OBG Flashcards
What may be the features of a uterus on examination in adenomyosis?
classically ‘boggy/bulky’ most likely to be tender
How is a diagnosis of adenomyosis made?
US +- MRI
What are 5 treatment options in adenomyosis if patient wishes to remain fertile?
- NSAIDs
- Hormonal therapies - OCPs, IUS, danazol, aromatase inhibitors
- MRI/US guided high-intensity US thermo-ablation
- Uterine artery embolisation
- adenomyomectomy surgery
What are 2 options for adenomyosis treatment in women who do not wish to preserve fertility?
- endometrial ablation
- hysterectomy
What is the most common non-obstetric surgical emergency in pregnancy?
appendicitis
How may the presentation of appendicitis differ in pregnancy?
most often close to McBurney point BUT can move cephalad e.g. R flank / RUQ; tenderness may be less prominent as uterus lifts abdo wall away; classically
* 1st trimester: pain RLQ
* 2nd trimester: umbilicus
* 3rd trimester: RUQ
What 3 things should be done in all cases of suspected ectopic pregnancy?
- admit as emergency
- if confirmed - anti-rhesus D prophylaxis
- manage it: expectantly, medically or surgically
What are the expectant vs medical vs surgical management of ectopic pregnancy?
- expectant: admit and observe 48h (if low risk, low bHCG and no pain)
- medical: methotrexate
- surgical: laparoscopic approach preferred -> salpingectomy (salpingotomy i.e. keep the tube if RFs for reduced fertility)
What are 10 indications for anti-D treatment in Rh D negative women?
- delivery of Rhesus +ve infant (live or stillborn)
- spontaneous miscarriage if followed by medical or surgical evacuation
- spontaneous complete miscarriage >12 weeks
- threatened miscarriage >12 weeks
- ectopic pregnancy managed surgically
- external cephalic version
- antepartum haemorrhage
- amniocentesis, CVS, fetal blood samplling
- abdo trauma
- having surgical or medical termination of pregnancy (unless have Abs) [ANY TOP]
What are 9 physiological changes of pregnancy?
- Rise in prolactin
- Rise in plasma volume by 50%
- Hb drops (dilution)
- WCC, platelets, ESR rise
- Cardiac output increases (increased stroke volume + HR)
- Urinary frequency increases - increased pressure on bladder and GFR
- BP drops during 2nd trimester, increases to normal third
- Ventilation and tidal volume increase
- Chloasma and scalp hair loss
What are 2 basic investigations to perform for infertility?
- Semen analysis
- Serum progesterone 7 days before menstruation (day 21 of 28 day cycle)
How is serum progesterone acted on in infertility?
<16 repeat, if consistently low refer to specialist
16-30 repeat
>30 indicates ovulation
What is the commonest type of ovarian cancer?
epithelial (90%) - 70-80% of cases = serous carcinoma
In addition to ovarian cancer what are 4 things that can cause a raised CA125?
- endometriosis
- benign ovarian cysts
- menstruation
At what threshold should US be organised based on CA125?
CA125 >35
What is the treatment for ovarian cancer?
combination of surgery and platinum based chemotherapy
What antiemetic is recommended first line for nausea/vomiting in pregnancy?
promethazine (ginger and acupuncture to p6 [wrist] also noted)
At what point after giving birth do women require contraception?
Day 21
What is the guidance for POP use after giving birth?
Can be started any time; additional contraception should be used for first 2 days after day 21
How long may it take for fertility to return after Depo Provera (medroxyprogesterone acetate) injections are stopped?
12 months
What is the main mechanism of action of Depo Provera?
Inhibition of ovulation (also cervical mucus thickening and endometrial thinning)
Which antibiotic drugs are safe to give mothers who are breastfeeding?
- penicillins
- trimethoprim
- cephalosporins
Which antibiotics are contraindicated in mothers who are breastfeeding?
- ciprofloxacin
- tetracyclines
- sulphonamides
- chloramphenicol
What are 9 additional drugs that should be avoided in breastfeeding mothers (as well as certain antibiotics)?
- amiodarone
- aspirin
- benzodiazepines
- carbimazole
- clozapine
- cytotoxic drugs
- lithium
- methotrexate
- sulphonylureas
What are 2 endocrine drugs safe in breastfeeding?
- glucocorticoids (lower doses)
- levothyroxine
What are 2 AEDs safe for breastfeeding?
- valproate
- carbamazepine
What psychiatric medications can be given in breastfeeding mothers?
- tricyclic antidepressants
- antipsychotics (not clozapine)
Which anticoagulants can be given in breastfeeding mothers?
Warfarin & heparin
What is the management of premature ovarian insufficiency?
Combined HRT or COCP until age 51
What is the definition of premature ovarian insufficiency?
Onset of menopausal symptoms and raised gonadotropin levels aged < 40 years
What are 7 causes of premature menopause?
- idiopathic
- bilateral oophorectomy (also hysterectomy with preservation of ovaries)
- radiotherapy
- chemotherapy
- infection e.g. mumps
- autoimmune disorders
- resistant ovary syndrome - due to FSH receptor abnormalities
What blood tests are required to diagnose premature ovarian insufficiency?
Elevated FSH/LH levels e.g. FSH >40 - raised FSH needs to be demonstrated on 2 blood tests 4-6 weeks apart
Low oestradiol <100
What is pre-menstrual syndrome?
symptoms during luteal phase (for the ~2 weeks before period starts) - mood swings, trouble sleeping, anxiety, bloating, breast tenderness, headaches
What is the treatment for pre-menstrual syndrome?
COCP (also cyclic or continuous antidepressants, CBT, dietary supplements)
first line is lifestyle advice
What is the first line treatment for menorrhagia?
LNG-IUS if require contraception, mefenamic acid or TXA if not
What is the primary mechanism of action of COCP?
inhibits ovulation by acting on HPA to suppress LH and FSH
What is the primary mechanism of action of the POP (apart from desogestrel)?
thickens cervical mucus
What is the primary mechanism of the implantable contraceptive (etonogestrel)?
inhibits ovulation (also thickens cervical mucus)
What is the primary mechanism of action of the intrauterine contraceptive device?
decreases sperm motility and survival
What is the primary mechanism of action of the intrauterine system (IUS)?
prevents endometrial proliferation (also thickens cervical mucus)
What are the phases of the menstrual cycle?
- menstruation: days 1-4
- follicular phase (proliferative phase): days 5-13
- ovulation: day 14
- luteal phase (secretory phase): days 15-28
What is going on in terms of ovarian histology during the follicular (proliferative) phase?
A number of follicles develop, one of which will become dominant around the mid-follicular phase
What is the ovarian histology during the luteal (secretory) phase?
Corpus luteum
What happens to endometrial histology during the follicular (proliferative) phase?
endometrial proliferation
What happens to endometrial histology during the luteal (secretory) phase?
endometrium changes to secretory lining under the influence of progesterone
What happens to homrone levels during the follicular (proliferative) phase?
- Rise in FSH - results in development of follicles
- Follicles secrete oestroadiol
- When egg matured, secretes enough oestradiol to trigger acute release of LH which leads to ovulation
What happens to hormone levels during the luteal (secretory) phase?
- progesterone is secreted by the corpus luteum, rises throughout this phase
- if feritlisation doesn’t occur - coprus luteum degenerates, progesterone levels fall
- oestradiol levels also rise again during this phase
What happens to cervical mucus during the follicular (proliferative) phase?
Following menstruation, it is thick and forms a plug across the external os; just prior to ovulation, it becomes clear, aceullular and low viscosity, stretchy (spinnbarkeit)
What happens to cervical mucus during the luteal (secretory) phase?
thick, scant and tacky
What happens to basal body temperature during the follicular (proliferative) phase?
falls prior to ovulation due to influence of oestradiol
What happens to basal body temperature during the secretory (luteal) phase?
Rises following ovulation in response to higher progesterone levels
What is placental abruption?
separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
What are 5 factors associated with placental abruption?
- proteinuric hypertension
- cocaine
- multiparity
- maternal trauma
- increasing maternal age
What are 6 clinical features in keeping with placental abruption?
- shock out of keeping with visible loss
- pain constant
- tender, tense (woody) uterus
- normal lie and presentation
- fetal heart: absent/distressed
- coagulation problems
What are 5 causes of recurrent miscarriage?
- antiphospholipid syndrome
- endocrine disorders: poorly controlled diabetes mellitus/ thyroid disorders, PCOS
- uterine abnormality e.g. uterine septum
- parental chromosomal abnormalities
- smoking
What is the management of asymptomatic bacteriuria in pregnancy?
screened + treated (associated with premature delivery + low birthweight)
What is the
What is first and second line treatment for primary dysmenorrhea?
First line: NSAIDs like mefenamic acid, ibuprofen
Second line: COCP
What is the key step in management for secondary dysmenorrhea?
Refer to gynaecology
How does the timing of pain differ in primary and secondary dysmenorrhoea?
More likely to be 3-4 days before onset of period if secondary; in primary, occurs with or just before period starting
What are 4 HPV strains most linked to cervical cancer?
16, 18, 31, 33
What are 9 risk factors for cervical cancer?
- HPV - 16, 18, 31, 33
- smoking
- HIV
- young age first coitus
- high number sexual partners
- young age first pregnancy
- high parity
- low socioeconomic class
- sexula partner with multiple sexual partners
Why is young age of first coitus a risk factor for cervical cancer?
adolescent cervix is more susceptible to carcinogenic stimuli as squamous metaplasia in the transformation zone is active during this time
Why is young age at first pregnancy a risk factor for cervical cancer?
metaplasia most active during first pregnancy
What can cause ovarian hyperstimulation syndrome (OHSS)? Give 3 examples
some forms of infertility treatment
1. gonadotropin or hCG treatment
2. clomifene (rare)
3. IVF
What happens for someone to develop OHSS?
thought that presence of multiple luteinised cysts in ovaries causehigh levels of oestrogens, progesterone + VEGF - increased membrane permeability, loss of fluid from intravascular compartment
What are 8 features of OHSS?
- abdominal pain
- abdominal bloating / ascites
- nausea / vomiting
- oliguria / anuria
- raised haematocrit >45%
- hypoproteinaemia
- VTE
- ARDS
How is OHSS severity categorised?
- mild: abdo pain, bloating
- moderate: nausea + vomiting, ascites on US
- severe: clinical ascites, oliguria, haematocrit >45%, hypoproteinaemia
- critical: VTE, ARDS, anuria, tense ascites
What is menometrorrhagia?
heavy and prolonged bleeding that occurs at irregular intervals
What is the definition of secondary amenorrhoea?
periods that were previously regular stop for 3 or more months
What is the only combined contraceptive patch licensed for use in the UK?
Evra patch
How does use of the contraceptive patch work?
- patch cycle lasts 4 weeks
- for first 3 weeks, patch worn every day, changed each week
- during 4th week patch not worn
What is the advice regarding delayed contraceptive patch change?
- delayed end of week 1 or 2: if delay < 48h: immediate change, no further precautions; if > 48h: change immediately, barrier 7 days, EC if UPSI
- end of week 3: remove old patch ASAP, new patch applied on usual cycle start day for next cycle (even if withdrawal bleeding); no additional contraception needed
- if application delayed at of patch-free week: additional barrier for 7 days following any delay
What are the 4 Ts of postpartum haemorrhage?
- Tone - uterine atony
- Trauma - e.g. perineal tear
- Tissue - retained placeneta
- Thrombin - clotting / bleeding disorder
What is the commonest cause of postpartum haemorrhage?
uterine atony (tone)
What is the definition of postpartum haemorrhage?
loss of >500ml after vaginal delivery
* Primary: within first 24h
* Secondary: between 24h - 6 weeks
What are the 2 commonest causes of secondary PPH?
- retained placental tissue
- endometritis
What are 9 risk factors for primary PPH?
- previous PPH
- prolonged labour
- pre-eclampsia
- increased maternal age
- polyhydramnios
- emergency C-section
- placenta praevia, planceta accreta
- macrosomia
- effect of parity - nulliparity now thought to be risk factor
What are 3 ways that the management of PPH can be divided?
- Mechanical
- Medical
- Surgical
What does mechanical management of PPH involve?
- palpate uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
- catheterisation to prevent bladder distension and monitor UO
What are 5 aspects of the medical management of primary PPH?
- IV oxytocin - slow IV injection, then IV infusion
- Ergometrine slow IV or IM
- Carboprost IM then intramyometrial
- Misoprostol sublingual or rectal
- ?possible role for tranexamic acid
Given in sequence
When is ergometrine (used in PPH) contraindicated?
if there is a history of hypertension
When is carboprost (used in PPH) contraindicated?
asthma
What is the first line surgical option for PPH where uterine atony is the only/main cause?
intrauterine balloon tamponade
What are 4 surgical options for management of PPH?
- intrauterine balloon tamponade
- B-Lynch suture
- Ligation of uterine arteries or internal iliac arteries
- Hysterectomy - if severe and would be life-saving procedure
What is the basic pathophysiology of Rhesus antibodies and pregnancy?
- rhesus system is the most important antigen found on red blood cells; D antigen most important of rhesus system
- if Rh -ve mother has Rh +ve child, leak of fetal red blood cells may occur - causes antibodies in mother
- in later pregnancies these can cross placenta and cause haemolysis in fetus
How is rhesus status in pregnant women managed?
- test for D antibodies in all Rh -ve mothers at booking
- give anti-D immunoglobulin to non-sensitised Rh -ve mothers at 28 and 34 weeks (or just 28 weeks depending on region)
What is the management of babies born to Rh -ve mothers?
should all have cord blood taken at delivery for FBC, blood group & direct Coombs test
What does the direct Coombs test involve for a baby born to a Rh -ve mother?
direct antiglobulin, will demonstrate antibodies on RBCs of baby
Waht does a Kleihauer test involve?
add acid to maternal blood, fetal cells are resistant
What are the signs of a fetal affected by haemolysis secondary to Rhesus D antibodies?
- oedematous - hydrops fetalis
- jaundice, anaemia, hepatosplenomegaly
- heart failure
- kernicterus
What is the treatment for haemolytic disease of the newborn?
transfusions, UV phototherapy
What treatment is offered for women at risk of pre-eclampsia?
aspirin 75mg OD from 12 weeks until birth of baby
1 or more high risk factors, 2 or more moderate
What is the management of hypertension in pregnancy?
- systolic >140 or diastolic >90
- increase above booking reasons of >30 systolic or >15 diastolic
What is the management of hypertension in pregnancy?
- oral labetalol first line
- oral nifedipine (e.g. if asthmatic) and hydralazine
What is the first line medical management of primary postpartum haemorrhage?
IV oxytocin ( oxytocin-> ergometrine-> carboprost [IM > intramyometrial], rectal misoprostol)
What is the preferred treatment option for DVT in pregnancy?
subcut LMWH
What are is the legislation re: termination of pregnancy?
Abortion Act 1967
- upper limit 24 weeks unless threat to life of woman / extreme physical or mental injury / severe fetal abnormality
2 medical professionals must sign legal document (1 in emergency)
Before 24 weeks permitted if:
- risk of physical or mental injury to mother greater than if pregnancy terminated / to existing children
- termination necessary to prevent grave permanent injury to physical or mental health of woman
- if child were born would suffer significant abnormalities as to be seriously handicapped
What are the medical options for termination of pregnancy?
Mifepristone followed by prostaglandins (e.g. misprostol) 48 hours later
What must be done after a medical TOP?
Multi level pregnancy test 2 weeks later (bhCG level not just positive/negative)
What are the rules for anti-D prophylaxis for TOP?
Give anti-D if having TOP after 10 weeks gestation
What are the options for surgical TOP?
- transcervical procedure: manual vacuum aspiration, electric vacuum aspiration, dilatation and evacuation
- cervical priming with misoprostol +- mifepristone
- under LA/ conscious sedation + LA, deep sedation, general anaesthesia
What is the commonest type of ovarian cyst?
Follicular cyst
What is the cause of follicular cysts?
Due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
What is the usual outcome of follicular cysts?
Commonly regress after several menstrual cycles
What are two types of functional (physiological) cysts?
Follicular and corpus Luteum
What is a corpus luteum cyst?
Usually breaks down and disappears if pregnancy doesn’t occur - if it doesn’t, fills with blood or fluid and cyst forms
What type of physiological ovarian cyst is more like to cause intra-peritoneal bleeding?
Corpus luteum cyst
What is the main benign germ cell ovarian tumour?
Dermoid cyst
What is the key type of benign germ cell tumour of the ovaries?
Dermoid cyst (mature cystic teratoma)
What is the most common benign ovarian tumour in women under 30?
Dermoid cyst
Which ovarian tumour is most commonly associated with torsion?
Dermoid cyst
What are 2 types of benign epithelial tumours of the ovary?
- Serous cystadenoma
- Mucinous cystadenoma
What is the commonest type of benign epithelial ovarian tumour?
Serous cystadenoma (commonly mistaken for serous carcinoma)
What can happen if a mucinous cystadenoma ruptures?
Can cause pseudomyxoma peritonei
What is the commonest identifiable cause of podtcoital bleeding?
Cervical ectropion (unidentifiable is single commonest)
What are the next steps if cervical screening (for hrHPV) is positive?
- cytology - if abnormal - colposcopy
- if cytology normal - repeat hrHPV screen at 12 months
- if hrHPV positive at repeat - cytology - if normal again repeat hrHPV at 12 months
- if third hrHPV positive - colposcopy
What happens if hrHPV screen is inadequate?
Repeat 3 months - if still inadequate colposcopy
What is the treatment of cervical intra-epithelial neoplasia (CIN)?
Large loop excision of transformation zone (LLETZ)
What risk is associated with intrahepatic cholestasis of pregnancy?
increased risk of premature birth
What is the management of intrahepatic choelstasis of pregnancy?
- induction of labour at 37-38 weeks (common practice, may not be evidence based)
- ursodeoxycholic acid
- vitamin K supplementation
What is the rate of recurrence of intrahepatic cholestasis of pregnancy in subsequent pregnancies?
45-90%
How is a diagnosis of gestation diabetes made?
- fasting glucose >5.6
- OGTT glucose >7.8
What are 5 risk factors for gestational diabetes?
- BMI >30
- previous macrosomic baby (4.5kg or more)
- previous GD
- 1st degree relative with diabetes
- family origin with high prevalence of diabetes e.g. Soutu Asian, Caribbean, middle Eastern
When should screening for gestational diabetes be performed?
- ASAP after booking in women with previous GD AND at 24-28 weeks if first test normal
- OGTT 24-28 weeks in woemnw tih any risk factors
What is the management of gestational diabetes?
- if plasma glucose <7 - trial of diet and exercise. if glucose targets not met at 1-2 weeks - metformin. still not met - short-acting insulin added to metformin
- if plasma glucose >7 - insulin
- if plasma glucose 6-6.9 + complications (macrosomia, hydramnios) - insulin
What drug should be offered for women with GD who cannot tolerate metformin / fail to meet glucose targets with metformin but decline insulin?
glibenclamide
How should medications be changed in pregnancy for women with pre-existing diabetes mellitus?
- stop oral hypoglycaemics apart from metformin + commence insulin
- folic acid 5mg/day
- detailed anomaly scan 20 weeks including 4 chamber view of heart + outflow tracts
What are the targets for self-monitoring of pregnant women (both pre-existing and gestational diabetes)?
- fasting: 5.3
- 1 hour after meals: 7.8
- 2 hours after meals: 6.4
What are the classic examination findings in endometriosis?
reduced organ mobility, tender nodularity in posterior vaginal fornix, visible vaginal endometriotic lesions
What are the investigations for endometriosis?
laparoscopy is gold standard; little role of investigation in primary care, if sx significant - refer for definitive diagnosis
What is the recommended first line treatment for endometriosis?
NSAIDs and / or paracetamol
if analgesia doesn’t help - COC or progestogens e.g. medroxyprogesterone acetate
What are 3 secondary care treatment options for endometriosis?
- GnRH analogues - induce pseudomenopause due to low oestrogen levels
- surgery - laparoscopic excision or ablation of endometriosis + adhesiolysis
- ovarian cystectomy for endometriomas
What are 3 situations when expectant miscarriage (watch + wait) is not appropriate + should be managed medically or surgically?
- increased risk of haemorrhage - late first trimester, coagulopathies or unable to have transfusion
- previous adverse and/or traumatic experience associated with pregnancy e.g. stillbirth, miscarriage, APH
- evidence of infection
What is the medical management of miscarriage?
vaginal misoprostol (prostaglandin analogue) binds to myometrial cells to cause strong myometrial contractions + expel tissue
+ antiemetics + pain relief
What is the surgical management of miscarriage?
vacuum aspiration (suction curettage, done in OPA under LA) or management in theatre
What supplements are recommended in uncomplicated pregnancy?
Folic acid 400mcg and vitamin D 10 mcg
What is shoulder dystocia?
complication of vaginal cephalic delivery
entails the inability to deliver the body of the fetus using gentle traction, the head having already been delivered
usually due to impaction of the anterior fetal shoulder on the maternal pubic symphysis
What are 4 risk factors for shoulder dystocia?
- Fetal macrosomia
- High maternal BMI
- DM
- Prolonged labour
What is first line management of shoulder dystocia during delivery?
McRoberts manoeuvre- flexing and abduction of mothers hips, increases the relative anterior-posterior angle of the pelvis
What 3 things might be considered for shoulder dystocia if mcroberts doesn’t work?
- Episiotomy
- Symphysiotomy
- Zavanelli manoeuvre
How does cerazette differ from other POP types?
12 hour window rather than 3 hours to take pill
What is the mechanism of cerazette?
= desogestrel, inhibits ovulation (secondarily caused thicker mucus secretion)
Until what time post-partum do women not need contraception?
day 21
When can the POP be started as contraception for women postpartum?
any time postpartum
For how long should additional contraception be used if the POP is initiated post-partum?
if initiated after day 21 - additional contraception for 2 days
What is the advice for COCP in women breastfeeding postpartum?
- UKMEC 4 if breastfeeding <6 weeks postpartum
- UKMEC2 if breastfeeding 6weeks - 6 months
When can COCP be started postpartum in women NOT breastfeeding?
should not be used in first 21 days due to increased VTE risk postpartum
For how long should additional contraception be used if the COCP is started after day 21 postpartum (in a non-breastfeeding woman)?
7 days
When can IUD or IUS be used postpartum for contraception?
within 48h OR after 4 weeks
How effective is the lactational amenorrhoea method?
98% effective if woman fully breastfeeding (no supplementary feeds), amenorrhoeic and <6 months post partum
What are 3 risks of a short inter-pregnancy interval (<12 months)?
- increased risk of preterm birth
- low birth weight
- small for gestational age (SGA) babies
How frequent is cervical screening?
- 25-49y: every 3y
- 50-64y: every 5y
- 65y: only if 2 of last 3 tests was abnormal
Why must aspirin be avoided in breastfeeding women?
risk of Reye’s syndrome; regular use of high doses could impair platelet function and produce hypoprothrombinaemia in infants if neonatal vitamin K stores are low
Why must aspirin be avoided in breastfeeding women?
risk of Reye’s syndrome; regular use of high doses could impair platelet function and produce hypoprothrombinaemia in infants if neonatal vitamin K stores are low
How does the risk of pregnant women developing listeriosis (caused by Listeria monocytogenes) compare to the general population?
20x greater in pregnancy
How can feral/neonatal infection with Listeria occur?
Transplacentally or vertically during childbirth
How can Listeria infection spread to the fetus/newborn in pregnant women?
Transplacentally or vertically during birth
How can Listeria infection spread to the fetus/newborn in pregnant women?
Transplacentally or vertically during birth
What are 4 complications of Listeria infection of the newborn?
- Miscarriage
- Preterm labour
- Stillbirth
- Chorioamnionitis
What is the only way that a diagnosis of Listeria infection (Listeriosis) can be made in pregnant women?
Blood cultures
What is the treatment of listeriosis in pregnant women?
Amoxicillin
What is the primary mode of action of the copper IUD?
Decreased sperm motility and survival preventing fertilisation
What is the mechanism of action of the IUS for contraception?
Prevents endometrial proliferation and causes cervical mucous thickening
How long is it before the IUD vs IUS can be relied upon for contraception?
Immediate for IUD, after 7 days for IUS
How long does the copper IUD last for?
5 years if copper just on stem; up to 10 on arms of the T as well
How long does the Mirena IUS last for?
5 years
If used as endometrial protection for women taking oestrogen only HRT how long is the Mirena IUS licensed for?
4 years
What increased the risk of uterine perforation with the IUS/IUD?
Breastfeeding (normally risk is 2 in 1000)
What increases the risk of perforation with IUS/IUD?
Pregnancy (normally risk is 2 per 1000)
What is the rate of expulsion if IUS/IUD?
1 in 20 (highest risk in first 3 months)
What are the respective levonorgestrel levels of kyleena, jaydess and Mirena?
Kyleena - 19.5mg
Jaydess - 13.5mg
Mirena - 52mg
What is the advice for switching between types of COCP with different progesterones?
BNF suggests omitting pill free interval when switching (FSRH contradicts)
What is the advice for switching between types of COCP with different progesterones?
BNF suggests omitting pill free interval when switching (FSRH contradicts)
What is the advice for switching between types of COCP with different progesterones?
BNF suggests omitting pill free interval when switching (FSRH contradicts)
What is Sheehan’s syndrome?
- anterior pituitary avascular necrosis due to significant blood loss - classically postpartum haemorrhage
- leads to reduced hormone production (FSH and LH) - resulting in amenorrheoa
- reduced lactation due to reduced PRL
- adrenal insuffiiency + adrenal crisis due to low ACTH (and consequently low cortisol)
- hypothyroidism (reduced TSH)
What is the management of Sheehan’s syndrome?
specialist endocrinologist manages it; replace missing hormones with oestrogen, progesterone, hydrocortisone, leothyroxine and growth hormone
What is Asherman’s syndrome?
symptomatic adhesions (synechiae) within uterus following damage e.g. after pregnancy-related dilatation and curettage (retained productions of conception, myomectomy) and after endometritis/pelvic infection
What are 4 symptoms of Asherman’s syndrome?
- secondary amenorrhoea
- lighter periods
- dysmenorrhoea
- infertility
What is the definition of primary amenorrhoea?
failure ot establish menstruation by 15y in girls with normal secondary sexual characeristics (e.g. breast development), or by 13 years if no secondary sexual characteristics
What are 7 causes of secondary amenorrhoea (after pregnancy excluded)?
- hypothalamic amenorrhoea (secondary stress, excessive exercise)
- polycystic ovarian syndrome (PCOS)
- hyperprolactinaemia
- premature ovarian failure
- thyrotoxicosis
- Sheehan’s syndrome
- Asherman’s syndrome
What are 6 initial investigations in primary/secondary amenorrhoea?
- exclude pregnancy with urinary/serum bHCG
- FBC, U+Es, coeliac screen, TFT
- gonadotrophins (to determine hypothalamic vs. ovarian cause)
- prolactin
- androgen levels (raised in PCOS)
- oestradiol
What are 9 UKMEC4 (absolute contraindications) for COCP?
- > 35y and smoking >15/day
- migraine + aura
- history of thromboembolic disease or thrombogenic mutation
- history of stroke or IHD
- breastfeeding <6w postpartum
- uncontrolled hypertension
- current breast cancer
- major surgery with prolonged immobilisation
- positive antiphospholipid antibodies (e.g. in SLE)
What is the management of ovarian cysts in pre-menopausal women?
- if cyst small (<5cm) + simple (unilocular) - repeat US in 8-12 weeks
- consider gynaecology referral if persists
What is the management of ovarian cysts in postmenopausal women?
by definition, physiological cysts unlikely - refer to gynaecology for assessment (regardless or nature or size)
What daily supplementation is recommended for breastfeeding women?
vitamin D 10mcg/ day
vitamin B12 if eat a vegan diet
What HPV strains are responsible for genital warts?
types 6 + 11
Which 4 types of HPV strains are including in the standard Gardasil vaccination used in the UK?
- 6
- 11
- 16
- 18
(quadrivalent)
What advice should be given to pregnant women for avoiding infection?
- advise how to avoid risk of listeriosis, salmonella and toxoplasmosis
- avoid unpasteurised milk and soft cheeses
- avoid undercooked meat and poultry, raw seafood
- avoid excess liquorice
- avoid excess caffeine
- wash fruit and vegetables before eating them
- avoid deli meats
- avoid raw eggs
What is the advice regarding intercourse during pregnancy?
reassure that intercourse thought to be safe during pregnancy
What is the advice about car travel to give to women who are pregnant?
seat belt should go above and below hump, not over it
How effective is the cervical screening programme at detecting cervical adenocarcinoma?
not effective - they are frequently undetected
What is the approach to cervical screening following pregnancy?
it is delayed until 3 months post partum unless missed screening or previous abnormal smears
When is the best time thought to be to take a cervical smear?
mid-cycle
What are 2 differences between nexplanon and implanon?
- the nexplanon applicator has been resgiend to try and prevent deep insertions (e.g. subcutaneous/IM)
- it is radiopaque and therefore easier to locate if impalpable
What is the mechanism of action of Nexplanon?
- slowly releases progestogen hormone etonogestrel
- prevent ovulation - main mechanism
- also thicken cervical mucus
How long does Nexplanon last?
3 years
Can nexplanon be used if there is a past history of thromboembolism, mgiraine etc.?
yes (doesn’t contain oestrogen)
How soon after termination of pregnancy can Nexplanon be used?
can be inserted immediately following termination of pregnancy
Do additional contraceptives need to be used with Nexplanon after insertion and for how long?
yes for first 7 days if not inserted on day 1 to 5 of a woman’s menstrual cycle
What is the main adverse effect of nexplanon?
irregular/heavy bleeding
How can irregular/heavy bleeding with nexplanon sometimes be managed?
using a co-prescription of the combined oral contraceptive pill
Which drugs can influence the effectiveness of nexplanon?
enzyme-inducing drugs e.g. rifampicin, certain antieplieptics
What is UKMEC 4 with nexplanon?
current breast cancer
When should menorrhagia be investigated further?
if symptoms suggestive structural or histological abnormality: IMB, PCB, pelvic pain and/or pressure symptoms
How long do menopausal symptoms typically last for?
7 years
What are the lifestyle modifications to help manage different symptoms of the menopause?
- hot flushes: regular exercise, weight loss and reduce stress
- sleep disturbance: avoid late evening exercise, good sleep hygiene
- mood: sleep, regular exercise + relaxation
- cognitive sx: regular exercise and good sleep hygiene
What are 4 contraindications to HRT?
- current or past breast cancer
- oestrogen-sensitive cancer
- undiagnosed vaginal bleeding
- untreated endometrial hyperplasia
What are 5 key risks of HRT?
- VTE (if oral; no increased risk if transdermal)
- stroke
- coronary heart disease
- breast cancer
- ovarian cancer
What are 3 non-HRT drug options for the management of vasomotor menopause symptoms
- fluoxetine
- citalopram
- venlafaxine
What non-HRT drug treatments can be used for vaginal dryness?
vaginal lubricant or moisturiser
What can be used to treat urogenital atrophy?
vaginal oestrogen (appropriate if taking HRT or not)
How long may HRT be required for vasomotor symptoms?
2-5 years with regular attempts to discontinue
What is the approach to stopping HRT and what should the woman be counselled?
gradually reduce - tell women this limits recurrence only in short term; in long term there is no difference in symptom control
What are 3 situations when menopausal patients should be referred to secondary care?
- treatment ineffective
- ongoing side effects
- unexplained bleeding
What is the definition of premature ovarian insufficiency?
the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years
What are 7 causes of premature menopause?
- idiopathic (commonest, may be familial)
- bilateral oophorectomy
- radiotherapy
- chemotherapy
- infection e.g. mumps
- autoimmune disorders
- resistant ovsry syndrome - FSH receptor abnormalities
How should FSH and LH be tested for in suspected premature ovarian failure?
should be demonstrated on 2 blood samples taken 4-6 weeks apart
What is the management of premature ovarian failure?
hormone replacement therapy or COCP until age 51y (average menopause)
What is the commonest adverse effect of the POP?
Irregular vaginal bleeding
When is additional contraception needed when starting the POP?
- if commenced from day 1 - 5 no additional contraception needed
- additional contraception needed for first 2 days in all other cases
What advice is given for switching from COCP to POP?
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)
Does POP have a pill free break?
No - unlike COCP
What are the missed pill rules for POP?
- if < 3 hours late: continue as normal
- if > 3 hours: take the missed pill as soon as possible, continue with the rest of the pack, extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
- (12 hours for cerazette)
What virus causes rubella?
togavirus
What is the a) incubation period and b) infectoius period in rubella?
- a) 14-21 days
- b) from 7 days before symptoms appear to 4 days after onset of rash
What are the features of congenital rubella syndrome?
- sensorineural deafness
- congenital cataracts
- congenital heart disease (e.g. patent ductus arteriosus)
- growth retardation
- hepatosplenomegaly
- purpuric skin lesions
- ‘salt and pepper’ chorioretinitis
- microphthalmia
- cerebral palsy
What condition is it difficult to distinguish rubella from clinically?
Parvovirus B19
What tests can help a diagnosis of rubella in a pregnant mother?
IgM antibodies raised in women recently exposed
What are 3 aspects of the management of rubella in pregnancy?
- discuss with local Health Protection Unit
- if woman doesn’t have immunity (although not routinely checked), keep away from people who may have rubella
- non-immune mothers should be offered MMR vaccination in the post-natal period
What is a rule of thumb for working out the symphysio-fundal height in pregnancy?
after 20 weeks, SFH = gestational age in weeks (to within 2 cm)
When is test of cure performed in pregnancy for chlamydia that has been treated?
6 weeks post infection
What are the cut offs when women should receive oral iron to treat anaemia in pregnancy?
- first trimester: <110
- second/third: <105
- postpartum: <100
oral ferrous sulphate or ferrous fumarate
What is the Bishop score used for?
used to help assess whether induction of labour will be required
What are 5 components of the Bishop score?
- cervical position
- cervical consistency
- cervical effacement (get thinner due to stretch)
- cervical dilation
- fetal station
How is the Bishop score interpreted?
- <5 indicates labour unlikely to start without induction.
- 8 or more: cervical is ripe, or favourable - high chance of spontaneous labour, or response to interventions to induce labour
What are 6 possible methods for induction of labour?
- Membrane sweep
- Vaginal prostaglandin E2 (PGE2) (aka dinoprostone)
- Oral prostaglandin E1 (misoprostol)
- Maternal oxytocin infusion
- Amniotomy
- Cervical ripening balloon
What does the membrane sweep for induction of labour involve?
- examining finger is passed through cervix to rotate against wall of uterus - separates chorionic membrane from decidua
- done at 40- and 41-week visit in nulliparous women, 41-weeks in parous women
Is the membrane sweep offered for induction of labour in isolation?
no - adjunct
What should be offered prior to induction of labour with the membrane sweep method?
vaginal examination
What does use of the cervical ripening balloon involve for induction of labour?
passed through endocervical cancel and gently inflated to dilate cervix
How is the Bishop score used to guide induction of labour methods?
- if 6 or less: vaginal prostaglandins or oral misoprostol; consider balloon catheter if risk of hyperstimulation / previous C section
- > 6: amniotomy and IV oxytocin infusion
What is the main complication of induction of labour?
- uterine hyperstimulation - prolonged and frequent contractions (aka tachysystole)
- may interrupt blood flow to intervillous space over time, can result in fetal hypoxaemia and acidaemia; also uterine rupture
What is the management of uterine hyperstimulation due to induction of labour?
remove vaginal prostaglandins, stop oxytocin infusion; consider tocolysis
When do progesterone levels peak?
day 21 (during luteal phase)
What proportion of fetuses are breech at 28 weeks vs near term?
25% at 28 weeks, 3% near term
What is the commonest type of breech fetus and what is this?
frank breech - hips flexed and knees fully extended
What is a rare type of breech presentation that carries a higher perinatal morbidity?
footling breech - one or both fet come first with bottom at higher position
What are 5 risk factors for breech presentation?
- uterine malformations, fibroids
- placenta praevia
- polyhydramnios or oligohydramnios
- fetal abnormality e.g. CNS malformation, chromosome disorder
- prematurity (increased incidence earlier in gestation)
What complication in pregnancy is more common in breech fetuses?
cord prolapse
What is the management of a breech fetus?
- if <36 weeks - many will turn spontaneously, observe
- if breech 36 weeks and above in nullips, 37 and above in multips - external cephalic version
- if unsuccessful - planned C section or vaginal delivery
What is the success rate of external cephalic version?
60%
What are 6 absolute contraindications to ECV?
- where caesarean delivery required
- APH within last 7 days
- abnormal CTG
- major uterine anomaly
- ruptured membranes
- multiple pregnancy
What are 5 key risks of smoking during pregnancy?
- increased risk of miscarriage
- increased risk of pre-term labour
- increased risk of stillbirth
- IUGR
- increased risk of sudden unexpected death in infancy
What are 4 risks of alcohol during pregnancy?
termed Fetal alcohol syndrome
1. learning difficulties
2. characteristic facies: smooth philtrum, thin vermilion (upper lip), small palpebral fissures, epicanthic folds, microcephaly
3. IUGR
4. Postnatal restricted growth
What are 2 maternal risks of cocaine use during pregnancy?
- hypertension, pre-eclampsia
- placental abruption
What are 2 fetal risks of cocaine use during pregnancy?
- prematurity
- neonatal abstinence syndrome
What is the risk of heroin use during pregnancy?
neonatal abstinence syndrome
What are 2 substances that can cause neonatal abstinence syndrome?
- heroin
- cocaine
What is the most important factor in deciding whether to decide whether to start HRT?
vasomotor symptoms (flushing, insomnia, headaches)
What is the most important reason for giving HRT to younger women going through premature menopause?
preventing development of osteoporosis
What type of oestrogens are used in HRT?
‘natural’ oestrogens - oestradiol, oestrone, conjugated oestrogen
(not synthetic oestrogens - e.g. ethinylestradiol, in COCP)
What type of progestogens are used in HRT?
synthetic (medroxyprogesterone, norethisterone, levonorgestrel, drospirenone), IUS
What is tibolone?
synthetic compound with oestrogen, progestogenic and androgenic activity
How do you decide between continuous or cyclical HRT?
in perimenopausal women still having periods / for 12 months afterwards - cyclical HRT (produces predictable withdrawal bleeding)
if postmenopausal (no periods for 12 months) - continuous
When during pregnancy should folic acid be taken?
from 3 months before conception to week 12
What are 8 critiera that mean a pregnant woman should take higher dose folic acid during pregnancy (5mg rather than 400mcg)?
- either partner has a neural tube defect
- previous pregnancy affected by NTD
- FH of NTD
- mother taking antiepileptic drugs
- mother has coeliac disease
- diabetes
- thalassaemia trait
- woman is obese (BMI >30)
What is the investigation of choice in ectopic pregnancy?
transvaginal ultrasound
What are 6 criteria for surgical management of ectopic pregnancy?
- size >35mm
- can be ruptured
- pain
- visible fetal heartbeat
- hCG >5000
- compatible with another intrauterine pregnancy
What are 6 criteria for expectant management of ectopic pregnancy?
- size < 35mm
- unruptured
- asymptomatic
- no fetal heartbeat
- hCG < 1000
- compatible if another intrauterine pregnancy
What are 6 criteria for medical management of ectopic pregnancy?
- size <35mm
- unruptured
- no significant pain
- no fetal heartbeat
- hCG < 1500
- NOT suitable if intrauterine pregnancy
What are the 3 things that form the triad of pre-eclampsia?
- new-onset hypertension >140/90 after 20 weeks of pregnancy
- proteinuria (PCR >30 = significant)
- oedema
- other organ involvement e.g. renal insufficiency (creat >90), liver, neurological, haematological, uteroplacental dysfunction
What are 5 potential consequences of pre-eclampsia?
- eclampsia / altered mental status / blindness / stroke / clonus / severe headaches / persistent visual scotomata
- fetal complications - IUGR, prematurity
- liver involvement - raised transaminases
- haemorrhage - placental abruption, intra-abdo, intra-cerebral
- cardiac failure
What are 6 neurological complications of pre-eclampsia other than eclampsia (seizures)?
- altered mental status
- blindness
- stroke
- clonus
- severe headaches
- persistent visual scotomata
What are 2 fetal complications of pre-eclampsia?
- IUGR
- prematurity
What are 3 forms of haemorrhage that can occur as a result of pre-eclampsia?
- placental abruption
- intra-abdominal
- intra-cerebral
What are 8 features of severe pre-eclampsia?
- hypertension >160/110 + proteinuria
- proteinuria: dipstick ++/+++
- headache
- visual disturbance
- papilloedema
- RUQ/epigastric pain
- hyperreflexia
- platelet count <100, abnormal LFTs or HELLP
What are 5 high risk factors for pre-eclampsia?
- hypertensive disease in previous pregnancy
- chronic kidney disease
- autoimmune disease e..g SLE, antiphospholipid
- T1/T2DM
- chronic hypertension
What are 6 moderate risk factors for pre-eclampsia?
- first pregnancy
- age 40 years or older
- pregnancy interval >10 years
- BMI >35
- FH pre-eclampsia
- multiple pregnancy
What is the management of pregnant women with BP >160/110?
admission for observation
What is the first line medication treatment for pre-eclampsia? What is the definitive management?
- oral labetalol (nifedipine / hydralazine if asthmatic)
- delivery of baby is definitive
What are 2 types of cancer that the COCP increases the risk of?
- breast cancer
- cervical cancer
When is additional contraception needed when starting COCP?
- if within first 5 days of cycle (period) - none
- otherwise - for first 7 days
What are 3 situations where the efficacy of the COCPD may be reduced?
- vomiting within 2 hours of taking
- medication inducing diarrhoea / vomiting e.g. orlistat
- liver enzyme-inducing drugs
A surge of which hormone causes ovulation?
LH
What is the definition of threatened miscarriage?
- painless vaginal bleeding < 24 weeks (usually 6- 9 weeks)
- cervical os closed
What proportion of pregnancies are complicated by threatened miscarriage?
up to 25%
What is the definition of missed (delayed miscarriage)?
- gestational sac containing dead fetus < 20 weeks without symptoms of expulsion
- may be light vaginal bleeding / discharge
- cervical os closed
What is meant by a blighted ovum, or missed pregnancy?
- type of missed miscarriage
- when gestational sac >25mm and no embryonic / fetal part seen, sometimes described as ‘blighted ovum’ or ‘anembryonic pregnancy’
What is the definition of incomplete miscarriage?
- not all products of conception have been expelled
- pain and vaginal bleeding
- cervical os open
When does the booking visit occur?
8 - 12 weeks (ideally < 10)
What 8 things are done at the booking visit?
- general information on diet, smoking etc.
- BP
- urine dip
- BMI check
- FBC, glood group, rhesus status, red cell alloantibodies, haemoglobinopathies
- hep B, syphilis
- HIV
- urine culture - asymptomatic bacteriuria
When is the dating scan performed?
10 - 13+6 weeks
When is Down’s syndrome screening performed?
11 - 13+6 weeks
When is the anomaly scan performed?
18 - 20+6 weeks
When is a second, third and fourth BP and urine dipstick performed in pregnancy?
16 weeks, 25 weeks, 28 weeks
When is symphysis-fundal height measured for the first time in primips vs multips?
25 weeks (28 weeks in multips)
When is discussion about options for prolonged pregnancy held?
40 weeks if primip, 41 weeks if multip
What are 4 common side effects of HRT?
- nausea
- breast tenderness
- fluid retention
- weight gain
What are 5 potential risks of HRT?
- increased risk of breast cancer (due to progestogen)
- endometrial cancer (reduced with addition of progestogen)
- VTE (increased by progestogen, eliminated with transdermal)
- stroke
- IHD if >10 y after menopause
When does the first screen for anaemia and alloantibodies take place in pregnancy?
8 - 12 weeks (booking visit)
At what 2 points in pregnancy is the woman screened for anaemia?
- booking 8-12 weeks
- 28 weeks
When is referral to a specialist generally warranted in a couple struggling to conceive?
after regular intercourse for 12 months
What are 7 indications to consider early referral to fertility services in couples struggling to conceive?
- female age > 35 years
- amenorrhoea
- previous pelvic / genitalia surgery
- previous STI in male / female
- abnormal genital examination in male / female
- varicocele
- significant systemic illness in male
When is the combined test for Down syndrome screening, including nuchal scan?
11-13+6 weeks
When can the triple or quadruple tests be offered for Down syndrome during pregnancy?
between 15 and 20 weeks
What are 4 risk factors for ovarian cancer?
- BRCA1 or BRCA2 gene
- early menarche
- late menopause
- nulliparity
latter 3 - increased ovulations
What test is diagnostic of ovarian cancer?
diagnostic laparotomy
CA125 and US for workup
What is the only effective treatment for large uterine fibroids causing problems with fertility if the woman wishes to conceive in the future?
myomectomy
What is the prevalence of uterine fibroids?
in later reproductive years:
* White: 20%
* Afro-Caribbean: 50%
What are 5 features of uterine fibroids?
- can be asymptomatic
- menorrhagia, IDA
- bulk-related: ower abdo pain, bloating, urinary sx
- subfertility
- rare: polycythaemia (Autonomous EPO production)
How is a diagnosis of fibroids made?
TVUS
What is the maangement of asymptomatic fibroids?
no treatment other than periodic review to monitor size and growth
What are 6 options for management of menorrhagia secondary to fibroids?
- IUS (CI if distortion of uterine cavity)
- NSAIDs
- TXA
- COCP
- POP
- injectable progestogen
What are 3 groups of treatment to shrink / remove fibroids?
- Medical - GnRH agonists
- Surgical - myomectomy, endometrial ablation, hysterectomy
- Uterine artery embolisation
What is 1 medical treatment to shrink / remove fibroids?
- GnRH agonists
(ulipristal no longer used - liver toxicity)
When are GnRH agonists used to treat fibroids?
short-term due to side effects e.g. menopausal sx and loss of bone mineral density
What are 3 surgical options to shrink / remove fibroids?
- myomectomy
- endometrial ablation
- hysterectomy
What is the prognosis of untreated fibroids?
generally regress after menopause
What is red degeneration of fibroids?
haemorrhage into the tumour - commonly occurs during pregnancy
What are 7 maternal risks of obesity during pregnancy?
- miscarriage
- VTE
- gestational diabetes
- pre-eclampsia
- dysfunctional labour, induced labour
- postpartum haemorrhage
- wound infection
What are 6 fetal risks of maternal obesity during pregnancy?
- congenital anomaly
- prematurity
- macrosomia
- stillbirth
- increased risk of obesity and metabolic disorders in childhood
- neonatal death
What advice should be given to obese women who become pregnant?
explain it poses a risk to health of them and their child - but should not diet while pregnant, risk will be managed by the health professionals
What management should be offered to obese women who are pregnant?
- 5mg folic acid from conception to end of first trimester
- OGTT for gestational diabetes 24-48 weeks
- if BMI >35 - birth in consultant led obstetric unit
- if BMI >40 antenatal consultation with obstetric anaesthetic + plan made
What is the guidance for obese women who are pregnant re: folic acid?
5mg from conception to end of first trimester
How long should contraception be used in the perimenopausal period?
- for 12 months after last period if > 50 years
- 24 months if < 50 years
What are the features of bleeding due to hydatidiform mole?
- bleeding in first or early second trimester
- exaggerated pregnancy symptoms - hypermesis
- large for dates uterus
- high serum hCG
What are the features of placental abruption vs placenta praevia?
- abruption - constant lower abdo pain, placenta praevia painless
- abruption - may be more shocked than suggested by visible blood loss; vaginal bleeding occurs in placenta praevia
- tense, tender uterus with normal lie and presentation in abruption but may be abnormal in PP (high presenting part)
- fetal heart may be distressed in abruption
What are 2 classic features of vasa praevia?
- rupture of membranes followed immediately by vaginal bleeding
- fetal bradycardia
What is the guidance for investigation in primary care of antepartum haemorrhage?
vaginal examination shouldn’t be performed in primary care - women with placenta praevia may haemorrhage
What is a risk to the mother of getting chickenpox during pregnancy?
5x greater risk of pneumonitis
What are 5 risks to the fetus of chickenpox during pregnancy?
Fetal varicella syndrome
1. skin scarring
2. eye defects (microphthalmia)
3. limb hypoplasia
4. microcephaly
5. learning disabilities
also risks of shingles in infancy / severe neonatal varicella if late in mother
What is the first step if a pregnant mother is exposed to chickenpox during pregnancy and is unsure about previously having chickenpox?
urgently check maternal blood for varicella antibodies
What is the management of exposure by pregnant women to chickenpox without previous chickenpox?
- oral aciclovir at 7 - 14 days after exposure (not immediately)
What is the management a pregnant woman who develops chickenpox during pregnancy?
- seek specialist advice
- oral aciclovir if present > 20 weeks and within 24h of onset of rash
- if < 20 weeks - consider aciclovir ‘with caution’
What should you advise if 1 COCP is missed?
take last pill even if it means taking 2 in one day then continue taking one daily; no additional contraceptive needed
What should you advise if 2 or more COCP doses are missed in week 1 and she has had UPSI?
- emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
- use condoms or abstain from sexn until has taken pills for 7 consecutive days
- take last pill even if it means taking 2 in 1 day
What should you advise if 2 or more COCP doses are missed in week 2 and she has had UPSI?
after seven consecutive days of taking the COC there is no need for emergency contraception
What should you advise if 2 or more COCP doses are missed in week 3 and she has had UPSI?
she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
What is the advice for folic acid in pregnant epileptic women?
shouhld all take 5mg OD
What is the risk of sodium valproate in pregnancy?
neural tube defects + neurodevelopmental delay
What is the advice re carbamazepine in pregnancy?
considered least teratogenic of older antiepileptics
What is the advice re phenytoin in pregnancy?
- associated with cleft palate
- if taking during pregnancy, should be given vit K in last month to prevent clotting disorders in newborn
What is the risk of lamotrigine in pregnancy?
- rate of congenital malformations low
- dose may need to be increased in pregnancy
What are 3 features associated with placenta praevia?
- multiparity
- multiple pregnancy
- embryos more likely to implant on lower segment scar from previous C section
What part of routine antenatal care may pick up placenta praevia?
20 week abdominal US
What is the best test to diagnose placenta praevia?
transvaginal US
What are the 4 features of classifical grading of placenta praevia?
- I: reaches lower segment but not internal os
- II: reaches internal os but doesn’t cover
- III: covers internal os before dilation but not when dilated
- IV: (major): completely covers internal os
What 2 medications should be administered to a woman in premature labour?
- tocolysis
- steroids - for fetal lung maturation
What are 11 risks of prematurity?
- increased mortality
- respiratory distress syndrome
- intraventricular haemorrhage
- necrotising enterocolitis
- chronic lung disease
- hypothermia
- feeding problems
- infection
- jaundice
- retinopathy of prematurity
- hearing problems
How can you distinguish between vulval carcinomas and vulval intraepithelial neoplasia?
- vulval carcinomas are commonly ulcerated
- vulval intraepithelial neoplasia - white or plaque-like lesions, don’t ulcerate
What causes the majority of vulval cancers?
squamous cell carcinoma
What are 5 risk factors for vulval carcinoma?
- HPV
- vulval intraepithelial neoplasia
- immunosuppression
- lichen sclerosus
- age
What is hydrops fetalis?
- can be caused by severe anaemia e.g. due to viral suppression of fetal erythropoiesis by parvovirus B19
- anaemia leads to heart failure
- leads to accumulation of fluid in fetal serous cavities
- e.g. asites, pleural and pericardial effusions
What is the treatment of hydrops fetalis?
intrauterine blood transfusions
At what point during pregnancy is intrahepatic cholestasis of pregnancy typically seen?
third trimester
What is the most common liver disease of pregnancy?
intraheptic cholestasis of pregnancy
What are 3 points of the management of obstetric cholestasis?
- ursodeoxycholic acid - symptomatic
- weekly LFTs
- induction at 37 weeks
What is a complication of cholestasis of pregnancy?
increased rate of stillbirth
not associated with maternal morbidity
When does acute fatty liver of pregnancy typically occur?
third trimester or period immediately following delivery
What is the management of acute fatty liver of pregnancy?
supportive care
once stabilised - definitive management is delivery
What are the 3 key features of HELLP syndrome?
haemolysis, elevated liver enzymes, low platelets
What are the 3 diseases of the spectrum of festational trophoblastic disorders?
- 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 5 key features of a hydatidiform mole?
- bleeding in first or early secsond trimester
- exaggerated pregnancy sx e.g. hyperemesis
- uterus large for dates
- high serum hCG
- HTN and hyperthyroidism (hCG can mimic TSH)
What are 2 features of a the management of a complete hydatidiform mole?
- urgent referral to specialist centre - evacuation of uterus
- effective contraception to avoid pregnancy in next 12 months
What proportion of patients with complete hydatidiform mole go on to develop choriocarcinoma?
2-3%
What is a partial hydatidiform mole?
- normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes.
- DNA is both maternal and paternal in origin
- Usually triploid - e.g. 69 XXX or 69 XXY.
- fetal parts may be seen
What is the key risk factor for chorioamnionitis?
premature rupture of membranes
What is the management of chorioamnionitis in a pregnant mother?
- if > 34 weeks - prompt delivery (via C section if necessary) - close monitoring if < 34w
- broad spectrum IVAB e.g. co-amoxiclav, amox + metronidazole
What is the normal fetal heart rate?
100-160 bpm
What are 2 possible causes of baseline bradycardia on a fetal CTG (<100)?
- increased fetal vagal tone
- maternal beta blocker use
What is meant by a late deceleration on CTG?
deceleration of the heart rate which lags behind the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction
What are 4 causes of baseline tachycardia on CTG?
- maternal pyrexia
- chorioamnionitis
- hypoxia
- prematurity
What are 2 causes of loss of baseline variability (<5 beats / min) on fetal CTG?
- prematurity
- hypoxia
What can cause early deceleration on CTG?
usuaully innocuous - indicates head compression
What is meant by early deceleration on CTG?
deceleration of the heart rate which commences with onset of a contraction and returns to normal on completion of the contraction
What does a late deceleration on fetal CTG indicate?
fetal distress e.g. asphyxia or placental insufficiency
What is meant by variable decelerations on CTG and what can this indicate?
slowing of fetal heart rate independent on contractions - may indicate cord compression
What are 5 causes of oligohydramnios?
- PROM
- Potter sequence - bilateral renal agenesis + pulmonary hypoplasia
- IUGR
- Post-term gestation
- Pre-eclampsia
What is the definition of oligohydramnios?
reduced amniotic fluid < 500ml at 32-36 weeks and amniotic fluid index < 5th percentile
How does tracheo-oesopahgeal fistula affect amniotic fluid volume?
causes polyhydramnios
What are 8 risk factors for endometrial cancer?
- nulliparity
- early menarche / late menopause
- unopposed oestrogen e.g. HRT
- obesity
- diabetes mellitus
- polycystic ovarian syndrome
- tamoxifen
- hereditary non-polyposis colorectal carcinoma
What are 3 protective factors for endometrial cancer?
- multiparity
- COCP
- smoking
What first line and subsequent investigations must be done in suspected endometrial cancer?
- first line: transvaginal US (endometrial thickness <4mm has strong negative predictive value)
- hysteroscopy with endometrial biopsy
What is the management of endometrial cancer?
- localised disease is treated with total abdominal hysterectomy + bilateral salpingo-oophorectomy
- patients with high-risk disease may have postoperative radiotherapy
- Progestogen therapy sometimes used in frail elderly women not suitable for surgery
What type of lifestyle advice should be given first line in premenstrual syndrome?
sleep, exercise, smoking, alcohol, regular (2-3 hourly) small balanced meals rich in complex carbohydrates
What is a contraindication to the use of tibolone?
within 12 months of LMP - may cause irregular bleeding
Others: 1. breast ca
2. Hormone dependent tumours
3. Thromoboembolic disorders
What are 2 side effects of clonidine?
dry mouth and dizziness
What is first line treatment of VTE in pregnancy?
LMWH
*Warfarin teratogenicity in first trimester and fetal haemorrhage in third trimester.
What is the diagnostic triad for hyperemesis gravidarum?
- weight loss >5% baseline
- dehydration (may result in increased hematocrit)
- electrolyte disturbance (Common abnormalities include hypokalemia, hyponatremia, and metabolic alkalosis (from vomiting). Ketosis may also be present due to starvation.)
What is the relationship between smoking and hyperemesis gravidarum?
smoking associated with lower risk of hypermesis.
*Nicotine may reduce HCG levels.
What are 3 indications for admission in hyperemesis gravidarum?
- Continued N+V + unable to keep down liquids or oral antiemetics
- Continued N+V with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
- Confirmed or suspected comorbidity (e.g. unable to tolerate oral abx for UTI)
+ lower threshold if comorbidity e.g. diabetes
What are 4 steps to the management of hyperemesis gravidarum?
- simple measures - avoid triggers, bland food, ginger, P6 (wrist) acupuncture
- first line: antihistamines/phenothiazines
- second line: ondansetron, metoclopramide, domperidone
- admission, IV hydration
What is the first line drug treatment for hypermesis gravidarum?
- antihistamines: oral cyclizine or promethazine
- phenothiazines: oral prochlorperazine or chlorpromazine
- combination drug doxylamine/ pyridoxine
What are the second-line drug options to treat hyperemesis gravidarum?
- oral ondansetron
- oral domperidone or metoclopramide (5 day smax - EPSEs)
What is the risk of ondansetron use in pregnancy?
in first trimester - risk of cleft palate
What is the standard screening test for Down syndrome?
- nuchal translucency measurement AND
- serum B-HCG + pregnancy-associated plasma protein A (PAPP-A)
What screening test results are suggestive of Down syndrome, from the combined test?
- increased beta HCG
- reduced PAPP-A
- thickened nuchal transclucency
What is offered to women for Down syndrome screening in pregnancy if they present late, and when?
- quadruple test (alfa-feto protein, unconjugated oestriol, hCG, inhibin A)
- 15-20 weeks
- DS suggested by raised hCG and inhibin, reduced AFP, unconjugated oestriol)
What does NIPT for Down screening involve?
- analyses small DNA fragments that circulate in the blood of a pregnant woman (cell free fetal DNA, cffDNA)
- cffDNA derives from placental cells and is usually identical to fetal DNA
*not diagnosti5dc; need for invasive testing like amniocentesis and CVS.
high sensitivity and specificity
What is a mnemonic to remember drugs contraindicated in breastfeeding?
BREAST MLCCC
* B: bromocriptine, benzodiazepines
* R: radioactive drugs, rizatriptan
* E: ergometrine
* A: aspirin, amiodarone, alcohol, atropine
* S: sulphonamides, sulphonylureas
* T: tetracyclines, (iso)tretinoin
* M: methotrexate
* L: lithium
* C: ciprofloxacin
* C: carbimazole
* C: chloramphenicol
What is a management of a blocked duct in a breastfeeding woman?
continue breastfeeding, seek advice re: positioning of the baby
breast massage
What is the management of nipple candidiasis in breastfeeding mother?
- treat mother + baby for nipple candidiasis + breast feeding should continue
- mother - miconazole, baby - nystatin for oral mucosa
What is the first line treatment for mastitis in breast feeding women?
- flucloxacillin 10-14 days
- breastfeeding or expressing should continue during treatment
What are 3 indications to treat mastitis in a breastfeeding mother?
- systemically unwell
- nipple fissure present
- symptoms don’t improve after 12-24h of effective milk removal or culture indicates infection
What is the cause of bilateral breast pain and redness in the first few days after an infant is born, with pain worst just before a feed?
breast engorgement
What may help relieve the pain of breast engorgement in a breastfeeding mother?
hand expression of milk
What is the presentation of Raynaud’s disease of the nipple in a breastfeeding woman?
intermittent pain present during + immediately after feeding; blanching of nipple, followed by cyanosis + or erythema
What are the treatment options for Raynaud’s disease of the nipple?
- minimising cold exposure
- heat packs after breastfeed
- avoiding caffeine
- stop smoking
- specialist input: oral nifedipine (off license)
What are 3 types of skin disorders in pregnancy?
- Atopic eruption of pregnancy
- Polymorphic eruption of pregnancy
- Pemphigoid gestationis
What is the commonest skin disorder of pregnancy?
Atopic eruption of pregnancy
What are 3 key differences between polymorphic eruption of pregnancy and pemphigoid gestationis?
- PEP occurs in abdominal striae, PG is in periumbilical region, can spread to trunk/back/buttocks/arms
- PG lesions are blistering
- PEP in 3rd trimester, PG in 2nd and 3rd
- PEP treated with emollients/topical steroid/PO steroid, PG always with oral steroid
What are 6 examination findings which are the normal physiological changes of pregnancy (considered pathological otherwise)?
- increased heart rate (and increase in stroke volume = inc CO)
- decreased BP in 1st/2nd trimesters
- bounding / collapsing pulse
- ejection systolic murmur (>90% of women)
- loud firs theart sound / sometimes third heart sound
- increase in tidal volume (but not resp rate)
What type of metabolic abnormality is normal in pregnancy?
mild fully compensated respiratory alkalosis
What happens to thyroid function during pregnancy?
- increase in total T4 and T3 in first half of pregnancy, but normal/slightly low free hormone due to increased TBG binding
- normal ranges of T4 and T3 slightly low in 2nd + 3rd trimester
- TSH production stimulated after first trimester only slightly - large rise indicates iodine deficiency
Why are pregnant women at increased risk of renal stones?
increased urinary calcium excretion in pregnancy
What are 4 ECG changes considered normal in pregnancy?
- LAD
- small Q waves and inverted T wave in lead III
- ST depression and inversion or flattening of T wave in inferior and lateral leads
- atrial and ventricular ectopics
What are 3 changes that would be seen on spirometry in pregnancy?
- increased tidal volume
- increased vital capacity
- reduced residual volume
RR doesn’t change
What is the mechanism of action of levonorgestrel (levonelle) pill for emergency contraception?
delays ovulation - prevents follicular rupture and causes luteal dysfunction
How many days from conception does it take for serum hCG to be detectable?
11 days (in 98% of patients)
What are the rules for gravida / para shorthand?
- G = total number of pregnancies
- includes current pregnancy
- if multiple e.g. twins - counts as one
- includes any miscarriages
- P = X + Y
- X = number of pregnancies beyond 24 weeks (twins count as 1, still birth >24w counts as 1 )
- Y = any miscarriages/terminations/ectopics <24w
What weeks are considered pre term and post-term?
- pre term: < 37
- post term: >42
What is the recommended management of hyperthyroidism e.g. Graves disease in pregnancy?
- trimester 1 / attempting conception: propylthiouracil
- trimester 2/3: carbimazole
What is the next step if a woman has a ‘higher chance’ of a baby with Down syndrome from initial screening tests (combined or quadruple testing)?
- 2nd screening test: non-invasive prenatal test NIPT
- diagnostic test: CVS, amniocentesis
What is the management of suspected pre-eclampsia?
emergency secondary care assessment for any woman in whom it is suspected
