ObGyn Flashcards
Molar pregnancy classically presents after how many weeks gestation
14
Name some of the symptoms of molar pregnancy?
1) Extreme morning sickness (due to high levels of b-hCG)
2) Heat intolerance and anxiety (due to the b-HCG mimicking TSH properties inducing a state of hyperthyroidism)
3) Vaginal bleeding
“Snowstorm” appearance on pelvic ultrasound is diagnostic of which condition?
Molar pregnancy
What most useful marker to monitor the treatment of molar pregnancy?
Beta human chorionic gondatotropin (b-HCG) to ensure that there is no foetal tissue remaining after evacuation of the products of conception
What is it important to monitor beta human chorionic gondatotropin (b-HCG) whilst treating a molar pregnancy?
To minimise the risk of developing choriocarcinoma
CA-125 is a marker of which kind of ObGyn cancer?
Ovarian cancer
Often used to monitor response to treatment and recurrence
Management of molar pregnancy
Managed by suction evacuation followed by serial beta hCG measurements and surveillance registration
What is the most common cause of postpartum haemorrhage
Uterine atony - the failure for the uterus to contract after delivery due to a lack of tone in the uterine muscle.
What is the major risk factor for uterine atony
Uterine over-distension, as seen in multiple pregnancy
Define Postpartum haemorrhage (PPH)
The loss of at least 500ml of blood within the first 24 hours of delivery.
The 4 causes of postpartum haemorrhage (PPH)
4 ‘T’s
Tone (uterine atony) - failure of the uterus to contract after delivery
Trauma either birth canal injury or tear.
Tissue - retainment of placental or foetal tissue
Thrombin i.e. coagulopathies
Clinical examination signs of uterine atony (postpartum haemorrhage)
Soft and high position of the uterus
Which type of contraception is contraindicated by current pelvic infection
IUS (intrauterine system that releases progesterone)
IUD (intrauterine device which releases copper)
How long can the Intra-uterine device stay for
Up to 10 years
What is the most effective form of emergency contraception
Intra-uterine device
Prevents implantation and can be used 120 hours after the first episode of UPSI or after the earliest expected date of ovulation.
Name an absolute contraindication for vaginal birth after caesarean
Classic caesarean section scar (vertical)
What type of miscarriage
Cervical os is closed
Gestational sac and fetal pole within the uterus
Threatened miscarriage
A process of miscarriage that has started but not yet progressed and thus the foetus remains viable
What type of miscarriage
Cervical os is closed
Uterus contains foetal tissue but no foetal heart beat
No vaginal bleeding
Missed miscarriage
Products of conception in the uterus with absent of foetal heartbeat indicating the foetus has died.
Define miscarriage
Involuntary spontaneous pregnancy loss <24 weeks gestation
What type of miscarriage
Cervical os open
Vaginal bleeding present
Foetal heartbeat on US
Products of contraception are in the uterus
Inevitable miscarriage
Foetus is currently alive i.e. no expulsion of products of conception, but the pregnancy will not continue and will proceed to incomplete or complete miscarriage
What type of miscarriage
Cervical os open
Vaginal bleeding present
No foetal heartbeat on US
Products of contraception are within the cervical canal or uterus
Incomplete miscarriage
No viable pregnancy is present but the products of conception remain in the uterus
What type of miscarriage
Cervical os closed
Vaginal bleeding present
No foetal heartbeat on US
Products of contraception are completely outside of the uterus
Complete miscarriage
The complete passage of all products of conception i.e. uterus is empty, and the cervix is closed
What are the three features to check on a trans-vaginal ultrasound scan to assess foetal viability in a miscarriage
Mean gestational sac diameter
Foetal pole
Foetal heart beat
What is the triad of features of hyperemesis gravidarum
5% prepregnancy weight loss
Dehydration
Electrolyte imbalance
What is the first line medication used for hyperemesis gravidarum
Antihistamines such as oral promethazine or oral cyclizine
Aim to control the nausea and vomiting
What is the classic presentation of Fitz-Hugh-Curtis syndrome
Right upper quadrant pain, sometimes associated with shoulder tip pain due to irritation of the diaphragm.
Commonly a complication of pelvic inflammatory disease, where adhesions (bands of scar tissue) form due to inflammation of the liver capsule
Name a potential complication of pelvic inflammatory disease
Chronic pelvic pain (40%)
Infertility (15%)
Ectopic pregnancy (1%)
Fitz-Hugh-Curtis syndrome (where adhesions (bands of scar tissue) form due to inflammation of the liver capsule)
How is Fitz-Hugh-Curtis syndrome definitively diagnosed
Laparoscopy
What are two common causes of pelvic inflammatory disease
Chlaymidia trachomatis (39%)
Neiserria Gonorrhoea (14%)
What is the name of the diagnostic criteria for Polycystic ovary syndrome
Rotterdam diagnostic criteria
PCOS can be diagnosed if two of the following criteria are present.
Name the 3 criteria
Polycystic ovaries on transabdominal and transvaginal ultrasound
Oligo-/anovulation
Clinical or biochemical features of hyperandrogenism
Name a complication of polycystic ovary syndrome
Infertility
What is the most common organism that causes septic arthritis
Staphylococcus Aureus
Name some of the NICE red flags for ovarian malignancy
Abdominal distension (bloating)
Feeling full (early satiety)
Loss of appetite
Pelvic or abdominal pain
Increased urinary urgency and/or frequency
Older age (>50)
What examination and management option are all women offered at 40 weeks gestation
Vaginal examination and membrane sweep
How are Bartholin’s gland abscess managed
Incision and drainage, with insertion of a word catheter to encourage marsupialisation
Oral antibiotics are usually sufficient to treat the infection
Contraction of chickenpox during the first trimester of pregnancy can lead to congenital varicella syndrome in the newborn due to the virus’ teratogenic effects. Typical features include low birth weight, limb hypoplasia, skin scarring, microcephaly and eye defects.
What medication should be given to the mother within 24 hours of the rash developing to prevent the baby from developing features such as limb hypoplasia, skin scarring and eye defects.
Acyclovir
What are the 4 characteristic features of antiphospholipid syndrome
CLOT:
Clots e.g. DVT
Livedo reticularis (mottled, lace-like appearance of the skin on the lower limbs)
Obstetric loss i.e.recurrent miscarriages
Thrombocytopenia (low platelet count)
Likely Dx:
Age between 30-50
Overweight
Menorrhagia
Dysmenorrhoea
Abdominal discomfort
Uterus can be palpated above the symphysis pubis
Uterine fibroids
Likely Dx:
Itching sensation around vulva
Thick creamy discharge
Negative whiff test
Genital candidiasis i.e. thrush
What is the recommended first line treatment for genital candidiasis
Single dose of oral fluconazole 150mg
Often it is patient preference - the mainstay is antifungal treatment
What type of bacteria is gonorrhoea
Intracellular gram-negative diplococci
What type of infection is the most common cause of pelvic inflammatory disease
Gonorrhoea
What is first line imaging investigation for a breast limb in under 40 years old
Ultrasound scan
What timescale should the booking visit be performed in pregnancy
8 - 12 weeks
The visit includes BP, urine dipstick, BMI check. Bloods include FBC, blood group, rhesus status, red cell alloantibodies, hepatitis B, syphilis, rubella, HIV test is offered, and urine culture
What is the timeframe for Down’s syndrome screening including nuchal scan
11 - 13 + 6 weeks
Mixing of RhD+ foetal blood with a RhD- mother who has already been sensitised before to RhD.
What is the complication that can occur as a result?
Haemolytic disease of the newborn
This is when the woman’s anti-D antibodies cross the placenta and enter foetus circulation, which contains RhD+ blood and bind to the antigens, causing the foetal immune system to attack and destroy its own RBCs.
Rhesus D- women are routinely offered anti-D prophylaxis to prevent haemolytic disease of the newborn.
When is the doses of anti-D prophylaxis given to rhesus negative women
Offered two doses in total = 28 and 34 weeks.
What is the timeframe for the anomaly scan to be performed during pregnancy
18-20 + 6 weeks
What are the criteria to be referred for further investigations (if they are trying for a baby)
Regular unprotected intercourse for 1 year, without a successful pregnancy
If they have known risk factors for infertility you may consider earlier referral
Define Placenta praevia
Placenta overlying the internal cervical os
Placenta praevia is where the placenta is fully or partially attached to the lower uterine segment. It is an important cause of antepartum haemorrhage – vaginal bleeding from week 24 of gestation until delivery.
Define antepartum haemorrhage
Vaginal bleeding from weeks 24 of gestation until delivery
What is the main risk factor for placenta praevia
Previous caesarean section
Vasa praevia is characterised by a triad of
(i) Vaginal bleeding
(ii) Rupture of membranes
(iii) Foetal compromise e.g. abnormal CTG
The bleeding occurs following membrane rupture when there is rupture of the umbilical cord vessels, leading to loss of fetal blood and rapid deterioration in fetal condition.
What test is used to determine the amount of feto-maternal haemorrhage and thus the dose of Anti-D required for the maternal Rhesus -ve
Kleihauer test
What investigation is used to definitive diagnosis placenta praevia
Transvaginal ultrasound
Likely Dx:
Painless vaginal bleeding after 24 weeks of pregnancy
Placenta praevia
If patient has known placenta praevia, how must she deliver?
Via Caesarean section aim for an elective caesarean section at 37-38 weeks gestation however low threshold for emergency due to risk of significant bleeding
Vaginal delivery is contraindicated with placenta praevia due to risk of significant haemorrhage
Management if mother presents not in labour with suspected placenta praevia.
ABC approach, resuscitation and stabilisation
IIf stable, perform urgent transvaginal ultrasound to diagnose placenta praevia. Consider corticosteroids if between 24-34 weeks gestation and there is risk of preterm labour
If the bleeding is not controlled, immediate caesarean section required
Characteristics of the third stage of labour
Period between the baby’s delivery and the expulsion of the placenta and membranes
How is the delivery of the placenta commonly managed
Manually by controlled cord traction.
This must be gentle, or else there is increased risk of causing complications such as uterine inversion and postpartum haemorrhage.
The delivery of the placenta is commonly managed manually by controlled cord traction. This must be gentle, or else there is increased risk of causing complications.
What two complications can occur
Uterine inversion
Postpartum haemorrhage
Characteristics of the latent first stage of labour
Regular painful contractions
Cervical changes, including effacement and dilatation up to 4cm
Characteristics of the established first stage of labour
Regular painful contractions
Progressive cervical dilatation to 4cm
Name the two stages of the first stage of labour
Latent first stage (0-4cm)
Established first stage (4-10cm)
Characteristics of the active second stage of labour
Full cervical dilatation i.e. 10cm
Active maternal pushing
Baby is visible
Characteristics of the passive second stage of labour
Full cervical dilatation i.e. 10cm
No active maternal pushing yet i.e. involuntary expulsive contractions
Name the two stages of the second stage of labour
Passive second stage (no active maternal pushing)
Active second stage (active maternal pushing and the baby is visible)
NOTE: she is in the second stage when the cervix is fully dilated i.e. 10cm
Characteristics of the third stage of labour
Period between the baby’s delivery and the expulsion of the placenta and membranes
How many stages of labour are there
3
First stage is split into: latent and established
Second stage is split into: passive and active
Third stage
Why do you not carry out a vaginal examination in any antenatal haemorrhage
They require a transvaginal ultrasound to rule out placenta praevia
This is due to the risk of inducing further haemorrhage
Name an infection that is a relative indication for C section
Active Herpes Simplex Virus (HSV) infection
Vaginal examination should be avoided in HSV as a measure to prevent ascending infection
Medication used for post-exposure HIV prophylaxis in an infant born to a low-risk mother (i.e. low viral load, <50 HIV RNA copies/mL)
Zidovudine
Also used for the management of untreated women presenting in labour at term, and is given intravenously throughout labour.
Management of a pregnancy women with newly diagnosed HIV
Start antiretroviral therapy (ART) as soon as possible
Tenofovir disoproxil/emtricitabine is a common first-line regime
If the mother’s HIV viral load is <50. Can she have a normal vaginal delivery?
Yes
Normal vaginal delivery can be recommended and supported
If the mother’s HIV viral load is >50.
Can she have a normal vaginal delivery?
Not recommended
An elective caesarean section is recommended
Can a women with HIV breastfeed?
Recommended not to
The safest way to feed infants born to women with HIV is with formula milk, as there is no on-going risk of HIV exposure after birth
However women with a low viral load on cART who choose to breastfeed should be informed of the risk of transmission, but supported to breastfeed if they wish, alongside additional monitoring
How and when invited for cervical screening
Women between the ages of 25 and 64 years
Every 5 year
What is the purpose of the cervical screening i.e. smear test
Testing for the presence of human papilloma virus (HPV), which is the main cause of cervical cancer
What two human papilloma virus (HPV) stains account for the majority of the cervical cancers
HPV 16 and 18
What medication is the recommended first-line anti-hypertensive agent in the management of pre-eclampsia
Oral labetalol
The definitive treatment of eclampsia is the delivery of the baby.
What other medication should be considered to prevent and treatment of eclamptic seizures
Intravenous magnesium sulphate should also be given and continued for 24 hours following the last seizure
What is the first line treatment of atrophic vaginitis
Characterised by inflammation and thinning of the genital tissues due to a fall in oestrogen levels, hence is most common after menopause.
Topical oestrogen
Likely Dx:
Post menopausal woman with vaginal dryness and thinning of the vaginal skin
Atrophic vaginitis
‘Woody uterus’ in pathognomoic of what condition
Placental abruption (the premature separation of the placenta from the uterine wall)
Likely Dx:
Pregnant women at term with severe abdominal pain with woody uterus and no vaginal bleeding
May have features of shock
Placental abruption (the premature separation of the placenta from the uterine wall)
Shock is very common as there is often a large blood loss even when there is not a lot of blood loss vaginally because the blood mostly remains between the placenta and the uterine wall and so external losses can be minimal
When should woman that is RhD -ve ben given anti-D after the onset of placental abruption
Within 72 hours
What is the biggest risk factor for a baby developing Group B Streptococcus
Previous baby with Group B Streptococcus infection
About 50% of infants born to women who carry GBS will go on to become carriers and less than 1% become ill with the infection themselves
Management of pregnant women at risk of developing Group B Streptococcus infection e.g. had a previous baby with GBS infection
Intrapartum antibiotics prophylactically
Intrapartum meaning given from the onset of labour until full delivery
First line benzylpenicillin
This is only for those undergoing vaginal delivery. Not required for C section
What patient groups are offered intrapartum antibiotics prophylaxis against GBS
Women with risk factors for developing GBS infection
AND
All women in preterm labour regardless of their GBS status
What is the first-line manoeuvre in shoulder dystocia
McRobert’s manoeuvre i.e. mother put into hyperflex and abduction of the her legs
Increases the relative anterior-posterior diameter of the pelvis
This may be accompanied with applied suprapubic pressure
Define category 1 caesarean section
Immediate threat to the life of mother or baby and delivery should expedite immediately within 30 minutes
Define category 2 caesarean section
Poses no immediate life-threatening event to the mother or baby, but urgent delivery is required (preferably between 60 and 75 minutes)
Define category 3 caesarean section
Early delivery is required (within 24 h), but there is no evidence of maternal or foetal compromise
HELLP syndrome.
What does HELLP stand for?
Haemolysis (anaemia)
Elevated Liver enzymes
Low platelets
HELLP syndrome is a complication of what condition
Complication of preeclampsia caused by elevated blood pressure in pregnancy
Most likely to occur immediately after the baby is delivered
Likely Dx:
Pregnant women in third trimester
Painless jaundice
Pruritus in hands and feet
Elevated bilirubin
LFT normal
Intrahepatic cholestasis of pregnancy
Risk factors for postpartum hemorrhage
High parity
Bleeding disorder e.g. von Willebrand disease
Pre-eclampsia
Multiple pregnancy
Gestational hypertension
What is the active management of the third stage of labor
Prophylactic uterotonic
Early cord clamping
Controlled cord traction to deliver the placenta
Oxytocin helps to contract the uterus, thereby preventing bleeding
Name the four causes of postpartum haemorrhage (PPH)
4 ‘T’s.
Tone (uterine atony) - failure of the uterus to contract after delivery.
Trauma - may come from a birth canal injury or tear
Tissue - retained placental or foetal tissue can lead to continued bleeding
Thrombin - coagulopathies can lead to continued bleeding due to a failure of clotting.
Define delayed puberty
Absence of menstruation and secondary sexual characteristics by age 13
OR
Absence of menstruation but with normal secondary sexual characteristics by age 15
What are uterine fibroids
Benign smooth muscle tumours of the myometrium of the uterus
What is the gold standard investigation for uterine fibroids
Trans-vaginal ultrasound - used to assess the size and location of the fibroids.
MRI is used if ultrasound is not detailed enough to assess the fibroid for surgery.
What is the first line non-surgical management option for uterine fibroids
Levonorgestrel-releasing intrauterine system (Mirena)
What is the first line management option for uterine fibroids in patients trying for a baby
Myomectomy - surgical removal of the fibroid from the uterine wall, and is generally fertility-sparing.
What medication is used in the treatment of dysmenorrhoea
Mefenamic acid
Dysmenorrhoea refers to painful menstruation
“MP is a pain”
What medication is used in the treatment of menorrhagia
Tranexamic acid
Menorrhagia refers to heavy periods
What is the most common cause of delayed puberty
Constitutional delay
Watch and wait approach
Most appropriate next step:
Smear: positive for HPV but negative cytology
Repeat smear in 12 months
12 months time:
If the sample is negative for HPV at 12 months, patients can be returned to routine recall.
Patients who remain positive for HPV, who still have normal cytology at 12 months should have a repeat smear test in another 12 months.
24 months time:
Patients who are then negative for HPV at 24 months can return to routine recall.
Patient who remains positive for HPV at 24 months (regardless of cytology result) should be referred to colposcopy
Risk factors for gestational diabetes
Previous gestational diabetes
Family history of diabetes (first generation)
Previous macrosomic baby of >4.5 kg
BMI >30
Investigating a patient for gestational diabetes with a risk factor of gestational diabetes (that is not previous gestation diabetes)
Oral glucose tolerance test at 24-28 weeks
Investigating a patient for gestational diabetes with a risk factor of previous gestation diabetes
Oral glucose tolerance test as soon as possible after the booking visit
Additional oral glucose tolerance test at 24-28 weeks if the first one is normal
Name a foetal complication of gestational diabetes
Macrosomia (birthweight >4kg) - due to excess maternal blood glucose crossing the placenta and inducing increased neonatal insulin production.
Pre-term delivery
Hypoglycaemia in the baby shortly after birth (due to sustained high foetal insulin levels after delivery) - if severe may lead to hypoglycaemic seizures
Increased risk of developing type 2 diabetes (later in life)
Name a maternal complication of gestational diabetes
Increased risk of :-
Hypertension
Pre-eclampsia
Developing type 2 diabetes
Increased risk of gestational diabetes in future pregnancies
How is gestational diabetes managed
Low glycaemic index diet, plus metformin and insulin if required.
Cervical motion tenderness is pathognomonic of what condition?
Pelvic inflammatory disease (PID)
How is pelvic inflammatory disease diagnosed
Clinical diagnosis
Likely Dx:
Bilateral abdominal pain
Cervical motion tenderness
Fever
Pelvic inflammatory disease
Likely Dx:
Pt with previous sexually transmitted infection or known pelvic inflammatory disease (PID) presenting with right upper quadrant pain
Fitz Hugh Curtis syndrome
This is secondary to inflammation of the liver capsule
Often caused in PID or a STI
How is pelvic inflammatory disease managed
Combination of antibiotics
AND
Analgesia
Review in 4 weeks
What are the two most common organisms that causes pelvic inflammatory disease
Gonorrhoea and Chlamydia
What supplement is given to women during pregnancy
Folic acid
To prevent neural tube defects within the first 12 weeks of pregnancy.
Higher doses are given to mothers who suffer from conditions that are at a higher risk of causing NTDs e.g. coeliac disease, diabetes, thalassaemia trait, obesity, taking antiepileptic drugs, family history of NTDs
What vitamin is given in the end stages of the third trimester to reduce the risk of haemorrhagic disease of the newborn
Vitamin K injection
Criteria for lactational amenorrhoea
Exclusively breastfeeding and no menstruation
Up until 6 months postpartum
When can the Combined oral contraceptive pill be started postpartum
> 6 weeks postpartum if they are not breastfeeding
What are the three contraindications for foetal blood sampling
Foetal blood sampling (FBS) is indicated when there is a suspicious cardiotocograph (CTG)
Contraindications include:
i) Prolonged decelerations on CTG
ii) Maternal infection e.g. HIV, herpes simplex
iii) Prematurity (<34 weeks)
Abnormal CTG -> Foetal blood sample is taken and shows:
pH < 7.20 (normal ≥7.25)
OR
Lactate is >4.9mmol/L (normal ≤ 4.1 mmol/L)
What is the next step of management
Urgent delivery
The sample indicates the foetus is acidotic, implying hypoxia and therefore needs urgent delivery
Abnormal CTG -> Foetal blood sample is taken and shows:
pH 7.21-7.24 (normal ≥7.25)
OR
Lactate is 4.2-4.8 mmol/L (normal ≤ 4.1 mmol/L)
What is the next step of management
Repeat the test in 30 minutes
Although not a great sample it is reasonable to retest in the first instance
First-line investigation for endometrial cancer
Transvaginal ultrasound to assess endometrial thickness.
Triple test screening for chromosomal abnormalities shows:
Low alphafetoprotein (AFP)
Low unconjugated oestradiol (uE3)
High human chorionic gonadotrophin beta-subunit (HCG)
Down syndrome
Congenital abnormality caused by a trisomy of chromosome 21
Name an abnormality seen with Down Syndrome
Congenital heart defects
Neural defects
Flat occiput
Upslanting palpebral fissures
Small, low-set ears
What is the recommended screening test for Down Syndrome
Combined test, that include :-
Nuchal translucency using ultrasound scan
PAPP-A hormone (level reduced in pregnancy affected with Down’s syndrome)
Beta-hCG hormone (raised in pregnancy affected by Down’s syndrome)
Define pre-eclampsia
New onset hypertension that occurs after 20 weeks gestation and the co-existence of ≥1 of the following conditions: proteinuria, maternal organ dysfunction, neurological complications, haematological complications or uteroplacental dysfunction
Drugs to avoid in breastfeeding
LAMBAST:
Lithium
Amiodarone
Methotrexate
Benzodiazepines
Aspirin
Sulfonamides
Tetracyclines
What condition is most likely to occur in future pregnancies after a Caesarean section
Increased risk of placenta accreta i.e. the abnormal implantation of the placenta into the uterine wall, a common site being the old Caesarean scar
What is the gold standard investigation to diagnose endometriosis?
Laparoscopy
Allows direct visualisation of the pelvis and, therefore, endometriotic deposits. It also has the added benefit of enabling immediate treatment of endometriosis at the time of diagnosis with techniques such as ablation or surgical excision of endometriotic lesions
What kind of beta HCG can be used to exclude a ruptured ectopic pregnancy in a women of childbearing age
Urine beta HCG
It is enough to confirm pregnancy
What are the 3 management options for ectopic pregnancy
Conservative management - closely followed up with repeat B-hCG tests. Rarely used.
Medical management - methotrexate (one off dose).
If the initial dose of methotrexate has failed to treat the ectopic, a second dose of methotrexate or surgical management may be indicated
Surgical management - often salpingectomy where the fallopian tube containing the ectopic is removed. In cases where the ectopic is in a woman with only one functioning fallopian tube, and they wish to remain fertile, a salpingotomy may be done where only the ectopic is removed.
Why is it recommended that patients undergo Salpingectomy for ectopic pregnancy
Salpingectomy - removal of the affected fallopian tube with the ectopic pregnancy within it.
Salpingotomy - removal of the ectopic pregnancy only. Carries the risk that not all the tissue may have been removed and so serial serum B-hCG measurements are performed to exclude any trophoblastic tissue still within the fallopian tube
What blood test is the most specific for intrahepatic cholestasis of pregnancy
Bile salts - raised
What is the name of the diagnostic criteria for polycystic ovary syndrome
Rotterdam diagnostic criteria
Diagnosed if two of the following are present:
Polycystic ovaries (>12 cysts seen on imaging or ovarian volume >10 cubic cm)
Oligo-/anovulation
Clinical or biochemical features of hyperandrogenism
What medication may be used to reduce hirsutism and induce regular menstruation in patients with polycystic ovary syndrome
Co-cyprindrol
Define Secondary amenorrhoea
Absence of menstruation for 6 months or longer in a woman with previously present menstrual cycles
What is the most common cause of secondary amenorrhoea
Pregnancy
Management of active primary herpes lesions are present on the mother at term
Offer the patient oral aciclovir and an elective Caesarian section
Aciclovir can be offered to treat the current presentation
C section to reduce the risk of vertical transmission to the foetus at delivery
How often should patients with HIV be screened by the cervical smear test
Annual cervical screening is recommended as they are at a higher risk of cervical cancer
Management of non-immune pregnant woman exposed to varicella zoster virus
Prophylactic varicella zoster immunoglobulin vaccine OR given antivirals 7-14 days after exposure (aciclovir)
Varicella zoster virus = chickenpox
If serology shows the mother is non-immune (varicella-antibody negative) then varicella zoster immunoglobulin vaccine prophyalxis.
The neonate should be monitored and given IV acyclovir following delivery
What is the next appropriate management step for any patient with antepartum haemorrhage (even despite normal obs)
Transfer to hospital where clinical history, abdominal examination and speculum examination should be performed
If haemodynamic compromised = major haemorrhage resuscitation
Diagnosis of premature ovarian insufficiency
Clinical features of menopause e.g. vaginal dryness, hot flushes and secondary amenorrhoea
PLUS
TWO elevated serum follicle-stimulating hormone (FSH) levels
- samples taken 4–6 weeks apart
- raised FSH indicates menopause
- two samples to ensure the first was not an anomalous
How are patients with premature ovarian insufficiency managed
Hormone replacement therapy (HRT) until at least the age of normal menopause, unless the risks of HRT treatment outweigh the benefits.
Premature ovarian insufficiency is defined as menopause in a woman aged below what age?
40 years
Name the causes of polyhydramnios
Mnemonic DITCH:
Diabetes
Idiopathic/infection
Twins
Congenital abnormalities
Heart failure
What medication can be used to manage polyhydramnios
NSAIDs, especially indomethacin
Work in reducing foetal urine output due to their prostaglandin inhibition. Reducing prostaglandin subsequently reduces bloodflow to the glomerulus of the kidney and as a result, reduces foetal urine output and thus the amount of amniotic fluid
Define prelabour rupture of membranes at term
PROM at term
The rupture of the amniotic membranes before the onset of labour after 37 weeks gestation
Complications of pre-labour rupture of membranes at term
Increased risk of neonatal infection and chorioamnionitis (infection of the placenta and amniotic fluid) due to ascending infection
To reduce the chance of infection if labour does not commence within 24 hours, induction of labour should be offered.
What investigation can be carried out to confirm the diagnosis of pre-labour rupture of membranes at term
Actim-PROM vaginal swab
Likely Dx:
Bloating/abdominal discomfort in a patient that has recently underwent egg retrieval procedure
Ovarian hyperstimulation syndrome
Known side effect of fertility treatments
Conservative management plus thromboprophylaxis (as ovarian hyperstimulation syndrome is a hypercoagulable state)
At what gestation should anti-D be administered for prophylaxis for RhD -ve mothers
28 and 34 weeks
What are the criteria used to diagnose gestational diabetes?
Fasting plasma glucose level of 5.6 mmol/l or above
OR
2-hour plasma glucose level of 7.8 mmol/l or above
(remember the numbers 5,6,7,8)
Indications for elective caesarean section
Abnormal presentation e.g. breech or transverse
Twin pregnancy if first twin is not cephalic
Maternal HIV (with a detectable viral load)
Primary genital herpes in third trimester
Placenta praevia
Anatomical reasons
Define gravidity
The number of times a woman has been pregnant.
Define parity
The number of times a woman has given birth to a foetus with a gestational age of >24 weeks, regardless of whether this was a live birth or stillbirth
Likely Dx:
Baby with jaundice within 24 hours after birth
At least the second pregnancy
Rhesus haemolytic disease of the newborn
What is the gold standard investigation for rhesus haemolytic disease of the newborn
Direct Coombs test -> positive
Direct Coombs test is used to detect antibodies or complement proteins attached to the surface of red blood cells
Most appropriate management plan if women with a breech presentation at 36 weeks
Offer a planned external cephalic version (ECV)
Procedure is performed around weeks 37-39 and aims to manually turn the foetus into a cephalic presentation.
Most babies that are breech will naturally turn to a cephalic presentation by week 36, but are unlikely to spontaneously turn beyond 36 weeks
Management of asymptomatic bacteriuria in pregnancy
Oral antibiotics are recommended in asymptomatic bacteriuria in pregnancy to prevent progression to pyelonephritis and increased risk of preterm labour
Likely Dx:
Fever
Secondary postpartum haemorrhage (>24 hrs after delivery)
Offensive vaginal discharge
Endometritis - endometrial infection
This may be due to retained placental tissue becoming infected and preventing full contraction of the uterus
Contraindications for vaginal delivery
Previous history of uterine rupture
Classical (vertical) caesarean section scar
Other condition that would normally contraindicate a vaginal delivery e.g. major placenta praevia, “footlong” breech presentation
What is the most common type of ovarian cyst?
Follicular cyst
Occur during the menstrual cycle when a follicle does not release an egg in ovulation. They are usually harmless and will self-resolve.
Likely Dx:
Youngish woman
Vulval mass
Swelling and mildly tenderness
Bartholin’s gland cyst
Likely Dx:
Youngish woman
Vulval mass which is extremely painful
Bartholin’s gland abscess
First line treatment for Bartholin’s gland cyst
Incision and drainage
Antibiotics in cases of abscess
LH, FSH and oestradiol levels in premature ovarian insufficiency?
Raised LH
Raised FSH
Low oestradiol
What is the initial management to prevent cord compression in cord prolapse
Keep the cord warm and mother goes onto a knee–chest position
What is the definitive management of cord prolapse
Caesarean section
What is the function of Tocolytics in labourx
Used to minimise contractions.
It can delay delivery while waiting for the caesarean section to occur.
What is the only surgical option available that will preserve fertility to manage fibroid
Myomectomy
Symptomatic ovarian fibroids that are greater than how many cm are normally treated with surgery
3cm
Clinical features of ovarian fibroids
Often asymptomatic
When symptoms occur, they usually involve menstrual dysfunction, in the form of menorrhagia and dysmenorrhoea.
If large enough, the fibroid may distort the uterine cavity to such extent they interfere with fertility.
Define secondary postpartum haemorrhage
Vaginal bleed from 24h to 6 weeks after delivery).
Loss of at least 500ml of blood within the first 24 hours of delivery is postpartum haemorrhage (PPH)
What medication can be used to improve the success rate of external cephalic version for breech presentation?
Beta-2 receptor agonists e.g. terbutaline
Can improve success rate as they cause relaxation of uterine muscles
Describe the medical termination of pregnancy
Mifepristone, a progesterone antagonist, blocks the progesterone required for continuation of the pregnancy
Misoprostol, a prostaglandin analogue. Causes smooth muscle contractions of the myometrium, resulting in expulsion of uterine contents.
Describe the surgical management of the termination of pregnancy
Suction termination
OR
Dilatation and evacuation/curettage ‘D&C’
Name the five ‘categories’ for requesting termination of pregnancy
i) Pregnancy < 24 weeks + 6 and continuing with the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family.
ii) Termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
iii) Continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated
iv) Substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
What is the most common type of uterine fibroid?
Intramural fibroid
Likely Dx:
Postmenopausal woman
Vulval soreness, burning, pruritis and bleeding
Vulval carcinoma
The majority of vulval carcinomas are?
Squamous cell carcinomas and occur on the labia majora
What are the main risk factors for vulval carcinomas?
Human papillomavirus (HPV) infection
Chronic inflammation, e.g., lichen sclerosus
Age
Gold standard way to diagnose vulval carcinomas
Biopsy
The main treatment option for simple cases of primary vulval cancer
Radical/wide local excision
The mainstay of treatment for vulval carcinomas is surgical removal
Likely Dx:
Sudden-onset stabbing abdominal pain in either the right or left iliac fossa
Associated vomiting episodes due to the severity of the pain
Negative urine BCG
Ovarian torsion
Ovarian torsion is an emergency where the ovary twists around its ligaments, cutting off its blood supply
What is the normal lining of the ectocervix?
Stratified squamous
Which medication is typically administered intra-operatively to aid delivery of the placenta?
IV Oxytocin
You are considering surgical management in a woman with fibroids. She still wishes to have children. What is the most suitable option?
Myomectomy
Which type of breech presentation is where both legs are flexed at the hips and knees?
Complete breech
Misoprostol is used in the medical management of miscarriage. What type of medication is it?
Prostaglandin analogue
What type of breech presentation is where both legs are flexed at the hip and extended at the knees?
Frank (extended) breech
What type of breech presentation is where one or both legs extended at the hip, so that the foot is the presenting part?
Footling breech
What type of virus is HIV?
Single stranded RNA virus
Why can’t d-dimer be used to diagnose a VTE in pregnancy?
A raised D-dimer can be normal in pregnancy. As D-dimer is an acute phase reactant, it can be raised in conditions other than VTE, so it’s use in the diagnosis of VTE is not reliable
What is the most common site of ectopic pregnancy?
Fallopian tube
What is the correct definition of recurrent miscarriage?
≥3 consecutive pregnancies that end in miscarriage
Where is LH produced in the body?
Anterior pituitary
Which hormone is endometriotic tissue most responsive to?
Oestrogen
What is adenomyosis?
Presence of functional endometrial tissue within the uterine myometrium
What is the most common position of the foetal head?
Occipito-anterior (the foetal occiput facing anteriorly)
A women receives VTE prophylaxis antenatally. How long should this be continued following delivery?
Continued for 6 weeks after delivery, as the post-partum period is associated with the highest risk of VTE.
What is the role of an episiotomy in the management of shoulder dystocia?
Allows better access for manoeuvres
What is third line therapy for hyperemesis gravidarum?
IV hydrocortisone
Once symptoms improve, convert to prednisolone PO and gradually reduce dose until lowest maintenance dose is reached
What is first line therapies for hyperemesis gravidarum?
Cyclizine
Prochlorperazine
Promethazine
Chlorpromazine
What are the second line therapies for hyperemesis gravidarum?
Metoclopramide (maximum 5 days due to risk of extrapyramidal side effects)
Domperidone
Ondansetron
What is the correct category for an elective Caesarean section?
Category 4
Emergency procedures are sub-classified into categories 1 - 3
Uterine fibroids are a benign tumour of which tissue?
Smooth muscle
What is the standard initial treatment for gestational diabetes?
Metformin
Insulin would be started on diagnosis if the fasting glucose is >7mmol/L or later in pregnancy if glucose is high or fetal abdominal circumference >95th centile.
How is oligohydramnios defined?
Amniotic fluid index <5th centile for the gestational age
Oligohydramnios refers to a low level of amniotic fluid during pregnancy
What is the epithelial lining of the endocervix?
Columnar
First line treatment for symptomatic cervical ectropion?
Cervical ectropion occurs when there is eversion of the endocervix, exposing the columnar epithelium to the vaginal milieu.
First line is to stop any oestrogen containing medications – most commonly the combined oral contraceptive pill
If symptoms of cervical ectropion persist despite stopping oestrogen containing medications what is the next best management option
Ablation of the columnar epithelium e.g. cryotherapy or electrocautery
What is the role of Kleihauer test in maternal isoimmunisation?
Assesses the prescence of fetal blood in the maternal circulation
What tissue is sampled in an amniocentesis?
Amniotic fluid
Which antibiotic should be added in cases of endomyometritis?
If there is suspicion of infection of the deeper uterine muscle (tender uterus) or overt sepsis, gentamicin should be added for additional antimicrobial cover
What is the main risk of amniocentesis?
Miscarriage
What is the definitive management of a uterine rupture?
Delivery by C-section and repair of the rupture
What is the usual first-line therapy in lichen sclerosus?
Topical steroids
What structure is the fetal station measured in relation to?
Ischial spines
What is the recommended treatment for antiphospholipid syndrome during pregnancy?
Anticoagulant e.g. low molecular weight heparin
AND
Anti-platelet agent e.g. low dose aspirin
In a woman with drug-managed gestational diabetes, what are the recommendations for delivery?
Deliver at 37-38 weeks
What is the standard initial treatment for iron deficiency anaemia?
Oral iron supplementation
A parental iron infusion (Ferrinject) can be considered if compliance with oral treatment is poor or there is evidence of malabsorption.
Which complication is most associated with an amnioreduction?
Rapid loss of amniotic fluid can cause the placenta to come away from the wall of the uterus, causing placental abruption.
What is the main mechanism of action of the intrauterine system (Mirena®)?
Thins the endometrium, inhibiting implantation, but it also thickens cervical mucus which reduces sperm motility.
What procedure is offered first line in a prolonged pregnancy?
Induction of labour is offered first-line in a post-dates pregnancy.
If the patient declines an induction they should be offered twice weekly monitoring.
What is the definitive diagnosis for a cervical polyp?
Histological examination after removal
During labour, what examination is used to assess the position of the fetal head
Vaginal examination
Which host cells are targeted by HIV?
CD4
Why are elective Caesarean sections typically planned for >39 weeks gestation?
Reduce risk of respiratory distress in newborn
For those where delivery needs to be expedited prior to 39 weeks’ gestation, the administration of corticosteroids to the mother should be considered
Which syndrome describes the development of intrauterine adhesions?
Asherman’s syndrome is an acquired condition causing intrauterine adhesions and can be caused by surgery on the uterus, pelvic infections, or treatment for cancer.
Bishop score of what is a prerequisite for induction of labour with an amniotomy?
Bishop score >7
What is the mainstay of induction of labour, and are the preferred primary method as advised by NICE guidelines (2008)
Vaginal prostaglandins
Prostaglandins act to prepare the cervix for labour by ripening it, and also have a role in the contraction of the smooth muscle of the uterus
What are the three main methods of induction
vaginal prostaglandins (mainstay treatment)
amniotomy
membrane sweep
Amniotomy is a method of induction of labour. What is often given alongside it?
Infusion of artificial oxytocin (Syntocinon) - acting to increase the strength and frequency of contractions. The aim is to start low and titrate upwards until there are 4 contractions every 10 minutes.
An amniotomy is where the membranes are ruptured artificially using an instrument called an amnihook. As with a membrane sweep, this process releases prostaglandins in an attempt to expedite labour. It is only performed when the cervix has been deemed as ‘ripe’ (see Bishop Score > 7)
When is membrane sweep offered
At 40 and 41 weeks’ gestation to nulliparous women
At 41 weeks to multiparous women.
What scoring system is used to assess ‘cervical ripeness‘ based on measurements taken during vaginal examination. It is checked prior to induction, and during induction to assess progress.
Bishop score
What is the definitive treatment of adenomyosis?
Hysterectomy
Adenomyosis is the presence of functional endometrial tissue within the myometrium of the uterus
In women at risk of uterine rupture, what is used to monitor the fetus?
Cardiotocography (CTG)
Which is a serious complication of breech presentation?
Cord prolapse
Which trimester of pregnancy does hyperemesis gravidarum usually peak in?
First
Reaches a peak in the 9th week, and usually settles by the 20th week.
Which point during pregnancy carries the greatest risk of developing a VTE?
Postpartum
Which investigation provides the definitive diagnosis of miscarriage?
Transvaginal ultrasound scan
In the most common form of shoulder dystocia, what does the anterior fetal shoulder become impacted against?
Pubic symphysis
What medications can be used to manage obesity in PCOS?
Orlistat
Pancreatic lipase inhibitor which can be used to manage obesity in PCOS
What is polyhydramnios?
Amniotic fluid index >95th centile
What is the upper gestational age limit for a pregnancy loss to be classified as a miscarriage?
24 weeks
Why is induction of labour offered to women with a prolonged gestation?
Reduce risk of stillbirth
What is primary dysmenorrhoea?
Menstrual pain with no underlying pelvic pathology
Hyperemesis gravidarum is thought to be due to increased levels of which hormone?
b-hCG (hormone released by the placenta)
PCOS is characterised by high levels of which hormone?
Testosterone
Which two medications are normally given in cases of preterm prelabour rupture of membranes?
Antibiotics and steroids
Antibiotics: oral erythromycin should be given for 10 days as they are at an increased risk of infection
Steroids are given to drive development of surfactant in the fetal lungs
definition of a secondary post-partum haemorrhage?
Bleeding from 24 hours after delivery to 12 weeks postpartum
Definition of post-partum haemorrhage
Loss of >500ml blood within 24 hours of delivery
What contraception is first line treatment for menorrhagia
Intra-uterine system (IUS) should be offered as the first-line
Menorrhagia - heavy periods
Serum progesterone is taken to confirm ovulation in patients who are struggling to conceive. It should be taken when during the menstrual cycle
7 days before the next expected period to coincide with ovulation.
What is placenta percreta
Characterised by chorionic villi that invade the perimetrium (outermost layer of the uterus)
What is placenta accreta
Attachment of the placenta to the myometrium.
As the placenta does not properly separate during labour there is a risk of postpartum haemorrhage
3 types:
Accreta - Attaches only to the myometrium
INcreta - INvades into the myometrium
PERcreta - gets to the PERimetrium
Renal agenesis (Potter sequence) can cause oligohydramnios.
How does it cause it?
Renal agenesis causes the fetus not to produce urine, hence the liquid inside the sac will be diminished causing oligohydramnios.
Next step in a patient who have two consecutive HPV results unavailable or inadequate cytology results
Refer to colposcopy
What is the first-line investigation for preterm prelabour rupture of the membranes
Speculum examination - sign of preterm prelabour rupture of the membranes is pooling of amniotic fluid in the posterior vaginal vault
Painless vaginal bleeding during pregnancy is pathognomonic of what condition
Placenta praevia
It is when the placenta is lying wholly or partly in the lower uterine segment
First line investigation for placenta praevia
Transvaginal ultrasound
After taking ulipristal acetate women should wait how long before starting regular hormonal contraception
5 days
What is the bacterium that causes Group B Streptococcal disease (GBS)
Streptococcus agalacticae
How long after levonorgestrel (Levonelle) for emergency contraception can you restart hormonal contraception
Immediately - no need to wait
If at the time of diagnosis of gestational diabetes, the fasting glucose level is >= 7 mmol/l - what medication should be started?
Insulin +/- metformin
Children under the age of what years are considered unable to consent for sexual intercourse and hence consultations regarding this age group should automatically trigger child protection measures regardless of Gillick competent
13
