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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
Advantages of breast feeding for mother
Breast cancer Ovarian cancer Osteoporosis
26
What is lactoferrin
High affinity for iron protein. High in colostrum. In breast milk too. Antibacterial qualities.
27
When do you use follow on milk
After 6 months
28
Name some minor postnatal problems
``` Infection PPH Fatigue Anaemia Backache urinary stress Incontinence Haemorrhoids ```
29
Name some major postnatal problems
``` Sepsis Severe PPH Preeclampsia Thrombosis Incontinence Breast abscess Depression ```
30
Describe PPH presentation
Sudden and profuse blood loss or persistent increased blood loss Faintness, dizziness or palpitations/tachycardia
31
Describe Infection presentation
Fever, shivering, abdominal pain and/or offensive vaginal loss
32
What does PPH stand for
Post partum haemorrhage
33
What is the preeclampsia presentation
Headaches accompanied by one or more of the following symptoms within first 72hrs after birth: Visual disturbances, Nausea or vomiting
34
What is thromboembolism presentation
Unilateral calf pain, redness or swelling | Shortness of breath or chest pain
35
Postnatal care assessment tool
Modified Early Obstetric Warning Score (MEOWS)
36
Sepsis definition
Infection plus systemic manifestations of infection
37
Severe sepsis definition
Sepsis plus sepsis induced organ dysfunction of tissue hypoperfusion
38
SROM define
Sustained rupture of membrane
39
Septic shock define
The persistence of hypoperfusion despite adequate fluid replacement therapy
40
Rhyme for sepsis
3 Ts white with Sugar
41
What are the signs of infection
``` Temperature Tachycardia Tachypnoea WCC high or low Hyperglycaemia ```
42
How many signs of infections are needed for sepsis
2
43
Risk factors for sepsis
``` Obesity Diabetes Anaemia Amniocentesis/invasive procedures Prolonged SROM Vaginal trauma/CS Ethnicity BME ```
44
Likely causes of sepsis
``` Endometritis Skin and soft tissue infection Mastitis UTI Pneumonia Gastroenteritis Pharyngitis Infection related to epidural/spinal ```
45
What else should you do when looking at potentially septic woman
History or signs of a new infection or infective source
46
BUFALO plus two
``` Blood cultures Urine output Fluid restriction Antibiotics Lactate Oxygen +ERPC +VTE prophylaxis ```
47
Primary PPH
More than 500ml
48
Minor PPH
<1500mls and no clinical signs of shock
49
Major PPH
>1500mls and continuing or clinical shock
50
Endometritis defintition
Infection of the lining of the womb
51
Secondary PPH define
Abnormal bleeding from birth canal from 24hrs to 12 weeks
52
Secondary PPH causes
``` Endometritis Retained products of conception (RPOC) Subinvolution of the placental implantation site Pseudoaneurysms Arteriovenous malformations ```
53
Secondary PPH investigations
Assess blood loss Assess haemodynamic status Bacteriological testing (HVS and endocervical swab) Pelvic ultrasound??
54
What can eclampsia cause
Seizures
55
What increases risk of VTE
``` Gestational age. Just after birth (3weeks) Obesity Multiple pregnancies Genetics Smoking C section ```
56
What is given in high risk women for VTE
LMWH 6 weeks
57
What is given in intermediate risk women for VTE
10 day LMWH
58
What is given in lower risk women for VTE
Early mobilisation and avoidance of dehydration. | TED stockings
59
What can cause a headache post partum
Post dural puncture headache from epidural or spinal anaesthesia
60
Symptoms of post dural puncture headache
``` Headache worse on sitting or standing Starts 1-7 days after spinal/epidural sited Neck stiffness Dislike of bright lights ```
61
Treatment of post dural puncture headache
Lying flat! Simple analgesia Fluids and caffeine?? Epidural blood patch
62
What must you do to prevent urinary retention and distention
Indwelling catheter
63
Urinary retention risk factors
``` Epidural analgesia Prolonged second stage of labour Forceps or ventouse delivery Extensive perineal lacerations Poor labour bladder care ```
64
What is urinary retention treatment aiming to do
Maintain bladder function Minimise risk of damage to UT Prevent bladder emptying problems
65
Red flags for mental health
- 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
66
Why is urinary retention more likely to happen
Epidurals so dont feel the sensations. | Trauma during birth
67
Why baby blues and common
Hormone changes Big change Sleep deprived Day 3-10
68
Postnatal depression symptoms
``` Depressed Irritable Tired Sleepless Appetite changes Negative thoughts Anxiety Affects bonding ```
69
Postpartum psychosis risk factors
FHx Bipolar diagnosis Traumatic birth or pregancy
70
Postpartum psychosis symptoms
``` Depression Mania Psychosis. -restless -unable to sleep -unable to concentrate -experiencing psychotic symptoms ```
71
Risk factors for PTSD
Perceived lack of care Poor communication Perceived unsafe care Perceived focus on outcome over experience of the mother
72
PTSD presentation
Anger, low mood, self-blame, suicidal ideation, isolation and dissociation Intrusive and distressing flashbacks
73
PTSD consequences
Women may delay or avoid future pregnancies Request caesarean sections to avoid vaginal delivery Avoidance of intimate physical relationships Impact on breastfeeding
74
Define Maternal death
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
75
Direct maternal death definition
Death relating from obstetric complications of pregnancy, labour of puerperium (e.g haemorrhage, genital sepsis, suicide)
76
Indirect maternal death definition
Death resulting from pre-existing disease / disease that developed in pregnancy but not a direct result of obstetric causes (cardiac disease, malignancies)
77
Why is VTE rate the same as 80s
Older fatter mums | Prevention measures
78
Gonadotrophin hormones
LH, FSH, hCG - gonadotrophs - glycoproteins
79
Steroid hormones
Oestrogens Progestins Androgens
80
Cytokines
Activins | Inhibins
81
Describe thecal cells
Sensitive to LH Synthesise Progesterone and Testosterone from cholesterol Androgens (E precursors)
82
Describe granulosa cells
Sensitive to FSH Converts Testosterone to E FSH induces LH receptors
83
What stops LH and FSH increasing at cycle day 15.
P and E made by corpus luteum negatively feedbacks to pituitary
84
Which hormone causes follicle to be selected
FSH rise
85
LH surge is controlled by
Oestrogen. Flips from negative feedback to positive
86
What does LH surge cause
Ovulation
87
Pregnancy homrones
hCG Progesterone Oestrogens
88
What produces hCG and whats the point
Blastocyst. Stops progesterone declining as stops luteal regression.
89
Progesterone action
Endometrial development Stops uterus contracting too early Promotes fat deposition Increases maternal ventilation
90
Where is oestrogen coming from
Ovary then both baby and mum
91
Which is the main oestrogen in pregnancy
E3
92
What would happen if you had no oestrogen
No progesterone would be made either
93
What happens to resp
Reduced inspiratory reserve
94
What happens to cardio
Increased HR and SV
95
Why should blastocyst be rejected
50% antigens from dad
96
Why isnt the blastocyst rejected
Differential gene expression. | Immune suppression
97
Failed endovascular invasion is associated with
``` Pre eclampsia IUGR Pre term labour Abruption Recurrent miscarriage ```
98
When is the window of implantation
20-24 days
99
What is decidua
Early endometrium which permits implantation
100
What is human implantation called
Haemochrorial placentation
101
Stages of implantation
1. Apposition 2. Interstitial implantation 3. Interstitial invasion 3. Endovacular invasion
102
Which arteries are targeted by the invasion
Spiral arteries
103
Define pregnancy
Pregnancy anywhere outside the uterus
104
Names of stages of placenta
Placenta acreta, increta, percreta
105
Which t cell is biased in pregnancy
Th2
106
Which Ig is secreted in breast milk
IgA
107
Which Ig crosses the placenta
IgG
108
Which Ig is involved in rhesus disease
IgG
109
Rhesus disease describe
First pregancy sensitises mother, subsequent pregnancies can result in fetal death
110
In rhesus disease who is rhesus positive
Father
111
Where is the acreta
Superficial myometrium
112
Where is the increta
Deeper myometrium
113
Where is the percreta
Penetrates uterine serosa | Effects other organs
114
Myometrial quiescence
Absence of uterine contractions
115
How is contraction prevented
G alpha S represses acto myosin ATPase activity.
116
What causes labour
Infection can Surfactant proteins Placental clock
117
Placental clock
ACTH = DHEA = Oestrogens increase gap junctions= increased contractility
118
What happens to progesterone before birth
Functional progesterone withdrawal
119
Which drug can be used to stop contraction
Nifedipine. Calcium blocker. | Atosiban- Oxytocin receptor anatagonist
120
Placental delivery mechanisms
Rpaid myometrial contraction Physiological pressure Immediate fibrin deposition over placental site
121
Drugs to inhibit uterine contraction
Beta 2 mimetics Nifedipine Progesterone Atosiban
122
Drugs to promote uterine uterine contraction
Syntocinon Ergometrine Misoprostol
123
How is quiescence maintained
G proteins signally | K+ extrusion from myometrial myocytes
124
Why does K+ extrusion from myometrial myocystes reduce contractions
Hyperpolarisation
125
Early pregnancy glucose levels
Lower. Maternal glycogen synthesis and fat deposition
126
Late pregnancy glucose levels
Higher. Maternal insulin resistnace. Glucose sparing for fetus
127
What can maternal insulin resistnace cause
Gestational diabetes | Macrosomic infants
128
What can macrosomic infants cause
Shoulder dystocia
129
Why use contraception
Control fertility Family spacing Reduce teenage pregnancy Reduce abortions
130
Fraser criteria
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
131
Assessment for contraception (history)
``` Age Weight BP Menstrual history Previous contraception Previous pregnancies Previous STIs PMHx FHx SHx DHx ```
132
Assessment for contraception (examination)
BP BMI Cervical smear STI screen
133
User failure contraceptive examples
Combined OCP Contraceptive patch POP Barrier methods
134
Non user failure contraceptive examples
``` Contraceptive injection Implant IUD IUS Sterilisation ```
135
Most effective contraceptive
Progesterone implant
136
How does COCP work
Oestrogen and progesterone. Prevents ovulation. Thickens cervival mucus. Thins lining of the womb.
137
COCP advantages
Reversible, reliable, regular predictable cycle. Well tolerated
138
Who cant have COCP
FHx of female cancers | Clotting disorders
139
COCP disadvantage
Lots of people cant have it. Drug interactions. Doesnt protect against STIs. VTE and cancer risk
140
How does POP or mini pill work
Progesterone only. Thickens cervical mucus. Thins endometrium. Reduced tubal motility.
141
Progesterone only contractive advantages
Anyone. | Prevents oestrogen SE
142
Progesterone only contraceptive disadvantages
Less effective. Erratic bleeding to start with. Risk of ovarian cysts and ectopics
143
Condom disadvantages
Failure
144
Femidom advantages
Protects from STIs Inserted any time No lubrication
145
Femidom disadvantages
Loud Messy Higher failure rate
146
Diaphragm and caps advantages
Woman in control | Inserted anytime before inercourse
147
Diaphragm and caps disadvantages
Requires staff for fitting Messy Dislodged
148
What is natural family planning
Monitor vaginal secretions and temperature measurements. Needs periods of abstinence and montioring.
149
What is lactational amenorrhea method
Baby must be only on breast milk
150
Injectable contraception
``` Depo-provera Every 12 weeks. Inhibits ovulation Sayana press- self inject it. Progesterone only ```
151
Why do injectables cause weight gain
Increase appetite
152
Describe implants
Single rod (nexplanon). Progesterone only. Easy insertion and removal. 3 years.
153
IUD describe
Copper contained in plastic frame. Casues foregin body reaction within the uterus , toxic to sperm and egg significantly reducing chance of fertilization
154
Why do you need to do STI screen when giving a coil
Prevent PID
155
IUS describe
Menorrhagia, progesterone HRT. Very effective few side effects. Very small amount of progesterone
156
Female sterilisation
Serious surgery, GA. No hormonal effects. Permanent.
157
Male sterilisation
Local anaesthetic. Surgery to vas deferens. Not reversible or immediate.
158
What is Emergency Contraception
EC is given after unprotected sexual intercourse to prevent pregnancy
159
Emergency contraceptions examples
Progesterone only (Leveonelle) pills or copper implants. Copper coil is more effective and can be used later.
160
Describe the latent phase of labour
irregular contractions Show mucoid plug Cervix is effacing and thinning Stay at home
161
Treatment for latent phase of labour
Position, water, snacks, paracetamol
162
Length of latent phase of labour
6 hours - 2/3 days
163
Define presentation
The anatomical part of the fetus which presents itself first through the birth canal
164
Define lie
The relationship between the long axis of the fetus and the long axis of the uterus
165
Define attitude
Presenting part flexed or deflexed
166
Define engagement
Widest part of the presenting part has passed through the brim of the pelvis
167
Define station
Relationship between the lowest point and the ischial spines
168
Describe Effacement
Starts in fundus. Retraction and shortening of muscle fibres. Fetus forced down pressure on cervix
169
How does effacing of the cervix vary with number of previous labours
First time mothers will take longer
170
Active labour definition
Regular, frequent contractions which are progressive. 4cm dilated
171
What inhibits oxytocin
Stress and anxiety
172
Factors which affect labour satisfaction
1. Personal expectations 2. Support from caregivers 3. Caregiver-paitent relationship 4. Involvement in decisions
173
Ways to deal with pain
Psychological methods Sensory methods Environment Complementary therapy
174
more support is associated with
Less operative births Less analgesia Shorter labours Better experience
175
What is the official name of gas and air
Entonox
176
Advantage of entonox
Short half life so leaves system quickly
177
Disadvantage of entonox
Vomitting
178
Diamorphine advantage
good pain releif
179
Diamorphine fetal SE
Respiratory depression | Diminishes breast seeking and feeding behaviour
180
Diamorphine maternal SE
Euphoria and dysphoria Nausea and vomiting Longer 1st and 2nd stage laboru
181
Epidural advantage
Most effective pain relief
182
Epidural maternal SE
``` Increase length Need more oxytocin More incidents of malposition Increase instrumental rate. Less mobile, less bladder control ```
183
Epidural fetal side effects
Tachycardia due to maternal temp | Diminishes breast feeding behaviours
184
Can you eat during labour
Should eat and drink as normal unless c section likely
185
Maternal observations during labour
``` BP, Pulse, Temp Bladder Contractions Drugs Vaginal examination Monitoring fetal heart ```
186
What is the transition of labour
``` SROM- clear Irritable, anxious, distressed Start to feel pressure Contrations can stop Support and reassurance ```
187
What is second stage of labour
``` Full dilatation External signs- head visible Spont bearing down Can have a latent phase Progress descent ```
188
How long does it take for active phase in primigravid
3 hours
189
How long does it take for active phase in multiparous
2 hours
190
What is helpful behaviour in second stage
Beneficial, upright position, spontaneous pushing. Privacy, dignity, safety
191
Mechanism of labour
``` Descent Flexion Internal rotation Crowning Extension Restitution Internal restituion of shoulders Lateral flexion ```
192
Why is skin to skin good
Very good. Releases oxytocin
193
What is 3rd stage
Cut and clamp cord. Oxytocic drugs. N and V. Check placenta and membranes complete.
194
What is PID
Pelvic inflammatory disease
195
What is NSU
Non specific urethritis
196
Non STI GU conditions
``` Candidiasis Bacterial vaginosis Gential dermatoses Vulval conditions Psychosexual problems Reactive arthritis ```
197
What is candidiasis
Imbalance of pH of the vulva
198
Sexual health history structure
``` HPC Past GU PMH DH Sexual history ```
199
Questions for sexual history
3-12 months - last intercourse - regular/ casual partner - male/female - condom use - type of SI
200
Sexual health history questions for females
Menstrual history Pregnancy history Contraception Cervical cytology history
201
Sexual health history questions for males
When last voided urine
202
Big 4 STIs
Syphilis Chlamydia Gonorrhea HIV
203
Genital examination for both sexes
Skin Inguinal nodes Pubic hair
204
Genital examination for women
``` Vulva Perineum Vagina Cervix Bimanual pelvic examination Possibly anus and ororpharynx ```
205
Genital examination for men
Penis Scrotum Urethral meatus Anus and Oropharynx in MSM
206
Asymptomatic screening for women
Self taken vulvo vaginal swab (for Gonorrhoea/Chlamydia NAAT) Bloods (for STS and HIV)
207
What is NAAT
Nucleic Acid Amplification Test
208
Why must patients be off antibiotics for two weeks before STI testing
False negative
209
Asymptomatic screening for heterosexual male
First void urine (chlamydia/ gonorrhoea NAAT) | Bloods (STS and HIV)
210
MSM screening
First void urine, pharyngeal swab and rectal swab (chlamydia/ gonorrhoea NAAT) Bloods (STS, HIV, Hep B (Hep C if indicated))
211
Female symptomatic presentations
``` Vaginal discharge Vulval discomfort/soreness, itching or pain Superficial dyspaerunia Pelvic pain Vulval lumps or ulcers Inter menstrual bleeding Post coital bleeding ```
212
Male symptomatic presentations
``` Pain on micturition Pain/ discomfort in urethra Urethral discharge Genital ulcers, sores or blisters Genital lumps Rash Testicular pain/ swelling ```
213
Symptomatic female screening
``` Vulvovaginal swab (Gono and Chlamy NAAT) High vaginal swab (BV, TV, Candida) Cervical swab (Gono) Dipstick urinalysis Bloods (STS and HIV) ```
214
Symptomatic male screening
Urethral swab (gono) First void urine (Gono and chlam NAAT) Dipstick urnialysis Bloods (STS and HIV)
215
MSM Symptomatic screening
Asymptomatic + urethral and rectal slides + urethral, rectal, pharyngeal culture plates
216
Hepatitis B screening
``` MSM Commercial sex workers (+partners) IVDUs (+partners) High risk areas -africa, asia, eastern europe (+partners) ```
217
Why do you need to culture gonorrhea
Because gonorrhea resistance is increasing
218
What predisposes to preeclampsia
``` Younger Older Black Primigravity Multifetal pregnancies HTN Renal disease ```
219
What is chronic hypertension
- before pregnancy - before 20th week - during pregnancy and not resolved post partum
220
What is gestational hypertension
- new HTN after 20weeks - systolic >140 - diastolic >90 - no or little proteinuria
221
Whats the difference between gestational hypertension and preeclampsia
Preeclampsia is where they have developed significant proteinuria
222
What is the difference between preeclampsia and eclampsia
Eclampsia is where they develop tonic clonic seizures
223
What is preeclampsia- eclampsia
- new HTN after 20 weeks | - increased BP with proteinuria
224
How do you take BP in pregnant women
Sitting position Cuff at heart level Not supine as would press on IVC Sit for 10mins before
225
Classification of preeclmapsia eclampsia
Mild preeclampsia Severe preeclampsia Eclampsia
226
Clinical criteria for severe preeclampsia (one or more)
``` 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 ```
227
Preeclampsia Superimposed Upon Chronic Hypertension
HT with or without proteinuria. | Can be thrombocytopenia and abnormal ALT/AST
228
How does preeclampsia effect the placenta
Failure of physiological change in spiral arteries. They dont dilate and they remain tortuous. Leading to ischaemic placenta and oxidative stress
229
How does preeclampsia affect the placenta
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.
230
Preeclampsia affect on coagulation system
Thrombocytopenia; low antithrombin III; higher fibronectin.
231
Preeclampsia affect on liver
HELLP syndrome (Haemolysis, Elevated ALT and AST, and Low Platelet count).
232
Preeclampsia affect on CNS
Eclampsia headache and visual disturbances Scotomata cortical blindness.
233
Symptoms fo preeclampsia
``` Visual disturbances. Headache similar to migraine. Epigastric pain - hepatic swelling and inflammation, stretch of liver capsule ± Oedema Rapid weight gain ```
234
Physical findings in preeclampsia
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.
235
Differential diagnosis for preeclampsia
Thrombotic Thrombocytopenic Purpura Haemolytic Uremic Syndrome Acute Fatty Liver of Pregnancy
236
Lab tests for preeclampsia
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
237
Preeclampsia treatment goal
prevent eclampsia and other severe complications | Palliate maternal condition to allow fetal maturation and cervical ripening.
238
Preeclampsia treatment
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
239
Indications for delivery in preeclampsia- maternal
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.
240
Why do you give magnesium sulfate in preeclampsia
To stop fits/ eclampsia developing
241
Indications for delivery in preeclampsia- fetal
Severe fetal growth restriction Nonreassuring fetal testing results Oligohydramnios Delivery should be based on maternal and fetal conditions as well as gestational age.
242
Preferrable delivery route for preeclampsia
Vaginal | Inducing can help
243
Which HTN drugs are used in pregnancy
Labetalol | Nifedipine
244
Premature definition
Before 37 weeks
245
Low birth weight baby definition
Less than 2.5kg
246
Can a baby be premature but not LBW
Yes
247
Can a baby be LBW but not premature
Yes
248
Why are more premature babies surviving
``` Antentatal steroids Artificial surfactant Ventilation Nutrition Antibiotics ```
249
Risk factors for pre term birth
``` Preterm labour PPROM Cervical weakness Amnionitis Medical/ obstetric disorders ```
250
Non recurrent risk factors for PTB
APH Vaginal bleeding Multiple pregnancy
251
Recurrent risk factors for PTB
``` Black race Previous preterm birth Smoking Genital infection Cervical weakness Socioeconomic ```
252
How can you prevent PTB (primary)
Smoking and STD Planned pregnancy Health advice
253
How can you prevent PTB (tertiary)
Prompt diagnosis Drugs: Tocolytics Anitbiotics Corticosteroids
254
Diagnosis of preterm labour
Persistent uterine activity AND change in cervical dilatation and/or effacement
255
How can you prevent PTB (secondary)
Select increased risk for surveillance and prophylaxis
256
Screening for preterm labour
Transvaginal cervical ultrasound | Qualitative fetal fibronectin test
257
False positives for fibronectin test
Cervical manipulation Sexual intercourse Lubricants Bleeding
258
How can you prevent PTB developing in high risk
Progesterone pessary
259
What increases chance of urinary incontinence
Smoking Obesity Multiparty Age
260
Why does genital tract atrophy after menopause
Oestrogen makes cells have more glycogen and therefore water
261
What is the pathophysiology of overactive bladder
Involuntary bladder contractions
262
Define incontinence
Involuntary leakage of urine
263
What is the pathophysiology of stress urinary incontinence
Sphincter weakness
264
Is stress or urge incontinence large volume leakage
Urge
265
What causes fistulas
Cancers
266
Other than stress and urge incontinence name 5 more
``` Fistula Neurological Overflow Functional Mixed ```
267
Overactive bladder presentation
``` Urgency incontinence Frequency Nocturia Nocturnal enuresis Intercourse 'Key in door' 'Handwash' ```
268
Stress incontinence presentation
``` Cough Laugh Lifting Exercise Movement ```
269
Simple urinary assessments
Frequency volume chart Urinalysis Residual urine measurement Questionnaire
270
What does Frequency volume chart tell you
``` Voided volume Frequency of urination Quantity and frequency of leakage Fluid intake Diurnal variation ```
271
Likely diagnosis from nitrites on MSU
Infection
272
Likely diagnosis from Leukocyte on MSU
Infection
273
Likely diagnosis from Microscopic haematuria on MSU
Glomerulonephritis, nephropathy, neoplasia, calculus, infection
274
Likely diagnosis from Proteinuria on MSU
Renal disease, cardiac disease
275
Likely diagnosis from glycosuria on MSU
Diabetes, IGT, nephropathy, reduced renal threshold
276
Incontinence questionnaire main categories
Urinary Vaginal Bowel Sexual
277
Treatment for stress incontinence
Conservative (Physio) Surgery (Sling, suspension). Aiming to strengthen the sphincter
278
Treatment for overactive bladder
``` Bladder drill Drugs Botox Augment Bypass ```
279
Drugs used for overactive bladder
Anticholinergic
280
General treatment for incontinence
Reassurance Support Lifestyle adaptation Containment
281
What are the containment options for incontinence
``` Bladder bypass: Catheters Leakage barriers (pads & pants) Vaginal support devices Skin care Odor control ```
282
Lifestyle adaptations for incontinence
Weight loss Smoking cessation Reduce caffeine Avoid straining and constipation
283
Which hormone can be given to treat incontinence
Oestrogen
284
Destrusor muscle neurotransmitter
Acetylcholine
285
Destrusor muscle receptors
Muscarinic (M2 and M3)
286
Which drug is used for incontinence
Oxybutinin- anticholinergic
287
What are the side of effects of antimuscarinics/ anticholinergics
Dry mouth Blurred vision Drowsiness Constipation
288
Which injection is used for incontinence when tablets havent worked
Botox
289
What non surgical things can be done for incontinence
Catheter Pads Physio
290
Surgery for stress incontinence princaples
Restore pressure transmission to urethre Support urethra Increase urethral resistance
291
Prolapse history
SCD pain Lump Discomfort Pelvic floor and sexual symptoms
292
Prolapse examination
Sims speculum
293
Prolapse investigations
Usually none (urodynamics, MRI, ultrasound)
294
Prolapse treatment
Reassuranc eand advice Treat pelvic floor symptoms Pessary Surgey
295
What is the pouch of douglas
Between the uterus and the rectum
296
What is supporting the uterus so it doesnt fall out
Pelvic floor muscle Fascia Uterosacral ligaments
297
Symptomatic prolapse describe
Dyspareunia Discomfort Obstruction Bothersome
298
Severe prolapse describe
Outside vagina Ulcerated Failed conservative measures
299
Two main things that cause prolapse
Childbirth (primary damage) | Age
300
Conditions which could predispose to prolapse
Connective tissue disorders like Ehlers Danlos
301
Anterior prolapse
Cystocele
302
Posterior prolapse
Rectocele
303
Uterus prolapse
Enterocele
304
Main operation for enterocele
Vaginal hysterectomy
305
Define menstruation
Monthly bleeding from reproductive tract induces by hormonal changes of the menstrual cycle.
306
What is the length of the menstrual cycle
The length of a menstrual cycle is the time from the start of a period to the start of the next
307
How much blood loss is normal
60-80ml
308
Which hormone is higher in follicular phase
Oestrogen
309
Which hormone is higher in luteal phase
Progesterone
310
On which day does ovulation occur
Day 14
311
Define menorrhagia
Heavy Menstrual Bleeding that occurs at expected intervals of the menstrual cycle
312
Define intermenstrual bleeding
Uterine bleeding that occurs between clearly defined cyclic and predictable menses
313
Define abnormal uterine bleeding
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
Heavy menstrual bleeding definition
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
What is PCB
Post coital bleeding
316
What is PMB
Post menopausal bleeding
317
What is IMB
Inter mestrual bleeding
318
Causes of Heavy Menstrual bleeding
Combination of coagulopathy Ovulatory endometrial dysfunction
319
Pathological causes of HMB
Uterine fibroids Uterine polyps Adenomyosis Endometriosis
320
Define uterine fibroids
Benign tumours of myometrium
321
Describe fibroids
well circumscribed whorls of smooth muscle cells with collagen
322
Define uterine polyps
common benign localised growths of the endometrium
323
Describe the microscopic detail of polyps
fibrous tissue core covered by columnar epithelium
324
Why do uterine polyps occur
arise as a result of disordered cycles of apoptosis and regrowth of endometrium
325
How would you see polyps
Transvaginal US | Hysteroscopy
326
Define endometriosis
endometrium type of tissue lying outside the endometrial cavity
327
Define adenomyosis
ectopic endometrial tissue within the myometrium
328
What do you call the ovarian cysts in endometriosis
Chocolate cysts
329
History questions about menses
``` Duration Cycle index of heaviness -clots -protection -flooding ```
330
Associated concerns to ask about in hisotry of HMB
``` Pain Premenstrual tension Infertility worries Cancer phobia Interference with quality of life Duration and relation to cycle Details of fertility Be aware ```
331
Associated non vaginal questions for HMB
Thryoid disease Clotting disorder Drug therapy
332
General examination in HMB
Sclera, palms, gingiva Thyroid gland Abdomen
333
Pevlic examination in HMB
Vulva and vagina Cervix Uterus Adnexae
334
Investigations for HMB
FBC TVS Endometrial biopsy Hysteroscopy
335
First line treatment for HMB
Reassurance
336
Second line treatment for HMB
Antifibrinolytics (tranexamic acid)
337
Third line treatment for HMB
NSAIDs (mefenamic acid)
338
Indications for endometrial ablation
``` Heavy menstrual loss Not expecting amenorrhoea Normal endometrium Uterus less than 12 weeks size Completed family ```
339
Contraindications for endometrial ablation
Malignancy Acute PID Desire for future pregnancy Excessive cavity length
340
Fibroids but want a baby
Myomectomy
341
Focussed gynae history- key symptoms
``` Pain Bleeding Urinary symptoms Bowel symptoms Prolapse Sexual history ```
342
Gynae history PMH
``` Menstrual history Contraception Sexual history Smears Past gynae history Past obstetric history Medical history Family history ```
343
How to take a menstrual history
Last menstrual period - normal - on time - duration - how heavy - how painful - any change
344
How do you write down menstrual period
X/Y X= duration Y= cycle
345
Normal period duration of bleeding
2-7 days
346
Normal length of cycle
21-35 days
347
Define menarche
Age of first period
348
Normal age of menarche
10-16
349
Define menopause
age/date of last spontaneous period
350
Normal age of menopause
4-55, average 51
351
Superficial dysparunia meaning
At start of intercourse, when penis is going in
352
Deep dysparunia
When the penis is deep
353
Define climacteric
Years before menopause associated with menopausal symptoms but still menstruating
354
Define postmenopausal
No periods for 1 year after the age of 50 (2 years if <50years)
355
Define gravida
Number of times pregnant total
356
Define parity
Number of babies theyve had (pregnancy over 24 weeks)
357
Things to ask in broad gynae history, medical and surgical
``` Previous abdo/pelvic surgery Major CVS/ resp/ gastro disease Endocrine disease Haematology Breast Ca T2DM ```
358
Family history in Gynae
Breast and ovarian cancer | BRCA gene
359
What does T2DM increase your risk of
Endometrial cancer | Ovarian cysts
360
Sexual history questions
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
Fertility history questions
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
Urogynaecology history
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
Obstetric history
``` Previous pregnancies Current symptoms Early scans PMH PGH FH SH MH Risk factors ```
364
Early pregnancy dating scan uses what
From crown rump length
365
What is the estimated date of delivery
40 completed weeks
366
Family history for obs history
Diabetes Heart disease Genetic abnormalities Thrombophilia
367
Questions to ask about previous pregnancies
``` Year Gestation Outcome Mode of delivery Complications ```
368
Pregnancy outcomes
Miscarriage Termination Ectopic Deliveries
369
Define miscarriage
Loss of pregnancy before 24 weeks
370
Define IUFD
Babies with no sign of life in utero
371
Define still birth
Baby delivered with no signs of life, known to have died after 24 weeks
372
Neonatal death definition
The death of a baby within the first 28 days of life
373
Early NND definition
Up to 7 days
374
Late NND definition
Between 7 and 28 days
375
When is the baby classed as term
37 to 42 weeks
376
When is the baby classed as pre term
Less than 37 weeks
377
When do you give aspirin in pregnancy
Low dose. high risk for preeclampsia
378
When is the baby classed as post term
More than 42 weeks
379
What does a + on PG mean
Loss after 24 weeks
380
What does a - on PG mean
Loss before 24 weeks
381
What to ask about previous labours
Show Contractions SROM Partogram
382
What is SROM
Spontaneous rupture of membrances
383
Define menopause
Cessation of menstruation.
384
When is menopause diagnosed
Diagnosed after 12 months of amenorrhoea or at onset of symptoms if hysterectomy
385
Define Perimenopause
Period leading up to the menopause
386
Describe perimenopause
Characterised by irregular periods and symptoms eg hot flushes, mood swings, urogenital atrophy
387
Central effects of decreased oestrogen levels
Vasomotor symptoms MSK symptoms Low mood and sexual difficulties
388
Local effects of decreased oestrogen levels
Urogenital symptoms such as vaginal dryness due to vaginal atrophy
389
General short term symptoms of menopause
Mood change/ irritability Loss of memory/ concentration Headaches, dry and itchy skin, joint pains Loss of confidence and lack of energy
390
Urogenital atrophy symptoms after menopause
``` Dyspareunia Recurrent UTIs PMB Urinary incontinence Prolapse ```
391
Long term effects of the menopause
Osteoporosis Cardiovascular disease Dementia
392
Why is there cardiovascular disease rates higher after menopause
Adverse changes in lipid. Increased prevalence with early menopause
393
Soft ways to manage menopause
Hollistic approach Lifestyle advice Reduce modifiable risk factors
394
Treatment options for menopause
``` Hormonal -HRT, vaginal oestrogens No hormonal -clonidine Non pharmaceutical -CBT ```
395
Name a non hormonal treatment for the menopause
Clonidine
396
Name a non pharmaceutical treatment for the menopause
CBT
397
Benefits of HRT
Relief of symptoms of menopause Bone mineral density protection Prevent long term morbidity
398
Risks of HRT
Breast cancer VTE Cardiovascular disease Stroke
399
How is breast cancer risk related to HRT
If long duration, during treatment increased risk
400
Should you give HRT to breast cancer patients or patients at risk of BC
Nope. Stop it on diagnosis or when at risk
401
When and why do you gibe transdermal HRT
When higher risk of VTE as reduces risk. Like BMI over 30 or higher VTE risk
402
Does HRT affect diabetes
No
403
Why give progesterone with oestrogen in HRT
It protects the endometrium from the stimulatory effects of unopposed oestrogen
404
Name a HRT med
Estradiol
405
Whats the regime for post menopausal HRT
Continuous combined
406
Whats the regime for perimenopausal HRT
Sequential
407
Who should have transdermal HRT
``` 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
What is premature ovarian insufficiency
Menopause before 40 High FSH 4 months amenorrhoea
409
Natural causes of premature ovarian insufficiency
Idiopathic Chromosomal Enzyme deficiencies AI
410
Iatrogenic causes of premature ovarian insufficiency
Surgery Chemo Radiotherapy
411
How to treat premature ovarian insufficiency
HRT
412
Are you fertile after menopause
Yes, 2 years if before 50, 1 year if over
413
Name non hormonal methods of HRT
``` AARA -alpha adrenergic receptor agonist (clonidine) SSRI SNRI Antiepileptic ```
414
Contraindications for HRT
undiagnosed abnormal PV bleeding, breast lump, acute liver disease
415
Cautions for HRT
Over 60, – fibroids, uncontrolled BP, migraine, epilepsy, endometriosis, VTE family history
416
What is informed consent
process by which a fully informed patient can participate in choices about her health care.
417
What is the legal term for failing to obtain informed consent before performing a test or procedure
Battery
418
Define autonomy
The right of patients to make decisions about their medical care without their health care provider trying to influence the decision.
419
Define competency
Idicates that a person has the ability to make and be held accountable for their decisions
420
What are the elements of full informed consent
``` Nature of decision Alternatives Risks, benefits and uncertainties Assess patient understanding Patient acceptance of procedure ```
421
Does the unborn baby have rights
No
422
Issues with consent to screening
Uncertainties of results (false positives/ negatives) | Consequences of results
423
Fraser recommendations
``` Patient should understand Encourage parental involvement Will they have sex anyway WIthout treatment will health suffer Whats best interests ```
424
Abortion legal requirmeents
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
Why is abortion good
Reduces harm and legal abortion has reduced maternal mortality as illegal abortions are dangerous.
426
Define endometriosis
The presence of endometriotic tissue outside the uterus
427
Why does endometriosis affect women of reproductive age
It is driven by oestrogen
428
Define adenomyosis
The presence of endometriotic tissue within the myometrium
429
What is the myometrium
The middle layer of the wall of the uterus
430
Describe theories of causation of endometriosis
Retrograde period Mesothelial metaplasia Impaired immunity
431
Describe presentation of endometriosis
Pain Subfertility No symptoms
432
What is the classic sign of endometriosis
A fixed retrograde uterus on bimanual vaginal examination
433
What is the gold standard investigation for endometriosis
Laparoscopy with biopsy for histological confirmation
434
What can lead to under diagnosis of endometriosis
If the laparoscopies are within 3 months of hormonal therapy
435
Name some medical endometriosis treatments
COCP Progestagens Mirena
436
What do you do if the medical treatment of endometriosis has failed
Laparoscopy with ablasion
437
Reasons breast cancer incidence is increasing
``` Less breast feeding Having children later Obesity HRT More older people More screening Alcohol ```
438
Genetic factors which increase breast cancer risk
BRCA1 BRCA2 Tp53
439
Modifiable risk factors for breast cancer
Weight (post menopause) Exercise Alcohol Extrogenous oestrogens
440
Non modifiable risk factors for breast cancer
Age of menarche and menopause Early parity and breast feeding Breast density Heredity
441
What is the NHS breast screening programme
47-70 every 3 years. Dual view mammography
442
What is a mammogram
Low dose XRay. Breast compressed to increase definition
443
Mammography problems
Overdiagnosis Anxiety Costs X ray dose
444
Who is screening more effective in
Elderly. Less dense breast. More likely to have cancer (also more likely to die of something else)
445
What is triple assessment for breast cancer diagnosis
Clinical Imaging Biopsy
446
Presenting symptoms of breast cancer
Painless lump Nipple discharge Nipple in drawing
447
Presenting signs of breast cancer
Painless lump Skin tethering Indrawn nipple
448
Describe how the lump feels in breast cancer
Irregular Hard Fixed
449
What is DCIS
Breast cancer precursor | Or can just stay DCIS
450
MRI scanning for breast cancer
Useful for implant assessment Only for difficult cancer diagnosis high risk screening
451
What makes it hard to image a womans breast
If they are young (dense breast) | Have breast implants
452
Why would you mastectomy
Multiple foci Larger than 20% She wants you to Inflammatory
453
What must you do if you get breast conservation not mastectomy
Radiotherapy
454
How do you improve appearance of post surgery breasts
Nipple tattooing | Augmentation
455
How do you choose axillary surgery in breast cancer
Full clearance if gland clinically involved. Sentinel node biopsy if glands clinically normal.
456
Name two types of breast cancer
Ductal carcinoma | Lobular carcinoma
457
Define grading
What the cancer looks like down the microscope
458
Define staging
The anatomical distribution
459
What is used for staging of breast cancer
TNM.
460
What is used for prognosis in breast cancer
Nottingham prognostic index
461
Why do you do arrays in breast cancer patients
For receptor sub typing. ER, Her-2, PgR
462
What drug would you give to a HER-2 positive disease
Hercpetin
463
Why would you give chemo
Bad cancer ie risk factors
464
When is tamoxifen given
Oestrogen sensitive cancers
465
Do you give adjuvant radiotherapy in breast cancer
Always
466
When is neoadjuvant chemotherapy brilliant
When herceptin sensitive, fit and well individual
467
Causes of infertility
``` Ovulatory Tubal Uterine Male Unexaplained (even splits) ```
468
Why do miscarriage rates go up with age
More chromosomal abnormalities
469
Principles of infertility care
``` Both partners together Explain Reassure Conception advice Support groups Counselling ```
470
Do you have to wait 2 years for infertility treatment
Not if there is an obvious problem
471
Preconception advice
``` Intercourse Folic acid Smears Immunisations Smoking cessation Alcohol Weight Environement PMH DHx ```
472
Reproductive disorders associated with obesity
``` PCOS Miscarriage Infertility Lower success rate Obstetric complications ```
473
Investigations for fertility problems
Ovulation function Semen quality Tubal patency
474
How do you monitor ovulation
Progesterone level | day 21- mid luteul
475
How is ovarian reserve tested
Antimullerian hormone
476
What do you look at with semen analysis
Count Motility Morphology
477
Sperm problem treatment
Dietary, lifestyle advice. IVF with ICSI Endocrine ?
478
Name the 3 anovulation causes
Hypothalamus (Low FSH/LH/oestrogen) PCOS Menopause
479
Causes of hypothalamus anovulation
Stress Weight loss Exercise Kallmans
480
Treatments of hypothalamus anovulation
FSH and LH
481
Treatment for PCOS in fertility
Ovulation induction- clomifene
482
Treatment for ovulation induction if clomifene hasnt worked
Metformin
483
Surgery for anovulation
Laparoscopic drilling
484
Causes of tubal infertility
``` Infections Endometriosis Surgical -adhesions -sterilisation ```
485
How to treat endometriosis for fertility
Diagnostic laparoscopy
486
How to treat unexplained infertility
Clomifene IUS IVF
487
Name three methods of assisted conception
Ovulation induction Stimulated intrauterine insemination In vitro fertilisation
488
How can you improve IVF success rate
ICSI
489
What are you more at risk with increasing age
``` HTN DM Operative delivery VTE Death ```
490
Name 4 things with which the chance of pregnancy decreases
Female age Successive cycles Obesity Environmental factors
491
What is the main risk of IVF
Mulitple pregnancy
492
Name three environmental factors which reduce the chances of pregnancy
Smoking Alcohol Caffeine
493
Which maternal death rate has reduced
Direct maternal death
494
Common preexisting medical disorders that cause maternal death
``` Cardiac Asthma Epilepsy HTN DM Thyroid Renal ```
495
Co incidental pregnancy disorders
Malaria Hepatitis Cancers
496
Steps to management of medical disorder and pregnancy
Preconception assessment Affect of disease on pregnancy Affect of pregnancy on disease
497
Prepregnancy advice for those with medical conditions
Wait until the patient is at their best
498
Name a disease that gets worse in pregnancy
Mitral stenosis
499
Name a disease that gets better in pregnancy
Rheumatoid arthritis (due to the relative immunosuppression)
500
What is done with pregnant people with medical conditions
Joint obstetric-medical clinics
501
Anaemia and pregnancy
Higher iron and folate requirements. Leads to low birthweight and preterm delivery
502
What is pregnant and non pregnant threshold for anaemia
110 for normal | 105 for pregnant
503
Treatment for anaemia in pregnancy
Oral iron therapy
504
Name a microcytic anaemia
Iron
505
Name a macrocytic anaemia
Folate | B12
506
Respiratory pregnancy changes
Increased metabolic rate, O2 consumption. Tidal volume increases.
507
What is the effect of increased tidal volume in pregnancy
pO2 increases, pCO2 decreases. Mild alkalosis
508
Asthma affect on fetus
Risk of hypoxia and inadequate placental perfusion. Premature growth and delivery
509
Can asthma drugs be used in pregnancy
yes
510
Why does Cardiac output increase in pregnancy
Due to increased stroke volume
511
Low risk cardiac lesions in pregnancy
Mitral incompetence Aortic incompetence ASD VSD
512
High risk cardiac lesions in pregnancy
Aortic stenosis Coarctation of aorta Prosthetic valves Cyanosed patients
513
When is the cardiac risk to mothers highest
After birth
514
Pregnant women with itching without rash
Obstetric cholestasis
515
Treatment for obstetric cholestasis
Ursodeoxycholic acid
516
Hyperthyroidism in pregnancy
Thryoid storm and fetal thyrotoxicosis
517
Hypothyroidism in pregnancy
Fine if already treated. Aim for adequate replacement with thyroxine
518
What is gestational diabetes
Carbohydrate intolerance first recognised in pregnancy. Risk of developing type 2 or this being first presnetation of type 1
519
Complications of diabetes in pregnancy
Big babies DKA Hypoglycaemia Shoulder dystocia
520
What is erbs palsy caused by
Shoulder dystocia
521
Renal changes in pregnancy
50% increase in renal blood flor and GFR | Low creatinine, urate and albumin normal
522
CKD in pregnancy
HTN Preeclampsia Premature Growth restriction
523
What does renal disease outcome and pregnancy depend on
Degree of renal dysfunction Maternal blood pressure Creatinine Proteinuria
524
Which epilepsy drugs are bad for baby
Valproate and more than one at once
525
Management of epileptic mums
Fetal screening Control seizures Plan for delivery Post partum support
526
Risk factors for VTE
Maternal age BMI Operative delivery
527
Investigation of DVT in pregnancy
Doppler ultrasound
528
Investigation fo PE in pregnancy
CTPA
529
Treatment of VTE in pregnancy
lmwh
530
Define screening
Process of identifyinf apparently healthy individuals who may be at an increased risk fo a disease or conditions
531
Define detection rate
Proportion of affected individuals who will be identified by screening test
532
Define false positive rate
Proportion of unaffected individuals with a higher risk/screen positive result
533
Define false negative rate
Proportion of affected individuals with a low risk/screen negative result
534
What does the fetal anomaly screening programme look for
Downs, Edwards, Pataus | 18-21 weeks
535
What does the infectious diseases screening programme look for
Hep B HIV Syphilis
536
What does the new born blood spot screening programme look for
CF Congenital hypothyroidism Sickle cell disease Inherited metabolic diseases
537
Which chromosome is involved in downs
Trisomy 21 Intelectual disability Structural cardiac disease Epilepsy, thyroid
538
Which chromosome is involved in Edwards
Trisomy 18
539
Edwards syndrome problems
Unusual head and facial features Brain and heart problems Growth problems
540
Which chromosome is involved in Pataus
Trisomy 13
541
Pataus problems
Rarely survive birth Congenital heart defects Facial defects Urogenital malformations
542
When and how are T21, T18 and T13 screened
14 week, nuchal translucency
543
Special circumstances for anomaly screening
Twins
544
What is the minimum number of ultrasounds a woman can have during pregnancy
2
545
What can an early ultrasound tell you
Fetal demise Multiple prenancy Gestational age
546
What can mid pregnancy scans find
``` Major abnormalities Conditions that may benefit brith Plan delivery Optimise treatment Choices about termination ```
547
Which infectious diseases are screened for in pregnancy
HIV Hep B Syphilis
548
Which haem dissorders are screened for
Coagulopathies Sickle cell Thalassaemias
549
What does newborn blood spot screen for
Sickle cell Cystic fibrosis Congenital hypothyroidism 6 metabolic disorders
550
What is hearing screening
Low sound before they leave. Repeated and then full audiology testing if negative.
551
New born and infant physical examination NIPE
``` General Eye problems Congenital heart defects Developmental dysplasia of hips Undescended testes ```
552
Maternal obstetric emergencies
Antepartum haemorrhage Postpartum haemorrhage VTE Preeclampsia
553
Fetal obstetric emergencies
Fetal distress Cord prolapse Shoulder dystocia
554
Define antepartum haemorrhage
Bleeding from anywhere in the genital tract after 24th week of pregnancy
555
Where can antepartum haemorrhage come from
Uterus Cervix Vagina Vulva
556
Identifiable causes of APH
``` Low lying placenta Placenta ccreta Vasa praevia Minor/ major abruption Infection ```
557
What is placenta accreta
Placenta adhering to the uterus
558
What is vasa praevia
Fetal blood vessels near the entrance to. the uterus
559
What does major low lying placenta mean
Covering/ reaching os
560
What does minor low lying placenta mean
Lower segment/ enroaching
561
What do you do if LLP identified at 20 week anomaly scan
Repeat at 32 weeks if major, repeat at 36 weeks in minor
562
Management of low lying placenta
Advise If recurrent bleeds, admit until delivery. Give anti D if Rh- Caessarean
563
Bleeding placenta praevia management
ABCDE Examination Fetal monitoring +- delivery Steroids
564
Why do you give steroids in emergencies
Develop the babies lungs
565
Define placenta accreta
The placenta grows into the uterine linig
566
Define placenta increta
The placenta grows into the muscular of the uterus
567
Define placenta percreta
The placenta grows through the wall of the uterus into surrounding tissue
568
Risks for placenta percreta
``` Placenta previa Previous c section IVF Advanced maternal age Smoking Prior uterine surgery ```
569
Management of placenta accreta
20 week scan C section at 36weeks Hysterectomy
570
What is vasa praevia
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
Define placental abruption
Premature seperation of the placenta from the uterine wall
572
How would you treat a small placental abruption
Conservative
573
How would you treat a large abruption
Resuscitation and delivery
574
Consequences of a large placental abruption
Fetal distress | Maternal shock
575
Complications after APH
``` Premature labour Blood transfusion Renal failure PPH DIC ARDS ITU ```
576
What is major PPH
>1000ml
577
What is minor PPH
500-1000ml
578
What is primary PPH
Within 24 hours of delivery, blood loss over 500mls
579
What is secondary PPH
After 24 hours and up to 12 weeks post delivery
580
What are the four Ts of PPH causes
Tissue (complete) Tone (contract) Trauma (tears) Thrombin (clotting)
581
Risk factors for PPH
``` Big baby 0 or lots of kids Multiple pregnancy Prolonged labour Maternal pyrexia Operative Shoulder dystocia Previous PPH ```
582
Risk factors for sepsis
``` Obesity Diabetes Vaginal discharge Prolonged SROM Group A strep infection in close contacts ```
583
Sepsis six bundle of treatment
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
Signs and symptoms of sepssi
``` Pyrexia Tachycardia Tachypnoea Hypo -thermia -oxia -tension Oligouria ```
585
Severe preeclampsia criteria
Hypertension and proteinuria and one other of - severe headache - visual disturbances - clonus - liver tender - papilloedema - abnormal liver enzymes - low platelets
586
Treatment for preeclampsia
Nifedipine and magnesium sulphate
587
What to monitor in severe preeclampsia
Platelets, liver and renal function Monitor urine output Fetal wellbeing Delivery
588
What is eclampsia
Onset of seizures in a woman with preeclampsia
589
Treatment of eclampsia
Magnesium sulphate and nifedipine
590
Should you treat mother or delivery baby first in eclampsia
Treat mum then delivery baby
591
What does a sinusoidal fetal trace suggest
Fetal compromise
592
What is cord prolapse
Where the cord is presenting after SROM. Exposure of the cord leads to vasospasm
593
Risk factors for cord prolapse
``` Premature SROM Polyhydramnios Long umbilical cord Fetal malpresentation Multiparty Multipregnancy ```
594
Management of cord prolapse
Call 999 Infuse fluid into bladder Trendelenburg Fetal monitoring
595
Define shoulder dystocia
Failure for the anterioir shoulder to pass under the symphysis pubis after delivery of the fetal head
596
Maternal complications of shoulder dystocia
PPH Extensive vaginal tear Pyschological
597
Neonatal complications of shoulder dystocia
Hypoxia Fits Cerebral palsy Brachial plexus injury- erbs palsy
598
Risk factors for predicting shoulder dystocia
``` Macrosomia Maternal DM Previous shoulder dystocia Disproportion of mum and fetus Obesity Prolonged labour Instrumental ```
599
Acronym for shoulder dystocia
HELPERR
600
What does the acronym for shoulder dystocia stand for
``` Help Episiotomy evaluation Legs in mcroberts Pressure suprapubic Enter pelvis Rotational manoeuvres Remove posterior arm ```
601
Where does labour pain come from in the first stage
T10-L1. S2-4 | Uterine contraction, cervical effacement and dilatation
602
Where does the pain come from in 2nd stage of labour
Stretching vagina and perineum, extrauterine, pelvic structures. S2-4 L5-S1
603
Non pharmacological therapies for labour pain
Acupuncture Hypnotherapy Massage Hydrotherapy
604
Simple analgesia for labour pain
paracetamol and codeine
605
Name an inhalational analgesia
Entonox
606
What is entonox
50% nitrous oxide and 50% oxygen
607
Single shot IM opioids that are given for labour pain
Morphine | Diamorphine
608
Why can diamorphine be given in childbirth
Rapidly eliminated by placenta
609
PCA opioids
Fentanyl
610
Name 3 regional anaesthetic techniques used in labour
Epidural Spinal Combined spinal epidural
611
Where is a spinal done
into the CSF
612
Where is the epidural done
Epidural CSF
613
What is tuffiers line
Between illiac crests, L23
614
Local anaesthetic name
Bupivacaine
615
Opioids names
Fentanyl | Diamorphine
616
Indications for epidural
``` Maternal request Cardiac or medical disease Augmented labour Multiple births Instrumental or perative delivery likely ```
617
Absolute contraindications for regional techniques
Maternal refusal Local infection Allergy to LA
618
Relative contraindications for regional techniques
``` Coagulopathy Systemic infection Hypovolaemia Abnormal anatomy Fixed cardiac output ```
619
Effects of regional techniques of analgesia
Vasodilatation Analgesia Motor blockade Fever
620
Adverse effects of regional techniques of analgesia
``` Cardiovascular Respiratory Neurological Drug related Headache ```
621
Different epidural regimens
Traditional Continuous infusion Continuous infusion and bolus Combined spinal epidural
622
Outcomes of regional anaesthetics
Superioir analgesia Maternal satisfaction Prolong labour Increase instrumental delivery
623
Anaesthesia for C section
Spinal and or epidural, up to the chest
624
GA risks
Altered physiology Aspiration Failed intubation Awareness
625
Advantages of. regional anaesthesia during labour
Safer Can see baby immediately Partner present Improved post op analgesia
626
Disadvantages of regional anaesthesia
Hypotension Headache Discomfort associated with pressure symptoms Failure
627
Why do small babies struggle in labour
They have very little reserve
628
Why do you look at lica volume
Indicates that the placenta is working well
629
What do you look for on fetal monitoring
Movements | Heart beat
630
Risk factors for still birth
``` Preexisting medical conditions High BMI Smoking Recreational drug use Low BMI Alcohol High maternal age Twins ```
631
Methods of fetal heart monitoring
Intermittent auscultation Pinard stethoscope Hand held doppler device
632
Disadvantages of intermittent auscultation
Not long term Cant detect decelerates variable quality
633
Advantages of intermittent auscultation
Inexpensive Non invasive Can be used at home
634
Advantages of cardiotocography (CTG)
Information about both FHR and uterine contractions Long term monitoring Average variability can be determined
635
Disadvantages of CTG
No improved outcomes in low risk No morphological assessment of heart Fetal exposure to ultrasound
636
What are indicators of fetal well being on CTG
Accelerations Variability Deccelerations
637
Acronym for CTG intepretation
``` Dr C Bra V A D O ```
638
What does Dr C BraVADO stand for in CTG intepretation
``` Define risk Contractions Baseline rate Variability Accelerations Decelerations Overal assessment ```
639
Normal fetal heart beat
110-160bpm
640
What are the three types of deceleration
Early Late Variable
641
What does the timing (early, late, variable) of decelerations refer to
How it lines up with contractions
642
What can cause variable decelerations
Cord compression
643
What is the gold standard for direct FHR monitoring
Scalp ECG (gives true beat to beat information)
644
Disadvantages of scalp ECG
Invasive Must have SROMed Perinatal infection
645
Ovarian cyst treatment
Remove the ovary Remove the cyst Laparotomy Laparoscopy
646
What % of pregnancies are miscarriage
20
647
Define a threatened pregnancy
Pregnancy associated with vaginal bleeding with or without abdominal pain
648
Which investigation for seeing if a delayed miscarriage has occured
Ultrasound scan
649
What is seen on ultrasound if the baby has died
Empty gestation seen or a fetal pole with no heart beat
650
In early pregnancy how often should the b-hCG level double
Every 36-48hours
651
In early pregnancy what type of ultrasound is best
Transvaginal
652
Do you need to treat an incomplete early miscarriage medically
No
653
What is a risk of surgical treatment of miscarriage
Uterine perforation
654
Name two drugs used fo expel a baby
Mifepristone (anti-progestogen), prostaglandin (misoprostol)
655
What % of pregnancies are ectopic
1
656
Where are ectopic pregnancies most commonly found
``` Fallopian tube (90%) Cornual Ovary Cervix Abdomen ```
657
Why dont ectopics work
Not enough myometrium, supporting muscle for the pregnancy
658
What does a low or static BhCG suggest
ectopic
659
What is worrying about an ectopic
Risk fo death with rupture
660
What drug can be used to treat an ectopic
Methotrexate
661
What is a molar pregnancy
When there is a large fluid filled vesicle in the placenta
662
What does an excessively high BhCG stand for
Molar pregnancy
663
What does the ultrasound scan of a molar pregnancy look like
Snow storm
664
Define hyperemesis in pregnancy
Excessive vomiting associated with dehydration and ketosis
665
What is associated with hyperemesis gravidarum
High levels of BhCG
666
What is the treatment for hyperemesis gravidarum
Rehydrate with IV fluids, vitamin supplements and nil by mouth until oral fluids can be tolerated
667
Define FGM
All procedures involving partial or total removal of female external genitalia or other injury to the female organs for non medical reasons
668
Type 1 FGM
partial or total removal of clitoris
669
Type 2 FGM
Excision
670
Type 3 FGM
Infibulation
671
Type 4 FGM
All other harmful procedures to the female genitalia. Piercing etc
672
Why does FGM happen
``` Status Virginity Part of being a woman Honour Religious Community Marriage ```
673
FGM and UK law
Illegal. Even to repair after birth. Illegal to take child out of UK for FGM
674
Gynae complications of FGM
``` Dyspareunia Sexual dysfunction Chronic pain Keloid scar Dysmenorrhoea UTI PTSD Difficulty concieving ```
675
Obstetric complications of FGM
``` Fear C sectionm PPH Vaginal lacerations Difficulty with interventions ```
676
Common paediatric gynaecological problems
Amenorrhoea Precocious puberty Delayed puberty Menstrual disorders
677
When is normal for menarche
11-14.5
678
How long do bleeds last
3-7 days
679
How long between periods
21-45 days
680
What precedes menarche
Secondary sexual characteristics, peak height velocity
681
Define primary amenorrhoea
No menses by age 16 in presence of secondary sexual characteristics
682
Primary amenorrhoea causes
Hypothalamic Pituitary Ovarian
683
Secondary amenorrhoea
Cessation after onset of menses
684
Causes of secondary amenorrhoea
Weight loss Excessive exercise PCOS
685
Oligomenorrhoea
Menses more than 35 days apart
686
Precocious puberty
Appearance of physical and hormonal signs of pubertal development at an earkier age than is considered normal
687
What age counts as precocious puberty
Age 8 girls | Age 9 boys
688
When is menarche precocious
before 10
689
How is puberty investigated
Secretion of high amplitude pulses of GnRH by the hypothalamus
690
Central causes of precocious puberty
Maturation of HPO axis | CNS trauma, tumours, hydrocephalus
691
Pseudopuberty causes
CAH, tumours of adrenals or ovaries
692
Order of puberty
Thlearche Pubarche Menarche

Phase 3A (25 decks)

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