Obs + Gynae Flashcards
1
Q
How does renal plasma flow change in pregnancy?
A
Increases
Increases during early trimesters, decreases towards end of third trimester
2
Q
How does total plasma volume change in pregnancy?
A
Increases: 30-50%
3
Q
Changes in heart in pregnancy?
A
Increased cardiac output
Increased stroke volume
Increased heart rate
4
Q
Changes in oncotic/osmotic pressure in pregnancy
A
Decreased serum albumin concentration
Decreased serum colloid osmotic pressure
5
Q
Changes in clotting system in pregnancy
A
Increased coagulation factors
Increased fibrinogen
6
Q
Changes in kidneys in pregnancy
A
Increased renal blood flow
Increased GFR
7
Q
Changes in lungs in pregnancy
A
Increased tidal volume
Increased minute ventilation
8
Q
Changes in GI system in pregnancy
A
Nausea + vomiting
Delayed gastric emptying
Prolonged small bowel transit time
Gastrointestinal reflux
9
Q
Normal physiological changes seen on blood tests in pregnancy
A
Slight anaemia
Slightly lowered platelets
Increased ALP
Decreased albumin, AST + ALT
Increased GFR
–> decreased Urea + Creatinine –> if Ur + Cr are even slightly raised, this can indicate serious renal disease
10
Q
Causes of antepartum haemorrhage
A
Placental abruption
Placenta praevia
Vasa praevia
Uterine rupture
Unexplained
11
Q
What is vasa praevia
A
Foetal vessels run in membranes below the presenting foetal part, unsupported by placental tissue or umbilical cord
12
Q
How does vasa praevia present?
A
PV bleeding (dark red)
After rupture of foetal membranes
Shock consistent with external loss
Painless bleeding
Rapid foetal distress
13
Q
Risk factors for vasa praevia
A
Low-lying placenta
Multiple pregnancy
IVF pregnancy
Bilobed (succenturiate lobed) placentas
14
Q
Management of vasa praevia
A
ABCDE assessment + resuscitation
Caesarean section
Monitor during pregnancy
Elective caesarean at 34-36 weeks
15
Q
What is placenta praevia?
A
When the placenta is inserted wholly, or in part, into the lower segment of the uterus
16
Q
What is major placenta praevia?
A
Grade III or IV
Placenta lies over the cervical os
17
Q
Why is major placenta praevia concerning?
A
Cervical effacement and dilatation would result in catastrophic bleeding
18
Q
What is minor placenta praevia?
A
Grade I or II
Placenta lies in lower segment, close to, or encroaching on the cervical OS
19
Q
Risk factor for placenta praevia
A
Previous Caesarean section
Increased age
Maternal smoking
IVF
20
Q
Presentation of placenta praevia haemorrhage
A
Painless, red PV bleeding
Profuse bleeding (shock consistent with external loss)
Often smaller previous APHs
Foetus may have abnormal lie
21
Q
Management of placenta praevia
A
ABCDE assessment + resuscitation
Caesarean section
Monitor during pregnancy
Elective caesarean at 38 weeks
22
Q
Presentation of placental abruption
A
Painful PV bleeding
PV loss does not correlate with shock (some women have no external loss)
Uterus = tender + firm (woody hard)
Pain is constant, with exacerbations
Foetal distress
May present in labour
23
Q
Risk factor for placental abruption
A
ABRUPTION
Abruption previously
Blood pressure e.g. hypertension or pre-eclampsia
Ruptured membranes (premature or prolonged)
Uterine injury
Polyhydramnios
Twins/multiple gestation
Infection in the uterus
Older age (>35)
Narcotic use (cocaine, amphetamines, and smoking)
24
Q
Placenta accreta
A
Placental villi are attached to the myometrium
25
Placenta increta
Villi invaded into >50% of the myometrium
26
Placenta percreta
Villi pass through whole myometrium up to the serosa
May involve other viscera e.g. bladder or bowel
27
Risk factors for abnormal placentation
Uterine surgery e.g. CS or myomectomy
Repeated surgical termination of pregnancy
IVF
Maternal age >35
28
Management of placenta accreta post delivery
Heavy bleeding:
- Blood replacement
- Balloon tamponade e.g. Rusch
- Hysterectomy
Minimal bleeding:
- Leave placenta in situ + monitor
29
Threatened miscarriage
Bleeding +/- abdominal pain
Closed cervix
Foetus alive
Before 24 weeks (usually 6-9 weeks)
30
Management of threatened misscarriage
Anti-D if >12 weeks or heavy bleeding, or pain on RhD-ve women
Sonography
31
Missed miscarriage
Cervical os closed
Foetus no longer alive
No symptoms have occurred - may have some light vaginal bleeding
Pregnancy symptoms may decrease
32
USS findings of missed miscarriage
Foetal pole >7mm
No foetal heart activity
Mean gestation sac diameter >25mm with no foetal pole or yolk sac
33
Management of missed miscarriage
Expectant/medical/surgical
34
Inevitable miscarriage
Bleeding +/- pain
Open cervical os
May have foetus with possible heartbeat
35
Management of inevitable miscarriage
Expectant/medical/surgical
36
Use of Anti-D in miscarriages
Given if >12 weeks, or heavy bleeding or pain in Rh-D -ve women
37
Presentation of incomplete miscarriage
Bleeding +/- pain with passage of large clots or tissue
Possible open cervical os - products of conception may be seen in dilated cervical os
Not all products of conception have been expelled
38
Presentation of complete miscarriage
Bleeding and pain cease
Closed cervix
USS: empty uterus, endometrial thickness <15 mm
39
Expectant management of miscarriage
Used if not bleeding heavily
Very effective in incomplete miscarriages
Less effective in women with intact sac
Repeat TVS at 2 weeks to ensure complete miscarriage
Surgical evacuation offered at later date
40
Medical management of miscarriage
Prostaglandin analogues (misoprostol) often given vaginally
41
How long might bleeding continue after medical management of miscarriage?
3 weeks after medical uterine evacuation
42
Surgical management of miscarriage
Evacuation of retained products of conception if there is excessive or persistent bleeding, or surgical management requested
Suction curettage used
43
Complications of surgical management of miscarriage
Infection
Haemorrhage
Uterine perforation
Retained products
Intrauterine adhesions
Cervical tears
Intraabdominal trauma
44
How can uterine and cervical trauma caused by surgical management of miscarriage be reduced?
Giving prostaglandin (misopristol or gemeprost) before the procedure
45
What is the 1st stage of labour divided into?
Latent phase
Active phase
46
How is the latent phase of labour defined?
Period taken for cervix to completely efface and dilate up to 3cm
47
How is the active phase of labour defined?
3cm-10cm full dilatation
48
Expected rate of cervical dilatation in the active phase
1cm/hour
49
When would failure to progress be considered in active phase of stage 1 of labour
<2cm dilatation in 2hour
Slowing in progress in parous women
50
Causes of poor progress in 1st stage of labour
Power - inefficient uterine activity (commonest)
Passenger - malpositions, malpresentation, or large baby
Passage - inadequate pelvis
Combination
51
Management of poor progress in 1st stage of labour
Membrane sweep
Prostaglandin pessary (as inpatient)
Amniotomy (artificial rupture of membranes) and reassess in 2 hours
Amniotomy + oxytocin infusion and reassess in2 hours (especially in nulliparous women)
Lower segment CS (if foetal distress)
52
What is Stage 2 of labour?
From full dilatation to delivery of the foetus
53
How long does Stage 2 normally last?
1 hour of active pushing
Should last no longer than 3h in nulliparous women, 2h in multiparous women
54
Causes of delay in Stage 2 of labour
Brow presentation
Face presentation
Compound/shoulder presentation
Transverse lie
Occiput posterior/Occiput Transverse position
Disproportion
55
Management of delay in Stage 2 of labour
Instrumental delivery e.g. ventouse, forceps
Surgical delivery
56
Risk factors for ovarian cancer
Nulliparity
Early menarche and/or late menopause (increased ovulations)
BRCA gene mutations
HNPCC (Lynch II syndrome)
Age
Obesity
Smoking
Recurrent use of clomifene
57
Factors that decrease the risk of ovarian cancer
COCP
Pregnancy
Breastfeeding
58
Presentation of ovarian cancer
Vague, common symptoms
Abdominal discomfort/distension (bloating, but persistent)
Early satiety
Loss of appetite
Pelvic pain
Increased girth/ascites
Urinary symptoms
Change in bowel habits
Abnormal vaginal bleeding
Detection of pelvic mass
59
Blood tests for ovarian cancer
FBC, U+E, LFTs (albumin)
Tumour markers
60
Examination findings for ovarian cancer
Pelvic/abdominal mass
Ascites
Omental mass (common site for metastasis) --> ommental cake
Pleural effusion
Supraclavicular lymph nodes
61
Tumour markers in ovarian cancer
- CA125 increased in 80% epithelial cancers
- CEA (carcinoembryonic antigen): raised in CRC, normal in ovarian cancer
- CA19.9: may be raised in mucinous tumours (also pancreas + breast)
- Others (for rarer tumours): AFP, hCG, LDH, inhibin, oestradiol
62
Imaging for ovarian cancer
Abdominal/pelvic USS
CXR
CT abdomen/pelvis
63
Potential findings on USS for ovarian cancer
Presence of pelvic mass
Ascites
64
Potential findings on CXR for ovarian cancer
Pleural effusion or lung metastases (for staging and properative assessment)
65
Potential findings on CT abdo/pelvis for ovarian cancer
Omental caking
Peritoneal implants
Liver metastases
Para-aortic lymph nodes
66
Stage I of ovarian cancer
Limited to ovaries
Ia = one ovary
Ib = two ovaries
Ic =ruptured capsule, tumour on ovarian surface, or positive peritoneal washings/ascites
67
Stage II of ovarian cancer
Limited to pelvis
IIa = uterus or tubes
IIb = other pelvic structures
IIc = positive peritoneal washing/ascites
68
Stage III of ovarian cancer
Limited to abdomen (including regional lymph node mets)
IIIa =- microscopic metastases
IIIb = macroscopic mets <2cm
IIIc = macroscopic mets >2cm
69
Stage IV of ovarian cancer
Distant mets outside abdominal cavity
70
5 types of epithelial cell ovarian cancers
Serous tumours (most common)
Endometroid carcinomas
Clear cell tumours
Mucinous tumours
Undifferentiated tumours
71
What might cause hip or groin pain with an ovarian mass?
Compression of the obturator nerve
72
What three factors does the risk of malignnacy index (RMI) take into account for ovarian masses?
Menopausal status
Ultrasound findings
CA125 level
73
Causes of raised CA125
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
Ovarian cancer, breast cancer, metastatic lung cancer, endometrial cancer (not vulval)
Ascites
Menstruation
Ovarian torsion
74
Surgical management of ovarian cancer
Total abdominal hysterectomy
Bilateral salpingo-oophrectomy
Infracolic omentectomy
Lymph node sampling (pelvic + para-aortic)
Peritoneal biopsies
Pelvic washings
Sampling of ascites
75
Medical management of ovarian cancer
Adjunct to surgical management
Chemotherapy: carboplatin + paclitaxel
Monitor response using CA-125 levels
Intraperitoneal chemotherapy
76
What is stress incontinence
Loss of urine associated with a rise in intrabdominal pressure e.g. coughing or sneezing
Due to weakness of pelvic floor and sphincter muscles
77
Risk factors for stress incontinence
Increasing age
Traumatic vaginal delivery
Obesity
Previous pelvic surgery
78
What is urge inctontinence?
Caused by overactivity of the detrusor muscle of the bladder (overactive bladder)
79
What is mixed incontinence?
A combination of urge incontinence and stress incontinence
80
Risk factors for urge incontinence
Increased age
Obesity
Smoking
Family history
Diabetes mellitus
81
When might overflow incontinence occur?
When there is chronic urinary retention due to an obstruction of outflow of urine
Occurs without the urge to pass urine
More common in men
82
Causes of overflow incontinence in women
Anticholinergic medications
Fibroids
Pelvic tumours
Neuro conditions e.g. MS, diabetic neuropathy, spinal cord injuries
83
Modifiable lifestyle factors that may contribute to incontinence symptoms
Caffeine consumption
Alcohol consumption
Medications
BMI
84
Modified Oxford grading system for strength of pelvic muscle contractions on bimanual examination
0 - no contraction
1: faint contraction
2: weak contraction
3: moderate contraction with some resistance
4: good contraction with resistance
5: strong contraction, a firm squeeze, and drawing inwards
85
Investigations for incontinence
Bladder diary - fluid intake, urination and incontinence
Urine dipstick testing - rule out UTI or DM
Post-void residual bladder volume
Urodynamic testing (urge incontince if not responding or other features)
86
Management of stress incontinence
Avoidance of caffeine, diuretics and overfilling bladeder
Avoid excessive or restricted fluid intake
Weight loss
Supervised pelvic floor exercises (3 months)
Surgery
Duloxetine (where surgery is less preferred)
87
Surgical management options for stress incontinence
Tension-free vaginal tape
Autologous sling procedures (uses fascia instead of tape)
Colposuspension
Intramural urethral bulking
88
Management of urge incontinence
Bladder retraining for at least 6 weeks (first line)
Anticholinergic medication e.g. oxybutynin, tolterodine, solifenacin
Mirabegron as alternative medication
Invasive procedures
89
Anticholinergic side effects
Dry mouth
Dry eyes
Urinary retention
Constipation
Postural hypotension
Cognitive decline, memory problems, and worsening of dementia
90
When is mirabegron contraindicated for an overactive bladder/incontinence
In uncontrolled hypertension
91
Invasive management options for urge incontinence
Botox bladder injections
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
Urinary diversion
92
What is red degeneration of a fibroid
Ischaemia, infarction and necrosis of fibroid due to disrupted blood supply - common in 2nd and 3rd trimester of pregnancy due to fibroid rapidly outgrowing blood supply, uterus changing shape and therefore arteries kinking
93
Classical patient of red degeneration of fibroid
Pregnant women - often 2nd and 3rd trimester
History of fibroids - or history of heavy periods and difficulty concieving etc
Severe abdominal pain and low-grade fever, tachycardia, vomiting
94
Management of red degeneration of fibroid
Supportive
Rest, fluids, analgesia
95
Commonest causes of PID
Neisseria gonorrhoeae --> tends to produce more severe PID
Chlamydia trachomatis
Mycoplasma genitalium
96
Risk factors for PID
No barrier contraception
Multiple sexual partners
Younger age
Existing STIs
Previous PID
Intrauterine device
97
Symptoms of PID
Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding e.g. intermenstrual or postcoital
Pain during sex (dyspareunia)
Fever
Dysuria
98
Examination findings in PID
Pelvic tenderness
Cervical excitation (motion tenderness)
Inflamed cervix
Purulent discharge
99
Investigations in PID
NAAT swabs - gonorrhoea, chlamydia, mycoplasma genitalium if available
HIV + syphylis test
High vaginal swab - bacterial vaginosis, candidiasis, trichomoniasis
Look for pus cells on swab from vagina or endocervix, under microscope (absence useful in excluding)
Pregnancy test - rule out ectopic
Inflammatory markers - raised
100
Management of PID
Referral to GUM
Contact tracing
Start antibiotics before swab results obtained: doxycycline, metronidazole, IM ceftriaxone
Leave in recently inserted coil. If no response within 72 hours, remove coil + prescribe any other necessary emergency contraceptives
101
Complications of PID
Sepsis
Abscess
Infertility
Chronic pevlis pain
Ectopic pregnany
Fitz-Hugh-Curtis syndrome
102
What is Fitz-Hugh-Curtis syndrome
Complication of PID
Caused by inflammation and infection of the liver capsule --> adhesions between liver and peritoneum
RUQ pain (can be referred to right shoulder)
Adhesiolysis required
103
USS measurements for assessing foetal size
Estimated foetal weight
Foetal abdominal circumference
104
Antibiotic usage in UTI in pregnancy
Nitrofurantoin (avoid in third trimester)
Amoxicillin
Cefalexin
105
Nitrofurantoin in pregnancy
Avoided in 3rd trimester due to risk of haemolytic anaemia
106
Trimethoprim in pregnancy
Avoided in 1st trimester
Folate antagonist --> neural tube defects
107
Sulfonamides in pregnancy
Avoided in 3rd trimester as are associated with kernicterus (brain damage due to high levels of billirubin)
108
Tetracyclines in pregnancy
Avoided as cause permanent staining of baby's teeth, and problems with skeletal development
109
Intramural fibroids
Within myometrium
As they grow, they change the shape and distort the uterus
110
Subserosal fibroids
Just below outer layer of uterus
Grow outwards and can become very large, filling abdominal cavity
111
Submucosal fibroids
Just below endometrium
Can be resected hysteropically
112
Presentation of fibroids
Often asymptomatic
Menorrhagia
Prolonged menstruation (>7 days)
Abdominal pain, worse during menstruation
Bloating/feeling full in abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia
Reduced fertility
Palpable pelvic mass, or enlarged firm non-tender uterus
113
Investigations of fibroids
Hyteroscopy for submucosal fibroids with heavy menstrual bleeding
Pelvic ultrasound for larger fibroids
MRI scanning may be considered before surgical options
114
Management of fibroids <3 cm
Same as for heavy menstrual bleeding
Mirena coil
Symptomatic management - NSAIDS + tranexamic acid
COCP
Cyclical oral progestogens
115
Management of heavy menstrual bleeding
If no identigied pathology, fibroids <3cm diameter or suspected/diagnosed adenomyosis -->
1st line = LNG-IUS
If declines or not suitable:
- Non-hormonal = tranexamic acid, NSAIDs
- Hormonal = COCP, cyclical oral progestogens
116
Surgical management for smaller fibroids with HMB
Endometrial ablation
Resection of submucosal fibroids during hysteroscopy
Hysterectomy
117
Management of fibroids >3cm
Symptomatic - NSAIDs, tranexamic acid
Mirena coil - depends on size + shape
COCP
Cyclical oral progestogens
118
Surgical management of larger fibroids
Uterine artery embolisation
Myomectomy (preserves ferility)
Hysterectomy
GnRH agonists prior to surgery to shrink fibroid
119
Symptoms of endometriosis
Cyclical abdominal or pelvic pain
Deep dyspareunia
Dysmennorhoea
Infertility/subfertility
Cyclical bleeding from other sites
May also suffer from continuous pain e.g. with adhesions
Urinary symptoms
Bowel symptoms
120
Possible examination findings in endometriosis
Endometrial tissue visible in vagina on speculum, especially in posterior fornix
Fixed cervix on bimanual
Tenderness in the vagina, cervix, and adnexa
121
Diagnosis of endometriosis
Gold standard = laparoscopic surgery + biopsy
Pelvic USS may reveal large endometriomas and chocolate cysts, but often unremarkeable
122
Management of endometriosis
Analgesia e.g. NSAIDs +/- paracetamol
Hormonal management: COCP, POP, Depo-Provera, Nexplanon implant, Mirena coil, GnRH agonists
Surgical management: laparoscopic surgery to excise or ablate tissue, and adhesiolysis. Surgery is only way to improve fertility
Final solution = hysterectomy + bilateral salpingo-oophrectomy.
123
Risk factors for ectopic pregnancy
Previous ectopic
Previous PID
Previous surgery to fallopian tubes
IUDs
Older age (>35)
Smoking
Age <18 at first sexual intercourse
Black
IVF
124
Presentation of ectopic pregnancy
Typically 6-8 weeks gestation
Missed period
Constant lower abdominal pain (LIF or RIF)
Vaginal bleeding
Lower abdominal or pelvic tenderness
Cervical motion tenderness
Dizziness or syncope
Shoulder tip pain (peritonitis)
125
USS findings for ectopic pregnancy
Transvaginal USS
Gestational sac containing yolk sac or foetal pole seen in a fallopian tube
Sometimes non-sepcific mass in tube
Mass containing empty gestational sac = blob/bagel/tubal ring sign
Mass moves separately to ovary, but looks like corpus luteum
Empty uterus/fluid in uterus (pseudogestational sac)
126
Management of pregnancy of unknown location
Serum hCG tracked over time - baseline + repeated at 48 hours to monitor (should double in normal pregnancy)
If hCG rises >63% --> repeat USS in 1-2 weeks to confirm intrauterine pregnancy
If rise <63% --> likely ectopic pregnancy
Fall >50% --> likely miscarriage --> urinary pregnancy test in 2 weeks to confirm completeness
127
Management of ectopic pregnancy
Expectant management
Medical management e.g. methotrexate
Surgical management - salpingectomy or salpingotomy (salpingotomy if risk factors for infertility e.g. csontralateral tube damage)
128
Criteria for expectant management of ectopic pregnancy
Follow-up must be possible
Unruptured ectopic
Adnexal mass <35 mm
No visible heartbeat
No significant pain
hCG >1000IU/L, <1500IU/L
129
Criteria for methotrexate management of ectopic pregnancy
Follow-up must be possible
Unruptured ectopic
Adnexal mass <35 mm
No visible heartbeat
No significant pain
hCG <1500 IU/L
Confirmed absence of intrauterine pregnancy on USS
Advised not to get pregnant for 3 months after treatment
130
Features for diagnosis of PCOS
Two of:
- Anovulation/oligo-ovulation
- Hyperandrogenism
- Polycystic ovaries on USS (string of pearls appearance)/increase ovarian volume
131
Symptoms of ovarian cysts (uncomplicated)
Pelvic pain
Bloating
Fullness in abdomen
Palpable pelvic mass
132
Follicular cysts
Commonest type of ovarian cyst
Developing follicle that fails to rupture --> cyst persists
Tend to disappear after a few menstrual cycles
Thin walls + no internal structures
133
Corpus luteum cysts
Occurs when corpus luteum fails to break down --> fills with fluid
Often seen in early pregnancy
May cause pelvic discomfort, pain, or delayed menstruation
134
Who does not require further investigation for ovarian cyst
Premenopausal women
Simple cyst <5cm on ultrasound
135
Women under 40 years with complex ovarian mass require what tumour marks for possible germ cell tumour
Lactate dehydrogenase (LDH)
Alpha-fetoprotein
Human chorionic gonadotropin
136
Management of simple ovarian cysts <5cm in premenopausal women
Tend to resolve within 3 cycles
No follow-up scan required
137
Management of simple ovarian cysts 5-7cm in premenopausal women
Routine referral to gynaecology
Yearly ultrasound monitoring
138
Management of simple ovarian cysts >7cm in premenopausal women
Consider MRI or surgical evaluation as hard to characterise with USS
139
Management of ovarian cysts in postmenopausal women
Correlate with CA125 result
Refer to gynaecologist (2 week wait if raised CA125)
Simple cysts <5cm --> monitored with 4-6months USS
Surgical intervention if required
140
Meig's syndrome
Ovarian fibroma (benign ovarian tumour)
Pleural effusion
Ascites
Removal of tumour results in resolution of effusion + ascites
presents in older women
141
When is ovarian torsion more likely to occur
Ovarian mass >5cm e.g. cyst or tumour (more likely with benign tumours)
During pregnancy
In younger girls before menarche due to longer infundibulopelvic ligaments
142
Presentation of ovarian torsion
Pelvic pain:
- Sudden onset
- Severe
- Unilateral
- Constant
- Progressively worsening
Nausea + vomiting
Localised tenderness
Potential palpable mass
143
Diagnosis of ovarian torsion
Pelvic ultrasound
Ideally transvaginal USS
'Whirlpool' sign = free fluid in pelvis and oedema of the ovary
Definitive diagnosis = laparoscopic surgery
144
Management of ovarian torsion
Emergency --> admit under gynaecology
Laparascopic surgery:
- Detorsion (fixed in place)
- Oophrectomy
145
Complications of ovarian torsion
Loss of function of ovary (typically other compensates)
Necrotic ovary not removed --> infection --> abscess ---> sepsis
Rupture --> peritonitis + adhesions
146
Small for gestational age vs foetal growth restriction
SGA = baby small for dates, no reason stated why. Baby may be growing appropriately and not at increased risk of complications
FGR = growth slowed due to pathology, with a higher risk of morbidity and mortality, many end up SGA
147
Placenta-mediated causes of IUGR
Idiopathic
Pre-eclampsia
Maternal smoking
Maternal alcohol
Anaemia
Malnutrition
Infection
Maternal health conditions
Refers to conditions that affect transfer of nutrients across the placenta
148
Non-placenta mediated causes of IUGR
Refers to pathology of foetus
Genetic abnormalities
Structural abnormalities
Foetal infection
Errors of metabolism
149
Risk factors for IUGR
Maternal age <16 or >35
Low BMI
Pre-pregnancy weight >75kg
Low interpregnancy interval (<6 months) or long interval (>120 months)
150
Risk factors for IUGR
Maternal age <16 or >35
Low BMI/Obesity
Diabetes
Low interpregnancy interval (<6 months) or long interval (>120 months)
Pre-existing maternal disease e.g. renal disease, hypertension
Pregnancy complications e.g. pre-eclampsia
Multiple pregnancy
Smoking
Drug use
151
Signs of IUGR
SGA
Reduced amniotic fluid volume
Abnormal Doppler studies ('head sparing')
Reduced foetal movements
Abnormal CTGs
152
Monitoring of SGA/IUGR
Women with 3 or more minor/1 or more major risk factors, or with issues measuring symphisis fundal height --> serial growth scans + umbilical artery doppler
153
Management of IUGR at term
Delivered if beyond 36 weeks
Labour induction or C-section are required
154
Management of IUGR preterm
Aim to prevent in utero demise or neurological damage, whilst maximising gestation
Abnormal doppler --> reviewed at least 2x weekly
If absent end-diastolic flow --> admit mother, give steroids if pre-34 weeks, daily CTG
Beyond 34 weeks, delivery often performed
155
Preterm prelabour rupture of membranes (P-PROM)
Amniotic sac has ruptured before onset of labour, and before 37 weeks gestation
156
Diagnosis of P-PROM
Pooling of amniotic fluid in vagina on speculum examination
If doubt of diagnosis -->
- Insulin-like growth factor-binding protein-1: present in high concentrations in amniotic flud, tested on vaginal fluid
- Placental alpha-microglobin-1 (similar alternative)
Ultrasound may be useful - oligohydramnios
157
Management of P-PROM
Prophylactic antibiotics to prevent chorioamnionitis: erythromycin 250mg qds for 10 days, or until labour is established
Induction of labour may be offered from 34 weeks
158
Options for prophylaxis of preterm labour
Vaginal progesterone (gel or pessary) - offered if cervical length <25mm on USS between 16-24GW, with no previous preterm birth/trauma
Cervical cerclage - offered if cervical length <25mm between 16-24GW, with previous premature birth or cervical trauma
159
When is rescue cervical cerclage offered
16-27+6 GW
When there is cervical dilatation without rupture of membranes
160
How is preterm labour with intact membranes diagnosed
Regular painful contraction and cervical dilatation without rupture of amniotic sac
<30GW: diagnosis based on clinical assessment
>30GW: TVUS may be used to assess cervical length. >15mm indicates preterm labour unlikely
Test for foetal fibronectin --> <50ng/mL means preterm labour is unlikely
161
Management of preterm labour
Foetal monitoring
Tocolysis: nifedipine or atosiban (24-33+6 GW). Used to delay by around 48 hours
Maternal corticosteroids (<35GW)
IV magnesium sulphate (<34GW)
Delayed cord clamping/cord milking at birth
162
Definition of primary amenorrhoea
Not starting menstruation:
- By 13 years with no other evidence of pubertal development
- By 15 years where there are other signs of puberty e.g. breast bud development
163
Hypogonadotropic hypogonadism
Deficiency of LH and FSH
164
Hypergonadotropic hypogonadism
Lack of response to LH and FSH by gonads
165
Causes of hypogonadotropic hypogonadism
Hypopituitarism
Damage to hypothalamus or pituitary
Significant chronic conditions e.g. CF or IBD
Excessive exercise or dietng
Constitutional delay in growth + development
Endocrine disorders
Kallman syndrome
166
Causes of hypergonadotropic hypogonadism
Previous damage to gonads
Congenital absence of ovaries
Turner's syndrome
167
Kallman syndrome
Genetic condition causing hypogonadotropic hypogonadism with failure to start puberty (deficiency of GnRH)
Associated with anosmia
168
Androgen insensitivity syndrome
Condition where tissues are unable to respond to androgen hormones e.g. testosterone
X-linked recessive condition caused by mutation in androgen receptor gene on X chromosome
Excess androgens --> oestrogen --> female secondary sexual characteristics
169
Features of androgen insensitivity syndrome
Normal female external genitalia and breast tissue
Testes in abdomen or inguinal canal
Absent uterus, upper vagina, fallopian tubes and oaries
Patients genetically male (XY chromosome)
Taller than female average
Lack of pubic hair, facial hair and male type muscle
Infertile
170
Development of organs in androgen insensitvity syndrome
Development of testes is indepedent of androgens
Female internal organs do not develop as testes produce anti-Mullerian hormone --> structures regress
Wolffian ductal structures regress as they require stimulation from androgens
171
Presentation of androgen insensitivity syndrome
Inguinal hernias in infancy, containing testes
Or primary amenorrhoea at puberty
Hormone tests:
- Raised LH
- Normal or raised FSH
- normal or raised testosterone (for male)
- Raised oestrogen (for male)
172
Management of androgen insensitivity syndrome
Bilateral orchiedectomy - risk of testicular cancer
Oestrogen therapy
Vaginal dilators, or vaginal surgery to create adequate length (if raised as female)
Psychological + social support
173
Management of hypogonadotrophic hypogonadism
Pulsatile GnRH can be used to induce ovulation + menstruation: may induce fertility
If pregnancy not wanted, COCP used for replacement sex hormones, to induce menstruation + prevent symptoms of oestrogen deficiency
174
Definition of secondary amenorrhoea
No menstruation >3 months after previous regular menstrual periods
Consider assessment and investigation at 3-6 months
If previously infrequent/irregular periods, investigate 6-12 months
175
Causes of secondary amenorrhoea
Pregnancy
Menopause + premature ovarian failure
Hormonal contraception
Hypothalamic/pituitary pathology
Ovarian causes e.g. PCOS
Uterine pathology e.g. Asherman's syndrome
Sheehan's syndrome
Thyroid pathology
Hyperprolactinaemia
176
Pituitary causes of secondary amenorrhoea
Tumours e.g. prolactinoma
Pituitary failure - trauma, radiotherapy, surgery or Sheehan syndrome
177
Hormone tests for secondary amenorrhoea
beta-hCG: rule out pregnancy
FSH: high FSH suggests primary ovarian failure
LH: high LH, or LH:FSH ratio suggests PCOS
Prolactin
TSH --> T3/T4
Testosterone: raised --> PCOS, androgen insensitivity syndrome, or congenital adrenal hyperplasia
178
Characteristic features of PCOS
Rottersam crtieria means 2/3 present:
Multiple ovarian cysts (or ovarian volume >10cm3)
Oligoovulation/anovulation --> Oligomenorrhoea
Hyperandrogenism (hirsutism or acne)
Insulin resistance
179
Presentation of PCOS
Oligomenorrhoea/amenorrhoea
Infertility
Obesity (70%)
Hirsutism
Acne
Hair loss in male pattern
180
Complications of PCOS
Insulin resistance + diabetes
Acanthosis nigricans (thickened, rough skin in axilla and on elbows. Velvety texture. Occurs with insulin resistance)
CVD
Hypercholesterolaemia
Endometrial hyperplasia + cancer
OSA
Depression + anxiety
Sexual problems
181
Differential diagnosis of hirsutism
Medications: phenytoin, ciclosporin, corticosteroids, testosterone, anabolic steroids
Ovarian or adrenal tumours secreting androgens
Cushing's syndrome
Congenital adrenal hyperplasia
182
Insulin resistance + androgens
Insulin resistance --> increased insulin secretion
Insulin --> release of androgens from ovaries and adrenal glands
Insulin --> supresses sex-hormone binding globulin (normally supresses function of androgens)
--> increased hyperandrogenism
Insulin --> halts development of follicles in ovaries
183
Blood tests in PCOS
Testosterone: raised
SHBG
LH: raised, raised LH:FSH ratio
FSH
Prolactin
TSH
Normal, or raised oestrogen
Raised insulin
184
Other investigations for pCOS
Transvaginal ultrasound - string of pearls apperance (follicles around periphery of ovaries)
- 12 or more developing follicles in one ovary
- Ovarian volume >10cm3
NB: not reliable in adolescents
75g 2h OGTT for insulin sensitivity
- Impaired fasting glucose = 6.1-6.9mmol/L
- IGT: at 2 hours 7.8-11.1mmol/L
- Diabetes: plasma glucose at 2 hours >11.1mmol/L
185
Management of PCOS
- Reduce risk of complications e.g.
Weight loss (use orlistat if BMI >30, lipase inhibitor)
Low GI, calorie-controlled diet
Exercise
Smoking cessation
Antihypertensives when required
Statins (QRISK>10%)
186
Endometrial cancer + PCOS
Usually, corpus luteum releases progesterone after ovulation
Oligo/anovulation in PCOS --> produce oestrogen, not progesterone
If >3 months between periods --> investigate with pelvic ultrasound to assess endometrial thickness (using cyclical progestogens to induce a period prior to USS)
187
How to reduce risk of endometrial cancer e.g. in PCOS
Mirena coil
Inducing a withdrawal bleed at least every 3-4 months:
- Cyclical progestogens e.g. medrocyprogesterone acetate 10mg od for 14 days
- COCP
188
Action of metformin in PCOS
Appetite reduction
Decreased LH from anterior pituitary --> decreased androgen production from theca cells + decreased oestrogen production --> follicular development
Increased sex-hormone binding globulin in the liver --> decreased free androgens
189
Options for infertility management in PCOS
Weight loss --> restore regular ovulation
Clomifene
Laparascopic ovarian drilling
IVF
Metformin + letrozole may also help restore ovulation
Screening for GDM if pregnant
190
Hirsutism management
Weight loss
Co-cyprindiol is a COCP used for hirsutism and acne - increased risk of VTE --> stopped after 3 months
Topical eflornithine for facial hirsutism. Takes 6-8 weeks, hirsutism will return within 2 months of stopping
Electrolysis/laser hair removal
Spironolactone
Finasterine
Flutamide
Cyproterone acetate
191
Normal function of Bartholin's glands
Produce mucus to help with vaginal lubrication
192
Presentation of Bartholin cyst
Swelling (ususally unilateral)
Tender
Fluid-filled cyst 1-4 cm
193
Complication of Bartholin cyst
Bartholin's abscess
Hot, tender, red + potentially draning pus
194
Management of Bartholin's cyst
Good hygeine
Analgesia
Warm compresses
Incision avoided due to recurrence
Biopsy if vulval malignancy needs to be excluded
195
Management of Bartholin's abscess
Antibiotics
Swab of pus - culture + sensitivities
Swab for chlamydia + gonorrhoea
Surgical management if required
- Word catheter (local)
- Marsupialisation (general)
196
Age mostly affected by cervical cancer
Women <35
Typically women of reproductive age
197
Virus associated with cervical cancer
Human papillomavirus (HPV)
Types 16 + 18 particularly associated + targeted with HPV vaccine
198
Risk factors for cervical cancer
Early sexual activity
Increased number of sexual partners (esp if they have had more partners)
Not using condoms
Non-engagement with screening
Smoking
HIV
COCP >5 years
Increased number of full-term pregnancies
FHx
Exposure to diethylstilbestrol during foetal development
199
Presentation of cervical cancer
During smear if asymptomatic
Abnormal vaginal bleeding: intermenstrual, postcoital, post-menopausal
Vaginal discharge (purulent, red-brown)
Pelvic pain
Dyspareunia
200
Concerning appearances of cervix
Ulceration
Inflammation
Bleeding
Visible tumour
201
Diagnosis of cervical intraepthelial neoplasia/cervical cancer
Colposcopy, not on smear test
+/- biopsy
202
Grades of cervical intraepithelial neoplasia
CNI: mild, affects 1/3 thickness, likely to return to normal without treatment
CNII: moderate dysplasia, affects 2/3 thickness, likely to progress to cancer if untreated
CNIII: severe dysplasia, very likely to progress (sometimes called cervical carcinoma in situ)
203
What does a smear test look at
Precancerous changes (dyskaryosis)
Cells from cervix transported using liquid-based cytology
Samples initially tested for high-risk HPV
204
Who is invited to cervical screening
Women aged 25-49: every three years
Women aged 50-64: every five years
Women with HIV: screened annually
Women >65: if they have not been screened since 50, or with recent abnormal smears
205
Outcome if HPV positive but cytology normal on cervical screening
Repeat HPV test after 12 months
206
Most common types of cervical cancer
Squamous cell carcinoma (70-80%)
Adenocarcinoma (10%)
207
What is cervical intraepithelial neoplasia
Cervical dysplasia/dyskaryosis
Abnormal growth of cervical mucosa
Porentially pre-malignant
Mostly result of HPV infection
208
Management of dyskaryosis if HPV negative
Return to normal screening recall
209
Management of dyskaryosis if HPV positive
Refer for colposcopy due to increased risk of histological abnormality
210
Stages of cervical cancer
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
Lymph nodes can be involved at any stage
211
Management of Stage 1a cervical cancer/CIN
Large loop excision of the transformation zone (LLETZ) or cone biopsy
212
Management of Stage 1b-2a cervical cancer
Radical hysterectomy
Removal of local lymph nodes (chemo and radiotherapy)
213
Management of stage 2b-4a cervical cancer
Chemotherapy + radiotherapy
214
Management of stage 4b cervical cancer
Combination of surgery, radiotherapy, chemotherapy + palliative care
215
Important facts about HPV vaccine
Strains 6 + 11 (genital warts), and 16 +18 (cervical cancer) covered
Given before sexually active (girls + boys aged 12-13)
2 doses required
216
Main form of endometrial cancer
Adenocarcinoma (80%)
Oestrogen-dependent
217
Risk factors for endometrial cancer
Consider as exposure to unopposed oestrogen
Increased age
Earlier onset menstruation
Late menopause
Oestrogen-only HRT
No or fewer pregnancies
Obesity (oestrogen in aipose tissue, and aromatase to convert androgens into oestrogen))
PCOS
Tamoxifen
Diabetes (type 2)
HNPCC or Lynch syndrome
218
Protective factors against endometrial cancer
COCP
Mirena coil
Increased pregnancies
Cigarette smoking (in postmenopausal women)
219
Presentation of endometrial cancer
POSTMENOPAUSAL BLEEDING (endometrial cancer until proven otherwise)
Postcoital or intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count
Pain + discharge are unusual
220
Investigations for endometrial cancer
TVUSS - endometrial thickness (<4mm post-menopause)
Pipelle biopsy - highly sensitive
Hysteroscopy (with endometrial biopsy)
221
Management for endometrial cancer
Total abdominal hysterectomy with bilateral salpingo-oophrectomy
Involves removing pelvic lymph nodes, surrounding tissues + top of vagina
Potential of: radiotherapy, chemotherapy, progesterone (slow progression of the cancer) in women not suitable for surgery
222
What is lichen sclerosus
Chronic, inflammatory, progressive skin disorder that most commonly affects the genitalia and perianal area
223
Epidemiology of lichen sclerosus
Women > Men
Two peaks of onset: prepubertal, peri- or post-menopausal woman
Can be associated with autoimmune diseases: type 1 diabetes, alopecia, hypothyroid an vitiligo
224
Presentation of lichen sclerosus
Typical = women aged 45-60 years
Vulval itching
Skin changes in vulva
Can be asymptomatic
Soreness + pain possibly worse at night
Skin tightness
Superficial dyspareunia
Erosions
Fissures
225
What is the Koebner phenomenon
Refers to when signs and symptoms are made worse by friction to the skin e.g. with lichen sclerosus
226
Appearance of skin in genital area in lichen sclerosus
Affects labia, perianal and perineal skin
Fissures, cracks, erosions or haemorrhages under the skin
'Porcelain-white' in colour
Shiny
Tight
Thin
Slightly raised
Papules or plaques
227
Management of lichen sclerosus
Potent topical steroids e.g. clobetasol propionate (dermovate) - gradually reduced in frequency
Emollients
228
Complications of lichen sclerosus
Squamous cell carcinoma of the vulva
Pain + discomfort
Sexual dysfunction
Bleeding
Narrowing of vaginal or urethral openings
229
What is a hydatidiform mole
Tumour that grows like pregnancy inside uterus - molar pregnancy
230
How is a complete mole formed
Two sperm cells fertilise an ovum with no genetic material
Sperm combine genetic material --> cells divide --> complete mole, with no foetal material
231
How is a partial mole formed
Two sperm cells fertilise a normal ovum --> three sets of chromosomes
Cell divides --> tumour (partial mole), some foetal material may form
232
Presentation of molar pregnancy vs normal pregnancy
More severe morning sickness
Vaginal bleeding
Increased enlargement of uterus
Abnormally high hCG
Thyrotoxicosis
233
Diagnosis of molar pregnancy
Pelvic ultrasound --> snowstorm apperance of pregnancy
Confirmed on histology after evacuation
234
Management of molar pregnancy
Evacuation of uterus
Histological examination of products of conception
Referral to gestational trophoblastic disease centre
Monitor hCG levels
Chemo if mole has metastasised
235
What is adenomyosis
Endometrial tissue within the myometrium
More common in later reproductive years + in multiparous women
236
Presentation of adenomyosis
Dysmennorhoea
Menorrhagia
Dyspareunia
Infertility or pregnancy-related complications
Tender + enlarged uterus (softer than with fibroids)
237
Investigation of adenomyosis
1st line: TVUS
MRI + transabdominal USS suitable alternatives
Gold standard: histological examination of uterus after hyseterectomy
238
Management
Symptoms tend to resolve after menopause
Not wanting contraception:
- Tranexamic acid (no associated pain)
- Mefenamic acid (associated pain)
Contraception acceptable:
- Mirena coil
- COCP
- Cyclical oral progestogens
Others:
- GnRH analogues
- Endometrial ablation
- Uterine artery embolisation
- Hysterectomy
239
Problems associated with adenomyosis in pregnancy
Infertility
Miscarriage
Preterm birth
SGA
P-PROM
Malpresentation
C-section
PPH
240
Uterine prolapse
Uterus descends into vagina
241
Vault prolapse
Occurs in women who have had a hysterectomy
Top of vagina descends into vagina
242
Rectocele
Defect in posterior vaginal wall -> rectum prolapses forward into vagina
243
Complications of rectocele
Foecal loading --> constipation, urinary retention, palpable lump in vagina (women may press lump backwards to allow opening of bowels)
244
Cystocele
Defect in anterior vaginal wall
Bladder prolapses backwards into vagina
--> urinary symptoms
245
Urethrocele
Prolapse of urethra
246
Cystourethrocele
Prolapse of bladder + urethra
247
Risk factors for pelvic organ prolapse
Multiple vaginal deliveries (especially if instrumental, prolonged, or traumatic)
Advanced age/postmenopausal
Obesity
COPD (coughing)
Chronic constipation (straining)
248
Presentation of pelvic organ prolapse
Feeling of something coming down in vagina
Heavy sensation in pelvis
Urinary symptoms
Bowel symptoms
Sexual dysfunction
Lump or mass felt by women in vagina - may be pushing it back themselves
249
Examination of pelvic organ prolapse
Ideally empty bladder and bowels
Dorsal and left lateral positions may be used
Sim's speculum - used to support vaginal wall while other walls are examined
Woman may cough or 'bear down' to assess full descent
250
Severity of uterine prolapse
Pelvic organ prolapse quantification (POP-Q)
0 = normal
1 = lowest part >1cm above introitus
2 = lowest part within 1cm of introitus
3 = lowest part >1cm below introitus
4 = full descent with eversion of vagina
251
Conservative management of pelvic organ prolapse
Women coping with mild symptoms, don't tolerate pessaries, or not a candidate for surgery
Physiotherapy for pelvic floor
Weight loss
Lifestyle changes for stress incontinence e.g. reduced caffeine intake/incontinence pads
Treatment of related symptoms eg. anticholinergic medications for stress incontinence
Vaginal oestrogen cream
252
Pessaries for pelvic organ prolapse
Ring - sit around cervix, holding uterus up
Shelf/Gellhorn - flat disc with stem, sit below uterus with stem pointing downwards
Cube
Donut
Hodge - rectangular almost. One side hooked around posterior aspect of cervix, other extends into vagina
Should be removed + cleaned/changed periodically (e.g. every 4 months)
Can cause vaginal irritation + erosion --> oestrogen cream
253
Surgery for pelvic organ prolapse
Definitive option
Many options incl. hyesterectomy
Complications
- Pain, bleeding, infection, DVT, risk of anaesthetic
- Damage to bladder or bowel
- Recurrence
- Altered experience of sex
254
Mesh repairs for pelvic organ prolapse
Now avoided completely
Complications:
- Chronic pain
- Altered sensation
- Dyspareunia (women or her partner)
- Abnormal bleeding
- Urinary or bowel problems
255
Commonest type of vulval cancer
Squamous cell carcinoma
(can be malignant melanomas, these are usually pigmented)
256
Risk factors for vulval cancer
Advanced age (>75)
Immunosuppression
HPV infection
Lichen sclerosus
257
What is vulval intraepithelial neoplasia
Premalignant condition of squamous epithelium - often white or plaque-like
High grade squamous intraepithelial lesion: associated with HPV infection, typically occurs in women aged 35-50 years
Differentiated VIN: associated with lichen sclerosus, aged 50-60 years
Diagnosed on biopsy
Managed by watch + wait, wide local excision, imiquimod cream, or laser ablation
258
Presentation of vulval cancer
Vulval lump
Ulceration
Bleeding
Pain
Itching
Groin lymphadenopathy
Appearance of labia majora (typically affected):
- Irregular mass
- Fungating lesion
- Ulceration
- Bleeding
259
Management of vulval cancer
2WW
Biopsy of lesion, sentinel node biopsy, and imaging for staging
Depend on stage:
- Wide local excision to remove cancer
- Groin lymph node dissection
- Chemo
- Radio
260
What is Asherman's syndrome
Adhesions form within uterus, following damage to the uterus
These form physical obstructions + distort pelvic organs --> menstruation abnormalities, infertility + recurrent miscarriages
261
What may lead to Asherman's syndrome
Pregnancy-related dilatation and curettage procedure e.g. treatment of retained POC
Uterine surgery e.g. myomectomy
Pelvic infection
262
Presentation of Asherman's syndrome
Presents following recent dilatation + curettage, uterine surgery or endometritis
Secondary amenorrhoea
Significantly lighter periods
Dysmenorrhoea
Infertility
263
Diagnosis of Asherman's syndrome/intrauterine adhesions
Gold standard: hysteroscopy (can dissect + treat adhesions)
Hysterosalpingography
Sonohysterography (uterus filled with fluid for pelvic USS)
MRI scan
264
Management of Asherman's syndrome
Dissect adhesions during hysteroscopy
Recurrence after treatment is common
265
What is shoulder dystocia
A complication of vaginal cephalic delivery
Inability of the body of the foetus to be delivered using gentle traction once head has been delivered
Usually due to impaction of anterior foetal shoulder on maternal pubic symphysis
Head may remain face downwards and not turn sidewayds
266
Risk factors for shoulder dystocia
Foetal macrosomia
High maternal BMI
Diabetes mellitus
Prolonged labour
267
Management of shoulder dystocia
Call for senior help
McRoberts' manoeuvre
Episiotomy may be required to allow better access for internal manoeuvres
Pressure to anterior shoulder by pressing on suprapubic area
268
What is McRoberts manoeuvre
Flexion + abduction of maternal hips (bringing thighs towards abdomen)
Increases anterior-posterior angle of pelvis (posterior pelvic tilt)
269
Rubins manoeuvre for shoulder dystocia
Reach into vagina to put pressure on psoterior aspect of baby's anterior shoulder - aid it to move under pubic symphysis
270
Wood's screw manoeuvre for shoulder dystocia
Performed during Rubins
Other hand reaches into vagina to put pressure on anterior aspect of posterior shoulder - rotates baby
(top shoulder forwards, bottom shoulder back)
Reverse can be tried if this does not wor
271
Zavanelli manoeuvre
Pushing baby's head back into vagina to allow delivery by emergency c-section
272
Complications of shoulder dystocia
Foetal hypoxia --> cerebral palsy
Brachial plexus injury + Erb's palsy
Perineal tears
PPH
273
Normal thickness of endometrium
<5mm
274
What is endometrial hyperplasia
Abnormal proliferation of endometrium (>normal proliferation during menstrual cycle)
Can be considered a pre-malignant condition
275
Management of endometrial hyperplasia
Simple, without atypia: high dose progestogens, repeat sampling in 3-4 months. Mirena may be used
Atypia: hysterectomy usually advised
276
What ovarian tumour is associated with development of endometrial hyperplasia
Granulosa cell tumours
277
Factors associated with endometrial hyperplasia
Taking oestrogen unopposed by progesterone
Obesity
Late menopause
Early menarche
Aged >35
Current smoker
Nulliparity
Tamoxifen (anti-oestrogen on breast, pro-oestrogen on uterus + bones)
278
Investigation of post-menopausal bleeding
1st: TVUSS +/- endemotrial pipelle biopsy
If inconclusive results --> hysteroscopy + biopsy (dilation + curettage)
279
Which ovarian tumours are associated with an increased production of hormones
Thecoma
Fibroma
Sertoli cell
Granulosa cell
280
Who is eligible for a vaginal birth after caesarean
Planned VBAC appropriate if:
- >/= 37 weeks gestation
- Single previous Caesarean delivery
Absolute contraindications: previous uterine rupture, classical (vertical) scar
281
Category 1 C-section
Immediate threat to life of mother or baby
Delivery of baby should occur within 30 minutes of decision
e.g. suspected uterine rupture, major placental abruption, cord prolapse, foetal hypoxia, persistent foetal bradycardia
282
Category 2 C-section
Maternal or foetal compromise, not immediately life-threatening
Delivery within 75 minutes of decision
283
Category 3 C-section
Delivery required, mother and baby are stable
284
Category 4 C-section
Elective
285
Indications for Caesarean-section
Absolute cephalopelvic disproportion
Placenta praevia (grades 3/4)
Pre-eclampsia
Post-maturity
IUGR
Foetal distress in labour/prolapsed cord
Failure to progress
Brow malpresentation
Placental abruption (if foetal distress. Dead --> deliver vaginally)
Vaginal infection e.g. active herpes
Cervical cancer
HIV with high viral load/not receiving any anti-retroviral therapy
Hep C (only if co-infected with HIV)
Twin pregnancy where first baby is breech
286
Investigations in menorrhagia
FBC
TVUS if symptoms suggest structural or histological abnormality e.g. intermenstrual/postcoital bleeding, pelvic pain, pressure symptoms
287
Management of menorrhagia, not requiring contraception
Mefenamic acid 500mg tds (if painful)
Tranexamic acid 1g tds
Both started on first day of period
288
Management of menorrhagia (+contraception)
1st line: intrauterine system (mirena)
COCP
Long-acting progestogens
289
Short-term option for HMB
Norethisterone 5mg tds
290
Normal foetal heart rate on CTG
110-160bpm
Tachycardia --> prematurity, hypoxia, foetal distress, maternal pyrexia or beta-agonists
Bradycardia --> severe foetal distress, foetal hypoxia or acidaemia
<90 sustained --> impending foetal demise
291
Normal foetal HR variability on CTG
Reassuring: 5-25bpm
Non-reassuring:
- <5bpm for 30-50 minutes
- >25bpm for 15-25 minutes
Abnormal:
- <5bpm for >50 minutes
- >25bpm for >25 minutes
- Sinusoidal
292
Interpreting accelerations on CTG
Accelerations = abrupt increase in baseline HR of >15bpm for >15 seconds
Presece of accelerations is reassuring - especially if they occur alongside uterine contractions
Absence is not concerning if the rest of the CTG is normal
293
Decelerations on CTG
Abrupt decrease in baseline HR of >15bpm fr >15 seconds
294
Early decelerations on CTG
Start when contractions begin, recover when they stop
Due to increased foetal intracranial pressure causing increased vagal tone
Physiological, not pathological
295
Variable decelerations on CTG
Rapid fall in baseline heart rate with variable recovery phase
May not have any relationship to uterine contractions
Most commonly caused by umbilical cord compression - may show acceleration followed by deceleration followed by acceleration (decels without these 'shoulders' are more concerning)
Foetus is not yet hypoxic, but needs close monitoring
296
Late decelerations on CTG
Decels begin at peak of contraction, and recover after contraction ends
Indicates insufficient blood flow to uterus and placenta --> foetal hypoxia + acidosis
e.g. maternal hypotension, pre-eclampsia or uterine hyperstimulation
297
Prolonged deceleration on CTG
>2 minutes
2-3 minutes = non-reassuring
>3 minutes = abnormal
298
Sinusoidal pattern on CTG
Smooth, regular, wave-like pattern
2-5 cycles a minute
Stable baseline around 120-160bpm
No beat to beat variability
Usually indicates:
- Severe foetal hypoxia
- Severe foetal anaemia
- Foetal/maternal haemorrhage
299
Non-reassuring features of decelerations on CTG
Variable with no concerning characteristics for 90+ minutes
Variable with any concerning characteristics in up to 50% of contractions for 30+ mins
Variable with any concerning characteristics in >50% contractions for <30 mins
Late decels in >50% contractions for <30 mins with no maternal/foetal clinical risk factors e.g. vaginal bleeding or significant meconium
300
Abnormal features of decelerations on CTG
Variable with any concerning characteristics in >50% of contractions for 30 minutes (less if any risk factors)
Late decels for 30 minutes (less with risk factors)
Acute bradycardia, or a single prolonged decel lasting 3 minutes or more
301
Concerning characteristics of variable decelerations on CTG
>60 seconds
Reduced baseline variability within the deceleration
Failure to return to baseline
Biphasic (W) shape
No shouldering
302
Folic acid supplementation in pregnancy
All women - 400mcg of folic acid until 12th week
Women at higher risk of conceiving a child with nueral tube defects: 5mg of folic acid before conception, until 12th week of pregnancy
303
Who is considered higher risk for neural tube defect during pregnancy
Either partner has had a NTD
Previous pregnancy affected by NTD
Family history of NTD
Antiepileptic drugs
Coeliac disease, diabetes, or thalassaemia trait
Woman is obese (>30 BMI)
304
Definition of premature ovarian insufficiency
Onset of menopausal symptoms + elevated gonadotrophin levels <40 years old
305
Causes of premature menopause
Idiopathic
Bilateral oophrectomy
Radiotherapy
Chemotherapy
Infection e.g. mumps
Autoimmune disorders
Resistant ovary syndrome (FSH receptor abnormalities)
306
Presentation of premature menopause
Similar to normal climacteric features
- Hot flushes
- Night sweats
Infertility
Secondary amenorrhoea
Raised FSH, LH levels
Low oestradiol
307
Blood tests for hormones in menopause/premature menopause
FSH >40 iu/L
- Elevated levels should be demonstrated on 2 blood samples, taken 4-6 weeks apart
Low oestradiol <100 pmol/L
High FSH seen due to decreased oestrogen --> decreased negative feedback on pituitary
308
Management of premature menopause
HRT/COCP until age of average menopause (51 years)
Sequential/cyclical HRT recommended for endometrial protection if they have a uterus
309
Definition of puerperal pyrexia
Temperature >38 degrees
In first 14 days following delivery
310
Causes of puerperal pyrexia
Endometritis - most common
UTI
Wound infections
Mastitis
Venous thromboembolism
311
Management of puerperal pyrexia
If endometritis suspected --> refer to hospital for IV antibiotics
- clindamycin + gentamicin until afebrile >24 hours
312
Dermoid cyst
Benign germ cell tumours
May contain skin appendages, hair + teeth
Most common bening ovarian tumour in women <30 years
Usually asymptomatic
Torsion is more likely than with other tumours
313
Use of levonorgestrel as emergency contraception
Should be taken ASAP
Must be taken within 72 hours of unproected sexual intercourse
Single dose 1.5mg (doubled if BMI >26, or weight >70kg)
Repeated dosing possible
Can restart hormonal contraception immediately
314
Use of ulipristal as emergency contraception
Selective progesterone receptor modulator
EllaOne
30mg oral dose ASAP - no later than 120 hours after intercourse
May reduce effectiveness of hormonal contraception - wait 5 days before restarting
Breastfeeding should be delayed for 1 week
Repeated dosing possible
315
Use of copper IUD as emergency contraception
Most effective method: should be offered to all women who meet criteria
Must be inserted within:
- 5 days of unprotected sexual intercourse
- OR 5 days after the likely ovulation date (if >5 days since UPSI)
May inhibit fertilisation or implantation
Prophylactic antibiotics given if high risk for STIs
May be left in situ for futue protection
316
Umbilical cord prolapse
Umbilical cord descends ahead of presenting part of the foetus
317
Complications of untreated umbilical cord prolapse
Compression of the cord, or cord spasm
--> fetal hypoxia
--> irreversible damage or death
318
Risk factors for umbilical cord prolapse
Prematurity
Multiparity
Polyhydramnios
Twin pregnancy
Cephalopelvis disproportion
Abnormal presentations
319
Management of cord prolapse
Presenting part of foetus may be pushed back into uterus to avoid compression
If past level of introitus: minimal handling, kept warm and moist to avoid vasospasm
Patient on all fours (or left lateral) whilst emergency c-section is prepaed
Tocolytics may be used
Retrofilling of bladder - may be helpful as gently elevates presenting part
Delivery: usually C-section, intrumental possible if head low and cervix fully dilated
320
Associations with hyperemesis gravidarum
Multiple pregnancies
Trophoblastic disease e.g. molar pregnancy
Hyperthyroidism
Nulliparity
Obesity
Smoking associated with decreased incidence
321
Triad for diagnosis of hyperemesis gravidarum
5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance
322
Management of hyperemesis
Antihistamines = 1st line
- Oral cyclizine/promethazine
- Oral prochlorperazine = alternative
Ondansetron + metoclopramide = 2nd line
- Ondansetron --> risk of cleft-lip/palate
- Metoclopramide --> EPSEs, not used >5 days
Ginger
P6 (wrist) acupressure
Admission may be needed for IV hydration
323
Complications of hyperemesis
Wernicke's encephalopathy
Mallory-Weiss tear
Central pontine myelinolysis
Acute tubular necrosis
SGA foetus
Pre-term birth
324
Testosterone therapy and pregnancy
Testosterone therapy in transgender males does not protect against pregnancy
If patient becomes pregnant, testosterone is contraindicated as it can have teratogenic effects
325
Mechanism of action of IUS
Levonorgestrel prevents endoemtrial proliferation + causes cervical mucous thickening
326
Potential problems associated with IUS insertion
First 6 months: irregular, frequent uterine bleeding, and spotting
Uterine perforation
Ectopic pregnancy
Infection
Expulsion
327
Definition of postpartum haemorrhage
Blood loss of 500ml after vaginal delivery
Primary PPH: occurs within 24 hours
328
Causes of primary PPH
Tone: uterine atony is the most common cause
Trauma e.g. perineal tear
Tissue e.g. retained placenta
Thrombin e.g. clotting/bleeding disorder
329
Initial management of primary PPH
Senior help
ABC approach
- Two, large bore peripheral cannulae
- Lie woman flat
- Bloods including group + save
- Commence warmed crystalloid infusion
Mechanical - rub fundus to stimulate contractions, catheterisation
330
Medical management of primary PPH
Medical:
- IV oxytocin (slow IV injection, followed by IV infusion)
- Ergoemtrine (slow IV or IM, unless history of hypertension
- Carboprost IM (unless history of asthma)
- Misoprostol sublingual
331
Surgical management of primary PPH
Intrauterine balloon tamponade - if uterine atony only/main cause of haemorrhage
B-Lynch suture
Ligation of uterine arteries or internal iliac arteries
Hysterectomy may be performed as a life-saving procedure
332
Management of chickenpox exposure in pregnancy
Check maternal blood for varicella antibodies
If not immune -->
If = 20 weeks gestatation, give varicella-zoster immunoglobulin (single dose) ASAP (within 10 days)
If >20 GW, give either VZIG or oral antivirals 7-14 days after exposure
If >20 GW, presenting within 24 hours of rash, oral aciclovir may be useful
333
Risks of chickenpox exposure in pregnancy
Mother: greater risk of pneumonitis
Foetus: foetal varicella syndrome, shingles in infancy, severe neonatal varicella
334
Features of foetal varicella syndrome
Dermatomal skin scarring
Neurological deficits
Foetal growth retardation
Limb hypoplasia
Eye defects
Hydrops fetalis
335
What is pre-eclampsia
Seen after 20 weeks gestation
Pregnancy-induced hypertension
With proteinuria (sign of end-organ dysfunction)
Oedema
336
What is eclampsia?
Development of seizures in association with pre-eclampsia
337
Definition of pregnancy induced/gestational hypertension
New onset HTN presenting after 20 weeks' gestation, without significant proteinuria
338
Risk factors for pre-eclampsia
High risk: Pre-existing hypertension
Previous hypertension in pregnancy
Existing autoimmune conditions
Diabetes
CKD
Moderate risk: >40 years old
Obesity
>10 years since previous pregnancy
Multiple pregnancy
First pregnancy
FHx pre-eclampsia
339
Prophylaxis for pre-eclampsia
Aspirin: from 12 GW until birth
If one high-risk, or more than one moderate-risk factors
340
Symptoms of pre-eclampsia
Headache
Visual disturbance/blurriness (papilloedema)
Nausea + vomiting
Upper abdominal/epigastric pain
Oedema (especially facial)
Reduced urine output
Hyperreflexia
341
Diagnosis of pre-eclampsia
Systolic >140mmHg, Diastolic >90mmHg
PLUS one of:
- Proteinuria
- Organ dysfunction e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia, or haemolytic anaemia
- Placental dysfunction e.g. foetal growth restriction, or abnormal Doppler studies
342
Quantifying proteinuria
Urine protein:creatinine ratio (>30mg/mmol)
Urine albumin:creatinine ratio (>8mg/mmol)
343
Management of gestational hypertension (no proteinuria)
Treat: aim for BP <135/85
Admission if BP >160/110
Weekly urine dipsticks, blood tests
Serial growth scans
Placental growth factor (PlGF) testing
344
Principles of management of pre-eclampsia
Scoring to decide whether to admit: fullPIERS, PREP-S
BP monitoring (at least every 48 hours)
USS monitoring performed two weekly
345
Medical management of pre-eclampsia
Urgent referral to obstetrics
1st line anti-hypertensive: labetolol (cannot give in asthma, HF or heart block)
2nd line: modified-release nifedipine
3rd line: methyldopa (needs to be stopped within 2 days of birth)
IV hydralazine - in critical care
IV magnesium sulphate - given during labour, and in 24 hours after to prevent seizures
Fluid restriction if severe, to avoid fluid overload
346
Management of gestational hypertension/pre-eclampsia after delivery
Enalapril
Nifedipine or amlodipine (1st line in black African or Caribbean patients)
Labetolol/atenolol (3rd line)
347
HELLP syndrome
Haemolysis
Elevated Liver enzymes
Low Platelets
348
Timing of booking visit
8-12 weeks (ideally <10 weeks)
349
Purpose of booking visit
General information e.g. diet, alcohol, smoking etc
BP, Urine dipstick, BMI
Booking bloods/urine:
- FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
- Hep B, syphilis
- HIV testing offered
- Urine culture for asymptomatic bacteriuria
350
Dating scan
10-13+6 weeks
Accurate gestational age calculated from crown rump length
Exclude multiple pregnancy
351
Timing of Down's syndrome screening
11-13+6 weeks
Including nuchal scan
352
Anomaly scan
18-20+6 weeks
353
Checkpoints for fundal level
Umbilicus - 20 weeks
Xiphoid sternum - 36 weeks
354
Factors associated with an increased risk of miscarriage
Increased maternal age
Smoking in pregnancy
Alcohol consumption
Recreational drug use
High caffeine intake
Obesity
Infections + food poisoning
Health conditions
Medications
Unusual shape/structure of womb
Cervical incompetence
355
When are foetal movements normally felt first
18-20 weeks (or 16-18 weeks in multiparous women)
If no movement by 24 weeks, referral should be made to maternal foetal medicine unit
356
Risk factors for reduced foetal movements
Posture e.g. felt more when lying down, less when standing
Distraction
Placental position e.g. anterior placenta
Medication e.g. alcohol + sedative medications
Foetal position e.g. anterior foetal position
Body habitus - obese patients less likely to feel prominent movements
Amniotic fluid volume - oligo/polyhydramnios can cause reduction
Foetal size - RFM more common in women with SGA foetus
357
Combined test for Down's syndrome screening
Done between 11-13+6 weeks
Nuchal translucencey: thickened
Serum beta-hCG: increased
Pregnancy associated plasma protein A: decreased
358
Quadruple test for Down's syndrome screening
Offered if women book later in pregnancy: done between 15-20 weeks
Alpha-fetoprotein: decreased
Unconjugated oestriol: decreased
hCG: increased
Inhibin A: increased
359
Findings on quadruple test suggestive of Edward's syndrome
Alpha feto-protein: decreased
Unconjugated oestriol: decreased
hCG: decreased
Inhibin A: normal
360
Testing for genetic anomaly diagnosis e.g. of Down's syndrome
Chorionic villous sampling
- 11-14 GW (not performed before 9-11 weeks)
- 1% risk of miscarriage
- Abnormal results due to placental mosaicism --> amniocentesis
Amniocentesis
- Performed >14 GW due to higher chance of talipes
Non-invasive prenatal testing
- Not technically diagnostic so CVS or amniocentesis may sstill be performed
361
Methotrexate and pregnancy
Methotrexate should be stopped at least 6 months before conception
Both partners should stop taking methotrexate - not just the woman
362
Use of COCP postpartum
Absolutely contraindicated if <6 weeks postpartum, and breastfeeding
- Reduces breast milk volume
UKMEC 2 if breastfeeding 6 weeks-6 months postpartum
Should not be used in first 21 days due to increased VTE risk post-partum
After day 21, additional contraception should be used for first 7 days
363
Use of POP postpartum
Can be started any time postpartum, regardless of breastfeeding status
After day 21, additional contraception should be used for first 2 days
364
Use of IUD/IUS postpartum
Can be inserted within 48 hours of childbirth, or after 4 weeks
365
After giving birth, when do women require contraception
After day 21
366
Presentation of overflow urinary incontinence
Incontinence
Voiding symptoms: straining, poor flow, incomplete emptying of bladder
Palpable bladder after voiding
On urodynamics: increased voiding detrusor pressure, decreased pek flow rate
367
Risk factors for amniotic fluid embolism
Increasing maternal age
Induction of labour
Caesarean section
Multiple pregnancy
368
Presentation of amniotic fluid embolism
Usually presents at labour + delivery, but can be postpartum
Acute onset
SOB
Hypoxia
Hypotension
Coagulopathy
Haemorrhage
Tachycardia
Confusion
Seizures
Cardiac arrest
369
Management of amniotic fluid embolism
Supportive - ABCD
A - secure airway
B - oxygen for hypoxia
C - IV fluids for hypotension, blood transfusion in haemorrhage
D - treat seizures + consider other deficits
370
Risk factors for transverse lie
Multiparity
Fibroids/other pelvic tumours
Multiple pregnancy
Prematurity
Polyhydramnios
Foetal abnormalities
Placenta praevia
371
Management of transverse lie
<36 weeks: no management required
>36 weeks:
- Active management = external cephalic version, performed as long as membranes have not been ruptured. Contraindicated in multiple pregnancy, or major uterine abnormality
- Elective caesarean
372
Complete (flexed) breech
Both legs flexed at hips and knees
Foetus appears 'cross-legged'
373
Frank (extended breech)
Both legs flexed at hip and extended at knee
Most common type of breech presentation
374
Footling breech
One or both legs extended at the hip so that the foot is the presenting part
375
Risk factors for breech presentation
Majority are chance occurences
Uterine risk factors:
- Multiparity
- Uterine malformations e.g. septate uterus
- Fibroids
- Placenta praevia
Foetal risk factors:
- Prematurity
- Macrosomia
- Polyhydramnios
- Multiple pregnancy
- Abnormality e.g. anencephaly
376
Management of breech presentation
ECV (external cephalic version): offered from 37 weeks, or 36 in primiparous women (before this time, babies may spontaneously convert)
Caesarean: if ECV unsuccessful/decline/contraindicated
Vaginal breech delivery
377
Important things to consider in vaginal breech delivery
Contraindicated in footling breech
'Hand off the breech' - do not put traction on baby during delivery as foetal head can extender
Maintain foetal scraum anteriorly by holding pelvis
Manoeuvres to aid delivery:
- Flex foetal knees to enable delivery of legs
- Lovsett's used to rotate body + deliver shoulders
- Mariceau-Smellie-Veit used to deliver head by flexion
378
UKMEC3 conditions for COCP
Disadvantages generally outweigh advantages
>35 years old, smoking <15 cigarettes/day
BMI >35
FHx of thromboembolic disease in first degree relative <45 years
Controlled hypertension
Immobility
Carrier of known gene mutations associated with breast cancer
Current gallbladder disease
379
UKMEC4 conditions for COCP
Unacceptable health risk
>35 years old, smoking >15 cigarettes/day
Migraine with aura
History of thromboembolic disease/thrombogenic mutations
History of stroke or ischaemic heart disease
Breastfeeding <6 weeks post-partum
Uncontrolled hypertension
Current breast cancer
Major surgery with prolonged immbolisation
Positive antiphospholipid antibodies e.g. in SLE
380
RIsk factors for VTE in pregnancy
Age >35
BMI >30
Parity >/=3
Smoker
Gross varicose veins
Current pre-eclampsia
Immobility
Family history of unprovoked VTE
Low risk thrombophilia
Multiple pregnancy
IVF pregnancy
381
When is prophylaxis of VTE given in pregnancy
Three risk fsctors: 28 weeks
Four or more risk factors: first trimester
382
Prophylaxis of VTE in pregnancy
Low molecular weight heparin e.g. dalteparin
Continued through antenatal period, and until 6 weeks postnatally
Stopped temporarily during labour, and restarted after delivery
Mechanical prophylaxis given if LMWH contraindicated: intermittent pneumatic compression, or anti-embolic compression stockings
383
Presentation of DVT
Unilateral (almost always)
Calf or leg swelling
Dilated superficial veins
Tenderness to calf
Oedema
Colour changes of leg
384
Bedside assessment of DVT
Measure calf circumference 10cm below tibial tuberosity
>3cm difference between calves is significant
385
Diagnosis of DVT
Doppler ultrasound
Repeated on day 3 + 7 if negative but there is a high index of suspicion
386
Diagnosis of PE in pregnancy
Suspected: CXR + ECG
CTPA: given if abnormal CXR, higher risk of breast cancer
VQ perfusion scan: higher risk of childhood cancer for foetus
387
Management of VTE
LMWH e.g. dalteparin
Based on weight in booking clinic
Should be started even before diagnosis is confirmed --> continued until 6 weeks postnatally, or three months in total (whichever is longest)
Can switch to oral anticoagulation e.g DOAC or warfarin, adter delivery
Thrombolysis is contraindicated
388
Presentation of obstetric cholestasis
Presents later in pregnancy - particularly third trimester
Main symptom = pruritis, particularly affecting palms of hands, and soles of feet
Fatigue
Dark urine
Pale, greasy stools
Jaundice
No rash
389
Investigations for obstetric cholestasis
LFTs: abnormal, particularly ALT, AST and GGT (rise in ALP is normal in pregnancy)
Bile acids: raised
390
Risk factors for obstetric cholestasis
Hepatitis
Multiple pregnancy
Obstetric cholestasis in previous pregnancy
Gallstones
Family history
391
Managament of obstetric cholestasis
Ursodeoxycholic acid - improves LFTs, bile acids, and symptoms
Emollients to soothe skin
Antihistamines can help sleeping
Water-soluble vitamin K given if clotting deranged
Monitor LFTs weekly during pregnancy, and after delivery
Planned delivery after 37 weeks may be considered
392
Symptoms with cervical ectropion
Mostly asymptomatic
Increased vaginal discharge, vaginal bleeding or dyspareunia
Postcoital bleeding is common
393
Examination findings for cervical ectropion
Well-demarcated border between redder, velvet columnar epithelium extending from os, and pale pink squamous epithelium of ectocervix
Border = transformation zone
394
Risk factors for cervical ectropion
Associated with higher oestrogen levels -->
Younger women
COCP use
Pregnancy
395
Management of cervical ectropion
Typically resolve with age, stopping of pill, or no longer pregnant
Problematic bleeding --> cauterisation of ectropion using silver nitrate, or cold coagulation during colposcopy
396
Cut offs for treatment of anaemia in pregnancy
First trimester <110g/L
Second trimester <105g/L
Postpartum <100g/L
397
Normal thickness of endometrium
<5mm
