O&G Flashcards
Components of a gynae hx
Personal details
PC
Specific gynaecological questions
Past obstetric hx
Past medical hx
Systems r/v
DHx: allergies, penicillin and latex
FHx
Personal/Social hx
PC in G
SOCRATES
NOTEPAD
Impact on QoL
Previous consultations
Order multiple PCs in order of severity/impact on life
Menstrual questions in G Hx
FMP
How often, how many days from the first day of bleeding to the next first day?
How long does it last? (/28)
Is it regular or irregular
Heavy (number of pads, flooding, presence of clots)
Is it or the days leading up to it painful
IMB?
PCB?
Vaginal discharge- characterise
Does she experience premenstrual tension?
When was her LMP?
If post-menopausal, has there been PMB?
Sexual/contraceptive questiosn in G
Sexually active?
Painful- penetration (superficial dyspareunia) or deep inside (deep), during and or after (delayed)
What contraceptive does she use and has she used in the past?
Cervical smear questions in G
When was her last smear
Ever had an abnormal smear?
What was done?
Cervical screening
Every 3 years between 25 and 49
Every 5 years between 50 and 64
Not performed after 64 unless never screened or hx of recent abnormal tests
Urinary/prolapse questions in G
Frequency (normal is 4-7pd)
Nocturia
Urgency
Leak urine, including when asleep (nocturnal enuresis), if so how severe is it and with what is it associated (e.g. coughing, lifting/straining, urgency)
Dysuria?
Haematuria
Dragging sensation or feel a mass in or at the vagina?
Past obstetric hx in G
Have you ever been pregnant?
If yes ask about previous pregnancies in chronological order
Ask how infant was born, weight and how the infant is now. Name
Any major complications in pregnancy or labour?
PMHx in G
Previous gynaecological operations
Ask about DVT, DM, lung and CHD, HTN, jaundice etc as in other medical histories
Systems R/V in G
CV, Resp, Neuro.
Specifically ask about urinary and GI symptoms
FHx in G
FHx of breast, ovarian carcinoma?
DM?
VTE
CHD
HTN
Personal/social history in G
Smoke
ETOH
MarriedStable relationship
Support at home?
Where does she live and what sort of accomodation
Allergies in G
Ask specifically about penicllin and latex
Abdo exam in G
General examination: seek the systemic effects of gynaecological problems and assess general health.
Appearance and weight. T. BP. Pulse and possible anaemia, jaundice or lymphadenopathy.
Comfortably on back with head on pillow. Exposed from xiphisternum to pubic symphysis.
EMPTY BLADDER
Inspect: scars, body hair distribution, irregularities, striae and hernias
Palpate: tenderness, palpate the abdomen generally looking for masses. Then palpate specifically looking for masses from above the umbilicus down to the pubic symphysis. If masses are present, do they arise from the pelvis (can you get below them)
Percuss: look for shifting dullness
Auscultate: BS
Vaginal Examination
Rectal examination
Vaginal examination in G
Privacy, explain, use bathroom. Chaperone- name documented in the notes. Use lubricating jelly.
Inspect: vulva and vaginal orifices
Digital bimanual examination
Cusco’s speculum examination
Sim’s speculum examination
Digital bimanual exmaination
Assesses pelvic organs
Left hand on aboomen above the pubic symphysis and pushed down so the organs are palpated
Two fingers inserted into the vagina
Uterus: normally the size and shape of a small pear. Size, consistency, regularity, mobility, anteversion/retroversion and tenderness
Cervix: hard or irregular?
Adnexa: lateral to the uterus on either side. Tenderness and size and consistency of any amss assessed. Separate from the uterus
Pouch of Douglas: uterosacral ligaments should be palpable: even, irregular or tender, mass?
Cusco’s speculum
Allows inspection of the cervix and vaginal walls.
NB anteverted uterus.
Look for ulceration, spontaneous bleeding or irregularities.
Cervical smear
Slowly withdraw partly closing speculum to allow inspection of the vaginal walls to the introitus and rotate as retract
Sim’s speculum
Allows better inspection of the vaginal walls and te prolapse.
Patient in left lateral position.
Rectal examination
Appropriate if posterior wall prolapse, to distingusih between an enterocoele and a rectocoele and in assessing malignant cervical disease
May be necessary if a woman complains of cyclical rectal bleeding- ?rectovaginal endometriosis
What is thelarche and when does it begin?
Adrenarche?
Menarche
What controls secondary sexual characteristics?
Beginning of breast development: 9-11 y
Growth of pubic hair (11-12)
13y
Oestrogen
D1-4 mensturation
Endometrium is shed as hormonal support is withdrawn, myometrial contraction also occurs
D5-13 proliferative phase
GnRH stimulate LH and FSH which induce follicular growth
Follicle produces oestradiol and inhibin which suppress FSH.
As oestradiol level rise and reach their maximum they cause a +ve feedback on the hypothalamus/pit and cause LH surge.
Ovulation occurs 36 hours after the LH surge
Oestradiol also promotes endometrial proliferation
D14-28 Luteal/secretory phase
Follicle becomes corpus luteum, produces oestradiol but relatively more progesterone, which peaks d21-28
This induces secretory changes in hte endometrium.
Towards the end of the luteal phase, the corpus luteum starts to fail if the egg hasn’t been fertilised and oestradiol/progesterone levels fall.
This decline in hormonal support causes the endometrium to break down, leading to menstruation and the restart of the cycle
What can be used to delay menstruation and why?
Continuous administration of exogenous progesterone as it maintains the secretory endometrium
Normal mensturation cut offs
Menarche <16y
Menopause >45y
Mensturation <8d
Blood loss <80ml
Cycle length 23-25
No IMB
Menorrhagia
Heavy menstrual bleeding
IMB
Bleeding between periods
Irregular periods
Periods outside of the range of 23-35d with a variability of >7d between the shortest and longest cycle
Secondary amenorrhoea
Periods stop for 6m or more.
Oligomenorrhoea
Irregular periods, >35d-6m
PMB
Bleeding 1 year after the menopause
Dysmenorrhoea
Painful periods
Premenstrual syndrome
Psychological and physical symptoms worse during the luteal phase
Menorrhagia def
Excessive bleeding in otherwise normal menstrual cycle
Excessive menstrual blood loss that interferes with the woman’s physical, emotional, social and material QoL +/- other smyptoms
>80mL (corresponds to the maximum amount that a woman on a normal diet can lose without becoming Fe deficient)
Aetiology and epidemiology HMB (menorrhagia)
Rare causes of HMB
1/3rd women complain of HMB
Fibroids= 30% HMB
Polyps= 10% HMB
Thyroid disease, haemostatic disorders and anticoagulant therapy.
What differentiates bleeding in malignancy from HMB?
Bleeding in malignancy tends to be irregular
Hx in menorrhagia
Ex in menorrhagia
Menstrual calendar. Flooding and passage of large clots. Contraception.
Anemia. Pelvic signs often absent. Irregular enlargement of the uterus suggests fibroids.
Tenderness without enlargement suggests adenomyosis.
Ix in menorrhagia
FBC: to check patient’s Hb
TFTs/Coagulation: to exclude systemic causes (if there are factors indicating this may be the case)
Transvaginal USS of hte pelvis: to exclude local organic causes (endometiral thickness, exclude fibroid, mass and detect larger intrauterine polyps (+/- biopsy or hysterectomy if USS is inconclusive)
Indications for USS biopsy in HMB
Endometrial thickness >10mm
?Polyp
Woman >40 with recent onset menorrhagia
Treatment failure/ineffective treatment
Before insertion of IUS if cycle not regular
Prior to endometiral ablation/diathermy as tissue will not be available for pathology
If abnormal uterine bleeding has resulted in acute admission
Mx of HMB
Rx
Sx
Exclude pathology
Depends on woman’s contraceptive needs.
1st line= intrauterine system- not option for woman who wishes to conceive . 90% reduction in blood loss.
2nd line: antifibrinolytics (tranexamic acid) taken during menstruation only. 50% reduction in blood loss
NSAIDs (mefanamic acid) inhibit prostaglandin synthesis reducing blood loss by around 30%. NB also useful for dysmenorrhoea.
Combined OCP- lighter mesntruation but less effective if pelvic pathology is present.
3rd line: progestogens, high dose orally or by IM will cuase amenorrhoea but bleeding follows withdrawl.
GnRH agonists: produces amenorrhoea. Duration is limited to 6 months unless add-back HRT used.
Sx
Hysterposcopic:
Polyp removal (if caused by local abnormalities)
Endometrial ablation technique
Transcervical resection of fibroid (TCRF).
More radical:
Myomectomy
Hysterectomy:
Uterine artery ambolisation
Features of IUS
Progestogen impregnated IUD is a coil that reduces menstural flow with fewer Ses.
Highly effective alternative to medical and surgical treatment.
It is contraceptive and also provides the progestogen component of HRT.
Distinguish from Cu IUDs that may increase menstrual loss
Sx approaches to HMB
Hysteroscopic
More radical
Hysterposcopic:
Polyp removal (if caused by local abnormalities)
Endometrial ablation technique: removal/destruction of endometrium- satisfcation is less than with hysterectomy. Most appropriate in older women with pure menorrhagia. Non sterilising.
Transcervical resection of fibroid (TCRF).
More radical:
Myomectomy: removal of fibroids from the myometrium: open or laparoscopic (<4fibroids, <8cm diameter). Used if fibroids causing symptoms but fertility is still required. GnRH agonists can be used to reduce size of fibroids first.
Hysterectomy: last resort.
Uterine artery ambolisation: treats menorrhagia for women who want to retain their uterus.
Rx management of HMB
1st line: IUS
2nd line: antifibrinolytics, NSAIDs, OCP
3rd line: progestogens, GnRH analogues
When are anovulatory cycles common
Just after menarche and before the menopause
What are some causes of IMB/oligomenorrhoea
Anovulatory
Pathological:
Non malignant
Fibroids, uterine and cervical polyps, adenomyosis, ovarian cysts and chronic pelvic infection.
Malignant:
Overain, cervical and most particulalry endometrial
Ix in IMB/oligomenorrhoea
FBC: to asssess the effect of blood loss
Ix to exclude malignancy:
Cerbical smear
USS of the cavity for women >35 with irregular/IMB and in younger women if treatment has failed, will also detect uterine fibroid or ovarian mass.
Endometrial biopsy
Mx of Oligomenorrhoea/IMB
Rx
Rx where no anatomical cause is detected
1st line: IUS or OCP.
2nd line: 2nd line Rx for menorrhagia
Sx:
Cervicaly polyp can be excised.
Definition of Amenorrhoea
Absence of menstruation
1o= hasn’t started by 16, may be manifestation of delayed puberty in which secondary sexual characteristics are not present by age 14. If 2o sexual characteristics are present, problem of menstrual outflow is more likely.
2o= 6m without menstruation in previosly normal mensturation
Oligomenorrhoea: >35d-6m
Classification of causes of amenorrhoea
Physiological
Pathological
Physiological causes of amenorrheoa
Pregnancy, after the menopause, during lactation, constitutional dleay
Pathological amenorrhoea
Hypothalamus
Pituitary
Adrenals
Ovary
Uterus
Outflow Tract
Drugs
Hypothalamus: Hypothalamic hypogonadism.
Pituitary: hyperprolactinaemia; rarer= other pituitary tumours, Sheehan’s syndrome
Adrenal/Thyroid; hypo/hyperthyroid. CAH/virilising tumours
Ovary:
- Acquired: PCOS, premature menopause, rare virilizing tumours*
- Congnetial: Turner’s (most common), other forms of gonadal dysgenesis*
Outflow problems:
- Congenital: Primary amenorrhoea with normal secondary sexual characteristics. Imperforate hymen and transverse vaginal septum. Rokitansky’s syndrome*
- Acquired: Usually secodary. Cervical stenosis, Asherman’s syndrome, endometrial resection or ablation*
Drugs: e.g. antipsychotics, GnRH analgoues, progestogens
Hypothalamic hypogonadism
Mx
Common, usually due to psychologica, lowe weight or excessive exercise
Tumours are a rare cause and may be excluded by MRI.
GnRH and FSH/LH and oestradiol are reduced.
Bone density may be reduced if there has been prolonged hypo-oestrogenism.
Oestrogen replacement (+progesterone for endometrial protection) i.e. OCP/HRT
Hyperprolactinaemia
Mx
Usually caused by pituitary hyperplasia or adenomas
Rx: bromocriptine, carbegoline or Sx
Affect of hypothyroidism on prolactin levels
Hyperprolactinaemia leading to amenorrhoea
Turners Syndrome
45 XO
Short stature, poor secondary sexual characteritsics, normal intelligence.
Most common congenital ovarian cause of amenorrhoea
Haematoclpos
Haematometra
Accumulation of menstrual flow in the vagina
or uterus
To outflow tract obstruction by either imperforate hymen or transverser vaginal septum
Rokitansky’s syndrome
Mullerian agenesis
Congential malformation characterised by failures of Mullerian duct development resulting in a missing uterus and variable degrees of vaginal hypoplasia.
Mullerian agenesis is the aetiology in 15% of cases of primary amenorrhoea
Asherman’s syndrome
Consequence of excessive curettage in ERPC performed following miscarriage or delivery.
Asherman’s syndrome, also known as intrauterine adhesions, is a condition where the cavity of the uterus develops scar tissue (adhesions).
Mx of osteoporotic risk in primary amenorrhoea
Treat underlying cause
Asses # risk. Correct any VitDD and ensure adequate Ca intake.
Consider HRT.OCP if amenorrhoea persists for more than 12m
What blood results suggests premature ovarian failure?
Persistently elevated FSH and LH in woman younger than 40y/o
What factors are suggestive of Asherman’s syndrome
Recent Hx of uterine or cervical Sx or severe pelvic infection (endometritis)
Definition of PCB
Vaginal bleeding following intercourse that is not menstrual loss
Except for first intercourse, this is always abnormal and cervical carcinoma must be excluded.
Aetiology of PCB
When the cervix is not covered in health suqamous epithelium it is more likely to bleed after mild trauma.
What are the most common causes of PCB
Cervical ectropions
Benign polyps
Invasive cervical cancer
(cervicitis, vaginitis (atrophic)
Mx of PCB
Cervical inspection + smear.
Polyp- avulsed and sent to histology.
Ectropion can be frozen with cryotherapy.
Abnormal smear-> colposcopy
Def dysmenorrhoea
Painful menstruation. Associated with high PG levels in the endometrium and is due to contraction and uterine ischaemia.
Causes of dysmenorrhoea
Primary: when no orgnaic cause is found.
Secondary: when pain is due to pelvic pathology. Fibroids, adenomyosis, endometriosis, PID, ovariant tumours,
What differentiates between primary and secondary dysmenorrhoea?
Primary usually coincides with the start of mensturaiton and is very common, particularly in adolescents. Responds to NSAIDs and ovulation suppresions e.g. OCP. Pelvic pathology more likely if medical treatment fails.
Secondary: pain often precedes and is relieved by onset of menstruation. Deep dyspareunia and menorrhoagia or irregular mensturation are common. P USS and laparoscopy useful.
Def precocious puberty
When menstruation occurs before the age of 10 and/secondary sexual characteristics are evident before age of 8.
Causes of precocious puberty
Central
Ovarian/adrenal
In 80% no pathological cause is found.
Central causes: increased GnRH secretion: meningitis, encephalitis, CNS tumours, hydrocephaly and hypothyroieism may prevent normal prepuberatl inhibition of hypothalamic GnRH release. Rx:
Ovarian/adrenal causes: increased oestrogen secretion: hormone producing tumours of the ovary/adrenal glands. Regression occurs after removal. McCune-Allbright syndrome.
McCune-Albright syndrome
Bone and ovarian cysts
Cafe au lait sports
Precocious puberty
Mx of precocious puberty
GnRH agonists used to inhibit sex hormone secretion causing regression of secondary sexual health characteristics
For increased oestrogen secretion cypropterone acetate (antiandrogenic progestogen) can be used
CAH in genetic female
Aetiology
Features
Rx
Recessive inheritance.
Defective cortisol production usually as a result of 21-hydroxylase deficiency.
ACTH exess causes incresed androgen production.
Presents at birth with ambiguous genitalia. GC deficiency may cause Addisonian crisis.
May present at puberty with enlarged clitoris and amenorrhoea.
Cortisol and MC replacemant.
AIS in genetic male
Occurs when male has cell receptor insensitvity to androgen which are peripherally converted to oestrogens.
Individual appears to be female.
Presentation is with amenorrhoea.
Uterus absent, rudimentary testes present which are removed due to possible malginant change.
Premenstrual syndrome
Psychological, behavioural and physical symptoms that are experienced on a regular basis during te luteal phase of te mesntrual cycle and often resolve by the end of menstruation.
Hx in PMS
Cyclical nature rather than symptoms themselves that enable diagnosis.
Tnesion, irritability, aggressoin, depression, loss of control.
Bloatedness, GI upset, Breast pain
Ex in PMS
Menstrual diaries.
Psychological evaluation as depression and neurosis may present at PMS
Mx of PMS
SSRIs either continuously or intermittently in the second half of the cycle.
OCP.
GnRH agonists and add back oestrogens.
Supplements: evening primrose oil is good for breast tenderness. Pyridoxine 50mg BD can help but may cause neuropathy in excess
Vitex agnus-castus extract.
Anatomy of the uterus
Superiorly: fundus
Laterally to fundus= cornu which is the communication with the fallopiam tubes
Supported at the inferior end by the uterosacral and cardinal ligaments.
Anteverted in 80%
Wall is made of smooth muscle which is lined by endometrium (glandular epithelium)
Serosa= peritoneum posteriorly. Also covers the uterus down to the bladder. Laterally the peritoneum is continuouous with the broad ligaments that run between the uterus and pelvic side wall. These are continuous with the fallopian tubest and round ligaements suepriorly and inferiroly contain the uterine blood supply, ureturs and parametrium
Uterine blood supply
Lymph drainage?
From uterine arteries
Pass over the ureturs laterally to the cervix. Pass inferiroly and superiorly supplying the myometrium and endometrium.
Anastamose at the cornu with the ovarian blood supply.
Inferiorly anastamose with the blood supply to the upper vagina.
Lymph to EI Nodes.
Blood supply of the dnometrium
Spiral and basal arterioles.
Spiral= important in mensturation and nourishment of growing fetus.
After ovulation under the influence of progesterone during the luteal phase the glands swell and blood uspply increases.
Fibroids definition
Leiomyomata, bening tumours of the myometrium
25% of wmeon.
More common near menopause, Afrocaribbean and in FHx.
Less common in parous women and those who have taken OCP or injectable progestogens
Fibroid sites
Subsersal
Intramural
Submucosal may form intracavity polyps
Aetiology of fibroids
Oestrogen and progesterone dependant
Fbiroids regress after menopause
Hx in fibroids
50% asymptomatic and discovered at pelvic/abdo exams. Symptoms relate to site rather than size
Menstrual problems (30%): menorrhagia, unchanged timing of menses. IMB may occur if fibroid is submucosal or polypoid.
Erratic bleeding
Pain: dysmenorrhoea, seldom cause pain unless torsion, red degeneration or sarcomatous chnage occur
Pressure effects: large fibroids pressing on bladder can cause frequency/urinary retnetion.
Hydronephrosis due to ureteric compressoin.
Fertility impairment due to obstruction of the tubal ostia or submucous fibroids preventing implamantation. Intramural fibroids that aren’t distorting the cavity can also reduce fertility through an unknown mechanism.
Ex in Fibroids
Solid mass palpable on pelvic/abdo examination which arises from pelvis and is continuous with the uterus.
Multiple small fibroids cause irregular knobbly enlargement of the uterus.
Cx of fibroids
Enlargement: can be very slow. Often stop and calcify after menopause although HRT may stimulate further growth. Enlarge in pregnancy. Pedunculated fibroids may undergo torsion
Degenerations: result of inadequate blood supply.
Red degeneration (more common in pregnancy): pain + uterine tenderness, haemorrhage and necrosis
Hyaline/cystic degeneration the fibroid is soft and partly liquefied.
Malignancy: 0.1% are leiomyosarcomata. may be malignant change or de novo transformation of myometrium
Fibroids in pregnancy
Premature labour
Malpresentations
Transverse lie
Obstructed labour
PPH
Red degeneration
Pedunculated fibroids may tort in post partum period
Ix in Fibroids
Dx: USS bu MRI/Laparoscopy may be required to distinguish from ovarian mass
Adenomyosis can exist as a fibroid like mass (MRI ddx)
Hysteroscopy/hysterosalpingogram to assess distortion of the uterine cavity- if fertility is an issue.
To establish fitness: Hb may be low due to vaginal bleeding, may also be high
Why may Hb be high in fibroids
They can secrete EPO
Mx of fibroids
Asymptomatic with small/slow-growing: no treatment
Large fibroids that are not removed should be serially measured by examination or USS.
Menorrhagia associated fibroids:
<3cm without distortion of uterine cavity, determine whether woman wants to conceive and use treatment options for menorrhagia: LNG-IUS. Tranexamic, NSAID or OCPs
Norethisterone/Depoprovera (Progestetone)
>3cm: refer: Sx intervention. In interim can try NSAIDs/Tranexamic acid.
Compressive symptoms: refer
Fertility/obstetric symptoms: refer
Sx treatment of fibroid
Hysteroscopic: fibroid polyp or small submucous fibroid can be resected. Pretreatment with GnRH agonist for 1-2m can shrink the fibroid, reduce vasculairy and thin the endometirum making resection easier and safer
Myomectomy: open or laparoscopic. NB heavy blood loss and small fibroids may be missed. Myomectomy performed if medical treatment has failed but preservation of reproductive function is required. Preceded by 2-3m of GnRH agonist. Perioperative injection of vasopressin into the myometrium reduces blood loss.
Adhesions can form at site of myomectomy which can reduce fertility if affecting the endometrial cavity or fallopian tubes. if the endometrial cavity is opened during myomectomy, C-section is indicated in future pregnancy due to risk of rupture.
Radical hysterectomy: Pretreatment with GnRH, common indication. Laparoscopic, vaginal or open.
Other treatmnents:
UAE
Ablation
Def adenomyosis
Prsece of endometirum and its underlying stroma in the myometrium.
Found in 40% of hysterectomy specimens.
Associated with endometriosis and fibroids. Symptoms subside postmenopausally.
NB in anedomyosis
Endometrial tissues grows into the myometrium. Occassionally may show varying degrees of atypia or invasion
Hx of adenomyosis
Ex of adenomyosis
Symptoms may be absent but painful, regular, heavy menstruation is common.
Uterus is mildly enlarged and tender
Dx of adenomyosis
Not easily diagnosed on USS but can be diagnosed on MRI
Mx of adenomyosis
IUS
OCP +/- NSAIDs may control the menorrhagia or dysmenorrhoea but hysterectomy often required.
Oestrogen dependant.
Endometritis
Secondary to STI, as a complication of surgery (C-section and intrauterine procedure) or because of foreign tissue e.g. IUD and RPC.
Infection in the postmenopausal uterus is commonly due to malginancy
Hx and Ex in enodemtritis
Tender uterus with pelvic and systemic infection
Pyometra
Pus accumulates in uterus and is unable to escape
Mx of endometritis
Antibiotics
ERPC
Intrauterine polyps
Small bening tumours that grow in to the uterine cavity. Most are endometrial although some come from submucous fibroid.
Often found in patients on tamoxifen for breast Ca.
Occassionally contian endometrial hyperplasia or carcinoma.
Dx at USS/hysteroscopy
What is the most common genital tract cancer?
Endometrial carcinoma
Epidemiology or endometrial carcinoma
Highest prevalence >60
15% occur premenopausally.
<1% <35y/o
Usually presents early.
Adenocarcinoma of columnar gland cells >90%. Rest is adenosquamous carcinoma- poorer prognosis
What increases the risk of endometrial carcinoa?
high oestrogen: progesterone
When oestrogen therapy is used unopposed by progestogens
Risk factors for endometrial carcinoma
Protective
Exogenous:
oestrogens without a progestogen
Tamoxifen (acts as an agonist in the postmenopausal uterus)
Endogenous:
Obesity
PCOS as it is associated with prolonged amenorrhoea.
Nulliparity
Late menopause
Ovarian granulosa cell tumours (oestrogen secreting)
Misc: DM, HTN. Lynch Type 2 syndrome: familal non-polyposis colonic, ovarian and endometrial carcinoma.
OCP and pregnancy
Premalignant disease in endoemtrial carcinoma
Cystic hyperplasia-> Endometrial hyperplasia with atypia
May cause menstrual abnormalities or PMB
Often coexists (40%) with carcinoma elsewhere in the uterine cavity
Hx in endoemtrial carcinoma
Ex in endometrial carcinoma
PMB: 10% risk of carcinoma. Likelihood that PMB is due to cancer rather than unknown or benign causes increases with age. Premenopausal patients have irregular or IMB or occasionally recent-onset menorrhagia. Cervical semar may contain abnormal columnar cells.
Ex: pelvis often appears normal. Atrophic vaginitis may coexist
Spread of endometrial carcinoma
Through the moymetrium to the cervix and upper vagina. May be ovarian involvement.
Lymphatic spread to pelvci then para-aortic nodes.
Staging is surgical and histological and includes LN involvement
Endometrial carcinoma staging
Only possible post hysterectomy
1: lesions confined to uterus
A: <0.5 myometrial invasion.
B: >0.5 myometrial invasion
Stage 2: as above but in cervix too
Stage 3: Tumour invades through the uterus.
A: invades serosa or adnexae
B: vaginal/parametrial involvement
Ci: pelvic node involvement
Cii: para-aortic involvement
Stage 4: further spread
A: bowel or bladder
B: distant mets
Dx of endometrial carcinoma
USS/hysteroscopy- biopsy required to make diagnosis
MRI performe din all patients or if spread is suspected due to other symptoms.
CXR to exclude extrapulmonary sprad
FBC, RFT, glucose testing.
ECG
Treatment of endometrial carcinoma
Sx: 75% present with Stage 1. Hysterectomy and bilatreal salpingooophorectomy (BSO) is performed either open or laparoscopically.
Routine lymphadenectomy is not beneficial in early stage disase.
RTx: External beam radiography used following hysterectomy for those at high risk of LN involvement but not in those with early stage disease. RFs: deep myometrial spread, poor hisotlogy or grade, cerbical stromal involvement.
Vaginal vault therapy.
Other: Progestogens seldom used. CTx may have a role in high risk early stage and advanced disease.
Px for endometrial carcinoma
Poor pxic factors
Recurrency common at the vaginal vault.
Older age
Advanced stage
Deep myometrial invasion in Stage 1 and 2
High tumour grade
Adenosquamous hisotlogy
Uterine sarcomas
3 categories
Rare
Leiomyosarcomas: malignant fibroid
Endometrial stromal tumours: most common in perimenopausal woman
Mixed mullerian tumours: derived from the embryological elements of the uterus and more common in old age.
Usually present with irregular/PMB or rapid painful enlargement of a fiborid
Treatment with hysterectomy.
RTx/CTx can be used adjuvantly but 5 year survival is 30%
Px for Endometrial Ca by stage
1
2
3
4
1: 85
2: 70
3-4: 50
4:25
Overall 75
First line treatment for dysmenorrhoea?
NSAIDs as they will inhibit PG synthesis, one of the main cuauses of dysmenorrhoea pains.
First line treatment in urinary incontinence
Urge
Stress
Urge: bladder retrianing
Stress: pelvic floor muscle training
Causes of urinary incontinence
Overactive bladder/urge incontinence: due to detrusor overactivity
Stress incontinence: leaking small amounts when coughing or laughing
Mixed incontinence
Overflow incontinence: due to bladder outlet obstruction e.g. prostate englargement
Ix of urinary incontinence
Bladder diaries (>3d)
Vaginal examination to exclude cystocele
Urine dipstick and culture
Mx of urge incontinence
Conservative: bladder rtraining (lasts for minimum of 6w, idea is to gradually increase the intervals between voiding)
Rx: Bladder stabilising drugs: antimuscarinic is first line.
Sx: sacral nerve
Mx of stress incontinence
Pelvic floor muscle training (minimum of 3 months)
Srugical procedures e.g. retropubic mid-uretthral tape procedures
Common causes of vaginal d/c
Less common causes
Physiological
TV
BV
Gonorrhoea, Chlamydia (rarely PC), ectropion, foreign body, Cervical Ca
Features of Candida d/c
Cottage cheese
Vulvitis
Pruritis
Features of TV d/c
Offesnive, yellow/green, frothy d/c
Vulvovaginitis
Strawberry cervix
Features of BV d/c
Offesnive, thin, white/grey, fishy d/c
What differentiates between ectopic and threatened miscarriage
Ix
Mild suprapubic pain at 10w
USS
What is the typical symptom of urogenital prolapse
Bearing down, heaviness, dragging sensation
Cervical excitation is seen in?
PID and ectopic pregnancy
What is the classical history of ectopic pregnancy?
Amenorrhoea
Abdo pain
Vaginal bleeding
In combination with shoulder tip pain- peritoneal bleed
What are the types of miscarriage?
Threatened
Missed (delayed)
Inevitabel
incomplete
Features of threatened miscarriage
Painless vaginal bleeding before 24w (typically 6-9w)
Bleeding often less than mensturation
Cervical os is closed
Complicates 25% of pregnancies
Features of missed (delayed) miscarriage
A gestational sac which contains a dead fetus before 20w without symptoms of expulsion
Mother may have light vaginal bleeding/discharge and symptoms of pregnancy which disappear
Typically painless
Cervical os is closed
When the gestational sac is >25mm and no embryonic/foetal part can be seen it is sometimes described as a blighted ovum or anembryonic pregnancy
Features of inevitable miscarriage
Heavy bleeding with clots and pain
Cervical os open
Features of incomplete miscarriage
Not all products of conception have been expelled
Pain and vaginal bleeding
Cervical os open
Features of complete miscarriage
Spontaenous abortion with expulsion of the entire foetus through the cervice
Pain and uterine contractions stop after the foetus has been expelled
Dx: USS shows an empty uterus
In a female with PMB what is the diagnosis
A 72-year-old nulliparous female presents with post menopausal bleeding. She reports that her last cervical screening was 14 years ago. On examination she is found to be obese and hypertensive. What is the most important diagnosis to rule out?
Vaginal squamous cell carcinoma
Cervical squamous cell carcinoma
Endometrial adenocarcinoma
Atrophic vaginitis
Leiomyosarcoma
In a female with postmenopausal bleeding (PMB), the diagnosis is endometrial cancer until proven otherwise.
Although all the options can result in PMB, the question states the most important one to rule out, which in this case would be endometrial adenocarcinoma due to its strong association with PMB and the importance of an early diagnosis prognostically.
In addition, the patient in this question has two risk factors for endometrial adenocarcinoma - hypertension and obesity. Other risk factors include diabetes mellitus, polycystic ovarian syndrome, tamoxifen use, late menopause and high levels of oestrogen.
Ix of amenorrhoea
Exclud pregnancy
Gonadotrophins: low levels indicate hypothalamic cause whereas high levels suggest an ovarian problem (e.g. premature ovarian failure)
Prolactin
Androgen levels: raised may be seen in PCOS
Oestradiol
TFTs
What are the key signs and symptoms of endometriosis?
Cyclical abdo pain and deep dyspareunia, may be associated with fertility problems
What are the classifications of ovarian cysts?
Physiological: follicular, corpus luteum cyst
Benign germ cell tumours: dermoid cyst
Benign epithelial tumours: serous cystadenoma, mucinous cystadenoma
Featrues of follicular cysts
Commonest type of ovarian cyst
Due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
Commonly regress after several menstrual cycles
Features of corpus luteum cyst
If pregnancy doesn’t occur corpus luteum cyst usually breaks down and disappears, if this doesnt occur the corpus luteum may fill with blood or fluid and form a cyst.
More likely to present with intraperitoneal bleed than physiological cysts.
Features of dermoid cysts
Mature cystic teratomas: lined with epithelial tissue
Most comon benign ovarian tumour in woman under 30 years.
Bilateral in 10-20%
Usually asymptomatic
Torsion is more likely than with other ovarian tumours
Serous cystadenoma
Most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer
Bilateral in around 20%
Mucinous cystadenoma
Second most common benign epithelial tumour
Large and amy become massive
If ruptures may cause pseudomyxoma peritonei
Pseudomyxoma peritonei
Pseudomyxoma peritonei (PMP) is a clinical condition caused by cancerous cells (mucinous adenocarcinoma) that produce abundant mucin or gelatinous ascites.[1] The tumors cause fibrosis of tissues and impede digestion or organ function, and if left untreated, the tumors and mucin they produce will fill the abdominal cavity. This will result in compression of organs and will destroy the function of colon, small intestine, stomach, or other organs. Prognosis with treatment in many cases optimistic,[2] but the disease is lethal if untreated, with death by cachexia, bowel obstruction, or other types of complications.
Disease most commonly caused by appendiceal primary cancer
A 22 year-old woman and her male partner present to their GP as they been unsuccessfully trying to conceive for 4 months. Her periods have been regular and there is no obvious cause in her history. What is the most appropriate next step in her management?
Refer the patient for a laparoscopy and dye test
Address how the couple are having sexual intercourse and reassure the patient
Refer the patient for a basal temperature test
Refer the patient for a luteal phase progesterone test
Refer the patient’s partner for semen analysis
A healthy couple can expect to take up to one year to conceive. Investigations are therefore usually performed after one year of regular attempts to conceive. It may however be prudent to address any mechanical reasons that are preventing the couple from conceiving, hence the sexual intercourse history.
Epidemiology of infertility
Infertility affects around 1 in 7 couples. Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years
What are the main causes of infertility?
Basic Ix
Male factor (30%)
Unexplained (20%)
Ovulation failure (20%)
Tubal damage (15%)
Other causes (15%)
Semen analysis
Serum progesterone 7d prior to expected next period
<16nmol/l serum progerstogen
Repeat, if consistently low refer to specialist
16-30nmol/l serum progestogen
Repeat
>30mnol/l serum progestogen
Indicates ovulation
Key counselling points to couples trying to conceive
Folic acid
BMI 20-25
Advise regular sexual intercourse very 2-3d
Smoking/drinking advice
Mx of abnormal cervical smears (around 5% of smears)
Moderate dyskaryosis
Severe dyskaryosis
Suspected invasive cancer
Inadequate
Moderate dyskaryosis: consistent with CINII, refer to colposcopy
Severe dyskaryosis: Consistent with CINIII refer to colposcopy
Suspected Invasive Ca: refer for urgent colposcopy
Inadequate: repeat smear, if 3 inadequate samples-> colposcopy
High risk HPV subtypes
16, 18 & 33
What are the causative organisms of PID?
Chlamydia- most common
N. Gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
What are the features of PID?
Lower abdo pain
Fever
Deep dsypareunia
Dyuria and menstrual irregularities may occur
Vaginal or cervical discharge
Cervical excitation
Ix of PID
Screen for chlamydia and Dx
Mx of PID
Rx: oral ofloxacin + metronidazole
or
IM ceftriaxome and oral doxy and oral metronidazole
In mild cases of PID, IUD may be left in, however more recent guidelines suggest that removal of IUD may be assocaiteed with better ST outcomes
Cx of PID
Infertility
Chronic pelvic pain
ectopic pregnancy
Def of PID
Inflammation/infection of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surroudning peritoneum. Usually as a result of ascending infection from the endocervix.
What is the action if a cervical smear shows borderline or low grade dyskaryosis?
If a cervical smear shows borderline or mild (low grade) dyskaryosis, the laboratory will also test the cytology sample for human papillomavirus (HPV). If HPV is found, the woman will be referred for colposcopy within 8 weeks. If HPV is not found, the woman will be returned to the routine screening programme
What are the USS features of adenomyosis
Imaging reveals a “boggy” uterus with subendometrial linear striations
What is Amsel’s criteria for the Dx of BV?
3/4 of:
thin, white homogenous d/c
clue cells on microscopy: stippled vaginal epithelial cells
Vaginal pH >4.5
Positive whiff test
A 53-year-old woman presents with urgency and frequency. Two weeks ago she consulted with a colleague as she felt ‘dry’ during intercourse. She has been treated for urinary tract infections on multiple occasions in the past but urine culture is always negative. Her only medication is continuous hormone replacement therapy. A vaginal examination is performed which shows no evidence of vaginal atrophy and no masses are felt. An ultrasound is requested:
Both kidneys, spleen and liver are normal size. Outline of the bladder normal. 5 cm complex ovarian cyst noted on left ovary. Right ovary and uterus normal
What is the most appropriate next step?
Refer for urodynamics
Pelvic floor muscle training
Trial topical oestrogen
Urgent referral to gynaecology
Refer for bladder retraining
Any ovarian mass in a post-menopausal woman needs to be investigated.- refer to gynae
Initial management for ovarian enlargement
What are the possible reports
USS
Unilocular- more likely to be physiological or benign
Complex- multilocular- more likely to be malignant
Mx of ovarian enlargement.
Depends on age and symptoms.
Premenopausal: conservative approach esp <35 as malignancy is less common. If the cyst is small (<5cm) and reported as simple- likely to be benign. Repeat USS in 8-12 w
Postmenopausal: physiological cysts are unlikely
any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment
How can the risk of ovarian malignancy be calculated?
Serum Ca125
USS
Menopausal findigns
Definition of premature ovarian failure
Premature menopausal symptoms
Elevated gonadtrophin levels
<40y/o
Causes of premature ovarian failure
Idiopathic
Chemotherapy
Autoimmune
Radiation
Symptoms of premature ovarian failure
Climacteric symptoms: hot flushes, night sweats
Infertility
Secondary amenorrhoea
Raised FSH, LH
What is HRT?
Small dose of oestrogen combined with progestogen (in women with a uterus)
Side effects of HRT
Nausea
Breast tenderness
Fluid retention and weight gain
Potential Cx of HRT
Increaed risk of breast Ca (increased by addition of a progestogen)
Incresed risk of endometrial reduced by addition of a progestogen. Additional risk eliminated if a progestogen is given continuously.
Increased risk of VTE, increased by addition of a progestogen
Increased risk of stroke
Increased risk of IHD if taken more than 10 years after menopause
When does the risk of breast cancer in those taken HRT normalise?
After HRT has been stopped for 5 years
What are the features of chlamydia infection?
Asymptomatic in ~70% of women and 50% of men
Women: cervicitis (discharge, bleeding), dysuria
Men: urethral d/c, dysuria
Potential complications of chlamydia infection
Epididymitis
PID
Endometritis
Increased incidence of ectopic pregnancies
Infertility
Reactive arthritis
Perihepatitis (Fitz-Hugh Curtis Syndrome)
Dx of Chlamydia
NAAT
Urine: first void urine sample, vulvovaginal or cervical swab
Mx chalmydia
Doxycycline (7d) or azithromycin (1d)
If pregnant than erythromycin or amoxicillin
For women and asymptomatic men: all partners from 6 months should be contacted
For men: all partners from the 4 weeks prior to symptoms
Contacts should be treated presumptively
Anatomy of the cervix
2-3cm long made up predominantly of elastic connective tissue.
Attached posteriorly to the sacrum by the uterosacral ligaments and laterally to the pelvic wall by the cardinal ligaments.
Lateral to the cervix is the parametrium which contains conective tissue, uterine vessels and the ureturs
Lining of the endovervix
Lining of the ectocervix
What is the junction between these two types of cell?
Columnar (glandular) epithelium
Continuous with the vagina, covered in squamous epithelium
Squamocolumnar junction
What is the transformation zone
Clinical signficance?
Durign puberty and pregnancy, partial eversion of the cervix occurs.
The lower pH of the vagina causes the exposed area of clumnar epithelium to undergo metaplasia to squamous epithelium
Cells undergoing metaplasia are vulnerable to agents that induce neoplastic change and cervical carcinoma typically originates from this area.
Blood supply of the cervix
Lymph drainage
Upper vaginal branches of the uterine artery
Obturator and itnernal and external iliac nodes, then to common iliac and para-aortic nodes
What is the characteristic spread of cervical carcinoma?
Lymph and locally by direct invasion into the uterus, vagina, bladder and rectum
Features of cervical ectropion
In which people is it common?
Symptoms?
When the columnar epithelium of the endocervix is visible as a red area around the os on the surface of the cervix.
Due to eversion and is a normal finding in younger women
Those who are pregnant/taking the pill
Aysmtpomatic, may cause post-coital bleeding.
Mx of cervical ectropion
Cryotherapy following colposcopy to exclude carcinoma.
Exposed columnar epithelium is also prone to infection
Features of acute cervicitis
Rare
Results from STD
Ulceration and infection occasionally found in severe degrees of prolapse when the cervix protrudes
Features of chronic cervicitis
Chronic inflamamtion/infection, often of an ectropion
Causes vaginal discharge and may cause inflammatory smears
Cryotherapy +/- antibiotics dependant on culture
Features of cervical poylps
Age group
Smyptoms
Mx
Benign tumours of the endocervical epithelium
More common in women >40
May be asymptomatic or cause IMB/PCB
Small polyps are aveulsed and examined.
Still need to Ix bleedign abnormalities.
Features of Nabothian follicles
Occur where squamous epitelium has formed by metaplasia over endocevical cells.
The columnar cell secreaions are trappped and form retention cysts whcih appear as white/opaque swellings on the ectocervix.
Treatment not required unles symptomatic
Nabothian follicle
Cervical ectropion
What is CIN?
Cervical intraepithelial neoplasia
Presence of aytpical cells within the squamous epithlium
Dyskaryotic exchibiting larger nuclei with frequent mitosis
What is the grading of CIN?
CIN-I: mild dysplasia, atypical cells found in the lower third of the epithelium
CIN-II: moderate dysplasia, atypical cells foudn in the lower 2/3rds of the epithelium
CIN-III: Severe dysplasia, abnormal cells occupy the full thickness of the epithelium= Carcinoma in situ. Malginancy ensures if these abnromal cells invade through the BM
Px CINII/III
1/3rd will develop cervical cancer over the next 10 years.
Px of CIN-I
Least malignant potential, can progress but commonly regresses spontaneously.
When is the peak incidence of CINIII?
<45, 25-29 years old
Which strains of HPV are most frquently associated with cervical cancer? How many are considered high risk?
Types 16, 18, 31 and 33
13/130 different strains, are considered high risk
What strains are included in the UK HPV vaccination programme?
Types 16 and 18 as they are responsible for 75 of cervical cancer cases.
What other factors increase risk of CIN?
OCP
Smoking
Immunocompromised
Features of UK cervical screening programme
Every 3 years 25-49
Every 5 years 50-64
>65: offer if they have not had a cervical screenign test since 50 years old or a recent cervical cytology sample is abnormal
What is CGIN?
What must then be excluded
Cervical glandular intraepithelial neoplasia
Adenocarcinoma of the cervix of endometrium should be excluded using both colposcopy and endocervcal curettage or with cone biopsy. Hysteroscopy can be used.
Mx of abnromal smear
Normal: continue with normal screening
Borderline/mild dyskaryosis: HPV triage: if negative, back to routine recall. If +ve-> colposcopy
Moderate dyskaryosis: colposcopy
Severe dyskaryosis: urgen colposcopy
CGIN: colposcopy, if abnormality not found-> hysteroscopy
Mx of CINII/III
LLETZ (large loop excision of transformation zone) aka diatheyrmy loop excision.
What are the major common complications of LLETZ?
Postoperative haemorrhage- uncommon
Risk of subsequent preterm delivery is increased
Discussion of abnormal smear with patient
Assume they have cancer- reassure about early warning cells.
CINIII- without treatment she has a 30% chance of developing cancer over 8-15 years.
Which type of cervical malignancy has a worse prognosis?
Adenocarcinoma
What is occult cervical carcinoma?
When there are no symtposm but the diagnosis is made by biopsy or LLETZ
Hx in clinical cervical carcinoma?
Ex?
PCB, IMB, PMB, an offensive vaginal discharge. Pain is not an early features but later disease which involves ureturs, bladder, rectum and nerves can cause: uraemia, haematuria, rectal bleeding an pain. Smears have usually been missed.
Ulcer or mass may be vissible or palpable on the cervix
Spread of cervical cancer
Locally: parametrium and vagina and then to the pelvic side wall. Lymphatic spread to the pelvic nodes is an early feature. Ovarian spread is rare with squamous. Haematological spread is later.
Staging of cervical carcinoma
NB limited due to lack of inclusion of LNs as prognostic consideration
Stage 1: confined to cervix
Stage 2: Invasion into the vagina but not the pelvic side wall
Stage 3: invasion of the lower vagina or pelvic wall or causing ureteric obstruction
Stage 4: invasion of blddder or rectal mucosa or beyond the true pelvis
Ix in cervical carcinoma
Dx: Tumour biopsy
Vaginal and rectal ecam to assess teh size of the lesion and local invasion. Examination under anaesthetic is performed
Cystoscopy for bladder involvement.
MRI detects size, spread and LN involvement.
To assess patient’s fitness for sx: CXR, FBC and U&Es.
Treatment of Stage 1aicervical malignancies
Stage 1ai with cone biopsy.: postoperative haemorrhage and preterm labour are the main complications. Simple hysterectomy preferred in older women.
Treatment of Stage 1 and 2 cervical malignancy that isn’t stage 1ai
Sx or CTx
CTx or RTx if: +ve LNs on MRI or after lymphadenectomy.
If LNs -ve as an alternative to hysterectomy
Surgical resection margins not clear
Palliation for bone bain/haemmorrhage.
Sx: Wertheim’s hysterectomy if LNs not involved. Ovarias left in young monan with squamous carcinoma. Cx: haemorrhage, ureteric and bladder damage, lymphocyst
Radical trachedectomy is less invasive procedure for women who wish to conserve fertility. (LNs negatvie|)
Wertheim’s hysterectomy
Radical abdominal hysterectomy
Involves node clearance, hysterectomy and removal of parametrium and upper 1/3rd of vagina
Younger women with squamous carcinom are left with ovaries
Radical trachedectomy
Removal of 80% of cervix and upper vagina
To preserve fertility
Stage 2b and worse or +ve LNs
RTx and CTx with platinum agents
Mx Recurrent cervix tumours
CTx/RTx
Pelvic exenteration can be considered if the disease is central.
Pelvic exenteration
Removal of the vagina, the uterus and cervix, the bladder and or the rectum
Px for cervical Ca
1a
1b
2
3-4
LNs involved
LN-ve
Overall
95
80
60
10-30
+ve 40
-ve 80
Overall 65
Poor pxic indicators in cervical malignancy
LN +ve
Advanced stage
Large priamry
Poorly differentiated tumour
Early recurrence
What is usually the cause of death in cervical carcinoma?
uraemia due to ureteric obstruction
Stage 1ai/1aii/b in cervical cancer
ai <3mm depth, <7mm across
aii <5mm depth, <7mm across
bi clnically visible lesion, greater than ai <4cm in greatest dimension
bii clinically visible lesin, <4cm
Stage 2ai/aii/b in cervical cancer
ai Involvement of upper 2/3rds of vagina without parametrial invasion <4cm
aii <4cm
b Invasion of parametrium
Componenets of an obstetric history
Pesronal details
PC/HPC
Hx of present pregnancy
Past obstetric Hx
Other Hx: past gynaecological hx, PMH, ROS, DHx, FHx, Social Hx, Allergies, VTE risk
PC in ObHx
Why is she in hospital?
Common reasons: HTN, pain, antepartum haemorrhage, unstable lie, possible ROM.
If the pregnancy has hitherto been uncomplicated, mention this
Hx of present pregnancy
Dates: What was the first day of her LMP
What was the length of her menstrual cycle, regular?
How many weeks gestation (38w= 36w since conception)
EDD: Nagle’s rule
Complications of pregnancy: bleeding, HTN, DM, anaemia, urinary infections, conern about fetal growth, other problems. Ask about hospital admissions during the pregnancy
Tests: what tests have been performed e.g. USS, blood tests, prenatal Dx tests
Nagle’s rule
Subtrate 3m from the date of the LMP, add 7d anjd one year.
NB if a cycle <28d, the EDD will be later and needs to be adjusted (add the number of days >28 to the date calculated using Nagle’s rule.
Same applies if shorter.
When is the USS dating performed?
11-13w+6
USS measurments to date pregnancy
Measurement of crown-rump length between w9 + 14
Head circumference between 14-20w if no early scan and LMP unknown.
NB of little use after 20w.
What is a consideration re EDD and women recently stopping OCP
Her cycles can be anovulatory and LMP is less useful
Past ObHx
Details of past pregnancies in chronological order.
Mode and gestation of delivery, if operative, why?
Birth weight and sex of the baby
Mother/baby had any Cxs?
Parity
Gravidity
Parity
Number of times a woman has delivered potentially viable babies (>24w)
Suffix denotes number of pregnaniecs that have miscarried or been terminated prior to 24w.
Nulliparous
Never delivered a potentially live baby, she may have had miscarriages or abortions
Muktiparous
Delivered at least one baby at 24w or more
Gravidity
Describes the number of times a woman has been pregnant.
PGHx in OBHx
Last cervical smear
Treated for an abnormal smear
Prior contraception
Difficulty conceiving
PMHx in ObJx
Surgeries
CHD
HTN
DM
Psychiatric disease
Epilepsy
FHx in OBHx
FHx of twins?
DM
HTN
Pre-eclampsia
Auto-immune disease
VTE or thrombophilia
Any inherited disorders
SHx in ObHx
Smoke
Drink
Drugs
Stable relationship? Social support
Domestic abuse
Palpation of the abdomen and what it tells you at
<24w
>24w
>36w
Dates, twins
Well-being by assessing size and liquor
To check lie, presentation and engagement
Ob Ex
General examination
Abodminal Examination
Consider examination of fundi, reflexes, T, epigastrium, legs, chest etc.
General examination in obstetrics
Appearance, T, oedema, anaemia
Height and weight
Chest, breasts, CVS examined
BP and urinalysis
Diastolic BP is recorded at as Korotkoff V: when the sound disappears
Abdominal examination in pregnancy
When is the uterus palpable?
Where is it found?
Semi-prone. Exposed from below the breasts to the symphysis pubis. Later pregnancy can include left lateral tilt to avoid aortocaval compression
Uterus normally palpable at 12-14w.
20w: umbilicus
What may be the cause if a uterus is larger than expected before 20w?
Incorrect dates, full bladder, multiple pregnancy, uterine fibroids, pelvic mass
Ob Ex
I
P
P
A
I: size of pregnant uterus, look for striae, linea nigra and scars in the suprapubic area. Fetal movements often visible in later pregnancy
Palpation: us the fetus adequately grown, is liquor volume normal? what is the lie? What is the presentation?
Ausculation: listening over the anterior shoulder the fetal heart should be heard with a Pinard’s stethoscope, should be 110-160bpm
Steps in palpation
- Find the funduse using the fingers and the ulnar border of the left hand. Measure the distance to the pubic symphysis with a tape measure. (after 24w this corresponds to the gestation +/- 2cm. Best for small for dates but only 70% sensitive. Look for tenderness or uterine irritability
- Use both hands to palpate down the fetus towards the pelvis using dipping movements to palpate the fetal parts and liquor volume. Polyhydramnios: bag will be tense and will need to dip far to feel anything. Head can be balloted, breech is softer and cannot be balloted. Lie: longitudinal, transverse, oblique (head/buttocks palpable in one of the iliac fossae)
- Turn to face the pelvis and press both hands firmly down to assess the presentation. Engagement of the head occurs when the widest diameter descends into the pelvis and is describe as fifths palpable.
Fifths palpable
2/5ths= engaged
Pawlik’s grip
Grasp the presenting fetal part between the thumb and index finger of the examining hand. Uncomfortable and seldom necessary
Findings in Ob Ex
Uterine Size: fundus palpable at 12-14w. Umbilicus at 20w. Xiphoid sternum at 36w. Fundal height increases 1cm/week after 24w
Presentation: Breech in 20% at 28w. 3% after 37
Engagement: usual in nulliparoius after 37w. Multiparous often not engaged
Presnting Ob Ex
Gynae Ex presentaiton
Definition of preterm delivery?
Whenare risks greatest?
24-37w
<34w
What are the complications of preterm delivery for the neonate?
Prematurity accounts for 80% of NICU occupancy
20% of perinatal mortality
up to 50% of cerebal palsy
Chronic lung disease
Blindness
Minor disability
What are the risks at 24w to neonate of preterm delivery?
1/3rd handicapped
1/3rd will die
What are the complications of preterm delivery to the mother?
Infection
Endometritis
C-section
Risk factors for spontaneous preterm labour
Complications of pregnancy
Maternal medical disease
Maternal demographs
Previous Hx
Lower socioeconomic class
Extremes of materanl age
Short inter-pregnancy interval
Maternal medical disease: renal failure, diabetes, thyroid disease
Pregnancy complications: pre-eclampsia, IUGR, male fetal gender, raised Hb, STIs and vaginal infection (BV), previous cerbical surgery, multiple pregnancy, uterine abnormalities, fibroids, UTIs, polyhydramnios, congenital fetal abnormalities, APH
Mechanisms of spontaneous preterm labour
Multiple pregnancy
Delivery before 34w occurs in 20% of twins and is the mean delivery of triplets
Excess liquor, polyhydramnious has the same effect, probably largely mediated by increased stretch
Mechanisms of preterm labour
Fetal survival response
More common when fetus is at risk: pre-eclampsia and IUGR or there is infection
Placental abruption often followed by labour
Iatrogenic preterm delivery aims to improve upon this mechanism
Mechanisms of preterm labour relating to the reproductive system
Uterine abnormalities e.g. fibroids or congenital abnormalities
Cervical incompetence: some follows previous surgery for CIN or multiple dilatations of the cervix, but in others cause is unknown
What are the manifestations of infection in pregnancy?
Chorioamnionitis, offensive liquor, neonatal sepsis and endometritis
What infective pathogens are risk factors for preterm delivery?
What is often seen in preterm delivery caused by infection?
BV, GBS, Trichomonas, Chlamdyia, (commensals)
Coexisting cervical component
Hx for predicting preterm labour
Those at increased risk
Particulalry those with previous Hx of late miscarriage or preterm labour
Most women are not identified as high risk on Hx alone
Ix for predicting preterm labour
Cervical length on transvaginal sonography is sensitive and specific
Defined as from the external to the internal os
Prevention of preterm labour
Cervical cerclage (vaginal or abdominal route) usually preprgancny. Ca be used as prophylaxis, prevention or as a “rescue suture” when an incompetent cervix is dilated
or
Transvaginal progesterone suppositaries
or
?antibiotics
or
fetal reduction
or
treatment of polyhydramnios through needle aspiration or NSAIDs (if fetal surveillance is intensive) as they reduce fetal urine output
or
treatment of medical disease
NICE guidlines prophylaxis of preterm
Vaginal progesterone or prophylactic cerclage to women:
with Hx of spontaneous preterm birth or midtrimester loss between 16 and 34w and in whome a TVUS has been carried out between 16 and 24w of pregnancy and has revealed a cervical length <25mm
Prophylactic vaginal progesterone to women with no Hx of spontaenous preterm bith or miscarriage in whom a TVUS has been performed and reveals a cervical length of <25mm
Consider cerclage in women who have had a TVUS which reveals a cervical length <25mm and who have had P-PROM or Hx of cervical trauma
When is shortened cervical length picked up on TVUS?
What is the measurement?
16-24w
25mm
What is a consideration for NSAIDs in the foetus?
Can cause premature closure of the FDA
What are the contraindications for rescue cervical cerclage?
Indications?
Signs of infection or active vaginal bleeding or uterine contractions
16-27+6w with a dilated cervix and exposed unruptured fetal membranes.
Hx in preterm labour
Painful contractions, these will stop spontaneously in half of women
With cervical incompetence, painless cervical dilatation may occur and woman may experience a dull suprapubic ache or increased discharge
Antepartum haemorrhage and fluid loss are common, the latter suggesting ROM
Examination in preterm labour
Fever
Lie and presentation may be checked
Digital vaginal examination is performed unless the membranes have rupture
An effaced or dilating cervix confirm the Dx but the course of preterm labour is unpredictable
Ix in preterm labour
Cardiotocography and USS to assess fetal state
To assess likelihood of delivery: if cervix is effaced fetal fibronectin is helpful. TVS of cerbical length is alos predictive, >15mm means unlikely
Look for infection: vaginal swabs, CRP, WCC (NB steroids will cause it to rise)
Broad Mx of preterm labour
Steroids given 24-34w, in those presenting with contraction these can be restricted to women who are fibronectin +ve or have a short cervix, these reduce perinatal morbidity and mortality by promoting pulmonary maturity. NB glucose control. As they take 24h to take effect delivery is often delayed using tocolysis. Repeated doses not recommended
Tocolysis: nifedipine or atosiban (oxytocin-R antag) can be given to allow steroids time to act or to allow transfer to a unit with NICU. Delay rather than stop labour and shouldn’t be used for more than 24h.
Detect and prevent infection
Mg Sulphate: neuroprotective for the neonate if given prior to delivery. NB toxic in OD.
Mode of delivery in preterm labour
Mode of delivery in preterm labour
Vaginal delviery reduces NRDS. Caesarian undertaken only for obstetric indications. Breech is more common in preterm laour
Conduct of delivery: membranes are notruptured in membrane. Labour may be slow allowing steroids more time to act. Forceps rather than ventouse are used. Unless immedaite resuscitation is required the cord should not be clamped for 45s.
Antibiotics are recommended in actual as opposed to threatened preterm labour due to increased risk and morbidity of GBS
NICE Dx of preterm
<30w clinically suspected preterm labour: treat
>30w: TVU measurment of cervix, >15mm unlikely preterm labour. Think of alternative dxs. <15mm treat for preterm
If TVS not available, fetal fibronectin +ve: treat, -ve: unlikely in preterm.
Do not use TVS and fetal fibronectin in combination to Dx preterm labour
NICE Mx of preterm labour
Nifedipine or oxytocin antagonist (atosiban)
Maternal corticosteroids
Mg Sulphate
Definition of preterm prelabour ROM (P-PROM)
Membranes rupture beofre labour at <37w
All the causes of preterm labour may be indicated
It occurse before 1/3rd of preterm deliveries
What are the Cxs of P-PROM?
Preterm deelivery and follows within 48h of >50% of cases
Infection of fetus or placenta (chorioamnionitis) or cord (funisitis) is common. May be the cause and thus occur before or it may follow
Prolapse of the umbilical cord may occur rarely
Absence of liquor <24w can result in pulmonary hypoplasia and postural deformities
Hx and Ex in P-PROM
Gush of clear fluid followed by further leaking
Ex: lie and presentation are checked.
Dx is with a pool of fluid in the posterior fornix on speculum examination
Digital examination to exclude cord prolapse if the presentation is not cephalic
What are the clinical features of chorioamnionitis?
Contractions or abdo pain
Fever
Tachycardia
Uterine tenderness
Coloured or offesnive liquor
Ix in P-PROM
Speculum examination, if pooling not observed consider IGF binding proetin 1 test or placental microglobulin-1 test of vaginal fluid
If the results are positive, in conjunction with clinical presentation, offer management in keeping with woman having P-PROM,
If negative, unlikely she has P-PROM
Mx of P-ROM (NICE)
Balance risk of infection with risk of preterm delivery.
Identify infection: CRP, WCC, CTG, do not use in isolation
Prophylactic antibiotics: Erythromycin (250mg QDS for <10d or until labour). If erythromycin is CIed consider oral penicllin.
Close maternal and fetal surveillance, if gestation reaches 36w, induce labour
Why is co-amoxiclav contraindicated in P-PROM as an antibiotic prophylaxis?
Increases risk of NEC in neonate.
What are the normal blood changes in pregnancy an and why?
Normally falls to a minmum in the second trimester by about 30/15
Occurs in both normal and chronically hypertensive women due to a reduction in SVR
Rises again by term to normal pre-pregnant levels
What is the normal increase in protein excretion in pregnancy?
<0.3g/24h
What is the definition of PIH?
When the blood pressure rises by 140/90
Can be either pre-eclampsia or transient HTN
Normally after 20 weeks
What is pre-eclampsia
HTN and proteinuria (>0.3g/24h)
Appears in hte second half of pregnacny normally with oedema
Occasionally proteinuria is absent in early stage of disease
What is pre-existing HTN
What are the implications?
BP >140/90 before pregnancy or before 20w gestation or if the woman is on antiHTNs
May be 1o or 2o to other disease
May also be pre-exisitng proteinuria because of renal disease
What are the implications of pre-existing HTN on pre-eclampsia?
6x risk of “superimposed” preeclampsia
What is the course of pre-eclampsia
HTN normally precedes proteinuria which is a relatively late sign
Variability in time and severity of presentation.
The degree of HTN can be used to help asses it
Early onset disease tends to be more severe, after delivery may take up to 24h for “cure”
Pre-eclampsia epidemiology
6% of nulliparous. Less common in multiparous unless additional risk factors are present
What is the recurrence rate of pre-ecl
15% but can be up to 50% if there has been severe disease before 28w.
What are the 2 stages of pre-eclampsia pathogenesis
Stage 1: occurs before 20w. Incomplete invasion of spiral arterioles by trophoblasts leading to decreased uteroplacental blood flow.
Stage 2: manifestation of disease. Ischaemic placenta induces widespread endothelial cell damage causing vasoconstriction, increased permeability and clotting dysfunction.
What are the principal risk factors for pre-ecl
Nulliparity
Previous Hx
FHx
Old maternal age
Disorders characterised by microvascular disease: chronic HTN, chronic renal disease, SCD.
DM
Pregnancies with large placenta: Twin pregnancies, molar, fetal hydrops
Autoimmune disease (esp antiphospholipid)
Renal disease
Obesity
What are the classifications for HTN in pre-ecl
And pre-eclampsia itself?
>140/90= mild
>150/100= modetae
>160/100= severe
Mild: proteinruia and mild/modearate HTN
Moderate: proteinuria and severe HTN with no maternal complications
Severe: proteinuria and HTN <34w or with maternal complications
What are the protein cut offs in pre-ecl?
Dipstick
PCR
24h
Trace: seldom significant
+1: possible significant, quantify
+2: likely significant, quantify
PCR >30mg/noml: confirmed significant proteinuria
24h collection: >0.3g.24h
Hx of pre-eclampsia
Ex
Usually asymptomatic, headache, drowsiness, visual disturbances, N+V or epigastric pain may occur at late stage
HTN usually first sign but occasionally absent
Oedema may be massive, not postural or of sudden onset
Epigastric tenderness suggestive of impending complications
Urine dipstick
What are the maternal complications of pre-eclampsia?
Eclampsia: grand mal seizures. Mortality can result from hypoxia and concomitant complications. Rx with Mg SO4
CBA: results from failure of cerebral blood flow autoregulation, antiHTNsives can help
Liver and coag problems: HELLP syndrome. DIC, liver failure and rupture may occur. Treatment is supportive and may incude MgSO4 prophylaxis
Renal failure: fluid balance monitoring, may require haemodialysis
Pulmonary oedmea: Severe pre-eclamptic is particulalry vulnerable to fluid overload. PO treated with O2 and frusemide, assisted ventilation. ARDS may develop.
What are the fetal complications of pre-ecl?
Perinatal mortality and morbidity are all increased. Stil birth
<34w: IUGR, spontaneous preterm labour. Preterm devliery often required
Term: affects grwoth less but still associated with increased morbidity and mortality
At all gestations there is an increased risk of placental abruption
Dx of pre-ecl
Monitoring of pre-eclampsia
If dipstick positive exclude UTI with cultures and quantiy proteins.
Blood tests: Hb often high, uric acid elevated. Rapid fall in platelets suggests impending HELLP.
ALTs suggest impending liver test or help. LDH levels rise with liver disease and haemolysis
RFT: rapidly rising creatinine suggests severe Cxs and renal failure
Fetal: USS, umbilical artery doppler and if abnromal CTG to evaluate fetal well-being
HELLP syndrome
Haemolysis
Elevated Liver enzymes
Low Platelets
Screening for pre-ecl
HTN and urinaylsis checks in all pregnant women, esp those at high risk.
Most common is uterine artery Doppler at 23w.
Preventing pre-eclampsia
High risk women: 75mg of aspirin OD from 12w until birth of baby
What factors indicate women should be on aspirin for pre-eclampsia risk?
HTN disease during previous pregnancy, CKD, Autoimmune disease, DM, chronic HTN= High risk
first pregnancy, >40y/o, pregnancy interval of more than 10 years, >BMI, FHx, multiple pregnancy= moderate risk, >1 of these=aspirin
What are the indications for hospital admission according to NICE in pre-ecl
Mild, moderate or sever HTN= admission
Significant proteinuria
Following admission, should have regular BP monitoring, repeat quanitifcation of proteinuria not necessary. Montor RFT, FBC, LEs
What is first line treatment for pre-ecl HTN?
Which severities?
Labetalol
Moderate and severe, to keep DBP between 80-100 and systolic to <150
Mx of severe HTN or pre-eclampsia
Anticonvulsants: IV Mg SO. Loading dose of 4g followed by a 24hr infusion
Anti-HTNs: labetalol (oral or IV), hydralazine (+/- hydralazine) (IV), nifedipine
Corticosteroids for fetalo lung maturation: betamethasone (if <34w)
What are the adverse effects of MgSO4
Severe respiratory depression and hypotension
Preceded by loss of patellar reflexes
NB renal impairment, stop
Timing of delivery for pre-eclampsia
<34w: after discussion with neonatal and anaesthetists and course of corticosteroids if sever HTN develops refractory to Rx. Maternal or fetal indications.
>34w when BP has been controlled and if corticosteroid course complete
34-36+6: depnding on fetal condition
>37w: within 24-48h of onset
Conduct of delivery in pre-ecl
<34w: Csec
>34w: labour can be induced with PGs, epidural analgesisa helps reduce BP.
Use anti-HTNs
determine need for haematological and biopchemical tests.
Do not rountiely limit second stage of labour.
if HTN is severe and refractory to treatment, recommend operative birth
Post-natal care in pre-ecl
BP: monitor, ask about symptoms each time BP is measured.
Monitor bloods
Monitor fluid balance. NB PO and ARDS. If urine output is persistently low, use CVP monitoring. If CVP is high (overload) frusemide. If low, fluid but not albumin. If normal and oliguria persists renal failure is likely, K levels indicate need for dialysis
BP maintained at 140/90, postnatal treatment is with beta-blocker, nifedipine and ACEI can be seocodn line
Aetiology of pre-pregancy 2o HTN
Obesity, DM, renal disease (PCD, RAS, chronic pyelo)
Rarer include phaeo, Cushing’s, cadiac, coarctation
What should be exluded in all hypertensives?
Fundal changes, renal bruit, radiofermoal delay.
Ix in pre-existing chronic HTN in pregnacny
To identify secondary HTN, exlude Pheoe as maternal mortality is very high (24h VMA)
Look for coexistant disease through renal USS and RFTs
Identify pre pregnancy degree of proteinuria to alloiw compairosn later in the pregnancy
Mx of pre-pregnancy HTN
Stop ACEI and ARBs due to teratogenicity. Labetalol. Nifedipine second line.
Keep dietary Na low.
Kepp BP <150/100.
If HTN is severe and refractory offer birth.
Screen for pre-ecl
Low dose aspirin.
Mx of PIH
Take account of additional RFs
If HTN is sever admit until moderate levels.
Monitor proteinruia at each visit.
Labetalol, second line nifedipine, methyldopa
Do not offer birth to <36w unless HTN is severe.
Def: APH
Bleeding from genital tract after 24w gestation.
What are the causes of APH?
Common:
Rarer:
Undetermined origin, placental abruption, placenta praevia
Incidental genital tract pathology, uterine rupture, vasa preavia, placenta praevia
Def: placent praevia
Epidimeology
How does it change?
Occurs when the placenta is implanted in the lower segment of the uterus
Complicates 0.4% of pregnancies at term.
At 20w the placenta is low-lying in many more pregancies but appears to move upwards as the pergnancy continues, only 1 in 10 apparently low-lying placenta will be praevia at term.
How can placenta praevia be classified?
Marginal (I-II): placenta in lower segment, not over os
Major: placenta completely or partially covering os
What increases the risk of placenta praecia?
Twins, age of mothers, uterine scarring
What are the cxs in placenta praevia?
Obstructs engagement of the head, may necessitate C-sec and cause transverse lie
Haemorrhage can be severe and may continue during and after delivery as the lower segement is less able to contract and constrict the maternal blood supply.
If placenta implants in previous c-sec scar it may be so deep as to prevent placental separation or even penetrate through the uterine wall into the surrounding structures such as the bladder (placenta accreta and placenta percreta respectively). May provoke massive haemorrhage at delivery and require hysterectomy.
Hx and Ex in placenta praevia
Intermittenet painless bleeds which increase in frequency and intensity over several weeks. (1/3rd won’t have experienced bleeding before delivery)
Ex: breech presentation and transverse lie. No fetal head engagement. Vaginal examination can provoke massive bleeding and is never performed in a woman who is bleeding vaginally until placenta praevia has been excluded.
May be found incidentally on USS
Ix of placenta praevia
USS
Most diagnosed prior to bleeding, if low lying placenta has been dxed at a 2nd trimester USS this is repeated vaginally at 32w to exclude praevia. A placenta <2cm from the itnernal os is likely to be praevia at term. If close to a previous c-sec scar, 3-d power USS is best to determine if there is placenta accreta.
CTG
FBC: clotting studies and cross-match
Mx of placenta praevia
Admit all women with bleeding. If placenta praevia is found on USS women often stay in hospital until delviery due to risk of haemorrhage.
Blood kept available.
IV access maintained
Steroids if <34w.
If asymptomatic can delay until 37w.
Delivery: C-sec at 39w by most senior person available. Intra-operative and PPH are common.
May be emergency if bleeding is severe.
Accreta or percreta should have been anticipated although it may occur without invasion through a scar. Uterine incision should be made away from the placenta which can be left in situ or hysterectomy. Treatment of haemorrhage can be with compression of the scar after placental removal through a Rusch balloon. Alternatively, hysterectomy
Def: placental abruption
When part or all of the placenta separates before fetal delivery. Occurs in 1% of pregnancies
Pathology of fetal abruption
Placenta separating may lead to considerable maternal bleeding. Can lead to further placental separation and acute fetal distress.
Blood revealed as APH
May also enter the liquor
Or the moyemtrium (visible haemorrhage is absent in 20%)
Types of palcental abruption
Revealed
Concealed: bleed into the myometrium
Cxs of placental abruption
Fetal death (30% of proven abruptions)
Haemorrhage often necessitates blood transfusion: DIC and renal failure may lead to maternal death
What are the risk factors for abruption?
IUGR
Pre-ecl
Pre-existing HTN
Maternal smoking
Hx of placental abruption (6% risk)
Autoimmune diesase
Cocaine usage
Multiple pregnancy
High maternal parity
Trauma
Sudden reduction in uterine volume (ROM in woman with polyhydramnios)
Hx and Ex in placental abruption
Painful bleeding, often dark. Degree of vaginal bleeding does not reflect severity of the abruption. If pain occurs alone= concealed
Ex: tachycardia suggests profound blood loss. hypotension after massvie loss, uterine tender and often contracting. In severe cases the uterus is woody hard and the fetus difficult to palpate. Fetal heart tones abnormal/absent. If coagulation failure has occured, widespread bleeding is evident
Ix of placental abruption
Clinical dx
Ixs help to establish severity and plan resuscitation
CTG: fetal heartbeat, ferquent uterine activity
USS may be used to estimate fetal weight and exclude placenta previa but abruption may not be visible.
FBC, coagulation screen, cross-match. Catheterisation with hourly UO, regular FBC, Us&Es, CVP monitoring may be required in severe cases.
Features of major placental abruption
Maternal collapse
Coagulopathy
Fetal distress/demise
Woddy hard uterus
Poor UO or renal failure
Degree of vaginal loss is unhelpful
Mx of palcental abruption
Admit if pain and uterine tenderness. IV fluids. Steroids if gestation <34w. Blood transfusion. Opiate analagesia.
Delivery: depends on fetal state and gestation:
Fetal distress: emergency C-sec
No fetal distress but gestation is >37w induction of labour with amniotomy. Monitor mother and fetal distress.
If fetaus is dead: coagulopathy is also likely. Blood products given and labour induced.
If there is no fetal distress, pregnacny is preterms and abruption appears to be minor, steroids and pregnancy -> high risk .
PPH is the majory risk
What is bleeding of undetermined origin
APH small and painless without placenta praevia, may be difficult to find a cause.
USS little help.
What is vasa praevia
Occurs when fetal BS runs in the membranes in front of the presenting part.
rare but occur when the umbilical cord is attached to the membranes rather than the palcenta.
Can be detected on USS.
When membranes rupture, the vessel may rupture too.
Typical presentation is painless, moderate baginal bleeding at amniotomy or SROM which is accompanied by severe fetal distress.
NB for APH?
Cervical carcinoma can present in pregnancy.
If a cervical smear is overdue the woman with small recurrent or postcoital haemorrhage should undergo speculum exmaintions.
Definition of shoulder dystocia
Epidemiology.
Consequences?
When additional manoeuvres are required after normal downward traction has failed to deliver the shoulders after the head has delivered
1 in 200 deliveries
Characteristically results in Erb’s palsy (waiter’s tip) from excessive traction on the neck leading to damage to the brachial plexus.
Delay and unskilled attempts at delivery can be lethal (can be as short as 5 minutes from head to shoulder delivery)
Risk factors for dystocia
Large baby (>4kg although this only accounts for half of all cases)
Previous shoulder dystocia
Raised maternal BMI
Labour induction
Low height
Maternal diabetes
Instrumental delivery
Most cases considered unpreventable due to poor ability to predict and the prevention involves C-section
Mx of shoulder dystocia
Rapid and skilled intervention
Sequence of actions:
Because obstruction is at the pelvic inlet, excessive traction is useless.
Senior help.
Gentle downward traction
Legs are hyperextended onto the abdomen
Suprapubic pressure applied
This method works in 90% alternative methods if this fails involve internal manoeuvres necessitating episiotomy:
If the shoulders are transverese, pressure behind the anterior shoulder will rotate it to the widest diameter, combined with pressure on the anterior part of the posterior shoulder (Wood’s screw) can force delivery.
If this fails, posterior arm is grasped and by extension at the elbow the hand is brought down. The trunk will either follow or rotation of the body using the arm is performed.
Last resorts: symphysiotomy
Lateral replacement of the urethra with a metal catheter
Zavanelli maneuvre: replacement of the head and C-section, usually irreversible fetal damage has occured by this point.
McRobert’s maneuvre
Leg hyperextnension used in shoulder dystocia
Wood’s screw manoeuvre
Pressure on anterior shoulder and pressure on anterior part of posterior shoulder used in shoulder dystocia
Zavanelli manoeuvre
Reducing head back into uterus prior to c-sec in shoulder dystocia
Definition of cord prolapse
Occurs after ROM
Umbilical cord descends below the presenting part.
Untreated the cord will be compressed or go into spasm and the baby will rapidly become hypoxic.
1 in 500 deliveries
Risk factors for cord prolapse
Preterm labour
Breech presentation
Polyhydramnios
Abnormal lie
Twin pregnancy
(>50% occur at artificial amniotomy)
Dx of cord prolapse
Fetal heart rate abnormality
Vaginal palpation of the cord or its appearance at the introitus
Mx of cord prolapse
Presenting part must be prevented from compressing the cord: pushed up by the examining finger or tocolytics e.g. terbutaline are given.
If the cord is out of the introitus it should be kept warm and moist but not forced back inside.
Patient should go on all fours whilst preparation of delivery is undertaken.
C-sec usually used but instrumental vaginal delivery is appropriate when the cervix is fully dilated.
Def of amniotic fluid embolism
When liqupr enters the maternal circulation causing anaphylaxis with sudden dyspnoea, hypoxia and hypotension. Often accompanied by seizures and cardiac arrest.
Acute heart failure is evident.
Extremely rare but serious as often causes death.
If patient survives for >30mins she develops DIC, PO and ARDS.
Risk factors for amniotic fluid embolism
Membrane rupture, during labour, C-sec, TOP.
Multiple mild predisposing factor: strong contractions in the presence of polyhydramnios.
Prevention impossible
Mx of amniotic fluid emoblism
NB often confused with other causes of collapse and with eclampsia.
ABC resusc.
O2 and CVP monitoring.
Blooods for clotting, FBC, U&Es, cross match.
Blood and FFP will be required.
ICU admission.
Def: uterine rupture
Can be de novo or an old scar. Fetus is extruded. Uterus contracts and bleeds from rupture site causing acue fetal hypoxia and massive internal maternal haemorrhage.
Rupture of a lower trasnverse C-sec scar is usually less severe than others as the lower segment is not very vascular.
Occurs in 1/1500 pregnancies. and in 0.7% of women who attempt a vaginal delivery after a single previous lower C-sec.
Dx made from fetal HR abnormalities, constant lower abdo pain, vaginal bleeding, contraciton cessation, maternal collapse.
Risk factors for uterine rupture
Labours with a scarred uterus
Classical C-sec or deep myotomy.
Rupture before labour is rare
Neglected obstrcuted labour is rare in the West.
Congenital uterine abnormalities occasionally cause rupture before labour.
Preventive mesaures include avoidance of induction and caution when using oxytocin in women with previous C-sec.
Mx of uterine rupture
Maternal resus with IV fluid and bloods
Bloods taken fro clotting, Hb, X-match
Urgent laparotomy for fetal delivery and repair/removal of uterus.
Uterine rupture has a high recurrence rate
Def uterine inversion
When the fundus inverts into the uterine cavity.
Usually follows traction on the placenta and occurs in 1 in 20000 deliveries
Haemorrhage, pain and profound shock.
Brief immediate attempt to push the fundus up via the vagina.
If not, GA and replacement performed with hydrosstatic pressure of several litres of salin which is run past a clenched fist at the introitus.
Causes of epileptiform seizures in pregnant
Maternal epilepsy
Exlampsia
Hypoxia of any cause
Mx of epileptfiorm seizures in obstetrics
Assume pre-eclampsia, Mg sulphate
ABC
What is LA toxicity
Excessive doses or inadvertent IV doses of LA can cause transient cardiac, respiratoey and neurological consequences
What is the optimal initial management of cord prolapse in a fully equipped hospital setting?
When cord prolapse is diagnosed before full dilatation, assistance should be immediately called and preparations made for immediate birth in theatre. T
here are insufficient data to evaluate manual replacement of the prolapsed cord above the presenting part to allow continuation of labour. This practice is not recommended
. To prevent vasospasm, there should be minimal handling of loops of cord lying outside the vagina.
To prevent cord compression, it is recommended that the presenting part be elevated either manually or by filling the urinary bladder.
Cord compression can be further reduced by the mother adopting the knee–chest or left lateral (preferably with head down and pillow under the left hip) position.
Tocolysis can be considered while preparing for caesarean section if there are persistent fetal heart rate abnormalities after attempts to prevent compression mechanically, particularly when birth is likely to be delayed.
Although the measures described above are potentially useful during preparation for birth, they must not result in unnecessary delay.
What are the aims of antenatal care? (6)
Detect and manage pre-existing maternal disorders that may affect outcome of pregnancy
Prevent or detect and manage maternal complications of pregnancy
” fetal compications
Detect congenital fetal problems
Plan with mother the circumstancs of delivery to ensure maximum safety for the mother and baby
Provide education and advice regarding lifestyle and ‘minor’ conditions of pregnancy
Preconceptual care, components
Previous pregnancies: implications
Health check: better performed before conception
Rubella status
Strict preconceptual glucose control in diabetics to reduce the incidence of congenital abnormalities
Medication optimisation
Folic acid supplementation e.g. 0.4mg/day preconceptually.
Advice regarding smoking, ETOH, drugs
When is the booking visit
What is its purpose
Should be before 10 weeks gestation
To secreen for potential cxs that may arise during pregnancy: Risk assessment using Hx and Ex.
Decide about type and frequency of antenatal care: need to be constantly re-evaluation as the pregnancy proceeds.
Check pregnancy gestation and arrange prenatal screening
General health chec,
Impact of age on pregnancy risk
<17y/o >35y/o are at greater risk of obstetric and mediocal cxs.
Chromosomal abnormalities increase with age
Impact of past obstetric Hx on pregnancy risk
Many obstetric disorders have a small but significant recurrence rate
include: preterm labour, small for dates, IUGR, stillbirth, APH, PPH, some congenital abnromalities, rhesus disease, pre-eclampsia, GDM
Impact of gynae Hx on pregnancy risk
Hx of subferitility increases perinatal risk: IVF/augmentatin of fertilisation increases likelihood of multiple pregnancy.
Previous uterine surgery (e.g. myomectomy) may be an indication for elective C-section
Cervical smear Hx
Impact on PMHx on pregnancy risk
HTN, DM, autoimmune disease, Hbopathy, thromboembolic disease, CVD, R disease or other serios diseases are at an increased risk of pregancy problems.
Direct questions re: depression are useful
Impact of FHx on pregnancy risk
DM in first degree relative increases rsik of GDM
HTN, thromboembolic, autoimmune disease and pre-eclampsia are also familial
Examination at booking visist
General health and nutritional status
BMI
Baseline BP
Incidental disease may be detected e.g. breast carcinoma
Abdo examination: limited before third trimester. Uterus palpable from 12w. Fetal heart can be ausucltated at this point.
If no recent smear, usually performed 3 months post-natally.
Booking visit investigations and details.
USS: 11-13+6 to date using crown-rump length. Also detects multiple pregnancy and allows screening for nuchal translucency.
DS screen: nuchal translucency, beta-hCG and pregnancy-associated plasma protein A (PAPPA) = combined test
Bloods: FBC (?anaemia). Serum Abs (anti-D) to identify those at risk of intrauterine isoimmunisation. GGT (in those at risk, normally perforemd later in pregnancy). Syphillis test (VDRL). Rubella immunity checked (vaccination postnatally). HIV and HBV screening. Hb electrophoresis.
Screening for infections implicatd in preterm labour (e.g. Chlamydia, BV).
Urine MC+S because asymptomatic bacteruria in pregnancy can lead to pyelnephritis in (20%)
Urinalysis for glucose, protein and nitrites
Folic acid supplementation 0.4mg/d
Vit d supplementation 10 microg/d recommended for women >30BMI, SEA or afrocarribean origin or with low sunlight absoprtion.
Fe supplementation should not be routine
What is the calorific intake in pregnancy?
ETOH?
Smoking in pregnancy?
Dental?
Coitus?
Infection avodiance
Exercise?
Seatbelt?
2500
Avoided or <1 unit
Smoking cessation with nicotine replacement therapy
Dental cehck up advised
Coitus is not contraindicated unless: placenta praevia, or ROMed.
Listeriosis is avoided by drinking pasteurised milk and avoiding soft and blue cheese, pate and undercooked or partially cooked prepared foods. Salmonella avoided by cooking eggs and poultry well.
Eservices advised.
Above and below the bump.
What are the two care options for pregnancy in hte UK?
Communiy: core team of midwives. Women can be referred to hospital
Consultant-led care
Risk assessment for VTE should be considered
When is the anomaly USS?
20w: enables detection of most structural fetal abnormalities.
What are the USS screening for risk assesments and whena re they performed?
Doppler of the uterine arteries at 23w can be used as a screening test for IUGR and pre-eclampsia.
Not performed routinely but in htose at risk
What are the NICE recommended appts schedules for antenatal visits in pregnancy?
Uncomplicated: 10 for nulliparous. 7 for multiparous
More frequent visits are appropriate for many “high-risk” pregnancies.
What are the components of the examination in antenatal visits?
BP
Urine dip-> urine culture/analysis if abnormality found
Abdominal exam: lie, engagement (unimportant until 36w)
Fetal heart
What is the 16w visit in pregnancy for?
Results of screening tests for chromosomal abnormalities.
R/v of booking bloods.
18-21w purpose of visit
Anomaly scan
Repeat scan arranged at 32w if low-lying placenta
Purpose of 25w antenatal vist
Exclusion of early onset pre-eclampsia (only in nulliparous)
Purpose of 28w antenatal visit
Fundal height
FBC and Abs
GTT is perforemd if indicated
Anti-D given to rhesus-negative women
Purpose of 31w antenatal visit
Fundal height, R/v of bloods from 28w (nulliparous only)
Purpose of 36, 38, 40 antenatal visits
Fundal height measured
Fetal lie and presentation
Referral for external cephalic version if presentation if breech (ECV)
Pelvic examination inappropriate unless induction is complicated or there is suspicion of obstruction (and placenta praevia has been excluded)
Purpose of 41w antenatal visit
Fundal height measure and fetal lie and presentation checked
Membrane sweeping is offered as is induciton of labour by 42w.
Itching in pregnancy
Common
Scleare checked for jaundice and LFTs and bile acids assessed
NB although rare liver issue in pregnancy may bpresent with itching
Pelvic girdle pain in pregnancy
Mx
Formerly pubic symphysis dysfunction
Common and causes varying degrees of discomfort
PT, corsets, analgesics and even crutches may be used
Care with leg abduction required
Heartburn in pregnancy
Mx
Affects 70%, most marked in supine position
Extra pillows are helpful.
Diet modification.
Antacids can be used
Ranitidine in severe cases (NB pre-eclampsia can present with epigastric pain)
Backache in pregnancy
Mx
Universal and may cause sciatica
Most cases resolve after delivery
PT, advice on posture and lifting, a firm mattress and corset may all felp
Constipation in pregnancy
Common and exacerbated by oral Fe.
High fibre intake.
Stool softners can be used.
Oedema in pregnancy
Common, worsens towards the end (unreliable sign of pre-eclampsia).
Sudden increase warrants assessment and FU of BP and urinalyis.
Benign oedema is helped by raising feet.
Diuretics should not be given.
Leg cramps in pregnancy
Affects 30% of women.
Treatments unproven but NaCl, Ca salts or quinine may be tried
Cause of carpal tunnel syndrome in pregnancy
Mx
Due to fluid retention compressing the median nerve.
Seldom severe, usually temporary. Splinting of the wrists may help.
Vaginitis in pregnancy
DDue to candida infection
Common and difficult to treat
Itchy, non-offensive, white-grey discharge.
Imidazole vaginal pessaires (e.g. clotrimazole) can be used for symptomatic infection.
Tiredness in pregnancy
Common, NB often incorrectly attributed to anaemia.
Changse in weight in pregnancy
Gain 10-15kg
Changes in UT in pregnancy
Uterus increases weight from 50g-1000g
Muscle hypertrophy, increased blood flow and contractility.
Cervix softens and may start to efface late in third trimester
Changes in blood in pregnancy
50% increase in blood volume
Increased red cell mass
Decreased Hb
Increased WCC
Changes in CVs in pregnancy
CO: 40% increase
Peripheral resitance: 50% reduction
BP: falls in mid-regnancy.
Changes in lung in pregnancy
Tidal volume: 40% increase
No change in RR
Changes to
Renal
Gut
Thyroid in pregnacny
Renal blood flow: 40% increase in GFR so creatinine/urea decreased
Reduce motility: delayed gastric emptying and constipation
Enlargement of thyroid.
First trimester
Second
Third
w1-12
13-27
28-birth
Components of a Bishop score
Cut offs
Cervical position
Cervical consistency
Cervical effacement
Cervical dilation
Fetal station
<5- indicates labour unlikely to start without induction
>9- indicates htat labour will most likely commence spontaneously.
What is the epidemiology of breech presenation?
present in 25% at 28w.
Only occurs in 3% of babies near term
What are the different types of breech presentation?
Frank: hips flexed and knees fully extended
Footling: one or both feet come first with the bottom at a higher position (rare but carries a higher perinatal morbidity)
What are the risk factors for breech presentation?
Uterine malformations: fibroids
Placenta praevia
Poly/oligohydramnios
Fetal abnromality (e.g. CNS malformation, chromosomal disorders).
Prematurity (due to increased incidence earlier in gestation)
Mx of breech presentation
<36w
36w
If reamins breech
Fetaus may turn spontaneously.
ECV: success rate of around 60% (RCOG recommend ECV should be offered from 36w in nulliparous and 37 in parous)
Planned C-sec or vaginal
What information about C-sec and breech is important
Planned C-sec carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth
There is no evidence that the long term health of babies with a breech presentation delivered at term is influenced by how the baby is born
Absolite contraindications of ECV
Indication for C-sec irrespective of fetal presentation (e.g. placenta praevia)
Severe oligohydramnios or ROM
Nonreassuring fetal monitoring test results
Hyperextended fetal head
Significant fetal or uterine anomaly
PLacental abruption
Multiple gestation (can be considered for the second twin after delivery of the first twin)
What are the relative contraindications of ECV?
Maternal HTN
Maternal obesity
fetal growth restriction
Oligohydramnios
Previous C-sec.
What differentiates clinically between cholestasis of pregnancy and acute fatty acid of pregnancy?
holestasis of pregnancy is characterised by severe pruritis, whereas acute fatty liver of pregnancy has predominantly non-specific symptoms (e.g. malaise, fatigue, nausea). With a normal FBC and viral screen a diagnosis of HELLP syndrome or viral hepatitis is unlikely.
Features of intrahepatic cholestasis of pregnancy (aka obstetric cholestatis)
Mx
Intrahepatic cholestasis of pregnancy: caused by impaired bile flow. Leads to build up of bile salts which can then deposit in the skin as well as the placenta.
Can be uncomfortable for mohter but may also cause sudden asphyxial events in fetus leading to anoxia and death.
pruritus: typically worse on palms, soles and abodmen
bilirubin < 100
occurs in 2nd and 3rd trimester
Increased risk of preterm birth
Mx: induction at 37w.
Ursodeoxycholic acid
Vit K supplementaiton
Features of acute fatty liver of pregnacny
Rare complication which may occure in third trimester or immediately following delivery
Abdo pain, N+V, headache, jaundice, hypoglycaemia, severe disease may result in pre-eclampsia
ALT typically elevated e.g. 500u/l
Mx: supportive care, stabilised: delivery is the definitive manageemtn
NB Gilbert’s and DJS may be exacerbated during pregnancy
What is the ovarian blood supply?
And the ligamental organisation?
From the ovarian artery which anastamoses with branches of the uterine artery in the broad ligament.
Overy lie the uretur in the ovarian fossa. Attached to the broad ligament by the mesovarium, the pelvic side wall by the infundibulopelvic ligament and to the uterus by the ovarian ligament
From which layer of the ovary does the most common carcinoma derive?
The outer cortex which is covered by germinal epithelium
What are the layers of the ovary?
Outer cortex: germinal epithelium
Inner medulla: connective tissue and bvs
Cortex contains the follicles and theca cells.
Whence is oestrogen secretion?
What can occur
Granulosa cells in the growing follicles and also by theca cells
Rare tumours of these cells secrete oestrogens.
What changes occur to the follicles during ovulation
Multiple enlarge every month under influence of FSH
Onle one reaches 20mm and ruptures in response to mid cycle LH surge
Collapsed follicle becomes a corpus luteum and continues to produce oestrogen and progesterone to maintain the endometrium.
If no implantation occurs the corpus luteum involutes and hormone levels decline.
If fertilisation occurs hCG from the trophoblast maintains the corpus luteum’s function and hormone production until 7-9w when the placenta takes over.
Follicular and lutein cysts result from persistence of these structures in nonpregnant women.
What are the symptoms of ovarian masses
Often silent and detected either when they are very large and cause abdominal distension or on USS.
Acute presentation is associated with “accidents”
What are the different types of ovarian cyst accidents?
Rupture of cyst into the peritoneal cavity.
Haemaorrhage into a cyst or peritoenal cavity
Torsion of the pedcile
What are the features of ovarian cyst rupture
Rupture of the cyst contents into the peritoneal cavity causes intense pain.
This is especially the cause with an endometrioma or dermoid cyst.
What are the features of haemorrhage of a cyst
Can occur into a cyst or the peritoneal cavity.
Often causes pain.
Peritoneal cavity haemorrhage can occasionally cause hypovolaemic shock
What are the features of torsion of the ovary?
Torsion of the pedicle (which is bulky due to the cyst) causes infarction of the ovary and tube and severe pain.
Sx and detorsion required urgently to save the ovary
What are the features of PCOS?
Causees oligomenorrhoea, hirsutism and subfertility.
Actually small multiple, poorly developed follicles rather than cysts
What is the most common gonadal dysgeneses?
Turner’s
Why are benign cysts classified with primary neoplasms of the ovary?
Because they may undrego malignant change
What are the three main groups of primary ovarian neoplasms?
Epithelial tumours
Germ cell tumours
Sex cord tumours
What are the most common ovarian masses premenopausally?
Follicular/lutein cysts
Dermoid cysts
Endometriomas
Benign epithelial tumour
What are the most common ovarian masses postmenopausally?
Benign epithelial tumour
Malignancy
Which group of women are epithelial tumours most commonly found in?
What are the features of epithelial tumours that make them unique?
Postmenopausal
Histology may demonstrate borderline malignancy where malignant histological features are seen without invasion. Such tumours may become frankly malignant and Sx is advised
How does the management of borderline epithelial cysts in younger women differ?
What is significant following removal of a cyst?
Close observation following removal of the cysts or affected ovary to retain fertility with close observation.
Recurrence as a borderline or invasive tumour can occur up to 20y later
What is the most common malignant ovarian neoplasm?
What is the benign form
Serous adenocarcinoma (50% of malignant neoplasms of the ovary) derives from the peithelial.
Serous cystadenoma
What proportion of ovarian malignancies is made up of mucinous adenocarcinoma?
What are the features?
10%
Mucinous cystadenoma can become very large and are less frequently malignant.
What is a rare borderline variant of the mucinous cystadenoma?
What happens?
What should be excluded?
Pseudomyxoma peritonei
Abdominal cavity fills with gelatinous mucin secretions.
Appendieal primary should be excluded.
What proportion of ovarian malignancies are accounted for by endometroid carcinomas?
25%
Similar histologically to endometrial carcinoma. with which it is associated in 20%
Which ovarian neoplasm has a particulaarly poor prognosis?
What proportion of ovarian malignancies are accounted for by this?
Clear cell carcinoma (epithelial tumours)
<10%
What are Brenner Tumours
Rare small and usually benign tumours of the ovarian epithelium
What are the relavent proprtions of the incidences of the following ovarian malignancies?
From which tissue layer do they arise
Serous adenocarcinoma
Mucinous adenocarcinoma
Endometroid carcinoma
Clear cell carcinoma
Epiethlium
50%
10%
25% (associated with endometrial carcinoma in 20% of cases)
<10%
Whence do germ cell tumours arise?
What are the different kingds of GCT?
From undifferentiated primordial germ cells of the gonad
What is a teratoma also known as?
What tissue do they arise from?
What are the features?
What is the malignant form?
Dermoid cyst
Undifferentiated primordial germs cells of the gonad.
Common benign tumours arising in young premenopasual women.
May contain fully differentiated tissue from all cell lines.
Commonly bilateral, seldom large, asymptomatic.
May rupture.
The solid teratoma
What is a dysgerminoma?
Features?
Female equivalent of the seminoma.
Very rare, most common ovarian malignancy in younger women.
Senesitive to RTx
What is the most common ovarian malignancy in younger women?
Dysgerminoma
Whence do sex cord tumours arise?
What are the different types?
From the stroma of the gona
Granulosa cell tumours
Tehcomas
Fibromas
What is a granulosa cell tumour?
Sex cord tumour.
Usually malignant but slow growing
Rare and found in postmenopausal women.
Stimulation of the endometrium may cause bleeding, endometrial hyperplasia, endometrial malignancy and precocious puberty (rarely in young girls)
How does a granulosa cell tumour cause endometrial changes?
What are these changes?
Secrete high livels of oestrogen and inhibin which can cause
bleeding
endometrial hyperplasia
malignancy
What is the tumour marker for granulosa cell tumours?
What is used for?
Serum inhibin
used to monitor for recurrence
What are the features of thecomas?
Rare
usually benign
Can secrete oestrogens or androgens
What are the features of fibromas?
Rare and benign tumours of the sex cord
Can cause Meig’s
What is Meig’s?
Ascites and usually right pleural effusions are found in conjunction with a small ovarian mass.
Effusion is benign and cured by removal of the mass
What is the proportion of ovarian masses are mets?
Where are the common sites?
10% of malignant ovarian masses
Breast
GIT
What are Krukenberg tumours
Mets to ovary from gut which contain “signet-ring” cells.
Primary malignancy may be difficult to detect and has very poor px
What are the features of endometriotic cysts
Endometriosis can cause altered blood to accumulate in “chocolates cysts”
In the ovary these are called endometriomas.
Rupture is painful though uncommon
“Tumour-like condition”
What are functional cysts?
Which causes more symptoms?
Follicular and lutein cysts are persistently enlarged follicles and CL respectively.
Only found in premenopausal women.
Protected against by OCP.
Lutein cysts.
“Tumour-like condition”
What is the Mx of functional cysts
Symptomatic treatment.
If asymptomatic, cyst is observed with serial USS.
Due to remote possibility of malignancy, if an apparent functional cyst >5mm persists beyond 2 months measure CA125 and consider laparoscopy to remove or drain the cyst
What is the 5 year survival rate of ovarian cancer
Why
<35%
Due to its silent nature
What is the epidemiology of ovarian malignacny
Rates increase with age
>80% in women >50
Highest age-specific incidence rates in 80-84
OCP use may be protective
What are the risk factors for ovarian malignancy?
Relate to number of ovulations:
Early menarche
Late menopause
Nulliparity
Familial: BRCA1 or 2 (also associated with breast), HNPCC (Lynch, lifetime incidence of bowel 80%) (if >2 relatives are affected the lifetime risk is 13%) if BRCA1: 50%.
What are the protective factors against ovarian malignancy?
Pregnancy
Lactation
Use of pill
Screening for ovarian cancer
Generally foer ealry malignant rather than premalignant
Those with BRCA1 and 2 are offered yearly TVUSS and CA125 or prophylactic SPO
What are the clinical features in terms of Hx in ovarian malignancy?
Vague/ absent, 70% present with Stage 3-4 disease
Warning signs;
Persistent abdominal distension (bloating)
Feeling full (early satiety) +/- loss of appetite
Pelvic or abdo pain
Increased urinary urgency and or frequency
Vaginal bleeding
Ask about breast/GI symptoms as ovarian mass may be met from these sites.
NB for overlap with IBS although this usually presents in younger women. Must exclude ovarian cancer in older women.
What are the clinical features in terms of Ex in ovarian malignancy?
Cachexia
Large abdo or pelvic mass (very large masses are less likely to be malignant)
Ascites
Breasts should be examined.
What are the features that make an ovarian mass more likely to be malignant?
Rapid growth >5cm
Ascietes
Advanced age
Bilateral masses
Solid or septate nature on USS
Increased vasculatiry
What is the normal spread of ovarian adenocarcinoma?
Usually spreads directly within the pelvis and abdomen (transcoelomic spread)
Lymapthic and histological spread can occur.
Staging is surgical and histological.
What are the stages of ovarian cancer
Stage 1: macroscopically confined to ovaries.
1a: one ovary affected, capsule intact
1b: both ovaries affected, capsule intact
1c: one/both, capsule not intact, or malignant cells in the abdominal cavity (ascites).
Stage 2: disease beyond ovaries, confined to pelvis
Stage 3: disease is beyond the pelvis but confined to the abdomen (frequent involvement of the omentum, small bowel and peritoneuM)
Stage 4: disease is beyond abdomen e.g. lungs or liver parenchyma
How is ovarian malignancy detected intiially
What is the cut off
What is the next action
CA125 should measured in women >50 with abdominal symptoms.
>35IU/mL
USS of abdomen or pelvis
If this dentifies ascites or pelvic or abdo mass, urgent referral to secondary care
How is ovarian cancer Dx established
What is a consideration in women <40?
CA125 measured if not already done so
Measure AFP and hCG as they are at increased risk of germ cell tumours.
How is the Risk of malignancy scored for women with ?ovarian cancer
What are the possible scores?
RMI= U x Mx CA125
U scored 1 point for: multilocular cysts, solid areas, metastases, ascites, bilateral lesions.
M menopausal status: 1= pre, 3= menopausal.
CA125= serum level.
What is the cut off of RMI?
>250-> referred to MDT
CT TAP may be performed, but staging usually established surgically.
What is the surgical Mx of ovarian Ca
Assess fitness for surgery
Midline laparatomy allows assessment of abdo and pelvis
Total hysterectomy with BSO and partial omentectomy perfromed.
Stage 1: sample retroperitoneal LNs
Stage 2 or greater they are all removed through block dissection.
Uterus and unilateral ovary may be preserved in younger women following laparoscopic Sx looking to maintain fertility however they require extensive f/u
What is the CTx Mx of ovarian Ca?
Confirmed tissue dx.
Very early, no CTx
Stage 1c: carboplatin
2-4 carboplatin +/- paclitaxel.
NB 2/3rds of women with initial response to CTx relapse within 2 years of completing treatment
RTx Mx of Ovarian Ca
Only used for dysgerminomas
What are the poor Pxic features of ovarian Ca?
What normally causes death?
Advanced stage
Poorly differentiated tumours
Clear Cell tumorus
Slow/poor response to CTx
Bowel obstruction or perf
Symptom control in palliative care of ovarian Ca
Pain?
N+V
Heavy vaginal bleeding
Ascites and bowel obstruction
Analgesic ladder, co-analgesics such as antidepressants steroids and cytotoxics may be used.
Antiemetics: anticholinergics, antihistamines, dopamine antagonists or 5HT-3 antags (ondanstrenon)
High dose progestogens may be helpful. RTx can be used.
Ascites: repeated paracentesis. Obstruction can be managed at home and resolution occurs in 1/3rd spontaneously. If partial: metoclopramide (pro-motility and antiemetic) + stool obstructers with enemas for constipation and a trial of dexmethasone.
Complete obstruction: cyclizine and odansetron for N+V with hyoscine for spasm. Surgical palliation indicated with acute, single-sight obstruction, may involve insertion of stents.
Terminal distress: good symptom control with anxiolytics and analgesics without oversedation
What is the definition of palliative care
Active total care of the patient whose disease is incurable
Increase QoL
Address symptoms
Mx of primary dysmenorrhoea
NSAIDs: mefanamic acid and ibuprofen effective in up to 80% ofr women.
Combined OCP= second line
What is the difference between 1o and 2o dysmenorhhoea
In primary dysmenorrhoea there is no underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. Excessive endometrial prostaglandin production is thought to be partially responsible.
Features
pain typically starts just before or within a few hours of the period starting suprapubic cramping pains which may radiate to the back or down the thigh
Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period. Causes include:
endometriosis
adenomyosis
pelvic inflammatory disease
intrauterine devices*
fibroids
What are the two methods of emergency contraception available in the UK?
Levonorgestrel (single does of a progesterone)
Ulipristal (progesterone R modulator)
What are the features of levonorgestrel?
should be taken as soon as possible - efficacy decreases with time
must be taken within 72 hrs of unprotected sexual intercourse (UPSI)*
single dose of levonorgestrel 1.5mg (a progesterone)
mode of action not fully understood - acts both to stop ovulation and inhibit implantation
84% effective is used within 72 hours of UPSI
levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
if vomiting occurs within 2 hours then the dose should be repeated
can be used more than once in a menstrual cycle if clinically indicated
*may be offered after this period as long as the client is aware of reduced effectiveness and unlicensed indication
What are the features of Ulipristal?
a progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
concomitant use with levonorgestrel is not recommended
may reduce the effectiveness of combined oral contraceptive pills and progesterone only pills
caution should be exercised in patients with severe asthma
repeated dosing within the same menstrual cycle is not recommended
breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel
What is an alternative to the emergency contraceptive pill and its features?
Intrauterine device (IUD)
must be inserted within 5 days of UPSI, or
if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
may inhibit fertilisation or implantation
prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
is 99% effective regardless of where it is used in the cycle
may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period
What are the high risk groups for pre-eclampsia?
What is the action taken?
NICE published guidance in 2010 on the management of hypertension in pregnancy. They also made recommendations on reducing the risk of hypertensive disorders developing in the first place. Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby. High risk groups include:
hypertensive disease during previous pregnancies
chronic kidney disease
autoimmune disorders such as SLE or antiphospholipid syndrome
type 1 or 2 diabetes mellitus
75mg Aspirin
What are the causes of urinary incontinence?
Causes
overactive bladder (OAB)/urge incontinence: due to detrusor over activity
stress incontinence: leaking small amounts when coughing or laughing
mixed incontinence: both urge and stress
overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
What is the initial investigation of UI?
bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude cystocele
urine dipstick and culture
What is the Mx of urinary incontinence?
Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant:
bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
bladder stabilising drugs: antimuscarinic is first-line
surgical management: e.g. sacral nerve stimulation
If stress incontinence is predominant:
pelvic floor muscle training (for a minimum of 3 months)
surgical procedures: e.g. retropubic mid-urethral tape procedures
D/c features of Candida
‘Cottage cheese’ discharge
Vulvitis
Itch
Trichomonas vaginalis
Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
Bacterial vaginosis
Offensive, thin, white/grey, ‘fishy’ discharge
What are the causes of vaginal discharge?
Common causes
physiological
Candida
Trichomonas vaginalis
bacterial vaginosis
Less common causes
Gonorrhoea
Chlamydia can cause a vaginal discharge although this is rarely the presenting symptoms
ectropion
foreign body
cervical cancer
What are acute causes of pelvic pain? (usually)
Ectopic pregnancy
UTI
Appendicitis
PID
Ovarian torsion
Miscarriage
Hx in ectopic pregnancy?
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
Shoulder tip pain and cervical excitation may be seen
Urinary tract infection
Dysuria and frequency are common but women may experience suprapubic burning secondary to cystitis
Appendicitis
Pain initial in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing’s sign: more pain in RIF than LIF when palpating LIF
Pelvic inflammatory disease
Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities may occur
Cervical excitation may be found on examination
Ovarian torsion
Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise.
Nausea and vomiting are common
Unilateral, tender adnexal mass on examination
Miscarriage
Vaginal bleeding and crampy lower abdominal pain following a period of amenorrhoea
Chronic causes of pelvic pain
Endometriosis
IBS
Ovarian Cyst
Urogenital prolapse
Endometriosis
Chronic pelvic pain
Dysmenorrhoea - pain often starts days before bleeding
Deep dyspareunia
Subfertility
Irritable bowel syndrome
Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit
Features such as lethargy, nausea, backache and bladder symptoms may also be present
Ovarian cyst
Unilateral dull ache which may be intermittent or only occur during intercourse. Torsion or rupture may lead to severe abdominal pain
Large cysts may cause abdominal swelling or pressure effects on the bladder
Urogenital prolapse
Seen in older women
Sensation of pressure, heaviness, ‘bearing-down’
Urinary symptoms: incontinence, frequency, urgency
N+V Mx in early pregnancy
Nausea and vomiting are very common in pregnancy, with 70-85% of pregnant women affected. Most cases are mild and do not require treatment, however anti-emetics may be considered if symptoms are persistent, severe and preventing daily activities. Suitable anti-emetics include cyclizine, metoclopramide, prochlorperazine, promethazine, chlorpromazine, domperidone and ondansetron. There is no evidence to suggest that any one of these drugs works better than another.
Mx of epilepsy in early pregnancy
Epilepsy affects 0.5% of pregnant women. It is a significant cause of maternal death, and so antiepileptic treatment is continued during pregnancy. However, antiepileptic drugs increase the risk of congenital abnormalities, particularly neural tube defects. Carbamazepine and lamotrigine are the safest drugs to prescribe, whereas sodium valproate should be avoided. This is because it is associated with a higher rate of congenital abnormalities and lower intelligence in children.
Preferred drug used in Mx of hyperthyroidism in early pregnancy?
Proplthiouricil
Mx of UTI in eraly pregnancy
Nitrofuratonin is preferred
Followed by trimethoprim and then cefalexin.
NB Nitrofurantoin should be avoided at term due to risk of neonatal haemolysis
Trimethoprim should be avoided during early pregnancy due to its action as a folic acid antagonist
What are the indications for induction of labour?
Indications
prolonged pregnancy, e.g. > 12 days after estimated date of delivery
prelabour premature rupture of the membranes, where labour does not start
diabetic mother > 38 weeks
rhesus incompatibility
What are the methods for induction of labour?
Method
membrane sweep
intravaginal prostaglandins
breaking of waters
oxytocin
A 19 year-old woman attends her GP for a repeat prescription of her combined oral contraceptive pill (COCP). Since starting it, she has been suffering from severe left sided headaches with changes in her vision before the headache begins. Clinical examination is normal. What is the most appropriate step in her management?
Stop the COCP and start treatment on a progesterone only contraceptive pill.
Immediately refer her to the emergency department
Refer her to a neurologist
Commence a different COCP
Stop the COCP and start an oestrogen only contraceptive pill
The woman is having migraines with aura - a condition that can increase using the COCP. Women who have migraine with aura should stop the pill immediately - this is because the oestrogen component of the COCP can increase the risk of the women having an ischaemic stroke. A progesterone-only contraceptive pill is therefore the only alternative contraceptive medication that can be prescribed, as the others have oestrogen.
What are the factors reducing HIV vertical transmission?
maternal antiretroviral therapy
mode of delivery (caesarean section)
neonatal antiretroviral therapy
infant feeding (bottle feeding)
ART in pregnancy
all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously
if women are not currently taking antiretroviral therapy the RCOG recommend that it is commenced between 28 and 32 weeks of gestation and should be continued intrapartum. BHIVA recommend that antiretroviral therapy may be started at an earlier gestation depending upon the individual situati
Mode of delivery in pregnancy (HIV)
Mode of delivery
vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
a zidovudine infusion should be started four hours before beginning the caesarean section
Neonatal antivrial therapy
zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.
A 28-year-old pregnant woman is seen at her booking appointment. Her obstetric history revealed she had pre-eclampsia in her last pregnancy. Which of the following medications should this patient be started on at 12-14 weeks gestation to reduce the risk of intrauterine growth retardation?
The following question tests the understanding of secondary prevention of women with pre-eclampsia. There is A level data showing that low-dose aspirin started at 12-14 weeks’ gestation is more effective than placebo at reducing occurrence of pre-eclampsia in women at high risk, reducing perinatal mortality and reducing the risk of babies being born small for gestational age . There is some evidence that low molecular weight heparin might reduce the placental insufficiency seen in pre-eclampsia, but long-term safety studies are not yet available. Labetalol and methyldopa are both common antihypertensive drugs used in the acute management of pre-eclampsia, however are not given prophylactically and do not reduce intrauterine growth retardation. Similarly to LMWH, unfractionated heparin has not been proven to prevent the development uteroplacental insufficiency.
NICE guidelines suggest that a woman who has a pre-labour rupture of membranes at term…
can either be offered induction of labour approximately 24 hours later or managed expectantly. Induction is often with vaginal PGE2.
What is the most appropriate first line investigation in a woman of reproductive age who has not conceived after 1 year of unprotected vaginal intervourse?
The most appropriate first line investigation in this patient is a day 21 progesterone. This is a non-invasive test and can tell you whether the patient is actually ovulating.
Both serum prolactin and thyroid function tests are not recommended unless patient’s have a specific reason for being tested i.e. a pituitary tumour or signs of overt thyroid disease.
What are the risks to the mother and foetus of VZV in pregnancy?
Risks to the mother
5 times greater risk of pneumonitis
Fetal varicella syndrome (FVS)
risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks
features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
Other risks to the fetus
shingles in infancy: 1-2% risk if maternal exposure in the second or third trimester
severe neonatal varicella: if mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases
Mx of VZV exposure in pregnant women?
Management of chickenpox exposure
if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies
if the pregnant women is not immune to varicella she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
consensus guidelines suggest oral aciclovir should be given if pregnant women with chickenpox present within 24 hours of onset of the rash
Features of ectopic pregnancy
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
lower abdominal pain: typically the first symptom. Pain is usually constant and may be unilateral. Due to tubal spasm
vaginal bleeding: usually less than a normal period, may be dark brown in colour
history of recent amenorrhoea: typically 6-8 weeks from start of last period; if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
Examination findings
abdominal tenderness
cervical excitation (also known as cervical motion tenderness)
adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
Examination in ectopic pregnancy?
adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
What are the risk factors for endometrial carcinoma?
obesity
nulliparity
early menarche
late menopause
unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
diabetes mellitus
tamoxifen
polycystic ovarian syndrome
A 25-year-old woman presents 5 months after having dilation and curettage for a miscarriage. Since this procedure she has not had a period. A pregnancy test is negative. Hysteroscopy is performed which reveals the diagnosis.
Asherman’s syndrome, or intrauterine adhesions, may occur following dilation and curettage. This may prevent the endometrium responding to oestrogen as it normally would.
Ix in 2o amenorrhoea
exclude pregnancy with urinary or serum bHCG
gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
prolactin
androgen levels: raised levels may be seen in PCOS
oestradiol
thyroid function tests
Causes of secondary amenorrhoea (after excluding pregnancy)
hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
Classification of tears following SVD
first degree: superficial damage with no muscle involvement
second degree: injury to the perineal muscle, but not involving the anal sphincter
third degree: injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS):
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: IAS torn
fourth degree: injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
Risk factors for perineal tears
Risk factors for perineal tears
primigravida
large babies
precipitant labour
shoulder dystocia
forceps delivery
Mx of mastitis
Mastitis affects around 1 in 10 breast feeding women. The BNF advises to treat ‘if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection’. The first-line antibiotic is flucloxacillin for 10-14 days. Breast feeding or expressing should continue during treatment.
Referral to hospital for review by the surgical team is only appropriate if a breast abscess is suspected. This patient has no palpable lump therefore an abscess is unlikely.
Indications for oral antibiotics in mastitis
Rx
Infected nipple fissure not improving after 12-24h following effective milk removal
Breast milk culture positive
Fluclox for 10-14d
Erythromycin or clarithromycin if penallergic
Predisposing factors for candidiasis
diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV, iatrogenic
Mx of candidiasis
options include local or oral treatment
local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat)
oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
Causes of recurrent vaginal candidiasis
compliance with previous treatment should be checked
confirm initial diagnosis i.e. high vaginal swab, exclude differential diagnoses such as lichen sclerosus
exclude predisposing factors (see above)
consider the use of an induction-maintenance regime, with daily treatment for a week followed by maintenance treatment weekly for 6 months
Down Syndrome screening tests in pregnancy.
The combined test is recommended at 10-14 weeks gestation. It involves an ultrasound scan for nuchal translucency and a blood test for levels of Beta-human chorionic gonadotrophin (beta-hCG) and pregnancy associated plasma protein A (PAPP-A). In pregnancies with Down Syndrome, PAPP-A is low and beta-hCG raised.
If the window for the combined test was missed, at 14-20 gestation, the quadruple test will be offered. This involves a blood test for levels of alfa-fetoprotein (AFP), unconjugated oestriol, beta-hCG and inhibin A. In pregnancies with Down Syndrome, AFP and unconjugated oestriol are low and beta-hCG and inhibin A are raised.
Norethisterone 5 mg tds can be used as
a short-term option to rapidly stop heavy menstrual bleeding.
Draw the flow chart for the Mx of a woman presenting with menorrhagia
Mx of pregnant women with previous Hx of GBS
Group B streptococcus is a bacteria which is put of the natural gut flora and can colonise the vagina. About 50% of babies born to women who carry Group B streptococcus will become carriers themselves but less than 1% will be ill themselves. The largest risk factor for a baby developing Group B streptococcus growth is the mother having a previous baby who has grown it - the risk is increased by a factor of 10.
High risk women should be treated with intrapartum antibiotics, this reduces the risk of the baby developing Group B streptococcus. There is no need for antibiotics prior to labour. Having a vaginal or rectal swab will not change management as intrapartum antibiotics would still be recommended even if they were negative.
Women who have known GBS carrier status prior to this pregnancy, but have not had a baby with a GBS pregnancy there is not a requirement for IV antibiotics during labour unless another risk factor is present.
Offer intrapartum antibiotic prophylaxis using intravenous benzylpenicillin to prevent early-onset neonatal infection for women who have had:
a previous baby with an invasive group B streptococcal infection
group B streptococcal colonisation, bacteriuria or infection in the current pregnancy.
Intrapartum use of GBS for mother antibiotic choice
Benzylpenicllin
Clindamycin if penallergic
What is first choice empirical antibiotic for use in baby in ?GBS infection
IV benzylpenicillin and gentamicin
Risk factors for GBS infection?
Risk factors for Group B Streptococcus (GBS) infection:
prematurity
prolonged rupture of the membranes
previous sibling GBS infection
maternal pyrexia e.g. secondary to chorioamnionitis
Women found to have GBS infection in the antenatal period should be treated with intravenous antibiotics during labour. This has been shown to reduce early-onset GBS disease in the neonate
Extent of the vulva
Area of skin that stretches from the labie majora laterally to mons pubis anteriorly and the perieneum posteriorly. Overlaps the vestibule, the area between the labia minora and the hymen with surrounds the urethral and vaginal orifices
What is the epithelium of the vagina
What is found anteriorly?
Posteriorly?
Lymphatic drainage
Squamous epithelium
Bladder and urethra
Upper third is the pouch of Douglas, lower posterior wall close to the rectum
Most occurs via the femoral via the inguinal LNs and to the EIA nodes of the pelvis
What are the most common vulval symptoms
Pruritus
Soreness
Burning
Superficial dyspareunia
What are the causes of pruritus vulave?
Infections:
Candidiasis (+ vaginal d/c)
Vulval warts
Pubic lice/scabies
Dermatological disease:
Any condition esp eczma, psoriasis, lichen simplex, lichen sclerosus, lichen planus, contact dermatitis
Neoplasia:
Carcinoma
Premlaignant disease (vulval intraepithelial neiplasia
Features of lichen simplex
Ix
Mx
AKA chronic vulval dermatitis
Chronic inflammatory skin condition
Presents with severe intractable pruritus, especially at night
Labia majora typically inflamed and thicekend with hyper and hypopigmentation.
Symptoms can exacerbated by chemical or contact dermatitis
May be exacerbated by chemical or contact dermatitis. Linked to stress/ low Fe stores,
Vulval biopsy indicated if biopsy in doubt
Irritants such as soap should be avoided
Emollionts, moderately potent steroid creams and antihistamines
Features of liche planus
Affects skin anywhere on the body but particulalry mucosal surfaces
Presents with flat, papular purphlish lesions.
Can be erosive and more commonly assoicated with pain than pruritus
Treatment is with high-potency steroid creams:
potent – such as betamethasone dipropionate
very potent – such as clobetasol propionate
Topical calcineurin inhibitors may be used as second-line therapy
Systemic corticosteroids may be used for short periods in severe ongoing disease
Features of lichen sclerosus
Vulval epithelium is thin with loss of collagen.
May have autoimmune basis and thyroid disease and vitiligo may coexist.
Typically postmenopausal.
Causes severe pruritis which may be worse at night.
Uncontrollable scratiching may cause trauma. Pink-white papules with coalesce.
May cause inflammatory adhesions
Vulval carcinoma may develop in 5%.
Biopsy important to exclude carcinom.
treatment with ultra-potent topical steroids.
Vulvodynia
Vulvar dysaesthesiia (AKA)
Dx of exclusion.
No evidence of vulavl disease
Can be provoked or spontaneous and subdivided into to site: local or generalised.
Hx of UTI, OCP, psychosexual disorders.
Topical agents tend to be unhelpful. Oral
durgs e.g. amitriptyline or gabapentin used
Spontaneous generalised vulvar dysaesthesia
Burning pain that is more common in older patients
Vulvar dysaesthesia of the vestibule
Causes superficial dyspareunia or pain using tampons and is more common in younger women in whom introitus damage must be excluded.
Features of candidial infection of the vulva
Irritation and soreness of the vulva and anus rather than discharge.
topical or oral antifungal therapy may be necessary
What is the pathogeneis of Bartholin’s cyst/abscess
Blockage of ducts of the glands behind the labia manora causes cyst formation.
Infection may occur with Staphy or E Coli and an abscess forms.
Treatment is with incision and drainage and marsupialisation.
What is marsupialisation
Where an incision is sutured open to reduce the risk of re-formation
What are the features of introital damage
Commonly follows childbirth.
Overtightening, incorrect apposition at perineal repair or extensive scar tissue can cause superficial dyspareuina.
If the introitus is too tight, vaginal dilators or surgey can be used
What is Fenton’s repair?
The Fenton’s procedure (also called Fenton’s repair) is an operation to remove scar tissue and widen the vaginal opening when a woman experiences persistently painful sexual intercourse.
Health problems that may require a Fenton’s procedure include:
- Lichen planus of the vulva or vagina
- Lichen sclerosus of the vulva
- Previous surgery on the genitals that results in painful intercourse
- Childbirth tears
- Episiotomy complications
- Radiotherapy to the genitals
What is a common error in the consideration of vaginal cysts
Often mistaken for a prolapse
What is vaginal adenosis
When columnar epithelium is found in the normally squamous epithelium of the vaginal.
Occurs in women whose mothers received diethylstillboestrol in pregnancy
Can turn malignant (clear cell carcinoma of the vagina) although often spontaenously resolves.
Women with DES exposure in utero undergo annual screening by colposcopy.
What is VIN
What are the two types
Presence of atypical cells in the vulval epithelium
Usual: nearly all VIN is usual. Associated with HPV, CIN, smoking and chornic immunosuppression, Nay be mutlifocal and varied aappearaence. Associated with warty or basaloid SCC.
Differentiated: associated with lichen sclerosis, seen in older women, usually unfocal, linked to keratinisiing SCC of the vulva. Higher risk of progression to cancer thean for VIN.
Mx of VIN
Pruritus or pain common: emollients or mild topical steroid may help.
Gold standard is local surgical excision for symptomatic relief, to confirm histology and exclude invasive disease.
15% of women undergoing excision have unrecongised invasive disease. Therefore if conservative management is used, adequate biopsies must be taken.
VIN=
Vulval Intraepithelial Neoplasia
Epidemiology for carcinoma of the vulva
5% of genital tract cancers.
Most common >60y/o
What is the pathology of vulval carcinoma
95% are SCC.
Melanomas, BCC, adenocarcinomas and others accoutn for the rest.
Aetiology of vulval carcinoma
VIN is premalignant.
However it often arises de novo
Associated with lichen sclerosis, ummonsuppresion, smoking and paget’s disease of the vulva
What is paget’s disease of the vulva
Extramammary Paget’s disease (EMPD), also extramammary Paget disease, is a rare, slow-growing, usually noninvasive intraepithelial (in the skin)adenocarcinoma outside the mammary gland and includes Paget’s disease of the vulva and the extremely rare Paget’s disease of the penis
Hx in vulval carcinoma
Pruritus
Bleeding or d/c
Mass
Malignancy often presents late due to unnoticed lesions or embarrassment
Ex in carcinoma of vulva
Ulcer or mass
Most commonly on the labia majora or clitoris.
Inguinal LNs may be enlarged, hard and nodal
Spread of vulval carcinoma
Local and via LN-> superfiical then deep inguinal nodes-> femoral-> EIA.
Contralateral spread may occur
Staging is surigcal and histological
50% present with Stage 1 disease
Staging of vulval carcinoma
Stage 1:
a: Tumour confined to vulva/perineum, <2cm in size with stromal invasion <1mm. Negative nodes.
b: Tumour confined to vulva perineum, >2cm in size or with stromal invasion >1mm. negative nodes.
Stage 2: tumour of any size with adjacent spread, negative nodes.
Stage 3: tumour of any size with positive inguinofemoral nodes.
Stage 4: tumours invades upper urethra/vagina/rectum, bladder, bone or distant metastases (IVA vs IVB)
Ix of vulval carcinoma
Biopsy
Fitenss for surgery: CXR, EXG, FBC, U&E, X match
Treatment of vulval carcinoma
Stage 1a: wide local excision
For other stages: WLE and groin lymphadenectomy through skin-sparing incisions.
If the tumours doesn’t extende to within 2cm of midline unilateral excision of LNs has emerged. This has replaced the radical vulvectomy.
Cxs: wound break down, infection, lymphoaedma, lymphocyst formation and sexual and body image probelms.
RTx may be used for large tumours prior to Sx.
Px of vulval carcinoma
Many patients die from other age-related disease
Surival at Stage 1: >90%
Stage 3-4: 40%
Features of secondary vaginal carcinoma
Common and arises from local infiltration from cervix, endometrium or vulva or from metastatic spread from cervix, endometrium or GI tumours
Features of rpiamry carcinoma of the vagina
2% of all genital tract malignancies.
Affects oder women and is usually squamous.
Presents with bleeding or discharge and a mass or ulcer is evident.
Treatment with intravaginal RTx or radical surgery.
Survival at 5y: 50%
Features of clear cell adenocarcinoma of the vagina
Most common in the late teenage years.
Most are a rare Cx of DES prescription to mother during pregnacies to try to prevent miscarriage in 1950-70.
Radical surgery and RTx: good survival
What is the importance of infection in pregnancy?
Maternal illness may be worse e.g. varicella
Maternal complications: HIV infection implicated in pre-eclampsia
Preterm labour
Vertical transmission can cause miscarriage, can be teratogenic or damage developed organ or can cause serious infection in child.
Neurologic damage is more common in present of bacterial infrection
Antibiotic usage may be limited by potential adverse effects on foetus.
Features of CMV
Herpesvirus transmitted by personal contact.
Up to 1% of women develop CMV infection, usually subclinical in pregnancy.
Common cause of handicap and deafness
Fetal effects of CMV infection
Vertical transmission occurs in 40%
10% of infected neonates are symptomatic at birth with IUGR, pneumonia and thrombicytopenia.
Most of these will develop serious neurological sequelae: hearing, visual and mental impairment or die
Asympthomatic neonates are at risk of deafness.
Dx of CMV infection
USS abnromalities inconsitently present but include intracranial or hepatic calcification.
Most diagnoiesd using CMV testing.
CMV IgM remains positive a long time after infection, which could predate pregnancy, titres willl rise and IgG avidity will be low with recent infection.
If maternal infection confirmed: amniocentesis >6w post maternal infection will confirm or refute vertical trnsmission
Mx of CMV infection in pregnancy
Most infected neonates are not seriously affected.
Close surveillance for USS abnormlities and fetal blood sampling at 32w may help determine those at greatest risk for severe sequelae.
No prenatal treatment and termination may be offered.
Routine screening not advised.
Herpes simplex virus features
Responsible for most genital herpes
Less than 5% of pregnant women have a history of prior infection but man more have Abs
Fetal/neonatal effects of HSV
Not teratogenic.
Neonatal infeciton is rare but has a high mortality.
Vertical transmission occurs at vaginal delivery, particularly if vesicles are present.
More likely to occur in context of recent maternal infection because the fetus will not have maternal Abs (Risk >40%)
Dx of HSV infection
Cliinically and swabs are of little use
Mx of HSV infection in pregnancy
Referral to GU clinic
C-section for those delivering within 6w of primary attack and those with genital lesions from primary infection at time of infection.
Risk is less in recurrent herpes and they can have normal labour.
Daily aciclovir in late pregnancy may reduce the frequency of recurrences at term.
Exposed neonates are given IV aciclovir.
NB if there are CNS features in child at risk of HSV infection
LP shuld be performed
Aciclovir IV until infection excluded
Features of rubella in pregnancy
Congenital rublleea is very rare in UK due to immunisation
Effects of rubella on fetus
Maternal infection causes multiple fetal abnromalities including deafness, cardiac disease, eye problems, rmental retardation.
Probability and severity decreases with advancing gestation.
At 9w the risk is 90% if after 16w risk is very low.
Mx of rubella in pregnancy
If a non-immune woman develoips Rubella before 16w, TOP offered.
Screening routine at booking to identify those in need of vaccination after end of pregnancy.
Rubella vaccine is live and thus contraindicated in pregnancy.
Features of toxoplasmosis in pregnancy
Caused by T. gondii
Follows contact with cat faeces, soil or eating infected meat.
Infection in pregnancy occurs in 0.2% of women in UK but is more common in europe
Fetal/neonatal effects of toxoplasmosis
Fetal infection occurs in <50%
More common as pregnancy progresses.
Earlier infection leads to more severe sequelae: mental retardation, convulsions, spasiticities and visual impairment.
Dx of toxoplasmosis in pregnacny
USS may show hydrocephalus
Maternal infection diagnosed after IgM testing.
Flase positives and negatives are common
Can be diagnosed or excluded using amniocentesis after 20w.
Mx of toxoplasmosis
Health education to reduce risk of toxoplasmosis
Spiromycin intiated once maternal infection confirmed.
Additional combination therapy may be used following confirmation of vertical transmission although TOP may be requested.
Features of VZV
Chickenpox in pregnancy is rare but can cause severe maternal illness
Fetal/neonatal affects of VZV
Teratogenicity is a rare consequence of early pregnacny infection (which is immediately treated with oral aciclovir).
Maternal infection in the 4w preceding pregnancy may cause severe neonatal infection, this is most common if delivery occurs within 5d or 2d before maternal symptoms
Mx of VZV in pregnancy
Ig used to prevent and aciclovir to treat infection.
Pregnant women exposed are tested to confirm immunity. Ig recommended if they are non-immune
Aciclovir if infection occurs.
In late pregnancy neonates delivered in the risk period are given Ig. closely monitored and aciclovir if infection occurs.
What are the infections screened for in pregnancy
Asymptomatic bacturia: MSU
Chlamydia (<25y/o)
HBV
HIV
Rubella
Syphillis
Why should parvovirus B19 be tested for if ?Rubella in pregnancy?
As they are clinically indistinguishable.
How to treat pain or fever in pregnancy
Paracetamol
Ibuporfen may be considered but should not be used beyoind 27w gestation.
Features of parvovirus B19 infection
Infects 0.26% of pregnant women and more during epidemics
Slapped cheek is calssic but many have arthralgia or are asymptomatic
Fetal/neonatal effects of B19
Virus suppresses fetal erythropoiesis causing anaemia and variable degrees of thrombocytopenia
Fetal death occurs in 10% of pregnancies usually before 20w
Dx of B19
Where materanl exposure or syymtpoms have occurred maternal IgM testing will prompt fetal surveillance
Anaemia is detectable on USS as increased blood flow velocity in the fetal middle cerebral arteral and subsequently as oedema (fetal hydrops) from fetal heart failure.
Maternal testing may also follow identification hydrops
Hydrops and anaemia spontaneously resolves in 50%
Mx of B19
Mothers infected are regulalry sacanned
Where hydrops is detected, in utero transfusion is given is this is severe.
Evidence of severe disease being associated with neurological damage
Features of GBS infection in pregnancy
Caused by carriage of Streptococcus agalactiae which is asymptomatic in about 25% of pregnant women
Neonatal effects of GBS
The fetus can be infected during labour after ROM. Most commmon in pre term labour or PROM.
Maternal fever
Early onset GBS occurs in 1 in 500 neonates. Causes severe illness and has a 6% mortality in term and 18% mortality in preterm.
IV benzyl can prevent vertical transmission
Risk factors for GBS transmission
Previously affected neonate
Positive urinary culture for GBS
Preterm labour
ROM >18h
Maternal fever in labour
Treatment is usual for incidental GBS carriage.
Strategy 1 vs Strategy 2 for GBS
Strategy 1= treatment based on RFs
Strategy 2: screening with vaginal and rectal swabs at 35-37w
Treat with IV benzlypenicillin in labour if swabs positive or RFs present
Features of HBV in pregnancy
Persitent HBV infeciton presint in 1% of pregnant women up to 25% in those from Asia and Africa.
Degree of infectivity depends on Ab status. HBsAb are immunologically cured and of low infectivity.
Those with surface Ag but not Ab and those with E Ag are more infectious
Neonatal effects of HBV infection
Vertical transmission occurs at delivery.
90% of infected neonates become chronic carriers compared to 10% of adults
Mx of HBV infection
Neonatal immunisation reduces the risk of infection by over 90%.
Maternal screening is routine in
Offer tenofovir disoproxil to women with HBV DNA greater than 107 IU/ml in the third trimester to reduce the risk of transmission of HBV to the baby UK
Advise women that there is no risk of transmitting HBV to their babies through breastfeeding if guidance on hepatitis B immunisation has been followed, and that they may continue antiviral treatment while they are breastfeeding.
Maternal effects of HIV in pregnancy
Does not hasten progression to AIDS
Increased incidence of pre-eclampsia (may be increased by ARTs)
Gestational diabetes may be more commmon
Neonatal/fetal effects of HIV
Stillbirth, pre-eclampsia, IUGR and prematurity more problem
Congenital abnormalities aren’t and ARTs not teratogenic
NB Folic acid antagonists may be prescribed to HIV infected women.
The most important risk is of vertical transmission, beyond 36w, intrapartum or during breastfeedings.
25% of infected neonates develop AIDS by 1y, 40% will develop AIDS by 5y
Mx of HIV in pregnancy
HIV +ve women should be managed in conjunction with their physician and have regular CD4 and viral load tests.
Prophylaxis against PCP if low CD4
Drug toxicity monitored with LFT, RFT, Hb and blood glucose.
Ix for genital tract infections.
HAART including zidovudine which reduces viraemia and maternal disease and should be continued throughout pregnancy and delivery.
Neonate treated for the first 6w.
Therapy in women not already taking HAARTs is usally started at 28w.
C-section
Reduces vertical transmission to <1%
Features of GAS
Traditionally responsible for puerperal sepsis.
Most common bacterium associated with maternal death in which sepsis is the leading cause (50%).
Caused by strep pyogenes, NB sore throat.
Infection during as opposed to after pregnancy is usally from children.
Chorioamnionitis. abdo pain, diarrhoea and severe sepsis may ensue.
Infected fetus usually dies in utero
Early recognition, culture and high dose antibiotics and ITU required in severe cases..
IFV in pregnancy
Immunisation recommended
Oseltamivir and zanamivir
Admit esp if respiratory symptoms
Syphillis in pregnancy
Active disease in pregnacny usually causes miscarriage, severe congenital disease or stillbirth
Benzylpenicillin will prevent but not reverse fetal damage.
VDRL used for screening/ PCR
Implications of TB in pregnancy
Tuberculin testing is safe
BCG is live and contraindicated.
Dx in late pregnancy is associated with prematurity and IUGR.
Treatment with first line drugs and vitamin B6 is safe in pregnancy
Streptomycin is contraindicated
Implications of HCV infection in pregnancy
Vertical transmission occurs in 6% and is increased by HIV coinfection and high viral load.
Infected neonates are prone to chronic hepatitis.
C-sec doesn’t reduce vertical transmission.
Screening restricted to high risk groups
Maternal cxs of malaria infection
Severe anaemia and other problems are more common
Fetal cxs of malaria
IUGR and stillbirth are more common
Congenital malaria complicates 1% of affected pregnancies
Artemisin combination therapy appears safe.
Intermittent preventative treatment of 2 dosease at least a month apart can prevent maternal and neonatal infection
Where is L monocytogenes found?
What does it cause?
Dx?
Prevention
Gram negative bacillus found in pates, soft cheeses and prepacked meals
Causes nonspecific febrile illness.
If bacteraemia occurs in pregnancy then a potentially fatal infection of the fetus may occur.
Blood cultures
Avoidance of high risk food.
What are the implications of chlamydia/gonorrhoea infection in the neonate
Associated with preterm labour and neonatal conjunctivitis.
Treatment of of chlamydia in pregnancy?
azithromycin or erythromycin.
NB tetracycline causes fetal tooth discolouration
Treatment of gonorrhoea in pregnancy
Cephalosporins due to high prevalence of penicllin resistance
Most common causes of BV
Implications in pregnancy
Mx
Gardnerella vaginalis and mycoplasma hominis
Preter, labour and late miscarriage more common
Screning and treatment with oral clindamycin reduces the risk of preterm birth.
Anatomy and function of the female lower UT system
Voluntary control of urine release achieved by the bladder and urethra
Normal function of the filling phase relies upon adequate bladder capacity and competent urethral sphincter.
Normal function of the voiding phase is dependant upon detrusor contractility and coordinated urethral relaxation.
Bladder has a smooth muscle wall: detrusor muscle
Can store around 500mL or urine although first urge to void is at 200mL.
Drained by the urethra which is 4cm long and has a muscular wall and external orifice in the vestibule
Nervous control of the bladder
PNS: aids voiding
SNS: prevent
Afferent fibres respond to bladder wall distension
Effeerent PNS bass back to the detrusor muscle and cause contraction.
Efferent SNS fibres also pass to the detrusor and are inhibted.
This is the micturition reflex and is controlled at the level of the pons.
The cerebral cortex modulates this through relaxation or contraction of the pelvic floor and the striated muscle of the urethra
What are the factors that influence continence.
Prssure in the urethra being greater than in hte bladder.
Bladder pressure is influenced by detrusor pressure and intra-abdominal pressure.
Urethral pressure is influenced by the inherent urethral muscle tone and by external pressure (pelvic floor and intra-abdominal pressure).
The detrusor muscle is expandable, as bladder fills there is no increase in pressure.
Increases in abdominal pressure are transmitted equally to the bladder and upper urethra.
Therefore coughing does not normally lead to urinary incontinence.
When does micturition occur
When bladder pressure exceeds urethral pressure.
Achieved volunterily by simultaenous drop in urethral pressure (partly due to pelvic floor relaxation) and in bladder pressure due to detrusor contraction.
What are the two main causes of female incontinence?
Uncontrolled increases in detrusor pressure
Increased intra-abdominal pressure transmitted to bladder but not urethra
Rarer causes include urine bypassing the sphincter through a fistula
Or pressure overwhelming the sphincter due to overfilling of thbladder due to neurogenic causes
Or outflow obstruction leading to overflow incontiinece
What are the implications of uncontrolled increases in detrusor pressure
Most common cause
Increased bladder pressure beyond that of the normal urethra due to
OAB or urinary urge incontinence (previously called detrusor instability) i
What are the implications and cause of increased intra-abdominal pressure transmission to the bladder but not the urethra?
Incontininece, normally as a consequence of the urethral neck slipping from the abdomen.
Bladder pressure therefore exceeds urethral pressure when intra-abdominal pressure is raised.
This is most commonly caused by urinary stress incontince
What are hte common urinary symptoms?
Incontinence
Daytime frequency
Nocturia
Nocturnal enuresis
Urgency
Bladder pain
Urethral pain
Dysuria
Haematuria
What is urinary incontinence?
The complaint of involuntary urinary leakage wihich can be divided into stress incontinence and urge incontinence.
What is daytime frequency?
Normal?
Number of times a women voids during waking hours
Normall 4-7
Increased daytime frequency defined by patients perception
What is nocturia
Having to wake at night one or more times to void
<70y/o >1 per night= abnormal
What is nocturnal enuresis
Urinary incontinence during sleep
What is urgency?
Sudden compelling desire to pass urine, which is difficult to deter.
Most frequently secondary to detrusor overactivity
Inflammatory bladder conditions may also present with this
What is bladder pain and where is it typiically felt?
Supra or retropubic.
Pain occurs with bladder filling and is relieved by emptying it.
Pain is indicative of an intravesical pathology such as interstitial cystitis or malignancy
What is dysuria?
Pain felt in the bladder or urethra on passing urine, most frequently associated with UTI
What are the features of urine dipstick tests?
Blood, glucose, protein, leucocytes and nitrites
Nitrites suggestive of infection, if +ve MCS
Glycosuria suggests diabetes
Haematuria suggests bladder carcinoma or calculi
What is a urine diary
When a patient keeps a record for a week of the time and volume of fluid intake and micturition
What is the use of postmicturition ultrasound or catheterisation
Exclude chornic urinary retention
What is cystometry
Directly measures via a catheter, the pressure in the bladder while the bladder is filled and provoked with coughing.
A pressure transducer also placed in vagina or rectum to measure abdominal pressuor.
How can true detrusor pressure by caclulated?
Subtraction of the abdominal pressure from the vescile pressure.
Should not normally alter with filling or provocation
If urinary leaking occurs with coughing in the absence of detrusor contraciton what is the likely diagnosis?
Urodynamic stress incontinence
What is the diagnosis if an involuntary detrusor contraction occurs?
Detrusor overactivity
What is the use of ultrasonography in investigation of the urinary tract
Excludes incomplete bladder emptying.
Checks for congenital abnromalities or abnormalities of the kidneys
What is the use of CT urogram?
With the use of contrast the integrity and route of the uretur is examined
What is the methylene dye test?
BLue dye is instilled into the bladder, leakage from places other than the urether i.e. fistulae can be seen
What is the definition of urinary stress incontinence?
Whendoes it become urodynamic stress incontinence
What is the most common cause
Complaint of involuntary leakage of urine on effort or exertion, on sneezing or coughing.
Once it has been confirmed by urodynamic studies
As a result of urethral sphincter weakness, can only be made with certainty after cystometry.
What proportion of female incontinence is caused by stress incontinence?
50%
Occurs to verying degress in more than 10% of women
What are the causes of stress incontinence?
Pregnancy and vaginal delivery
Esp: prolonged labour, forceps delivery
Obestity and age.
Prolapse commonly exists but is not always related.
Previous hysterectomy (when indication was not for prolapse or urianry symptoms) may predispose to USI
What is the mechanism of stress incontinence
Increase in intra-abdominal pressure, normally the bladder neck is equally compressed and its pressure rises so the P difference remains unchanged.
If the bladder neck has slipped below the pelvic floor because its supports are weak it will not be compressed.
If the rest of the urethra are unable to compensate the bladder pressure exceeds urethral pressure and incontinence results.
Hx in stress incontinence
Disruption of patients life
Stress incontinence predominantes, may also complain of frequency, urgency or urge incontinence.
It is important to have the patient prioritise her symptoms as treatment for USI vs OAB differs.
Faecal incontinence may coexist (perineal tear during childbirth)
Ex in Stress incontinence
Sim’s speculum, often but not invariable reveals a cystocoele or urethrocoele.
Leakage of urine with coughing may be seen.
Abdo palpation to exclude bladder distension.
Ix in stress incontinence
Urine dipstick
Bladder diaries
Can measure post-void residual volume by bladder scan
Try conservative management before:
Cystometry is required to exclude overactive bladder is considered or if overactive bladder symptoms fail to respond to medical treatment
UTIs, MCS and antibiotics
Positive for leucocytes and nitrites with symtpoms; send an MSU for MCS and start empirical antibitotics.
Symptomatic and negative test for leucoytes or nitrites send an MSU for MCS and consider empirical antibiotics
If asymptomatic with postivie L and N, do not offer antibiotics without the results of MSU
If asymptomatic and negative for either L or N do not send for MCS as unlikely UTI
Mx of stress urinary incontinence
Conservative:
Modification of fluid intake
Lose weight if obese
Cause of chronic cough can be reduced e.g. smoking.
1st line Pelvic floor muscle training
Medical:
[Duloxetine (not routinely used as second line treatment unless woman prefers not to have surgery]
2nd line Sxical:
Considered when conservative measures have failed and woman’s QoL is being signficantly impact.
Need to be clear that USI is the cause
Mid-urethral sling using tension free tape and trans-obturator baginal tape are first line with cure rates up to 90%
If sx fails, artifical urinary sphincter may be considered.
What is duloxetine and its adverse effects
SNRI that enhances urethral striated sphincter activity
Associated with significant and dose-dependant reduction in frequency of incontinence episodes.
Can cause nausea, dyspepsia, dry mouth, dizziness, insomnia or drowsiness
What are the Cxs of surgery for USI?
Bladder perforation
Postoperative voiding difficulty
Bleeding
Infection
de novo detrusor overactivty and suture or mesh erosion
What is TVT?
Tension-free vaginal tape: synthetic polypropylene tape placed in a U-shape under the midurethra ander LA or GA, tension adjusted as woman coughs
Cystouerthroscopy is performed to ensure there has been no damage to bladder or urethra
What is TOT
Transobturator tape
Similar to TVT with different insertion methd (via the transobturator foramen)
Reduced risk of bladder perf as retropubic space isn’t entered.
What is injectable periurethral bulking?
Injection of bulking agents for the treatment of USI. Has a low immediate success rate but low morbidity so may be appropriate in patients where surgery has failed or very elderly patients.
What is the difference between USI and stress incontinence?
Stress incontinence is a symptom
USI is a disorder diagnosed only following cystometry
Def OAB?
Urgency with or without urge incontinence, usually with frequency or nocturia in the absence of proven infection.
What is detrusor overactivity?
Urodynamic diagnosis characterised by involuntary detrusor contractions during the filling phase which may be spontaenous or provoked by coughing.
What is the epidemiology of OAB
causes 35% of female incontinence
Aetiology of OAB
Can follow operations for USI in which case it may be caused by bladder neck obstruction.
May occasionally occur in hte context of detrusor overactivity occuring the presence of a neuropathy e.g. MS or SC injury
Mechanism of incontinence in OAB
Detrudor contraction normally felt as urgency. If strong enough it causes the bladder pressure to overcome the urethral pressure and the patient leaks= urge incontinence.
Can occur spontaneously or with provocation e.g. rise in IAP.
Hx in OAB
Urgency and urge incontinence
Frequency
Nocturia
Stress incontinence also common
Some patients leak at night or at orgasm
Hx of childhood enuresis is common
Faecal urgency
Ex in OAB
often normal but an incidental cystocoele may be present
Ix in OAB
Urine dip
Urine diary: frequent passage of small volumes of urine, particularly at night and may show high intake of caffeine containing drinks.
After lifetyle changes and trial of Rx, cystometry
Mx of OAB
Lifestlye changes:
Reduce fluid intake, obesity, avoiding caffeine, drugs that alter bladder function such as diuretic and antipsychotics should be reviewed.
Conservative:
1st line Bladder training lasting a minimum of 6 weeks
Medical:
Muscarinic antagonists
2nd line: Oxybutynin or toiterodine or darifenacin, offer durg with lowest acquisition cost
3rd line: oestrogens, mirabegron for symptomatic control
Sxical (only after cystometry):
Botulinum toxin injection
Percutnaeous nerve stimulation
Clam augmentation ileocystoplasty is used only for very severe and resistant symptoms, woman has to be willing to self catheterise
Urinary diversion (last ditch)
Anticholinergics MOA in OAB
Adverse effects
Suppress detrusor overactivity
Block muscarinic receptors that mediate detrusor smooth-muscle contraction relaxing the detrusor muscle
Dry mouth, dizziness (oxybutynin), constipation, blurred vision, drosiness and dizziness. Have also been known to induce delerium
MOA of oestrogens in OAB
Many women develop bladder filling symptoms after menopause
Improves symptoms of vaginal atrophy.
Can reduce symptoms of urgency, urge incontinence, frequency and notcuria
Botulinum A MOA in OAB
Cxs
Blocks NMJ transmission causing weakness
Injected cystoscopicall into the detrusor muscles with sparing of the trigonium.
Lasts 6m on average.
Voiding dysfunction and urinary retention
Features of neuromodulation and sacral nerve stimulation
Continuous stimulation of hte S3 nerve root via an electrical pulse generator improves the ability to suppress detrusor contractions
Causes of urgency and frequency
UTI
Bladder pathology
Pelvic mass
Overactive bladder
USI
What is Mixed incontinence
Combination of USI and OAB
Dx made at cytometry
Most bothersome symptom treated first
Def acute urinary intention
Features
Patient unable to pass urine for 12h or more.
Catheterisation producing as much or more urine than bladder capacity
Painful unless due to epidural anaesthesia or failure of the afferent pathway
Causes of acute urinary retention
Mx
Childbirth: epidural, vulval or perineal pain
Sx
Drugs such as anticholinergics
Retroverted gravid uterus
Pelvic mass
Neurological disease
Catheterisation for 48h whilst cause is treated
Features of chronic retention and urinary overflow
1% of incontinence
Bladder overdistension eventually causes overflow
Can be due to urethral obstruction or detrusor inactivity
Pelvic masses and incontinence sx are the most common causes of urethral obstruction
Autonomic neuropathies e.g. DM or previous overdistension of the bladder can cause detrusor inactivity.
Presentation may mimic stress incontinence or loss may be continuous
Examination reveals a distended non-tender bladder
Dx with USS or catheter after micturition
Features of painful bladder syndrome and interstitial cystitis
PBS= suprapubic pain due to bladder filling accompanied by other symptoms e.g. frequency in the absence of UTI
Dx of interstital cystitis reserved for pateitns with painful bladder who have characteristic cystoscopic and histological features.
Treatments include dietary modificatiion, bladder training, TCAs, analgesics and intravesical drug infusion
What are the most common fistulae causing incontinence
Vesicovaginal
Urethrovaginal
Commonly as a result of obstructed labour in the developing world, in West normally due to Sx, RTx or Ca.
Ix with CTU or cystoscopy.
Sx often required
Name that fistula!
- urethrovaginal
- vesicovaginal
- vesicouterine
- ureterovaginal
What are the cut offs for anaemia in pregnancy?
Anaemia in pregnancy is defined using different cut off values than in non-pregnant women and varies according to trimester. British Committee for Standards in Haematology (BCSH) guidance gives the following values:
first trimester Hb less than 110 g/l
second/third trimester Hb less than 105 g/l
postpartum Hb less than 100 g/l
What are the management options for anaemia in pregnancy?
Royal College of Obstetricians and Gynaecologists (RCOG) guidelines advise for normocytic or microcytic anaemia a trial of oral iron should be considered as the first step, and further investigations only required if no rise in haemaglobin after 2 weeks.
Parenteral iron is only indicated if oral iron is not tolerated, absorbed, patient is not compliant or they are near term and there is insufficient time for oral iron to be effective.
Blood transfusion is inappropriate at a slighlty low level of haemoglobin without active bleeding.
Define placental abruption
Epidemiology
Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
1/200 pregnancies
What are the associated factors for placental abruption?
Cause - not known but associated factors:
proteinuric hypertension
multiparity
maternal trauma
increasing maternal age
What are the clinical features of placental abruption
Clinical features
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.
Risk factors include: maternal hypertension (common), cocaine, trauma, uterine overdistension, tobacco and previous placental abruption.
What are the causative organisms for PID?
Causative organisms
Chlamydia trachomatis - the most common cause
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
What are the features of PID?
Features
lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities may occur
vaginal or cervical discharge
cervical excitation
Ix of PID
screen for Chlamydia and Gonorrhoea
Mx of PID
due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment
oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in. The more recent BASHH guidelines suggest that the evidence is limited but that ‘ Removal of the IUD should be considered and may be associated with better short term clinical outcomes’
Cxs of PID
Complications
infertility - the risk may be as high as 10-20% after a single episode
chronic pelvic pain
ectopic pregnancy
Def PID
Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum. It is usually the result of ascending infection from the endocervix
What are the major causes of bleeding in the 1st trimester?
Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole
Causes of bleeding in 2nd trimester?
Spontaneous abortion
Hydatidiform mole
Placental abruption
Causes of bleeding in 3rd trimester?
Bloody show
Placental abruption
Placenta praevia
Vasa praevia
Hydatidiform mole features
Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high
Features of placenta praevia
Vaginal bleeding, no pain. Non-tender uterus* but lie and presentation may be abnormal
*vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage
Features of vasa praevia
Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen
What are indications for gynae referral in hyperemesis gravidarum?
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).
Def: hyperemesis gravidarum
Hyperemesis gravidarum describes excessive vomiting during pregnancy. It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks*.
*and in very rare cases beyond 20 weeks
Cxs of hyperemesis gravidarum
Wernicke’s encephalopathy
Mallory-Weiss tear
central pontine myelinolysis
acute tubular necrosis
fetal: small for gestational age, pre-term birth
Mx of hyperemsis gravidarum
antihistamines should be used first-line (BNF suggests promethazine as first-line)
ginger and P6 (wrist) acupressure: NICE Clinical Knowledge Summaries suggest these can be tried but there is little evidence of benefit
admission may be needed for IV hydration
Mx of primary herpes infection within 6w of delivery
Oral aciclovir 400 mg TDS (three times daily) until delivery is recommended in the RCOG guidelines for women who present with a primary herpes infection in their third trimester of pregnancy, especially if the woman is expected to deliver within 6 weeks.
When is IV aciclovir indicated in HSV infection during pregnancy?
IV aciclovir for the mother or for the infant is only recommended if there has been a preterm pre-labour rupture of membranes or a spontaneous vaginal delivery in the presence of a primary herpes infection.
What are the ToRCH infection?
toxoplasmosis, other, rubella, CMV, herpes
HSV 6w before delivery?
It can be difficult to differentiate between a primary infection and a recurrent infection and the guidelines recommend suppressive therapy for both infections after 36 weeks until delivery. Recommended method of delivery in a primary infection is a Caesarean section. For a recurrent infection the risk of transmission is low due to maternal antibodies and a Caesarean section is not recommended.
Mx of HSV
Management
gingivostomatitis: oral aciclovir, chlorhexidine mouthwash
cold sores: topical aciclovir although the evidence base for this is modest
genital herpes: oral aciclovir. Some patients with frequent exacerbations may benefit from longer term aciclovir
A 22-year-old woman presents with a thin, purulent, and mildly odorous vaginal discharge. She also complains of dysuria, intermenstrual bleeding and dyspareunia. A swab shows a Gram negative diplococcus.
IM ceftriaxone + oral azithromycin
The 2011 British Society for Sexual Health and HIV (BASHH) guidelines recommend ceftriaxone 500 mg intramuscularly as a single dose with azithromycin 1 g oral as a single dose. The azithromycin is thought to act synergistically with ceftriaxone and is also useful for eradicating any co-existent Chlamydia infections
A 27-year-old woman complains of an offensive ‘musty’, frothy, green vaginal discharge. On examination you an erythematous cervix with pinpoint areas of exudation.
The correct answer is Oral metronidazole
The ‘strawberry cervix’ is actually quite rare outside of examinations - some studies suggest only 2% of patients with Trichomonas vaginalis have this finding
A 30-year-old woman presents with an offensive ‘fishy’, thin, grey vaginal discharge. Testing the discharge shows the pH to be > 4.5.
Oral metronidazole
Amsell’s criteria for BV Dx?
Amsel’s criteria for diagnosis of bacterial vaginosis - 3 of the following 4 points should be present:
thin, white homogenous discharge
clue cells on microscopy: stippled vaginal epithelial cells
vaginal pH > 4.5
positive whiff test (addition of potassium hydroxide results in fishy odour)
Mx of PPH
ABC
IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
IM carboprost
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
Secondary PPH
occurs between 24 hours - 12 weeks**
due to retained placental tissue or endometritis
Primary PPH
occurs within 24 hours
affects around 5-7% of deliveries
most common cause of PPH is uterine atony (90% of cases). Other causes include genital trauma and clotting factors
Use of PGE2 in pregnancy?
Initiating labour
Uses of indomethacin and salbutamol in pregnancy?
Tocolytics
Use of mifepristone in pregnancy?
Medical abortion
Use of oxytocin/ergometrine in pregnancy?
oxytocin / ergometrine is commonly used to encourage smooth muscle contraction in uterine blood vessels, reducing the risk of postpartum haemorrhage.
Variable decelerations
Independent of contractions
May indicate cord compression
Late deceleration
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
Early deceleration
Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction
Usually an innocuous feature and indicates head compression
Baseline bradycardia CTG
Heart rate < 100 /min
Increased fetal vagal tone, maternal beta-blocker use
Baseline tachycardia CTG
Heart rate > 160 /min
Maternal pyrexia, chorioamnionitis, hypoxia, prematurity
Loss of baseline variability CTG
< 5 beats / min
Prematurity, hypoxia
Classification of PPH?
What are the four Ts?
Primary postpartum haemorrhage is defined as the loss of 500ml or more from the genital tract within 24 hours of the birth of a baby. This can be further defined as minor haemorrhage (500-1000ml) or major haemorrhage (>1000ml), and causes 6 deaths/million deliveries.
Causes can be grouped into the ‘four T’s’:
tone
tissue (retained placenta)
trauma
thrombin (coagulation abnormalities)
Vitamin A in pregnancy?
FUnctions of vitamin D?
Vitamin A is teratogenic in high doses, and pregnant women should not exceed a daily intake of >10,000IU. Women are therefore advised to avoid any supplements containing vitamin A, such as normal multivitamin tablets, in pregnancy (NHS Choices). However, as supplements in the UK are now limited to a maximum vitamin A content of 6,000IU, if they have been taking one it should not be cause for concern. Pregnant women are also advised to avoid eating liver, as it has high levels of vitamin A.
Vitamin A is a fat soluble vitamin.
Functions
converted into retinal, an important visual pigment
important in epithelial cell differentiation
antioxidant
Consequences of vitamin A deficiency
night blindness
HRT Adverse effects?
Side-effects
nausea
breast tenderness
fluid retention and weight gain
Potential complications
increased risk of breast cancer: increased by the addition of a progestogen
increased risk of endometrial cancer: reduced by the addition of a progestogen but not eliminated completely. The BNF states that the additional risk is eliminated if a progestogen is given continuously
increased risk of venous thromboembolism: increased by the addition of a progestogen
increased risk of stroke
increased risk of ischaemic heart disease if taken more than 10 years after menopause
Breast cancer
in the Women’s Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer
the increased risk relates to duration of use
breast cancer incidence is higher in women using combined preparations compared to oestrogen-only preparations
the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT
Parity and gravity
Parity is the number of pregnancies a woman has had which have been carried to a viable age; in the UK this is 24 weeks. The number after ‘+’ is the number of pregnancies which have not been carried to a viable age. It can be thought of the number of fetuses/babies which have come from her, in contrast to gravida which is the number of times the uterus has contained a foetus. For example twins are counted as Gravida 1 Parity 2. Parity also does not increase until the foetus is born but gravida technically increases from conception (though in practice from a woman’s first appointments with her doctor).
Potential Cxs of Chlamydia infection?
Potential complications
epididymitis
pelvic inflammatory disease
endometritis
increased incidence of ectopic pregnancies
infertility
reactive arthritis
perihepatitis (Fitz-Hugh-Curtis syndrome)
Fitz-Hugh–Curtis syndrome
Fitz-Hugh–Curtis syndrome is a rare complication of pelvic inflammatory disease(PID) named after the two physicians, Thomas Fitz-Hugh, Jr and Arthur HaleCurtis who first reported this condition in 1934 and 1930 respectively.[1][2][3] It involves liver capsule inflammation[4]leading to the creation of adhesions.
Ix of Chlamydia
Investigation
traditional cell culture is no longer widely used
nuclear acid amplification tests (NAATs) are now rapidly emerging as the investigation of choice
urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique
Placenta praevia
Associated factors
multiparity
multiple pregnancy
embryos are more likely to implant on a lower segment scar from previous caesarean section
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.
. If magnesium sulphate is not available, or if it fails to terminate the seizure what can be considered?
A BZD e.g. midazolam
Guidlines on usage of Mg Sulphate?
should be given once a decision to deliver has been made
in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
The major breastfeeding contraindications tested in exams relate to drugs (see below). Other contraindications of note include:
galactosaemia
viral infections - this is controversial with respect to HIV in the developing world. This is because there is such an increased infant mortality and morbidity associated with bottle feeding that some doctors think the benefits outweigh the risk of HIV transmission
Women who are considering taking the progestogen only pill (POP) should be counselled in what most common side effect?
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.
Between 10% and 25% of women using a POP will discontinue this method within 1 year as a result of these bleeding patterns.
Advise on starting the POP?
Starting the POP
if commenced up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods (e.g. Condoms) should be used for the first 2 days
if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
Taking the POP
should be taken at same time everyday, without a pill free break (unlike the COC)
Missed pills
if < 3 hours* late: continue as normal
if > 3 hours*: take missed pill as soon as possible, continue with rest of pack, extra precautions (e.g. Condoms) should be used until pill taking has been re-established for 48 hours
Other issues around the POP
Other potential problems
diarrhoea and vomiting: continue taking POP but assume pills have been missed - see above
antibiotics: have no effect on the POP**
liver enzyme inducers may reduce effectiveness e.g. rifampicin
discussion on STIs
Missed POP
if < 3 hours* late: continue as normal
if > 3 hours*: take missed pill as soon as possible, continue with rest of pack, extra precautions (e.g. Condoms) should be used until pill taking has been re-established for 48 hours
Def: puerperal pyrexia
Causes?
Mx?
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)
A 28 -year-old is found to have an ectopic pregnancy at 10 weeks gestation. She undergoes surgical management of the ectopic with a salpingectomy. She is known to be rhesus negative. What is the recommendation with regard to anti-D?
In surgical management of an ectopic pregnancy then Anti-D immunoglobulin should be administered.
Anti-D is not required in circumstances where a medical management of the ectopic has been used, nor for treatment of pregnancy of unknown location.
Coombs test:
Direct Coombs: Is a investigation used to look for autoimmune haemolytic anaemia,
Indirect: Used antenatally to detect antibodies in the maternal blood that can cross the placenta and result in haemolytic disease of the newborn.
Listeriosis in pregnancy
pregnant women are almost 20 times more likely to develop listeriosis compared with the rest of the population due to changes in the immune system
fetal/neonatal infection can occur both transplacentally and vertically during child birth
complications include miscarriage, premature labour, stillbirth and chorioamnionitis
diagnosis can only be made from blood cultures
treatment is with amoxicillin
Blood cultures and LP for Listeria infection
CSF may reveal a pleocytosis, with ‘tumbling motility’ on wet mounts
Side effects of IUD
IUDs make periods heavier, longer and more painful
the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic
uterine perforation: up to 2 per 1000 insertions
the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
What is the gold standard Ix for endometriosis?
Diagnostic laparoscopy
Mx of fibroids
medical: symptomatic management e.g. with combined oral contraceptive pill. GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment
surgery is sometimes needed: myomectomy, hysterscopic endometrial ablation, hysterectomy
uterine artery embolization
Def: endometriosis
Epidemiology
Presence and growth of tissue similar to endometrium outside of the uterus
1-2% of women are diagnosed and peak is between 30 and 45. Although prevalence may be 1-20%, asymptomatic
Where is enodmetriosis most commonly found?
Pathology
Uterosacral ligaments and on or behind the ovaries
Occasionally it affects the umbilicus or abdominal wound scars, vagina, bladder rectum, even lungs
Oestrogen dependent, regresses after menopause and during pregnancy.
Acucumulated altered blood is dark brown and can form a chocolate cyst (endometrioma) in the ovarias.
Can cause inflammation with progressive fibrosis and adhesions, in the most severe form the entire pelvis is frozen due to adhesion
Aetiology of endometriosis
Retrograde menstruation
More distant foci may be through mechanical, lymphatic or blood-borne spread.
Degree of inherited predisposition
NB poor symptomatic correlation with extent of disease
Hx in endometriosis
May be asymptomatic
Causes chronic pelvic pain, usually cyclical
Dysmeorrhoea before the onset of mensturation
Dyspareunia
Subfertility
Dyschezia
Menstrual probloms
Rupture of chocolate cyst: acute pain, may be first symptom
Cyclical haematuria, rectal bleeding or bleeding from the umbilicus are uncommon and suggestive of severe disease
Ex in endometriosis
VE@ tenderness and or thickening behind the uterus or in the adnexa
In severe cases the uterus may be retroverted and immobile
A rectovaginal nodule of enodmetriosis may be apparent on digital examination or visible on speculm.
With mild endometriosis the pelvis feels normal
Ix in endometriosis
Laparoscopy with visualisation and biopsy
active lesions are red or punctate marks
White scars or brown spots represent less active endometriosis
TVU may be useful to dx/exclude endometriomas and may also suggest the presence of adenomyosis although MRI is a better investigation for this.
If theere is clinical evidence of deeply infiltrating endometriosis extent of involvement can be examined with MRI, Intravenous pyelogram and barium studies
CA125 may be raised but of little diagnostic merit
When to suspect endometriosis
Symptoms after severeal years of painless periods
Pelvic examinatoin likely to be normal
Pelvis USS likely to be normal
Mx of endometriosis
Asymptomatic do not require treatment although nb in the low risk of missing ovarian ca
Symptomatic relief:
Pain: offer NSAID e.g. ibuprofen naproxen or mefenamic acid.
Paracetamol if NSAIDs CIed.
Rx (NB should be in women who do not wish to conceive):
Trial hormonal treatment:
COCP (not suitable for older women or smokers)
Progestogen preparations: denogestrel or IUS cyclical or continuous. Side effects may be severe.
GnRH analgoues: induce temprorary menopausal state so side effects mimic the menopause although add back HRT can minimise these
If woman does not want hormonal contraception offer an oral progestogen e.g. medroxyprogesterone
Sxical: diathermy ec can be used at laparascopy using see and treat approach. (This may improve conception rates)
BSO
TVU appearance of ovary described as ground glass
Ovarian endometrioma
What is important to note in women undergoing BSO for endometriosis
Will need HRT
However if endometriosis remains then there is risk of malignant change in ectopic endometrium
Consideration should be given to providing a combined preparation
Fertility and endometriosis
Found in 25% of diagnostic laps for subfertility.
Def: Chronic Pelvic Pain
Intermittent or constant pain in the lower abdomen or pelvis with >6m duration not occuring exclusively with mesntruation or intercourse
Can present in primay care as migraine, low back pain and affects 15% of adult women
NB for CPP
Exclude pathological causes
Through TVU, MRI or lap as appropriate
Possible causes of CPP
Varies over menstrual cycle: endometriosis, adenomyosis (oestrogen important as condition not typically seen in postmenopausal and suppression of ovarian activity cures 2/3rds).
Adhesions: ovarian tissue can become trapped followiing Sx and cause cyclical pain
IBS
Interstitial cystitis.
Psychological factors.
Mx of CPP
Depends on cause
?IBS: antispasmodics, analgesia
Cyclical pain: therapeutic trial using COCP or GnRH analogue with add back HRT for 3-6m before laparscipy.
IUS
A pregnant 25-year-old woman attends her booking appointment. Although she is symptom-free, urine dipstick indicates a urinary tract infection. Which of the following antibiotics should be avoided in the first trimester of pregnancy?
Trimethoprim
Amoxicillin
Cefalexin
Nitrofurantoin
Erythromycin
Whether symptomatic or asymptomatic it is important to treat urinary tract infections in pregnancy to prevent progression to pyelonephritis.
As trimethoprim is a folate antagonist it should be avoided in the first trimester - this is the time when the neural tube forms and there is a risk of teratogenicity. The other antibiotics listed are not contraindicated in the first trimester. However, erythromycin is not typically used to treat urinary tract infections, and nitrofurantoin should be avoided close to full term as there is a risk of causing neonatal haemolysis.
Sulfonamides and quinolones should also be avoided in pregnancy.
(BNF 5.1.13)
What are gestational trophoblastic disorders?
Describes a spectrum of disorders originating from the placental trophoblast:
complete hydatidiform mole
partial hydatidiform mole
choriocarcinoma
What is a complete hydatidiform mole?
Benign tumour of trophoblastic material. Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin
What are the features of hydatidform moles?
Features
bleeding in first or early second trimester
exaggerated symptoms of pregnancy e.g. hyperemesis
uterus large for dates
very high serum levels of human chorionic gonadotropin (hCG)
hypertension and hyperthyroidism* may be seen
*hCG can mimic thyroid-stimulating hormone (TSH)
What is the Mx of hydatidiform moles?
What is the Px?
Management
urgent referral to specialist centre - evacuation of the uterus is performed
effective contraception is recommended to avoid pregnancy in the next 12 months
Around 2-3% go on to develop choriocarcinoma
What are the features of partial hydatidiform moles?
n a partial mole a normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen
What are the two stages of the first stage of labour?
First stage is broken into two stages:
Latent: Time taken for the cervix to completely efface and dilate to 3cm
Active: From 3cm to 10cm
What are the time limits of the second stage of labour?
Second stage is from 10cm to delivery of the baby
2 hours is the maximum recommended in multiparous women
3 hours is the maximum recommended in nulliparous women
Remember, in the context of an epidural, 1 hour of passive second stage (without pushing) is advised
What is the third stage of labour?
Third stage is from delivery of the baby to delivery of the placenta and membranes
Third stage is from delivery of the baby to delivery of the placenta and membranes
Active: Uses uterotonics, clamping of the cord and controlled cord traction
Meds include syntocinon and ergometrine: syntometrine, or oxytocin
They are generally given as the anterior shoulder is born
Physiological: The cord is only clamped when pulseless in the absence of medications and the placenta delivered through maternal efforts alone
Should be converted to active management if placenta not delivered in 1hr
What are the active forms of managing 3rd stage of labour
Active: Uses uterotonics, clamping of the cord and controlled cord traction
Meds include syntocinon and ergometrine: syntometrine, or oxytocin
They are generally given as the anterior shoulder is born
What is the definition of labour?
Labour may be defined as the onset of regular and painful contractions associated with cervical dilation and descent of the presenting part
Signs of labour include
regular and painful uterine contractions
a show (shedding of mucous plug)
rupture of the membranes (not always)
shortening and dilation of the cervix
What is nexplanon?
What are the contraindications?
Implanon was a non-biodegradable subdermal contraceptive implant which has been replaced by Nexplanon. From a pharmacological perspective Nexplanon is the same as Implanon. The two main differences are:
the applicator has been redesigned to try and prevent ‘deep’ insertions (i.e. subcutaneous/intramuscular)
it is radiopaque and therefore easier to locate if impalpable
Contraindications
UKMEC 3*: ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2), unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer, positive antiphospholipid antibodies**
UKMEC 4**: current breast cancer
.
*proven risks generally outweigh the advantages
**there is some contradiction in the guidance issued by the FSRH but their most recent document (revised 2010) lists positive antiphospholipid antibodies as UKMEC 3
***a condition which represents an unacceptable risk if the contraceptive method is used
Def: recurrent miscarriage
What are the common causes?
Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions. It occurs in around 1% of women
Causes
antiphospholipid syndrome
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
uterine abnormality: e.g. uterine septum
parental chromosomal abnormalities
smoking
What is TTTS?
Twin-to-twin transfusion syndrome (TTTS) is a relatively common complication of monochorionic twin pregnancies. The two fetuses share a single placenta, meaning that blood can flow between the twins. In TTTS, one fetus, the ‘donor’ receives a lesser share of the placenta’s blood flow than the other twin, the ‘recipient’. This is due to abnormalities in the network of placental blood vessels. The recipient may become fluid-overloaded whilst the donor can become anaemic. One fetus may have oligohydramnios and the other may have polyhydramnios as a result of differences in urine production, causing additional problems. In severe cases, TTTS can be fatal for one or both fetuses.
TTTS usually occurs in early or mid-pregnancy, thus ultrasound examinations performed between 16 and 24 weeks focus on detecting this condition. After 24 weeks the main purpose of ultrasound examinations is to detect fetal growth restriction.
What is the incidence of multiple pregnancies?
The incidence of multiple pregnancies is as follows
twins: 1/105
triplets: 1/10,000
Twins may be dizygotic (non-identical, develop from two separate ova that were fertilized at the same time) or monozygotic (identical, develop from a single ovum which has divided to form two embryos). Around 80% of twins are dizygotic
What are the risks of monoamniotic monozygotic twins?
Monoamniotic monozygotic twins are associated with:
increased spontaneous miscarriage, perinatal mortality rate
increased malformations, IUGR, prematurity
twin-to-twin transfusions: recipient is larger with polyhydramnios (do laser ablation of interconnecting vessels)
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 complications of twin preganancies:
Antenatally
For the fetus?
Labour?
Antenatal complications
polyhydramnios
pregnancy induced hypertension
anaemia
antepartum haemorrhage
Fetal complications - perinatal mortality (twins * 5, triplets * 10)
prematurity (mean twins = 37 weeks, triplets = 33)
light-for date babies
malformation (*3, especially monozygotic)
Labour complications
PPH increased (*2)
malpresentation
cord prolapse, entanglement
Mx of twin pregnancies
Management
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
Mx of infertility in PCOS
Infertility
weight reduction if appropriate
the management of infertility in patients with PCOS should be supervised by a specialist. There is an ongoing debate as to whether metformin, clomifene or a combination should be used to stimulate ovulation
a 2007 trial published in the New England Journal of Medicine suggested clomifene was the most effective treatment. There is a potential risk of multiple pregnancies with anti-oestrogen* therapies such as clomifene. The RCOG published an opinion paper in 2008 and concluded that on current evidence metformin is not a first line treatment of choice in the management of PCOS
metformin is also used, either combined with clomifene or alone, particularly in patients who are obese
gonadotrophins
General Mx in PCOS
Mx of hirsutism and acne
General
weight reduction if appropriate
if a women requires contraception then a combined oral contraceptive (COC) pill may help regulate her cycle and induce a monthly bleed (see below)
Hirsutism and acne
a COC pill may be used help manage hirsutism. Possible options include a third generation COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. Both of these types of COC may carry an increased risk of venous thromboembolism
if doesn’t respond to COC then topical eflornithine may be tried
spironolactone, flutamide and finasteride may be used under specialist supervision
Mx of genital warts
Topical podophyllum or cryotherapy are first choice
Imiquimod is ssecond line
A 48-year-old female smoker attends the GP for information regarding contraception. Her last menstrual period was 9 months ago and she is convinced that she has ‘gone through the menopause’. The most suitable form of contraception is:
None, this lady has gone through the menopause and is protected
The combined oral contraceptive pill for 12 months (COCP)
The intrauterine system (IUS)
Hormone replacement therapy (HRT)
Barrier methods alone
The menopause is a retrospective diagnosis and is said to occurred 12 months after the last menstrual period. Women who menopause under the age of 50 require contraception for at least 2 years after their last menstrual period. Those over the age of 50 require only 1 year of contraception. In view of this, it would be inappropriate to say this lady does not require any contraception because she is protected. Similarly prescribing the COCP for only 12 months would be equally inappropriate. The fact that she is also a smoker would mean that the risks outweigh the benefits of the COCP as she is over the age of 35. Hormone replacement therapy should not be used solely as a form of contraception and barrier methods are less effective than the other types of contraception listed thus the most appropriate answer is the IUS. This will take the patient through the menopause and can be used for 7 years (off-licence) or 2 years after her last menstrual period.
What is the advice to women planning pregnancy and taking antiepileptics?
Take folic acid 5mg per day before pregnancy
(Risk of congenital defects in non-epileptic mothers 1-2%, in mothers taking antiepileptic medication rises to 3-4%)
Sodium valproate in pregnancy
The November 2013 issue of the Drug Safety Update also carried a warning about new evidence showing a significant risk of neurodevelopmental delay in children following maternal use of sodium valproate.
The update concludes that sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary. Women of childbearing age should not start treatment without specialist neurological or psychiatric advice.
Mx of hyperemesis gravidarum
Management
antihistamines should be used first-line (BNF suggests promethazine as first-line)
ginger and P6 (wrist) acupressure: NICE Clinical Knowledge Summaries suggest these can be tried but there is little evidence of benefit
admission may be needed for IV hydration
What proportion of threatened miscarriages go on to miscarry?
25%
What is the most common identifiable cause of postcoital bleeding?
Causes
no identifiable pathology is found in around 50% of cases
cervical ectropion is the most common identifiable causes, causing around 33% of cases. This is more common in women on the combined oral contraceptive pill
cervicitis e.g. secondary to Chlamydia
cervical cancer
polyps
trauma
A 21-year-old female presents for review. She is 14 weeks pregnant and has been seen by the midwives for her booking visit. There have been no pregnancy related problems to date. Tests taken revealed the following:
Blood group:A Rhesus negative
What is the most appropriate management regarding her rhesus status?
Give first dose of anti-D at 28 weeks
No action required unless antenatal vaginal blood loss
Give first dose of anti-D as soon as possible
Give anti-D just prior to delivery
No action required
Rhesus negative woman - anti-D at 28 + 34 weeks
NICE recommend giving rhesus negative woman anti-D at 28 weeks followed by a second dose at 34 weeks
Cx of DM during pregnancy
Maternal
Neonatal
Maternal complications
polyhydramnios - 25%, possibly due to fetal polyuria
preterm labour - 15%, associated with polyhydramnios
Neonatal complications
macrosomia (although diabetes may also cause small for gestational age babies)
hypoglycaemia (secondary to beta cell hyperplasia)
respiratory distress syndrome: surfactant production is delayed
polycythaemia: therefore more neonatal jaundice
malformation rates increase 3-4 fold e.g. sacral agenesis, CNS and CVS malformations (hypertrophic cardiomyopathy)
stillbirth
hypomagnesaemia
hypocalcaemia
shoulder dystocia (may cause Erb’s palsy)
What is Galactocele?
Galactocele typically occurs in women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct. A build up of milk creates a cystic lesion in the breast. The lesion can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.
What are the NICE guidlines warranting CTG monitoring?
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.
You are called to see a 32-year-old woman who has vaginal bleeding one hour post delivery. Formal measurement estimates the blood loss at 1200mls including liquor. Blood pressure is 98/52mmHg and heart rate 110bpm. Bleeding is ongoing. Which of the following options is most appropriate?
IV access, group O RhD negative blood, tranexamic acid
IV access, crossmatch, tranexamic acid
IV access, group and save, commence crystalloid infusion
IV access, crossmatch, commence crystalloid infusion
IV access, commence crystalloid infusion, consider ballon tamponade
This scenario is classed as a major post partum haemorrhage (PPH) due to an estimated blood loss of greater than 1000 mls. An ABCD approach should be instituted with prompt senior involvement. As this is a major PPH, group and save is inappropriate. Tranexamic acid is an antifibrinolytic which may be used in vaginal bleeding secondary to heavy menstrual bleeding, but has no role in PPH.
The causes of PPH can be divided into four T’s (uterine Tone, Tissue, Trauma and Thrombin). In uterine atony bimanual uterine compression should be trialed first and a Foley catheter passed to ensure an empty bladder. Uterine balloon tamponade is a suitable first line surgical management, but pharmacological measures should be trialled first. These include a bolus of intravenous syntocinon (repeated if necessary), followed by ergometrine, syntocinon infusion and carboprost in turn.
A fluid challenge should be instituted in the first instance while blood products are awaited. The RCOG state that up to 3.5L of warmed crystalloid can be infused at an appropriate rate while waiting for blood products.
Combined oral contraceptive pill: missed pill
If 1 pill missed?
If >1 pill missed
If 1 pill is missed (at any time in the cycle)
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
If 2 or more pills missed
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH:’This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed’
if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
How does teh FSRH categorise risk factors for the COCP?
1 - no restrictions on the use of contraceptive method
2 - advantages of contraceptive method generally outweigh the theoretical and proven risks
3 - theoretical and proven risks generally outweigh the advantages of the contraceptive method, can still be given based on expert clinical judgement
4 - condition that poses unacceptable risk if the contraceptive method is used
What are hte bsolute contraindications for hte COCP?
Migraine with aura
Breastfeeding <6 weeks post-partum
Age 35 or over smoking 15 or more cigarettes/day
Systolic 160mmHg or diastolic 95mmHg
Vascular disease
History of VTE
Current VTE (on anticoagulants)
Major surgery with prolonged immobilisation
Known thrombogenic mutations
Current and history of ischaemic heart disease
Stroke (including TIA)
Complicated valvular and congenital heart disease
Current breast cancer
Nephropathy/retinopathy/neuropathy
Other vascular disease
Severe (decompensated) cirrhosis
Hepatocellular adenoma
Hepatoma
Raynaud’s disease with lupus anticoagulant
Positive antiphospholipid antibodies
Which of the following is the most commonly recognised risk of combined hormone replacement therapy (HRT)?
Leukaemia
Endometrial cancer
Gallbladder disease
Meigs syndrome
Cellulitis
Unopposed oestrogen increases the risk of endometrial cancer and remains elevated for 5 or more years after stopping therapy
The risk is not eliminated completely with additional sequential progestogen
No increased risk has been found with continuous combined HRT
Risk of ovarian cancer is higher the longer HRT is taken.
But when the HRT is stopped, the risk goes back down to normal over a few years
Venous thromboembolism risk is more than doubled with HRT but absolute risk remains small
Risk of breast cancer is increased as it simulated delaying menopause.
Every year the menopause is naturally delayed, the risk increases by 2.8%
With HRT the risk is increased by 2.3% by year
The risk of gallbladder disease is increased in women taking HRT - though this risk may be reduced with transdermal administration
Mx of gonorrhoea
Management
ciprofloxacin used to be the treatment of choice. However, there is increased resistance to ciprofloxacin and therefore cephalosporins are now used
the 2011 British Society for Sexual Health and HIV (BASHH) guidelines recommend ceftriaxone 500 mg intramuscularly as a single dose with azithromycin 1 g oral as a single dose. The azithromycin is thought to act synergistically with ceftriaxone and is also useful for eradicating any co-existent Chlamydia infections
if ceftriaxone is refused or contraindicated other options include cefixime 400mg PO (single dose)
What is the most common cause of septic arthritis in young adults?
Gonorrhoea
What are the potential Cxs of gonorrhoea infection?
Disseminated gonococcal infection (DGI) and gonococcal arthritis may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults. The pathophysiology of DGI is not fully understood but is thought to be due to haematogenous spread from mucosal infection (e.g. Asymptomatic genital infection). Initially there may be a classic triad of symptoms: tenosynovitis, migratory polyarthritis and dermatitis. Later complications include septic arthritis, endocarditis and perihepatitis (Fitz-Hugh-Curtis syndrome)
Key features of DGI?
Key features of disseminated gonococcal infection
tenosynovitis
migratory polyarthritis
dermatitis (lesions can be maculopapular or vesicular)
Features of chorioamnionitis
Chorioamnionitis (which can affect up to 5% of all pregnancies) is a potentially life-threatening condition to both mother and foetus and is therefore considered a medical emergency. It is usually the result of an ascending bacterial infection of the amniotic fluid / membranes / placenta. The major risk factor in this scenario is the preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens. Prompt delivery of the foetus (via cesarean section if necessary) and administration of intravenous antibiotics is widely considered the mainstay of initial treatment for this condition.
Normal SFH
The measurement of the symphysis-fundal height in centimetres should closely match the foetal gestational age in weeks within 1 or 2 cm from 20 weeks gestation
Anything less= small for dates
Anything more= polyhydramnios
Injectable contraceptive (medroxyprogesterone acetate)
Inhibits ovulation
The Faculty for Sexual and Reproductive Health (FSRH) state Progestogen-only injectable contraception works primarily by inhibiting ovulation.
Progestogen-only pill (excluding desogestrel)
The Faculty for Sexual and Reproductive Health (FSRH) state All POPs alter cervical mucus to prevent sperm penetration into the upper reproductive tract. In addition, traditional POPs inhibit ovulation but this can be variable.
Intrauterine system (levonorgestrel)
The Faculty for Sexual and Reproductive Health (FSRH) state Most of the contraceptive effect of the LNG-IUS is mediated via its progestogenic effect on the endometrium which prevents implantation.
You are called to see a 33-year-old patient complaining of vaginal bleeding 12 hours after a vaginal delivery. On arrival, she is alert, complaining of breathlessness and giddiness. Her blood pressure is 97/73 mmHg. She has no history of a bleeding disorder, and you are told she did not tear. She has a blue cannula in situ with nothing attached, and the midwife has bleeped the registrar on call.
What is your immediate course of action?
Bleep your FY2
Insert a large bore cannula
500mL crystalloid fluid challenge
Vaginal examination
Give oxytocin
Post-partum haemorrhage should be managed with an ABC approach.
This lady is symptomatic and hypotensive. It would be most appropriate to commence a fluid challenge in the first instance whilst awaiting help from your registrar.
A blue cannula (22G) however will only provide a flow rate of 31 mL/minute. Insertion of a large bore cannula is thus the priority in this lady who is actively bleeding.
A vaginal examination may also prove useful, as you may find that there are retained products of conception in the cervix causing a vasovagal reaction leading to hypotension. However, your registrar would be able to provide you with assistance to perform that after you have begun fluid resuscitation.
Cannula size and colour order
Blue 22G (very small - for difficult hand veins)
Pink 20G (small - suitable for the majority of patients that require IV fluids)
Green 18G (average sized - suitable for IV fluids and smaller blood transfusions)
Grey 16G (large - for use in large blood transfusions and emergency use)
Brown 14G (very large and painful - again, for emergency use)
A 24-year-old woman presents to the emergency department with intermittent abdominal pain and vaginal bleeding. She thinks her last period was 6 weeks ago but cannot be certain. She has never been pregnant before and has no previous gynaecological history.
She is systemically well with a blood pressure of 130/85 mmHg and pulse 79 bpm. A pregnancy test performed in the department is positive and transvaginal ultrasound confirms a pregnancy in the adnexa with a fetal heart beat present. What is the most appropriate management in this case?
Reassure and discharge with routine follow-up appointment
Mifepristone and misoprostol
Admit and observe
Surgical management - salpingectomy or salpingotomy
Methotrexate
This patient has a confirmed ectopic pregnancy. There is no evidence the pregnancy has ruptured but definitive treatment is still the safest course.
Expectant management of ectopics may be an option in those without acute symptoms and declining beta-HCG levels. Close monitoring is essential and intervention is advised if symptoms manifest or beta-HCG levels begin to rise.
The presence of a fetal heart beat makes both conservative and medical management unlikely to be successful and also risky in terms of rupture, which would be a medical emergency.
Surgical removal of the ectopic is the most appropriate option here. If the contralateral tube is healthy then salpingectomy may be the best option. However, if the contralateral tube is damaged, salpingotomy preserves the functional tube and helps minimise the risk of future infertility.
‘Traditional’ POPs (Micronor, Noriday, Nogeston, Femulen)
Missed pills
If less than 3 hours late
no action required, continue as normal
If more than 3 hours late (i.e. more than 27 hours since the last pill was taken)
action needed - see below
Action required, if needed:
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
Cerazette (desogestrel) missed pill
If less than 12 hours late
no action required, continue as normal
If more than 12 hours late (i.e. more than 36 hours since the last pill was taken)
action needed - see below
Action required, if needed:
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
First line Ix for endometrial carcinoma
The first step in the investigation of possible endometrial cancer is to preform a trans-vaginal ultrasound scan to measure the endometrial thickness. Different hospitals have different cut-offs for endometrial thickness and further investigation. If the endometrial lining is thickened then a hysteroscopy will be preformed and an endometrial biopsy taken.
Treatment for endometrial cancer is usually laparoscopic hysterectomy with bilateral salpingo-oophorectomy, with or without radiotherapy.
Grading of Perineal Tears
1
2
3
4
The RCOG has produced guidelines suggesting the following classification of perineal tears:
first degree: superficial damage with no muscle involvement
second degree: injury to the perineal muscle, but not involving the anal sphincter
third degree: injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS):
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: IAS torn
fourth degree: injury to perineum involving the anal sphincter complex (EAS and
IAS) and rectal mucosa
When should early referrals for infertility be considered in females?
Previous STI
>35y/o
Previous pelvic Sx
Abnormal genital examination
Amenorrhoea
When should early referrals for infertility be considered in males?
Previous Sx on genitali
Varicocele
Significant systemic illness
Abnormal genital examination
Previous STI
A pregnant woman is found to have tested positive syphilis during her routine booking visit bloods. She is currently 12 weeks pregnant. What is the most appropriate management?
Oral doxycycline
Recommend termination of pregnancy and administer antibiotic therapy
Repeat test in 4 weeks and treat if still positive
IM benzathine penicillin G
IM human normal immunoglobulin (HNIG)
Management
benzylpenicillin
alternatives: doxycycline
the Jarisch-Herxheimer reaction is sometimes seen following treatment. Fever, rash, tachycardia after first dose of antibiotic. It is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment.
The 2008 British Association for Sexual Health and HIV (BASHH) guidelines recommend IM benzathine penicillin G in this scenario.
Doxycycline should not be used in pregnancy. Immunoglobulins are used to provide protection against viral illnesses such as rubella.
young woman of 28 weeks gestation presents to the emergency department with painless vaginal bleeding, she appears well and is haemodynamically stable.
Which investigation is most likely to help confirm the diagnosis?
Abdominal ultrasound with colour flow doppler
Speculum
Digital vaginal examination
Kleihauer test
Full blood count and urea and electrolytes
RCOG guidelines clearly state that the definitive diagnosis of placenta praevia is through ultrasound scan imaging. There is no screening programme for placenta praevia , however the UK National screening committee supports local practices which during the routine 20 week scan, comment and look for evidence of the placenta covering the cervical os.
Transvaginal ultrasound scans be safely performed at 20 weeks, in addition to the abdominal ultrasound scan to help improve the accuracy of localisation and RCOG guidelines state that they should be used to confirm the diagnosis of placenta praevia
Which of these is correct in regards to the management of endometrial cancer?
Most patients present with stage 1 disease, and are therefore amenable to surgery alone
Endometrial biopsy is not required for diagnosis
Chemotherapy is used more extensively in treatment than radiotherapy
Lymphadenectomy in early stage disease is usually beneficial
Progestogens are often used in treatment
1: Correct, 75% of patients present with stage 1 disease, which is generally treated with a hysterectomy and bilateral salpingo-oophorectomy.
2: Endometrial biopsy is required for diagnosis.
3: Radiotherapy is used more often than chemotherapy, particularly in treating high-risk patients post-hysterectomy or in pelvic recurrence.
4. Routine lymphadenectomy is not usually beneficial.
5. Progestogens are now seldom used in treatment.
A 30-year-old para 1+0 has presented at term in labour. On vaginal examination, the occiput can be palpated posteriorly (near the sacrum). Which of these is correct regarding your further management of these patients?
The fetal head may rotate spontaneously to an OA position
Delivery is impossible without rotation
Augmentation should be avoided if labour is slow
If instrumentation is necessary, a ventouse is associated with the most successful outcomes
Mothers will generally experience a later urge to push than if position was OA
1: Correct.
2: Delivery is possible in the OP position, however labour is likely to be longer and more painful.
3: Augmentation should be used if progress is slow.
4: Kielland’s forceps are associated with the most successful outcomes, however require particular expertise.
5: Generally, women will experience an earlier urge to push in OP than OA.
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:
Ruptured ovarian cyst
Intestinal obstruction
Hyperemesis gravidarum
Ovarian hyperstimulation syndrome
Pelvic inflammatory disease (PID)
This question concerns complications that may arise during IVF. The most unlikely answer is hyperemesis gravidarum as the patient is not currently pregnant. Given the patient’s reason for IVF (tubal disease) - PID may seem like a reasonable answer however it would be likely that this patient would have already been screened for this disease prior to the commencement of IVF and have been appropriately treated. A ruptured cyst would present with a much more acute picture of pain and systemic signs/symptoms. Obstruction may be on a list of differentials considering the patient’s past medical history however in the scenario this patient’s Crohn’s is well-controlled and the patient would present with central colicky pain and bile-stained vomiting. Thus in this scenario ovarian hyperstimulation syndrome is a much more likely diagnosis. This is associated typically with the use of human chorionic gonadotrophin (HCG) in the maturation of follicles during IVF. It presents with lower abdominal discomfort, nausea, vomiting and abdominal distension. Patients may also develop ascites, hypotension and in serious cases acute respiratory distress syndrome and venous thromboembolism. Patients are treated with fluid replacement and thromboprophylaxis.
Note: The actual effect on azathioprine during pregnancy is not fully known - the BNF suggests there are some reports of an association between low birth weight and premature births and exposure to the drug however most physicians would advise women with Crohn’s disease that are on maintenance treatment with azathioprine to continue taking this drug as the risk of harm from a flare up of Crohn’s disease outweighs the risk of harm of taking this medicine.
Features of Ovarian hyperstimulation syndrome
Cx seen in some forms of infertility treatment, presence of high levels of luteinized cysts within the ovaries results in high levels of oestrogens and progesterone and also VEGF which leads to increased membrane permeability and loss of fluid from the intravascular compartment.
More likely to be seen following gonadotrophin or hCG treatment, more rare in clomifene therapy
Classification of OHSS
Mild
Moderate
Severe
Crticial
Mild:
Abdo pain, bloating
Moderate:
Mild+ N+V, USS evidence of ascites
Severe:
Moderate + clinical evidence of ascites, oliguria, HCt >45% hypoproteinaemia.
Crticial:
Severe + thromboembolism, ARDS, anuria, tense ascites
What is mefenamic acid?
An NSAID not recommended in pregnancy
What is tranexamic acid?
Plasminogen activator inhibtor that acts as an antifibrinolytic to prevent heavy menstrual bleeding.
Used when a patient wishes to conceive and there is no dysmenorrhoea
A 32 year-old lady has a diagnosis of fibroids and has been trying for a baby for 18 months. She has been under investigation at the sub-fertility clinic and no abnormality has been found except for three small submucosal fibroids, for which she does not have any symptoms. Her partner has had sperm analysis which found no abnormality.
Which of the following treatments are most appropriate in this situation?
Myomectomy
Goserelin acetate (GHRH agonist)
Endometrial ablation
Uterine artery embolisation
Ulipristal acetate
Myomectomy is the only treatment option here that will also retain this lady’s fertility. Depending on the operation performed, and whether the uterine cavity was entered, the lady would need counselling in regards to delivery, since often a caesarean section is advised due to risk of uterine rupture.
GnRH agonists effectively turn off the ovaries, which causes the fibroids to shrink and therefore are easier to remove surgically. On stopping the medication, the fibroids grow back. As this treatment turns off the ovaries, it inhibits ovulation and therefore means that pregnancy is not possible during this time. As a treatment on its own, it would not be suitable in this case as it causes temporary infertility and fibroid regrowth on cessation. However, if combined with a myomectomy, it would provide a suitable treatment option.
Endometrial ablation destroys the endometrial lining, therefore meaning that an embryo would not be able to implant.
Uterine artery embolisation is not recommended if trying to conceive as it cuts down the blood supply to the uterus significantly, therefore meaning that the fetus would be unable to implant and grow.
Ulipristal acetate is a selective progesterone receptor modulator. It is used pre-operatively for women with fibroids as it has been proven to shrink them, thus making surgery easier. This medication affects fertility, thus is not suitable for women trying to get pregnant, unless (like GnRH agonists) it is used for a short period in combination with surgery.
Why should a pregnant woman be resuscitated in the left lateral position?
To prevent compression of the IVC reducing venous return to the hear
Dx of PE in Pregnanacy
ECG and CXR in all patients
If CXR normal, compression duplex doppler.
CXR normal-> V/Q
CXR abnormal-> CTPA
NB d-dimer is usually raised in first trimester of pregnancy and is thus not useful.
CTPA in pregnancy
CTPA slightly increases the lifetime risk of maternal breast cancer(increased by up to 13.6%, background risk of 1/200 for study population). Pregnancy makes breast tissue particularly sensitive to the effects of radiation
V/Q Scanning in pregnancy
V/Q scanning carries a slightly increased risk of childhood cancercompared with CTPA (1/280,000 versus less than 1/1,000,000)
What are the Fraser Guidelines?
What do they constitute?
Used to determine provision of COCP to children under 16y
the young person understands the professional’s advice
the young person cannot be persuaded to inform their parents
the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment
unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent
Fraser vs Gillick competence
Some doctors use the term Fraser competency when referring to contraception and Gillick competency when referring to general issues of consent in children.
A 35-year-old woman comes to see you, her GP, because she feels tearful and low since the birth of her son 1 month ago and she isn’t sleeping well. She says she thinks the baby hates her and feels they aren’t bonding, though she is still breast feeding. She has a good family network, including the baby’s father and has never suffered with depression in the past. She does not feel suicidal and has not been abusing any substances, you do not feel the baby is at risk. What is the most appropriate management?
Refer to social services
Antidepressant therapy
Cognitive behavioural therapy (CBT)
Mindfulness
Prescribe zopiclone
The National Institute for Health and Care Excellence recommends that for women without previous history of severe depression, the first line treatment for moderate to severe depression in pregnancy or the post-natal period should be a high intensity psychological intervention (such as CBT).
If this is refused, or symptoms do not improve, then an antidepressant should be used. NICE suggests a selective serotonin re-uptake inhibitor (SSRI) or tricyclic antidepressant (TCA). Mindfulness may be useful for women with persistent subclinical depressive symptoms. You would only need to involve social services if you felt that someone in the household may be at risk. According to the British National Formulary (BNF) zopiclone should be avoided whilst breast feeding as it is present in breast milk
False Labor
Occurs in the last 4 weeks of pregnancy
Presentation: contractions felt in the lower abdomen. The contractions are irregular and occur every 20 minutes. Progressive cervical changes are absent.
Braxton Hicks contractions
Braxton Hicks contractions, also known asprodromal labor or practice contractions, or false labor, are sporadic uterine contractions that sometimes start around six weeks into a pregnancy. However, they are not usually felt until the second trimester orthird trimester of pregnancy. [1]
You are the junior doctor on the labour ward, and are called to a 27-year-old’s first delivery. She underwent spontaneous preterm rupture of membranes at 34 weeks, and now the umbilical cord is palpable vaginally above the level of the introitus.
Which of these is correct regarding your management of this patient?
Tocolytics, e.g. terbutaline, should be avoided
The presenting part of the fetus may be pushed back into the uterus
The patient is advised to lie supine
The cord may be pushed back into the uterus
Natural labour would be the usual delivery method of choice
This is a case of cord prolapse, which occurs after membrane rupture when the umbilical cord descends below the presenting part of the fetus. It can lead to fetal hypoxia and death due to the cord being compressed or going into spasm.
1: Tocolytics should be used to reduce cord compression and allow Caesarean delivery
2: Correct, to avoid compression
3: The patient is advised to go onto all fours
4: The cord should not be pushed back into the uterus
5: Immediate Caesarean section is the delivery method of choice
What are the indications for assessment of a newborn by the neonatal team after any degree of meconium?
RR >60
Grunting
HR <100 >160
CRT >3
T >38 or 37.5 on 2 occasions 30 minutes apart
SaO2 <95
Central cyanosis
Def Eisenmenger’s?
With what is it associated?
What are its features?
Mx?
Reversal of a left to right shunt in a congenital heart defect due to pulmonary hypertension which has occurred as a result of remodelling of pulmonary microvasculature?
VSD, ASD, PDA
Original murmur may disappear
Cyanosis
Clubbing
RV failure
Haemoptysis, embolism
Heart-lung transplant required
A woman who is 10 weeks pregnant presents to clinic with a pre-existing heart condition. Which of the following put her at the highest risk of complications?
Ventricular septal defect
Patent ductus arteriosus
Coarctation of the aorta
Chronic mitral regurgitation
Eisenmenger’s syndrome
Eisenmenger’s syndrome is the correct answer as it has a maternal mortality ranging from 30% to 50%, with a 50% risk of foetal loss if the mother survives. It occurs when a long standing left to right shunt reverses; not only are mother and baby at risk of hypoxaemia but also of thromboembolic events.
Isolated VSDs are well tolerated during pregnancy, provided it is not associated with pulmonary hypertension or eisenmenger’s, and so considered a low-risk lesion
PDA during pregnancy is not associated with additional maternal risk, provided the shunt is small to moderate and the pulmonary artery pressures are normal. Percutaneous closure is now considered first-line therapy, and it is reasonable to close even asymptomatic small PDAs. Following repair of more significant PDAs, women are at no additional risk for complications during pregnancy.
Coarctation is well tolerated during pregnancy, although hypertension, heart failure, angina, and aortic dissection are possible complications. Coarctation can be associated with intracerebral aneurysms, which may rupture during pregnancy. It is therefore considered to be a moderate-risk lesion, even when repaired.
In chronic mitral regurgitation, the physiologic reduction in SVR partially compensates for the additional volume overload generated by the regurgitant valve. Should heart failure occur, it can be treated safely with nitrates, hydralazine and dihydropyridine calcium channel-blocking agents. It is considered a low risk lesion, especially after repair.
Varencline
a nicotinic receptor partial agonist
has been shown in studies to be more effective than bupropion
nausea is the most common adverse effect. Other common problems include headache, insomnia, abnormal dreams
varenicline should be used with caution in patients with a history of depression or self-harm. There are ongoing studies looking at the risk of suicidal behaviour in patients taking varenicline
contraindicated in pregnancy and breast feeding
Bupropion
a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
should be started 1 to 2 weeks before the patients target date to stop
small risk of seizures (1 in 1,000)
contraindicated in epilepsy, pregnancy and breast feeding. Having an eating disorder is a relative contraindication
Smoking in pregnant women
Pregnant women
NICE recommended in 2010 that all pregnant women should be tested for smoking using carbon monoxide detectors, partly because ‘some women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense.’. All women who smoke, or have stopped smoking within the last 2 weeks, or those with a CO reading of 7 ppm or above should be referred to NHS Stop Smoking Services.
Interventions
the first-line interventions in pregnancy should be cognitive behaviour therapy, motivational interviewing or structured self-help and support from NHS Stop Smoking Services
the evidence for the use of NRT in pregnancy is mixed but it is often used if the above measures failure. There is no evidence that it affects the child’s birthweight. Pregnant women should remove the patches before going to bed
as mentioned above, varenicline and bupropion are contraindicated
A 36-year-old woman suffers from a major postpartum haemorrhage after delivering twins. The obstetric consultant examines her and suspects uterine atony to be the cause. The protocol for major PPH is initiated. Bimanual uterine compression fails to control the haemorrhage. Which drug is an appropriate next step in the management of uterine atony?
Intramuscular carboprost
Intravenous oxytocin
Rectal misoprostol
Intravenous carboprost
None - proceed immediately to balloon tamponade
Uterine atony is the most common cause of primary postpartum haemorrhage. It entails failure of the uterus to contract fully following the delivery of the placenta, which hinders the achievement of haemostasis. Uterine atony is associated with overdistension, which may be due to multiple gestation, macrosomia, polyhydramnios or other causes.
In addition to the usual steps taken in an episode of PPH (including an ABC approach if the patient is unstable), the following management should be initiated in sequence:
bimanual uterine compression to manually stimulate contraction
intravenous oxytocin and/or ergometrine
intramuscular carboprost
intramyometrial carboprost
rectal misoprostol
surgical intervention such as balloon tamponade
Mx of PPH?
ABC
Bimanual uterine compression
IV oxytocin and or ergometrine
IM carboprost
Intramyometrial carboprost
Rectal misoprostol
Balloon Tamponade
In sequence
What are the expected results in DS screening if trisomy present?
Low alpha fetoprotein (AFP)
Low oestriol
High human chorionic gonadotrophin beta-subunit (-HCG)
Low pregnancy-associated plasma protein A (PAPP-A)
Thickened nuchal translucency
A 40-year-old woman returns to the GP to discuss her recent blood results. A CA 125 was measured after she reported persistent abdominal bloating and urinary urgency over the past 2 months. Her CA 125 level is reported as 15 IU/ml. Normal CA 125 <35 IU/ml
Which one of the following is the most appropriate next action?
Refer to gynaecology clinic
Give advice on a bladder retraining programme
Assess for other cause of symptoms and advise to return if these become more frequent
Refer for ultrasound of abdomen and pelvis
Re-test CA 125
If serum CA 125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis
If the ultrasound suggests ovarian cancer, refer the woman urgently.
For any woman who has normal serum CA125 (less than 35 IU/ml), or CA125 of 35 IU/ml or greater but a normal ultrasound: clinicians should assess her carefully for other clinical causes of her symptoms and investigate if appropriate. If no other clinical cause is apparent, they should advise her to return to her GP if her symptoms become more frequent and/or persistent.
Referral to the gynaecology clinic is not warranted at this time. While bladder retraining is a treatment option for overactive bladder syndrome; it is not the most appropriate approach to dealing with this patient’s symptoms. From above we can see that referral for an ultrasound would be necessary if CA 125 was raised to sufficient levels but this is not the case. Re-testing CA 125 would also be of no value at this time. In this case, a thorough assessment for alternative causes of this patient’s symptoms is the best form of action at this stage.
Epilepsy: contraception
For women taking phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine:
UKMEC 3: the COCP and POP
UKMEC 2: implant
UKMEC 1: Depo-Provera, IUD, IUS
Epilepsy: contraception
For lamotrigine:
UKMEC 3: the COCP
UKMEC 1: POP, implant, Depo-Provera, IUD, IUS
Def: preterm labour
24-37w
Most important before 34w as neonatal risks are greater.
What are the causes of preterm delivery?
Can be as a result of spontaneous labour or can be iatrogenic (obstetric induction due to maternal/fetal risks)
Neonatal Cxs of preterm labour
Accounts for 80% of NICE occupancy
20% of perinatal mortality
50% of cerebal palsy
Chronic lung ndisease
Blindness
Minor disability
Earlier the gestation the greater the risk to the fetus
Px of preterm delivery
24w: 1/3rd of neonates die, 1/3tf handicapped
by 32w both of these risks are less than 5%
Maternal risk of preterm labour
Infection
Endometritis post natally
Risk factors for spontaneous preterm labaour
Previous Hx
Socioeconomic class
Maternal age
Short inter-pregnancy interval
Maternal medical disease e.g. renal failure, DM, thyroid disease
Preganancy complications: pre-eclampsia, IUGR, male fetus
Raised Hb
STIs
BV
Previous cervical Sx
Multiple pregnancy
Uterine abnormalities and fibroids
UTI
Polyhydramnios
Congenital fetal abnromalities
APH
Three mechanisms fo preterm labour
(Castle analogy)
Too many defenders:
Multiple pregnancy, excess liquor.
Probably largely mediated by increased stretch
Defenders jumpm out:
Fetal surivavl response: pre-eclampsia, IUGR, infection, placental abruption
Poor castle design:
Uterine abnormalities
Cerbical incompetence
Enemy knock down walls:
Infection, may be subclinical, BV, GBS, Trichomonmas and Chlamydia
Poor dental health
Prediction of preterm labour: Hx
Those with risk factors
Previous Hx of late miscarriage or prteterm labour
Often not identified on history alone
Ix in predicitng preterm labour
TVS: cervical length is both sensitive and specific
Prevention of preterm labour
Limited to women at high risk, strategies should begin by 12w
Cervix: cervical cerclage either vaginally or abdominally. Prepregnancy and laparoscopy.
Progesterone supplementation: low risk women with short cervix on USS may benefit
Infection: screening and treatment of UTIs and BV
Fetal reduction: higher order multiple reduction at 10-14w
Polyhydramnios: needle aspiration (amnioreduction) or if fetal surveillance is intesive NSAIDs which reduce fetal urine output and cause premature closure of fetal PDA
Treatment of medical disease e.g. thyroid disease
3 situtations in which cervical cerclage is used?
Elective., 12-14w
Scanned regulalry and used if significant shortening
Rescue
NB re metronidazoole in preterm labour
Increases risk of preterm labour
Clinical features of Preterm labour
Hx
Ex
Painful contractions (stop spontaneously in 50%) and labour will not continue until term
Painless cervical dilatation may occur in cervical incompetence or the woman may experience a dull suprapubic ache
APH and fluid loss common
Fever
Lie and presentation checked with palpation
DVE is performed unless membranes have ruptured. Effaced or dilating cervix confirms dx but the course of preterum labour is unpredictable
Ix in preterm labour
CTG + USS to assess fetal state
Fetal fibronectin can be useful. Negative= unlkely delivery. TVS may be used >15mm means delivery unlikely
To look for infection: vaginal swabs, maternal CRP, WCC NB steroids
Def: Red blood cell isoimmunisation
Occurs when the mother mounts an immune response against antigens on fetal RBCs that enter her circulation.
Resulting Abs then cross the placenta and cause fetal RBC destruction
Pathophysiology of RBC isoimmunisation
Blood groups
ABO and rhesus genotype
Rhesus system consists of 3 linked gene pairs. Aone allele of each pair is dominant to the other. C, D, E.
An individual inherits one allele of each pair from each parent in Mendelian fashion
D is most significant.
Dd/DD express the D antigent and are D rhesus positive.
dd= Rhesus negative and will recognise the D antigen as foreign if they are exposed to it
Sensitisation in RBC isoimmunisation
Small amounts of fetal blood and cross te placenta during uncomplicated pregnancies and particularly at sensitising events at delivery.
If fetus is D-rhesus positive and mother is D-rhesus negative the mother will create anti-D Abs
Haemolysis in RBC isoimmunisation
Immunity is permanent and if the mother’s immune system is exposed again to the antigen e.g. a subsequent pregnancy, large amounts of Abs are rapidly created.
They can cross the plaecnta and bind to fetal RBCs which are then destroyed in the fetal reticuloendothelial system.
This causes haemolytic anaemia and ultimately death.
Rhesus haemolytic disease.
A similar immune response can be mounted against other RBC antigens
What are the other antibodies that can be involved in haemolytic disease of newborn?
Anti-C
Anti-Kell (not a rhesus)
Esp. after blood transfusion
What are some potentially sensitising events for haemolysis in newborn?
TOP or ERPC after miscarriage
Ectopic pregnancy
Vaginal bleeding <12w or heavy
ECV
Invasive uterine procedure e.g. amniocentesis or CVS
Intrauterine death
Delivery
Prevention of Rhesus disease
Produciton of maternal anti-D can be prevented by the administration of exogenous anti-D to the mother
This mops up fetal RBCs that have crossed the placenta by binding to their Ags, preventing maternal immune recognition.
Anti-D usually given even if both parents are known to be rhesus negative due to possibilty of non-paternity
NB Anti-D is pointless if sensitisation has already occurred
Antenatal use of Anti-D
Anti-D should be given to all women who are rhesus negative at 28w.
Also given to such women within 72h of any sensitising event.
Anti-D <12w
Not required for spontaneous miscarriage before 12+0 unless there is intrumentation of the wob
In pregnancies <12w anti-D indicated in ectopic, molar, TOP and intrauterine bleeding where this is heavy, repeated or associated with abdominal pain.
Anti-D <12w alwasy given:
Ectopic or TOP regardless of method of management
NB NICE recommends not offering anti-D if ectopic is medically managed although there is no clear evidence to support this
Anti-D in 12w-20
For potentially sensitising events between 12 and 20 weeks of gestation, a dose of 250 IU should be administered within 72 hours of the event.
Women who are RhD negative presenting with continual uterine bleeding between 12 and 20 weeks of gestation should be given at least 250 IU anti-D Ig, at a minimum of six-weekly intervals.
A maternal blood group and antibody screen should be undertaken to determine or confirm the RhD group and check for the presence of immune anti-D in these cases.
If anti-D is identified, further history should be obtained and investigation undertaken to determine if this is immune or passive. If this is not clear then the women should be offered anti-D prophylaxis, as the assumption should be made that it is passive.
Anti-D 20-Term
Within 72h of sensitising event
FMH is required to detect fetal cells in maternal circulation and to estimate the volume of FMH to calculate additional anti-D dosease.
What is FMH and when is it used?
Fetal maternal haemorrhage, used to determine the degree of fetal blood loss into the maternal circulation
>20w to determine anti-D dosing
Prevention of rheus disease
Booking and 28w: check for Abs
Rhesus negative: give anti-D at 28w, after any bleeding or protentially sensitising event and after delivery if fetaus is positive
Manifestations of rhesus disease
Mild: neonatal jaundice only
More sufficient haemolysis may cause neonatal anaemia.
More severe: in utero anaemia-> cardiac failure ascites and oedema-> hydrops. Death will follow.
Rhesus disease in subsequent pregancies
Worsesns as maternal Ab production increases
Mx of rhesus isoimmunisation
Identifiaction of women at risk
Assessing if how severely the fetus is anaemic
In utero blood transufion or delivery
Identifiication of risk for fetal haemolysis
Unsensitised women screened at 28w.
If anti-D levels <10IU/mL, significant fetal problem unlikely, checked every 2-4w
>10IU/mL further investigation
Anti-Kell Abs less predictive of severity and USS used earlier
How to assesss severity of fetal anaemia
USS
Doppler USS of the peak velocity in systle (PSV) in the fetal MCA has high sensitivity for significant anaemia in <36w.
Used fortnightly in at-risk pregnancies
Very severe anaemia (<5g/dL) is detectable as fetal hydrops or excessive fetal fluid. US-guided blood sampling can be used to confirm suspected fetal anaemia.
Treatment of fetal anaemia
Fetal blood sampling is performed with rhesus negative, high Hct, CMV-negative blood ready to be injected down needle if anaemia si confirmed.
This proicess will need to be continued until delviery at 36w.
All neonates born to rehus-negative women should have the blood group checked, FBC, blood film and bilirubin to detect degrees of isoimmunisation
What is the lie of the fetus
Describes the relationship of the fetus to the long axis of the uterus
What are the different kinds of fetal lie?
Longitudinal
Transverse or
Oblique
What is the proportion of abnromal lie?
1 in 200 births
Before term it is normal
What are the causes of abnormal lie?
Circumstances that allow more room to turn:
e.g. polyhydramnios, high parity (more lax uterus) are the most common causes resulting in an unstable or constantly changing lie
Conditions that prevent turning:
Fetal and uterine abnormalities and twin pregnancies
Conditions that prevent engagement:
Placenta praevia, pelvic tumours or uterine deformities
Unstable lie in nulliparous women is rare
Cxs of abnormal lie
If the head or breech cannot enter the pelvis, labour cannot deliver the fetus.
An arm or the umbilical cord may prolapse when membranes rupture
If neglected, obstruction eventually causes uterine rupture
What is the difference between oblique and transverse lie?
Head in flank= transverse
Head in one iliac foss= oblique
Mx of abnormal lie
No management required before 37w unless the woman is in labour
Agter 37w woman is admitted incase of ROM, USS performed to exclude particular causes e.g. polyhydramnios and placenta praevia
ECV unjustified as fetus turns back.
If spontaneous version occurs and persists for 48h the mother is discharged.
An abnormal lie will usually stabilise before 41w.
At 41w or if the woman is in labour the persistently abnromal lie is delivered by Caesarean.
Def: breech presentation
Presentation of the buttocks
Occurs in 3% of term pregnancies.
More common earlier in pregnancy therefore more common in preterm labour
Extended breech
70% has both legs extended at the knee
Flexed breech
15%
Has both legs flexed at the knee
Footling breech
15%
One or both feet present below the buttocks
Causes of breech presentation
No cause found in most
Previous breech has occurred in 8%
Prematurity
Conditions that prevent movement or head engagement are more common
Dx of Breech presentation
Only important from 37w or if patient is in labour
Upper abo discomofort common
Hard head normally palpable and balottable at the fundus
USS confirms Dx and can help detect fetal abnormalitiy, pelvic tumour or placenta praevia and ensures the prequisites for ECV are met
Cxs of breech presentation
Perinatal and long-term morbidity and mortality are increaesd
Fetal abnromalities are more common but even normal breech babies have higher rate of LT neurological handicap which is independent from the mode of delivery.
Labour has potential hazards: increased risk of cord prolapse.
Also risk of trapped head.
Mx of Breech presentation
ECV from 37w
Caesareab section (if ECV has failed or is contraindicated)
Vaginal delivery
Features of ECV
Attempt to turn the baby to a cephalic presentaiton.
Reduces the number of breech presentations at term.
Success rate is 50%
3% of successfully turned breeches will turn back.
Where ECV fails, only 3% will turn spontaneously before delivery
ECV technique
Without anaesthetic
Made easier with administration of a tocolytic if uterine tone is high or an initial attempt has failed.
Breech disengaged from the pelvis and pushed upwards and to the side.
USS guided
CTG straight after
Anti-D for rhesus negative women.
Safety of ECV
Risk very low
Placental abruption and uterine rupture have been reported.
Risk of emergency C-section
Factors affecting success of ECV
Low succes rates seen in nulliparous
Caucasions
Where the breech is engaged
Head not easily palpable
Uterine tone high
Obese women
Liquor volume reduced
What are the Absolute contraindications to ECV
C-section required anyway e.g. placenta praevia
Twins
Membranes ruptured
APH within last 7d
Abnromal CTG
Major uterine abnromalitiy
Relative contraindications to ECV
Small for dates with abnormal doppler
Proteinuric pre-eclampsia
Oligohydramnios
Major fetal abnormalities
Scarred uterus
Unstable lie
What is the safest method of delivery for singleton term breech?
C section
Reduces mortality by 1% and ST morbidity but does not affect LT outcomes.
Maternal morbidity is not increased.
NB 1/3rd of attempted vaginal breech deliveries ends with emergency C-sections.
Unfavourable factors for vaginal breech birth
Contraindications to vaginal delivery
Contracted pelvis
Footling breech
Large baby >3800g
Growth restricted baby
Hyperextended fetal neck in labour
Lack of suitably trained clinician
Previous C-section
Vaginal breech birth
Intrapartum care
Pushing not encouraged until the buttocks are visible
CTG
Epidural common
In 30% there is slow cervical dilatation in the frist stage or particularly poor descent in the second.
Oxytocin not advised-> C-section
What is a common cause of a difficult breech delivery
Injudicious traction causing extension of the head.
Once the buttocks distend the perineum an episiotomy may be made but is not essential.
Delivery in Breech
Fetus delivers as far as the umbilicus with maternal effort
Legs can flexed out of the vagina whilst the back is kept anterior,
Once the scapula is visible the arms are hooked down by sweeping it across the chest
If arms cannot be reached as they are extended superiorrly, Lovset’s procedure is required.
Once the back of the neck is visible, the operator supports the entire weight of the fetus on one palm and forearm, with their finger in its mouth to guide the head over the perineum and maintain flexion. The other hand presses against the occiput.
If this fails, forceps.
What is Lovset’s procedure
Required in breech if arms are extended above the head.
Hands placed around the body with the thumbs on the sacrum, rotating the baby 180 degrees clockwise then counter-clockwise with gentle downward traction.
Allows the shoulders to enter the pelvis
What is the Mauricea-Smellie-Veit manouvre
Used in breech to deliver the head:
Operator supports the entire weight of the fetus on one palm and forearm.
Finger in mouth to guide head over the perinum and maintain flexion.
Other hand presses against the occiput
What is the purpose of instrumental delivery
Aim is to prevent fetal and maternal morbidity. Shape of the pelvis will only allow delviery if the head it posterior or occasionally anterior
What are Simpson’s Forceps, Neville-Barnes forceps?
When are they suitable
Non-rotational
Only suitable when the baby’s head is occipitoanterior
What are Kiellan’d forceps?
Rotational forceps allowing a malpositioned head to be rotated by the operator to the OA position before the application of traction.
Safety of ventouse and forceps
Failure: both methods can fail
Maternal Cxs and need for analgesia are greater with forceps. Either instrument can cause vaginal laceration, blood loss or third-degree tears. Cervical and uterine tears are very rare.
Fetal complications: worse with the vventous. Lives a chignong which diminishes over hours. Scalps lacerations, cephalohaematomata are more common with ventous
Facial bruising, nerve damage and even skull and neck fractures occur with injudicious use of forceps and prolonged traction by either instrument is dangerous.
Chaning instrument: associated with increased fetal trauma and is only appropriate if a ventouse has achieved descent to pelvic outlet but is then replaced by a low cavity forceps delivery.
What are the indiciations ofor instrumental vaginal delivery?
Prolonged second stage: most common indication
Fetal distress; more common in the second stage
Prophylactic use indicated to prevent pushing in some women who have medical problems e.g. cardiac disease or HTN
In breech delivery to control the head
Prolonged second stage, use of instrument
1h of pushing has failed to deliver the baby
If the mother is exhausted it may be performed earlier
The length of the passive second stage is less important
What are the approaches to prevent instrumental delivery
All labours: continuous support with delivery in the most comfortable maternal position possible. Epidural, analgesia, CTG, and induction predispose to instrumental delivery.
Epidural analgesia and isntrumental delviery
Epidural increases the risk of instrumental delivery.
If used, maternal pushing should be delayed at least an hour after the diagnosis of second stage unless the head is visible. Oxytocin should be considered if descent of the head is poor (Nulliparous women)
What determines the type of delivery and the choice of instrument?
Position and descent of the head.
With either instrument, if moderate traction does not produce immediate and progressive descent, C-section is indicated
Features of a low cavity delivery
Head below the level of the ischial spines with bony prominences palpable vaginally on the lateral wall of the mid pelvis and is usually OA.
Forceps/ventouse are appropriate.
Pudendal block with perineal infiltration is usually sufficient.
Features of a mid-cavity delivery
Head is not palpable adominally but is at or just below the level of the ischial spines.
Epidural or spinal.
Trialled in theatre if there is doubt about the potential success. May be OA, OT or OP
OA mid-cavity delivery
Forceps or ventouse
OT mid-cavity
Usually this is as a result of insufficient descent of the head to make it rotate.
Descent achieved with ventouse with rotation resulting
Non-rotational forceps are contraindicated.
Rotational forceps may be able to achieve rotation in situ followed by descent.
OP mid-cavity delivery
Often accompanied by extension of the fetal haed.
1/5th may still be abdominally palpable.
Need for instrumental delivery is unsuual in multiparous women and if required this position should be suspected.
Requires rotation 180deg, Klielland’s most effective.
What are the prerequisites for instrumental vaginal delivery
Head must not be palpable abdominally
Head must be at or below the level of the ischial spines
Cervix must be fully dilated, with the second stage reached.
Position of the head must be known
Adequate analgesia
Bladder should be empty
Delivery for a valid reason
Ventouse vs forceps
Ventous causes:
Higher failure rate
More fetal trauma
no difference in APGAR
Less maternal trauma.
What is the usual C-section operation?
Lower segment Caesarean section in which the abdominal wall is opened with a suprapubic transverse incision and the lower segment of the uterus is also incised transversely to deliver the baby
When might a “classical” C-section be used?
Extreme prematuirty
Multiple fibroids
Transverse fetus
Indications for emergency C-section
Prolonged first stage
Fetal distress
Features of prolonged first staeg
Diagnosed when dilatation is not imminenet by 12h or earlier if labour was initially rapid.
Occasionally ful dilatation is achieved but not all of the criteria for instrumental delivery are met.
What are the 3ps of a prolonged labour
Powers: inefficient uterine action
Passenger: malposition or malpresentation
Passage: pelvic abnormalities and cephalo-pelvic disproportion
When is elective C-section usually performed
39w
If earlier, steroids should be considered
What are the absolute indications for elective caesarean
Placenta praevia
Severe antenatal fetal compromise
Uncorrectable abnormal lie
Previous vertical C-section
Gross pelvic deformity
What are the relative indications for elective C section?
Breech
Severe IUGR
Twin pregnancy
DM and other diseases
Previous C-sec
Older nulliparous patients.
What are the most common indications for delivery before 34w
Severe pre-eclampsia and IUGR
What are the different types of C section
Emergency: immediate threa to mother or fetus e.g. severe fetal distress
Urgent: maternal/fetal compromise that is not immediately life threatening e.g. dystocia
Scheduled: needing early delivery but no compromise
Elective: at time to suit mother and team
Peri/post-mortem: for fetus and mother during maternal arrest or for fetus after maternal death
What are the maternal complications of C-section
Greater than with a vaginal delivery. Greater when in labour rather than elective.
Haemorrhage and the need for transfusion
Uterine or wound infection (20%)
Bladder/bowel damage.
VTE
Prophylactic antibiotics and thromboprophylactic measures.
1/5000 will die after caesarean
What are the fetal complications of C section
Increased risk of fetal respiratory morbidity at any gestation and should not be before 39w in uncomplicated pregnancy for this reason.
Fetal lacerations rre rare
Bonding and breastfeeding affected by emergency procedures.
Neonatal morbidity and mortality is increased with elective C-section.
What are the risks of C-section to subsequent pregnancy
Become increasingly difficult
Increase in stilbirths in subsequent pregnancies
Increased incidence of placenta praevia, also increased risk of placenta accreta or percreta (best diagnosed with 3D power Doppler)
Mx of placenta praevia
Most senior person with anaesthetic support
Cross match blood
Facilities for internal iliac or uterine artery embolisation are advised
Uterine incision should avoid the placenta, which can be left in situ or hysterectomy performed.
In less severe cases compression of the placenta with a Rusch balloon may alleviate or reduce haemorrhage.
Ultimately delay in performing hysterectomy can be lethal.
What is labour
Process whereby the fetus and placenta are expelled from the uterus, usually between 37 and 422 gestation
Dx: painful uterine contractions accompany dilatation and effacement of the cervix
What are the stages of labour
Stage 1: initiation to full dilatation
2: Dilatation to fetus delivery
3: Delivery of fetus to delivery of placenta
What are the 3 mechanical factors determinining the progress of labour
Powers
Passage
Passenger
What are features of the powers of labour
Once labour is established the uterus contract 45-60s every 2-3 minutes
This pulls the cervix up: effacement and causes dilatation, this is aided by the pressure of the head as the uterus pushes the head down into the pelvis.
Poor uterine activity is a commmon feature of nulliparous women and in induced labour but is rare in multiparous women
What factors constitute tthe passage in labour
Bony pelvis
Soft tissues
What are hte palnes of the pelvis?
Inlet: transverse diameter is 13cm, wider than the 11cm AP diameter
Mid-cavity: is almost round, transverse and AP diameters are similar
Outlet: AP (12.5cm) is greater than the transverse (11cm)
In the lateral wall of the round mid-pelvis, the ischial spines are palpable vaginally and are used as landmarks to assess the head’s descent.
What is “station” and how is it measured
Level of the descent of the head
Measured in relation to the ischial spines
Station 0 means the head is above the level of the spines
+2 means it is 2 below
-2 means it is 2 above
What are the features of the soft tissues in passage
Cerbical dilatation is prerequisite for delivery and is dependant on contractions. Pressure of head and the ability of the cervix to soften allows distension.
The soft tissues of the vagina and perineum need to be overcome in the second stage.
What are the features of passenger
Attitude
Position
Size
What is the gregma
Anterior fontanelle
What is the vertex of fetal head
The area between the occipit (posterior fontanelle) and the bregma (anterior fontanelle)
What is the attitude of the fetal head
What is the ideal attitude?
Degree of flexion of the head on the neck
Maximum flexion keeping the head bowed- vertex presentation.
Presenting diameter is 9.5cm running from the anterior fontanelle to below the occiput at the back.
Aextension results in a larger diameter
What is a brow presentation
Extension of the fetal head by over 90 degrees, increases the diameter to 13cm.
What is a face presentation
Extension by 120 degrees.
What is the position of the fetal head?
The degree of rotation of the head on the neck.
If the sagittal suture is transverse, the fetal head will fit the pelvic inlet best.
At the outlet the saggital suture must be vertical for the head to fit.
Therefore the head must rotate 90 degrees during labour.
What is the normal delivery of the fetal head?
OA: occipitut anterior
OP in 5% is more difficult.
What does position of the OT position imply?
Non-rotation and that delivery without assistance is impossible.
What is moulding of the fetal head?
Compression of the fetal head due to the sutures allowing the bones of the head to come together
Pressure of the scalp on the cervix to cause localised swelling or caput.
Terms describing the fetal head
Presentation: i.e. cephalic or breech
Presenting part: lowest part of the fetus palpable e.g. vertex, brow, face
Position: OA, OT, OP
Attitude: degree of flexion
What are the movements of the fetal head in delivery
Engagement in OT
Descent and flexion
Rotation 90 deg to OA
Descent
Extension to deliver
Restitution and delivery of shoulder
What is the show?
A pink/white mucus plug form the cerivx and or rupture of membranes
What are the phases of Stage 1 of labour?
Latent phase: cervix dilates slowly for first 3cm
Active phase: average dilatation is at a rate of 1cm/h in nulliparous and 2cm/h in multiparous
Active first stage should not normally last longer than 12h
What are the stages of the second stage of labour
Passive: lasts from full dilation until the head reaches the pelvic floor and the woman experienes the desire to push. Rotatio and flexion are commonly completed, may last a few minutes
Active: when the mother is pushing/ Fetus is delviered on average after 40 minutes or 20 minuts (multip vs nullip). If it takes >1h spontaenous delivery becomes decreasingly likely.
Process of delivery of the baby
As the head reaches the perineum it extends to come up and out of the pelvis
Perineum stretches and often tears
Episiotomy is indicated if progress is slow or in fetal distress
The head then restitutes, rotating 90 degress to adopt the transverse position in which it entered the pelvis
With the next contraction, the shoulders the deliver, with the anterior shoulder coming under the pubic symphysis first, usually aided by lateral body flexion in a posterior direction. Posterior shoulder delivery is aided by flexion in an anterior direction
What are the features of a normal 3rd stage of labour
15 mins
<500mL blood loss
Uterine muscle fibres contract to compress the BVs formerly supplying the placenta
What is the prevalence of perineal trauma following delivery?
Intact in 1/3rd of nullips and in 1/2 of multips
What is the difference between induciton and augmentation
Artificial initiation of labour= induction
Augmentation= strengthening the contractions of established labour
What determines the likelihood of the success of labour induction
Favourability of the cervix (Bishop’s score)
What are the methods for induction
Natural
Medical: PGs
Oxyotcin following amniotomy
Surgical: Amniotomy
Features of inductions with prostaglandins
PGE2 (2mg)
Inserted into posterior vaginal fornix, best method in most nullips and multips (unless te cervix is very favourable)
Either starts labour or improves the ripeness of the cervix to allow amniotomy.
If one dose doesn’t improve cervical ripeness, a second dose may be given >6h later providing there is no uterine activity.
>2 doses are not helpful
Features of induction with amniotomy
Forewaters are ruptured with an amnihook (ARM)
Oxytocin infusion is usually started within 2h if labour has not ensued.
Oxyotcin alone may be used if ROM has already occurred
What is natural induction
Cervical sweeping: passing a finger through the cervix and stripping between the membranes at the lower segment of the uterus.
At 40w this reduces the chance of induciton and postdates pregnancy
What are some common indications for induction
Prolonged pregnancy
Suspected growth restriction
PROM
Pre-eclampsia
Medical disease: HTN and DM
What are the fetal indications for induction
High risk situations e.g. prolonged pregnancy
Suspected IUGR
Compromise
APH
Poort Ob Hx
PROM
What are the materno-fetal indications for induction?
Pre-eclampsia
Maternal disease e.g. DM
What are the maternal indications for induction
Social
In utero death
What are the absolute contraindications to induction
Acute fetal compromise
Abnormal lie
Placenta praevia
Pelvic obstruction or deformity
Usually considered inappropriate after >1 C-sect
What are the relative contraindications for induction
One previous C-sec (increased scar rupture rate)
Prematurity
What is the Mx of induced labour
Because of both the indication and the use of drugs, the fetus is at increased risk during induction
CTG following induction with Pg (1hr) or when they stimulate uterine activity
Oxyoticn also warrants CTG monitoring
Induction increases the time spent in early labour
What are the Cxs of induced labour?
Failure/slow start of labour due to ineffcient uterine activity
Risk of instrumental delivery or C-section is higher
Uterine overactivity: fetal distress and uterine rupture
Umbilical cord prolapse at amniotomy
PPH more likely
IP and PP infection also more likely
Prematurity due to acciden e.g. incorrect gestation
Amniotic fluid embolism (if Oxyotcin used and ARM not performed)
What are the contraindications for VBAC?
Vaginal delivery after C-section:
Vertical uterine scar
Multiple previous Caesareans (>2)
What are the factors influencingvaginal delviery after one C-sec
60-80% of women will deliver vaingally, others will require an emergency C-sec
Factors associated with increased success:
Spontaneous labour
Inter-pregnancy interal <2y
Low age and BMI
Previous Vaginal delivery
Previous C-sec was elective or for fetal distress.
Smaller subsequent fetus and engagement of the head
What are the maternal risks of VBAC?
Vaginal delivery safest, emergency C sec least safe.
Risk of blood transfusion or uterine infection higher
Serious maternal morbidity is greater with increasing number of C-secs: placenta accreta
What are the fetal risks of VBAC?
Higher mortality as risk of antepartum stillbirth elminiated by 39w elective C sec
Uterine rupture
What is significant in terms of fetal implications of C-sec
TTN is higher in elective C-secs
Fetal morbidity is increased with increasing number of prior caesareans
Mx of VBAC
Hospital delivery and CTG monitoring advised
Induction avoided
Augmentation also increases the risk of scar rupture
Epidural safe but labour should not be prolonged
Scar rupture presents as fetal distress accompanied by scar pain, contraction cessation, vaginal bleeding and maternal collapse.
Immediate laparotomy if rupture suspected
What is prelabour term ROM
Rupture of membranes without onset of labour
Different from PPROM: prelabour preterm rupture of membranes
What is hindwater ruptre
Leaking of liquor but membranes remain in front of the fetal head
What are the risks of PROM
Cord prolapse: rare, usually a Cx of transverse lie or breech
Risk of infection, increased by vaginal examination, GBS presence, increased duration of membrane rupture
Mx of Prelabour ROM
Confirmation
Lie and presentation checked
DVE avodied, may be performed if risk of cord prolapse or fetal distress
Vaginal swab
Fetal auscultation or CTG
Induce or await onset of labour
Induciton of labour in prelabour ROM
Waiting for labour in ROM
Does not increase risk of C-sec and associated with a lower chance of maternal infection and of NICE admission, particularly if GBS carrier
Only 20% do not enter labour spontaenously
Maternal pulse, T and fetal HR measured every 4h.
Meconium or infection warrants induction.
After 18h: antibiotic prophylaxis vs GBS and induction
What is the cut off for antibiotic prophylaxis in Prelabour ROM?
18h
vs GBS
and induce labour
Metronidazole
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Possible increased risk of preterm labour
Use with caution
Clindamycin
Safe to breastfeed
Penicillins
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Nil known risks
Safe
Erythromycin
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Nil known
Safe
Cephalosporins
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Safe
Nil known risks
Augmentin
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Possible increased neonatal risk if preterm birth- NEC
Use with caution
Penicllins
Safe to breastfeed
Tetracyclines
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Discolour teeth if 2nd trimester
Avoid
Erythromycin as alternative
Safe to breastfeed
Timethoprim
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Folic acid antagonist
Avoid in pregnancy
Cephalosporins as an alternative
Safe
Fundamentals of analgesic use in pregnancy
Paracetamol best used, codeine if more severe
NSAIDs
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Closure of fetal DA.
Fetal IUGR
Possible cerebral haemorrhage
Caution (avoid for analgesia)
Monitor fetus with USS
Paracetamol
Safe to breast feed
Aspirin
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Nil known risk
Use if high risk of pre-eclampsia
Alternatives NA
Safe to breastfeed
Paracetamol
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Nil known risk
Safe
Safe to breastfeed
Opiates
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Maternal/fetal dependancy
Only if severe pain or drug dependancy
Methadone if opiate addict
Beware accumulation in breast feeding
Warfarin
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Teratogenic
Risk of fetal haemorrhage
Only use if artifical heart valves and with specialist advice
LMWH
Safe to breast feed
LMWH
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Maternal bleeding in OD
Safe for fetus
Use if indicated
Safe to breast feed
Fundamentals of analgesics in pregnancy
Best use paracetamol, plus codeine if more severe
Fundamentals of anticoagulants in pregnancy
Probably underused
Warfarin only used in exceptional circumstances
ACEI
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Fetal renal failure
Teratogenic
Avoid in pregnancy
Methyldopa as alternative
Captopril is safe for breast feeding
Methyldopa
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Nil known risk
Best 1st line
Safe to breast feed
Beta blockers
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Possible IUGR if early
Caution, 3rd line
Methyldopa as alternative
Safe to breast feed
Ca antagonists
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Nil known risk
Best second line e.g. nifedipine
Safe to breast feed
Thiazide diuretics
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Maternal hypovolaemia
Avoid in pregnancy
Methyldopa as alternative
Safe to breast feed
Thyroid hormone in pregnancy
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Use if indicated
Monitor thyroid
Propylthiouracil
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Fetal hypothyroidism
Use minimal dose
Monitor thyroid
Carbimazole
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Fetal hypothyroidism, aplasia cutis
Use minimum dose
Propylthiouracil as alternative
Monitor thyroid
Inslin
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Maternal hypoglycaemia
Use with usual precautions
Safe to breast feed
Metformin
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Probably safe
Use with caution
Insulin as alternative
Safe to breast feed
Ciclosporin
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Nil known effects
Continue, monitor leveles
Probably safe
Azathioprine
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Minimal risk
Continue if indicated
Safe to breastfeed
Prednisolone
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
No fetal effects
Maternal GDM, HTN
Use minimum dose
Safe to breastfeed
TCAs
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Largely safe
Use if high risk of relapse
Fluoxetine as an alternative
Safe to breast feed
SSRIs
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Paroxetine teratogenic (3% risk), others probably safe
Use if high risk of relapse, fluoxetine preferentially
Safe to breast feed
Lithium
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Teratogenic (10% risk)
Use only if high risk of relapse
Alternatives difficult
Watch for toxicity
Neuroleptics in pregnancy
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Possibly mildly teratogenic although largely unknown
Usually continue due to risk of relapse but avoid clozapine
Alternatives difficult
Probably safe to breast feed
Sodium valproate
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Impaired childhood cognition, cognition teratogenic (4-9% risk)
Minimise combinations and consider cahgne if <12w
Carbamezapine as an alternative
Safe to breast feed
Carbamezapine
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Teratogenic (3% risk)
Usually continue
Safe to breast feed
Lamotrigine
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Teratogenic (1-5% risk)
Usually continue
Safe to breast feed
Fundamentals of antiepileptics in pregnancy
Best sorted preconception
Seizure control imperative
Minimise combinations and doses
High dose folic acid
Steroids
Betamethasone and dexamethsone
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Nil known risk with single course
Use if high risk for preterm labour
Betamethasone best
NA
NA
Beta-agonists
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Nil known risk at anti-asthmatic doses
Use if indicated
Safe to breast feed
Ursoedoxycholic acid
In pregnancy
Risk
Conclusion
Alternatives
Breastfeeding
Safe
Use for cholestasis
What is the background risk of congenital malformations?
1-2%
Hb in pregnancy
10.5-14
Higher with supplementation
High Hb associated with worse perinatal outcomes, rapid drop in platelets suggestive in PET
WBC in pregnancy
5-11
Levels unchanged in pregnancy but rise in labour
Platelets in pregnancy
100-450
Slight drop towards term
Free T4 in pregnancy
Free T3 in pregnancy
TSH
NB
11-22
Slightly lower in early pregnancy
43-45
Slightly lower in early pregnancy
0-4
Aim for 1.5-2 if replacement therapy
NB: undertreated and subclinical hypothyroidism associated with cognitive deficit in childhood
Renal function in pregnancy
Urea
Creatinine
Uric acid
Na
K
Prtoein excr
NB
2.8-3.8
Lowered in pregnancy
50-80
Lowered in pregnancy
x100, should ve
Unchanged
K usually slighlty low in pregnancy
Slightly raised protein excretion
Increased renal excretion in pregnancy, high creatinine/uric acid common with PET
Liver funciton in pregnancy
ALP
ALT
AST
ALbumin
NB
<500
Raised
<30
Reduced
<35
Reduced
28-37
Reduced
Rapid rise in liver enzymes common with complications of PET
ESR in pregnancy
>30, elevated, no clinical use in pregnancy
CRP in pregnancy
<8, unchanged by pregnancy
Glucose in pregnancy
NB
<6: fasting
<8 after food
Slight fall in pregnancy
Tight glucose control improves outcomes with maternal diabetes.
What is breakthrough bleeding?
Irregular bleeding associated with hormonal contraception
What are the causes of breakthrough bleeding?
Bleeding problems are more common with progestogen-only methods:
COCP
POCP
Contraceptive depot
IUS
Emergency hormonal contraception
Def: puerperium
6w period following delivery when the body returns to its preprgenant state
Maternal morbidity and mortality associated with pregnancy is highest during this period
Changes to the genital tract during the puerperium
Uterus contracts and the BVs that supplied the placenta occlude
Uterine size reduces over 6w and shouldn’t be palpable abdominally within 10d
Contractions or after pains may be felts for 4d.
Os closes by 3d
Lochia, cervical discahrge may be bloo stained for 4w.
Menstruation delayed by lactation but occurs after 6w if woman is not lactating
Changes to the CVS during the puerperium
CO and BV decrease to prepregnant levels within a wekk
Loss of oedema can take up to 6w
BP normalises within 6w
Changes to the urianry tract during the puerperium
Physiological dilatation of pregnancy reduces over 3m
GFR decreases
Changes to the blood during the puerperium
U+Es return to normal
Hb and HCt rise thie haemoconcentration
WCC falls
Platelets and clotting factors rise, predisposing to thrombosis
Generalities of postnatal care
Do not separate mother and baby
Early mobilisation
Couneselling
Check uterine involution, lochia, BP, pulse, T daily
Analgesia may be required for perineal pain which can be helped through pelvic floor exercises
FBC, Fe if appropriate in conjunction with laxatives
Discussion of delivery
Psych referral if indicated by history
Physiology of lactation
Dependant on prolactin (ant pit) which stimulats milk secretion. Levels of prolactin in conjunction with the decline in oestrogen and progesterone promote milk secretion
Oxytocin from post pit stimulations ejection in respoonse to suckling which also stimulates prolactin release
Can produce up to 1000ml
Since oxytocin is controlled by hypo, emotional or physical stress may inhibit
What is colostrum
A yellow fluid contianing fat-laden cells, proteins (IgAs) and minerals which is passed for the first 3d before the milk comes in
What is the correct positioning for breast feeding
Baby’s lower lip should be planted below the nipple so the entire nipple is drawn into the mouth.
Why is Vit K given postpartum?
To reduce the chances of haemorrhagic disease of the newborn
What are the advantages of breastfeeding?
Protextion against infeciton in neonate
Bonding
Protection against Ca in mother
£
Advice about postnatal contraception
Lactation not adequate alone.
Usually started 4-6w post delivery
Combined contraceptive suppresses lactation and contraindicated if breastfeeding
Progesterone only safe
IUD safe: screen for infeciton.
Insert at end of third stage or at 6w
Def: primary post partum haemorrhage
Loss of >500mL blood <24h after delivery
<1000mL after C-sec
Occurs in 10%
What are the causes of PPPH?
Retained placenta
Uterine causes
Vaginal causes
Cervical tears
Coagulopathy
Features of retained placenta
Occurs in 2.5% of deliveries.
Partial separation can cause blood to accumulate in the uterus, which will rise
Collapse may occur in the absence of external loss
Features of uterins causes of PPPH
Account for 80%
Uterus fails to contract either due to atony, retained placenta
Atony is more common with prolonged labour, grand multparity and overdistension of the uterus and fibroids
Features of vaginal causes of PPPH
Accounts for about 20%
Bleed from perineal tear or episiotomy may be obvious but bleed from higher vaginal tear must be considered, especially after instrumental
Features of cervical tears and PPPH
Rare but associated with precipitate labour and instrumental delivery
Coagulopathy causing PPPH
Congenital disorders
Anticoagulant therapy
DIC
Prevention of PPH
Oxytocin in 3rd stage of labour decrease incidence by 60%
As effective as ergometrine
Contraindication of ergometrine in PPH prevention
Causes vomiting and is contraindicated in HTNive women
What are the risk factors for PPH?
Previous hx
Previous C sec
Coagulation defefct or anticoagulant therapy
Instrumental/C-sec
Retained placenta
APH
Polyhydramnios, multiple pregnancy
Grand multiparity
Uterine malformation or fibroids
Prolonged/induced labour
Clinical features of PPH
Blood loss should be minimal after placental delivery
Enlarged uterus suggest uterine cause
Inspect vaginal walls and cervix for tears
May be abdominal blood loss e.g. uterine rupture without pain or overt bleeding
Mx of PPH
ABC: nursed flat, cross matched blood. Restore BV. Page anaesthetist, haematologists, seniors
Retained placenta should be removed manually if there is bleeeding if it is not expelled within 60mins of delivery
Identify and treat cause: examination
Bimanual uterine compression
Oxytocin and or ergometrine given to contract the uterus
If this fails examination under anaesthetic performed for retained placental fragment and inspect of the vagina
If uterine atony persists, PgF2 injected into myometrium
Persistent haemorrhage despite medical treatment requires surgery.
May be compressed using Rusch balloon if bleeding from placental bed alone
B-Lynch (brace suture may be used)
Uterine artery embolisation
Hysterectomy if these fail
Def: secondary PPH
Excessive blood loss occuring 24h-6w after delivery
Causes of secodarry PPH
Due to endometritis +/- retained placental tissue
Rarely incidental gnaecological pathology or
gestational trophoblastic disease
Uterus enlarged and tender with an open internal cervical os.
Ix in secondary PPH
Vaginal swab
Blood count
Cross-match
USS: although difficult to differentiate between blood clot and retained placental tissue
Antibiotics
ERPC may be used if bleeding is heavy and acute. Chronic can be managed with antibiotics alone.
Histlogical examination of evacuated tissues will exclude gestational trophoblastic disease
What is characteristic of endometritis?
Endometritis due to reatined tissue causes bleeding that slows but does not stop with antibiotics and gets worse again once the course is finished
Def postpartum fever
>38 in first 14d
What are the common causes of postpartum pyrexia
Infection: genital tract sepsis. Most common after C-sec. Prophylactic antibiotics reduce this
DVT often causes low grade pyrexia
What organisms most commonly cause postpartum genital sepsis
GAS
Staph
E. Coli
What are the features of postpartum genital tract sepsis
Lochia may be offesnive
Uterus enlarged and tender
Urinary infection, chest infeciton, mastitis, perineal infection and wound infection are alos common.
Ix of postpartum pyrexia
Bloods
Urine
High vaginal
Fetal cultures
Broad spectrum antibiotics
What proportion of obstetric deaths from DVT occur post-partum?
50%.
Early mobilisation and hydration importatnt for all women
What are third day vlues
Temporary emotional lability, affect 50% of women. Support and reassurance
What should be considered in postnatal depression
Postpartum thyroiditis
Mx of pregnant women with Hx of mental illness
See a psychiatrist before delivery
MDT plan for postnatal discharge arranged
Pre-eclampsia postnatally
Takes 25h before illness improves.
BP peaks 4-5d post delivery and may need treatment for weeks.
Fluid balance, renal funciton and UO should be monitored.
BP and hpatic/cardiac failures
Continue BP measurements for 5d postnatally
What complications of the urinary tract are common in the puerperium
Retention of urine
UTI
Incontinence
Features of urine retention in the puerperium
Common after delivery, may not be painful after epidural.
May present with frequency, stress incontinence or severe abdominal pain.
Infection, overflow incontinence and permanent voiding difficulties may follow.
Strict fluid charts and abdominal palpation help to identify.
Postmicturition USS can be used to assess the residual volume
Treatment is with catheteritsation
Incontinence in the puerperium
Occurs in 20% of women
Overflow and infection should be excluded using postmicturition ultrasound or catheterisation and an MSU
Symptoms of stress incontinence usually improve with pelvic floor exercises
Complications of perineal trauma in the puerperium
Perineal trauma: repaired
Pain: persists more than 8w in 10%. Superficial dyspareunia is common. Diclofenac is effective.
Paravaginal haematoma: excrutiating pain te perinum a few hours after delivery., sometimes identified on USS. Drained under anaesthetic
Bowel problems in the puerperium
Constipation and haemorrhoids: laxatives
Incontinence of faeces or flatus
Features of faecal/flatus incontinence in the puerperium
Affects 4% of women mostly transiently
Can be caused by pudendal nerve or anal sphincter damage.
Anal manometry and ultrasound used to assess and managed on basis of symptoms.
Formal repatir may be required after which deliveries should be by C-sec
What are the risk factors for incontinence following delivery?
Forceps
Large babies
Shoulder dstocia
Persistent OP position
What are the normal flora and pH of the vagina?
Lactobacillus
Acidic pH <4.5
In prepubertal girls and postmenopausal women, lack of oestrogen results in a thin, atrophic epithelium with a higher pH and reduced resistance to infection
What is thrush and its features
Infection with Candida albicans
Most common cause of vaginal infection and found in up to 20% of women, often asymptomatically.
Cotttage cheese discahrge
Vulval irritaiton and itching.
Superficial dyspareunia and dysuria may occur.
Vagina and or vulva are inflamed or red
Risk factors for thrush
Pregnancy
DM
Use of antibiotics
Rx of candida
Topical imidazole (e.g. clotrimazole)
or
oral fluconazole.
What is BV and its features
When normal latcobacilli ar eovergrown by a mixed flora including anaerobes, Garderella and Mycoplasma hominis
Found in 12% of women
Grey-white discharge
Vagina not red or itchy
Fishy odor from amines released by bacterial proteolysis
Dx of BV
Raised vaginal pH
Positive whiff test (when 10% KOH added)
Presence of clue cells
Vulvitis
Cottage-cheese discharge
Candida
Grey-white discharge
Fishy odor
BV
Rx in BV
Metronidzaole
or clindamycin cream
Signficiance of BV obstetrically
Can cause secondary infection in PID
Also an association with preterm labour
What is vaginal infection and discharge in children often due to?
Foreign body.
May also be due to atrophic vaginitis due to low oestrogen levels
Toxic shock syndrome in a young woman menstruating
Occurs as a rare complication of a retained, hyperabsorbable tampon
Toxin producing Staph aureus.: high fever, hypotension and multisystem failure
Abx and ICU
What are the principles in the management of STIs?
Screen for concurrent disease
Regular sexual partner should also be screened and treated.
Partner notification
Maintenance of confidentiality.
Education
Barrier methods of contraception
What is the most common sexually transmitted bacterial organism in the world?
Chlamydia
Symptoms of chlamydia
May be asymptomatic
Urethritis and vaginal discharge
What is the significant Cx of chlamydia infeciton?
Pelvic infection (may be silent)
Can cause tubal damage leading to subfertility or chornic pelvic pain.
Can also cause Reiter;s yndrome
Rx of chlamydia
Azithromycin or doxycylcine
Dx of chlamydia
NAAT
Reiter’s syndrome
Urethritis
Conjunctivitis
Arthritis
(see, pee, climb a tree)
Causative organism in chlamydia
Chlamydia trachomatis
Causative organism in gonorrhoea
Neisseria gonorrhoeae
Symptoms of gonorrhoea
Asymptomatic in women, vaginal discharge, urethritis, bartholinitis and cervicitis can occur. Pelvis commonly infected
Systemic complications of gonorrhoea?
Vacteraemia
Acute monoarticular septic arthritis
Rx in gonorrhoea
Azithromycin or ceftriaxone
What are condylomata acuminata?
Genital warts
Treatment of genital warts?
Topical podophyllin or imiquimod cream
Genital herpes causative agent?
HSV Type 2.
Although Type 1 implication increasing.
Features of genital herpis
Primary infeciton is the worst with multiple small painful vesicles and ulcers around the introitus.
Local lymphadenoapthy, dysuria and systemic symptoms are common.
Secondary bacterial infection, aspetic meningitis or urinary retention may also occur.
Rx of genital herpes
Aciclovir (also valaciclovir or famciclovir) used in severe infections
Causative organism in syphillis?
Treponema pallidum
Features of primary syphillis
Solitary, painless, vulval ulcer (chancre)
Features of secondary syphillis
Untreated primary, secondary may develop weeks later:
Rash, IFV-like symtpoms and warty genital or perioral growths (condylomata lata)
Latent syphillis follows
What are the complications of tertiary syphillis
AR
Dementia
Tabes dorsalis
Gummata in skin and bone.
Treatment of syphillis
IM penicillin
Causative organism in trichomonas infection
Trichomonas vaginalis
Flagellate protozoan
Symptoms of TV
Grey-green offesnive discharge
Vulval irritaiton
Superficial dyspaerunia
Cervicitis has a punctuate erythematous (“strawberry”) appearance)
Treatment of TV
Metronidazole
Causative orgnaism in chancorid
Haemophils ducreyi
Causative organism in lymphogranuloma venereum
Chlamydia subtypes
Causative organism in donovanosis
Calymmatobacterium granulomatis
What are the infective causes of genital ulcerative disease
Herpes
Syphillis
Chancroid
Lymphogranuloma venereum
Donovanosis
AIDS=
Development of opportunisitc infections or malignancy
CD4 <200
Smears in HIV +ve women
Yearly due to increased risk of lesion progression
Features of endometrtiis
Infection confined to the cavity of the uterus which, if left untreated, commonly spreads to the utereus
Often the result of either instrumentation of the uterus or as a complication of pregnancy or both.
Common orgnaisms causing endometritis
E Coli
BV
Staph
Clostridia
Chlamydia
Gonococcus
Presentation of endometritis
Persistent and heavy vaginal bleeding accompanied by pain
Uterus is tender and the cervical os is commonly open
Fever may be absent byt septicaemia can ensure.
Ix and Mx of endometritis
Vaginal and cervical swabs
FBC
Pelvis USS (not very reliable)
Empirial antibiotics
ERPC
Def: PID
Traditionally describes sexuallly transmitted pelvic infection, endometritis usually co-exists
Pelvic infection in pregnancy
Almost never occurs in the presence of a viable pregnancy
What are the risk factors for PID
Sexual factors (80%)
Multiple partners
No use of barrier protection
COCP and Mirena IUS are protective.
What causes the spread of asymptomatic STIs to the pelvis?
Usually spontaneous
Can be the result of uterine instrumentation e.g. TOP, ERPC, Lap and dye test, intrauterine devices
Or complicatins of childbirth and miscarriage (infection often caused by non-sexually transmitted bacteria)
Descending infection from the appendix may also occur
Bacteria implicated in PID
Frequently polymicrobial
Chlamydia (60%) (asymptomatic- symptoms commonly due to secondary infection)
Gonococcus (acute presentation)
Pathology of PID
Endometritis
Bilateral salpingitis
Ovary sparing normally
Fitz-Hugh- Curtis syndomr
Hx in PID
Many have no smyptoms and present later with subfertility and or menstrual problems
Bilateral lower abdominal pain with deep dyspareunia is the hallmark
Usually with abnormal vaginal bleeding or discharge
Bilateral lower abdominal pain with deep dyspareunia
PID
Ex in PID
Tachycardia, high fever, signs of lower abdominal peritonism with bilateral adnexal tenderness and cervical excitation
Pelvic abscess may be palpable
What is cervical excitation
Pain on movement of the cervix
Ix in PID
Endocervical swabs for Chlamydia and gonococcus
Blood cultures
WBC
CRP
Pelvis USS helps to exclude abscess or ovarian cyst
What is the gold standard Ix in PID
Laparoscopy with fimbrial biopsy and culture
Mx of PID
Analgesic
Parenteral cephalosporin e.g. IM ceftriaxone + foxy and metronidazole or ofloxacin and metronidazole
Admit
Dx should be reviewed if no significant improvement in 24h and a laparoscopy performed
Pelvis abscess may requrie drainage.
NB rupture of a large pelvis abscess may be life-threatening
Cx of PID
Early: formation of abscess or pyosalmpinx
Later: tubal obstruction and subfertility.
Ectopic pregnancy x6 more common following pelvic infection
Chance of tubal damage following one episode of acute PID is 12%
What is chronic PID
Persisting infection and is the result of non/inadequate treatment of PID)
Dense pelvic adesions and fallopians may be obstructed and dilated with fluid (hydrosalpinx) or pus (pyosalpinx).
Symptoms of Chronic PID
Chronic pelvic pain or dysmenorrhoea
Deep dyspareunia
Heavy + irregular menstruation
Chronic vaginal discharge
Subfertility
May have similar examination feature sto endometriosis
Abdominal and adnexal tenderness and a fixed retroverted uterus
PID
Endometriosis
Dx of chronic PID
Laparoscopy as culture is often negative.
Rx of chronic PID
Analgesics
Abx of evidence of active infection.
Adhesiolysis
Salpingectomy
Features of PID
Silent (chlamydia)
Bilateral pain
Caginal discharge
Cervical excitation
Adnexal tenderness
Fever
WCC and CRP raised
What are the characteristics of physiological vaginal discahrge
Usually non-offensive
Increases around ovulation, during prgnancy and in women taking COCP.
Exposure of columnar epithelium in cervical eversion and ectropion may cause discharge one infection has been exluded.
Watery vaginal discharge in post-menopausal women
?Fallopian tube carcinoma
Bloody/offensive vaginal discharge
Suggestive of cervical carcinoma but any genital tract malignancy may be responsible.
Def: early neonatal death
Occurs within 7d of delivery
Def: stillbirth
Fetus delivered after 24w
Def: neonatal death
Death within 28d of delivery
Def: miscarriage
Fetus born with no signs of life <24w.
(if born with signs of life <24w classified as a neonatal death)
Def: perinatal mortality rate
Corrected perinatal mortality rate
Sum of stillbirths and early neonatal deaths per 1000 total births
Excludes those that are due to congenital malformations
How are causes of neonatal death classified?
Extended Wigglesworth and supplemented by the Obstetric Aberdeen classification sysytem
What is te most common cause of neonatal mortality?
Preterm delivery
What proportion of stillbirths are accounted for by IUGR?
>10% stillbirths
APH in neonatal death
Occurs in 10%
What are the principle causes of perinatal mortality
Unexplained antepartum stillbirth
IUGR
Prematurity
Congenital anomalies
Intrapartum hypoxia
APH
Def: maternal death
Death of a woman during pregnancy or within 42d of its cessation from any cause related to or aggravated by the pregnacny
Def: late maternal death
After 42d post-delivery and <1y
What is the difference between direct and indirect maternal death
Obstetric complication vs previous or new disease but not the result of pregnancy
What are hte factors affecting maternal death rates
Socioeconomic
Obstetric
Pre-existing health
Level of care
Reporting methods
What are the obstetric factors affecting maternal death rates?
Extremes of maternal age
High parity
Multiple pregnancy
Multiple previous C-sec
What are the global causes of maternal mortality?
Haemorrhage
Obstructed labour
infection
Severe pre-ecl
and the consequences of illegal abortion
What are the main casuses of direct deaths in the UK in pregnancy
Sepsis: most common cause
VTE
Haemorrhage
Hypertensive disease: mostly as a result of ICH
Other causes: disorders of early pregnancy (ectopic), genital tract infeciton, amniotic fluid embolism, anaesthesia, acute fatty liver, genital tract trauma
What are the main causes of indirect deaths in the UK?
Cardiac disease: acquired and congenital disease
Psychiatric disease
Other: drug?ETOH related death, domestic violence, epilepsy and ICH
Provision of contraception to <16 y/o
Child has capacity
Try to get child to discuss with parent
Be convinced that the child’s physical or mental health will ne affected without the treatment
and it is in the child’s best interests to have the treatment without parental knowledge
What is the Bolam principle
A doctor is not guilty of negligence if he or she has acted in accordance with the practice accepted as proper by a responsible body of medical men skilled in that particular art.
What is the risk of stillbirth for women induced at 41-42w?
1 in 300
Observations in labour
T, pulse, BP should be monitored
If circumstances predispose to abnormalities e.g. epidural, this should be more frequent
What are the Cxs of epidural
Mx
Hypotension
managed with fluids and ephidrine
How can aortocaval compression be prevented?
What is the implication in labour?
By maintaing left lateral tilt
Women should not go through labour flat on their back
Hydration in labour
Dehydration is common
IV fluids necessary in epidrual
What is Mendelson’s syndrome?
Aspiration of stomach content into the lungs during anaesthesia
Most common cause of maternal aneasthetic death.
Cyanosis.
Tachycardia.
Massive pulmonary oedema.
Bronchospasm, which occurs often (unlike with amniotic fluid embolism).
Hypotension.
Hypovolaemia with haemoconcentration (the reactive transudation of fluid into the lungs contributes to this).
What are the implciations of Mendelson’s syndrome
Eating is often discouraged during labour
Ranitidine may be given to reduce stomach acidity
Def and risks of pyrexia in labour
>37.5
Associated with increased risk of neonatal illness and is not always as a result of chorioamnionitis
More common with epidrual anaesthesia and prolonged labour.
Cultures of vagina, urine and blood are taken.
Antipyretics often administered
Antibiotics warranted if fever reaches 38deg or there are other risk factors for sepsis
Urinary tract in labour
Neglected retention of urine can irreversibly damage the detrusor muscle.
Epidural usually removes bladder sensation
Catheterisation may be needed but not necessarey for all.
Women should be encouraged to micturate during labour
What is used to monitory progression in labour?
The partogram
What consitutes hte partogram
Progression in dilatation of the cervix
+/- descent of the head
Assessed on VE and plotted against time.
What is the usual minimum rate of dilatation after hte latent phase in labour?
1cm/h
What is the most common cause of slow progress in labour?
Inefficient uterine action.
Common in nullips and inductions but rarer in multips
Mx of persistently slow progress?
Augmentation initially with amniotomy
Then qith oxytocin
What is hyperactive uterine action?
Occurs with excessively strong or frequent or prolonged contractions.
Fetal distress occurs as placental bloo flow is diminished
Associated with placental abruption, with too much oxytocin or as a side effect of PG administration to induce labour.
Mx of hyperactive uterine action
If there is no evidence of abruption a tocolytic e.g. sablutaoml can be given IV or subcut
C-section usually indicated due to fetal distress
Features of nullip labour
First stage: slow progress usually due to inefficient uterine action. Augmentation can sometimes correct passenger probelsms of attitude or position.
ARM may be used
If ARM fails to produce further cervical dilatation in 1-2h oxytocin may be used and titrated up.
CTG monitoring is advised
Nullips are at less risk of uterine rupture
Effects of oxytocin in nullip labour
Will usually increase dilatation within 4h if it is going to be succesfull
C-section in nullips in labour, cut off for C-sec
12-16h
Mx of the second stage in nullip labour
If descent is poor, oxytocin should be started and pushing delayed by 2h
If epidural has been used, the urge to push characteristic of second stage may be diminshed
What is the cut off for the active stage of labour?
If lasts longer than 1h, spontaneous delivery becomes less likely because of maternal exhaustion.
Fetal hypoxia and maternal trauma are also more common.
If the head is distending the perineum, episiotomy can be performed.
If not, instruments may be used
Features of the first stage in multip labour
Slow progress is unusual.
Uterus likely to be effective.
Therefore failure to progress is more likely to be the fetal head: its attitude or position
Multip also more prone to rupture.
Augmentation with oxytocin may only be performed after careful exclusion of malpresentation.
Features of OP presentaiton in labour
Longer
More painful
Backache
Early desire to push,
If progress in labour is normal, no action is needed as OP may spontaenously revert to OP.
If labour is slow, augmentation is used.
If the position is persistent, delivery will be face to pubis and completed by flexion rather than extension.
C-section may be required.
If associated with prolonged second stage, instrumental delivery usually achieved with rotation to OA using ventouse or Kielland’s
When does OT position become significant
If vaginal delivery has not been achieved after 1h of pushing in the second stage.
Usually associated with poor powers so rotation with traction may be required
Ventouse
Mx of brow presentation
C section
Features of face presentation
Fetal compromise more common.
If the chin is anterior, mento-anterior, delivery may be possible.
If the chin is mento-posterior, extension of the head over the perineum is impossible and C-section indicated
Common causes of failure to progress in labour
Powers: inefficient uterine action
Passenger: fetal size, OT, OP, disorder of flexion e.g. brow
Passage: cephalo-pelvic disproportion, cervix
Def of cephalopelvic disproportion
Retrospective dx made on the inability to deliver a particular fetus despite:
presence of adequate uterine activity
absence of maposition or presentation.
Slightly more likely with very large babies, sort women or where the head remains high in a nullip at term.
Featuers of pelvic vaiants
Found in 50-80% of caucasian women.
Arthropod (20%) has a narrower inlet with a transverse diameter less than the AP diameter.
Android pelvis is heart shaped.
Platypelloid levis: oval shape of the inlet persists with the mid pelvis
What conditions contribute to abnormal pelvic architecture?
RIckets and osteolmalacia
Poorly healed pelvic fractures
Spinal abnormalities
Poliomyelitis
Congenital malofrmations
What proportion of cerebal palsies can be attributed solely to intrapartum problems?
10%
What are the causes of intrapartum damage to the fetus?
Fetal hypoxia
Infeciton/inflammation in labour
Meconium aspiration
Trauma
Fetal blood loss
Def: fetal distress
Hypoxia that may result in fetal damage or death if not reversed or the fetus delivered urently.
What is the fetal scalp pH indicative of fetal distress
<7.2
Neurological damage becomes common when it is <7
What are some causes of acute fetal hypoxia in labour?
Placental abruption
Hypertonic uterine states
Use of oxytocin
Prolapse of the umibilcal cord
Maternal hypotension
Intrapartum risk factors for fetal distress?
Antepartum?
Long labour
Mecnoium
Use of epidruals and oxytocin
IUGR
Pre-ecl
What factors are used to diagnose fetal distress?
Color of liquor
FHR
CTG
Fetal ECG monitoring
Fetal blood sampling
What is the significance of undiluted meconium on fetal mortality
4x increase in perinatal mortality.
Indication for caution and hence closer surveillance with a CTG as:
Fetus may aspirate it
Hypoxia is more likely
FHR monitoring
Auscultated every 15 mins during first stage
Every 5 mins during the second
Using Pinard’s or Doppler for 60s after a contraction.
Distressed fetus normally exhibits abnormal HR patterns which can be heard.
Appropriate monitoring for low risk pregnancies.
CTG indicated if abnormalities are detected
pH <7.2 on fetal scalp m,onitoring
Delivery expedited by fastest route possible
CTG
DR C BRAVADO
DR: Define risk: other factors e.g. meconium, fever, IUGR
C: Contaction per 10 minutes
BR: Baseline rate 110-160bpm
Tachys associated with fever, fetal infection, fetal hypoxia. Steep sustained deterioration in rate suggests acute fetal distress
V Variability: ST variation in FHR should be >5bpm except during fetal sleep which normally lasts 45 minutes, reduced variability suggests hypoxia
A: Accelerations of fetal heart with movements or contractions
D: decelerations. Early are synchronous with contractions and are a normal response to head compression.
Variable decelerations vary in timing and classically reflect cord compression which can ultimately cause hypoxia
Late: persist after the contraction and are suggestive of fetal hypoxia
O: Overall assessment
Def uterine hyperstimulation
Contractions >5/10 minutes
What is the normal baseline variability in FHR?
>5bpm except during sleep.
Prolonged reduction in variability suggests hypoxia
Early decelerations
Synchronous with contractions as a normal response to head compression
Variable decelerations
Vary in timing and may reflect cord compression which may ultimately cause hypoxia
Late decelerations
Persist after the contraction is completed and are suggested of fetal hypoxia
What are the levels of screening for fetal distress
Level 1: intermittenet auscultation, if abnromal, meconium, long or high risk, proceed to
Level 2: continuous CTG. If sustained bradycardia, delvier.
Level 3: Fetal blood sampling, if abnormal proceed to
Level 4: delivery
What are the disadvantages of CTG
Reduces maternal mobility
Increases obstetric intervention
No proven reduction in mortality or LT handicap
More puerperal sepsis
Mx of fetal distress
Left lateral psotion
O2 and IV fluids
Stop oxytocin infusion with B2 agonists
VE to exclude cord prolapse or rapid progress
FBS and delivery expedited if <7.2
If FHR pattern continues or deteriorates a second sample will be needed
Implications of low-grade maternal fever
Strong risk factor for seizures, fetal death and cerebal palsy even in the absence of evidence of infection.
Combination with fetal hypoxia is particulalry dangerous.
Features of meconium aspiration
Aspiration by fetus into lungs where it causes a chemical pneumonitis
More common in the presence of fetal hypoxia
Where the meconium is thick, amnioinfusion of saline reducs the incidence of meconium aspiration although questions remain around maternal safety and this is rarely performed
Causes of fetal blood loss
Vasa praevia
Feto-maternal haemorrhage
Placental abruption
What is entonox
NO and O2: Gas and air
Can casue light headed ness, nausea and hyperventilation
What opiates are used in labour
Pethidine or meptid are widely used
Easy administration
Analgesic efect may lead to sedation or confusion.
Antiemetics usually needed.
Opiates can cause respiratory depression in newborn and reversal with naloxone may be indicated
What are the principle complications of spinal anaesthesia?
Hypotension
Total spinal analgesia causing respiratory paralysis (rare)
Use of pudendal nerve block
Low-cavity instrumental vaginal deliveries
bilateral injection around the pudendal nerve where it pases by the ischial spine
Location of epidural?
L3 and L4
LA injection into the epidural space.
Complete sensory and partial motor blockade from the upper abdomen downwards may occur
When may epidural anaesthesia be advised in labour?
If labour is long
HTNive women
Abolish a premature urge to push
Analgesia for insrumental or C-sect
What are the disadvantages of epidural?
Increased midwifery supervision of BP and HR
Woman bed bound
Urinary retention
Maternal fever is more common
Instrumental (but not CS) more common
Transient hypotension (minimised by IV fluids)
Transient fetal bradycardia although rarely precipitates fetal distress
Contraindications to epidural
Sepsis
Coaglopathy or anticoagulant therapy (unless LMWH)
Active neurological disease
Spinal abnormalities
Hypovolaemia
What are the major complications of epidrual
Spinal tap
Total spinal analgesia
Hypotension
LA toxicity
Higher instrumental delivery rate
Poor mobility
Urinary retention
Maternal fever
Features of spinal tap
Inadvertent puncture of the dura mater causing CSF leakage
Leads to severe headache, characteristically worse when sitting up
How does epidural change the approach to second stage of labour
Normal to wait an hour before pushing in second stage
Encouraged to push 3 times for 10 seconds during every contraction
Approach to episiotomy
Perineum infiltrated with LA
Cut made with scissors from the fourchette to the mother’s right side of the perineum
Delivery of placenta
Gentle contunous traction on cord
Suprapubic pressure to prevent uterine inversion
Def: retained placenta
3rd stage longer than 30 minutes
Oxytocin infusion started and injected into the vein of the cord and milked up
In the absence of bleeding, can be left for 1h
First degree perineal tear
Injury to skin only
Second degree perineal tear
Involving the perianal muscles but not anal sphincter
Third degree tear
Involving anal sphincter complex
3a: <50% of external anal sphincter
3b: >50% of external anal shpincter
3c: internal anal sphincter also involved
Fourth degree tear
Involving anal sphincter and epithelium
Mx of first and second degre tears
Sutured under LA
Absorbable material used/
Continueous sutures used
Mx of 3rd and 4th degree tears
Occur in 1-3%
Sphincter repaired under epidural and spinal anaesthetic
Torn ends of the external sphincter are mobilised and sutured usually overlapping
Internal sphincter requires seperate suturing if damaged.
Antibiotics and laatives given
PT assessment
30% have incontinence of flatus or faecas or urgency
What are the risk factors for 3rd/4th degree teasr?
Forceps
Large babies
Nulliparity
And the now obsolete midline episiotomy
What are the principles of fast labour
Early diagnosis of labour
2-hourly VEs
Early correction of slow progress with amniotomy and oxytocin
C section by 12h if delivery not imminent.
What are the criteria for home birth?
Woman’s request
Low risk
37-41w
Cephalic
Clear liquor
Normal FHR
All maternal obs normal
What are the 3 principle routes for gynaecological operations?
Abdominal route through a lower tranverse incision (Pfannsteil) or vertical midline
Vaginal route
Laparoscopic
Features of diagnostic hysteroscopy
Rigid or flexible hysteroscope passed through the cervix
Cavity distended using CO2 or saline
Can be performed without anaesthetic, cervical LA block or under GA
Used as an adjunct to endometrial biopsy
What is TCRE?
Transcervical resection of endometrium
What is TCRF
Transcervical resection of fibroid
What are the Cxs or hysteroscopic surgery
Uterine perforation
Fluid overload
When is TCRE best used?
With bleeding that is heavy but regular and painless
In women approaching menopause
Doesn’t ensure sterility
NB biopsy to be taken before diatherym
What is a Veress needle
Used in laparscopy to insufflate the abdomen with CO2
What is lap and dye?
When dye is passed through the cervix to assess tubal patency
What are the advantages of laparscopic surgery?
Better visualisation of tissues
Less tissue handling
Less infection
Reduced hopsital stay
Faster postoperative recovery with less pain
What are hte indications for hysterectomy
Menstural disorders
Fibroids
Endometriosis
Chronic PID
Treatment of pelvic malignancy
Prolapse
PPH
What is the approach to hysterectomy
1:
Blood: anastamosis between uterine and ovarain arteries, if hte ovaries are removed the ovarian artery and vein ar ligated instead
Round ligament
2:
Blood: main uterine artery
Cardinal ligament.
Bladder dissected off the cervix and upper vagina to prevent injury to it or the ureters
3: Cervicovaginal branches of the uterine artery
Uterosacral ligament
What are the different types of hysterectomy?
TAH
VH
Lap H
Wertheim’s H
What happens in a subtotal hysterectomy?
Cervix is reatined
What is the indication for VH?
Uterine prolapse
What is LAVH?
Laparoscopically assisted vaginal hysterectomy
What is Wertheim’s hysterectomy?
Involves removal of hte parametrium
Upper third of the vagina
Pelvic LNs
Indication is Stage 1a(ii)-2 cervical carcinoma
What is Shcauta’s hysterectomy?
Radical hysterectomy performed vaginally
What are hte Cxs of hysterectomy?
Mortality: 1 in 10000
Immediate: haemorrhage, bladder or uteric injury
Postoperative: VTE, apin, retention and infetion of urine. Wound and chest infection. Pelvic haematoma. LMWH and prophylactic antibiotics
Long term: prolapse, genuine stress incontinence, premature menopause, pain and psychosexual problems
Features of D&C
Dilatation and curettage
Cervix dilated with steel rods Hegar dilators of increasing size
Endometrium is curetted to biopsy it
This is diagnostic procedure inferior to hysteroscopy and is not commonly performed
What is LLETZ
Surgery for CIN
Involves using cutting diathermy under LA to remove the transformation zone of the cerix
Increases risk of subsequent preterm delivery
What is a cone biopsy
Removal of the transformation zone and the enodcervix by making a circular ct
Used to stage early cervical carcinoma and is sufficient for Stage 1ai
Increased cervical damage means there is a significant risk of subsequent preterm delivery
What is the approach to repairing a cystocoele
Excision of prolapsed vaginal wall and plication of the bladder base and fascia
Vagina then closed
What is the approach to repairing a rectocoele
Levator ani on each side plicated
What is important to ascertain in vaginal prolapse repair?
Whether the patient is sexually active as it may lead to overtightening of the vagina
Other complications include urinary retention
What is hysteropexy?
Re-suspension of the prolapsed uterus using a strip of non-absorbable bifurcated mesh to lift the uterus and hold it in place
One end is attached to the cervix and the other to the anterior longitudinal ligament over hte sacrum.
What is sacrocolpoplexy?
Used for prolapse of the vaginal vault after hysterectomy
Mesh attached from vaginal vault to the sacrum
What is TVT?
Tension free vaginal tape
Vertical incision made on the anterior vaginal wall over the midurethral section.
Lateral dissection around hte urethra
Tape is introduced vaginally with trocards entering the retropubic space.
Cystoscopy performed to ensure there is no bladder perforation.
If the tape is over tightened, acute urinary retention may occur
What is Burch colposuspension
Involves dissection into the extraperitoneal space over the bladder and anterior vaginal wall.
Vaginal wall on either side of the bladder neck is hitched up to the iliopectineal ligaement on either side of the pubic symphysis.
Usually performed for failed tape procedures
What are the operations for fibroids?
Myomectomy
Uterine artery embolisation (for women who do not want a hysterectomy but do not wish to preserve fertility)
Hysterectomy
What are the risks of myomectomy
Adhesions
Uterine rupture during labour
Perioperative haemorrhage: requiring transfusion and rarely, hysterectomy
How are the risks of thromboembolism minimised in gynae sx?
Stop OCP 4w prior to major abdominal surgery
If HRT is not stopped, LMWH must be used
All mobilised early and given TEDs
LMWH given according to risk assessment
Thromboprophylaxis in gynae surgery
Low risk
Minor surgery or major surgey <30 mins with no risk factors
Thromboprophylaxis in gynae surgery
Moderate risk
Consider Teds or subcut LMWH for
Sx >30 mins
Obesity
Gross varicose veins
Current infection
Prior immobility
Major current illness
Thromboprophylaxis in gynae surgery
High risk
Use LMWH for 5d or until mobile for
C sx
Prolonged Sx
History of DVT
Thrombophilia
>3 moderate risk factors
What is a foley catheter?
Indwelling transurethral catheter
When is a suprapubic catheter used in gynae sx?
Following surgery for genuine stress incontinence so that the ability to pass urine urethrally can be assessed before catheter removal
What are the principle causes of perinatal mortality?
Unexplained
Preterm delivery
IUGR
Congenital abnormalities
Intrapartum including hypoxia
Placental abruption
What are the major associations with cerebal palsy?
Minor?
Prematurity
IUGR
Infection
Pre-ecl
Congenital abnormalities
Intrapartum fetal distress
Postnatal events
Autoimmune disease
Multiple pregnanc
Placental abruption
Def: SFD
Small for dates
Weight of the fetus is less than the tenth centile for its gestation, if at term 2.7kg
Def: IUGR
Describes fetuses that have failed to reach their own “growth potential”
In utero growth is slowed
May end up SFD
Def: fetal compromsie
Chronic situation when conditions for normal growth and neurological development are not optimum.
Most identfiiable causes involve poor nutrient transfer through the placenta: placental dysfunction.
Commonly there is IUGR but this may also be absent.
What are the aims of fetal surveillance?
Identify high risk pregnancy
Monitor the fetus for growth and well being
Intervene at an appropriate time balancing the risk of in utero compromise against those of intervention/prematurity
What factor prepregnancy are suggestive of a high risk pregnancy
Poor past obstetric history or very small baby
Maternal disease
Assisted conception
Extremes of reproductive age
Heavy smoking or drug abuse
What factors during pregnancy are suggestive of a high-risk pregnancy?
HTN, proteinuria
Vaginal bleeding
SFD baby
Prolonged pregnancy
Multiple pregnancy
What are the Ixs used to identify high-risk pregnancies?
Cervical scan at 23w
Uterine artery Doppler
Maternal blood tests e.g. PAPP-A
What is PAPP-A?
Placental hormone the maternal level of which is reduced in the first trimester with chromosomal abnormallities
Used as a DS screnning
Low level also constitutes a high risk for IUGR, placental abruption and consequent stillbirth
What are the features of maternal uterine artery doppler
Uterine circulation develops a low resistancei in pregnancy.
Abnormal waverforms at 23w suggest failure of low resistance circulation and identifies 75% of pregnancies at risk of adverse neonatal outcomes in the early third trimester
esp: pre-ecl, IUGR, palcental abruption.
Most sensitive at 23w
What is the cornerstone of identifying SFD?
Measurement of the symphysis fundal height
What is USS used for in antenatal care?
USS asessment of fetal growth, which are subsequently recorded on centile charts.
Rate of growth can be determined by previous scans
Pattern of smallness may often help e.g. the fetal abdomen will often stop enlarging before the head which is spared: asymmetrical growth restriction
Allows for consitutional non-pathological determinents of fetal grwoth
Benefits: serial USS safe and useful.
Limitations: one-off USS in later pregnancy are of limited benefit
What is suggestive of placental dysfunction?
Reduced flow in umbilical artery in fetal diastole compared to systole suggests placental dysfunction.
What are the benefits and limitations of doppler umbilical artery waveforms
Umbilical artery waveforms help identify which small fetuses are actually growth restricted and therefore copromosied. Also predates CTG abnormalities and correlates well with severe compromise.
Limitations: Doppler is not a useful screening tool in low-risk pregnancies
What is the use of doppler wavforms of the fetal circulation?
So all major fetal vessels can be seen but the most commonly measured are the MCA and the ductus venosus,
With fetal compromise, the MCA often develops a low resistance pattern in comparison to the thoracic aorta or the renal vessels- head sparing effect.
Velocity of flow also increases with fetal anaemia.
Benefits: use is restricted to high-risk preegnancies and specific situtations.
Limitations: routine use does not reduce perinatal mortality or morbidity
Incraesed diastolic flow in the MCA on fetal doppler?
Suggests reduced resistance in the fetal MCA.
Suggests head sparing
Indicative of fetal compromise
What are the features of USS assessment of biophysical profile?
Limb movements
Tone
Breathing movements
Liquor volume
Scored 2 each out of 8
CTG also included and the score is out of 10
Low score suggests fetal compromise
Benefits: it is useful in high-risk pregnacny where CTG or doppler give equivocal results.
Limitations: time consuming and of little use in low risk pregnancy
What is a kick chart?
The mother records the number of individual movements that she experiences every day
Benefits: most compromised features have reduced movements in the days or hours before demise, reduction in fetal movements is an indication for more sophisticated testing.
Limitations: compromised fetuses stop moving only shortly before death, of limited benefit in reducing perinatal mortality
SFD
Other cut off
<10th centile
<3rd centile i.e. 97th centile
What are the constitutioal determinants of fetal size and health?
Affect growth and birth weight without causing IUGR
Low maternal height and weight
Asian
Female fetal gender
All associated with smaller babies
What are the pathological determinants of fetal growth causing IUGR?
Pre-existing maternal disease
Maternal pregnancy complications
Multiple pregnancy
Smoking
Drug usage
Infection eg. CMV
Extreme malnutrition
Congenital (chromosomal included) abnormalities
Male obesity
DM
and Male gender
All assocaited with increased risk of adverse outcomes
Cx of IUGR
Stillbirth
Cerebal palsy
Preterm delivery: both iatrogenic and spontaenous
Maternal risks
Dx of SFD
Made using ultrasound.
Umbilical artery doppler
Amniotic fludi volume (often reduced) with fetal redistribution of blood flow apaprent in MCA
CMV infection or chromosomal abnormality testing may be indicated
CTG: only become abnormal when severe compromise or fetal distress is present
SFD
IUGR
Mx of SFD
Growth recheced at fortnightly fetus
Small but consistently growing fetus with normal umbilical artery doppler values does not need internvention
Mx of IUGR at term
Small for dates with abnormal Doppler values is delivered if beyond 36w
Induction or c-sect required
Mx of IUGR at preterm
Aim is to prevent in utero demise or neurological damage with ongoing placental dysfunction whil maximising the gestation to avoid cxs of prematurity.
IUGR fetus with anbormal doppler values is reviewed twice a week. I fabsent end-diastolic flow is seen the mother is admitted, given steroids if pre-34w and has a daily CTG
A severely preterm IUGR is delayed until the CTG or fetal dopplers become abnormal.
Def: SFD
Fetus’s weight or estimated weight is below the tenth/fifth/third centile
Def: IUGR
Implies compromise: growth has slowed or is less than expected, taking into account constitutional factors
Def: prolonged pregnancy
>42w
NB risks of perinatal mortality and morbidity start between 41 and 42w.
What is the risk of still birth between 37w and 43 w
- 35 at 37w
- 12 at 43w
What are the risks of prolonged pregnancy
Stillbirth
Neonatal illness and encephalopathy
Meconium passage
Dx of fetal distress
Mx of prolonged pregnancy
From 41w: examine patient vaginally and induce, unless cervix very unfavourable or patient prefers to wait
If no indcution: sweep cervix and arrange daily CTG
If CTG abnormal: delivery by c-sect
What is the probability of twin pregnancy?
Triplet?
1 in 80
1 in 1000
What are the types of multiple pregnancy?
DZ
MZ
What are the features of DZ twins?
2/3rds of all multiple pregnancies or triplets results from fertilisation of different oocytes by different sperm
May be of different sex and are no more genetically similar than siblings from different pregnancies
Features of MZ twins
Result from mitotic division of a single zygote into identical twins.
Whether they share the same amnion or placenta depends on the time at which division occured
What are DCDA twins?
Dichorionic diamniotic MZ twins.
When division occurs before day 3: leads to twins with separate placentas and amnions
What are MCDA twins?
Monochroionic diamniotic MZ twins
Occurs with division between d4 and 8
Leads to twins with a shared placenta but separate amnions
What are MCMA twins?
Monochroionic monoamniotic twins
Occurs with later division (9-13d) and is very rare
Twins have a shared placenta and single amniotic sac
What are the issues with MC twins
Monochorionic twins have a higher fetal loss rate, particulalry before 24w
What are the most common types of MZ twins?
MCDA (70%)
DCDA (30%)
MCMA: very rare
What factors contribute to the likelihood of multiple pregnancy?
Assisted conception
Genetic factors
Increasing maternal age
Parity
Geenrally affect DZ twins
Dx of multiple pregnancy
Vomiting may be more marked in early pregnancy
Uterus is large for dates.
May feel multiple fetal poles in later pregnancies
Multiple pregnancy and antepartum complications
Virtually all obstetric risks are exagerrated in multiple pregnancies
Maternal:
GDM and pre-ecl more common
Anaemia: greater increase in blood volume and dilutional effect and also becuase more Fe and folic acid are needed.
Fetal:
Twins have greater mortality (x6)
LT handicap (5x increase)
Triplets fare worse with 18x risk of ganidcap
Preterm delivery, IUGR, monochorionicity
What are the antepartum risks for all multiples?
Miscarriage: first trimester death. Late miscarriage more common in MC twins
Preterm labour: main cause of perinatal mortality. 40% of twins and 80% triplet pregnancies deliver <36w.
IUGR
Congenital abnormalities are more common per baby in dichorionic
Co-twin death: if one of a pair of DC twins dies, the other usuallly survies although the risk of preterm delivery is increased
Why and what are the Cxs of monochorionicity?
Result largely from the shared blood supply in the single placenta.
Twin-twin transfuision syndrome
IUGR
Co-twin death
Monoamniotic twins
What is twin-twin transfusion syndomre
Occurs only in 15% of MCDA twins
Results from unequeal blood distribution through vascular anastamoses of the shared placenta.
One twin is volume depleted and develpops anaemia, IUGR and oligohydramnios. The other gets fluid overloaded and may develop polycytheamia, cardiac failure and massive polyhydramnios.
Both twins are at very high risk of in utero death or severely preterm delivery.
Even with optimal treatment, survival of both twins occurs in 50% with one twin in 80%.
10% of survivors have neurological disability
How is TTTS staged?
Quintero system
1-5
What is a particular problem in IUGR of MC twins
Where the umbilical artery waveform of the smaller twin is very erratic (selective IUGR with intermittenet absent or reversed end diastolic flow- sIUGR with iAREDF) which may be the result of superficial artery artery anastomoses. Sudden in utero death occurs in up to 20%
What occurs wth co-twin death?
The drop in BP of the dead twin allows acute transfusion of blood from one to the other which may rapidly lead to hypovolaemia and in 30% death or neurological damage
What are the features of monoamniotic twins
Not only the placenta but the amniotic sac is also shared. The cords are always entangled. In utero demise is sudden.
What are the intrapartum Cxs of multiple pregnacny?
Malpresentation of the first twin occurs in 20%
Second twin has an increased risk of death after the first has been delivered because of cord prolapse, hypoxia, tetanic uterine contraction, placental abruption, may present as a breech
PPH more common.
Mx of twin pregnancies antepartum
High risk pregnancy
Fe and folic acid supplementation prescribed.
Selective reduction can be discussed, only indicated in twins when one of them has a congenital abnormalitiy.
Transvaginal US of cervical length may identify those at most risk of preterm delivery.
Idenfy IUGR
What is the lambda sign?
Sign of dichorionic twins
Dividing membrane is thicker as it meets the placenta
What is the T sign?
Thin dividing memrane as it meets the placenta.
MZ twins
Mx of TTTS?
Laser photocoagulation of the placental anastomoses in a fetal medicine centre is the preferred treatment.
Intrapartum Mx of multiple pregnancies
Mode: C-sect: reduces risk of death and hypoxia in second twin. vaginal can be discussed when the first fetus is cephalic, regardless of the lie of the second.
Method: Induction or C-sec is usualy at 37-38w (DC) or 34-37w(MC) after which time perinatal mortality is increased.
CTG monitoring due to increased risk of fetal hypoxia, particularly for the second twin.
Delivery of twins
First as normal
Second:
Maternal contractions often diminish after the first twin. Usually these return after a few miinutes, oxytocin can be started if not. Lie of the second twin is cehcked and ECV performed if not longitudinal. Once the head or breech enters the pelvis, the membranes are ruptured and pushing again beings.
Delivery usually achieved within 20 mins of the first. Excessive delay is associated with increased mortality.
What is breech extraction
Performed under general, epidural or spinal anaesthesia.
Involves inserting a hand into the uterus, grasping the feet and guiding them down.
What are the different classifications of congenital abnormalities?
Structural
Chromosomal
Inherited
or as a result of intrauterine infection or durg exposure
What is the prevalence of congenital abnormalities?
Major?
Affect 2% of all pregnancies
1% major
What proportion of perinatal deaths are accounted for by congenital abnormalities?
25%
What makes a good screening test?
Cheap
High sensitivity and specificity
Is safe
Must also be an acceptable diagnostic test
Condition must be serious enough to warrant testing
What is the difference between a screening and a diagnostic test?
Screening teast is available for all women and gives a measure of the risk of the fetus being affected by a particular disorder
A diagnostic test is performed on women with a “high risk” to confirm or refute the possibility e.g. this fetus doesn’t have down syndrome
What is sensitivity
Proprotion of subjects with the condition classified by a test as screen positive for a condition
What is NPV
Probability that a subject who is screen negative will not have the condition
What is the specifcity of a test?
Proportion of subjects without the condition who are classified as screen negative
What is the screen positive rate?
The proportion of subjects who are classified as high risk by a tst
What is the PPV?
Probability that a subject who is screen positive will have the condition
When is AFP raised at screening tests?
In neural tube defects.
May also indicate a higher risk of third trimester Cxs
Seldom used as USS is more accurate
What components constitute the DS screening test?
beta-HCG
PAPP-A
AFP
Oestriol
Inhibin A
Results can be integrated with other risk factors e.g. amternal age and USS measurements to screen for trisomies 21, 18, 13
Larger nuchal translucency=
Greater risk of DS
Also indicates a higher risk of structural (particulalry cardiac) abnormalities in addition, 50% of fetuses with trisomies have structural abnormalities e.g. exomphalos
When is nuchal translucency test performed?
11 and 14w
What is nuchal translucenecy?
Space between skin and soft tissue overlying the cervical spien
What may polyhydramnios indicate? And so?
May be the result of a fetal abnoramlity
Warrants a repeat, detailed USS examination
Features of amniocentesis
Diagnostic test involving removal of amniotic fuid using a USS guided fine gauge needle.
Safest performed at 15w
1% miscarry
What can be diagnosed using amniocentesis?
Infections e.g. CMV and toxoplasmosis
Inherited disorders e.g. sickle-cell anaemia, thalassaemia, CF
Features of CVS
Involves biopsy of the trophoblast by passing a fine gauge needle through the abdominal wall or cervix and into the placenta after 11w.
Higher miscarriage rate than amniocentesis
Can be performed at 11w.
Down’s syndrome=
Trisomy 21
Usually the result of non-dysjunction at meiosissis
May arise as a result of a balanced chromosomal translocation in the parents.
More common with advancing maternal age.
What is the most common chromosomal abnormality
DS
What are the clinical features of DS?
Mental retardation
Characteristic facies: epicanthic folds and flat facial profile
Congenital cardiac disease (50%)
Abundant neck skin
Intestinal stenosis
Umbilical hernia
hypotonia
Predisposition to leukaemia
Simian palmar crease
Recurrence rate is low unless it is the result of a balanced partental translocation
USS in DS
Thickened nuchal translucenecy
Some structural abnormalities
Absent or shortened nasal bone
TR
Blood test results in DS
Low PAPP-A (1st trimester)
Low AFP (1st/2nd trimester)
Low oestriol
High inhibin
High HCG
What is Trisomy 18
Edward’s syndrome
What is Trisomy 13
Patau’s syndrome
Patau’s syndrome
(Trisomy 13)
Clinical features of Patau Syndrome
Polydactyly
Microcephaly and mental retardation
Clef-lip and palate
Cardiac defects
Renal defects
Umbilical hernia
Rocker-bottom feet
Rocker-bottom feet
Patau (Trisomy 13)
Edwards syndrome
(Trisomy 18)
Clinical features of Edwards
Prominent occiput
Mental retardation
Low set ears
Short neck
Overlapping fingers
Mircognathia
Congenital heart defects
Renal malformation
Limited hip abductio
Kilnfelters
47 XXY
Males have normal intellect, small testes, infertile
Turners syndrome
45 XO
Affected individuals are female, infertile but with preserved intellect
What is the triple test for DS?
Blood test at 16w using AFP, hCG and oestriol
Not hugely accurate, should only be used when screening occurs later than 14w
What is the combined test for DS?
Maternal age
PAPP-A
Beta-hCG
Nuchal translucency as measured by USS at 11-14w
What are neural tube defects?
Result of failure of closure of the neural tube.
Neural tissue often exposed allowing degradation.
Best known examples are spina bifida (severe disability), anaencephaly (incompatible with life(
How can NTDs be prevented
Preconceputal folica cid supplementation for 3months at 0.4mg/d
Risk of NTDs
1 in 200
Recurrent NTDs occur in 1 in 10 pregnancies but this risk is greatly reduced by high dose folic acid.
What is ventriculomegaly
Often due to NTDs, aqueduct stenosis or agenesis fo the copus callosum
Px depends on severity and cause
Akinesia syndromes in utero
Cause abnormal posture and are usualy lethal
Polyhydramnios follows impaired swallowing
Frog eye appearance on USS?
Anencephaly
Epidmeiology of congenital cardiac defects
Occur in 1% of pregnancies
More common in women with congenital cardiac disease or women who have had previously affected offsrping and when other structural/chromosomal abnormalities are present.
In utero therapy for congenital defects
Medical:
Steroids to mature lungs
Antiarrythmic drugs
NSAIDs for polyhydramnios
Surgical:
Laser treatment for TTTS
Amnioreduction for polyhydramnios
Pleuramniotic shunt for hydrops/effusions
Vesicoamniotic shunt for urethral valves
Bllod/platelet transfusion
Tracheal occlusion for diaphragmatic hernia
Valvoplasty for critical AS
Cord occlusion of monochorionic twins
Open:
Neural tube defect surgery
What is exomphalos
Partial extrusion of the abdominal contents in the peritoneal sac
Fifty percent of affected infants have chromosomal problem and amniocentesis is offered.
Isolated, small defects have a good prognosis after postnatal surgery.
Exomphalos
What is gastrochisis
Free loops of bowel in the amniotic cavity and is assoicated with ohter abnormalities.
More common when the mother is very young
Postnatal surgery is indicated: >90% survive
Gastroschisis
What are diaphragmatic hernias
Cause the abdominal contents to herniate into the chest leading to pulmonary hypoplasia
Associated abnromalities are common.
60% with isolated defects survive.
In utero tracheal occlusion can improve prognosis in severe cases
Pleural effusions in utero
May cause pulmonary hypoplasia and hydrops. in utero shunting isuseful
What are CCAMs and pulmonary sequestrations?
Congenital cystic adenomatous malformations and pulmonary sequestrations are visisble as solid or cystic masses of varying sizes.
Px usually good
Featuers of oesophageal atresia and traceho-oesophageal fistulae?
Stomach non-visible or small.
Polyhydramnios
WWhat is a classic double bubble of the stomach associated with?
Duodenal atreasia,c aused by stomach and dilated upper duodenum.
DS very common
Polyhydramnios
What does lower gut atresia cause?
Dilated bowel +/- polyhydramnios
Meconium ileus due to CF is common
Hydronephrosis in utero
Can be mild to severe
Unilateral or bilateral
Due to obstructino or reflux
More prone to infection and therefore renal damage
What do posterior urethral valves cause?
Obstruct the male urethra, cause oligohydramnios, bladder and renal dilation and damge which can range from lethal to renal failure in adulthood.
What are skeletal dysplasia syndromes?
Affect the limbs, when they are lethal e.g. thanatophoric dysplasia, chest is frequently small
What is the cause of isolated limb abnormalities
Amniotic bands- constriction deformities involving the amnion
What is fetal hydrops?
Occurs when fluid accumulates in two or more areas in the fetus.
Has a high mortality and is rarer in late pregnancy due to its high mortality
What are the causes of fetal hydrops
Immune: anaemia and haemolysis (e.g. rhesus)
Non-immune:
- Chromsomal e.g. DS
- Cardiac abnromalities or arrythmias
- Structural abnromalities e.g. pleural effusion can cause hydrops
- Anaemia causing cardiac failure (e.g. parvovirus infection), FMH or fetal alpha thalassaemia major
- TTTS
Ix of fetal hydrops
USS assessment: MCA
Kleihauer and aprvovirus, CMV and toxoplasmosis testing
Fetal blood sampling
When can hydrops be cured?
Only possible where anaemia (transfusion) or compression by fluid collection e.g. pleural effusion (vesicoamniotic shunting) have caused hydrops
Def: polyhydramnios
Increased liquor volume. Deepest liquor pool >10cm
Causes of polyhydramnios
Idiopathic
Maternal disorders (established and GDM), renal failure
Twins (esp TTTS)
Fetal anomaly (particuallry upper GI obstructions or inability to swallow)
Clinical features of polyhydramnios
Maternal discomfort
Large for dates
Taut uterus
Difficult palpation of fetal parts
Cxs of polyhydramnios
Preterm labour
Maternal discomfort
Abnormal lie
Malpresentation
Mx of polyhydramnios
To diagnose fetal anomaly: detailed USS
To diagnose DM: maternal blood glucose
To reduce liquor: If <34w and severe, amnioreduction, or use of NSAIDs to reduce fetal urine output
Consider steroids if <34w
Delivery: vaginal unless persistent unstable lie or other obstetric indication
What are the consequences of raised fetal blood glucose levels
Induces fetal hyperinsulinaemia leading to fetal fat deposition and excessive growth-> macrosmia
Why does glucose tolerance decrease in pregnancy?
Altered carbohydrate metabolism and the antaonistic effects of human placental lactogen, progesterone and cortisol.
Pregnancy is diabetogenic.
What is significant about renal glucose excretion in pregnancy?
Threshold for glycosuria decreases, therefore glucose in urine may occur at physiological blood concentrations
Pre-existing diabetics in pregnancy
Insulin requirements increase
Def: GDM
Carbohydrate intolerance which is diagnosed in pregnancy and may or may not resolve after pregnancy
NICE definition of GDM
Fasting plasma glucose level of >5.6
2 hour plasma glucose level of >7.8 after a 75g glucose load (GTT)
Fetal cxs in DM
T1DM and T2DM are similalrly effected. GDM less so
Congenital abnormalities: neural tube and cardiac defects and are related to periconceptual glucose control
Preterm labour
Reduced fetal lung maturity
Raised birthweight: dystocia and birth trauma
Fetal compromise
Fetal disress
Sudden fetal death are more common
How does polyhydramnios arise in GDM?
Fetal pancreatic islet cell hyperplasia leads ot hyperinsulinaemia and fat deposition
Leads to incresased UO and polyhydramnios
Maternal cxs of DM in pregnancy
INsulin requirements increase
DKA rare
Hypoglycaemia may result from attempts to achieve optimum glucose control
Infection: UTI, wound or endometrial more common
Pre-ecl more common
Pre-existing IHD aggravated
C-sect or instrumental delivery more likely.
Diabetic nephropathy associated with poorer fetal outcomes but doesn’t deteriorate in pregnancy
Diabetic retinopathy often deteriorates and may need to be treated in pregnancy
Preconceptual care of diabetic women wishing to conceive
Baseline RFTs, BP and retina
Glucose optimised
5mg folic acid/d
BP control with labetalol or methyldopa
How is DM monitored during pregnancy
HbA1c
Who should be screened for GDM?
BMI >30
Previous macrosmic baby
Previous unexplained still birth
Previous GDM
First degree relative with GDM
Family origin with high prevalence of DM
Dx test for GDM
OGTT
Mx of DM in pregnancy
Non-drug treatment: lifestyle changes
Medication:
Offer metformin if lifestyle changes do not impact on blood glucose levels in 1-2w
Insulin as alternative to metformin.
If fasting glucose above 7, insulin and metformin.
NB advise women to always have fasting acting glucose source available
Fetal monitoring in DM
Normal USS
Fetal echocardiography is also indicated.
Mx of pre-ecl risk in DM in pregnancy
75mg daily from 12w
NB in any pregnant woman presenting unwell with hyperglycaemia
DKA
Timing and mode of delivery in GDM
By 39w. Offer C-sect if fetal weight exceeds 4kg
Glucose levels maintained by sliding scale of insulin and dextrose infusion during labour
What are the common complications for the neonate immediately after delivery in GDM
Hypoglycaemia due to its accustomisation to hyperglycaemia
RDS occurs even after 38w.
Mx of GDM after delivery
Dose of insulin can be changed to prepregnant doses
Indications for GTT in pregnancy
Risk factors
Polyhydramnios
Persistent glycosuria (2+ on 1 occasion or 1+ on 2 occassions)
Draw Mx of GDM
Folllow up to women with GDM after delivery
OGTT at 3m
50% will be diagnosed as diabetic within the next 10y
Why is an ejection systolic murmur heard in 90% of pregnant women?
40% increase in CO.
40% increase in BV
50% reduction in SVR
BP drops, flow rate increases.
Increased blood flow produces a flow murmur
How does the ECG change in pregnancy?
Left axis shift
Inverted T waves
How are women with cardiac disease assessed prepregnancy
Echo
Mx of labour in women with cardiac disease
Fludi balance monitoring
Elective epidural analgesia
Elective forceps delivery helps avoid the additional stress of pushing
Antibiotics for those at risk of endocarditis
Mx of PDA, VSD and ASD in pregnant women
Do not usually cause complicatiosn
Pulmonary HTN and pregnancy e.g. Eisenmenger’s syndrome
High maternal mortality rate (40%)
Pregnancy contraindicated and usually terminated
AS in pregnancy
Severe disease causes an inability to increase cardiac output when required and should be corrected before pregnancy.
Beta-blockade often used
Epidrual analgesia is contraindicated. Thromboprophylaxis required for aortic valves
Mitral valve disease and pregnancy
Should be treated before pregnancy
In severe stenosis HF may develop late in pregnancy and beta blockade should be used.
Artificial metal valves are particularly prone to thrombosis and warfarin is used after the first 12w despite risk to fetus
What is peripartum cardiomyopathy
Rare cause of HF specific to pregnancy
Develops in the last month or the first 6m after pregnancy in the absence of a recognisable cause.
Cause of maternal death and leads to permanent LVD in >50%
Treatment is supportive with diruetics and ACEI
Asthma in pregnancy
Doesn’t need to be a change in control as medication generally safe
Women on LT steroids require an increased dose in labour because the chronically suppressed addrenal cortex is unable to produce adequate steroids for the stress of labour
Supplementation in epileptics during pregnancy
Folic acid 5mg daily
36w: Oral vit K
Fetal echocardiography and anomaly scan are important to exclude fetal abnormalities
Cxs of hypothyroidism in pregnancy
High perinatal mortality.
Even subclinical hypothyroidism is associated with:
miscarriage
preterm delivery
intellectual impairment in childhood
Also associated with an increased risk of pre-eclampsia, particulalry if antithroid antibodies are pregsent.
TSH monitored
Cause of neonatal thyrotoxicosis and goritre
Antithyroid Abs in mother suffering from Graves disease that cross the placenta
Implications of poorly controlled hyperthyroidism in pregnancy?
Risk of thyrotoxicosis: acute symptoms and HF usually near or at delivery.
Treated with PTU rather than carbimazole
Propylthiouracil
Used to treat hyperthyroidism in pregnancy
Can cross the placenta and occasionally causes neonatal hypothyroidism
Features of postpartum thyoridtis
Common and can cause postnatal depression
Risk factors:
Antithyroid Abs
T1DM
Transient and usually subclinical hyperthyroidism usually about 3 months postpartum, folled by 4 months of hypothyroidism which is permanent in 20%
Clinical features of acute fatty liver in pregnancy
Acute hepatorenal failure, DIC and hypoglycemia
Early symptoms: malaise, vomiting, jaundice and vague epigastric pain.
Early dx and prompt delivery essential.
Correction of clotting defects and hypoglycaemia
Supportive treatment with blood products, fluid blanace and occasionally dialysis
Mx of intrahepatic cholestasis of pregnancy
Vit K 10mg/d to reduce risk of haemorrhage
Ursodeoxychlic acid
Induction at 38w
Why does intrahepatic cholestasis of pregnancy occur?
Due to increased sensitivity to the cholestatic effects of oestrogen
Dx of antihphospholipid syndrome
1+ clinical criteria:
Vascular thrombosis
1+ death of fetus >10w
Pre-ecl or IUGR requiring delivery <34w
3+ fetal losses <10w, otherwise unexplained
With laboratory criteria:
Lupus anticoagulant or high anticardiolipin Abs or anti-b2 glycoprotein Ab
(Measured twice >3m apart)
What are the adverse outcomes of antiphospholipid syndrome?
Due to placental thrombosis:
Recurrent miscarriage
IUGR
Early pre-ecl
Fetal loss rate is high
Mx of antiphospholipid syndrome
2% of pregnant women have the Abs
Mx with aspirin and LMWH and is restricted to those with the syndrome.
Pregnancy is managed as a high risk, with serial USS and elective induction of labour at least by term.
Postnatal anticoagulation
Pregnancy in CKD
Inadvisable if creatinine level is >200mmol as renal function often deteriorates late in the pregnancy
Differentiation between proteinuria in CKD and pre-ecl
CKD present <20w
Fetal cxs of CK
Pre-ecl
IUGR
Polyhydramnios
Preterm delivery
Mx of CKD in pregnancy
USS for fetal growth
RFTs
Screen for UTIs
Control of HTN
Dialysis
Vaginal delivery appropriate
UTI in pregnancy
Associated with preterm labour and increased perinatal morbidity and mortality
Asymptomatic bacteriuria affects 5% but is more likely (20%) to lead to pyelonephritis in pregnancy
ECG and PE in pregnancy
ECG changes of normal pregnancy can mimic those of a PE
LMWH dosing in pregnancy
More is needed than in nonpregnant women as clearance is more rapid
Risk assessment for VTE
High
Intermediate
Moderate
Maternal and fetal risks of obesity in pregnacny
Maternal:
High risk of thromboembolism, pre-ecl, DM
C-sec, wound infections, difficult sx, PPH, maternal death
Fetal:
Higher rate of congenital abnromalities, DM and pre-ecl
x2-3 perinatal mortality
Mx of obesity in pregnancy
Preconceptual advise
5mg folic acid
High risk if >35BMI: screen for GDM, and BP surveillance.
BMI >40 require formal anaesthetic risk assessment
BPAD and pregnancy
Well or at low risk of relapse, stop Li
Unwell or at high risk, continue Li with blood monitoring due to increased excretion during pregnancy
Higher risk of maternal sucidie and postnatal medication is important
Paroxetine in pregnancy
May cause cardiac defects and is not advised
Clozapine and olanzapine in pregnancy
Usually avoided
Risks and management of opiate use in pregnancy
Not teratogenic, use associated with: preterm delivery, IUGR, stillbirth, developmental delay and SIDS
Methadone maintenance
Risk and management of cocaine use in pregnancy
Probably teratogenic and can cause childhood intellectual impairment. Associated with IUGR and placental abruption as well as preterm delivery, stillbirth and SIDS
COunsellying
Ecstasy and pregnancy
Teratogenic: cardiac defects, gastroschisis
Pregnancy cxs similar to that of cocaine
Counselling
BZDs and pregnancy
Associated with facial clefts, cause neonatal hypotonia
Fetal alcohol syndomre
Facial abnormalities
IUGR
Microcephaly
Developmental delay
>18 units per day
What are alcohol spectrum disorders
Encompass lesser variants of fetal alcohol syndrome
Risks of smoking in pregnancy
Dose dependent
Increased risk of
Miscarraige
IUGR
Preterm birth
Placental abruption
Stillbirth
SIDS
Fe deficiency anaemia in pregnancy
Folic acid deficiency may coexist
Symptoms absent until Hb <9
MCV reduces but may initially be normal
Ferritin levels reduced
Treatment is with oral Fe, can cause GI upset
In severe cases IV Fe is quicker
Foods rich in Fe
Meat, particulalry kidney, and liver, eggs, green vegetables
Foods rich in folic acid
lightly cooked or raw green vegetables.
Fish
Adult HbA
2 alpha
2 beta
Fetal HbF
2 alpha
2 gamma
Maternal complications of sickle cell disease
More frequent crises
Pre-ecl
Thrombosis
Infections
Fetal cxs of SCD
Miscarraige
IUGR
Preterm labour
Death
Mx of SCD in pregnancy
Regular exchange blood transfusions
Infection screening
Hydration
Folic acid supplementation
Fe avoided because of overload
Def: perimenopause
Time beginning with the first features of the approaching menopause e.g. vasomotor symtpoms and mesntural irregulatiry and ends 12 months after the last menstrual period
Def: surgical menopause
Following BSO
Causes of premature menopause
Premature ovarian failure
Infections
Autoimmune disease
CTx
Ovarian dysgensis
Metabolic disease
Mx of premature menopause
Oocyte donation for fertility treatment
HRT until 50
20% of PMB caused by
Endometrial carcinoma
Cervical carcinoma
Premalignant endometrial hyperplasia with cytological atypia
Purulent blood stained vaginal discahrge ina post menopausal woman
Investiage to exclude endometrial cancer or (uncommonly) a divertiuclar avscess draining via the uterus or vagina
Causes of PMB
Endometrial carcinoma
Endometrial hyperplasia +/- atypia and polyps
Cervical carcinoma
Atrophic vaginitis
Cervicitis
Ovarian Ca
Cervical polyps
Mx of PMB
Bimanual and pseculum +/- cervical smear
TVS to measure endometrial thickness, thickened endometrial cavity or fluid filled cavity: malignancy, hyperplasia or polyps
Early, intermediate and late effects of menopause
Early: psychological symptoms
Intermediate: skin atrophy, genital tract atrophy, urinary tract atrophy
Late: Cerebrovascular accidents, cardiac disease, bony fractures
What are the vasomotor symptoms of menopause?
Hot flushes and night sweats
May begin before periods stop and are usually present for less than 5y
Symptoms of vaginal atrophy
Dyspareunia
Cessation of sexual activity
Itching
Burning
Dryness
Urinary symptoms: frequency, urgency, notcuria, incontinence, recurrent infection
What are the risk factors for osteoporosis
Genetic
Constitutional
Environmental
Drugs
Disease
When are FSH levels best measured
Between days 2 and 5 of the cycle to aboid the mid cycle preovulatory increase and the luteal phase suppression
AMH measurement
Produced by small ovarian follicles and give a direct measurement of ovarian reserve, low levels are consistent with ovarian failure.
AMH levels are stable throughout the menstrual cycle and so can be measured on any day
Ix in ?premature ovarian failure
FSH (AMH)
TFTs
Catecholamnies
LH, oestradiol and progesterone
Why is the hip better than the spine in terms of estimating bone density?
Spine may have falsely increased values due to osteophytes from OA, kyphosis, scoliosis and aortic calcification
HRT
single
combined
Oestrogen alone in women who have had a hysterectomy
Combined with progestogens in those who ahve not.
Delivery of oestrogens
Delivery of progestogens
Oral
Transdermal
Subcut
Orally
Transdermally
IUS
Why are synthetic oestrogens not used for the HRT?
Because of their greater metabolic impact
What oestrogens are used in HRT
Oestradioll, oestrone, oestriol
Synthesised from plants
What progestogens are used in HRT
levonorgestrel
Norethisterone
What is tibolone
Synthetic steroid compound that is inert but is converted in vivo to metabolites with oestrogenic, progestogenic, and andorgenic actions.
Used in post-menopausal women who desire amenorrhoea and treats vasomotor, psychological and libido problems
Conserves bone mass
Oestrogen only HRT
Used in women after hysterectomy
May be concenrs about a remnant of endometrium in the cervical stump if it was a subtotal hysterectomy.
If this is suspected, presence or absence of bleeding following HRT is a useful test
What is sequential HRT and its effects
10-14d every 4w or 1`4d every 13w
Leads to monthly bleeds or 3 monthly bleeds
What is continuous HRT and its effects
Used every day
Leads to no bleeds
When is the IUS useful in menopause
During the perimenopausal period if there is menorrhagia
Post-menopause, preferred HRT
Continuous combined regmines because of the lack of induced bleeding and because it may reduce the risk of endometrial cancer
Continuous combined therapy induces endometrial atrophy.
IU delivery may be used but can be technically difficult in older women
Mx of urogenital symptoms of menopause
Vaginal administration by cream or pessary (oestriol) or oestradiol by table ot ring
Benefits of oestrogens in menopausal symptoms
Oestrogen reduces vasomotor symptoms
Oestrogens also reduced vaginal atrophic symptoms
May improve sexuality
Testosterone can be added
Benefits of HRT for osteoporosis
HRT reduces the risk of #s
Benefits of HRT in CRC
HRT reduces the risk of CRC by 1/3rd
Risks of HRT: breast cancer
Combined but not oestrogen only HRT increases risk
Risk fallson stopping combined therapy and normalises after 5y
Risks of HRT: endometrial cancer
Unopposed oestrogen replacement therapy increases endometrial cancer risk
Risks of HRT: VTE
HRT increases risk of VTE x2
Risks of HRT: gall bladder
Oral HRT increases risk of gallbladder disease
Non-oestrogen therapy for vasomotor symptoms of menopause
Progestogens
Clonidine: of lmited value
SSRIs: are ffective in ST
Gabapentin may be effective
Bisphosphonates in menopause
e.g. alendronate, risendronate and ibandronate
Used in prevention and treatment of osteoporosis
Princple adverse effect is irritation of the upper GI
May affect fetal skeleton, so aren’t advised in women wishing to conceive
Strontium ranelate
Decreases the risk of osteoporotic vertebral and hip #s
Raloxifene
Selective oestrogen receptor modulator, reduces the incidence of osteoporosis-related vertebral ‘s
Denosumab
RANKL Ab
Used whe bisphosphonates are contraindicated
Def: septic miscarriage
The contents of hte uterus are infected causing endometritis.
Vaginal loss is usually offensive, uterus is tender and a fever may be present.
If plevic infection occurs there is abdominal pain and peritonsim
What is the cause of >60% one off sporadic miscarriages?
Isolated non-recurring chromosomal abnormalities.
Ix in ?miscarraige
USS: will show uterine contents. If in doubt, the scan should be repeated 1w later.
Bloods: HCG levels (if raised and no intrauterine gestational sac is visible, ectopic)
FBC
Rhesus group
Mx of miscarriage
Admit: if ectopic, septic or heavy bleeding
Resus: contents in cervical os. IM ergometrine will reduce bleeding but is only used if the fetus is non-viable
If there is a fever, swabs for culture and IV antibiotics
Anti-D is gient to women who are rhesus negative
Mx of threatened miscarriage
90% of women in whom fetal heart activity is detected at 8w will not miscarry
Mx of non-viable intrauterine pregnancy
Expectant
Medical: prostaglandins
Surgical: ERPC
Cxs of miscarriage
Vaginal bleeding with expectant or medical management can be heavy
Risks of expectant/medical management include need for surgical evacuation, risk of infection is not incresed.
Infection may become systemic leading to endotoxic shock
Counselling after miscarriage
Miscarriage was not result of anything they did
Reassurance as to the high chance of successful pergnancies is important
Referral to a support group
Causes of recurrent miscarriage
Antiphospholipid Abs: LMWH and aspirin
Chromsoomal defects: parental karyotyping, CVS or amniocentesis. Use of donor oocytes
Anatomical: uterine abnormalities (USS or hysterosalpingoram), cervical incompetence (>16w)
Infection
Obesity
Smoking
PCOS
Excess caffeiene intake
Higher maternal age
Statuatory grounds for abortion in the UK
Surgical methods of abortion
Suction curettaeg (7-13w)
Dilatation and evacuation (>13w)
Antibiotic cover required for both
Medical methods of abortion
Antiprogesterone: mifepritsone + prrostaglandin (mifeprostol, gemeprost, PGE1 analogues (36-48h later) is the most effective in <7w and can be used up to 9w
Prostaglandin alone can be used
Byeond 22w: KCI injected into the umbilical vein or fetal heart
What are the cxs of TOP
Haemorrhage
Infection
Uterine perforation
Cervical trauma
Failure
What is the most common site of ectopic pregnancy?
Fallopian tube (95%)
Sites of ectopics
Hx of ectopic
Lower abdominal pain
Scanty dark vaginal bleeding
Pain may be initially colicky (as the tube tries to exude the sca) and then become constant
Syncopal episodes and shoulder tip pain suggests intraperitoneal blood loss
Ix in ectopic
Pregnancy test
USS: TV
Quantitative serum hCG is useful if the uterus is empty ifmaternal >1000IU then if a uterine pregnancy were present it should be visible on TVS. If the level is lower but rises more than 66% in 48h, an earlier but intrauterine pregnancy is normal.
Declining or slower rising levles of hCG suggest an ectopic or nonviable intrauterine pregnancy
What is a heterotropic pregnancy
When an intrauterine and an ectopic pregnacny coexist
Mx of symptomatic suspected pregnancy
NBM
ABC
FBC and cross-match
Pregnancy test
USS
Laparoscopy or medical management if criteria met.
What are the issues with salpingostomy
10% chance a repeat surgery for persisting ectopic is required- detected by failure of serum hCG to fall on follow up.
Increased risk of repeat ectopic as damaged tube remains
Medical management of ectopic
If the ectopic is unruptured, with no cardiac activity and an hCG level <3000 IU
Methotrexate as a systemic sinlg edose can be used.
Serial hCGs are used to confrm that trophoblastic tissue has gone.
SSecond dose may be required.
Conservative management of ectopic
If the ectopic is small and unrupture or if the location of the pregnancy is not clear and hCG le3vles are low and declining. Careful observation may suffice
Cx of ectopic pregnancy
Serial hCG to confirm resolution.
70% will have subsequent successful pregnancy following salpingectomy
Def: hypermesis gravidarum
When N+V is so severe as to cause severe dehydration, weight loss or electrolyte disturbance.
Mild NVP
Nausea and occasional morning vomiting
50% pregnant women
No treatment required
Moderate NVP
More persistent vomiting
5% pregnant women
Often admitted to hsopital
Severe NVP
Hyperemesis gravidarum
Mx of hyperemsis gravidarum
Exclude predisposing conditions: UTI, multiple or molar pregnancy
IV rehydration
Antiemetics: promethyazine or cyclizine
metoclopramide second line
Thiamine
Steroids in severe cases
Def: gestatuiational trophoblastic disease
Trohpohblastic tissue which is part of the blastocyst that normally invades the endometrium proliferates in a more aggressive way than is normal: hCG secreted in excess
Prolifreation can be localised and noninvasive.
May also have characteristics of malignant tissue, invasive in the uterus alone= invasive mole. If metastasises= choreocarcinoma
What is a complete hydatidiform mole
Entirely paternal in origin. When one sperm fertilises an empty oocyte and undergoes mitosis.
Result is diploid tissue, usually 46XX
What is a partial hydatidiform mole
Triploid, derived from two sperms entering one oocyte. Variable evidence of a foetus
What is gestational trophoblastic neiplasia
When there is evidence of persistence of gestational trophoblastic disease (hydatidiofrm mole, invasive mole, choriocarcinoma), commonly defined as elevation of hCG.
Hx and Ex in GTD
Heavy vaginal bleeding, hyperemesis
Uterus large for dates, pre-eclampsia and hyperthyroidism can occur
Snowstorm appearance of swollen villi
Complete hydatidiform mole
Mx of GTD
Trophoblastic tissue removed by ERPC and diagnosis confirmed histologically
Bleeding often heavy
Serial hCG levels taken, pesristent or rising levels are suggestive of malignancy.
Pregnancy and COCP avoided until hCG levels are normal as they may increase the need for CTx
Cx of GTD
Recurrence of molar pregnancy occurs in 1 in 60, after every subsequent pregnancy, further hCG samples are required to exclude disease recurrence
GTN (molar pregnancy only accounts for 50% as malignancy may also follow miscarriages and normal pregnancy, usualy presents as persistent vaginal bleeding)
Mx of GTN
Highly malignant but very sensitive to CTx
Patients are risk stratified
Low risk: methotrexate and folic acid
High risk: Combination CTx
What is the difference between primary and secondary infertility?
Primary: female never conceived
Secondary: previously conceived even if the pregnancy ended in miscarraige or TOP
What are the four basic conditions required for pregnancy?
1: Egg must be produced (anovulation)
2. Adequate sperm must be released (Male factor)
3. Sperm must reach the egg (fallopain tube damage, 25%, sexual 5% and cervical 5% problems may also prevent fertilisation)
4. Fetilised egg must implant
What are the most common factors contributing to suberfitility
Ovulatory 30%
Male 25%
Tubal 25%
Coital 5%
Cervical <5%
Unxeplained 30%
Because more than one cause may be present, the percentage total is >100%
Why does fertility decline with increasing age?
Mainly due to reduced genetic quality of remaining oocytes rather than ovulatory problems
What is the dominant follicle
The largest follicle with sufficeient gonadotrophin receptors which competes with the other follicles for diminishing stimulating hormones. It is the most likely to survive and continue growth.
Development is coregulated by inhibin B which also suppresses FSH
Ix of ovaulation
D21 progesterone (or progesterone 7d before the end of the cycle)
- USS can monitor follicular growth: not performed
- Over the counter LH predictor kits that analyse urine
- Temperature charts
What is PCO?
Characteristic TVS appearnace of >12 small follciles in an enlarged ovary.
Found in 20% of women, the majority of whom have regular ovulatory cycles.
Development of other features leads to diagnosis of full syndrome
Clinical dx of PCOS criteria
>2 of:
PCO on USS Irregular periods (\>35d)
Hisutism: clinical (acne or hirsutism) and or biochemical (raised testosterone)
Pathophysiology of PCOS
Disordered LH production with peripheral insulin resistance
Combination of raised LH and insulin acitng on PCO leads to increased ovarian androgen production.
What are the additional Ix indicated in PCOS?
Bllods: FSH investigated (raised in ovarian failure, low in hypothalamic disease, normal in PCOS), Prolactin (to exclude a prolactinoma) and TSH. Serum testosterone. LH
USS
Other: DM screening and abnormal lipids or FHx of CVD
Clinical feautres of PCOS
None
Subfertility
Oligomenorrhoea or amenorrhoea
Hisutism and or acne
Obesity
Miscarriage
Cxs of PCOS
50% develop T2DM
30% develop GDM
Endometrial C more common in women with many years of amenorrhoea due to unopposed oestrogen action
Treatment of PCOS symtpoms other than infertility
Advice re diet and exercise which should result in reduction of insulin levels and improvement in all PCOS symptoms
Treatment with COCP will regulate mesntruation and treat hirsutism
At least three to four bleeds per year, whether spontaenous or induced, are necessary to protect hte endomertium
Cyproterone acetate (anti-androgen) or spironolactone are effective treatments for hisutsim but conception must be avoided.
Metformin can be used (also promotes ovulation)
Causes of anovulation
Hyptholamus:
Hypothalamic hypogonadism: reduction in GnRH causes amenorrhoea. Occurs with anoerxia nervosa.
Kallman’s syndrome (can be treated with exogenous gonadotrophins- bone protection with OCP or HRT required)
Pituitary:
Hyperprolacinaemia: suppresses GnRH release (CT indicated if neurological symptoms are present) treated with dopamine antagonist restores ovulation. Sx needed if this fails
Pituitary damage: pressure from tumours, Sheehan’s
Ovarian:
Preamture ovarian failure
Gonadal dysgenesis
Luteinised unruptured follicle syndrome
Thyroid:
Hyper or hypo
Androgen secreting tumours
What is Kallman’s snydomre
Occurs when GnRH secreting neurones fail to develop
What is a consideration of exogenous GnRH therapy?
Osteoporosis
LT managed by OCP or HRT
What is luteinised unruptured follicle syndrome
Present whena a follicle develops but the egg is never released
Lifestlye changes to induce ovulation
Advice regarding risks
Folic acid
Restoration of normal weight
Treat specific causes
Smoking should cease
Treatment of PCOS
Clomifene: first line ovulation induction drug in PCOS. Limited to 6m used. Anti-oestrogen. Only given at start of the cycle from 2-6
Metformin: second line (has a lower live birth rate compared to clomifene) although it doesn’t increase the risk of multiple pregnancy
Increases the effectiveness of clomifene in clomifene resistant women.
Laparoscopic ovarian diathermy: as effective as gonadotrophis and with lower multiple pregnancy rate. Can also check tubal patency during the procedure
Gonadotrophins
Considerations of clomifene therapy
Given for 6m and at the start of the cylce from days 2 to 6.
Monitored by TVS to assess ovarian response and endometrial thickenss.
If no respons than the dose can be increased from 50 to 100 and even 150mg/day
If three or more follicles develop then cycle cancellation indicated to reduce the risk of multiple pregnancy.
Leads to endometrial thinning
Use of gonadtrophin induction of ovulation
Used when clomifene has failed but also in hypothalamic hypogonadism
Mutliple pregnanices are a consideration so a low-dose step up regiment is followed.
Once a follicle is of sufficient size, ovulation can be stimulated by injection of hCG or recombinant LH.
GnRH pumps can be used to stimulate FSH and LH production form the pituitary in a physiological manner.
What are the side effects of ovulation induction
Mutliple pregnancy: more likely with clomifene or gonadotrophins but not metformin
Ovarian hyperstimulation syndrome: gonadtrophins and rarely clomifene overstimulates the follicles which can get very large and painful (more common during IVF)
Ovarian and breast carcinomas: generally not a risk
Features of Ovarian hyperstimulation syndrome
Risk factors include gonadotrophin stimulation, age <35y, previous OHSS, ovaries of PCO morphology
Prevention includes using lowest effective gonadotrophin doses, USS monitoring, coasting (withdrawing gonadotrophins for a few days) or cancelling IVF cycle.
In severe cases hypovolaemia, electrolyte disturbances, ascites, thromboembolism and pulmonary oedema may develop. OHSS can be fatal
Admission may be required: restoration of intravascular volume, electrolyte monitoring, analgesia and thromboprophylaxis
On what is spermatogenesis dependant?
Pituitary LH and FSH
LH acts via testosterone production in the Leydig cells of the testis
FSH controls sertoli cells which are involved in synthesis and transport of sperm
Takes 7d for sperm to develop fully
Features of male semen analysis
Sample produced by mastrubation with last ejaculation having occurred 2-7d previously.
Must be analysed within 1-2h of produciton
Abnormal analysis must e repeated after 12w.
If persistently abnormal, examination and investigations of the male must follow.
Features of normal semen
Vollume
Sperm Count
Progressive motility
>1.5ml
>15m
>32%
Azoospermia
No sperm present
Oligospermia
<15m/ml
Severe oligospermia
<5m/ml
Asthenospermia
Absent or low motility
Causes of abnormal semen analysis
Unknown
Smoking/ETOH/drugs/chemicals/inadequate local cooling
Genetic
Antisperm Abs
Ix and treatment of male factor
Semen: if abnormal repeat and examine scrotum and optimise lifestyle factors
If oligospermic then: intrauterine insemination
If moderate to severe oligospermia: IVF with intracytoplasmic sperm inection
If azoospermic: examine for presence of vas deferens, check karyotype, CF, hormone profile, surgical sperm retreival
Common causes of abnormal/absent sperm release
Idiopathic
Drug exposure: sulfasalzine, anabolic steroids
Varicocoele
Antisperm Abs
Other causes: infection, mumps orchitis, testicular abnormalities, obstruction to delivery (e.g. congenital absence of the vas deferens), hypothalamic problems, Kallman’s, hyperprolactinaemia, rterograde ejaculation (due to neurological disease secondary to DM or TURP)
Kallman’s
hypogonadotrophic hypogonadism
With what is vas deferens agenesis associated?
CF
What do high levels of FSH and LH with low testosterone in males suggest?
Primary testicular failure e.g. due to:
cryptorchidism, surgery, RTx or CTx.
Causes of tubal damage
Infection: PID: main cause. If there are peritubal adhesions or clubbed and closed fimbrial ends, laparsocopic adhesiolysis and salpingostomy can be performed. Ectopic rates increased
Endometriosis
Previous surgery/sterilisation
Causes of cervical problems in failure to fertilise
Antibody production
Infection in hte vagina or verxi that prevents adequate mucus
Cone biopsy
IUI to bypass cervix often used
Tests for detection of tubal damage
Lap and dye
Hysterosalpingogram
HSG
Hysterosalpingogram
Radio-opaque contrast injected through the cervix. Spillage from the fimbrial end can be seen on XR. Can also be done transvaginally.
How is ovarian reserve measured and what is its significance in IVF
AMH
Must be present for IVF to be performed i.e. premature ovarian failure cannot use IVF
What are the stages of IVF
Multiple follicular development
Ovulation and egg collection
Fertilisation and culture
Embryo transfer
What are the cxs of assisted conception
Superovulation
Egg collection: intraperitoneal haemorrhage and pelvic infection may complicated the USS-guided aspiration of mature follicles necessary for IVF
Pregnancy: increased multiples, rates of ectopics, increased perinatal mortality and morbidity.
What is the Pearl Index?
The risk of pregnancy per 100 women years of using the given contraceptive
What are the considerations for contraceptives in women with IBD?
Malabsorption can reduce th efficacy of oral contraception
Alternative methods should be used such as combined patches, progesterone only injectables and implants
Depo-provera should not be a first line option as it increases the risk of osteoporosis
Cut off for natural contraception when breat feeding
Contraceptive option afterwards?
21d
Combined pill reduces breast milk volume and should be avoided 6w postpartum and is relatively contraindicated 6-6m post partum.
Progestogen only methods have no effect and can be used in the 6 weeks postpartum
Advice to perimenopausal women re contraception
<50y/o: continue contraception for at least 2y after the LMP
>50y/o at least 1y,
What are the different types of hormaonal contraception?
Progestogen as a tablet: progestogen only pill (mini pill)
Progestogen as a depot: Nexplanon, Depo-Provera or in the levonorgesrel containing IUS
3: Combined hormonal contraception:
COC
Transdermal patch
Vaginal ring
How does the COCP work
Exerting negative feedback on gonadotrophin release inhibiting ovulation.
Also thin the endometrium and thicken cervical mucus
What are the dosing regimens for COCP and what does it contain?
3w on, 1w off
Most contain synthetic oestrogens: ethinyldoestradiol
Bleeding occurs at the end of the pill packet due to withdrawal of hormonal inhibition.
Pill packets can be taken back to back to reduce the frequency of the withdrawal bleed
What is oestradiol valarate
Natural oestrogen found in some new types of COC
Feautres of ethinyloestradiol containing COC
Monophasic containing same dose of both hormones every day.
Standard dose pill: 30-40
Low dose: 20
Usual choice is 30-35 ug
Bleeding determined by type of progestogen rather than oestrogen dose or the phasic regmin
Features of COCP containing oestradiol valerate
Natural oestrogen combined with a synthetic progestogen: dienogest
Four phases of oestrogen and progestogen dose over 26 days followed by 2 fill days.
What are the common progestogenic side effects?
Depression
PMS-tension like symptoms
Bleeding, amenorrhoea
Acne
Breast discomfort
Weight gain
Reduced libido
What are the common oestrogenic side effects
Nausea
Headaches
Increased mucus
Fluid retention and weight gain
HTN
Breast tenderness and fullness
Bleeding
What are the other noncontraceptive uses of the COCP
Menstrual cycle control
Menorrhagia
PMS symptoms
Dysmenorrhoea
Acne/hirsutism
Prevention of recurrent simple ovarian cysts
COC in reduced absorption
If woman suffering from D+V or taking some oral antibiotics.
Should follow missed pill instructions for day of the illness
If she vomits within 2h of taking the pill she should take another one or follow the rules for missed pill
If she is taking broad spectrum antibiotics she should use condoms for the course and for 7d post course
If she takes liver inducing drugs, increased dose may be required
What are the instructions for missed standard strength preparations
Low strength?
One or two missed pills nayhere in the pack not a problem
Only one pill can be missed
Forgotten pill should be taken ASAP and pack cntinued as normal but should use condoms for 7d.
If there are less than seven pills remaining in the packet, avoid a pill-free break by running straight into the next packet.
Pill and surgery
Normally stopped 4 weeks before.
Not discontinued before minor surgery
Counselling women starting pill
Advise of major cxs and benefits
Stop smoking
Advise to seek medical attention if symptoms suggestive of major cxs
Advise re absorption issue
Stress the importance of F/U and BP monitoring
What are the major risks of the COCP?
VTE and MI (multiplied by smoking, obestity), more common with 3rd generation pills.
Cerebrovascular accident
Focal migraine
HTN
Jaundice
Liver, cervical and breast carcinoma
What are the absolute contraindications to COCP?
Hx of VTE
Hx of cerebrovascular accidant, IHD, HTN
Migraine with aura
Active breast/endometrial cancer
Inherited thrombopilia
Pregnancy
Smokers >35, smoking >15/d
BMI >40
DM with vascular Cxs
Acute/chronic liver disease
What are the relative contraindications to the COCP?
Smokers
Chronic inflammatory disease
Renal impairment, DM
Age >40
BMI 35-40
Breastfeeding up to 6m postpartum
What should be done if breakthrough bleeding doesn’t stop after 3m
Consider changing the pill to one containing a more potent progestogen or using an increased strength for ethinyloestradiol.
What are the advantages of the COCP
Contraceptive
Non-contraceptive benefits:
Regular, less painful and lighter mesntruation
Protection against simple ovarian cysts, benign breast cysts, fibroids and endometriosis.
May improve features of PCOS.
Reduced risk of PID
Reduction in incidence of ovarian, endometrial and bowel carcinoma
What are the features of the combined transdermal patch
Adhesive patch that releases ethinyloestradiol and the progestogen norelgestromin.
A new patch is applied weekly for 3 consecutive weeks then replaced.
This is followed by a patch free week
What is Evra
Combined transdermal patch
What is Nuvargin
Combined vaginal ring
Features of Nuvaring
Latex free, releases a daily dose of ethinyloestradiol and progestogen.
Inserted and worn for 3w
Removed to allow for a 7d ringe free break and a withdrawal bleed.
New ring is then inserted.
Reduced synthetic oestrogen side effects.
Shouldn’t be remved during intercourse
What are the features of the mini-pill
Contains a low dose (350mg norethisterone) and must be taken every day without a break and at the same time +/-3h
MOA: makes cervical mucus hostile to sperm and inhibits ovulation in 50%
Progestogenic side effects: vaginal spotting, PMS-like symptoms
Functional ovarian cysts can occur.
Can be used in those in whom COCP is contraindicated.
Missed POP
Not taken within 3h
Another should be taken ASAP and condoms used for 2d
What is Cerazette
A different POP, contains a higher dose and inhibits ovulation in 90% of cycles.
More effective and can be taken within a 12h window
What is the benefit of depot progesteogen administration
Bypass portal circulation
Similar MOA to minipill
Ovulation normally also prevented.
Also protect against functional ovarian cysts and ectopic pregnancy.
What are the features of Depo-Provera
Contains medroxyprogesterone acetate
Administered by IM very 3m.
Often causes irregular bleeding in the first weeks but this is usually followed by amenorrhoea.
Bone density decreases over first 2-3y then stabilises and is regiained after stopping.
Other methods are preferred in teenagers to allow them to reach peak bone mass.
Useful during lactation
What is Noristerat
Alternative depot injection with similar efficacy to Depo-Provera.
Lasts 8w
Recommended as a ST interim contraceptive.
What are the features of Nexplanon
Single 40mm rod containing progestogen inserted into the upper arm using LA.
Lasts 3y
Side effects include progestogenic symptoms, irregular bleeding especially in the first year.
What is Levonelle
What are its features
Contains a single 1.5mg dose of levonorgestrel
Morning after pill. Taken within 24h and no later than 72
Affects sperm function and endometrial reciptivity.
95% success if used within 24h
58% if delayed until 72h
Vomiting may occur plus menstrual distrubances
What is ellaOne
What are its features
Selective progesterone receptor modulator (like mifepristone)
Prevents or delays ovulation
Can be used up to 120h after unprotected intervourse.
It will reduce the effectiveness of progesterone containing contraceptives and so women should use condoms or avoid unprotected intercourse until the next period.
IUD as an emergency contraceptive
Usually prevents implantation and is the most efficacious method
Can be inserted up to 5d after either the episode of intercourse or the expected day of ovulation.
Antibiotic prophylaxis usually given at the time of insertion
What is the failure rate of the male condom?
2-15 per 100 woman years
Features of copper containing IUDs
Operate primarily by preventing fertilisaiton with the Cu ions being toxic to sperm
Also block implantation
Copper either wound around an inert frame which sits within the uterine cavity or threads which are attached to the fundus
What is the Mirena coil and its features
IUD that contain the progestogen levonorgestrel
Released locally over 5y
Known as the IUS.
Contraceptive effects are local through changes to the cervical mucus and uterotubal fluid which impair sperm migration coupled with endometrial changes, impeding implantation.
Also reduces menstrual loss and pain.
Systemic side effects are low.
Irregular ligt bleeding is the main problem
What are the Cx of IUS?
Pain or cervical shock: due to inreased vaginal tone can complicate insertion, devices can be expelled within first month.
Perforation of the uterie wall can occur at insertion or afterwards. Expulsion or preforation will cause the threads to disappear but they may also have been cut too short. If the threads are not visible- USS, if it is not present then an XR will reveal whether it is in the abdomen.
Heavier or more painful menstruation can occur (with non-progestogen devices)
Increased risk of PID if women have symptomatic STIs when the coil is inserted.
Increased risk of infection
Increased risk of ectopic pregnancy if pregnancy does occur, although the risk of ectopic pregnancy is lower than in a woman using no contraception.
If not ectopic, IUD should be removed to reduce the risk of miscarraige
What are the absolute contraindications to the IUD
Endometrial or cervical cancer
Undiagnosed vaginal bleeding
Active/recent pelvic infection
Current breast cancer (for progesteogen IUS)
Pregnancy
What are the relative contraindications to the IUD?
Previous ectopic
Exessive menstrual loss (unless IUS0
Multiple sexual partners
Young/nullip
Immunocompromised
What is the counselling that should be given before inserting IUD
Advise of major risks
Seek medical help if:
IMB
Experiences pelvic pain or a vaginal discharge
If she feels she might be pregnant
Advise to check for strings after each period
What is the most common technique for female sterilisation?
Filshie clips that are applied to the fallopian tubes laparoscopically, occluding the lumen.
What is an alternative to tube clipping for female sterilisation
Transcervical sterilisation:
Hysteroscopic placement of microinserts into the proximal part of each tubal lumen
Inserts expand, causing fibrosis and occlusion of the lumen, which is confirmed 3m later with a hysterosalpingogram
Reversal of female sterilisation
Not possible with hysteroscopic
Not guaranteed with Filshie clips
Not available on the NHS
Difference beween endometriosis and adenoymosis?
Endometriosis: presence and grwoth of tissue similar to endometrium outside of the uterus.
Adenoymosis: growth of endometrial tissue in myomterium
A 47-year-old woman,comes to the clinic to discuss contraception. She stopped having her periods 12 months ago. She is normotensive with a blood pressure recording of 122/78 mmHg in clinic. She smokes 10 cigarettes per day. She has a past history of breast cancer, successfully treated 4 years ago. You advise:
Cerazette (Progesterone-only-pill)
No longer requires contraception
Copper Intrauterine Device (Cu-IUD)
Rigevidon (Combined oral contraceptive pill)
Depot injection
This woman has entered the postmenopausal period as she has not had a period for 12 months. Even though she is postmenopausal she still requires contraception because she is under the age of 50. Guidelines advise: ‘Women using non-hormonal methods of contraception can be advised to stop contraception after 1 year of amenorrhoea if aged over 50 years, 2 years if the woman is aged under 50 years.’ (FSRH)
A copper coil is the best option for this woman because of her past history of breast cancer. All other methods, as they are hormonal, are a UKMEC Category 3, and this may be considered an unacceptable risk.
COCP in women >40
COCP use in the perimenopausal period may help to maintain bone mineral density
COCP use may help reduce menopausal symptoms
a pill containing 40 years
What are the 3 categories to describe a CTG
Normal
Non-reassuring
Abnormal
A 30-year-old female presents to her GP seeking contraception. She has three children and states she has completed her family. She is open to long-acting reversible contraception. After receiving advice about all options available, she opts for the copper IUD. Besides pregnancy, which of the following is it important to exclude?
Migraines with aura
Pelvic inflammatory disease
History of ectopic pregnancy
History of venous thromboembolism
Smoking history
Pelvic inflammatory disease is an absolute contraindication to the insertion of a copper IUD. Women at risk, such as those with multiple sexual partners or symptoms suggestive of pelvic inflammatory disease, should be tested and, if necessary, treated for any infections which could cause pelvic inflammatory disease such as Chlamydia trachomatis and Neisseria gonorrhoeae . Testing for these infections is done using endocervical swabs.
Insertion of a copper IUD is in itself a risk for developing pelvic inflammatory disease, however this risk is low in women who are at low risk of sexually transmitted infections.
Potential issues with IUDs
Make periods heavier, longer and more painful
IUS associated with inital frequent uterine bleeding and spotting
Uterine perforation
Increased risk of ectopic pregnancies (in women using contraception, NB lower than in woman not using contraception)
Increased risk of PID for 20d after insertion
Risk of insertion in 1/20
A 21-year-old female presents to her GP asking for medication to prevent menstruation when she goes away on holiday in 2 weeks’ time. She is a non-smoker and has no significant past medical history. What would be the drug of choice for short-term cessation of menstruation in this case?
Depot medroxyprogesterone acetate
Combined oral contraceptive
Cerazette
Oral norethisterone
GnRH analogue
This patient does not have any menstrual problems and wants short-term cessation of her menses. Norethisterone 5 mg three times a day is licensed for the postponement of periods, and is often prescribed to women who wish not to have a period when going on holiday. It must be started three days prior to the expected onset on menstruation. Menstruation resumes as normal two to three days after stopping the tablets.
Note that this is a high dose and should not be used for longer than it is needed i.e. in the short-term. You may wish to read the following article regarding the risk of venous thromboembolism with norethisterone
Norethisterone 5 mg TDS can also be used to rapidly stop heavy menstrual bleeding.
A 32-year-old gravid 2, para 2 at 24 weeks gestation attends an antenatal clinic and wishes to discuss delivery options for her pregnancy. On history, you find that her previous pregnancies were delivered by vaginal and elective caesarean section respectively. Which of the following is an absolute contraindication for vaginal delivery following previous cesarean section?
Chorioamnionitis
Classical caesarean scar
Post-term dates
Pre-eclampsia
Two previous caesarean sections
Planned vaginal birth after caesarean (VBAC) is contraindicated in patients with previous classical caesarean scars, previous episodes of uterine rupture and patients with other contraindications to vaginal birth (e.g. placenta praevia). Women with two or more previous caesarean sections may be offered VBAC. The other options in this question are not absolute contraindications.
Indications for C section
absolute CPD
placenta praevia grades 3/4
pre-eclampsia
post-maturity
IUGR
fetal distress in labour/prolapsed cord
failure of labour to progress
malpresentations: brow
placental abruption: only if fetal distress; if dead deliver vaginally
vaginal infection e.g. active herpes
cervical cancer (disseminates cancer cells)
Cxs of C section
DVT/PE
PPH
Infeciton: wound, endometritis, UTI
Retained placental tissue, ileus, ureteric trauma, transient abdominal distension
Diagnosis of Sheehan’s
by inadequate prolactin and gonadotropin stimulation tests in patients with a history of severe PPH.
A 36-year-old nulliparous presents at 37 weeks gestation with the report of a reduction in foetal movements for the past 3 hours associated with abdominal cramping and a small amount of peri vaginal bleeding. Her pregnancy has been otherwise uneventful. It is decided that a cardiotocography (CTG) is needed to further investigate her presentation. Which of the following features of a CTG is a worrying sign and would prompt further investigation?
Stable baseline heart rate of 91 bpm with normal variability
Single early deceleration
Baseline variability of 6 beats / min
Multiple early decelerations
Single prolonged deceleration for 3 minutes duration
According to NICE guidelines, bradycardia or a single prolonged deceleration that persists for >3 minutes or more is an abnormal CTG results and indicates the need for urgent investigation.
A 34-year-old gravid 3, para 2 presents in spontaneous labour and has an uncomplicated vaginal delivery. 30 minutes after delivery, the patient reports heavy vaginal bleeding which you estimate to be around 700mL. Which of the following is true regarding postpartum haemorrhage (PPH)?
Active management of third stage of labour increases risk of PPH
Prophylactic oxytocics in the third stage of labour do not reduce risk of PPH
Most cases of PPH have no identifiable risk factors
Oxytocin is not as effective as misoprostol in the management of PPH
Age is the strongest risk factor for PPH
The correct answer is 3.) most cases of PPH have no identifiable risk factors.
In terms of the other options, active management of the third stage of labour has been shown to lower maternal bleeding and reduce the risk of PPH. Similarly, prophylactic oxytocics are routinely used in third stage management as they have been shown to effectively reduce risk of PPH. Oxytocin is 1st line in the management of PPH and has been shown to be more effective than misoprostol. While age is a risk factor for PPH, it is not the strongest risk factor.
A 30-year-old female presents to her GP for advice about contraception. She is provided with information and advice regarding all methods of contraception available and decides to opt for a copper IUD. A pregnancy test done at the surgery is negative. She has a regular 28-day cycle. At what point in her menstrual cycle can the IUD be inserted?
Days 1-7
Days 8-14
Days 15-21
Days 22-28
Anytime during cycle
The copper IUD can be fitted at any point during the menstrual cycle. It can also be fitted immediately after first or second-trimester abortion, and from 4 weeks postpartum.
Note the importance of advising the patient to refrain from intercourse or use adequate contraception to prevent pregnancy until the IUD is fitted.
A 32-year-old female with long standing hypothyroidism is confirmed as pregnant at 8 weeks gestation. She is taking 75 micrograms of levothyroxine and this dose has remain unchanged over the past 18 months. Blood tests show the following:
fT411.7 pmol/L
TSH2.77 mU/L
What is the most appropriate action in relation to this woman’s levothyroxine dose?
Increase to 100 micrograms daily
Maintain at 75 micrograms per day
Reduce to 50 micrograms per day
Change to liothyronine
Reduce to 25 micrograms per day
Although the thyroid function tests are normal, thyroxine demands increase during pregnancy, and most woman require their dose increased by at least 25-50 micrograms levothyroxine. Therefore, it would be sensible to increase the dose to 100 micrograms in this case.
women with established hypothyroidism who become pregnant should have their dose increased ‘by
at least 25-50 micrograms levothyroxine’* due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value
Interactions of levothyroxine
iron: absorption of levothyroxine reduced, give at least 2 hours apart
How long does the combined contraceptive patch last?
4w
For the first 3w the patch is worn every day and needs to be changed each week
During the 4th week if the patch is not worn there will be a withdrawal bleed
For delays in changing the patch, different rules apply depending what week of the patch cycle the woman is in.
If the patch change is delayed at the end of week 1 or week 2:
If the delay in changing the patch is less than 48 hours, it should be changed immediately and no further precautions are needed.
If the delay is greater than 48 hours, the patch should be changed immediately and a barrier method of contraception used for the next 7 days. If the woman has had sexual intercourse during this extended patch-free interval or if unprotected sexual intercourse has occurred in the last 5 days, then emergency contraception needs to be considered.
For delays in changing the patch, different rules apply depending what week of the patch cycle the woman is in.
If the patch removal is delayed at the end of week 3:
The patch should be removed as soon as possible and the new patch applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.
If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle.
A 20-year-old pregnant lady is found to be anaemic 10 weeks gestation. A full blood count is ordered:
Hb85 g/L
MCV95 fL
The lab also reports a high reticulocyte count. A blood film shows target cells and Howell-Jolly bodies. What is the most likely cause of the anaemia?
Folate defficiency
Anaemia of chronic disease
Iron defficiency
Thalassaemia
Sickle cell disease
The full blood count confirms a normocytic anaemia. Folate and B12 deficiency cause megaloblastic anaemia which is characterised by macrocytosis. Iron deficiency and thalassaemia typically cause microcytosis. Therefore, based on the MCV it can be inferred that sickle cell disease is the most likely answer.
In addition, the Howell-Jolly bodies suggest hyposplenism which can occur in Sickle cell disease due to splenic infarctions.
The high reticulocyte count suggests increased destruction (e.g. haemolysis) or increased loss (e.g. bleeding) of red cells. Sickle cell disease results in a chronic haemolytic anaemia due to premature destruction of abnormally shaped red cells. This would result in a high reticulocyte count.
Abnormal category for CTG
Within the abnormal category lie the following:
Heart rate - >180 BPM or <100 BPM
Variability - Less than 5 for over 90 minutes
Decelerations - Non-reassuring variable decelerations for over 30 minutes since starting conservative measures to improve occuring with over 50% of contractions OR late decelerations present for over 30 minutes not improving with conservative measures occurring with over 50% of contractions OR bradycardia or a single prolonged deceleration lasting 3 minutes or more.
A 15 year old girl presents with amenorrhoea, having never started her periods. Which element of her history would lead you to reassure her that there is no need to investigate yet?
She has not developed breasts or axillary/pubic hair
Family history of late menarche
History of acne and scanty, dark facial hair
She is sexually active
Cyclical abdominal pain
Primary amenorrhoea can be diagnosed in women above the age of 14 with no secondary sexual characteristics, or above the age of 16 with secondary sexual characteristics. Primary amenorrhoea is commonly constitutional and has a familial distribution; in these cases there is no anatomical or physiological abnormality and patients will generally start menstruating by the age of 18.
Lack of breast or body hair development suggests this is true primary amenorrhoea and so warrants investigation. Acne and facial hair may suggest virilisation, e.g. in polycystic ovarian syndrome. In a woman who is sexually active, pregnancy may be a cause of amenorrhoea and should always be excluded. Cyclical abdominal pain associated with amenorrhoea may suggest an anatomical abnormality such as an imperforate hymen.
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
A women of child bearing age comes into your GP surgery. She wishes to try to conceive for a baby in one years time and does not wish to conceive sooner due to barrister exams she has this year. She ideally wants to fall pregnant soon after her exams. Which of the follow methods of contraception is most associated with delayed return to fertility?
Intrauterine system
Condoms
Combined oral contraceptive pill
Depo-Provera
Progesterone only pill
Condoms work as a barrier contraceptive and do not affect ovulation and hence do not delay fertility.
The intrauterine system (IUS) works by thickening cervical mucous and in some women may prevent ovulation, however the majority of women still ovulate. After removal of the IUS the majority of women regain fertility immediately.
The combined oral contraceptive pill can delay return to normal menstrual cycle in some women but the majority will be able to conceive within a month of stopping. The progesterone only pill is less likely to delay return to normal cycle as it does not contain oestrogen.
Because Depo-Provera lasts up to 12 weeks, it can take several months for the body to return to the normal menstrual cycle and hence delay fertility. For this reason, it is the least appropriate method for this woman who wants to return to ovulatory cycles immediately.
Adverse effects of injectables contraceptives
Irregular bleeding
Weight gain
May potentially increase risk of osteoporosis: only used in adolescents if no alternative
Not quickly reversible and there is a variable return to fertility
A pregnant woman asks for advice about alcohol consumption during pregnancy. Which one of the following is in line with current NICE guidelines?
1 to 2 units once or twice per week throughout pregnancy
Avoid first and second trimester. If then chooses to drink 1 to 4 units no more than twice per week
1 to 2 units once per week throughout pregnancy
Avoid first trimester. If then chooses to drink 1 to 2 units once or twice per week
Avoid alcohol throughout pregnancy
the government now recommend pregnant women should not drink. The wording of the official advice is ‘If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk.’
A hepatitis B serology positive woman gives birth to a healthy baby girl. She is surface antigen positive. What treatment should be given to the baby?
Hep B vaccine
Hep B vaccine and 0.5 millilitres of HBIG within 12 hours of birth
0.5 millilitres of HBIG within 12 hours of birth only
Hep B vaccine and 0.5 millilitres of HBIG within 12 hours of birth with a further hepatitis vaccine at 1-2 months and a further vaccine at 6 months
No treatment required
This question tests your knowledge of the Hepatitis B vaccine schedule in baby’s born at risk of developing hepatitis B. For babies who are born to mothers who are hepatitis B surface antigen positive, or are known to be high risk of hepatitis B, should receive the first dose of hepatitis B vaccine soon after birth and those born to mother’s who are surface antigen positive should also receive 0.5 millilitres of hepatitis B immunoglobulin within 12 hours of birth. The baby should then further receive a second dose of hepatitis B vaccine at 1-2 months and at 6 months.
A 28-year-old woman who is 32 weeks pregnant presents with itch.
On examination her abdomen is non tender with the uterus an appropriate size for her gestation. There is no visible rash, although she is mildly jaundiced. Her heart rate is 74/min, blood pressure 129/62mmHg, respiratory rate 20/min, oxygen saturations are 98% in air, temperature 36.8°C.
A set of blood results reveal:
Hb110 g/lNa+139 mmol/lBilirubin54 µmol/l
Platelets243 109/lK+4.1 mmol/lALP353 u/l
WBC8.2 109/lUrea4.6 mmol/lALT84 u/l
Neuts5.7 109/lCreatinine74 µmol/lγGT207 u/l
Lymphs1.8 * 109/lAlbumin34 g/l
What is the most likely cause of her symptoms?
Intrahepatic cholestasis of pregnancy
HELLP syndrome
Pre-eclampsia
Acute fatty liver of pregnancy
Biliary colic
The answer here is intrahepatic cholestasis of pregnancy.
This is a common cause of itch in the third trimester of pregnancy. It will give a cholestatic picture of liver function tests (LFTs) with a high ALP and GGT, with a lesser rise in ALT. Patients may also be jaundiced with right upper quadrant pain and steatorrhoea. Ursodeoxycholic acid is a common treatment.
The cholestatic LFTs could indicate biliary colic, however the absence of abdominal pain here makes it very unlikely.
Acute fatty liver of pregnancy also occurs in the third term of pregnancy but a hepatic picture would be expected on LFTs, with a rise in ALT/AST greater than that of ALP, a raised white cell count and potential clotting abnormalities. This condition is rare and patients are likely to be unwell with nausea, vomiting, jaundice and possible encephalopathy.
In HELLP syndrome you would see a haemolytic anaemia, the mild anaemia seen here does not correlate with this and also low platelets not seen here.
This lady is not hypertensive and does not have any other features of pre-eclampsia so this is unlikely. In late pre-eclampsia a hepatic derangement of LFTs might be seen.
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.
Hb115 g/l
Platelets250 * 109/l
WBC5 * 109/l
PT12 seconds
APTT30 seconds
Which of the following underlying conditions would most likely explain the findings on physical exam?
HELLP syndrome
Heroin abuse
Cocaine abuse
Disseminated intravascular coagulopathy
Pre-eclampsia
pre-eclampsia and HELLP syndrome are known causes of placental abruption, which typically presents with hyperreflexia. HELLP syndrome can be ruled out since the full blood count shows no indication of anaemia or low platelets as would be expected in this condition. Dilated pupils + hyperreflexia seen on physical examination point towards cocaine abuse. Heroin abuse would often present with pinpointed pupils and has not been associated with an increased risk of placental abruption. Although pre-eclampsia in pregnancy is associated with an increased risk of placental abruption, the findings on physical exam are more consistent with that of cocaine abuse. Disseminated intravascular coagulopathy is a complication placental abruption, not an underlying cause. Additionally, the normal partial thromboplastin time (PTT) and activated partial thromboplastintime (APTT) decrease the likelihood of underlying DIC.
Risks of smoking in pregnancy
Increased risk of miscarriage
Increased risk of pre-term labour
Increased risk of stillbirth
IUGR
Increased risk of sudden unexpected death in infancy
Risks of ETOH in pregnancy
Fetal alcohol syndrome (FAS)
learning difficulties
characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures
IUGR & postnatal restricted growth
microcephaly
Binge drinking is a major risk factor for FAS
Risks of cocaine in pregnancy?
Maternal risks
hypertension in pregnancy including pre-eclampsia
placental abruption
Fetal risk
prematurity
neonatal abstinence syndrome
Risks of heroin in pregnancy
Risk of neonatal abstinence syndrome
You are reviewing your patients on the post-natal ward and are discussing a patient who suffered from gestational diabetes during her pregnancy. Post-delivery her blood glucose levels have now returned to normal. The consultant asks you what sort of follow up patients like this have with regards to the gestational diabetes?
Fasting BGL before being discharged
No follow up
Fasting blood glucose level (BGL) 6-13 weeks post-partum
6 monthly Hb1Ac levels
75g 2 hour Oral Glucose Tolerance Test (OGTT)
One of the first things that needs to be insured is that women who have been diagnosed with gestational diabetes should discontinue the blood-glucose lowering therapy immediately after the birth.
Before discharge the BGL must be tested to ensure there is no persisting hyperglycaemia
Remind women who suffered gestational diabetes during pregnancy of the symptoms of hyperglycaemia
Explain the risk of gestational diabetes in future pregnancies
Offer lifestyle advice to those whose BGL have returned to normal after delivery
Offer a fasting plasma glucose test 6-13 weeks after the birth - this usually takes place at the 6 week post-natal check at the GP
A 24-year-old woman comes to the sexual health clinic. She states she has had 3 episodes of unprotected sex within the last 4 days. She states she uses the combined oral contraceptive pill (COCP) but does not take this regularly and has missed several pills in her current packet. She states that she last had a period 10 days ago. What should she be offered for emergency contraception?
Levonorgestrel
Cu-IUD
Nothing as she is covered by her COCP
Mirena coil
Ulipristal acetate
This woman requires emergency contraception because she had several episodes of unprotected sexual intercourse (UPSI) and has missed pills in her current packet of COCP. It is not clear if she has real contraceptive cover due to her poor compliance with taking the COCP.
The copper-bearing intrauterine device (Cu-IUD) is the best method for this woman as she has presented 4 days after UPSI. It is difficult to assess her expected ovulation date as her periods could be withdrawal bleeds from her intermittent COCP use. The Cu-IUD has a low documented failure rate so women should initially be offered this as a means of emergency contraception. It also serves the dual purpose of long-term reversible contraception which may benefit this woman as she has difficulty taking the COCP.
As this woman has poor compliance she should first be offered a pregnancy test before insertion of Cu-IUD.
As this woman has presented within 120 hours of UPSI she can be offered ulipristal acetate (ellaOne) but this would be a second choice to a Cu-IUD. Levonorgestrel (Levonelle One) is not indicated for use after 72 hours of UPSI. Mirena coil is not used for emergency contraception.
A woman comes to the GP surgery as she has a long term medical condition but wishes to try to conceive. Which of the following conditions is NOT an indication for high dose folic acid?
Obesity
Coeliac disease
Epilepsy treated with sodium valproate
Depression treated with an SSRI
Type 1 diabetes
SSRIs are taken safely by many women during pregnancy. The associated effect on the foetus is centred around the instant withdrawal that occurs at birth, and the baby may be initially jittery and hypotonic, rather than with any neural tube malformations.
Prevention of neural tube defects (NTD) during pregnancy:
all women should take 400mcg of folic acid until the 12th week of pregnancy
women at higher risk of conceiving a child with a NTD should take 5mg of folic acid until the 12th week of pregnancy
women are considered higher risk if any of the following apply:
→ either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
→ the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
→ the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
A 22 year old woman who is 7 weeks pregnant attended the early pregnancy assessment unit with vaginal bleeding. The ultrasound scan confirmed a viable intrauterine pregnancy and she was discharged. A few days later, her endocervical swab results are noted to have isolated Chlamydia trachomatis. She is allergic to azithromycin. What is the most suitable management?
Topical clindamycin
Oral flucloxacillin
Oral doxycycline
Oral levofloxacin
Oral erythromycin
Chlamydia infection in pregnancy is associated with premature delivery, amnionitis and puerperal infection. If cervical chlamydia infection is present at delivery, there is a high likelihood of neonatal chlamydia.
Neonatal chlamydia can include complications such as conjunctivitis and pneumonia.
Patients should be referred to a sexual health clinic for a full sexual health screen and for contact tracing.
Suitable treatments in pregnancy include erythromycin, amoxicillin or azithromycin. Doxycycline is contraindicated in pregnancy due to the risk of teeth and bone abnormalities in the fetus.
Repeat testing sometime after completion of treatment is recommended in pregnancy to ensure therapeutic cure.
A 27 year-old lady is day 1 post emergency caesarean section for failure to progress in the first stage. She has been complaining of pain and heavy vaginal bleeding since delivery and in the morning was noted to have heavy, offensive lochia and a boggy poorly contracted uterus above the umbilicus.
What is the most appropriate treatment?
Urgent ultrasound scan
Speculum examination
Examination under anaesthesia
IV antibiotics and review after first dose
Urgent MRI scan
This is a typical history of retained products, which can happen after caesarean section if care is not taken to make sure that all the placental membranes are removed. The uterus does not contract down well as the products are still in the cavity, and the discharge is offensive suggesting that the products have become infected.
This lady needs and urgent examination under anaesthesia to remove the products. The products often pass by themselves without the need for anaesthesia, however after day 1 this is unlikely so intervention is needed. Sometimes a scan would be done before but with a history this clear, it is not necessary. It is also hard to pick up products on scan sometimes as they can be very small.
A speculum examination would be helpful to show is the os was still open, however the os remains open in heavy bleeding so this information would not give us a diagnosis.
IV antibiotics are probably needed in this case, however the infection will not resolve until the products are removed and therefore surgery is also needed.
An MRI is not helpful in this situation as it is not useful for detecting intrauterine pathology, and would probably take a long time to organise which is unhelpful in this acute situation.
A 22-year-old female, gravidity 1 and parity 0 at 10 weeks’ gestation is involved in a high speed vehicle collision and her abdomen hits the steering wheel. Maternal vital signs are stable. No uterine contractions are present, and there is no vaginal bleeding. U/S shows an intact placenta. Which is the most appropriate next step?
Caesarean delivery
Betamethasone
Blood type and Rhesus testing
Induce labour
Discharge home on bed rest
Important points:
A pregnant woman with abdominal trauma should have Rhesus testing asap because women who are Rhesus-negative should be given anti-D to prevent Rhesus isoimmunization.
A 17-year-old girl who is nine weeks pregnant has a surgical termination of pregnancy. She feels well a few hours after the procedure. Which of the following risks is most common following a TOP?
Infection
Haemorrhage
Uterine perforation
Cervical trauma
Failure
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.
A 16-year-old girl comes to your GP surgery worried that she has not yet started her periods. She is quite short, has a webbed neck, low set ears and widely space nipples. A heart murmur is heard on auscultation. What type of murmur are you most likely to hear?
Systolic, loudest over the pulmonary valve
Diastolic, loudest over the pulmonary valve
Systolic, loudest over the aortic valve
Systolic, loudest over mitral valve
Diastolic, loudest over mitral valve
From the clinical picture, you should have a differential diagnosis of Turner’s syndrome. Patients with Turner’s syndrome are prone to have bicuspid aortic valve, aortic valve stenosis and/or aortic coarctation. For this reason, you would be expecting to hear a systolic murmur which is loudest over the aortic region.
A 24 year old woman presents to your surgery with vaginal discharge. She says it smells quite strongly, but isn’t itchy. She has no dysuria or dyspareunia. She has no post-coital bleeding.
On examination, there is a watery discharge with an odour. There is no erythema to the labia. Her cervix looks healthy and there is no cervical excitation.
What is the most likely diagnosis?
Gonorrhoea
Bacterial vaginosis
Chlamydia
Herpes simplex
Candidiasis
Clearly you would want more information about sexual history for this lady, and in all likelihood would send triple swabs regardless. However, a diagnosis of Gonorrhoea is unlikely given the healthy looking cervix. You would also expect a more green and purulent discharge for Gonorrhoea rather than a watery discharge. Gonorrhoea is particularly problematic as it can present with a normal examination, however is not often associated with an odour.
In a similar line, you would expect to see more problems with the cervix for a diagnosis of Chlamydia and a more mucopurulent discharge. Chlamydia can also cause cervical excitation which this lady does not have.
Herpes simplex doesn’t tend to cause vaginal discharge, and would instead present as a crop of ulcers or tingling type sensations around the vulva. Patients can have a flu like illness, and may have some lymphadenopathy.
For candidiasis, or thrush, you would expect a lot more itching in the history. It would also be more likely to have a thick creamy consistency like cottage cheese. There is a higher probability with thrush that you would get vulval irritation.
Bacterial vaginosis is the most likely diagnosis on balance. It gives a characteristic fishy odour, and is often a thin watery discharge that can have a green or white hue. It often doesn’t cause irritation or soreness, and can be completely asymptomatic. Diagnosis would be confirmed with a vaginal pH > 4.5 and clue cells on microscopy.
A 34-year-old woman who is 35 weeks pregnant presents to her general practitioner with painful blisters affecting the vagina and cervix, along with inguinal lymphadenopathy. She has never had these symptoms before. The GP diagnoses primary genital herpes. Which of the following management strategies is most appropriate?
Simple analgesia only
Oral aciclovir for 5 days
Oral aciclovir until delivery and delivery by caesarean section
Caesarean section
Oral aciclovir until delivery
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.
It can be difficult to clinically distinguish between primary and recurrent episodes of genital herpes. If a patient has not noticed the symptoms in the past it is recommended that management is initiated on the assumption that it is the first episode. Type-specific HSV antibody testing can be performed in order to confirm or refute this, but this can take 2-3 weeks to yield results - hence the recommendation to initiate the above management plan which can later be modified if appropriate.
A 29 year-old woman who is taking antidepressant therapy for moderate depression visits her general practitioner (GP) to talk about becoming pregnant. After discussion, the woman and her GP agree that she should continue antidepressant therapy if she falls pregnant in the near future. Which of the following drugs must be avoided in pregnancy due to risk both of fetal malformation and maternal hypertensive crisis?
Phenelzine
Imipramine
Sertraline
Fluoxetine
Amitriptyline
There are no antidepressants licensed for use during pregnancy, however it is not uncommon for medication to be continued if a patient is already taking it and is likely to struggle without it.
Phenelzine is a monoamine-oxidase inhibitor (MAOI). The BNF strongly advises that MAOIs be avoided in pregnancy due to an increased risk of neonatal malformations. Maternal hypertensive crisis has also been reported in association with this class of antidepressant.
Fluoxetine and sertraline are selective serotonin reuptake inhibitors. They are associated with a small increased risk of congenital heart disease and can cause neonatal withdrawal symptoms.
Imipramine and amitriptyline are tricyclic antidepressants. Imipramine use during pregnancy is associated with a wide range of neonatal symptoms including tachycardia and respiratory depression.
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. Which of the following test results would be expected in this patient?
High beta hCG, high TSH, high thyroxine
High beta hCG, low TSH, high thyroxine
High beta hCG, high TSH, low thyroxine
Low beta hCG, low TSH, high thyroxine
Low beta hCG, high TSH, low thyroxine
The clinical presentation in this question is consistent with that of a molar pregnancy. A basic understanding of physiology is needed to answer this question correctly. Molar pregnancies are characterised by significantly high levels of beta hCG for gestational age, and are therefore used as a tumour marker of gestational trophoblastic disease. The biochemical structure of beta hCG is very similar to that of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and thyroid-stimulating hormone (TSH). That being said, high levels of beta hCG can stimulate the thyroid gland to produce thyroxine (T4), and then triiodothyronine (T3). This can result in signs and symptoms of thyrotoxicosis. High levels of T4 and T3 have a negative feedback effect on the pituitary gland to stop secretion of TSH, causing and overall reduction in TSH levels.
A 19-year-old woman has a positive pregnancy test and is found to have an ectopic pregnancy after an intrauterine pregnancy is excluded. She has no pain or other symptoms at this time. Her serum beta-human chorionic gonadotropin (B-hCG) level is 1397 IU/L. A transvaginal ultrasound reveals a 29mm adnexal mass but no heartbeat. There is no free fluid in the abdomen. She says she would like a follow-up appointment following her treatment. What is the first line treatment?
Methotrexate
Urgent laparoscopic salpingectomy
Monitor B-hCG
Misoprostol
Mifepristone
The National Institute for Health and Care Excellence (NICE) states that if a woman has a small (<35mm) unruptured ectopic pregnancy with no visible heartbeat, a serum B-hCG level of <1500 IU/L, no intrauterine pregnancy and no pain, then first line treatment should be with methotrexate as long as the patient is willing to attend for follow-up.
Methotrexate is an antimetabolite chemotherapeutic drug. It interferes with DNA synthesis and disrupts cell multiplication^1 thus preventing the pregnancy from developing.
The other treatment option is laparoscopic salpingectomy (or salpingotomy where there is risk of infertility). This should be offered where the ectopic is larger than 35mm, is causing severe pain or if the B-hCG level is >1500. There is a risk of infertility if a problem arises with the remaining Fallopian tube in the future.
USS of hydatidform mole
On ultrasound, the mole appears as a solid collection of echoes with numerous small anechoic spaces which resembles a bunch of grapes (also known as ‘snow-storm’ appearance).
A 25-year-old receives a letter from her GP explaining that her first smear showed mild dyskaryosis, and she was Human Papilloma Virus (HPV) positive. She was subsequently referred to the colposcopy clinic where she underwent treatment for cervical intraepithelial neoplasia (CIN) stage 1.
Which cell cycle protein does the HPV E6 protein inhibit in the process of cell transformation?
pRB
c-RAF
p53
PTEN
c-Ras
The E6 protein binds to p53, preventing it from halting cell division. The E7 protein binds to pRb.
The Human Papilloma Virus (HPV) is the causative agent in almost all cervical carcinomas. It is spread easily via sexual transmission, and although most types do not cause cancer, persistence of high-risk oncogenic types, such as 16, 18, 33 and 45 cause cell transformation and neoplasia. The aim of the cervical screening programme is to prevent cervical intraepithelial neoplasia from progressing to cancer.
HPV itself is a double-stranded DNA virus, consisting of an icosahedral capsid (encoded by L1 and L2) and proteins E1-E7 (involved in replication and cell transformation).
HPV invades keratinocytes of the skin and mucous membranes and uses the host DNA replication machinery to replicate itself. HPV enters the basal compartment and as the surface cells naturally shed, the HPV infected cells migrate upwards and begin to replicate, resulting in a huge increase in viral copy number. Normally, the E2 protein blocks the E6 and E7 proteins, but when HPV DNA integrates into host cell DNA, E2 is inhibited. The E6 protein inhibits the tumour suppressor p53 and the E7 protein inhibits pRb, enabling uncontrolled cell division.
HPV evades the immune response as there is no active cytolysis, it is not blood borne, it can disable antigen presenting cells and inhibit interferon synthesis. Most people do eventually mount an immune response to HPV. It is not known why some people are persistently infected with HPV, but it could be related to an inherent problem in immunity, as well as other co-factors, such as smoking and multiparity.
The HPV vaccine consists of the L1 nucleocapsid protein (Gardasil uses L1 proteins from 6, 11, 16 and 18), which is non-oncogenic. Intramuscular injection of the vaccine means that stromal dendritic cells encounter the protein, producing a robust antibody response against L1, thus protecting against HPV infection.
UKMEC 1-4
UKMEC1 - No restriction
UKMEC2 - Advantages > Disadvantages
UKMEC3 - Disadvantages > Advantages
UKMEC4 - Unacceptable risk
UKMEC 3
- > 35 years old and smoker of < 15 cigarettes per day
- BMI > 35
- Migraine with no aura
- Family history of deep vein thrombosis or pulmonary embolism in first degree relative < 45 years old
- Controlled hypertension
- Immobility e.g. Wheelchair use
- Breast feeding and 6 weeks to 6 months postpartum
UKMEC 4
- >35 years old and smoker of > 15 cigarettes per day
- migraine with aura
- Personal history of deep vein thrombosis or pulmonary embolism
- Personal history of stroke or ischaemic heart disease
- Uncontrolled hypertension
- Breast cancer
- Recent major surgery with prolonged immobilisation
- Breast feeding and < 6 weeks postpartum
A woman who is 28 weeks pregnant presents with shortness of breath and unilateral leg oedema. You suspect a pulmonary embolism and consult your seniors as to the best test to confirm the diagnosis. Which of the following is the best reason to choose a ventilation/perfusion (V/Q) scan over CT pulmonary angiography (CTPA)?
It requires less specialist training to perform
It is cheaper
There is less radiation to the breast tissue
It is less harmful to the foetus
It is easier to interpret
Breast tissue in premenopausal women is highly sensitive to radiation; in the long-term, CTPA confers a 14% increased risk against the background for breast cancer in pregnant women who are under 40 years old and should therefore be avoided.
In 2012 NHS costing report documented the cost of a V/Q scan as £162 with CTPA as £100; both cost an additional £20 each for reporting.
There is often more disagreement between radiologists as to the presence or absence of a PE on V/Q scan and so results are given as high or low probability in the context of a scoring system such as the Wells score.
Radiation exposure to the fetus with V/Q scans and CTPA are equivocal
A 20 year-old woman who is 30 weeks pregnant wishes to visit rural Burundi to attend a family funeral. Her general practitioner explains that this is a high risk area for malaria and advises her against visiting whilst pregnant, but the woman is adamant that she will go. Which of the following drugs should be offered as prophylaxis?
Atovaquone
Piperaquine
Doxycycline
No antimalarial prophylaxis can be prescribed in pregnancy
Mefloquine
Travel to malarial areas should ideally be avoided during pregnancy. However, if travel is unavoidable then the benefits of taking prophylaxis are usually considered to outweigh the risks. Mefloquine is recommended by the Royal College of Obstetricians and Gynaecologists (RCOG) as the drug of choice for prophylaxis in the second and third trimesters. Although chloroquine is considered to be relatively safe, the RCOG states that with very few areas in the world free from chloroquine-resistance, mefloquine is essentially the only drug considered safe for prophylaxis in pregnant travellers.
Doxycycline, like other tetracyclines, should be avoided in pregnancy due to effects on skeletal development and discoloration of teeth. Piperaquine has been found to be teratogenic in animal studies. There is insufficient information about the effect of atovaquone in pregnancy.
Which of the following presentations has the greatest mortality and morbidity?
Occipitoposterior presentation at delivery
Footling presentation at delivery
Face presentation at delivery
Transverse lie at 30 weeks
Breech presentation at 20 weeks
Footling presentations are a rare but the most risky form of breech- there is a 5-20% risk of cord prolapse, which can obstruct foetal blood flow and is an obstetric emergency.
40% of babies are breech at 20 weeks but only 3% at term- there is still plenty of room for the foetus to turn around and resolve to head down.
In occipitoposterior presentation the posterior fontanelle is found in the posterior quadrant of the pelvis; greater rotation is required so labour is usually longer. There is a greater rate of intervention- 22% require forceps and 5% require caesarean section.
Face presentations normally occur by chance when the head extends rather than flexes as it engages.
99% rotate so the chin lies behind the symphysis and the head can be born by flexion; in 1%the chin rotations to the sacrum and caesarean section is indicated.
Transverse lie is where the shoulder is presenting. It occurs in multiparous women due to their uterine muscles being less tight than a nulliparous woman. Extracephalic version may be attempted from 32 weeks and thus is manageable at 30 weeks.
A 28-year-old patient presents with painless vaginal spotting. Her last menstrual period was 9 weeks ago. Transvaginal ultrasound showed an ectopic pregnancy of 3-cm in diameter and beta-hCG of 1000 lU/litre. She was given a single dose of methotrexate and reassessed at day 4. Her beta-hCG levels rose to 1,300 IU/litre. What would be the next best management step?
Second dose of methotrexate
Second measurement of beta-hCG levels
Laparoscopic surgery with salpingectomy
Laparoscopic surgery with salpingostomy
Emergency laparotomy
This question tests the understanding of the management of ectopic pregnancy. According to the NICE guidelines, systemic methotrexate should be offered to women who have all of the following
No significant pain
An unruptured ectopic pregnancy with adnexal mass less than 35mm with no visible heart beat
A serum hCG less than 1,500 IU/liter
No intrauterine pregnancy ( as confirmed by ultrasound)
In addition to the criterion mentioned above, it is important to be familiar with the contraindications of using methotrexate. Once given, the patient should have her beta-hCG levels measured twice (at day 4 and day 7). Normally, beta-hCG levels rise on day 4 compared to pre-treatment levels. This is due to the death of trophoblastic cells. A second beta-hCG level should therefore be taken at day 7 and ensure that levels are dropping. Although a second dose of methotrexate is a common approach ,it should only be considered if the beta-hCG levels do not fall >15% on day 7 compared with day 4. Laparoscopic surgery is preferred in women with ruptured ectopic pregnancy not meeting the criteria for medical treatment. The decision to have a salpingotomy over salpingectomy depends on the condition of the contralateral tube and desire for future fertility. In this scenario, laparoscopic surgery should be considered if medical therapy with methotrexate fails. An emergency laparotomy is not indicated in this patient, as she is stable.
Causes of hyperechogenic bowel?
CF
Down’s
CMV
Causes of increased nuchal translucency
Down’s
Congenital
Abdominal wall defects
A 37-year-old woman in her second pregnancy has delivered a live male infant. She has no past medical history of note. Ten minutes after delivery, she complains of a sudden onset severe occipital headache that is associated with vomiting. On examination there is evidence of photophobia. Shortly after this she losses consciousness and has a Glasgow coma score of 8. What is the most likely diagnosis?
Extra-dural haematoma
Sheehan’s syndrome
Sub-dural haematoma
Subarachnoid haemorrhage
Intracerebral haemorrhage
A subarachnoid haemorrhage (SAH) is a type of stroke which is usually the result of bleeding from a berry aneurysm in the Circle of Willis. Key clinical features include a sudden onset headache which reaches maximum severity in seconds to minutes (‘thunderclap headache’) and meningitic symptoms (for example photophobia and neck stiffness).
What are the long term Cxs of PCOS?
Subfertility
DM
Stroke and TIA
Coronary artery disease
Obstructive sleep apnoea
Endometrial Ca
A 27-year-old primiparous woman has had a prolonged first stage of labour and the foetal heart rate on auscultation was 172 beats per minute. Cardiotocography (CTG) is initiated. Over the last 30 minutes the CTG has changed. The latest recording shows a baseline foetal heart rate of 175 beats per minute, a baseline variability of 7 beats per minute, some accelerations are present and there are variable decelerations. What is the next step?
Do nothing as the CTG is not worrying
Conservative measures and take foetal blood sample
Plan immediate delivery
Conservative measures (change position, optimise hydration) only
Give IV oxytocin to initiate contractions
Cardiotocography (CTG) is used to assess foetal well being by measuring the foetal heart rate and maternal contractions. A normal trace is reassuring but an abnormal trace can require further monitoring or require additional investigations.
There are four important features when interpreting a CTG:
Baseline foetal heart rate
Baseline variability
Presence of accelerations
Presence/absence of decelerations
The CTG described in this case has 2 non-reassuring features - the foetal heart rate is 175 bpm and there are variable decelerations. This makes the CTG abnormal but it does not require urgent intervention as there is no bradycardia or prolonged late decelerations. NICE guidelines suggest that conservative measures should be initiated and a foetal blood sample should be taken in order to determine the next step in management. Planning for delivery will be discussed with the consultant obstetrician after the foetal blood sample is obtained. While oxytocin may help to initiate contractions in order to move into the 2nd stage of labour, this should not be done until foetal well being is confirmed through foetal blood sample.
What are the characteristic levels for normal bladder function?
Should have a voiding detrusor pressure risk of <70cm
Peak flow rate of >15ml/s
High voiding detrusor pressure with low peak flow rate is indicative of bladder outflow obstruction
A 34-year-old woman attends a routine antenatal clinic at 16 weeks gestation.
She has no significant past medical history but suffers with occasional frontal headaches.
She is noted to have a blood pressure of 148/76mmHg.
Urinalysis reveals;
pH6.5
Protein+1
Nitrates0
Leuc0
Blood0
What is the most likely diagnosis?
Gestational hypertension
Pre-eclampsia
HELLP
Nephrotic syndrome
Chronic hypertension
The answer here is chronic hypertension.
At 16 weeks gestation, this lady is too early into her pregnancy to have developed any of the pregnancy related causes of hypertension. The small amount of protein in her urine may also indicate relatively long standing hypertension. Intermittent frontal headaches are a common occurrence and are not a sign of pre-eclampsia in this case.
Pre-eclampsia and gestational hypertension would only occur after 20 weeks gestation. Pre-eclampsia with significant proteinuria, gestational hypertension without.
Nephrotic syndrome would be associated with a larger degree of proteinuria.
A 35-year-old woman comes to see you in clinic with a 12 month history of heavy periods with clots and flooding. She does not experience any pelvic pain.
On examination she has a palpable bulky uterus.
You book her in for a transvaginal ultrasound scan and decide to start her on some treatment in the interim.
What is the most appropriate first line management?
Levonorgestrel releasing intrauterine system
Oral norethisterone
Combined oral contraceptive pill
Depot injection
Tranexamic acid
This is a question regarding management of menorrhagia.
In this scenario, this lady most likely has uterine fibroids and is therefore appropriately being sent for transvaginal ultrasound for further assessment.
NICE Clinical Knowledge Summaries dictate that tranexamic acid or NSAIDs are the most suitable 1st line agents to use to manage symptoms while awaiting results of investigations. Since the patient does not have pelvic pain, tranexamic acid is most appropriate.
It would not be appropriate to insert a levonorgestrel releasing IUS before delineating the anatomy in someone whom you’re suspicious of fibroids.
A 21-year-old woman presents to the emergency department with a 2 day history of nausea and severe constant pain localised since onset to the right iliac fossa. There is no fever nor diarrhoea and no vaginal bleeding. She is on the contraceptive implant that was placed 5 months ago. You suspect ovarian torsion. How would you definitively diagnosis this?
Laparotomy
Laparoscopy
CT abdomen pelvis with contrast
CT abdomen pelvis without contrast
Transvaginal and transabdominal ultrasound
Ovarian torsion can only be definitively diagnosed invasively. Laparoscopy (keyhole) is the usual method of surgery and allows diagnosis by visual inspection and also allows management with detorsion.
Laparotomy (open) is another option for surgery but is usually reserved for patients with suspected or confirmed malignancy to prevent seeding and malignant spread. Laparotomy may also be used for those patients in whom laparoscopy may be difficult, for example due to size, either obesity or small size in infants.
Ultrasound is the imaging modality of choice to confirm clinical suspicion of ovarian torsion, but cannot provide a definitive diagnosis. Combining transvaginal with transabdominal methods of ultrasound provides the best images of reproductive organs. Features on ultrasound include visualisation of the twisting of vessels (whirlpool sign), ovarian oedema, and reduced blood flow to and within the ovary when examining with colour Doppler. Diagnostic reliability of non-invasive imaging is also dependent on sonographer/radiologist expertise.
CT would show similar findings to ultrasound, but this is more costly and has the added risk of radiation. In a CT with contrast, there would be lack of enhancement of the affected ovary. A CT without contrast is appropriate for imaging renal stones but would not demonstrate ovarian torsion or structural changes within organs very well.
N.B. Differential diagnoses for this presentation would be appendicitis and ectopic pregnancy. These can be ruled out from the history.
Appendicitis:
Abdominal pain was localised since onset to the right iliac fossa rather than starting as diffuse and localising later on.
There is no diarrhoea.
There is no fever.
Ectopic pregnancy:
There is no vaginal bleeding.
This patient is on the contraceptive implant.
A 25-year-old para 1+0 presents at 36 weeks with painless vaginal bleeding. She reports that she has had intermittent spotting over the last 4 weeks, but they have increased in volume and frequency. Her blood pressure is 125/80mmHg and her heart rate is 85bpm. On examination, her abdomen is soft and non-tender, and the fetal head is not engaged and high.
What examination should you perform to confirm your initial working diagnosis?
LFTs and urine dipstick
Vaginal examination
Abdominal ultrasound
Vaginal ultrasound
Cardiotocography of the fetus
The findings in this case are classical of placenta praevia.
- These investigations would be used to partly investigate pre-eclampsia
2: Vaginal examinations should always be avoided in a pregnant woman with unexplained vaginal bleeding
3: Correct, this should show a low-lying placenta
4: Vaginal investigations should always be avoided in a pregnant woman with unexplained vaginal bleeding
5: This would elicit any fetal distress, however would not confirm a diagnosis of placenta praevia
A 64 year-old obese lady presents to the rapid access clinic after one episode of post menopausal bleeding. She has an ultrasound scan which shows an endometrial thickness of 4mm. A pipelle biopsy comes back as negative.
What is the most appropriate management?
Serial ultrasound scans every 6 months
Follow up 1 year
Discharge
Hysteroscopy and endometrial biopsy
Repeat pipelle 3 months
The correct answer here is discharge the patient back to her GP, while obviously telling the patient to report back if she has any further episodes of vaginal bleeding. The combination of the endometrium being thin on scan and there being no histological evidence of abnormal tissue is reassuring enough to say at the moment her risk of endometrial cancer is low.
Pipelle biopsies are shown to have a very high sensitivity in detecting endometrial cancer (>99%). Without any further episodes of vaginal bleeding repeating a pipelle in 3 months is not indicated. As the sensitivity of pipelle biopsy is so high, a hysteroscopy and endometrial biopsy is not needed in this case. This is an invasive procedure, which is uncomfortable as an outpatient and therefore often needs a general anaesthetic, which carries further risks. Sometimes a hysteroscopy and endometrial biopsy is needed, for example if the pipelle is not possible in the outpatient setting (e.g. due to patient not tolerating it, a stenosed cervix etc.) or if there is other pathology, for example polyps, which need to be visualised.
Ultrasound scanning has not been shown to be a reliable screening test for endometrial cancer, and therefore repeating the ultrasound scans is not helpful.
There is no need to follow the patient up in 1 year, as if she does not have any further episodes of bleeding the risk of endometrial cancer remains low. It is however very important to explain to the patient that even though this time she was low risk, she could be in early stages or still go on to develop endometrial cancer, and therefore she should see her GP immediately about any further episodes of vaginal bleeding.
A 76 year old woman presents with post-menopausal bleeding for the past 4 months. She is diagnosed with well-differentiated adeno-carcinoma (stage II) on endometrial biopsy. There is no evidence of metastatic disease. Which is the most appropriate treatment?
Transcervical endometrial resection
Total abdominal hysterectomy
Provera (medroxyprogesterone acetate)
Wertheim’s radical hysterectomy
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the treatment of choice for stage I and II endometrial carcinoma. Provera is a progesterone used as a hormonal treatment for endometrial carcinoma - it acts by slowing the growth of malignant cells in the endometrium. Wertheim’s radical hysterectomy includes removal of lymph nodes and is used to treat stage IIB endometrial carcinoma.
A 28-year-old woman with rheumatoid arthritis asks for advice about conception. Which one of the following statements is true?
Methotrexate may be continued during pregnancy as long as the woman takes folic acid 5mg daily
NSAIDs should be avoided in the first and second trimester
Woman with rheumatoid should be encouraged to conceive as soon as possible (ideally within 1 year) after diagnosis to minimise the risk of complications
TNF-α blockers are absolutely contraindicated in pregnancy
Hydroxychloroquine is considered safe during pregnancy
Hydroxychloroquine is considered safe during pregnancy
Methotrexate in pregnancy
methotrexate is not safe in pregnancy and needs to be stopped at least 3 months before conception
What is significant about anaesthetics in pregnant woman with RA?
patients should be referred to an obstetric anaesthetist due to the risk of atlanto-axial subluxation
NSAIDs in pregnancy
NSAIDs may be used until 32 weeks but after this time should be withdrawn due to the risk of early close of the ductus arteriosus
Sulfasalazine and hydroxychloroquine in pregnancy
Considered safe
Leflunomide in pregnancy
Is not considered safe
A 32-year-old nulliparous female is induced into labour at 39 weeks gestation due to a history of pre-eclampsia and intrauterine growth restriction. Her cervix is favourable and she has undergone artificial rupture of membranes. On inspection of the partogram you note that there has been no uterine activity. What treatment is most suitable?
Syntometrine
Vaginal prostaglandin (PGE2)
No treatment required
Syntocinon
Caesarian section
Syntocinon is a synthetic oxytocin analogue and is the drug of choice for stimulating labour when the contractions are considered too weak.
A 33-year-old female presents to her GP as she missed her Noriday pill (progestogen only) this morning and is unsure what to do. She normally takes the pill at around 0900 and it is now 1230. What advice should be given?
Take missed pill as soon as possible and advise condom use until pill taking re-established for 48 hours
Take missed pill as soon as possible and omit pill break at end of pack
Perform a pregnancy test
Take missed pill as soon as possible and no further action needed
Emergency contraception should be offered
Take missed pill as soon as possible and advise condom use until pill taking re-established for 48 hours
A 27-year-old woman presents 1 week following a first trimester miscarriage with continued low abdominal pain and vaginal bleeding. She is tearful and explains she had a previous miscarriage a year ago and wants this process to be over as soon as possible. A trans-vaginal ultrasound is performed and an incomplete miscarriage is suspected. What is the most appropriate management of this patient?
Oral misoprostol
Admit for observation
Intravenous syntocinon infusion
Oral mifepristone
Vaginal misoprostol
An incomplete miscarriage occurs when some, but not all, of the products of conception are expelled from the uterus. Retained products of conception pose an infection risk to the mother and so should be treated promptly. Bleeding in miscarriage can be serious and physiological signs of shock should not be missed.
The National Institute of Health and Care Excellence (NICE) recommends that during an incomplete miscarriage, medical management of miscarriage should be offered where ‘expectant management’ is unacceptable to the patient. A single dose of misoprostol 600 micrograms as a vaginal pessary is first line medical management of an incomplete miscarriage. If this is not tolerated then oral administration is acceptable. Other management options include manual vacuum aspiration under local anaesthetic and surgical management under general anaesthetic.
Medical management as opposed to expectant management is often offered to women who have previously had a traumatic experience of pregnancy, such as a previous miscarriage or still birth.
A 33-year-old woman is reviewed regarding her asthma control. You notice from her records that she has never had a cervical smear and raise this with her. She responds that she is a lesbian and has never had sex with a man. What is the most appropriate advice to give?
She does not need to have a smear
She may need to have a smear if her partner has previously had heterosexual relationships
She should have cervical screening as per normal
She does not need to have a smear but does need a one-off HPV test
She should be referred to colposcopy clinic for a case-based assessment
HPV, the causative agent of cervical cancer, can be transmitted during lesbian sex. Lesbian and bisexual women should therefore have cervical screening as normal. Unfortunately the uptake amongst lesbian women is around 10 times worse than the general female population, sometimes as a consequence of incorrect advice from healthcare professionals.
What is oxybutynin
Anti-muscarinic used in treatment of detrusor muscle over-activity
A 34-year-old woman from Zimbabwe presents with continuous dribbling incontinence after having her 2nd child. Apart from prolonged labour the woman denies any complications related to her pregnancies. She is normally fit and well.
A.Bladder diary for 3 days
B.Urodynamic studies
C.Bladder drill training for 6 weeks
D.Pelvic floor exercises 3 months
E.Oxybutynin
F.IV urography
G.Urinary dye studies
H.None of the above
Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services. A dye stains the urine and hence identifies the presence of a fistula.
A 36-year-old with menorrhagia has is investigated and found to have a 1.5 cm uterine fibroid which is not distorting the uterine cavity. She has three children and wants ongoing contraception, but is using only condoms at the moment. What is the most appropriate initial treatment for her menorrhagia?
Intrauterine system
GnRH agonist
Tranexamic acid
Refer for consideration of a myomectomy
Combined oral contraceptive pill
As the fibroid is less than 3 cm medical treatment can be tried. NICE Clinical Knowledge Summaries recommend an intrauterine system initially, which will also provide contraception.
Treatment options for TTTS
Indomethacin to reduce foetal urine output
Laser obliteration of placental vascular communications
Selective foetal reduction
After birth, the donor may require blood transfusions to treat anaemia. The recipient twin may need exchange transfusions/ heart failure medications.
A 32-year-old woman comes to see her GP asking to be put on the combined oral contraceptive pill as she has recently started a new sexual relationship. She does not want any long acting contraceptives and has tried the progesterone only pill in the past and had side effects.
Which one of the following would be an absolute contraindications to prescribed the combined oral contraceptive pill?
Migraine without aura
1st degree relative with a history of venous thromboembolism
Smoking 10 cigarettes a day
HIV positive and using antiretrovirals
Systemic Lupus Erythematosus
When prescribing the oral contraceptive pill there are a number of risk factors that must be screened for. These risk factors are split into a four point scale with level 4 being considered an unacceptable health risk.
All answer except for Systemic Lupus Erythematosus are considered level 3 where the disadvantages generally outweigh the advantages but prescription can be given if deemed appropriate.
A 30-year-old who is currently 27 weeks pregnant comes to see you about a thin, white discharge. Swabs are taken and clue cells are seen on microscopy. Which treatment do you initiate?
Metronidazole 400mg bd for 7 days
Single dose of metronidazole 2g
Intravaginal clindamycin cream 2% od for 7 days
Intravaginal metronidazole gel 0.75% od for 5 days
Oral clindamycin 300mg bd for 7 days
Offer treatment to all pregnant women with symptomatic bacterial vaginosis (BV). If a pregnant woman is incidentally found to have BV and has no symptoms, discuss with the woman’s obstetrician whether treatment is appropriate. Oral metronidazole is the treatment of choice. High-dose regimens are not recommended during pregnancy. Intravaginal metronidazole gel or clindamycin cream are alternative choices if the woman prefers a topical treatment or is unable to tolerate oral metronidazole. Oral clindamycin is not widely recommended in primary care because of an increased risk of pseudomembranous colitis.
What are the most likely locations of ectopic pregnancy?
These are the various sites of ectopic pregnancy and their prevalence in % :
tubal ectopic: 93-97%
ampullary ectopic: most common ~70% of tubal ectopics and ~65% of all ectopics
isthmal ectopic: ~12% of tubal ectopics and ~11% of all ectopics
fimbrial ectopic: ~11% of tubal ectopics and ~10% of all ectopics
interstitial ectopic/cornual ectopic: 3-4%; also essentially a type of tubal ectopic
ovarian ectopic/ovarian pregnancy; 0.5-1%
cervical ectopic/cervical pregnancy; rare <1%
scar ectopic: site of previous Caesarian section scar; rare
abdominal ectopic: rare; ~1.4%
A 26-year-old woman presents to her general practitioner requesting contraception. She has a past medical history of severe Crohn’s disease. Her periods are regular with a 29 day interval and 5 days of bleeding. Her body mass index is 23kg/m² and she does not smoke.
Which of the following methods of contraception would it be most appropriate to prescribe?
Qliara (Dienogest with estradiol valerate)
Micronor (Norethisterone)
Microgynon 30 (Ethinylestradiol with levonorgestrel)
Cerazette (Desogestrel)
Evra transdermal patch (Ethinylestradiol with norelgestromin)
Oral contraceptives should be used with caution in patients with a history of inflammatory bowel disease affecting the small bowel due to the risk of malabsorption. There is no evidence to suggest that the efficacy of the Evra patch is reduced.
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?
1 month
6 weeks
6 months
12 months
Return to normal screening, every 3 years
This woman has been treated for cervical intraepithelial neoplasia (CIN) at her colposcopy appointment. She requires follow-up to determine if the lesion has been adequately treated. Women who have been treated for CIN II should be offered cervical screening at 6 months and 12 months post-treatment. This should then be followed by annual screening for a total of 10 years.
If a woman has a positive-test after treatment they should return to colposcopy.
A 30 year old type 2 diabetic presents to the diabetics clinic advising that she wishes to become pregnant. The patient normally has good glycaemic control and is currently being treated with metformin and gliclazide. What advice should you give her about potential changes to her medication during pregnancy?
Patient may continue on metformin but gliclazide must be stopped
Patient can continue on both medications
Patient may continue on gliclazide but metformin must be stopped
Both drugs must be stopped and the patient must be switched to insulin
Both drugs must be stopped and the patient must be switched to liraglutide
The correct answer is that the patient may be continued on metformin but that the gliclazide must be stopped. In the management of type 2 diabetes in pregnancy ‘women with pre-existing diabetes can be treated with metformin, either alone or in combination with insulin’. While it is likely that the patient will be required to switch to insulin it is not an absolute requirement. Both gliclazide and liraglutide are contraindicated in pregnancy.
A 30-year-old woman is 24 weeks pregnant and she receives a letter about her routine cervical smear. She asks her GP if she should make an appointment for her smear. All her smears in the past have been negative. What should the GP advise?
Reschedule the smear to occur at least 12 weeks post-delivery
Take the smear now
This smear can be missed, she will be re-entered for routine screening in 3 years
Perform a speculum exam to visualise the cervix for abnormalities
Seek advice of an obstetric consultant
NICE guidelines suggest that a woman who has been called for routine screening wait until 12 weeks post-partum for her cervical smear. If a smear has been abnormal in the past and a woman becomes pregnant then specialist advice should be sought. If a previous smear has been abnormal, a cervical smear can be performed mid-trimester as long as there is not a contra-indication, such as a low lying placenta.
A 25-year-old female comes to see her GP with a positive pregnancy test following a missed period. Given her last menstrual period it is estimated that she is 4-5 weeks pregnant. Although the news is unexpected, she is happy to continue with the pregnancy, however she is a known epileptic and is concerned about her medication.
Which of the following medications are recommended for epileptics in pregnancy?
Sodium valproate
Phenytoin
Lamotrigine
Primidone
Phenobarbitone
Anti-epileptics in pregnancy can be a tricky subject. Many are known to cause severe congenital defects (both structural and intellectual) and as such the first line of care is good contraceptive advice and planning with the patient in question. This is however, not always possible and there will always be cases where a patient becomes pregnant whilst on anti-epileptic medication prior to consulting with a doctor.
The recent MBRRACE-UK and the NICE clinical guidelines both state that most women with epilepsy and of child bearing age are currently prescribed lamotrigine and during pregnancy this may require a dose increase. Phenytoin, phenobarbitone and sodium valproate are all known to have an adverse effect on cognitive abilities and therefore are usually avoided unless absolutely necessary.
Lamotrigine, carbamazepine and levetiracetam are known to have the smallest effects on the developing foetus, however all epileptics who are either pregnant or are planning to become pregnant should be referred to specialist care as soon as possible.
A 35-year-old woman with no significant past medical history presents requesting contraception. She recently got married and says that she is likely to want to start trying for children with her husband in one year. She currently smokes between 15-20 cigarettes per day. Which of the following contraceptives would it be most appropriate to prescribe?
Mirena intrauterine device (Levonorgestrel)
Cerazette (Desogestrel)
Microgynon 30 (Ethinylestradiol with levonorgestrel)
Nexplanon implant (Etonogestrel)
Depo-provera injection (Medroxyprogesterone acetate)
Microgynon 30 would be contraindicated in this lady as she is over 35 years old and smokes >15 cigarettes per day. Depo-provera could be used, but can be associated with prolonged amenorrhoea up to 1 year after discontinuation, which would not suit this lady who wants to try for a family in 1 year. The insertion of both Mirena and Implanon and subsequent removal in the space of a year is likely to be more of a burden to this lady than taking an oral contraceptive over the same time period.
Cerazette, a progesterone only pill, is not contraindicated and can easily be stopped in 1 year.
Heterotropic pregnancy
describes a very rare situation in which there are simultaneous ectopic and uterine pregnancies. It is usually treated by surgical removal of the ectopic pregnancy.
Mx of VZV in pregnancy
If any doubt about previous chickenpox- urgently check Ab titres
If the pregnant womanm is not immune she should be given VZIG which is effective up to 10 days post exposure
Should be prescribed oral acyclovir if present within 24h of rash onset
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 shows a resting rate of 105 beats per minute and late decelerations. What is the most likely diagnosis?
Placental abruption
Bloody show
Placenta accreta
Vasa praevia
Placenta praevia
Vasa praevia describes a complication in which fetal blood vessels cross or run near the internal orifice of the uterus. The vessels can be easily compromised when supporting membranes rupture, leading to frank bleeding.
The classic triad of vasa praevia is rupture of membranes followed by painless vaginal bleeding and fetal bradycardia. Unlike placenta praevia, vasa praevia carries no major maternal risk but fetal mortality rates are significant. The two conditions may be difficult to distinguish in acute clinical situations, but for examination purposes a preceding rupture of membranes will usually be emphasised. Although ultrasound scans can detect vasa praevia, many cases are undetectable antenatally.
At her booking visit, a woman mentions to her midwife that she has been previously diagnosed with immune thrombocytopenic purpura (ITP). Which procedure carries the greatest risk of haemorrhage in the newborn?
External cephalic version
Forceps delivery
Prolonged ventouse delivery
Fetal blood sampling
Caesarean section
Immune thrombocytopenia (ITP) is an autoimmune condition that can occasionally complicate pregnancies, especially if there is placental passage of maternal antiplatelet antibodies.
The high pressure exerted by the vacuum during a ventouse delivery can cause bleeding in the neonate. Cephalohaematoma or more severely, subgaleal haemorrhage, can be exacerbated in the context of neonatal thrombocytopenia. Fetal blood sampling and forceps might be used with caution but would not be as high-risk. A Caesarean section would pose a greater risk to the mother, rather than the neonate.
A 26 year old woman with long standing hypertension gives birth to a healthy male child. The patient advises that she wishes to breastfeed the child but is concerned about the medication affecting the baby. Which of the following antihypertensive drugs would NOT be safe for the patient to use while breast feeding?
Losartan
Enalapril
Nifedipine
Labetalol
Atenolol
The correct answer is Losartan. Losartan is an ARB which are contraindicated in pregnancy unless absolutely essential and not recommended in breast feeding. The other options; Enalapril, Nifedipine, Labetalol and Atenolol are all safer in breast feeding.
A 24-week pregnant woman attends the early pregnancy unit as she has been told that her uterus is small for this date. On ultrasound she is found to have oligohydraminos.
Which of the following options is a cause of oligohydraminos?
Duodenal atresia
Microcephaly
Trisomy 21
Bartter’s syndrome
Renal agenesis
Oligohydraminos is a conditions where there is a deficiency of amniotic fluid during pregnancy. This can often present as smaller symphysiofundal height.
Renal agenesis is a cause of oligohydraminos (abnormally low volume of amniotic fluid) as the amniotic fluid is mainly derived from foetal urine
A primiparous 25-year-old woman is in labour. The midwife co-ordinating delivery contacts you as she is concerned that labour is not progressing. She has just examined the cervix and tells you that it is not dilating at a satisfactory rate. What is the minimum acceptable rate of cervical dilatation in the established first stage of labour?
4cm in 4 hours
2cm in 4 hours
2cm per hour
1.5cm per hour
1cm in 4 hours
NICE define delay in the established first stage of labour as:
Cervical dilatation of less than 2cm in 4 hours for first labours
Cervical dilatation of less than 2cm in 4 hours or a slowing in the progress of labour for second or subsequent labours.
A 36-year-old woman who used to inject heroin has recently been diagnosed HIV positive. She is offered a cervical smear during one of her first visits to the HIV clinic. How should she be followed-up as part of the cervical screening program?
Attend colposcopy annually
6 monthly cervical cytology
Cervical cytology every three years (normal screening program)
Annual cervical cytology
Attend colposcopy every three years
Women who are HIV positive are at an increased risk of cervical intra-epithelial neoplasia (CIN) and cervical cancer due to a decreased immune response and decreased clearance of the human papilloma virus. (1) HIV positive women who have low-grade lesions (CIN1) do not clear these lesions and these can progress to high-grade CIN or cervical cancer. Even those women who are effectively treated with antiretrovirals have a high risk of abnormal cytology and an increased risk of false-negative cytology. (1)
Women with HIV should be offered cervical cytology at diagnosis.. Cervical cytology should then be offered annually for screening.
A 13 week pregnant woman is diagnosed with bacterial vaginosis (BV) following high vaginal swab results, which were taken due to offensive vaginal discharge. She is otherwise clinically well and has no drug allergies. Which of the following treatments is recommended?
No treatment required
Amoxicillin
Doxycycline
Cefalexin
Metronidazole
BV is characterised by an overgrowth of mainly anaerobic organisms. It is a common cause of vaginal discharge and is not considered to be a sexually transmitted infection.
Approximately 50% of women are asymptomatic. When symptoms are present, BV is characterised by a fishy-smelling vaginal discharge.
Symptomatic BV in pregnancy is associated with late miscarriage and preterm delivery.
Treatment should be offered to all pregnant woman who are symptomatic. This consists of oral metronidazole 400mg twice daily for 5-7 days (2grams stat dose is not recommended in pregnancy).
Treatment is considered on a individual basis for pregnant woman with BV who are asymptomatic. This is because evidence suggests that identification and treatment of asymptomatic pregnant women does not lower the risk of preterm births.
A 22 year old woman attends the family planning clinic enquiring about contraception. She is currently taking carbamazepine for epilepsy and her BMI is 39 kg/m². She has no other past medical history. Which of the following would be the most suitable contraceptive to offer her?
Progesterone only pill (POP)
Copper intrauterine device
Combined oral contraceptive pill (COCP)
Progesterone injection (Depo-Provera)
Progesterone implant (Nexplanon)
All woman who are taking an enzyme-inducing drug (EID) (carbamazepine is an example of an EID) should be advised to use a reliable contraceptive that is unaffected by EIDs.
Examples of contraceptives that are unaffected by EIDs are:
Copper intrauterine device
Progesterone injection (Depo-provera)
Mirena intrauterine system
The copper intra-uterine device is usually the preferred option, as it is a non-hormonal method.
In the above scenario, the patient is obese with a BMI of 39 kg/m². Therefore, the contraceptive injection (Depo-Provera) would not be the most suitable option. This is because it is associated with weight gain (2-3kg over 1 year).
In patients on EIDs who wish to take the COCP (providing there are no contraindications) it is important to inform them that the effectiveness is decreased and there is an increased risk of pregnancy.
It is recommended that the dose of oestrogen is increased to 50mcg with no pill-free interval, or reduced to 4 days from 7 days (to reduce the chance of ovulation). In addition, barrier methods would also be advised. This applies when the patient is on an EID and for 4 weeks after stopping.
In patients on EIDs who wish to take the POP or progesterone implant, then additional barrier contraception would be required while using EIDs and for 4 weeks after stopping.
Note - rifampicin and rifabutin are potent EIDs and require longer periods of using barrier contraception after stopping (8 weeks).
If emergency contraception is required, the copper intra-uterine device is again the best option. If levonorgestrel (Levonelle) is used, then double the standard dose is recommended. Ulipristal acetate (ellaOne) is not recommended.
Nancy is a 29 year old lady who has given birth to a baby boy 3 days ago and is keen to discuss future contraception. She was previously on the combined pill but is keen to avoid using anything if she can. She is not breast-feeding. How long after giving birth does she not require any contraception?
Up to 28 days
She needs contraception immediately after giving birth
Up to 21 days
Up to 2 months
Up to 14 days
Prior to Day 21 postpartum no contraceptive methods are required. In non-breastfeeding
women, ovulation may occur as early as Day 28. As sperm can survive for up to 7 days in the
female genital tract, contraceptive protection is required from Day 21 onwards if pregnancy
is to be avoided.
A 17-year-old female comes to your GP clinic. She has recently travelled to Egypt to see her family, and now has come to visit as she is suffering with per vaginal bleeding and urinary incontinence.
She consents to examination with a chaperone present and you identify signs that suggest there have been recent trauma to the genitalia. You suspect this is a case of female genital mutilation.
What is the most appropriate course of action?
Report this to the police
Provide symptomatic treatment only
Refer to secondary care for further investigation
Contact child protection services
Call the family in for a discussion
Female genital mutilation (FGM) is a criminal act. The GMC has now issued guidance that all cases of FGM must be reported to the police in under 18s.
The mandatory duty does not apply in over 18s. It also does not apply if a doctor can identify that another doctor has already made a report to the police in connection with the same act of FGM.
Providing symptomatic treatment only would be in breach of GMC guidance and would put your registration at risk.
Calling in the family for discussion may not be appropriate and may lead to further distress for the patient. You would still need to make a police report.
Contacting child protection services may be an additional necessary step, but it is imperative that a police report is made in the first instance.
Referring to secondary care for investigation may be useful for treating any symptoms of FGM, but again a police report needs to be made.
Type 1 FGM
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
Type 2 FGM
Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Type 3 FGM
Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
Type 4 FGM
All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.
A 49-year-old lady with a background of hypertension and previous DVT after a flight to Australia comes to see you about hot flushes. They are severely interfering with her sleep and her work as a retail manager. She last had a period 4 months ago and her husband has had a vasectomy. Which of these treatments would you recommend?
Cyclical oestrogen with progesterone
Oestrogen patches
Mirena intrauterine system
Clonidine
Tibolone
For a woman with a personal or family history of thromboembolic disease, offer lifestyle advice or non-hormonal therapies. For vasomotor symptoms, consider a 2 week trial of Paroxetine/ Fluoxetine/ Citalopram/ Venlafaxine or a 24 week trial of Clonidine. If these measures are inadequate and the woman requires treatment, refer to a specialist in thrombophilia.
Vitamin recommendation in overweight women
Vitamin D
Obese women and 3rd stage of labour
Offer active third stage due to the higher risk of PPH
GDM cut offs in pregnancy
Impaired glucose tolerance 2hour glucose greater than or equal to 7.8
Diabetes random gluocse greater than or equaly to 7 or 2 hour glucose greater than or equal to 7.8
Soft systolic flow murmur audible across the praecordium
Phyisological, due to dilatation across the tricuspid vavle causing mild regurgitant flow.
Warfarin and trimesters
First trimester: highest risk of teratogenicity- fetal warfarin syndrome
Still exists in mid and third triemsters
Nasal hypoplasia
Vertebral calcinosis
Brachydactyly
Fetal warfarin syndrome
CTG vs maternal BP in eclamptic fit
Mother should have BP checked before fetal CTG as it is not possible to deliver the fetus until the mother is stable
22w, unwell with chorioamnionitis mx
Antibiotics
Induce labour
No steroids
Can cause mid-treimester loss, early meconium and preterm labour
Food-borne infection
Listeriosis
Blistering condition, presents with febrile illness and if untreated can lead to maternal and fetal death
Impetigo herpetiformis
A blistering condition that starts at the umbilicus and spreads
Pemphiogid gestationis
A rash of the trunk and upper limbs with abdominal sparing
Prurigo gestationis
Blood sugar reference rangs in pregancny around meals
Pre-meal: <5.5
1 hour post meal <7.8
