O&G Flashcards
Ectopic pregnancy
Rfs
symptoms
investigations
management
complications
prior, PID, pelvic/tubular surgery
abdominal pain/adnexal mass, vaginal bleeding, amenorrhea
rupture/risk of rupture = hemodynamic instability (hypotension, tachycardia), cervical motion tenderness
pregnancy test/hcg
transvaginal ultrasound
management
1. expectant
- if asymptomatic and haemodynamically stable, serial hCG measurements until the levels are undetectable
no significant pain, no rupture, mass <35mm and hcg level between 1500 - 5000, no heartbeat, then medical or surgical management. requirements not met then surgical
- Medical
IM methotrexate and serial hcg measurement - Surgery
- salpingectomy or salpingostomy if infertility risk
Avoid Copper IUD in future (risk factor for ectopic pregnancy)
antiD prophylaxis
Acute Fatty liver of pregnancy
symptoms
investigations
management
complicaitons
malaise, nausea, vomiting, and influenza-like symptoms; jaundice, which often follows, can begin abruptly. may cause abdominal pain
most patients have associated HTN
LFTs = 1st line, elevated
glucose test may show hypoglycemia, do hepatic ultrasound to rule out other causes
supportive care - Correct coagulopathy, electrolytes and hypoglycaemia [treat using FFP and vitamin K,
50% dextrose]
expedite delivery
Screen baby for LCHAD deficiency
Cholecystitis
symptoms
investigations
management
RUQ pain, nausea, vomiting
ultrasound - may not pick up stones
analgesia ,fluids, antibiotics, ERCP
VTE in pregnancy
symptoms
investigations
management
pleuritic chest pain shortness of breath
CXR = first line
if normal CXR -> bilateral lower limb doppler
CTPA = 3rd line - risk of maternal breast cancer
LMWH is irreversible! (contrast to unfractionated heparin) therefore must be stopped at least 24 hours before birth/delivery or the use of spinal/epidural analgesia
in patient with VTE, avoid a general anesthetic, if necessary use IVC filter
miscarriage
rfs
symptoms
investigations
types of miscarriage
management
complications
Rfs include chromosomal abnormalities, increasing maternal age, autoimmune disorders eg APS,
vaginal bleeding with or without clots
suprapubic pain may occur
transvaginal ultrasound, pelvic exam, hcg
Missed = no vaginal bleeding, closed cervical os, pregnancy identified with no fetal cardiac activity or empty sac without fetal pole
Threatened = vaginal bleeding, closed cervical os, fetal cardiac activity. Avoid physical activity and sex. Progestins given
Inevitable = vaginal bleeding, dilated cervix, fetal tissue may be seen or felt at or above cervical os.
Incomplete = vaginal bleeding, dilated os, some products of conception expelled. gestational sac but no evidence of fetal pole
Complete = vaginal bleeding, closed cervix, products of conception completely removed/ empty uterus
management:
1. Expectant management for 7-14 days
- Medical
- vaginal misoprostol. side effects include vaginal bleeding, pain and nausea
- can give antiemetics and pain relief too - Surgical
- d&C
pregnancy test after 3 weeks
rhesus immunoglobulin
Complications = bleeding, retained products of conception, ashermans syndrome
Post partum hemorrhage
definition
causes
risk factors
symptoms
investigations
management
loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby.
Main causes = 4TS
1. uterine aTony = main cause
2. Tissue = Retained placenta - if Ultrasound shows thin endometrial stripe, means this is NOT the case
3. Trauma eg cervical laceration from assisted delivery -> occurs immediately and not associated with enlarged boggy uterus. or uterine inversion (smooth mass protruding from cervix or vagina, no palpable uterine fundus, abdominal pain)
4. Thrombin (deranged clotting as result of bleeding)
RFs= Previous post partum haemorrhage, uterine wall scar, prolonged labour, increased fetal size, , multiple pregnancy, uterine fibroids
- perform vaginal exam and remove placenta if still there
- rub up a uterine contraction (address atony if cause)
- IM scyntocinon/syntometrine
- IV cannula
- blood - fbc, coagulation, clotting
minor blood loss (500- 1000ml);
- IV crystalloid infusion
- venepuncture
major blood loss >1000
- ABC assessment
- blood transfusion
- IV crystalloids until blood available
gestational diabetes
symptoms
investigations
management
complications
polyuria
dysuria
thirst
risk factors - elevated BMI, previous gestational diabetes, previous macrosomic baby, non-white ancestry, family history of diabetes mellitus, and advanced maternal age
random and fasting
urinary ketones - rule out T1DM
HBA1C - rule out preexisting diabetes
obstetric USS - increased insulin in baby can increase growth, diabetes can cause polyhydramnios, congenital abnormalities may be present especially with preexisting diabetes
- fasting plasma glucose level of 7.0 mmol/litre or above or >6 with large fetus or polyhydramnios:
= insulin +/- metformin (+ diet and exercise, glucose monitoring)
- fasting plasma glucose level below 7 mmol/ litre:
= diet and exercise changes + glucose monitoring. if target not met after 1-2 weeks -> metformin -> insulin if ineffective
elective birth for no later than 40+6 weeks gestation
Discontinue blood glucose lowering treatment immediately after delivery
Fasting blood glucose at 6-13 weeks postnatal to exclude new diagnosis of diabetes
mother - hypertension, stillbirth
baby - macrosomia, neonatal hypoglycemia, congenital abnormalities
pre-existing diabetes mellitus
management
stop all glucose lowering medication except metformin and insulin
folic acid from preconception to 12 weeks gestation
low dose aspirin from 12 weeks gestation
Capillary blood glucose monitoring should be performed by the patient a min. of 7x/day
Specialist foetal cardiac scan at 19-20 weeks
Serial growth scans every 4 weeks from 28-36 weeks
Preterm labour
symptoms
investigations
management
complications
(born before 37+0 weeks gestation)
painful uterine contractions
dilated cervix
RF: previous preterm baby (biggest rf), blood(eg antepartum hemorrhage,PROM), infection (eg UTI), uterine distension (multiple pregnancy, polyhydramnios)
USS - estimate fetal weight
FBC + CRP - rule out infection
CTG - establish wellbeing of fetus
- maternal corticosteroids essential!!; 1st line = IM betamethasone,
- IV antibiotics - penicillin!!
offer tocolytic agent, nifedipine 1st line, atosiban.
IV magnesium sulphate (for neuroprotection of the neonate) if birth is expected within
the next 24 hours. monitor for toxicity - 10ml 10% calcium gluconate as antidote
Premature rupture of membranes PROM
definition
risk factors
management
Complications
Rupture of amniotic sac in ABSENCE of uterine contractions. Therefore NOTHING to do with Labour.
If rupture occurs after 37 Weeks = PROM (Premature rupture of membranes)
Before 37 weeks = Preterm Premature rupture of membranes (pPROM)
Rfs:
Occurred in previous pregnancy
Genital or urinary tract infection (BV)
Smoking
Polyhydramnios
Abdominal trauma, antepartum bleeding
diagnosis:
- speculum exam = pooling in posterior fornix, clear fluid, blood or meconium.
- Ultrasound can be carried out to assess amniotic fluid volume (low in PROM and pPROM - AFI <5cm (oligohydramnios))
- Nitrazine test (strip turns blue) and Fern test -> confirms fluid is amniotic fluid
Management
- AVOID digital examination (risk of infection, may precipitate labor in pPROM)
- 24 hr fetal heart monitoring
- oral erythromicin
- expectant management/IOL
- in Pprom, give IM betamethasone
Intrauterine infections -> endometritis, chorioamnionitis -> fever, fetal tachycardia, tender uterus, purulent amniotic fluid, sepsis
Preterm labour
Placental abruption as decompression/decreased fluid (fetal hypoxia, maternal hemorrhage and dic)
Umbilical cord prolapse
Placenta previa
symptoms
investigations
management
complications
placenta overlying cervical os
painless vaginal bleeding in second or third trimester
RFs: previous PP, multiple pregnancies, previous uterine surgery
ultrasound - placenta position
if bleeding, admit to hospital, resuscitation is 1st line:
1. antifibrinolytic - tranexamic acid
2. consider transfusion of RBCs, FFP and platelets
3. continuos fetal heart monitoring
do not perform digital vaginal exam
give c section
Placental abruption
symptoms
investigations
management
complications
continuous abdominal pain (contrast painless placenta previa)
with or without vaginal bleeding
with or without fetal heart rate abnormalities
uterine contractions
associated with smoking, HTN, Substance misuse, polyhydramnios, sudden rupture of membranes, multiparity, previous history of abruption
ultrasound - may show signs 25% of times
fetal heart rate monitoring - abnormal
1st line = stabilise mother
- bloods and fluids and antifibrinolytics as needed
- Give anti-D immunoglobulin in Rh-negative women
If mother is haemodynamically unstable or there is evidence of foetal distress →
urgent c section (irrespective of gestation)
If mother is haemodynamically stable, and there is no evidence of foetal distress →
>34 weeks → induction of labour/vaginal delivery
<34 weeks → conservative, give steroids and admit to antenatal ward for close monitoring. If bleeding settles, consider discharging home with weekly serial growth scans until term
DIC, hypovolemia leading to renal failure, chronic anaemia and post partum haemorrhage
*contrast to preterm labour which USS is typically normal and does not cause fetal heart rate abnormalities
Uterine Rupture
symptoms
investigations
management
complications
Rfs = trauma, previous c-section or myomectomy eg for fibroids, short interpregnancy interval (myometrial weakness)
Abdominal pain sudden onset, hemodynamic instability, fetal HR abnormalities. Acute abdomen (rebound, guarding).
New abdominal mass (loss of fetal station from 0 to -3)
Emergency c section. Hysterectomy most times
Obstetric/ intrahepatic cholestasis
symptoms
investigations
management
complications
history of pruritis without a rash - typically palms and soles but may be present widespread
excoriations may be seen
raised bile acids
RF - family or personal history, liver disease
bile acids + LFTS
diagnosis of exclusion - abnormal liver function tests and exclusion of other causes of itching and abnormal liver function.
conservative - topical menthol with aqueous cream to alleviate itch = 1st line
medical - ursodeoxycholic acid and or chlorphenamine for itch
vitamin K
monitor LFTs and bile acids weekly until delivery
deliver at 37 weeks, no later than 40, continuous CTG monitoring
Measure LFTs 6 Weeks post-natal to ensure resolution
mother - postpartum hemorrhage, gestational diabetes, preeclampsia
child - preterm, stillbirth
normal fetus blood pH?
In the foetus a normal PH is >7.25. A borderline result would be 7.2-7.25. Immediate delivery would be indicated if the result was <7.2.
premature ovarian failure
treatment
complicaitons
eostrogen (endometrial cancer, breast cancer SEs) + progesterone (bloating, constipation, irritability SEs)
hypothyroid disease
osteoporosis
sexual dysfunction
insomnia
perineal tear grading?
risk factors?
managment?
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.
forceps delivery is risk factors
surgical repair
antibiotics, analgesia, laxatives, physiotherapy
what is the most effective emergency contraception method?
Copper IUD
Management for slow-progressing labour
step 1 = artificial rupture of membranes
step 2 = start on oxytocin infusion if still not progressing
step 3 = C section
if Progress in labour is slow from the start, eg less than 2 cm increase in cervical dilatation in 4 hours = primary dysfunctional labour - often due to ineffective uterine action
Secondary arrest = failure to progress when there was adequate or expected progress to begin with.
Listeria infection in pregnancy treatment?
complications?
ampicillin, erythromycin
(listeria resistant to cephalosporins, gentamicin avoided in pregnancy)
spontaneous septic abortion
premature labour
listeria can range from mild flu like illness to septicaemia, meningoencephalomyelitis, maternofetal and neonatal listeriosis. Contaminated food is a potential source of infection
Contraindications to HART therapy
Contraindications to oestrogen therapy are undiagnosed vaginal bleeding, severe liver disease, pregnancy, venous thrombosis, and personal history of breast cancer. Well-differentiated and early endometrial cancer, once treatment for the malignancy is complete, is no longer an absolute contraindication. A family history of breast cancer is not an absolute contraindication.
Oxytocin
Side effects?
Methods of administration?
Water intoxication and hyponatremia (it is an antidiuretic)
Uterine hyper stimulation -> can be corrected using Terbutaline
IV
IM
Complications of asthma in pregnancy?
Fetus - preterm, LBW, intrauterine growth retardation
Mother - preeclampsia, gestatinal HTN
urge incontinence investigations?
management?
frequency volume chart
conservative fluid advice: avoid drinking minimal or excessive fluid
smoking cessation, weight loss BMI over 25
1st line = bladder training for 6 weeks - trying to increase time between wees
2nd line = antimuscarinics - oxybutinin, tolterodine etc
local eostrogen - in post menopausal women
