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PACES > O&G > Flashcards

O&G Flashcards

1
Q

What is the combined test and when would you perform?

A

Nuchal translucency, beta-HCG and PAPP-A. (Mama bHCG and Papa PAPP-A)

11-14 weeks.

Tests for Downs, Edwards, Patau.

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2
Q

When is the serum triple test offered? What is it and what does it test for?

A

14-20 weeks
bHCG, AFP, oestradiol (HAO)
Downs and spina bifida

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3
Q

Quadruple test? What is it, when is it, what does it test for?

A

15-22 weeks

Triple test + Inhibin A (AFP, HCG, oestriol)

Chromosomal abnormalities and spina bifida

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4
Q

Down’s USS and blood findings in utero

A

USS: thickened nuchal translucency, short nasal bone, tricuspid regurgitation

Bloods:
Low oestriol, PAPP-A and AFP
High bHCG and Inhibin A

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5
Q

Klinefelters

A

47XXY (boys)

Normal intelligence
Small testes
Infertile

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6
Q

Mx of Herpes Simplex in pregnancy

A

CS if delivery within 6 weeks of primary attack, otherwise low risk

Daily acyclovir close to term

IV acyclovir to exposed neonates (vaginal del, SROM)

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7
Q

GBS in pregnancy; how do you prevent vertical transmission and when would you give it?

A

IV penicillin in vaginal labour if:

  • Previous GBS
  • Intrapartum fever
  • Preterm labour
  • Rupture of membranes > 18 hours

OR swab if risk factors present

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8
Q

HIV in pregnancy; how would you monitor the HIV?

A

Viral loads at least every 3 months and at 36 weeks

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9
Q

Protocol for pregnant women in contact with chicken pox if not immune?

A

Give VZV IgG is less than 10 days since contact or less than 10 days since rash appearance

If develop chicken pox , give acyclovir
Avoid delivery until at least 7 days post rash appeared

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10
Q

Risk factors for pre eclampsia

A 
Nullips
Previous PET
FHx
Maternal age
Chronic HTN
DM
Twins
Obesity
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11
Q

Classification of PET

A

Mild 140/90
Moderate 150/100
Severe 160/110

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12
Q

What to screen for in PET?

A

Headaches, drowsiness, visual disturbances, nausea and vomiting, epigastric pain

Fundoscopy, neurological examination (reflexes and eye movements)

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13
Q

Complications of PET?

A 
Maternal: 
Eclampsia
HELLP syndrome 
DIC
Renal failure 
Pulmonary oedema

Fetal:
Stillbirth
IUGR
Placental abruption

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14
Q

Tx recommended to women at risk of PET?

A

Low dose aspirin before 16 weeks

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15
Q

Management of gestational hypertension

A

BP/urinalysis twice weekly, USS every 2-4 weeks

Post natal: May get worse briefly, monitor bloods and fluid balance. BP with GP

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16
Q

Delivery and PET?

A

IOL at 40 weeks for gestational HTN

Mild PET: 37 weeks
Moderate/severe: 34-36 weeks

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17
Q

Complications of GDM

A 
Maternal:
UTI
Endometrial infection
PET
Instrumental delivery 
Fetal:
Macrosomia
Polyhydramnios
Preterm labour
Congenital abnormalities (more in established DM)
Shoulder dystocia and birth trauma
Neonatal hypoG
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18
Q

Monitoring and management of pre-existing DM in pregnancy

A

Home glucose monitoring
Fortnightly visits up to 34 weeks, then weekly

Fetal echo along with normal scans, USS, umbilical artery doppler if PET or IUGR

Aspirin daily from 12 weeks
Delivery by 39

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19
Q

Management of GDM

A

Offer review in joint antenatal DM clinic in 1 week

Give glucometer, measure fasting, 1 hour and 2 hour post meal

Advise re diet and exercise, can refer to dietician.

If fasting glucose <7, offer 1 week trial exercise and diet. If unsuccessful, metformin then insulin.

If fasting glucose >7 give insulin. If deny/cannot tolerate insulin, give glibenclamide

ANC every 1-2 weeks, some extra growth scans later on in pregnancy (32, 36wks) and for fetal wellbeing (38,39wks)

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20
Q

Delivery in GDM

A

Give birth in facility with advanced neonatal resus

No later than 40 + 6 weeks, otherwise IOL or ECS

BMs every hour, maintain between 4 and 7mmol

STOP maternal insulin immediately!
BM on baby immediately and every 2-4 hours, mother to feed ASAP and at frequent intervals

Follow up with HbA1c check at 6 and 13 weeks post natal

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21
Q

Teratogenic cardiac drugs?

A

Warfarin and ACEis

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22
Q

Safe anti epileptic drugs in pregnancy? What else would you give?

A

Carbamazepine and lamotrigine (higher dose)

Folic acid 5mg/day (high) and Vit K

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23
Q

Tx of hyperthyroidism in pregnancy? Risks?

A

Propylthiouracil ; crosses placenta so keep dose low and test thyroid function

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24
Q

Mx of baby after delivery with mother on anti-epileptics?

A

Give Vit K IM

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25
Q

Mx of obstetric cholestasis?

A

weekly LFT and clotting, serial USS for fetal growth

Medication:
ursodeoxycholic acid to relieve itching
Vit K as high risk of PPH

IOL at 37 weeks; risk of stillbirth

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26
Q

MOA of the implantable contraceptive

A

Prevents ovulation, thickens cervical mucous

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27
Q

MOA of the POP

A

thickens cervical mucous

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28
Q

Fertility counselling points:

A

folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice

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29
Q

Mx of primary PPH

A

ABC
IV syntocinon (oxytocin) or IV ergometrine
IM carboprost

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30
Q

Symptoms of endometriosis

A

chronic pelvic pain
dysmenorrhoea - pain often starts days before bleeding
deep dyspareunia
subfertility

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31
Q

Gold standard Ix and Mx for endometriosis

A

Laparoscopy

Mx:
NSAIDs/paracetamol for symptomatic relief
COCP or progestogens

If no improvement refer to secondary care

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32
Q

Levonelle

A

84% effective is used within 72 hours of UPSI

single dose of levonorgestrel 1.5mg (a progesterone)

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33
Q

EllaOne

A

30mg oral dose taken as soon as possible, no later than 120 hours after intercourse

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34
Q

Drugs to avoid whilst breastfeeding

A

antibiotics: ciprofloxacin (floxy floppy), tetracycline (dodgy teeth), chloramphenicol (grey baby), sulphonamides

psychiatric drugs: lithium, benzodiazepines
aspirin

thyroid: carbimazole (you would be an ‘azole’ to take it)

methotrexate (toxic to everything)

sulphonylureas (will fill your baby with urea)

cytotoxic drugs (just toxic)

amiodarone (will screw with your baby’s heart)

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35
Q

Management of T1DM in pregnancy

A

weight loss for women with BMI of > 27 kg/m^2

stop oral hypoglycaemic agents, apart from metformin, and commence insulin

folic acid 5 mg/day from pre-conception to 12 weeks gestation

detailed anomaly scan at 20 weeks

Blood glucose monitoring: fasting, pre meal, 1hr post meal, bedtime

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36
Q

Need for contraception after the menopause

A

12 months after the last period in women > 50 years

24 months after the last period in women < 50 years

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37
Q

Late deceleration; what is it and what does it indicate? How would you proceed?

A

Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction

Indicates fetal distress e.g. asphyxia or placental insufficiency

Do foetal blood sampling!

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38
Q

Loss of baseline variability; what is it and what does it indicate?

A

< 5 beats / min

Prematurity, hypoxia

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39
Q

APH is defined as bleeding after…

A

24 weeks

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40
Q

Score to assess severity of hyperemesis

A

PUQE Pregnancy-Unique Quantification of Emesis

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41
Q

Bishops score

A

A score of 5 or less suggests that labour is unlikely to start without induction. Therefore in this case, vaginal PGE2 is indicated for cervical ripening and labour induction.

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42
Q

Simple ovarian cyst found on USS in a 24 year old woman. What do you do next?

A

Repeat USS in 12 weeks, if cyst persists, refer to gynae

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43
Q

PMB; Ix and criteria, Tx?

A

Ix: USS and endometrial sampling by outpatient pipelle biopsy

Pre menopausal: >7mm
Post menopausal: > 5mm

Tx for atypic: TAH and BSO for post menopausal women, progestogens and 6 monthly biopsy for pre menopausal

30% will progress to cancer

Tx without atypia: progestogens

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44
Q

Tx of early stage cervical cancer in post menopausal women

A

simple hysterectomy

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45
Q

cystocele surgery?

A

Anterior colporrhaphy (when the vaginal wall is repaired) or colposuspension

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46
Q

vaginal vault prolapse - surgery?

A

sacrocolpoplexy

47
Q

Medical management of an ectopic pregnancy can only be performed for …?

A

ONLY if they can be followed up

1) An unruptured embryo
2) <35mm in size
3) Have no heartbeat
4) No pain
5) Have a B-hCG level 1500-5000IU/L

Counsel that may need second dose if HCG levels don’t fall 15% by day 4 and on waiting 3 months before trying to conceive.

48
Q

foetal macrosomia classification?

A

birth weight >4kg

49
Q

Hyperemesis gravidarum, diagnostic criteria triad

A

5% pre-pregnancy weight loss
dehydration
electrolyte imbalance

50
Q

Active management of labour

A

To prevent PPH

Uterotonic drugs (oxytocin after delivery of anterior shoulder)
Deferred clamping and cutting of cord, over 1 minute after delivery but less then 5 minutes
Controlled cord traction after signs of placental separation
51
Q

Monitoring in Labour

A

FHR monitored every 15min (or continuously via CTG)
Contractions assessed every 30min
Maternal pulse rate assessed every 60min
Maternal BP and temp should be checked every 4 hours
VE should be offered every 4 hours to check progression of labour
Maternal urine should be checked for ketones and protein every 4 hours

52
Q

What is a contraindication for using epidural anaesthesia during labour?

A

Coagulopathy

53
Q

Lacational amenorrhoea

A

is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum

54
Q

When can you start the COCP after delivery?

A

day 21

UKMEC 2 - if breast feeding 6 weeks - 6 months postpartum*

55
Q

How do you calculate RMI?

A

Menopausal age + CA125 + ultrasound score

56
Q

Indications

A

All women should be counselled at 38 weeks about IOL and going post term

  • Post dates
  • Pre eclampsia (34 for severe, 37 for mild, 40 for GHTN)
  • PROM (do after 24 hours)
  • GDM (40 weeks)
  • Macrosomic
57
Q

Contraindications to IOL

A

Anything that is a CI to vaginal delivery; breech if mother refuses CS and ECV fails, placenta praevia, vasa praevia,

58
Q

IOL procedure

A
  1. Sweep
  2. Vaginal prostaglandins (PGE2) 6 hours apart, 2 dose max (Dinopristone)
  3. Discuss caesarean
59
Q

Progression in labour

A

LABOUR (3cm to fully dilated)SHOULD NOT >12 HOURS
Second stage should not >1 hour

After you are 3cm dilated, you should progress at 1cm/hr (nullips) or 2cm/hr (multips)

60
Q

Mx of PPH

A

Uterine massage

  1. Oxytocin injection
  2. Ergometrine
  3. Oxytocin infusion
  4. Misoprostol
  5. Carboprost
61
Q

If they refuse induction post 42 weeks?

A

See twice weekly for CTG and USS

62
Q

Contraception and epilepsy

A

Not on carbamazepine

63
Q

ECV success rates

A

40% in nullips

60% in multips

64
Q

Smears - when to refer?

A

If borderline/mild and HPV positive, 6 week refer to colposcopy

If moderate/severe, 2 week refer to colposcopy

Women who have been treated for CIN1, CIN2, or CIN3 should be invited six months after treatment for ‘test of cure’ repeat cytology in the community. Once three repeat smears are negative, back to routine recall

65
Q

Sterilisation and contraception

A

Use up until day of surgery
If clips, 1 month
If Essure, for 3 months

66
Q

Methods of sterilisation

A

Tubal occlusion ; filshie clips (laparoscopically)
Fallopian implants; Essure (done hysteroscopically)
Salpingectomy

Can be reversed but not on NHS. Can also do IVF if want to get pregnant

67
Q

Failure rates of sterilisation?

A

1 in 200 for clips

1 in 500 Essure

68
Q

Monitoring after medical tx of ectopic

A

Take 2 serum hCG measurements in the first week (days 4 and 7) after treatment
and then 1 serum hCG measurement per week until a negative result is obtained

If hCG levels plateau or rise, reassess the woman’s condition for further treatment.

69
Q

Surgical mx of ectopic

A

Salpingectomy or salpingostomy.

Women having a salpingostomy may need further treatment by way of methotrexate or salpingectomy. Measure HCG every week until negative result obtained

Salpingectomy, women should do urine pregnancy test after 3 weeks

70
Q

Copper IUD as emergency contraception?

A

5 days post UPSI or 5 days post ovulation

71
Q

Before the ECS? Drugs?

A

Catheter
Ranitidine beforehand
LMWH, stockings

72
Q

HIV testing

A

post 6wks exposure - Rapid point of care test or Finger prick test (antibody)
Positive must be confirmed

Antibody-antigen test as early as 2 weeks

Additional tests should be offered to everyone at 3 months to definitely confirm result

73
Q

Tx of eclampsia

A

IV magnesium sulphate

Delivery

74
Q

Before the ECS? Drugs?

A

Catheter
Ranitidine as anti emetic
LMWH, stockings

75
Q

HIV testing

A

post 6wks exposure - Rapid point of care test or Finger prick test (antibody)
Positive must be confirmed
Negative can be retested after 3 months

Antibody-antigen test as early as 2 weeks

76
Q

Expectant Mx of miscarriage

A

If not stopped bleeding 7-14 days, tell them to come back.

Urinary pregnancy test at 3 weeks at home, call if +ve

Any miscarriage above 12 weeks requires Anti-D

77
Q

Medical mx of miscarriage

A

Misoprostol

Pain relief, enti-emetics. If bleeding not started within 24 hours, come back. Bleeding can continue for up to 3 weeks.

Urinary pregnancy test at 3 weeks at home

78
Q

Miscarriage rate

A

1 in 5

Doesn’t make you more likely to have it in the future or affect your fertility. You can start trying again as soon as you feel ready.

79
Q

Surgery for miscarriage

A

Manual vacuum aspiration; can beoutpatient, not GA

or dilatation and evacuation under GA

80
Q

TOP Mx

A

<14 weeks, medical or surg
>24 weeks, give fetocide in the form of KCL

Abx and anti-D after surgery

81
Q

Tests to determine pregnancy of unknown location

A

HCG levels 48 hours apart. If decrease >50%, likely to not be viable.

Ask patient to take a second pregnancy test 14 days after second reading.

If increase 63% or more, could be intrauterine ectopic. Do TVUS 7-14 days.

82
Q

Mx of twins

A

More antenatal appointments. If have risk factors, such as high BMI, nullip, age, then give low dose aspirin from 12 weeks

83
Q

Added risk of twins

A 
Maternal mortality 2.5x higher
PET
Hyperemesis 
TTTS
Pre term labour
Miscarriage 
Anaemia
84
Q

How can we classify twin pregnancies, and what are the features of these on ultrasound?

A

DCDA - two placentas and two amniotic sacs - on USS two distinct gestational sacs and yolk sacs. May also see twin peak sign (lambda sign), and thick intertwin membrane. Discordant sex can also be used.
MCDA - one placenta and two amniotic sacs - on USS one gestational sac and two yolk sacs. A thin intertwin membrane may also be seen.
MCMA - one placenta and one amniotic sac - on USS one gestational sac and one yolk sac. No intertwin membrane

85
Q

Twins and delivery

A

60% of women with twins deliver before 37 weeks.

This can either be by us starting the labour (inducing you) or a c-section.

(triplets 35-36 weeks)

86
Q

Cysts in premenopausal

A

<50mm, will likely regress within 3 cycles
>50-70mm, yearly USS
>70mm, surgery

87
Q

Cysts in post menopausal women

A

Ca125
RMI
If <50mm and not concerning, monitor in 4 months
If concerning, RMI >200, TAH and BSO

88
Q

Types of ovarian cysts

A

Functional vs pathological

89
Q

GDM follow up

A

Fasting plasma glucose 6-13 weeks and annual HbA1C

90
Q

GDM Mx

A

If fasting glucose >7, give insulin
6-6.9 - lifestyle and metformin
6-6.9 + macrosomia - insulin

91
Q

Explain a molar pregnancy

A

A molar pregnancy is where a foetus doesn’t form properly in the womb and a baby doesn’t develop.
A lump of abnormal cells grows in the womb instead of a healthy foetus.
This growth is called a “hydatidiform mole”, which can be either:
a complete mole, where there’s a mass of abnormal cells in the womb and no foetus develops
a partial mole,where an abnormal foetus starts to form, but it can’t survive or develop into a baby

92
Q

Complete vs partial mole

A

Complete mole: haploid sperm duplicates to become diploid, which fertilise an empty ovum, this proliferates to form abnormal placental tissue

Partial mole: triploid due to diploid sperm plus maternal DNA

93
Q

What is a choriocarcinoma?

A

Malignant trophoblastic cancer of the placenta

Rapidly growing and often metastasises to the lungs

94
Q

Symptoms of molar pregnancy

A

Bleeding in first trimester, hyperemesis, uterus large for dates

95
Q

Management of molar pregnancy

A

Evacuation by suction curettage for smaller moles, may need oxytocic agent for larger moles. Give anti-D

Measure HCG every 2 weeks after evacuation at SPECIALIST CENTRE (CX). Rate of decrease in HCG indicates risk

Chemotherapy offered to destroy persistent trophoblastic tissue to minimise choriocarcinoma risk

DO NOT get pregnant until 6 months after HCG normal

96
Q

MSC SOUR

A 
Menstrual
Sexual
Contraception
Smear
Obs
Urinary
Rectal
97
Q

Tx for anaemia in pregnancy

A

Ferrous sulphate

98
Q

How common is it to carry GBS? Why do we worry about it?

A

25% of women

Worry because can cause sepsis and death, high risk of deafness and cerebral palsy in survivors

99
Q

HIV in pregnancy, opening line

A

HIV is a virus that damages the cells in your immune system and weakens your ability to fight everyday infections and disease

There is a risk that a mother can pass HIV to her baby, but with treatment and precautions this reduces from 25% to <1%

100
Q

Additional tests required in HIV in pregnancy

A 
Hepatitis C 
Varicella zoster
Measles
Toxoplasma 
HIV: viral load, CD4 count, HIV resistance testing, LFTs, monitor for drug toxicity
Screen genital infections
101
Q

Tx for HIV in pregnancy

A

HAART with zimovudine/lamivudine backbone

Treatment with zidovudine mono therapy may be considered if viral load <10000 and willing to have CS

102
Q

Tx for babies born to HIV infected mothers

A

ARVs within 4 hours until 4-6 weeks old

Tested for HIV within first 2 days, confirmed at 18 months

103
Q

What do you do if the HIV patient refuses treatment and what are the rights of the fetus in this case?

A

Pre-birth planning meeting with social services to discuss safeguarding issues
Tell the mother that it is the paediatrician’s role to advocate on behalf of the child’s wellbeing and to prevent where possible HIV infection
If she continues to refuse, legal permission should be sought at birth to treat the infant for 4 weeks with ART and prevent breastfeeding

104
Q

Obstetric complications with HAART

A

Preterm delivery
GDM (test for this if already on HAART)
Pre-eclampsia

105
Q

Complications of hyperemesis gravidarum

A

Hypokalaemia, Wernicke’s, Korsakoff’s, Mallory-Weiss tear, DVT secondary to dehydration

106
Q

Tx for hyperemesis

A

Normal saline, potassium, cyclising or metoclopramide, thiamine and folic acid, TED stockings +/- LMWH

107
Q

Fetal alcohol syndrome features

A

Microcephaly, ptosis, short palpebral fissures, thin upper lip, long smooth philtrum

108
Q

Key points for drug use in pregnancy

A

This patient should be managed as a high-risk patient and with a MDT approach

She should be discussed with the Drug & Alcohol services team and should receive specialised antenatal care from them.

She should be advised not to immediately cut out all drugs, as withdrawal would be dangerous.

Detoxification with methadone could be started.

109
Q

Naegles rule

A

+7 days, +1 year, -3 months

110
Q

What is the difference between IUGR and SGA?

A

SGA refers to babies below the third centile for gestational age, they are small but do not drop off centiles. It is applied postnatally.
IUGR refers to babies who are not growing in utero and they may drop off centiles. It is a result of maternal, fetal and placental factors. It is applied antenatally. IUGR can be classified into symmetrical and asymmetrical growth.

111
Q

symmetrical and asymmetrical growth restriction?

A

Asymmetrical IUGR: Late gestational nutritional failures e.g. Pre-eclampsia, maternal starvation, smoking, heart disease

Symmetrical IUGR: Genetic factors e.g. Chromosomal anomalies or early insults to the foetus e.g. infection

112
Q

What are the effects of heroin on pregnancy?

A

Neonatal withdrawal → Jitteriness, sneezing, yawning, poor feeding, vomiting diarrhoea, weight loss and seizures

113
Q

Ix for SGA

A

Screening for toxoplasmosis, CMV (malaria, syphilis if high risk travel)
Refer for umbilical artery surveillance every 2 weeks from 26-28 weeks
Measure EFW and AC every 2 weeks
Other surveillance: amniotic fluid maximum pool depth (<2cm = oligohydramnios), computerised CTG

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