Obs and gynae - stuff to learn pre exam Flashcards
What is hCG secreted by?
Secreted by – trophoblastic cells of the blastocyst
Prevents corpus luteum degenerating before placenta is formed
VArying degrees if morbid adherence of the placenta?
Placenta accreta – placenta invades into the superficial myometrium
Placenta increta - invades into the deeper myometrium
Placenta percreta – invades through myometrium, into nearby organs of the abdomen (bladder, bowel)
What is the only antibody that can cross the placenta?
IgG - role in rhesus disease of the newborn
When do you give anti-D prohphylaxis?
28 - 34 weeks and then after birth
What are some tocolytic drugs?
Cause myometrium to become hyperpolarised:
B2 agonists – salbutamol and ritodrine
CCB - nifedipine
These are known as TOCOLYTIC DRUGS (stop labor)
How do you induce labour?
Firstly – membrane sweep is done before medication to try and encourage labour to start on its own (promotes positive feedback of stretch oxytocin release)
Prostaglandin PGE2 – pessary or vaginal gel
Oxytocin – the analogue given is syntocinon
Which drugs are given to prevent/stop post-partum bleeding?
Oxytocin
Ergometrine
Combined form – syntometrine
Helps the placenta be delivered after the baby comes out
Then makes the uterus contract to stop bleeding
What is the first stage of labour?
FIRST STAGE (preparation phase):
Latent phase - painful, irregular contractions, cervical effacement and dilation to 4cm
Active phase – >4cm, regular contractions, majority of dilatation happens in this phase
What is the second stage of labour?
SECOND STAGE (pushing stage):
Passive stage – complete diltation but no pushing
Active stage – maternal pushing until delivery
What are the 3 main causes of failure to progress in labour?
- Power: Poor uterine contractions
- Passenger: Malpresentation
- Passage: Pelvis not wide enough
What is the most common type of breech presentation?
Extended breech - bottom first
What is the correct positioning of a baby’s head when presenting?
Occipito anterior
What spinal level do you give an epidural at
L3-L4 usually bupivacaine
What three conditions do you screen for in the foetal anomaly screening programme?
Down’s syndrome – trisomy 21
Edward’s syndrome – trisomy 18
Patau’s syndrome – trisomy 13
When should the booking visit be?
8-12 weeks
Anomaly scan dates
18-20+6
What are the 3 infectious diseases should be screened for in pregnant women?
HIV
Hepatitis B
Syphillis
What diseases as newborns screened for on the blood spot programme?
Sickle cell disease (and thallassamia)
Congenital hypothyroidism
Cystic fibrosis
And 6 inborn errors of metabolism:
Maple syrup urine disease
Phenylketonuria
Homocysteinuria
3 more that I will never remember
When is the NIPE check done and what does it screen for?
First = within 72 hours of birth
Second = by GP at 6-8 weeks
Screens for problems with:
Hips – DDH
Reflexes
Eyes – absent red reflex, congenital cataracts
Heart
Mouth and palate
Undescended testes/checks of the genitals
What is the difference between early and late decelerations on a CTG?
Early – most likely due to uterine contractions - head compression due to uterine contractions
Late – whilst the uterus is relaxing, sign of distress of the baby
Variable deceleration - cord compression
Normal CTG values
Baseline HR - 110-160bpm
Variability - >5bpm
Accelerations present
No decelerations present
What is APH?
Genital tract bleeding from 24 weeks
Abruption vs praevia?
abruption is painful with relatively little PV bleeding
Placenta praevia is heavy bleeding that is painless -> if 2cm away from os normal vaginal delivery otherwise prepare for C-section at 37-38 weeks
What is vasa praevia?
PV bleeding with signs of foetal distress
The major foetal vessels are presenting before the foetus
These vessels are exposed meaning they are prone to rupture which can be potentially fatal for the foetus
Causes of primary pph?
The 4 T’s:
Tone – uterine atony - most common - unpalpable uterus
Tissue – retained products (i.e. placenta)
Trauma – i.e. a big tear in the genital tract
Thrombin – clotting disorder
Management of uterine atony?
Mechanical -> medical -> surgical
Emptying bladder can help
Rub the abdomen to help the uterus contract
Bimanual compression of the uterine
IV Syntocinon(combination of ergometrine and oxycotin to help the uterus contract)
IM Carboprost
Surgical options also available (B-lynch sutures, internal iliac artery ligation)
Managing a PPH
Medications to stop the bleeding – ergometrine, oxytocin, syntometrine (combination of ergo and oxy) - these cause the uterus to contract which should stop the bleeding
IM Carboprost if this doesn’t work
If mild/moderate – IV fluids, oxygen, blood products, try and find and prevent the source of bleeding
If severe (>1500mls) – medical emergency – call 2222
What is the sepsis 6?
Blood cultures
IV fluids
Monitor hourly urine output – catheterise
Broad spectrum IV antibiotics
ABG – lactate
High flow oxygen
What is HELLP syndrome?
H – haemolysis
E L– elevated liver enzymes (ALT and AST)
L P – low platelets
What prophylactic treatment should you give in subsequent pregnancies for someone with a history of pre-eclampsia?
Aspirin 75mg
From 10 – 36 weeks’ gestation
(the spiral arteries form around 12 weeks so aspirin is thought to help them develop properly)
What is the puerperium?
From delivery of the placenta to 6 weeks following birth
What antibodies would you be looking for in anti-phospholipid syndrome?
Lupus anticoagulant antibodies
Anti-cardiolipin antibodies
Phospholipid antibodies
What is foetal alcohol syndrome and how does it present?
Lupus anticoagulant antibodies
Anti-cardiolipin antibodies
Phospholipid antibodies
What are the different down antenatal screening tests?
Combined test - more reliable - nuchal, BHCG and PaPPA (11-14 weeks)
Triple - (14-20) weeks : Beta HCG , AFP , oestriol
Quad test - AFP, HCG, oestriol and inhibin A (14-20 weeks)
What are the chicken px guidelines in preg?
if the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible
RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure
Aciclovir if >20 weeks and presents within 24 hrs of rash
Mx of UTI’s in pregnancy?
Nitrofurantoin (avoid in the third trimester)
Amoxicillin (only after sensitivities are known)
Cefalexin
Trimethopri, - avoid in 1st trimester
What is a breast cancer triple assessment ?
Clinical assessment (history and examination)
Imaging (ultrasound or mammography)
Histology (fine needle aspiration or core biopsy)
What are some features that may suggest breast cancer?
Lumps that are hard, irregular, painless or fixed in place
Lumps may be tethered to the skin or the chest wall
Nipple retraction
Skin dimpling or oedema (peau d’orange)
2 week wait!!!!!!
What is a fibroadenoma?
Fibroadenomas are common benign tumours of stromal/epithelial breast duct tissue. They are typically small and mobile within the breast tissue. They are sometimes called a “breast mouse”, as they move around within the breast tissue.
Smooth, round, mobile, defined edges and does not increase risk of actal cancer
Breast cysts?
On examination, breast cysts are:
Smooth
Well-circumscribed
Mobile
Possibly fluctuant
Require triple assessment size and pain dependent on menustral cycle
Lipoma?
Lipomas are benign tumours of fat (adipose) tissue. They can occur almost anywhere on the body where there is adipose tissue, including the breasts.
On examination, lipomas are typically:
Soft
Painless
Mobile
Do not cause skin changes
They are typically treated conservatively with reassurance.
What are the two types of breast pain?
Breast pain (mastalgia) is common. It can be:
Cyclical – occurring at specific times of the menstrual cycle - hx
Non-cyclical – unrelated to the menstrual cycle - meds, infection , preg
In men with gynaecomastia what do you need to check for
Testicular cancer - leydig tumors
Causes : steroids and spirinolactone
How do you treat hyperprolactinaemia
Dopamine agonists (e.g., bromocriptine or cabergoline) can be used to treat the symptoms of hyperprolactinaemia. They block prolactin secretion and improve symptoms
Duct ectasia?
dilation of the large ducts in the breasts. Ectasia means dilation. There is inflammation in the ducts, leading to intermittent discharge from the nipple. The discharge may be white, grey or green.
Smoking a big RF -> Do triple assessment
Intraductal papilloma?
intraductal papilloma is a warty lesion that grows within one of the ducts in the breast. It is the result of the proliferation of epithelial cells. The typical presentation is with clear or blood-stained nipple discharge.
Benign tumors
Triple assessment and excision
Lactational mastitis
Mastitis mainly because of breast feeding -> Staph Aureus
Fluclox continue breast feeding
Complication: Can have a 2ndary candida infection after abx course ->miconazole topical
Breast abscess
Can be lactational or non lactational -> Fluctualant tender lump in the breast
Start with conservative mx and if that does not work move onto using flucox
Genes associated with breast cancer?
The BRCA1 gene is on chromosome 17. In patients with a faulty gene:
Around 70% will develop breast cancer by aged 80
Around 50% will develop ovarian cancer
Also increased risk of bowel and prostate cancer
The BRCA2 gene is on chromosome 13. In patients with a faulty gene:
Around 60% will develop breast cancer by aged 80
Around 20% will develop ovarian cancer
DCIS
Pre-cancerous or cancerous epithelial cells of the breast ducts
Localised to a single area
Often picked up by mammogram screening
Potential to spread locally over years
Potential to become an invasive breast cancer (around 30%)
Good prognosis if full excised and adjuvant treatment is used
Invasive ductal carcinoma?
NST means no special/specific type, where it is not more specifically classified (e.g., medullary or mucinous)
Also known as invasive breast carcinoma of no special/specific type (NST)
Originate in cells from the breast ducts
80% of invasive breast cancers fall into this category
Can be seen on mammograms
Pagets disease of the nipple
Paget’s Disease of the Nipple
Looks like eczema of the nipple/areolar
Erythematous, scaly rash
Indicates breast cancer involving the nipple
May represent DCIS or invasive breast cancer
Requires biopsy, staging and treatment, as with any other invasive breast cancer
What is the breast cancer screening on offer in the UK?
mammogram every 3 years to women aged 50 – 70 years.
Every year from even 3o onwards in high risk woman
First degree male relative, 1st degree<40, bilateral <50
What meds can you give in conjunction with breast cancer tx?
Tamoxifen if premenopausal
Anastrozole if postmenopausal (except with severe osteoporosis)
Also used a prophylaxis chemo prevention in high risk owmen
What imaging would be useful in what age group?
Ultrasound scans are typically used to assess lumps in younger women (e.g., under 30 years). They are helpful in distinguishing solid lumps (e.g., fibroadenoma or cancer) from cystic (fluid-filled) lumps.
Mammograms are generally more effective in older women. They can pick up calcifications missed by ultrasound.
MRI scans may be used:
For screening in women at higher risk of developing breast cancer (e.g., strong family history)
To further assess the size and features of a tumour
Hormone treatment in oestrogen + cancers?
Tamoxifen for premenopausal women
Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole or exemestane)
anything -mab is something targetted to HER2
Definition of primary amenorrhoea?
Failure to menstruate by the age of 16
Or failure to menstruate by the age of 14 in someone with no secondary sexual characteristics
causes of primary amenorrhoea?
Tuner’s syndrome
GU malformations (i.e. an imperforate hymen – especially if they are having cyclical pain)
Hypothalamic failure (exercise, stress, anorexia) – switches off the drive from the hypothalamus
Constitutional delay
Kallmann’s syndrome (also has anosmia – can’t hear, can’t smell, can’t see, no periods)
Hyperprolactinaemia/ prolactinoma
Gonadal dysgenesis (i.e. they did not form ovaries or a uterus)
Swyer syndrome – XY but look like a girl
Late onset CAH
2ndary amenorrhoea?
Absence of periods for ≥ 6 months
In someone who is not pregnant
What are biochem findings in someone with premature ovarian failure?
Hypergondatrophism – they will have high levels of GnRH
Hypooestrogenism – low levels of oestrogen
Raised FSH
Triad of features and criteria for PCOS?
ROTTERDAM CRITERIA – 2 out of 3 must be present:
12 cysts on the ovary OR an ovary > 10ml
Signs of clinical (excess hair) or biochemical (on a blood test) raised testosterone/hyperandrogenism
Oligo or amenorrhoea
Tx of PCOS?
Clomifene – induces ovulation
Metformin
Ovarian drilling to help them get pregnant
If finished family/not wanting to get pregnant – COCP with regular withdrawal bleeds
Hair removal cream for hirsutism
diagnosis of premature ovarian failure?
Age < 40 years
FSH > 25 in 2 samples > 4 weeks apart
Plus 4 months of amenorrhoea
What is the definition of a recurrent miscarriage?
The loss of ≥ 3 consecutive pregnancies before 24 weeks’ with the same biological father
Ectopic pregnancy signs Ix?
USS – intrauterine pregnancy? Foetal heartbeat?
Serial HCG measurements
Pelvic examination – CERVICAL EXCITATION /motion tenderness on speculum examination
Stages of Cervical cancer?
1- cervix
2- top of vagina
3. Nearby organbs
4- everywhere
Most common type of cervical and endometrial cancer?
cervical -> SCC
Endometrial: Adenocarcinoma
What is adenomyosis and when would you see it?
Excess endometrial tissue in the myometrium (muscle layer of the uterus)
Unlike endometriosis (which is seen more commonly in younger ladies who haven’t had children), adenomyosis tends to happen in older women who have had lots of children
So presents much later than endometriosis
Period alot longer and often lasts 2 weeks after period ends - dyspareunia and dysmenorrhoea
tx - hysterectomy
Signs you would see on examination for PID?
Cervical excitation (motion tenderness) on vaginal examination – BIG ONE FOR THE EXAMS
Vaginal discharge
Adnexal tenderness
different types of prolapses and their features?
Cystocele – anterior wall of vagina and bladder – causes frequency and dysuria
Rectocele – lower posterior wall or vagina and rectum – may beed to insert finger to vagina or press on perineum to aid defecation
Enterocele – upper posterior wall of vagina and intestine
Uterine prolapse – protrusion of the uterus fown the vagina
Vault prolapse – if the woman has had a total hysterectomy
Rf’s for ovarian cancer?
family history: mutations of the BRCA1 or the BRCA2 gene
many ovulations*: early menarche, late menopause, nulliparity
What investigations would you do if you suspected ovarian cancer?
Ca125 - but this can be raised in endometriosis etc + ultrasound
generally managed by surgery
Ovarian torsion?
Whirlpool sign on ultrasound :
Features
Usually the sudden onset of deep-seated colicky abdominal pain.
Associated with vomiting and distress
fever may be seen in a minority (possibly secondary to adnexal necrosis)
Vaginal examination may reveal adnexial tenderness
What are the most common type of ovarian cysts?
- FOllicular cysts most common physiological cyst- due to non rupture of the dominant follicle - goes away by itself
- Corpus luteum cysts are also physiological cysts but are more likely to present with bleeding
What are the hormonal changes in the menopause?
Oestrogen and progesterone levels are low
LH and FSH levels are high, in response to an absence of negative feedback from oestrogen
What is premature ovarian insufficency and when does it begin?
Premature menopause is menopause before the age of 40 years. It is the result of premature ovarian insufficiency.
What test can you use to dx menopause in women under 40?
NICE guidelines (2015) recommend considering an FSH blood test to help with the diagnosis in:
Women under 40 years with suspected premature menopause
Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle
FSH will be raised
What are the general rules for the use of HRT’s?
remember the basics of choosing the HRT regime. Women with a uterus require endometrial protection with progesterone, whereas women without a uterus can have oestrogen-only HRT. Women that still have periods should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds. Postmenopausal women with a uterus and more than 12 months without periods should go on continuous combined HRT.
If cytology normal and hrHPV+?
the test is repeated at 12 months
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
What happens when a cervical screening sample is ‘inadequate’?
Repeat the sample within 3 months
2 consecutive inadequates will lead to colposcopy
What bishops score would indicate an induction of labour?
Less than 5 means labour is unlikely to begin withut induction
8 or more - there is a high chance of spontaneous labour
How do you induce labour? step by step
membrane sweep -> Vaginal prostaglandin E2 ->oxytocin
What is a vault prolapse?
Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina.
Rectocele?
posterior vaginal wall -> associated with constipation and faecal loading
patients often describe using fingers to help stools pass
Cystocele
Anterior vaginal wall -> bladder prolapses backwards
What is the ix you would carry out for overflow incontinence ?
Urodynamic testing - it is basically chronic urinary retention and whatever the bladdr cannot hold you expel
Stress incontinence mx?
Supervised pelvic floor exercises for at least three months before considering surgery
Surgery
Duloxetine - SNRI
Urge incontinence?
Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line
Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin
Mirabegron is an alternative to anticholinergic medications
Invasive procedures where medical treatment fails
Booking visit?
8-12 weeks (ideally before 10)
General advice
Bloods and urine including infectious disease screen
Dating scan?
10-13+6
Nuchal scan for downs?
11-13+6
Anomaly scan?
18-20+6
When do you give anti-D
28 then 34 weeks
What are the requirements for an instrumental delivery?
2nd stage of labour - failure to progress or maternal stress
The requirements for instrumental delivery can be easily remembered by the mnemonic FORCEPS:
Fully dilated cervix generally the second stage of labour must have been reached
OA position preferably OP delivery is possible with Keillands forceps and ventouse. The position of the head must be known as incorrect placement of forceps or ventouse could lead to maternal or fetal trauma and failure
Ruptured Membranes
Cephalic presentation
Engaged presenting part i.e. head at or below ischial spines the head must not be palpable abdominally
Pain relief
Sphincter (bladder) empty this will usually require catheterization
In what situations should you just give anti D at unsched times
within 72hrs
delivery of a Rh +ve infant, whether live or stillborn
any termination of pregnancy
miscarriage if gestation is > 12 weeks
ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
external cephalic version
antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling
abdominal trauma
When would you use the coombs test and when the K one?
Coombs in the first trimester and K one in 2nd or thrid
When can you give the copper IUD post 5 days ?
The copper intrauterine device can be used up to 120 hours of UPSI, OR within 5 days of the earliest expected date of ovulation
What are accelerations and decelerations that you would find on a CTG
both are 15bpm for 15s either way
