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OBGYN Flashcards

1
Q

PCOS diagnostic criteria?

A

2/3 of the following present:

  1. Infrequent or no ovulation (oligomenorrhoea)
  2. Clinical or biochemical signs of hyperandrogenism or elevated levels of total or free testosterone
  3. Polycystic ovaries on USS (>12) or increased ovarian volume
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2
Q

Primary vs secondary PPH

A

Primary within 24hours of delivery (4Ts)

Secondary 24hrs-6 weeks (retained placenta or endometriosis)

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3
Q

Combined test

A

11 - 13+6

BHCG, PAPP-A, NT

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4
Q

Quadruple test

A

15-20

AFP, unconjugated oestriol, BHCG, Inhibin A

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5
Q

Criteria for lactational amenorrhea

A

amenorrhoeic, <6 months post-partum, and breastfeeding exclusively

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6
Q

Diagnosistic TRIAD of Hyperemesis Gravidarum

A
  • 5% pre-pregnancy weight loss
  • dehydration
  • electrolyte imbalance
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7
Q

Admission criteria for Hyperemesis Gravidarum

A
  • Continued nausea and vomiting and unable to keep down liquids or oral antiemetics
  • Continued nausea and vomiting with ketonuria and/or weight loss (>5% of PPBW), despite treatment with oral antiemetics
  • A confirmed or suspected comorbidity
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8
Q

Scoring system for ‘nausea and vomiting of pregnancy’ (NVP)

A

Pregnancy-Unique Quantification of Emesis (PUQE)

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9
Q

Amsel’s criteria for diagnosis of bacterial vaginosis

A

3/4 should be present:

  • thin, white homogenous discharge
  • clue cells on microscopy: stippled vaginal epithelial cells
  • vaginal pH > 4.5
  • positive whiff test (addition of potassium hydroxide results in fishy odour)
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10
Q

BV treatment

A

Oral metronidazole

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11
Q

Gonorrhoea treatment

A

IM ceftriaxone

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12
Q

Contraceptives - time until effective (if not first day period)

A
  • instant: IUD
  • 2 days: POP
  • 7 days: COC, injection, implant, IUS
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13
Q

At which week should you refer to an obstetrician for lack of fetal movements?

A

24 weeks

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14
Q

Past 28 weeks, when should you refer to an obstetrician for further assessment.

A

less than 10 movements within 2 hours

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15
Q

MAD POPS

RF for reduced foetal movement

A
  • Medications ie alcohol, benzos, opiates
  • Amniotic fluid volume ie. oligo and polyhydramnios
  • Distraction
  • Posture
  • Obesity
  • Position of foetus
  • Size of foetus
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16
Q

Investigation for reduced foetal movement

A

Handheld Doppler or ultrasonography

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17
Q

Investigation for reduced foetal movement

A

>28 weeks = HHD

  • No HB → USS
  • HB present → CTG for 20mins

24-28 weeks OR <24 weeks and movement felt previously = HHD

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18
Q

CHAT

High risk groups for hypertensive disorders in pregnancy

A
  • chronic kidney disease
  • hypertensive disease during previous pregnancies
  • autoimmune disorders such as SLE or antiphospholipid syndrome
  • type 1 or 2 diabetes mellitus
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19
Q

What should woman who are high risk for Htn in pregnancy be taking

A

Aspirin 75mg od from 12 weeks until the birth of the baby

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20
Q

Htn in pregnancy values

A
  • systolic > 140 mmHg or diastolic > 90 mmHg
  • or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
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21
Q

Pre-eclampsia

A

PIH in association with proteinuria (> 0.3g / 24 hours)

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22
Q

Mx for pyrexia >38 degrees during labour

A
  • Benzylpenicillin as GBS prophylaxis
  • Vancomycin if known severe penicillin allergy
  • Erythromycin in PPROM
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23
Q

4Ps

RF for GBS infection

A
  • prematurity
  • prolonged rupture of the membranes
  • previous sibling GBS infection
  • Pyrexia e.g. secondary to chorioamnionitis
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24
Q

Preveous GBS detected or preveous baby with GBS disease

A
  • Council re 50% increased risk
  • Offer IPA OR
  • testing in late pregnancy (if + offer IAP)
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25
Q

Indications to offer IPA

A
  • GBS detected in a previous pregnancy
  • Previous baby with GBS disease
  • Preterm labour regardless of their GBS status
  • Pyrexia during labour (>38ºC)
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26
Q

What bacteria causes GBS

A

Streptococcus agalacticae (gram + cocci in chains)

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27
Q

Lochia

A

Vaginal discharge containing blood, mucous and uterine tissue which may continue for 6 weeks after childbirth

Ultrasound indicated if lochia persists >6 weeks

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28
Q

Lochia

A

Vaginal discharge containing blood, mucous and uterine tissue which may continue for 6 weeks after childbirth

Ultrasound indicated if lochia persists >6 weeks

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29
Q

In what trimester do Intrahepatic cholestasis of pregnancy and fatty liver of pregnancy occur

A

3rd

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30
Q

Features of Intrahepatic cholestasis of pregnancy

A
  • pruritus, often in palms and soles
  • no rash
  • raised bilirubin
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31
Q

Mx of Intrahepatic cholestasis of pregnancy

A
  • ursodeoxycholic acid for symptomatic relief
  • weekly liver function tests
  • Induction at 37 weeks
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32
Q

Intrahepatic cholestasis of pregnancy complication

A

Stillbirth

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33
Q

Acute fatty liver of pregnancy features

A
  • abdominal pain
  • nausea & vomiting
  • headache
  • jaundice
  • hypoglycaemia
  • severe disease may result in pre-eclampsia
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34
Q

Investigation for Acute fatty liver of pregnancy

A

Elevated ALT e.g. 500 u/l

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35
Q

Management of acute fatty liver of pregnancy

A
  • support care
  • once stabilised delivery is the definitive management
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36
Q

Screening for anaemia in pregnancy

A
  • The booking visit (8-10 weeks) AND
  • 28 weeks
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37
Q

Cut-offs for oral iron therapy in pregnancy

A
  • First trimester< 110 g/L
  • Second/third trimester< 105 g/L
  • Postpartum< 100 g/L
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38
Q

Management of anaemia in pregnancy

A
  • oral ferrous sulfate or ferrous fumarate
  • Continue Tx for 3 months after iron deficiency is corrected to allow iron stores to be replenished
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39
Q

Pathophysiology of acute fatty liver of pregnancy

A
  • Due to long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus (AD)
  • Fetus and placenta are unable to break down fatty acids.
  • Fatty acids enter maternal circulation, and accumulate in liver → inflammation and liver failure.
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40
Q

The combined test

A
  • Between 11 - 13+6 weeks
  • NT + serum B-HCG + PAPP-A
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41
Q

Combined test findings for Down’s, Edwards and Pataus

A
  • Down’s syndrome = ↑ HCG, ↓ PAPP-A, thickened NT
  • Edward (18) and Patau (13) give similar results but hCG tends to lower
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42
Q

The quadruple test

A
  • 15 - 20 weeks
  • AFP, unconjugated oestriol, B-HCG and inhibin A
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43
Q

Quadruple test findings for Down’s, Edwards and Pataus

A
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44
Q

What is meant by ‘lower chance’ and ‘higher chance’ on combined and quadruple test results

A
  • ‘lower chance’: 1 in 150 chance or more e.g. 1 in 300
  • ‘higher chance’: 1 in 150 chance or less e.g. 1 in 100
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45
Q

‘Higher chance results’ next steps

A

Offered NIPT or a diagnostic test (e.g. amniocentesis or CVS)

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46
Q

NIPT

A
  • analyses cell free fetal DNA, cffDNA → Derived from placental cells and identical to fetal DNA
  • High sensitivity and specificity (esp for trisomy 21)
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47
Q

CVS vs amniocentesis

A
  • CVS → USSguided biopsy of the placental tissue. Used when testing is done earlier in pregnancy (before 15 weeks), 2% risk miscarriage
  • Amniocentesis → USS-guided aspiration of amniotic fluid. Used later in pregnancy, 1% risk miscarriage
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48
Q

ABRUPTION

RF for placental abruption

A
  • Abruption previously
  • BP (i.e. Htn or pre-eclampsia);
  • Ruptured membranes (premature or prolonged)
  • Uterine injury
  • Polyhydramnios;
  • Twins
  • Infection
  • Older age (>35)
  • Narcotic use (i.e. cocaine, smoking)
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49
Q

Clinical features of placental abruption

A
  • Sudden onset, continue severe abdo pain
  • Vaginal bleeding
  • Shock
  • CTG indicating fetal distress
  • “woody” abdomen on palpation →large haemorrhage
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50
Q

Concealed vs revealed abruption

A

Concealed: cervical OS closed, most bleeding remains within uterine cavity

Revealed: blood loss is observed via vagina

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51
Q

7: ECB CF CC

Initial steps to manage major haemorrhage

A
  • Escalate to senior obstetrician, midwife, anaesthetist
  • 2x grey cannula
  • Bloods - FBC, UE, LFT, coagulation studies
  • Crossmatch 4 units of blood
  • Fluid and blood resus as required
  • CTG monitoring of foetus
  • Close monitoring of mother
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52
Q

Definitive Mx of abruption

A

Fetus alive and < 36 weeks

  • fetal distress: immediate caesarean
  • no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation

Fetus alive and > 36 weeks

  • fetal distress: immediate caesarean
  • no fetal distress: deliver vaginally

Fetus dead

  • induce vaginal delivery
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53
Q

How to determine what dose of Anti-D prophylaxis is required

A

Kleihaur test to quantify amount of Fatal blood mixed with maternal blood → determine dose of Anti-D

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54
Q

Maternal complications of abruption

A
  • shock
  • DIC
  • renal failure
  • PPH
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55
Q

foetal complications of abruption

A
  • IUGR
  • hypoxia
  • death
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56
Q

RF for GD

A
  • BMI of > 30 kg/m²
  • previous macrosomic baby weighing 4.5 kg or above
  • previous gestational diabetes
  • first-degree relative with diabetes
  • family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
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57
Q

Screening for GD

A

OGTT

  • Previous GD → perform OGTT asap after Booking AND at 24-28 weeks if first test is normal
  • Any of the other risk factors → OGTT at 24-28 weeks
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58
Q

Diagnosis of GD

A
  • fasting glucose is >= 5.6 mmol/L
  • 2-hour glucose is >= 7.8 mmol/L
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59
Q

Mx of GD

A

<7mmol/l

  1. Trial of diet and exercise for 1-2 weeks
  2. Metformin
  3. Short acting insulin

>7mmol/l → Insulin

>6 mmol/l + complications ie. macrosomia or hydramnios → Insulin

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60
Q

Management of pre-existing diabetes

A
  • weight loss if BMI > 27 kg/m^2
  • Stop oral hypoglycaemics, apart from metformin, and commence insulin
  • folic acid 5 mg/day from pre-conception to 12 weeks gestation
  • detailed anomaly scan at 20 weeks incl four-chamber view of heart and outflow tracts
  • tight glycaemic control reduces complication rates
  • treat retinopathy as can worsen during pregnancy
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61
Q

Targets for self monitoring of pregnant women (pre-existing and gestational diabetes)

A
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62
Q

Alternative to metformin or insulin for GD

A

Glibenclamide (a sulfonylurea)

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63
Q

Retinopathy screening for pre-existing diabetes in pregnancy

A

Should be performed shortly after booking AND at 28 weeks

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64
Q

CHAT

High RF for pre-eclampsia

A
  • CKD
  • Hypertensive disease in previous pregnancy or pre-existing Htn
  • Autoimmune disorders (SLE, APS)
  • Type 1 or type 2 Diabetes
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65
Q

Moderate RF for pre-eclampsia

A

BMI > 35

Age > 40

Multiple pregnancy

First pregnancy or >10 years since last pregnancy

FxH of pre-eclampsia

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66
Q

How to rule out pre-eclampsia

A

Placental growth factor (PlGF) between 20-35 weeks to rule of pre-eclampsia

In pre-eclampsia PlGF is LOW

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67
Q

Scoring system to determine whether woman with pre-eclampsia should be admitted

A

fullPIERS and PREP-S

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68
Q

Medical Mx of pre-eclampsia

A
  1. Labetolol
  2. Nifedipine (modified-release)
  3. Methyldopa (stop within two days of birth)

Severe pre-eclampsia OR eclampsia → hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia

During labour → IV magnesium sulphate (cont for 24 hours afterwards)

Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

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69
Q

The Bishop scoring system

A
  • Assess the need for induction
  • Position, consistency, effacement and dilatation and foetal station
  • Score < 5 means induction will likely be necessary
  • Score ≥ 8 indicates labour will likely occur spontaneously
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70
Q

Indications for Induction of labour

A
  • Prolonged pregnancy
  • PPROM, where labour does not start
  • Diabetic mother > 38 weeks
  • Pre-eclampsia
  • Rhesus incompatibility
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71
Q

Induction methods

A
  • vaginal prostaglandin E2 (PGE2)
  • membrane sweep
  • maternal oxytocin infusion
  • amniotomy
  • cervical ripening balloon
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72
Q

Main complication of induction of labour

Management

A

Uterine hyperstimulation

Mx

  • Remove vaginal prostaglandin and stop oxytocin.
  • Start tocolysis with terbutaline
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73
Q

Causes of Increased AFP

A
  • NTD
  • Abdominal wall defects
  • Multiple pregnancy
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74
Q

Causes of Decreased AFP

A
  • Down’s syndrome
  • Trisomy 18
  • Maternal diabetes mellitus
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75
Q

3 types of placenta accreta

A
  • accreta: chorionic villi attach to myometrium
  • increta: chorionic villi invade the myometrium
  • percreta: chorionic villi invade through the perimetrium
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76
Q

Screening for postpartum depression

A

Edinburgh Postnatal Depression Scale

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77
Q

Causes of folic acid deficiency

A
  • phenytoin
  • methotrexate
  • pregnancy
  • alcohol excess
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78
Q

Prevention of NTD during pregnancy

A
  • All women should take 400mcg of folic acid until 12th week of pregnancy
  • High risk woman should take 5mg of folic acid from before conception until the 12th week of pregnancy
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79
Q

High risk for NTD

A
  • Either partner has a NTD
  • Previous pregnancy with NTD
  • FxH of NTD
  • Antiepileptic drugs
  • Coeliac disease, diabetes, or thalassaemia trait
  • BMI of 30 kg/m2 or more
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80
Q

PPH primary vs secondary

A

PPH is blood loss of > 500 ml after a vaginal delivery

  • Primary within 24 hours
  • Secondary PPH occurs between 24 hours - 6 weeks
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81
Q

Risk factors for primary PPH

A
  • previous PPH
  • prolonged labour
  • pre-eclampsia
  • Emergency C-section
  • placenta praevia, placenta accreta
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82
Q

Management of PPH

A
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83
Q

RA drugs safe in pregnancy

A

sulfasalazine and hydroxychloroquine

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84
Q

When to stop Methotrexate

A

Both partners should stop 6 months before trying to conceive

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85
Q

Clinical features of Placenta praevia

A
  • shock in proportion to visible loss
  • no pain
  • uterus not tender
  • lie and presentation may be abnormal
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86
Q

Diagnosis of placenta praevia

A

20-week anomaly scan to diagnose placenta praevia

Repeat TVS at:

  • 32 weeks gestation
  • 36 weeks gestation (if present at 32-week scan,
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87
Q

RCOG definitions of placenta praevia

A
  • Low-lying placenta → placenta is within 20mm of internal cervical os
  • Placenta praevia → placenta is over the internal cervical os
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88
Q

Classical grading of placenta praevia

A
  • I - placenta reaches lower segment but not the internal os
  • II - placenta reaches internal os but doesn’t cover it
  • III - placenta covers the internal os before dilation but not when dilated
  • IV (‘major’) - placenta completely covers the internal os
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89
Q

Management of placenta praevia

A
  • Elective c-section for grades III/IV at 37-38 weeks
  • If grade I then trial of vaginal delivery may be offered

If a woman with known placenta praevia goes into labour prior to elective c-section → emergency c-section

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90
Q

Mx of placenta praevia with bleeding

A
  • admit
  • ABC approach to stabilise the woman
  • if not able to stabilise → emergency caesarean section
  • if in labour or term reached → emergency caesarean section
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91
Q

2 absolute indications for a C-section

A
  • absolute cephalopelvic disproportion
  • placenta praevia grades 3/4
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92
Q

Planned VBAC

A

Appropriate method of delivery for women at >= 37 weeks with a single previous Caesarean delivery

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93
Q

2 CI to VBAC

A
  • Previous uterine rupture
  • Classical caesarean scar
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4
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94
Q

Anti-D routine IM injections

A

Rhesus negative mothers

  • 28 weeks
  • Birth (if babies blood group found to be positive)
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95
Q

Anti-D additional indications ie. sensitising events

A
  • antepartum haemorrhage
  • amniocentesis
  • abdominal trauma
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96
Q

Within what timeframe of a sensitising event is Anti-D given

A

72 hours

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97
Q

What is the Kleinhauer test

A
  • Performed after any sensitising event >20 weeks
  • Checks how much foetal blood has passed into maternal circulation
  • Determines dose of Anti-D
98
Q

Anticoagulants in pregnancy

A
  • NOACs are CI in pregnancy
  • Women already on NOACs should be switched to LMWH
99
Q

Management of chickenpox exposure in pregnancy

A

If doubt about mothers exposure hx → check for varicella antibodies

If not immune:

  • <= 20 weeks → VZIG asap
  • > 20 weeks → either VZIG or antivirals (aciclovir or valaciclovir) 7 to 14 days after exposure
100
Q

SSRIs of choice in breastfeeding women

A

Sertraline or paroxetine

101
Q

PPROM complications (foetal and maternal)

A
  • fetal: prematurity, infection, pulmonary hypoplasia
  • maternal: chorioamnionitis
102
Q

Investigation for PPROM

A
  • Sterile speculum examination → look for pooling of amniotic fluid in posterior vaginal vault
  • Ultrasound may be useful to show oligohydramnios
103
Q

What investigation is CI in PPROM

A

Digital examination due to the risk of infection

104
Q

Management of PPROM

A
  • admit
  • Regular obs to ensure chorioamnionitis is not developing
  • oral erythromycin should be given for 10 days
  • corticosteroids to reduce risk of RDS
  • consider delivery at 34 weeks
105
Q

RF for shoulder dystocia

A
  • fetal macrosomia
  • high maternal BMI
  • DM
  • prolonged labour
106
Q

Mx shoulder dystocia

A

McRoberts’ manoeuvre

(flexion and abduction of hips, mother’s thighs towards abdomen)

107
Q

Maternal and foetal complications of shoulder dystocia

A

Maternal

  • PPH
  • perineal tears

Fetal

  • brachial plexus injury
  • neonatal death
108
Q

Stages of postpartum thyroiditis

A
  1. Thyrotoxicosis
  2. Hypothyroidism
  3. Normal thyroid function
109
Q

Antibody in postpartum thyroiditis

A

Thyroid peroxidase antibodies are found in 90% of patients

110
Q

Management of postpartum thyroiditis

A

Thyrotoxic phase → propranolol for symptom control

Hypothyroid phase → thyroxine

111
Q

Booking visit

A

8 - 12 weeks (ideally < 10 weeks)

  • Booking bloods/urine
  • urine culture to detect asymptomatic bacteriuria
112
Q

Early scan to confirm dates, exclude multiple pregnancy

A

10 - 13+6 weeks

113
Q

Down’s syndrome screening including NT

A

11 - 13+6 weeks

114
Q

Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron

Routine care: BP and urine dipstick

115
Q

Anomaly scan

A

18 - 20+6 weeks

116
Q

Routine care: BP, urine dipstick, symphysis-fundal height (SFH)

A

25 weeks (only if primip)

117
Q

Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron

118
Q

First dose of anti-D prophylaxis to rhesus negative women

119
Q

Second dose of anti-D prophylaxis to rhesus negative women*

120
Q

Check presentation - offer external cephalic version if indicated

121
Q

Most common breech

A

A frank breech → hips flexed, knees fully extended.

122
Q

Breech associated with greatest mortality and morbidity

A

Footling breech, → one or both feet come first with the bottom at a higher position

123
Q

RF for breech

A
  • uterine malformations ie. fibroids
  • placenta praevia
  • polyhydramnios or oligohydramnios
  • fetal abnormality
  • prematurity
124
Q

Breech position increases risk of what complication

A

cord prolapse

125
Q

Mx of breech

A
  • ECV from 36 weeks in nulliparous women
  • ECV from 37 weeks in multiparous women

If still breech → planned caesarean section or vaginal delivery

126
Q

‘MAMA R’ can’t have ECV

Absolute CIs to ECV

A
  • Multiple pregnancy
  • Antepartum haemorrhage within last 7 days
  • Major uterine anomaly
  • Abnormal CTG
  • Ruptured membranes
127
Q

Antenatal complications of twins

A
  • polyhydramnios
  • pregnancy induced hypertension
  • anaemia
  • antepartum haemorrhage
128
Q

Fetal complications of twins

A
  • prematurity
  • light-for date babies
  • malformation
129
Q

Labour complications of twins

A
  • PPH increased
  • malpresentation
  • cord prolapse, entanglement
130
Q

Mx twins during pregnancy

A
  • Rest
  • USS for diagnosis + monthly checks
  • additional iron + folate
  • more antenatal care (e.g. weekly > 30 weeks)
  • precautions at labour (eg. 2 obstetricians)
131
Q

TTTS affects what type of twins?

A

Monochorionic twins (share placenta)

132
Q

How does TTTS affect the foetuses

A

Placental BV abnormalities mean ‘donor’ foetus receives less placental BF than ‘recipient’ foetus

  • Recipient → fluid-overloaded
  • Donor → anaemic
  • Differences in urine production → one may have oligohydramnios and other may have polyhydramnios
133
Q

Investigation for TTTS

A
  • Usually occurs in early or mid-pregnancy
  • USS at 16 and 24 weeks focus on detecting TTTS
  • >24 weeks purpose of USS is to detect IUGR
134
Q

FORCEPS

Requirements for instrumental delivery

A
  • Fully dilated cervix
  • OA position (OP possible with Keillands forceps and ventouse)
  • Ruptured Membranes
  • Cephalic presentation
  • Engaged presenting part
  • Pain relief
  • Sphincter (bladder) empty
135
Q

Indications for instrumental delivery

A
  • Prolonged active second stage
  • Maternal exhaustion
  • Foetal distress
  • Breech presentation
136
Q

Puerperal pyrexia

A

temperature of > 38ºC in the first 14 days following delivery

137
Q

Causes of Puerperal pyrexia

A
  • Endometritis: most common cause
  • UTI
  • Wound infections (perineal tears, c-section)
  • Mastitis
  • VTE
138
Q

Mx of puerperal pyrexia

A

If endometritis is suspected → refer to hospital for IV Abx

Clindamycin and gentamicin until afebrile for >24 hours

139
Q

Types of endometrial hyperplasia

A
  • simple
  • complex
  • simple atypical
  • complex atypical
140
Q

Mx of endometrial hyperplasia

A

Simple EH without atypia:

  • High dose progestogens + repeat sampling in 3-4 months
  • ie. levonorgestrel IUS

Atypia: Hysterectomy

141
Q

Features of fibroids

A
  • Asymptomatic
  • Menorrhagia (→ Iron-deficiency anaemia)
  • Bulk-related symptoms
  • Sub-fertility
141
Q

Features of fibroids

A
  • Asymptomatic
  • Menorrhagia (→ Iron-deficiency anaemia)
  • Bulk-related symptoms
  • Sub-fertility
142
Q

Bulk related symptoms of fibroids

A
  • lower abdo pain: cramping pains, often during menstruation
  • bloating
  • urinary symptoms eg. frequency
143
Q

Rare feature of fibroids

A

Polycythaemia secondary to autonomous production of erythropoietin

144
Q

Rare feature of fibroids

A

Polycythaemia secondary to autonomous production of erythropoietin

145
Q

Diagnosis of fibroids

146
Q

Mx asymptomatic fibroids

A

No treatment is needed other than periodic review to monitor size and growth

147
Q

Mx of menorrhagia secondary to fibroids

A
  • levonorgestrel IUS
  • NSAIDs e.g. mefenamic acid
  • Tranexamic acid
  • COCP
  • progestogen (oral or injectable
148
Q

Medical Tx to shrink/remove fibroids

A

Medical

  • GnRH agonists may reduce size of fibroid

Surgical

  • myomectomy
  • hysteroscopic endometrial ablation
  • hysterectomy
  • uterine artery embolization
149
Q

Why are GnRH agonists used short term?

A

Side-effects → menopausal symptoms

  • Hot flushes
  • Vaginal dryness
  • Loss of BMD
150
Q

Complications of fibroids

A
  • Subfertility
  • Iron-deficiency anaemia
  • Red degeneration → haemorrhage into tumour, commonly occurs during pregnancy
151
Q

Mx miscarriage

A
  1. Expectant - wait 7-14 days
  2. Medical - vaginal misoprostol
  3. Surgical - vacuum aspiration (suction curettage) or surgical management in theatre
152
Q

Types of urogenital prolapse

A
  • cystocele, cystourethrocele
  • rectocele
  • uterine prolapse
  • less common: urethrocele, enterocele (herniation of POD, incl SI into vagina)
153
Q

RF for urogenital prolapse

A
  • increasing age
  • multiparity, vaginal deliveries
  • obesity
  • spina bifida
154
Q

Mx of urogenital prolapse

A
  • if asymptomatic and mild → no tx
  • conservative: weight loss, pelvic floor exercises
  • ring pessary
  • surgery
155
Q

Surgical options for urogenital prolapse

A

Cystocele/cystourethrocele → anterior colporrhaphy, colposuspension

Uterine prolapse → hysterectomy, sacrohysteropexy

Rectocele → posterior colporrhaphy

156
Q

Clinical features of endometriosis

A
  • chronic pelvic pain
  • secondary dysmenorrhoea
  • deep dyspareunia
  • subfertility
157
Q

non-gynaecological features of endometriosis

A
  • Urinary symptoms e.g. dysuria, urgency, haematuria.
  • Dyschezia (painful bowel movements)
158
Q

non-gynaecological features of endometriosis

A
  • Urinary symptoms e.g. dysuria, urgency, haematuria.
  • Dyschezia (painful bowel movements)
159
Q

Pelvic exam findings of endometriosis

A
  • Reduced organ mobility
  • Tender nodularity in posterior vaginal fornix
  • Visible vaginal endometriotic lesions may be seen
160
Q

Investigation for endometriosis

A

laparoscopy is the gold-standard

161
Q

Mx of endometriosis

A
  1. NSAIDs and/or paracetamol
  2. COCP or progestogens

If no response to above → refer to secondary care for GnRH analogues or surgery

162
Q

Primary vs secondary dysmenorrhea

A

Primary

  • No underlying pelvic pathology
  • Pain typically starts just before or within a few hours of period starting

Secondary

  • Due to underlying pathology
  • Pain usually starts 3-4 days before period
163
Q

Mx dysmenorrhea

A

Primary

  1. NSAIDs ie. mefenamic acid and ibuprofen are
  2. COCP

Secondary → refer to gynaecology for investigation

164
Q

Primary amenorrhea

A

Primary amenorrhoea is defined as not starting menstruation:

  • By 13 years when there is no other evidence of pubertal development
  • By 15 years of age where there are other signs of puberty ie breast bud development
165
Q

Secondary amenorrhea

A
  • No menstruation for > 3 months after previous regular menstrual periods.
  • No menstruation for 6-12 months in women with previously infrequent irregular periods
166
Q

Causes of primary vs secondary amenorrhea

167
Q

Investigations for amenorrhea

A
  • Exclude pregnancy
  • FBC, UE, coeliac screen, TFT
  • Gonadotrophins
  • Prolactin
  • Androgen levels
  • Oestradiol
168
Q

Gonadotrophin results for amenorrhea

A
  • LOW = hypothalamic cause, RAISED = ovarian problem (POF)
  • RAISED if gonadal dysgenesis (e.g. Turner’s syndrome)
169
Q

Cervical screening

A
  • 25-49 years: 3-yearly screening
  • 50-64 years: 5-yearly screening
170
Q

Cervical screening in pregnancy

A

Usually delayed until 3 months post-partum

171
Q

Bleeding in the first trimester

A

Symptoms suggesting ectopic → EPAU

  • pain and abdominal tenderness
  • pelvic tenderness
  • cervical motion tenderness

>6 weeks → EPAU for TVS

<6 weeks and no pain → Expectant, repeat pregnancy test in 7 days

172
Q

Cervical cancer RF

A
  • HPV 16,18 & 33
  • smoking
  • HIV
  • early first intercourse, many sexual partners
  • high parity
  • lower socioeconomic status
  • COCP
173
Q

Mechanism of HPV causing cervical cancer

A

HPV 16 & 18 produces oncogenes E6 and E7

  • E6 inhibits the p53 TSG
  • E7 inhibits RB suppressor gene
174
Q

RF ovarian cancer

A
  • FxH: BRCA1 or BRCA2
  • Many ovulations: early menarche, late menopause, nulliparity
175
Q

Investigation for ovarian cancer

A
  1. Abdo and pelvic exam
  2. CA125
  3. USS

Refer to gynaecology if an abdo exam demonstrates ascites or pelvic or abdominal mass

176
Q

Basic investigations for infertility

A
  • semen analysis
  • Progesterone 7 days prior to expected next period
177
Q

Interpretation of day 21 progesterone in assessing fertility

178
Q

Key counselling points for fertility

A
  • folic acid
  • aim for BMI 20-25
  • advise regular sexual intercourse every 2 to 3 days
  • smoking/drinking advice
179
Q

Initial imaging modality for suspected ovarian cysts/tumours

A

USS

  • simple: unilocular, likely to be benign
  • complex: multilocular, likely to be malignant
180
Q

Cysts in pre vs post-menopausal women

A

Premenopausal

  • Conservative approach as malignancy is less common
  • If < 5 cm and ‘simple’ then likely to be benign.
  • Repeat USS for 8-12 weeks, refer if persists

Postmenopausal

  • REFER for assessment regardless of nature or size
182
Q

HRT CIs

A
  • Current or past breast cancer
  • Any oestrogen-sensitive cancer
  • Undiagnosed vaginal bleeding
  • Untreated endometrial hyperplasia
183
Q

What is the only instance where oestrogen can be prescribed for HRT withOUT progesterone?

A

If the woman does NOT have a uterus

(oral or transdermal patch)

184
Q

Mx of vasomotor symptoms of menopause

A

fluoxetine, citalopram or venlafaxine

185
Q

Mx of vaginal dryness due to menopause

A

vaginal lubricant or moisturiser

186
Q

Mx of psychological symptoms of menopause

A

self-help groups, CBT or antidepressants

187
Q

Mx urogenital symptoms of menopause

A

Urogenital atrophy → vaginal oestrogen

Vaginal dryness → moisturisers and lubricants

188
Q

Non-Hormonal Treatments for Menopausal Symptoms

A
  • Lifestyle changes: diet, exercise, weight loss, smoking cessation, reducing alcohol, caffeine and stress
  • Cognitive behavioural therapy (CBT)
  • Clonidine
  • SSRI (eg. Fluoxetine)
  • Venlafaxine (SNRI)
  • Gabapentin
189
Q

Clonidine

A

Agonist of alpha-2 adrenergic receptors and imidazoline receptors

  • Lowers BP and reduces HR
  • Helpful for vasomotor symptoms and hot flushes, particularly if HRT is CI
190
Q

Indications for HRT

A
  • Premature ovarian insufficiency
  • Reducing vasomotor symptoms
  • Improving low mood, decreased libido, poor sleep and joint pain
  • Reducing risk of osteoporosis in <60s
191
Q

Risks of HRT

A

Increased risk of:

  • breast cancer (combined)
  • endometrial cancer
  • VTE
  • stroke and CAD in long term use in older women
192
Q

Ways to reduce the risks of HRT

A
  • Reduce risk of endometrial cancer by adding progesterone in women with a uterus
  • Reduce VTE by using patches
193
Q

Mx of PMS

A

Mild

  • Advice on sleep, exercise, smoking and alcohol
  • Regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates

Moderate

  • new-generation COCP ie. yasmin®

Severe

  • SSRI
  • Continuously or just during the luteal phase eg. day 15–28)
194
Q

Investigation for ectopic pregnancy

195
Q

RF for endometrial cancer

A
  • obesity
  • nulliparity
  • early menarche and late menopause
  • unopposed oestrogen
  • diabetes mellitus
  • tamoxifen
  • PCOS
  • HNPCC
196
Q

Investigation for suspected endometrial cancer

A

women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway

197
Q

Staging of ovarian cancer

A

1: Confined to ovary
2: Outside ovary but within pelvis
3: Outside pelvic but within abdomen
4: Distant metastasis

198
Q

Mx of vaginal candidiasis

A
  • First line oral fluconazole 150 mg as a single dose
  • clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is CI
  • If vulval symptoms, consider adding a topical imidazole
  • If pregnant → only LOCAL treatments (e.g. cream or pessaries)
199
Q

Androgen insensitivity syndrome

A

X-linked recessive

Causes genotypically male children (46XY) to have a female phenotype

200
Q

Most common cause of PMB

A

vaginal atrophy

201
Q

Features of complete hydatidiform mole

A
  • vaginal bleeding
  • uterus size greater than expected for gestational age
  • abnormally high serum hCG
  • ultrasound: ‘snow storm’ appearance of mixed echogenicity
202
Q

3 main categories of anovulation

A

Class 1 → Hypogonadotropic hypogonadal anovulation

  • ie. hypothalamic amenorrhoea

Class 2 → normogonadotropic normoestrogenic anovulation

  • ie. PCOS

Class 3 → hypergonadotropic hypoestrogenic anovulation

  • premature ovarian insufficiency
203
Q

In which class of anovulation are ovulation induction usually unsuccessful?

What is the alternative

A

Class 3 → ie. premature ovarian insufficiency

  • In this class, any attempts at ovulation induction are typically unsuccessful
  • Usually require IVF with donor oocytes
204
Q

Forms of ovulation induction

A
  1. Exercise and weight loss (first line in woman with PCOS)
  2. Letrozole (first line medical therapy in PCOS)
  3. Clomiphene citrate
  4. Gonadotropin therapy (for class 1 ovulatory failure)
205
Q

MoA and SE of Letrozole

A

MoA - aromatase inhibitor

  • Reduces negative feedback of oestrogens to pituitary → increases FSH → promotes follicular development

SE: fatigue and dizziness

206
Q

MoA and SE of Clomiphene

A

MoA - SERMs

  • Blocks negative feedback effect of oestrogens at hypothalamus → increase in GnRH pulse frequency → increases FSH and LH → stimulates follicular development

SE: hot flushes, abdominal distention and pain, nausea and vomiting

207
Q

Why is Letrozole first line compared to Clomiphene and Gonadotropin therapy

A

Rate of mono-follicular development is much higher with letrozole compared to clomiphene and gonadotropin therapy

Gonadotropin therapy is also a/w increased risk of ovarian hyperstimulation syndrome

208
Q

Ovarian hyperstimulation syndrome

A

Ovarian enlargement with multiple cystic spaces + increase in capillary permeability → fluid shift from intravascular to extra-vascular space

Can result in:

  • Hypovolaemic shock
  • Acute renal failure
  • Venous or arterial thromboembolism
209
Q

Management of OHSS

A
  • Fluid and electrolyte replacement
  • Anti-coagulation therapy
  • Abdominal ascitic paracentesis
  • Pregnancy termination to prevent further hormonal imbalances
210
Q

Diagnosing vaginal candidiasis

A

Clinical unless >4 episodes in year (chronic)

211
Q

Investigating chronic vaginal candidiasis

A
  1. Check compliance with past tx
  2. Confirm diagnosis
  • HVS for MCS
  • consider blood glucose to excl diabetes
  • excl ddx ie lichen sclerosus
  1. Consider induction-maintenance regime
  • induction: oral fluconazole every 3 days for 3 doses
  • maintenance: oral fluconazole weekly for 6 months
212
Q

Tx of PID

A
  • oral ofloxacin + oral metronidazole OR
  • IM ceftriaxone + oral doxycycline + oral metronidazole
213
Q

Complications of PID

A
  • Perihepatitis (Fitz-Hugh Curtis Syndrome)
  • Infertility
  • Chronic pelvic pain
  • Ectopic pregnancy
214
Q

Meigs’ syndrome

A

Benign ovarian tumour (usually fibroma) associated with ascites and pleural effusion

215
Q

Staging system for cervical cancer

A

FIGO Staging

I → confined to cervix

II → Extension beyond cervix but not to pelvic wall

III → Extension beyond cervix to the pelvic wall

IV → Extension beyond pelvis OR involvement of bladder or rectum

216
Q

Management of cervical cancer

A

IA

  • hysterectomy +/- lymph node clearance
  • if wanting to preserve fertility → cone biopsy

IB

  • B1 radiotherapy + chemotherapy
  • B2 radical hysterectomy with pelvic lymph node dissection

II, III and IV

  • Radiation + chemotherapy
  • Consider palliative chemo for IVB
217
Q

Need for contraception after the menopause

A
  • 12 months after last period > 50 years
  • 24 months after last period < 50 years
218
Q

Emergency hormonal contraception

A

Levonorgestrel (Levonelle)

  • within 72 hours UPSI
  • H-contraception can be started immediately

Ulipristal (EllaOne)

  • selective progesterone receptor modulator
  • within 120 hours UPSI
  • H-contraception 5 days later

IUD

  • Inserted within 5 days UPSI OR
  • If >5 days, may be fitted upto 5 days after likely ovulation date
219
Q

Postpartum contraception

A

POP

  • can start any time postpartum
  • past day 21 additional contraception for first 2 days
  • small amount enters breast milk but not harmful

COCP

  • UKMEC 4 if breastfeeding < 6 weeks postpartum
  • CI in first 21 days due to VTE risk
  • past day 21 additional contraception for first 7 days

IUD/ IUS

  • Either within 48 hours of childbirth OR after 4 weeks
220
Q

UKMEC categories

A
  1. condition for which there is no restriction for the use of the contraceptive method
  2. advantages generally outweigh the disadvantages
  3. disadvantages generally outweigh the advantages
  4. represents an unacceptable health risk
221
Q

Contraceptive patch regime

A

wear one patch a week for three weeks and do not wear a patch on week four

222
Q

Breastfeed and emergency contraception

A
  • Breastfeeding should be delayed for one week after taking ulipristal
  • No restrictions for levonorgestrel
223
Q

Contraceptive MoAs

224
Q

COCP If 1 pill is missed (at any time in the cycle)

A
  • take last pill even if it means taking two pills in one day and then continue taking pills daily
  • no additional contraception needed
225
Q

COCP If 2 or more pills missed

A

If missed in week 1 (Days 1-7)

  • Emergency contraception if UPSI in pill-free interval or week 1

If missed in week 2 (Days 8-14):

  • No need for emergency contraception so long as pill has be taken for seven consecutive days

If missed in week 3 (Days 15-21):

  • finish pills in current pack and start a new pack the next day (omitting pill free interval)
226
Q

Switching from a traditional POP to COCP

A

7 days of barrier contraception is needed

227
Q

Mode of delivery for HIV in pregnancy

A
  • vaginal delivery recommended if viral load is < 50 copies/ml at 36 weeks
  • Otherwise C-section
  • Zidovudine infusion should be started four hours before C-section
228
Q

Baby born to mother with HIV

A

Requires neonatal antiretroviral therapy

  • Oral Zidovudine to neonate if maternal viral load is <50 copies/ml.
  • Otherwise triple ART for 4-6 weeks
229
Q

Factors which reduce vertical transmission of HIV in pregnancy

A
  • maternal ART
  • c-section
  • neonatal ART
  • bottle feeding
230
Q

Risk malignancy index (RMI)

A

Pre-surgical prognostic criteria for ovarian cancer

  • CA125 levels
  • menopausal status
  • USS score
231
Q

When should VTE prophylaxis be started in pregnancy

A

Start LMWH from:

  • 28 weeks if there are three risk factors
  • First trimester if there are four or more of these risk factors

Risk assessment done at booking and any subsequent admissions

232
Q

Except for RFs, list 4 other senators where VTE prophylaxis is required

A
  • Previous VTE
  • High-risk thrombophilias
  • Hospital admission
  • Surgical procedures
  • Cancer or arthritis
  • OHSS
233
Q

Duration of VTE prophylaxis

A

Continued throughout antenatal period and for 6 weeks postnatally

Temporarily stopped in labour → started immediately after delivery (except with PPH, spinal anaesthesia and epidurals)

234
Q

Alternative if LMWH is CI

A
  • Intermittent pneumatic compression
  • Anti-embolic compression stockings
235
Q

What is required to diagnose a miscarriage

A
  • TVS demonstrating a CRL > 7mm with no cardiac activity
  • 2 different sonographers
236
Q

3 manoeuvres for shoulder dystocia

A
  1. McRoberts - hyperflex and abduct hips, apply suprapubic pressure
  2. Wood’s screw manoeuvre - put hand in vagina and rotate foetus 180 degrees
  3. Rubin manoeuvre - press on posterior shoulder to allow anterior shoulder extra room
237
Q

RF for cord prolapse

A
  • prematurity
  • multiparity
  • polyhydramnios
  • twin pregnancy
  • cephalopelvic disproportion
  • abnormal presentations e.g. Breech, transverse lie
238
Q

Mx cord prolapse

A
  • Push presenting part back into the uterus
  • Minimal handling and keep warm and moist if past introitus
  • ‘all fours’ (L lateral is an alternative)
  • Tocolytics
  • Retrofill the bladder
  • C-section is first-line but if cervix is fully dilated and the head is low, consider instrumental
239
Q

Antiphospholipid syndrome in pregnancy

A

Aspirin + LMWH (disc at 34 weeks)

240
Q

Babies born to mothers who are hep B surface antigen +, or high risk of hepB

A

Hep B vaccine and 0.5 millilitres of HBIG within 12 hours of birth Further second dose at 1-2 months and at 6 months

Finals (8 decks)

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