O&G Flashcards
pregnant patient with 2 previous miscarriages and a stillbirth. What is her gravidity and parity?
G4 P1+2
pregnant patient at 38+6 weeks. SFH has decreased from 36w visit. Most likely reason?
Increase in foetal station
in which situation must you never perform PV examination
placenta praevia
what is the foetal fibronectin test used for?
predicts probability of preterm labour in next 48h
pelvic girdle pain in pregnancy / symphysis pubis dysfunction? what is it and mx
pain due to pressure on pubic symphysis, radiates to thighs and gets worse as pregnancy progresses. Mx: analgesics, pelvic support braces/crutches, physio
different types of speculum
cusco’s speculum = beak shaped. sim’s speculum = c shaped, used in surgery and to visualise prolapse
most common cause of primary pph
uterine atony
endometritis
retained products of conception, resulting in infection post-partum. results in ongoing lochia with unpleasant smell and clots.
how long should you avoid conceiving if you’ve been treated with methotrexate after ectopic?
3 months
connective tissue disorders in pregnancy –> complication?
congenital heart block
echogenic bowel
Down’s syndrome
category 1 c section
immediate threat to life of mother/baby, must deliver within 30 minutes of making a decision
category 4 c section
elective c/s
kallmann syndrome
hypogonadotrophic hypogonadism + anosmia –> low LH, FSH, GnRH
Indications for high dose folic acid
BMI>30, antiepileptic drug use, diabetes, fhx/pmhx of neural tube defects, coeliac disease, thalassemia trait
galactocoele
occlusion of lactiferous ducts in women who have stopped breastfeeding –> build up of milk –> painless, non-tender lump on breast
combined contraceptive patch
cycle lasts 4 weeks. the patch is worn every day and changed every week. on week 4, patch is not worn and there is a withdrawal bleed.
Contraceptive patch: What do you do if at the end of week 1 or 2, there is a delay in changing patch of <48h?
change patch ASAP
Contraceptive patch: What do you do if at the end of week 1 or 2, there is a delay in changing patch of >48h?
change patch and use barrier contraception for next 7d
when are women who have been treated CIN1/2/3 invited back for a smear
6 months after procedure to check the lesion has been adequately treated
Describe antenatal care for women with pre-eclampsia
blood and scans every 2 weeks, BP checks 3x/week
Describe intrapartum care for women with pre-eclampsia
arrange delivery for 37 weeks, can choose between iol or elective c/s, labour ward with continuous CTG
Describe postpartum care for women with pre-eclampsia
observe for 24h, monitor BP 4x/day, discharge but measure BP every 1-2d for up to 2 weeks after discharge. GP review at 2 and 6 weeks to check BP. Wean off medication.
Congenital toxoplasmosis infection presentation
C's hydrocephalus intracerebral calcifications convulsions chorioretinitis
Toxoplasmosis tx
spiramycin for positive mother and negative baby
Secondary PPH timeframe
24h - 12 weeks postpartum
routine vaccinations offered to pregnant women
influenza + pertussis
Layers that you go through in a lower segment C/S
skin, superficial fascia, deep fascia, rectus sheath, rectus abdominalis, transversalis fascia, extraperitoneal tissue, peritoneum, uterus
Where does cervical cancer metastasise to first?
pelvic lymph nodes
Where does ovarian cancer metastasise to first
para-aortic lymph nodes
HRT is associated with an increased risk in…
breast cancer, endometrial cancer, VTE
mode of HRT that is not associated with increased risk of VTE?
transdermal patch
Lichen sclerosus Mx
1) wash with emollient soap substitute instead of regular soap, avoid irritants (laundry detergent/tight clothing), 2) highly potent steroids, 3) calcineurin inhibitors, 4) biopsy if no improvement after tx
focused questions to ask in obstetric cholestasis
jaundice, pale stools, dark urine, FLAWS
Mx in obstetric cholestasis
Immediate Mx: aqueous creams, ursodeoxycholic acid to reduce bile acids/itching, cool baths, loose clothing.
Antenatal care: weekly LFTs + bile acid tests. some women may have CTG and more frequent ultrasound scans; under consultant obstetrician led antenatal care.
Delivery: IOL at 37 weeks under consultant led team with continuous CTG, 6-8 week post-partum check up.
complications of obstetric cholestasis
stillbirth, prematurity, meconium
intracytoplasmic sperm injection vs intrauterine insemination
intracytoplasmic sperm injection = injecting sperm directly into egg cell; intrauterine insemination = injecting sperm cell into uterus (don’t do this if problem with tubal patency)
Levonorgestrel C/I
BMI>26/body weight>70kg, in which case give double dose (3mg instead of 1500 micrograms)
congenital CMV infection presentation
jaundice
microcephaly
periventricular calcification
chorioretinitis
VTE during pregnancy Mx
LMWH until 6 week postnatally
Cal-exner bodies
found in granulosa cell ovarian tumours; “call your gran”
Urge incontinence - who should be cautious about giving antimuscarinics to?
avoid antimuscarinics in elderly frail women due to increased risk of falls. Give beta agonist instead, eg mirabegron.
definition of prolonged active stage in nulliparous and multiparous women?
How does having an epipdural change this definition?
nulliparous = >3h, multiparous =>2h. This is an indication for instrumental delivery.
Having an epidural adds 1h to the above.
Low platelets in pregnancy - ddx?
gestational thrombocytopenia, ITP
when does gestational thrombocytopenia present?
3rd trimester
when does ITP present?
1st trimester
Neville Barnes forceps vs Kielland’s forceps
Neville Barnes forceps = can ONLY be used in OA position, CANNOT be used to rotate position.
Kielland’s forceps = CAN be used to rotate baby to OA position.
Why are Kielland’s forceps rarely used?
risk of perineal tears and need for episiotomy
Pregnancy of Unknown Location Mx
two beta Hcg readings 48h apart. If there is an increase of >63%, pregnancy is viable so do TVUSS 7-14d later.
Between 50% decrease and 63% increase = ectopic.
< 50% decrease = miscarriage.
Major indications for aspirin
diabetes, CKD, pre-existing HTN, autoimmune disease
What measurements are decreased in pregnancy?
Hb, platelets, protein S
When can IUS/IUD be inserted post-partum?
within 48h of delivery or after 4 weeks
Define uterine hyperstimulation
5 or more contractions in 10mins
Uterine hyperstimulation Mx
if due to excess prostaglandins, give tocolytics.
if due to syntocin infusion, stop infusion/reduce dose.
Hypothyroidism in pregnancy Mx
bHCG cross reacts with TSH receptors on thyroid so there is a physiological increase in T4 in pregnancy. To mimic this, increase levothyroxine dose by 25 micrograms a day.
Mg sulphate toxicity presentation
respiratory depression, arrhythmias, loss of deep tendon reflexes
Mg sulphate toxicity Mx
10ml 10% calcium gluconate
Lambda sign
triangular wedge shape of placenta on USS. indicates dichorionic twin pregnancy.
polymorphic eruption in pregnancy
benign, self-limiting
pruritis that spares umbilicus
lesions become confluent
Pruritic urticarial papules and plaques (PUPP)
itchy striae
Most common cause of secondary PPH
endometritis
Mx for babies born from HIV pregnancy
wash baby as soon as delivered
give oral zidovudine within 4h of birth + for 4-6 weeks
check for HIV at birth, discharge, 6 weeks, 12 weeks.
Herpes simplex in pregnancy Mx
if infected in 1st/2nd trimester, give course of oral aciclovir then again from 36 weeks onwards until delivery; vaginal delivery possible provided sores have healed by then.
if infected in 3rd trimester, give oral aciclovir and elective C/S advised.
proteinuria without hypertension in pregnancy > 20 weeks
1) if symptoms of UTI / leukocytes or blood in urine, suspect UTI and send for urine MC&S
2) if protein 1+, reassess in 1 week, safetynet, do a protein creatinine ratio
3) if protein 2+, urgent same day assessment
itchy bumpy rash that spares the umbilicus
polymorphic eruption of pregnancy
after a molar pregnancy, how long should the woman be told to avoid pregnancy after the beta-HCG has returned to normal?
6 months
supplement given in severe hyperemesis gravidarum
thiamine
Bartholin’s cyst vs abscess
painless vs painful!
C/S is routinely offered
when HIV with/without concurrent infections
Breech where ECV has failed
Multiple pregnancy where first baby is breech
Primary genital herpes infection in third trimester
Placenta praevia major
CTG baseline variability
5-25 bpm
CTG accelerations
rise of fetal heart rate of >15bpm for at least 15s
What measurement is used on USS for dating?
crown rump length. if >14 weeks, biparietal diameter.
EDD is used unless USS date differs by >1 week
Passage of baby through pelvis - name stages
descent, engagement, neck flexion, internal rotation into OA, neck extension, external rotation, lateral flexion
Describe menstrual cycle
FSH stimulates growth of 6-12 follicles.
As follicles mature, granulosa cells produce oestrogen, which inhibits LH and FSH.
Eventually only 1 follicle matures fully, the rest undergo atresia.
Oestrogen levels continue to rise, causing rise in FSH and surge in LH.
This stimulates release of egg from follicle.
Remaining corpus luteum releases progesterone, reaching a peak at day 21.
Twin to twin transfusion syndrome
one twin gains at the other’s expense. in monochorionic pregnancy.
Therapeutic amniocentesis can be used to reduce amniotic fluid pressure.
Foetal station of 0
Presenting part is level with the ischial spines
Bishop’s score at which labour is unlikely to be imminent
<5
Gold standard test for tubal patency
laparoscopy and dye
Bloody show
mucus-like vaginal bleeding, indicates preparation for labout
how is anti-D given following sensitising events?
<20 weeks, give 250IU anti-D. >20 weeks, give 500IU anti-D. Given IM asap after event, ideally within 72h.
Braxton Hicks contractions
feels like real contraction but uterus just contracts sporadically in pregnancy. Relieved by warm baths, time, rest, changing activities, drinking water.
How does uterine rupture present?
CTG abnormalities, maternal tachycardia, hypotension, shock
Why does uterine hyperstimulation cause foetal distress?
not enough time in between contractions to allow adequate blood flow to foetus
Uterine rupture Mx
immediate laparotomy to deliver baby
How does atosiban work?
competitive inhibition of oxytocin by binding to myometrial receptors
How do beta agonists work? e.g., terbertuline, salbutamol, ritodrine
stimulate beta receptors on myometrial cell membranes, reducing intracellular Ca levels, inhibiting contraction
PID with fever Mx
IV abx
Headache after delivery dx
post dural puncture headache
define premature ovarian insufficiency
menopause before 40yo
POI Mx
HRT to take until age 51yo
When does active labour begin?
when cervix has dilated to 4cm
Abortion act clause A
continuing pregnancy has greater risk of harm to mother and existing children than terminating it & pregnancy <24weeks
UTI in pregnancy 2nd line Mx
cefalexin/amoxicillin
Endometrioma on USS
ground glass appearance
Abortion act clause B
risk of serious harm to physical/mental health of mother, can have TOP at any point
Abortion act clause C
mother’s life is at risk, can have TOP at any point
Abortion act clause D
continuing pregnancy has greater risk to baby and would cause it to be severely handicppaed
Side effect of progesterone implant
irregular bleeding
What is nexplanon
progesterone implant
What is preferred imaging in PE in pregnant women
V/Q scan has lower radiation dose than CTPA
Target glucose levels in GDM
fasting <5.3, 1hr<6.4, 2hr <7.8
Induction of labour steps
prostaglandin pessary for 24h, vaginal prostaglandin gel for 6h x2, rupture of membranes with amnihook, if labour has not started 2h after ROM –> start IV syntocin infusion
what murmur is common if pregnancy
soft systolic murmur due to dilatation across tricuspid valve
DOACs in pregnancy
discontinue due to teratogenic effects, replace with LMWH
when would you start to feel baby move?
16-24 weeks
when should you worry if woman has not felt baby kicking yet
24 weeks
probability that a pregnancy will miscarry
common!
1 in 5 miscarry
Booking appointment by 10 weeks
Initial contact folate up to 12 weeks vit D daily smoking + alcohol cessation advice BMI, BP, urine dip bloods - anaemia, blood group, rhesus state, red cell alloantibodies, haemoglobinopathies Screen for HIV/hep B/syphillis Offer down's syndrome screen
Dating scan 10-14 weeks
finalise gestational age + EDD
viability
singleton/multiple pregnancy
can include NT scan
16 weeks appointment
Review test results
BP, BMI, urine dip
can have influenza/pertussis vaccine
OGTT if hx of previous GDM
20 week anomaly scan
structural anomalies placenta position gender growth amniotic liquor volume
28 week appointment
BMI, BP, urine dip, SFH
if risk factors for GDM, offer OGTT
1st dose of anti-D (500IU)
34 week appointment
BP, BMI, urine dip, SFH
2nd dose of anti-D (500IU)
give info on labour + discuss birth plan
what additional antenatal appointments do nulliparous women have?
25, 31, 40 week appointments with GP to review BP, BMI, urine dip, SFH
36 week appointment
BP, BMI, urine dip, SFH
give info on breastfeeding, vitamin K for newborn, care for baby, post-natal issues
38 week appointment
BP, BMI, urine dip, SFH
discuss prolonged pregnancy
41 week appointment
BP, BMI, urine dip, SFH
offer membrane sweep + IOL
TOP mx
Abx prophylaxis + anti-D
< 9 weeks = mifepristone + misoprostol at home
>9 weeks = mifepristone + misoprostol in clinical setting
<14 weeks = vacuum aspiration under local
>14 weeks = dilatation + evaucation under GA
why would women prefer medical TOP over surgical
not under anaesthetic so feel more in control of situation
why would women prefer surgical TOP over medical
under anaesthetic so unaware of events
what happens after a TOP
2 week F/U to check: whether abortion is complete, infection, mental health, advice about contraception + sexual health
TOP Ix
basic obs, urine dip, pregnancy test, STI screen
bloods - group/save, rhesus state, cross match
does TOP affect fertility
most women don’t have any complications + fertility is not affected. A small number with complications (severe infection/damage eg) may have their fertility affected
can girls under 16yo consent to TOP without parental consent?
assess Gillick competence (ability to sufficiently understand info + make an informed decision)
see if you can encourage her to tell her parents
if you feel that their physical/mental health is likely to suffer w/o TOP + it is in their best interests, then 2 doctors can decide + go ahead
questions to ask when woman is interested in COCP
BMI, hx of migraines with aura, smoking, breast cancer, gall bladder/liver disease, risk factors for VTE
Disadvantages of COCP, POP, patch, implant, injection, IUD, IUS
COCP = minor side effects are nausea/headache/mood changes, rare but increased risk of clots/cervical cancer/breast cancer POP = no major disadvantages, may have unpredictable bleeding patch = may have skin reaction implant = irregular bleeding injection = weight gain IUD = invasive, heavier/more painful periods possible IUS = invasive
Prolapse Ix
general physical examination + BMI
abdo exam to look for masses
resp exam to look for anything that might precipitate prolapse, eg persistent cough
pelvic exam –> bimanual + sims speculum exam, ask to cough to assess extent of prolapse
risk factors for cervical cancer
smoking, COCP, high number of sexual partners, immunodeficiency
hyperemesis gravidarum
general examination looking for clinical sx of dehydration
basic obs
urine pregnancy test + urine dip for ketones/UTI
compared pre pregnancy weight with current weight
bloods - FBC, U&Es, LFTS, TFTs
pelvic USS to confirm intrauterine viable pregnancy
Fibroid degeneration mx
self-resolves, paracetamol, best rest, oral fluids
if pain is severe, can admit for opioid analgesia
how do fibroids affect pregnancy
can cause malpresentation of baby or obstruct labour –> c-section may be indicated
when is expectant mx indicated in ecptopic
bhcg<1000, asymptomatic, no intrauterine pregnancy
expectant mx in ectopic
twice weekly F/U until bHCG<20
when is medical mx indicated in ectopic
no significant pain unruptured ectopic mass < 35mm no visible heart beat serum bHCG<1500 able to return to F/U
medical mx in ectopic
single dose methotrexate, return to F/U to check bHCG at day 4, day 7 and 1x/week until -ve
when is surgical mx indicated in ectopic
ruptured significant pain bhcg>5000 mass > 35mm fetal heart beat detected unable to return for F/U
PCOS complications
infertility
insulin resistance + pregnancy
heart disease
sleep apnoea
PE Mx
LMWH to take during pregnancy until 6 weeks post-partum
intrapartum mx in women taking LMWH
stop LMWH 24h before delivery if planned or as soon as delivery begins
postpartum mx in women taking LMWH
warfarin can be given 5d post-partum, warfarin/LMWH safe during breastfeeding, joint review with obstetrics + haematology post-partum,
probability that a VBAC is successful
75%
25% will need emergency C/S
C/I for VBAC
longitudinal C/S scar
more than 2 C/S
breech
placenta praevia
risks of VBAC
small risk of uterine rupture, infection, haemorrhage
benefits of VBAC
shorter hospital stay
quicker recovery
reduced risk of neonatal resp distress
Ovarian cancer mx
total abdominal hysterectomy + bilateral salpingo-oophorectomy
examine all peritoneal surfaces, biopsies of pelvic and para-aortic lymph nodes, consider infracolic omentectomy if indicated
chemotherapy if stage 2 or above
tests to complete when suspecting PID
pregnancy test urinanalysis + culture vaginal wet mount with pH NAAT testing for chlamydia + gonorrhoea CRP/ESR
outpatient abx for PID
IM ceftriaxone single dose
PO doxycycline 14d
PO metronidazole 14d
inpatient abx for PID
IV doxycycline
IV cefoxitin
complications in PID
infertility, ectopic, chronic pelvic pain
counselling for PID
infection (often UTI/STI) which has spread to the organs in your reproductive system
usually outpatient abx regimen
if no improvement within 72h, admit for IV abx
discuss contact tracing, safe sex, barrier contraception
how common is endometriosis
10% of women of reproductive age
endometriosis mx
analgesia
COCP/POP/IUS
if fertility desired, consider fertility sparing surgery for excision; need to take GnRH agonists for 3m
if fertility not desired, consider hysterectomy + oophorectomy
how would you explain endometriosis in counselling
the tissue that lines your womb grows in other places, including your ovaries and fallopian tubes
what investigation should you avoid in placenta praevia
bimanual/vaginal examination!!!
careful speculum examination can be performed to check rupture of membranes / whether cervical os is closed
asymptomatic placenta praevia mx
rescan at 32 weeks
rescan at 36 weeks
if still present, then book elective C/S for 36-37 weeks
symptomatic placenta praevia mx
A to E approach high flow O2 2 wide bore cannulae - take bloods for FBC/U&E/CRP/G&S/crossmatch/rhesus state/Kleihauer's/clotting screen, give IV fluids + blood transfusion continuous CTG monitoring give anti-D
if haemodynamically unstable/foetal resp distress –> C/S
if haemodynamically stable –> admit for close monitoring + steroids, discharge if no bleeding for 48h, elective c/s for 36-37 weeks
HIV in pregnancy Ix
abdo exam bloods - FBC, U&Es, CRP, LFTs HIV status - viral load, CD4 count, viral genotype resistance pattern hepatitis screen STI screen
HIV in pregnancy Mx
arrange contact with joint obstetrician/HIV specialist clinic every 1-2 weeks
start zidovudine monotherapy if not already on ART
monitor CD4 and viral load
if viral load <50 –> vaginal delivery may be attempted
if viral load >50 –> elective C/S
intrapartum IV zidovudine infusion
wash baby + give zidovudine when born + continue for 4 weeks
check baby for HIV at birth, discharge, 6 weeks, 6 months
DO NOT BREASTFEED!
when should you worry about reduced foetal movements
no foetal movements for >90 mins
mx in the community if reduced foetal movements
lie in left lateral position
if <10 felt in 2hrs –> schedule antenatal appointment
Ix for reduced foetal movements`
basic obs abdominal examination pelvic examination, including speculum foetal doppler USS if heartbeat present --> continuous CTG if heartbeat absent --> immediate pelvic USS
sx of menopause
hot flushes night sweats loss of libido dryness/pain in vagina irregular/absent periods difficulty sleeping headaches joint pain
hot flushes in menopause mx
conservative - sleep with windows open, wear loose clothing
medical - SSRI or SNRI
atrophic vaginitis mx
conservative - lubricants
medical - topical oestrogens
describe cyclical HRT
monthly - take oestrogen every day + progesterone for last 14 days of month
3 monthly - take oestrogen every day + progesterone for last 14 days of 3 month cycle
why is HRT needed
reduced vasomotor symptoms
prevents osteoporosis
risks of HRT
VTE, CVS disease, breast cancer
need for contraception during menopause
if <50yo, need contraception until >2 years of amennorhea
if >50yo, need contraception until >1 year of amennorhea
Risk of uterine rupture in VBAC without syntocin + with syntocin
Without syntocin = 1 in 200
With syntocin = 1 in 100
Induction of labour in VBAC
AVOID prostaglandins
Use mechanical methods, eg balloon inserted for 12h for inflation + cervical dilation
Can use syntocin still with caution
Shoulder dystocia
Lie bed flat + tell woman to stop pushing
Emergency buzzer + call seniors
External manoeuvres (McRoberts, then apply suprapubic pressure)
Consider episiotomy
Internal manoeuvres (Rubin II, woodscrews, deliver posterior arm)
Repeat manoeuvres on all fours
Consider symphisiotomy/fetal cleidotomy/Zavenellis
Emergency C/S
Most common breech presentation
Frank (70%) - legs flexed at hip and knees extended
Success rate of ECV
50%
Biphasic decels
Non-reassuring
Analgesia for instrumental delivery
Pudendal nerve block
Local anaesthetic
Analgesic ladder
Natural methods (breathing exercises, etc) –> entonox –> either epidural or pethidine/morphine IM or IV/PCA using fentanyl
Meconium stained liquor + abnormal CTG Mx
C/S
What is labour
Contractions + cervical change (effacement + dilation)
Describe stage 1 of labour
Latent = cervix dilated up to 4cm Active = cervix dilated > 4cm
Describe stage 2 of labour
Stage that begins when cervix is fully dilated and ends when baby is delivered
Passive (no pushing, baby descends)
Active (pushing)
If already contracting, what should you NOT give
Prostaglandins due to risk of uterine hyperstimulation
Do ARM if membranes not ruptured yet, otherwise IV syntocin (easier to titrate than prostaglandins)
Define delayed third stage of labour
> 30 mins after delivery of baby
PPH 4Ts Mx
Tone - rub up contraction
Tissue - check placenta complete
Trauma - check perineum/vaginal tissue
Thrombin - clotting screen and review hx
PPH Mx
Call for help + MOH call 2222 A to E approach High flow O2 2 wide bore IV cannulae Take bloods - FBC, U&E, LFTs, G&S, XM, clotting screen IV fluids + transfusion when it arrives Insert catheter Uterine massage Bimanual compression if vaginal delivery IV syntometrine / ergometrine IM carboprost Bakri balloon if vaginal B lynch sutures if C/S Uterine artery embolization Iliac artery ligation Hysterectomy
Amenorrhea
Absence of periods 6 months
Regular periods definition
21-35 day cycles
Sex hormone binding globulin in PCOS
Decreases
Safe antiepileptics in pregnancy
Lamotrigine
Levetiracetam
Normal SFH relative to gestational age
Gestational age +/- 2 = normal SFH
how long should COCP be discontinued for before/after a major surgery?
stop taking it 4 weeks before and resume 2 weeks after major surgery
cervical smear due during pregnancy mx
delay smear until 12 weeks post partum
Meig’s syndrome
fibroma
pleural effusion
ascites
who is offered group B strep intrapartum abx prophylaxis
previous baby with group B strep
group B infection in current pregnancy
how to structure HRT PACES counselling
1) oestrogen only or combined - do you have a womb? do you have a mirena coil?
2) cyclical or continuous - cyclical if still menstruating, continuous if 1 year of amenorrhoea
3) assess risk factors for HRT
how do you know that the head is engaged
when the widest diameter of the baby’s head has descended into the pelvis + head is less than 2/5 palpable
risk of developing fetal varicella syndrome following maternal varicella exposure before 20 weeks gestation
around 1%
chickenpox exposure mx in pregnant women without immunity for 1) < 20 weeks 2) >20 weeks
1) VZIG injection asap, if rash appears see midwife/gp asap + have oral aciclovir within 24h of onset
2) oral aciclovir day 7-14 after exposure
At which point in labour should IM syntocinon be administered
when anterior shoulder is delivered
after a molar pregnancy, for how long should she be told to avoid pregnancy after the beta-HCG has returned to normal
6 months
When do you give VZIG for pregnant women
<20 weeks and exposed to chickenpox contact, have VZIG asap!
When do you give aciclovir to pregnant women? (VZV)
> 20 weeks,
1) give aciclovir immediately if they present with a rash
2) give aciclovir 7-14 days after exposure
what is ICSI
intracytoplasmic sperm injection - when sperm is injected directly into egg
used when there is male factor infertility
COCP absolute C/I
>35yo + smoking >15/day migraine with aura hx of VTE / MI / stroke breastfeeding < 6 weeks post partum antiphospholid syndrome major surgery with prolonged immobilisation uncontrolled HTN
advice to give someone about barrier contraception when starting COCP
if starting the pill on day 1-5 of cycle, it is immediately effective. Otherwise, barrier contraception for first 7 days until effective.
you have found an ovarian cyst on TVUSS. when should you refer to gynae?
if the cyst is irregular shaped or multilocular
if there is strong blood flow/ascites
mx of simple cysts in pre menopausal women
pregnancy test + TVUSS then rest of mx depends on size of cyst
<5cm = discharge
5-7cm = yearly TVUSS to monitor for changes
>7cm = MRI +/- surgery
mx of complex cysts in pre menopausal women
serum CA-125, αFP, βHCG, LDH
cystectomy
raised AFP in pregnancy
omphalocoele
low AFP in pregnancy
Down’s syndrome
Edward’s syndrome
maternal obesity
maternal DM
when can you do forceps
fully engaged head
fully dilated
lochia expected time period
up to 6 weeks
mx of simple/complex cysts in post menopausal women
Ca-125 + RMI calculation (Ca-125 + TVUSS findings + menopausal status)
best ix for obstetric cholestasis
LFTs
when can COCP not be used post-partum
must not be used 3 weeks post-partum
must not be used for 6 weeks post-partum if breastfeeding
when can POP be used post-partum
can be used at any time after day 21 post-partum
additional contraception needed for 2 days
When is LMWH given
4+ risk factors or previous VTE = throughout pregnancy until 6 weeks post partum
3 risk factors = 28 weeks until 6 weeks post partum
2 risk factors = for 10 days post partum
Surgical options for stress incontinence
bulking agent
colposuspension
rectal fascia sling
mid urethral tape
Surgical options for urge incontinence
botulinum injection
sacral nerve stimulation
cystoplasty
urinary diversion
breastmilk jaundice vs breastfeeding jaundice
breast milk jaundice = cause unknown, assoc. w/ glucoronidase + break down of bilirubin
breastfeeding jaundice = due to decreased breastmilk intake
examples of category 1 C/S indications
cord prolapse uterine rupture major placental abruption foetal hypoxia foetal bradycardia
when should you delivery by for a category 2 c section
within 75 mins
Which contraception causes a delay in returning to normal fertility?
progesterone only injectable
pms mx
1) lifestyle advice
2) cocp
3) ssri
incontinence ix
urine dipsticks + culture
vaginal examination to exclude pelvic organ prolapse
bladder diary (for at least 3 days)
urodynamic studies are indicated if there is diagnostic uncertainty
conditions for IUS in fibroids
fibroids must be <3cm and not distorting uterine cavity
woman presents to GP with persistent smelly pink discharge post-partum and is also pyrexic. mx?
refer to hospital for IV abx (gentamycin + clindamycin)
what maintains the production of progesterone by the corpus luteum in early pregnancy
bhcg produced by synctiotrophoblasts
rash in pregnancy that does not spare the umbilicus
pemphigoid gestationis
MoA of progesterone implant, injection, desogesterel
inhibits ovulation
thickens cervical mucus
MoA of classic POP
thickens cervical mucus
MoA of IUD as emergency contraception
prevents implantation + spermicide
MoA of IUS
thickens cervical mucus
thins endometrium
when do you start intervening during the active first stage of labour
when cervical dilation <2cm every 4hrs, look at frequency and strength of contractions. Intervene if needed.
TVUSS process
look for fetal heart beat
look for foetal poles for crown rump length
look for gestational sac
at which size of the crown rump length should you be able to hear foetal heart beat?
> 7mm
if no heart beat heard and >7mm, possible miscarriage so get 2nd opinion or rescan
at which size of the gestational sac should you be able to see a foetus
> 25mm
if no foetus seen and GS>25mm, possible miscarriage so get 2nd opinion or rescan
