O&G Flashcards
What is the biggest RF for stillbirth?
IUGR
What are the different types on incontinence?
stress
urge
mixed
Ix in urinary incontinence
- Examine patient – PV/PR, signs of POP
- Urine dipstick
- Bladder diary (3 days)
- Post-void residual volume (usually via bladder scan)
- Can refer for urodynamics if considering surgical management or complex history
Which muscles make up the levator ani?
- pubococcygeus
- puborectalis
- iliococcygeus
Diameters (conjugates) of the female pelvis
Anatomical conjugate: from pubic symphysis to sacral promontory
Transverse diameter: greatest width of the pelvic inlet
Oblique diameter: from the iliopectineal eminence of one side to the opposite sacro-iliac joint
Straight conjugate: from lower border of symphysis to coccyx
Pudendal nerve roots
S2-S4
What is monosomy X?
Turner’s syndrome
47XXY
klinefelter syndrome
types of abnormalities with placental invasion
○ Accreta (invades endometrium)
○ Increta (invaades myometrium)
○ Percreta (invades through endometrium and myometrium)
Risk factor: previous C-section
Commonest placenta invasion abnormality
placenta accreta
78%
invades through the endometrium
What are the 7 layers for c-sections?
skin
fat
camper’s facscia
scraps fascia
rectus sheath
rectus muscles
parietal peritoneum
visceral peritoneum
uterus muscular layer
arcuate line
below you only have the anterior component of the rectus sheath
1/3 of distance between the umbilicus and the pubis
types of incision for c-sec
- pfannensttiel
- Joel-cohen
- maylard
- midline vertical
Palmer’s point
3cm below costal margin MCL
used commonly on left side (b/c liver on the right) in pts with significant hx of abdo surgery
Where is the pouch of Douglas?
it is the rectouterine pouch
Borders of the pelvic outlet
Pubic arch
Ischial tuberosity
Tip of coccyx
posterior end of perineal diamond
coccyx
Which hormone does not peak at day 14 of the mmenstrual cycle?
progesterone
LH, FSH and
progesterone is produced where in pregnancy?
corpus lutetum -> placenta
definition of menopause
1 year without periods
IMB
intermenstrual bleeding
PCB
post coital bleeding
What is the name of the ‘standard’ speculum used in O&G?
cusco’s
What is a miscarriage
spontaneous abortion
loss of pregnancy that occurs during the first 23 weeks
symptoms of miscarriage
PV bleeding
+/- lower abdo pain/cramping
can be asymptomatic if early
Reasons for miscarriage
- chromosomal abnormalities (e.g. aneuploidy - monosomy/trisomy/polyploidy/translocation - balanced or unbalanced)
- if blastocyst fails to implant
- ectopic pregnancy: if blastocyst implants into another tissue rather than the endometrial lining e.g. uterine tube
- insufficient progesterone from corpus luteum
- placental insufficiency (in hormone or blood supply to the foetus
- tertogenic damage
- MVAs/accidental falls
- uterine abnormalities (septate uterus/ submucosal fibroid)
- infectious: listeria monocytogenes, toxoplasma gondii, CMV, HSV causing severe fetal infection leading to miscarriage
- maternal disease: obesity, DM, thyroid dysfunction, PCOS, APS, SLE, HTN
- increased age of either parent
it is suspected that 50% are due to fetal abnormalities incompatible with life
What is polyploidy?
it is a chromosomal abnormality
when the zygote has more than 1 set of 23 chromosomes e.g. 69 or 92 in total
it i generally not viable and leads to a miscarriage
What is a threatened miscarriage?
currently ongoing pregnancy in woman presenting with bleeding/pain
cervical os closed
viable intrauterine pregnancy
What is early pregnancy?
the first 12 weeks(completed)
What is an early pregnancy loss
pregnancy loss occuring in the first (completed) 12 weeks
what is recurrent miscarriage?
loss of three or more consecutive pregnancies
What are early pregnancy complications? (list)
miscarriage
ectopic pregnancy
pregnancy of unknown location
Ix to confirm miscarriage
TVUS
pelvic examinaiton
bHCG
Why do we measure bHCG and not HCG?
HCG is made up of 2 subunits: alpha and beta
alpha subunit is the same in LH, FSH, TSH and HCG
How many couples are affected by recurrent miscarriage?
1%
How common are miscarriages
1 in 5 (20%) of clinical pregnancies
how many UK hospital admissions annually are due to early pregnancy loss?
50 000
What is the suspected cause of 50% of miscarriages?
fetal abnormalities incompatible with life
RFs for miscarriage
- maternal age >35
- previous miscarriage
- APS
- infective factors
- maternal illness
- uterine cavity abnormalities
RFs for miscarriage
- maternal age >35
- previous miscarriage
- APS
- infective factors
- maternal illness
- uterine cavity abnormalities
RFs for miscarriage
- maternal age >35
- previous miscarriage
- APS
- infective factors
- maternal illness
- uterine cavity abnormalities
Why does APS lead to miscarriages?
AP ABs inhibit trophoblastic function and differentiation, cause a local inflammatory response and cause thrombosis of placental vasculature.
How do you call a miscarriage without symptoms?
missed miscarriage
Questions to ask in a pregnant women presenting with abdo pain and PVB
- quantify bleeding
- systemically well? (fevers? N&V? dizzoness? unwell?)
- spontaneous or IVF?
- is the pregnancy planned?
- have you had scans earlier in the pregnancy?
- LMP? was she using any contraception?
- tell me about previous pregnancies/gynae conditions
- PMH/PSH
What should you determine on VE of a pregnant woman with PV bleeding?
- speculum: assess if the os is open or closed (re miscarriage); POC may be visible within the external os - remove
- abdomen: likely to be soft in early pregnancy
What are the different ‘types’ of miscarriage (5+3)
complete
incomplete
missed/delayed/silent
threatened
inevitable
+ viable IUP
+ pregnancy of uncertain viability
+ pregnancy of unknown location
complete miscarriage
- miscarriage has occured in a woman with previously confirmed pregnancy
- she will have experienced pregnancy
- cervical os may be open or closed
- no products of conception remaining in the uterus
incomplete miscarriage
- nonviable pregnancy in a woman who has experienced some beeding that may or may not be ongoing.
- cervical os may be open or closed
- nonviable pregnancy tissue seen within the uterus (retained products of conception)
missed/delayed/silent miscarriage
nonviable pregnancy in an asymptomatic woman
cervical os is closed
nonviable pregnancy seen
threatened miscarriage
currently ongoing pregnancy in woman presenting with bleeding/pain
cervical os closed
viable intrauterine pregnancy
inevitable miscarriage
ongoing pain and bleeding
open cervical os
products of conception low in the uterus or within the cervix
pregnancy of uncertain viability
scan findings suggest pregnancy may not be progressing normally
small sac without metal pole seen/ fetus seen <6mm without cardiac activity
pregnancy of unknown location
+ve pregnanct test without scan confirmation of intrauterine of extrauterine pregnancy
no intrauterine or extraunterine pregnancy seen on scan
What can an inconclusive scan in early pregnancy mean?
- too early to see pregnancy on scan
- pregnancy is located in the womb but no progressing normally
- miscarriage may be later diagnosed
- ectopic pregnancy
- factors like obesity/being overweight/fibroids can affect the quality of the USS
-> measure b-hCG and re-scan in?
What is the medical management of miscarriage?
- Mifepristone 200 mg PO at appointment (softens cervix, dilates, sensitises myometrium to prostaglandin induced contractions)
- 48h later: Misoprostol 800 ug PV with tampon (4x200ug tablets) - induces miscarriage, induces contractions; remove tampon after 3h and use sanitary pads thereafter
- pain relief: co-dydramol 10/500 2 tablets up to 4x/day; can cause dizziness and nausea
- ibuprofen PRN
Mifepristone MoA
Mifepristone, an antiprogestogenic steroid, sensitises the myometrium to prostaglandin-induced contractions and ripens the cervix.
Misoprostol
Misoprostol is a synthetic prostaglandin analogue that has antisecretory and protective properties, promoting healing of gastric and duodenal ulcers. It also acts as a potent uterine stimulant.
what is the pregnant person likely to experience during medical management of miscarriage?
- cramping lower abdominal pain (like bad period pains) and heavy bleeding within 4-6 hours; can take longer to start
- expect very heavy bleeding and passing clots and tissue
- best to have another adult present during the process
- start taking the pain relief tablets at the same time as misoprostol insetion
- heaviest bleeding will usually not last more than 12h
- lighter bleeding can continue for several days (up to 2w)
- seek advice if lightheaded, dizzy, unwell, soaking more than 4 large pads
What to do in medical mx of miscarriage if heavy bleeding does not occur within 48h?
contact EPU team
may need to try a second dose of misoprostol tablets
if bleeding does not occur after second dose, discuss whether the pt would like to proceed with medical management
seek healthcare if sx of infection like fever, shivering, offensive discharge
after care of medical management of miscarriage
- home urine pregnancy test after 3w (-ve results suggests that the womb is empty; if positive re-attend for USS and review; retained tissue may have to be surgically removed)
- next period should be 4-6w post miscarriage; contact EPU if after 6w no period
- there are support groups
- may be a difficult time, encourage pt to seek support form loved ones, support groups, GP, specialist nurse etc.
What is the success rate of medical miscarriage managemnt?
52-92%
higher (70-96%) in women who have already started bleeding before the tablets are given
Risks of medical management of miscarriage
- 23% will need surgical management
- 3-4% will need a second dose of tablets
- infection
- diarrhoea, dizziness, headaches, N&V, rash
- intrauterine adhesions in 19% women in any form of miscarriage management
Risks of medical management of miscarriage
- 23% will need surgical management
- 3-4% will need a second dose of tablets
- infection
- diarrhoea, dizziness, headaches, N&V, rash
- intrauterine adhesions in 19% women in any form of miscarriage management
what is expectant management of msicarriage?
waiting for the miscarriage to happen naturally without treatment
success rate of expectant management of miscarriage
50%
Risks of expectant management of miscarriage
- infection (in 2-3%, usually managed with abx)
- failure (50%)
- heavy bleeding requiring hospital admission (2%); some may need emergency surgery
- unpredictable
expectant management of miscarriage - when should you do a pregnancy test?
2w after the bleeding has stopped
contact EPU with the result
DDx for APH
- placenta praevia
- placental abruption
- trauma
- vasa praevia
- masses
- ectropion
- infections
- cervical polyps
- idiopathic
- iatrogenic: rare
- rare: Fallopian tube cancer
think of locations:
- perineum
- cervix
- uterus/placenta
- other
Define APH
Bleeding from or into the genital tract from 24+0 weeks of pregnancy
amount does not matter
placenta praevia - presentation
- painless bleeding
- low-lying placenta on scan
placenta lying in the lower uterine segment, either covering the internal cervical os or within 2cm of internal os
placental abruption presentation
- pain + bleeding
Can you diagnose placenta praevia on the 20w scan?
no, only in the 3rd trimester
the lower segment of the uterus has not formed at 20w
the monographer can comment on a low-lying placenta but would never call it placenta praevia
RFs for placenta praevia
- trauma to the lower uterine segment (previous C-section or gynaecological surgery)
- large placenta (e.g. multiple pregnancy)
Most of the time there is no real reason why it is implanted there
What is more common in pregnancies with placenta praevia?
- malpresentations are more common in PP (breech, transverse) - if a scans shows this, make sure you keep clinically examining the woman before you sign her up for a c-section
how is the placenta delivered post baby being born?
- uterine contractions, the SA decreases - shearing causes the placenta to separate.
- gush of blood comes out
- then the midwife can pull the placenta out
What are the reasons for the subcutaneous fat suture in c-sections?
- nicer scar healing - it reduces the tension in the skin allowing the scar to heal nicely
- prevents infection - abdominal fat is a potential dead space - there is very little blood supply. there is a risk of collections forming in gaps and then these can lead to infection.
The guideline is to do this if there is >2cm fat layer, however, some surgeons still do it if there is less fat.
What are the indications for an instrumental delivery of the baby
Maternal
- inadequate progress
- maternal exhaustion
- maternal medical conditions that mean acive pushing or prolonged exertion should be limited e.g. intracranial pathologies, some congenital heart conditions, severe hypertension
Foetal
- suspected foetal compromise in the 2nd stage of labour usually monitored by CTG or abnormal foetal blood sample
- clinical concerns e.g. significant APH
How many times can you attempt instrumental delivery of the baby?
three contractions and pulls - if unsuccessful, the attempt should be abandoned
What is the retractor used in c-sections which protects the bladder?
Doyen Retractor
retracts the bladder away from the incision sit eon the uterus and guards it against potential injury when suturing.
Name of the forceps that may be used in c-sections to pull the baby’s head
Wrigley’s forceps
What are contraindications for instrumental delivery of the baby
Absolute:
- unengaged fetal head in singleton pregnancies
- incompletely dilated cervix in singleton pregnancies
- true cephalo-pelvic disproportion (fetal head too large to pass through pelvis)
- Breech and face presentations
- preterm gestation (<34w) for ventouse
- high likelihood of any foetal coagulation disorder in ventouse
Relative:
- severe non-reassuring fetal status with staion of the head above the level of the pelvic floor i.e. fetal scalp not visible
- delivery of the sceond twin when the head has not quite enaged or the cervix has reformed
- prolapse of the umbilical cord with fetal compormise when the cervix is completely dilated and the station is mid cavity
What are the risks associated with instrumental deliveries?
Forceps
- 3rd/4th degree tears (more in forceps, less in ventouse)
- pain +
Ventouse:
- cephalohaematoma
- subgaleal haematoma
- fetal retinal haemorrhage
Pre requisites for instumental delivery
- fully dilated
- ruptured membranes
- cephalic presentation
- defined fetal position
- fetal head at least at the level of ischial spines and no more than 1/5 palpable per abdomen
- empty bladder
- adequate pain relief
- adequate maternal pelvis
Pre requisites for instumental delivery
- fully dilated
- ruptured membranes
- cephalic presentation
- defined fetal position
- fetal head at least at the level of ischial spines and no more than 1/5 palpable per abdomen
- empty bladder
- adequate pain relief
- adequate maternal pelvis
What is the rate of 3d/4th degree tears in normal vaginal delivery / ventouse / forceps?
normal: 1:100
ventouse: 4:100
forceps: 10:100
What is a malpresentation
any presentation that is not vertex
e.g. breech, shoulder, brown, face
Where is the vertex?
is is the area between the parietal eminences and the anterior and posterior fontanelles
What is the association between breech presentation and gestation?
incidence of breech preesntation increases with decreasing gestation
term - 3%
32 w - 15%
28 w - 25%
What are the different types of breech presentation?
- extended/frank breech (50%)
- flexed or complete breech (25%)
- footling breech (25%)
baby position in extended breech presentation
hips are flexed and knees extemded with the feet situated adjacent to the fetal head
baby position in flexed breech presentation
flexed at the hips and knees
baby position in footling breech presentation
flexed a hips and knees
feet present to the maternal pelvis, not the breech
Dx of breech presentation
- head felt at fundus on abdo exam
- auscultation of foetal heart higher than in cephalic presentation
- vaginal exam in labour to confirm
- in doubt -> USS (will also determine the type of breech)
Complications of breech delivery
- increased perinatal mortality and morbidity (usually associated with delivering the aftercoming head)
- rapid compression and decompression of the head can cause intracranial injury
- birth trauma
- cord prolapse (more likely in footling and premature breech)
What is meant by ‘nuchal arms’
In the context of breech vaginal delivery
when the babys arms are extended, reaching behind the head, during delivery -> this can also reduce the available space for the head
What types of birth trauma are associated following vaginal breech delivery?
- intracranial haemorrhage/tentorial tear
- spinal cord injury
- soft tissue injury
- liver rupture
- adrenal haemorrhage
- nerve palsies (e.g. brachial plexus or facial nerve)
- factures of the clavicle/humerus
What are the 4 main causes for the increased perinatal morbidity and mortality associated with vaginal breech delivery?
- prematurity
- cord prolapse
- birth trauma
- congenital abnormality
ECV
External cephalic version
What are the management options for breech presentation?
- ECV (external cephalic version) at 36/37w
- moxibustion (burning a stick of moxa herb near an acupuncture point on the little toe for 15-20 minutes until baby turns - offered at 34w)
- ELCS
- planned vaginal breech delivery
all women with breech presentation should be offered ECV, preferably around 37 weeks gestation.
If not successful or they decline the gold standard is ELCS.
How does ECV work?
Attempt to turn the fetus to cephalic presentation by manual manipulation thought the maternal anterior abdominal wall
usually at 37w gestation to allow time for spontaneous version and minimise the number of successful versions returning to breech.
if Rh-ve give anti-D
done on LW in case an emergency C/S needs to be performed.
Contraindications to ECV
- pelvic mass
- APH
- Placenta praevia
- multiple pregnancy
- ruptured membranes
Where should ECV be performed?
on labour ward
because there is a risk (1:300) that it will cause foetal distress requiring immediate c-section
Extra consideration for Rh -ve women in ECV
should be given anti-D Ig following attempted version because of the possibility of fetomaternal transfusion
What is the success rate of ECV?
50% result in successful version
What antenatal assessment is required for vaginal breech delivery?
- exclude macrosomic fetus by US-estimated fetal weight (EFW)
a fetus with EFW > 4kg may best be delivered by CS
US at term is associated with an error of 10-20%
Special considerations in vaginal breech delivery
- neonatologist should be present b/c vaginal breech delivery is regarded as high risk
- continuous foetal HR monitoring is recommended
- some obstetricians do not advocate for the use of syntocinon for slow progress and prefer to perform a c-section instead
- exclusion of cord prolapse is mandatory in ROM and if fHR becomes abnormal
- epidural is recommended b/c there is an increased level of manipulation
- routine episiotomy is recommended
What is the rate of breech presentation at term?
3%
How many planned vaginal breech deliveries go ahead?
about half
due to a low threshold to perform CS
Lovset manoeuvre
Mauiceau-Smellie-Vei manoeuvre
Why is episiotomy recommended in breech vaginal delivery?
- to further increase access
- to prevent delay due to soft tissues
Why is episiotomy recommended in breech vaginal delivery?
- to further increase access
- to prevent delay due to soft tissues
Ablation
- laser
- loop (scraping)
you need a normal biopsy before this
they must have also completed their family, can’t do one if you want more children.
difficult if they later need a hysteroscopy + biopsy
TCRF
transcervical removal of fibroids
What antibiotic is given during C-section?
How can you detect bladder injury in c-section
check catheter tubing
methylene blue if worried: 200-300mls with saline into catheter tubing, if you see blue in operating field call urosurgery
bladder injury in CS
call uro-surgeons, they will fix it
Levels of which hormones are measured in the quadruple test?
bhCG
AFP
uE3
inhibin A
What are the four features on CTG to look at?
- baseline HR
- variability
- accelerations
- decelerations
foetal ECG
Stan analysis
How often do you do monitor fHR intermittently?
every 15 minutes in 1st stage
every 5 mins in 2nd stage
after contraction for 1 min
concerning if decelerating for 1 min and recovering slowly that would be worrying
CEFM
continuous external fetal monitoring
Oxford/ cCTG
with computer analysis
analyses the STV
does a computer analysis of what we would usually analyse with the naked eye
therefore more detailed
does not analyse anything different
Indications for continuous CTG
maternal
- pre-ecclampsia
- GDA
- VBAC
- cardiac/lung disease
- pyrexia
- bleeding
- induced labour
- epidural use
foetal
- prematurity
- IUGR
- SGA
Issues in labour:
- meconium staining of liquor
- maternal tachycardia (<120)
DR - define risk
C - contractions (frequency in 10 minutes)
Br - baseline rate
A - accelerations
Va - variability
D - deceleratioins
O - overall impression
normal BR on CTG
110-160
mature baby would be 120-140
premature baby would be at 130-160
as the baby matures the vagal stimulation increases
e.g. 160 would be abnormal in a 42 w baby; 120 would be
normal variability on CTG
5-25 bpm
good indication of NS functioning
Acceleraton on CTG
15 bpm above baseline
for 15 seconds?
double check
CTG features on induction
The tocograph does not show strength of contractions
variability in timing
morphology and size
loss
major PPH def
> 1000 mls in first 24h
When do you do GBS swab in pregnant women?
35-37w
Who goes to DAU?
- reduced fetal movement
- high risk
- women for pre-assessment before ELSCS (MRSA screen, covid swab)
Whatt staff works at DAU?
more senior staff
e.g. cons, reg
senior midwifes
When is DAU open?
during the day mo-fr
on weekends, bank holidays or nights the women have to go to triage instead
DAU - who can refer?
- anyone can refer - GPs,
- incl. pregnant woman can call and say she’s unwell and wants to be seen
Booking Bloods
- FBC
- blood group
- rhesus +/-
- HIV
- ## Hep B/C
early fetal demise
fetal pole seen
no heart beat
should be more than 7mm
delayed miscarriage
earlier used to be called ‘missed’
failed pregnancy with no foetal pole
delayed miscarriage
earlier used to be called ‘missed’
failed pregnancy with no foetal pole
delayed foetal demise
7mm
?????
What are the3 defining characteristics of hyperemesis gravidarum?
- has to last <5% of pregnancy (usually mainly in the 1st TM)
- weight loss
- dehydration and electrolyte disurbance
Management of hyperemesis gravidarum?
1st line: antihistamine e.g. cyclizine or promethazine
2nd line: ondansetron or metoclopramide
Steroids may be used in refractory cases
If patients want to avoid medication they can try P6 acupressure or ginger
admission may be required in severe electrolyte disturbances, severe dehydration and ketonuria (3+)
What are the complications associated with hyperemesis gravidarum?
- anaemia
- malnutrition
- venous thromboembolism
- depression
When is the combined test for Down Syndrome offered to women?
10-14 weeks GA
What does the combined test for down syndrome include?
nuchal translucency
b-hCG (typically high in DS)
PAPP-A (typically low in DS)
What is in the triple/quadruple test?
b-hCG
unconjugated oestriol
alpha fetoprotein
quadruple test also includes inhibin A
MoA clomiphene
ovulation inducing agent
blocks oestrogen receptors in the hypothalamus and pituitary gland and increases the release of LH and FSH
Risk factors for placenta praevia
IVF/assisted conception (6x higher in singleton pregnancies)
multiparity
multiple pregnancy
previous C/S (emryos more likely to implant where the scar was)
smoking
drug use
advanced maternal age
minimum GA to speak about placenta praevia or low lying placenta
16w
Mx of asymptomatic placenta praevia/low lying placenta
- identified at 20 w scan
- advise to avoid sex
- rescan at 32w (only 10% go on to have low lying placenta)
- if at 32w still there, rescan at 36;
- if still low-lying/praevia at 36w -> recommend elective C/S at 36-37 w (before spontaneous labour can occur)
When should women with placenta praevia/low-lying placenta be offered C/S?
elective C/S @ 36-37/40
to avoid onset of spontaneous labour
in symptomatic women with bleeding +/- other RFs for preterm delivery, consider late preterm delivery via C/S @34-36w
definitions of placenta praevia/low lying placeta
praevia: placenta covering the internal cervical os directly
low lying: placental edge<20 mm / 2 cm from internal cervical os
Identified after 16w (usually at 20w scan) with TAUSS or TVUSS
Management of symptomatic placenta praevia
= painless bleeding
- ABCDE approach
(IV access, bloods (FBC, RhD status, X-match, clotting screen), cCTG) - give anti-D if Rh-ve
?delivery
- if mum haemodynamically unstable/foetal distress -> expedite delivery (irrespective of gestation)
- stable + no evidence of foetal distress -> steroids + admit until bleeding stops (and for further 48 h observation)
- rescan at 36/40
- recommend ELSCS at 34-36 if a hx of PV bleeding or other RFs at risk of preterm delivery
What is the danger of placenta praevia?
increased risk of bleeding
risks of delivery in PP/low lying Placenta
major blood loss
may need blood transfusion
may require hysterectomy
Screening test results indicating Edwards syndrome
quadruple test:
- low AFP
- low oestriol
- low hCG
- normal inhibin A
