O+G 7 Flashcards
Which cysts are sometimes referred to as chocolate cysts due to the external appearance?
Endometriotic cyst
A 35-year-old lady and her husband present to the rheumatology clinic. They both suffer from rheumatoid arthritis which is well controlled by medication. They would like to start a family and would like to know if they need to make any changes to their medication. They are both taking methotrexate. Which one of the following would be the most appropriate advice?
Methotrexate: must be stopped at least 3 months before conception in both men and women
Which drugs for RA can be taken during pregnancy?
sulfasalazine and hydroxychloroquine
How often is the Depo Provera (medroxyprogesterone acetate) injectable contraceptive given?
Every 12 weeks
On routine antenatal swabs, a mother is found to be colonised with Group B Streptococcus. However, she did not receive adequate intrapartum antibiotic prophylaxis and she delivers a healthy baby girl by vaginal delivery. Her baby does not require any resuscitation and remains well in the post natal ward. The mother is eager for discharge home. What is the most appropriate course of action with regards to her child?
Maternal colonisation with group B streptococcus is a minor risk factor for early onset sepsis in the newborn. Newborns with only one minor risk factor for early onset sepsis should remain in hospital for at least 24 hours with regular observations. Two or more minor risk factor or one red flag warrant empirical antibiotic therapy with Benzylpenicillin and Gentamicin and a full septic screen. Red flags include the following:
- Suspected or confirmed infection in another baby in the case of a multiple pregnancy
- Parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour periods before and after the birth [This does not refer to intrapartum antibiotic prophylaxis]
- Respiratory distress starting more than 4 hours after birth
- Seizures
- Need for mechanical ventilation in a term baby
- Signs of shock
A 33-year-old primigravida woman of 32 weeks gestation presents to the Emergency Department with premature rupture of membranes. There have been no complications of the pregnancy so far and the woman is normally fit and well. How is she best managed?
Admit her for at least 48 hours and prescribe antibiotics and steroids
A 28-year-old woman presents the Emergency Department at 35-weeks gestation with lower abdominal pain and vaginal bleeding. She is alert and responsive. Physical examination revealed a heart rate of 115 bpm, blood pressure of 90/60 mmHg and O2 saturation of 99%. On neurological exam, her pupils were dilated and her reflexes were brisk.
Hb 115 g/l Platelets 250 * 109/l WBC 5 * 109/l PT 12 seconds APTT 30 seconds
Which of the following underlying conditions would most likely explain the findings on physical exam?
Cocaine abuse
A 29-year-old woman goes into labour. The midwife examines her and states that the head is now at the level of ischial spine. What terminology is used to describe the head in relation to the ischial spine?
Station
A 27-year-old woman attends colposcopy as she had moderate dyskaryosis on her recent cervical smear. On colposcopy she has aceto-white changes and a punch biopsy followed by cold coagulation. Histology of the biopsy shows CIN II. When should she next be offered cervical screening?
Women who have been treated for CIN II should be offered cervical screening at 6 months through cervical screening and a HPV test of cure.
If a woman has a positive-test after treatment they should return to colposcopy.
A woman presents to have a Nexplanon (etonogestrel) inserted. Where is the most appropriate place to insert the implant?
Subdermal, non-dominant arm
A 23-year-old woman who is 10 weeks pregnant presents with severe vomiting. She is now having difficulty keeping down fluids and a dipstick of her urine shows ketones ++. Which one of the following is not associated with an increased risk of this condition?
Smoking is associated with a decreased incidence of hyperemesis gravidarum
A woman who is 12 weeks pregnant presents as she is concerned following a recent antenatal scan. The scan has reportedly shown increased nuchal translucency. Other than Down’s syndrome, which other condition is associated with this finding?
Congenital heart defects
Abdominal wall defects
What are the causes of hyperechogenic bowel?
- cystic fibrosis
- Down’s syndrome
- cytomegalovirus infection
What is placental abruption?
Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
What’s the incidence of placental abruption?
1/200
What’s the cause of placental abruption?
Cause - not known but associated factors:
- proteinuric hypertension
- multiparity
- maternal trauma
- increasing maternal age
What are the clinical features of placental abruption?
- shock out of keeping with visible loss
- pain constant
- tender, tense uterus
- normal lie and presentation
- fetal heart: absent/distressed
- coagulation problems
- beware pre-eclampsia, DIC, anuria
A 23-year-old woman is counselled by her doctor regarding contraceptive options. What is the most common adverse effect experienced by women using a progestogen only pill?
Irregular bleeding
Women should be advised about the likelihood and types of bleeding patterns expected with POP use. As a general guide:
- 20% of women will be amenorrhoeic
- 40% will bleed regularly
- 40% will have erratic bleeding.
A 27 year old woman attends her GP with breast pain. She is 2 weeks postpartum and is exclusively breastfeeding. She complains of a 3 day history of worsening right sided breast pain, which has not improved with continued feeding and expressing. On examination, she appears well, her temperature is 38ºC. There is a small area of erythema superior to the right nipple, which is tender to touch. She has no known allergies.
What would be the most appropriate management?
Oral flucloxacillin and encourage to continue breastfeeding
First-line conservative management includes analgesia and encouraging effective milk removal (continue breastfeeding or expressing from affected side) in order to prevent further milk stasis. It is also important to ensure that there is correct positioning and attachment when feeding.
If symptoms do not improve after 12-24 hours of conservative management then antibiotics should be prescribed. First-line choice is oral flucloxacillin (500mg four times a day for 14 days) or erythromycin if penicillin allergic. Second-line choice is co-amoxiclav.
A 25-year-old present 8 weeks after her last menstrual period. She complains of severe nausea, vomiting and vaginal spotting. Pregnancy test was positive and transvaginal ultrasound showed an abnormally enlarged uterus. What would you expect levels of BHCG, TSH and T4 to be in this patient?
High beta hCG
low TSH
high thyroxine
What’s the most likely diagnosis?
jaundice, mild pyrexia, hepatitic LFTs (ALT above 500), hypoglycaemic, raised WBC, coagulopathy and steatosis on imaging.
acute fatty liver of pregnancy
A 45-year-old woman has come into your post-menopausal bleed clinic. When taking a history, you ask about her medical history and family history for things that may increase her risk of endometrial cancer. Which of the following is associated with increased risk of endometrial cancer?
Anorexia nervosa Familial adenomatous polyposis HNPCC/Lynch syndrome Intrauterine system (Mirena coil) Use of combined oral contraceptive pill
HNPCC/Lynch syndrome is a strong risk factor for endometrial cancer.
What risks are assoicated with termination of pregnancy?
- Infection can happen in up to 10% of TOP cases. Antibiotics are given to reduce the risk of infection. Signs and symptoms of an infection are unlikely to occur so soon after the procedure.
- Retained tissue pregnancy occurs in less than 1% of cases.
- Haemorrhage occurs in less than 1% of cases, but is more likely to occur in pregnancies greater than 20 weeks gestation.
- Failure occurs in less than 1% of cases.
- Injury to the cervix occurs in less than 1% of cases.
What methods are used to terminate a pregnancy?
The method used to terminate pregnancy depend upon gestation
- less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
- less than 13 weeks: surgical dilation and suction of uterine contents
- more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
What is the abortion act?
Subject to the provisions of this section, a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith:
- that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or
- that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or
- that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or
- that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
A 25-year-old woman is to have an elective laparoscopic cholecystectomy in 8 weeks time. She takes no medications other than the combined oral contraceptive pill. What should be done with regards to her pill and her upcoming surgery?
Stop the pill 4 weeks before surgery and restart 2 weeks after surgery
During a lower segment Caesarian section which layers will you cut through?
- Superficial fascia
- Deep fascia
- Anterior rectus sheath
- Rectus abdominis muscle
- Transversalis fascia
- Extraperitoneal connective tissue
- Peritoneum
- Uterus
What are the indications for a c-section?
Emergency c-section?
Instrumental delivery?
Elective
Absolute
- absolute CPD (cephalopelvic disproportion)
- fetal distress in labour/prolapsed cord
- uncorrectable abnormal lie
- previous classical CS
- placenta praevia grades 3/4
Relative
- breech
- severe IUGR
- multiple pregnancy
- medical comorbidities
- previous 3/4th degree tear with symptoms
- previous LSCS
- macrosomic baby
- maternal request
- primary genital herpes in 3rd trimester
- delivery before 34 weeks
- cervical cancer (disseminates cancer cells)
Emergency
- prolonged first stage (not fully dilated after 12 hours in established labour)
- fetal distress if CS is quickest option or instrumental delivery not possible
- failure of labour to progress
- placental abruption: only if fetal distress; if dead deliver vaginally
Instrumental
- prolonged second stage (if baby not delivered after 1hr active pushing or 2hr primips)
- fetal distress (CTG/FBS)
An 18-year-old attends her GP the morning after unprotected sexual intercourse (UPSI). She would like emergency contraception to ensure she is not pregnant. A pregnancy test is negative. Which is the most appropriate next step in management?
- a copper intrauterine contraceptive device (copper coil)
- an oral progesterone-only contraceptive (levonorgestrel)
- a selective progesterone receptor modulator (ulipristal acetate)
These both act to prevent a fertilised ovum being implanted.
For how many hours after unprotected sex can levonorgestrel be given?
72 hours
What is danazol used for?
Danazol is a derivative of ethisterone. It can be used to treat endometriosis and fibrocystic breast disease. It will not prevent implantation and can cause virilisation of female fetuses, so is contraindicated in pregnancy.
A 34-year-old lady presents to the gynaecology department complaining of heavy, painful periods, and difficulty conceiving. She is concerned, as she and her husband would like to start a family soon. On further investigation, an ultrasound scan reveals a 4.5cm submucosal uterine fibroid. Which treatment is most appropriate to treat her fibroids?
The only effective treatment for large fibroids causing problems with fertility is myomectomy if the woman wishes to conceive in the future
A 22-year-old female has a Nexplanon inserted. For how long will this provide effective contraception?
3 years
What is lochia and how long after birth might it persisit?
Lochia may be defined as the vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth.
A 32-year-old 1 week post-partum female presents to her local emergency department with a few days history of vaginal bleeding: initially bright red blood which has now changed in colour to become brown. She is changing her sanitary pads once every 3 hours and is worried that the caesarean section birth has caused damage to her womb. On examination she is visibly distressed but afebrile. She is normotensive with a heart rate of 95 beats per minute and a respiratory rate of 19 breaths per minute. Abdominal examination does not cause pain and reveals a caesarean section scar which is pink and not tender. What is the most appropriate management at this stage?
Lochia typically takes the course of fresh bleeding, which undergoes colour changes before finally stopping. The patient can be reassured and advice should be given to her regarding lochia. Specifically, she should be told that if this begins to smell badly, its volume increases or it doesn’t stop, she should seek medical help. In this case the volume is not excessive and there are no concerning features to the lochia or abnormal observations.
What is puerperal pyrexia?
Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery.
What causes puerperal pyrexia and how do you manage it?
Causes:
- endometritis: most common cause
- urinary tract infection
- wound infections (perineal tears + caesarean section)
- mastitis
- venous thromboembolism
Management
- if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
An 18-year-old girl presents to her GP with discharge. She reports a new sexual partner with whom she is not using barrier protection. On examination thick cottage-cheese like discharged is visualised. She reports no other symptoms of note. What is the most likely diagnosis?
Candida albicans
Cottage-cheese like discharge is almost pathognomonic of thrush
What are the features of candida albicans?
- ‘cottage cheese’, non-offensive discharge
- vulvitis: dyspareunia, dysuria
- itch
- vulval erythema, fissuring, satellite lesions may be seen
A 20-year-old female presents with a 3-month history of abdominal pain. Abdominal ultrasound shows an 8cm mass in the right ovary. Histopathological analysis reveals Rokitansky’s protuberance. What is the most likely diagnosis?
Teratomas (dermoid cysts)
What is a Rokitansky protuberance?
The inner lining of every mature cystic teratoma contains single or multiple white shiny masses projecting from the wall toward the centre of the cysts. When hair, other dermal appendages, bone and teeth are present, they usually arise from this protuberance. This protuberance is referred to as the Rokitansky protuberance.
A 17-year-old Somali girl has presented to the emergency department with recurrent urinary tract infections. On examination, with a chaperone, you notice the girl may have had a clitoridectomy. You believe the girl has been subjected to female genital mutilation (FGM). She asks for antibiotics and for no one else to be informed. As well as treating the infection, what should you do?
Inform the medical team and the police
The Good Medical Council (GMC) state that we should report all known cases of FGM in under-18s to the police, either by calling 101 or through existing local routes.
Give examples of LARCs
Long-acting methods of reversible contraception (LARCs)
- implantable contraceptives
- injectable contraceptives
- intrauterine system (IUS): progesterone releasing coil
- intrauterine device (IUD): copper coil
A 22-year-old woman has just had an artificial rupture of membranes in order to augment a slowly progressing labour. Her partner is helping her move into a more comfortable position when she suddenly becomes breathless and collapses from the bed. She is unconscious and unresponsive with a blood pressure of 82/50 mmHg and a heart rate of 134 beats per minute. What is the most likely diagnosis?
A history of sudden collapse occurring soon after a rupture of membranes is suggestive of amniotic fluid embolism.
When would you do continuous CTG monitoring?
If any of the following are present or arise during labour;
- suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
- severe hypertension 160/110 mmHg or above
- oxytocin use
- the presence of significant meconium
- fresh vaginal bleeding that develops in labour - this was a new point added to the guidelines in 2014
Fresh vaginal bleeds developing in labour could be a sign of placental rupture (the most common cause of antepartum haemorrhage) or placental praevia (second most common cause of antepartum haemorrhage) and therefore monitoring of the baby is required.
A 23-year-old woman, gravidity 2 and parity 1, at 37 weeks gestation presents after fainting and has severe abdominal pain. Blood pressure = 92/58 mmHg and heart rate = 132/min. On examination she is cold and her fundal height is 37 cm; the cervical os is closed and there is no vaginal bleeding. Which is the most appropriate diagnosis?
Placental abruption
What are the clinical features of placental abruption?
- shock out of keeping with visible loss
- pain constant
- tender, tense uterus
- normal lie and presentation
- fetal heart: absent/distressed
- coagulation problems
- beware pre-eclampsia, DIC, anuria
- Presents with sudden abdominal pain in the third trimester.
- On examination the mother can be seen to be in extreme pain and cold to touch.
- Bleeding is present in 80% of cases.
- Absence of visible bleeding does not rule out this diagnosis.
What are the risk factors for placental abruption?
- maternal hypertension (common)
- cocaine
- trauma
- uterine overdistension
- tobacco
- previous placental abruption
How do you treat hyperemesis gravidarum?
- antihistamines should be used first-line (BNF suggests promethazine as first-line). Cyclizine is also recommended by Clinical Knowledge Summaries (CKS)
- ondansetron and metoclopramide may be used second-line
- ginger and P6 (wrist) acupressure: CKS suggest these can be tried but there is little evidence of benefit
- admission may be needed for IV hydration
Which cancers does COCP protect against?
ovarian and endometrial cancer
Which cancers does the COCP increase the risk of?
breast and cervical cancer
What’s the diagnosis?
Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
Trichomonas vaginalis
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
A 38-year-old pregnant woman presents to antenatal clinic complaining of headaches and rapid swelling of her ankles over the last 3 days. She is 30+4 weeks pregnant, gravida 1 para 0. She has a past medical history of diabetes mellitus type II which is lifestyle controlled. On examination the fundal height is measuring small for dates and she is sent for an ultrasound scan which reveals oligohydramnios.
Which of the following is the most likely cause of this patient’s oligohydramnios?
Pre-eclampsia
What is oligohydramnious?
In oligohydramnios there is reduced amniotic fluid. Definitions vary but include less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile.
What causes oligohydramnious?
- premature rupture of membranes
- fetal renal problems e.g. renal agenesis
- intrauterine growth restriction
- post-term gestation
- pre-eclampsia
A well 35-year-old female attends the GP practice with her partner as she is struggling to become pregnant. They have been trying for a year with regular sexual intercourse. What is the most appropriate first line investigation?
day 21 progesterone
A woman who is 32 weeks pregnant presents to the emergency department with a painless leakage of fluid from the vagina. There was an initial gush 2 hours ago, and a steady drip since. She is examined with a sterile speculum and the fluid is confirmed as amniotic fluid. The woman also states she has a severe allergy to penicillin. What is the best management to reduce the risk of infection?
10 days erythromycin should be given to all women with PPROM
A 19-year-old woman presents to your surgery 14 weeks into her second pregnancy. Her pregnancy has been progressing normally so far, including a normal dating scan at 10 weeks.
She visited 24 hours ago due to excessive nausea and vomiting and was started on oral cyclizine 50mg TDS. However, she is still unable to tolerate any oral intake, including fluids. Her urine dip is positive for ketones.
What is the most appropriate next step?
Arrange admission to hospital.
Failure of oral antiemetics to control symptoms, ketonuria and weight loss (>5% of pre pregnancy body weight) are all reasons to refer a woman to gynaecology for urgent assessment and intravenous fluids. It is particularly important to keep a low threshold for referral if the woman has a concurrent condition which may be affected by prolonged nausea and vomiting (for example diabetes).
A 36-year-old nulliparous woman is admitted in labour at 37 weeks gestation. On examination, the cervix is 7 cm dilated, the head is direct Occipito-Anterior, the foetal station is at -1 and the head is 2/5 ths palpable per abdomen. The cardiotocogram shows late decelerations and a foetal heart rate of 100 beats/min which continue for 15 minutes. How should this situation be managed?
Caesarian section
The cardiotocogram is very concerning (the late decelerations which are a worrying sign especially in the context of foetal bradycardia) and indicates that the baby needs to be delivered immediately. Instrumental delivery is not possible because the cervix is not fully dilated and the head of the baby is high. Oxytocin and vaginal prostaglandin are contraindicated due to foetal distress. Therefore the safest approach in this case is an emergency caesarian section.
Which factors increase the risk of miscarriage?
- Increased maternal age
- Smoking in pregnancy
- Consuming alcohol
- Recreational drug use
- High caffeine intake
- Obesity
- Infections and food poisoning
- Health conditions, e.g. thyroid problems, severe hypertension, uncontrolled diabetes
- Medicines, such as ibuprofen, methotrexate and retinoids
- Unusual shape or structure of womb
- Cervical incompetence
A 24 year-old lady with type 1 diabetes presents to the maternity department at 25+3 weeks gestation with tightenings and a thin watery discharge. Her pregnancy so far has been uncomplicated and all scans have been normal. She has well controlled diabetes by using an insulin pump.
A speculum examination is performed and no fluid is noted, the cervical os is closed. A fetal fibronectin (fFN) test is performed which comes back as 300 (positive).
What is the most appropriate management?
Admit for 2 doses IM steroids and monitor BMs closely, adjusting pump accordingly.
Having a positive result means that the obstetric team can optimise everything, in case the lady does go into premature labour. This includes ensuring neonatal intensive care are aware, and administering steroids to help with neonatal lung maturity. As this lady is at high risk of premature labour, and is currently experiencing tightenings, it would be incorrect to discharge the patient without any further monitoring.
What is a fetal fibronectin test?
Fetal fibronectin (fFN) is a protein that is released from the gestational sac. Having a high level has been shown to be related with early labour, and depending on the level different probabilities can be calculated for labour within one week, two weeks etc. Having a high level however does not mean that early labour is definite, some women will go to term even with a raised fFN
What proportion of pregnancies are complicated by diabetes and what types occur?
1 in 20 pregnancies. NICE estimate the following breakdown:
- 87.5% have gestational diabetes
- 7.5% have type 1 diabetes
- 5% have type 2 diabetes
A 24-year-old woman who has just returned from holiday presents to your clinic 6 days after unprotected sexual intercourse. She reports having a regular 28-day cycle with ovulation around day 14. She is currently on day 16 of her cycle.
What would be the most appropriate method of emergency contraception for this patient?
An IUD can be inserted up to 5 days after the likely ovulation date in women presenting >5 days after UPSI and requesting emergency contraception
A 30-week pregnant mother presents to the labour ward after she felt that her waters had broken. She has no pain or contractions and feels well. After examination, she is diagnosed with preterm pre-labour rupture of membranes.
Which drug should be administered to the mother to reduce the chance of respiratory distress syndrome in the newborn?
Dexamethasone is a corticosteroid which should be administered antenatally to patients with preterm prelabour rupture of membranes to reduce the chance of respiratory distress syndrome.
A 33-year-old woman presents to the emergency department with worsening left-sided abdominal pain. She reports the pain started suddenly 5 hours ago and has been steadily getting worse. The pain started suddenly following intercourse. She is unsure about the date of her last menstrual period as she currently has the Mirena coil fitted. She denies any vaginal bleeding or discharge. Apart from the pain, she has no other symptoms and her observations are stable.
Her lower abdomen is tender on palpation but there is no guarding or rigidity. Pelvic exam including bimanual exam is unremarkable. The Mirena coil threads are clearly visualised.
Ultrasound shows free fluid in the pelvic cavity. Urinary pregnancy test is negative.
What is the most likely diagnosis?
Ruptured ovarian cyst
Classically:
Ruptured ovarian cyst: sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity
A 38-year-old patient who is undergoing in vitro fertilisation (IVF) for tubal disease presents 4 days after egg retrieval with abdominal discomfort, nausea and vomiting. She has a past medical history of well-controlled Crohn’s disease and is currently taking azathioprine maintenance therapy. On examination her abdomen is visibly distended. The most likely diagnosis is:
Ovarian hyperstimulation syndrome
This is associated typically with the use of human chorionic gonadotrophin (HCG) in the maturation of follicles during IVF.
What are the symptoms of mild, moderate, severe and critical ovarian hypersensitivity syndrome?
Mild
- Abdominal pain
- Abdominal bloating
Moderate
- As for mild
- Nausea and vomiting
- Ultrasound evidence of ascites
Severe
- As for moderate
- Clinical evidence of ascites
- Oliguria
- Haematocrit > 45%
- Hypoproteinaemia
Critical
- As for severe
- Thromboembolism
- Acute respiratory distress syndrome
- Anuria
- Tense ascites
When is nexplanon effective?
- licensed for up to 3 years of use
- effective immediately as contraception, if inserted up to and including day 5 of the menstrual cycle
- if inserted after day 5 of the menstrual cycle, the advice would be to abstain from sexual intercourse or use condoms for the first 7 days (providing the clinician is ‘reasonably certain’ that the woman is not pregnant).
How long can ellaone be taken after unprotected sex?
ellaOne (ulipristal acetate) is effective if taken within 120 hours of unprotected intercourse.
From what is BHCG secreted and what does it do?
Human chorionic gonadotrophin (HCG) is secreted by the syncytiotrophoblast into the maternal bloodstream, where is acts to maintain the production of progesterone by the corpus luteum in early pregnancy
From when can you detect bHCG in the maternal blood
8 days post conception
How much does smoking increase the risk of cervical cancer?
2 fold
Mneumonic for CTG interpretation
DR C BRA VADO:
DR- define risk: why is this patient on a CTG monitor? e.g. pre-eclampsia, antepartum haemorrhage, maternal obesity, maternal ill health
C- contractions. Look at the bottom of the trace, each contraction is shown by a peak. In established labour you would expect 5 contractions in 10 minutes. Each large square = 1 minute duration, so count the number of contractions in 10 squares.
BRA- baseline rate. The fetal baseline rate should be approximately 110-160 beats per minute. Each large square = 10 beats and each small square = 5 beats. A fetal bradycardia is below 110 beats per minute and a fetal tachycardia is above 160 beats per minute.
V- baseline variability. The fetal heart rate should vary between 5 to 25 beats per minute. Below 5 beats per minute, the variability is said to be reduced.
A- accelerations. Are there accelerations in fetal heart rate? Accelerations are a rise in fetal heart rate of at least 15 beats lasting for 15 seconds or more. There should be 2 separate accelerations every 15 minutes. Accelerations typically occur with contractions.
D- decelerations. Are there decelerations in fetal heart rate? These are a reduction in fetal heart rate by 15 beats or more for at least 15 seconds. Decelerations are generally abnormal and should prompt senior review. In particular, late decelerations, which are slow to recover are indicative of fetal hypoxia.
O- overall impression/diagnosis. As a medical student it is important to be aware of two features- terminal bradycardia and terminal decelerations. A terminal bradycardia is when the baseline fetal heart rate drops to below 100 beats per minute for more than 10 minutes. A terminal deceleration is when the heart rate drops and does not recover for more than 3 minutes. These make up a ‘pre-terminal’ CTG and are indicators for Emergency Caesarean section.
Until how many weeks would you expect a head to be free on palpation?
37
A 28-year-old woman who is 34 weeks pregnant is diagnosed with a urinary tract infection after routine dipstick testing. Laboratory analysis shows group B streptococcus to be the cause and this is treated with a short course of oral antibiotics. How should this woman be managed with respect to delivering her baby in a few weeks time?
Intrapartum antibiotics
For non-penicillin-allergic patients intrapartum antibiotics will consist of intravenous benzylpenicillin given as soon as possible after the start of labour, then at 4-hourly intervals until delivery.
A 35-year-old woman is found at her dating ultrasound scan to be pregnant with monochorionic twins. Her midwife explains that she will need regular scans throughout her pregnancy. What is the main pathology that ultrasound monitoring performed between 16 and 24 weeks gestation aims to detect?
Twin-to-twin transfusion syndrome
What’s the incidence of multiple pregnancies?
twins: 1/105
triplets: 1/10,000
What’s the difference between monozygotic and dizygotic twins?
2/3 of twins Dizygotic: different oocytes fertilized by different sperm
1/3 of twins Monozygotic: division of zygote after fertilization
What does dichorionic mean?
Two placentas. Can either be DZ or MZ (division before 3 days)
In 30% of MZ twins the eggs divide before day 3 resulting in DCDC MZ twins
What does monochorionic mean? What are the different types?
Just one placenta. Always MZ
MCDA (monochorionic, diamniotic) means one placenta but 2 amniotic sacs (division of egg between 4 and 8
In 70% of MZ twins the eggs divide before day 3 resulting in DCDC MZ twinsdays)
MCMA (monochorionic, monoamniotic) means one placenta and one amniotic sac (division of egg 9-13 days)
What type of twins are affected by TTTS?
MCDA twins
What type of twins does the lambda sign indicate?
Dichorionic twins
What type of twins does the t sign indicate?
monochorionic twins
When are additional scans done to assess for growth of multiple pregnancies?
28, 32, 36 weeks
How is TTTS detected?
- usually between 16 and 22 weeks by ultrasound
- tricuspid regurgitation or polyhydramnios around recipient
- massive abdominal distention
How and when are twins normally delivered?
- Induction or caesarean
- 37-38 weeks for DC twins
- 34-35 weeks for MC twins
What treatment is given for TTTS?
Laser photocoagulation of the placental anastomoses using ultrasound.
50% both survive
80% one survives
What is the risk of death of the second twin delivered?
5 times more
What proportion of twins are premature?
40%
What causes TTTS?
What happens to the babies?
- unequal blood distribution through vascular anastomoses of the shared placenta
- one twin, the ‘donor’ is volume depleted and develops anaemia, IUGR and oligohydramnios
- the other, ‘recipient’ gets volume overloaded and may develop polycythaemia, cardiac failure and massive polyhydramnios
What is sIUGR with iAREDF?
selective IUGR with intermittent absent or reversed end diastolic flow
- the umbilical artery waveform of the smaller twin is very erratic
- may be the result of superficial artery-artery anastomoses
What are the predisposing factors for dizygotic twins?
- previous twins
- family history
- increasing maternal age
- multigravida
- induced ovulation and in-vitro fertilisation
- race e.g. Afro-Caribbean
What are the antenatal complications associated with twins?
- polyhydramnios
- pregnancy induced hypertension
- anaemia
- antepartum haemorrhage
What are the labour complications associated with twins?
- PPH increased (*2)
- malpresentation
- cord prolapse, entanglement
How do you manage multiple pregnancies?
- rest
- ultrasound for diagnosis + monthly checks
- additional iron + folate
- more antenatal care (e.g. weekly > 30 weeks)
- precautions at labour (e.g. 2 obstetricians present)
- 75% of twins deliver by 38 weeks, if longer most twins are induced at 38-40 wks
A 26-year-old primigravida presents at 39 weeks with rupture of membranes and bleeding. She describes a flood of cloudy fluid followed by continuous vaginal bleeding. She is very anxious but denies any localised pain or tenderness. Her pregnancy has so far been uncomplicated, but she has not attended her antenatal scans. Cardiotocography indicates bradycardia and late decelerations. What is the most likely diagnosis?
Vasa praevia
What is the classic triad of vasa praevia?
Rupture of membranes followed by painless vaginal bleeding and fetal bradycardia.
What are the requirements for instrumental delivery?
FORCEPS:
- Fully dilated cervix generally the second stage of labour must have been reached
- OA position preferably OP delivery is possible with Keillands forceps and ventouse. The position of the head must be known as incorrect placement of forceps or ventouse could lead to maternal or fetal trauma and failure
- Ruptured Membranes
- Cephalic presentation
- Engaged presenting part i.e. head at or below ischial spines the head must not be palpable abdominally
- Pain relief
- Sphincter (bladder) empty this will usually require catheterization
N.B. There must also be a clear indication for instrumental delivery
What are the indications for a forceps delivery?
- fetal distress in the second stage of labour
- maternal distress in the second stage of labour
- failure to progress in the second stage of labour
- control of head in breech deliver
A 31-year-old female (P0 G1) is 30 weeks pregnant. She has recently been informed that her baby is in the breech position. A consultant has discussed the possible options with her, which include the external cephalic version (ECV). She wants to know when is the earliest time she can be offered ECV.
36 weeks for first baby
37 weeks for multiparous
Which of the following foods should be avoided in pregnancy?
Cooked liver Cottage cheese Cooked chicken Natural yoghurt Cooked crabmeat
Liver should be avoided in pregnancy as it contains high levels of vitamin A, a teratogen.
A 35-year-old lady on the labour ward developed a primary postpartum haemorrhage (PPH) 4 hours after giving birth. After appropriate resuscitation, she was examined and uterine atony identified as the cause. Pharmacological management was thus commenced, but without success. What is the most appropriate initial surgical intervention?
Intrauterine balloon tamponade
A 33-year-old woman who is 35 weeks pregnant presents to the Emergency Department with severe continuous abdominal pain. She had some vaginal bleeding an hour ago but this has mostly stopped now, with only a small amount of bloody discharge remaining. She is pale and clammy and obstetric examination reveals a firm, woody uterus which is very tender. Her pulse is 102bpm and her blood pressure is 98/65 mmHg. What is the most likely diagnosis?
Placental abruption
A hepatitis B serology positive woman gives birth to a healthy baby girl. The mother is surface antigen positive. What treatment should be given to the baby?
- Hep B vaccine and 0.5 millilitres of HBIG within 12 hours of birth
- further hepatitis vaccine at 1-2 months and a further vaccine at 6 months
Why is Migraine with aura is a complete contraindication to using the combined oral contraceptive pill?
due to an increased risk of ischaemic stroke
What are the causes of primary amenorrhoea?
- Constitutional delay i.e. a late bloomer, has secondary sexual characteristics
- Anatomical i.e. mullerian agenesis (patient develops secondary sexual characteristics and has variable absence of female sexual organs)
- Imperforate hymen (characterised by cyclical pain and the classic bluish bulging membrane on physical examination)
- Transverse vaginal septae (characterised by cyclical pain and retrograde menstruation)
- Turner syndrome (XO chromosome)
- Testicular feminisation syndrome (XY genotype, no internal female organs)
- Kallmann syndrome (failure to secrete GNRH)
What are the causes of secondary amenorrhoea?
- Pregnancy
- Patient is using contraception
- Menopause
- Lactational amenorrhoea
- Hypothalamic amenorrhoea (suppression of GnRH due to stress, excessive exercise, eating disorder)
- Endocrinological (hyperthyroidism, polycystic ovary disease, Cushing’s syndrome, hyperprolactinaemia, hypopituitarism)
- Premature ovarian failure (autoimmune, chemotherapy, radiation therapy)
- Asherman’s syndrome (iatrogenic intrauterine adhesions/cervical stenosis)
What are the causes of delayed puberty with short stature?
- Turner’s syndrome
- Prader-Willi syndrome
- Noonan’s syndrome
What are the causes of delayed puberty with a normal stature?
- polycystic ovarian syndrome
- androgen insensitivity
- Kallman’s syndrome
- Klinefelter’s syndrome
