O&G Flashcards
1
Q
Snowstorm appearance in USS
A
Molar pregnancy
2
Q
Woman w painless PV bleeding, what ix should you never do first?
A
Vaginal exam should NOT be done until USS done (exclude placenta praevia)
3
Q
State the anatomy/structures of the types of placenta below.
a) Placenta Accreta
b) Placenta Increta
c) Placenta Percreta
d) Placenta Praevia
A
a) Invades into endometrium, not myometrium
b) Invades into myometrium through endometrium
c) Through the uterus, i.e. into abdomen, through myometrium
d) Covering the os (contraindication to vaginal birth)
4
Q
O/E wooden uterus and bleeding, pt is in pain and a known smoker
Likely diagnosis?
A
Placental abruption
5
Q
RFs of placental abruption
A
Pre-eclapmsia HTN Abdo trauma Cocaine Smoking
6
Q
What is the role of AMH in reproductive tract formation?
A
AMH drives degeneration of Mullerian duct (goes onto form uterus, cervix and upper vagina)
Lack of AMH leads to degeneration of Wolffian duct (goes onto form epididymis, vas deferens, seminal ducts)
7
Q
15 yo presents as mum worried she has never had a period, normal breast and pubic hair development
Likely diagnosis?
A
aka Mayer-Rokitansky-Kuster-Hauser syndrome
Failure of lower Mullerian duct to develop
Also have associated w renal defects
8
Q
13 yo presents w severe acute pelvic pain, has not had their first period, pain is worsening monthly for the last 3 months
Likely diagnosis?
A
Imperforate hymen .
9
Q
Which organ structures would be affected if the metanephros was impaired?
A
Renal tract
10
Q
Indomethacin vs prostaglandins for patent ductus arteriosum in fetus
A
Indomethacin (NSAID) used to CLOSE it
Prostaglandins used to keep it OPEN
- multiple cardiac defects, can be useful to have patent to maintain circulation
11
Q
What are these structures formed from in the fetus?
a) Median umbilical ligament
b) Ligamentum arteriosum
c) Ligamentum teres of liver
d) Fossa ovalis
d) Ligamentum venosum
e) Medial umbilical ligament
A
a) Allantois duct (mediaN)
b) Ductus arteriosum
c) Umbilical vein
d) Foramen ovale
e) Ductus venosus
f) Umbilical artery (mediaL)
12
Q
What is the karyotype of the following molar pregnancies?
a) Partial
b) Complete
A
a) Triploid: 69XXX, 69 XXY, 69 XYY
b) Majority are 46XX due to subsequent mitosis of the fertilising sperm
13
Q
What are the 7 layers we go through in a C-section?
A
- Skin
- Fat
- Rectus sheath
- Rectus
- Parietal peritoneum
- Visceral peritoneum
- Uterus
14
Q
What are the ideal types of incisions for a C-section
A
Transverse
- lower post-op pain, and increased cosmesis
Joel Cohen
- reduced op time and
15
Q
What are the ideal types of incisions for a C-section
A
Transverse
- lower post-op pain, and increased cosmesis
Joel Cohen
- reduced op time and reduced post-op infection
16
Q
Which arteries do we need to avoid damaging when inserting a laparoscopic port?
A
Superior and inferior epigastric arteries (anastomose at umbilicus)
Supplies anterior abdo wall and part of diaphragm - lead to severe bleed and bruising
17
Q
Where is Palmer’s point and why do we use it?
A
3cm below costal margin on the left midclavicular line
Visceral-parietal adhesions rarely found here
Use indicated to insert first laparoscopic port when pt has multiple prior abdo surgery or is obese
18
Q
What are the borders of the pelvic inlet?
A
Sacral promontory
Arcuate line (ilium)
Pubic symphysis
19
Q
What are the borders of the pelvic outlet?
A
Pubic arch
Ischial tuberosity
Tip of coccyx
20
Q
What are the average diameters of pelvic inlet/outlet?
A
Average width: 11cm
Average top-to-bottom: 13cm
21
Q
What is pudendal nerve block used for?
A
LA for quick pain relief prior to instrumental delivery
Pudendal nerve supplies clitoris, perineum, and anus
22
Q
What is the use of the ischial spines?
A
Landmark for pudendal blocks
- Bony prmenines at 4 and 8 o’clock at about finger-length into the cagina
23
Q
What is the use of the ischial spines?
A
Landmark for pudendal blocks
- Bony prmenines at 4 and 8 o’clock at about finger-length into the cagina
24
Q
When may episiotomies be performed?
A
NEVER prophylatically
During second stage of labour to avoid tearing damage
- usually isntrumental delivery
- under pudendal block
25
Where can tearing damage occur during labour?
Anal sphincter (incontinence)
Perineal body (reduce postpartum pelvic floor dysfunction)
Reduce blood loss (muscles well supported)
26
What is cut through during an episiotomy?
Perineal skin
Bulbospongiosus
Deep transverse perineal muscle
27
What is the levator ani made up of?
Group of muscles:
- Puborectalis
- Pubococcygeus
- Iliococcygeus
28
Describe the types of prolapse below:
a) Cystocele
b) Rectocele
c) Uterine prolapse
d) Vaginal vault
a) Herniation of bladder
b) Herniation of rectum
c) Herniation of uterus
d) Herniation of vaginal canal, typically post-hysterectomy
All herniate through the levator hiatus
29
How can we quantify how bad prolapse sx are?
POP-Q
- quantify and describe degree of prolapse
- help determine mx plan
30
What do we want to avoid cutting in an episiotomy?
AVOID
- Bartholin's glands
- Perineal body
31
What do the levator ani muscles do?
Support urethra, vagina, and rectal canal
| Support fetal head during delivery
32
What complications can occur if the levator ani muscles are damaged?
Urinary stress incontinence
Anal incontinence
Pelvic floor prolapse
33
What are the main hormones involved in the menstrual cycle?
LH
- androgen production and ovulation
FSH
- oestrogen production and recruitment of follicles
Estradiol
- preparation of endometrium for implantation and secondary sex characteristics
Progesterone
- maintenance of pregnancy and inhibits lactation
34
What do LH and FSH act on to make which hormones?
LH stimulates androgen secretion from ovarian thecal cells
FSH stimulates oestrogen secretion from ovarian granulosa cells
35
Define menopause
Last period 12 months ago
36
4 Ts of PPH
Tissue (retained placenta)
Tone (atony of uterus)
Tears/trauma
Thrombin (coagulopathy)
37
Primary postpartum haemorrhage definition
Minor
- Loss of >500ml blood <24hr of delivery
Major
- Loss of >1000ml blood <24hr delivery
38
Secondary postpartum haemorrhage definition
Abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally
39
Causes and RFs of PPH due to atony
Overdistension of uterus
- polyhydramnios, multiple gestation, macrosomia
Intra-amniotic infection
- fever, prolonged rupture of membranes
Functional/anatomic distortion of uterus
- rapid labour, prolonged labour, fibroids, placenta praevia, uterine abnormalities
```
Uterine relaxants (Mg and nifdeipine)
- terbutaline, halogenated anaesthetics, glyceryl trinitrate
```
Bladder distention
- may prevent uterine contraction
40
Causes of PPH due to tissue
```
Retained placenta (cotyledone or succenturiate lobe)
- likely w placenta accreta
```
Retained blood clots
41
Causes and risk factors of PPH due to thrombin
Pre-existing state
- haemophilia A, ITP, VWd, hx of previous PPH
Acquired in pregnancy
- gestational thrombocytopenic, pre-eclampsia
Disseminated intravascular coagulation
Therapeutic anticoagulation
- hx of thromboembolic disease
42
Causes and risk factors of PPH due to trauma
Lacerations of cervix, vagina or perineum
- precipitous delivery, operative delivery
Extensions, lacerations at C-section
- malposition, deep engagement
Uterine rupture
- previous uterine surgery
Uterine inversion
- high parity w excessive cord traction
43
Green top guideline measures for minor PPH and no clinical shock
Intravenous access (one 14-gauge cannula)
Urgent venepuncture (20 ml) for:
– group and screen
– full blood count
– coagulation screen, including fibrinogen
Pulse, respiratory rate and blood pressure recording every 15 minutes
Commence warmed crystalloid infusion
44
Green top guideline measures for major PPH or continuing to bleed or clinical shock
ABCDE
Position patient flat and keep them warm
Transfuse blood as soon as possible, if clinically required
Until blood is available, infuse up to 3.5 l of warmed clear fluids, initially 2 l of warmed isotonic crystalloid
(Further fluid resuscitation can continue with additional isotonic crystalloid or colloid)
45
Monitoring and ix in major PPH and ongoing haemorrhage or clinical shock
Immediate venepuncture
- cross-match
- FBC
- coagulation screen
- renal and LFT for baseline
Monitor obs
Foley catheter to monitor urine output
Two peripheral cannulae 14 gauge
Consider ART, ICU, escalating if abnormal MEOWS
46
How is uterine atony managed if this is the cause of PPH?
1. Palpate uterine fundus and rub it to stimulate contractions
2. Ensure bladder empty with Foley catheter
Next steps...
3. Oxytocin 5 iu by slow IV
4. Ergometrine 0.5mg slow IV or IM injection
5. Oxytocin infusion
Further surgical steps...
6. Uterine balloon tamponade
7. Hysterectomy final resort
47
What is a contraindication to ergometrine use?
Hypertension therefore pre-eclampsia
48
How should secondary PPH be managed?
Assessment of vaginal microbiology (high vaginal and endocervical swabs)
Start abx therapy if endometritis is suspected
Pelvic US to exclude retained placenta
Surgical evacuation of retained placental tissue if needed
49
6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later. Shoulder tip pain and cervical excitation may be present
Ectopic pregnancy
50
Bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high
Hydatidiform mole
51
Constant lower abdominal pain and, woman may be more shocked than is expected by visible blood loss. Tender, tense uterus* with normal lie and presentation. Fetal heart may be distressed
Placental abruption
52
Vaginal bleeding, no pain. Non-tender uterus* but lie and presentation may be abnormal
Placental praevia
*vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage
53
Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen
Vasa praevia
54
Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities may occur
Cervical excitation may be found on examination
Pelvic inflammatory disease
55
Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise.
Nausea and vomiting are common
Unilateral, tender adnexal mass on examination
Ovarian torsion
56
Chronic pelvic pain
Dysmenorrhoea - pain often starts days before bleeding
Deep dyspareunia
Subfertility
Endometriosis
57
Unilateral dull ache which may be intermittent or only occur during intercourse. Torsion or rupture may lead to severe abdominal pain
Large cysts may cause abdominal swelling or pressure effects on the bladder
Ovarian cyst
58
Seen in older women
Sensation of pressure, heaviness, 'bearing-down'
Urinary symptoms: incontinence, frequency, urgency
Urogenital prolapse
59
What would the following on a CTG suggest?
a) baseline bradycardia
b) baseline tachycardia
c) loss of baseline variability
d) early deceleration
e) late deceleration
f) variable decelerations
a) increased fetal vagal tone, maternal beta-blocker use
b) maternal pyrexia, chorioamnionitis, hypoxia, prematurity
c) prematurity, hypoxia
d) usually innocuous feature and indicates head compression
e) indicates fetal distress, e.g. asphyxia or placental insufficiency
f) may indicate cord compression
60
What gives you +1 in the Bishops score?
Intermediate cervical position and consistency (firm-soft)
40-50% cervical effacement
1-2cm cervical dilation
-2 fetal station
61
What gives you +2 in the Bishops score?
```
Anterior cervical position
Soft cervical consistency
60-70% cervical effacement
3-4cm cervical dilation
-1, 0 fetal station
```
62
What gives you +3 in the Bishops score?
80% cervical effacement
>5 cm cervical dilation
+1, +2 fetal station
63
High risk factors for pre-eclampsia
Hypertensive disease in a previous pregnancy
Chronic kidney disease
Autoimmune disease, such as systemic lupus Erythematosus or antiphospholipid syndrome
Type 1 or type 2 diabetes
Chronic hypertension
64
Moderate risk factors for pre-eclampsia
```
First pregnancy
Age 40 years or older
Pregnancy interval of more than 10 years
Body mass index (BMI) of 35 kg/m² or more at booking
Family history of pre-eclampsia
Multiple pregnancy
```
65
Define pre-eclampsia
Onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
- proteinuria
- other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
66
Maternal complications of pre-eclampsia
```
Eclampsia
Cerebrovascular accident
Haemolysis, HELLP
Disseminated intravascular coagulation (DIC)
Liver failure
Renal failure
Pulmonary oedema
```
67
Ix for pre-eclampsia
Confirm diagnosis
- MSU, urine protein measurement (PCR or 24h collection)
Monitor
- Watch BP, serial FBC, uric acid, U&Es, LFTs, clotting screen, platelets, creatinine
- fetal surveillance
68
Preventative tx for pre-eclampsia (incl when it is done)
Women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth
≥ 1 high risk factors
≥ 2 moderate factors
69
Mx of pre-eclampsia during pregnancy
Definitive tx is give birth
Antenatal
- Labetalol, nifedipine, methyldopa - antihypertensives
70
Features of severe pre-eclampsia
```
Hypertension: typically > 160/110 mmHg and proteinuria as above
Proteinuria: dipstick ++/+++
Headache
Visual disturbance
Papilloedema
RUQ/epigastric pain
Hyperreflexia
Platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
```
71
Mx of eclampsia
IV magnesium sulfate
- prevent and treat seizures
- continue for 24hrs after last seizures/delivery
**Respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
72
Questions you must ask in a gynae hx
Menstrual
- LMP, cycle, heavy, IMB, PMB, PCB
Sex
- active, painful, contraception, STI scren
Smear
- last one done, any abnormal
Urinary
- frequency, incontinence, lump/heavy
Obs hx
- ever been pregnant, detail
73
Pharmacological tx for menorrhagia
1st line
- Mirena (IUS) if doesn't want to get pregnant
2nd line
- Tranexamic acid (1st line wants fertility)
- NSAIDs; mefenamic acid (1st line wants fertility)
- COCP
3rd line
- Progestogens (high oral dose/IM Depo-Provera)
- GnRH analogues
74
When is an endometrial biopsy indicated?
Endometrial thickness
- >10mm in premenopausal
- >4mm in postmenopausal
Age > 40
Menorrhagia with IMB
Prior to endometrial ablation/diathermy to collect tissue for pathology lab
If abnormal uterine bleeding results in acute admission
75
Causes of postcoital bleeding
Cervical Ca
Cervical ectropion
Cervical polyps
Cervicitis, vaginitis
76
Surgical tx for menorrhagia
Hysteroscopic surgery: resection or ablation
Hysterectomy
Myomectomy/embolisation if fibroids
77
Ix for menorrhagia
FBC
Pelvic USS
Endometrial biopsy +/- hysteroscopy if IMB/thickened or irregular endometrium/age > 40 years
78
Structural causes of menorrhagia
```
PALM
Polyps
Adenomyosis
Leiomyomas
- submucosal
- other
Malignancy and hyperplasia
```
79
Pt presents with thick white vaginal discharge, non-offensive order, vulval itch, superficial dyspareunia, dysuria
What is dx and what signs and microscopy would you expect?
Vulvovaginal candidiasis/thrush
Signs:
- vulval erythema
- oedema
- fissuring
- satellite lesions
Microscopy:
- yeasts and pseudohyphae
80
Pt presents with thin vaginal discharge, offensive and fishy odour, no discomfort or itch noted
What is dx and what signs and microscopy would you expect?
Bacterial vaginosis
Signs:
- discharge coating vagina and vestibule
- no inflammation of vulva
Microscopy:
- "clue" cells
81
Pt presents with profuse yellow discharge, offensive odour, vulval itch, dysuria, lower abdominal pain, and dyspareunia
What is dx and what signs would you expect?
Trichomoniasis
Signs:
- vulvitis and vaginitis
- 'strawberry' cervix
82
Three most common causes of vaginal discharge in reproductive years
Thrush
Bacterial vaginosis
Trichomoniasis vaginalis
83
Potential complications of ERPC
Evacuation of retained products of conception
- bleeding
- cervical trauma
- infection
- retained products of conception
- repeat ERPC needed
- uterine perforation
84
Which five drugs can be used to cause uterine contractions?
```
Syntocinon
Syntometrine
Ergometrine
Carboprost (hemabate)
Misoprostol
```
85
Non-structural causes of menorrhagia
```
COEIN
Coagulopathy
Ovulatory dysfunction
Endometrial (1o disorder of mechanisms regulating local endometrial haemostasis)
Iatrogenic
Not yet specified
```
86
How is pre-eclampsia classified based on timing of manifestations?
Early: < 34 weeks
Late: > 34 weeks
87
How is urinary protein assessed in pregnancy?
Bedside dipstick
- +/++ = need to quantify
Protein: creatinine ratio (PCR)
- >30mg/nmol = confirmed significant proteinuria
24h urine collection
- >0.3g/24h = confirmed significant proteinuria
88
What would you see in HELLP syndrome?
H (haemolysis)
- dark urine, raised lactic dehydrogenase (LH), anaemia
EL (elevated liver enzymes)
- epigastric pain, liver failure, abnormal clotting
LP (low platelets)
- normally self-limiting
89
What would you see in HELLP syndrome?
H (haemolysis)
- dark urine, raised lactic dehydrogenase (LH), anaemia
EL (elevated liver enzymes)
- epigastric pain, liver failure, abnormal clotting
LP (low platelets)
- normally self-limiting
90
Fetal complications of pre-eclampsia
Intrauterine growth restriction (IUGR)
Preterm birth
Placental abruption
Hypoxia
91
Criteria for admission in suspected/confirmed pre-eclampsia
Symptomatic
Proteinuria with PCR >30, or >0,3/24h on 24-h collection
Severe hypertension: >/= 160/110mmHg
Growth restriction with abnormal umbilical artery Doppler
Abnormal CTG
Abnormal sFit-1/PIGF assay
92
What preventative tx can be given if at increased risk for pre-eclampsia?
Aspiring 75mg from <16 weeks
93
What preventative tx can be given if at increased risk for pre-eclampsia?
Aspiring 75mg from <16 weeks
94
Fetal complications of GDM
Macrosomia
Congenital abnormalities
Preterm labour
Birth trauma
95
Maternal complications of GDM
```
Hypertension, pre-eclampsia
Retinopathy
DKA
Nephropathy, UTIs
C-section, instrumental delivery wound, endometrial infection
Increased insulin requirements
```
96
Risk factors for GDM
```
Previous hx of GDM
Previous fetus >4.5kg
Previous unexplained stillbirth
First-degree relative with diabetes
BMI > 30
Racial origin
Polyhydramnios
Persistent glycosuria
```
97
What is initial GDM treatment?
Initial treatment if fasting between 5.6-7:
Give glucometer
Advise re diet and exercise
Check HbA1c to identify pre-existing diabetes
Review in 2 weeks
98
What is initial GDM treatment?
Give glucometer
Advise re diet and exercise
Check HbA1c to identify pre-existing diabetes
Review in 2 weeks unless fasting > 7 => commence insulin
After 2 weeks if > 5.3 before meals or > 7.8 1-h after meals => commence metformin
99
When would you commence metformin in GDM?
If 2 weeks after advise re diet and exercise and blood glucose monitoring but have the following readings:
Glucose before meals > 5.3
Glucose 1-h after meals > 7.8
100
How is antiphospholipid syndrome diagnosed?
+1 clinical criteria
- vascular thrombosis
- 1+ death of fetus > 10 weeks
- pre-eclampsia or IUGR needing delivery < 34 weeks
- 3+ fetal losses < 10 weeks, otherwise unexplained
WITH lab criteria
- lupus anticoagulant
- high ACAs or anti-B2-glycoprotein I antibody (measured twice >3 months apart)
101
How is antiphospholipid syndrome diagnosed?
+1 clinical criteria
- vascular thrombosis
- 1+ death of fetus > 10 weeks
- pre-eclampsia or IUGR needing delivery < 34 weeks
- 3+ fetal losses < 10 weeks, otherwise unexplained
WITH lab criteria
- lupus anticoagulant
- high ACAs or anti-B2-glycoprotein I antibody (measured twice >3 months apart)
102
Major risk factors for VTE
Any previous VTE (unless single post surgery)
High-risk thrombophilia
Low-risk thrombophilia with FHx
103
Intermediate risk factors for VTE
BMI > 40
Readmission or prolonged admission (>/= 3 days)
Surgical procedure (except perineal repair)
Major medical comorbidity
C-section in labour
104
When would you give LMWH in pregnancy?
If 4+ risk factors, prophylactic LMWH throughout pregnancy and 6 weeks postnatal
If 3 risk factors, prophylactic LMWH from 28 weeks gestation and 6 weeks postnatal
If 2 risk factors, consider prophylactic LMWH for 10 days postnatally
105
When would you give LMWH in pregnancy?
If 4+ risk factors, prophylactic LMWH throughout pregnancy and 6 weeks postnatal
If 3 risk factors, prophylactic LMWH from 28 weeks gestation and 6 weeks postnatal
If 2 risk factors, consider prophylactic LMWH for 10 days postnatally
106
How is the fetus managed in if mother has diabetes background?
Cardiac scan, growth scans at 32 and 36 weeks
Induction at 37-39 weeks; C-section if > 4-4.5kg
Beware neonatal hypoglycaemia
107
What postnatal follow-up is required for GDM?
Fasting blood glucose at 6 weeks
108
Complications of sickle cell disease in pregnancy
Maternal
- crises, thrombosis, pre-eclampsia
Fetal
- IUGR increased perinatal mortality
109
Complications of sickle cell disease in pregnancy
Maternal
- crises, thrombosis, pre-eclampsia
Fetal
- IUGR increased perinatal mortality
110
Pt presents with pruritus without a rash and elevated liver enzymes
How would you manage?
Cholestasis
- ursodeoxycholic acid (UDCA)
- increased risk of stillbirth, discuss induction from 38 weeks
- monitor LFTs, give vit K late pregnancy
111
Types of fibroids and where they are found
Subserous polyp
- pedunculated out of outer layer of uterus into pelvic/abdominal cavity
Subserous
- outer layer of uterus
Intracavity polyp
- pedunculated into uterine cavity
Intramural
- middle layer of uterus
Submucosal
- endometrium/inner layer of uterus, can grow into uterine cavity
Cervical (self-explanatory m8)
112
Sx of fibroids
```
None (50%)
Menorrhagia (30%)
Erratic/bleeding (IMB)
Pressure effects
Subfertility
```
113
Complications of fibroids
```
Torsion of pedunculated fibroid
Degenerations
- red (pregnancy), hyaline/cystic, calcification (PMB and asx)
Malignanct
- leiomyosarcoma
```
114
What is adenomyosis?
Endometrial tissue in myometrium causing moderate enlargement
May be asx, commonly have painful, regular, heavy periods
O/E uterus mildly enlarged and tender
115
Risk factors for endometrial carcinoma
Endogenous E2 excess
- PCOS, obesity, nulliparity, early menarche, late menopause
Exogenous E2
- unopposed E2 therapy, tamoxifen therapy
Misc
- diabetes, Lynch type II syndrome
116
Spread and staging for endometrial carcinoma
Stage 1, 90% 5YSR
- A = < 1/2 of myometrial invasion
- B = > 1/2 of myometrial invasion
Stage 2, 75% 5YSR
- as above but also cervical stromal invasion, NOT in uterus
Stage 3 (invades uterus), 60% 5YSR
- A => invades serosa/adnexae
- B => vaginal and/or parametrial involvement
- Ci => pelvic node involvement
- Cii => para-aortic involvement
Stage 4 (further spread), 25% 5YSR
- A => in bowel or bladder
- B => distant mets
117
Most common type of endometrial cancer
Adenocarcinomas
- type 1 less aggressive, E2 dependant
- type 2 more aggressive, not E2 dependant
118
What are potentially rhesus sensitising events?
Termination of pregnancy
Evacuation of retained products of conception after miscarriage
Ectopic pregnancy
Vaginal bleeding < 12 weeks, or > 12 weeks if heavy
External cephalic version
Invasive uterine procedure (amniocentesis, CVS)
Intrauterine death
Delivery
119
How do we prevent rhesus disease antenatally?
Booking and 28 weeks
- check women for antibodies
If rhesus-negative with unknown baby Rh status/Rh+
- give anti-D 1500IU at 28 weeks, after any rhesus sensitising event, and after delivery if neonate Rh+
120
What can rhesus disease lead to in pregnancy?
Haemolysis causes anaemia
Hydrops and fetal death if severe
Neonatal jaundice and/or anaemia if less severe
121
Prevention methods of cervical cancer
HPV vaccination
Prevention of CIN: sexual and barrier contraceptive education
Identification and treatment of CIN: cervical smear programmes
122
Spread and staging for cervical carcinoma
Stage 1
- lesions confined to the cervix
Stage 2
- invasion into vagina but not the pelvic side wall
Stage 3
- invasion of lower vagina or pelvic wall, or causing ureteric obstruction
Stage 4
- invasion of bladder or rectal mucosa, or beyond the true pelvis
123
Stages of cervical carcinoma and their treatment
1ai
- cone biopsy or simple hysterectomy
1aii-1bi
- laparoscopic lymphadenectomy and radical trachelectomy
1bii-2a
- radical hysterectomy (if lymph node -ve) or chemo-radiotherapy
2b+/lymph node +ve
- chemo-radiotherapy alone
124
Indications for chemo-radiotherapy for cervical carcinoma
Lymph nodes +ve on MRI or after lymphadenectomy
If lymph node -ve as alternative to hysterectomy
Surgical resection margins not clear
Palliation for bone pain or haemorrhage (radiotherapy)
125
Most common type of cervical cancer
90% squamous
Can also get adenocarcinomas
126
Which HPV strains do we vaccinate against?
Gardasil 9: 6, 11, 16, 18, 31, 33, 45, 52 and 58
Cervical cancer
- 16 and 18 (>80% case)
- 31, 33, 45, 52, 58 (another 15% of cases)
Genital warts
- 6 and 11 (around 90% cases)
127
Common ovarian masses
Premenopausal
- follicular/lutein cysts
- dermoid cysts
- endometriomas
- benign epithelial tumour
Postmenopausal
- benign epithelial tumour
- malignancy
128
Most common type of ovarian malignancy
Epithelial carcinoma, 90% cases
| If < 30 yo - germ cell tumour
129
Possible signs and sx of ovarian cancer
Pain (unusual)
Abdominal distension or mass palpated by pt
Urinary urgency and/or frequency
Vaginal bleeding
130
What features are suggestive of a malignant ovarian mass?
```
Rapid growth (> 5cm)
Ascites
Advanced age
Bilateral masses
Solid/separate nature on USS
Increased vascularity
```
131
Describe the overall stages of ovarian cancer
Stage 1
- disease macroscopically confined to ovaries
- a = one ovary, b = both ovaries, c = +ve peritoneal washings/ruptured capsule
Stage 2
- disease extending to pelvis, i.e. fallopian tubes, uterus
Stage 3
- Abdominal disease and/or affected lymph nodes
Stage 4
- Disease beyond abdomen, e.g. lungs or liver parenchyma
132
How does ovarian cancer typically spread?
Via transcoelomic spread
| - directly within the pelvis and abdomen
133
Name epithelial ovarian tumours
```
Serous cystadenomas (b/m)
Mucinous cystadenomas (b/m)
Endometrioid carcinoma (m)
Clear cell carcinoma (m)
Brenner tumour (b)
```
134
Name germ cell ovarian tumours
```
Dermoid cysts (b)
Solid teratoma (m)
Dysgerminoma (m)
```
135
Name sex cord ovarian tumours
Granulosa cell tumours (b/m)
Thecomas (b)
Fibromas (b)
136
Risk factors for ovarian cancer
FHx
Nulliparity
Early menarche, late menopause
137
Tx for ovarian cancer
Surgery
- total abdominal hysterectomy,
- bilateral salpingo-oophorectomy
- omentectomy
- lymph node biopsy/removal
Debulk all advanced tumours
Consider laparoscopy + oophorectomy alone for young women looking to preserve fertility with close monitoring
Neoadjuvant chemotherapy
138
Causes of pruritus vulvae
Infection
- candidiasis
- vaginal warts
- pubic lice, scabies
Dermatological disease
- i.e. eczema, psoriasis, lichen simplex, contact dermatitis
Neoplasia
- carcinoma
- premalignant disease (vulval intraepithelial neoplasia)
139
Which pathogens result in a Bartholin's gland cyst abscess?
Staphylococcus or E. coli
140
How are Bartholin's gland cyst abscesses treated?
Incision and drainage, and marsupialization (incision sutured open to reduce risk of re-formation)
141
Most common type of vulval malignancy
Squamous cell carcinoma (95% cases)
142
What is vulval malignancy associated with?
```
Lichen sclerosis
Immunosuppression
Vulvar intraepithelial neoplasia
Oncogenic HPVs
Paget's disease of the vulva
Age > 60 years old
```
143
What is the lymph drainage of the vulva?
Inguinal -> femoral -> pelvic
144
Symptoms of PID
```
Pelvic pain (can be unilateral), constant or intermittent
Deep dyspareunia
Vaginal discharge
Irregular menses/intermenstrual or postcoital bleeding
```
145
Signs of PID
Cervical motion pain (cervical excitation)
Adnexal discomfort (commonly bilateral but may be unilateral)
Fever (unusual in chronic infection)
146
Complications of PID
```
Pelvic abscess
Chronic PID
Subfertility
Chronic pelvic pain
Ectopic pregnancy
```
147
Candidiasis features
Itch, cottage cheese discharge +/- vulvitis
148
Bacterial vaginosis features
Malodour, worse w intercourse, not usually associated w vulvovaginitis
149
Trichomoniasis features
Vulvovaginitis/cherry red cervix
| 50% asx
150
Gonorrhoea vaginal discharge features
Rare cause of discharge but pts with gonorrhoea commonly have BV (30%)
151
Chlamydia vaginal discharge features
Rare cause of discharge, occasional mucopurulent cervicitis
152
Primary vaginal HSV vaginal discharge features
Frank, vulvovaginitis with cervicitis and genital/cervical ulceration
153
Foreign body vaginal discharge features
Anaerobic/malodorous, will resolve with removal, abx not usually required
154
What is atrophic vaginitis due to?
Due to E2 deficiency and common during lactation/after the menopause
155
Causes of prolapse
```
Vaginal delivery and pregnancy
Congenital collagen deficiency
Menopause
Chronic elevated abdominal pressure (cough, obesity)
Pelvic surgery or masses
```
156
Types of female genital prolapses
Anterior wall
- cystocele
- urethrocele
Apical
- Uterus, cervix, upper vagina; vaginal vault if previous hysterectomy
Posterior wall
- rectocoele, enterocoele (pouch of Douglas)
157
Sx of prolapse
Often asx
Dragging sensation
Vaginal lump
Urinary frequency, incontinence (anterior wall)
Occasional difficulty in defecating (posterior wall)
158
Mx for prolapses
General
- lose weight
- treat chest problems including smoking
Pessaries
- ring or shelf, if frail
- change 6-9 monthly
Surgery
- hysteropexy, vaginal hysterectomy
- anterior/posterior repair
- sacrospinous fixation or sacrocolpopexy
159
Surgical tx for uterine prolapse
Hysteropexy, vaginal hysterectomy
160
Surgical tx for cystocoele
Anterior wall repair
161
Surgical tx for rectocoele
Posterior wall repair
162
Surgical tx for vault prolapse
Sacrospinous fixation, sacrocolpopexy
163
Define preterm delivery
Delivery > 24 weeks and < 37 weeks
164
Causes of preterm delivery
```
Subclinical infection
Cervical incompetence
Multiple pregnancy
Antepartum haemorrhage
Diabetes
Polyhydramnios
Fetal compromise
Uterine abnormalities
Idiopathic
Iatrogenic
```
165
Features of preterm delivery
```
Abdominal pain
Antepartum haemorrhage
Ruptured membranes
Sepsis
If cervical incompetence - silent sx
```
166
Methods to prevent preterm delivery
Abx if BV, UTI, STI
Vaginal cervical suture if cervix shortens on US
Elective suture if repeated preterm deliveries/miscarriages
Progesterone pessaries if cervix shortens
Fetal reduction, amnioreduction
167
Mx of preterm delivery
```
Steroids if < 34 weeks, tocolysis for max. 24 h
Magnesium if 23-32 weeks
Abx if in confirmed labour only
C section if indicated
Inform neonatologists
Transfer to NICU
```
168
Complication of preterm delivery
Neonatal morbidity (50% of all cerebral palsy result of preterm delivery) and mortality
169
Ix if suspected PPROM
Lie and presentation checked
Speculum examination to see if pooling of fluid in posterior fornix
Digital examination AVOIDED to reduce risk of infection
170
Complications of twin pregnancies
Maternal
- pre-eclampsia, anaemia, GDM, operative delivery
All twins
- increased morbidity and mortality due to miscarriage, preterm labour, placental insufficiency/IUGR, antepartum and postpartum haemorrhage, malpresentations
MC twins
- congenital abnormalities, twin-twin transfusion, IUGR
171
Types of twins
DC (70% cases)
- dichorionic
- either monozygotic or dizygotic; do not share placenta or sac
MCDA (30% cases)
- monochorionic diamniotic
- monozygotic twins that share placenta but not amniotic sac
MCMA (1% cases)
- monochorionic monoamniotic
- monozygotic twins that share placenta and amniotic sac
172
Mx of multiple pregnancy
Early diagnosis, identify chorionicity
Consultant care
Iron + folic acid supplements
Anomaly scan, increased surveillance for pre-eclampsia, diabetes, anaemia
Serial US at 28, 32 and 36 weeks
Increased surveillance if MC twins
Delivery at 37 if DC, 36 if MC
Labour continuous CTG
C-section if first twin not cephalic
Otherwise after 1st twin delivered, check lie of 2nd - ECV if indicated
Ventouse or breech extraction if fetal distress
173
What extra surveillance is required for MC twins?
USS fortnightly from 12 weeks for TTTS and IUGR
174
What is TTTS?
Twin-twin transfusion syndrome
- unequal blood distributed between MC twins
- treated with laser ablation (50% both twins survive, 80% one twin survives)
175
Diagnosis of TTTS
Discordant liquor volumes
Recipient twin larger - polyhydramnios, fluid overload, heart failure
Donor twin smaller - stuck with oligohydrmanios
176
Complications of TTTS
Late miscarriage and severe preterm delivery
In utero death
Neurological damage
177
Risk factors for placental abruption
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
178
Describe the gradings of perineal tears
First-degree tear: Injury to perineal skin and/or vaginal mucosa.
Second-degree tear: Injury to perineum involving perineal muscles but not involving the anal sphincter.
Third-degree tear: Injury to perineum involving the anal sphincter complex:
- Grade 3a tear: Less than 50% of external anal sphincter (EAS) thickness torn.
- Grade 3b tear: More than 50% of EAS thickness torn.
- Grade 3c tear: Both EAS and internal anal sphincter (IAS) torn.
Fourth-degree tear: Injury to perineum involving the anal sphincter complex (EAS and IAS) and anorectal mucosa.
179
What should the post operative plan for any obstetric anal sphincter repair include?
Antibiotics alongside adequate analgesia.
Laxatives are required to reduce the risk of constipation and the need for straining.
A dedicated physiotherapy appointment should be made to guide pelvic floor exercises, as well as a gynaecology outpatient appointment to check for symptoms of incontinence.
The GP sees all patients after delivery at their 6 week check, however the GP alone should not be expected to manage the recovery after a 3rd or 4th degree tear
180
What are the categories of C-sections?
1. immediate threat to the life of the woman or fetus
2. maternal or fetal compromise which is not immediately life-threatening
3. no maternal or fetal compromise but needs early delivery
4. delivery timed to suit woman or staff.
181
What are normal urinary sx?
Daytime voiding: 4-7 voids per day
| Nocturnal enuresis: only single void per night (after 70)
182
Urodynamic stress incontinence vs stress incontinence
Urodynamic stress incontinence (USI)
- disorder diagnosed only after cytometry of which stress incontinence is major sx
Stress incontinence
- description of a symptom 'I leak when I cough' but may be result of overactive bladder or overflow incontinence
183
Causes of urgency and frequency
```
UTI
Bladder pathology
Pelvic mass compressing the bladder
Overactive bladder
Urodynamic stress incontinence
```
184
Stress incontinence mx
Conservative
- lose weight if obese
- stop smoking
- reduce excessive fluid intake
- pelvic floor muscle training
Medical
- duloxetine (if does not want surgery)
Surgical
- Burch colposuspension
- injectable periurethral bulking agents
- mid-urethral sling procedures (tension-free vaginal tape)
185
Urge incontinence/overactive bladder mx
Conservative
- lose weight if obese
- stop smoking
- reduce excessive fluid intake
- bladder training
Medical
- anticholinergics/antimuscarinics (oxybutynin, tolterodine, solefinacin)
- sympathomimetics (mirabegron)
- botulinum toxin A
Other
- neuromodulation and sacral nerve stimulation
- surgery if severe (clam augmentation ileocystoplasty)
186
Define spontaneous miscarriage
Fetus dies or delivers dead before 24 weeks of pregnancy
187
Types of miscarriages
```
Threatened
Inevitable
Incomplete
Complete
Septic
Missed
```
188
Bleeding, fetus still alive, uterus expected size from dates, and cervical os closed
Which miscarriage is this?
Threatened
| - only 25% go onto miscarry
189
Heavy bleeding, fetus could be alive, cervical os open
Which miscarriage is this?
Inevitable
| - miscarriage about to occur
190
Some fetal parts passed, os usually open
Which miscarriage is this?
Incomplete
191
All fetal tissue has passed, bleeding diminished, uterus no longer enlarged, cervical os closed
Which miscarriage is this?
Complete
192
Endometritis, vaginal loss is offensive, uterus is tender,
Which miscarriage is this?
Septic
- contents of uterus infected
- if pelvic infection, abdo pain and peritonism occurs
193
Uterus smaller than expected date, cervical os closed, fetus is undeveloped/dead
Which miscarriage is this?
Missed
194
Miscarriage expectant mx
If woman willing and no signs of infection
- success within 2-6 weeks in > 80% cases
- large intact sac associated w lower success rates
Risks: heavy bleeding, need for surgical evacuation, infection
195
Miscarriage medical mx
Vaginal or oral prostaglandin = misoprostol
Urine pregnancy test repeated 3 weeks later to exclude ectopic or molar pregnancy
Risks: heavy bleeding, need for surgical evacuation infection
196
Miscarriage surgical mx
Surgical management of miscarriage (SMM)
- under GA using vacuum aspiration
- tissue examined histologically to exclude molar pregnany
Risks: Asherman's syndrome, uterus perforation
197
Ix for recurrent miscarriage
Antiphospholipid antibody screen (repeat at 6 weeks if +ve)
Karyotyping of fetal miscarriage tissue
Thryoid function
Pelvic USS (and MRI or hysterosalpingogram if abnormal)
198
Grounds for termination of pregnancy in England, Scotland and Wales
1. Continuing pregnancy would be risk to life of pregnant woman greater than if pregnancy was terminated
2. Termination necessary to prevent grave permanent injury to physical or mental health of pregnant woman
3. Pregnancy has not exceeded 24th week and risk to pregnant woman physical and mental health > if continues with pregnancy
4. Pregnancy has not exceeded 24th week and risk to any existing children of pregnant woman physical or mental health > if continues with pregnancy
5. Substantial risk if child born it would suffer from severe physical or mental abnormalities
199
Surgical methods of TOP
Surgical curettage
- between 7 and 12-14 weeks
Dilatation and evacuation (D&E)
- above 14 weeks
- cervix prepared with preop vaginal misoprostol and abx prophylaxis given
200
Medical methods of TOP
Antiprogesterone MIFEPRISTONE then prostaglandin MISOPROSTOL 36-48 hours later
- most effective method < 7 weeks and 13-14 weeks
201
Complications of TOP
```
Haemorrhage
Infection
Uterine perforation
Cervical trauma
Failure of procedure
Multiple surgical abortions -> increased risk of preterm delivery
```
202
Mx of sx suspected ectopic pregnancy
```
NBM
FBC and cross-match blood
Pregnancy test
USS
Laparoscopy or consider medical mx if criteria met
IV access
```
203
Criteria for expectant mx of an ectopic pregnancy
```
Size < 35 mm
Unruptured
Asx
No fetal heartbeat
hCG < 1000 IU/L
Compatible if another intrauterine pregnancy
```
204
Criteria for medical mx of an ectopic pregnancy
```
Size < 35 mm
Unruptured
No significant pain
No fetal heartbeat
hCG < 1500 IU/L
Not suitable if intrauterine pregnancy
```
205
Criteria for surgical mx of an ectopic pregnancy
```
Size > 35 mm
Can be ruptured
Pain
Visible fetal heartbeat
hCG > 5000 IU/L
Compatible with another intrauterine pregnancy
```
206
Tx options for ectopic pregnancy
Expectant
- criteria met, hCG < 1000 IU/L
- close monitoring over 48 hours
- if hCG levels rise or sx manifest, next step in mx
Medical
- METHOTREXATE
- criteria met, hCG < 1500 IU/L
- only done if pt willing to attend follow up (
- serial hCG taken to confirm all trophoblastic tissue gone
Surgical
- salpingectomy or salpingotomy
- criteria met, hCG > 5000 IU/L
207
What is hyperemesis gravidarum?
Nausea and vomiting in early pregnancy so severe it causes:
1. dehydration
2. wt loss
3. electrolyte disturbance
Subsidies by 14 weeks usually
208
Pt who is 8 weeks pregnant comes in with vaginal bleeding and severe vomiting
O/E uterus is large, cervical os is closed
USS shows 'snowstorm' appearance
How would you manage this pt?
Trophoblastic disease suspected
- hCG will be high
- needs histology to confirm diagnosis
Tissue removed by suction curettage (ERPC) and serial hCG taken to ensure all tissue removed
Pregnancy must be avoided until completion of surveillance period
209
Risk factors for spontaneous miscarriage
```
Increasing maternal age
>50% chromosomal abnormalities
Antiphospholipid syndrome
Uterine abnormalities
Parental chromosome abnormalities
```
210
When would you give anti-D for miscarriage mx?
Anti-D if rhesus -ve when:
1. miscarriage occurs from 12 weeks' gestation
2. treated medically or surgically at any gestation
211
Risk factors for ectopic pregnancy
```
Tubal damage (PID, surgery)
Previous ectopic
Endometriosis
IUCD
POP
IVF
```
212
Where do ectopic pregnancies occur in the reproductive tract?
95% in fallopian tube
- most in ampulla
- more dangerous if isthmus
Can occur in ovary, cervix, peritoneum
213
Maternal infection suitable for screening
Syphilis
Hep B
Rubella
Can also consider: Chlamydia, BV, beta-haemolytic streptococcus
214
Teratogenic maternal infections
```
Cytomegalovirus
Rubella
Toxoplasmosis
Syphilis
Herpes zoster
```
215
Methods to prevent vertical transmission of HIV
Maternal antiretroviral therapy
Elective caesarean section
Avoidance of breastfeeding
Neonatal antiretroviral therapy
216
Prevention of vertical transmission of group B streptococcus
Treat with IV penicillin intrapartum if:
- previous hx
- intrapartum fever > 38oC
- current preterm labour
- rupture of membranes > 18hrs
Can screen with vaginal and rectal swab at 35-37 weeks to treat same as above if +ve
217
Why should consumption of pates, soft cheese, and prepacked meals be avoided during pregnancy?
Risk of Listeria monocytogenes infection
- gram +ve bacillus causing non-specific febrile illness
- can be fatal infection for fetus
- prevention is to avoid high-risk foods in pregnancy
218
Consequences of HIV infection to fetus
Prematurity
IUGR
Stillbirth
219
What requires continuous CTG monitoring if any of the following are present or arise during labour?
Suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
Severe hypertension 160/110 mmHg or above
oxytocin use
Presence of significant meconium
Fresh vaginal bleeding that develops in labour
220
Which fibroids do you do an open myomectomy for?
Very large and/or numerous subserosal or intramural fibroids
221
Which fibroids do you do a hysteroscopic myomectomy for?
Submucous fibroids in the uterine cavity
222
Which fibroids do you do a laparoscopic myomectomy for?
Small number of subserous fibroids
223
Circumstances that allow more room for fetus to turn
```
Polyhydramnios
High parity (lax uterus)
```
224
Conditions that prevent fetus from turning
Fetal abnormalities
Uterine abnormalities (fibroids)
Twin pregnancies
225
Conditions that prevent engagement of fetus
Placenta praevia
Pelvic tumours
Uterine deformities (fibroids)
226
Mx of breech presentation
37 weeks ECV offered (anti-D if rhesus -ve)
Elective C section at 39 weeks
Planned vaginal breech birth
227
Contraindications to ECV
```
If fetus compromised
Vaginal delivery contraindicated (placenta praevia)
Multiple pregnancy
Rupture of membranes
Recent antepartum haemorrhage
```
228
Which vaginal breech births are more risky?
Fetus > 3.8 kg
Evidence of fetal compromise
Extended head or footling legs
229
What are the breech presentations?
Extended (70%)
- bum first, thighs against chest and feet up by ears
Flexed (15%)
- bum first, feet next to bottom, thighs against chest and knees bent
Footling (15%)
- one or both baby's feet below its bottom
230
What manoeuvres are used for vaginal breech delivery?
Delivery of bottom = hands off approach
Delivery of legs & lower body = Pinard's manoeuvre if extended, spontaneous if flexed
Delivery of shoulders = Loveset's manouvre to rotate due to allow for winging of scapulae
Delivery of head = Maueiceau-Smellie-Veit manouvere where baby rested on forearm and head pulled downwards
231
Risk factors for shoulder dystocia
Macromia
GDM
Previous shoulder dystocia
Obesity
232
Complications of shoulder dystocia
Maternal
- perineal tears
- psychological trauma
Fetal
- brain hypoxia
- Erb's palsy (upper brachial plexus injury)
233
Mx of shoulder dystocia
Senior and neonatal help called
McRoberts' (legs hyperextended onto abdomen)
Suprapubic pressure
Episiotomy if it will make internal rotation easier
Wood's screw (place pressure behind posterior shoulder to rotate it)
Symphysiotomy/cleidotomy (last resort)
Zavanelli (replace head for C section - irreversible fetal damage by this point + last last resort)
234
How is a cord prolapse diagnosed?
At vaginal examination, usually after identification of fetal distress
235
Risk factors for cord prolapse
```
Preterm labour
Breech presentation
Polyhydramnios
Abnormal lie
Multiple pregnancy
Artificial amniotomy
```
236
Cord prolapse mx
Mother goes onto all fours
Presenting part pushed up by examining finger
CAT 1 C Section
237
Classification of placenta praevia
Marginal
- placenta in lower segment, not over os
Major
- placenta completely or partially covering os
238
Causes of antepartum haemorrhage
Common
- undetermined origin
- placental abruption
- placenta praevia
Rarer
- incidental genital tract pathology
- uterine rupture
- vasa praevia
239
Presentation of placenta praevia
Incidental finding on USS
Vaginal bleeding
Abnormal lie, breech presentation
240
Placental abruption vs placenta praevia
Abruption
- shock inconsistent with external loss
- severe pain
- bleeding could be absent, often dark
- tender, hard uterus
- fetus normal, could be distressed or dead
- normal USS, placenta not low
Praevia
- shock consistent with external loss
- no pain or tenderness
- red and often profuse blood, often small APHs
- fetus lie often abnormal/lie, HR normal
- placenta low
241
Major risk factors for placental abruption
```
IUGR
Pre-eclampsia
Pre-existing HTN
Maternal smoking, cocaine use
Previous abruption
```
242
Features of major placental abruption
```
Maternal collapse
Coagulopathy
Fetal distress or demise
Woody hard uterus
Poor urine output or renal failure
N.B degree of vagina loss often unhelpful
```
243
Clinical features of placental abruption
```
Pallor
Hypotension
Tender, hard uterus
Fetal distress or absent heart sounds
Tachycardia
Abdominal pain
Vaginal bleeding
```
244
Mx of major placental abruption
Call for senior help, including senior midwife, obstetric SHO or reg, alert the consultant
Call the anaesthetic SHO or reg
Call the on-call haemoatlogist
Alert blood transfusion lab and call porters for delivery of blood
Initial A-E management with focus on circulation
Establish two large bore cannulae and take FBC, coagulation screen, U&Es, cross match (4 units)
Position lady into left lateral tilt and keep warm
Replace fluid loss with warmed crystalloid Hartmann's solution
Transfuse blood asap +/- blood products
Assess fetus health with CTG and prep theatres for CAT 1 C section for delivery
245
Factors associated with placenta praevia
Large placenta
Scarred uterus
High parity/age
Multiple pregnancy
246
Complications of placenta praevia
Haemorrhage
Preterm, C section
Risk of placenta accreta if previous LSCS
247
Complications of placental abruption
Fetal death
Massive haemorrhage causing DIC
Renal failure
Maternal death
248
Ddx of endometriosis
Adenomyosis
Chronic PID
Chronic pelvic pain
IBS
249
Endometriosis tx
Medical
- analgesia
- COCP
- Progesterones
- GnRH +/- HRT
- IUS
Surgical
- Laparoscopic laser ablation/diathermy/scissors +/- adhesiolysis
- Hysterectomy and bilateral salpingo-oophorectomy (BSO)
250
Peritoneal inflammation causing fibrosis, adhesions, and chocolate cysts
Endometriosis
251
Why do we routinely palpate the pregnant abdomen?
< 24 weeks
- check dates, assess if twins
> 24 weeks
- assess well-being by assessing size and liquor
> 36 weeks
- check lie, presentation and engagement
252
What do you examine on the pregnant abdomen?
Inspect
- size, scars, fetal movements
Palpate
- symphysis-fundal height and plot on serial measurement chart
- > 24 weeks assess lie and presentation, liquor volume, engagement of presenting part
Listen
- fetal heart over anterior shoulder using doppler
253
Clinical features of PCOS
```
Subfertility
Oligomenorrhoea/amenorrhea
Hirsutism and/or acne
Obesity
Miscarriage
```
254
Ix for PCOS
TVUSS
FSH, LH, AMH, testosterone, prolactin, TSH work up
Fasting lipids and glucose to screen for diabetes and hypercholesterolaemia complications
255
How many bleeds per year are required to provide a protective factor from endometrial Ca?
3-4/year (doesn't matter if spontaneous or induced)
256
Common causes of anovulation
```
PCOS
Hypothalamic hypogonadism
- anorexia, stress, exercise, idiopathic
Hyperprolactinaemia
Thyroid disease
Premature ovarian insufficiency
```
257
First-line ovulation induction drug in PCOS
Clomifene
| - anti-oestrogen thus increasing release of FH and LSH via negative feedback loop
258
Risks of ovulation induction
Multiple pregnancy
Ovarian hyperstimulation syndrome
Ovarian and breast Ca (not the largest risk, conflicting evidence)
259
Reasons why sperm may not meet the egg for fertilisation
```
Tubal damage
- Infection (PID)
- Endometriosis
- Surgery/adhesions
Cervical problems
Sexual problems
```
260
Indications for assisted conception
```
When all other methods have failed
Unexplained subfertility
Male factor subfertility => ICSI
Tubal blockage
Endometriosis
Genetic disorders
```
261
Overview of stages in IVF
Multiple follicular development
Ovulation and egg collection
Fertilisation and culture
Embryo transfer
262
Complications of assisted conception
Superovulation
- multiple pregnancy, OHSS
Egg collection
- intraperitoneal haemorrhage, pelvic infection
Pregnancy complications
- higher rates of ectopic pregnancy, chromosomal & gene abnormalities seen
263
Common side effects of progestogenic contraception
```
Depression
Premenstrual tension-like symptoms
Bleeding: amenorrhoea
Acne
Breast discomfort
Weight gain
Reduced libido
```
264
Common side effects of oestrogenic contraception
```
Nausea
Headaches
Increased mucus
Fluid retention and weight gain
Occasionally hypertension
Breast tenderness and fullness
Bleeding
```
265
Advice if woman forgets to take 1 pill of the COCP
If 1 pill is missed (at any time in the cycle)
- take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
- no additional contraceptive protection needed
266
Advice if woman forgets to take 2 pills of the COCP in a row
If 2 or more pills missed
- take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
- the women should use condoms or abstain from sex until she has taken pills for 7 days in a row
```
Week 1 (day 1-7): EMERGENCY CONTRACEPTION if UPSI in pill-free interval/week 1
Week 2 (day 8-14): NO NEED for emergency contraception if taken all okay prior
Week 3 (day 15-21): finish pills in pack and OMIT PILL-FREE INTERVAL
```
267
How long before surgery should you stop the COCP?
4 weeks
268
Counselling points re COCP
Major complications and benefits
Stop smoking
See doctor if signs of major complications, i.e. DVT
Remind about poor absorption when taken with abx and if vomiting
What to do about missed pills
Stress important of follow-up and blood pressure measurement
269
Major complications of COCP
```
Cerebrovascular accident
Focal migraine
Hypertension
Breast carcinoma
Cervical carcinoma
Deep vein thrombosis and pulmonary embolism
```
270
Absolute CIs to COCP
```
Hx of VTE
Hx of CVA, IHD, severe HTN
Migraine with aura
Active breast/cervical Ca
Inherited thrombophilia
Pregnancy
Smokers > 35 and smoking > 15 cigs/day
BMI > 40
Diabetes with vascular complications
Active/chronic liver disease
```
271
Relative CIs to COCP
```
Smokers
Chronic inflammatory disease
Renal impairment, diabetes
Age > 40
BMI 35-40
Breastfeeding up to 6 months postpartum
```
272
3 hour POPs
Micronor, Noriday, Nogeston, Femulen
273
12 hour POP
Cerazette (desogestrel)
274
Absolute CIs to IUD
```
Endometrial/cervical Ca
Undiagnosed vaginal bleeding
Active/recent pelvic infection
Current breast Ca (for progesterone IUS)
Pregnancy
```
275
Relative CIs to IUD
```
Previous ectopic pregnancy
Excessive menstrual loss (unless progesterone IUS)
Multiple sexual partners
Young/nulliparous
Immunocompromised, including HIV+
```
276
Counselling points to consider before IUD insertion
```
Major risks
Inform her doctor if experiences
- IMB
- pelvic pain
- vaginal discharge
- thinks she may be pregnant
Check for strings after each period
```
277
Labour stages
1st
= Initiation of painful contractions to full cervical dilatation
2nd
= Full cervical dilatation to delivery of fetus
3rd
= Delivery of fetus to delivery of placenta
278
Movements of fetal head during labour
1. Engagement in occipito-transverse position for head to pass through pelvic inlet
2. Descent and flexion into mid-cavity, measured by descent relative to ischial spines (station)
3. Rotation 90o to occipito-anterior position for head to pass through pelvic outlet
4. Descent
5. Extension and delivery
6. Restitution and delivery of shoulders thanks to head rotating 90o (external rotation)
279
General mx of first stage labour
Maternal
- obs, position, fluid, analgesia
Fetal
- intermittent auscultation/CTG, resus +/- fetal blood sample if abnormal HR, LSCS if fetal distress
Labour
- vaginal exam, augmentation if required, LSCS if dilatation not imminent by 12 hours
280
General mx of second stage labour
Maternal
- obs, position, fluid, analgesia
Fetal
- intermittent asucultation/CTG
Labour
- oxytocin, push when mum has desire/head visible, instrumental delivery if not delivered after 1 hour of pushing or prerequisites met
281
Slow labour is...
... progress slower than 0.5cm/h after 4cm (latent phase)
282
Prolonged labour is...
... > 12 h duration after latent phase
283
Features of occiptio-posterior position baby
Slow labour
Back pain
Early desire to push
284
Common indications for induction
```
Prolonged pregnacy
Suspected growth restriction
Prelabour term rupture of membranes
Pre-eclampsia
Medical disease: hypertension and diabetes
```
285
Causes of PMB
```
Endometrial Ca
Endometrial hyperplasia
Cervical Ca
Atrophic vaginitis
Cervicitis
Ovarian Ca
Cervical polyps
```
286
HRT impact on cancer risks
Increased risk
- breast if combined
- endometrial if E2 only
Decreased risk
- potentially colon
287
Long term complications of hysterecomy
Prolapse
Genuine stress incontinence
Premature menopause
Pain and psychosexual problems
288
When are scans done antenatally?
11-13+6
= scan to date and identify twins
18-20+6
= routine anomaly scan
Serial USS later if
- polyhydramnios
- breech
- suspected IUGR
289
Routine booking ix
```
Urine culture
FBC
Antibody screen
Serological test for syphilis
Rubella IgG
HIV and Hep B
USS
Screen for chromosomal abnormalities
Haemoglobin electrophoresis
```
290
Physiological blood changes seen in pregnancy
Blood volume increases 50%
Red cell mass increases
Haemoglobin decreases due to dilution
White blood cell count increases
291
Physiological CVS changes seen in pregnancy
Cardiac output 40% increase
Peripheral resistance 50% reduction
BP small mid-pregnancy fall
292
Physiological lung changes seen in pregnancy
Tidal volume 40% increase
| RR no change
293
USS findings for Down's syndrome
```
Thickened nuchal syndrome
Some structural abnormalities
Absent or shortened nasal bone
Tricuspid regurgitation
Severe fetal growth restriction
```
294
Antenatal blood test findings for Down's syndrome
1st trimester
- low PAPP-A
- high B-hCG
- low AFP
2nd trimester
- high B-hCG
- low AFP
- low E2
- high inhibin
295
Mx of polyhydramnios
Detailed USS screening
Exclude gestational diabetes
Consider reducing liquor if severe
- amnioreduction
- NSAIDs to reduce fetal urine output
Delivery
- vaginal unless persistent unstable lie or other obstetric indication
296
Major risk factors for SGA
```
Previous hx of SGA or stillbirth
Heavy smoking
Cocaine usage
Heavy daily exercise
Maternal illness, i.e. diabetes
Parental SGA
```
297
Non-rotational forceps
Simpson's
| Neville-Barnes
298
Rotational forceps
Kielland's
299
Indications for instrumental delivery
Prolonged active second stage
Maternal exhaustion
Fetal distress in second stage to expedite delivery
300
Prerequisites for instrumental delivery
```
Head not palpable abdominally
Head at/below ischial spines on vaginal examination
Cervix fully dilated
Position of head known
Adequate analgesia
Valid indication for delivery
Bladder empty
```
301
Forceps vs ventouse
Ventouse causes:
- higher failure rate
- more fetal trauma
- no difference in Agpar scores
- less maternal trauma
302
Indications for C section
Emergency
- failure to progress in labour
- fetal distress
Elective
- previous C section
- breech presentation
303
Complications of instrumental delivery
Maternal
- lacerations, haemorrhages, third-degree tears
Fetal
- lacerations, bruising, facial nerve injury, hypoxia if prolonged delivery
304
What is the puerperium?
6-week period post-delivery where body returns to its pre-pregnant state
305
Advantages of breastfeeding
```
Protection against infection in neonate
Bonding
Protection against cancers (mother)
Cannot give too much (no overfeeding)
Cost saving lol
```
306
Define stillbirth
Fetus born dead at 24+ weeks
307
Define neonatal death
Neonate dies < 28 days after delivery (early is < 7 days)
308
Polymorphic eruptions of pregnancy
Pruritic condition associated with the last trimester
Lesions often first appear in abdominal striae
Periumbilical area is often spared
Management depends on severity: emollients, mild Potency topical steroids and oral steroids may be used
309
Chemo for ovarian Ca
Carboplatin
- not cisplatin as more nephrotoxic not a vibe
Paclitaxel
- peripheral neuropathy, neutropenia, myaliga so also give
STEROIDS
310
Bevacizumab indication
3rd line ovarian Ca tx
- surgery done
- chemo done
- bitch still struggling
