Obs & Gynae Flashcards
1
Q
Risk Factors of PET? (pre-eclampsia)
A
Nulliparity
Afrocarribean
Prior Hx of PET
Extremes of maternal age
FH
Multiple pregnancy
Chronic HTN
2
Q
Triad of diagnosis of PET?
A
Hypertension
Proteinuria
Pitting oedema
3
Q
PET Symptoms?
A
RUQ pain
Severe headache/blurred vision
Pitting oedema - swollen face
Seizures
Reduced foetal movement
4
Q
What is HELLP syndrome?
A
Haemolysis
Elevated liver enzymes
Low platelets
It is associated with PET and gestational hypertension - however is different from both of these.
5
Q
Risk factors for miscarriage?
A
Increasing maternal age
Increased gravidity
Prior miscarriage
Smoking
6
Q
Presentation pf miscarriage?
A
PVB, cramping abdo pain
BhCG - will be over 1000, but rapidly decreasing over repeated measurements
Speculum may see products of conception
7
Q
Reasons for miscarriage?
A
Chromosomal abnormality - normally trisomy of some kind
Abnormal development
Uterine defects
Infection/environment
Trauma- although must be major
8
Q
Types of miscarriage?
A
Threatened
Incomplete
Complete
Missed
Septic
9
Q
Treatment of miscarriage?
A
Conservative
- let it happen naturally. Can happen in a few days/weeks
- bleeding can last for 2/3 weeks, severe bleeding or pain should only last 1-2 hrs
- causes infection in 1 in 4 women
- delay in all the tissue being expelled
Surgical
- operation under GA
- risks such as uterine perforation and infection and major bleeding
Medical
- misoprostol vaginal pessaries (4 pessaries)
- induces the miscarriage
- heavy bleeding and pain
- infection risks are low
- 1 in 100 risk of blood transfusion due to massive haemorrhage
10
Q
Phases of the menstrual cycle? When does menstruation occur?
A
Follicular phase (Day 1-14)
Ovulation (Day 14)
Luteal phase (14-28)
Menstruation occurs right at the end of the cycle around day 28/day 1.
11
Q
Synopsis of the Hypothalamic-Pituitary-Ovarian axis?
A
Hypothalamus releases Gonadatrophin releasing hormone (GnRH) every 90mins
Anterior Pituitary releases LH and FSH
LH acts on the ovaries to stimulate Oestrogen and Progesterone production (progesterone in luteal phase)
FSH stimulates the growth of follicles in follicular stage.
12
Q
Synopsis of the actions of the pituitary hormones and the ovarian hormones in the menstrual cycle.
A
LH:
Rises steadily until day 14 where here is an LH surge causing the rupture of the primary follicle and release of the ovum.
FSH:
pretty stable apart from slight increase at day 14 (Oestrogen feedback)
Oestrogen:
Increase from day 5 to day 13 (produced by developing follicle) This also causes the LH surge - positive feedback.
Progesterone:
Stable until day 16 or so when the corpus luteum starts synthesising - this decreases at day 23 if the corpus luteum regresses.
13
Q
Hormonal changes in menopause?
A
LH increases, FSH increases more consistently and this can be used as a diagnostic test (>30).
Oestrogen and Progesterone both decline.
14
Q
Pros and Cons of HRT?
A
Pros:
Osteoporosis risk decreased
Reduction of symptoms (not depression)
Cons:
Small increased risk of breast and uterine cancer
Side effects of nausea and breast tenderness
VTE risk in first year
Stroke risk
15
Q
Ectopic symptoms?
A
Vaginal bleeding - dark brown
Pelvic pain
Shoulder tip pain
Amenhorroea
Bowel symptoms
Fainting/dizziness
16
Q
Common causes of PPH?
A
Uterine atony (most common)
retained placenta
Vaginal and Vulval lacerations
17
Q
What is uterine atony?
A
When the uterus can no longer contract leading it bleed profusely.
18
Q
Definition of PPH?
A
> 500ml of blood loss within 24 hour of delivery
500-1000ml is minor
>1000ml is major
19
Q
Way to calculate EDD?
A
Add 9 months and 1 week to LMP
20
Q
What is thought to be the cause of hyperemesis gravidarum?
A
High circulating levels of hCG
21
Q
causes of IUGR?
A
Smoking (30-40% of cases)
Alcohol
HTN
Diabetes
PET
22
Q
What does asymmetrical intrauterine growth restriction (normal head circumference with reduced abdominal circumference) suggest?
A
Placental insufficiency - If the placenta is not supplying adequate blood to the fetus the body directs prioritises brain development at the expense of the body. As a result the abdominal circumference decreases whilst the head circumference remains normal.
23
Q
Complications of induction?
A
Uterine hyper stimulation
Prolapsed cord
Section needed
Uterine rupture
24
Q
When do women begin feeling foetal movement?
A
At 18-20 weeks
25
What does symmetrical IUGR normally represent?
It normally represents some kind of foetal abnormality - normally chromosomal.
26
Two types of abortion?
Medical termination
Surgical
27
Process of medical abortion?
Mifepristone (antiprogesterone) (600mg) followed by Misoprostol (prostaglandin analogue) (gemeprost 1mg) 48 hours later
>50% abort within an hour of misoprostol dose
28
Rough process of surgical abortion? Types?
Cervix is first dilated then uterine cavity is manually evacuated.
Manual vacuum aspiration (6-7 weeks)
Electric vacuum aspiration (6-15 weeks)
Dilatation and evacuation (GA, due to larger size)
29
How do you do a late pregnancy termination? When would you?
20-24 weeks:
3 methods:
1. Dilatation and extraction, KCl or Digoxin to stop fetal heartbeat, then GA and removal of fetus using sopher forceps.
2. Induction of labour with misoprostol/mifepristine/oxytocin
3. Intra amniotic infusion of hypertonic saline and/or prostaglandin to induce contractions.
30
Definition of spontaneous miscarriage?
Spontaneous miscarriage:
- loss of recognised pregnancy before 20 weeks or <500g
31
Types of spontaneous miscarriage?
Threatened miscarriage:
- Closed cervical os with uterine bleeding <20 weeks & confirmed viable gestation.
Inevitable miscarriage:
- Heavy bleeding clots & pain
- Open cervical os
- Pregnancy will miscarraige
Incomplete:
- partially expelled contents
Complete:
- Hx of bleeding and U/S has confirmed no gestation.
Missed:
- Foetus is dead but has not ben expelled
- (early foetal demise)
- Early pregnancy symptoms have gone
- Preg test may still be positive
- Continuous brown discharge & threatened miscarriage
Recurrent:
- Three or more sequentially
32
Principles of antenatal care?
Educate on normal changes in pregnancies
Identify maternal R/Fs
Screen for fetal problems
33
Preconception antenatal care? (3)
1. Folic acid 3 months prior to conception
2. Avoid teratogenic drugs
3. Preconception counselling
- Lifestyle changes: Alcohol, smoking weight
- Stabilise medical disorders
34
Food hygiene advice for pregnancy?
Seafood:
- nothing raw
- 2 portions of fish a week
- No Shark/Swordfish
Don't eat anything unpasteurised
No raw eggs, or raw meat
Avoid soft cheese
No raw sprouts
Limit caffeine to <300mg daily
35
Antenatal care at booking (first appointment - as soon as preggers)?
Vitamin D 10mcg from day of booking
Food hygiene advice
Screening
36
Risk factors for Gestational Diabetes?
Previous large baby >4.5kg
1st degree relative with diabetes
Family origin with high prevalence of diabetes (South Asian, black Carribean, Middle Eastern, )
PCOS
BMI>30
On any antipsychotic medication
37
What is MBRRACE UK?
Runs a national programme monitoring and investigating the cause of maternal and fetal deaths in the UK.
38
Maternal screening?
Medical Screening:
- Pre-existing conditions
- Risk Factors for conditions (PET/GDM)
- HIV, Hep B, Rubella, Syphilis
- Anaemia
- BP
- Blood group (Rhesus status)
- Gestational diabetes
- Placenta praevia
Other screening:
- BMI
- Domestic violence
- Mental health problems
- Migrant women:
- Cardiovascular
- Female Genital Mutilation (FGM)
39
Scans and screening for the fetus?
Dating scan @ 8-14 weeks
Combined test @ 11-13+6 weeks
- Screening for chromosomal disorders
- Take both blood and nuchal scans
QUAD test @ 15-16 weeks
- alpha-fetoprotein (AFP)
- total human chorionic gonadotrophin (hCG)
- unconjugated oestriol (uE3)
- inhibin-A (inhibin)
Anomaly scan @ 18-20+6 weeks
Growth scans @ (24)-28-32-36 weeks
40
When can you do SFH measurement from?
24 weeks
41
What is the puerperium?
Period of time following the birth of the baby ~ 6 weeks
42
Maternal issues in the puerperium?
Mood:
- Watch out for post-natal depression
- 50% experience low mood, typically in the first week
Nutrition:
- iron rich foods
- Anaemia post pregnancy is common
Involution
- Uterus returns to normal size and position
- Afterpains: Contractions experienced after birth, can be due to oxytocin release when breastfeeding
CSC healing
Lochia (vaginal discharge post-partum
Perineal pain:
- Pelvic floor exercises
Urine output:
- exclude urinary retention
- Think about incontinence
Bowel movements:
- Constipation
- Haemorrhoids
- Urgency and soiling - rule out anal sphincter damage
Legs:
- Exclude DVT/VTE
43
What is puerperal fever? 5 causes?
Infection post-partum (in the puerperium)
1. genital tract/uterine
2. UTI
3. Breast infection
4. VTE
5. Other. e.g. flu
44
Things to consider in perinatal mental health?
- Stress of transition to motherhood
- Postnatal blues
- Postnatal depression - suicide risk
- Traumatic birth - PTSD
- puerperal psychosis.
45
Physiological endocrine & metabolic changes during pregnancy?
Endocrine:
- FSH and LH drop
- Prolactin increases
- Cortisol increase (lipogenesis and fat storage), followed by insulin.
Metabolic:
- BMR increased by 15-20%, slowly over the course of the pregnancy
- 12-16kg weight gain is recommended
46
Physiological CVS & haematological changes during pregnancy?
CVS:
- Peripheral vasodilatation
- Cardiac output increases by 20% by week 8, then up to 40%
- Increase in SV and HR
- systolic murmurs are normal, diastolic are not
- Third heart sound is normal
Haematological:
- Plasma volume increased by 50%
- Dilution anaemia is caused by this
- Increased iron demand
-
47
Physiological respiratory changes during pregnancy?
Respiratory system:
- Tidal volume increase by 200ml
- Increased vital capacity and decreased residual volume
- 20% increased oxygen consumption
48
Physiological renal changes during pregnancy?
Renal:
- GFR increase
- Reduced Urea, creatinine and bicarb
49
Other general physiological changes during pregnancy?
Others:
- Nausea and vomiting is common
- Appetite is usually increased
- Heartburn
- Constipation is common (motility decreased to increase nutrient absorption
50
2012-14 maternal mortality?
8.5 per 100,000 (was 90 in 1952)
51
What is an indirect and direct death in maternity?
Maternal death is death while pregnant or within 42 days of birth
Indirect:
- Deaths resulting form pre-existing disease, or developed during pregnancy as a result of physiological changes of maternity
Direct:
- Death from obstetric complications: interventions, omissions or incorrect treatment.
52
Top causes of maternal death?
1. Cardiac disease
2. Sepsis
3. Neuro
4. Other
53
What are late and coincidental maternal deaths?
Late:
- between 42 days and 1 year after birth, that are as of a result of direct or indirect causes
Coincidental:
- Deaths that happen to occur in the pregnancy period but are not related
54
Two big R/F for maternal death in the UK?
>35
Black ethnic minorities
55
Physiological changes that affect insulin in pregnancy, and may cause GDM?
1. Insulin antagonists are produced by the placenta.
2. Increased insulin resistance (especially 3rd trimester) leads to increased insulin production in normal women
56
Effect of pregnancy on diabetes complications (type 1)?
Increased insulin requirements (as increased insulin resistance):
1. Tight control can lead to hypoglycaemia
- associated with maternal death
2. diabetic nephropathy and retinopathy may deteriorate
3. DKA may occur (should provide home ketone testing kit)
57
Effect of diabetes on pregnancy complications (maternal and fetal factors)?
Maternal:
- Antepartum haemorrhage
- PET
- Premature labour
Fetal:
- Microsomia (IUGR)
- Macrosomia
- Shoulder dystocia
- Risk of sudden fetal death
- Congenital abnormalities
- Hypoglycaemia
58
What HbA1c level are we aiming for before pregnancy?
48mmol/mol
Shouldn't have pregnancy if >86mmol/mol
59
pre-pregnancy planning for diabetic women?
Stop teratogenic drugs associated e.g. ACE inhibitors, statins
Retinal screen
Renal screen
?Basal-bolus insulin regime
60
What basal/bolus regime do they use in pregnancy?
Rapid acting insulin for each meal
Long acting at bedtime
61
What level of glycaemic control are we aiming for during pregnancy?
Fasting: < 5.3mmol/L
1 hour post-prandial <7.8mmol/L
62
What medication should you give when managing diabetes in pregnancy?
T2DM should continue metformin and often need insulin
Aspirin 75mg from 12 weeks (for PET risk)
63
Extra scans for diabetes in pregnancy?
Early dating scan and anomaly scan
4 weekly growth scan from 28 weeks
64
When should you deliver for diabetes in pregnancy?
37 - 38+6
65
What extra should you do during delivery with a woman who has diabetes?
Good glycaemic control peridelivery - to reduce risk of fetal hypoglycaemia:
- can give infusion
If preterm start steroids and insulin infusion
66
GDM risks to pregnancy?
Macrosomia, birth trauma, shoulder dystocia, increased induction, increased LSCS, pre-eclampsia
Neonatal hypoglycaemia, polycythaemia, increased perinatal mortality rate
67
How and when do you test for GDM?
2-hour 75g oral glucose test (OGTT) for women with risk factors for GDM at 26-28 weeks:
- Only water from midnight
- Fasting blood glucose
- 75g glucose challenge
- 2-hour blood glucose
GDM if fasting ≥5.6 mmol/l or 2-hour ≥7.8 mmol/l
In those with previous GDM, either early self monitoring or early OGTT (repeat 26-28 weeks if early OGTT normal).
68
Management of GDM antenatally?
Explain implications
- Glucose control will reduce risk of macrosomia
- Trauma during birth
- Induction of labour
- C section
- Neonatal hypoglycaemia
- Perinatal death
Teach self monitoring
Diet (low GI) and exercise advice
4 weekly growth scans from 28 weeks
Delivery by 40+6 weeks
69
GDM management during labour?
May need insulin infusion (maintain glucose within 4-7mmol)
Check blood glucose before leaving explain that insulin requirements rapidly decrease, and may need to stop treatment
Baby needs early feeding and hypoglycaemia management
6-13 week fasting blood sugar test to exclude diabetes, as risk of T2DM in future
70
How do you manage hypoglycaemia in the pregnant woman?
Pretty much as you would in a non-pregnant lady
Mild (3-4mmol/L)
Administer 10-20g of fast acting glucose:
- 150 - 200ml fruit juice
- 3-4 heaped teaspoons dissolved in water
Moderate (2-3mmol/L)
- 1-2 cubes of dextrose gel
Severe (<2mmol/L)
- ABCDE
- IM glucagon 1mg
- Consider IV glucose bolus
Check glucose level every 15mins, when >4mmol/L eat 15g of carbs - brown bread, banana, digestive biscuits
Recheck glucose again (after 15mins)
71
What level of glucose is hypoglycaemia
4 'hit the floor' : <4mmol/L = hypoglycaemia
72
Symptoms of Hypoglycaemia Mild-Severe?
Mild:
- Trembling, sweaty, hungry, palpitations, nausea
Moderate:
- Confusion, weakness, drowsiness, headache, dizzy, nausea
Severe:
- Unconscious/fitting
73
DKA pathophysiology?
Insulin deficiency:
- Increased glucagon, cortisol, GH, catecholamines
- Peripheral insulin resistance
Lead to
Hyperglycaemia, dehydration, ketosis, electrolyte imbalance
Lipolysis and decraesed lipogenesis = Ketone bodies and acidosis
Hyperglycaemia induced osmotic diuresis:
- Dehydration
- Hyperosmolarity
- Electrolyte loss
- Potassium deficiency
74
DKA presentation?
High blood glucose (>15mmol/L)
Polyuria
Polydipsia
Lethargy
Blurry vision
Abdo pain, nausea and vomiting
Collapse/unconscious
75
Difference with DKA in pregnancy? Management?
Can occur at much lower glucose levels.
Need to always consider in anyone with diabetes who is unwell
Always check blood ketones
Fetal monitoring
VTE prophylaxis
Management consists of fluid replacement, insulin and potassium replacement. Address cause.
Refer to diabetes team
76
Physiological/physical changes to coagulation in pregnancy?
Increased levels of clotting factors (i.e. fibrinogen and prothrombin).
Reduced levels of endogenous anticoagulants
- Slight increase in fibrinolysis (but not enough to offset the original changes)
ALSO baby is compressing vessels in pelvis (left common iliac vein)
77
R/Fs for VTE in pregnancy?
Prev. VTE
Thrombophilia
>35
Smoking
Obesity
Immobility
Infection
Surgery
PET
78
Very high risk factors, high risk factors, intermediate R/Fs and for VTE in pregnancy?
Very high:
- Previous VTE with long-term anticoagulant therapy
- Antithrombin deficiency
- Antiphospholipid syndrome
High risk:
- Prev. VTE (without Tx)
Intermediate risk:
- High risk thrombophilia
- Single prev. VTE assoc. w/ surgery with no throbopilia or FH
Low risk:
- Low risk thrombophilia
79
Manangement of VTE risk Very high to Low?
Very high:
- Antenatally High dose LMWH, and 6 weeks postnatal anticoag
High:
- Antenatal and 6 weeks postnatal LMWH
Intermediate:
- LMWH from 28 weeks to 6 weeks post natal
Low:
- Just consider as R/F
80
Contraindications to LMWH?
Known bleeding disorder
Active Antenatal/postpartum bleeding
Placenta praevia
Stroke in prev. 4 weeks (either type)
Severe renal/liver disease
81
Can you use aspirin or warfarin as an anticoagulant in pregnancy?
Aspirin - no
Warfarin - only postnatally
82
VTE presentation in pregnancy?
Can be non-specific and asymptomatic, however can present classically:
- As DVT (calf swelling, tenderness)
- As PE (Dyspnoea, chest pain, cough, tachycardia and tachypnoea)
83
Investigation for DVT in pregnancy?
Leg compression duplex US/S
ECG
CXR
FBC, LFTs, U&Es, Clotting
V/Q or CTPA
D-Dimer NOT reliable in pregnancy
84
VTE treatment?
LMWH
Thrombolysis
IVC filter
IV hep
Thoracotomy, embolectomy
85
When should you stop LMWH in pregnancy?
Labour
Bleeding
86
Obstetric cholestasis presentation in pregnancy?
Usually >30 weeks gestation
Intense pruritis (with no rash) (usually palms and soles)
- can be worse at night
Can have other cholestatic signs:
- Pale stools
- dark urine
- Jaundice
Fatigue
87
Obstetric cholestasis management?
Monitor LFTs
- If fall completely or rise above 100, may need to think about other causes
Treatment:
- topical emolients
- Ursodeoxycholic acid (UDCA)
- Can offer Vit K
- fetal monitoring during labour
88
Risks associated with obstetric cholestasis?
Increased risk of fetal distress
Increased risk of premature birth
Maternal morbidity (itch and sleep)
89
Management of epilepsy in pregnancy?
Pre pregnancy:
- monotherapy advised
DO detailed USS at 18-22 weeks
- as abnormalities are more common
Vit K for women on enzyme inducing treatment from 36 weeks and stat for the baby
Seizures:
- should be self limiting
- rectal/IV BDZ if prolonged
90
Types of urinary incontinence?
Stress incontinence
Urge incontinence (Overactive bladder)
Others:
- Retention w/ overflow
- Fistula
91
Presentation of stress incontinence?
Leakage that arises when there is an increase in intra-abdominal pressure:
- coughing
- laughing
- sneezing
60-70% of cases
92
Presentation of Urge incontinence (OAB)?
Incontinent in response to detrusor overactivity
Urgency, and will be incontinent if cannot reach the toilet in time, happens day and night.
30% of cases
93
R/Fs for urinary incontinence?
Childbirth
Menopause/tissue atrophy
Connective tissue issues
Obesity/constipation
Smoking
94
Investigations for urinary incontinence?
Urinalysis +/- microscopy and culture
Bladder diary
Pad test
Urodynamics
- Abnormal is <15mls
95
Treatment for stress urinary incontinence?
Pelvic floor exercises
Lose weight, stop smoking
Bladder retraining
Continence pessary
- Duloxetine
Surgery for stress:
- Slings
- Open culposuspension
- Tape (TVT or TOT)
96
Treatment for Urge urinary incontinence?
Lifestyle:
- lose weight, avoid irritants
Bladder retraining
Medical:
- anticholinergics (e.g. oxybutinin)
- Mirabegron
Surgical:
- Sacral nerve root stimulation
- Botox
- Detrusor myectomy
- Cystoplasty
97
Types of prolapse?
Anterior:
- Cystocele (bladder)
- Urethra (urocele)
Posterior:
- Rectocele (rectum)
- Enterocele ( small bowel)
Uterine prolapse:
- First degree: Uterus and cervix descent but does not reach introitus
- Second degree: Cervix at level of introitus
- Third degree: Cervix and uterus out of introitus
- Procidentia (everything is out inc. vagina)
Vault prolapse
- procidentia without uterus (after TAH)
98
Symptoms of a genital prolapse?
Dragging
Feel lump/bulge/pressure
May have urinary symptoms such as frequency/urgency (all of them actually)
Some difficulties with sex such as dyspareunia, loss of sensation etc
Some bowel symptoms, such as constipation, urgency and incontinence - splinting (have to push inside the vagina to poo)
99
Treatment of prolapse?
If no symptoms then no treatment
Try to tackle underlying R/Fs (smoking, obesity)
Physiotherapy (Pelvic Floor)
Vaginal pessaries
- the physical structure helps to keep things in place, can try for 6 months or have permanently
- Ring pessary is sexually active
Surgery
- If voiding symptoms, recurrence, pt preference
- Mesh repair (can use/or not)
- Anterior colpopexy - Cystocele
- Posterior colpopexy - Rectocele
100
Surgical treatments for heavy periods?
Hysterectomy
Focal removal of polyps/cancer/fibroids
Uterine artery embolisation for fibroids
Ablation:
- MEA (microwave endometrial ablation)
- Novosure (Radio frequency)
- Hydrothermal (90degree water for 10 mins)
- Balloon with hot oil
- Lasers (rare)
101
Definitive tests for fetal abnormalities?
CVS (chorionic villus sampling)
- Invasive
- Performed between 11-13 weeks
- Samples the placenta
- 2-3% risk
Amniocentesis
- Invasive
- Sample of amniotic fluid
- Normally done at 15-16 weeks
- Needle inserted under USS
- 0.5-1% miscarriage risk
NIPT (non-invasive pre natal) testing
- 99% sensitivity for downs
- Blood test
102
What is ECV? When/on whom would you perform it?
External cephalic version (if baby is breech)
- from 36 weeks in nulliparous
- from 37 weeks in multip
103
Contraindications to ECV?
C-section is needed anyway
Antepartum haemorrhage in last week
Multiple pregnancy
Ruptured membranes
104
Process of induction?
Use Prostin E2, then manually burst the waters, then use oxytocin
105
The 3 Ps that affect birth?
Passage - Pelvis shape
Passenger - baby position, baby size
Power - contraction power
106
What type of bleeding do you have with fibroids?
Cyclical
107
Post coital bleeding 3 main Ddx?
Polyp
Cervical ectropion
Cervical Cancer
108
3 main differentials for pelvic pain?
Primary dysmenorrhoea (psychological?)
Secondary:
- PID
- endometriosis
- Adenomyosis (endometriosis in the myometrium)
109
Placenta Praevia presentation? Types?
Post 28th week painless bleeding (normally profuse and sudden)
110
2 most common differentials for Antepartum haemorrhage (24-delivery)?
Placenta Praevia
Placental abruption
111
What is placenta praevia?
Placenta in front of cervical canal
- Major: fully covering internal os
- Minor: leading edge is in lower segment but not covering internal os
112
Complications associated with placenta praevia?
Shock following bleeding
VTE
Placenta accreta
Neonatal mortality
Preterm
Low birth weight
113
Management of placenta praevia?
Minor:
- extra monitoring, if the edge is <2cm over then can give birth vaginally
Major:
- LSCS (38 weeks)
- No penetrative sex
- Stay in hosp. from 34 weeks if had bleed, immediate transfer to hosp if any bleed
114
What is placental abruption?
Premature separation of the placenta before delivery.
Blood collects between placenta and uterus
Can be concealed (no bleeding) or revealed (bleeding).
115
Placental abruption presentation?
Rock solid abdomen
Lots of pain
Heavy breathing
Difficulty locating fetal heartbeat
Can have bleeding
116
Amount of contractions per 10mins you are aiming for (in 2nd stage)
3/4 contractions in 10 mins
117
What are you looking for in a foetal CTG?
DR C BRAVADO
DR - Define risk
C - contractions (how many etc.)
BRA - Baseline HR (110 - 160)
V - variability (how wiggly is it) want it to be variable
A - accelerations (peak - good thing)
D - Decelerations (trough - bad thing)
O - Overall
118
Antepartum haemorrhage all Ddx?
Placental abruption
Placenta praevia
Ectropion
Cervical cancer/polyp
Vasa praevia (babies blood after membranes rupture)
Infection
119
What is vasa praevia? Risks?
The placenta has developed away from the attachment of the cord and the vessels divide in the membrane
Risks:
- Fetal haemorrhage and death
120
Different cesarean sections and their timing?
Cat 1 - 30 mins
Cat 2 -60 mins
Cat 3 - When possible (today)
Elective
121
Abnormal vaginal bleeding Ddx?
Structural:
- Polyps (vagina, cervix, endometrium)
- Adenomyosis
- Fibroids (leiomyoma)
- Malignancy
Non-structural:
- Coagulopathy
- endometrial
- Iatrogenic
- Ovulatory dysfunction
122
Types of amenorrhoea?
Primary:
- No menarche at all by 14 (may wait till 16)
Secondary:
- periods have stopped (for 6 months)
123
Ddx of primary amenorrhoea?
Secondary sexual characteristics present:
- Constitutional delay (no abnormality)
- GU malformation e.g. imperforate hymen
- Androgen insensitivity syndrome (actually undescended testes and male, but did not respond to androgens)
- Hyperprolactinaemia
- Pregnancy
Sexual characteristics not present:
- Ovarian failure
- Hypothalamic failure (stress, exercise, underweight)
- Congenital adrenal hyperplasia
- HPA failure
124
Ddx of secondary amenorrhoea?
Pregnancy. Always.
PCOS
Premature ovarian failure
Depot and implant
Underweight
Thyroid disease
Iatrogenic (drugs)
Cancer
125
Fibroids presentation?
>30 y/o
50% asymptomatic
Heavy/long periods
Recurrent miscarriage/infertility
Abdo mass O/E
126
Types of fibroids?
Intramural
- within the uterine wall (most common)
Submucosal
- Growing into uterine cavity
Subserosal
- Growing out from uterus
127
What is endometriosis?
Endometriosis is a chronic oestrogen-dependent condition characterised by the growth of endometrial tissue in sites other than the uterine cavity.
128
Endometriosis presentation?
Dysmenorrhoea
Dyspareunia
Cyclical pelvic pain
Subfertility
Can have blood in poo/wee
129
Common teratogenic drugs?
ACE inhibitors
Valproate
130
Treatment for HTN/PET in pregnancy?
Labetalol
Nifedipine (calcium channel antag)
Aspirin (by 16 weeks)
131
What may cause breech presentation?
Macrosomia
Multip
Placenta praevia
polyhydramnios
Congenital uterine abnormalities
132
Types of twin pregnancy?
Dizygotic - non-identical
Monozygotic - identical
All dizygotic twins are diamniotic (inner) and dichorionic (outer) will have separate placentae
Depending when the monozygotic twins embryo splits they may share a chorion/amnion:
Monochorionic diamniotic: (most common)
- Share placenta, but not inner amnion
Monochorionic Monoamniotic:
- Share placenta
- Also share inner amniotic sac
133
Four Ts regarding causes of postpartum haemorrhage?
Tone (atony)
Tears/Trauma
Tissue (retained afterbirth)
Thrombin (clotting disorders)
134
Treatment for atony?
Syntocin
Ergometrine (not in HTN)
Misoprostol (rectal)
Carboprost (causes diarrhoea)
135
Primary and secondary PPH?
Primary <24hrs
Secondary >24hrs
136
4 common causes of perinatal death?
1. infection
2. RDS
3. Brain haemorrhage (SAH)
4. Necrotizing enterocolititis
137
Macrosomia is defined as above what weight?
Above 4.5 kg
138
When should pregnancy be offered for women with multiple pregnancies?
Triplets:
- 35 weeks
Uncomplicated monochorionic
- 36 weeks
Dichorionic
- 37 weeks
139
Management of labour in multiple pregnancy?
Obtain IV access
Group and save
Fetal monitoring
Monitor fetal presentation (can confirm by USS)
If first twin in cephalic then can do vaginal delivery
- If second is breech then can do CS or ECV
If first twin is breech or transverse then do CS
If after first baby mum loses contractions start oxytocin infusion.
140
Vessels in the umbilical cord?
Two arteries and a vein
Vein is taking blood to baby
Arteries are taking blood away
141
4 main maternal complications in multiple pregnancy?
Hyperemesis (more HCG)
Anaemia
APH (placenta praevia and abruption)
PET (4x greater)
142
Fetal complications associated with multiple pregnancy?
Non-specific:
- Structural defects (only in monochorionicity)
- Chromosomal abnormalities (
- Prem birth
- IUGR
- One fetal death (okay for survivor in first and second trimesters, but will initiate delivery in the third)
Specific:
- TTTS
- Monoamniotic twins
- Twin reversed arterial perfusion sequence
143
What is Twin-Twin transfusion syndrome?
Treatment?
10-15% of monochorionic pregnancies
Net blood flow from one twin (donor) to another (recipient) through arterial to venous anastamoses in the shared placenta.
Donor becomes oliguric and oligohydramnios (often IUGR)
Recipient becomes Polyhydramnios and has high output cardiac failure.
Treatment is
1. laser the anastamoses
2. periodically drain the amniotic fluid
144
What signs do you look for on USS for whether it is di/monochorionic?
Dichorionic
- Lambda sign
Monochorionic
- No lambda sign
If diamniotic there is a T sign as they join the placenta
145
What is twin reversed arterial perfusion sequence?
Very rare complication
One twins heart stops and the other twin starts to perfuse it due to arterial to arterial anastamoses in the placenta,
The donor twin can die of cardiac failure.
146
What is cervical intraepithelial neoplasia, what are the classifications of this?
Precancerous changes confined to the cervical epithelium
CIN I
- confined to lower third of epithelium
CIN II
- confined to lower and middle thirds of epithelium
CIN III
- full thickness of epidermis
147
When do you treat CIN? How do you treat it?
Treat CIN II and III
Large loop excision of transformation zone
CIN I you repeat screen in 1 year
148
Presentation of cervical cancer?
Early:
- Thin discharge
- PVB (postcoital, intermenstrual, perimenopause, postmenopase)
- Blood stained discharge
Late (spread):
- Pain
- Leg oedema
Urinary and rectal symptoms:
- dysuria
- Rectal bleeding
- Haematauria
149
Diagnosis of cervical cancer
Biopsy
150
Staging of cervical cancer?
1. Confined to cervix
2. Beyond cervix
3. Pelvic walls
4. Outside cervix or onto other organ
151
Treatment for cervical cancer?
Depends on patient age, family planning, fitness, stage
Surgery:
- LLETS
- Radical hysterectomy
- Can remove bladder/bowel in recurrence
- can preserve ovaries/sexual function
Brachytherapy - local area radiation
Teletherapy - external beam radiotherapy
152
Medical treatments for heavy bleeding?
Fibroids:
- gnRH analogues (may cause shrinkage)
IUS
Mefenamic acid (NSAID)
Tranexamic acid (antifibronlytics) (hypercoagulant)
COCP
Synthetic pregestins
153
R/Fs for cervical cancer?
Essentially HPV R/Fs:
Early age of sex
No vaccine
Not going to smears
Smoking
Multiple partners
COCP
Immunosuppression
Other STI
154
R/Fs for endometrial cancer?
Most are oestrogen dependent and as such prolonged period of oestrogen exposure is the main R/F, so early menarche and late menopause.
Also unopposed oestrogen activity, so this is in anovulatory cycles or as a result of medication.
Prolonged oestrogen stimulation leads to the development of endometrial hyperplasia
Nulliparous
Obesity (9/10 pts)
Endometrial hyperplasia
PCOS
Diabetes
155
Types of endometrial cancer?
Oestrogen-dependent (type 1) 80%
Non-oestrogen dependent (type 2)
- Serous
- Clear cell
156
Presentation of endometrial cancers?
>50 y/o
Post menopausal bleeding
Watery vaginal discharge
IMB
Glandular abnormalities in smear
157
Rare genetic abnormality that may lead to endometrial cancer?
HNPCC
Hereditary non-polyposis colorectal cancer
Strong family history of bowel, endometrial & gastric CA
158
Investigation for endometrial cancer?
2 week cancer referral
Trans vaginal USS
- looking for endometrial thickness
Biopsy
Hysteroscopy
159
Investigations to stage endometrial cancer?
Surgical staging - to assess for adjuvant radiotherapy
Histology to assess grade and stage
Imaging:
- MRI to look for local invasion
- CXR for mets
160
4 Stages of endometrial cancer?
1 - Confined to uterus
2. Cervical stroma
3. Adnexal structures or lymph nodes
4. Bowel, bladder and distant mets
161
Endometrial cancer treatment?
Surgical:
TAH and Bilateral salpingo-oophrectomy (BSO) +/- lymph nodes
Radio:
- if high risk of recurrence
Chemo for mets
162
Endometrial cancer prognosis?
Most present at stage 1 and have good prognosis (75% survival rate)
163
Ovarian cancer prognosis?
Not good, lots present late
164
R/F for ovarian cancer?
Low parity
Infertility/clomifene
HRT
Smoking
Obesity
165
Protective factors for ovarian cancer?
COCP
Breast feeding
Hysterectomy
Salpingectomy
BSO
Tubal sterilisation
166
Types of ovarian cancer?
Epithelial (60-70%)
Germ cell (20-30%)
Ovarian sex cord
Metastatic
167
Two different grades of ovarian cancer?
Type 1 low grade:
- Ovarian
- Slow progression
- Borderline tumours
Type 2 High grade:
- Fimbrial origin
- Rapid progression
- BRACA mutations
168
Ovarian cancer presentation?
Non-specific symptoms:
- Abdo pain
- Abdo distention
- Change in bowel habit
- Urinary and pelvic symptoms
PMB, rectal bleeding
Met symptoms
169
Blood marker for ovarian cancer?
CA 125
170
Stages of ovarian cancer?
Stage 1
- limited to ovaries
Stage 2
- uterus/fallopian tubes
- intraperitoneal
Stage 3
- Outside pelvis, but abdo
Stage 4:
- Pleural effusions
- Out of abdomen
171
Treatment for ovarian cancer?
Early:
- Debulking plus chemo
Advanced:
- Chemo, interval debulking
followed by adjuvant chemo
Chemo:
- Carboplatin +/- taxol
- Can give intraperitoneal now
172
Types of vulval cancer?
SCC
- 90%
Also
- Melanoma
- Verroucas carcinoma
- Adenocarcinoma
173
Causes of vulval cancer?
VIN (vulval intraepithelial carcinoma)
- Usual type (linked to HPV 16 and 18)
- Differentiated type (linked to lichen sclerosis) >50 y/o
Pagets disease
- abnormal changes in vulval skin
174
Presentation of vulval cancer?
Often present for another reason or incidentally as people are unwilling to discuss that area.
Normally unifocal and on the labia majora
Persistent itching or burning of the vulva
Lump or wart or ulcer
Abnormal bleeding
Dysuria
175
Stages of vulval cancer?
1. Confined to vulva/perineum, no nodal invasion
2. Any size spread to the lower 1/3 of urethra or vagina or anus, negative nodes
3. Positive inguino-femoral nodes
4. Other regional areas, B = distant mets
176
Treatment for vulval cancer?
Surgery
- has become more and more conservative, will try to take as little as possible, may need reconstructive surgery later
Radio:
- adjuvant if microscopic nodal involvement/positive margins
- Primary if unfit for surgery
Chemo:
- Adjuvant to reduce the extent of surgery
- Recurrent/metastatic cancer
177
Prognosis of vulval cancer?
5 year survival rate >80% if no nodes
50% with inguinal nodes
10-15% if iliac or pelvic nodes involved
178
Ectopic pregnancy most frequent location?
98% in fallopian tubes
179
R/Fs for ectopic?
Previous
PID
Tubal damage
Pelvic surgery
Infertility
IVF
Smoking
180
Ectopic pregnancy management?
Anti D if R neg.
Conservative only if HCG levels are falling rapidly
Methotrexate if:
- No significant pain.
- Unruptured ectopic pregnancy with an adnexal mass <35 mm and no visible heartbeat.
- No intrauterine pregnancy seen on ultrasound scan.
- Serum hCG <1500 IU/L.
Surgical (salpingectomy) if:
- Significant pain.
- Adnexal mass ≥35 mm.
- Fetal heartbeat visible on scan.
- Serum hCG level ≥5000 IU/L.
181
What is small for gestational age and IUGR?
Small for gestational age
- birth weight is below a certain centile for its gestation at birth
IUGR:
- baby has not met its genetic growth potential
182
Causes of IUGR?
Fetal:
- Chromosomal abnormality
- Constitutionally small
Maternal
- Malnutrition
- Drugs (smoking/alcohol)
- Placental insufficiency (PET)
183
Pathophysiology of PCOS?
Excess androgens
Insulin resistance
Raised LH
Raised Oestrogen
184
PCOS presentation?
- Oligomenorrhoea (defined as <9 periods per year).
- Infertility or subfertility.
- Acne.
- Hirsutism.
- Alopecia.
- Obesity or difficulty losing weight.
- Psychological symptoms - mood swings, depression, anxiety, poor self-esteem.
- Sleep apnoea.
185
PCOS investigations?
Testosterone may be high
LH > FSH
USS - polycystic ovaries (not always needed)
Thyroid
Blood sugars
186
Treatment for PCOS?
Advised weight control
Treatment is targeted at individual symptoms
Not planning pregnancy
- Co-Cyprindrol, for hirsuitism and acne
- COCP (menstrual irregularity)
- Metformin
- Eflornithine, for hirsuitism
- Orlistat for weight loss
Planning pregnancy
- Clomifene
- Metformin
- Lap ovarian drilling
- gonadotrophins (resistant to clomifene)
187
Diagnosis of labour?
Uterine contractions together with effacement (thinning and drawing up of the cervix) and cervix dilatation
188
Management of pre-labour rupture of membranes?
Normal labour will commence in 90% of women within 48 hours with conservative management:
- Mum must be apyrexial
- Cephalic
- Liquor clear
- Slight risk of chorioamnionitis
189
Stages of labour?
First stage
- From onset to full dilatation
Second
- From full dilatation until head is delivered
Third
- Delivery of baby to expulsion of placenta and membranes
190
Classification of perineal tears?
First degree
- Vaginal epithelium and vulval skin only
Second degree
- Injury to perineal muscles, but not anal sphincter
Third degree
- Injury to perineum involving anal sphincter
Fourth degree
- Anal sphincter and anal/rectal mucosa
191
Indications for episiotomy?
A rigid perineum that is impairing delivery
Large tear is imminent
Most instrumental deliveries
Shoulder dystocia
Vaginal breech delivery
192
How do you repair tears/episiotomy?
Episiotomy/first/second degree
- local anaesthetic at bedside
Third/fourth
- In theatre
193
Types of instrumental delivery?
Forceps
Ventouse
194
Indications for instrumental delivery?
Fetal distress
Second stage delay
195
Reasons for C-Section?
Pre-labour:
- Placenta praevia
- Fetal growth restriction
- PET
- Malpresentation
- Abruption
In labour:
- Fetal distress or delay if mum is not fully dilated or unsuitable for vaginal
196
Cervical excitation is found in which two conditions?
Ectopic pregnancy and PID
197
Fetal Fibronectin Positive (high) means what?
High risk of premature labour
198
How do you investigate placenta praevia?
Transvaginal USS
199
Most common benign ovarian tumour in women under the age of 25 years?
Dermoid cyst
200
The most common cause of ovarian enlargement in women of a reproductive age?
Follicular cyst
201
Most common type of ovarian pathology associated with Meigs' syndrome?
Fibroma
202
Late decelerations in the CTG, what management?
Fetal blood sampling
203
Most useful investigation for endometriosis?
Laparoscopy
204
What is most likely to cause cord prolapse?
Artificial amniotomy
205
Management of cord prolapse?
Presenting part lifted manually or filled urinary bladder.
Can use tocolytics whilst preparing for section
206
PAPP-A, AFP nuchal translucency and BHCG results in downs?
Low alpha fetoprotein (AFP)
High human chorionic gonadotrophin beta-subunit (-HCG)
Low pregnancy-associated plasma protein A (PAPP-A)
Thickened nuchal translucency
207
Most common cause of placenta accreta?
previous caesarean section
208
Folic acid doses in pregnancy?
All women should take 400mcg of folic acid until the 12th week of pregnancy
Women at higher risk of conceiving a child with a NTD should take 5mg of folic acid until the 12th week of pregnancy
209
What steroid do you give for fetal lung maturation?
Dexamethasone
210
First line endometriosis management?
COCP
