OBS & GYN Flashcards
1
Q
Define pathological amenorrhea.
A
Failure to menstruate for at least 6 months.
2
Q
Classification of amenorrhea?
A
◉ Primary amenorrhea:
◆ Lack of menstruation before the age of 15;
◆ Lack of menstruation before the age of 13 (without breast developments).
◉ Secondary amenorrhea
◆ Cessation of menstrual cycles following the appearance of it.
3
Q
Causes of amenorrhea?
A
◉ Pregnancy
◉ Hypothalamic
* Most common
* Low BMI
* Excessive exercise
* Low GnRH ⟶ ⬇︎FSH and ⬇︎ LH ⟶ ⬇︎ oestrogen
◉ Polycystic ovarian syndrome
◉ Hyperprolactinaemia
* Pituitary tumors
* Antipsychotic agents
* Hypothyroidism
◉ Premature ovarian failure
* ⬆︎FSH levels
◉ Anatomical problems
* Usually results in primary amenorrhea
* Imperforated hymen
* Mullerian agenesis
* Asherman syndrome
◉ Thyroid problems
◉ Post-pill amenorrhea
* > 6 months amenorrhea after stopping the combined oral contraceptives
* Low-normal levels of oestrogen, FSH, LH
* Mildly raised prolactin
4
Q
Anaemia of pregnancy
A
◉ First trimester
◆ < 110 g/L
◉ Second trimester
◆ < 105 g/L
◉ Third trimester
◆ < 100 g/L
5
Q
What is the management of anaemia of pregnancy?
A
Ferrous sulphate.
6
Q
What are the sympotms (presentation) of antiphospholipid syndrome?
A
- ≥ 3 unexplained consecutive miscarriages before 10 weeks gestation (1st trimester)
- ≥ 1 second trimester miscarriages
- Vascular thrombosis (arterial or venous)
7
Q
What is the investigation in antiphospholipid syndrome?
A
- Lupus anticoagulant
- Anticardiolipin antibody
- Anti-b₂-gylcoprotein I antibody
8
Q
Rx of antiphospholipid syndrome?
A
- Low dose AAS (75 mg)
- Heparin
9
Q
What is the cause of Bacterial Vaginosis?
A
◆ Gardnerella vaginalis
10
Q
Symptoms of Bacterial Vaginosis
A
- (Homogenous) grey-white discharge
- Thin and profuse discharge
- Fishy smell (when KOH added)
- ⬇︎PH (>4.5)
11
Q
Rx of Bacterial Vaginosis
A
- Metronidazole
- Clindamicine
➔ May resolve spontaneously
➔ High recurrence rate
12
Q
OBS & GYN
What are the main risks for cervical cancer?
A
◆ HPV (Human papillomavirus) (HPV 16, 18, 31 and 33).
- Multiple sexual partners
- Smoking
- Immunossupression
- Combined oral contraceptives pills (they don’t wear condoms)
13
Q
Management of pathological CTG
A
◉ Conservative management
◆ Most initial / appropriate:Change mothers position
◆ Start intravenous fluids
◉ Expedite delivery
14
Q
Describe the presentation of ectropion
A
➔ The ectocervix (the vaginal part of the cervix) is lined by stratified squamous epithelium.
➔ The endocervix (the bit inside the uterus) is lined with columnar epithelium
➔ The columnar epithelium (marches over) migrates to the outside covering the ectocervix.
15
Q
What is the cause of ectropion?
A
⬆︎ leves of oestrogen
- Pregnancy
- COCP
- Ovulation phase in young women
16
Q
Sympotms of ectropion
A
- Ussually asymptomatic
- Post-coital bleeding
- Non purulent discharge
17
Q
Rx of ectropion
A
If not bleeding, no therapy
* Stop COCP
- Silver nitrate (ablation)
* Cryotherapy
* Diathermy (ablation)
18
Q
What organisms cause cervicites?
A
- Chlamydia
- Neisseria gonorrhoeae
19
Q
Symptoms of cervicites
A
- Usually asymptomatic
- Vaginal discharge
- Lower abdominal pain
- Intermenstrual bleeding
- Post coital bleeding
20
Q
Regarding the following test:
Vulvovaginal swab for Nucleic Acid Amplification Test (NAAT)
When is this test performed (to diagnose what conditions)?
A
- Chlamydia
- Gonorrhoea
21
Q
How is the diagnosis of cervicites made?
A
Step 1
- Vulvovaginal swab NAAT
—> If positive for gonorrhoea then step 2:
Step 2
- “Endocervical swab” & ‘high vaginal swab’ for culture
22
Q
What is the investigation done in Ectropion?
A
- Colposcopy: red ring around the cervical os.
23
Q
What is the organism that causes chickenpox?
A
Varicela zoster virus.
24
Q
Describe the (infectious) risk period for neonatal varicella.
A
If the mother develops chickenpox:
- 7 days before given birth
- 7 days after given birth
—> IVIG given to neonate.
25
What is the `treatment` for **neonatal varicella**?
IVIG.
26
What is the **time period risk** of infection for *Fetal Varicella Zoster*?
Before 20 weeks gestation.
27
What are the **(fetal) symptoms** for `fetal varicella zoster`?
- Skin scarring
- Microphtalmia (eye defects)
- Limb hypoplasia
- Microcephaly
- Learning disabilities
28
What is the `investigation` in **Bacterial Vaginosis**
`Microscopy:`
- Positive whiff test
- **Clue cells positive**
29
# `In a pregnant patient`
What is the *management* for `chickenpox` **WITHOUT RASH** development?
**STEP 1**
- Check if exposure was within the exposure period.
- If yes, then proceed to step 2.
**STEP 2**
- If patient is immunocompetent:
* Check for past history of varicella
* If past history is positive, then varicella IgG serology **is not required**.
- If patient is immunocompromised:
* Varicella IgG serology REGARDLESS of past hx of varicella.
**STEP 3**
- If patient doesn’t have varicella IgG antibodies: Aciclovir FROM DAY 7 after exposure (not before).
30
What is the `exposure period` for **chicken pox**?
- 2 days before the rash develops
- To 5 days after the rash appeared or until vesicles dried and crusted.
31
# In a pregnant patient
What is the *management* for `chickenpox` **WITH RASH** development?
Aciclovir
32
Describe what is **chorioamnionitis**.
Infection caused after rupture of the membranes (prolonged) —> ascending of vaginal bacteria —> infection of the chorion and amnion membranes of fetus.
33
What are the **risk factors** for `chorioamnionitis`
- Prolonged labour
- Internal/Invasive monitor of labour
- Multiple vaginal exams
- Amniotic fluid with meconium
34
Symptoms of **chorioamnionitis**
- Fever
- Tachycardia
- Abdominal pain
- Uterine tenderness
- Fetal distress
- Foul smelling amniotic fluid
35
Management of **chorioamnionitis**
IV antibiotics
36
What is the **cause** of `Trichomoniasis`?
Trichomonas vaginalis.
37
What are the **symptoms** of `trichomoniasis`?
* Frothy yellow - green discharge
* Smelly odour
* Itching
* Strawberry cervix
* Motile organisms
38
Rx of `trichomoniasis`
Metronidazole.
39
What is the `cause` of **candidiasis** (vulvovaginal)?
Candida albicans.
40
What are the **symptoms** of `genital candidiasis`?
* White cheese like discharge
* No smell (odourless)
* Itching
41
What is the **Rx** of `candidiasis`?
Clotrimazole.
42
What is the **reccomended contraception** for `menorrhagia` in a *young woman* **NOT sexually active**?
IUS
43
What is the **reccomended contraception** for `dysmenorrhoea`?
**NSAID's:**
* Mefenamic acid.
44
# `Sexually active women`
What is the reccomended **contraception** for `menorrhagia, dysmenorrhoea, fibroids` (not distorting the uterine cavity)?
► IUS mirena (levonorgestrel IUS).
**< 20 YO**
* COCP
* POP
* Implant
**Woman with sickle cell disease**
* Depo-provera IM
45
What is the reccomended **emergency contraception**?
**Within 72h**
* Levonelle pill
**Within 120h**
* IUD
* Ellaone pill
46
Which contraception has the `lowest pearl index`?
Etonegestrel implant (Nexplanon).
47
What is the **absolute contraindication** of COCP?
Migraine with aura.
48
# `Short term and easy reversible`
What is the recommended **post-partum contraception**?
► POP (progesterone only pill)
* To be given at 6 week post birth.
49
Describe the **STEP BY STEP** **management** for `menorrhagia`.
**First line:**
* Levonorgestrel-releasing intrauterine system (MIRENA)
**Second line:**
* Tranexamic acid
*`OR`*
* NSAIDS
*`OR`*
* COCP
**Third line**
* Norethisterone
*`OR`*
* Injected long acting progestogens
➔ **When to pick `endometrial ablation`**
* Family completed
* Low hemoglobin
50
What are the **symptoms** of `acute fatty liver of pregnancy`?
➔ **Same as HELLP syndrome**
**`Except:`**
* No haemolysis
* Ammonia
* Hypoglycaemia
51
What is the **management** of `eclampsia`?
► `MgSO4`
**Loading dose**
* 4-6g IV + 100ml normal saline (5-15min).
**Maintenance**
* 1g infusion per hour over 24h
**Recurrence seizures**
* Bolus of 2-4g
► `Delivery at the earliest`
52
Describe `MgSO4 toxicity`
⬆︎ **MgSO4 plasma [.]**
* Decreased urinary output
* QRS widening
* QT interval prolongation
**10 mEq/L**
* Loss of deep tendon reflexes
**15 mEq/L**
* Atrioventricular block
* Respiratory arrest
**25 mEq/L**
* Cardiac arrest
53
# Obs & Gyn
What is the **therapeutic range** for magnesium sulfate?
4 - 8 mEq/L.
54
# Obs & Gyn
Management of MgSO4 toxicity?
* Stop MgSO4 infusion
* Calcium gluconate 1g over 10 min.
55
**Symptoms** of `ectopic pregnancy`?
* Lower abdominal pain
* Vaginal bleeding
* Amenorrhoea (6-8weeks)
* Shoulder tip pain (due to peritoneal bleeding)
## Footnote
Located usually on the fallopian tubes.
56
What are the **risk factors** for `ectopic pregnancy`?
* `Pelvic inflammatory disease`
* Previous ectopic
* Endometriosis
* Previous tubal surgery
* Assisted reproductive treatments
57
What is the **management** of `ectopic pregnancy`?
**Medical management:**
➔ `Methotrexate`
* Haemodynamically stable
* No significant pain
* Fetal mass < 35mm with no heartbeat
* Serum hCG < 5000 IU/L
**Surgical management:**
➔ `Laparatomy`
* Haemodynamically unstable
* Pain
* Ruptured ectopic
* Visible heartbeat
* Cannot come for a follow up
## Footnote
➔ `Laparascopy`: if haemodynamically STABLE.
58
Symptoms of **endometrial cancer**
* Post menopausal bleeding
59
**Risk factors** of endometrial cancer
* Nulliparity
* Early menarche
* Late menopause
* Obesity
* PCOS
* Tamoxifen (antiestrogen used in breast cancer)
* Unopposed oestrogen (HRT, adding progestogen ⬇︎ the risk)
60
What is the **investigation** done in `endometrial cancer`?
**First line**
* Transvaginal ultrasound
* Endometrium > 4 mm thickness (proceed to following step)
**Definitive diagnosis**
* Hysteroscopy with endometrial biopsy
61
Describe what is endometriosis.
Endometrial tissue outside the uterine cavity.
62
Symptoms of `endometriosis`
* Chronic pelvic pain
* Dysmenorrhoea
* Deep dyspareunia
* Infertility
63
What is the **investigation** done in `endometriosis` (ENDOMETRIAL TISSUE OUTSIDE THE UTERUS)?
**Gold standard**
- Laparascopy (diagnosis and treatment ablation)
➔ Transvaginal ultrasound often normal
64
**Causes** of female infertility?
- Tubal damage due to PID.
- Ovulation failure.
- Unexplained.
65
What is the investigation done in female infertility?
**1. Mid-luteal progesterone**
- Taken 7 days prior to expected menstruation date
- Day 21 on a 28 day cycle.
**2. FSH**
**3. LH**
**4. Hysterosalpingogram (HSG)**
**5. Laparoscopy (tubal patency)**
66
Differential diagnosis of female infertility.
**PCOS**
- FSH: normal
- LH: high
- Oestradiol: normal to mild elevation
- Prolactin: normal to mild elevation
**Premature ovarian failure**
- FSH: high
- LH: high
- Oestradiol: low
- Prolactin: normal
**Prolactinoma**
- FSH: decreased
- LH: decreased
- Oestradiol: decreased
- Prolactin: very high
**Sheehan’s syndrome**
- FSH: low
- LH: low
- Oestradiol: low
- Prolactin: low
**Turner syndrome**
- FSH: high
- LH: high
- Oestradiol: very low
- Prolactin: normal
67
Describe the different fibroid locations.
**Submucosal fibroids**
- Beneath the endometrium, bulges into the uterine cavity.
**Intramural fibroids**
- Most common
- Within the uterine wall
**Subserosal fibroids**
- Outside of the uterus wall
68
What is the management of asymptomatic fibroids?
- Annual follow up to monitor size.
- If rapid growth or suspected malignancy investigate
69
What is the management of **fibroids** with `menorrhagia`?
**First line:**
* MIRENA (if no uterine distortion)
**Second line:**
* Tranexamic acid
*`OR`*
* NSAIDS
*`OR`*
* COCP
**Third line**
* Norethisterone
*`OR`*
* Injected long acting progesterones
70
What is the management of **fibroids** with `SEVERE menorrhagia`?
Ulipristal acetate.
71
What is the **SURGICAL** management of **fibroids** with `menorrhagia`?
* Hysterectomy
* Myomectomy
* Uterine artery embolization
* Endometrial ablation (fibroids < 3cm)
72
Describe the time period for cervical screening
| `Testing for cytology and HPV`
**25 - 49 yo:**
- Every 3 years
**50 - 64:**
- Every 5 years
73
Describe the time period for **breast screening**.
**50 - 70 YO**
Every 3 years.
74
Describe the **cervical screening** `step by step`.
| **`HR-HPV`**
**Step 1 `HR-HPV test`:**
`- If negative:`
◆ Routine recall (25-49 every 3 years, 50-64 every 5 years).
`- If positive:`
◆ Cytology triage
**Step 2 HR-HPV + ➜ `Cytology triage`:**
`- If cytology normal:`
◆ Re-test HR-HPV in 12 months.
`- If cytology abnormal:`
◆ Colposcopy referral
75
What is the *step by step management* of `genital herpes` on a **pregnant woman** on the `1st and 2nd trimester`?
**1st episode of genital herpes:**
- Aciclovir 400 mg 3x/day for 5 days;
- From the 36th week: aciclovir 400 mg 3x/day until birth;
- C-section birth.
**Recurrent genital herpes:**
- Risk of neonatal herpes is low for vaginal birth.
- From the 36th week: aciclovir 400 mg 3x/day until birth.
76
What is the *step by step management* of `genital herpes` on a **pregnant woman** on the `3rd trimester`?
**1st episode of genital herpes:**
- Aciclovir 400 mg 3x/day `until birth`;
- C-section birth.
**Recurrent genital herpes:**
- Risk of neonatal herpes is low for vaginal birth.
- From the 36th week: aciclovir 400 mg 3x/day until birth.
77
What is the **screening time** for `gestational diabetes`?
24 - 28 weeks.
78
How is the **diagnosis** of `gestational diabetes` done?
**Oral glucose tolerance test:**
`Fasting:` ≥ 5.6 mmol/L
`2h glucose level:` ≥ 7.8 mmol/L
79
How is the **treatment** of `gestational diabetes` done?
**Fasting glucose < 7mmol/L:**
- Diet and exercise;
- Monitor glucose at home 4x/day (fasting and 1h post meals);
- Offer metformin if glucose ⬆︎ after 1-2 weeks.
**Fasting glucose ≥ 7mmol/L:**
- Insulin (with or w/out metformin)
- Diet and exercise.
## Footnote
**NO WEIGHT LOSS!**
80
What are the **symptoms** of `molar pregnancy`?
- Hyperemesis (due to ⬆︎ hCG);
- Painless 1st trimester vaginal bleeding;
- Uterus large for date.
81
What are the **investigations** in `molar pregnancy`?
- **βhCG:** ⬆︎⬆︎
- **USS**: snowstorm/grapes
- Large theca lutein cysts
82
What is the **management** of `molar pregnancy`?
- Suction curettage;
- Monitor urine and serum hCG twice a week until normal values.
- Chemo if choriocarcinoma or ⬆︎⬆︎ βhCG even after uterive evacuation.
83
When can a woman conceive again after molar pregnancy?
**6 months:**
- after normalisation of hCG.
**12 months:**
- after completing chemo
| Contraception: oral or barrier.
84
What are the `indications` for the use `HRT`?
**After menopause:**
- Hot flashes
- Night sweats
- Mood and sleep disturbances
- Headaches
**Early menopause:**
- HRT until 51 years of age
- Prevents osteoporosis
- Cardio protective
85
What are the **risks** associated with `HRT`?
- Breast cancer
- Endometrial cancer (if not given progestogen)
- Ovarian cancer
- Thromboembolism
- Stroke
86
Which is the **safest HRT** on a patient with:
- Migraines
- Risk of clots
- Risk of stroke
- Smoker
Transdermal HRT.
87
# Systemic HRT
When to use `Oestrogen-only` **HRT**?
- Hysterectomy
- IUS
| No need for progestone to protect the endometrial lining.
88
In what situations is advisable to take `combined` **HRT**?
| **`Both oestrogen and progestorone.`**
- Intact womb.
- To prevent against endometrial cancer.
89
# Combined HRT
When to use `sequential/cyclical` **HRT**?
- Early menopause
- Still bleeding
- First 14 days oestrogen only
- Later 14 days oestrogen & progestorone.
90
# Combined HRT
When to use `continuous` **HRT**?
- Menopausal women for > 12 months
- Continuous oestrogen & progestorone
91
What is the **investigation** done in `hyperemesis gravidarum`?
- Electrolytes
- Ketonuria
92
What is the **treatment** of `hyperemesis gravidarum`?
- Normal saline + K⁺
**1st line antiemetics:**
- Cyclizine
- Prochlorperazine
- Promethazine
- Chlorpromazine
- Doxylamine with pyridoxine
**2nd line antiemetics:**
- Metoclopramide
- Ondaserton
- Domperidone
**3rd line antiemetics:**
- Corticosteroids
`Other medications:`
- Thiamine (wernick encephalophathy)
- LMWH
93
Symptoms of intrahepatic cholestasis of pregnancy.
- Pruritus 2nd and 3rd trimester, worse at night (w/out rash)
- Bile acid ≥ 19 micromols
94
Investigation in intrahepatic cholestasis of pregnancy
- Bile acids > 19
- LFT's.
95
Rx of constipation in pregnancy.
- Isphagula (small hard stools)
- Lactulose (when stools remain hard)
- Senna (stools soft but difficult to pass)
96
# Obs & Gyn
Management of stress incontinence
- Pelvic floor exercise
- Surgical tape procedure
- Duloxetine (non surgical candidates)
97
# Obs & Gyn
Management of urge incontinence
- Bladder retraining (increase time in between need to void);
- Anti-muscarinic agents (oxybutin, tolterodine)
98
Define threatened miscarriage.
- Vaginal bleeding
- Fetal heart present
- Cervical os closed
- Little to no pain.
99
Define missed miscarriage.
- Fetus is dead but retained;
- Cervical os is closed.
100
Define inevitable miscarriage.
- Heavy bleeding and clots;
- Cervical os is opened.
101
Define incomplete miscarriage.
- Not all conception products have been expelled.
102
Define complete miscarriage.
- Heavy bleeding and clots;
- Complete expulsion of all products of conception;
- USS: empty uterine cavity.
103
What are the **rules** for `missed COCP` pills?
◉ **1 pill is missed:**
- Take the pill ASAP even if 2 pills are taken on the same day;
- Continue with the rest of the pack as usual;
- No additional contraception needed.
◉ **2 pills missed:**
- Take the pill ASAP even if 2 pills are taken on the same day;
- Continue with the rest of the pack as usual;
- `No UPSI until COCP have been taken for 7 days in a row.`
► **When were the pills missed?**
◆ `Pill free week:` emrgency contraception if UPSI.
◆ `Week 1:` emergency contraception if UPSI.
◆ `Week 2:` No need for emergency contraception.
◆ `Week 3:` No need for emergency contraception + omit free pill week.
104
What are the **rules** for `missed POP` pills?
◉ **Traditional POP's:**
➜ `> 3h late (> 27h since last pill):`
- Take the missed pill ASAP
- Continue with the pack **AT THE USUAL TIME**.
- No UPSI on the next 48h.
- If UPSI occurred after missed pill ⟶ emergency contraception.
◉ **Cerazette (desogestrel):**
➜ `> 12h late (>36h from last pill):`
- Take the missed pill ASAP
- Continue with the pack **AT THE USUAL TIME**.
- No UPSI on the next 48h.
- If UPSI occurred after missed pill ⟶ emergency contraception.
105
What is the dose of **folic acid** taken in `pregnancy` and for how long?
| For all women.
- 400 mcg/day for the first 12 gestational weeks.
106
In **which conditions** is acid folic `increased` (in pregnant women)?
What is the **dose**?
**Dose:**
- 5 mg daily for the first 12 gestational weeks.
**Conditions:**
- *BMI > 30*
- *DM*
- *On antiepileptic medication*
- Previous pregnancy with neural tube defect
- Family hx of neural tube defect
- Personal hx of neural tube defect
## Footnote
1st three condition more important.
107
In **which conditions** is acid folic `taken throrought the pregnancy`?
What is the **dose**?
- Sickle cell disease
- Thalassemia
- Thalassemia trait
➜ 5mg/daily for the entire gestation.
108
How is **ultrasound diagnosis** of `miscarriage` done?
**Crown to rump lenght `miscarriage`:**
- ≥ 7 mm
- No heartbeat
**Gestational sac:**
- ≥ 25 mm
- No fetal pole
109
What are the **contraception methods** influenced by `hepatic enzyme inducers`?
- COCP
- POP
- Implants
110
What are the **contraception methods** `SAFE` when taken with `hepatic enzyme inducers`?
- Mirena
- Copper IUD
- Depo-provera injections
111
What are the `hepatic enzyme inducers drugs`?
**CRAP GPs**
- **C**arbamazepine
- **R**imfapicine
- **A**lcohol (chronic)
- **P**henytoin
- **G**riseofulvin
- **P**henorbabitone
- **S**ulfonylureas
112
Risk factors for ovarian cancer?
- ⬆︎ age
- Gene mutation BRCA1 and BRCA2
- Family hx
- Nulliparity
- Obesity
- Smoking
113
Protective factors against ovarian cancer.
- COCP
- Pregnancy
114
**Symptoms** of `ovarian cancer`?
➔ **Patient > 50 YO**
- Vague abdominal symptoms
- Abdominal distension
- Bloating
- Early satiety
- Loss of apetite
- Pelvic pain
115
What is the step by step **management** of `ovarian cancer`?
**1st step:**
- Abdominal examination
**2nd step:**
`➜ Normal abdominal examination:`
- Test CA-125
- If CA-125 ≥ 35UI/ml **`⟶`** urgent abdominal and pelvis USS
- If USS abnormal **`⟶`** GYN urgent referral.
`➜ Abnormal abdominal examination`
- Ascites, pelvic, abdominal mass.
- GYN urgent referral.
116
What is the cause of PID?
- Chlamydia
- Neisseria gonorrhea
117
Risk factors for PID
- < 25 YO
- New / multiple sexual partners
- Previous STI's
- IUD's
- Uterine instrumentation
118
Symptoms of PID?
- Lower abdominal pain
- Dyspareunia
- Vaginal bleeding
- Purulent vaginal / cervical discharge
- Fever
- Cervical motion tenderness
119
Rx of PID?
**Outpatient**
`Option A`
- Single dose of 1g of ceftriaxone IM / 500 mg ceftriaxone IM
**+**
- Oral doxycycline 100 mg / twice a day for 14 days
**+**
- Metronidazole 400 mg / twice a day for 14 days
`Option B`
- Oral metronidazole **+** oral ofloxacin for 14 days.
**Inpatient:**
`Option A`
- Ceftriaxone IV +Doxycycline IV + Oral metronidazole
`Option B`
- IV metronidazole + IV ofloxacin
120
What is placenta abruption?
- Premature separation of the placenta before birth;
- Bleeding can be concealed (behind the placenta);
- Bleeding can be through the cervix.
121
What are the `risk factors` for **placenta abruption**?
- Pre-eclampsia
- Multiparity
- Trauma
- Cocaine
- Smoking
122
What is the `management` for **placenta abruption**?
- Fluid resuscitation
- Blood transfusion
- C-section and delivery
123
Describe what is placenta praevia?
When the placenta lies in the lower uterine segment (entirely or partially).
124
What are the `symptoms` for **placenta praevia**?
- Painless vaginal bleeding
- Abnormal fetal lie
125
What is the `management` for **placenta praevia**?
- Continuous monitoring
- C-section
126
What is the `investigation` done in **placenta praevia**?
- Speculum exam
- Transvaginal USS.
| **Digital cervical exam `NOT DONE!!`**
127
DDx of antenatal haemorrhage.
**Placenta praevia:**
- CTG no fetal distress;
- Painless bleeding
- Blood is from maternal circulation
**Placenta abruption:**
- CTG with fetal distress
- `Painful` bleeding (might be absent if concealed).
**Vasa praevia:**
- CTG with fetal distress (fetoplacental circulation)
- Painless bleeding
128
What are the **symptoms** of `PCOS`?
- Oligoamenorrhea
- Subfertility
- Hirsutism
- Acne
- Obesity
- Hyperglicemia
- Acanthosis nigricans
- Alopecia
129
What **investigation** is done in `PCOS`?
- ⬆︎LH:FSH
- ⬆︎ Testosterone
- USS: Multiple cysts in the ovaries or ↑ ovarian volume.
130
What is the **management** of `PCOS`?
- Fertility improvement
- Fertility/Pregnancy
- Regular periods
- Hyperglycaemia
- Last line
- **Fertility improvement:** weight loss
- **Fertility:** Clomifen
- **For regular periods:** COCP
- **Hyperglycaemia:** Metformin
- **Last line:** laparascopic ovarion drilling
131
When can COCP be used postpartum?
**Not breastfeeding:** ≥ 6 weeks
**Breastfeeding:** ≥ 6 months
| < 6 weeks: risk of clots.
>6 and < 6 months: ⬇︎ breast milk.
132
# **Postpartum contraception**
Woman who is not breastfeeding.
| When should contraception be initiated?
- 3 weeks (21 days).
- `NOT COCP` (> 6 weeks only).
| < 6 weeks: risk of clots.
133
# **Postpartum contraception**
When can IUS/IUD be inserted after birth?
- Within 48h postpartum
OR
- After 28 days postpartum
| Risk of uterine perforation.
134
What ACEi antihypertensives are safe postpartum?
- Enalapril.
135
# **Post-pill amenorrhea**
After how long should the patient **wait before investigations can be done**?
6 months.
136
What investigations are done in **post-pill amenorrhea**?
- **FSH:** normal
- **LH:** Normal
- **Oestrogen:** normal
- **Thyroid function:** normal
- **Prolactin:** slightly elevated
137
What is the treatment of **post-pill amenorrhea**?
- Reassurance
- Clomiphene *(to induce ovulation if wanting to get pregnant)*.
138
How is the **diagnosis** of `pre-eclampsia` made?
➜ Hypertension
➜ ≥ 20 weeks gestation
➜ And/or one of the following:
► **Protein:Creatinine ratio:**
- PCR ≥ 30 mg/mmol
► **Albumin:Creatinine ratio:**
- ACR ≥ 8 mg/mmol
► **24h urine protein:**
- ≥ 0.3 g/24h
139
Management of pre-eclampsia?
**First line:**
- Labetalol oral
- Hydralazine (IV)
- Nifedipine or methyldopa
► MgSO₄
► Delivery
140
Define premature ovarian syndrome.
- Onset of menopausal symptoms;
- ↑ gonadotropin
- `< 40 years`.
141
**Investigation** done in `premature ovarian failure`?
-⬆︎ FSH: >25 IU/L (Taken 4 weeks apart)
- ⬇︎ Oestradiol
142
**Management** of `premature ovarian failure`?
HRT until 51 years of age.
143
Describe the different menopause terms.
**Premature menopause:**
- 12 months of amenorrhoea
- < 40 years
**Early menopause:**
- 12 months of amenorrhoea
- 40 - 45 YO
**Menopause:**
- 12 months of amenorrhoea
- > 45 YO
**Perimenopause:**
- Symptoms of menopause
- < 12 months of amenorrhoea
144
When does PMS happen?
- Luteal phase (after ovulation and before menstruation).
145
Management of PMS?
COCP.
146
Management of ⬇︎ fetal movements.
`> 28 weeks gestation + mother sure of ⬇︎ fetal movements`
**First step:**
- Fetal hand-held dopller ultrasound
- If visible fetal heartbeat go to next step.
**Second step**
- CTG
`> 28 weeks gestation + mother UNSURE of ⬇︎ fetal movements`
- Mother should lie on her side for 2h
- Count fetal movements
- If < 10 ⟶ go to hospital.
147
Explain how does **Rhesus negative pregnancy** happens.
- Rh negative mother gives birth to Rh positive baby;
- Antibodies formed cause haemolysis in subsequent pregnancies.
148
Explain the `prevention of Rh incompatibility` in pregnancy.
- All Rh negative mothers should be tested for anti-D antibody;
**Not previously sensitised mothers**
-Offer anti-D immunoglobulin at 28 weeks (single dose) or at 28 and 34 weeks (2 doses).
149
# **Rh incompatibility**
When can anti-D immunoglobulin be given within 72h?
- Delivery of Rh positive infant
- Abortion
- Miscarriage after 12 weeks
- Ectopic pregnancy
- Antepartum haemorrhage
- Amniocentecis and chorionic villus sampling
150
Name the teratogenic medications.
- Warfarin
- Methotrexate
- Sodium valproate
- Retinoids
| Use of contraception whiles taking these drugs.
151
What is the **Rx of UTI** in `pregnant woman`?
**Trimethoprim**
- Avoid in the 1st trimester
**Nitrofurantoin**
- Avoid at term (from 37 weeks)
**2nd & 3rd trimester:**
- Cefalexin
- Trimethoprim
152
What is drug of choice for **pain relief** in `pregnancy`?
Paracetamol.
153
Management of postmenopausal UTI?
**1st line:**
- Vaginal oestrogen
**2nd line:**
- Prophylatic antibiotics
154
Postpartum endometritis Rx
IV co-amoxiclav.
155
When are **ultrasounds** offered thorought the course of an `uncomplicated pregnancy`.
**10 - 13 weeks:** dating scan
**18 - 20 weeks:** fetal anomaly scan
156
Nutrional supplements of an uncomplicated pregnancy?
**Folic acid:** 400 mcg per day until 12 weeks.
**Vitamin D:** 10 mcg/day for the entire pregnancy.
157
Pregnancy trimesters in weeks.
**- 1st trimester:** conception until 12 weeks.
**- 2nd trimester:** 13 weeks until 27 weeks.
**- 3rd trimester:** 28 weks to term.
