Obs and Gynae Flashcards
What is the definition of a miscarriage?
Loss of intrauterine pregnancy before 24 weeks of gestation
How common is miscarriage?
15-20% of clinically diagnosed pregnancies
Once a foetal heart has been seen, what is the risk of miscarriage?
5%
What is a threatened miscarriage?
Vaginal bleeding at < 24 weeks gestation with proven intrauterine pregnancy and foetal heart
What proportion of women with threatened miscarriage will have a continuing pregnancy?
50%
What is an anembryonic pregnancy? And how is it diagnosed?
Blighted ovum
Fertilised egg attaches to uterine wall but embryo doesn’t develop, cells develop to form the pregnancy sac
Occurs in first trimester
Symptoms of pregnancy due to bHCG levels rising
Diagnosed with USS which shows empty sac of 4cm or above
What is an inevitable miscarriage?
Internal cervical os open in association with bleeding
What is an incomplete miscarriage?
Products of conception remaining in uterus
What is a complete miscarriage?
Uterus empty
What is a delayed or silent miscarriage?
Missed miscarriage
Gestational sac with/without fetus present but no foetal heart
Diagnosis made on scan
What examinations would you perform on a patient presenting with a miscarriage?
ABC (vital signs)
Abdominal
Vaginal (speculum): Cervix state, Amount of bleeding
What would be your acute management of a woman presenting with a miscarriage?
IV access, fluid resuscitation
Determination of blood & Rhesus group
FBC, G&S and crossmatch if heavy bleeding
Syntocinon (oxytocin), misoprostol (PGE1 analogue)
Surgical management
What is an ectopic pregnancy?
Pregnancy implanted outside uterine cavity
What is the most common site for ectopic pregnancy implantation?
Ampulla
What are some risk factors for ectopic pregnancy?
Previous PID Previous ectopic pregnancy Previous tubal surgery (e.g. sterilisation, reversal) Pregnancy in presence of IUCD POP Assisted reproduction Smoking Maternal age >40y
What are acute symptoms of ectopic pregnancy and why do they occur?
Low abdominal pain – peritoneal irritation by blood
Vaginal bleeding – shedding of decidua
Shoulder tip pain – referred from diaphragm
Fainting - hypovolaemia
What are chronic symptoms of ectopic pregnancy?
Asymptomatic
Gastrointestinal symptoms
What are signs of an ectopic pregnancy?
Abdominal tenderness
Adnexal tenderness / mass
Shock – tachycardia, hypotension, pallor
What are possible outcomes of an ectopic pregnancy?
Unlikely to continue beyond few months, exceptional to reach period of viability
Resolve spontaneously
Catastrophic rupture- intraabdominal haemorrhage
How is the diagnosis of ectopic pregnancy made?
History and examination: bleeding, pain
Ultrasound: Empty uterus, adnexal mass, free fluid, occasionally live pregnancy outside of uterus
Serum beta hCG - serial: Slow rising, plateau
Laparoscopy
What is the acute management of ectopic pregnancy?
IV access, FBC, Coag, G&S
IV resuscitation
Surgical: Laparoscopic salpingectomy / salpingotomy. Laparotomy
What is Hyperemesis Gravidarum?
Complication of pregnancy
Severe nausea and vomiting such that weight loss and dehydration occur
Often gets better after 20th week
Elevated beta HCG causes adverse reaction
What are risk factors for hyperemesis gravidarum?
First pregnancy UTI Multiple pregnancy Obesity Prior hyperemesis FH of hyperemesis Trophoblastic disorder: molar pregnancy Hx of eating disorder
What investigations would you do for a patient presenting with hyperemesis gravidarum?
Renal function Liver function FBC Urinalysis and MSU Ultrasound
What are possible consequences of hyperemesis gravidarum?
Dehydration
Electrolyte imbalance: Metabolic alkalosis, hypokalaemia, hypernatremia
Oesophageal tears: Mallory Weiss
Thrombosis: DVT/PE/Cerebral sinus
Weight loss
Vitamin deficiency: vit B1- thiamine, Wernicke’s encephalopathy
Psychological impact
What are management steps for hyperemesis gravidarum?
IV fluids
Antiemetics: cyclizine, metoclopramide, ondansetron
Thromboprophylaxis: clexane
Vitamin supplementation: thiamine
Steroids
Antibiotics if UTI
Termination of pregnancy if so ill that her life at risk
What ovarian cyst accidents can occur?
Cyst haemorrhage Rupture Infection Torsion Occasional- DVT, urine retention
At what size do ovarian cysts need monitoring?
4cm and above
In what type of ovarian cysts do haemorrhages most occur and during what time of the cycle?
Common in follicular or luteal cysts
Usual day 20-28 of cycle
Why do cyst haemorrhages occur?
Vascular nature of the theca intima
What different symptoms can occur from contents of ovarian cyst ruptures?
Blood from cyst wall can cause peritoneal irritaion and stretch the capsule so causes severe pain
Clear fluid contents causes momentary pain which usually settles in 24h
What factors are associated with ovarian torsion?
Reduced venous return as a result of stromal oedema, internal haemorrhage, hyperstimulation or a mass
Ovary and Fallopian tube are typically involved
What are signs and symptoms of ovarian torsion?
Nausea and vomiting Adnexal mass more than 5cm Increased temperature Rigid abdomen Systemically unwell Peripheral vasoconstriction Tachypnoea Acidosis
What is the management for ovarian torsion?
Investigations- FBC, G&S, USS
Conservative- analgesia, Follow up scan in 6 weeks
Surgical- no improvement in 48 hours, unstable, suspicion of torsion. Cystectomy, Detorsion and fixation, Oophorectomy
What is the initial management for acute vaginal bleeding?
IV resuscitation
Correct coagulopathy
TXA- 1g tds for 4 days
Norethisterone 5mg TDS (progestogen)
How do you assess foetal health antenatally?
Low risk pregnancy: Foetal movements: pattern, normal for that individual, Customised growth chart
High risk pregnancy: USS for foetal measurements, Dopplers, Cardiotocograph (CTG)
What Doppler scans can be done to assess foetal wellbeing?
Uterine artery Doppler
Umbilical artery
Middle cerebral artery
Ductus venosus
How often should a customised foetal growth chart be updated?
Fundal height measurements every 2-3 weeks
What ultrasound measurements are taken to assess foetal growth?
Head circumference
Biparietal diameter
Abdominal circumference
Femur length
What is occurring if you see reduced flow in an umbilical artery doppler?
Increased placental vascular resistance, reduces velocity of end-diastolic flow in umbilical cord artery
What does it mean if you see an absent or reversed end diastolic velocity on an umbilical artery Doppler?
Bad news- baby is trying to redistribute limited flow to vital organs
What is Middle cerebral artery peak-systolic flow velocity (MCA-PSV) used to measure?
Detect foetal anaemia
What are ductus venosus Dopplers used to detect and what might it trigger?
May be used as a trigger for delivery of IUGR foetus
Late sign of fetal decompensation
Reflects decreased ability to handle venous return
Predictive of pH<7.2
How is foetal health assessed during labour?
CTG
Foetal blood sampling
Neonatal assessment: Cord blood gases, Apgar scores
What conditions are required for foetal blood sampling to occur?
Cervix has to be open and membranes ruptured
What are possible interpretations of foetal blood sampling and what do these results mean?
Normal: over 7.25
Borderline: 7.21–7.24 in next hour, deliver baby or repeat
Abnormal: less than 7.20 deliver baby by safest fastest route possible
What is an apgar score designed to identify?
Babies which need resuscitation
What are the different categories of apgar scores?
Colour: blue, blue extremities/pink body, no cyanosis
Heart rate: 0, less than 100, over 100
Reflex irritability: no response, grimace, cry
Tone: none, some flexion, flexed arms and legs resist extension
Breathing: absent, irregular gasping, strong
What is a maternal death?
Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by
the pregnancy or its management, but not from accidental or
incidental causes
What is late maternal death?
One which occurs more than six weeks but less than one year after the end of pregnancy
How are maternal deaths divided up by causes?
Direct deaths: obstetric complications of pregnant state (eg amniotic fluid embolism, pre-eclampsia)
Indirect deaths: medical or medical health conditions exacerbated by pregnancy (e.g cardiac disease)
Coincidental deaths, where the cause is unrelated to pregnancy (eg RTA, homicide)
What are current maternal mortality rates in the U.K.?
10 per 100,000
What are the biggest causes of maternal death? Both direct and indirect
Indirect: Cardiac disease, Neurological, Psychiatric
Direct: Thrombosis, Genital Tract sepsis, Haemorrhage
In which age groups are maternal mortality rates highest?
Over age 35 confers increased risk, particularly over 40
In which social groups are maternal death rates highest?
Most deprived, lowest 20%
In which ethnic groups are maternal mortality rates highest?
Indian
African
What are the top 3 causes of VTE in women?
Post partum
Pregnancy
3rd/4th generation contraceptives
What puts women into the high risk category for VTE at an antenatal assessment?
Any previous VTE except a single event related to major surgery
What puts women into the intermediate risk category for VTE at an antenatal assessment?
Hospital admission
Single previous VTE related to major surgery
High risk thrombophilia and no VTE
Medical comorbidites: cancer, heart failure, active SLE, IBD or inflammatory arthropathy, nephrotic syndrome, T1DM with nephropathy, sickle cell, current IVDU
Any surgical procedure
Ovarian hyperstimulation syndrome
What is the recommended management for a woman who is deemed to be high risk of VTE at antenatal assessment?
Antenatal prophylaxis with LMWH
Refer to thrombosis in pregnancy team
What is the recommended management for a woman who is deemed to be intermediate risk of VTE at antenatal assessment?
Consider antenatal prophylaxis with LMWH
What are some lower risk risk factors for VTE in pregnancy?
Obesity Age over 35 Parity of 3 or more Smoker Gross varicose veins Current pre eclampsia Immobility FH of unprovoked or oestrogen provoked VTE in first degree relative Low risk thrombophilia Multiple pregnancy IVF
What is the management if a women is deemed to be low risk of VTE at antenatal assessment?
If four or more risk factors: prophylaxis from first trimester
Three risk factors: prophylaxis from 28 weeks
Less than three risk factors: mobilisation and avoidance of dehydration
What are some transient risk factors for VTE which can occur in pregnancy?
Dehydration/hyperemesis
Systemic infection
Long distance travel
What are some postnatal risk factors for VTE?
Age over 35 Obesity Parity of 3 or more Smoking Elective c section Family Hx of VTE Low risk thrombophilia Gross varicose veins Current systemic infection Immobility Current pre eclampsia Multiple pregnancy Preterm delivery Stillbirth in this pregnancy Mid cavity rotational or operative delivery Prolonged labour over 24h Post partum haemorrhage over 1L or requiring transfusion
What is the management for VTE risk post partum?
2 or more risk factors: at least 10 days post partum prophylactic LMWH
Fewer than 2: early mobilisation and avoidance of dehydration
Which mode of delivery confers the biggest risk of maternal sepsis?
Caesarian section after labour onset
What are possible delays to management of genital tract sepsis post partum?
Delay in identification of the source of infection
When recognised as genital tract – not fully investigated or monitored
Over-reliance on antibiotics to control infection at source
Poor recourse to imaging & repeated imaging – MRI / CT scan
Reluctance to take surgical measures - appropriate drainage of
collections or surgical excision of infected tissue
What are the 4 Ts causes of maternal haemorrhage?
Uterine Tone
Retained placental Tissue
Trauma
Thrombin (clotting disorders)
What monitoring and investigations should be done for a patient with post partum haemorrhage?
2x 14g cannulae FBC, coagulation, U and Es, LFTs Crossmatch ECG, pulse oximetry Foley catheter Hb bedside testing Blood products Consider central/arterial line Commence record chart Weigh all swabs and estimate blood loss
What medical treatment should be done for a patient with post partum haemorrhage?
Bimanual uterine compression Empty bladder Oxytocin 5iu x 2 Ergometrine 500 micrograms Oxytocin infusion 40 u in 500 ml Carboprost 250 micrograms IM every 15 mins up to 8 times Carboprost intramyometrial 0.5mg Misoprostal 1000 micrograms rectally
What procedures should be carried out in theatre for post partum haemorrhage?
Examination of uterus under anaesthesia to see if contracted
Intrauterine balloon tamponade
Brace suture
Consider interventional radiology
Surgery: bilateral uterine artery ligation, bilateral internal iliac ligation, hysterectomy, uterine artery embolisation
Consider ICU
What are the main causes of maternal cardiac death?
MI
Aortic dissection: Marfan’s, Type IV Ehlers-Danlos
Cardiomyopathy
What are recommendations for dealing with maternal cardiac problems?
Thorough history and examination
Phone a friend (the Medical Reg)
Repeat investigations: ECG, Troponin, Early recourse to angioplasty, CXR/MRI/Echo
What post natal lifestyle advice would you offer to a woman with epilepsy?
Take showers not baths
What are some key messages in how to reduce maternal mortality and deal with complex comorbidities?
Pre-pregnancy counselling by doctors with experience of managing their disorder in pregnancy
Coordinated multidisciplinary obstetric and medical clinic, avoiding need to attend multiple appointments and poor communication between senior specialists responsible for care
Individualised care plan made together by members of multidisciplinary team
Appropriately trained senior physicians involved in care of pregnant and post partum women with new onset symptoms or known underlying medical disorders
Morbidly obese pregnant women should be looked after by
specialist multidisciplinary teams
Senior surgical opinion essential when dealing with surgical complications in pregnancy or postpartum and should not be
delayed by team hierarchy. Early discussion between
consultant obstetrician and consultant surgeon is vital
What are signs and symptoms of ectopic pregnancy?
Abdominal or pelvic pain Vaginal bleeding Peritonism Sudden rupture causing severe pain and shock Pain on defecation or urination Amenorrhoea of 4-8 weeks
What beta HCG and USS results make ectopic pregnancy very likely?
Beta HCG >6000 with no intrauterine sac visible on abdo USS
Beta HCG >1500 with no intrauterine sac visible on transvaginal USS
What are likely causes of post menopausal vaginal bleeding?
Atrophic vaginitis
Endometrial dysplasia
Carcinoma
What is cervical ectopy?
Exposure of the endocervix on the ectocervix
Why is cervical ectopy an unlikely cause of post menopausal vaginal bleeding?
Squamocolumnar junction is drawn up into cervical canal following menopause
What is a yttrium-90 implant?
High energy beta emitting isotope which delivers localised radiotherapy
What is the UKMEC scale?
UK medical eligibility criteria for decision of whether to start a woman on the COCP
1: a condition for which there is no restriction for the use of the contraceptive method
2: advantages generally outweigh disadvantages
3: disadvantages generally outweigh advantages
4: represents an unacceptable health risk
What are some examples of UKMEC 3 conditions?
More than 35 years old and smoking less than 15 cigarettes a day
BMI over 35
Family history of thromboembolic disease in first degree relative <45 years old
Controlled hypertension
Immobility
Carrier of known gene mutations association with breast cancer
What are some examples of UKMEC 4 conditions?
More than 35 years old and smoking more than 15 cigarettes a day
Migraine with aura
History of thromboembolic disease or thrombogenic mutation
History of stroke or ischaemic heart disease
Breast feeding <6 weeks post partum
Uncontrolled hypertension
Current breast cancer
Major surgery with prolonged immobilisation
What is Fitz Hugh Curtis syndrome?
Rare complication of pelvic inflammatory disease involving liver capsule inflammation leading to the creation of adhesions
Acute onset RUQ pain aggravated by breathing, coughing, laughing which may refer to right shoulder
A 28 year old woman presents to ED with prior Hx of chlamydia. She has low grade fever and abdo pain worse over the past 6 hours. The pain is in the right upper quadrant and radiates into the shoulder. USS, urine dip and beta HCG are all negative. What is the cause of her symptoms?
Fitz Hugh Curtis syndrome
What is the most common sexual transmitted infection in the UK?
Chlamydia trachomatis
What are features of chlamydia?
Asymptomatic in 70% women, 50% men
Women: cervicitis - discharge, bleeding, dysuria
Men: urethral discharge, dysuria
What are potential complications of chlamydia?
Epididymitits Pelvic inflammatory disease Endometritis Ectopic pregnancy risk Infertility Reactive arthritis Perihepatitis - Fitz Hugh Curtis syndrome
How do you investigate chlamydia?
Nuclear acid amplification test of urine, vulvovaginal swab or cervical swab
Who is eligible for the national chlamydia screening programme?
All men and women aged 15-24
What is the management for chlamydia?
Doxycycline (7 day course) or azithromycin (single dose, 1g stat)
Who needs to be contacted when a diagnosis of chlamydia is made?
Men with urethral symptoms: all contacts since and 4 weeks prior to onset of symptoms
Women and asymptomatic men: all partners from last 6 months or most recent partner
How should identified contacts of confirmed chlamydia cases be treated?
Offer treatment prior to results of investigations being known - treat then test
What is the FIGO staging system?
International federation of gynaecology and obstetrics
Stage 0: carcinoma in situ
Stage 1: confined to organ of origin
Stage 2: invasion of surrounding organs or tissue
Stage 3: spread to distant nodes or tissues in pelvis
Stage 4: distant mets
A 22 year old female who is 24 weeks pregnant presents with frank haematuria. She is sexually active. She has had a previous c section. What is the likely diagnosis?
Placenta percreta - invasive placental implantation into mymetrium which can extend into bladder causing bleeding
What are risks to the mother of chickenpox exposure during pregnancy?
5x greater risk of pneumonitis
What is foetal varicella syndrome?
Exposure of chickenpox to foetus mainly before 20 weeks
Skin scarring, micropthalmia, limb hypoplasia, microcephaly, learning disabilities
When is there a risk of neonatal varicella?
If mother develops rash between 5 days before and 2 days after birth
What should be done if a pregnant mother who has been exposed to chickenpox is shown to be not immune?
Varicella zoster immunoglobulins as soon as possible, effective up to 10 days post exposure
If within 24 hours of onset of rash, oral aciclovir can be used
What is the luteal phase?
Mature ovarian follicle forms corpus luteum which produces progesterone
Lasts around 14 days
Subnuclear intracytoplasmic granules appear in glandular cells in endometrium, they progress to apex and release contents into endometrial cavity - secretory phase
Why can ovarian problems cause thigh pain?
Obturator nerve crosses the floor of the ovarian fossa (lateral pelvic between internal and external iliac vessels)
Referred pain to medial thigh
What is the blood supply to the ovary?
Ovarian artery - branch of the abdominal aorta
What are the most common organisms which can cause a septic miscarriage?
E. coli
Bacteroides
Streptococci
Clostridium perfringens
An Asian woman who is G3P1+1 was admitted with a history of excessive vomiting, vaginal bleeding at 10 weeks gestation and minimal abdominal pain. Abdominal examination indicates a soft uterus, 16 weeks gestation and doughy consistency. An USS shows no foetal parts but a snowy pattern. The beta HCG was higher than the value for 10 weeks gestation. What is the diagnosis?
Hydatiform mole
What is the most common cause of death in pregnancy?
VTE
What are pregnancy related risk factors for VTE?
Maternal age over 35 Obesity Immobilisation Sepsis Caesarian delivery Previous thrombosis Inherited procoagulant conditions - factor V Leiden
Why is hyperemesis gravidarum a recognised risk factor for DVT?
Dehydration and bed rest
How does placenta previa classically present?
Painless bleed, occurring most often at 34 weeks
Baby in transverse lie
During what time frame is post partum thyroiditis most likely to occur?
Within 3 months of delivery
What is the management of post partum thyroiditis?
Symptomatic relief - beta blockers for tremor, anxiety
Observation for development of persistent hypo or hyperthyroidism
How does a uterus feel which has had placental abruption?
Tender
Hard
Difficult to palpate foetal parts
What are the anaesthetic risks to a pregnant women and foetus?
Gravid uterus compresses aorta, IVC and diaphragm
Risk of anaesthetic agent on infant
Risk of aspiration - Mendelsons syndrome
If previous C section, risk of uterine rupture
Epidural anaesthesia - increased rate of use of forceps
How can Mendelsons syndrome be prevented in a pregnant woman undergoing anaesthetic?
Pressure applied posteriorly through cricoid cartilage to occlude oesophagus and reduce risk of regurgitation during induction
Use of antiacid medications prior to surgery
By what amount does pregnancy increase the risk of VTE?
12x
What factors increase the risk of ectopic pregnancy?
Previous tubal surgery
Endometriosis
Damage
Pelvic inflammatory disease
Why are ACE inhibitors absolutely contraindicated in pregnancy?
Teratogenic in first trimester with cardiac, renal and neurological abnormalities, cause oligohydramnios
Fetotoxic in second and third trimester
What problems does warfarin cause if used in pregnancy?
Defective ossification with mid face hypoplasia, saddle nose and cardiac abnormalities
Teratogenic in first trimester
Occasionally used beyond first trimester but with increased risk of foetal cerebral haemorrhage
What problems can anticonvulsant use in pregnancy cause?
Neural tube defects
How can risk be reduced in taking anticonvulsants during pregnancy?
Taking folate supplementation prior to conception
What problems can phenytoin use cause in pregnancy?
Neural tube defects
Foetal hydantoin syndrome - orofacial defects and reduced intelligence
What type of delivery is common with placenta previa?
Caesarean section
Why is external cephalic version contraindicated in placenta previa?
Delivery commonly by Caesarean section so no point
Also increased risk of bleeding
How does placenta previa present?
Painless bleeding
What is a recognised hazard of placenta previa?
Post partum haemorrhage
What is Ashermans syndrome?
Adhesions and fibrosis of endometrium often associated with dilation and curretage of the intrauterine cavity
How much folic acid should women with diabetes take who are planning a pregnancy?
5mg/day
Above what HbA1c level should women be advised to avoid pregnancy?
Above 86
What is the management for gonorrhoea?
IM ceftriaxone stat
Oral azithromycin stat
What is the incubation period for gonorrhoea?
2-5 days
What are features of gonorrhoea?
Males: urethral discharge, dysuria
Females: cervicitis, vaginal discharge
Why is immunisation against gonorrhoea not possible?
Variation of type IV pili (adhere to surfaces) and Opa proteins (bind to receptors or immune cells)
What local complications can occur as a result of gonorrhoea?
Urethral strictures
Epididymitis
Salpingitis
Disseminated infection
What is the most common cause of septic arthritis in young adults?
Gonococcal infection
What are classic symptoms of disseminated gonococcal infection?
Tenosynovitis Migratory polyarthritis Dermatitis Septic arthritis Endocarditis Perihepatitis (fitz-Hugh-Curtis)
What is the management for herpes simplex infection in pregnancy?
Election c section at term if primary attack at greater than 28 weeks
Recurrent herpes should be treated with suppressive therapy and be advised that risk of transmission is low
What level of prolactin is suggestive of a prolactinoma?
Over 1000
When should progesterone be measured in the menstrual cycle to detect ovulation?
21 day progesterone in typical 28 day cycle
In a longer cycle - 35 days, measure at 28 days
Mid luteal phase
When should gonadotrophin levels be measured in a menstrual cycle?
Early follicular phase
What are features of a prolactinoma?
Amenorrhoea
Infertility
Galactorrhoea
Visual field defects
What is a hydatidiform mole? What is the best marker to measure for this?
Abnormal pregnancy from which only placental tissue is generated
10% undergo transformation to malignant trophoblastic disease
HCG levels as this is produced by the placenta
What is red degeneration of a fibroid?
Blood supply to fibroid is compromised leading to pain and uterine tenderness
Why do fibroids lead to large for dates pregnancies?
Fibroids are oestrogen dependent and increase in size in pregnancy
What is the treatment for fibroids?
Bed rest
Analgesia
What are complications of fibroids?
Red degeneration
Malpresentation
Obstructed labour
Post partum haemorrhage
What are some obstetric causes of DIC?
Eclampsia Placental abruption Placenta praevia Severe sepsis Amniotic fluid embolism
When does cervical ectopy occur?
Puberty
Pregnancy
COCP
Oestrogen dominant states
Which marker can be used to detect premature rupture of membranes in equivocal cases?
Alpha fetoprotein
What are options for analgesia in an emergency c section?
Spinal or general anaesthetic
What are analgesia options for a straightforward assisted delivery (ventouse or forceps) at the perineum? What about if it is deep cavity forceps delivery?
Pudendal block and local infiltration of anaesthetic
Deep: spinal required
Which type of delivery is recommended if foetal bradycardia is present and the cervix is fully dilated?
Neville Barnes forceps - rapid
What is the Mauriceau-Smellie-Veit manoeuvre?
Method of breech delivery of the head
What is recommended to help deliver a second twin who is in transverse position with membranes in tact?
Internal podalic version
What is pregnancy induced hypertension?
Blood pressure greater than 140/90 after 20 weeks gestation
Can be transient or pre eclampsia
Who is at risk of developing pre eclampsia and should therefore be prescribed aspirin 75mg OD from 12 weeks until birth of baby?
HTN during previous pregnancy
Chronic kidney disease
Autoimmune disorders such as SLE or antiphospholipid syndrome
Type 1 or 2 diabetes Mellitus
What happens to blood pressure in normal pregnancy?
Blood pressure falls in first trimester and continues to fall until 20-24 weeks
After this time blood pressure increases to pre pregnancy levels by term
How is HTN in pregnancy defined?
Systolic >140
Diastolic >90
Or increase in readings above booking readings of >30 systolic or >15 diastolic
What is the difference between pre existing HTN and pregnancy induced HTN?
Pre existing: Hx HTN before pregnancy or BP >140/90 before 20 weeks
Pregnancy induced HTN: HTN occurring in second half of pregnancy (after 20 weeks) but with no proteinuria or oedema
What are maternal complications of pre eclampsia?
Pulmonary oedema Renal failure Liver failure DIC HELLP syndrome CVA Eclampsia
What are foetal complications of pre eclampsia?
IUGR
Hypoxia
Preterm birth
Placental abruption
What is the drug of choice for treating hypertension in pregnancy?
Labetalol
Methyldopa
Nifedipine
What should be done to reduce the risk of pre eclampsia in a lady who has had it before?
Take aspirin 75mg OD from 12 weeks to the birth of the baby
What does a bishops score calculate?
Predict whether induction of labour will be required
Score of 5 or less suggests labour unlikely to start without induction and a cervical ripening method required
What are indications for induction of labour?
Prolonged pregnancy: >12 days after estimated date of delivery
Prelabour premature rupture of membranes where labour doesn’t start
Diabetic mother >38 weeks
Rhesus incompatibility
What are methods of induction of labour?
Membrane sweep
Intravaginal prostaglandins
Breaking of waters
Oxytocin
What are the components of a bishop score?
Cervical dilation Cervical effacement Cervical consistency Cervical position Foetal station
Why should women with migraine with aura stop taking the COCP?
Oestrogen component increases the risk of ischaemic stroke
Which factors reduce vertical transmission of HIV?
Maternal antiretroviral therapy
Mode of delivery: c section with intrapartum zidovudine
Neonatal antiretroviral therapy
Infant feeding: bottle feed
What is the most appropriate first line investigation for a woman who is of reproductive age who has not conceived after 1 year of unprotected vaginal sexual intercourse in the absence of any known cause of infertility?
Day 21 progesterone - non invasive and can tell you whether they are ovulating
What is HELLP syndrome?
Haemolysis
Elevated Liver enzymes
Low Platelets
Severe form of pre eclampsia
What is management for HELLP syndrome?
Delivery of foetus IV magnesium sulfate for seizure prophylaxis IV dexamethasone Control of BP Replacement of blood products
What are risk factors for pre eclampsia?
>40 years old Nulliparity Multiple pregnancy BMI >30 Diabetes mellitus Pregnancy interval more than 10 years Family history of pre eclampsia Previous history pre eclampsia Pre existing vascular disease - HTN or renal disease
What is sheehans syndrome?
Hypopituitarism caused by ischaemic necrosis due to blood loss and hypovolaemic shock
What are indications for antibiotics in lactational mastitis?
Infected nipple fissure
Symptoms not improving after 12-24 hours despite effective milk removal and/or breast milk positive culture
What is post partum haemorrhage?
Blood loss over 500ml
Primary: within 24 hrs delivery
Secondary: 24 hrs to 12 weeks
What is the most common cause of post partum haemorrhage?
Uterine atony
What are risk factors for post partum haemorrhage?
Previous PPH Prolonged labour Pre eclampsia Increased maternal age Polyhydramnios Emergency C section Placenta praevia Placenta accreta Macrosomia Ritodrine
What is the management of post partum haemorrhage?
ABC
IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
IM carboprost
B lynch suture
Ligation of uterine arteries or internal iliac arteries
Hysterectomy - life saving
Why does secondary post partum haemorrhage occur?
Retained placental tissue or endometritis
What is a normal foetal heart rate?
100-160 bpm
What is a late deceleration on cardiotocography? What does it suggest?
Deceleration of heart rate which lags the onset of a contraction and does not return to normal until after 30 secs following end of contraction
Indicates foetal distress - asphyxia or placental insufficiency
What is variable deceleration on a cardiotocograph? What does it indicate?
Deceleration of heart rate independent of contractions
May indicate cord compression
How long after unprotected sex can levonorgestrel be used for emergency contraception?
Licensed for 72 hours
Can be considered up to 120 hours if other methods are contraindicated
What are options for emergency contraception?
Copper intrauterine contraceptive device
Oral progesterone only contraceptive: levonorgestrel
Selective progesterone receptor modulator: ulupristal acetate
What is early deceleration on a cardiotocograph? What does it indicate?
Deceleration of heart rate which commences with onset of contraction and returns to normal on completion of contraction
Usually innocuous feature and indicates head compression
What does baseline tachycardia on a cardiotocograph suggest?
Maternal pyrexia
Chorioamnionitis
Hypoxia
Prematurity
What are causes of post partum haemorrhage?
4 Ts Tone Tissue (retained placenta) Trauma Thrombin (coagulation abnormality)
What differentiates a major and minor post partum haemorrhage?
Minor - 500-1000ml
Major - over 1000ml
What are causes of premature ovarian failure?
Idiopathic
Chemotherapy
Autoimmune
Radiation
What are side effects of HRT?
Nausea
Breast tenderness
Fluid retention
Weight gain
What are potential complications of HRT?
Breast cancer, especially if with progestogen
Endometrial cancer, reduced by progestogen
VTE, increased with progestogen
Stroke
Ischaemic heart disease if more than 10 years after menopause
What is the pearl index?
Technique used to describe efficacy of a method of contraception
Number of pregnancies that would be seen if 100 woman used that contraceptive method for one year
What is eclampsia?
Development of seizures in association with pre eclampsia
What is the most immediate treatment in eclampsia?
Treat seizure: magnesium sulphate IV bolus 4g over 5-10 mins followed by infusion of 1g/hour
Name some drugs which are contraindicated in breast feeding
Antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides Psychiatric drugs: lithium, benzos Aspirin Carbimazole Sulphonylureas Cytotoxic drugs Amiodarone
What is the dose of folic acid that women who are trying to conceive should take? When should this carry on until? What if there is a previous pregnancy affected by neural tube defects or FH?
400 micrograms per day
Continue until 12th week of pregnancy
If history: 5 milligrams
How long does a woman need to be amenorrhoeic for after menopause before contraception is no longer required?
Over 50: stop after 1 year
Under 50: stop after 2 years
What is the most common adverse effect of the progesterone only pill?
Irregular vaginal bleeding
When should a progesterone only pill be started?
If commenced up to and including day 5, immediate protection otherwise need additional contraceptive for 2 days
If switching from COCP gives immediate protection if continued from previous packet
What is missed pill advice for cerazette?
If >12 hours, take missed pill as soon as possible, continue rest of pack, extra precautions until pill taking re established for 48 hours
How is shoulder dystocia managed?
McRoberts manoeuvre: hyperflex legs and apply suprapubic pressure
If this fails then episiotomy to allow internal manoeuvres: woods screw, grasping and manipulation of the posterior arm
Last resort: symphisiotomy and zavanelli manoeuvre which involves c section
What are some absolute contraindications to the use of the oral contraceptive pill?
Cancer of breast and genitalia End stage liver disease Previous or present VTE hx Cardiac abnormalities Congenital hyperlipidaemia Undiagnosed abnormal uterine bleeding
What are features of uterine fibroids?
May be a asymptomatic Menorrhagia Lower abdo pain Bloating Urinary symptoms: frequency Subfertility
How is a diagnosis of uterine fibroids made?
Transvaginal ultrasound
What is the management of uterine fibroids?
Levonorgestrel releasing intrauterine system
Tranexamic acid
Combined oral contraceptive pill
GnRH agonists
Myomectomy, hysteroscopic endometrial ablation, hysterectomy
Uterine artery embolisation
What are complications of uterine fibroids?
Red degeneration: haemorrhage into tumour, commonly during pregnancy
What are causes of puerperal pyrexia?
Endometritis Urinary tract infection Wound infections: perineal tears, c section Mastitis Venous thromboembolism
What are risk factors for breech presentation?
Uterine malformations Fibroids Placenta praevia Polyhydramnios or oligohydramnios Foetal abnormality: cns malformation, chromosomal disorder Prematurity
What is the management for a breech presentation?
If <36 weeks, many will turn spontaneously
If still breech at 36 weeks: external cephalic version (37 weeks in multip)
If baby still breech, planned c section or vaginal delivery
What needs to be administered after a surgically managed ectopic pregnancy?
Anti D immunoglobulin
In a rhesus negative pregnancy, if rhesus sensitivity occurs, what should be done?
Anti d immunoglobulin
Kleihauer test to determine proportion of foetal RBCs present
In what situations should anti d immunoglobulins be given?
Delivery of a rhesus positive infant Any termination of pregnancy Miscarriage if >12 weeks gestation Ectopic pregnancy if managed surgically External cephalic version Antepartum haemorrhage Amniocentesis, chorionic villus sampling, foetal blood sampling
What is a kleihauer test?
Add acid to maternal blood, foetal cells are resistant
Measure amount of foetal haemoglobin in maternal blood
What are features of rhesus disease in a newborn?
Oedema (hydrops foetalis) Jaundice Anaemia Hepatosplenomegaly Heart failure Kernicterus
Which contraceptive is contraindicated in women who are breastfeeding? Why?
Combined oral contraceptive pill if less than 6 weeks postpartum
Reduce breast milk volume
When can an interuterine system be started post partum?
From 4 weeks postpartum
When can the POP be started post partum?
On or after day 21
What is an absolute contraindication to insertion of a copper IUD?
Pelvic inflammatory disease
What is the gold standard investigation for endometriosis?
Laparoscopy
What are features of endometriosis?
Chronic pelvic pain Dysmenorrhoea Deep dyspareunia Subfertility Urinary symptoms Dyschezia
What drug can be used pre surgery to reduce the size of fibroids?
Gonadotrophin releasing hormone analogue
What is the management of uterine fibroids?
Symptomatic management with levonorgestrel releasing intrauterine system, tranexamic acid, COCP
GnRH agonists to reduce size of fibroid
Surgery: myomectomy, hysteroscopic endometrial ablation, hysterectomy
Uterine artery embolisation
How long until different forms of contraception become effective?
IUD: immediate
POP: 2 days
COCP, injection, implant, IUS: 7 days
Unless taken on first day of period
What is a hyatidiform mole?
Benign tumour of trophoblastic material
Occurs when empty egg is fertilised by single sperm that then duplicates its own DNA
What are features of a hyatidiform mole?
Bleeding in first or early second trimester
Exaggerated symptoms of pregnancy: hyperemesis
Uterus large for dates
High serum beta HCG
HTN
Hyperthyroidism
How is a hyatidiform mole managed?
Urgent referral to specialist centre
Evacuation of uterus
Contraception recommended to avoid pregnancy in 12 months
If a woman is treated for CIN II, after how long should she have further colposcopy?
6 months
What are associations with hyperemesis gravidarum?
Multiple pregnancies Trophoblastic disease Hyperthyroidism Nulliparity Obesity
What is twin to twin transfusion syndrome?
Complication of monochorionic twin pregnancies
Two foetuses share a single placenta meaning blood can flow between the twins
The donor receives lesser share of blood flow than the recipient
What are associated features of monoamniotic monozygotic twins?
Increased spontaneous miscarriage Perinatal mortality Increased malformations IUGR Prematurity Twin to twin transfusions
What are predisposing factors to dizygotic twins?
Previous twins Family history Increasing maternal age Multigravida Induced ovulation In vitro fertilisation Afro Caribbean race
What are antenatal complications of twins?
Polyhydramnios
Pregnancy induced HTN
Anaemia
Antepartum haemorrhage
What are foetal complications of twins?
Prematurity
Light for date babies
Malformation
What are labour complications of twins?
Post partum haemorrhage increased risk
Malpresentation
Cord prolapse, entanglement
How is the management of a lady carrying twins different from that of a normal pregnancy?
Rest
Ultrasound for diagnosis and monthly checks
Additional iron and folate
More antenatal care - weekly after 30 weeks
Precautions at labour - 2 obstetricians present
Induction at 38-40 weeks
What are risk factors for pre eclampsia?
Over 40 years old Nulliparity Multiple pregnancy BMI over 30 Diabetes Mellitus Pregnancy interval more than 10 years Family history Previous history Pre existing vascular disease
What does pre eclampsia predispose to?
Foetal prematurity and IUGR Eclampsia Haemorrhage: placental abruption, intra abdominal, intra cerebral Cardiac failure Multi organ failure
What are features of severe pre eclampsia?
HTN >170/110 and proteinuria >0.3g/24 hours Headache Visual disturbance Papilloedema RUQ/epigastric pain Hyperreflexia Platelet count <100 Abnormal liver enzymes
What is the management of pre eclampsia?
Treat BP >160/110 with oral labetolol, nifedipine and hydralazine
Delivery of baby
What is the next step if a smear result is reported as borderline or mild dyskaryosis?
Original sample is tested for HPV subtypes 16,18 and 33
If negative, go back to routine recall
If positive, refer for colposcopy
What is the next step if a smear result is reported as moderate dyskaryosis?
Consistent with CIN II, refer for colposcopy
What is the next step if a smear result is reported as severe dyskaryosis?
Consistent with CIN III, refer for urgent colposcopy within 2 weeks
What is the next step if a smear result is reported as suspected invasive cancer?
Refer for urgent colposcopy within 2 weeks
What is the next step if a smear result is reported as inadequate?
Repeat smear, if persistent (3 inadequate samples) then assess by colposcopy
Which medication can be used to help with infertility in PCOS?
Clomifene - selective oestrogen receptor modulator
Causes release of gonadotrophin by hypothalamus
What is the most common presenting symptom of a molar pregnancy?
Vaginal bleeding
Why do hyatidiform moles produce large amounts of beta HCG?
Contain large amounts of abnormal chorionic villi
What is HELLP syndrome?
Severe manifestation of pre eclampsia
Haemolysis
Elevated liver enzymes
Low platelets
What is haematocolpos?
Build up of menstrual blood in the vagina
What are causes of primary amenorrhoea?
Turners syndrome
Testicular feminisation
Congenital adrenal hyperplasia
Congenital malformations of genital tract
What is secondary amenorrhoea?
Menstruation has previously occurred but has now stopped for at least 6 months
What are causes of secondary amenorrhoea?
Pregnancy Hypothalamic: stress, excessive exercise PCOS Hyperprolactinaemia Premature ovarian failure Thyrotoxicosis Sheehans syndrome Ashermans syndrome
What initial investigations should be done for amenorrhoea?
Exclude pregnancy with beta HCG Gonadotrophins: low levels indicate hypothalamic cause, raised level suggests ovarian problem Prolactin Androgen levels: raised in PCOS Oestradiol Thyroid function tests
What is amsels criteria for diagnosis of BV?
3 of 4 must be present
Thin, white homogenous discharge
Clue cells on microscopy: stippled vaginal epithelial cells
Vaginal pH >4.5
Positive whiff test: addition of potassium hydroxide gives fishy odour
What is the management of BV?
Oral metronidazole for 5-7 days
What are risks of BV in pregnancy?
Increased risk of preterm labour
Low birth weight
Chorioamnionitis
Late miscarriage
When can the menopause be diagnosed?
12 months after last period in women over 50
24 months after last period in women under 50
What is meigs syndrome?
Ascites
Pleural effusion
Benign ovarian tumour
What are risk factors for placental abruption?
Proteinuric hypertension
Multiparity
Maternal trauma
Increasing maternal age
Which factors need to be addressed when deciding on an appropriate HRT regime?
Is there a uterus or not? - if uterus, combined oestrogen and progesterone
Is the patient perimenopausal or menopausal? - perimenopausal use cyclical
Is a systemic or local effect required? - local effect, vaginal dryness can use creams
What are clinical features of placental abruption?
Shock out of keeping with visible loss Pain constant Tender, tense uterus Normal lie and presentation Foetal heart absent or distressed Coagulation problems
What is the management of hyperemesis gravidarum?
Antihistamines: promethazine
Ginger
P6 wrist acupressure
Admission for IV hydration
What are complications of hyperemesis gravidarum?
Wernickes encephalopathy Mallory Weiss tear Central pontine myelinosis Acute tubular necrosis Foetal: small for gestational age, pre term birth
What is sheehans syndrome?
Complication of severe post partum haemorrhage in which pituitary undergoes ischaemic necrosis which can manifest as hypopituitarism - lack of post partum milk production and amenorrhoea
When should metformin be used to help with fertility in cases of PCOS?
If woman is unable to lose weight or still unable to conceive in spite of losing weight
When should anti d be given to women who are rhesus negative during pregnancy?
At 28 and 34 weeks
What does a bishop score assess?
Need for induction
Cervical position, consistency, effacement and dilatation, foetal station
Score less than 5 indicates induction will be necessary
Score above 9 labour will likely occur spontaneously
What are adverse effects of tamoxifen?
Menstrual disturbance: bleeding, amenorrhoea
Hot flushes
VTE
Endometrial cancer
What is a galactocele?
Occlusion of a lactiferous duct in women who have recently stopped breastfeeding
Milk build up creates cystic lesion in breast
What features suggest placenta praevia?
Vaginal bleeding after 20 weeks gestation
Painless bleeding
High presenting part
Abnormal foetal lie
Which features warrant continuous CTG monitoring during labour?
Suspected chorioamnionitis or sepsis or temp above 38
Severe HTN 160/110
Oxytocin use
Presence of significant meconium
Fresh vaginal bleeding that develops in labour
What are causes of post partum haemorrhage?
Tone
Tissue
Trauma
Thrombin
What is the management of uterine atony causing post partum haemorrhage?
Bimanual uterine compression
Foley catheter passed to ensure empty bladder
Bolus IV syntocinon followed by ergometrine, syntocinon infusion and carboprost in turn
Uterine balloon tamponade
Which fluid should be used in major post partum haemorrhage?
Up to 3.5L warmed crystalloid while waiting for blood products
What is missed pill advice for COCP?
If 1 missed: take last pill even if requires 2 on one day, no additional protection required
If 2 missed: take last pill, use condoms or abstain from sex until taken pills for 7 days in a row. If pills missed in week 1 - emergency contraception, if week 3 finish current pack and start new pack next day, omit pill free week
What are symptoms of chorioamnionitis?
Uterine tenderness Foul smelling discharge Fever Tachycardia Neutrophilia Baseline foetal tachycardia
What are the diagnostic criteria for PCOS?
Infrequent or no ovulation
Clinical or biochemical signs of hyperandrogenism or elevated total or free testosterone
Polycystic ovaries on USS or increased ovarian volume
Which hormone abnormalities are present in PCOS?
Disordered LH production
Peripheral insulin resistance
Increased androgen production
What are complications of PCOS?
Obesity Type 2 diabetes Subfertility Miscarriage Endometrial cancer
How does clomifene work to help with fertility in PCOS?
Anti oestrogen
Block oestrogen receptors in hypothalamus and pituitary to increase release of LH and FSH
Given on days 2 to 6 of each cycle to initiate follicular maturation
How is premature ovarian failure defined?
Onset of menopausal symptoms and elevated gonadotrophin levels before age 40
At what point should delivery be considered in a pre eclampsic woman before 34 weeks gestation?
Severe HTN remains refractory to treatment
Maternal or foetal indications develop
What are risk factors for shoulder dystocia?
Foetal macrosomia
High maternal body mass index
Diabetes
Prolonged labour
What does a snow storm appearance on USS scan of the uterus suggest?
Hyatidiform mole
Why are cystic masses seen in the adnexa in a molar pregnancy?
Excessive beta HCG production which stimulates the ovaries resulting in large benign theca lutein cysts
If a woman who is pregnant is called for a routine cervical smear, what should happen?
Wait until 12 weeks post partum
Which drug should be used to treat syphilis in pregnancy?
IM benzathine penicillin G
What is the most important treatment for prevention of neonatal respiratory distress syndrome?
Dexamethasone administered to mother before birth
What are risk factors for surfactant deficient lung disease?
Prematurity Male Diabetic mother Caesarean section Second born of premature twins
What might a chest X-ray of a premature baby show?
Ground glass appearance with indistinct heart border - surfactant deficient lung disease
What is placenta praevia?
Placenta lying wholly or partly over the lower uterine segment
What should be done if a woman has a low lying placenta at her 16-20 week scan?
Rescan at 34 weeks
No need to limit activity or intercourse unless they bleed
If still present at 34 weeks and grade 1/2 then scan every 2 weeks
If high presenting part or abnormal lie at 37 weeks then c section
What is the management of placenta praevia with bleeding?
Admit
Treat shock
Cross match
Final USS at 36-37 weeks to determine method of delivery
C section for grade 3/4 between 37-38 weeks
If grade 1 then vaginal delivery
What is ovarian hyperthecosis?
Presence of luteinised theca cell nests in ovarian stroma
Causes severe hyperandrogenism and virilisation
What are side effects of the medical regimen for termination of pregnancy?
Risk of failure Uterine rupture Incomplete expulsion of products of conception Scarring Uterine infection
What is ovarian hyperstimulation syndrome?
Complication seen in some forms of infertility treatment
Presence of multiple lutenised cysts in ovaries results in high levels of oestrogen and progesterone and VEGF resulting in increased membrane permeability ad loss of fluid from intravascular compartment
Presents with abdominal pain, bloating, n and v, ascites, oliguria, VTE
Which layers are cut through in order to perform a c section?
Skin Superficial fascia Deep fascia Anterior rectus sheath Rectus abdominis Transversalis fascia Extraperitoneal connective tissue Peritoneum Uterus
What are some indications for a c section?
Absolute cephalopelvic disproportion Placenta praevia grade 3/4 Pre eclampsia Post maturity IUGR Foetal distress in labour/prolapsed cord Failure of labour to progress Brow presentation Placental abruption if foetal distress Vaginal infection e.g. Active herpes Cervical cancer
What are serious risks of c section?
Need for emergency hysterectomy Further surgery at later date including curettage for retained tissue Admission to ITU Thromboembolic disease Bladder injury Ureteric injury Death
What are risks to future pregnancies after having a c section?
Uterine rupture
Antepartum stillbirth
Placenta praevia and accreta
What are frequent risks of c section?
Persistent wound and abdominal discomfort
Repeat c section when vaginal delivery attempted in subsequent pregnancy
Readmission to hospital
Haemorrhage
Infection: wound, endometritis, UTI
What are management options for menorrhagia in women who want to try for a baby?
Mefenamic acid 500mg TDS
Tranexamic acid 1g TDS
Both started on first day of period
What are management options for menorrhagia in women who also require contraception?
Intrauterine system - Mirena
COCP
Long acting progestogens
Which treatment for fibroids is recommended if a patient is trying to conceive?
Myomectomy
Why are GnRH agonists not a good treatment option for fibroids in a lady who is trying to conceive?
They turn off the ovaries which causes fibroids to shrink and makes them easier to surgically remove
It therefore inhibits ovulation and means that pregnancy is not possible
What is ulipristal acetate? And what is it used for?
Selective progesterone receptor modulator
Used pre op for women with fibroids to shrink them
What special measures are needed for HIV positive mothers in pregnancy?
Even if viral load low, need cART in early pregnancy to ensure stays low
Viral load measured in 3rd trimester and c section recommend if RNA >1000 copies
Breastfeeding avoided as it increases risk of transmission even if taking cART
Which factors reduce vertical transmission of HIV to a baby?
Maternal antiretroviral therapy
C section
Neonatal antiretroviral therapy
Infant bottle feeding
What are risk factors for cord prolapse?
Prematurity Multiparity Polyhydramnios Twin pregnancy Cephalopelvic disproportion Abnormal presentation: breech, transverse lie Placenta praevia Long umbilical cord High foetal station
How is cord prolapse managed?
Presenting part of foetus pushed back into uterus
Tocolytics can be used
If cord past level of introitus, kept warm and moist but not pushed back inside
Patient goes on all fours until c section
What are the management steps for post partum haemorrhage with uterine atony?
A to E approach Bimanual uterine compression IV oxytocin and/or ergometrine Intramuscular carboprost Intramyometrial carboprost Rectal misoprostol Balloon tamponade
What is pyometra?
Collection of pus in uterus
Occurs with low grade infection
Associated with occlusion of the cervical canal - carcinoma of cervix or endometrium, pelvic radiotherapy
What does active management of the 3rd stage of labour involve?
Uterotonic drugs
Deferred clamping and cutting cord, over 1 minute after delivery but less than 5 mins
Controlled cord traction after signs of placental separation
Which drug is recommended to reduce risk of PPH for active management of third stage of labour?
10 IU oxytocin by IM injection after delivery of anterior shoulder
What are risk factors for breech presentation?
Uterine malformations, fibroids Placenta praevia Polyhydramnios/oligohydramnios Foetal abnormality Prematurity
What is the management for breech presentation?
If <36 weeks: will often turn spontaneously
If still breech at 36 weeks: external cephalic version, 37 weeks if multip
If still breech: c section or vaginal delivery
What are indications for induction of labour?
Prolonged pregnancy >12 days after EDD
Premature rupture membranes
Diabetic mother >38 weeks
Rhesus incompatibility
What are methods of induction of labour?
Membrane sweep
Intravaginal prostaglandins
Breaking of waters
Oxytocin
What is Sheehans syndrome?
Post partum hypopituitarism due to pituitary gland necrosis - blood loss and hypovolaemic shock during and after childbirth
What are complications of preterm prelabour rupture of the membranes?
Foetal: prematurity, infection, pulmonary hypoplasia
Maternal: chorioamnionitis
What is the management of preterm prelabour rupture of the membranes?
Admission Regular observations to ensure chorioamnionitis isn't developing Oral erythromycin for 10 days Antenatal corticosteroids Delivery considered at 34 weeks
What are red flags which would warrant empirical antibiotic therapy (benzylpenicillin and gent) against group B strep infection in a neonate?
Suspected or confirmed infection in another baby in multiple pregnancy
Parenteral antibiotic treatment given to woman for confirmed or suspected invasive bacterial infection at any time during labour or in 24 hours before and after birth
Respiratory distress starting more than 4 hours after birth
Seizures
Need for mechanical ventilation in term baby
Signs of shock
Which is the most appropriate contraception for a woman with breast cancer?
Copper intrauterine device
All hormonal forms are UKMEC 4 - unacceptable risk
What is the management of genital warts?
Multiple non keratinised: topical podophyllum
Solitary keratinised: cryotherapy
How does an implantation bleed present?
Slight painless vaginal bleeding at expected time of menstruation
What does bishops score assess?
Dilatation, length, consistency and position of cervix and station of presenting part - how likely is spontaneous labour
After what time during gestation is a pregnant lady no longer recommended to fly?
36 weeks
How long after delivery can a mother fly?
2-3 days
What are symptoms of pre eclampsia?
Headache
Epigastric pain
Hyperreflexia
Photophobia
What are some causes of an isolated raised AFP in pregnancy?
Foetal abdominal wall defects
Multiple pregnancy
Bleeding in pregnancy
A 40 year old lady at 35 weeks gestation had an intrauterine death. Amniocentesis at 16 weeks showed trisomy 13. USS at 18 weeks showed IUGR with facial clefts, ocular anomalies and polydactyly. What was the underlying malformation?
Patau syndrome
Less than 20% survive first year
An amniocentesis at 18 weeks shows serum AFP 2.5 higher than median and acetylcholinesterase has been detected in the amniotic fluid. What is the defect?
Open neural tube defect: spina bifida, encephalocele or anencephaly
If blood results show low AFP, unconjugated oestriol and hCG what is the likely defect in the foetus?
Edwards syndrome: trisomy 18
IUGR and a single umbilical artery
Which is the most common type of ovarian cyst?
Follicular cyst
What is the most common benign ovarian tumour in women under 30?
Dermoid cyst (teratoma)
What advice should pregnant women be given about the flu vaccine?
Offer it during flu season Oct to Jan
What is the most common type of ovarian cancer?
Serous carcinoma
What is vasa praevia?
Baby’s blood vessels cross or run near internal opening of uterus
At risk of rupture when supporting membranes rupture as unsupported by umbilical cord or placental tissue
What is Mayer rokitansky kuster Hauser syndrome?
Müllerian agenesis
Absence of upper part of vagina, Fallopian tubes and uterus
If late decelerations are detected on a CTG, what needs to be done?
Urgent foetal blood sampling to assess for foetal hypoxia and acidosis
If acidosis, urgent delivery
What are risk factors for placenta accreta?
Previous Caesarian section
Placenta praevia
What is placenta accreta?
Attachment of placenta to myometrium
Due to defective decidua basalis
Placenta doesn’t properly separate during labour
What is a chocolate cyst?
Endometrioid cyst
How long until an intrauterine system can be relied on as a contraception method?
7 days or first day of period
What causes chancroid?
Haemophilus ducreyi
What are features of chancroid?
Painful genital ulcers
Unilateral painful inguinal lymph node enlargement
Ulcers usually have sharply defined, ragged, undermined border
What causes lymphogranuloma venereum?
Chlamydia trachomatis
What is the woodscrew manoeuvre?
Put hand into vagina and attempt to rotate the foetus 180 degrees
What manoeuvres can be attempted in shoulder dystocia?
Mcroberts: hyperflex legs onto abdomen and apply suprapubic pressure
Rubin: press on posterior shoulder
Woodscrew: hand in vagina and attempt to rotate foetus 180 degrees
What is hydrops fetalis?
Abnormal accumulation of fluid in two or more foetal compartments including ascites, pleural effusion, pericardial effusion, skin oedema
What are causes of hydrops fetalis?
Rhesus incompatibility Parvovirus B19 Cytomegalovirus Syphilis Alpha thalassemia Turner syndrome Twin twin transfusion syndrome Maternal hyperthyroidism Noonan syndrome Iron deficiency anaemia Paroxysmal SVT - heart failure
What is the management for primary genital herpes?
Oral aciclovir
If a pregnant woman has been exposed to rubella, what should be done?
Blood serology
If rising IgM antibody titre, indicative of infection
Requires treatment with immunoglobulin
If IgG antibody - previous exposure and immunity
What is polymorphic eruption of pregnancy?
Pruritic condition associated with last trimester
Lesions often appear first in abdominal striae
How is uterine inversion managed?
A to E approach
Johnsons method - slowly pushing uterus upwards towards umbilicus
If this fails, o’Sullivan’s technique - infusion of warm saline into vagina
How does chorioamnionitis present?
Uterine tenderness
Rupture of membranes with foul odour
Maternal signs of infection
How does septic miscarriage present?
Heavy/prolonged bleeding
Cramping
Which viruses cause genital warts?
HPV 6 and 11
Risk of which cancers is reduced by taking the COCP?
Ovarian
Endometrial
Bowel
What is a pearl index?
Measures number of pregnancies that occur for each contraceptive method if used for 100 women for 1 year
Given as perfect use and typical use
What is a LARC and what are the options?
Long acting reversible contraception IUD IUS Depot injection Subdermal implant
What is foetal fibronectin?
Protein released from gestational sac
High level related to early labour
What are the contents of the COCP?
20, 30 or 35ugms of ethinyloestradiol and different progestogens
What are the contents of a contraceptive transdermal patch?
20ugm/day ethinyloestradiol and 150ugm/day norelgestromin
How should a contraceptive transdermal patch be used?
Apply weekly for 3w, then 1w off
What are benefits of the COCP?
Reduces menstrual disorders: functional ovarian cysts by 93%, menorrhagia and irregular bleeding by 50%, dysmenorrhoea by 40%, PMS
Reduces iron deficiency anaemia by 50%
Reduces PID by 50%
Reduces ectopic pregnancy by 90%
Treatment of endometriosis
Reduces risk of ovarian, endometrial and bowel cancer
What are risks of the COCP?
Thrombosis: Depends on oestrogen dose, Depends on type of progestogen. Extra risk if known thrombophilia, severe obesity, BMI > 39, migraine with aura, cancer
Breast Cancer
Cervical cancer
Hepatocellular ca
What are some absolute contraindications to the COCP?
Past or Present Circulatory Disease: Arterial/ venous thrombosis; IHD; Severe risk factors for arterial/venous disease;
atherogenic lipid disorders; prothrombotic abnormalities; conditions predisposing to thrombosis; leg surgery (4w before and 2w after); severe inflamm bowel disorders; migraine with focal aura; TIA; CVA; Pulmonary hypertension; structural heart disease with increased risk thrombosis; amaurosis fugax
Liver Disease: Active disease with abn LFTs; cholestatic jaundice; adenoma/carcinoma; acute porphyrias
Possible Pregnancy
Allergy
Undiagnosed genital tract bleeding
History serious condition affected by sex steroids/ cocp: porphyrias; chorea; COC induced hypertension; pancreatitis sec to high
triglycerides; pemphigoid gestationis; COC- assoc Steven-Johnson syn; trophoblastic disease
Oestrogen – dependent neoplasms: Current ca breast
Past Benign Intracranial Hypertension
What are options for progesterone only contraception?
Progestogen-only Pill (POP) cerazette Emergency Contraception ( Levonelle / EllaOne ) Injectable (Depot-Provera) Intrauterine (Mirena) Subdermal Implant (Nexplanon)
What are advantages of progesterone only pills?
Greater safety ( no oestrogen ) More methods available Greater range of applicability
What are disadvantages of progesterone only contraception?
Variable efficacy
Loss cycle control ( irregular bleeding )
Amenorrhoea
What are absolute contraindications to the POP?
Serious side effect on COC not clearly due only to oestrogen/ on POP;
Liver adenoma; carcinoma; steroid assoc cholestatic jaundice
Current breast cancer
Recent trophoblastic disease
Acute porphyria Allergy
Undiagnosed abnormal genital tract bleeding Pregnancy
What are the different methods of emergency contraception?
Levonelle – 1500ugms levonorgestrel, Within 72 hrs; 95% effective in first 24hrs
EllaOne – 30mgs ulipristal, Within 5 days; More effective than levonelle early on
Copper IUD – incl gynaefix, Most effective
What are indications for emergency contraception?
UPSI: unprotected sexual intercourse
Failed barrier method
Missed pills – 2 in week 1 / 4 mid packet
What are side effects of emergency contraception?
23% nausea
6% vomiting
What are contraindications to emergency contraception?
Allergy
Pregnancy
What are side effects of the depot contraceptive injection?
Acne
Weight gain
Reduced bone density
Slow return to fertility
What are advantages of the copper coil?
Not user dependent
Good efficacy ( failure rate 1% or less p.a. )
Immediately reversible contraceptive
What are disadvantages of the IUD?
Requires insertion and removal
Increased risk infection first 60 days
May precipitate menorrhagia and dysmenorrhoea
What is the hormone component of the IUS? How long does it last?
20 ugms levonorgestrel daily for 5 yrs
Must change after 4 years if used as part of HRT
What are advantages of the IUS?
Failure rate equal to or less than female sterilisation
Control of menorrhagia
May reduce dysmenorrhoea
Protects endometrium
What are disadvantages of IUS?
Some systemic absorption
Persistence of irregular bleeding in some patients
Insertion can be difficult
What are advantages of nexplanon subdermal implant?
Good contraception – failure rate below that of female sterilisation
Preferable mode of LARC for adolescents cf coil
Relatively easy to implant
Immediate return of fertility when removed
What are disadvantages of the nexplanon subdermal implant?
Persistence of irregular bleeding in some patients
Needs to be inserted and removed
Migration of implant
When is female sterilisation an option?
Only if all other methods tried / fully explored in situation where contraception is critical
What are advantages and disadvantages of female sterilisation?
Permanent but no longer the most effective
Can be reversed but no guarantee
Lifelong failure rate 5/1000 (10x failure of vasectomy)
Requires invasive procedure
Hysteroscopic method becoming available
What is the average age of menopause?
51 years
What are symptoms of menopause?
Anxiety and depression; panic attacks; palpitations; concentration problems; fatigue; poor memory; mood swings; sleep disturbance; stress
Dry skin and hair; brittle nails; itching; hair loss; dry mouth; dry eyes
Night sweats and hot ‘’flashes’’
Vaginal dryness; increase frequency uti; weak bladder; reduced libido
Nausea; bloating; bowel problems
Pain: headaches; dysmenorrhoea; breast pain; joint pain
Weight gain
Dizziness
Why do menopausal women get hot flushes?
Thermoneutral zone above which we sweat and a range of temperatures of the immediate environment in which a standard healthy adult can maintain normal body temperature without needing to use energy above and beyond normal basal metabolic rate;
above – we sweat; below – we shiver
In menopause: narrow thermoneutral zone, small fluctuations in core body temperature cause hot flushes due to decline in oestrogen
Oestrogen modulators e.g. Tamoxifen
What factors can widen the thermoneutral zone?
Norepinephrine: SNRI e.g. venlafaxine
Oestrogen
Certain antidepressants: SSRI’s
What are indications for HRT?
Treatment of menopausal symptoms where risk-benefit ratio is favourable, in fully informed women, in lowest possible dose to control symptoms and for shortest duration possible
Women with early menopause (<45 years) until age of natural menopause (taken as 51 years) for bone protection
HRT should only be used for the prevention of osteoporosis in
women unable to use other medicines licensed for this use
What are contraindications for HRT?
Oestrogen sensitive tumours Breast cancer VTE / known thrombophilia Stroke Myocardial infarction Other cancers: Ovarian, endometrial
What are benefits of HRT?
Symptom control
Quality of life
Decreased risk of osteoporosis
Decreased risk of colon cancer
In which patients would the risk of HRT be deemed too great?
AGE OVER 70
PAST HISTORY: HEART DISEASE and STROKE
What are non HRT alternatives to treat vasomotor symptoms in a menopausal woman?
SSRI /SSNRI (fluoxetine, paroxetine, venlafaxine)
Clonidine
Gabapentin
Other medications: red clover, black cohosh, sage
Diet: soya
Lifestyle: weight loss, alcohol
What are non HRT alternatives for bone protection in a menopausal woman?
Vitamin D and calcium
Bisphosphonates
Receptor modulators e.g. Prolia
What are non HRT alternatives to treat urogenital atrophy in a menopausal woman?
Topical oestrogen e.g. Ovestin, Vagifem, Orthogynest
What non HRT alternatives can be used to treat dyspareunia in a menopausal woman?
Vaginal moisturisers e.g. Replens, Sylk
Lubricants e.g. KY jelly
What is the function of progestogens in HRT?
Protect the endometrium
Which progestogen HRT combination has the lowest association of endometrial hyperplasia / cancer?
Continuous combined
What are differences between sequential and continuous combined HRT?
14 days every month or every 3 months (sequential)
Continuous combined has the lowest association of endometrial hyperplasia / cancer
Bleed-free (continuous) vs withdrawal bleeds (sequential)
Sequential preparations can be monthly or three monthly bleeds
What are advantages of transdermal route of HRT?
Avoids gastric / liver
Less side effects
Less impact on clotting factors (patches, gels, vaginal rings)
What reviews need to be done for women on HRT?
3m – check bp
Yearly – bp and re discuss risks
NB: CARE with mirena use…4 years only
Which position minimises aortocaval compression during anaesthesia in pregnancy?
Left lateral tilt (15 degrees)
What is mandelsons syndrome? How is it avoided?
Chemical pneumonitis caused by aspiration during anaesthesia especially during pregnancy
Avoided by cricoid pressure applied posteriorly through the cricoid cartilage during induction
What is the second stage of labour? When is it active?
From full dilatation to delivery of the foetus
Active when voluntary pushing
How long after delivery of the head should the body be delivered?
Within 3 mins
How many times should a woman have antenatal visits in the first and subsequent pregnancies if they are uncomplicated?
First: 10 visits
Subsequent: 7 visits
What methods can be used to induce labour?
Membrane sweep
Vaginal prostaglandin gel
What bishops score would indicate that labour is unlikely to start without induction?
<5
What are components of a bishop score?
Cervical position Cervical consistency Cervical effacement Cervical dilation Foetal station
When does the booking visit occur in pregnancy?
8-12 weeks
Ideally <10
What bloods/urine tests are done at the booking visit during pregnancy?
FBC Blood group Rhesus Red cell alloantibodies Haemoglobinopathies Hepatitis B Syphilis Rubella HIV (offered) Urine culture for asymptomatic bacteriuria
When should the dating scan happen in pregnancy?
10-13+6 weeks
When should Down’s syndrome screening occur in pregnancy?
11-13+6 weeks
When should the foetal anomaly scan happen during pregnancy?
18-20+6 weeks
In which patients is cyclical HRT most appropriate?
In those who have had a period in the last 12 months
Or in those with premature menopause (under 40) who have had a period in last 2 years
When is the first dose of anti D prophylaxis given to rhesus negative women in pregnancy?
28 weeks
How long should the second stage of labour take?
Primigravida: within 2 hours of diagnosis of second stage
Multigravida: 60 mins
Extra hour is allowed in cases with epidural anaesthesia
What are causes of decreased variability of foetal heart rate on CTG during labour?
Baby is asleep Maternal drugs: benzos, opioids, methyldopa Foetal acidosis (hypoxia) Prematurity: less than 28 weeks Foetal tachycardia >140bpm Congenital heart abnormalities
What is the first line investigation for endometrial cancer? What result is reassuring?
Trans vaginal ultrasound
Normal endometrial thickness <4cm has a high negative predictive value
What features of mastoiditis would warrant antibiotic prescription?
Infected nipple fissure
Symptoms don’t improve or are worsening after 12-24 hours despite effective milk removal
Bacterial culture positive
What is the pearl index a measure of?
Contraceptive efficacy
High number, high risk of pregnancy
What are the different types of breech presentation?
Frank breech
Complete breech
Footling breech
What are causes of oligohydramnios?
PROM Foetal renal problems IUGR Post term gestation Pre eclampsia
How does clomiphene induce ovulation?
Anti oestrogen
Inhibits oestrogen binding in anterior pituitary preventing negative feedback
Results in increased LH and FSH causing induction of ovulation
What is the most common cause of infertility in females presenting to fertility clinic?
PCOS
What is the most common cause of hyperprolactinaemia and amenorrhoea?
Pregnancy
What are some potential rhesus d sensitising events in pregnancy in a rhesus negative mother?
Ectopic
Evacuation of retained products of conception and molar pregnancy
Vaginal bleeding <12 weeks if painful, heavy or persistent
Vaginal bleeding >12 weeks
Chorionic villus sampling and amniocentesis
Antepartum haemorrhage
Abdominal trauma
External cephalic version
Intra uterine death
Post delivery if baby is RhD positive
Which methods of contraception should be discontinued after age 50?
COCP
Depo provera
What are associations with hyperemesis gravidarum?
Multiple pregnancies Trophoblastic disease Hyperthyroidism Nulliparity Obesity
What is management of hyperemesis gravidarum?
Antihistamine: promethazine first line
Ginger and P6 wrist acupressure
Admission for IV hydration if ketotic
What are complications of hyperemesis gravidarum?
Wernickes encephalopathy Mallory Weiss tear Central pontine myelinolysis Acute tubular necrosis Foetal: small for gestational age, pre term birth
What factor changes make pregnancy a hypercoagulable state?
Increase: factor V, VII, VIII, IX, X, XII, fibrinogen, plasminogen
Decrease: XI, protein S
What is adenomyosis?
Abnormal presence of endometrial tissue within the myometrium
Present with dysmenorrhea and menorrhagia, deep dysparurina
What are management steps for obstetric cholestasis?
Induction of labour at 37 weeks
Ursodeoxycholic acid
Vitamin k supplementation
Antihistamines and topical menthol emollient for symptomatic relief
What are options for treating an ectopic pregnancy?
If small (<35mm), unruptured, no heartbeat, bHCG <1500, no intrauterine pregnancy, no pain - methotrexate If large, pain, bHCG >1500 - laparoscopic salpingectomy
What are major and absolute contraindications to depo provera?
Pregnancy Undiagnosed vaginal bleeding Decompensated cirrhosis Primary liver malignancy Multiple CV risk factors HTN with vascular disease Stroke Lupus with positive anti phospholipid antibodies Current ischaemic heart disease Breast cancer in last 5 years Thromboembolic disorders Known sensitivity to MPA Recent trophoblastic disease
What should be given to a pregnant lady who is non immune to varicella zoster and has been exposed to chickenpox?
Varicella zoster immunoglobulin given within 10 days of exposure
What is the first line management of post partum haemorrhage?
5U of IV syntocinon (oxytocin) followed by 0.5mg ergometrine
What is pre eclampsia?
HTN >140/90
Proteinuria: PCR >30, >0.3g/24hr
Oedema
After 20 weeks gestation
What are risk factors for development of pre eclampsia?
Previous Hx pre eclampsia Multiple pregnancy Hx HTN, diabetes, CKD Primip New paternity Pregnancy interval: less than 2 years or more than 10 years Obesity Over 40 or under 18 FHx pre eclampsia PCOS Lupus IVF
What are signs and symptoms of severe pre eclampsia?
Headache Peripheral oedema Visual disturbance Hyperreflexia Clonus Epigastric pain
Which antihypertensive drugs can safely be used in pregnancy?
Labetalol
Hydralazine
Methyldopa
Nifedipine
What are risk factors for neonatal GBS infection?
Prematurity
PROM
Previous sibling GBS infection
Maternal pyrexia eg secondary to chorioamnionitis
What should be given to a lady having an eclamptic seizure? What needs to be checked to monitor toxicity?
Magnesium sulphate IV
Check reflexes
What is HELLP syndrome?
Haemolysis
Elevated LFTs
Low platelets
Complication of eclampsia
What should be given to reduce risk of pre eclampsia in a patient with risk factors?
Aspirin 75mg OD from 12 weeks to delivery
What is the most common cause of primary post partum haemorrhage?
Uterine atony
Which women are at high risk of HTN disorders in pregnancy? What should be given prophylactically to reduce the risk?
HTN during previous pregnancy
CKD
Autoimmune disease: SLE, antiphospholipid syndrome
Type 1 or 2 diabetes
Chronic HTN
Low dose aspirin from 12/40 until birth of baby
Which women are at moderate risk of HTN disorders in pregnancy?
First pregnancy Age 40 or older Pregnancy interval of more than 10 years BMI 35 or more at first visit Family history of pre eclampsia Multiple pregnancy
What are management options for menorrhagia?
Does not need contraception: mefenamic acid 500mg tds (particularly if also dysmenorrhoea) or tranexamic acid 1g tds both started on first day of period
Needs contracpetion: IUS mirena first line, COCP, long acting progestogens
Norethisterone 5mg tds can be used short term to rapidly stop menstruation
What are complications of preeclampsia?
IUGR Preterm birth Placental abruption HELLP syndrome Eclampsia: seizures Organ damage DIC Stroke CV disease
How long should a patient on methotrexate wait before trying to conceive?
For at least 3 months after stopping treatment in both men and women
What are treatment options for twin to twin transfusion syndrome?
Indomethacin to reduce foetal urine output
Laser obliteration of placental vascular communications
Selective foetal reduction
Donor: blood transfusion after birth
Recipient: exchange transfusions/ heart failure medications
When should ECV be offered to women pregnant with breech babies?
36 weeks in nulliparous
37 weeks in multiparous
What is the pathophysiology of pre eclampsia?
Insufficient placentation
Failure of spiral arteries to dilate leads to decreased flow and increased resistance
Release of pro inflammatory proteins which cause vascular hyperpermeability and damage
Vasoconstriction to try to increase flow
Activation of RAAS leads to HTN
How regularly should monitoring occur during normal labour?
Intermittent auscultation immediately after contraction for at least 1 minute and at least every 15 mins
Pulse every 15 mins
Contraction monitoring every 15 mins: strength and duration (3/4 per 10 mins lasting <1 min each)
Which patients need an OGTT screen in pregnancy?
BMI over 30
Previous macrosomic baby weighing 4.5 kg or above
Previous gestational diabetes
Family history of diabetes (first-degree relative with diabetes)
Minority ethnic family origin with a high prevalence of diabetes - Asian, afrocarribean
What are values for haemoglobin which define anaemia in pregnancy?
First trimester: less than 110
Second/third trimester: less than 105
Post partum: less than 100
What are contraindications to a vaginal birth after Caesarean section?
Previous classical Caesarean scars
Previous episodes of uterine rupture
Other contraindications to vaginal birth: placenta praevia
Within what time frame should VZIG be given after a pregnant woman is exposed to chickenpox if they are non immune?
Within 10 days of exposure
What are treatments for genital warts?
Multiple non keratinised warts: topical podohyllum
Solitary keratinised: cryotherapy
How much should beta HCG rise in early pregnancy?
By at least 60% in first 48h and double in 72 hours
What triad of symptoms needs to be present for a diagnosis of hyperemesis gravidarum can be made?
5% pre pregnancy weight loss
Dehydration
Electrolyte imbalance
A healthy woman who is 3 weeks postpartum and breastfeeding seeks contraception. She would like to have another child in one year. Which is the preferred method of contraception?
Progesterone only contraceptive: POP or depo
A 32 yr old woman attends for a repeat prescription of her
ethinylestradiol/norgestimate (Cilest) pill. She complains of nausea and headaches since starting her oral contraceptive 5 months ago. What do you recommend?
Switch to another COCP with less oestrogen
A 33 yr old non-obese woman wants to discuss contraceptive options. She is married with 2 children and does not wish to have any more children. Her medical history includes hypertension and migraines with aura. She does not want a coil. Which is the best approach for hormonal contraception for her?
Implanon
An 18 yr old woman with a seizure disorder seeks contraception to start today. She is taking carbamazepine. Which contraceptive method would be most appropriate?
Depo-medroxyprogesterone acetate
A 23yr old frantic woman attends the pharmacy for advice. She had sexual intercourse last night and her partners condom broke. She states she has a medical history of Type 2 DM and hypothyroidism. What should she be advised?
Buy levonorgestrel-containing emergency contraception
What percentage of breastfeeding women will fall pregnant in the first 6 months if no other form of contraception is used?
2%
A 27yr old woman started on low dose COCP (containing 20mcg ethinyl estradiol) 2 mths ago. She went away for the weekend and missed 3 doses of medication. It is the 3rd week of her
cycle. What should she do?
Take a tablet as soon as possible, then continue taking daily. Use condoms or abstain from sex until tablets taken for 7 days in a row. Start the next pack immediately, without the usual pill-free week
A 39yr old non-smoking female has a history of migraines with aura. She has 2 children, one conceived with IUD in situ, and has no immediate plans for others. She is obese and weighs 115kg. What contraceptive method would be the best option?
Implanon
The most clinically useful indicator of approaching ovulation is?
LH surge
A 36yr old woman who is fairly non-adherent to medications and has never been on hormonal contraception in the past is seeking to try a contraceptive. She is a smoker. What would be the most appropriate option?
Depo-medroxyprogesterone
A 26yr old woman attends Out of Hours on a Sunday. She has a history of depression, dysmenorrhoea and smoking. She is not currently using hormonal contraception. She and her boyfriend had UPSI 5 days ago. What is the best recommendation?
Ulipristal-containing emergency contraception
What is the median age of menopause?
51
How often should mammography be done after the menopause?
Every 3 years
In cases of premature menopause, HRT therapy is recommended until what age?
51
Which HRT is recommended for women who are experiencing menopausal symptoms but are still having periods?
Cyclical HRT
Roughly what percentage of 80yr old women have an osteoporotic fracture?
40%
What is the definition of the menopause?
No menstrual period for 12 months
What is the most useful test to determine if a woman is peri menopausal?
FSH
Before what age is deemed premature menopause?
40
In which patients with HIV is an elective c section recommended?
At 38 weeks if viral RNA levels >1000 at this time
Which factors reduce vertical transmission of HIV?
Maternal antiretroviral therapy
C section
Neonatal antiretroviral therapy
Bottle feeding
What are causes of increased nuchal translucency on an USS?
Down’s syndrome
Congenital heart defects
Abdominal wall defects
What are causes of hyperechogenic bowel on an USS?
Cystic fibrosis
Down’s syndrome
Cytomegalovirus infection
What is pregnancy induced HTN?
Raised BP after 20 weeks gestation with no proteinuria
140/90 or more
In what circumstance could the onset of preeclampsia occur before 20 weeks gestation?
Hydatidiform mole (triploid pregnancy)
What are the definitions of HTN and proteinuria required to diagnose pre eclampsia?
HYPERTENSION: Diastolic 90mmHg or above on 2 occasions 4-6 hours apart OR 110mmHg or more on one occasion
PROTEINURIA : >300mg/24 hours or PCR >30
What are the different severities of HTN in pregnancy?
Mild: 140-149/90-99
Moderate: 150-159/100-109
Severe: 160 or more/110 or more
What is the incidence of HTN and PET in pregnancy?
10% women have hypertension
5% pregnancies have PET
1-2% pregnancies have severe PET
What are maternal risks of pre eclampsia?
DEATH Blindness Neurological sequelae (haemorrhage/infarction) Fits (Eclampsia) Renal impairment/failure Hepatic failure/rupture Abruption DIC
What are foetal risks of pre eclampsia?
Death
Abruption leading to hypoxia
IUGR: onset PET <28 weeks, >50% babies have IUGR
Hypoxia
Prematurity: PET is cause of >40% iatrogenic preterm deliveries, respiratory complications (RDS), neurodevelopmental complications (learning difficulty/reduced IQ in up to 60%)
What are risk factors for pre eclampsia?
Primiparous First pregnancy with new partner Family history (1 in 3 PET risk if mother had it) Twins/multiples Pregestational Diabetes Previous PET (if severe/ <28 weeks, 50% recurrence) Essential hypertension Renal disease SLE Antiphospholipid syndrome Thrombophilias Age >40 Obesity
What is the pathophysiology of pre eclampsia?
Reduced placental perfusion
Inadequate vascular remodelling at ~16 wks
Relative hypoperfusion causing oxidative stress
Widespread endothelial dysfunction
Systemic disease
Who needs aspirin in pregnancy?
HIGH RISK, women with ANY of: hypertensive disease during a previous pregnancy, chronic kidney disease, autoimmune disease such as systemic lupus erythematosis or antiphospholipid syndrome, type 1 or type 2 diabetes, chronic hypertension
MODERATE RISK, women with >1 of: first pregnancy, age 40 years or older, pregnancy interval of more than 10 years, BMI first visit
of 35 kg/m or more, family history of pre-eclampsia, multiple pregnancy
What dose of aspirin is used for pre eclampsia prophylaxis?
75mg per day aspirin from 12 weeks to delivery
What questions are important to ask a woman who you suspect may be pre eclamptic?
Headache (classically severe): Effects of hypertension
Visual disturbances, ‘flashing lights’: Sign of cerebral vasospasm/impending eclampsia
Epigastric pain: Hepatic congestion/liver capsule stretching
Is baby moving normally? Fetal wellbeing
What maternal investigations should be done for pre eclampsia?
FBC: platelet count, Platelets <100 indicate progressive/worsening disease
U+E: signs renal dysfunction (late)
Urate: hyperuricaemia (early, doesn’t predict outcomes well)
LFTs: elevated transaminases, Can indicate worsening of disease
Clotting: not routinely if plts>100
URINARY: MSU to exclude UTI as cause of protein, PCR to quantify proteinuria
What foetal assessment needs to be done in a woman presenting with pre eclampsia?
Clinical
USS for growth
CTGs
Cervical assessment –vaginal examination, depending on gestation
What monitoring needs to be done for mild pre eclampsia?
Monitor BP: community midwife, Day assessment or Triage Unit (outpatient management)
Monitor bloods: Weekly or twice weekly (depends on situation)
Monitor fetus: CTG, Serial USS
What is the definitive treatment for pre eclampsia?
Deliver when:
BP/protein or clinical condition deteriorates so become moderate or severe PET
Reaches 41 weeks and no change in condition
Foetal condition mandates delivery even if maternal condition stable
What monitoring needs to be done for moderate pre eclampsia?
Monitor BP: Admit initially-4 hourly BP, Consider antihypertensives if <36 weeks to prolong pregnancy. If 36 weeks or greater ?delivery
Monitor bloods: Check on admission, Check 2-3x weekly (if wish to prolong pregnancy)
Monitor foetus: CTG, Serial USS (Dopplers)
What is the definitive treatment for moderate pre eclampsia?
Deliver when:
Reaches 36-37 weeks or diagnosis after this gestation
Foetal condition mandates delivery even if maternal condition stable and below this gestation
What is severe pre eclampsia?
SYSTOLIC 160-180+ DIASTOLIC >110 - Severe hypertension
HEAVY PROTEINURIA
May present unwell or asymptomatic
What might be some signs of severe pre eclampsia?
CNS: Disorientation/ irritability, Hyperreflexia, FITS, Clonus, Blindness, Scotoma, Papilloedema
Hepatic: Abnormal LFTs/dysfunction, Epigastric tenderness
Renal: Elevated creatnine, urea, urate, Oliguria, Heavy proteinuria >5g in 24 hrs
Haemtological: thrombocytopenia, Haemolysis
Pulmonary: Shortness of breath
Where should severe pre eclampsia be managed?
Immediate admission to hospital
High dependency care
Invasive monitoring (arterial line +/- CVP)
NICU for baby if early gestation
Senior multidisciplinary involvement early-obs and anaesthetics
What are the aims of treatment in severe pre eclampsia?
Prevent seizures Control hypertension (to prevent cerebral haemorrhage) Deliver safely (stabilise, +/- Intrauterine transfusion +/- steroids)
What maternal assessment is required for a patient with severe pre eclampsia?
BP- every 15 minutes [MEOWS]
Urine output-hourly
Urinary protein dipstix
Strict fluid balance chart: Restrict 60-80ml/hr
Bloods: U+E, urea, creatinine, urate, FBC esp. platelets, G+S, LFTs
Deep tendon reflexes and presence of clonus
CTG
Which antihypertensives can be used to try and control BP in severe pre eclampsia?
IV hydralazine (5mg every 15 minutes to acutely control BP)
IV labetolol (Not good if asthmatic or already signs of pulmonary oedema-first line in many places now)
Oral nifedipine 10mg NOT SUBLINGUAL
Methyldopa TOO SLOW ONSET (24-48 hours) for use in acute situation
Aim for diastolic 80-99, systolic <150
Who needs antihypertensive therapy in pregnancy?
Systolic blood pressure of 160 mm/Hg or more = anti-hypertensive treatment (irrespective of diastolic)
What management is required to prevent fits in moderate/severe pre eclampsia?
Magnesium sulphate: All severe and moderate PET, 4g IV over 15 minutes, then infusion 1g/ hour
Monitor reflexes, urine output (>30ml/hr) and respiratory rate (>12/minute)– Slows neuromuscular conduction and decreases CNS irritability
Best anticonvulsant in these circumstances AND IN ECLAMPSIA
No effect on BP
Tell anaesthetist if GA as potentiates effects of muscle relaxants
What features might suggest magnesium toxicity when using mag sulphate for pre eclampsia and how do you treat it?
Levels: Therapeutic 2-4 mmol/l, Warmth, flushing, slurred
speech 3.8-5mmol/l, Loss of patellar reflexes >5 mmol/l, Respiratory depression >6 mmol/l, Respiratory arrest 6.3-7mmol/l, Cardiac arrest, asystole >12 mmol/l
If urine output OK then likely not to accumulate (85% renal excretion)
If urine output falls, reduce dose to 0.5g/hour
If signs toxicity, stop. Antidote = Calcium gluconate 1g IV over 3 minutes
How should baby be delivered in severe pre eclampsia?
If severe PET, should NOT transfer
Ensure SCBU aware if baby premature
Give antenatal steroids if time but usually, if require IV therapy, delivery is indicated once stabilised
If cervix favourable and patient >36 weeks, consider short trial IOL
If cervix unfavourable and/or <36 weeks, deliver by LSCS
Anaesthesia regional vs general: Risk of sharp rise of BP on intubation, This may be obtunded by large dose alfentanyl or
similar, Need experienced and senior anaesthetist to give GA
in these circumstances
Syntometrine should not be given for active management of third stage if mother is hypertensive, or if blood pressure has not been checked
When should fits in pregnancy be considered not eclamptic?
Beware known epileptics: If BP normal, no protein, typical for their type of fit-may be epilepsy BUT any fit must be considered as eclampsia until proven otherwise especially of BP slightly up
Any FOCAL fit is not eclampsia: Consider SOL eg cerebral bleed/infarction due to severe PET, Arrange head CT urgently
What is the treatment for eclampsia?
IV magnesium sulphate-4g loading, then continue infusion at 1g/hr
If recurrent fits or fit already on MgSO4 then further 2g IV bolus/increase infusion to 1.5g/hr
If fits persist: check magnesium levels, contact anaesthetists, consider CT, consider intubation and ventilation
If antenatal, stabilise and deliver baby
What post natal care should be given for eclamptic women?
Watch closely on HDU/LW: every 15 mins BP, SaO2, pulse, resps. Hourly reflexes, urine output, fluid restriction 60-80ml/hr. One to one care
Anticipate possible worsening BP or seizures in first 18-24 hours
Hence MgSO4, may need antihypertensives de novo
Continue MgSO4 for 24 hours and then review. Do not need to taper off MgSO4, just stop
Do not feed within 12 hours as significant risk ileus- sips H2O only until next morning then review for bowel sounds
How should HTN be managed post natally?
Hypertension may persist for some weeks
Switch to oral treatment when feasible: Atenolol, Nifedipine
Polypharmacy may be required to control BP-consult with physicians
Ensure regular BP checks arranged on discharge with review and follow-up by GP, Good communication key
Check BP days 1, 2, 3-5 and 7
If still hypertensive at 6 weeks, refer physicians
What is HELLP syndrome?
Haemolysis Elevated Liver Enzymes Low Platelets
What are risks of essential HTN in pregnancy?
To mum: Worsening of BP, Superimposed pre-eclampsia, Medical over-intervention
To baby: Teratogenesis from certain drugs (eg ACEI), IUGR, Pre-eclampsia, Hypoglycaemia if on labetolol and breastfeeding
What should be done pre pregnancy to optimise a woman who has essential HTN?
If planned, review medications: Take off teratogenic meds e.g. ACEI or similar, Take off diuretics (reduce plasma vol and foetal perfusion)
Optimise diet/ weight loss (if raised BMI)
Stop smoking
Start folic acid
What should be done in early pregnancy for women with essential HTN?
Review meds at booking: Take off any teratogenic meds
Start folic acid
Early booking at hospital for risk review
Dating scan +/- NT (combined) scan
Plan for pregnancy including issues re: obesity, screening for GDM
Low dose aspirin from 12 weeks
What is normal labour?
Spontaneous onset of contractions at term with a normally grown fetus in cephalic presentation progressing to full dilatation with a spontaneous vaginal delivery of a live infant
What things may constitute abnormal labour?
Prolonged rupture of membranes
Prolonged pregnancy with induction of labour
Intra-uterine growth restriction / macrosomia
Abnormal presentation
Failure to progress
Operative vaginal delivery
Retained Placenta
What is PROM?
prelabour rupture of membranes, sometimes referred to as premature rupture of membranes. Can also be used to mean prolonged rupture of membranes
spontaneous rupture of membranes (SROM) at term without the onset of spontaneous contractions
What is PPROM?
preterm prelabour rupture of membranes, ie before 37 weeks
What are risks of prelabour rupture of membranes?
Maternal/neonatal infection
Prolapsed cord
What are next step options for PROM?
Immediate induction of labour Expectant management (should not exceed 96 hours)
What are risks of prolonged pregnancy?
Stillbirth
Meconium liquor / aspiration
What methods are used to induce labour?
Prostaglandins – ripen cervix and prime uterus for contractions
Artificial rupture of membranes
Syntocinon infusion
At what rate should active stage of labour progress?
0.5 -1.0 cm / hr cervical dilation
What are the latent and active phases of labour?
Latent phase of labour: effacement + 0-3cm dilation
Active phase of labour: 3-10cm dilation
How can progress in labour be assessed?
Engagement / station of fetal head
PA (abdominal palpation): engagement (fifths palpable: 5/5 to 0/5)
VE: descent of fetal head (station: -3 to +3)
Foetal position: LOA, LOT, DOP, ROP, ROT, ROA
What factors contribute to abnormal labour?
Power: Effective contractions, Maternal factors: e.g. hydration, Membranes intact? Augment contractions e.g. syntocinon
Passenger: Foetal size, Foetal position (OA vs OP), Encourage OA position (all fours, upright), Epidural
Passage: Assess pelvis, Cephalo-pelvic disproportion (CPD), Retrospective diagnosis, normal size baby in occipito-posterior position, big baby in occipito-anterior position
What features on a CTG would be reassuring?
DR: define risk C: contractions, how many in 10 mins BR Baseline rate: 110–160 V Variability: 5 or more bpm A: accelerations present D Decelerations: None O: overall impression
What features on a CTG would be non reassuring?
Baseline rate: 100–109 or 161–180
Variability: < 5 for 40–90 minutes
Decelerations: Typical variable decelerations with over 50% of contractions, occurring for over 90 minutes or single prolonged deceleration for up to 3 minutes
What features on a CTG would be abnormal?
Baseline rate: < 100, > 180, Sinusoidal pattern, 10 minutes or more
Variability: < 5 for 90 minutes
Decelerations: Either atypical variable decelerations with over 50% of contractions or late decelerations, both for over 30 minutes or single prolonged deceleration for more than 3 minutes
What is a pathological CTG?
A FHR trace with two or more features classified as non-reassuring or one or more classified as abnormal
What is a suspicious CTG?
A FHR trace with one feature classified as non-reassuring and the remaining features classified as reassuring
When is foetal blood sampling done and what action do the results warrant?
For pathological trace
Must be at least 3-4 cm dilated
pH>7.25: reassuring, but if CTG deteriorates then repeat
pH: 7.20-7.25: repeat in 30 minutes or deliver
pH<7.20: deliver
What causes hot flushes in the menopause?
Thermoneutral zone: above which we sweat and below which we shiver
Narrow thermoneutral zone - small fluctuations in core body temperature cause hot flushes. Caused by decline in oestrogen, Oestrogen modulators e.g. Tamoxifen
What can be used to widen the thermoneutral zone?
Norepinephrine: SNRI e.g. venlafaxine
Oestrogen
Certain antidepressants e.g. SSRI’s, paroxetine
What are indications for HRT?
For treatment of menopausal symptoms where risk-benefit ratio is favourable, in fully informed women, in lowest possible dose to control symptoms and for shortest duration possible
For women with early menopause (<45 years) until age of natural menopause (taken as 51 years) for bone protection
HRT should only be used for prevention of osteoporosis in women unable to use other medicines licensed for this use
What are contraindications to HRT?
Oestrogen sensitive tumours: Breast cancer VTE / known thrombophilia Stroke Myocardial infarction Other cancers: Ovarian, endometrial
What are the benefits of HRT?
Symptom control Quality of life Osteoporosis Reduced risk colon cancer AGE UNDER 50 AGE 50-60 and SYMPTOMS
What are some non HRT alternatives?
Vasomotor symptoms: SSRI /SSNRI (fluoxetine, paroxetine, venlafaxine), Clonidine, Gabapentin, Other medications: red clover, black cohosh, sage, Diet: soya, Lifestyle: weight loss, alcohol,
Bone protection: Vitamin D and calcium, Biphosphonates, Receptor modulators e.g. Prolia
Urogenital atrophy: Topical oestrogen e.g. Ovestin, Vagifem, Orthogynest
Dyspareunia: Vaginal moisturisers e.g. Replens, Sylk, Lubricants e.g. KY jelly
Why is oestrogen only HRT always bleed free?
Only prescribed for women who no longer have a uterus
Why is depo provera usually contraindicated as a HRT option?
Risk of bone density loss
What preparations of HRT are protective against endometrial hyperplasia/cancer?
14 days every month or every 3 months (sequential) or continuous combined. Continuous combined has lowest association of endometrial hyperplasia / cancer
What is testosterone replacement indicated for?
Low sex drive (hypoactive sexual desire disorder) in women who have hysterectomy and bilateral salpingoophrectomy resulting in a surgically-induced menopause
Women should also be taking oestrogen replacement therapy (HRT)
Up to age 60
What are indications for a hysterectomy?
Fibroids causing bleeding/pain/other problems Uterine prolapse Cancer of cervix, uterus, ovaries Endometriosis Abnormal vaginal bleeding Chronic pelvic pain Adenomyosis
What are different types of hysterectomy?
Subtotal: upper part of uterus only
Total: uterus and cervix
Radical: uterus, cervix, top part of vagina
With or without bilateral salpingoophrectomy
What are the causes of pain in labour?
Uterine contraction to expel fetus causes cervical dilatation (stretching pain)
Myometrial contraction is painful of itself (ischaemic pain)
Descent past vagina and perineum in second stage (more stretching pain)
Episiotomy (cutting pain)
Which nerve roots are responsible for transmitting labour pains?
T10-L1 supply endometrium, placenta, baby
S2-S4 supply cervix and vagina
What are adverse effects of maternal pain in labour?
Sympathetic stimulation: Catecholamine release, Haemodynamic changes – tachycardia, increase CO, hypertension
Delayed gastric emptying.
Increased adrenocortical activity – stress response
Impaired uterine contraction
Decreased uteroplacental blood flow
Maternal and fetal acidosis
What are methods of pain relief in labour?
Midwife-led care TENS Entonox Pethidine Remifentanil Pudendal blocks Epidurals Combined spinal epidural
What is nice guidance on complimentary choices during labour for pain relief?
Advise woman and her birth companion that breathing exercises, immersion in water and massage may reduce pain during latent first stage of labour
Do not offer or advise aromatherapy, yoga or acupressure for pain relief during latent first stage of labour. If a woman wants to use any of these techniques, respect her wishes
What benefits does midwife led care have during labour for pain relief?
Anxiolysis Support Controlled breathing Relaxation Position Birthing pole Water - hydrotherapy
How is remifentanil given in labour?
Given as PCA (patient controlled analgesia) IV
Example 40 microgram bolus with two-minute lockout
What are indications for epidural during labour?
Maternal request. Physiological challenge: Pre-eclampsia, Diabetes mellitus, Cardiorespiratory disease Multiple pregnancy Breech presentation Other high risk etc
What are contraindications to epidural in labour?
Unwilling patient Coagulopathy Local or general sepsis Elevated ICP Uncorrected hypovolaemia Inadequate staffing
Which drugs are used in epidurals?
Bupivacaine: binds intracellular portion of sodium channels to stop action potentials
Fentanyl: mew opioid agonist, modulates onward transmission in spinothalamic tract
What are benefits of epidurals in labour?
Usually excellent pain relief Reduction in anxiety Retained sensorium Do not affect baby Reduction in physiological stress In place for operative procedures Satisfaction rate >85%
What are harms and risks of epidurals in labour?
May not work for labour (1:8) or operative delivery (1:20)
Temporary leg weakness and increased chance operative vaginal delivery - dose
Low blood pressure (1:50)
Severe headache (1:100)
Temporary nerve damage (1:1,000)
Longer nerve damage (1:13,000)
Serious or permanent harms (<1:50,000)
Why might general anaesthesia be used for a c section?
Foetal distress
Anticipated heavy bleeding
Patient choice
What is preterm delivery?
Extreme preterm 24-28 weeks
Very preterm 28-<32
Moderate to late preterm 32-<37
What is the incidence of pre term birth?
7.3%
What are neonatal sequelae of pre term birth?
Neonatal / infant death Chronic respiratory disease Hypoxic ischaemic encephalopathy Necrotising enterocolitis Retinopathy of prematurity Developmental delay Learning disability
What are causes of preterm delivery?
Preterm prelabour rupture of membranes: ascending infection, smoking
Infection: chorioamnioitis, neonatal sepsis and post partum endometritis
Cervical weakness: Previous cervical treatment, Previous obstetric trauma, Infection
Over distension uterine cavity: macrosomia, multiples, polyhydramnios, uterine anomalies
Vascular: placental abruption
What are medical indications for induction of pre term labour?
Maternal: Preeclampsia, Renal disease, Prelabour premature rupture of membranes, Diabetes, Obstetric cholestasis
Foetal: Growth restriction
What are risk factors for pre term labour?
Previous preterm birth Parity =0, or >5 Smoking (two fold increase in PPROM) Ethnicity (black women) Drug abuse (cocaine) Twin pregnancy Lower socioeconomic status BMI <20 Uterine abnormality Education (nil beyond secondary) Inter pregnancy interval <1year Congenital abnormalities Extremes maternal age Cervical damage (cone biopsy) Current pregnancy factors (recurrent APH, intercurrent illness, surgery)
What blood tests can be used to assess risk of preterm labour?
Fetal fibronectin: Produced by fetal cells, Thought to act as a glue between chorion and decidua, Sensitivity (true +ve) 41%, Specificity (true –ve) 86%
Phosphorylated insulin like growth factor binding protein-1: Trade name Actim Partus, Negative predictive value 100%
What investigations should be done for preterm prelabour rupture of membranes?
Nitrazine testing: Amniotic fluid alkaline, stick goes black if pH elevates, Urine, blood, semen cause false positives
High vaginal swab
Monitor maternal wellbeing: Observations
Inflammatory markers
What is the management of preterm prelabour rupture of membranes?
If clinical evidence chorioamnioitis: Antenatal corticosteroids, Deliver, Broad spectrum antibiotics
If no evidence chorioamnioitis – expectant management, Admit, Antenatal corticosteroids, Antibiotics (erythromycin for 10 days), Consider delivery from 34 weeks (usually 36)
What are benefits of antenatal steroids for PPROM?
Reduce risk respiratory distress syndrome (RDS) 44%
Reduce risk intraventricular haemorrhage 46%
What are examples of tocolytic drugs?
Nifedipine
Terbutaline (beta 2 agonist)
Atosiban (oxytocin antagonist)
Indomethacin
How can risk of subsequent preterm labour be prevented?
High risk care pathway
Treat bacterial vaginosis
Smoking cessation
Treat asymptomatic bacteriuria (2-10% pregnancies, Increases risk pyelonephritis 19%, Decreased rate preterm delivery by 40%)
Cervical Length monitoring
Cervical cerclage (stitch): Electively (previous history preterm delivery), Ultrasound indicated (cervical shortening on scan), Rescue (dilating cervix)
What are the early steps of development of a fertilised egg?
3 days after ovulation, morula (early blast) is fomulated
4 days after ovulation, late blast is fomulated
6-7 days after ovulation, egg imbeds in the uterus
What are the different layers of decidua?
Decidua basalis
Decidua parietalis
Decidua capsularis
What are functions of the placenta?
Endocrine: human chorionic gonadotropin (HCG), human placental lactogen (HPL), Relaxin, Human chorionic thyrotropin (HCT), Estrogen, Progesterone
Defence: barrier between maternal and fetal circulation (IgM)
Substance exchange: supply of nutrition/oxygen, removal of fetal waste products
What is human placental lactogen?
Modifies metabolic state of mother to facilitate energy supply of foetus
Has anti insulin properties leading to increased maternal blood glucose
Secreted by syncitiotrophoblast
Why is pregnancy a diabetogenic state?
Human placental lactogen: anti insulin and lipolytic effects
Steroid hormones have anti insulin effect
Some insulin destroyed by placenta
Where does amniotic fluid come from?
Early from serum dialysis
Late from fetal urine
How is amniotic fluid absorbed?
By fetal membranes
Fetal swallowing
What is the function of amniotic fluid?
Protection
Lung development
What volumes of amniotic fluid are normal?
8 weeks:5-10ml
10 weeks:30ml
20 weeks:400ml
38 weeks:1000ml
What changes occur to the maternal circulation during pregnancy?
Heart: enlarged (dilation and hypertrophy), grade I or II systolic ejection murmur (physiological)
ECG changes: upward displacement by enlarging uterus causes heart to shift to left and anteriorly, left axis deviation (depressed ST segment, inversion/flattening of T-wave in lead III)
Blood volume: increases (30-45%) from 1st trimester. Volume increase about 1500ml (plasma 1000ml, red cell 500ml)
Cardiac output: increases by 30-50% with 15% increase in heart rate and 25-increased stroke volume
BP: 30% declines in first trimester, then slowly increases to levels in non-pregnant state
What are changes in blood components in pregnancy?
Red cell: red cell increase (30%), reticulocyte increased, Hb decrease (dilutional and demand)
WBC: Leukocyte counts in upper limits of normal
Albumin decreased
ESR increased significantly up to 100mm/h
Why is pregnancy a hypercoagulable state?
Increase in clotting factors: VIII, vWf, ristocetin cofactor(RCoA), FX, FVII, Fibrinogen (at term 200% above pre-pregnant levels)
Decrease in natural anticoagulants: Protein S
Reduction in fibrinolytic activity: increase in plasminogen activator inhibitor (PAI-1) produced by placenta leads to decreases in tissue
plasminogen activator (t-PA) activity. D-dimers increase in pregnancy
Endothelial changes: increased permeability, vascular tone
Platelet count decreases: increased destruction and haemodilution with a maximal decrease in third trimester
What changes occur to the respiratory system in pregnancy?
Hormonal changes to mucosal vasculature of respiratory tract:
capillary engorgement in nose, oropharynx, larynx, and trachea
Upward displacement by gravid uterus causes a 4 cm elevation of diaphragm, but: total lung capacity decreases only slightly because of compensatory increases in transverse and antero-posterior diameters of chest as well as flaring of ribs. These changes brought about by hormonal effect of relaxin (from placenta) that loosen ligaments
Oxygen consumption: increases in response to needs of growing fetus, culminating in rise of 20% at term. During labour, oxygen consumption further increased (over 60%) as a result of exaggerated cardiac and respiratory work load
Progressive increase in minute ventilation starts soon after conception and peaks at 50% above normal around second trimester. 40% rise in tidal volume and a 15% rise in respiratory rate. Dead space remains unchanged, alveolar ventilation is about 70% higher at end of gestation
Pregnancy is state of compensated respiratory alkalosis: arterial PCO2 drops, arterial PO2 unchanged, decrease in bicarbonate prevents pH change. Lower maternal PCO2 facilitates oxygen/carbon-dioxide
transfer to/from foetus
Many women complain of feeling short of breath in pregnancy without explanatory pathology
What are physiological hepatic and gastric changes in pregnancy?
Basal metabolic rate increases by 15-20%
Normal weight gain approximately 12.5 kg, usually at rate of 0.5kg per week for last 20 weeks, 5 kg is fetus, placenta, membranes and amniotic fluid, maternal stores of fat, protein, increased intra- and extra-vascular volume
Appetite usually increased, sometimes with specific cravings
Progesterone relaxes lower oesophageal sphincter
GI motility is reduced and transit time is consequently longer
Gallbladder may dilate and empty less completely
Gums become spongy, friable and prone to bleeding
Carbohydrate metabolism: pregnancy is a diabetogenic state
Palmar erythema, spider angiomas benign during pregnancy
Liver enzymes: Alkaline phosphatase levels rise due to placental production, Uric acid levels decreased, No change in transaminases, bilirubin level
What changes occur to kidney function in pregnancy?
Glomerular filtration rate (GFR) increases
Creatinine clearance increases
Serum creatinine and urea decreases
Increase in glomerular filtration overwhelms ability of renal tubules to reabsorb leading to glucosuria and proteinuria
Decrease in plasma osmolality
Smooth muscle of renal pelvis and ureter relax and dilate, ureters become longer, more curved, an increase in residual urine volume
Bladder smooth muscle also relaxes, increasing capacity
5% of pregnant women have bacteriuria, often asymptomatic, greater risk of developing pyelonephritis
What are some physiological effects of the enlarging gravid uterus?
Aorta-caval compression: compresses IVC and lower aorta
when patient lies supine. Obstruction of IVC reduces venous return to heart leading to fall in cardiac output
Respiratory changes: reduced TLC
Left axis deviation of heart
Stomach and intestines: upward displacement of stomach leading to increased intragastric pressures and change in angle of gastroesophageal junction (oesophageal reflux)
Vertebrae: Exaggerated lordosis with changing centre of gravity
Hydronephrosis: Compression of ureter between gravid uterus and iliopsoas muscle (R > L)
What are signs and symptoms of pregnancy?
Nausea and vomiting Food cravings Anaemia Oedema Palpitations Dizziness Dyspnoea Gastro-esophageal reflux Striae gravidarum Polymorphic eruption of pregnancy Hyperpigmentation: linea nigra, chloasma Back pain Constipation Urinary frequency
What is Mendelsons syndrome?
Chemical pneumonitis or aspiration pneumonitis caused by aspiration during anaesthesia especially during pregnancy
What is subfertility?
Failure to achieve pregnancy after 12 months of regular unprotected sexual intercourse
What factors are important to know about when assessing subfertility?
Female age Ovulation Sperm production Tubal function Uterine function Duration of trying Lifestyle: obesity, smoking, alcohol Medical Hx Previous pregnancy
What are the most common causes of subfertility?
Ovulation Disorder (20-30%) Tubal Damage (20-30%) Male factors (25-40%) Unexplained (10-20%) Endometriosis (5-10%) Other eg fibroid (4%)
What are important pre conception advice points for women struggling with subfertility?
Medical history: Stabilise condition, Switch to medications suitable for pregnancy, referral to obstetrician to discuss impact of pregnancy on condition
O and G history: Menstrual history, dysmenorrhoea, regular cycle?,
previous pregnancies, Smear Hx, Hx of STIs/PID, dyspareunia, contraception
Weight: Aiming for BMI 20-30
Lifestyle changes: smoking, alcohol and caffiene
Timing of intercourse: 2-3 times a week
Folic acid: 400mcg OD (5mg if diabetic)
Virology screen: rubella (+/- immunisation)
What aspects of a pre conception history are important from a male perspective when dealing with subfertility?
Medical Hx Any children? Injury to testicles Hx of mumps/infections Hx STIs Previous surgery (inc vasectomy) Use of body-building drugs (anabolic steroids)
What features warrant immediate referral for subfertility problems?
Female: Age > 35 years, Previous ectopic pregnancy, Known tubal disease (Hx of STI/PID), Tubal/pelvic surgery, Amenorrhoea/oligomenorrhoea
Male: Testicular maldescent, Chemo/radiotherapy, Urogenital surgery, Hx STIs, Varicocele, Erectile/ejaculation dysfunction
When is the most fertile period?
6 days before ovulation
What initial investigations should be done for subfertility?
Female patient with regular cycles: FSH day 1-5 - ?ovulation reserve (AMH), Progesterone – mid-luteal (day 21 if 28 day cycle) ?ovulation
Female patient with irregular cycles: FSH/LH (with menses or anytime) ?pituitary function, Oestrogen and Progesterone (anytime) ?ovarian function, Prolactin/free testosterone (anytime) ?cause
All women: TV USS – pelvic anatomy ?PCOS ?fibroids
Male patient: Semen fluid analysis – sample after 2-5 days of abstinence – repeat in 3/12 if abnormal
What elements are assessed in semen fluid analysis?
Volume: 1.5ml Total Sperm: > 39 million Sperm concentration: 15 million/ml Progressive motility: > 32% Total motility: >40% Normal morphology: > 4%
What is the difference between oligospermia and azoospermia?
Oligospermia – low sperm count (<15million/ml)
Azoospermia – no sperm
What are different types of azoospermia?
Obstructive: Blocked epididymis/vas deferens, Congenital absence of vas deferens
Non-obstructive: Testicular failure – karyotype and testicular biopsy?any spermatogenesis, Failure to stimulate spermatogenesis – HPO axis
How should tubal disease be investigated for subfertility?
Investigation of tubes and uterine cavity: Hysterosalpingography (HSG) – X-ray, Hysterocontrastsonography (HyCoSy) – USS, Laparoscopy and Dye test. Done in first 10 days of cycle to not disrupt an early pregnancy
Need HVS/cervical swab first or prophylatic Abx – risk of ascending infection
How can ovulation be induced? What are problems with it?
Anti-oestrogens (Clomiphene). Blocks oestrogen receptors in anterior pituitary causing up regulation of FSH
Started day 2 – 6 of cycle – given for 5 days
Starting dose 50mg, can increase to 100mg
Ovulate 5-10 days after last dose (mean = 7 days)
No longer than 6 months
At least first cycle should be monitored with serial ultrasound scans
Induces ovulation in 70-85%
40-50% couples conceive
Increased risk of multiple pregnancy
When should intrauterine insemination be considered?
Failed to conceive after ovulation induction
Unexplained infertility with normal tubes
Endometriosis
Sperm preparation required
What is the success rate of IVF?
32.2% if aged < 35 years
27.7% 35-37 years old
5% 43-44 years old
When is intracytoplasmic sperm injection indicated?
Usually indicated with severe oligospermia or azoospermia
What is a maternal death?
Death of a woman while pregnant or within 42 days of end of pregnancy from any cause related to or aggravated by pregnancy or its management, but not from accidental or incidental causes
What is a direct maternal death?
Deaths resulting from obstetric complications of pregnant state (pregnancy, labour, puerperium), from interventions, omissions, incorrect treatment or from a chain of events resulting from any of above
What is an indirect maternal death?
Deaths resulting from a previous existing disease, or disease that developed during pregnancy and which was not result of direct obstetric causes, but which was aggravated by physiological effect of pregnancy
What is a late maternal death?
Deaths occurring between 42 days and 1 year after end of pregnancy that are result of direct or indirect maternal causes
What is the MBRRACE report?
Confidential enquiry Investigate why mothers die How to improve care and services Answers for family left behind Publish triennially
What are the most common causes of maternal death in the U.K.?
Indirect Causes (most common): Cardiac Disease, Sepsis, Neurological, psychiatric Direct: thrombosis, Haemorrhage, Amniotic Fluid Embolism
In which groups of women are maternal mortality rates highest?
Older women
Those living in deprived areas
Women from some ethnic minority groups (African, Caribbean and Pakistani)
Medical co-morbidities
By how much is VTE risk increased in pregnancy?
4-6 fold
What are the 4 Ts causing post partum haemorrhage?
Tone
Tissue
Trauma
Thrombin
What is amniotic fluid embolism and how does it present?
Liquor enters maternal circulation
Dyspnoea, hypoxia, hypotension, +/- seizures, cardiac arrest
Rare, but 80% cases die
If woman survives for 30 minutes she can develop DIC, pulmonary oedema, ARDS
What reg flags need urgent psychiatric assessment in a pregnant or post partum woman?
Recent significant changes in mental state or emergence of new symptoms
New thoughts or acts of violent self harm
New and persistent expressions of incompetency as a mother or
estrangement from the infant
Which women may require admission to mother and baby unit for psychiatric reasons?
Rapidly changing mental state Suicidal ideation Pervasive guilt or hopelessness Significant estrangement from the infant Beliefs of inadequacy as a mother Evidence of psychosis
What are the most common causes of maternal death globally?
Direct causes: Post partum haemorrhage, Post natal infections, Pre-eclampsia and eclampsia, Delivery complications, Unsafe abortion
Where are maternal death rates highest globally?
Sub Saharan Africa
What are methods of reducing maternal deaths globally?
Antenatal care
Access to skilled care during childbirth
Care and support postnatally
Oxytocin for management 3rd stage
Basic sanitation and early antibiotics to prevent infection
Early detection pre-eclampsia and access to MGSO4
Contraception, safe abortion service
What are different types of breech presentation?
Frank (65%): hip flexed, knees extended
Complete (10%): hips and knees flexed
Incomplete (25%): Footling, kneeling
What are risk factors for breech presentation?
Prematurity/ Preterm labour Primigravida Uterine abnormalities Uterine Fibroids Placental abnormalities (eg praevia) Pelvic anatomy Foetal anomalies Multiple Pregnancy Oligohydramnios/ Polyhydramnios Grand multiparity Fetal Death
What is external cephalic version?
Manoeuvre used to turn a fetus from a breech or transverse position into a vertex position
What are contraindications to ECV?
Absolute: Where caesarean delivery is required, Recent antepartum haemorrhage, Abnormal cardiotocography, Major uterine anomaly, Ruptured membranes, Multiple pregnancy (except delivery of second twin)
Relative: SGA fetus with abnormal Doppler parameters, Proteinuric Pre-eclampsia, Oligohydramnios, Major fetal anomalies, Scarred uterus, Unstable lie
When should ECV be offered?
From 36 weeks in nulliparous women
From 37 weeks in multiparous women
What drugs should be given for ECV?
Tocolytic: beta mimetic
Analgesia
What should women be informed after ECV?
After unsuccessful ECV, only a few babies will spontaneously turn cephalic
A few babies revert to breech after successful ECV
Labour after ECV is associated with a slightly increased rate of c section and instrumental delivery when compared with spontaneous cephalic presentation
ECV after one caesarean delivery appears to have no greater risk than with an unscarred uterus
Women undergoing ECV who are D negative should undergo testing for fetomaternal haemorrhage and be offered anti-D
From what gestation can a foetus usually be seen on a scan?
Transabdominal scan from 6.5 weeks
TVscan from 5.5 weeks
What are risk factors for ectopic pregnancy?
Previous PID Previous ectopic pregnancy Previous tubal surgery (e.g. sterilisation, reversal) Pregnancy in presence of IUCD POP Assisted reproduction Smoking Maternal age >40y Up to 50% have no risk factors
What are symptoms of ectopic pregnancy?
Acute: Low abdominal pain – peritoneal irritation by blood, Vaginal bleeding – shedding of decidua, Shoulder tip pain – referred from diaphragm, Fainting - hypovolaemia
Chronic (Atypical): Asymptomatic, gastrointestinal symptoms
What are signs of ectopic pregnancy?
Abdominal tenderness
Adnexal tenderness / mass
Shock – tachycardia, hypotension, pallor
How is a diagnosis of ectopic pregnancy made?
USS: Empty uterus, adnexal mass, free fluid, occasionally live pregnancy outside of uterus
Serum beta hCG - serial: Slow rising, plateau, failing
Laparoscopy
What are management options for ectopic pregnancy?
Conservative: Self resolving with close watch
Medical: Methotrexate
Surgical: Laparoscopic salpingectomy / salpingotomy. Laparotomy
What is the difference between UK and WHO definition of miscarriage?
UK definition- Loss of intrauterine pregnancy before 24 weeks of gestation
WHO definition- expulsion of fetus weighing 500g or less and less than 22 completed weeks gestation
What is the difference between early and late miscarriage?
Early miscarriage- <12 weeks
Late miscarriage- >12 weeks
What are causes of miscarriage?
Foetal: Chromosomal, Malformations, Placental, Multiple pregnancy
Maternal: Disease- Diabetes, hyperthyroidism, Age, BMI, Infection, Uterine/ cevical anamolies, Previous miscarriage, trauma
What investigations should be done for suspected miscarriage?
Ultrasound Measurement of serum beta hCG Determination of blood and Rhesus group FBC, G and S and admit if significant bleeding Psychological support
What are possible USS appearances in keeping with miscarriage?
Products of conception: Incomplete miscarriage
Empty uterus: Not pregnant, Too early gestation, Extrauterine pregnancy, Complete miscarriage
Empty sac: Non-viable pregnancy, Too early gestation
Foetal pole with no FH: If tiny, may be very early gestation, Delayed miscarriage
By how much does beta HCG usually rise in a viable pregnancy?
Doubling time approx 2 days in viable pregnancy
By how much does beta HCG usually decrease in miscarriage?
Halving time 1-2 days in complete miscarriage
At what value of beta HCG should a foetal pole be seen on USS?
1500-2000
What is the management of incomplete miscarriage?
Conservative: unsuitable if infection/ heavy bleeding, review after 1-2 weeks, can continue up to 6-8 weeks. Risk of unplanned intervention, transfusion due to bleeding, failure
Medical: Misoprostol 600-800mcg (Pregnancy test after 3 weeks). Risk of bleeding, failure
Surgical (Evacuation of retained products of conception): Suction curettage usually under GA- first line if infection, heavy bleeding. Risks of bleeding ,infection, perforation, failure
What are partial and complete hyatidiform moles?
Partial Mole: Associated with fetus, triploid
Complete Mole: No fetal pole, diploid chromosomes paternally derived –androgenetic
In which patients are there higher incidences of molar pregnancies?
Southeast Asia (8/1000)
Extremes of reproductive age (>40 x5-10)
Previous molar pregnancy
Low carotene diet
How does a molar pregnancy present?
Vaginal bleeding
Excessive N and V ‘Hyperemesis gravidarum’
Uterus large for dates
How is a diagnosis of molar pregnancy made?
Ultrasound (Snow storm appearance)
Histology after surgical evacuation
What is the management of a molar pregnancy?
Suction evacuation
Avoid cervical ripening
Above will cure 99.5% of partial, 84% of complete
Avoid hysteroscopy- increase the likelihood of chemotherapy
What is the risk of choriocarcinoma following molar pregnancy?
3% risk choriocarcinoma following complete mole, less following partial mole
For how long should beta HCG levels be monitored after a molar pregnancy?
6 months to 2 years
What is the most common Gynae cancer in the U.K.?
Endometrial
What is the peak age of endometrial cancer?
64 – 74
What is the most common type of endometrial cancer?
Endometrial Adenocarcinoma
What are risk factors for endometrial cancer?
Obesity Nulliparity Early menarche Late menopause Unopposed oestrogen Tamoxifen Oestrogen producing tumours Diabetes PCOS HNPCC
How does endometrial cancer present?
Pre-menopausal: Abnormal vaginal bleeding, Intermenstrual bleeding, Irregular bleeding / periods
Postmenopausal: Postmenopausal Bleeding (PMB), 10% of women with PMB will have a malignancy – Less commonly blood stained, watery or purulent vaginal discharge
How is a diagnosis of endometrial cancer made?
Endometrial sampling by Pipelle or (less commonly) Dilation and Curettage
Hysteroscopy: gold standard
Transvaginal Ultrasound: useful for investigation of PMB, use >5mm cut off for endometrial thickness
What is the FIGO staging system for endometrial cancer?
1: Limited to myometrium
2: Cervical spread
3: Uterine serosa, Ovaries / Tubes Vagina, Pelvic / Para-aortic Lymph Nodes
4: Bladder / bowel involvement, Distant metastatsis
What is the management of endometrial cancer?
Conservative
Medical: Progestogens (oral or intrauterine/Mirena IUS), Primary Radiotherapy
Surgical: Hysterectomy, BSO, peritoneal washings, Laparoscopic / Open (TAH), Pelvic Lymph node dissection, Adjuvant Radiotherapy if high risk of recurrence (Brachytherapy, External beam), Advanced disease/inoperable disease/unfit for surgery- Chemotherapy, Radiotherapy, Hormones, Palliative Care
What is the peak age of onset of ovarian cancer?
70-74 years
Which are the most common ovarian tumours?
Surface epithelium: serous, mucinous, endometroid, clear cell, Brenner
Teratoma
What are risk factors for epithelial ovarian cancer?
Reproductive history: Nulliparity, Infertility, Early menarche, Late menopause HRT Asbestos Talcum powder Smoking,diet, alcohol
What factors are protective against ovarian cancer?
COCP Pregnancy Breastfeeding Hysterectomy Oophorectomy Sterilisation
Which gene underlies 50% familial ovarian epithelial tumours?
BRCA1
How does ovarian cancer present?
Abdominal swelling Pain Anorexia N and V Weight loss Vaginal bleeding Change in bowel habit
How should ovarian cancer be investigated?
Pelvic examination TVS FBC, U and E, LFTs CA125 CXR CT to assess peritoneal, omental and retroperitoneal disease Radiologically (USS/CT) guided biopsy Cytology of ascitic tap Surgical exploration Histopathology
Other than epithelial ovarian cancer, what can cause a raised CA125?
Ca pancreas, breast, colon, lung
Menstruation, PID, Endometriosis
Liver disease, ascites, pleural and pericardial effusions
Recent laparotomy
What is nice guidance on use of CA125?
Ca125 as initial screen if symptoms
USS if Ca125 abnormal
Look for other causes of raised Ca125 ifUSS normal
What is the staging of ovarian cancer?
1: Limited to ovary / ovaries
2: Spread to pelvic organs
3: Spread to rest of peritoneal cavity, Omentum, Positive Lymph nodes
4: Distant metastatsis, Liver parenchyma, Lung
What is the management of epithelial ovarian cancer?
Combination of Surgery + chemotherapy
Staging laparotomy, TAH, BSO and debulking
Platinum (Carboplatin) and Taxane (paclitaxel)
In women of reproductive age, where tumour is confined to one ovary, oophorectomy only may be considered
Which age groups get cervical cancer?
Bimodal: 30s and 80s
What are risk factors for cervical cancer?
Young age at first intercourse Multiple sexual partners Smoking Long term use of COCP Immunosuppression/HIV HPV (Human papilloma virus)
Which are the oncogenic subtypes of HPV?
16, 18, 31, 33 etc
What are low risk HPV types?
6, 11, 42, 43, 44
How does HPV cause cervical cancer?
Produce proteins (E6 and 7) which suppress products of ‘p53’ tumour suppressor gene in keratinocytes
What are possible report outcomes from cervical cytology?
Normal Inadequate Borderline Mild Dyskaryosis Moderate Dyskaryosis Severe Dyskaryosis Possible Invasion
How often are cervical smears offered?
First invitation age 25
3 yearly from 25 to 50
5 yearly from 50 – 65
After 65 selected patients only
Which smear results warrant referral to hospital?
Inadequate smear on three occasions Borderline smear + for HR-HPV Mild dyskaryosis + for HR-HPV Moderate dyskaryosis Severe dyskaryosis Abnormal glandular cells present Suggestion of Invasive disease
What features are looked for on colposcopy?
Abnormal vascular pattern (mosaicism, punctation)
Abnormal staining of the tissue (aceto-white, brown iodine)
What are treatment options for CIN?
Destructive: cryocautery, diathermy, laser vaporisation
Excisional: LLETZ (large loop excision of thetransformation zone), cold knife cone
What follow up is required for CIN after treatment?
CIN 1: Smears at 6, 12, 24 months
CIN 2/3: Smears at 6, 12, 24 months then annually for 8 years
HPV Test of Cure for all treated women: Local protocols, Smear and HPV test at 6 months. Discharge to normal recall if HPV negative
How does cervical cancer present?
PCB
PMB
Intermenstrual bleeding
Blood stained vaginal discharge
What is staging of cervical cancer?
1: Confined to cervix (90%), A Microinvasive (depth<5 mm/width<7mm), B Clinical lesion
2: Beyond cervix but not pelvic side wall or lower 1/3 of vagina (60%), A Upper 1/3 Vagina, B Parametrium
3: Pelvic spread, reaches side wall or lower 1/3 of vagina (30%), A Lower 1/3 of vagina, hydronephrosis, B Extends to pelvic side wall, hydronephrosis
4: Distant spread (10-20%), A Invades adjacent organs (bladder/bowel), B Distant sites
What is the management of cervical cancer?
Microinvasive carcinoma: conservative. If fertility is an issue, cone biopsy can be used. Once family is complete, hysterectomy is appropriate
Clinical Lesions (1b - 2a): Radical hysterectomy or chemoradiotherapy (survival same)
Clinical lesions beyond stage 2a: Chemoradiotherapy
Postoperative radiotherapy: with lymph node involvement
Recurrent disease: Radiotherapy, chemotherapy, exenteration,
palliative care
What are complications of surgery for cervical cancer?
Infection VTE Haemorrhage Vesicovagina fistula Bladder dysfunction Lymphocyst formation Short vagina
What are complications of radiotherapy for cervical cancer?
Vaginal dryness Vaginal stenosis Radiation cystitis Radiation proctitis Loss of ovarian function
What is a radical trachelectomy?
Cervicectomy - cervix and upper vagina removed
Womb left in place so possible to have baby after
What is pelvic exenteration?
Radical surgery to remove all organs from pelvic cavity
Bladder, urethra, rectum, anus
Have to have permanent colostomy and urinary diversion
What vaccinations are available for HPV?
Gardasil: 6,11,16,18 Cervarix:16 and 18 NHS Programme 3 im injections over 6 months Ideally prior to SI 5 years protection Still need smears (HPV 31, 45 and others)
What is Prostap?
Leuprorelin acetate
Gonadorelin (LHRH) analogue
Used in prostate cancer, endometriosis, uterine fibroids, thinning lining of uterus before surgery
Which patients are high risk of VTE in pregnancy and therefore require antenatal prophylaxis with LMWH?
Single previous unprovoked VTE
Thrombophilia or FH and previous VTE
Previous recurrent VTE >1
Which patients are moderate risk of VTE in pregnancy and therefore should be considered for antenatal prophylaxis with LMWH?
Single previous VTE with no FH or thrombophilia
Thrombophilia but no VTE
Medical comorbidities: heart or lung disease, SLE, cancer, inflammatory conditions, nephrotic syndrome, sickle cell disease, IVDU
Surgical procedure
Which risk factors should be considered for VTE in pregnancy and the presence of 3 or more of them requires antenatal prophylaxis with LMWH?
Age >35
Obesity (BMI >30)
Parity 3 or more
Smoker
Gross varicose veins
Current systemic infection
Immobility: paraplegia, SPD, long distance travel
Pre eclampsia
Dehydration/hyperemesis/Ovarian hyperstimulation syndrome
Multiple pregnancy or assisted reproduction
What is a risk of malignancy index?
For ovarian cancer
Product of USS score, menopausal status and serum CA125 level RMI=UxMxCA125
U: 1 point each for multilocular cysts, solid areas, mets, ascites, bilateral. Max 3
M: 1 if pre menopausal, 3 if post menopausal
In which patients are 3rd or 4th degree tears more likely?
First vaginal delivery Previous 3rd or 4th degree tear Assisted delivery, particularly forceps Episiotomy Previous episiotomy Macrosomic baby Baby born OP Long pushing phase Distance between vaginal opening and anus shorted than average
A 25 year old with a diagnosis of PCOS presents with heavy irregular periods. She has no partner at present and does not with to conceive. On examination she has a BMI of 29 and some slight hirsutism. Which contraceptive is suitable?
Dianette- combined oestrogen with cyproterone acetate
Treat menorrhagia and may improve hirsutism
A 32 year old with BMI 34.5 with history of oligomenorrhoea is seeking fertility. She has tried to lose weight unsuccessfully and finds difficulty with diet. Her investigations confirm PCOS. What is appropriate treatment?
Metformin and clomifene combined
What may be presenting features of ovarian neoplasms other than the non specific general features?
Hirsutism due to testosterone secretion Acute abdomen due to torsion Rupture or haemorrhage Thyrotoxicosis: struma ovarii Amenorrhoea
What is the incidence of placenta praevia?
5% pregnancies at 16-20 weeks
0.5% at delivery
Most placentas move away from cervix
Wha factors are associated with placenta praevia?
Multiparity Multiple pregnancy Lower segment scar from previous LSCS Previous placenta praevia Endometrial damage
What are clinical features of placenta praevia?
Shock in proportion to visible loss No pain Uterus not tender Lie and presentation may be abnormal Foetal heart normal
What are grades of placenta praevia?
1: reaches lower segment but not internal os
2: reaches internal os but doesn’t cover it
3: covers internal os before dilation but not when dilated
4: completely covers internal os
What are potential complications of chlamydia?
Epididymitis PID Endometritis Increased incidence ectopic pregnancy Infertility Reactive arthritis Perihepatitis (Fitz Hugh Curtis syndrome)
What is amsels criteria for diagnosis of BV?
3 of following:
Thin white homogenous discharge
Clue cells on microscopy (stippled vaginal epithelial cells)
Vaginal pH >4.5
Positive whiff test: addition of potassium hydroxide results in fishy odour
A 27 year old woman complains of offensive musty frothy green vaginal discharge. On examination there is an erythematous cervix with pinpoint areas of exudation. What is the diagnosis and management?
Trichomonas vaginalis - strawberry cervix
Treat with oral metronidazole
What is the management of gonorrhoea?
IM ceftriaxone 500mg
Oral azithromycin 1g stat dose
What is the management for women presenting with primary herpes infection in third trimester of pregnancy?
Oral aciclovir 400mg TDS until delivery
C section planned delivery
IV aciclovir required for mother/infant if PPROM or spontaneous vaginal delivery in presence of primary infection
What is management of hyperemesis gravidarum?
Antihistamines first line: promethazine
Ginger
P6 wrist acupuncture
Admission for IV hydration if ketonuria or weight loss >5%
What are associations of hyperemesis gravidarum?
Multiple pregnancy Trophoblastic disease Hyperthyroidism Nulliparity Obesity
What are complications of hyperemesis gravidarum?
Wernickes encephalopathy Mallory Weiss tear Central pontine myelinosis Acute tubular necrosis Foetus: SGA, pre term birth
What are normal values for Hb in pregnancy?
First trimester: 110
Second/third: 105
Postpartum: 100
What are important factors when doing an FSH test for menopause?
2 tests, 4-8 weeks apart
Must be tested off contraception
How is an IUD used as emergency contraception?
Must be inserted within 5 days of UPSI or up to 5 days after likely ovulation date
Prophylactic antibiotics may be given if considered high risk of STI
99% effective
Should be kept in at least until next period but can be left long term
How should levonorgestrel be used as emergency contraception?
Taken within 72 hours of UPSI
84% effective
If vomiting occurs within 2 hours, repeat dose
Can be used more than once in menstrual cycle if clinically indicated
How should ulipristal (EllaOne) be used as emergency contraception?
Taken within 120 hours of UPSI
Concomitant use with levonorgestrel not recommended
Caution in patients with severe asthma
Repeating in same menstrual cycle not recommended
Breastfeeding should be delayed for 1 week after taking
What is primary dysmenorrhoea?
No underlying pelvic pathology
Pain just before or within few hours of period starting
Suprapubic cramping pain which may radiate down back or thigh
What is management of primary dysmenorrhoea?
NSAIDs such as mefenamic acid and ibuprofen
COCP second line
What is secondary dysmenorrhoea?
Develops many years after menarche Result of underlying pathology Pain starts 3-4 days before period Causes: endometriosis, adenomyosis, PID, IUD, fibroids Requires referral to gynae
Which vaccines are offered in pregnancy?
Influenza in flu season
Pertussis ideally at 28-32 weeks
What is active management of the third stage?
Uterotonic drugs
Deferred clamping and cutting of cord, over 1 minute after delivery but less than 5 mins
Controlled cord traction after signs of placental separation
What are treatment options for twin to twin transfusion syndrome?
Indomethacin to reduce foetal urine output
Laser obliteration of placental vascular communications
Selective foetal reduction
After birth: donor twin may need blood transfusions to treat anaemia. Recipient may need exchange transfusions/heart failure meds
Which is the most appropriate treatment for fibroids for a lady wanting to conceive?
Myomectomy
What are contraindications to VBAC?
Classical c section scar
Previous uterine rupture
Other contraindication to vaginal birth eg placenta praevia
What is the management of uterine inversion post partum?
A to E approach
Uterine repositioning: Johnson’s method (push uterus towards umbilicus), O’Sullivans (infusion of warm saline into vagina)
Prepare theatres for potential laparotomy
Consider tocolytics to allow uterine relaxation (will worsen haemorrhage)
Urinary catheter
Pain management
What layers are cut through to do a c section?
Skin Superficial fascia Deep fascia Anterior rectus sheath Rectus abdominis Transversalis fascia Extraperitoneal connective tissue Peritoneum Uterus
What are contraindications for ECV?
Multiple pregnancy
Antepartum haemorrhage
Placenta praevia
What are potential sensitising events in pregnancy for a rhesus negative woman?
Ectopic pregnancy
Evacuation of retained products and molar pregnancy
Vaginal bleeding <12 weeks if painful, heavy or persistent
Vaginal bleeding >12 weeks
Chorionic villus sampling and amniocentesis
Antepartum haemorrhage
Abdo trauma
ECV
Intra uterine death
Post delivery if baby is rhesus D positive
