OBGYN Flashcards
Preterm labour is weeks
37
Post-term labour is >? weeks
42
How can you work out estimated delivery date
1st day of LMP + 9 months and 7 days
OR
1st day LMP + 40 weeks
Trimester 1 is
0-12 weeks
Trimester 2 is
12-27 weeks
Trimester 3 is
27-40 weeks
When can you hear fetal heart beat with doppler
From 12 weeks
When can you hear fetal heart beat with Pinard and where do you listen
From 24 weeks
Over the anterior shoulder
Describe the position of the uterus and how/when it ascends throughout pregnancy
<12 weeks: in pelvis
16 weeks: half way between PS and umbilicus
20-34 weeks: at umbilicus
36 weeks: under ribs
When does the head engage in a) primips b) multips
Primips 37 weeks (if not consider placenta previa)
Multips onset of labour
Definition of maternal death
During pregnancy or within 42 days of birth
Risk factors assessed for VTE in pregnancy
BMI 30+ (40+ counts as 2) Age >35 Parity 3+ Smoker Varicose veins Pre-eclampsia Immobility 1st degree with unprovoked VTE Thrombophilia Multiple pregnancy IVF
Aspirin is giving in pregnancy to reduce the risk of what complication?
Pre-eclampsia
Risk factors for pre-eclampsia
Hypertensive disease in previous pregnancy CKD Autoimmune disease - SLE, APLS DM Chronic HTN First pregnancy Age 40+ >10 years between pregnancies BMI 35+ FH of pre-eclampsia Multiple pregnancy
If a patient is considered high risk for pre-eclampsia what medication do you start, what dose and when
Aspirin 75mg OD 12-37 weeks
Indications for OGTT at 26 weeks
BMI >30 Previous baby >4.5kg 1st degree relative with DM Family origin: South Asian (India, Pakistan, Bangladesh), Chinese, Black Caribbean, African, Middle Eastern (Saudi Arabia, United Arab Emirates, Iraq, Syria, Oman, Qatar, Kuwait, Lebanon, Egypt) Previous unexplained FDIU Previous congenital abnormality PCOS
Indications for OGTT at 16 weeks
Previous GDM
Severe PCOS
When should folic acid be taken?
3 months before conception and until 12 weeks gestation
What is the normal dose of folic acid
400 micrograms
What are some indication for higher dose folic acid (5mg)
High BMI
Hx of NTH (personal or FH)
Antiepileptic medication
DM
Risks of alcohol in pregnancy
IUGR
Facial abnormalities
Learning abnormalitis
Risks of smoking in pregnancy
LBW Preterm labour SIDS Miscarriage Neonatal breathing difficulties
Which vitamin should be avoided during pregnancy
Vitamin A (>700mcg) - so avoid liver products
How long is maternity leave and how long is maternity pay
52 weeks leave
39 weeks pay
When should nausea and vomiting resolve spontaneously by in pregnancy
Around 16-20 weeks
Common symptoms in pregnancy
Nausea and vomiting Constipation Haemorrhoids Heartburn Varicose veins Vaginal discharge Backache
Which medication is used to treat vaginal candida during pregnancy
Topical Imidazole
How many routine antenatal appointments are offered for a) primips b) multips
Primips - 10
Multips - 7
In general, how frequent are antenatal appointments
4wkly to 28
2-3wkly to 36
weekly 36+
Appointment weeks for primips
<12, 16, 25, 28, 31, 34, 36, 38, 40, 41
Appointment weeks for multips
<12, 16, 28, 34, 36, 38, 41
What happens at a booking visit
General advice/info Risk factors screened for VTE, GDM and Pre-eclampsia BMI + BP + urine dip Screening counselling Assess for DV and FGM Bloods
What bloods are done at booking
HIV, HBV and syphilis
Hb and platelet level
Blood group and antibody status
If family origin questionnaire high risk: sickle cell and thalassaemia.
At how many weeks do you start measuring SFH
25/26 weeks
When during pregnancy do you test for anaemia
At booking and 28 weeks
At how many weeks do you give the first and second dose of anti-D
28 and 34
At how many weeks do you have discussions/plans for delivery
34
At how many weeks do you discuss post-natal care
36
When can the combined test be performed
11-14 weeks
When can the quadruple test be performed
14-20 weeks
Which abnormalities does the combined test assess the risk of
Trisomy 21, 18 and 13
Which factors are assessed in the combined test
Nuchal transluscency
hCG
PAPP-A
Age
Which disorder does trisomy 21 cause
Down syndrome
Which disorder does trisomy 18 cause
Edwards syndrome
Which disorder does trisomy 13 cause
Patau’s syndrome
What does the quadruple test assess the risk of
Down syndrome only
What is measured in the quadruple test
AFP
Unconjugated estradiol
hCG
Inhibin A
When is the anomaly scan performed
18-21 weeks
In Down syndrome are PAPP-A, beta-hCG, AFP, Inhibin A and unconjugated estridiol high or low
Unconjugated estridiol, AFP and PAPP-A low
Inhibin-A and Beta-hCG high
When can CVS be carried out
10-13 weeks
Risk of miscarriage in CVS
1-2%
When can amniocentesis be carried out
15+ weeks
Risk of miscarriage in amniocentesis
0.5-1%
When can the private non-invasive screening test be carried out
10+ weeks
How much does the private non-invasive screening test cost
£400
Roughly when would you expect to feel fetal movements
20+ weeks
At how many weeks do you give prophylactic anti-D
28 + 34
If a patient has a resus sensitising event or +ve cord sample how quickly should you give treatment dose anti-D
Within 72 hours
Rhesus sensitising events
Any bleed Miscarriage (including threatened) TOP Ectopic Trauma Placental abruption ECV Amniocentesis CVS
When is whooping cough (pertussis) vaccine offered during pregnancy
27-36 weeks
Risks of chickenpox in pregnancy
Maternal pneumonia, encephalitis, hepatitis
Fetal varicella syndrome if <28 weeks, infant shingles if 28-36 weeks, born with chickenpox if after 36 weeks
What happens if a pregnancy woman comes into contact with chickenpox
If you’ve had it before you’ll have your antibody levels checked and if low get a booster. If never had it/not sure then seek medical advice if you come into contact with it during pregnancy as will need treatment
What can you tell diabetic women how pregnancy will affect their diabetes
Pregnancy causes higher insulin requirements and resistance to insulin
Worsening nephropathy/retinopathy ect
More hypos
May need higher doses of medication
Can only take metformin and insulin during pregnancy
Risks that diabetes poses to pregnancy
Increased risk of miscarriages, VTE, infection, rate of induction/CS, congenital malformations (skeletal, cardiac, NTDs), unexplained still birth
Macrosomia, polyhydraminos, shoulder dystocia, stillbirth, neonatal hypoglycaemia
Why does maternal hyperglycaemia/DM cause macrosomia
Maternal hyperglycaemia –> fetal hyperglycaemia –> increased fetal insulin = growth factor –> macrosomia
Pre-conception advice for diabetic women
Good glycaemic control reduces risk
Higher dose folic acid (5mg)
Retinopathy and nephropathy screens up to date
Medication review
How do you diagnose gestational diabetes
Fasting glucose 5.6+ or 2hr post OGTT 7.8+
OGTT done in morning after overnight fast of 8hrs, then 75gram OGTT and test after 2hrs
Blood glucose targets during pregnancy
HbA1c <48 Random 4-7 Fasting <5.3 Post-prandial <7.8 Keep above 4 always
When do you aim to deliver a pregnancy where mum had pre-existing diabetes
37-39 weeks
Risks of high BMI in pregnancy
Miscarriage, congenital malformations, GDM, macrosomia, pre-eclampsia, VTE, difficult fetal monitoring in labour, anaesthetic risk, PPH, post-natal infection
Risk factors for shoulder dystocia
Macrosomia Raised BMI DM IOL Epidural Instrumental delivery
Pre-existing HTN in pregnancy happens before how many weeks?
<20 weeks
Pregnancy induced hypertension and pre-eclampsia occur after how many weeks into the pregnancy?
> 20 weeks
Difference between pregnancy induced hypertension and pre-eclampsia
Proteinuria in pre-clampsia, none in pregnancy induced hypertension
Diagnostic criteria for pregnancy induced hypertension
> 20 weeks gestation
BP 140/90 on 2 occasions
No proteinuria
No pre-existing hypertension
Diagnostic criteria of pre-eclampsia
>20 weeks gestation BP 140/90 on 2 occasions plus one of; Proteinuria Systemic involvement (high Cr, high LFTs, RUQ pain, neuro or haem involvement) Fetal growth restriction
What pre-eclampsia symptoms do you tell women at risk to look out for
Severe headache Blurred vision/flashes Severe RUQ/subcostal pain Vomiting Sudden swelling of face/hands/feet
Which medications are used to lower blood pressure in pregnancy
Labetalol
Nifedipine
Hydralazine
Features of HELLP syndrome
Haemolysis
Elevated liver enzymes
Low platelets
Management of pre-eclampsia
Lower BP
Manage post-partum fluid balance (pulmonary oedema mortality)
Prevent/control seizures - magnesium sulphate infusion
Anaemic Hb levels for each trimester of pregnancy
1st <110
2nd <105
3rd <100
How do you treat anaemia in pregnancy
Ferrous sulphate/fumarate trial for 2 weeks
Continue for 3 months after Hb returns to normal and for 6 weeks post partum to replenish stores
Which diabetic meds are safe in pregnancy
Metformin
Insulin
Which is the safest anti-epileptic med during pregnancy
Lamotrigine
When can Trimethoprim and Nitrofurantoin be used in pregnancy
Trimethoprim after the 1st trimester
Nitrofurantoin before the 3rd trimester
What fetal abnormality can SSRIs cause
Congenital heart defects
Are NSAIDs safe in pregnancy
No - risk of oligohydraminos and premature closure of ductus arteriosus
A soaked sanitary pad is roughly how much blood loss
100ml
Differentials for antepartum haemorrhage
Ectropion PV infection Premature labour GU cancer Vaginal/rectal fissure/abrasion Placental abruption Placenta previa Vasa previa
4 T’s of causes for PPH
Tone
Tissue
Trauma
Thrombus
Which number do you call to activate the obstetric haemorrhage pathway
2222
How can you try to stop bleeding in an obstetric haemorrhage
Bimanual compression Empty bladder - insert foley catheter Syntocinon/Ergometrine IV max 2 doses Syntocinon infusion Misoprostol sublingual/rectal, can repeat after 20 mins
Primary PPH occurs how soon after birth?
Within 24 hours of birth
Secondary PPH occurs when?
24 hours - 12 weeks after birth
How many ml is a minor/moderate/major/massive PPH
Minor 500
Moderate 1000
Major 15000
Massive 2000
Most common causes of secondary PPH
Retained products
Infection
Dysfunctional uterine bleeding
Medications used in primary PPH management
Syntocinon Ergometrine Syntometrine Misoprostol Carboprost Tranexamic acid
Describe the hormonal pathway involved in menstruation
Hypothalamus releases GnRH –> pituitary releases LH + FSH which act on the ovaries to cause estrogen release and follicle maturation
Describe the follicular phase of menstruation
FSH, follicles mature, graafian follicle produces estrogen which thickens endometrium and thins cervical mucus. Oestrogen initially suppresses LH until threshold then sudden spike of LH day 12. 24-48hrs after LH surge follicle ruptures and releases secondary oocyte which quickly matures into ootid then mature ovum which enters fallopian tube.
Describe the luteal phase of menstruation
LH + FSH turn the ruptured follicle into the corpus luteum which produces progesterone – makes endometrium receptive, increases estrogen production, negatively feeds back on LH+FSH. When they fall the corpus luteum degenerates so drop in progesterone that causes menstruation.
When in the menstrual cycle are women most fertile
5 days before and 1-2 days after ovulation
Or within the 9 days after the end of the period
Ovulation occurs on roughly which day of the menstrual cycle
13
Differentials for heavy menstrual bleeding
Dysfunctional uterine bleeding Fibroids Endometriosis PID Endometrial/cervical polyps Adenomyosis PCOS Endometrial cancer Contraception Coagulopathy Hypothyroidism
Indications for hysteroscopy
>45 with abnormal bleeding Infertility Menstrual disorders Lost IUD Persistent IMB PCB Enlarged uterus Pelvic mass PMB
Medications used to manage heavy menstrual bleeding in women who want to have children
Tranexamic acid
Methanamic acid
Take while you’re bleeding
Hormonal medications/devices used to manage heavy menstrual bleeding
1st line is Mirena coil
Progesterone only pill
COCP
Depot injection
What are the medications used to shrink uterine fibroids
Ulipristal acetate - 3 month course, check LFTs
Gonadotopin releasing hormone analogues - Goserelin acetate injection
Surgical treatments of fibroids for women who still want children
Hysteroscopic resection of fibroids
Myomectomy
Surgical treatments of fibroids for women who don’t want future pregnancies
Endometrial ablation
Uterine artery embolisation
MRI guided percutaneous laser ablation
Hysterectomy
Differentials of bleeding in early pregnancy
Implantation bleed Miscarriage Ectopic Cervical ectropion/polyp/malignancy Genital tract trauma Molar pregnancy
Describe the type of bleed you get due to implantation
Light, short lived, bleeding/spotting, dark with a pink/brown tint, 6-12 days after conception (near when next period is expected)
Early miscarriage happens during what period of gestation
0-12 weeks
Late miscarriage happens during what period of gestation
12-24 weeks
Causes and risk factors for miscarriage
Chromosomal abnormalities
Cervical incompetence
Fetal malformations
Smoking, alcohol, cocaine, stress, previous TOP, previous miscarriage, age, chronic maternal illness, uterine malformations, high BMI
USS diagnostic criteria of miscarriage
CRL >7mm with no FH
Sac >25mm with no contents
What is a threatened miscarriage
Pregnancy confirmed
PV bleed
Cervix closed
USS shows viable pregnancy
What % of threatened miscarriages lead to successful pregnancies
90%
What is an inevitable miscarriage
Pregnancy confirmed
PV bleed + abdo pain
Cervix open
POC not passed yet
What is a complete miscarriage
All POC have passed
Cervix now closed
USS shows empty uterus
What is incomplete miscarriage
PV bleeding and pain
Cervix open
Some tissue passed, some remains in uterus
What is a missed/delayed miscarriage
Asymptomatic
Cervix closed
No POC passed
USS shows non viable pregnancy
What is a blighted ovum
Missed miscarriage where development stopped before the embryonic pole was visible. Gestational sac may continue to grow
What is a septic miscarriage
Miscarriage + sepsis (fever, significant abdo tenderness)
How many miscarriages count as recurrent
3+
How much should b-hCG increase by in a normal pregnancy
Double every 48hrs
Reached max 100,000) at 10 weeks then decreases
What level of b-hCG indicated gestational sac should be visible on transvaginal USS
> 1500 (roughly 5 weeks gestation)
What are the 3 main management options of a miscarriage
Expectant
Medical
Surgical
Describe the expectant management of a miscarriage
Varies, can take days/weeks
May bleed for several weeks
May pass POC or they may be reabsorbed
Follow up sacn at 2-3 weeks
Describe the medical management of a miscarriage
If <10 weeks just Misoprostol (uterine contractions)
If >10 weeks usually Mifepristone first (stops pregnancy hormones) then misoprostol
Describe the surgical management of a miscarriage
Manual vaccum aspiration or dilation and curettage
What part of the fallopian tube do ectopic pregnancies most commonly occur in
Ampulla
Management options for ectopic pregnancies
Conservative if <6weeks, asymptomatic, falling hCG
Methotrexate
Salingotomy
Salpingectomy
How long after Methotrexate for ectopic can you try to get pregnant again
3 months
Differentials of PV discharge
Bacterial vaginosis Candida Chlamydia Gonorrhea Trichomonas vaginalis Foreign body Cervical polyps Genital tract malignancy Genital tract fistula
Itch, frothy yellow discharge and ‘strawberry cervix’ are associated with which STI
Trichomonas vaginalis
What is included in an asymptomatic sexual health screen
Self swab for chalmydia and gonorrhea
Bloods for HIV and syphilis
When is cervical screening performed
Every 3 years from age 25-49
Every 5 years from age 50-64
Describe the result possibilities for cervical smear
Low grade - which can be borderline or moderate
High grade - which can be moderate or severe
If routine smear shows no dyskariosis but is HPV positive what do you do
Repeat smear in 1 year
If a smear result shows low grade dyskariosis how do you decide whether or not to send for colposcopy
Send for colposcopy if it is HPV positive as well
Management of a biopsy result of CIN1
No treatment
Repeat smear in 1 year
Management of biopsy result CIN3
Large loop excision of the transformation zone
After a LLETZ procedure when do you re-smear as a ‘test of cure’
6 months
What does ‘HPV triage’ mean
It means that all smears that are reported as borderline or mild (low grade) dyskariosis will be tested for HPV. If positive they will be referred to colposcopy, if negative they will return to routine recall
PV discharge that is grey/white and thin/watery, fishy odour and clue cells on microscopy. What is the likely organism/infection
Bacterial vaginosis
Normal labour is delivery at how many weeks
37-42
Describe the 1st stage of labour
Contractions cause cervical changes
Subdivided into latent and active phase
Latent - contractions not regular/established, <4cm
Active - contractions regular and established, >4cm
When does the 1st stage of labour end
When the cervix is 10cm dilated
As you progress through the 1st stage of labour what happens to contractions
They last longer, are more frequent and are stronger
Latent phase 30 second contractions every 5-30 mins
Active phase 1min contractions every 3-5 mins
Transition phase into the 2nd stage of labour they are 60-90 second contractions every 30 seconds-2 mins
What is the dilation rate for a primip
1cm every 2 hours
What is the dilation rate for a multip
1cm every 1 hour
What does the second stage of labour refer to
Delivery of the baby
What does the third stage of labour refer to
Delivery of the placenta
Describe the mechanisms of deliver
Descent
Engagement - station 0
Neck flexion + internal rotation into the occipitoanterior position so shoulders are in line with the widest part
Head passes below pubic symphysis - station +4
Head extension and delivery of the head
Restitution - head externally rotates
Shoulder externally rotated into the AP plane
Delivery of the anterior shoulder by gentle downward traction
Delivery of the posterior shoulder by gentle upward traction
Signs of placental separation
Uterus contracted
Cord lengthening
Blood trickle
Describe how the 3rd stage of labour can be actively managed
Oxytocin IM Check for signs of separation Clamp and cut the cord Apply upward pressure on the uterus to prevent inversion and downward traction on the cord until it's at the vulva then upward traction Examine for trauma Examine the placenta
What is engagement of the head and how can you tell
Largest diameter of the head into the largest diameter of the pelvis
When the head is 3/5ths palpable or less
What is assessed in APGAR scoring
Appearance - blue/pale, just extremities blue, pink
Pulse - absent, <100, >100
Grimace - absent, minimal response to stimulation, prompt response to stimulation
Activity - absent, flexion, active
Respiration - absent, slow/irregular, vigorous cry
At how many minutes do you measure APGAR score
1 and 5 mins
Common causes of a low APGAR score
Difficult birth
CS
Fluid aspiration
Indications for CTG
Maternal tachycardia, pyrexia, suspected sepsis, abdo pain, hypertension, suspected pre-eclampsia
Significant meconium
PV bleed
Delayed 1st or 2nd stage
Oxytocin use
Contractions over 60 seconds or more than 5 of them in 10 mins
What is the mneumonic used to assess CTG tracings
DR C BRAVADO
What does DR C BRAVADO stand for
Define risk Contractions Baseline rate Variability Accelerations Decelerations Overall
Describe a normal CTG
100-160 bpm
Variability 5-25
No/early decelerations
What are the 4 grades/types of placenta previa
Low lying
Marginal
Partial
Complete
Scans for placenta previa
If 20 week scan shows placenta previa then have another scan (TV) at 32 weeks (most will have resolved). If still low at 32 weeks have another scan (TV) at 36 weeks. If still low will likely need to plan for CS
Differentials of abdo pain in pregnancy
Preterm labour Placental abruption Chorioamnionitis Acute fatty liver of pregnancy Pre-eclampsia GI cause - appendicitis, pancreatitis, peptic ulcer ect GU cause - stones, adnexal torsion, cystitis Fibroid torsion
Clinical features of placental abruption
Bleeding Abdo pain Woody hard uterus Fetal compromise Maternal shock
What can you test for to try to rule out likely pre-term labour
Fetal fibronectin levels in vaginal secretions
How can you manage pre-term labour
Steroids for lung maturity - Betamethasone
Tocolytics to reduce contractions - Nifedipine, Atosiban, Indomethacin
MgSO4 for fetal neuroprotection
Inform the neonatal team
How long roughly should the second stage of labour last in a) primips b) multips
a) 3 hours
b) 2 hours
What do you have to check before performing operative vaginal delivery
No more than 1/5th of the head palpable abdominally
Leading point of the skull is below the ischial spines
What are the advantages/disadvantaged of Ventouse vs forceps
Ventouse less trauma to perineum/vagina but more likely to fail and to cause cephalohaematoma
How long after c-section do you need LMWH for
6 weeks
What % of women under the age of 40 will conceive within 2 years of trying
90%
To maximise chances of conceiving how often should you advise couples to be having sex
2-3 times per week
Primary vs secondary infertility
Secondary if they have conceived in the past
What is the most common female disease that causes infertility
PCOS
What test can you do to assess if a woman is ovulating or not
Mid-luteal (day 21) progesterone (will be raised if ovulating)
What can be used as a marker for ovarian reserve
Anti-Mullerian Hormone (AMH)
Name of the scan to assess fallopian tube pregnancy
Hysterosalpingogram
What does low, normal and high FSH/LH indicate in infertility testing
Low suggests hypothalamic or pituitary pathology
Normal suggests oocytes present but folliculogenesis may be impaired
High suggests reduced ovarian reserve/oocytes
3 tests that can indicate ovarian reserve
AMH
FSH
Antral follicle count
How can you assess if a woman is ovulating
If she has a regular cycle
Mid-luteal progesterone
FSH + LH high, Oestradiol low
Premature ovarian failure
FSH + LH + Oestradiol all low
Hypothalamic or pituitary cause
FSH normal + LH raised + Oestradiol normal
PCOS
What medication can be used for anovulation
Clomiphene citrate
Can also try Metformin, Gonadotrophins
Clinical features of ovarian hyperstimulation syndrome
Ascites Effusions Nausea and vomiting Abdo tenderness VTE risk
Which class of medication can be used to aid fertility in women with ovulatory disorders secondary to hyperprolactinaemia
Dopamine agonists
What are the 3 main types of assisted conception
Intrauterine insemination
IVF: In-vitro fertilisation
ICSI: Intracytoplasmic sperm injection
Diagnostic criteria for PCOS
Need 2 of 3 features: Oligo/anovulation,
Clinical or biochemical signs of hyperandrogenism
Polycystic ovaries
Clinical features of PCOS
Onset in adolescence, Oligo/amenorrhoea, infertility Obesity/metabolic syndrome Hirsutism, androgenic alopecia Acne vulgaria, oily skin, acanthosis nigricans (hyperpigmented velvety plaques usually in axilla or neck)
Confirmatory test for endometriosis
Laparoscopy
Ovarian cancer marker
CA 125
The RMI (risk of malignancy index) is used to assess for which type of cancer
Ovarian
What are the 3 features used to asses the RMI score
CA125
Menopausal status
USS score
Which medication class can worsen stress incontinence
Alpha blockers (e.g. Doxazocin)
Is AFP high or low in neural tube defects
High
Is AFP high or low in Downs syndrome
Low
If a baby is still breech at 36 weeks what do you do
Refer for ECV
A Bishop score of ? indicates that labour is unlikely to start without induction
< 5
A Bishop score of ? indicates that labour will most likely commence spontaneously
> 9
3 causes of increased nuchal translucency
Down’s syndrome
Congenital heart defects
Abdominal wall defects
The following results would be expected in a trisomy 21 (Down’s syndrome) pregnancy:
Low alpha fetoprotein (AFP)
Low oestriol
High human chorionic gonadotrophin beta-subunit (-HCG)
Low pregnancy-associated plasma protein A (PAPP-A)
Thickened nuchal translucency
Organism that causes bacterial vaginosis
Gardnerella vaginalis
Features of vaginal discharge caused by BV infection
Thin
White
Really offensive fishy smell
Clue cells (stippled vaginal epithelial cells) on microscopy indicate which infection
Bacterial vaginosis
Management of bacterial vaginosis
Oral Metronidazole for 5-7 days
Can use topical metronidazole or clindamycin as alternatives
Diagnostic test for endometriosis
Laparoscopy
Diagnostic imaging for adenomyosis
MRI pelvis
What is adenomyosis
The presence of endometrial tissue within the myometrium. It is more common in multiparous women towards the end of their reproductive years.
Symptoms of adenomyosis
Dysmenorrhea
Menorrhagia
Enlarged, boggy uterus
Criteria for an ectopic pregnancy to be managed expectantly
1) An unruptured embryo
2) <30mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of <200IU/L and declining
Maximum gestation for abortion
24 weeks
The methods used to terminate pregnancy depending on gestation
Less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
Less than 13 weeks: surgical dilation and suction of uterine contents
More than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
First line treatment for urge incontinence
Bladder retraining
First line treatment for stress incontinence
Pelvic floor exercises
Definition of primary post-partum haemorrhage (minor and major)
The loss of 500ml or more from the genital tract within 24 hours of the birth of a baby
Minor = 500-1000
Major = >1000
Diagnostic criteria for hyperemesis gravidarum
- 5% pre-pregnancy weight loss
- Dehydration
- Electrolyte imbalance
Pre-conception advice to optimise chance of conception
Optimise underlying medical conditions
Healthy BMI (19-30)
Stop smoking, alcohol, recreational
Sex every 2 days (2-3 times a week) from 6 days before ovulation and until 2 days after
Folic acid
Up to date with smears
Full immunisation history - including Rubella
Causes of infertility
Ovulatory problems - PCOS, premature ovarian failure, thyroid
Tubal - adhesions, obstructions (endometriosis, salpingitis)
PCOS
Hyperprolactinaemia
Hypergonadotrophic hypogonadism
Lifestyle factors
Decreased sperm quantity or quality
Infertility tests: FSH + LH + Oestradiol are all low
Hypothalamic or pituitary cause
Infertility tests: FSH is normal, LH is raised and Oestradiol is normal
PCOS
Infertility tests: FSH + LH are high and Oestradiol is low
Premature ovarian failure
What tests are used to assess ovarian reserve
AMH, FSH, antral follicle count
Test for ovulation
Mid-luteal progesterone: 7 days before expected period (day 21 of 28 day cycle) failure to rise indicates anovulation
How are the fallopian tubes and uterus assessed during infertility investigation
Hysterosalpinography (dye into uterus and XR)
Sonohysterosalpingography (fluid into uterus and USS)
TV USS
Women thought to have comorbid conditions (PID, endometriosis, previous ectopic) are offered diagnostic laparoscopy and dye. Can treat at the same time.
Medical treatment options for infertility
Clomifene or Tamoxifen to induce ovulation
Metformin for PCOS
Gonadotrophins may be offered to women with clomifene-resistant anovulatory infertility. They are also effective in improving fertility in men with hypogonadotropic hypogonadism
Pulsatile gonadotrophin-releasing hormone and dopamine agonists are other treatments that induce ovulation. Dopamine agonists can be considered for women with ovulatory disorders secondary to hyperprolactinaemia.
Surgical management options for infertility
Tubal microsurgery/catheterisation
Surgical ablation/laparoscopic resection of endometriosis or adhesions
Surgical corrections of epididymal blockage
Types of assisted conception
Intrauterine insemination IVF ICSI - intracytoplasmic sperm injection Donor insemination Oocyte donation
Features of ovarian hyperstimulation syndrome
Abdo bloating Abdo pain Nausea and vomiting If severe: Oliguria Generalised oedema Abdo pain/distention caused by enlarged ovaries and acute ascites Hydrothorax, VTE, respiratory distress syndrome
Possible complications of assisted conception
Ovarian hyperstimulation syndrome
Ectopic
Pelvic infection
Multiple pregnancy
Grades of placenta previa
1 - low lying
2 - marginal (minor)
3 - partial
4 - complete (major)
Management of placenta previa
If seen at 20 week scan, book for scans at 32 and 36 weeks as TV USS
If still present at 36 weeks plan for CS
Safety net antepartum bleeding, pre-term labour
Risk factors for breech presentation
Twins Oligo/polyhydramnios Fibroids Placenta previa Pelvic tumour/deformities
Management options for breech presentation
ECV at 36 weeks
Vaginal breech delivery
CS
Contraindications to ECV
Twins
Antepartum haemorrhage
Previous CS
Risks of ECV
Cord entanglement
Abruption
Induction
Biggest risk of a baby in transverse lie at term
Cord prolapse
Trisomy 13
Patau’s syndrome
Trisomy 18
Edward’s syndrome
Trisomy 21
Down’s syndrome
When is the combined screening test
12 weeks (11-14)
When is the quadruple screening test
16 weeks (15-20)
What does the combined test measure
Nuchal translucency
hCG
PAPP-A
What does the quadruple test measure
AFP
Unconjugated estriol
Beta-hCG
Inhibin A
Conditions screened for in a) combined test b) quadruple test
A) Patau’s, Edward’s, Down’s
B) Down’s
What gestation is the private antenatal non-invasive screening test available from
10 weeks
Ratio classed as high risk from the antenatal chromosomal screening
> 1:150
Combined test - is each marker high/low in Down’s syndrome
PAPP-A low
hCG high
NT high
Quadruple test - is each marker high/low in Down’s syndrome
AFP low
uE3 low
hCG high
Inhibin high
When can CVS be performed
11-14 weeks
When can amniocentesis be performed
15+ weeks
Does CVS or amniocentesis have a lower miscarriage rate
Amniocentesis
Antenatal trisomy screening - how long until patient gets results
Usually within 2 weeks if low risk, within 3 working days if high risk
