OB/GYN Flashcards
pre eclampsia definition
new HTN in pregnancy after 20 weeks gestation
pathology pre eclampsia
endothelial cell damage and vasospasm, which can affect the foetus and almost all matenal organs
mild PE
moderate PE
severe PE
Mild = proteinuria and mild/moderate HTN
Moderate = proteinuria and 160/110
Severe = proteinuria and any HTN before 34 weeks or with maternal compliocations
Early and late PE
Early = <34 weeks
Late = >34 weeks
features PE
Headache
Epi pain
Visual disturbances
Oedema
None until later stage
Maternal compliations PE
Eclampsia
CVAs
liver/renal failure
HELLP
Pulmonary oedema
Foetal complications PE
FGR
Abruption
Foetal morbidity and mortality
Pre ec prevention
Aspirin if <16 weeks and increased risk
Threatened miscarriage
Bleeding but foetus still alive, Os closed
Inevitable miscarriage
heavy bleeding, cervical os open
Incomplete miscarriage
some foetal parts passed
Complete miscarriage
all foetal tissue passed
Septic miscarriage
contents of uterus infected
Missed miscarriage
Foetus has not developed or has died but not recognised until bleeding occurs
Endometriosis definition
Presence and growth of tissue similar to endometrium outisde the uterus
RF endometriosis
Nulliparous
White
FHx
Reproductive age group
Retrograde menstruation
S+S endometriosis
Cyclical pelvic pain
Dysmennorhoea
Deep dyspareunia
Subfertility
Dyschezia
Tenderness/thickeneing behind uterus or adnexa
Ix endometriosis
Laparoscopy
Transvaginal USS
MRI if deeply infiltrating
Mx endometriosis
Pain relief
The pill
GnRH agonists
Mirena coil
Laparoscopic surgery
Hysterectomy
Aetiology endometrial cancer
Obesity
T2DM
Nulliparity
Late menopause
Oestrogen only HRT
Unopposed oestrogen
S+S endometrial cancer
Post menopausal bleeding
Abnormal bleeding
Abnormal discharge
Haematuria
Anaemia
Ix endometrial cancer
Transvaginal USS
Endometrial biopsy
Hysteroscopy
Mx endometrial caner
Surgery = hysterectomy +/- pelvic LN
Radiotherapy = adjuvant
Progesterone therapy
Cervical cancer aetiology
High risk HPV
Vulval cancer sx
itching and soreness
Persistent lump
Bleeding
Pain on passing urine
Ovarian cancer presentation
No Sx
Bloating/IBS
Abdo pain/discomfort
Change in bowel habit
Urinary frequency
Bowel obstruction
Obstetric cholestasis
Characterised by otherwise unexplained pruritus and abnormal LFTs +/- raised bile acids
Obstetric cholestasis causes/RF
later pregancy (28 weeks)
Increased oest and prog levels
genetics
South Asian
Hep C
Multiple preg
OC previously
Gallstones
Obsetric cholestasis presentation
Pruritus (palms and soles)
Fatigue
Dark urine
Pale greasy stools
Jaundice
Complications OC
Sudden stillbirth
Meconium passage
PPH
OC Ix
LFTs
Bile acids
Rise in ALP with no other abnormal LFTs = placental production
Mx OC
Ursodeoxycholic acid (UCDA)
Emollients
Antihistamines
Vitamin K 10mg/day from 36 weeks
LFTs weekly and 10 days after delivery
Gestational diabetes definition
Carbohydrate intolerance diagnosed in pregnancy which may or may not resolve after pregnancy
Complications GDM
Large for date foetus
Macrosomia
Shoulder dystocia
Congenital abnormalities
Polyhydramnios
Neonatal hypoglycaemia
RF GDM
Previous GDM
Previous macrosomic baby
BMI >30
Ethnic origin
FHX diabetes (1st degree)
When to screen for GDM
OGTT 24-28 weeks gestation
In morning after fasting = drink 75g glucose
Normal results are <5.6mmol/l fasting and <7.8mmol/l at 2 hours
GDM Mx
4 weekly USS from 28 - 36W
Fasting glucose <7, trial diet and exercise then met then insulin
Above 7 metformin
above 6 plus macrosomia start insulin and metformin
Delivery 37-39W
* 1st line
Diet management
* 2nd line
If targets not met with 1st line after 1-2 weeks, offer metformin (insulin if contraindicated)
Insulin if pre-meal glucose >6 OR 1hr post-prandial glucose >7.5
* 3rd line
Targets not met with 1+2 then add insulin
* Fasting glucose 6-6.9 and complications
Immediate insulin +/- metformin and die
Targets for GDM blood sugars
Fasting 5.3
1h after meal 7.8
2h after meal 6.4
Pre existing DM
Folic acid pre pregnancy
Sliding scale needed in delivery
Planned delivery
Retinopathy screening
Shoulder dystocia
Anterior shoulder of baby becomes stuck behind the pubic symphysis of the pelvis
Causes of shoulder dystocia
Macrosomia secondary to GDM
Previous dystocia
Obesity
Presentation dystocia
Failure of restitution
Turtle neck sign
Mx dystocia
McRoberts manoeuvre = hyperflexion of hips
Suprapubic pressuer
Episiostomy
Rubins = reach into vagina put presure on anterior shpilder
wood screw = rotate baby
Dystocia complications
Foetal hypoxia (cerebal palsy)
Brachila plexus injury and bells palsy
Perineal tears
PPH
HTN meds that should be stopped in pregnancy
- ACEi
- Angiotensin receptor blockers
- Thiazide diuretics
HTN meds safe in pregnancy
- Labetalol
- CCB
- Alpha blockers
What can undertreated or untreated hypothyroidism in pregnancy cause
- Miscarriage
- Anaemia
- Small for gestational age
- Pre-eclampsia
Dose of levothyroxine in pregnancy
- Needs to be increased by 25-50mcg (30-50%)
- Titrated based on TSH level = measured every 6 weeks
- TSH lowers in pregnancy which is why dose increased
Safe epilepsy drugs
- Levetiracetam, lamotrigine, carbamazepine
- SV avoid
- Phenytoin avoid (cleft)
What is vasa praevia
- Foetal blood vessels run in the membranes in front of the presenting part
- Vessels are placed over internal cervical os, before the foetus. therefore outside the protection of the cord or placenta
Vasa praevia presentation
- Painless, moderate vaginal bleeding at the rupture of the membranes
- Severe foetal distress
- USS
- Antepartum haemorrhage
- DVE = pulsating foetal vessels seen in membranes through dilated cervix
VP management
- Immediate C section
- Asymptomatic - corticosteroids 32 weeks, elective CS
Type 1 and 2 VP
- Type 1 = foetal vessels are exposed as a velamentous umbilical cord
- Type 2 = foetal vessels are exposed as they travel to an accessory placental lobe
When induction is offered
- Prelabour ROM
- Foetal growth restriction
- Pre eclampsia
- Obstetric cholestasis
- DM
- IUFD
- Bishop score 8 or more
Prostaglandin induction
- PGE2 inserted into vagina
- Stimulated cervix and uterus to cause osnet of labour
Amniotomy +/- oxytocin
- ARM then oxytocin infusion started within 2 hours if labour not ensued
CRB
- Silicone balloon insetred into cervix and gently inflated to dilate
Why incidence of VTE is increased in pregnancy
- Blood clotting factors are increased
- Fibrinolytic activity reduced
- Blood flow altered
- Stagnation of blood and hypercoagulable states
RF VTE in pregnancy
- Smoking
- Parity >3
- Age >35
- BMI >30
- Reduced mobility
- Multiple pregnancy
- Pre ec
- Varicose veins
- FHx
- Immobility
- IVF
Pulmonary embolus
- Chest pain and dyspnoea
- Tachy, raised RR and JVP
- CXR, ABG and CT
- CTPA or VQ
Prophylaxis DVT/PE
- from 28 weeks if 3 RF
- 1st trimester if 4+ RF
- LMWH continued throughout antenatal and for 6 weeks post
- Temporarily stopped in labour
- Mechanical if contraindicated LMWH = pneumatic compression, anti-embolism stockings
DVT
- Unilateral
- Calf swelling
- Dilated superficial veins
- Tender calf
- Oedema
- Colour change
- Ix = doppler USS
Mx VTE
- LMWH started immediately, before confirming diagnosis
- Massive PE and haemodynamic compromise = unfractioned heparin, thrombolysis, surgical embolectomy
Risks of UTI in pregancy
- Preterm delivery
- Low birth weight
- Pre ec
Asymptomatic bacteriuria
- Bacteria in urine with no Sx
- Tested routinely throughout pregnancy
UTI S+S
Lower
- Dysuria
- Suprapubic pain
- Frequency
- Urgency
- Haematuria
Pyelo
- Fever
- Loin, suprapubic or back pain
- Vomiting
- Haematuria
- Renal angle
Urine dipstick
- Nitrites
- Leukocytes
- Nitrites
Causes of UTI
- E coli most common
- Klebsiella
Mx UTI
- 7 days abx
- Nitrofurantoin (avoid in 3rd trimester)
- Amoxicillin
- Cefalexin
- Trimethoprim avoid in early pregnancy
Cord prolapse
- After rupture of membranes, UC descends below presenting part
RF cord prolapse
- Preterm labour
- Breech
- Polyydramnios
- Abnormal lie
- Twins
- amniotomy
Mx cord prolapse
- Pushed up by finger
- Tocolytics can be given (terbutaline)
- All fours
- Immediate CS
Uterine rupture
- Muscle layer of uterus (myometrium) ruptures
- Incomplete = perimetrium remains intact
- Complete = perimetrium ruptures and contents of uterus released into peritoneal cavity
FR uterine rupture
- Previous CS = scar is a point of weakness
- Previous surgery
- BMI
- Parity
- Age
- Induction
Rupture presentation
- Acutely unwell mother
- Abnormal CTG
Rupture Mx
- Maternal resuscitation with fluids and blood required
- Emergency CS
- Repair or removal of uterus
Uterine inversion
- Fundus inverts into uterine cavity
- Haemorrhage, pain and shock
- Brief attempt to push fundus up into vagina
- Replacement with hydrostatic pressure run past a clenched fist at the introitus into the vagina
Rubella in pregnancy
- Congenital rubella syndrome caused by maternal infection
- Pregnant women should not be given MMR vaccine as it is live = need before or after
Features of rubella syndrome - Congenital deafness
- Congenital cataracts
- Congenital heart disease
- Learning disability
Chickenpox/VZV
- Foetal varicella syndrome = growth restriction, microcephaly, scars, hypoplasia
- Severe neonatal varicella infection
- Treat with IV varicella immunoglobulins
Features of congenital CMV
- Growth restriction
- Microcephaly
- Hearing loss
- Vision loss
- LD
- Seizures
Triad of features of congenital toxoplasmosis
- Intracranial calcification
- Hydrocephalus
- Chorioretinitis
Complications of parovirus in pregnancy
- Miscarriage
- Severe foetal anaemia
- Hydrops fetalis
- Maternal pre ec like syndrome
Congenital zika syndrome
Microcephaly
Foetal growth restriction
Ventriculomegaly
HSV in pregnancy
- Neonatal infection rare but high mortality
- Vertical transmission at delivery
- CS recommended
- Exposed neonates given acyclovir
Neonatal effects HIV
- Stillbirth
- Pre ec
- Growth restriction
- Prematurity
- Vertical transmission
Group B strep
- Causes severe illness
- Vertical transmission can be prevented by high dose IV penicillin throughout labour
- RF = previous, positive culture, preterm labour, ROM >18hrs, maternal fever
Toxoplasmosis
- Causes LD, convulsions, spasticity’s and vision issues
- Spiramycin started
- Vertical transmission confirmed = pyrimethamine and sulfadiazine with folinic acid
Grounds for TOP
A = continuing would risk life of woman more
B = necessary to prevent permanent injury to physical or mental health
C = not exceeded its 24th week and continuance would be greater risk
D = not exceeded 24th week and continuance would be greater to children
E = risk that if child would suffer physical or mental abnormalities as to be seriously handicapped
Legal requirements for TOP
- 2 registered medical practitioners
- Registered practitioner in an NHS or approved hospital
Medical TOP
- Mifepristone = anti-progestogen = halts pregnancy and relaxes cervix
- Misoprostol = prostaglandin analogue = binds to prostaglandin receptors and activates them = soften cervix and stimulate contractions
- Used together mif then miso 36-48hrs later
- Rh -ve women should have anti D 10 w or above
Surgical TOP
- Cervix prepared first = misoprostol, mifepristone or osmotic dilators
- Dilation and suction
- Dilation and forcep evacuation
Complications TOP
- Haemorrhage
- Infection
- Uterine perforation
- Cervical trauma
Adenomyosis definition
Presence of endometrial tissue inside the myometrium
- Associated with endometriosis and fibroids
Adenomyosis S+S
Painful heavy periods, regular
Dyspareunia
1/3 asymptomatic
Exam = uterus mildly enlarged and tender
Adenomyosis Ix
- TVUSS
- MRI
Adenomyosis Mx
No contraception wanted
- TXA when no associated pain
- Mefenamic acid when associated pain
Contraception
- Mirena coil
- COP
- Progesterone’s
Atrophic vaginitis
- Dryness and atrophy of the vaginal mucosa related to lack of oestrogen
- Occurs in women entering menopause = oestrogen falls and mucosa is thinner, less elastic, dry
AV S+S
- Itching and dryness
- Dyspareunia
- Bleeding due to localised inflammation
Exam - Pale mucosa
- Thin skin
- Reduced folds
- Erythema and inflammation
- Dryness
- Sparse pubic hair
AV Mx
- Lubricant
- Topical oestrogen
Causes of infertility
- Ovulation issues
- Male factor problems
- Sperm unable to reach egg = tubal, coital, cervical
- Implantation
General advice for fertility
- 400mcg folic acid a day
- Health = BMI, smoking, alcohol
- Intercourse every 2-3 days
Primary care Ix infertility
- BMI
- Chlamydia screen
- Semen analysis
- Female hormone testing
- Rubella immunity
Missing 1 pill when the pill is >24hrs late
<72hrs since last pill was taken
- Take missed pill ASAP even if 2 in 1 day
- No extra protection needed
Missing >1 pill (>72hrs since last pill)
- take most recent pill ASAP
- Additional contraception for 7 days
- if days 1-7 emergency contraception
- 8-14 no emergency contraception
- 15-21 no emergency contraception and back to back
