Obs and gynae Flashcards
What does obstetrics encompass?
health pre-pregnant, pregnant, childbirth and immediately after
What does gynae encompass?
Women’s health
What is gravidity?
number of times pregnant
What is parity?
number of times given birth to a foetus 24 wks+
Questions to ask in a gynae history?
menstruation/LMP (last menstrual period) = frequency, duration, heavy, pain, intermenstrual, postcoital, vaginal discharge, postmenopausal, clots; pain (colicky and felt in sacrum and groins could be uterine and ovarian tends to be in right iliac fossa down to front thigh of knee) associated symptoms; sex = activity, pain, contraception (problems, types, how long); obs hx (no. of children, problems with pregnancy and labour, outcome, puerperium, miscarriages/termiantions); GI and urinary symptoms (freq, nocturia, urgency, nocturnal enuresis, associations, dysuria, haematuria), incontinence, prolapse; FH; past medical and surgical; SH; DH; FH (GDM, pre-eclampsia)
Gynae examination?
appearance, weight, temp, bp, pulse, anaemia, jaundice, lymphadenopathy; breasts, abdo, vaginal (metal speculum warmed with lube – vulva and vaginal orifice for colour, ulcers, lumps, prolapses); digital pelvic exam (pt lie flat with ankles up to body with knees apart with left hand placed around pubic symphysis); uterus = size of small pear, size, consistency, regularity, mobility, tenderness, anteversion/retroversion; cervix = how hard, ulceration, bleeding, irregular, adnexa (attaches organs together) assessed for tenderness/size/masses, pouch of Douglas behind cervis and uterosacral ligaments palpable; Sims’ speculum for inspection of vaginal walls and prolapse (SEE PAGE 1 OF WOMEN’S HEALTH NOTES), can use DRE if posterior wall prolapse suspected; check abdo for tenderness (ascites and pregnancy)
Anatomy of the vulva?
has all entrances (vagina, urethra, clitoris, labia minora and fourchette) and around is labia majora and perineum; when hymen broken (tampons or intercourse) leaves tags at mouth of vagina
Anatomy of the vagina?
leads to uterus via cervix; muscular walls; lactobacilli keep acidic from puberty to menopause
Anatomy of the cervix?
mostly connective tissue and os in centre; circular in nulliparous but slit in parous women; mucin-secreting glands lube vagina
Anatomy of the uterus?
thick myometrium lined with columnar epithelium; uterosacral, round and broad ligaments hold in place; pouch of Douglas posteriorly; 14wks pregnant will fill pelvis; should be in anteverted position and can be bimanually palpated
Anatomy of the adnexae?
fallopian tubes, ovaries (in rectovaginal pouch) and associated connective tissue (parametria)
Some abnormalities of the gynae anatomy?
vaginal septae (partition in vagina), duplication of cervix/uterus; can diagnose bicornate uterus (divided uterus) by hysterosalpingogram and can cause recurrent miscarriage; may be unable to perforate hymen (primary amenorrhoea, lower abdo pain, swelling and pressure from haematocolops [built up menstrual blood]); small, thin ovaries found in Turner’s syndrome
Obstetric hx?
- Current – general things, gravidity and parity, LMP (last menstrual period and use this +40wks to give gestation), EDD (estimated date of delivery – 1st trimester scan ideal), irregular/long cycles and HRT all make EDD inaccurate, general health and symptoms, fetal movements >20wks, any problems, tests/scans
- Past hx – age (can give problems if older), all past (miscarriages, terminations and reason and normal; pre-eclampsia, GDM, preterm etc), antenatal problems, delivery/sex/weight/problems/date for past births; postnatal and neonatal life; difficulty with conception, smear hx, previous gynae problems, PMH in general; psych hx; surgical hx
- DH, FH, SH (drugs, alcohol, smoking, domestic violence)
How to work out EDD?
9 months and 10 days after LMP
What is symphysis fundal height and its measurements?
shows how much uterus grows during pregnancy (palpated in abdomen); should be halfway between pubic and umbilicus at 16wks, at umbilicus at 20-24wks, under ribs at 36wks
o Inaccurate when – bad hx, multiple, fibroids, polyhydramnios, maternal size, hydatidiform mole
o Check for stretch marks and noticeable linea nigra (after 1st trimester/13wks)
5 ways to assess foetus in uterus?
palpate orientation or baby, presentation (bit going to breach, mainly the head), engagement (how large the breach area is – measured in 5ths palpable); ascultate heart with doppler until 12wks then stethoscope; movement at 18-20wks and should increase then plateau at 32wks, every 20-40mins (if reduced then urgent and must let med team know – IUGR/stillbirth)
Anatomy of the breast?
- Nipple/areolar leads to lobule groupings via large then small ducts; lactiferous sinus just below surface of nipple and superficial fat protects lobules and ducts
- Proliferation of breast tissue occurs around ovulation every cycle
What is a mammography, it’s indications and results?
• Mammography (over 40s) – used for screening asymptomatic women, assess symptomatic, sensitivity 90%, follow up and surveillance for breast cancer survivors; 2 views (mediolateral oblique [MLO] which should show pectorals and tissue next to chest wall and craniocaudal [CC] which shows the gland and nipple centred)
o Things to check – pt identity, movement blur, nipple in profile, MLO (inframammary fold, pectoralis muscle to nipple, lower axilla), good exposure, CC have retromammary space
o Abnormals – asymmetrical densities, focal mass, parenchymal distortion, microcalcification, skin thickening, enlarged axillary nodes
o Symptomatic - <35yrs = examine, US; >35yrs = examine, bilateral mammogram and US
Ways to scan breast?
MRI with contrast and mammography
RFs for breast cancer?
> 35yrs first child, lobular carcinoma in situ (LCIS), alcohol (>40g/day harmful), ADH, HRT 5+yrs, oral contraceptive, obesity post menopause; BRCA1/2, CDH1 and Tp53 genes
Features of breast cancer?
painless lump (irregular, hard, fixed), nipple discharge, nipple in-drawing, skin tethering, indrawn nipple, older age
Diagnosis of breast cancer?
clinical score, imaging score, biopsy score (all 1-5)
Staging of breast cancer?
TMN (tumour size, mets and nodes) can also use Nottingham Prognostic Index
Subtypes and treatments of breast cancer?
Luminal A, Luminal B, HER2- and triple -ve; luminals can be ER+/-PR positive; treatments = endocrine (tamoxifen or ER+ve) for luminals, chemo for all but luminal A (for high risk) and HER2- use trastuzumab, ER +ve use bisphosphonates for high risk
Treatment for breast cancer?
radio and pre-op chemo (small tumour); mastectomy for large relative to breast size and position (medial more dangerous – can shrink with radio/chemo first) but more likely to recur, reconstruction; axillary surgery if glands involved (full clearance but partial if glands found to be normal), with glands removed may cause arm oedema as lymph no longer there to drain
High risk with breast cancer?
young age, ER-ve, HER-2+ve, high grade, node positive, Ki67 +ve, tumour size, high oncotype DX recurrence score
Tamoxifen SEs?
flushes, nausea, vaginal bleeding
What are aromatase inhibitors?
better than tamoxifen, inhibit aromatase enzyme for making androgens to oestrogen; no DVT or endometrial cancer risk like tamoxifen
Radiotherapy risks?
high rate of capsule formation, skin viability risk, wound healing, loss of elasticity, fat necrosis, fibrosis, implant extrusion
Reconstruction for breast cancer?
either implants or autologous (latissimus dorsi, gluteal muscle – but can interfere with physical activity/job); stick on nipples, nipple tattoos, new nipples constructed from skin
Treatment for breast cancer mets?
hormonal treatments, bisphosphonates, densoumab, chemo (CMF, doxorubicin, taxanes, Herceptin)
Types of breast lumps and management?
benign breast change (puberty to menopause, tender and painful, cyclical variation, rubbery feel, leave and reassure), fibroadenoma (usually puberty, smooth, mobile, non-tender, leave unless enlarging/tender/atypical), cyst (35-55yrs, usually multiple, feel cystic usually, aspirate), sebaceous cyst, papilloma (dilated ductal system, usually benign yet remove, multiple means breast cancer risk), fat necrosis, mastitis/abscess (breast sepsis, pyrexia and flu-like, respond to abx, staph aureus; if chronic and periductal then excise duct), cancer, sarcoma/lymphoma/mets, implant related, duct ectasia (asymptomatic, nipple discharge, bloody discharge, nipple inversion, menopause; breast duct becomes blocked from duct narrowing and breast widening), can get benign cyclical breast pain (record diary; management = reassure, NSAIDs PRN, low fat, correct fitting bra)
What is paget’s disease of the nipple?
malignant cells infiltrate epidermis via mammary duct epithelium; thickened skin results
S+Ss of paget’s?
unilateral usually, usually nipple, eczematous change, itching, erythema, scales, erosions, discharge, bleeding; can indicate breast cancer
Treatment of paget’s?
treat as cancer but can be more conservative if need be
Overview of normal menstruation?
investigate if none by 16 or no signs by 14yrs; first start of puberty is growth spurt; controlled by hypothalamic-pituitary-ovarian axis; pulsatile gonadotrophin-releasing hormone get Pituitary to release FSH and LH which stimulate ovaries to make oestrogen and progesterone that -ve feedback; <16yrs, >45yrs menopause, <8 days, blood loss <80mL, cycle length 23-35 days, no intermenstrual bleeding; monthly bleeding from hormonal changes, length = start of one to start of other
Day 1-4 of menstruation?
menstruation; cycle lengths vary; soon after menarche and menopause will be irregular (also HRT)
Days 4-13 of menstrual cycle?
GnRH pulses increase levels of LH and FSH which stimulate development of primary follicle in ovary; follicle makes oestradiol and inhibin which suppress FSH secretion in -ve feedback so only one egg and follicle matures; oestradiol rises and +ve feedback to cause LH secretion and surge (36 hours after ovulation occurs); oestradiol also develops endometrium (endometrial proliferation), cervical mucous receptive to sperm, mucous stringy and white
Days 14-28 of menstruation?
oestrogen level high enough to stimulate LH and ovulation; primary follicle then forms corpus luteum and produces progesterone and endometrium ready for implantation (secretory phase); cervical mucous hostile to sperm; corpus luteum broken down so hormones low, spiral arteries constrict, endometrium sloughs off (normal loss 20-80mL over 2-7 days)
Menopause overview?
ovaries don’t develop follicles; no -ve feedback so gonadotrophin levels rise and so periods stop
How to postpone menopause?
use norethisterone 3 days before period or take 2 packets combined pill consecutively without break
What is secondary amenorrhoea?
periods stop >6 months
Hx to ask for menstruation?
duration, cycle, heaviness (clots, protection, flooding); pain, premenstrual tension, infertility worries and details, cancer phobia, interference with QOL, duration and relation to cycle; social and work
Examination for menstruation?
sclera, palms, gingiva, thyroid, abdo; specific = vulva, vaginal, cervix, uterus (fibroids and adenomyosis), adnexae
Diseases that can lead to abnormal menstruation?
thyroid disease (temp intolerance, hair consistency, lethargy), clotting disorder, anti-clotting/blood thinning drugs
What is intermenstrual bleeding and causes?
bleeding clearly between cycles and menses; fall in oestrogen levels; other causes = cervical polyps, ectropion (columnar epithelium migrating to front of os), carcinoma, cervicitis, HRT, IUCD, chlamydia, pregnancy
What is endometrial proliferation and how to treat?
continuous high oestrogen (obesity) can make it hyperplastic and can cause irregular heavy bleeding; treat = address cause, Mirena coil, can lead to endometrial carcinoma
What is pyometra?
uterus distended by pus from salpingitis; drain uterus and treat cause
What is haematometra?
uterus filled with blood from obstruction; rare (imperforate hymen, carcinoma, stenosis
What is endometrial tuberculosis and treatment?
rare; blood borne and affects fallopians first; menstrual pain and disorders if active, salpingitis; exclude lung disease; check up scans and RIPE treatment
What is abnormal uterine bleeding?
abnormal in vol, regularity, timing, non-menstrual (PCB, IMB, PMB)
What is menorrhagia?
excessive bleeding in normal cycle (80mL
Causes of menorrhagia?
endometrial haemostasis (balance between fibrin deposition and platelet aggregation with platelet inhibition and fibrinolysis), uterine prostaglandin levels, uterine polyps, fibroids (irregular enlargement of uterus), chronic pelvic infection, ovarian tumours, malignancy, adenomyosis (endometrium breaks through to myometrium – 40yrs, with endometriosis and fibroids)
S+Ss of menorrhagia?
absent, painful, reg, heavy menstruation, uterus can be enlarged and tender
Investigations for menorrhagia?
Hb, coagulation, TFT, transvaginal US, endometrial biopsy (if endometrium thicker >10mm, polyps, women >40 with recent menorrhagia to exclude malignancy), not responding to treatment use hysteroscope, smear hx, STI screen
Treatment for menorrhagia?
first line progesterone IUD (too much = amenorrhoea), second = antifibrinolytics (tranexamic acid – inhibits plasminogen activator), NSAIDs (mefenamic acid – inhibits COX and blocks PGE2 receptors), combined OC (all reduce blood loss) or IUD, others are IM/oral progesterone like norethisterone (least effective in luteal phase so use 5-25 day, best for anovulatory and chaotic bleeding), gonadotrophin-releasing hormones (danazol – stops sex steroid production); polyps resected under anaesthesia, endometrial ablation for older women (reduces fertility; if heavy, not expecting amenorrhoea, completed family, uterus less than 12 wks size), transcervical resection of endometrium/fibroid; myomectomy = removal of fibroids from myometrium; hysterectomy = last resort for abnormal uterine bleeding; uterine artery embolization for menorrhagia from fibroids who want to keep uterus
Irregular menstruation causes?
anovulatory cycles (absence of ovulation and luteal phase and varying menstruation), pelvic pathology (fibroids, uterine/cervical polyps, adenomyosis, ovarian cysts, chronic infection)
Investigations for irregular menstruation?
menorrhagia?, Hb, malignancy?, US for women >35 and where treatment failed, biopsy if endometrium thickened
Treatment for irregular menstruation?
drugs (IUS, combined OC pill), cervical polyp excised and surgery same as menorrhagia but ablative less useful
Amenorrhoea primary and oligomenorrhoea definitions?
primary = not occurred by 16yrs; oligomenorrhoea = occurs every 35 days-6 months
Causes of amenorrhoea?
pregnancy, menopause, pathological with hypothalamus, pituitary, thyroid (hypo/hyper), adrenals (congenital adrenal hyperplasia), ovary (ovarian insufficiency), uterus, outflow tract, drugs causing = progestogens, GnRH analogues, antipsychotics, Turner’s; secondary causes = premature menopause, polycystic ovary syndrome (PCOS), hyperprolactinaemia, hypothalamic-pituitary-ovarian (delayed from stress etc), pregnancy, Asherman’s syndrome (uterine adhesions)
Causes of hyperprolactinaemia?
pituitary hyperplasia, benign adenomas (use bromocriptine or surgery), tumours and Sheehan’s syndrome, thyroid, premature menopause, Turner’s syndrome, imperforate hymen (membrane partially covering vagina) and transverse vaginal septum obstruct menstrual flow (accumulates in vagina/uterus – surgery), also cervical stenosis (stops blood from uterus)
Tests for amenorrhoea?
pregnancy test, serum free androgen index (high in PCOS), FSH/LH low for hypothalamic-pituitary-ovarian, prolactin, TFT, testosterone (secreting tumour)
Treatment for amenorrhoea?
HRT for ovarian failure; diet, stress management and psych and some drugs
Causes of postcoital bleeding?
cervical ectropions (glandular cells inside cervix present on outside from eversion – discharge, postcoital bleeding and aka cervical erosion, columnar epithelium around os of endocervix = red), benign polyps, invasive CC
Investigations for postcoital bleeding?
cervix and smear
Treatment for postcoital bleeding?
ectropion frozen with cryotherapy, colposcopy used
Dysmenorrhoea pathophysiology and definition?
high prostaglandins in endometrium, from contraction/uterine ischaemia, painful periods and can have N+V; primary with no organic cause
Treatments for dysmenorrhoea?
pain use NSAIDs (mefenamic acid) or ovulation suppression (combined pill), pelvic pathology if this doesn’t work (secondary)
Secondary causes of dysmenorrhoea?
deep dyspareunia (pain on intercourse/penetration) and menorrhagia, pelvic US, fibroids, adenomyosis, endometriosis, pelvic inflammatory disease, ovarian tumours
What is precocious puberty?
menstruation <10yrs; rare and usually no pathology; stop sexual development
Causes of precocious puberty?
= meningitis, CNS tumours, hydrocephaly, ovarian, adrenal tumours
Treatment for precocious puberty?
GnRH agonists
What is McCune-Albright syndrome?
bone and ovarian cysts, café-au-lait spots and precocious puberty
Causes of ambiguous development?
congenital adrenal hyperplasia (AR inherited); ACTH gives high androgen production (enlarged clitoris, amenorrhoea)
Treatment for ambiguous development?
cortisol and mineralcorticoid replacement
What is premenstrual syndrome?
95% have psych, behavioural, physical symptoms and 5% debilitating before menstruation; behaviour = irritable, aggressive, depressed; others = bloated, minor GI upset, breast pain, headache
Treatment for premenstrual syndrome?
SSRIs, 100mcg oestrogen HRT, GnRH agonists, sometimes CBT, diet, exercise; total hysterectomy may be indicated
What is postmenopausal bleeding?
> 1yr after last period
Causes of PMB?
endometrial carcinoma, vaginitis, foreign bodies, carcinoma of cervix/vagina, endometrial/cervical polyps, oestrogen withdrawal; consider bleeding from other areas
When to take endometrial sample?
unexpected bleeding patterns with HRT, over 45yrs and PMB
What are uterine fibroids?
benign tumours of myometrium, whorls of smooth muscle cells with collagen
Risks for fibroids?
menopause, Afro-caribbean, FH (reduce with OC pill); types = intramural, subserosal, submucosal; growth = oestrogen dependent (stop growing after menopause and can be slow), 50% asymptomatic and more from site than size
S+Ss of fibroids?
menorrhagia, dysmenorrhoea, frequency and retention (large and on bladder), fertility reduced (tubal ostia blocked), pedunculated fibroids (grows on stalk-like growth – peduncle) can have torsion (pain); may be felt abdo, press on bladder (urinary retention), veins (varicose)
What is red degeneration with fibroids?
pain, tenderness, haemorrhage, necrosis, common in pregnancy and can cause severe pain, N+V; premature labour, malpresentations and obstructed labour; thrombosis of capsular veins leading to engorgement and inflammation
What is cystic degeneration of fibroids?
fibroid soft and partly liquefied
Investigations for fibroids?
MRI diagnostic, hysteroscopy/hysterosalpingogram for uterine cavity distortion, Hb low (bleeding) or high (high EPO); size
Treatment for fibroids?
don’t use HRT (can increase size); asymptomatic nothing needed; GnRH (max 6 months – temporary amenorrhoea and fibroid shrinkage; goserelin), ulipristal acetate (induces amenorrhoea and is a selective progesterone receptor modulator; only for a few months to shrink them) small resected (myomectomy – treat failed but reproductive function needed), adhesions in surgery reduce fertility, hysterectomy (only cure), uterine artery embolization to reduce fibroids
Endometritis causes?
secondary to STI, complication of surgery, foreign material in IUD, malignancy; uterus tender
Treatment of endometritis?
abx and evacuation of retained products of conception
What are intrauterine polyps?
benign tumours in uterus (disordered apoptosis and regrowth of endometrium); most endometrial but some submucosal; 40-50yrs, in post-menopause = tamoxifen
S+Ss of intrauterine polyps?
menorrhagia and IMB
Investigations of intrauterine polyps?
US or hysteroscopy
Treatment for intrauterine polyps?
Resection of polyp
Haematometra definition and causes?
menstrual blood in uterus from outflow obstruction; from fibrosis, cone biopsy or carcinoma of cervical canal
Types of congenital malformations?
; Mullerian ducts don’t fuse at 9 wks (total = 2 uteruses), renal problems, malpresentations, preterm labour, recurrent miscarriage, retained placenta
Endometrial carcinoma overview?
most common genital tract cancer (mostly adenocarcinoma of columnar endometrial gland cells); 60yrs
Risks for endometrial carcinoma?
oestrogen:progesterone ratio, HT, DM, obesity, PCOS, nulliparity (never done a pregnancy past 20wks), late menopause, ovarian granulosa cell tumours, tamoxifen
S+Ss of endometrial carcinoma?
oestrogen causes cystic hyperplasia/menstrual abnormalities or PMB, irregular/IMB in premenopausal, atrophic vaginitis (post-menopausal bleeding)
Investigations of endometrial carcinoma?
surgical staging; US (thickness >4mm), endometrial biopsy, hysteroscopy, FBC, renal function, glucose, ECG, most are stage 1
Bad prognosis indicators for endometrial carcinoma?
high age/stage, deep, myometrial spread, higher grade, adenosquamous pathology
Treatment for endometrial carcinoma?
uterus preserved then progestogens and 6 monthly endometrial biopsy, otherwise hysterectomy and bilateral salpingo-oophorectomy, vaginal vault when bad prognosis, can use adjuvant radio
Types of gynae sarcomas?
leiomyosarcomas (malignant fibroids), endometrial stromal tumours (perimenopausal women) and mixed Mullerian tumours (with PMB)
Benign cervical disorders?
cervical ectropion (red ring around os as endocervix epithelium migrated to ectocervix; from puberty, combined pill and pregnancy, prone to bleeding, excess mucous and infection, no treatment but can stop pill or diathermy), acute cervicitis (rare from STI), chronic cervicitis = usually ectropion, discharge, cryotherapy with/out abx, can mask neoplastic change on smear; cervical polyps (>40yrs, asymptomatic or cause IMB/PCB; if small avulse, endocervical epithelium; hysteroscopy to exclude IU polyps); Nabothian follicles (squamous epithelium over endocervical cells, treatment not needed unless symptoms)
Cervical intraepithelial neoplasia overview?
atypical cells in squamous epithelium, pre-invasive stage of cancer; 1-3 grade, histology diagnose (dyskaryosis – high false +ves and -ves); 1 = atypical cells in low 1/3rd of lower epithelium, 2 = 2/3rds, 3 = full thickness; peak age = 25-29
Risks for cervical intraepithelial neoplasia?
HPV, more sexual contacts, virus proteins inactivate tumour suppressor genes, smoking, immunocompromise; refer for colposcopy if risk (visualise cervix and paint with acetic acid to see dense white areas of risk and take biopsies; abnormal looking vessels indicate invasive carcinoma); grade 2/3 = excision with cutting diathermy (large loop excision of the transition zone [LLETZ], usually during colposcopy high cure rate
Prevention for cervical intraepithelial neoplasia?
HPV vaccination (only protects against some strains)
Smear overview?
visualise with speculum; suspicious areas identified and scrape off squamo-columnar transitional zone of cervix for chlamydia and HPV; 3 yearly 25-50yrs, 5yearly until 64yrs
S+Ss cervical cancer?
PCB, offensive vaginal discharge, IMB/PMB and later stages uraemia, haematuria, rectal bleeding, pain, ulcer/mass visible, altered bowel habit (blood borne spread = late feature); tumour spread to parametrium, vagina and pelvic side wall, cervical smear +ve, weight loss, ureteric obstruction, vesicovaginal fistula
Diagnosis for cervical cancer?
bimanual examination (cervix rough and hard, cervix fixed), tumour biopsy, staging from vaginal and rectal exam, cystoscopy (bowel), MRI/PET for tumour size and mets, bloods; colposcopy
Treatment for cervical cancer?
stage 1a with cone biopsy, up to stage 2 with surgery/chemo/radio, sometimes radical abdo hysterectomy (pelvic node clearance, parametrium, upper vagina) or radical trachelectomy (keep fertility), palliative radio for bone pain/haemorrhage; death usually uraemia from ureteric obstruction
HPV vaccine protection and who eligible?
offered at 12yrs to kids; for prevention only mainly against HPV 6 and 11; don’t prevent all cancers; HPV strong cervical cancer risk
Risks from ovarian masses?
• Silent masses and detected when large (>5cm); rupture of cyst = peritonitis; epithelial tumours mostly in postmenopause, histology of borderline malignancy
Common ovarian neoplasms?
cystadenoma/adenocarcinoma (mucinous cystadenoma v large and less common), exclude pseudomyxoma peritonei and appendiceal tumour; also endometrial carcinoma and clear cell carcinoma (rarer but poorer prognosis – associated with endometriosis)
S+Ss of ovarian masses?
asymptomatic, chronic pain, dyspareunia, cyclical pain, acute pain (torsion [rare] and bleeding), irregular bleeding, abdo swelling, hormonal effects, discharge
What is a dermoid cyst?
common benign in premenopausal women, bilateral, large and asymptomatic
What is dysgerminoma?
most common ovarian malignant; granulosa cell tumours malignant but slow in postmenopausal, lots of oestrogen and inhibin; ovary common mets site for breast and GI
What is endometrioma?
blood-filled cysts in ovaries; OC pill prevents follicular and lutein cysts
What is ovarian cancer overview?
low 5yr survival; most >50yrs and most are epithelial carcinomas
Risks for ovarian cancer?
early menarche, late menopause, nulliparity, smoking, obesity, asbestos, BRCA1/2 or HNPCC (offered yearly transvaginal US and CA 125 screening)
Protective factors against ovarian cancers?
pregnancy, lactation and OC pill
S+Ss ovarian cancer?
mostly absent/vague (70% stage 3/4), persistent abdo distension, early satiety, loss of appetite, pelvic/abdo pain, increased urinary frequency, IBS, cachexia, abdo/pelvic mass, ascites, weight loss, bloating
Investigations of ovarian cancers?
breasts palpated, staging surgical and histology, CA125 levels in >50 with symptoms, US abdo/pelvis, <40yrs alpha fetoprotein and hCG, CT/MRI staging, FBC, TVS
Treatment for ovarian cancer?
total hysterectomy, bilateral salpingo-oopherectomy, partial omentectomy, carboplatin for 1c and above, radio only for dysgerminomas, chemo post-op
Poor prognosis for ovarian cancers?
later stage, poorly differentiated, clear cell tumours, slow chemo response
N+V treatment for ovarian cancers?
60% with advanced; from opiates, metabolic causes, vagal stimulation, psych; use = anticholinergics, antihistamines, dopamine agonists, 5HT-3 agonists (ondansetron)
Bowel obstruction for ovarian cancers?
metoclopramide, stool softeners, enemas, cyclizine (total obstruction), hyoscine (spasm)
Definition for sexual function?
important for arousal, plateau, orgasm, resolution; also emotional, physical, biological, psychological, sexual stimuli and drive all important too
What is hypoactive sexual desire disorder (HSDD)?
loss of libido and sexual desire, affects personal relationships and causes distress; mainly from psychosexual
Organic causes of HSDD?
menopause, depression, chemo, radio
Hx for HSDD?
start?, normal sexual function?, different to partner’s beliefs?, relationship problems?
Treatment for HSDD?
testosterone and psychosexual counselling
Causes of dyspareunia?
superficial = infections, skin conditions (lichen sclerosis); can be deep; treat the cause (lubricants, local anaesthetic gel); if don’t treat can become fearful and avoid
What is vaginsmus?
difficult for woman to be penetrated even if want to
What causes vaginsmus and treatment?
contraction of the thigh adductors and pelvic floor muscles; exclude vaginal septae (anatomical); treatment = vaginal dilators, relaxation techniques and her own fingers
What is vulvodynia?
burning pain in absence of visible findings or neuro disorder
Treatment for vulvodynia?
physio, psychosexual, pain management, first-line = pelvic floor exercises, internal and external perineal massage, topical anaesthetic; can use tricyclic antidepressants and gabapentin
What is Peyronie’s disease?
fibrous scar tissue on penis causing painful, curved erections; non-cancerous
Treatment for Peyronie’s disease?
verapamil oral, interferon injections (breaks down fibrous tissue)
What is hypospadias?
congenital and urethral meatus not at tip but along shaft instead
Treatment for hypospadias?
surgery
Aspermia definition?
lack of semen when ejaculating or antegrade ejaculation; associated with infertility
Causes of aspermia?
hormonal level change, infection, spinal cord injury, diabetes, anti-hypertensives, alcohol, radiation, chemo, congenital
Treatment for aspermia?
either treat cause (infection) or offer artificial conception (ICSI/IVF etc)
What is anejaculation?
– inability to ejaculate semen (orgasmic/anorgasmic); prostate and seminal ducts fail to release semen
Treatment for anejaculation?
Artificial insemination
Common symptoms for vulval/vaginal disorders?
itching, soreness, burning, superficial dyspareunia
What is pruritus vulvae?
may be general or localised; local = infection, vaginal discharge, allergies to washing powder, vulval dystrophy; obesity and incontinence exacerbate, autoimmune?
Tests for pruritus vulvae?
smear, examination, vaginal and vulval swabs, diabetes and thyroid disease?, biopsy, vulval dermatitis = ferritin
Treatment for pruritus vulvae?
treat cause, avoid sensitizers, usually not successful, topical steroids
What are lichen disorders of vulvae?
chronic inflammatory skin with severe intractable pruritus (mainly night)
What is lichen simplex?
labia majora inflamed and thickened, stress, low iron; vulval biopsy, avoid irritants and antihistamines
What is lichen planus?
affect mucosa of mouth and GU tract (flat, papular, purple lesions); autoimmune; treat = potent steroid creams
What is lichen sclerosis?
vulval epithelium thin and collagen loss; autoimmune; discomfort, pain, dyspareunia, carcinoma in 5%; use ultra-potent topical steroids
What is leukoplakia?
white patches due to skin thickening and hypertrophy; itchy and analysed to see if pre-malignant
Treatment for leukoplakia?
topical corticosteroids, psoralens with UV phototherapy, methotrexate and ciclosporin
What is vulvovaginitis and treatment?
unknown cause, inflammatory; shiny erythematous patches with/out petechiae; intravaginal clindamycin cream and hydrocortisone to vulva
What is vulvitis?
inflammation from infection (candida, herpes, chemicals) and often with discharge
What is vulvar dysaethesia/pain?
provoked or spontaneous (burning pain more common in older); associated = PMH of GU infections, previous OC, psychosexual
Treatment for vulvar dysaethesia?
Amitriptyline or gabapentin
Vulval infections?
herpes simplex, vulval warts, syphilis, donovanosis can affect vulva; candidiasis (diabetics, obese, immunocompromised, pregnant), may need antifungals
What is Bartholin’s gland cyst/abscess?
blockage and infection with staph or E coli (glands under labia minora and make lubricant during sexual excitement); painful red with large tender swelling, can get vaginal cysts
Treatment of Bartholin gland cysts?
incision and drainage by marsupialisation
What is vaginal adenosis?
columnar epithelium in squamous of the vagina, can resolve spontaneously or into clear cell carcinoma
What is vulval intraepithelial neoplasia and associations?
usually warty, basaloid, mixed, 35-55yrs, reddening, whitening, pigmentation, plaques, papules, erosions, nodules, hyperkeratosis; associated = HPV, CIN, smoking, immunosuppression, warty/basaloid squamous cell carcinoma; differentiated type rare and with lichen sclerosis, risk of progression is higher, pruritus and pain
Treatment of vulval intraepithelial neoplasia?
local excision
Vulval carcinoma associations?
> 60yrs; most squamous cell (others are melanomas/basal cell); association = lichen sclerosis, immunosuppression, smoking, Paget’s disease of vulva
S+Ss of vulval carcinoma?
pruritus, bleeding, discharge, mass, large inguinal lymph nodes; staging surgically and histology
Treatment of vulval carcinoma?
stage 1 is wide local excision, others are that with groin lymphadenectomy, may use pre-op radiotherapy
Vulval malignancy S+Ss?
secondary malignancy from cervix, endometrium and vulva (primary rare); older women and squamous; bleeding, discharge, mass
Vulval malignancy treatment?
intravaginal radio/radical surgery; survival 50% for 5 yrs
Vaginal cancer overview?
very rare if primary; most squamous and older women and upper 1/3rd; associated with CIN, pelvic radio, long-term inflammation (pessaries/procidentia = complete uterus prolapse)
Vaginal cancer S+Ss and treatment?
S+Ss = bleeding; treat = radio, poor prognosis
What is urethrocele?
lower anterior vaginal wall and urethra
What is cystocele?
upper anterior vaginal wall and bladder
What is apical prolapse?
uterus, cervix and upper vagina
What is enterocele?
upper posterior wall of vagina
What is rectocele?
lower posterior wall of vagina and anterior wall of rectum; these are all the areas involved in the prolapse (vagina/uterus beyond anatomical confines from weakness from support)
Risk for prolapse?
vaginal delivery, pregnancy, Ehlers-Danlos, menopause, obesity, chronic cough, constipation, heavy lifting, pelvic mass/surgery
3 degrees of prolapse?
first = prolapse halfway to introitus, second = to introitus, third = outside of vagina
S+Ss of prolapse?
usually asymptomatic, dragging sensation/lump, worse at end of day/standing, severe = interferes with sex, ulcerates, bleeds, cystourethrocele can cause urinary frequency, stress incontinence, back ache, tenesmus
Investigations for prolapse?
examine abdo, exclude polyps and masses, vaginal cysts, pelvic US, urodynamic testing if incontinent, Sims speculum
Prevention of prolapse?
pelvic floor exercises, avoidance of excessive long 2nd stage, weight reduction, stop smoking, physio
Treatment of prolapse?
pessaries (women unfit for surgery – artificial pelvic floor, ring most common and changed 6-9months, can cause urinary retention, pain or infection); vaginal hysterectomy for uterovaginal prolapse; hysteropexy (resuspension of prolapsed uterus) for uterine prolapse; sacrocolpopexy (lifts the vagina up using metal mesh) for vaginal vault prolapse; hysterectomy best treatment if severe and untreatable but can leave vault (where cervix was) and this can prolapse
Best pelvic US?
transvaginal is best, homogeneity, low intensity echoes, linear central shadow = normal; 20mm endometrium = investigated, tamoxifen thickens it
Main causes of incontinence?
overactive bladder (increase in detrusor) or increased intra-abdo pressure (stress incontinence)
History for incontinence?
daytime voids (4-7), nocturia, nocturnal enuresis, urgency and voiding difficulties, incomplete emptying, bladder pain, dysuria, haematuria, UTI, prolapse, bowel movement abnormal, ADLs
What is stress incontinence?
Urethral sphincter weakness
Causes of stress incontinence?
pregnancy, prolonged labour, forceps delivery, obesity, age
S+Ss of incontinence?
frequency, urgency, urge incontinence, faecal incontinence, cysto/urethrocele
Investigations of stress incontinence?
urine dipstick, cystometry, test pelvic floor strength, urinalysis, imaging (US), urodynamics, cystoscopy, MSU
Treatment of stress incontinence?
lose weight, pelvic floor exercises for 3 months, vaginal cones/sponges, duloxetine for moderate/severe, surgery after everything else (tension-free vaginal tape/trans-obturator tape)
Overactive bladder definition?
urgency without incontinence (can be urge urinary incontinence too), frequency, nocturia without infection, leak at orgasm, childhood enuresis
Overactive bladder causes?
detrusor overactivity, idiopathic, MS, spinal cord injury, postmenopause
Overactive bladder treatment?
reduce fluid, avoid caffeine, bladder training (education, timed voiding and positive reinforcement), anticholinergics (suppress detrusor), oestrogen, Botox (weakens muscle), neuromodulation/sacral nerve stimulation
Acute urinary retention causes?
childbirth, surgery, drugs (anticholinergics), retroverted gravid uterus, pelvic masses and neuro; mimics stress incontinence, leaking from bladder overflow
Acute urinary retention investigations?
US or catheter after micturition
Acute urinary retention treatment?
catheter for 48hrs, ISC (intermittent self catheterisation)
Painful bladder syndrome definition and S+Ss?
suprapubic pain from bladder filling, frequency with no UTI; interstitial cystitis from painful bladder filling with cystoscopic and histological
Treatment of painful bladder syndrome?
diet changes, bladder training, TCAs, analgesics, intravesical infusion of drugs, surgery
Endometriosis defintion?
• Presence/growth of endometrium tissue out of uterus, driven by oestrogen; 30-45yrs and nulliparous
Endometriosis S+Ss?
pelvis/ovaries, inflammation, progressive fibrosis, adhesions with pain, dysuria, dysmenorrhoea before menstruation, deep dyspareunia, subfertility, pain on defecation (dyschezia), menstrual problems, tenderness/thickening behind uterus, bleeding at area of tissue, cyclical pain
Causes of endometriosis?
Retrograde menstruation?
Investigation of endometriosis?
laparoscopy with biopsy (active/red lesions on peritoneum, if white/brown then less active, extensive adhesions means more severe), transvaginal US, MRI (excludes adenomyosis), American fertility society grading system, bimanual exam = fixed retroverted uterus, tender nodes over uterosacral ligaments
Treatment of endometriosis?
asymptomatic don’t need treating, analgesia (NSAIDs), OC pill (without break) or GnRH analogues (danazol – temporary menopause so bone demineralisation so <6months, mirena), IUS (less pain and dysmenorrhoea), scissors, laser or bipolar diathermy for lesions, surgery to dissect lesions, hysterectomy last resort; problems post-op = chronic pain (difficult to treat and need a specialist), consider other non-gynae problems (IBS etc), analgesia to treat (GnRH analogues, opiates, gabapentin if neuropathic)
Chronic pelvic pain definition?
• Intermittent/chronic pain in lower abdo/pelvis >6months; not just menstruation/intercourse
Investigation of chronic pelvic pain?
psych evaluation, tansvaginal US, MRI, laparoscopy
S+Ss of chronic pelvic pain?
IBS/interstitial cystitis (endometriosis/adenomyosis), depression, sleep disorder
Treatment of chronic pelvic pain?
cyclical pain with OC pill/GnRH analogue, counselling, psychotherapy, amitriptyline, gabapentin
Risks for candidiasis?
pregnant, diabetes, abx, steroids
S+Ss for candidiasis?
non-offensive discharge, vulval irritation, itching, superficial dyspareunia, dysuria; diagnose = culture
Treatment for candidiasis?
imidazoles (clotrimazole) or oral fluconazole
Bacterial vaginosis definition?
normal lactobacilli replaced by anaerobes and Gardnerella
S+Ss of bacterial vaginosis?
grey-white discharge, fishy odour, regular sex partners, concurrent STIs, child sexual abuse; diagnose = high pH, clue cells
Treatment of bacterial vaginosis?
metronidazole or clindamycin cream
Risks for bacterial vaginosis?
preterm labour, intra-amniotic infection, post-termination sepsis, HIV susceptible
Chlamydia S+Ss?
usually asymptomatic, urethritis, vaginal discharge, pelvic infection (subfertility/chronic pelvic pain/PID), Reiter’s syndrome
Investigations of chlamydia?
nucleic acid amplification
Treatment of chlamydia?
azithromycin/doxycycline
Gonorrhoea S+Ss?
asymptomatic, vaginal discharge, urethritis, bartholinitis, cervicitis, bacteraemia, monoseptic arthritis, PID
Investigations and treatment of gonorrohoea?
culture, endocervical swabs; treat = ceftriaxone
Genital warts definition?
from HSV2; virus dormant in dorsal root ganglia
Genital warts S+Ss?
multiple small painful vesicles and ulcers around introitus, vulvitis, lymphadenopathy, dysuria, systemic flu symptoms, attacks = less painful with tingling before
Genital herpes investigation and treatment?
examination and viral swabs; treat = acyclovir for severe, strong analgesia
Syphilis S+Ss?
solitary painless vulval ulcer (first), then wks after rash, flu symptoms, warty genital growth, tertiary rare but AR, dementia, tabes dorsalis
Syphilis investigation and treatment?
syphilis EIA; treat = parenteral penicillin
Trichomoniasis S+Ss?
offensive grey-green fishy discharge, vulval irritation, superficial dyspareunia, asymptomatic
Trichomoniasis investigation and treatment?
wet film microscopy; treat = metronidazole
Endometritis definition?
untreated can spread to pelvis, fallopians and ovaries; from complication of pregnancy/instrumentation of uterus (C-section, miscarriage, abortion); chlamydia and gonococcus
Endometritis S+Ss?
heavy vaginal bleeding and offensive discharge, lower abdo pain, tender uterus
Endometritis investigations and treatment?
swabs and FBC; treat = broad-spectrum abx, evacuation of retained products of conception
Acute pelvic infection/PID?
– upper genital tract infection with dense pelvic adhesions and obstructed fallopian tubes if persists
PID causes?
ascending infection from endocervix (STI, uterine instrument, post-partum) or from descent (appendix)
PID S+Ss?
chronic lower abdo pain, dysmenorrhoea, deep dyspareunia, heavy/irregular menstruation, chronic vaginal discharge, subfertility, similar to endometriosis, fever
PID investigations?
= laparoscopy (diagnosis uncertain), MC+S, endocervical swabs for chlamydia/gonorrhoea, FBC, CRP, blood cultures, TVS if abscess suspected
PID treatment?
analgesics, abx (ceftriaxone +/- doxycycline if high risk), salpingectomy, contact tracing
PID complications?
tubo-ovarian abscess, Fitz-Hugh-Curtis syndrome, recurrent PID, ectopic, subfertility
Vaginal discharge normal physiology?
increases in ovulation, pregnancy and OC pill
Vaginal discharge causes?
exposure of columnar epithelium in adenomyosis and ectropion, bacterial vaginosis and candidiasis, foreign body (offensive), cervical carcinoma (bloody), fallopian tube carcinoma (watery)
Atrophic vaginitis definition and overview?
low oestrogen and before menarche, during lactation and after menopause, treat with oestrogen cream, HRT
What is contact tracing?
notify sexual partners of individual diagnosed with HIV/AIDS; public health duty and should be anonymous/confidential of who the sexual partner is
What are triple swabs?
for symptomatic; endocervical NAAT swab, a high-vaginal charcoal media swab and an endocervical charcoal media swab
Subfertile definition?
conception not happened after 1yr unprotected sex (either primary or secondary [had a previous terminage/miscarriage])
Subfertile causes?
anovulation, inadequate sperm, fallopian tube damage, defective implantation, unexplained, endometriosis, male causes, >35yrs predisoposes; regular cycles = ovulatory (higher serum progesterone in mid-luteal phase means ovulation)
What is infertile?
Both partners have fertility problems
History for infertility?
age, duration of subfertility; previous pregnancies/children; menstrual hx; pelvic pain; STI hx; previous surgery; smoking; drinking; medical hx; sex hx and problems during; male = undescended testes, mumps, drugs, smoking, alcohol
Examination and investigation for fertility?
BMI, endocrine disorder signs, exclude pelvic pathology, cervical smear; invest = chlamydia, hormonal profiling, TSH, prolactin, testosterone, MMR vaccine, semen analysis, mid-luteal progesterone (ovulation); TVS, hysterosalpingogram (and with contrast), laparoscopy and dye = gold standard for tube patency
Polycystic ovary syndrome definition?
transvag US with multiple small follicles in enlarged ovary (12+); most cases of anovulatory infertility
S+Ss of PCOS?
irregular periods, hirsutism (acne/more body hair/raised testosterone), disordered LH, peripheral insulin resistance, more androgens, obese, oligo/amenorrhoea, anovulation
Investigations of PCOS?
FSH, prolactin, TSH (all for anovulation), testosterone (hirsutism), LH, US, screening for diabetes and lipids
Increased risk for PCOS?
DM2, gestational diabetes, endometrial cancer (rf for this = obesity, HT, DM, PCOS, tamoxifen, late menopause)
Treatment of PCOS?
diet, weight loss, exercise, OC pill (to menstruate to protect endometrium), cyproterone acetate (hirsutism), eflornithine (for facial hirsutism), clomifene (first line ovulation induction - <6months, blocks oestrogen receptors in hypothalamus and pituitary, assess with transvag US for ovarian response and endometrial thickness), metformin, laparoscopic ovarian diathermy and gonadotrophins are all good 2nd line ovulation treatments (increases perinatal complication rates), cyproterone for anti-androgen
Long-term risk of PCOS?
GDM, T2DM, CVD, endometrial cancer
What is hypothalamic hypogonadism?
low GnRH causing amenorrhoea
Risks for hypothalamic hypogonadism?
anorexia, diets, athletes, stress, benign tumours or hyperplasia of pituitary cells, PCOS, hypothyroidism, psychotropics
Treatment for hypothalamic hypogonadism?
increase weight, CT, bromocriptine/cabergoline (dopamine inhibits prolactin that reduces GnRH)
What is premature ovarian failure?
anovulation so donor eggs needed for pregnancy; hyper/hypothyroid can reduce fertility
Premature ovarian failure treatment?
health advice, risk of multiple pregnancy with ovulation induction and folic acid, normal weight, no smoking
What is ovarian hyperstimulation syndrome?
gonadotrophins overstimulate follicles (large and painful); common in IVF
Risks for ovarian hyperstimulation syndrome?
gonadotrophin stimulation, <35yrs, previous OHSS, polycystic ovaries
Prevention for OSS?
= low gonadotrophin dose, US monitoring
Complications for OSS?
hypovolaemia, electrolyte disturbance, ascites, thromboembolism, pulmonary oedema
Male subfertility risks?
idiopathic oligospermia, asthenozoospermia, alcohol, smoking, drugs, industrial chemicals, varicocele, infections, mumps, orchitis, testicular abnormalities, obstruction to delivery, hypothalamic problems, hyperprolactinaemia, retrograde ejaculation
Male subfertility examination?
body form, gynaecomastia, orchidometer (orchitis), rectal exam
Male subfertility investigations?
semen analysis repeated 12wks later if abnormal, high FSH and LH with low testosterone means primary testicular failure, azoospermia and no vas deferens check for CF, testosterone and FSH for androgen deficiency
Treatment of male subfertility?
lifestyle changes, loose clothing and testicular cooling, hypogonadotrophic hypogonadism (2x FSH and LH 6-12 months), may need intrauterine insemination
Disorders of fertilisation overview?
pelvic inflammatory disease most common form of tubal damage (hx pelvic pain, vaginal discharge, abnormal menstruation, asymptomatic), endometriosis, pelvic surgery (adhesions), sometimes cervical cancer and sexual problems
Disorders of fertilisation S+Ss?
Usually asymptomatic
Investigation of disorders of fertilisation?
laparoscopy and dye test for fallopians, hysteroscopy, hysterosalpingogram (shape of uterus and patency of fallopians); ovarian reserve testing (FSH, antral follicle count, antimullerian hormone); use IVF and ICSI
What is intrauterine insemination?
washed sperm injected into uterus after gonadotrophin ovulation induction, for unexplained subfertility, cervical, sexual and male factors, tubes should be patent
Ways to induce ovulation?
weight loss/gain; clomifene citrate (50mg 2-6days of cycle; anti-oestrogen; menopause symptoms; only for 6-12 cycles; follicular monitoring for hyperstimulation); laparoscopic ovarian drilling (PCOS only; aim to reduce LH and increase -ve feedback); gonadotrophins (if clomifene resistance; injected; expensive); metformin (PCOS, not licensed)
What is IVF and the steps for it?
success higher in <36, need normal ovarian reserve (no ovarian failure – test with antimullerian hormone), get multiple follicular development with 2wks daily FSH+LH (GnRH analogue to stop LH surge and stop premature ovulation), eggs collected under IV sedation with US and incubated with washed sperm to growth medium until cleavage/blastocyst, progesterone 4-8wks in gestation
ICSI definition?
for male subfertility but can be surgically retrieved; inject sperm into egg cytoplasm; preimplantation genetic diagnosis to test for defects; surrogate?
ICSI complications?
superovulation and higher ectopic rates
Donor insemination definition?
male can’t donate sperm (azoospermia), high risk genetic disorder, HIV transmission
Intrauterine insemination definition?
mild male subfertility, coital difficulties, unexplained, same-sex couples; can be combined with ovarian stimulation
In vitro maturation definition?
immature eggs collected from ovaries and matured before ICSI; reduces risk of ovulation stimulation drugs and hyperstimulation (PCOS)
Ooplasmic transfer definition?
– 2 mothers; one for nucleus and other for mtDNA and cytoplasm
What makes contraception less effective?
small bowel disease and malabsorption for oral, IBD higher osteoporosis (<18yrs), breast feeding (98% stops pregnancy), women <50 advised to continue contraception up to 2yrs after last period; non-compliance
When to avoid combined hormonal contraception?
venous disease/heart disease RF; arterial disease; liver disease; cancer; previous pregnancy complications; hepatic enzyme-inducing drugs; avoid if migraines as risk of ischaemic strokes (especially if with aura)
Prevention in place of contraception?
• Important to have sex education in schools, condoms (don’t use oil based lubes), femidom, cap over cervix, cervical sponges, spermicide used with a barrier; aim to not have sex 6 days prior to ovulation to 2 days after (cervical mucous should be clear and slippery before ovulation and then sticky and tacky – no sex when slippery to 3 days after tacky); Persona use urine sticks measure oestorgen-3-gluconoride + LH, give her a green/amber/red light when not ovulating and can have sex, use 8 times per cycle and v effective
How does the combined OC pill work?
ve feedback on gonadotrophin release and inhibits ovulation; thin endometrium and thicken cervical mucous, 1 tablet daily for 3ks then stop for a week, vaginal bleeding at end of each packet (determined by progesterone used), some contain ethinyloestradiol (same O+P dose) or oestradiol valerate (natural O and synthetic P – 26 pill days then 2 free)
What is the OC pill for?
menarche-menopause, stop recurrent simple ovarian cysts
Things to note with the combined pill?
diarrhoea (reduced absorption), vomits 2hrs after taking take another, broad spectrum abx use condoms as well, liver enzyme inducing drugs use more oestrogen, forgotten pill taken asap, pill stopped 4wk before major surgery
SEs of the combined pill?
nausea, headaches, breast tenderness
What is the combined transdermal patch?
releases ethinyloestradiol then norelgestromin (progestogen); new patch weekly for 3wks then week break
What is the combined vaginal ring?
daily ethinyloestradiol and etonogestrel; same rule as patch; don’t remove during intercourse
What is the progestrogen-only pill and how does it work?
levonorgestrel or norethisterone; every day without a break at same time; makes cervical mucous hostile to sperm and inhibits ovulation in 50%, not affected by broad-spectrum
SEs of progesteron only pill?
vaginal spotting, weight gain, mastalgia, pre-menstrual symptoms
What is depo-provera and noristerat?
medroxyprogesterone acetate IM 3 months
SEs of the depo injection?
irregular bleeding in 1st wks then amenorrhoea, bone density increases, noristerat as short-term interim
What is the nexoplanon?
40mm rod of etonogestrel into upper arm and lasts 3yrs
Types of emergency contraception?
levonelle has levonorgestrel (take in 24hrs), affects sperm and endometrial receptivity; ulipristal is selective progesterone receptor modulator prevents/delays ovulation, if IUD inserted then stops implantation and can be inserted 5 days after sex
Types of barrier contraception?
diaphragms and caps before sex and 6hours after; also use with spermicide (nonoxynol-9)
How to use IUCD?
screen for STD/prophylactic abx before; use immediately after TOP/miscarriage for 4wks
Types of IUCD and indications?
copper (prevent fertilisation; more ectopic/PID risk) or progesterone like Mirena/Jaydess (change cervical mucous and uterotubal fluid so no sperm migration, can be used for menorrhagia and dysmenorrhoea)
Complications of IUCD?
low failure and SEs; can perforate uterus, be expelled, PID association, dysmenorrhoea/menorrhagia
Female sterilisation types?
use of clips and applied laparoscopically; other is transcervical sterilisation (microinserts into proximal tubal lumen); confirm 3months later by hysertosalpingogram
Vasectomy definition?
more effective and ligation and removal of small section of vas deferens (confirm by azoospermia in 2 sperm samples up to 6months)
Complications of female sterilisation?
failure, infection and chronic pain; make sure consent properly and that they know it’s permanent and won’t regret later (reversibility 50% effective and not on NHS)
Progesterone changes in pregnancy?
from corpus luteum til 35 days post-conception then by placenta causes smooth muscle excitability, raises body temp
Oestrogen changes in pregnancy?
increase breast and nipple growth, water retention and protein synthesis
Thyroxine changes in pregnancy?
increase thyroid from more colloid made
Prolactin changes in pregnancy?
from pituitary increases
Uterus changes in pregnancy?
late in pregnancy cervical collagen reduces and vaginal discharge from cervical ectopy, cell desquamation, more mucous
Cardiac output changes in pregnancy?
increased stroke volume and pulse rate; bp mainly diastolic falls in 2nd trimester; increased venous pressure so may get varicose from venous dilation (increase in renin and angiotensin)
What is aorto-caval compression?
from uterus when on back which reduces CO significantly; put woman on her left side tilting 15 degrees on side
Other changes in pregnancy?
ventilation increases, gut motility decreases, micturition frequently common, palmar erythema, spider naevi, striae
Minor symptoms in pregnancy in 1st 12wks?
amenorrhoea, nausea, vomiting, bladder irritability, breasts engorge, nipples large, Montgomery’s tubercles prominent, increased vulval vascularity, cervix softens, uterine globular, temp rises (37.8)
Other symptoms in pregnancy?
Headaches, palpitations and fainting – dilated peripheral circ; stand slowly and drink; Urinary frequency – exclude UTI, fetal head pressure on bladder, GFR increases; abdo pain; SOB; constipation – gut motility low, fluid and fibre, avoid stimulant laxatives, piles common, rest with feet up and stockings; GORD – pyloric sphincter relaxation from progesterone, foetus pressing on GI, pillows, other GORD treatment; MSK – symphysis pubis dysfunction, analgesia and physio; carpal tunnel syndrome – from fluid retention; itchy/rashes – common (pruritic eruption of pregnancy/PEP), 35wks+, emollients and weak topical steroids; ankle oedema – very common, measure BP, check protein (pre-eclampsia) and DVT usually harmless and elevate feet; leg cramps – raise foot 20cm in bed, sometimes restless leg syndrome harder to treat; chloasma – dark pigmentation on face; nausea/vomiting – starts by 4wks and usually declines, small meals, low stress
What is hyperemesis gravidarum?
• Persistent vomiting causing weight loss and ketosis in pregnancy; v rare; higher in multiple, molar pregnancy, previous HG
S+Ss hyperemesis?
can’t keep F+D down, weight low, nutritional deficiency, dehydration, hypovolaemia, tachycardia, postural hypotension, electrolyte disturbance with hypokalaemia, hyponatraemic shock, polyneuritis, behaviour disorder, haematemesis (Mallory-Weiss), ptyalism (can’t swallow saliva), spitting
Tests hyperemesis?
urine dip (ketones and UTI), U+Es, FBC (raised haematocrit), albumin low, transaminases abnormal, TFTs abnormal
Treatment hyperemesis?
hospital if oral anti-emetics not working; fluid replacement; don’t use glucose (wernicke’s encephalopathy – use folic acid and thiamine), daily U+Es; anti-emetics (promethazine, cyclizine, metoclopramide and ondansetron if these fail) use corticosteroids if these fail; high risk of VTE so stockings and thromboprophylaxis
Problems with sickle cell disease for pregnant women?
pregnancy worsens anaemia (crises and acute chest syndrome increased); advise on cold intolerance, hypoxia, dehydration
Advice for sickle cell disease?
genetic counselling for child and test partner; echo to exclude pulmonary hypertension, bp, urinalysis, U+Es, LFTs, retinal screening, iron overload screening
Treatment for sickle cell disease?
daily penicillin, update vaccines (more at risk to infections), 5mg folic acid OD; prenatal testing and tell medical team before so they can prepare; 12wks give aspirin 75mg OD so no pre-eclampsia, TEDs in hosp; regular testing as seen above at visits
S+Ss of crises in sickle cell disease and management?
fever, severe pain, chest pain, SOB; fluids, opiates and O2; delivery 38-40wks, monitor foetus and maternal sats, 7 days thromboprophylaxis after (progesterone contraception)
Increased risk for cardiac disease in pregnancy?
risk increased from pulmonary hypertension, effect on haemodynamics, NHYA functional class I-IV and cyanosis present, arrhythmias, TIA, HF, left tract outflow tract obstruction, low EF
Advice for pulmonary HT in pregnant?
25-40% mortality, advise against pregnancy, Eisenmenger’s etc
Advice for congenital HD in pregnant?
uncorrected can mean IUGR (intrauterine growth restriction), get foetal echo
Marfan’s advice for pregnant?
risk of aortic dissection, offer root replacement pre-pregnancy
Mitral stenosis advice for pregant
dyspnoea, orthopnoea, PND risks and treat AF and pulmonary oedema
Arrhythmias advice for pregnant?
exclude anaemia and hyperthyroidism, SVT treat with adenosine
Artificial valves advice for pregnant?
warfarin can harm foetus and heparin could mean valve thrombosis, can have LMWH
Cardiac failure management for pregnant?
diuretics, vasodilators, B-blockers and inotropes then ACEI once delivered
Management of cardiac disease in pregnancy?
prevent anaemia, obesity, smoking, treat hypertension, echo, HF = admission; O2 and drugs to hand for labour, vaginal delivery aim for, epidurals safe if no hypotension, avoid fluids and ergometrine (use oxytocin)
Psych things to avoid and reasons during pregnancy?
avoid paroxetine, fluoxetine and citalopram but SSRIs fine (same for ante/postnatal depression); try to avoid valproate as mood stabiliser (lamotrigine and carbamazepine have lower chance of NTD); lithium is teratogenic, deffo stop it during labour, don’t breastfeed; higher incidence of foetal abnormalities in schizophrenic; avoid benzos for foetal withdrawal and cleft lip/palate
Problems during pregnancy from anaemia?
can increase risk of postpartum haemorrhage (PPH – when uterus cannot tense from muscle fibres to restrict in size post-birth and knot itself and cervix cuts off), infection, HF severity
Definition of anaemia during pregnancy?
<150g/L and steepest decline in 20wks
Testing of anaemia during pregnancy and treatment?
Hb at 1st and 28wks, malaria, SCT, FBC (MCV), iron and ferritin (main cause is deficiency), check folate too; iron deficiency = need way more iron if pregnant so can give oral/parenteral iron; thalassaemias = don’t give iron, alpha more likely to mean anaemic foetus
Problems of HIV in pregnancy?
increased risk of foetus contracting from vaginal birth, membrane rupture >4hrs and increased viral load
Prevention of HIV in foetuses?
antiretroviral use, C-section, bottle feeding
Antenatal management for HIV?
HIV test, if +ve MDT and monitor viral load and drugs, check for hep B, C, varicella zoster, measles and toxoplasmosis and offer vaccines, give HAART if women needs or if not then must take at 24wks
Premature labour management of HIV?
if membrane ruptures <34wks give steroids, erythromycin, HAART and decide if needs delivered or not; if >34wks deliver baby
Intrapartum and postpartum management of HIV?
intrapartum = vaginal <50 copies/mL, HAART, limit trauma to foetus; C-section at 38wks; postpartum = avoid breastfeeding and give cabergoline within 24hrs to stop lactation, newborns given zidovudine in 4hrs or HAART if high risk, test babies, co-trimoxazole prophylaxis given to babies high risk of transmission
Prenatal management of DM?
plan pregnancy, HbA1c <43mmol/L, 5mg folic acid OD before, stop ACEI and hypoglycaemics other than metformin, don’t if severe nephropathy and screen retinopathy
Complications for women with DM?
maternal: pre-eclampsia, infection, C-section; foetus: miscarriage, malformation, macroscopic (shoulder dystocia, IUGR), polyhydramnios, preterm
Antenatal management of DM?
anomaly scan and foetal echo 18-20wks, aim for normoglycaemia, review insulin regularly (needs increase through pregnancy), aim for fasting 3.5-5.9mmol/L, assess renal function (best to be <120umol/L creatinine), monitor foetal growth, metformin used
Delivery management of DM?
elective delivery at 38wks, corticosteroids for preterm for lung maturity, aim for glucose 4-7mmol/L (if above give sliding scale insulin and take off immediately after birth and return to normal regimen, should have to reduce dose through delivery), avoid hypers, monitor foetus
Postnatal management for those with DM?
encourage breastfeeding (should be fine with regimen), prepregnancy counselling before next baby
Definition of GDM?
OGTT >7.8mmol/L
Why screen for GDM?
screen if FH, previous baby >4.5kg, ethnicity, BMI >30, previous GDM
Treatment for GDM?
only give hypoglycaemics (metformin/glibenclamide) if can’t control levels without; 50% develop T2DM (screen postpartum)
Pre-pregnancy general counselling?
• Stop smoking; weight loss (BMI 18.5-30); exercise; folic acid to stop neural tube defects and cleft lip until 13wks; vit D for those at risk; no alcohol and drugs to stop Foetal alcohol syndrome; change medication if teratogenic and monitor if have chronic disease; age (higher miscarriage); genetic counselling
What is the placenta for?
• For respiration, nutrition and excretion; immune foetal protection; endocrine
Structure of the placenta?
• Placental villi functional units of the placenta; on maternal surface is syncytiotrophoblast (direct contact to maternal blood), then cytotrophoblast, then basement membrane then mesenchymal stroma then basement membrane of the foetal vessels
Circulation of the placenta overview?
uteroplacental circ = maternal blood through intervillous spaces, if this becomes high resistance and low flow then IUGR and pre-eclampsia; fetoplacental circ = 2 umbilical arteries, divide and feed to chorionic villus where is oxygenated and picks up nutrients then drains to umbilical vein; maternal and foetal vessels occur in countercurrent and never mix
Things to look for in placenta after birth?
look for blood abnormalities (pH, clotting, Hb, Coombs, LFTs, blood group, infection)
Overview of antenatal care?
• Detect disease in mother; help promote fetal welfare, prepare for birth, monitor trends (bp most important for pre-eclampsia)
What happens in a 1st antenatal visit before 10wks?
full obs hx; risk assess for pre-eclampsia/venous thromboembolism; any diseases; gestational diabetes (glucose tolerance at 28wks for at risk [high BMI, heavy baby, FH]); past psych; tropical diseases if out of UK; social care for women unsupported/domestic violence; EXAMINATION (heart, lungs, bp, weight, abdo, smear, varicose veins, genetically cut?; TESTS = mainly blood (Hb, group, abs, syphilis/rubella, serology, HIV, serology, MSU, genetic
Pathway for screening?
identify the eligible, provide info, inform about test, document the decision, perform test, communicate the results, have follow-up and treatment for those positive, optimise health outcomes
Screened diseases during pregnancy?
sickle cell, thalassaemia, infectious diseases screening, Down’s, Edward’s, Patau’s, foetal anomalies, diabetic eye screening, newborn infant physical exam, newborn hearing screen, newborn blood spot
Thalassaemias during pregnancy?
beta = less B chains made and alpha = less A chains made in Hb (imbalance of alpha and beta chains leads to precursor deaths); BETA = more Hb delta and Hb gamma (lots of Hb which cannot be used), categories = MINOR [heterozygous, asymptomatic, anaemia mild/absent, hypochromic and microcytic, iron stores normal]; INTERMEDIA [symptomatic with moderate anaemia but not regular transfusions, splenomegaly, bone deformities, leg ulcers, gallstones, infections – blood = not carrying enough oxygen so tissues can die causing things like infections etc]; MAJOR [in 1 year olds; can’t thrive and bacterial infections; severe anaemia; transfusions needed; hypertrophy of bone marrow; microcytic; homozygous; need iron-chelating so no iron overload as big problem; ascorbic acid to increase urinary iron exctretement]; ALPHA = FOUR GENE DELTION [no alpha chain synthesis and only Hb Barts present (4 gamma chains and cannot carry O2), infants stillborn or die after birth]; THREE GENE DELETION [severe reduction in alpha chain synthesis, HbH disease and has 4 beta chains; moderate anaemia and splenomegaly]; TWO GENE DELETION [microcytosis with/without anaemia]; ONE GENE DELETION [normal blood usually]
Pathophysiology of sickle cell anaemia?
Hb is insoluble and polymerises when deoxygenated and flexibility of cells decreased and become rigid and sickled; SEE PAGE 24 FOR MORE STUFF ON ITS PATHOGENESIS; sickling means shorter RBC survival and obstruction of microcirculation = tissue infarction and pain; HbS releases O2 easier than normal Hb; HETEROZYGOUS [symptom free unless hypoxic and can offer protection against falciparum anopheles (malaria)];
Complications from sickle cell anaemia?
HOMOZYGOUS [vaso-occlusive crises (acute pain in hands and feet and avascular necrosis of bone marrow in children and in long bones of adults for same reasons {SEE WHICH ARE LONG BONES FROM PHASE 1} – blockage due to cells taking up small vessels; can have CNS infarction in kids); acute chest syndrome (occlusion in pulmonary vessels; mortality most common with pulmonary hypertension and chronic lung disease; infection, fat embolism from bad bone marrow or occlusion can cause this); pulmonary hypertension (mean pulmonary artery pressure greater than 25mmHg by right heart catheterisation; usually from repeated chest crises); anaemia (chronic haemolysis; cell can get trapped in spleen and cause splenomegaly and then acute haemolysis and can lead to non-functioning spleen); BONE MARROW APLASIA
Diagnosis of sickle cell anaemia?
Hb = 60-80g/L, raised reticulocytes, sickled erythrocytes and Hb electrophoresis confirms diagnosis
Treatment of sickle cell anaemia?
keep well (no infections etc); folic acid if have haemolysis; IV fluids, pain killers and oxygen for attacks (common sense)
Pathway for sickle cell?
offered to all at 8-10wks; family origin questionnaire with bloods; test biological father; offered termination if affected foetus
When is US done for baby and what for?
<11wks for location, viability, dating of pregnancy; dating a pregnancy
What is a nuchal translucency scan for?
11-13wks for viability, dates, multiple, chorionicity, most with genetic abnormalities detected; chromosomal using nuchal folds and blood test; also if high nuchal translucency then can mean fetal heart failure
US anomaly scan and soft markers?
18-22wks for structural abnormalities (lethal = anencephaly, bilateral renal agenesis, major cardiac, trisomies 13/18); soft markers (choroid plexus cysts, echogenic bowel [higher chromosome abnormality, congenital infection, CF, bowel obstruction], 2 vessel umbilical cord, mild renal pelvic dilation); info and specialist help if abnormality found
What are foetal echoes, foetal growth scans and doppler US?
- Fetal echo – for at risk of fetal cardiac abnormalities (drugs, history)
- Fetal growth scans – need accurate gestational age; head circ, abdo circ, liquor vol, at least 2wks apart
- Doppler US – uterus, placenta and foetus blood flow
Problems with Down’s?
trisomy 21 (Down’s) = increased rate of miscarriage and increased age increases incidence, can have cardiac abnormalities (VSD/ASD), most common aneuploidy
Problems with Edward’s?
trisomy 18 = Edward’s, most don’t survive after 1yr (VSD, rocker-bottom feet and small chin, LD, resp problems and other organs)
Problems with Patau’s?
trisomy 13 = Patau’s and very rare and most children die (microcephaly, exomphalos [umbilical hernia from thin abdo wall), cleft palate, holoprosencephaly [brain development abnormal]); can test in 1st trimester with combined test with NT scan
Testing methods during pregnancy?
• Alpha fetoprotein – 10% can have a foetal defect with high AFP
• Pregnancy associated plasma protein A – secreted mainly by placenta so low means poor early placentation; can mean trisomies or even predict pre-eclampsia
• Invasive testing – increased genetic disease risk; chorionic villus = 10-13wks, transabdo/transcervical using US, can mean 1-2% miscarriage and introduce blood-borne virus; amniocentesis = 16+wks, transabdo to take fluid that has foetal cells shed in it
• Cell free foetal DNA – non-invasive for prenatal chromosome abnormalities; used to guide anti-D use in Rh-ve women
• Diabetic eye screening – over 6wks pregnant; existing diabetics, tested at least 2x in pregnancy, early appt and scan
• Newborn infant physical – within 72 hours then 6-8wks; identify defects; screen eyes, heart, hips, testes and refer to specialist if needed
• Newborn hearing
And newborn bloodspot
Reason for newborn hearing?
identify permanent deafness and severity; helps develop communication if found early
How to test newborn hearing?
screened within 4wks birth; use automated otoacoustic emission test (AOAE – clicking in ear and ear response recorded) and sometimes also automated auditory brainstem response test (AABR – sensors on head, neck and shoulder and clicking sounds played)
Newborn bloodspot tests for?
SCD, CF, congenital hypothyroidism, 6 inherited metabolic disorders, PKU, medium-chain acyl CoA dehydrogenase deficiency, maple syrup urine disease, isovaleric acidaemia, glutaric aciduria type 1, homocystinuria
Day 3 of normal foetal development?
Early cleavage stage embryos are ‘totipotent’ – the nuclei of individual blastomeres are each capable of forming an entire fetus; keep embryos past day 3 so can tell it’s gonna have a normal stage of development
Day 4 of foetal development?
Cells flatten; • Maximise intracellular contacts
• Tight junctions form
• Polarisation of outer cells
Day 5/6 of foetal development?
Tight junctions between outer cells – forms the trophectoderm
• Fluid filled cavity expands (blastocyst)
• Blastocyst stage - >80 cells (50-66% comprise trophectoderm, rest the ICM)
• Day 5/6 – cavity expands and diameter increases and ZP thins (in uterine cavity)
• Day 6+ (hatching) - Blastocyst expansion and enzymatic factors cause the embryo to hatch from the ZP
Day 6-10 of foetal development?
- Maturing of egg begins in fallopian tubes and called the in vivo stage (nutrients supplied by cumulus cells, fallopian tube secretions and uterine secretions); give growth factors and cytokines (IGF-I and IGF-II and LIF)
- Early implantation – mainly pyruvate used and not metabolically active but after this needs more glucose and more energy in blastocyst stage (in uterine cavity for blastocyst stage)
What is apposition?
unstable adhesion to uterine lining; always attaches by embryonic pole (bit closest to egg sac) to receptive endometrium (day 19-22 must implant in this window)
What is attachment?
stronger and more stable adhesion; trophoblast forms protrusions into endometrium also interaction by receptor-ligand; apical surfaces of endometrium express adhesion molecules and trophoblastic cells do; integrins join
What is invasion in foetal development?
trophoblast erodes endometrium into blood vessels and makes contact with maternal blood to give chorionic villi by enzymes (synctiotrophoblast)
What is decidual reaction?
progesterone primed endometrial stromal cells next o blastocyst differentiate into secretory cells/decidual cells; endometrial glands enlarge and local uterine wall = very vascularised; more secretions to help blastocyst implant; however this is not a requirement as can have ectopic pregnancies
Impact of HCG on foetal development?
alpha made in committed cytotrophoblast cells; beta made in synctiotrophoblast cells and is limiting and these rising indicates starting implantation in day 7-8; makes sure corpus lutem continues to make progesterone in first trimester of pregnancy; essential to early pregnancy; interacts with endometrium with specific receptors; immunosuppressive; doubling of HCG in 1.3 days in 10-12 days of pregnancy
Definition of normal birth?
spontaneous in onset, low risk at start if labour and remaining so in labour and delivery; infant born spontaneously in vertex position 37-42wks, then after both mother and baby in good condition, in 24 hours of first contractions; no induction of labour; spinal, epidural, analgesia used forceps or ventouse, C-section or episiotomy used; feed baby after birthing
What is the first stage of labour and describe (split into two)?
latent (long + painful and contractions vary and irregular, mucoid plug seen, cervix starts to efface and dilate to 4cm, 2-3 days; harder in primiparous women [first baby]), first stage = established (stronger contractions, cervix effaces and dilates to 10cm [good dilation is 1/2cm per hour], assess strength and freq of contractions and temp of mother, urinary bladder, vaginal exam 4hours for dilatation and head position, liquor state, foetal heart)
Second stage of labour?
(full dilation to birth of foetus, 2-3 hours longest but can be 5 minutes, woman pushing with abdo and valsalva manoeuvre to birth, same measurements as above but offer oxytocin if contractions wane; can be a passive hour after dilatation then active stage, use syntometrine as anterior shoulder exposed to reduce chance of PPH and reduce 3rd stage time unless has heart/pulse problems)
Third stage of labour?
birth of foetus to expulsion of the placenta, retroplacental haemorrhage aids, less than an hour
Presentation positions of baby?
most will be cephalic (head down), small amount will be breech (bum down) and transverse (back down); best of all is left occipitoanterior (LOA)
How do contractions work during pregnancy?
starts in fundus (pacemaker); retraction of muscle fibres; build in amplitude as labour progresses; foetus forced down putting pressure on cervix
What is effacement?
cervical ripening is where cervix softens and thins (usually long 4cm bottleneck and during pregnancy tight closed and mucous plug)
What is dilatation and the target dilatation?
opening of cervix from retraction of muscles and pressure of baby on cervix; full = 10cm, done by vaginal exam
What makes up the foetal skull?
frontal, parietal and temporal bones; not fully formed and 3 bones are separate; allows baby to navigate through cervix
What is cervical show?
when mucous plug dislodges from cervix; in early labour when starts to dilate
What is descent in labour?
into pelvis 37wks onwards, from increased abdo muscle tone and increased strength and freq of contractions
What is flexion in labour?
(uterine contractions uterine contractions exert force on foetal spine and forces the occiput to meet the pelvic floor, then the foetal neck flexes so the foetal skull has a smaller diameter for birthing, more successful if foetus back to mother’s front
What is internal rotation in labour?
each contraction pushes foetal head onto pelvic floor and after each contraction small rebound means slight rotation each time until head is 90 degrees rotated
What is extension in labour?
foetal occiput slips beneath suprapubic arch allowing head to extend, foetal head now born facing the mother’s back
What is restitution/external rotation?
foetus my naturally align head with shoulders [restitution], shoulders have to negotiate pelvic outlet and may have to externally rotate
What happens in the delivery of the body in birth?
gentle downward traction with foetal spine, helped by midwife to deliver shoulder then upwards traction to deliver posterior shoulder, too much force can damage brachial plexus
What is bishop scoring?
group of measurements from vaginal exam (station, dilation, effacement, position, consistency of cervix) that determine if cervix ripe for spontaneous labour; out of 8
What is rupture of the membranes?
release the amniotic fluid surrounding and cushioning the baby; the foetus can swallow amniotic fluid and helps creates urine and meconium; sometimes baby born in amniotic sac (en caul)
What is delayed cord clamping and why is it done?
not immediately clamp cord but allowed at least 1 minute to transfuse blood to baby; good for pre-term babies; allows time for baby to transition, increase in RBCs, iron and stem cells, less need for inotropic support
How is the placenta delivered?
management is active (give oxytocin to uterine contract and birth the placenta, not too much force or snap the cord or invert uterus) or physiological (without intervention)
Positions for the woman during birth?
ideally meant to be upright (increases diameter of pelvic outlet, less risk of compressing aorta, stronger and longer contractions); encourage women to have strong sighs and concentrate on out-breaths to less thought on the pain and not hyperventilating; in water bath as well
Non-pharma pain management options for woman during childbirth?
water immersion (below 37.5 degrees), aromatherapy, massage, hypnobirthing (breathing techniques), TENS machine (transcutaneous electrical nerve stimulation); non-invasive, partner can be involved, no risk, some work better than others
Analgesic treatment during childbirth?
Entonox (fast-acting and short half-life and use alongside other analgesia but can cause nausea and drowsiness), paracetamol and condeine; opioids (diamorphine, pethidine, remifentanil – given by midwife, doesn’t slow labour, sleep between contractions, given with anti-emetic, can cross the placenta to baby so be careful and can cause resp depression in mother and foetus); pudendal nerve block using lidocaine into sacrum, not good enough for forceps; lidocaine into perineum before episiotomy; epidurals (mix of bupivacaine and fentanyl, administered by pump through spine [T10-S5] and works completely in 90% but can slow labour, takes hour to work and may need urinary catheter, CTG monitoring, can cause hypotension [good for pre-eclampsia], headache and nerve damage; can be topped up when needed); combined spinal epidural (used to cover a C-section taking longer); spinal anaesthesisa (used mainly for LSCS, single injection)
Reasons for a home birth?
must be low risk; reasons = more relaxed, hosp fear, midwife continuous care, family support, avoid intervention; could mean a worse outcome if problems (maternal mortality same but perinatal worse)
Criteria for operative vaginal section?
o Consent and explain o 1/5th or less head felt in abdo o ROM o Adequate analgesia o Adequate contractions o Empty bladder o Fully dilated cervix o Check position of head and presentation o Check instrument o Have neonatal specialist there
Indications for operative vaginal birth?
o Maternal = prolonged second stage, maternal exhaustion, medical avoidance or can’t of pushing (cardiac, tetraplegic)
o Foetal = suspected distress, for the head when breech presentation
Indications for forcep delivery?
assisted breech/face presentation, <34wks, some C-sections, suspected coagulopathy/thrombocytopenia, cord prolapse, general anaesthesia, significant caput (foetal head swelling from labour); abandon if 3 pulls from forceps doesn’t help
What are low-cavity forceps?
head on perineum to lift out baby; can be used in LSCS
What are mid-cavity non-rotational forceps?
only used when sagittal suture lies in AP direction; blades put in between contractions
What are mid-cavity rotational forceps?
for rotating by experienced doctors
What is a ventouse device?
suction to get foetal scalp into a ventouse cup; creates an artificial caput on the head called a chignon that takes 24-48hrs to resolve
Problems with ventouse and complications?
o More likely for foetal trauma but must be >34wks and no maternal coagulopathy; more likely to fail; metal cup, soft cup, Kiwi OmniCup (single use)
• Complications – maternal GU trauma, spiral vaginal tears, foetal injuries (haemorrhages, fx, nerve palsies), most common for foetal is with ventouse causing cephalhaematoma (others = scalp lacerations and retinal haemorrhage), obstetric brachial plexus injury (can also be from large weight and shoulder dystocia)
When to stop using ventouse delivery?
no descent with each pull and after 3 pulls; go to emergency LSCS
Post-delivery management of ventouse delivery?
vit K, analgesia, document time and vol of 1st urine (catheterise if spinal/epidural), thromboprophylaxis needed?, future deliveries discussed
Definition of primary PPH?
loss of >500ml in first 24hours post birth; causes = tone (uterine atony = most common), tissue (retained products of conception), trauma (genital tract), thrombin clotting disorders
Definition of secondary PPH?
excessive blood loss after 24 hours (5-12days); from placental tissue retained and can be with infection, uterine involution can be incomplete
RFs for PPH?
antenatal = previous, BMI over 35, maternal Hb >85 at labour, APH, over 35yrs, >4 kids, uterine malformation, large/low placenta, overdistended uterus, abruption; labour = prolonged, induced, oxytocin use, C-section
Management for PPH?
call for emergency help; high flow O2 and may need to intubate; do bloods (all the normal ones); IV fluids; catheterise and monitor urine output; try to deliver placenta and stimulate contractions; repair tears
Drugs used to stimulate contractions?
syntometrine, oxytocin, ergometrine, misoprostol, carboprost
Theatre procedures to stop PPH?
if drugs don’t stop it; consider laparotomy; Rusch balloon, B-lynch suture, internal iliac/uterine artery ligation; hysterectomy if necessary
What is a retained placenta?
not complete by 30 mins with active management, by 60 mins with physiological 3rd stage; won’t deliver spontaneously; danger of PPH
How to manage a retained placenta?
if doesn’t separate from uterus then not too much cord traction as may snap or uterus invert; check placenta not in vagina, palpate abdo, rub up contraction, put baby to breast to stimulate oxytocin (may give oxytocin too), proximally cord clamp, empty bladder; after 30 mins examine to see if need manual removal
Manual removal of a retained placenta?
lithotomy position; one hand on abdo to stabilise uterus and other hand into uterus; manually separate and then pull out and give oxytocin and abx after
How to manage uterine inversion?
immediately push fundus back through cervix; crossmatch blood and take to theatre (tocolytics, manual push up and if this doesn’t work then laparotomy)
What is a velamentous placenta?
umbilical vessels in membrane before placenta insertion
What is placenta succenturia?
separate lobe away from placenta that may not separate normally (PPH)
What is vasa praevia?
foetal vessels from velamentous insertion more likely to damage and haemorrhage (C-section)
What is placenta membranacea?
thin placenta surrounds baby (may fail to separate and APH risk
What is placenta accrete?
abnormal adherence to uterus (increta = to myometrium and percreta if to serosa); PPH risk; need hysterectomy; RF = previous C-section; diagnose prenatally by Doppler
What is placenta praevia?
placenta lies in lower uterine segment (over the cervix); advise against penetrative sex and digital examination; transvaginal US to diagnose and speculum to check for cervical cancer, CTG
RFs for placenta praevia?
C-section (placenta can attach to scar), multiparity and twins, old mother (>35yrs), assisted conception, fibroids, manual removal of placenta
S+Ss placenta praevia?
APH, abnormal foetal lie, obstruction during labour, accrete, intermittent bleeding usually only after 20wks with no pain;
Treatment for major placenta praevia?
advise for C-section but minor normal vaginal birth; o Delivery – want baby out by 39 weeks but aim for 37
How can DIC happen in a mother?
secondary to procoagulant substance release in mother for any reason (pre-eclampsia, dead foetus etc)
Tests for DIC?
= Kaolin and clotting factors
Management for DIC?
give fluids and blood, plasma and calcium gluconate and remove source
How can ITP occur in a pregnant woman?
IgG abs formed and 10% can cross the placenta causing thrombocytopenia in foetus as well as mother; consider HIV and SLE
Management of ITP in pregnant woman?
give steroids if platelets too low; aim for non-traumatic delivery with no instruments used if possible; cord blood at delivery and may have to give baby IVI at birth if platelets low
S+Ss of amniotic fluid embolism?
dyspnoea, chest pain, resp arrest, hypotension, foetal distress, seizures, low consciousness, cardiac arrest
Management of amniotic fluid embolism?
prevent resp death (O2 and IVI if develop DIC), resus, monitor foetus, if mother has cardiac arrest deliver baby by C-section, correct hypotension
What is moulding during birth?
natural and is where skull pieces move over each other to allow birth by reducing diameter; slight moulding is where bones touch, extreme is where bones overlap and can’t be reduced
What is cephalhaematoma?
subperiostal swelling and may be absorbed over time but can contribute to jaundice
What is caput succedaneum?
oedematous swelling over presenting part of head from venous collection from where presenting part squeezed by pelvis; disappears over 1-2 days
What is Erb’s palsy?
from shoulder dystocia and unable to move arm; most resolve in 6 months with physio
What is subaponeurotic haematoma?
associated with ventouse; can cause anaemia/jaundice
How can intracranial injuries result and how to treat them?
difficult, fast labour, instrumental and breech deliveries; check babies platelets; anoxia can cause intravertebral haemorrhage and asphyxia can cause intracerebral haemorrhage; supportive treatment
Types of anal sphincter injury?
1st and 2nd affect perineal skin and or muscle; 3rd = part or all of anal sphincter and 4th = into mucosa
Problems with anal sphincter injury?
repair can help alleviate incontinence but may not; greatest risk after 1st vaginal birth and if it happens then subsequent births also for pudendal nerve injury
Management of anal sphincter injury?
abx, anal US, specialist physio, laxatives
What is a vesicovaginal fistula?
bladder to vagina leading to incontinence; obstructed labour (mainly those younger and smaller pelvises and malnourished) = head compresses against tissues of vagina, bladder and rectum causing ischaemia of these and foetal asphyxiation, 2 days after foetus died is soft enough to expel vaginally, then 3 days later expels sloughed ischaemic tissue leaving a fistula, fibrosis healing and vagina and rectum stenose and become incontinent
What is management of vesicovaginal fistula?
urinary catheter and surgery; monitor those at risk
Defintion of a C-section?
delivery through incision in abdo wall
Reasons for C-section 1st time?
failure to progress, foetal distress, breech
Why to avoid a C-section?
support in labour, induction at 41wks, consultant involvement, foetal blood sampling, 4hour partogram (maternal and foetal key data on graph during labour against time; cervical dilation, foetal HR, labour duration and vitals)
Types of C-section?
o Lower uterine segment incision – 3cm above pubis symphysis to reduce blood loss; transverse incision in lower segment for less adhesions formed, lower blood loss, less scarring
o Classical CS – vertical incision on uterus and transverse or vertical on skin; rarely used; some reasons why: very premature, foetus lies transverse, maternal cardiac arrest; more likely to have adhesions and infection
Other indications of C-section?
repeat CS, foetal compromise (bradycardia), malpresentation, failure to progress, severe pre-eclampsia, IUGR, placenta praevia
Category for C-section?
1 = immediate threat to life, within 30mins (abruption/foetal bradycardia); 2 = maternal or foetal compromise; 3 = semi-elective (pre-eclampsia); 4 = elective (carried out after 39wks, give corticosteroids for foetal lung maturity if before this)
Complications from C-section?
blood loss >1L, uterine lacerations, blood transfusion, bladder laceration, bowel injury, ureteral injury, hysterectomy, haemorrhage more likely with praevia/abruption; post-op = infections, endometritis, UTI, VTE (have LMWH prophylaxis); long-term = praevia, uterine rupture and accreta risk
Post-op care from C-section?
1-1 support; skin to skin contact; check: pulse, resps, BP and sedation every 30 mins; use MEOWS (modified early obstetric warning score chart); remove catheters after 12 hours epidural; mobilise early; remove wound dressing after 24hours; analgesia; can be discharged after 24hours if well
Tear types from birth?
perineal; labial (common, painful, heal quickly but if both labia then stitch to stop fusion); first-degree (superficial and just skin); second-degree (involve perineal muscle – common repair to episiotomy); third-degree (involve anal sphincter; 3a = less than 50% sphincter, 3b = more than 50%, 3c = anal internal and external); fourth-degree (also mucosa)
Management for 3rd or 4th degree tear?
abx after surgery, lactulose, high fibre diet, pelvic floor exercises and follow-up
Reason for episiotomy?
to prevent 3rd degree and over tears and make larger opening (instrumental, distressed baby)
How to do episiotomy?
vaginal epithelium, perineal skin, bulbocavernous muscle, superficial and deep transverse perineal muscles; use lidocaine; repair go deep from mucosa stitched first, then muscle, then skin
What is involved in the puerperium?
• 6 weeks after delivery; uterus involutes form 1kg to 100g; afterpains as uterus contracts; cervix firm over 3 days; internal os closes over 3 days and external over 6; lochia (sloughed endometrium, red cells etc) passed is (rubra – blood cervical discharge, foetal membrane, vernix, meconium) then yellow to day 10 (serosa – cervical mucous, exudate, foetal membrane, micro-organisms, WBCs) then white to 6 weeks (alba – cholesterol, epithelial cells, fat, micro-organisms, mucous, leucocytes); breasts make milky white and colostrum from last trimester then tender and engorge 3-4 days after birth
Problems in first few days of the puerperium?
thromboprophylaxis?, anti-D?, check temp, bp, breasts, legs, lochia (if red then could be endometritis), fundal height, pelvic floor exercises, vaccinate against rubella, HT may need drugs, check Hb, contraception
What is puerperal pyrexia?
temp over 38 in first 2wks; examine fully; culture MSU, high vaginal swabs, blood, sputum; 90% urinary genital tract
S+Ss for endometritis?
lower abdo pain, offensive lochia, tender uterus, urgent abx (also for breast infection to stop abscess)
What is puerperal psychosis?
different to mild depression; high suicidal drive, severe depression, mania, schizophrenic behaviour with delusions; exclude infection causing delirium; will see by 3 months; sudden onset and rapid deteriorate; some mothers may also develop postnatal depression; refer to specialist psych ward
What are the baby blues?
due to sudden hormonal and chemical changes in body and may seem like postnatal depression
The S+Ss baby blues?
feeling emotional, irritable, low mood, restless; not as severe as postnatal depression (lose interest in baby and withdraw etc)
6-week postnatal exam consistents?
see how mother related to baby; bp and weight; FBC if anaemic; cervical smear; contraception plans; ask about depression, incontinence, backache; intercourse? (gentle recommended so no air embolism); sexual problems common; dyspareunia complaints
What is lactational amenorrhoea?
breastfeeding delays ovulation (contraception); does this by decreasing freq and amount of gonadtrophin surges; lasts 6 months; contraceptive decrease if: breastfeeding decreases, periods start, night feeding stops, separation from baby, ill baby, baby gets supplements; when this happens give contraception
Regulatory advice for starting progesterone only pill postpartum?
– can start at any time and no effect on baby; some can leak into breast milk; precautions if started after 21 days
Regulatory advice for starting combined pill postpartum?
start at 3 weeks if not breastfeeding; not recommended if breastfeeding til 6 months and affect early milk production
Regulatory advice for starting depo postpartum?
not recommended in those breastfeeding as can cause problems with liver and sex steroids
Regulatory advice for starting progesterone implant postpartum?
not recommended until 6wks in those breastfeeding; 21-28 wks in those breastfeeding
Regulatory advice for starting IUD postpartum?
either within 48hrs or after 4wks to minimise uterine perforation
Regulatory advice for starting sterilisation postpartum?
wait significant amount of time as need time to process if want it and more likely to fail
Causes of uterine rupture?
usually due to dehiscence (wound reopens) of CS scars
RFs of uterine rupture?
obstructed labour in multiparous, previous surgery, high forceps delivery, internal version, breech extraction
Vaginal birth after C-section problems?
successful in 3/4s; less risk of neonatal resp problems; more risk of: endometritis, blood transfusion, uterine rupture, perinatal death; use CTG in labour
S+Ss of uterine rupture?
usually in labour; pain variable; vaginal bleeding variable; unexplained maternal tachycardia, sudden maternal shock, cessation of contractions, disappearance of presenting part, foetal distress; postpartum = PPH if uterus well-contracted, bleeding continuing after vaginal repair, shock
Management of uterine rupture?
suspected = category 1 CS; O2 at 15L/min; IVI; crossmatch blood; repair if rupture small; may need hysterectomy; post-op abx cover
What is Mendelson’s syndrome?
cyanosis, bronchospasm, pulmonary oedema, tachycardia when inhale gastric acid in general anaesthesia
Prevention of Mendelson’s syndrome?
preop H2 antagonists, sodium citrate, gastric emptying, cricoid pressure, endotracheal tubes, pre-extubation of stomach
Management of Mendelson’s syndrome?
tilt pt head down; aspirate pharynx; aminophylline and hydrocortisone; aspirate bronchial tree; abx prevent pneumonia; ventilation
Predisposing factors for multiple births?
FH, older mother, induced ovulation, IVF (more likely to also have: older mother, genetic defects, low birthweight, prematurity and vasa praevia), Nigerian
Definition of monochorionic and monoamniotic twins?
- Monochorionic – share placenta
* Monoamniotic – share amniotic sac
Features of multiple pregnancies?
uterus large for gestational dates, hyperemesis, polyhydramnios, >2 poles felt, multiple foetal parts, 2 foetal hearts detected, US confirms, 11-13wks confirms mono/dichorionic
Complications from multiple pregnancies?
polyhydramnios, pre-eclampsia, anaemia, APH, abruption, placental praevia, GDM, PPH, malpresentation, vasa praevia rupture, cord prolapse and entanglement
Foetal complications from multiple pregnancies?
higher mortality, prematurity (37 wks for twins and 33 for triplets), IUGR, malformation, placental vascular anastomoses (one twin donor and other recipient so one gets bigger than other, stopped by laser coagulation in utero)
Management of multiple pregnancies?
US at 11-13 wks (viability, chorionicity, malformations, NT), consultant led; educate about preterm labour and more antenatal visits; more support and offer elective birth; selective reduction at 12wks from triplet to twins; identify risk of preterm by cervical length US
Definition of polyhydramnios and oligohydramnios?
- Polyhydramnios – too much amniotic fluid; S+Ss = SOB, heartburn, constipation, swollen ankles; over 8cm in single deepest pocket
- Oligohydramnios – too little amniotic fluid; IUGR and increased perinatal mortality risks; less than 500ml at 32-36wks; under 2cm in single deepest pocket
Definition of stillbirth?
- Born dead after 24 weeks; mother may feel guilty, labour seem futile, sad
- Macerated = skin has peeled in utero and looks different to fresh stillbirth
Causes of stillbirth?
unknown, placental, ante-intrapartum haemorrhage, congenital abnormality, maternal disease, IUGR, mechanical; multiple, smoking, socioeconomic, higher age, IVF, obesity
Diagnosis of stillbirth?
absent foetal movements; no foetal HS on US; offer to call companion if alone; repeat US if mother requests
Management of stillbirths?
Rh-ve give anti-D; Kleihauer to see if fetomaternal haemorrhage; check temp, BP, proteinuria, blood clotting screen; advise delivery if complications (pre-eclampsia); allow home to reflect; check coagulopathy 2x weekly if not induced in 48hrs; use mifepristone oral to induce and prostaglandin vaginally; offer comfort and locks of hair and photos if she wants them; funeral etc; discuss future pregnancy at follow-up and cause if known; bereavement counsellor assigned; screen for depression
Tests for stillbirth antenatally?
maternal = Kleihauer, FBC, CRP, LFT, HbA1c, cultures, viral screen (TORCH), thrombophilia, abs, MSU; foetal = swabs and placental, lithium heparin tube for cord blood infection, examine, post-mortem discussed with parents (if refused MRI, cytogenetics, tissue samples)
Management for giving anti-D immunoglobulin?
• Give 250u before 20 wks and 500u after; at 20 wks do Kleihauer test to check if feto-maternal haemorrhage; don’t give anti-D if know they are sensitised to them (abs present); if Rh-ve woman then give abs unless child is Rh-ve too; given in deltoid and also if big bleed
Mean age of menopause?
51
Causes of premature menopause?
surgery, infections, AI, chemo, ovarian dysgenesis, metabolic diseases
Perimenopause S+Ss?
vasomotor symptoms and menstrual irregularity (hot flushes, mood swings, urogenital atrophy [dyspareunia, recurrent UTIs, PMB], joint and muscle pain, low libido, irritable, low mood, loss of memory and conc, headaches, lethargy, loss of confidence); ends 12 months after last period
What to exclude from PMB over 12 months?
exclude cancer of endometrium and cervix
Non-malignant causes of PMB?
poorly oestrogenised vag wall, diverticular abscess
Investigations of PMB?
bimanual and speculum, cervical smear, transvaginal sonography (thick endometrium and fluid filled cavity = malignancy risk, hysteroscopy if >4mm, single bleeding episode)
Symptoms and consequences of menopause?
mainly hot flushes and night sweats, vaginal atrophy, urinary problems (both from low oestrogen), dyspareunia/painful sex, itching, burning and dryness, loss of interest in sex and arousal from it; lower bone density and quality leading to fx (Colle’s, hip and spine), CVD risk, dementia increase, risks = parental hx, early menopause, use of corticosteroids, immobile, previous fx
Investigations of menopause?
FSH levels for ovarian reserve (higher = less eggs), vary daily in perimenopause so check in days 2-5; also antimullerian hormone; TFTs for HRT response; low progesterone = inovulation; DEXA
Treatment for menopause S+Ss?
diet, exercise, HRT = oestrogen (oestradiol, oestrone, oestriol) for peeps with hysterectomy or progesterone (levonorgestrel and norethisterone) if not; topical on vag; tibolone = post-menopause for wanting amenorrhoea and vasomotor, psych and libido problems; testosterone for libido; progestogens with oestrogens so no endometrial hyperplasia (this is useful for perimenopause with menorrhagia or need contraception); oestrogen for hot flushes or progestogens, clonidine and SSRIs; HRT lowers risk spine, hip fx, colorectal cancer, increases risk breast cancer (oestrogen and progesterone), VTE, gallbladder disease, stroke, CVD; use for 5 yrs and evaluate and should use until median age of menopause; aim for lowest effective dose; try to avoid transdermal as worse risks (uses: gastric upset, migraine, epilepsy, high VTE risk)
Non-hormonal treatment for menopause?
alpha adrenergic receptor antagonist (clonidine), SSRI/SNRI, anti-epileptics (gabapentin), vit D, lubricants for vaginal dryness
Length of fertility post-menopause?
2 years if menopause <50, 1 year if menopause >50yrs
Inevitable miscarriage indication?
If can get finger in os
What is a threatened miscarriage?
uterus bleeding but foetus still alive
How to diagnose delayed miscarriage?
US
Common ectopics and how to treat?
– fallopian tube the most common, then ampullary; consider when empty uterus but positive pregnancy test; usually static or slowly rising BcHG levels; can do salpingotomy (open up fallopian tube) to remove embryo; can treat with methotrexate if healthy woman
At risk during antenatal care?
Ht, diabetes, epilepsy, RA, asthma, ITP, gastro, any disease, complications in current pregnancy, complications in previous pregnancy (3rd or 4th degree tear etc), issues with woman (high/low BMI, smoking, alcohol, drugs, old/young)
What is US used for foetal monitoring?
growth (head circ, abdo, full length and estimated weight), liquor volume (fluid around baby from urine), umbilical artery dopplers (look for placental insufficiency)
What is antenatal foetal monitoring?
takes into acc symphysis fundal height, BMI, estimated foetal weight (form US) and plots this on graph to see what centile the woman is in
What is intermittent ascultation?
doppler US after each contraction in low risk women; every 15 mins in 1st stage and 5 mins in 2nd; can use a pinard stethoscope
What is APGAR?
5 things to check a baby’s health 1-5min of birth (appearance [body pink = 2], pulse [100bpm = 2], grimace [grimace/cough/cry = 2], activity [active motion = 2] and respiration [good cries = 2]); scored 0-2 for each
What is continuous cardiotocography and it’s indications?
if risk of foetal compromise in labour; sensitive other than finding foetal hypoxia; either foetal scalp electrode (screw in direct contact with the foetus and much more accurate but need to rupture membranes; gold standard but rarely used) or abdo probe; indications = post-maturity, induction of labour, maternal cardiac problems, pre-eclampsia, prolonged ROM, dematurity, diabetes, haemorrhage, oligohydramnios, small, multiple, pyrexia etc
What should be the baseline rate in CTG?
average foetal HR (100-160 = normal),
What is the variability in CTG?
bandwidth of the baseline (>5 = normal)
What are accelerations and how to correct them in CTG?
upward spikes >15bpm for >15 secs (deceleration = opposite); how to correct = get weight off maternal vessels if lying supine, IV fluids if hypotensive, reduce oxytocin if too many contractions/bradycardia
what to do if there is an abnormal trace in CTG?
use foetal blood sampling from scalp and analyse in blood gas machine, woman should be dilated 4cm and ROM, don’t do if suspected blood viruses, if it fails deliver asap; also looks at frequency of contractions
What is DR C BRAVADO in CTG?
– define risk; contractions (bottom trace), baseline rate, variability (how squiggly bottom line is), accelerations, decelerations (timing based off when contraction occurs; early = usually head compression which is fine; variable = vary in shape and time and often cord compression; late = concerning as could be hypoxia), overall assessment
What is a spontaneous miscarriage?
dies or delivers dead before 24wks; high rate when older mother
What is an inevitable miscarriage?
bleeding heavier and os open
What is an incomplete miscarriage?
some foetal parts passed and os open
What is a complete miscarriage?
= bleeding stopped, uterus not enlarged and os closed
What is a septic miscarriage?
uterus contents infected so endometritis (abdo pain and peritonism)
What is a missed miscarriage?
foetus not developed but not known until bleeding happens (how much, haemodynamically shock?, pain/bleeding worse than period, uterine size correct, what’s cause?)
Investigations for miscarriage?
US for >66% HCG with viable intrauterine pregnancy
Treatment for miscarriage?
IM ergometrine for bleeding, anti-D for rhesus -ve treated surgically, for non-viable use prostaglandin with oral mifepristone; surgery = ERCP with vacuum aspiration
What is rhesus disease of the newborn?
haemolysis occurring; RBCs from rhesus positive foetus cross placenta in pregnancy and delivery to rhesus negative maternal blood circ; stimulate maternal abs
Cause of rhesus disease of the newborn?
small foetal-maternal haemorrhage unrecognised; can get foetal anaemia in subsequent pregnancies as the abs go back into foetal circulation via placenta and haemolyse their Hb; excess bilirubin processed by placenta until birth and then stops so can cause jaundice at birth (high levels = brain damage);
Complications of rhesus disease of the newborn?
hydrops fetalis and polyhydramnios in severe cases
Treatment for rhesus disease of the newborn?
O-ve blood transfusion, anti-d prophylaxis and ABO and RhD blood typing done
What is recurrent miscarriage?
> 3 in a row
Causes of recurrent miscarriage?
antiphospholipid abs, chromosome defects, cervical incompetence, uterine abnormalities, obesity, smoking, PCOS, excess caffeine, older, infection (bacterial vaginosis);
Treatment for recurrent miscarriage?
thrombosis in uteroplacental with aspirin and low dose LMW heparin, few treatments, refer to specialist
Legislation for abortion?
legal limit (abortion act and human fertilisation and embryology act) 24wks but past this if grave risk of life to woman, severe foetal abnormality, injury risk; 2 doctors must sign
Before abortion management?
counselling, support, consent, abx prophylaxis; tests = hb, blood groups, rhesus, haemogoblinopathies, chlamydia
How is abortion carried out?
suction curettage 7-13wks; above 13 wks = dilation and evacuation, abx; <7wks = mifepristone with prostaglandin
Complications from abortion?
haemorrhage, infection, uterine perforation, cervical trauma, failure
Post-abortion care?
anti-D?, contraception, info on symptoms, refer if emotional/MH risk
Risk for ectopic pregnancy?
older, lower socioeconomic, PID, previous ectopic, smoking, assisted conception, surgery, endometriosis, IUCD; mainly fallopians but also cervix, cornu, ovary, abdo; can rupture if thin-walled when trophoblastic invasion
S+Ss for ectopic pregnancy?
abdo/vag bleeding, pain (colicky to constant), collapse, shoulder pain, intraperitoneal blood loss, pain of pelvis/uterus, closed os, amenorrhoea, diarrhoea, dizziness, collapse, normal sized uterus, peritonism
Investigations for ectopic?
US not useful, serum hCG (slow rising levels), FBC, group and save, serum progesterone
Treatment for ectopic?
blood cross matched, anti-D if needed, salpingectomy to remove tube or salpingostomy to take ectopic out of tube, methotrexate if no rupture and <3000IU/ml hCG; SEs = conjunctivitis, stomatitis, diarrhoea, abdo pain
What is hyperemesis gravidarum?
severe N+V so severe dehydration, weight loss or electrolyte disturbance; more common in multiparous, won’t past 14wks
Treatment for hyperemesis?
IV rehydration until can have oral then small regular meals, 1st line metoclopramide and cyclizine, if these fail ondansetron, sometimes steroids and psych
Different types of gestational trophoblastic disease?
= premalignant hydatidiform mole, malignant conditions of choriocarcinoma, rare is placental site trophoblastic tumour (slow growing and after chemo is excised); sperm fertilises an empty ovum and proliferates without maternal DNA (there is mtDNA present) and aggressive proliferation of chorionic villi, hCG secreted; localised non-invasive = hydatidiform mole, complete is sperm fertilises empty oocyte (diploid), partial is 2 sperms into 1 oocyte (triploid or more – less malignant); only malignant if in uterus or metastasis
S+Ss gestational trophoblastic disease?
heavy, frequent vag bleeding, severe vomiting, early pregnancy failure, severe morning sickness; use US for snowstorm appearance and histology
Risks for gestational trophoblastic disease?
older, Asian and previous mole
Complications from gestational trophoblastic disease?
= can get huge theca-lutein cysts that can rupture and tort, hyperthyroidism
Removal for gestational trophoblastic disease?
suction curettage of molar tissue; lower risk = methotrexate and folic acid, higher risk = combination chemo, avoid pregnancy and give anti-D if Rh-ve
S+Ss choriocarcinoma?
years after pregnancy can be, malaise, uterine bleeding, mets, nodules on CXR, pulmonary artery obstruction from emboli causing PAH
Treatment for choriocarcinoma?
combo chemo and specialist team, good outcome if no mets
Predisposition for HT in pregnancy?
primigravidity, young female, blacks, multifetal, hypertension, renal disease, collagen vascular disease
Diagnosis for pre-eclampsia?
rise in bp (140/90 or higher) and proteinuria (0.3g/24hour or more or 2+ on urine dipstick; oliguria, 5+ proteinuria, impaired LFTs, thrombocytopenia, oedema all can mean severe), don’t necessarily need oedema; superimposed if new onset proteinuria after 20wks but already have HT; mild/moderate if without severe HT; early <34wks
Pathophysiology of pre-eclampsia?
the spiral artery to the endometrium/arcuate artery does not become dilated and low resistance so ischaemia, vasoconstriction, damage, less renal perfusion so increase in bp
Complications from pre-eclampsia?
maternal = death, CVA, elevated LFTs and low platelet count (HELLP), DIC, liver failure, renal failure, pulmonary oedema; child = IUGR, preterm, oligohydramnios, intrauterine foetal death
S+Ss pre-eclampsia?
(usually only seen in severe) = visual, migraine, epigastric pain, maybe oedema and weight gain; physical = RUQ tenderness, retinal vasospasm/oedema, brisk reflexes, ankle clonus
Tests for pre-eclampsia?
FBC (platelets/Hb), serum uric acid, LFTs, protein, dipstick; not much antepartum management other than little activity
Treatment and cure for pre-eclampsia?
; cure = delivery but can harm the baby if premature; treatment = control bp and monitor 4 hourly (aspirin; severe = hydralazine and labetalol but avoid in asthma and CHF, oral nifedipine used with care), fluid balance, monitor foetus, anticonvulsants to prevent eclampsia (parenteral magnesium sulfate), deliver if >34wks if severe; delivery = vaginal preferable, epidural, spinal are advantageous, use hydralazine/labetalol to reduce HT
What is gestational HT and how to diagnose?
new HT 20wks after gestation; little/no proteinuria; ¼ develop pre-eclampsia; over 140/90 (increase each by 10mm/Hg each time for severity); check urine for proteinuria and give labetalol checking bp and urine 2x weekly; similar advice to chronic HT
What is eclampsia?
have pre-eclampsia with generalised tonic-clonic seizures
Treatment for eclampsia?
use magnesium sulfate to prevent and treat and DR ABC (use calcium gluconate if toxicity); repeated seizures use diazepam; catheterise; monitor with CTG
Risks from chronic HT and pregnant?
before 20wk, increased risk of IUGR, pre-eclampsia, placental abruption (placenta comes away from walls of uterus before birth meaning O2 and nutrient deprivation); change ACEI, A2A blockers and thiazides to labetalol/methyldopa preconception
Antenatal management of chronic HT?
aim for bp <150/90, 75mg aspirin until birth, foetal US every 4wks from 28wks, arrange cardiotocography if abnormal (CTG – measures foetal heartbeat and uterine contractions)
Intrapartum management of chronic HT?
monitor bp hourly, if severe and not controlled operative delivery and oxytocin only at 3rd labour stage
Postnatal management of chronic HT?
change methyldopa to other antihypertensive as risk post-natal depression, check bp for few days after, avoid diuretics if breastfeeding
What is HELLP?
haemolysis, elevated liver enzymes, low platelets
S+Ss of HELLP?
RUQ pain, N+V, dark urine; treat same as eclampsia
Definition of prematurity?
before 37wks, 259 days from LMP; low birth weight below 2500gm, very low 1500 and extremely low 1000
Risks from prematurity?
largest cause of perinatal death of normal foetuses, developmental delay, visual impairment, other diseases; improvements from: steroids, artificial surfactant, ventilation, nutrition, abx
Reasons for prematurity?
spontaneous (cervical weakness, amnionitis, premature ROM) sometimes induced from medical disorders; multiple births and polyhydramnios increasing the stretch, any problems (abruption, infection, pre-eclampsia etc), uterine abnormalities, malignancy, UTIs
RFs for prematurity?
antepartum haemorrhage/vaginal bleeding, multiple babies, recurrent (race, previous preterm, genital infection [UTI, pyelonephritis, appendicitis], cervical weakness, socioeconomics), smoking, funnel present at cervix found on US
Prevention of prematurity?
primary (stop smoking, prevent multiple, planned pregnancy), secondary (screening high risk), tertiary (quick dx, tocolysis (anti-contraction medication) and abx, corticosteroids)
Diagnosis of prematurity?
persistent uterine activity, change in cervical dilatation and/or effacement; foetal fibronectin = protein found in choriodecidual interface, abnormal finding after 20wks, if found early could mean high chance of labour in 2wks but high false +ve rate
Treatment of prematurity?
progesterone, cervical cerclage (stitch put in cervix to make opening smaller), manage RFs; management = assess symptoms, vaginal swabs and speculum (infections), gestational duration, cervical examination and US if less than 3cm dilated; find best delivery method; glucocorticoids for helping foetal surfactant production (betamethasone); magnesium sulfate (neuroprotective effect and help prevent cerebral palsy)
Management of baby before 28wks delivery?
26degree temp, heat, food wrap bag and not dry; if older in towels, use cord delay clamping (3mins) to give more O2 and nutrients
How to manage preterm labour?
treat cause; give corticosteroids; nifedipine only drug to show foetal benefit not tocolytics; check breech presentation, rule out PROM, foetal fibronectin and IV abx to stop infection
Contraindications for tocolytics and which is best?
Cis = heart conditions, chorioamnionitis, foetal death, lethal abnormality condition needing immediate delivery or any other reason for allowing preterm birth; nifedipine is best for woman and less likely to affect foetus (resp depression)
SEs of tocolytics?
low bp, headache, flushing, high pulse and risk of MI
Management or PROM?
rule out chorioamnionitis (expedite delivery if this is it) and sepsis; take temp, MSU and HVS (high vaginal swab); management = corticosteroids and erythromycin for foetal lung maturity; rupture usually starts labour but if not then monitor and don’t allow intercourse, swimming, tampons to prevent infection; if infection takes hold then IV abx and expedite
Complications of PROM?
infection, preterm, pulmonary hypoplasia and limb contractures
How to judge risk of small for gestational age (SGA)?
chart using SFH and maternal age, parity, BMI, ethnicity, birthweights of previous children; doppler at 20-24wks if risk high
RFs for SGA?
maternal age >40yrs; smoker; drugs; previous SGA; diabetes; hypertension; renal impairment; antepartum bleeding; pre-eclampsia; placental factors = abnormal trophoblast invasion (pre-eclampsia, infarction, abruption); foetal = genetic and congenital abnormalities, infections and multiple
Complications from SGA?
intrapartum foetal distress, meconium aspiration, emergency C-section
Definition of SGA?
estimated foetal weight or abdo circ <10th centile for gestational age
Management of SGA?
umbilical artery dopplers good then growth scans 2-3wks and if normal aim for IOL 37wks; if abnormal consider C-section; warm welcome for baby, feed within 2hrs birth
Longterm risks for SGA?
hypertension, coronary artery disease, T2DM, autoimmune thyroid disease
Definition and risks from large for gestational age?
above 95 centile; obesity major cause; risk of shoulder dystocia, hypoglycaemia, hypocalcaemia, left colon disease (similar to Hirschsprung’s and gives temporary bowel obstruction)
What is postmaturity?
• >42wks pregnancy
Complications from post-maturity?
intrapartum death, early neonate death, placental insufficiency, induction of labour, macrosomia, shoulder dystocia, foetal injury, less mouldable skull (more ossified), more meconium passage, C-section
Management of post-maturity?
membrane sweep (get as much from vaginal exam when finger in cervix to stimulate natural prostaglandins and can stimulate natural labour), offer induction after 41wks but if refused monitor CTG 2x weekly
Management of maternal collapse?
• DR ABC immediately (CPR in left lateral position); prioritise mother
Investigations of maternal collapse?
FBC, U+Es, LFTs, coagulation, uric acid, group and save, ABG, CXR, ECG etc
Causes of maternal collapse?
- Obs causes – massive haemorrhage, eclampsia, intracranial haemorrhage, amniotic fluid embolism, uterine inversion causing neurogenic shock, severe sepsis, peripartum cardiomyopathy
- Others – massive PE, pre-exisiting cardiac, anaphylaxis, stroke, meningitis, OD, DKA, malaria (abroad)
Antepartum haemorrhage (APH) causes?
- Ask about domestic violence (can harm foetus and mother)
- Causes – DANGEOUS = abruption, placenta praevia, vasa praevia (foetus can bleed out), UTERINE = circumvallate placenta, placental sinuses, LOWER GI = cervical polyps, erosions, carcinoma, cervicitis, vaginitis, vulval varicosities
What is placental abruption?
part of placenta detaches from uterus; depends on detachment and blood loss
Risks for abruption?
pre-eclampsia, smoking, IUGR, PROM, multiple etc; can cause placental insufficiency (foetal anoxia/death), blood constriction reduces contraction force, PPH
S+Ss of abruption?
backache, abdo tenderness, uterine hypercontractility, DIC, renal failure, Sheehans, foetal heart abnormal, coagulation problems, pain, shock more than blood loss appears, tense uterus
What is placental praevia?
placenta attaches in lower part of uterus that can cover cervix
S+Ss of praevia?
no pain, shock in proportion to blood loss, uterus non-tender, small bleeds then large, abnormal lie, foetal heart normal, coagulation usually normal
APH management?
IV infusion, bloods (clotting) and raise legs if severe; O2; catheterise; C-section for praevia and beware PPH; milder = IV, crossmatch, coagulation, U+Es, pulse, BP, blood loss check
PROM definition?
• 37wks + rupture before labour
Causes of PROM?
mostly unknown, lower GI infection, polyhydramnios, multiple, malpresentation
PROM complications?
serious infection, chorioamnionitis, endometritis
Management of PROM?
conservative if up to 24hrs: liquor clear, mother well, foetus well; take temp reg and avoid sex; report abnormal changes to labour ward
When to induce labour?
not spontaneous within 24hours; • Usually for hypertension, pre-eclampsia, prolonged pregnancy or rhesus disease
How to induce labour?
use vaginal prostaglandin for 6 hours then oxytocin if no contractions; only use IV abx if infection found (HVS, MSU and cultures); monitor foetal heart if this declined
When to immediately induce labour after ROM?
= group B strep carriers, HIV for vaginal delivery, chorioamnionitis, foetal movement concerns, herpes simplex, meconium-stained liquor
What to monitor in newborn immediately?
every hour up to 10; well-being, chest, nasal flare, cap refill, feeding, muscle tone, temp, resps, HR; monitor for sepsis
Why do skin to skin technique after birth?
wrap baby to mum to: keep warm, stabilise HR and reduce stress
Contraindications for induction of labour?
malpresentations, foetal distress, placental praevia, cord presentation, vasa previa, pelvic tumour
What is primip?
first pregnancy
What results got from cervical assessment?
cervical dilatation, length of cervix, station of head, cervical consistency, position of cervix; higher score = more favourable (>5 at least)
Causes of breech presentation?
idiopathic, uterine abnormalities, premature, placenta praevia, oligohydramnios, foetal abnormalities
Commonest types of breech?
extended (flexed at hips but extended at knees), flexed (hips and knees flexed so presenting is buttocks and genitals), footling (greatest risk of cord prolapse)
Diagnosis of breech?
usually during labour; pain under ribs, no head felt in pelvis and balloted at fundus; by US
How to do an external cephalic version?
manoeuvring breech into forward somersault but only do this if planned vaginal delivery after 36-37wks
Contraindications of external cephalic version?
placenta praevia, multiple, APH, ROM, IUGR, abnormal CTG, foetal abnormality, scarring uterine, pre-eclampsia/hypertension
Best way to deliver breeched baby?
LSCS
How to deal with a vaginal delivery breech?
try not to interfere til scapula present and keep spine anterior if you can; Mauriceau-Smellie-Veit manoeuvre to get out head or use forceps
What is occipitoposterior position breech?
mother has long anthropoid pelvis (50%) which is felt by palpation; labour prolonged because of degree of rotation needed (hydration and analgesia); most have normal vaginal delivery but some require forceps and C-section; feel posterior fontanelles in posterior of pelvis
What is face presentation breech?
from anencephaly, tumour of or shortened foetal neck muscles; head extends rather than flexes at breech; most rotate so chin behind symphysis and born by flexing; if chin rotates to sacrum then C-section; feel eyes and nose in early vaginal exam before oedema
What is brow presentation breech?
diagnosed in early labour; halfway between flexion and extension; if persists then LSCS; feel anterior fontanelle and supraorbital ridges on vaginal exam
What is transverse lie breech?
diagnosis = uterus wider than sides, lower pole empty, head in 1 flank, foetal heart heard various places; only feel ribs/shoulder/hand if ROM; if persists then C-section; risk of cord prolapse
What is cord prolapse?
• Cord through cervix after ROM before presenting part; emergency = cord compression and vasospasm means foetal asphyxia
Causes of cord prolapse?
2nd twin, footling breech, premature, polyhydramnios, unengaged head, transverse lie; carry out C-section
S+Ss cord prolapse?
obvious if happened; vaginal exam; foetal bradycardia or heart decelerations
Management of cord prolapse?
senior help and keep cord in vagina; stop presenting part occluding cord; either deliver by LSCS or instrumental if fully dilated; tocolytics like terbutaline
o Steps – push up presenting part back in vagina during contractions; knee to chest position; 500mL saline into bladder and catheterise; tocolysis to reduce contractions
o Delivery – best to do by ventouse/forceps/breech presentation if under 15mins; take pH and base excess from cord after
What is shoulder dystocia?
need obs manoeuvres to release shoulders in birth when gentle downward traction failed; high rate of foetal mortality and morbidity; risk of PPH, 4th degree perineal tears, brachial plexus injuries
Risks for shoulder dystocia?
large foetus, BMI>30, induction, oxytocin use, prolonged 1st/2nd stage, assisted vaginal delivery, previous hx, DM
Management of shoulder dystocia?
speed to reduce asphyxiation risk (cord squashed); prompt shoulder dystocia drills; help (MDT), episiotomy (space for internal movements), legs (in McRoberts position so that each thigh touches abdomen to straighten sacrum, 90% effective), suprapubic pressure (apply steady rocking/traction to foetal head from mother’s sacrum to let anterior shoulder enter pelvis), enter the pelvis (help with rotating shoulders to oblique diameter; if fails switch posterior shoulder to anterior), roll (mother onto all fours if fails)
o Other manoeuvres – maternal symphysiotomy, push baby back up by head to flexed occipito-anterior position and C-section (Zavanelli – usually severely acidotic baby at this stage); cleidotomy (cut through clavicles if baby dead before birth)
Risks from shoulder dystocia?
Erb’s palsy and fractured clavicles to baby
Causes of meconium-stained liquor?
- Late pregnancy baby can pass some meconium staining amniotic dull green (insignificant); • During labour – fresh meconium passed (dark green, sticky, lumpy); may be a response to stress of normal labour (CTG and consultant-led care)
- PROM with meconium stained – immediate induction and neonate support care
What is a delay in labour?
• Less than 2cm dilatation per 4 hours in 1st stage
How to assess woman with delay in labour?
review notes, examine abdo and contractions, foetal heart monitoring and amniotic colour, vaginal assessment, analgesia/rehydration, previous C-section (have to be careful with oxytocin for scars)
Management of delay in labour?
oxytocin and reassess in 4hours if ROM (offer epidural); consider LSCS if not working
Things to consider with ante/perinatal rash?
non-infectious or infectious; maculopapular = rubella and parvovirus B19; also think of streptococcus, meningococcus, EBV, syphilis
• In general – earlier the infection more likely to affect foetus
S+Ss of measles ante/perinatal?
severe encephalitis and pneumonia in pregnancy; RNA paramyxovirus, droplet, v infectious; infectious 2-5 days before and after rash; S+Ss = fever, generalised maculopapular erythematous rash, Koplik’s spots, cough, coryza, conjunctivitis and corneal scarring
Complications of measles ante/perinatal?
foetal loss and preterm; if rash 6 days before/after birth then give baby human normal globulin to stop neonatal subacute sclerosing panenecephalitis
Rubella S+Ss ante/perinatal?
childhood vaccination; spread by droplet and half asymptomatic; most dangerous to foetus in 1st 12wks; foetus features = cataracts, deafness, cardiac lesions, purpura, jaundice, hepatosplenomegaly, thrombocytopenia, cerebral palsy, microcephaly, foetal death
Rubella treat ante/perinatal?
give TOP if found in 1st trimester
Cytomegalovirus complications ante/perinatal?
more motor and cognitive impairment; impairments = IUGR, microcephaly, hepatosplenomegaly, thrombocytopenia, jaundice
Toxoplasmosis S+Ss peri/antenatal?
similar symptoms to glandular fever; S+Ss = fever, rash, eosinophilia; complications to foetus = similar to above
Treatment and prevention of toxoplasmsosi ante/perinatal?
spiramycin in mothers and pyrimethamine if foetus is infected, prednisolone in baby if infected; prevention = avoid raw meat, cat litter and sheep
Parvovirus S+Ss and complications peri/antenatal?
droplet; S+Ss = slapped cheek rash, maculopapular rash, fever, arthralgia; complications = foetal erythropoiesis and cardiac toxicity (cardiac failure and foetal hydrops);
Treatment parvovirus ante/perinatal?
monitor for anaemia and treat
Intrauterine syphilis S+Ss?
neonate S+Ss = rhinitis, snuffles, rash, hepatosplenomegaly, jaundice, ascites, hydrops, nephrosis, deaf, meningitis
Intrauterine syphilis treatment?
benzylpenicillin
Listeria S+Ss peri/antenatal?
S+Ss = fever, shivering, myalgia, headache, sore throat, vomiting, cough, diarrhoea, vaginitis, miscarriage and stillbirth; infection from milk and soft cheese
Diagnosis listeria ante/perinatal?
bloods, meconium, blood cultures
Treatment listeria ante/perinatal?
ampicillin and gentamicin
Complications listeria ante/perinatal?
leucopenia, rashes, fever, conjunctivitis, fits, resp distress
Complications HBV ante/perinatal?
neonates get chronic infection and hepatocellular cancer risk
Treatment for HBV ante/perinatal?
give immunoglobulin and vaccinate
Herpes simplex complications and treatment ante/perinatal?
complications = blindness, LD, epilepsy, jaundice, resp distress, DIC; if in last trimester give acyclovir/valaciclovir and elective C-section; foetus = conjunctival lesions and pustules on area of trauma from birth
Varicella zoster treatment ante/perinatal?
give baby varicella immune immunoglobulin and deliver baby after 7 days if get near due date; if before then give oral acyclovir; test all women not had chickenpox before
Complications chlamydia peri/antenatal?
low birthweight, premature membrane rupture, death, pneumonitis, pharyngitis, conjunctivitis
Treatment chlamydia ante/perinatal?
cleanse eye and erythromycin and same to mother
Gonoccocal conjunctivitis S+Ss?
lid swelling, purulent discharge, corneal rupture
Treatment gonococcal conjunctivitis ante/perinatal?
cefotaxime, chloramphenicol eye drops
Causes group B strep peri/antenatal?
pneumonia, meningitis and septicaemia in newborn
Treatment group B strep peri/antenatal?
in labour give abx = high GBS vaginal swab, previous GBS baby, gestation <37wks, any fever; treat = benzylpenicillin and clindamycin if allergic
Jaundice treatment peri/antenatal?
give phototherapy as can break up the bilirubin (baby cannot do this themselves)
Sepsis antenatal complications?
- Big cause of maternal death and mainly strep A; better survival if found early
- Sepsis – infection plus systemic infection manifestations; severe = sepsis with organ dysfunction or tissue ischaemia; shock = persistent tissue ischaemia with fluids
Sepsis antenatal RFs?
obesity, diabetes, immunosuppressed, anaemia, vaginal discharge, invasive procedures, cervical cerclage, ethnicity, prolonged ROM
S+Ss sepsis antenatal?
fever, rigors, diarrhoea, vomiting, rash (maculopapular), abdo/pelvic pain, offensive vaginal discharge, cough, urinary symptoms
Diagnosis sepsis antenatal?
> 38degrees or <36; tachypnoea, systolic hypotension, confusion, significant oedema, hyperglycaemia, raised WCC, raised lactate
• SEPSIS 6
Treatment sepsis antenatal?
Iv broad spectrum abx; fluids; vasopressors to combat hypotension; oxygen; immunoglobulin against strep; can mean preterm labour so notify neonatal; avoid epidural/spinal anaesthesia, pyrexia means foetus degree hotter and tachycardia
Sepsis features in puerperium?
period 6wks after birth where mother returns to prepregnant state; if sepsis here then investigate and genital tract, uterus leading to endometritis may be or mastitis and breast abscess; features = fever, rigors, diarrhoea, breast engorgement, abdo pain, offensive vaginal discharge, cough, urinary symptoms, lethargy, reduced appetite
Abruption S+Ss?
triad of abdo pain, uterine rigidity and vaginal bleeding; painful bleeding (dark blood), shock in proportion to blood loss, uterus tender and contracting (filled with blood so woody uterus)
Abdo pain in uterine rupture, fibroids and torsion?
uterus rotates >90degrees, abdo pain, shock, tense uterus and urinary retention
Causes of abdo pain in pregnancy?
Abruption, uterine rupture, fibroids, torsion, appendicitis, cholecystitis (commoner as biliary stasis and more cholesterol; subcostal pain, nausea, vomiting; only surgery in complicated), pancreatitis, UTI, gastroenteritis (common and can be severe; manage at home if can; rehydration and rest)
Complications in pregnancy from BMI>30?
gestational hypertension, pre-eclampsia, GDM, VTE, miscarriage, stillbirth and others
Management of obesity in pregnancy?
5mg folic acid 1month before conception and first trimester; give vit D, glucose tolerance test, mobilise; if over 40 then heparin and TED stockings
When to assess for VTE in pregnancy?
• Every woman should have VTE risk assessment at booking; avoid immobility and dehydration
RFs for VTE from pregnancy?
venous stasis, trauma to pelvic veins at delivery, procoagulant changes (high fibrinogen and factors 10 and 9, less anticoagulation) and these changes from 1st trimester til 6wks postpartum
Prevention of VTE in pregnancy?
LMWH drug of choice and given until 6wks postpartum and depends on bodyweight
Those at high risk of VTE?
hx of VTE, antithrombin 3 deficiency
Intermediate risk of VTE?
thrombophilia, medical comorbidities (cancer, inflammatory, resp), over 35yrs, obesity, parity 3+, smoker, varicose, current infection, pre-eclampsia, immobility, dehydration, multiple, assisted reproduction
What is thrombophilia?
tendency to increased clotting
Causes of thrombophilia?
factor 5 leiden, protein c deficiency, protein s deficiency, antithrombin 3 deficiency, acquired thrombophilia; screen women who’ve had previous VTE or FH
DVT S+Ss?
leg swelling, pain, redness, tenderness, pyrexia, erythema, oedema, WBC can be raised
PE S+Ss?
SOB, chest pain, haemoptysis, collapsed, raised JVP, DVT S+Ss, raised resp, hypoxic, severe = low resp and cardiac arrest
Investigations for VTE in pregnancy?
FBC, U+Es, LFTs, clotting screen, ABG, ECG, CXR, compression/duplex US and -ve = LMWH and do V/Q scan, D-dimers less effective but if low not likely to be VTE
Treatment of VTE in pregnancy?
massive PE in pregnancy use thrombolysis or percutaneous catheter thrombus fragmentation, embolectomy only can be done in certain specialist areas, LMWH (enoxaparin/dalteparin BD) safer but may have to use unfractionated heparin afterwards, continue this 6months and then 6wks postpartum or switch to warfarin; if in labour LMWH stopped (avoid anaesthesia til 12 hours after last dose), may have to use unfractionated heparin if high risk
What is involved in hysterescopy?
cutting diathermy, glycine irrigation
When to do laparoscopy in gynae?
macroscopic pelvic disease, dysmenorrhoea, infertility, ectopics assessments or to sterilise, remove adhesions or remove ectopics
Indications for hysterectomy and what it involves?
– for menstrual disorders, fibroids, endometriosis, chronic PID, prolapse, pelvic malignancy; involves removing uterus and cervix in total but keep cervix in subtotal; vaginal for prolapse; radical for 1a-2a cervical carcinoma (parametrium, upper third vagina, pelvic lymph nodes)
S+Ss ovarian torsion?
sudden onset unilateral lower abdo pain from exercise and also N+V/adnexal mass
S+Ss ovarian cyst?
unilateral dull ache and worse on sex
Advice for attempting conception?
BMI 20-25, folic acid, sex 2-3x per week, quit smoking/drinking
What is Mittelschmerz?
pain halfway through ovulation cycle
What is Asherman’s syndrome?
adhesions/fibrosis of endometrium, associated with dilation and curettage of uterus
What is Sheehan’s syndrome?
hypopituitarism from ischaemic necrosis from blood loss/hypovolaemia in or after childbirth
What is Meig’s syndrome?
ascites, pleural effusion, ovarian fibroma
What is a dermoid cyst and complications?
onset at 30, asymptomatic and bilateral; mucinous cystadenoma can mean pseudomyxoma peritonei if rupture
FGM definition?
any procedure that partially or fully removes or injures female external genitalia, interferes with natural function of women’s bodies
The 4 types of FGM?
- Type 1 – partial/total removal of clitoris (clitoridectimy)
- Type 2 – partial/total removal of clitoris and labia minora (excision)
- Type 3 – narrowing of vaginal orifice by cutting and positioning labia minora and/or majora with/without clitoris excision (infibulation)
- Type 4 – other if not medical or cosmetic (pricking, piercing [if under 18yrs], incision, scraping, cauterising)
Reasons for FGM?
status and respect, keeps chastity, upholds family honour, tradition rather than religion, social acceptance and belonging to community; mainly in African (central and eastern countries), Middle East and South-East Asian countries
UK legislation around FGM?
illegal to perform and assist FGM and take child overseas to do this; recording mandatory requirement (if found in a pt, reported to safeguarding only if over 18yrs and must report to police if under 18 the next day)
Gynae problems resulting from FGM?
dyspareunia, sexual dysfunction (anorgasmia or androgen insensitivity syndrome [genetically male but genitals may be female or somewhere between, doesn’t respond to testosterone efficiently]), chronic pain, keloid scar formation, dysmenorrhoea, urinary outflow obstruction, PTSD, difficulty conceiving, blood loss, sepsis, tetanus, hepatitis, HIV
Obs problems resulting from FGM?
childbirth fear, C-section needed, PPH risk, episiotomy needed, vaginal lacerations and vaginal fistula, long hosp stay, difficulty performing vaginal exams, difficulty for FSE, difficulty for foetal blood sampling, difficulty catheterising
Treatment of FGM?
• Reversal of infibulation – ideally preconception; use a small dilator and cut fused labia with diathermy then suture edges; may need episiotomy if have to reverse infibulate during labour (wait until crowning to do this procedure); can offer epidural
Frequency of contractions in established labour?
4 every 10-15 mins
Which breech presentation is ok for vaginal delivery?
Extended breech
What are the 3 Ps that must be correct for labour to work?
need power of contractions, passenger to be right size and passage to be large enough
What is syntocinon?
IV infusion of oxytocin
What is the meconium?
• Meconium is the newborn’s first poo made of bile, cells etc (better to poo outside uterus than in)
Things to look for in the abdomen in a pregnant woman?
bdominal shape: this may give an initial indication of the fetal lie.
Fetal movements: these are typically visible from 24 weeks gestation.
Surgical scars: may provide clues regarding previous abdominal surgery (e.g. caesarian section).
Linea nigra: a dark line running vertically down the middle of the abdomen (a normal finding in pregnancy).
Striae gravidarum: reddish or purple lesions that develop due to overstretching of the abdominal skin as the gravid uterus expands (commonly referred to as stretch marks).
Striae albicans: mature stretch marks which appear silver-like in colour and are less pronounced.
Where the uterus lies in 3 milestones of gestation?
12 weeks gestation: pubic symphysis
20 weeks gestation: umbilicus
36 weeks gestation: the xiphoid process of the sternum
The 3 types of foetal lie?
Longitudinal lie: the head and buttocks are palpable at each end of the uterus.
Oblique lie: the head and buttocks are palpable in one of the iliac fossae.
Transverse lie: the fetus is lying directly across the uterus.
What is the foetal head measured in?
The fetal head is divided into fifths when assessing engagement:
If you are able to feel the entire head in the abdomen, it is five fifths palpable (i.e. not engaged).
If you are not able to feel the head at all abdominally, it is zero fifths palpable (i.e. fully engaged).
What is the symphyseal-fundal height?
distance between the fundus and the upper border of the pubic symphysis. After 20 weeks gestation, the symphyseal-fundal height should correlate with the gestational age of the fetus in weeks (+/- 2cm).
What are you looking for when inspecting the vulva?
Ulcers: typically associated with genital herpes.
Abnormal vaginal discharge: causes include candidiasis, bacterial vaginosis, chlamydia and gonorrhoea.
Scarring: may relate to previous surgery (e.g. episiotomy) or lichen sclerosus (destructive scarring with associated adhesions).
Vaginal atrophy: most commonly occurs in postmenopausal women.
White lesions: may be patchy or in a figure of eight distribution around the vulva and anus, associated with lichen sclerosus.
Masses: causes include Bartholin’s cyst and vulval malignancy.
Varicosities: varicose veins secondary to chronic venous disease or obstruction in the pelvis (e.g. pelvic malignancy).
What are the three things of the cervix you’re assessing during a vaginal digital exam?
Position (e.g. anterior or posterior)
Consistency (e.g. irregular, smooth)
Cervical motion tenderness: involves severe pain on palpation of the cervix and may suggest pelvic inflammatory disease or ectopic pregnancy.
What 5 factors are you assessing when doing a bimanual exam of the uterus?
Size: the uterus should be approximately orange-sized in an average female.
Shape: may be distorted by masses such as large fibroids.
Position: the uterus may be anteverted or retroverted.
Surface characteristics: note if the uterus feels smooth or nodular.
Tenderness: may suggest inflammation (e.g. pelvic inflammatory disease, ectopic pregnancy).
Best time to measure progesterone levels?
Day 21 of menarche
Normal hormone levels in women?
premenopausal oestrogen 15-350 pg/mL, progesterone while ovulating (luteal stage of cycl) = 2–25 ng/mL, testosterone = 15 to 70 nanograms per deciliter (ng/dL), Mid-cycle peak = FSH is 4 – 25 and LH is 10 - 75
What does HELLP stand for?
haemolysis, elevated LFTs and low platelet count
Why is microsomia common in mothers with pre-eclampsia?
Placental insufficiency
Medical treatment of PPH?
Sytocinon, tranexamic acid and misoprostol
What happens from progesterone secretion in secretory phase of menstruation?
Stromal cells grow, glands swell, blood supply increases in endometrium
Normal length of menstruation?
8 days
Normal menstrual cycle length?
23-35 days
Hormone changes in the puerperium?
decrease in placental hormones (human placental lactogen, hcg, oestrogen, progesterone) and increase in prolactin
Protective factors in lactoferrin in breast milk?
in colostrum more, regulates iron absorption in intestines and delivery or iron to cells; protection against bacterial infection, some viruses, fungi; helps regulate bone marrow function; boosts immune system
Postnatal problems (minor and major)?
minor = infection, PPH, fatigue, anaemia, backache, mastitis, stress incontinence, haemorrhoids, constipation, the blues; major = sepsis, severe PPH, pre-eclampsia, thrombosis, uterine prolapse, incontinence, post-dural puncture headache, breast abscess, depression/psychosis
Sepsis RFs postnatal?
obesity, diabetes, anaemia, amniocentesis, prolonged ROM, vaginal trauma, BAME
Sepss causes postnatal?
endometritis, skin/soft tissue infection, mastitis, UTI, pneumonia, gastroenteritis, pharyngitis, infection from epidural/spinal
Sepsis S+Ss?
<36/38< temp, HR >90bpm, resp rate >20bpm, WCC >12/<4 x 10^9/l, hyperglycaemia >7.7mmol/L
Sepsis managemrnt in mothers?
BUFALO (Bloods culture, Urine output, Fluid resus, Abx, Lactate, Oxygen) plus delivery (ERCP) and VTE prophylaxis
Definition major PPH?
With clinical shock or 1500+mls
What is a major risk increase postpartum, especially in older women, surgical deliveries and medical comorbidities?
VTE
S+Ss post-dural puncture headache?
Headache, neck stiffness, photophobia, recent epidural/spinal
Treatment post-dural puncture headache?
Lie flat, simple analgesia
Definition of urinary retention postpartum?
abrupt onset/aching or not of able to micturate needing catheter 12hours after birth or not able to spontaneously void within 6hours of vaginal delivery
Mental health questions to ask postnatal everytime?
Mood and suicide
Diagnosis and features of adenomyosis?
Seen on MRI and painful and menorrhagia
Treatment for adenomyosis?
Usually hysterectomy but can manage with HRT/GnRH
What is the abnormality of two uteruses and cervixes?
didelphys
Cause of ovarian infarction?
Torsion of the pedicles (also have pain)
How to write gravidity and parity for stillbirth and twins?
o -1 next to the parity number is a stillborn after 24 wks
o For twins would be G1P2
Two types of speculums?
Cusco and Sims (for prolapse)
Go through the pathophysiology of pre-eclampsia?
placental problem; normally spiral arteries dilate 10x at 20wks so more perfusion to baby; pre-eclampsia incomplete trophoblastic invasion of spiral arteries so arteries become fibrous and narrow, less placental perfusion so placenta releases pro-inflammatory proteins which go into mum’s circ that causes vasoconstriction and endothelial damage, vasospasm leads to glomerular damage leading to proteinuria (hypertension with proteinuria)
Give pathophysiology explaining RUQ pain in pre-eclampsia?
hypertension and endothelial damage leads to liver swelling and damage causing capsule to stetch causing pain (RUQ pain)
Give pathophysiology of HELLP syndrome in pre-eclampsia?
endothelial damage causing platelets used up to adhere to damage, haemolysis from clotting and RBC death at sites of damage, elevated liver enzymes from liver damage
Give pathophysiology of peripheral oedema in pre-eclampsia?
from endothelial damage so tissue fluid leaks out to hands and feet and face
When to hospitaise someone with pre-eclampsia?
170/110 bp or proteinuria above 30
3 classes of placenta praevia?
complete = over the os, partial = partially over the os, marginal = 2cm of the os (but at least 4cm for vaginal delivery)
Management to give after birth to prevent PPH?
Syntometrine and fundal pressure to stimulate uterine involution
4 Ts for assessing PPH?
tissue [bit of placenta left], trauma [during birth], tone [not complete uterine involution], thrombin [clotting disorders]
Neural control of micturition?
parasympathetic for voiding and sympathetic prevent it
Bladder capacity?
500mls
Rarer causes of incontinence?
Overflow and fistula formation
Acute urinary retention definition?
12+ hours of no micturition
Causes of chronic urianry retention?
detrusor inactivity or urethral obstruction
Cysts in endometriosis?
Chocolate-coloured and can be painful if ruptured
What is the cutting of adhesions called?
Adhesiolysis
When to refer early for infertility?
menstrual disorder, previous PID/STI, previous abdo surgery, abnormal pelvic surgery, >35yrs
6 aspects of preconception advice?
Folic acid, stop smoking and drinking alcohol, have medical condition under control, BMI under 35, avoid contact with toxic substances, up to date with vaccinations and discuss current medications
Signs of ovulation for conception?
may have vaginal spotting, more discharge, pelvic pain, cervical mucous usually acellular and ‘fern’ on a dry slide, body temp drops; LH surge tester kits and high serum progesterone
Hormones patho for PCOS?
Increased free serum androgens
Complications of ovulation induction?
multiple pregnancy, ovarian hyperstimulation syndrome and ovarian/breast carcinoma
Complications from assisted conception?
Superovulation and pregnancy complications
What is the pearl index?
risk of pregnancy per 100 women years using a contraceptive
What is premature menopause and its causes?
before age of 40; can be due to infections, surgery, AI, ovarian dysgenesis and metabolic diseases
Age HRT is indicated in women to if early menopause?
50yrs
Treatment of osteoporosis postmenopause?
bisphosphonates (alendronate), strontium ranelate for hip fx, raloxifene for prevention spinal fx, parathyroid hormone peptides prevention vertebral fx, denosumab reduces osteoclast activity and for CI in bisphosphonates and stops fx, calcium and vit D
When is the foetus engaged in pregnancy?
Head more than 2/5ths palpable
Normal HR in a foetus with a pinard stethoscope?
110-160bpm
Definition of APH?
50mls+ blood loss
When is uterus palpable?
12wks gestation
Testing for neural tube defects?
maternal levels of alpha fetoprotein often raised
Markers used for testing perinatal chromosomal abnormalities?
chorionic gonadotrophin beta subunit (B-hCG), pregnancy-associated plasma protein A (PAPP-A), AFP, oestriol, inhibin A
What is the nuchal translucency and what’s it for?
the space between skin and soft tissue over the cervical spine (larger = more likely to have structural damage)
What is gastroschisis?
free loops of bowel in amniotic cavity, more common in young mother
What is foetal hydrops?
extra fluid accumulates in 2 or more areas of foetus
Causes of foetal hydrops?
abs causing anaemia, chromosomal abnormalities, structural abnormalities, cardiac abnormalities, anaemia, twin-twin transfusion syndrome
Diagnosis of CMV in newborn?
CMV IgM blood test
Consequences for foetus with group A strep?
chorioamnionitis with abdo pain diarrhoea, severe sepsis all in puerperium
When to give aspirin for those at risk of pre-eclampsia?
Before 16wks
What not to use for HT in pregnancy due to teratogenecity?
ACEi and warfarin
What is red blood cell isoimmunisation?
Foetal RBCs enter maternal bloodstream and mother’s abs attack and destroy them (rhesus disease of the newborn)
How do contractions work?
[positive feedback from presenting part onto cervix stimulating more oxytocin], longitudinal fibres down the uterus when contracts pulls fundus to cervix causing it to efface and dilate
How is progress of descent in labour measured?
progress of labour measured by ischial spines which is 0 and if below is +cms and above is -cms
What is a fontanelle and both ones on the head?
Bits between skull bones, occiput and bregma
Main positions of the baby?
occiput posterior or occiput anterior (best one) or occiput transverse (worst one)
Abx increasing chance of preterm labour?
Metronidazole
Investigations for preterm labour?
CTG, foetal fibronectin, transvaginal scanning for cervical length, vaginal swabs for infection and CRP
Definition of APH?
bleeding from genital tract >24wks gestation
Investigations for placental abruption?
CTG and US for foetus; FBC, coagulation, group and save, catheterisation with urine output, U+Es, CVP monitoring for mother
Treatment and delivery for abruption?
IV fluids with steroids if preterm, anti-D, opiate analgesia sometimes, C-section if distress, monitor with CTG and amniotomy if after 37wks
Definition of foetal compromise?
chronic and situation where conditions for foetus are not optimal (poor nutrient transfer, IUGR etc)
How does the corpus luteum prevent menstruation when oocyte fertilised?
Bhcg produced preventing sloughing off of endometrium, eventually the Bhcg is produced by placenta to take over it’s role
Assessment for polyhydramnios?
limb movements, tone, breathing movements, liquor volume
Problems affecting external cephalic version?
Caucasians, obese, low liquor volume
How do monoamniotic twins occur?
division in monozygotic twins after day 3 of fertilisation
What date do monochorionic twins divide?
after day 9
What date do conjoined twins divide?
incomplete division (after day 13)
What happens in twin-twin transfusion syndrome?
unequal blood distribution in shared placenta so donor develops anameia, IUGR, oligohydramnios; recipient polycythaemia, cardiac failure, polyhydramnios
Description of the pelvis relating to the mechanisms of labour?
inlet is transverse and passenger needs to transverse, mid-cavity is round and needs to be cephalic, outlet is round but in a different plane and foetus head needs to rotate to 90 degrees
Areas of the foetal head from posterior to anterior?
head has occiput, vertex and then bregma from posterior to anterior
What is cervical show?
pink/white mucous plug
What is cephalo-pelvic disproportion?
outlet too small for the head; retrospective diagnosis usually; no inadequate uterine contractions, no malpresentation
How to diagnose foetal distress/hypoxia?
pH of <7.2 on foetal scalp
Investigations/indications for foetal distress?
or meconium stained liquor [pea-soup], abnormal HR patterns from pinard/hand-held doppler, CTG, foetal blood sampling for pH
What is hyperstimulatory contractions?
> 5 per 10 mins
Dx diagnosis for postpartum depression?
Postpartum thyroiditis
Definition of early neonatal death?
within 7 days of delivery
Definition of neonatal death?
within 28 days of delivery
Definition of maternal mortality?
death during pregnancy or within 42 days of cessation, late can be when until a year after
What are the fraser guidelines?
if mental capacity can consent under 16yr old child to contraception without parents involvement if asked them to involve parents, danger to themselves and would keep having sex
What is gillick competency?
is the same as fraser but for general medical procedures
Causes of higher plasma volume and how much does it increase by?
Na+; 30-50% more plasma (1-2L), increase in renin-angiotensin aldosterone system; not fully understood why increases; lower threshold for thirst
Consequences of higher plasma volume?
lower plasma osmolality and lower plasma oncotic pressure (oedema in ankles etc)
Renal complications of higher plasma?
compression of ureters as dilate (hydronephrosis and urinary stasis)
PALM COEIN mnemonic for menorrhagia causes?
polyp, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory, endometrial, iatrogenic, not classified
S+Ss and treatment obstetric cholestasis?
Pruritus (palms, soles, abdo), raised bilirubin and jaundice in 20%; 37-38wks induction of labour, vit K, ursodeoxycholic acid
Two factors that are protective for endometrial cancer?
OC pill and smoking
Treatment for immunocompromised patients with toxoplasmosis?
Pyrimethamine and sulphadiazine
Abx for bacterial vaginosis?
Metronidazole
Abx for campylobacter?
Clarithromycin
