Obs and Gynae Flashcards
What investigations would you do in a woman presenting with menorrhagia?
FBC in ALL women
pelvic exam?
TVS - if symptoms (IMB, PCB, pelvic pain, pressure)
How would you manage menorrhagia?
Depends upon if needing contraception No contraception required - mefenamic acid (particularly in dysmenorrhoea) - tranexamic acid Start both on day 1 of cycle If require contraception - IUS (1st line) - COCP - long-acting progestogens
What is a short-term treatment for menorrhagia?
Northisterone 5mg TDS to rapidly stop menstrual bleeding
What is screened for antenatally?
Sickle cell, alpha and beta thalassaemia Infections Down's Edward's Patau's syndromes Foetal anomaly scan Diabetic eye screening
When is sickle cell and thalassaemia screening offered and to whom? When would you test the father too?
All pregnant women at 8-10 weeks
Test father: If woman is genetic carrier OR if woman too late to get screening test
What questionnaire should be done with sickle cell and thalassaemia screening antenatally?
Family Origin Questionnaire
When are chorionic villous sampling and amniocentesis done?
CVS at 10-12 weeks
Amnio at 15-20 weeks (don’t do amnio before 15 weeks as risk of talipes)
What should be done if prenatal diagnosis shows baby has sickle cell or thalassaemia?
Offer termination OR
refer to paediatric haematologist
When are infections disease antenatal screening offered and what diseases are screened for?
Offered to all pregnant in early pregnancy and to all unbooked women in labour
Re-offer at 20 weeks if declined in early pregnancy
HIV, Hep B, syphilis
How are babies managed whose mothers are screened positive for HepB? Why is it important to screen for Hep B in pregnancy?
Hep B vaccine 24hrs after birth
Then at 4,8,12,16 weeks then 12 months
If baby contracts HepB perinatally, 90% risk of chronic Hep B, but if gets later as a child, risk is much lower.
Can be transmitted vertically, during delivery or during breastfeeding
Increases risk cirrhosis and liver cancer
What are the risks of maternal syphilis in pregnancy?
Can cross placenta and cause stillbirth, miscarriage, preterm labour or congenital syphilis
What tests can be offered to all women to check for Down’s, Edward’s or Patau’s syndromes?
Combined teset
Quadruple test
When is the combined test and what should be offered if miss it?
Combined test = 11-14 weeks (T21/13/18) If missed/no result after 2 attempts: Quadruple test at 14-20 weeks for T21 And 18-21 week scan for T13 and 18 Combined and quadruple offered in twin pregnancies
What is assessed as part of the combined test?
Risk of T21 and risk of T13/18
- Maternal age
- serum biochemical markers: PAPP-A, free bHCG
- USS: Nuchal translucency, crown rump length
What results are given in combined test? What is the cut off for prenatal diagnostic testing?
Results: 2 results, 1 for T21, 1 for T13/18
Individual results in DC twins
Cut off for PND = 1 in 150
What are the purposes of the early pregnancy scan?
Confirm viability EDD - gestational age using CRL CRL and nuchal translucency as part of combined test Multiple or single pregnancy Major structural anomalies
When is the early pregnancy scan and how is it done?
8-14 weeks
Transabdominal USS
When is the quadruple test offered? What does it involve?
Offered to late bookers, or not able to do combined test or obtain NT 14-20 weeks - tests for T21 ONLY, bloods only - alpha feto protein - total bHCG - oestriol - inhibin A Diagnostic testing cut off = 1 in 150 Can't do individual results in DC twins
What occurs in a positive screening test for T21, T13 or T18?
Mother contacted within 3 working days+ offered appointment
Options:
- await anomaly scan at 20 weeks
- Non-invasive prenatal testing (private)
- invasive testing (CVS or ACS) - 0.5-1% miscarriage risk
What is non-invasive prenatal testing?
Private sector but coming into NHS soon
Analyses foetal DNA from maternal blood from 10 wks
For: T21, 18, 13 and gender
99% sensitive - small risk confined placental mosaicism
When is the foetal anomaly scan? What happens if it is not completed?
18+0 to 20+6 weeks
Offer again at 23 weeks if not completed
What occurs if abnormal results of foetal anomaly scan at 20 wks occurs?
Referred to foetal medicine within 3 working days
Report to National Congenital Anomalies and Rare Diseases Register (NCARDR)
Refer to neonatologists, paediatrics etc.
Who is offered diabetic eye screening and when is it offered?
Women who are diabetic and become pregnant offered within 6 weeks of notification of pregnancy
- have early booking appointment and scan
- Diabetic midwives refer to DES
- Maternity diabetic team can access results
What is the puerperium?
Time from delivery of placenta until 6 weeks post-partum
What hormonal changes occur post partum?
Decrease in placental hormones
- oestrogen, progesterone, hPL, HCG
And increase in prolactin
What occurs in convolution of uterus and genital tract?
Muscle - ischemia, autolysis, phagocytosis
Decidua - shed as lochia rubra, series then alba
Why is breastfeeding sometimes partially or fully contraceptive?
Prolactin inhibits ovulation
What is primary PPH?
Blood loss >500ml after birth of baby
What is a major PPH vs minor PPH?
Major = >1500ml loss or signs of shock Minor = <1500ml loss and no signs of shock
What is secondary PPH?
Abnormal or excessive PV bleeding 24hrs to 2weeks after birth
What are some causes of secondary PPH?
Endometritis Retained products of conception Subinvolution of placental invasion Pseudoaneurysms Aterio-venous malformations
What investigations would you do for secondary PPH?
Assess blood loss/haemodynamic state
High vaginal swab
Pelvic ultrasound in some cases
When is VTE risk highest in pregnancy?
Increases massively post-partum, is 22x higher at 3 weeks pospartum
Risk persists until 6 weeks post partum
What groups are high risk for VTE? What treatment do they get?
High risk = 6 weeks LMWH post-partum
- previous VTE
- antenatal LMWH
- high risk thrombophilia
- low risk thrombophilia and FH
What is given for intermediate risk VTE post-partum? What VTE score gives this?
Score of 2 or more = intermediate
Tx: 10 days LMWH postnatally
Risks: CS, BMI>40, readmission or prolonged admission in puerperium, surgical procedure in puerperium, medical comorbidities
If 3 or more or persisting - lengthen treatment
What is done for VTE risk score of less than 2?
Early mobilisation and hydration
How do post-dural headaches present?
Headache, worse on sitting or standing
Starts within week of epidural/spinal
Neck stiffness
Photophobia
How are post-dural headaches managed?
Lying flat
Simple analgesia
Fluids and caffeine
Epidural blood patch
What is defined as urinary retention?
Requiring catheter >12hr after birth
Or
not spontaneously micturating within 6 hrs post vaginal delivery
What are the risk factors for urinary retention?
Epidural analgesia Prolonged 2nd stage of labour Forceps or ventouse delivery Extensive perineal lacerations Poor labour bladder care
What are the “baby blues”?
Emotional and tearful 3-10 days after giving birth
Give the red flags for post-partum mental health disorder
- significant change in mental state/new symptoms
- persistent feeling of incompetency or estrangement from infant
- suicidal/self-harm persisting thoughts
What dose of aspirin is commonly given during pregnancy and what is it to prevent?
150mg (low dose aspirin) to prevent pre-eclampsia and subsequent premature birth or SGA
What risk factors on their own indicate need for low dose aspirin?
- hypertension in previous pregnancy
- CKD
- Autoimmune
- T1 or T2DM
- Chronic HTN
- Previous SGA
What risk factors do you need 2 of to require low dose aspirin?
- family history of pre-eclampsia
- BMI>35
- Age>40
- Primiparity
- more than 10 years since last pregnancy
- Multiple pregnancy
When can heart disease be worst in regards to pregnancy?
Afterwards - as blood pressure rises post-partum
What Hb levels indicate anaemia in pregnancy?
1st trimester = <110
2nd trimester = <105
3rd trimester = <105
Post-delivery = <100
How does iron deficiency anaemia increase risk of PPH?
Decreased oxygenation to uterus myometrium - more likely to have atony and prolonged bleeding
What does macrocytic anaemia in pregnancy suggest deficiency of?
Folate or B12, ferritin
Treat with folic acid 5mg (high dose) OD and check Hb level in 4 wks
What may happen with asthmatic women in labour?
1/3 get worse - increases risk of IUFGR, premature birth, CS, neonatal hypoxia
Can treat with usual medications
Oral steroids weight up risks as can lead to cleft palate
What is the leading cause of maternal death?
Cardiac disease - ischaemic heart disease
Especially after delivery with increased afterload
What might you screen for regarding cardiac disease in pregnant women?
- usual RFs: obesity, smoking, alcohol, HTN, diabetes
Also rheumatic fever as a child?
Monitor foetal growth with regular growth scans
How is obstetric cholestasis diagnosed?
By exclusion
Check LFTs and bile acids for other causes, possibly liver scan
Raised bile acids and raised LFTs in OC
What are the features of obstetric cholestasis?
What are its risks?
Itching but no rash
Risks: premature birth, still birth
How is obstetric cholestasis managed?
Tx: ursodeoxycolic acid
Why might hyperthyroidism become a problem in pregnancy?
HCG can mimic TSH on thyroid TSH receptors - so worse in 1st trimester but then improves as HCG acts less on thyroid
Can lead to maternal thyrotoxicosis and cardiac failure
If TSH-Abs, can cross placenta and cause foetal thyrotoxicosis
How is hyperthyroidism managed in pregnancy?
Propylthiouracil or carbimazole Both risks PTU - maternal liver failure Carbimazole - foetal anomalies Monitor foetal growth with growth scans - restricts
What can maternal hypothyroidism lead to in pregnancy?
Poor neurodevelopment, learning difficulties or early foetal loss
How is hypothyroidism managed in pregnancy?
Thyroxine - increase by 25mcg especially in 1st trimester - start asap
How is diabetes (chronic or gestational) managed in pregnancy?
Diabetic eye screening offered week6 and check renal function
Stop ACE-inhibitors and statins
Regular appointments to monitor BM chart, blood pressure and urinalysis
BM chart - aim for <5.3 fasting and <7.8 after meal
Treat with: metformin, insulin or glibenclamide
Monitor after pregnancy annually as at increased risk of T2DM with GDM
Folic acid 5mg- increased risk neural tube defects
Foetal growth scans - risk of macrosomia and polyhydramnios
What are the maternal and neonatal risks of GDM?
Maternal: progressive retinopathy, hypoglycaemia, DKA, pre-eclampsia, premature labour
Neonate: IUFGR, macrosomia, shoulder dystocia, foetal anomaly, stillbirth, miscarriage, neonatal hypoglycaemia distress
What are the risks of renal disease in pregnancy?
Maternal: pre-eclampsia, severe HTN, CS due to this
Neonate: IUFGR, stillbirths, anomalies due to medication e.g. ACE-I
How is renal disease in pregnancy managed?
Risk assessment pre-pregnancy
Monitor blood pressure, urinalysis for proteins
Creatinine monitoring - if goes up then is bad as should be low in pregnancy
Foetal growth scans
What neurological conditions are common in pregnancy?
Epilepsy and migraines
What may occur with epilepsy in pregnant women?
Can get worse - increased seizure frequency or sudden expected death if poorly controlled
Counsel medication - don’t take valproate!
Risk of foetal anomalies - medication or epilepsy itself, foetal hypoxia risk, spina bifida
Risk of seizures during labour - exhaustion + pain
How is epilepsy managed in pregnancy?
Counsel on medication
Folic acid 5mg
Monitor for foetal anomalies
Plan for delivery + analgesia (avoid pethidine)
Postpartum support - advice in caring for baby
What should you do if you suspect VTE?
DVT - Dopper ultrasound
PE - VQ scan and CTPA
Therapeutic dose LMWH
What are the characteristics of gestational hypertension?
No hypertension prior to pregnancy
New hypertension after 20th week (>140/90)
Very little proteinuria
What are the characteristics of pre-eclampsia?
New hypertension after 20th wk
With proteinuria
What is chronic hypertension?
Hypertension diagnosed before pregnancy, or before 20th week or during pregnancy that is not resolved post-partum
What is pre-eclampsia superimposed on chronic hypertension?
HTN and no proteinuria <20 weeks but new onset proteinuria after 20 weeks
Hypertension and proteinuria <20 weeks but sudden increase in proteinuria, BP, thrombocytopenia, abnormal liver enzymes
What is the diagnostic criteria for pre-eclampsia?
BP: Systolic >140, diastolic >90
Proteinuria >0.3g protein/24hr or +2 urine dip
What classifies mild, moderate or severe pre-eclampsia?
Mild = 140-140/90-99 Mod = 150-159/100-109 Sev = 160/110+ + haematological impairment
What classifies pre-eclampsia as early or late?
Early = <34 weeks
Late > 34 weeks
What features may you get in severe pre-eclampsia?
>160/110, 5mg proteinuria or 3+ Oliguria <400ml/24hrs Visual changes, headache, scotomata, mental status change Pulmonary oedema Epigastric or RUQ pain Impaired LFTs Thrombocytopenia IUFGR Oligohydramnios Rapid weight gain - fluid retention Retinal vasospasm/oedema
What neurological findings may you have on examination if imminent eclampsia?
Brisk reflexes
Sustained ankle clonus
Neuromuscular irritability
What lab findings may you get in imminent eclampsia?
Low platelets, LFTs raised
Raised serum uric acid
How should you manage mild pre-eclampsia <37 wks?
If new onset, hospitalise to check
Then can be managed at home with HBPM and maternal and foetal evaluation twice a week
How should you manage pre-eclampsia with persistent proteinuria, high BP, restricted foetal growth and abnormal lab results <37 weeks?
Hospitalise
How would you manage mild pre-eclampsia >37 weeks, stable condition and unfavourable cervix?
Deliver at 40 weeks
How would you manage mild pre-eclampsia >37 weeks, with favourable cervix, foetal jeopardy, persistent headaches and visual disturbances?
Give MgSO4
Delivery
How would you manage mild gestational hypertension without proteinuria (not pre-eclampsia)?
Manage at home with HBPM
How would you manage acute severe HTN?
Parenteral hydrazaline and labetalol
(avoid labetalol in asthmatics or CF)
Oral nifedipine - use with caution
What are the indications for delivery in pre-eclampsia?
Gestational age >37wks
Platelet count < 100 000
Progressive decline LFTs, renal function
Suspected placental abruption
Persistent symptoms e.g. headache, visual, RUQ
Foetal growth restriction, oligohydramnios
How would delivery be done in pre-eclampsia?
Vaginal preferable with epidural
Induced within 24 hrs
Give hydralazine and labetalol prior to labour
What is classed as low birth weight?
<2.5kg
What might be some spontaneous causes of preterm birth?
Preterm labour
Premature rupture of membranes
Cervical weakness
Amnionitis
What are non-recurrent risk factors for pre-term birth?
Vaginal bleeding
Antepartum haemorrhage
Multiple pregnancy
What are recurrent risk factors for pre-term birth?
Race, previous birth history Genital infection cervical weakness Socioeconomic factors Smoking
What infections may predispose to preterm birth?
Genital - bacterial vaginosis
Non-genital - UTI, pyelonephritis, appendicitis
How is bacterial vaginosis treated?
Metronidazole and erythromycin
What are primary prevention methods for spontaneous pre-term birth?
Smoking cessation STD prevention Prevention of multiple pregnancy Planned pregnancy Variable work shifts Physical and sexual activity advice Cervical assessment 20-26 weeks
What is tertiary prevention of preterm birth?
Prompt diagnosis and referral
Tocolytics, antibiotics
Corticosteroids
What is diagnosis of preterm labour?
Persistent uterine contractions AND change in cervical dilatation or effacement
What is secondary prevention of pre-term labour?
Screening through
- TVS
- Qualitative foetal Fibronectin test
Offered to women who are high risk for preterm birth or are threatening e.g. cervix <3cm
What is done in the TVS screening for preterm birth?
TVS measures length of cervix - should be more than 20cm unshortened
What is fibronectin test?
Fibronectin = exctracellular matrix protein at choriodecidual interface
If present on vaginal swab after 20 weeks - may mean membrane detachment
10 min procedure with ELISA monoclonal antibody on swab
Gives risk of delivering pre-term
What can cause false fibronectin results?
False positive: Sexual intercourse, Vaginal bleeding, Cervix manipulation
Lubricants - false negative
What hormone may be given to reduce risk of preterm birth?
Progesterone - IM or pessary
For past history of PTB or short cervix
What indicates a cervical cerclage?
Cervical incompetency
Or previous PTB or short cervix
Would you do a cervical examination if membranes are ruptured?
No, as can introduce infection
What do growth scans measure?
Foetal growth - HC, AC, FL, weight
Liquor volume
Umbilical artery dopplers
Scans every 3-4 weeks
What parameters on growth scans are good?
Foetal growth between 10th and 90th centile and not moving across centiles - staying on trajectory
End-diastolic artery flow - absent or reverse is bad!
What does asymmetrical IUFGR mean?
Small body with normal head size - more common restriction of growth
Usually due to placenta insufficiency - smoking, diabetes, HTN, pre-eclampsia
What does symmetrical IUFGR mean?
Small head and body in proportion to one another
Intrinsic factors - infection eg TORCH, global growth restriction, neurological sequalae
What are the complications of IUFGR?
Premature birth, still birth, low birth weight - increased risk of SIDS
How is intermittent auscultation during labour done?
For low risk mothers
After contraction, listen with Pinard stethoscope or hand-held Doppler for 1 minute
Repeat at least every 15 mins
What is a CTG and what is it used for?
Used for continuous foetal heart monitoring in higher risk mothers. Uses Dopper USS to:
measure foetal heart rate, mother’s heart rate and uterine contractions
Hospital-based, restricts maternal movement,
What is the risk of ultrasound on foetus?
Can convert energy into heat - but very low risks
What is the mneumonic for interpreting CTGs?
Dr - Define risk C - contractions Bra - baseline rate V - variability A - acceleration D - deceleration O - overall impression
What counts as an acceleration or deceleration?
Rises/falls more than 15 beats for more than 15s
What are you looking for in CTG variability?
Early, late or variable accelerations or decelerations in relation to time of contraction
LATE IS BAD! - possible cord compression
Normal range = 5-25bpm from baseline
What should baseline rate be on a CTG?
Baseline = 110-160 bpm
What decelerations are concerning?
Late! >90 mins variable or early decelerations Acute bradycardia >3 mins Decelerations lasting >60s Reduced variability within deceleration Biphasic deceleration shape Tachysystole (more than 5 contractions/10mins)
What counts as a pathological CTG?
2 or more non-reassuring features OR 1 abnormal feature
1 non-reassuring = suspicious
What is the gold standard for foetal heart rate monitoring and what circumstances is it done in?
Scalp ECG (STAN) At least 2cm dilated and ruptured membranes
When would foetal scalp blood sampling be done?
If CTG pathological and sufficiently dilated to perform
To check foetal oxygenation
Small incision on scalp, capillary tube to collect blood
What is checked on foetal scalp blood sampling?
Mostly looking at pH
>7.25 is normal, less than this is abnormal - delivery
If borderline, repeat in 30 mins, keep checking CTG
If normal, but CTG abnormal, repeat blood sample
Give some examples of non-pharmacological obstetric anaesthesia
Trained support Acupuncture Hypnotherapy Massage TENS Hydrotherapy Aromatherapy Homeotherapy
What pharmacological analgesia may be given in obstetrics?
Entono, paracetamol, codeine
Opioids - Single shot or PCA
Regional techniques - epidural or spinal, combined
What are side effects of morphine?
Nausea, vomiting, respiratory depression, pruritis, drowsiness
What opioids are given single shot and what are given PCA/IV?
Single shot - morphine, diamorphine, pethidine
PCA/IV - Renifentanol - short-acting, more able to match peaks and less side effects
Which opioid should not be given in 2nd stage of labour?
Diamorphine - eliminated quickly through placenta
Which opioid increases seizure risk?
Pethidine
Where does epidural go and what are the risks?
L3/4 through spinous ligaments but not through dura.
Large needle as places catheter into extradural space - risk of puncturing dura and causing post-dural headache
- bupivacaine or fentanyl
Where is spinal done and what are the risks?
L3/L4 through spinous ligaments and through dura into CSF
Smaller needle with ongoing catheter - single dose which can last about 1hr
Bupivacaine used
What are absolute and relative contraindications to regional analgesia?
Absolute - maternal refusal, local infection, allergy
Relative: Coagulopathy, systemic infection, Hypovolaemia, Abnormal anatomy/scoliosis, fixed cardiac output
What are side effects of regional analgesia?
Vasodilatation, drop in BP, Analgesia, motor blockade, fever
Post-dural headache, neurological problems
In CS, numbed up to T3/T4 - risk of resp depression
When are spinals preferred?
For caesarean sections
When might general anaesthetic be used in CS?
Imminent threat to mother or foetus
Contraindication to regional
Maternal preference
Failed regional
What are the risks with GA in CS?
Aspiration - give antacids preoperatively
Foetal Respiratory distress - adequate oxygenation pre-op
Failed intubation - extubate when awake
Lack of awareness
Give analgesia afterwards
When should a woman be sutured before?
16 weeks, then removed in last month of pregnancy
What defines an APH?
Bleeding from anywhere in genital tract >50ml after 24th week
(if less than 50ml it is called a PV bleed)
What are obstetric causes of APH?
Placenta praevia Placenta accreta Vasa praevia Abruption Infection Also think: domestic violence, drug, cancer
What is placenta praevia and how may it be classified?
= low-lying placenta within 2cm of internal os
Major means completely covering os
Minor means partially covering os
When is placenta praevia identified and what is monitored after this?
Identified usually at 20 week USS
Further USS to monitor if moves up uterus as uterus expands
Bleeding may be due to placenta praevia as vessel invasion of cervix
What is placenta accreta?
Placenta has invaded myometrium of uterus with no cleavage between placenta and uterus - very serious
What is vasa praevia?
Foetal vessels run in membrane across cervical os - small amount of blood loss will cause foetal distress
What infections may cause APH?
Cervical or PID
Will get irritation and bleeding
How is placenta praevia diagnosed?
Diagnosed at 20 week anomaly scan - high presenting part, abnormal lie
If anterior placenta and previous CS, may be invasive disease
How is placenta praevia monitored?
TVS - to see os and placenta
How does placenta praevia present?
PAINLESS BLEED May have small bleed and then massive herald bleed a few hours later so if small, still: - Cross match bloods Give anti-D if rhesus negative Plan delivery
What is the delivery plan for placenta praevia?
If small bleeds only or one-off - then plan for caesarean at 36-37wks
If heavy or recurrent bleeding, delivery before this
What should be done in emergency delivery following APH?
ABCDE 14/16 cannulas IV fluids (crystalloid) cross match 6 units of blood Senior team and paeds called ASAP Foetal monitoring Steroids and magnesium if <34 weeks Do CS once mum is stable - otherwise will die under GA
What are the different types of placenta accreta?
Accreta - into myometrium
Increta - through whole myometrium
Percreta - through into abdominal cavity
What increases risk of placenta accreta?
Previous CS!! or previous gynae surgery eg fibroid removal
How are placenta accretas diagnosed and managed?
If find low lying placenta at 20wk scan and loss of definition between wall and placenta or abnormal vasculature, or RFs - do MRI!
MRI = diagnosis
Arrange elective CS at 36-37wks + MDT (haem, vascular, paeds, anaesthetist)
If emergency - do emergency CS and hysterectomy
How is vasa praevia diagnosed?
Presents with APH painless, small bleed, mother stable but foetal CTG abnormalities or distress
Diagnosed with TVS
IF ruptured membranes - major foetal haemorrhagic risk
If not ruptured, foetus may be OK
What are the features of placental abruption?
See bleed = revealed Can't see bleed = concealed (depends on lie of placenta) PAIN!!!! Hard woody uterus - filled with blood Maternal shock AND foetal shock/distress Consider delivery or close observation
What are the complications of APH?
Premature labour/delivery
Acute tubular necrosis
DIC - need to give clotting factors
PPH more likely
What is a primary PPH?
PPH <24 hrs after delivery >500ml
What is secondary PPH?
PPH >24hrs after delivery >500ml
Up to 12 weeks post-delivery
What is a minor vs major PPH?
Minor = 500-1000ml Major = >1000ml
What are the 4Ts that can cause PPH?
Tone (atony) - syntocin, misoprostol
Trauma - look for tears
Tissue - retained placental products
Thrombin - check clotting factors
What are the risk factors for PPH?
APH Big baby Shoulder dystocia Prolonged labour Multiple pregnancy Nulliparity or grand multiparity Maternal pyrexia Operative delivery Previous PPH
What are the major risk factors for maternal sepsis?
Obesity
Diabetes
Impaired immunity
What are the potential crises from pre-eclampsia?
Can develop into eclampsia (seizures) within 2 weeks Abruption Retinal vasospasm/oedema Cerebral oedema Pulmonary oedema Renal failure HELLP
What is HELLP?
Haemolysis, Elevated Liver enzymes, Low Platelets
How would you manage HELLP?
Stabilise BP - hydrazaline, labetalol, nifedipine
Check bloods - platelets, LFTs, renal function
Give MgSO4 - lowers seizure threshold
Monitor urine output - limit intake to 80ml/hr
Treat coagulation defects
Monitor foetus - CTG, USS growth check
Only deliver once mother is stable!!
How would you manage a pregnant woman with a seizure initially?
Assume eclampsia until proven otherwise
Give IV MgSO4 as is safe
What is foetal presentation?
The lowest part of foetus presenting to pelvic outlet or cervix
What can occur if cord is presenting part?
If membranes intact - baby OK
If membranes rupture, cord can prolapse - become compressed and compromise foetal blood supply
Baby can die within 6 minutes
What are risk factors for cord prolapse?
Non-cephalic presentation PROM Polyhydramnios Long umbilical cord Multiparity Multiple pregnancy
How is cord prolapse managed?
Emergency delivery
Until then: Move foetal head up, Trendelenburg position
Constant foetal monitoring
Relieve pressure on cord
What is shoulder dystocia?
Failure to move foetal shoulders under symphysis pubis after delivery of foetal head
What are the maternal complications of shoulder dystocia?
PPH risk - atony, tear
Tear - 3rd or 4th degree
PTSD
What are neonatal complications of shoulder dystocia?
Hypoxia (after 6 mins shoulder stuck)
Brachial plexus palsy
Cerebral palsy
How is shoulder dystocia managed?
Pain relief for mum - but not time for spinal
Break anterior clavicle or posterior humerus - heal quickly and avoids brachial plexus injury
What are the risk factors for shoulder dystocia?
Macrosomia GDM Previous shoulder dystocia Disproportion between mother and foetus Postmaturity and induction of labour Maternal obesity Prolonged 1st or 2nd stage of labour Instrumental delivery
How is shoulder dystocia prevented?
Only way is CS
Or induce at 39 weeks - try to avoid before 37 weeks to reduce risk cerebral palsy
When is symphysio-fundal height done?
At antenatal appointments after 28 weeks. Only reliable after 20th week
What does raised BP and proteinuria before 20 weeks gestation suggest?
Can’t have pre-eclampsia this early
Suggests renal disease
What is done with urine samples in antenatal clinics?
Urinalysis - leukocytes, nitrites, haematuria, proteinuria
ALL have MC+S as can have asymptomatic bacturia in pregnancy - increased risk of pyelonephritis, sepsis, premature labour
How are haemoglobinopathies screened for in antenatal clinics?
Screened for with thalassaemia and sickle cell disease screening
FBC - MCH low <28pg
When would you be offered screening for GDM?
At 8-12 week appointment if risk factors:
- previous GDM
- diabetes
- family history diabetes
- BMI>30
- previous baby>4.5kg
- South Asian, Black of Middle Eastern
When and how is GDM screening done?
Oral glucose tolerance test at 24-28wks
Fast for 10-12 hrs, drink 75g oral glucose, check blood glucose 2hrs later
Aiming for <5.6 fasting, <7.8 after drink. If higher then is GDM
How is GDM managed?
Try exercise and diet first, check BM daily on waking and 2h post meal
Blood glucose checked every 2 weeks
Offer metformin, insulin if not controlled in 2 wks
Foetal USS every 4 weeks from diagnosis
Plan for CS at week 38 or induced labour
What are the risks of GDM?
Polyhdramnios Macrosomia and shoulder dystocia Hypoglycaemic newborn Risk of jaundice or congenital defects newborn Increased risk of stillbirth Maternal T2DM, CVD PPH - from tears and atony
What investigations would you do for polyhydramnios?
USS
Blood glucose
Infection screen
Maternal antibodies if concerned its hydrops fetalis
What are the features of polyhydramnios?
Swelling - ankle oedema Constipation Heartburn Uterus large for date Premature rupture of membranes Abnormal foetal presentation More common in twins
What are the risks of polyhydramnios?
Risk of premature birth PROM Cord prolapse PPH Foetal health
How would you manage polyhydramnios?
Treat cause, extra USS Drainage if needed Labour induction if foetal distress Steroids if premature Reduce foetal urination - prostaglandin synthetase inhibitors reduce renal flow
What can cause polyhydramnios?
Idiopathic Oesophageal/duodenal atresia Congenital heart defects or infections Spina bifida, microcephaly Hydrops fetalis Drug use Maternal hypercalcaemia GDM Multiple pregnancy
What causes oligohydramnios?
Rupture of amniotic membrane Twin-to-twin transfusion Foetal urinary tract malformation Chronic hypoxia Post-term pregnancy HTN or Pre-eclampsia Maternal dehydration Drug use - e.g. ACE-inhibitor
What may oligohydramnios show on examination?
Foetal parts felt through abdomen
small SFH - exclude IUFGR
How would you manage olighydramnios?
Before term - watch and wait Continuous CTG in labour At term - vaginal delivery, after term = CS Treat cause and maternal dehydration Amnioinfusion
What can cause placental insufficiency?
Diabetes HTN clotting disorder Anaemia Medication e.g. LMWH Smoking and drugs
What are features of placental insufficiency?
Mother fine
Reduced foetal movements
Smaller uterus than previous pregnancies
Vaginal bleeding if abruption
What is diagnostic of placental insufficiency?
USS
Alpha feto-protein levels in maternal blood
Foetal non-stress test
Diary of baby movement
What are the risks of IUGR?
Low birth weight Caesarean section Hypoxia Polycythaemia Meconium aspiration Hypoglycaemia
What defines premature infant?
One born before 37 weeks gestation, 259 days from LMP or 245 days from conception
What is a premature rupture of membranes?
Rupture of membranes before labour begins
What can cause PROM?
Uterine infections Low socioeconomic Smoking Alcohol Previous preterm Stillbirth Vaginal bleed
What are complications of PROM?
Chorioamnionitis - increased infection risk to mother and baby = infection of placenta Premature birth Placental abruption Cord prolapse Postpartum infection
What is a miscarriage?
Spontaneous loss of pregnancy before 24 weeks gestation
What is a complete miscarriage?
All products of pregnancy expelled and bleeding stopped
What is a threatened miscarriage?
Vaginal bleeding in viable pregnancy before 24 weeks
What is a delayed miscarriage?
Non-viable pregnancy on USS with no pain or bleeding
What is an incomplete miscarriage?
Diagnosed non-viable pregnancy, bleeding begun but not all products have left the uterus
What is an inevitable miscarriage?
non-viable pregnancy, bleed begun and os is open. Pregnancy tissue remains in uterus - will become incomplete then complete miscarriage
What is recurrent miscarriage?
3 or more consecutive miscarriages before 24 wks gestation
What are the causes of miscarriage?
Chromosomal or foetal abnormalities Antiphospholipid syndrome Anatomical cause Endocrine - PCOS, DM Infective - bacterial vaginosis No cause in 50% couoples
What are risk factors for miscarriage?
Old age Obesity Stress Previous miscarriage Heavy metals, pesticide Older father Smoking
When should you suspect a miscarriage?
Any pregnant woman presenting with vaginal bleeding in first 24 weeks OR
Any woman of reproductive age with amenorrhoea or breast tenderness that presents with vag bleeding
May contain products of conception in blood
Pain worse than normal period pain
How would you test for miscarriage?
TVS - tell if miscarriage, ectopic, intra-uterine
b-HCG - slow rise or falling if miscarriage
progesterone - low means non-viable
How would you manage a confirmed miscarriage?
Watch and wait, counsel, 1-2 weeks urine bHCG to check if negative. If positive, repeat TVS
Repeat TVS if bleed or pain>7 days
If retained products, then oral misoprostol
Surgery if persistent bleed - manual evacuation or vacuum aspiration
Anti-D for all rhesus negative women
How would you manage a miscarriage if gestation >15 weeks?
2 step medical management: Anti-progestogen = mifepristone Then 36-48hrs later misoprostol Usually completes wtihin 6-8hrs If under 12 weeks, misoprostol only, if under 9 weeks, then expectant management
What is an ectopic pregnancy?
Implantation of embryo outside uterine cavity, most commonly fallopian tubes
What are the risk factors for ectopic pregnancy?
Sterilisation PID Family history ectopic pregnancy STDs History of infertility/IVF Smoking >35years Contraception (IUD/IUS)
What may be presenting features of ectopic pregnancy?
Abdo or pelvic pain,
Amenorrhoea or missed period
Vaginal bleed with or without clot
Faint, dizzy, nausea, vomiting, shoulder tip pain, passage of tissue, rectal pressure
How would you test for ectopic pregnancy?
Pregnancy test - if not confirmed pregnant already
B-HCG - should be doubling in 36-48hrs normal pregnancy, if rising slower than this may be ectopic
TVS (MRI 2nd line)
How would you manage ectopic pregnancy?
If no pain and HCG<1000 - watchful waiting
If unruptured but painful or bHCG rising then METHOTREXATE - check on USS not intra-uterine
Surgery - salpingectomy or otomy if foetal heartbeat, >35mm, abdo pain, rupture, high HCG. Give anti-D
What must be considered before giving methotrexate?
Check not intra-uterine pregnancy with TVS or USS
Check liver and kidney function
Check compliance ability as need repeated b-HCG measurements until <25 (no longer pregnant)
How can labour be induced/accelerated?
Sweep
Prostaglandin pessary or balloon
Artificial rupture of membranes
IV oxytocin after amniotomy
What is foetal lie vs foetal presentation vs position?
Foetal lie is long axis of foetus in relationship to mother
Foetal presentation - lowest or presenting part of foetus
Position - foetal head position as in birth canal (occipito-anterior is safest)
How might abnormal lie be managed/changed?
External manipulation to cephalic at 36-38wks
Only 50% success rate
Risk of ruptured membranes, foetal distress, abruption, APH
CI: ruptured membrane, previous CS, uterus abnormal
How is breech presentation managed?
If before 32-35 weeks, not to worry as can turn
If after 35 weeks, then plan for C section at term
How is brow presentation managed?
C section only
How is face presentation managed?
Chin anterior then possible normal but may need C section
Chin posterior = C section
How is shoulder presentation managed?
C section
How is malposition of occipito-anterior managed?
If long or short rotation - normal delivery but prolonged. Monitor partogram and position of head regularly
If arrest/transverse - manual rotation, forceps delivery or vaccum extraction
C section maybe
What is failure to progress?
Failure to dilate cervix or failure for foetus to descend
What can cause failure to progress?
False diagnosis of labour
cephalopelvic disproportion
Dysfunctional uterine activity
How is progress measured in labour?
Partogram started once 4cm dilated Measures - Cervix dilation, descent of head, Contractions, maternal pulse, BP, urine, temp, foetal pulse Alert and action line Alert - Careful observations Action - Induction or C section
What is a prolonged latent phase?
Cervix not dilated to 4cm after 8hrs of regular contractions
What is a prolonged active phase?
Cervix dilated but to right of alert line
Active labour should take 4-8hrs with 3-4 contractions every 10 minutes
How would you manage a prolonged latent phase?
exclude cephalopelvic disproportion
Then reassure, ARM and oxytocin infusion
How would you manage prolonged established labour/active phase?
Exclude CPD, amniotomy, oxytocin infusion
If fails to dilate 2cm in 4hrs, needs C section
What occurs in obstructed labour?
Uterine contractions good initially but overworked so become hypoactive - secondary arrest
Then in subsequent labour, upper segment thickens, lower segment thins, Bandl’s ring between 2 segments. Risk of uterine rupture
If so, hydrate mother, blood tranfusion and C section (even if foetus dead)
What are some causes of uterine rupture?
Obstructed labour Previous caesarean Late pregnancy Inappropriate use of oxytocin Higher risk in multiparous women
What are features of uterine rupture?
Foetal distress/tachycardia
Maternal PAIN, shock
Vaginal bleeding
Can feel knobbly hands and feet of baby abdominally
How is uterine rupture managed?
Blood transfusion, correct dehydration
Emergency C section
Laparotomy hysterectomy or if previous CS scar rupture then suture uterus back up
When is forceps preferred over ventouse?
If <36 weeks to reduce damage to baby’s head
What are complications of instrumental delivery?
Maternal: Tears (3rd or 4th degree affecing walls and muscles of anus), Trauma leading to PPH, high risk of DVT, urinary and anal incontinence
Foetus: Chignon mark (resolves 48hrs)
Bruise cephalohaematoma - self-resolves
What is the APGAR score?
Scores newborn health risk at 1 and 5 minutes
Measures Activity, Pulse/HR, Grimace, Appearance, Respiration
What APGAR scores are reassuring, abnormal or need intervention?
Reassuring = 7-10 Abnormal = 4-6 Intervention = 0-3
How would you manage an uncomplicated lower UTI in pregnancy?
Paracetamol, lots of fluids, nitrofurantoin (if not at 36+ weeks) for 7 days
2nd line: amoxicillin or cephalexin for 7 days
If symptoms don’t improve in 48hrs, urgent review, follow up sensitivity
Give the features of Group B strep in pregnancy?
Is a commensal of vagina or rectum, can pass to baby in delivery
Screen all women at 35-37 weeks for group B strep with vaginal and rectal swab
What are signs that may infect baby with Group B strep?
Premature labour PROM 18h before delivery Previous baby with GBS Fever during labour UTI
How is group B strep of neonate prevented?
If mother positive for GBS and has risk factors, give IV pencillin during labour
What are complications of group B strep infection in neonates?
Early onset - pneumonia, meningitis, sepsis, BP unstable, GI and renal issues
Late onset - meningitis more common
What are maternal features suggesting gonorrhoea infection?
May be asymptomatic or yellow discharge, dysuria, abnormal menstrual bleed, rectal pain if spread
Could spread to uterus or cervix to cause PID or disseminated gonoccoal infection
How is gonorrhoea picked up and treated?
Screened at first antenatal visit (8-12 weeks)
Treated Ceftriaxone
How can baby pick up gonorrhoea infection and how may they present?
During delivery if mother has gonorrhoea
Presents 2-5days post-delivery - scalp, eye, urethra, URTI infection, serious eye conditions or sepsis
How is neonatal gonorrhoea treated?
Treat baby - Ceftriaxone
If eye disease - erythromycin ophthalmic ointment
What is hyperemesis gravidarum?
Nausea and vomiting to varying levels during pregnancy due to b-HCG levels
More severe than morning sickness and perseveres beyond 16-20 week mark when morning sickness would usually cease
What are the risks with hyperemesis gravidarum?
Risks are more common if high HCG e.g. twins or molar pregnancy: Excessive vomiting Dehydration Ketosis Weight loss Dizziness and hypotension DVT
How is hyperemesis gravidarum managed?
Check for twin or molar pregnancy with USS
Check TFTs, LFTs, U+Es, potassium
Rehydrate - IV fluids, vitamin supplements, nil by mouth until oral fluids tolerated
Anti-emetics - ondansetron, cyclosine, metoclopramide
Steroids
What is the normal menstruation cycle range for duration? What is normal range of blood loss in menstruation?
21 to 35 days
60-80ml
What is menorrhagia?
Heavy menstrual bleeding that occurs at expected intervals
Heavy menstrual bleeding >80 ml or subjective feeling of too much blood loss interfering with physical, emotional, social and material life
What is intermenstrual bleeding?
Uterine bleeding occurring between defined cyclic and predictable menses
What is abnormal uterine bleeding?
Any menstrual bleeding from uterus that is abnormal in timing, regularity or volume or non-menstrual
What are some causes of HMB?
Coagulopathy
Ovulatory
Endometrial disorder - fibroids, adenomyosis, polyps
Possibly malignancy - but often is PCB, IMB or PMB
Idiopathic - dysfunctional uterine bleeding of ovulatory or anovulatory type
What is a fibroid?
Benign tumour of smooth muscle (myometrium)
= Leiomyoma
What is a uterine polyp?
Benign localised growths of endometrium with fibrous core and covered in columnar epithelium
Malignant changes are rare
What is adenomyosis?
Ectopic endometrial tissue within myometrium
Can form localised adenomyoma or be diffuse
What might you need to exclude when assessing a lady with heavy menstrual bleeding?
Exclude thyroid disease - either hyper or hypo
Exclude clotting disorder
Exclude drug therapy - warfarin, heparin
What investigations should you do in menorrhagia?
FBC
TVS
Endometrial biopsy if >45 years, not responding to treatment
Hysteroscopy - unresponsive to treatment, abnormal scan, assess suitability for OP ablation
What are good non-contraceptive methods of treating menorrhagia?
Tranexamic acid (anti-fibrinolytic) Mefenamic acid (NSAID) - good for dysmenorrhoea
What are contraceptive methods of treating menorrhagia?
IUS
COCP
Progestagen - if anovulatory or chaotic bleeds
Endometrial ablation - if completed family, uterus <12 weeks size, normal uterine cavity, no infection
Myomectomy - resection of fibroids
Hysterectomy
What is premature ovarian insufficiency?
= premature menopause <40 yrs
What is the average age of menopause?
51
When is menopause diagnosed?
After 12 months amenorrhoea
What is perimenopause?
The period leading up to menopause
What are some common features of perimenopause?
Hot flushes Mood swings Aching muscles and joints Urogenital atrophy Irregular periods
What hormonal changes occur in menopause?
Ovarian function declines and produce less oestrogen
No inhibition of FSH and LH so rise
What are the short-term features of menopause?
Vasomotor symptoms - night sweats, hot flushes
Dry itchy skin, achey joints
Mood swings, irritability, loss of concentration, lack of confidence/energy
Headaches
What are medium term features of menopause?
Urogenital atrophy - dyspareunia, vaginal dryness
Recurrent UTIs
PMB
What are long-term consequences of menopause?
Osteoporosis
CVD - increased in early menopause
Dementia
What is the lifestyle management of menopause?
Modifiable risk factors - exercise, weight loss, diet, smoking, alcohol
Inform about options
What options are there for treating menopausal symptoms?
HRT (oestrogen or oestrogen and progesterone)
Vaginal oestrogens
Clonidine - for hot flushes
CBT
What are the benefits and risks of HRT?
Benefits: reduces risk osteoporosis, reduces menopausal symptoms, prevents long-term morbidity
Risks: HRT oestrogen and progesterone significantly increases risk of breast cancer
VTE risk, stroke, CVD risk (although CVD reduces if HRT in first 2 years of menopause)
What should you do regarding HRT in women with breast cancer or history of breast cancer?
If gets breast cancer while on HRT, discontinue HRT
If history of breast cancer, do not routinely offer HRT - only if very severe symptoms
When might you give oestrogen only HRT?
If woman has no uterus
If has uterus- AVOID and use progestogen with it as unopposed oestrogen can cause endometrial proliferation and neoplasia!
What are the two types of oestrogen and progestogen HRT?
Sequential - progestogen 12-14 days every 4 weeks
Continuous combined - progestogen daily. May use Mirena with oestrogen therapy for this (change 4yrs)
Can also use Tibolone daily too but not within 12 months of LMP
Which type of HRT will stop periods and which type will still have them?
Continuous combined - no periods
Sequential - periods every 4 weeks when withdraw oestrogen
Why might you give transdermal HRT?
Gastric upset, steady absorption Perceived VTE risk Older women - reduce HRT risks Medical conditions e.g. HTN Patient preference
What can cause premature menopause?
Idiopathic majority
Iatrogenic - chemo, radiotherapy, surgery
Other - chromosomal abnorms, inhibin B mutation, autoimmune disease, FSH receptor gene polymorphisms
How is menopause diagnosed?
FSH > 25 in 2 samples that are 4 wks apart
AND
12 months amenorrhoea
Should contraception be used in menopause?
Yes - fertile for 2 more years if under 50 and 1 more year if over 50
When should you be cautious in giving HRT?
Older women >60
Not given to anyone with undiagnosed vaginal bleeding
Not in breast cancer or acute liver disease
Cautions - fibroids, HTN uncontrolled, migraine, epilepsy, endometriosis, VTE risk
What non-hormonala treatments may be given for menopausal symptoms?
Clonidine - adrenergic receptor for hot flushes
SSRI - low dose (don’t use paroxetine/fluoxetine if on tamoxifen)
SNRI - low dose
Anti-epileptics (gabapentin)
When is reversal of infibulation aimed to be done at?
Preconception
Or antenatally before 20 weeks
What might you do during delivery for a woman who has had FGM?
Anterior episiotomy
Medial and lateral to prevent further tearing if needed
What is the normal range of ages for menarche?
11 - 14.5
What is primary amenorrhoea?
Not menstruated by the age of 15
What age should you refer if primary amenorrhoea and no secondary sexual characteristics?
13 - refer to specialist to see if chromosomal abnormalities
Give the possible causes of primary amenorrhoea with secondary sexual characteristics?
look it up hehe
What is polycystic ovarian syndrome?
Polycystic ovaries
Hyperandrogenism
Oligovulation
Insulin resistance
What is the pathophysiology of PCOS?
Ovaries stimulated by excess LH and hyperinsulinaemia has a role
Excess androgen produced by theca cells, free testosterone raised due to drop in sex binding hormone from liver
Cysts are immature follicles not true cysts
PCOS can exist without cysts and without raised androgen levels
What are the features of PCOS?
Oligo or amenorrhoea Infertility Weight gain Hirsutism, male pattern balding, acne Acanthosis nigricans Sleep apnoea Mood swing - depression, anxiety, low self-esteem
What are some complications of PCOS?
Obesity - HTN, stroke, dyslipidaemia, MI
Miscarriage
Autoimmune thyroid disease
Increased risk of endometrial cancer
What is diagnostic criteria for PCOS?
At least 2 of:
Polycystic ovaries (12+ peripheral follicles or ovarian volume>10cm3)
Signs hyperandrogenism
Oligovulation <9 per year or anovulation
What might you see on blood tests for PCOS?
Bloods: normal or raised LH, normal FSH
(if raised FSH too, then think ovarian insufficiency)
Low oestradiol, high oestrogen, high prolactin
High or normal testosterone - if really high could be androgen secreting tumour
Low sex hormone binding globulin
Check TFTs as hypothyroidism can mimic
Fasting glucose for insulin resistance
What might you see on USS in PCOS?
> 5 follicles per ovary
What might you see on VE in PCOS?
Excess cervical mucus
How would you manage PCOS?
Weight loss - diet, exercise
No smoking
Screen for T2DM
Treat sleep apnoea and complications
COCP - reduces androgenism and cancer risk, back to back 3 months then breakthrough bleed - COCP CI in obesity >35
Metformin, Clomifene, ovarian drilling if want to be fertile
Hirsutism cosmetic - anti-androgen cyproterone
What is Asherman’s syndrome?
Inflammatory or iatrogenic
Can be due to severe endometriosis causing scar tissue across uterus, reducing volume of cavity and changes menstrual cycle
What are the features of Asherman’s syndrome?
Amenorrhoea, reduced blood flow, interrupted menstrual blood flow with pain, blockage of cervix, recurrent miscarriage or infertility
How would you test for Asherman’s syndrome
XR = diagnostic
or can do hysteroscopy
How is Asherman’s syndrome managed?
Cutting of scar tissue
Hormone therapy to encourage menstruation
What affects prolactin production?
Produced by lactotroph cells of anterior pituitary and also from hair follicles, adipose tissue and immune cells
Increased by TRH, vasoactive intestinal peptide, epidermal growth factor
Inhibited by dopamine
What are physiological causes of hyperprolactinaemia?
Breastfeeding, pregnancy, stress
Macroprolactinaemia from immune cells
What are intracranial causes of hyperprolactinaemia?
Pituitary tumours - secreting (prolactin) or non-secreting (acts by inhibiting dopamine so prolactin rises)
Prolactinoma - benign tumour of pituitary that produces prolactin
What are other causes of hyperprolactinaemia?
Cushing’s
Anti-dopamine drugs e.g. antipsychotics
PCOS
Cirrhosis
What is the commonest intracranial cause of hyperprolactinaemia?
Microadenoma of pituitary gland
Malignant very rare - can be part of autosomal dominant MEN1
What are the effects of prolactinomas?
High prolactin inhibits FSH and LH - amenorrhoea, infertile, hirsutism, reduced libido, galactorrhoea
Headache, bitemporal hemianopia
What tests would you do for hyperprolactinaemia?
TFTs, pregnancy test, basal serum prolactin (repeat if low, if high suspect macroprolactinaemia), visual field test
MRI - pituitary
Assess pituitary function
How would you manage hyperprolactinaemia?
Find underlying cause
Dopamine cabergoline if symptomatic. If asymptomatic don’t treat
2nd line - surgery
Oestrogen containing contraception if needed
What is a molar pregnancy/hyatidiform mole?
Abnormal growth of trophoblasts - complete or partial
Complete - placental tissue abnormal, swells and filed with cysts, no formation foetal tissue (empty egg and 1 or 2 sperm fertilise so all father’s chromosomes)
Partial - some formation of foetus, some normal placental tissue, usually early miscarriage (1 maternal chromosome but 2 father’s chromosomes - 69 instead of 46)
What are the risk factors for molar pregnancy?
Pregnancy under 20 or over 35
Previous molar pregnancy
What does molar pregnancy present with?
May be like normal pregnancy
Severe nausea, vomiting, vaginal bleeding 1st trim, passage of grape-like cysts
Pelvic pressure or pain, rapid uterine growth
HTN, preeclampsia, anaemia, hyperthyroid
Ovarian cysts
What are complications of molar pregnancy after removal?
After removed, molar pregnancy tissue may still be present and become gestational trophoblastic neoplasia - lots of HCG
Requires chemotherapy or hysterectomy
How is molar pregnancy diagnosed and managed?
Higher HCG than normal pregnancy
USS
Surgery to remove or meds
What are different types of ovarian cyst?
Follicular
Corpus luteum cyst
Dermoid cyst (teratoma)
Endometriomas
What are the risk factors for ovarian cysts?
Hormone problem eg IVF Pregnancy Endometriosis Severe pelvic infection Previous ovarian cyst
What are features of ovarian cysts?
Most asymptomatic and self-resolve
Large: pelvic pain, fullness or heaviness in abdo/pelvis, bloating
Emergency - sudden severe abdo pain, shock, pain with fever, tachypnoea weak
How do you investigate ovarian cysts?
Pelvic exam Pregnancy test - may be corpus luteum cyst/ectopic Pelvic ultrasound Laparoscopy CA125 to check for ovarian cancer
How would you manage ovarian cysts?
Watch and wait if small, not growing
Oral contraceptive pill to stop further growth
Surgery if growing
What occurs in ovarian torsion?
Ovaries get wrapped around utero-ovarian ligament, sometimes with fallopian tube twisting
Cuts of blood supply to ovary and fallopian tube, more likely R
What can cause ovarian torsion?
Pregnancy in 1st trimester Infertility treatment Ovarian cysts Long utero-ovarian ligament Tube ligation
How does ovarian torsion present?
Severe acute onset lower abdominal pain, radiating to groin and flank
Can be intermittent if ovary twisting is intermittent
If cyst on ovary, may rupture so fluid in abdo, nausea vomiting, fever, adnexal lump
How would you investigate ovarian torsion?
Pelvic exam - adnexal lump
Exclude UTI, pregnancy, consider appendicitis
How would you manage ovarian torsion?
Surgery to untwist - if can’t untwist then oopherectomy or salpingo-oopherectomy
COCP to stop cysts recurring
How would you manage lichen sclerosis?
Steroid cream, wash with emollient soap Dab genitals dry after urine Wear cotton underwear Vaginal lubricant If affecting life, surgery to widen vagina Monitor for vulval cancer
What is oligmenorrhea?
Menses more than 35 days apart
What would you rule out in a girl presenting with delayed menarche?
TFT - thyroid disorders
Coeliac
Check bone profile - increased risk of osteoporosis
What is infertility?
Failure to conceive after 1 year unprotected intercourse
What is the average age for first birth?
28.5yrs
When might you refer to infertility specialists in a couple struggling to conceive?
If failing after 1 year unprotected sex
Or if over 35 or have suspected infertility issues due to medical conditions - menstrual disorder, previous abdo/pelvic surgery, previous PID/STI, abnormal pelvic exam
Or male - undescended testes, testicular torsion, previous STD, systemic illness, abnormal genital function
What preconception advice would you give?
Intercourse 2-3 x a week Folic acid 0.4mg or 5mg if high risk No alcohol, smoking cessation Aim BMI 19-30 Smear test, rubella vaccine Screen for medical conditions Drug history - any teratogenic, illict Environmental/occupational exposure
What fertility problems may obesity present?
PCOS Infertility Miscarriage Obstetric complications ART less effective - Don't give treatment to BMI>35 Men also improve fertility with BMI<30
What test would you do first in a couple presenting with infertility at specialist?
Check woman is ovulating!
Mid-luteal progesterone peak (usually day 21)
If long or irregular cycle, do series and then minus one week from next period starting to select correct progesterone test
How do you measure ovarian reserve?
FSH levels at day 2. <4 is good >8.9 is bad
Antral Follicle Count - >16 good, <4 bad
Anti-Mullerian Hormone - >25 good, <5.4 bad
How would you assess male fertility?
Sperm count, motility, morphology
If abnormal, repeat in 3 months
What might you do if sperm count is very low?
Examine patient - secondary sexual characteristics, testicular size
If <5m/ml
- Endocrine - FSH, LH, prolactin
- Karyotype - Kleinfelters
- Cystic fibrosis screen (congenital bilateral abscess of vas deferens (CBAVD) - check mother if father positive
Urology for further imaging - vasogram, USS
When might you do a testicular biopsy to assess low sperm count?
If azoospermic
Only if cryopreservation facilities available
How might the “tubes” be assessed in infertility services?
Laparoscopy + dye test (if high risk eg PID, STI, previous surgery, pain)
Or hysterosalpingogram for low risk
Do swab for STIs before lap or HSG
How might you treat mild, moderate or severe male infertility?
Mild - intrauterine sperm injection or IVF
Moderate - IVF
Severe - Intracytoplasmic sperm injection
How might azoospermia be managed?
Donor insemination
Surgery - correct epidymal block, reverse vasectomy, varicoele
If hypogonadotrophic hypogonadism - give gonadotrophins (LH, FSH)
If prolactinaemia - give bromocriptine
What lifestyle measures may improve male fertility?
Don't overheat, wear boxers Smoking cessation, limit alcohol Occupation exposure - reduce if can Diet supplements - folic acid, zinc, selenium, vit E Lose weight if obese
What may cause hypothalamic anovulation?
Stress
Excessive exercise
Kallman’s
Anorexia nervosa - weight loss
How might hypothalamic anovulation be treated to improve fertility?
Get to healthy weight, and normal exercise levels
GnRH pump
Commonly give - LH and FSH
What pituitary problems may lead to anovulation? How may you treat?
Pituitary adenoma - either prolactin secreting or inhibiting dopamine - bromocriptine
Or prolactinoma - bromocriptine
Sheehan’s syndrome - give LH and FSH
What is the commonest ovarian cause of infertility and what is its treatment? What are other ovarian causes?
Commonest = PCOS - clomifene
Premature ovarian insufficiency (high FSH) - donor egg
Hyper/hypothyroidism
Adrenal insufficiency
How would you improve fertility in PCOS?
Weight loss
If not improved then Clomifene (or Tamoxifen or Letrizole) for up to 6 cycles
Monitor progesterone and USS
Risk of multiple preganncy and ovarian cancer
Metformin for insulin resistance
If these don’t work - laparoscopic ovarian drilling or gonadotrophin ovulation induction
What might cause tubal infertility?
PID, STIs, endometriosis, surgical adhesions, sterilisation
Hydrosalpinx, adhesions
How is hydrosalpinx managed?
Found on dye test - bulges, dye not coming out
Surgery - Salpingectomy
IVF - once tubes are out so dye cannot kill embryo
How might surgery help fertility in tubal disease?
Adhesiolysis Reversal of sterilisation Salpingostomy Tubal catheterisation - selective salpingography, hysteroscopic Ablation, resection of endometriosis
How is unexplained infertility diagnosed? How is it managed?
By exclusion
Mx: IVF
