Lists

Question 1

Signs of hyperprolactinaemia may include:

Answer 1

Reduced libido and arousal
Gynaecomastia
Menstrual irregularities
Amenorrhoea, and
Galactorrhoea.

Question 2

Capgras syndrome?

Answer 2

people have been replaced by exact copies of themselves.

Question 3

Ganser Syndrome?

Answer 3

Feigns insanity by giving nonsense answers

Question 4

Othello Syndrome?

Answer 4

Irrational belief partner is cheating

Question 5

Broad features of AN?

Answer 5

Phobic avoidance of normal weight
Relentless dieting
Self-induced vomiting
Laxative use
Excessive exercise
Amenorrhoea
Lanugo hair
Hypotension
Denial
Concealment
Over-perception of body image
Enmeshed families.

Question 6

Features of Edwards and Patau’s (18 and 13 respectively). Which are common to both, and which are different?

Answer 6

Patau syndrome is associated with:

microcephaly
mental retardation
microphthalmia
cleft lip and palate
polydactyly
rocker-botttom feet, and
congenital heart defects. 

Edwards syndrome is associated with:

mental retardation
microphthalmia
prominent occiput
low-set ears
rocker-bottom feet
flexion deformities of the hands, and
complex congenital heart defects.

Common to both: 
Mental retard
Cardiac defects
rocker bottom feet 
Microphthalmia

Question 7

When are NSAID’s prefered over TXA for menorrhagia?

Answer 7

If there is pain.

Question 8

Considerations with a woman with epilepsy and the baby?

Answer 8

May need to increase antiepileptic during preg as plasma levels fall.

Lamotrigine is the preferred, however we cannot say conclusively it has no side effects. However, there is probably more risk of switching during preg due to risk of seizures.

Need to supplement folate with this, and give vitamin k the month before labour.

Screening with AFP and second trimester needed. (neural tube)

Question 9

Epidurals and PPH?

Answer 9

Nil association

Question 10

Explain aspirin poisoning and it’s metabolic effects (not inc. Reye’s)

Answer 10

Phase 1 involves a respiratory alkalosis due to respiratory stimulation and urinary loss of sodium and potassium
Phase 2 involves acidosis due to urinary exchange of H for K (a paradoxical aciduria) despite a respiratory alkalosis
Phase 3 involves a metabolic acidosis due to accumulation of metabolic acids and dehydration.

Question 11

When do most paeds cardiac defect deaths occur?

Answer 11

<1 year old

Question 12

Which oral hypoglycaemic is continued in preg?

Answer 12

Diabetes in pregnancy is associated with an increased risk of fetal malformation and pregnancy-related complications. Most oral hypoglycaemic drugs should be stopped, but metformin can be continued as its benefits outweigh the risks of treatment. Treatment should be supplemented with insulin to obtain a target HbA1c <43 mmol/mol (6.1%).

Diabetes related medications which are probably safe in pregnancy include:

Metformin
Isophane (NPH) insulin
Short acting insulin analogues, such as aspart and lispro.
Many medications have insufficient safety data to be used routinely in pregnancy.

Diabetes related medications which should be avoided in pregnancy include:

All other oral hypoglycaemic drugs, such as gliclazide, pioglitazone and DPP-IV inhibitors
Long acting insulin analogues such as glargine and detemir
Injectable drugs such as exenatide or liraglutide
Statins
ACE-inhibitors.

Question 13

Antiphospholipid syndrome ab’s?

Answer 13

Anticardiolipin

Question 14

manage aspirin poisoning?

Answer 14

Treatment of children with salicylate poisoning includes ABC as required.

Gastric lavage is required.

Blood levels are often misleading especially if enteric coated tablets have been taken.

It is important to monitor the urine volume and pH at all times.

A forced alkaline diuresis is induced with a bicarbonate infusion.

Correction of dehydration and maintenance is calculated with haemodialysis in severe cases.

In the event of a coagulopathy vitamin K administration may be necessary.

Question 15

Do twins incidence increasing with maternal age?

Answer 15

Dizygotes only

Question 16

List some things increasing in incidence with maternal age?

Answer 16

Increasing maternal age sees an increase in:

Hypertension
Pre-eclampsia
Diabetes, and
Caesarean section rates.
In addition, the risk of miscarriage, ectopic pregnancy, and chromosomal abnormalities increases with maternal age.

In the confidential enquiry into maternal deaths (CEMD) between 1997-1999, maternal mortality more than doubled in women >35 years of age compared to those <30-years-old.

There is an increase in dizygotic twins with increasing maternal age.

Question 17

Please discuss the mechanism of citalopram

Answer 17

An SSRI

Block SERT at presynaptic terminal to increase 5-HT at the synaptic cleft.

This increases post synpatic response to serotonin. However, by activating autoreceptors on the presynaptic cleft, it can lead to negative feedback, thus worsening the symptoms iniitally. However, these downregulate eventually, and the response improves.

Note this mechanism is the same for tolerance, except observed on the post synaptic membrane

Question 18

What is atrophic triginitis? What othet atophic itis’ are there in this condition?

Answer 18

Trigone of the bladder. Also vagnitis and uretheritis

Question 19

Substances causing oxidative crises in patients with G6PD

Answer 19

Nitrofurantoin, Fava beans, antimalarials

Question 20

Symptoms of a macroadenoma?

Answer 20

Headache
Features of raised intracranial pressure
Visual disturbance
Bitemporal hemianopia
Suppression of other pituitary functions.

Remember it compresses the cavernous sinus i.e. nerves 3,4,6

Question 21

Familial Mediterranean Fever

Answer 21

This boy has recurrent episodes of abdominal pain, fever and arthritis. There is hepatomegaly. All these point to familial Mediterranean fever.

If you didn’t get this, you have ligma

Question 22

Antibiotics for pertussis? Why would you give these?

Answer 22

Consider antibiotics if:

Diagnosed in catarrhal or early paroxysmal phase (may reduce severity)
Cough for less than 14 days (may reduce spread; reduces school exclusion period)
Admitted to hospital
Complications (pneumonia, cyanosis, apnoea)
Antibiotic options:

Neonates
Azithromycin 10 mg/kg oral daily for 5 days
Children who cannot swallow tablets:
Clarithromycin liquid 7.5 mg/kg/dose (max 500mg) oral BD for 7 days
Children who can swallow tablets:
Azithromycin (for children = 6 months old): 10mg/kg (max 500 mg) oral on day 1, then 5mg/kg (max 250mg) daily for 4 days
If macrolides are contraindicated:
Trimethoprim-sulphamethoxazole (8mg-40mg per ml)
0.5ml/kg (max 20ml) BD for 7 days

Question 23

Antibodies in coeliac? What other chronic diseases does it increase the risk of?

Answer 23

Antibodies in coeliac are anti-TTG and anti-gliadin antibodies. Also Anti-EMA but they don’t contribute to the disease process.

Chronic diseases are T cell lymphomas and small bowel cancers.

Question 24

Intellectual disability has a wide differential, and causes can be divided into prenatal, perinatal and postnatal. Please list the ddx.

Answer 24

Over half are caused by factors prenatally, others by factors perinatally,
and some postnatally.
PRENATAL:
- Chromosomal Down’s syn, Fragile X syn, VCF syn)
- Genetic  tuberous sclerosis, metabolic disorder (e.g. PKU)
- Syndromes  e.g. William’s syn, Prader-Willi syn
- Infections  rubella virus, CMV
- Drugs, toxins  excessive alcohol
- Major structural abnormalities of the brain

PERINATAL FACTORS:
- Lack of oygen (hypoxia)
- Trauma
- Infections
- Biochemical abnormalities, e.g. hypoglycaemia
- Children with LBW are at increased risk of having these
complications after birth

POSTNATAL FACTORS:
- Head injuries MVA, near-miss drowning accidents
- Infections such as meningitis and encephalitis
- Poisons
- For mild ID the cause is often not known, although it may be
caused by any of the factors listed previously

Also, must be noted that other causes of learning difficulties include:

• hypothyroidism and diabetes
• Dyslexia, ADHD, Down’s Syndrome, Fragile X, Tuberous Sclerosis, ASD, FASD, Absence Epilepsy

Also hearing and vision difficulties can present this way. Consider causes of deafness such as neurofibromatosis

Question 25

The risks of childhood obesity? Aside from sustaining obesity into adulthood and thus getting those risks.

Answer 25

Increasing risk of type 2 diabetes mellitus (T2DM) Slipped femoral epiphysis Behavioural problems (including truancy) Depression (not schizophrenia).

Question 26

Features of a congenital CMV infection pls

Answer 26

Microcephaly, seizures, neonatal jaundice, hepatosplenomegaly, deafness and mental retardation are some of the features that may occur. Note the seizures are from the intracranial calcifications.

Question 27

Complications of measles:

Answer 27

The prodromal stage fever conjunctivitis, runny nose and coughing lasts for five days. Koplik's spots are bright red lesions with a central white dot which appear on the buccal mucosa. These are virtually diagnostic. The typical macular confluent rash appears on the face from days three to five and spreads to the rest of the body. Diagnosis is made from clinical features, viral culture from lesions and a greater than fourfold rise in antibody titres. Otitis media, pneumonia, meningitis and very rarely several years after primary infection subacute sclerosing panencephalitis (SSPE).

Question 28

Features of lead poisoning?

Answer 28

``` Anorexia Hyperirritability General apathy Vomiting Colicky abdominal pain, and Constipation. ``` Anaemia may be present, and there may be a history of developmental regression. The anaemia may be normocytic (due to haemolysis) or microcytic. Megaloblastic anaemia is one where there is increased numbers of lobes of granulocyte nuclei - this is specific to B12 or folate, whereas the macrocytosis caused by sideroblastic anaemia would be a macrocytosis without megaloblastosis. Lead poisoning per se can cause a hypochromic microcytic anaemia. But lead can also cause an acquired sideroblastic anaemia, which is normo- or macro-cytic. Note that congenital sideroblastic anaemia is normo- or micro-cytic. Neurological symptoms include behavioural problems, seizures and ataxia. At levels greater than 100 renal tubular dysfunction can occur. At significant exposure levels, lead can act as an enzyme inhibitor to delta amino levulinic acid dehydratase, which causes a fall in serum delta amino levulinic acid levels.

Question 29

Hypertrophic scar vs keloid

Answer 29

Hypertrophic is a raised scar that is painles and raised, and occurs relatively soon after surg. However, it goes away.

Question 30

Compartment syndrome: which occurs later: sensory or motor loss? Why do you know this?

Answer 30

Sensory. Cramps you get from prolonged sitting. Also motor is more heavily myelinated than spinothalamic.

Question 31

When does atopic eczema usually start?

Answer 31

First year of life

Question 32

Aside from topical steroids, what are some treatments for eczema?

Answer 32

Frequent bathing and hydrating of the skin avoiding strong soaps, and the liberal use of moisturisers and lubricants are first line treatments.

Question 33

Clinical features of a small VSD? What about large?

Answer 33

Small VSDs are associated with: Physiological splitting of S2 (S2 split during inspiration only; considered normal). Fixed splitting of S2 is associated with atrial septal defects and some larger VSDs Harsh pansystolic murmur heard loudest at the lower left sternal edge Normal growth and development, and No cyanosis. Large VSDs are associated with: Poor neonatal weight gain Congestive cardiac failure which can manifest initially as mild tachycardia, mild breathlessness and hepatomegaly Palpable thrill Harsh pansystolic murmur heard loudest at the lower left sternal edge There may also be a mid-diastolic rumbling murmur of functional mitral stenosis when occurs when the shunt (L to R) is large. This effect is caused by the increased blood flow through the left atrium. No cyanosis initially, although when the shunt reverses (R to L; Eisenmenger syndrome) cyanosis can occur.

Question 34

Comment on the risk of infective endocarditis in VSD

Answer 34

Increased risk

Question 35

Causes of croup pls

Answer 35

Causative viruses are parainfluenza (types 1,2,or 3), respiratory syncytial viruses and measles virus.

Question 36

Complications of paeds iron overdoses? What is the chelator

Answer 36

Perf of intestines, secondary pyloric stenosis, hepatic necrosis Note that when the iron is absorbed into liver mitochondria, they seem to improve. they will deteriorate again. Treatment relies on the administration of desferrioxamine parenterally and supportive treatment. Gastric lavage is no longer used as iron tablets are large and sticky therefore it is unlikely to be of benefit.

Question 37

Side effects of phenytoin pls. What about valproic acid?

Answer 37

Drug induced SLE, gingivial hyperplasia, hisutism, generalised lymphadenopathy Haematological side effects are: ``` Megaloblastic anaemia Aplastic anaemia Thrombocytopenia, and Agranulocytosis. Neurological side effects include peripheral neuropathy and ataxia. In rare cases side effects may also include nystagmus and dyskinesias. ``` Eye involvement may occur in cases of overdosages; these include blurred vision and nystagmus. Valproate: Alopecia, thrombocytopaenia, hepatotoxicity, pancreatitis (PATH) https://mynotes4usmle.tumblr.com/post/76290241381/neuro-pharmacology-remember#.W-C-S_kzaHs

Question 38

Foetal and Maternal complications of GDM

Answer 38

Foetal: ```  Birth trauma (obstructed vaginal delivery)  increased need for c-section  Macrosomia, organomegaly, polycythaemia, jaundice  Hyperinsulinaemia  Shoulder dystocia  Neonatal hypoglycaemia  Increased need for premature delivery  ARDS  Increased need to c-section  IUFD  LONG-TERM  impaired glucose tolerance, T2DM, obesity ``` ``` Maternal Miscarriage  Preeclampsia  Infection  Induction of labour  Trauma  C-section  PPH  Increased risk of T2DM + HTN  Increased risk of hypoglycaemia ```

Question 39

Stridor DDX

Answer 39

Laryngomalacia, tracheomalacia, epiglottitis, croup, foreign body aspiration, anaphylaxis, subglottal stenosis (previous intubation), haemangioma, laryngeal web, vocal cord paraylysis, GOR, hypocalcaemia (laryngeal tetany). Other less common causes in older kids include bacterial tracheitis, severe tonsilitis, inhalation of hot gases in a fire, and retropharyngeal abscesses

Question 40

FAp extracolonic manifestations

Answer 40

FAP * Extracolonic manifestations: o Osteoma – o Desmoid tumours: mesenteric strangulation is an issue (in abdo wall or small bowel mesentry) * Abdosurgery speeds up growth o Gastroduodenal polyps – 5% develop fatal duodenal cancer * Upper GIT scope from 20 – 5 yearly o Retinal pigmentation (Congenital hypertrophy of the retinal pigment epithelium) * Give total colectomy and ileorectal anastomosis à need to monitor 6 monthly rectal polyps o Rectal cancer risk is 15% at 15 years and may develop despite surveillance, low cx rate and good bowel function Restorative proctocolectomy and ileal pouch-anal anastomosis à eliminates risk of cancer but morbidity is worse

Question 41

Surgical Complicatiosn Unique to a herniaraphy

Answer 41

Surgical complications o Urinary retention o Scrotal swelling and haematomaà oedema, swelling, bruisesà resolve o Wound infectionà removal or mesh and Abs o Recurrent hernia à 2% o Nerve injury- ilioinguinal nerve (lateral cutaneous nerve to thingh in femoral) o Persiting pain – nerve entrapment, neuroma, osteitis pubis if sutures inserted in pubic tubercle, pressure on cord o Testicular iscahemia and atrophy- testicular artery comprimsied o Hydrocele * Laparoscopic technique may not be successful à open * Damage to large blood vessels, gut or bladder * Gas used in laproscopy can result in heart and lung complications: rare * Testicular and scrotal swelling/bruising * Damage to vas deferens * Adhesions * Recurrence of hernias or hernia formation at incision sites * Visceral injury – viscera sliding hernia when sac is being dissected away from them

Question 42

Toxic megacolon cause

Answer 42

- Inflammatory bowel disease (ulcerative colitis > Crohn’s disease)
 - Infectious colitis o Bacterial: C. difficile, Salmonella, Shigella, Campylobacter o Viral: Cytomegalovirus o Parasitic: Enterobacter histolytica - Triggers: hypokalemia, constipating agents (opioids, antidepressants, loperamide, anticholinergics), barium enema, colonoscopy

Question 43

Management steps for pilonidal disease?

Answer 43

Conservative, I&D, and cystotomy

Question 44

Types of rectal prolapse?

Answer 44

Type one and two. One is just the mucosa protruding past the external anal sphincter. This is more common in children. Two is complete, and involves the full thickness of the wall. and is broken up like this: First degree: Prolapse includes the mucocutaneous junction. 2nd: Without involvement of the mucocutaneous junction 3rd: Prolapse is internal, concealed or occult. This is otherwise known as an internal intussusception.

Question 45

Management of rectal prolapse?

Answer 45

- Type I o Conservative: gentle manual reduction of prolapsed area, especially in children o Mucosectomy with excision of redundant mucosa, mostly in adults - Type II o Conservative: reduce if possible o Surgery: Removal of segment of bowel and remaining bowel is sutured to the pelvic bone  Can be abdominal, laparoscopic, perineal (through the anus), trans sacral approaches  In general, a transabdominal repair is used for younger patients and a perineal repair for the elderly and frail patients. A full mechanical bowel preparation and parenteral antibiotic prophylaxis are essential for minimising septic complications.  Abdominal approach: rectoplexy (Ripstein operation) • + sigmoid resection (as redundant) is the Frykman-Goldber operation • SEPSIS RATE HIGHER BUT CONSTIPATION LOWER DUE TO NO KINKING AS IN IN RIPSTEIN  Perineal approach: perineal proctosigmoidectomy: Altemeier operation UNDER GA OR REGIONAL. In jack-knife position, circumfrential incision 1cm above dentate line. Prolapsed rectum is unfolded and redundant resected and mesorectum is ligated and divided to deliver through opening. Coloanal anastgomosis

Question 46

Diff between a high and low perianal fistula and how they are managed:

Answer 46

A high is above the anorectal ring and usually indicates more serious pathology. A low is usually idiopathic and has a less serious aetiology. • Low fistula o The mainstay of treatment is to identify the internal and external openings and to ‘lay open’ the intervening track by fistulotomy. This allows the track to heal by secondary intention. Special assessment of the adequacy of the sphincter mechanism should be considered in females who have had several vaginal deliveries because occult injuries to the anal sphincters and pudendal nerve may already be present. • High fistula: Fistulotomy is contraindicated if the internal opening is above the levator mechanism division would cause incontinence o Caution should be exercised when more than one-third of the external anal sphincter needs to be divided o Instead insert a seton between the two openings: silk or silastic tubing is railroaded into the track and loosely tied. The seton may act as a drain and if it is progressively tightened it may gradually divide the muscle while allowing it to heal by fibrous tissue formation. Alternatively, the seton downstages the sepsis and facilitates subsequent repair of the fistula with an advancement rectal flap. Occasionally, with more complex fistulas, a proximal stoma is constructed to divert the faecal stream, in addition to other local surgical manoeuvres.

Question 47

types of perianal fistulae?

Answer 47

Intersphincteric transsphinteric suprasphincteric Extrasphicteric

Question 48

What are some risk factors for gallstones you learnt today?

Answer 48

Terminal ileum dmaage, weight loss (learnt why: rapid weight loss leads to excess mobilisation of cholesterol and biliary stassis), TPN (due to impaired gallbladder emptying). I would also imagine dehydration is a risk factor. Remember oestrogen slows the transit of bile in the biliary system which is the pathogenesis of cholestasis in pregnancy.

Question 49

Hepatocystic triangle vs Calot's triangle. What lies within Calot's triangle?

Answer 49

Hepatocystic triangle is the one that has the free inferior border of the liver, the common hepatic duct, and the cystic duct. The Calot's triangle replaces the cystic artery with the inferior free border of the liver. Also note that Lund's node is contained within Calot's triangle, and it's commonly inflamed in cholecystitis.

Question 50

What is Hartmann's Pocuh

Answer 50

This is the junction of the neck of the gallbladder and the cystic duck. THis is where stones fall to be stuck.

Question 51

Organisms in Cholecystitis if gets infected? Why does it get well localisedsomatic pain?

Answer 51

Organisms are e. coli (commonest), then klebsiella, then strep faecalis. It's localised when it touches the peritoneum.

Question 52

What is Boas' sign?

Answer 52

Right subscapular pain

Question 53

Two new complications of cholecystitis?

Answer 53

Phlegmon: when the gall bladder, bowel, and omentum adhere. Mucocoele: long term cystic duct obstruction results in a mucinous accumulation of fluid in the gallbladder.

Question 54

Why would you do a hida scan?

Answer 54

If the USS for cholecystitis is negative. Positive result is no dye being taken up into the gallbladder.

Question 55

Patient isn't going to tolerate a general and a cholecystectomy. How can we approach this?

Answer 55

Percutaneous cholecystostomy is an image-guided placement of drainage catheter into gallbladder lumen. This minimally invasive procedure can aid the stabilisation of a patient to enable a more measured surgical approach with time for therapeutic planning.

Question 56

The patient has a post operative fever,and pain in the RUQ after a cholecystectomy. What is the diagnosis unitl proven otherwise?

Answer 56

Bile duct injury

Question 57

What is post cholecystectomy syndrome?

Answer 57

Sphincter of Oddi dysfunction. It's a persistence or recurrence of pain after the cholecystectomy. Alternative explanations include post op adhesions.

Question 58

Pre operative consideration unique to biliary tract disease?

Answer 58

Vitamin K supplementation or FFP if the need is urgent.

Question 59

Causes of idiopathic pancreatitis?

Answer 59

Pancreatic divisum, microlithiasis/ sludge, stricture lesions

Question 60

Role of USS and CT in pancreatitis?

Answer 60

Role of US is to rule out gallstones, and is commonly used in the first episode of pancreatitis. CT is to assess any complications such as a pseudocyst and to measure the extent of the necrosis. CT best done around the 72 hour mark otherwise it's known to underestimate the extent of the disease.

Question 61

Pancreatitis can be diagnosed with 2/3 of these features

Answer 61

Persistent epigastric pain Elevated panc enzymes 3x normal Radiologic findings consistent with pancreatitis. CT is better than US for this, but US will tell us the aetiology if it's gallstones.

Question 62

how do we divide the management of acute pancreatitis? Describe the steps involved?

Answer 62

→ Treatment with acute pancreatitis is directed four ways: general, local, complications and cause - General o Treat fluid loss • If severe: careful fluid replacement with central venous pressure measurement may be necessary • Monitor urine output: IDC o Oxygen, Analgesia o PPI o AWS, thiamine o NBM o Nutrition- initially fast the patient, enteral nutrition has now been shown to prevent mucosal barrier breakdown and abscess formation → NG feeds if severe - Local o There is no specific treatment for the pancreatic inflammation • Therefore treatment is directed at minimising the progression of the disease and preventing complications o Antibiotics: imipenem • Only if they have an infection, not just because they are febrile • Prophylaxis not shown to be effective o ERCP • Early ERCP (<72 hours) versus conservative management extensively studies • Benefit in cholangitis and obstructive jaundice but there has been conflicting evidence in the remainder of acute pancreatitis o Laparoscopic cholecystectomy recommended during same admission for all groups o Necrosectomy • Indications • Infected necrosis with septic complications • Sterile necrosis with progressive deterioration • Surgical intervention within first 2 weeks carries high mortality - Complications o Surgical intervention in pancreatitis is reserved for the treatment of complications and in gallstone pancreatitis for the treatment of the cause o Severe pancreatitis with infected necrosis: Debriding necrosed tissue necessary • As seen on a CT or the presence of organisms in tissue that as been aspirated from the pancreas following a percutaneous radiologically guided needle approach o Pseudocysts: treated via percutaneous or endoscopic techniques or open surgery o Abscess drainage → percutaneous or open - Cause o Gallstones: Cholecystectomy, ERCP

Question 63

There are some procedures for the spleen: splenoraphy, arterial embolisation, a partial or total splenectomy, or even bed rest 9grade of laceration + 1 day). What are some indications for a total splenectomy?

Answer 63

``` Hereditary spherocytosis ITP (particularly if it responded to IVIG) Intractable haemorrhage Splenic vein thrombosis Hereditary spherocytosis ```

Question 64

Blood supply of the thyroid gland

Answer 64

Superior thyroid artery is from the external cartoid, the inferior thyroid artery is from the subclavian artery.

Question 65

What are struma ovarrii?

Answer 65

Literally goitre of the ovary. Cause of hyperthyroidism.

Question 66

Surgical indications for Grave's disease? Other causes of hyperthyroid?

Answer 66

Relapse following initial medical management Non compliance with treatment Ophthalmopathy Other causes of hyperthyroid such as adenomas and TMNG are best treated with a thyroidectomy (hemi, sub total, or complete) after having their thyroid function stabilised initially.

Question 67

Discuss the treatment of hyperthyroidism with PTU or carbimazole? What are the side effects, and how long do we treat for? Why is carbimazole prefered?

Answer 67

It's used until we get remission. Usually about 6-18 months. Major side effects include hepatitis, agranulocytosis and fever. It can cause a rash. Prefered Carbimazole because it's longer duration of action, more rapid effect and lower incidence of side effects

Question 68

After remission, what's the follow up for thyroid treatment? Additionally, how do we manage opthalmopathy

Answer 68

Follow up after ceasing antithyroid is 1,2,3,6 months and then annualy after that. To treat ophthalmopathy, cease smoking, prevent drying, high dose pred in severe, and consider surgical decompression.

Question 69

Which cancer does TMNG increase risk of?

Answer 69

Follicular. This is not the most common: papillary is. It goes papillary, follicular, medullary, anaplastic. Of course, the other type is lymphoma, and this is usually if there is an underlying Hashimoto's in the patient as well.

Question 70

Commonest solitary nodule of thyroid?

Answer 70

TMNG

Question 71

Indications for surgery of a TMNG?

Answer 71

- Indications for surgical treatment of a multinodular goitre include the presence of obstructive symptoms, thyrotoxicosis, suspicious or malignant changes on FNAC, a strong family history of thyroid cancer, the presence of retrosternal extension, or a past history of head and neck irradiation - surgery is undertaken, total thyroidectomy is the preferred option, because it removes all tissue likely to cause symptoms and avoids the possibility of later recurrence, which is of the order of 30%. Lifelong thyroxine replacement is required after total thyroidectomy

Question 72

Two ways to manage thyroid cancer? How does the management change when it's medulary?

Answer 72

One way is to do a total thyroidectomy and follow up with a radioactive iodine ablation to remove chance of mets. The second way is to do a lobectomy, and this can only be done in young, healthy guys with a small papillary carcinoma. That is for papillary and follicular. For the medullary, we do a total thyroidectomy and we also do a central node dissectio, lateral neck dissection, and mediastinal clearance if they have positive nodal involvement. Medullary carcinoma does not respond to the radioiodine ablation, and so we need to manage it like this.

Question 73

Describe the ddx if we see a thyroid nodule?

Answer 73

Aside from a cancer, dominant nodule in TMNG, simple thyroid cyst, colloid cyst, adenoma, nodularity in area of thyroiditis. Only need to really operate if causing symptoms.

Question 74

Secondary hyperparathyroidism is associated with hyperphosphataemia. Why? What about primary?

Answer 74

Hyper PTH primary increases phosphate excretion in proximal tubule for calcium reabsorption. This mechanism doesn't work in CKD, and also we get the stimulus for high PTH due to the lack of alpha hydroxylase meaning we don't get mature vitamin D. Thus, high phosphate and low calcium.

Question 75

Signs of cancer on mammography | When do us USS when investigating lump

Answer 75

Spiculated lesions (radial scar) Calcification Mass with an irregular border We do an USS when investigating women under 35

Question 76

In Australia, how do we diagnose a syphilis infection?

Answer 76

We can either swab ulcers for NAAT, or we can do a blood test called EIA (enzyme immunoassay). This is specific for syphilis. After this, we do a rapid plasma reagen (RPR) and TPHA (treponema pallidum haemagglutination test) assay to look for activity. This is from the Australian STI guidelines. The EIA is a new approach. The old way was to do a specific first (TPPA/ TPHA) and then follow up with an RPR or a VDRL to check for disease acitivity. I will need to clarify this with Lauren. To diagnose in babies, do an IGM.

Question 77

Draw out blood supply of the brain, and discuss the strokes occurring with each artery.

Answer 77

If you can't do this, you're a howler. Go look it up.

Question 78

Lithium side effects bubs?

Answer 78

``` Leukocytosis Insipidus Tremors Hypothyroidism Increased urine Mums beware (ebstein's anomaly of tricuspid) ``` LITHIUM

Question 79

Therapeutic range of lithium

Answer 79

DEPENDS WHAT YOU READ However, a safe bet is to say 0.6mmol/L - 1.0mmol/L. As long as it's not 1.5 lol

Question 80

Discuss the diabetes cycle of care. What is included in a primary care management plan for T2DM?

Answer 80

https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/4732816f-9855-4c7e-bbec-ddd2f1144fea.pdf

Question 81

Features of cauda equina please. What are some common mechanisms for this injury?

Answer 81

Cauda equina extends from L2 - S5. Tapers off from the conus medullaris. Features depends on the severity and the level at which the deficit occurs. It includes saddle anaesthesia, weakness, anaesthesia/ sensory deficiency, pain. Other features can include a loss of sphincter tone resulting in incontinence, sexual problems (erectile dysfunction), absent deep tendon reflexes. Also note that the absent cremasteric reflex is L1-L2, and the absent bulbocavernosus reflex is S2-S4 (anal wink). The number one causes of cauda equina is a disc herniation. Other causes are lumbar stenosis, trauma, cancer mets, infections or abscesses, inflammatory disease, CIDP, Paget's, ankylosing spondylitis.

Question 82

The diagnostic features of social anxiety disorder. What about specific phobias?

Answer 82

They have intense fear of social situations and negative evaluation and causes them to avoid it. They always get this anixety response, and have done so for more than 6 months. The symptoms are out of proportion, they cause impairment, and are not explained by anything else. Specific phobias: Intense fear of specific things that cause avoidance Always get the anxiety response, and have done so for 6 months or more Significant impairment, and not better explained by anything else.

Question 83

GAD features in DSM?

Answer 83

1) Excessive worry or anixety for most days for more than 6 months which patient finds difficult to control 2) Needs three or more REMDIS features Restlessness Easy fatigue Muscle tension Difficulty concentrating/ distractibility Irritability Sleep disturbance Causes significant impairment. Not better explaned by another medical or psyche thin.

Question 84

Management principles of GAD

Answer 84

``` Treatment: - Lifestyle: caffeine and alcohol avoidance, sleep hygiene - Psychological: CBT including relaxation techniques, mindfulness - Biological: o 1st line: SSRI/SNRI o 2nd line: bupropion, buspirone o 3rd: Add benzo o Beta blocker not recommended ```

Question 85

Diagnostic elements of Anorexia Nervosa? What about bullimia?

Answer 85

Restriction of energy intake Intense fear of gaining weight Disturbance in perception of appearance This can be the restricting or the binge eating + purging subtypes. The specifiers are that mild is BMI > 17, mod is 16-17, severe is 15-16, and extreme is - 15 Bullimia is: Recurrent episodes of binge eating characterised by both of the following: eating a large amount of food in a single meal AND sense of lack of constrol over eating during this episode. Recurrent, innappropriate compensatory behaviour in order to prevent weight gain, e.g. self induced vomiting, use of medication such as laxatives, diuretics, enemas or others, fasting or excessive exercise. Binge eating and innappropriate behaviours both occur at least once a week for 3 months Self-evaluation is undoubtedly influenced by body shape and weight Disturbance does not occur during an episode of AN! Can be in full or partial remission, and the severity is based on the number of compensatory behaviours undertaken in a single week.

Question 86

Admission criteria for anorexia and bullimia?

Answer 86

For anorexia, it's: Admit to medical ward if: <65% standard body weight, hypovolaemic, HR <40, significant electrolyte abnormality For bullimia it's just an electrolyte abnormality.

Question 87

How to manage anorexia? Bullimia?

Answer 87

Refer for psychotherapy, monitor weight and bloods regularly, and admit based on the criteria. Both of them can be managed with SSRI's, CBT, family therapy and recognition of the health risks, and regular monitoring.

Question 88

Physical signs of billimia

Answer 88

Fatigue and muscle wasting Tooth decay Parotid gland swelling Reddened knuckles/ Russell's sign (callouses on the knuckles from the self induction of vomiting

Question 89

Comment on the prognosis of Anorexia Nervosa and Bullimia?

Answer 89

Anorexia: o Early intervention better o 1 in 10 adolescents continue to have anorexia into adulthood o 70% assume weight of at least 85% expected level, 50% resume normal menstrual function o Long-term mortality 10-20% - Bulimia: o Relapsing/remitting disease o Good prognostic factors: onset before 15yo, achieving health weight within 2 years of treatment o Poor prognostic factors: later age of onset, previous hospitalisation, individual and familial disturbance o 60% have good treatment outcome, 30% intermediate outcome, 10% poor outcome

Question 90

Describe refeeding syndrome?

Answer 90

Refeeding ysndrome is when we have a low phosphate level in the body. There is a low amount intracellularly, because a lot of this is shunted to the serum to bring the levels back up. However, when we give insulin, it cannot be compensated, and all the phosphate is driven intracellularly (we get an exacerbated insulin response with long term starvation). Thus, we get hypophosphataemia. Please note that we can also get hypokalaemia with this.

Question 91

Manic Diagnostic Criteria? Hypomanic?

Answer 91

Needs three digfast features, needs to be present for one week with a persistently elevated moood which is abnornal. Needs to cause distress or impairment and no med or substance causes. Hypomania only has to be longer than four days and is not causing impairment.

Question 92

Persistent depressive disorder is defined as a depressive disorder with less than 5 MSIGECAPS features that persists for how long?

Answer 92

One year in kids, two years in adults

Question 93

Manic and depressive episodes need to be differentiated from what in the criterion for BPAD 1 and 2

Answer 93

Schizoaffective, schizophrenia and schizophreniform

Question 94

Management of BPAD?

Answer 94

General approach: o Psychological: long-term psychodynamic psychotherapy, CBT, IPT o Pharmacological: lithium, anticonvulsants (valproate), antipsychotics, Monotherapy with antidepressants should be avoided o Other: ECT o Social: vocational rehab, social skills training, education of family/friends - Patient presenting with acute manic episode: o Need to stabilise patient so admit to AMHU and give antipsychotic (1st line is olanzapine , 2nd quetiapine) and benzodiazepine for sleep/to calm down o Consider starting mood stabiliser with above medications if patient is in severe manic episode, otherwise you can start these after reducing mania o Mood stabilisers: lithium (check renal + liver + thyroid function before starting) or anti-convulsants (eg. valproate or lamotrigine) o ECT can be used if patient not-responding to trial of antipsychotic + benzo + mood stabiliser Prognosis: - 15% suicide rate - Relapsing and remitting: depressive symptoms seem to occur more frequently and last longer - 90% have recurrent manic episode within 5 years

Question 95

What are the negative symptoms of schizophrenia?

Answer 95

Avolition, alogia, anhedonia

Question 96

Mechanism of SSRI's

Answer 96

4 ways it works. It inihibits pre ysnaptic uptake of serotonin. And postsynaptic. First step. 2: Increases serotonin in the synaptic cleft. More serotonin to bind to post synaptic receptors. 3: increased binding at post synapse. this is the antidepressant effect. Pre synaptic receptors get downregulated. 4: Post synaptic receptors also become downregulated which is when side effects decrease.

Question 97

Theory of increased suicidality;

Answer 97

Two explanations. The first is that post synaptic increased serotoin activity reduces anehdonia and increases motivation - get energy to kill themselves. 2nd explanation is that presynaptic serotonin binding provides autoregulation of the neuron and reduces the serotonin response initially but over two weeks these downregulate.

Question 98

Clozapine therapy is monitored how???

Answer 98

First, we do a baseline echo, ecg and bloods. We do monthly FBC and clozapine levels We do 3-6 monthly weight, waist circumference, BP, fasting blood glucose and blood lipids.

Question 99

How we diagnose Cauda Equina

Answer 99

Spinal MRI if the patient is stable.

Question 100

What is the COPDx mnemonic?

Answer 100

``` COPDX: Case finding and confirm diagnosis Optimise function Prevent deterioration Develop a plan of care Manage eXacerbations ```

Question 101

Case finding and confirmation in COPDX includes what

Answer 101

Smoking is the most important risk factor. It's diagnosed with an FEV1/FEV of 0.7 Should be accompanied by a regular assessment of severity If it's reversible consider asthma. By more than 400mL.

Question 102

Case finding and confirmation is followed by optimising function. What is included in this heading?

Answer 102

Do a proper assessment and increas the pharmacotherapy in a stepwise fashion. Adhere to the inhaler technique, and use non-pharm therapies like pulmonary rehab and exercise. Comorbid conditions are common.

Question 103

Prevent deterioration

Answer 103

Smoking cessation is the most important intervention. Preventing exacerbations also has a role. Give them all the flu and pneumococcal vaccine. Mucolytics (such as dornase alpha) can be helpful. If the patient is having hypoxaemia, the patinet is benefitting from the oxygen therapy. REMEMBER that. It's just if they have hypoxaemia. Prevents complications. Note that you need to have this on for 18 hours pr day. Polycythaemia, right sided heart failure, or evidence of pulmonary hypertension are also indications for this therapy.

Question 104

Develop a long term care plan?

Answer 104

Put them on a GP management plan, with liaison with the specialists.

Question 105

Manage exacerbations

Answer 105

Control it lol. Bronchodilators, steroids, oxygen therapy, treat with antibiotics if they have increased volume of sputum, fever, and crackles.

Question 106

Failure rates of an MTOP vs STOP?

Answer 106

2.5% vs 0.2%.

Question 107

Describe the work up for an abortion

Answer 107

Counselling: explore feelings and concerns, what she bases information on and get a psychologist involved to assess reasons. Bloods: get a FBC, RH group and antibody status USS if needed to confirm intrauterine pregnancy Plan for contraception needs to be covered!! With any of these gynae things, make sure you cover the post op contraceptives.

Question 108

Discuss the use of misoprostol and antibiotics with a surgical MTOP?

Answer 108

Misoprostol is used if they are being admitted overnight. That is, if they are going to be over 14 weeks. Misoprostol is given the night before or on the day, and this helps them expel any retained products of conception. Just note it can cause diarrhoea. It should also be noted that before 14/10 weeks, they are just done as day case D&C and aren't staying overnight so no misoprostol. Antibiotics can be used prophylactically, and used to treat anyconcommmitant STI. We do a midstream and first catch. Usually it's doxycycline and metronidazole that's given.

Question 109

Misoprostol actions on the female reproductive system?

Answer 109

It cuases uterine contractions AND cervical ripening (dilation).

Question 110

When do we submit the gestational sac for histology?

Answer 110

before 6.5 because this is when it's easiest to miss.

Question 111

Symptoms of Asherman's?

Answer 111

They get subfertility, but remember they also get chronic pain usually related to the cycle.

Question 112

What are some contraindications to the medical abortion?

Answer 112

``` ▪ On steroids ▪ Adrenal failure ▪ Coagulopathy ▪ Hypersensitivity to prostaglandins ▪ > 9 weeks pregnant ```

Question 113

Describe the method of a medical abortion?

Answer 113

Protocol/ method 1) Must have pre-work up + counselling 2) USS showing intra-uterine pregnancy 3) Mifepristone is taken 4) Sub-lingual or buccal misoprostol 36 -48 hrs. later 5) Cramps + bleeding start 1 – 2h after misoprostol 6) Abortion over in few hours ▪ must have adult carer with phone until all over ▪ Phone help-line + SMS messaging offered by MS Health ▪ must have cooperation of nearest hospital ▪ must have detailed instructions for emergencies and follow-up

Question 114

How do we follow up our medical abortion patients?

Answer 114

They come in 14 days later. This is when the bleeding should have stopped. We should check to ensure there is no infection, the bleeding has diminished, and they are emotionally well. Confirm pregnancy terminated by doing a qunatitative BHCG or USS. Contraception has been discussed and is in place.

Question 115

How to verify if there is excess bleeding?

Answer 115

Completely soaked pad ▪ 2 pads/hr for 2 consecutive hours ▪ Clots size of fist ▪ hypovolemia

Question 116

List ALL the options for analgesia in labour?

Answer 116

They are divided into non pharm an pharm. Non pharm is reduction of painful stimuli, activat peripheral sensory receptors, enhance descending inhibitory pathways. Reduce painful stimuli involves maternal movements, changing positions, counter pressure, breathing nd relaxation techniques. Activating the peripheral sensory receptors is superficial heat, cold immersion in water, warm water shower, touch + massage, acupuncture + acupressure, aroma therapy, TENS (helpful in latent 1st stage) and intradermal sterile water injections Enhance the descending inhibitory pathways is attention ofocusing and distraction, hypnosis, and old fashion gritting your teeth. Pharmacological involves the inhalational analgesia, parenteral analgesia, regional anlgesia, and nerve blocks

Question 117

Discuss the water immersion as a technique for labour analgesia?

Answer 117

It reduces the rates of spinal and epidural rates because it's actually an effective analgesia method. People can have it if they've been a low risk pregnancy and labour, they have a cephalic presentation, they are post 37 weeks, they are a singleton and they are less than BMI 35. Contraindications are narcotic analgesia in the past 4 hours, high risk pregnancy, multiple pregnancy, requirements of continuous CTG and inducted labour. You must get consent, and confirm the labour is progressed i.e. in stage one and the cervix is more than 5cm dilated. Monitor maternal and water temp, and you must ensure you are ready to help them out of the water if they are decompensating. Be prepared for an unintended water birth.

Question 118

Discuss the use of nitrous oxide:

Answer 118

It acts quickly, and has a really short half life. It does not affect the foetus. some side effects are nausea, vomiting, dizziness, euphoria, disorinetation, generalied tingling and sedation, and its effectiveness is very variable. Contraindications nclude Vitamin B12 deficiency (or pernisious), if sedated and can't hold the mask correct, history of pneuoomothorax, bowel obstruction, increased ICP or intraoccular surgery/ orbit fracutres. Must seek advice if BPAD or schizophrenia. It must be self administed with coaching i.e. remind the patient to breath into it during a contraction, and stop when it ends. Signs of overdose are a reduced respiratory effort, so just monitor for that. Start at 50% N2O 50% O2 and can go 70% N20

Question 119

Opioids in labour cpatain?

Answer 119

IM morphine. Provides limited pain relief, but induces a useful euphoria. it takes 30 minutes to work. Causes the usual side effects, and in the newborn, causes resp depression/ rowsiness, so will impair APGARs. Can also affect feeding. Because of this, if the birth is due within four hours or if we want a water immersion, we do not give.

Question 120

Describe the types, advantages, disadvantages, contraindications, complications of an epidural

Answer 120

it can be caudal and lumbar. They all contain a local anaesthetic and an opioid (prevents excessive motor blockade). The reason the pain fibres are preferentially blocked is that they have less myelination than the motor fibres. Advantages are that the woman is conscious for birth, baby has no side effects (no maternal or foetal sedaton), it controls pain very well, is most effective, allows for top up doses, allows ambulation, no increase in caesar rates, no increased back pain. Disadvantage is that it prolongs labour (increased duration of the second stage), and it does increase the rate of instrumental vaginal delivery with either forceps or vacuum. Increased risk of post partum fever, maternal hypotension, foetal hypoxia from the maternal hypotension, foetal bradycardia, and if the epidural fails, the next logical step is to do a caesarean section. We therefore like to do epidurals if they request it, they have multpple comribdities, they have multiple pregancy or we're doing an assisted vaginal birth. Contraindications are if they refuse, if there is active matenral haemorrage/ coagulopathy, if they are septic or there is a local inection at the insertion site. Complications are divided into common, uncommon and rare. Common; Nausea, vomiting, headache, inadequate block, pain and bruising at the site, bloody tap, motor blockade, urinary retention, foetal brady. uncommon is infection at the site, itching, excess bleeding, temporary nerve damage, dural puncture and subsequent post dural puncture headache. Rare side effects include permanent nerve damage,epidural haematoma, epidural abscess, respiratory depression, and meningitis. Epidurals will take a few hours to go away, so they must have assistance with ambulation. We do epidurals during active stage one usually when it's requested. it's very uncommon to initiate after this really.

Question 121

Outline the clinical approach to an epidural

Answer 121

If they request it around the start of the active labour stage one, here is what we do: Informed consent + written and documented antenatally o Advantages + disadvantages o Complications o Need for IV + catheter o Can no longer have water immersion o Time it takes to wear off and how it feels when it does 2) Arrange anaesthetist review 3) Inform anaesthetist when woman wants the epidural 4) Must have IV access 5) Ensure good circulatory volume (may need IV fluids) 6) Position to avoid aorto-caval compression 7) Continuous DTG monitoring 8) Empty bladder with in-out catheter (+ ongoing good bladder care) 9) Regular monitoring of maternal vital signs ? consider giving with subcut terbutaline or sublingual terbutaline to ↓rates of foetal bradycardia Remifentanil PCA is now used for ‘fall-back’ when regional analgesia is contraindicated. The major drawback is the danger of profound maternal respiratory depression, even from a small overdose – this is why remifentanil was only licensed for administration in highly monitored environments.

Question 122

What is a spinal and how is it different to an epidural?

Answer 122

A spinl anaesthetic is an injection of local anaesthetic into the subarachnoid space. It is just one injection, whereas epidurals are with a continuous catheter often so we can give those top up doses.

Question 123

Go over those antenatal care flashcards from Dr Tucker! The one about the pre preg consult is particularly good.

Answer 123

yessir.

Question 124

Important things to discuss on the first antenatal visit + examination

Answer 124

``` Last normal menstrual period ▪ Estimated due date (EDD) o Assists with gauging future investigation results o Naegele’s rule = 7 days + 9months after LNMP o Dating scans (accurate <12 weeks) ▪ Obstetric Hx o Any past births, issues o Abortions / misscarriages o Mode of delivery o Birth weights, gender o Complications ▪ Gynaecological Hx o Cervical procedures o Periods o Hormones ▪ PMHx + PSurgHx ▪ Family Hx o Including partner’s ▪ Medications + allergies ▪ Social o Smoking + alcohol o Finances o Social supports Initial Antenatal Examination ▪ General appearance ▪ BMI ▪ Vital Signs ▪ Neck o Goitre? o Thyroid issues? o Bruits? ▪ Chest o Lungs + heart o Breast examination ▪ Abdomen o General abdomen examination ▪ Vaginal examination o Not done routinely, only when indicated o Hx of discharge? o Bleeding? o FGM history ```

Question 125

There are numerous investigations you order over the course of the antenatal care. Please discuss.

Answer 125

``` Booking bloods (on first visit) o FBC = ?anemia, Thalassemia, ↓plt o Group + Ab screen = for HDN o Serology ▪ Rubella ▪ Syphilis ▪ Hepatitis B + C ▪ HIV o Mid-stream urine MCS o Others ▪ Iron studies ▪ Vit D testing (<50 level) ▪ TSH ▪ Chlamydia ``` ▪ 28 / 40 = OGTT/ FBC/ Ab ▪ 36 / 40 = FBC / Abs ▪ 18 – 22 / 40 = Morphology scan ▪ USS – 1st Trimester + 2nd Trimester

Question 126

When do we do give anti-d

Answer 126

At 28 weeks and 34 weeks. 36 weeks is when we do ECV, and I think I often get confused between these.

Question 127

What is some general advice you would give a woman at an anenatal clinic visit?

Answer 127

``` Diet o Adequate o Iodine, iron, folate o Avoid risk foods ▪ Exercise o Light to moderate exercise ▪ Smoking ▪ Alcohol ▪ Drugs = esp illicit o Placental insufficiency o Placental abruption o Early labour o Issues on the baby – e.g. opiate withdrawal ▪ Constipation o High fibre diet o Fluids o Metamusil, dietary fibre ```

Question 128

At each antenatal checkup, what do you need to cover?

Answer 128

``` General wellbeing ▪ Symptoms o Pain o Bleeding o Fluid loss ▪ Foetal Movements o > 10 movements / day o Count movements around meals o Any changes from normal movement for you? ▪ Examination o Maternal weight – can counsel about BMI o Blood Pressure o Abdominal examination – LEOPOLD’S MANOUVRE ▪ Fundal height ▪ Fundus ▪ Back/limbs ▪ Pelvic grip – 1+2 o Comment on: ▪ Fundal Height ▪ Lie ▪ Presentation ▪ Vertex ▪ Position ▪ Engagement o Vaginal exam – NOT ROUTINE! (swabs, labour, confirm presenting part, pelvis capacity) ```

Question 129

When is the best time to do ECV and why?

Answer 129

It's around 36 weeks because before this there is a good chance it will spontaneously change it's orientation.

Question 130

What is the foetal denomentator? What is this used to describe?

Answer 130

The denominator is the presenting part we use to describe based on where it is related to hte maternal pelvis. For instance, if the baby is in vertex, we say it's the occiput. If breech, it's the sacrum, and in facial presentation it's the mentum. Some presentations inclue right occipitoanterior or left occipitoanterior (based on which direction the occiput is facing, right and left occipitolateral, and irght or left occipitoposterior.

Question 131

What are some common complaints in pregnancy, and how do we deal with them?

Answer 131

``` Morning Sickness o Hormonal o 80% of women o Diet / anti-emetics o Assess hydration + urine ketones o Usually reduces in 2nd + 3rd trimester o Rule out other causes: multiple pregnancy, molar pregnancy, UTI ▪ Constipation o Progesterone effect o Diet / Laxitives o Most are safe in pregnancy ▪ Heart Burn o Enlarged uterus o Progesterone mediated LOS relaxation o Light meals, meals 2 – 3hrs before bed o Semi-recumbent sleep o Ant-acids ▪ Mylanta, gastrogel ▪ PPI if refractory ▪ Pelvic Pain o Physiotherapy o ? round ligament pain (in groin, lateral to uterus, ↑ on movement) o ? pubic symphisis dysfunction o MUST EXCLUDE SERIOUS CAUSES ▪ Varicose veins / haemorrhoids o Venous obstruction = ↑ venous pressure o Supportive tights, rest, elevation o Family + self-history very indicative o Usually resolve post pregnancy ▪ Carpal Tunnel Syndrome o Must exclude renal, liver, pre-eclampsia issues o May just be from fluid increase o Physiotherapy + Splints o Surgery in select cases ▪ Vaginal Discharge o ↑ vascularity of vagina / cervix = normal o Swabs for infection testing o Reassurance ```

Question 132

What are some of the styles of antenatal care?

Answer 132

Search for Aus Government Department of Health Models of maternity care

Question 133

Normal weight gain in pregnancy/

Answer 133

Make sure they know there is no normal weight. If htere is a pre normal BMI, we say 11.5-16kg total is a good amount of weight gain. Don't just binge on unhealthy foods though because of the risk of GDM.

Question 134

Please look at the normal antenatal schedule i your notes.

Answer 134

Thx

Question 135

Assessment of a previa? They usually present with malpresentation, painless PV bleed (90%) or pain.

Answer 135

Do leopold's to confirm presentation (breech is the mal), AVOID VE because this triggers bleeding, and just do a transvaginal/ transabdo USS.

Question 136

How do we manage?

Answer 136

if diagnosed before 20 weeks, just call it a low lying placenta. It will likely move. It it doesn't, make the diagnosis. We need to grade it, estimate blood loss, gestational age of baby, position of baby,health of baby and health of mother need to be weighed up. We need to relive symptoms and prolong the pregnancy. bed rest and hospitalisation can form part of the management. CTG, and high risk antenatal clinic is recommended. Blood transfusions for the mother, and avoid irritating the uterus or cervix (no sex or orgasms). Caesarean is likely the way these are delivered.

Question 137

New rf's for placental abruption?

Answer 137

Advanced maternal age, multiple pregnancies, Polyhydramnios, thrombophilias, amniocentesis, ECV

Question 138

Can placenta previa cause conenital malformation?

Answer 138

yeah lol. Also IUGR, distress and iatrogenic pematurity. Remember to admit these patients to the ward for overnight monitoring and investigation. If they are found to be okay, they can go home.

Question 139

Why are multiple preganncies are risk factor for placental abruption?

Answer 139

Because the sudden uterine decompression from birth of first one causes a great negative pressure.

Question 140

Complications of abruptio placenta inclue very shock complications. There is one more specific.

Answer 140

Foetomaternal haemorrhage. Do a rosette and kleihauer-betcke test to assess the amount of anti D to give in a rhesus negative woman.

Question 141

The clinical presentation of an abrupted placenta?

Answer 141

``` PV bleeding Abdominal pain (or lower back pain) Labour Abdominal tenderness (woody hard) + tender uterus Foetal distress Hypovolaemia and shock Very frequent uterine contractions ``` Clinical diagnosis. Don't do an USS ya berry.

Question 142

Management of an abrupted placenta?

Answer 142

``` History, examination, investigations  Options, resuscitation  Fetal monitoring  Factors to consider: o Maternal condition o Fetal condition o Gestational age o Level of neonatal care availability Difficult to diagnose in mild forms ``` 12,15 • Consider admission for surveillance as clinically indicated • Give Rh D immunoglobulin to all non-sensitised Rh D negative women independent of whether routine antenatal prophylactic Rh D immunoglobulin has been administered17 [refer to Table 9] • Consider antenatal corticosteroids between 24 and 34 weeks + 6 days gestation17 • Monitor for disseminated intravascular coagulopathy (DIC) and request urgent clotting studies, platelet count as indicated44 o Do not delay treatment by waiting for coagulation results if massive blood loss occurs44 • Significant placental abruption requires urgent delivery by CS44 o Incision – mid line preferable if other abdominal injuries suspected o Refer to Queensland Clinical Guideline Postpartum haemorrhage for management of PPH, blood/product replacement and MTP activation protocols34

Question 143

How do you work up a patient with a bleed in early pregnancy ya bitch?

Answer 143

``` History:  LMP  Pregnancy test  History about bleeding/tissue passed  Pregnancy symptoms  History of trauma  Abdominal pain  Fainting / shoulder pain / dizziness  Bladder and bowel symptoms  Gynae history – PID/contraception  Obstetric history  PMHx  PSHx – pelvis surgery  Meds  Allergies  Social history Examination:  General  Abdominal  Pelvic examination o Speculum o Bimanual Differential diagnoses:  Miscarriage  Ectopic pregnancy  Molar pregnancy  Other causes ``` ``` Investigations:  FBC  Bhcg  Blood group  MSU  USS ```

Question 144

Go over the USS findings from DR Tucker's cards and draw them out. I never remember.

Answer 144

Thanks

Question 145

Types of miscarriage?

Answer 145

Complete: no medical or surgical intervention needed. Incomplete: RPOC Threatened: early pregnancy bleeding with other causes excluded not associated with dilation of the cervix. Miscarriage: there is no conceptus, but there is also no bleeding. Septic miscarriage: complicated by pelvic infection Inevitable miscarriage is when they are in the process of happening.

Question 146

Management of miscarriage can be either expectant, medical or surgical. Discuss the clinical considerations of each:

Answer 146

Expectant: offered if they prefer it. However, to do it, they need to have access to medical emergency care and be linked into the appropriate hospital similar to a medical abortion. Follow up is 7 days, and if there is evidence of RPOC on this follow up, we can continue current or expedite the process. Medical management is with misoprostol. Contraindications include if it's a suspected ectopic or gestational trophoblastic disease (the other two differentials for bleeding in early pregnancy), IUD in situ, allergy to prostaglandins, medical contraindications. Inform them bleeding can continue for up to two weeks after (lightly). Follow up is in 48 hours, and consider surgical management. Also on day eight, and we do FBC, BHCG, USS. Medical review in 6 weeks. Surgical is a D&C. If theyhave persistent bleeding, are haemodynamically unstable, or there is evidence of a suspected GTD/ RPOC or if it's infected. GIVE ANTI D

Question 147

Go over caesareans with your dear mother.

Answer 147

yeah.

Question 148

Efficacy of breast feeding contracpetion?

Answer 148

2%. This may be too high.

Question 149

Which medications can effect the efficacy of the COCP

Answer 149

Valproate and other CP450 enzyme inducers Antibiotics St John's Wort Clomiphene citrate lol

Question 150

failure rate of vasectomy and tubal ligation

Answer 150

Vasectomy is 1/2000, tubal ligation is 1/200. I have heard differently though in the same deck of flashcards lol

Question 151

Mirena side effects

Answer 151

Irregular PV bleeding in the first 3-4 months, amenorrhoea in up to 30% by 1 year Hormonal symptoms: nausea, headaches, breast tenderness, bloating Benign and usually self-limiting ovarian cysts

Question 152

Side effects of the depot provera?

Answer 152

``` Menstrual disturbance (regular, irregular or even amenorrhoea) Delayed conception (fertility may not return for 6-12 months) Weight gain (probably due to progestagen ↑ appetite) Bone loss (small risk of ↓ bone density with prolonged use) ```

Question 153

Absolute CI's to COCP? Relative?

Answer 153

< 6 weeks post partum Smoker over age of 35 Hypertension (systolic >160mmHg or diastolic >100mg) Current or past history of VTE Ischaemic heart disease History of CVA Complicated valvular heart disease (pulmonary hypertension, atrial fibrillation, history of subacute bacterial endocarditis) Migraine headache with focal neurological symptoms Breast cancer (current) (pretty sure this is the progesterone component that makes this a CI i.e. in HRT if there is progesterone in it, this is what increases the risk of breast cancer) Diabetes with retinopathy/nephropathy/neuropathy Severe cirrhosis Liver tumour (adenoma or hepatoma) relative Ci's include if they are smoker under 35, conrolled HTN, migraine >35, symptomatic gallstones, mild cirrhosis, hx of oestrogen induced cholestasis, interfering medications, and if they are less than 6 months post partum

Question 154

COCP dose? Failure rate?

Answer 154

20-30 microg of oestorgen 50-60 microg of progesteroen Actual failure rate is 9% and this is due to incorrect use. <1% though if it's used correctly.

Question 155

Benefits of the COCP? Risks/

Answer 155

Risks Benefits  Increased risk of VTE  Increased risk of cancer (cervical, breast)  Compliance issues – 9% failure rate if not use correctly  Breast tenderness  If hypertensive – increased risk of MI + stroke  Increased risk of hepatocellular Ca (rare)  Interactions with some other medications  Good return to fertility  If used correctly, effective contraceptive method  Useful in treatment of acne, menorrhagia, dysmenorrhea, PCOS, PMS  Protective against cancer (ovarian, colon, endometrial)  Decreased risk of benign breast disease

Question 156

Important things to counsel them about before starting COCP? What about depo provera?

Answer 156

Counseling:  Importance of compliance – explain the packaging, how to take, when to take, discuss active and sugar pills  OCP has no protection against STDs – use in conjunction with condoms  7d rule – when commencing, require 7 days of another contraceptive before you are covered  Can commence on any day of the cycle  Breakthrough bleeding, even when taking active pills  Able to take active pills for up to 12m (useful in treatment of menstrual migraines) before needling to bleed o Recommended to use for 3m periods and then bleed  Advise women >50yo to use alternative method  No protection against STDs – use in conjunction with a condom  Importance of timed injections – needs to be given every 3 months (13 weeks) o Two week “grace period” – patients who are =2 weeks late can just receive the injection without the need for pregnancy testing (this is because ovulation does not occur for at least 14/7 o If >2 weeks late for injection, recommended to do pregnancy test + back-up contraception (e..g condom or abstinence) for 7/7  SEs: menstrual irregularities, bloating, dizziness, reduced libido  Ideal time to commence is within 7d of onset of menses of 7d before discontinuing another method of contraception – but can be started at any time o Always advise of need for alternative contraception in first 7d

Question 157

Normal dose of paracetamol:

Answer 157

1g 4-6 hourly is max normal dose paracetamol for adults

Question 158

Fluclox

Answer 158

500mg QID

Question 159

Benefits of a depo provera?

Answer 159

```  Long acting (2-3m) + very effective  Useful in poor compliance pts  Amenorrhea  Reduced pelvic pain assoc w/ periods or endometriosis  Protection against endometrial and ovarian Ca, and PID  Useful in pts with heavy PV bleeding, dysmenorrhea, or IDA  Few drug interactions ```

Question 160

Risks and benefits of implanon?

Answer 160

Risks are that you need to be a trained practioner to give it and it's invasive, so can cause local damage. Benefits though is that it isn't user dependent, has high continuation rates, fewer contraindications and it lasts for 3 years. The return to fertility is something like like one month. It's contraindicated in current breast cancer, cirrhosis, unexplained PV bleeding and in a hx of breast cancer.. Also, if hte chick palys rugby or some other highly dangerous sport, they need to be careful as this can break.

Question 161

What to tell patients about emegency contraceptive?

Answer 161

it doesn't protect against STi's, it's OTC, it loses efficacy the more you use it, and a preg test is needed in two weeks.

Question 162

Absolute contraindications to the IUD?

Answer 162

Pregnancy, septic abortion/ postpartum sepsis, unexplained PV bleeding, gestational torphoblastic disease, endometrial cancer, distortions of the uterine cavity, and current PID

Question 163

Contraindications to the mirena?

Answer 163

o Pts with acute liver disease or liver tumour o Known or suspected pregnancy (if first insertion, test if pregnant) o Current or recent PID, lower genital tract infection o Postpartum endometriosis, cervicitis, cervical dysplasia (always do a pap smear), uterine or cervical malignancy o Progesterone-dependent tumours o Undiagnosed abnormal uterine bleeding

Question 164

Counselling for patients on an IUD?

Answer 164

No protection against STDs – use in conjunction with condoms o Patients can check the string of their IUD to ensure in the correct place o Keep a record of date for replacement of IUD – should not stay in any longer than recommended time o Return to GP if any unusual symptoms – discharge, lower abdo pain, pain during intercourse

Question 165

Remember to counsel Mum on ectopic pregnancy management.

Answer 165

K

Question 166

Management considerations for patient with chronic diabetes mellitus pre conception?

Answer 166

Control it Put them on a high risk clinic care Take them off hypoglycaemics except for metformin and insulin Education and refer to diaebtes educator + endocrinologist as they may need more insulin. Fortnightly visits hehe

Question 167

Maternal risks in diabetics?

Answer 167

Risks of caesars Risks of increased complications, including post partum haemorrhage Increased worsening of microvascular complications increased risk of precclampsia and other things Macrosomia (foetal hyperinsulinaemia, still birth)

Question 168

How do you approach the risk of cardiac abnormalities in pregnant women?

Answer 168

Do a normal morphology scan, and then follow this up with another one at 22-24 weeks to look for cardiac defects. 50% of foetal abnormalities in pregnancy are cardiac in diabetic women. Termination of pregnancy can be offered if they are detected before 20 weeks.

Question 169

Common foetal abnormalities associated with diabetes:

Answer 169

``` Macrosomia and hyperinsulinaemia Bowel Neural tube defects Cardiac Urinary tract Sacral agenesis ```

Question 170

Perinatal diabetes care should involve?

Answer 170

Careful BGL control. Consult with diabetes educator and endocrinology team. regular foetal growth scans from 24w (abnormalities and polyhydramnios), They can have spontaneous labour up to forty weeks if they have good BGL control, normal foetal growth, and no polyhydramnios or other complications. Also, be aware that at birth they are at risk of hypoglycaemia, ARDs, polycythaemia, neonatal jaundice, hypocalcaemia and hypomagnesaemia.

Question 171

GESTATIONAL DIABETES: what is the definition in Queensland?

Answer 171

OGTT done at 26-28 weeks will show: fasting >5.1 mmol/L, 1hr >10mmol/L, 2 hr >8.5 mmol/L

Question 172

Discuss the pathogenesis of GDM

Answer 172

Pregnancy is a state of insulin resistance, so there is increased insulin. This is magnified in women who are already at risk of poor glucose tolerance. Additionally, more insulin is going to the baby due to their metabolic requirements. Thus, they get more insulin and fat storage leading to macrosomia. Please note there is also a lower renal threshold for glucose in pregnancy, so glycosuria is common.

Question 173

maternal risk factors for GDM?

Answer 173

 BMI >30  Maternal age >40yo  Previous GDM / glucose intolerance / macrosomic baby >4500g  Previous perinatal loss  PCOS  Family history diabetes (first-degree relative)  Meds – corticosteroids, antipsychotics  Multiple pregnancy  Ethnicity – South Asian, Black Carribean, Middle Eastern

Question 174

What are some of the complications of GDM?

Answer 174

Foetal: - Note that the structural abnormalities seen in chronic diabetes don't apply, because GDM is theoretically occurring after the embryogenesis. before birth: Macrosomia, IUFD, During birth: neonatal hypoglycaemia, ARDS, prematurity iatrogenic, neonatal jaundice, shoulder dystocia, hyperinsulinaemia After birth: impaired glucose toelrance, and increased risk of T2DM and obesity. ``` Maternal complications: - MIscarriage Pre ec infection Induction of labour/ trauma/ c section PPH increased irsk of T2DM + HTN Increased risk of hypoglycaemia. ```

Question 175

Outline in detail the management of gestational diabetes mellitus?

Answer 175

Management: ANTENATAL:  Multidisciplinary team approach  Targets: (to be measured QDS, and if controlled can be BD) (eTG) o Fasting <5.3mmol/L o 1hr post-prandial <7.8mmol/L o 2hr post-prandial <6.7 mmol/l  Lifestyle – diet, physical activity, cease smoking + alcohol  Pharmacological o Metformin +/- supplemental insulin PLUS lifestyle o If high on average, or still getting 2-3 high readings each week, or if fetus is macrosomic (>75th percentile)  Antenatal care – considered high risk, monitor regularly  Monitor growth  Monitor fetal BGL after delivery POSTNATAL  FOLLOW-UP: OGTT @ 6 weeks post-partum to ensure normalized  Encourage breastfeeding – increased energy demands may means less insulin required by women (insulin is safe)  Insulin requirement is ~20% less in breastfeeding women than before they were pregnant HAPO Study – 2008 (Hyperglycaemia and Pregnancy Outcome)  “Continuous linear relationship between maternal glucose and fetal growth and that fetal growth can be modified by glucose-lowering therapies, with diet and lifestyle intervention often being successful”  “ pharmacological intervention, treatment strategies starting with oral hypoglycaemic agents (metformin or glibenclamide) but often involving progression to insulin to ensure adequate glycaemic control are as successful but not superior to insulin alone”  “important influence of maternal glycaemia on offspring birthweight:  “Importantly, infant adiposity as estimated by sum of skin-fold thickness exhibited a similar strong linear relationship with maternal glucose”

Question 176

how diagnosis pre ec

Answer 176

2 measures of BP >140/90 + 1 organ system involvement. Pretty sure this has to be after 20 weeks.

Question 177

reflex findings in pre ec on neuro exam?

Answer 177

hyperreflexia and clonus

Question 178

How do we reduce the risk of pre-ecclampsia in women with risk factors?

Answer 178

We reduce the risk by giving them 100mg aspirin daily. We also tell them to seek helpimmediately if they feel like they have symptoms listed in pre ec.

Question 179

Risk factors for pre ec

Answer 179

``` previous Older age First preg with current partner Family history pre-existing diabetes or hypertension Multiple preg Renal disease ```

Question 180

How do we work up a pre-ecclampsia?

Answer 180

measure BP in clinic? Screen for proteinuria on dipstick and quantify if positive. FBC, LFT, LDH, urate CTG + USS

Question 181

Indications for MgSO4

Answer 181

Eclampsia, severe pre-ecclampsia, any signs of neuro findings. You should transfer to a high level service when giving this.

Question 182

Management of HELLP

Answer 182

if above 34 weeks gestation, should deliver. Consider platelet transfusion.

Question 183

Imminent ecclampsia is defiend as what?

Answer 183

``` Imminent eclampsia = ≥ 2 of the following symptoms: o Frontal headache o Visual disturbance o Altered LOC o Hyperreflexia o Epigastric tenderness ``` ``` Management:  Resus DRSABCD  Goals of treatment: o Terminate the seizure o Prevent recurrence o Control HTN o Prevent maternal and fetla hypoxia  MgSO4 is the anticonvulsant drug of choice  Plan birth (if antepartum) ASAP!!! ```

Question 184

Management of pre-ecclampsia after it's been diagnosed?

Answer 184

multidisciplinary team approach is advocated for, and except where there is acute foetal compromise, stabilise there woman and addres the problems of pre-ecclampsia. Timing + mode of birth: o Recommend vaginal birth unless c-section indicated for other obstetric indications o Moderate HTN:  If otherwise well  expectant management beyond 37w o Preeclampsia:  Dependent of severeity and gestation o HELLP syndrome  Plan birth ASAP!!!!  Intrapartum monitoring o Close clinical surveillance required o Minimum ½ hourly BP o Continuous CTG o IV access o Multidisciplinary involvement  Intrapartum care: o 2nd stage:  If BP is within target range = usual care  If BP not responsive to initial drug therapy, advise assisted/operative birth o 3rd stage:  Active management as increased risk of PPH  DO NOT GIVE ergometrine or syntometrine DVT prophylaxis to you bitch.

Question 185

Post partum, what do we do with our pre-ecclampsia ladies?

Answer 185

HTN and pre-ecclampsia may develop for the first time post partum. ask frequently about the symptoms (notably headaches and epigastric pain), and give them VTE prophylaxis. Continue with the antihypertensives Warn methyldopa is associated with depression (post partum depression warning) Discharge + follow up: o First and second line drugs are compatible for breastfeeding o If taking ACE-I, discuss contraception o Recommend F/U screening after 6w to ensure resolution or need for ongoing care o Advise to avoid smoking, maintain healthy weight and exercise, attain healthy BMI (esp if overweight) o Assessment for traditional CV risk markers (e.g. annula BP, serum lipids, BGL) o Risk reduction for future pregnancy (e.g. aspirin, change from ACE-I, pre-conceptual advice on BP control)

Question 186

types of breech? How do we manage?

Answer 186

Footling: one or both feet are pointing downwards and will deliver first. Frank: foot in the face of a frank breech. Flexed hips but extended knees. Complete: everything is flexed.

Question 187

Talk me through the use of instruments when delivering. What can't you do, what are the indictions etc.

Answer 187

Foreceps are used if there is failure to progress. Note: failure to progress is defined in a nulliparous woman as 0.5cm per hour (less than) and in a multip 1cm per hour. Or, if in stage 2, it's 1 hour for a multip and 2 hours for a nulliparous woman. remember though fr second stage we allocated some leeway if they have had an epidural. Foreceps are used if stage 2 fails to progress. Power, position, presentation need to be intact for us to use it (i.e. cannot use foreceps if less than +2 foetal descent. Syntocinin is given while we do it, and the mother MUST get an episiotomy. Babies can get laceration and the various birth injuries which includes a fracture. Remember the mother can have the episiotomy tears.

Question 188

How do manage a breech presentation?

Answer 188

Often you discuss with your consultant if there is a need for a caesar. Altenratively, to do vaginally you do: - Hand gently supporting the emerging breech Keep the sacrum anterior Do the Lorsett Manoeuvere + Mariceau Smellie Veit

Question 189

What is an early miscarriage? what is a late miscarriage? How many pregs have a miscarriage?

Answer 189

8-20%. Early is before 12 weeks and late is beyond 12. A misscarriage is loss before 20 weeks or before 500g.

Question 190

recurrent miscarriages?

Answer 190

3 or more consecutive

Question 191

Miscarriage risk factors. Causes?

Answer 191

Increased age, previous, history of STI's and PID, smoking, alcohol, BMI, fever; chromosomal abnormality is the biggest cause, and it's mainly aneuploidy. ``` Others are CONGENITAL ANOMALIES o Genetic (e.g. anencephaly) o 2* to extrinsic factors (amniotic bands) o Teratogens (mercury, ↑ BGL) ▪ CVS OR AMNIOCENTESIS ▪ ABDOMINAL TRAUMA o CVS o Amniocentesis o Fall, MVA o Domestic violence ▪ INFECTIONS o TORCH infections ▪ MATERNAL CONDITIONS o Hyperthyroidism o DM o PCOS ▪ HYPERCOAGULABLE STATE (APL – UNCLEAR…) ```

Question 192

How does a miscarriage present?

Answer 192

Cramping pelvic pain, PV bleeding, PV dark discharge, amenorrhoea, loss of pregnancy symptoms, cervical shock, incidental finding

Question 193

what is cervical shock?

Answer 193

Cervical shock is vasovagal syncope produced by stimulation of the cervical canal during dilatation. This is leading to hypotension and braydcardia. It's usually caused when the products travel through the cervical canal.

Question 194

How do we examine for and investigate a miscarriage?

Answer 194

``` Examination ▪ ABC + Vitals o IVCs +/- fluids o Analgesia for the pain ▪ Abdomino-pelvic examination o Inspect for distension o Guarding / peritonism o Tenderness o Keep open mind! Could be GIT! o Speculum o Bimanual examination ▪ Urine β-HCG Investigation ▪ FBC – assess blood loss ▪ Serum B-hcg – for confirmation ▪ Group + Hold and Rh status – for possible replacement, may need anti-D ▪ TV USS Β-HCG ▪ Serum is best  doubles every 48 hours ▪ <5IU/L = normal, not pregnant ▪ 1500IU/L = should see IU pregnancy on TVUSS ▪ Need serial tests to establish viability + loss Group + Hold ▪ Determine Rhesus status ▪ May need if becomes HDS or needs surgery DR DILGIR LECTURE Ultrasound ▪ βHCG  1500 – should see an IU pregnancy (TV USS)  5000 – should see an IU pregnancy (TA USS) ```

Question 195

how do we diagnose a miscarriage?

Answer 195

▪ > 25mm mean sack diameter with NO foetal pole + yolk sac ▪ CRL >7mm with NO FHR

Question 196

The management of a miscarriage can be expectant, medical, or surgical. Please discuss the intricacies of each. In addition, what are some counselling measures you would take with a woman who's had a miscarriage

Answer 196

Expectant: if they are educated and aware of the consequences, can do expectant management. Must have haemodynamic stability, be reliable, understand there will be pain and bleeding, and have access to the follow up similar to the abortion. ALL CASES if they are beyond 12 weeks need an antiD dose. Review in a week and do an ultrasound to see progress. 10% failure rate. medical: offered if it's the preference, stable, done before 9 weeks, or as the step up if there is failure of the expectant management or there is a retained products of conception diagnosed on ultrasound follow up of the expectant management. Need to review the medical cases in 2 weeks to ocnfirm it's complete and no RPOC (USS). Educate about the painfulness, and the side effects of the misoprostol (Nausea and vomiting, diarrhoea, fever). Offer analgesia, and remember they should watch out for signs of infection. ``` Surgical is considerd when: - They prefer Unstable Infected Failed other options in a stepwise approach. ``` This is a dilatation and curetage. remember the risk of perf! Counselling: Educate them that they should get their period again in 4-8 weeks. Continu folate if want to try for pregnancy again, or take contraception. Conceive again after two normal periods. Early USS in pregnancy in future Social support offered

Question 197

How do we defined recurrent pregnancy loss?

Answer 197

3 in a row if less than 35 years but 2 if older.

Question 198

risk factors for recurrent pregnancy loss?

Answer 198

``` Previous pregnancy loss ▪ AMA ▪ ↑ parity ▪ Uterine factors o Congenital abnormalities o Sub-mucosal leiomyomas o Intrauterine adhesions ▪ APS – antiphospholipid syndrome (5% - 15%) ▪ Poorly controlled DM ▪ PCOS ▪ Hyperprolactinemia ▪ Genetic – Chromosomal abnormalities (e.g. balanced translocations) ```

Question 199

How do you work up and manage?

Answer 199

``` EVALUATION ▪ Karyotype the foetus ▪ Uterine assessment (e.g. hysteroscopy, HSG) ▪ Autoimmune - ACA + LA ▪ TFT ``` MANAGEMENT ▪ Genetic counselling if chromosomal abnormality ▪ Surgical management of uterine anomaly ▪ Treat hyperprolactinemia ▪ APS – Aspirin + prophylactic LMWH ▪ Serial USS + support when they do fall pregnant

Question 200

Types of ectopic pregnancy?

Answer 200

``` Cornual (interstitial) Tubal (isthmus) Tubal (ampullar) Infundibular ovarian Peritoneal Cervical Abdominal ```

Question 201

Uterine activity in pregnancy is about balance between activating an inhibitory factors. List some inhibitors. What stimulates contractions?

Answer 201

Progesterone, prostacyclin, relaxin, nitric oxide, PTHrP, CRH Prostaglandins and oxytocin

Question 202

Define labour?

Answer 202

regular uterine contraction lasting 30-60 seconds every five minutes, and progressive cervical dilaton

Question 203

What are the mechanisms of labour? Discuss.

Answer 203

Effacement, dilatation, and the three p's: power (uterine activity), passage (maternal pelvis + vagina), and passenger (foetal factors). Powers: - Normally contractions occur once every 5 minutes, and they last 30-60 seconds. They are measured using montevideo units, which is measured using a catheter. Adequate MVU is 200-250. They usually measure the sum of contractions in 10 minutes. Interventions here include the induction of labour (prostaglandins) and augmentation using oxytocin or rupture of labour. Passage refers to the pelvis passage and if there is cephalpelvic disproportion. Passenger refers to the foetal head diameter (widest part), foetal attitude, foetal lie and the foetal presentation.

Question 204

What are the cardinal movements of labour?

Answer 204

Descent (engagement), flexion, internal rotation, extension, external rotation, expulsion).

Question 205

Describe the stages of labour

Answer 205

First stage is either latent or active. Latent phase is to 3cm, and active is beyond this to 10cm. Normal active for nulliparous is 1.2cm/ hour and for multip it is 1.5cm/hr. The second stage is the delivery of the foetus. Remember, prolonged in a multip is going to be 1 hour and in a nullip it's going to be 2 hours. Third stage is placenta. mean here is 30 minutes.

Question 206

The following are terms used extensively in obstetrics: failed induction, active labour, arrest of first stage. What do these mean?

Answer 206

Failed induction is failure to have regular contractons (every three minutes) and failure of the cervix to change after at least 24 hours of oxytocin. Active labour is when the cervix is between 3-4cm, this is when the rate of dilation picks up greatly. However, it's observed this can take up to 6cm or some mothers. Arrest of first stage is when there is no change in cervixx when it's 3-4cm dilated over 2 hours. 1st stage arrest can be diagnosed ONLY if: ⃝ Woman has reached 6 cm and the water has broken ⃝ AND there has been no cervical change for: o 4 or more hours of adequate contractions o OR; 6 or more hours of inadequate contractions If the mom is still <6 cm, then she needs additional time and interventions before an arrest of labour can be diagnosed, because she is still in early labour

Question 207

What is the arrest in the second stage?

Answer 207

there are two ways we can diagnose it. WHEN PUSHING TAKES PLACE: ▪ >3 hours in first-time moms with an epidural, ▪ >2 hours in first-time moms without an epidural, ▪ >2 hours in experienced moms with an epidural, ▪ > 1 hour in experienced moms without an epidural NO IMPROVEMENT IN DESCENT OR ROTATION AFTER: ▪ ≥ 4 hours in first-time moms with an epidural, ▪ ≥ 3 hours in first-time moms without an epidural, ▪ ≥ 3 hours in experienced moms with an epidural, ▪ ≥ 2 hours in experienced moms without an epidural

Question 208

Discuss intrapartum foetal assessment.

Answer 208

it can be either extenral or internal. External is either an external foetal monitor or CTG. Internal is foetal scalp electrode or intrauterien pressure catheter (to measure the montevideo units over 10 minutes and hopefully achieve 200 - 250).

Question 209

What are the patterns of foetal heart rate monitoring? Discuss some trends?

Answer 209

Baseline is 120-160. we call that normal. higher or lower is brady or tachy. Variability is either absent, minimal (<5bpm), moderate 5-25 or marked 25. Periodic changes are also acceleratiosn and decelerations. We use 32 weeks to define the deceleration point, and we say that 10bpm over baselin under 32 weeks is an accel, but if over 32 it's 15. Decelerations are also things that we observe. These can be variable, early or late. A variable deceleration is due to umbilical cord compression, and it's due to either the artery or the veins compressing. If there is a vein compression, then HR goes up.If there is artery compression, heart rate drops. An early deceleration refers to the vagal reflex during labour, and is due to the cervix compressing the head of the baby. A late decel is when there is uteroplacental insufficiency.

Question 210

umbilical vein vs arteries

Answer 210

2 arteries and one vein. The vein carries nutrients and oxygen TO the baby, whereas the veins carry it away.

Question 211

how manage an abnormal foetal heart rate?

Answer 211

``` Hypotension o Maternal position – left lateral recumbent o IVF hydration, ephedrine 2) Maternal O2 administration 3) Cessation of contractions o Discontinue oxytocin o Uterine relaxants – terbutaline 4) Amnioinfusion 5) Expedite delivery ```

Question 212

How can we intervene in an abnormal labour?

Answer 212

``` ▪ Augmentation o Oxytocin o Achieve adequate uterine contractions o Requires reassuring foetal status ▪ AROM ▪ Therapeutic rest ▪ Operative vaginal delivery ▪ Cesarean delivery ```

Question 213

When does obstetric cholestasis occur?

Answer 213

Third trimester usually when the oestrogen is at it's highest.

Question 214

How does obstetric cholestasis present? How do we diagnose?

Answer 214

Clinical Presentation/History:  Pruritis (onset ~28w, esp in multiple pregnancies – esp hands + soles of feet) without rash – look for excoriations  Sleep disturbance (due to pruritis)  Jaundice +/- steatorrhea (2-4w after pruritis) – rare  Dark urine + pale stools – rare  Malaise + anorexia (occasional)  Past hx gallstones +/- pruritis while on OCP  FHx obstetric cholestasis or pruritis in pregnancy and/or gallstones Investigations:  Serum bile acids (>10mmol/L is diagnostic // >40mmol/L assoc w severe fetal risk + requires admission)  Elevated transaminases (not diagnostic) (rules out others)  Prolonged INR/PT in severe cases  Liver + GB USS to exclude obstructive GB disease and to establish gallstones

Question 215

Foetal effects of obstetric cholestasis? How do we manage?

Answer 215

Differential Diagnoses:  Pre-existing liver disease, alcohol or other drugs  Viral hepatitis  Hep A/B/C + CMV + EBV  Autoimmune liver disease  Pre-eclampsia + acute fatty liver disease of pregnancy Fetal effects:  Stillbirths usually after 38w with little to no warning  Severe OC (>40mmol/L serum bile acids) o Assoc w/ increased fetal mortality + morbidity, inc;  Pre-term birth (25% vs 6.5%)  NICU admission (12% vs 5.6%)  IUFD (1.5% vs 0.5%) Antenatal management:  Obstetrician – consider high risk care  Plan delivery (esp if dx >37w)  consider delivery at 38w  Admission is severe (bile acids >40), otherwise consider outpatient Mx  Fetal surveillance: o Report any decreased or absence of fetal mvoements o Perform umbilical artery Doppler for changes  Pharmacological intervention: o Ursofalk (for symptom relief, esp pruritis) o Antihistamines (drowsy or non-drowsy) o Recommend sorbolene, pinetarsol, aqueous craem, bicarb baths o Vit K 10mg daily if prolonged INR/PT (if left untreated, increases the risk of PPH)  Investigations: o Weekly serum bile acids (twice weekly in severe cases) o Weekly LFTs (twice weekly in severe cases) o Coags after dx of severe + before induction of labour Counselling:  40-60% risk of recurrence in subsequent pregnancies  Reassure no long-term sequelae for mum or bub  If familial OC, at risk of chronic liver disease  require long-term follow-up  Follow-up with GP review at 1/12 post-partum to check bile acids + LFTs  Physician review at 6/52 post-partum if abnormalities present

Question 216

How does an ARM work? Define abortion?

Answer 216

Abortion: termination of pregnancy (spontaneously or intentionally) <20 weeks gestation or <500g birthweight Artificial rupture of membrane (ARM): when membranes are ruptured intentionally to induce labour (decreased intrauterine pressure  baby’s head moves down  increased pressure on cervix  PGs produced)

Question 217

Which foetal lie is unstable?

Answer 217

Oblique

Question 218

Types of cephalic presentations

Answer 218

Vertex, military, brow, face from order of the most flexed to the most extended.

Question 219

Foetal denominators please?

Answer 219

Foetal occiput, chin/mentum and sacrum are the chosen points in vertex, face and breech presentations respectively

Question 220

great grand multip?

Answer 220

More than 10

Question 221

What is low, very low and extemely low birth weight

Answer 221

2500, 1500, 1000

Question 222

Perinatal period?

Answer 222

28 days after birth

Question 223

Placental attachments?

Answer 223

Placenta Decidua: chorionic villi attach normally to decidua o Placenta Accreta: chorionic villi attach to myometrium o Placenta Increta: chorionic villi invade into myometrium o Placenta Percreta: chorionic villi invade past myometrium

Question 224

Describe what is term

Answer 224

Pre-Term: <37 weeks gestation o Term: 37-42 weeks gestation o Post-Term: >42 weeks gestation

Question 225

What is PPH?

Answer 225

Primary PPH: ≥500mL blood loss within 24 hrs of delivery o Secondary PPH: excess blood loss from 24 hours to 6 weeks postdelivery (no quantified volume)

Question 226

What is viability in Aus?

Answer 226

24 weeks or 500g

Question 227

List the four T's in order of occurence.

Answer 227

Tone, trauma, tissue, thrombin. 70% is tone.

Question 228

Causes of an atonic uterus

Answer 228

Large baby, polyhydramnios, multiple pregs, twins, prolonged labour, anaesthetic, mag sulf

Question 229

Trauma

Answer 229

Laceration of cervix or vagina during a c section or instrumental delivry

Question 230

Risk factors for a PPH

Answer 230

``` Over 35 Macrosomia Asian Past PPH Caesar Coag disorders Meidcation induced hypotonia like mag sulf Obeseity Prolonged labour Existing uterine abnormlaioties ```

Question 231

Aetiology of tissue pph

Answer 231

Either we pull too much or there is an accreate, increta or postcreta and can't be delivered as easily.

Question 232

Signs and symptoms of PPH are as you would expect. How do we investigate?

Answer 232

Do HCT, weigh the kidney ishes and weigh the sheets (kidney dish is 700mL apparently), and you can also monitor vitals.

Question 233

How to reduce the risk of PPH?

Answer 233

Use of uterotonics during the third stage of labour (active management Early cord clamping (balance with risk of IDA) and controlled cord traction, and uterine massage after placetal birth.

Question 234

To manage a PPH, you do the following standard management. DRSABCD + get help, assess blood loss, monitor vitals, keep warm, give O2 if necessary o Dual IV access 14-16 gauge o Urgent bloods: FBC, group & hold, cross match, coag profile, U&E, Ca, lactate o Avoid dilutional coagulopathy, 2-3L crystalloid max until RBCs ready o Insert IDC to monitor urine output o Identify underlying cause: 4 Ts What is management if it's tone?

Answer 234

o Fundal massage o 5 IU IV Oxytocin over 2 minutes, repeat in 5 minutes up to total dose 10IU (DON’T DO QUICKLY, CAN CAUSE ISCHAEMIC ECG CHANGES), plus… o Start IV infusion of 40 IU IV Oxytocin/ 1 L of crystalloid at 125- 250ml/hr rate o 250 microg IV Ergometrine maleate over 2 minutes (CONTRAINDICATED eclampsia, pre-eclampsia, retained placenta  check placental borders) o 800-1000 microg PR misoprostol o Transfuse blood products and transfer to OT if continues o If this doesn’t fails, transfer to OT:  Apply bimaual compression, consider intrauterine balloon tamponade  If critical, consider B lynch suture, bilateral uterine artery ligation or hysterectomy  Bilateral uterine artery ligation

Question 235

Important management steps in a trauma, tissue or thrombin PPH?

Answer 235

Trauma: if stable and minor, repair as necessary. Take to OT and give blood transfusions if it's severe. ``` Tissue: Give oxytocin VE and visualise placenta USS if necessary Controlled cord traction Massage fundus only after the placenta is out and whole Transfer to OT if these fail to remove. ``` Thrombin: - Look for other signs of haemorrhage, as this may well be systemic Do a coags study Keep body temp elevaed Give 4 units RBC 4 units ffp 10 UNITS CRYOPRECIPITATE Clacium gluconate if low calcium

Question 236

What is a secondary post partum haemorrhage. Aetiology? Management?

Answer 236

between 24 hrs and 6 weeks Retained products, infection, pre-existing disease such as uterine fibroids, polyps, cervical polyps, trauma. Manage with bed rist and IV ab's (triples). If retained products, refer. Also use uterotonics and digital evacuation of the uterus under a GA.

Question 237

Risks factors for preterm birth and PPROM?

Answer 237

Maternal Characteristics Medical and Pregnancy Conditions Age <18 or >35 yo Short Cervical Length Ethnicity: ATSI, African, Asian Previous PTB Cigarette Smoking Infections: bacterial vaginosis, chorioamnionitis High or low BMI Multiple Gestation

Question 238

Describe the pathogenesis of preterm labour or pprom

Answer 238

It's multifactorial. Influenced by PG synthesis, oxytocin release, hormonal rations, (decreased progesterone and increased oestrogen), mechanical stretch in the uterus and changes in the uterine blood flow.

Question 239

Signs and symptoms of a PPROM or preterm labour?

Answer 239

Signs Symptoms SIgns include prescence of liquour on examination, cervical ripening, regular uterine activity. Symptoms include vaginal fluid loss (PPROM), pelvic pressure, lower abdo cramping and back pain. Differential diagnoses: - Urinary incontinence - Physiological vaginal discharge - Bacterial infection (eg. Bacterial vaginosis) - Cervical mucous (sign of impending labour anyway)

Question 240

How are these tihngs diagnosed?

Answer 240

Sterile speculum exam looking for cervical ripening and liquour or intact membranes. Assess the liquor colour and smell. If it's mec stained it might be labour, bloody and foul smelling might be an infection. If liquour not obvious, apply pad, encourage movement and inpspect pad later. DO NOT DO A BIMANUAL BECAUSE THIS CAN CAUSE INFECTION.

Question 241

INvestigationss needed in PPROM?

Answer 241

FHR and CTG monitoring for isngs of foetal distress HIgh vaginal swab for MCS + low vaginal/ anal swab for GBS. Midstream urine for MCS. If have these infections, you may want to keep them in because they could get a chorioamnionitis. FBC and CRP to assess infectious signs Foetal fibronectin: Indications: symptomatic labour between 22-36 weeks, intact membranes, cervical dilation <3cm  Contraindications: ROM, dilation >3cm, cervical cerclage insitu  >50ng/mL = positive = increased risk of PTB

Question 242

What is a cervical cerclage?

Answer 242

Cervical cerclage, also known as a cervical stitch, is a treatment for cervical incompetence or insufficiency, when the cervix starts to shorten and open too early during a pregnancy causing either a late miscarriage or preterm birth.

Question 243

Talk about the management of PPROM?

Answer 243

Management: - Admit to hospital if: fFN >50, cervical dilation present, ROM, contractions regular and painful, foetal distress present or clinical judgment favours - Monitor maternal and foetal obs regularly - Antenatal corticosteroids: o Decreased risk respiratory distress syndrome, intraventricular haemorrhage and neonatal death o Initial 2 doses 11.4mg IM Betamethasone 24 hours apart, if PTB expected within 24 hours delivery doses 12 hours apart o Repeat dose in 7 days if risk continues - Tocolysis: o Little evidence about use of tocolysis with PPROM before 34 weeks  associated with decreased delivery within 48 hours but increased risk of chorioamnionitis o Contraindications: chorioamnionitis, in-utero foetal death, preeclampsia, placental abruption o Nifedipine 20mg PO, repeat after 30 minutes if contractions continue, repeat after another 30 minutes if contractions continue o Maintenance dose 20mg PO every 6 hours for 48 hours - Antibiotics: o Recommended for presence of GBS, imminent PTB regardless of GBS status and chorioamnionitis o Ampicillin or amoxicillin 2g IV initially then 1g IV 6 hourly (clindamycin if allergic), PLUS… o Gentamicin 5mg/kg IV OD, PLUS… o Metronidazole 500mg IV BD - Magnesium sulphate: o Neuroprotective, reduces risk of cerebral palsy o Given if 24-30 weeks gesation o Loading dose: 4g IV bolus over 20 minutes o Maintenance dose: 1g/hour for 24 hours or birth - If birth imminent, inform senior obstetric and paediatric/NICU teams - If PTB does not occur and is not likely, discharge home with appropriate education on signs and symptoms that warrant hospital return, eg. signs of infection Complications: - Prematurity: increased risk of neonatal morbidity and mortality - Infection: increased risk of maternal morbidity and mortality

Question 244

Risk factors for shoulder dystocia? How is the diagnosis made?

Answer 244

``` Previous shoulder dystocia GDM Post-date pregnancy Macrosomia Maternal short stature High pregnancy weight gain Abnormal pelvic anatomy Prolonged 1st or 2nd stage Instrumental delivery ``` Diagnosis is made based on the turtle necking sign where head goes out then in, and when gentle downward traction of the foetal head fails to delivery the anterior shoulder.

Question 245

Define shoulder dystocia

Answer 245

Usually due to anterior shoulder impacting maternal pubic symphysis AFTER BIRTH OF THE FOETAL HEAD

Question 246

Management of shoulder dystocia?

Answer 246

HELPERR Help Activate instituional protocol, appropriate notification, additional staff, additional back up, neonatal resus, obs backup, anaesthesia, theatre booked. Episiotomy Needed to do additional manoueveres. May not need to, do this in response to first line treatment. ``` Legs McRoberts Manouvere Flex maternal hips so that thighs are on abdo and knees are towards nipples - Straightens lumbosacral lordosis, increases AP diameter of pelvis, flexes foetal spine - Reduces >40% of dystocias ``` Pressure Suprapubic pressure by assistant while the hips are flexed. Use a CPR style hand position for this, Attempt this for 30-60 seconds. Reduces 50% of dystocias when done with McRoberts. Enter Rubin II and Woodscrew. Approach anterior foetal shoulder from behind - Exert pressure on scapula to adduct most accessible shoulder and rotate to oblique positon - Continue McRoberts Wood Screw Manoeuvre: - Approach posterior foetal shoulder from front - Gently rotate shoulder toward symphysis Reverse Woodscrew Manoeuvre: - Approach posterior shoulder from behind - Rotate foetus in opposite direction from Rubin or Wood Screw manoeuvres (apply pressure to posterior aspect of shoulder) Remove posterior arm Roll the woman Roll to the McRoberts all fours position. Increases the pelvic diameter. Gravity may also contribute to dislodging. Delivery of the posterior shoulder with gentle downward traction. May attempt all enter manouveres in this position. Last resort manourvers: Clavicle fracture, symphysiotomy, zavanelli. (Give uterine relaxant and push baby back up - Perform CS - Increased risk PPH and uterine rupture)

Question 247

Complications of polyhydramnios

Answer 247

Umbilical cord prolapse, abruption, uterine atony, malposition, PPROM,

Question 248

Complications of oligohydramnios

Answer 248

IUGR, preterm birth, cord compression in labour, and more likely to get caesars because of worrying decompressions.

Question 249

Complications of dystocia?

Answer 249

3rd and 4th degree tears Anal sphincter damage PPH Uterine rupture Symphysis separation Neonatal brachial plexus palsy (Erb's Palsy) Neonatal clavicular fracture Foetal acidosis Foetal hypoxic brain injury

Question 250

Classification of female sexual dysfunction

Answer 250

Desire disorders: Hypoactive sexual desire, sexual aversion disorder Arousal disorders orgasmic disorder Dyspareunia

Question 251

Causes of dyspareunia?

Answer 251

Superficial: vulval: infection, lichen schelrosus, atrophic vulvitis, chemical reaction, mass (bartholin's cysts), trauma. Vaginal: vaginismus, atrophic vaginitis, trauma. Cervical: cervical mass, trauma Deep: Cystitis, endometriosis, adenomyosis, PID, fixed retroverted uterus, pelvic mass, tumour, IBD and IBS

Question 252

Brief description of lichen sclerosus, what the signs and symptoms are, and how to diagnoses + manage?

Answer 252

Remember it's a risk factor for SCC. Signs: white, scar like lesions on the vulvar with some excoriations. Can be on perineum too. Symptoms: dyspareunia, pruitis, pain Investigations + diagnosis: clinical. Can do biopsy. Manage by avoiding exacerbating factors, topical steroids, PV oestrogen and watching for changes due to SCC risk.

Question 253

Atrophic Vaginitis: what are some risk factors and clinical features?

Answer 253

Aside from menopause and ovary failure, smoking, chemorads/ anti oest, smoking, nulliparity, decreased sexual activity. We can get vaginal dryness, and dyspareunia with thinning of the mucosa. It's associated with itch, bleeding, tightness, and it's seeing increased urinary frequency and urgency due to the atrophic urethritis and trigonitis.

Question 254

Diagnosis of atrophic vaginitis?

Answer 254

Pelvic exam, vaginal bedside pH (if alkaline it's probs bacterial vaginosis), STI screen, PAP smear, pelvic and transvaginal USS if bleeding

Question 255

Management of atorphic vaginitis:

Answer 255

``` Lubricant when having sex Topical oestrogens Reassurance Moisturisers HRT could be considered ```

Question 256

Complications of atrophic vaginitis?

Answer 256

Bleeding, vaginal infections, urinary symptoms

Question 257

PID has two causes. What are they, what are the clinical features and how to diagnose?

Answer 257

They are endometriosis and they are chronic STI. They can present with PV bleeding, deep dyspaerunia, subfertility, vaginal discharge, pelvic pain, discharge, palpable adnexal masses, cervictis etc. also fevers. To diagnose it, I would just do an STI screen, with vaginal and urethral swabs, with midstream urine. Beta HCG, Pap smear, pelvic and transvaginal ultrasound.

Question 258

Manage PID?

Answer 258

Temporary abstinence, may require surgical removal of the adhesions, treat partners

Question 259

Complications of PID?

Answer 259

Chronic pain, infertility, ectopics, pelvic abscesses.

Question 260

How do we diagnose endometriosis?

Answer 260

Definitive = on laparoscopy/ laparotomy. Presumed = dysmenorrhoea and pelvic pain even if not showing up on the exam or USS.

Question 261

Most accepted theory of endometriosis pathogenesis?

Answer 261

Retrograde menstruation. Increased risks are menorrhagia, cervical stenosis, and outflow tract obstruction.

Question 262

Commonest place for endometriosis:

Answer 262

In descending order, ovaries, uterosacral ligaments, ovarian fossae, then pouch of douglas.

Question 263

Defintive diagnosis is on laparotomy and biopsy. What will it show?

Answer 263

Will show any 2 of the following 3: 1. Endometrial type epithelia / glands 2. Endometrial type stroma 3. Evidence of cyclical activity (recent or old blood, hemosiderin laden-MACs)

Question 264

Classic features of endo?

Answer 264

Dysmenorrhoea, dyspareunia, dyschezia

Question 265

What is metorrhagia, and what is menometorrhagia?

Answer 265

Menometorrhagia is a combination of menorrhagia and metorrhagia, where metorrhagia is intermenstrual bleeding.

Question 266

Examination findings in endometriosis?

Answer 266

``` Bluish discoloration on external genitalia ▪ Cervical motion tenderness ▪ Uterine motion tenderness ▪ Mass in / tender nodules in: o posterior vaginal fornix o adnexa o pouch of Douglas o rectovaginal ▪ Fixed or ↓ mobility of uterus ▪ Retroverted uterus ```

Question 267

Comment on the use of laparoscopy in infertile women?

Answer 267

Do it. 1/2 of these will have endo, and in those who don't, they have significant pelvic pathology anyway.

Question 268

Management of endo?

Answer 268

Use mefanamic acid and paracetamol to control the pain. Hormonal is also used, and we can used COCP/ progestogens, and GnRH agonists. The last line is danazol. All as effective as each other. Use the surgical (laparoscopy) to ablate implants, excise adhesions and remove endometriomas.

Question 269

Go over the stages of endometriosis?

Answer 269

1: scarce 3: endometriomas 4: DENSE adhesions

Question 270

Things to look for in a fertility assessment?

Answer 270

Male factors - adequate functional and motile sperm? Ovulation diagnosis: is the woman ovulating? Tubal function tests: can the sperm and the egg meet? Uterus + cervix: can implantation persist? Ovarian reserve?

Question 271

What is infertility?

Answer 271

1 year of unable to get preg. Primary and secondary.

Question 272

What features make you think no IVF for you?

Answer 272

Advancing maternal age, more than 7 years of trying, and no previous female pregnancies.

Question 273

History questions for infertility?

Answer 273

``` HISTORY Both ▪ Assess amount + timing of intercourse ▪ Occupational factors that may affect fertility ▪ Previous hx of STI ▪ Chronic medical conditions ▪ Drug history + prescription medications Female partner:  Menstrual history  ? ovulation  Pelvic pain / dysmenorrhoea  ? endometriosis  Past abdominal surgery  ? adhesions  ? exposed in utero to DES  ? rubella status  Gyne history  PCOS, fibroids, endometriosis Male partner o ? Hx of cryptorchidism o ?timing of orchiopexy o ? testicular torsion o ? inguinal hernia repair o Androgen / steroid use o STI history (+ mumps!) ```

Question 274

Some exam findings in infertility?

Answer 274

``` EXAMINATION   NOT USUALLY DONE!!! Female ▪ Obesity / ↑ BMI ▪ Thyroid dysfunction features ▪ Cushing’s features ▪ PCOS, hyperandrogenism ▪ Galactorrhoea (?↑prolactin) ▪ Abdominal surgical scars ▪ Pelvic exam o Cervical anomaly / pathology o Take STI test samples o Assess for cervical/ uterine / adnexal tenderness o Size + contour of uterus o +/- DRE is endometriosis suspected ``` ``` Male ▪ Degree of 2* sexual development ▪ BMI ▪ Gynecomastia ▪ Genital exam o Size + location of urethral meatus o Structures o Evaluate testes (location + size) o Epidydimitis? o Assess for varicoceles / hydroceles ▪ DRE to assess prostate ```

Question 275

Describe fluid make up of sperm:

Answer 275

70% seminal vesicle secretion, 20% prostate, 5% bulbourethral gland, 5% semen from testes. It takes less than 30 minutes for liquefaction to occur as the prostate fluids break down the coagulating factors. The longer it takes, the fewer sperm get to the ova.

Question 276

Sperm concentration: what is oligozoospermia?

Answer 276

Less than 20 mil per mL. No sperm in the sample is azoospermia. Note that artefact is common.

Question 277

Remember how in females we said we needed to assess ovulation, tubal function, uterine factors, cervical factors and ovarian reserve?

Answer 277

Ovulation is assessed by doing a day 21 (7 day post menses) progesterone. Basal body temperature is important, and doing it daily for three months will show a spike when we ovulate. USS follicle monitoring can be done too. Tubal function: hysterosalpingogram. Look at the anatomy. Uterine factors: hysteroscopy Cervical factors: a post coitus test is done that looks at secretions. Ovarian reserve: Can also do a day 3 FSH.

Question 278

Talk to me about the De Lancey levels of support

Answer 278

Three levels. Level one eoncempasses sacrum, uterus and the cervix. The levels of support here are the cardinal ligaments and the uterosacral ligaments. Things that can go wrong are dragging, fullness/ feeling a mass, bulging. Level two encompasses the upper part of the vagina, the bladder, and the rectum (and pubis but not a part). The methods of support here are the levator ani, pubovesicle and puborectal ligaments and the things that can go wrong are digitation (have to insert your fingers into the vagina to defaecate), urge incontinence (urge is a problem with bladder hyperactivity remember), and cystocole, UTI's (from retention due to funny angle of the bladder). The third level is the opening of the vagina, the genital hiatus and the anal canal. The supports here are the perineal body (external anal sphincter, bulbospongiosus, the transverse perinealmuscles and the things that can go wrong are digitation, rectocoele, stress incontinence (hypermobility of the urethra), and a widened genital hiatus (causing flatus and reduced pleasure) and anorectal incontinence. All of these are having risk factors including increased intrabdominal pressure (pregnancy, obesity, NOT VAGINAL BIRTH) and weakeneded ligaments (things like Marfan's, EHlers Danlos).

Question 279

Types of incontinence. Managmeent of urge and stress?

Answer 279

Mixed, overflow, urge, stress, true. Urge is through bladder training and kegel's. Stress is via HRT, stopping them from smoking, losing weight, or you could get them to do a suburethral tape or sling procedure. Remember to rule out UTI's.