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.
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
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
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
5
Q
Klinefelters
A
47XXY (boys)
Normal intelligence
Small testes
Infertile
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)
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
8
Q
HIV in pregnancy; how would you monitor the HIV?
A
Viral loads at least every 3 months and at 36 weeks
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
10
Q
Risk factors for pre eclampsia
A
Nullips Previous PET FHx Maternal age Chronic HTN DM Twins Obesity
11
Q
Classification of PET
A
Mild 140/90
Moderate 150/100
Severe 160/110
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)
13
Q
Complications of PET?
A
Maternal: Eclampsia HELLP syndrome DIC Renal failure Pulmonary oedema
Fetal:
Stillbirth
IUGR
Placental abruption
14
Q
Tx recommended to women at risk of PET?
A
Low dose aspirin before 16 weeks
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
16
Q
Delivery and PET?
A
IOL at 40 weeks for gestational HTN
Mild PET: 37 weeks
Moderate/severe: 34-36 weeks
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
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
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)
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
21
Q
Teratogenic cardiac drugs?
A
Warfarin and ACEis
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
23
Q
Tx of hyperthyroidism in pregnancy? Risks?
A
Propylthiouracil ; crosses placenta so keep dose low and test thyroid function
24
Q
Mx of baby after delivery with mother on anti-epileptics?
A
Give Vit K IM
25
Mx of obstetric cholestasis?
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
26
MOA of the implantable contraceptive
Prevents ovulation, thickens cervical mucous
27
MOA of the POP
thickens cervical mucous
28
Fertility counselling points:
folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice
29
Mx of primary PPH
ABC
IV syntocinon (oxytocin) or IV ergometrine
IM carboprost
30
Symptoms of endometriosis
chronic pelvic pain
dysmenorrhoea - pain often starts days before bleeding
deep dyspareunia
subfertility
31
Gold standard Ix and Mx for endometriosis
Laparoscopy
Mx:
NSAIDs/paracetamol for symptomatic relief
COCP or progestogens
If no improvement refer to secondary care
32
Levonelle
84% effective is used within 72 hours of UPSI
| single dose of levonorgestrel 1.5mg (a progesterone)
33
EllaOne
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
34
Drugs to avoid whilst breastfeeding
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)
35
Management of T1DM in pregnancy
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
36
Need for contraception after the menopause
12 months after the last period in women > 50 years
| 24 months after the last period in women < 50 years
37
Late deceleration; what is it and what does it indicate? How would you proceed?
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!
38
Loss of baseline variability; what is it and what does it indicate?
< 5 beats / min
| Prematurity, hypoxia
39
APH is defined as bleeding after...
24 weeks
40
Score to assess severity of hyperemesis
PUQE Pregnancy-Unique Quantification of Emesis
41
Bishops score
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.
42
Simple ovarian cyst found on USS in a 24 year old woman. What do you do next?
Repeat USS in 12 weeks, if cyst persists, refer to gynae
43
PMB; Ix and criteria, Tx?
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
44
Tx of early stage cervical cancer in post menopausal women
simple hysterectomy
45
cystocele surgery?
Anterior colporrhaphy (when the vaginal wall is repaired) or colposuspension
46
vaginal vault prolapse - surgery?
sacrocolpoplexy
47
Medical management of an ectopic pregnancy can only be performed for ...?
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
foetal macrosomia classification?
birth weight >4kg
49
Hyperemesis gravidarum, diagnostic criteria triad
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
50
Active management of labour
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
Monitoring in Labour
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
What is a contraindication for using epidural anaesthesia during labour?
Coagulopathy
53
Lacational amenorrhoea
is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum
54
When can you start the COCP after delivery?
day 21
UKMEC 2 - if breast feeding 6 weeks - 6 months postpartum*
55
How do you calculate RMI?
Menopausal age + CA125 + ultrasound score
56
Indications
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
Contraindications to IOL
Anything that is a CI to vaginal delivery; breech if mother refuses CS and ECV fails, placenta praevia, vasa praevia,
58
IOL procedure
1. Sweep
2. Vaginal prostaglandins (PGE2) 6 hours apart, 2 dose max (Dinopristone)
3. Discuss caesarean
59
Progression in labour
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
Mx of PPH
Uterine massage
1. Oxytocin injection
2. Ergometrine
3. Oxytocin infusion
4. Misoprostol
5. Carboprost
61
If they refuse induction post 42 weeks?
See twice weekly for CTG and USS
62
Contraception and epilepsy
Not on carbamazepine
63
ECV success rates
40% in nullips
| 60% in multips
64
Smears - when to refer?
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
Sterilisation and contraception
Use up until day of surgery
If clips, 1 month
If Essure, for 3 months
66
Methods of sterilisation
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
Failure rates of sterilisation?
1 in 200 for clips
| 1 in 500 Essure
68
Monitoring after medical tx of ectopic
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
Surgical mx of ectopic
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
Copper IUD as emergency contraception?
5 days post UPSI or 5 days post ovulation
71
Before the ECS? Drugs?
Catheter
Ranitidine beforehand
LMWH, stockings
72
HIV testing
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
Tx of eclampsia
IV magnesium sulphate
| Delivery
74
Before the ECS? Drugs?
Catheter
Ranitidine as anti emetic
LMWH, stockings
75
HIV testing
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
Expectant Mx of miscarriage
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
Medical mx of miscarriage
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
Miscarriage rate
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
Surgery for miscarriage
Manual vacuum aspiration; can beoutpatient, not GA
or dilatation and evacuation under GA
80
TOP Mx
<14 weeks, medical or surg
>24 weeks, give fetocide in the form of KCL
Abx and anti-D after surgery
81
Tests to determine pregnancy of unknown location
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
Mx of twins
More antenatal appointments. If have risk factors, such as high BMI, nullip, age, then give low dose aspirin from 12 weeks
83
Added risk of twins
```
Maternal mortality 2.5x higher
PET
Hyperemesis
TTTS
Pre term labour
Miscarriage
Anaemia
```
84
How can we classify twin pregnancies, and what are the features of these on ultrasound?
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
Twins and delivery
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
Cysts in premenopausal
<50mm, will likely regress within 3 cycles
>50-70mm, yearly USS
>70mm, surgery
87
Cysts in post menopausal women
Ca125
RMI
If <50mm and not concerning, monitor in 4 months
If concerning, RMI >200, TAH and BSO
88
Types of ovarian cysts
Functional vs pathological
89
GDM follow up
Fasting plasma glucose 6-13 weeks and annual HbA1C
90
GDM Mx
If fasting glucose >7, give insulin
6-6.9 - lifestyle and metformin
6-6.9 + macrosomia - insulin
91
Explain a molar pregnancy
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
Complete vs partial mole
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
What is a choriocarcinoma?
Malignant trophoblastic cancer of the placenta
Rapidly growing and often metastasises to the lungs
94
Symptoms of molar pregnancy
Bleeding in first trimester, hyperemesis, uterus large for dates
95
Management of molar pregnancy
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
MSC SOUR
```
Menstrual
Sexual
Contraception
Smear
Obs
Urinary
Rectal
```
97
Tx for anaemia in pregnancy
Ferrous sulphate
98
How common is it to carry GBS? Why do we worry about it?
25% of women
Worry because can cause sepsis and death, high risk of deafness and cerebral palsy in survivors
99
HIV in pregnancy, opening line
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
Additional tests required in HIV in pregnancy
```
Hepatitis C
Varicella zoster
Measles
Toxoplasma
HIV: viral load, CD4 count, HIV resistance testing, LFTs, monitor for drug toxicity
Screen genital infections
```
101
Tx for HIV in pregnancy
HAART with zimovudine/lamivudine backbone
Treatment with zidovudine mono therapy may be considered if viral load <10000 and willing to have CS
102
Tx for babies born to HIV infected mothers
ARVs within 4 hours until 4-6 weeks old
| Tested for HIV within first 2 days, confirmed at 18 months
103
What do you do if the HIV patient refuses treatment and what are the rights of the fetus in this case?
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
Obstetric complications with HAART
Preterm delivery
GDM (test for this if already on HAART)
Pre-eclampsia
105
Complications of hyperemesis gravidarum
Hypokalaemia, Wernicke's, Korsakoff's, Mallory-Weiss tear, DVT secondary to dehydration
106
Tx for hyperemesis
Normal saline, potassium, cyclising or metoclopramide, thiamine and folic acid, TED stockings +/- LMWH
107
Fetal alcohol syndrome features
Microcephaly, ptosis, short palpebral fissures, thin upper lip, long smooth philtrum
108
Key points for drug use in pregnancy
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
Naegles rule
+7 days, +1 year, -3 months
110
What is the difference between IUGR and SGA?
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
symmetrical and asymmetrical growth restriction?
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
What are the effects of heroin on pregnancy?
Neonatal withdrawal → Jitteriness, sneezing, yawning, poor feeding, vomiting diarrhoea, weight loss and seizures
113
Ix for SGA
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
