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My notes - med > Obgyn > Flashcards

Obgyn Flashcards

1
Q

Abdo pain in early preg

A

Ectopic

Miscarriage

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2
Q

Abdo pain in late preg

A 
Labour
Placental abruption
Symphysis pubis dysfunction
Pre-eclampsia/HELLP
Uterine rupture
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3
Q

Abdo pain at any time in preg

A

Appendicitis

UTI

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4
Q

Ectopic pregnancy RF

A

damage to tubes (salpingitis, surgery)
prior ectopic
IVF

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5
Q

Threatened miscariage

A 
<24w
Painless vag bleed
Usually week 6-9
Cervical os closed
25%
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6
Q

Missed miscarriage

A

<20w
Gestational sac w dead fetus with no expulsion
Light PV blood/discharge
Gestational sac >25mm w no fetal parts –> blighted ovum/anembryonic

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7
Q

Inevitable miscarriage

A

Cervix open

Heavy bleeding w clots + pain

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8
Q

Incomplete miscarriage

A

not all products expelled

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9
Q

Placental abruption ft

A 
shock out of keeping with visible loss
Constant pain
Tenter, tense uterus
Normal lie + presentation
Fetal heart: absent/distressed
Coag problems
Beward pre-eclampsia/DIC/anuria
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10
Q

Placental abruption

A

Separation of normally sited placenta from uterine wall

Maternal hemorrhage into the space

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11
Q

Symphysis pubis dysfunction

A

Ligament laxity causes pain over pubic symphysis w radiation to groins and medial aspects of thighs

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12
Q

Uterine rupture RF

A

previous CS

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13
Q

Uterine rupture ft

A

maternal shock
abdo pain
vaginal bleeding

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14
Q

UTI in preg risks

A

pre term delivery

IUGR

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15
Q

Appendicitis in preg

A

RLQ in 1st tri
Umbilicus 2nd tri
RUQ 3rd tri

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16
Q

Breech mortality and morbidity due to:

A

vaginal birth trauma/hypoxia (CS @39w)
prematurity
cord prolapse (esp footling)
Intracranial hr - compression of head in delivery

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17
Q

External cephalic version offered when

A

if still breech as of 36w to avoid CS

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18
Q

Major concern in breech baby

A

cord prolapse

Admit at 37/40

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19
Q

Frank breech

A

Extended

hips bent, legs straight up by face

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20
Q

Complete breech

A

Flexed

sitting cross legged

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21
Q

footling breech

A

one or both feet as presenting part

Premature often

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22
Q

Maternal RF/Causes Breech

A 
Multiparity (muscle laxity)
Uterine malformations (bicornuate, septate, fibroids)
Polyhydramnios (sometimes oligo)
Android pelvis
Placenta previa
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23
Q

Fetal RF/causes Breech

A 
Prematurity
Macrosomia (big head)
Twins
Abnormality (anencephaly, T21 hypotonia)
NMD
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24
Q

LT risks of CS

A 
Repeat
Scar dehiscence
Placenta accreta
Massive hr + potential hysterectomy
Recovery 6w
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25
Q

ECV risks

A 
cord entanglement
placental abruption
APH
fetal distress
**pre and post CTG
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26
Q

ECV contraindications

A 
APH
PROM
Uterine abnormality
Prior CS
Abnormal CTG
Twins
Placenta previa
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27
Q

Breech mgmt

A

ECV >36w
ELCS vs Vaginal breech
>37w ELCS recommended for primip, multip can wait till 40w to see if they turn

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28
Q

Unstable lie mgmt

A

ADMIT @ 37w
Keep until delivery with ELCS @ 39
**if turns cephalic, need to wait 48h at cephalic before discharge or >38 induce

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29
Q

PROM

A

rupture of membranes AFTER 37 weeks

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30
Q

PPROM

A

rupture of membranes BEFORE 37 weeks

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31
Q

Prolonged ROM mgmt

A

> 18h
Benzylpenicillin
@24h –> augment/induce with Oxytocin if cephalic and no HVS and CRP taken

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32
Q

GBS+ prolonged ROM mgmt

A

> 18h

Benxylpenicillin and augment/induce righgt away

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33
Q

PPROM RF

A

African
APH, cerclage, amniocentesis, polyhydramnios, multiple preg
PTD, STD
Smokers, poor

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34
Q

ROM

A

GUSH clear fluids followed by trickling
Need toknow time
Contraction, PV bleed
Confirm w speculum exam - pool of clear fluid @ posterior fornix

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35
Q

Chorioamnionitis

A 
Uterine tenderness
Foul smelling discharge
Tachy
fever
CTG tachy
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36
Q

ROM confirm

A

speculum exam - pool of clear fluid @ posterior fornix

Amnisure - rapid immunoassay, HVS if <37w

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37
Q

PPROM increases risks of:

A 
PIN PICCk
Preterm delivery
Infection - neonatal sepsis
Periventricular leucomalacia (holes in brain)
RDS, TTN
IVH
Cerebral palsy
Chronic lung disease
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38
Q

PPROM mgmt

A

Admit
If signs of chorioamnionitis or maternal sepsis give benzylpen (if allergic –> clindamycin) + deliver
No sepsis –> aim to deliver after 34w, ideally 36-37
Erythromycin PO 10d, IV BenzylPen till HVS clear
Bloods, HVS weekly
CTG twice daily
Doppler 2-3/w
IV fluids, Analgesia
Steroids if <36w
Innohep, stockings
NO tocolytics unless transfering
MOD - If cephalic use oxytocin for IOL, not cephalic LSCS
MgSO4 for neuroprotection <32w

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39
Q

Small for dates (SFD)

A

Fetus below 10th centile

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40
Q

P53 gene mutation

A

breast CA

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41
Q

Nulliparity cancers

A

Ovarian
Endometrial
Breast

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42
Q

COCP risks

A

Breast CA

Cervical CA

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43
Q

20yo, 1w crampy, constant low abdo pain, intermenstrual bleed, dyspareunia, dysuria

A

PID

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44
Q

30yo, nulliparous, severe dysmenorrhea, heavy + irregular bleeding, pain on defection, dyspareunia

A

Endometriosis

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45
Q

RF endometrial CA

A

late menopause

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46
Q

Late menopause can lead to

A

Cervical CA
Ovarian CA
Breast CA

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47
Q

Unopposed estrogen

A

endometrial CA

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48
Q

Womens CA w smoking

A

cervical CA

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49
Q

Types of cervical CA

A 
Squamous cell (80%)
Adenocarcinoma (20%)
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50
Q

Cervical CA ft

A

abnormal vaginal bleeding (postcoital. intermentrual, postmeno), vaginal discharge

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51
Q

Cervical CA RF

A 
HPV (16, 18. 33)
Smoking (2 fold increase)
HIV
Early intercourse, many partners
High parity
Low SES
COCP
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52
Q

Smear: high risk HPV +ve w normal cytology

A

repeat 12 mo

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53
Q

Smear high risk HPV w cytological evidence of dyskaryosis

A

colposcopy

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54
Q

Smear: 3 successive high risk w no cytology

A

colposcopy

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55
Q

Smear: 2 smears inadequate, 3 mo apart

A

colposcopy

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56
Q

HIV cervical screening

A

yearly cytology

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57
Q

Primary amenorrhea

A

No periods by 14 (if no other puberty signs)

No periods by 16 (if other signs - breast buds)

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58
Q

Puberty starts at:

A

8-14 girls (breasts/hair/periods)

9-15 boys

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59
Q

Hypogonadotrophic hypogonadism

A

Low LH and FSH from pituitary –> low estrogen/test from gonads
Problem in hypo or pit

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60
Q

Causes of hypogonadotrophic hypogonad

A 
Kallman's
Prader-Willi
Pit tumour
Hyperprolactinemia
Cranial tumour
Radiation tx
Drugs (opiates, alcohol)
Systemic/chronic illness
Idiopathic
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61
Q

Hypergonadotrophic hypogonadism

A

Gonads not responding to gonadotrophins, no neg feedback = HIGH LH and FSH

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62
Q

Hypergonadotrophic hypogonadism causes

A 
Hypothyroid
Hyperprolactinemia
Congenital adrenal hyperplasia
Turners
Androgen insensitivity syndrome
PCOS
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63
Q

Hypothalamic causes of primary amenorrhea

A

hx excessive exercise, stress, eating dx, chronic disease, low bmi

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64
Q

Hormonal causes primary amenorrhea

A

Androgen excess, thyroid problems, high prolactin, dysmorphic

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65
Q

Structural primary amenorrhea

A

abdo and pelvic exam

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66
Q

Primary amenorrhea IX

A

Pelvic US

Hormones (LH, FHS, TSH, prolactin)

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67
Q

Assess pubertal status

A

Height + weight

Dev of pubic hair, breast tissue, acne

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68
Q

Secondary amenorrhea

A

No periods x 3mo after already having had them

Ix after 6mo

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69
Q

Secondary amen causes

A 
Preg
Meno
Hypothalamic
Pituitary
Ovarian
Uterine
Hypothyroid
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70
Q

Hypothalamic secondary amen

A

Physiologic stress stops GnRH production

  • excessive exercise
  • low weight/eatign dx
  • chronic disease
  • psychological
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71
Q

Pituitary causes of secondary amen

A

tumour (prolactinoma)

failure (sheehan)

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72
Q

Ovarian secondary amen

A

PCOS
Premature ovarian failure
Menopause

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73
Q

Uterine secondary amen

A

Asherman’s syndrome

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74
Q

Sheehan’s syndrome

A

Woman loses life threatening amount of blood during child birth or severe low BP –> lack of O2 –> damage to pituitary gland –> low ant-pit hormones

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75
Q

Asherman’s syndrome

A

Scar tissue in uterus or cervix, makes walls of the organ stick together and reduce uterus size (D&C, endometriosis, infection,)

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76
Q

FSH high in secondary amen

A

primary ovarian failure

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77
Q

High LH or LH:FSH ratio in secondary amen

A

PCOS

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78
Q

Secondary amen Ix

A

FSH, LH
MRI head
TSH

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79
Q

Androgen Insensitivity Syndrome

A

Male characteristics don’t develop = female phenotype w male sex organs (testes in abdomen - inguinal canal)
No uterus, upper vagina, fallopian tubes or ovaries.
Infertile

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80
Q

Androgen insensitivity syndrome causes

A

Usually testes make Mullerian hormone - stops male developing female sex hormones
Insensitivity to androgens - no pubic hair, no facial hair or male type muscle development

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81
Q

Androgen insensitivity syndrome mgmt

A

estrogen therapy

bilateral orchidectomy

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82
Q

Premenstrual syndrome

A

Fluctuation of hormones, esp E and P
Bloating, headaches, backaches, anxiety, low mood, irritability
**resolve with onset of menstruation

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83
Q

PMS tx

A

symptom diary
lifestyle change
COCP
SSRI

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84
Q

If PMS has significant effect on QOL

A

premenstrual dysphoric disorder

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85
Q

Causes of menorrhagia

A 
Fibroids
Hormone imbalance (PCOS, thyroid disease, obesity)
Copper coil
Ehlers-Danlos
Bleeding disorders (vWD)
Endometrial Ca
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86
Q

Menorrhagia ix

A

pelvic exam

Pelvic/transvag US if abn pelvic exam, postcoital bleed, intermenstrual bleed, pelvic pain

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87
Q

Menorrhagia mgmt

A

Exclude pathology (anemia, CA) and manage cause
If no contracep:
-tranexamic acid if no pain (antifibrinolytic)
- mefenamic acid (NSAID - reduce pain + bleed)
Contracep:
- Mirena coil, COCP, POP (norethisterone), Depo injection
If all fails:
- endo ablation
- hysterectomy

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88
Q

Fibroids

A

common in later reproductive age (meno)
Afro carribean
Increase in estrogen sensitivity

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89
Q

Fibroid locations

A

Intramural
Subserosal
Submucosal
Pedunculated

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90
Q

Intramural fibroids

A

within myometrium

change shape of uterus as they grow

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91
Q

Subserosal fibroids

A

below outer layer of uterus

grow outwards, can be v big, fill abdominal cavity

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92
Q

Submucosal fibroids

A

below lining of uterus (endometrium)

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93
Q

Pedunculated fibroids

A

on a stalk

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94
Q

Fibroids Sx

A 
Asymptomatic
Menorrhagia (top one)
>7 day periods
Abdo pain worse during period
Bloating or full feeling
Urinary/bowel sx
Deep dyspareunia
Reduced fertility
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95
Q

Fibroids dx

A

Pelvic/transvag US

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96
Q

Fibroids conservative mgmt

A

analgesia, tranexamic acid
mirena coil (fibroid <3cm and no uterus distortion)
COCP
GnRH agonist (goserelin) to reduce size, induce menopause sx. Used to reduce size prior to myomectomy

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97
Q

Other fibroids mgmt

A

Uterine artery embolization (starves fibroid of O2, shrinks it)
Myomectomy (removes tumoour via abdo surg)
Hysteroscopic endometrial ablation (destroy endo via telescope through cervix w diathermy resecting loop)
Hysterectomy

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98
Q

Fibroids complications

A 
Space occupying problems (premature labour, block vag delivery, miscarriage)
Infertility
Heavy bleeding - anemia
Constipation
UTI/Urine obstruction
Red/carneous degeneration
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99
Q

Red/carneous degeneration

A

Hemorrhage infarct of fibroid
Occurs in preg
Abdo pain, low grade fever, vom
Conservative mgmt

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100
Q

Postcoital bleeding causes

A 
Idiopathic
Cervical ectropion
Cervical inflamm from infection (Chlamydia)
Cervical ca
Atrophic vaginitis
Polyps
Trauma
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101
Q

Intermenstrual bleeding

A

Cervical ectropion/polyp/CA
STI
Endometrial polyp/Ca
Iatrogenic contraception related bleeding

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102
Q

Cervical ectropion

A

Columnar epi of endocervix displayed on ectocervix visible on speculum
Caused by increased estrogen
Cause discharge or postcoital bleed

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103
Q

Cervical ectropion tx

A

silver nitrate

diathermy

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104
Q

Cervical ectropion transformation zone

A

where the endo (columnar) meets the ecto (stratified squamous)

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105
Q

Nabothian cyst

A

fluid filled cysts on surface of cervix, 1cm, harmless
Squamous epi of ectocervix covers mucous secreting columnar epi - traps in cyst
After childbirth or cervicitis secondary to pelvic infection
Can biopsy to exclude pathology

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106
Q

Asherman’s Syndrome sx

A

amenorrhea
dysmenorrhea
infertility
recurrent miscarriages

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107
Q

Asherman’s syndrome diagnosis

A

Sonohysterography (pelvic US after uterus filled w fluid)

Hysteroscopy is gold standard - can dissect adhesions during

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108
Q

Endometriosis

A

Ectopic endometrial tissue outside the uterus
Responds to menstrual cycle to causes sig pain during menstruation due to bleeding around local tissues in pelvis
Can irritate local tissues - causing chronic pelvic pain - worse at certain times & w sex

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109
Q

Endometriosis sx

A 
Abdo/pelvic pain (cyclical)
Deep dyspareunia
Cyclical bleeding from other sites (hematuria)
Fertility issues
Endo tissue visible in vagina
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110
Q

Endometriosis Ix

A

Laparoscopy for dx of abdo endometrial tisue

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111
Q

Endometriosis mgmt

A

Analgesia
COCP to reg cycle
Progesterone to stop menstruation (depo)
GnRH agonists - medical menopause
Laparoscopic surgery - dissect/cauterize ectopic tissue
Hysterectomy + bilat salpingo-oopherectomy last resort

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112
Q

Ovarian cysts

A

PCOS trias

Do CA125 to rule out CA

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113
Q

PCOS triad

A

Polycystic ovaries on scan
anovulation
hyperandrogenism

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114
Q

Ovarian cysts sx

A

Asymptomatoc
Pelvic pain
Bloating
Fullness
Very large cysts (mucinous cystadenomas) can be felt as pelvic mass
Can be acute if torsion, hemorrhage, or rupture

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115
Q

Functional ovary cyst

A

Follicular cyst is developing follicle
-Fail to rupture & release egg –> persist
-Usually go away after a few cycles - harmless
Corpus luteum cyst - after follicle releases egg and luteum faisl to break down

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116
Q

Serous cystadenoma

A

benign tumour of epithelial cells

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117
Q

Mucinous cystadenoma

A

benign tumour of epithelial cells, can become v big

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118
Q

Dermoid cyst

A

benign ovarian tumour
teratomas, fro germ cells filled w diff tissues
Complication: torsion

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119
Q

Ovarian cyst comps

A

rupture - bleed into peritoneum
torsion
hemorrhage cyst

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120
Q

Meig’s syndrome

A

older women
Ovarian tumour is fibroma
Assoc w pleural effusion + ascites
Things resolve once removed

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121
Q

PCOS sx

A 
Weight gain
hirsutism
oligomenorrhea/amenorrhea
Poor fertility
Acanthosis nigricans
Impaired glucose tolerance
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122
Q

PCOS hormones

A

LH high
LH:FSH high
Insulin high
Testosterone high

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123
Q

PCOS rotterdam criteria

A 
2/3 to make dx
SHOP
String of pearls
Hyperandrogenism
Oligomenorrhea
Prolactin Normal
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124
Q

PCOS insulin resistance

A

high levels of insulin = higher levels of androgens

metformin can improve the insulin resistance, also lifestyle

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125
Q

PCOS mgmt

A

Weight loss
COCP
Infertility: weight loss, metformin, clomifene

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126
Q

Hirsutism mgmt (PCOS)

A

Co-cyprindiol (Dianette) - anti-androgen, contraception, VTE risk
Topical eflornithine - facial hair
Spironolactone, finasteride (5 alpha reductase inhibitor to decrease testosterone), flutamide (nonsteroidal antiandrogen)

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127
Q

Premature Ovarian Failure

A

menopaise <40y
Raised LH and FSH
Causes: idiopathic, chemo/radio, autoimmune, Turners

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128
Q

Menopause

A

12 mo after last period
Contracep x 2y after LMP <50, 1y >50
Drop in E and P
LH, FSH usually high in resp to drop in E & P

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129
Q

Perimeno sx

A 
hot flush
emotional lability
premenstrual syndrome
irreg periods
heavier/lighter periods
vaginal dryness
reduced libido
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130
Q

Perimeno sx mgmt

A 
HRT
Tibolone (only after 12mo LMP)
SSRI - fluoxetine/citalopram
Clonidine
CBT
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131
Q

Tibolone

A

synthetic steroid w weak E, P and androgenic activity

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132
Q

Clonidine

A

reduce hot flush (antihypertensive)

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133
Q

HRT non-hormonal

A

Lifestyle
SSRI - fluoxetine
Venlafaxine - SNRI hot flush
Clonidine

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134
Q

HRT considerations

A 
Perimeno - cyclical tx
Post meno - continuous tx
Local - topical
Systemic
Has uterus - add progesterone
No uterus - no progesterone
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135
Q

HRT estrogen + Prog

A

lowers risk endometrial CA
increases risk breast CA
Can give the P via mirena coil

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136
Q

Risks of HRT

A

increases breast CA & endo CA risk
Increase risk stroke, thrombosis
Higher risk with longer use

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137
Q

SE of HRT

A

bloating
breast swell/tender
weight gain
headache

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138
Q

Uterus develops from:

A

paramesonephric ducts (Mullerian ducts)

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139
Q

Bicornuate uterus

A

2 horns of uterus
Adverse preg outcomes but usually successful
Miscarriage, premature, malpresentation

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140
Q

Imperforate hymen

A

completely formed without any opening, menses sealed in vagina
Intense cyclical pain/cramping assoc with menstruation but no bleeding
Dx w exam, tx surgical incision
If not tx - endometriosis

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141
Q

Transverse vaginal septum

A 
Septum wall forms across the vagina, either perforate or imperforate
Perf: difficult sex and tampon
Imperf: similar to imperf hymen
Dx: exam, US, MRI
Tx: surgical cirrection
Comps: stenosis of vagina
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142
Q

Vaginal agenesis

A

Vaginal hypoplasia - small
Agenesis - absent due to failure of mullerian ducts to develop
Assoc w absent uterus and cervix
Ovaries stay

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143
Q

Uterine prolapse 0

A

normal

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144
Q

Uterine prolapse 1

A

above introitus >1cm

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145
Q

Uterine prolapse 2

A

<1cm from introitus (above or below)

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146
Q

Uterine prolapse 3

A

1 cm below introitus and >2cm of vagina above introitus

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147
Q

Uterine prolapse 4

A

full eversion from vagina

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148
Q

Rectocele

A

defect in posterior wall of vagina - constipation and urinary retention, pressure, pain

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149
Q

Cystocele

A

Defect anterior vag wall

Can also be prolapse of urethra (urethrocele) or both bladder and urethra (cystourethrocele)

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150
Q

Uterine prolapse sx

A 
urinary, bowel, sexual dysfunc
feeing of something coming down
dragging/heavy sensation in pelvis
Lump/mass
worse on strain
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151
Q

Uterine prolapse mgmt

A

Physio. Lifestyle for stress incont (reduced caffeine, incontinence pads). Tx sx with anticholinergic meds -oxybutinin. Vag estrogen cream.
Pessary -ring/Gellhorn/cube/ donut/hodge. Remove and clean every 4 months. (can cause erosion and irritation)
Surgery - hysterectomy, mesh repair controversial. Comps: infx, bleed, damage to bladder/bowel, chronic pain

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152
Q

Urge incont

A

overactive bladder detrusor muscle

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153
Q

Stress incont

A

weakness of sphincter allowing urine to leak during cough/laugh

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154
Q

Causes of incontinence

A

age
BMI
prev preg
vaginl deliveries

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155
Q

Incontinence Ix

A

Diary
dipstick + culture
post-void residual volume w bladder scan
Urodynamic tests

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156
Q

Stress incont mgmt

A 
weight loss
avoid: caffeine/diuretic/overfilling bladder
Pelvic floor exercises
Duloxetine (SNRI)
Surgery (tension free vaginal tape)
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157
Q

Urge incont mgmt

A 
bladder retraining (gradually increase time between voids)
Antimuscarinic (oxybutinin, tolterodine)
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158
Q

Bartholin’s cyst

A

Unilateral
1-5cm
resolve w good hygiene, analgesia, warm compress
Can become abscess if infx - hot, red, tender, pus

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159
Q

Bartholins abscess mgmt

A 
Abx
Swab of pus/fluid
Staph/strep/e.coli/gonorrhea
Fluclox or erythromycin if pen all
Co-amox for broader coverage
I&D needed sometimes
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160
Q

Lichen Sclerosis

A

autoimmune
labia, perianal, perineal skin
fissures, cracks, erosions, hemorrhages under skin

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161
Q

Lichen sclerosis sx

A 
itch
pain
tight skin
painful sex (superficial dyspareunia)
Skin looks white, shiny, papules/plaques, tight and thin, raised.
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162
Q

Lichen Sclerosis comps

A

pain and discomfort
Bleeding
5% risk vulval cancer (SCC)

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163
Q

Lichen Sclerosis tx

A

no cure
biopsy if suspicious lesions
topical steriods (dermovate)
emollients

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164
Q

Cervical CA pop

A

Young women

Peak reproductive years

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165
Q

Cervical CA causes

A 
HPV (16/18/33)
Early sex
Many partners
Smoking
HIV
COCP
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166
Q

Cervical CA presentation

A

Abnormal bleed (intermenstual, postcoital, post meno)
Vag discharge
Pelvic pain
Urinary (dysuria, freq)

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167
Q

Cervical CA stage 1

A

confined to cervix

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168
Q

Cervical CA stage 2

A

uterus/upper 2/3 vagina

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169
Q

Cervical CA stage 3

A

pelvic wall/lower 1/3 vag

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170
Q

Cervical CA stage 4

A

bladder/rectum/beyond pelvis

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171
Q

CIN 2

A

moderate dysplasia, likely to progress to CA if no tx

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172
Q

CIN 3

A

severe dysplasia, will progress if no tx - cervical carcinoma in situ

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173
Q

Smear w mild dyskaryosis

A

tested for HPV

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174
Q

Smear screen

A

25-49 - 3y

50-64 - 5y

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175
Q

Smear mild (CIN 1)

A

continue routine screen, no other Ix unless HPV +

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176
Q

Smear moderate dyskaryosis (CIN 2)

A

ref to colposcopy under 2w

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177
Q

Smear severe dyskaryosis

A

suspected CA

refer colposcopy under 2w

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178
Q

Smear inadequate

A

repeat

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179
Q

Smear HPV +

A

refer colposcopy

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180
Q

CIN + Stage 1A tx

A

colposcopy + excision/ablation

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181
Q

Cervical ca: Stage 1B-2A w tumour <4cm

A

radical hysterectomy + removal of local LN

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182
Q

Cervical ca: Stage 2B-4A or tumour >4cm

A

chemo + radio

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183
Q

Cervical ca: Stage 4B

A

chemo/palliative

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184
Q

HPV

A

most common cause Cervical ca
Anal, vulval, vaginal, penis, mouth, throat cancers
inhibits genes p53 and pRb
Sexually transmitted

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185
Q

HPB warts

A

6 and 11

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186
Q

HPV cancer

A

16, 18, 33

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187
Q

Gardasil against

A

HPV 6, 11, 16, 18

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188
Q

Gardasil against

A

HPV 6, 11, 16, 18

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189
Q

Endo CA risks

A 
Age (60y peak)
Long estrogen exposure (early period, late meno, HRT, no preg)
Obesity
HNPCC/Lynch syndrome
Tamoxifen (breast CA SERM)
DM
PCOS
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190
Q

Endo CA pres

A

post meno bleed

inter mentrsual bleed

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191
Q

Endo Ca ix

A

tranvag US for endo thickness (norm <4mm)

Hysteroscopy with endo biopsy

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192
Q

Endo CA mgmt

A
  • total abdominal hysterectomy w bilat salpingo-ooph
  • Wertheim’s hysterectomy includes the pelvic LNs
  • Radiotherapy
  • Progesterone - slow progression of Ca when surgery not appropriate
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193
Q

Ovarian Ca pop

A

presents late, 60’s

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194
Q

Ovarian Ca RF

A 
Age (peak at 60)
BRCA1 and BRCA 2 genes (FH)
More ovulations = greater risk (early periods, late meno, no preg)
Ovesity
HRT
Smoking
Breast feeding protective
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195
Q

Ovarian CA pres

A 
Bloating
Pelvic pain
Urinary sx
weight loss
abdo mass
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196
Q

CA125 high in:

A 
Ovarian Ca
During menstruation
Endometriosis
Livery cirrhosis
Benign ov cysts
Fibroids
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197
Q

Ovary ca Ix

A

CA125
Abdo/pelvic US
Diagnostic laparoscopy

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198
Q

Ovary staging system

A

FIGO

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199
Q

Ovary Ca stage 1

A

only in ovary

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200
Q

Ovary Ca stage 2

A

out of ovary but inside pelvis

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201
Q

Ovary Ca stage 3

A

out of pelvis but in abdo

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202
Q

Ovary Ca stage 4

A

spread out of abdo (distant mets)

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203
Q

Ovary Ca mgmt

A

surgery

Chemo

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204
Q

Krukenberg tumour

A

ovarian malig. secondary to mets from another site

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205
Q

Vulval Ca

A

Usually SCC

Vulval Intraepithelial Neoplasia (VIN)

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206
Q

Vulval Ca RF

A

advanced age
HPV
lichen sclerosus

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207
Q

Vulval CA pres

A 
pain
itching
discomfort
discharge
bleeding
abnormal appearance or palpation on self exam
LN in groin
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208
Q

Vulval CA appearance

A

labia majora

irregular mass, fungating, ulcerating, bleeding

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209
Q

Vulval Ca dx

A

biopsy

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210
Q

Vulval Ca mgmt

A 
urgent (2w) referral
Incisional bx if low concern
Sentinel node bx for LN spread
Wide local excision to remove cancer
Groin LN dissection to stage and clear CA nodes
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211
Q

Bacterial Vaginosis

A 
Lactobacilli - healthy bacteria produce lactic acid to keep pH low and prevent overgrowth
Other bacteria (Gardnerella) overgrow and reduce lactobacilli - causing BV
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212
Q

Bact Vag tx

A

metronidazole

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213
Q

Bact vag mgmt

A

Vag swabs to exclude Clam/Gon

Avoid irrigation or cleaning w soaps that disrupt flora

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214
Q

Bact Vag in preg

A

early delivery risk

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215
Q

Bact Vag pres:

A 
Fishy smelling watery/grey dischrge
Dysuria
High pH
"Clue cells"
Can increase risk of transmitting STI
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216
Q

Candidiasis

A

More common in DM and immunosuppression

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217
Q

Candidiasis pres

A

itchy
thick, white discharge
vulval and vaginal irritation

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218
Q

Candidiasis mgmt

A

Clotrimazole cream
1 x clotrimazole pessary
1 x oral fluconazole (150mg)

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219
Q

Gonorrhea

A

Gram - diplococcus
Young, sexually active, multiple partners
More sx than Chlam
In endocervix

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220
Q

Gonorrhea pres

A

Odourless, green, purulent discharge
Dysuria
Pelvic pain
Testicular pain

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221
Q

Gonorrhea dx

A

NAAT detects DNA of gon on endocervical swabs or urine

Endocervical swab for culture + sensitivity

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222
Q

Gonorrhea tx

A

GUM clinic
Single dose ceftriacone 500mg IM and azithromycin 1g oral
Re-test for cure
Contact tracing

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223
Q

Chlamydia

A

Gram neg

Most common cause reversible infertility

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224
Q

Chlamydia pres

A

PV discharge
Pelvic pain
Abnormal bleed
Painful sex

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225
Q

Chlamydia exam

A

Cervical excitation
Pyrexia
Purulent discharge
Pelvic/abdo tender

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226
Q

Chlam dx

A

Vulvovaginal swab female
First catch urine men
NAAT

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227
Q

Chlam tx

A

GUM
Doxycycline 7d
Singe dose 1g azithromycin (better compliance)
No need to re test

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228
Q

Lymphogranuloma venereum

A

Lymphoid tissue around side of infx in those with Chlam

3 stages

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229
Q

Lymphogranuloma venereum stage 1

A

painless ulcer

on penis or vaginal wall or rectum

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230
Q

Lymphogranuloma venereum stage 2

A

lymphadenitis - swelling, inflammation, pain of LN infected with bacteria.

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231
Q

Lymphogranuloma venereum stage 3

A

where inflamm in rectum and anus - proctocolitis leads to anal pain and discharge

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232
Q

PID

A

Inflammation, usually from infx, of organs of pelvis
Usually from cervix infx
Major cause infertility and pain

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233
Q

PID bacteria

A

Chlamydia trachomatis

Neisseria gonorrhea

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234
Q

PID presentation

A 
pelvic pain/low abdo pain
fever
dysuria
deep dyspareunia
vag discharge
abnormal bleeding
menorrhagia
cervical excitation
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235
Q

PID mgmt

A

oral ofloxacin 400mg BD + oral metronidazole 400mg BD x 14d
OR
IM ceftriaxone 500mg single dose + oral doxycycline 100mg BD w oral metronidazole 400mg x 14d
- treat based on clinical dx
- consider removal of IUD
- GUM referral

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236
Q

Fits-Hugh-Curtis Syndrome

A

PID causes inflammation of liver capsule –> adhesions between liver + peritoneum
RUQ pain referred to R shoulder tip if diaphragmatic irritation

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237
Q

Herpes Simplex

A

HSV 1 - cold sores
HSV 2 - genital herpes
SOME overlap
Can cause aphthous ulcers - stomatitis herpetiformis

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238
Q

HSV pres

A

labial ulceration/vesicles
pain
no discharge
ask re: sex contacts

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239
Q

HSV dx

A

clinical

swab for viral PCR

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240
Q

HSV mgmt

A

Acyclovir (oral in stomatitis and genital, topical for cold sores)
Can require long term

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241
Q

HSV + preg

A

Acyclovir can be used
Neonatal HSC infx has high morb + mort
Risk of vertical trans should be minimized
- if lesions >28w - ELCS at term (6w for fetus to get passive imunity)
- if recurrent genital herp is known- acyclovir
**NO increased risk miscarriage

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242
Q

% women conceive in 1st year

A

85%

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243
Q

How many women struggle w fertility

A

1/7

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244
Q

How long without conception for Ix

A

12 mo <35

6mo >35

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245
Q

Causes of infertility

A 
Sperm
Ovulation
Tubal
Uterine
Unexplained
40% a mix of male and female issues
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246
Q

Advice for conception

A 
folic acid 400mg/d
healthy BMI
No smoking or excessive alcohol
Sex 2-3 times/week
times intercourse not needed/recommended
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247
Q

Infertility Ix

A 
BMI 
Semen analysis
Serum LH, FSH on day 2-5
Serum progesterone d21
Anti-mullerian hormone (anytime)
US pelvis (structures, PCO)
Screen for chlam/gon
Hysterosalpingogram (patency of tubes and can help conception)
Laparoscopy + dye test (patency of F tubes, adhesions, endometriosis)
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248
Q

What day to take LH, FSH for infertility

A

d 2-5

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249
Q

Infertility: high FSH

A

poor ovarian reserve

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250
Q

Infertility: high LH

A

PCOS/ovarian failure

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251
Q

Infertility BMI

A

High - PCOS

Low - amenorrhea

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252
Q

When to take infertility progesterone

A

Day 21

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253
Q

Infertility high progesterone

A

ovulation occurred and corpus luteum has formed and is secreting progesterone

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254
Q

Infertility anti-mullerian hormone

A

Marker of ovarian reserve

Rls by granulosa cells in follicles - falls as eggs used up

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255
Q

Anovulation mgmt

A

Ovarian drill for PCOS
Clomifene d2-6 (or Letrozole)
Gonadotrophins (LH, FSH)
Metformin

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256
Q

Clomifene

A

SERM
Day 2-6
Stops neg feedback of E on hypothalamus - increases secretion of LH and FSH

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257
Q

Letrozole

A

Aromatase inhibitor

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258
Q

Metformin in infertility

A

If insulin insensitivity and obesity (PCOS) - increases likelihood of ovulation

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259
Q

Infertility: tubal issues mgmt

A

Cannulation during hysterosalpingogram
Laparoscopy to remove adhesions or endo
IVF (30% success/cycle)

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260
Q

Infertility: uterine factors mgmt

A

Surgery to correct polyps, adhesions, structural issues

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261
Q

Infertility: sperm mgmt

A

surgical sperm retrieval
intra-uterine insemination
intracytoplasmic sperm injection (ICSI)

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262
Q

Sperm analysis instructions

A

No ejac x 3d prior and at most 5d
No hot baths/sauna/tight undies
Get the full sample
Deliver to lab within 1h

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263
Q

Things affecting sperm sample

A 
Hot baths
tight undies
smoking
alcohol
raised BMI
Caffeine
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264
Q

Normal semen volume

A

> 1.5ml

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265
Q

pH of semen

A

> 7.2

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266
Q

Concentration of sperm

A

> 15million/ml

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267
Q

Total # sperm

A

39million/sample

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268
Q

Motility of sprm

A

> 40% are mobile

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269
Q

Vitality sperm

A

> 58%

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270
Q

% normal sperm in sample

A

> 4%

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271
Q

Ovarian hyperstimulation syndrome

A

Comp of infertility tx - promote development of eggs in ovaries
Leads to multiple developing leuteinised ovarian cysts
Release E, P and vascular endothelial growth factors

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272
Q

Ovarian hyperstim syndrome ft

A 
Abdo pain + bloating
N/V
Diarrhea
Hypotension
Ascites
Reduced UO
Prothrombotic state - VTE

Mild –> abdo pain, bloat
Severe –> ascites, oliguria, hypoproteinameia, hematrocrit >45%

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273
Q

Ovarian hyperstim mgmt

A

Supportive and tx complications (ascitic drainage, anticoag)

ICU

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274
Q

Early Preg: folic acid + vits

A

400mcg/d before and until 12 weeks - NTD

Vitamin D

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275
Q

Early Preg: avoid

A 
Vitamin A supplements
Eating liver/paté (teratogenic)
Drinking
Smoking (IUGR/preterm)
Unpasteurized dairy/blue cheese (listeriosis)
Uncooked poultry
Contact sports
Flying - increased VTE risk
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276
Q

Early Preg: smoking risks

A 
IUGR
Miscarriage
Stillbirth
Pre-term labour
Placental abruption
Pre-eclampsia
Cleft-lip/palate
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277
Q

Ectopic presentation

A

Delayed menses, hx of sex
Low abdo pain, constant in iliac fossa, worsening
Vag bleed - light/spot
***shock if ruptured
Lower abdo tender
Cervical excitation
Avoid palpating adnexa - can rupture preg

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278
Q

Ectopic sites

A 
95% tubal (isthmus, ampulla, infundibular)
Interstitial/Cornual
Cervical
Ovarian
Abdominal
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279
Q

Ectopic RF

A 
PIPPA
Previous ectopic
IUD in situ
PID
Pelvic/tubal surgery
Assisted reprod.
Cervical STI (C/G)
Smoking
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280
Q

Ectopic blood tests

A

FBC
Group Save
hCG - normally doubles every 48h…if NOT doubling, likely ectopic “suboptimal rise in hCG”

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281
Q

Ectopic Ix

A

US
- HCG >1500 should see normal preg
- HCG >150 and no IUP –> ectopic till proven otherwise
IF <1500 and equivocal US –> serial HCG and US
GS in adnexa, free fluid, no IUP

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282
Q

Ectopic mgmt: expectant

A 
Pain free
Stable
hCG <1500
Unruptured tubal ectopic <35mm
No HR
Able to attend F/U
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283
Q

Ectopic mgmt: medical

A 
MTX 50mg - interfere w DNA synthesis, kills trophoblast tissue
Pain free
Stable
hCG <10,000
Unruptured tubal ectopic <35mm
No HR
Able to attend F/U
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284
Q

Ectopic mgmt surgical

A 
Laparoscopic w Salpingectomy or salpingostomy GOLD STAND
Pain
Unstable
Tubal ectopic >35mm
HR
hCG >5000
Unable for F/U
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285
Q

miscarriages

A

1/5 women

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286
Q

Missed miscarriage

A

fetus died <20w, remains in uterus

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287
Q

Threatened miscarriage:

A

Os closed
FH seen
bleeding

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288
Q

Inevitable miscarriage

A

Os open
FH seen
bleeding

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289
Q

Incomplete miscarriage

A

Os open
No FH
retained products of conception - infx risk.
Need misoprostol pessary or evacuation of retained products of conception

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290
Q

Complete miscarriage

A

Os closed
No FH
No products left

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291
Q

Anembryonic preg

A

Gestational sac but no embryo in it

<25mm and no tissue - confirmed

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292
Q

Recurrent miscarriage

A

3 in a row

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293
Q

Causes of recurrent miscarriages

A 
idiopathic (older women)
Antiphospholipid syndrome
Thrombophilia (2nd tri)
Uterine abnormalities
Genetic factors
Chronic histiocytic intervillositis
Chronic ill (DM, SLE)
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294
Q

Recurrent miscarriage ix

A

Antiphospholipid Ab
Pelvic US
Genetic testing of parents (microarray)

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295
Q

Termination of preg: medical

A

<9w

Mifepristone (anti progestogen) and misorpostol (prostaglandin)

296
Q

Termination of preg: surgical

A

<15w Cervical dilatation & suction of contents

<24w cervical dilatation & forcep evacuation

297
Q

Post TOP care

A

Bleeding + cramps

Use protection

298
Q

TOP complications

A 
Infx
Bleed
Pain
Failed abortion
Damage to local structures
299
Q

Peak of hyperemesis grav

A

8-12w

300
Q

Cause of hyperemesis grav

A

high hCG
More common in molar preg and multiples
Worse in first preg + obesity

301
Q

RCOG hyperemesis grav criteria

A

> 5% weight loss
Dehydration
Electrolyte imbalanace

302
Q

Hyperem grav mgmt

A

Assess severity w PUQE score
Antiemetics - mild, + ginger
Admission if severe

303
Q

Hyperem grav antiemetics

A

Prochlorperazine (stemetil)
Cyclizine
Ondansetron
Metoclopramide (short term - occulogyric crisis)

304
Q

Hyperem grav admissions

A 
Unable to tolerate antiemetics/keep fluids down
Ketones in urine (>= +2)
Electrolyte imbalances (hyponatremia)
305
Q

Hyperem grav admit tx

A

IV antiemetics
IV rehydration
Thiamine supplementation
Thromboprophylaxis (LMWH, Teds)

306
Q

Complete mole

A

Dispermic: 2 sperm fertilize egg = triploid conceptus w 69ch
Monospermic: 1 sperm fert egg, maternal CH lost, paternal doubles - 46chrom but all from dad
No normal tissue

307
Q

Partial mole

A

2 sperm fertilize egg @ same time - new sell has 3 x chromosomes (69)- divides into a partial mole
some fetal material
**1-3% choriocarcinoma, follow up w HCG

308
Q

Molar preg presentation

A 
Severe morning sickness
Vag bleed, no pain
Increased enlargement of uterus
Abnormally high hCG
Thyrotoxicosis (tachy, HTN, sweat, anx)
309
Q

Molar preg Ix

A

US pelvis - snowstorm appearance, multiple cysts

Confirm w histology of mole

310
Q

Molar preg mgmt

A 
Evacuate uterus - D&C
Histology
Ref to gestational trophoblastic disease centre
Measure hCG to ensure return to normal
Can metastasize
311
Q

Anemia screening

A

Booking (8-12w)

28w

312
Q

Hb in preg

A

Falls due to increase plasma volume diluting it

313
Q

Bloods in early preg

A

FBC (normal >110 @ book, >105 @ 28w)
Ferritin (12-300ng)
B12 (>200ng)
Folate (>4ng)

314
Q

Anemia mgmt preg

A

Ferrous sulphate 200mg TDS
(If low ferritin but not anemic - supplementary iron)
Low B12 –> test pernicious anemia (IF Ab) - B12 injections or tablets
Low folate - 5mg daily

315
Q

Pre-eclampsia

A

> 20w
Preg induced HTN w proteinuria.
HTN w end organ damage

316
Q

Pre-eclampsia triad

A

HTN
Proteinuria
Edema

317
Q

Preg induced HTN/Gestational

A

> 20w

318
Q

Eclampsia

A

Pre eclampsia + seizures

319
Q

Target BP in Preg HTN

A

<135/85

Over tx –> decreased placental perfusion

320
Q

HTN tx benefits

A

Reduces severe htn dev

Lowers stroke risk

321
Q

Anti-HTN in preg

A

Labetolol (1st)
Nifedipine or methyldopa (2nd)
MgSO4 during birth
ACE/Diuretic –> congenital malformations

322
Q

Pre-eclampsia RF

A 
Major (1):
Pre existing HTN
DM
Prev gest HTN or PET
CKD
Autoimmune dx (SLE, antiphos)
Moderate (1+): FAMOUS
First preg
Age 40+
Multi preg
Obesity (BMI>35)
Unusual gap (>10y)
Significant FHx of pre eclamps
323
Q

Pre eclampsia dx

A

> 140/90 on +1 occasion AND
Proteinuria >0.3/24h
Protein Cr ratio: 30, +2 on dipstick

324
Q

If have pre eclamps RF: prophylaxis

A

Aspirin 75-150mg OD from 12/40

325
Q

Pre eclamps monitoring

A 
BP
Sx
Urine dipsticks
Bloods (platelets, LFT (ALT), UE)
Hb (low due to HELLP)
Fetal mvmt
Serial growth scans
AFI
Umbilical doppler
326
Q

Placental Growth Factor

A

Supports trophoblasts - offer between w 20-35 to those w chronic or gestational HTN
Low levels - high risk Pre-E and IUGR

327
Q

Pre-eclamps fetal comps

A

IUGR
Intra uterine death
Premature delivery

328
Q

Pre eclamps maternal comps

A 
SHAME
Stroke
HELLP
Abruption
Multi organ failure
Eclampsia
329
Q

HELLP

A

Hemolysis
Elevated Liver enzymes
Low Platelets
–> eventually DIC

330
Q

Eclampsia tx

A

1st: MgSO4
2nd: midazolam

331
Q

Pre eclamps US

A

At dx and every 2w

332
Q

Red flag eclampsia sx

A

Headache
Vision change
Epi/RUQ pain
Breathlessness (ARDS)

333
Q

Red flag eclampsia signs

A

Peri-orbital edema
Hyper reflexia
Clonus

334
Q

Pre-eclamps delivery

A

> 34w
Maternal steroids up to 36w
Delay delivery by 24h for steroids

335
Q

Maternal steroid injection benefits

A

Reduse intraventricular hemorrhage
RDS
necrotising enterocolitis

336
Q

Early delivery in pre eclamps

A

High BP
Impaired renal or hepatic
Fetal distress

337
Q

Eclampsia mgmt

A

ABC
Manual uterine displacement or turn mom on side (aspiration and aorto-caval compression)
Control fits: MgSO4
Control HTN: IV labetolol or hydralazine

338
Q

Rh +

A

no tx

339
Q

Rh -

A

Become sensitized if birth Rh+ baby

Next time: mom’s Anti-D cross into fetus - hemolysis of baby

340
Q

Hemolytic disease of newborn

A

Mom Rh - and had Rh+ baby last time, this time Ab attack babies RBCs

341
Q

Anti-D injection

A

IM, 28w and at birth to Rh- mom
After birth too if baby was Rh +
**ANY time sensitization could occur (vag bleed, amniocentesis, trauma)

342
Q

Kleihauer test

A

Check how much fetal blood has passed to mom after sensitization event >20w to assess need for further Anti-D

343
Q

GDM risks to baby

A 
SMASHH
Shoulder dystocia
Macrosomia
Amniotic fluid excess
Stillbirth
Hypoglycemia, hypocalcemia, hypomag
HTN, Hyperbili, hyperinsulin/hyperphos
RDS
****NOT miscarriage or congential mal
344
Q

GDM usually starts

A

2nd tri

345
Q

Pre existing DM risks

A

congenital abnorm

Miscarriages

346
Q

Causes of issues in GDM

A

Mom hyperglycemia –> fetal hyperglycemis (causes polyhydramnios), baby gets hyperinsulinemia (causes fetal macrosomia–> shoulder dystocia) and then they are born w neonatal hypoglycemia

347
Q

Pre existing DM

A

5mg folic acid from preconception
HbA1C <48 before trying to get preg
Avoid preg if HbA1c >86 (sacral agenesis)

348
Q

Signs of pre existing DM

A

1st tri glycosuria
high random blood sugar
confirm w OGTT

349
Q

GDM RFs

A 
Raised BMI (>30)
Prev GDM
Asian, Black, Mid East
Prev macrosomic baby (>4.5kg)
FHx DM
OTHERs to screen: prev stillbirth, polyhydramnios, big for dates, PCOS)
Macrosomia/Polyhydramnios currently
LT steroid use
350
Q

Pre exising DM effects on preg

A

1st tri: increased insulin secretion + sensitivity - mom hyperglyc.
2nd tri: increase insulin resisit, need more insulin
Acceleration of retinopathy
Decreased renal func

351
Q

Pre existing DM mgmt

A

Stop ACE
Manage w team
Screen + monitor for vascular comps
Early iability scan @ 8w

352
Q

OGTT process

A 
Fast from midnight
Fasting sugar test
75g glucose drink
Measure at 1hr and 2hr
Normal: 5, 6, 7, 8
<5.6 or (5.1) @ base, <7.8 @2 (or 8.5)
353
Q

GDM path

A

Increased glucose load + insulin resistance –> DM
Placental lactogen + Placental progesterone increase in 2nd tri
More calories and less exercise, more fat deposition
Increased cortisol and Gh in preg
All lead to insulin resistance

354
Q

Preg Scans

A 
LMP
8-10 w: booking
11-13w: dating
20w: anomaly
24-28w: OGTT
28 + 34w: Anti-D
355
Q

GDM mgmt

A

Fasting <7: diet, lifestyle
Fasting >7: insulin
Fasting >6 + macrosomia: insulin

356
Q

Effects of GDM on mom

A 
POP-SIS
Polyhydramnios
Operative delivery
PET
Sig ris recurrence
Infx
Sig trauma to vag
357
Q

Fetal hypoglycemia

A

Unwell
G3
Seizure
Brain dmg

358
Q

GDM meds

A

1st: Metformin - 500mg daily w food
2nd: Add single injection intermediate acting insulin (Isophane) or Glibenclamide
3rd: Short acting insulin before means (Novorapid)

359
Q

GDM mgmt + delivery

A

Growth scans: 28, 32, 36

If not large, consider ELCS - if not, induce @ 38-40w

360
Q

Shoulder dystocia manoeuvers

A 
McRoberts
Rubin's
Woodscrew
Suprapubic pressure
break clavicle
Episiotomy
CS + zavanelli
361
Q

Shoulder dystocia Mcroberts

A

flex (kneed to chest) + externally rotate hips to stretch symphysis and open pelvic outlet

362
Q

Shoulder dystocia suprapubic pressure

A

rotates fetal shoulder into wider oblique diameter or under pub symph

363
Q

Shoulder dystocia woodscrew

A

reach in and rotate shoulder

deliver posterior shoulder

364
Q

SGA

A

<10th centile for GA

365
Q

Causes of SGA

A 
idiopathic
pre eclampsia
maternal smoking/alcohol
anemia
malnutrition
infx
multips
constitutional
Abnormal SGA (genetic, structure)
366
Q

Tyles of SGA

A 
SWAN
Starved small (FGR)
Wrong small
Abnormal small
Normal small
367
Q

Wrong small SGA

A

normal growth velocity

= wrong dates

368
Q

Abnormal small

A

decreased growth velocity

= chromosomal, structural, infx, genetic

369
Q

Starved small (fetal growth restriction)/ IUGR

A

Decreased growth velocity

= placental dysfunc, maternal disease, pre-eclamps, drug/alcohol/coke

370
Q

Normal small

A

normal growth velocity

= genetic, constitutional

371
Q

Growth restriction comps

A

Now: perinatal mor(stillbirths), preterm birth, birth asphyxia
Later: HTN, T2DM

372
Q

SGA symmetrical

A

abnormal small
normal small
wrong small

373
Q

SGA asymmetrical

A 
Abdo smaller than head - brain sparing effect
Starved small (IUGR)
374
Q

Neonatal SGA compa

A

hypoglycemis
polycythemia (neonatal jaundice)
Prem comps: intraventricular hemorrhage, RDS, Necrotising enterocolitis

375
Q

SGA RFs

A 
>40
Miltiple preg
BMI >35
Maternal dx (HTN, DM + vascular dx, Renal dx, antiphospho)
Prev SGA
Pre-eclamps
Smoking
Prev stillbirth
Low levels PAPPA (preg assoc plasma prot A)
376
Q

SGA monitoring

A

Low risk - SF height
Med risk - uterine artery doppler @ 20w
High - serial US w artery doppler, Screen for pre eclamps - maybe Aspirin prophyl
Serial scans: growth, AFI

377
Q

Arterial flow

A

Normal - mountains continuous
Absent diastolic - mountains + space
Reversed - mountains + valley

378
Q

Reversed end diastolic flow

A

Emergency - stillbirth likely
Prepare early delivery
Monitor (GTG, AFI, UAD)
Steroids

379
Q

Indications maternal steroids

A

Planned pre term birthd
PPROM
Spontaneous preterm labour

380
Q

Maternal steroids

A

IM betamethasone 12mg 12hx2
or dexamthasone 12mg 24hx2
**may need extra insulin if DM

381
Q

Mat steroids reduces risk of

A 
Intraventricular hem
Patent ductus
RDS
Nec entero
Fetal death
382
Q

MgSO4 benefits

A 
Lower risk CP
Imrpved blood flow, less hypoxic damage at delivery
Give if delivery within next 12h
4g slow IV (15-20min) then 1g/h
Main benefit 24-30w
383
Q

43yo, birth 6mo ago, 5cig, no conditions, prev heavy bleeding

A

IUD levonorgestrel

  • long duration
  • smoking CI COCP
  • copper IUD will make bleeding even heavier
384
Q

53yo, no period 16mo, sister BCA

A

None needed: >50 and over 12mo no period

IF <50 - would need contraception till 24mo no period

385
Q

50yp, on HRT for hot flush, having periods, uterine fibroids, not regular med

A

Prog implant

  • progest only when on HRT
  • no coil - fibroids
  • no injection >50 - bone density
386
Q

Less advised contraception >40

A

> 40 - COCP

>45 depo provera

387
Q

COCP in perimeno

A

Maintain bone density
reduce meno sx
<30mcg ethinylestradiol better <40y

388
Q

Depo-Provera perimeno

A

Delay of return to fertility >40 of 1y

Loss of bone density

389
Q

<50 non hormonal contraception

A

IUD, condom

Stop after 2y amenorrhea

390
Q

> 50 non hormonal contracep

A

stop after 1y amen

IUD, condom

391
Q

<50 COCP

A

Can continue till 50

392
Q

> 50 COCP

A

switch to non-hormonal, progesterone only

393
Q

Depo provera <50

A

Continue till 50

394
Q

Depo >50

A

switch to non hormonal and stop after 2y amen OR

Prog only method

395
Q

Implant <50

A

can use beyond 50

396
Q

Implant >50

A

continue

if amenorrhea - check FSH and stop after 1y if FSH>30 or stop @55

397
Q

POP <50

A

can use beyond 50

398
Q

POP >50

A

continue

if amenorrhea - check FSH and stop after 1y if FSH>30 or stop @55

399
Q

Constraception on HRT

A

POP can be used if HRT has some progesterone

If not: IUS

400
Q

Postmeno w atypical endometrial hyperplasia tx

A

total hysterectomy w bilat salpingo-oopherectomy

401
Q

Post meno endo biopsy at what thickness

A

> 5mm

402
Q

Endometrial hyperplasia w/o atypia tx

A

high dose progesterone, repeat sample in 3-4mo

Levonorgesterel IUS

403
Q

Booking visit

A

Genera;: diet, alcohol, smoking, alcohol folic acid, vit D, antenatal classes
BP, urine dip, BMI
Bloods: FBC, Blood group, Rh, red cell Ab, hemoglobinopathis
Hep B, syphilis
HIV
Urine culture - bacteriuria

404
Q

10-13+6 w visit

A

Scan to confirm dates

Exclude multiples

405
Q

11-13+6w visit

A

DS screen including nuchal scan

406
Q

16w visit

A

Routine: BP, urine dip
info on anomaly scan
Hb<11 –> iron

407
Q

25 w visit

A

Only if first baby

Routine: BP, urine dip, SF height

408
Q

18-20+6w visit

A

anomaly scan

409
Q

31 w visit

A

only if first

Routine: BP, urine dip, SF height

410
Q

34w visit

A

Routine: BP, urine dip, SF height
Second dose Anti-D
Labour plan

411
Q

28w visit

A

Routine. BP, urine dip, SFH
Screen anemia and RBC Ab
Hb <10.5 - iron
First Anti-D dose

412
Q

36 w visit

A

Routine: BP, urine dip, SFH
check presentation, ECV if breech
Info on Breast feed, vit K, baby blues

413
Q

38w visit

A

Routine: BP, urine dip, SF height

414
Q

40w visit

A

Only if first

Discuss options for prolonged preg

415
Q

41w visit

A

Routine: BP, urine dip, SF height

Discuss IOL

416
Q

Cord prolapse mgmt

A 
have woman go on knees + elbows
push fetus back up (not cord)
Tocolytics
IF PAST INTROITUS - keep warm and moist, dont push it back
Emergency CS
417
Q

Cord prolapse comps

A

cord compression
cord spasm
fetal hypoxia

418
Q

Cord prolapse RF

A 
prematurity
multiparity
polyhydramnios
twins
cephalopelvic disproportion
Abnormal presentation (breech)
Placenta previa
Long cord
high fetal station
artificial ROM
419
Q

PPROM Ix

A

Sterile speculum exam for fluid i posterior vag vault

US for oligohydramnios

420
Q

PPROM maternal complications

A

chorioamnionitis

421
Q

MgSO4 induced resp depression tx

A

calcium gluconate

422
Q

Nipple pain causes

A

poor latch
blocked duct (continue BF, massage, change positions)
nipple candidiasis (miconazole cream mom, nystatin suspension baby)
Mastitis
engorgement
Raynauds

423
Q

When to tx mastitis

A

systemically unwell
nipple fissure
sx not improved 12-24h post milk removal
culture shows infx

424
Q

Mastitis tx

A

flucloxacillin 10-14d
Continue BF
If no tx, can develop breast abscess needing I&D

425
Q

Breast engorgement

A

fever x 24h
red breast
painful, difficulty feeding
expression makes it better

426
Q

Raynauds nipple

A

intermittent pain during/after feeding
blanching followed by cyanosis/redness
Pain leaves when colour returns
Tx: minimize cold, use heat packs, avoid caffeine, no smoking

427
Q

Ovarian Ca tx

A

surg + platinum based chemo

428
Q

Female genital mutilation T1

A

partial/total removal of clitoris/prepuce

429
Q

Female genital mutilation T2

A

partial/total removal of clitoris + labia minora +/1 majora

430
Q

Female genital mutilation T3

A

narrowing of vaginal orifice w covering seal by positioning labia minor/major over it +/- clitoris excision
infibulation

431
Q

Female genital mutilation T4

A

all other harmful procedures: pricking, piercing, incising, scraping,cauterization

432
Q

Ectopic most common site

A

ampulla of F tube

433
Q

Ectopic ++ dangerous location

A

isthmus

434
Q

Contraceptive implant MOA

A

**inhibit ovulation
alter cervical mucus
? thin endo

435
Q

COCP MOA

A

*inhibit ovulation

436
Q

POP MOA

A

*thicken cervical mucus

437
Q

Desogestrel only pill MOA

A

*inhibit ovulation

thickens mucus

438
Q

Injection contraception (medroxyprogesterone acetate)

A
  • inhibit ovulation

thickens mucus

439
Q

Copper coil MOA

A

decrease sperm motility + survival

440
Q

IUS MOA (levonorgestrel)

A

*prevent endo prolif

thickn mucus

441
Q

Plan B - Levonorgestrel MOA

A

inhibit ovulation

442
Q

Plan B ulipristal MOA

A

inhibit ovulation

443
Q

Plan B IUD MOA

A

*toxic to sperm + ovum

inhibits implantation

444
Q

Premature ovarian failure

A

no menses for 1y <40

Can start w irregular cycles

445
Q

Premature ovarian failure sx

A 
hot flush
vaginal dryness
vag atrophy
sleep disturbance
irritability
high FSH (>40) and LH
Low E (<100)
446
Q

Prem ovarian fail causes

A 
idiopathic (and fhx)
Bilateral oopherectomy
Radiotherapy
Chemo
Infx (mumps)
Autoimmune
Resistant ovary syndrome (FSH receptor abn)
447
Q

Amiodarone in BF

A

no

448
Q

ABX ok in BF

A

penicillin
cephalosporins
trimethoprim

449
Q

Anti epileptics OK i BF

A

Sod val

carbamazepine

450
Q

Asthma meds ok in BF

A

salbutamol

theophyllines

451
Q

Psych drugs OK in BF

A

TCA

Antipsychotics (NOT CLOZAPINE)

452
Q

HTN drugs ok in BF

A

BB

hydralazine

453
Q

Anticoags ok in BF

A

warfarin

heparin

454
Q

Abx bad in bf

A

ciproflox
tetracycline
chloramphenicol
sulphonamides

455
Q

Psych drugs bad in bf

A

lithium

benzoss

456
Q

Bad in BF drugs

A 
aspirin
carbimazole
mtc
sulfonylureas
cytotoxic drugs
amiodarone
457
Q

Cholestasis in preg comps

A

stillbirth

458
Q

Cholestasis in preg mgmt

A 
IOL @ 37-38w
ursodeoxycholic acid
Vit K supplement
emollients for itch
Antihistaine - sleep
Vit K - if clotting abnormal
459
Q

Cholestasis in preg sx

A

Itch on palms + soles, abdo
jaundice sometimes
raised bilirubin

460
Q

1st degree tear

A

vaginal mucosa

no muscle

461
Q

2nd degree tear

A

subcutaneous/submucosal tissue

perianal muscle, no sphincter

462
Q

3rd degree tear

A

external anal sphincter

3a: <50% EAS
3b: >50% EAS
3c: IAS

463
Q

4th degree tear

A

through external anal sphincter + iAS, into rectal mucosa

464
Q

RF for perianal tears

A 
primigravida
large babies
precipitant labour
shoulder dystocia
forceps
465
Q

Prev baby with early or late onset GBS disease

A

maternal IV abx prophylaxix w benzylpenicillin ASAP (or clindamycin if allerg)

466
Q

neonatal infx <4d

A

GBS

467
Q

co-amoxiclav in preg - comps

A

nec enterocolitis

468
Q

GBS RF

A

prematurity
prolonged ROM
prev sibling GBS ifx
maternal pyrexia (2ndary to chorioamnionitis)

469
Q

missed/incomp Miscarriage medical mgmt

A

vaginal misoprostol alone, could do oral too
should start to expel in 24h
Give analgesia + antiemetics

470
Q

Miscarriage expectant mgmt

A

wait 7-14d

if not, go to med or surg

471
Q

When to use medical/surg mgmt miscarriage

A

risk of hemorrhage (late 1st tri, coagulops)
prior adverse/traumatic experice w preg
infx

472
Q

Surg mgmgt miscarriage

A 
vacuum aspiration (LA)
evacuation of retained prod (GA)
473
Q

Large for gestational age

A

Macrosomia

>4kg

474
Q

LGA causes

A 
Constitutional
GDM
Prev macrosomia
Maternal obesity or rapid weight gain
Overdue
Male
Incorrect dating
Polyhydramnios
Fibroids
475
Q

Macrosomia risks to mom

A 
Shoulder dystocia
failure to progress
perianal tear
instrumental deliv
PPH
Uterine rupture
476
Q

Macrosomia risk to baby

A

Birth injury (erbs palsy, clavicular fracure, fetal distress, hypoxia)
Neonatal hypoglycemia
Obesity

477
Q

Chickenpox in preg

A 
Dangerous
Varicella pneumonitis - lung infx
Fetal varicella syndrome - devt abnorm
Severe neonatal varicella - if infx at dleiv
TEST IgG if not sure re immunity
478
Q

Mom lacks varicella immunity

A

IV varicella immunoglobulins within 10d of exposure

479
Q

Rubella in preg

A 
congenital rubella syndrome
- sensorineural deafness
- congenital health disease
- cataracts
Screened at booking
DONT get vaccine, its live
480
Q

Rubella vaccine in preg

A

NO

481
Q

Chorioamnionitis

A

Infx of amniotic sac + fluid

Life threatening

482
Q

Chorioamnionitis pres

A

fever
abdo pain
sepsis (tachy tachy hypotension)
fetal compromise on CTG

483
Q

Chorioamnionitis tx

A

Sepsit 6

Early delivery

484
Q

Twins antenatal care

A

5mg folic
iron sup
vit D

485
Q

Twin scanning

A

2 weekly from 16w in monochorionic

4 weekly scans from 20w in dichorionic

486
Q

Delivery date diamniotic

A

37-38w

Give steroids

487
Q

Delivery method twins

A

Monoamniotic : ELCS @ 32-34w

Diamniotic: vaginal if presenting twin cephalic, second will need CS

488
Q

Twins complications

A 
Anemia
Polyhydramnios
HTN
IUGR
Prematurity
Increased perinatal mortality
Malpresentation
PPH
Twin Twin Transufion Syndrome
489
Q

TTTS

A

recipient gets majority of blood - overloaded (w polyhydramnios)
Donor starved, anemic
Laser tx to destroy connection

490
Q

DS screen combined test

A

first line most accurate
11-14w
US nuchal translucency (>6mm DS)
Meternal bloods (bHCG higher = risk, PAPPA - lower = risk)

491
Q

DS screen triple test

A 
15-20w
Only materna bloods
hCG
AFP - lower = more risk
Serum estriol - lower = risk
492
Q

DS quadruple test

A

15-20w

Same as triple (HCG, AFP, E) + Inhibin A (high = risk)

493
Q

DS amniocentesis

A

If risk >1/150 - offer amniocentesis or chorionic villus sampling

494
Q

Chorionic villus sampling

A

Biopsy of placental tissue

Done <15w

495
Q

Amniocentesis

A

US aspiration amniotic fluid

Later in preg

496
Q

Placenta previa

A

Lying low
Minor - not covering internal os
Major - covering internal os

497
Q

Placenta Previa RF

A 
prev CS
older
structural abnormal (eg fibroids)
Parity
D&C/surgery
498
Q

Placenta previa mgmt

A 
rest
avoid sex
avoid vag exam/speculum
US 34w to assess position - repeat every 2w if still close to os
ELCS @37w or vag if passage clear
499
Q

Placenta previa pres

A 
painless bright red blood
soft uterus
Normal FHR
HCT relfects blood loss
Abn presentation
500
Q

Placental abruption pres

A

painful dark red blood
shock, abnormal CTG, woody abdomen
HCT not consistent w blood loss

501
Q

Placenta previa comps

A

hemorrhage (ante/post partum)

502
Q

Uterine causes of antepartum hemorrhage

A

Placental abruption
Placenta previa
Vasa previa
Marginal bleed

503
Q

Cervical causes of antepartum hemorrhage

A

show
cervical CA
Cervical polyp/ectropion

504
Q

Vaginal causes of antepartum hemorrhage

A

trauma

infection

505
Q

Placental abruption

A

premature separation of placenta from uterus

506
Q

Placental abruption RF

A 
idiopathic
smoking
pre eclampsia
trauma
prev abruption
Cocaine
Thombophilia
Twins
Deficient endo (prev CS, endometritis, curettage)
507
Q

Concealed abruption

A

Os remains closed, hemorrhage stays in uterine cavity - underestimate severity

508
Q

Abruption mgmt

A

Rescuss
Deliver (unstable/featle distress/heavy bleed-CS, stable/no distress - induce @ 37)
Anti-D if Rh-
Watch for PPH

509
Q

Obstetric cholestasis pres

A

3rd tri
itchy on palms/ soles/ abdo
No rash
Abnormal LFTs and bile acids

510
Q

Acute fatty liver of preg

A

rapid accumulation of fat in hepatocytes in 3rd tri
Acute hepatitis
Immediate admission and delivery - high risk liver fail and mortality for both

511
Q

Acute fatty liver pres

A 
Malaise
N/V
jaundice
Abdo pain
LFT: high ALT
512
Q

VTE RF

A 
Smoking
Parity >3
Age > 35
BMI > 30
Reduced mobility
Mltip preg
Hx VTE
FHx VTW
Low risk thrombophilia
513
Q

Braxton hicks

A

practice ctx
irregular, from 3rd tri
Mild & crampy to srong

514
Q

Labour signs

A

Show (mucus plug)
ROM
Regular, painful ctx

515
Q

IOL

A 
over dates (12d)
Macrosomia
reduced fetal mvmt
pre-eclampsia
PROM
516
Q

Bishop score

A 
determine whether to induce labour
5 things, 0-3 score each
<5 = labour needs induction
- fetal station
- cervix position
- cervix dilatation
- cervix effacement
- cervix consistency
517
Q

IOL 1st line options

A

membrane sweep

vaginal pessary - prostaglandins

518
Q

Membrane sweep

A

Finger in
Stim cervix
Should start labour within 48h

519
Q

IOL vaginal pessaries

A

Prostaglandin E2

Hospital setting for monitoring before allowing back home

520
Q

IOL 2nd line

A

oxytocin infusion

521
Q

Continuous CTG indications

A 
sepsis
oxytocin
meconium
pre-eclampsia (>160/110)
antepartum hemorrhage
522
Q

CTG reading

A 
DR C BRAVADO
Define Risk (low/high)
Ctx (freq/dur)
Baseline Rate (brady/tachy/n)
Variability (5-10bpm)
Acceleration (present/absent)
Deceleration (early/late/var)
Overall (reassuring/not)
523
Q

CTG findings

A 
DR ( PET/GDM/42+w)
Ctx (5/10m = hyperstim)
Baseline (110-160)
Vari (5-15bpm)
Accel (2 in 20min - 15bpm change for 15s)
Decel (abnormal)
524
Q

Syntocinon

A

synthetic oxytocin
IOL, stimulate ctx
CAN also be used post birth for bleeding
Increases conc. of Ca inside muscles cells

525
Q

Ergometrine

A

stimulate ctx of uterus during labour. V often after birth.

Works on alpha adrenergic, dopaminergic, serotonin R as stimulant on uterine muscles

526
Q

Syntometrine

A

Syntocinon + ergometrine

Stim labour + uterine ctx, bleeding after birth

527
Q

Active mgmt 3rd stage

A

Helps avoid PPH

  • Empty bladder
  • IM syntocinon after birth
  • Cord clamp 1m after birth (delayed)
  • Palpate abdomen, wait till uterine ctx to deliver placenta
  • Deliver placenta w gentle traction, while other hand pushes placenta up to avoid prolapse
  • Examine placenta
528
Q

Failure to progress

A

2 ctx/10min
Syntocinon 1st line, titrated up @ 30min intervals
Aim for 4ctx/10min

529
Q

CS layers

A 
Skin
Fat
Rectus sheath
Rectus muscle
Peritoneum
Abdominal cavity
530
Q

ELCS

A

spinal anesthetic

after 39w usually

531
Q

ELCS indications

A 
prior CS
Placenta previa
Breech
Cephalopelvic disproportion
Choice
IUGR
Post-dates
Uncontrolled HIV
Cervical CA
532
Q

Emergency CS cat 1

A

immediate threat to life of mom or baby, target delivery time 30min

533
Q

Emergency CS cat 2

A

no imminent threat but required urgently due to compromise of mom/baby - 75min

534
Q

Emergency CS cat 3

A

delivery needed but mom and baby stable

535
Q

Emergency CS cat 4

A

elective

536
Q

CS comps

A

anesthetic risk
surgical: bleeding, infx, pain, VTE
Damage to structures: ureter, bladder, bowel, blood vessels
Effect on abdo organs: ileus. adhesions, hernias
Effects on future preg: repeat CS, uterine rupture, placenta previa, stillbirth
Baby: lacerations, TTTN

537
Q

VBAC

A

Possible as long as the cause of the initial CS unlikely to reoccur
Assess likelyhood of success (75% usually)
Risk uterine rupture 0.5%

538
Q

VBAC contraindications

A

prev uterine rupture
classical CS scar
placenta previa

539
Q

Post CS VTE prophylaxis

A

10d LMWH if emergency

Elective doesnt need LMWH unless other health issues

540
Q

Age of viability

A

23w

10% chance of survival

541
Q

Extreme prematurity

A

<24w

542
Q

Very preterm

A

28-34

543
Q

Moderate/late preterm

A

34-37w

544
Q

Term

A

> 37w

545
Q

Prophylaxis of preterm labour

A

Progesterone pessary/gel - decrease activity of myometrium, prevent cervix remodelling
Cervical cerclage - stitch in cervix to support + keep closed, can remove at labour or term

546
Q

Progesterone pessary indications

A

<25mm cervix length on US between 16-24 weeks gestation

547
Q

Cervical cerclage indications

A

<25mm cervix length on US between 16-24 weeks gestation who have prev. premature birth

548
Q

PPROM

A

preterm prelabour rupture of membranes

549
Q

PPROM dx

A

speculum - AF in vagina
Amnisure (PAMG-1 placental alpha microglobin 1)
prophylactic abx - erythromycin x 10d can delay birth

550
Q

Preterm labour but no ROM

A

<30w clinical exam enough to offer mgmt

>30w TVUS to assess cervix length - <15mm = mgmt OR fetal fibronectin

551
Q

Preterm labour w no ROM mgmt

A

fetal monitoring (CTG)
Tocolysis
Maternal steroids
MgSO4

552
Q

Tocolysis

A

Stop uterine ctx
Nifedipine used
Used to buy time

553
Q

Antenatal steroids

A

<36w

Lung maturity

554
Q

MgSO4 in preterm

A

protect fetal brain, reduce risk of CP
Use in 24h around delivery if <34w
***WATCH FOR TOXICITY

555
Q

Uterine rupture

A

incomp: peritoneal lining around uterus intact
complete: lining ruptures, contents of uterus into peritoneal cavity
Hemorrhage

556
Q

Uterine rupture tx

A

emergency laparotomy

557
Q

Uterine rupture RF

A 
VBAC
Prev uterine injury
High BMI
High parity
IOL
558
Q

Shoulder dystocia Rubins

A

pressure on posterior part of babies anterior shoulder to help deliver under the symph pub

559
Q

Shoulder dystocia Zavanelli + CS

A

pushing babies head back up so it can be delivered by CS

560
Q

Shoulder dystocia comps

A

Fetal hypoxia (CP)
Erbs palsy (brachial plexus)
Perineal tears
PPH

561
Q

Cord prolapse mgmt

A 
emergency CS
presenting part of baby pushed back up to get it off the cord
lie in left lateral position or all 4s
tocolysis while waiting
Dont push the cord back in
562
Q

Indications for instrumental delivery

A

failure to prog
fetal/maternal distress
control of head in various position

563
Q

Risks of instrumental delivery

A

increased hemorrhage

Increased need for episiotomy

564
Q

Ventouse comp

A

cephalohematoma

565
Q

Forceps comp

A

facial nerve palsy, fat necrosis leading to hardened lumps on cheeks

566
Q

PPH defns

A

500ml vaginal

1L CS

567
Q

PPH RF

A 
Prev PPH
Multiple
Grand multipara (5+ vag del)
Large baby
Failure to progress in 2nd stage
Pre eclampia
Retained placenta
568
Q

PPH 4 T’s

A

Tone - atonic uterus
Trauma - genital tract, inversion
Tissue - retained placenta
Thrombin - bleeding disorder

569
Q

PPH preventative measures

A

treat anemia in ante-natal period
Empty bladder - full reduced ctx
Oxytocin in 3rd satge
Tranexamic acid IV during CS 3rd stage if high risk

570
Q

PPH mechanical tx

A

rub uterus

catheterize

571
Q

PPH medical tx

A 
Syntocinon/ergometrince stat
40u synt in continuous infuion
Carboprost - prostaglandin analogue stim ctx(caution in asthma)
Misoprostol - ctx
Tranexamic acid - reduce bleed
572
Q

PPH surgical tx

A

balloon tamponade
B-Lynch suture (suture around uterus to compress it)
Uterine artery ligation
Hysterectomy - last resort

573
Q

Uterine Inversion

A

Fundus drops down through cervix - cause of PPH
Life threatening
Can happen if puling too hard on umbilical cord

574
Q

Uterine inversion mgmt

A

Johnson’s maneuver - use hand to push it back up

575
Q

UKMEC 1

A

no restriction in use

576
Q

UKMEC 2

A

advantages > disadvantagea

577
Q

UKMEC 3

A

dis>adv

578
Q

UKMEC 4

A

Unacceptable risk

579
Q

COCP MOA

A

prevent ovulation
thicken mucus
thin endometrium
99%

580
Q

COCP types

A

Monophasic
phasic
every day

581
Q

COCP monophasic

A

identical pills x 21d
nothing x 7d
Gap: withdrawal of hormones leading to menses
Yasmine: ethinylestradiol, drospirenone
Microgynon: ethinylestradiol, leveonotgestrel.

582
Q

COCP phasic

A

pills have varying amounts of hormones to closer match the changes occuring over the month
Logynon

583
Q

COCP every day

A

monophasic but includes 7 sugar pills

Microgynon ED

584
Q

COCP SEs

A 
breakthorugh bleed
headache/migraine
Breast tender
Libido change
Acne (improve/worsen)
585
Q

COCP risks

A

HTN
Thombosis
Increased BCa (reduced endo, ova, cerv)

586
Q

COCP contraindications

A 
>35 + smoker
Pregnancy
Prev VTE
Prev Stroke/heart disease
Uncontrolled HTN
FH thrombosis (<45y)
Migraine + aura
BCa
587
Q

COCP missed 1 pill

A

Most recent ASAP (even 2 at same time)

No extra protection

588
Q

COCP missed >1 pill

A

Most recent one ASAP
Additional ctcp until 7 pill days straight
D1-7 - need Plan B if UPSI
D8-14 - no plan B needed
D15-21 - no plan B needed and go straight into next pack without week off

589
Q

When to starts COCP

A

1st day of period - will protect right away

Other times - need 7d barrier

590
Q

POP

A

Take continuously, no pill free times
Good in breast feeding
Good if E contraindicated

591
Q

POP MOA

A

thickens mucus
prevents ovulation
99%

592
Q

POP timing

A

Traditional: within 6h window daily - up to 3hr late (Micronor, norgeston - levono)
Cerazette (desogestrel): take within 24h window - can be 12h late and still work

593
Q

POP side effects

A 
Irreg bleed or amenorrhea (3packs)
Breast tender
Headache
Libido change
Acne
594
Q

Copper Coil MOA

A

reduce sperm motility and survival

595
Q

Copper coil benefits

A

5y
Insert anytime in cycle, effective immediately
No hormones - safe for VTE risk or hormone cancers

596
Q

Copper coil drawbacks

A 
Increase period and intermenstrual bleeding
Uterine perforation
PID
Ectopic preg
Fall out
597
Q

Copper coil uses

A

emergency contraception w/in 5 d of intercourse

598
Q

Mirena coil (levonorgestrel) MOA

A

Thickens mucus
Reduce endo lining
prevent implant

599
Q

Mirena benefits

A

5y, >99%
make periods lighter or stop
GOOD for ppl on HRT who need prog.
Good for endometriosis

600
Q

Mirena drawbacks

A 
spotting/irregular bleed/menorrhagia/dysmenorrhea
Alternative ctcp needed 7d
Uterine perf
PID
ectopic
fall out
601
Q

Mirena other uses

A

first line tx for menorrhagia
HRT
endometriosis - atrophy

602
Q

Progesterone implant MOA

A 
In subcut tissue of upper arm
3y
Inhibits ovulation
Thickenc mucus
thins endometrium
603
Q

Progesterone implant benefits

A 
Effective (99%)
no need to remember
Improve dysmenorrhea
Makes periods lighter/stop
No affect on bone mineral density
No risk of thrombosis
604
Q

Progesterone implant drawbacks

A

Minor operations with LA to insert/remove
Worse acne
Can have menorrhagia
Reduced libido

605
Q

Depo Provera MOA

A 
3 monthly IM @ GP
Good if cant have COCP or can't remember
Medroxyprogesterone acetate
prevents ovulation
thickens mucus
606
Q

Depo provera fertility

A

can take 12mo to return

607
Q

Depo provera starting

A

first day of cycle

If later, need 7 days barrier

608
Q

Depo Provera side effects/risks

A 
Ammenorrhea (light/stop)
Irregular/spotting (first 3 shots)
Weight gain
Acne
OSTEOPOROSIS
609
Q

Sterilization

A

Consider it permanent

Reversal only 25-50% successful

610
Q

Female sterilization

A 
Laparoscopy under GA
During CS
Flocking (filshie clips), tying/cut, remove tubes
>99% effective
Alternative ctcp until next menstruation
611
Q

Male sterilization

A

Vasectomy - cutting vas deferens to prevent sperm reaching semen
Under LA, 15-20min
>99% effective
Need ctcp for 2mo and semen testing to confirm sterility

612
Q

Ctcp post birth

A 
Not needed until 21d post delivery
POP safe in breastfeeding
Avoid COCP in BF
Lactational amenorrhea (full BF with no periods) - 98% effective
If no BF - any contraception is fine
613
Q

EC - levonorgestrel

A

POP - inhibits implantation, and sometimes ovulation
Single dose, 72h
SE: vom, if <2h - repeat dose
Can trigger/worsen depression
**careful if prior ectopic or malabsorption syndromes

614
Q

EC - Ulipristal

A

Progesterone receptor modulator
Single dose, 120h
Abdo pain/diarrhea/vom - <3h then repeat
**careful in uncontrolled asthma, avoid BF for 1w

615
Q

EC - IUD

A

Copper coil - 5d UPSI or 5d estimated ovulation
Toxic to sperm
Inhibit fert & implant
Most effective
Can lead to PID, prophyl ABX
Keep in until after next period or long term

616
Q

6w postnatal check

A

GP, same time as newborn check

  • Gen wellbeing
  • Mood
  • Bleeding
  • Scar healing
  • Ctcp
  • BF
  • Fasting blood if GDM
  • BP (if HTN/PreE)
  • Urine dip (protein)
617
Q

Postpartum anemia

A 
Optimize anemia in preg
FBC day after birth:
-<100 - oral iron (ferrous sulphate 200 TDS
-<80 - iron infusion + oral iron
- <70 - blood transfusion + oral
618
Q

Mastitis cause

A

Staph aureus
accumulation of milk in duct, bacteria can enter nipple and into duct.
regularly expressing milk can prevent this.

619
Q

Mastitis + abscess

A

I & D

620
Q

Mastitis sx

A

pain + tender
erythema
local warmth, inflammation
Fever

621
Q

Mastitis mgmt

A

conservative: expressing, analgesia
Abx if fever + infs (flucloxacillin, erythromycin if pen allergy) - sample of milk for culture+sens
Continue BF

622
Q

Postnatal depression

A

1/10 women, peak 3mo after birth

623
Q

Baby blues

A

majority of women in week following

Esp primips

624
Q

Puerperal sychosis

A

1/1000 few weeks following birth

625
Q

Postpartum thyroiditis stages

A

1: hyperthyroid (<3mo)
2: hypo (3-9)
3: normal within 1 y

626
Q

Postpartum hyperthyroid tx

A

Symptomatic control w propranolol

627
Q

Postpartum hypothyroid tx

A

levothyroxine

628
Q

Sheehan’s presentation

A

Hypo-pit

  • decreased lactation (prolactin)
  • amenorrhea (LH, FSH)
  • adrenal insuff (ACTH)
  • hypothyroid (TSH)
629
Q

Sheehan mgmt

A

manage each deficiency in turn

630
Q

PPH initial mgmt

A 
Resus
ABC/call for help/Team approach
O2/ recovery position
IV access
Fluids/blood
Baseline bloods (FBC, coag, X)
Catheterize
631
Q

PPH specific measures

A 
Rub up uterine ctx
oxytocic agent
EUA/remove products/repair tears
Balloon tamponade
B-Lynch suture
Internal iliac ligation
HHysterectomy
IR
632
Q

PPH agents

A

Syntocinon - IM, IV
Ergo - IM
Carbo
Miso - rectal

633
Q

PPH follow up

A

explain to pt and partner
HDU
Risk of recurrence & Mx in next preg
- avoid anemia, active mgmt 3rd stage

634
Q

Mgmt 1st tri bleed

A

Always HCG before doing US

635
Q

Early preg failure sx

A 
Int low abdo pain, bleeding, preg
Bleeding worsens till pass tissue
Can be asymptomatic
HCG falls or plateaus
US findings
636
Q

US poor indicators

A

irregular gestational sac
absent yolk sac
retroplacental clot
failure of pole to grow - confirms EPF

637
Q

Emrbyo @ 5-4w

A

gestational sac present if HCG >1500-2000

638
Q

Embryo @ 5-6w

A

yolk sac in gestational sac if >10mm
Gestational sac > 18mm –> see embryo
Cardiac activity when embryo >5mm

639
Q

Ectopic physical exam

A

Closed cervix
Adnexal fullness/tender
Peritoneal signs (rupture)
Unstable vitals (rupture)

640
Q

miscarriage HCG

A

plateau/ falling

641
Q

Miscarriage US

A

irregular GS
Retroplacental hemorrhage
Fetal pole w no HR

642
Q

Methotrexate for ectopic: imp

A

Avoid sun
Avoid leafy greens/kegumes/prenatal vits
Toxicity: stomatitis, myelosuppresion, iatrogenic hepatitis, pneumonitis, stevens johnson

643
Q

Molar preg Ca

A

1-3% partial moles

15% complete

644
Q

Molar preg RF

A

Extremes of age
Southeast asia/India
Prev mole

645
Q

Asses low BP post surg

A 
Colour/consciousness
Pani/light headed/cold
BP/HR/RR/Temp/CapRefill
Urine output
Examine abdo: distension/hematoma
Inspect PV bleeding/clots
Drug chart - opiates
Epidural/spinal anesthesia
Operative record for blood loss
646
Q

Causes low BP post surg

A

Hemorrhage (abdo/pelvic)
Inadequate fluids/underestimated blood loss
Meds/Anesthesia related

647
Q

Low BP post op mgmt

A 
Elevate bed
Increase fluids
Additonal venflon
FBC/G&X/U&E/Coag
O2
Ask for Registrar
648
Q

Mgmt if suspect post op hemorrhage

A 
Inform theatre staff
inform consultatn
HDU
Explain and reassure pt
Inform next of kin
649
Q

Placental migration

A

lower uterine segment develops - placenta migrates upwards

650
Q

Mgmt previa +abruption

A

ABC
IV
FBC, G/X, Coag
PA - deliver mmediate

651
Q

Premature

A 
<37w
<34 more sig
1/3 after ROM
1/3 medically indicated
1/3 idiopathic/spont
652
Q

Premature RF

A 
Hx preterm del
Mutips
Interpreg interval <6m
Hx cervical surg
Short cervix <25mm
Infx - bacteriuria, UTI, BV
653
Q

Premature mgmt

A

Progesterone suppository/pessary

654
Q

Membranes ruptured?

A 
Sterile speculum
Nitrazine reaction of fluid
Ferning
Oligohydramnios by US
Amnisure
655
Q

Premature infx?

A

GBS status
STI status
UTI
Chorioamnionitis

656
Q

Labour defn

A

Regular cts
effacement >80%
dilatation>2cm

657
Q

Assessing likelihood of preterm delivery

A

Fetal fibronectin

US cervical length

658
Q

Fetal fibronectin

A

if neg, unlikely to deliver in 7014d
If pos, less sure itll happen
DONT do if bleeding ir within 24h of sex/DVE/endovag US

659
Q

Preterm labour mgt

A

Antenatal steroids
tocolysis (<34w w atociban)
transfer
GBS prophyl (benzylpen)

660
Q

GBS screen

A

35-37w

if neg w/in 5 weeks of delivery dont need prophylaxis

661
Q

Whn to GBS prophyl

A

GBS bacteriuria during current preg
previous birth of infant w GBS
+GBS swab in late gestation
unknown GBS status at onset of labout AND GBS rf (membrane rupture >18h, labour <37w, fever)

662
Q

Assess fluid leak @ 28 w

A

Hx/Physical
Sterile speculum, amnisure, US
Admit, keep baby in there
G&H, CRP, FBC, vag swab, MSU, start oral erythromycin…buy time
Counsel re risks - baby to NICU, RDS, bronchopulmonary dysplasia, feeding issues, necrtotising enterocolitis
Counsel re chorioamnionitis (need to deliver)
Cord prolapse
PA
Try to ge her to 34-35w

663
Q

Preterm bay risks

A

RDS
bronchopulmonary dysplasia
feeding issues
necrtotising enterocolitis

664
Q

Assess fluid leak @ 38w

A

Hx, confirm amnisure and US
24h assuming no GBS
If nothing by 24 hours - accelerate
Abx @ 18h

665
Q

PPROM infx

A

13-60%

666
Q

PPROM 24-34w

A

Steroids
Abx(ampicillin/erythromycin])
Monitor: temp, techy, uterine tenderness, NST, AFI, BPP)

667
Q

PPROM risks

A 
Prematurity
infx/chorioamnionitis
Pulm hypoplasia
orthopedic problems
abnormal presentation
bleeding/PA
cord prolapse
668
Q

PPROM >34w

A

induce labour

669
Q

Premature baby mgmt

A

Level 3 NICU
Continuous monitoring
Malpresentation comon
Avoid vacuum

670
Q

PROM at term mgmt

A

consider infx risk
GBS prophyl
IOL?

671
Q

Delivery time for twins

A

Every baby cecreases gestational age at delivery by 3-4 weeks

672
Q

Multips comps

A 
HTN
GDM
Systems overload
Preamature birth
PPH
Operative deliveries
TTTS
673
Q

Instrumental delivery requirements

A 
FORCEPS
Full analgesia/anesthesia, no Force
Os fully dilated
Rom
Contractions adequate
Episiotomy, Empty bladder
Position of fetus, Pelvis ok
Skill of operator
674
Q

Sevre pre eclampsia mgmt

A

Admit
prevent seizures
Lower BP (cerebral hem)
Expidite delivery

675
Q

Severe pre eclampsia maternal eval

A

Vitals, neuro, DTRs 15-60min until stable
Foley catheter - output + dipstick hourly
NST monitor
FBC, BUN, Cr, AST, ALT, LDH, Electrolytes, uric acid
Give: MgSO4, BP meds

676
Q

MgSO4 MOA

A

slows neuromuscular conducton, reduce CNS irritablity

677
Q

Magnesium tox

A 
Thera (4-8)
Loss of patellar reflex (8-10)
Somnolence 12
RespDep 17
Paralysis 17
Cardiac arrest >30
678
Q

Antihypertensives

A

Aim for 90-110 diastolic
Labetalol (BB)
Hydralazine (vasodilate)
Alt: CCB nifedipine, methyldopa

679
Q

when to do CS in severe pre eclamps

A

continuous seizures
fetal distress
unfavourable cevix
sevre prematuriy

680
Q

Postpartum mgmt pre eclamps

A

rapid improvement
rsk of seizure in first 24h
Continue monitoring MgSO4 levels, BP, urine
watch for fluidoverload

681
Q

Seizure mgmt

A

protect airway
prevent injury
MgSO4
plan delivery

682
Q

Postpartum endometritis

A 
Fevere
uterine tender
foul discharge
Tachy
Risk of: Bacteremia, sepsis/ adhesions/ abscess
683
Q

postpartum endometritis RF

A 
prolonged ROM
multiple exams
instrumentation
anemia
low SES
CS
684
Q

Endometritis tx

A

IV abx

clindamycin/gentamicin +/- ampicillin

685
Q

Breast engorgement

A 
gradual onset
bilateral
gen swell
gen pain
feels well
no fever
686
Q

Plugged duct pres

A 
gradual onset 
unilateral
localswell
localpain
feels well
no fever
687
Q

Mastitis pres

A 
sudden onset
unilatera
local swell
localpain
feels unwell
fever
688
Q

Causes of abnormal bleeding

A 
PAADD
Preg (exclude this first)
Anatomy (vulvar, vag, cervical, uterine)
Anovulation (irreg menses, stress, obesity)
Diseases (endocrin)
Drugs
689
Q

Abn bleed - vulval

A

excoriation
dysplasia
atrophy

690
Q

Abn bleed vagina

A

vaginitis

atrophy

691
Q

Abdn bleed cervix

A

ectropion (normal eversion of trans zone, OCP use causes, post coital bleed, no tx)

cervicitis (intermenses spotting, post sex - from G/C, dysplasia, BV, trich)

Cervical polyp - benign, neoplasia, remove + cauterize

692
Q

Abn bleed iterus

A

fibroids
adenomyosis
endo polyp

693
Q

Fibroid types

A 
Pedunculated
intracavitary - resect w hysteroscope
intramural
submucous
subserous
MYOMECTOMY
694
Q

Fibroid workup

A

physical
US
MRI

695
Q

fibroids

A
  • common, asymptomatic, a lot in African, can have heavier menses and intermenstrual spotting
    Pelvic pain, pressure, dyspareunia
696
Q

Adenomyosis

A

extension of endometrial glands into uterine muscle - from trauma (myomectomy/CS)
Sx: dysmenorrhea

697
Q

Endometrial polyp

A

benign growth of endo glands
Can be passed in menses
Assoc w: metrorrhagia

698
Q

Endometrial hyperplasia

A

Abnormal proliferation of endo glands

699
Q

RF endo hyperplasia

A

Excessive unopposed estrogen (obesity, PCOS)
Chronic anovulation
Tamoxifen

700
Q

Tamoxifen

A

SERM
reduce risk of recur
shrink tumour
lower risk in high risk women

701
Q

Tamoxifen side effects

A 
meno-like sx: hot flush
night sweat
vaginal dryness
weight gain
fluid retention
Irreg loss of periods
Leg swelling
Nausea
Vag discharge
702
Q

Endo hyperplasia Tx

A

D&C

Progestin (oral or local, Mirena) - only if not worried about malignancy

703
Q

Endo hyperplasia malignancy risk

A

simple (1%)
complex (3%)
simple + atypia (10%)
complex + atypia (27%)

704
Q

Abn bleed - anovulation causes

A 
Hyperandrogen
-PCOS
-Congenital adrenal hyperplasia
-Androgen producing hormones
Hypothalamus
-Anorexia
-Immaturity
-Hypo/Hyperthyroid
-Cushing's
-Stress
-Excercise
705
Q

Abn bleed - disease

A

Malig
Coag
Thyroid
Liver/renal

706
Q

Abn bleed - drugs

A 
OCP
Copper IUD
Depo Provera
HRT
Steroids (ameno)
Chemo (ameno)
Antipsych (ameno)
Anticonvuls (ameno)
707
Q

Abn bleed tests

A 
Preg test
Anatomy: exam, cervical cytology/culture, bx)
Anov: TSH, prolactin etc
Disease
Drugs: hx
708
Q

Sigh: hirsutism

A

PCOS

709
Q

sign: acanthosis nigricans

A

DM

710
Q

sight: buffalo hump

A

cushings

711
Q

How to check for ovulation

A

progesteron D21 and home LH ovulation kit

712
Q

Anotomical causes of bleeding Ix

A

Exam - visualized lesions, size of uterus
Imaging - US (endo thick, uterus sze, adnexa)
Endo bx: >35 w prolonged E or other risk of hyperplasia. >40 w anovulatory bleeding. Any post-meno bleed

713
Q

Mgmt menorrhadia

A 
NSAID (reduce PG-->vascoconstric-t-->less blood)
Hormone CTCP (COCP, DP, Mirena)
GnRH agonist (Depo lupron) - 3 month injection, chemical meno, add oral progest to decrease SEs, halts menses, shrink fibroids, ONLY for 6 mo - bone density)
714
Q

Polyp removal

A

hysteroscope

715
Q

Endometrial ablation

A

<10-12cm in size

716
Q

Uterine artery embolization

A

shrink fibroids

helpful for pressure/pain sx

717
Q

Myomectomy

A

pt who desires future childbrearing

risk of re growth

718
Q

Hysterectomy

A

dependent on syze and surgeon

Vag/abdo/lap

719
Q

Varicella

A

Contageous
Resp droplets
Latent infx
Risk fetal injury <2% even in 1st 1/2 of preg - circular limb scars

720
Q

Most likely comp of varicella in preg

A

Pneumonia

Give VZ IgG

721
Q

Varicella at delivery

A

Infx at deliver - neonate at risk
Disseminated muccocutaneous infx
Visceral infx
Give baby VZ IgG

722
Q

Herpes zoster

A

Latent varicella
No risk to baby
Tx Acyclovir

723
Q

Parvovirus transmission

A

resp drop

blood trans

724
Q

Parvovirus pres

A

erythema infectiosum
-slapped cheek
Transient aplastic anemia

725
Q

Parvovirus effects

A

crosses placenta (33% chance)
Suppress fetal bone marrow
Dx - MCA doppler
Highest risk 1st tri

726
Q

Parvovirus dx

A

Mom: Serology IgM + IgG, PCR
Fetal: US, MCA doppler

727
Q

Parvo tx

A

single transfusion, or sometimes 3 small transfusions

728
Q

Hep B

A

DNA virus
Danger of co-infx w hep D
Need universal screening

729
Q

Serology for Vacinated Hep B

A

+Hep B surface Ab

730
Q

Serology acute infx hepB

A

anti-core Ab IgM

731
Q

Serology HepB infx

A

Hep B surface antigen

732
Q

Serology hepB high infectivity

A

Hep E antigen

733
Q

HepB Mgmt

A

Immunoprophylaxis not fully protective if mom has high viral load
Tenofovir 28 w from del

734
Q

Hep C

A 
RNA virus
More prevalent than B or A
Chronic liver disease
Chronic carrier state
Perinatal transmission low unless HIV
Vag delivery OK
735
Q

Hepatitis baby mgmt

A

Baby bath
no scalp elcetrodes
no instruments
baby IgG right away and then 3 vaccines (HepB no IgG or shots)

736
Q

Peurperium

A

Uterus involutes - 12d
Lochia (decidua) passes - 4-6w
Ovulation/menses - resumes in non BF within 6w
CVS: CO, BP normal by 2w
Coag: fibrinolysis normal within 30min, pro-coag state remains
Met: insulin resistance goes immediately

My notes - med (14 decks)

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