Obs and Gynae Flashcards
What is the action of GnRH?
stimulates the anterior pituitary to release LH and FSH
What is the action of LH and FSH?
Stimulate the development of follicles in the ovaries. Theca granulosa cells around the follicles secrete oestrogen which has a negative feedback effect on the hypothalamus and anterior pituitary to supress the realease of GnRH, LH and FSH
What is the action of oestrogen?
Stimulates: Breast development Growth and development of female sex organs Blood vessel development in the uterus Development of the endometrium
Where and when is progesterone produced?
By the corpus luteum after ovulation. When pregnancy occurs, progesterone production is taken over by the placenta after 10 weeks
What is the action of progesterone?
Thicken and maintain the endometrium
Thicken cervical mucus
Increase body temperature
why do overweight children tend to enter puberty earlier?
Aromatase is an enzyme found in fat tissue which is also important in the creation or oestrogen
What staging system is used to stage puberty?
The tanner system
When is the normal window for puberty to start in males and females?
Females= 8-14 Males= 9-15
What are the 2 phases of the menstrual cycle?
Follicular and luteal.
Follicular is from the start of menstruation to ovulation
Luteal is from the moment of ovulation to the start of menstruation
Which cells secrete oestrogen?
Granulosa cells in the follicles
When does ovulation occur?
14 days before the end of a menstrual cycle
Which hormone maintains the corpus luteum and where is it produced?
hCG
the placenta
What triggers the break down of the endometrium and menstruation to occur?
Fall in oestrogen and progesterone
A surge in which hormone triggers ovulation?
LH
What causes pre-eclampsia?
High vascular resistance in the spiral arteries which results in a sharp rise in maternal blood pressure
What are the effects of progesterone produced in pregnancy on the mum?
Relaxes the lower oesophageal sphincter, constipation, hypotension, headaches and skin flushing, body temp raises between 0.5 and 1 degree
What is the trend in HCG levels in pregnancy?
Double every 48-72 hours until they plateau around 8-12 weeks
What happens to maternal blood pressure in pregnancy?
Decreased BP in early and middle pregnancy, should return to normal by term
What happens to the maternal kidneys in pregnancy?
Physiological hydronephrosis due to dilatation of the ureters and collecting system
Increased GFR and excreted protein
Why is there anaemia in pregnancy?
There is increased RBC production due to increased folate, b12 and iron requirements. Plasma volume increases more than RBC production
Why are pregnant women more susceptible to VTE?
Clotting factors such as fibrinogen, factor VII, VIII and X increase in pregnancy
Why is ALP 4x higher than normal in pregnancy?
The placenta excretes ALP
What is the first stage of labour?
True contraction onset until 10cm cervical dilatation
What is the second stage of labour?
From 10cm cervical dilatation until delivery of the babay
What is the third stage of labour?
From delivery of the baby to delivery of the placenta
Which prostagladin has the key role in ripening the cervix?
Prostaglandin E2
What are the 3 phases of the 1st stage of labour and what do they involve?
Latent phase: From 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
Active phase: From 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
Transition phase: From 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.
What are the 3 types of breech presentation?
Complete breech (hips and knees are flexed) Frank breech (hips flexed, knees extended) Footling breech (one foot is hanging through the cervix
Where does -5 station of decent correlate to?
When the baby is high up, around the pelvic inlet
Where does 0 station of decent correlate to?
when the head is at the ischial spines
Where does +5 station of decent correlate to?
when the head is 5cm lower than the ischial spines
What does active management of the placenta involve?
IM oxytocin
Careful traction of the umbilical cord to guide the placenta out
How is primary amenorrhea defined?
No period by 13 years if there is no other evidence of pubertal development
OR
No period by 15 years where there are other signs of puberty
What is the first sign of puberty in females?
breast bud formation
What are the 2 categories of hypogonadism (lack of oestrogen and testosterone)
Hypogonadtrophic hypogonadism (lack of LH and FSH)
Hypergonadtrophic hypogonadism (lack of response to LH and FSH by the gonads)
Name some causes of hypogonadotrophic hypogonadism
Hypopituitarism
Significant or chronic conditions
Excessive exercise or dieting
Kallman syndrome
Name some causes of hypergonadotrophic hypogonadism
Previous damage to the gonads
Congenital absence of the ovaries
Turner’s syndrome
Which congenital cause of amenorrhoea is associated with anosmia?
Kallman’s syndrome
How does congenital adrenal hyperplasia present?
Tall for age Facial hair primary amenorrhoea Deep voice Early puberty
What are the investigations for primary amenorrhoea?
FBC (anaemia) U&Es (kidney disease) Anti TTG/ Anti EMA for coeliac disease FSH and LH TFT Insulin like GF to screen for GH deficiency Prolactin Genetic testing for tuners
Imaging (x ray of wrist for bone age, pelivic ultrasound, MRI brain)
How can hypogonadotrophic hypogonadism be managed?
Pulsatile GnRH to induce ovulation and menstruation or the pill if pregnancy is not wanted
How is secondary amenorrhoea defined?
No menstruation for more than 3 months after previous regular menstrual periods
What are the common causes for secondary amenorrhoea?
Pregnancy Menopause Hormonal contraception PCOS Asherman's syndrome Stress Pituitary tumours Hyperthyroidism
How can secondary amenorrhoea be assessed?
Detailed Hx and examination
Hormonal blood tests
Ultrasound of pelvis to diagnose PCOS
What can LH, FSH profiles tell you about the causes of amenorrhoea?
High FSH suggests primary ovarian failure
High LH:FSH suggests PCOS
How often should women with PCOS on the pill have a withdrawal bleed?
every 3-4 months to reduce the risk of endometrial hyperplasia and cancer
In which phase of the menstrual cycle does PMS occur?
Luteal
How can PMS be diagnosed?
Keep a symptom diary which should demonstrate a cyclical pattern. A definitive diagnosis can be made under the care of a specialist by administering a GnRH analouge to see if symptoms improve
How can PMS be managed?
Lifestyle changes
COCP
SSRI
CBT
Name some causes of heavy menstrual bleeding
Dysfunctional uterine bleeding Fibroids Endometriosis Contraceptives Anticoagulation Bleeding disorders Endometrial hyperplasia or cancer PCOS
Which investigations should be done in heavy menstrual bleeding
Pelvic examination Speculum Bimanual FBC Hysteroscopy/ ultrasound Swabs Coag screen
What is the management of heavy menstrual bleeding
Tranexamic acid
Mefenamic acid if associated pain
Mirena
COCP
Progesterones
Endometrial ablation
What are the 4 types of uterine fibroid?
Intramural
Subserosal (under the outer layer of the uterus, towards the abdominal cavity)
Submucosal
Pedunculated
How do fibroids usually present?
Heavy menstrual bleeding
What is the mangement of small fibroids (less than 3cm)?
Mirena coil
Symptomatic management
COCP
Cyclical oral progesterone
Surgical- endometrial ablation, resection, hysterectomy
What is the management of larger fibroids (greater than 3cm)?
Refer to gyane
NSAIDs and tranexamic acid
Mirena coil
COCP
Uterine artery embolisation
Myomectomy
Hysterectomy
GnRH agonists such as goserelin reduces the size of fibroids before surgery
What are the complications of fibroids?
Red degeneration of the fibroid Torsion Reduced fertility Pregnancy complications HMB
What is red degeneration and how does it present?
Ischaemia, infarction and necrosis of a fibroid due to disrupted blood supply
Presents with severe abdominal pain, low grade fever, tachycardia and vomiting
What are ‘chocolate cysts”?
Endometriomas in the ovaries
What is the presentation of endometriosis?
Cyclical abdominal or pelvic pain
Deep dyspareunia
Dysmenorrhoea
Infertility
What can be found on examination in endometriosis?
Endometrial tissue visible in the vagina on speculum examination (particularly in the posterior fornix)
A fixed cervix on bimanual examination
Tenderness in the vagina, cervix and adnexa
How is endometriosis diagnosed?
Laproscopic surgery is gold standard
What is the management of endometriosis?
Analgesia
Hormonal management- COCP, mirena, GnRH agonists
Surgical- laparoscopic surgery or hysterectomy
What is adenomyosis?
Endometrial tissue inside the myometrium
How does adenomyosis present?
Dysmenorrhoea
Menorrhagia
Dyspareunia
How is adenomyosis diagnosed?
TV ultrasound
MRI
Histological examination of uterus after hysterectomy is gold standard but usually not appropriate
How can adenomyosis be managed?
Tranexamic/ mefenamic acid
Mirena
GnRH analoges
Endometrial ablation
What is the average age of menopause?
51
How is the menopause diagnosed?
It is a retrospective diagnosis made after a woman has had no periods for 12 months
What is the sex hormone profile of someone who has gone through the menopause?
Oestrogen and progesterone levels are low
LH and FSH are high
Which conditions do the lower levels of oestrogen in menopause make you more susceptible to?
CVD and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
Which blood test is used to diagnose menopause/ peri-menopause?
FSH blood test (results >30mIU/mL)
What is the advice regarding contraception in women who are going through the menopause?
Use contraception for:
Two years after the last menstrual period in women under 50
One year after the last menstrual period in women over 50
Why is the depot injection unsuitable for women >45 years old?
Reduces bone density. Women around this age also have their bone density reduced by less oestrogen due to menopause.
How is premature ovarian insufficiency defined?
Menopause before the age of 40 years
what will a sex hormone profile show in premature ovarian insufficiency?
Raised LH and FSH
Low oestrogen
What are the causes for premature ovarian insufficiency?
Idiopathic Iatrogenic Autoimmune Genetic Infection
How does premature ovarian insufficiency present?
Irregular menstrual periods and symptoms of low oestrogen levels (hot flushes, night sweats, vaginal dryness)
What are the diagnostic criteria for primary ovarian insufficiency?
Younger than 40
Typical menopausal symptoms
Elevated FSH
What is the management of primary ovarian failure?
HRT
Why must progesterone be supplied in HRT alongside oestrogen?
Unopposed oestrogen causes endometrial hyperplasia and endometrial cancer.
Women without an uterus can have just oestrogen therapy
What is a non-hormonal alternative for vasomotor symptoms of menopause?
Clonidine (alpha-2 adrenergic receptor agonist)
What are the side effects of clonidine?
Dry mouth, headaches, dizziness and fatigue
What are the risks of HRT?
Increased risk of breast cancer
Increased risk of endometrial cancer
Increased risk of VTE
Increased risk of stroke and CVD
What are the different ways you can deliver oestrogen?
Patches
Orally
What are the different ways you can deliver progesterone?
Patch
Coil
Orally
How long does it take to feel the full effects of HRT?
3-6 months
When should you stop HRT/ oestrogen containing contraceptives in relation to surgery?
4 weeks before
What are the side effects of exogenous oestrogen?
Nausea and bloating Breast swelling Breast tenderness Headaches Leg cramps
What are the side effects of exogenous progesterone?
Mood swings Bloating Fluid retention Weight gain Acne and greasy skin
What are the diagnostic criteria for PCOS?
Oligoovulation or anovulation
Hyperandrogenism
Polycystic ovaries on ultrasound
(these are called the rotterdam criteria)
What is a dermatological sign of insulin resistance?
Acanthosis nigrans (thickened rough skin usually found in the axilla and on the elbows)
What do blood tests show in PCOS?
Raised LH Raised LH to FSH ratio Raised testosterone Raised insulin Normal oestrogen
What is the gold standard test for identifying polycystic ovaries? What does it show?
TV ultrasound, gives a string of pearl appearance
An ovarian volume of >10cm3 can indicate PCOS without the presence of cysts
What is the management of PCOS?
Weight loss
Smoking cessation
Mirena coil/ cyclical progesterones to protect against endometrial cancer
Why are people with PCOS at a higher risk of endometrial cancer?
Under normal circumstances, the corpus luteum releases progesterone after ovulation. Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. They continue to produce oestrogen and do not experience regular menstruation. Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation. This is similar to giving unopposed oestrogen in women on hormone replacement therapy. It results in endometrial hyperplasia and a significant risk of endometrial cancer.
How can infertility be managed in PCOS?
Weight loss
Clomifene
Laparoscopic ovarian drilling
IVF
Metformin
When are ovarian cysts concerning for malignancy?
In postmenopausal women
What are the symptoms associated with ovarian cysts?
Pelvic pain
Bloating
Fullness in the abdomen
A palpable pelvic mass
What is the tumour marker for ovarian cancer?
CA125
When does an ovarian cyst not need investigating?
In premenopausal women and the cyst is less than 5cm on ultrasound
What are the non-cancerous causes of a raised CA125?
Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy
Which tool is used to estimate the risk of an ovarian mass being malignant?
Risk of malignancy index (RMI)
What is the presentation of ovarian torsion?
Sudden onset severe unilateral pelvic pain
Associated nausea and vomiting
What are the initial and the gold standard investigations?
Pelvic ultrasound is the initial investigation.
laparoscopic surgery is the gold standard.
What is seen on pelvic ultrasound in ovarian torsion?
Whirlpool sign (free fluid in the pelvis and oedema of the ovary
What is the management of ovarian torsion?
Laparoscopic surgery to un-twist or remove the ovary
What is asherman’s syndrome?
Adhesions form within the uterus following damage to the uterus
What are the complications of asherman’s syndrome?
Menstruation abnormalities, infertility and recurrent miscarriages
What is the gold standard investigation for Asherman’s syndrome?
Hysteroscopy
What is the management of Asherman’s syndrome?
Dissecting the adhesions during hysteroscopy
What is a cervical ectropion?
When the columnar epithelium extends from the endocervix (inside the canal) to the ectocervix
What is the classic symptom of cervical ectropion?
Post-coital bleeding
Which populations are cervical ectropions more common in and why?
Younger women
COCP
Pregnancy
It is associated with higher oestrogen levels
What is the presentation of cervical ectropion?
Increased vaginal discharge, vaginal bleeding, dyspareunia, post-coital bleeding
How can cervical ectropion be diagnosed?
Speculum examination will reveal columnar epithelium spreading out of the os. There will be a well demarcated border between red and pink
What is the management of ectropion?
Ectropion should resolve as a patient gets older.
Problematic bleeding can be resolved with cauterisation using silver nitrate or cold coagulation
What are nabothian cysts?
Fluid filled cysts on the surface of the cervix
What is the presentation of pelvic organ prolapse?
A feeling of something coming down A dragging sensation Urinary symptoms Bowel symptoms Sexual dysfunction
Which sort of tool should be used to examine prolapse?
Sim’s speculum
How is uterine prolapse graded?
Pelvic organ prolapse quantification system (POP-Q)
Grade 0= normal
1= lowest part is >1cm above the introitus
2= the lowest part is within 1cm of the introitus
3= lowest part is more than 1cm below the vagina
4= full descent and eversion
What are the 3 management options for pelvic organ prolapse?
- conservative management
- vaginal pessary
- surgery
What does conservative management of prolapse include?
Physio Weight loss Lifestyle changes Treatment of symptoms (eg stress incontinenece) vaginal oestrogen cream
What causes urge incontinence?
overactivity of the detrusor muscle
How do you assess the severity of incontinence?
Ask about frequency of urination and incontinence
How many times do you change pads/ clothes
Night time urination
How can incontinence be investigated?
Bladder diary
Urine dipstick
Post-void residual bladder volume
Urodynamic testing
What is the management of stress incontinence?
Supervised pelvic floor exercises
surgery
Duloxetine
What is the management of urge incontinence?
Bladder retraining Anticholinergic medication Mirabegron (alternative to antocholinergics), surgery Botox
How does atrophic vaginitis present?
In post-menopausal women.
Symptoms of itching, dryness, dypareunia and bleeding
What is the management of atrophic vaginitis?
Vaginal lubricants
Topical oestrogen creams/ pessaries
How is a bartholin’s cyst managed?
Good hygiene, analgesia and warm compresses
Antibiotics
Word catheter or marsupialisation
How does lichen sclerosus present?
Chronic inflammatory condition which presents with patches of shiny “porcelain white” skin. Usually affects the labia, perineum and perianal skin
What is the management of lichen sclerosus?
Should be followed up every 3-6 months
Use potent topical steroids
What is the key complication of lichen sclerosus?
Squamous cell carcinoma of the vulva
What is type 1 FGM?
Removal of part or all of the clitoris
What is type 2 FGM?
Removal of part of or all of the labia minora and the labia majora
What is type 3 FGM?
infibulation
What is type 4 FGM?
All other unnecessary procedures to the female genitalia
What is the rule regarding reporting FGM?
It is mandatory to report all cases of FGM in patients under 18 to the police
Which structure in the fetus is the origin of the upper vagina, cervix and fallopian tubes?
The mullerian duct
Why do male foetuses not grow female reproductive organs?
They produce anti-mullerian hormone which leads to the regression of the mullerian duct
What is the inheritance pattern of androgen insensitivity syndrome?
It is X-linked
What is androgen insensitivity syndrome?
Cells are unable to respond to androgen hormones due to a lack of androgen receptors . Extra androgens are converted into oestrogen which results female secondary sexual characteristics despite being genetically XY
Which organs do people with androgen insensitivity syndrome have?
They have testes in the abdomen or inguinal canal. The female internal organs do not develop because the testes produce anti-mullerian hormone
How does androgen insensitivity syndrome present?
Inguinal hernias and primary amenorrhoea
What is the traditional management of androgen insensitivity syndrome?
Bilateral orchidectomy
Oestrogen therapy
vaginal dilators and surgery
Which type of cancer is the most common cervical cancer?
Squamous cell carcinoma
Which virus is cervical cancer most strongly associated with?
HPV types 16 and18
What are the symptoms of cervical cancer?
Abnormal vaginal bleeding
Vaginal discharge
Pelvic pain
Dyspareunia
What is the grading system for cervical dyplasia?
Cervical intraepithelial neoplasia (CIN)
CIN 1= mild, likely to return to normal without treatment
CIN 2= Moderate, likely to progress to cancer if left untreated
CIN3= severe, very likely to progress to cancer if untreated
How often should people be smear tested?
Every 3 years 25-49
Every 5 years 50-64
What action should be taken if a smear returns negative for HPV?
Continue routine smearing
What action should be taken if a smear returns inadequate?
Repeat in 3 months
What action should be taken if a smear returns HPV positive with normal cytology?
Repeat in 12 months
What action should be taken if a smear returns HPV positive with abnormal cytology?
Refer for colposcopy
Which staging system is used for cervical cancer?
FIGO (international federation of obstetrics and gynaecology)
What are the key risk factors for endometrial cancer?
Unopposed oestrogen
Obesity
Diabetes
How can endometrial hyperplasia be managed?
Progesterones
Either mirena or oral
Which type of biopsy is highly sensitive for endometrial cancer?
Pipelle
Which nerve may ovarian cancer press on causing hip or groin pain?
Obturator nerve
Which form of contraception should be avoided in wilsons disease?
The copper coil
What are the UKMEC 4 contraindications to the COCP?
Uncontrolled HTN
Migraine with aura
History of VTE
Aged over 35 and smoking more than 15 cigarettes a day
What are the rules regarding contraception and the menopause?
Contraception is required for 2 years in women under 50 and 1 year in women over 50 after the last period
How long does lactational ammenorrhea work as contraception? What are the caviats?
6 months
They must be fully breast feeding and ammenorrhoeic
Which forms of contraception are considered safe in breastfeeding?
Progesterone only pill and implant
COCP is MEC4 up until 6 weeks post partum
When, in the postpartum period, can the copper coil or IUS be inserted?
Either within 48 hours of birth or >4 weeks after
What is the mechanism of action for the COCP?
Prevents ovulation
Oestrogen and progesterone have a negative feedback on the hypothalamus and anterior pituitary. This supresses LH and FSJ
Which types of COCP are recommended by NICE and why?
Pills containing levonorgestrel or northisterone because they have a lower risk of VTE (microgynon or leostrin)
What are the rules if someone starts the COCP on the first day of their period?
Offers protection straight away, no additional contraception is required. This is the case up to the 5th day of the cycle
What are the rules if someone starts the COCP after the 5th day of the menstrual cycle?
Condom use for 7 days
What advice should you give someone who is changing COCPs?
Finish one pack, immediately start the new pack without the pill free period
What advice should you give someone who is switching from a POP to COCP?
Switch at anytime but 7 days of additional protection
What is the rule if someone has missed a pill but it is <72 hours since the last pill was taken?
Take missed pill as soon as possible, no extra protection required
What are the rules if someone has missed more than one pill(>72 hours since last pill)?
Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)
Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight
If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex
If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required
If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period.
How should a patient be counselled if they are vomiting and have diarrhoea?
A day of vomiting/ diarrhoea is classed as a missed pill
How long before a major operation should a COCP be stopped?
4 weeks
What are the contraindications to POP?
Active breast cancer
What are the 2 types of POP?
Traditional (norgeston)
Degesterol- only pill (cerzette)
what is the mechanism of action of a traditional POP?
Thickening the cervical mucus
Altering the endometrium
What is the mechanism of action of a desogestrel POP?
Inhibiting ovulation
What is the advice if someone starts POP on day 1 to 5 of the menstrual cycle?
They are protected immediately
What is the advice if someone starts POP after day 5 of the menstrual cycle?
additional contraception is required for 48 hours
When are POPs classed as missed?
if they are >3 hours late and a traditional POP
If they are >12 hours late for desogestrel POP
What is the proper name for the depot contraceptive?
Depot medroxyprogesterone acetate (DMPA)
How long is the interval between depot injections?
12-13 weeks
What is a contraindication to depot?
Active breast cancer
What are the key complications of the depot injection?
osteoporosis and weight gain
What is the mechanism of action for the depot injection?
Inhibits ovulation by inhibiting FSH secretion which prevents the development of follicles in the ovaries
What is the contraindication for the implant?
Active breast cancer
What is the mechanism of action of the implant?
Inhibits ovulation
Thickens cervical mucus
What are the rules regarding extra protection at different times of the menstrual cycle?
The IUS can be inserted up to day 7 without any need for additional contraception, if inserted after day 7 then 7 days of condoms baybey
How long after UPSI can levonorgesterol be taken?
within 72 hours
How long after UPSI can ullipristal be taken?
within 120 hours
How long after UPSI can the copper coil be inserted?
5 days
What are the contraindications for ullipristal?
breast feeding should be avoided for 1 week after taking ullipristal
Ullipristal should be avoided in paitients with severe astham
Which investigations should be done for female infertility?
Serum LH and FSH on day 2-5 of the cycle Serum progesterone on day 21 Anti-mullerian hormine TFTs Prolactin
Which drug can be given to stimulate ovulation?
Clomifene.
Stops negative feedback of oestrogen leading to a surge in gnrh
What is oligospermia?
Reduced number of sperm in the semen sample
What is cyrptozoospermia?
Very few sperm in a sample
Which investigations can be done for male infertility?
Hormonal analysis (LH, FSH. testosterone)
Genetic testing
Vasography
Testicular biopsy
What is ovarian hypersensitivity syndrome?
A complication of ovarian stimulation during IVF infertility treatment
Presents with oedema, ascites and hypovolaemia
What are the risk factors for an ectopic pregnancy?
Previous ectopic Pelvic inflammatory signals Previous surgery to the fallopian tubes IUDs Older age Smoking
When does an ectopic pregnancy usually present?
around 6-8 weeks gestation
How does an ectopic pregnancy present?
Missed period Constant lower abdominal pain Vaginal bleeding Lower abdominal tenderness Cervical motion tenderness (on bimanual examination) Shoulder tip pain (peritonitis)
What is pregnancy of unknown location?
When there is a positive pregnancy test but there is no evidence on ultrasound scan
What pattern should hGC follow in a normal pregnancy?
Should roughly double every 48hrs
What is the management of an ectopic pregnancy?
Refer to the early pregnancy assessment unit (EPAU)
3 options: expectant management (await natural termination) Medical management (methotrexate) Surgical management (salpingectomy)
Which patients with ectopic pregnancies will need surgical management?
Those with: Pain Adnexal mass >35mm Visible heartbeart HCG levels >5000
When is a miscarriage defined as early?
Before 12 weeks
When is a miscarriage defined as late?
Between 12 and 24 weeks
What is the term for when the fetus is no longer alive but no symptoms have occured?
Missed miscarriage
What is the term for vaginal bleeding with a closed cervix and the fetus is alive?
Threatened miscarriage
What is the term for vaginal bleeding with an open cervix?
Inevitable miscarriage
What is the term for when the retained products of conception remain in the uterus after the miscarriage?
Incomplete miscarriage
What is the term for when a full miscarriage has occurred and there are no products of conception left in the uterus?
Complete miscarriage
What is the term for when a gestational sac is present but contains no embryo?
Anembryonic pregnancy
What is the investigation of choice for diagnosing an ultrasound?
Transvaginal ultrasound
Which miscarriages can be managed with expectant management?
If <6weeks gestation
How are miscarriages medically managed?
Misoprostol (it is a prostaglandin analogue which softens the cervix and stimulates contractions)
What are the side effects of misprostolol?
Heavy bleeding
Pain
Vomiting
Diarrhoea
How is recurrent miscarriage defined?
3 or more consecutive miscarriages
How is the risk of miscarriage in patients with anti-phospholipid syndrome managed?
Low dose aspirin
LMWH
What are the investigations for recurrent miscarriage?
Test for antiphospholipid antibodies
Test for hereditary thrombophilias
Pelvic ultrasound
Genetic testing of products of conception
What are the legal requirements for an abortion?
Must be signed by 2 registered medical practioners
Must be carried out by a registered medical practitioner
Which 2 drugs are used for medical abortion?
Mifepristone (anti-progestogen)
Misoprostol (prostaglandin analogue) 1-2 days later
What should be given to rhesus negative women who are having TOP, or surgery for miscarriage/ectopic?
Anti-D prophylaxis
When should vomiting in pregnancy resolve by?
16-20 weeks
How is hyperemesis gravidarum diagnosed in pregnancy?
More than 5% weight loss
Dehydration
Electrolyte imbalance
How is hyperemesis gravidarum assessed?
Pregnancy unique quantification of emesis score
What is the management of hyperemesis?
- Prochlorperazine
- Cyclizine
- Ondansetron
- Metoclopramide
FLOOIDS
What is a complete molar pregnancy?
When two sperm cells fertilise an empty ovum. These sperm combine genetic material and the cell start to divide to form a tumour called a complete mole
What is a partial molar pregnancy?
A partial mole occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The cell divides and multiplies into a tumour called a partial mole.
How does a molar pregnancy present?
More severe morning sickness Vaginal bleeding Increased enlargement of the uterus Abnormally high hCG Thyrotoxicosis
What can be seen on an ultrasound of a pelvis with a molar pregnancy?
Snowstorrm apperance
What is the management of a molar pregnancy?
Evacuation of the uterus
Occasionally chemo if the mole has metastasised
When is the first trimester?
Start of pregnancy to 12 weeks
When is the second trimester?
13 weeks to 26 weeks
When is the third trimester?
27 weeks until birth
When should fetal movements begin?
20 weeks
When should a booking clinic appointment be?
Before 10 weeks
When should the dating scan be?
Between 10 and 13+6 weeks
When should an anomaly scan be?
Between 18 and 20+6
Which 2 vaccines are offered to all pregnant women and when in their pregnancy?
Whooping cough
Influenza
What are the features of fetal alcohol syndrome?
Microcephaly Thin upper lip Smooth, flat philtrum Learning disability Hearing and vision problems
What do the booking bloods screen for?
Blood group, antibodies, rhesus D status
FBC for anaemia
Screening for thalassaemia and sickle disease
When is the combined test for downs syndrome conducted and what does it involve?
Between 11 and 14 weeks gestation
Ultrasound for nuchal translucency
Maternal blood tests (beta HCG and pregnancy associated plasma protein A PAPPA)
What is offered when the risk of down’s is greater 1 in 150?
They are offered amniocentesis or chorionic villus sampling then karyotyping is undertaken
What impact does pregnancy have on the management of hypothyroidism?
Levothyroxine should be increased
Which medications for hypertension are safe to use in pregnancy?
Labetalol Calcium channel blockers (nifedipine) Alpha blockers (doxazosin)
Which anti-epileptic medications are safe to use in pregnancy?
Levetiracetam, lamotrigine, carbamazipine
What is the first line medication for rheumatoid arthritis in pregnancy?
Hydroxychloroquine
Why are NSAIDs avoided in pregnancy?
They can cause premature closure of the ductus arteriosus in the fetus and can delay labour
Why are ACE inhibitors and ARBs avoided in pregnancy?
oligohydramnios
Hypocalvaria
Why is lithium avoided in pregnancy?
Can cause Ebstein’s abnormality
What are the rules around women being offered the MMR vaccine?
Pregnant women should not receive the MMR vaccine because it is a live vaccine
How can it be checked if a woman has had chicken pox before?
IgG levels for VZV
If a women has not had chicken pox before but is exposed to it during pregnancy, how can this be managed?
IV varicella immunoglobulins
What treatment do women who are rhesus positive require?
No additional treatment
What treatment do women who are rhesus negative require?
IM anti-D (this attaches to and destroys D positive fetal cells in the maternal circulation and prevents sensitisation)
Which test can be undertaken to work out how much fetal blood has passed into maternal circulation during a sensitisation event?
The kleihauer test
How is low birth weight defined?
Less than 2500g
What are the 2 categories of causes for fetal growth restriction?
Placenta mediated growth restriction
Non-placenta mediated growth restriction
Placenta mediated is anything to do with mum, non placenta mediated is anything to do with the babies
What are the complications of fetal growth restriction?
Fetal death or stillbirth Birth asphyxia Neonatal hypothermia Neonatal hypoglycaemia CVD Type 2 diabetes Obesity Mood and behaviour problems
How is SGA monitored in women who are low risk?
Symphysis fundal height from 24 weeks. If this is below the 24th centile then they are booked for serial growth scans with uterine artery dopplers
Which investigations can be done to investigate the causes of SGA?
Blood pressure and urine dipstick for pre-eclampsia
Uterine artery doppler
Detailed fetal anatomy scan
Karyotyping for chromosomal abnormalities
Testing for infections
What is the major risk of macrosomia?
Shoulder dystocia
What are the investigations for a large for gestational age baby?
Ultrasound to exclude polyhydramnios
Oral glucose tolerance test
What are dizygotic twins?
non-identical twins (from 2 different zygotes)
How are dichorionic diamniotic twins seen on ultrasound?
There is a membrane between the twins with a lambda sign or twin peak sign
How are monochorionic diamniotic twins be identified on ultrasound?
There is a membrane between the twins with a t sign
How are monochorionic monoamniotic twins identified on ultrasound?
There is no membrane between the twins
What is twin to twin transfusion syndrome?
twin-twin transfusion syndrome is when the connection between the blood supplies of the fetuses. One fetus becomes the donor and is starved of blood as the other is the recipient so becomes fluid overloaded
When is planned birth offered in twins?
32 and 33 + 6 weeks for uncomplicated monochorionic monoamniotic twins
36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins
37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins
Before 35 + 6 weeks for triplets
What are the risks from UTI in pregnancy?
Low birth weight, pre-eclampsia, preterm delivery
How is UTI screened for in pregnancy?
Frequent urinary samples for asymptomatic bacteruria (which is advised against in all other populations except the pregnant)
When in pregnancy should nirtofurantoin be avoided?
In the third trimester
When in pregnancy should trimethoprim be avoided?
In the first trimester
When are pregnant ladies screened for anaemia?
In the booking clinic and at 28 weeks
Why is there a normal drop in haemoglobin levels in pregnancy?
The plasma volume increases leading to a reduction in haemoglobin concentration
What is the management of pregnant women with iron deficient anaemia?
Ferrous sulphate 200mg TDS
When should VTE prophylaxis be started for pregnant women?
From 28 weeks if there are 3 risk factors, from the 1st trimester if there are four or more risk factors At birth (of baby not the mum) if not
What should pregnant women be given as VTE prophylaxis?
LMWH
How should pregnant women who are suspected to have a DVT or PE be assessed?
Wells score D-dimers do not work in pregnant women.
Doppler ultrasounds should be done in women with suspected DVT
Women with suspected PE should have- CXR, ECG and CTPA or V/Q scan
What is pre-eclampsia?
Hypertension with end organ dysfunction.
What is the triad of symptoms in pre-eclampsia?
Hypertension
Proteinuria
Oedema
What is the difference between pregnancy induced HTN and chronic HTN?
Chronic is HTN which occurs before 20 weeks
Pregnancy induced is after 20 weeks without proteinuria
What is the difference between pregnancy induced HTN and pre-eclampsia?
Pre-eclampsia is HTN with end organ damage (proteinuria).
In pregnancy induced HTN there is no proteinuria
What is the difference between pre-eclampsia and eclampsia?
Eclampsia is pre-eclampsia with the spicy addition of seizures
What is the pathophysiology of pre-eclampsia?
The formation of lacuane in the placenta is inadequate, this leads to high vascular resistance in the spiral arteries and poor perfusion of the placenta
What are the high-risk risk factors of pre-eclampsia?
Pre-existing HTN Previous HTN in pregnancy Existing auto-immune conditions Diabetes CKD
When are women offered prophylaxis against pre-eclampsia? What is this?
If women have one high-risk RF or more than one moderate risk RF then they are offered aspirin
What are the symptoms of pre-eclampsia?
Headache Visual disturbances or blurriness N&V Epigastric pain (due to liver swelling) Oedema Reduced urine output Brisk reflexes
What are the diagnostic criteria for pre-eclampsia?
Systolic BP >140
Diastolic BP>90
With any of:
Proteinuria
Organ dysfunction
Placental dysfunction
Which blood test cane be used to rule out pre-eclampsia?
PIGF
Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels. In pre-eclampsia, the levels of PlGF are low. NICE recommends using PlGF between 20 and 35 weeks gestation to rule-out pre-eclampsia.
At what BP should pregnant women be admitted?
BP>160/110
What is the management of pre-eclampsia?
Labetolol is first-line as an antihypertensive
Nifedipine (modified-release) is commonly used second-line
Methyldopa is used third-line (needs to be stopped within two days of birth)
IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures
What is HELLP syndrome?
A combination of features which occur as a complication of pre-eclampsia and eclampsia
Haemolysis
Elevated Liver enzymes
Low Platelets
What are the risk factors for gestational diabetes?
Previous gestational diabetes
Previous macrosomic baby
BMI>30
Family history of diabetes
What is the screening test used in gestational diabetes?
OGTT
What are the OGTT glusose level cut offs for gestational diabetes?
Fasting >5.6
At 2 hours >7.8
Remember as 5 6 7 8
What is the management of gestational diabetes?
Fasting glucose of <7, trial diet and exercise before going onto metformin and insulin
Fasting glucose >7 go straight into metformin then insulin.
If fasting glucose is >6 but there is also macrosomia then start insulin (+/- metformin)
How should pregnant women with pre-existing diabetes be managed?
5mg folic acid before becoming pregnant
Women with existing type 1 and 2 diabetes should be managed with insulin and metformin. All other oral diabetic medicine should be stopped
Retinopathy screening should be performed shortly after booking
What are the 2 main complications of gestational diabetes?
Macrosomia and neonatal hypoglycaemia
Which complication is obstetric cholestasis associated with?
An increased risk of stillbirth
What is the presentation of obstetric cholestasis?
Itching, particularly in the palms of the hands and the soles of the feet Fatigue Dark urine Pale, greasy stools Jaundice
What investigations should be done for someone with suspected obstetric cholestasis? What are the results of these?
LFTs and bile acids
LFTs (ALT, AST and GGT) and bile acids will be raised
What is the primary management of obstetric cholestasis?
Ursodeoxycholic acid
Symptoms of itching can be managed with emollients and antihistamines
Weekly monitoring of LFTS and planned delivery at 37 weeks
What is the presentation of acute fatty liver of pregnancy?
General malaise and fatigue N&V Jaundice Abdominal pain Anorexia Ascites
What is the management of acute fatty liver of pregnancy?
It is an obstetric emergency so requires prompt admission and delivery of the baby
If there is acute liver failure then a transplant may be needed
What is polymorphic eruption of pregnancy and how is it managed?
An itchy rash which occurs in the 3rd trimester. It is associated with stretch mark and is characterised by uritcarial papules, wheals and plaques
The symptoms can be controlled with topical emollients and steroids
What is atopic eruption of pregnancy and what is the management?
It is a flare-up of eczema which occurs during pregnancy. It typically presents in the 1st and 2nd trimester of pregnancy.
There are 2 types: E-type which features eczematous skin and P-type which features intensely itchy papules on the abdomen, back and limbs
What is pemphigoid gestationis?
It is an autoimmune condition which occurs in pregnancy.
Pemphigoid gestationis usually occurs in the second or third trimester. The typical presentation is initially with an itchy red papular or blistering rash around the umbilicus, that then spreads to other parts of the body. Over several weeks, large fluid-filled blisters form.
How is a low-lying placenta defined?
A placenta within 20mm of the internal cervical os
How is placenta praevia defined?
When the placenta is over the internal cervical os
What are the 3 top causes of antepartum haemorrhage?
Placenta praevia, placental abruption and vasa praevia
what are the risk factors for placenta praevia?
Previous casaerean sections Previous placenta previa Older maternal age Maternal smoking Structural uterine abnormalities Assisted reproduction
What is the management of placenta praevia?
repeat TV scans at 32 and 36 weeks
Corticosteroids from 34 weeks until 35+6 in order to mature the lungs
Planned C-section between 36 and 37 weeks. If spontaneous labour occurs then an emergency C-section should be done
How can a haemorrhage be managed in labour?
Emergency C section Blood transfusions Intrauterine balloon tamponade Uterine artery occlusion Emergency hysterectomy
What is vasa praevia?
Fetal vessels are exposed, outside the protection of the umbilical cord or placenta
What are the 2 types of vasa praevia?
Type I- the fetal vessels are exposed as a velamentous umbilical cord
Type II- the fetal vessels are exposed as they travel to an accessory placental lobe
How can vasa praevia present?
It is usually asymptomatic so is diagnosed when seen on examination, by ultrasound or when very dark red bleeding occurs following rupture of membranes
What is the management of vasa praevia?
Corticosteroids given from 32 weeks
Elective c-section from 34-36 weeks
What is placental abruption?
When the placenta separates from the wall of the uterus during pregnancy
What are the risk factors for placental abruption?
Previous placental abruption Pre-eclampsia Trauma Cocaine Multiple pregnancy Smoking
What is the presentation of placental abruption?
Sudden onset severe abdominal pain which is continuous Vaginal bleeding Shock Abnormalities Woody abdomen
How is the severity of antepartum haemorrhage defined?
Spotting= spots of blood on underwear
Minor haemorrhage= less than 50ml blood loss
Major haemorrhage= 50-1000ml blood loss
Massive blood loss= more than 1000ml or signs of shock
what is a concealed abruption?
The cervical os remains closed so the blood is not revealed until delivery
How should a placental abruption be managed?
Manage shock (2x grey cannula, crossmatch 4 units of blood, close monitoring)
Ultrasound
Antenatal steroids
Kleihauer test to assess how much anti-d needs to be administered
Emergency C section and active management of the 3rd stage
What is placenta accreta?
The placenta implants deeper, through and past the endometrium
What are the 3 layers of the uterine wall?
Endometrium
Myometrium
Perimetrium
What are the 3 stages of placenta accreta?
Superficial placenta accreta- implants into the surface of the myometrium but not beyond
Placenta increta- the placenta attaches deeply into the myometrium
Placenta percreta- invades past the myometrium and perimetrium reaching other organs such as the bladder
How can placenta accreta be diagnosed?
Ultrasound
Diagnosed at birth when it is difficult to deliver the placenta and this causes significant post-partum haemorrhage
MRI scans can be used to assess the depth and width of the invasion
How is placenta accreta managed?
Complex uterine surgery
Delivery should be planned between 35 and 36 weeks
What are the 4 types of breech?
complete
Incomplete
Extended
Footling
How is breech mangaged?
Babies who are breech before 36 weeks usually turn spontaneously, if not then external cephalic version can be used at 37 weeks
If still breech, a C-section should be offered but mothers could still have. a vaginal delivery
If it is a twin pregnancy and the first baby is breech then a caesarean is required
How is ECV performed?
AT 36 weeks in nulliparous women, at 37 in parous women
Give SC terbutaline (tocolysis) to relax the uterus and turn the baby. There is a 50% success rate
Rhesus D negative women require anti-D prophylaxis
How is stillbirth defined?
The birth of a dead fetus after 24 weeks gestation
What are the 3 symptoms which should always be screened for to prevent stillbirth?
- reduced fetal movements
- abdominal pain
- PV bleeding
How is fetal death confirmed?
Ultrasound
How is stillbirth managed?
Induce labour with mifepristone or misoprostol and vaginal delivery.
What are the 3 major causes of cardiac arrest in pregnancy?
Obstetric haemorrhage
PE
Sepsis
How can aortocaval compression lead to cardiac arrest and how can you resolve this?
The mass of the uterus can press of the inferior vena cava and aorta, this reduces cardiac output and leads to hypotension and cardiac arrest. Move the patient into a left lateral position
When should a C section be performed in a woman who has had a cardiac arrest?
If there is no response after 4 minutes of CPR
CPR continues in more than 4 mins in a womna more than 20 weeks gestation.
This improves the survival of the mother but decreases the chances of the baby surviving.
What are the 3 stages of labour?
First stage- from the onset to 10cm cervical dilatation
Second stage- from 10cm to delivery of the baby
Third stage- from delivery of the baby until delivery of the placenta
What are the 3 stages of the 1st phase of labour?
Latent - from 0-3cm dilatation of the cervix
Active phase- from 3-7cm
Transition phase- from 7cm to 10cm
When is the first phase of labour established?
When there are regular, painful contractions and the cervix is dilated from 4cm onwards
When is a baby classed as premature?
If they are born before 37 weeks gestation
When is a baby classed as extreme preterm?
If they are born under 28 weeks
When is a baby classed as very preterm?
28-32 weeks
When is a baby classed as moderate to late preterm?
32-37 weeks
How can preterm labour be prevented?
Vaginal progesterone
Cervical cerclage
When is preterm prophylaxis offered to women?
When the cervical length is <25mm between 16 and 24 weeks gestation
How can rupture of membranes be diagnosed?
Speculum examination which reveals pooling of amniotic fluid in the vagina
How should PPROM be managed?
Prophylactic antibiotics to prevent the development of chorioamnionitis
How can preterm labour be diagnosed?
If less than 30 weeks, does not need investigating and can be treated as preterm labour.
If more than 30 weeks, do TV ultrasound and if cervical length is <15mm then offer management
How can preterm labour be delayed once it has already started?
Tocolysis- stop uterine contractions.
This can be done using nifedipine or atosiban
When should corticosteroids be given?
In women with suspected preterm labour of babies less than 36 weeks
When should magnesium sulphate be give?
IV during delivery and then 24 hours after delivery of preterm babies less than 34 weeks gestation
When is induction of labour offered?
Between 41 and 42 weeks gestation or if it is beneficial to start labour early
Which score can be used to determine whether to induce labour? What score predicts a successful induction of labour?
The bishop score
Score >8
How can labour be induced?
- Membrane sweep
- Vaginal prostagladin
- Cervical ripening balloon
- Artifical rupture of membranes with an oxytocin infusion
- Oral mifepristone
What can occur if there is uterine hyperstimulation?
Fetal compromise
Emergency C section
Uterine rupture
How can uterine hyperstimulation be managed?
Stopping oxytocin infusion
Tocolysis with terbutaline
What is a reassuring baseline rate on a CTG?
110-160
What is a reassuring variability on a CTG?
5-25
What are the 4 types of decelerations found on a CTG?
Early
Late
Variable
Prolonged
What causes early declarations on a CTG?
These are gradual dips and recoveries in fetal heartbeat in response to uterine contractions. The lowest point of the heart beat corresponds to the peak of the contraction. These are completely normal
What are late declarations?
These are gradual falls in heart rate that start after uterine contractions. There is a delay between contractions and changes in heart rate. This is called by hypoxia
What are variable declarations?
Decelerations which are unrelated to uterine contractions. These are worrying when more than 90 mins
What are prolonged deceleration?
Declarations which last between 2 and 10 mins with a drop of more than 15 mins from baseline. These are always abnormal
What are the 3 things you should look at on a CTG?
Baseline rate
Variability
Decelerations
What is the normal physiological response to fetal scalp stimualtion?
Acceration
What is the management of fetal bradycardia?
There is a “rule of 3’s” for fetal bradycardia when they are prolonged:
3 minutes – call for help
6 minutes – move to theatre
9 minutes – prepare for delivery
12 minutes – deliver the baby (by 15 minutes)
How should a CTG be interpreted?
DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG)
C – Contractions
BRa – Baseline Rate
V – Variability
A – Accelerations
D – Decelerations
O – Overall impression (given an overall impression of the CTG and clinical picture)
What can infusions of oxytocin be used for?
To induce labour
Progress labour
Improve the frequency and strength of uterine contractions
Prevent or treat post partum haemorrhage
What is atosiban and what can be it be used?
A oxytocin receptor antagonist.
Can be used as an alternative to nifedipine for tocolysis
What can ergometrine be used for?
It stimulates smooth muscle contraction. This is useful for the delivery of the placent. It can only be used after the delivery of the baby
What is syntometrine?
a combination of oxytocin and ergometrine
When is terbutaline used?
Used for tocolysis in uterine hyperstimulation
What are the 3 Ps which influence the progress in labour?
Power
Passenger
Passage
How is delay in the first stage of labour defined?
Less than 2cm of cervical dilatation in 4 hours
Slowing of progress in multiparous women
What is recorded on a partogram?
Cervical dilatation
Descent of the fetal head
How is delay in the second stage of labour defined?
If a pushing lasts over:
2 hours in nulliparous women
1 hour in multiparous women
What is longitudinal lie?
The fetus laid straight up and down
What is transverse lie?
The fetus is laid straight side to side
What is oblique lie?
The fetus is at an angle
What is complete breach?
Hips and knees are flexed (cannonball)
What is a Frank breach?
With hips flexed and knees extended, bottom first
What is a footling breach?
Foot hanging through the cervix (gross)
What does active management of the third stage of labour involve?
IM oxytocin and controlled cord traction
Which form of simple analgesia should be avoided in pregnancy?
NSAIDs
What are the anaesthetic options which can be put into an epidural?
Levobupivacaine or bupivacaine mixed with fentanyl
What is the most significant risk factor for cord prolapse?
When a fetus is in an abnormal lie after 37 weeks gestation
What is the management of cord prolapse?
Emergency c section
Position the patient on all fours to reduce the compression on the cord
What is shoulder dystocia?
The anterior shoulder becomes stuck behind the pubic symphysis of the pelvis
How is shoulder dystocia managed?
- Pull alarm, bleep anaesthetics and paeds
- Episiotomy
- McRoberts manoeuvre (hyperflexion of the hips, bringing knees to abdomen)
- Pressure to the anterior shoulder
- Wood’s screw manouevre (reach into the vagina with both hands. Push posterior shoulder back and anterior shoulder forwards)
What are the key complications of shoulder dystocia?
Fetal hypoxia
Brachial plexus injury, Erb’s palsy
Perineal tears
Postpartum haemorrhage
What should be administered after instrumental delivery to reduce the risk of maternal infection?
a single dose of co-amoxiclav
What is the key risk to baby in ventouse and forceps delivery?
Ventouse- cephalohaematoma
Forceps- facial nerve palsy
What is a first degree tear?
Injury is limited to the frenulum of the labia minor and superficial skin
What is a second degree tear?
Involves the perineal muscles
What is a third degree tear?
Involves the anal sphincter
What is a fourth degree tear?
Involves the rectal mucosa
Which women who have had tears can be offered an elective C section in subsequent pregnancies?
Women who are symptomatic after 3rd or 4th degree tears
How are postpartum haemorrhages defined?
> 500ml loss after a vaginal delivery
> 1000ml loss after a C-section
Minor= <1000ml blood loss Major= >1000ml blood loss
What are the causes of post-partum haemorrhage?
The 4 Ts= Tone Trauma Tissua Thrombin
How can a post partum haemorrhage be managed?
ABCDE
Fluid resus
Oxygen
Fresh frozen plasma
Stop bleeding:
Mechanical- rub uterus to stimulate contraction, catheterise
Medical- Oxytocin, tranexamic acid
Surgical- balloon tamponade, hysterectomy
What is a secondary postpartum haemorrhage?
When bleeding occurs from 24 hours to 12 weeks
What are the 2 key causes of sepsis in pregnancy?
Chorioamnionitis
UTI
What are the key signs of chorioamnionitis?
Abdominal pain
Uterine tenderness
Vaginal discharge
What is an amniotic fluid embolism?
Rare but severe condition where the amniotic fluid passes into the fetal blood. This is problematic because amniotic fluid contains fetal tissue which causes an immune response from the mother
How does an amniotic fluid embolism present?
Presents similarly to sepsis, PE or anaphylaxis
SOB, tachycardia, haemorrhage, confusion, seizures, cardiac arrest
How is an amniotic fluid embolism managed?
Supportive
Medical emergency- ABCDE
How does uterine rupture present?
Acutely unwell Abnormal CTG Hypotension, collapse Woody uterus Ceasing of uterine contractions
What are the 3 options for managing uterine inversion?
Johnson manoeuvre- push back in, give oxytocin
Hydrostatic methods- fill with water to inflate back into a normal position
Surgery
What is postpartum endometritis?
Inflammation of the endometrium which is usually caused by infection
How does postpartum endometritis present?
Foul smelling discharge Bleeding which gets heavier Lower abdominal or pelvic pain Fever Sepsis
How can postpartum endometritis be diagnosed?
Vaginal swabs
Urine cultures and sensitivities
What is the most significant risk factor for retained products of conception (RPOC)?
Placenta accreta
How does RPOC present?
Vaginal bleeding
Abnormal vaginal discharge
Lower abdominal or pelvic pain
Fever
What are the 2 main complications of evacuation of retained products of conception?
Endometritis
Asherman’s syndrome
What are the risks of iron infusion?
They carry a risk of allergic and anaphylactic reactions.
Contraindicated in active infections because iron worsens infection
What is the name for the screening tool for postnatal depression?
The Edinburgh postnatal depression scale
Which bacteria most commonly causes mastitis?
Staph aureus
What is the management of mastitis?
Conservative- continue breast feeding, express milk, heat packs
Flucloxaxillin
What is the management of nipple candida?
Topical miconaozle
What is the typical pattern of postpartum thryroiditis?
Thyrotoxicosis (usually in the first three months)
Hypothyroid (usually from 3 – 6 months)
Thyroid function gradually returns to normal (usually within one year)
What is the management of postpartum thyroiditis?
Treat thyrotoxicosis with propranolol
Treat hypothyroidism with levothyroxine
What is sheehan’s syndrome?
A rare complication of post-partum haemorrhage where the drop in circulating volume leads to avascular necrosis of the pituitary gland
Which hormones are affected by sheehan’s syndrome?
Anterior pituitary hormones TSH ACTH FSH LH GH prolactin
What is the presentation of sheehan’s syndrome?
Reduced lactation
Amennorhoea
Adrenal insufficiency
Hypothyroidism
What is the management of sheehan’s syndrome?
Replace missing hormones
oestrogen, progesterone, hydrocortisone, levothyroxine, growth hormone
