O&G Flashcards
Cord Prolapse types
Occult- alongside baby
Overt- cord below baby
Risk Fx for cord prolapse
What stops head being in pelvis?? Premature Breech Abnormal lie Polyhydramnosis Grand multifarious 5+ labours Placenta prévia Second twin artificial rupture of membranes
Managing cord prolapse
Relieve pressure with position and manually elevate
Bladder catheterise and fill to elevate baby head
Tocolytics to stop contractions
Squished and cooling so will vasospasm avoid!
Signs of cord prolapse
Feral decels on Ctg
Feral bradycardia
Risk fx shoulder dystocia
Maternal Induction of labour Bmi >30 Diabetes Previous SD Prolonged labour first or 2nd stage Instrumented Augmented (syntocinon)
Fetal
Macrosomia (>5kg c section. 4.5kg discuss.
Pelvis shape at risk of shoulder dystocia
Out of gynacoid, anthropoid, platypelloid, Android:
Platypelloid and anthropoid
Complications of shoulder maternal and fetal
Maternal:Perineal tear
Baby: Baby clavicle and thumb fx
Contusion
Brachial plexus injury
Major causes of postpartum haemorrhage
4 T
Tone- uterine atony
Trauma- lower genital tract lac, anal sphincter injury
Tissue/ retained placenta
Thrombin- coagulopathy
Time for secondary PPH
24h-6weeks
Mx PPH
Help A-E Treat cause If trauma compress Tissue remove and check clots Thrombin give products Tone bimanual compression and uterotonics
Causes of retained placenta
Uterine atony
Multiple pregnancy
Placenta accrete
Amniotic fluid embolisation risks
Oxytocin C section AVB Stillbirth Polygydramnosis None ...
Signs amniotic fluid embolism
Tachy hypertensive fluid overloaded (cough, pulmonary oedema)
Maternal collapse (left lateral displacement)
How many mls a min does perimortem c section give mum
500ml a minute!!
Positioning in shoulder dystocia
McRoberts will already be in lithotomy
Which maternal conditions is ergometrine used in active management of 3rd stage labour
Severe hypertension
Severe cardiac disease
Manoeuvres in SD
Axial traction sideways
Delivery 6o clock posterior arm
Active management of 3rd stage vs 60mins definition of retained placenta
30mins if active 60mins if not
If woman needs transferred during cord prolapse what position
Left tilt in ambulance
All 4s is best when still
Cut off time by CS after CPR
4mins after collapse baby 5-6 mins after commenced CPR
Induction of labour
Augmentation
Use oxytocin
Start labour
Slow: 1:10 slow progress - give hormone
Terbutaline
Use if wait for theatre in cord prolapse
Delay contractions
Medical promotion of uterine contraction
Syntocinon
Ergometrine
Carboprost
Misoprostol
Reversible causes of collapse in pregnancy
Hypoxia hypothermia hyperkalaemia hypokalaemia hypovlycaemia
Toxin tension tamponade thrombus
Eclampsia (Mg toxicity) and ICH
Amniotic fluid embolism
Ie more bleeding risk and relative hypovolaemia
Peripartum cardiomyopathy, MI, aortic dissection
PE and other emboli
Suicide
Ccx of pre eclampsia
ICH Placental abruption and DIC Eclampsia HELLP Renal failure Pulmonary oedema Acute respiratory arrest
Fetal Ccx pre eclampsia
IU growth restriction Oligohydrannios Hypoxia due to placenta insufficiency Placental abruption Premature
Management of hypertension
Moderate BP 150-160 oral labetolol
Severe >180 oral/iv labetolol oral nifedipine
IV hydralzine
High dependency check BP every 15mins/30mins
Management eclamptic seizure
Left lateral position uterus
O2
Iv
Mg sulfate 4g in 5min to load
Reduce cerebral vasospasm
If severe and birth is planned or after fit
Continue for 24h
Why monitor urine output following MGSO4 in eclampsia
Renal excretion and risk of toxicity in oliguria
What to monitor when giving MGSO4
Urine out
Deep tendon reflexes
Hrly RE
INDICATE TOXICITY -> arrest
Managing MGSO4 toxicity
AE
STOP IT
IV calcium gluconaye 10ml 10%
Tube and ventilate
Signs of pre eclampsia
Severe HA
Epigastric pain
BP and Urine
Contraindications for LMWH
Vw disease
Severe liver disease
Severe renal disease (egfr <30 as its Renal elimination)
Sx of uterine fibroids
Heavy menstrual bleed Abdo swelling Pressure Subfertile Difficult pregnancy (miscarriage and red degeneration) Pain = Tortion
? Mass
Signs of PID
Pyrex > 38C Abdo distension and tender RUQ? Suggests peri hepatic inflam = Fitz-Hugh-Curtis Rebound and guarding Discharge on speculum Tender VA
Ix PID
Iron Bhcg FBC CRP MSU Swabs TVU (tubo ovarian abscess) Laparoscopy
Rx PID
Empirical ABx
Cef 500mg IM stay then oral doxy 100mg bD + metronidazole 400mg
Can give oral oflox
Pain relief
Refer GU med
Diagnosis ovarian cyst
US
CA125 CEA hCG aFP
Rx ovarian cyst
<6cm and no Sx can conservatively manage ?Ca125 and scan
> 6cm remove
Types of ovarian cyst
1: Functional
Sx endometriosis and diagnosis
Dysmenorrhoea
Dysparenuria
Pelvic pain
Sun fertile
Fixed tender retroverted uterus
TVU CA125 often up lap + biopsy
Rx endometriosis
Conservative
NSAID Progesterone COCP Mirena
GnRH analogue prior to surgery
Can cauterise may need cystectomy
Ovarian Cyst accidents and Ix
Tortion
Rupture
Haemorrhage
Infection
bhCG MSU FBC CRP CA125
TV US
Pathophys of HPV and cancer
Subtype 16 and 18
Enters cell and release proteins E6 and E7
Keep it in the cell and then bind p53 and Rb
Leaves cells open to unchecked proliferation
Interferes at the transitional zone leading to CIN and SCC
HPV vaccine schedule
2 injections or 3 if delayed to 15
GARDISAL covers 6,11,16 and 18
Protects against cervical vulval anal and warts
12-13 years
Ix if abnormal cervix on visualisation
Punch biopsy and large loop excision of transformation zone (LLETZ)
Refer
Colposcopy
Cervical cancer appearance
Acetowhite
Punctated
Mosaic
Abn vessels
Rx CIN
Cold coagulation / cryotherapy
LLETZ laser excise
Sx cervical cancer
Unscheduled bleeding
Offensive discharge
Obstructive uropaphy
Supraclav node
Staging cervical ca
FIGO
Includes examination under anaesthesia (bimanual/PR)
MRI
Sizing stage 1
Stage 2 involvement of upper vaginal 11b = parametrium
III: lower 1/3 vagina b= pelvic wall/hydronephrosis
IV: spread
Treatment options cervical cancer
LLETZ
Trachectomy
HYSTERECTOMY ? Nodes
Radical hysterectomy stage 1b and 2a
Chemorad /NACT
May need urostomy
Risk fx vulval cancer
Smoking HPV ALTERRED IMMUNE Age Lichen sclerosis
Types Vulval cancer
Most SCC
Also adeno/melanoma/BCC etc
Types of vulval cancer and histology
Usual (thick, high nuclear to cytoplasm, mitotic figures)
Warty (multinucleate cells, koliocytes
Basaloid (less differentiated and high N:C)
Differentiated (enlarged keratinocytes thick epidermis)
Sx VIN
Pruritis Pain Ulcer Leukoplakia Lump ASx Labia majora, minora and posterior fourchette
Rx VIN
Surgery - radial? Laser?
Ablation- chemo (imiquimod)
Laser
Photodynamic
Complications o inguinofemoral lymphadenectomy
Wound breakdown increase
Cellulitis / erisipalis
Male factors in subfertility
AZOO:
1- Obstructive azoospermia - not getting into ejaculate ?CF
2- NON OBSTRUCTIVE (testicular failure or small volume ?XXY
3- no spermatic Emed is in hypogonadotrophic hypogonadism
Female factors in subfertility
1- Ovulatory
Regular cycle? Check mid luteal pg day 21
Amenorrhoea- HPG (HP failure rate ?tumoir ?BMI)
HP dysfunction (PCOS, prolactin up, thyroid)
Fertilisation
Implantation
Rx PCOS
BMi
Clomifene (SERM)
Letrozole (aromatise inhibitor)
Metformin
Ovarian drilling
ART
Ix incontinance
Abdo and bimanual Vaginal inspection (bivalve, speculum, ?prolapse ?atrophy ? Fistula ? Ulcer Cough - leak?
Urine dip and culture
Bladder diary
Cystoscope and renal imaging
Urodynamic in those with failed conservative, before surgery, rx complications
Manage incontinance
Lifestyle, PR, bladder retrain ABx Anticholinergics (oxybutanin, solfenacin B3 agonist Duloxetine
Surgery - sling, colposuspension,
Side fx anticholinergics
Dry mouth eyes and constipation
Components of a partogram
Dilation Descent in relation to ischial spines Frequency on contractions Status of membranes and ?blood/meconium Drugs and fluids Maternal HR Baby HR
Indicators of a problem on partogram
Alert and action
What does progression of labour depend on?
Power
Passenger
Passage
Management of failure to progress
Artificial rupture of membranes
Oxytocin infusion
Instrument delivery
C section
Fetal varicella syndrome
Skin scar eye defect limb hypoplasia neuro (microcephaly cortical atrophy mental restriction)
Pep for newborn drug
Zidovudine within 4h birth for 4 weeks. Avoid breastfeeding risk 5-20%.
Antenatal and postnatal findings haemolytic disease of newborn
Ante: polyhydramnios, thick placenta, hydrops (subcut oedema, pleural and pericardial effusion, ascites, hepatosplenomegaly), death
Post: jaundice, hepatosplenomrgaly, kernicterus, hypoglycaemia
Pathology of maternal rhesus-ve group +ve fetus
Maternal IgG crosses placenta and destroys fetal RBC
Preventing rhesus disease
Blood transfusion
AntiD prophylaxis
When is AntiD required
After ectopic After molar After termination <12 week vaginal bleed which is heavy <12 week medical or surgical management of miscarriage Sensitising event post 12 week
After delivery testing of infant cord and mat blood
Derm disease in pregnancy
Acne Psoriasis Infection (candida, varicella, warts) Atopic eruption AI (SLE, pemphigus)- pemphigus gestationis Obstetric cholestasis
Atopic eruption of pregnancy types and appearance
Exzematous- rough and red. Face, neck and creases.
Prurigo- bumps widespread
Manage atopic eruption of pregnancy
Aqueous cream Topic steroid Antihis Narrow band UVB ORAL steroids
Polymorphic eruption of pregnancy site and rx
Lower abdomen and striae. Umbilical soaring.
Self care, emollient, moderate topical CS, antihis for sleep (itch ie chlorphenamine
Risks of pemphagoid gestationis
Fetal growth restrict
Blistering of inane
Secondary infection
Due to IgG binding BM
Polyhydramnios clinical suspicious
Large for dates
Tense abdomen
Unable to feel foetal pets
Amniotic fluid index >90th centiles by measuring single deepest vertical pool
Risks and associations of polyhydramnios
Placental abruption Malpresentation Cord prolapse Large for dates C section PPH Premature Perinatal death
Associations with oligonydramnios
Poor outcome Prolonged pregnancy Ruptured membranes IUGR Fetal renal congenital abnormalities Hypoxia in cord compression
Risk fx for gestational diabetes
FHx
BMI >30
Previous macrosomic baby
Previous GDM
Pro pregnancy hormones and factors vs pro labour
Preg: progesterone, NO, catecholamines, relaxin
Labour: oestrogen, oxytocin, PGs (promote cervical ripening and uterine contractility from COX -> arachnidonic acid) , CRH, inflam mediators (IL8, TNfa, IL6 -> pro inflammatory TF and cervical ripening)
Cervical ripening
Cervix softens and effaces
PG increase this by inhibiting Collagen synthesis and stimulating collagenase (via fibroblasts) to break down the collagen in the cervix
Bishop score
Cervical ripening
Induction of labour- methods
Unfavourable bishop score <=6 PGs (PGE2 gel in posterior forbid). Artificial rupture when score >6. Can cause GI upset.
Favourable ARM and syntocinon with CTG
Pain relief in labour
Mat support (less analgesia) Environmental (music mobilisation) Birth pool Education Inh analgesic entonox Systemic opioid diamorphine with antiemetic unless delivery within 4h Pidendal analgesia Regional (epidural can prolong 2nd stage and incidence of instrumental delivery; spinal for theatre pt General
Puerperal Pyrexia
Usually genital tract ie endometritis or UTI
?breast
?DVT
MSSU and swabs
Management genital warts
Podophyllotoxin caution in pregnancy
Imiquimod
Cryotherapy
Leave 12/12
Smelling discharge
Bacterial vaginitis
Bacterial vaginosis
Reduced lactobacilli and more Gardenerella vsginalis
Alkaline discharge smell worse after sex as more alkaline!!!
Associated with preterm labour
Ix: vagina wall pH swab alkaline />4.5 with Amsels criteria
DDx: candida (itch)/ trichimonas (discomfort)
Rx: metronidazole 5d (no alcohol)
Trichomonas
Flagellated protozoan
30% have co-infection with gonorrhoea and chlamydia
Detrimental to pregnancy
Malodorous discharge and dysparenuria
Unprotected anal and oral intercourses male male
CT/NG NAAT throat rectum and urine
Rx gonorrhoea
Ceftriaxone
Candida
Sx: itch, pain, discharge, dysparenuria
Swelling, fissure, discharge, vulvovaginitis
Rx- clotrimazole pessary and ? Fluxonazole tablet unless risk of pregnancy (pessary)
Tertiary syphilis
Gummma
CV
neuro
Post chacre … rash (2ary)
Clinical indicators HIV
Thrombocytopenia CIN2 Recurrent shingles Recurrent bac pneumonia Dementia STI
When to not medically manage ectopic
HD unstable >3.5cm Pain ++ Intrauterine pregnancy Can’t be followed up post methotrexate
Choice 1500-5000 with no pain, Unruptured, smaller than 35mm, no heartbeat, no intrauterine
Give anti D Ig if R-ve
Rx PPROM
Ix = FBC and CRP USS CTG Doppler Rx= steroids, erythromycin 10d/till delivery (whatever is sooner)
Complications of PPROM
Mat
Fetal
