Obs and Gynae Flashcards
Why is toxoplasmosis important in pregnancy?
Can cause congenital infections
- problems with baby eyes
- reduces IQ
- still birth
Which food stuffs should be avoided in order to avoid toxoplasmosis?
Raw or undercooked meat
Unpasteurised milk
Neural tube defects can occur in faetal alcohol syndrome. True or false?
False
What are the routine blood tests taken at booking (around 12 weeks) of pregnancy?
FBC - looking for anaemia Syphilis - to treat it (if there) blood group - check if patient is rhesus negative HIV Hb - check for haemaglobinopathies
If patient is rhesus negative, what do you do?
Give anti-D
What haemoglobinopathies are screened for in pregnancy?
Sickle cell anaemia
thalasaemia
What is PAPP-A?
screening for downs syndrome - not diagnostic
Diagnostic tests for Downs Syndrome?
Amniocentesis
CVS
Which 3 trisomies are screened for?
Trisomy 18 (edwards syndrome) Trisomy 13 (patous syndrome) Trisomy 21 (downs syndrome)
Downs syndrome is associated with increased maternal age. True or false?
True
At what week is the anomaly scan carried out?
Week 20
What is gastroschisis?
Abdo wall not formed properly.
Good prognosis
What is omphalocele?
Poot prognosis
Associated with significant genetic abnormalities
Which medicine could prevent anencephaly and spina bifida?
Folic acid
What is the normal dose of folic acid pre-pregnancy?
400
At 19 weeks, a Rh-ve woman who has had PV bleeding requires anti-D. True or false?
True
- should be given after 12 weeks
haemolytic disease of the newborn has been eradicated due to the use of anti-D. True or false?
False
is anti-d given routine to any rhesus negative women?
Yes, as long as the woman has no D antigens (ie unless she has already mounted an immune response)
Sickle cell disease is associated with African/ afro-carribean origin. True or false?
True
Mum Rh+ve, will she mount a response even if baby is Rh-ve?
No
If a baby is at risk of having foetal anaemia, how is this identified? and how do you manage?
Titres of antibiody are going up from mum blood test
Can then do an in-utero transfusion
If mum on her back, how should the baby come out? head first looking up/down?
Head first looking down
Opiates slow/speed up labour?
Slows
does epidural anaesthesia increase the risk of needing a C section?
No
just increases the risk of assisted vaginal delivery (woman less lokely to push)
Umbilical artery carries oxygenated blood from the foetus to the placenta. True or false?
False
- deoxygenated
Ductus arteriosis shunts pulmonary artery to what?
Descending aorta
What type of decelerations are physiological
Early decelerations
- Sign of baby being compressed by uterine contractions
What are the signs of cerebral irritation in pre-eclampsia?
Hyper-reflexia
Clonus
Confusion
Classical features of pre-eclampsia (3)
Raised BP
Significant proteinuria
Oedema
What blood test should be sent if you suspect someone has pre-eclampsia?
FBC - Hb, platelet
Coag
What are the foetal risks to pre-eclampsia
IUGR
Still birth
often needs pre-term delivery
When placenta lies over cervix what is this?
Placenta praevia
Placenta praevia is typically painless/painful?
Painless
Placenta abruption is typically painless/painful?
Painful
Mother with small amount of bleeding, painless
However, severe foetal distress
What is the likely issue?
Vasa pravia
If you get a group and save for a patient, how long does this last for?
72 hours
In an emergency, what type of blood can be used universally?
O-ve
In a massive antepartum haemorrhage, which types of blood products may need to be used?
Red cells
Platelets
Cryo - for fibrinogen
What are the safest type of twins to carry?
- dichorionic
- monochorionic
Dichorionic
What significant complication can you get from carrying monochorionic twins?
twin to twin transfusion
What is the main cause of a port partum haemorrhage?
Atonic uterus
uterotonic management
Rub the uterus up and down Oxytocin - offered to all women that deliver Ergometrine Oxytocin infusion Carboprost Misoprostol
All women are offered oxytocin at delivery. Why is this
It reduces the risk (by 50%)of post partum haemorrhage
What time of day is best to take a pregnancy test?
In the morning, first urine. As urine is more concentrated
In a bimanual vaginal examination, which areas are you assessing? (4)
Vulva/external vagina Cervix Uterus Adnexa - ovaries / fallopian tubes / pouch of douglas Any additional significant findings
In speculum examination, what is the redder area around the cervical os called?
Ectropion
Which age of women get a cervical smear
25-64
Cervical smear positive + no abnormal cells identified. What is management
Recall in 1 year
Cervical smear positive + presence of abnormal cells. What is the next thing to do?
Colposcopy
What colour is a vaginal swab?
Name 2 conditions it screens for?
Vaginal swab - blue
Screens for
- bacterial vaginosis
- trichomonas vaginalis
What colour is a vulvo-vaginal swab?
Name 2 conditions it is used to screen for?
Vulvo-vaginal swab - orange
Screens for
- chlamydia
- gonorrhoea
What are the 4 T causes of post partum haemorrhage
Tone
Trauma
Tissue
Thrombin
What is the first line treatment of post partum haemorrhage
Uterine massage
- helps the uterus to contract to reduce bleeding after placenta has been delivered
Why is oxybutynin not the first line medication used in the treatment of urge incontinence in the elderly?
Can cause cognitive impairment
Patient with nocturia. Which medication might be usefull?
Desmopressin
Which area of the cervix is particularly vulnerable to HPV infection
Transformation zone
If you are doing speculum examination and about to do a smear but the cervix is clearly abnormal (looks malignant). What do you do?
DO NOT do the smear test
Refer urgently to the 2 week wait cancer referral
25 year old P0 patient goes for routine cervical screening. Results suggest CIN1. Outline the treatment
Follow up at 12 months with repeat smear
Follow up at 24 months with repeat smear.
If normal by that point, back to routine smear
If persistent low grade abnormality at 2 years then treat (excision or ablation)
What might mosaicism and punctuation in the cervix suggest
Severe dyskaryosis
Why do you try and do ablation instead of LETZ in young female
Risks of pre-term labour
Try to do ablation instead of LETZ in young woman. But why might you have to do LETZ?
If severe CIN3
Patient presents for TOP (21 year old student PO0+0 around 6/7 weeks gestation. What are key points to cover in Hx
LMP Menstrual cycle Previous pregnancies and outcomes Any current pregnancy symptoms Reason for termination How she feels about pregnancy Contraception Asthmatic ? (use of prostaglandins) Allergies SHx
Patient presents for TOP (21 year old student PO0+0 around 6/7 weeks gestation. What are key points to cover in investigation
US - confirm pregnancy and gestation
Bloods - check if rhesus -ve / HIV / Syphilis
Swab - STI
If exclusively breastfeeding, you can’t get pregnant. True or false?
True (i think?)
If patient is anaemic prior to having TOP procedure, what should you do?
IV iron
Young female recently entered new sexual relationship. with malodourous discharge and cervical excitation, non specific abdominal tenderness
Pelvic inflammatory disease
Stress incontinence tried conservative messares, not worked, what Ix do you do?
Urodynamics
- to prove the woman has urodynamic proven stress incontinence
First line anticholinergic medication for urge incontinence?
Tolteridone
- not oxybutynin because of cognitive impairment
When about to start mirabegron, what do you need to check with the patient?
If they have uncontrolled hypertension
Surgery is more common in urge/stress incontinence?
Stress
WHat is the only surgical treatment to remember for urge incontinence?
Botox
Chronic lower pelvic pain - nothing helps
Difficult to manage
No abnormalities on investigations
Rule out all differentials - what do you think is going on?
Functional - bladder pain syndrome
What is the name of a stage 4 prolapse (everything hanging out)
Procidentia
Where should the leading edge of the vagina be (ie what -cm) in relation to the interoitus in normal woman?
-3cm above the interoitus
a child who has not yet reached the age of 13 is
incapable of consenting to any form of sexual activity. True or false?
True
- referral to child protection
What are the 3 features needed to give you a diagnosis of hyperemesis gravidarum?
5% weight loss
dehydration
electrolyte imbalance
First line treatment option for hyperemesis gravidarum
Antiemetics
- antihistamine type (cyclizine, promethazine)
- prochloperazine
Can give oral / IV / IM
Second line treatment option for hyperemesis gravidarum
Metoclopramide (beware of extrapyramidal SEs)
Odansetron
Why is odanetron rarely used in pregnancy
risk of cleft palate
Third line treatment option for hyperemesis gravidarum
Steroids
What do you need to be aware of when prescribing steroids in pregnancy and what additional measures do you need to take?
Measure foetal growth - growth scans
Possibility of pre term delivery
Which analgesia should you not prescribe in pregnant patients and why?
NSAIDs
- closure of ductus arteriosus
- reduction in foetal urine production –> less amniotic fluid
Is NSAID safe in breast feeding?
Yes
Methotrexate and pregnancy
Anyone who is on methotrexate must stop for 3 months before conceiving
What are the 3 IV antibiotics used for severe pelvic inflammatory disease
IV ceftriaxone 2g BD +
IV metronidazole +
PO doxycycline
Can you insert a coil at C section?
Yes
Woman gives birth and intends on breast feeding. She wants to take COCP. IS this possible and why?
No
Can only take after 6 weeks
Miss C is a 28 year old para 0. She has come to see you in clinic today as she is experiencing heavy menstrual bleeding. She is currently trying to conceive. Her past medical history includes polycystic ovarian syndrome and childhood asthma. Her BMI is 29 and her mother has had a DVT in the past. Miss C is not currently on any medications.
Miss C describes an irregular cycle ranging from 28 to 42 days. While she is menstruating she finds they are incredibly painful and she often floods through her underwear despite wearing a tampon and pad having to change them upwards of 6 x a day. A TVUSS shows a normal uterus with polycystic ovaries.
What treatment options ar available
Tranexamic acid for 3-4 days during menstruation
Folic acid
In pregnant woman what should ramipril be switched to?
Labetolol
In pregnant woman who is asthmatic, what should ramipril be switched to?
nifedipine
If a patient is known to have essential hypertension. Which medication should you start during pregnancy (from about 12 weeks onwards)?
Aspirin
In the first trimester, pregnant women have a lower/higher Hb level physiologically?
Why is this?
LOWER Hb level in first trimester
- increased cardiac output, increases plasma volume which reduces Hb by dilution
When does implantation bleeding typically occur?
About 10 days after ovulation, when fertilised egg attaches to uterine wall
Name 3 possible causes of recurrent misscarriage
APS
Thrombophilia
Balanced translocation
In molar pregnancy, HCG is often very high / low?
High
A 35 year old woman contacts the gynaecology ward reporting vaginal bleeding. She is pregnant. She is incredibly anxious as she had a miscarriage last year.
She tells you she has no pain and has had the same pad on for 2 hours although it is fresh red. Her pregnancy test was positive 5 days ago and her LMP was 6 weeks ago with a 28 day cycle.
Do you want to see her the same day and what advice will you give her?
No
- bleeding but NOT in pain
Advice
- return if bleeding continues / if pain occurs
- repeat urine pregnancy test in 7-10 days (return if +ve)
- negative pregnancy test means she has misscarried
Transvaginal US scan or transabdominal US scan for misscarriage?
Transvaginal US scan
If on US no foetal HR detected but CRL > 7mm then what is likely
misscarriage
Potential outcomes of a pregnancy of unknown location
Ectopic
Missed Misscarriage
Intrauterine
Potential outcomes of a pregnancy of unknown location
Ectopic
Missed Misscarriage
Intrauterine
A 35 year old woman contacts the gynaecology ward reporting vaginal bleeding. She is pregnant. She is incredibly anxious as she had a miscarriage last year. She tells you she has pain in her left side for the last 3 days. Her LMP was 5th December with a 28 day cycle. Her pregnancy test was positive 5 weeks ago. She is awaiting a follow-up consultation in the fertility clinic as she had an x-ray test which said she might have a “blocked tube” but missed her period while waiting to be seen.
Do you want to see her the same day and what advice will you give her?
Yes
- this is ?ectopic pregnancy so woman must be seen urgently
- she is in pain
Which medical management is used for ectopic pregnancy?
Methotrexate
Monitoring HCG levels in ?ectopic pregnancy. What would you expect?
HCG levels drop by 15% each 48 hrs
Patient has pregnancy of unknown location. She is seen by the registrar, HCG levels taken and the plan is made for out-patient follow-up. What will this involve and what would you say to the patient?
HCG outcomes:
Come back in 48 hours for repeat HCG blood tests
HCG outcomes
HCG doubles - intrauterine pregnancy
HCG reduces by 50% - misscarraige
HCG increases slowly - ectopic
A 21 year old woman has been an in patient on the gynaecology ward with hyperemesis requiring IV fluid hydration. It has been a struggle to control her vomiting but she has now not vomited for several hours on a combination of 2 anti-emetics. She is 11+4 weeks by dates.
She is fit for discharge. The early pregnancy clinic is able to scan her. You are asked to review her scan report before she goes home: A/V uterus is enlarged and contains a multiple cystic structures measuring 65x40x35mm
What is likely diagnosis?
molar pregnancy
Almost half of shoulder dystocias occur in normal birth weights. True or false?
True
Which position do you get the patient into if ?shoulder dysctocia
McRoberts position
Name 3 potential complications to foetus in shoulder dystocia
Foetal hypoxia
Brachial plexus nerve palsy (erbs or klumpkes)
Reduced foetal blood pH
Injury to C8, T1 is erb’s / klumpkes palsy?
What will position be?
Klumpkes palsy
claw hand
What is the window period for chlamydia/gonorrhoea?
14 days
What is the window period for syphilis / hep B
3 months - due blood test 3 months after exposure
What is the window period for HIV
45 days
MSM should get offered which 3 vaccinations
HPV
Hep A
Hep B
22 year old woman presents with bleeding after sex and change in vaginal discharge. She has never had a smear but would be interested to have one because her aunty had cervical cancer and she have heard that it runs in families.
Should you carry out a smear test?
Why/why not?
No
Do bimanual vaginal examination and have a look but no smear necessary
Common to have changes in the cervix under age of 25 so won’t give accurate result
If you’re not within screening age you do not need a smear test. True or false?
True
What is the most effective form of emergency contraception
Coil (IUD)
Why should the depo injection only be given to women OVER the age of 18
Can alter bone development
With which emergency contraception (LNG / UPA) can you quick start any method of contraception afterwards?
LNG
- UPA is an anti-progesterone whereas the pill has progesterone can cancel out effects
Uterotonics should / should not be given in second stage labour
Should not be given
Woman has been actively pushing for 90 mins with no sign of imminent delivery. If her contractions have gone off, what should you give?
Syntocinin - increases the power and strength of contractions
Spontaneous delivery but placentanot delivered 40 mins later and EBL 500ml with ongoing bleeding. What is the likely diagnosis and what is the management plan?
Diagnosis: retained placenta -> PPH
Management:
- FBC, G+S, coag screen
- Prophylactic administration of syntometerine OR
- Oxytocin 10 units
- Cord clamping and cutting, controlled cord traction
Shoulder dystocia - highlight 4 potential risks to mother
PPH due to uterine atony
Perineal tears
Uterine rupture
Transient femoral neuropathy
Shoulder dystocia - highlight 3 potential risks to baby
Hypoxia
Brachial plexus injury
reduced foetal blood pH
Breech presentation - highlight 3 potential risks to baby
Cord prolapse
Head entrapment
Perinatal morbidity
Shoulder dystocia -> tried mcrobert’s position but not working -> what do you move on to
Suprapubic pressure (try and dislodge anterior shoulder)
If both mcrobert’s postion and suprapubic pressure fails, what is the next step?
internal manouvres
A woman presenting with a footling breech should be offered a vaginal delivery. True or false
False
- Elective caesarean section
A woman presenting with a frank breech should be offered a vaginal delivery. True or false?
True
If at 36 weeks, a woman has an uncomplicated singleton BREECH pregnancy, what should be offered?
External cephalic version (ECV)
+ discussion regarding mode of delivery
If at 36 weeks, a woman has an uncomplicated singleton BREECH pregnancy and is offered ECV but DECLINES it, what should be done?
Elective caesarian section
The diagnosis of breech presentation during labour is a contraindication for vaginal breech birth. True or false?
False
36 year old type 1 diabetic at 36 weeks presents for
routine growth scan rv. She describes reduced fetal
movements over the last 48 hours and hypoglycaemic
episodes.
You request a ctg and the midwife returns to you
fifteen minutes later to ask you to review it: HR 170,
no variability, no accels, deep late decelerations
How do you proceed?
Category 1 c section (delivery within 30 mins)
42 year old prim at 30 weeks referred as measuring
small for dates
Scan shows baby measures below the 5th centile for
gestation but otherwise appears well (liquor and flows
normal).
How do you proceed antenatally?
What is the labour plan?
Weekly BP and urine
2 weekly US scan
SVD with IOL and continuous CTG ideally
Elective C section is not done before X weeks?
39 weeks
Patient’s with epilepsy should receive what during pregnancy?
High dose folic acid (5mg)
Patient with gestational diabetes has a 50% chance of developing type 2 diabetes in later life. True or false?
True
What does HELLP syndrome start for?
Haemolysis
Elevated liver enzymes
Low platelets
Which antihypertensives can you give IV in pregnancy
IV labetolol
IV hydralazine
under 34 weeks with pre-eclampsia and baby needs delivered. Which delivery method?
C-section
over 34 weeks with pre-eclampsia and baby needs delivered. Which delivery method?
IOL vaginal birth
First line sepsis antibiotic management in an obstetric woman that is NOT penicillin allergic?
Co-amoxiclav
What is first line sepsis antibiotic management in an obstetric woman that is penicillin allergic?
Clindamycin + Gentamicin
D-dimer is useful in pregnancy. True or false?
False
For breech presentation, what is external cephalic version?
Manually turning the foetus into a cephalic presentation
In foetal hypoxia, the umbilical artery INCREASES/DECREASES its resistance?
Increases
In foetal hypoxia, the middle cerebral artery INCREASES/DECREASES its resistance?
Decreases
What is the first line antibiotic used to prevent ascending infections leading to chorinoaminonitis?
erythromycin
membranes are ruptured followed by small amount of dark vaginal bleeding and is accompanied by an acute fetal bradycardia and decelerations - what does this make you think of
Vasa preavia
Vasa previa is maternal/foetal blood loss?
Foetal
acute constant abdominal pain even when the uterus is relaxed which may be referred to the should tip suddenly collapse and on abdominal palpation, fetal parts will be felt easily. What is likely diagnosis?
Uterine rupture
Getting chicken pox in pregnancy is worse if you get it at an early/late gestation?
Early = worse
pregnant women who are not sure if they have had chicken pox, or never had chicken pox and have been in contact with a child or adult with chicken pox - how should you manage this?
A blood test to check IgG antibodies to varicella zoster virus will confirm immunity to the virus.
If a pregnant woman is not immune to varicella zoster virus and has had significant exposure what should be done?
she should be offered varicella-zoster immunoglobulins (VZIG) as post-exposure prophylaxis as soon as possible (within 10 days)
Which condition can cause hearing loss, visual impairment or blindness, mild to severe learning difficulties and epilepsy in an infected fetus
CMV
jaundice, petechial rash, hepatosplenomegaly, microcephaly and infants born small for gestational age all point towards
Congenital CMV infection
Parovirus B19
Slapped cheek syndrome
Parovirus B19 is associated with hydrops fetalis. True or false?
True
- accumulation of fluid in at least 2 compartments
Women who are not immune to rubella and contract this within the first trimester are at risk of ?
Misscarriage
Woman with HIV cannot have vaginal delivery. True or false? Why?
False
- Provided the woman has a viral load of <50copies/ml, she can be offered vaginal delivery. Otherwise caesarean section is protective to the baby.
WHat is the leading cause of maternal death?
VTE/DVT
Suspect DVT in pregnant woman, what investigation do you want to do?
Duplex US
What is the agent of choice for antenatal thromboprophylaxis?
LMWH
Warfarin is contraindicated in breast feeding. True or false?
False
A small for gestational age fetus has an estimated fetal weight or abdominal circumference below which centile?
10th
What is there a risk of in a baby that has been delivered by a mother with gestational diabetes?
Risk of neonatal hypoglycaemia
Risk of duodenal atresia in what?
Polyhydramnios
What is the main risk of vaginal delivery after a C section
Uterine rupture
Patient with pre-eclampsia. If BP is a problem during labour, what could you do?
Give epidural - reduces BP
Anterior pituitary gland releases FSH and LH. What do these hormones act on
FSH: granulosa cells - oestrogen and inhibin
LH: theca cells - androgens which get converted to oestrogen (by aromatisation)
Inhibin: selectively inhibits FSH/LH at the anterior pituitary?
FSH
What is the best predictor of imminent ovultion?
LH surge
Where does progesterone come from?
Secreted from corpus luteum in secretory phase of menstrual cycle
Progesterone production peaks X days before the start of the next menses
7
- this is useful in assessment of infertility to check if ovulation has occurred
Name a prostaglandin inhibitor which is widely used for heavy menstrual bleeding
- how does it work
Mefenamic acid
- acts by increasing the ratio of vasoconstrictor to the vasodilator
What is the first line treatment of dysfunctional uterine bleeding
Progestogen releasing IUCD
Name 4 possible treatment options (in order) for dysfunctional uterine bleeding
Progestogen releasing IUCD
COCP
Anti-fibrinolytics (eg tranexamic acid)
NSAIDs (eg mefanamic acid)
When is tranexamic acid taken?
During menstruation ONLY
Woman with dysfunctional uterine bleeding but she is hoping to conceive soon. Which treatment would be best for her?
Tranexamic acid or mefenamic acid
When is mefenamic acid taken?
During menstruation ONLY
Woman with dysfunctional uterine bleeding and severe pain associated but she is hoping to conceive soon. Which treatment would be best for her?
Mefenamic acid
Name an example of a GnRH analogue
Groselin
GnRH analogues are only used short term. Why?
Risk of osteoporosis
Women thinking of surgical management for dysfunctional uterine bleeding must make sure their family is complete. True or false?
True
Name 4 potential causes of intermenstrual bleeding
Polyps
Cervical ectropion
Malignancy
Pelvic inflammatory disease
How do GnRH analgogues work?
They mimic the GnRH hormone and when given continuously, will downregulate the pituitary and decrease FSH and LH and decrease oestrogen and progesterone levels.
women over the age of 55 with PMB should be investigated when? what method? and why?
within 2 weeks by transvaginal ultrasound for endometrial cancer
