Obs and Gynae Flashcards
1
Q
What is cystocele?
A
defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina
2
Q
what is a grade 1 cystocele?
A
mild - the bladder droops only a short way into the vagina
3
Q
what is grade 2 cystocele?
A
medium - bladder sunk to reach opening of vagina
4
Q
what is grade 3 cystocele?
A
advances - bladder bulges out through opening of vagina
5
Q
what are 7 risk factors for pelvic organ prolapse?
A
advanced age and post menopause low oestrogen
overweight
childbirth - vaginal delivery
constipation and straining
heavy lifting
chronic cough
previous pelvic surgery
6
Q
What are 6 symptoms of cystocele?
A
pelvic heaviness/fullness
bluge in vagina
aching/pressure in lower belly/pelvis/back that get worse with standing/lifting/coughing
frequent UTIs and LUTS
pain during sex
constipation
7
Q
What are 6 symptoms of pelvic organ prolapse?
A
pelvic heaviness/fullness
bluge in vagina
urinary incontinance
constipation
pelvic/back/abdo pain
sexual dysfunction
8
Q
What is the conservative management for pelvic organ prolapse?
A
physio - pelvic floor exercise
weight loss
lifestyle changes
symptom treatement
vaginal oestrogen cream
9
Q
what are the 5 different types of pessaries that can be used for vaginal prolapse?
A
Ring
shelf/gellhorn - flat disc with stem
Cube
Donut
Hodge - rectangularish
10
Q
what should be given with pessaries to protect from vaginal irritation?
A
oestrogen cream
11
Q
what is the difinitive treatment for pelvic organ prolapse?
A
surgery
12
Q
What is rectocele?
A
defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.
particularly associated with constipation
can develop faecal loading and urinary retention
13
Q
what is uterovaginal prolapse?
A
where the uterus +/- the vagina itself descends out of the vagina
14
Q
what are 6 risk factors for vaginal fistula?
A
childbirth
injury
surgery
infection
radiation
IBD
15
Q
what is a vesicovaginal fistula?
A
urinary bladder and vagina fistula
16
Q
what is an enterovaginal fistula?
A
opening between small intestine and vagina
17
Q
what are 4 investigations of vaginal fistulae?
A
Dye test - into bladder and rectum to check for leakage
Imaging - USS, CT, MRI
conoloscopy
cystourethroscopy
18
Q
What is triple assessment of breast lumps?
A
clinical assessment - Hx and exam
Imaging - USS, mamography
histology - fine needle/core biopsy
each scored 1-5 from normal to malignant
19
Q
what is fibroadenoma?
A
Benign tumours of stromal/epithelial breast duct tissue
most common cause of breast mass
normally more likely in early reproductive years
painless, smooth, round, firm, well defined, mobile, usually <3cm
Surgical excision if >3cm
20
Q
what does a fibroadenoma look like on imagina?
A
Mammogram - well-circumscribed, oval hypodense or isodense mass, may have calcifications
US - Well-circumscribed, round to ovoid or macrolobulated mass with uniform hypoechoginecity
21
Q
what is a fibrocystic breast ?
A
usually in pre/perimenopausal women
Lumpiness, breast pain, fluctuation in beast size
sometimes tender
fluctuate with menstruation
22
Q
what are 5 management options for cyclical breast pain?
A
wear supportive bra
NSAIDs
Avoid caffeine
Apply heat
Hormonal tx - danazol, tamoxifen - specialist
23
Q
what are breast cysts?
A
benign individual fluid filled lumps - most common cause of breast lump
can be painful and may fluctuate in size over cycle
Smooth
well circumscribed
mobile
Possibly fluctuant
24
Q
what do breast cysts look like on mammography?
A
halo appearance
25
what do breast fat necrosis lumps present with?
Painless, hard, fixed, irregular masses, can cause skin changes
very like malignancy and require biopsy
26
what are 5 risk factors for fat necrosis?
Trauma
Biopsy
breast infection
smoking
obesity
27
what is breast papilloma?
breast lump usually in ducts
usually benign but can be associated with cancer
bloody nipple discharge is typical
Common premenopausal
Lumpectomy due to increased risk of malignancy
28
what are breast abscesses?
breast lump typical in breastfeeding
ruptured sub-areolar ducts leak into periductal space
must be differentiated from inflammatory breast cancer
29
what is breast lipoma?
benign tumours of adipose tissue
soft, painless, mobile, no skin changes
30
what is galactocele?
occur in lactating women often after stopping
breast milk filled cysts due to lactiferous ducts being blocked
firm mobile, painless lump usually beneath areola
31
what is the most common causative pathogen of infective mastitis?
staphylococcus aureus
32
what are 4 bacteria that can cause mastitis/breast absecesses?
S. Aureus - most common
strep
enterococcal species
anaerobes
33
what is mastitis?
inflammation of breat with or without infection
common with breast feeding
34
what are breast absecesses?
a localised area of infection with a walled off collection of puss - with or without mastitis
35
what are 6 symptoms of mastitis?
fever
decreased milk outflow
breast warmth, tenderness, swelling, redness
breast pain
purulent nipple discharge
flu like symptoms
36
what may be felt in breast abcesses?
Swollen fluctuant tender lump
37
what are 3 investigations for breast abscess?
breast ultrasound
needle aspiration drainage
cystology of nipple discharge/aspiration
38
what are 3 investigations for mastitis?
milk/aspirate/discharge/biopsy culture and sensitivity
histopathological exam of biopsy
pregnancy test
39
what lifestyle treatment is there for breastfeeding mastitis?
continue breastfeeding/expressing milk
heat packs
warm showers
simple analgesia
40
what is the treatment of suspected infective lactational mastitis?
Abx - flucloxacillin or erythromyacin (in allergy) for 10 days if still symptomatic 12-24 hours after 1st presentation with lifestyle management
41
what is the Abx management of non-lactational mastitis?
Co-Amoxiclav
2 - erythromycin
42
what is the treatment of breast abscess?
surgical drainage
Abx
US breast
43
what are 5 signs of silicone breast implant rupture?
Change in breast shape and size
increasing pain
increased firmness
swelling over weeks
USS - snowstorm appearance
44
what is ductal ectasia?
benign condition of milk duct due to walls thickening and getting blocked
more common in women approaching menopause
often asymptomatic but can cause discharge from breast, lumps under nipple or rarely breast pain
can be surgically treated
45
What is the name of the extention of breast tissue to the axilla?
tail of spence
46
what is the name of a breast milk filled cyst caused by lactiferous duct blockage?
galactocele
47
what chemical has a inhibitory effect on prolactin?
Dopamine
48
what enzyme in adipose tissue converts androgens to oestrogen?
aromatase
49
which common heart meds can cause gynaecomastia?
Spiro
Also digoxin
50
what is intraductal papilloma?
a benign wart like lump that develops in one or more of the milk ducts in the breast
can cause a lump, nipple discharge and pain or discomfort
51
What is the healthhy bacteria in the vagina?
lactobilli - produce lactic acid and reduce pH of vagina (<4.5)
52
What is normal vaginal pH?
3.5-4.5
53
what is the most common cause of vaginal thrush?
Candida albicans
54
What are 4 risk factors for thrush?
increased oestrogen (pregnancy)
poorly controlled diabetes
immunosuppresion
Broad spectrum ABx
55
what are the symptoms of vaginal thrush?
thick white discharge
vulva and vaginal itching and irritation
56
What are 6 complications of vaginal thrush?
erythema
fissures
oedema
pain during sex (dyspareunia)
dysuria
excoriation
57
what is one test that can be used to distiguish between trush and BV/trichomonas?
vaginal pH swab
>4.5 in BV and Trichomonas
<4.5 in candidiasis
58
what swab is used for vaginal MCS?
charcoal swab - for BV, candidiasis, gonorrhoea, trichomonas, other bacteria
59
What is the management for thrush?
antifungal cream - clotrimazole 5g 10% single dose
antifungal pessary - clotrimazole 500mg single dose
Oral antifungal - fluconazole 150mg single dose
60
what should you tell patients using antifungal creams?
can degrade latex condoms and prevent spermacides from working => use other forms of birth control for at least 5 days
61
what are 9 risk factors for ectopic pregnancy?
Prev ectopic
tubal surgery
Hx of STD
Smoking
IVF
IUD pregnancy
Black ethnicity
age <18 first intercourse
age >35 at time of presentation
62
what is the presentation of an ectopic pregnancy?
Missed period
Constant lower RIF/LIF pain
Vaginal bleeding
lower abdo or pelvic tenderness
cervical motion tenderness
Shoulder tip pain - peritonitis
Dizziness or syncope
63
when does ectopic pregnancy usually present?
6-8 weeks
64
what hCG level will mean pregnancy is visible on USS?
> 1500 IU/L
65
what are the 6 criteria for expectant management of ectopic pregnancies?
available for follow up
unruptured
mass <35mm
no heart beat
no significant pain
HCG <1500 IU/L
66
what drug is used for medical management of ectopic pregnancies?
IM methotrexate
67
what is the criteria for medical management of ectopic pregnancies?
HCG levels <5000 IU/L
Confirmed absence of intrauterine pregnancy on US
<35mm
minimal pain
no heart beat
68
what is the criteria for surgical management of ectopic pregnancy?
>35mm mass
Significant pain
foetal heartbeat visible on TVUS
Serum hCG >5000
69
what is the 1st line surgical management of ectopics in women with no fertility risk factors?
Laproscopic Salpigectomy
70
What embrionic structure does the female genital system develop from?
paramesonephric (mullerian) ducts
71
what are 4 abnormal female organ formations?
bicornuate uterus - heart shaped
imperforate hymen
transverse vaginal septae - septum in vagina
vaginal hypoplasia and agenesis - abnormally small/absent vagina
72
what is androgen insensitivity syndrome?
a condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors. X-linked recessive genetic condition, caused by a mutation in the androgen receptor gene on the X chromosome. Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics despite XY genetics
73
what are the complications of androgen insensitivity syndrome?
slightly taller than average female
no pubic or facial hair
increased risk of testicular cancer unless removed from abdomen
infertility
74
what is the usual presentation of androgen insensitivity syndrome?
inguinal hernias
primary amenorrhoea
75
What is menopause?
no periods for 12 months due to the end of menstruation
Average age 51
76
what is premature menopause?
Menopause before 40 years
77
What cells secrete oestrogen?
ganulosa cells
78
What are 8 perimenopausal symptoms?
Hot flushes
emotional lability/low mood
reduced libido
premenstrual syndrome
irregular periods
joint pain
heavier/lighter periods
vaginal dryness and atrophy
79
What are 4 conditions menopause increases the risk of?
CVD and stroke
osteoporosis
pelvic organ prolapse
urinary incontinance
80
when should FSH be used to diagnose menopause?
<40 years
<45 years with menopausal symptoms
81
How long is contraception required after menopause?
2 years if <50
1 year is >50
82
what is the management of perimenopausal symptoms?
HRT
tibolone - synthetic steroid
clonidine - reduces hot flushes
CBT
SSRIs
testosterone gel for libido
vaginal oestrogen/moisturisers
83
what is adenomyosis?
Endometrial tissue inside the myometrium
More common with mutiparous women
84
What are 5 presetations of adenomyosis?
Dysmenorrhoea
menorrhagia
dyspareunia (pain in intercourse)
Infertility
Enlarged/tender (boggy) uterus but softer than w/ fibroids
85
what is the 1st line investigation for adenomyosis ?
TV ultrasound
86
What is the gold standard investigation for adenomyosis?
histological exam after hysterectomy
87
what are 2 non-contraceptive treatments for mennhoragia?
Tranexamic acid - when no pain (antifibrinolytic reduces bleeding)
Mefenamic acid - with pain (NSAID - reduced bleeding and pain)
88
What are 3 contraceptive managements options for mennorhagia?
1 - IUS - mirena coil
2 - COCP
4 - cyclical oral progestogens
89
what are 4 specialist managements of menorrhagia?
GnRH analogues to induce meno-pause like state
endometrial ablation
uterine artery embolisation
hysterectomy
90
what are 9 complications of adenomyosis in pregnancy?
infertility
miscarriage
preterm birth
small gestation
preterm premature rupture of membranes
malpresentation
c-section
PPH
91
What is asherman's syndrome?
where adhesions form in uterus following damage
92
What are 3 risk factors for ashermans syndrome?
dilation and curettage (after retained products of conception)
uterine surgery
pelvic infection
93
what are 4 presentations of asherman's syndrome?
secondary amenorrhoea
light periods
dysmenorrhoea
infertility
94
What are 4 investigations for asherman's syndrome?
hysteroscopy
hysterosalpingography
sonohysterography
MRI
95
What is lichen sclerosus?
a chronic inflamatory autoimmune skin condition causing patches of shiny white skin on labia, perineum and perianal skin most commonly as well as axilla and thighs. can also affect men on foreskin and glans penis
96
what are 3 risk factors for lichen sclerosus?
Postmenopausal
Autoimmunity - thyroid, T1DM
Site of injury - Koebner phenomenon
97
what is lichen planus?
autoimmune condition causing chronic inflammation with shiny purplish flat top raised areas with white lines across surface called wickhams striae
98
what are 7 presentations of lichen sclerosus?
white skin patches
itching
soreness
skin tightness
painful sex
erosions
fissures
99
what is the appearance of lichen sclerosis?
Porcelain white
shiny
tight
thin
slightly raised
papules or plaques
100
what is the management for lichen sclerosus?
topical steroids - dermovate - clobetasol propionate 0.05%
OD for 4 weeks then gradually reducing in frequency
emollients
101
what is a key complication of lichen sclerosus?
5% risk of developing squamous cell carcinoma of the vulva
102
what are 4 complications of lichen sclerosis?
pain and discomfort
sexual dysfunction
bleeding
narrowing of vaginal or urethral openings
103
what is atrophic vaginitis?
atrophy of the vaginal mucosa due to lack of oestrogen
104
What are 6 patient presentations of atrophic vaginitis?
itching
dryness
dyspareunia (painful sex)
bleeding (due to inflammation)
recurrent UTIs, Stess incontinance, prolapse
White, yellow possibly malodorous discharge
105
what are 6 signs of atrophic vaginitis on examination?
pale mucosa
thin skin
reduced skin foldes
erythema and inflammation
dryness
sparse pubic hair
106
what is the management of atrophic vaginitis?
topical oestrogen - cream, pessaries, ring
Systemic HRT
107
what are 3 contraindications to use of topical oestrogens in atrophic vaginitis?
Angina
VTE
breast cancer
108
what are the 4 parameters to measure 'normal' menstruation by?
Frequency
regularity
duration
volume
109
what are 4 risk factors for abnormal uterine bleeding?
Extremes of reproductive age
PCOS
endocrine disorders - hypothyroid, hyperprolactinoma
obesity
110
what is the emergency management of excessive uterine bleeding?
1st - hormone therapy - 25mg IM conjugated oestrogens
2nd - Tranexamic acid, Surgery
Blood products and fluids if haemodynamically unstable
111
what are the two types of endometrial hyperplasia
hyperplasia without
atypical hyperplasia
112
what is the treatment for endometrial hyperplasia?
progestogens - IUS or continuous oral progestogens
113
what is a normal endometrial thickness post menopause?
<4mm
114
what are endometriomas seen in the ovaries often called?
chocolate cysts (from endometriosis)
115
what are some possible cause of endometriosis?
retograde menstruation through fallopian tubes into abdomen
Embryonic cells meant to be endometrial tissue remained outside uterus in development of fetus
lymphatic spread
metaplasia
116
what are 7 presentations of endometriosis?
cyclical abdominal or pelvic pain
deep dyspareunia
dysmenorrhoea
cyclical bleeding from other sites
subfertility
fixed retroverted uterus
palpable mass - endometrioma
Dyschezia - painful pooping
117
what is the gold standard investigation for endometriosis?
laproscopic surgery + biopsy
118
what is the medical management of endometriosis?
1 - NSAIDs
2 - COCP or Progesterone only, depo, implant or IUS
3 - GnRH analogous
119
what are 4 risk factors for fibrids?
increased patient weight
40+
black ethnicity
low vit D
120
What is a complete mole in a molar pregnancy?
when 2 sperm cells fertalise an ovum with no genetic materium and combine genetically to form a tumour with 46 paternal chromosomes
121
what is a partial mole in a molar pregnancy?
when 2 sperm fertilise a normal ovum at the same time causing a haploid cell (3 sets of chromosomes which divides and multiplies to form a partial mole - there may be some foetal material
usually 69 chromosomes
122
what are 6 possible indications of molar pregnancy compared to normal pregncncy?
severe morning sickness
vaginal bleeding
increased enlargement of uterus
abnormally high hCG
thyrotoxicosis (hcg can mimic TSH and stimulate thyroid)
123
what is a sign of molar pregnancy on USS?
snow storm appearance
124
what is the management of molar prregnancy?
evacuation of uterus
histology
referal to gestational trophoblastic disease centre
hCG level monitoring
125
what can be a complication of molar pregnancy?
metastasis
126
what are 6 presentations of prolactinoma?
amenorrhoea/oligomenorrhoea
infertility
galactorrhoea
lowered libido
erectile dysfunction
visual deterioration (bilateral temoral hemianopia)
127
what is the most common type of pituitary tumour in women?
prolactinoma - 50%
128
what is the 1st line medical treatment of prolactinoma?
dopamine agonist - carbergoline 0.5mg once weekly
(2nd line OCP in premeno women)
129
what is the surgical management of prolactinoma?
tras-sphenoidal surgery
130
what is the most common type of ovarian tumour?
epithelial cell tumour
131
what are beingn ovarian tumours?
dermoid cysts
germ cell tumours
teratomas. particularly associated with ovarian torsion
132
What are the 3 diagnostic features for PCOS diagnosis?
Rotterdam criteria
Anovulation/oligoovulation
Hyperandrogenism (hirsutism and acne)
Polycystic ovaries on USS
2 features = diagnosis
133
What are 5 potential presentations of ovarian cysts?
pelvic pain - w/ torsion, rupture or haemorrhage
bloating
fullness in abdomen
palpable pelvic mass (V large cysts)
Infertility
134
what are 5 medications that can cause hirsutism?
Phenytoin
Ciclosporins
corticosteroids
testosterone
Anabolic steroids
135
what are 4 differentials for hisutism?
Medications
Ovarian or adrenal tumours
Cushings
Congenital adrenal hyperplasia
136
what is the mechanism for insulin resistance in PCOS?
Insulin promotes the release of androgens and supresses sex hormone binding globulin (produced in liver)
SHBG normally binds to androgens and suppresses function
High insulin levels also contribute to halting development of follicles in ovaries leading to anovulation and multiple partially developed follicles
137
what are functional cysts?
follicular cysts for developing follicles can sometimes fail to rupture and release the egg and therefore persist for a short while
138
what is the most common type of ovarian cyst?
functional (follicular) cysts
139
what type of cysts are often seen in early pregnancy?
corpus luteum cysts - may cause pelvic discomfort pain or delayed menstruation
140
What are 5 types of ovarian cysts?
serous cystadenomas
Mucinous cystadenoma
Endometriomas
dermoid cysts
sex cord stromal tumours (can be benign or malig)
141
what are serous cystadenomas?
benign ovarian tumours of epithelial cells
142
what are mucinous cystadenomas?
benign ovarian tumour of epithelial cells which can grow very large
143
what are endometriomas?
ovarian cysts made of endometrial tissues - patient with endometriosis
144
what are dermoid cysts?
AKA teratomas
come from germs cells - hair, skin, teeth, bones
associated with ovarian torsion
145
what are sex cord stromal tumours?
rare tumours that can be benign or malignant arising from connective tissue or embryonic structures
146
what is the management of simple ovarian cysts in premenopausal women?
<5cm - will almost always resolve in 3 cycles
5-7cm - routine referral to gyne
>7cm - surgical evaluation
147
what are 2 possible surgical managements of ovarian cysts?
ovarian cystectomy
oophorectomy
148
what is the presentation of ruptured ovarian cysts?
Pain - sudden onset severe pelvic pain
Peritonism
Haemodynamic instability
GI symptoms
Urinary symptoms - dysuria, urinary frequency
Fever
149
What is Meig's syndrome?
ovarian fibroma (benign ovarian tumour)
pleural effusion
Ascites
typically in older women. removal of tumour results in complete resolution of symptoms.
150
when is ovarian torsion more likely?
In pregnancy
with a mass >5cm
before menarche and women of rFeproductive age
fertility treatment - ovarian hyperstimulation
151
what is the pathophysiology of ovarian hyperstimulation syndrome?
Hyperstimulation causes release of vasoactive substances from ovaries leading to capillary permeability and fluid shift from intravascular compartment to third space - SOB due to pleural effusions
152
what are 4 features of ovarian torsion?
unilateral sudden onset severe pain
nausea and vomiting
palpable mass
localised tenderness
153
what can be seen on US in ovarian torsion?
Whirlpool sign
free fluid in pelvis and oedema of ovary
154
How is ovarian torsion definitively diagnosed?
Laparoscopy
155
what are 3 STDs that can cause PID?
Neisseria gonorrhoea
Chlamydia trachomatis
Mycoplasma genitalium
156
What are non STDs that can cause PID?
Gardenerella vaginalis (associated with BV)
Haemophilus influenzae
Escheriachia coli
157
what are 6 presentations of PID?
pelvic/low abdomen pain
abnormal discharge
abnormal bleeding
dyspareunia
fever
dysuria
158
what 4 things may be found on a PID examination?
pelvic tenderness
cervical motion tenderness
cervicitis
purulent discharge
159
What are 7 investigations for PID
NAAT swabs for gonorrhoea, chlamydia, mycopasma genitalium
HIV test
Syphilis test
High vag swab for BV, candidiasis, trichomoniasis
Look for pus cells on microscope (absence excludes PID)
Pregnancy test (?ectopic)
Inflammatory markers
160
what is the management of PID?
1 - Stat IM 1g Ceftriaxone + 14 days Doxycycline 100mg BD PO + Metronidazole 400mg BD PO
2 - Ofloxacin PO + Metronidazole PO
161
What are 6 complications of PID?
Sepsis
abscess
infertility
chronic pelvic pain
ectopic pregnancy
Fiz-hugh-curtis syndrome
162
what is fiz-hugh-curtis syndrome?
inflammation and infection of liver (Glisson's) capsule causing adhesions between liver and peritoneum => RUQ pain
163
What is the treatment for PID?
IM Ceftriaxone 1g (for gonorrhoea)
Doxycycline 100mg BD 14 days (chalmidia, MG)
Metronidazole 400mg BD 14 days (anaerobes)
if have coil => leave in unless not responding after 72 hours
164
what are 8 non-diagnostic features that may be present in PCOS?
insulin resistance and diabetes
acanthosis nigricans
CVD
hypercholesterolaemia
endometrial hyperplasia and cancer
Obstructive sleep apnoea
depression and anxiety
sexual problems
165
what are 4 hormonal blood tests for PCOS?
Raised LH
raised LH to FSH ratio
raised testosterone
Raised insulin
normal or raised oestrogen
166
What can be seen on USS of PCOS?
'string of pearls' appearance
>12 cysts on a single ovary
OR
>10cm3 ovarian volume => diagnostic criteria
167
what test can be used for diabetes in PCOS?
Oral glucose tolerance test
168
what is impaired fasting glucose on OGTT?
fasting 6.1-6.9 mmol/L
169
what is impaired glucose tolerance of OGTT?
at 2 hours
glucose 7.8-11.1 mmol/L
170
what is diabetes in OGTT?
Plasma glucose >11.1 at 2 hours
171
What medication can be given for weight loss that impairs lipid absorption?
Orlistat - lipase inhibitor
BMI >30
172
What can be used to reduce risk of endometrial cancer in people with PCOS?
cyclical progesterone or COCP to induce withdrawal bleed
Mirena coil
173
what are 4 medications that can be used for fertility in PCOS?
Clomifene
Laproscopic ovarian drilling
Metformin
Letrozole
174
what 2 medications can be used to treat hirsutism?
co-cyprindiol
topical elfornithine
Specialist - electrolysis, laser removal, spiro, finasteride, flutamide, cyproterone acetate
175
what is the surgical management of ectopics?
laproscopic salpingectomy or salpingotomy
when there is pain, mass >35mm, visible heartbeat or HCG >5000
176
what medication do you need to give Rhesus -ve women in surgical ectopic removal?
anti rhesus D
177
What counts as a miscarriage?
<24 weeks gestation
early <12 weeks
late 12-24 weeks
178
what are 5 risk factors for miscarriage?
Maternal age >35
Hx of previous miscarriages
Prev cervical cone biopsy
Lifestyle - smoking, alcohol, obesity
Medical conditions - uncontrolled diabetes, thyroid disorders
179
what is recurrent miscarriage?
3+ consecutive miscarriages
180
what are 7 causes of recurrent miscarriages?
Idiopathic
Antiphospholipid syndrome
hereditary thrombophilia - Factor V leiden, prothrombin mutation, protein s deficiency
uterine abnormalities
genetic factors
chronic histiocytic intervillositis
Chronic disease - DM, Thyroid disease, SLe
181
what can be given to women with antiphospholipid syndrome to increase chance of successful pregnancy?
low dose aspirin
LMWH
182
what is a missed miscarriage?
when the foetus is no longer alive but no symptoms have occurred
183
what is a threatened miscarriage?
vaginal bleeding with closed cervix and alive foetus
184
what is an inevitable miscarriage?
vaginal bleeding and open cervix
185
what is an incomplete miscarriage?
retained products of conception remain in uterus after miscarriage
186
what is a complete miscarriage?
a full miscarriage has occurred with no products remaining
187
what is anembryonic pregnancy?
a gestational sac is present but contains no embryo
188
what are 3 features looked for on ultrasound to confirm pregnancy?
mean gestational sac diameter
foetal pole and crown rump length
foetal heart beat
189
at what gestational crown rump length is a foetal heart beat expected?
7mm
190
at what mean gestational sac diameter is a foetal pole expected?
25mm
191
what is the management of a miscarriage <6 weeks?
expectant management
Repeat urine pregnancy test after 7-10 days
192
what is the management for miscarriage >6 weeks?
referral to early pregnancy assessment unit
USS for location and viability
193
what is expectant management of miscarriage?
repeat urine pregnancy test 3 weeks after bleeding and pain settle to confirm complete miscarriage
194
what is medical management of miscarriage >6 weeks?
Misoprostol (prostaglandin analogue to stimulate cervical ripening and uterine contractions)
195
what are 4 side effects of misoprostol?
heavier bleeding
pain
vomiting
diarrhoea
196
what is the surgical management of miscarriage?
manual vacuum aspiration (LA) <10 weeks
electric vacuum aspiration (GA)
+ misoprostol
+ anti D to -ve women
197
what is the management of threatened miscarriage?
Vaginal progesterone 400mg BD
if they have vaginal bleeding and have previously miscarried
198
what is the management of incomplete miscarriage?
medical - misoprostol
surgical - evacuation under GA
199
when should a pregnancy test be done after a miscarriage >6 weeks?
3 weeks post symptoms
200
What are the 2 legal documents for abortion?
1967 abortion act
1990 human fertilisation and embryology act
201
what are the legal requirements for abortion?
2 medical practitioners sign to agree abortion is indicated
must be carried out by registered medical practitioner in NHS hospital or approved premise
202
what are 3 indications for abortion post 24 weeks?
continuing pregnancy risks life of woman
Termination prevents grave permanent injury to physical or mental health of the woman
substantial risk of physical or mental abnormalities in the child
203
what 2 medications are used in a medical abortion?
mifepristone (anti-progestogen)
misoprostol (prostaglandin analogue) 1-2 days later
Anti-D in rhesus -ve mother if >10 weeks
204
what are 3 surgical managements of termination of pregnancy?
Cervical priming - misoprostal, mifepristone or osmotic dilaters
Vacuum aspiration
Dilation and curettage - between 14-24 weeeks
205
what is used to confirm successful termination of pregnancy?
Urine pregnancy test at 3 weeks post termination
206
what are 5 complications of abortion?
Bleeding
Pain
Infection
Failure of abortion
Damage to cervix or other structures
207
What is an USS signs of diamniotic dichorionic twins?
lambda or 'twin peak' sign
208
what is an USS sign of monochorionic diamniotic twins?
T sign
209
what are 7 risks to the mother with multiple pregnancy?
anaemia
polyhydramnious
HTN
malpresentations
spont preterm labour
instrumental delivery/caesarian
PPH
210
what are 7 risks to the foetuses in multiple pregnancy?
Miscarriage
Stillbirth
foetal growth restriction
prematurity
twin-twin transfusion syndrome
twin anaemia polycythaemia sequence
congenital abnormalities
211
what is twin-twin transfusion syndrome?
only monochorionic multiples
Abnormal connection between blood supply of babies causing shunting of blood to one foetus (recipient) and away from the other (donor)
The recipient gets overloaded and therefore HF and polyhydramnios.
The donor gets growth restricted, anaemic and oligohydramnios
Tx - laser seperation
212
what is twin anaemia polycythaemia sequence?
similar to twin to twin but less acute
one twin becomes anaemic whilst the other develops polycythaemia
213
whenis the monitoring for anaemia in multiple pregnancy?
booking
20 weeks
28 weeks
214
what is the scan monitoring for monochorionic twins?
every 2 weeks from 16 weeks
215
what is the scan monitoring for dichorionic twins?
every 4 weeks from 16 weeks
216
when is birth planned for monochorionic monoamniotic twins?
32-34 weeks
Must be sectioned
217
when is birth planned for monochorionic diamniotic twins?
36-37 weeks
218
when is birth planned for dichorionic diamniotic twins?
37-38 weeks
219
when is birth planned for triplets?
before 35+6 weeks
220
What are 11 things obesity increases risk of in pregnancy?
Gestational diabetes (screen BMI >30)
Pre-eclampsia and HTN (BMI >35)
VTE (BMI > 30)
mental health problems
inaccurate symphysis fundal height measurements
PPH
Caesarean birth
Congenital anomalies
Stillbirth
Prematurity
Macrosomia
221
what causes gestational diabetes?
due to insulin resistance and relative glucose intolerance in pregnancy
222
what are 7 risk factors for gestational diabetes?
prev. gestational diabetes
prev. macrosomic baby
BMI>30
Ethnic origin
FHx of diabetes (1st degree relative)
Advanced maternal age
PCOS
223
what counts as a macrosomic baby?
>4.5kg (9lb 12oz)
224
what test is use for gestational diabetes?
glucose tolerance test between 24-28 weeks
225
what are 3 indications of gestational diabetes?
large for date foetus
polyhydramnios
Glu on dipstick
226
what is gestational diabetes on fasting GTT level?
>5.6 mol/L
227
what is gestational diabetes at 2 hour GTT level?
>7.8 mmol/L
228
what is the follow up of gestational diabetes?
monthly US scans
229
what is the initial management of gestational diabetes?n (3)
1 - diet and exercise (fasting glucose <7 mmol/L)
2 - metformin (if not under control after 2 weeks)
3 - Insulin
(fasting >7 mmol/L or >6 mmol/L with macrosomia)
230
what is the fasting glucose target for pregnant women?
<5.6 mmol/L
231
what is the 1 and 2 hour post prandial glucose target for pregnant women?
1 hour - 7.8mmol/L
2 hours - 6.4 mmol/L
232
How much folic acid should those with existing diabetes take in the 1st trimester?
5mg OD
233
when is delivery planned for those with pre-existing diabetes in pregnancy?
between 37-38+6 weeks
234
what is the maximum gestation women with gestational diabetes can give birth up to?
40+6 weeks
235
when is retinal screening performed for diabetics in pregnancy?
at booking and at 28 weeks
236
what is the post-natal management of mothers with gestational diabetes?
Can usually stop antidiabetic medications immediately
Fasting glucose at 6 weeks
237
what is the maternal risk in pre-existing diabetes?
miscarriage
pre-eclampsia risk increased
infection - uti, resp, endometrial. andwound
increased c-section rate
238
what are 6 risks to the baby of a diabetic mother?
neonatal hypoglycaemia
neonatal jaundice
congenital abnormalities - heart, skeletal, neural tube
shoulder dystocia
polycythaemia
childhood obesity
239
When is a variable rate insulin infusion (sliding scale) started intrapartum?
with 2 BMs >7
240
What is the target intrapartum blood glucose level?
4-7 mmol/L
241
what is given preconception to pregnant women to prevent neural tube defects?
Folic acid 400microg till 12 weeks unless there are risk factors for neural tube defects or obesity in which case 5mg is given
242
can ACEI or ARBs be taken in pregnancy?
NO
cause oligohydramnios, miscarriage, hypocalvaria (malformation of skull), renal failure in neonate, hypotension in neonate
243
can thiazide like diuretics be taken in pregnancy?
NO
244
what usually happens to BP in 1st trimester?
falls until 20-24 weeks then increases to pre-pregnancy pressures
245
what is the management of pre-existing HTN in pregnancy?
1 - Labetalol
2 - CCB - nifedipine
Alpha blockers - doxazosin
246
what is the 1st line management of severe hypertension in pregnancy <37 weeks?
labetalol (>160 systolic but also for consideration >140)
247
what is gestational hypertension vs pre-existing hypertesion?
gestation has onset >20 weeks, pre-existing = <20 weeks gestation
there is no proteinuria or oedema in gestational HTN and usually resolves following birth
248
what is the management of gestational hypertension >37 weeks?
delivery (+labetalol if >160/110)
249
what is pre-eclampsia?
New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of proteinuria
or organ involvement
250
what is the pathophysiology of pre-eclampsia?
when blastocyst implants the outermost syncytiotrophoblast grows chorionic villi into endometrium
trophoblast invasion sends signals to spiral arteries to become more fragile, reduce vascular resistance and form pools (lacunae) at around 20 weeks
when this process does not occur it causes pre-eclampsia due to increased vascular resistance leading to increased oxidative stress in placenta and systemic inflammation
251
what are 5 high risk factors for pre-eclampsia?
pre-existing HTN
Prev. HTN in pregnancy
autoimmune consitions
diabetes
CKD
252
what are 6 moderate risk factors for pre-eclampsia?
>40 years
BMI >35
10+ years since prev. pregnancy
multiples
first pregnancy
FHx of pre-eclampsia
253
what are 8 symptoms of pre-eclapsia?
headache
visual disturbance/blurring
nausea and vomiting
upper abdo/epigastric pain
oedema
reduced urine output, proteinuria
brisk reflexes
RUQ/Epigastric pain
254
what is needed for a diagnosis of pre-eclampsia?
blood pressure >140/90
+
Proteinuria OR
Organ dysfunction (^creatinine, ^liver enzymes,seizures, thrombocytopenia, haemolytic anaemia) OR
Placental dysfunction (foetal growth restriction or abnormal dopplers)
255
how can proteinuria be quantified in pre-eclampsia?
urine protein:creatinine ratio >30mg/mmol
urine albumin:creatinine ration >8 mg/mmol
256
what blood test can be used to test for pre-eclapsia?
placental growth factor (between 20-35 weeks)
257
what is the prophylaxis treatment for pre-eclampsia?
Aspirin 75-150mg OD from 12 weeks-birth
women with 1 high risk or 2 moderate risk factors
258
what is the management for gestational hypertension?
aim 135/85 mmHg
Urine dip every week
bloods weekly - FBC U+E LFTs
Serial growth scans
PlGF test once (20-35 weeks)
Admit if >160/110 mmHg
259
How often are scans with pre-eclapsia?
every 2 weeks
260
what is the medical management of pre-eclampsia?
1st line - labetalol
2nd line - nifedipine
3rd line - methyldopa
261
what can be given in severe pre-eclampsia or eclapsia?
IV hydralazine
262
what is the management in labour of pre-eclamptics?
IV magnesium sulphate (prevent seizures) - give for 24 hours post birth
Fluid restriction to avoid fluid overload
263
what is the post delivery management of pre-eclampsia?
1st line - enalapril
1st line in black afro or Caribbean people - Nifedipine/amlodipine
3rd line labetolol or atenolol
264
what are 3 foetal complications of pre-eclampsia?
IUGR
Prematurity
Placental abruption
265
what is HELLP syndorme?
complication of pre-eclampsia and eclampsia
Haemolysis
Elevated liver enzymes
Low Platelets
management = delivery
266
what are 8 complications of pre-eclampsia?
foetal growth restriction
eclampsia
pulmonary oedema
stroke
placental abruption
CVD
renal failure
still birth
267
what are the levels for anaemia in pregnacy?
<110 g/L 1st trimester
<105 g/L 2nd/3rd trimester
<100g/l postpartum
268
why does physiological anaemia occur in pregnancy?
blood volume increases naturally in pregnancy to a greater extent than red cell mass
269
what is the management of anaemia in pregnancy?
Oral iron - ferrous sulphate 200mg OD
B12 if needed - IM hydroxocobalamin, oral cyanocobalamin
Folic acid - 5mg if deficient
270
what counts as postpartum anaemia?
Hb <100 g/l
271
what is the management of postpartum anaemia?
<100 g/l - Oral ferrous sulphate
<90 g/l - iron infusion
<70 g/l - blood transfusion
272
why is pregnancy a hypercoagulable state?
increase in factors VII, VIII, X and fibrinogen
Decrease in protein S
Uterus presses on IVC causing venous stasis
273
What are 12 risk factors for VTE in pregnancy?
smoking
Para >3
Age >35
BMI >30
reduced mobility/immobility
Multiples pregnancy
pre-eclampsia
gross varicose veins
FHx of VTE
Thrombophilia
IVF pregnancy
274
what are the guidelines for starting VTE prophylaxis in pregnancy?
from 28 weeks with 3 risk factors
from booking with 4+ risk factors
until 6 weeks pospartum
275
what blood thinners are contraindicated in pregnancy?
Warfarin
DOACS
276
what prophylaxis is given for VTE in pregnancy?
LMWH - Dalteparin enoxiparin, tinzaparin
Given until 6 weeks postnatal
277
what are 5 presentations of DVT?
unilateral calf/leg swelling (>3cm difference)
dilated superficial veins
tender calf
oedema
colour changes to leg
278
what are 8 presentations of PE?
SOB
cough/haemoptysis
pleuritic chestr pain
hypoxia
tachycardia
tachypnoea
low-grade fever
haemodynamic instability
279
what is the gold standrd investigation for DVT?
compression duplex US
280
what is the gold standard investigation for PE?
CT pulmonary angiogram (CTPA)
281
what weight is used for treatment dose LMWH in pregnancy DVT/PE?
booking weight
282
what are 3 conditions that group b strep infection of the newborn can cause?
meningitis
sepsis
pneumonia
283
what increases baby's risk of GBS infetion from mother?
preterm birth
previous baby with GBS
signs of infection during labour
+ urine or GBS swab in pregnancy
ROM >24 hours before birth
284
what is the risk of GBS infection in a second pregnancy?
50% - should have prophylactic Abx or testing in late pregnancy
285
who should receive intrapartum Abx?
GBS in prev pregnancy
Prev Baby with GBS disease
Premature labour
Pyrexia during labour
286
which antibiotic is used for intrapartum antibiotic prophylaxis in group B strep?
IV benzylpenicillin 3g (+1.5g 4 hourly until delivery)
287
which antibiotic is given intrapartum for GBS in women with penicillin allergy?
Vamcomycin 1g every 12 hours (in severe beta-lactam allergy)
Cephlasporins can be used in non sever penicillin allergy
288
What test is used for Group B strep in pregnancy?
enriched culture medium test at 35-37 weeks
289
what is the treatment for BV in pregnANCY?
oral metronidazole 400mg BD 5-7 days
OR
Intravaginal metronidazole gel 0.75% OD 5 days
290
what are the 3 different types of puerperal infection?
endometritis (most common)
myometritis
parametritis (supporting tissue around uterus)
291
what are 6 signs of puerperal infection?
pain below waist/in pelvic area
pale clammy skin due to blood loss
foul smelling vaginal discharge
raised HR
fever/chills/aches
Loss of appetite
292
what bacteria most commonly causes puerperal infection?
Group B strep (or other streps)
293
what are 5 risk factors for puerperal infection?
caesarean
many VEs
delay of birth after ROM
retained tissues
meconium in liquor
use of balloon for induction
294
what antibiotics are usually used for puerperal infection?
Clindamycin and gentamicin
295
what is the treatment for trichomonas in pregnancy?
metronidazole 400-500mg TD 5-7days
CANNOT DO 2g SINGLE DOSE
296
What does UTI in pregnancy increase the risks of ?
preterm delivery
posibly - low birth weight, pre-eclampsia
297
what would be seen on a dipstick of someone with a UTI?
Nitrites
Leukocytes
?blood
298
what is the management of uti in pregnancy?
SEND FOR CULTURE
1 - Nitrofurantoin (trimester 1+2) 50mg QDS 7 days or 100mg MR
2 - Amoxicillin 500mg TDS 7 days
OR Cefalexin 500mg BD 7 days
299
how should asymptomatic bacteriuria be treated?
managed like UTI due to risk of progression to acute pyelonephritis
300
can nitrofurantoin be used in pregnancy?
Yes but NOT IN THIRD TRIMESTER
Risk of neonatal haemolysis
301
Can trimethoprim be used in pregnancy?
NOT IN FIST TRIMESTER
folate antagonist => risk of neural tube defects and congenital malformations
302
what 4 things can congenital rubella cause?
deafness
congenital cataracts
congenital heart disease
learning disabilities
303
Can pregnancy women get the MMR vaccine?
NO - live vaccine
304
what complications can varicella zoster cause in pregnant mothers?
varicella pneumonitis
hepatitis
encephalitis
305
what are 5 features of congenital varicella syndrome?
foetal growth restriction
microcephaly, hydrocephalus and learning disability
limb hypoplasia
cataracts and eye inflammation
306
what kind of bacteria is listeria?
gram pos bacilli
307
what can listeria cause in pregnancy?
miscarriage or foetal death
sever neonatal infection
308
what are 6 complications of congenital cytomegalovirus?
foetal growth restriction
microcephaly
hearing loss
vision loss
learning disability
seizures
309
where does toxoplasma gondii come from?
parasite from cat poo
310
what is the classical triad of congenital toxoplasmosis?
intracranial calcification
hydrocephalus
chorioretinitis (eye inflamation)
311
what are the complications of parovirus B19 in pregnancy?
miscarriage or foetal death
severe fetal anaemia
hydrops fetalis (foetal heart failure)
maternal pre-eclampsia like syndrome
312
what are 3 signs of congenital zika syndrome?
microcephaly
foetal growth restriction
intracranial abnormalities
313
what is the management of varicella zoster exposure in pregnancy?
Check maternal varicella antibodies if unsure of status
Oral Acyclovir - take day 7-14 post exposure
historically IV varicella zoster immunoglobulins
314
what is the management of chickenpox in pregnancy?
>20 weeks - oral acyclovir
315
what hormone causes uterine contraction?
oxytocin
316
what are 6 risk factors for atonic uterus?
primiparity/grand multiparity
Multiples
high BMI
foetal macrosmia
polyhydramnios
uterine fibroids
317
what is oligohydramnios?
too little amniotic fluid below the 5th centile
318
what is the aprox average amount of amniotic fluid at term?
500ml
319
what are 7 causes of oligohydramnios?
preterm ROM
placental insufficiency (too much blood to brain rather than abdo and kidneys)
renal agenesis
non-functional foetal kidneys
obstructive uropathy
genetic/chromosomal abnormalities (neuropathies)
viral infections
320
what are 7 causes of polyhydramnios?
conditions stopping foetal swallowing
anaemia or foetal hydrops
twin-twin transfusion
maternal DM
maternal lithium ingestion (causes foetal DI)
macrosomia
idopathic (most common)
321
what are 5 complications of polyhydramnios?
congenital malformations or abnormalities
increased risk preterm labour
increased risk atony and PPH
increased risk malpresentations
increased risk cord prolapse
322
what are the 3Ps of labour?
Power (uterine contractions)
Passenger (size/position/presentation of baby)
Passage (shape/size of pelvis)
323
what is the latent phase of labour?
from 0-3cm dilation
irregular contractions
324
is the active phase of labour?
4-10cm dilation
Strong regular contractions
325
What is. the second stage of labour?
from 10cm to delivery
326
what is the 3rd stage of labour?
delivery of baby to delivery of placenta
327
How long should delivery of the placenta take with active management?
30 mins
328
how long should delivery of the placenta take without intervention?
60 mins
329
what is active management of the 3rd stage of labour?
IM oxytocin
Controlled cord traction
330
what are the 3 different types of breech presentation?
extended breech
flexed breech
footling breech
331
what are 6 risk factors for malpresentation?
multparity
uterine malformations/fibroids
placenta praevia
macrosomia
polyhydramnios/oligohydramnious
multiples/prematurity
332
what are 5 complications. of malpresentation?
foetal head entrapment
premature ROM
birth asphyxia
intracranial haemorrhage
cord prolapsd
333
what are 7 risk factors for uterine rupture?
prev c section
prev uterine surgery
increased BMI
High parity
increased age
Induction of labour
use of oxytocin
334
what are 5 signs of uterine rupture?
abdo pain
vag bleeding
ceasing of contractions
hypotension
tachycardia
collapse
335
what is. an incomplete uterine rupture?
when. the perimetrium remains intact
336
what is classed as premature?
<37 weeks
<28 weeks - extreme
28-32 - very prem
32-37 - moderate to late prem
337
what are 2 prophylaxis for preterm labour?
vaginal progesterone
cervical cerclage (stitch)
(<25mm on TV USS 16-24 weeks)
338
what 2 proteins can be tested for to check ROM?
insulin like growth factor binding protein 2
Placental alpha-microglobin-2
339
what is the management of preterm ROM?
prophylactic Erythromycin 250mg QDS for 10 days/until labour
induction of labour from 34 weeks
340
what are 5 management options for preterm labour?
foetal monitoring
Suppression of labour with nifedipine or terbutaline
maternal corticosteroids (<35 weeks)
IV Mag sulphate (<34 weeks for brain protection)
Delayed cord clamping and milking
341
what are 3 signs of magnesium toxicity?
reduced resp rate
reduced BP
absent reflexes
342
what is the management for cord prolapse?
Initial - call for help, get pt to adopt left lateral or knee-chest position, Give O2 and toncolysis
Continue to monitor foetus
Elevate presenting part off cord until delivery
Fill bladder with saline to elevate presenting part
emergency caesarean section
343
what are the 2 causes of foetal hypoxia in cord prolapse?
cord compression
arterial vasospasm (cold air)
344
what are 5 risk factors for cord prolapase?
Malpresentation - breech, transverse, unstable
Artificial rupture of membranes + induction
Polyhydramnios
PROM
345
what are 5 presentations of cord prolapse?
Abnormal foetal heart rate
Foetal bradycardia
Palpable umbilical cord
Supped onset symptoms post rupture of membranes
Patient reported sensation
346
what are 3 neonatal complications of cord prolapse?
Hypoxic ischaemic encephalopathy
Intrapartum asphyxia
Neonatal death
347
what are 3 cord prolapse complications for the mother?
C-section and associated risks
Emotional trauma
Risk of uterine rupture
348
what are 4 indications for instrumental delivery?
failure to progress
foetal distress
maternal exhaustion
control of head position
349
what are 5 risks of instrumental delivery to the mother?
PPH
episiotomy/tears
injury to anal sphincter
incontinance of bladder/bowel
nerve injury
350
what 2 nerves can be damaged in instrumental delivery?
obturator or femoral
351
what are 5 risks of instrumental delivery to the baby?
cephalohaematoma w/ ventouse
facial nerve palsy w/ foreceps
skull fracture
subgaleal haemorrhage
spinal cord injury
352
what are 2 nerve injuries that can occur to the mother with instrumental delivery?
femoral nerve - causes weakness of knee extension, loss of patella reflex, numbness to anterior thigh and medial lower leg
obturator nerve - weakness of hip adduction, rotation and numbness to medial thigh
353
what is the presentation of injury to the lateral cutaneous nerve of the thigh?
numbness to anteriolateral thigh
due to prolonged flexion of hip in lithotomy position
354
what is the presentation of lumbosacral plexus injury?
foot drop and numbness of antieriorlateral thigh, lower leg and foot
due to compression by foetal head in second stage of labour
355
what is the presentation of common peroneal nerve injury?
foot drop and numbness in lateral lower leg
due to compression by head of fibula when in lithotomy position
356
what is obstructed labour?
when a physical blockage prevents childbirth - too small pelvis, too big baby, fibroids, malpresentation
more common in asia and africa
357
what is placenta accreta?
where placenta implants into the myometrium but not beyond
358
what is placenta increta?
where the placenta attaches deeply into the myometrium
359
what is placenta percreta?
when the placenta invades past the myometrium and perimetrium into the abdomen
360
what are 6 risk factors for placenta accreta?
prev accreta
prev endometrial curettage
prev c-section
multigravida
increased maternal age
low lying/placenta praevia
361
how does placenta accreta present?
Painless PV bleeding in 3rd trimester
antenatal uss
At birth
362
when is a baby with placenta accreta induced?
35 to 36+6 weeks
reduce risk of spont labour
given steroids antenatally
363
what are 3 options for placenta accreta management?
hysterectomy
uterus preserving surgery
expectant management
364
what are 5 complications of placenta accreta?
PPH
DIC
Hysterectomy
Preterm birth
Foetal death
365
what are 4 causes of antepartum haemorrhage?
placenta praevia
placental abruption
vasa praevia
placenta accreta
366
what are 3 possible causes of minor pv spotting in pregnancy?
cervical ectropian
infection
vaginal abrasion
367
what is the presentation of placenta praevia?
Painless vaginal bleeding usually after 30 weeks - often diagnosed on 20-week anomaly scan
368
what are 6 complications of placenta praevia?
antepartum haemorrhage
emergency c-section
emergency hysterectomy
maternal anaemia and transfusions
preterm birth and low birth weight
still birth
369
what is classed as a low lying placenta?
within 20mm of internal cervical os
370
what is placenta praevia?
placenta overlying cervical os
90% resolve spontaneously before becoming symptomatic
371
what are 6 risk factors for placenta praevia?
prev c-section
prev placenta previa
IVF
older maternal age
maternal smoking
structural uterine abnormalities
372
what is the management for placenta praevia?
Repeat TVUS at 32 and 36 weeks
Corticosteroids 34-35+6 weeks for lung maturity
elective c-section at 36-37 weeks
373
what is the grading for placenta praevia?
1 - low lying <20mm to os
2 - marginal - reaches margin of Os but does not cover
3 - partially covers os
4 - complete
374
what is the gold standard imaging for placenta praevia?
MRI
375
what are 10 risk factors for placental abruption?
prev. placenta abruption
pre-eclampsia
bleeding in early pregnacy
trauma
multiple pregnancy
foetal growth restriction
multigravida
increased maternal age
smoking
cocaine or amphetamine use
376
what is the presentation of placental abruption?
sudden onset severe continuous abdo pain
vaginal bleeding
shock
CTG abnormality
woody uterus on palpation
377
what are 3 investigations for placental abruption?
US Abdo
CTG - to assess foetus
Bloods - FBC, Coag, LFTs, U+E - Kleihauer test for foetal cells in maternal circulation
378
what is the management of placental abruption?
A-E + Resus
Delivery if >37 weeks,
Corticoteroids if 24-34 weeks and stable
Active 3rd stage management
Anti-D immunoglobulin
379
what are 3 maternal and 3 foetal complications of placental abruption?
Maternal
- Severe haemorrhage + DIC
- Hysterectomy to control bleeding
- Death
Foetal
- Prem
- Stillbirth
- Low birth weight
380
what is classed as a minor antepartum haemorrhage?
<500ml
381
what is classed as a major antepartum haemorrhage?
500-1000ml loss
382
what is classed as a massive antepartum haemorrhage?
>1000ml blood loss
OR
signs of shock
383
what is the management of massive antepartum haemorrhage?
senior review
2x grey canula
blods - FBC, UE, LFT. Coag
cross match 4 units of blood
Flood and blood resus as required
CTG monitor foetus
close monitoring. ofmother
384
what connective tissue in the umbilical cord protects the blood vessels?
whartons jelly
385
what are the two types of vasa praevia?
1 - foetal vessels exposed as cord inserts into membranes outside placenta
2 - vessels exposed as travel to accessory placental lobe from placenta
386
what are 3 risk factors for vasa praevia?
low lying placenta
IVF
multiples
387
what are 3 presentations of vasa praevia?
antenatal TV scan
Painless antepartum haemorrhage in 2nd/3rd trimester
bright red blood on ROM in labour or foetal vessals seen on VE
388
how is vasa praevia diagnosed?
transvaginal or transabdominal USS
389
what is the management for vasa praevia?
corticosteroids from 32 weeks
elective c-section 34-36 weeks
390
what are 5 complications of vasa praevia?
Foetal exsanguination
hypoxic ischaemic encephalopathy
preterm labour
IUGR
necessity for c-section
391
what is classed as a minor PPH?
500-1000ml
392
what is classed as a major PPH?
1000ml+
393
what is a primary PPH?
bleeding within 24 hours of birth
394
what is a secondary PPH?
24 hours -12 weeks after birth
395
what are the 4 Ts of PPH?
tone (atony)
trauma (tears)
tissue (retained placenta)
thrombin (bleeding disorder)
396
what are 12 risk factors for PPH?
previous PPH
grandmultiparity
obesity
macrosomnia/polyhydramnios
prolonged labour
pre-eclampsia
placenta accreta
placenta praevia
retained placenta
instrumental delivery
pre-existing anaemia
induction
397
what are 4 preventative measures for PPH?
Tx anaemia antenatally
give birth with empty bladder
active management of 3rd stage
IV tranexamic acid during section in high risk patients
398
what are 2 mechanical managements of PPH?
fundal massage
catheterisation
399
what are 5 medical managements of PPH?
IV/IM oxytocin
IV/IM ergometrine (without Hx hypertension)
IM carboprost (without Hx asthma)
Misoprostol sublingual
Tranexamic acid
400
what are 4 surgical managements of PPH?
1 - interuterine balloon tamponade
B-lynch suture (braces)
Uterine artery ligation
Hysterectomy
401
what is antepartum haemorrhage?
bleeding PV from 24 weeks
402
what does rhesus disease cause in the new born?
haemolysis
403
what is the prophylaxis for rhesus disease of the newborn?
anti-D IM injection in negative mothers
prevents sensitasation in the mother given at 28 weeks
404
when is anti-d given in a normal pregnancy?
28 weeks
Birth (if baby +ve)
sensitisation events
405
what are 8 situations when anti-D should be given?
delivery or Rh+ infant
any termination of pregnancy
miscarriage if gestation >12 weeks
ECV
Antepartum haemorrhage
amniocentesis, chorionic villus sampling, foetal blood sampling
abdominal trauma
406
what are 6 signs of rheusus disease of the newborn?
oedematous - hydros fetalis
jaundice
anaemia
hepatosplanomegaly
heart failure
kernicertus
407
what test is used to titrate the dosage of anti-D?
Kleinhauer test
408
what does the kleinhauer test check?
how much foetal blood has passed into the maternal circulation during a sensitisation event after 20 weeks
409
what is low birth weight?
<2500g
410
what is placental insufficiency?
when o2 and nutrients cannot sufficiently supplu placenta and foetus due to insufficient spiral arteries
411
what are 6 risk factors for placental insufficiency?
Pre-eclampsia/hypertension
smoking, drinking, drugs
Advanced maternal age
primiparity
prev IU growth restriction baby
medications - cancer, antiepileptics
412
what 2 medications can be given for placental insufficiency?
aspirin
heparin
413
what is the combined test?
11-14 weeks gestation
uss - nuchal translucency >6cm
bloods -
bHCG - Raised
PAPPA - Low
Screening for downs
414
what physiological changes in pregnancy are there in relation to maternal fluid retention?
Increased total plasma volume (30-50%)
Decreased plasma oncotic pressure
415
How long does the corpus luteum produce progesterone for in pregnancy?
10 weeks
416
what are 6 physiological hormonal changes in pregnancy?
Increased ACTH which causes an increase in steroid hormones (cortisol and aldosterone)
Increased prolactin - suppresses FSH and LH
Increased melanocyte stimulating hormone causes hyperpigmentation - linea nigra, melasma
Increase in T3 and T4
Increase in progesterone and oestrogen
increase then slow fall in HCG after 12 weeks
417
what is the change in the size of the uterus in pregnancy?
from around 100g to around 1.1kg
418
what hormone allows break down of collagen in the cervix to prepare for effacement?
prostaglandins
419
what are 7 physiological cardiac changes in pregnancy?
Increased blood volume
increased plasma volume
increased cardiac output - increased stroke volume and HR
decreased peripheral vascular resistance
decreased BP (early and mid pregnancy)
varicose veins
peripheral vasodilations (can cause flushing and hot sweats)
420
what are 2 physiological respiratory changes in pregnancy?
increased tidal volume
increased resp rate
421
what are 5 physiological renal changes in pregnancy?
increased blood flow to kidneys
increased GFR
increased aldosterone => increased Na+ and water
increased protein excretion
dilation of the ureters and collecting system - physiological hydronephrosis (R>L)
422
what are 3 nutrients that are in higher demand in pregnancy?
iron
folate
B12
423
what is the first line management of cholestasis of pregnancy?
1 - emmolients and antihistamines
2- ursodeoxycholic acid
424
what are 4 risk factors for shoulder dystocia?
macrosomia
High maternal BMI
Diabetes
Prolonged labours
425
what is the 1st line management of shoulder dystocia?
McRoberts manoeuvre
426
what is the management of one missed COCP?
take missed pill even if have to take two in one day
no additional contraceptive needed
427
what is the management if 2+ OCPs are missed?
take yesterdays and todays dose then continue taking normally
Use condoms for 7 days
428
what is the management of unprotected sex on OCP with missed pills in week 1?
emergency contraception
429
what is the management of unprotected sex on OCP with missed pills in week 2?
no need for additional contraception
430
what is the management of unprotected sex on OCP with missed pills in week 3?
finish pills in current pack and start new pack immediately no need for pill free interval
431
where is the most common site of ectopic pregnancy?
ampulla of fallopian tubes
432
what are 4 risk factors for hyperemesis gravidum?
increased levels of beta-hCG - multiple pregnancies, trophoblastic disease
nulliparity
obesity
family or personal history of NVP
433
what is associated with decreased levels of hyperemesis gravidum?
smoking
434
what is the triad of hyperemesis gravidum?
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
435
what is the first line management of hyperemesis gravidum?
antihistamines: oral cyclizine or promethazine
phenothiazines: oral prochlorperazine or chlorpromazine
436
what is the second line management of hyperemsis gravidum?
oral ondasetron
oral metoclopramide or domperidone
437
what complication can ondansetron use in pregnancy cause?
cleft lip and palate
438
what are 4 complications of hyperemesis gravidum?
acute kidney injury
Wernicke's encephalopathy
oesophagitis, Mallory-Weiss tear
venous thromboembolism
439
what are 4 different types of uterine fibroids?
intramural - within myometrium and distort shape
subserosal - grow outwards into abdomen
submucosal
pedunculated
440
what are 7 features of fibroids?
asymptomatic
menorrhagia - may result in iron-deficiency anaemia
bulk-related symptoms
lower abdominal pain: cramping pains, often during menstruation
bloating
urinary/bowel symptoms
Deep dyspareunia
subfertility
441
how are fibroids diagnosed?
Hysteroscopy for submucosal
TV Pelvic US
442
when should people with fibroids be referred to gynae?
>3cm
443
what can be a cause of thick green nipple discharge most common in postmenopausal smokers?
Mammary duct ectasia
444
what type of contraception can be used in trans men?
Progesterone only
non-hormonal
445
How long after UPSI can Levonorgestrel (Levonelle) be taken?
72 hours
446
How long after UPSI can Ulipristal (ella one) be taken?
120 hours
447
what patients should Ulipristal use be cautioned in?
Asthmatics
448
How long after taking Ulipristal do you need to wait to start hormonal contraception?
5 days
449
How long after UPSI can the copper IUD be fitted?
5 days
450
what is the most common ovarian cyst?
follicular cyst - due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
451
what is the most common benign ovarian tumour in women <30?
Dermoid cyst - torsion in more likely
452
what is amniotic fluid embolism?
when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.
453
what antibiotics should be avoided in breast feeding?
ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
454
what psychiatric drugs should be avoided in breast feeding?
lithium, benzodiazepines
455
What are 6 drugs that should be avoided in breast feeding?
aspirin
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone
456
what medication can be used to suppress lactation?
cabergoline
457
what are 5 risk factors for breech presentation?
uterine malformations, fibroids
placenta praevia
polyhydramnios or oligohydramnios
fetal abnormality (e.g. CNS malformation, chromosomal disorders)
prematurity (due to increased incidence earlier in gestation)
458
what is the management for breech presentation?
<36 weeks - many turn spontaneously
>36 weeks - ECV from 36/37 weeks in nuli/mulitparous women
Planned caesarean or breech vaginal delivery
459
when should external cephalic version (ECV) be offered in breech presentation?
37 weeks (can be 36 in primies)
460
what are 6 contraindications to ECV?
where caesarean delivery is required
antepartum haemorrhage in last 7 days
abnormal cardiotocography
major uterine anomaly
ruptured membranes
multiple pregnancy
461
what are 5 reasons for a Cat 1 section?
suspected uterine rupture
major placental abruption
cord prolapse
fetal hypoxia
persistent fetal bradycardia
462
how quick should a cat 1 section be?
within 30 mis
463
How quick should a cat 2 section be?
within 75 mins
464
what is the results of a positive combined test?
↑ HCG, ↓ PAPP-A, thickened nuchal translucency => Downs likely
465
what tests are included in the quadruple test?
alpha-fetoprotein
unconjugated oestriol
human chorionic gonadotrophin
inhibin A
466
what is the quadruple test result for downs?
alpha-fetoprotein - LOW
unconjugated oestriol - LOW
human chorionic gonadotrophin - HIGH
inhibin A - HIGH
467
what is the quadruple test result for edwards?
alpha-fetoprotein - LOW
unconjugated oestriol - LOW
human chorionic gonadotrophin - LOW
inhibin A - NORMAL
468
what is the quadruple test result for neural tube defects?
alpha-fetoprotein - HIGH
unconjugated oestriol - NORMAL
human chorionic gonadotrophin - NORMAL
inhibin A - NORMAL
469
what is the management of eclampsia in pregancy?
IV magnesium sulphate
470
How long should magnesium sulfate continue after delivery in eclampsia?
24 hours
471
what is the first line management for mag sulfate induced respiratory depression in eclampsia?
calcium gluconate
472
what folic acid supplementation should pregnant women take?
400mcg of folic acid until the 12th week of pregnancy
473
What risk factors mean women should take 5mg of folic acid pre-pregnancy?
Personal or FHx of neural tube defect
anti-epileptic drugs
coeliac disease, diabetes, or thalassaemia trait
BMI >30 kg/m2
474
what is the diagnostic threshold for gestational diabetes?
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
5,6,7,8
475
what is the fasting glucose target in pregnancy for those with diabetes?
5.3 mmol/L
476
what is the 1 hour post meal glucose target in pregnancy?
7.8 mmol/L
477
what is the 2 hour post meal glucose target in pregnancy?
6.4 mmol/L
478
what are 6 indications for induction?
Overdue >41 weeks
PPROM/PROM
diabetic mother > 38 weeks
pre-eclampsia
obstetric cholestasis
intrauterine fetal death
479
what score is used to assess whether induction of labour is necessary?
Bishop score
480
what is the bishop score that indicates need for induction?
<5
481
what is the bishop score that indicates no need for induction?
>8 inclusive
482
what is the management of bishop score <6 inclusive?
vaginal prostaglandins or oral misoprostol
balloon catheter if higher risk of hyperstimulation or prev c-sections
483
what is the management of bishop score >6?
amniotomy and an intravenous oxytocin infusion
484
what is the main complication of induction of labour?
uterine hyperstimulation
485
what are 4 complications of PROM?
fetal: prematurity, infection, pulmonary hypoplasia
maternal: chorioamnionitis
486
what can be seen on sterile speculum exam in PROM?
pooling of amniotic fluid in the posterior vaginal vault
487
How can PROM be tested for if fluid pooling not seen?
testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein‑
488
what medication should be given in PROM?
Oral erythromycin 10 (TEN) days
Corticosteroids (<34 weeks)
489
What are 8 situations where anti-D should be given ASAP?
delivery of Rh +ve infant - live or stillborn
termination of pregnancy
miscarriage > 12 weeks
ectopic pregnancy - surgically managed
external cephalic version
antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling
abdominal trauma
490
what tests should be done on the cord blood of any baby born to Rh -ve mother?
FBC
Blood group and save
Direct coombs test
491
what are the 3 stages of postpartum thyroiditis?
Thyrotoxicosis
hypothyroid
return to normal
492
what is the management of the thyrotoxic phase of postpartum thyroiditis?
propanalol - to treat symptoms
493
what is the management for fibroids <3cm?
1 - Mirena coil
symptomatic - tranexamic and mifenamic acid
2 - COCP, cyclical progestogens
Surgical - Endometrial ablation, resection of submucosal fibroids during hysteroscopy, Hysterectomy
494
what is the management of fibroids >3cm?
refer to gynae - options as <3cm +
Uterine artery embolisation
Myomectomy
Hysterectomy
+ GnRH analogues to shrink before myomectomy
495
what are 8 complications of fibroids?
iron deficiency anaemia
Reduced fertility
Pregnancy complications
Constipation
Urinary outflow obstruction + UTI
Red degeneration
Torsion of the fibroid
Malignant change to a leiomyosarcoma - very rare (<1%)
496
what is red degeneration of fibroids?
ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply usually in pregnancy
Presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia.
497
what are fibroids made out of?
smooth muscle proliferation
498
what are endometrial polyps made out of?
endometrial tissue
499
when should induction be offered in cholestasis of pregnancy?
37-38 weeks
500
what are 8 things that increase risk of IUGR?
Maternal age of <16 or >35
low BMI or a pre-pregnancy weight of >75kg. interpregnancy interval < 6 months or >10 years
Pre-eclampsia
smoking, drugs and alcohol
clotting disorders
diabetes
congenital abnormalities
501
what are 4 features of congenital syphilis?
Generalised lymphadenopathy
Hepatosplenomegaly
Rash
Skeletal malformations
502
what are 4 causes of retrograde ejaculation?
Bladder neck surgery
Congenital abnormality
Diabetic autonomic neuropathy
Transurethral resection of the prostate
503
what infectious disease screening is offered in pregnancy?
HIV
syphilis
hepatitis B
504
when does the dating scan happen?
11+2-14+1 weeks
505
when is the booking visit and what happens?
<10 weeks
Ht and Wt
screening offered
BP and urinalysis
risk assessed
vaccines offered
506
when does the anatomy scan occur?
18-20+6 weeks
507
when is Anti-D given in normal pregnancy?
28 weeks and 34 weeks
508
what are 11 risk factors for small for gestational age baby?
Maternal age >40
Smoker
Maternal cocaine use
Maternal daily vigorous exercise
Previous SGA baby
Previous stillbirth
FHx SGA
Chronic hypertension
Diabetes with vascular disease
Renal impairment
Antiphospholipid syndrome
509
what are 6 foetal surveillance techniques?
Symphyseal fundal height Foetal abdominal circumference.
Femur length.
Head circumference / biparietal diameter.
Liquor volume / amniotic fluid index (normal = 5-25cm)
umbilical/MCA artery Doppler
510
what level is raised bile acids in pregnancy?
>19 micromol/L
511
what are 3 analgesias used in labour?
Entonox
IM opioids - diamorphine or morphine
Epidural - bupivacaie and fentanyl
512
what counts as delay in the first stage of labour?
cervical dilation <2cm in 4 hours
513
what counts as delay in the second stage of labour?
nuliparous > 2 hours
multiparous >1 hour
514
what are 6 contraindications to the copper IUD and the IUS?
1. PID
2. Gonorrhoea or chlamydia
3. Unexplained vaginal bleeding / endometrial cancer
4. Postpartum / post-abortion septicaemia
5. Gestational trophoblastic disease
6. Purulent cervicitis, pelvic TB
515
at what crown rump length should a foetus have a heart beat?
>7 mm
516
what is the normal positioning of the baby throughout birth?
Descent, engagement, flexion, internal rotation, crowning, extension of presenting part, external rotation of head, delivery
517
what is the management of asymptomatic bacteriuria in pregnancy?
Confirm presence of bacteriuria with second culture and begin culture dependent antibiotic
518
What counts as polyhydramnious?
AFI of >24cm (or 2000ml+)
519
what counts as oligohydramnious?
AFI of <5cm (or under 200ml)
520
what are 4 neonatal complications due to anti-epileptic use in pregnancy?
Orofacial defects
neural tube defects
congenital heart defects
haemorrhagic disease of the new born
521
what are 6 causes of hydrops fetalis?
severe anaemia
cardiac abnormalities
chromsomal abnormalities (turners, downs, edwards, pataus)
Infection (toxoplasmosis, rubella, CMV, varicella, parvovirus)
twin-twin trasnfusion syndrome
chorioangioma
522
what is the Hb monitored in pregnancy?
booking and 28 weeks
523
How do you read CTGs?
DR C BRAVADO
DR - Define risk
C - contractions - <5 in 10 inclusive
BRa - Baseline rate - 110-160 BPM
V - Variability - 5 -25 bpm variability
A - Accelerations - rise of 15bpm for >15s, should be 2 every 15 mins
D - Decelerations - drop of 15bpm for >15s
O - overall impression
524
in what age range is cervical screening every 3 years?
25-49 - every 3 years
525
in what age range is cervical screening every 5 years?
50-65 - every 5 years
526
what happens if high risk HPV is found on a smear?
Cytology is examined
527
what happens if there is inadequate results on a smear?
another smear in 3 months
528
what happens if cytology is abnormal in cervical smear?
colposcopy
529
what are 5 examples of abnormal cytology on cervical smear?
Borderline changes in squamous/endocervical cells
Low-grade dyskaryosis
High grade dyskaryosis
Invasive squamous cell carcinoma
Glandular neoplasia
530
what happens in high risk HPV is positive but cytology normal in cervical smear?
Repeat smear in 12 months
531
what happens in 2 inadequate samples in a row in cervical smear?
Colposcopy
532
what happens if high risk HPV is +ve but cytology normal two smears in a row?
Repeat smear in 12 months
533
what is the management of high risk HPV on 3 smears in a row? (screening, 12 mon recall, another 12 mon recall)
Colposcopy
534
what 2 strands of HPV cause most cervical cancer?
16 and 18
535
what increases risk of contracting HPV?
Ealy sexual activity
Increased number of sexual partners
Unprotected sex
536
How often do women with HIV get cervical screening?
Every year
other immunocompromised women may also get increased screening frequency
537
How long post partum should a cervical smear be delayed?
3 months
538
What is different about cervical screening in Scotland?
every 5 years from 25-65 never every 3 years
539
when is cytology performed in cervical screening?
only if +ve for high risk HPV
540
what stains are used in colposcopy?
Acetic acid - causes abnormal cells to appear white - acetowhite
Iodine solution - abnormal areas do not stain
541
what is the management of cervical intraepithelial neoplasia found on colposcopy?
Large loop excision of the transformation zone - LLETZ
Cone biopsy - under GA
542
what 2 strains of HPV cause genital warts?
6 and 11
543
when should patients with CIN return to colposcopy for test of cure?
6 months
544
what is the risk of SSRIs in pregnancy?
1st trimester - risk of congenital heart defects
3rd trimester - risk of persistent pulmonary hypertension
545
What SSRI has the highest risk of congenital malformations in 1st trimester?
Paroxetine
546
how does pregnancy affect the thyroid?
increased levels of thyroxine binding globulin in pregnancy which causes an increase in the levels of total thyroxine but does not affect free thyroxine levels
547
what are 3 risks of untreated thyrotoxicosis in pregnancy?
risk of foetal loss
maternal heart failure
premature labour
548
what is the most common cause of thyrotoxicosis in pregnancy?
grave's disease
549
what is the management of thyrotoxicosis in pregnancy?
propylthiouracil 1st trimester
550
why is carbimazole contraindicated in pregnancy?
can cause congenital abnormlities
551
what is a risk of propylthiouracil use?
severe hepatic injury
552
what is the management of hypothyroidism in pregnancy?
measure TSH every trimester and 6-8 weeks post partum
Need increased dose of thyroxine in pregnancy - up to 50% as early as 4-6 weeks gestation
553
when are the normal 1st signs of breast development?
9-13 years
554
when is menarche ususally?
11-15 years
555
what is tanner stage 1 for girls?
<10 years
no pubic hair or breast development
556
what is tanner stage 2 for girls?
10-11 years
light and thin pubic hair
breast buds form
557
what is tanner stage 3 for girls?
11-13 years
course and curly pubic hair
breasts begin to elevate beyond the areola
558
what is tanner stage 4 for girls?
13-14
adult-like pubic hair - not reaching thigh
areola mound forms and projects from surrounding breast
559
what is tanner stage 5 for girls?
>14 years
hair extending to medial thigh
areolar mounds reduce and adult breasts form
560
what is classed as a hypoactive uterus in labour?
<2 contractions in 10 minutes lasting <40s
