O&G 2 Flashcards
Combined screening test (test + timing)
- US
- nuchal translucency
- serum tests (bhCG, PAPP-A) Not: AFP (used for neural tube defects)
done at 11-12 weeks
Terminology with screening
there is a CHANCE of something happening -> do not say risk
based on Down syndrome Society
people have different tolerances of what chance they are
Diagnostic tests for foetal abnormalities (invasive)
CVS and amniocentesis
When are CVS and amniocentesis done
CVS: (early) - 11-14w
amnio: 15w-18w (fetal cells shed into the amniotic fluid)
CVS issues
- 0.5 - 2% risk of miscarriage
- moscaiicm - may have patches of maternal tissue, normal tissue
- insufficient sample
- Infection 0.1%
- local reaction: pain and bleeding
full karyoteyp takes 2 w
prelim results are PCR
more spontaneous miscarriages in early pregnancy so CVS > amanio ? check if the procedure risk is the one that a os stated
only people with risk of trisomies >150 chance will be offered CVS aaamnio
or if the couple had aa previous pregnancy affected
anomaly scan - when?
around 20w
what anomalies does the 20w scan look for?
- neural tube defects
- cleft lip/palate
- cystic lesions in neck and lungs
- pulmonary malformations
- renal agenesis
- hydronephrosis
- hyperechogenic bowel can be associated with CF or the baby having swallowed some blood
- limbs: any signs of short limbs
- cord too check if there are 2 or 3 vessels in it
Not:
- hand digits
What is the next step if an anomaly is detected during the anomaly scan?
Referral to foetal medicine unit
What should you offer to calculate in PACES questions on IUGR/SGA?
GA based on mums EDD from USS
Late foetal loss
22-24w
immediate postpartum death within 7 days
early neonatal death
neonatal death 7d-1y post birth
late neonatal death
is the definition of neonatal death GA dependant?
no - can be termed this regardless of GA
IUD - what form of delivery is recommended?
vaginal
- helps with the grief, to allow time for the grief to develop and it might feel surreal if the pregnancy ends with an operation
Steps after miscarriage?
stop smoking
normalise BMI
genetic testing? counselling?
optimise any health conditions
offer early pregnancy scan at 6-7 weeks
not earlier because many not be seen and can cause a lot of stress
Breaking bad news
Mx of chronic hypertension in pregnancy
- additional antenatal appts (weekly, 2- or 4-weekly based on pts needs)
- stop ACEi and ARBs within 2 working days of notification of pregnancy and offer alternatives
- start aspirin 75-150 mg OD from 12w for PE prophylaxis
- offer anti-HTN treatment if BP > or = 140/90 mmHg
use LABETOLOL, NIFEDIPINE or METHYLDOPA
aim BP < or = 135/85 mmHg
fetal monitoring in chronic HTN in pregnancy
at 28, 32 and 36w carry out
- USS fetal growth and amniotic fluid
- umbilical artery doppler velocimetry
blood vessels inspected on fetal USS
- MCA
- umbilical A
- ductus venosus
- ???
When should aspirin be started in pregnant women with chronic HTM and what is the purpose?
at 12 w
to prevent pre-ecclampsia from developing
What dose of aspirin should be given to pregnant women with chronic HTN to prevent pre-ecclapmsia?
75-150 mg OD
Which anti-HTM meds are given to women with chronic HTN in pregnancy?
Labetalol
Nifedipine
Methyldopa
MoA Labetalol?
dual a1 and b1/b2 adrenergic receptor antagonist
Which meds can be prescribed for gestational HTN?
labetalol
nifedipine
methyldopa
aim BP in gestational HTN
</= 135/85
Blood tests in gestational HTN
FBC
LFTs
Renal function
at presentation and then weekly
What anti-HTN medication in pregnancy is contraindicated if the patient has asthma?
Labetalol
therefore use nifedipine instead
What anti-HTN for gestational HTN is contraindicated in a PMH of depression?
methyldopa
Define gestational HTN
BP >140/90 mmHg in pregnancy with no hx of HTN when not pregnant.
without proteinuria
should resolve within 6w PP
What are the main risks associated with untreated gestational HTN?
- IUGR
- pre-eclampsia
- placental abruption
What is vasa praevia?
Condition where foetal blood vessels run across the internal os of the cervix
presents typically with heavy, painless PV bleeding during labour -> Obs emergency b/c foetus loses O2 supply and CTG trace deteriorates -> em CS
What are risk factors for vasa praevia?
- IVF
- multiple pregnancy
Most common benign cause of postmenopausal PV bleeding
atrophic vaginitis
investigations in postmenopausal PB bleeding
- TVUS!!!! measure the thickness of the endometrium (>4mm would be abnormal and warrants endometrial biopsy)
What underlying conditions can increase the endometrial thickness in postmenopausal women and should be addressed?
obesity
T2DM
sx of obstetric choleostasis
itching of palms and soles, worse at night with no rash
deposition of bile salts in the skin causes itching
jaundice
pale stools
dark urine
in severe cases the lack of bile in the intestine can cause malabsorption of vitamin K and bleeding therefore.
supported by deranged LFTs and raised bile acids in blood
Risks associated with obstetric cholestasis
- premature birth
- stillbirth
- meconium passage
-> therefore close monitoring
Mangement of PID
Abx:
ceftriaxone (1g IM stat), doxycycline (100 mg PO BD for 14d), metronidazole (400 mg PO BD for 14d) -> given right away
review after 72h
consider removing copper IUD/IUS if in situ sx still present after 72h
What glucose measurement should be done for pts with a hx of gdm?
2h OGTT
risk factors for stress incontinence
- increased age
- multiparity
- traumatic delivery
- obesity
Mx of stress incontinence
1st line: 3 months of pelvic floor physiotherapy/exercises
Duloxetine (SNRI) 40 mg BD is used for depression but can also be used as an adjunct to pelvic floor exercises as it increases the activity of the urethral sphincter
if exercises +/- duloxetine is ineffective/unacceptable -> surgery (urethral bulking agents, autologous fascial slings, Burch colposuspension)
Considerations for pregnant women to avoid toxoplasmosis
- wash fruit and vegetables thoroughly!!
- do not handle cat faeces
- avoid unpasteurised milk (products)
- avoid raw or undercooked meat
mnemonic for congenital infections associated with morbidity and mortality
TORCH
Toxoplasmosis
Others (Varicella, listeria)
Rubella
Cytomegalovirus
Herpes simplex virus
What does toxoplasmosis in pregnancy cause?
- most babies will have no gross congenital abnormalities but have delayed neurological developmental sequelae (e.g. developmental delay, epilepsy. blindness, deafness)
Surgical ToP methods
- MVA: used up to 14w (cervix may be ripened with misoprostol; vacuum, suction used to evacuate the uterine cavity)
- dilatation and evacuation: over 14 w (the cervix has to be dilated more in order to remove larger foetal parts; contents of uterus are evacuated sing forceps and vacuum) USS used to confirm complete evacuation
What is symphysis pubis dysfunction?
pelvic girdle pain
pain associated with excessive movement of the pubic symphysis due to laxity of the pelvic ligaments
Mx of pelvic girdle pain in pregnancy
conservative: exercise to strengthen the surrounding muscles, warm baths, support belts.
Medical: paracetamol
Why should ibuprofen be avoided in pregnancy?
because it is associated with an increased risk of miscarriage; before 30w it may be considered in rare cases where the benefits outweigh the risks.
after 30w it should be avoided because NSAIDs may cause premature closure of the ductus arteriosus, persistent pulmonary hypertension of the newborn and oligohydramnios
What can codeine in the 3rd trimester cause?
neonatal withdrawal syndrome
neonatal respiratory distress
What are the components of the risk malignancy index in ovarian cancer?
Ca-125
menopause status
USS findings
Which USS findings contribute to a higher risk of ovarian cancer?
- multioculated cysts
- solid areas
- bilateral lesions
- ascites
- intra-abdominal metastases
Mx of ovarian cacner
- depends on stage
mainstay is a total hysterectomy +bilateral sapling-oophrectomy with or without platinum based chemotherapy
Are biopsies performed in ?ovarian cancer?
No
because disrupting the surface of the mass may increase the risk of metastasis
Which ovarian cancer subtype would cause changes in a blood hormone profile and what change?
granulose cell tumours may cause a high oestrogen level
What does HRT increase the risks of?
VTE
Breast cancer
endometrial cancer
gallbladder disease
What conditions does HRT decreases the risks of?
colorectal cancer
osteoporosis
what does baseline bradycardia on CTG indicate?
cord prolapse, epidural/spinal anaesthesia, rapid foetal descent
what does baseline tachycardia on CTG indicate?
maternal pyrexia, hypoxia, prematurity
what does reduced baseline variability on CTG indicate?
hypoxia, prematurity
What do early decelerations on CTG indicate?
usually they are a benign feature caused by head compression during descent
what do late decelerations on CTG indicate?
foetal distress
What do variabel decelerations on CTG indicate?
sometimes due to cord compression
What is cervical ectropion?
physiological process
glandular columnar epithelium (usually present on the endocervix) extends into the ectocervix (which usually consists of stratified squamous epithelium).
this is due to increased exposure to oestrogen (e.g. puberty, pregnancy, OCP)
What is cervical ectropion?
physiological process
glandular columnar epithelium (usually present on the endocervix) extends into the ectocervix (which usually consists of stratified squamous epithelium).
CTZ shifts (cervical transformation zone; also SC junction)
this is due to increased exposure to oestrogen (e.g. puberty, pregnancy, OCP)
Type of epithelium in endocervix and ectocervix
Endocervix: glandular columnar epithelium
ectocervix: stratified squamous epithelium
Steps (ladder) if major PPH management
MOH call; A-E including insertion of wide bore cannulas, supplementing oxygen etc.
- IV or IM syntocinon (alternatively IM ergometrine or syntometrine)
- IM carbprost
- balloon tamponade
- B-Lynch suture
- hysterectomy
What is carboprost?
Prostaglandin F2alpha analogue
careful in asthma, may precipitate bronchoconstriction
Risk factors for PID
- unprotected sex
- multiple sexual partners
- immunocompromised (e.g. HIV)
- Iatrogenic (IUS/IUD insertion within 21d, Hysteroscopy, SMM/STOP)
Complications of PID
early:
- tubo-ovarian abscess
- sepsis
- fitz-hugh-syndrome (perihepatic adhesions)
late
- chronic pelvic pain
- ectopic pregnancy
- tubal infertility
PID DDx
- appendicitis
- cervicitis
- UTI
- endometriosis
- adnexal tumours
Ix for PID
- FBC, CRP, HVS/urine, USS
- examination (obs, abdo tenderness, adnexal tenderness, cervical excitation tenderness, mass, speculum, discharge)
- hx
Mx of PID
Triple Therapy
Ceph
Doxycycline
Metronidazole
for 2 w
Mx of pelvic abscesses in the context of PID
- may need drainage
- if diameter more than 3 cm unlikely to resolve without surgical intervention
Hydrosalpinx
- usually late complication of PID
- non-functional distended tube
- incomplete separations on USS
- beads on string appearance if zoomed our
- beware in postmenopausal women because they are less likely to have PID, ?malignancy
Infected endometrioma
- ‘chocolate cysts’
- looks like endometriosis
- symptoms of PID
What other conditions is PID associated with
MI
Stroke
Ovarian Cancer
Are oral abx recommended in asymptomatic bacteriuria in pregnancy?
yes - because it reduces the risk of spontaneous miscarriage and preterm labour
(nitrofurantoin or cefalexin)
Causes for oligohydramnios?
bilateral renal agenesis (can be potter sequence)
pre-ecclampsia
IUGR
post term gestation
PROM
How does renal agenesis lead to oligohydramnios?
state in which the kidneys do not form
this can result in underproduction of amniotic fluid
Which anti-HTN med for pregnancy is contraindicated in asthma?
What should you give instead?
Labetalol
Give nifedipine instead
Which anti-HTN med for pregnancy is contraindicated in depresssion?
methyldopa
Name some tocolytics used
Salbutamol
Indomethiacin
Indications for tocolytic Medication
to delay delivery of the baby in a woman presenting with preterm contractions
RCOG guideline for 1st line management of PPH due to uterine atony
5U of IV Syntocinon (oxytocin)
followed by 0.5 mg of ergometrine (i.m., or can also be given by slow IV injection)
(Green-top Guideline No.52)
When should you rescan a patient with a low-lying placenta on the 20w scan?
32 w
Sx of OHSS
- nausea
- vomiting
- abdo pain
- bloating
- diaarrhoea
- SoB
- fever
- oliguria
- peripheral oedema
Complications of AKI
- thromboembolism
- dehydration
- pulmonary oedema
- AKI
PAPPA and beat hCG in Down syndrome?
beta HCG is high
PAPPA is low
Complications associated with shoulder dystocia
maternal
- postpartum haemorrhage
- perineal tears
fetal
- brachial plexus injury
- neonatal death
Risk Factors for cord prolapse
prematurity
multiparity
polyhydramnios
twin pregnancy
cephalopelvic disproportion
abnormal presentations e.g. Breech, transverse lie
What are risk factors for GDM?
BMI >30
Previous macrosomic baby 4.5 kg or more
Previous GDM
FH of diabetes (1st degree relative)
Ethnicity with high prevalence of diabetes
Ref: NICE ng3 recommendation GDM
What are indication for immediate treatment with insulin for women with GDM?
fasting glucose > or = 7.0 mmol/L
or fasting glucose 6.0 - 6.9 mmol/L with complications like macrosomia or hydramnios.
What should women with pre-existing diabetes aim for good glucose control pre-conception and throughout pregnancy?
to reduce risks of:
- miscarriage
- congenital malformation
- stillbirth
- neonatal death
Risks can be reduced but not eliminated!
What should you inform women with diabetes regarding how pregnancy will affect diabetes and vice versa who are planning to get pregnant?
- role of diet, weight and exercise
- risks of hypoglycaemia and impaired awareness of hypoglycaemia in pregnancy
- how N&V in pregnancy can affect blood glucose.
- increased risks of baby being LGA, increasing the risk of birth trauma, IoL, instrumental delivery and C/S
- diabetic retinopathy assessment before and during pregnancy
- diabetic nephropathy assessment before pregnancy
- importance of maternal blood glucose control during labour and birth and need for easily feeding of the baby to reduce the risk of neonatal hypoglycaemia a
- possibility that the baby may have health problems in the first 28d and possibility of NICU admission
- risk of diabetes/obesity and/or other health problems later in life.
What does UKMEC stand for?
UK medical eligibility criteria
Folic acid dose for women with diabetes who want to conceive? For how long?
5 mg / day
to be taken until 12 w of gestation
plasma glucose targets in women with T1DM pre-pregnancy
fasting: 5 mmol/L - 7 mmol/L on waking
4 mmol/L - 7 mmol/L before meals at other times of the day
HbA1c target for women with diabetes wanting to get pregnant
below 48 mmol/mol (6.5%)
if this is achievable without causing problematic hypoglycaemia
With what HbA1c levels should you strongly advice women not to get pregnant?
> 86 mmol/mol (10%)
this is because of the associated risks
which common medications should be stopped immediately when pregnant?
ACEi
ARBs
statins
Should all women with pre-existing diabetes be offered retinal assessment at their first appt?
yes - unless they had one in the last ?3 or ?6 months
What results indicate that you should refer to nephrology before stopping contraception to get pregnant?
- serum creatinine 120 micromol/L or more
- urinary albumin:creatinine ratio is 30 mg/mmol
- eGFR is less than 45 ml/min/1.73m2
Should all women with diabetes have a renal assessment before stopping contraception to get pregnant?
yes
(incl. a measure of albuminuria)
Role of HbA1c in diabetes in pregnact
- should be measure at booking in women with pre-existing diabetes to assess the risk for the pregnancy.
- also consider measuring in 2nd and 3rd trimester in women with diabetes.
- measure in women diagnosed with GDM to identify women who may have pre-existing T2DM.
- do not routinely use to assess a woman’s blood glucose control in 2nd and 3rd TM
When would you offer CSII (insulin pump therapy) in pregnancy?
In women with insulin-treated diabetes who
- are using multiple daily injections of insulin
- AND do not achieve blood glucose control without significant disabling hypoglycaemia.
What is CSII?
continuous subcutaneous insulin infusion
aka insulin pump therapy
How often should women with diabetes in pregnancy check their plasma glucose?
T1DM and T2DM/GDM managed with multiple daily insulin injections
- fasting
- pre-meal
- 1h post-meal
- bedtime
T2DM/GDM with diet and exercise or oral therapy:
- fasting
- 1h post meal
target blood levels in diabetes in pregnancy (fasting, 1h and 2h post-meal)
fasting: below 5.3 mmol/L
1h: below 7.8 mmol/L
2h: below 6.4 mmol/L
Above which value should pregnant women taking insulin keep their capillary plasma glucose?
above 4 mmol/L
is diabetic retinopathy a contraindication to vaginal birth?
yes
Retinopathy assessments during pregnancy
- offer at booking (unless had in the last 3 months)
- additional retinal assessment at 16-20w (if have retinopathy)
- additional retinal assessment at 28w
What kind of retinal assessment should be offered at booking for women with diabetes?
digital imaging with mydriasis using tropicamide
should you use eGFR to measure kidney function in pregnancy women?
no
When should you consider referring a pregnant woman with diabetes to a nephrologist?
- serum Cr > 120 micromol/L or moren
OR - urinary Alb:Cr ratio > 30mg/mmol
OR - total protein excretion > 0.5 g/day
what kidney finding would make you consider thromboprophylaxis for pregnant women?
proteinuria 5g/day or higher
(alb:Cr ratio greater than 220 mg/mmol)
Detecting congenital malformations in diabetes in pregnancy - what scan should be offered?
USS @ 20w to detect feral structural abnormalities incl examination of foetal heart (4 chambers. outflow tracts and 3 vessels)
What additional monitoring of foetal growth is offered for women with diabetes in pregnancy?
USS of foetal growth and amniotic fluid volume every 4w from 28 - 36 w
How often should pregnant women with diabetes be reviewed in an antenatal/obs med/endo clinic?
every 1-2 the clinic should be in contact with the woman for blood glucose control assessment
What should you offer women with previous GDM ?
- 75g 2h OGTT asap (if booking in 1stt or 2nd TM)
- offer self monitoring
What is the upper limit of when women with uncomplicated GDM should give birth?
40+6
What type of OGTT should be offered to pregnant women?
75g 2h OGTT
When do we test for GDM?
24-28w
with OGTT
Summary of additional appts for women with GDM
- 10w: offer OGTT for women with previous GDM who book in 1st TM
- 16w: offer OGTT or monitoring to women with PMH of GDM
- 24-28w OGTT shows DM
- 28 w growth scan + AFV
- 32w growth scan + AFV
- 36w growth scan + AFV + discussion re delivery
- 38w offer tests of fetal wellbeing
- 39w offer tests of fetal wellbeing
ANC contact evert 1-2 w re glucose levels
advise women with uncomplicated GDM to give birth no later than 40+6 weeks
Summary of additional appts for pregnant women with T1/T2DM
- 10w: asses diabetes control and complications; risk; HbA1c; offer retinopathy/nephropathy screening. arrange ANC.
- 16-20w retinal assessment for women with retinopathy
- 20w scan for foetal abnormalities
- 28 w growth scan + AFV; retinal assessment.
- 32w growth scan + AFV
- 36w growth scan + AFV + discussion re delivery
- 37-38 weeks: offer IoL or C/S if appropriate
Is diabetes in pregnancy a CI to tocolysis or antenatal steroids for lung maturation?
no
(give women on steroids additional insulin according to agreed protocol and monitor closely)
What tocolytic medication should not be used in pregnant women with diabetes?
betamimetic medicines
when should women with pre-existing diabetes deliver?
37+0 to 38+6
How often should you monitor blood glucose in women with diabetes giving birth? What is the aim?
every hour
aim 4 - 7 mmol/L
is diabetes a CI for VBAC?
no
When can you discharge a baby born to aa diabetic mum to community care
- once 2h old
AND - maintaining blood glucose levels and feeding well
Considerations for the baby following birth in maternal diabetes
- give birth in a hospital with 24h advanced neonatal care.
- measure blood glucose every 2-4 hours
- mum should feed the baby asap after birth (within 30 minutes) and then every 2-3h until feeding maintains their pre-fed capillary levels at a minimum of 2.0 mmol/L
How soon should babies of diabetic mums be fed?
- mum should feed the baby asap after birth (within 30 minutes) and then every 2-3h until feeding maintains their pre-fed capillary levels at a minimum of 2.0 mmol/L
Indications for tube feeding/IV dextrose in babies born to diabetic mothers
- capillary plasma glucose below 2.0 mmol/L on 2 consecutive readings despite maximal support feeding
- abnormal clinical signs
- baby will not efefctively feed orally
How can you maintain babies blood glucose levels if they are not feeding and born to diabetic mum?
tube feeding
or
IV dextrose
Mx of hypoglycaemia in neonates
dextrose
When should you consider giving IV dextrose and insulin intrapartum?
in women with t1dm
in women with diabetes that are not maintaining plasma glucose at 4-7 mmol/L
Following birth, should women reduce or increase their insulin?
reduce
then monitor blood glucose levels to find the appropriate dose.
When should women with GDM stop glucose lowering therapy?
immediately after birth
however test for persisting hyperglycaemia before transferring too community care
When should women with GDM stop glucose lowering therapy?
immediately after birth
however test for persisting hyperglycaemia before transferring too community care
When should women who had GDM be offered fasting plasma glucose test following birth?
6-13w after birth to exclude diabetes
after 13w can also offer HbA1c
offer annual HbA1c test to women with GDM who have a negative postnatal test for diabetes.
How many UKMEC categories are there?
1-4
UKMEC 1- definition
a condition for which there is no restriction for the uses of the method
UKMEC 2 - definition
a condition where advantages > theoretical/proven risks
UKMEC 3 - definition
theoretical/proven risks > advantages
the provision of aa method requires expert clinical judgement and/or referral to a specialist contraceptive provider
UKMEC 4 - definition
unacceptable health risk
