carcinoma
What is the management of PCOS?
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
What investigations might you consider in PCOS?
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
What is the pathophysiology of GDM?
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.
What are som risk factors of GDM?
- 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
What are the maternal risks of GDM?
PIH / PE
T2DM in later life
Foetal macrosomia leading to increased rate of C section, obstructed labour, perineal tears
What are the foetal risks of GDM?
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
What are the neonatal risks of GDM?
hypoglycaemia
respiratory distress
Klumpkes / Erbs Palsy
Clavical Fracture
Packaging problems eg. positional talipes
Jaundice
Electrolyte disturbance (Mg/Ca)
Polyhydramnios
Congenital abnormality, especially cardiac
What is teh aetiology of PCOS?
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.
What is the incidence of PCOS?
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 %.
What is the most common symptom / sign of PCO?
What is the difference between PCO and PCOS?
Fifty percent of women with PCO have no symptoms
or signs.
The presence of signs / symptoms.
What is the simplified pathogenesis of PCOS?
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.
What is the first line Rx of PCOS (regardless of the presenting complaint)?
Diet & Exercise
(Will help with infertility, oligomenorrhea/amenorrhea, acne, hirsuitism and obesity)
What role does the hypothalamus play in the menstural cycle?
It releases GnRH in a pulsatile fashion which stimulates the anterior pituitary to release FSH and LH
What does the ovary secrete?
Which hormone provides negative feedback to the pituitary?
The ovary secretes oestrogen, progesterone, testosterone and inhibin (and AMH).
The inhibin acts as negative feedback to the pituitary.
What happens in the follicular phase of the ovarian cycle?
When does it start and when does it end?
How long does it go for?
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.
What causes ovulation, specifically?
LH surge
(which is caused by an increasingly higher amount of oestrogen secreted by the follicle)
what IS the corpus luteum?
What is it’s role?
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).
When does the luteal phase start?
When does it end?
How long does it last for?
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.
what is the life span of a corpus luteum, and what is this significance of this?
14 days (if egg not fertilised)
The significance of this is that the luteal phase is always 14 days
Describe the mechanism of contraception and a withdrawal bleed with the COCP, using your knowledge from the menstural cycle physiology.
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.
When should the first ANC visit ideally occur?
Within 10 weeks of conception
Which examination components / investigations should be performed at EVERY ANC visit prior to 12 weeks gestation?
BP
BMI
Urine dipstick
Which exmaination components / Ix findings should occur at EVERY ANC visit between 12 and 20 weeks?
BMI
urine dipstick
BP
fundal palpation
intermittent auscultation of foetal heart
Which examination conponents / Ix are performed at EVERY ANC visit between 20 and
BMI
BP
urine dipstick
fundal palpation
intermittent auscultation of the foetal heart
ask about foetal movements
What specific examination components / Ix should be performed at EVERY ANC visit after 24 weeks?
BP
BMI
urine dipstick
auscultate foetal heart
fundal palpation
ask about foetal movements
SFH
palpation of lie and presentation
What are the routine investigations which should be performed on the first ANC visit?
What else should be conisdrered?
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
When is USS commonly performed in pregnancy?
(not neccessarily routinely)
- Can do one in early pregnancy
- Dating scan @ 12 weeks (and aneuploidy risk)
- Scan at 20 weeks to see position of placenta + foetal morphology
- Third trimester scans can depict planetal function & EFW
Only the middle two are routine!
What Ix should be considered on the first ANC, and how do you decide whether or not to perform them?
2G, 3T, 4C?
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
When is a dating scan performed?
How is this used to measure GA?
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.
What are the routine antenatal investigations which are NOT done in the first antenatal visit
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
What are the risk factors for downs syndrome?
- 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
Counsel a patient regarding screening for down syndrome
-
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
- CVS is performed at the end of the first trimester
- The first part ascertains your risk but is not diagnostic
Compare the risk of miscarriage in CVS / amniocentesis
CVS 1% above background
amnio 0.5% above background
Compare the sensitivity of CVS & amniocentesis in detecting trisomy 21
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%
What markers are looked for in the first trimester screening?
What results indicate DS?
What results indicate Edwards syndrome?
- 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
What markers are looked for in second trimester screening?
What is indicative of trispomy 21?
What is indicative of trisomy 18?
What is indicative of NTDs?
- 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
What do you need to consider / ask in preconceptual counselling?
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
What routine TREATMENT is required in the antenatal period and when?
Influenza vaccine
Whooping cough vaccine at 26 weeks
Rhogam at 26 and 34 weeks if Rh negative
There are a whole lot of concerns for someone with PCOS in later life, relating to increased oestrogen levels (eg. endometrial hyperplasia). Why?
Obesity - increased peripheral conversion of oestrogen
what are the menstural phases in order
- Menses
- Proliferative
- Secretory
What is the buzzword for U/S findings for PCOS?
Chain of pearls / ring of pearls
How many times can a patient with GDM / DM in pregnancy go over the target levels before you have to “step up” treatment?
twice / week
If more than twice - step up Rx from lifestyle –> insulin –> metformin
What Ix are required for suspected endometrial Ca in a woman who has post menopausal bleeding?
- 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)
Who has early GDM screening?
And when do they have it?
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
Cx of polyhydramnios?
Unstable lie
Cord prolapse
When do you deliver in a patient with GDM or DM in pregnancy?
If they are being treated by lifestyle –> can go to 42
If on insulin –> can’t go past 40
When do you use cyclical versus continuous HRT and why?
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
What is the defitive management of endometrial cancer?
- Hysterectomy (TAH)
- Consider bilateral salpingectomy and oopherectomy (BSO)!
- Staging of the pelvic lymph nodes
What should you always do before a speculum exam (which I always forget?)
General insepection of the vulva and perineum
As well as check pads for blood / liqour
How thick should the endometrium be on U/S in a post-menopausal woman?
What is the risk of down syndrome in advancing age?
What is considered “high risk” on screening tests?
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!
Compare the sensitivities of 1st and 2nd Trimester Screening tests for down syndrome?
1st is more sensitive 85-90%
2nd is less sensitive 70-75%
Compare the timing, miscarriage rate and sensitivity of miscarriage and amniocentesis
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%)
What are the causes of APH
BIG CAPUT
Bloody show
Infection
Giant haemorrhoids
Cancer
Abruptio placentae
Praevia - placenta or vasa
Uterine rupture
Trauma
In what suspected clinical situations should you avoid / not do a vaginal exam?
PPROM / PROM
Placenta Praevia
Compare findings on an abdominal exam in placenta praevia / previa versus versus placental abruption
Praevia / previa = uterus is soft
Abruption = uterus is tender and hard
Compare the colour of blood and the duration of bleeding in placenta praevia versus abruption?
praevia = bright red, often ongoing
abruption = dark red, often single instance
Ruptured membranes + immediate bleeding + abnormal FHR = ?
Vasa praevia
What is the management of placenta praevia?
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
What is the defitnitive management / checklist for the management of any obstetric OSCE?
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)
When / in what situations should you give antenatal steroids?
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
What is the dosage of antenatal steroids?
Betamethasone: 2 x 12mg, 24 hours apart
Dexamethsone: 4 x 6mg, 12 hours apart
What are the benefits of antenatal steroids?
Antenatal steroids are associated with a significant reduction in rates of
- Neonatal death
- Neonatal Respiratory Distress Syndrome
- Neonatal intraventricular haemorrhage
What are the risk factors for endometrial cancer?
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)
What are the protective factors for endometrial cancer?
COCP
Mirena
Smkoing (causes earlier menopause, anti-oestrogen ffect)
When should you order an ultrasound if you suspect endometrial cancer?
Just after period when endometrium is at its thinnest
What is an important DDx of a fibroid (leiomyoma)?
Leiomyosarcoma!
What is the typical presentation of ovarian cancer?
older woman with vague pain + plus “abdominal swelling” (ascites)
Ovariam cancer features on ultrasound?
>5cm
Multicystic
Solid area
Ascites
Bilateral
Increased blood flow
What is the tumour marker for ovarian Ca?
CA125
sensitivity 81% specificity 75%
What is the definitive management of ovarian cancer?
Much more aggressive than endometrial cancer\
AGGRESIVE SURGERY + chemo
infracolic omentectomy
washings
biopsies of noes
appendicectomy!
+ chemo
When do you do a cone biosy rather than a LLETZ on culposcopy?
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)
What is the options of treatment for cervical cancer?
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
Why is hyperthyroidism so common in pregnancy?
Because HCG is similar in structure to TSH
What is a threatened miscarriage?
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
What is an inevitable miscarriage?
PV bleeding
cervical os open
gestational sac + foetal pole is present on U/S
What is an incomplete miscarriage?
PV bleeding in
Cervical os is open
Some of the products of conception are in utero on U/S, but not all
What is a complete miscarriage?
What is a DDx?
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.
What is a missed miscarriage?
What is a DDx / the same thing?
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!
Bleeding in early pregnancy
Cervical os closed
foetus still alive on U/S
What type of miscarriage?
Threatened miscarriage
Bleeding in early pregnancy
Cervical os open
Products on conception still in utero / still alive
What type of miscarriage?
Inevitable miscarriage
Bleeding in early pregnancy
Cervical os open
some of the products on conception in utero on US but some passed
what type of miscarriage?
incomplete
Bleeding in early pregnancy
Cervical os closed
No products on conception on US
What type of miscarriage?
Complete miscarriage
No PV bleeding
Cx os closed
Foetus is small for dates / no heart beat
Missed miscarriage
Asymptomatic foetal demise
When should you start investigating for the causes of miscarriage?
>3 miscarriages
ie. “recurrent miscarriage”
What are the causes of recurrent miscarriage?
SLEIGH
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
How should you counsel a woman who has experienced her first miscarriage?
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
What is the management of miscarriage?
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
What are the differentials for bleeding in early pregnancy?
Miscarriage
Ectopics
STITCH
Subchorionic haemorrhage
Trauma
Infection
Trophoblastic
Cervical cancer, polys or ectropion
Heterotropic pregnancy
How do you diagnose miscarriage on ultrasound?
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
What is the most common type of gestational trophoblastic disease?
Hydatitaform mole
What is the typical appearance of hydatiaform mole on ultrasound?
Complete = “snow storm” appearnce
What is the surgical management of PPH?
6Bs
Bladder – insert a urinary catheter!
Bimanual compression (not technically surgical)
Balloon Tamponade
B-Lynch Suture
Bilateral uterine artery ligation
Bail! – Hysterectomy
What are the types of bleeding in pregnancy?
BEP
APH
IPH
PPH
What is the definition of primary PPH?
Bleeding within the first 24 hours post partum
>500mL loss in NVD
>750mL loss in C section
What are the causes of primary PPH?
Tone
Tissue
Trauma
Thrombin
What are the causes of secondary PPH?
What are your DDx to consider?
The two main causes are:
- Infection
- Tissue - retained products of conception
- 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!)
What are the complications of PPH?
Hypovolaemic shock + end organ damage
Anaemia
AKI
Sheehan’s syndrome
Lactation failure or delay
What is the baseline risk of PPH?
10-15%
What are the risk factors for PPH?
PIG FIT CUPPA
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
How do you test for an iron deficiency anaemia in pregnancy?
Ferritin
(Don’t do full iron studies because iron handling changes)
What is the active management of the third stage of labour?
Why is it employed?
- immediate administration of prophylactic uterotonics
- early cord clamping
- controlled cord traction
It is emplyed to reduce the risk of PPH
What is the medical management of PPH?
ME MSIS PM
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)
What are the CIs for misoprostol and ergometrine?
Misoprostol = asthma
Ergometrine = HT / PIH / PET
What is the definitive management of PPH?
Position + BIM + ME MSIS PM + 4Bs
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
What are the things to know about a backri balloon?
Can stay in for >24 hours
Have to be on a broad spectrum ABx
What is the definitive management of PPH?
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?
What are the blood tests required in suspected pre-eclampsia?
FBE
LFT
Coags
UEC
Uric acid
FWT for proteinuria
What is the treatment of GBS?
Benzylpenicillin
If hypersensitive: Cephazolin
If immediately hypersensitive: Clindamycin
If resistant to clindamycin or suspecptibility testing unavailable: Vancomycin
What is the management of hyperemesis gravidarum?
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!]
what is the term given to the age at which a woman first has sex?
coitarche
what is the definition of a still birth?
foetal death after 20 weeks gestation
What are the risks of C section
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
What are the indications for C section?
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
What are the risk factors for PPH?
PIG FIT CUPPA
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”
What are the Post-partum complications / considerations?
Pain
Perineum
Pissing
Pooing
Pyrexia
Psyche
PPH
PE + GDM
Protection + Pap Smear
PE / DVT
Rhesus status
Rubella immunity
What is the broad strokes of managaement for PPH?
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
How do you define and categorise PPH?
A loss of >500mL of blood after pregnancy
Primary
- In the first 24 hours
Secondary
- 24h - 6 weeks
What are the causes of primary PPH
Tone [uterine atony]
Tissue [Retained products (placenta or membranes)]
Thrombin [DIC, coagulopathy]
Trauma [Laceration to the cervix, vaginal, perineum and (rarely) uterine rupture]
At what gestation, in Victoria, until what gesttaion is abortion legal upon request?
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
Up until what gestation is medical termination of pregnancy offered?
What is involved?
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
What Ix do you need before medical TOP?
An ultrasound to confirm
- GA (only until 9 weeks)
- to ensure it is intrauterine (can’t use it ectopic pregnancy)
What should be done if the results of a Pap smear are unsatisfactory?
Repeat 6-12 weeks
Not before 6 weeks because want cells to recover
What is the name of the surgical TOP procedure in the first trimester?
Dilation, suction and curretage / vacuum extraction
What is involved in a vacuum extraction?
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
What is involved in a medical TOP?
Mifepristone / RU486 orally
+
Misopristol (vaginally or orally) 48 hours later!
what is the definitive management of chlamydia?
Azythromycin 1g as a single dose
OR
Doxycycline 100mg BD for 7 days
What is more common, chlamydia or gohnorrhea?
If you saw a patient with urtheral discharge - what would you think?
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
what is the overall management of chlamydia?
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
What is required of a doctor if they diagnose an STI?
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
What are the complications of chlamydia?
PID
Infertility
Ectopic pregnancy
Epididymitis
Reactive arthritis
Who should be screened for chlamydia?
How is the specimen collected?
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).
What are the two main causes of PID?
Chlamydia
Gohnorrhea
What is the typical presentation of chlamydia?
Asymptomatic!
They may be infertile before they get symptoms!
“Man with copious urethral discharge 2-10 days after unprotected sex” on Monash MCQs = ?
Gohnorrhea
What is the typical presentation of gohnorrhea in a male?
In a female?
If it has infected the anus?
If it has infected the thoat?
Man: copious uretheral discharge
Woman: usually asymptomatic
Infections of the cervix, anus and throat usually cause no symptoms.
What is the defitive management of gohnorrhea?
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
Who should be screened for gohnorrhea?
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)
what investigations can be performed to screen for gohnorrhea?
urine (mid stream)
endocervical specimen MC&S
culuture of discharge (if symptomatic)
What is the defitive management of gohnorrhea?
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
What is a chancre?
A painLESS genital ulcer caused by syphillus
Is a chancre painful or painless?
What is it associated with?
A painless geintal ulcer caused by primary syphillus.
Also comes with local lymphadenopathy
What is the definitive management of syphillus?
benzathine penicillin 1.8 g IM, as a single dose
What is the defitive management of the ‘Big Three’ STIs?
Chlamydia: 1 dose of azithromycin (or x 7 of doxycyline)
Gohnorrhea: IM ceftriaxone (+ azithromycin for chlamydia)
Syphillus: IM benzathine penicillin
What is the difference between genital herpes and genital warts?
Genital herpes = HSV
Genital warts = caused by HPV types 6 and 11
What causes cold sores?
What causes genital herpes?
HSV 1
HSV 2
Describe the pathophysiology of HSV
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.
What is the defitive management of HSV?
Acyclovir
Protected sex whilst there is active lesions
What is the first thing you should do in any obstetric emergency?
Call for help
What increases the risk of cord prolapse?
breech
malpresentation
multiple gestation
grand multiparity
preterm labour
abnormal placentation
polyhydramnios
all to do with more space in utero / head not plugging the os
What are the types of breech?
Which one is bad?
complete
incomplete - this one is bad
frank
What is the difference between cord prolapse and presentation?
cord presentation = intact membranes
cord prolapse = ruptured membranes, cord doesn’t necessarily have to be external
What should you do before AROM?
VE
Palpate for the head.
If there is a soft, pulsatile structure it could be cord presentation or vasa previa
pain in uterine rupture is descriped as what?
epidural doesn’t cover it
What is a cause of a regression in station and cervical dilatation?
Either intra-rater error
OR
uterine rupture
Where do you apply suprapubic pressure in shoulder dystocia?
The posterior aspect of the shoulder
what drug helps to relax the uterus, often in C section?
gtn
What is the mortality rate of amniotic fluid embolism?
>80%
how do you diagnose amniotic fluid embolism?
only at autopsy
foetal squames in patient lungs
What is the definiton of secondary PPH?
>500mL loss
24/24-6/52 post birth
what are the risks of curette?
perforation
bleeding
asherman’s syndrome
when can you insert a mirena after vaginal birth?
after C section?
6 weeks
12 weeks
You can give an implanon almost immediately after birth, what do you have to be careful of?
That their lochia has stopped and that they don’t have PPH
because can get heavy bleeding
What is the CURRENT schedule for routine Pap smear
screening?
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)
What will routine cervical cancer screening involve in the future?
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
When should a Pap smear NOT be performed?
Avoid during menstruation, obvious vaginal infection,
within 24 hours of intercourse
(incrased risk of UNSATISFACTORY SMEAR)
Describe what should occur is a LSIL is found on cervical screening?
what is another name for genital warts?
condylomata acuminata
What is the definitive management of HSIL found on cervical screening?
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
How long does the second stage of labour take?
What is the maximum amount of time it should take?
1 hour in multis
2 hours in primis
3 hours if epidural
should take no longer than 3 hours!
What is recommended to be used in the third stage of labour to reduce the risk of PPH?
Does this include C section?
By how much does this drug reduce the risk of PPH?
What route and what dose?
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)
What is the stepwise approach to PPH?
Non-Surgical
Think of a creepy prime minister intructing his wife to massage him
“Massage ME MSIS PM”
Massage
Metrine-Ergo
Metrine-Synto
Infusion of Syntocinon
Prostaglandins
Misoprostol
Surigcal
The 4Bs
Balloon Tamponade
B-Lynch Suture
Bilateral urerine artery ligation
Bail! - Hysterectomy
What is a cause of post-coital bleeding, in an otherwise healthy young woman (usually taking the OCP)?
Cervical ectroption
What are some “buzz wordy” risk factors for endometrial cancer and why?
Obseity (fat produces oestrogen)
Nulligravid (?)
Older age (anovulation, unopposed oestrogen)
PCOS + infertility (anovulation, unopposed oestrogen)
Unopposed oestrogen increases risk of endometrial cancer
What is secondary PPH?
What are its causes?
How does it present?
PPH due to endometritis
Usually caused by retained products
Febrile women, approx 1-2 weeks post birth with lower abdominal pain and vaginal bleeding
What is cervical motion tenderness / excitation?
What does it signify?
Tenderness of the cervix on movement
Can signify pelvic inflammatory disease (PID), ectopic pregnancy
Used to DDx from appendicitis or gastrointestinal pathology
Describe the features looked for on ultrasound when suspecting a miscarriage
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.
What is the morning after pill?
In what time period can it be taken?
What is the failure rate?
“Postinor” / Levonorgesterol
Within 72hours
1-2%
What is the Yupze method?
Where can someone get it?
When should it be used?
What is the failure rate?
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%
When can the copper IUD be used for emergency contraception?
What are it’s advantages?
When shouldn’t it be used?
What is it’s failure rate?
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%
When can mifeprisone be used as emergency contraception?
How effective is it?
What does the woman need to be educated about?
What are it’s advantages?
=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
Once you have chosen a method of contraception for a woman, what do you have to explain?
SMERBB
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)
What are the phases of the menstural cycle?
Follicular phase
Luteal phase
Which homrones cause follicle development?
The hypothalamus secretes GnRH
, the anterior pituitary, in turn, secretes LH and FSH which stimulates a follicale to grow
What causes the FSH / LH surge?
The growing follicale secretes oestrogen, which causes more secretion of GnRH, which in turn causes more secretion of FSH/LH - causing a surge!
What stimulates ovulation?
The LH/FSH surge (preceedes it by one day)
How long is the follicular phase?
When does it end?
It’s length of time is variable - it ends at ovulation.
It is approximately 14 days long
What happens in the follicular phase?
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
How long does the Luteal phase last for?
14 days
What marks the end of the follicular phase?
The corpus luteum dicintegrates, so no more O/P/inhibin so no more inhibitiion of GnRH/FSH/LH
what phase of the menstural cycle corresponds with the follicular phase?
menstural flow
proliferative phase
what phase of the menstural cycle corresponds with the luteal phase?
secretory phase
what questions on a history regarding menorrhagia, may suggest a structural / anatomical cause?
intermenstural bleeding
post-coital bleeding
What is another name for fibroids?
Of what tissue are they composed?
Where are they located?
Leiomyoma
Composed of myometrial tissue
They can be located within the myometrium, sub mucosal, sub-serosal or pedunculated
how are fibroids different to polyps?
fibroids are made of myometrial tissue
polyps are made of entometrial tissue
What is the clinical presentation of fibroids / leiomyomata?
- 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
What would you include on examination of a woman with menorrhagia?
- General examination - look for signs of anaemia
- Abdominal examination
- Speculum examination
- Bimanual examination
what investigations would you order for a woman with menorrhagia?
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
What are the causes of menorrhagia?
BITCHFACE
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
What is the management of menorrhagia?
Basics
- DRABC: resuss if anaemic
- Iron supplementation if iron deficient
Place & Person
Ix and confirm Diagnosis
- Examination:
- general
- abdominal
- speculum
- bimanual
- Investigations:
- Urine for chlamydia/gohnorrhea
- FBE
- UEC
- Coags
- TFTs
- Hysteroscopy
- Biopsy
- Diagnostic labaroscopy
- Defninitive Management
- Pharmacological
- Tranexamic acid
- NSAIDs
- OCP
- Surgical
- Mirena
- Endometrial ablation / rescection
- Mymectomy (fibroids)
- Hysterectomy
- Pharmacological
What options does a woman with menorrhgia have if she hasn’t completed her family?
Tranexamic acid
OCP & NSAIDS - can cease when trying to get pregnant
Mirena - can remove when trying to get pregnant
Myomectomy (for fibroids)
What are a woman’s options for the treatment of menorrhagia if she has completed her family?
Endometrial resection or ablation
Hysterectomy
When should women receive testing for GDM, and who should receive this screening?
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.
What is the gold standard test for GDM? How is this test performed and measured? What else can be performed if this test cannot be done.
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
If a woman has GDM, what other testing should be done?
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.
What are the parameters for diagnosing GDM and DM in pregnancy?
GDM:
0 hours = 5.5 - 7
1 hour = > 10
2 hours = 8.5 - 11
Can’t diagnose DM in pregnancy
who is eligible for the free boostrix vaccine?
- 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.
From what GA does the symphysio-fundal height become accurate?
And what is “normal”?
How do you measure it?
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.
When should you start to ask about foetal movements?
18-20 weeks normally
What else is required other than folate supplementation in pregnancy?
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
what are some reasons as to why a newborn may have difficulty breast feeding?
- 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!
what are some reasons concerning the mother why breast feeding may not be an option?
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
What are the benefits of breast feeding?
ABCDEFGH
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
What pharmacological tehrapy may be used to increase breast milk supply?
Galactagogues
Domperidone (Motilium) and Metaclopromide (Maxalon)
What tests should one have before the insertion of a myrena?
Tests for chlamydia
Pregnancy test
How do you instruct someone to collect a urine specimen for chlamydia testing?
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
How often and at what aged should one be screened for chlamydia?
Yearly in all sexually active young people aged 15–29 years
What is the specific test for chalmydia?
Nucleic acid amplification test (NAAT) most commonly by PCR
how does the mirena work?
Locally secretes a high dose of progesterone:
- makes the mucous thicker - a barrier to sperm entry
- thins the endometrium so the egg can’t implant
- the mirena itself acts as a barrier to sperm
what is a normal AFI?
5-25cm
What are the components of the biophysical profile?
Non-stress test
Gross body movements
Foetal breathing
Muscle tone
Amniotic fluid index
What is menopause?
The permanent cessation of menstruation in non-hysterectomied women.
What is perimenopause?
The time from the onset of cycle irregularity through until 12 months after the menstrual period.
What is primary ovarian insufficiency?
When the cessation of ovarian function occurs before the age of 40 years (ie. cessation of menstruation before age 40)
what are the signs of oestrogen excess?
Breast tenderness
Menorrhagia
Migraine
Nausea
Shorter cycle length and a shorter follicular phase
What are the signs of oestrogen deficiency?
General:
- Fatigue
- Headaches
- Muscle/joint aches
Cognitive:
- Depression
- Memory loss
- Difficulty concentrating
Vasomotor:
- Hot flushes
- Night sweats
- Urogenital Vaginal dryness/itching
- Urinary frequency/urgency
what are the medically concerning physiological effects of oestrogen deficiency?
Metabolic syndrome Osteoporosis Vaginitis
what are the differential diagnoses for primary ovary insufficiency? ie. what are causes of secondary amenorrhea?
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)
what are the porential risks of HRT
Remember: ABCEIOU (see summary)
Breast cancer
DVT / PE
Stroke
Endometrial cancer
Cholecystitis
How do you diagnose menopause?
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.
What are the considerations required before starting HRT?
ABC,EIOU
Age (
Blood Pressure & Breast Cancer
Clotting: DVT / PE & Cardiovascular Risk
Endometrial cancer & Everyday symptoms
I (bone) – OP
O – cholecystitis
Uterus? ie. Hysterectomy?
In a woman who has never had a hysterectomy, what sprt of HRT would you prescribe?
Oe + P
In a woman who is only experiecing urogenital symptoms, what route of HRT would you consider?
Vaginal
What are the options for combined HRT? And what are the advantages / indications for each?
- Continuous Use - oestrogen and progesterone both daily. Have to have had cessation of period for one year or greater before commencing.
- Cyclycal Use - oestrogen daily and progesterone for 10-14 days of teh cycle. May have withdrawl bleed upon cessation of progesterone.
What are the possible immediate side effects of HRT?
Signs of oestrogen excess (headache, breast tenderness, nausea)
What are the gynae systems questions?
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
What is the overall definitive management of menopause?
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
What are the other, “non-emotional” names for abortion and miscarriage?
spontaneous pregnancy loss
early pregnancy failure
how common are miscarriages?
20% of recognised pregnancies will end in pregnancy loss
What are the outcomes of bleeding in early pregnancy?
- 60% have ongoing pregnancy
- 30% have early pregnancy loss
- 9.5% have ectopic pregnancy
- 0.5% other
What is the other 0.5%?
S – subchorionic haemorrhage
T – trauma (vaginal)
I – Infection (STI/PID)
T – trophoblastic disease
C – cervical polyps or cancer
H – heterotopic pregnancy
Placenta – previa
How common is bleeding in early pregnancy??
15-20% of women will experience BEP
What investigations would you order for someone with bleeding in early pregnancy?
- 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
when is a tranvaginal ultrasound most reliable?
when is a transabdominal ultrasound most reliable?
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
at what GA is a transvaginal U/S usually 100% sensitive, for intra-uterine pregnancy?
ie. how early can you reliable tell if there is an intra-uterine preganncy?
5.5 weeks gestation
detection of heart beat also rules out non-viable pregnancy
how quickly does the B-HCG increase in a normal, viable, intra-uterine pregnancy (which you would use when requesting serial B-HCG)?
What might be a reason for the B-HCG increasing too quickly?
What might be a reason for the B-HCG not increasing quickly enough?
What might be a reason for fluctuating B-HCG?
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
What are the types of shock associated with bleeding in early pregnancy?
- 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
what are the most common sites of implantation in an ectopic pregnancy?
- fallopian tube (95%)
- ovaries (3%)
- peritoneum (1%)
what is a heterotopic pregnancy and when is it most common?
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)
what is the classic triad of the signs/symptoms ectopic pregnancy?
… and if it is more severe?
- amenorrhea
- irregular bleeding
- lower abdominal pain
if more severe:
- hypotension
- tacchycardia
- shoulder tip pain
How would you investigate for a suspected ectopic pregnancy?
- 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.
What are the three broad strokes of management for extopic pregnancies?
what might be required in ALL of these management options?
expectant management
surgical management
medical management
Regardless of treatment option, RCOG recommends anti-D for all non-isoimmunised Rhesus negative mothers.
describe the medical management of ectopic pregnancy?
- 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.
What is a salpingectomy and when may it be required?
Removal of fallopian tube.
In a ruptured / bleeding ectopic pregnancy.
What are the options for the surgical management of ectopic pregnancy? What do you need to monitor afterward? And what is a potential complication of this type of management?
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
how would you define recurrent miscarriage?
3 or more pregnancy losses
how do you define early pregnancy loss?
spontaenous loss of pregnancy before 20 weeks
how do you define chemical pregnancy?
what is the “opposite” of chemical pregnancy?
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)
at what gestational age can the gestational sac be viewed on ultrasound?
after 5 weeks
what is a complete miscarriage?
what is an incomplete miscarriage?
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.
What is an inevitable miscarrigae?
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.
What is threatened and missed miscarriage?
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
What is a septic miscarriage?
A miscarriage complicated by infection – can lead to PID, sepsis and death
What is an anembryonic pregnancy and what is it’s other name?
“Blighted ovum”
When a gestational sac forms but no embryo develops.
What is the risk of miscarriage in women with a negative history, once the foetal heart is detected?
How about if they have a history of miscarriage?
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.
How do you diagnose miscarriage in someone
with B-HCG
Falling levels or failure to rise 50% in 48 hours suggests an abnormal pregnancy.
how do you diagnose miscarriage in someone >5.5 weeks gestation?
TVUS
in broad brushstrokes, what are the types of management for miscarriage?
Expectant
OR
Medical
OR
Surgical
what is the surgical management of miscarriage?
Dilatation and suction curettage
what should you warn women post D&C?
- 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
what is the medical management of miscarriage?
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)
What is the mechanism of action of misoprostol?
It is a prostaglandin E1 analogue –> causes strong uterine contractions
What is the mechanism of action of mifepristone?
Progesterone antagonsist. Used to “prime” the uterus before misoprostol. Causes the embryo to detach and ripens the cervix.
Regardless of the type of management for miscarriage (medical, surgical, expectant), what else needs to be done in terms of management?
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
What are the possible causes of recurrent miscarraige?
Only investiagte after 3 miscarriages
What investigations are required prior to the surgical method of miscarriage?
- 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
In what type of miscarriage will expectant management be most successful?
How long might the process take?
When is expectant management no longer offered?
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.
What is Gestational Trophoblastic Disease?
A spectrum of placental tumours that arise from genetically abnormal embryos. GTD may be benign (most commonly) or rarely malignant.
How long should the second stage of labour take?
1 hour in multigravid women
2 hours in primigravid women
3 hours if having epidural
no longer than three hours
How long should the third stage of labour take?
No longer than 30 minutes
When is syntocin administered during normal labour?
After the anterior shoulder is delivered
How quickly should the cervix dilate in the first stage of labour?
1cm/hour during in multiparous women
2cm/hour in nuliparous women
How long should labour take, overall?
No longer than 8 hours in multiparous women
No longer than 12 hours in nulliparous women
what are the indications for IOL?
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
What are the risks of IOL?
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
What are the relative contraindications of IOL?
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.
what are the artifical ways in which we can “ripen” the cervix?
PGE2
Transcervical catheter
Stretch and sweep
When can a stretch and sweep be performed?
post dates ie. > 40 weeks
what is the preferred method of cervical ripening in a woman requiring / requesting a VBAC?
Transcervical foley catheter
What tool is used to assess how “ripe” the cervix is? What are it’s components?
What do the scores indicate?
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
How would you proceed with IOL in a woman who has a Bishop’s Score of 10?
Favourable cervix
Most likely AROM + syntocin
how would you proceed with IOL in a woman with a modified bishops score of 4?
Unfavourable cervix.
Most likely PGE2 or transcervical catheter (the latter if VBAC)
If a woman has had PROM or PPROM and you are inducing labour, what do you use?
“In term PROM or PPROM, either PGE2 or an oxytocin infusion are acceptable, regardless of cervical status, as they are equally effective”
What action should be taken in the case of cord prolapse?
Push and hold the cord back into the pelvis, and put mother into the trendelenberg position
when can you give syntocinon after prostaglandins?
>6 hours post
if a woman’s membranes are intact, what is required prior to the administration of syntocinon?
AROM
what is a definite prerequisiute before you perform AROM and why?
the baby’s head must be fixed and engaged, otherwise may
–> cord prolapse
What is a specific indication for ARM, other than the other indications for IOL?
If you need to take scalp lactate
what are some specific risks of syntocinon?
hyponatraemia and oedema (because oxytocin is similar in structure to ADH)
what are some specific risks of PGE2
tachysystole and uterine rupture if previous uterine surgery
what else is usually done in the case of instrumental delivery?
episiotomy
When would you choose forceps instead of vaccuum delivery?
Face presentation
Bleeding from skull
How many C-sections may a woman have previously had, whilst still being able to have a VBAC?
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
What are the prerequisites for the use of forceps?
Fully Diated Cervix
Fully dilated cervix
OA position (ideal)
Ruptured membranes
Contractions/catheter
Episiotomy and epidural
Presentation: cephalic
Station: Spines or below (0 or
what is the other medical term for rupture of membranes?
amniorrhexis
what proportion of women in term PROM spontaneously go into labour in 24 hours?
90%
How common is term PROM?
It occurs in 10% of all pregnancies
define prolonged rupture of membranes
when a woman doesn’t go in to labour before 24 hours after her membranes have ruptutred
how common is PPROM?
occurs in 1-3% of all pregnancies
What proportion of women in PPROM go in to spontaneous labour in 24 hours?
50%
how do you “Investigate and confirm a diagnosis” of PROM (either pre-term or term)?
What shouldn’t you do?
And what can you do it you’re uncertain?
- 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
what are the risks of prelabour rupture of membranes?
maternal infection
foetal infection
cord prolapse
placental abruption
Describe the management of Term PROM?
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
- SAM BLACK
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?
what extra investgations do you need to do if you suspect PPROM?
- Collect cervico-vaginal swabs for microscopy and culture (Chlamydia trachomatis and Neisseria gonorrhoeae)
- Collect low vaginal and ano-rectal swabs for GBS
What extra compnonents of definitive management apply for PPROM (compared to just term PROM)?
Give antenatal steroids
Erythromycin should be given for (250mg po 6 hourly for 10 days) following the diagnosis of PPROM
Describe the differing definitive management of PPROM depending on GA?
- consider termination OR expectant management
- 24-34 weeks gestation
- expectant management (unless complication for foetus or mother)
- 34 weeks gestation
- active management
Is there a role for tocolysis to delay the onset of labour, in the case of PROM?
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
What are the three major causes of antepartum haemorrhage?
- placenta previa
- placental abruption
- vasa previa
what is the risk of miscarriage in CVS?
1/100
what is the risk of miscarriage with amniocentesis?
1/200 (half of that of CVS)
at what GA week can you perform CVS?
10-14 weeks
at what GA can you perform amniocentesis?
> 15 weeks
what are the outcomes to mother and foetus of failure of trophoblastic invasion (at 20 weeks which usually causes vasdilation of uterine arteries)?
- maternal blood pressure - Gestational HT (increased blood volume, no drop in perippheral vascular resitance due to uterine artery dilation)
- endothelial dysfunction of materal kidneys - Pre-eclampsia (proteinuria, oedema)
- endothelial dysfunction of maternal liver - HELLP syndrome
- endothelial dysfunction of maternal brain - liver
5. placental abruption
6. IUGR
Why is placental abruption dangerous?
Mother can lose large amounts of blood
+
The bleeding can be concealed (may not have PV bleeding)
What proprortion of mothers with placental abruption present with PV bleeding?
2/3
1/3 of women don’t have any PV bleeding! The bleeding is concealed and they are bleeding into their uterus.
of the causes of antepartum haemorrhage, which are maternal blood loss and which are foetal blood loss?
- placenta previa and abruption - maternal blood loss
- vasa previa - foetal blood loss
what is involved in the first trimester screeing?
aka ‘triple test’ as it involves maternal serum screening (looking for PAPP-A and free B-HCG) + an ultrasound which looks for nuchal translucency.
what is involved in second trimester screening?
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)
what does first trimester screening screen for?
what does second timester screening screen for?
- Trisomy 21 (Downs Syndrome) and Trisomy 18 (Edwards Syndrome)
- As above + neural tube defects - however the 20 week ultrasound is more reliable for this, anyway
In the first trimester screening, what results would increase the risk of trisomy 21? what results would increase the risk of trisomy 18?
- 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)
What results would you expect on the second trimester screening test for the abnormailites which it is testing for?
Trisomy 21 - Increased B-HCG and inhibin, reduced estriol and AFP
Trisomy 18 - reduced all of them
NTDs - increased AFP
compare and contrast first and second trimester screening tests?
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)
what is an alternative screening option to first and second trimester screening?
Non Invasive Perinatal Screening (NIPS) aka “percept”
A blood test looking at foetal cells in the maternal circulation
Newer test - expensive (over $400 AUD)
when can you undergo first trimester screening?
Maternal Serum Screening - 10/40
U/S - 12/40
when can you undergo second trimester screening?
14 - 20 weeks
when can you have amniocentesis?
15/40 or later
when can you perform CVS?
12-13 / 40
how do you define antepartum haemorrhage (versus bleeding in eraly pregnancy)?
APH = bleeding after 20 weeks
BEP = bleeding before 20 weeks
what are the major causes of -
- bleeding in early pregnancy
- antepartum haemorrhage
- post partum haemorrhage
- miscarriage, ectopic pregnancy
- placental abruption, placenta previa, vasa previa
- uterine atony
What clinical findings (signs or symptoms) may be evident in a woman with placental abruption?
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
what are the risk factors for placental abruption?
CV risk factors (HT, DM, hyperlipidaemia)
Trauma
Sudden uterine decompression - following ROM or delivery of the first twin
Chorionamnitis
how do you diagnose placental abruption?
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!
what is a major clinical difference in terms of symptoms between placenta previa and placental abruption?
placenta previa is usally painless PV bleeding, placental aburption is painful
What is the general management of all antepartum haemorrhage?
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
what are the complications of placental abruption?
- 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
what is the dosage of antenatal steroids which should be given?
Two doses of 12 mg IM betamethasone, given 24 hours apart
OR
Four doses of 6mg IM dexamethasone, given 12 hours apart
Define a major versus a minor placenta previa?
major = covering the os
minor = within 2-3 cm of the os
when is placenta previa usually diagnosed?
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
Majority of women with placenta previa will have been diagnosed with a low lying placenta at the 20 week scan.
When else should placenta previa be investigated for / excluded, irrespective of U/S reuslts?
- PV bleeding after 20 weeks especially if associated with:
- abnormal lie
- high presenting part
what proportion of pregnancies have a low lying placenta?
what proportion have placenta previa?
5%
0.5%
(most migrate)
what should you tell a woman who has been diagnosed with a low lying placenta?
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
compare and contrast the clinical and examination findings of placenta previa and placental abruption?
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
if a woman is diagnosed with a low lying placenta at 20 weeks, what is the management?
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
what is placenta accreta, increta and perceta?
Why are these potentially dangerous?
When are they diagnosed?
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.
what are the 10 Ps of post natal complications?
- Pain
- Perineum
- Pissing
- Pooing
- PPH
- PreEclampsia / GDM
- PE / DVT
- Pyrexia (mastitis, endometritis)
- Psych
- Protection
What are your differentials for post-partum fever?
Causes of Post-Op Fever
- Wound
- Wind (atelectasis)
- Water (IV lines)
- Walking (DVT / PE)
- Wonder drugs
- Whizz (UTI)
Pregnancy Specific
- Mastitis
- Endometritis
What Ix would you perform for endometritis / post-partum genital-tract sepsis?
FBE
U&Es
High vaginal swab
Pelvic ultrasound for retained products
What are the best choices of contraception post-partum?
What are not good choices?
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
Define primary and secondary post partum haemorrhage?
Primary
•Occurs in the first 24 hours after delivery
Secondary
•Occurs after 24hrs and before 6 weeks after pregnancy (end of post-partum period)
What are the causes of primary PPH?
- Tone (uterine atony)
- Trauma (uterine rupture, laceration)
- Tissue (retained products)
- Thrombin (coagulopathy)
what is used in the Rx of uterine atony?
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
how do you organise your thoughts around the types of contraception?
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
- Oestrogen + Proggesterone
- Emergency
- Mifepristol (RU486)
- Copper IUD
- Levonorgestrel
what drug is implanon?
how effective is it?
what is it’s effects on menses?
how long can it stay in for?
what tests should be performed prior to insertion?
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
What are the relative contraindications to contraception?
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
When is implanon contraindication?
Breast Cancer
But use with caution and explain all possible risks to patients with “HOMESICKL”
what are the progesteronic side effects?
HAIL M
Hirsuitism
Acne + Apetite Increase / Weight Gain
Irregular bleeding
Loss of libido
Mood swings
(Think: progesterone is a hormone of pregnancy)
what needs to be done prior to mirena insertion?
how long can it be left in for?
can it be used in nulliparous women?
- pap semar normal and up to date
- chlamydia screen negative
- B HCG negative
Can be left in for 5 years
Yes, it can be used but usually requires insertion by specialist in Australia
What are the risks of IUDs?
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
How often do you have to have the depot-provera?
every 3 months
what are some indications for the COCP?
Contraception
Acne
Dysmenorrhea
Menorrhagia
Endometriosis
what are some specific medical conditions in which the COCP will not be efficacious?
IBD (CD & UC)
Gastroenteritis (Diarrhoea & Vomitting)
What are the options of emergency contraception, and their efficacy?
Briefly describe their AE?
At what time frames can each be used?
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
What should also be discussed if a patient attends a clinic for emergency contraception?
- Counselling RE adequate, ongoing contraception
- Offer an STI screen, education if required RE barrier protection from STIs
- Ascertain if the sex was consensual-non consensual
- Discuss pap smears
- Abortion if emergency contraception fails
If a woman had unprotected sex 4 days ago and is seeking emergency contraception, what can be offered?
Copper IUD
Mifepristone RU486
If a woman had unprotected sex 12 hours ago and is seeking emergency contraception, what could be offered?
LNG
Yupze Method (although less effective than levonorgesterl)
Copper IUD
RU486
Describe how you would counsel someone who wanted to start the OCP?
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
- Long acting
Conclusion: Check understanding, offer written information, gain informed consent
What is another name for a hydatidiform mole?
molar pregnancy
What is GTD and what is a hydatidiform mole?
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.
bleeding in early pregnancy + haemodynamic instability = ?
RUPTURED ECTOPIC PREGNANCY UNTIL PROVEN OTHERWISE
don’t waste time, straight to Rx
May not get time for all Ix
