Obs & Gynae 🤰🏽 Flashcards
how many categories of perineal tears are there
4
describe category 1 perineal tear
first degree tear
tear limited to superficial perineal skin or vaginal mucosa only
describe category 2 perineal tear
second degree tear
tear extends to perineal muscles and fascia but anal sphincter is intact
describe category 3 perineal tear
third degree tear
split into 3 subcategories :
3a: less than 50% of the thickness of the external anal sphincter is torn
3b: more than 50% of the thickness of the external anal sphincter is torn, but the internal anal sphincter is intact
3c: external and internal anal sphincters are torn, but anal mucosa is intact
describe category 4 perineal tear
fourth degree tear
Perineal skin, muscle, anal sphincter and anal mucosa are torn
describe category 4 perineal tear
fourth degree tear
Perineal skin, muscle, anal sphincter and anal mucosa are torn
describe category 4 perineal tear
fourth degree tear
Perineal skin, muscle, anal sphincter and anal mucosa are torn
mx of shoulder dystocia
immediately call for help
first line is McRoberts manoeuvre
describe the McRoberts manoeuvre
hyperflex maternal hips (knees to chest position) and tell the patient to stop pushing
may be accompanied with applied suprapubic pressure
second line manoeuvres for shoulder dystocia
Wood’s screw manoeuvre
Rubin manoeuvre II
does episiotomy help with shoulder dystocia
it will not relieve it as it is a bony obstruction but may be indicated to allow space for internal manoeuvres
what is cleidotomy
fracturing the fetal clavicle
what is symphysiotomy
cutting the pubic symphysis
what is the zavanelli manoeuvre
replacement of the head into the canal and then subsequent caesarean
clinical features of shoulder dystocia
Difficulty in delivery of the fetal head or chin.
Failure of restitution – the fetal remains in the occipital-anterior position after delivery by extension and therefore does not ‘turn to look to the side’.
‘Turtle Neck‘ sign – the fetal head retracts slightly back into the pelvis, so that the neck is no longer visible, akin to a turtle retreated into its shell.
oligohydramnios
lower than normal volume of amniotic fluid
oligohydramnios complications
clubbed feet, facial deformity and congenital hip dysplasia
underdevelopment of the lung can result in pulmonary hypoplasia
combination of the above = potter syndrome
pathophysiology of cervical ectropion
columnar epithelium of cervix extends out into ectocervix so its more fragile and prone to bleeding
how would cervical ectropion present on examination
red velvet halo appearance
how would cervical ectropion present clinically
post-coital bleeding
increased vaginal discharge
dyspareunia
mx cervical ectropion
self resolve
but can be cauterised with silver nitrate or cold coagulation
when should a woman attend cervical screening
every 3 years when ages 25-49
then every 5 years aged 50-64
risk factors for cervical cancer
early first sexual intercourse
many sexual partners
COCP use
smoking
HIV
family history
missed screening
high parity
how does cervical cancer present
mostly asymptomatic
post-coital bleeding
what investigations would you perform for a cervical cancer case
colposcopy to confirm
CT/MRI/PET for staging
investigations to perform for PCOS
LH - raised
LH:FSH ratio - raised
testosterone - raised
transvaginal USS shows a string of pearls
mx of PCOS
weight loss
mirena coil/COCP/cyclical progestogens
what is ovarian torsion
ovary twists in relation to surrounding connective tissue, Fallopian tube and blood supply
how does ovarian torsion present clinically
sudden onset severe unilateral pelvic pain that is constant and progressively worse
associated nausea and vomiting
localised tenderness and palpable mass
what ix do you want to do with ovarian torsion
transvaginal USS which will show a whirlpool sign
mx of ovarian torsion
laparoscopic surgery for definitive diagnosis
complications of ovarian torsion
loss of ovary function if mx is not prompt
may become necrotic and lead to abscess/sepsis
rupture may lead to peritonitis/adhesions
how do ovarian cysts present clinically
pelvic pain
bloating
fullness in abdomen
possible pelvic mass
ix to perform for ovarian cysts
pelvic USS
mx of ovarian cysts - not including pre or post menopausal women
order tumour markers + assess malignancy
under 40 - no further diagnosis
surgical intervention
mx of ovarian cysts - pre-menopausal women
<5cm - resolves
5-7 - refer to gynae for annual USS
>7cm - MRI scan or surgical evaluation
mx of ovarian cysts - post-menopausal women
raised CA125 need 2ww
simple cyst <5cm need USS every 4-6 months + CA125 monitoring
if a non immune pregnant women encounters varicella zoster virus < 20 weeks what do you do
give VZV Ig prophylaxis as this encounter could have teratogenic effects
if a non immune pregnant women encounters varicella zoster virus > 20 weeks what do you do
give oral aciclovir
how is congenital toxoplasmosis spread
toxoplasma gondii - cat faeces
intracranial calcification
hydrocephalus
chorioretinitis
features of congenital toxoplasmosis
how to treat congenital toxoplasmosis - first trimester
spiramycin
how to treat congenital toxoplasmosis - after 18 weeks
triple therapy
pyrimethamine
sulfadiazine
folinic acid
placenta accreta
placenta Attaching to myometrium
placenta increta
placenta Into the myometrium
placenta percreta
placenta PERforating through myometrium and reaching uterine serosa
mx of adherent placenta (intreat,accreta,percreta)
elective c-section between 35-36+6 weeks gestation
tx of post partum haemorrhage
ABCDE approach + insert 2 large bore cannulas + FBC
uterine massage + IV oxytocin
what is HELLP syndrome
combination of features which occurs as a complication of pre-eclampsia and eclampsia
Haemolysis
Elevated Liver enzymes
Low Platelets
sx of acute fatty liver in pregnancy
jaundice
headache
hypoglycaemia
ix acute fatty liver in pregnancy
raised ALT, AST, bilirubin, WBC
low platelets
features of acute fatty liver of pregnancy
rapid accumulation of fat within hepatocytes
usually occurs in 3rd trimester/immediately after delivery
features of cholestasis in pregnancy
reduced outflow of bile acids leading to build up of bile acids - pruritus
common in south asians
develops in later pregnancy
sx of cholestasis of pregnancy
jaundice + pruritus + pale greasy stool
ix cholestasis pregnancy
raised ALT, AST, GGT, bilirubin + bile acids
tx cholestasis pregnancy
ursodeoxycholic acids
induce at 37 weeks
indications for induction of labour
41-42 weeks
PROM
pre-eclampsia
firs line for induction of labour
membrane sweep
what is an umbilical cord prolapse
umbilical cord descends below the presenting part of foetus and through the cervix into the vgaina after rupture of fetal membranes
mx of umbilical cord prolapse
obstetric emergency
push presents part of foetus back into uterus
ask mother to go on all fours until c-section §
what is a bartholin gland cyst
refers to cystic dilation of one of the greater vestibular glands due to obstruction
what are bartholin glands
a paired structure located in the vulva
they produce a mucus fluid involved in vulval and vaginal lubrication
who do bartholin gland cysts most commonly affect
sexually active women
not children - not developed properly or older women due to menopause causing atrophy of the glands
what is bartholin gland cysts clinically characterised by
painless swelling in the vulva
what are the clinical features associated with bartholin gland cyst
unilateral painless swelling
if large they may cause discomfort walking, sitting or during sex
also if large can be disfiguring
o/e soft non tender mass - normal gland shouldn’t be palpable
clinical features associated with bartholin gland abscess
painful swelling
surrounding erythema
fluctuant soft painful mass
mx of bartholin gland cysts
depends on size
<3cm - warm compresses or baths
> 3cm or abscess - surgical incision and drainage
what is the most likely organism to cause a bartholin gland cyst
Escherichia Coli
what virus is the most co moon cause of cervical cancer
HPV specifically HPV 16 and 18
what is the most common type of cervical cancer
squamous cell carcinoma
what should prompt you to refer women on 2ww suspected cervical cancer pathway
unexplained cervical sx
postmenopausal bleeding - if not on HRT
persistent premenopausal bleeding or blood-stained discharge
stage 1a cervical cancer
invasive carcinoma <5mm
stage 1b cervical cancer
invasive carcinoma >5mm
stage 2a cervical cancer
involvement limited to upper 2/3 of vagina w/o parametrial involvement
stage 2b cervical cancer
upper 2/3 of vagina with parametrial involvement
stage 3a cervical cancer
lower third of vagina no extension to pelvic wall
stage 3b cervical cancer
extension to pelvic wall and/or causes hydronephrosis or non-functioning kidney
stage 3c cervical cancer
involvement of pelvic and/or para-aortic lymph nodes
stage 4a +b cervical cancer
a - spread to adjacent pelvic organs
b- spread to distant organs
mx of cervical cancer stage 1
1A - Large loop excision of the transformation zone (LLETZ) or knife cone biopsy can be used.
mx of cervical cancer stage 1a2-2a
modified radical hysterectomy with lymphadenectomy <4cm
for over 4cm - chemo radiation
mx cervical cancer stage 2b-4a
chemoradiation
mx cervical cancer stage 4b
chemotherapy, single-agent therapy and palliative radiotherapy may all be used
cervical smears should be delayed until 3 months after?
birth
miscarriages
terminations
what is CIN
cervical intraepithelial neoplasia refers to pre-malignant cervical dysplasia
epithelial lesions that may progress to cancer
how many types of CIN are
3
what’s the mx if CIN 1 is found
repeat review in 12 months
what the mx if CIN 2 is found
may resolve but as risk of cancer is increased removal if indicated
mx if CIN 3 is found
removal
knife cone biopsy, laser conisation, large loop excision of the transformation zone (LLETZ), l and cryocautery
clinical features of ectopic pregnancy
features may be subtle and non-specific therefore every woman of child bearing age must be offered a pregnancy test when presenting to hospital with an acute complaint
sx ectopic pregnancy - more severe side
abdominal/pelvic pain
vaginal bleeding
amenorrhoea
shoulder tip pain
urinary discomfort
GI upset
ix ectopic pregnancy
transvaginal USS
first line mx for uterine fibroid <3cm
IUS Mirena
what can cause a post partum haemorrhage
the four Ts
Tone
Trauma
Tissue
Thrombin
Foetal complications of polyhydramnios
Umbilical cord prolapse
Preterm labour and delivery
PROM
Placental abruption
Malpresentation of foetus
What is chandeliers sign
Informal name for cervical excitation
Cervical excitation is a sign of inflammation of pelvic organs and/or peritoneum
Most commonly presents in PID
What factors makes a woman eligible for screening for gestational diabetes and should be offered an OGTT at 26-28 weeks
BMI above 30
Previous macrosomic baby (4.5kg or above)
Previous gestational diabetes
1st degree relative with diabetes
Ethnic origin with high prevalence of diabetes
what does APGAR score stand for
activity
pulse
grimace
appearance
respiratory effort
when is the APGAR score calculated
at 1 and 5 minutes of life
how many categories of Caesarean section are there
4
describe each category of c-section
cat 4 - elective
cat 3 - scheduled
cat 2 - urgent not immediately life threatening
cat 1 - emergency life threatening
contraindications for vaginal delivery post Caesarean
classical vertical c-section scar
previous history of uterine rupture
risk factors for neonatal GBS infection
positive GBS culture in current or previous pregnancy
previous birth resulting in GBS infection
pre-term labour
PROM
intrapartum fever
chorioamnionitis
mx GBS
intrapartum antibiotic prophylaxis (couple of hours before delivery)
antibiotics are given IV during labour and delivery if risk factors present
usually penicillin
how would a neonatal group b infection present
neonatal sepsis
pneumonia
meningitis
what are the risk factors for thromboprophylaxis and how many does someone need to be started on LMWH?
Age > 35
Body mass index > 30
Parity > 3
Smoker
Gross varicose veins
Current pre-eclampsia
Immobility
Family history of unprovoked VTE
Low risk thrombophilia
Multiple pregnancy
IVF pregnancy
3 RFs = LMWH from 28 weeks until 6 weeks post natal
>3 = LMWH immediatley until 6 weeks post natal
most common type of vulval cancer
squamous cell carcinoma
90%
with ectopic pregnancies when is surgical management preferred (salpingectomy)
pt is in a lot of pain
mass is >35mm
USS identifies heartbeat
B-hCG levels are over 5000 IU/L
features of fibroids
more common in afro-caribbean women
present with:
menorrhagia
lower abdo pain
infertility
+ compressive sx which include urinary frequency, pedal oedema and constipation
treatment of fibroids
LNG-IUS 1st line
contraindicated if patient has large fibroids that make insertion hard
second line - COCP
risk factors for endometrial cancer
exposure to unopposed oestrogen leads to an increased risk :
nulliparity
obesity
early menarche
late menopause
polycystic ovary syndrome
oestrogen-only hormone replacement therapy
what test and when should it be carried out for a pt to check infertility
serum progesterone test 7 days before the end of the cycle at peak luteal level
When is the first dose of anti-D prophylaxis administered to rhesus negative women?
28 weeks
How does PCOS present
Oligomenorrhoea
Sub fertility
Acne
Hirsuitism
Obesity
Mood swings
Male pattern baldness
Rotterdam criteria for PCOS
Used to diagnose PCOS when other causes have been excluded if 2 of the following are present
polycystic ovaries
Oligo-/anovulation
Clinical or biochemical findings of hyperandrogenism
2 types of combined HRT and when are they used
Cyclical - perimenopausal women who are still having menstrual periods
Continuous - for post menopausal women who are not having menstrual periods
When is combined HRT indicated
Helpful in treating vasomotor, cognitive and urogenital symptoms of menopause
For example if a menopausal lady came in with only urogenital symptoms e.g vaginal dryness and pain you would prescribe vaginal moisturiser and lubricants
Vasomotor symptoms of menopause
Hot flushes
Night sweats
Cognitive and psychological symptoms of menopause
Depression
Anxiety
Mood swings
Lethargy
Reduced concentration
Urogenital symptoms of menopause
Vaginal dryness
Reduced libido
Problems with orgasm
Dyspareunia
Risks of oral HRT
increased risk of breast and endometrial cancer
Increased risk of venous thromboembolism
Clinical features of endometriosis
Dysmenorrhea
Dyspareunia
Subfertility
Young female with dysmenorrhea and Dyspareunia with normal sized uterus and normal speculum exam
Medical management of endometriosis
Analgesia first line
Hormonal therapies e.g COCP
Investigations for endometriosis
Trans vaginal ultrasound
GOLD STANDARD is diagnostic laparoscopy
What is Pelvic inflammatory disease
Occurs when infection spreads from vagina through into the cervix and then into the upper genital tract
Spread sexually
Causes of PID
chlamydia most common
Clinical features of PID
Bilateral abdo pain
Discharge
Post coital bleeding
Fever
Cervical motion tenderness on bimanual exam
Adnexal tenderness
Investigating PID
Pelvic exam
Pregnancy test
Swabs for gonorrhoea and chlamydia
Bloods
Transvaginal USS
Management of PID
Analgesia
IM ceftriaxone, oral doxycycline and oral metronidazole
Fitz-Hugh-Curtis syndrome features
Occurs when adhesion for, between anterior liver capsule to the anterior abdo wall or diaphragm on a background of PID
Laparoscopy is required for definitive diagnosis
Treatment involves abx
What are fibroids
Benign smooth muscle tumours of the myometrium of the uterus
Incidence increased with age peak being in women in their 40s
Presentation of fibroids
Often asymptomatic
Menstrual dysfunction
If large enough interfere with fertility
If large may be palpable
Pelvic exam may reveal irregularly emlarged uterus
Non-surgical management of fibroids (<3cm)
NSAIDs
Anti-fibrinolytics
Combined hormonal contraception
Mirena coil - FIRST LINE depending on patients wishes of fertility
What is atrophic vaginitis
Aka vulvovaginal atrophy is characterised by inflammation and thinning of the genital tissues due to a fall in oestrogen levels hence is most common after menopause
Clinical features (presentation) of atrophic vaginitis
Loss of public hair
Loss of vaginal folds
Vaginal dryness and itching
Dyspareunia
Post coital bleeding
Vaginal discharge
Urinary symptoms
Might not tolerate speculum
Treatment of atrophic vaginitis
Vaginal lubricants
Clinical presentation of ovarian cancer
Abdo discomfort
Bloating
Early satiety
Urinary frequency
Change in bowel habits
MOA of misoprostol
prostaglandin analog that causes uterine contractions
