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Phase 4 > Obs and Gynae > Flashcards

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

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2
Q

what is a grade 1 cystocele?

A

mild - the bladder droops only a short way into the vagina

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3
Q

what is grade 2 cystocele?

A

medium - bladder sunk to reach opening of vagina

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4
Q

what is grade 3 cystocele?

A

advances - bladder bulges out through opening of vagina

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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

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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

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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

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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

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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

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10
Q

what should be given with pessaries to protect from vaginal irritation?

A

oestrogen cream

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11
Q

what is the difinitive treatment for pelvic organ prolapse?

A

surgery

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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

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13
Q

what is uterovaginal prolapse?

A

where the uterus +/- the vagina itself descends out of the vagina

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14
Q

what is urge incontinence?

A

caused by overactivity of detrusor muscle meaning people feel the sudden need to pass urine

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15
Q

what is stress incontinance?

A

due to weakness of the pelvic floor and sphincter muscles urine to leaks at times of increased pressure on the bladder like laughing , coughing or surprise

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16
Q

what is overflow incontinence?

A

occurs with chronic urinary retention (more common in men) and without the urge to pass urine can be due to anticholinergic meds, fibroids, pelvic tumours and neuro conditions

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17
Q

what are 6 risk factors for urinary incontinance in women?

A

increased age
pregnancy
obesity
pelvic organ prolapse
Neurological disorder
FHx

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18
Q

what are 4 investigations for urinary incontinance in women?

A

urinalysis
urodynamic tests
bladder diary
post void residual bladder volume

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19
Q

what is the gold standard investigation of urinary incontinence?

A

urodynamic testing

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20
Q

what are 3 differential of urinary incontinance?

A

UTI
pregnancy
urogenital fistula

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21
Q

what are 4 lifestyle managements of stress incontinance

A

avoid caffine
avoid smoking
weight loss
reduce fluid intake

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22
Q

What is the first line medication to manage stress incontinance?

A

Duloxetine

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23
Q

What are 3 contra-indications to duloxetine?

A

hepatic impairment
severe renal impairement (<30 creatinine clearance)
Uncontrolled hypertension

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24
Q

what are 4 surgeries for stress incontinance?

A

tension-free vaginal tape
autologous sling
colosuspension
intramural urethral bulking

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25
Q

what is the management of urge incontinance?

A

bladder retraining
anticholinergic medication

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26
Q

what are 3 examples of anticholinergic medications for urge incontinance?

A

Oxybutynin
tolterodine
darifenacin

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27
Q

what are 4 anticholinergic side effects?

A

dry mouth and eyes
constipation
urinary retention
cognitive decline

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28
Q

what are 4 invasive options for urge incontinance?

A

Botulinum toxin type A - botox - injection in bladder wall
percutaneous sacral nerve stimulation
augmentation cystoplasty
urinary diversion

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29
Q

what is one non-anticholinergic that can be used to treat urge incontinance?

A

Mirabegron

CAN CAUSE HYPERTENSIVE CRISIS!!

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30
Q

what are 6 risk factors for vaginal fistula?

A

childbirth
injury
surgery
infection
radiation
IBD

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31
Q

what is a vesicovaginal fistula?

A

urinary bladder and vagina fistula

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32
Q

what is an enterovaginal fistula?

A

opening between small intestine and vagina

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33
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

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34
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

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35
Q

what is fibroadenoma?

A

most common cause of breast mass
normally more likely in early reproductive years
painless, smooth, round, firm, well defined, mobile, usually <3cm

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36
Q

what is a fibrocystic breast ?

A

usually in pre/perimenopausal women
mobile with dystinct borders - lumpy breasts
sometimes tender
fluctuate with mentruation

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37
Q

what do breast fat necrosis lumps present with?

A

hard, fixed masses
very like malignancy and require biopsy

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38
Q

what is breast papilloma?

A

breast lump usually in ducts
usually benign but can be associated with cancer

bloody nipple discharge is typical

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39
Q

what are breast abscesses?

A

breast lump typical in breastfeeding
ruptured sub-areolar ducts leak into periductal space
must be differentiated from inflammatory breast cancer

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40
Q

what is breast lipoma?

A

benign tumours of adipose tissue
soft, painless, mobile, no skin changes

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41
Q

what is galactocele?

A

occur in lactating women often after stopping
breast milk filled cysts due to lactiferous ducts being blocked
firm mobile, painless lump beneath areola

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42
Q

what is the most common causative pathogen of infective mastitis?

A

staphylococcus aureus

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43
Q

what is mastitis?

A

inflammation of breat with or without infection
common with breast feeding

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44
Q

what are breast absecesses?

A

a localised area of infection with a walled off collection of puss - with or without mastitis

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45
Q

what are 5 symptoms of mastitis?

A

fever
decreased milk outflow
breast warmth, tenderness, swelling, redness
breast pain
flu like symptoms

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46
Q

what are 3 investigations for breast abscess?

A

breast ultrasound
needle aspiration drainage
cystology of nipple discharge/aspiration

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47
Q

what are 3 investigations for mastitis?

A

milk/aspirate/discharge/biopsy culture and sensitivity
histopathological exam of biopsy
pregnancy test

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48
Q

what lifestyle treatment is there for breastfeeding mastitis?

A

continue breastfeeding/expressing milk
heat packs
warm showers
simple analgesia

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49
Q

what is the treatment of suspected infective mastitis?

A

Abx - flucloxacillin or erythromyacin (in allergy) for 10 days if still symptomatic 12-24 hours after 1st presentation with lifestyle management

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50
Q

what is the treatment of breast abscess?

A

surgical drainage

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51
Q

what is ductal ectasia?

A

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

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52
Q

What is the name of the extention of breast tissue to the axilla?

A

tail of spence

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53
Q

what is the name of a breast milk filled cyst caused by lactiferous duct blockage?

A

galactocele

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54
Q

what chemical has a inhibitory effect on prolactin?

A

Dopamine

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55
Q

what enzyme in adipose tissue converts androgens to oestrogen?

A

aromatase

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56
Q

which common heart meds can cause gynaecomastia?

A

digoxin and spiro

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57
Q

what is intraductal papilloma?

A

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

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58
Q

What is the healthhy bacteria in the vagina?

A

lactobilli - produce lactic acid and reduce pH of vagina (<4.5)

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59
Q

What is normal vaginal pH?

A

3.5-4.5

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60
Q

what is the most common cause of vaginal thrush?

A

Candida albicans

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61
Q

What are 4 risk factors for thrush?

A

increased oestrogen (pregnancy)
poorly controlled diabetes
immunosuppresion
Broad spectrum ABx

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62
Q

what are the symptoms of vaginal thrush?

A

thick white discharge
vulva and vaginal itching and irritation

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63
Q

What are 6 complications of vaginal thrush?

A

erythema
fissures
oedema
pain during sex (dyspareunia)
dysuria
excoriation

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64
Q

what is one test that can be used to distiguish between trush and BV/trichomonas?

A

vaginal pH swab
>4.5 in BV and Trichomonas
<4.5 in candidiasis

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65
Q

what swab is used for vaginal MCS?

A

charcoal swab - for BV, candidiasis, gonorrhoea, trichomonas, other bacteria

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66
Q

What is the management for thrush?

A

antifungal cream - clotrimazole 5g 10% single dose
antifungal pessary - clotrimazole 500mg single dose
Oral antifungal - fluconazole 150mg single dose

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67
Q

what should you tell patients using antifungal creams?

A

can degrade latex condoms and prevent spermacides from working => use other forms of birth control for at least 5 days

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68
Q

what are 9 risk factors for ectopic pregnancy?

A

Prev ectopic
tubal surgery
Hx of STD
Smoking
IVF
IUD pregnancy
Black ethnicity
age <18 first intercourse
age >35 at time of presentation

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69
Q

what is the presentation of an ectopic pregnancy?

A

Missed period
Constant lower RIF/LIF pain
Vaginal bleeding
lower abdo or pelvic tenderness
cervical motion tenderness
Shoulder tip pain - peritonitis
Dizziness or syncope

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70
Q

when does ectopic pregnancy usually present?

A

6-8 weeks

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71
Q

what hCG level will mean pregnancy is visible on USS?

A

> 1500 IU/L

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72
Q

what are the 6 criteria for expectant management of ectopic pregnancies?

A

available for follow up
unruptured
mass <35mm
no heart beat
no significant pain
HCG <1500 IU/L

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73
Q

what drug is used for medical management of ectopic pregnancies?

A

IM methotrexate

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74
Q

what is the criteria for medical management of ectopic pregnancies?

A

HCG levels <5000 IU/L
Confirmed absence of intrauterine pregnancy on US
<35mm
minimal pain
no heart beat

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75
Q

what is the criteria for surgical management of ectopic pregnancy?

A

> 35mm mass
Significant pain
foetal heartbeat visible on TVUS
Serum hCG >5000

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76
Q

what is the 1st line surgical management in women with no fertility risk factors?

A

Laproscopic Salpigectomy

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77
Q

What embrionic structure does the female genital system develop from?

A

paramesonephric (mullerian) ducts

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78
Q

what are 4 abnormal female organ formations?

A

bicornuate uterus - heart shaped
imperforate hymen
transverse vaginal septae - septum in vagina
vaginal hypoplasia and agenesis - abnormally small/absent vagina

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79
Q

what is androgen insensitivity syndrome?

A

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

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80
Q

what are the complications of androgen insensitivity syndrome?

A

slightly taller than average female
no pubic or facial hair
increased risk of testicular cancer unless removed from abdomen
infertility

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81
Q

what is the usual presentation of androgen insensitivity syndrome?

A

inguinal hernias
primary amenorrhoea

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82
Q

What is menopause?

A

no periods for 12 months due to the end of menstruation

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83
Q

what is premature menopause?

A

Menopause before 40 years

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84
Q

What cells secrete oestrogen?

A

ganulosa cells

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85
Q

What are 8 perimenopausal symptoms?

A

Hot flushes
emotional lability/low mood
reduced libido
premenstrual syndrome
irregular periods
joint pain
heavier/lighter periods
vaginal dryness and atrophy

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86
Q

What are 4 conditions menopause increases the risk of?

A

CVD and stroke
osteoporosis
pelvic organ prolapse
urinary incontinance

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87
Q

what is the management of perimenopausal symptoms?

A

HRT
tibolone - synthetic steroid
clonidine - reduces hot flushes
CBT
SSRIs
testosterone gel for libido
vaginal oestrogen/moisturisers

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88
Q

what is adenomyosis?

A

Endometrial tissue inside the myometrium
More common with mutiparous

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89
Q

What are 5 presetations of adenomyosis?

A

Dysmenorrhoea
menorrhagia
dyspareunia (pain in intercourse)
Infertility
Enlarged/tender (boggy) uterus but softer than w/ fibroids

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90
Q

what is the 1st line investigation for adenomyosis ?

A

TV ultrasound

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91
Q

What is the gold standard investigation for adenomyosis?

A

histological exam after hysterectomy

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92
Q

what are 2 non-contraceptive treatments for mennhoragia?

A

Tranexamic acid - when no pain (antifibrinolytic reduces bleeding)
Mefenamic acid - with pain (NSAID - reduced bleeding and pain)

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93
Q

What are 3 contraceptive managements options for mennorhagia?

A

IUS
COCP
cyclical oral progestogens

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94
Q

what are 4 specialist managements of menorrhagia?

A

GnRH analogues to induce meno-pause like state
endometrial ablation
uterine artery embolisation
hysterectomy

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95
Q

what are 9 complications of adenomyosis in pregnancy?

A

infertility
miscarriage
preterm birth
small gestation
preterm premature rupture of membranes
malpresentation
c-section
PPH

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96
Q

What is asherman’s syndrome?

A

where adhesions form in uterus following damage

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97
Q

What are 3 risk factors for ashermans syndrome?

A

dilation and curettage (after retained products of conception)
uterine surgery
pelvic infection

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98
Q

what are 4 presentations of asherman’s syndrome?

A

secondary amenorrhoea
light periods
dysmenorrhoea
infertility

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99
Q

What are 4 investigations for asherman’s syndrome?

A

hysteroscopy
hysterosalpingography
sonohysterography
MRI

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100
Q

What is lichen sclerosus?

A

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

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101
Q

what are 3 risk factors for lichen sclerosus?

A

Postmenopausal
Autoimmunity - thyroid, T1DM
Site of injury - Koebner phenomenon

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102
Q

what is lichen planus?

A

autoimmune condition causing chronic inflammation with shiny purplish flat top raised areas with white lines across surface called wickhams striae

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103
Q

what are 7 presentations of lichen sclerosus?

A

white skin patches
itching
soreness
skin tightness
painful sex
erosions
fissures

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104
Q

what is the appearance of lichen sclerosis?

A

Porcelain white
shiny
tight
thin
slightly raised
papules or plaques

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105
Q

what is the management for lichen sclerosus?

A

topical steroids - dermovate - clobetasol propionate 0.05%
OD for 4 weeks then gradually reducing in frequency
emollients

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106
Q

what is a key complication of lichen sclerosus?

A

5% risk of developing squamous cell carcinoma of the vulva

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107
Q

what are 4 complications of lichen sclerosis?

A

pain and discomfort
sexual dysfunction
bleeding
narrowing of vaginal or urethral openings

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108
Q

what is atrophic vaginitis?

A

atrophy of the vaginal mucosa due to lack of oestrogen

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109
Q

What are 6 patient presentations of atrophic vaginitis?

A

itching
dryness
dyspareunia (painful sex)
bleeding (due to inflammation)
recurrent UTIs, Stess incontinance, prolapse
White, yellow possibly malodorous discharge

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110
Q

what are 6 signs of atrophic vaginitis on examination?

A

pale mucosa
thin skin
reduced skin foldes
erythema and inflammation
dryness
sparse pubic hair

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111
Q

what is the management of atrophic vaginitis?

A

topical oestrogen - cream, pessaries, ring

Systemic HRT

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112
Q

what are 3 contraindications to use of topical oestrogens in atrophic vaginitis?

A

Angina
VTE
breast cancer

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113
Q

what are the 4 parameters to measure ‘normal’ menstruation by?

A

Frequency
regularity
duration
volume

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114
Q

what are 4 risk factors for abnormal uterine bleeding?

A

Extremes of reproductive age
PCOS
endocrine disorders - hypothyroid, hyperprolactinoma
obesity

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115
Q

what is the emergency management of excessive uterine bleeding?

A

1st - hormone therapy - 25mg IM conjugated oestrogens

2nd - Tranexamic acid, Surgery

Blood products and fluids if haemodynamically unstable

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116
Q

what are the two types of endometrial hyperplasia

A

hyperplasia without
atypical hyperplasia

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117
Q

what is the treatment for endometrial hyperplasia?

A

progestogens - IUS or continuous oral progestogens

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118
Q

what is a normal endometrial thickness post menopause?

A

<4mm

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119
Q

what are 7 presentations of uterine fibroids?

A

Menorrhagia
Prolonged menstruation
Abdominal pain, worse during menstruation
Bloating or feeling full in the abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia
Reduced fertility

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120
Q

what are endometriomas seen in the ovaries often called?

A

chocolate cysts (from endometriosis)

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121
Q

what are some possible cause of endometriosis?

A

retograde menstruation through fallopian tubes into abdomen
embryonic cells
lymphatic spread
metaplasia

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122
Q

what are 7 presentations of endometriosis?

A

cyclical abdomina or pelvic pain
deep dyspareunia
dysmenorrhoea
subfertility
fixed retroverted uterus
palpable mass - endometrioma
painfull pooping

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123
Q

what is the gold standard investigation for endometriosis?

A

laproscopic surgery + biopsy

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124
Q

what is the medical management of endometriosis?

A

1 - NSAIDs
2 - COCP or Progesterone only, depo, implant or IUS
3 - GnRH analogous

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125
Q

what are 4 risk factors for fibrids?

A

increased patient weight
40+
black ethnicity
low vit D

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126
Q

What is a complete mole in a molar pregnancy?

A

when 2 sperm cells fertalise an ovum with no genetic materium and combine genetically to form a tumour

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127
Q

what is a partial mole in a molar pregnancy?

A

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 csome foetal material

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128
Q

what are 6 possible indications of molar pregnancy compared to normal pregncncy?

A

severe morning sickness
vaginal bleeding
increased enlargement of uterus
abnormally high hCG
thyrotoxicosis

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129
Q

what is a sign of molar pregnancy on USS?

A

snow storm appearance

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130
Q

what is the management of molar prregnancy?

A

evacuation of uterus
histology
referal to gestational trophoblastic disease centre
hCG level monitoring

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131
Q

what can be a complication of molar pregnancy?

A

metastasis

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132
Q

what are 6 presentations of prolactinoma?

A

amenorrhoea/oligomenorrhoea
infertility
galactorrhoea
lowered libido
erectile dysfunction
visual deterioration (bilateral temoral hemianopia)

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133
Q

what is the most common type of pituitary tumour in women?

A

prolactinoma - 50%

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134
Q

what is the 1st line medical treatment of prolactinoma?

A

dopamine agonist - carbergoline 0.5mg once weekly

(2nd line OCP in premeno women)

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135
Q

what is the surgical management of prolactinoma?

A

tras-sphenoidal surgery

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136
Q

what is the most common type of ovarian tumour?

A

epithelial cell tumour

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137
Q

what are beingn ovarian tumours?

A

dermoid cysts
germ cell tumours

teratomas. particularly associated with ovarian torsion

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138
Q

What are the 3 diagnostic features for PCOS diagnosis?

A

Rotterdam criteria

Anovulation/oligoovulation
Hyperandrogenism (hirsutism and acne)
Polycystic ovaries on USS

2 features = diagnosis

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139
Q

What are 5 potential presentations of ovarian cysts?

A

pelvic pain - w/ torsion, rupture or haemorrhage
bloating
fullness in abdomen
palpable pelvic mass (V large cysts)
Infertility

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140
Q

what are 5 medications that can cause hirsutism?

A

Phenytoin
Ciclosporins
corticosteroids
testosterone
Anabolic steroids

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141
Q

what are 4 differentials for hisutism?

A

Medications
Ovarian or adrenal tumours
Cushings
Congenital adrenal hyperplasia

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142
Q

what is the mechanism for insulin resistance in PCOS?

A

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

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143
Q

what are functional cysts?

A

follicular cysts for developing follicles can sometimes fail to rupture and release the egg and therefore persist for a short while

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144
Q

what is the most common type of ovarian cyst?

A

functional (follicular) cysts

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145
Q

what type of cysts are often seen in early pregnancy?

A

corpus luteum cysts - may cause pelvic discomfort pain or delayed menstruation

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146
Q

What are 5 types of ovarian cysts?

A

serous cystadenomas
Mucinous cystadenoma
Endometriomas
dermoid cysts
sex cord stromal tumours (can be benign or malig)

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147
Q

what are serous cystadenomas?

A

benign ovarian tumours of epithelial cells

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148
Q

what are mucinous cystadenomas?

A

benign ovarian tumour of epithelial cells which can grow very large

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149
Q

what are endometriomas?

A

ovarian cysts made of endometrial tissues - patient with endometriosis

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150
Q

what are dermoid cysts?

A

AKA teratomas

come from germs cells - hair, skin, teeth, bones

associated with ovarian torsion

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151
Q

what are sex cord stromal tumours?

A

rare tumours that can be benign or malignant arising from connective tissue or embryonic structures

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152
Q

what is the management of simple ovarian cysts in premenopausal women?

A

<5cm - will almost always resolve in 3 cycles
5-7cm - routine referral to gyne
>7cm - surgical evaluation

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153
Q

what are 2 possible surgical managements of ovarian cysts?

A

ovarian cystectomy
oophorectomy

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154
Q

what is the presentation of ruptured ovarian cysts?

A

Pain - sudden onset severe pelvic pain
Peritonism
Haemodynamic instability
GI symptoms
Urinary symptoms - dysuria, urinary frequency
Fever

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155
Q

What is Meig’s syndrome?

A

ovarian fibroma (benign ovarian tumour)
pleural effusion
Ascites

typically in older women. removal of tumour results in complete resolution of symptoms.

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156
Q

when is ovarian torsion more likely?

A

In pregnancy
with a mass >5cm
before menarche and women of rFeproductive age
fertility treatment - ovarian hyperstimulation

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157
Q

what are 4 features of ovarian torsion?

A

unilateral sudden onset severe pain
nausea and vomiting
palpable mass
localised tenderness

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158
Q

what can be seen on US in ovarian torsion?

A

Whirlpool sign
free fluid in pelvis and oedema of ovary

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159
Q

How is ovarian torsion definitively diagnosed?

A

Laparoscopy

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160
Q

what are 3 STDs that can cause PID?

A

Neisseria gonorrhoea
Chlamydia trachomatis
Mycoplasma genitalium

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161
Q

What are non STDs that can cause PID?

A

Gardenerella vaginalis (associated with BV)
Haemophilus influenzae
Escheriachia coli

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162
Q

what are 6 presentations of PID?

A

pelvic/low abdomen pain
abnormal discharge
abnormal bleeding
dyspareunia
fever
dysuria

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163
Q

what 4 things may be found on a PID examination?

A

pelvic tenderness
cervical motion tenderness
cervicitis
purulent discharge

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164
Q

What are 7 investigations for PID

A

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

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165
Q

what is the management of PID?

A

1 - Stat IM 1g Ceftriaxone + 14 days Doxycycline 100mg BD PO + Metronidazole 400mg BD PO

2 - Ofloxacin PO + Metronidazole PO

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166
Q

What are 6 complications of PID?

A

Sepsis
abscess
infertility
chronic pelvic pain
ectopic pregnancy
Fiz-hugh-curtis syndrome

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167
Q

what is fiz-hugh-curtis syndrome?

A

inflammation and infection of liver (Glisson’s) capsule causing adhesions between liver and peritoneum => RUQ pain

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168
Q

What is the treatment for PID?

A

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

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169
Q

what are 8 non-diagnostic features that may be present in PCOS?

A

insulin resistance and diabetes
acanthosis nigricans
CVD
hypercholesterolaemia
endometrial hyperplasia and cancer
Obstructive sleep apnoea
depression and anxiety
sexual problems

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170
Q

what are 4 hormonal blood tests for PCOS?

A

Raised LH
raised LH to FSH ratio
raised testosterone
Raised insulin
normal or raised oestrogen

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171
Q

What can be seen on USS of PCOS?

A

‘string of pearls’ appearance

> 12 cysts on a single ovary
OR
10cm3 ovarian volume => diagnostic criteria

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172
Q

what test can be used for diabetes in PCOS?

A

Oral glucose tolerance test

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173
Q

what is impaired fasting glucose on OGTT?

A

fasting 6.1-6.9 mmol/L

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174
Q

what is impaired glucose tolerance of OGTT?

A

at 2 hours
glucose 7.8-11.1 mmol/L

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175
Q

what is diabetes in OGTT?

A

Plasma glucose >11.1 at 2 hours

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176
Q

What medication can be given for weight loss that impairs lipid absorption?

A

Orlistat - lipase inhibitor
BMI >30

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177
Q

What can be used to reduce risk of endometrial cancer in people with PCOS?

A

cyclical progesterone or COCP to induce withdrawal bleed
Mirena coil

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178
Q

what are 4 medications that can be used for fertility in PCOS?

A

Clomifene
Laproscopic ovarian drilling
Metformin
Letrozole

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179
Q

what 2 medications can be used to treat hirsutism?

A

co-cyprindiol
topical elfornithine

Specialist - electrolysis, laser removal, spiro, finasteride, flutamide, cyproterone acetate

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180
Q

what is the surgical management of ectopics?

A

laproscopic salpingectomy or salpingotomy

when there is pain, mass >35mm, visible heartbeat or HCG >5000

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181
Q

what medication do you need to give Rhesus -ve women in surgical ectopic removal?

A

anti rhesus D

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182
Q

What counts as a miscarriage?

A

<24 weeks gestation
early <12 weeks
late 12-24 weeks

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183
Q

what is a missed miscarriage?

A

when the foetus is no longer alive but no symptoms have occurred

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184
Q

what is a threatened miscarriage?

A

vaginal bleeding with closed cervix and alive foetus

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185
Q

what is an inevitable miscarriage?

A

vaginal bleeding and open cervix

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186
Q

what is an incomplete miscarriage?

A

retained products of conception remain in uterus after miscarriage

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187
Q

what is a complete miscarriage?

A

a full miscarriage has occurred with no products remaining

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188
Q

what is anembryonic pregnancy?

A

a gestational sac is present but contains no embryo

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189
Q

what are 3 features looked for on ultrasound to confirm pregnancy?

A

mean gestational sac diameter
foetal pole and crown rump length
foetal heart beat

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190
Q

what is the management of a miscarriage <6 weeks?

A

expectant management
Repeat urine pregnancy test after 7-10 days

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191
Q

what is the management for miscarriage >6 weeks?

A

referral to eArly pregnancy assessment unit
USS for location and viability

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192
Q

what is expectant management of miscarriage?

A

repeat urine pregnancy test 3 weeks after bleeding and pain settle to confirm complete miscarriage

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193
Q

what is medical management of miscarriage?

A

Misoprostol (prostaglandin analogue to stimulate cervical ripening and uterine contractions)

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194
Q

what are 4 side effects of misoprostol?

A

heavier bleeding
pain
vomiting
diarrhoea

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195
Q

what is the surgical management of miscarriage?

A

manual vacuum aspiration (LA) <10 weeks
electric vacuum aspiration (GA)
+ misoprostol
+ anti D to -ve women

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196
Q

what is the management of incomplete miscarriage?

A

medical - misoprostol
surgical - evacuation under GA

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197
Q

What are the 2 legal documents for abortion?

A

1967 abortion act
1990 human fertilisation and embryology act

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198
Q

what are the legal requirements for abortion?

A

2 medical practitioners sign to agree abortion is indicated
must be carried out by registered medical practitioner in NHS hospital or approved premise

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199
Q

what are 3 indications for abortion post 24 weeks?

A

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

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200
Q

what 2 medications are used in a medical abortion?

A

mifepristone (anti-progestogen)
misoprostol (prostaglandin analogue) 1-2 days later

Anti-D in rhesus -ve mother if >10 weeks

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201
Q

what are 3 surgical managements of termination of pregnancy?

A

Cervical priming - misoprostal, mifepristone or osmotic dilaters
Vacuum aspiration
Dilation and curettage - between 14-24 weeeks

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202
Q

what is used to confirm successful termination of pregnancy?

A

Urine pregnancy test at 3 weeks post termination

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203
Q

what are 5 complications of abortion?

A

Bleeding
Pain
Infection
Failure of abortion
Damage to cervix or other structures

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204
Q

What is an USS signs of diamniotic dichorionic twins?

A

lambda or ‘twin peak’ sign

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205
Q

what is an USS sign of monochorionic diamniotic twins?

A

T sign

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206
Q

what are 7 risks to the mother with multiple pregnancy?

A

anaemia
polyhydramnious
HTN
malpresentations
spont preterm labour
instrumental delivery/caesarian
PPH

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207
Q

what are 7 risks to the foetuses in multiple pregnancy?

A

Miscarriage
Stillbirth
foetal growth restriction
prematurity
twin-twin transfusion syndrome
twin anaemia polycythaemia sequence
congenital abnormalities

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208
Q

what is twin-twin transfusion syndrome?

A

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

209
Q

what is twin anaemia polycythaemia sequence?

A

similar to twin to twin but less acute
one twin becomes anaemic whilst the other develops polycythaemia

210
Q

whenis the monitoring for anaemia in multiple pregnancy?

A

booking
20 weeks
28 weeks

211
Q

what is the scan monitoring for monochorionic twins?

A

every 2 weeks from 16 weeks

212
Q

what is the scan monitoring for dichorionic twins?

A

every 4 weeks from 16 weeks

213
Q

when is birth planned for monochorionic monoamniotic twins?

A

32-34 weeks
Must be sectioned

214
Q

when is birth planned for monochorionic diamniotic twins?

A

36-37 weeks

215
Q

when is birth planned for dichorionic diamniotic twins?

A

37-38 weeks

216
Q

when is birth planned for triplets?

A

before 35+6 weeks

217
Q

What are 11 things obesity increases risk of in pregnancy?

A

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

218
Q

what causes gestational diabetes?

A

due to insulin resistance and relative glucose intolerance in pregnancy

219
Q

what are 7 risk factors for gestational diabetes?

A

prev. gestational diabetes
prev. macrosomic baby
BMI>30
Ethnic origin

FHx of diabetes (1st degree relative)
Advanced maternal age
PCOS

220
Q

what counts as a macrosomic baby?

A

> 4.5kg (9lb 12oz)

221
Q

what test is use for gestational diabetes?

A

glucose tolerance test between 24-28 weeks

222
Q

what are 3 indications of gestational diabetes?

A

large for date foetus
polyhydramnios
Glu on dipstick

223
Q

what is a normal fasting GTT level?

A

<5.6 mol/L

224
Q

what is the normal 2 hour GTT level?

A

<7.8 mmol/L

225
Q

what is the initial management of gestational diabetes?n (3)

A

1 - diet and exercise
2 - metformin (if not under control after 2 weeks)
3 - Insulin
(fasting >7 mmol/L)

226
Q

what is the fasting glucose target for pregnant women?

A

<5.6 mmol/L

227
Q

what is the 1 and 2 hour post prandial glucose target for pregnant women?

A

1 hour - 7.8mmol/L
2 hours - 6.4 mmol/L

228
Q

when is delivery planned for those with complicated diabetes in pregnancy?

A

between 37-38+6 weeks

229
Q

what is the maximum gestation diabetic women can give birth up to?

A

40+6 weeks

230
Q

when is retinal screening performed for diabetics in pregnancy?

A

at booking and at 28 weeks

231
Q

what is the post-natal management of mothers with gestational diabetes?

A

HbA1c at 13 weeks then annually

232
Q

what is the maternal risk in pre-existing diabetes?

A

miscarriage
pre-eclampsia risk increased
infection - uti, resp, endometrial. andwound
increased c-section rate

233
Q

what are 6 risks to the baby of a diabetic mother?

A

neonatal hypoglycaemia
neonatal jaundice
congenital abnormalities - heart, skeletal, neural tube
shoulder dystocia
polycythaemia
childhood obesity

234
Q

When is a variable rate insulin infusion (sliding scale) started intrapartum?

A

with 2 BMs >7

235
Q

What is the target intrapartum blood glucose level?

A

4-7 mmol/L

236
Q

what is given preconception. to pregnant women. to prevent neural tube defects?

A

Folic acid 400microg till 12 weeks unless there are risk factors for neural tube defects or obesity

237
Q

can ACEI or ARBs be taken in pregnancy?

A

NO
cause oligohydramnios, miscarriage, hypocalvaria (malformation of skull), renal failure in neonate, hypotension in neonate

238
Q

what is the 1st line management of severe hypertension in pregnancy <37 weeks?

A

labetalol (>160 systolic but also for consideration >140)

239
Q

what is the management of gestational hypertension >37 weeks?

A

delivery (+labetalol if >160/110)

240
Q

what is pre-eclampsia?

A

New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of proteinuria
or organ involvement

241
Q

what are 5 high risk factors for pre-eclampsia?

A

pre-existing HTN
Prev. HTN in pregnancy
autoimmune consitions
diabetes
CKD

242
Q

what are 6 moderate risk factors for pre-eclampsia?

A

> 40 years
BMI >35
10+ years since prev. pregnancy
multiples
first pregnancy
FHx of pre-eclampsia

243
Q

what are 8 symptoms of pre-eclapsia?

A

headache
visual disturbance/blurring
nausea and vomiting
upper abdo/epigastric pain
oedema
reduced urine output, proteinuria
brisk reflexes
RUQ/Epigastric pain

244
Q

what is needed for a diagnosis of pre-eclampsia?

A

blood pressure >140/90
+
Proteinuria OR
Organ dysfunction (^creatinine, ^liver enzymes,seizures, thrombocytopenia, haemolytic anaemia) OR
Placental dysfunction (foetal growth restriction or abnormal dopplers)

245
Q

what blood test can be used to test for pre-eclapsia?

A

placental growth factor (between 20-35 weeks)

246
Q

what is the prophylaxis treatment for pre-eclampsia?

A

Aspirin from 12 weeks-birth

women with 1 high risk or 2 moderate risk factors

247
Q

what is the management for gestational hypertension?

A

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

248
Q

How often are scans with pre-eclapsia?

A

every 2 weeks

249
Q

what is the medical management of pre-eclapsia?

A

1st line - labetalol
2nd line - nifedipine
3rd line - methyldopa

250
Q

what can be given in severe pre-eclampsia or eclapsia?

A

IV hydralazine

251
Q

what is the management in labour of pre-eclamptics?

A

IV magnesium sulphate (prevent seizures)
Fluid restriction to avoid fluid overload

252
Q

what is the post delivery management of pre-eclampsia?

A

1st line - enalapril
1st line in black afro or Caribbean people - Nifedipine/amlodipine
3rd line labetolol or atenolol

253
Q

what is HELLP syndorme?

A

complication of pre-eclapsia and eclapsia

Haemolysis
Elevated liver enzymes
Low Platelets

254
Q

what are 8 complications of pre-eclampsia?

A

foetal growth restriction
eclampsia
pulmonary oedema
stroke
placental abruption
CVD
renal failure
still birth

255
Q

what are the levels for anaemia in pregnacy?

A

<110 g/L 1st trimester
<105 g/L 2nd/3rd trimester
<100g/l postpartum

256
Q

why does physiological anaemia occur in pregnancy?

A

blood volume increases naturally in pregnancy to a greater extent than red cell mass

257
Q

what is the management of anaemia in pregnancy?

A

Oral iron - ferrous sulphate 200mg OD
B12 if needed - IM hydroxocobalamin, oral cyanocobalamin
Folic acid - 5mg if deficient

258
Q

what counts as postpartum anaemia?

A

Hb <100 g/l

259
Q

what is the management of postpartum anaemia?

A

<100 g/l - Oral ferrous sulphate
<90 g/l - iron infusion
<70 g/l - blood transfusion

260
Q

What are 12 risk factors for VTE in pregnancy?

A

smoking
Para >3
Age >35
BMI >30
reduced mobility/immobility
Multiples pregnancy
pre-eclampsia
gross varicose veins
FHx of VTE
Thrombophilia
IVF pregnancy

261
Q

what are the guidelines for starting VTE prophylaxis in pregnancy?

A

from 28 weeks with 3 risk factors
from booking with 4+ risk factors

262
Q

what prophylaxis is given for VTE in pregnancy?

A

LMWH - Dalteparin (5000 units)
also enoxiparin or tinzaparin

Given until 6 weeks postnatal

263
Q

what are 5 presentations of DVT?

A

unilateral calf/leg swelling (>3cm difference)
dilated superficial veins
tender calf
oedema
colour changes to leg

264
Q

what are 8 presentations of PE?

A

SOB
cough/haemoptysis
pleuritic chestr pain
hypoxia
tachycardia
tachypnoea
low-grade fever
haemodynamic instability

265
Q

what is the gold standrd investigation for DVT?

A

doppler uss

266
Q

what is the gold standard investigation for PE?

A

CT pulmonary angiogram (CTPA)

267
Q

what are 3 conditions that group b strep infection of the newborn can cause?

A

meningitis
sepsis
pneumonia

268
Q

what increases baby’s risk of GBS infetion from mother?

A

preterm birth
previous baby with GBS
signs of infection during labour
+ urine or GBS swab in pregnancy
ROM >24 hours before birth

269
Q

which antibiotic is used for intrapartum antibiotic prophylaxis in group B strep?

A

IV benzylpenicillin 3g (+1.5g 4 hourly until delivery)

270
Q

which antibiotic is given intrapartum for GBS in women with penicillin allergy?

A

Vamcomycin 1g every 12 hours (in severe beta-lactam allergy)

Cephlasporins can be used in non sever penicillin allergy

271
Q

What test is used for Group B strep in pregnancy?

A

enriched culture medium test at 35-37 weeks

272
Q

what is the treatment for BV in pregnANCY?

A

oral metronidazole 400mg BD 5-7 days
OR
Intravaginal metronidazole gel 0.75% OD 5 days

273
Q

what are the 3 different types of puerperal infection?

A

endometritis (most common)
myometritis
parametritis (supporting tissue around uterus)

274
Q

what are 6 signs of puerperal infection?

A

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

275
Q

what bacteria most commonly causes puerperal infection?

A

Group B strep (or other streps)

276
Q

what are 5 risk factors for puerperal infection?

A

caesarean
many VEs
delay of birth after ROM
retained tissues
meconium in liquor
use of balloon for induction

277
Q

what antibiotics are usually used for puerperal infection?

A

Clindamycin and gentamicin

278
Q

what is the treatment for trichomonas in pregnancy?

A

metronidazole 400-500mg TD 5-7days

CANNOT DO 2g SINGLE DOSE

279
Q

What does UTI in pregnancy increase the risks of ?

A

preterm delivery
posibly - low birth weight, pre-eclampsia

280
Q

what would be seen on a dipstick of someone with a UTI?

A

Nitrites
Leukocytes
?blood

281
Q

what is the management of uti in pregnancy?

A

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

282
Q

how should asymptomatic bacteriuria be treated?

A

managed like UTI due to risk of progression to acute pyelonephritis

283
Q

can nitrofurantoin be used in pregnancy?

A

Yes but NOT IN THIRD TRIMESTER
Risk of neonatal haemolysis

284
Q

Can trimethoprim be used in pregnancy?

A

NOT IN FIST TRIMESTER

folate antagonist => risk of neural tube defects and congenital malformations

285
Q

what 4 things can congenital rubella cause?

A

deafness
congenital cataracts
congenital heart disease
learning disabilities

286
Q

Can pregnancy women get the MMR vaccine?

A

NO - live vaccine

287
Q

what complications can varicella zoster cause in pregnant mothers?

A

varicella pneumonitis
hepatitis
encephalitis

288
Q

what are 5 features of congenital varicella syndrome?

A

foetal growth restriction
microcephaly, hydrocephalus and learning disability
limb hypoplasia
cataracts and eye inflammation

289
Q

what kind of bacteria is listeria?

A

gram pos bacilli

290
Q

what can listeria cause in pregnancy?

A

miscarriage or foetal death
sever neonatal infection

291
Q

what are 6 complications of congenital cytomegalovirus?

A

foetal growth restriction
microcephaly
hearing loss
vision loss
learning disability
seizures

292
Q

where does toxoplasma gondii come from?

A

parasite from cat poo

293
Q

what is the classical triad of congenital toxoplasmosis?

A

intracranial calcification
hydrocephalus
chorioretinitis (eye inflamation)

294
Q

what are the complications of parovirus B19 in pregnancy?

A

miscarriage or foetal death
severe fetal anaemia
hydrops fetalis (foetal heart failure)
maternal pre-eclampsia like syndrome

295
Q

what are 3 signs of congenital zika syndrome?

A

microcephaly
foetal growth restriction
intracranial abnormalities

296
Q

what is the management of varicella zoster exposure in pregnancy?

A

Check maternal varicella antibodies if unsure of status

Oral Acyclovir - take day 7-14 post exposure

historically IV varicella zoster immunoglobulins

297
Q

what is the management of chickenpox in pregnancy?

A

> 20 weeks - oral acyclovir

298
Q

what hormone causes uterine contraction?

A

oxytocin

299
Q

what are 6 risk factors for atonic uterus?

A

primiparity/grand multiparity
Multiples
high BMI
foetal macrosmia
polyhydramnios
uterine fibroids

300
Q

what is oligohydramnios?

A

too little amniotic fluid below the 5th centile

301
Q

what is the aprox average amount of amniotic fluid at term?

A

500ml

302
Q

what are 7 causes of oligohydramnios?

A

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

303
Q

what are 7 causes of polyhydramnios?

A

conditions stopping foetal swallowing
anaemia or foetal hydrops
twin-twin transfusion
maternal DM
maternal lithium ingestion (causes foetal DI)
macrosomia
idopathic (most common)

304
Q

what are 5 complications of polyhydramnios?

A

congenital malformations or abnormalities
increased risk preterm labour
increased risk atony and PPH
increased risk malpresentations
increased risk cord prolapse

305
Q

what are the 3Ps of labour?

A

Power (uterine contractions)
Passenger (size/position/presentation of baby)
Passage (shape/size of pelvis)

306
Q

what is the latent phase of labour?

A

from 0-3cm dilation
irregular contractions

307
Q

is the active phase of labour?

A

4-10cm dilation
Strong regular contractions

308
Q

What is. the second stage of labour?

A

from 10cm to delivery

309
Q

what is the 3rd stage of labour?

A

delivery of baby to delivery of placenta

310
Q

How long should delivery of the placenta take with active management?

A

30 mins

311
Q

how long should delivery of the placenta take without intervention?

A

60 mins

312
Q

what is active management of the 3rd stage of labour?

A

IM oxytocin
Controlled cord traction

313
Q

what are the 3 different types of breech presentation?

A

extended breech
flexed breech
footling breech

314
Q

what are 6 risk factors for malpresentation?

A

multparity
uterine malformations/fibroids
placenta praevia
macrosomia
polyhydramnios
multiples/prematurity

315
Q

what are 5 complications. of malpresentation?

A

foetal head entrapment
premature ROM
birth asphyxia
intracranial haemorrhage
cord prolapsd

316
Q

what are 7 risk factors for uterine rupture?

A

prev c section
prev uterine surgery
increased BMI
High parity
increased age
Induction of labour
use of oxytocin

317
Q

what are 5 signs of uterine rupture?

A

abdo pain
vag bleeding
ceasing of contractions
hypotension
tachycardia
collapse

318
Q

what is. an incomplete uterine rupture?

A

when. the perimetrium remains intact

319
Q

what is classed as premature?

A

<37 weeks

320
Q

what are 2 prophylaxis for preterm labour?

A

vaginal progesterone
cervical cerclage (stitch)

(<25mm on TV USS 16-24 weeks)

321
Q

what 2 proteins can be tested for to check ROM?

A

insulin like growth factor binding protein 2
Placental alpha-microglobin-2

322
Q

what is the management of preterm ROM?

A

prophylactic Erythromycin 250mg QDS for 10 days/until labour

induction of labour from 34 weeks

323
Q

what are 5 management options for preterm labour?

A

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

324
Q

what are 3 signs of magnesium toxicity?

A

reduced resp rate
reduced BP
absent reflexes

325
Q

what is the management for cord prolapse?

A

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

326
Q

what are the 2 causes of foetal hypoxia in cord prolapse?

A

cord compression
arterial vasospasm (cold air)

327
Q

what are 5 risk factors for cord prolapase?

A

Malpresentation - breech, transverse, unstable
Artificial rupture of membranes + induction
Polyhydramnios
PROM

328
Q

what are 5 presentations of cord prolapse?

A

Abnormal foetal heart rate
Foetal bradycardia
Palpable umbilical cord
Supped onset symptoms post rupture of membranes
Patient reported sensation

329
Q

what are 3 neonatal complications of cord prolapse?

A

Hypoxic ischaemic encephalopathy
Intrapartum asphyxia
Neonatal death

330
Q

what are 3 cord prolapse complications for the mother?

A

C-section and associated risks
Emotional trauma
Risk of uterine rupture

331
Q

what are 4 indications for instrumental delivery?

A

failure to progress
foetal distress
maternal exhaustion
control of head position

332
Q

what are 5 risks of instrumental delivery to the mother?

A

PPH
episiotomy/tears
injury to anal sphincter
incontinance of bladder/bowel
nerve injury

333
Q

what 2 nerves can be damaged in instrumental delivery?

A

obturator or femoral

334
Q

what are 5 risks of instrumental delivery to the baby?

A

cephalohaematoma w/ ventouse
facial nerve palsy w/ foreceps
skull fracture
subgaleal haemorrhage
spinal cord injury

335
Q

what is obstructed labour?

A

when a physical blockage prevents childbirth - too small pelvis, too big baby, fibroids, malpresentation

more common in asia and africa

336
Q

what is placenta accreta?

A

where placenta implants into the myometrium but not beyond

337
Q

what is placenta increta?

A

where the placenta attaches deeply into the myometrium

338
Q

what is placenta percreta?

A

when the placenta invades past the myometrium and perimetrium into the abdomen

339
Q

what are 6 risk factors for placenta accreta?

A

prev accreta
prev endometrial curettage
prev c-section
multigravida
increased maternal age
low lying/placenta praevia

340
Q

how does placenta accreta present?

A

Painless PV bleeding in 3rd trimester
antenatal uss
At birth

341
Q

when is a baby with placenta accreta induced?

A

35 to 36+6 weeks
reduce risk of spont labour
given steroids antenatally

342
Q

what are 3 options for placenta accreta management?

A

hysterectomy
uterus preserving surgery
expectant management

343
Q

what are 5 complications of placenta accreta?

A

PPH
DIC
Hysterectomy
Preterm birth
Foetal death

344
Q

what are 4 causes of antepartum haemorrhage?

A

placenta praevia
placental abruption
vasa praevia
placenta accreta

345
Q

what are 3 possible causes of minor pv spotting in pregnancy?

A

cervical ectropian
infection
vaginal abrasion

346
Q

what is the presentation of placenta praevia?

A

Painless vaginal bleeding usually after 30 weeks - often diagnosed on 20-week anomaly scan

347
Q

what are 6 complications of placenta praevia?

A

antepartum haemorrhage
emergency c-section
emergency hysterectomy
maternal anaemia and transfusions
preterm birth and low birth weight
still birth

348
Q

what is classed as a low lying placenta?

A

within 20mm of internal cervical os

349
Q

what is placenta praevia?

A

placenta overlying cervical os

90% resolve spontaneously before becoming symptomatic

350
Q

what are 6 risk factors for placenta praevia?

A

prev c-section
prev placenta previa
IVF
older maternal age
maternal smoking
structural uterine abnormalities

351
Q

what is the management for placenta praevia?

A

Repeat TVUS at 32 and 36 weeks

Corticosteroids 34-35+6 weeks for lung maturity

elective c-section at 36-37 weeks

352
Q

what is the grading for placenta praevia?

A

1 - low lying <20mm to os
2 - marginal - reaches margin of Os but does not cover
3 - partially covers os
4 - complete

353
Q

what are 10 risk factors for placental abruption?

A

prev. placenta abruption
pre-eclampsia
bleeding in early pregnacy
trauma
multiple pregnancy
foetal growth restriction
multigravida
increased maternal age
smoking
cocaine or amphetamine use

354
Q

what is the presentation of placental abruption?

A

sudden onset severe continuous abdo pain
vaginal bleeding
shock
CTG abnormality
woody uterus on palpation

355
Q

what are 3 investigations for placental abruption?

A

US Abdo
CTG - to assess foetus
Bloods - FBC, Coag, LFTs, U+E - Kleihauer test for foetal cells in maternal circulation

356
Q

what is the management of placental abruption?

A

A-E + Resus
Delivery if >37 weeks,
Corticoteroids if 24-34 weeks and stable
Active 3rd stage management
Anti-D immunoglobulin

357
Q

what are 3 maternal and 3 foetal complications of placental abruption?

A

Maternal
- Severe haemorrhage + DIC
- Hysterectomy to control bleeding
- Death

Foetal
- Prem
- Stillbirth
- Low birth weight

358
Q

what is classed as a minor antepartum haemorrhage?

A

<500ml

359
Q

what is classed as a major antepartum haemorrhage?

A

500-1000ml loss

360
Q

what is classed as a massive antepartum haemorrhage?

A

> 1000ml blood loss
OR
signs of shock

361
Q

what is the management of massive antepartum haemorrhage?

A

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

362
Q

what connective tissue in the umbilical cord protects the blood vessels?

A

whartons jelly

363
Q

what are the two types of vasa praevia?

A

1 - foetal vessels exposed as cord inserts into membranes outside placenta
2 - vessels exposed as travel to accessory placental lobe from placenta

364
Q

what are 3 risk factors for vasa praevia?

A

low lying placenta
IVF
multiples

365
Q

what are 3 presentations of vasa praevia?

A

antenatal TV scan
Painless antepartum haemorrhage in 2nd/3rd trimester
bright red blood on ROM in labour or foetal vessals seen on VE

366
Q

how is vasa praevia diagnosed?

A

transvaginal or transabdominal USS

367
Q

what is the management for vasa praevia?

A

corticosteroids from 32 weeks
elective c-section 34-36 weeks

368
Q

what are 5 complications of vasa praevia?

A

Foetal exsanguination
hypoxic ischaemic encephalopathy
preterm labour
IUGR
necessity for c-section

369
Q

what is classed as a minor PPH?

A

500-1000ml

370
Q

what is classed as a major PPH?

A

1000ml+

371
Q

what is a primary PPH?

A

bleeding within 24 hours of birth

372
Q

what is a secondary PPH?

A

24 hours -12 weeks after birth

373
Q

what are the 4 Ts of PPH?

A

tone (atony)
trauma (tears)
tissue (retained placenta)
thrombin (bleedin gdisorder)

374
Q

what are 12 risk factors for PPH?

A

previous PPH
grandmultiparity
obesity
macrosomnia/polyhydramnios
prolonged labour
pre-eclampsia
placenta accreta
placenta praevia
retained placenta
instrumental delivery
pre-existing anaemia
induction

375
Q

what are 4 preventative measures for PPH?

A

Tx anaemia antenatally
give birth with empty bladder
active management of 3rd stage
IV tranexamic acid during section in high risk patients

376
Q

what are 2 mechanical managements of PPH?

A

fundal massage
catheterisation

377
Q

what are 5 medical managements of PPH?

A

IV/IM oxytocin
IV/IM ergometrine (without Hx hypertension)
IM carboprost (without Hx asthma)
Misoprostol sublingual
Tranexamic acid

378
Q

what are 4 surgical managements of PPH?

A

interuterine balloon tamponade
B-lynch suture (braces)
Uterine artery ligation
Hysterectomy

379
Q

what is antepartum haemorrhage?

A

bleeding PV from 24 weeks

380
Q

what does rhesus disease cause in the new born?

A

haemolysis

381
Q

what is the prophylaxis for rhesus disease of the newborn?

A

anti-D IM injection in negative mothers
prevents sensitasation in the mother given at 28 weeks

382
Q

when is anti-d given?

A

28 weeks
Birth (if baby +ve)
sensitisation events

383
Q

what test is used to titrate the dosage of anti-D?

A

Kleinhauer test

384
Q

what does the kleinhauer test check?

A

how much foetal blood has passed into the maternal circulation during a sensitisation event after 20 weeks

385
Q

what is low birth weight?

A

<2500g

386
Q

what is placental insufficiency?

A

when o2 and nutrients cannot sufficiently supplu placenta and foetus due to insufficient spiral arteries

387
Q

what are 6 risk factors for placental insufficiency?

A

Pre-eclampsia/hypertension
smoking, drinking, drugs
Advanced maternal age
primiparity
prev IU growth restriction baby
medications - cancer, antiepileptics

388
Q

what 2 medications can be given for placental insufficiency?

A

aspirin
heparin

389
Q

what is the combined test?

A

11-14 weeks gestation
uss - nuchal translucency >6cm
bloods - bHCG and PAPPA - increased HCG and low PAPPA

Screening for downs

390
Q

what physiological changes in pregnancy are there in relation to maternal fluid retention?

A

Increased total plasma volume (30-50%)
Decreased plasma oncotic pressure

391
Q

How long does the corpus luteum produce progesterone for in pregnancy?

A

10 weeks

392
Q

what are 6 physiological hormonal changes in pregnancy?

A

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

393
Q

what is the change in the size of the uterus in pregnancy?

A

from around 100g to around 1.1kg

394
Q

what hormone allows break down of collagen in the cervix to prepare for effacement?

A

prostaglandins

395
Q

what are 7 physiological cardiac changes in pregnancy?

A

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)

396
Q

what are 2 physiological respiratory changes in pregnancy?

A

increased tidal volume
increased resp rate

397
Q

what are 5 physiological renal changes in pregnancy?

A

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)

398
Q

what are 3 nutrients that are in higher demand in pregnancy?

A

iron
folate
B12

399
Q

what is the first line management of cholestasis of pregnancy?

A

1 - emmolients and antihistamines

2- ursodeoxycholic acid

400
Q

what are 4 risk factors for shoulder dystocia?

A

macrosomia
High maternal BMI
Diabetes
Prolonged labours

401
Q

what is the 1st line management of shoulder dystocia?

A

McRoberts manoeuvre

402
Q

what is the management of one missed COCP?

A

take missed pill even if have to take two in one day

no additional contraceptive needed

403
Q

what is the management if 2+ OCPs are missed?

A

take yesterdays and todays dose then continue taking normally

Use condoms for 7 days

404
Q

what is the management of unprotected sex on OCP with missed pills in week 1?

A

emergency contraception

405
Q

what is the management of unprotected sex on OCP with missed pills in week 2?

A

no need for additional contraception

406
Q

what is the management of unprotected sex on OCP with missed pills in week 3?

A

finish pills in current pack and start new pack immediately no need for pill free interval

407
Q

where is the most common site of ectopic pregnancy?

A

ampulla of fallopian tubes

408
Q

what are 4 risk factors for hyperemesis gravidum?

A

increased levels of beta-hCG - multiple pregnancies, trophoblastic disease
nulliparity
obesity
family or personal history of NVP

409
Q

what is associated with decreased levels of hyperemesis gravidum?

A

smoking

410
Q

what is the triad of hyperemesis gravidum?

A

5% pre-pregnancy weight loss
dehydration
electrolyte imbalance

411
Q

what is the first line management of hyperemesis gravidum?

A

antihistamines: oral cyclizine or promethazine

phenothiazines: oral prochlorperazine or chlorpromazine

412
Q

what is the second line management of hyperemsis gravidum?

A

oral ondasetron
oral metoclopramide or domperidone

413
Q

what complication can ondansetron use in pregnancy cause?

A

cleft lip and palate

414
Q

what are 4 complications of hyperemesis gravidum?

A

acute kidney injury
Wernicke’s encephalopathy
oesophagitis, Mallory-Weiss tear
venous thromboembolism

415
Q

what are 7 features of fibroids?

A

asymptomatic
menorrhagia - may result in iron-deficiency anaemia
bulk-related symptoms
lower abdominal pain: cramping pains, often during menstruation
bloating
urinary symptoms, e.g. frequency, may occur with larger fibroids
subfertility

416
Q

how are fibroids diagnosed?

A

TV USS

417
Q

what is the management of menhorrhagia in fibroids?

A

levonorgestrel intrauterine system (LNG-IUS)
NSAIDs e.g. mefenamic acid
tranexamic acid
combined oral contraceptive pill
oral progestogen
injectable progestogen

418
Q

what is the management to treat fibroids?

A

GnRH analogues
surgery - myomectomy, hysteroscopic endometrial ablation, hysterectomy, uterine artery embolisation

419
Q

what can be a cause of thick green nipple discharge most common in postmenopausal smokers?

A

Mammary duct ectasia

420
Q

what type of contraception can be used in trans men?

A

Progesterone only
non-hormonal

421
Q

How long after UPSI can Levonorgestrel (Levonelle) be taken?

A

72 hours

422
Q

How long after UPSI can Ulipristal (ella one) be taken?

A

120 hours

423
Q

what patients should Ulipristal use be cautioned in?

A

Asthmatics

424
Q

How long after taking Ulipristal do you need to wait to start hormonal contraception?

A

5 days

425
Q

How long after UPSI can the copper IUD be fitted?

A

5 days

426
Q

what is the most common ovarian cyst?

A

follicular cyst - due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle

427
Q

what is the most common benign ovarian tumour in women <30?

A

Dermoid cyst - torsion in more likely

428
Q

what is amniotic fluid embolism?

A

when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.

429
Q

what antibiotics should be avoided in breast feeding?

A

ciprofloxacin, tetracycline, chloramphenicol, sulphonamides

430
Q

what psychiatric drugs should be avoided in breast feeding?

A

lithium, benzodiazepines

431
Q

What are 6 drugs that should be avoided in breast feeding?

A

aspirin
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone

432
Q

what medication can be used to suppress lactation?

A

cabergoline

433
Q

what are 5 risk factors for breech presentation?

A

uterine malformations, fibroids
placenta praevia
polyhydramnios or oligohydramnios
fetal abnormality (e.g. CNS malformation, chromosomal disorders)
prematurity (due to increased incidence earlier in gestation)

434
Q

when should external cephalic version (ECV) be offered in breech presentation?

A

37 weeks (can be 36 in primies)

435
Q

what are 5 reasons for a Cat 1 section?

A

suspected uterine rupture
major placental abruption
cord prolapse
fetal hypoxia
persistent fetal bradycardia

436
Q

how quick should a cat 1 section be?

A

within 30 mis

437
Q

How quick should a cat 2 section be?

A

within 75 mins

438
Q

what is the results of a positive combined test?

A

↑ HCG, ↓ PAPP-A, thickened nuchal translucency => Downs likely

439
Q

what tests are included in the quadruple test?

A

alpha-fetoprotein
unconjugated oestriol
human chorionic gonadotrophin
inhibin A

440
Q

what is the quadruple test result for downs?

A

alpha-fetoprotein - LOW
unconjugated oestriol - LOW
human chorionic gonadotrophin - HIGH
inhibin A - HIGH

441
Q

what is the quadruple test result for edwards?

A

alpha-fetoprotein - LOW
unconjugated oestriol - LOW
human chorionic gonadotrophin - LOW
inhibin A - NORMAL

442
Q

what is the quadruple test result for neural tube defects?

A

alpha-fetoprotein - HIGH
unconjugated oestriol - NORMAL
human chorionic gonadotrophin - NORMAL
inhibin A - NORMAL

443
Q

what is the management of eclampsia in pregancy?

A

IV magnesium sulphate

444
Q

How long should magnesium sulfate continue after delivery in eclampsia?

A

24 hours

445
Q

what is the first line management for mag sulfate induced respiratory depression in eclampsia?

A

calcium gluconate

446
Q

what folic acid supplementation should pregnant women take?

A

400mcg of folic acid until the 12th week of pregnancy

447
Q

What risk factors mean women should take 5mg of folic acid pre-pregnancy?

A

Personal or FHx of neural tube defect
anti-epileptic drugs
coeliac disease, diabetes, or thalassaemia trait
BMI >30 kg/m2

448
Q

what is the diagnostic threshold for gestational diabetes?

A

fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L

5,6,7,8

449
Q

what is the fasting glucose target in pregnancy for those with diabetes?

A

5.3 mmol/L

450
Q

what is the 1 hour post meal glucose target in pregnancy?

A

7.8 mmol/L

451
Q

what is the 2 hour post meal glucose target in pregnancy?

A

6.4 mmol/L

452
Q

what are 6 indications for induction?

A

Overdue >41 weeks
PPROM/PROM
diabetic mother > 38 weeks
pre-eclampsia
obstetric cholestasis
intrauterine fetal death

453
Q

what score is used to assess whether induction of labour is necessary?

A

Bishop score

454
Q

what is the bishop score that indicates need for induction?

A

<5

455
Q

what is the bishop score that indicates no need for induction?

A

> 8 inclusive

456
Q

what is the management of bishop score <6 inclusive?

A

vaginal prostaglandins or oral misoprostol

balloon catheter if higher risk of hyperstimulation or prev c-sections

457
Q

what is the management of bishop score >6?

A

amniotomy and an intravenous oxytocin infusion

458
Q

what is the main complication of induction of labour?

A

uterine hyperstimulation

459
Q

what are 4 complications of PROM?

A

fetal: prematurity, infection, pulmonary hypoplasia
maternal: chorioamnionitis

460
Q

what can be seen on sterile speculum exam in PROM?

A

pooling of amniotic fluid in the posterior vaginal vault

461
Q

How can PROM be tested for if fluid pooling not seen?

A

testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein‑

462
Q

what medication should be given in PROM?

A

Oral erythromycin 10 (TEN) days
Corticosteroids (<34 weeks)

463
Q

What are 8 situations where anti-D should be given ASAP?

A

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

464
Q

what tests should be done on the cord blood of any baby born to Rh -ve mother?

A

FBC
Blood group and save
Direct coombs test

465
Q

what are the 3 stages of postpartum thyroiditis?

A

Thyrotoxicosis
hypothyroid
return to normal

466
Q

what is the management of the thyrotoxic phase of postpartum thyroiditis?

A

propanalol - to treat symptoms

467
Q

what is the management for fibroids <3cm?

A

1 - Mirena coil

symptomatic - tranexamic and mifenamic acid

2 - COCP, cyclical progestogens

Surgical - Endometrial ablation, resection of submucosal fibroids during hysteroscopy, Hysterectomy

468
Q

what is the management of fibroids >3cm?

A

refer to gynae - options as <3cm +

Uterine artery embolisation
Myomectomy
Hysterectomy

+ GnRH analogues to shrink before myomectomy

469
Q

what are 8 complications of fibroids?

A

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%)

470
Q

what is red degeneration of fibroids?

A

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.

471
Q

when should induction be offered in cholestasis of pregnancy?

A

37-38 weeks

472
Q

what are 8 things that increase risk of IUGR?

A

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

473
Q

what are 4 features of congenital syphilis?

A

Generalised lymphadenopathy
Hepatosplenomegaly
Rash
Skeletal malformations

474
Q

what are 4 causes of retrograde ejaculation?

A

Bladder neck surgery
Congenital abnormality
Diabetic autonomic neuropathy
Transurethral resection of the prostate

475
Q

what infectious disease screening is offered in pregnancy?

A

HIV
syphilis
hepatitis B

476
Q

when does the dating scan happen?

A

11+2-14+1 weeks

477
Q

when is the booking visit and what happens?

A

<10 weeks
Ht and Wt
screening offered
BP and urinalysis
risk assessed
vaccines offered

478
Q

when does the anatomy scan occur?

A

18-20+6 weeks

479
Q

when is Anti-D given in normal pregnancy?

A

28 weeks and 34 weeks

480
Q

what are 11 risk factors for small for gestational age baby?

A

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

481
Q

what are 6 foetal surveillance techniques?

A

Symphyseal fundal height Foetal abdominal circumference.
Femur length.
Head circumference / biparietal diameter.
Liquor volume / amniotic fluid index (normal = 5-25cm)
umbilical/MCA artery Doppler

482
Q

what level is raised bile acids in pregnancy?

A

> 19 micromol/L

483
Q

what are 3 analgesias used in labour?

A

Entonox
IM opioids - diamorphine or morphine
Epidural - bupivacaie and fentanyl

484
Q

what counts as delay in the first stage of labour?

A

cervical dilation <2cm in 4 hours

485
Q

what counts as delay in the second stage of labour?

A

nuliparous > 2 hours
multiparous >1 hour

486
Q

what are 6 contraindications to the copper IUD and the IUS?

A
  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
487
Q

at what crown rump length should a foetus have a heart beat?

A

> 7 mm

488
Q

what is the normal positioning of the baby throughout birth?

A

Descent, engagement, flexion, internal rotation, crowning, extension of presenting part, external rotation of head, delivery

489
Q

what is the management of asymptomatic bacteriuria in pregnancy?

A

Confirm presence of bacteriuria with second culture and begin culture dependent antibiotic

490
Q

What counts as polyhydramnious?

A

AFI of >24cm (or 2000ml+)

491
Q

what counts as oligohydramnious?

A

AFI of <5cm (or under 200ml)

492
Q

what are 4 neonatal complications due to anti-epileptic use in pregnancy?

A

Orofacial defects
neural tube defects
congenital heart defects
haemorrhagic disease of the new born

493
Q

what are 6 causes of hydrops fetalis?

A

severe anaemia
cardiac abnormalities
chromsomal abnormalities (turners, downs, edwards, pataus)
Infection (toxoplasmosis, rubella, CMV, varicella, parvovirus)
twin-twin trasnfusion syndrome
chorioangioma

494
Q

what is the Hb monitored in pregnancy?

A

booking and 28 weeks

495
Q

How do you read CTGs?

A

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

496
Q

o

A
497
Q

in what age range is cervical screening every 3 years?

A

25-49 - every 3 years

498
Q

in what age range is cervical screening every 5 years?

A

50-65 - every 5 years

499
Q

what happens if high risk HPV is found on a smear?

A

Cytology is examined

500
Q

what happens if there is inadequate results on a smear?

A

another smear in 3 months

501
Q

what happens if cytology is abnormal in cervical smear?

A

colposcopy

502
Q

what are 5 examples of abnormal cytology on cervical smear?

A

Borderline changes in squamous/endocervical cells
Low-grade dyskaryosis
High grade dyskaryosis
Invasive squamous cell carcinoma
Glandular neoplasia

503
Q

what happens in high risk HPV is positive but cytology normal in cervical smear?

A

Repeat smear in 12 months

504
Q

what happens in 2 inadequate samples in a row in cervical smear?

A

Colposcopy

505
Q

what happens if high risk HPV is +ve but cytology normal two smears in a row?

A

Repeat smear in 12 months

506
Q

what is the management of high risk HPV on 3 smears in a row? (screening, 12 mon recall, another 12 mon recall)

A

Colposcopy

507
Q

what 2 strands of HPV cause most cervical cancer?

A

16 and 18

508
Q

what increases risk of contracting HPV?

A

Ealy sexual activity
Increased number of sexual partners
Unprotected sex

509
Q

How often do women with HIV get cervical screening?

A

Every year

other immunocompromised women may also get increased screening frequency

510
Q

How long post partum should a cervical smear be delayed?

A

3 months

511
Q

What is different about cervical screening in Scotland?

A

every 5 years from 25-65 never every 3 years

512
Q

when is cytology performed in cervical screening?

A

only if +ve for high risk HPV

513
Q

what stains are used in colposcopy?

A

Acetic acid - causes abnormal cells to appear white - acetowhite
Iodine solution - abnormal areas do not stain

514
Q

what is the management of cervical intraepithelial neoplasia found on colposcopy?

A

Large loop excision of the transformation zone - LLETZ

Cone biopsy - under GA

515
Q

what 2 strains of HPV cause genital warts?

A

6 and 11

516
Q

when should patients with CIN return to colposcopy for test of cure?

A

6 months

517
Q

what is the risk of SSRIs in pregnancy?

A

1st trimester - risk of congenital heart defects
3rd trimester - risk of persistent pulmonary hypertension

518
Q

What SSRI has the highest risk of congenital malformations in 1st trimester?

A

Paroxetine

Phase 4 (22 decks)

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