O&G Flashcards
Herpes Mx in PregC
labour<6wks=CS aciclovir tds labour>6wks=reassure
Guidelines issued by the Royal College of Obstetricians and Gynaecologists state that women who present with first-episode genital herpes during their third trimester should be managed with daily suppressive oral aciclovir 400mg until delivery. Delivery should be by caesarean section due to a high risk of neonatal HSV (herpes simplex virus) transmission.
Headache in PregC (differentials)
Migraine-most common Viral meningitis- Cerbral vein thrombosis Subarachnoid Idiopathic intracranial hypetension
VZV infx in PregC Tx
Test for VZ Abs and give VZIG w/in 10 days
External cephalic version (Contraindications)
Offered from 36wks (37 in multiparous) Contraindications-Multiple pregnancy, Maj uterine abnorm, antepartum haemorrhage, rupture of membranes,
DM Mx postpartum
After eating and drinking ~6hrs sliding scale reduced to preprgC doses of insulin
SLE in PregC risks
Spont Miscarriage, fetal death, PET, Preterm, fetal growth restriction
Listeria trasnmission
Soft cheese and Pate
Toxoplasmosis transmission
Cats, faeces
Rashes in PrgC
Pemphigoid gestationis - Blistering of trunk, spreads from umbilicus PUPP - Abdo stretch marks and periumbilical sparing Prurigo gestationis - trunk+upper limbs abdo sparing Impetigo hepetiformis - blisting and febrile
Threatened miscarriage
PVB <24wks
Missed miscarriage
Loss of pregC w/o passage of the products of conception or PVB
Septic miscarriage
loss of PregC complicated w/ infx of the retained conceptus
Incomplete miscarriage
loss of PregC w/ PVB and passage of not all of the concptus Tx - med: misoprostol Surg: suction evacuation
Complete miscarriage
loss of PregC w/ all of products of conception expelled
Hyperemis Gravidarum
Px - Severe vomiting, dehydration, RF’s - multiple pregC Tx - fluid restoration and anti emetics
Fetal pole and fetal heart
6 wks
Blighted ovum/anembryonic pregC
Gestational sac w/o embryonic pole or yolk sac development Mx - 2 scans 10-14/7 apart
Ectopic PregC Mx med criteria (4)
Criteria: Small ectopic <3cm, no fetal pulse, no clinical compromise, no free fluid in the pouch of douglas, bHCG <3000
Med: Methotrexate IM (+/- another dose 7/7), monitor bHCG on days 4+7. Drop by 15% needed otherwise 2nd dose given
HRT risks
Inc risk of: Stroke, breat Ca, ovarian Ca, VTE, CAD
Epilepsy Mx in PregC
Carbamazepine lamotrigine
COCP
MOA - inhibits ovulation
POP
MOA - thickens cervical mucus
Desogestrel
MOA - inhibits ovulation, thickens cervical mucus
Injectable contraceptive/medoxyprogesterone acetate
Lasts how long?
MOA - inhibits ovulation, thickens cervical mucus
12wks
Implantable/etonogestrel/Implanon
MOA - inhibits ovulation, thickens cervical mucus
Lasts 3yrs
Itrauterine device
MOA - decreases sperm motility and survival
Intrauterine system/levonorgestrel
MOA - prevents endometrial proliferation, thickens cervical mucus
Levonorgestrel/Levonelle Emergency conc
MOA - Inhibits ovulation <72hrs 58% effective (24hrs 95% effective)
Ulipristal/ellaOne Emergency conc
MOA - Inhibits ovulation <120hrs effective condoms until next period
IUD Emergency conc
MOA - prevents implantation, spermicidal <5days after UPSI or expected day of ovulation
primary PPH
Def: minor 1000-500ml/maj>1000 blood loss from the genital tract w/in 24hrs Ax - 4 T’s: Tone, Tissue, Trauma, Thrombin
Fibroids
Def: benign smooth muscle tumours of the uterus, more common in black women Px - asymp, menorrhagia, lower abdo pain, bloating, urinary Sx, subfertility Ix - transvagianl US Mx - Sx Mx IUS,tranexamic acid, COCP, GnRH, myomectomy, uterine artery embolization
Menstrual cycle 6 steps
- GnRH released from hypothalamus 2. Inc FSH+LH released from ant pit. 3. FSH induces follicular growth creating oestradiol 4. Oestradiol inhibits other follicle development (only one follicle) 5. positive feedback and LH surge causing ovulation 36hrs after surge 6. Luteal phase of follicle (now corpus luteum) increases progesterone, enhancing endometrial receptivity
CMV infx in pregC Fetal effects (4)
Deafness IUGR Hydrocephalus Thrombocytopenia
DR C BRAVADO
Define risk - prev CS, PET, DM, PVB, IUGR Contractions - Baseline RAte - 110-160, tachy w/pyrexia, brady=distress Variability - 5-25, dec in fetal sleep, prolonged dec=bad Accelerations - 15 for 15s good, w/ contractions Decelerations - early/late/varied (varied=cord compression+oligohydramnios) Overall impression
Reiter’s syndrome ‘can’tx3’
Can’t see, can’t pee, can’t climb a tree conjunctivitis, urethritis, arthritis
Rise in this hormone maintains PregC if fertilized
Progesterone
Stimulates proliferation of stromal and glandular elements of endometrium
Oestradiol
3 P’s of labour
Power, passage, passenger
3 stages of labour
- From diagnosis of labour to full cervical dilation 10cm latent (<4) active (4-10) 2. From full dilation to delivery ~40mins nullips/~20mins multips 3. Delivery of fetus to delivery of placenta
Itching and derraged LFT’s esp. bile acid. Rsk=Stillbirth, preterm and meconium staining. Tx=induce @ 37-38 + Urodeoxycholic acid
Obstetric cholestasis
Ruptured membranes, Offensive pv discharge. Tx- Abx and induction of labour (removal of infx nidus)
Chorioamnionitis
Px - Severe vomiting, dehydration, RF’s - multiple pregC Tx - fluid restoration and anti emetics
Hyperemis Gravidarum
Ax - placental insufficiency Px - Microsomaly and microcephaly (head can be normal if placental insufficiency occurs later in PregC)
IUGR
Epx - under 35 Ax - 90% SCC + HPV RF: STI Px - PCB, IMB, deep dyspareunia, crampy lower abdo pain, cerval bleeding on contact Ix - Biopsy for staging Tx - surgical, chemo, radio
Cervical cancer
Def: implantation of a fertilized ovum outside of the uterus, mostly tubular Px - 6-8wks amenorrhoea, lower abdo pain, PVB, peritoneal bleeding (shoulder pain), Mx - methotrexate, or surgical
Ectopic PregC
Px - pelvic pain, fever, deep dyspareunia, discharge, menstrual irregularities, cervical excitation Tx - IMcef, po doxy, po met
Pelvic inflammatory disease
Px - sudden onset unilateral lower abdo pain, N+V, tender adnexa
Ovarian torsion
Px - chornic pelvic pain, dysmenorrhoea (pain before period), deep dyspareunia, subfertility, chocolate cyst
Endometriosis
Px - pressure/heaviness or bearing down sensation, urinary Sx i.e. incontinence, freq, urge
Urogenital prolapse
4 O’s: Obesity, O children, Oestrogen unopposed, O sugar (DM)
Endometrial Ca
Px - PVB 1st-2nd tri, uterus large for dates, hyperemesis gravidarum, snowstorm, ground glass?, inc hCG
Hydatidiform mole/molar PregC
Px - PVB 3rd tri, constant pain, signs of shock/hypovolaemia, woody uterus
Placental abruption
Px - PVB 3rd tri, no pain, non tender uterus, no BV
Placenta praevia
Ax - fetal bld vessels runs directly in front of presenting part Px - rupture of membranes followed immediately by large PVB, severe fetal distress, CS often not fast enough to save fetus
Vasa praevia
CTG normal ranges:
Baseline
Variability
Accelerations
Deeccelerations
Baseline - 110-160
Variability - >5 beats per minute
Accelerations - present
Decelerations - None
Fetal bld sampling indications
Pathological CTG
Fetal bld sampling risks/contraindications
Infx - HIV, HepC
Hb abnormalities - immune thrombocytopenia, Haemophilia B
Px - Umbilical cord below presenting part.
Important - Cord can become obstructed or spasm, starving the fetus of oxygen
Cord prolapse - Obs emergency
Cord prolapse Mx
Mx - Call fro help, IV access, stop woman pushing, elevate presenting part, deliver immediately (Instrumental/CS depending on quickest option)
Induction of labour indications (3 categories)
Contraindications (3 absolutes)
Fetal - suspected IUGR, Antepartum haemorrhage, prolonged pregnancy
Materno-fetal - PET, DM
Maternal - social, in utero death
Contraindications - acute fetal compromise,
Prostaglandin E2 (PGE2) PV
Induction of labour - starts labour/ripens cervix to allow amniotomy
Oxytocin infusion and ARM
Induction of labour
CTG sens and spec
High sens low spec
high Sens - 100 people w/ disease 98 will have +ve result
High Spec - 100 people who don’t have disease 98 won’t have it
Inductin of labour w/ intrauterine death
po mifepristone + po/pv misoprostol
Epidural contraindications (4)
Hypotension, abnormal lie, placenta praevia, pelvic obsruction
Ax - Chorionic vili in contact with the myometrium
Px - Rsk of PPH
Mx - Syntocinon, Balloon tamponade, iliac artery ligation, hysterectomy
Placenta accreta
Fetal cariac physiology (6)
Umbilical arteries occluded causing:
Reduced venous return to the right side of the heart
Therfore right atrial pressure closing the foramen ovale
Breathing causes dec pressure in pulmonary circulation=inc rt ventricular output
Pulmonary artery vasodilates
Inc pressure on left side
PDA closes due to rising oxygen levels
Large and small villi w/ scallpoed outlines+ trophoblastic hyperplasia
Hydatidiform mole
Ext. tender fluctuant swelling on labia minora
Mx of urge incontinence
Cons: Bladder retraining min 6wks
Med: Oxybutynin
Pretermination assessment
Abx prophylaxis for chlamydia
Contraception discussion
Risks of STOP
Risk of uterine perf is 1 in 300
Bonemarks of the pelvic outlet (3)
Pubial arch, ischial tuberosities, coccyx
Most inferior aspect of the peritoneal cavity
Pouch of douglas
Px - sudden onset epigastric pain, N+V, jaundice, high uric acid, hypoglycaemia, high uric acid
Acute fatty liver of PregC
Px - Pain in suprapubic area that radiates to upper thighs and perineum, worse on walking
Smphysis pubis dysfunction
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Brow presentation
DM complicates what % of PregC
2-5%
% of babies born from DM mothers >50th percentile
85%
Rsk of major congenital malformation if 1st maternal HbA1c>10%
25%
Rsk of recurrence of gestational DM in future PregC
60%
% of women who will develop T2DM in next 10 years (after gestational DM)
50%
Perimenopausal woman w/ uterus
Cyclical combined hormone replacement therapy
Postmenopausal amenorrhoeic women w/ uterus
Continuous combined hormone replacement therapy
Postmenopausal amenorrhoeic woman w/o uterus
Oestrogen-only hormone replacement
Osteoporosis Tx
Bisphosphonates
Infx prophylaxis in preterm rupture of membranes
Erythromycin
Abx assoc w/ necrotizing enterocolitis
Co-amoxiclav
Px - severe abdominal pain, cessation of contractions, significant fetal distress, VBAC,
Uterine rupture
Px - PVB @ ROM/ARM, CTG abnormalities,no pain
Vasa praevia
Resp rate in PregC
Stays the same
Hb Conc in PregC
Decreases
Renal bld flow in PregC
Increases
Albumin changes in PregC
Decreases
Heart Rate in PregC
Increases
Px - PCB, Wt loss, ealry sexual activity, multiple partners, smoking
Cervical Ca
Px - IMB, menorrhagia, bado swelling, bulky uterus, subfertility, dyspareunia
Fibroids
Px - Bright red growth of speculum
Mx - avulsed and cauterized
Cervical polyps
Absolute contraindications to COCP w/ respect to
VTE
Arterial disease
Migraines
VTE: personal Hx of VTE BMI>39, 2 of - Fhx, obesity>30, varicose veins, immobilization
Arterial dis (2 of): Fhx, DM, smoker, HTN, >35yo, obese
Migraine: migraine wiyth typical aura
Anti-D prohylaxis for miscarriage after how many weeks?
12wks
Sensitizing events warranting anti-D prophylaxis (6)
Antepartum haemorrhage
Closed abdominal injury
external cephalic version
invasive prenatal diagnosis
intrauterine procdures
intrauterine death
Rheus prophylaxis dose <20wks
Rheus prophylaxis dose >20wks
250iu
500iu
Commonest (~85%) oestrogen producing tumour
20-30yo
Mucinous adenocarcinoma
commenest of all ovarian malignancies
30-40, 30% bilateral, 30% malignant
Serous adenocarcinoma
Meig’s syndrome
Fibroma
Pleural effusion
Ascites
Pseudomyxoma peritonei, jelly belly
Mucinous adenocarcinoma
Arise from germ cells and contain ectodermal tissue
Teratoma
CIN 2 or 3 Mx
30% will develop into Ca
Ablation (diathermy or cryocautery)
Excision techniques (cone biopsy or large loop excision of transformational zone/LLETZ)
Cervical Ca stage *I and IIA Tx
*Excluding IA1
(Cevrical Ca stage IA1 Tx)
Wetheim’s procedure (Hysterectomy, upper 1/3rd of vagina, parametrium, pelvic lymph nodes +/- ovaries if not young)
(Cone biopsy)
Cervical Ca >IIB Tx
Radio and chemo
Cervical Ca stage IB1 Tx maintaining fertility
Radical trachelectomy
Maternal jaundice, AST/ALT inc> ALP+GGT
(Hepatic picture)
Acute fatty liver of PregC
Infx in PregC
Fetal: sensorineural deafness, cataracts, congenital heart disease, LD’s HepSplenMeg, microcephaly
Maternal: flu like Sx, rash
Rubella
Infx in PregC
Fetal: dermatomal skin scarring, neurological defects, limb hypoplasia, eye defects
Varicella zoster
Ovarian venous drainage
Pampiniform plexus in broad ligamnet, ovarian vein, right IVC/left renal vein
Vaginal relations
Post
Lat
Ant
Post: Pouch of douglas, rectum, anal canal
Lat: Levator ani, visceral pelvic faschia, ureters
Ant: Base of the bladder, urethra
Mesometrium, mesosalpinx, mesovarium
Broad ligament
Infundibulum, ampulla, isthmus, uterine part
Fallopian tubes
RF: ARM
Cord prolapse
Mx of PPH (Atonic uterus)
Cons: Empty bladder, uterine massage,
Med: Oxcytocin infusion, carboprost
Surg: B-lynch suture, uterine artery ligation, hysterectomy
Maximum diameter of the head has passed through the pelvic brim
Engagement
Movement required for easy passage into the mid cavity
Flexion
Levator ani muscles helps the head move into an OP position
Internal rotation
Movement causes crowning of the head
Extension
Movement that realigns the head w/ the shoulders
Restitution
Subfertility, PMHx of surgery
Asherman’s syndrome
Adhesion
Kielland’s foreceps
Rotation
Neville-Barnes foreceps
Traction (w/ 3x contractions before CS)
Most sensitive parameter to assess fetal growth and detect IUGR
Abdominal circumference
Secondary dysmenorrhoea causes/associations
Endometriosis, PID, fibroids, LLETZ
Secondary dysmenorrhoea Tx
Cons: Hot water bottle
Medical: NSAIDS (Ibuprofen/mefanamic acid), COCP, depot P
Acute fatty liver of PregC vs Obstetric cholestasis
Pain in acute fatty liver
Pain in suprapubic area that radiates to upper thighs and perineum, worse on walking
+Mx
Symphysis pubis dysfunction
confirmed by pain on increasing pressure on pubis
Mx - analgesics pelvic support braces
Diamond shape
Anterior fontanelle
Y shape or triangular
Posterior fontanelle
Types of breech (most to least common)
Extended, flexed, footling
Beta-agonist tocolytic
Ritodine
Inhibits smooth mucle contractions in an attempt to delay labour
Contraindicated in diabetes and cardiac disease
Tx for menorrhagia
1st line
2nd line
3rd line
Surgical
1st line w/ contraception: IUS
2nd line (No contraception): tranexamic acid, NSAIDS (mefanamic acid)
2nd line (w/ contraception): COCP
3rd line: Progestogens, GnRH agonists
Surgical non-sterilizing- polyp removal, endometrial ablation, myomectomy, *uterine artery embolization
Surgical + sterilizing: Hysterectomy
*Fertility is reduced but classed as non-sterilizing procedure therefore contraceptives are advised afterwards
Risk of malignancy index (RMI) calculation
U*M*CA125
U=ultrasound score
M=menopausal staus
RMI>250 referred
Cervical tumour staging
0: Carcinoma in situ
I:lesion confined to cervix
II: Invasion into upper vagina but not pelvic wall
III: Invasion of lower vagina/pelvic wall, or causing ureteric obstruction
IV: Invasion of bladder or rectal mucosa
Intermittent abdo pain relieved following sudden watery discharge
Fallopian tube carcinoma
Hx of dilation and curettage (TOP), adhesions
dyspareunia, amenorrhoea, oligomenorrhoea, infertility
Asherman’s syndrome
Secondary menorrhoea (6 causes)
Gonadal failure: premature ovarian failure
Pituitary dysfunction: pituitary tumour
Physiological causes: stress, travel and wt changes can reduce GnRH
Endocrine dysfunction: hypothyroidism
oestrogen metabolism dysfunction: anorexia nervosa
Booking visit (6)
Info
BP
BMI
Urine dip + culture
Bloods: FBC, Rhesus, alloantibodies, Hbopathies, HepB, Syhpilis, rubella screen.
HIV
Parvovirus B19 inf. What do the following mean:
IgG+ve IgM-ve
IgG-ve IgM+ve
IgG-ve IgM-ve
Immune to parvovirus - reassure
Non-immune recent infx <4wks - refer to ftal medicine
Missed pills POP’s
Action <3hrs
Action >3hrs
<3hrs = no action
>3hrs = take as soon as possible
Missed pills cerazette (desogestrel)
<12hrs
>12hrs
<12hrs no action
>12hrs take as soon as possible
Cyclical combined HRT indications
LMP<1yr ago
Continuous combined HRT indications
Taken cyclical combined for 1yr
>1yr since LMP
>2yr since LMP in premature menopause (<40)
Continous oestrogen therpay indication
Hysterectomy
Non-hormonal Tx for menopausal vasomotor Sx
SSRI’s (paroxetine, fluoxetine, citalopram, venlafaxine)
Time until contraceptives effective:
IUD
POP
COCP, implant, injection, IUS
IUD: Immediately
POP: 2 days
COCP/Implant/Injection/IUS: 7 days
Follicular cyst genesis
Non-rupture of the dominant follicle
Commonly regress
Face presentation Mx
Emergency CS
Mx of stress incontinence
Cons: Pelvic floor exercises (8contractions 3*day for min 3mnths)
Med: PV oestrogen/pessary
Surgical: TOT/TVT
Antiemetics in hyperemesis gravidarum
Promethazine
NSAID effective after CS, contraindicated during pregC
Diclofenac
Main Oestrogen secreted by the ovaries prior to meonpause
17beta-Oestradiol
Male cell that contains 23 single chromosomes prior to spermiogenesis
Spermatid
Male cell that contains 46 double-structured chromosomes
Primary spermatocyte
PE Mx
Enoxaparin 80mg BD
Single episode of brown stained vaginal discharge
Atrophic vaginitis
2014 feedback
UTI Tx in PregC
Nitro, Trimethoprim, Cefalexin
PCOS Tx increasing fertility
Clomiphene
Most common cause of male infertility
Varicocele
Scrotal pain relieved on lifting
Epididimo-orchitis
Fetal effects of Paroxetine
Cardiac abnormalities (VSD’s/ASD’s)
Fetal effects of Fluoxetine
Persistent pulmonary hypertension of the newborn
Mx of depressin in PregC
Preffered SSRI in PregC
Slowly withdraw and watchful waiting
Sertraline?
Dysmenorrhoea vs Menorrhagia
Mx
Painful vs heavy
Dys: NSAIDs (Ibuprofen/Mefanamic acid), COC preparations, (3rd line POP)
Menorrhagia: NSAIDS (Mefanamic acid/tranexamic) or IUS, COCP, long acting progesterones