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5th (Final year) > Obs & Gynae > Flashcards

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

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2
Q

Triad of diagnosis of PET?

A

Hypertension
Proteinuria
Pitting oedema

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3
Q

PET Symptoms?

A

RUQ pain
Severe headache/blurred vision
Pitting oedema - swollen face
Seizures
Reduced foetal movement

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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.

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5
Q

Risk factors for miscarriage?

A

Increasing maternal age
Increased gravidity
Prior miscarriage
Smoking

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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

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7
Q

Reasons for miscarriage?

A

Chromosomal abnormality - normally trisomy of some kind

Abnormal development

Uterine defects

Infection/environment

Trauma- although must be major

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8
Q

Types of miscarriage?

A

Threatened
Incomplete
Complete
Missed

Septic

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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

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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.

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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.

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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.

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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.

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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

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15
Q

Ectopic symptoms?

A

Vaginal bleeding - dark brown
Pelvic pain
Shoulder tip pain
Amenhorroea

Bowel symptoms
Fainting/dizziness

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16
Q

Common causes of PPH?

A

Uterine atony (most common)
retained placenta
Vaginal and Vulval lacerations

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17
Q

What is uterine atony?

A

When the uterus can no longer contract leading it bleed profusely.

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18
Q

Definition of PPH?

A

> 500ml of blood loss within 24 hour of delivery

500-1000ml is minor
>1000ml is major

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19
Q

Way to calculate EDD?

A

Add 9 months and 1 week to LMP

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20
Q

What is thought to be the cause of hyperemesis gravidarum?

A

High circulating levels of hCG

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21
Q

causes of IUGR?

A

Smoking (30-40% of cases)
Alcohol
HTN
Diabetes
PET

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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.

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23
Q

Complications of induction?

A

Uterine hyper stimulation
Prolapsed cord
Section needed
Uterine rupture

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24
Q

When do women begin feeling foetal movement?

A

At 18-20 weeks

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25
Q

What does symmetrical IUGR normally represent?

A

It normally represents some kind of foetal abnormality - normally chromosomal.

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26
Q

Two types of abortion?

A

Medical termination

Surgical

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27
Q

Process of medical abortion?

A

Mifepristone (antiprogesterone) (600mg) followed by Misoprostol (prostaglandin analogue) (gemeprost 1mg) 48 hours later

> 50% abort within an hour of misoprostol dose

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28
Q

Rough process of surgical abortion? Types?

A

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)

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29
Q

How do you do a late pregnancy termination? When would you?

A

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.
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30
Q

Definition of spontaneous miscarriage?

A

Spontaneous miscarriage:
- loss of recognised pregnancy before 20 weeks or <500g

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31
Q

Types of spontaneous miscarriage?

A

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

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32
Q

Principles of antenatal care?

A

Educate on normal changes in pregnancies

Identify maternal R/Fs

Screen for fetal problems

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33
Q

Preconception antenatal care? (3)

A
  1. Folic acid 3 months prior to conception
  2. Avoid teratogenic drugs
  3. Preconception counselling
    - Lifestyle changes: Alcohol, smoking weight
    - Stabilise medical disorders
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34
Q

Food hygiene advice for pregnancy?

A

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

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35
Q

Antenatal care at booking (first appointment - as soon as preggers)?

A

Vitamin D 10mcg from day of booking

Food hygiene advice

Screening

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36
Q

Risk factors for Gestational Diabetes?

A

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

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37
Q

What is MBRRACE UK?

A

Runs a national programme monitoring and investigating the cause of maternal and fetal deaths in the UK.

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38
Q

Maternal screening?

A

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)
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39
Q

Scans and screening for the fetus?

A

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

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40
Q

When can you do SFH measurement from?

A

24 weeks

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41
Q

What is the puerperium?

A

Period of time following the birth of the baby ~ 6 weeks

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42
Q

Maternal issues in the puerperium?

A

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

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43
Q

What is puerperal fever? 5 causes?

A

Infection post-partum (in the puerperium)

  1. genital tract/uterine
  2. UTI
  3. Breast infection
  4. VTE
  5. Other. e.g. flu
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44
Q

Things to consider in perinatal mental health?

A
  • Stress of transition to motherhood
  • Postnatal blues
  • Postnatal depression - suicide risk
  • Traumatic birth - PTSD
  • puerperal psychosis.
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45
Q

Physiological endocrine & metabolic changes during pregnancy?

A

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

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46
Q

Physiological CVS & haematological changes during pregnancy?

A

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
-

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47
Q

Physiological respiratory changes during pregnancy?

A

Respiratory system:
- Tidal volume increase by 200ml
- Increased vital capacity and decreased residual volume
- 20% increased oxygen consumption

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48
Q

Physiological renal changes during pregnancy?

A

Renal:
- GFR increase
- Reduced Urea, creatinine and bicarb

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49
Q

Other general physiological changes during pregnancy?

A

Others:
- Nausea and vomiting is common
- Appetite is usually increased
- Heartburn
- Constipation is common (motility decreased to increase nutrient absorption

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50
Q

2012-14 maternal mortality?

A

8.5 per 100,000 (was 90 in 1952)

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51
Q

What is an indirect and direct death in maternity?

A

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.

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52
Q

Top causes of maternal death?

A
  1. Cardiac disease
  2. Sepsis
  3. Neuro
  4. Other
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53
Q

What are late and coincidental maternal deaths?

A

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

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54
Q

Two big R/F for maternal death in the UK?

A

> 35

Black ethnic minorities

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55
Q

Physiological changes that affect insulin in pregnancy, and may cause GDM?

A
  1. Insulin antagonists are produced by the placenta.
  2. Increased insulin resistance (especially 3rd trimester) leads to increased insulin production in normal women
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56
Q

Effect of pregnancy on diabetes complications (type 1)?

A

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)
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57
Q

Effect of diabetes on pregnancy complications (maternal and fetal factors)?

A

Maternal:
- Antepartum haemorrhage
- PET
- Premature labour

Fetal:
- Microsomia (IUGR)
- Macrosomia
- Shoulder dystocia
- Risk of sudden fetal death
- Congenital abnormalities
- Hypoglycaemia

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58
Q

What HbA1c level are we aiming for before pregnancy?

A

48mmol/mol

Shouldn’t have pregnancy if >86mmol/mol

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59
Q

pre-pregnancy planning for diabetic women?

A

Stop teratogenic drugs associated e.g. ACE inhibitors, statins

Retinal screen

Renal screen

?Basal-bolus insulin regime

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60
Q

What basal/bolus regime do they use in pregnancy?

A

Rapid acting insulin for each meal

Long acting at bedtime

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61
Q

What level of glycaemic control are we aiming for during pregnancy?

A

Fasting: < 5.3mmol/L

1 hour post-prandial <7.8mmol/L

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62
Q

What medication should you give when managing diabetes in pregnancy?

A

T2DM should continue metformin and often need insulin

Aspirin 75mg from 12 weeks (for PET risk)

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63
Q

Extra scans for diabetes in pregnancy?

A

Early dating scan and anomaly scan

4 weekly growth scan from 28 weeks

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64
Q

When should you deliver for diabetes in pregnancy?

A

37 - 38+6

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65
Q

What extra should you do during delivery with a woman who has diabetes?

A

Good glycaemic control peridelivery - to reduce risk of fetal hypoglycaemia:
- can give infusion

If preterm start steroids and insulin infusion

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66
Q

GDM risks to pregnancy?

A

Macrosomia, birth trauma, shoulder dystocia, increased induction, increased LSCS, pre-eclampsia

Neonatal hypoglycaemia, polycythaemia, increased perinatal mortality rate

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67
Q

How and when do you test for GDM?

A

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).

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68
Q

Management of GDM antenatally?

A

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

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69
Q

GDM management during labour?

A

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

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70
Q

How do you manage hypoglycaemia in the pregnant woman?

A

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)

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71
Q

What level of glucose is hypoglycaemia

A

4 ‘hit the floor’ : <4mmol/L = hypoglycaemia

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72
Q

Symptoms of Hypoglycaemia Mild-Severe?

A

Mild:
- Trembling, sweaty, hungry, palpitations, nausea

Moderate:
- Confusion, weakness, drowsiness, headache, dizzy, nausea

Severe:
- Unconscious/fitting

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73
Q

DKA pathophysiology?

A

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

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74
Q

DKA presentation?

A

High blood glucose (>15mmol/L)

Polyuria

Polydipsia

Lethargy

Blurry vision

Abdo pain, nausea and vomiting

Collapse/unconscious

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75
Q

Difference with DKA in pregnancy? Management?

A

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

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76
Q

Physiological/physical changes to coagulation in pregnancy?

A

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)

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77
Q

R/Fs for VTE in pregnancy?

A

Prev. VTE

Thrombophilia

> 35

Smoking

Obesity

Immobility

Infection

Surgery

PET

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78
Q

Very high risk factors, high risk factors, intermediate R/Fs and for VTE in pregnancy?

A

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

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79
Q

Manangement of VTE risk Very high to Low?

A

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

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80
Q

Contraindications to LMWH?

A

Known bleeding disorder

Active Antenatal/postpartum bleeding

Placenta praevia

Stroke in prev. 4 weeks (either type)

Severe renal/liver disease

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81
Q

Can you use aspirin or warfarin as an anticoagulant in pregnancy?

A

Aspirin - no

Warfarin - only postnatally

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82
Q

VTE presentation in pregnancy?

A

Can be non-specific and asymptomatic, however can present classically:

  • As DVT (calf swelling, tenderness)
  • As PE (Dyspnoea, chest pain, cough, tachycardia and tachypnoea)
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83
Q

Investigation for DVT in pregnancy?

A

Leg compression duplex US/S

ECG

CXR

FBC, LFTs, U&Es, Clotting

V/Q or CTPA

D-Dimer NOT reliable in pregnancy

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84
Q

VTE treatment?

A

LMWH

Thrombolysis

IVC filter

IV hep

Thoracotomy, embolectomy

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85
Q

When should you stop LMWH in pregnancy?

A

Labour

Bleeding

86
Q

Obstetric cholestasis presentation in pregnancy?

A

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
Q

Obstetric cholestasis management?

A

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
Q

Risks associated with obstetric cholestasis?

A

Increased risk of fetal distress

Increased risk of premature birth

Maternal morbidity (itch and sleep)

89
Q

Management of epilepsy in pregnancy?

A

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
Q

Types of urinary incontinence?

A

Stress incontinence

Urge incontinence (Overactive bladder)

Others:
- Retention w/ overflow
- Fistula

91
Q

Presentation of stress incontinence?

A

Leakage that arises when there is an increase in intra-abdominal pressure:
- coughing
- laughing
- sneezing

60-70% of cases

92
Q

Presentation of Urge incontinence (OAB)?

A

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
Q

R/Fs for urinary incontinence?

A

Childbirth
Menopause/tissue atrophy
Connective tissue issues
Obesity/constipation
Smoking

94
Q

Investigations for urinary incontinence?

A

Urinalysis +/- microscopy and culture

Bladder diary

Pad test

Urodynamics
- Abnormal is <15mls

95
Q

Treatment for stress urinary incontinence?

A

Pelvic floor exercises

Lose weight, stop smoking

Bladder retraining

Continence pessary
- Duloxetine

Surgery for stress:
- Slings
- Open culposuspension
- Tape (TVT or TOT)

96
Q

Treatment for Urge urinary incontinence?

A

Lifestyle:
- lose weight, avoid irritants

Bladder retraining

Medical:
- anticholinergics (e.g. oxybutinin)
- Mirabegron

Surgical:
- Sacral nerve root stimulation
- Botox
- Detrusor myectomy
- Cystoplasty

97
Q

Types of prolapse?

A

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
Q

Symptoms of a genital prolapse?

A

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
Q

Treatment of prolapse?

A

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
Q

Surgical treatments for heavy periods?

A

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
Q

Definitive tests for fetal abnormalities?

A

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
Q

What is ECV? When/on whom would you perform it?

A

External cephalic version (if baby is breech)
- from 36 weeks in nulliparous
- from 37 weeks in multip

103
Q

Contraindications to ECV?

A

C-section is needed anyway
Antepartum haemorrhage in last week
Multiple pregnancy
Ruptured membranes

104
Q

Process of induction?

A

Use Prostin E2, then manually burst the waters, then use oxytocin

105
Q

The 3 Ps that affect birth?

A

Passage - Pelvis shape

Passenger - baby position, baby size

Power - contraction power

106
Q

What type of bleeding do you have with fibroids?

A

Cyclical

107
Q

Post coital bleeding 3 main Ddx?

A

Polyp

Cervical ectropion

Cervical Cancer

108
Q

3 main differentials for pelvic pain?

A

Primary dysmenorrhoea (psychological?)

Secondary:
- PID
- endometriosis
- Adenomyosis (endometriosis in the myometrium)

109
Q

Placenta Praevia presentation? Types?

A

Post 28th week painless bleeding (normally profuse and sudden)

110
Q

2 most common differentials for Antepartum haemorrhage (24-delivery)?

A

Placenta Praevia

Placental abruption

111
Q

What is placenta praevia?

A

Placenta in front of cervical canal
- Major: fully covering internal os
- Minor: leading edge is in lower segment but not covering internal os

112
Q

Complications associated with placenta praevia?

A

Shock following bleeding

VTE

Placenta accreta

Neonatal mortality

Preterm

Low birth weight

113
Q

Management of placenta praevia?

A

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
Q

What is placental abruption?

A

Premature separation of the placenta before delivery.

Blood collects between placenta and uterus

Can be concealed (no bleeding) or revealed (bleeding).

115
Q

Placental abruption presentation?

A

Rock solid abdomen
Lots of pain
Heavy breathing
Difficulty locating fetal heartbeat
Can have bleeding

116
Q

Amount of contractions per 10mins you are aiming for (in 2nd stage)

A

3/4 contractions in 10 mins

117
Q

What are you looking for in a foetal CTG?

A

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
Q

Antepartum haemorrhage all Ddx?

A

Placental abruption

Placenta praevia

Ectropion

Cervical cancer/polyp

Vasa praevia (babies blood after membranes rupture)

Infection

119
Q

What is vasa praevia? Risks?

A

The placenta has developed away from the attachment of the cord and the vessels divide in the membrane

Risks:
- Fetal haemorrhage and death

120
Q

Different cesarean sections and their timing?

A

Cat 1 - 30 mins
Cat 2 -60 mins
Cat 3 - When possible (today)

Elective

121
Q

Abnormal vaginal bleeding Ddx?

A

Structural:
- Polyps (vagina, cervix, endometrium)
- Adenomyosis
- Fibroids (leiomyoma)
- Malignancy

Non-structural:
- Coagulopathy
- endometrial
- Iatrogenic
- Ovulatory dysfunction

122
Q

Types of amenorrhoea?

A

Primary:
- No menarche at all by 14 (may wait till 16)

Secondary:
- periods have stopped (for 6 months)

123
Q

Ddx of primary amenorrhoea?

A

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
Q

Ddx of secondary amenorrhoea?

A

Pregnancy. Always.

PCOS

Premature ovarian failure

Depot and implant

Underweight

Thyroid disease

Iatrogenic (drugs)

Cancer

125
Q

Fibroids presentation?

A

> 30 y/o

50% asymptomatic

Heavy/long periods

Recurrent miscarriage/infertility

Abdo mass O/E

126
Q

Types of fibroids?

A

Intramural
- within the uterine wall (most common)

Submucosal
- Growing into uterine cavity

Subserosal
- Growing out from uterus

127
Q

What is endometriosis?

A

Endometriosis is a chronic oestrogen-dependent condition characterised by the growth of endometrial tissue in sites other than the uterine cavity.

128
Q

Endometriosis presentation?

A

Dysmenorrhoea

Dyspareunia

Cyclical pelvic pain

Subfertility

Can have blood in poo/wee

129
Q

Common teratogenic drugs?

A

ACE inhibitors
Valproate

130
Q

Treatment for HTN/PET in pregnancy?

A

Labetalol

Nifedipine (calcium channel antag)

Aspirin (by 16 weeks)

131
Q

What may cause breech presentation?

A

Macrosomia

Multip

Placenta praevia

polyhydramnios

Congenital uterine abnormalities

132
Q

Types of twin pregnancy?

A

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
Q

Four Ts regarding causes of postpartum haemorrhage?

A

Tone (atony)
Tears/Trauma
Tissue (retained afterbirth)
Thrombin (clotting disorders)

134
Q

Treatment for atony?

A

Syntocin

Ergometrine (not in HTN)

Misoprostol (rectal)

Carboprost (causes diarrhoea)

135
Q

Primary and secondary PPH?

A

Primary <24hrs

Secondary >24hrs

136
Q

4 common causes of perinatal death?

A
  1. infection
  2. RDS
  3. Brain haemorrhage (SAH)
  4. Necrotizing enterocolititis
137
Q

Macrosomia is defined as above what weight?

A

Above 4.5 kg

138
Q

When should pregnancy be offered for women with multiple pregnancies?

A

Triplets:
- 35 weeks

Uncomplicated monochorionic
- 36 weeks

Dichorionic
- 37 weeks

139
Q

Management of labour in multiple pregnancy?

A

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
Q

Vessels in the umbilical cord?

A

Two arteries and a vein

Vein is taking blood to baby

Arteries are taking blood away

141
Q

4 main maternal complications in multiple pregnancy?

A

Hyperemesis (more HCG)

Anaemia

APH (placenta praevia and abruption)

PET (4x greater)

142
Q

Fetal complications associated with multiple pregnancy?

A

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
Q

What is Twin-Twin transfusion syndrome?

Treatment?

A

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
Q

What signs do you look for on USS for whether it is di/monochorionic?

A

Dichorionic
- Lambda sign

Monochorionic
- No lambda sign

If diamniotic there is a T sign as they join the placenta

145
Q

What is twin reversed arterial perfusion sequence?

A

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
Q

What is cervical intraepithelial neoplasia, what are the classifications of this?

A

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
Q

When do you treat CIN? How do you treat it?

A

Treat CIN II and III

Large loop excision of transformation zone

CIN I you repeat screen in 1 year

148
Q

Presentation of cervical cancer?

A

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
Q

Diagnosis of cervical cancer

A

Biopsy

150
Q

Staging of cervical cancer?

A
  1. Confined to cervix
  2. Beyond cervix
  3. Pelvic walls
  4. Outside cervix or onto other organ
151
Q

Treatment for cervical cancer?

A

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
Q

Medical treatments for heavy bleeding?

A

Fibroids:
- gnRH analogues (may cause shrinkage)

IUS

Mefenamic acid (NSAID)

Tranexamic acid (antifibronlytics) (hypercoagulant)

COCP

Synthetic pregestins

153
Q

R/Fs for cervical cancer?

A

Essentially HPV R/Fs:

Early age of sex
No vaccine
Not going to smears
Smoking
Multiple partners
COCP
Immunosuppression
Other STI

154
Q

R/Fs for endometrial cancer?

A

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
Q

Types of endometrial cancer?

A

Oestrogen-dependent (type 1) 80%

Non-oestrogen dependent (type 2)
- Serous
- Clear cell

156
Q

Presentation of endometrial cancers?

A

> 50 y/o

Post menopausal bleeding
Watery vaginal discharge
IMB
Glandular abnormalities in smear

157
Q

Rare genetic abnormality that may lead to endometrial cancer?

A

HNPCC

Hereditary non-polyposis colorectal cancer

Strong family history of bowel, endometrial & gastric CA

158
Q

Investigation for endometrial cancer?

A

2 week cancer referral

Trans vaginal USS
- looking for endometrial thickness

Biopsy

Hysteroscopy

159
Q

Investigations to stage endometrial cancer?

A

Surgical staging - to assess for adjuvant radiotherapy

Histology to assess grade and stage

Imaging:
- MRI to look for local invasion
- CXR for mets

160
Q

4 Stages of endometrial cancer?

A

1 - Confined to uterus

  1. Cervical stroma
  2. Adnexal structures or lymph nodes
  3. Bowel, bladder and distant mets
161
Q

Endometrial cancer treatment?

A

Surgical:
TAH and Bilateral salpingo-oophrectomy (BSO) +/- lymph nodes

Radio:
- if high risk of recurrence

Chemo for mets

162
Q

Endometrial cancer prognosis?

A

Most present at stage 1 and have good prognosis (75% survival rate)

163
Q

Ovarian cancer prognosis?

A

Not good, lots present late

164
Q

R/F for ovarian cancer?

A

Low parity

Infertility/clomifene

HRT

Smoking

Obesity

165
Q

Protective factors for ovarian cancer?

A

COCP

Breast feeding

Hysterectomy

Salpingectomy

BSO

Tubal sterilisation

166
Q

Types of ovarian cancer?

A

Epithelial (60-70%)

Germ cell (20-30%)

Ovarian sex cord

Metastatic

167
Q

Two different grades of ovarian cancer?

A

Type 1 low grade:
- Ovarian
- Slow progression
- Borderline tumours

Type 2 High grade:
- Fimbrial origin
- Rapid progression
- BRACA mutations

168
Q

Ovarian cancer presentation?

A

Non-specific symptoms:
- Abdo pain
- Abdo distention
- Change in bowel habit
- Urinary and pelvic symptoms

PMB, rectal bleeding

Met symptoms

169
Q

Blood marker for ovarian cancer?

A

CA 125

170
Q

Stages of ovarian cancer?

A

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
Q

Treatment for ovarian cancer?

A

Early:
- Debulking plus chemo

Advanced:
- Chemo, interval debulking
followed by adjuvant chemo

Chemo:
- Carboplatin +/- taxol
- Can give intraperitoneal now

172
Q

Types of vulval cancer?

A

SCC
- 90%

Also
- Melanoma
- Verroucas carcinoma
- Adenocarcinoma

173
Q

Causes of vulval cancer?

A

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
Q

Presentation of vulval cancer?

A

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
Q

Stages of vulval cancer?

A
  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
Q

Treatment for vulval cancer?

A

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
Q

Prognosis of vulval cancer?

A

5 year survival rate >80% if no nodes

50% with inguinal nodes

10-15% if iliac or pelvic nodes involved

178
Q

Ectopic pregnancy most frequent location?

A

98% in fallopian tubes

179
Q

R/Fs for ectopic?

A

Previous

PID

Tubal damage

Pelvic surgery

Infertility

IVF

Smoking

180
Q

Ectopic pregnancy management?

A

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
Q

What is small for gestational age and IUGR?

A

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
Q

Causes of IUGR?

A

Fetal:
- Chromosomal abnormality
- Constitutionally small

Maternal
- Malnutrition
- Drugs (smoking/alcohol)
- Placental insufficiency (PET)

183
Q

Pathophysiology of PCOS?

A

Excess androgens

Insulin resistance

Raised LH

Raised Oestrogen

184
Q

PCOS presentation?

A
  • 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
Q

PCOS investigations?

A

Testosterone may be high

LH > FSH

USS - polycystic ovaries (not always needed)

Thyroid

Blood sugars

186
Q

Treatment for PCOS?

A

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
Q

Diagnosis of labour?

A

Uterine contractions together with effacement (thinning and drawing up of the cervix) and cervix dilatation

188
Q

Management of pre-labour rupture of membranes?

A

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
Q

Stages of labour?

A

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
Q

Classification of perineal tears?

A

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
Q

Indications for episiotomy?

A

A rigid perineum that is impairing delivery

Large tear is imminent

Most instrumental deliveries

Shoulder dystocia

Vaginal breech delivery

192
Q

How do you repair tears/episiotomy?

A

Episiotomy/first/second degree
- local anaesthetic at bedside

Third/fourth
- In theatre

193
Q

Types of instrumental delivery?

A

Forceps

Ventouse

194
Q

Indications for instrumental delivery?

A

Fetal distress

Second stage delay

195
Q

Reasons for C-Section?

A

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
Q

Cervical excitation is found in which two conditions?

A

Ectopic pregnancy and PID

197
Q

Fetal Fibronectin Positive (high) means what?

A

High risk of premature labour

198
Q

How do you investigate placenta praevia?

A

Transvaginal USS

199
Q

Most common benign ovarian tumour in women under the age of 25 years?

A

Dermoid cyst

200
Q

The most common cause of ovarian enlargement in women of a reproductive age?

A

Follicular cyst

201
Q

Most common type of ovarian pathology associated with Meigs’ syndrome?

A

Fibroma

202
Q

Late decelerations in the CTG, what management?

A

Fetal blood sampling

203
Q

Most useful investigation for endometriosis?

A

Laparoscopy

204
Q

What is most likely to cause cord prolapse?

A

Artificial amniotomy

205
Q

Management of cord prolapse?

A

Presenting part lifted manually or filled urinary bladder.

Can use tocolytics whilst preparing for section

206
Q

PAPP-A, AFP nuchal translucency and BHCG results in downs?

A

Low alpha fetoprotein (AFP)
High human chorionic gonadotrophin beta-subunit (-HCG)
Low pregnancy-associated plasma protein A (PAPP-A)
Thickened nuchal translucency

207
Q

Most common cause of placenta accreta?

A

previous caesarean section

208
Q

Folic acid doses in pregnancy?

A

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
Q

What steroid do you give for fetal lung maturation?

A

Dexamethasone

210
Q

First line endometriosis management?

A

COCP

5th (Final year) (34 decks)

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