Not core conditions Flashcards
Definitions- gestational age and parity
Gestational age: the duration of the pregnancy starting from the date of the last menstrual period
Parity: the number of times a women has given birth after 24 weeks gestation, regardless of whether the fetus was alive
The trimesters
First trimester: start -> 12 weeks gestation
Second trimester: 13 ->26 weeks gestation
Third trimester: 27 weeks gestation to birth
Booking appointment
The first initial meeting at 8-12 weeks
Baseline assessment: weight, height, BMI, BP
Risk assessment:
- discuss FGM
- discuss domestic violence
- rhesus negative = book anti-D prophylaxis
- gestational diabetes = book oral glucose tolerance test
- FGR = book additional growth scans
- VTE = provide prophylactic LMWH if high risk
- pre-eclampsia = provide aspirin if high risk
Booking appointment: education and booking bloods
Education:
- what to expect
- lifestyle advice
- supplementation advice
- plans for birth
- advise on later screening tests
- breast feeding and antenatal classes
- discuss mental health
Booking bloods:
- blood group, antibodies and rhesus status
- FBC
- screening for thalassemia (all) and sickle cell (high risk)
Pregnancy supplement advice
400mg folic acid from before pregnancy to 12 weeks
10mcg or 400 IU daily of vitamin D
Avoid vitamin A supplements and eating liver or pate
Pregnancy diet advice and flying
Avoid unpasteurised dairy or blue cheese (risk of listeriosis)
Avoid undercooked or raw poultry (risk of salmonella)
Dont drink alcohol
Dont smoke
Okay to fly up to:
- 37 weeks in a single pregnancy
- 32 weeks in a twin pregnancy
Dating scan
10-14 weeks
Scan to identify accurate gestational age from the crown rump length. Identification of multiple pregnancies
Foetal anomaly scan
Between 18 and 20+6 weeks
This is an ultrasound to identify any anomalies
Combined test
Between 11 and 14 weeks
USS- measures nuchal translucency (>6mm indicative of Down’s syndrome)
Maternal blood tests:
- beta-HCG (raised indicates a greater risk)
- PAPPA (decreased indicates a greater risk)
Triple test
Tests for down syndrome
Between 14 and 20 weeks
Maternal blood tests:
- beta-HCG
- alpha-fetoprotein (low result indicates greater risk)
- serum oestriol (low result indicates a greater risk)
Quadruple test
Between 14 and 20 weeks
Identical to the triple test but also includes maternal blood testing for inhibin A (raised indicates a greater risk)
Further Antenatal test for downs syndrome
When the risk is greater than 1 in 150, the women is offered either amniocentesis or chorionic villus sampling
Antenatal appointments
25 (nulliparous only)
28
31 (nulliparous only)
34
36
38
40 (nulliparous only)
41
42
Routine antenatal appointments- whats done
Discuss plans for the remainder of the pregnancy
Measure SFH from 24 weeks onwards
Measure fetal presentation from 36 weeks onwards
Urine dips for pre-eclampsia and bacteriuria
BP for pre-eclampsia
Additional antenatal appointments
OGGT for women at risk of gestational diabetes between 24-28 weeks
Anti-D injections in rhesus negative women at 28 and 34 weeks
USS for placenta praevia at 32 weeks
Serial growth scans for women at risk of FGR
Vaccines offered during pregnancy
Pertussis vaccine from 16 weeks gestation
Flu vaccine when it is autumn or winter
What factors make a pregnancy high risk
DM
Epilepsy
HTN
Prev IUGR
Multiple pregnancy
Increased BMI
Smokers
Substance misuse
Function of HFEA (Human fertility and embryo authority)
Keep info about embryos under review
Publicize services provided to public
Police licensing
Female puberty and growth spurt
Growth spurt: 11.5
Puberty: 8-14
Tanners staging female
Stage 1 (>10): No pubic hair, no breast bud
Stage 2 (10-11): light pubic hair, breast bud behind aereolar
Stage 3 (11-13): course and curly pubic hair, breast elevates beyond areolar
Stage 4: (13-14): adult like pubic hair, not reaching thigh, areolar mound forms and projects to surrounding breast
Stage 5: (14+): Hair extends into medial thigh, areolar mound reduces and adult breast forms
Hormones and puberty
What hormone initiates puberty: GnRH
What hormone stimulates oogenesis and sperm production: FSH
What happens to FSH and LH levels before puberty: FSH plateaus a year before menarche, LH continues to rise and spikes just before menarche
Tanner staging male
Tanner stage 1: villus hair, testes <2.5cm
Tanner stage 2: enlargement of the testes and scrotum, scrotum roughens and reddens. Pubic hair sparse across base of penis
Tanner stage 3: Enlargement of penis (length at first): further growth of testes, hair spreads to mons pubis
Tanner stage 4: Penis enlarges in breadth and development of glans, rugae appear on scrotum. Adult hair but not spread to medial thigh
Tanner stage 5: adult like appearance in size and shape. Pubic hair course and full- inverted triangle, on medial thigh but not linea alba
Symptoms of puerperium
Painful perineum
Urinary incontinence
Mastitis
Dyspareunia
Backache
Anaemia
Baby blues
Hormonal changes in the menopause
Oestrogen decreases, and as a result, LH and FSH increase. GnRH increases. Lack of oestrogen results in failing follicular development
Follicular phase menstrual cycle
Day 1-14
FSH stimulates development of secondary follicles
Granulosa cells surrounding follicles secrete oestrogen
Oestrogen decreases amounts of LH and FSH at low levels. At high levels there is an LH surge which causes ovulation
Luteal phase of menstrual cycle
Follicle becomes corpus luteum which secretes progesterone
If fertilisation occurs embryo secretes bHCG which maintains corpus luteum
If no fertilisation –> decreased progesterone, and oestrogen leading to menstruation
Uterine involution
By day 10-14 the uterus returns to the pelvic organs (autolysis). Goes from 1kg to 40/60g. Oxytocin can aid involution
Lochia
Lochia rubra: bright red, clots, 1-3 days after delivery
Lochia serosa: pinkish/brown, day 4-10 postpartum
Lochia alba: yellowish, white cream colour. Lasts approx 11 days-6 weeks postoartum
When do vaginal rugae return after birth
After 3-6w rugae reappear
Hormonal changes after birth
Decreased progesterone (so lactalbumin can proliferate)
Increased prolactin
When do periods return after birth: 12 weeks
Prolactin and oxytocin function
Prolactin- milk production
Oxytocin- milk let down
Physiological changes after birth
Decreased plasma volume
Fall in HR and CO
Hypercoaguable state for 6w
Triple assessment- breast cancer
If >M3 on mammogram
- History and examination
- Mammogram
- Biopsy for histology
Biopsy stages
B1 = normal
B2 = benign
B3 = Uncertain
B4 = Suspicion of malignancy
B5 = malignant
Genetic testing- breast and ovarian cancer
Testing for BRCA1/BRCA2 and TP53
- Only offered if family history suggests if cancer within the family might have happened because of a faulty gene
- Test the family member with breast/ovarian cancer, if the gene is present can test family members who have not had cancer
- Blood sample
- If family member with cancer is not available for testing you should be tested if family history suggests you have a 10% chance of having the faulty gene
- If you have had breast/ovarian cancer should be offered genetic testing if there is a 10% chance of a faulty gene in your family
Genetic testing- what a positive result means (BRCA)
- Not guaranteed to get cancer
- If you have one of the BRCA genes, there is a 50% chance you will pass this on to any children you have and 50% chance that each of your siblings already has it
- Women with the faulty BRCA1 gene, for example, have a 65 to 79% lifetime risk of breast cancer and a 36 to 53% risk of ovarian cancer before the age of 80.
Advice for women for a positive genetic test of BRCA1/ BRCA2
- Can have annual breast screening
- Lifestyle changes: avoid the COCP, drinking alcohol, being overweight
- Medicine (chemoprevention): Tamoxifen, Raloxifene and anastrozole for women at increased risk
Surgery: Mastectomy, removing ovaries (before the menopause)
Genetic testing- Miscarriage
- If you’ve had your third miscarriage karyotyping is recommended
- Half of all miscarriages happen because babys chromosomes are abnormal. This is usually a one off
- Rarely due to unbalanced translocation, where one parent carries a balanced translocation. Means some DNA is missing
- Can then be offered IVF with genetic testing
Genetic testing- Miscarriage
- If you’ve had your third miscarriage karyotyping is recommended
- Half of all miscarriages happen because babys chromosomes are abnormal. This is usually a one off
- Rarely due to unbalanced translocation, where one parent carries a balanced translocation. Means some DNA is missing
- Can then be offered IVF with genetic testing
Tests for recurrent miscarriages
- Antiphospholipid antibodies- diagnosed with 2 positive tests 12 weeks apart
- Karyotyping
- Pelvic ultrasound to assess uterine anatomy
- For second trimester miscarriages should be screened for inherited thrombophilias including factor V Leiden, factor II (prothrombin) gene mutation and protein S
STI testing
- Men who have sex with men should have repeat testing every 3 months if they are at increased risk of STI’s
- Annually everyone under 25 should receive at STI test and after every sexual partner
Treatment for menorrhagia
1) Mirena releases 20 micrograms of levonorgestrel daily inside the uterus which makes the endometrium thin and reduce or stop menstrual bleeding. Mirena is an effective long-term management option for menorrhagia.
2) Tranexamic acid is an antifibrinolytic drug which can also be used to prevent and treat bleeding during caesarean section and other surgeries or significant bleeding following a trauma.
3) Mefenamic acid is a NSAID which reduces the bleeding and relieve any pain associated with menorrhagia.
Prescribing in pregnancy
First trimester- can produce congenital malformations (teratogenic)
Second and third trimester- can effect the growth or functional development of the fetus
Screening for prostate cancer
- Screening is not done in the UK
- Digital rectal exam
- PSA test, shouldnt be done if asymptomatic
- 2 week wait referral if either are abnormal
- Then confirmed by biopsy or MRI
- Transperineal template biopsy, transrectal USS biopsy, MRI CT
Diagnosing testicular cancer
- Two week wait referral
- Testicular ultrasound
- Blood tests: AFP (alpha feto-protein), Human chorionic gonadatrophin (HCG), Lactate dehydrogenase (LDH)
- The only way to confirm it is to remove the whole testicle and test it
Postpartum contraception
- Immediately after birth: Implant, injection, POP, condoms
- An IUD and IUS can be inserted within 48 hours after birth otherwise you have to wait 4 weeks
-3 weeks: if not beast feeding you can use the combined pill, vaginal ring and contraceptive patch - 6 weeks: if breast feeding you can start the COCP, vaginal ring and contraceptive patch
What causes a raised PSA
BPH, Prostatitis, Ejaculation
Risk of steroids in pregnancy
Increased maternal HTN
Gestational diabetes
Osteoporosis
Doxycycline
Drug type: Tetracycline
Contraindications: Myansthenia Gravis (increases muscle weakness), SLE, children under 8, alcohol dependence
Azithromycin
- Drug type: Macrolide
- Indication: Chlamydia, Gonorrhoea, Trichomoniasis
- Contraindications: Electrolyte disturbance (prolonged QT), myansthenia gravis
Metronidazole
- Class: Nitroimidazole
- Indications: BV, PID, Trichomoniasis
- Contraindications: UV light
Tranexamic acid
- Indications: Menorrhagia, prevention of haemorrhage
- Contraindications: DIC, Hx contraindications, thromboembolic disease
- Dug class: Antifibrinolytic
- Side effects: diarrhoea, NV, allergic dermatitis
Mefanamic acid
- MoA: COX inhibitor, decreases prostaglandins which decreases the number of contractions, NSAID
- Indications: Dysmenorrhoea, Menorrhagia, RA pain
- Contraindications: active GI bleed, Hx Gi bleeding due to NSAID, IBD
- Side effects: Agranulocytosis, anaemia, GI discomfort, DIC
