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Belle: Phase 3a > Obs And Gynae > Flashcards

Obs And Gynae Flashcards

1
Q

Describe the HPG axis in the menstrual cycle

A

GnRH secretion > LH and FSH secretion from anterior pituitary
LH: theca cells = androgen production
FSH: granulosa cells = androgen conversion to oestrogen + inhibin secretion (negative feedback)
Oestrogen + progesterone = negative feedback
High oestrogen alone = positive feedback

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2
Q

Describe the follicular phase (days 1-13) of the ovarian menstrual cycle

A

15-20 early antral follicles
Day 7: selection of dominant follicle
Day 13: LH surge due to high oestrogen alone - Graafian follicle (secondary oocyte)

Oestrogen rises throughout

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3
Q

Describe ovulation (day 14) in the ovarian menstrual cycle

A

Graafian follicle ruptures and releases oocyte with antral fluid
Remaining follicular cells begin to produce progesterone, becoming corpus luteum

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4
Q

Describe the luteal phase (day 15-28) in the ovarian menstrual cycle

A

Corpus luteum produces oestrogen, progesterone (peaks at day 21), and inhibin
Spontaneously regresses after 14 days, allowing LH/FSH to rise again

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5
Q

What happens to progesterone levels due to the loss of corpus luteum

A

Decrease

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6
Q

Describe the proliferative phase of the uterine menstrual cycle

A

Endometrial proliferation, spiral arterioles, secretory gland formation
Under the influence of oestrogen

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7
Q

Describe the secretory phase of the uterine menstrual cycle

A

Glands secrete glycogen, glycoproteins etc
Myometrial contraction inhibited
Under the influence of progesterone

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8
Q

Normal pregnancy term

A

37 + 0 weeks

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9
Q

Gravidity (G) definition

A

Number of times a woman has been pregnant regardless of the outcome (includes current pregnancy)

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10
Q

Parity (P) definition

A

number of times a woman has delivered a foetus with a gestational age greater than 24 weeks, regardless of outcome

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11
Q

Where does fertilisation most often occur in the Fallopian tubes

A

Ampulla

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12
Q

Describe the four stages of fertilisation

A
  1. Capacitation: final stage of sperm maturation
  2. Acrosome reaction: lytic enzyme release, penetrates oocyte membrane
  3. Cortical reaction: prevents multiple sperm from fertilising egg
  4. Syngamy: fusion of pronuclei
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13
Q

Describe the stages of blastocyst implantation at the endometrium

A
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14
Q

Name the 3 layers of a blastocyst

A
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15
Q

Describe the formation of the placenta

A

Starts to form directly after implantation (day 6-7)

Outer trophoblast cells invade into endometrium

By day 14, the cells have invaded into maternal cells, forming chorionic villi

By day 21, foetal blood vessels have grown into the chorionic villi

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16
Q

Which haematological components INCREASE in pregnancy

A

Plasma volume
Red cell mass
White cell count – neutrophilia
Clotting factors – survival mechanism

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17
Q

Which haematological components DECREASE in pregnancy

A

Hb concentration – physiological anaemia
Platelet count
Fibrinolysis

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18
Q

What percentage does cardiac output increase during 1st trimester

A

45%:
• 30% due to increased stroke volume (preload)
• 15% due to increased heart rate

NB: Rises by a further 33% in labour.

• MAP = CO * SVR

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19
Q

(?) What is increased cardiac output caused by in the beginning of pregnancy

A

Reduced peripheral vascular resistance

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20
Q

Respiratory changes in pregnancy

A

Minute ventilation rises by 40%
Low paCO2

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21
Q

Renal changes in pregnancy

A

Sodium retention
Increased renal clearance

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22
Q

Gastrointestinal changes in pregnancy

A

sphincter relaxation, delayed gastric
emptying, dysmotility

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23
Q

Endocrine changes in pregnancy

A

prolactin and thyroid hormone increased,
oestrogen and progesterone increase throughout

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24
Q

Uterine hypertrophy changes in weight

A

60g non-pregnant, 1kg at term

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25
Q

Weeks 1-10 embryonic development

A

Neural tube closure at 4 weeks
Heartbeat at 4-5 weeks, definitive circulation by 11 weeks
Isolated limb movements at 10 weeks

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26
Q

Week 11-term foetal development

A

CRL = crown-rump length

Week 12: CRL 56mm, weight 14g (pictured)
Week 16: CRL 122mm
Week 24: CRL 210mm
Surfactant Production 24 weeks

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27
Q

Amniotic fluid

A

Amniotic cavity adjacent to epiblast of bilaminar disc from day 7.
• Initially collection of extracellular fluid derived from maternal plasma. • Foetal renal function by 22 weeks.
• Mainly foetal urine
• Swallowed by foetus
• Up to 1000ml at term (usually)

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28
Q

Definition of pre eclampsia

A

new onset hypertension and proteinuria
(2+) after 20 weeks gestation // hypertension plus systemic effect

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29
Q

Pathogenesis of pre eclampsia

A

abnormal invasion of trophoblast into maternal spiral arterioles

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30
Q

Pathophysiology of pre eclampsia

A

systemic vasoconstriction = ECLAMPSIA multisystem damage: liver, kidneys, CNS, haematological, placental insufficiency

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31
Q

Risk factors pre eclampsia

A

nulliparity, twin pregnancy, previous hx,
family hx, obesity, age 40+,etc.

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32
Q

Signs symptoms pre eclampsia

A

headache, oedema, RFM, hyperreflexia

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33
Q

Investigations pre eclampsia 1st line

A

PLGF, urinalysis, blood pressure, U+Es, LFTs, FBC

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34
Q

Investigations pre eclampsia 2nd line

A

2-weekly CTG, umbilical artery Doppler, USS foetus

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35
Q

Management pre eclampsia 1st line

A

labetalol / nifedipine / methyldopa

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36
Q

Management pre eclampsia 2nd line

A

delivery (<34 weeks, give MgSO4 and
betamethasone / dexamethasone)

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37
Q

Management high risk pre eclampsia

A

Aspirin from 12 weeks

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38
Q

Eclampsia definition

A

Tonic-clonic seizures in presence of pre-eclampsia

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39
Q

Eclampsia management

A

delivery, magnesium sulfate

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40
Q

HELLP syndrome

A

Haemolysis, Elevated Liver enzymes, Low Platelets

Management: delivery

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41
Q

DIC management

A

Platelet and FFP infusion

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42
Q

Pre eclampsia complications

A

Eclampsia
HELLP syndrome
DIC
Intrauterine growth restriction
Intrauterine foetal death
Renal failure
Acute liver failure
Stroke
Heart failure

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43
Q

Causes of antepartum haemorrhage

A

Placental Abruption
Placenta Praevia
Vasa Praevia
Cervical Ectropion
50% unexplained

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44
Q

Placental abruption definition

A

premature separation of placental
bed

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45
Q

Presentation of placental abruption

A

Acute abdominal pain (but not always)
Contractions
Antepartum haemorrhage (but not always)
“Woody” uterus on palpation

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46
Q

Placental abruption investigations

A

Bloods, coagulation screen, USS foetus,
CTG monitoring

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47
Q

Management of placental abruption

A

Expedite delivery (induction or C-Section,
dependant on foetal condition)

48
Q

Placenta praevia definition

A

placenta lying in lower segment of the uterus – Grades 1-IV

49
Q

Presentation of placenta praevia

A

painless antepartum haemorrhage, soft uterus

50
Q

Investigations placenta praevia

A

bloods, coag screen,
USS foetus, CTG monitoring (i.e.
APH investigations).
• Low-lying placenta should be
detected on routine 20 week anomaly scan
• Follow-up TVUSS at 32 weeks

51
Q

Management placenta praevia

A

Elective C section

52
Q

Pelvic girdle components

A

Sacrum
Coccyx
2 x innominate bones: ilium, ischium, pubis

53
Q

3 signs of labour

A

Progressive contraction (3-5 in 10)
Bloody show
Ruptured membranes (waters break)

54
Q

How long does the latent stage (3cm dilated cervix) of normal labour last?

A

6-8 hours

55
Q

How much increase in dilation occurs during the active stage (3cm-10cm dilated)

A

0.5-1cm per hour

56
Q

What is the second stage of labour

A

From full dilation to birth
NB: If you’re having your 1st baby, this pushing stage should last no longer than 3 hours. If you’ve had a baby before, it should take no more than 2 hours

57
Q

Describe the third stage of labour

A

Baby delivered
Placenta delivered

Active labour: Within 30 minutes of delivery - Assisted with syntocinon (synthetic oxytocin) IM and gentle cord traction

58
Q

Describe the movement stages of baby delivery

A
  1. Engagement and descent - widest diameter
  2. Flexion - narrowest diameter
  3. Internal rotation of head into OA - crowning
  4. Extension
  5. Restitution - head aligns with shoulders
  6. External rotation - shoulders rotate
  7. Delivery of shoulders - gentle traction
59
Q

Failure to progress definition

A

Insufficient rate of dilation / foetal descent

60
Q

Causes of failure to progress

A

Power: hypotonic uterine activity (>45s, 3-5 in 10min)
Passage: pelvic dimensions (inlet/outlet)
Passenger: position (rotation), attitude (flexion) and head size

61
Q

Failure to progress management

A

Augmentation of labour - ARM, synctinon infusion
Instrumental delivery - forceps or ventouse
Caesarean section

62
Q

Indications for instrumental delivery

A

Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in various fetal positions

63
Q

Given to mothers during an instrumental delivery to reduce infection

A

Co-amoxiclav

64
Q

Instrumental delivery risks to mother

A

Postpartum haemorrhage
Episiotomy
Perineal tears
Injury to the anal sphincter
Incontinence of the bladder or bowel
Nerve injury (obturator or femoral nerve)

65
Q

Main complication using ventouse method of instrumental delivery

A

Cephalohaematoma

66
Q

Main complication of using forceps method of instrumental delivery

A

Facial nervy palsy

67
Q

4 Indications for an elective Caesarian section

A

Previous caesarean
Placenta praevia
Breech presentation
Multiple pregnancy

68
Q

Categories of emergency C section

A

Category 1: immediate threat to the life of the mother or baby. [Decision to Delivery] = 30 minutes
Category 2: not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. [Decision to Delivery] = 75 minutes.
Category 3: delivery is required, but mother and baby are stable
Category 4: elective caesarean

69
Q

Layers of the abdomen dissected in a C section

A

Skin
Subcutaneous tissue
Fascia / rectus sheath
Rectus abdominis muscles
Peritoneum
Vesicouterine peritoneum (and bladder)
Uterus (perimetrium, myometrium and endometrium)
Amniotic sac

70
Q

Measures used to reduce the risks in C section

A

H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) before the procedure
Prophylactic antibiotics during the procedure to reduce the risk of infection
Oxytocin during the procedure to reduce the risk of postpartum haemorrhage
Venous thromboembolism (VTE) prophylaxis with low molecular weight heparin

71
Q

Shoulder dystocia definition

A

anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered

Obstetric emergency!

72
Q

Main cause of shoulder dystocia

A

macrosomia secondary to gestational diabetes.

73
Q

Presentation of shoulder dystocia

A

Turtle neck sign (head is delivered but then retracts back into the vagina)
Failure of restitution
Difficulty delivering head/chin

74
Q

Complications of shoulder dystocia

A

Fetal hypoxia (and subsequent cerebral palsy)
Brachial plexus injury and Erb’s palsy
Perineal tears
Postpartum haemorrhage

75
Q

Management of shoulder dystocia

A

1st line: call for help/MDT
2nd line: instruct mum to stop pushing + lie flat on the bed
3rd line: McRobert’s + suprapubic pressure + axial traction (90% of cases)
4th line: internal manoeuvres/deliver posterior arm
5th line: all fours, repeat
6th line: episiotomy (enlarge vaginal opening), Zanvanelli (push back for C section), symphsiotomy

76
Q

McRoberts manoeuvre in shoulder dystocia

A

Hyper flex ion of the mother at the hip (knee to abdomen) = posterior pelvic tilt = pubic symphysis up and out of the way

77
Q

Primary postpartum haemorrhage definition

A

500ml blood loss within 24 hours of vaginal delivery
1000ml blood loss within 24 hours of caesarean section

78
Q

Secondary post partum haemorrhage definition

A

From 24 hours to 12 weeks after birth

79
Q

Classifications of PPH

A

Minor: 500-1000
Major: 1000-1500
Massive obstetric haemorrhage: 1500+

80
Q

4 causes of PPH

A

4 T’s!
Tone - atonic uterus (prolonged labour, macrosomia, twins)
Trauma - genital tract injury
Tissue - retained placenta/membranes
Thrombin - coagulopathy e.g. DIC in pre-eclampsia

81
Q

Risk factors for PPH

A

Previous PPH
Multiple pregnancy
Obesity
Large baby
Pre-eclampsia

82
Q

Management of PPH

A

Dependent on cause
Fundal massage + syntocinon (40 units) + ergometrine
Rhesus: fluids, oxygen, blood products

83
Q

Most common site for ectopic pregnancy

A

Fallopian tube

NB: Isthmus site causes most bleeding

84
Q

Risk factors ectopic pregnancy

A

Previous ectopic
Previous PID
Previous surgery to the fallopian tubes
Intrauterine devices (coils)
Older age
Smoking

85
Q

When does ectopic pregnancy typically present

A

6-8 weeks gestation

86
Q

Features of ectopic pregnancy

A

Missed period
Constant lower abdo pain in the right or left iliac fossa
Vaginal bleeding
Tenderness/guarding

87
Q

Ectopic pregnancy investigations

A

Pregnancy test
Transvaginal ultrasound scan

88
Q

Management of a unruptured ectopic pregnancy

A

Methotrexate (highly teratogenic) OR laparoscopic salpingectomy (key hole to remove affected fallopian tube) or laparoscopic salpingotomy

89
Q

Management of ruptured ectopic pregnancy

A

Laparoscopic salpingectomy / salpingotomy + resuscitation +/- post op methotrexate

90
Q

Differentials for acute lower abdo pain in young female

A

Appendicitis
Ectopic pregnancy
Ovarian torsion
Miscarriage
Cyst rupture
PID/tubal abscess

91
Q

Investigations acute lower abdo pain in young female

A

Urine pregnancy test
TV USS

I.e. ectopic until proven otherwise

92
Q

Early miscarriage definition

A

Spontaneous termination of pregnancy before 12 weeks gestation

93
Q

Late miscarriage definition

A

Spontaneous termination of pregnancy between 12 and 24 weeks gestation

94
Q

Miscarriage gold standard Ix

A

TV USS

95
Q

Three key features on TV USS for miscarriage

A

Mean gestational sac diameter
Fetal pole and crown-rump length
Fetal heartbeat

96
Q

Management miscarriage less than 6 weeks gestation

A

Expectant management providing there is no pain or complications or risk factors (eg. Previous ectopic)
No scan needed
Repeat urine pregnancy test after 7-10 days - negative = confirmed

97
Q

Miscarriage management more than 6 weeks gestation

A

Early pregnancy assessment unit (EPAU) > TV USS:
Options:
- Expectant management
- Medical management (misoprostol)
- Surgical management

98
Q

Misoprostol pharmacology

A

Prostaglandin analogue
Prostaglandins soften the cervix and stimulate uterine contractions

99
Q

Incomplete miscarriage definition

A

Retained products of conception remain - risk of infection
Medical or surgical management (evacuation using vacuum aspiration)

100
Q

Recurrent miscarriage definition

A

Three or more consecutive miscarriages

101
Q

Causes of recurrent miscarriage

A

Idiopathic (particularly in older women)
Antiphospholipid syndrome (hyper coagulable state)
Uterine abnormalities
Chronic disease e.g. diabetes, untreated thyroid disease, SLE (secondary antiphospholipid syndrome)

102
Q

Antiphospholipid syndrome Ix

A

Anti-phospholipid antibodies

103
Q

Antiphospholipid syndrome treatment

A

Low dose aspirin
LMWH

104
Q

Legal framework for a termination of pregnancy

A

1967 abortion act
1990 human fertilisation and embryology act

105
Q

1990 changes to abortion act

A

Latest gestational age from 28 weeks to 24 weeks

106
Q

Medical abortion treatment

A
  1. Mifespristone (anti-protestogen) halts pregnancy and relaxes cervix
  2. Misoprostol (prostaglandin analogue) 1-2 days later - softens cervix and stimulates uterine contractions

NB: rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis

107
Q

Chorionicity definition

A

Number of placentas

108
Q

Amnionicity definition in twin pregnancy

A

Number of amniotic sacs

109
Q

Significant complication of gestational diabetes

A

Macrosomia
Neonatal hypoglycaemia

110
Q

Women with risk factors for gestational diabetes screening test

A

OGTT at 24-28 weeks gestation

111
Q

OGTT

A

75g glucose drink
Blood sugar measured before glucose (fasting) and 2 hours after
Normal results:
Fasting: <5.6 mmol/l
At 2 hours: <7.8 mmol/l

112
Q

Management for gestational diabetes

A

Fasting < 7: trial of diet and exercise by 1-2 wks followed by metformin then insulin
Fasting > 7: insulin +/- metformin
Fasting glucose > 6 + macrosomia: insulin +/- metformin

113
Q

Women with pre-existing diabetes management

A

5mg folic acid preconception to 12 weeks gestation
Retinopathy screening for diabetic retinopathy
Planned delivery between 37 and 38 + 6 weeks for pre-existing (gestational - up to 40 + 6)
Type 1: sliding scale insulin regime

114
Q

Neonatal hypoglycaemia - management if glucose falls below 2 mmol/l

A

IV dextrose of nasogastric feeding

115
Q

Prophylaxis for VTE starting points in pregnancy (RCOG guidelines)

A

3 + risk factors: 28 weeks
4 + risk factors: first trimester

Prophylaxis = LMWH e.g. dalteparin

116
Q

DVT/PE 2a notes

To do: VTE pregnancy diagnosis + management

A

Belle: Phase 3a (7 decks)

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