Obs and Gynae anki 3 Flashcards
What is stress incontinence?
Leaking small amounts when coughing/laughing
What is mixed incontinence?
Both urge and stress
What is overflow incontinence?
Due to bladder outlet obstruction
E.g. from prostate enlargement
When is cystometry not recommended?
In patients with clear histories and a clear cause of incontinence
When is a cystogram suggested as an investigation for urinary incontinence?
When a fistula is suspected
When should you be cautious in prescribing anticholinergics for urge incontinence?
In the elderly due to risk of falls
When is a vaginal vault prolapse most common?
After a hysterectomy
What is the surgical management for a uterine prolapse?
Hystrectomy, sacrohysteropexy
What is the surgical management of a rectocele?
Posterior colporrhaphy
When can’t LNG-IUS(levornegstrel intrauterine device) be used for treating uterine fibroids?
If there is distortion of the uterine cavity
What treatment/management should be used to shrink/remove fibroids?
GnRH agonists-> short term treatment to reduce size of fibroids
Surgical->myomectomty, ablation, uterine artery embolisation, hysterectomy
Why can’t GnRH agonists be used long term to treat fibroids?
Side effects such as menopausal symptoms (hot flushes, vaignal dryness) and loss of bone mineral density
Where do submucosal fibroids grow?
Just below the lining of the uterus (endometrium)
What is Meig’s syndrome?
Triad of:
Ovarian fibroma(benign ovarian tumour)
Pleural effusion
Ascites
Typically occurs in older women->remove tumour and other issues resolve
What should be considered in a patient presenting with recurrent ovarian cysts?
PCOS
Can’t be diagnosed just off cysts, needs 2 of:
Anovulation
Hyperandrogenism
Polycystic ovaries on US
What is the commonest type of ovarian cyst?
Follicular cysts
Whatg are the tumour markers for a germ cell tumour?
Lactate dehydrogenase(LDH)
Alpha-fetoprotein(α-FP)
Human chorionic gonadotropin(HCG)
What is taken into account with the risk of malignancy index for ovariance tumours?
Menopausal status
Ultrasound findings
CA125 level
What is ovarian torsion?
Ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply
When can ovarian torsion happen in normal ovaries in girls before menarche
When girls have longer infundibulopelvic ligaments that can twist more easily
What might be present upon examination of a patient with ovarian torsion?
Localised tenderness
Palpable mass in the pelvis-may be absent
What parts of the body does lichen sclerosus typically affect?
Gential and anal regions of the body
What is the most common type of cervical cancer?
Squamous cell carcinoma
What is the second most common type of cervical cancer?
Adeoncarcinoma
What is the most common casue of cervical cancer?
HPV-typically type 16 and 18
What is meant by dysplasia?
Premalignant changes
What is the grading system for the level of dysplasia in the cervix?
Cervical intraepithelial neoplasia(CIN)
What is the first thing smear tests looking for cervical cancer are tested for?
High risk HPV
If HPV is negative, cells aren’t examined further, returned to normalm screening programme
What might be seen in cervical cancer screening in women with the coil/IUD?
Actinomyces-like organisms-no treatment required unless symptomatic
What is pelvic exenteration?
Operation that involved removing ost or all of the pelvic organs including vagina cervix, uterus, fallopian tubes, ovaries bladder and rectum
Last resort for cervical cancer
Significant implications
What monoclonal antibody can be used to treat cervical cancer?
Bevacizumab(avastin) used in combination with other chemo to treat metastatic/recurrent cervical cancer
Which strains does the HPV vaccine Gardasil protect against?
Strains 6,11,16,18,31,33,45,52,58
What might you find on bimanual pelvic examination in a patient with endometrial cancer
Enlarged uterus(may be normal)
What is the most common type of endometrial cancer?
Adenocarcinoma
What stimulates the growth of endometrial cancer cells?
Oestrogen
Why is obesity a risk factor for endometrial cancer?
Adipose tissue is a source of oestrogen
Why are women with PCOS more at risk of endometrial cancer and how does this affect their treatment?
Less likely to ovulate and form a corpus luteum-> progesterone not produced-> endometrial lining has more exposure to unopposed oestrogen-> neoplasia/cancer
COCP, Mirena coil, cyclical progesterone-induce a withdrawal bleed
Why does ovarian cancer typically carry a poor prognosis?
Uusally diangosed late
What is the peak age of incidence of ovarian cancer?
60 years
What is the most common origin of ovarian cancer?
Epithelial origin-serous carcinomas
What is recognised as the site of origin of many ovarian cancers?
Distal end of the fallopian tubes
Where do epithelial ovarian cancers originate from?
Epithelium which lines the fimbria of the fallopian tubes or ovaries
Where do epithelial ovarian tumours typically spread to first?
Peritoneal cavity-> particularly bladder, paracolic gutters and diaphragm
Where do germ cell ovarian tumours typically originate from?
Germ cells in the embryonic gonad
Where do ovarian sex cord stromal tumours arise from?
Connective tissue
Which is more aggressive: sex cord stromal ovarian tumours or ovarian epithelial tumours?
Epithelial
Which genes are associated with developing ovarian cancer?
BRCA1&2
Why does late stage ovarian cancer cause ascites
Vascular growth factors causing increased vessel permeability
When should CA125 not be used?
For screening for ovarian cancer in asymptomatic women
What is the most common type of vulval cancer?
Squamous cell carcinoma
Which skin cancers can affect the vulva?
Squamous cell carcinoma-most common
Basal cell carcinoma
Melanomas
What proportion of patients with lichen sclerosus get vulval cancer?
About 5%
What is vulval intraepithelial neoplasia?
Premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer
What type of VIN is associated with HPV infection and younger women?
High grade squamous intraepithelial lesion
Which type of VIN is associated with lichen sclerosus?
Differentiated VIN
What might be seen on a pelvic exam of a patient with endometriosis?
Tender, nodular masses may be palpable on ovaries or ligaments surrounding the uterus
Reduced organ mobility
Visible vaginal endometriotic lesion
When do symptoms of adenomyosis tend to resolve?
After menopause
What might be found on examination of a patient with adenomyosis?
Enlarged and tender uterus
Feels more soft than a uterus containing fibroids
When is atrophic vaginitis most common?
After menopause
What is the difference between early and late miscarriages?
Early-most common: <13 weeks
Late: 13-24 weeks
What is the definitive way a miscarriage can be diagnosed?
Transvaginal US: fetal cardiac activity (from 5.5 weeks gestation)
Also fetal crown rump length(>7mm) and mean sac diameter
>25mm-failed pregnancy
<25mm: repeat scan in 10-14 days
What surgery would be performed in a miscarriage?
<12 weeks: manual vacuum aspiration
>12 weeks: evacuation of retained products of conception(ERPC)
What risks are associated with conservative management of msicarriage?
Allowing it to pass naturally
Risks: infection, hemorrhage
What risks are associated with surgical management of a miscarriage?
Infection
Uterine perforation
Haemorrhage
What would be seen on a transvaginal US in a threatened miscarriage?
Viable pregnancy
What would be seen on a transvaginal ultrasound of a patient with an inevitable miscarriage?
Internal cervical os open
Fetus viable or non-viable
What might be seen on a transvaginal US in a patient with a missed/delayed miscarriage?
No fetal heart pulsation where crown rump >7mm
What might be seen on an ultrasound of a patient who has had a complete miscarriage?
No POC in uterus
Endometrium <15mm diameter
Previous pregnancy proof
What might be found on examination of a patient with an ectopic pregnancy?
Bimanual exam: Cervical tenderness-Chandelier sign
Hameodynamic instability of ectopic ruptures, signs of peritonitis
Vaginal exam: Pouch of Douglas
When is IM methotrexate likely to be used as treatment for an ectopic pregnancy
Patients with:
Well controlled pain
B-HCG<1500iU
Unruptured and no visible heartbeat
What is the most common site for an ectopic pregnancy to occur?
Ampullary portion of fallopian tube
What is oligohydramnios?
Lower levels of amniotic fluid within the uterus
What results in low levels of amniotic fluid
Anything that decreases urine production, blocks urine outputs, or ruptures membranes
What is polyhydramnios?
Presence of too much amniotic fluid in the uterus
What is the first stage of labour?
Period that starts with regular uterine contractions and ends when cervix is fully dilated to 10cm
Which hormones are primarily indicated in the first stage of labour?
Prostaglandins and oxytocin
What is the second stage of labour?
Period from complete cervical dilation to delivery of the foetus
What is the third stage of labout?
Period beginning at the delivery of the foetus and ending with delivery of placenta and foetal membranes
What is pre-term labour?
Onset of regular uterine contractions and cervical changes occuring before 37 weeks gestation
What is preterm birth?
Delivery of baby >20wks but <37wks
What is the premature rupture of membranes?
Rupture of membranes at least one hour before onset of contractions
What is prolonged premature rupture of membranes?
Rupture of membranes >24 hours before onset of labour
What is pre-term premature rupture of the membranes?
Early rupture of the membranes <37 weeks gestation
What is menopause?
Permanent cessation of menstruation characterised by at lease 12 months of amenorrhoea in otherwise health women who aren’t using contraception
What is the underlying cause of menopause?
Ovarian failure resulting in oestrogen deficiency
What is perimenopause?
Period when symptoms of menopause begin, continues until 12 months after last menstrual period
What is the difference between premature ovarian insufficiency and menopause?
Premature ovarian insufficiency: <40 years
When should oestrogen only HRT be used vs oestrogen and progesterone?
Oestrogen only: for women with a hysterectomy
Otherwise use combined
What medication can be used as a non hormonal treatment for menopause
Clonidine
alpha 2 adrenergic receptor agonist
What is the normal duration of a menstrual cycle?
21-35 days
Which axis controls the menstrual cycle?
Hypothalamic-pituitary-gonadal axis
What is the role of FSH in menstruation?
Binds to granulosa cells to stimulate follicle growth, permit the conversion of androgens(from theca cells) to oestrogens and stimulate inhibin secretion
What is the role of LH in menstruation?
Acts on theca cells to stimulate production and secretion of androgens
What is the corpus luteum?
Tissue in the ovary that forms at the site of a ruptured follicle following ovulation.
Produces oestrogens, progesterone and inhibin to maintain conditions for fertilisation and implantation
What produces HCG?
synctiotrophoblast of embryo
When does menses occur?
Start of new menstrual cycle
Occurs in absence of fertilisation when corpus luteum has broken down and internal lining of uterus is shed
What is PCOS?
Condition characterised by hyperandrogenism, ovulation disorders and polycystic ovarian morphology
What might be seen on imaging in a patient with PCOS?
Transvag/Transabdo US
Increased ovarian volume and multiple cysts
What might be found on blood tests of patients with PCOS
increase in LH:FSH ratio
prolactin normal or mildly raised
testosterone normal or mildly raised
sex hormone-binding globulin normal/low
What is the most common cause of Asherman’s syndrome?
Post pregnancy related dilatation and curettage procedure e.g. retained products of conception
What is the prognosis of Asherman’s syndrome like?
Recurrence of adhesions post treatment is common
When do congenital malformations of the female genital tract typically present?
Often not until or after puberty
What is ovotesticular disorder of sex development?
‘True hermaphroditism’
Presence of both ovarian and testicula tissue in single patient
Many menstruate and some can become pregnant
Treatment: remove contradictory organs and reconstruct external genitalia corresponding to sex of rearing-can wait until person can decide gender
What symptoms might someone with endometrial polyps present with?
Asx
Abnormal uterine bleeding: menorrhagia, intermenstrual bleeding
Postmenopausal bleeding
Infertility or recurrent pregnancy loss
What is pelvic inflammatory disease(PID)?
Infeciton/inflammation of the pelvic organs including uterus, fallopian tubes, ovaries and peritoneum, usually due to ascending infection form endocervix from vagina
What is urolithiasis?
Urinary tract stones-> solid concretions or crystal aggregations formed in urinary system from substances present in urine
What is the circular body of the breast?
Large and most prominent part of the breast
What is the axillary tail of the breast?
Inferior lateral edge or pec major towards axillary fossa
Nipple at centre surrounded by areola
Where do veins in the breast drain into?
Axillary and internal thoracic veins
Where does the skin of the breast drain into?
Axillay, inferior deep cervical and infraclavicular nodes
Where does the nipple and areola of the breast drain into?
Drains to subareolar lymphatic plexus
Which hormones regulate the production and secretion of milk from the breast?
Prolactin
Oxytocin
Where do fibroadenomas originate from?
Originate from lobules
Where does breast cancer most commonly metastasise to?
Bones
Liver
Lungs
Brain
What is the most common subtype of breast cancer?
Invasive ductal carcinoma
What is the difference between invasive and pre-invasive breast cancer?
Invassive: penetrated through the basement membrane
What screening is in place for breast cancer?
Mammogram every 3 years for women aged 50-70yrs
What is the criteria for a 2 week wait referral for breast cancer?
Unexplained breast lump in a woman >30yrs
>50 yrs with unilateral nipple changes: discharge, retraction etc
Consider if:
Skin changes suggestive of breast cancer
>30yrs with a lump in axilla
What mammogram features might be seen in a patient with pre-invasive breast cancer?
Unifocal/widespread microcalcifications
What mammogram features might be seen in a patient with invasive breast cancer?
Irregular spiculated mass
Clustered microcalcifications
Linear branching calcifications
What surgical techniques might be used for a patient with breast cancer?
Tumour excision
Mastectomy
Breast reconstruction
Sentinel node biopsies during surgery/axillary node clearance if invasive
When is radiotherapy used for breast cancer treatment?
Recommended after a wide local excision
Or after a mastectomy for those with >4 positive axillary nodes
When might chemotherapy be used for breast cancer treatment?
Downstage a primary lesion or after surgery depending on stage of tumour, e.g. if axillary node disease
Why is anastrazole used for post-menopausal women?
It’s an aromatose inhibitor
Sromatisation accounts for majority of oestrogen production in post menopausal women
When is hormonal therapy offered to women?
If tumours are positive for hormone receptors
HER2 over expressing hormone receptor negative patients
What is Paget’s disease of the nipple?
Rare condition characterised by the presence of cancer cells in the nipple
Often underlying DCIS/invasive breast cancer
What is the role of oxytocin in labour?
Surge in levels at onset of labour will contract the uterus
What is the role of prolactin in pregnancy
Starts the process of milk production in the mammary glands
What is the role of oestrogen in labour
Surges at onset of labour to inhibit progesterone to prepare the smooth muscles for labour
What is the role of prostaglandins in labour
Aid with cervical ripening
What is the role of beta endorphins in labour?
Natural pain relief
What is the role of adrenaline in labour?
Released when birth is imminent to give the woman energy for birth
What is meant by dilation in pregnancy and how is this measured?
Diameter of opening of the cervix
Measured in cm through vaginal exam
What is the most common pelvis type in females?
Gynaecoid
When does ‘descent’ stage of labour happen?
Can be from 37 weeks gestation onwards
Might not happen until established labour
What pain managment techniques might be used in labour
Non invasive:
Water immersion
Massage
TENS machine
Pharmacological:
Entonox(gas and air)
Paracetemol
Codeine
Diamorphine
Pethidine
Remifentanyl
Whata re the disadvantages of using entotox?
Can cause nausea/light headedness
Effect wears off quickly
What is the ventouse?
Instrument that attaches a cup to a fetal head via a vacuum
What stage of labour should the decision for an operative vaginal delivery be based on?
2nd stage of labour
What is the combined test?
Assesses chance of fetus having Down’s, Edward’s or Patau’s using maternal and fetal measurements
When is the combined test done?
11-14 weeks-anomaly screen
What things are measured in the combined test?
Maternal:
Age
Free B-HCG(high: downs, low: Edwards.pataus)
Pregnancy associated plasma protein A-PAPP-A(low in all 3)
Fetus via US:Nuchal translucency(high-Down’s)
Crown Rump length
What is nuchal translucency?
Measure via US the thickness of the nuchal pad at the nape of the fetal neck
What is the quadruple test?
Screens for Down’s syndrome
When is the quadruple test offered?
14-20 weeks
What weeks are in 1st trimester?
<13 weeks
What weeks are in 2nd trimester?
14-27
What weeks are in 3rd trimester?
28-40
What things are check in the quadruple test?
Alpha fetoprotein(AFP)
hCG or free bhCG
Inhibin A
Unconjugated oestriol(uE3)
Which is more accurate-the combined test or the quadruple test?
Combined
Quadruple has a lower detection rate and higher screen positive rate
What is the cut off for combined/quadruple screening test?
> =1/150-higher risk
What options are available for women who have been deemed higher risk of Down’s syndrome?
No further testing
Non-invasive prenatal testing(NIPT)
Prenatal diagnostic testing
What is non-invasive prenatal testing(NIPT)?
Assess placental cell-free fetal DNA found in maternal blood and combines with mother’s probability of a trisomy to provide a likelihood ratio
Screening test only-positive result needs to be confirmed through invasive testing
When is the anomaly scan offered?
18-20+6 weeks
What is mastitis?
Inflammation of the breast tissue with/without infectoin associated with lactation
What is puerperal mastitis?
Mastitis associated with lactation in postpartum women
What organism is implicated in infective mastitis?
S.aureus
What organism most commonly causes bacterial vaginosis?
Mc gardnerella vaginalis
Often polymicrobial
What is the treaatment for bacterial vaginosis?
Oral/vaginal gel: metronidazole or clindamycin
Avoid douching, shampoos etc, recurrence is common
What is vulvovaginal candidiasis?
‘Yeast infection/thrush’
Fungal infection of lower reproductive tract
What should be done if treatement for vulvovaginal candidiasis fails?
Consider further ix
Assess risk factors-> diabetes control etc
Medication concordance
Specialist referral
Why is vulvovaginal candidiasis more common in pregnancy?
Oestrogen->increased glycogen production-> promotes candida growth
What organism causes chlamydia?
Chlamydia trachomatis
Obligate intracellular gram negative organism
When would test of cure be done for chlamydia treatment?
Pregnant women
Poor compliance
Rectal infection
Persistent symptoms
What is the incubation period of gonorrhoea
2-5 days
What might be seen on microscopy in a patient with v
Gram negative diplococci
Polymorphonucelar leukocytes
Which HPV strains are associated with cancer?
HPV 16/18-cervical cancer
What is the best treatment for genital warts in pregnancy?
Physical ablation
What should be monitored in patients with HIV?
CD4 count
HIV viral load
FBC
E&Es
Urinalysis
AST, ALT, bilirubin
What is PEP?
Post exposure prophylaxis
Given within 72 hours, lasts for 1 month
What medications are used in PEP?
Truvada(1 tablet daily) + raltegravir(1 tablet BD)
What would be seen on transvagianl US in a threatened miscarriage?
Viable pregnancy
What is the treatment for a threatened miscarriage?
Reassurance
If heavy: admit and observe
If >12 weeks + rhesus negative: Anti D
What is the role of misoprostol in miscarriage management?
Vaginal misoprostol->stimulate cervical ripening and myometrial contractions
What should be done if the cause of polyhydramnios is idiopathic?
Baby’s 1st feed needs to be examined
NG tube to check for fistula/atresia
Why is there a higher risk of postpartum haemorrhage in patient with polyhydramnios?
Uterus has to contract more to achieve haemostasis
What is the difference between post-term pregnancy and post dates pregnancy?
Post term: past 42 weeks
Post dates: pregnancy past estimated delivery date(EDD) or due date(40 weeks gestation)
What should be considered as a differential for prolonged pregnancy?
Consider inaccurate dating
Incidence of this has decreased now due to 11-14 week scans
What is the main complication of a prolonged pregnancy?
Stillbirth
What is placenta praevia?
Placenta lying over the cervical os
Why is it important to identify placenta praevia early?
Important cause of antepartum haemorrhage-> vaginal bleeding from 24 weeks gestation
What is placental abruption?
Part of all of the placenta separates from the uterus prematurely
What might be found on exam of a patient with placental abruption?
‘woody’ uterus
Tense all the time and painful on palpation
What is meant by ‘breech’ presentation?
Baby present bottom down
When is a vaginal breech brith contraindicated?
Footling breech due to risk of head trapping
What is the difference between ‘lie’, ‘presentation’ and ‘position’ with regards to fetal position?
Fetal lie: relationship between long axis of fetus and mother
Presentation: fetal part that first enter the mother’s pelvis
Position: fetal head position as it enters the birth canal
What is pre-eclampsia?
Placental condition affecting women from 20 weeks gestation characterised by hypertension and proteinuria
What is the criteria for pre-eclampsia?
Criteria:
Htn(>140/90) on 2 occasions at least 4 hours apart
Significant proteinuria >300mg protein in 24 hr sample or >30mg/mmol urinary protein: creatinine ratio
Women >20 wks gestation
What should be given for magnesium sulfate toxicity
Calcium gluconate
What is the target MAP in a patient on treatment for eclampsia?
<120mmHg
What is trichomoniasis?
STI caused by flagellated protozoan parasite: trichomonas vaginalis
Primarily infects the urogenital tract
What kind of organism is trichomonas vaginalis?
Highly motile, flagellates protozoan parasite
What is the incubation period of trichomoniasis
7 days
What is lymphogranuloma venereum?
STI caused by L1, L2 or L3 serovars of chlamydia trachomatis
What is the treatment for bacterial balanitis?
Oral flucloxacillin
Clarithromycin in penicillin allergy
What is syphilis?
STI caused by the spircohete bacterium treponema pallidum
What is the incubation period of syphilis?
9-90 days
What tests can be used to diagnose syphilis?
Dark field microscopy: shouldn’t be used for oral lesions
PCR: oral lesions
Serological testing-main-used for screening, diagnosis confirmation and treatment monitoring
Serology usually done using a combination of treponemal and non-treponemal tests
What is the treatment for breast cysts?
If large/painful: might need draining
Usually no treatment
What is mammaary duct ectasia?
Dilatation of the large breast ducts
When is mammary duct ectasia most common?
Most common around the menopause
What might mammography look like in a patient with mammary duct ectasia?
Potentially similar to cancer
When does HELLP syndorme usually manifest?
3rd trimester
What is the main risk of a cord prolapse?
Acute risk ro umbilical blood supply to infant
What is vasa praevia?
Fetal vessels unprotected by umbilical cord or placental tissue run dangerously close to or across the internal cervical os
What od fetal vessels lack the protection of?
Wharton’s jelly
What is velamentous insertion?
Umbilical cord inserts into the chorioamniotic membranes instead of centrally into placental mass
What is puerperal psychosis?
Severe psych disorder that typicallly develops within the first 2 weeks following childbirth
What is the main risk of peurperal psychosis
Self harm/suicide
Harm to baby
What is postpartum depression?
Significant mood disorder that can develop any time up to one year after the birth of a baby
Which antidepressants are safe for use in breastfeeding?
SSRIs: sertraline and paroxetine
What needs to be balanced when deciding delivery time in a patient with PPROM?
Increased risk of maternal chorioamnionitis
Decreased risk of respiratory distress syndrome
What is postpartum haemorrhage?
Loss of >=500ml blood within the first 24 hours of a vaginal delivery
What is the difference between primary and secondary postpartum haemorrhage?
Primary: within 24 hours
Secondary: 24hours-12 weeks
What usually causes secondary postpartum haemorrhage?
Retained placental tissue or endometritis
What is the Kleihauer test?
Determines proportion of fetal RBCs present-used in rhesus negative pregnancies
What tests are used in rhesus negative pregnancies?
All babies born to rheesus negative mother will have cord blood taken for FBC, blood group and direct Coombs test
Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
Kelihauer test: add acid to maternal blood, fetal cells are resistant
What is the current law surrounding abortion in the UK?
1967 abortion act
Abortion up to 24 weeks in most cases
What kind of medication is mifepristone and how does it work?
Progesterone antagonist
Blocks progesterone required for continuation of pregnancy
What kind of medication is misoprostol and how does it work?
Prostaglandin analogue
Stimulates uterine myometrium contractions resulting in expulsion of uterine contents
Where can medical termination of pregnancy occur?
Early: 0-9 weeks:: at home
9-24weeks: clinic
What might be required for later pregnancies undergoing medical termination of pregnancies?
> =22 weeks
Feticide(intracardiac KCl injection)-stops fetal heart before abortion
What options are there for surgical termination of pregnancy?
Suction termination
Dilatation and evacuation/curettage
Cervical priming with misoprostol +/- mifepristone
Women generally offered local anaesthesia alone, conscious sedation with local anaethetics, deep sedation or general anaesthetic
When are women considered high risk for developing neural tube defects?
Either partner has a neural tube defect, previous pregnancy affected by NTD, or fhx
Women is taking antieepileptic drugs, has coeliac disease, diabetes or thalassaemia trait
Woman is obese: BM>=30kg/m2
What screening is done for gestational diabetes?
Oral glucose tolerance test: OGTT
If previous gestational diabetes: OGTT asap after booking and at 24-28 weeks if first test normal
Any other risk factors: OGTT at 24-28 weeks
Whata re the features of pre-existing hypertension in pregnancy?
History of htn before pregnancy or elevated BP before 20 weeks gestation
No proteinuria or oedema
Mc in older women
3-5% of pregnancies
What organism causes Group B strep infection?
Bacterium streptococcus agalactiae
What is obesity during pregnancy defined as?
BMI>30kg/m2 at first booking visit
What is the main consequence of cephalopelvic disproportion?
Obstructed labour-? dystocia etc
What is the most common cause of cephalopelvic disproportion?
Contracted pelvis with an average sized infant
What is prolonged labour?
AKA dystocia
Slow cervical dilation and/or descent of fetus, typically beyond expected time frame of 20 hrs for primigravida and 14 hrs for multigravida women
What is obstetric cholestasis?
AKA intra-hepatic cholestasis of pregnancy
Impaired bile flow-> accumulation of bile acids, typically manifests after 24 weeks
What is the main risk assoociated with obstetric cholestasis?
Risk of spontaneous intrauterine death
What is shoulder dystocia?
Type of obstructed labour where following delivery of fetal head the anterior shoulder becomes impacted behind maternal pubic symphysis
Complication of vaginal cephalic delivery
What is the McRoberts manoeuvre?
Hyperflexion and abduction of mother’s legs tightly into abdoment
Applied suprapubic pressure
Routine traction in axial direction to assess if shoulders have been delivered
What is symphysiotomy?
Division of maternal symphysial ligament
What is the Zavanelli manoeuvre?
Replacement of head into canal and subsequent delivery via C section
What monitoring should be done following the delivery of a baby with shoulder dystocia?
Mother: examined for PPH, severe perineal tears and genital tract trauma
Baby: examined by neonatologist for injury including brachial plexus injury, hypoxic brain injury, humeral/clavicle fractures
Why are pregnant women predisposed to anaemia?
During pregnancy: both plasma volume and RBC mass increase
Plasma volume increases disproportionately ->haemodilution effect
What screening is done for anaemia in pregnancy?
All screened at booking and at 28 weeks
Mutiple pregnancy: extra screening at 20-28 weeks
What is treatment for micro/normo-cytic anaemia in pregnancy?
Mc: iron deficiency anaemia
Trial of oral iron(100-200mg)-repeat FBC after 2 weeks of treatment
Parental iron infusion considered if poor complicance or evidence of malabsorption
What is the treatment for beta thalassaemia in pregnancy?
Folate supplementation and blood transfusions as requiredAim for Hb of 80g/L during pregnancy and 100g/L at delivery
What is the treatment for sickle cell disease in pregnancy?
Folate supplementation and irone supplementation if lab evidence of iron deficiency
What is the incubation period and infectivity period of rubella?
Incubation period: 14-21 days
Infectious from 7 days before symptoms appear to 4 days after onset of rash
What signs/sympotms might newborn with congenital rubella syndrome have?
Sensorineural deafness
Cataracts or retinopathy
Congenital heart disease
Also:
Organ dysfunction
Microcephaly
Micrognathia
Haematological abnormalities
Low birth weight
Developmental delay and learning disability later in life
Characteristic petechial rash described as a ‘blueberry muffin’ rash
Cerebral palsy’
Salt and pepper’ chorioretinitis
Why is it important to check parvovirus B19 serology in patients who might have congenital rubella syndrome?
Difficult to distinguish rubella from parvovirus B19 clinically
Parvovirus B19-30% risk of transplacental infection with a 5-10% risk of fetal loss
When should MMR vaccines not be givenn?
Women known to be pregnant or attempting to be pregnancy
When is an amniotic fluid embolism most likely to occur?
During or shortly after labour
When is hyperemesis gravidarum most common?
Between 8-12 weeks
When should hospital admission be considered in patients with hyperemesis gravidarum?
Continued n+v and unable to keep down liquids/oral antiemetics
Continued n+v +ketonuria +/- weight loss despite treatment of oral antiemetics
Confirmed/suspected comorbidity(e.g. unable to tolerate abx for UTI)
What risks are associated with metoclopramide use in pregnancy?
Can cause extrapyramidal side effects: don’t use for >5 days
When does acute fatty liver of pregnancy most commonly develop?
Sx almost always ddevelop in 3rd trimester
When might liver transplantation be considered for acute fatty liver of pregnancy
Heaptic rupture
Acute liver failure
Post birth
What thromboprophylaxis might be used in pregnancy?
LMWH
What VTE prophylaxis might be used in pregnancy?
LMWH
What is obstructed labour?
Failure of fetus to descend through the birth canal due to a barrier blocking its descent despite strong uterine contractions
Usually occurs at pelvic brim
What is ovarian hyperstimulation syndrome?
Complication arising from iatrogenic induction of ovulation, characterised by an exaggerated response to hormonal therapies used in procedures like IVF
What is the risk to the mother of exposure to VZV in pregnancy?
5 times greater risk of pneumonitis
What is placental insufficiency?
Oxygen and nutrients aren’t sufficiently transferred to the fetus via the placenta during pregnancy
When should a VTE assessment be completed in a pregnant woman?
At booking and on any subsequent hospital admission
What treatments/prophylaxis for VTE should be avoided in pregnancy?
DOACs
Warfarin
What kind of twin is more at risk of complications and needs to be monitored more closely?
Monozygotic
Why is the rate of dizygotic twins increasing?
Infertility treatment
What is twin-to-twin transfusion syndrome?
Severe condition that can occur in 10-15% of twins sharing a placenta(monochorionic twins)
What signs and symptoms might be exhibited in twin-to-twin transfusion syndrome
Heart failure in both twins
Fetal hydrops
Donor twin: high output cardiac failure: severe anaemia
Recipient twin: fluid overload due to excess blood volume
What is the most common puerperal infection and why?
Endometritis
Lining of uterus undergoes trauma and tears during the birthing process
Whata re the most common causes of puerperal infection?
S.pyogenes
S.auureus
E.coli
What is primary amenorrhoea?
Never had a period
13+ no primary sex development
15+ no secondary sex development
What is seconday amenorrhoea?
6 months without a period in normal cycle
Whhat is an imperforated hymen?
Hymen blocks the passage of the vagina preventing menstrual blood and discharge
What is Sheehan’s syndrome?
Postpartum hypopituitarism causing necrosis of pituitary secondary to hypovolaemic shock
When is serum progesterone measured?
7 days before the end of the menstrual cycle(usually day 21)
What medications might be used for treating fertility?
Clomiphene
FSH and LH injections
GnRH or DA agonists
What surgical options are there for treating infertility?
Assisted reproductive technology including IVF or intracytoplasmic sperm injection
Treat underlying cause: e.g. fibroids, endo etc
Which location of an ectopic pregnancy would increase the risk of rupture?
Isthmus
Name some risk factors for placenta accreta
Previous C-section
Placenta praevia
Previous termination of pregnancy
D&C
Advanced maternal age
Uterine structural defects
What are the different types of placenta accreta?
Placenta accreta
Placenta increta
Placenta percreta
How is placenta accreta diagnosed?
Doppler USS
MRI
Can be hard to diagnose antenatally
Name some complications of placenta accreta
Increased risk of severe postpartum bleeding
Preterm delivery
Uterine rupture
How is placenta accreta managed?
Elective C section and hysterectomy
If fertility key: attempt placental resection
What is placenta accreta?
Spectrum of abnormalities of placental implantation into the myometrium of the uterine wall due to a defective decidua basalis
What is the placenta accreta type of the spectrum?
Chorionic villi attach into myometrium rather than being restricted within the decidua basalis(doesn’t penetrate through the thickness of the muscle)
What is placenta increta?
Chorionic villi invade into but not through the myometrium
What is placenta percreta?
Chorionic villi invade through the perimetrium(through full thickness of myometrium to the serosa)
Increased risk of uterine rupture and in severe cases may attach to other organs like bladder/rectum
Name the risk factors for placental abruption
ABRUPTION
Abruption previously
Blood pressure(pre-eclampsia or clampsia)
Ruptured membranes-premature/prolonged
Uterine injury(trauma)
Polyhydramnios
Twins/multiple gestations
Infection-chorioamnionitis
Older age >35
Narcotic` use(cocaine, etc)
How many weeks gestation is a quadruple test done?
15-20 weeks
How many weeks is amniocentesis offered?
15-20
What are the indications for higher folic acid in pregnancy?
MORE folic acid(5mg)
M-metabolic: T1DM, coeliac
O-obesity: BMI>30
Relative: (PMHx)
Epilepsy(AED’s)
+haem: sickle cell etc
