O+G 5 Flashcards
What contraceptives can be used after birth?
After giving birth women require contraception after day 21.
Progestogen only pill (POP)
- the FSRH advise ‘postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.’
- after day 21 additional contraception should be used for the first 2 days
- a small amount of progestogen enters breast milk but this is not harmful to the infant
Combined oral contraceptive pill (COC)
- absolutely contraindicated - UKMEC 4 - if breast feeding < 6 weeks post-partum
- UKMEC 2 - if breast feeding 6 weeks - 6 months postpartum
- the COC may reduce breast milk production in lactating mothers
- may be started from day 21 - this will provide immediate contraception
- after day 21 additional contraception should be used for the first 7 days
Lactational amenorrhoea method (LAM)
- is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum
Which contraceptives inhibit ovulation and thicken cervical mucus?
Desogestrel-only pill Injectable contraceptive (medroxyprogesterone acetate) Implantable contraceptive (etonogestrel)
How does Intrauterine system (levonorgestrel) work?
Primary: Prevents endometrial proliferation
Also: Thickens cervical mucus
As emergency oral contraception:
Inhibits ovulation
What are the features, investigations and treatment for mittelschmerz?
- Usually mid cycle pain.
- Often sharp onset.
- Little systemic disturbance.
- May have recurrent episodes.
- Usually settles over 24-48 hours.
- Full blood count- usually normal
- Ultrasound- may show small quantity of free fluid
- Conservative
What are the features, investigations and treatment for endometriosis?
- 25% asymptomatic, in a further 25% associated with other pelvic organ pathology.
- Remaining 50% may have menstrual irregularity, infertility, pain and deep dyspareurina.
- Complex disease may result in pelvic adhesional formation with episodes of intermittent small bowel obstruction.
- Intra-abdominal bleeding may produce localised peritoneal inflammation.
- Recurrent episodes are common.
- Ultrasound- may show free fluid
- Laparoscopy will usually show lesions
- Usually managed medically, complex disease will often require surgery and some patients will even require formal colonic and rectal resections if these areas are involved
What are the features, investigations and treatment for ovarian tortion?
- Usually sudden onset of deep seated colicky abdominal pain.
- Associated with vomiting and distress.
- Vaginal examination may reveal adnexial tenderness.
- Ultrasound may show free fluid
- Laparoscopy is usually both diagnostic and therapeutic
- Laparoscopy
What are the features, investigations and treatment for PID?
- Bilateral lower abdominal pain associated with vaginal discharge.
- Dysuria may also be present.
- Peri-hepatic inflammation secondary to Chlamydia (Fitz Hugh Curtis Syndrome) may produce right upper quadrant discomfort.
- Fever >38
- Full blood count- Leucocytosis
- Pregnancy test negative (Although infection and pregnancy may co-exist)
- Amylase - usually normal or slightly raised
- High vaginal and urethral swabs
- Usually medical management (metronidazole, doxycycline, IM ceftriaxone)
What’s the most common type of ovarian pathology associated with Meigs’ syndrome?
Meigs’ syndrome is a benign ovarian tumour (usually a fibroma) associated with ascites and pleural effusion
What’s the most common benign ovarian tumour in women under the age of 25 years?
Dermoid cyst (teratoma)
What’s the most common cause of ovarian enlargement in women of a reproductive age?
Follicular cyst
What are the types of benign ovarian cysts?
- physiological cysts
- benign germ cell tumours
- benign epithelial tumours
- benign sex cord stromal tumours
What causes follicular cysts and what happens to them?
- due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
- commonly regress after several menstrual cycles
What is a corpus luteum cyst and how do they present?
- during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
- more likely to present with intraperitoneal bleeding than follicular cysts
What are dermoid cysts?
What’s the median age of diagnosis?
How often are they bilateral?
How do they present?
- also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
- most common benign ovarian tumour in woman under the age of 30 years
- median age of diagnosis is 30 years old
- bilateral in 10-20%
- usually asymptomatic. Torsion is more likely than with other ovarian tumours
What’s the most common type of ovarian cancer?
Serous carcinoma (epithelial in origin)
What can happen if a mucinous cystadenoma ruptures?
may cause pseudomyxoma peritonei
What is the most common benign epithelial ovarian tumour?
- Serous cystadenoma
2. Mucinous cystadenoma
What are defining features of mucinous cystadenomas?
typically large and may become massive
A 30-year-old female presents to her GP seeking contraception. She has three children and states she has completed her family. She is open to long-acting reversible contraception. After receiving advice about all options available, she opts for the copper IUD. Besides pregnancy, which of the following is it important to exclude?
Pelvic inflammatory disease
Pelvic inflammatory disease is an absolute contraindication to the insertion of a copper IUD.
A 27-year-old woman presents complaining of heavy menstrual bleeding. She reports saturating her pads with blood regularly and frequently has to change them hourly. She is otherwise asymptomatic and has no desire to have children in the near future. Following a normal examination, what is the most appropriate management?
Intrauterine system
How do you treat a woman with menorrhagia?
Does not require contraception
- either mefenamic acid (NSAID) 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period
if no improvement then try other drug whilst awaiting referral
Requires contraception, options include
1st line: intrauterine system (Mirena)
2nd line: combined oral contraceptive pill
3rd line: long-acting progestogens (e.g Depo Provea)
Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.
A 30-year-old woman who is 41 weeks pregnant is being induced in the labour ward. She has an artificial rupture of membranes, but the midwife notices that the umbilical cord is visibly protruding from the vagina. She is brought for an emergency caesarean section. What is the correct position for her to be in while being prepared for surgery?
on all fours, on knees and elbows, while someone pushes the presenting part of the fetus up
A woman presents to her GP complaining of bleeding after sexual intercourse. What is the most common identifiable cause of postcoital bleeding?
Cervical ectropion
What are the causes of post coital bleeding?
- no identifiable pathology is found in around 50% of cases
- cervical ectropion is the most common identifiable causes, causing around 33% of cases. This is more common in women on the combined oral contraceptive pill
- cervicitis e.g. secondary to Chlamydia
- cervical cancer
- polyps
- trauma
What’s the Bishop’s score? Below what result requires induction?
The Bishop’s score is used to predict whether induction of labor will be required.
A score of 5 or less suggests that labour is unlikely to start without induction.
What proportion of pregnancies are induced?
20%
What are the indications for induction of labour?
- prolonged pregnancy, e.g. > 12 days after estimated date of delivery
- prelabour premature rupture of the membranes, where labour does not start
- diabetic mother > 38 weeks
- rhesus incompatibility
What are the methods for inducing labour?
- membrane sweep
- intravaginal prostaglandins (PGE2)
- breaking of waters
- oxytocin
What is the most effective method of emergency contraception and should be offered to all appropriate women seeking emergency contraception?
Intra-uterine device. Not affected by BMI
What is thought to reduce the effectiveness of oral hormonal emergency contraceptives? What is recommended?
- reduced in patients with a high BMI.
- A double dose of levonorgestrel (Levonelle) is advised in patients with a BMI of over 26kg/m² or body weight greater than 70kg
What are the types of emergency contraceptive and how should they be taken?
- levonorgestrel
- ulipristal, a progesterone receptor modulator
- IUD
Levonorgestrel
- should be taken as soon as possible - efficacy decreases with time
- must be taken within 72 hrs of unprotected sexual intercourse (UPSI)*
- single dose of levonorgestrel 1.5mg (a progesterone)
mode of action not fully understood - acts both to stop ovulation and inhibit implantation
- 84% effective is used within 72 hours of UPSI
- levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
if vomiting occurs within 2 hours then the dose should be repeated
- can be used more than once in a menstrual cycle if clinically indicated
Ulipristal
- a progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
- 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
- concomitant use with levonorgestrel is not recommended
- Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having Ulipristal. Barrier methods should be used during this period
- caution should be exercised in patients with severe asthma
- repeated dosing within the same menstrual cycle was previously not recommended - however, this has now changed and ulipristal can be used more than once in the same cycle
- breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel
Intrauterine device (IUD)
- must be inserted within 5 days of UPSI, or
if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
may inhibit fertilisation or implantation
- prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
- is 99% effective regardless of where it is used in the cycle
- may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period
*may be offered after this period as long as the client is aware of reduced effectiveness and unlicensed indication
A 35-year-old obese gravida 3 para 2 has developed a swollen and tender left leg; she is currently at 32 weeks of gestation and started on the appropriate treatment regimen. Due to her weight, the clinician decides to monitor her treatment with a specific blood test. Which blood test is this?
Anti-Xa activity
In clinically suspected DVT or PE, treatment with low-molecular-weight heparin (LMWH) should be commenced immediately until the diagnosis is excluded by objective testing, unless treatment is strongly contraindicated.
Routine measurement of peak anti-Xa activity for patients on LMWH for treatment of acute VTE in pregnancy or postpartum is not recommended except in women at extremes of body weight (less than 50 kg and 90 kg or more) or with other complicating factors (for example, with renal impairment or recurrent VTE).
When is VTE risk in pregnancy assessed?
at booking and on any subsequent hospital admission
How do you treat women with risk of VTE?
A woman with a previous VTE history is automatically considered high risk and requires low molecular weight heparin throughout the antenatal period and also input from experts.
A woman at intermediate risk of developing VTE due to hospitalisation, surgery, co-morbidities or thrombophilia should be considered for antenatal prophylactic low molecular weight heparin.
The assessment at booking should include risk factors that increase the womans likelihood of developing VTE. These risk factors include:
- IVF pregnancy
- Gross varicose vein
- Family history of unprovoked VTE
- Immobility
- Smoker
- Age > 35
- Low risk thrombophilia
- Parity > 3
- Current pre-eclampsia
- Body mass index > 30
- Multiple pregnancy
(IVF IS A Last Point of Call for Blessed Mums)
Four or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal. If a woman has three risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.
Which muscarinic antagonists are used to treat urinary incontinence?
- oxybutynin
- solifenacin
- tolterodine
How do you treat a 30-year-old woman presents with an offensive ‘fishy’, thin, grey vaginal discharge. Testing the discharge shows the pH to be > 4.5?
Oral metronidazole for bacterial vaginosis
What criteria is used to identify bacterial vaginosis?
Amsel’s criteria for diagnosis of bacterial vaginosis - 3 of the following 4 points should be present:
- thin, white homogenous discharge
- clue cells on microscopy: stippled vaginal epithelial cells
- vaginal pH > 4.5
- positive whiff test (addition of potassium hydroxide results in fishy odour)
How do you treat a 27-year-old woman who complains of an offensive ‘musty’, frothy, green vaginal discharge. On examination you an erythematous cervix with pinpoint areas of exudation?
Oral metronidazole
The ‘strawberry cervix’ is actually quite rare outside of examinations - some studies suggest only 2% of patients with Trichomonas vaginalis have this finding.
How do you treat a 22-year-old woman who presents with a thin, purulent, and mildly odorous vaginal discharge. She also complains of dysuria, intermenstrual bleeding and dyspareunia. A swab shows a Gram negative diplococcus.
(neisseria gonorrhoea)
ceftriaxone 500 mg intramuscularly as a single dose with azithromycin 1 g oral as a single dose. The azithromycin is thought to act synergistically with ceftriaxone and is also useful for eradicating any co-existent Chlamydia infections
What causes vaginal discharge?
Common causes
- physiological
- Candida
- Trichomonas vaginalis
- bacterial vaginosis
Less common causes
- Gonorrhoea
- Chlamydia can cause a vaginal discharge although this is rarely the presenting symptoms
- ectropion
- foreign body
- cervical cancer
What’s the diagnosis?
‘Cottage cheese’ discharge
Vulvitis
Itch
Candida
What’s the diagnosis?
Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
Trichomonas vaginalis
What’s the diagnosis?
Offensive, thin, white/grey, ‘fishy’ discharge
Bacterial vaginosis
What’s the vertical transmission risk of babies born to hep B mothers? Is it safe to breast feed?
Without intervention the vertical transmission rate is around 20%, which increases to 90% if the woman is positive for HBeAg.
Yes, safe to breast feed.
What proportion of women are hep B positive?
1% western women
Which women are screened for hep B?
All pregnant women
How should babies born to hep B mothers be managed?
babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin
A 72-year-old woman presents to her GP with symptoms of vaginal pain, itching and dyspareunia. After ruling out other potential causes of her symptoms the GP diagnoses her with atrophic vaginitis.
Which treatments could be used as adjunct therapies, in combination with topical oestrogen cream, to treat her symptoms?
The pain, itching and dyspareunia experienced in atrophic vaginitis is due to dryness of the vaginal mucosa. Topical oestrogen cream should be use as first line-treatment to help restore the vaginal mucosa, however, lubricants and moisturisers can provide effective short term relief while waiting for topical oestrogen creams to have effect.
A 23-year-old primigravida woman at 36 weeks gestation presents with mild irregular labor pains in the lower abdomen. On examination she has a firm, posterior, closed cervix. Fetal heart tones are heard. The pain stops during the consultation. What is the most appropriate next step?
Reassure and discharge
This is false labour which is characterised by:
- Occurs in the last 4 weeks of pregnancy
- Presentation: contractions felt in the lower abdomen. The contractions are irregular and occur every 20 minutes. Progressive cervical changes are absent.
How long does labour usually last?
Stage 1 - from the onset of true labour to when the cervix is fully dilated. In a primigravida lasts typical 10-16 hours
latent phase = 0-3 cm dilation, normally takes 6 hours
active phase = 3-10 cm dilation, normally 1cm/hr
A young woman at 30 weeks gestation, presents with painless bright red vaginal bleeding, she reports two previous scanty episodes of painless vaginal bleeding, but feels that this episode has been much more severe.
What is the most likely diagnosis?
Placenta praevia
What is placenta praevia?
placenta lying wholly or partly in the lower uterine segment
What proportion of women have placenta praevia?
- 5% will have low-lying placenta when scanned at 16-20 weeks gestation
- incidence at delivery is only 0.5%, therefore most placentas rise away from cervix
What are the risk factors of placenta praevia?
- multiparity
- multiple pregnancy
- embryos are more likely to implant on a lower segment scar from previous caesarean section
What are the clinical features of placenta praevia?
- shock in proportion to visible loss
- no pain
- uterus not tender
- lie and presentation may be abnormal
- fetal heart usually normal
- coagulation problems rare
- small bleeds before large
When is placenta praevia often picked up? What is done to improve accuracy of location?
- on the routine 20 week abdominal ultrasound
- transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe
What are the grades of placenta praevia?
I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV - placenta completely covers the internal os
A 25 year old woman with a known diagnosis of premenstrual syndrome (PMS) attends her GP requesting some medical treatment. She has made the suggested lifestyle modifications, with little improvement in her symptoms. She is not planning on starting a family any time soon. Which of the following treatments would be most suitable to offer her, assuming that there are no contraindications?
Management of PMS includes lifestyle advice - healthy diet, exercise, reduction in stress levels and regular sleep.
The combined oral contraceptive pill and selective serotonin re-uptake inhibitors are recommended for moderate to severe symptoms.
A 36-year-old multiparous woman is in advanced labour at 37 weeks gestation. An ultrasound confirms a breech presentation. She is fully dilated and has been pushing for an one and a half hours, however the buttocks are still not visible. How should this situation be managed?
Caesarean section
What proportion of pregnancies are breech?
- 3% of term babies
- 25% preterm babies
What are the types of breech?
- 70% extended/frank breech
- 15% flexed breech
- 15% footling breech (one or both feet below the buttocks
What are the risk factors for breech presentation?
- uterine malformations, fibroids
- placenta praevia
- polyhydramnios or oligohydramnios
- fetal abnormality (e.g. CNS malformation, chromosomal disorders)
- prematurity (due to increased incidence earlier in gestation)
Management of breech presentation
- if < 36 weeks: many fetuses will turn spontaneously
- if still breech at 36 weeks NICE recommend external cephalic version (ECV)- this has a success rate of around 60%. The RCOG recommend ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women
- if the baby is still breech then delivery options include planned caesarean section or vaginal delivery
A 36-year-old with menorrhagia is investigated and found to have a 1.5 cm uterine fibroid which is not distorting the uterine cavity. She has three children and wants ongoing contraception, but is using only condoms at the moment. What is the most appropriate initial treatment for her menorrhagia?
If a uterine fibroid is less than 3cm in size, and not distorting the uterine cavity, medical treatment can be tried (e.g. IUS, tranexamic acid, COCP etc)
What’s the diagnosis?
A 26-year-old woman presents 3 months after giving birth to her first child. During labour she had a large post-partum haemorrage. She did not breastfeed but has not had a period since.
Sheehan syndrome describes hypopituitarism caused by ischemic necrosis due to blood loss and hypovolaemic shock.
Features of Sheehan’s syndrome
- agalactorrhoea
- amenorrhoea
- symptoms of hypothyroidism
- symptoms of hypoadrenalism
What’s the diagnosis?
A 25-year-old woman presents 5 months after having dilation and curettage for a miscarriage. Since this procedure she has not had a period. A pregnancy test is negative. Hysteroscopy is performed which reveals the diagnosis.
Asherman’s syndrome
Asherman’s syndrome, or intrauterine adhesions, may occur following dilation and curettage. This may prevent the endometrium responding to oestrogen as it normally would.
A 23-year-old woman is in labour and there is failure of progression. You suspect there may be some shoulder dystocia. There are several ways to attempt to deliver this baby, but what is the Woodscrew Manoeuvre?
Put your hand in the vagina and attempt to rotate the foetus 180 degrees
Management of shoulder dystocia
- call for help
- McRoberts’ manoeuvre and supra pubic pressure
- Wood’s screw manoeuvre (for shoulders that are transverse- pressure behind the anterior shoulder)
- grab posterior arm
- last resorts include symphisiotomy after lateral replacement of the urethra with a metal catheter and the zavanelli manoeuvre
- caesarean section but fetus is normally damaged by this time
A 22-year-old woman is 14 days postpartum. She is formula feeding her baby. She attends her GP requesting emergency contraception as she had unprotected sexual intercourse (UPSI) 2 days ago. Which of the following would you recommend?
No emergency contraception required
Emergency contraception (EC) is not required before day 21 postpartum. The earliest date of ovulation in a non-breastfeeding woman is thought to be day 28 postpartum. Therefore, contraception is required from day 21 onwards, as sperm can survive for up to 7 days. A woman who is exclusively breastfeeding will take longer to ovulate, however, contraception should still be advised if pregnancy is not desired.
After how many days postpartum can progesterone only EC (Levonelle and ellaOne) can be used in both breastfeeding and non-breastfeeding woman?
21
Can you insert a cupper IUD post partum?
The Cu-IUD should not be inserted before day 28 postpartum, due to the increased risk of uterine perforation if inserted before this time.
You are a doctor working in gynaecology. One of your patients on the ward has endometrial hyperplasia. Which medication is associated with the development of this condition?
Tamoxifen
A new mother who is 4 weeks post-partum presents for review. She has developed a warm, red tender patch to on the right breast just lateral to the areola. This has been getting worse for the past three days and feeding is now painful. She saw the midwife yesterday who helped with positioning but this has not improved matters. On examination she has mastitis of the right breast with no obvious abscess. What is the most appropriate management?
Flucloxacillin for 10-14 days, continue breast feeding
What proportion of breast feeding women get mastitis?
10%
When should you treat mastitis?
- if systemically unwell
- if nipple fissure present
- if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection
When does breast pain from engorgement typically occur?
- In the first few days after the infant is born and almost always affects both breasts
- The pain or discomfort is typically worse just before a feed.
What’s the problem for the baby with breast engorgement?
Milk tends to not flow well from an engorged breast and the infant may find it difficult to attach and suckle.
What are the risks of prematurity?
- increased mortality depends on gestation
- respiratory distress syndrome
- intraventricular haemorrhage
- necrotizing enterocolitis
- chronic lung disease, hypothermia, feeding problems, infection, jaundice
- retinopathy of newborn, hearing problems
What’s the definitive treatment for adenomyosis?
- Hysterectomy
- but can use GnRH agonists
What is adenomyosis and who is it most common in?
- Adenomyosis is characterized by the presence of endometrial tissue within the myometrium.
- in multiparous women towards the end of their reproductive years.
What’s the condition?
dysmenorrhoea
menorrhagia
enlarged, boggy uterus
Adenomyosis
A neonate is born at 32 weeks gestation after prolonged premature rupture of membranes (PROM). Approximately 12 hours after birth the neonate presents with temperature instability, respiratory distress and lethargy. Sepsis is confirmed by blood cultures. What is the most likely infectious agent?
Sepsis in the neonate can broadly be divided into early-onset (<48 hours since birth) and late-onset (>48 hours from birth).
Early-onset sepsis is associated with acquisition of micro-organisms from the mothers birth canal (GBS).
Late-onset sepsis normally occurs due to hospital acquired pathogens such as Staphylococcus epidermidis and Staphylococcus aureus.
A 30-year-old woman who is investigated for obesity, hirsutism and oligomenorrhoea is diagnosed as having polycystic ovarian syndrome (PCOS) following an ultrasound scan. She is hoping to start a family and her doctor starts metformin to try and improve her fertility. What is the mechanism of action of metformin in PCOS?
Increases peripheral insulin sensitivity
The majority of patients with polycystic ovarian syndrome have a degree of insulin resistence which in turn can lead to complicated changes in the hypothalamic-pituitary-ovarian axis.
What’s the incidence of PCOS?
5-20% of women of reproductive age
Treatments for PCOS
Hirsutism and acne
- COC pill
- then topical eflornithine may be tried
Infertility
- weight reduction if appropriate
- the management of infertility in patients with PCOS should be supervised by a specialist.
- clomifene was the most effective treatment but risk of multiple pregnancies with anti-oestrogen therapies such as clomifene
- metformin is not a first line treatment of choice in the management of PCOS
- metformin is also used, either combined with clomifene or alone, particularly in patients who are obese
- gonadotrophins
How do anti-oestrogen therapies such as clomifene work when used to treat PCOS?
work by occupying hypothalamic oestrogen receptors without activating them. This interferes with the binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion
Which of the following presentations has the greatest mortality and morbidity?
Occipitoposterior presentation at delivery Footling presentation at delivery Face presentation at delivery Transverse lie at 30 weeks Breech presentation at 20 weeks
Footling presentation at delivery
there is a 5-20% risk of cord prolapse, which can obstruct foetal blood flow and is an obstetric emergency
What is an occipitoposterior presentation and what complications can arise?
In occipitoposterior presentation the posterior fontanelle is found in the posterior quadrant of the pelvis; greater rotation is required so labour is usually longer.
There is a greater rate of intervention
- 22% require forceps
- 5% require caesarean section.
What is a face presentation and what type of delivery is indicated?
Face presentations normally occur by chance when the head extends rather than flexes as it engages.
99% rotate so the chin lies behind the symphysis and the head can be born by flexion; in 1%the chin rotations to the sacrum and caesarean section is indicated.
What is a transverse lie? Which women are more likely to have it? What is done?
Transverse lie is where the shoulder is presenting. It occurs in multiparous women due to their uterine muscles being less tight than a nulliparous woman. Extracephalic version may be attempted from 32 weeks.
A 45-year-old woman presents at 10 weeks gestation for a routine check. She has a previous history of severe pre-eclampsia. Her BMI is 38 kg/m^2. Her blood pressure was 145/94 mmHg.
What treatment would you advise to reduce the risk of pre-eclampsia?
Aspirin
The female in this question has several risk factors for pre-eclampsia: BMI > 35 kg/m^2, past obstetric history of pre-eclampsia and age > 40 years. Women at high risk of pre-eclampsia are advised to take 75 mg of aspirin daily from 12 weeks until the birth of the baby according to the NICE guidelines.
The NICE guidelines also advise that anti-hypertensive treatment is not required for mild hypertension (140/90 to 149/99 mmHg).
How is anaemia in pregnancy defined?
- first trimester Hb less than 110 g/l
- second/third trimester Hb less than 105 g/l
- postpartum Hb less than 100 g/l
When are pregnant women screened for anaemia?
the booking visit (often done at 8-10 weeks), and at
28 weeks
When should women receive oral iron tablets?
Booking visit < 11 g/dl
28 weeks < 10.5 g/dl
further investigations only required if no rise in haemaglobin after 2 weeks
When is parenteral iron given to iron deficient pregnant ladies?
Parenteral iron is only indicated if oral iron is not tolerated, absorbed, patient is not compliant or they are near term and there is insufficient time for oral iron to be effective.
A 28-year-old lady presents to the early pregnancy unit in her tenth week of pregnancy with crampy abdominal pain and a day history of dark spotting. Transvaginal ultrasound scan identifies an intrauterine pregnancy with a crown-rump length of 10mm and no fetal heartbeat. The cervical os is closed indicating a missed miscarriage. The patient requests for medical management of her miscarriage.
What do you do?
Give vaginaloral misoprostol
When is methotrexate used?
medical management of an ectopic pregnancy
How can you manage a missed miscarriage?
3 ways:
- Expectant management:
First line and involves waiting for 7-14 days for the miscarriage to complete spontaneously - Medical management:
Give the patient vaginal misoprostol. Advise them to contact the doctor if the bleeding hasn’t started in 24 hours. Should be given with antiemetics and pain relief. Often preferred if there is a higher risk of haemorrhage (late first trimester or coagulopathies), evidence of infection or previous adverse experiences. - Surgical management:
May involve manual vacuum aspiration under local anaesthetic as an outpatient or surgical management in theatre under general anaesthetic (previously referred to as ERPC).
What does ERPC mean?
Evacuation of Retained Products of Conception
A 30-year-old woman is brought into the emergency department in intense pain. She has a past medical history of endometriosis, and it is one week since her last period. On ultrasound scan there is free fluid in the pelvis. What is the cause of her acute abdomen?
Ruptured endometrioma
What’s the incidence of endometriosis?
Around 10% of women of a reproductive age have a degree of endometriosis.
What are the clinical features of endometriosis?
- chronic pelvic pain
- dysmenorrhoea - pain often starts days before bleeding
- deep dyspareunia
- subfertility
- non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
- on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
What are the investigations and management for endometriosis?
Investigation
- laparoscopy is the gold-standard investigation
- there is little role for investigation in primary care (e.g. ultrasound)- if the symptoms are significant the patient should be referred for a definitive diagnosis
Management depends on clinical features - there is poor correlation between laparoscopic findings and severity of symptoms. NICE published guidelines in 2017:
- NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief
- if analgesia does help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried
If analgesia/hormonal treatment does not improve symptoms or if fertility is a priority the patient should be referred to secondary care. Secondary treatments include:
- gonadotrophin-releasing hormone (GnRH) analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
- drug therapy unfortunately does not seem to have a significant impact on fertility rates
- surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility
