Obs/ Gynae Flashcards
What happens to the total volume of the lungs in pregnancy?
Decreases
What happens to the tidal volume in pregnancy?
Increases
What is pelvic inflammatory disease?
Infection and inflammation of female pelvic organs- uterus, fallopian tubes, ovaries and the surrounding peritoneum
What organisms cause pelvic inflammatory disease?
Chlamydia trachomatis- most common
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
What are the features of pelvic inflammatory disease?
Lower abdominal pain
Fever
Deep dyspareunia
Dysuria and menstrual irregularities may occur
Vaginal or cervical discharge
Cervical excitation
What are the investigations for pelvic inflammatory disease?
Pregnancy test to exclude ectopic
High vaginal swab
Screen for chlamydia and gonorrhoea
Pelvic inflammatory disease management?
Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
Removal IUD might give better short term outcomes
Pelvic inflammatory disease complications?
Perihepatitis
Infertility
Chronic pelvic pain
Ectopic pregnancy
What are the harms and benefits of the combined oral contraceptive pill?
99% effective if taken correctly
Small risk of blood clots
Very small heart attack/stroke risk
Increased risk breast and cervical cancer
When does the combined oral contraceptive pill become effective?
Within first 5 days of cycle no need for additional contraception. Any other point 7 days of alternative contraception.
Same time every day
What may reduce COCP efficacy?
Vomiting within 2 hours of taking pill
Medications that induce diarrhoea or vomiting may reduce effectiveness eg orlistat
Liver enzyme inducing drugs
Risk factors for ovarian cancer?
BRCA 1 or BRCA 2 mutations
Many ovulations- early menarche, late menopause, nulliparity
What are the clinical features of ovarian cancer?
Very vague
Abdominal distension and bloating
Abdominal and pelvic pain
Urinary symptoms- urgency
Early satiety
Diarrhoea
Ovarian cancer investigations?
CA125
If CA 125 raised then ultrasound of abdomen and pelvis
Diagnosis usually involves diagnositc laparotomy
Ovarian cancer management?
Surgery and chemotherapy
What are the features of placenta praevia?
Shock in proportion to visible loss
No pain
Uterus not tender
Lie and presentation my be abnormal
Fetal heart usually normal
Coagulation problems rare
Small bleeds before large
How to diagnose placenta praevia?
Digital vaginal examination should not be performed before USS as could cause bleeding
Often picked up on 20 week USS
Grading of placenta praevia?
I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV (‘major’) - placenta completely covers the internal os
What are the barrier methods of contraception?
Condoms
What are the daily methods of contraception?
Combined oral contraceptive pill
Progesterone only pill
What are the long-acting methods of reversible contraception (LARCs)
Implantable contraceptives
Injectable contraceptives
Intrauterine system (IUS)- progesterone releasing coil
Intrauterine device (IUD)- copper coil
How does the combined oral contraceptive pill work?
Inhibits ovulation
Increased risk of VTE
Increased risk of breast and cervical cancer
How does the progesterone only pill work?
Thickens cervical mucus
Irregular bleeding common side effect
How does the injectable contraceptive work?
(Medroxyprogesterone acetate)
Primary: inhibits ovulation
Also thickens cervical mucus
Lasts 12 weeks
How does the implantable contraceptive work?
Etonogestrel
Primary: Inhibits ovulation
Also thickens cervical mucus
Irregular bleeding
Lasts 3 years
How does the intrauterine contraceptive device work?
Decreases sperm motility and survival
How does the intrauterine system work?
(Levonorgestrel)
Primary: prevents endometrial proliferation
Also thickens cervical mucus
Irregular bleeding
What is desogestrel?
A type of progestogen-only pill that also inhibits ovulation
Features of cervical cancer?
May be detected during routine cervical cancer screening
Abnormal vaginal bleeding- postcoital, intermenstrual or postmenopausal
Vaginal discharge
Which types of HPV cause cervical cancer?
16, 18 and 33
What are some cervical cancer risk factors?
HPV 16, 18 and 33
Smoking
HIV
Early first intercourse, many sexual partners
High parity
Lower socioeconomic status
COCP
When is endometrial cancer usually seen?
Post menopause
What are the risk factors for endometrial cancers?
Excess oestrogen- nulliparity, early menarche, late menopause, unopposed oestrogen (HRT without progestogen)
Metabolic syndrome- obesity, diabetes, polycystic ovarian syndrome
Tamoxifen
Hereditary nonn-polyposis colorectal carcinoma
Protective factors against endometrial cancer?
Multiparity, COCP, smoking
Features of endometrial cancer?
Classic symptom- postmenopausal bleeding- slight before becoming heavier
Others-
Premenopausal women with menhorrhagia or intermenstrual bleeding
Pain uncommon
Vaginal discharge unusual
Endometrial cancer investigations?
Women older than 55 presenting with post menopausal bleeding reffered using cancer pathway
First line- trans vaginal ultrasound
Hysteroscopy with endometrial biopsy
Endometrial cancer management?
Surgery- total abdominal hysterectomy
High risk patients may have postoperative radiotherapy
Progestogen therapy in frail elderly women not suitable for surgery
What is placental abruption?
Seperation of normally sited placenta from uterine wall, causes maternal haemorrhage into intervening space
What are the factors associated with placental abruption?
Proteinuric hypertension
Cocaine use
Multiparity
Maternal trauma
Increasing maternal age
What are the clinical features of placental abruption?
Shock out of keeping with visible loss
Pain constant
Tender, tense uterus
Normal lie and presentation
Fetal heart- absent/distressed
Coagulation problems
Beware pre-eclampsia, DIC, anuria
What happens with a negative hrHPV result?
Return to normal recall unless-
Test of cure pathway
Untreated CIN1 pathway
Follow up borderline changes in endocervical cells
Follow up incompletely excised cervical cancer
Positive hrHPV result?
Samples examined cytologically
If cytologically abnormal- colposcopy
If cytology normal- repeat test in 12 months
What are the different results from an abnormal colposcopy?
This includes the following results:
Borderline changes in squamous or endocervical cells.
Low-grade dyskaryosis.
High-grade dyskaryosis (moderate).
High-grade dyskaryosis (severe).
Invasive squamous cell carcinoma.
Glandular neoplasia
What are the options from a normal colposcopy?
Repeat after 12 months
If the repeat test is now hrHPV -ve → return to normal recall
If the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
What to do with inadequate hrHPV?
Repeat within 3 months
If two consecutive inadequate- colposcopy
How often is Depo Provera given?
Via IM every 12 weeks
What are the adverse effects of the depo?
Irregular bleeding
Weight gain
Potential increase of osteoporosis- only use in adolescents if no other contraception is suitable
Not quickly reversed and fertility may return after varying time
Contraindications- breast cancer
What are the risk factors for urinary incontinence?
Advancing age
Previous pregnancy and childbirth
High BMI
Hysterectomy
Family history
What are the types of urinary incontinence?
Overactive bladder- detrusor overactivity
Stress incontinence- cough/laugh
Mixed incontinence- both urge and stress
Overflow incontinence- bladder outlet obstruction
Functional incontinence
Investigations for urinary incontinence?
Bladder diaries kept for minimum of 3 days
Vaginal examination
Urine dipstick and culture
Urodynamic studies
Management for urge incontinence?
Bladder retraining- lasts six weeks
Bladder stabilising drugs- antimuscarinics are first line- oxybutinin, tolterodine or darifenacin. No oxybutinin in frail old women
Mirabegron useful if concern over anticholinergic side effects in elderley patients
Management for stress incontinence?
Pelvic floor muscle training- at least 8 contractions performed 3 times a day for mimimum of 3 months
Surgical procedures
Duloxetine if decline surgery
What are the symptoms of the menopause?
Change in periods- length of menstrual cycles, dysfunctional uterine bleeding may occur
Vasomotor symptoms- hot flushes, night sweats- usually occur daily and may continue for 5 years
Urogenital changes- vaginal dryness and atrophy, urinary frequency
Psychological- anxiety and depression, short term memory impairment
Longer term complications- osteoporosis, increased risk of ischaemic heart disease
When should a urine culture to detect asymptomatic bacteriuria be carried out?
8-12 weeks (ideally < 10 weeks)
What should happen at 8 - 12 weeks (ideally < 10 weeks)?
Booking visit
General information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
BP, urine dipstick, check BMI
Booking bloods/urine
FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
Hepatitis B, syphilis
HIV test is offered to all women
Urine culture to detect asymptomatic bacteriuria
10 - 13+6 weeks
Early scan to confirm dates, exclude multiple pregnancy
11 - 13+6 weeks
Down’s syndrome screening including nuchal scan
16 weeks
Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
Routine care: BP and urine dipstick
18 - 20+6 weeks
Anomaly scan
25 weeks (only if primip)
Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
28 weeks
Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women
31 weeks (only if primip)
Routine care as above
34 weeks
Routine care as above
Second dose of anti-D prophylaxis to rhesus negative women*
Information on labour and birth plan
36 weeks
Routine care as above
Check presentation - offer external cephalic version if indicated
Information on breast feeding, vitamin K, ‘baby-blues’
40 weeks (only if primip)
Routine care as above
Discussion about options for prolonged pregnancy
41 weeks
Routine care as above
Discuss labour plans and possibility of induction
Which contraceptives take 7 days to become effective?
COCP
Nexplanon (implantable contraceptive)
Intrauterine system (Mirena)
Depo provera (injectable contraceptive)
Which contraceptives take 2 days to become effective?
Progesterone only pill
What are the two most common medical disorders complicating pregnancy?
- Hypertension
- Gestational diabetes
What are the risk factors for gestational diabetes?
BMI of > 30 kg/m²
Previous macrosomic baby weighing 4.5 kg or above
Previous gestational diabetes
First-degree relative with diabetes
Family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
What is the screening for gestational diabetes?
Oral glucose tolerance test (OGTT)
Previous gestational diabetes: OGTT performed asap and at 24-28 weeks if first normal
Women with any other RFs offered at 24-28 weeks
What are the diagnostic thresholds for gestational diabetes?
Fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
What is the management of gestational diabetes?
Newly diagnosed seen in a joint diabetes and antenatal clinic within a week
Women taught about self monitoring blood glucose
Diet advice
If the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered
If glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
If glucose targets are still not met insulin should be added to diet/exercise/metformin
Gestational diabetes is treated with short-acting, not long-acting, insulin
If at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
If the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered
Glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
What is the management of pre-existing diabetes in pregnancy?
Weight loss for women with BMI of > 27 kg/m^2
Stop oral hypoglycaemic agents, apart from metformin, and commence insulin
Folic acid 5 mg/day from pre-conception to 12 weeks gestation
Detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
Tight glycaemic control reduces complication rates
Treat retinopathy as can worsen during pregnancy
What are the target blood glucose levels for self monitoring pregnant women?
Fasting- 5.3 mmol/l
1 hour- 7.8 mmol/l
2 hour- 6.4 mmol/l
What is Hyperemesis gravidarum?
Extreme morning sickness
When is hyperemesis gravidarum most common?
Between 8 and 12 weeks but may persist up to 20 weeks
What are the risk factors for hyperemesis gravidarum?
Increased levels of beta-hCG eg ( multiple pregnancies, trophoblastic disease)
Nulliparity
Obesity
Family or personal history of NVP
Smoking associated decreased incidence of hypermesis
When would you consider admission for nausea and vomiting in pregnancy?
Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
What triad should be present for the diagnosis of hyperemesis gravidarum?
5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance
What scoring system is used to classify the severity of NVP?
Pregnancy-Unique Quantification of Emesis (PUQE)
What is the management of hyperemesis gravidarum?
Simple measures
Rest and avoid triggers e.g. odours
Bland, plain food, particularly in the morning
Ginger
P6 (wrist) acupressure
First-line medications
Antihistamines: oral cyclizine or promethazine
Phenothiazines: oral prochlorperazine or chlorpromazine
Second-line medications
Oral ondansetron
Oral metoclopramide or domperidone- metoclopramide may cause extrapyramidal side effects so not to be used for more than 5 days
Admission for IV hydration
Normal saline with added potassium used to rehydrate
What are the complications of hyperemesis gravidarum?
Triad of- dehydration, weight loss, electrolyte imbalance
AKI
Wernicke’s encephalopathy
Oesophagitis, Mallory-Weiss tear
Venous thromboembolism
Fetal outcome- little adverse effect- maybe low birth weight, slight increase prem
What are the two types of emergency contraception?
Emergency hormonal contraception- levonorgestrel, ulipristal
Intrauterine device (IUD)
What are the two types of hormonal emergency contraception?
Levonorgestrel
Ulipristal
What are the features of levonorgestrel?
Taken as soon as possible- efficacy decreases with time
Must be taken within 72 hours of unprotected sexual intercourse (UPSI)
Single dose of 1.5mg should be doubled for those with BMI over 26 or weight over 70kg
If vomiting occurs within 3 hours dose should be repeated
Can be used more than once in a menstrual cycle if clinically indicated
Hormonal contraception can be started immediately after using levornogestrel
What are the features of ulipristal (EllaOne)?
30mg dose take as soon as possible, no later than 120 hours after intercourse
Don’t use with levonorgestrel
Ulipristal may reduce the effectiveness of the hormonal contraceptive. Contraceptive with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods used during this time.
Caution exercised in patients with severe asthma
Ulipristal can be used more than once in the same cycle
Breastfeeding delayed one week after ulipristal, no restrictions with levonorgestrel
What are the features of IUD for emergency contraception?
Copper IUD most effective method of emergency contraception and offered to all women if they meet criteria
Must be inserted within 5 days of UPSI
If more than 5 days, may be fitted up to 5 days after the likely ovulation date
Prophylactic antibiotics may be given if patient at high risk of STI
99% effective no matter where used in cycle
May be left in situ for long term contraception. If to be removed, kept until at least next period
Ectopic pregnancy investigation?
A pregnancy test will be positive
Transvaginal ultrasound is the investigation of choice
Ectopic pregnancy management?
Expectant management
Medical management- methotrexate- patient must attend follow up
Surgical management- salpingectomy or salpingotomy
What are the features of expectant management of ectopic pregnancy?
Size <35mm
Unruptured
Asymptomatic
No fetal heartbeat
hCG <1000IU/L
Compatable with another intrauterine pregnancy
Involves closely monitoring patient over 48 hours and if B-hCG levels rise again or symptom manifest intervention performed
What are the features of medical management of ectopic pregnancy?
Size <35mm
Unruptured
No significant pain
No fetal heartbeat
hCG<1500 IU/L
Not suitable if intrauterine pregnancy
Medical management involves using methotrexate and only done if patient willing to attend follow up
Methotrexate is teratogenic no pregnacy 3 months after
What are the features of surgical management of ectopic pregnancy?
Size >35mm
Can be ruptured
Pain
Visible fetal heartbeat
hCG >5000IU/L
Compatible with another intrauterine pregnancy
Surgical management can involve salpingectomy or salpingotomoy
Salpingectomy is the first-line for women with no other risk factors for infertility
Salpingotomy considered for women with risk factors for infertility such as contralateral tube damage-
Around 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or salpingectomy)
What is the triad of pre-eclampsia?
New-onset hypertension
Proteinuria
Oedema
What is the definition of pre-eclampsia?
New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
Proteinuria
Other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
Pre eclampsia consequences?
Eclampsia- also altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
Fetal complications- Intrauterine growth retardation
Prematurity
Liver involvement- elevated transaminases
Haemorrhage- placental abbruption, intra-abdominal, intro-cerebral
Cardiac failure
Features of severe pre eclampsia?
Hypertension- typically >160/110 and proteinuria
Proteinuria: dipstick ++/+++
Headache
Visual disturbance
Papilloedema
RUQ/epigastric pain
Hyperreflexia
Platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
Risk factors for pre eclampsia?
High risk factors
Hypertensive in previous pregnancy
CKD
Autoimmune disease
DM T1/T2
Chronic hypertension
Moderate risk factors
First pregnancy
Over 40
Pregnancy interval over 10 years
BMI 35 or more
FH pre eclampsia
Multiple pregnancy
Pre eclampsia prevention?
Women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth
≥ 1 high risk factors
≥ 2 moderate factors
Pre eclampsia initial management?
Emergency secondary care assessment for any woman with suspected pre-eclampsia
Women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed
Further management of pre-eclampsia?
Oral labetalol first line. Nifedipine if asthmatic, hydralazine may also be used
What are the features of endometriosis?
Chronic pelvic pain
Secondary dysmenorrhoea- pain often starts days before bleeding
Deep dyspareunia
Subfertility
Non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
On pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
Investigations for endometriosis?
Laparoscopy is gold standard
Endometriosis management?
NSAIDs and/or paracetamol are first line
If analgesia doesn’t work then COCP or progestogens (medroxyprogesterone acetate)
If analgesia does not improve symptoms or fertility a priority refer to secondary care
Endometriosis secondary care management?
GnRH analogues
Drug therapy has no significant impact on fertility rates
Surgery
If trying to conceive can use laparoscopic excision or ablation of endometriosis
At what time after birth will women require contraception?
After day 21
What are the options for postpartum contraception?
Progesterone only pill (POP)
Can start POP anytime postpartum
After day 21 additional contraception for first 2 days
Combined oral contraceptive pill (COCP)
Absolute contraindication if breastfeeding <6 weeks post partum
UKMEC 2 if 6 weeks-6 months postpartum and breastfeedng
Not used in the first 21 days due to increase VTE risk post partum
After day 21 additional contraception for first 7 days
IUD or IUS inserted within 48 hours of childbirth or after 4 weeks
Lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breast feeding, amenorrhoeic and < 6 months post-partum
What is conceiving within 12 months associated with?
Increased risk preterm birth, low birth weight and small for gestational age babies
What scale may be used to screen for postnatal depression?
Edinburgh postnatal depression scale
10-item questionnaire, with a maximum score of 30
Indicates how the mother has felt over the previous week
Score > 13 indicates a ‘depressive illness of varying severity’
Includes a question about self-harm
What are the three types of postpartum mental health problems?
‘Baby-blues’
Postnatal depression
Puerperal psychosis
‘Baby blues’ features?
Typically 3-7 days after giving birth and more common in primips
Mothers are characteristically anxious, tearful and irritable
Reassurance and support
Postnatal depression feaetures?
10% women
Most cases start within a month and peak at 3 months
Features similar to depression
Support and reassurance
CBT may be helpful
Sertraline and paroxetine may be beneficialif symptoms are severe
Puerperal psychosis features?
Onset 2-3 weeks after birth
Severe swings in mood (similar to bipolar) and disordered perception (auditory hallucinations)
Admission to hospital- ideally mother and baby unit
25-50% risk of recurrence following future pregnancies
What is the name for chickenpox exposure in pregnancy?
Fetal varicella syndrome
What is the risk to the mother in fetal varicella syndrome?
5x risk pneumonitis
Features of feta varicella synrome for fetus?
Skin scarring
Eye defects (microphthalmia)
Limb hypoplasia
Microcephaly
Learning disabilities
Other risks
Shingles in infacy
Severe neonatal varicella
Chicken pox exposure management?
If doubt about mother previously having chicken pox maternal blood should be checked for varicella antibodies
If the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible
VZIG effective up to 10 days after exposure
If the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure
Management of chicken pox in pregnancy?
Specialist advice
Risk of serious chicken pox infection (maternal), fetal varicella risk and the safety of aciclovir in pregnancy
Oral aciclovir given if pregnant woman is ≥ 20 weeks and presents within 24 hours of onset of the rash
If the woman is < 20 weeks the aciclovir should be ‘considered with caution’
What is the scale of UK Medical Eligibility Criteria (UKMEC)?
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
UKMEC 3 example conditions COCP?
More than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
Family history of thromboembolic disease in first degree relatives < 45 years
Controlled hypertension
Immobility e.g. wheel chair use
Carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
Current gallbladder disease
UKMEC 4 example conditions COCP?
More than 35 years old and smoking more than 15 cigarettes/day
Migraine with aura
History of thromboembolic disease or thrombogenic mutation
History of stroke or ischaemic heart disease
Breast feeding < 6 weeks post-partum
Uncontrolled hypertension
Current breast cancer
Major surgery with prolonged immobilisation
Positive antiphospholipid antibodies (e.g. in SLE)
Is DM UKMEC classified for COCP?
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
What is postpartum haemorrhage?
Postpartum haemorrhage (PPH) is defined as blood loss of > 500 ml after a vaginal delivery and may be primary or secondary
Primary PPH occurs within 24 hours
What are the causes of PPH?
4 Ts:
Tone (uterine atony): the vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)
Risk factors for primary PPH?
Previous PPH
Prolonged labour
Pre-eclampsia
Increased maternal age
Polyhydramnios
Emergency Caesarean section
Placenta praevia, placenta accreta
Macrosomia
PPH management?
PPH life threatening- senior members of staff involved immediately
ABC approach
Mechanical:
Palpate the uterine fundus and rub it to stimulate contractions
Catheterisation to prevent bladder distension and monitor urine outpur
Medical:
IV oxytocin (syntocinon): slow IV injection followed by an IV infusion
Ergometrine slow IV or IM (unless hypertension history)
Carboprost IM (unless history of asthma)
Misoprostol sublingual
Surgical:
Intrauterine balloon tamponade first line surgical management
B-lynch suture, ligation uterine arteries etc
If severe uncontrolled then hysterectomy sometimes performed
When does secondary PPH occur?
24 hours- 6 weeks due to retained placental tissue or endometritis
What to do if someone misses one COC pill?
Take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
No additional contraceptive protection needed
What to do if someone misses 2 or more pills?
Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
The women should use condoms or abstain from sex until she has taken pills for 7 days in a row
If pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
If pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception
If pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
High risk factors for preeclampsia?
Hypertensive in previous pregnancy
CKD
Autoimmune disease
DM T1/T2
Chronic hypertension
Moderate risk factors for preeclampsia?
First pregnancy
Over 40
Pregnancy interval over 10 years
BMI 35 or more
FH pre eclampsia
Multiple pregnancy
What to do woman with previous VTE who is pregnant?
Input from expert
Add low molecular weight heparin
What makes a woman intermediate VTE risk in pregnancy?
Hospitalisation, surgery, comorbidities or thrombophilia
Risk factors increase chances of VTE in pregnancy
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
4+ warrants immediate treatment with LMWH continued until 6 weeks postnatal
What drugs should be avoided in pregnancy related to VTE?
Direct oral anticoagulants (DOACs)
Warfarin
What is gestational hypertension?
New onset hypertension diagnosed after 20 weeks without significant proteinuria
What are the categories of gestational hypertension?
Mild 140-149 over 90-99
Moderate 150-159 over 100-109
Severe >160 over >110
What are the three groups of gestational hypertension?
Pre-existing HTN- over 140/90 before pregnancy or before 20 weeks, no proteinuria/oedema
If already on an ACE/ARB stop
Pregnancy induced HTN- occuring in second half of pregnancy (after 20 weeks), no proteinuria, no oedema, resolves following birth
Pre-eclampsia- pregnancy induced hypertension in association with proteiuria, oedema may occur
Management of gestational hypertension?
1st- Oral labetalol (not for asthmatics)
2nd- Oral nifeddipine
Rules for traditional POPs if missed? (Micronor, Noriday, Nogeston, Femulen)
If less than 3 hours late
no action required, continue as normal
If more than 3 hours late (i.e. more than 27 hours since the last pill was taken)
action needed
Rules for Cerazette (desogestrel) if missed?
If less than 12 hours late
no action required, continue as normal
If more than 12 hours late (i.e. more than 36 hours since the last pill was taken)
action needed - see below
Action if any POP missed, and needs action?
Action required, if needed:
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
What are the red flags for group b strep in a baby?
Two or more minor risk factors or one red flag antibiotic therapy with benzylpenicillin and gentamicin.
One minor risk observe for 24 hours
Red flags:
Suspected or confirmed infection in another baby in the case of a multiple pregnancy
Parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour periods before and after the birth [This does not refer to intrapartum antibiotic prophylaxis]
Respiratory distress starting more than 4 hours after birth
Seizures
Need for mechanical ventilation in a term baby
Signs of shock
Risk factors for GBS infection?
Prematurity
Prolonged rupture of the membranes
Previous sibling GBS infection
Maternal pyrexia e.g. secondary to chorioamnionitis
First choice antibiotic for GBS?
Benzylpenicillin
Who should be offered intrapartum antibiotic prophylaxis (IAP) for GBS?
Previous GBS in a pregnancy (or offer testing late in pregnancy and antibiotics if positive)
Women with a previous baby with early or late onset GBS disease
Preterm labour regardless of GBS status
Women with pyrexia of >38 during labour
RFs for perineal tears?
Primigravida
Large babies
Precipitant labour
Shoulder dystocia
Forceps delivery
Perineal tears classification?
First degree- superficial no muscle involvement, do not require repair
Second degree- injury to perineal muscle but not involving anal sphincter, requires suturing
Third degree- injury to perineum involving anal sphincter complex, require repair in theatre
Fourth degree- injury to perineum involving anal sphincter complex and rectal mucosa, repair on theatre
What are the features of uterine fibroids?
May be asymptomatic
Menorrhagia
Bulk related symptoms- lower abdo pain, cramping, bloating, urinary symptoms
Subfertility
Rare features- polycythemia secondary to autonomous production of erythropietin
How to diagnose uterine fibroids?
Transvaginal ultrasound
Uterine fibroids management?
Asymptomatic- review periodically
Treatment to shrink:
Medical- GnRH agonists- use for short periods loss of bone density
Surgical:
Myomectomy- performed abdominally, laparoscopically or hysteroscopically
Hysteroscopic endometrial ablation
Polycythaemia due to autonomous production of erythropoietin
Treatment of menhorrhagia secondary to fibroids?
1st Levonorgestrel intrauterine system (LNG-IUS)
NSAIDs- mefeanamic acid
Tranexamic acid
COCP
Oral progestogen
Injectable progestogen
What are the three stages of postpartum thyroiditis?
- Thyrotoxicosis
- Hypothyroidism
- Normal thyroid function (but high recurrence rate in future pregnancies)
Thyroid peroxidase antibodies are found in 90% of patients
What is the management of postpartum thyroiditis?
Thyrotoxic phase- propanolol for symptom control
Hypothyroid phase- treat with thyroxine
Contraceptive effectiveness times (if not on first day of period)?
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
Most common adverse effect of POP?
Irregular vaginal bleeding is the most common
POP cover start?
Up to and including day 5 immediate, otherwise 2 days and use condoms inbetween
If switching from COCP immediate protection if continued from end of pill packet
What conditions are a contraindication to breast feeding?
Galactosemia
Viral infections
Which drugs can be given to breastfeeding mothers?
The following drugs can be given to mothers who are breastfeeding:
Antibiotics: penicillins, cephalosporins, trimethoprim
Endocrine: glucocorticoids (avoid high doses), levothyroxine*
epilepsy: sodium valproate, carbamazepine
asthma: salbutamol, theophyllines
Psychiatric drugs: tricyclic antidepressants, antipsychotics**
Hypertension: beta-blockers, hydralazine
Anticoagulants: warfarin, heparin
Digoxin
Which drugs are contraindicated while breastfeeding?
The following drugs should be avoided:
Antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
Psychiatric drugs: lithium, benzodiazepines
Aspirin
Carbimazole
Methotrexate
Sulfonylureas
Cytotoxic drugs
Amiodarone
Clozapine
What does primary amenhorroea, little or no axillary and pubic hair and elevated testosterone mean?
Androgen insensitivity syndrome
Features of androgen insensitivity syndrome?
Primary amenorrhoea
Little or no axillary and pubic hair
Undescended testes causing groin swellings
Breast development may occur as a result of the conversion of testosterone to oestradiol
What are the three components of the risk malignancy index (RMI) in ovarian cancer?
US findings
Menopausal status
CA125 levels
RFs for shoulder dystocia?
Fetal macrosomia (association with maternal diabetes)
High maternal BMI
DM
Prolonged labour
Shoulder dystocia management?
Senior help called immediately
McRoberts manoeuvre should be perfromed- this manoeuvre entails flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen
this rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery.
Shoulder dystocia compliations?
Potential complications include:
Maternal:
Postpartum haemorrhage
Perineal tears
Fetal:
Brachial plexus injury
Neonatal death
Which antidepressant for breastfeeding women?
Sertraline
HRT side effects?
Nausea
Breast tenderness
Fluid retention and weight gain
Complications of HRT?
Increased risk of breast cancer- increased by progesterone
Increased risk of endometrial cancer- oestrogen by itself not given to women with a womb- reduced by the addition of progesterone
Increased risk VTE- increased by addtion of progesterone, transdermal HRT does not increase VTE risk
Increased risk of stroke
Increased risk of ischaemic heart disease
What are the investigations for reduced fetal movements?
If past 28 weeks-
1. Handheld doppler to confirm fetal heartbeat
2. If not detected immediate ultrasound offered
3. If present CTG used for at least 20 mins to monitor fetal HR
If fetal movements not felt by 24 weeks referral should be made
What are some causes of folic acid deficiency?
Phenytoin
Methotrexate
Pregnancy
Alcohol excess
What are the concequences of folic acid deficiency?
Macrocytic, megaloblastic anaemia
Neural tube defects
What is the prevention of neural tube defects during pregnancy?
All women should take 400mcg of folic acid until 12th week of pregnancy
Women at higher risk of NTD should take 5mg folic acid from before conception until 12th week of pregnancy
Which women are higher risk for neural tube defects?
Either partner has a NTD, FH or previous prgnancy with NTD
Woman taking antiepileptic drugs, coeliac disease, DM or thalassaemia
Woman is obese 30 BMI or more
How long can the mirena coil stay in?
5 years
What is eclampsia?
Development of seizures in association with pre-eclampsia
What is used to prevent seizures in preeclampsia and treat sezirues when they develop (eclampsia)?
Magnesium sulphate
What should be monitored while giving magnesium sulphate?
Urine output, reflexes, respiratory rate and oxygen saturations
What is the treatment for respiratory depression when using magnesium sulphate?
Calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
How long to treat with magnesium sulphate in eclampsia?
Treatment should continue for 24 hours after last seizure of delivery
What else should you do in severe pre eclampsia/eclampsia?
Fluid restriction to prevent fluid overload
What are the features of vulval cancer?
In older women
Lump or ulcer on labia majora
Inguinal lymphadenopathy
May be associated with itching/irritation
What are the risk factors for ectopic pregnancy?
Anything slowing ovum’s passage to the uterus:
Damage to tubes (pelvic inflammatory disease, surgery)
Previous ectopic
Endometriosis
IUCD
Progesterone only pill
IVF (3% of pregnancies are ectopic)
Look at induction of labour
N
When should an ectopic pregnancy be managed surgically?
> 35mm
hCG over 5000IU/L
What is amniotic fluid embolism?
This is when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction
When can amniotic fluid embolism occur?
During labour, after delivery in the immediate post partum or during caesarean insection
What are the symptoms/signs of amniotic fluid embolism?
Symptoms include: chills, shivering, sweating, anxiety and coughing.
Signs include: cyanosis, hypotension, bronchospasms, tachycardia, arrhythmia and myocardial infarction.
Management of amniotic fluid embolism?
Critical care unit
What is the most common cause of primary postpartum haemorrhage (PPH)?
Uterine atony
What is syntocinon?
Synthetic oxytocin
What are the three features of Meig’s syndrome?
A benign ovarian tumour
Ascites
Pleural effusion
What are the four main types of ovarian tumour?
Surface derived tumours
Germ cell tumours
Sex cord-stromal tumours
Metastasis
What is the management of placenta praevia on a 20 week scan?
- Rescan at 32 weeks
- No need to limit activity or intercourse unless they bleed
- If still present at 32 weeks then scan every 2 weeks
- Final ultrasound at 36-37 weeks to determine method of delivery- elective aesarean section for grades III/IV between 37-38 weeks, trial of vaginal may be offered if grade I
- If know placenta praevia goes into labour prior to the electve caesarean secton emergency caesarean section should be performed due to PPH risk
Placent praevia with bleeding management?
- Admit
- ABC approach to stabilise woman
- If not able to stabilise- emergency caesarean section
- If in labour or term reached- emergency caesarean section
What is the investigation for ectopic pregnancy?
Transvaginal utrasound
How to differentiate between causes of bleeding in pregnancy?
Painless Praevia
Agony Abruption
What type of bleeding in placena praevia?
Painless and bright red
What type of bleeding in placental abruption?
Pain and dark red
What is dysmenorrhoea?
Excessive pain during the menstrual period
What is primary dysmenorrhoea?
No underlying pelvic pathology. Usually appears within 1-2 years of menarche.
Pain typically starts just before or within a few hours of period starting
Suprapubic cramping pains which may radiate to the back or down the thigh
What is the management of primary dysmenorrhoea?
1st- NSAIDs such as mefenamc acid and ibuprofen
2nd- COCP
What is secondary dysmenorrhoea?
Develops many years after the menarche. Is the result of underlying pathology. Pain usually starts 3-4 days before the onset period.
Causes incude:
Endometriosis
Adenomyosis
Pelvic inflammatory disease
Intrauterine devices (copper coil, inrauterine system (mirena) may help)
Fibroids
What is the management for seconday dysmenorrhoea?
Refer to gynae
Depends on cause
What suggests Down’s syndrome on a 12 weeks combined screening test result?
High HCG
Low PAPP-A
Nuchal translucency- thickened
When can a chorionic villous sampling test be performed?
Between 11 weeks and the end of the 13th week
When can amniocentesis be performed?
From the 15th week onwards
What are the guidelines on antenatal testing for Down’s?
The combined test is now standard- tests should be done between 11-13+6 weeks
Combined is- nuchal translucency measurement, serum B-HCG and pregnancy-associated plasma protein A (PAPP-A)
Trisomy 18 and 13 give similar results to Down’s but HCG lower
Quadruple test
If women book later in pregnancy quadruple test should be offered between 15-20 weeks
What is in the quadruple test?
Alpha-fetoprotein
Unconjugated oestriol
Human chorionic gonadotrophin
Inhibin A
What is in the combined test?
Nuchal translucency measurement
Serum B-HCG
Pregnancy-associated plasma protein A (PAPP-A)
Downs syndrome result on quadruple test?
Alpha-fetoprotein- low
Unconjugated oestriol- low
HCG- high
Inhibin A- high
What results come from the combined and quadruple tests?
Both tests return a lower chance or higher chance result
Lower chance- 1 in 150 or more
High chance- 1 in 150 or less
What is non-invasive prenatal screening test (NIPT)
If a woman has a higher chance result she will be offered a second screening test (NIPT) or a diagnostic test (amniocentesis or chorionic villus sampling (CVS). Given NIPT non-invasive and highly sensitive and specific this is preffered choice
What are the features of NIPT?
Analyses small DNA fragments that circulate in the blood of a pregnant woman
cffDNA derives from placental cells
Analysis of cffDNA allows early detection chromosomal abnormalities
Sensitivity and specificity are very high for trisomy 21 (>99%)- similarly high for other chromosomal abnormalities
What should women on epileptics who are trying to conceive receive?
5mg folic acid instead of 400mcg
What is vaginal candidiasis?
Thrush- very common 80% caused by Candida albicans
Risk factors for vaginal candidiasis?
DM
Drugs- antibiotics, steroids
Pregnancy
Immunosuppression- HIV
What are the features of vaginal candidiasis?
Cottage cheese, non offensive discharge
Vulvitis- superficial dyspareunia, dysuria
Itch
Vulval erythema, fissuring, satellite lesions
What are the investigations for vaginal candidiasis?
High vaginal swab- not indicated if the clinical features consistent with candidiasis
Management vaginal candidiasis?
Local or oral
1st- Oral fluconazole
Clotrimazole 500mg intravaginal pessary as single dose if oral therapy contraindicated
If there are vulval symptoms consider adding topical imidazole in addition to an oral or intravaginal antifungal
If pregnant only local treaments may be used
Recurrent vaginal candidiasis management?
4 or more episodes per year
Compliance checked
Confirm candidiasis with high vaginal swab
Blood glucose to exclude diabetes
Consider induction maintinence regime-
Induction: Oral fluconazole every 3 days for 3 doses
Maintinence- oral fluconazole weekly for 6 months
What are the characteristics of ovarian torsion?
Sudden onset unilateral lower abdominal pain. May coincide with exercise
N+V common
Unilateral, tender adnexal mass on examination
What is it called if fallopian tube also involved in torsion?
Adnexal torsion
RFs for ovarian torsion?
RFs
Ovarian mass
Being reproductive age
Pregnancy
Ovarian hyperstimulation syndrome
Features of ovarian torsion?
Usually sudden onset of deep seated colicky abdominal pain
Vomiting and distress
Fever in minority
Vaginal examination shows adnexial tenderness
Ultrasound may show whirlpool sign
Laparoscopy both diagnostic and theraputic
Features for PID case?
Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities
Cervical excitation may be found on examination
What virus causes rubella?
Togavirus
Features of congenital rubella syndrome?
Sensorineural deafness
Congenital cataracts
Congenital heart disease (e.g. patent ductus arteriosus)
Growth retardation
Hepatosplenomegaly
Purpuric skin lesions
‘salt and pepper’ chorioretinitis
Microphthalmia
Cerebral palsy
How to diagnose rubella in pregnancy?
Suspected cases should be discussed immediately with the local Health Protection Unit
IgM antibodies raised in women recently exposed to the virus
Difficult to differentiate between rubella and parvovirus B19
Rubella in pregnancy management?
Discuss with local Health Protection Unit
If a woman has no immunity advise to keep away from people who might have rubella
Non-immune mothers should be offered the MMR vaccination in the post-natal period- MMR should not be given to known pregnant mothers or ones trying to get pregnant
Do antibiotics have any effect on the POP?
No
What is the range for the combined test?
11-13+6 weeks
What is the rage for the quadruple test?
15-20 weeks
What is the main problem with the Nexplanon implant?
Irregular heavy bleeding
When can levonorgestrel be taken vs ulipristal?
Levonorgestrel within 72 hours
Ulipristal within 120 hours
Management for early delivery?
Administer tocolytics and steroids
Infertility management in PCOS?
Weight reduction
Metformin, clomifene or a combination should be used to stimulate ovulation
Clomifene 1st, metformin more used in overweight
General management of PCOS?
Weight reduction
COC may help regulate cycle if contraception required
Hirstuism and acne management in PCOS?
COC may help
2nd Eflornithine
What is placenta accreta?
The attachment of the placenta to the myometrium. Placenta does not properly seperate during labour higher risk of post partum haemorrhage
What are the three types of placenta accreta?
Accreta: chorionic villi attach to the myometrium
Increta: chorionic villi will invade into the myometrium
Percreta: chorionic villi will invade through the perimetrium
What is intrahepatic cholestasis of pregnancy?
Most common liver disorder in pregnancy
What are the features of intrahepatic cholestasis of pregnancy?
Pruritis- often in palms and soles
Clinicallydetectable jaundice
Raised bilirubin
What is the management of intrahepatic cholestasis of pregnancy?
Ursodeoxycholic acid is used for symptomatic relief
Weekly liver function tests
Women are typically induced at 37 weeks
What are the features of acute fatty liver of pregnancy?
Abdominal pain
Nausea & vomiting
Headache
Jaundice
Hypoglycaemia
Severe disease may result in pre-eclampsia
What is the investigation for acute fatty liver of pregnancy?
ALT is typically elevated e.g. 500 u/l
What is the management of acute fatty liver of pregnancy?
Support care
Once stabilised- delivery
What is the investigation for ectopic pregnancy?
Transvaginal ultrasound
What is menorrhagia?
Heavy menstrual bleeding >80ml per menses
What are the menorrhagia investigations?
Full blood count
Transvaginal ultrasound scan if symptoms suggest structural or histological abnormality (intermenstrual or post coital bleeding, pelvic pain/pressure symptoms)
What is the management for menorrhagia for women who do not require contraception?
Either mefenamic acid (particularly with dysmenorrhoea) or tranexamic acid
Both started on first day of period
What is the management for menorrhagia for women who require contraception?
1st- intraterine system (Mirena)
2nd- COCP
3rd- long acting progestogens (depo provera)
What are the characteristics of malignant ovarian cysts?
Irregular, solid tumour
Ascites
At least 4 papillary structures
Strong blood flow
What are the types of physiological cysts?
Follicular cysts- commonest type ovarian cyst
Corpus luteum cyst- more likely to intraperitoneal bleed than follicular
What to do to prophylactically treat someone for pre-eclampsia?
Low dose aspirin started at 12-14 weeks
When should IUD copper be offered as emergency contraception?
In all cases as more effective especially if ovulation has just occured (14 days) as other two stop ovulation
Unless contraindicatted
What are the feaetures of PCOS?
Subfertility and infertility
Menstrual disturbances- oligomenorrhoea and amenorrhoea
Hirsutism, acne
Obesity
Acanthosis nigricans
What are the investigations for PCOS?
Pelvic ultrasound- multiple cysts on the ovaries
Baseline investigations- FSH, LH, Prolactin, TSH, testosterone, sex hormone-binding globulin
Raised LH:FSH ratio
Prolactin normal to mildly elevated
Testosterone normal to mildly elevated
SHBG normal to low
Check impaired glucose tolerance
What are the diagnostic criteria for PCOS?
Rotterdam criteria- PCOS diagnosis made if 2 of the following 3 are present:
Infrequent/no ovulation
Clinical and biochemical signs of hyperandrogenism (hirsutism, acne or elevated levels of testosterone)
Polycystic ovaries on ultrasound scan
How late does Cerazette (desogestrel) have to be before action needed?
12 hours
What makes you think adenomyosis?
> 30 with dysmenorrhoea, menorrhagia and an enlarged boggy uterus
What is adenomyosis?
Endometrial tissue within the myometrium
More common in multiparous women towards the end of their reproductive years
Features of adenomyosis?
Dysmenorrhoea
Menorrhagia
Enlarged, boggy uterus
Investigations for adenomyosis?
1st- Transvaginal ultrasound
MRI is alternative
Management of adenomyosis?
Symptomatic treatment- tranexamic acid to manage menorrhagia
GnRH agonists
Uterine artery embolisation
Hysterectomy- definitive treatment
What is the max end of normal hCG results and what does a high one make you think?
210,000 mIU/ml
If higher suggests a molar pregnancy- complete hydatidiform mole
What are the features of a molar pregnancy?
Vaginal bleeding
Uterus size greater than expected for gestational age
Abnormally high hCG
Ultrasound: Snow storm appearance of mixed echogenicity
What should be monitored during treatment with magnesium sulphate?
Urine output, reflexes, respiratory rate and oxygen saturations
How often is smear testing done?
Between 25-64 years
25-49 years- 3-yearly
50-64 years- 5-yearly
Cervical screening not offered to patients over 64
What are the special situations related to cervical screening?
Cervical screening in pregnancy delayed until 3 months post partum unless missed screening/previous abnormal smears
Women never sexually active before are low risk so may want to opt out
What are the three types of gestational trophoblastic disorders?
Complete hydatidiform mole
Partial hydatidiform mole
Choriocarcinoma
What are the features of complete hydatidiform mole?
Bleeding in first or early second trimester
Exaggerated symptoms of pregnancy- hyperemesis
Uterus large for dates
Very high hCG
Hyertension and hyperthyroidism my be seem (hCG can mimick TSH)
What is the management of a molar pregnancy?
Urgent referral to specialist centre- evacuation of uterus performed
Effective contraception recommended to avoid a pregnancy in the next 12 months
What is expectant management of miscarriage?
Waiting for spontaneous miscarrige
Wait 7-14 days for miscarrige to complete spontaneously
If expectant management unsuccessful then medical or surgical management offered
Situations where medical or surgical:
Increased risk of haemorrhage- late first trimester or coagulopathies
Previous adverse/ traumatic pregnancy- stillbirth, miscarrige, antepartum haemorrhage
Evidence of infection
What is the medical management of miscarrige?
Tablets to expedite the miscarrige
Vaginal misprostol- prostaglandin analogue
Contact doctor if bleeding not stopped within 24 hours
Given antiemetics and pain relief
What is the surgical management of miscarrige?
Surgical procedure under local or general anaesthetic
Vacuum aspiration (suction curettage) or surgical management in theatre
Vacuum aspiration done under local anaesthetic as an out patient
What must be given to rhesus D negative women having a termination after 10 weeks?
anti-D prophylaxis
What are the medical options for termination of pregnancy?
Mifepristone (anti-progestogen) followed 48 hours later by prostaglandins (e.g. misoprostol) to stimulate uterine contractions
Takes hours/days to complete
Pregnancy test required at 2 weeks to confirm the pregnancy has ended. Should detect the level of hCG (rather than positive or negative)- termed a multi level pregnancy test
What are the surgical options for termination of pregnancy?
Transcervical procedures- vacuum aspiration, electric vacuum aspiration and dilitation and evacuation
Following surgical abortion an intrauterine contraceptive can be inserted immediately after evacuation of the uterine cavity
Choice of termination of pregnancy?
Choice between medical and surgical offered up to and including 23+6 weeks gestation
After 9 weeks medical abortions less common- increased likelihood of products of conception seen and decreased success rate
Before 10 weeks medical abortions usually done at home
What to do if a woman with hypertension on ACEi/ARB gets pregnant?
Stop immediately and give alternative antihypertensives (labetalol) while awaiting specialist review
Define hypertension in pregnancy?
systolic > 140 mmHg or diastolic > 90 mmHg
Increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
Then catagorise into pre-existing, pregnancy induced or pre- eclampsia
Proteinuria/oedema
What do fibroids appear as on ultrasound?
Hypoechoic masses
What does a complete hydatidiform mole appear as on ultrasound?
Snow-storm appearance
What is the treatment for CIN (cervical intraepitheliar neoplasia)?
Large loop excision of the transformation zone (LLETZ)
How long should 400IU vitamin D be taken during pregnancy?
It should be taken for the full duration of pregnancy
What are the reasons for taking 5mg of folic acid instead of 400mcg?
Either partner has NTD, previous pregnancy NTD or FH NTD
Woman taking antiepileptic drugs, has coeliac, diabetes or thalassemia
Obese 30+ BMI
What is tested for on booking visit?
4 3 2 1
4 blood (FBC, rhesus, blood group, alloantibodies)
3 virus (hepB, HIV, syphilis) rubella no more
2 UTI (dipstick, culture)
1 full physical examination (breast, BMI, BP)
What are the three main catagories of anovulation?
Class 1 (hypogonadotropic hypogonadal anovulation) - notably hypothalamic amenorrhoea (5-10% of women)
Class 2 (normogonadotropic normoestrogenic anovulation) - polycystic ovary syndrome (80% of cases)
Class 3 (hypergonadotropic hypoestrogenic anovulation) - premature ovarian insufficiency (5-10% of cases). In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive
What are the forms of ovarian induction?
Exercise and weight loss
Letrozole
Clomiphene
Gonadotrphin therapy
What is ovarian hyperstimulation syndrome?
Ovarian hyperstimulation syndrome (OHSS) is one of the potential side effects of ovulation induction
Hypovolaemic shock
Acute renal failure
Venous or arterial thromboembolism
What are the indications for induction of labour?
Prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
Prelabour premature rupture of the membranes, where labour does not start
Maternal medical problems:
diabetic mother > 38 weeks
pre-eclampsia
obstetric cholestasis
Intrauterine fetal death
What is the Bishop’s score used for?
Use to assess whether the induction of labour is required
Score of <5 indicates labour unlikely to start without an induction
Score of ≥ 8 indicates high chance of spontaneous labour
What are the components of a Bishop’s score?
Look up table
Cervical postition
0- posterior
1- intermediate
2- anterior
Cervical consistency
0- firm
1- intermediate
2- soft
Cervical effacement
0- 0-30%
1- 40-50%
2- 60-70%
3- 80%
Cervical dilitation
0- <1 cm
1- 1-2 cm
2- 3-4 cm
3- >5 cm
Fetal station
0- -3
1- -2
2- -1, 0
3- +1,+2
Management of induction of labour?
Options-
1st- Membrane sweep
Vaginal prostoglandin E2 (PGE2)- dinoprostone
Oral prostoglandin E1- misoprostol
Maternal oxytocin
Amniotomy
Cervical ripening balloon
if the Bishop score is ≤ 6
vaginal prostaglandins or oral misoprostol
mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
if the Bishop score is > 6
amniotomy and an intravenous oxytocin infusion
NICE guidelines on labour induction?
If the Bishop score is ≤ 6
vaginal prostaglandins or oral misoprostol
Mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
If the Bishop score is > 6
amniotomy and an intravenous oxytocin infusion
What are the complications of labour induction?
Uterine hyperstimulation:
Prolonged and frequent uterine contractions
Fetal hypoxia
Uterine rupture
Management:
Removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started
Consider tocolysis
What used for tocolysis?
It’s Not My Time
Indomethacin
Nifedipine
Magnesium sulphate
Terbutaune
What is ruptured endometrioma?
Intense pain
Ruptured endometriosis, fluid in abdomen
Learn the hand innervation
Rock, Paper, Scissors –> Median, Radial, Ulnar
What is the management of placental abruption?
Fetus alive and under <36 weeks
Fetal distress: emergency caesarean
No fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Fetus alive and >36 weeks
Fetal distress: immediate caesarean
No foetal distress: deliver vaginally
Foetus dead- induce vaginal delivery
Features of intrahepatic cholestasis of pregnancy?
Pruritus - may be intense - typical worse palms, soles and abdomen
Clinically detectable jaundice occurs in around 20% of patients
Raised bilirubin is seen in > 90% of cases
Management of intrahepatic cholestasis of pregnancy?
Induction of labour at 37-38 weeks is common practice but may not be evidence based
Ursodeoxycholic acid
Vitamin K supplementation
Why give higher folate?
MORE folic acid (5mg) for:
M- Metabolism diseases- Diabetes and Coeliac
O- Obesity (BMI >30)
R- Relative (Family or personal Hx of NTDs)
E- Epilepsy (on anti-epileptic meds)
(+Thalassaemia and Sickle Cell- less likely in exams)
Antipsychotics too
Edward’s syndrome quadruple test result?
EdwardIAn- inhibin A stands out
Alpha fetoprotein- low
Unconjugated oestriol- low
hCG- low
Inhibin A- normal
Which one out of Edward’s, Patau and Down’s gives high hCG?
Down’s
Down’s syndrome quadruple test result?
Alpha fetoprotein- low
Unconjugated oestriol- low
hCG- high
Inhibin A- high
Neural tube defects quadruple test result?
Alpha fetoprotein- High
Unconjugated oestriol- normal
hCG- normal
Inhibin A- normal
Who should be prescribed aspirin throughout preganncy?
Anyone with risk factors for pre-eclampsia- 1 high risk or two moderate risks
High risk factors:
Hypertensive disease in a previous pregnancy
Chronic kidney disease
Autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
Type 1 or type 2 diabetes
Chronic hypertension
Moderate risk factors:
First pregnancy
Age 40 years or older
Pregnancy interval of more than 10 years
Body mass index (BMI) of 35 kg/m² or more at first visit
Family history of pre-eclampsia
Multiple pregnancy
What is umbilical cord prolapse?
The umbilical cord descending before the presenting part of the uterus
What are the risk factors for umbilical cord prolapse?
Prematurity
Multiparity
Polyhydraminos
Twin pregnancy
Cephalopelvic disproportion
Abnormal presentation- breech, transverse lie
When do most cord prolapses happen?
At artificial rupture of the membranes
What is the management of umbilical cord prolapse?
Obstetric emergency
Presenting part of the fetus may be pushed back into the uterus to avoid compression
If cord past the level of introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm
Ask patient to go on all fours until immediate caesarian ready
Tocolytics may be used to reduce the uterine contractions
Retrofilling the bladder with 500-700ml of saline may be helpful
Instrumental vaginal possible if cervix fully dilated and head is low
Which contraception is contraindicated in PID?
Intrauterine device
Intrauterine system
Both last for 5 years
What is the most effective form of contraception?
Implantable contraceptive
Contraindications- current breast cance- UKMEC 4
What can happen when you stop l-dopa?
Similar to neuroleptic malignant sydrome
What are the differential diagnoses of bleeding in the first trimester?
Miscarriage
Ectopic pregnancy
Implantation bleeding
Difference between traditional POPs and desogestrel (Cerazette)
Latest traditional can be- 3 hours
Latest desogestrel can be- 12 hours
What are the three types of foetal lie?
Longitudinal lie
Transverse Lie
Oblique
Risk factors for transverse presentation?
Women who have had previous pregnancy most common
Fibroids and pelvic tumours
Twins or triplets
Prematurity
Polyhydraminos
Foetal abnormalities
How to diagnose transverse lie?
Abnormal foetal lie detected during routine antenatal appointments
Abdominal examination
Ultrasound scan
Complications of transverse lie?
Pre-term rupture membranes (PROM)
Cord-prolapse
What is the management of transverse/oblique lie?
Before 36 weeks none most resolve
After 36 weeks:
Active management- external cephalic version (ECV) of the foetus- can be late in pregnancy or early in labour- contraindications- maternal rupture in last 7 days, multiple pregnancy (except 2nd twin), major uterine abnormality.
Elective caesarean section
Which insertable contraceptive should you avoid in heavy menstrual bleeding or those with a history of it?
Copper intrauterine device
Postpartum contraception options?
POP anytime- contraception used first two days
COCP- UKMEC 4 if less than 6 weeks post partum, UKMEC2 6 weeks to 6 months, not in first 21 days as VTE risk, after 21 days additional contraception for first 7 days
IUD or IUS can be used within 48 hours of childbirth or after 4 weeks
Lactationnal amenorrhoea method 98% effective if fully breastfeeding, amenorrhoeic and <6 months post partum
What to do with a woman 10 weeks presenting with confusion, ataxia, nystagmus?
Give Pabrinex (B vitamins)
Wernicke’s encephalopathy can come from vomiting (hyperemesis gravidarum)
What is the name of trying to turn a breech baby after 36 weeks?
External cephalic version (ECV)
How to sort breech babies?
If less then 36 weeks reassureit might move round
If over 36 weeks give external cephalic version (ECV) a go
If it fails offer planned caesarean or vaginal delivery
What are the absolute contraindications for ECV?
Where caesarean delivery is required
Antepartum haemorrhage within the last 7 days
Abnormal cardiotocography
Major uterine anomaly
Ruptured membranes
Multiple pregnancy
What is used for rehydration in hyperemesis gravidarum?
Admit for IV saline with potassium replacement
What is the medical management for miscarrige?
Just vaginal misoprostol
Contact doctor if bleeding not stopped in 24 hours
Misoprostol expels products of contraception, don’t need mifepristone to end pregnancy as would be the case in an abortion
What are the surgical options for miscarrige?
Vaccum aspiration
Surgical management
What are the side effects of GnRH analogues?
Menopausal symptoms and loss off mineral bone density
Used in fibroids
Check fibroids
On Passmed
How to suppress lactation?
Stop lactation reflex- stop suckling
Supportive measures- well supported bra and analgesia
Cabergoline is the medication of choice
What is given before fibroid surgery?
GnRH analogues to try and reduce the size of the fibroid (uterus) before surgery- particularly for hysterectomy
COCP not taken 4-6 weeks before surgery due to VTE risk
At what point is the menopause said to have happened?
12 months since last period
Women under 50 who menopause require contraception for 2 years, over 50 only 1 year
How long should women use contraception after the menopause?
If menopause happened over 50- 1 year
If menopause happened under 50- 2 years
What are the two types of caesarean section?
Lower segment caesarean- now over 99% of cases
Classic caesarean- longitudinal incision
What are the indications for caesarean section?
Absolute cephalopelvic disproportion
Placenta praevia grades 3/4
Pre-eclampsia
Post-maturity
IUGR
Fetal distress in labour/prolapsed cord
Failure of labour to progress
Malpresentations: brow
Placental abruption: only if fetal distress; if dead deliver vaginally
Vaginal infection e.g. active herpes
Cervical cancer (disseminates cancer cells)
What are the catagories of caesarean section?
Category 1- immediate threat to life of mother or baby- suspected uterine rupture, cord prolapse, foetal hypoxia, persistent fetal bradycardia- to be delivered within 30 mins
Category 2- Maternal or fetal compromise not immediately life threatening - delivery should occur within 75 minutes
Category 3- delivery required but mother and baby stable
Category 4- elective caesarean
What are contraindications to vaginal birth after caesarean?
Previous uterine rupture
Classical caesarean scar
How can you differentiate between a seizure and a pseudoseizure?
Elevated prolactin 10-20 mins after episode can differentiate between general tonic clonic/partial and non-epileptic pseudo seizure
Serum prolactin raised in true seizures
Tongue biting in true seizures
What factors favour pseudo seizures over true seizures?
Pelvic thrusting
Family member with epilepsy
Much more common in females
Crying after seizure
Don’t occur when alone
Gradual onset
What is the target time for thrombectomy in acute stroke?
6 hours
Stroke features?
pelvic thrusting
family member with epilepsy
much more common in females
crying after seizure
don’t occur when alone
gradual onset
What is the management of primary dysmenorrhoea?
1st- NSAIDs such as mefenamic acid and ibuprofen
COCP is 2nd line
What is cervical ectropion?
Ectocervix transformation. Caused by elevated levels of oestrogen (pregnancy. COCP, ovulatory phase)
Features:
Vaginal discharge
Post coital bleeding
Ablative treatment
What is fibroid degeneration and when might it occur?
Uterine fibroids are sensitive to oestrogen and can grow during pregnancy
If growth outstrips blood supply can undergo red degeneration
This presents with low grade fever, pain and vomiting
Conservative management- rest, analgesia- should resolve within 4-7 days
What is the management for endometrial cancer?
Surgery
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
Patients with high risk disease may have post operative chemotherapy
What are the long term complications of vaginal hysterectomy with antero-posterior repair?
Enterocele and vaginal vault prolapse
Urinary retention may occur acutely
What are the investigations for bladder incontience?
All types of incontinence
Bladder diaries
Vaginal examination to exclude prelvic organ prolapse
Urine dipstick and culture
Urodynamic studies
Is Carbamazepine enzyme inducing?
Yes, can’t use with UKMEC 3COCP, POP UKMEC2 implant
Hb normal values in pregnancy?
Before 115
First trimester Hb less than 110 g/l
Second/third trimester Hb less than 105 g/l
Postpartum Hb less than 100 g/l
Normocytic or microcytic anaemia a trial of oral iron should be considered as the first step, and further investigations only required if no rise in haemaglobin after 2 weeks.
What is the management for anaemia in pregnancy?
Normocytic or microcytic
Oral ferrous sulphate or ferrous fumarate
Treatment continued for 3 months after iron deficieny corrected to allow iron stores to be replenished
How long can bHCG remain raised after an abortion?
For 3/4 weeks
Do a pregnancy test with hCG level 2 weeks after the termination to confirm
When can hormonal contraception be started after levornogestrel and ulipristal?
Levornogestrel- imediately
Ulipristal- 5 days after taking- barrier methods used during this period
Ulipristal used with caution in asthmatics
Both can be used more than once in a menstrual cycle
Bleeding in the first trimester management?
<6 weeks- if no pain or risk factors then expectant management, return if bleeding develops, repeat pregany test in 7-10 days
> 6 weeks if bleeding refer to the early pregnancy assesment unit for a transvaginal ultrasound scan
What fluid should be prescribed in hyperemesis gravidarum?
IV normal saline with potassium chloride
Treat hypokalaemia
First line for overactive bladder?
Bladder retraining
What is syntometrine?
Syntocinon and ergometrine
What are the types of miscarriage?
Threatened-
Painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
The bleeding is often less than menstruation
Cervical os is closed
Missed-
A gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
Mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear.
Pain is not usually a feature
Cervical os is closed
When the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
Inevitable-
Heavy bleeding with clots and pain
Cervical os is open
Incomplete-
Not all products of conception have been expelled
Pain and vaginal bleeding
Cervical os is open
When does gestational cardiac activity begin?
Around 5 weeks of age
When to check serum progesterone?
7 days before next period as that is when it is highest
Fetus alive and < 36 weeks
Placental abruption
Fetal distress- immediate caesarean
No fetal distress- observe closely, SteroidS, no tocolysis, threshold to deliver depends on gestation
What factors reduce vertical HIV transmission in pregancy?
Maternal antiretroviral therapy
Mode of delivery (caesarean section)
Neonatal antiretroviral therapy
Infant feeding (bottle feeding)
Offer HIV screening to everyone
Should women with HIV be offered antiretroviral therapy?
Yes everyone with HIV
How should baby be delivered in a mother with HIV?
Vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
A zidovudine infusion should be started four hours before beginning the caesarean section
Should the baby get antiretroviral therapy?
Zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks
Breast feeding not reccomended in UK
After how long should women treated for CIN1, CIN2, or CIN3 be recalled?
Cervical intraepithelial neoplasia
6 months for test of cure
What is the most common cause of post menopausal bleeding?
Vaginal atrophy
(Can occur in women taking HRT)
(Can occur in endometrial hyperplasia?
Who gets OGTT at 24-28 weeks?
Anyone with risk factors:
BMI of > 30 kg/m²
Previous macrosomic baby weighing 4.5 kg or above
Previous gestational diabetes
First-degree relative with diabetes
Family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Gastroschisis vs Exomphalos
Gastroschisis
Vaginal can be attempted
- without a peritoneal covering.
- lateral to the umbilical
Mx - surgical correction ASAP
- cover with sling-film(since no peritoneal covering)
Omphalocele
Caesarean indicated
- with peritoneal covering
- umbilical site
Mx - no need csling film BUT surgical treatment usually in staged (may take months) to allow lung adaptation
When emergency contaception on COCP?
If 7 days missed consecutively- start again as new user
What is Sheehan’s syndrome?
Sheehan syndrome describes hypopituitarism caused by ischemic necrosis due to blood loss and hypovolaemic shock
Amenorrhoea and symptoms of hypothyroidism
(Big cause is PPH)
What is Asherman’s syndrome?
May occur after dilitation and cutterage
Can prevent endometrium responding to oestrogen- could cause amenorrhoea
Define secondary and primary amenorrhoea?
Primary: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics
Secondary: cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea
Causes of secondary amernorrhoea?
Hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
Polycystic ovarian syndrome (PCOS)
Hyperprolactinaemia
Premature ovarian failure
Thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
What is a galactocele?
Presents in women who have recently stopped breast feeding
Should be painless
When does fibroid degeneration usually happen?
Within the first or second trimester
What is the presentation of chorioamnionitis?
RF is premature membrane rupture
Deliver foetus and IV antibiotics
Fever, tachycardia, neutrophilia, uterine tenderness and foul smelling discharge
What is HELLP syndrome?
Acronym for Haemolysis, Elevated Liver enzymes and Low Platelet count
Can develop in the late stages of pregnancy
Got a cross over with severe pre eclampsia
What are the features of HELLP syndrome?
Nausea & vomiting
Right upper quadrant pain
Lethargy
Investigations: haemolysis, elevated liver enzymes, low platelets
Treatment: Delivery
What is the management of intrahepatic cholestasis of pregnancy?
Ursodeoxycholic acid is used for symptomatic relief
Weekly liver function tests
Women are typically
induced at 37 weeks
What are the investigation results for PCOS?
Raised LH:FSH ratio
Testosterone may be normal or mildly elevated
Sex hormone binding globulin (SHBG) is normal to low
Why are all newborns offered vitamin K?
All relatively deficient and breastmilk poor source- reduces the risk of haemorrhagic disease of the newborn
Either IM or orally
What is premenstrual syndrome (PMS)?
Emotional and physical symptoms women may experience before the luteal phase
Doesn’t occur pre puberty, in pregnancy or post menopause
PMS symptoms?
Emotional symptoms include:
anxiety
stress
fatigue
mood swings
Physical symptoms:
bloating
breast pain
What is the management of PMS?
Mild symptoms- lifestyle advice- sleep, exercise, smoking, alcohol, small regular meals
Moderate symptoms- COCP
Severe symptoms- SSRIs
What is the cause of secondary amenorrhoea in a very athletic woman?
Hypothalamic hypogonadism
What are the causes of puerperal pyrexia?
Temperature of > 38ºC in the first 14 days following deliver
Endometritis: most common cause
Urinary tract infection
Wound infections (perineal tears + caesarean section)
Mastitis
Venous thromboembolism
Management:
If endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
What is the treatment for vaginal vault prolapse?
Sacrocolpoplexy
Surgical options for urogenital prolapse?
Cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
Uterine prolapse: hysterectomy,
sacrohysteropexy
Rectocele: posterior colporrhaphy
What is endometrial hyperplasia?
Abnormal proliferation of the endometrium- abnormal intermentrual bleeding- higher risk for endometrial cancer
Simple or atypical
Simple- high dose progestogens, levornogestrel system
Atypia- hysterectomy
What to do with Hep B women who give birth?
Babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin
Hep B cannot be transmitted through breast feeding but HIV can
When to do ECV?
36 weeks in nulliparous
37 in multiparous
What is premature ovarian insufficiency syndrome?
Onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40
What are the causes of premature menopause?
Idiopathic
Bilateral oophorectomy
Radiotherapy
Chemotherapy
Infection
Autoimmune disorders
What are the features of premature ovarian insufficiency?
Similar to normal climacteric
Climacteric symptoms- hot flushes, night sweats
Infertility
Secondary amenorrhoea
Raised FSH, LH levels (elevated FSH from two samples taken 4-6 weeks apart)
Low oestradiol
What is the management of premature ovarian insufficiency?
HRT or COCP until average age of menopause (51)
Must a woman be exclusively breast feeding for lactational amenorrhoea method to be affective?
Yes
Where is the most dangerous place for an ectopic?
The isthmus- most at risk of rupture
Most common in the ampulla
Features allowing for the expectant management of ectopic pregnancy?
Expectant management of an ectopic pregnancy can only be performed for
1) An unruptured embryo
2) <35mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of <1,000IU/L and declining
Placental abruption risk factors?
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
Examples of GnRH analogues?
Goserelin
Triptorelin
Features of the patch contraception?
For the first 3 weeks, the patch is worn everyday and needs to be changed each week. During the 4th week, the patch is not worn and during this time there will be a withdrawal bleed
Delayed changing of the patch contraception?
If the patch change is delayed at the end of week 1 or week 2:
If the delay in changing the patch is less than 48 hours, it should be changed immediately and no further precautions are needed.
If the delay is greater than 48 hours, the patch should be changed immediately and a barrier method of contraception used for the next 7 days. If the woman has had sexual intercourse during this extended patch-free interval or if unprotected sexual intercourse has occurred in the last 5 days, then emergency contraception needs to be considered.
If the patch removal is delayed at the end of week 3:
The patch should be removed as soon as possible and the new patch applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.
If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle.
Investigation for menorrhagia?
FBC
Ultrasound scan
Management of menorrhagia?
Requires contraception:
Mirena coil- intrauterine system
COCP
Long-acting progestogens
Does not require contraception:
Mefenamic acid (helps with dysmenorrhoea)or tranexamic acid
What is tested for at booking appointment?
HIV, syphillis, Hep B
Sickle cell, thalassemia
What is the classic triad of vasa praevia?
Rupture of the membranes followed by painless vaginal bleeding and foetal bradycardia
What to monitor with magnesium sulphate
Respiratory rate and reflexes
(urine output, oxygen sats)
Complications of HRT?
Increased risk of breast cancer- by addition of progestogen
Increased risk of endometrial cancer- oestrogen by itself not given to women with a womb
Increased risk of VTE- due to addition of progestogen- not the case for transdermal
Increased risk of stroke
Increased risk of ischaemic heart disease if taken 10 years after menopause
Endometrial hyperplasia vs vaginal atrophy as a cause of PMB?
Both have bleeding
Vaginal atrophy- most common and assocaited with dryness and dyspareunia, post coital bleeding
Endometrial hyperplasia- associated with obesity, no pain or post coital bleeding
How to confirm pre term premature rupture of the membranes (PPROM)?
A sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection
if pooling of fluid is not observed NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSure®) or insulin-like growth factor binding protein‑1
Ultrasound may also be useful to show oligohydramnios
What is the management of PPROM?
Admission
Regular observations to ensure chorioamnionitis is not developing
Oral erythromycin should be given for 10 days
Antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
Delivery should be considered at 34 weeks of gestation - there is a trade-off between an increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
Monitoring results of a molar pregnancy?
bHCG- High
TSH- Low
Thyroxine- High
bHCG can stimulate the thyroid gland to produce thyroxine, negative feedback so TSH low
What is the management of pre menstrual syndrome?
Mild symptoms- lifestyle advice- exercise, smoking, alcohol
Moderate symptoms- new-generation COCP (contains drospirenone)
Severe symptoms- SSRI
Management of GBS in pregnancy?
Women with previous GBS offered intrapartum antibiotic prophlaxis or testing late in pregnancy and then antibiotics
If woman has GBS requires intrapartum benzylpenicillin
Which contraceptive is assocaited with weight gain?
Depo provera
Also delay in fertility returning of up to 1 year, increased risk osteoporosis and irregular bleeding
What are the features of ovarian failure (including premature)?
Amenorrhoea, climateric symptoms (hot flushes, night sweats), lost oestradiol, raised gonadotrophins
What is the treatment of mastitis?
Flucloxacillin
Continue breastfeeding
Are positive antiphospholipid antibodies (e.g. in SLE) UKMEC 4 in the COCP?
Yes
SSRIs and pregnancy?
- BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
Ectopic vs miscarrige?
In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy
COCP cancer associations?
Combined oral contraceptive pill
increased risk of breast and cervical cancer
protective against ovarian and endometrial cancer
Most important risk factor for placenta accreta?
Caesarean sections
Can the mirena coil act as the progesterone part of HRT?
Yes for up to 4 years
The patient can then just take oestradiol
What are the signs of labour?
Regular and painful uterine contractions
A show (shedding of mucous plug)
Rupture of the membranes (not always)
Shortening and dilation of the cervix
What are the three stages of labour?
Labour may be divided in to three stages
stage 1: from the onset of true labour to when the cervix is fully dilated
stage 2: from full dilation to delivery of the fetus
stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered
How do you monitor labour?
Monitoring in Labour
FHR monitored every 15min (or continuously via CTG)
Contractions assessed every 30min
Maternal pulse rate assessed every 60min
Maternal BP and temp should be checked every 4 hours
VE should be offered every 4 hours to check progression of labour
Maternal urine should be checked for ketones and protein every 4 hours
What are the components of stage 1 labour?
Stage 1 - from the onset of true labour to when the cervix is fully dilated. In a primigravida lasts typical 10-16 hours
latent phase = 0-3 cm dilation, normally takes 6 hours
active phase = 3-10 cm dilation, normally 1cm/hr
Also
Latent- 0-3cm
Active- 3-7cm
Transition- 7-10cm
Components of stage 2 labour?
Stage 2 - from full dilation to delivery of the fetus
‘passive second stage’ refers to the 2nd stage but in the absence of pushing (normal)
active second stage’ refers to the active process of maternal pushing
less painful than 1st (pushing masks pain)
lasts approximately 1 hours
if longer than 1 hour (can be left longer if epidural) consider Ventouse extraction, forceps delivery or caesarean section
episiotomy may be necessary following crowning
associated with transient fetal bradycardia
When can IUD be fitted for emergency contraception?
must be inserted within 5 days of UPSI, or
if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
Likely ovulation date is normal length of period (take the shortest one) and subtract 14
Extremley friendly and extroverted, short, learning difficulties, transient neonatal hypercalcaemia and a supravalvular aortic stenosis?
William’s syndrome
What are the contraindications for planned vaginal birth after caesarean (VBAC)
Previous uterine rupture or classical caesarean scar
SSRI of choice in breastfeeding women?
Paroxetine
What are the normal physiological changes in pregancy?
Reduced urea, reduced creatinine, increased urinary protein loss
What to do with babies who don’t breastfeed well and lose 10% bodyweight in the first week?
Refer to speacialist midwife led clinic
PID management?
Intramuscular ceftriaxone + oral doxycycline + oral metronidazole
Remove copper IUD
PMS syndrome management?
Mild- Lifestyle advice
Moderate- new generation COCP
Severe- SSRI
Tamoxifen causes which type of cancer?
Endometrial
Difference between IgM and IgG in chickenpox?
IgG- got antibodies
IgM- met someome with virus, immediate infection
When does pregnancy test become negative after abortion?
4 weeks
Pregnancy test taken 2 weeks after
What is a macrosomic baby in weight?
Over 4.5 kg
How many miscarriges for it to be recurrent?
3 or more
Causes:
Antiphospholipid syndrome
Endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
Uterine abnormality: e.g. uterine septum
Parental chromosomal abnormalities
Smoking
Who is at risk of ovarian hyperstimulation syndrome when undergoing IVF?
PCOS women
Abdominal pain/bloating
N+V
Oliguria
Ascites
Thromboembolism
Acute respiratory distress syndrome
Increased/Decrease alpha fetoprotein causes?
Increased
Increased AFP
Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy
Decreased
Down’s syndrome
Trisomy 18
Maternal diabetes mellitus
When is primary amenorrhoea diagnosed?
15 if secondary sexual characteristics
13 with no secondary sexual characteristics
What are the PCOS investigations?
PElvic ultrasound
FSH, LH, TSH, testosterone, sex hormone-binding globulin (SHBG)
LH:FSH ratio raised
Prolactin normal or elevated
Testosterone normal or elevated
SHBG normal to low
Rotterdam criteria:
Infrequent/no ovulation
Clinical/biochemical hyperandrogenism
Polycystic ovaries on USS
Do you get increased ketones in hyperemesis gravidarum?
Yes
Any bleeding over 55 and post menopausal?
Refferal using suspected cancer pathway
First-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
Hysteroscopy with endometrial biopsy
Are antiepileptics safe in preganancy?
Yes
Management of no foetal distress less than 36 weeks placental abruption?
Admit for obersvation and give steroids
Which group B streptococcus causes sepsis in neonates?
Streptococcus agalacticae
In chains
Random information about food in pregancy?
Vit A may be teratogenic- so avoid liver
Take folic acid and vit D
No drinking
No smoking
Cervical cancer treatment?
For stage IA
Most likely to preserve fertility- cone biopsy
Recommended for women who don’t want children- hysterectomy with lymph node clearance- gold standard
Later sage- radiotherapy and chemotherapy
Who is the legal mother is surregacy?
The woman who gave birth, not the genetic parents
When are croup and bronchiolitis more common?
Croup- Autumn
Bronchiolitis- Winter
Neonatal resuscitation guidelines?
Neonatal resuscitation guidelines
Birth: Dry the baby, remove any wet towels and cover and start the clock or note the time.
Within 30 seconds: Assess tone, breathing and heart rate.
Within 60 seconds: If gasping or not breathing - open the airway and give 5 inflation breaths
Re-assess: If no increase in heart rate look for chest movement
If chest not moving: Recheck head position, consider 2-person airway control and other airway manoeuvres, repeat inflation breaths and look for a response.
If no increase in heart rate look for chest movement
When the chest is moving: If heart rate is not detectable or slow (< 60 min-1) - start chest compressions with 3 compressions to each breath.
Reassess heart rate every 30 seconds. If heart rate is not detectable or slow (<60 beats per minute) consider venous access and drugs
What is Mittelschmerz?
Usually mid cycle pain.
Often sharp onset.
Little systemic disturbance.
May have recurrent episodes.
Usually settles over 24-48 hours.
Fine adhesions between liver and abdomiinal wallM
Fitz-Hugh-Curtis (PID complication)
it is characterised by right upper quadrant pain and may be confused with cholecystitis
When is the copper coil contraindicated for emergency contraception?
PID or suspected STI
When should COCP be discontinued before surgury?
4 weeks before
Which contraceptive causes weight gain?
Depo provera
Who is adenomyosis more common in?
Multiparous women towards the end of their reproductive years
dysmenorrhoea
menorrhagia
enlarged, boggy uterus
NICE recommend transvaginal ultrasound as the first-line investigation
MRI is an alternative
symptomatic treatment
tranexamic acid to manage menorrhagia
GnRH agonists
uterine artery embolisation
hysterectomy
considered the ‘definitive’ treatment
What is the triad for chorioamnionitis?
Maternal pyrexia
Maternal tachycardia
Foetal tacycardia
More likely in pre-term PROM
What type of contraception can patients who have had a gastric band/bypass/duodenal switch not have?
Oral contraceptives due to lack of efficacy
If semen sample is abnormal in infertility, in how long should it be retested?
In 3 months
Should be performed after minimum of 3 days and max of 5 days of abstinence
Deliver to lab within an hour
In what situations is miscarriage better managed medically than surgically?
Increased risk of haemorrhage
she is in the late first trimester
if she has coagulopathies or is unable to have a blood transfusion
Previous adverse and/or traumatic experience associated with
pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
Evidence of infection
What is the surgical intervention for miscarriage?
Vacuum aspiration
Blood pressure over what level in pregnancy needs to be admitted?
160/110
POP including desogestrel to become active?
2 days
What could presence of pelvic pain in pregnancy on the background of menhorhagia be?
Fibroid degeneration
Grow in pregnancy due to oestrogen
Enlarged uterus
Remember postpatum thyroiditis
Three stages:
1.Thyrotoxicosis
2. Hypothyroidism
3. Normal thyroid function
What is hCG produced by?
First the embryo
Then the placental trophoblast
Main role is to prevent the disintergration of the corpus luteum
When are progesterone levels highest?
When you measure for ovulation
7 days before end of cycle
Hb cut offs for iron supplelemtation in pregnancy?
First trimester < 110 g/L
Second/third trimester < 105 g/L
Postpartum < 100 g/L
Treat with oral ferrous sulphate
Treatment for fibroids causing infertility?
Myomectomy
Contraindication for progesterone injectabe?
Breast cancer
Abruption RFs?
ABRUPTION:
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen- C-section);
P for Polyhydramnios;
T for Twins or multiple gestation/multiparity;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
When can the implant be inserted after birth?
Immediately
After 4 weeks if breast feeding
Do all women with secondary dysmenorrhoea need reffering to gynaecology?
Yes
Does pre eclampisa/ pregnancy induced hypertension have to occur after 20 weeks?
Yes, if before it is pre existing hypertension
How is vesicoureteric reflux diagnosed?
A micturating cystourethrogram
Contraception if COCP started on day 0-5 of menstrual cycle?
None it works straight away
Does phenytoin reduce folic acid?
Yes
OGTT when?
Previous gestational diabetes- at booking and 24-28 weeks
Other risk factors- just 24-28 weeks
Causes for oligohydraminos?
Causes:
Premature rupture of membranes
Potter sequence
bilateral renal agenesis + pulmonary hypoplasia
Intrauterine growth restriction
Post-term gestation
Pre-eclampsia
Ovarian cancer staging?
Stage 1 (1 word) = ovary
Stage 2 (2 words) = ovary + pelvis
Stage 3 (3 words) = ovary + pelvis + abdomen
Stage 4 = distant metastasis
Stage 1 Tumour confined to ovary
Stage 2 Tumour outside ovary but within pelvis
Stage 3 Tumour outside pelvic but within abdomen
Stage 4 Distant metastasis
Shoulder dystocia baby complications?
Erb’s palsy occurs due to damage to the upper brachial plexus most commonly from shoulder dystocia. Damage to these nerve roots results in a characteristic pattern: adduction and internal rotation of the arm, with pronation of the forearm. This classic physical position is commonly called the ‘waiter’s tip’
Klumpke’s palsy occurs due to damage of the lower brachial plexus and commonly affects the nerves innervating the muscles of the hand
What should all women with previous hypertension or a high risk factor for pre-eclampsia/eclampsia get?
Aspirin from 12 weeks to all pregnant women who are at moderate or high risk of pre-eclampsia
How many features need to be present for PCOS to be diagnosed?
2/3 on the Rotterdam scale:
oligomenorrhoea
clinical and/or biochemical signs of hyperandrogenism
polycystic ovaries on ultrasound
Management of endometrial hyperplasia?
Management
Simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
Atypia: hysterectomy is usually advised
What does fetal fibronectin mean?
High level related to early labour
Give steroids incase go into labour, monitor BMs if diabetic as can mess them up
Vasomotor symptoms such as flushes in meopause can be treated with what?
Fluoxetine
Potenitally sensitising events for rhesus negative women?
Potentially sensitising events in pregnancy:
- Ectopic pregnancy
- Evacuation of retained products of conception and molar pregnancy
- Vaginal bleeding < 12 weeks, only if painful, heavy or persistent
- Vaginal bleeding > 12 weeks
- Chorionic villus sampling and amniocentesis
- Antepartum haemorrhage
- Abdominal trauma
- External cephalic version
- Intra-uterine death
- Post-delivery (if baby is RhD-positive)
How often should HIV women be screened for HPV?
Every year
Women who are HIV positive are at an increased risk of cervical intra-epithelial neoplasia (CIN) and cervical cancer due to a decreased immune response and decreased clearance of the human papilloma virus
How long to carry on magnesium in pre eclampsia?
Until 24 hours after EITHER last seizure or delivery
Can a raised alphafeto protein suggest gastrochsis and exomphalos?
Yes
Asherman’s syndrome?
Secondary amenorrhoea due to uterine adhesions following surgery or trauma from birth
What is Meig’s syndrome?
The three features of Meig’s syndrome are:
a benign ovarian tumour
ascites
pleural effusion
Types of prolapse and the surgical options?
Types
cystocele, cystourethrocele
rectocele
uterine prolapse
less common: urethrocele, enterocele (herniation of the pouch of Douglas, including small intestine, into the vagina)
Surgical options
cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
uterine prolapse: hysterectomy, sacrohysteropexy
rectocele: posterior colporrhaphy
VEAL CHOP?
VEAL CHOP
Variable decelerations –> Cord compression
Early decelerations –> Head compression
Accelerations –> Okay!
Late decelerations –> Placental Insufficiency
Can ECV be attempted in labour?
Only if amniotic sac not ruptured
COCP effect on cancers?
Higher risk of screening cancers- cervical and breast
Lower risk of old age cancers- ovarian and endometrial
SSRIs in preganancy?
1st trimester- CHD
3rd trimester- persistant pulmonary hypertension of the newborn
Type of ultrasound for PCOS?
Pelvic ultrasound
How long can lochia last?
Up to 6 weeks
How to remember placental abruption?
ABRUPTION:
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
Potter sequence?
Cause of oligohydraminos- renal agenesis and pulmonary hypoplasia
Does pheytoin reduce folate levels?
Yes, phenytoin reduces folate
Dribbling urine after a prolonged labour?
Vesicovaginal fistula
Membrane rupture sepsis risk?
Prolonged rupture of the membranes >24 hours
Patau vs Edwards on quadruple?
Same
On quadruple/combined similar to Down’s but hCG lower
What to do with baby in Hep B mother?
Can breastfeed as doesn’t go into the milk
Babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin
Vaccine+HBIG within 12 hours of birth
Hep B vaccine 1-2 months then 6 months
Ovulation hormone locations?
FSH/LH- anterior pituitary
Oestrogen- ovaries
Proesterone- corpus luteum of ovary
What are the phases of the cycle?
Menstration
Follicular phase
Ovulatory phase
Luteal phase- last 14 days
FSH causes maturation of an egg
Oestrogen causes lining of uterus to grow
LH causes ovulation
Progesterone maintains the uterus lining, inhibits both LH and FSH
Cells seen in bacterial vaginosis?
Clue cells
UTI treatment?
Trimethoprim tetarogenic
1st- nitrofurantoin (avoid near term)
2nd- amoxicillin
MEN- 7 days treatment
Women- 3 days
Russell’s sign?
Calluses on knuckles or back of hand in bulimia
EEG benign rolandic epilepsy?
Face seizures at night
Centrotemporal spikes
Secondary dysmenorrhoea?
Referral to gynae
Endometriosis treatment?
NSAIDs/Paracetamol
COCP or progestogens
GnRH analogues
Surgery- ablation, laparoscopic excision
