master deck Flashcards
1
Q
early pregnancy symptoms?
A
tiredness
nasuea
breast tenderness
2
Q
… is the commonest complication in early pregnancy
A
miscarriage
3
Q
… % of clinical pregnancies end is miscarriage
A
20%
4
Q
risk factors for miscarriage?
A
- maternal age over 35
- smoking
- structural uterine abnormalities
- history of miscarriage
- hormonal dysfunction
- exposure to teratogens
- contraceptive device in situ
5
Q
define threatened miscarriage?
A
bleeding, cramps, but baby is okay
6
Q
define spontaneous miscarriage?
A
embryo passed out of uterus
7
Q
define complete miscarriage?
A
- endometrial thickness <15 mm, cramping bleeding
- need to have IU gestation sac (IUGS) previously to make diagnosis
8
Q
define incomplete miscarriage?
A
- endometrial thickness > 15 mm (still tissue in uterus), cramping or bleeding
- need to have IU gestation sac previously to make diagnosis
9
Q
define inevitable miscarriage?
A
- cervical os open and ongoing bleeding, heaving bleeding
10
Q
define consecutive miscarriage?
A
3 spontaneous miscarriage
11
Q
symptoms and signs of miscarriage?
A
vaginal bleeding
abdo cramps
loss of pregnancy symptoms
no symptoms
12
Q
presentation of miscarriage ?
A
bleeding on wiping is common
cervical excitation may suggest ectopic pregnancy
13
Q
investigations of miscarriage ?
A
transvaginal ultrasound
- may qualify as pregnancy of uncertain viability if borderline – come back in 10-14 days and repeat ultrasound
14
Q
how can miscarriage be diagnosed on ultrasound ?
A
transvaginal ultrasound
1. embryo > 7mm and no cardiac pulsation
2. gestational sac > 20 mm and mopey (no yolk sac or embryo)
15
Q
management options for miscarriage?
A
- conservative
- exclude signs of infection
- follow-up scans every 2 weeks
- generally move to medical or surgical after one or 2 weeks in reality
- very important to counsel patients on signs to be aware of (heavy bleeding), may need emergency ERCP
- can take paracetamol, nurofen at home - medical
- 80-91% success rate
- can take at home, will have bleeding and pain, but should settle in 1 or 2 days
- nausea, vomitting, headache
- mifepristone (progesterone antagonist, taken in hospital) followed by misoprostol (prostaglandin analogue - contracts uterus) 36 hrs later - surgical: ERPC or manual vacuum aspiration (MVA)
- suspicion of molar pregnancy
- cytogenetic sampling is required for recurrent miscarriage
- large gestational sac - higher risk of hemorrhage
- allergies to tablets
- risks include: hemorrhage, infections, incomplete evacuations, uterine perforation, cervical tears, asherman’s syndrome
- misoprostol before surgery to soften cervix
16
Q
follow-up for miscarriage?
A
urine pregnancy test 14 days post for hug levels - less than 1000 is successful
17
Q
how may someone with an ectopic pregnancy present ?
A
shoulder tip pain/peritonitis
fainted/collapse
small amount of bleeding
vital signs usually normal unless ruptured
18
Q
risk factors for ectopic pregnancy?
A
- previous pelvic inflammatory disease
- history of IVF
- tubal surgery
- infertility
- smoking
- increased maternal age
19
Q
management of ectopic pregnancy?
A
- stable patient - monitor HCG until under 20. if HCG low at the start then 88% will resolve on their own
- medical
- methotrexate IM injection: need to check renal and liver profile prior to ir
- must be stable patient and will need follow-up. HCG on day 4 and 7, follow until less than 20 - surgical
- unstable patients
-laparoscopy or laparotomy
- salpingostomy or salpingectomy (needed for rupture
- follow- up Hcg
20
Q
management of rupture ectopic pregnancy?
A
ABCs
get help
take bloods (type and crossmatch)
surgery
21
Q
women who had a ectopic pregnancy what is required ?
A
- next pregnancy requires early scan to rule out ectopic
- future fertility
- need anti-D in rhesus negative
22
Q
what are obstetrical complications of T1DM (maternal) ?
A
- HTN, PET and related hypertensive disease
- worsening of complications of T1DM: retinopathy, neuropathy, UTI, cardiac disease
- miscarriage
- hypoglycaemia (
- DKA
- hyperglycaemia
- complicated labour; induction/CS
23
Q
what are fetal complications of T1DM?
A
- growth restriction, placental insufficiency
- premature delivery (due to polyhydraminos)
- macrosomia/shoulder dystocia/birth trauma
- congenital malformations
- perinatal mortality (still birth)
- hypoglycaemia (requires feeding from mother within an hour to avoid complications
- polycythemia, hypocalcemia, hyperbilirubinemia
- cardiomyopathy
24
Q
how does maternal hyperglycaemia affect the fetus ?
A
- causes fetal hyperglycaemia, which leads to osmotic diuresis (excessive fetal urine - polyhyraminos) and fetal hyperinsulinemia
- fetal hyperinsulinemia causes macrosomia and increased erythropoiesis (causing polycythemia)
25
preparation for pregnancy T1DM?
1. high dose folic acid 3 months before
2. HbA1c <6.5%
3. fasting blood glucose target of 3.5-5.5 mmol/L
4. review medications
- discontinue ACEi/ARB
- avoid statin
- swap antihypertensives to those safe in pregnancy (labetalol, nicardipine, methyldopa)
5. get to a normal BMI
6. screen for microvascular complications, and hypertension
26
T1DM monitoring during pregnancy?
MDT - with endometrial
sugars checked 7 times/day
high dose folic acid given until 12 weeks
aspirin from week 12 to reduce preeclampsia
monitor insulin usage - insulin demand and usage should increase as pregnancy continues - if it is falling, this might be a sign of imminent fetal demise (due to placental insufficiency)
regular scans: 11-14 weeks, then every 2-4 weeks until 36 weeks
**need to be delivered before or at 39 weeks - or earlier depending on complications
27
how is T1DM managed in Labour?
sliding scale insulin
hourly blood glucose
half insulin infusion after placenta delivery, check blood glucose every 2hours
28
what needs to be done immeditately after delivery in the case of T1DM ?
1) breast feed immediately within 1 hour; at increased risk of hypoglycaemia, respiratory distress
29
what is the definition of preterm labour?
onset of labour before 37 weeks
- extreme: before 28 weeks
- very preterm: 28-32 weeks
-moderate to late: 32-37
30
ethology of preterm labour?
1) uterine stretch: polyhydraminos, multiple pregnancies, abruption
2) inflammation: UTI, ascending infection
3) cervical weakness
- or short cervix
- if 5mm at 23 weeks - 80% chance of preterm labour
- presents as painless dilation of the cervix +/- precipitous labour
4) iatrogenic (we induce it)
5) idiopathic
31
risk factors for preterm birth?
1. history of preterm birth
2. multiple pregnancies
3. cervical surgery (multiple LLETZ or single cone biopsy
4. low SES
5. vaginal bleeding in early pregnancy (chorion separates and gets bleeding behind it, source of infection, leads to PPROM and early contractions)
6. extremes of age and BMI
7. uterine anomalies
8. medical conditions (LSE
9. pre-eclampsia
10. shorter inter pregnancy intrervals
32
causes of preterm labour?
1. cervical incompétence
2. abruption
3. infection
4. uterine anomaly
5. placental insufficiency
33
neonatal complications of prematurity?
1. interventricular hemorrhage
2. retinopathy of prematurity
3. pulmonary edema/pulmonary hemorrhage
4. hypothermia
5. sepsis
6. necrotizing enterocolitis
7. respiratory distress syndrome: bronchopulmonary dysplasia and chronic lung disease of prematurity
8. apnea of prematurity - give caffeine (methylxanthines) to stimulate breathing pattern.
34
what is fetal fibronectin?
normally found between uterus and amniotic sac. if it negative unlikely to deliver within the next 7 days
35
what is magnesium sulfate used for?
1. used in pre-eclampsia to raise the seizure threshold
2. acts a short term tocolytic
3. reduces the risk of cerebral palsy
4. given when delivery is expected within 12 hours -- before 32 weeks
36
what is atosiban ?
- inhibits oxytocin induced contractions
- it is a tocolytic (stops contractions)
37
what are the indications for tocolytics ?
1. 24-36 weeks
2. given to delay for 24 hours (to Give time to deliver steroids, get centre when she can delivery)
38
what can be done to prevent preterm labour?
1. progesterone PV
2. cervical sutures (cerclage) give at 12-14 weeks
39
risk of hysterectomy?
1. excessive bleeding, need for transfusion
2. damage to ureters
3. damage to tubuloinfundibular ligament which contains ovarian artery
4. general: infection, VTE, bleeding, anaesthetic risks
40
only... % of fibroids are symptomatic
25%
41
.. of women in the 50s have fibroids
50%
42
treatment options for fibroids?
1. hysteroscopy and resection
2. progesterone coil
3. transexamic acid for heavy bleeding relief
4. myomectomy
5. Interventional radiology and can embolise fibroid to cut off blood supply
6. hysterectomy
43
risks of fibroids in pregnancy?
1. preterm birth
2. growth restriction
3. later miscarriage
4. abnormal lie
5. low fibroid could obstruct cervix
6. PPH
44
differential for post menopausal bleeding?
endometrial hyperplasia/cancer
endometrial polyps
atrophic vaginitis
cervical cancer
45
endometrial cancer is usually what type? what is another subtype
adenocarcinoma
papillary serous cancer
46
risk factors for endometrial cancer?
early menarche
late menopause
nulliparity
obesity
PCOS
tamoxifen
47
stages of endometrial cancer?
1. confined to the uterus
2. into the cervix, but not beyond
3. local spread into the vaginal vault
4. distant mets
48
investigations for endometrial cancer?
1. transvaginal ultrasound: >3cmm if not on HRT, >5 mm if on HRT
2. biopsy
- pipette
- +/- outpatient hysteroscopy (combined with biopsy, D+C/ablation, insertion of mirena coil
3. if confirmed
- CT TAP (staging)
49
surgery for endometrial cancer
total abdominal hysterectomy + bilateral salpingophorectomy + bilateral sentinel lymph node biopsy
- follow-up radical if vaginal recurrence +/- chemo/rad if advanced stage
50
risks of ovarian cancer
increased number of ovulation
ovulation
51
familial syndromes associated with ovarian cancer ?
BCRA1/2
Lynch syndrome (associated with colorectal and endometrial cancer_
52
OCP and tubal ligation is... for ovarian cancer
protective
53
classification of ovarian cancer
1. epithelial
2. sex-cord stromal
3. germ cell tumour
54
staging of ovarian cancer?
1. one ovary
2. into the pelvis
3. into the abdominal cavity
4. distant mets
55
what is Meigs syndrome?
triad of:
- benign ovarian mass
- ascites
- pleural effusion
**both ascites and pleural effusion resolve with resection of the tumour
56
management of ovarian cancer?
1. total abdominal hysterectomy + bilateral salpinogo-oophorectomy, peritoneal washings
2. omentectomy
3. chemo: paclitaxel
- used for cytoreduction before surgery
57
only screening for ovarian cancer?
TVUS and Ca-125 in a patient who is BRCA positive
58
investigations for suspected ovarian cancer?
1. ultrasound
2. CA-125 + CT TAP
59
90% of ectopic pregnancies occur in the ...
Fallopian tubes
60
investigations for primary amenorrhea?
1. bloods (FSH, LH, +/- estradiol, prolactin, TSH)
2. Pelvic/transabdominal US
3. karyotype +/- MRI
61
if primary amenorrhea occurs in the presence of inappropriate secondary sexual characteristics, it is likely a problem with ?
HPO axis
62
if primary amenorrhea occurs in the presence of secondary sexual characteristics, it is likely a problem with the anatomy
anatomy
63
define precocious puberty?
<8 years old
most often central cause
64
contraindications to oral combined contraceptive?
migraine with aura
personal or family history of DVT
65
post partum hemorrhage is defined as ?
defined as bleeding from the genital tract >500 ml after delivery of the baby
- primary if within 24 hours of delivery
66
pre-pregnancy risk factors for PPH?
1. high parity
2. persona/family history of coagulopathy
3. need for anticoagulant
4. previous PPH
67
antenatal risk factors for PPH?
polhydraminos
macrosomia
multiple pregnancy
known placenta accrete
IUD
68
intrapartum risk factors for PPH ?
precipitous labour
dystocia
infection
antepartum hemrorhage
instrumental delivery
cesarean section
amniotic fluid embolism
69
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