OBS + GYN Flashcards

Question 1

Q

Question 2

Q

What is leiomyoma -presentation -dx -mx

Answer

A

-Most are asymptomatic and can present as pressure symptoms, menorrhagia, dysmenorrhoea -Submucosal; menorrhagia, subfertility, pregnancy loss -Sub serosal; acute torsion Dx; -TVUS–> diagnose and assess location +/- endometrial biopsy if suspicious to exclude malignancy -FBC–> anaemia -MRI done for pre-op planning Mx; -only done if symptomatic Medical; -COCP, mirena, depot -GnRH agonist for 6 months Surgical; done if want to keep uterus -myosure; hysteroscopic removal -myomectomy; laparoscopic vs transabdominal

Question 3

Q

What is the management for secondary amenorrhea

Answer

A

-Restore menses -Treat underlying cause; thyroid, pituitary, PCOS, autoimmune -Improve fertility; IVF, adhesiolysis

Question 4

Q

What are the ix for primary amenorrhea -what are the levels for hyper and hypogonatropic hypogonadism

Answer

A

-FSH, LH, Oestradiol, prolactin, TSH -Hypo= FSH <7 and LH <5 -Hyper= FSH >20 and LH >40

Question 5

Q

What are the ix for menorrhagia

Answer

A

-Bedside; speculum/pelvic exam +/- STI screen -Bloods; FBC, iron studies, TFT, BHCG -If indicated do; coags, TVUS, hysteroscopy

Question 6

Q

What is the mx for menorrhagia

Answer

A

-Counsel patient; explain normal menstrual physiology -Medical; NSAIDS, tranexamic acid (reduce blood loss), COCP (can block menstruation), GnRH agonist (blocks menstruation and can reduce size of fibroids), progesterone -Surgical; endometrial ablation, hysterectomy

Question 7

Q

What are the indications for a hysteroscopy

Answer

A

o >35y o USS inconclusive o Determine location of lesion o Endometrial biopsy

Question 8

Q

What are the indications for endometrial biopsy

Answer

A

-Taken to exclude endometrial cancer or atypical hyperplasia in those with; persistent intermenstrual bleeding, treatment failure for dysmenorrhea or menorrhagia

Question 9

Q

What is the mx of PMS

Answer

A

Non-pharmacological; Regular exercise Relaxation techniques CBT Pharmacological; COCP - suppresses ovulation to treat somatic symptoms SSRI - sertraline reduce affective & somatic symptoms NSAIDs for pain Spironolactone - consider if fluid retention

Question 10

Q

What is endometriosis -RF

Answer

A

-Abnormal growth of endometrial tissues (glands and stroma) beyond the uterine cavity (to ovaries, uterosacral ligament) -affects 15-30% of fertile women, mainly regresses after menopause RF; family history, anything that promotes retrograde menstruation (outflow obstruction, menorrhagia, nuliparity, cervical stenosis)

Question 11

Q

What ix are performed for diagnosis of endometriosis

Answer

A

TVUS Exploratory laparotomy (diagnostic); Direct visualisation with biopsy is required for definitive diagnosis Appearance - mulberry spots (dark blue or brown-black growths) in the pelvis; endometrioma of ovaries (chocolate cyst) -Will show endometrial type epithelia/glands, endometrial type stroma, evidence of cyclical activity (old blood, haemosiderin laden MO) -Laparoscopy is indicated in infertile women regardless of pain symptoms or TVUS results as 50% will have endometriosis and the other % will have pelvic pathology

Question 12

Q

What is the management for endometriosis

Answer

A

-Start treatment before surgical confirmation of disease -Explanation; Describe disease, Chronic condition often requiring long-term treatment, Good thing is it can be effectively treated
-Medical;
Use - start immediately, may be stopped post-surgery if pain is controlled COCP*
- inhibits ovulation which reduces cyclical pain; use continuously if effective; Mirena is an alternative NSAIDs* - paracetamol + naproxen with menstruation Goserelin
- indicated for endometriomas (down regulates gonadotropins), reduces pain and recurrence

Surgical;
Indications–> Infertility, Severe pain or other symptoms responding to medical therapy
Procedure–> Laparoscopy with excision of implants, ovarian cystectomy of endometriomas
-Bilateral salpingo-oophorectomy with hysterectomy is definitive

Question 13

Q

What is a uterine fibroid/leiomyoma -who does is occur in -how does it present -what are the RF -what are the different types

Answer

A

-Leiomyoma is a benign tumour of the smooth muscle and occurs in 70% of women by the age of 45 –> each develop from a single SMC and respond to oestrogen (decrease in size after menopause)
-majority are asymptomatic though can present with AUB, pelvic/low back pain, pressure symptoms (difficulty urinating, constipation or rectal pain, abdominal cramping) or fertility issues, menorrhagia/dysmenorrhea, miscarriages, premature contractions
RF; high BMI, nulliparity, fam hx, HTN Types; subserosal (most common), intramural, sub mucosal
-Fibroids may outgrow their blood supply and degenerate–> can cause severe pain -Clinical exam will reveal an enlarged uterus or uterine mass that may be smooth or irregular

Question 14

Q

What is the medical termination of pregnancy available in QLD

Answer

A

MS-2 step; consists of miferpristone (anti-progesterone) and then take misoprostal 2 days later (causes uterine cramping)
Have heavy bleeding for 2-3 days, and bleeding continues for 10-14 days
2% have failure of termination, some may require D&C
Medical termination needs to be done within 9 weeks (63 days)

Question 15

Q

What are the steps in STI management/workup

Answer

A

Assess patient risk; 6 P’s
Obtain test sample; urine vs swab
Begin tx if high risk of suspicion (even before test result comes back)
Advise; no sexual intervouse for 7 days post tx, no sex with partners from last 2 mo. until tested and treated, contact tracing of all STI (patient vs practitioner)
Inform patient of; practice of safe sex and risk and complications of STI’s
Test for cure after treatment

Question 16

Q

How is a diagnosis of PCOS made
-what is the criteria used

Answer

A

Rotterdam criteria; requires 2 out of 3 components

Oligo/anovulation
- cycles last longer than 35 days or go for less than 21 days (need to wait 2 years after menarche for this to be conclusive)
Hyperandrogenism (clinical or biochemical)
- Hirsutism, increased free testosterone (can’t be on contraception for 3 months as this can falsly eleveate levels)
Polycystic ovaries on USS
- TVUS identify over 10 antral follicles in each ovary

Other tests to aid in diagnosis;

HMB - FBC, TFTs, swabs

Androgens - free testosterone; ↑free androgen index (↑total testosterone : SHBG); ↑DHEAS

Day 3 LH & FSH - determine if ovulatory; ↑LH:FSH

Prolactin - rule out hyperprolactinemia (anovulatory)

TFTs - hyperthyroidism

OGTT & fasting lipids;

All women with PCOS are insulin resistant (mandatory OGTT)

Associated with dyslipidaemia

Question 17

Q

What is the mx of PCOS

Answer

A

-Lifestyle measures; weight reduction, healthy diety with reduced calories, increase exercise–> even 5% weight loss can restore menses

-Irregular menstrual cycles; manage with COCP, cyclic progestins, metformin (improves ovulation)
Infertility; counsel the patient on importance of lifestyle factors, can use clomiphene citrate (triggers the brain’s pituitary gland to secrete an increased amount of follicle stimulating hormone (FSH) and LH (luteinizing hormone)), can also consider using metformin, gonadotrophins or surgical management with ovarian drilling
-Hirsutism; cosmetic therapy such as laser, or COCP (containing cyproterone acetate), anti-androgen monotherapy (spironolactone, finasteride)

Question 18

Q

What are the risk factors for endometrial cancer

what are the protective factors
how is a dx made
what is the mx

Answer

A

Age over 60
HTN, obesity, diabetes, unopposed oestrogen (type 1)
clear cell carcinosarcoma, not linked to oestrogen exposure (type 2- poorer prognosis)
Lynch syndrome
Protective; multiparity, smoking, progesterone (mirena), OCP, normal BMI
Dx; pipelle biopsy or hysteroscopy D/C

-Mx;
-hysterectomy and bilateral salping-oopherectomy and LN
sampling
-progesterone; if want to preserve fertility or poor surgical candidate (use mirena)
-chemoradiation if high risk

Question 19

Q

Why has screening for cervical cancer changed

Answer

A

Grows slowly; most people are exposed over their lifetime but can clear the virus on their own- also majority of women are vaccinated
More known about the developement of HPV

Question 20

Q

What is the staging for cervical cancer

Answer

A

0 - CIN

1 - limited to cervix

2 - upper 1/3 of vagina involved

3 - pelvic wall or lower 1/3 of vagina

4 - beyond pelvis (bladder, rectum, distant metastasis)

Question 21

Q

How are uterine prolapse/cystocele/rectocele/enterocele graded and classified

Answer

A

-Using POP-Q system
Grade 0; not present
Grade 1; descent halfway to the vaginal introitus (>1cm above hymenal ring)
Grade 2; descent to the vaginal introitus (<1cm above or below the hymenal ring)
Grade 3; descent halfway past the vaginal introitus
Grade 4; prolapse fully outside the vaginal introitus

Question 22

Q

What is the management for cervical cancer (not LSIL/HSIL)

Answer

A

Surgery;

cone biopsy for small lesions
radical hysterectomy + nodal staging (after family)
tracehlectomy +nodes (cervix and upper part of vagina is removed but uterus kept)-> done if wanting to preserve fertility

Chemoradiation;
-done for advanced stages where cancer is in parametrium/invasive

Question 23

Q

What are the Delancy levels of vaginal support
-What organs are contained and what are the support ligaments for;
Level 1
Level 2
Level 3

Answer

A

Level 1; uterus and cervix- supported by cardinal and uterosacral ligaments + round ligament
Level 2; split into anterior and posterior- anterior has bladder supported by pubo-cervical fasciae and posterior has recutm supported by recto-vaginal fasciae
Level 3; also split into anterior and posterior- anterior has urethra supported by pubourethral ligament, posterior has perineal body and anus supported by pernieal muscles/membrane/levator ani

Question 24

Q

What are the common symptoms of a pelvic organ prolapse
-What are the management options

Answer

A

-Vaginal bulge, dragging in the lower pelvis/back, sexual dysfunction, difficulty urinating/defecating, urinary incontinence, manual digitation (empties rectum by pushing contents out via vaginal digitation)

-Management depends on age, fertility plans and degree of prolapse
-Non surgical mx; pelvic floor exercises, ring pessaries
-Surgical; post-menopausal women need 4-6 wks of oestrogen therapy to improve quality of vaginal tissue;
UTERINE; hysterectomy or uteropexy
URETHRAL; anterior vaginal repair with or without mesh
RECTAL; posterior vaginal repair

Question 25

Q

What are the 4 main types of incontinence; what are they, what are the main causes and management
-what are the 2 other subtypes

Answer

A

*1. stress**
urine loss with exertion or straining (coughing, laughing, exercise)
due to failure of normal anatomic supports of the urethrovesical junction or failure of the bladder neck to close sufficiently
due to vaginal births, chronic constipation, obesity
Mx; strengthen the muscles (kegel’s), occlusive pessaries, localised oestrogen (engorgement of periurethral blood supply causes thickening of the urethrl mucosa), surgical suburethral sling
*2. urge
**sensory incontinence (urine irritates bladder and causes frequency) and motor incontinence (detrusor hyperactivity- urge to micturate before bladder is full)
caused by acute/chronic UTI’s, bladder cancer/stones, interstitial cystitis, can be secondary to an obstruction
mx with CBT or oxybutynin
*3. mixed
**involuntary leakage of urine associated with a combinatino of urge and stress symptoms
*4. overflow**
frequent or constant dribbling and difficulty voiding (associated with overdistension of bladder)–> caused by MND, outlet obstruction (pelvic organ prolapse), diabetic neuropathy, radical pelvic surgery
Other types include anatomical and functional

Question 26

Q

What are investigations for incontinence

Answer

A

-Mid stream urine; dipstick and analysis (looking for UTI)

Urinary diary; track input, output, frequency of voiding and incontinence
If conservative treatment options fail then can investigate with urodynamic studies–> looks at urine flow rates, residual volume measurement, intrinsic detrusor pressure measurement

Question 27

Q

What are the conservative, medical and surgical mx options for tx of incontinence

Answer

A

Conservative; treat UTI’s, weight loss, manage chest conditions (to decrease cough), limit water intake, manage medications (decrease diuretic dose), limit caffiene, bladder training
Medical; anticholinergics (oxybutinin- decreases detrusor stimulation), botox injections, pessaries
Surgical; polypopylene tension free vaginal tape

Question 28

Q

What is a colposcopy

what are the indications
what is the process
what is done if an abnormality is found

Answer

A

*INDICATIONS;**
Symptomatic - post-coital bleeding, dyspareunia, discharge etc.
HPV 16 or 18 identified on screening
LSIL - <30 & still present at 12 month re-test OR >30 with no history of negative test in past 2 years
Any HSIL
Any glandular abnormality/adenocarcinoma
*PROCESS;**
Inspection of the cervix-> need to identify the SCJ (border between pink ecto and red endocervix) and also the transformation zone (velvety red patch)
Apply acetic acid–> ectropions, CIN and cervical cancer will all turn white–> biopsy these portions
Apply iodine–> dysplastic/cancer will turn yellow whilst normal tissue will turn dark brown–> biopsy these areas
abnormal areas will have irregular margins, punctuation and mosaicism
Biopsy the most abnormal areas-> if biopsy shows dysplastic cells in only upper 1/3rd of epithelium= LSIL (CIN1), if biopsy shows dysplastic cells spanning 2/3rd of whole depth of epithelium= HSIL (CIN 2/3)
LSIL and HSIL can spontaneously clear but can also progress to cancer–> NEED TO COUNSEL THAT THIS IS NOT CANCER BUT A PRECURSOR AND THAT HSIL REQUIRES TREATMENT BUT LSIL DOES NOT

Question 29

Q

How are HSIL lesions managed

Answer

A

LLETZ procedure; large loop excision of the transformation zone–> can be done in clinic or under general anaesthetic
Cone biopsy; indicated if cancer is very likely or there are suspected glandular abnormalities–> has to be done under general as large portion of tissue is taken
*Follow-up**
Will have testing after the procedure at 3,6 and 12 months - colposcopy and HPV

Question 30

Q

What are the presenting features of vulval cancer

what are the RF
what is the mx

Answer

A

Presenting features; vulval lesions, itch/discharge
RF; 90% are SCC, linked to HPV, smoking, chronic vulval irritation or inflammation, lichen sclerosis, smokers, immunosuppression

-Mx; surgical excision and LN resection if >1mm invasion, may also need chemo/radiation depending on stage

Question 31

Q

What are the presenting features of ovarian cancer

what are the RF
what are the types of sex cord-stroma tumours
what are the type of germ cell tumours
what are the stages for ovarian cancer
what is the mx for ovarian cancer

Answer

A

Presenting features; pelvic/abdominal pain, abdo discomfort/bloating, ascites, back/leg pain, weight loss, nausea, anorexia, ovarian torsion, virilisation/increased oestrogen, upper abdo mass, pleural effusion (meegs syndrome)
RF; nulliparity, infertility, fam hx, BRCA 1/2
Sex cord stromal tumours; arise from granulosa/thecal/stromal cells in the ovaries; become fibroma, thecoma, sertoli cell tumour
Germ cell tumour; arise from ova; teratoma, dysgerminoma, emrbyonal cancer –> majority are malignant and release AFP/B-HCG

Staging;
1; confined to one ovary
2; beyond ovary within pelvis
3; peritoneal implants of LN
4; distant mets (pleural effusion)

*Management;**
all managed surgically
oopherectomy for stage 1
hysterectomy + BSO (bilateral salpingo-oopherectomy) + cytology washings + peritoneal biopsies
chemotherapy

Question 32

Q

what are the presenting features of vaginal cancer
what are the RF
what is the mx

Answer

A

Presents as vaginal mass, discomfort, vaginal discharge, post-coital bleeding, lesion seen on VE
RF; 1-3% of gynae cancers, all same RF as cervical cancer-> smokers, COCP, immunosuppression, STI’s
Mx; surgical excision/radiation

Question 33

Q

What is gestational trophoblastic disease

signs, symptoms
types
management

Answer

A

-Occurs when there is abnormal proliferation of trophoblastic tissue (placental) triggered by 2 sperm fertilising 1 egg
-4 main types;
Complete mole; empty ova with 2 sperm
Partial mole; ova with 2 sperm, can form fetal parts
Invasive mole; invades the myometrium and can cause haemorrhage
Choriocarcinoma; trophoblastic tissue spreads and is highly malignant, can spread to lungs
-Presents with extreme symptoms of pregnancy; hyperemesis gravidarum, abnormal bleeding, high BHCG, can present due to missed periods
-Managed by D+C, monitor BHCG afterwards until negative, COCP after toe nsure no early pregnancies, if BHCG not dropping then may need to use chemotherapy to eradicate tissue (esp. choriocarcinoma)

Question 34

Q

What is an ectopic pregnancy

what are the RF
what are the common sites
what are the ix
how do they present
what are the complications (what is the pathopophys of rupture)

Answer

A

Pregnancy outside of the uterine cavity–> embryo most commonly will impant in the fallopian tubes but can also be found in the ovaries, peritoneal cavity, cervix
RF; previous ectopic, IUD, IVF, PID, tubal ligation
Haemorrhage can occur when the trophoblastic cells invade the walls of the fallopian tubes and erode into BV
Present as missed menses, abdo pain (initiailly unilateral and then becoming generalised peritonitis, PV bleeding (early spotting developing ot haemorrhage), shoulder tip pain, syncope

Ix; BHCG, FBC (anaemia), G+H, UEC/LFT (before giving methotrexate), coags, TVUS (IUP will be visible by 5-6 weeks, if no IUP visible but high BHCG suspect ectopic)
-Features of ectopic on USS; absent IUP, tubal pregnancy visualised in adnexa (uncommon), free fluid in pouch of douglas (if peritoneal implantation)

Question 35

Q

What is the mx of an ectopic pregnancy

Answer

A

Expectant; aka conservative management (done if found incidentally, if the patient is haemodynamically stable, if BHCG is falling and theres no signs of rupture)–> is the woman’s preference, need to educate woman on need for follow up if ongoing pain/bleeding and need for BHCG testing every 2 days until level begins to fall
Medical; Unruptured & haemodynamically stable, small <3cm, no active bleeding, BHCG <5000, routine bloods normal (FBC/UECs/LFTs)–> use methotrexate (inhibits DNA synthesis) and perform follow up BHCG and then USS at 1 week AND advise to delay imminent pregnancy due to teratogenicity
Surgical; done if preferred or evidence of rupture, unstable, excessive bleeding–> salpingectomy (removal of tube) or salpingotomy (removal of ectopic with conservation of tube)

Supportive care;
IDC & monitor U/O - if severe
NBM
IVFs
Analgesia & anti-emetics
Anti-D Ig - give to Rh -ve women to prevent the formation of RhD Abs
-Give info about management option chosen, what side effects to expect (N/V, abdominal pain, PV bleeding), and access to services (psychological support)

Question 36

Q

What are risk factors for prematurity

Answer

A

Multiple pregnancy
Cervical insufficiency
Pre-eclampsia
Placental abruption
IVF
Poor maternal nutrition, limited antenatal care, low SES, prior abortions

Question 37

Q

What are some causes of a vulval itch

Answer

A

Can be based on appearance;
Erythematous;dermatitis, candidiasis, psoriasis, tinea, vulval intraepithelial neoplasia
Pallor; lichen sclerosus, lichen simplex, vulval intraepithelial lesion
Erosions; apthous ulcers, lichen planus, herpes
Itchy vaginal discharge; candidiasis, bacterial vaginosis, trichomoniasis, STI, foreign body

OR can be based on cause;
Infection; candidiasis, trichomoniasis, HSV
Dermatoses; dermatitis, warts, psoriasis, tinea cruris, lichen planus/sclerosus
Local irritation; atrophic vaginitis, hari removal, lubricants, condoms, tight clothing, sanitary wear

Question 38

Q

What are the common effects of menopause on the;

Vasomotor system
Urogenital system
Breasts
Bones
CVS
Skin
Psychology

Answer

A

Vasomotor; hot flushes, night sweats, insomnia–> due to rapid decrease in oestrogen causing relief of inhibition of hypothalamus= release of adrenaline and serotonin
Urogenital;
-there is decreased vascularity and epithelial lining= atrophy and irritation
-decreased glycogen and lactic acid= alkaline state= infection
-laxity of ligaments in the pelvic floor= incontinence and prolapse
Breast; dense tissue is replaced by fat= sag
Bone; decreased oestrogen causes relief of inhibition of RANK= osteoclastic action and bone resorption=osteoporosis
CVS; oestrogen causes high HDL/low LDL= high CVS risk
Skin; decreased collagen causing thinning and drieness
Psych; anxiety, irritability, forgetfullness (limited evidence)

Question 39

Q

What are the management options for menopause
-indications for HRT, contraindications, side effects of HRT

Answer

A

Lifestyle changes;
-Stress reduction (CBT, mindfullness), Regular exercise–> resistance aids in bone strength, healthy diet, optimal weight, avoid smoking, decrease caffiene and alcohol
Vasomotor symptoms; avoid trigers, sleep in cool room
Address bone density; vitamin D + calcium, exercise and weight training

Non-hormonal options;
-Address vasomotor symptoms; SSRI/SNRI (venlaxafine- reduce hot flash), clonidine, gabapentin

HRT;

recommended in women with distressing menopausal vasomotor symptoms, those with primary ovarian insufficiency (used until normal age of menopause)
CI; CVD, CVA, VTE, BrCa, AUB, smokers, active SLE, abnormal LFT
Can cause breast tenderness, fluid retention, menstrual spotting, increased risk of VTE
Women with a uterus require both oestrogen and progesterone for HRT

Question 40

Q

What is the MOA of the COCP
What are some adverse effects
How should a patient be counselled to take the pill

Answer

A

Synthetic oestrogen and progesterone causes inhibition of ovulation, decreases receptivitity of endometrium to implantation, increases cervical mucous production to prevent entry of sperm
Also used for acne (hormonal), endometriosis, dysmenorrhoea/menorrhagia
Adverse effects; nausea, breakthrough bleeding (due to thinning of endometrium), decreased libido, mood change, HTN, altered lipid profiles, VTE

Need to counsel patient to;

Begin the pill on the first day of your period (or within 5 days), the placebo tablets allow for a withdrawal bleed (pregnancy should be suspected if withdrawal bleed is missed twice), continue taking pill everyday and if one pill is missed take it the next day (can double up and still be protected if they have been taking the pill for 7 consecutive days), if more than one pill is missed take most recent pill and then continue taking pill for next 7 days whilst also using barrier contraception (as won’t be protected)
This goes for vomiting and antibiotics- continue taking pill but use barrier contraception for 7 days after
Advise to seek help urgently if suffering from chest pain, leg pain, severe headache
Follow up in 4-6 months to assess side effects and check BP

Question 41

Q

What are the risks and benefits between COCP and progesterone only mini pill

Answer

A

COCP;

reduce risk of endometrial and ovarian cancer
window to take pill
aids in acne, dysmenorhea, menorrhagia, endometriosis, contraception
Risk of breast and cervical cancer, risk of VTE
CI in those over 35/obese/smokers/clotting history/breast feeding

Minipill;

has to be taken at same time every day (only lasts 24 hours)
can be taken in those with thrombophilia or past VTE, those who are breastfeeding & can be used any time after pregnancy (although nothing required for first 3 weeks), can be taken by smokers >35 and other contraindications to COCP (those with clotting disorders)

Question 42

Q

What is the MOA of the mirena

what are some cautions/CI
what are some adverse effects
how to counsel patient

Answer

A

MOA; IUD releases levonorgestrel (synthetic progesterone) and prevents implantation in endometrium, thickens cervical mucus, can suppress ovulation in some women (hence why some get amenorrhea)
Caution with anatomically disorted or fixed retroverted uterus due to difficulty with implantation and also risk of perforation, CI in pregnancy/breast cancer/SLE
Safe to use with breastfeeding

Adverse effects;
-Post insertion pain or cramps, prolonged or irregular bleeding (settles after 3-6 months), reduced menstrual flow, expulsion of devise, depression, acne, uterine perforation, risk of pregnancy

Counsel;

Periods may be irregular and prolonged, may have spotting, may have amenorrhea
See your doctor if you have signs of infection; fever, abdo pain, discharge
Regularly check for presence of the strings
Replace every 5 years

Question 43

Q

What is the MOA of medroxyrogesterone (depot)
What are the indications and CI
What are the adverse effects
How often are injections given

Answer

A

Is progestin that can be given orally or IM for contraception (IM), HMB or secondary amenorrhea (oral), endometriosis, HRT
CI; breast cancer, current VTE, SLE, surg (basically anyting promoting clotting), SAFE FOR BREAST FEEDING
Adverse effects; 50% become amenorrhoic, delayed return of periods, loss of BMD, weight gain, menstrual irregularity, prolonge dbleeding, acne, decreased BMD, decreased libido, androgenic effects, cholestatic jaundice
Injections given every 12 weeks for contraception, injections can be given within 2 week window of the next date

Question 44

Q

What are the different methods of female sterilisation

what are the other options needing to be discussed
what are the risks and complications of sterilisation
contraindicatikons
do they need concurrent contraception?

Answer

A

Laparoscopic; involved using titanium clips to clamp off each fallopian tube
Caeserean section; done after delivery and uterine closure, the fallopian tibes are tied and cut, this method is irreversible
Hysteroscopic; given GA, cervix is dilated and a hysteroscope is inserted through the cervix, once the tubal ostia (opening) is visualised a coil is placed to obstruct it; need post op imaging to ensure correct placement

-Other methods women needs to be informed about for contraception are COCP/Mirena/Depo/Implanon/minipill and also male vasectomy (which is a shorter procedure with less risk)

Risks and complications;
-Unsatisfactory placement of device leading to failure, bowel/bladder/vessel damage during procedure, may need to convert to open if unable to do it laparoscopically, all other general risks (NV, bleeding, reaction to gas, aetlectasis, DVT), increased risk of ectopic, pregnancy (1 in 250) adhesions, hernias, menorrhagia or oligomenorrhoea, REGRET

contraindications; not 100% definite on decision, suspected or confirmed preg, active or recent pelvic infection, untreated acute cervicitis, unexplained or severe vaginal bleeding

-Need to inform patient to use contraception until the procedure as the procedure can’t be done if a blastocyst has already implanted, also need to use contraception until next menses after sterilisation to ensure adequacy

Question 45

Q

What is the procedure for male sterilisation
how effective is it
what are the CI
what are the differences between a conventional and no-scalpel vasectomy
what are the complications and risks
do they still need to use contraception? what is the follow up
what is the pre-op and post-op info for patient

Answer

A

Vasectomy
99% effective and have a better success rate than bilateral tubal ligation in female (33x more effective than the pill)
CI; coercion or unsure about decision, large hydroceles or varicoceles, scrotal infection
Conventional vasectomy involves incising the scrotal skin and surgically separating the vas from surrounding structures and then tying and cutting the ends–> takes longer and has more pain/recovery time
Non-scalpel vasectomy; vas is located on palpation and small incision is made, vas is brought out and clipped, placed back in scrotum and bandaid used for incision–> quicker, less pain and recovery time

Risks;
-scrotal bruise, testicular/epididymal cyst, ejaculate may never clear of sperm, spontaneous recanalisation and re-anastamosis of vas deferens, epididymitis, granuloma formation leading to pain on ejaculation, chronic testicular pain, fistula formation, general surgical risks

-Still need to use contraception for 6-10wks until semen analysis is done and can confirm no presence of sperm

Pre-op; don’t eat or drink for 3-6 hrs, bring scrotal support (jock strap), shave hair around area
Post-op; can’t driv immediately after, avoid exertion, use analgesia, avoid sexual intercourse for 1 week and refrain from ejaculating for 1 wk

Question 46

Q

What are risk factors for a miscarriage

when do miscarriages mainly occur
what are the causes of miscarriage

Answer

A

RF; high maternal age, previous miscarriage, hx of STI/PID, smoking, alochol, high BMI, fever
-Majority occur within the first 2-3 months of conception, rarely after 15wks
Causes;
-Chromosomal abnormalities; responsible for 50%
-Congenital abnormalities; genetic, secondary to extrinsic factors, teratogens
-Amniocentesis
-Abdo trauma; fall, mva, domestic violence
-Infections; TORCH
-Maternal conditions; hyperthyroism, DM, PCOS
-Hypercoagulable state

Question 47

Q

How does a miscarriage present

what are the ix
what is the mx
What is a a D/C
What counselling should the woman recieve

Answer

A

Presentation; cramping pelvic pain, PV bleeding or dark d/c, amenorrhoea, loss of pregnancy symptoms, cervical shock (retained products may irritate vagal nerve and cause low HR/BP)
IX;
-FBC, serum bHCG (if under 51 means not preg), group and hold + Rh status (if bleeding lots, or may need anti-d for future preg), TVUSS

Mx;

Expectant- done if non-viable pregnancy and the patient is educated, need to be haemodynamically stable and have access to ED; need review after 7-10 days (is basically doing nothing and waiting for contents to be excreted)
Medical- done if small RPOC and early foetal demise and if incomplete miscarriage; given PV misoprostal and wait for contents to be excreted; need to be educated that it will be painful and have sig. bleeding and need USS in 2-3 wks to confirm no RPOC
Surgical- done if women prefers, if the products are infected, having heavy bleeding and unstable haemodynamically, will undergo dilation and curettage

Dilation and curettage;
-Prime cervix with misoprostal (also increass frequency of uterine contractions) –> dilate and enter uterus and remove lining with curette
Risks; infection, retained products, adhesions, perforation, injury to surrounding organs

Counsel; menses should return in 1-2 months, attempt to conceive again in 3 months (or 2 normal periods), recieve USS early in next pregnancy

Question 48

Q

What are the 2 types of abortion

what is their mechanism
what are the CI and risks
what is the follow up

Answer

A

Medical (MTOP)
-Give mifepristone at day 1 (progesterone antagonist that causes women to reject conceptus and cause vasoconstriction) and on day 3 give misoprostal (prostaglandin that causes uterus to contract and expel contents)
Benefits;
-Does not need a hospital, a surgeon, an anaesthetic, or any instrumentation –> needs phone access to doctor
-Takes 1-2 hours to expel after taking misoprostol
-Cheaper - $500
-Gives the woman more privacy, and some degree of control

Limitations;

More likely to fail at 2.5%
More likely to be incomplete at 5%
Carries a very slightly greater risk of infection and bleeding
CI in adrenal failure, coagulopathy, more than 9 wks preg
*Surgical abortion (STOP)**
Use D/C

Benefits;

Completed in 30 painless minutes
Avoids what might be an unpleasant experience
Less likely to fail (0.2%)
More likely to be complete (1% for STOP)
Can be more easily combined with on-going contraception

Limitations;

More expensive - $1000
Risk of haemorrhage, trauma, sepsis, cervical stenosis, incompetence, Asherman’s syndrome, uterine rupture

Follow up in 2 weeks to make sure; bleeding has stopped, no risk of infection, do USS to make sure no RCOP

Question 49

Q

What are the risk factors for pre-eclampsia
-What are the results on organs? (renal, liver, neuro, haem, lungs, fetus)

Answer

A

Past pre-eclampsia
Fam hx of pre-eclampsia
Antiphospholipid syndrome
Maternal age above 40
High BMI
DM, HTN, Renal disease
Multiple pregnancy (ie twins/triplets), primigravida (first time preg)

Effects; PROTEINURIA, HTN, OEDEMA
Renal; proteinuria, oliguria (due to reduced GFR)
Liver; elevated LFT, severe epigastric/RUQ pain
Neuro; headaches, hyperreflexia/clonus, persistant visual disturbances, convulsions, stroke
Haem; low platelets, MAHA, haemolysis, DIC–> due to endothelial activation
Lungs; pulmonary oedema
Foetus; growth restriction
-Can develop HELLP syndrome; Haemolysis, elevated LFT, low platelet count–> causes DIC and placenta abruption

Question 50

Q

How is pre-eclampsia prevented

how is a woman with HTN managed (if identified in routine ante-natal screening)
what anti-htn drugs are contraindicated in pregnancy

Answer

A

Prevention; in mod-high risk pt recommend aspirin daily from 12wks till birth; also need to assess mother with BP/urine dip at every visit

Woman with HTN/pre-eclampsia;

antihypertensive medication is initiated or continued due reduce risk of intracerebral bleed
If the woman did not have pre-existing HTN then her HTN is likely to disappear by week 12
Considered if HTN mod but started if HTN severe (above 160/110)–> first line medication include methyldopa, labetalol, hydralazine
She will recieve regular monitoring of her BP, urine (for PCR), CTG and USS (for foetal growth)
If concerned about pre-eclampsia; order FBC/coag studies/LFT/UEC
Recommend delivery at 37 weeks
If her pre-eclampsia leads to organ dysfunction she may require early delivery of the baby

CI; ACE-I, diuretics, ARB, atenolol

Question 51

Q

What is eclampsia
-how is it managed

Answer

A

-Is pre-eclampsia that is then complicated by generalised tonic-clonic seizures
-Eclampsia is imminent if the patient has 2 or more of the following symptoms–> frontal headache, visual disturbance, altered LOC, hyperreflexia, epigastric tenderness
-Caused by cerebral oedema caused by pre-eclampsia
Mx;
-DRABCD
-Order FBC/UEC/LFT/Coag/G+H
-Give MgSO4 (if actively seizing whilst prepping MgS04 then give benzo)
-Give IV anti-htn (like labetalol)
-Once stable- deliver baby
-Send mother to HDU/ICU

Question 52

Q

What are common medication teratogens
-what are factors that make a pregnancy high risk

Answer

A

ACE-I, ARBS, warfarin (switch to LMWH as does not cross placenta), antiepileptics, lithium, isoretinoin (like roaccutane), methotrexate, NSAIDS (foetal renal impairment, premature closure of ductus arteriosus, increased risk of miscarriage)
High risk preg; extremes of age, high BMI, prev high risk pregnancy, hx of alcoholism/smoking (that have not yet ceased), hx of medical conditions (HTN, DM, epilepsy), multiparous (leads to weakening of the uterine wall causing increased risk of rupture)

Question 53

Q

What are the routine screening for foetal anomalies and when are they done

what are the 2 types of diagnostic tests
what are the 3 types of USS scans performed during preg

Answer

A

Screening;

CFTS (combined first trimester screening); done at 11-14 weeks and is the triple test looking at BHCG, PAPPA, USS nuchal translucency
2nd trimester scan; is the quadruple test- BHCG, UE3, AFP, Inhibin A
NIPT- noninvasive pre-natal testing; can detect aneuploidy but is not covered by government
- If any screening indicates an abnormality the patient goes for a diagnostic test

Diagnostic tests;

Chorionic villi sampling; biopsy of the placenta, done in first trimester
Amniocentesis; 2nd trimester; detects chromosomal/neural tube/genetic defects- 1% chance of spontaneous foetal loss

USS scans;

Dating scan; confirms pregnancy and viability
Nuchal translucency scan; 11-14 weeks; used to detect CVS abnormalities
Morphology scan; 18-20 weeks; assess viability and looks at the anatomical structures

Question 54

Q

What is the method for analysing a CTG
-what things should be recorded

Answer

A

-DR C BRAVADO
DR; define risk; normal pregnant women in labour don’t generally get a CTG (reserved for those at high risk- maternal medical condition, multiple pregnancy, IUGR, pre-eclampsia, PPROM/PROM/Premature labour)
C; contractions; should occur every 2-3 mins and last around 45s-1 min
BRA; baseline fetal HR; should be 100-160 bpm
V; variability; measured by the fluctuations around the fetal HR- should be 5-25
A; acceleration; need at least 2 for CTG to be normal, is 15 beats above the baseline lasting for 15s
D; decelerations (should be 0)
O; outcome; normal CTG?

Record the;

baseline rates
baseline variability
accelerations
decelerations
management

Question 55

Q

What are the 4 main types of decelerations
-what causes them

Answer

A

Early; due to fetal head compressing on cervix and causing ‘high ICP’–> triggers baroreceptors and causes bradycardia; occurs at start of contraction and ceases with contraction; NORMAL
Variable; looks like a V; the babys HR is responding at different times to the contractions and has no continuity; due to cord compression and can spontaneously resolve when the uterus stops contracting and the cord moves; however can be pathological if coupled with tachy
Late; BAD SIGN; baby HR doesn’t respond to contractions until after the contraction has ended; due to uteroplacental insufficiency (hypoxia); causes a ‘U’ shape; due to decreased BF to fetus causing decreased O2 delivery and myocardial depression; when the contraction stops and BF returns the fetal HR will increase again
Prolonged; lasts longer than 90s but under 5 mins; caused by hypoxia but significance depends on clinical picture

Question 56

Q

What is the pathogenesis of gestational diabetes mellitus
-what are the RF

Answer

A

Increased insulin resistance by the mother due to increased human placental lactogen/cortisol/thyroid hormone/glucagon–> causes an insulin resistant state–> triggers mothers placenta to increase insulin production–> if the mother is unable to increase her insulin production= GDM
Insulin does not cross the placenta, but glucose does–> insulin resistance acts to increase glucose available for the foetus–> once glucose is removed (post-birth) the fetus is at risk of developing hypoglycaemia

RF;

ATSI/Asian/Indian/Islander
Past GDM or macrosomic birth
High BMI/AGE -Multiple births
Fam hx of GDM/pmhx of PCOS

Question 57

Q

What complications arise from GDM
-How is GDM screened and diagnosed

Answer

A

Maternal; complications from delivery of macrosomic baby (PPH), 50% develop T2DM within 20 yrs, miscarriage, infection, preeclampsia, complications of DM (retinopathy, nephropathy)
Fetal; macrosomia+complications (shoulder dystocia), RDS (hyperglycaemia reduces surfactant production), IUGR (placental insuffiency), polyhydramnios, increased risk of obesity/T2DM later in life

Screening; all women do a OGTT at 24-28 weeks (if high risk the test is done in the first trimester and again at 24-28wk)
Diagnosed; if the OGTT has a 2hr BSL of greater than 8.5 the pt has GDM (or a fasting above 5.1)
-only need one elevated level

Question 58

Q

How is GDM managed;

non-pharm
pharm
extra ante-natal care?
birth?
post partum?

Answer

A

Non-pharm;
Diet- refer to dietician and reduce carbohydrate intake
Exercise- 20-30min a day, referal to exercise physiologist if need

Pharm;
Metformin; if BSL not resolving after 2 wks; crosses placental barrier but no teratogenic effects; start at 500mg OD and can increase upt to 3g; may exacerbate N/V
Insulin; started if still not controlled on metformin (can be used in conjunction with metformin); if fasting glucose is high then put on long acting, if post-prandial glucose is high then do rapid acting before meals; need to check BSL at clinic every 3 days to ensure level correction
-Both ceased post partum

+ Start aspirin to prevent PTE + folate/iodine

Monitoring- 4daily BSL checks; before meals and 2hrs post prandial; aim for fasting below 5 and 2hr post below 6.7
Increased ante-natal care; referal to high risk ante-natal clinic, testing for preeclampsia, discuss GWG (if normal BMI only want to increase weight by 11-16kg), regular USS from 24wks to assess foetal growth+doppler of cord to assess placental insuffiency, regular urinalysis

Birth; if greater than 4500g recommended caesar
Spontaenous birth is recommended if no complications
Need to consider risks of shoulder dystocia/PPH if macrosomic

Post partum;

feed within 30-60min of birth
regular BSL monitoring of baby and mother; monitor for 24hr
perform OGTT at 6wks to ensure not still hyperglycaemic; if still high BSL then pt has T2DM

Question 59

Q

What is the 3rd stage of labour

what are the signs that the third stage of labour is occurring
how long does this stage last for
what is the process
what complications can arise

Answer

A

Delivery of the placenta
indicated by a large gush of blood and then lengthening of the cord
normally lasts 5-10 min if been given syntometrine, or 30-60 if no syntometrine
need to place controlled cord contraction when the uterus contracts

Complications;

post partum haemorrhage
retained placenta
inversion of uterus

Question 60

Q

What is a Bishop score

Answer

A

PV exam scoring system to determine if labour is likely to commence spontaneously or if induction will be required
assesses; cervical dilation, consistency, length and position plus station of presenting part

Question 61

Q

What is recorded on a partogram

Answer

A

Maternal; BP, HR, RR, BSL and temp
FHR, amniotic fluid (blood, meconium, not perf)
Abdo palpation findings
Cervicograph (dilation and descent of cervix)
If oxytocin has been given
Ix performed
Results of the VE; caput, moulding, station, position, presentation
Bishops score

Question 62

Q

What is caput and moulding

Answer

A

Caput succedaneum= occurs when the foetal head is compressed by the dilating cervix and causes diffuse swelling of the scalp

Moulding; bones of fetal head can overlap (as the fissures and sutures havent closed yet) and allow the diameter of the fetal head to reduce, allowing it to pass through the pelvis

Question 63

Q

What is placental abruption

what are the classifactions
what are the RF
how does placental abruption present
what are the ix
what is the mx

Answer

A

Rupture of maternal vessels in the decidua basalis where it interfaces with the anchoring villi of the placenta
The accumulating blood splits the decidua and separates the thin layer of the decidua with its placental attachement–> the bleed can be small or dissect through the placental decidual interface
Can be complete (whole placenta detached), incomplete (part of the placenta is detached), concealed (no PV bleeding), apparant (PV bleeding)

RF;

Previous placental abruption
Early preg
Pre-eclampsia
Abdominal trauma
Smoking, drug misuse
PROM, IU infection, low BMI, polyhydramnios

Presentation;

dark vaginal bleeding, abdominal pain, uterine irritability/contractility, uterine hypercontractile, uterine hypercontractile state (woody feel), back pain, foetal distress, foetal demise, BUT CAN PRESENT ASYMPTOMATICALLY
need to consider aburption in mother <20wks with sudden onset abdo pain without sign. bleeding

Ix;

CTG-> might show high freq and low amplitude, elevated baseline tone
Foetal HR-> recurrent late or variable decelerations
FBC, G&H, antibodies, kleihauer test (measures fetal Hb in maternal blood)

Mx;

ABC/RESUS/STABILISE
Give RhD Ig + give steroids if gestational age between 24-34 wks
If stable; continue to IOL
If fetal distress; straight to emergency c/s
If significant bleeding may require MTP
If mild bleeding;
Less than 37 wks; CTG, haematocrit, USS to monitor bleeding-> continue until baby mature or continual bleeding
Over 37 weeks; stabalise and deliver (iol or c/s)

Question 64

Q

What is placenta previa

what are the classifications
what are the RF
what is the presentation
what is the dx
what is the mx
complications

Answer

A

-Placenta previa is when the palcenta is insterted partly or wholly into the lower segment of the uterus in the third trimester of pregnancy

Classified into;
Major- placenta overlies the internal os
Minor- placenta doesn’t overly the internal os but is in the lower segment
-Graded based on how much it covers the os (grade 1= lower segment but doesn’t cover os, grade 4- placenta completely covers and surrounds os)

RF;
-previous placenta previa, previous C/S, previous TOP, multiparity, multi-pregnancy, advanced maternal age, smoking, IVF, endometritis

Presentation;

Can be asymptomatic ans just picked up on USS
Can present as painless antepartum haemorrhage, maternal aneamia, foetal malpresentation

Diagnosis;

Made with transvaginal USS (better than transabdo as there will be no fetus to obstruct the view)
picked up on 18wk morphology scan

Mx;

If identified on 18wk scan, redo scan in 32nd week (high grade) or 36th wk (low grade)
counsel on risk of haemorrhage, may need hysterectomy or tubal ligation
give corticosteroids (if delivering before/at 37 weeks, replace iron/blood)
perform caeser at 37 wks (ideally 39 but will have higher risk of bleeding
grade 1 may be able to deliver vaginally at 36 wks

Complications;
fetal hypoxia, IUGR, prematurity, vasa previa, APH, PPROM

Answer 64

A

Vasa previa is when unprotected/unsupported foetal umbilical vessels pass over the cervical os
RF; twins, low lying placenta, placenta prevua, bilobate placenta

Presents;

on 3rd trimester as painless vaginal bleeding with foetal distress
VE may be able to palpate foetal vessels
Causes severe foetal distress and abnormalities in foetal HR during labour

Management;

elective C/S before onset of labour- consider 35/36 wks
potential neonatal resus

Answer 65

A

>500ml blood loss via vaginal birth, >1L via caeser (if over 1L= major bleed)- leading cause of maternal morbidity

Tone; uterine atony is most common cause (70%) and can be due to overdistended uterus (macrosomia, mulitple pregnancy), uterine exhaustion (prolonged labour, anaesthetic use), uterine distortion (fibroids, placentra previa), intra-amniotic infection, iatrogenic (MgS04-given for preeclampsia)
Tissue; retained placental products (accreta), retained blood clots in atonic uterus, abnormal placentation
Trauma; laceration (of uterus, cervix, vagina, perineum), episiotomy tear, uterine rupture, uterine inversion (when too much traction is placed on cord without stabilising uterus)
Thrombin; coagulopathy- acquired (DIC,TTP, Preeclampsia) or pre-existing (haemophilia), anticoagulants

Prevention;

Antenatal; correct anaemia, determine site of placenta
Labour; birht in a tertiary unit, G+H with available blood products, active third stage management (give oxytocin, controlled cord traction, placental massage, delayed cord clamping)

Ix; VBG, Clotting - point of care ROTEM if available, FBC (Hb, PLTs), UECs, G&H and cross-match (2 units pRBCs), coagulation, CMP, LFTs

Mx;
-Resus; ABCDE->
-apply bimanual compression
TONE-> massage fundus and give oxytocin (can also give ergometrine, misoprostol, carboprost if not responding), check placenta and membranes are complete and the bladder is empty
TRAUMA-> inspect all sites and clamp obvious bleeders
TISSUE-> DON’T MASSAGE FUNDUS AS MAY DISLODGE MORE TISSUE-> apply controlled cord traction and attempt delivery, give oxytocin, transfer to OT is the placenta is adhered or has parts missing
THROMBIN-> activate MTP and avoid acidosis/hypothermia, give TXA2 + platelets + clotting factors
THEATRE;
-Ligation of arteries, hysterectomy
-Tone; hysterectomy, balloon tamponade
-Tissue; manual removal of products
-Trauma; tissue repair

Answer 66

A

McRoberts; flexion and abduction of maternal hips and flexing knees so her thighs are on her abdomen; aids in straightening the lumbosacral angle and rotating maternal pelvis to increase to diameter of the pelvis

Rubins 1 manouvre; suprapubic pressure applied along with the McRoberts manouvre to reduce the foetal bisacromial dimaeter and rotate the shoulders

Rubin 2; hand inserted into the posterior aspect of the vagina and pressure applied to the to the posterior aspect of the anterior shoulder; rotates the shoulder towards the oblique diameter; anticlockwise

Woods manouvre; only done if rubin 2 unsuccessful; introduce second hand and rotate baby

Zavanelli manouvre; vaginal replacement of the head and then delivery via C/S

Answer 67

A

Non-pharm; psychoprohylaxis (breathing and relaxation techniques), upright positioning, activation of peripheral sensory receptors (TENS, water immersion, massage)

Pharm; use a pyramid scheme

Paracetamol; early preg only
Morphine or pethidine; used if birth not expected within 4hrs (DO NOT GIVE WITHIN 2 HOURS OF DELIVERY AS CAN CAUSE FETAL RESP DEPRESSION)
Inhaled nitrous oxide; used in early labour, gives mother control but can cause confusion and disorientation
Regional analgesia;
-> Epidural; spinal cord terminates at L1/L2, insert needle into epidural space between L3/L4 or L4/L5 and insert catheter–>inject opiods and local anaesthetic to numb from below hips
->Spinal block; Needle penetrates the dura and injected into the spinal CSF encasing the spinal cord –> used for C/S

Answer 68

A

-Foetal death after 20wks or over 400g birthweight, prior to complete extraction or expulsion from the mother

Causes; congenital abnormality, haemorrhage, placenta issues (insufficiency or abruption), pre-eclampsia, obstetric complications (spontaneous premature labour, PROM, polyhydramnios, oligohydramnios, intrapartum asphyxia, birth trauma), cord prolapse, IUGR, liver disease, DM, infections during preg

RF; IUGR, previous still birth, congenital foetal anomaly, nulliparity, smoking, maternal obesity, advancing maternal age, pre-existing DM, thrombophilia, APH

DX;
Intrauterine- assess wit USS to show lack of foetal heart activity
At birth- no signs of life; nil beating heart, pulsating umbilical cord, definite voluntary muscle movements

Mx;

SPIKES
Educate on delivery; vaginal + active 3rd stage management
If <28wks= misoprostol per vaginum x 8 doses, if >28wks= oxytocin infusion + ARM once labour initiated
If the death was after 20wks gestation or birthweight above 400g then the death needs to be reported to perinatal data collection and death certificate + burial needed

Answer 69

A

PROM; term (greater than 37wk) ROM at least 4hrs before contractions commence
PPROM; premature (below 37wk)

RF; multiple gestations, congenital anomoly, cervical laxity, previous self/fam hx of PROM, infection, multiparity

Complications; infection (chorioamnionitis, neonatal sepsis, maternal sepsis, endometritis), abruption, cord prolapse

Diagnosis made; history (when did it occur, volume, colour/smell (blood stained, clear etc), presence of contractions, gestaitonal age, obs hx) + sterile speculum exam revealing pooling of amniotic fluid in vagina (can test with nitrazine paper or amniosure (looks at alpha-1microglobulin) and can look for oligohydramniosis with USS

Answer 70

A

PROM

need to determine whether managing expectant or active
Expectant–> done if GBS-ve, quick access to hosp, understands the risks and benefits, normal CTG–> D/C home with advice to continue observations, have daily CTG use/4hrly temps/reg pad checks
Active–> manage as pre-term labour; commence tocolysis (nifedipine), commence prophylactic Abx (penicillin), start steroids (betamethasone- 2 doses apart), MgSO4 (if less than 34 wks)–> if tocolysis has failed or is CI then prepare for labour with oxytocin infusion

PPROM

Suspected but not confirmed; admit for pad checks
Confirmed + signs of pre-term labour; suppress labour (tocolysis), obeserve and offer analgesia, give steroids, give proph Abx–> if still no labour start PO erythromycin and d/c home w twice weekly CTG and weekly high vaginal swab
Confirmed and active labour–> steroids + proph Abx + MGSO4, continuous CTG, aim for vaginal delivery
No evidence of labour; d/c home

Answer 71

A

-VBAC is successful in 60-80% of cases
Indicated; maternal choice, when only one caeser has occurred, when the mother wants to maintain normal antomy and wants another vaginal delivery
CI; if more than 3 caesers, previous uterine rupture or incision other than a low transverse, prev hysterotomy or myomectomy

Risks; uterine rupture (esp if multiple preg, macrosomia or multiple C/S), need for blood transfusion, hypoxic ischaemic encephalopathy, PPH, episiotomy tear, death

Benefits; shorter inpatient stay, low risk of DVT/PE, improves maternal bonding due to immediate skin to skin, decrease neonatal resp distress

Counsel;

ask about the birth plan she wants, does she want another caeser?
ask about past c/s hx–> when (CI VBAC if in last 18months), why (emergency or planned), type (only low transverse can have VBAC), complications after, issues with the baby?
PMHX/PSHX/SOCIAL/FMHX/MED/ALLERGIES
BRABAD–> counsel on risks and benefits
provide time for pt to think, arrange follow up with obs/gyn
provide ways to increase VBAC success (lose weight)
If decide to book caeser; advise to come to hospital as soon as contractions start, take FBC/GH/CROSS/put on CTG, perform 4hrly VE

Answer 72

A

Contraception; OCP is not effective with AED that interfere with liver enzymes (ie. phenytoin, carbimazole)-> if wanting contraception better to go for progesterone only pill or the bar/mirena
Conception;
-need to involve neurologist
-aim to have seizures under ontrol 6 months before conception and aim to either cease AED or be on the lowest dose
-switch from sodium valproate to phenytoin/carbimazole/phenobarbitone (as teratogenic)
-encourage 5mg folic acid use
-if needs to continue AED, explain need for continual use as skipping medication can put mother and baby at risk
-monitoring plasma levels for AED levels regularly (1-2monthly)
-reduce triggers; sleep and eat well

Preg/post-partum;

need to have oral Vit K in last 4 weeks of preg (as AED reduces synthesis) and also IMI of Vit K post partum (fetus and mother)
if already on AED, continue throughout labour and post partum
encourage breast feeding (low dosage of AED will pass into breast milk but monitor baby for drowsiness)
encourage not to bath baby alone, to feed baby on ground or whilst sitting, minimise carrying of baby

Answer 73

A

*Primary herpes;** get serology and typing done from genital lesions
If in 1st or 2nd timester then suppress with aciclovir until 36 weeks (if labour begins less than 6 wks after tx, perform C/S, if over 6wks the vaginal delivery)
If in 3rd timester deliver via C/S and tx with aciclovir for 5days
*Recurrent herpes**; suppress mother from 36wk then do vaginal delivery if no active lesions
*Neonatal herpes;**
SEM; skin eyes mouth; pustular lesions, vesicular lesions, buccal lesions, keratitis/conjunctivitis (can cause blindness)
CNS; tremors, seizures, fatigue, bulging fontanelles, high icp
Systemic; DIC, hepatomegaly (high LFT, low platelet), respiratory, sepsis
*MX of neonatal;
**collect swabs, collect urine (HSV PCR), FBC, LFT, HSV PCR, coag, +/- LP for CSF analysis and PCR
start IV acyclovir
reassess for hearing/vision problems, recurrence and CNS impairment

Answer 74

A

Monozygotic; 1 single ova and 1 single sperm combine and then the conceptus splits= identical twins
-are all monochorionic but can be di or monoamniotic
Dizygotic= 2 ova and 2 sperm= genetically different, 50% both sexes, 25% unisex

Complications of pregnancy;
-exaggerated symptoms of N/V, GORD, weight gain, oedema, anaemia, IUGR (high risk in monochorionic), GDM, PET, miscarriage, APH, preterm labour, PROM

Complications of the labour;
-cord entanglement, asphyxiation of twin B if placental separation occurs, labour obstruction

-Consider IOL at 38/39 weeks, only do vaginal birth if twin A cephalic

Answer 75

A

SGA; <10th percentile

Parameters; head circumference, abdo circumference, foetal length
IUGR is SGA caused by a pathological process; can be asymmetrical or symmetrical
RF; old or young maternal age, anaemia, chronic health conditions, pre-natal drug use, congenital or chromosomal abnormalities, TORCH infection, twin;twin transfusion, multipreg, small placenta, placenta accreta/abruption/infarction

Symmetrical; small parents, asian, IUGR from early age (chromosomal abnormalities)
Asymmetrical; late onset pathology

Ix for IUGR;

assess mother for PET and infections
offer amniocentesis–> look for chromosomal abnormalities
foetal USS surveillance (if growth plateus or stops; indication for caeser), CTG, refer to high risk clinic

Answer 76

A

Mothers with a hx of GBS, febrile mothers (in labour), PPROM over 18h, preterm labour under 37wks
give IV penicillin (or ampicillin) during labour

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