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Phase 3a > Obs/Gynae > Flashcards

Obs/Gynae Flashcards

1
Q

pre eclampsia definition

A

new HTN in pregnancy after 20 weeks gestation

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2
Q

pathology pre eclampsia

A

endothelial cell damage and vasospasm, which can affect the foetus and almost all matenal organs

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3
Q

mild Pre Ec
moderate PreEc
severe Pre Ec

A
  • Mild = proteinuria and mild/moderate HTN
  • Moderate = proteinuria and 160/110
  • Severe = proteinuria and any HTN before 34 weeks or with maternal compliocations
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4
Q

Early and late Pre Ec

A
  • Early = <34 weeks
  • Late = >34 weeks
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5
Q

features Pre Ec

A
  • Headache
  • Epi pain
  • Visual disturbances
  • Oedema
  • None until later stages
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6
Q

Maternal compliations Pre Ec

A
  • Eclampsia
  • CVAs
  • liver/renal failure
  • HELLP
  • Pulmonary oedema
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7
Q

Foetal complications Pre Ec

A
  • FGR
  • Abruption
  • Foetal morbidity and mortality
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8
Q

to confirm PreEc

A
  • urine protein measurements
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9
Q

Pre ec prevention

A
  • Aspirin if <16 weeks and increased risk
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10
Q

Threatened miscarriage

A

Bleeding but foetus still alive, Os closed

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11
Q

Inevitable miscarriage

A

heavy bleeding, cervical os open

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12
Q

Incomplete miscarriage

A

some foetal parts passed

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13
Q

Complete miscarriage

A

all foetal tissue passed

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14
Q

Septic miscarriage

A

contents of uterus infected

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15
Q

Missed miscarriage

A

Foetus has not developed or has died but not recognised until bleeding occurs

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16
Q

Endometriosis definition

A

Presence and growth of tissue similar to endometrium outisde the uterus

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17
Q

RF endometriosis

A
  • Nulliparous
  • White
  • FHx
  • Reproductive age group
  • Retrograde menstruation
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18
Q

S+S endometriosis

A
  • Cyclical pelvic pain
  • Dysmennorhoea
  • Deep dyspareunia
  • Subfertility
  • Dyschezia
  • Tenderness/thickeneing behind uterus or adnexa
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19
Q

Ix endometriosis

A
  • Laparoscopy
  • Transvaginal USS
  • MRI if deeply infiltrating
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20
Q

Mx endometriosis

A
  • Pain relief
  • The pill
  • GnRH agonists
  • Mirena coil
  • Laparoscopic surgery
  • Hysterectomy
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21
Q

Aetiology endometrial cancer

A
  • Obesity
  • T2DM
  • Nulliparity
  • Late menopause
  • Oestrogen only HRT
  • Unopposed oestrogen
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22
Q

S+S endometrial cancer

A
  • Post menopausal bleeding
  • Abnormal bleeding
  • Abnormal discharge
  • Haematuria
  • Anaemia
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23
Q

Ix endometrial cancer

A
  • Transvaginal USS
  • Endometrial biopsy
  • Hysteroscopy
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24
Q

Mx endometrial cancer

A
  • Surgery = hysterectomy +/- pelvic LN
  • Radiotherapy = adjuvant
  • Progesterone therapy
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25
Q

Cervical cancer aetiology

A
  • High risk HPV 16 18
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26
Q

Cervical cancer treatment for stage 2 +

A
  • Radiotherapy
  • Chemo
  • Palliative
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27
Q

Vulval cancer sx

A
  • itching and soreness
  • Persistent lump
  • Bleeding
  • Pain on passing urine
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28
Q

Ovarian cancer presentation

A
  • No Sx
  • Bloating/IBS
  • Abdo pain/discomfort
  • Change in bowel habit
  • Urinary frequency
  • Bowel obstruction
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29
Q

Obstetric cholestasis

A
  • Characterised by otherwise unexplained pruritus and abnormal LFTs +/- raised bile acids
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30
Q

Obstetric cholestasis causes/RF

A
  • later pregancy (28 weeks)
  • Increased oest and prog levels
  • genetics
  • South Asian
  • Hep C
  • Multiple preg
  • OC previously
  • Gallstones
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31
Q

Obsetric cholestasis presentation

A
  • Pruritus (palms and soles)
  • Fatigue
  • Dark urine
  • Pale greasy stools
  • Jaundice
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32
Q

Complications Obstetric Cholestasis

A
  • Sudden stillbirth
  • Meconium passage
  • PPH
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33
Q

Obstetric Cholestasis Ix

A
  • LFTs
  • Bile acids
  • Rise in ALP with no other abnormal LFTs = placental production
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34
Q
  • Mx Obstetric Cholestasis
A
  • Ursodeoxycholic acid (UCDA)
  • Emollients
  • Antihistamines
  • Vitamin K 10mg/day from 36 weeks
  • LFTs weekly and 10 days after delivery
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35
Q

Gestational diabetes definition

A
  • Carbohydrate intolerance diagnosed in pregnancy which may or may not resolve after pregnancy
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36
Q

Complications GDM

A
  • Large for date foetus
  • Macrosomia
  • Shoulder dystocia
  • Congenital abnormalities
  • Polyhydramnios
  • Neonatal hypoglycaemia
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37
Q

RF GDM

A
  • Previous GDM
  • Previous macrosomic baby
  • BMI >30
  • Ethnic origin
  • FHX diabetes (1st degree)
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38
Q

When to screen for GDM

A
  • OGTT 24-28 weeks gestation
  • In morning after fasting = drink 75g glucose
  • Normal results are <5.6mmol/l fasting and <7.8mmol/l at 2 hours
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39
Q

GDM Mx

A
  • 4 weekly USS from 28 - 36W
  • Fasting glucose <7, trial diet and exercise then met then insulin
  • Above 7 metformin
  • above 6 plus macrosomia start insulin and metformin
  • Delivery 37-39W
    • 1st line
  • Diet management
    • 2nd line
  • If targets not met with 1st line after 1-2 weeks, offer metformin (insulin if contraindicated)
  • Insulin if pre-meal glucose >6 OR 1hr post-prandial glucose >7.5
    • 3rd line
  • Targets not met with 1+2 then add insulin
    • Fasting glucose 6-6.9 and complications
  • Immediate insulin +/- metformin and diet
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40
Q

Targets for GDM blood sugars

A
  • Fasting 5.3
  • 1h after meal 7.8
  • 2h after meal 6.4
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41
Q

Pre existing DM

A
  • Folic acid pre pregnancy
  • Sliding scale needed in delivery
  • Planned delivery
  • Retinopathy screening
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42
Q

Shoulder dystocia

A
  • Anterior shoulder of baby becomes stuck behind the pubic symphysis of the pelvis
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43
Q

Causes of shoulder dystocia

A
  • Macrosomia secondary to GDM
  • Previous dystocia
  • Obesity
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44
Q

Presentation dystocia

A
  • Failure of restitution
  • Turtle neck sign
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45
Q

Mx dystocia

A
  • McRoberts manoeuvre = hyperflexion of hips
  • Suprapubic pressuer
  • Episiostomy
  • Rubins = reach into vagina put presure on anterior shpilder
  • wood screw = rotate baby
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46
Q

Dystocia complications

A
  • Foetal hypoxia (cerebal palsy)
  • Brachila plexus injury and bells palsy
  • Perineal tears
  • PPH
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47
Q

HTN meds that should be stopped in pregnancy

A
  • ACEi
  • Angiotensin receptor blockers
  • Thiazide diuretics
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48
Q

HTN meds safe in pregnancy

A
  • Labetalol
  • CCB
  • Alpha blockers
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49
Q

What can undertreated or untreated hypothyroidism in pregnancy cause

A
  • Miscarriage
  • Anaemia
  • Small for gestational age
  • Pre-eclampsia
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50
Q

Dose of levothyroxine in pregnancy

A
  • Needs to be increased by 25-50mcg (30-50%)
  • Titrated based on TSH level = measured every 6 weeks
  • TSH lowers in pregnancy which is why dose increased
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51
Q

Epilepsy in pregnancy

A
  • May worsen seizure control = stress, lack of sleep, hormones, altered medicines
  • Ideally should be controlled with single drug before coming pregnant
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52
Q

Safe epilepsy drugs

A
  • Levetiracetam, lamotrigine, carbamazepine
  • SV avoid
  • Phenytoin avoid (cleft)
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53
Q

What is vasa praevia

A
  • Foetal blood vessels run in the membranes in front of the presenting part
  • Vessels are placed over internal cervical os, before the foetus. therefore outside the protection of the cord or placenta
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54
Q

Vasa praevia presentation

A
  • Painless, moderate vaginal bleeding at the rupture of the membranes
  • Severe foetal distress
  • USS
  • Antepartum haemorrhage
  • DVE = pulsating foetal vessels seen in membranes through dilated cervix
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55
Q

Vasa Praevia management

A
  • Immediate C section
  • Asymptomatic - corticosteroids 32 weeks, elective CS
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56
Q

Type 1 and 2 Vasa Praevia

A
  • Type 1 = foetal vessels are exposed as a velamentous umbilical cord
  • Type 2 = foetal vessels are exposed as they travel to an accessory placental lobe
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57
Q

When induction is offered

A
  • Prelabour ROM
  • Foetal growth restriction
  • Pre eclampsia
  • Obstetric cholestasis
  • DM
  • IUFD
  • Bishop score 8 or more
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58
Q

Prostaglandin induction

A
  • PGE2 inserted into vagina
  • Stimulated cervix and uterus to cause osnet of labour
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59
Q

Amniotomy +/- oxytocin

A
  • ARM then oxytocin infusion started within 2 hours if labour not ensued
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60
Q

CRB

A
  • Silicone balloon insetred into cervix and gently inflated to dilate
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61
Q

Why incidence of VTE is increased in pregnancy

A
  • Blood clotting factors are increased
  • Fibrinolytic activity reduced
  • Blood flow altered
  • Stagnation of blood and hypercoagulable states
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62
Q

RF VTE in pregnancy

A
  • Smoking
  • Parity >3
  • Age >35
  • BMI >30
  • Reduced mobility
  • Multiple pregnancy
  • Pre ec
  • Varicose veins
  • FHx
  • Immobility
  • IVF
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63
Q

Pulmonary embolus

A
  • Chest pain and dyspnoea
  • Tachy, raised RR and JVP
  • CXR, ABG and CT
  • CTPA or VQ
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64
Q

Prophylaxis DVT/PE

A
  • from 28 weeks if 3 RF
  • 1st trimester if 4+ RF
  • LMWH continued throughout antenatal and for 6 weeks post
  • Temporarily stopped in labour
  • Mechanical if contraindicated LMWH = pneumatic compression, anti-embolism stockings
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65
Q

DVT

A
  • Unilateral
  • Calf swelling
  • Dilated superficial veins
  • Tender calf
  • Oedema
  • Colour change
  • Ix = doppler USS
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66
Q

Mx VTE

A
  • LMWH started immediately, before confirming diagnosis
  • Massive PE and haemodynamic compromise = unfractioned heparin, thrombolysis, surgical embolectomy
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67
Q

Risks of UTI in pregancy

A
  • Preterm delivery
  • Low birth weight
  • Pre ec
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68
Q

Asymptomatic bacteriuria

A
  • Bacteria in urine with no Sx
  • Tested routinely throughout pregnancy
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69
Q

Causes of UTI

A
  • E coli most common
  • Klebsiella
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70
Q

Mx UTI

A
  • 7 days abx
  • Nitrofurantoin (avoid in 3rd trimester)
  • Amoxicillin
  • Cefalexin
  • Trimethoprim avoid in early pregnancy
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71
Q

Cord prolapse

A
  • After rupture of membranes, UC descends below presenting part
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72
Q

RF cord prolapse

A
  • Preterm labour
  • Breech
  • Polyydramnios
  • Abnormal lie
  • Twins
  • amniotomy
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73
Q

Mx cord prolapse

A
  • Pushed up by finger
  • Tocolytics can be given (terbutaline)
  • All fours
  • Immediate CS
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74
Q

Uterine rupture

A
  • Muscle layer of uterus (myometrium) ruptures
  • Incomplete = perimetrium remains intact
  • Complete = perimetrium ruptures and contents of uterus released into peritoneal cavity
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75
Q

RF uterine rupture

A
  • Previous CS = scar is a point of weakness
  • Previous surgery
  • BMI
  • Parity
  • Age
  • Induction
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76
Q

Rupture presentation

A
  • Acutely unwell mother
  • Abnormal CTG
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77
Q

Rupture Mx

A
  • Maternal resuscitation with fluids and blood required
  • Emergency CS
  • Repair or removal of uterus
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78
Q

Uterine inversion

A
  • Fundus inverts into uterine cavity
  • Haemorrhage, pain and shock
  • Brief attempt to push fundus up into vagina
  • Replacement with hydrostatic pressure run past a clenched fist at the introitus into the vagina
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79
Q

Rubella in pregnancy

A
  • Congenital rubella syndrome caused by maternal infection
  • Pregnant women should not be given MMR vaccine as it is live = need before or after
    Features of rubella syndrome
  • Congenital deafness
  • Congenital cataracts
  • Congenital heart disease
  • Learning disability
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80
Q

Chickenpox/VZV

A
  • Foetal varicella syndrome = growth restriction, microcephaly, scars, hypoplasia
  • Severe neonatal varicella infection
  • Treat with IV varicella immunoglobulins
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81
Q

Triad of features of congenital toxoplasmosis

A
  • Intracranial calcification
  • Hydrocephalus
  • Chorioretinitis
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82
Q

Complications of parovirus in pregnancy

A
  • Miscarriage
  • Severe foetal anaemia
  • Hydrops fetalis
  • Maternal pre ec like syndrome
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83
Q

HSV in pregnancy

A
  • Neonatal infection rare but high mortality
  • Vertical transmission at delivery
  • CS recommended
  • Exposed neonates given acyclovir
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84
Q

Neonatal effects HIV

A
  • Stillbirth
  • Pre ec
  • Growth restriction
  • Prematurity
  • Vertical transmission
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85
Q

Group B strep

A
  • Causes severe illness
  • Vertical transmission can be prevented by high dose IV penicillin throughout labour
  • RF = previous, positive culture, preterm labour, ROM >18hrs, maternal fever
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86
Q

Grounds for TOP

A

A = continuing would risk life of woman more
B = necessary to prevent permanent injury to physical or mental health
C = not exceeded its 24th week and continuance would be greater risk
D = not exceeded 24th week and continuance would be greater to children
E = risk that if child would suffer physical or mental abnormalities as to be seriously handicapped

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87
Q

Legal requirements for TOP

A
  • 2 registered medical practitioners
  • Registered practitioner in an NHS or approved hospital
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88
Q

Medical TOP

A
  • Mifepristone = anti-progestogen = halts pregnancy and relaxes cervix
  • Misoprostol = prostaglandin analogue = binds to prostaglandin receptors and activates them = soften cervix and stimulate contractions
  • Used together mif then miso 36-48hrs later
  • Rh -ve women should have anti D 10 w or above
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89
Q

Surgical TOP

A
  • Cervix prepared first = misoprostol, mifepristone or osmotic dilators
  • Dilation and suction
  • Dilation and forcep evacuation
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90
Q

Complications TOP

A
  • Haemorrhage
  • Infection
  • Uterine perforation
  • Cervical trauma
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91
Q

Adenomyosis definition

A

Presence of endometrial tissue inside the myometrium
- Associated with endometriosis and fibroids

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92
Q

Adenomyosis S+S

A

Painful heavy periods, regular
Dyspareunia
1/3 asymptomatic
Exam = uterus mildly enlarged and tender, boggy

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93
Q

Adenomyosis Ix

A
  • TVUSS
  • MRI
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94
Q

Adenomyosis Mx

A

No contraception wanted
- TXA when no associated pain
- Mefenamic acid when associated pain
Contraception
- Mirena coil
- COP
- Progesterone’s

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95
Q

Atrophic vaginitis

A
  • Dryness and atrophy of the vaginal mucosa related to lack of oestrogen
  • Occurs in women entering menopause = oestrogen falls and mucosa is thinner, less elastic, dry
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96
Q

Atrophic Vag S+S

A
  • Itching and dryness
  • Dyspareunia
  • Bleeding due to localised inflammation
    Exam
  • Pale mucosa
  • Thin skin
  • Reduced folds
  • Erythema and inflammation
  • Dryness
  • Sparse pubic hair
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97
Q

Atrophic Vag Mx

A
  • Lubricant
  • Topical oestrogen
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98
Q

Causes of infertility

A
  • Ovulation issues
  • Male factor problems
  • Sperm unable to reach egg = tubal, coital, cervical
  • Implantation
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99
Q

General advice for fertility

A
  • 400mcg folic acid a day
  • Health = BMI, smoking, alcohol
  • Intercourse every 2-3 days
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100
Q

Primary care Ix infertility

A
  • BMI
  • Chlamydia screen
  • Semen analysis
  • Female hormone testing
  • Rubella immunity
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101
Q

Female hormone testing infertility

A
  • Serum LH and FSH days 2-5 of cycle
  • Serum progesterone on day 21 of cycle
  • Anti mullerian hormone
  • TFTs
  • Prolactin
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102
Q

Female hormone testing infertility results

A
  • High FSH = poor ovarian reserve
  • High LH = PCOS
  • Rise in progesterone day 21 = ovulation
  • AMH = high = good ovarian reserve
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103
Q

Fertility Ix in secondary care

A
  • USS pelvis
  • Hysterosalpingogram
  • Laparoscopy and dye test
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104
Q

Mx anovulation

A
  • Weight loss
  • Clomifene to stimulate ovulation or letrozole
  • Gonadotrophins
  • Ovarian drilling
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105
Q

IUI

A
  • for unexplained subfertility, cervical, sexual and some male factors
  • Sperm injected directly into cavity of uterus
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106
Q

IVF

A
  • Embryos fertilised outside uterus and transferred back
  • Normal ovarian reserve needed
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107
Q

Menopause

A
  • Retrospective diagnosis made after a woman has had no periods for 12 months
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108
Q

Menopause physiology

A
  • Decline in development of ovarian follicles and without there is a reduced production of oestrogen
  • Oestrogen and progesterone levels are low
  • Therefore LH and FSH levels are high, in response to an absence of negative feedback from oestrogen
109
Q

Perimenopause

A
  • Vasomotor symptoms and irregular periods
  • Hot flushes
  • Emotional lability
  • PMS
  • Joint pains
  • Period variation
  • Dryness and atrophy
  • Reduced libido
110
Q

Risks associated with menopause

A
  • OP = effects reliably reversible with oestrogens
  • CVD = adverse changes in lipid, increased prevalence with early menopause
  • Dementia = increased prevalence with early menopause
111
Q

HRT risks

A
  • Breast cancer
  • VTE = oral>transdermal
  • CVD
  • Stroke (oral)
112
Q

HRT

A
  • Progesterone should be used for at least 12-14 days every 4 weeks = protects endometrium from unopposed oestrogen
  • Oestrogen = oral, patch, gel, vaginal, implant
113
Q

Who should have transdermal HRT

A
  • GI upset
  • Need for steady absorption = migraine, epilepsy
  • Perceived increased risk VTE
  • Older women
  • Medical conditions
  • Choice
114
Q

Lichen sclerosis

A
  • Chronic inflammatory skin condition that presents with patches of shiny white skin
  • Affects labia, perineum and perianal skin
  • Autoimmune condition associated with DM, alopecia, hypothyroid and vitiligo
115
Q

Lichen Sclerosis S+S

A
  • Itching
  • Skin changes
  • Soreness (may worse at night)
  • Skin tightness
  • Superficial dyspareunia
  • Erosions
  • Fissures
  • Koebner phenomenon = worse by friction
116
Q

Lichen Sclerosis Mx

A
  • Potent topical steroids = clobetasol propionate 0.005% (dermovate)
  • Emollients
117
Q

For what maximum period following termination is positive test normal

118
Q

HELLP syndrome

A
  • Haemolysis
  • Elevated Liver enzymes
  • Low platelets
  • Usually jsut after birth
119
Q

S+S HELLP

A

Headache
Nausea and/or vomiting
Epigastric pain
Right upper quadrant abdominal pain due to liver distention
Blurred vision
Peripheral oedema
Mx = delivery

120
Q

Transient tachypnoea newborn

A

Hyper inflated lungs and fluid
C section
Respiratory distress
Oxygen support

121
Q

Requirements for instrumental delivery

A

Fully dilated and in 2nd stage
OA presentation
Ruptured membranes
Cephalic presentation
Engaged head
Pain relief
Sphincter empty

122
Q

Hyperemesis gravidarum

A
  • More than 5% weight loss compared to before pregnancy
  • Dehydration
  • Electrolytes
123
Q

hyperemesis investigations

A
  • PUQE score = <7 mild, 7-12 moderate, >12 severe
  • Urine dip = ketones
  • Bloods
124
Q

When to admit Hyperemesis G

A
  • unable to tolerate oral antiemetics or keep fluids down
  • More than 5% weight loss
  • Ketone urine
  • Other med conditions
125
Q

Mx Hyperemesis G

A
  • IV or IM antiemetics
  • IV fluids = normal saline with KCL
  • U+E monitoring
  • Thiamine supplementation to prevent deficiency
  • Thromboprophylaxis
    Prochlorperazine (stemetil)
    Cyclizine
    Ondansetron
    Metoclopramide
126
Q

RF for ectopic

A
  • PID
  • Tubal damage
  • Previous ectopic
  • Over 35
  • Smoking
  • Ectopic whilst pregnant
127
Q

S+S ectopic

A
  • Lower abdo pain
  • Scant dark vaginal bleeding
  • Colicky then constant pain
  • Syncopal episodes and shoulder tip pain
  • Amenorrhoe 4-10 weeks
128
Q

Ix ectopic

A
  • Tachycardia, tender abdo
  • Cervical excitation
  • Pregnancy test
  • USS TV = GOLD
  • laparoscopy
129
Q

Mx ectopic

A
  • Medical = methotrexate (no sig pain, <35mm, hCG <1500)
  • Surgical = salpingectomy or salpingotomy (>35mm, FHR, hCG >5000)
130
Q

PPH definition

A
  • Primary = loss of >500ml <24 hrs after
  • Secondary = 24hrs - 12 weeks after
  • Minor = <1000ml
  • Major >1000ml
131
Q

Aetiology PPH

A
  • Tone = uterine atony
  • Trauma
  • Tissue = retained placenta
  • Thrombin = bleeding disorder
132
Q

RF PPH

A
  • Tone Trauma Tissue Thrombin
  • Antepartum haemorrhage
  • Coag defect
  • Instrumental delivery
  • Multiparity
  • Obesity
133
Q

Mx PPH

A
  • ABCDE
  • 2 large bore cannulas
  • Fluid resus
  • Oxytocin/bolus infusion
  • Ergometrine
  • Haemobate/carboprost
  • TXA
  • Massage uterus
  • Catheter
  • Bimanual compression
  • Misoprostol PR
  • Surgery = rusch balloon, b lynch, ligation, hysterectomy
134
Q

PPH prevention

A
  • Anaemia antenatally treated
  • Give birth with empty bladder
  • Active Mx 3rd stage = IM oxy
  • IV TXA
135
Q

Placenta praevia definition

A
  • Implanted in lower segment of uterus
  • Major = lies over cervical internal os
  • Minor = leading edge of placenta in lower uterine segment, not covering os
136
Q

S+S Placenta Praevia

A
  • Intermittent painless bleeds
  • Increase in severity and frequenct over several weeks
  • Breech or transverse
137
Q

Placenta Praevia Ix

A
  • NEVER vaginal exam
  • 20 week scan = repeat at 32 and 36
  • TV USS
138
Q

Placenta Praevia Mx

A
  • ABCDE
  • bloods
  • IV access
  • Steroids if <34
  • Planned delivery
  • CS if placental edge <2cm from internal os
139
Q

Placental abruption definition

A

Part or all of the plcenta separated before delivery of foetus

140
Q

Abruption RF

A
  • IUGR
  • Pre ec
  • HTN
  • Smoking or cocaine use
  • multiple pregnancy
141
Q

S+S Abruption

A
  • painful bleeding due to blood behnd placenta and in myometrium
  • Dark blood
  • Hypotension and tachycardia
  • Woody abdo, tender
  • CTG distress
142
Q

Abruption Mx

A
  • ABCDE
  • FBC, coag, cross match
  • Catheterisation
  • Steroids <34 weeks
  • IV access, fluids and bloods
  • Foetal distress = urgent delivery CS
  • > 37 weeks, no distress = induce via amniotomy
  • Preterm and no distress = steroids
143
Q

Adherent placenta

A
  • Accretta = chorionic villi attach to myometrium rather than being restricted in decidua basalis
  • Increta = chorionic villi invade myometrium
  • Percreta = invade through myometrium
144
Q

Preterm prelabour rupture of membranes

A
  • Speulum exam = pooling fluid
  • IGFBP1 +ve
  • Proph abx = erythromycin 250mg 4XD for 10 days = prevent chorioamnionitis
  • Induction 34 week
145
Q

Ovarian torsion S+S

A
  • Acute severe pelvic or abdo pain, unilateral and constant
  • N+V
  • Palpable abdo mass
  • Feeding intolerance
  • Strenuous exercise
  • Peritoneal signs
  • Cervical motion tenderness
  • Fever
146
Q

Ovarian torsion Ix

A
  • Clinical suspicion
  • TV USS = whirlpool sign, free fluid and oedema
  • Preg test
147
Q

Mx torios

A
  • Laparoscopic surgery
  • Oophorectomy
148
Q

Prolapse RF

A
  • Vaginal delivery
  • Congenital factors
  • Menopause
  • Chronic cough, constipation, heavy lifting
  • Obesity
149
Q

S+S Prolapse

A
  • Dragging sensation
  • Worse standing or end day
  • Intercourse disruption
  • Ulceration
  • Urinary frewuency and incomplete bladder emptying
  • Stress incontinene
  • Rectocele
150
Q

Ix prolapse

A
  • Abdo exam
  • Sim speculum
  • Urine dip
  • Bladder diary
  • USS if mass suspected
151
Q

Prolapse mx

A
  • weight loss
  • physio
  • pessary
  • hysteropexy
  • anterior repair
  • sacrospinous fixation
  • colpocleisis
152
Q

Urethrocele

A
  • Lower anterior wall inolving urethra
153
Q

Cystocele

A

upper anterio vaginal wall involving bladder

154
Q

Pathophysiology PCOS

A
  • Disordered LH production and peripheral insulin resistance
  • Raised LH and insulin = increased ovarian androgen production
  • Raised insulin = increased adrenal androgens and reduce hepatic SHBG = increased free andorgens
  • Increased intraovarian androgens disrupt foliculogenesis
155
Q

S+S PCOS

A
  • oligo or amennorhoea
  • infertility
  • obesity
  • hirsutism
  • acne
  • hair loss
  • DM
  • acanthosis nigria=cans
  • high cholesterol
  • sleep apnoea
  • depression and anxiety
156
Q

PCOS IX

A
  • Testosterone (-/up), SHBG (-/low), LH (-)
  • free androgen index
  • raised LH:FSH ration
  • Pelvis and TV USS + GOLD = 12 or more developing follciels in 1 ovary, string of pearls
157
Q

PCOS Mx

A
  • Reduce risks associated with obesity
  • Mirena coil
  • withdrawal bleed with cyclical progestogens
158
Q

Presentation of ovarian cysts

A
  • Pelvic pain
  • Bloating
  • Full abdo
  • Palpable mass
159
Q

Functional cysts

A
  • Follicular = thin walls and no internal structures, developing follicle
  • Corpus luteum = fills with fluid instead of breaking down = pelvid discomfort, pain, delayed menstruation
160
Q

primary neoplasms

A
  • Epithelial tumours = PM wome
  • Germ cell tumours = benign, teratomas/dermoid = young pre menopause, teeth and tissue
161
Q

Ix cysts

A
  • Pre menoapusal with <5cm cyst = no need ix
  • CA125
162
Q

cyst mx

A

• Dermoid = gynaecologist
• Simple ovarian <5cm = leave to resolve
• 5-7cm = routine gynae referral and yearly USS
• <7cm = MRI or surgical evaluation

163
Q

Fibroids

A

benign tumours of myometrium/smooth muscle
grow in response to oestrogen

164
Q

S+S fibroids

A
  • HMB
  • IMB
  • Dysmenorhoea
  • Urinary frequency
  • Bloating
  • Dyspareunia
165
Q

fibroids ix

A
  • hysteroscopy if submucosal
  • pelvic uss
  • mri
166
Q

mx fibroids

A
  • <3cm = same as HMB = Mirena coil, NSAIDS and TXA, COP
  • Smaller fibroids with HMB = endometrial ablation, resection, hysterectomy
  • > 3cm = same as above along with myomectomy
  • GnRH agonists can reduce size of fibroids before surgery = induce a menopausal like state and reduce amount of oestrogen maintaining the fibroid
167
Q

RF PID

A
  • STI
  • Unprotected sex with multiple partners
  • recent instrumentation
168
Q

S+S PID

A
  • uterine tenderness
  • lowe abdo paon
  • abnormal discharge
  • abnormal bleeding
  • RUQ pain
  • Dysmennorhoea
  • Subfertility
  • Dyspareunia
  • Adnexal and CM tenderness
169
Q

Ix PID

A
  • swabs
  • wbc, crp
  • pelvic uss
  • laparoscopy
170
Q

mx pid

A
  • analgesia
  • cephalosporin
  • remove iud
  • 500mg ceftriaxone IM
  • Doxy 100mg BD and met 400mg BD for 14 days
171
Q

Dichorionic diamniotic

A
  • 2 separate placentas and 2 separate sacs
  • membrane between twins with a lamba or twin peak sign in USS
  • Best outcomes
172
Q

Monochorionic diamniotic

A
  • single placenta but 2 sacs
  • Membrane between twins = T signs USS
173
Q

Monochorionic monoamniotic

A
  • Single placenta and single sac
  • No membrane separating the twins
174
Q

twin-twin transfusion syndrome

A
  • Happens when share placenta
  • 1 foetus may recieve majority of blood while other is starved
  • Recipient gets majority of blood and can become fluid overloaded = HF and polyhydramnios
  • Doner = GR, anaemia and oligohydramnios
  • Tertiary specialist foetal medicine centre
  • Laser treatment can be used to destroy conenction between 2 blood supplies
175
Q

Twin anaemia polycythaemia sequence

A
  • Less acute than transfusion syndrome
  • 1 anaemic and other polychythaemic
176
Q

Antenatal care multiple pregnancies

A

Additional monitoring for anaemia at:
- booking
- 20 weeks
- 28 weeks
USS
- 2 weekly from 16w for monochorionic
- 4 weekly from 20w for dichorionic

177
Q

when to investigate infertility

A

trying to conceive without success for 12 months or 6 if >35 and ovarian stores likely reduced

178
Q

Causes of infertility

A
  • Ovulatory disorders
  • Tubal damage
  • Male infertility
  • Uterine or peritoneal disorders
  • 25% unknown
179
Q

Ovulation disorders

A
  • Group 1 = hypogonadotrophic hypogonadism = hypothalamic pituitary failure
  • Group 2 = dysfunctions of hypothalamic-pituitary ovarian axis (PCOS)
  • Group 3 = ovarian failure = high gonadotrophins and hypogonadism
180
Q

pre testicular causes infertility

A
  • Pathology of pituitary gland or hypothalamus
  • Suppression due to stress, chronic conditions or hyperprolactinaemia
    -Kallman
181
Q

Post testicular causes

A
  • Damage to testicle or VD
  • Ejaculatory duct obstruction
  • Retrograde ejaculation
  • Scarring
  • Absence of VD
  • Young’s syndrome
182
Q

Female hormone testing

A
  • Serum LH and FSH on day 2-5
  • High FSH = poor ovarian reserve
  • High LH = PCOS
  • Serum progesterone on day 21
  • AMH = ovarian reserve
  • TFT
  • Prolactin
183
Q

Anovulation mx (PCOS)

A
  • weight loss
  • clomifene
  • letrozole
  • gonadotrophins
  • ovarian drilling in pcos
184
Q

S+S ovarian hyperstimulation

A
  • Abdo pain and bloating
  • N+V
  • Diarrhoea
  • Hypotension and hypovolaemia
  • Ascites
  • Pleural effusions, renal failure, prothrombic state
185
Q

S+S cervical cancer

A
  • Abnormal bleeding
  • Vaginal discharge
186
Q

Cervical screening

A
  • Detects pre malignant screening
  • Sample is tested for high-risk strains of HPV 1st and cytology only if positive
  • 25-49 = 3 years
  • 50-64 = 5 years
187
Q

Negative hrHPV

A
  • return to normal recall
188
Q

Positive hrHPV

A
  • Cytology
  • Abnormal cytology = colposcopy
  • Normal cytology = repeat at 12 months = if the -ve return to normal. If now +ve and cytology still normal = further tests 12 months later (same process)
189
Q

Ovarian cancer

A
  • Vague S+S = bloating, pain, urinary
  • NICE = CA125 done initially and if raised do USS
  • Surgery and chemo
190
Q

IUGR

A
  • <10th centile
    Asymmetrical
  • Extrinsic factors
  • Maternal conditions
  • Pregnancy conditions
  • Later stages
  • 70% of IUGR
    Symmetrical
  • Intrinsic factors
  • Global growth restriction
  • Increased risk neuro sequalae
191
Q

Maternal sepsis

A
  • Temp <36 or >38
  • Tachycaedia >90
  • Tahcypnoea = RR >20
  • WCC >12 or <4x10
  • Hyperglycaemia >7.7
192
Q

Post dural headache

A
  • Headache worse on sitting or standing
  • Neck stiff
  • Avoid lights
  • Lie flat
  • Simple analgesia
  • Epidural blood patch
193
Q

stress incontinence S+S

A
  • Coughing
  • Sneezing
  • Effort
  • Exercise
194
Q

Urge incontinence S+S

A
  • Overactive bladder
  • Sudden urgency
  • Frequency
  • Nocturia
195
Q

Incontinence Ix

A
  • Dipstick
  • Vaginal examination
  • Bladder diary
196
Q

Urge Mx

A
  • Bladder retraining
  • Antimuscarinic drugs
  • Invasive mx
197
Q

Stress mx

A
  • Pelvic floor training
  • Duloxetine
  • Surgery
198
Q

USS findings for miscarriage

A
  • Heartbeat = viable pregnancy
  • Heartbeat expected when crown-rmp length 7mm
  • <7mm CR lenght and no HB = repeat after 1 week
  • CL >7mm and no FHB = 1 week again before confirming
  • If mean gestational sac diameter of 25mm+ and no foetal pole = after 1 weeks
199
Q

Miscarriage mx <6w gestation

A
  • Expectant mx if no pain
  • Repeat urine after 7-10 days
200
Q

Miscarriage >6w gestation

A
  • EPAU = USS
  • Expectant
  • Medical = misoprostol
  • Surgical
201
Q

Incomplete miscarriage mx

A
  • Misoprostol or surgery
202
Q

Primary amennorhoea

A
  • hypogonadic hypogonadism = decreased LH and FSH leads to decreased oestrogen= damage to pituitary, exercise, Kallman’s
  • hypergonadic hypogonadism = turners = increased LH and FSH but decreased oestrogen
  • not started by 13 and no development
  • CAH = decreased cortisol and aldosterone
203
Q

Causes of menorrhagia

A
  • Dysfunctional uterine bleeding
  • Fibroids
  • Endometriosis and adenomyosis
  • PID
  • Contraception
  • Bleeding disorders
  • PCOS
204
Q

Ix menorrhagia

A
  • Pelvic exam = spec and bimanual
  • FBC
  • hysteroscopy if submucosal fibroids, endometrial pathology or persistent IM bleed
  • USS = palpable mass, adenomyosis, hard to interpret exam
205
Q

Ix fibroids

A
  • Hysteroscopy if submucosal and HMB
  • Pelvis USS if large
  • MRI beofre surgeyr
206
Q

Mx fibroids

A
  • <3cm = mirena, TXA
  • smaller surgery = ablation, resection
  • > 3cm = gynae referral = mirena, surgery
  • GnRH agonists used before surgery
207
Q

Asherman’s syndrome S+S

A
  • Secondary amennorhoea
  • Lighter periods
  • Dysmenorrhoea
208
Q

Asherman’s ix

A
  • hysteroscopy
  • hysterosalpingography
  • sonohysterography
  • MRI scan
209
Q

Ectropion

A
  • columnar epithelium of endocervix extends to ectocervix
  • Postcoital bleed due to fragility
  • associated with high oestrogen levels
  • o/e = well demarcated border between columnar epithelium from os and pale pink squamous epitheloim of ectocervix
  • cauterisation of problematic
210
Q

FGM

A
  • Mandatory to report all cases <18 to police
  • If unborn child of a pregnant woman at risk referral should be made
211
Q

Androgen insensitivity S+S

A
  • Inguinal hernias
  • Primary amenorrhoea
  • Raised LH, normal/raised FSH, raised testosterone and oest in males
  • Bilateral orchidectomy and oestrogen therapy
212
Q

Complete mole

A
  • 2 sperm cells fertilise an empty ovum = sperm combine genetic material and divide and grow
213
Q

Partial mole

A
  • 2 sperm cells fertalise normal ovum = haploid cell and multiplies
214
Q

Ix molar pregnancy

A
  • More severe morning sickness
  • Vaginal bleeding
  • Increased enlargement of uterus
  • Abnormally high hCG
  • Thyrotoxicosis
  • USS = snowstorm
215
Q

Failure to progress

A
  • Power
  • Passenger
  • Passage
216
Q

3 phases of 1st stage

A
  • Latent = 0-3cm = 0.5cm/hr
  • Active = 3-7cm = 1cm/hr
  • Transition = 7-10cm = 1cm/hr
    Delay = <2cm in 4hrs or slowing of progress in multiparous woman
217
Q

2nd stage

A
  • 10cm - delivery of baby
  • Delay = pushing over 2hrs in nulli and 1hr in multi
  • Power = give oxytocin
  • Passenger, presentation and passage
218
Q

3rd stage

A
  • Delivery of baby to delivery of placenta
    Delay
  • > 30m with active mx
  • > 60m with physiological mx
219
Q

Postpartum endometritis

A
  • inflammation of the endometrium
  • Usually caused by infection
  • common after cs so proph abx given
220
Q

S+S endometritis

A
  • Foul smelling discharge or lochia
  • Bleeding that gets heavier or doesnt improve with time
  • Lower abdo pain
  • Fever
  • Sepsis
221
Q

Postpartum anaemia

A
  • Hb <100g/l = oral iron 3Xd for 3m
  • <90 = consider iron infusion and oral
  • <70 = iron infusion and oral
222
Q

Mx mastitis

A
  • Conservative = warm showers and analgesia
  • infection - flucloxacillin or erythromycin
  • Continue breastfeeding
223
Q

Postpartum thyroiditis

A
  • Changes in thyroid function within 12m delivery
  • Thyrotoxicosis, hypothyroidism or both
224
Q

Stages of thyroiditis

A
  • thyrotoxicosis - first 3m
  • hypothyroid 3-6m
  • gradually return to norml
225
Q

S+S thyrotoxicosis

A
  • anxiety and ittitability
  • sweating and heat intolerance
  • tachycardia
  • wl
  • frequent loose stool
  • raised T34 and suppressed TSH
226
Q

S+S hypothyroidism

A
  • Wight gain
  • fatigue
  • dry skin
  • coarse hair
  • low mood
  • fluid retention
  • T34 low and tsh high
227
Q

thyroiditis mx

A
  • 6-8w TFTs
    thyrotoxicosis = symptoms control with propranolol
  • hypothyroid = evothyroxin
228
Q

Sheehans syndrome

A
  • Complication of PPH
  • Dopr in circulating BP leads to avascular necrosis of pituitary gland
  • only affects anterior pituitary
229
Q

Sheehans presentation

A
  • Reduced lactation
  • amennorhoea
  • Adrenal insufficiency and adrenal crisis
  • hypothyoirism and low thyroid hormones
230
Q

Mx sheehans

A
  • replacement of missing hormones
231
Q

Asymptomatic baceteruria mx

A
  • nitrofurantoin
  • amoxicillin
  • cefalexin
232
Q

POPQ grading

A

0 = normal
1 = lowest part more than 1cm above introitus
2 = lowest part within 1cm introitus
3 = lowest part >1cm below but not fully descended
4 = full descent with eversion of vagina
Beyond introitus = uterine procindentia

233
Q

foetal hydrops

A
  • abnormal accumulation of serous fluid in 2+ foetal compartments
  • Immune or non-immune causes
234
Q

Non immune causes FH

A
  • Severe anaemia
  • Cardiac abnormality
  • Csome disorders
  • Infection
  • twin twin transfusion
  • Chorioangioma
235
Q

DR C BRAVADO

A

DR = define risk
C = contractions
BRA = baseline rate = 110-160bpm
V = baseline variability = 5-25bpm
A = accelerations = 15 lasting 15s+
D = decelerations = 15 for 15
O = overall impression

236
Q

Breech Mx

A
  • ECV from 37 weeks = tocolysis first
  • Vaginal or CS
237
Q

What is a kleihauer test

A
  • quantifies how much foetal blood is mixed with maternal blood to determine dose of anti D required
238
Q

Rotterdam criteria trio PCOS

A

At least 2 of
- oligoovulation or anovulation
- Hyperandrogenism
- Polycystic ovaries on USS

239
Q

When to doe expectant in ectopic

A
  • Unruptured
  • Adnexal mass <35mm
  • No visible heartbeat
  • No significant pain
  • HCG <1500 iu/l
240
Q

Methotrexate in ectopic pregnancy

A
  • HCG <5000
  • Confirmed absence of intrauterine pregnancy on USS
241
Q

Surgery for ectopic

A
  • Pain
  • Adnexal mass >35mm
  • Visible heartbeat
  • HCG >5000 iu/l
  • Salpingectomy 1st line
  • Salpingotomy to preserve fertility
242
Q

Urge incontinence

A
  • overactive bladder
  • sudden need to wee and rush to loo but incontinent before get there
  • Bladder retrain
  • Anticholinergic = oxybutynin
  • Surgery
243
Q

Stress incontinence

A
  • Weakness of pelvic floor
  • Urinary leakage when laugh, cough etc.
  • Avoid caffeine, diuretics and overfill
  • Weight loss
  • PF exercises
  • Surgery or duloxetine
244
Q

Incontinence Ix

A
  • Bladder diary
  • Dipstick
  • Post void bladder volume
  • Urodynamic testing (urge not responding to 1st line)
245
Q

Mixed mx

A
  • Manage according to most predominant type of incontinence
246
Q

First degree tear

A
  • Frenulum of labia minora and suoerficial skin
  • no suture
247
Q

2nd degree tear

A

Includes perineal muscles but not anal sphincter
- on ward

248
Q

3a tear

A
  • fascia and muscles of perinium and <50% external anal sphincter
  • theatre
249
Q

3b tear

A
  • fascia and muscles of perineum and >50% anal sphincter
250
Q

4 tear

A
  • external and internal anal sphincters torn and anal epithelium
  • rectal mucosa
251
Q

Erbs palsy affects…

252
Q

Bishop score

A
  • Foetal station
  • Cervical position
  • Cervical dilatation
  • Cervical effacement
  • Cervical consistency
  • 8 or more = spontaneous 4
253
Q

RF for ectopic

A
  • previous
  • ID
  • surgery
  • coil
  • older age
  • smoking
  • endometriosis
  • IVF
  • POP
  • anything that slows egg movement
254
Q

Mx menorrhagia if contraception wanted

A
  • Mirena
  • COP
  • POP
255
Q

Mx menorrhagia if no contraception

A
  • TXA
  • mefenamic
256
Q

Downs combined test

A
  • 12 weeks
  • USS for NT = >6
  • BHCG = high
  • PAPPA = low
257
Q

Down quadruple test

A
  • 14-20w
  • BHCG = high
  • AFP = low
  • Oestriol = low
  • Inhibin A = high
258
Q

CVS downs

A
  • before 15w
  • 1/11 miscarriage
259
Q

Amniocentesis

A
  • 15-20w or alter
  • 1/200 miscarriage
260
Q

when is vaginal progesterone given in premature labour

A
  • cervical length <25mm between 16 - 24w
261
Q

when is cervical cerclage given

A
  • cervical length <25mm between 16-24
  • previous premature birth or cervical trauma
262
Q

Abx given in prom

A
  • erythromycin 250mg 4xday for 10 days
263
Q

Gillick competence

A
  • <16 can consent to own medical treatment
264
Q

Fraser competence

A
  • <16 and contraception
265
Q

high RF for pre ec

A
  • previous preg
  • CKD
  • autoimmune
  • DM
  • chronic htn
    1+ = aspirin
266
Q

moderate RF pre ec

A
  • 1st preg
  • 40+
  • pregnancy interval 10 yrs
  • BMI 35
  • FHx
  • multiple preg
  • 2+ = aspirin
267
Q

who takes 5mg folic acid

A
  • on anti-epileptic
  • coeliac disease
  • DM
  • BMI >30
  • neural tube defect
    take until 12 weeks
268
Q

When do you measure peak progesterone levels?

A

7 days before the start of next period
e.g. if someone has a 7/28 cycle measure progesterone on day 21

Phase 3a (23 decks)

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