Obs And Gynae Flashcards
Which hormones are actively involved in transforming a pregnancy into the labour phase?
Progesterone levels decrease and oxytocin increases which increase uterine contractions
Prostaglandin levels increase which lead to cervical ripening and increase uterine contractions
Oestrogen and relaxin also contribute to this
When is a foetus considered mature?
Maintain an independent existence outside the uterus
Breathe / maintain oxygenation
Feed / Maintain blood sugars
Maintain body temperature
When is a foetus considered viable?
Can survive extra-uterine
Usually 23-24 weeks depending on neonatal intensive care facilities
When is a foetus considered term?
Gestational age
37 completed weeks till 42 weeks
When is a foetus considered pre term?
Earlier than 37 completed weeks and after accepted age of viability (23-24 weeks)
When is a foetus considered post mature?
After 42 weeks
What processes have to occur in the process of parturition?
Cervical ripening / effacement
Cervical dilatation
Uterine contractions
Foetal membrane rupture
What is cervical effacement?
Cervix shortens and thins
What is a bloody show?
Mucus plug loosened and released from cervix as it starts to efface
What is the latent phase of labour?
Once cervix effacement starts to dilation of 4cm and regular contractions have begun
What factors contribute to cervical ripening?
Cyclooxygenase-2
Prostaglandin E2 (PGE2) and F2-alpha
Hyaluronic acid
Chemotaxis for leukocytes, causes increased collagen degradation
Stimulation of interleukin (IL)–8 release
Activity of matrix metalloproteinases 2 and 9
Cervical collagenase and elastase
Why can infection or inflammation lead to pre term labour?
Cytokines: interleukins 1 and 6 released as inflammatory response can trigger the process of cervical ripening and uterine contractions as they lead to the production of prostaglandins E2 and F2a
What are indications for inducing labour using prostaglandins?
Prolonged pregnancy
Pre labour rupture of membranes
Concerns about health of mother: pre eclampsia
Concerns about health of baby: poor growth
What can be used to induce labour?
Prostaglandin E2
Propess and cervidil: controlled release vaginal insert
Prostin and glandin: vaginal suppositories
What are the names of the foetal membranes?
Chorion: outermost membrane, contributes to placenta formation
Amnion: when first formed, closely covers embryo, fills with amniotic fluid to become protective sac
What cellular changes occur to allow growth of the uterus?
Smooth muscle hyperplasia and hypertrophy
When is the first trimester?
0-12 weeks
When is the second trimester?
13-28 weeks
When is the third trimester?
29-40 weeks
What are the layers of the uterus?
Endometrium: highly vascular mucosa, stratum functionalis (shed during menstruation), stratum basalis (permanent, gives rise to new functionalis after each cycle)
Myometrium: three layers of muscle
Perimetrium/serosa: visceral peritoneum
What happens to the Myometrium prior to parturition?
Increased expression of contraction-associated proteins,
including oxytocin receptors, connexin-43, and prostaglandin F2alpha receptors
Down-regulation of the nitric oxide (NO) pathway and other
vasorelaxing peptides
What happens to the myometrium during labour?
Prostaglandins and oxytocin act in synergy to trigger contractility through an increase in intracellular Ca2+ concentration
What percentage of deliveries are pre term?
7-10%
What factors could cause pre term labour?
Increasing maternal age, stress (domestic abuse)
Pre term rupture of membranes: infection, smoking, drug use, previous PROM, polyhydramnios, multiple gestation, amniocentesis, poor nutrition, cervical insufficiency, low SES, underweight
Pre term contractions
Cervical insufficiency: previous cervical biopsy, uterine abnormalities, trauma to cervix
What are tocolytics? Give examples
Used to suppress premature labour, buy time for administration of betamethasone
Terbutaline/salbutamol: B2 agonist
Nifedipine: ca channel blocker
Atosiban: oxytocin antagonist
Indomethacin: NSAID
Magnesium sulfate: myosin light chain inhibitor, reduce risk of cerebral palsy
What is Oligohydramnios? What increases the risk of this?
Foetal chromosomal abnormalities Intra uterine infections PG inhibitors, ACE inhibitors Obstruction of foetal urinary tract Intra uterine growth restriction Amnion nodosum: failure of secretion by amnion cells covering placenta Post maturity
What is polyhydramnios? What increases the risk?
Twins/ multiple gestation Gestational diabetes Gastrointestinal atresia of foetus Rhesus disease in mother Chorioangioma Chromosomal abnormality of foetus Hydrous fetalis: fluid build up in foetus' abdomen or thorax
What factors can be used to predict the risk of pre term labour?
Past obstetric history
Cervical length
Bacterial vaginosis
Cervical factors: Fetal fibronectin, actim partus
What is foetal fibronectin?
Found at interface of chorion and decidua: “glue” that binds foetal sac to uterine lining
Leaks info vagina if pre term delivery is likely to occur so can be measured as a screening test
What is actim partus?
Phosphorylated insulin like growth factor binding protein detected in cervical samples
Has high negative predictive value - negative result, labour will not begin in next 7 days so can be sent home with confidence
What risks are there to the foetus if delivered pre term?
Respiratory distress syndrome (hyaline membrane disease) Intraventricular haemorrhage Necrotising enterocolitis Patent ductus arteriosus Cerebral palsy
What treatment can be given in clinic for pre term labour?
Bed rest
Antibiotics
Cervical stitch
Progesterone
What effect does bacterial vaginosis have on inducing pre term labour? What can be done to treat it?
Good predictor of PTL in high risk women - 7 fold increased risk
Clindamycin can prevent preterm labour if BV positive
What length should a normal cervix be?
4-5cm when not pregnant
Average of 3.5cm in pregnancy
What is a primigravida?
Woman who is pregnant for the first time
What is a multiparous woman?
Has borne more than one child
What is the difference between a still birth and a miscarriage?
Miscarriage: foetus dies in utero before 24 weeks, not issued a death certificate
Still birth: foetus dies in utero after 24 weeks, issued a death certificate
What is the transformation zone of the cervix?
Inside glandular, outside stratified squamous epithelium
Most common place for abnormal cells to develop - Pap smear
Which hormone is responsible for maintaining a pregnancy in quiescence?
High levels Progesterone, low levels oestrogen - uterine quiescence and and cervical rigidity
What is pregnancy induced hypertension?
Increase in BP, no proteinuria, returns to normal after pregnancy
What is pre-eclampsia/eclampsia?
Increase in BP with proteinuria
What is essential hypertension in pregnancy?
Occurs before 20 weeks, >140/90 mmHg
What change in korotkoff sounds might you get in a pregnant lady?
Pregnancy increased blood volume, can hear softening and stopping of Korotkoff sounds
In some women can hear sounds at very low cuff inflation pressure
What happens to MAP, CO and plasma volume through a pregnancy?
CO and plasma volume increase dramatically up to 20/30 weeks and decrease back to normal after delivery
MAP decreases slightly to 20 weeks and then rises back to baseline again towards term
What medication changes might be required in essential hypertension in pregnancy?
Changing doses of anti-hypertensive medication throughout pregnancy
What happens to GFR and urea levels in pregnancy?
Renal changes in pregnancy: Increase blood flow to kidney
Increased GFR
Lower urea levels in pregnant women
What is the pathophysiology of pre-eclampsia?
Failed adaptation to pregnancy
Inadequate placentation
Foetal cells don’t adequately invade and so spiral artery dilation doesn’t occur sufficiently
High flow, high pressure system
Placenta signals to mother that it is not receiving enough supply so causes hypertension, proteinuria, liver dysfunction and if left untreated, cerebral oedema
What is the treatment for pre eclampsia?
Delivery of the foetus
What cardiac disease problems are made worse by pregnancy?
Increased blood flow: Normal to hear end diastolic flow murmur
Arrhythmia: Worse
If valvular heart disease: May not be able to increase CO, Heart failure
What respiratory change occur in pregnancy?
Rib cage and breast enlargement
Diaphragm pushed cranially: changes in lung vol
Increased mucosal engorgement: nasal – epistaxis
Asthma symptoms worse as lung capacity is decreased
Respiratory rate increases: normal
What happens to T cell levels in pregnancy? And what significance does this have in asthma and RA?
T helper 1 cell levels decrease: this means that RA symptoms are decreased in pregnancy as less interferon gamma is released
T helper 2 cell levels increase: this means that asthma is made worse as increased mast cell activation, B cells releasing IgE and eosinophils are released
Describe the functional flow of immunity following antigen detection
Antigen detected by antigen presenting cell
This signals to t helper cells which release cytokines to activate natural killer cells, macrophages and B cells
B cells release antibodies to opsonise the cell
T helper cells also directly activate cytotoxic T cells
How do t helper cells differentiate from naive to type 1 or 2?
Naive cells signalled by IL-6 from APCs and IL-4 from mast cells, eosinophils and NK cells cause differentiation to T helper 2 cells
Naive cells signalled by IL12 from APCs and IFNgamma from NK cells and t helper 1 cells cause differentiation to t helper 1 cells
What do t helper 1 cells do?
Fight viruses, cancer, yeast and intracellular pneumonia
Cell mediated immune responses
What do t helper 2 cells do?
Normal bacteria, Parasites, Toxins, Allergens
Humoral immune response
What change in immune balance must occur during pregnancy?
Pregnancy maternal and paternal antigens similar to tissue graft. Change in immune balance in pregnancy: decrease in t helper 1 cells which would lead to rejection. Decrease in IL-2 and IFNgamma
Increase in t helper 2 cells which lead to tolerance. Increase in IL-4, 5 and 10
Worsening of asthma, More susceptible to influenza (H1N1), Rheumatoid arthritis better
If the placenta in a pregnancy is small, what does this increase the risk of for the child in later life?
Increase in heart disease, diabetes,hypertension, obesity
If a foetus encounters starvation during pregnancy, what are they at increased risk of in later life?
Increase in heart disease, diabetes obesity
What factors can cause in utero programming of a foetus which can lead to problems later in life?
Maternal stress Infection Smoking Under nutrition Placental dysfunction Alcohol
What in utero programming can occur which affect vasculature and metabolism?
Thrifty phenotype hypothesis
Reduced pancreatic B cell mass
Insulin resistance in muscle liver and adipose tissue
Changes to HPA and neuroendocrine axis: results in over nutrition
Kidney glomerular number affected: hypertension and renal disease
All results in metabolic syndrome
Which bio marker measured antenatally is associated with failure of formation of the vertebral arches?
Raised maternal serum alpha feto protein (AFP)
Neural tube defects
What is genetic imprinting?
Certain genes are expressed in parent of origin specific manner
Involves methylation
Occurs in germline and maintained in all somatic cells
What is DNMT?
DNA methyl transferase
Catalyse transfer of methyl group to DNA
When located in a gene promoter, DNA methylation acts to repress gene transcription
What role does DNMT play in germ cells?
Immature gamete acted on by DNMT to convert to mature gamete
What role does DNMT play in silencing of the X chromosome and imprinted genes?
Acts on pluripotent stem cells to help them on an embryonic lineage
What placental features can affect nutrient supply to a foetus?
Hormone production and metabolism: oestrogen, progesterone, human placental lactogen and hCG Nutrient consumption and production Transporter abundance Blood flow Size and morphology
What is the function of hCG released by the placenta?
Prevents atrophy of the corpus luteum
Stimulates corpus luteum to release more progesterone and oestrogen
What is the role of progesterone released by the placenta?
Prevent spontaneous abortion as it prevents contractions of the uterus and is necessary for implantation
What is the role of oestrogen released by the placenta?
Proliferation of breasts and uterus
Also increases blood supply towards end of pregnancy through vasodilation
What is the role of human placental lactogen released from the placenta?
Develop foetal metabolism and general growth and development
Acts on lactogenic receptors to modulate embryonic development, metabolism, stimulate production of IGF, insulin, surfactant and adrenocortical hormones
When does oogenesis occur?
Oocytes are all formed in prior to birth
Imprinting occurs in mother uterus
Describe how adverse intrauterine environment for a foetus can have an effect on multiple generations
Adverse intrauterine environment can lead to poor placentation
This in turn results in adverse pregnancy outcomes which increases risk of early onset cardiovascular problems
This is exacerbated by poor socioeconomic status, deprivation and ethnicity which then increases the risk of adverse intrauterine environments in future generations
How is high maternal weight linked with childhood obesity?
Maternal obesity can lead to an adverse intrauterine environment and then an increased birth weight of the baby
This then predisposes to childhood obesity which is further exacerbated by low socioeconomic status, deprivation and ethnicity which then increases risk of developing into an obese adult and the cycle continues
What percentage of couples experience sub fertility in England and Wales?
15%
What percentage of couples experience recurrent miscarriages?
2%
What percent of pregnancies result in premature delivery?
10%
What percentage of women in England and Wales have maternal obesity?
30%
What percentage of pregnant women in the uk experience gestational diabetes?
5%
What percentage of pregnant women experience pre eclampsia?
2%
What percentage of pregnant women experience growth restriction of their foetus?
2%
What problems occur in pregnancy in the developing world?
Much higher incidence of complications
Low birth weight Eg Malawi 18% low birth rate
Intergenerational disease
Name some complications of obesity in pregnancy
Conception: decreased fertility
Embryonic period: increased risk of miscarriage and foetal malformations
Foetal period: abnormal growth, decreased detection of foetal anomalies
Pregnancy: gestational diabetes, hypertensive disorders, increased depression risk, infections, respiratory problems
Delivery: increased risk of induction of labour, instrumental delivery, Caesarian section, anaesthetic complications, intrapartum monitoring difficulties, risk of birth trauma
Postpartum: increased risk postpartum haemorrhage, thrombosis, wound infection, weight retention, T2DM, decreased breast feeding levels
Name some complications for the child if their mother was obese during pregnancy
Increased risk childhood obesity
Increased risk of metabolic syndrome in adulthood
What role does GLUT4 play in the development of diabetes in pregnant women?
Resistance to GLUT4
Reduced GLUT4 expression in adipose tissue and skeletal muscle so reduced glucose uptake by tissues
What molecular factors contribute to the development of insulin resistance in pregnancy?
Increased leptin
Decreased adiponectin
Increased TNF alpha
Increased AFABP (adipocyte fatty acid binding protein)
Why will a baby born to a diabetic mother be hypoglycaemic after birth?
High glucose levels in mum means high glucose levels in foetus
This leads to increased insulin levels in foetus which remain high after delivery and therefore more glucose is taken up into cells
How can obesity lead to hyperglycaemia in pregnancy?
Obesity leads to inflammation which in turn leads to insulin resistance and therefore hyperglycaemia
Hyperglycaemia causes glucotoxicity which in turn exacerbates inflammation and insulin resistance
How does hyperglycaemia lead to diabetes in pregnancy?
Hyperglycaemia leads to pancreatic beta cell damage which in turn results in decreased insulin output
What damaging effects can hyperglycaemia have in pregnancy?
Placental vascular damage Atherosclerosis Nephropathy Retinopathy Neuropathy Immune dysfunction Poor wound healing
What percentage of women across the world die of post partum haemorrhage?
10%
What is controlled cord traction?
Give ergometrine or oxytocin first
Pull gently, as soon as uterus feels hard, lift it towards her umbilicus
First pull downwards and backwards then more anteriorly
Describe the milk let down reflex and how this can help to reduce post partum haemorrhage
Baby suckling triggers mechanoreceptors in nipple
Signals sent to higher brain centres and hypothalamus (baby crying can directly stimulate these centres)
Dopaminergic neurons are inhibited, decreased signals via portal system to anterior pituitary so inhibition of prolactin cells is removed
Prolactin secretion occurs which triggers milk secretion
Hypothalamus signals also to oxytocin neurons which via posterior pituitary lead to increased oxytocin and therefore smooth muscle contraction of both the breast and the uterus, so reducing bleeding
What changes occur to maternal blood during pregnancy?
Increase in maternal blood volume by 45%
Increase in plasma volume by 55%
Increase in red blood cell volume by 15%
Decrease in haemoglobin by 17%
Overall haematocrit 35.5%, dilutional anaemia
Can tolerate haemorrhage better than non pregnant women
What are average blood losses at delivery?
600 ml with vaginal delivery
1000ml with C/Section
What changes in coagulation factors are present in pregnant women?
Increase in pro-coagulants: II, VII, VIII, X, XII, Fibrinogen
Decrease in Protein C&S
Decreased fibrinolytic state: Increased serum plasminogen activator
inhibitor PAI-1, Placental activator inhibitor 2
Why are pregnant women more prone to thrombosis?
Increased coagulation factors
Pressure effects of pregnancy
Less mobile
How is foetal wellbeing measured in the first trimester?
Assessment of gestational age using Crown to Rump Length (CRL): dating pregnancy
Measurement of nuchal translucency (weeks 11-13+6): Down’s syndrome screening
When should fusion of the neural tube occur in a pregnancy? Therefore what supplement should the mother take during this time?
Should happen by 6 weeks
Take folic acid for first 12 weeks
What is gastroschisis?
Congenital defect of the abdo wall where baby’s abdo contents freely protrude through with no overlying sac or peritoneum
Located at junction of umbilicus and normal skin and is almost always to the right of the umbilicus
Defect occurs 5-8 weeks after conception
What is exomphalos?
Defect in development of muscles of abdo wall
Organs can end up outside of the abdomen in a sac - omphalocele
What is being examined for on a mid trimester ultrasound? And when can it be performed?
18+0 to 20+6 weeks
Foetal anatomy
Placental site
Looks for: anencephaly, open spina bifida, cleft lip, diaphragmatic hernia, gastroschisis, exomphalos, serious cardiac abnormalities, bilateral renal agenesis, lethal skeletal dysplasia, Edwards syndrome (T18), Pataus syndrome (T13)
When do you start measuring symphysio-fundal height?
24-26 weeks
When pregnancy has moved out of pelvis and into abdomen
How is foetal growth measured?
Estimated weight calculated from: Head circumference, Abdominal circumference, Femur length
What foetal growth problems may be detected on a growth scan?
Symmetric vs asymmetric growth restriction: HC and AC similar, Reduction in AC to preserve brain development
Small for gestational age
Foetal growth restriction: Growth under 10th centile
What problems may small for gestational age babies encounter towards the end of pregnancy?
Normal, but have less in reserve. CTG may be abnormal
Dont cope well with stress of labour
What are the components of a biophysical profile to assess foetal wellbeing?
Foetal movement
Resting tone
Breathing movements
Amniotic fluid volume
When might a Doppler ultrasound be used to assess foetal wellbeing?
Small babies
Pre eclampsia
Diabetic mothers
What should a Doppler ultrasound of an umbilical cord show in utero?
2 arteries, small - deoxygenated
1 vein, big - oxygenated blood
What uses of Doppler ultrasound are there in pregnancy?
Assessment of fetal wellbeing: Measure flow in umbilical artery
Assessment of fetal anaemia: Measure flow in Middle Cerebral Artery
Timing of delivery: give estimate of how long we can prolong pregnancy
What are reassuring features on a cardiotocography trace?
Baseline 110-160 bpm
Accelerations
Variability >5
No decelerations
What is a CTG useful for predicting?
High negative predictive value: when normal, fetal acidaemia unlikely, When abnormal, fetus acidaemia could still be unlikely
Used antenatally: Changes may reflect the end stage process of chronic hypoxia
What is foetal scalp blood sampling used for?
Used during labour to confirm whether foetal oxygenation is sufficient
pH and lactate are measured: acidosis shown by low pH and high lactate, pH 7.20 or less, baby needs to come out
Shallow cut by transvaginally inserted blood lancet, followed by a thin pipe to site which samples capillary blood
What is atrophic vaginitis?
Reduced oestrogen levels cause atrophy of the vaginal mucosa leading to dryness and bleeding
What level of endometrial wall thickness should lead to a biopsy of the endometrial lining to look for cancer?
Over 5mm
Which metabolite of arachidonic acid can be used in termination of pregnancy?
Prostaglandin E2
What are risk factors for endometrial cancer?
Early menarche Nulliparity Late menopause Tamoxifen or tibolone use Pelvic irradiation HRT FH breast, ovarian and colon cancer
A 35 year old smoker comes to the gp wanting contraception 6 months after having a child. She suffers from migraines and has had previous ectopic pregnancies. She would like contraception that can be reversed as she would like another child in the near future. What is the best option?
Nexplanon implant
Migraines and smoker over the age of 35, oestrogen is contraindicated
Ectopic pregnancies mean a coil would not be advised
Progesterone injection can take 6 months to reverse so implant is the right option
What are risk factors for pre eclampsia?
First pregnancy
Extremes of maternal age
Family history
Co morbidities - diabetes, SLE and thrombophilia
What are signs and symptoms of pre eclampsia?
Headaches Visual disturbances Proteinuria Hypertension Epigastric pain Nausea and vomiting
What is given to control eclampsia?
Magnesium sulphate
What is the quadruple test to detect Down’s syndrome in pregnancy?
Maternal alpha feto protein
Unconjugated estriol
Inhibin A
Woman’s age
What is the antibiotic of choice to treat neisseria gonorrhoea infection?
Cefixime 400mg
What is the treatment of choice for chlamydia infection?
Azithromycin 1g
What is given to treat bacterial vaginosis?
Metronidazole 400mg for 5 days
What would you expect to see on a microscopic analysis of a high vaginal swab from a patient with bacterial vaginosis?
Epithelial clue cells
What is amsels criteria which is used to diagnose bacterial vaginosis?
Thin homogenous discharge
Vaginal pH of more than 4.5
Amine odour after adding 10% potassium hydroxide to vaginal fluid
Presence of clue cells after adding sodium chloride solution
If 3/4 present then diagnosis made
What are clue cells?
Epithelial cells covered with bacteria after adding sodium chloride solution
How would a blood test differentiate between PCOS and Cushing’s as a cause for infertility?
FSH:LH ratio 3:1 in PCOS
Condition starts at an earlier age
What are contraindications for using the combined oral contraceptive pill?
Age over 35 Current smoker of 10 cigarettes a day History of DVT History of migraines without focal neurological signs BP of 140/90
What are some gynaecological causes of abdominal pain?
Ruptured or torted abdominal cyst Urinary tract infection Pelvic inflammatory disease Pregnancy Ectopic pregnancy Primary dysmenorrhea Malignancy
What are some causes of galactorhoea?
Pregnancy
Hyperprolactinaemia - prolactinoma, hypothyroidism, renal failure, haloperidol
Which HPV causes genital warts?
HPV 6
Which HPVs cause cervical cancer?
HPV 16 and 18
A 32 year old woman sees her GP about heavy periods. She was referred to a gynaecologist who diagnosed a small fibroid. She has one child. What is the most appropriate management?
Intra uterine contraceptive device to control the size and the bleeding
What is the most common site for implantation of an ectopic pregnancy?
Ampulla of the Fallopian tube
What factors may increase the risk of cervical carcinoma?
HPV 16 and 18 Prolonged pill use High parity High number of sexual partners STIs and HIV infection
What cell type is the most common cause of cervical carcinoma?
Squamous cell
Describe the stages of cervical carcinoma
Stage 1: tumours confined to cervix
Stage 2: have spread to upper 2/3 of vagina
Stage 3: have spread to lower 1/3 of vagina
Stage 4: have spread to bladder and rectum
Stage 4b: have spread to distant organs
What signs and symptoms would be present in a patient with endometriosis?
Menorrhagia: heavy periods Pelvic pain related to menstrual cycle Enlarged boggy uterus felt on examination (adenomyosis) Dyspareunia Thigh pain Pain on defecation
A woman presents to her GP complaining of vaginal discharge which is thin, frothy and offensive smelling. A swab is taken and reported as demonstrating motile Protozoa. What is the most likely diagnosis?
Trichomoniasis
What are some symptoms of lymphogranuloma venereum?
Blood or pus in stools Tenesmus Swelling Painless sores in the genital area Groin lymphadenopathy
What are features of Behçet’s disease?
Systemic vasculitis Recurrent oral and genital ulcers Ocular inflammation Skin manifestations Neurological problems
What are side effects of progesterone?
Headaches Acne Breast pain Weight gain Mood swings
When in a menstrual cycle would a patient with menorrhagia be advised to take tranexamic acid?
During heavy bleeding periods
What are surgical options for fibroids?
Myomectomy
Uterine artery ablation
Hysterectomy
What is Mefenamic acid?
NSAID
Used to treat mild to moderate pain including menstrual pain and can be used to prevent migraines associated with menstruation
What is occurring if there is cervical dilatation in the absence of uterine contraction during pregnancy?
Cervical insufficiency
What is active management for the 3rd stage of labour?
Prophylactic administration of oxytocin, prostaglandins or ergot alkaloids, cord clamping/cutting and controlled cord traction
If on pelvic examination of a pregnant woman heading to term, macroscopic blood is present, what should be done?
Pelvic examination deferred until placenta previa is excluded with ultrasound
What 4 things can be determined from digital examination of a pregnant woman heading to term?
Degree of cervical dilation
Cervical effacement
Position
Consistency - soft or firm
What can be used to monitor timings of uterine contractions?
Tocodynamometry
How is foetal monitoring achieved during labour?
Cardiotocography: continuous or intermittent
Intermittent auscultation
How can risk of foetal intolerance for labour be assessed?
Foetal scalp capillary sampling
Assess foetal oxygenation and blood pH, below 7.2 needs further investigation
If a woman has premature rupture of foetal membranes, what should be done prophylactically?
Group b strep prophylaxis
What are the 2 methods for augmenting labour?
Low dose oxytocin with long intervals between dose increments
Early amniotomy, hourly cervical examinations, early diagnosis of inefficient uterine activity, high dose oxytocin infusion
What are some risk factors for labour not progressing during the first stage?
Premature rupture of membranes Nulliparity Induction of labour Increasing maternal age Previous perinatal death Pregestational or gestational DM HTN Infertility treatment
What is the term for when the foetal head forcibly extends the vaginal outlet?
Crowning
Which spinal levels are involved in uterine contraction pain?
T10-L1
What are women who take oestrogen hrt at increased risk of?
MI Stroke Breast cancer Endometrial cancer Gallstones Raised triglyceride levels Blood clots
What factors may influence the age at which a woman experiences menopause?
Smoking Socio economic status Age at menarche Parity Previous oral contraceptive hx BMI Ethnicity Family history
What diagnoses should be considered in a woman with vaginal itch and discharge?
Vulvovaginal candidiasis
Trichomonas
Bacterial vaginosis
What are the criteria for the diagnosis of bacterial vaginosis?
Three of:
Characteristic vaginal discharge
Amine test: raised vaginal pH using narrow range indicator paper >4.7
Fishy odour on mixing drop of discharge with 10% potassium hydroxide
Presence of clue cells on microscopic examination of vaginal fluid
What are some risk factors for uterine fibroid development?
Increased BMI
Age in 40s
Black ethnicity
What are risk factors for ovarian cancer?
BRCA1/2 mutations Increasing age FH ovarian cancer FH breast cancer Never used OCP Lynch II syndrome
What are risk factors for ovarian cyst formation?
Pre menopausal age group Early menarche First trimester of pregnancy Personal hx of infertility or PCOS Increased intrinsic or extrinsic gonadotrophins Tamoxifen therapy Personal or family hx of endometriosis
What is hydrops fetalis?
Abnormal amounts of fluid build up in two or more body areas of a fetus or newborn
Immune: complication of Rh incompatibility
Nonimmune: more common, heart or lung problems, severe anemia (e.g. from thalassemia or infections), and genetic or developmental problems, including Turner syndrome
What checks are performed in a routine antenatal check?
Fundal height Foetal movements BP Urine dip Liquor Lie Presentation Engagement
What are possible reasons for an uncomplicated pregnancy still ongoing more than 2 weeks after due date?
Patient declines induction of labour
No appointment slots available for induction
Cervix unfavourable and pt and obstetrician prefer to delay induction
What are the different types of lochia produced after delivery? What does each contain and what is the consistency/colour?
Lochia rubra: blood, foetal membranes, decidua, vernix caseosa. Red in colour, lasts 3-5 days
Lochia serosa: serous exudate, erythrocytes, cervical mucous. Thinned, turned brown/pink, lasts to day 10
Lochia Alba: leukocytes, epithelial cells, cholesterol, fat, mucous, microorganisms. White/yellow, from week 2-6
What is the single most important risk factor for post partum maternal infection?
Delivery by cesarean section
What are risk factors for endometritis?
Cesarean delivery Young age Low SES Prolonged labour Prolonged rupture of membranes Multiple vaginal examinations Placement of intrauterine catheter Pre existing infection Colonisation of lower genital tract Twin delivery Manual removal of placenta
What are risk factors for post partum psychiatric illness?
Unwanted pregnancy Feeling unloved by mate Age under 20 Unmarried status Low self esteem Economic problems Limited parental support Past or present emotional problems
If a cervical smear shows borderline or mild dyskaryosis what needs to be done?
Send sample for HPV test
If negative back to routine recall
If positive refer for colposcopy
If a cervical smear shows moderate or severe dyskaryosis what needs to be done?
Consistent with CIN II moderate
CIN III severe
Refer for colposcopy
What are high risk subtypes of HPV for cervical cancer?
16, 18 and 33
What cell type are most cervical cancers derived from?
Squamous cell carcinoma
What are risk factors for cervical cancer?
Young at first intercourse Multiple sexual partners Smoking Long term use of COCP Immunosuppression and HIV Low SES HPV: STI
How is HPV oncogenic?
HPV 16 and 18 produce proteins E6 and 7 which suppose products of p53 in keratinocytes
Describe the natural history of cervical cancer
HPV may cause CIN
CIN 1 can regress spontaneously
CIN 3: can progress to invasion
Where does cervical cancer most commonly occur?
Transformation zone
What determines whether a cervical smear result is CIN 1, 2 or 3?
The thickness of abnormal cells
Histological diagnosis
How is cervical screening performed?
Cells collected from cervix by liquid based cytology
How regularly does cervical screening occur?
25 to 49 every 3 years
50 to 64 every 5 years
65+ as required for those with recent abnormal tests
Woman who have not had an adequate screening test since age 50 may be screened on request
If a cervical screen report says inadequate, when should it be repeated?
3 months
Under which circumstances should a patient be referred to hospital following a cervical smear?
Inadequate smear on 3 occasions Moderate dyskaryosis Severe dyskaryosis Abnormal glandular cells present Suspicion of invasive disease
What features on colposcopy would suggest CIN or invasion?
Abnormal vascular pattern: mosaicism, punctation
Abnormal staining of tissue: aceto white, brown iodine
What is the treatment for CIN?
Destructive: cryocautery, diathermy, laser vaporisation
Excisional: LLETZ (large loop excision of transformation zone), cold knife cone
What are risks of large loop excision of transformation zone for treatment of CIN?
Bleeding Infection Cervical stenosis Pre term birth Mid trimester miscarriage
What is the follow up after treatment of CIN?
Smear and HPV test of cure at 6 months
What hormone results would you expect in a pregnant lady?
LH and FSH normal
Oestrogen raised
Prolactin raised
Testosterone normal
What are your differentials if a patient is amenorrhoeic but hormone studies are all normal?
Uterine or vaginal abnormalities
Imperforate hymen
Absent uterus
Lack of endometrium
