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Obs and Gynae Flashcards

1
Q

Explain the hypothalamic-pituitary-gonadal axis

A
  • Hypothalamus releases GnRH
  • GnRH stimulates the pituitary to produce LH and FSH
  • LH and FSH stimulate the development of the follicles in the ovaries
  • Theca granulosa cells around the follicles secrete oestrogen which then has a negative feedback on the hypothalamus and the anterior pituitary, which then suppresses GnRH, LH and FSH
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1
Q

What are the actions of oestrogen?

A
  • breast tissue development
  • growth and development of the female sex organs at puberty
  • blood vessel development in the uterus
  • development of the endometrium
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2
Q

When is progesterone produced/what by?

A
  • corpus luteum
  • after ovulation
  • when pregnancy occurs it is produced by the placenta from 10 weeks onwards
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3
Q

What is the role of progesterone?

A
  • thicken and maintain the endometrium
  • thicken the cervical mucus
  • increase the body temperature
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4
Q

What is the follicular phase?

A

start of menstruation to the moment of ovulation

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5
Q

What is the luteal phase?

A

moment of ovulation to the start of menstruation

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6
Q

At what point do follicles develop FSH receptors?

A

When they reach secondary follicle stage

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7
Q

Describe what happens in the follicular phase

A
  • FSH stimulates development of secondary follicles
  • Granulosa cells around the follicles secrete increasing amounts of oestrogen (making the cervical mucus more permeable)
  • oestradiol has a negative. feedback effect on the hypothalamus which then reduces LH and FSH
  • one follicle develops and becomes the dominant follicle which then releases an ovum when LH spikes
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8
Q

Describe the luteal phase of the menstrual cycle

A
  • follicle that released the ovum collapses ->corpus luteum
  • corpus luteum secretes progesterone (and a small amount of oestrogen)
  • if fertilised, the embryo secretes HCG which maintains the corpus luteum, without it will degenerate
  • if no fertilisation occurs then the progesterone and oestrogen drops and causes the endometrium to break down and menstruation to occur
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9
Q

What is the definition of menorrhagia?

A

Whatever the woman considers to be excessive and impacting on quality of life

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10
Q

What are the uterine causes of heavy menstrual bleeding?

A
  • fibroids
  • endometrial polyps
  • adenomyosis
  • pelvic infection
  • endometrial malignancy
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11
Q

What medical disorders can cause heavy menstrual bleeding?

A

clotting disorders

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12
Q

Investigations for heavy menstrual bleeding

A
  • coagulation disorders
  • serum ferritin
  • thyroid testing if other symptoms
  • consider biopsy to exclude endometrial cancer or atypical hyperplasia
  • transvaginal USS if suspected structural or histological abnormality
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13
Q

Explain the management of heavy menstrual bleeding

A
  • no contraception needed/wanted: mefenamic acid or tranexamic acid (take during menses)
  • contraceptive: IUS firstline, COCP, progestogens
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14
Q

What is primary amenorrhoea?

A
  • failure to mensturate by age 15
  • may be associated with normal or delayed/absent development of secondary sexual characteristics
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15
Q

What is secondary amenorrhoea?

A
  • established menses stop for ≥6 months in the absence of pregnancy
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16
Q

What is the definition of oligomenorrhoea?

A
  • cycle persistently greater than 35 days in length
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17
Q

Investigations for primary amenorrhoea

A
  • plasma FSH, LH, oestrodiol, prolactin, TFT
  • karyotype
  • X ray for bone age
  • cranial imaging
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18
Q

Explain the causes of primary amenorrhoea in someone with secondary sexual characteristics, and a present uterus on USS

A
  • Outflow tract obstruction: imperforate hymen or transverse vaginal septum
  • normal anatomy: hormone profile
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19
Q

What are the physiological causes of secondary amenorrhoea?

A
  • pregnancy
  • lactation
  • menopause
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20
Q

What are the hypothalamic causes of secondary amenorrhoea?

A
  • weight loss/anorexia
  • heavy exercise
  • stress
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21
Q

What are the ovarian causes of secondary amenorrhoea?

A
  • PCOS
  • premature ovarian failure
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22
Q

What is the rotterdam criteria?

A
  1. Clinical or biochemical evidence of hyperandrogenism (high free androgen index)
  2. Oligomenorrhoea/amenorrhoea
  3. USS features of PCOS
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23
Q

What are the consequences of PCOS?

A
  • reduced fertility
  • insulin resistance and diabetes
  • hypertension
  • endometrial cancer due to unopposed oestrogen
  • depression and mood swings
  • snoring and daytime drowsiness
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24
Q

What is the management of PCOS?

A
  • education
  • weight loss and exercise
  • endometrial protection
  • fertility assistance
  • lifetime awareness ± screening for complications
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25
Q

What is primary dysmenorrhoea

A
  • begins with onset of ovulatory cycels
  • typically within first 2 years of menarche
  • pain is most severe on the day of or the day prior to start of menstruation
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26
Q

What is the treatment of dysmenorrhoea?

A
  • prostaglandin synthesis inhibitors (NSAIDs)
  • COC
  • depot progestogens
  • levonorgestrel-releasing intrauterine system
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27
Q

What is secondary dysmenorrhoea?

A
  • associated with pelvic pathology
  • endometriosis, adenomyosis, pelvic infection and fibroids
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28
Q

What is the definition of post menopausal bleeding?

A

Bleeding occurring >12 months after LMP

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29
Q

Cells of ectocervix

A

Squamous

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30
Q

Cells of the endocervix

A

columnar epithelium/glandular epithelium

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31
Q

What is the most common cancer of the ectocervix?

A

Squamous cell cancer

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32
Q

What is the most common cancer of the endocervix?

A

Adenocarcinoma

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33
Q

What is the transformation zone of the cervix?

A

Area at the junction of the ectocervix and endocervix (squamo-columnar junction)

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34
Q

Describe the NHS cervical screening programme

A

Age group 25-64
- those age 25-49 every 3 years
- those 50-64 every 5 years
- anyone who has a cervix

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35
Q

What are the 3 types of results from smear test?

A
  • HPV negative, return to routine screening
  • HPV positive wiht no abnormal cells -> repeat HPV test in one year
  • HPV positive with cell changes -> refer to colposcopy
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36
Q

Which HPV viruses are the most common causes of cervical cancer?

A
  • 16
  • 18
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37
Q

What are the preventative measures for HPV infection

A
  • barrier contraception
  • HPV vaccine (6,11, 16, 18)
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38
Q

What are the risk factors for cervical cancer?

A
  • HPV (16, 18, 33)
  • smoking
  • HIV
  • early first intercourse, many sexual partners
  • high parity
  • lower socioeconomic status
  • COCP use
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39
Q

For how long should cervical screening be delayed in pregnant women?

A

until 3 months post partum

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40
Q

What happens if a cervical smear sample is inadequate?

A
  • repeat sample in 3 months time
  • if two consecutive samples are inadequate then refer to colposcopy
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41
Q

Treatment of CIN

A

Large loop excision of the transformation zone

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42
Q

CIN 1

A

mild dysplasia, affecting 1/3 the thickness of the epithelial, likely to return to normal without treatment

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43
Q

CIN 2

A

moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated

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44
Q

CIN 3

A

Severe dysplasia, very likely to progress to cancer if untreated

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45
Q

What are the possible cytology results

A
  • inadequate
  • normal
  • borderline changes
  • low grade dyskaryosis
  • high grade dyskaryosis moderate or severe
  • possible invasive squamous cell carcinoma
  • possible glandular neoplasia
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46
Q

Role of acetic acid in colposcopy

A
  • abnormal cells appear white
  • CIN and cancer cells
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47
Q

Iodine in colposcopy

A
  • stains healthy cells brown
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48
Q

What is endometriosis?

A

Chronic condition, growth of ectopic endometrial tissue outside of the uterine cavity

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49
Q

What are the clinical features of endometriosis?

A
  • chronic pelvic pain
  • secondary dysmenorrhoea (pain often starts days before bleeding)
  • deep dyspareunia
  • subfertility
  • can have urinary symptoms or painful bowel movements
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50
Q

Endometriosis signs on pelvic examination

A
  • reduced organ mobility
  • tender nodularity in the posterior vaginal fornix
  • visible vaginal endometriotic lesions may be seen
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51
Q

Investigation for endometriosis

A

Laparoscopy is the gold standard

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52
Q

Management of endometriosis

A
  • NSAIDs and/or paracetamol
  • COCP or progestogens if analgesia doesn’t help
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53
Q

What are the secondary treatments of endometriosis

A
  • DnRH analogues
  • surgery: laparoscopic exciison or ablation of endometriosis plus adhesiolysis
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54
Q

What is pelvic inflammatory disease?

A

Describes infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and surrounding peritoneum

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55
Q

What is the most common cause of PID?

A

Chlamydia trachomatis

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56
Q

What are the causes of pelvic inflammatory disease?

A
  • chlamydia trachomatis
  • neisseria gonorrhoeae
  • mycloplasma genitalium
  • mycoplasma hominis
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57
Q

What are the features of PID?

A
  • lower abdominal pain
  • fever
  • deep dyspareunia
  • dysuria and mentrual irregularities
  • vaginal or cervical discharge
  • cervical excitation
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58
Q

Investigations for PID

A
  • pregnancy test to exclude ectopic pregnancy
  • high vaginal swab
  • screen for chlamydia and gonorrhoea
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59
Q

What is the management of PID?

A
  • oral doxycycline
  • oral metronidazole
  • intramuscular ceftriaxone
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60
Q

What are the complications of PID?

A
  • perihepatitis: right upper quadrant pain
  • Infertility
  • chronic pelvic pain
  • ectopic pain
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61
Q

What hormone are fibroids sensitive to?

A

Oestrogen (so can grow during pregnancy)

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62
Q

Fibroid degeneration symtpoms

A

Often occurs during pregnancy

  • low grade fever
  • pain
  • vomiting
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63
Q

What are fibroids?

A

Benign smooth muscle tumours of the uterus

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64
Q

What are the symptoms of fibroids?

A
  • may be asymptomatic
  • menorrhagia
  • lower abdominal pain: cramping
  • bloating
  • urinary symptoms
  • sub-fertility
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65
Q

Investigation for fibroids

A

transvaginal USS

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66
Q

Management of fibroids

A
  • symtpomatic management with levonorgestrel releasing intrauterine system
  • GnRH may reduce size
  • myomectomy, hysteroscopic endometrial ablation, hysterectomy
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67
Q

What are the physiological cysts?

A
  • follicular cysts: due to non rupture of the dominant follicle
  • corpus luteum cyst: corpus luteum fails to break down
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68
Q

What are the benign germ cell tumours?

A

Dermoid cysts

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69
Q

What are the benign epithelial tumours?

A
  • serous cystadenoma
  • mucinous cystadenoma
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70
Q

What cyst is most common with torsion?

A

Dermoid

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71
Q

What is the most common benign tumour in women under 30?

A

Dermoid cysts

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72
Q

What is ovarian torsion?

A
  • partial or complete torsion of the ovary on its supporting ligament
  • this may compromise blood supply
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73
Q

What are the risk factors of ovarian torsion?

A
  • ovarian mass
  • being of reproductive age
  • pregnancy
  • ovarian hyperstimulation syndrome
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74
Q

What are the features of ovarian torsion

A
  • sudden onset, deep colicky abdominal pain
  • vomiting and distress
  • fever in minority
  • vaginal exam may demonstrate adnexial tenderness
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75
Q

USS of ovarian torsion

A

may show free fluid or whirlpool sign

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76
Q

What is the management of ovarian torsion?

A

Surgical detorsion (laparascopically) or salpingo-oophorectomy

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77
Q

Who should be referred to gynaecology in relation to ovarian cysts?

A
  • any postmenopausal woman with any cyst
  • premenopausal women with a simple cyst can be referred if persists after 8-12 weeks
  • complex cysts should be biopsied
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78
Q

What is infertility?

A

The inability of a heterosexual couple to conceive in 12 months of regular unprotected intercourse

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79
Q

What is primary infertility?

A

Never conceived

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80
Q

What is secondary infertility?

A

at least one previous pregnancy

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81
Q

What are the factors that can affect fertility?

A
  • age (mostly female)
  • weight
  • timing of intercourse, sperm needs to be deposited before ovulation due to progesterone
  • duration of sub-fertility
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82
Q

Directions on sample for semen analysis

A
  • 3-5 days of abstaining
  • then give sample
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83
Q

What is assessed in a semen analysis?

A
  • volume
  • concentration
  • total motility
  • progressive motility
  • normal forms
  • vitality
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84
Q

What further testing should be carried out if semen analysis demonstrates oligospremia or azoospermia

A
  • karyotype
  • Y microdeletions
  • CF status
  • FSH
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85
Q

What options can be considered if oligospermia?

A
  • Surgical sperm retrieval
  • ICSI (intracytoplasmic sperm injection)
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86
Q

What are the types of azoospermia?

A
  • obstructive (normal spermatogenesis but unable to leave)
  • non-obstructive(testicular failure, high FSH)
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87
Q

What are the causes of obstructive azoospermia?

A
  • congenital absence of vas deferens (test CF)
  • blockage of the epididymis or vas deferens
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88
Q

Group 1 no or irregular cycle

A
  • primary or secondary amenorrhoea
  • low levels of endogenous gonadotropins
  • negligable levels of endogenous oestrogen activity
  • low FSH, LH, E2
  • normal/increased prolactin
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89
Q

Group 2 no or irregular cycle

A
  • anovulation with a varitey of menstrual disorders
  • endogenous oestrogen activity
  • normal urinary gonadotropins
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90
Q

Group 3 no or irregular period

A
  • primary or secondary amenorrhoea
  • primary ovarian failure
  • low endogenous oestrogen activity
  • pathologically high gonadotropin levels
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91
Q

What are the causes of group 3 amenorrhoea/oligomenorrhoea

A
  • Idiopatihic
  • Chemo/XRT
  • Surgical removal of ovaries
  • Autoimmune
  • Chromosomal
  • Turners (45XO)/ Turners mosaic
  • Pure gonadal dysgenesis
  • Androgen insensitivity (46XY)
  • Fragile X
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92
Q

How do you assess tubal patency?

A
  • hysterosalpingogram
  • laparoscopy and dye test
  • Hysterosalpingo-contrast-ultrasonography
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93
Q

What is the NHS scotland criteria for fertility treatment?

A
  • woman must be under 43 by the time treatment is complete and under 42 by the time screening is carried out
  • womans BMI must be under 30 and over 18.5
  • both must have stopped smoking for a period of at least 3 months
  • couple must have been in a cohabiting stable relationship for 2 years
  • neither person sterilised
  • at least one of the couple must not have a biological child
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94
Q

What are the assisted conception techniques?

A
  • intrauterine insemination ± ovulation induction
  • In vitro fertilisation (IVF)
  • Intracytoplasmic sperm injection (ICSI)
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95
Q

What is ovarian hyperstimulation syndrome?

A
  • Ovaries ‘over respond’ to gonadotrphin injections
  • Systemic disease resulting from release of vasoactive products from hyperstimulated ovaries
  • higher risk in PCOS
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96
Q

Symptoms of menopause

A
  • change in periods: length change, dysfunctional bleeding
  • vasomotor symptoms: hot flushes, night sweats
  • urogenital changes: vaginal dryness and atrophy, urinary frequency
  • psychological: anxiety, depression, short term memory impairment
  • longer term: osteoporosis, increased risk of ischaemic heart disease
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97
Q

What are the types of HRT?

A
  • combined
  • cyclical
  • continuous
  • oestrogen only
  • patch/gell/tablet
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98
Q

Who should not receive oestrogen only HRT and why?

A
  • any woman with a uterus
  • increases endometrial cancer risk
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99
Q

when would you give continuous vs cyclical hrt?

A
  • continuous if no period for 12 months
  • cyclical if still getting a period
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100
Q

What are the cons of HRT?

A
  • Increased breast cancer risk in combined
  • increased VTE/stroke risk if tablet
  • Side effects: nausea, breast tenderness, fluid retention and weight gain
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101
Q

What are the pros of HRT?

A
  • relieves menopausal symptoms
  • prevents osteoporosis
  • maintains muscle strength
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102
Q

What are the non hormonal options to help with menopausal symtpoms?

A
  • lifestyle changes: exercise, diet, stop smoking, reduce alcohol and caffeine consumption
  • CBT
  • clonidine for vasomotor symptoms
  • SSRI
  • gabapentin
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103
Q

What are the causes of post menopausal bleeding?

A
  • vaginal atrophy
  • HRT
  • endometrial hyperplasia
  • endometrial cancer
  • cervical cancer
  • vaginal cancer
  • ovarian cancer
  • trauma
  • bleeding disorders
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104
Q

When to refer for PMB

A
  • women over 55
  • 2 week USS
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105
Q

Acceptable depth of endometrial lining in post menopausal women

A

<5mm

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106
Q

What is the most common cause of PMB?

A

Vaginal atrophy

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107
Q

Treatment of vaginal atrophy

A

topical oestrogens, lubricants

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108
Q

Risk factors for endometrial hyperplasia

A
  • obesity
  • unopposed oestrogen
  • tamoxifen use
  • diabetes
  • PCOS
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109
Q

Treatment of endometrial hyperplasia

A

dilatation and curettage

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110
Q

Cystocele

A

Anterior vaginal wall defect, bladder prolapses in to vagina

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111
Q

Rectocele

A

Posterior vaginal wall defect, rectum prolapses into the vagina. Can result in faecal loading causing constipation

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112
Q

Vault prolapse

A

In women with a hysterectomy and no uterus the top of the vagina (vault) descends into the vagina

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113
Q

What are the risk factors for urogenital prolapse?

A
  • multiple vaginal deliveries
  • traumatic delivery
  • increasing age and postmenopausal
  • obesity
  • chronic resp condition resulting in cough
  • chronic constipation resulting in straining
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114
Q

What are the treatments for urogenital prolapse?

A
  • conservative: physio, weight loss, lifestyle changes, vaginal oestrogen
  • vaginal pessary
  • surgery
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115
Q

enterocele

A

prolapse of the upper posterior vaginal wal (posterior fornix) and pouch of douglas, usually contains loops of small bowel

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116
Q

What provides support to the uterus?

A
  • vaginal walls
  • transverse cervical ligaments
  • round and broad ligaments
  • indirect support from pelvic floor
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117
Q

What supports the cervix and upper 1/3 vagina?

A
  • transverse cervical ligament
  • uterosacral ligaments
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118
Q

Symptoms of prolapse

A
  • sensation of heaviness/dragging/pressure
  • sensation of bulge
  • bleeding/discharge
  • backache
  • dyspareunia
  • urinary incontinence/frequency/urgency
  • constipation/straining
  • faecal incontinence or urgency of stool
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119
Q

Stage 0 prolapse

A

No prolapse

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120
Q

Stage 1 prolapse

A

more than 1cm above hymenal ring

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121
Q

stage 2 prolapse

A

prolapse extends from 1cm above to 1cm below hymenal ring

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122
Q

Stage 3 prolapse

A

Prolapse extends 1cm or more below the hymenal ring, no vaginal eversion

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123
Q

Stage 4 prolapse

A

Vagina completely everted

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124
Q

What is the most common prolapse?

125
Q

Where is a pessary placed?

A

Between the posterior aspect of the symphysis pubis and posterior fornix

126
Q

What are the complications of pessaries?

A
  • interference with sex
  • ulceration
  • infection
  • difficulty and discomfort during removal
  • fistula if neglected
127
Q

Surgery for anterior compartment defect

A

anterior colporrhaphy

128
Q

surgery for posterior compartment defect

A

posterior colporrhaphy

129
Q

Explain the micturition cycle

A
  • bladder fills: detrusor relaxes, urethral sphincter and pelvic floor contracts
  • first sensation to void: bladder half full, urination is voluntarily inhibited until appropriate time
  • normal desire to void
  • micturition: detrusor contracts, pelvic floor relaxes
130
Q

What maintains continence?

A
  • brain
  • spinal cord and nerves: pelvic and pudendal
  • bladder
  • urethral sphincter
  • pelvic floor
131
Q

What are the types of urinary incontinence?

A
  • Urgency incontinence
  • mixed
  • stress incontinence
132
Q

What is urge incontinence?

A

Leakage of urine in repsonse to an involuntary contraction of the detrusor muscle

133
Q

Overactive bladder

A

symptoms of urgency with or without urge incontinence, usually with frequency and nocturia

134
Q

What is stress incontinence?

A

Leakage occurs with a rise in intra-abdominal pressure without a detrusor contraction

135
Q

Investigations in suspected urinary incontinence

A
  • urine dip and culture
  • bladder diary: minimum 3 days
  • cystoscopy and renal tract imaging : recurrent uti or haematuria
  • urodynamic testing
136
Q

What is the medical management of overactive bladder?

A
  • anticholinergic drugs: oxybutynin, tolterodine, solfenacin
137
Q

What is the surgical management of over active bladder?

A
  • botox to detrusor muscle
  • percutaneous sacral nerve stimulation
  • augmentaton cystoplasty
138
Q

missed miscarriage

A

Fetus is no longer alive

139
Q

Threatened miscarriage

A

Vaginal bleeding with a closed cervix and fetus that is alive

140
Q

Inevitable miscarriage

A

vaginal bleeding with an open cervix

141
Q

complete miscarriage

A

a full miscarriage has occurred and there are no products of conception left in the uterus

142
Q

early miscarriage

A

before 12 weeks

143
Q

Late miscarriage

A

Between 12 and 14 weeks

144
Q

investigation to diagnose miscarriage

145
Q

Management of miscarriage

A
  • less than 6 weeks: expectant (await and do urine pregnancy test after 7-10 days)
  • More than 6: referral to early pregnancy unity, USS then: expectant, medical, or surgical
146
Q

What is the medical management of miscarriage?

A
  • misoprostol
  • vaginal suppository or oral dose
147
Q

What is the surgical management of miscarriage?

A
  • manual vacuum aspiration undler local anaesthetic
  • electric vacuum aspiration under general anaesthetic
  • give misoprostol before to soften the cervix
148
Q

What is the management of incomplete miscarriage?

A
  • medical (misoprostol)
  • Surgical (evacuation of retained products of conception)
149
Q

What are the causes of miscarriage?

A
  • idiopathic
  • antiphospholipid syndrome
  • hereditary thromophilias
  • uterine abnormalities
  • genetic factors in parents
  • chronic histiocytic intervillositis
  • chronic diseases e.g. diabetes, untreated thyroid disease, SLE
150
Q

What is antiphospholipid syndrome?

A
  • antiphospholipid antibodies
  • blood becomes prone to clotting: hypercoagulable state
151
Q

Investigations for recurrent miscarriage

A
  • antiphospholipid antibodies
  • test for hereditary thrombophilias
  • pelvic USS
  • genetic tesitng of products of conception from third or future miscarriages
  • genetic testing on parents
152
Q

Most common site of ectopic

A

Fallopian tube

153
Q

What are the risk factors for ectopic pregnancy?

A
  • previous ectopic
  • previous pelvic inflammatory disease
  • previous surgery to the fallopian tubes
  • intrauterine devices
  • older age
  • smoking
154
Q

Presentation of ectopic pregnancy

A
  • constant lower abdo pain in iliac fossas
  • vaginal bleeding
  • lower abdominal pain or tenderness
  • cervical motion tenderness on bimanual examination
  • should tip pain due to peritonitis
155
Q

Management of pregnancy of unknown location

A
  • Track the serum hCG
  • intrauterine pregnancy hCG will rise above 63% every 48 hours, if this is the case then repeat the uss in one - two weeks
  • a rise of less than 63% indicates potential ectopic pregnancy
  • fall of more than 50% indicates miscarriage
156
Q

What is the management of ectopic pregnancy?

A
  • expectant (await miscarriage)
  • medical with methotrexate
  • surgical (salpingectomy or salpingotomy)
157
Q

Criteria for expectant management of ectopic pregnancy

A
  • follow up must ensure successful termination
  • must be unruptured
  • adnexal mass <35mm
  • no visible heart rate
  • no significant pain
  • HCG <1500
158
Q

Criteria for medical management of ectopic pregnancy

A
  • follow up must ensure successful termination
  • must be unruptured
  • adnexal mass <35mm
  • no visible heart rate
  • no significant pain
  • HCG <5000
  • confirmed absence of intrauterine pregnancy on ultrasound
159
Q

How long should a woman treated with methotrexate for ectopic wait until conceiving?

160
Q

What are the common side effects of methotrexate for ectopic?

A
  • vaginal bleeding
  • nausea and vomiting
  • abdominal pain
  • stomatitis
161
Q

What happens in a medical abortion?

A
  • mifepristone is given
  • misoprostol is given 1-2 days later
162
Q

Who should get anti-D for termination?

A

Rhesus negative women with a gestational age over 10 weeks

163
Q

Diagnosis of hyperemesis gravidarum

A
  • more than 5% weight loss compared with before pregnancy
  • dehydration
  • electrolyte imbalance
164
Q

How can you assess severity of emesis in pregnancy

A
  • PUQE score
  • <7 mild
  • 7-12 moderate
  • > 12 severe
165
Q

Order of preference of antiemetics for pregnancy

A
  • prochlorperazine
  • cyclizine
  • ondasetron
  • metoclopramide
166
Q

When should you consider admission for hyperemesis gravidarum?

A
  • unable to tolerate oral antiemetics or keep fluids down
  • more than 5% weight loss compared with pre pregnancy
  • ketones in urine
167
Q

complete mole

A

two sperm fertilise an ovum that contains no genetic material. No foetal material forms

168
Q

partial mole

A

two sperm cells fertilise a normal ovum so it has three sets of chromosomes. Some foetal material forms

169
Q

Symptoms of molar pregnancy

A
  • more severe morning sickness
  • vaginal bleeding
170
Q

Signs of a molar pregnancy

A
  • increased enlargement of the uterus
  • abnormally high hCG
  • thyrotoxicosis
  • USS showing snowstorm appearance
171
Q

Gravida

A

How many pregnancies a woman has had

172
Q

para

A

Number of times a woman has given birth after 24 weeks regardless of if fetus is alive or not

173
Q

When is a dating scan?

A

Between 10 and 13+6 weeks

174
Q

What happens at a dating scan?

A

An accurate gestational age is calculated from the crown rump length and multiple pregnancies are identified

175
Q

When does the anomaly scan take place?

A

Between 18 and 20+6 weeks

176
Q

When does OGTT take place

A

24-28 weeks gestation

177
Q

When do rhesus negative women get anti d (in normal pregnancy)

A

28 and 34 weeks

178
Q

What vaccines are recommended for all pregnant women?

A
  • whooping cough
  • influenza
179
Q

At what point in pregnancy is flying not recommended?

A
  • 37 weeks in a single
  • 32 weeks in a twin pregnancy
180
Q

When does the combined test occur?

A

between 11 and 14 weeks gestation

181
Q

combined test result indicating downs

A
  • nuchal trnaslucency greater than 6mm
  • low Pregnancy associated plasma protein A (PAPPA)
  • high beta hCG
182
Q

when does triple test occur

A

14 to 20 weeks

183
Q

triple test result suggestive of downs

A
  • high beta hcg
  • low alpha fetoprotein
  • low serum oestriol
184
Q

What happens when risk score for downs syndrome is greater than 1 in 150?

A

Offered:
- chorionic villus sampling if before 15 weeks
- amniocentesis
- may be offerened NIPT

185
Q

sodium valporate in pregnancy

A

Avoided as causes neural tube defects and developmental delay

186
Q

Phenytoin in pregnancy

A

causes cleft lip and palate

187
Q

What are the drugs safe for pregnancy for rheumatoid

A
  • hydroxychloroquine
  • sulfasalazine
188
Q

When may sensitisation in rhesus occur?

A
  • antepartum haemorrhage
  • amniocentesis procedures
  • abdominal trauma
189
Q

What are the causes of placenta mediated growth restriction?

A
  • idiopathic
  • pre-eclampsia
  • maternal smoking
  • anaemia
  • malnutrition
  • infection
  • maternal health conditions
190
Q

What are the causes of non placenta mediated growth restriction

A
  • genetic abnormalities
  • structural abnormalities
  • fetal infection
  • errors of metabolism
191
Q

What is large for gestational age

A
  • Over 4.5kg at birth
  • over 90th percentile during pregnancy
192
Q

What are the causes of macrosomia?

A

-constitutional
- maternal
- previous macrosomia
- maternal obesity or rapid weight gain
- overdue
- male baby

193
Q

What are the risks of macrosomia

A
  • failure to progress
  • perineal tears
  • instrumental delivery or caesarean
  • postpartum haemorrhage
  • uterine rupture
  • shoulder dystocia
  • birth injury (e.g. erbs palsy, clavicle fracture)
  • neonatal hypoglycaemia
  • obesity in childhood and later life
  • type 2 diabetes in adulthood
194
Q

What is pre eclampsia?

A
  • hypertension
  • end organ dysfunction: proteinuria
  • after 20 weeks gestation
  • oedema
195
Q

What are the high risk factors for pre exlampsia?

A
  • pre existing hypertension
  • previous hypertension in pregnancy
  • existing autoimmune condiitons
  • diabetes
  • chronic kidney disease
196
Q

Prophylaxis for pre eclampsia

A

aspirin from 12 weeks

197
Q

What are the symptoms of pre-eclampsia?

A
  • headache
  • visual disturbance or blurriness
  • nausea and vomiting
  • upper abdominal or epigastric pain
  • oedema
  • reduced urine output
  • brisk reflexes
198
Q

Diagnosis of pre eclampsia

A
  • systolic above 140, distolic above 90
    any one of:
  • proteinuria
  • organ dysfunction e.g. raised creatinine or liver enzymes, seizures, thrombocytopenia)
  • placental dysfunction e.g. fetal growth restriction
199
Q

What is the management of pre-eclampsia?

A
  • labetalol 1st line, nifedipine 2nd
  • intravenous hydralazine in critical care
  • IV magnesium sulfate during labour and 24 hours afterwards
  • switch to enalapril afterwards
200
Q

What is HELLP syndrome?

A
  • haemolysis
  • elevated liver enzymes
  • low platelets
201
Q

When should you do OGTT for women (risk factors)

A
  • previous gestational diabetes
  • previous macrosomic baby
  • BMI >30
  • ethnic origin, black caribbean, middle eastern, south asian
  • family history of diabetes
202
Q

OGTT fasting less than 7

A

Diet and exercise for 1-2 weeks then metformin then insulin

203
Q

OGTT fasting glucose above 7

A

insulin ± metformin

204
Q

fasting glucose above 6 with macrosomia

A

insulin ± metformin

205
Q

What are the targets for gestational diabetes?

A
  • fasting 5.3
  • 1 hour post meal 7.8
  • 2 hours post meal 6.4
  • avoiding levels of 4 or below
206
Q

what is the risk to the baby whose mums have diabetes?

A
  • neonatal hypoglycaemia
  • macrosomia
  • polycythaemia
  • jaundice
  • congenital heart disease
  • cardiomyopathy
207
Q

symptoms of obstetric cholestasis

A
  • itching (particularly palms of the hands and soles of the feet)
  • fatigue
  • dark urine
  • pale, greasy stools
  • jaundice
208
Q

Investigations obstetric cholestasis

A
  • abnormal liver function tests: ALT, AST, GGT
  • raised bile acids
209
Q

What liver function test is normally raised in pregnancy and why

A

ALP produced by placenta

210
Q

Management of obstetric cholestasis

A
  • ursodeoxycholic acid
  • emollients
  • antihistamines
211
Q

presentation of acute fatty liver of pregnancy

A
  • general malaise and fatigue
  • nausea and vomiting
  • jaundice
  • abdo pain
  • anorexia
  • ascites
212
Q

What is placenta praevia?

A

Placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus (over the internal cervical os)

213
Q

What are the risks of placenta praevia?

A
  • antepartum haemorrhage
  • emergency caesarean
  • emergency hysterectomy
  • maternal anaemia and transfusions
  • preterm birth and low birth weight
  • stillbirth
214
Q

What are the risk factors for placenta praevia?

A
  • previous caesarean
  • previous placenta praevia
  • older maternal age
  • maternal smoking
  • structural uterine abnormalities
  • assisted reproduction (e.g. IVF)
215
Q

What are the risk factors for placental abruption?

A
  • previous placental abruption
  • pre-eclampsia
  • bleeding early in pregnancy
  • trauma
  • multiple pregnancy
  • fetal growth restriction
  • multigravida
  • increasing maternal age
  • smoking
  • cocaine or amphetamine use
216
Q

Presentation of placental abruption

A
  • sudden onset severe abdo pain
  • vaginal bleeding
  • shock
  • CTG abnormalities indicating distress
  • woody abdomen
217
Q

What is the management of placental abruption?

A
  • If <36 weeks and fetal distress then immediate caesarean
  • If <36 weeks and no fetal distress then observe and steroids
  • If >36 weeks then vaginal birth if no distress, if there is distress then caesarean
218
Q

What is placenta accreta?

A

The placenta embeds past the endometrium into the myometrium and beyond.

219
Q

Placenta increta

A

Myometrium

220
Q

Placenta percenta

A

Myometrium, perimetrium, may reach other organs.

221
Q

Risk factors for placenta accreta

A
  • previous placenta accreta
  • previous endometrial curettage
  • previous caesarean
  • multigravida
  • increased maternal age
  • low lying placenta or placenta praevia
222
Q

Delivery time for placenta accreta

A

35 to 36+6 weeks

223
Q

What is the management of placenta accreta?

A
  • caesaran at 35 to 36+6
  • hysterectomy is recommended
  • uterus saving surgery
  • expectant: allow time for the placenta to be absorbed by the body
224
Q

Complete breech

A

hips and knees fully flexed,

225
Q

Incomplete breech

A

one leg flexed at the hip and extended at the knee

226
Q

Extended breech

A

Both legs flexed at the hip and extended at the knee

227
Q

Footling breech

A

Foot presenting through the cervix with the leg extended

228
Q

Management of breech

A
  • external cephalic version at 36 weeks if nulliparous, 37 weeks if had children before (give tocolysis to soften uterus)
  • vaginal or caesarean
229
Q

What is the first stage of labour?

A

From onset of labour until 10cm dilatation

230
Q

Second stage of labour

A

from 10cm dilation to delivery of baby

231
Q

third stage of labour

A

from delivery of baby until delivery of placenta

232
Q

What are braxton hicks contractions?

A
  • occasional irregular contractions of the uterus
  • do not progress or become regular
  • normally felt between the second and third trimester
233
Q

What are the signs of labour?

A
  • show from mucus plug
  • rupture of membranes
  • regular painful contractions
  • dilating cervix on examination
234
Q

latent phase of first stage

A

from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.

235
Q

active phase of first stage

A

from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.

236
Q

transition phase of first stage

A

from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.

237
Q

Rupture of membranes

A

Amniotic sac has ruptured

238
Q

Preterm prelabour rupture of membranes

A

The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation

239
Q

prophylaxis for preterm labour

A
  • vaginal progesterone if cervical length less than 25mm between 16 and 24 weeks gestation
  • cervical cerclage (stitch in the cervix) if less than 25mm between 16 and 24 weeks, or if previous premature birth or cervical trauma
240
Q

What is the management of preterm prelabour rupture of the membranes?

A
  • prophylactic antibiotics to prevent chorioaminonitis (erythromycin)
  • induction of labour from 34 weeks
241
Q

What is the management of preterm labour?

A
  • fetal monitoring
  • tocolysis with nifedipine
  • maternal corticosteroid before 35 weeks gestation
  • IV magnesium sulphate if before 24 weeks
242
Q

What are the options for managing failure to progress?

A
  • amniotomy (artificial rupture of the membranes)
  • oxytocin infusion
  • instrumental delivery
  • caesarean section
243
Q

What is cord prolapse?

A

When the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes

244
Q

What is the management of cord prolapse?

A
  • emergency caesarean section. The cord should be kept warm and wet and have minimal handling whilst waiting for delivery
  • if baby is compressing a prolapsed cord then the presenting part can be pushed upwards (mum in left lateral position or on all fours)
245
Q

What is shoulder dystocia?

A

baby becomes stuck behind the pubic symphysis after the head has been delivered

246
Q

What is the turtle neck sign?

A

head is delivered but then retracts back into the vagina (shoulder dystocia)

247
Q

What is the management of shoulder dystocia?

A
  • should call anaesthetics and paediatrics
  • episiotomy
  • mcroberts manoeuvre (press on the suprapubic region of the abdomen)
  • rubins manoeuvre (reach into the vagina and put pressure on the posterior aspect of the baby’s anterior shoulder)
  • Wood screw manoeuvre (during rubins manoeuvre)
  • zavanelli manoeuvre
248
Q

McRoberts manoeuvre

A

Hyperflexion of the mother at the hip (knees to abdomen)

249
Q

Rubins manouvre

A

Reaching in to the vagina and putting pressure on the posterior aspect of the baby’s anterior shoulder. Can then do a wood’s screw manouvre to rotate the baby

250
Q

Zavanelli manoeuvre

A

Pushing the baby’s head back into the vagina so the baby can be delivered by emergency c section

251
Q

What are the complications of shoulder dystocia?

A
  • fetal hypoxia and subsequent cerebral palsy
  • brachial plexus injury and erb’s palsy
  • perineal tears
  • postpartum haemorrhage
252
Q

What are the indications of an instrumental delivery?

A
  • failure to progress
  • fetal distress
  • maternal exhaustion
253
Q

What are the risks to the mother during instrumental delivery?

A
  • postpartum haemorrhage
  • episiotomy
  • perineal tears
  • injury to the anal sphincter
  • incontinence of the bladder or bowel
  • nerve injury (obturator or femoral)
254
Q

What are the risks to the baby of instrumental delivery?

A
  • cephalohaematoma with ventouse
  • facial nerve palsy with forceps

rarely:
- subgaleal haemorrhage
- intracranial haemorrhage
- skull fracture
- spinal cord injury

255
Q

What is venotuse

A

Suction cup on a cord, the suction cup goes onto the baby’s head

256
Q

Femoral nerve injury symptoms

A
  • weakness of knee extension
  • loss of the patella reflex
  • numbness of the anterior thigh and medial lower leg
257
Q

Obturator nerve injury

A
  • weakness of hip adduction and rotation
  • numbness of the medial thigh
258
Q

First degree perineal tear

A

injury is limited to the frenulum of the labia minora and superficial skin

259
Q

Second degree perineal tear

A

injury to the frenulum of the labia minora and the perineal muscles but not the anal sphincter

260
Q

Third degree perineal tear

A
  • labia minora
  • perineal muscles
  • anal sphincter but not affecting the rectal mucosa
261
Q

Fourth degree perineal tear

A
  • labia minora
  • perineal muscles
  • anal sphincter
  • rectal mucosa
262
Q

What are the complications of a perineal tear?

A
  • pain
  • infection
  • bleeding
  • wound dehiscence or breakdown

Lasting complications
- urinary incontinence
- anal incontinence and altered bowel habit
- fistula between bowel and vagina
- sexual dysfunction and dyspareunia
- psychological and mental health consequences

263
Q

What are the options for management of the third stage of labour?

A
  • physiological management: placenta delivered by maternal effort without medication or cord traction
  • active management: oxytocin, traction to the umbilical cord
264
Q

What volume of blood loss is required to be considered a post partum haemorrhage?

A
  • 500ml after vaignal
  • 1000ml after caesarean
265
Q

minor Post Partum Haemorrhage

A

under 1000ml blood loss

266
Q

major post partum haemorrhage

A

over 1000ml

267
Q

What are the causes of post partum haemorrhage?

A
  • tone: uterine atony (most common)
  • trauma e.g. perineal tear
  • tissue: retained placenta
  • Thrombin: bleeding disorder
268
Q

What are the risk factors for post partum haemorrhage

A
  • previous PPH
  • multiple pregnancy
  • obesity
  • large baby
  • failure to progress in second stage
  • prolonged third stage
  • pre-eclampsia
  • placenta accreta
  • instrumental delivery
  • general anaesthesia
269
Q

What is the management of post partum haemorrhage?

A
  • ABCDE
  • lie woman flat
  • 2x large bore cannnula
  • FBC, U+Es, clotting screen
  • group and cross match 4 units
  • warmed IV fluid and blood resuscitation as required
  • oxygen
  • fresh frozen plasma
  • stop bleeding: mechanical/medical/surgical
270
Q

Mechanical treatment of PPH

A
  • rubbing the uterus through the abdomen to stimulate a uterine contraction
  • catheterisation (bladder distension prevents the uterus from contracting)
271
Q

Medical treatment of PPH

A
  • oxytocin
  • ergometrine
  • carboprost
  • misoprostol
  • tranexamic acid
272
Q

Surgical management of PPH

A
  • intrauterine baloon tamponade
  • B lynch suture (suture around the uterus to compress it)
  • Uterine artery ligation : ligation to one or more of the arteries supplying the uterus to reduce the blood flow
  • hysterectomy as a last resort
273
Q

What is the most common cause of secondary postpartum haemorrhage?

A

Retained products of conception or infection e.g. endometritis

274
Q

What is the definition of secondary postpartum haemorrhage?

A
  • ultrasound for retained products of conception
  • antibiotics for infection
275
Q

Category 1 caesarean section

A
  • immediate threat to the life of mother or baby
  • decision to delivery time is 30 minutes
276
Q

Category 2 caesarean section

A
  • not imminent threat to life
  • required urgently due to compromise of the mother or baby
  • decision to delivery time is 75 minutes
277
Q

Category 3 caesarean section

A
  • delivery is required
  • mother and baby are stable
278
Q

Category 4 caesarean section

A

Elective caesarean

279
Q

What are the layers of the abdomen that need to be dissected during a caesarean?

A
  • skin
  • subcutaneous tissue
  • fascia/rectus sheath
  • rectus abdominis muscle
  • peritoneum
  • vesicouterine peritoneum
  • uterus
  • amniotic sac
280
Q

Risk factors of amniotic fluid embolism

A
  • increasing maternal age
  • induction of labour
  • caesarean
  • multiple pregnancy
281
Q

Presentation of amniotic fluid embolism

A
  • shortness of breath
  • hypoxia
  • hypotension
  • coagulopathy
  • haemorrhage
  • tachycardia
  • confusion
  • seizure
  • cardiac arrest
282
Q

What are the risk factors for uterine rupture?

A
  • vaginal birth after caesarean
  • previous uterine surgery
  • increased bmi
  • high patiry
  • increased age
  • induction of labour
  • use of oxytocin
283
Q

What is the presentation of uterine rupture?

A
  • abdominal pain
  • vaginal bleeding
  • ceasing of uterine contractions
  • hypotension
  • tahcycardia
  • collapse
284
Q

Presentation of endometritis

A
  • foul smelling discharge or lochia
  • bleeidng that gets heavier or doesnt improve with time
  • lower abdominal or pelvic pain
  • fever
  • sepsis
285
Q

investigations for endometritis

A
  • vaginal swab
  • urine culture and sensitivities
286
Q

Presentation of retained products of conception

A
  • vaginal bleeding that gets heavier or is not improving with time
  • abnormal vaginal discharge
  • lower abdominal or pelvic pain
  • fever if infection occurs
287
Q

diagnosis of retained products of conception

288
Q

Management of retained products of conception

A

Evacuation of retained products of conception under general anaesthetic
- vacuum, aspiration and curettage

289
Q

What are the complications of dilatation and curettage?

A
  • endometritis
  • asherman’s syndrome (adhesions form within the uterus
290
Q

Management of post partum anaemia

A
  • Hb under 100g/l start oral iron
  • Hb under 90 g/l consider an iron infusion in addition to oral iron
  • Hb under 70g/l blood transfusion in addition to oral iron
291
Q

What score can you use to assess postnatal depression?

A

Edinburgh postnatal depression scale. Score of 10 or more suggests postnatal depression

292
Q

Presentation of mastitis

A
  • breast pain and tenderness (unilateral)
  • erythema in a focal area of breast tissue
  • local warmth and inflammation
  • nipple discharge
  • fever
293
Q

Management of mastitis

A
  • continue breastfeeding, expressing milk and breast massage
  • if not effective or infection suspected then flucloxacillin
294
Q

Management of postpartum thyroiditis

A
  • thyrotoxicosis: symptomatic control such as propranolol
  • hypothyroidism: levothyroxine
295
Q

What is sheehan’s syndrome?

A

Complication of psot partum haemorrhage where drop in circulating blood leads to avascular necrosis of the pituitary gland

Only affects the anterior pituitary gland

296
Q

What hormones does the anteiror pituitary release?

A
  • thyroid stimulating hormone
  • adrenocorticotropic hormone
  • follicle stimulating hormone
  • luteinising hormone
  • growth hormone
  • prolactin
297
Q

Presentation of sheehans

A
  • reduced lactation
  • amenorrhoea
  • adrenal insufficiency and adrenal crisis due to lack of cortisol
  • hypothyroidism with low thyroid hormones
298
Q

Management of sheehans

A
  • oestrogen and progesterone as HRT
  • hydrocortisone
  • levothyroxine
  • growth hormone
299
Q

What is the management of a complex ovarian cyst in pre-menopausal women?

A
  • serum CA125
  • alpha fetoprotein
  • beta HCG
  • book for an elective cystectomy
300
Q

Edward’s syndrome quadruple test result

A
  • low AFP
  • low oestriol
  • low hCG
  • normal inhibin A
301
Q

In pre-eclampsia, how long should you continue magnesium sulfate?

A

for 24 hours after delivery or last seizure

302
Q

When is the booking visit?

A

8-12 weeks (ideally less than 10)

303
Q

Early scan to confirm dates

304
Q

Down’s sydrome screening including nuchal scan

305
Q

Anomaly scan

A

18-20+6 weeks

306
Q

First step in PPH

A

Uterine massage and catheter
THEN oxytocin

307
Q

How long should someone who is taking methotrxate for RA wait to conceive?

A

6 months (both partners)

307
Q

What position should be adopted in cord prolapse?

Finals (37 decks)

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