Obs and Gynae Flashcards
1
Q
What is Lichen Sclerosis and how does it present?
A
- Benign skin condition.
- Any age (usually post menopausal)
- Thin skin
- White (leukoplakia), Red (inflammation)
- Perineum/perianal- atrophy in figure of 8 pattern
- Anatomical shrinkage/ adhesions
- Extragenital plaques- trunk, back
2
Q
Investigations and management of Lichen Sclerosis
A
- Ix: Swabs, vulval biopsy
- Tx: Emollient creams, shor course steroids, surgery if micturition affected
3
Q
Presentation of Bartholin cyst
A
- Cyst/ abscess in posterior forchette.
- Vulval pain esp walking/sitting
- Dyspareunia
- ?Sepsis
4
Q
Investigations at booking appointment
A
- Booking = 8-12w
- Bedside- urine dip, BP, glucose if DM RF
- Bloods- Type, Rh, haemoglobinopathies, anaemia, RBC autoAb, HIV, HepB, syphilis, rubella
- Sickle cell and thallaesemia <10w
- DM eye screening at 1st appointment
5
Q
What is looked at in dating scan?
A
- Dating scan= 12w.
- Looking at:
- ?Single, viable, intrauterine foetus
- Crown-rump length. ?Gestation and EDD
- Nuchal translucency <12w risk of abnormality
6
Q
When is the anomaly scan and what are you looking for?
A
- 18-20w
- Structural abnormalities - anencephaly, open spina bifida, cleft lip, diaphragmatic hernia, gastroschisis, emophalmos, cardiac abnormalities, renal agenesis, skeletal dysplasia
- Trisomies
- Low lying placenta –> transvaginal USS
7
Q
Pre-conception care
A
- Multivitamins, folic acid (400 micrograms) until 12w
- Lifestyle- stop smoking, no alcohol, optimise BMI, pelvic floor exercises
- Vit D once preg - 10 micrograms OD in preg
8
Q
Indications for 5mg Folic Acid
A
- DM
- High BMI
- Coeliac / Malabsorption
- Sickle cell
- Epilepsy
- Prev. FHx NTD
- Multiple Preg
9
Q
Indications for growth scans. What are you looking for in growth scans?
A
- >28w, every month in complicated
- Hx of IUGR
- HTN or PMH
- DM
- Epilepsy
- Smoking/ substance misuse
- BMI >35
- Multiple Preg
- Growth - head, abdo circumference, femur length
- Amniotic fluid
- Blood flow- umbilical artery (deoxygenated blood from baby to mum). End diastolic flow.
10
Q
Down’s Screening
A
- 1st Trimester- Combined test. Nuchal translucency, PAPa (low), betaHCG (high). If risk >1 in 250 –> ?amniocentesis/ chorionic villus sampling
- 2nd Trimester - Quadruple test. AFP, unconjugated estradiol, betaHCG, Inhibin A, maternal age
- CVS- 10-13w. Sample of placenta. Complications- miscarriage, amniotic fluid leak, sepsis
- Amniocentesis- >15w. Complications- miscarriage, amniotic fluid leak, uterine bleeding, maternal Rh sensitisation, sepsis. More accurate + safer
11
Q
What is term and what are the 3 stages of labour?
A
- Term= 37-42w
- Stage 1= 4-10cm. Reg painful contractions. Start partogram. Progress 0.5cm every hour. FHR every 15mins.
- Stage 2= 10cm - birth. Passive 1-2h –> active. FHR every 5mins.
- Stage 3= Birth - expulsion of placenta
12
Q
High risks births that would require continuous monitoring
A
- Pre-eclampsia
- Macrosomia
- IUGR
- Premature
- DM
- Breech
- Prev. C-section
- APH
- Oxytocin
- Epidural
- Meconium
13
Q
What are you looking at to interpret a CTG?
A
DR C BRVADO
- Define Risk
- Contractions - rate, duration, rhythm, strength
- Basline RAte (norm 110-160)
- Variability >10-15 bpm
- Accelerations- early/variable/late (?hypoxia)
- Decelerations
- Overall assessment and plan
14
Q
Causes of Non-Progressive Labour
A
- Powers:
- Aim 4-5 contractions/10 mins lasting 1 min.
- Ineffective contractions or hyperactive (oxytocin)
- Tx- Inefficient –> amniotomy, augmentation, oxytocin. Hyperactive –> reduce oxytocin
- Passage- Cephalo-pelvic disproportion. Pelvis 13cm at inlet, 11cm at outlet. Tx: assisted, c-sec
- Passenger:
- Malpresentation- face, brow (urgent C-sec), breech
- Unstable lie –> cord prolapse?
15
Q
What is APH and what might cause it?
A
- APH= any leed after 24w upto labour
- Uterine causes:
- Placenta previa
- Placental abruption
- Vasa previa
- Circumvallate placenta
- Lower genital tract causes:
- Ectropion
- Cervical polyp
- Cervical carcinoma
- Cervicitis
16
Q
Ix and Tx of APH
A
- Ix:
- DO NOT DO PV/ SPECULUM EXAM
- Bedside- CTG, urinalysis
- Bloods- Hb, G+S/ Cross-match, Rh status, U+Es, LFTs
- Imaging- USS
- Tx:
- ABCDE + Anti-D
- ?Transfusion
- ?C-section
17
Q
What is placenta previa? RF, Presentation, Tx and complications
A
- = Low lying placenta in 20w scan, PP Dx at 3rd trimester via TVUSS
- Minor/ major
- RF: Infection, multiple preg, fertility, smoking, parity, fibroids, prev. PP, age, trauma, abdo surg
- Presentation:
- Painless bleeding. Bright red.
- SNT abdo
- Displaced presenting part eg transverse lie
- Tx:
- Anti-D
- Manage bleed - ?transfusion
- Minor >2cm away from os. Vaginal.
- Major- C-section
- Complications: PPH, placenta accreta, preterm labour, malpresentation
18
Q
Vasa previa - presentation, Ix, Tx
A
- Foetal BVs cross os –> membrane rupture –> BVs rupture
- Presentation - Membrane rupture w/ painless bleeding
- Ix- Kleihaeur test - ?foetal blood
- Tx- Urgent C-section
19
Q
What is placenta accreta?
A
- Placenta attached to myometrium –> gets left behind.
- RF: Prev. c-section
20
Q
Placental abruption - RF, presentation, Ix, Tx, complications
A
- = Placenta separates from uterus whilst baby still in womb.
- RF: ECV, trauma, pre-eclampsia, parity, smoking, prev PA, anatomy, IUGR, multiple preg, AI, alcohol, drug s
- Presentation:
- Any stage of preg.
- Painful APH. Dark blood.
- Signs of shock - inconsistent w/ blood loss
- Concealed/ revealed
- Tender, contracting ‘woody’ uterus
- Ix- USS to rule out previa
- Tx:
- ABCDE, resus, CTG, anti-D
- Foetal distress –> urgent c-sec
- No foetal distress- expectant management and induction at 37w
- Complications: Foetal death, haemorrhage, DIC, renal failure, maternal death, PPH, Sheehan’s (pituitary necrosis secondary to hypovolaemic shock)
21
Q
Tx of Pre-existing HTN in pregnancy
A
- = HTN <20w
- Aim <150/100
- Stop ACEi/ ARBs
- Aspirin 75mg
- Test for proteinuria reg
- Growth scans 28 + 32w
22
Q
What is pregnancy induced hypertension, it’s stages and their management
A
= After 20w with no significant proteinuria. Resolves 6w post-partum
- Mild (<150/100)- no Tx, BP measurement weekly, urine dip each visit, routine bloods only
- Mod (<160/110)- oral labetalol, BP measurement 2x/w, urine dip each visit, bloods at presentation - U+Es, LFTs, FBC
- Severe (>160/110)- admission, oral labetalol, BP measurement QDS, urine dip daily. Bloods Presentation + weekly
23
Q
Pre-eclampsia, Presentation, Ix, Tx
A
- = >20w with HTN and proteinuria
- Presentation:
- HTN
- Headahce
- RUQ pain/ vomiting
- Blurred vision
- Hyper-reflexia/ Clonus
- Swelling
- Fundoscopy- papilloedema
- Ix:
- Bedside- urine PCR or 24h urine collection for ?proteinuria, CTG
- Bloods- U+Es, FBC (platelets), clotting, urate (??DIC)
- Imaging- growth scan
- Tx:
- Antihypertensives: labetalol, nifedipine, methyldopa
- Cure= deliver placenta. Indications to deliver- Term, IUGR, foetal distress, refractory HTN with 3 drugs at highest dose, changes in bloods, eclampsia, HELLP, DIC
24
Q
RF for pre-eclapmsia
A
- High risk: (any one –> 75mg Aspirin 12w)
- Prev. Pre-eclampsia or PIH
- DM
- Pre-existing HTN
- CKD
- SLE/ antiphospholipid
- Moderate risk (any 2 –> aspirin)
- Age >40y
- BMI >35
- Multiple preg
- Preg interval >10y
- 1st preg/ 1st preg w/ new partner
25
Q
Key features of HELLP syndrome
A
- = Haemolysis, Elevated Liver Enzymes, Low Platelets
- Haemolysis - LDH. Blood film= gold standard
- Liver enzymes- LFTs
- Platelets - FBC
26
Q
Complications of Pre-eclampsia
A
- Intracerebral haemorrhage
- Liver rupture
- HELLP/ DIC
- Eclampsia
- Renal failure
- Placental abruption
- IUGR
27
Q
Key features of eclampsia
A
- = Seizures
- Can fit after delivery - don’t discharge until >36 hours post-delivery. Reg BP and fluid restriction.
- Tx:
- BP control
- Magnesium sulfate IV –> diazepam –> lorazepam –> intubation
- Magnesium sulfate toxicity- reduced reflexes/ UO/ RR. Tingling around mouth. Antidote= sodium gluconate
28
Q
Complications of DM in pregnancy
A
Maternal
- Infections, UTIs
- Pre-eclampsia
- C-section
- Retinopathy
- Nephropathy
Foetal
- Miscarriage, IUD
- Macrosomia/ IUGR
- Congenital abnormalities
- Neonatal hypoglycaemia
- NTD
- Heart disease
- Polyhydramnios
- Miscarriage
- Risk DM later in life
- Shoulder distocia
- Pre-term
29
Q
Management of Pre-existign DM in pregnancy
A
- MDT!!!
- Pre-conception:
- HbA1c <43
- Baseline kidney function, eye check, BP
- Stop sulfonylureas, statins, ACEi
- 5mg Folic Acid
- Antenatal care:
- Booking by 8w. DM antenatal clinic every 2w.
- Cardiac scan 24w, growth scans from 28w
- Glucose monitoring. Increase insulin 2/3?. Aim BM <6.0mmol
- 75mg Aspirin >12w
- Intrapartum care:
- Delivery <29w
- C-section if est weight >4kg
- Glucose/Insulin/K+ sliding scale. Aim 4-7mmol/L. Measure every hour
- Post-partum:
- Baby- risk of hypo –> feed within 1h
- Insulin back to normal
- 6w check - HbA1c, OGTT, FBC
30
Q
RF for GDM
A
- Prev. GDM (screen 18w)
- Prev. foetus >4.5kg
- Prev. unexplained still birth
- >35y
- FDR with DM
- BMI >30
- PCOS
- Race- SE Asia, Caribbean, middle east
- Polyhydramnios
- Persistent glycosuria
- –> OGTT at 24-28w. Fasting –> bloods –> 75g glucose –> bloods 2h later
31
Q
Treatment of GDM
A
- Diet control
- Oral hypoglycaemics eg metformin
- Insulin
- Growth scans
- Delivert 38-41w
- Do fasting HbA1c at 6w. Annual testing - 40% T2DM later in life
32
Q
Key features of obstetric cholestasis
A
- Abnormal sensitivity to oestrogen –> cholestasis
- Genetic - FHx, S Asia esp
- Presentation:
- >28w
- ITCH - palms and soles, ++ night, excoriations, no rash
- Jaundice
- Ix:
- Monitor CTG.
- Elevated LFTs (ALP, GGT, Bile acids) –> measure weekly.
- Tx:
- 6w follow up. Should have resolved.
- Induce at 37w (risk still birth)
- Med- ursodeoxycholic acid, chlorphenamine, Vit K from 36w
- Cons- topical emollients
33
Q
Classification of obesity in pregnancy and complications
A
- BMI 30-34.9= Obese, 35-39.9= Severely obese, BMI >40= Morbidly obese
Maternal
Baby
Difficulty palpating foetus
Macrosomia/ IUGR
Spont + recurrent miscarriages
Foetal/ infant death
Pre-eclampsia
CVD
GDM
T1DM/T2DM
VTE
Cancer
Infections eg wound
Asthma
PPH
Congenital abnormalities
C-section + complications
34
Q
What is Rhesus Isoimmunisation and Mechanism?
A
- Rh -ve mother concieves a Rh +ve foetus (D-antigen)
- Sensitising event –> foetal cells can enter maternal blood stream –> maternal antibody response (sensitisation)
- Not a prob in 1st pregnancy (IgM can’t cross placenta) –> NEXT PREG –> IgG can cross placenta
- Immunodestruction of foetal RBCs –> Rh Haemolytic disease of newborn - RBC destruction, jaundice.
35
Q
Rhesus sensitising events
A
- DELIVERY
- Miscarriage
- Trauma
- Placental insufficiency
- TOP
- Invasive AN testing eg amniocentesis
- APH
- ECV
- Blood transfusion
36
Q
How does Anti-D work and when should it be given?
A
- Immunoglobulin injected into mother –> binds to D antigen on foetal RBCs –> cannot mount IgG response. No sensitisation.
- Given at 28w, 34w and <72h after potential sensitising event.
- Kleihauer test - how much foetal blood in maternal bloodstream = how much anti-D is needed
37
Q
Signs of foetal anaemia in Rh isoimmunisation
A
- Ix: Do Doppler of foetal MCA, foetal blood sampling if anaemia likely
- Polyhydramnios
- Cardiomegaly
- Ascites/ pericardial effusion
- Variability on CTG
- Hyperdynamic circulation
- Hydrops and foetal death in severe
- –> Tx= foetal blood transfusion/ delivery if >36w
38
Q
Management of Rh Isoimmunisation
A
- ID risk - determine foetal blood type (paternal blood), Ab testing every 2w (if increased –> look for signs of foetal anaemia)
- Assess severity - doppler foetal MCA 2 weekly. Anaemia likely –> foetal blood sample
- Tx:
- Anti-D to prevent sensitisation
- Transfuse blood if foetus anaemic. Deliver if >36w
- Post-natal check - FBC, Bili, Rh status
39
Q
Causes of maternal collapse and management
A
- Pregnancy specific - Amniotic fluid embolism, APH, PPH, eclampsia
- Non-Pregnancy specific - Sepsis, VTE, PE, haemorrhage, drug-induced, hypoglycaemia, MI, arrhythmia
- Tx:
- MEOWS >7= senior r/v ASAP
- ABCDE (don’t lie flat)
- No response to CPR in 4 mins in >20mins –> perimortem C-section
40
Q
Key features of sepsis in pregnancy
A
- Signs and symptoms may be less distinctive. Most common post-natal
- Commonest cause= GBS
- Tx: sepsis 6, continuous EFM
41
Q
Key features of post-partum pyrexia
A
- Maternal fever >38 in 1st 14d
- Common sites of infection- UTI, LRTI, mastitis, perineal, c-section wound –> O/E: abdo, breast, IV access sites, chest, legs
- Pathogens: GBS, staph, E. Coli
- Ix: Blood, urine, high vaginal and foetal swabs
- Tx: Sepsis 6. Broad spec ABx
42
Q
Key features of chorioamnionitis
A
- = Infection within the womb –> PPROM
- Common cause: E.Coli, GBS, STI, UTI
- Presentation:
- Fever
- ++ HR and foetal HR
- Foul smelling vaginal discharge
- Abdo pain
- Leukocytosis (high WCC)
- PPROM
- Ix and Tx: Sepsis 6. Swabs.
43
Q
Key features of amniotic fluid embolism
A
- Defect in amniotic sac –> pressure –> fluid into maternal blood stream –> embolises into pulm. circulation –> blockage of vessels and immunological/ inflammatory reaction –> DIC, foetal hypoxia, still birth
- Can happen PP (upto 30 mins after delivery)
- RF: TOP, amniocentesis, placental abruption, trauma, c-section
- Tx= supportive
44
Q
Why are pregnant women at increased risk of VTE and how are they risk assessed?
A
- VTE 10x more common in preg:
- Change in clotting factors - less factor 11,13 and platelets, more fibrinogen
- More venous stasis - obstruction and reduced mobility
- High mortality antenatally, higher risk post-partum
- All pregnant women assessed for VTE risk at booking, admission, labour and post-natal:
- 3 or more –> prophylaxis over 28w
- 4 or more –> Tx throughout preg
- Postnatal 2 or more –> prophylaxis
- Risk assessment based on: Prev VTE or FHx in 1st degree relative, co-morbidities, known high risk of thrombophilia, >35y, obesity, parity>2, smoker, gross varicose veins
45
Q
Presentation, Ix, and Tx of VTE in preg/post-partum
A
- Presentation- PE, DVT
- Ix:
- Bedside- obs, urine dip, measure calves, CTG
- Bloods- clotting, FBC (platelets), PT, U+Es, LFTs. NOT D-DIMER
- Imaging - Doppler USS, PE - CXR/ V/Q scan, growth scan
- Tx:
- Cons- compression stockings
- LMWH (based on risk or presentation). Tx - continue 6-8w post partum
- Prev VTE –> IV heparin
- Stop anti-coagulation 24h before labour
46
Q
RF, classification, and presentation of multiple pregnancy
A
- RF: IVF, FHx, maternal age, W African
- Presention:
- ++ Preg Sx, large
- >1 heart beat (>10bpm)
- Labda sign on USS
- Classification:
- Dizygotic- non-identical.
- Monosyzgot- single egg splits –> timing determines chorionicity (placentas) and amnionicity (sacs)
47
Q
Complications of Multiple Pregnancy
A
Mother
- Miscarriage
- Anaemia
- Pre-eclampsia
- DM
- APH/PPH
Baby
- Stillbirth
- Pre-term labour
- Malpresentation
- IUGR
- Foeto-foetal transfusion syndrome à HF in recipient
- Congenital abnormalities
- Cord entanglement/ prolapse
- Development/social consequences
- Polyhydramnios
48
Q
Antenatal care and intrapartum care of multiple pregnancy
A
- High dose folic acid
- Aspirin 75mg
- ?Iron if anaemia
- 1st trimester scan to determine chorionicity and amnionicity
- Mono –> 2 weekly scans from 16w
- Di –> 4 weekly scans from 20w
- Intrapartum;
- IV syntocin drop
- C-section if mono, non-cephalic prsentation of 1st twin, triplets, other RF
49
Q
Different types of breech presentation
A
50
Q
Management of Breech presentation
A
- ECV:
- >36w (>37 if multiparous)
- NB prophylactic Anti-D
- Tocolytic meds + analagesia –> ECV
- Contraindications- labour, prev c-sec, APH, abnormal uterus, abnormal CTG, multiple preg
- Risks- placental abruption, cord damage, uterine rupture, PPROM
- Spon Breech delivery:
- Trained staff. Lying down on back with manoevers
- Risks: Anoxia due to prolapsed cord, traumatic injury to aftercomign head, fracture spine/ arm
- Continuous CTG
- C-Section:
- Indications- footling, large, small, narrow pelvis, no trained professionals
51
Q
Definition of IUGR and classification
A
- = Estimated weight/ abdo circumference <10th centile of customised growth chart (weight, height, ethnicity, parity, Hx past pregs)
- Classification:
- Constitutionally small eg short mum
- Non-placenta mediated growth restriction - structural/ chromosome abnormality, inborn errors of metabolism
- Symmetrical - early preg
- Mixed
- Asymmetrical- late. Head/ femur length diff
52
Q
RF for IUGR
A
- >35y
- Infection
- Nulliparity
- Pre-eclampsia
- Prev SGA/ still birth
- Malnutrition
- Medical condtion affecting BF eg antiphospholipid, AI, renal, BP, DM
- Smoking/ substances
- Low/high BMI
- DM
67
Q
Classification of perineal trauma
A
- Injury to skin only
- Involves perineal muscles (+ episotomy)
- Involves anal sphincter complex
- Involves anal sphincter and anal epithelium
