OBGYN Flashcards
What is involved in female hormone testing for infertility? What do they indicate?
- Serum LH and FSH on day 2 to 5 of the cycle
- Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).
- Anti-Mullerian hormone
- Thyroid function tests when symptoms are suggestive
- Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea
High FSH = poor ovarian reserve
High LH = ?PCOS
Anti-Mullerian hormone indicates ovarian reserve
What imaging investigations can be done in female infertility?
- Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus
- Hysterosalpingogram to look at the patency of the fallopian tubes
- Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis
What is the management of anovulation?
- weight loss in PCOS
- clomifene (stimulates ovulation)
- letrozole 2nd
- gonadotrophins if resistant to clomifene
- ovarian drilling in PCOS
- metformin if insulin sensitivity and obesity
How does clomifene work?
anti-oestrogen (selective oestrogen receptor modulator)
given on days 2-6 of cycle
stops negative feedback of oestrogen on hypothalamus => inc in GnRH => inc in FSH and LH
What is the management of tubal factors?
- Tubal cannulation during a hysterosalpingogram
- Laparoscopy to remove adhesions or endometriosis
- In vitro fertilisation (IVF)
What is a suitable contraception in someone with breast cancer?
Avoid hormonal contraception, use copper coil or barrier method
What is a suitable contraception in someone with cervical or endometrial cancer?
Avoid intrauterine system e.g. Mirena coil
What is a suitable contraception in someone with Wilson’s disease?
Avoid copper coil
What are some contraindications for COCP?
- Uncontrolled hypertension (particularly ≥160 / ≥100)
- Migraine with aura
- History of VTE
- Aged over 35 smoking more than 15 cigarettes per day
- Major surgery with prolonged immobility
- Vascular disease or stroke
- Ischaemic heart disease, cardiomyopathy or atrial fibrillation
- Liver cirrhosis and liver tumours
- Systemic lupus erythematosus and antiphospholipid syndrome
- Breastfeeding before 6 weeks postpartum
How long after menopause is contraception still required?
2 years in women under 50 and 1 year in women over 50
What contraception should not be used in women over 50 and why?
progesterone injection (Depo-Provera) due to risk of osteoporosis
How long should amenorrhoeic women keep taking POP?
- until FSH > 30 IU/L on 2 tests 6 wks apart then cont contraception for 1 more year OR
- 55 years of age
How long before fertility returns after childbirth?
21 days
lactational amenorrhoea is 98% effective for up to 6 months (if fully breastfeeding)
What contraception can be used after childbirth?
POP and implant are safe at any time
Copper coil or Mirena coil can be inserted either within 48hrs of birth or 4 weeks after but not in between
COCP should be avoided in breastfeeding before 6 weeks post partum
How does COCP prevent pregnancy?
- Preventing ovulation (this is the primary mechanism of action)
- Progesterone thickens the cervical mucus
- Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation
How do oestrogen and progesterone affect the hypothalamus and anterior pituitary?
They suppress the release of GnRH, LH, and FSH through negative feedback.
Why are pills containing drospirenone (e.g., Yasmin) used for premenstrual syndrome?
Drospirenone has anti-mineralocorticoid and anti-androgen effects that help with bloating, water retention, and mood changes.
What COCP is used for treating acne and hirsutism, and why is its use limited?
Dianette (containing cyproterone acetate); it has a higher risk of venous thromboembolism (VTE) and is usually stopped after acne control.
What are the three common regimes for taking the COCP?
21 days on, 7 days off; 63 days on, 7 days off (tricycling); continuous use without a pill-free period.
How should the COCP be started to provide immediate contraceptive protection?
On the first day of the menstrual cycle.
What is the protocol when switching from a traditional progesterone-only pill to the COCP?
Extra contraception (e.g., condoms) is required for 7 days.
What are common side effects in the first three months of COCP use?
Unscheduled bleeding, breast pain, mood changes, headaches, and hypertension.
What are the long-term risks associated with COCP use?
Small increased risk of venous thromboembolism, breast and cervical cancer, myocardial infarction, and stroke.
What are some benefits of the COCP?
Effective contraception, rapid return of fertility, and reduced risks of endometrial, ovarian, and colon cancer.
What BMI level is a relative contraindication (UKMEC 3) for the COCP?
A BMI above 35.
What should be done if a woman misses one pill?
Take the missed pill as soon as possible, and no extra contraception is required if the other pills are taken correctly.
What should be done if more than one pill is missed (72 hours since the last pill)?
Take the most recent missed pill and use additional contraception (e.g., condoms) for 7 days.
When is emergency contraception required after missing more than one pill?
If more than one pill is missed between day 1 – 7 of the packet and unprotected sex has occurred.
What is the only UKMEC 4 contraindication for using the POP?
Active breast cancer.
What are the two types of progestogen-only pills?
Traditional POP (e.g., Norgeston, Noriday) and desogestrel-only POP (e.g., Cerazette).
What is the time limit for taking the traditional POP and still being protected?
It must be taken within 3 hours of the scheduled time.
What is the time limit for taking the desogestrel-only POP and still being protected?
It can be taken up to 12 hours late and still be effective.
How do traditional progestogen-only pills work?
By thickening the cervical mucus, altering the endometrium, and reducing ciliary action in the fallopian tubes.
What is the primary mechanism of action of the desogestrel-only pill?
Inhibiting ovulation
(+thickening the cervical mucus, altering the endometrium, and reducing ciliary action in the fallopian tubes)
When does the POP provide immediate protection from pregnancy?
When started between day 1 to 5 of the menstrual cycle.
How long does it take for the POP to thicken cervical mucus enough to prevent sperm entry?
48 hours.
When switching from a COCP to a POP, when can the POP be started without extra contraception?
If the woman has taken the COCP consistently for more than 7 days or is on days 1-2 of the hormone-free period.
What is the most common side effect of the POP?
What other side effects can occur with the POP?
Changes in the bleeding schedule (unscheduled bleeding).
Breast tenderness, headaches, and acne.
What are the risks associated with the traditional POP?
Increased risk of ovarian cysts, small risk of ectopic pregnancy, and minimal increased risk of breast cancer.
What should be done if a POP is missed?
Take the missed pill as soon as possible, continue with the next pill at the usual time, and use extra contraception for 48 hours.
How often is the DMPA/progesterone-only injection given?
Every 12 to 13 weeks.
How long can it take for fertility to return after stopping the DMPA?
Up to 12 months.
What are the two versions of DMPA used in the UK?
Depo-Provera (intramuscular) and Sayana Press (subcutaneous, self-injectable).
What is the UK MEC 4 contraindication for DMPA?
Active breast cancer.
Name a few UK MEC 3 conditions where DMPA use is cautioned.
Ischaemic heart disease, stroke, unexplained vaginal bleeding, severe liver cirrhosis, liver cancer.
Why is osteoporosis a concern with DMPA?
It decreases bone mineral density due to suppressed estrogen production.
At what age is DMPA UK MEC 2, and when should women consider switching to an alternative?
MEC 2 for women over 45 years, and switching should occur by age 50.
What is the main action of the DMPA injection? What other mechanisms contribute to DMPA’s contraceptive effects?
Inhibition of ovulation by suppressing FSH secretion from the pituitary gland.
Thickening cervical mucus and altering the endometrium.
What is the lifetime risk of developing breast cancer for women?
Approximately 1 in 8 women will develop breast cancer in their lifetime.
Name risk factors for developing breast cancer.
- Increased estrogen exposure,
- more dense breast tissue,
- obesity,
- smoking, and
- family history (first-degree relatives).
How does the combined contraceptive pill affect breast cancer risk?
It gives a small increase in risk, but this risk returns to normal ten years after stopping the pill.
What type of hormone replacement therapy (HRT) increases breast cancer risk?
Combined HRT (containing both estrogen and progesterone).
What are the BRCA genes?
Tumor suppressor genes that, when mutated, increase the risk of breast cancer, as well as ovarian and other cancers.
What is the risk of breast cancer by age 80 for women with a faulty BRCA1 gene?
Around 70% will develop breast cancer by age 80.
What is the risk of ovarian cancer by age 80 for women with a faulty BRCA2 gene?
Around 20%
What does Ductal Carcinoma In Situ (DCIS) signify?
Pre-cancerous or cancerous epithelial cells in the breast ducts, localized to a single area.
What is Lobular Carcinoma In Situ (LCIS)?
A pre-cancerous condition usually found in pre-menopausal women, often asymptomatic and diagnosed incidentally.
How common is Invasive Ductal Carcinoma (NST)?
It makes up about 80% of invasive breast cancers.
Describe Inflammatory Breast Cancer.
It accounts for 1-3% of breast cancers and presents with swollen, warm, tender breast tissue, often mimicking an abscess.
What is Paget’s Disease of the Nipple?
It appears as an erythematous, scaly rash on the nipple, indicating potential underlying breast cancer.
What is the NHS breast cancer screening program?
It offers a mammogram every 3 years for women aged 50-70
What criteria may warrant referral for patients at higher risk due to family history?
A first-degree relative with breast cancer under 40,
a first-degree male relative with breast cancer,
or two first-degree relatives with breast cancer.
What are some clinical features that may suggest breast cancer?
Hard, irregular, painless lumps; nipple retraction; skin dimpling; lymphadenopathy in the axilla.
What may be offered to high-risk women for breast cancer prevention?
Chemoprevention with Tamoxifen (if premenopausal) or Anastrozole (if postmenopausal).
What is the NICE guideline for urgent referral of suspected breast cancer?
A two-week wait referral for unexplained breast lumps in patients aged 30 or above, unilateral nipple changes in patients aged 50 or above, unexplained lump in the axilla in patients aged 30 or above, and skin changes suggestive of breast cancer.
What comprises the triple diagnostic assessment for suspected breast cancer?
Clinical assessment, imaging (ultrasound or mammography), and biopsy.
What are the surgical options for breast cancer treatment?
Breast-conserving surgery (e.g., wide local excision) and mastectomy (removal of the whole breast).
What are the two main types of hormone treatment for oestrogen-receptor positive breast cancer?
Tamoxifen for premenopausal women and aromatase inhibitors for postmenopausal women.
What is the follow-up recommendation for breast cancer survivors?
Yearly surveillance mammograms for 5 years.
What is a fibroadenoma, and who is it most commonly found in? Describe the characteristics of a fibroadenoma.
A fibroadenoma is a common benign tumor of breast duct tissue, typically found in women aged 20-40.
Fibroadenomas are painless, smooth, round, well-circumscribed, firm, and mobile lumps, usually up to 3 cm in diameter.
What are fibrocystic breast changes, and how are they classified?
Fibrocystic breast changes are a normal variation characterized by lumpiness and tenderness, fluctuating with the menstrual cycle. They are considered a benign condition.
What symptoms are associated with fibrocystic breast changes?
Lumpiness, breast pain (mastalgia), and fluctuation of breast size.
How are fibrocystic breast changes managed?
Management includes excluding cancer and addressing symptoms through supportive bras, NSAIDs, avoiding caffeine, heat application, and hormonal treatments.
What are breast cysts, and when do they commonly occur? What are the characteristics of breast cysts?
Breast cysts are benign, fluid-filled lumps most common between ages 30 and 50, particularly during the perimenopausal period.
Breast cysts are smooth, well-circumscribed, mobile, and possibly fluctuating lumps.
What is fat necrosis, and what causes it? Describe the appearance of fat necrosis on examination.
Fat necrosis is a benign lump formed by localized degeneration of fat tissue, commonly triggered by trauma, radiotherapy, or surgery.
Fat necrosis can be painless, firm, irregular, and may be fixed in local structures, sometimes causing skin dimpling or nipple inversion.
What is a lipoma, and how is it characterized?
A lipoma is a benign tumor of fat tissue, typically soft, painless, mobile, and without skin changes.
What is a galactocele, and in which population does it occur?
A galactocele is a milk-filled cyst that occurs in lactating women, often after stopping breastfeeding.
What are phyllodes tumors, and what is their potential behavior?
Phyllodes tumors are rare tumors of breast connective tissue, which can be benign, borderline, or malignant, with the potential to metastasize.
What is the primary treatment for phyllodes tumors?
Surgical removal of the tumor and surrounding tissue, with possible chemotherapy for malignant cases.
What is mammary duct ectasia?
Mammary duct ectasia is a benign condition characterized by dilation of the large ducts in the breasts, often associated with inflammation.
What type of nipple discharge is associated with mammary duct ectasia?
The discharge may be white, grey, or green.
In which population is mammary duct ectasia most frequently observed?
It most frequently occurs in perimenopausal women.
What is a significant risk factor for developing mammary duct ectasia?
Smoking is a significant risk factor.
What are common presentations of mammary duct ectasia?
Common presentations include nipple discharge, tenderness or pain, nipple retraction or inversion, and a breast lump that may discharge when pressure is applied.
What is a key finding on a mammogram associated with mammary duct ectasia? What other investigations may be performed for mammary duct ectasia?
Microcalcifications are a key finding, although they are not specific to this condition.
Other investigations include ductography, nipple discharge cytology, and ductoscopy.
How does mammary duct ectasia typically resolve? What management strategies may be used for mammary duct ectasia?
Mammary duct ectasia may resolve without treatment and is not associated with an increased risk of cancer.
Management may include reassurance after excluding cancer, symptomatic management of mastalgia, antibiotics for suspected infection, or surgical excision (microdochectomy) in problematic cases.
What is an intraductal papilloma?
An intraductal papilloma is a benign warty lesion that grows within one of the ducts in the breast, resulting from the proliferation of epithelial cells.
What is the typical presentation of an intraductal papilloma?
The typical presentation includes clear or blood-stained nipple discharge, tenderness or pain, and a palpable lump.
They are often asymptomatic and may be detected incidentally on mammograms or ultrasounds.
At what age do intraductal papillomas most commonly occur?
They most often occur between the ages of 35 and 55 years.
How can ductography be used in the diagnosis of intraductal papillomas?
Ductography involves injecting contrast into the abnormal duct and performing mammograms to visualize that duct; the papilloma appears as an area that does not fill with contrast (a “filling defect”).
What is the management for intraductal papillomas?
Intraductal papillomas require complete surgical excision. After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been detected on biopsy.
What is the management of lactational mastitis?
management is conservative, with continued breastfeeding, expressing milk and breast massage. Heat packs, warm showers and simple analgesia can help symptoms.
If fever/suspected infection: Flucloxacillin is the first line, or erythromycin.
A sample of milk can be sent to the lab for culture and sensitivities. Fluconazole may be used for suspected candidal infections.
Women should be encouraged to continue breastfeeding
What is the treatment in candida of the nipple in a breastfeeding person?
Both the mother and baby need treatment, or it will reoccur. Treatment is with:
- Topical miconazole 2% to the nipple, after each breastfeed
- Treatment for the baby (e.g., oral miconazole gel or nystatin)
What are the typical presentations of mastitis or breast abscesses?
Symptoms include nipple changes, purulent nipple discharge, localized pain, tenderness, warmth, erythema, hardening of the skin, and swelling.
What feature suggests the presence of a breast abscess?
A swollen, fluctuant, tender lump within the breast suggests a breast abscess.
What antibiotics are recommended for non-lactational mastitis?
Co-amoxiclav or erythromycin/clarithromycin plus metronidazole are recommended for non-lactational mastitis.
What is required for the management of a breast abscess?
Management requires referral to the surgical team, antibiotics, ultrasound for diagnosis, drainage, and microscopy, culture, and sensitivities of the drained fluid.
What causes urge incontinence?
Urge incontinence is caused by overactivity of the detrusor muscle of the bladder.
What is stress incontinence?
Stress incontinence occurs due to weakness of the pelvic floor and sphincter muscles, allowing urine to leak during increased pressure (e.g., laughing, coughing).
What is overflow (urinary) incontinence?
Overflow incontinence occurs when there is chronic urinary retention, leading to leakage without the urge to urinate.
What are common causes of overflow incontinence?
Causes include obstruction, anticholinergic medications, fibroids, pelvic tumors, and neurological conditions.
What are some risk factors for urinary incontinence?
Risk factors include increased age, postmenopausal status, high BMI, previous pregnancies, pelvic organ prolapse, and neurological conditions.
What tests can help investigate urinary incontinence?
Urine dipstick testing, post-void residual volume measurement, and urodynamic testing may be performed.
How is stress incontinence managed?
Management involves pelvic floor exercises, lifestyle modifications, medications (like Duloxetine), and possibly surgery.
What surgical options exist for stress incontinence?
Surgical options include tension-free vaginal tape procedures, autologous sling procedures, colposuspension, and intramural urethral bulking.
What is the first-line treatment for urge incontinence?
Bladder retraining is the first-line treatment for urge incontinence.
What medications are commonly used for urge incontinence?
Anticholinergic medications (e.g., oxybutynin, tolterodine) and mirabegron are commonly used.
What are some potential side effects of anticholinergic medications?
Side effects can include dry mouth, urinary retention, constipation, cognitive decline, and worsening of dementia.
What are invasive options for managing overactive bladder?
Invasive options include botulinum toxin injections, percutaneous sacral nerve stimulation, augmentation cystoplasty, and urinary diversion.
What precautions should be taken when using mirabegron?
Blood pressure should be monitored regularly, as mirabegron is contraindicated in uncontrolled hypertension.
What is an endometrioma, and what is it commonly called?
An endometrioma is a lump of endometrial tissue outside the uterus, often referred to as a “chocolate cyst” when located in the ovaries.
What does adenomyosis refer to?
Adenomyosis refers to endometrial tissue within the myometrium (muscle layer) of the uterus.
What is the exact cause of endometriosis?
The exact cause is unclear, but theories include retrograde menstruation, embryonic cell development, lymphatic spread, and metaplasia of cells.
What are the main symptoms of endometriosis?
The main symptom is pelvic pain, but it can also include cyclical abdominal or pelvic pain, dyspareunia, dysmenorrhea, infertility, and cyclical bleeding from other sites.
What complications can arise from endometriosis?
Complications include chronic non-cyclical pain due to adhesions, reduced fertility, and potential bleeding in urine or stools.
How is endometriosis diagnosed?
Diagnosis can be made through pelvic ultrasound and is definitively confirmed via laparoscopy with biopsy.
What is the American Society of Reproductive Medicine (ASRM) staging system for endometriosis?
The ASRM staging system grades endometriosis from Stage 1 (small superficial lesions) to Stage 4 (deep, large lesions with extensive adhesions).
What hormonal management options are available for endometriosis?
Options include the combined oral contraceptive pill, progesterone-only pill, medroxyprogesterone acetate injection, Nexplanon implant, Mirena coil, and GnRH agonists.
What surgical options are available for managing endometriosis?
Surgical options include laparoscopic excision or ablation of endometrial tissue, adhesiolysis, hysterectomy, and bilateral salpingo-oophorectomy.
What are GnRH agonists used for in the treatment of endometriosis?
GnRH agonists induce a menopause-like state to help reduce pain by shutting down ovarian function temporarily.
List three risk factors for ectopic pregnancy.
Previous ectopic pregnancy, pelvic inflammatory disease, and smoking.
What are the classic symptoms of an ectopic pregnancy?
- Missed period,
- constant lower abdominal pain,
- vaginal bleeding,
- cervical motion tenderness
What ultrasound findings can indicate an ectopic pregnancy?
A gestational sac in the fallopian tube, an empty uterus, or a pseudogestational sac.
How is human chorionic gonadotropin (hCG) used in monitoring ectopic pregnancies?
hCG levels are tracked over time; a rise of less than 63% after 48 hours may indicate an ectopic pregnancy.
What are the criteria for expectant management of an ectopic pregnancy?
- Unruptured ectopic
- adnexal mass < 35mm
- no significant pain
- HCG < 1500 IU/L,
- no visible heartbeat.
What are the two surgical options for ectopic pregnancy management?
Laparoscopic salpingectomy and laparoscopic salpingotomy.
When is laparoscopic salpingectomy preferred over salpingotomy?
It is preferred unless there is a high risk of infertility due to damage to the other fallopian tube.
What is a “threatened miscarriage”?
Vaginal bleeding with a closed cervix and a fetus that is alive.
What ultrasound finding indicates an anembryonic pregnancy?
A gestational sac without a fetal pole, with a mean gestational sac diameter of 25mm or more.
What is the first-line management for a miscarriage in women without risk factors for heavy bleeding or infection?
Expectant management, allowing 1–2 weeks for the miscarriage to occur spontaneously.
What medication is used for medical management of miscarriage, and what does it do?
Misoprostol, a prostaglandin analogue that softens the cervix and stimulates uterine contractions.
What are the key side effects of misoprostol?
Heavier bleeding, pain, vomiting, and diarrhea.
When is manual vacuum aspiration typically used, and under what conditions?
For women below 10 weeks gestation, particularly parous women, as an outpatient procedure under local anesthesia.
What are the two main treatment options for an incomplete miscarriage?
Medical management with misoprostol or surgical management via evacuation of retained products of conception (ERPC).
What is a key complication of the evacuation of retained products of conception (ERPC)?
Endometritis, or infection of the endometrium.
At what crown-rump length without a fetal heartbeat is a non-viable pregnancy confirmed after a repeat scan?
7mm or more.
What is the definition of recurrent miscarriage?
Three or more miscarriages.
How does the risk of miscarriage change with age?
- 10% in women aged 20–30 years
- 15% in women aged 30–35 years
- 25% in women aged 35–40 years
- 50% in women aged 40–45 years
When are investigations initiated for recurrent miscarriage?
After three or more first-trimester miscarriages or one or more second-trimester miscarriages
Name three causes of recurrent miscarriage.
Antiphospholipid syndrome
uterine abnormalities
hereditary thrombophilias, most common is Factor V Leiden
How is the risk of miscarriage reduced in patients with antiphospholipid syndrome?
By using low-dose aspirin and low molecular weight heparin (LMWH).
List three uterine abnormalities that can cause recurrent miscarriage.
Uterine septum
bicornuate uterus
cervical insufficiency
What is chronic histiocytic intervillositis?
A rare condition where histiocytes and macrophages accumulate in the placenta, causing inflammation, recurrent miscarriage, and adverse outcomes.
What investigations are typically performed for recurrent miscarriage?
Antiphospholipid antibodies
Testing for hereditary thrombophilias
Pelvic ultrasound
Genetic testing of products of conception
Genetic testing on parents
What are the legal requirements for performing an abortion?
- Two registered medical practitioners must agree abortion is indicated.
- It must be carried out by a registered medical practitioner in an NHS hospital or approved premise.
What is the role of mifepristone in a medical abortion?
Mifepristone is an anti-progestogen that blocks progesterone, halts the pregnancy, and relaxes the cervix.
What is the role of misoprostol in a medical abortion?
Misoprostol is a prostaglandin analogue that softens the cervix and stimulates uterine contractions.
What medications are used for cervical priming before surgical abortion?
Misoprostol, mifepristone, or osmotic dilators.
What are the guidelines for diagnosing hyperemesis gravidarum?
The RCOG guideline (2016) criteria for diagnosing hyperemesis gravidarum are “protracted” NVP plus:
* More than 5 % weight loss compared with before pregnancy
* Dehydration
* Electrolyte imbalance
How is the severity of hyperemesis gravidarum assessed?
Pregnancy-Unique Quantification of Emesis (PUQE) score. This gives a score out of 15:
< 7: Mild
7 – 12: Moderate
> 12: Severe
What is the management of hyperemesis gravidarum?
Antiemetics:
* Prochlorperazine (stemetil)
* Cyclizine
* Ondansetron
* Metoclopramide
Ranitidine or omeprazole can be used if acid reflux is a problem.
Admission if:
* Unable to tolerate oral antiemetics or keep down any fluids
* More than 5 % weight loss compared with pre-pregnancy
* Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant)
* Other medical conditions need treating that required admission
What is a hydatidiform mole?
A type of tumour that grows like a pregnancy inside the uterus, also called a molar pregnancy.
What are the two types of molar pregnancy?
- Complete mole – No fetal material forms; caused by two sperm fertilising an “empty ovum.”
- Partial mole – Some fetal material forms; caused by two sperm fertilising a normal ovum, resulting in three sets of chromosomes.
What are key clinical features that suggest a molar pregnancy?
- Severe morning sickness.
- Vaginal bleeding.
- Rapid enlargement of the uterus.
- Abnormally high hCG levels.
- Thyrotoxicosis (due to hCG mimicking TSH).
What is the characteristic ultrasound finding of a molar pregnancy?
A “snowstorm appearance” on pelvic ultrasound.
How is a molar pregnancy confirmed?
By histological examination of the evacuated mole after uterine evacuation.
What is the management for a molar pregnancy?
- Evacuation of the uterus to remove the mole.
- Histological examination of the products of conception.
- Referral to a gestational trophoblastic disease centre for follow-up.
- Monitoring hCG levels until they return to normal.
What is the most accurate first-line screening test for Down’s syndrome?
The combined test, performed between 11 and 14 weeks gestation.
What does the combined test include?
Ultrasound: Measures nuchal translucency (>6mm suggests higher risk).
Maternal blood tests:
* Beta-HCG: Higher result = greater risk.
* PAPPA: Lower result = greater risk.
What is the triple test, and when is it performed?
How is the quadruple test different from the triple test?
A maternal blood test performed between 14 and 20 weeks gestation, measuring:
* Beta-HCG: Higher = greater risk.
* AFP: Lower = greater risk.
* Serum oestriol: Lower = greater risk.
Quadruple test includes an additional marker: inhibin-A (higher result = greater risk).
What invasive tests provide a definitive diagnosis of Down’s syndrome?
- Chorionic villus sampling (CVS): Biopsy of placental tissue (used before 15 weeks).
- Amniocentesis: Aspiration of amniotic fluid (used after 15 weeks).
What risk score from screening indicates the need for invasive testing for Down’s syndrome?
> 1 in 150
What is non-invasive prenatal testing (NIPT)?
What are the advantages of NIPT?
A maternal blood test analysing DNA fragments from placental tissue to detect conditions like Down’s.
Less invasive than CVS or amniocentesis.
Provides a good indication of Down’s syndrome.
Used for women with a risk >1 in 150.
What is the risk of untreated hypothyroidism during pregnancy?
Miscarriage, anaemia, small for gestational age, and pre-eclampsia
Which antihypertensive medications should be avoided during pregnancy due to risk of congenital abnormalities?
- ACE inhibitors (e.g., ramipril)
- ARBs (Angiotensin receptor blockers) (e.g., losartan)
- Thiazide and thiazide-like diuretics (e.g., indapamide).
Which anti-epileptic drugs are safer for use in pregnancy?
Levetiracetam
Lamotrigine
Carbamazepine.
What anti-epileptic drugs are avoided in pregnancy due to teratogenic effects?
- Sodium valproate (neural tube defects, developmental delay)
- Phenytoin (causes cleft lip and palate).
How does rheumatoid arthritis typically change during pregnancy?
Symptoms often improve during pregnancy but may flare postpartum.
Which drugs are contraindicated or safe for rheumatoid arthritis during pregnancy?
Contraindicated: Methotrexate (teratogenic).
Safe: Hydroxychloroquine, sulfasalazine, corticosteroids (during flares)
Why are NSAIDs generally avoided in pregnancy, especially in the third trimester?
They can cause premature closure of the ductus arteriosus in the fetus and delay labour.
What are the potential neonatal side effects of beta-blockers used during pregnancy?
Fetal growth restriction
Neonatal hypoglycaemia
Neonatal bradycardia
What effects can ACE inhibitors and ARBs have on the fetus during pregnancy?
Oligohydramnios (reduced amniotic fluid)
Miscarriage or fetal death
Hypocalvaria (incomplete skull formation)
Neonatal renal failure and hypotension
What is neonatal abstinence syndrome (NAS), and what causes it?
NAS is caused by maternal opiate use and presents with irritability, tachypnoea, high temperatures, and poor feeding in the neonate within 3–72 hours after birth.
Why is warfarin contraindicated in pregnancy?
Teratogenic effects (craniofacial malformations)
Fetal loss
Bleeding risks (maternal, fetal, or neonatal)
What condition is associated with lithium use in the first trimester?
Ebstein’s anomaly – a congenital heart defect involving the tricuspid valve.
How should lithium be monitored during pregnancy?
Monitor levels every 4 weeks initially.
Increase to weekly monitoring from 36 weeks.
What are the risks of SSRIs during pregnancy?
- Congenital heart defects (first trimester)
- Persistent pulmonary hypertension (third trimester)
- Mild neonatal withdrawal symptoms
Why is isotretinoin (Roaccutane) contraindicated in pregnancy?
It is highly teratogenic, causing miscarriages and congenital defects. Reliable contraception is essential during and for one month after treatment.
What is congenital rubella syndrome, and how is it prevented?
- Caused by maternal rubella infection during the first 20 weeks of pregnancy, especially before 10 weeks.
- Features: Congenital deafness, cataracts, heart disease (PDA, pulmonary stenosis), learning disability.
- Prevention: MMR vaccine before pregnancy; avoid in pregnancy as it’s a live vaccine.
What are the risks of chickenpox during pregnancy?
- Severe maternal illness: pneumonitis, hepatitis, encephalitis.
- Fetal varicella syndrome (growth restriction, microcephaly, dermatomal scars, limb hypoplasia, cataracts).
- Severe neonatal varicella (if near delivery).
- Treatment: IV varicella immunoglobulin for non-immune women after exposure; oral aciclovir if rash develops after 20 weeks.
How is listeriosis transmitted, and what are its risks in pregnancy?
- Source: Unpasteurised dairy, processed meats, contaminated food.
- Risks: Miscarriage, fetal death, severe neonatal infection.
- Prevention: Avoid high-risk foods and maintain good hygiene.
What are the features of congenital cytomegalovirus (CMV) infection?
- Caused by: Maternal CMV infection during pregnancy (via infected saliva or urine).
- Features: Growth restriction, microcephaly, hearing and vision loss, learning disability, seizures.
What is the classic triad of congenital toxoplasmosis?
- Intracranial calcifications.
- Hydrocephalus.
- Chorioretinitis (eye inflammation).
Cause: Maternal infection with Toxoplasma gondii (from cat feces or contaminated food).
What are the complications of parvovirus B19 infection during pregnancy?
fifth disease, slapped cheek syndrome, erythema infectiosum
- Fetal risks: Miscarriage, severe anaemia, hydrops fetalis (heart failure).
- Maternal risks: Pre-eclampsia-like syndrome (mirror syndrome).
- Diagnosis: IgM (recent infection), IgG (immunity), rubella antibodies (rule out rubella).
What is congenital Zika syndrome, and how is it diagnosed?
- Features: Microcephaly, growth restriction, ventriculomegaly, cerebellar atrophy.
- Cause: Maternal Zika virus infection (via mosquitos or sexual transmission).
- Diagnosis: Viral PCR and Zika antibodies.
- Management: Referral to fetal medicine; no treatment available.
How is Rhesus incompatibility managed?
- Prevention: anti-D inj to Rh-ve women at **28wk and birth **
- give anti-D during sensitisation events within 72 hrs: antepartum haemorrhage, amniocentesis, abdominal trauma
What is Kleihauer test?
checks how much fetal blood has passed into the mother’s blood during a sensitisation event.
What defines Small for Gestational Age (SGA)?
A fetus measuring below the 10th centile for their gestational age.
<3rd centile is severe
What are the two ultrasound measurements used to assess fetal size?
Estimated fetal weight (EFW) and fetal abdominal circumference (AC).
What is the difference between SGA and Fetal Growth Restriction (FGR)?
SGA Good: Refers to a fetus that is small for dates but may still be healthy.
FGR Bad: Refers to pathological smallness due to insufficient oxygen or nutrients from the placenta.
What conditions can lead to placenta-mediated growth restriction?
Pre-eclampsia, smoking, alcohol, malnutrition, maternal anaemia, infections, and other maternal health conditions.
Name three examples of non-placenta-mediated causes of FGR.
Genetic abnormalities, structural abnormalities, and fetal infections.
List three other signs of FGR besides being SGA.
Reduced amniotic fluid volume, abnormal Doppler studies, and reduced fetal movements.
What are two short-term complications of FGR?
Fetal death or stillbirth, and neonatal hypoglycaemia.
What long-term risks are associated with growth-restricted babies?
Cardiovascular disease, type 2 diabetes, obesity, and mood/behavioral problems.
What are three major risk factors for SGA?
Previous SGA baby.
Smoking.
Pre-eclampsia.
How is low-risk SGA monitored during pregnancy?
By measuring the symphysis fundal height (SFH) at every antenatal appointment from 24 weeks and plotting it on a growth chart.
When are women booked for serial growth scans with umbilical artery Doppler?
- If they have three or more minor risk factors.
- If they have one or more major risk factors.
- If SFH measurement is unreliable.
Name two investigations done when a fetus is identified as SGA.
Blood pressure and urine dipstick for pre-eclampsia.
Detailed fetal anatomy scan by fetal medicine.
What is the management plan for a fetus identified as SGA?
- Aspirin for pre-eclampsia prevention.
- Treat modifiable risk factors (e.g., stop smoking).
- Serial growth scans.
- Early delivery if growth is static or other concerns arise
What is the criteria for large for gestational age?
.>4.5kg at birth
EFW >90th centile
What are some causes of macrosomia?
- Constitutional
- Maternal diabetes
- Previous macrosomia
- Maternal obesity or rapid weight gain
- Overdue
- Male baby
What are the risks to the mother for a baby with macrosomia?
- Shoulder dystocia
- Failure to progress
- Perineal tears
- Instrumental delivery or caesarean
- Postpartum haemorrhage
Uterine rupture (rare)
What are the risks to the baby in macrosomia?
- Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia)
- Neonatal hypoglycaemia
- Obesity in childhood and later life
- Type 2 diabetes in adulthood
What are some investigations for macrosomia?
- Ultrasound to exclude polyhydramnios and estimate the fetal weight
- Oral glucose tolerance test for gestational diabetes
How can shoulder dystocia be prevented?
- Delivery on a consultant lead unit
- Delivery by an experienced midwife or obstetrician
- Access to an obstetrician and theatre if required
- Active management of the third stage (delivery of the placenta)
- Early decision for caesarean section if required
- Paediatrician attending the birth
How is twin-twin transfusion syndrome treated?
laser treatment may be used to destroy the connection between the two blood supplies.
What additional scans are required for multiple pregnancy?
- 2 weekly scans from 16 weeks for monochorionic twins
- 4 weekly scans from 20 weeks for dichorionic twins
How is delivery managed in monoamniotic vs diamniotic twins?
Monoamniotic twins require elective caesarean section at between 32 and 33 + 6 weeks.
Diamniotic twins (aim to deliver between 37 and 37 + 6 weeks)
Why are urinary tract infections particularly concerning during pregnancy?
They increase the risk of preterm delivery, low birth weight, and pre-eclampsia.
How are urinary tract infections managed in pregnancy?
With 7 days of antibiotics such as nitrofurantoin, amoxicillin (after sensitivity testing), or cefalexin.
dont use nitro in the 3rd trimester
Why should nitrofurantoin be avoided in the third trimester?
Why should trimethoprim be avoided in the first trimester?
nitro - neonatal haemolysis
trim - tube defects
What are the RCOG guidelines on VTE prophylaxis?
- 28 weeks if there are three risk factors
- First trimester if there are four or more of these risk factors
What are the three main features of pre-eclampsia?
Hypertension
Proteinuria
Oedema
Name the high-risk factors for pre-eclampsia.
- Pre-existing hypertension
- Previous hypertension in pregnancy
- Autoimmune conditions (e.g., systemic lupus erythematosus)
- Diabetes
- Chronic kidney disease
Name the moderate-risk factors for pre-eclampsia.
Age over 40
BMI > 35
More than 10 years since last pregnancy
Multiple pregnancy
First pregnancy
Family history of pre-eclampsia
How is pre-eclampsia diagnosed according to NICE guidelines?
Systolic BP > 140 mmHg or diastolic BP > 90 mmHg
Plus one of the following:
* Proteinuria (1+ or more on dipstick)
* Organ dysfunction (e.g., raised creatinine, liver enzymes, seizures)
* Placental dysfunction (e.g., fetal growth restriction, abnormal Dopplers)
What are significant levels for urine protein:creatinine and albumin:creatinine ratios in pre-eclampsia?
Protein:creatinine ratio: > 30 mg/mmol
Albumin:creatinine ratio: > 8 mg/mmol
What medications are used for pre-eclampsia prophylaxis?
Aspirin from 12 weeks gestation until birth for women with:
* One high-risk factor or
* Two or more moderate-risk factors.
What is the first-line antihypertensive for pre-eclampsia?
Labetalol
What is used to prevent seizures in severe pre-eclampsia?
IV magnesium sulphate.
What is HELLP syndrome, and what does it stand for?
HELLP syndrome is a complication of pre-eclampsia/eclampsia characterized by:
* H: Haemolysis
* EL: Elevated Liver enzymes
* LP: Low Platelets
What medications are used post-delivery to manage hypertension in pre-eclampsia?
First-line: Enalapril
First-line for Black African/Caribbean patients: Nifedipine or amlodipine
Third-line: Labetalol or atenolol
What are the risk factors that warrant gestational diabetes testing according to NICE guidelines?
- Previous gestational diabetes
- Previous macrosomic baby (≥ 4.5kg)
- BMI > 30
- Ethnic origin (black Caribbean, Middle Eastern and South Asian)
- Family history of diabetes (first-degree relative)
How often is fetal growth measured in gestational diabetes?
4 weekly
What is the management of gestational diabetes according to fasting glucose levels?
- Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
- Fasting glucose above 7 mmol/l: start insulin ± metformin
- Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
What screening test should be offered for pregnant women with pre-existing diabetes?
Retinopathy screening, after booking and at 28wks
What are the delivery plans for women with pre-existing gestational diabetes?
planned delivery between 37 and 38+6 wks
Women with gestational diabetes can give birth up to 40 + 6
What is the risk to babies with mothers with diabetes?
- Neonatal hypoglycaemia
- Polycythaemia (raised haemoglobin)
- Jaundice (raised bilirubin)
- Congenital heart disease
- Cardiomyopathy
What is the presentation of obstetric cholestasis
- itching palms of hands and soles of feet
- fatigue
- dark urine
- pale-greasy stool
- jaundice
If a rash is present, an alternative diagnosis should be considered, such as polymorphic eruption of pregnancy or pemphigoid gestationis.
What is the management of obstetric cholestasis?
- emollients
- antihistamines e.g. chlorphenamine
- vit K if PT deranged
When does acute fatty liver of pregnancy present? What is the risk?
3rd trimester
high risk of liver failure and mortality
What is the most common cause of acute fatty liver of pregnancy?
long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus, which is an autosomal recessive condition.
What is the management of acute fatty liver of pregnancy?
OBSTETRIC EMERGENCY
* admission and delivery
* consider liver transplant
What are the key features of polymorphic eruption of pregnancy? When does it occur?
- Urticarial papules (raised itchy lumps)
- Wheals (raised itchy areas)
- Plaques (larger inflamed areas of skin)
3rd trimester
How is polymorphic eruption of pregnancy managed?
- Topical emollients
- Topical steroids
- Oral antihistamines
- Oral steroids in severe cases
What are the two types of atopic eruption of pregnancy?
E-type (eczema-type): Eczematous, inflamed, itchy skin, typically on the elbows, knees, neck, face, and chest.
P-type (prurigo-type): Intensely itchy papules on the abdomen, back, and limbs.
2nd and 3rd trimester
How does pemphigoid gestationis typically present?
- Starts as an itchy red papular or blistering rash around the umbilicus.
- Progresses to large fluid-filled blisters (bullae) over weeks.
What are the risks to the baby with pemphigoid gestationis?
- Fetal growth restriction
- Preterm delivery
- Blistering rash after delivery (maternal antibodies pass to the baby)
What are the RCOG definitions of low-lying placenta vs placenta praevia?
- Low-lying placenta is used when the placenta is within 20mm of the internal cervical os
- Placenta praevia is used only when the placenta is over the internal cervical os
What are the risk factors for placenta praevia?
- Previous caesarean sections
- Previous placenta praevia
- Older maternal age
- Maternal smoking
- Structural uterine abnormalities (e.g. fibroids)
- Assisted reproduction (e.g. IVF)
How does placenta praevia present? How is it diagnosed?
Presentation: usually asymptomatic, may present with painless vaginal bleeding usually after 36wks
Diagnosis: 20-wk anomaly scan
What is the management of placenta praevia?
- Repeat TVUSS at 32wks and 36wks
- Corticosteroids between 34-35+6 wks (fetal lungs)
- Planned delivery between 36-37 wks
What are some risk factors of vasa praevia?
Low lying placenta
IVF pregnancy
Multiple pregnancy
What are the risk factors for placental abruption?
- Previous placental abruption
- Pre-eclampsia
- Bleeding early in pregnancy
- Trauma (consider domestic violence)
- Multiple pregnancy
- Fetal growth restriction
- Multigravida
- Increased maternal age
- Smoking
- Cocaine or amphetamine use
What is the typical presentation of placental abruption?
- sudden onset severe continuous abdominal pain
- vaginal bleeding
- shock
- abdnormal CTG/foetal distress
- “woody” abdomen on palpation
What are the RCOG guidelines on placental abruption severity classification?
- Spotting: spots of blood noticed on underwear
- Minor haemorrhage: less than 50ml blood loss
- Major haemorrhage: 50 – 1000ml blood loss
- Massive haemorrhage: more than 1000 ml blood loss, or signs of shock
always considered concealed abruptions
What are the risk factors of placenta accreta?
- Previous placenta accreta
- Previous endometrial curettage procedures (e.g. for miscarriage or abortion)
- Previous caesarean section
- Multigravida
- Increased maternal age
- Low-lying placenta or placenta praevia
How should a pregnant woman be positioned during a cardiac arrest?
left lateral position, 15 deg
What are the extra considerations for pregnant women in cardiac arrest?
- A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta
- Early intubation to protect the airway
- Early supplementary oxygen
- Aggressive fluid resuscitation (caution in pre-eclampsia)
- Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR
What are the 3 stages of labour?
First stage – from the onset of labour (true contractions) until 10cm cervical dilatation
Second stage – from 10cm cervical dilatation until delivery of the baby
Third stage – from delivery of the baby until delivery of the placenta
What are the three phases in the first phase of labour?
Latent phase – from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
Active phase – from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
Transition phase – from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.
What is the role of vaginal progesterone in labour?
- prophylaxis for preterm labour.
- decreasing activity of the myometrium and preventing the cervix remodelling in preparation for delivery
- offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation
What is the management of PPROM?
- prophylactic Abx - erythromycin 250mg QDS 10 days
- induction of labour after 34 weeks
What is Preterm Labour with Intact Membranes?
regular painful contraction and cervical dilatation, without rupture of the amniotic sac
What is the management of preterm labour with intact membranes?
- Fetal monitoring (CTG or intermittent auscultation)
- Tocolysis with nifedipine: suppresses labour
- Maternal corticosteroids: before 35 weeks gestation to reduce neonatal morbidity and mortality
- IV magnesium sulphate: before 34 weeks gestation and helps protect the baby’s brain
- Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth
What is the Bishop score?
determines whether to induce labour
* Fetal station (scored 0 – 3)
* Cervical position (scored 0 – 2)
* Cervical dilatation (scored 0 – 3)
* Cervical effacement (scored 0 – 3)
* Cervical consistency (scored 0 – 2)
Score 8 or more = successful induction
What are options for induction of labour?
- Membrane sweep
- Vaginal prostaglandin E2 (dinoprostone)
- Cervical ripening balloon
- Artificial ROM
- Oral mifepristone + misoprostol - for stillbirth
What is a complication of vaginal prostaglandins? How is it managed?
Uterine hyperstimulation: contractions >2min duration, >5 contraction/10 min
Remove it, give tocolysis with terbutaline
What are the components of CTG monitoring?
Fetal heart rate transducer: Above the fetal heart, using Doppler ultrasound.
Contraction transducer: Near the uterine fundus, using ultrasound to measure uterine wall tension.
What are some indications for continuous CTG monitoring during labour?
- Sepsis
- Maternal tachycardia (>120 bpm)
- Significant meconium
- Pre-eclampsia (BP >160/110)
- Fresh antepartum haemorrhage
- Delay in labour
- Use of oxytocin
- Disproportionate maternal pain
What are the five key features to look for on a CTG?
- Contractions: Number per 10 minutes.
- Baseline rate: The average fetal heart rate.
- Variability: Changes around the baseline.
- Accelerations: Increases in heart rate.
- Decelerations: Decreases in heart rate.
What are the ranges for a normal baseline fetal heart rate and variability?
Baseline rate: 110–160 bpm.
Variability: 5–25 bpm.
What are the four types of decelerations?
- Early decelerations: Gradual dips with contractions, non-pathological.
- Late decelerations: Delayed dips after contractions, caused by hypoxia, concerning.
- Variable decelerations: Abrupt dips, often due to umbilical cord compression.
- Prolonged decelerations: Last 2–10 minutes, caused by sustained hypoxia, concerning
What is the “rule of 3’s” for fetal bradycardia?
3 minutes: Call for help.
6 minutes: Move to theatre.
9 minutes: Prepare for delivery.
12 minutes: Deliver the baby by 15 minutes.
What is a sinusoidal CTG pattern, and what does it indicate?
A sinusoidal pattern has smooth, regular waves (amplitude 5–15 bpm) and often indicates severe fetal anaemia, such as from vasa praevia with fetal haemorrhage.
What is DR C BRaVADO, and how is it used?
DR: Define Risk
C: Contractions
BRa: Baseline Rate
V: Variability
A: Accelerations
D: Decelerations
O: Overall impression (normal, suspicious, pathological, or urgent intervention).
What is the primary function of oxytocin during labour?
List the main uses of oxytocin in labour and postpartum care.
Oxytocin stimulates cervical ripening and uterine contractions during labour, and is also involved in lactation.
- Induce labour
- Progress labour
- Strengthen uterine contractions
- Prevent or treat postpartum haemorrhage
What is Atosiban, and when is it used?
Atosiban is an oxytocin receptor antagonist used for tocolysis in premature labour, particularly when nifedipine is contraindicated.
What is ergometrine used for, and when should it be avoided?
Uses:
* Deliver the placenta
* Prevent or treat postpartum haemorrhage (only after delivery of the baby)
Avoid:
* Eclampsia
* Significant caution in hypertension
What is Syntometrine?
A combination of oxytocin (Syntocinon) and ergometrine, used to prevent or treat postpartum haemorrhage.
What is misoprostol, and for what conditions is it used?
Misoprostol is a prostaglandin analogue used for:
* Medical management of miscarriage
* Induction of labour after intrauterine fetal death
* Alongside mifepristone for abortions
What is mifepristone, and how does it work?
Mifepristone is an anti-progestogen medication that blocks progesterone, halting pregnancy and ripening the cervix. It is used with misoprostol for abortions and induction of labour after intrauterine fetal death.
What are the two main uses of nifedipine in pregnancy?
- Reduce blood pressure in hypertension and pre-eclampsia.
- Tocolysis in premature labour to suppress uterine activity.
What is terbutaline, and when is it used?
Terbutaline is a beta-2 agonist that suppresses uterine contractions, used for tocolysis in cases of uterine hyperstimulation.
What is carboprost, and when should it be avoided?
Function: A synthetic prostaglandin analogue used in postpartum haemorrhage when oxytocin and ergometrine are inadequate.
Avoid: In asthma patients, as it can cause life-threatening exacerbations.
How does tranexamic acid work, and what is it used for?
Mechanism: Tranexamic acid prevents plasminogen from converting to plasmin, reducing the breakdown of blood clots.
Use: Prevention and treatment of postpartum haemorrhage.
What are some managements of shoulder dystocia?
- Episiotomy
- McRoberts manoeuvre
- Pressure to anterior shoulder
- Rubins manoeuvre
- Wood’s srew manoeuvre
- Zavanelli manoeuvre
What are complications of shoulder dystocia?
- Fetal hypoxia (and subsequent cerebral palsy)
- Brachial plexus injury and Erb’s palsy
- Perineal tears
- Postpartum haemorrhage
What medication should be given following an instrumental delivery?
A single dose of co-amoxiclav
What risks to the mother are increased in instrumental delivery?
- Postpartum haemorrhage
- Episiotomy
- Perineal tears
- Injury to the anal sphincter
- Incontinence of the bladder or bowel
- Nerve injury (obturator or femoral nerve)
What risks to the baby are increased in instrumental delivery?
Cephalohaematoma with ventouse
Facial nerve palsy with forceps
Subgaleal haemorrhage (most dangerous)
Intracranial haemorrhage
Skull fracture
Spinal cord injury
When is active management of the third stage of labour indicated?
Postpartum Haemorrhage
More than a 60-minute delay in delivery of the placenta (prolonged third stage)
What are the steps in active management of the third stage of labour?
- IM oxytocin
- cord clamped within 5 mins
- Controlled cord traction
- Uterus massage
- Placenta examined
What are the 4 T’s for PPH?
T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)
What are some mechanical treatments for PPH?
- Rubbing the uterus through the abdomen to stimulates a uterine contraction
- Catheterisation (bladder distention prevents uterus contractions)
What are some medical treatments for PPH?
- Oxytocin
- Ergometrine
- Carboprost
- Misoprostol
- Tranexamic acid
