O&G Flashcards
What markers are screened for in the combined test?
PAPP-A
beta-hCG
Nuchal translucency (NT)
*performed from 10-13 weeks
What markers are screened for in the quadruple test?
Unconjugated oestradiol
Total hCG
AFP
Inhibin A
Can you use chemotherapy to treat cancer in pregnant patients?
Yes, although it may be teratogenic in the first trimester, it may be used in the 2nd and 3rd trimesters. Ideally, birth should be 2-3 weeks after the most recent chemotherapy session to allow for bone marrow regeneration.
*Tamoxifen is not safe in pregnancy and breastfeeding. Radiotherapy is contraindicated in pregnancy unless it is a life-saving option
What is routinely offered to pregnant obese women?
Mechanical and pharmaceutical thromboprophylaxis
Vitamin D 10mg OD
Obstetric anaesthetist review
Active management of 3rd stage labour (syntometrine and controlled cord traction) due to higher risk of PPH
GDM assessment
What are risk factors for 2nd trimester miscarriage?
Uterine septum
Incompetent cervix (including previous procedures like cone biopsy)
Autoimmune diseases (like SLE or scleroderma)
Chromosomal abnormalities of fetus
Which investigation is the most useful for ruling out a pulmonary embolism in pregnancy?
Women presenting with symptoms and signs of an acute PE should have an electrocardiogram (ECG) and a chest X-ray (CXR) performed.
In women with suspected PE who also have symptoms and signs of DVT, compression duplex ultrasound should be performed. If compression ultrasonography confirms the presence of DVT, no further investigation is necessary and treatment for VTE should continue.
When the chest X-ray is abnormal and there is a clinical suspicion of PE, CTPA should be performed in preference to a V/Q scan.
*D-dimers are naturally raised in the first trimester of pregnancy + are only of predictive value and not diagnostic
What is the management of PPROM (pre-term pre-labour rupture of membranes)?
Aim is to deliver by 37+0 weeks as early delivery is associated with improved outcomes
Give 10-day course of erythromycin prophylaxis or until in established labour (whichever is sooner)
Offer steroids for fetal lung maturation if under 34 weeks
Consider magnesium sulphate (usually if under 30 weeks and in labour and a planned birth within 24 hours)
What physiological changes in pregnancy do you see?
Marked increase in fibrinogen, factor VII, factor X and factor XII throughout pregnancy
Stroke volume increases from the first trimester and is over 30% higher than the non-pregnant state by the third trimester
Haemodilution caused by a relative increase in plasma volume compared to the red cell mass reduces the Hb concentration
Thrombocytopenia
NOTE: You also get a physiological murmur (soft systolic flow frequently audible on auscultation of the praecordium due to dilatation across the tricuspid valve causing mild regurgitant flow)
What do you want to do in HIV+ve pregnant lady?
Avoid vertical transmission to reduce morbidity (one procedure is to wash the baby shortly after delivery)
You also avoid interventions which increase the risk of maternal/fetal blood transfusion such as amniocentesis, fetal blood sampling or forceps delivery
What anticoagulants can be given in pregnancy?
Warfarin should be avoided due to its teratogenic effects. This is most prominent in the first trimester and is associated with fetal warfarin syndrome (nasal hypoplasia, vertebral calcinosis and brachydactyly). Warfarin effects in the second and third trimester are reduced but it can still cause cerebral malformations and ophthalmic disorders.
Heparin and DOACs are both indicated for treatment of PE but there is only evidence of heparin hence it is preferred
How do you acutely manage a seizing pregnant patient?
Call for help –> ABC –> left lateral tilt –> protect airway –> prepare magnesium sulphate
*Tilting on the left will relieve any aortocaval compression and stop the woman chocking if she vomits
*Magnesium sulphate is used for a cerebral membrane stabiliser
*You need to prioritise the pregnant lady first so make sure she is fine before monitoring the fetus
How to prevent vertical transmission of HSV in pregnancy?
If HSV is present at the time of delivery or within 6 weeks of the due date, a caesarean is the safest mode of delivery. If the patient labours within 6 weeks, then she should consider a caesarean section.
If the patient refuses to have a CS, IV aciclovir during labour and close liaison with the neonatologist is recommended.
*Neonatal HSV can cause encephalitis, hepatitis and disseminated skin lesions.
When is ECV offered?
From 36 weeks in nulliparous women and from 37 weeks in multiparous women
*You would offer tocolytics (to relax the uterus) and CTG (monitor fetus)
Examples of absolute contraindincations for ECV
Multiple pregnancy
Major uterine abnormality (i.e. bicornuate uterus)
Anterpartum haemorrhage within 7 days
Rupture of membranes
Examples of relative contraindications for ECV
Small for gestational age with abnormal Doppler scan
Pre-eclampsia
Scarred uterus
Oligohydramnios
What is SLE and what are its risks in pregnancy?
SLE is a systemic connective tissue disorder that is more common in black African and black Caribbean women - it may manifest as arthritis, renal impairment, neurological involvement, haematological complications, serositis, pericardtitis. Pregnancy increases the likelihood of a flare by 40-60%
SLE in pregnancy creates an increased risk of spontaneous miscarriage, fetal death, pre-eclampsia, preterm delivery and fetal growth restriction
How does Listeria monocytogenes affect pregnancy?
It can cause listeriosis, and pregnant women are at risk due to being immunocompromised.
It is a food-borne infection and can be present in unpasteurised cheese and pâté.
It can cause a 2nd trimester loss, early meconium and preterm labour.
What is pruritic urticarial papules and plaques of pregnancy (PUPP)?
It is a benign itchy, raised rash caused by an immune response to connective tissue damage from stretching of the skin in the abdomen. It is most commen in first pregnancies.
The rash starts in the anbdomen in stretch marks (with peri-umbilical sparing) and then moves around the body.
It normally occurs after 34 weeks and disappears after birth
Is sodium valproate absolutely contraindicated in pregnancy?
No, it is recommended to be avoided due to its high risks of congenital malformations.
However if it is the only anti-convulsant that works for a patient, they should continue it, even though there may be risks to the fetus.
What is the diagnosis criteria for gestational diabetes?
75g 2-hour oral glucose tolerance test (OGTT) for women with risk factors at 24-28 weeks. If they previously had gestational diabetes, offer the OGTT as soon as possible after booking, and a second OGTT at 24-28 weeks if the results for the first one was normal
DIagnose gestational diabetes if:
a fasting plasma glucose level of 5.6 mmol/litre or above or
a 2‑hour plasma glucose level of 7.8 mmol/litre or above.
What are the target blood glucose levels for pregnant women?
Fasting: 5.3 mmol/litre
and
1 hour after meals: 7.8 mmol/litre or
2 hours after meals: 6.4 mmol/litre.
*pregnant women with diabetes who are taking insulin to maintain their capillary plasma glucose level above 4 mmol/litre
Complications of gestational diabetes mellitus
Women who develop GDM have a 35-60% chance of developing T2DM over the next 10-15 years
Shoulder dystocia with macrosomic fetus
Stillbirth
Neonatal hypoglycaemia
Pre-eclampsia
How do you manage a pregnant lady with HIV?
Aim to reduce risk of vertical transmission from motjher to fetus. The mother needs to aim for a viral load of under 50 copies/ml.
o ART: all women should be offered ART regardless of whether they were previously taking it
o Delivery: vaginal delivery is recommended if viral load <50/mL at 36 weeks, otherwise C-section
o Neonatal ART: zidovudine (oral or IV) is usually administered orally to the neonate if maternal viral load is <50/mL; otherwise, triple ART should be used. Continue therapy for 2-4 weeks
o Breastfeeding: all women in the UK should be advised NOT to breastfeed
What is a missed miscarriage?
The loss of pregnancy without the passage of products of conception or bleeding.
*Not when “you didn’t know what happened”
What are pseudosacs?
They may be confused with an early gestational sac but they represent decidualised reactive tissue. They can be a sign of an ectopic pregnancy, so it is important to rule them out.
What are risk factors for ectopic pregnancies?
Previous ectopic pregnancy
Previous tubal surgery
Intrauterine device/system
Pelvic Inflammatory disease
IVF
How do you differentiate an ovarian torsion from a ruptured ovarian cyst?
The type of pain is different:
Although both present with a suddent onset abdominal pain, the ovarian torsion will not improve with simple analgesia. The cyst rupture pain may be reduced by simple analgesia and may decrease gradually as the peritoneal lining (which initially caused pain from irritation by the leaking fluid/blood of the cyst) absorbs the intraperitoneal free fluid.
*Both are different to a rupture ectopic pregnancy which will present with significant tachycardic hypotension
What are the risks of commencing HRT?
Increased risk of heart disease in women who start HRT 10 years after menopause
There is a slight increase in the risk of stroke
There is an increased risk of breast cancer
There is a slight increased risk of ovarian cancer
There is an increased risk of VTEs
There is an increased risk of endometrial cancer in oestrogen-only HRT if the woman still has a uterus
What is a theca lutein cyst?
It is an ovarian cyst made of multiple luteinised follicular cells and is most common when the ovary is exposed to raised levels of beta hCG (as seen in multiple pregnancy).
What are the risks of a caesarean section (important to know for elective purposes)?
You are twice as likely to have a stillbirth in a subsequent pregnancy
There is an increased risk of placenta praevia in future pregnancies
1-2% of babies will suffer lacerations
The risk of infection is 6%
The risk of bladder damage is 1 in 1000
*Other risks include venous thromboembolism (4–16 in 10000), significant haemorrhage (≈five in 100) and the need for hysterectomy (eight in 1000). The risk of death for caesarean section is around one in 12000.
What is vaginismus?
The inability to engage in penetrative sex due to involuntary spasm of the pubococcygeus muscle
What are long-term consequences of PCOS?
Endometrial hyperplasia (treat with progestogens and a withdrawal bleed should be induced every 3-4 months)
Sleep apnoea
Diabetes
Acne (due to hyperandrogenism)
Infertility or difficulties conceiving
Which of the following is not true?
1. The risk of VTE is highest in the first year of taking HRT
2. Thrombophilia screen should be carried out prior to starting HRT
3. There is no evidence of a continuing VTE risk after stopping HRT
4. Personal history of VTE is a contraindication to oral HRT
5. If a woman develops any VTE whilst on HRT, it should be stopped immediately
Thrombophilia screen should be carried out prior to starting HRT.
It is a very costly test - could consider if there is a family history of VTE
How do you manage ovarian cysts?
A risk of malignancy index (RMI) can be calculated using the CA 125 value, the characteristics of the cyst on ultrasound and the menopausal status. The features of concern on ultrasound are bilateral cysts, multiloculated cysts, solid components, ascites and metastases. RMI <50 has a 3 per cent chance of cancer. RMI between 50 and 250 has a 20 per cent chance of cancer and an RMI >250 has a 75 per cent chance of cancer. If the cyst is simple and less than 5 cm in diameter with a CA 125 <30U/ml then conservative management (D) would be appropriate with 4-monthly scans and CA 125 levels for 1 year.
*You can consider a laparoscopic cystectomy to aspirate the cyst contents and excising the cyst capsule (to prevent recurrence) if other management fails and if the patient was sufficiently symptomatic
What should you do before prescribing oestrogens?
You should ultrasound the pelvis and ensure that the endometrial thickness is <4mm. This is really important if there is postmenopausal bleeding as you want to exclude endometrial cancer (but also cervical cancer)
What is triptorelin?
Gonadotropin-releasing hormone agonist that creates a temporary artificial menopause by reducing FSH and LH levels. This is a great option to cope with severe endometriosis for up to 6 months - any more and there is a risk of loss of bone density.
This is a great option before considering a laparoscopy to clear the disease
What is the function of progesterone?
It is released by the corpus luteum following ovulation and its main function is to enhance endometrial receptivity (in the event that an embryo should need to implant).
Progestogenic effects include:
* increase in respiratory rate
* increase in sodium excretion
* reduced bowel motility
* increase in body temperature
What is the function of oestrogen?
Oestrogen plays a role in ovulation as well as causing the proliferation of the endometrium.
Oestrogenic effects include:
* Increased uterine growth
* Increased fat deposition
* Increased bone resorption
* Endometrial growth stimulation
What is premenstrual syndrome?
A condition that is associated with distressing physical, behavioural and psychological symptoms in the absence of organic or underlying psychiatric disease - this recurs regularly during the luteal phase of each menstrual cycle and disappears/regresses by the end of menstruation.
First line measures include: SSRIs, vitamin B6, improved diet and physical exercise, CBT and trial of Yasmin or Cilest COCP.
Other complementary treatments (with no evidence) can be used such as St. John’s Wort, Ginkgo Biloba and Evening Primrose Oil
What is the first-line treatment of pelvic inflammatory disease?
Ceftriaxone 1 g as a single intramuscular (IM) dose, followed by oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days.
OR
Oral ofloxacin 400 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days. Levofloxacin (500 mg once daily for 14 days) may be used as a more convenient alternative to ofloxacin.
OR
Oral moxifloxacin 400mg once daily for 14 days - use this one if initial test for Mycoplasma genitalium is positive
What is an episiotomy and which structures does it cut through?
It is a procedure where you cut structures in the vulval area (around 45º from the midline) to create extra space for the delivery of the fetal head.
It cuts through the:
* bulbospongiosus muscle - inserts into the fascia of the corpus cavernosa and originates from the perineal body
* Superficial trasverse perineii (STP) - goes from the ischial ramus and tuberosity to the perineal body
* Vaginal mucosa
* Perineal membrane - has two parts (dorsal and ventral). The ventral part consists of the urethra and surrounding structures. The dorsal part consists of the attachment of the lateral wall of the vaginal and perineal body to the ischiopubic rami
How do the following conditions cause an increase risk to the fetus if a fetal blood sample (FBS) is performed?
HIV
Hepatitis C
Maternal immune thrombocytopenia
Factor IX deficiency
HIV and Hepatitis C are blood-borne viruses and invasive tests such as FBS can increase the risk of vertical transmission
Factor IX is haemophilia B and this should be avoided as there is a risk the fetus may be affected
In maternal immune thrombocytopenia there is a risk the fetus may have a low platelet count
What is the sensitivity and specificity of CTG monitoring?
High sensitivity, low specificity
Its purpose was to reduce the number of babies born with fetal acidosis and poor APGAR scores. It is quite sensitive and will pick up if a fetus becomes acidotic through suspicious/pathological changes. However it is not very specific with 50% of babies delivered due to a pathological CTG having normal blood gases
How do you deliver a transverse lie fetus?
You can try performing ECV and if that doesn’t work then you will have to opt for caesarean delivery as IOL in a transverse lie increases the risk of uterine rupture
What are the signs of uterine rupture and how do you proceed?
Significant fetal heart rate abnormality and the CTG will not register any contractions
A ‘crash’ caesarean delivery is normally performed with subsequent repair, if possible, of the uterus, although a caesarean hysterectomy is sometimes necessary.
What are contraindications to epidural anaesthesia?
Absolute:
* Patient refusal
* Allergies to anaesthetic agents
* Systemic infection
* Skin infection over the intended epidural site
* Bleeding disorders
* Platelet count <80,000/ml
* Uncontrolled hypotension (epidural causes peripheral vasolidation and worsens this)
Relative:
* Hypertroiphic obstructive cardiomyopathy
* Aortical stenosis
* Mitral stenosis
Where does a pudendal nerve block happen?
The pudendal nerve is a sensory and motor nerve arising from the sacral plexus and forms from the ventral spinal nerve roots S2-S4. The pudendal nerve passes through the greater sciatic foramen, traversing through the sacrospinous and sacrotuberous ligaments. It then re-enters the perineum through the lesser sciatic foramen along with the internal pudendal artery and vein.
A pudendal nerve block (transvaginal approach) aims to block the nerve as it enters the lesser sciatic foramen, 1 cm inferior and medial relative to the attachment of the sacrospinous ligament to the ischial spine.
How does disseminated intravascular coagulation (DIC) present?
PT (high or low)
aPTT (high or low)
Bleeding time (high or low)
Platelets (high or low)
Active haemorrhage (yes or no)
PT - high
aPTT - high
Bleeding time - high
Platelets - low
Active haemorrhage - yes
What is a B-Lynch suture?
It is an external uterine suture that helps with uterine contractions in PPH
How does an intrauterine balloon help with PPH?
It provides internal uterine tamponade against any bleeding vessels
How does internal artery ligation help with PPH?
It prevents blood flow down to the uterine artery, hence reducing the blood volume reaching the uterus
What is peri-partum cardiomyopathy?
It develops in the last month of pregnancy and up to 5 months post-partum, causing the woman’s heart to become enlarged and weakened.
Risk factors include multiple pregnancies, hypertension in pregnancy and advances maternal age.
It presents as SOB, tachycardia, tachypnoea and signs of congestive cardiac failure. X-ray findings will show cardiomegaly and pulmonary oedema.
It is rare but has a mortality rate of 9-15%
Which of the following does not occur in fetal circulation?
* Right ventricular output increases
* Decrease in venous return
* Closure of foramen ovale
* Pulmonary artery vasoconstriction
* Closure of ductus arteriosus
Pulmonary artery vasoconstriction
Occlusion of umbilical vessels –> reduces venous return to the right heart –> reduced right arterial pressure and hence closure of foramen ovale.
As fetus starts to breath –> pulmonary pressure lowers and right ventricular output increases (accomodated by vasodilation of the pulmonary arteries).
Increased flow through pulmonary system –> increased venous return of the left side of the heart –> increased pressure on the left side –> closure of ductus arteriosus due to rising oxygen levels
How does Sheehan’s syndrome present?
It can present as absence of lactation and periods, fatigue and less commonly diabetes insipidus. If long-standing this can further cause SIADH.
It is due to a PPH significant enough to cause hypovolaemia - this alongisde hypotension can cause reduced blood flow to the anterior pituitary (which is hyperplastic during pregnancy) and cause severe necrosis or infarction.
Treatment is hormone replacement
How does toxoplasmosis infection in pregnancy present?
It can be caused by Toxoplasma gondii and this is contracted from undercooked meat and cat faeces.
It can cause chorioretinitis, macro- or micro-cephaly, convulsions and long-term neurodevelopmental delay.
Initial infections in the mother is usually mild and she may often not be aware of it.
How does a patient with an imperforate hymen present?
Primary amenorrhoea but with pubertal features (suggesting hypothalamic-pituitary axis is intact).
On speculum examination there will be accumulation of blood inside the vagina (haematocolpos) - can present as intermittent bloating.
What are risk factors of molar pregnancies?
Extremes of ages
Previous molar pregnancy
Race (SE Asia)
How do molar pregnancies present?
Unusual/heavy bleeding (beyond 6 weeks of pregnancy) with a pregnancy that is large for dates.
Ovaries are also enlarged due to the size of theca lutein cysts
What are Bartholin’s glands and how are Bartholin’s abscesses treated?
They are paired glands (approx 0.5cm in diameter) and commonly found at the 4- and 8-o’clock positions in the labia minora.
They are normally non-palpable and they secrete vaginal lubricant into the vestibule via the Bartholin’s ducts during sexual arousal. However if these ducts become blocked, an abscess of the gland can develop.
Treatment is usually with marsupialisation - opening the abscess and suturing its lining to the outside to create a permanent opening, thereby reducing recurrence.
Oral antibiotics can be used post-surgery
What is clomiphene?
It is a selective oestrogen receptor modulator which through inhibition of negative feedback on the hypothalamus, increases the production of gonadotrophins. This then induces ovulation.
What are the risks of IVF?
- Increased risk of ectopic pregnancies
- Increased risk of fetal congenital abnormalities
- Increased chance of multiple pregnancies (twins, triplets)
- Increased risk of SGA babies (in singleton pregnancies) and low birth weight
- Increased risk of pregnancy-induced hypertension (especially if egg was donated)
What needs to be discussed prior to surgical termination of pregnancy (STOP)?
Antibiotic prophylaxis or screening for chlamydia
Offer post-termination contraception
Explain the risks - bleeding, infection, failure of procedure, need to repeat procedure and perforation of uterus
What are risk factors for cervical cancer?
Smoking
HIV (due to immunocompromised status)
Early first intercourse
Multiple sexual partners - further associations with COCP and multiparity (not causal factors but associative factors with increased sexual activity)
What is a vesico-vaginal fistula?
Common fistula between the bladder and the vagina caused by obstructed labour (most common cause worldwide). The fetal head sits adjacent to the bladder and overtime, this can cause the tissues to become necrotic and breakdown, eventually forming a fistula. However the most common cause in resource-rich countries is pelvic surgery.
A simple test for this in clinic is passing a catheter and filling the bladder with methylene blue dye. Then you would perform a speculum examination to see if there is dye in the vagina.
2nd line investigations would be an examination under anaesthesia and cystoscopy
What are first line linvestigations for subfertility (female)?
Day 1-3 LH and FSH
Mid-luteal phase progesterone (day 21)
*These would provide an indication as to whether the woman is ovulating or not.
Further investigations would include an USS to look at the size of the uterus and to detect the presence of any fibroids/polyps. An hysterosalpingogram (HSG) would be useful to assess tubal patency.
What are the normal ranges for sperm analysis?
- Average ejacualte volume is 1.5-6ml
- Sperm count should be 15 million/ml
- pH should be between 7.2 and 8.0
- > 4% of sample should have normal morphology
- 50% of the sperm should have normal motility
*Male factor subfertility is the cause of 25-40% of subfertile couples
How does ovarian hyperstimulation syndrome (OHSS) present?
Presents with abdominal pain, distension and swelling, nausea and vomiting, SOB, oedema/ascities.
Blood will become haemoconcentrated with hypoproteinaemia and ascities - which can lead to a pleural effusion
Ovaries will be enlarged on USS and in severe cases >12cm. Due to haemoconcentration, patients are at an increased risk of VTE so will require decompression stockings and prophylactic anticoagulants. The hypoproteinaemia (low albumin) can also lead to decreased intravascular plasma and eventually hypercoagulability.
If the OHSS is severe there may be problems perfusing the kidneys well if much of the intravascular volume is being drawn into the third space by the decrease in oncotic pressure in the blood vessels. This may lead to oliguria. Fluid balance and management is key to these patients.
What organisms can cause bacterial vaginosis?
- Gardnerella species
- Mobiluncus
- Bacteroides
- Mycoplasma
Due to an imbalance of the naturally occuring flora in the vagina so it presents with an off-white offensive discharge with a fishy smell. Swabs can show clue cells and a loss of vaginal acidity.
What are the bony landmarks of the pelvic outlet?
Pubic arch (inferior margin of the pubic symphysis)
Ischial tuberosities (left and right, aka ischial spines)
Tip of the coccyx
What are the landmarks of the pelvic inlet?
The promontory of the sacrum
The arcuate line of the ilium
The iliopubic eminence
What is a Wertheim’s hysterectomy?
Also known as a radical hysterectomy
Operation for cervical cancer - involves removing the uterus, upper 1/3 of the vagina and all the parametrium
*Wertheim’s hysterectomy + some bowel resection = pelvic exenteration
Endometrial cancer staging
I-A tumour confined to the uterus, no or <1⁄2 myometrial invasion
I-B tumour confined to the uterus, >1⁄2 myometrial invasion
II cervical stromal the invasion, but not beyond the uterus
III-A tumour invades the serosa or adnexa
III-B vaginal and/or parametrial involvement
III-C1 pelvic lymph node involvement
III-C2 para-aortic lymph node involvement, with or without pelvic node involvement
IV-A tumour invasion bladder and/or bowel mucosa (D)
IV-B distant metastases including abdominal metastases and/or inguinal lymph nodes
How do you diagnose and manage ovarian cancers?
You need a histological diagnosis at operation (even if imaging is already pointing to the whereabouts/spread of the cancer)
A staging laparotomy establishes the type and extent of the primary cancer and allows optimal cytoreduction (or ‘debulking surgery’) where as much of the disease as possible is removed at operation.
Even in advanced cancers, the preferred treatment for all women who are fit for operation is optimal cytoreductive surgery. Chemotherapy may also be indicated since ovarian cancers are highly sensitive to platinum based agents and the vinca alkaloids.
What is Meig’s syndrome?
Triad of:
* Right-sided pleural effusion
* Ascites
* benign overian fibroma
What are patients on long-term steroids prior to surgery at risk of?
Patients on >10mg predisolone/day (or equivalent) for 3 months or more will require steroid supplementation due to secondary corticosteroid insufficiency. Patients on <10mg predisolone will still have a normal HPA response.
For major gynaecological surgery, such as vaginal hysterectomy, 50mg of hydrocortisone 8-hourly from induction is the standard practice, and may be stopped after 2 or 3 days, or when normal gut function returns and the patient can resume oral steroids. This is alongside 50mg IV hydrocortisone at the induction of anaesthesia.
Questions 2, 12, 13, 16, 20 of section 8 are on female pelvic anatomy
read if want
What can cause chest pain in a patient with ischaemic heart disease?
Anaemia - the myocardium will be deprived of oxygen so chest pain can develop even thought it may not be significant enough to cause an actual infarction
How do you calculate the risk of malignancy index score (RMI)?
You need to use the CA-125 score, the characteristics of the cyst on USS and the menopause status.
You give 0, 1 or 3 points to USS characteristics:
* Presence of bilateral cysts
* Multiloculated cysts
* Cysts with solid components
* Ascites
* Metastases
You then do the following calculation:
USS points x CA-125 x 3 (if post-menopausal)
RMI <50 has a 3 per cent chance of cancer. RMI between 50 and 250 has a 20 per cent chance of cancer and an RMI >250 has a 75 per cent chance of cancer.
What is important to consider in intermenstrual bleeding?
It is important to take pelvic swabs as pelvic infections are very common causes of new-onset intermenstrual bleeding
Which of the following is not at risk when inserting a lateral port in a laparoscopy?
* Superficial epigastric artery
* External iliac vein
* Iliohypogastric nerve
* Superior epigastric artery
* Ilioinguinal nerve
Superior epigastric artery
What do women with heart valvular problems require in an instrumental delivery?
Intra-partum prophylactic antibiotics due to infection-prone procedure
What is the role of prostaglandins and collagenase in the cervix during pregnancy?
Prostaglandins remodel the cercix
Collagenase aids in cervical softening
Both prepare the cervix for labour
What does maternal cortisol do?
Regulates uterine blood flow through effects on vascular endothelium and smooth muscle
What is the vessel that carries oxygenated blood from the placenta and in adult life forms part of the falciform ligament?
Umbilical vein
What are the trimesters in pregnancy?
1st: 1 to 12 weeks
2nd: 13 to 27 weeks
3rd: 28 to 40+ weeks
At how many weeks is a baby considered at term
37 weeks
What does baseline variability on a CTG demonstrate?
Reflection of the normal fetal autonomic nervous system
What is a biophysical profile?
It is an assessment of fetal breathing, gross body movements, fetal tone, reactive fetal heart rate and amniotic fluid.
This is usually done after 28 weeks on USS
What can be used to date pregnancies when booked between 14 and 20 weeks?
Head circumference
What is cordocentesis?
It is a relatively unusual procedure but can be performed where a fetal blood sample is required - i.e. to determine platelet count in suspected alloimmune thrombocytopaenia
Why do women need to be admitted to hospital at term if the fetal lie is unstable?
When the fetal lie is unstable, the longitudinal axis of the baby relative to the mother still fluctuares at term - this increases the risk of cord prolapse if the membranes rupture
What risks do monozygotic twin pregnancies carry?
Death or handicap of the co-twin in 25% of cases
How often should USS surveillance for monozygotic twins in the 3rd trimester be carried out?
Fortnightly
What is multi-fetal reduction?
The reduction of the number of fetuses in multiple pregnancies (>2) in order to improve the survival of the fetuses and reduce the possibility of preterm birth
What is an US measurement of the cervical length used for?
It is helpful in predicting preterm labour in multiple pregnancies
Why is intrauterine bleeding linked to reccurent episodes of threatened miscarriage in early pregnancy?
Blood is irritant to the uterus
What is cervical cerclage?
Surgical procedure to place a stitch/suture around the cervix.
It is done to prevent premature delivery or miscarriage in at risk women due to cervical insufficiency/weakness
It is contraindicated in the presence of vaginal bleeding, contractions or infection
What is the nitrazine test?
It tests for the alkaline pH of amniotic fluid to check if there has been rupture of membranes or not
It has a high negative predictive value
What is the Jarish-Herxheimer reaction?
It is a temporary reaction with an increased released of pro-inflammatory cytokines usually within the first 24h of syphilis treatment.
Symtpoms include:
* Fever
* Chills
* Headache
* Muscle aches
* Flushing of the skin
* Rapid heart rate
* Low blood pressure
* Sweating
* Increased breathing rate
Name the mechanisms of labour
Engagement
Descent
Flexion
Internal rotation
Extension
Restitution
External rotation
Delivery of the shoulders and fetal body
*Chapter 14 ten teachers
What is effacement?
It is a process where the cervix shortens in length and becomes included into the lower segment of the uterus
It can start weeks before the onset of labour but will complete by the end of the latent phase
How long should a third stage of labour last?
<30 mins
How long should an active 2nd stage of labour last?
<2 hours in primiparous
<1 in women with previous vaginal delivery
What is uterine inversion?
It is a rare complication of the 3rd stage of labour. It is caused by excessive traction on the umbilical cord prior to placental separation
Klumpke’s vs Erb’s palsy?
Klumpke’s palsy, also known as “claw hand,” is a rare condition that results from damage to the lower brachial plexus, affecting the nerves that control the muscles of the forearm and hand. This can cause weakness or paralysis of the hand and fingers, with the fingers appearing curved or claw-like.
Erb’s palsy, on the other hand, is a more common condition that occurs when the upper brachial plexus is injured, affecting the nerves that control the shoulder, upper arm, and elbow. This can cause weakness or paralysis of the affected arm, with the arm appearing to be held at the side and rotated inward.
Management for primary dysmenorrhoea?
First line: NSAIDS like mefenamic acid or ibuprofen - inhibit prostaglandin production
2nd line: COCP
Placental abruption management
Fetus alive and < 36 weeks
* Fetal distress: immediate caesarean
* No fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Fetus alive and > 36 weeks
* Fetal distress: immediate caesarean
* No fetal distress: deliver vaginally
Fetus dead
* Induce vaginal delivery
Placental abruption complications
Maternal:
* Shock
* DIC
* Renal failure
* PPH
Fetal:
* IUGR
* Hypoxia
* Death
Delivery with HIV positive women
Vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
A zidovudine infusion should be started four hours before beginning the caesarean section
What do medical terminations of pregnancy involve (<9 weeks)?
Usually given mifepristone (oral) followed by at least one dose of prostaglandins (usually vaginal misoprostol)
What is the treatment for hyperemesis gravidarum?
1st line - cyclizine or promethazine
2nd line - ondansetron or metoclopramide
3rd line - steroids (hydrocortisone)
Alternative therapy - ginger tablets + P6 acupressure
*Metoclopramide is 2nd line due to chance for extra-pyramidal symptoms (EPS)
*Ondansetron is 2nd line due to increased risk of cleft lip/palate when taken in 1st trimester
*
Complications include: VTE, depression, anaemia, dehydration, electrolye imbalances - give KCl and vitamin B1
What is tubal microsurgery?
Surgical treatment of subfertility which involces tubal catheterisation or cannulation to resolve proximal tubal obstructions
What are contraindications to methyldopa?
Psychiatric history - anxiety, depression
Liver disease
MAOI use
Severe aortic stenosis
What are contraindications to labetolol?
Asthma or severe COPD
Cardiogenic Shock
Heart block or bradycardia
Severe liver disease
MAOI use
What is a side effect of hydralazine?
Causes a sudden and profound drop in blood pressure so patients may require pre-emptive administration of fluids
Neonatal varicella vs congenital varicella
Neonatal varicella does not have any teratogenic effects but it can cause extensive cutaneous involvement, pneumonitis and encephalitis.
You administer VZIG if birth occurs within 7 days of onset of chickenpox in the mother + monitor for signs of infection until 28 days post-delivery.
If neonatal varicella is contracted, treat with aciclovir
What are characteristics of congenital varicella?
Cutaneous scarring
Eye defects
Limb hypoplasia
Neurological abnormalities
What does a mid-luteal progesterone indicate?
It implies ovulation has taken place - after ovulation, the corpus luteum produces progesterone resulting in a high concentration of progesterone during the luteal phase
What is anti-mullerian hormone (AMH)?
It is important in regulating the development of follicles and is only present in the ovary until menopause - useful biomarker for ovarian reserve and helps predicts the outcome of assisted reproduction
How does genital herpes present?
Caused by HSV virus
Around 2-12 days post-exposure, patients will get painful, red lumps which turin into blisters within 24 hours. The blisters break and leave shallow, painful ulcers that take 2-4 weeks to heal after the initial infection
Other symptoms - dysuria and systemic (fever, malaise, headaches)
