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
