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obs and gynae Flashcards

1
Q

what is the most common type of cervical cancer

A

squamous cell carcinoma

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2
Q

what is the most common type of endometrial cancer

A

adenocarcinoma

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3
Q

what is the most common type of vulval cancer

A

squamous cell carcinoma

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4
Q

what is the most common type of ovarian cancer

A

adenocarcinoma

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5
Q

symptoms of ovarian cancer

A

bloating, early satiety, abdo fullness, pelvic pain, abnormal bleeding, weight loss, urinary symptoms, bowel habit change

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6
Q

symptoms of cervical cancer

A

post coital bleeding
incidental finding on smear
inter menstrual bleeding
deep dyspareunia

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7
Q

presentation of vulval cancer

A 
itching
bleeding
ulceration
abnormal lump
fungating lesion
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8
Q

symptoms of endometrial cancer

A

post menopausal bleeding
menorrhagia
intermenstrual bleeding
post coital bleeding

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9
Q

causes of post menopausal bleeding

A 
endometrial cancer
endometrial hyperplasia
vaginal dryness
trauma
cervical cancer
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10
Q

causes of post coital bleeding

A

cervical ectropion
cervical cancer
cervical polyp
endometrial polyp

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11
Q

causes of menorrhagia

A 
fibroids
polyp
dysfunctional uterine bleeding
systemic: hypothyroid
endometrial cancer
endometrial hyperplasia
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12
Q

2WW criteria post menopausal bleeding

A

anyone over the age of 55 post menopausal bleeding

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13
Q

2WW criteria cervical cancer

A

abnormal smear results

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14
Q

risk factors for cervical cancer

A

HPV 16 and 18, smoking

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15
Q

risk factors for ovarian cancer

A

obesity, BRCA 1 and 2, increased number of ovulations so early menarche, late menopause

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16
Q

risk factors for endometrial cancer

A

post menopausal, HRT, COCP, early menarche, late menopause, no pregnancies

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17
Q

risk factors for vulval cancer

A

smoking,

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18
Q

causes of pelvic pain

A

acute: ectopic, ovarian torsion
chronic: large fibroid, large cyst, endometriosis (cyclical), adenomyosis (cyclical)

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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

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20
Q

name 4 types of ovarian cancer

A

teratoma

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21
Q

investigations for cervical cancer

A

HPV testing and cervical cytology
colposcopy and biopsy
CT for FIGO staging

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22
Q

investigations for ovarian cancer

A 
TVUSS or transabdo USS
laparoscopic exploration and biopsy
CA 125
AFP,BHCG,LDH
CT for staging
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23
Q

investigations for endometrial cancer

A

TVUSS for endometrial thickness
hysteroscopy and biopsy
CT for staging

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24
Q

investigations for vulval cancer

A

biopsy / resect lesion

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25
Q

what staging systems are used for gynae cancers

A

FIGO

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26
Q

cervical cancer staging (1-4)

A 
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
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27
Q

ovarian cancer staging (1-4)

A
  1. ovary only
  2. pelvic only
  3. past pelvis but still in abdo
  4. distal mets
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28
Q

treatment of cervical cancer

A

large loop excision

hysterectomy

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29
Q

treatment of ovarian cancer

A

oophrectomy
hysterectomy and bilateral salpingoophrectomy
chemotherapy
radiotherapy

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30
Q

treatment of endometrial cancer

A

hysterectomy

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31
Q

symptoms of ectopic pregnancy

A

unilateral severe pelvic pain, amenorrhoea for 6-8 weeks, PV bleed (often brown),

ruptured: pallor, syncope, hypotension, pv bleed, tachy

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32
Q

risk factors for ectopic pregnancy

A

endometriosis

PID

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33
Q

what investigations should you do for suspected ectopic pregnancy

A

TVUSS
BHCG
pregnancy test

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34
Q

management of ectopic pregnancy

A

medical:
watch and wait for 48 hours
IM methotrexate

surgical: laparoscopy oophrectomy

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35
Q

management of ectopic pregnancy ruptured

A

laparoscopic oophrectomy

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36
Q

management of unruptured ectopic, embryo <3cm and BHCG <1500 and no heart beat

A

watch and wait for 48 hours, expectant

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37
Q

criteria for watch and wait (expectant) for ectopic pregnancy

A

no heart beat, BHCG < 1500, embryo less than 3 cm and unruptured

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38
Q

complications of ectopic pregnancy

A

haemorrhage into perionteum
peritonitis
subfertility

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39
Q

investigation findings in ectopic pregnancy

A

empty uterus
mass in fallopian tubes
fluid in pouch of douglas if ruptured

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40
Q

most common location for ectopic pregnancy

A

ampulla

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41
Q

definition of premature menopause

A

cessation of menstruation for 12 months, before the age of 40

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42
Q

what blood test do you do to test for menopause

A

FSH levels

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43
Q

causes of premature menopause

A

prev chemo, radiotherapy

premature ovarian insufficiency

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44
Q

management of premature menopause

A

HRT for all women until normal age of menopause (age 50) to protect bones and other symptoms of oestrogen deficiency

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45
Q

HRT choice for women with uterus

A

combined

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46
Q

HRT for women without uterus

A

oestrogen

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47
Q

describe menstrual cycle

A

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.

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48
Q

function of progesterone

A

maintains endometrial thickness

maintains thick cervical mucus

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49
Q

function of oestrogen

A

secondary sex characteristics

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50
Q

where is oestrogen produced

A

follicles in ovary

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51
Q

where is progesterone produced

A

corpus luteum

placenta

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52
Q

investigations for menorrhagia

A

FBC to look for anaemia
TVUSS
hysteroscopy if abnormal USS
systemic: TFT’s, HBa1c

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53
Q

medical management of dysfunctional uterine bleeding

A

1st line NSAID mefenamic acid
tranexamic acid to stop bleeding
tx the cause:

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54
Q

medical management of dysfunctional uterine bleeding

A

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

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55
Q

investigations for post menopausal bleeding

A

TVUSS
hysteroscopy
speculum and bimanual exam

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56
Q

total contraindications to HRT

A

current or past breast cancer

current or recent DVT/PE

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57
Q

definition of endometriosis

A

endometrial lining growing outside of the uterus

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58
Q

symptoms of endometriosis

A

cyclical abdo/pelvic pain, menorrhagia, deep dyspareuia, subfertility, bloating
urinary frequency, dysuria
dyszchecia, pr bleed

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59
Q

gold standard investigation in endometriosis

A

laporoscopic exploration

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60
Q

name 4 causes of a raised CA 125

A

ovarian cancer
endometriosis
liver disease

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61
Q

name 3 findings on examination in a pt with endometriosis

A

fixed retroverted uterus
fixed cervix
adnexal mass
pain on examination

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62
Q

where would you find chocolate cysts

A

ovaries - endometriomas

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63
Q

how can you optimise fertility in endometriosis

A

removing ectopic endometrial tissue via surgery

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64
Q

1st line management endometriosis

A

NSAID symptom control - mefenamic acid, tranexamic acid

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65
Q

2nd line management of endometriosis

A

contraception COCP, mirena, depot

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66
Q

management options for endometriosis

A

nsaid symptom control
hormonal - cocp, depot mirena
goserelin GnRH analogue can be used short term

surgical - removal of endometriomas
hysterectomy

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67
Q

what is adenomyosis

A

endometrial tissue growing in the myometrium

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68
Q

investigations in adenomyosis

A

TVUSS

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69
Q

management of adenomyosis

A

hormonal control

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70
Q

symptoms of menopause

A

vasomotor - flushes, night sweats, tachy,
neuro - brain fog, low mood,
weight changes

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71
Q

SE / complications of menopause

A

dementia
parksinsons
osteoporosis

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72
Q

what is an adnexal torsion

A

when the ovary and the fallopian tube twist on the ligaments

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73
Q

risk factors for ovarian torsion

A

large cyst

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74
Q

presentation of ovarian torsion

A

sudden onset severe unilateral pelvic pain associated with nausea and vomiting, low grade fever
can also be intermittent if twists and un twists

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75
Q

1st line investigation for suspected ovarian torsion

A

TVUSS

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76
Q

findings on TVUSS for ovarian torsion

A

whirlpool sign - fluid

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77
Q

gold standard investigation for ovarian torsion

A

laparoscopic exploration

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78
Q

what is a polyp made of

A

endometrial epithelium

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79
Q

what is a fibroid made of

A

endometrium and smooth muscle

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80
Q

most common type of fibroid

A

intramural

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81
Q

symptoms of fibroids

A 
asymptomatic
menorrhagia
pelvic pain / ache / fullness
dyspareunia
urinary symptoms (if large) - frequency
bowel symptoms (if large)
subfertility if large / blocking
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82
Q

complications of fibroids in pregnancy

A

red degeneration in 2nd or 3rd trimester when fibroid breaks down and becomes necrotic
miscarriage
premature labour

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83
Q

investigations for fibroids

A

TVUSS

hysteroscopy

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84
Q

management of fibroids (medical and surgical) and how to choose what to do

A

medical - mirena
symptoms - mefenamic acid
surgical - endometrial abalation, uterine artery embolisation, fibroidectomy

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85
Q

which type of fibroid is most likely to cause heavy menstrual bleeding

A

submucosal

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86
Q

treatment of symptomatic polyps

A

polypectomy

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87
Q

where is a barthaloins cyst located

A

posterior vagina on each side in the vulva

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88
Q

what is the treatment of barthaloins cyst

A

no treatment needed unless large then can drain

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89
Q

what is treatment of barthaloins abscess

A

antibiotics - usually e.coli infection, drainage

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90
Q

where is a gartners duct cyst located

A

upper vagina

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91
Q

where are urethral diverticulums located

A

lateral vaginal wall

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92
Q

what are symptoms of a urethral diverticulum

A

recurrent uti,

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93
Q

where are nabothian cysts located

A

on the cervix

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94
Q

what is a cervical ectropion

A

an area of the cervix that has changed from squamous to columnar

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95
Q

what is the most common cause of post coital bleedinh

A

cervical ectropion

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96
Q

what factors increase risk of developing a cervical ectropion

A

young age

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97
Q

what is lichen sclerosis

A

when elastin in vaginal skin turns into collagen and becomes hard, dry and pale (lichenified)

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98
Q

name 2 complications of lichen sclerosis

A

narrowing of vaginal and urethral openings due to skin tightness
SCC of vulva

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99
Q

what would you find on examination in lichen sclerosis

A

pale looking vulva, dry, hard

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100
Q

symptoms of lichen sclerosis

A

itching, soreness, dryness

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101
Q

what is the management of lichen sclerosis

A

dermovate (topical steroid 0.05%) long term for maintenance, can up to every day if symptoms are bad

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102
Q

what 3 factors make up the risk of malignancy index for ovarian cancer / ovarian cysts

A

menopause status
ca 125 level
USS findings

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103
Q

what tests should you do in patients with ovarian cysts

A

TVUSS

Ca 125

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104
Q

what tests should you do with all women aged under 45 with complex cyst (not functional)

A

AFP
BHCG
LDH
ca 125

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105
Q

management of simple 2-5cm ovarian cyst

A

nothing

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106
Q

management of ovarian cyst simple 5-7cm

A

monitor with yearly USS

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107
Q

management of ovarian cysts over 7cm

A

refer to gynae for further investigation eg laparoscopy or mri

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108
Q

when is a total hysterectomy with bilateral salpingoophrectomy preferred in women with ovarian cysts

A

when it is a complex cyst and under age 45 eg serous cyst, mucinous cyst, dermoid cyst

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109
Q

red flag symptoms for ovarian cysts to ask about that may indicate malignancy

A 
weight loss
bloating
ascites
early satiety
change in bladder or bowel habits
palpable mass
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110
Q

risk factors to ask about in ovarian cysts that increase risk of malignancy

A

BRCA 1 + 2 status, family history, HRT

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111
Q

name 4 types of ovarian cysts that may turn malignant

A

serous
mucinous
dermoid teratomas
sex cell stromal

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112
Q

name the 2 functional ovarian cyst types

A

follicular and corpus luteum

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113
Q

which type of ovarian cyst is likely to be very large

A

mucinous

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114
Q

which type of cyst contains hair, teeth, skin and bone cells

A

dermoid

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115
Q

which medication is used to shrink the size of fibroids whilst waiting for surgery

A

GnRH analogues eg goserelin in the short term

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116
Q

what is the most common complication following a surgical termination of pregnancy

A

infection!

others: retained pregnancy tissue, failure, trauma to cervix, haemorrhage,

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117
Q

what is gillick competence

A

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

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118
Q

when can you start re taking the progesterone only pill post-partum

A

immediately regardless of breastfeeding status

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119
Q

when do women need to start contraception after giving birth

A

day 21

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120
Q

when can you start COCP after birth

A

after 6 weeks - 6 months if breastfeeding

never start before 6 weeks bc reduces lactation for breast feeding and increases VTE risk post partum

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121
Q

when can the mirena coil be inserted post partum

A

after 48 hours

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122
Q

if not started on day 1-5of menstrual cycle, how long does POP take to be effective

A

2 days

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123
Q

if not started on day 1-5 of menstrual cycle how long does COCP take to be effective

A

7 days

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124
Q

management of premenstrual syndrome

A

a new generation COCP taken continuously

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125
Q

name 3 functions of the placenta

A

to remove fetal waste
to provide fetus with nutrients
produces steroid and hormones that maintain pregnancy
barrier against infection

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126
Q

where is the basal plate located

A

in the placenta next to the maternal side

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127
Q

where is the chorionic plate located

A

in the placenta on the fetal side

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128
Q

what is the decidual reaction

A

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.

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129
Q

what is the function of the decidua

A

forms the basal plate of the placenta
allows implantation of the blastocyts
supplies nutrients early on

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130
Q

describe the maturation of oocytes and when each stage occurs

A

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

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131
Q

how many chromosomes are in a primary oocyte

A

46, x

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132
Q

how many chromosomes are in a secondary oocyte

A

23, x

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133
Q

describe the process of fertalisation

A

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

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134
Q

which hormone is responsible for ovulation

A

surge in LH, FSH stimulates follicles

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135
Q

which hormone is responsible for the decidual reaction

A

progesterone

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136
Q

what is the normal amniotic fluid volume at 12 weeks

A

50ml

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137
Q

what is the normal amniotic fluid volume at 36-38 weeks

A

1L

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138
Q

cause of green amniotic fluid

A

meconium - a sign of fetal distress

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139
Q

cause of gold amniotic fluid

A

rhesus incompatibility indicating haemolysis of fetal RBC’s

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140
Q

what colour should amniotic fluid be

A

clear

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141
Q

cause of tobacco coloured amniotic fluid

A

intra uterine death

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142
Q

what is amniotic fluid made up of

A

water, glucose, protein, urea, electrolytes, lipids

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143
Q

name 4 functions of amniotic fluid

A

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

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144
Q

when is the cut off date for pregnancy viability

A

24 weeks = viable pregnany so bleeding before that = misscarriage bleeding after that = antepartum bleed

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145
Q

explain gravida

A

total number of pregnancies including past and current

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146
Q

explain parity

A

total number of pregnancies that have gone past viable stage (24 weeks) so including still births but not including miscarriage

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147
Q

what is nullipara

A

first time giving birth

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148
Q

what is a primagravida

A

pregnant for first time

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149
Q

what is a multipara

A

more than 2 pregnancies made it past 24 weeks

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150
Q

what is a multigravida

A

previously been pregnant

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151
Q

how do you calculate the period of gestation in the early stages vs later stages

A

early stages = days from last day of last menstrual period

later stages = days from expected due date

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152
Q

how do you determine the station of the fetus

A

the lowest bony part of the body eg feet if breach or skull if head compared to the level of the ischial spines

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153
Q

what is engagement

A

when the widest part of the foetus has passed through the pevlis

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154
Q

what is attitude

A

whether the foetus is flexed or deflexed - flexed is easier to deliver

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155
Q

describe the first stage of labour

A

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

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156
Q

how many cm does it need to be to be classed as active labour

A

4cm

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157
Q

how fast does the cervix dilate in nulliparous women

A

2cm per hour

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158
Q

how fast does the cervix dilate in multiparous women

A

1cm per hour

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159
Q

when is the first stage of labour classed as failure to progress and how do you manage it

A

16 hours

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160
Q

how do you manage the 1st stage of active labour

A

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

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161
Q

what should the fetal heart rate be between in labour

A

120-160 bpm

162
Q

how often do contractions happen in 2nd stage of labour

A

every 2-5 mins

163
Q

how long do uterine contractions last in 2nd stage of labour

A

60-90 seconds

164
Q

when should vacuum extraction and forceps be used

A

after 2 hours of active pushing if fetus still not birthed

165
Q

when should vacuum extraction and forceps be used

A

after 2 hours of active pushing if fetus still not birthed, unless woman has had an epidural then wait 3 hours before intervention

166
Q

what should you do if fetal heart rate drops below 100bpm in active second stage of labour

A

do a vaginal examination to make sure cord hasn’t prolapsed

167
Q

what should be used to clean the vulva once the fetal head is visable by 5cm

A

chlorhexadine

168
Q

what score should be completed once the baby is born

A

APGAR score

169
Q

what injection is given to all new born babies, how much and when

A

IM vitamin K (phytomenadione) 1mg at birth, at 3-4 days and after 6 weeks

170
Q

which scoring tool can be used to screen for post-natal depression

A

edinburgh scale

171
Q

how much would you expect the fundal height to increase by after 24 weeks gestation

A

1cm per week

increasing by more than that you would be concerned about multiple pregnancy or a large baby

172
Q

presentation of fibroid degeneration in pregnancy

A

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
Q

presentation of fibroid degeneration in pregnancy

A

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
Q

risk factors for still birth

A 
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
Q

what position does the fetus descend in before engagement

A

occipito transverse

176
Q

what is engagement

A

where the widest diameter of the fetal presenting part (usually widest diameter of the head) reaches the pelvic brim

177
Q

in which direction does the fetus turn in before it crowns

A

internally rotates 90 degrees so the head is occiput anterior

178
Q

what is the normal rotation of the baby for birth

A

occiput anterior

179
Q

how are the shoulders of the baby birthed

A

head naturally externally rotates and then anterior shoulder is birthed by downward traction and upward traction to birth the posterior shoulder

180
Q

how is the fetal body delivered

A

naturally with contractions

181
Q

name 4 indications for induction of labour

A 
5 x P's
post dates >41 weeks
PPROM
pre eclampsia
placenta previa
plus diabetes
182
Q

what method of inducing labour would you use in a woman with a bishop score of 0-4

A

PGE2 - dinoprostone gel inserted into posterior fornix of vagina

183
Q

what type of drug is dinoprostone

A

PGE2 - prostaglandin E2 analogue

184
Q

which type of drug is used for aborting in utero fetal death in the second trimester

A

misoprostol - PGE1

185
Q

why is misoprostol not used in the 3rd trimester to induce labour

A

because it increases the risk of uterine hypertonicity which is risky for fetus and mother and can cause uterine rupture

186
Q

how would you induce labour in a woman with a bishop score over 5

A

PGE2 and or amniotomy

187
Q

what should you check for before performing an amniotomy

A

bishop score over 5
cord prolapse
? low lying placenta

188
Q

how would you manage the labour of a patient who has already had PGE2 and after 6 hours has a bishop score of 4

A

repeat PGE2

189
Q

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

190
Q

how would you manage a patient who has had PGE2 and after 6 hours the bishop score is 5+

191
Q

how would you manage a patient who has had PGE2 and amniotomy to induce labour and still hasn’t gone into labour

A

IV oxytocin infusion

192
Q

how would you manage a patient who has had PGE2, amniotomy, IV oxytocin and still hasn’t gone into labour after 6 hours

A

repeat PGE2 gel

193
Q

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

194
Q

when is IV oxytocin indicated in the induction of labour

A

after PGE2 gel and amniotomy, must have bishop score of over 5

195
Q

what is the definition of failure to progress

A

failure to dilate more than 2cm in 4 hours or slowing in progress of multiparous woman

196
Q

how would you manage a woman who is 41 weeks with no signs of labour

A

membrane sweep

197
Q

how does a membrane sweep work

A

put your finger between the membrane of placenta to help them rupture

198
Q

what 3 factors affect progress in labour

A

power - strength of contractions
passenger - size of baby eg cephalopelvic disproportion, malpresentation, abnormal lie
passage - shape and size of pelvis and soft tissue

199
Q

complications of oxytocin infusion

A

uterine hyperstimulation

200
Q

how can you identify a fetus in the occiput posterior position

A

fetal back is palpable in the flank and heart beat heard loudest here

201
Q

how do you manage a labour where baby is occiput posterior

A
  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
Q

how do you manage breech presentation at 37 weeks

A

offer external cephalic version

203
Q

how do you manage breech presentation at <36 weeks

A

wait - usually turns at around 36 weeks naturally

204
Q

at what week does the fetus turn to cephalic from breech

205
Q

how do you manage a breech presentation that has had a failed ECV

206
Q

how do you manage a birth where there is late identification of breech presentation

A 
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
Q

name 5 causes of failure to progress

A 
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
Q

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

A

cephalopelvic disproportion

209
Q

cervix stops dilating at 4cm after 8 hours what is the cause

A

prolonged latent phase

210
Q

cervical dilation in labour is to the right of the partogram what is the cause

A

prolonged active phase

211
Q

infrequent contractions, cervix not dilated and no palpable contractions (weak) what is the cause

A

false labour

212
Q

how would you manage a cord prolapse

A 
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
Q

what increases the risk of a cord prolapse

A

malpresentation

post-amniotomy

214
Q

what does a cardiotocograph measure

A

fetal heart rate and uterine activity

215
Q

what is the normal baseline fetal heart rate on cardiotocograph

216
Q

what is a reassuring level of variability on CTG

A

variability over 5

217
Q

what causes an acceleration on CTG

A

fetal movement, considered normal

218
Q

what causes deceleration on CTG and when is it considered a worrying sign

A

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
Q

what is measured on a partogram

A 
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
Q

how is a delay in progress in the 3nd stage of labour defined

A

more than 60 minutes with physiological management

more than 30 minutes with active management

221
Q

how is a delay in the second stage of labour defined

A

more than 2 hours of pushing in nulliparous and more than 1 hour in multiparous

222
Q

what is a braxton hick contraction

A

occasional irregular contraction of the uterus that happens in the late stages of pregnancy, feels like temporary tightening or cramping

223
Q

how can you diagnose the onset of labour

A

mucus show
cervical dilatation and effacement
regular painful contractions
rupture of membranes

224
Q

what is given to the mother after an instrumental delivery

A

stat co-amoxiclav to prevent infection

225
Q

name 4 indications for an instrumental delivery

A

fetal distress
maternal exhaustion
failure to progress in 2nd stage
to control the head in delivery in abnormal position

226
Q

what increases the risk of requiring an instrumental delivery

A

epidural - reduces effective contractions

227
Q

risks to the mother of an instrumental delivery

A 
peristotomy
femoral and obtruator nerve damage
infection
PPH
anal sphincter injury
228
Q

risks to the baby of an instrumental delivery

A 
cephalohaematoma
facial nerve palsy / paralysis
intracranial haemorrhage
subgaleal haemorrhage
skull fracture
bruises
fat necrosis
229
Q

main complication of ventouse delivery for baby

A

cephalohaematoma

230
Q

main complication of forceps delivery for baby

A

facial nerve palsy

231
Q

which nerves are at risk of being damaged (maternal) in an instrumental delivery

A

obtruator: causes weak hip adduction and rotation and numb medial thigh
femoral: weak knee extension and numb anterior thigh

232
Q

where are the transducers placed when measuring cardiotocography

A

one placed over fetal heart

one placed above fundus to measure contractions

233
Q

name 6 indications for continuous CTG monitoring

A

Maternal:

  • sepsis
  • maternal tachycardia >120
  • pre eclampsia
  • fresh antepartum haemorrhage
  • use of IV oxytocin
  • disproportionate maternal pain

fetal:
- meconium

234
Q

what does a deceleration on CTG usually indicate

A

hypoxia if late or prolonged

if in time/ early contraction then normal

235
Q

what are early decelerations on CTG

A

when fetal heart rate drops at the same time as a contraction - usually normal

236
Q

what are late decelerations a sign of on CTG and when do they occur

A

a sign of fetal hypoxia and occur just after a contraction

237
Q

describe a reassuring CTG

A

no or early decelerations, good variability

238
Q

describe a non-reassuring CTG

A

prolonged decelerations, fetal bradycardia
late decelerations
multiple decelerations

239
Q

name 2 indications on CTG for urgent intervention

A

fetal bradycardia or prolonged deceleration more than 3 minutes

240
Q

how would you manage a non-reassuring / abnormal CTG reading

A
  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
Q

describe the rule of 3’s for fetal bradycardia in labour

A

3 minutes = escalate to senior
6 minutes = move patient to theatre
9 minutes = prepare for delivery
12 minutes = deliver

242
Q

how does fetal scalp stimulation work

A

an acceleration in response to stimulation is reassuring

243
Q

when would you perform a fetal scalp sample

A

when there is an abnormal CTG or you suspect fetal hypoxia

244
Q

describe abnormal fetal scalp sampling and what you would do

A

pH <7.2 is hypoxic and acidotic do deliver immediately

245
Q

where is descent of the fetal head measured in comparison to

A

the ischial spines

246
Q

describe uterine over efficiency

A

birth within 2 hours of contractions starting

worrying bc can cause fetal hypoxia due to frequent strong contractions and intracranial haemorrhage

247
Q

what is tetanic uterine activity and what is it a complication of

A

where the uterus remains contracted due to over use of oxytocin

248
Q

how do you manage tetanic uterine activity

A

IV salbutamol or terbutaline to relax the uterus

249
Q

complications of shoulder dystocia

A

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
Q

how do you manage shoulder dystocia

A
  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
Q

what is the rubin manouver and woodscrew manouvers used in

A

shoulder dystocia to birth the baby

252
Q

how can you predict pre term labour

A

short cervical length on TVUSS

253
Q

name 5 causes of pre term labour

A

infection, pre eclampsia, IUGR, multiple pregnancy, fibroids, uterine abnormalities, polyhydraminos

254
Q

how do you prevent pre term labour in high risk women

A

cervical cerclage (stitch in cervix at 12-14 weeks)
progesterone supplements
treat causes eg aspiration for polyhydraminos

255
Q

name 3 contraindications to cervical cerclage

A

infection, PROM, twins, bleeding

256
Q

what tests can be done to determine pre term labour

A

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
Q

between what gestation is labour classed as pre term

A

between 24 and 37 weeks

258
Q

how do you manage premature labour

A
  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
Q

how long can nifedipine be used for in preterm labour

A

less than 24 hours

260
Q

contraindications to nifedipine for use in pre term labour

A

infection
acute fetal distress
eclampsia
basically any thing that means delivery needs to happen ASAP

261
Q

diagnostic criteria for pre term labour

A

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
Q

how long after premature rupture of membranes is baby usually born

263
Q

how do you manage premature rupture of membranes at gestation over 35 weeks

A

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
Q

how do you manage premature rupture of membranes at gestation less than 35 weeks (preterm premature rupture of membranes)

A

do speculum exam to confirm

high vaginal swab and MSU to check for infection

265
Q

criteria for giving tocolysis in premature labour

A

can give nifedipine (CCB) for tocolysis if…
no contraindications (infection, fetal distress)
cervix >5cm dilated
must be less than 34 weeks gestation

266
Q

how do you manage premature rupture of membranes where there are signs of infection eg tachy, high temp, offensive vaginal discharge

A

immediate antibiotics and delivery

267
Q

how is an accurate gestational age calculated on USS

A

crown rump length

268
Q

what week is the dating scan

A

between 10 and 13 weeks

269
Q

what date is the anomaly scan

A

between 18 and 20+6 weeks

270
Q

when do they do OGTT in women at risk of gestational diabetes

A

24-28 weeks

271
Q

what bloods are taken at pregnancy booking appt before 10 weeks

A

fbc for anaemia
thalassaemia screen in all women
blood group, abo and rhesus D status

272
Q

advice for preterm premature rupture of membranes for ladies who dont have labour induced

A

home, no sex, no swimming or tampons

273
Q

which drug is used to develop premature fetal lungs

A

beclometasone 2 x doses 24 hours apart

274
Q

what weeks do they give the anti - D injections

A

28, 32 and at birth

275
Q

what is polyhydraminos

A

increased secretion of amniotic fluid = excessive amniotic fluid amounts
associated with fetal abnormality or multiple pregnancy

276
Q

name a cause of acute polyhydraminos

A

acute rapid accumulation of fluid is associated with monochorionic twins and can present with SOB, tachycardia, vomiting and severe abdo pain

277
Q

treatment of chronic / slow accumulating polyhydraminos

A

amniocentesis to remove around 500ml fluid at a time to prevent premature labour. Usually done at around 30-35 weeks.

278
Q

what is oligohydraminos

A

lower than normal amniotic fluid volume

279
Q

name 3 causes of oligohydraminos

A
  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
Q

name 2 complications of oligohydraminos

A

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
Q

how do you treat oligohydraminos

A

give transcervical infusion of saline into amniotic sac around the time of labour to prevent cord compression

282
Q

define small for gestational age

A

fetal weight below 10th centile for gestation and head circumfrance below 10th centile for gestation

283
Q

causes of small for gestational age

A 
chromosomal abnormalities
maternal infection
pre eclampsia
multiple pregnancy
placental insufficiency
284
Q

name 2 risk factors for small for gestational age babies

A

maternal cocaine use
maternal smoking
maternal illness
previous still birth

285
Q

how do you investigate small for gestational age babies

A
  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
Q

what is used to predict fetal compromise in small for gestational age babies

A

pulsatility index

287
Q

what 3 things are looked at on doppler USS when investigating small for gestational age babies

A

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
Q

how would you manage a small for gestational age baby at less than 32 weeks

A

steroids to develop lungs
daily CTG monitoring
if CTG abnormal do c-section

289
Q

how would you manage a small for gestational age baby at more than 32 weeks

A

steroids plus c-section delivery

290
Q

name causes of antepartum haemorrhage

A

vasa previa
placenta previa
placent accreta
placental abruption

291
Q

name causes of antepartum haemorrhage

A 
vasa previa
placenta previa
placent accreta
placental abruption
cervical ectropion
polyps
malignancy
292
Q

describe the grades of placenta previa

A

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
Q

how do you manage placenta previa

A
  • 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
Q

delviery method for grade 1 placenta praevia

295
Q

delivery method for grade 2-4 placenta praevia

296
Q

name 3 complications of placenta praevia

A

PPH
fetal hypoxia
abnormal lie if fetal head cant engage properly

297
Q

what is placenta accreta and who is at risk of developing it

A

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
Q

what is placenta accreta, increta and percreta and who is at risk of developing it

A

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
Q

how would you manage a woman with placenta accreta

A
  1. elective C-section (+potential hysterectomy) @36-37 weeks to avoid PPH in normal labour
300
Q

what is vasa praevia

A

where fetal blood vessels run across the membranes below the presenting fetal part across the internal os

301
Q

presentation of vasa previa

A

bleeding when membranes rupture
bleeding at amniotomy
or spontaneous bleeding
fetal bradycardia follows the bleed

302
Q

management of vasa previa

A

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
Q

describe a placental abruption

A

part of the placenta separates before delivery of fetus which can either cause a visible or a hidden bleed

304
Q

name 3 risk factors for placental abruption

A

smoking
high blood pressure
domestic abuse
previous abruption

305
Q

how do you differentiate between a bleed caused by placenta praevia and placental abruption

A

placenta praevia = painless

placental abruption = painful

306
Q

how does placental abruption present

A

painful vaginal bleeding (not always bc can be hidden bleed)
woody hard and tender uterus
fetal distress

307
Q

how do you manage placental abruption

A

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
Q

what is HELLP syndrome

A

a hypertensive disorder characterised by haemolysis, elevated liver enzymes (AST and ALT) and low platelets

309
Q

what is the management for HELLP syndrome

A

definitive: delivery

can give steroids and blood transfusions in the interim

310
Q

clinical presentation of HELLP syndrome

A 
high BP
peripheral oedema
RUQ pain from liver distension
headache
nausea and vomiting
epigastric pain 
blurred vision
311
Q

name 3 maternal complications of HELLP syndrome

A

placental abruption
organ failure
DIC

312
Q

name 3 fetal complications of HELLP syndrome

A

fetal hypoxia
IUGR
preterm labour

313
Q

when does pre eclampsia usually start

A

from 20 weeks gestation

314
Q

name the 2 main characteristics of pre eclampsia

A

proteinuria and high blood pressure

315
Q

name 4 risk factors for pre eclampsia

A 
prev pre eclampsia
nulliparous
obesity
multiple pregnancy
increasing maternal age
co-morbidities
316
Q

what drug is used for hypertension in pregnancy

317
Q

what drug is used for prevention and treatment of eclampsia seizures

A

magnesium sulfate

318
Q

what is the difference between gestational hypertension and pre eclampsia

A

no proteinuria in gestational htn

319
Q

how does pre eclampsia present

A 
blurred vision
headaches
vomiting
brisk reflexes
reduced urine output
basically all symptoms of the complications
320
Q

complications associated with pre eclampsia

A

end organ damage eg renal failure
liver failure - raised enzymes
hellp
seizures

321
Q

management of pre eclampsia

A
  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
Q

what is a pyogenic granuloma

A

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
Q

how do you manage a polymorphic eruption of pregnancy

A

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
Q

name 6 causes of intrauterine growth restriction

A 
pre eclampsia
maternal smoking
maternal anaemia
maternal malnutrition
maternal health conditions
inborn errors of metabolism
325
Q

what do you measure on USS for IUGR

A

fetal abdominal circumfrance

estimates fetal weight

326
Q

name 3 complications of IUGR

A

still birth
preterm delivery
neonatal hypoglycaemia
birth asphyxia

327
Q

diagnostic criteria for gestational diabetes

A

on OGTT test
fasting glucose >5.6
2 hour glucose >7.8

328
Q

what should all women at high risk of developing pre eclampsia be given from week 12 of pregnancy

A

75mg aspirin daily

329
Q

management of pregnant lady <20 weeks who has been exposed to chicken pox

A

check antibodies for immunity

if no immunity can give post exposure prophylaxis of varicella immunoglobulins up to 10 days post exposure

330
Q

management of pregnant laxy >20 weeks who has been exposed to chicken pox

A

give po aciclovir or VZIG if not immune between 7-14 days post exposure

331
Q

management of pregnant woman with chicken pox

A

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
Q

definition of primary PPH

A

a loss of 500ml or more of blood from the genital tract in the following 24 hours after birth

333
Q

name 2 risk factors for uterine rupture

A
  1. vaginal birth after c section

2. labour with oxytocin infusion (hyperstimulation)

334
Q

management of uterine rupture

A

resus - o2, fluids, blood transfusion

always c-section, then if rupture is small then can surgically repair it, if large rupture then hysterectomy

335
Q

signs and symptoms of uterine rupture

A

maternal shock
fetal distress
prolonged PPH continuing after vaginal repair
stopped contractions in labour

336
Q

name the 4 causes of a PPH

A 
4 x T's
tissue (retained conception products)
tone (uterine atony)
trauma
thrombin (clotting disorders)
337
Q

how can you prevent a PPH in births that are high risk eg macrosoma, multiple pregnancy, traumatic births

A

give prophylactic oxytocin infusion to manage the 3rd stage of labour

338
Q

define a secondary PPH

A

bleeding after 24 hours of delivery

339
Q

what is the most common cause of a secondary PPH

A

retained products of conception

340
Q

how do you manage a secondary pph

A
  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
Q

what drugs can be used to delivery retained products of conception

A

iv oxytocin
ergometrine
carboprost

342
Q

name a complication of severe PPH

A

sheehan syndrome where there is pituitary gland ischaemia causing hypopituitarism eg low fsh, low lh, low prolactin = amenorrhoea and no lactation after birth

343
Q

when do you test for gestational diabetes

A

do OGTT screening at 28-29 weeks

344
Q

diagnosis of gestational diabetes

A

fasting glucose of >5.6

or 2 hour glucose of >7.6

345
Q

management of gestational diabetes

A
  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
Q

name 5 risk factors for gestational diabetes

A

obesity
previous large baby
stillbirth
1st degree relative with diabetes

347
Q

what drugs are given to people with pre existing diabetes during pregnancy

A
  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
Q

management of pre existing diabetes in pregnancy

A
  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
Q

name complications for the fetus if mother has pre existing diabetes

A
  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
Q

at what week should babies of pre existing diabetic mothers be born

A

37-39

if over 4kg estimated fetal weight then must be c-section

351
Q

how do you manage acute fatty liver in pregnancy

A

prompt delivery bc can cause acute hepatorenal failure, pre eclampsia and DIC
correct clotting abnormalities
blood products
dextrose to correct hypo’s

352
Q

how do you manage hyperthyroidism in pregnancy

A

give the mother propylthiouracil instead of carbimazole bc anti thyroid antibodies cross the placenta and can cause neonatal thyrotoxicosis

353
Q

name 3 complications of intrahepatic cholestasis of pregnancy

A
  1. still birth
  2. PPH
  3. meconium passage in neonate
354
Q

management of intrahepatic cholestasis of pregnancy

A

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
Q

what type of twins does twin to twin transfusion syndrome usually occur in and how do you manage it

A

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
Q

when do you deliver babies in women with pre eclampsia

357
Q

what is the antidote for magnesium sulfate when given to treat eclampsia

A

calcium gluconate given if causes respiratory depression

358
Q

at what week should you refer women if no fetal movements have been felt

359
Q

at what age do you usually start feeling fetal movements

A

18-20 weeks

360
Q

what is the definition of reduced fetal movements

A

less than 10 movements in 2 hours past 28 weeks gestation

361
Q

how do you investigate reduced fetal movement

A
  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
Q

what is hyperemesis gravidarium

A

severe vomiting in first trimester, usually resolves by week 20

363
Q

signs of hyperemesis gravidarium

A 
hypotension
shock
hyponatraemia
tachy
postural hypotension
ketosis
weight loss
dehydration
mallory weiss tears
364
Q

how do you investigate hyperemesis gravidarium

A
  1. urine dip for ketones
  2. FBC + U+E
  3. bhcg to look for multiple pregnancy
365
Q

how do you manage hyperemesis gravidarium

A

cyclizine
fluids
thiamine and folic acid to prevent wernickes

366
Q

describe missed miscarriage

A

when the cervical os is CLOSED and the sac contains a dead fetus but no symptoms of expulsion

367
Q

describe inevitable miscarriage

A

cervical os open

heavy bleeding with clots and pain

368
Q

describe threatened miscarriage

A

painless PV bleeding, cervical os is closed

369
Q

describe incomplete miscarriage

A

pain and PV bleed, cervical os open, not all products expelled

370
Q

how would you manage a miscarriage less than 6 weeks gestation

A

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
Q

how would you manage a miscarriage over 6 weeks gestation

A
  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
Q

how would you manage a miscarriage over 6 weeks gestation with bleeding risk

A

medical misoprostol suppository or oral

or surgical vacuum aspiration

373
Q

how would you manage an incomplete miscarriage

A

misoprostol or surgery to remove retained conception products (evacuation of retained products of conception under GA)

374
Q

how would you manage an inevitable miscarriage

A

conservative -> medical or surgical

375
Q

how would you manage a missed/delayed miscarriage

A

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
Q

how would you manage a threatened miscarriage

A

leave it alone, uss to confirm viability

377
Q

how do you confirm viability of a pregnancy on USS

A

fetal pole (can see when CRL is over 25mm)
crown rump length (must be over 7mm)
mean gestational sac diameter
fetal heart beat

378
Q

how does chorioamnionitis present and how do you manage it

A 
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
Q

name 6 causes of miscarriage

A 
insufficient cervix
APL
PCOS
poorly controlled chronic disease
placental abnormality
380
Q

define recurrent miscarriage

A

loss of 3 or more consecutive pregnancies

381
Q

how do you investigate and manage recurrent miscarriage

A

thrombophilia screen
antiphospholipid antibodies
pelvic USS for uterine abnormalities

382
Q

what is naegeles rule

A

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
Q

obstetric analgesia ladder

A
  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
Q

describe 1st degree perineal tear and its management

A

tear limited to SUPERFICIAL perineum and vaginal mucosa

385
Q

describe 2nd degree perineal tear and its management

A

tear involves superficial perineum, vaginal mucosa and underlying muscle
anal sphincter remains in tact

386
Q

describe 3rd degree perineal tears and their management

A

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
Q

when can you do vaginal birth after a previous c-section

A

if they have had 1 previous c section they can have vaginal birth
if 2 prev c-section must do c-section

388
Q

what drug is given to neonates whos mother has HIV from birth

A

zidovudine

389
Q

for what period after birth do you not require contraception

390
Q

when after birth can you have a coil

A

within 48 hours

391
Q

when after birth can you have the pop

A

immediately

392
Q

when after birth can you have the cocp

A

deffo not in 1st 3 weeks
need a VTE assessment first
if high risk for VTE must wait for 6 weeks

393
Q

when after birth can you have the implant

A

immediately

394
Q

when after birth can you have the depot

A

immediately

395
Q

name 4 contraindications to tocolysis

A 
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
Q

1st line management of post partum depression in breastfeeding

A

paroxetine

397
Q

what are the two types of hydatiform mole and how are they created

A

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
Q

how does a hydatiform mole present

A 
pv bleed
large for gestation uterus
thyrotoxicosis can occur 
nausea
hyperemesis gravidarium
399
Q

how do you investigate a molar pregnancy

A

bhcg levels and transvaginal uss

400
Q

what would you see on TVUSS in a molar pregnancy

A

snowstorm apprerance

401
Q

name a complication of a molar pregnancy

A

choriocarcinoma

invasion

402
Q

how do you manage a molar pregnancy

A

not compatible with life so surgical suction curettage and 2 weekly serum and urine bHCG to ensure clearance for 6 months

finals (18 decks)

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