obs and gynae Flashcards
1
Q
what is the most common type of cervical cancer
A
squamous cell carcinoma
2
Q
what is the most common type of endometrial cancer
A
adenocarcinoma
3
Q
what is the most common type of vulval cancer
A
squamous cell carcinoma
4
Q
what is the most common type of ovarian cancer
A
adenocarcinoma
5
Q
symptoms of ovarian cancer
A
bloating, early satiety, abdo fullness, pelvic pain, abnormal bleeding, weight loss, urinary symptoms, bowel habit change
6
Q
symptoms of cervical cancer
A
post coital bleeding
incidental finding on smear
inter menstrual bleeding
deep dyspareunia
7
Q
presentation of vulval cancer
A
itching bleeding ulceration abnormal lump fungating lesion
8
Q
symptoms of endometrial cancer
A
post menopausal bleeding
menorrhagia
intermenstrual bleeding
post coital bleeding
9
Q
causes of post menopausal bleeding
A
endometrial cancer endometrial hyperplasia vaginal dryness trauma cervical cancer
10
Q
causes of post coital bleeding
A
cervical ectropion
cervical cancer
cervical polyp
endometrial polyp
11
Q
causes of menorrhagia
A
fibroids polyp dysfunctional uterine bleeding systemic: hypothyroid endometrial cancer endometrial hyperplasia
12
Q
2WW criteria post menopausal bleeding
A
anyone over the age of 55 post menopausal bleeding
13
Q
2WW criteria cervical cancer
A
abnormal smear results
14
Q
risk factors for cervical cancer
A
HPV 16 and 18, smoking
15
Q
risk factors for ovarian cancer
A
obesity, BRCA 1 and 2, increased number of ovulations so early menarche, late menopause
16
Q
risk factors for endometrial cancer
A
post menopausal, HRT, COCP, early menarche, late menopause, no pregnancies
17
Q
risk factors for vulval cancer
A
smoking,
18
Q
causes of pelvic pain
A
acute: ectopic, ovarian torsion
chronic: large fibroid, large cyst, endometriosis (cyclical), adenomyosis (cyclical)
19
Q
causes of pelvic pain
A
acute: ectopic, ovarian torsion, cyst rupture, PID
chronic: large fibroid, large cyst, endometriosis (cyclical), adenomyosis (cyclical), premenstrual syndrome
20
Q
name 4 types of ovarian cancer
A
teratoma
21
Q
investigations for cervical cancer
A
HPV testing and cervical cytology
colposcopy and biopsy
CT for FIGO staging
22
Q
investigations for ovarian cancer
A
TVUSS or transabdo USS laparoscopic exploration and biopsy CA 125 AFP,BHCG,LDH CT for staging
23
Q
investigations for endometrial cancer
A
TVUSS for endometrial thickness
hysteroscopy and biopsy
CT for staging
24
Q
investigations for vulval cancer
A
biopsy / resect lesion
25
what staging systems are used for gynae cancers
FIGO
26
cervical cancer staging (1-4)
```
1. cervix only
2a - cervix + upper 1/3 vagina
2b cervix + lower 2/3 vagina and pelvic wall
3. bladder and bowel involvement
4. distal mets
```
27
ovarian cancer staging (1-4)
1. ovary only
2. pelvic only
3. past pelvis but still in abdo
4. distal mets
28
treatment of cervical cancer
large loop excision
| hysterectomy
29
treatment of ovarian cancer
oophrectomy
hysterectomy and bilateral salpingoophrectomy
chemotherapy
radiotherapy
30
treatment of endometrial cancer
hysterectomy
31
symptoms of ectopic pregnancy
unilateral severe pelvic pain, amenorrhoea for 6-8 weeks, PV bleed (often brown),
ruptured: pallor, syncope, hypotension, pv bleed, tachy
32
risk factors for ectopic pregnancy
endometriosis
| PID
33
what investigations should you do for suspected ectopic pregnancy
TVUSS
BHCG
pregnancy test
34
management of ectopic pregnancy
medical:
watch and wait for 48 hours
IM methotrexate
surgical: laparoscopy oophrectomy
35
management of ectopic pregnancy ruptured
laparoscopic oophrectomy
36
management of unruptured ectopic, embryo <3cm and BHCG <1500 and no heart beat
watch and wait for 48 hours, expectant
37
criteria for watch and wait (expectant) for ectopic pregnancy
no heart beat, BHCG < 1500, embryo less than 3 cm and unruptured
38
complications of ectopic pregnancy
haemorrhage into perionteum
peritonitis
subfertility
39
investigation findings in ectopic pregnancy
empty uterus
mass in fallopian tubes
fluid in pouch of douglas if ruptured
40
most common location for ectopic pregnancy
ampulla
41
definition of premature menopause
cessation of menstruation for 12 months, before the age of 40
42
what blood test do you do to test for menopause
FSH levels
43
causes of premature menopause
prev chemo, radiotherapy
| premature ovarian insufficiency
44
management of premature menopause
HRT for all women until normal age of menopause (age 50) to protect bones and other symptoms of oestrogen deficiency
45
HRT choice for women with uterus
combined
46
HRT for women without uterus
oestrogen
47
describe menstrual cycle
day 1-14 follicular phase
day 15-28 luteal phase
day 14 = ovulation
follicular phase: rising FSH causes follicles to develop, oestrogen is also rising, then when oestrogen suddenly drops there is a surge in LH which causes ovulation
luteal phase: after ovulation the corpus luteum forms and starts to produce progesterone if the egg isn' fertilised. Then when the corpus luteum begins to break down the levels of oestrogen and progesterone begin to fall again causing the uterine lining to shed. as oestrogen is falling, LH and FSH begins to be released from anterior pituitary again as there is no negitive feedback bringing us back to day 1 where follicles begin to develop again.
48
function of progesterone
maintains endometrial thickness
| maintains thick cervical mucus
49
function of oestrogen
secondary sex characteristics
50
where is oestrogen produced
follicles in ovary
51
where is progesterone produced
corpus luteum
| placenta
52
investigations for menorrhagia
FBC to look for anaemia
TVUSS
hysteroscopy if abnormal USS
systemic: TFT's, HBa1c
53
medical management of dysfunctional uterine bleeding
1st line NSAID mefenamic acid
tranexamic acid to stop bleeding
tx the cause:
54
medical management of dysfunctional uterine bleeding
1st line NSAID mefenamic acid
tranexamic acid to stop bleeding
2nd line - hormonal control- cocp, mirena, depot
tx the cause: endometrial ablation, resection of fibroids, polyp removal, uterine artery embolisation
radical - hysterectomy
55
investigations for post menopausal bleeding
TVUSS
hysteroscopy
speculum and bimanual exam
56
total contraindications to HRT
current or past breast cancer
| current or recent DVT/PE
57
definition of endometriosis
endometrial lining growing outside of the uterus
58
symptoms of endometriosis
cyclical abdo/pelvic pain, menorrhagia, deep dyspareuia, subfertility, bloating
urinary frequency, dysuria
dyszchecia, pr bleed
59
gold standard investigation in endometriosis
laporoscopic exploration
60
name 4 causes of a raised CA 125
ovarian cancer
endometriosis
liver disease
61
name 3 findings on examination in a pt with endometriosis
fixed retroverted uterus
fixed cervix
adnexal mass
pain on examination
62
where would you find chocolate cysts
ovaries - endometriomas
63
how can you optimise fertility in endometriosis
removing ectopic endometrial tissue via surgery
64
1st line management endometriosis
NSAID symptom control - mefenamic acid, tranexamic acid
65
2nd line management of endometriosis
contraception COCP, mirena, depot
66
management options for endometriosis
nsaid symptom control
hormonal - cocp, depot mirena
goserelin GnRH analogue can be used short term
surgical - removal of endometriomas
hysterectomy
67
what is adenomyosis
endometrial tissue growing in the myometrium
68
investigations in adenomyosis
TVUSS
69
management of adenomyosis
hormonal control
70
symptoms of menopause
vasomotor - flushes, night sweats, tachy,
neuro - brain fog, low mood,
weight changes
71
SE / complications of menopause
dementia
parksinsons
osteoporosis
72
what is an adnexal torsion
when the ovary and the fallopian tube twist on the ligaments
73
risk factors for ovarian torsion
large cyst
74
presentation of ovarian torsion
sudden onset severe unilateral pelvic pain associated with nausea and vomiting, low grade fever
can also be intermittent if twists and un twists
75
1st line investigation for suspected ovarian torsion
TVUSS
76
findings on TVUSS for ovarian torsion
whirlpool sign - fluid
77
gold standard investigation for ovarian torsion
laparoscopic exploration
78
what is a polyp made of
endometrial epithelium
79
what is a fibroid made of
endometrium and smooth muscle
80
most common type of fibroid
intramural
81
symptoms of fibroids
```
asymptomatic
menorrhagia
pelvic pain / ache / fullness
dyspareunia
urinary symptoms (if large) - frequency
bowel symptoms (if large)
subfertility if large / blocking
```
82
complications of fibroids in pregnancy
red degeneration in 2nd or 3rd trimester when fibroid breaks down and becomes necrotic
miscarriage
premature labour
83
investigations for fibroids
TVUSS
| hysteroscopy
84
management of fibroids (medical and surgical) and how to choose what to do
medical - mirena
symptoms - mefenamic acid
surgical - endometrial abalation, uterine artery embolisation, fibroidectomy
85
which type of fibroid is most likely to cause heavy menstrual bleeding
submucosal
86
treatment of symptomatic polyps
polypectomy
87
where is a barthaloins cyst located
posterior vagina on each side in the vulva
88
what is the treatment of barthaloins cyst
no treatment needed unless large then can drain
89
what is treatment of barthaloins abscess
antibiotics - usually e.coli infection, drainage
90
where is a gartners duct cyst located
upper vagina
91
where are urethral diverticulums located
lateral vaginal wall
92
what are symptoms of a urethral diverticulum
recurrent uti,
93
where are nabothian cysts located
on the cervix
94
what is a cervical ectropion
an area of the cervix that has changed from squamous to columnar
95
what is the most common cause of post coital bleedinh
cervical ectropion
96
what factors increase risk of developing a cervical ectropion
young age
97
what is lichen sclerosis
when elastin in vaginal skin turns into collagen and becomes hard, dry and pale (lichenified)
98
name 2 complications of lichen sclerosis
narrowing of vaginal and urethral openings due to skin tightness
SCC of vulva
99
what would you find on examination in lichen sclerosis
pale looking vulva, dry, hard
100
symptoms of lichen sclerosis
itching, soreness, dryness
101
what is the management of lichen sclerosis
dermovate (topical steroid 0.05%) long term for maintenance, can up to every day if symptoms are bad
102
what 3 factors make up the risk of malignancy index for ovarian cancer / ovarian cysts
menopause status
ca 125 level
USS findings
103
what tests should you do in patients with ovarian cysts
TVUSS
| Ca 125
104
what tests should you do with all women aged under 45 with complex cyst (not functional)
AFP
BHCG
LDH
ca 125
105
management of simple 2-5cm ovarian cyst
nothing
106
management of ovarian cyst simple 5-7cm
monitor with yearly USS
107
management of ovarian cysts over 7cm
refer to gynae for further investigation eg laparoscopy or mri
108
when is a total hysterectomy with bilateral salpingoophrectomy preferred in women with ovarian cysts
when it is a complex cyst and under age 45 eg serous cyst, mucinous cyst, dermoid cyst
109
red flag symptoms for ovarian cysts to ask about that may indicate malignancy
```
weight loss
bloating
ascites
early satiety
change in bladder or bowel habits
palpable mass
```
110
risk factors to ask about in ovarian cysts that increase risk of malignancy
BRCA 1 + 2 status, family history, HRT
111
name 4 types of ovarian cysts that may turn malignant
serous
mucinous
dermoid teratomas
sex cell stromal
112
name the 2 functional ovarian cyst types
follicular and corpus luteum
113
which type of ovarian cyst is likely to be very large
mucinous
114
which type of cyst contains hair, teeth, skin and bone cells
dermoid
115
which medication is used to shrink the size of fibroids whilst waiting for surgery
GnRH analogues eg goserelin in the short term
116
what is the most common complication following a surgical termination of pregnancy
infection!
| others: retained pregnancy tissue, failure, trauma to cervix, haemorrhage,
117
what is gillick competence
children under the age of 16 can consent to their own treatment if they are deemed to have enough intelligence and understanding of what is involved in the treatment., they must have capacity to consent so must be able to retain, weigh up, communicate and understand the treatment and other options available to them.
a child cannot refuse treatment if it will lead to death or serious harm
when assesing gillick competency you should consider whether there are any safeguarding concerns - a child cannot be gillick competent if you think they are being pressured by someone else to make a decision
118
when can you start re taking the progesterone only pill post-partum
immediately regardless of breastfeeding status
119
when do women need to start contraception after giving birth
day 21
120
when can you start COCP after birth
after 6 weeks - 6 months if breastfeeding
| never start before 6 weeks bc reduces lactation for breast feeding and increases VTE risk post partum
121
when can the mirena coil be inserted post partum
after 48 hours
122
if not started on day 1-5of menstrual cycle, how long does POP take to be effective
2 days
123
if not started on day 1-5 of menstrual cycle how long does COCP take to be effective
7 days
124
management of premenstrual syndrome
a new generation COCP taken continuously
125
name 3 functions of the placenta
to remove fetal waste
to provide fetus with nutrients
produces steroid and hormones that maintain pregnancy
barrier against infection
126
where is the basal plate located
in the placenta next to the maternal side
127
where is the chorionic plate located
in the placenta on the fetal side
128
what is the decidual reaction
the reaction that prepares the body after implantation and the changes in the uterus that occurs during implantation
the endometrium becomes increasingly vascular, has increased secretory activity and uterine glands dilate.
129
what is the function of the decidua
forms the basal plate of the placenta
allows implantation of the blastocyts
supplies nutrients early on
130
describe the maturation of oocytes and when each stage occurs
oocytes mature into primary oocytes with 46 X
the under goes 1st meiotic division but doesn't actually complete until puberty
at puberty the follicle matures and 1st meiotic division completes
then secondary oocyte (23, X) forms when the primary oocyte splits into 2nd oocyte and polar body
if fertalisation occurs after ovulation the 2nd meitoic division completes and the female pronucleus is formed as 23, x and a second polar body is formed
the female pronucleus can now join with the male pronucleus to start forming an embryo
131
how many chromosomes are in a primary oocyte
46, x
132
how many chromosomes are in a secondary oocyte
23, x
133
describe the process of fertalisation
sperm meets oocyte
acrosomal cap of the sperm head releases hyaluronase to eat the corona radiata to be able to penetrate the zona pellucida
once zona pellucida has been penetrated it hardens so no other sperm can penetrate
completion of 2nd meiotic division occurs shortly after
male and female pro nuclei then restore original diploid number of chromosomes
zygote is formed containing mum and dads genetic info
134
which hormone is responsible for ovulation
surge in LH, FSH stimulates follicles
135
which hormone is responsible for the decidual reaction
progesterone
136
what is the normal amniotic fluid volume at 12 weeks
50ml
137
what is the normal amniotic fluid volume at 36-38 weeks
1L
138
cause of green amniotic fluid
meconium - a sign of fetal distress
139
cause of gold amniotic fluid
rhesus incompatibility indicating haemolysis of fetal RBC's
140
what colour should amniotic fluid be
clear
141
cause of tobacco coloured amniotic fluid
intra uterine death
142
what is amniotic fluid made up of
water, glucose, protein, urea, electrolytes, lipids
143
name 4 functions of amniotic fluid
to protect fetus from shock
to maintain fetal temp
allows for growth of and free movement of fetus
flushes the birth canal in first stage of labour (ROM) with anti microbial effects
144
when is the cut off date for pregnancy viability
24 weeks = viable pregnany so bleeding before that = misscarriage bleeding after that = antepartum bleed
145
explain gravida
total number of pregnancies including past and current
146
explain parity
total number of pregnancies that have gone past viable stage (24 weeks) so including still births but not including miscarriage
147
what is nullipara
first time giving birth
148
what is a primagravida
pregnant for first time
149
what is a multipara
more than 2 pregnancies made it past 24 weeks
150
what is a multigravida
previously been pregnant
151
how do you calculate the period of gestation in the early stages vs later stages
early stages = days from last day of last menstrual period
| later stages = days from expected due date
152
how do you determine the station of the fetus
the lowest bony part of the body eg feet if breach or skull if head compared to the level of the ischial spines
153
what is engagement
when the widest part of the foetus has passed through the pevlis
154
what is attitude
whether the foetus is flexed or deflexed - flexed is easier to deliver
155
describe the first stage of labour
when contractions become painful and more regular
start off as irregular and far apart (5-10 mins) this latent phase usually lasts 6 hours to 3 days
patient advised to stay at home during this phase
the cervic begins to efface and cervical dilation begins up to 4 cm
active labour begins after cervix is dilated by 4cm
regular painful and more frequent contractions
fetal head descends into pelvis
cervix dilated by 1cm per hour until 9-10cm when head should be engaged and woman feels urge to push
156
how many cm does it need to be to be classed as active labour
4cm
157
how fast does the cervix dilate in nulliparous women
2cm per hour
158
how fast does the cervix dilate in multiparous women
1cm per hour
159
when is the first stage of labour classed as failure to progress and how do you manage it
16 hours
160
how do you manage the 1st stage of active labour
temp and bp every 2 hours
monitor strength and frequency of contractions
monitor fetal heart rate - should be between 120-160 bpm
doppler ultrasound transducer
vaginal examination every 4 hours
161
what should the fetal heart rate be between in labour
120-160 bpm
162
how often do contractions happen in 2nd stage of labour
every 2-5 mins
163
how long do uterine contractions last in 2nd stage of labour
60-90 seconds
164
when should vacuum extraction and forceps be used
after 2 hours of active pushing if fetus still not birthed
165
when should vacuum extraction and forceps be used
after 2 hours of active pushing if fetus still not birthed, unless woman has had an epidural then wait 3 hours before intervention
166
what should you do if fetal heart rate drops below 100bpm in active second stage of labour
do a vaginal examination to make sure cord hasn't prolapsed
167
what should be used to clean the vulva once the fetal head is visable by 5cm
chlorhexadine
168
what score should be completed once the baby is born
APGAR score
169
what injection is given to all new born babies, how much and when
IM vitamin K (phytomenadione) 1mg at birth, at 3-4 days and after 6 weeks
170
which scoring tool can be used to screen for post-natal depression
edinburgh scale
171
how much would you expect the fundal height to increase by after 24 weeks gestation
1cm per week
| increasing by more than that you would be concerned about multiple pregnancy or a large baby
172
presentation of fibroid degeneration in pregnancy
fibroids grow bigger in 1st trimester due to increased oestrogen and can degenerate causing a low grade fever, pelvic pain, vomiting and a larger than expected uterus
usually resolves on its own within 4-7 days
173
presentation of fibroid degeneration in pregnancy
fibroids grow bigger in 1st trimester due to increased oestrogen and can degenerate causing a low grade fever, pelvic pain, vomiting and a larger than expected uterus
usually resolves on its own within 4-7 days
manage with analgesia and watchful waiting
174
risk factors for still birth
```
intrahepatic cholestasis of pregnancy - early delivery
age over 35
obesity
drinking
smoking
haemorrhage
cord prolapse
diabetes
pre eclampsia
placental abruption
maternal group B strep infection
```
175
what position does the fetus descend in before engagement
occipito transverse
176
what is engagement
where the widest diameter of the fetal presenting part (usually widest diameter of the head) reaches the pelvic brim
177
in which direction does the fetus turn in before it crowns
internally rotates 90 degrees so the head is occiput anterior
178
what is the normal rotation of the baby for birth
occiput anterior
179
how are the shoulders of the baby birthed
head naturally externally rotates and then anterior shoulder is birthed by downward traction and upward traction to birth the posterior shoulder
180
how is the fetal body delivered
naturally with contractions
181
name 4 indications for induction of labour
```
5 x P's
post dates >41 weeks
PPROM
pre eclampsia
placenta previa
plus diabetes
```
182
what method of inducing labour would you use in a woman with a bishop score of 0-4
PGE2 - dinoprostone gel inserted into posterior fornix of vagina
183
what type of drug is dinoprostone
PGE2 - prostaglandin E2 analogue
184
which type of drug is used for aborting in utero fetal death in the second trimester
misoprostol - PGE1
185
why is misoprostol not used in the 3rd trimester to induce labour
because it increases the risk of uterine hypertonicity which is risky for fetus and mother and can cause uterine rupture
186
how would you induce labour in a woman with a bishop score over 5
PGE2 and or amniotomy
187
what should you check for before performing an amniotomy
bishop score over 5
cord prolapse
? low lying placenta
188
how would you manage the labour of a patient who has already had PGE2 and after 6 hours has a bishop score of 4
repeat PGE2
189
how would you manage the labour of a patient who has had 2x doses of PGE2 whos bishop score hasn't changed after 12 hours
C-section
190
how would you manage a patient who has had PGE2 and after 6 hours the bishop score is 5+
Amniotomy
191
how would you manage a patient who has had PGE2 and amniotomy to induce labour and still hasn't gone into labour
IV oxytocin infusion
192
how would you manage a patient who has had PGE2, amniotomy, IV oxytocin and still hasn't gone into labour after 6 hours
repeat PGE2 gel
193
how would you manage a patient who has had a PGE2, amniotomy, IV oxytocin and a repeat PGE2 and still hasn't gone into labour after 10 hours
C-section
194
when is IV oxytocin indicated in the induction of labour
after PGE2 gel and amniotomy, must have bishop score of over 5
195
what is the definition of failure to progress
failure to dilate more than 2cm in 4 hours or slowing in progress of multiparous woman
196
how would you manage a woman who is 41 weeks with no signs of labour
membrane sweep
197
how does a membrane sweep work
put your finger between the membrane of placenta to help them rupture
198
what 3 factors affect progress in labour
power - strength of contractions
passenger - size of baby eg cephalopelvic disproportion, malpresentation, abnormal lie
passage - shape and size of pelvis and soft tissue
199
complications of oxytocin infusion
uterine hyperstimulation
200
how can you identify a fetus in the occiput posterior position
fetal back is palpable in the flank and heart beat heard loudest here
201
how do you manage a labour where baby is occiput posterior
1. monitor with partogram
2. if there is a delay in the 2nd stage of more than 2 hours then intervene
3. forceps / ventouse
4. if gets stuck in transverse then C-section
202
how do you manage breech presentation at 37 weeks
offer external cephalic version
203
how do you manage breech presentation at <36 weeks
wait - usually turns at around 36 weeks naturally
204
at what week does the fetus turn to cephalic from breech
36 weeks
205
how do you manage a breech presentation that has had a failed ECV
c-section
206
how do you manage a birth where there is late identification of breech presentation
```
sometimes happens in multiple pregnancy
get woman not to push until the bum is visable
birthed on all 4's
epistotomy needed
if poor descent then emergency C-section
```
207
name 5 causes of failure to progress
```
cephalopelvic disproportion
hypoactive uterus (low resting tone, weak contraction)
```
hyperactive incoordinate uterus - increased resting tone, v painful, slow cervical dilation
malpresentation / malposition
shoulder presentation - obstructs labour
208
a woman fails to progress and there is an arrest in descent of the fetus and dilation despite good strong contractions what is the cause
cephalopelvic disproportion
209
cervix stops dilating at 4cm after 8 hours what is the cause
prolonged latent phase
210
cervical dilation in labour is to the right of the partogram what is the cause
prolonged active phase
211
infrequent contractions, cervix not dilated and no palpable contractions (weak) what is the cause
false labour
212
how would you manage a cord prolapse
```
push the fetal presenting part back up
on all 4's
make sure cord doesn't get cold (spasm)
check fetal heart sounds
emergency C-section
```
213
what increases the risk of a cord prolapse
malpresentation
| post-amniotomy
214
what does a cardiotocograph measure
fetal heart rate and uterine activity
215
what is the normal baseline fetal heart rate on cardiotocograph
110-160
216
what is a reassuring level of variability on CTG
variability over 5
217
what causes an acceleration on CTG
fetal movement, considered normal
218
what causes deceleration on CTG and when is it considered a worrying sign
during contractions in the early stage decelerations can occur and are conidered normal
in late stages if decelerations occur AFTER contractions its a worrying sign of fetal distress
219
what is measured on a partogram
```
maternal heart rate, BP, UO, temp
descent of fetal head
fetal HR
frequency of contractions
status of membranes and colour of liquid
drugs and fluids that have been given and when
```
220
how is a delay in progress in the 3nd stage of labour defined
more than 60 minutes with physiological management
| more than 30 minutes with active management
221
how is a delay in the second stage of labour defined
more than 2 hours of pushing in nulliparous and more than 1 hour in multiparous
222
what is a braxton hick contraction
occasional irregular contraction of the uterus that happens in the late stages of pregnancy, feels like temporary tightening or cramping
223
how can you diagnose the onset of labour
mucus show
cervical dilatation and effacement
regular painful contractions
rupture of membranes
224
what is given to the mother after an instrumental delivery
stat co-amoxiclav to prevent infection
225
name 4 indications for an instrumental delivery
fetal distress
maternal exhaustion
failure to progress in 2nd stage
to control the head in delivery in abnormal position
226
what increases the risk of requiring an instrumental delivery
epidural - reduces effective contractions
227
risks to the mother of an instrumental delivery
```
peristotomy
femoral and obtruator nerve damage
infection
PPH
anal sphincter injury
```
228
risks to the baby of an instrumental delivery
```
cephalohaematoma
facial nerve palsy / paralysis
intracranial haemorrhage
subgaleal haemorrhage
skull fracture
bruises
fat necrosis
```
229
main complication of ventouse delivery for baby
cephalohaematoma
230
main complication of forceps delivery for baby
facial nerve palsy
231
which nerves are at risk of being damaged (maternal) in an instrumental delivery
obtruator: causes weak hip adduction and rotation and numb medial thigh
femoral: weak knee extension and numb anterior thigh
232
where are the transducers placed when measuring cardiotocography
one placed over fetal heart
| one placed above fundus to measure contractions
233
name 6 indications for continuous CTG monitoring
Maternal:
- sepsis
- maternal tachycardia >120
- pre eclampsia
- fresh antepartum haemorrhage
- use of IV oxytocin
- disproportionate maternal pain
fetal:
- meconium
234
what does a deceleration on CTG usually indicate
hypoxia if late or prolonged
| if in time/ early contraction then normal
235
what are early decelerations on CTG
when fetal heart rate drops at the same time as a contraction - usually normal
236
what are late decelerations a sign of on CTG and when do they occur
a sign of fetal hypoxia and occur just after a contraction
237
describe a reassuring CTG
no or early decelerations, good variability
238
describe a non-reassuring CTG
prolonged decelerations, fetal bradycardia
late decelerations
multiple decelerations
239
name 2 indications on CTG for urgent intervention
fetal bradycardia or prolonged deceleration more than 3 minutes
240
how would you manage a non-reassuring / abnormal CTG reading
1. escalate to senior midwife / consultant
2. assess for cause
3. fetal scalp stimulation to see if causes acceleration
4. fetal scalp sample to look for hypoxia
5. delivery
241
describe the rule of 3's for fetal bradycardia in labour
3 minutes = escalate to senior
6 minutes = move patient to theatre
9 minutes = prepare for delivery
12 minutes = deliver
242
how does fetal scalp stimulation work
an acceleration in response to stimulation is reassuring
243
when would you perform a fetal scalp sample
when there is an abnormal CTG or you suspect fetal hypoxia
244
describe abnormal fetal scalp sampling and what you would do
pH <7.2 is hypoxic and acidotic do deliver immediately
245
where is descent of the fetal head measured in comparison to
the ischial spines
246
describe uterine over efficiency
birth within 2 hours of contractions starting
| worrying bc can cause fetal hypoxia due to frequent strong contractions and intracranial haemorrhage
247
what is tetanic uterine activity and what is it a complication of
where the uterus remains contracted due to over use of oxytocin
248
how do you manage tetanic uterine activity
IV salbutamol or terbutaline to relax the uterus
249
complications of shoulder dystocia
shoulders get stuck bc they return to transverse diameter so causes a clavicular or humerus fracture, causes brachial plexus damage = erbs palsy and klumpkes paralysis = adducted arm and claw hand
250
how do you manage shoulder dystocia
1. put legs in mcroberts
2. epistotomy
3. apply suprapubic pressure, rotate, remove posterior arm and do rubin manouver followed by woodscrew then reverse woodscrew
251
what is the rubin manouver and woodscrew manouvers used in
shoulder dystocia to birth the baby
252
how can you predict pre term labour
short cervical length on TVUSS
253
name 5 causes of pre term labour
infection, pre eclampsia, IUGR, multiple pregnancy, fibroids, uterine abnormalities, polyhydraminos
254
how do you prevent pre term labour in high risk women
cervical cerclage (stitch in cervix at 12-14 weeks)
progesterone supplements
treat causes eg aspiration for polyhydraminos
255
name 3 contraindications to cervical cerclage
infection, PROM, twins, bleeding
256
what tests can be done to determine pre term labour
fetal fibronectin assay - positive result means likely to be born in 7 days
TVUSS - cervical length less than 15mm means premature labour likely
CTG+USS
vaignal swabfpr infection
257
between what gestation is labour classed as pre term
between 24 and 37 weeks
258
how do you manage premature labour
1. steroids to mature fetal lung
2. tocolysis with nifedipine to delay labour to allow time for steroids to work
3. if chorioamnionitis give IV abx + immediate delivery (no tocolysis)
4. magnesium sulfate to protect fetal brain
259
how long can nifedipine be used for in preterm labour
less than 24 hours
260
contraindications to nifedipine for use in pre term labour
infection
acute fetal distress
eclampsia
basically any thing that means delivery needs to happen ASAP
261
diagnostic criteria for pre term labour
less than 36 weeks gestation
regular uterine contractions between 5-10 mins for at least 1 hour
cervix more than 2.5cm dilated and 75% effaced
262
how long after premature rupture of membranes is baby usually born
7 days
263
how do you manage premature rupture of membranes at gestation over 35 weeks
usually fine - confirm with speculum exam
if labour doesn't start but cervix is favourable then can induce with oxytocin
if cervix isn't favourable then wait 48 hours to allow cervical ripening
264
how do you manage premature rupture of membranes at gestation less than 35 weeks (preterm premature rupture of membranes)
do speculum exam to confirm
| high vaginal swab and MSU to check for infection
265
criteria for giving tocolysis in premature labour
can give nifedipine (CCB) for tocolysis if...
no contraindications (infection, fetal distress)
cervix >5cm dilated
must be less than 34 weeks gestation
266
how do you manage premature rupture of membranes where there are signs of infection eg tachy, high temp, offensive vaginal discharge
immediate antibiotics and delivery
267
how is an accurate gestational age calculated on USS
crown rump length
268
what week is the dating scan
between 10 and 13 weeks
269
what date is the anomaly scan
between 18 and 20+6 weeks
270
when do they do OGTT in women at risk of gestational diabetes
24-28 weeks
271
what bloods are taken at pregnancy booking appt before 10 weeks
fbc for anaemia
thalassaemia screen in all women
blood group, abo and rhesus D status
272
advice for preterm premature rupture of membranes for ladies who dont have labour induced
home, no sex, no swimming or tampons
273
which drug is used to develop premature fetal lungs
beclometasone 2 x doses 24 hours apart
274
what weeks do they give the anti - D injections
28, 32 and at birth
275
what is polyhydraminos
increased secretion of amniotic fluid = excessive amniotic fluid amounts
associated with fetal abnormality or multiple pregnancy
276
name a cause of acute polyhydraminos
acute rapid accumulation of fluid is associated with monochorionic twins and can present with SOB, tachycardia, vomiting and severe abdo pain
277
treatment of chronic / slow accumulating polyhydraminos
amniocentesis to remove around 500ml fluid at a time to prevent premature labour. Usually done at around 30-35 weeks.
278
what is oligohydraminos
lower than normal amniotic fluid volume
279
name 3 causes of oligohydraminos
1. uteroplacental insufficiency causing intrauterine growth restriction
2. abnormalities in fetal urinary system eg renal agenesis
3. premature rupture of membranes
4. post date gestation (fluid levels decrease close to date)
280
name 2 complications of oligohydraminos
impaired development of fetal lung = pulmonary hypoplasia
causes limited space for fetus to move so can get club foot, dysplasia of the hip, facial abnormalities
can cause cord compression during labour
281
how do you treat oligohydraminos
give transcervical infusion of saline into amniotic sac around the time of labour to prevent cord compression
282
define small for gestational age
fetal weight below 10th centile for gestation and head circumfrance below 10th centile for gestation
283
causes of small for gestational age
```
chromosomal abnormalities
maternal infection
pre eclampsia
multiple pregnancy
placental insufficiency
```
284
name 2 risk factors for small for gestational age babies
maternal cocaine use
maternal smoking
maternal illness
previous still birth
285
how do you investigate small for gestational age babies
1. serial growth scans at 3 weekly intervals
2. umbilical artery doppler scan to look at the PULSATILITY INDEX, and looks at the difference in peak systolic and end diastolic flow --> an extreme ratio or evidence of reverse or absent end diastolic flow shows there is a poor flow of blood getting to the fetus
3. doppler USS of middle cerebral artery - increased flow = bad
4. ctg to monitor fetal distress
5. test for cause
286
what is used to predict fetal compromise in small for gestational age babies
pulsatility index
287
what 3 things are looked at on doppler USS when investigating small for gestational age babies
umbillical artery doppler looks at
1. pulsatility index
2. difference in peak systolic and end diastolic flow - absent of revesed end diastolic flow shows no blood getting to fetus
3. flow through middle meningeal artery (high flow bad)
288
how would you manage a small for gestational age baby at less than 32 weeks
steroids to develop lungs
daily CTG monitoring
if CTG abnormal do c-section
289
how would you manage a small for gestational age baby at more than 32 weeks
steroids plus c-section delivery
290
name causes of antepartum haemorrhage
vasa previa
placenta previa
placent accreta
placental abruption
291
name causes of antepartum haemorrhage
```
vasa previa
placenta previa
placent accreta
placental abruption
cervical ectropion
polyps
malignancy
```
292
describe the grades of placenta previa
minor (1+2) -marginal and in lower segment, don't cross the os
major (3+4) 3 is partially covering os, 4 is complete covering of cervical os
293
how do you manage placenta previa
- repeat USS at 34 weeks to check the location of placenta and how far it is from the os
- if small amounts of bleeding and less than 34 weeks expectant management
- if large amounts of bleeding do blood transfusion and c-section
- give anti-D to rhesus -ve women
delivery method for all except grade 1 is planned C-section
294
delviery method for grade 1 placenta praevia
normal
295
delivery method for grade 2-4 placenta praevia
c-section
296
name 3 complications of placenta praevia
PPH
fetal hypoxia
abnormal lie if fetal head cant engage properly
297
what is placenta accreta and who is at risk of developing it
when the placenta grows into the myometrium and implants deep so it is difficult to detach
consider in all women with a previous c section (implants over c section scars usually) and a low lying placenta on USS
298
what is placenta accreta, increta and percreta and who is at risk of developing it
when the placenta grows into the myometrium and implants deep so it is difficult to detach (accreta), increta is an even deeper version and percreta is where it invades local structures like bladder and bowel
consider in all women with a previous c section (implants over c section scars usually) and a low lying placenta on USS
299
how would you manage a woman with placenta accreta
1. elective C-section (+potential hysterectomy) @36-37 weeks to avoid PPH in normal labour
300
what is vasa praevia
where fetal blood vessels run across the membranes below the presenting fetal part across the internal os
301
presentation of vasa previa
bleeding when membranes rupture
bleeding at amniotomy
or spontaneous bleeding
fetal bradycardia follows the bleed
302
management of vasa previa
urgent c-section
if fetal head has descended below ischial spines already might be quicker to do an instrumental delivery
just get baby out fast
303
describe a placental abruption
part of the placenta separates before delivery of fetus which can either cause a visible or a hidden bleed
304
name 3 risk factors for placental abruption
smoking
high blood pressure
domestic abuse
previous abruption
305
how do you differentiate between a bleed caused by placenta praevia and placental abruption
placenta praevia = painless
| placental abruption = painful
306
how does placental abruption present
painful vaginal bleeding (not always bc can be hidden bleed)
woody hard and tender uterus
fetal distress
307
how do you manage placental abruption
ABCDE
blood transfusion 1500ml
anti-d
2 hourly bloods to monitor for coagulopathy
steroids if <34 weeks and no fetal distress
c-section immediately if fetal distress on ctg
if >37 weeks and no fetal distress then do amniotomy and delivery
308
what is HELLP syndrome
a hypertensive disorder characterised by haemolysis, elevated liver enzymes (AST and ALT) and low platelets
309
what is the management for HELLP syndrome
definitive: delivery
| can give steroids and blood transfusions in the interim
310
clinical presentation of HELLP syndrome
```
high BP
peripheral oedema
RUQ pain from liver distension
headache
nausea and vomiting
epigastric pain
blurred vision
```
311
name 3 maternal complications of HELLP syndrome
placental abruption
organ failure
DIC
312
name 3 fetal complications of HELLP syndrome
fetal hypoxia
IUGR
preterm labour
313
when does pre eclampsia usually start
from 20 weeks gestation
314
name the 2 main characteristics of pre eclampsia
proteinuria and high blood pressure
315
name 4 risk factors for pre eclampsia
```
prev pre eclampsia
nulliparous
obesity
multiple pregnancy
increasing maternal age
co-morbidities
```
316
what drug is used for hypertension in pregnancy
labetalol
317
what drug is used for prevention and treatment of eclampsia seizures
magnesium sulfate
318
what is the difference between gestational hypertension and pre eclampsia
no proteinuria in gestational htn
319
how does pre eclampsia present
```
blurred vision
headaches
vomiting
brisk reflexes
reduced urine output
basically all symptoms of the complications
```
320
complications associated with pre eclampsia
end organ damage eg renal failure
liver failure - raised enzymes
hellp
seizures
321
management of pre eclampsia
1. labetalol
2. nifedipine 2nd line anti hypertensive
3. magnesium sulfate
4. iv hydralazine can be used in severe critial pre eclampsia
5. fluid restriction during labour
6. deliver baby if fetal distress
322
what is a pyogenic granuloma
a red nodule (hemangioma) that is caused by benign proliferation of capillaries. is more common in pregnancy. develops over days. usually on fingers.usually self resolving
323
how do you manage a polymorphic eruption of pregnancy
an urticarial rash usually on abdomen in 3rd trimester that is itchy, usually self resolving after birth but give emoillient and topical steroids or oral anti histamines
324
name 6 causes of intrauterine growth restriction
```
pre eclampsia
maternal smoking
maternal anaemia
maternal malnutrition
maternal health conditions
inborn errors of metabolism
```
325
what do you measure on USS for IUGR
fetal abdominal circumfrance
| estimates fetal weight
326
name 3 complications of IUGR
still birth
preterm delivery
neonatal hypoglycaemia
birth asphyxia
327
diagnostic criteria for gestational diabetes
on OGTT test
fasting glucose >5.6
2 hour glucose >7.8
328
what should all women at high risk of developing pre eclampsia be given from week 12 of pregnancy
75mg aspirin daily
329
management of pregnant lady <20 weeks who has been exposed to chicken pox
check antibodies for immunity
| if no immunity can give post exposure prophylaxis of varicella immunoglobulins up to 10 days post exposure
330
management of pregnant laxy >20 weeks who has been exposed to chicken pox
give po aciclovir or VZIG if not immune between 7-14 days post exposure
331
management of pregnant woman with chicken pox
if over 20 weeks and presents within 24 hours of the rash onset then po aciclovir
if under 20 weeks then consider aciclovir with caution
332
definition of primary PPH
a loss of 500ml or more of blood from the genital tract in the following 24 hours after birth
333
name 2 risk factors for uterine rupture
1. vaginal birth after c section
| 2. labour with oxytocin infusion (hyperstimulation)
334
management of uterine rupture
resus - o2, fluids, blood transfusion
| always c-section, then if rupture is small then can surgically repair it, if large rupture then hysterectomy
335
signs and symptoms of uterine rupture
maternal shock
fetal distress
prolonged PPH continuing after vaginal repair
stopped contractions in labour
336
name the 4 causes of a PPH
```
4 x T's
tissue (retained conception products)
tone (uterine atony)
trauma
thrombin (clotting disorders)
```
337
how can you prevent a PPH in births that are high risk eg macrosoma, multiple pregnancy, traumatic births
give prophylactic oxytocin infusion to manage the 3rd stage of labour
338
define a secondary PPH
bleeding after 24 hours of delivery
339
what is the most common cause of a secondary PPH
retained products of conception
340
how do you manage a secondary pph
1. do uss to check for retained conception products
2. prophylactic antibiotics to prevent infection
3. resus: cross match, fluid, blood, o2
4. delivery retained products eg via uterine massage, IV oxytocin, ergometrine or carboprost
5. if still bleeding take to theatre to assess for uterine rupture
341
what drugs can be used to delivery retained products of conception
iv oxytocin
ergometrine
carboprost
342
name a complication of severe PPH
sheehan syndrome where there is pituitary gland ischaemia causing hypopituitarism eg low fsh, low lh, low prolactin = amenorrhoea and no lactation after birth
343
when do you test for gestational diabetes
do OGTT screening at 28-29 weeks
344
diagnosis of gestational diabetes
fasting glucose of >5.6
| or 2 hour glucose of >7.6
345
management of gestational diabetes
1. lifestyle modification if mild
2. if more moderate eg fasting <7 but over 5.6 give metformin
3. if really high fasting give insulin
346
name 5 risk factors for gestational diabetes
obesity
previous large baby
stillbirth
1st degree relative with diabetes
347
what drugs are given to people with pre existing diabetes during pregnancy
1. 5mg folic acid
2. prophylacic aspirin 75mg from week 12 of pregnancy to prevent pre eclampsia
3. insulin and metformin can be continued, others need to stop (insulin might need to be increased to maintain range glucose levels)
4. aim for fasting glucose between 4-7
348
management of pre existing diabetes in pregnancy
1. check HBa1c at booking <6.5% = better
2. continue insulin and metformin, increase insulin as required to hit target fasting between 4-7
3. be aware hypo's may increase
4. folic acid 5mg
5. aspirin 75mg from week 12
6. monitor maternal renal function and regular pre eclampsia checks
7. increased fetal scans to monitor fetal growth and liqor volume (more likely macrosomia and polyhydraminos)
8. recommended birth at 37-39 weeks
9. VRIII in labour
349
name complications for the fetus if mother has pre existing diabetes
1. macrosomia bc causes pancreatic cell hyperplasia meaning hyperinsulinaemia and fat deposition
2. increased risk of neonatal hypo
3. polyhydraminos
4. increased risk of obstructed labour
5. birth trauma and dystocia
6. respiratory distress syndrome
7. has to be delivered before dates
350
at what week should babies of pre existing diabetic mothers be born
37-39
| if over 4kg estimated fetal weight then must be c-section
351
how do you manage acute fatty liver in pregnancy
prompt delivery bc can cause acute hepatorenal failure, pre eclampsia and DIC
correct clotting abnormalities
blood products
dextrose to correct hypo's
352
how do you manage hyperthyroidism in pregnancy
give the mother propylthiouracil instead of carbimazole bc anti thyroid antibodies cross the placenta and can cause neonatal thyrotoxicosis
353
name 3 complications of intrahepatic cholestasis of pregnancy
1. still birth
2. PPH
3. meconium passage in neonate
354
management of intrahepatic cholestasis of pregnancy
ursodeoxycholic acid
vitamin K at 36 weeks to reduce bleeding risk
induction of labour at 37-38 weeks
6 week follow up after birth to ensure it has resolved
355
what type of twins does twin to twin transfusion syndrome usually occur in and how do you manage it
monoamniotic twins
causes the placental vessels to connect the 2 fetal circulations and 1 fetus recieves more blood than the other
causes 1 small twin and polyhydraminos
manage with fetoscopic laser abalation of the communicating vessels
356
when do you deliver babies in women with pre eclampsia
36 weeks
357
what is the antidote for magnesium sulfate when given to treat eclampsia
calcium gluconate given if causes respiratory depression
358
at what week should you refer women if no fetal movements have been felt
24 weeks
359
at what age do you usually start feeling fetal movements
18-20 weeks
360
what is the definition of reduced fetal movements
less than 10 movements in 2 hours past 28 weeks gestation
361
how do you investigate reduced fetal movement
1. handheld doppler to confirm fetal heart beat
2. if no heat beat do USS
3. if heart beat is present then do CTG monitoring
4. if CTG worrying then do USS
362
what is hyperemesis gravidarium
severe vomiting in first trimester, usually resolves by week 20
363
signs of hyperemesis gravidarium
```
hypotension
shock
hyponatraemia
tachy
postural hypotension
ketosis
weight loss
dehydration
mallory weiss tears
```
364
how do you investigate hyperemesis gravidarium
1. urine dip for ketones
2. FBC + U+E
3. bhcg to look for multiple pregnancy
365
how do you manage hyperemesis gravidarium
cyclizine
fluids
thiamine and folic acid to prevent wernickes
366
describe missed miscarriage
when the cervical os is CLOSED and the sac contains a dead fetus but no symptoms of expulsion
367
describe inevitable miscarriage
cervical os open
| heavy bleeding with clots and pain
368
describe threatened miscarriage
painless PV bleeding, cervical os is closed
369
describe incomplete miscarriage
pain and PV bleed, cervical os open, not all products expelled
370
how would you manage a miscarriage less than 6 weeks gestation
expectant management if the woman has no risk factors eg history of ectopic
do a repeat pregnancy test in 7-10 days to confirm abortion
371
how would you manage a miscarriage over 6 weeks gestation
1. refer to early pregnancy assessment unit
2. USS to confirm location and viability of pregnancy
3. if no risk factors for bleeding do expectant and give 1-2 weeks for spontaenous abortion and repeat urinary pregnancy test after 3 weeks
4. if has bleeding risks then do either medical or surgical management
medical - misoprostol
surgical - <10 weeks then can do manual vacuum, over 10 weeks will need electrical vacuum aspiration (requires GA) + give misoprostol before surgery to soften the cervix
372
how would you manage a miscarriage over 6 weeks gestation with bleeding risk
medical misoprostol suppository or oral
or surgical vacuum aspiration
373
how would you manage an incomplete miscarriage
misoprostol or surgery to remove retained conception products (evacuation of retained products of conception under GA)
374
how would you manage an inevitable miscarriage
conservative -> medical or surgical
375
how would you manage a missed/delayed miscarriage
do uss to confirm viability and location of pregnancy
serial BHCG measurements over 48 hours
if falls over 48 hours then confirms pregnancy wont develop
can do medical or surgical management
376
how would you manage a threatened miscarriage
leave it alone, uss to confirm viability
377
how do you confirm viability of a pregnancy on USS
fetal pole (can see when CRL is over 25mm)
crown rump length (must be over 7mm)
mean gestational sac diameter
fetal heart beat
378
how does chorioamnionitis present and how do you manage it
```
fever
abdo pain
offensive vaginal discharge
evidence of preterm prom
foetal tachycardia and signs of distress
```
mgx: broad spec ABX, admission and prep for delivery
379
name 6 causes of miscarriage
```
insufficient cervix
APL
PCOS
poorly controlled chronic disease
placental abnormality
```
380
define recurrent miscarriage
loss of 3 or more consecutive pregnancies
381
how do you investigate and manage recurrent miscarriage
thrombophilia screen
antiphospholipid antibodies
pelvic USS for uterine abnormalities
382
what is naegeles rule
used to estimate due date from last menstrual period date
| add 1 year and 7 days to the first day of last menstrual period and minus 3 months
383
obstetric analgesia ladder
1. non pharm: reposition, movement, massage, heat pack, warm bath
2. nitrous oxide
3. paracetamol
4. PO coedine or IV diamorphine
5. epidural
6. pudendal nerve block
384
describe 1st degree perineal tear and its management
tear limited to SUPERFICIAL perineum and vaginal mucosa
385
describe 2nd degree perineal tear and its management
tear involves superficial perineum, vaginal mucosa and underlying muscle
anal sphincter remains in tact
386
describe 3rd degree perineal tears and their management
tears all the way through to the muscle and involves anal sphincter
3a = <50% thickness and only external sphincter torn
3b = >50% thickness, external sphincter torn
3c = both external and internal sphincters torn
387
when can you do vaginal birth after a previous c-section
if they have had 1 previous c section they can have vaginal birth
if 2 prev c-section must do c-section
388
what drug is given to neonates whos mother has HIV from birth
zidovudine
389
for what period after birth do you not require contraception
3 weeks
390
when after birth can you have a coil
within 48 hours
391
when after birth can you have the pop
immediately
392
when after birth can you have the cocp
deffo not in 1st 3 weeks
need a VTE assessment first
if high risk for VTE must wait for 6 weeks
393
when after birth can you have the implant
immediately
394
when after birth can you have the depot
immediately
395
name 4 contraindications to tocolysis
```
gestation over 34 weeks
IUGR
non reassuring CTG
cervical dilation over 4cm
chorioamnionitis
maternal: pre eclampsia, haemorrhage
```
basically anything that means delivery shouldn't be delayed or the baby is ok to come out now
396
1st line management of post partum depression in breastfeeding
paroxetine
397
what are the two types of hydatiform mole and how are they created
partial and complete
a complete mole is formed when a sperm fertalises an empty egg so just get proliferation of chorionic tissue but no fetus products
a partial mole is formed when 2 sperms penetrate one egg and there is bits of fetal tissue present
398
how does a hydatiform mole present
```
pv bleed
large for gestation uterus
thyrotoxicosis can occur
nausea
hyperemesis gravidarium
```
399
how do you investigate a molar pregnancy
bhcg levels and transvaginal uss
400
what would you see on TVUSS in a molar pregnancy
snowstorm apprerance
401
name a complication of a molar pregnancy
choriocarcinoma
| invasion
402
how do you manage a molar pregnancy
not compatible with life so surgical suction curettage and 2 weekly serum and urine bHCG to ensure clearance for 6 months
