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obs and gynae Flashcards

1
Q

Define puerperium

A

From the delivery of the placenta to six weeks following the birth

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2
Q

Stages of the puerperium

A

Return to prepregnant state
Initiation/suppression of lactation
Transition to parenthood

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3
Q

Endocrine changes in puerperium

A

Decreased placental hormones

Increase in prolactin

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4
Q

Name 4 placental hormones

A

Human placental lactogen
Hcg
Oestrogen
Progesterone

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5
Q

How long does it take for progesterone and oestrogen levels to go back to prepregnant levels

A

7 days

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6
Q

What does the muscle of the uterus and genital tract do

A

Ischaemia, autolysis and phagocytosis

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7
Q

What does teh decidua of the puerperium do

A

Shed as lochia; rubra, serosa and alba

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8
Q

Where is the uterus 1 day after delivery

A

Umbilicus

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9
Q

What is lochia rubra

A

Day 0-4 of bleeding

  • blood
  • cervical discharge
  • decidua
  • vernix
  • meconium
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10
Q

What is lochia serosa

A 
Day 4-10 of bleeding
-more pink
WBC
Exudate
Cervical mucus
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11
Q

What is lochia alba

A

Day 10-28 of bleeding

  • clear liquid
  • cholesterol
  • fat
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12
Q

What is Colostrum

A

Produced instantly.
Colostrum – is very rich in proteins, vitamin A, and sodium chloride, but contains lower amounts of carbohydrates, lipids, and potassium than mature milk.

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13
Q

Advantage and disadvantage of colostrum

A

Doesnt help with putting on weight but does contain WBC

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14
Q

How long does lactation suppression take if the mother isnt breast feeding

A

7-10 days

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15
Q

What hormones control lactogenesis

A

Prolactin (milk production)
Oxytocin (milk ejection reflex)
Insulin and cortisol

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16
Q

Where is prolactin secreted from

A

Anterior pituitary gland

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17
Q

Where does prolactin act on

A

Lactocytes

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18
Q

When are prolactin levels highest

A

More secreted at night

Peak after feed to produce milk for following

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19
Q

Which hormone post partum suppresses ovulation

A

Prolactin

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20
Q

Where is oxytocin released

A

Posterior pituitary gland

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21
Q

Where does oxytocin act in breast feeding

A

Myo epithelial cells

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22
Q

What stimulates oxytocin and prolactin release

A

Baby sucks

= sensory impulses pass from the nipple to brain

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23
Q

What helps oxytocin reflex

A

Sight, sound and smell of baby. Conditioned over time

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24
Q

What hinders oxytocin reflex

A

Anxiety, stress, pain and doubt

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25
Q

Advantages of breast feeding for mother

A

Breast cancer
Ovarian cancer
Osteoporosis

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26
Q

What is lactoferrin

A

High affinity for iron protein. High in colostrum. In breast milk too. Antibacterial qualities.

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27
Q

When do you use follow on milk

A

After 6 months

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28
Q

Name some minor postnatal problems

A 
Infection
PPH
Fatigue
Anaemia
Backache
urinary stress Incontinence
Haemorrhoids
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29
Q

Name some major postnatal problems

A 
Sepsis
Severe PPH
Preeclampsia
Thrombosis
Incontinence
Breast abscess 
Depression
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30
Q

Describe PPH presentation

A

Sudden and profuse blood loss or persistent increased blood loss
Faintness, dizziness or palpitations/tachycardia

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31
Q

Describe Infection presentation

A

Fever, shivering, abdominal pain and/or offensive vaginal loss

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32
Q

What does PPH stand for

A

Post partum haemorrhage

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33
Q

What is the preeclampsia presentation

A

Headaches accompanied by one or more of the following symptoms within first 72hrs after birth: Visual disturbances, Nausea or vomiting

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34
Q

What is thromboembolism presentation

A

Unilateral calf pain, redness or swelling

Shortness of breath or chest pain

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35
Q

Postnatal care assessment tool

A

Modified Early Obstetric Warning Score (MEOWS)

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36
Q

Sepsis definition

A

Infection plus systemic manifestations of infection

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37
Q

Severe sepsis definition

A

Sepsis plus sepsis induced organ dysfunction of tissue hypoperfusion

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38
Q

SROM define

A

Sustained rupture of membrane

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39
Q

Septic shock define

A

The persistence of hypoperfusion despite adequate fluid replacement therapy

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40
Q

Rhyme for sepsis

A

3 Ts white with Sugar

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41
Q

What are the signs of infection

A 
Temperature
Tachycardia
Tachypnoea
WCC high or low
Hyperglycaemia
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42
Q

How many signs of infections are needed for sepsis

A

2

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43
Q

Risk factors for sepsis

A 
Obesity
Diabetes
Anaemia
Amniocentesis/invasive procedures
Prolonged SROM
Vaginal trauma/CS
Ethnicity BME
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44
Q

Likely causes of sepsis

A 
Endometritis
Skin and soft tissue infection
Mastitis
UTI
Pneumonia
Gastroenteritis
Pharyngitis
Infection related to epidural/spinal
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45
Q

What else should you do when looking at potentially septic woman

A

History or signs of a new infection or infective source

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46
Q

BUFALO plus two

A 
Blood cultures
Urine output
Fluid restriction
Antibiotics
Lactate
Oxygen
\+ERPC
\+VTE prophylaxis
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47
Q

Primary PPH

A

More than 500ml

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48
Q

Minor PPH

A

<1500mls and no clinical signs of shock

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49
Q

Major PPH

A

> 1500mls and continuing or clinical shock

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50
Q

Endometritis defintition

A

Infection of the lining of the womb

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51
Q

Secondary PPH define

A

Abnormal bleeding from birth canal from 24hrs to 12 weeks

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52
Q

Secondary PPH causes

A 
Endometritis
Retained products of conception (RPOC)
Subinvolution of the placental implantation site
Pseudoaneurysms 
Arteriovenous malformations
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53
Q

Secondary PPH investigations

A

Assess blood loss
Assess haemodynamic status
Bacteriological testing (HVS and endocervical swab)
Pelvic ultrasound??

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54
Q

What can eclampsia cause

A

Seizures

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55
Q

What increases risk of VTE

A 
Gestational age.
Just after birth (3weeks) 
Obesity
Multiple pregnancies
Genetics
Smoking
C section
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56
Q

What is given in high risk women for VTE

A

LMWH 6 weeks

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57
Q

What is given in intermediate risk women for VTE

A

10 day LMWH

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58
Q

What is given in lower risk women for VTE

A

Early mobilisation and avoidance of dehydration.

TED stockings

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59
Q

What can cause a headache post partum

A

Post dural puncture headache from epidural or spinal anaesthesia

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60
Q

Symptoms of post dural puncture headache

A 
Headache
worse on sitting or standing
Starts 1-7 days after spinal/epidural sited
Neck stiffness
Dislike of bright lights
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61
Q

Treatment of post dural puncture headache

A

Lying flat!
Simple analgesia
Fluids and caffeine??
Epidural blood patch

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62
Q

What must you do to prevent urinary retention and distention

A

Indwelling catheter

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63
Q

Urinary retention risk factors

A 
Epidural analgesia
Prolonged second stage of labour
Forceps or ventouse delivery
Extensive perineal lacerations
Poor labour bladder care
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64
Q

What is urinary retention treatment aiming to do

A

Maintain bladder function
Minimise risk of damage to UT
Prevent bladder emptying problems

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65
Q

Red flags for mental health

A
  • recent significant change in mental state or emergence of new symptoms
  • new thoughts or acts of violent self harm
  • new and persistent expressions of incompentency as a mother or estrangement from the infant
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66
Q

Why is urinary retention more likely to happen

A

Epidurals so dont feel the sensations.

Trauma during birth

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67
Q

Why baby blues and common

A

Hormone changes
Big change
Sleep deprived
Day 3-10

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68
Q

Postnatal depression symptoms

A 
Depressed
Irritable
Tired
Sleepless
Appetite changes
Negative thoughts
Anxiety
Affects bonding
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69
Q

Postpartum psychosis risk factors

A

FHx
Bipolar diagnosis
Traumatic birth or pregancy

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70
Q

Postpartum psychosis symptoms

A 
Depression
Mania
Psychosis.
-restless
-unable to sleep
-unable to concentrate
-experiencing psychotic symptoms
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71
Q

Risk factors for PTSD

A

Perceived lack of care
Poor communication
Perceived unsafe care
Perceived focus on outcome over experience of the mother

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72
Q

PTSD presentation

A

Anger, low mood, self-blame, suicidal ideation, isolation and dissociation
Intrusive and distressing flashbacks

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73
Q

PTSD consequences

A

Women may delay or avoid future pregnancies
Request caesarean sections to avoid vaginal delivery
Avoidance of intimate physical relationships
Impact on breastfeeding

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74
Q

Define Maternal death

A

Death within pregnancy or 42 days of termination of pregancy

  • any duration
  • any site
  • any cause related to or aggravated by pregnancy or its management.
  • not accidental or incidental causes
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75
Q

Direct maternal death definition

A

Death relating from obstetric complications of pregnancy, labour of puerperium (e.g haemorrhage, genital sepsis, suicide)

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76
Q

Indirect maternal death definition

A

Death resulting from pre-existing disease / disease that developed in pregnancy but not a direct result of obstetric causes (cardiac disease, malignancies)

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77
Q

Why is VTE rate the same as 80s

A

Older fatter mums

Prevention measures

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78
Q

Gonadotrophin hormones

A

LH, FSH, hCG

  • gonadotrophs
  • glycoproteins
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79
Q

Steroid hormones

A

Oestrogens
Progestins
Androgens

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80
Q

Cytokines

A

Activins

Inhibins

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81
Q

Describe thecal cells

A

Sensitive to LH
Synthesise Progesterone and Testosterone from cholesterol
Androgens (E precursors)

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82
Q

Describe granulosa cells

A

Sensitive to FSH
Converts Testosterone to E
FSH induces LH receptors

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83
Q

What stops LH and FSH increasing at cycle day 15.

A

P and E made by corpus luteum negatively feedbacks to pituitary

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84
Q

Which hormone causes follicle to be selected

A

FSH rise

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85
Q

LH surge is controlled by

A

Oestrogen. Flips from negative feedback to positive

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86
Q

What does LH surge cause

A

Ovulation

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87
Q

Pregnancy homrones

A

hCG
Progesterone
Oestrogens

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88
Q

What produces hCG and whats the point

A

Blastocyst. Stops progesterone declining as stops luteal regression.

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89
Q

Progesterone action

A

Endometrial development
Stops uterus contracting too early
Promotes fat deposition
Increases maternal ventilation

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90
Q

Where is oestrogen coming from

A

Ovary then both baby and mum

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91
Q

Which is the main oestrogen in pregnancy

A

E3

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92
Q

What would happen if you had no oestrogen

A

No progesterone would be made either

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93
Q

What happens to resp

A

Reduced inspiratory reserve

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94
Q

What happens to cardio

A

Increased HR and SV

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95
Q

Why should blastocyst be rejected

A

50% antigens from dad

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96
Q

Why isnt the blastocyst rejected

A

Differential gene expression.

Immune suppression

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97
Q

Failed endovascular invasion is associated with

A 
Pre eclampsia
IUGR
Pre term labour
Abruption
Recurrent miscarriage
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98
Q

When is the window of implantation

A

20-24 days

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99
Q

What is decidua

A

Early endometrium which permits implantation

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100
Q

What is human implantation called

A

Haemochrorial placentation

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101
Q

Stages of implantation

A
  1. Apposition
  2. Interstitial implantation
  3. Interstitial invasion
  4. Endovacular invasion
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102
Q

Which arteries are targeted by the invasion

A

Spiral arteries

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103
Q

Define pregnancy

A

Pregnancy anywhere outside the uterus

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104
Q

Names of stages of placenta

A

Placenta acreta, increta, percreta

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105
Q

Which t cell is biased in pregnancy

A

Th2

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106
Q

Which Ig is secreted in breast milk

A

IgA

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107
Q

Which Ig crosses the placenta

A

IgG

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108
Q

Which Ig is involved in rhesus disease

A

IgG

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109
Q

Rhesus disease describe

A

First pregancy sensitises mother, subsequent pregnancies can result in fetal death

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110
Q

In rhesus disease who is rhesus positive

A

Father

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111
Q

Where is the acreta

A

Superficial myometrium

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112
Q

Where is the increta

A

Deeper myometrium

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113
Q

Where is the percreta

A

Penetrates uterine serosa

Effects other organs

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114
Q

Myometrial quiescence

A

Absence of uterine contractions

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115
Q

How is contraction prevented

A

G alpha S represses acto myosin ATPase activity.

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116
Q

What causes labour

A

Infection can
Surfactant proteins
Placental clock

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117
Q

Placental clock

A

ACTH = DHEA = Oestrogens increase gap junctions= increased contractility

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118
Q

What happens to progesterone before birth

A

Functional progesterone withdrawal

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119
Q

Which drug can be used to stop contraction

A

Nifedipine. Calcium blocker.

Atosiban- Oxytocin receptor anatagonist

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120
Q

Placental delivery mechanisms

A

Rpaid myometrial contraction
Physiological pressure
Immediate fibrin deposition over placental site

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121
Q

Drugs to inhibit uterine contraction

A

Beta 2 mimetics
Nifedipine
Progesterone
Atosiban

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122
Q

Drugs to promote uterine uterine contraction

A

Syntocinon
Ergometrine
Misoprostol

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123
Q

How is quiescence maintained

A

G proteins signally

K+ extrusion from myometrial myocytes

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124
Q

Why does K+ extrusion from myometrial myocystes reduce contractions

A

Hyperpolarisation

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125
Q

Early pregnancy glucose levels

A

Lower. Maternal glycogen synthesis and fat deposition

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126
Q

Late pregnancy glucose levels

A

Higher. Maternal insulin resistnace. Glucose sparing for fetus

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127
Q

What can maternal insulin resistnace cause

A

Gestational diabetes

Macrosomic infants

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128
Q

What can macrosomic infants cause

A

Shoulder dystocia

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129
Q

Why use contraception

A

Control fertility
Family spacing
Reduce teenage pregnancy
Reduce abortions

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130
Q

Fraser criteria

A

Contraception can be prescribed to a girl
under 16 yrs old if:-
-The girl understands the doctors advice
-The doctor has tried to persuade her to tell her parents or allow him to
-She will begin or continue having intercourse without contraception
-Her physical or mental health is likely to suffer if she does not receive contraceptive advice
-Her best interests require the prescriber to give contraceptive advice +/- treatment without parental consent

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131
Q

Assessment for contraception (history)

A 
Age
Weight
BP
Menstrual history
Previous contraception
Previous pregnancies
Previous STIs
PMHx
FHx
SHx
DHx
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132
Q

Assessment for contraception (examination)

A

BP
BMI
Cervical smear
STI screen

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133
Q

User failure contraceptive examples

A

Combined OCP
Contraceptive patch
POP
Barrier methods

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134
Q

Non user failure contraceptive examples

A 
Contraceptive injection
Implant
IUD
IUS
Sterilisation
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135
Q

Most effective contraceptive

A

Progesterone implant

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136
Q

How does COCP work

A

Oestrogen and progesterone. Prevents ovulation. Thickens cervival mucus. Thins lining of the womb.

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137
Q

COCP advantages

A

Reversible, reliable, regular predictable cycle. Well tolerated

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138
Q

Who cant have COCP

A

FHx of female cancers

Clotting disorders

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139
Q

COCP disadvantage

A

Lots of people cant have it. Drug interactions. Doesnt protect against STIs.
VTE and cancer risk

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140
Q

How does POP or mini pill work

A

Progesterone only. Thickens cervical mucus. Thins endometrium. Reduced tubal motility.

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141
Q

Progesterone only contractive advantages

A

Anyone.

Prevents oestrogen SE

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142
Q

Progesterone only contraceptive disadvantages

A

Less effective.
Erratic bleeding to start with.
Risk of ovarian cysts and ectopics

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143
Q

Condom disadvantages

A

Failure

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144
Q

Femidom advantages

A

Protects from STIs
Inserted any time
No lubrication

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145
Q

Femidom disadvantages

A

Loud
Messy
Higher failure rate

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146
Q

Diaphragm and caps advantages

A

Woman in control

Inserted anytime before inercourse

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147
Q

Diaphragm and caps disadvantages

A

Requires staff for fitting
Messy
Dislodged

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148
Q

What is natural family planning

A

Monitor vaginal secretions and temperature measurements. Needs periods of abstinence and montioring.

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149
Q

What is lactational amenorrhea method

A

Baby must be only on breast milk

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150
Q

Injectable contraception

A 
Depo-provera
Every 12 weeks. 
Inhibits ovulation
Sayana press- self inject it.
Progesterone only
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151
Q

Why do injectables cause weight gain

A

Increase appetite

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152
Q

Describe implants

A

Single rod (nexplanon). Progesterone only. Easy insertion and removal. 3 years.

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153
Q

IUD describe

A

Copper contained in plastic frame. Casues foregin body reaction within the uterus , toxic to sperm and egg significantly reducing chance of fertilization

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154
Q

Why do you need to do STI screen when giving a coil

A

Prevent PID

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155
Q

IUS describe

A

Menorrhagia, progesterone HRT. Very effective few side effects.
Very small amount of progesterone

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156
Q

Female sterilisation

A

Serious surgery, GA. No hormonal effects. Permanent.

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157
Q

Male sterilisation

A

Local anaesthetic. Surgery to vas deferens. Not reversible or immediate.

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158
Q

What is Emergency Contraception

A

EC is given after unprotected sexual intercourse to prevent pregnancy

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159
Q

Emergency contraceptions examples

A

Progesterone only (Leveonelle) pills or copper implants. Copper coil is more effective and can be used later.

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160
Q

Describe the latent phase of labour

A

irregular contractions
Show mucoid plug
Cervix is effacing and thinning
Stay at home

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161
Q

Treatment for latent phase of labour

A

Position, water, snacks, paracetamol

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162
Q

Length of latent phase of labour

A

6 hours - 2/3 days

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163
Q

Define presentation

A

The anatomical part of the fetus which presents itself first through the birth canal

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164
Q

Define lie

A

The relationship between the long axis of the fetus and the long axis of the uterus

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165
Q

Define attitude

A

Presenting part flexed or deflexed

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166
Q

Define engagement

A

Widest part of the presenting part has passed through the brim of the pelvis

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167
Q

Define station

A

Relationship between the lowest point and the ischial spines

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168
Q

Describe Effacement

A

Starts in fundus. Retraction and shortening of muscle fibres. Fetus forced down pressure on cervix

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169
Q

How does effacing of the cervix vary with number of previous labours

A

First time mothers will take longer

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170
Q

Active labour definition

A

Regular, frequent contractions which are progressive. 4cm dilated

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171
Q

What inhibits oxytocin

A

Stress and anxiety

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172
Q

Factors which affect labour satisfaction

A
  1. Personal expectations
  2. Support from caregivers
  3. Caregiver-paitent relationship
  4. Involvement in decisions
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173
Q

Ways to deal with pain

A

Psychological methods
Sensory methods
Environment
Complementary therapy

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174
Q

more support is associated with

A

Less operative births
Less analgesia
Shorter labours
Better experience

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175
Q

What is the official name of gas and air

A

Entonox

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176
Q

Advantage of entonox

A

Short half life so leaves system quickly

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177
Q

Disadvantage of entonox

A

Vomitting

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178
Q

Diamorphine advantage

A

good pain releif

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179
Q

Diamorphine fetal SE

A

Respiratory depression

Diminishes breast seeking and feeding behaviour

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180
Q

Diamorphine maternal SE

A

Euphoria and dysphoria
Nausea and vomiting
Longer 1st and 2nd stage laboru

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181
Q

Epidural advantage

A

Most effective pain relief

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182
Q

Epidural maternal SE

A 
Increase length
Need more oxytocin 
More incidents of malposition
Increase instrumental rate.
Less mobile, less bladder control
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183
Q

Epidural fetal side effects

A

Tachycardia due to maternal temp

Diminishes breast feeding behaviours

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184
Q

Can you eat during labour

A

Should eat and drink as normal unless c section likely

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185
Q

Maternal observations during labour

A 
BP, Pulse, Temp
Bladder
Contractions
Drugs
Vaginal examination
Monitoring fetal heart
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186
Q

What is the transition of labour

A 
SROM- clear
Irritable, anxious, distressed
Start to feel pressure
Contrations can stop
Support and reassurance
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187
Q

What is second stage of labour

A 
Full dilatation
External signs- head visible
Spont bearing down
Can have a latent phase
Progress descent
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188
Q

How long does it take for active phase in primigravid

A

3 hours

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189
Q

How long does it take for active phase in multiparous

A

2 hours

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190
Q

What is helpful behaviour in second stage

A

Beneficial, upright position, spontaneous pushing. Privacy, dignity, safety

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191
Q

Mechanism of labour

A 
Descent
Flexion
Internal rotation
Crowning
Extension
Restitution
Internal restituion of shoulders
Lateral flexion
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192
Q

Why is skin to skin good

A

Very good. Releases oxytocin

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193
Q

What is 3rd stage

A

Cut and clamp cord. Oxytocic drugs. N and V. Check placenta and membranes complete.

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194
Q

What is PID

A

Pelvic inflammatory disease

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195
Q

What is NSU

A

Non specific urethritis

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196
Q

Non STI GU conditions

A 
Candidiasis
Bacterial vaginosis
Gential dermatoses
Vulval conditions
Psychosexual problems
Reactive arthritis
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197
Q

What is candidiasis

A

Imbalance of pH of the vulva

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198
Q

Sexual health history structure

A 
HPC
Past GU
PMH
DH
Sexual history
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199
Q

Questions for sexual history

A

3-12 months

  • last intercourse
  • regular/ casual partner
  • male/female
  • condom use
  • type of SI
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200
Q

Sexual health history questions for females

A

Menstrual history
Pregnancy history
Contraception
Cervical cytology history

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201
Q

Sexual health history questions for males

A

When last voided urine

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202
Q

Big 4 STIs

A

Syphilis
Chlamydia
Gonorrhea
HIV

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203
Q

Genital examination for both sexes

A

Skin
Inguinal nodes
Pubic hair

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204
Q

Genital examination for women

A 
Vulva
Perineum
Vagina
Cervix
Bimanual pelvic examination
Possibly anus and ororpharynx
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205
Q

Genital examination for men

A

Penis
Scrotum
Urethral meatus
Anus and Oropharynx in MSM

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206
Q

Asymptomatic screening for women

A

Self taken vulvo vaginal swab
(for Gonorrhoea/Chlamydia NAAT)
Bloods (for STS and HIV)

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207
Q

What is NAAT

A

Nucleic Acid Amplification Test

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208
Q

Why must patients be off antibiotics for two weeks before STI testing

A

False negative

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209
Q

Asymptomatic screening for heterosexual male

A

First void urine (chlamydia/ gonorrhoea NAAT)

Bloods (STS and HIV)

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210
Q

MSM screening

A

First void urine, pharyngeal swab and rectal swab (chlamydia/ gonorrhoea NAAT)
Bloods (STS, HIV, Hep B (Hep C if indicated))

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211
Q

Female symptomatic presentations

A 
Vaginal discharge
Vulval discomfort/soreness, itching or pain
Superficial dyspaerunia
Pelvic pain
Vulval lumps or ulcers
Inter menstrual bleeding
Post coital bleeding
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212
Q

Male symptomatic presentations

A 
Pain on micturition
Pain/ discomfort in urethra
Urethral discharge
Genital ulcers, sores or blisters
Genital lumps
Rash
Testicular pain/ swelling
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213
Q

Symptomatic female screening

A 
Vulvovaginal swab (Gono and Chlamy NAAT)
High vaginal swab (BV, TV, Candida)
Cervical swab (Gono)
Dipstick urinalysis
Bloods (STS and HIV)
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214
Q

Symptomatic male screening

A

Urethral swab (gono)
First void urine (Gono and chlam NAAT)
Dipstick urnialysis
Bloods (STS and HIV)

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215
Q

MSM Symptomatic screening

A

Asymptomatic
+ urethral and rectal slides
+ urethral, rectal, pharyngeal culture plates

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216
Q

Hepatitis B screening

A 
MSM
Commercial sex workers (+partners)
IVDUs (+partners)
High risk areas 
-africa, asia, eastern europe (+partners)
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217
Q

Why do you need to culture gonorrhea

A

Because gonorrhea resistance is increasing

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218
Q

What predisposes to preeclampsia

A 
Younger
Older
Black
Primigravity
Multifetal pregnancies
HTN
Renal disease
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219
Q

What is chronic hypertension

A
  • before pregnancy
  • before 20th week
  • during pregnancy and not resolved post partum
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220
Q

What is gestational hypertension

A
  • new HTN after 20weeks
  • systolic >140
  • diastolic >90
  • no or little proteinuria
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221
Q

Whats the difference between gestational hypertension and preeclampsia

A

Preeclampsia is where they have developed significant proteinuria

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222
Q

What is the difference between preeclampsia and eclampsia

A

Eclampsia is where they develop tonic clonic seizures

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223
Q

What is preeclampsia- eclampsia

A
  • new HTN after 20 weeks

- increased BP with proteinuria

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224
Q

How do you take BP in pregnant women

A

Sitting position
Cuff at heart level
Not supine as would press on IVC
Sit for 10mins before

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225
Q

Classification of preeclmapsia eclampsia

A

Mild preeclampsia
Severe preeclampsia
Eclampsia

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226
Q

Clinical criteria for severe preeclampsia (one or more)

A 
BP: >160 systolic,   >110 diastolic
Proteinuria: >5gm in 24 hrs, over 3+ urine dip
Oliguria: < 400ml in 24 hrs
CNS: Visual changes, headache, scotomata, mental status change
Pulmonary Edema
Epigastric or RUQ Pain
Impaired Liver Function tests
Thrombocytopenia: <100,000
Intrauterine Growth Restriction
Oligohydramnios
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227
Q

Preeclampsia Superimposed Upon Chronic Hypertension

A

HT with or without proteinuria.

Can be thrombocytopenia and abnormal ALT/AST

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228
Q

How does preeclampsia effect the placenta

A

Failure of physiological change in spiral arteries. They dont dilate and they remain tortuous. Leading to ischaemic placenta and oxidative stress

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229
Q

How does preeclampsia affect the placenta

A

GFR and renal blood flow decrease
Raised uric acid levels
Proteinuria
Hypocalciuria; alterations in regulatory hormones
Impaired Na excretion and suppression of renin angiotensin system.

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230
Q

Preeclampsia affect on coagulation system

A

Thrombocytopenia; low antithrombin III; higher fibronectin.

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231
Q

Preeclampsia affect on liver

A

HELLP syndrome (Haemolysis, Elevated ALT and AST, and Low Platelet count).

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232
Q

Preeclampsia affect on CNS

A

Eclampsia
headache and visual disturbances
Scotomata
cortical blindness.

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233
Q

Symptoms fo preeclampsia

A 
Visual disturbances. 
Headache similar to migraine.
Epigastric pain - hepatic swelling and inflammation, stretch of liver capsule
± Oedema 
Rapid weight gain
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234
Q

Physical findings in preeclampsia

A

Blood Pressure
Proteinuria
Retinal vasospasm or oedema
Right upper quadrant (RUQ) abdominal tenderness
Brisk, or hyperactive, reflexes common during pregnancy
Ankle clonus is a sign of neuromuscular irritability that raises concern.

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235
Q

Differential diagnosis for preeclampsia

A

Thrombotic Thrombocytopenic Purpura
Haemolytic Uremic Syndrome
Acute Fatty Liver of Pregnancy

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236
Q

Lab tests for preeclampsia

A

Haemoglobin, platelets
Serum uric acid
Liver function tests
If 1+ protein by clean catch dip stick
Timed collection for protein and creatinine
Accurate dating and assessment of fetal growth

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237
Q

Preeclampsia treatment goal

A

prevent eclampsia and other severe complications

Palliate maternal condition to allow fetal maturation and cervical ripening.

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238
Q

Preeclampsia treatment

A

Hospitalisation
new-onset PE - to assess maternal and fetal conditions.
preterm onset of severe gestational hypertension or preeclampsia.
Ambulatory management at home or day-care unit for mild gestational hypertension

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239
Q

Indications for delivery in preeclampsia- maternal

A

Gestational age 38 wks
Platelet count < 100,000 cells/mm3
Progressive deterioration in liver and renal function
Suspected abruptio placentae
Persistent severe headaches, visual changes, nausea, epigastric pain, or vomiting
Delivery should be based on maternal and fetal conditions as well as gestational age.

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240
Q

Why do you give magnesium sulfate in preeclampsia

A

To stop fits/ eclampsia developing

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241
Q

Indications for delivery in preeclampsia- fetal

A

Severe fetal growth restriction
Nonreassuring fetal testing results
Oligohydramnios

Delivery should be based on maternal and fetal conditions as well as gestational age.

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242
Q

Preferrable delivery route for preeclampsia

A

Vaginal

Inducing can help

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243
Q

Which HTN drugs are used in pregnancy

A

Labetalol

Nifedipine

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244
Q

Premature definition

A

Before 37 weeks

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245
Q

Low birth weight baby definition

A

Less than 2.5kg

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246
Q

Can a baby be premature but not LBW

A

Yes

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247
Q

Can a baby be LBW but not premature

A

Yes

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248
Q

Why are more premature babies surviving

A 
Antentatal steroids
Artificial surfactant
Ventilation
Nutrition
Antibiotics
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249
Q

Risk factors for pre term birth

A 
Preterm labour
PPROM
Cervical weakness
Amnionitis
Medical/ obstetric disorders
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250
Q

Non recurrent risk factors for PTB

A

APH
Vaginal bleeding
Multiple pregnancy

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251
Q

Recurrent risk factors for PTB

A 
Black race
Previous preterm birth
Smoking
Genital infection
Cervical weakness
Socioeconomic
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252
Q

How can you prevent PTB (primary)

A

Smoking and STD
Planned pregnancy
Health advice

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253
Q

How can you prevent PTB (tertiary)

A

Prompt diagnosis
Drugs: Tocolytics
Anitbiotics
Corticosteroids

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254
Q

Diagnosis of preterm labour

A

Persistent uterine activity AND change in cervical dilatation and/or effacement

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255
Q

How can you prevent PTB (secondary)

A

Select increased risk for surveillance and prophylaxis

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256
Q

Screening for preterm labour

A

Transvaginal cervical ultrasound

Qualitative fetal fibronectin test

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257
Q

False positives for fibronectin test

A

Cervical manipulation
Sexual intercourse
Lubricants
Bleeding

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258
Q

How can you prevent PTB developing in high risk

A

Progesterone pessary

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259
Q

What increases chance of urinary incontinence

A

Smoking
Obesity
Multiparty
Age

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260
Q

Why does genital tract atrophy after menopause

A

Oestrogen makes cells have more glycogen and therefore water

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261
Q

What is the pathophysiology of overactive bladder

A

Involuntary bladder contractions

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262
Q

Define incontinence

A

Involuntary leakage of urine

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263
Q

What is the pathophysiology of stress urinary incontinence

A

Sphincter weakness

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264
Q

Is stress or urge incontinence large volume leakage

A

Urge

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265
Q

What causes fistulas

A

Cancers

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266
Q

Other than stress and urge incontinence name 5 more

A 
Fistula
Neurological
Overflow
Functional
Mixed
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267
Q

Overactive bladder presentation

A 
Urgency incontinence
Frequency
Nocturia
Nocturnal enuresis
Intercourse
'Key in door'
'Handwash'
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268
Q

Stress incontinence presentation

A 
Cough
Laugh
Lifting
Exercise
Movement
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269
Q

Simple urinary assessments

A

Frequency volume chart
Urinalysis
Residual urine measurement
Questionnaire

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270
Q

What does Frequency volume chart tell you

A 
Voided volume
Frequency of urination
Quantity and frequency of leakage
Fluid intake
Diurnal variation
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271
Q

Likely diagnosis from nitrites on MSU

A

Infection

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272
Q

Likely diagnosis from Leukocyte on MSU

A

Infection

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273
Q

Likely diagnosis from Microscopic haematuria on MSU

A

Glomerulonephritis, nephropathy, neoplasia, calculus, infection

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274
Q

Likely diagnosis from Proteinuria on MSU

A

Renal disease, cardiac disease

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275
Q

Likely diagnosis from glycosuria on MSU

A

Diabetes, IGT, nephropathy, reduced renal threshold

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276
Q

Incontinence questionnaire main categories

A

Urinary
Vaginal
Bowel
Sexual

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277
Q

Treatment for stress incontinence

A

Conservative (Physio)
Surgery (Sling, suspension).
Aiming to strengthen the sphincter

278
Q

Treatment for overactive bladder

A 
Bladder drill
Drugs 
Botox
Augment
Bypass
279
Q

Drugs used for overactive bladder

A

Anticholinergic

280
Q

General treatment for incontinence

A

Reassurance
Support
Lifestyle adaptation
Containment

281
Q

What are the containment options for incontinence

A 
Bladder bypass: Catheters 
Leakage barriers (pads &amp; pants) 
Vaginal support devices 
Skin care 
Odor control
282
Q

Lifestyle adaptations for incontinence

A

Weight loss
Smoking cessation
Reduce caffeine
Avoid straining and constipation

283
Q

Which hormone can be given to treat incontinence

284
Q

Destrusor muscle neurotransmitter

A

Acetylcholine

285
Q

Destrusor muscle receptors

A

Muscarinic (M2 and M3)

286
Q

Which drug is used for incontinence

A

Oxybutinin- anticholinergic

287
Q

What are the side of effects of antimuscarinics/ anticholinergics

A

Dry mouth
Blurred vision
Drowsiness
Constipation

288
Q

Which injection is used for incontinence when tablets havent worked

289
Q

What non surgical things can be done for incontinence

A

Catheter
Pads
Physio

290
Q

Surgery for stress incontinence princaples

A

Restore pressure transmission to urethre
Support urethra
Increase urethral resistance

291
Q

Prolapse history

A

SCD pain
Lump
Discomfort
Pelvic floor and sexual symptoms

292
Q

Prolapse examination

A

Sims speculum

293
Q

Prolapse investigations

A

Usually none (urodynamics, MRI, ultrasound)

294
Q

Prolapse treatment

A

Reassuranc eand advice
Treat pelvic floor symptoms
Pessary
Surgey

295
Q

What is the pouch of douglas

A

Between the uterus and the rectum

296
Q

What is supporting the uterus so it doesnt fall out

A

Pelvic floor muscle
Fascia
Uterosacral ligaments

297
Q

Symptomatic prolapse describe

A

Dyspareunia
Discomfort
Obstruction
Bothersome

298
Q

Severe prolapse describe

A

Outside vagina
Ulcerated
Failed conservative measures

299
Q

Two main things that cause prolapse

A

Childbirth (primary damage)

Age

300
Q

Conditions which could predispose to prolapse

A

Connective tissue disorders like Ehlers Danlos

301
Q

Anterior prolapse

302
Q

Posterior prolapse

303
Q

Uterus prolapse

A

Enterocele

304
Q

Main operation for enterocele

A

Vaginal hysterectomy

305
Q

Define menstruation

A

Monthly bleeding from reproductive tract induces by hormonal changes of the menstrual cycle.

306
Q

What is the length of the menstrual cycle

A

The length of a menstrual cycle is the time from the start of a period to the start of the next

307
Q

How much blood loss is normal

308
Q

Which hormone is higher in follicular phase

309
Q

Which hormone is higher in luteal phase

A

Progesterone

310
Q

On which day does ovulation occur

311
Q

Define menorrhagia

A

Heavy Menstrual Bleeding that occurs at expected intervals of the menstrual cycle

312
Q

Define intermenstrual bleeding

A

Uterine bleeding that occurs between clearly defined cyclic and predictable menses

313
Q

Define abnormal uterine bleeding

A

Any menstrual bleeding from the uterus that is either abnormal in volume (excessive duration and heavy), regularity, timing (delayed or frequent) or is non-menstrual (PCB, IMB, PMB)

314
Q

Heavy menstrual bleeding definition

A

Menstrual blood loss that is subjectively considered to be excessive by the woman and interferes with her physical, emotional, social and material quality of life

315
Q

What is PCB

A

Post coital bleeding

316
Q

What is PMB

A

Post menopausal bleeding

317
Q

What is IMB

A

Inter mestrual bleeding

318
Q

Causes of Heavy Menstrual bleeding

A

Combination of coagulopathy
Ovulatory
endometrial dysfunction

319
Q

Pathological causes of HMB

A

Uterine fibroids
Uterine polyps
Adenomyosis
Endometriosis

320
Q

Define uterine fibroids

A

Benign tumours of myometrium

321
Q

Describe fibroids

A

well circumscribed whorls of smooth muscle cells with collagen

322
Q

Define uterine polyps

A

common benign localised growths of the endometrium

323
Q

Describe the microscopic detail of polyps

A

fibrous tissue core covered by columnar epithelium

324
Q

Why do uterine polyps occur

A

arise as a result of disordered cycles of apoptosis and regrowth of endometrium

325
Q

How would you see polyps

A

Transvaginal US

Hysteroscopy

326
Q

Define endometriosis

A

endometrium type of tissue lying outside the endometrial cavity

327
Q

Define adenomyosis

A

ectopic endometrial tissue within the myometrium

328
Q

What do you call the ovarian cysts in endometriosis

A

Chocolate cysts

329
Q

History questions about menses

A 
Duration
Cycle 
index of heaviness
-clots
-protection
-flooding
330
Q

Associated concerns to ask about in hisotry of HMB

A 
Pain
Premenstrual tension
Infertility worries
Cancer phobia
Interference with quality of life
Duration and relation to cycle
Details of fertility
Be aware
331
Q

Associated non vaginal questions for HMB

A

Thryoid disease
Clotting disorder
Drug therapy

332
Q

General examination in HMB

A

Sclera, palms, gingiva
Thyroid gland
Abdomen

333
Q

Pevlic examination in HMB

A

Vulva and vagina
Cervix
Uterus
Adnexae

334
Q

Investigations for HMB

A

FBC
TVS
Endometrial biopsy
Hysteroscopy

335
Q

First line treatment for HMB

A

Reassurance

336
Q

Second line treatment for HMB

A

Antifibrinolytics (tranexamic acid)

337
Q

Third line treatment for HMB

A

NSAIDs (mefenamic acid)

338
Q

Indications for endometrial ablation

A 
Heavy menstrual loss
Not expecting amenorrhoea
Normal endometrium
Uterus less than 12 weeks size
Completed family
339
Q

Contraindications for endometrial ablation

A

Malignancy
Acute PID
Desire for future pregnancy
Excessive cavity length

340
Q

Fibroids but want a baby

A

Myomectomy

341
Q

Focussed gynae history- key symptoms

A 
Pain
Bleeding
Urinary symptoms
Bowel symptoms
Prolapse
Sexual history
342
Q

Gynae history PMH

A 
Menstrual history
Contraception
Sexual history
Smears
Past gynae history
Past obstetric history
Medical history
Family history
343
Q

How to take a menstrual history

A

Last menstrual period

  • normal
  • on time
  • duration
  • how heavy
  • how painful
  • any change
344
Q

How do you write down menstrual period

A

X/Y
X= duration
Y= cycle

345
Q

Normal period duration of bleeding

346
Q

Normal length of cycle

A

21-35 days

347
Q

Define menarche

A

Age of first period

348
Q

Normal age of menarche

349
Q

Define menopause

A

age/date of last spontaneous period

350
Q

Normal age of menopause

A

4-55, average 51

351
Q

Superficial dysparunia meaning

A

At start of intercourse, when penis is going in

352
Q

Deep dysparunia

A

When the penis is deep

353
Q

Define climacteric

A

Years before menopause associated with menopausal symptoms but still menstruating

354
Q

Define postmenopausal

A

No periods for 1 year after the age of 50 (2 years if <50years)

355
Q

Define gravida

A

Number of times pregnant total

356
Q

Define parity

A

Number of babies theyve had (pregnancy over 24 weeks)

357
Q

Things to ask in broad gynae history, medical and surgical

A 
Previous abdo/pelvic surgery
Major CVS/ resp/ gastro disease
Endocrine disease
Haematology
Breast Ca
T2DM
358
Q

Family history in Gynae

A

Breast and ovarian cancer

BRCA gene

359
Q

What does T2DM increase your risk of

A

Endometrial cancer

Ovarian cysts

360
Q

Sexual history questions

A

HPC
Date of last sexual contact and number of partners in the last three months
Gender of partner(s), anatomic sites of exposure, condom use, any suspected infection, infection risk or symptoms in partners
Previous STIs
For women: last menstrual period (LMP), contraception, cervical cytology
Blood borne virus risk assessment and vaccination history
Establish competency, safeguarding children/vulnerable adults

361
Q

Fertility history questions

A

Duration of infertility, investigation results and previous treatment
Menstrual history.
Medical, surgical, and gynecological history (including STIs/PID, smears, Rubella immunity)
Systems review to include symptoms of thyroid disease, galactorrhea, hirsutism.
Obstetric history
Sexual history, including sexual dysfunction and frequency of coitus.
Family history, including infertility, birth defects, genetic mutations.
Lifestyle history: occupation, exercise, stress, weight, smoking, drug and alcohol use.
Male partner: children to previous partner, lifestyle, PMH including STIs, mumps, testicular trauma

362
Q

Urogynaecology history

A

HPC
General gynaecology (including obstetric and surgical)
Urinary symptoms: urgency, frequency, incontinence (urge/stress), voiding problems, nocturia
Bowel symptoms: constipation, IBS, digitation, incontinence
Prolapse symptoms: vaginal lump, sensation of SCD
Lifestyle – fluid intake, caffeine, weight,

363
Q

Obstetric history

A 
Previous pregnancies
Current symptoms
Early scans
PMH PGH
FH
SH
MH
Risk factors
364
Q

Early pregnancy dating scan uses what

A

From crown rump length

365
Q

What is the estimated date of delivery

A

40 completed weeks

366
Q

Family history for obs history

A

Diabetes
Heart disease
Genetic abnormalities
Thrombophilia

367
Q

Questions to ask about previous pregnancies

A 
Year
Gestation
Outcome
Mode of delivery
Complications
368
Q

Pregnancy outcomes

A

Miscarriage
Termination
Ectopic
Deliveries

369
Q

Define miscarriage

A

Loss of pregnancy before 24 weeks

370
Q

Define IUFD

A

Babies with no sign of life in utero

371
Q

Define still birth

A

Baby delivered with no signs of life, known to have died after 24 weeks

372
Q

Neonatal death definition

A

The death of a baby within the first 28 days of life

373
Q

Early NND definition

A

Up to 7 days

374
Q

Late NND definition

A

Between 7 and 28 days

375
Q

When is the baby classed as term

A

37 to 42 weeks

376
Q

When is the baby classed as pre term

A

Less than 37 weeks

377
Q

When do you give aspirin in pregnancy

A

Low dose. high risk for preeclampsia

378
Q

When is the baby classed as post term

A

More than 42 weeks

379
Q

What does a + on PG mean

A

Loss after 24 weeks

380
Q

What does a - on PG mean

A

Loss before 24 weeks

381
Q

What to ask about previous labours

A

Show
Contractions
SROM
Partogram

382
Q

What is SROM

A

Spontaneous rupture of membrances

383
Q

Define menopause

A

Cessation of menstruation.

384
Q

When is menopause diagnosed

A

Diagnosed after 12 months of amenorrhoea or at onset of symptoms if hysterectomy

385
Q

Define Perimenopause

A

Period leading up to the menopause

386
Q

Describe perimenopause

A

Characterised by irregular periods and symptoms eg hot flushes, mood swings, urogenital atrophy

387
Q

Central effects of decreased oestrogen levels

A

Vasomotor symptoms
MSK symptoms
Low mood and sexual difficulties

388
Q

Local effects of decreased oestrogen levels

A

Urogenital symptoms such as vaginal dryness due to vaginal atrophy

389
Q

General short term symptoms of menopause

A

Mood change/ irritability
Loss of memory/ concentration
Headaches, dry and itchy skin, joint pains
Loss of confidence and lack of energy

390
Q

Urogenital atrophy symptoms after menopause

A 
Dyspareunia
Recurrent UTIs
PMB
Urinary incontinence
Prolapse
391
Q

Long term effects of the menopause

A

Osteoporosis
Cardiovascular disease
Dementia

392
Q

Why is there cardiovascular disease rates higher after menopause

A

Adverse changes in lipid. Increased prevalence with early menopause

393
Q

Soft ways to manage menopause

A

Hollistic approach
Lifestyle advice
Reduce modifiable risk factors

394
Q

Treatment options for menopause

A 
Hormonal
-HRT, vaginal oestrogens
No hormonal
-clonidine
Non pharmaceutical
-CBT
395
Q

Name a non hormonal treatment for the menopause

396
Q

Name a non pharmaceutical treatment for the menopause

397
Q

Benefits of HRT

A

Relief of symptoms of menopause
Bone mineral density protection
Prevent long term morbidity

398
Q

Risks of HRT

A

Breast cancer
VTE
Cardiovascular disease
Stroke

399
Q

How is breast cancer risk related to HRT

A

If long duration, during treatment increased risk

400
Q

Should you give HRT to breast cancer patients or patients at risk of BC

A

Nope. Stop it on diagnosis or when at risk

401
Q

When and why do you gibe transdermal HRT

A

When higher risk of VTE as reduces risk. Like BMI over 30 or higher VTE risk

402
Q

Does HRT affect diabetes

403
Q

Why give progesterone with oestrogen in HRT

A

It protects the endometrium from the stimulatory effects of unopposed oestrogen

404
Q

Name a HRT med

405
Q

Whats the regime for post menopausal HRT

A

Continuous combined

406
Q

Whats the regime for perimenopausal HRT

A

Sequential

407
Q

Who should have transdermal HRT

A 
Gastric upset eg Crohns
Need for steady absorption eg migraine/epilepsy
Perceived increased risk of VTE
Older women ‘higher risk of HRT’
Medical conditions eg hypertension
Patient choice
408
Q

What is premature ovarian insufficiency

A

Menopause before 40
High FSH
4 months amenorrhoea

409
Q

Natural causes of premature ovarian insufficiency

A

Idiopathic
Chromosomal
Enzyme deficiencies
AI

410
Q

Iatrogenic causes of premature ovarian insufficiency

A

Surgery
Chemo
Radiotherapy

411
Q

How to treat premature ovarian insufficiency

412
Q

Are you fertile after menopause

A

Yes, 2 years if before 50, 1 year if over

413
Q

Name non hormonal methods of HRT

A 
AARA
-alpha adrenergic receptor agonist (clonidine)
SSRI
SNRI
Antiepileptic
414
Q

Contraindications for HRT

A

undiagnosed abnormal PV bleeding, breast lump, acute liver disease

415
Q

Cautions for HRT

A

Over 60, – fibroids, uncontrolled BP, migraine, epilepsy, endometriosis, VTE family history

416
Q

What is informed consent

A

process by which a fully informed patient can participate in choices about her health care.

417
Q

What is the legal term for failing to obtain informed consent before performing a test or procedure

418
Q

Define autonomy

A

The right of patients to make decisions about their medical care without their health care provider trying to influence the decision.

419
Q

Define competency

A

Idicates that a person has the ability to make and be held accountable for their decisions

420
Q

What are the elements of full informed consent

A 
Nature of decision
Alternatives
Risks, benefits and uncertainties
Assess patient understanding
Patient acceptance of procedure
421
Q

Does the unborn baby have rights

422
Q

Issues with consent to screening

A

Uncertainties of results (false positives/ negatives)

Consequences of results

423
Q

Fraser recommendations

A 
Patient should understand
Encourage parental involvement
Will they have sex anyway
WIthout treatment will health suffer
Whats best interests
424
Q

Abortion legal requirmeents

A

Before 24 weeks
Prevents grave permanent injury to mothers physical or mental health
Continuing preganncy is more risky than termination
If child was born it would suffer

425
Q

Why is abortion good

A

Reduces harm and legal abortion has reduced maternal mortality as illegal abortions are dangerous.

426
Q

Define endometriosis

A

The presence of endometriotic tissue outside the uterus

427
Q

Why does endometriosis affect women of reproductive age

A

It is driven by oestrogen

428
Q

Define adenomyosis

A

The presence of endometriotic tissue within the myometrium

429
Q

What is the myometrium

A

The middle layer of the wall of the uterus

430
Q

Describe theories of causation of endometriosis

A

Retrograde period
Mesothelial metaplasia
Impaired immunity

431
Q

Describe presentation of endometriosis

A

Pain
Subfertility
No symptoms

432
Q

What is the classic sign of endometriosis

A

A fixed retrograde uterus on bimanual vaginal examination

433
Q

What is the gold standard investigation for endometriosis

A

Laparoscopy with biopsy for histological confirmation

434
Q

What can lead to under diagnosis of endometriosis

A

If the laparoscopies are within 3 months of hormonal therapy

435
Q

Name some medical endometriosis treatments

A

COCP
Progestagens
Mirena

436
Q

What do you do if the medical treatment of endometriosis has failed

A

Laparoscopy with ablasion

437
Q

Reasons breast cancer incidence is increasing

A 
Less breast feeding
Having children later
Obesity
HRT
More older people
More screening
Alcohol
438
Q

Genetic factors which increase breast cancer risk

A

BRCA1
BRCA2
Tp53

439
Q

Modifiable risk factors for breast cancer

A

Weight (post menopause)
Exercise
Alcohol
Extrogenous oestrogens

440
Q

Non modifiable risk factors for breast cancer

A

Age of menarche and menopause
Early parity and breast feeding
Breast density
Heredity

441
Q

What is the NHS breast screening programme

A

47-70 every 3 years. Dual view mammography

442
Q

What is a mammogram

A

Low dose XRay. Breast compressed to increase definition

443
Q

Mammography problems

A

Overdiagnosis
Anxiety
Costs
X ray dose

444
Q

Who is screening more effective in

A

Elderly. Less dense breast. More likely to have cancer (also more likely to die of something else)

445
Q

What is triple assessment for breast cancer diagnosis

A

Clinical
Imaging
Biopsy

446
Q

Presenting symptoms of breast cancer

A

Painless lump
Nipple discharge
Nipple in drawing

447
Q

Presenting signs of breast cancer

A

Painless lump
Skin tethering
Indrawn nipple

448
Q

Describe how the lump feels in breast cancer

A

Irregular
Hard
Fixed

449
Q

What is DCIS

A

Breast cancer precursor

Or can just stay DCIS

450
Q

MRI scanning for breast cancer

A

Useful for implant assessment
Only for difficult cancer diagnosis
high risk screening

451
Q

What makes it hard to image a womans breast

A

If they are young (dense breast)

Have breast implants

452
Q

Why would you mastectomy

A

Multiple foci
Larger than 20%
She wants you to
Inflammatory

453
Q

What must you do if you get breast conservation not mastectomy

A

Radiotherapy

454
Q

How do you improve appearance of post surgery breasts

A

Nipple tattooing

Augmentation

455
Q

How do you choose axillary surgery in breast cancer

A

Full clearance if gland clinically involved. Sentinel node biopsy if glands clinically normal.

456
Q

Name two types of breast cancer

A

Ductal carcinoma

Lobular carcinoma

457
Q

Define grading

A

What the cancer looks like down the microscope

458
Q

Define staging

A

The anatomical distribution

459
Q

What is used for staging of breast cancer

460
Q

What is used for prognosis in breast cancer

A

Nottingham prognostic index

461
Q

Why do you do arrays in breast cancer patients

A

For receptor sub typing. ER, Her-2, PgR

462
Q

What drug would you give to a HER-2 positive disease

463
Q

Why would you give chemo

A

Bad cancer ie risk factors

464
Q

When is tamoxifen given

A

Oestrogen sensitive cancers

465
Q

Do you give adjuvant radiotherapy in breast cancer

466
Q

When is neoadjuvant chemotherapy brilliant

A

When herceptin sensitive, fit and well individual

467
Q

Causes of infertility

A 
Ovulatory
Tubal
Uterine 
Male
Unexaplained
(even splits)
468
Q

Why do miscarriage rates go up with age

A

More chromosomal abnormalities

469
Q

Principles of infertility care

A 
Both partners together
Explain
Reassure
Conception advice
Support groups
Counselling
470
Q

Do you have to wait 2 years for infertility treatment

A

Not if there is an obvious problem

471
Q

Preconception advice

A 
Intercourse
Folic acid
Smears
Immunisations
Smoking cessation
Alcohol
Weight
Environement 
PMH
DHx
472
Q

Reproductive disorders associated with obesity

A 
PCOS
Miscarriage
Infertility
Lower success rate
Obstetric complications
473
Q

Investigations for fertility problems

A

Ovulation function
Semen quality
Tubal patency

474
Q

How do you monitor ovulation

A

Progesterone level

day 21- mid luteul

475
Q

How is ovarian reserve tested

A

Antimullerian hormone

476
Q

What do you look at with semen analysis

A

Count
Motility
Morphology

477
Q

Sperm problem treatment

A

Dietary, lifestyle advice.
IVF with ICSI
Endocrine ?

478
Q

Name the 3 anovulation causes

A

Hypothalamus (Low FSH/LH/oestrogen)
PCOS
Menopause

479
Q

Causes of hypothalamus anovulation

A

Stress
Weight loss
Exercise
Kallmans

480
Q

Treatments of hypothalamus anovulation

A

FSH and LH

481
Q

Treatment for PCOS in fertility

A

Ovulation induction- clomifene

482
Q

Treatment for ovulation induction if clomifene hasnt worked

483
Q

Surgery for anovulation

A

Laparoscopic drilling

484
Q

Causes of tubal infertility

A 
Infections
Endometriosis
Surgical
-adhesions
-sterilisation
485
Q

How to treat endometriosis for fertility

A

Diagnostic laparoscopy

486
Q

How to treat unexplained infertility

A

Clomifene
IUS
IVF

487
Q

Name three methods of assisted conception

A

Ovulation induction
Stimulated intrauterine insemination
In vitro fertilisation

488
Q

How can you improve IVF success rate

489
Q

What are you more at risk with increasing age

A 
HTN
DM
Operative delivery
VTE
Death
490
Q

Name 4 things with which the chance of pregnancy decreases

A

Female age
Successive cycles
Obesity
Environmental factors

491
Q

What is the main risk of IVF

A

Mulitple pregnancy

492
Q

Name three environmental factors which reduce the chances of pregnancy

A

Smoking
Alcohol
Caffeine

493
Q

Which maternal death rate has reduced

A

Direct maternal death

494
Q

Common preexisting medical disorders that cause maternal death

A 
Cardiac
Asthma
Epilepsy
HTN
DM
Thyroid
Renal
495
Q

Co incidental pregnancy disorders

A

Malaria
Hepatitis
Cancers

496
Q

Steps to management of medical disorder and pregnancy

A

Preconception assessment
Affect of disease on pregnancy
Affect of pregnancy on disease

497
Q

Prepregnancy advice for those with medical conditions

A

Wait until the patient is at their best

498
Q

Name a disease that gets worse in pregnancy

A

Mitral stenosis

499
Q

Name a disease that gets better in pregnancy

A

Rheumatoid arthritis (due to the relative immunosuppression)

500
Q

What is done with pregnant people with medical conditions

A

Joint obstetric-medical clinics

501
Q

Anaemia and pregnancy

A

Higher iron and folate requirements. Leads to low birthweight and preterm delivery

502
Q

What is pregnant and non pregnant threshold for anaemia

A

110 for normal

105 for pregnant

503
Q

Treatment for anaemia in pregnancy

A

Oral iron therapy

504
Q

Name a microcytic anaemia

505
Q

Name a macrocytic anaemia

A

Folate

B12

506
Q

Respiratory pregnancy changes

A

Increased metabolic rate, O2 consumption. Tidal volume increases.

507
Q

What is the effect of increased tidal volume in pregnancy

A

pO2 increases, pCO2 decreases. Mild alkalosis

508
Q

Asthma affect on fetus

A

Risk of hypoxia and inadequate placental perfusion. Premature growth and delivery

509
Q

Can asthma drugs be used in pregnancy

510
Q

Why does Cardiac output increase in pregnancy

A

Due to increased stroke volume

511
Q

Low risk cardiac lesions in pregnancy

A

Mitral incompetence
Aortic incompetence
ASD
VSD

512
Q

High risk cardiac lesions in pregnancy

A

Aortic stenosis
Coarctation of aorta
Prosthetic valves
Cyanosed patients

513
Q

When is the cardiac risk to mothers highest

A

After birth

514
Q

Pregnant women with itching without rash

A

Obstetric cholestasis

515
Q

Treatment for obstetric cholestasis

A

Ursodeoxycholic acid

516
Q

Hyperthyroidism in pregnancy

A

Thryoid storm and fetal thyrotoxicosis

517
Q

Hypothyroidism in pregnancy

A

Fine if already treated. Aim for adequate replacement with thyroxine

518
Q

What is gestational diabetes

A

Carbohydrate intolerance first recognised in pregnancy. Risk of developing type 2 or this being first presnetation of type 1

519
Q

Complications of diabetes in pregnancy

A

Big babies
DKA
Hypoglycaemia
Shoulder dystocia

520
Q

What is erbs palsy caused by

A

Shoulder dystocia

521
Q

Renal changes in pregnancy

A

50% increase in renal blood flor and GFR

Low creatinine, urate and albumin normal

522
Q

CKD in pregnancy

A

HTN
Preeclampsia
Premature
Growth restriction

523
Q

What does renal disease outcome and pregnancy depend on

A

Degree of renal dysfunction
Maternal blood pressure
Creatinine
Proteinuria

524
Q

Which epilepsy drugs are bad for baby

A

Valproate and more than one at once

525
Q

Management of epileptic mums

A

Fetal screening
Control seizures
Plan for delivery
Post partum support

526
Q

Risk factors for VTE

A

Maternal age
BMI
Operative delivery

527
Q

Investigation of DVT in pregnancy

A

Doppler ultrasound

528
Q

Investigation fo PE in pregnancy

529
Q

Treatment of VTE in pregnancy

530
Q

Define screening

A

Process of identifyinf apparently healthy individuals who may be at an increased risk fo a disease or conditions

531
Q

Define detection rate

A

Proportion of affected individuals who will be identified by screening test

532
Q

Define false positive rate

A

Proportion of unaffected individuals with a higher risk/screen positive result

533
Q

Define false negative rate

A

Proportion of affected individuals with a low risk/screen negative result

534
Q

What does the fetal anomaly screening programme look for

A

Downs, Edwards, Pataus

18-21 weeks

535
Q

What does the infectious diseases screening programme look for

A

Hep B
HIV
Syphilis

536
Q

What does the new born blood spot screening programme look for

A

CF
Congenital hypothyroidism
Sickle cell disease
Inherited metabolic diseases

537
Q

Which chromosome is involved in downs

A

Trisomy 21
Intelectual disability
Structural cardiac disease
Epilepsy, thyroid

538
Q

Which chromosome is involved in Edwards

A

Trisomy 18

539
Q

Edwards syndrome problems

A

Unusual head and facial features
Brain and heart problems
Growth problems

540
Q

Which chromosome is involved in Pataus

A

Trisomy 13

541
Q

Pataus problems

A

Rarely survive birth
Congenital heart defects
Facial defects
Urogenital malformations

542
Q

When and how are T21, T18 and T13 screened

A

14 week, nuchal translucency

543
Q

Special circumstances for anomaly screening

544
Q

What is the minimum number of ultrasounds a woman can have during pregnancy

545
Q

What can an early ultrasound tell you

A

Fetal demise
Multiple prenancy
Gestational age

546
Q

What can mid pregnancy scans find

A 
Major abnormalities
Conditions that may benefit brith
Plan delivery
Optimise treatment
Choices about termination
547
Q

Which infectious diseases are screened for in pregnancy

A

HIV
Hep B
Syphilis

548
Q

Which haem dissorders are screened for

A

Coagulopathies
Sickle cell
Thalassaemias

549
Q

What does newborn blood spot screen for

A

Sickle cell
Cystic fibrosis
Congenital hypothyroidism
6 metabolic disorders

550
Q

What is hearing screening

A

Low sound before they leave. Repeated and then full audiology testing if negative.

551
Q

New born and infant physical examination NIPE

A 
General
Eye problems
Congenital heart defects
Developmental dysplasia of hips
Undescended testes
552
Q

Maternal obstetric emergencies

A

Antepartum haemorrhage
Postpartum haemorrhage
VTE
Preeclampsia

553
Q

Fetal obstetric emergencies

A

Fetal distress
Cord prolapse
Shoulder dystocia

554
Q

Define antepartum haemorrhage

A

Bleeding from anywhere in the genital tract after 24th week of pregnancy

555
Q

Where can antepartum haemorrhage come from

A

Uterus
Cervix
Vagina
Vulva

556
Q

Identifiable causes of APH

A 
Low lying placenta
Placenta ccreta
Vasa praevia
Minor/ major abruption
Infection
557
Q

What is placenta accreta

A

Placenta adhering to the uterus

558
Q

What is vasa praevia

A

Fetal blood vessels near the entrance to. the uterus

559
Q

What does major low lying placenta mean

A

Covering/ reaching os

560
Q

What does minor low lying placenta mean

A

Lower segment/ enroaching

561
Q

What do you do if LLP identified at 20 week anomaly scan

A

Repeat at 32 weeks if major, repeat at 36 weeks in minor

562
Q

Management of low lying placenta

A

Advise
If recurrent bleeds, admit until delivery. Give anti D if Rh-
Caessarean

563
Q

Bleeding placenta praevia management

A

ABCDE
Examination
Fetal monitoring +- delivery
Steroids

564
Q

Why do you give steroids in emergencies

A

Develop the babies lungs

565
Q

Define placenta accreta

A

The placenta grows into the uterine linig

566
Q

Define placenta increta

A

The placenta grows into the muscular of the uterus

567
Q

Define placenta percreta

A

The placenta grows through the wall of the uterus into surrounding tissue

568
Q

Risks for placenta percreta

A 
Placenta previa
Previous c section
IVF
Advanced maternal age
Smoking
Prior uterine surgery
569
Q

Management of placenta accreta

A

20 week scan
C section at 36weeks
Hysterectomy

570
Q

What is vasa praevia

A

Fetal vessels coursing through the membrances over the internal cervical os and below the fetal presenting part, unprotected by placental tissue or the umbilical cord

571
Q

Define placental abruption

A

Premature seperation of the placenta from the uterine wall

572
Q

How would you treat a small placental abruption

A

Conservative

573
Q

How would you treat a large abruption

A

Resuscitation and delivery

574
Q

Consequences of a large placental abruption

A

Fetal distress

Maternal shock

575
Q

Complications after APH

A 
Premature labour
Blood transfusion
Renal failure
PPH
DIC
ARDS
ITU
576
Q

What is major PPH

577
Q

What is minor PPH

A

500-1000ml

578
Q

What is primary PPH

A

Within 24 hours of delivery, blood loss over 500mls

579
Q

What is secondary PPH

A

After 24 hours and up to 12 weeks post delivery

580
Q

What are the four Ts of PPH causes

A

Tissue (complete)
Tone (contract)
Trauma (tears)
Thrombin (clotting)

581
Q

Risk factors for PPH

A 
Big baby
0 or lots of kids
Multiple pregnancy
Prolonged labour
Maternal pyrexia
Operative
Shoulder dystocia
Previous PPH
582
Q

Risk factors for sepsis

A 
Obesity
Diabetes
Vaginal discharge
Prolonged SROM
Group A strep infection in close contacts
583
Q

Sepsis six bundle of treatment

A

1) O2 to over 94
2) Blood cultures
3) IV antibiotics
4) IV fluid restriction
5) Bloods: Hb, lactate, glucose
6) hourly urine output

584
Q

Signs and symptoms of sepssi

A 
Pyrexia
Tachycardia Tachypnoea
Hypo
-thermia
-oxia
-tension
Oligouria
585
Q

Severe preeclampsia criteria

A

Hypertension and proteinuria and one other of

  • severe headache
  • visual disturbances
  • clonus
  • liver tender
  • papilloedema
  • abnormal liver enzymes
  • low platelets
586
Q

Treatment for preeclampsia

A

Nifedipine and magnesium sulphate

587
Q

What to monitor in severe preeclampsia

A

Platelets, liver and renal function
Monitor urine output
Fetal wellbeing
Delivery

588
Q

What is eclampsia

A

Onset of seizures in a woman with preeclampsia

589
Q

Treatment of eclampsia

A

Magnesium sulphate and nifedipine

590
Q

Should you treat mother or delivery baby first in eclampsia

A

Treat mum then delivery baby

591
Q

What does a sinusoidal fetal trace suggest

A

Fetal compromise

592
Q

What is cord prolapse

A

Where the cord is presenting after SROM. Exposure of the cord leads to vasospasm

593
Q

Risk factors for cord prolapse

A 
Premature SROM
Polyhydramnios
Long umbilical cord
Fetal malpresentation
Multiparty
Multipregnancy
594
Q

Management of cord prolapse

A

Call 999
Infuse fluid into bladder
Trendelenburg
Fetal monitoring

595
Q

Define shoulder dystocia

A

Failure for the anterioir shoulder to pass under the symphysis pubis after delivery of the fetal head

596
Q

Maternal complications of shoulder dystocia

A

PPH
Extensive vaginal tear
Pyschological

597
Q

Neonatal complications of shoulder dystocia

A

Hypoxia
Fits
Cerebral palsy
Brachial plexus injury- erbs palsy

598
Q

Risk factors for predicting shoulder dystocia

A 
Macrosomia
Maternal DM
Previous shoulder dystocia
Disproportion of mum and fetus
Obesity
Prolonged labour
Instrumental
599
Q

Acronym for shoulder dystocia

600
Q

What does the acronym for shoulder dystocia stand for

A 
Help
Episiotomy evaluation
Legs in mcroberts
Pressure suprapubic
Enter pelvis
Rotational manoeuvres
Remove posterior arm
601
Q

Where does labour pain come from in the first stage

A

T10-L1. S2-4

Uterine contraction, cervical effacement and dilatation

602
Q

Where does the pain come from in 2nd stage of labour

A

Stretching vagina and perineum, extrauterine, pelvic structures.
S2-4
L5-S1

603
Q

Non pharmacological therapies for labour pain

A

Acupuncture
Hypnotherapy
Massage
Hydrotherapy

604
Q

Simple analgesia for labour pain

A

paracetamol and codeine

605
Q

Name an inhalational analgesia

606
Q

What is entonox

A

50% nitrous oxide and 50% oxygen

607
Q

Single shot IM opioids that are given for labour pain

A

Morphine

Diamorphine

608
Q

Why can diamorphine be given in childbirth

A

Rapidly eliminated by placenta

609
Q

PCA opioids

610
Q

Name 3 regional anaesthetic techniques used in labour

A

Epidural
Spinal
Combined spinal epidural

611
Q

Where is a spinal done

A

into the CSF

612
Q

Where is the epidural done

A

Epidural CSF

613
Q

What is tuffiers line

A

Between illiac crests, L23

614
Q

Local anaesthetic name

A

Bupivacaine

615
Q

Opioids names

A

Fentanyl

Diamorphine

616
Q

Indications for epidural

A 
Maternal request
Cardiac or medical disease
Augmented labour
Multiple births
Instrumental or perative delivery likely
617
Q

Absolute contraindications for regional techniques

A

Maternal refusal
Local infection
Allergy to LA

618
Q

Relative contraindications for regional techniques

A 
Coagulopathy
Systemic infection
Hypovolaemia
Abnormal anatomy
Fixed cardiac output
619
Q

Effects of regional techniques of analgesia

A

Vasodilatation
Analgesia
Motor blockade
Fever

620
Q

Adverse effects of regional techniques of analgesia

A 
Cardiovascular
Respiratory
Neurological
Drug related
Headache
621
Q

Different epidural regimens

A

Traditional
Continuous infusion
Continuous infusion and bolus
Combined spinal epidural

622
Q

Outcomes of regional anaesthetics

A

Superioir analgesia
Maternal satisfaction
Prolong labour
Increase instrumental delivery

623
Q

Anaesthesia for C section

A

Spinal and or epidural, up to the chest

624
Q

GA risks

A

Altered physiology
Aspiration
Failed intubation
Awareness

625
Q

Advantages of. regional anaesthesia during labour

A

Safer
Can see baby immediately
Partner present
Improved post op analgesia

626
Q

Disadvantages of regional anaesthesia

A

Hypotension
Headache
Discomfort associated with pressure symptoms
Failure

627
Q

Why do small babies struggle in labour

A

They have very little reserve

628
Q

Why do you look at lica volume

A

Indicates that the placenta is working well

629
Q

What do you look for on fetal monitoring

A

Movements

Heart beat

630
Q

Risk factors for still birth

A 
Preexisting medical conditions
High BMI
Smoking
Recreational drug use
Low BMI
Alcohol
High maternal age
Twins
631
Q

Methods of fetal heart monitoring

A

Intermittent auscultation
Pinard stethoscope
Hand held doppler device

632
Q

Disadvantages of intermittent auscultation

A

Not long term
Cant detect decelerates
variable quality

633
Q

Advantages of intermittent auscultation

A

Inexpensive
Non invasive
Can be used at home

634
Q

Advantages of cardiotocography (CTG)

A

Information about both FHR and uterine contractions
Long term monitoring
Average variability can be determined

635
Q

Disadvantages of CTG

A

No improved outcomes in low risk
No morphological assessment of heart
Fetal exposure to ultrasound

636
Q

What are indicators of fetal well being on CTG

A

Accelerations
Variability
Deccelerations

637
Q

Acronym for CTG intepretation

A 
Dr
C
Bra
V
A
D
O
638
Q

What does Dr C BraVADO stand for in CTG intepretation

A 
Define risk
Contractions
Baseline rate
Variability
Accelerations
Decelerations
Overal assessment
639
Q

Normal fetal heart beat

A

110-160bpm

640
Q

What are the three types of deceleration

A

Early
Late
Variable

641
Q

What does the timing (early, late, variable) of decelerations refer to

A

How it lines up with contractions

642
Q

What can cause variable decelerations

A

Cord compression

643
Q

What is the gold standard for direct FHR monitoring

A

Scalp ECG (gives true beat to beat information)

644
Q

Disadvantages of scalp ECG

A

Invasive
Must have SROMed
Perinatal infection

645
Q

Ovarian cyst treatment

A

Remove the ovary
Remove the cyst
Laparotomy
Laparoscopy

646
Q

What % of pregnancies are miscarriage

647
Q

Define a threatened pregnancy

A

Pregnancy associated with vaginal bleeding with or without abdominal pain

648
Q

Which investigation for seeing if a delayed miscarriage has occured

A

Ultrasound scan

649
Q

What is seen on ultrasound if the baby has died

A

Empty gestation seen or a fetal pole with no heart beat

650
Q

In early pregnancy how often should the b-hCG level double

A

Every 36-48hours

651
Q

In early pregnancy what type of ultrasound is best

A

Transvaginal

652
Q

Do you need to treat an incomplete early miscarriage medically

653
Q

What is a risk of surgical treatment of miscarriage

A

Uterine perforation

654
Q

Name two drugs used fo expel a baby

A

Mifepristone (anti-progestogen), prostaglandin (misoprostol)

655
Q

What % of pregnancies are ectopic

656
Q

Where are ectopic pregnancies most commonly found

A 
Fallopian tube (90%)
Cornual
Ovary
Cervix 
Abdomen
657
Q

Why dont ectopics work

A

Not enough myometrium, supporting muscle for the pregnancy

658
Q

What does a low or static BhCG suggest

659
Q

What is worrying about an ectopic

A

Risk fo death with rupture

660
Q

What drug can be used to treat an ectopic

A

Methotrexate

661
Q

What is a molar pregnancy

A

When there is a large fluid filled vesicle in the placenta

662
Q

What does an excessively high BhCG stand for

A

Molar pregnancy

663
Q

What does the ultrasound scan of a molar pregnancy look like

A

Snow storm

664
Q

Define hyperemesis in pregnancy

A

Excessive vomiting associated with dehydration and ketosis

665
Q

What is associated with hyperemesis gravidarum

A

High levels of BhCG

666
Q

What is the treatment for hyperemesis gravidarum

A

Rehydrate with IV fluids, vitamin supplements and nil by mouth until oral fluids can be tolerated

667
Q

Define FGM

A

All procedures involving partial or total removal of female external genitalia or other injury to the female organs for non medical reasons

668
Q

Type 1 FGM

A

partial or total removal of clitoris

669
Q

Type 2 FGM

670
Q

Type 3 FGM

A

Infibulation

671
Q

Type 4 FGM

A

All other harmful procedures to the female genitalia. Piercing etc

672
Q

Why does FGM happen

A 
Status
Virginity
Part of being a woman
Honour
Religious
Community
Marriage
673
Q

FGM and UK law

A

Illegal. Even to repair after birth. Illegal to take child out of UK for FGM

674
Q

Gynae complications of FGM

A 
Dyspareunia
Sexual dysfunction
Chronic pain
Keloid scar
Dysmenorrhoea
UTI 
PTSD
Difficulty concieving
675
Q

Obstetric complications of FGM

A 
Fear
C sectionm
PPH
Vaginal lacerations
Difficulty with interventions
676
Q

Common paediatric gynaecological problems

A

Amenorrhoea
Precocious puberty
Delayed puberty
Menstrual disorders

677
Q

When is normal for menarche

678
Q

How long do bleeds last

679
Q

How long between periods

A

21-45 days

680
Q

What precedes menarche

A

Secondary sexual characteristics, peak height velocity

681
Q

Define primary amenorrhoea

A

No menses by age 16 in presence of secondary sexual characteristics

682
Q

Primary amenorrhoea causes

A

Hypothalamic
Pituitary
Ovarian

683
Q

Secondary amenorrhoea

A

Cessation after onset of menses

684
Q

Causes of secondary amenorrhoea

A

Weight loss
Excessive exercise
PCOS

685
Q

Oligomenorrhoea

A

Menses more than 35 days apart

686
Q

Precocious puberty

A

Appearance of physical and hormonal signs of pubertal development at an earkier age than is considered normal

687
Q

What age counts as precocious puberty

A

Age 8 girls

Age 9 boys

688
Q

When is menarche precocious

689
Q

How is puberty investigated

A

Secretion of high amplitude pulses of GnRH by the hypothalamus

690
Q

Central causes of precocious puberty

A

Maturation of HPO axis

CNS trauma, tumours, hydrocephalus

691
Q

Pseudopuberty causes

A

CAH, tumours of adrenals or ovaries

692
Q

Order of puberty

A

Thlearche
Pubarche
Menarche

Phase 3A (25 decks)

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