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Obs and Gynae Flashcards

1
Q

What is the action of GnRH?

A

stimulates the anterior pituitary to release LH and FSH

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2
Q

What is the action of LH and FSH?

A

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

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3
Q

What is the action of oestrogen?

A 
Stimulates: 
Breast development
Growth and development of female sex organs
Blood vessel development in the uterus
Development of the endometrium
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4
Q

Where and when is progesterone produced?

A

By the corpus luteum after ovulation. When pregnancy occurs, progesterone production is taken over by the placenta after 10 weeks

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5
Q

What is the action of progesterone?

A

Thicken and maintain the endometrium
Thicken cervical mucus
Increase body temperature

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6
Q

why do overweight children tend to enter puberty earlier?

A

Aromatase is an enzyme found in fat tissue which is also important in the creation or oestrogen

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7
Q

What staging system is used to stage puberty?

A

The tanner system

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8
Q

When is the normal window for puberty to start in males and females?

A 
Females= 8-14
Males= 9-15
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9
Q

What are the 2 phases of the menstrual cycle?

A

Follicular and luteal.

Follicular is from the start of menstruation to ovulation

Luteal is from the moment of ovulation to the start of menstruation

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10
Q

Which cells secrete oestrogen?

A

Granulosa cells in the follicles

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11
Q

When does ovulation occur?

A

14 days before the end of a menstrual cycle

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12
Q

Which hormone maintains the corpus luteum and where is it produced?

A

hCG

the placenta

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13
Q

What triggers the break down of the endometrium and menstruation to occur?

A

Fall in oestrogen and progesterone

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14
Q

A surge in which hormone triggers ovulation?

A

LH

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15
Q

What causes pre-eclampsia?

A

High vascular resistance in the spiral arteries which results in a sharp rise in maternal blood pressure

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16
Q

What are the effects of progesterone produced in pregnancy on the mum?

A

Relaxes the lower oesophageal sphincter, constipation, hypotension, headaches and skin flushing, body temp raises between 0.5 and 1 degree

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17
Q

What is the trend in HCG levels in pregnancy?

A

Double every 48-72 hours until they plateau around 8-12 weeks

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18
Q

What happens to maternal blood pressure in pregnancy?

A

Decreased BP in early and middle pregnancy, should return to normal by term

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19
Q

What happens to the maternal kidneys in pregnancy?

A

Physiological hydronephrosis due to dilatation of the ureters and collecting system

Increased GFR and excreted protein

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20
Q

Why is there anaemia in pregnancy?

A

There is increased RBC production due to increased folate, b12 and iron requirements. Plasma volume increases more than RBC production

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21
Q

Why are pregnant women more susceptible to VTE?

A

Clotting factors such as fibrinogen, factor VII, VIII and X increase in pregnancy

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22
Q

Why is ALP 4x higher than normal in pregnancy?

A

The placenta excretes ALP

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23
Q

What is the first stage of labour?

A

True contraction onset until 10cm cervical dilatation

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24
Q

What is the second stage of labour?

A

From 10cm cervical dilatation until delivery of the babay

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25
What is the third stage of labour?
From delivery of the baby to delivery of the placenta
26
Which prostagladin has the key role in ripening the cervix?
Prostaglandin E2
27
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.
28
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 ```
29
Where does -5 station of decent correlate to?
When the baby is high up, around the pelvic inlet
30
Where does 0 station of decent correlate to?
when the head is at the ischial spines
31
Where does +5 station of decent correlate to?
when the head is 5cm lower than the ischial spines
32
What does active management of the placenta involve?
IM oxytocin | Careful traction of the umbilical cord to guide the placenta out
33
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
34
What is the first sign of puberty in females?
breast bud formation
35
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)
36
Name some causes of hypogonadotrophic hypogonadism
Hypopituitarism Significant or chronic conditions Excessive exercise or dieting Kallman syndrome
37
Name some causes of hypergonadotrophic hypogonadism
Previous damage to the gonads Congenital absence of the ovaries Turner's syndrome
38
Which congenital cause of amenorrhoea is associated with anosmia?
Kallman's syndrome
39
How does congenital adrenal hyperplasia present?
``` Tall for age Facial hair primary amenorrhoea Deep voice Early puberty ```
40
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)
41
How can hypogonadotrophic hypogonadism be managed?
Pulsatile GnRH to induce ovulation and menstruation or the pill if pregnancy is not wanted
42
How is secondary amenorrhoea defined?
No menstruation for more than 3 months after previous regular menstrual periods
43
What are the common causes for secondary amenorrhoea?
``` Pregnancy Menopause Hormonal contraception PCOS Asherman's syndrome Stress Pituitary tumours Hyperthyroidism ```
44
How can secondary amenorrhoea be assessed?
Detailed Hx and examination Hormonal blood tests Ultrasound of pelvis to diagnose PCOS
45
What can LH, FSH profiles tell you about the causes of amenorrhoea?
High FSH suggests primary ovarian failure | High LH:FSH suggests PCOS
46
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
47
In which phase of the menstrual cycle does PMS occur?
Luteal
48
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
49
How can PMS be managed?
Lifestyle changes COCP SSRI CBT
50
Name some causes of heavy menstrual bleeding
``` Dysfunctional uterine bleeding Fibroids Endometriosis Contraceptives Anticoagulation Bleeding disorders Endometrial hyperplasia or cancer PCOS ```
51
Which investigations should be done in heavy menstrual bleeding
``` Pelvic examination Speculum Bimanual FBC Hysteroscopy/ ultrasound Swabs Coag screen ```
52
What is the management of heavy menstrual bleeding
Tranexamic acid Mefenamic acid if associated pain Mirena COCP Progesterones Endometrial ablation
53
What are the 4 types of uterine fibroid?
Intramural Subserosal (under the outer layer of the uterus, towards the abdominal cavity) Submucosal Pedunculated
54
How do fibroids usually present?
Heavy menstrual bleeding
55
What is the mangement of small fibroids (less than 3cm)?
Mirena coil Symptomatic management COCP Cyclical oral progesterone Surgical- endometrial ablation, resection, hysterectomy
56
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
57
What are the complications of fibroids?
``` Red degeneration of the fibroid Torsion Reduced fertility Pregnancy complications HMB ```
58
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
59
What are 'chocolate cysts"?
Endometriomas in the ovaries
60
What is the presentation of endometriosis?
Cyclical abdominal or pelvic pain Deep dyspareunia Dysmenorrhoea Infertility
61
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
62
How is endometriosis diagnosed?
Laproscopic surgery is gold standard
63
What is the management of endometriosis?
Analgesia Hormonal management- COCP, mirena, GnRH agonists Surgical- laparoscopic surgery or hysterectomy
64
What is adenomyosis?
Endometrial tissue inside the myometrium
65
How does adenomyosis present?
Dysmenorrhoea Menorrhagia Dyspareunia
66
How is adenomyosis diagnosed?
TV ultrasound MRI Histological examination of uterus after hysterectomy is gold standard but usually not appropriate
67
How can adenomyosis be managed?
Tranexamic/ mefenamic acid Mirena GnRH analoges Endometrial ablation
68
What is the average age of menopause?
51
69
How is the menopause diagnosed?
It is a retrospective diagnosis made after a woman has had no periods for 12 months
70
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
71
Which conditions do the lower levels of oestrogen in menopause make you more susceptible to?
CVD and stroke Osteoporosis Pelvic organ prolapse Urinary incontinence
72
Which blood test is used to diagnose menopause/ peri-menopause?
FSH blood test (results >30mIU/mL)
73
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
74
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.
75
How is premature ovarian insufficiency defined?
Menopause before the age of 40 years
76
what will a sex hormone profile show in premature ovarian insufficiency?
Raised LH and FSH | Low oestrogen
77
What are the causes for premature ovarian insufficiency?
``` Idiopathic Iatrogenic Autoimmune Genetic Infection ```
78
How does premature ovarian insufficiency present?
Irregular menstrual periods and symptoms of low oestrogen levels (hot flushes, night sweats, vaginal dryness)
79
What are the diagnostic criteria for primary ovarian insufficiency?
Younger than 40 Typical menopausal symptoms Elevated FSH
80
What is the management of primary ovarian failure?
HRT
81
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
82
What is a non-hormonal alternative for vasomotor symptoms of menopause?
Clonidine (alpha-2 adrenergic receptor agonist)
83
What are the side effects of clonidine?
Dry mouth, headaches, dizziness and fatigue
84
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
85
What are the different ways you can deliver oestrogen?
Patches | Orally
86
What are the different ways you can deliver progesterone?
Patch Coil Orally
87
How long does it take to feel the full effects of HRT?
3-6 months
88
When should you stop HRT/ oestrogen containing contraceptives in relation to surgery?
4 weeks before
89
What are the side effects of exogenous oestrogen?
``` Nausea and bloating Breast swelling Breast tenderness Headaches Leg cramps ```
90
What are the side effects of exogenous progesterone?
``` Mood swings Bloating Fluid retention Weight gain Acne and greasy skin ```
91
What are the diagnostic criteria for PCOS?
Oligoovulation or anovulation Hyperandrogenism Polycystic ovaries on ultrasound (these are called the rotterdam criteria)
92
What is a dermatological sign of insulin resistance?
Acanthosis nigrans (thickened rough skin usually found in the axilla and on the elbows)
93
What do blood tests show in PCOS?
``` Raised LH Raised LH to FSH ratio Raised testosterone Raised insulin Normal oestrogen ```
94
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
95
What is the management of PCOS?
Weight loss Smoking cessation Mirena coil/ cyclical progesterones to protect against endometrial cancer
96
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.
97
How can infertility be managed in PCOS?
Weight loss Clomifene Laparoscopic ovarian drilling IVF Metformin
98
When are ovarian cysts concerning for malignancy?
In postmenopausal women
99
What are the symptoms associated with ovarian cysts?
Pelvic pain Bloating Fullness in the abdomen A palpable pelvic mass
100
What is the tumour marker for ovarian cancer?
CA125
101
When does an ovarian cyst not need investigating?
In premenopausal women and the cyst is less than 5cm on ultrasound
102
What are the non-cancerous causes of a raised CA125?
``` Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy ```
103
Which tool is used to estimate the risk of an ovarian mass being malignant?
Risk of malignancy index (RMI)
104
What is the presentation of ovarian torsion?
Sudden onset severe unilateral pelvic pain | Associated nausea and vomiting
105
What are the initial and the gold standard investigations?
Pelvic ultrasound is the initial investigation. | laparoscopic surgery is the gold standard.
106
What is seen on pelvic ultrasound in ovarian torsion?
Whirlpool sign (free fluid in the pelvis and oedema of the ovary
107
What is the management of ovarian torsion?
Laparoscopic surgery to un-twist or remove the ovary
108
What is asherman's syndrome?
Adhesions form within the uterus following damage to the uterus
109
What are the complications of asherman's syndrome?
Menstruation abnormalities, infertility and recurrent miscarriages
110
What is the gold standard investigation for Asherman's syndrome?
Hysteroscopy
111
What is the management of Asherman's syndrome?
Dissecting the adhesions during hysteroscopy
112
What is a cervical ectropion?
When the columnar epithelium extends from the endocervix (inside the canal) to the ectocervix
113
What is the classic symptom of cervical ectropion?
Post-coital bleeding
114
Which populations are cervical ectropions more common in and why?
Younger women COCP Pregnancy It is associated with higher oestrogen levels
115
What is the presentation of cervical ectropion?
Increased vaginal discharge, vaginal bleeding, dyspareunia, post-coital bleeding
116
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
117
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
118
What are nabothian cysts?
Fluid filled cysts on the surface of the cervix
119
What is the presentation of pelvic organ prolapse?
``` A feeling of something coming down A dragging sensation Urinary symptoms Bowel symptoms Sexual dysfunction ```
120
Which sort of tool should be used to examine prolapse?
Sim's speculum
121
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
122
What are the 3 management options for pelvic organ prolapse?
1. conservative management 2. vaginal pessary 3. surgery
123
What does conservative management of prolapse include?
``` Physio Weight loss Lifestyle changes Treatment of symptoms (eg stress incontinenece) vaginal oestrogen cream ```
124
What causes urge incontinence?
overactivity of the detrusor muscle
125
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
126
How can incontinence be investigated?
Bladder diary Urine dipstick Post-void residual bladder volume Urodynamic testing
127
What is the management of stress incontinence?
Supervised pelvic floor exercises surgery Duloxetine
128
What is the management of urge incontinence?
``` Bladder retraining Anticholinergic medication Mirabegron (alternative to antocholinergics), surgery Botox ```
129
How does atrophic vaginitis present?
In post-menopausal women. | Symptoms of itching, dryness, dypareunia and bleeding
130
What is the management of atrophic vaginitis?
Vaginal lubricants | Topical oestrogen creams/ pessaries
131
How is a bartholin's cyst managed?
Good hygiene, analgesia and warm compresses Antibiotics Word catheter or marsupialisation
132
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
133
What is the management of lichen sclerosus?
Should be followed up every 3-6 months | Use potent topical steroids
134
What is the key complication of lichen sclerosus?
Squamous cell carcinoma of the vulva
135
What is type 1 FGM?
Removal of part or all of the clitoris
136
What is type 2 FGM?
Removal of part of or all of the labia minora and the labia majora
137
What is type 3 FGM?
infibulation
138
What is type 4 FGM?
All other unnecessary procedures to the female genitalia
139
What is the rule regarding reporting FGM?
It is mandatory to report all cases of FGM in patients under 18 to the police
140
Which structure in the fetus is the origin of the upper vagina, cervix and fallopian tubes?
The mullerian duct
141
Why do male foetuses not grow female reproductive organs?
They produce anti-mullerian hormone which leads to the regression of the mullerian duct
142
What is the inheritance pattern of androgen insensitivity syndrome?
It is X-linked
143
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
144
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
145
How does androgen insensitivity syndrome present?
Inguinal hernias and primary amenorrhoea
146
What is the traditional management of androgen insensitivity syndrome?
Bilateral orchidectomy Oestrogen therapy vaginal dilators and surgery
147
Which type of cancer is the most common cervical cancer?
Squamous cell carcinoma
148
Which virus is cervical cancer most strongly associated with?
HPV types 16 and18
149
What are the symptoms of cervical cancer?
Abnormal vaginal bleeding Vaginal discharge Pelvic pain Dyspareunia
150
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
151
How often should people be smear tested?
Every 3 years 25-49 | Every 5 years 50-64
152
What action should be taken if a smear returns negative for HPV?
Continue routine smearing
153
What action should be taken if a smear returns inadequate?
Repeat in 3 months
154
What action should be taken if a smear returns HPV positive with normal cytology?
Repeat in 12 months
155
What action should be taken if a smear returns HPV positive with abnormal cytology?
Refer for colposcopy
156
Which staging system is used for cervical cancer?
FIGO (international federation of obstetrics and gynaecology)
157
What are the key risk factors for endometrial cancer?
Unopposed oestrogen Obesity Diabetes
158
How can endometrial hyperplasia be managed?
Progesterones Either mirena or oral
159
Which type of biopsy is highly sensitive for endometrial cancer?
Pipelle
160
Which nerve may ovarian cancer press on causing hip or groin pain?
Obturator nerve
161
Which form of contraception should be avoided in wilsons disease?
The copper coil
162
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
163
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
164
How long does lactational ammenorrhea work as contraception? What are the caviats?
6 months | They must be fully breast feeding and ammenorrhoeic
165
Which forms of contraception are considered safe in breastfeeding?
Progesterone only pill and implant COCP is MEC4 up until 6 weeks post partum
166
When, in the postpartum period, can the copper coil or IUS be inserted?
Either within 48 hours of birth or >4 weeks after
167
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
168
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)
169
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
170
What are the rules if someone starts the COCP after the 5th day of the menstrual cycle?
Condom use for 7 days
171
What advice should you give someone who is changing COCPs?
Finish one pack, immediately start the new pack without the pill free period
172
What advice should you give someone who is switching from a POP to COCP?
Switch at anytime but 7 days of additional protection
173
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
174
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.
175
How should a patient be counselled if they are vomiting and have diarrhoea?
A day of vomiting/ diarrhoea is classed as a missed pill
176
How long before a major operation should a COCP be stopped?
4 weeks
177
What are the contraindications to POP?
Active breast cancer
178
What are the 2 types of POP?
Traditional (norgeston) | Degesterol- only pill (cerzette)
179
what is the mechanism of action of a traditional POP?
Thickening the cervical mucus | Altering the endometrium
180
What is the mechanism of action of a desogestrel POP?
Inhibiting ovulation
181
What is the advice if someone starts POP on day 1 to 5 of the menstrual cycle?
They are protected immediately
182
What is the advice if someone starts POP after day 5 of the menstrual cycle?
additional contraception is required for 48 hours
183
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
184
What is the proper name for the depot contraceptive?
Depot medroxyprogesterone acetate (DMPA)
185
How long is the interval between depot injections?
12-13 weeks
186
What is a contraindication to depot?
Active breast cancer
187
What are the key complications of the depot injection?
osteoporosis and weight gain
188
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
189
What is the contraindication for the implant?
Active breast cancer
190
What is the mechanism of action of the implant?
Inhibits ovulation | Thickens cervical mucus
191
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
192
How long after UPSI can levonorgesterol be taken?
within 72 hours
193
How long after UPSI can ullipristal be taken?
within 120 hours
194
How long after UPSI can the copper coil be inserted?
5 days
195
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
196
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 ```
197
Which drug can be given to stimulate ovulation?
Clomifene. Stops negative feedback of oestrogen leading to a surge in gnrh
198
What is oligospermia?
Reduced number of sperm in the semen sample
199
What is cyrptozoospermia?
Very few sperm in a sample
200
Which investigations can be done for male infertility?
Hormonal analysis (LH, FSH. testosterone) Genetic testing Vasography Testicular biopsy
201
What is ovarian hypersensitivity syndrome?
A complication of ovarian stimulation during IVF infertility treatment Presents with oedema, ascites and hypovolaemia
202
What are the risk factors for an ectopic pregnancy?
``` Previous ectopic Pelvic inflammatory signals Previous surgery to the fallopian tubes IUDs Older age Smoking ```
203
When does an ectopic pregnancy usually present?
around 6-8 weeks gestation
204
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) ```
205
What is pregnancy of unknown location?
When there is a positive pregnancy test but there is no evidence on ultrasound scan
206
What pattern should hGC follow in a normal pregnancy?
Should roughly double every 48hrs
207
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) ```
208
Which patients with ectopic pregnancies will need surgical management?
``` Those with: Pain Adnexal mass >35mm Visible heartbeart HCG levels >5000 ```
209
When is a miscarriage defined as early?
Before 12 weeks
210
When is a miscarriage defined as late?
Between 12 and 24 weeks
211
What is the term for when the fetus is no longer alive but no symptoms have occured?
Missed miscarriage
212
What is the term for vaginal bleeding with a closed cervix and the fetus is alive?
Threatened miscarriage
213
What is the term for vaginal bleeding with an open cervix?
Inevitable miscarriage
214
What is the term for when the retained products of conception remain in the uterus after the miscarriage?
Incomplete miscarriage
215
What is the term for when a full miscarriage has occurred and there are no products of conception left in the uterus?
Complete miscarriage
216
What is the term for when a gestational sac is present but contains no embryo?
Anembryonic pregnancy
217
What is the investigation of choice for diagnosing an ultrasound?
Transvaginal ultrasound
218
Which miscarriages can be managed with expectant management?
If <6weeks gestation
219
How are miscarriages medically managed?
Misoprostol (it is a prostaglandin analogue which softens the cervix and stimulates contractions)
220
What are the side effects of misprostolol?
Heavy bleeding Pain Vomiting Diarrhoea
221
How is recurrent miscarriage defined?
3 or more consecutive miscarriages
222
How is the risk of miscarriage in patients with anti-phospholipid syndrome managed?
Low dose aspirin | LMWH
223
What are the investigations for recurrent miscarriage?
Test for antiphospholipid antibodies Test for hereditary thrombophilias Pelvic ultrasound Genetic testing of products of conception
224
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
225
Which 2 drugs are used for medical abortion?
Mifepristone (anti-progestogen) | Misoprostol (prostaglandin analogue) 1-2 days later
226
What should be given to rhesus negative women who are having TOP, or surgery for miscarriage/ectopic?
Anti-D prophylaxis
227
When should vomiting in pregnancy resolve by?
16-20 weeks
228
How is hyperemesis gravidarum diagnosed in pregnancy?
More than 5% weight loss Dehydration Electrolyte imbalance
229
How is hyperemesis gravidarum assessed?
Pregnancy unique quantification of emesis score
230
What is the management of hyperemesis?
1. Prochlorperazine 2. Cyclizine 3. Ondansetron 4. Metoclopramide FLOOIDS
231
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
232
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.
233
How does a molar pregnancy present?
``` More severe morning sickness Vaginal bleeding Increased enlargement of the uterus Abnormally high hCG Thyrotoxicosis ```
234
What can be seen on an ultrasound of a pelvis with a molar pregnancy?
Snowstorrm apperance
235
What is the management of a molar pregnancy?
Evacuation of the uterus | Occasionally chemo if the mole has metastasised
236
When is the first trimester?
Start of pregnancy to 12 weeks
237
When is the second trimester?
13 weeks to 26 weeks
238
When is the third trimester?
27 weeks until birth
239
When should fetal movements begin?
20 weeks
240
When should a booking clinic appointment be?
Before 10 weeks
241
When should the dating scan be?
Between 10 and 13+6 weeks
242
When should an anomaly scan be?
Between 18 and 20+6
243
Which 2 vaccines are offered to all pregnant women and when in their pregnancy?
Whooping cough | Influenza
244
What are the features of fetal alcohol syndrome?
``` Microcephaly Thin upper lip Smooth, flat philtrum Learning disability Hearing and vision problems ```
245
What do the booking bloods screen for?
Blood group, antibodies, rhesus D status FBC for anaemia Screening for thalassaemia and sickle disease
246
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)
247
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
248
What impact does pregnancy have on the management of hypothyroidism?
Levothyroxine should be increased
249
Which medications for hypertension are safe to use in pregnancy?
``` Labetalol Calcium channel blockers (nifedipine) Alpha blockers (doxazosin) ```
250
Which anti-epileptic medications are safe to use in pregnancy?
Levetiracetam, lamotrigine, carbamazipine
251
What is the first line medication for rheumatoid arthritis in pregnancy?
Hydroxychloroquine
252
Why are NSAIDs avoided in pregnancy?
They can cause premature closure of the ductus arteriosus in the fetus and can delay labour
253
Why are ACE inhibitors and ARBs avoided in pregnancy?
oligohydramnios | Hypocalvaria
254
Why is lithium avoided in pregnancy?
Can cause Ebstein's abnormality
255
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
256
How can it be checked if a woman has had chicken pox before?
IgG levels for VZV
257
If a women has not had chicken pox before but is exposed to it during pregnancy, how can this be managed?
IV varicella immunoglobulins
258
What treatment do women who are rhesus positive require?
No additional treatment
259
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)
260
Which test can be undertaken to work out how much fetal blood has passed into maternal circulation during a sensitisation event?
The kleihauer test
261
How is low birth weight defined?
Less than 2500g
262
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
263
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 ```
264
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
265
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
266
What is the major risk of macrosomia?
Shoulder dystocia
267
What are the investigations for a large for gestational age baby?
Ultrasound to exclude polyhydramnios | Oral glucose tolerance test
268
What are dizygotic twins?
non-identical twins (from 2 different zygotes)
269
How are dichorionic diamniotic twins seen on ultrasound?
There is a membrane between the twins with a lambda sign or twin peak sign
270
How are monochorionic diamniotic twins be identified on ultrasound?
There is a membrane between the twins with a t sign
271
How are monochorionic monoamniotic twins identified on ultrasound?
There is no membrane between the twins
272
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
273
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
274
What are the risks from UTI in pregnancy?
Low birth weight, pre-eclampsia, preterm delivery
275
How is UTI screened for in pregnancy?
Frequent urinary samples for asymptomatic bacteruria (which is advised against in all other populations except the pregnant)
276
When in pregnancy should nirtofurantoin be avoided?
In the third trimester
277
When in pregnancy should trimethoprim be avoided?
In the first trimester
278
When are pregnant ladies screened for anaemia?
In the booking clinic and at 28 weeks
279
Why is there a normal drop in haemoglobin levels in pregnancy?
The plasma volume increases leading to a reduction in haemoglobin concentration
280
What is the management of pregnant women with iron deficient anaemia?
Ferrous sulphate 200mg TDS
281
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 ```
282
What should pregnant women be given as VTE prophylaxis?
LMWH
283
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
284
What is pre-eclampsia?
Hypertension with end organ dysfunction.
285
What is the triad of symptoms in pre-eclampsia?
Hypertension Proteinuria Oedema
286
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
287
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
288
What is the difference between pre-eclampsia and eclampsia?
Eclampsia is pre-eclampsia with the spicy addition of seizures
289
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
290
What are the high-risk risk factors of pre-eclampsia?
``` Pre-existing HTN Previous HTN in pregnancy Existing auto-immune conditions Diabetes CKD ```
291
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
292
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 ```
293
What are the diagnostic criteria for pre-eclampsia?
Systolic BP >140 Diastolic BP>90 With any of: Proteinuria Organ dysfunction Placental dysfunction
294
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.
295
At what BP should pregnant women be admitted?
BP>160/110
296
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
297
What is HELLP syndrome?
A combination of features which occur as a complication of pre-eclampsia and eclampsia Haemolysis Elevated Liver enzymes Low Platelets
298
What are the risk factors for gestational diabetes?
Previous gestational diabetes Previous macrosomic baby BMI>30 Family history of diabetes
299
What is the screening test used in gestational diabetes?
OGTT
300
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
301
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)
302
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
303
What are the 2 main complications of gestational diabetes?
Macrosomia and neonatal hypoglycaemia
304
Which complication is obstetric cholestasis associated with?
An increased risk of stillbirth
305
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 ```
306
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
307
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
308
What is the presentation of acute fatty liver of pregnancy?
``` General malaise and fatigue N&V Jaundice Abdominal pain Anorexia Ascites ```
309
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
310
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
311
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
312
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.
313
How is a low-lying placenta defined?
A placenta within 20mm of the internal cervical os
314
How is placenta praevia defined?
When the placenta is over the internal cervical os
315
What are the 3 top causes of antepartum haemorrhage?
Placenta praevia, placental abruption and vasa praevia
316
what are the risk factors for placenta praevia?
``` Previous casaerean sections Previous placenta previa Older maternal age Maternal smoking Structural uterine abnormalities Assisted reproduction ```
317
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
318
How can a haemorrhage be managed in labour?
``` Emergency C section Blood transfusions Intrauterine balloon tamponade Uterine artery occlusion Emergency hysterectomy ```
319
What is vasa praevia?
Fetal vessels are exposed, outside the protection of the umbilical cord or placenta
320
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
321
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
322
What is the management of vasa praevia?
Corticosteroids given from 32 weeks | Elective c-section from 34-36 weeks
323
What is placental abruption?
When the placenta separates from the wall of the uterus during pregnancy
324
What are the risk factors for placental abruption?
``` Previous placental abruption Pre-eclampsia Trauma Cocaine Multiple pregnancy Smoking ```
325
What is the presentation of placental abruption?
``` Sudden onset severe abdominal pain which is continuous Vaginal bleeding Shock Abnormalities Woody abdomen ```
326
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
327
what is a concealed abruption?
The cervical os remains closed so the blood is not revealed until delivery
328
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
329
What is placenta accreta?
The placenta implants deeper, through and past the endometrium
330
What are the 3 layers of the uterine wall?
Endometrium Myometrium Perimetrium
331
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
332
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
333
How is placenta accreta managed?
Complex uterine surgery | Delivery should be planned between 35 and 36 weeks
334
What are the 4 types of breech?
complete Incomplete Extended Footling
335
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
336
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
337
How is stillbirth defined?
The birth of a dead fetus after 24 weeks gestation
338
What are the 3 symptoms which should always be screened for to prevent stillbirth?
1. reduced fetal movements 2. abdominal pain 3. PV bleeding
339
How is fetal death confirmed?
Ultrasound
340
How is stillbirth managed?
Induce labour with mifepristone or misoprostol and vaginal delivery.
341
What are the 3 major causes of cardiac arrest in pregnancy?
Obstetric haemorrhage PE Sepsis
342
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
343
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.
344
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
345
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
346
When is the first phase of labour established?
When there are regular, painful contractions and the cervix is dilated from 4cm onwards
347
When is a baby classed as premature?
If they are born before 37 weeks gestation
348
When is a baby classed as extreme preterm?
If they are born under 28 weeks
349
When is a baby classed as very preterm?
28-32 weeks
350
When is a baby classed as moderate to late preterm?
32-37 weeks
351
How can preterm labour be prevented?
Vaginal progesterone | Cervical cerclage
352
When is preterm prophylaxis offered to women?
When the cervical length is <25mm between 16 and 24 weeks gestation
353
How can rupture of membranes be diagnosed?
Speculum examination which reveals pooling of amniotic fluid in the vagina
354
How should PPROM be managed?
Prophylactic antibiotics to prevent the development of chorioamnionitis
355
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
356
How can preterm labour be delayed once it has already started?
Tocolysis- stop uterine contractions. This can be done using nifedipine or atosiban
357
When should corticosteroids be given?
In women with suspected preterm labour of babies less than 36 weeks
358
When should magnesium sulphate be give?
IV during delivery and then 24 hours after delivery of preterm babies less than 34 weeks gestation
359
When is induction of labour offered?
Between 41 and 42 weeks gestation or if it is beneficial to start labour early
360
Which score can be used to determine whether to induce labour? What score predicts a successful induction of labour?
The bishop score Score >8
361
How can labour be induced?
1. Membrane sweep 2. Vaginal prostagladin 3. Cervical ripening balloon 4. Artifical rupture of membranes with an oxytocin infusion 5. Oral mifepristone
362
What can occur if there is uterine hyperstimulation?
Fetal compromise Emergency C section Uterine rupture
363
How can uterine hyperstimulation be managed?
Stopping oxytocin infusion | Tocolysis with terbutaline
364
What is a reassuring baseline rate on a CTG?
110-160
365
What is a reassuring variability on a CTG?
5-25
366
What are the 4 types of decelerations found on a CTG?
Early Late Variable Prolonged
367
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
368
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
369
What are variable declarations?
Decelerations which are unrelated to uterine contractions. These are worrying when more than 90 mins
370
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
371
What are the 3 things you should look at on a CTG?
Baseline rate Variability Decelerations
372
What is the normal physiological response to fetal scalp stimualtion?
Acceration
373
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)
374
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)
375
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
376
What is atosiban and what can be it be used?
A oxytocin receptor antagonist. | Can be used as an alternative to nifedipine for tocolysis
377
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
378
What is syntometrine?
a combination of oxytocin and ergometrine
379
When is terbutaline used?
Used for tocolysis in uterine hyperstimulation
380
What are the 3 Ps which influence the progress in labour?
Power Passenger Passage
381
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
382
What is recorded on a partogram?
Cervical dilatation | Descent of the fetal head
383
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
384
What is longitudinal lie?
The fetus laid straight up and down
385
What is transverse lie?
The fetus is laid straight side to side
386
What is oblique lie?
The fetus is at an angle
387
What is complete breach?
Hips and knees are flexed (cannonball)
388
What is a Frank breach?
With hips flexed and knees extended, bottom first
389
What is a footling breach?
Foot hanging through the cervix (gross)
390
What does active management of the third stage of labour involve?
IM oxytocin and controlled cord traction
391
Which form of simple analgesia should be avoided in pregnancy?
NSAIDs
392
What are the anaesthetic options which can be put into an epidural?
Levobupivacaine or bupivacaine mixed with fentanyl
393
What is the most significant risk factor for cord prolapse?
When a fetus is in an abnormal lie after 37 weeks gestation
394
What is the management of cord prolapse?
Emergency c section | Position the patient on all fours to reduce the compression on the cord
395
What is shoulder dystocia?
The anterior shoulder becomes stuck behind the pubic symphysis of the pelvis
396
How is shoulder dystocia managed?
1. Pull alarm, bleep anaesthetics and paeds 2. Episiotomy 3. McRoberts manoeuvre (hyperflexion of the hips, bringing knees to abdomen) 4. Pressure to the anterior shoulder 5. Wood's screw manouevre (reach into the vagina with both hands. Push posterior shoulder back and anterior shoulder forwards)
397
What are the key complications of shoulder dystocia?
Fetal hypoxia Brachial plexus injury, Erb's palsy Perineal tears Postpartum haemorrhage
398
What should be administered after instrumental delivery to reduce the risk of maternal infection?
a single dose of co-amoxiclav
399
What is the key risk to baby in ventouse and forceps delivery?
Ventouse- cephalohaematoma | Forceps- facial nerve palsy
400
What is a first degree tear?
Injury is limited to the frenulum of the labia minor and superficial skin
401
What is a second degree tear?
Involves the perineal muscles
402
What is a third degree tear?
Involves the anal sphincter
403
What is a fourth degree tear?
Involves the rectal mucosa
404
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
405
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 ```
406
What are the causes of post-partum haemorrhage?
``` The 4 Ts= Tone Trauma Tissua Thrombin ```
407
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
408
What is a secondary postpartum haemorrhage?
When bleeding occurs from 24 hours to 12 weeks
409
What are the 2 key causes of sepsis in pregnancy?
Chorioamnionitis | UTI
410
What are the key signs of chorioamnionitis?
Abdominal pain Uterine tenderness Vaginal discharge
411
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
412
How does an amniotic fluid embolism present?
Presents similarly to sepsis, PE or anaphylaxis SOB, tachycardia, haemorrhage, confusion, seizures, cardiac arrest
413
How is an amniotic fluid embolism managed?
Supportive | Medical emergency- ABCDE
414
How does uterine rupture present?
``` Acutely unwell Abnormal CTG Hypotension, collapse Woody uterus Ceasing of uterine contractions ```
415
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
416
What is postpartum endometritis?
Inflammation of the endometrium which is usually caused by infection
417
How does postpartum endometritis present?
``` Foul smelling discharge Bleeding which gets heavier Lower abdominal or pelvic pain Fever Sepsis ```
418
How can postpartum endometritis be diagnosed?
Vaginal swabs | Urine cultures and sensitivities
419
What is the most significant risk factor for retained products of conception (RPOC)?
Placenta accreta
420
How does RPOC present?
Vaginal bleeding Abnormal vaginal discharge Lower abdominal or pelvic pain Fever
421
What are the 2 main complications of evacuation of retained products of conception?
Endometritis | Asherman's syndrome
422
What are the risks of iron infusion?
They carry a risk of allergic and anaphylactic reactions. | Contraindicated in active infections because iron worsens infection
423
What is the name for the screening tool for postnatal depression?
The Edinburgh postnatal depression scale
424
Which bacteria most commonly causes mastitis?
Staph aureus
425
What is the management of mastitis?
Conservative- continue breast feeding, express milk, heat packs Flucloxaxillin
426
What is the management of nipple candida?
Topical miconaozle
427
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)
428
What is the management of postpartum thyroiditis?
Treat thyrotoxicosis with propranolol | Treat hypothyroidism with levothyroxine
429
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
430
Which hormones are affected by sheehan's syndrome?
``` Anterior pituitary hormones TSH ACTH FSH LH GH prolactin ```
431
What is the presentation of sheehan's syndrome?
Reduced lactation Amennorhoea Adrenal insufficiency Hypothyroidism
432
What is the management of sheehan's syndrome?
Replace missing hormones oestrogen, progesterone, hydrocortisone, levothyroxine, growth hormone

Alice's finals cards (21 decks)

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