Obs & Gynae Flashcards
1
Q
Hyperemesis
A
Definition:
- Triad: >5% pre-pregnancy weight loss, dehydration, electrolyte imbalance
- 1-3 in 100 get HG, 80% get morning sickness
Ix: Weight, U&Es, obs, urine dipstick (ketones). Offer USS for multiple pregnancy or GTD
PUQE score >/=13 = SEVERE admission
Admit if:
- Unable to keep down fluids/oral anti-emetics
- Ketonuria
- Weight loss >55
- Co-morbidities
RFs:
- Multiple pregnancies
- Multip
- GTD
- Hyperthyroid
- Nulliparity
- Obese/Diabetes
Admitting = IV saline + KCl, Pabrinex (thiamine) + VTE prophylaxis (LMWH)
- Cyclizine or Prochlorperazine (anti-histamine)
- Ondansetron or Metoclopramide (antiemetic)
- Ondansetron = small risk of cleft palate
- Metoclopramide = dont use >5 days, EPSEs
Complications
- Wernickes
- Blood clots because you’re dehydrated
- Eletrolyte imbalance
- Mallory-Weiss tear
Counselling
- Explain diagnosis - 8 in 10 women have vomiting, 1 in 10 have severe vomiting = HG, often needs hospital treatment
2
Q
VBAC
A
Definition: Vaginal birth after C-section
Success rate = 75%
- Previous successful VBAC (85-90% success)
Indications for safe VBAC:
- Singleton
- Previous vaginal delivery
- Spontaneous onset of labour (not induced)
- Normal baby
- Cephalic
- >37wk GA
- 1 previous C-section only
Absolute contraindications:
- Previous uterine rupture
- Previous classic C-section
- Other contraindications (e.g. placenta praevia)
Relative contraindications:
- ≥2 previous C-sections
- Induction (increases risk of rupture)
VBAC Benefits:
- Higher chance of uncomplicated future pregnancies
- Less pain after birth
VBAC Risks:
-
1 in 200 risk of uterine rupture
- 1 in 100 if syntocinon is used
- Can end up as emergency C-section
ERCS Risks:
- Placenta praevia/accreta in future
- Pelvic adhesions
ERCS Benefits:
- Avoids risk of uterine scar rupture
- Avoids risk of Emergency C-section
- Able to plan recovery
Counselling:
- Discuss options (VBAC or ERCS)
- Risks of VBAC
- Risks of ERCS
3
Q
SGA
A
Definition:
- SGA = EFW or AC ≤10th centile for GA
- IUGR = Reduced growth RATE, baby eventually becomes SGA
Risk factors
- Placental insufficiency
- HTN
- Pre-eclampsia
- Smoking, alcohol, drugs
- Maternal
- Previous stillbirth
- Anti-Phospholipid syndrome
- Renal disease
- Foetal
- Chromosomal abnormalities
- Infection (CMV, rubella)
- Multiple pregnancy
- Other
Complications
- The earlier baby’s growth is restricted, the poorer the outcome
- If baby is small but healthy, no increased risk of complications
- If baby is growth restricted, at risk of:
- Stillbirth
- Serious illness
- Dying shortly after birth
- Neurodevelopmental delay (if <26wks)
Mx:
- Monitoring
- Low risk
- Uterine Artery Doppler (UAD) at 20-24wks
- If normal, another one in 3rd trimester
- If abnormal, serial scans every appointment
- High risk
- Serial USS + UAD scans every appointment
- Low risk
- Delivery
- Immediate = Abnormal CTG/EFM, reverse end-diastolic flow
- Deliver by 37wks
- Steroids at 36wks
- Consultant
- If UAD is abnormal, REFER TO FETAL MEDICINE
Counselling:
- Lowest 10% of all babies (smallest 10 out of every 100 babies)
-
Risk factors:
- Placental insufficiency
- Infection
- Chromosomal abnormalities
4
Q
Termination
A
Note: Abortion act
Medical:
- PO Mifepristone
- PV Misoprostol 24-48hrs later
0-9
- Can be done at home
- Bleeding for 2wks
- Urine pregnancy test in 2-3wks
9+ wks
- Clinical setting (due to increased pain + bleeding)
- Repeat doses of misoprostol needed every 3hrs (max 5)
22+ wks - Feticide (Intracardiac KCl injection)
SEs of Medical
- Nausea & Diarrhoea
- PV Bleeding
- Cramps (needs painkillers)
Surgical
<14 - MVA
- Can be LA or GA
- PV misoprotol to dilate cervix
- Then use vacuum suction to evacuate uterus
- Takes 10 mins
Dilatation & Evacuation (curettage) - 14+ wks
- Ultrasound required to confirm evacuation
SEs of surgical
- Cramps
- Failure to end pregnancy
- Surgical risks
Counselling:
- NO effect on future pregnancy
- Safety net: Smelly discharge, fever or more symptoms of pregnancy
- 2
5
Q
Pre-eclampsia
A
2-3 in 100 women
Definition:
- New HTN (>140/90) after 20wks pregnancy
- Proteinuria
Complications: Early delivery, reduced placental function (IUGR), eclampsia
Admit to antenatal ward if:
- Severe HTN (>160/110)
- Sx of late-stage disease (headache, visual disturbance, epigastric pain, hyperreflexia, impending pulmonary oedema)
- Abnormal LFTs/U&Es
- Haemotological abnormalities (low Pt, DIC)
- Suspected foetal compromise
Management:
- Monitoring:
- BP every 1-2 days, every day if admitted
- Bloods (FBC, LFTs, U&Es) 2x week
- USS foetus every 2 wks (growth, liquor etc..)
- Medical: Anti-hypertensives
- 1st line = Labetalol
- 2nd line = Nifedipine (asthmatics)
- 3rd line = methyldopa
- Aim for BP <135/85
- Consider IV magnesium sulphate if features of severe pre-eclampsia and birth is planned within 24hrs
- Delivery
- Elective C-section OR Induction
- Aim for 37wks, earlier if maternal/foetal concerns
- Post-natal
- Monitoring:Observe for at least 24hrs
- Check BP at least 4x a day (while in postnatal ward)
- After discahrge, check BP every 1-2 days for 2 wks until pt is off treatment and HTN has resolved
- Medical:
- Continue antihypertensive if required
- Stop methyldopa within 2 days after birth!!!
- Reduce dose if BP falls <130/80
- GP F/U at 2 weeks post-discharge if still on antihypertensive for medication review
- Post-natal F/U at 6-8wks to ensure HTN has resolved
- HTN+proteinuria should resolve within 6wks
- Monitoring:Observe for at least 24hrs
6
Q
PPH
A
Minimise risk
- Prophylactic uterotonics for 3rd stage of labour in ALL WOMEN
- Vaginal birth = IM oxytocin 10U
- C-section = IV oxytocin 5U (±TXA if risk factors for PPH)
- Call for senior help, alert midwife in charge
- Call 2222, alert obstetric haemorrhage
- Review drug chart, partogram, previous Hb
MINOR PPH (500-1000ml)
- ABCDE
- 1x IV access (14 gauge)
- URGENT venepuncture
- FBC, clotting screen
- G&S cross-match 4 units of blood
- Commenced crystalloid infusion
- Obs every 15mins
MAJOR PPH (>1000ml)
- ABCDE
- Position patient FLAT
- Keep woman warm
- Transfuse ASAP
- Infuse warm isotonic crystalloids
- CONTINUOUS obs monitoring
Mx
- Conservative
- Bimanual compression of uterus
- Medical
1. IV/IM syntocinon
2. Ergometrine
3. Carboprost
- Medical
- Surgery
- Transfer to theatre
- Intrauterine balloon tamponade
- Brace suture
- Uterine artery embolisation
- Hysterectomy
7
Q
PID
A
Definition: Ascending infection of female reproductive system, including womb, fallopian tubes and ovaries
Risk factors:
- Multiple sexual partners
- STIs
- <25yo
- Past PID
Complications:
- Infertility
- Ectopic pregnancy
- Chronic pelvic pain
Management
- Consider removing IUD if no response to Tx after 72hrs
- Outpatient
- IM Ceftriaxone single dose
- PO Doxy + Metro 2wks BD
- Come back in 3 days, if not better start IV
- Inpatient (>38 or Oral Mx failed)
- IV cefoxitin + doxy
- Avoid sex during Tx
- STI screening + contact tracing
- Barrier contraception
- F/U in 2-4wks to ensure resolution
8
Q
Cervical cancer
A
Differentials for IMB:
- Pregnancy
- Cervical causes:
- Cervical polyps + ectropian
- Chlamydia gonorrhoea
- CIN or Cervical cancer
- Uterine causes:
- Fibroids
- Endometrial polyp
- Endometrial cancer
- Endometritis
- Other
- Missed COCP pills
- Tamoxifen
- Cervical screening (a smear test) checks the health of your cervix. The cervix is the opening to your womb from your vagina.
- It’s not a test for cancer, it’s a test to help prevent cancer.
- All women and people with a cervix aged 25 to 64 should be invited by letter.
- During the screening appointment, a small sample of cells will be taken from your cervix.
- The sample is checked for certain types of human papillomavirus (HPV) that can cause changes to the cells of your cervix. These are called “high risk” types of HPV.
- If these types of HPV are not found, you do not need any further tests.
- If these types of HPV are found, the sample is then checked for any changes in the cells of your cervix. These can then be treated before they get a chance to turn into cervical cancer.
- You’ll get your results by letter, usually in about 2 weeks. It will explain what happens next.
