Obs and Gynae Flashcards
Hyperemesis Gravidarum is most pronounced in the ____ trimester (____ weeks). It can be distinguished from normal/physiological vomiting during pregnancy by 3 specific criteria:
____
____
____
1st trimester
0-13 weeks
>5% weight loss pre-pregancy
Clinical dehydration
Electrolyte Imbalance
Hyperemesis Gravidarum can lead to complications including:
Severe Dehydration
Anaemia
Malnutrition
Depression
Venous Thromboembolsim
Electrolyte imbalance (e.g hyponatraemia or wernicke’s encephalopathy)
Mallory-Weiss tear
Management of Hyperemesis Gravidarum includes:
1st line: Cyclizine / Promethazine / Prochlorperazine (dopamine antagonists)
2nd line: Metaclopramide (dopamine and 5HT antagonist)
3rd line: Odansetron (to be given with caution as can cause cleft palate if given in first trimester)- 5HT antagonist.
*can also giver ginger supplements and acupuncture to help vomiting*
If patients are severely dehydrated, have ketonuria (+3) and/or severe electrolyte imbalance – Admit to hospital.
Always consider psychological effects Hypermesis Gravidarum (i.e vomiting 10 times daily) could have on patient.
Misscarriage: Spontaneous death of foetus in utero before ____ gestation.
5 Types:
24 weeks - abdo pain and bleeding
OS open: I+I
Inevitable - Open cervical OS. Likely to dispel pregnancy without medical intervention. POC not seen.
Incomplete - Same as above but POC can be seen in vaginal canal
OS closed: TMC
Threatened - Abdo pain and vaginal bleeding but gestational sac and foetal heartbeat seen on TV ultrasound.
Missed - Patients didnt realise they were pregnant and present with Abdo pain and vaginal bleeding. The uterus still contains foetal tissue, but the foetus is no longer alive (i.e no foetal heartbeat on TV ultrasound). Cervical os closed.
Complete - Abdo pain and vaginal bleeding but the patient has passed foetal tissue. Cervical os is closed and no heartbeat or sac on TV ultrasound. No POC visible.
Septic - Abdo pain and vaginal bleeding but also gestational sac becomes infected. Patients likely to show systemic signs of sepsis.
Screening for down syndrome is done at weeks ___ and uses an algorithm that includes 4 main components. Name them.
10-14
Nuchal Translucency (> 6mm indicates possible down syndrome)
B-HCG (Very High in DS)
PAPP-A (low)
Maternal age
If patients miss their original Down Syndrome screening (i.e combined test 10-13 weeks), they can do another test (quad test) from ____ weeks which includes 3/4 components. Name them.
______ (up to 15 weeks only) and ______ (16+ weeks) are two tests that can be offered to confirm diagnosis if tests above indicate a high risk of DS.
14-20 Weeks
B-HCG -very high
Unconjugated Oestriol - low
Alpha FetoProtein (AFP) - low
+/- Inhibin A - low
NIPT - Non Invasive Prenatal Testing is now also an option and more accurate than the quad and combined test. But suspicion of trisomy 21 needs to be high to qualify for this test.
Chorionic Villous Sampling (up to 15 weeks only)
Amniocentesis (16+ weeks)
*both carry risk of misscarriage* (CVS higher risk)
Gestational Hypertension
Defined as blood pressure **_____** with no concomitant ____ after 20 weeks’ gestation in a woman with no PMH of hypertension.
Remember a blood pressure > _____ requires treatment, whilst a blood pressure >____ requires admission to hospital.
Management:
1st line:
2nd line:
>140/90 mmHg
Proteinuria
>150/100 mmHg
> 160/110 mmHg
Labetalol (b-blocker and thus contrindicated in asthma)
Nifedipine (ca channel blocker)
Gold standard investigation for Endometriosis:
Diagnostic Laporoscopy
3 types of emergency contraception:
Levonorgestrel (Progestogen) - must be taken no later than 72 hours post sexual intercourse.
EllaOne (Ulipristal acetate) - Preferred in patients with a high BMI. Must be within 5 days.
*both these oral forms work by inhibiting ovulation* - (if ovulation has already occured then they are not effective)
Gold standard is actually Copper IUD - spermicidal and causes endometritis. Must be within 5 days. *Only method that works after ovulation*. NB - not to be used if patient is pregnant Urine B-HCG.
Downsides - Permanent and invasive
______ hormone: Produced by granulosa cells of ovary. Good marker of ovarian reserve
Anti-Mullerian
Menopause < 40 yo can be investigated by checking which hormone?
FSH
*oestrogen low and so FSH not inhibited at pituitary*
Syphilis
STI caused by _______ bacteria
Primary syphilis – Painless ulcer (_____) and regional lymphadenopathy (inguinal)
Secondary syphillis - _____ involvement and _____ (attached)
Tertiary syphilis – Neurosyphilis, Cardiovascular , _____ syphilis (_____ lesions with centre of necrotic tissue)
*also important to note that syphillis has an older demographic to Chlamydia/Gonorrhoea, primarily affecting men between the ages of ____ , much like mycoplasma genitalium.
Treponema Pallidum
Chancre
Multisystem
Condylomata
Gummatous / Granulomatous
25-40
Classically, syphilitic aneurysms occur in 90% of cases on the thoracic aorta, and in 10% in the abdominal aorta
Post- menopausal bleeding is often benign (ex. _____ ) however a significant proportion of cases can be endometrial cancer and so further investigation with _____ is necessary
If TV ultrasound shows endometrial thickness > ____ then a ___ is needed to determine whether thickness is due to endometrial hyperplasia or endometrial cancer
Biopsy with no ____ indicates hyperplasia with a very low risk of associated cancer and so patient can be treated with ____ (ex. Oral or IUD ______ ) to reduce endometrial thickness. Patient should be reviewed in ____ with TV ultrasound and further biopsy.
Biopsy with ____ suggests high risk of progressing to endometrial cancer and 1st line management in post- menopausal women is a ____ . Endometrial ___ is also an option.
However, in younger reproductive females who would like to preserve fertility (ex. ____ patient more likely to get endometrial cancer), conservative management with ____ can be considered with patient reviewed (i.e TV ultrasound and biopsy every ____ )
Atrophic vaginitis
Transvaginal ultrasound
>4mm
biopsy
atypia
progestogens
levonorgestrel
6 months
Atypia
Total hysterectomy
Ablation
PCOS
Progestogens
3 months
_____ , _____ and _____ can all increase the risk of endometrial cancer as they provide unopposed levels of oestrogen stimulation to the endometrium.
COOP
Obesity
Type 2 Diabetes Mellitus
Itching of the hands and soles of feet (particularly) at night with no rash is a common presentation of obstetric cholestasis (i.e blocking of the biliary tree). This leads to high levels of circulating ____ which causes itching to the skin.
If rash is present it suggests a ______.
Due to obstruction in the biliary tree, there is also a higher level of circulating bilirubin and this leads to____ , _____ and ____.
Low levels of bile salts in the intestine also reduces the ability of the intestine to absorb ____ soluble vitamins such as ____ , and thus may lead to a _____ - Dangerous in the event of a bleed.
Bile salts
Polymorphic eruption of pregnancy - no blisters / pemphigoid gestationis - blisters (autoimmune skin eruption - more common in people with graves etc.)
Jaundice, pale stools, and dark urine
Fat soluble
Vitamin K
Coagulopathy (High INR/high PT)
- Obstetric cholestasis is associated with an increased risk of ____, ____, and _____.
Pre-mature birth, **stillbirth** and meconium passage.
In obstetric cholestasis remember that patients will have deranged ____ and increased levels of circulating bile salts on blood investigation.
**Remember** it is normal for ___ to rise in pregnancy as the ____ produces it. Thus an isolated rise in ___ is normal in pregnancy and not indicative of pathology
LFTs
ALP
Placenta
ALP
Management in obstetric cholestasis includes:
_____ improves LFTs, bile salts and symptoms.
_____ and _____ can also provide symptomatic relief.
Condition resolves after _____.
Ursodeoxycholic acid
Emollients and anti-histamines
Delivery
Pelvic Inflammatory disease can lead to____, ___ and ____ and so should be treated immediately.
Subfertility, ectopic pregnancy and chronic pelvic pain
Treatment of Pelvic Inflammatory Disease in the non septic patient is with oral _______ therapy.
Triple antibiotic therapy (Ceftriaxone / Doxycycline and Metronidazole) and review within 3 days.
Treatment of PID in the septic patient needs IV antibiotic therapy.
An important differential in PID to consider is a ____ . This is a late complication of PID and is life threatening condition if ruptures as can cause sepsis. _____ used to rule this out.
**Tubo-ovarian abcess **
TV Ultrasound
Patients who have previously suffered from gestational diabetes during pregnancy should have a ______ as soon as possible after ____ booking visit. If glucose tolerance is ok at this point, they should be retested at 24 weeks.
Patients that have an increased preponderance to develop GD (____, _____, _____) and ethnicities such as should also have a _____ at ____ weeks.
Patients with pre-existing Type 1 and 2 DM should have their Hba1c tested at booking visit. Check _____ and fundoscopy for retinopathy as in general, Insulin resistance is ____ during pregnancy.
2hr Oral Glucose Tolerance Test (OGTT)
9/10 week
2hr OGTT
(Obesity, Macrosomic baby, Familial history of GDM)
Afro-Caribbeans, South Asians, and middle easterns
24 weeks
Renal function
Increased
Stress incontinence risk factors:
Age
Obesity
Multiparity
Traumatic delivery
Gynae surgery
Treatment for stress incontinence:
1st line: Pelvic floor exercises (3-month with physiotherapist)
2nd line: Duloxetine (SNRI)
3rd line: Surgery
All TORCH congenital infections can present with non-specific symptoms such as:
Petechiae and purpura
Hepatosplenomegaly
Jaundice
Seizures
Small for gestational age (SGA)
Haemolytic anaemia
Toxiplasmosis Gondii causes a classic triad of symptoms:
It also presents with a ____ rash.
- Intracranial calcifications (diffuse as opposed to CMV which are paraventricular)
- Hydrocephalus (vs. microcephalus in CMV)
- Chorioretinitis (also in CMV)
Blueberry muffin
Toxiplasmosis gondii is a ____ that can be picked up from ___, ____, _____, and _____ .
Usually the mother is asymptomatic, and the earlier the infection in pregnancy the lower the risk of transmission to the foetus. Highest transmission is in the ____ trimester.
Increases risk of _____, _____, and _____ .
Parasite
Raw vegetables, Uncooked meats, Unpasteurised goat’s milk, and Cat faeces.
3rd Trimester.
Misscarriage, stillbirth and preterm.
In toxiplasmosis gondii, only ___ % are symptomatic at birth. Patients can go on to develop ___, ___, ___, and ___.
25%
Developmental delay
Epilepsy
Blindness
Deafness
Bacteria Listeria Monocytogenes can be passed from mother to foetus via ingestion of _____.
Defining characteristics include:
**soft cheese**
Spontaneous abortion
Pustular lesions
Neonatal meningitis
Sepsis
Rubella (aka german measles) is Viral infection caused by the rubella virus that occurs in unvaccinated mothers who present with ___, ____ and ___.
Unvaccinated
Non-specific rash
Fever
Lymphadenopathy
Rubella infection in the mother is most dangerous in the first ___ weeks, as beyond this point it is unlikely to be transmitted to the foetus.
16 weeks (90% of infections are transmitted to foetus in the 8-10 weeks of pregnancy)
The classic triad of rubella infection in the newborn is:
Cardiac abnormalities (ex. PDA - continuous “machine like” murmur)
Cataracts
Deafness
Cytomegalovirus (CMV) :
- Only ___ symptomatic at birth, causes long-term complications such as:
10%
- Intrauterine growth restriction (like rubella)
- Chorioretinitis (like toxiplasmosis)
- Periventricular calcifications
- Microcephaly
- Sensorineural deafness (like rubella)
**Remember C for Cephalus/Chorioretinitis/Calcifications M for Micro and V for periVentricular calcifications.**
The average age of the natural menopause is ____ years, but can occur much earlier or later. Menopause occurring before the age of 45 is called ______ and before the age of 40 is ____ .
51
Early menopause
Premature menopause
*Generally, women having an early or premature menopause are advised to take HRT until approximately the average age of the menopause, for both symptom control and bone protective effect*
Risks associated with HRT (X6):
Endometrial Cancer (reduced by giving progestogen)
VTE (not with patch)
CVD/Stroke (only if started in women >60/ stroke not increased w/ patch)
Breast Cancer (risk goes up slightly - no increase in mortality - because patients have hormone receptors and thus wide range of therapies available)
Very small increased risk of ovarian cancer after 5yrs of therapy and >50yrs old. (1 more per 1000)
Gallbladder disease (increased in all HRT)
_____ phase is always 14 days long in the menstrual cycle.
Luteal
Contraceptions that stop bleeding/menstruation (i.e amenorrhoea)
IUS (progestogen)
POP
DMPA (depot-medroxyprogesterone acetate) - depot - most effective at causing amenorrhoea - 45% after 12 months.
*any of the progestogen only contraceptives*
Vaginal atrophy/vaginal dryness treatment
Topical Lubricants
Local Oestrogen pessary/cream
A woman is considered potentially fertile for:
- _____ yrs after her last menstrual period if she is less than 50 yrs.
- ____ yrs after last period if > 50 yrs.
2 yrs
1 yr
Premature ovarian failure needs to be identified and treated due to risk of:
CVD
Stroke
Osteoporosis
Cognitive impairment
Dementia
Parkinsonism
*Premature ovarian insufficiency is defined as menopause before the age of 40 years*
https://zerotofinals.com/obgyn/gynaecology/prematureovarianinsufficiency/
Which HRT method does not confer an increased risk of VTE?
Transdermal Patch
Diagnosis of premature ovarian failure:
Based on a combination of oligomenorrhoea / amenorrhoea of more than ____ duration associated with elevated gonadotropins (____ >___ iu/l) on at least ___ occasions measured ___ weeks apart in women under the age of 40.
4 months’
40
Two
4-6
Menopause can be diagnosed clinically diagnosed clinically after ___ months of amenorrhoea in a woman aged over ___ yrs.
12 months
45 yrs
Non-pharmacological treatment of menopause?
Lifestyle:
Stop Smoking
Stop Alcohol
Stop Caffeine
Sleeping in cold room / wear lighter clothes/ Sleep hygiene
Exercise (bone and CVS health)
CBT
Weight loss (reduces breast cancer risk)
Symptoms of menopause:
Vasomotor - Hot flushes/Night Sweats/Palpitations
Psychological - Low mood / Anxiety / Reduced libido
Local - Vaginal dryness/ Atrophy / Itchiness
/ Urinary incontinence / dysparunia / UTI’s
Non-hormonal pharmacological treatment of menopause?
SSRI/SNRI (Fluoxetine / citalopram/ Venlafaxine)
Vaginal lubricant
Clonidine (for vasomotor symptoms)
Gabapentin (hot flushes)
Complimentary symptoms (ex isoflavones/ red clover/ black cohosh)
Pharmacological treatment of menopause?
HRT (oestrogen +/- progesterone)
*Women with a uterus - give progesterone to negate increased risk of endometrial cancer with unoppossed oestrogen exposure*
*Women without a uterus can have oestrogen only therapy*
Mirena coil (IUS w/ progestogen) :
Length of action for contraception ____ yrs.
Length of action for HRT ____ yrs.
5 yrs
4 yrs
If you remember one thing about HRT for your exams, remember the basics of choosing the HRT regime.
Women with a uterus require endometrial protection with _____, whereas women without a uterus can have oestrogen-only HRT.
Women that still have periods should go on ___ HRT, with cyclical progesterone and regular breakthrough bleeds.
Postmenopausal women with a uterus and more than ___ months without periods should go on continuous combined HRT
Progesterone
Cyclical
12
There are some essential contraindications to consider in patients wanting to start HRT:
Undiagnosed abnormal bleeding
Endometrial hyperplasia or cancer
Breast cancer
Uncontrolled hypertension
Venous thromboembolism
Liver disease
Active angina or myocardial infarction
Pregnancy
To follow the ____ Guidelines, the young person must:
- The young person ____ the professional’s advice. U
- The young person cannot be____ to inform their parents or let the healthcare professional discuss it. P
- The young person is likely to begin, or to continue having, _____ with or without contraceptive treatment.S
- Unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to ____ S
- The young person’s best _____ require them to receive contraceptive advice or treatment with or without parental consent. I
UPSSI
Fraser Guidelines
Understands
Persuaded
Sexual intercourse
Suffer.
Interests
During a consultation it is intergral to assess for coercion or pressure to take contraception (from an older partner for example) as this may raise safeguarding concerns.
Injection/ depot
Pros:
Cons:
Pros:
Amenorrhoea (>45%)
Can be used in breast feeding
Doesn’t require daily adherence
Cons:
Permanent
Fertility (at least 12 months to return)
Weight gain
BMD (shouldnt be given to <20 yr olds)
No protection from STI
Implant
Pros:
Cons:
Pros:
3yrs
Cons:
Irregular bleeding
Bruising/Painful/ Surgical incision to take out/ Can migrate/ Scar
IUD (copper coil)
Pros:
Emergency Contraception
Long Acting (5-10 yrs)
No Hormones
Cons:
HMB
Pain
Invasive
Fitting issues (Can be expelled/ can cause uterine perforation/ hypotensive shock)
Ectopic (slight increase)
IUS (mirena/jaydess)
Pros:
Cons:
Pros:
Amenorrhoea
Regulates menorrhagia (1st line)
Local effect only
Fertility returns straight away once removed
Cons:
Invasive
Which class of medications is important to ask about when assessing suitability for contraception?
Anti-epileptics (ex. lamotrigine and carbamezapine - CYP450).
Women ovulate __ days before last mentrual period. This is why its important to know cycle length.
14 days.
For example 21 days cycle (ovulate at 8 days)
28 day cycle (ovulate at 14 days)
30 day cycle (ovulate at 16 days)
*Luteal phase is always 14 days*
Female fertility can be checked by measuring the level of _____ 7 days before menstruation because this is when its at its peak (mid luteal phase), and indicates that _____ has occurred.
Progesterone
Ovulation
Tubal patency can be observed using ____ and ____ .
Ultrasound
Xray
(surgery also possible)
Termination of pregnancy
- < 10 weeks a _____ or medical termination with ____and ____
- 10- ___ weeks a _____ surgery is recommended. Sometimes misoprostol is used in addition to soften the cervix.
- 14- 24 weeks a ______ and _____ technique - aspiration, forceps and ultrasound.
- If Ectopic use _____.
Vaccum aspiration
Mifepristone and Misoprostol
14 weeks
Vacuum aspiration
Dilatation and evacuation
Methotrexate
What is the 1st line analgesic that is safe to use in pregancy?
Paracetamol is safe throughout pregnancy.
NSAIDs are teratogenic: increased risk of _____ if used in early pregnancy.
If used after ____ weeks NSAIDs can close ductus arteriosus and can also cause ______ of the newborn and _____.
Codeine: not generally recommended during pregnancy, especially in 3rd trimester as cause _____ and ____ syndrome.
Misscarriage
30
Persistent pulmonary hypertension
Oligohydramnious.
Respiratory distress
Neonatal withdrawal
Change in bowel habit / bloating / early satiety / fullness / loss of appetite / weight loss / vaginal bleeding / Pelvic or abdominal pain/ polyuria are all important symptoms to rule out in a post-menopausal woman as they may indicate ovarian cancer.
**_____ and _____ are signs of late stage disease. **
Polyruia
Change in bowel habit
RMI - _____
Includes 3 factors
_____ x _____ x_____
If RMI gives a high score - ___/___ imaging determines extent of disease. This determines type of surgery and whether patient needs (Neo) adjuvant chemotherapy.
RISK MALIGNANCY INDEX (RMI):
Menopause status x Ca125 x TV ultrasound
MRI/CT
___Obesity_ , ____ , _____ , ____, and _____ further compounds the already increased risk of a VTE in pregnancy.
Treatment: _____ (i.e _____) for at least ____ months and up to ___ weeks post-partum.
Investigation: **_____ **.
Unless patient is exhibiting signs of a PE (breathlessness/Tachycardic/Tachypnoiec/chest pain/dizziness/palpitations) - ECG/Chest x-ray/ VQ scan/ CTPA
Obesity
Multiple pregnancies (i.e twins)
Assisted reproductive technology (i.e IVF)
Age (>35 yo)
Family history
Low molecular weight heparin
Enoxaparin
3 months
6 weeks
Duplex-ultrasound (Doppler + Normal ultrasound)
HRT
Reduces the risk of (X2):
Osteoporosis
Colon cancer (up to X 1/3)
Cardiotocography (CTG)
*Remember – DR C BRVADO
Define Risk : why is the patient on a CTG monitor?
Contractions - can have up to 5 in 10 minutes
Baseline Rate: 110-160 bpm
Accelerations: Rise of 15 bpm for 15 seconds or more. Usually have 2 every 15 minutes and are close to the contractions.
Variabilty: 5-25 bpm
Decelerations: Reduction of 15bpm for 15 seconds or more
Overall Impression
Cardiotocography (CTG):
Baseline bradycardia:____, ____, or ____.
Baseline Tachycardia:____, ____, or ______.
Reduced Baseline Variability: _____ or _____.
Early Deceleration: _____.
Late deceleration: ____ (e.g ____).
Variable deceleration: _____.
Baseline bradycardia: Cord prolapse, epidural/spinal anaesthesia, rapid foetal descent.
Baseline Tachycardia: Mother usually pyrexic, baby is hypoxic, or prematurity
Reduced Baseline Variability: Hypoxic, premature
Early Deceleration: Benign sign that baby’s head is compressed during descent.
Late deceleration: Fœtal distress (ex.asphyxia)
Variable deceleration: Cord compression
Cervical ectropion
Exposure and migration of ____ (columnar epithelium) to ____ (squamous epithelium) caused by high levels of _____ exposure. (Ex. ___, ____, _____) and exposure to more ____ environment of vagina.
Diagnosis of exclusion as need to exclude cervical cancer with a smear.
Endocervix
Ectocervix
Oestrogen
(ex. COOP, Puberty, Pregnancy)
acidic
May cause visible erythematous ring (differential cervical cancer/dysplasia), post-coital vaginal bleeding and mucous discharge but most often is symptomless.
Contact Trauma from sexual intercourse also an important differential.
Induction of labour steps (4X)
- _____ (___hrs)
- _____ (every ___hrs)
- _____ (w/ ____)
- _____ (IV/IM)
Syntocinon infusion needs to be judiciously titrated with _____ as it can cause ____ and ____.
- Prostaglandin Pessary (24hrs)
- Prostaglandin gel (every 6 hrs)
- Artificial Rupture of Membranes (AROM - w/ Amnihook)
- Syntocinon (IV/IM)
Frequency of contractions
Uterine hyperstimulation
Foetal distress
Missed Oral Contraception
- COOP: Take last missed pill, prescribe emergency contraception, and advise against sexual intercourse/additional contraceptive measures for ___ days.
- POP: Take last missed pill, avoid sexual intercourse/use additional contraceptive measures for next ___ hrs. If patient has sex in this period prescribe emergency contraception (i.e levonorgestrel, ulipristal)
7 days
48 hrs
Loss of >___ ml blood is considered a Post Partum Haemorrhage (PPH). Loss of ____ is considered a major PPH
500 ml
1000 ml/1L
PPH Management:
- ____
- ____
- ____
- ____
- ____
**Can also use ______ instead of syntocinon, but contraindicated with patients w/ ____ or ____ during pregnancy as they raise blood pressure.**
- Syntocinon (IV/IM)
- Carboprost (prostaglandin)
- Balloon Tamponade
- B-Lynch Suture
- Hysterectomy
ergometrine/syntometrine (uterine smooth muscle stimulants)
hypertension
pre-eclampsia
**Syntocinon: is an ____ analogue and works by ______.
**Carboprost (Prostaglandin E2 receptor causes _____ ) needs to be carefully monitored in ____ as it can cause _____ **.
increasing the intracellular level of Ca2+.
myometrial contraction
asthmatics
bronchoconstriction
Bartholin’s Cyst.
Common benign lesion caused by _____ and subsequent dilatation of ____.
- Usually affects women of _____ years.
- Often painless, but patients (often recurrent) can also present with erythematous, tender lump called bartholin’s abcess, which can give systemic symptoms (i.e fever).
- Bartholin’s cyst can be treated with____ and ____.
- Bartholin’s abcess needs_____ and either ____ for ____weeks, or ____.
obstruction
bartholin’s gland
reproductive (20-30)
Bartholin’s cyst: warm baths and simple analgesia.
broad spectrum antibiotics
balloon catheterization for 4-6 weeks
Marsupialisation
- ____ is a normal bleeding process that occurs in the ___ weeks after delivery.
- ____ may make the condition worse.
- ____ should be avoided in this period as they pose a serious infection risk.
Lochia
4-6 weeks
- Consists of blood, mucous, products of conception and so can be quite clotty and red at first and relatively heavy. This later (over a number of weeks) becomes brown and lighter.
- Breastfeeding may make the condition worse as it activates a neuroendocrine reflex arc that stimulates the uterus to contract.
- Patients should avoid using tampons as this presents a serious risk of infection.
Endometritis: Inflammation of the endometrium that often occurs ___.
- Usually caused by ____ and gram negative microbes.
- Presentation: 2-3 days of _______, period cramps, ____, uterine tenderness and fever.
- Treatment: _____.
after delivery
Group B strep
foul-smelling bloody discharge
lower abdominal pain
co-amoxiclav (amoxicillin/clavulanic acid)
Urge Incontinence/OAB
- Treated usually with ____ of bladder training.
- If this is not successful then anticholinergics ( **antimuscarinics**) such as ____, _____, and ____ can be added.
- However, remember antimuscarinics are contra-indicated in ____. In these patients a _____ can be used.
Antimuscarinics: oxybutynin, tolterodine and darifenacin
Elderly patients as they can increase likelihood of having a fall.
B3-agonist - mirabegron
Indications for forceps delivery.
FORCEPS :
Fully Dilated
Occipito-anterior position
Ruptured Membranes
Cephalic presentation
Engaged presenting part (*remember 3/5 or 2/5 suggests baby is engaged within pelvis)
Pain relief adequate
Sphincter (empty bladder)
Vulvovaginal Candidiasis
- Caused by ____
- Presents with « ____ and ____ »
Treated with intra-vaginal ____ antifungal ___ containing ____.
Candida albicans
Itching and white curd-like discharge
Pessary/cream
Clotrimazole
Anaemia in pregnancy is very common due to an ____. This gives a concomittant low _____ . ____ however is expected to increase.
Increased plasma volume
Haemoglobin concentration
MCV
Idiopathic thrombocytopaenia purpura (ITP) is a condition in which autoantibodies attack the ____ present on ___ cells. This leads to a dramatic loss of circulating platelets in the ____ trimester.
Important to pick up ITP as it can cause neonatal thrombocytopaenia and thus increases the risk of _____ in the fœtus
Antigens
Platelet
1st
intracranial haemorrhage
What are the 1st and 2nd line treatments for Idiopathic Thrombocytopaenia in pregnancy?
- 1st line: Steroids
- 2nd Line: IVIG
Platelet count at term is important as >70X109 needed for ____ and >50X109 is needed for ____.
epidural
safe delivery
Gestational thrombocytopaenia is a most often asymmptomatic drop in platelet count that occurs in most pregnancies (drop of ~ 10%) It is unlikely to lead to a platelet number below 70X109/L. Most often occurs in the *___ trimester*.
3rd
Pregnancy of unknown location (PUL)
- B-HCG < ____ unlikely to see pregnancy on ultrasound.
- B-HCG >____ should be able to see prenancy on ultrasound.
- If B-HCG ____ in ____hrs this indicates a Intra-Uterine Pregnancy.
- If B-HCG ____ in 48hrs, this indicated a Miscarriage.
- If B-HCG is in between these two windows, this indicated an ___.
1000 IU/L
1500 IU/L
increases by >63% in 48 hrs - Intruterine pregnancy
decreases by >50% in 48hrs - Miscarriage.
Ectopic Pregnancy.
A ___ is taken at booking visit (____ weeks) to identify any clinically relevant asymptomatic bacteria (ex E.coli).
This is because asymptomatic bacteriuria (UTI) is associated with ___ and ____ during pregnancy.
Midstream urine sample (MUS)
8-10 weeks
Preterm
Pyelonephritis
What is the 1st line treatment for a UTI in pregnancy?
Nitrofurantoin
Which antibiotics are contraindicated in pregancy?
Trimethoprim (causes folate deficiency and thus neural tube defects)
Doxycycline (teratogenic and also must be avoided in children)
Cervical smear screening:
Age _____ : Every ____ years.
Age ____ : Every ___ years.
25-50
3 yrs
50-65
5 yrs
Grades of CIN or _____, are determined by how many layers of the _____ are affected by ____ and how severely the dyskarytotic the cells are. (i.e abnormal ____:_____ ratio).
Cervical Intraepithelial Neoplasia
Squamous Epithelium
Dyskaryosis
Cytoplasmic : Nucleus
Pelvic Floor Prolapse Risk Factors:
Child birth (multiparous)
Traumatic/Forceps/Episiotomy
High BMI
Gynaelogical/Pelvic organ surgery
Menopause (lack of oestrogen causes reproductive organ atrophy)
Connective Tissue Disorder (Ehlers-Danlos syndrome)
Complications of an epidural:
Urinary retention
Hypotension
Spinal Headache
Respiratory Depression of Foetus due to opioid.
Epidural complications :
- **Urinary retention** as neural output to bladder is blocked
- **Hypotension** as anaesthetic can block sympathetic output and thus cause widespread vasodilation (thus always monitor BP during epidural)
- **Spinal headache** as accidental penetration of subarachnoid space causes leakage of CSF
- **Opioid** as could reach the baby and cause respiratory depression.
Monochorionic pregnancies need to be monitored every __ weeks from ___ weeks of gestation to scan for abnormalities.
Whereas
Dichorionic pregnancies need to be scanned every ___ weeks from ___ weeks gestation
2
16
4
20
Causes of Pathological/Abnormal Uterine Bleeding:
Remember “PALM COIEN”
PALM (Structural Causes)
Polyp
Adenomyosis
Leiomyoma (Fibroids/leiomyomata)
Malignancy
COEIN (Non-structural causes)
Coagulopathy (ex. Leukaemia -low platelet count / Drugs - warfarin or heparin / Von Willebrand Disease)
Ovulatory (PCOS these patients more at risk of endometrial cancer due to unopposed oestrogen action). When ovulation fails, the corpus luteum does not form and progesterone is not produced. The endometrium then continues to proliferate in the second half of the cycle as well as in the first half (due to unopposed oestrogen produced from follicles in the ovaries). This leads to a bulky endometrium. This is eventually shed and results in heavy and prolonged bleeding often occurring at a longer interval than the normal cycle.
Endometrial (endometritis secondary to chlamydia infection / Endocrine)
Iatrogenic (COCP/Progestogens/Implants/IUD) à wait 3 months to see if it settles and if not use NSAID or Anti-fibrinolytic (tranexamic acid)
Not otherwise classified (arterio-venous malformation / uterine isthmocoele or C-section scar defect)
Fetal squamous cells in maternal blood vessels is confirmatory for ____.
Amniotic Fluid Embolism
The risk of fetal and maternal blood mixing is highest during the 3rd trimester and delivery. Foetal cells act as thrombogenic factors. While this condition is rare, it carries a very high mortality and even those who survive tend to have severe deficits including neurological defects.
Acute shortness of breath, tachycardia, and tachypnoea, wedge-shaped infarction on chest x-ray.
The resultant hypoventilation is causing the hypoxia.
Our maon differential at this stage is PE as pregnancy is a hypercoagulable state and there is an increased risk of thrombus formation, thereby increased risk of embolisation.
Somatic innervation to the bladder is via the ___, ___, and ___ nerves. Autonomic nerves travel in these nerve fibres too.
Bladder filling leads to detrusor relaxation (____) coupled with sphincter contraction.
The _____ nervous system causes detrusor contraction and sphincter relaxation. Overall control of micturition is centrally mediated via centres in the ____.
Pudendal, Hypogastric and Pelvic
Sympathetic
Parasympathetic
Pons
Pre-Eclampisa:
De Novo ___ after ___ weeks pregnancy and ______.
Aetiology unclear but due to increased ____ in the ____ arteries supplying the placenta, release of ____ , and ____ dysfunction.
Hypertension
20
Proteinuria
vascular resistance
spiral arteries
inflammatory cytokines
endothelial
Risk factors for pre-eclampsia:
Biggest risk factor is Chronic disease:
Diabetes (Type 1 and 2) /Chronic Hypertension or Hypertension in previous pregnancy/CKD/Autoimmune disease: Antiphospholipid syndrome + SLE
Lower risk factors:
- FH (If you have 1st degree relative you are 25% more likely)
- Obese
- Multiple pregnancies (twins etc)
- Older mother
- 1st time mother
- 10 yr pregancy interval
Common presenting features of PCOS.
Oligomenorrhoea
Subfertility
Acne
Hirsuitism
Obesity
Mood swings/depression/anxiety
Male pattern baldness
Acanthosis nigricans (secondary to insulin resistance)
Which criteria is used to diagnose PCOS?
Rotterdam diagnostic criteria
Assuming that other causes have been excluded, PCOS can be diagnosed if two of the following are present:
Polycystic ovaries (>12 cysts seen on imaging or ovarian volume >10 cubic cm)
Oligo-/anovulation
Clinical or biochemical features of hyperandrogenism
What investigations can be done in someone you suspect has PCOS?
Bloods:
LH:FSH ratio: Increased (>2). This is also helpful in excluding menopause where the ratio is normal. (FSH often normal)
Total testosterone: normal/slightly raised
Fasting and oral glucose tolerance tests: helps diagnose insulin resistance.
Other tests that might be indicated if other pathologies are suspected include:
_TFTs (_thyroid dysfunction)
17-hydroxyprogesterone levels (CAH)
Prolactin (hyperprolactinaemia)
DHEA-S and free androgen index (androgen secreting tumours)
24-hour urinary cortisol (Cushing’s syndrome)
Imaging:
Transabdominal and transvaginal ultrasound: Shows increased ovarian volume and multiple cysts.
Management of PCOS:
Conservative:
Weight loss and exercise control
Education about increased cardiovascular, diabetes and endometrial cancer risks.
Pharmacological treatment for women not planning pregnancy:
Co-cyprindrol - Useful for reducing hirsutism and inducing regular menstruation.
Combined Oral Contraceptive Pill (COCP) - Used to reduce irregular bleeding and protects against endometrial cancer.
Metformin - Helps with menstrual regularity, hirsutism and acne.
Pharmacological treatment for women wishing to conceive
Clomiphene - Induces ovulation and improves conception rates.
Metformin - Can be used with/out clomiphene to increase the chances of a pregnancy.
Ovarian drilling - is a 2nd line laparoscopic surgical procedure where diathermy or laser is used to damage the hormone producing cells of the ovary.
Gonadotrophins - Can induce ovulation if clomiphene and metformin have failed.
What happens at the booking appointment (10 weeks)?
Comprehensive History
Baseline Blood tests
Urinalysis
Blood pressure
BMI
Ultrasound
Contraindications to vaginal delivery after C section:
Previous Classical (vertical scar) C-section
Previous Uterine Rupture
Usual contraindications to vaginal delivery (placenta praevia)
*VBAC usually has a success rate of around 60-80%. Thus, there is still a risk of having to perform an emergency Caesarean section. Risk is increased with increasing number of prior Caesarean deliveries.
*VBAC usually has a success rate of around ___ . *
*VBAC usually has a success rate of around 60-80%. Thus, there is still a risk of having to perform an emergency Caesarean section. Risk is increased with increasing number of prior Caesarean deliveries. *
Risk Factors for ectopic pregnancy.
Pelvic inflammatory disease
Pelvic surgery
IUS/IUD
Assisted reproduction e.g. IVF
*Anything that slows the ovum’s passage through the fallopian tube to the uterus is a risk factor for developing an ectopic pregnancy*
Indications for a caesarian section:
Abnormal presentation (breech or transverse)
Twins (if first twin is not cephalic)
HIV positive mother
Primary Genital Herpes in first trimester (recurrent herpes is safe to deliver vaginally)
Placenta Praevia
Anatomical Reasons
First Stage of Labour:
____ phase: ____ cm cervical dilation w/ irregular contractions and dilation of ___cm/hr
___ phase: ___ cm cervical dilation w/ regular contractions and dilation of ___ cm/hr
___ phase: ___ cm cervical dilation w/ regular strong contractions and dilation of ___ cm/hr
The first stage of labour is from the onset of labour (true contractions) until the cervix is fully dilated to 10cm. It involves cervical dilation (opening up) and effacement (getting thinner). The “show” refers to the mucus plug in the cervix, which prevents bacteria from entering the uterus during pregnancy, falling out and creating space for the baby to pass through.
The first stage has three phases:
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.
Prolonged rupture of membranes (PROM) : Amniotic sac ruptures more than ___hrs before delivery.
18hrs
Tocolysis involves using medications to stop uterine contractions. ____ is the medication of choice for tocolysis.
_____ is an oxytocin receptor antagonist that can be used as an alternative when nifedipine is contraindicated.
Nifedipine, a calcium channel blocker.
Atosiban
Induction of labour can be used where patients go over the due date. IOL is offered between ____ weeks gestation.
41 and 42 weeks
The ____ score is a scoring system used to determine whether to induce labour.
Five things are assessed and given a score based on different criteria:
A score of ___ or more predicts a succesful induction of labour.
The Bishop score is a scoring system used to determine whether to induce labour.
Five things are assessed and given a score based on different criteria (minimum score is 0 and maximum is 13):
Pregnancy Can Enlarge Dainty Stomachs!
- Position
- Consistency
- Effacement
- Dilation
- Station - Fetal station refers to where the presenting part is in your pelvis
*A score of 9 or more predicts a successful induction of labour and a likely vaginal delivery. A score below this suggests cervical ripening may be required to prepare the cervix.*
1 point is added to the score for each of the following:
Presence of pre-eclampsia
Each previous vaginal delivery
1 point is subtracted for each of the following:
Post-dates pregnancy
No previous vaginal deliveries
Premature pre-term rupture of membranes
200mg ___ Mifepristone followed by ___ micrograms Misoprostol vaginally ___ hours later can be given to terminate pregnancies from weeks 10-24.
Oral
800mg misoprostol
36-48
Terbutaline is a ____. It is used for ___ in uterine hyperstimulation.
Beta 2 (adrenergic) agonist
Tocolysis
Carboprost is a ____ analogue. It is given as a deep ____ injection in postpartum haemorrhage when ergometrine and oxytocin have failed. Crucially it needs to be used with extreme caution in patients who have _____ , as it can cause a life threatening exacerbation.
Prostaglandin
Intramuscular
Asthma
Tranexamic acid is a ____ . It binds to ___ preventing its breakdown to the enzyme ____. This enzyme breaks down blood clots.
antifibrinolytic
fibrinogen
plasmin
What is the most significant risk factor for an umbilical cord prolapse?
How does this present?
What is the management of this condition?
Abnormal lie (i.e unstable/transverse/oblique) after 37 weeks
Foetal distress on the CTG/Vaginal or speculum examnination can confirm
Emergency C-section
_____ involves hyperfelxion of the mother at the hip (bringing knees to abdomen). This provides a posterior pelvic tilt, lifting the pubic symphisis up and out of the way.
McRoberts Manoevre (1st line management in shoulder dystocia)
_____ manoevre involves reaching into the vagina and putting pressure on the posterior aspect of the baby’s anterior shoulder to force it down and under the pubic symphysis.
Rubin’s Manoevre
____ maneouvre involves pushing the baby’s head back into the vagina so that it can be delivered by emergency C-section
Zavanelli
The key complications of shoulder dystocia are:
Foetal hypoxia
Erb’s plasy (brachial plexus injury - C5-C6)
Perineal tears
Post-partum haemorrhage
A single/stat dose of ____ is used after _____ delivery to reduced the risk of maternal infection.
Co-amoxiclav
Instrumental
Epidural carries an increased risk of ____ delivery.
Instrumental
The key risks to the baby to remember in instrumental delivery are:
Cephalohaematoma (ventouse)
Facial Nerve Palsy (forceps)
Instrumental dleivery can cause damage to which two nerves in the mother. This usually resolves over 6-8 weeks.
Obturator
Femoral
Classification of perineal tears.
1st degree:
2nd degree:
3rd degree:
4th degree:
1st degree: Junction between frenulum of labia minora and superficial skin
2nd degree: Perineal muscles (not including anal sphincter)
3rd degree: Anal sphincters
A: < 50% External anal sphincter
B: >50% External anal sphincter
C: Both external and internal anal sphincter affected
4th degree: Mucosa
What are the advantages of active management of the 3rd stage of labour?
Name the two measures that consitute active management.
Shortens 3rd stage (~half an hour)
Reduces the risk of bleeding or post-partum haemorrhage
Intramuscular dose of oxytocin
Umbilical cord traction (during uterine contractions)
Post-partum haemorrrhage classifications
500ml after vaginal delivery
1000ml after caesarian
Minor <1000mls
Major >1000mls
Moderate 1000-2000mls
Severe >2000mls
4 causes of PPH can be remembered with a mnemonic:
Which one is the most common?
PPH
4Ts
Tone (atony most common cause)
Trauma (e.g perineal tear)
Tissue (retained placenta/POC- endometritis)
Thrombin (bleeding disorder)
Intravenous infusion of oxytocin is given as ___units in ___ mls.
40 units
500mls
Primary post-partum haemorrhage is bleeding within ___ hrs.
Secondary post-partum haemorrhage is bleeding within ___ hrs to ___ wks.
24 hrs
24hrs -12 weeks
There are four categories of emergency caesarean section:
Category 1: There is an immediate threat to the life of the mother or baby. Decision to delivery time is ___minutes.
Category 2: There is not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Decision to delivery time is ___ minutes.
Category 3: Delivery is required, but mother and baby are stable.
Category 4: This is an elective caesarean, as described above.
There are four categories of emergency caesarean section:
Category 1: There is an immediate threat to the life of the mother or baby. Decision to delivery time is 30 minutes.
Category 2: There is not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Decision to delivery time is 75 minutes.
Category 3: Delivery is required, but mother and baby are stable.
Category 4: This is an elective caesarean, as described above.
The most commonly used skin incision is a transverse lower uterine segment incision. There are two possible incisions:
____ is a curved incision two fingers width above the pubic symphysis
_______ is a straight incision that is slightly higher (this is the recommended incision)
The most commonly used skin incision is a transverse lower uterine segment incision. There are two possible incisions:
Pfannenstiel incision is a curved incision two fingers width above the pubic symphysis
Joel-cohen incision is a straight incision that is slightly higher (this is the recommended incision)
Contraindications to vaginal birth after C- section (VBAC).
Previous uterine rupture
Previous classical/longitudinal scar c-section
Other reasons for not having a vaginal delivery (ex. placenta praevia)
Two key causes of sepsis in pregnancy are:
____
and
____.
Two key causes of sepsis in pregnancy are:
Chorioamnionitis
Urinary tract infections
All patients admitted to maternity inpatient units, such as at the antenatal ward and labour ward, will have monitoring on a MEOWS chart. MEOWS stands for ______. This includes monitoring their physical observations to identify signs of sepsis.
MEOWS - Maternity early obstetric warning system.
3 options for treating a uterine inversion:
Johnson Manoevre (manually pushing the uterus back into position. held in place for several minutes with concomitant oxytocin infusion)
Hydrostatic methods (inflating the uterus with fluid)
Surgery (laporotomy and uterus pulled back to normal position)
Management of GBS infection
Intrapartum antibiotics
Penicillin
Vancomycin (if penicillin is contraindicated)
____ syndrome is a complication associated with oligohydramnios. It is a fetal condition which presents with _____ and various structural malformations as a result of compression in utero.
Potter’s syndrome is a complication associated with oligohydramnios not polyhydramnios. It is a fetal condition which presents with pulmonary hypoplasia and various structural malformations as a result of compression in utero.
Folic Acid ____ per day has been shown to reduce the occurrence of neural tube defects and should be recommended to all woman pre-pregnancy and up to ____ weeks gestation.
400 micrograms
12 weeks gestation
Contraception is not required for the first ___ weeks after delivery
Contraception is not required for the first 3 weeks after delivery
Lactational amenorrhoea method may be used as contraception postpartum. However, is is time-limited and can only be used for the first
____ postpartum.
6 months
Absolute contraindications to breastfeeding are:
absolute contraindications to breastfeeding are:
Infants of mothers with TB infection
Infants of mothers with uncontrolled/unmonitored HIV
Infants of mothers who are taking medications which may be harmful e.g. amiodarone/lithium/methotrexate/gliptins (e.g sitagliptin)
NICE recommends that with women a risk factor besides previous gestational diabetes should be offered an oral glucose tolerance test at ____ weeks.
In the case of previous history of gestational diabetes, they are offered an oral glucose tolerance test as soon as possible after the booking visit followed by an additional test at 24-28 weeks if the first one is normal.
NICE recommends that with women a risk factor besides previous gestational diabetes should be offered an oral glucose tolerance test at 24-28 weeks.
In the case of previous history of gestational diabetes, they are offered an oral glucose tolerance test as soon as possible after the booking visit followed by an additional test at 24-28 weeks if the first one is normal.
In this first stage of labour, contractions should be approximately ____ per ___ minute period, lasting ____ seconds.
3-5 contracitons
per 10 minutes
lasting 30-60 seconds
Women with gestational diabetes should give birth no later than ____ weeks of gestation
40+6 weeks
The symptoms of extreme morning sickness, heat intolerance, anxiety, and vaginal bleeding all suggest ____ which classically presents after ____ weeks gestation.
Molar Pregnancy
14 weeks
B-hCG levels are often much higher than would be expected in a normal pregnancy.
Trans-vaginal ultrasound is also used which in a complete molar pregnancy may show a ‘snowstorm’ appearance, low resistance of blood vessel flow, and absence of a foetus.
What is the management of an eclamptic seizure?
IV Magnesium Sulphate (4g over 15 minutes) - loading dose
Maintenance dose - 1g/hr for 24hrs after seizure
____ Rule, the expected delivery date (EDD) is calculated by adding ___ months to the __ plus ___ days
Naegele’s Rule, the EDD is calculated by adding 9 months to the LMP plus 7 days
____ , especially in trace amounts, is a common finding during pregnancy as there is an increased ____ and a reduction in tubular reabsorption of filtered glucose.
Glucosuria
Glomerular filtration rate
When is the first dose of anti-D prophylaxis administered to rhesus negative women?
28 weeks / 6 months
A prolonged 2nd stage of labour is defined as ___ hours or more from full dilatation in a nulliparous woman with epidural anaesthesia.
Three
A prolonged 2nd stage of labour is defined as __three\_ hours or more from full dilatation in a nulliparous woman with epidural anaesthesia.
Woody uterus’ in pathognomoic of ____
Placental Abruption
Remember with placental abruption the bleeding may be concealed and thus not PV.
80% of cervical cancers are ____ cancer. ____ is the next most common type. Rarely there exists other forms such as ____ cancer.
Squamous cell carcinoma
Adenocarcinoma (2nd most common)
Small cell cancer
HPV promotes the development of cancer by inhibiting tumour suppressor genes ___ and ___.
HPV produces two proteins that inhibit these tumour suppressor genes - ___ and ___.
p53 and pRb. (pat rabbit)
E6 suppresses p53
E7 suppresses pRb.
Cervical cancer risk factors:
High Sexual Activity (early stage of activity/no.partners/no partners of partner/not using condoms)
Non-adherence to cervical screening
Family history
Smoking
Immunosuppression
HIV (cervical smear every year)
COCP (if greater than 5 years of use)
Increased number of full term pregancies
Diethylbestrol during foetal development (used to prevent misscarriage before 1971)
CIN is sometimes called ____
Cervical carcinoma in situ
____ (___) is a monoclonal antibody used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer. It targets ____ and may also be seen in the treatment of wet age-related macular degeneration.
Bevacizumab (Avastin)
VEGF - A
Around 80% of endometrial cancers are ____. It is an _____ dependent cancer.
Adenocarcinoma
Oestrogen-dependent cancer - oestrogen stimulates growth of endometrial cancer cells.
Endometrial hyperplasia is a ___ condition involving thickening of the endometrium. The risk factors, presentation and investigations of endometrial hyperplasia are similar to endometrial cancer. Most cases of endometrial hyperplasia will return to normal over time. Less than ___ % go on to become endometrial cancer. There are two types of endometrial hyperplasia to be aware of:
____
and
____.
precancerous
5
Hyperplasia without atypia
Atypical hyperplasia
Endometrial hyperplasia is a precancerous condition involving thickening of the endometrium. The risk factors, presentation and investigations of endometrial hyperplasia are similar to endometrial cancer. Most cases of endometrial hyperplasia will return to normal over time. Less than 5% go on to become endometrial cancer. There are two types of endometrial hyperplasia to be aware of:
Hyperplasia without atypia
Atypical hyperplasia
Endometrial Hyperplasia may be treated using:
Intrauterine System (i.e mirena coil)
Continuous oral Progestogens (.eg medroxyprogesterone/levonorgestrel)
Endometrial cancer and hyperplasia risk factors:
Older age
Obesity
Oestrogen window (Early mearche/late menopause)
PCOS
Nulliparous or few pregnancies
Oestrogen only hormone replacement therapy
Tamoxifen (anti-oestrogen in breast but oestorgen mimetic in the endometrium and thus causes hypertrophy - increases E.cancer risk 2-3 fold)
Factors not related to oestrogen exposure:
Diabetes (insulin stimulates endometrial cell growth)
HNPCC or Lynch syndrome
The referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer is:
Postmenopausal bleeding (more than ___ months after the last menstrual period)
NICE also recommends referral for a ______ in women over ____ years with:
Unexplained ______
Visible _____ plus raised platelets, anaemia or elevated glucose levels.
The referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer is:
Postmenopausal bleeding (more than 12 months after the last menstrual period)
NICE also recommends referral for a transvaginal ultrasound in women over 55 years with:
Unexplained vaginal discharge
Visible haematuria plus raised platelets, anaemia or elevated glucose levels
There are three investigations to remember for diagnosing and excluding endometrial cancer:
Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause)
Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer
Hysteroscopy with endometrial biopsy
The usual treatment for stage 1 and 2 endometrial cancer is a _____.
Other treatment options depending on the individual presentation include:
The usual treatment for stage 1 and 2 endometrial cancer is a total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO (removal of uterus, cervix and adnexa).
A radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina
Radiotherapy
Chemotherapy
Progesterone may be used as a hormonal treatment to slow the progression of the cancer
Around 90% of vulval cancers are _____ carcinomas.
Less commonly they can be ____.
Squamous cell
Malignant melanomas
Risk factors for vulval cancer:
Increasing age (particularly > 75)
Lichen sclerosis (around 5% get vulval cancer)
Immunosuppression
HPV infection
_______ (VIN) is a premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer. VIN is similar to the premalignant condition that comes before cervical cancer (cervical intraepithelial neoplasia).
High grade squamous intraepithelial lesion is a type of VIN associated with _____ that typically occurs in younger women aged _____ years.
Differentiated VIN is an alternative type of VIN associated with _____ and typically occurs in ____ women (aged _____ years).
Vulval intraepithelial neoplasia (VIN) is a premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer. VIN is similar to the premalignant condition that comes before cervical cancer (cervical intraepithelial neoplasia).
High grade squamous intraepithelial lesion is a type of VIN associated with HPV infection that typically occurs in younger women aged 35 – 50 years.
Differentiated VIN is an alternative type of VIN associated with lichen sclerosus and typically occurs in older women (aged 50 – 60 years).
Treatment for vulval cancer:
- Wide local excision possibly involving lymph nodes
- Chemotherapy
- Radiotherapy
Treatment for VIN :
Watch and wait
Wide local excision
Imuiquimod
Laser ablation
Investigations for establishing diagnosis of vulval cancer:
Biopsy
Sentinel node biopsy
Further Imaging (CT abdomen/pelvis for staging)
Risk factors for shoulder dystocia:
Previous shoulder dystocia (10X risk)
Diabetes
Obesity (high BMI)
Twins
Inducing labour
Oxytocin drip
Prolonged 1st or 2nd stage of labour
Instrumental delivery
Signs of Magnesium sulfate toxicity
Poor urinary output
Respiratory depression
Hypo or areflexia.
Complications of Pre-eclampsia
Peripheral Oedema (often pulmonary and cerebral)
Renal failure
HELLP syndrome
For cord prolapse if theyre dilated (i.e >10cm) then you have to ____. If they are not (i.e 4cm etc) then they need _____.
Deliver
to be taken to theatre for C-section.
3 foetal shunts
Ductus Venosus
Foramen Ovale
Ductus Arteriosus
2/3 of multiple pregancies are ____ whilst a 1/3 are Monozygotic.
Of these monozygotic pregnancies
30% are _____
70% are ____
1% are ____
and
0.1% are ____.
Dizygotic
30% are DCDA - dichorionic (2 placentas) diamniotic (2 amniotic sacs)
70% are MCDA - Monochorionic (one placenta) Diamniotic (2 amniotic sacs)
1% are MCMA - Monochorionic Monoamniotic
and
0.1% are conjoined twins.
Multiple pregnancy is increased in _____.
Assisted Reproductive Technology (ART)
The timeline for each pregnancy begins on the _____.
1st day of the last menstrual period.
Foetal movements begin from about ____ weeks gestation
20
Before 10 weeks - ____ clinic
Offer a baseline assessment and plan the pregnancy
Between 10 and 13 + 6 - ____
An accurate gestational age is calculated from the ____ (CRL), and multiple pregnancies are identified
16 weeks - Antenatal appointment
Discuss results and plan future appointments
Between 18 and 20 + 6 - ____
An ultrasound to identify any anomalies, such as heart conditions
25, 28, 31, 34, 36, 38, 40, 41 and 42 weeks - Antenatal appointments
Monitor the pregnancy and discuss future plans
Booking
Dating scan
Crown Rump Length (CRL)
Anomaly scan
There are two vaccines offered to all pregnant women:
______ from 16 weeks gestation
_____ when available in autumn or winter.
Live vaccines, such as the _____ vaccine, are avoided in pregnancy.
There are two vaccines offered to all pregnant women:
Whooping cough (pertussis) from 16 weeks gestation
Influenza (flu) when available in autumn or winter
Live vaccines, such as the MMR vaccine, are avoided in pregnancy.
A Nuchal Translucency > ___ indicates possible down syndrome.
6mm
Obstetric cholestasis is associated with _____ and _____ . Planning delivery for 37-38 weeks allows adequate development of the foetus without unnecessarily prolonging the risk of spontaneous death
spontaneous foetal death
maternal haemorrhage
Signs of placental separation and imminent placental delivery:
Gush of blood
____ of the umbilical cord
_____ of the uterus in the abdomen
Lengthening
Ascension
Meconium is the first faeces passed by a newborn, in contrast to later faeces it is usually very thick and _____ in colour. It is usually passed after delivery.
The presence of meconium in the amniotic fluid may lead to development of ______ (MAS).
dark green
meconium aspiration syndrome
Sometimes it may be expelled prior to birth into the amniotic fluid, which is known as “meconium stained liquor”.
MAS is caused by passage of the meconium from the amniotic fluid into the foetal lungs.
This can cause blockage and inflammation of the airways and is associated with significant morbidity and mortality.
What is the management of patients with hypothyroidism during pregnancy?
In hypothryopid pregancies, NICE recommends increasing levothyroxine by 25 mcg as soon as pregnancy is confirmed despite a euthyroid state and rechecking TFTs in 4 weeks.
This patient is currently euthyroid but because of her pregnancy, needs an increased dose of levothyroxine. The explanation for this is that in pregnancy there is a physiological increase in serum free thyroxine until the 12th week of pregnancy as the foetus is dependent on mother’s circulating thyroxine until the 12th week of development when the foetal thyroid develops.
Menorrhagia is defined as blood loss during a menstrual period to which a patient’s quality of life is affected. In about half of cases, there is no underlying pathology and this is referred to as ______.
Dysfunctional uterine bleeding.
Amniotic fluid is important for the development of the fetal lungs thus oligohydramnios can lead to_____.
fetal pulmonary hypoplasia.
3 examples of ____ bacteria associated with bacterial vaginosis are:
Anaerobic
Gardnerella Vaginalis (most common)
Mycoplasma Hominis
Prevotella
Remember that ____ on microscopy mean bacterial vaginosis.
Clue cells
Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.
Asymptomatic BV does not usually require treatment. Additionally, it may resolve without treatment.
_____ is the antibiotic of choice for treating bacterial vaginosis. It specifically targets _____ bacteria. It can be given orally or via a ____.
____ is an alternative but is a less optimal choice of antibiotic
Metronidazole
Vaginal gel
Anaerobic
Clindamycin
Whenever prescribing metronidazole advise patients to avoid ____ for the duration of treatment.
Alcohol
This is a crucial association you should remember, and something examiners will look out for when you are explaining the treatment to a patient.
Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.
The National Chlamydia Screening Programme (NCSP) aims to screen every sexually active person under the age of ___ or when they____.
25
Change partner
Everyone that tests postive shuld be re-screened 3 months later to ensure they havent picked up the infection again (it is NOT to see if the treatment has worked)
Name the two different types of swab that can be used to test for STI’s?
Charcoal Swabs
Nucleic Acid Amplification Tests (NAATs)
1st line for treating uncomplicated Chlamydia infection _____
Doxycycline 100mg twice daily for 7 days.
Doxycycline is contraindicated in pregnancy and breast feeding and thus an alternative option in the treatment of chlamydial infection is____
Azithromycin/Erythromycin/Amoxicllin
A test of cure should only be done in cases of rectal chlamydia.
______ (LGV) is a condition affecting the lymphoid tissue around the site of infection with chlamydia. It most commonly occurs in men who have sex with men (MSM). LGV occurs in three stages:
Doxycycline 100mg twice daily for ____ days is the first-line treatment for LGV. Erythromycin, azithromycin and ofloxacin are alternatives.
Lymphogranuloma Venereum (LGV)
21 days
The primary stage involves a painless ulcer (primary lesion). This typically occurs on the penis in men, vaginal wall in women or rectum after anal sex.
The secondary stage involves lymphadenitis. This is swelling, inflammation and pain in the lymph nodes infected with the bacteria. The inguinal or femoral lymph nodes may be affected.
The tertiary stage involves inflammation of the rectum (proctitis) and anus. Proctocolitis leads to anal pain, change in bowel habit, tenesmus and discharge. Tenesmus is a feeling of needing to empty the bowels, even after completing a bowel motion.
For uncomplicated gonorrhoeal infection 1st line therapy is:
____ if sensitivities are not known.
____ if sensitivites are known.
Ceftriaxone (IM) if not known
Ciprofloxacin (Oral)if known
A key complication of gonnococcal conjunctivits to remember is neonatal conjunctivitis (i.e _____) as this is a medical emergency and may cause sepsis, perforation of the eye and blindness.
Ophthalmia Neonatorum
The absence of ___ cells on microscopy is useful for excluding PID.
Pus cells
_____ syndrome is a complication of PID and is caused by inflammation and infection of the ____, which lead to ____ between the liver and peritoneum. This syndrome can lead to ___ pain which can be referred to the ____ if there is diaphragmatic irritation. Laporoscopy can be used to visualise and also treat the adhesions via adhesiolysis.
Fitz-Hugh-Curtis syndrome
Liver Capsule
Adhesions
RUQ
Shoulder tip
Bacteria can spread via the peritoneum/lymph/blood.
Trichomonas vaginalis is a type of ____ spread through sexual intercourse. Trichomonas is classed as a protozoan, and is a single-celled organism with flagella. Flagella are appendages stretching from the body, similar to limbs. Trichomonas has four flagella at the front and a single flagellum at the back, giving a characteristic appearance to the organism
Examination of the cervix can reveal a characteristic “______ ” (also called colpitis macularis).
Treatment is with _____.
Parasite
Strawberry cervix
Metronidazole
The herpes simplex virus can also cause aphthous ulcers (small painful oral sores in the mouth), ____ (inflammation of the cornea in the eye) and _____ (a painful skin lesion on a finger or thumb).
herpes keratitis
herpetic whitlow
HSV-1 is most associated with ____.
HSV-2 typically causes ____.
Cold Sores (Most common cause of genital herpes via oro-genital sex)
Genital Herpes (HSV-2 is usally a cause of re-infection (i.e reactivation of a previous infection )
Incubation - few days to 3 weeks
But this is not a hard rule and either strain can cause either cold sores or gential herpes.
Treatment of genital herpes is with ___ .
Aciclovir (400mg TDS for 5-10 days)
Alternatives are valaciclovir/famciclovir
Non-Pharmacological:
Analgesia
Saline Bathing
Local anaesthetic gel - Lidocaine 5% medicated plaster (Versatis®)* is licensed for the symptomatic relief of neuropathic pain
Warm water urination (in shower)
Counsel on risk of infection to others
Counsel on pregnancy
*Refractive/recurrent disease can be treated with long term aciclovir - 3-12 months*
Pregnant Women (before ___ weeks) that are asymptomatic with genital herpes infection can have a vaginal delivery provided it is 6 weeks after the initial infection.
If symptomatic a ___ is recommended.
In addition if women contract the virus after 28 weeks a ____ is also recommended.
28
C -section X2
Aciclovir is safe to use during preganncy and is given during the initial infection and prophylactically in pregnancy.
A single deep _____ dose of ____ is the standard treatment for syphillis.
Intramuscular (IM)
Benzathine Benzylpenicillin (penicillin)
What are the 3 steps to consider when choosing a HRT formulation?
- Are the symptoms local? Local: Use topical oestrogen cream/tablets
- Does the woman have a uterus? Yes: Use combined HRT No: Use Oestrogen only
- Has the woman had a period in the last 12 months? Yes: Use cyclical pregestogen (given 10-14 days per month) No: Use Continuous Progestogen (If under 50 only given if no period for > 24 months as can cause irregular breakthrough bleeding prompting investigation elsewhere) .
The Mirena coil is licenced for ____ yrs for endometrial protection (i.e in a combined HRT regimen)
4 Years.
The ____ cells of the ovaries respond to LH and FSH to secrete oestrogen.
Theca Granulosa Cells
Puberty Starts at age ____ in girls and ____ in boys. Girls have an earlier pubertal growth spurt. Puberty usually takes about ___ yrs from start to finish.
8-14 in girls
9-15 in boys
4 years
____ is the enzyme in adipose tissue responsible for the creation of oestrogen, and thus the reason overweight children often enter puberty at an earlier age.
Aromatase
Puberty in girls usually begins with ____ and is followed by ____ , and finally menarche.
Breast budding
Pubic hair
The Stage of Pubertal development can be measured using the ____ scale which is based on the findings of sexual characteristics.
Tanner Scale
____ ovarian cancer is the most common type of ovarian cancer of all ovarian tumours. _____ is the most common subtype of epithelial ovarian cancer and is characterised by the presence of ____ on histology.
Epithelial
Serous cystadenocarcinoma
Psammoma bodies
The symptoms of reduced libido, galactorrhoea (bilateral milky discharge from the breasts that is not associated with pregnancy or lactation) and amenorrhoea are highly suggestive of _____.
Hyperprolactinaemia.
Category 1 (immediate) Caesarean section should be performed where there is evidence or clinical suspicion of ____.
Acute foetal compromise (eg. cord prolapse)
Ovarian torsion is a gynaecological emergency and diagnostic delay can lead to a loss of the ovary due to compromised blood supply. It usually presents with sudden onset, unilateral pain in the right or left iliac fossa. This is often severe, constant and accompanied with nausea & vomiting. A raised CRP and white cell count is suggestive of an underlying inflammatory response. The ____ sign is a characteristic sign of ovarian torsion that can be seen on ultrasound or CT scan. It demonstrates the twisting of the ovarian ___ .
‘Whirlpool’
Pedicle
____ is the most effective method of preventing GBS infection in the newborn.
Intra-partum antibiotic prophylaxis
Antibiotics (commonly a penicillin) are given intravenously during labour and delivery if risk factors for GBS infection are present
Macrosomia refers to a birthweight of greater than ___.
4.5kg
Any invasive uterine procedure is a potential sensitising event, thus any rhesus negative woman undergoing procedures such as amniocentesis or chorionic villus sampling must be given ____ (in addition to the routine doses).
Anti-D prophylaxis
Cervical ectropion is particularly more common in ____ , during pregnancy, and in women taking combined hormonal contraception. The high levels of ___ trigger an enlargement of the cervix, causing eversion of the endocervical canal, which appears as a red ring.
Adolescents
Oestrogen
Patients with severe pre-eclampsia should have blood tests____ to anticipate if a patient is developing HELLP syndrome, a complication of pre-eclampsia involving___ , elevated liver enzymes and low platelets.
Three times per week
Haemolysis
Risk Factors for Ovarian Cancer
Older age
Smoking
Greater number of ovulations (early menarche, late menopause)
Obesity
HRT
BRCA 1 and 2 genes
Uterine hyper-stimulation is defined as greater than __ contractions occurring within ___ and is due to administration of ___ or oxytocin for induction of labour.
5
within 10 minutes
prostaglandins
____ is mid-cycle ovulatory pain and it is common. The pain is due to rupture of the Graafian (dominant) follicle, each month, which results in the release of an ovum into the fallopian tube. The pain can vary from being right-sided to left-sided depending on which ovary is ovulating that month. Duration of pain can vary from minutes up to a few days and it can be controlled using simple analgesics such as paracetamol and NSAIDs.
Mittelschmerz
External cephalic version is usually offered at ___ weeks and involves applying pressure to the maternal abdomen in an attempt to “turn” the baby.
36 weeks
The uterus usually returns to its non-pregnant size by ___ weeks post-partum
4 weeks
____ rule is used to calculate the EDD based on the first day of the woman’s last menstrual period (LMP). The calculation is to add __ and ___ days to the first day of the LMP and subtract three months.
Naegele’s
one year and 7 days
Tocolysis 1st line?
Oral Nifedipine
Other agents that can be used:
IV Atosiban (Oxytocin receptor antagonist)
IV Terbutaline (beta-agonist and thus off label due to cardiovascular risk - smooth muscle relaxation)
Indomethacin (NSAID)
Contraindications to Tocolysis
- Greater than 34 weeks gestation
- Non-reassuring cardiotocograph, fatal foetal anomaly or intrauterine death
- Intrauterine growth restriction or placental insufficiency
- Cervical dilation greater than 4cm
- Chorioamnionitis
- Maternal factors such as pre-eclampsia, ante-partum haemorrhage, haemodynamic instability
The drug-specific contraindications should also be considered, for example cardiac disease such as severe hypotension or heart failure is a contraindication to nifedipine.
Layers to go through on a C-section
Skin - subcutaneous fat - rectus sheath - rectus abdominus muscle - peritoneum - uterine myometrium - amniotic sac
Female causes of Infertility:
Female
Ovulatory Dysfunction:
- Age
- PCOS
- Premature Ovarian Failure
- Cushing’s syndrome
- Pituitary Tumours
- Hyperprolactinaemia
- Turner’s/Kleinfelters syndrome
- Sheehan’s Syndrome (pituitary infarction)
Structural:
- Endometriosis
- Pelvic Inflammatory Disease
- Asherman’s Syndrome (Intrauterine adhesions)
- Bicornuate Uterus
- Fibroids
- Cervical Damage (ex. cone biopsy)
Male causes of Infertility:
General
- Obesity
- Smoking
- Excessive alcohol
- Compressive issues (Sitting down all day/tight underwear)
- Anabolic steroids
- Ilicit drug use
Testicular Factors
- Varicocele
- Cryptorchidism (undescended testes)
- Testicular Cancer
- Kleinfelter’s syndrome
Genital Tract
- Congenital genital tract disorders
- Disorders of ejaculation
- Obstruction of the ejaculatory system (conegnital or acquired)
What is Dysfunctional Uterine Bleeding?
The cause of up to 50% of Menorrhagia (mentrual bleeding affecting QOL).
Means there is no underlying pathology
Which types of twins are associated with the greatest risk of complications?
Monochorionic Monoamniotic
*Monochorionic monoamniotic twins are identical (monozygotic) twins that share the same amniotic sac. These share a placenta with two separate umbilical cords. These types of twins are at high risk of developing complications such as cord entanglement (because there is no membrane separating the two umbilical cords), cord compression, twin-to-twin transfusion syndrome and pre-term birth.
The COCP is absolutely contraindicated in women who are breast feeding ___ weeks post partum
The COCP is absolutely contraindicated in women who are breast feeding < 6 weeks post partum (UKMEC 4)
Absolute Contraindications to COCP (UKMEC 4)
- Family history of early age VTE (<45 years)
- Ongoing or previous Breast cancer
- Pregnancy
- Obesity
- Breast feeding (< 6 weeks post partum)
- BRCA genes
___ are the recommended contraceptives as they can be started any time following delivery.
IUD/IUS may also be used but must be fitted withing ___ hrs of delivery or ___ weeks after delivery.
POP and Implant
<48hrs
>4 weeks
Basically cannot insert in 48hrs - 4 week window post partum
Which treatments offer the best chance of preventing further miscarriage in a patient with anti-phospholipid syndrome?
Antiplatelet (Aspirin)
AND
Anticoagulant (i.e LMWH)
*not only do yopu want reduced platelet aggregation/activity but when they do aggregate, it is important that the clotting cascade doesn’t work and thus the fibrin meshwork isnt formed.*
Bacterial vaginosis (BV) typically presents with a copious _____ with a characteristic ___ odour. It does not normally cause vulval itch.
It is caused by an overgrowth of anaerobic bacteria in the vagina. BV should always be treated in pregnancy as it may confer a greater risk of _____ or ____.
BV is treated in pregnancy with either intravaginal gel (e.g. _____ or _____ ) or oral _____ .
Bacterial vaginosis (BV) typically presents with a copious watery grey-white discharge with a characteristic ‘fishy’ odour.
It does not normally cause vulval itch.
It is caused by an overgrowth of anaerobic bacteria in the vagina. BV should always be treated in pregnancy as it may confer a greater risk of premature birth or miscarriage.
BV is treated in pregnancy with either intravaginal gel (e.g. Metronidazole or Clindamycin) or oral Metronidazole.
For nulliparous and multiparous women, the recommended time for ECV is ____ and ___ weeks respectively
36 and 37 weeks
What drug class is Clomiphene and when is it given?
Clomiphene is an anti-oestrogen (selective oestrogen receptor modulator) and is given daily from day 2-6 of the cycle. It is used to treat anovulation.
Works by reducing circulating oestrogen activity, thereby reducing the suppression of the HPA and subsequently FSH/LH.
Which of the following is the reason for taking high dose folic acid?
Obesity (BMI > 30)
Folic acid is converted to tetrahydrofolate (THF), which is involved in the synthesis of DNA and RNA. Deficiency in folic acid can cause neural tube defects (NTD). Obese women with a BMI > 30 kg/m2 are at a higher risk of conceiving a child with neural tube defects and are recommended to take _5 mg of folic acid from before conception until the 12th week of pregnanc_y.
All women should take 400 mcg folic acid until the 12th week (normal dose - 400mcg) of pregnancy.
Other risk factors include previous pregnancy with NTD, family history of NTD, use of antiepileptic drugs, coeliac disease, diabetes, and thalassaemia traits.
A potential side effect of ferrous sulphate in the treatment of menorrhagia is the development of _____.
A potential side effect of ferrous sulphate is the development of dark stool (harmless)
Remember poo after guinness is black because of iron.
Passage of fetal and placental tissue during a miscarriage can appear as ____ tissue and be accompanied by blood clots.
Greyish
Prior to attempting an instrumental delivery, a nerve block is performed to provide regional analgesia.
Which nerve is blocked in this circumstance?
Pudendal Nerve
*Lidocaine is injected 1–2cm medially, and below the right and left ischial spines transvaginally with a specially designed pudendal needle.*
After evacuation of a hydatidiform mole, the levels of b-hCG are expected to fall and pregnancy should be avoided for 1 year. However, if they fail to drop, _____ should be suspected.
Malignant Choriocarcinoma
What is the classical triad of amniotic fluid embolism and when is it most likely to occur?
The classic triad involves coagulopathy, hypoxia and hypotension.
Amniotic fluid embolism is most likely to occur during or shortly after labour. The pathophysiology is not completely understood.
What is the classical clinical triad of vasa praevia?
The classical triad of clinical features is rupture of membranes, painless vaginal bleeding, and fetal bradycardia (fetal heart rate <100bpm).
It presents with rupture of membranes followed immediately by vaginal bleeding.
*Vasa praevia is a condition where the fetal blood vessels (which are unprotected by the umbilical cord) run close to or across the internal cervical os. This is dangerous as rupture of membranes can cause rupture of the fetal vessels and subsequent fetal haemorrhage.*
Jaundice within 24 hrs of birth is always ____
Pathological
What is the most appropriate initial management of an inverted uterus (often following an active 3rd stage of labour)?
Johnson’s Manoevre: Immediately replace the fundus through the cervix with the palm of the hand, followed by two large bore cannullas
This is because a tight ring forms around the uterus and this must be prevented as soon as possible.
CVS is typically offered between ___ weeks gestation whilst amniocentesis can be offered from ___ weeks
CVS : 11-13 weeks
Amniocentesis : 15 weeks
Remember there is a risk of foetal limb abnormalities if CVS is performed before 11 weeks.
What is the treatment for Herpes Simplex Virus infection?
Oral Acyclovir
IV acyclovir is only used in systemic/disseminated disease (i.e fever/multiple mucosal sites/meningitis)
What criteria is used to make a diagnosis of Bacterial Vaginosis?
What are the components of this criteria and how many are needed to make a diagnosis?
Amstel Criteria for Bacterial Vaginosis
In order to diagnose bacterial vaginosis, the Amstel criteria are used. Three out of four features are needed to confer a diagnosis:
Vaginal pH >4.5
Homogenous grey discharge
Whiff test - 10% potassium hydroxide produces fishy odour
Clue cells present on wet mount (i.e microscopy)
What is the treatment of bacterial vaginosis?
The treatment of choice is Metronidazole or Clindamycin.
The treatment used in pregnancy is Metronidazole.
What is the most appropriate hormonal contraception to use in a patient with a history of epilepsy?
Depo - provera (medroxyprogesterone acetate) injection does not go through first pass metabolism and thus does not induce the CYP450 enzymes like many epileptic drugs. This means that its concentration is unaffected by anti-epileptics unlike COCP.
Need to avoid 1st pass metabolism (i.e Ingestion)
Emergency Contraception options:
IUD/Copper coil - Can be taken within 5 days of UPSI
Ella One - Can also be taken within 5 days of UPSI
Levonelle - Can be taken within 3 days of UPSI (not as effective as ella one)
The ______ reaction is a classical reaction to ___ treatment in syphilis infection, characterized by fever, rash, rigors and tachycardia.
Jarisch-Herxheimer
Penicillin
It is thought that as the bacteria are lysed by the antibiotic, they secrete an endotoxin which can cause an inflammatory response
It does not occur in all cases, but it is imperative to warn patients that this may occur during treatment.
Reassure and dicharge with analgesia unless very ill in which case consider admission.
What are the HIV opportunistic infections and their associated CD4 count?
CD4 < 200 cells/mm<strong>3</strong> : Fungal infections such as PCP (pneumocystic jiroveci) and Candidiasis
CD4 < 100 cells/mm<strong>3</strong> : Cryptococcal Meningitis
CD4 < 50 cells/mm3: Cerebral Toxoplasmosis / Progressive Multifocal Leukoencephalopathy (PML) / Disseminated Mycobacterium Avium Complex (MAC) / CMV retinitis.
CD4 cells/mm3 > 200 and low viral load (i.e RNA) : Same susceptibility to infection as the normal population and thus Streptococcal Pneumonia and TB etc are the most likely organisms
*TB can be contracted at any CD4 level*
What is the gold standard for diagnosis of HIV infection?
HIV antibody and HIV antigen test.
Need to wait at least 4 weeks after intial transmission before these tests are suitable as it takes time to develop the viral load and the subsequent antibody response (I.e seroconversion) Often means patients need to be re-tested weeks later.
It is thus common practice to test at 4 weeks and at 3 months.
What is the treatment of uncomplicated Gonorrhoea?
** Most regimes give IM Ceftriaxone 1 g if sensitivities are NOT known**
Oral Ciprofloxacin (500mg) if sensitivites are known
(azithromycin covers potential chlamydia infection)
UKMEC 4 / Absolute Contraindications to COCP.
Uncontrolled Hypertension (Particularly >160/100)
History of VTE
Migraine w/ aura
Major Surgery w/ prolonged immobility
CVD - IHD/AF/Cardiomyopathy/Vascular Disease/Stroke
Smoking > 15/day and aged >35
Liver Cirrhosis and Liver tumours
Systemic lupus erythematosus (SLE) / Antiphospholipid syndrome
*It is worth noting that Obesity (BMI >35) is UKMEC 3 and thus the risks outweigh the benefits*
After the last period contraception is required for ___ yrs in a woman <50 and for ___ yrs in a woman > 50.
2
1
Lactational amenorrhoea is over 98% effective as contraception for up to ___ months after birth.
6 months
Benefits of COCP
Very effective (99% perfect use / 91% typical use)
Rapid return of fertility once stopped
Improves Premenstrual Syndrome/symptoms, Menorrhagia and Dysmenorrhoea
Reduced risk of Endometrial, Ovarian and Colon cancer
Reduced risk of Benign Ovarian Cysts
It is recommended to start the COCP on the ___ day of the cycle. Protection is conferred when starting the pill up to day __ of the cycle withoput any need for additional contraception.
If starting outside of this window, barrier protection should be used for the first ___ days of consistent pill use.
It is recommended to start the COCP on the 1st day of the cycle. Protection is conferred when starting the pill up to day 5 of the cycle withoput any need for additional contraception.
If starting outside of this window, barrier protection should be used for the first 7 days of consistent pill use.
The only UKMEC 4 for the Implant and Depo is ____.
Active Breast Cancer
The traditional POP (i.e Norgestron / Noriday) cannot be delayed by more than ___ hrs or it is considered a ‘missed pill’.
The ____ -only pill cannot be delayed by more than ___ hrs.
3 hrs
Desogestrel
12 hrs
It takes ____ hours before the progestogen-only pill thickens the cervical mucus enough to prevent sperm entering the uterus, protecting against pregnancy.
The combined pill takes ____ days before the woman is protected from pregnancy, as it works by inhibiting ovulation rather than thickening the cervical mucus.
Therefore, additional contraception is required for 48 hours with the POP and seven days with the COCP when starting after day 5 of the menstrual cycle. Both can be started within the first 5 days of the menstrual cycle and work immediately, as it is very unlikely a woman will ovulate this early in the cycle.
It takes 48 hours before the progestogen-only pill thickens the cervical mucus enough to prevent sperm entering the uterus, protecting against pregnancy.
The combined pill takes seven days before the woman is protected from pregnancy, as it works by inhibiting ovulation rather than thickening the cervical mucus.
Therefore, additional contraception (i.e condoms) is required for 48 hours with the POP and seven days with the COCP when starting after day 5 of the menstrual cycle.
Both can be started within the first 5 days of the menstrual cycle and work immediately without the need for additional contraception, as it is very unlikely a woman will ovulate this early in the cycle.
Remember however that the patient may need emergency contraception depending on sexual activity in the preceding days. Sex since missing pill or sex within 48hrs of starting pop.
____ is the implant used in the UK, it contains ___ mg of ____
Nexplanon
68mg
Etonogestrel (progestin)
Implant and the Depot (DMPA) need extra contraception (i.e condoms) for ___ days if started after day 5 of the cycle.
7 days
Benefits and Drawbacks of the Implant
Benefits:
Permanent (3 yrs) and doesn’t require adherence (perfect use and typical use both 99%)
Can improve painful bleeding (i.e dysmenorrhoea)
Can reduce bleeding and even amenorrhoea
Does not cause weight gain
Does not cause loss of BMD
Does not increase risk of DVT
No restrictions for obese patients
Drawbacks:
Invasive and insertion can be painful
Can migrate and become impalpable (needs X-ray or ultrasound investigation)
Does not protect against STI
Can worsen acne
Can cause problematic bleeding
Implant can fracture or bend
Contraindications to insertion of the IUS/IUD?
Pelvic Inflammatory disease or local infection (i.e STI etc)
Immunosuppresion
Uterine cavity distortion (fibroids etc)
Pelvic cancer
Pregnancy
Unexplained bleeding
The copper coil is notably contraindicated in ____ disease
Wilson’s disease
Benefits and Drawbacks of Copper Coil
Benefits:
Permanent for 5-10 yrs depending on device
Doesnt need adherence
Very effective - 99% Perfect and typical use
No Hormones (no VTE or cancer increase risk)
Immediately effective once inserted
May reduce endometrial/cervical cancer risk
Drawbacks:
Invasive
Has certain risks w/ insertion (i.e bleeding/pain/uterine perforation/PID)
Infection risk
Menorrhagia or intermenstrual bleeding (often settles)
No STI protection
Increased risk of an Ectopic
Can fall out (5%)
All IUS devices provide contraception protection for ___ yrs except for ____ which provides protection for ___ yrs.
5 yrs
Jaydess
3 yrs
Mirena and ___ coils are both licenced for menorrhagia.
The Mirena coil can also be used for ____ .
Levosert
HRT
The IUS device can be inserted up to day ___ of the menstrual cycle without the need for additional contraception. If insertion is after this point, then exclude pregnancy and provide extra contraception for ___ days.
7
7
Benefits and Drawbacks of IUS
Benefits:
Can reduce menorrhagia/dysmenorrhoea and Pelvic pain related to endometriosis
No BMD loss
No increased risk of VTE
No restrictions in Obesity
Drawbacks:
Invasive and requires procedure
Does not protect against STI’s
Can cause spotting or irregular bleeding
Ectopic risk
Increase incidence of Ovarian cysts
Systemic absorption can cause acne/breast tenderness and headaches
Can fall out (5%)
Can cause pelvic pain
____ organisms are often found incidentally in patients during a smear test when patients have a coil. Unless causing symptoms, this does not need to be treated.
Actinomyces-like organisms (ALO’s)
Ulipristal is of the _____ class and is contraindicated in which two conditions?
Selective progesterone receptor modulator (SPRM)
Breast feeding (cannot breast feed for a week)
Asthma
What is the 1st line treatment of Pneumocystis Pneumonia in HIV patients?
Co-trimoxazole
Side effects include:
- Stevens-Johnson syndrome/TEN
- Drug-induced lupus
- Agranulocytosis
What is the classical triad of pneumocystis pneumonia infection?
Fever
Non productive cough (however can have superimposed bacterial infection)
Exertional breathlessness associated with onset of infection
***Exertional breathlessness is a specific sign for PCP, and is used to stratify severity***.
On examination, the chest is often clear, however sometimes there are end inspiratory crackles present.
The ___ sign is pathognomic of LGV (Lymphogranuloma Venereum)
“Groove” Sign
LGV (subtype of chlamydia infection) begins with a painless ulcer which progresses to form painful inguinal buboes, causing the characteristic “groove” sign.
This may be accompanied by fever and malaise.
Men who have sex with men (MSM) are at higher risk of LGV.
Missed pill rules:
Use emergency contraception if she had UPSI in pill free interval. Week _
No need for emergency contraception. Week _
Take the last pill that was missed, finish the current pack and start the next pack immediately after. Week ___.
1
2
3
____ is first line for strong opioid analgesia in the latent first stage of labour.
Diamorphine IM
It has the advantage of a rapid duration of onset (within 20 minutes) and lasts for 2-4 hours.
Although spinal epidural is a valid form of analgesia, it is usually not sited until the woman is in ‘established labour’.
In HIV infection, ff the mother’s viral load is < ___ , a ___ delivery can be used. If the viral load is greater than this, a ___ is recommended
50
Normal Vaginal Delivery
C-section
What is the 1st line treatment for trichomoniasis (a flagellated single cell parasite of the protozoan species) infection?
Metronidazole (remember this is the same treatment for BV which is an important differential)
CD4 count
500 cells/mm3
cART (combined antiretroviral therapy)
An ovarian cyst is most likely to rupture during ____.
Physical activity (e.g. sexual intercourse, exercise).
Genital warts are primarily caused by ____ serotypes 6 and 11.
Human Papilloma Virus
Management of genital warts
Depends on the wishes of the patient. If the patient is not concerned about their appearance, a conservative approach can be adopted.
If there is concern, keratinised lesions can be removed using ____ whilst non keratinised lesions can be removed using _____, imiquimod or sinecatechins. The likelihood of recurrence is high.
Cryotherapy
Podophyllotoxin
_____ is the most common cause of epididymoorchitis in older males, which is often associated with urinary tract infections.
E.coli
NICE recommend the use of ____ in the treatment of vaginal candidiasis in pregnancy
Intravaginal clotrimazole
Changes to maternal physiology to consider when prescribing
This can also be described as pharmacokinetics as this is what the body does to the drug during pregnancy.
i.e
Absorption
Distribution
Metabolism
Excretion
Which contraceptives are a good alternative to COCP (lots of drug interactions) when prescribing in pregnancy?
Progesterone Only Pill
IUD
Pharmacokinetics can be described as ____
whilst
Pharmacodynamics can be described as ____
Pharmacokinetics - what the body does to the drug
Pharmacodynamics - what the drug does to the body
Pharmacokinetics during pregnancy
Note that not only is metabolism altered during pregnancy, but renal clearance is also increased dramatically due to the increased circulating blood flow and thus GFR.
To summarize in pregnancy:
Reduced/Slowed Absorption
Increased Volume of Distribution (remember increased circulating blood volume and Fat:Water ratio) Metabolism and Excretion
What are the main CYP450 enzymes
Percentage of drugs metabolised by these CYP450 subtypes:
CYP3A4 - 55%
CYP2D6 - 30%
* Concentrations of both these CYP450 enzymes increases during pregnancy leading to increased metabolism and thus renal clearance. This leads to a suboptimal concentration of the drug and thus therapeutic benefit*
CYP2D9 (10%)
CYP1A2 (3%) - *Note this enzyme decreases during pregnancy and thus can lead to toxicity of drugs administered that are also induced by CYP450*
Medications to avoid during pregnancy (teratogens)
ACEIs - Renal dysfunction, skull ossification.
Aminoglycosides - Deafness, vestibular damage.
Cytotoxic drugs - Multiple defects, abortion.
Anti-thyroid drugs - Foetal goitre.
Carbamazepine - Neural tube defects.
Diethylstilboestrol - Vaginal carcinoma.
Lithium - CVS defects (Ebstein anomaly - abnormal tricuspid valve_)_
Phenytoin- Foetal hydantoin syndrome.
Retinoids - Craniofacial, cardiac & CNS defects.
Sodium valproate - Neural tube defects.
Warfarin - Foetal warfarin syndrome.
Drugs to avoid in 3rd trimester
•Tetracyclines: Tooth discolouration.
•Warfarin: Foetal intracranial haemorrhage.
•Androgens: Masculinisation of female foetus.
•NSAIDs: Closure of foetal ductus arteriosus.
•Opioids: Withdrawal effects in neonate.
•Theophylline: Neonatal irritability.
•SSRIs: Neonatal irritability.
___ and ___ are the anti-epileptics considered to be safe in pregnancy (usual maintenance dose).
Soldium valproate can only be used if there is a _____ but is generally contraindicated unless prescribed under the guidance of a specialist due to its teratogenic effects.
Lamotrigine (more evidence) > Levetiracetam
Valproate pregnancy prevention programme in place
What is the diagnostic test of choice for soemone suspected of having Chlamydia infection?
NAAT
(Nucleic acid amplification test)
1st line antibiotic for the treatment of chlamydia?
Doxycycline (100mg BD 7 days)
*Azithromycin no longer recommended due to bacterial resistance*
For < ____ yo repeat screening is offered for chlamydia infection. This is to test for re-infection (not whether treatment has worked for original infection).
25’s
_____ (LGV) is a sexually transmitted disease, found in tropical areas.
Chlamydia trachomatis serovars ____ cause lymphatic destruction of genital tissues,leading to a painless non-indurated lesion on the penis, followed by the ‘____ sign’. This is swelling of the inguinal ligament, leading to noticeable grooves above and below.
Investigations
Diagnosis is carried out using PCR (NAAT) of the ulcers
Management
Treatment is with ____
Lymphogranuloma Venereum
L1/L2/L3
Groove
Doxycycline.
*LGV has a slightly older demographic than other STI’s affecting primarily men between the ages of 25-40*
___ sign is when an inguinal lymphoadenopathy (AKA a BUBO) is split by poubarts ligament and is pathognomonic of ____ infection.
Groove Sign
Lymphogranuloma Venereum
How do we investigate a patient with suspected gonorrhoea?
NAAT
Microscopy is possible unlike chlamydia and you may see gram negative diplococci however whilst microscopy is 90% sesistive in men with discharge it is only 50% sensitive for women.
- Anyone with a positive NAAT needs to be swabbed in an areas of sexual contact for culture.
____ (1st line) and ___ are the antibiotics of choice in gonorrhoeal infection.
A test of cure is recommended ___ weeks after treatment to monitor disease clearance and decide on whether the antibiotic regimen used was effective or needs altering
The current guidance on treatment recommends treatment with both Ceftriaxone (1st line) and Azithromycin (lots of resistance to this strain atm) to cover possible Chlamydia co-infection
A test of cure is recommended to monitor disease clearance 2 weeks after treatment and decide on whether the antibiotic regimen used was effective or needs altering.
All partners should be notified with permission from the patient.
Partners only treated empirically if they have had sex in last 14 days
Complications of STI’s (Chlamydia and Gonorrhoea)
PID (sepsis - subfertility - Ectopic risk)
Epididymo-Orchitis (EO)
SARA (Sexually Acquired Reactive Arthritis)
Perihepatitis (Fitz-Hugh-Curtis syndrome)
HIV risk
Gonorrhoea can also cause a disseminated rash.
Untreated gonorrhoea can lead to major complications, such as:
Infertility in women: Gonorrhoea can spread into the uterus and fallopian tubes, causing pelvic inflammatory disease (PID). PID can result in scarring of the tubes, greater risk of pregnancy complications and infertility.
Infertility in men: Gonorrhoea can cause a small, coiled tube in the rear portion of the testicles where the sperm ducts are located (epididymis) to become inflamed (epididymitis). Untreated epididymitis can lead to infertility.
Infection that spreads to the joints and other areas of the body: The bacterium that causes gonorrhoea can spread through the bloodstream and infect other parts of your body, including your joints. Fever, rash, skin sores, joint pain, swelling and stiffness are possible results.
Increased risk of HIV/AIDS: Having gonorrhoea makes you more susceptible to infection with human immunodeficiency virus (HIV), the virus that leads to AIDS. People who have both gonorrhoea and HIV are able to pass both diseases more readily to their partners.
_____ is a tiny bacteria that can cause a non specific urethritis and can present similarly to other STI’s like gonorrhoea and chlaymdia. However it is often asymptomatic.
Can be tested for using ____ and is treated similarly to chlamydia in uncomplicated infection with ____.
However Complicated infection needs to be managed with a different antibiotic called ____
Mycoplasma Genitalium
NAAT
Doxycyline + Azithromycin
**Moxifloxacin** (14 days OD)
Primary syphillis often present around ___ weeks after initial infection with a ____.
3 weeks
Chancre
*often described as single painless indurated*
Secondary syphillis most commonly presents around ____ after initial infection.
Most common symptom is a _____ (75%)
Wart like lesions called _____
Mucocutaneous lesions (6-30%)
Generalised lymphadenopathy (50-86%)
Multi-system involvement- Sore throat, malaise, weight loss, fever, musculoskeletal.
3 months
Maculopapular Rash
**Condylomata lata**
Multisystem involvement can also lead to nephritis/hepatitis etc and often can cause neurological symptoms (tinnitus/ocular syphillis/stroke)
Tertiary Syphillis leads to:
Cardiovascular (____ yrs after initial infeciton)
- Symptomatic/complicated in 10%
- Ascending aorta: dilatation & aortic regurgitation
- Rarely: coronary ostial stenosis, saccular aneurysm
_____ (2-15 years after inital infection)
• ____ lesions with central necrosis
10-30
Gummatous
Granulomatous
Neurosyphillis (3 types)
_____ (15-25 years)
Lightening pains, sensory ataxia, _____ Pupil
General Paresis (10-25 years)
Progressive severe dementia with seizures
Meningo-vascular (2-7 years)
Often affects younger patients
____ artery most commonly affected
Focal arteritis leading to ischaemic stroke Prodrome of headache, labile emotions, insomnia
Tabes Dorsalis (type of neurosyphillis)
Argylle- Robertson pupil (dilates to accommodation but not light)
MCA -middle cerebral artery
Syphillis can be diagnosed using ____ microscopy or ____.
**Dark Ground** Microscopy (useful only for penile chancres)
NAAT (pcr)
Cna also do serology (i.e blood test)
The _____ reaction is a classical reaction to penicillin treatment in syphilis infection. The reaction occurs within ____ hours and is characterized by fever, rash, rigors and tachycardia.
It is thought that as the bacteria are lysed by the antibiotic, they secrete an endotoxin which can cause an inflammatory response
It does not occur in all cases, but it is imperative to warn patients that this may occur during treatment.
Jarisch-Herxheimer
24 hours
Management
Should a patient experience serious symptoms, it is advisable to admit and monitor the patient and hydrate as required
Jarisch Herxheimer reaction (JHR) is a transient clinical phenomenon that occurs in patients infected by spirochetes who undergo antibiotic treatment. The reaction occurs within 24 hours of antibiotic treatment of spirochete infections, including syphilis, leptospirosis, Lyme disease, and relapsing feve
Syphillis follow up:
Primary Syphilis
• All partners in last ____
Secondary and Early latent Syphilis
• All partners in last ___
Late Latent and Tertiary Syphilis
• Guided by previous serology but potentially all previous partners
*Serology is monitored for 12 months whilst on treatment to see that levels of bacteria are falling appropriately*
3 months
2 years
Clinical Features of HSV
Genital ulcers (painful)
Dysuria
Mouth ulcers
Prodromal illness (fever flu like symptoms)
Vaginal or Penile discharge
Lymphadenopathy (first episode bilateral - recurrent infection - unilateral)
Extragenital manifestations of HSV?
Neurological:
Meningitis
Encephalitis
Dermatological:
*dermatitis herpetiformis*
*herpetic whitlow*
Ophthamological:
Herpetic eye disease (dendritic corneal ulcers)
Diagnosis of HSV is made using ___
1st line: Viral PCR of skin lesions
Can also used:
Serology - IgG
Sometimes culture can be used
Pregnant women with HSV are offered ____ at 36 weeks gestation to minimise risk of passing to fetus.
Aciclovir
*Risk of neonatal herpes is much increased if mother acquires HSV during pregnancy. This is because there is not enough time to produce the IgG antibody that would protect the baby*
- in this case aciclovir and C-Section would be offered to mother to reduce the risk of transmission.
HPV
_____ (low risk strains often cause benign neoplasia ex. condylomata)
___ (high risk strains often cause Intraepithelial Neoplasia in the vulva, cervix, anus etc)
6 and 11
16 and 18 (McCarthy and Schneiderlinn)
Cervarix (bivalent) immunises against two types: 16 and 18.
Gardasil: protects against 6, 11, 16 and 18
Management of HPV (genital)?
Cryotherapy (irritates and stimulates surrounding skin mounting immune response)
Topical Agents (Imiquimod)
Electro-cautery
Surgery
Nothing (30% wil disappear)
*Gynae referral if suspect Intraepithelial Neoplasia*
All acute hepatitis infections are notifiable illnesses for public health.
Hepatitis B Serology Interpretation:
Surface antigen (HBsAg) – _____
E antigen (HBeAg) – _____
Core antibodies (HBcAb) – ____ (acute infection antibody ___ Chronic infection antibody ___)
Surface antibody (HBsAb) – _____
Hepatitis B virus DNA (HBV DNA) – _____
Surface antigen (HBsAg) – active infection
Envelope antigen (HBeAg) – marker of viral replication and implies high infectivity
Envelope antibody (HBeAb) - stopped replicating
Core antibodies (HBcAb) – implies past or current infection (IgM high in acute infection / IgG high in chronic or cleared infection )
Surface antibody (HBsAb) – implies vaccination or past or current infection
Hepatitis B virus DNA (HBV DNA) – this is a direct count of the viral load
*remember Hep B is only DNA virus*
Management of Hepatitis B
Antivirals
1st line: Peginterferon
2nd line: Tenofovir or entecavir
Also screen for co-infection of Hep D
and
Refer to Hepatology
Hepatitis B is the only ____ virus.
DNA
Which type of hepatitis does not have an available vaccine?
Hepatitis C
This disease is now CURABLE with antiviral treatment
Investigations in Hep C infection?
Hep C Antibody
Hep C RNA load (PCR)
Acute and Chronic Hepatitis C Infection features:
Most infections are _____ , and only ____ clear the virus. ___ go on to develop chronic infection
Patients with chronic infection have persistently high LFTs, and ____ develops in 20-30%.
1-4% of patients with cirrhosis develop ____ , and 2-5% develop liver failure.
asymptomatic
15-25%
75%
cirrhosis
hepatocellular carcinoma
Most common type of vulval cancer?
Squamous cell carcinoma
Possible to also get:
Adenocarcinoma (bartholin’s/Paget’s - premalignant condition)
Basal Cell Carcinoma
Malignant Melanoma
*thing to remember with vulval cancer is its essentially a skin cancer*
2 biggest risk factors for vulval cancer?
Lichen Planus/Lichen Sclerosis (5% Lifetime Risk)
and
HPV (16, 18 and 32)
Fetal heartbeat can be heard via TV ultrasound from as early as ____ weeks
6 Weeks
Management of Misscarriage
Most common site of ecotpic pregnancy?
Ampulla of fallopian tube
Clinical presentation of Ectopic
Remember blood is usually brown due to decidua breaking down
Management of Ectopic Pregnancy
Medical Management:
1st line (unless patient very unwell) - one-off dose of methotrexate.
(The woman is required to come to a follow-up appointment)
If the initial dose of methotrexate has failed to treat the ectopic they will require either a second dose of methotrexate or surgical management.
Surgical Management:
Surgical management is recommended if the patient would be unable to attend follow-up or if the ectopic is advanced. An advanced ectopic is indicated if any of the following are present:
The patient is in a significant amount of pain
There is an adnexal mass of size ≥35mm
B-hCG levels are ≥5000IU/L (consult local guidelines)
Ultrasound identifies a foetal heartbeat
Surgical management is often in the form of a salpingectomy where the Fallopian tube containing the ectopic is removed, unless only one functioning Fallopian tube, and they wish to remain fertile, a salpingotomy may be done where only the ectopic is removed.
Salpingotomy carries the risk that not all the tissue may have been removed and so serial serum B-hCG measurements are done to exclude any trophoblastic tissue still within the Fallopian tube.
Classic presentation of Placental abruption
Remember often much more painful than placenta praevia
- Can be concealed and thus get no blood
- Woody as in hard because of uterine spasms (contracted muscle)
Risk factors for placenta praevia
Main one is Previous C-Section
Management of pre-eclampsia
1st line: Labetalol (contraindicated in asthma)
- Nifedipine/Methyldopa
Delivery
Biggest risk factor for Uterine rupture? (occurs during delivery - no contractions/pain)
Vaginal delivery after previous C-Section
Management of a Uterine Rupture?
Emergency Laporotomy
What is the main differential for a amniotic fluid embolism?
PE
*Remember Amniotic Fluid Embolism is extremely rare*
Management: Delivery (Category 1 C-Section) and Resus mother
What is the management of Shoulder Dystocia?
Call for help
Ask mother to stop pushing
1st line - McRoberts Manoevre (90% successful)
2nd line:
All-fours position
Internal rotational manoeuvres:
Woods’ screw manoeuvre: anterior shoulder is pushed towards the foetal chest and the posterior shoulder is pushed towards the foetal back.
Rubin manoeuvre II: rotation of the anterior shoulder towards the foetal chest.
If External Cephalic Version (ECV) at 37 weeks is declined, what risk is the pregancy at?
Umbilical Cord Prolapse
High risk of fetal mortality as placental blood supply is compromised (often bradycardia on ECG)
