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3a PTS - PM - ZTF > Obs&Gynae > Flashcards

Obs&Gynae Flashcards

1
Q

Name 4 risk factors for ovarian cancer

A

Age >60
Family history (BRCA1 or BRCA2)

Increased number of ovulations:
Early menarche
Late menopause
Nulliparity - as pregnancy stops ovulation
Link with recurrent use of clomifene (stimulates ovaries to ovulate - used for subfertility)

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2
Q

Name 3 protective factors for ovarian cancer

A

Inhibition of ovulation
Combined contraceptive pill
Breastfeeding
Pregnancy

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3
Q

Most common type and subtype of ovarian cancer

A

Epithelial cell tumours (90%)
- serous tumours most common subtype (70-80%)

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4
Q

Presentation of ovarian cancer (4)

A

Non-specific symptoms (causes poor prognosis)

Abdominal bloating
Loss of appetite
Pelvic pain
Urinary symptoms e.g. urgency
Weight loss
Abdominal or pelvic mass
Ascites
Hip or groin pain - from obturator nerve being pressed by mass

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5
Q

Initial investigations for ovarian cancer

A

CA125 blood test (not very specific) - if raised, urgent abdomen and pelvic ultrasound

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6
Q

Management of ovarian cancer

A

Combination of surgery and platinum-based chemotherapy

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7
Q

Prognosis of ovarian cancer

A

80% of women have advanced disease at presentation
All stage 5 year survival is 46%

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8
Q

Fibroids definition

A

Benign smooth muscle tumours of the uterus

Also known as uterine leiomyomas

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9
Q

In which ethnic group are fibroids more common

A

Afro Caribbean women

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10
Q

Presentation of fibroids

A

May be asymptomatic
Most frequent presenting symptom = Menorrhagia - may result in iron-deficiency anaemia
Bulk-related Sx - cramping pains during menstruation, bloating, urinary Sx e.g. frequency
Sub-fertility
Palpable mass (firm, non-tender)

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11
Q

Diagnostic Ix of fibroids

A

TV ultrasound

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12
Q

Surgical options for larger fibroids (>3 cm)

A

Myomectomy (only effective treatment for fibroids causing fertility problems)

Other:
Hysteroscopic endometrial ablation
Hysterectomy
Uterine artery embolisation

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13
Q

4 medical management options for fibroids <3cm / menorrhagia secondary to fibroids

A

1st line Symptomatic management/trying to conceive: NSAIDs + tranexamic acid or mefanamic acid

If not trying to conceive:
1st line: Mirena coil (levonorgestrel intrauterine system)
2nd line: Combined oral contraceptive
Cyclical oral progestogens

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14
Q

When are GnRH agonists e.g. goserelin typically used in the treatment of fibroids + why are they only used short term?

A

Before surgery to reduce size of fibroid

only used short term due to side effect profile: menopausal symptoms (hot flushes, vaginal dryness), loss of bone mineral density

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15
Q

Major complication of fibroids during pregnancy

A

Red degeneration of fibroids

ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply (oestrogen makes the fibroids grow with demand beyond supply)

more likely to occur in larger fibroids during the second/third trimester

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16
Q

How does red degeneration of fibroids present

A

Severe abdominal pain
Low grade fever
Tachycardia
Vomiting

managed conservatively with rest and analgesia

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17
Q

Early miscarriage definition

A

Before 12 weeks gestation

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18
Q

Late miscarriage definition

A

Between 12 and 24 weeks

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19
Q

Missed miscarriage definition

A

gestational sac contains dead foetus before 24 weeks without symptoms of expulsion / cervix closed

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20
Q

Threatened miscarriage definition

A

vaginal bleeding typically 6-9 weeks but closed cervix os + foetus alive

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21
Q

Inevitable miscarriage definition

A

vaginal bleeding with clots and pain + open cervix os

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22
Q

Incomplete miscarriage definition

A

foetus no longer alive but retained products of conception remain + cervical os is open

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23
Q

Investigation of choice for diagnosing miscarriage + findings in sequential order

A

TV ultrasound:
Mean gestational sac diameter
Fetal pole and crown-rump length
Fetal heartbeat

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24
Q

Anembryonic pregnancy

A

When the gestational sac is >25 m and no embryonic/fetal part can be seen

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25
Q

3 types of management for miscarriage

A

Expectant (do nothing + await spontaneous miscarriage for 1-2 weeks) 1st line for women with no risk factors
Medical (misoprostol)
Surgical

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26
Q

Misoprostol definiton + use in miscarriage

A

Prostaglandin analogue: PGE1: softens the cervix and stimulates uterine contractions leading to expulsion of tissue

Given as vaginal suppository + as pain relief

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27
Q

3 reasons to use medical or surgical management of miscarriage instead of expectant

A

Increased risk of haemorrhage
Previous adverse/traumatic experience associated with pregnancy
Evidence of infection

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28
Q

Two main surgical management options for miscarriage

A

Manual vacuum aspiration under local anaesthetic as an outpatient (<10 weeks gestation)
Electric vacuum aspiration under general anaesthetic in theatre

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29
Q

Pelvic inflammatory disease most common causative organism

A

Chlamydia trachomatis

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30
Q

Mild PID management

A

Start antibiotics immediately before swab results

1st line:

CEFTRIAXONE singular IM dose

followed by 14 days of: oral DOXYCYCLINE PLUS oral METRONIDAZOLE twice daily

Leave in a recently inserted coil - if no response to Abx after 72 hours, remove coil and prescribe emergency contraceptives

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31
Q

Presentation of PID

A

Lower abdo pain
Cervical excitation
Fever
Deep dyspareunia
Dysuria and menstrual irregularities
Vaginal discharge

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32
Q

PID investigations

A

Pregnancy test to exclude ectopic pregnancy
High vaginal swab - these are often NEGATIVE (difficult to diagnose)
Screen for chlamydia and gonorrhoea

fever > 38 = severe infection = admit to hospital

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33
Q

4 complications of PID

A

Perihepatitis (Fitz-Hugh Curtis syndrome) - 10% of cases, RUQ pain, radiation to shoulder
Infertility - 10-20% after single episode
Chronic pelvic pain
Ectopic pregnancy

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34
Q

Causes of raised CA125 (4)

A

Ovarian cancer
Breast cancer
Adenomyosis
Ascites
Endometriosis
Menstruation
Ovarian torsion
Endometrial cancer
Liver disease

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35
Q

Placental abruption definition

A

Separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space

Occurs in approx 1/200 pregnancies

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36
Q

Name 5 risk factors for placental abruption

A

Previous PA
Hypertension (proteinuric)
IUGR
Cocaine use
Multiparty
Maternal trauma (consider DV)
Increasing maternal age
Smoking

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37
Q

Presentation of placental abruption

A

PAIN: Continuous, sudden onset, severe abdominal pain
BLEEDING: Vaginal bleeding (antepartum haemorrhage)
SHOCK: (hypotension and tachycardia) out of keeping with visible blood loss
TENDERNESS: Tender, tense uterus - abdomen “woody” abdomen on palpation
FETUS: Abnormalities on the CTG indicating fetal distress, lie normal + engaged

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38
Q

4 severity scales of antepartum haemorrhage

A

Spotting
Minor haemorrhage - less than 50ml
Major haemorrhage - 50 - 1000ml
Massive haemorrhage - more than 1000ml or signs of shock

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39
Q

Maternal complications of placental abruption

A

Shock
DIC
Renal failure
PPH

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40
Q

Fetal complications of placental abruption

A

IUGR
Hypoxia
Death - responsible for 15% of perinatal deaths

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41
Q

1st line Management of placental abruption < 36 weeks

A

Fetal distress: Immediate caesarean section

No fetal distress: IV dexamethasone and monitoring

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42
Q

1st line Management of placental abruption fetus alive and > 36 weeks

A

Fetal distress: immediate caesarean

No fetal distress: deliver vaginally

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43
Q

Three causes of antepartum haemorrhage

A

Placenta praevia
Placental abruption
Vasa praevia

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44
Q

Placenta praevia definition

A

A placenta lying wholly or partly in the lower uterine segment, lower than the fetus + over the internal cervical os

  • Praevia = Going before *
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45
Q

Risks of placenta praevia

A

Maternal (4):
Antepartum haemorrhage
Emergency c-section
Emergency hysterectomy
Maternal anaemia and transfusions

Fetal (2):
Preterm birth and low birth weight
Stillbirth

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46
Q

Risk factors associated with placenta praevia

A

Multiparty
Multiple pregnancy
Previous c-section (due to embryo implanting on scar tissue)
Previous PP
Older maternal age
Maternal smoking
Assisted reproduction e.g. IVF

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47
Q

Presentation of placenta praevia (differential from placental abruption)

A

PAIN: no pain
SHOCK: in proportion to visible loss of blood
BLEEDING: red and often profuse (often history of small APHs)
TENDERNESS: Uterus not tender
FETUS: lie abnormal/head high, heart rate usually normal

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48
Q

In suspected placenta praevia, what investigation should not be performed before an ultrasound?

A

Digital vaginal examination as it may provoke a severe haemorrhage

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49
Q

Investigation of choice for suspected placenta praevia

A

TV ultrasound

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50
Q

Next step if low lying placenta found at 20 week scan

A

Rescan at 32 weeks to assess

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51
Q

Grading of placenta praevia

A

I - reaches lower segment but not internal os
II - reaches internal os but doesn’t cover it
III - placenta covers internal os before dilation but not when dilated
IV / major - placenta completely covers the internal os

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52
Q

Management of woman with grade III/IV placenta praevia at final ultrasound at the 36-37 weeks

A

Offer elective Caesarian section between 37-38 weeks

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53
Q

Management: woman with known placenta praevia goes into labour (with or without bleeding) prior to elective Caesarian section

A

Emergency Caesarian section - due to risk of PPH (major cause of death in women with placenta praevia)

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54
Q

Which medication is given between 34 and 35+6 weeks to mature the fetal lungs if there is a risk of preterm delivery in PP

A

Corticosteroids

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55
Q

3 measurements on ultrasound used to assess fetal size

A

Head circumference
Abdominal circumference
Femur length

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56
Q

Low birth weight definition

A

< 2500g at any gestational age

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57
Q

Fetal/intrauterine growth restriction (FGR/IUGR) definition

A

Small fetus due to PATHOLOGY:
1. placenta mediated (reduced amounts of nutrients and oxygen being delivered to the fetus through the placenta)
2. non-placenta mediated (e.g. genetic abnormality)

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58
Q

Constitutionally small definition

A

Size matching the mothers and others in the family and growing appropriately on the growth chart

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59
Q

4 causes of placenta mediated FGR

A

Pre-eclampsia
Maternal smoking
Maternal alcohol
Malnutrition

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60
Q

Definition of large for gestational age

A

Weight of new born = > 4.5kg / pregnancy = above 90th centile

(also known as macrosomia)

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61
Q

Major cause of macrosomia

A

Gestational diabetes

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62
Q

Major risk of macrosomia during birth

A

Shoulder dystocia

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63
Q

3 antibiotics commonly considered safe in pregnancy

A

PeniCillins
Cephalosporins
Clindamycin

Avoid the Ts and keep the Cs

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64
Q

Important risk of developing a UTI in pregnancy

A

Preterm delivery

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65
Q

Only category of patients tested for asymptomatic bacteriuria

A

Pregnant women

x 2 urine cultures needed to confirm

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66
Q

Two most common organisms found in pregnancy UTI

A

E.coli
Klebsiella pneumoniae

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67
Q

management of UTI in pregnancy

A

Urine culture should be sent in all symptomatic cases and at the first antenatal visit to test for asymptomatic bacteriuria

Symptomatic/Asyptomatic - 7 days of:

Nitrofurantoin (avoid in third trimester due to risk of neonatal haemolysis)
OR
Amoxicillin (only after sensitivities are known)
OR
Cefalexin

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68
Q

Why is Trimethoprim use avoided in pregnancy

A

Folate antagonist (congenital malformations particularly neural tube defects e.g. spina bifida)

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69
Q

Risk factors for urinary incontinence

A

Advancing age
Previous pregnancy and childbirth
Postmenopause
High BMI
Hysterectomy
Family history

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70
Q

Types of urinary incontinence with definitions

A

Urge incontinence: overactivity of the detrusor muscle i.e. overactive bladder - struggle to get to the toilet on time once you need it (urgency)

Stress incontinence: weakness of the pelvic floor and sphincter muscles - urine leaks out at times of increased pressure e.g. laughing, coughing, surprises

Mixed: urge + stress

Overflow incontinence: bladder outlet obstruction e.g. prostate enlargement

Functional incontinence: comorbid physical conditions e.g. dementia

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71
Q

Urinary incontinence investigations

A

Bladder diary for minimum of 3 days
Urinalysis to rule out UTI or DM and cultures if infection is present^
Post-void residual bladder volume using bladder scan
Vaginal examination to exclude pelvic organ prolapse
Urodynamic testing

^In patients > 65 urinalysis is not performed to assess for UTIs as asymptomatic bacteriuria is common

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72
Q

Urge incontinence management

A

1st line: bladder retraining (6 weeks, gradually increase intervals between voiding)

2nd line: bladder stabilising drugs - antimuscarinics are 1st line (oxybutinin, tolterodine or darifenacin), mirabegron can be used in frail elderly patients where anticholinergic SE are a concern i.e. confusion

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73
Q

Stress incontinence management

A

1st line: pelvic floor muscle training (at least 8 contractions 3 times per day for 3 months)

2nd line: surgery - retropubic mid-urethral tape procedures

3rd line if surgery is declined: Medication - Duloxetine (SNRI) acts on pudendal nerve to cause contraction

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74
Q

Clinical features of endometriosis

A

Chronic pelvic pain (over 6 months) - cyclical or continuous
Secondary dysmenorrhea (pain often starts days before bleeding)
Deep dyspareunia
Subfertility
Non-gynaecological: urinary symptoms (dysuria, urgency, haematuria), dyschezia (painful bowel movements)

O/E pelvis: reduced organ mobility, tender nodulatirty

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75
Q

Endometriosis gold standard investigation

A

Laparoscopy

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76
Q

Management of endometriosis

A

1st line for symptomatic relief: NSAIDs/paracetamol

2nd line: Hormonal treatments e.g. 1st line COC, 2nd line progestogens e.g. IUD, pill, injection, implant ?

3rd line: GnRH analogues (induce pseudomenopause)

Trying to conceive: surgery
- laparoscopic excision or ablation of endometriosis plus adhesiolysis
- ovarian cystectomy for endometriomas

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77
Q

Types of ovarian cyst (4)

A

Functional cysts i.e. follicular/corpus luteum
Benign germ cell tumours
Benign epithelial tumours
Benign sex cord stromal tumours

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78
Q

Management of complex (I.E. multi-loculated) ovarian cysts

A

Biopsy to exclude malignancy

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79
Q

Types of physiological/functional cyst

A

Follicular cysts:
- commonest type of ovarian cyst
- non-rupture of the developing follicle
- commonly regress after several menstrual cycles

Corpus luteum cysts:
- corpus luteum doesn’t break down (e.g. early pregnancy) and fills with fluid

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80
Q

Type of benign germ cell tumour usually lined with epithelial tissue and may contain skin appendages, hair and teeth

A

Dermoid cyst
- most common benign ovarian tumour in woman under the age of 30 years

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81
Q

Clinical presentation of ovarian cyst where further investigations would NOT be needed

A

Premenopausal woman with a simple ovarian cyst less than 5cm on ultrasound

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82
Q

Ovarian torsion involving fallopian tube name

A

Adnexal torsion

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83
Q

Risk factors for ovarian torsion

A

Ovarian mass (present in 90%)
Reproductive age
Pregnancy
Ovarian hyper stimulation syndrome

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84
Q

Clinical presentation of ovarian torsion

A

Sudden onset of deep seated colicky abdominal pain (DDx: appendicitis unlikely to be of sudden onset)
Associated with vomiting and distress
Vaginal examination may reveal adnexial tenderness

DDx with appendicitis: leucocytosis in appendicitis

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85
Q

Diagnostic investigation/1st line treatment for ovarian torsion

A

Laparoscopy / surgical detorsion

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86
Q

4 signs of labour

A

Regular and painful uterine contractions
A show (shedding of mucous plug)
Rupture of the membranes (not always)
Shortening and dilation of the cervix

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87
Q

3 stages of labour

A

Stage 1: from the onset of true labour to when the cervix is fully dilated (10cm)
Stage 2: from full dilation to birth of the fetus
Stage 3: from birth of fetus to when the placenta and membranes have been completely delivered

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88
Q

Monitoring in labour (with timings)

A

FHR every 15 min (or continuously via CTG)
Contractions every 30 min

Maternal pulse rate every hour

Every 4 hours:
Maternal BP + temp
VE should be offered to check progression
Maternal urine (for ketones + proteins)

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89
Q

2 phases of Stage 1 labour

A

Latent phase = 0-3cm dilation (normally takes 6 hours)
Active phase = 3-10cm dilation (normally 1cm/hr)

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90
Q

Indications for induction of labour (4)

A
  1. Prolonged pregnancy e.g. 1-2 weeks after the estimated date of delivery
  2. Prelabour premature rupture of the membranes, where labour does not start
  3. Maternal medical problems (diabetic mother > 38 wks, pre-eclampsia, obstetric cholestasis)
  4. Intrauterine fetal death
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91
Q

Bishop score factors

A

C-SPED (cervix changes in labour)

Cervical Consistency
Fetal Station
Cervical Position
Cervical Effacement/Ripening (thinning)
Cervical Dilation

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92
Q

Interpretation of the bishop score

A

< 5 = labour is unlikely to start without induction

> 8 = cervix is ripe/favourable and there is a high chance of spontaneous labour or response to interventions to induce labour

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93
Q

Preferred method of induction if Bishop score is < 6

A

Vaginal prostaglandins or oral misoprostol

If there is a high risk of hyper stimulation/previous C section:
Mechanical methods such as balloon catheter

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94
Q

Preferred method of induction if Bishop score is >6

A

Amniotomy and an IV oxytocin infusion

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95
Q

Possible methods of labour induction

A

Membrane sweep (adjunct)
Vaginal prostaglandin E2 (PGE2) - dinoprostone
Oral prostaglandin E1 - misoprostol
Maternal oxytocin infusion
Amniotomy (breaking of waters)
Cervical ripening balloon

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96
Q

Main complication of induction of labour

A

Uterine hyperstimulation
- prolonged and frequent uterine contractions (tachysystole)
- interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and academia

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97
Q

Management of uterine hyperstimulation

A

Remove the vaginal prostaglandins if possible and stop the oxytocin infusion
Consider tocolysis

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98
Q

Clinical presentation ectopic pregnancy

A

Lower abdominal/iliac fossa pain (constant/unilateral)
Vaginal bleeding
History of recent amenorrhoea (typically 6-8 weeks from start of last period)
Peritoneal bleeding can cause shoulder tip pain and pain of defecation

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99
Q

Examination findings ectopic pregnancy

A

Pain and abdominal tenderness
Pelvic tenderness
Cervical excitation (cervical motion tenderness)

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100
Q

Investigation of choice for ectopic pregnancy

A

Transvaginal ultrasound (adnexal mass moving separately to ovary)

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101
Q

Criteria for performing expectant management of ectopic pregnancy (monitoring over 48 hours before intervening)

A

Size <35 mm
Unruptured embryo
Asymptomatic
No fetal heartbeat
HCG < 1000

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102
Q

Management option of ectopic pregnancy

hCG level <1500, unruptured, symptomatic (but not significant pain), size <35mm

A

IM methotrexate

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103
Q

Ectopic pregnancy >35 mm in size or B-hCG >5000 or presence of foetal heartbeat

A

Surgical management (laparoscopic salpingectomy or salpingotomy)

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104
Q

Salpingectomy vs salpingotomy for management of ectopic pregnancy

A

SalpingECTOMY (removal): 1st line for women with no other risk factors for fertility

SalpingOTOMY (incision): consider for women with risk factors for infertility such as contralateral tube damage

NB: 1 in 5 women who undergo salpingotomy require further treatment (methotrexate or salpingectomy)

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105
Q

Risk factors for ectopic pregnancy (8)

A

DAISIE

Damage to tubes i.e. PID, surgery
Age > 35
IVF (3%)
Smoking
IUCD / Progesterone only pill
Endometriosis / previous Ectopic

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106
Q

Where is the most dangerous location for an ectopic to localise

A

Isthmus

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107
Q

Most common site of ectopic pregnancy

A

Ampulla of fallopian tube

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108
Q

Primary amenorrhoea definition

A

Failure to establish menstruation by 16 years with normal secondary sexual characteristics (e.g. breast development) or by 14 years with no secondary sexual characteristics

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109
Q

Secondary amenorrhoea definition

A

Cessation of menstruation for at least 6 months in women with previous normal and regular menses, or 12 months in women with previous oligomenorrhoea

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110
Q

Causes of primary amenorrhoea

A

Normal secondary sexual characteristics

  1. Androgen insensitivity syndrome (testicular feminisation)
  2. Imperforate hymen (consider if painful cycles with no bleeding)

No secondary sexual characteristics

Hypogonadrotropic hypogonadism (low FSH and LH)

  1. Functional hypothalamic amenorrhoea (e.g. secondary to anorexia)

Hypergonadotropic (high FSH and LH)

  1. Gonadal dysgenesis (e.g. Turner’s syndrome) - MOST COMMON CAUSE OF PRIMARY AMENORRHOEA

Heterosexual development:
5. CAH

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111
Q

Causes of secondary amenorrhoea (after excluding pregnancy)

A

Hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
Hyperprolactinaemia, hypopituitarism
Sheehan’s syndrome
Thyrotoxicosis
PCOS
Premature ovarian failure
Asherman’s syndrome (intrauterine adhesions)

Think: endocrine organs

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112
Q

Investigations for amenorrhoea

A

Exclude pregnancy with urine or serum bHCG
FBC, U+E, coeliac screen, TFT
Gonadotropins (low levels = hypothalamic, raised levels = ovarian / gonadal dysgenesis (e.g. Turners))
Prolactin
Androgen levels (PCOS)
Oestradiol

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113
Q

Androgen insensitivity syndrome key points (3)

A
  1. X-linked recessive condition
  2. 46 XY
  3. end-organ resistance to testosterone causing genotypically male children to have a female phenotype
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114
Q

What to exclude when diagnosing secondary amenorrhoea

A

Exclude pregnancy, lactation, and menopause (in women 40+)

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115
Q

Features of androgen insensitivity syndrome

A

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

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116
Q

Diagnosis of androgen insensitivity syndrome

A

Buccal smear or chromosomal analysis to reveal 46XY genotype

After puberty, testosterone concentrations are in the high-normal to slightly elevated reference range for postpubertal boys

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117
Q

Management of androgen insensitivity syndrome

A

Counselling - raise the child as female
Bilateral orchidectomy
Oestrogen therapy

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118
Q

Pathology of androgen insensitivity syndrome

A

XY without androgen influence

No stimulation from androgens during embryogenesis = Wolffian ducts aren’t maintained = no male internal or external genitalia

SRY gene on the Y chromosome = obliteration of Müllerian ducts / testes remain

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119
Q

UKMEC 3 conditions for COC

A

> 35 years old and smoking < 15 cigarettes/day (UKMEC 4 = >35 + > 15)

BMI > 35

carrier of BRCA1/BRCA2

family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
most epilepsy medication

current gallbladder disease

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120
Q

UKMEC 4 conditions for COC

A

> 35 years old and smoking > 15 cigarettes/day

breast feeding < 6 weeks post-partum
current breast cancer

migraine with aura
uncontrolled hypertension
history of thromboembolic disease, stroke or ischaemic heart disease
major surgery with prolonged immobilisation

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121
Q

Most effective method of emergency contraception

A

Copper coil

99% effective regardless of where it is used in the cycle

Should be offered unless contraindicated

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122
Q

3 options for emergency contraception after UPSI:
72 hours
120 hours
5 days

A

72 hours = Levonorgestrel
120 hours = Ulipristal (C/I in severe asthma)
5 days = IUD/copper coil (5 days after UPSI or within 5 days of ovulation)

NB: levonorgestrel and ulipristal work by inhibiting ovulation so will be less effective after ovulation

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123
Q

Downs syndrome combined test (11 to 13+6 weeks)

A

Ultrasound: Nuchal translucency measurement (thickened)

Maternal blood test:
1. Serum B-HCG (high)
2 Pregnancy-associated plasma protein A (PAPP-A) (low)

Also screens for Edwards + Patau’s

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124
Q

Downs syndrome triple/quadruple blood test (for women 15-20 weeks)

A

alpha-fetoprotein
unconjugated oestriol
human chorionic gonadotrophin
triple
+ inhibin A
quadruple

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125
Q

Fetal anomolies DDx Down Syndrome vs Edward syndrome (trisomy 18) / Patau syndrome (trisomy 13)

A

hCG tends to be high in down syndrome

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126
Q

Management of higher chance combined/quad test

A

1st: Non-invasive prenatal screening test (NIPT) high sensitivity + specificity so preferred choice

Diagnostic tests also offered:
Amniocentesis
Chorionic villus sampling

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127
Q

Conditions which all pregnant women should be offered screening

A

Anaemia
Bacteriuria
Blood group, Rhesus status and anti-red cell antibodies
Down’s syndrome
Fetal anomalies
Hepatitis B
HIV
Syphilis
Neural tube defects
Risk factors for pre-eclampsia

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128
Q

Antenatal care: 8-12 weeks (ideally under 10 weeks)

A

Booking visit
- General information
- BP, urine dipstick, check BMI

Booking bloods/urine
FBC (inc. anaemia), blood group, rhesus status, red cell alloantibodies, haemoglobinopathies, hepatitis B, syphilis, HIV

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129
Q

When is Down’s syndrome screened for

A

11 - 13+6

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130
Q

Antenatal care: 18-20+6 weeks

A

Anomaly scan

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131
Q

Antenatal care: 28 weeks

A

Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell antibodies If Hb < 10.5 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women

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132
Q

when is anti-D given in Rh-negative women

A

28 and 34 weeks

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133
Q

diagnostic thresholds for gestational diabetes

A

fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L

5678

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134
Q

RF for gestational diabetes (7)

A
  1. Previous gestational diabetes
  2. First degree relative with DM
  3. Previous macrosomic baby (>4.5kg)
  4. Obesity (BMI > 30)
  5. Family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
  6. PCOS
  7. Maternal age >40
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135
Q

Screening for gestational diabetes

A

OGTT is gold standard

Previous GD: ASAP after booking (13-14 weeks) and 24-28 weeks if normal

Risk factors for GD e.g. 1st degree relative with diabetes: OGTT at 24-28 weeks

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136
Q

Management of a women with >1 high risk factor or >2 moderate factors for hypertensive disorders in pregnancy

A

aspirin 75-150mg daily from 12 weeks gestation until the birth

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137
Q

Initial management after assessment of pre-eclampsia

A

arrange emergency secondary care assessment for any woman in whom pre-eclampsia is suspected

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138
Q

1st line medication pre-eclampsia/hypertensive disorders in pregnancy

A

Oral labetalol

Asthmatic, HF, heart block: Nifedipine

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139
Q

pre-eclampsia definition

A

new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:

  • proteinuria
  • other organ involvement e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
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140
Q

Risk factors for endometrial cancer (4)

A
  1. excess oestrogen (nulliparity, early menarche, late menopause, unopposed oestrogen e.g. HRT w/o progestogen)
  2. metabolic syndrome (obesity, diabetes mellitus, pcos)
  3. tamoxifen
  4. hereditary non-polyposis colorectal carcinoma
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141
Q

Protective factors of endometrial cancer (3)

A

multiparity
COC
smoking

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142
Q

Classic symptom of endometrial cancer

A

postmenopausal bleeding

All women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway

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143
Q

1st line investigation endometrial cancer

A

1st line: TV ultrasound

Diagnostic: hysteroscopy with endometrial biopsy

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144
Q

Basic investigations for infertility

A

semen analysis

serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21: >30 indicates ovulation

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145
Q

4 key counselling points for infertility

A

folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice

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146
Q

3 types of urogenital prolapse

A

Uterine descent
Cystocele
Rectocele

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147
Q

Presentation of urogenital prolapse

A

sensation of pressure, heaviness, ‘bearing-down’

urinary symptoms: incontinence, frequency, urgency

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148
Q

4 risk factors for urogenital prolapse

A

increasing age
multiparity, vaginal deliveries
obesity
spina bifida

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149
Q

80% of vulval cancers type

A

squamous cell carcinomas

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150
Q

Typical of onset vulval cancer

A

Over 65

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151
Q

2 features of vulval cancer

A

lump or ulcer on the labia majora
inguinal lymphadenopathy

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152
Q

age with highest incidence of cervical cancer in UK

A

25-29

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153
Q

Most common type of cervical cancer

A

squamous cell cancer (80%)

adenocarcinoma (20%)

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154
Q

Features cervical cancer

A

Postcoital, intermenstrual or postmenopausal bleeding
Purulent discharge
Red brown discharge

may be detected during routine cervical cancer screening

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155
Q

Major cause of cervical cancer

A

Human papillomavirus (HPV), particularly serotypes 16,18 & 33

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156
Q

risk factors for cervical cancer

A

smoking
human immunodeficiency virus
early first intercourse, many sexual partners
high parity
lower socioeconomic status
combined oral contraceptive pill
aged 45-49

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157
Q

Levels of cervical intraepithelial neoplasia/dysplasia (CIN) found during colposcopy + biopsy

A

CIN 1: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment

CIN 2: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated

CIN 3: severe dysplasia, very likely to progress to cancer if untreated

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158
Q

Treatment for cervical intraepithelial neoplasia (CIN) 2 and 3

A

Large loop excision of transformation zone (LLETZ)

Screen done at 6 months as a test of cure

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159
Q

cervical screening post pregnancy

A

usually delayed until 3 months post partum

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160
Q

risks associated with monoamniotic monozygotic twin pregnancies

A

spontaneous miscarriage, perinatal mortality

malformations, IUGR, prematurity

twin-to-twin transfusions

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161
Q

predisposing factors for dizygotic twins

A

previous twins
family history
increasing maternal age
multigravida
induced ovulation and in-vitro fertilisation
race e.g. Afro-Caribbean

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162
Q

Antenatal complications of multiple pregnancy (4)

A
  1. polyhydramnios
  2. pregnancy induced hypertension
  3. anaemia
  4. antepartum haemorrhage
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163
Q

Labour complications of multiple pregnancy

A

PPH increased (*2)
malpresentation
cord prolapse, entanglement

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164
Q

Vasa praevia emergency presentation

A

Rupture of membranes followed immediately by painless vaginal bleeding

Followed by foetal compromise (fetal bradycardia is classically seen)

Membrane rupture leads to major fetal haemorrhage (mortality 60%)

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165
Q

screening tool for post partum depression

A

The Edinburgh Postnatal Depression Scale

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166
Q

6 important hormones in labour

A

Oxytocin (uterine contraction)
Prolactin (begins milk production)
Oestrogen (inhibits progesterone to prepare smooth muscles)
Prostaglandins (cervical ripening)
B-endorphins (pain relief)
Adrenaline (energy)

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167
Q

Mechanisms of labour

A

Descent
Engagement
Flexion
Internal rotation
Crowning
Extension of presenting part
Restitution
External rotation
Delivery

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168
Q

2 membranes of the placenta

A

Amnion (around the baby)
Chorion (around the placenta)

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169
Q

Antepartum haemorrhage definition

A

Bleeding from anywhere within the genital tract after the 24th week of pregnancy

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170
Q

Eclampsia

A

Onset of seizures in a woman with pre-eclampsia

Seizures in a pregnant woman are always eclampsiauntil proven otherwise

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171
Q

Management of eclampsia

A

Stabilise mum first, then deliver baby

  1. IV magnesium sulphate
    Treatment should continue 24 hours after delivery or 24 hours after last seizure
    Monitor reflexes + resp rate
  2. Treat hypertension(labetalol , nifedipine, hydralazine)
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172
Q

Risk factors for sepsis in pregnancy

A

Obesity
Diabetes
Impaired immunity / immunosuppressantmeds
Anaemia
History of group B Strepinfection
Amniocentesis and otherinvasive procedures

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173
Q

Cord prolapse

A

Occurs when cord is presenting(first cord, thenbaby)
After rupturing membrane
Exposure of the cord leads to vasospasm
Can causesignificant riskoffetalmorbidityandmortality from hypoxia

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174
Q

Cord prolapse risk factors

A

Premature rupture membranes
Polyhydramnios
Long umbilical cord
Fetalmalpresentation
Multiparity
Multiple pregnancy

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175
Q

Assessing the 4 causes of PPH

A

The four ‘T’s
-Tissue: ensure placenta complete(MROP)
-Tone: ensure uterus contracted(uterotonics)
-Trauma: look for tears(repair)
-Thrombin: check clotting(transfusion RPC/ CP/FFP)

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176
Q

Sulfonamides in 3rd trimester associated risk

A

Associated with kernicterus

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177
Q

When should nitrofurantoin be avoided in pregnancy

A

3rd trimester due to risk of haemolytic anaemia in neonate with G6PD deficiency

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178
Q

Investigation for pregnancy of unknown location

A

Serum bHCG baseline and repeated after 48 hours

  1. Intrauterine = bHCG doubles
  2. Ectopic = rises but doesn’t double
  3. Miscarriage = falls by half or more
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179
Q

Management option for ovarian torsion if the ovary is non-viable, involvement of fallopian tube, malignancy

A

Salpingo-oophorectomy

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180
Q

Risk factors for IUGR

A

Maternal age of <16 or >35
Low BMI/Pre-pregnancy weight of >75kg
Pre-eclampsia
Trisomy 18
Low inter pregnancy interval (<6 months) or high (>120 months)

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181
Q

Premature preterm rupture of membranes investigation

A

Presence of pool of fluid in the vagina at sterile speculum examination

No pooling of fluid: test the fluid for PAMG-1 or IGF-1

Ultrasound may show oligohydramnios

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182
Q

Management of preterm premature rupture of the membranes

A

oral erythromycin for 10 days (or until the woman is in established labour) to prevent chorioamnionitis

antenatal corticosteroids to reduce the risk of respiratory distress syndrome e.g. IM betamethasone

delivery should be considered at 34 weeks gestation

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183
Q

When does premature prelabour rupture of the membranes occur before

A

36 + 6 weeks

associated with preterm birth

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184
Q

5 differential factors to remember placental abruption vs placenta praevia

A

SHOCK
PAIN
BLEEDING
TENDERNESS
FETUS

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185
Q

uterine rupture (complete)

A

Rupture of the muscle layer of the uterus (myometrium)

Complete rupture = contents of the uterus are released into the peritoneal cavity

This leads to significant bleeding and high morbidity and mortality for baby and mother

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186
Q

Major risk factor for uterine rupture

A

Previous caesarean section

scar on the uterus becomes susceptible to rupture with excessive pressure e.g. excessive stimulation by oxytocin

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187
Q

key presenting feature of uterine rupture

A

ceasing of uterine contractions

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188
Q

management of uterine rupture

A

emergency C section

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189
Q

management of pregnant woman with previous VTE

A

prophylactic low molecular weight heparin throughout antenatal period and 6 weeks postnatal

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190
Q

Risk factors pregnancy VTE

A

Previous VTE
Age > 35
BMI > 30
Parity > 3
Smoker
Pre-eclampsia
Multiple pregnancy
Thrombophilia (Factor V Leiden deficiency)

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191
Q

Which medications should be avoided in management of VTE in pregnancy

A

DOACs e.g. apixaban + warfarin

use LMWH e.g. dalteparin

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192
Q

Non-viable pregnancy definition

A

crown rump length (CRL) measures 7mm or more with no heartbeat

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193
Q

management of CIN1

A

no treatment needed but follow up after 12 months

194
Q

Risk factors for GBS infection in a neonate (4)

A

Maternal pyrexia
Prematurity
Previous sibling GBS infection
Prolonged rupture of the membranes

195
Q

Most common type of vaginal cancer

A

Secondary (metastatic) e.g. from the cervix or endometrium

primary vaginal cancer is rare

196
Q

Most common primary vaginal cancer

A

Squamous cell carcinoma (85%)

197
Q

Vasa praevia management

A

If detected antenatally:
1. Corticosteroids, given from 32 weeks gestation to mature the fetal lungs
2. Elective caesarean section, planned for 34 – 36 weeks gestation

Antepartum haemorrhage:
1. Emergency caesarean section is required to deliver the fetus before death occurs

198
Q

Adenomyosis

A

endometrial tissue in the lining of the uterus grows into the muscular wall of the uterus

‘Enlarged, boggy uterus’

causes heavy menstrual bleeding

199
Q

Role of LH in menstrual cycle

A

Ovulation (release of the ovum from the dominant follicle)

200
Q

Role of FSH in menstrual cycle

A

Development of the secondary follicle

201
Q

Role of estradiol (E2)/oestrogen in menstrual cycle

202
Q

Role of progesterone in menstrual cycle

203
Q

Describe the levels of FSH, LH, progesterone, oestrogen in the menstrual cycle

A

Progesterone peaks 7 days after ovulation has occurred

204
Q

Polyhydramnios

205
Q

Diagnosis of polyhydramnios

A

AFI >24 cm (or 2000ml +)

206
Q

Most common cause of polyhydramnios

A

Idiopathic

207
Q

Rotterdam criteria definition for PCOS

A

2 out of 3 features for diagnosis:

  1. Polycystic ovaries (either 12 or more follicles or increased ovarian volume [> 10 cm3]
  2. Oligo-ovulation or anovulation
  3. Clinical and/or biochemical signs of hyperandrogenism
208
Q

role of metformin in PCOS (4)

A
  1. Appetite reduction
  2. Decreases androgen production
  3. Decreases LH from the anterior pituitary
  4. Decreases sex-hormone binding globulin in the liver
209
Q

HELLP syndrome

A

Haemolysis (anaemia, high LDH)
Elevated Liver enzymes (AST, ALT)
Low Platelets / prolonged bleeding time

Severe variant of pre-eclampsia

210
Q

Management of HELLP syndrome

A

immediate delivery
dexamethasone

211
Q

HELLP syndrome presentation (4)

A

nausea & vomiting
right upper quadrant pain
lethargy
dark urine

212
Q

causes of recurrent miscarriage

A

antiphospholipid syndrome (think in patient with arthralgia + recurrent miscarriages)
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders
Polycystic ovarian syndrome
uterine abnormality: e.g. uterine septum
Parental chromosomal abnormalities
smoking

213
Q

Management of gestational diabetes fasting glucose <7mmol/L

A
  1. Trial of diet and exercise
  2. If targets are not met within 1-2 weeks, start metformin
  3. Add insulin to metformin if glucose is still not controlled or if metformin C/I
214
Q

Management of gestational diabetes fasting glucose of 7mmol/L or above

A

immediate insulin +/- metformin, and diet and exercise

215
Q

Pre-eclampsia other features

A

Hyperreflexia *(increased intracranial pressure which increases tendon reflexes)
Epigastric pain (oedema in the liver capsule can cause right upper quadrant pain)
Facial oedema
Headache
Papilloedema (visual disturbance are caused by the pressure of oedema on the optic nerve)
Reduced urine output

216
Q

Pre-eclampsia risk factors

A

Aged 40 years or older
Nulliparity
Pregnancy interval of more than 10 years
Family history of pre-eclampsia
Previous history of pre-eclampsia
Body mass index of 30kg/m^2 or above
Pre-existing vascular disease such as hypertension
Pre-existing renal disease
Multiple pregnancy

217
Q

Seizure prophylaxis in severe pre-eclampsia

A

IV magnesium sulphate + deliver within 24-48 hours if presenting after 37 weeks

218
Q

Kleinhauer test

A

investigation used to detect feto-maternal haemorrhage in a suspected sensitising event to ensure enough anti-D immunoglobulin has been given to the mother

219
Q

fetal baseline heart rate

A

Approx 110-160 bpm

220
Q

fetal baseline rate variability

A

between 5 to 25 bpm

221
Q

when is contraception recommended on HRT

A

under 50: 2 years after your last period
over 50: 1 year after last period

222
Q

Who can have HRT containing unopposed oestrogen

A

Women who have had a hysterectomy

unopposed oestrogen increases risk of endometrial cancer

223
Q

Surgical excision of breast fibroadenoma

224
Q

Fibroadenoma presentation

A

Highly mobile, firm, non-tender, smooth breast lump

Common in women under the age of 30 years

also described as ‘a breast mouse’ because it moves easily under the skin

menstruation can increase the size of the fibroadenoma + causes it to be tender

225
Q

Fibroadenosis/fibrocystic disease presentation

A

Most common in middle-aged women

‘Lumpy’ breasts which may be painful

Symptoms may worsen prior to menstruation

226
Q

Paget’s disease of the breast key sign

A

Unilateral nipple eczema

227
Q

Inflammatory breast cancer key sign

A

Oedema (peau d’orange)

228
Q

Mammary duct ectasia presentation

A

Dilation of the large breast ducts

Most common around the menopause

May present with a tender lump around the areola +/- white or green nipple discharge +/- inverted nipple

229
Q

Duct papilloma presentation

A

May present with blood stained discharge

230
Q

Fat necrosis of the breast presentation

A

More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump

231
Q

Breast abscess presentation

A

Painful, red, hot swelling above areola
Usually in 20-30 year old, breastfeeding

232
Q

Breast abscess risk factors (2)

A

Breastfeeding
Smoking

233
Q

Phyllodes tumour management

A

Wide excision

234
Q

Breast cyst management

A

aspiration
blood stained or persistently refilling should be biopsied or excised

235
Q

Fat necrosis management

A

can mimic breast cancer

Imaging and core biopsy

236
Q

Duct papilloma management

A

Microdochectomy (total duct excision)

237
Q

In-situ vs invasive ductal carcinoma

A

In-situ = basement membrane intact

238
Q

Breast cancer screening programme

A

Women aged 50-70 every 3 years

239
Q

Breast cancer 2 week referral pathway indications

A

aged 30+ with unexplained breast lump +/- pain
aged 50+ with any concerning nipple changes e.g. discharge, retraction

240
Q

Breast cancer with no palpable axillary lymphadenopathy pre-surgical investigation

A

Axillary ultrasound

241
Q

Breast cancer with no palpable axillary lymphadenopathy + pre-surgical axillary ultrasound is negative investigation

A

Sentinel node biopsy to assess the nodal burden

242
Q

Breast cancer with palpable lymphadenopathy management at primary surgery

A

Axillary node clearance

243
Q

Surgical options breast cancer tumour removal

A

Wide local excision (lumpectomy) - 2/3
Mastectomy - 1/3

244
Q

Recommended adjunct therapy after wide-local excision

A

Radiotherapy - may reduce risk of recurrence by 2/3

245
Q

Which result on biopsy guides tamoxifen treatment

A

if the tumour is oestrogen receptor positive

246
Q

Hormonal therapy for pre and peri monopausal women with ER+ breast cancer

247
Q

Hormonal therapy for post-menopausal women with breast cancer

A

Aromatase inhibitors e.g. anastrozole

aromatase enzyme converts androgens to oestrogens

248
Q

3 complications of tamoxifen

A

Endometrial cancer
VTE
Menopausal symptoms

249
Q

Most common type of breast cancer

A

Invasive ductal carcinoma

250
Q

Fetal hydrops definition

A

abnormal accumulation of serous fluid in 2+ fetal compartments (pleural/ pericardial
effusions, ascites, skin oedema, polyhydramnios or placental oedema)

251
Q

Immune cause of fetal hydrops

A

blood group incompatibility between mother and fetus causing fetal anaemia

252
Q

Non immune causes of fetal hydrops

A

Severe anaemia – congenital parvovirus B19 infection, alpha thalassaemia major, massive
materno-feto haemorrhage
Cardiac abnormalities
Chromosomal – Trisomy 13, 18, 21, or Turners
Infection – toxoplasmosis, rubella, CMV, varicella
Twin- Twin transfusion syndrome (in the recipient twin)
Chorioangioma

253
Q

Most common cause of anaemia in pregnancy

A

Iron deficiency

this can be due to inadequate dietary intake, previous pregnancy, or recurrent loss of iron during menstruation

254
Q

1st line pharmacological treatment to induce labour

A

Vaginal PGE2 e.g. dinoprostone

255
Q

Features of obstetric cholestasis

A

Pruritus (may be intense, typically worse on palms, soles and abdomen)
Clinically detectable jaundice (20%)
Raised bilirubin (>90%)

256
Q

Management of obstetric cholestasis (2)

A

Induction of labour at 37-38 weeks (due to risk of stillbirth)
Ursodeoxycholic acid

257
Q

Risk factors for obstetric cholestasis

A

Hepatitis C
Multiple pregnancy
Obstetric cholestasis in previous pregnancy
Presence of gallstones

258
Q

Risk factors for breech presentation

A

Uterine malformations/fibroids
Placenta praevia
Polyhydramnios or oligohydramnios
Fetal abnormality
Prematurity

259
Q

Breech presentation at 36 weeks (nulliparous) or 37 weeks (multiparous)

A

External cephalic version (ECV)

260
Q

ECV contraindications

A

where caesarean delivery is required
antepartum haemorrhage within the last 7 days
abnormal cardiotocography
major uterine anomaly
ruptured membranes
multiple pregnancy

261
Q

Breast cancer risk factors

A

BRCA1/2
Oestrogen exposure (age of menarche and menopause)
Low parity (breastfeeding is protective)
Western lifestyle (diet, alcohol, obesity, exercise)

262
Q

Major risk of placenta accreta

A

Postpartum haemorrhage

263
Q

Placenta accreta definition

A

attachment of the placenta to the myometrium, due to a defective decidua basalis

264
Q

2 risk factors placenta accreta

A

Previous C section
Placenta praevia

265
Q

Risk factors abnormal fetal lie

A

Multiple pregnancy
Uterine leiomyomas
Placenta praevia
Prematurity

266
Q

After how many weeks gestation should anti-D prophylaxis be offered in a rhesus D negative woman in TOP

A

After 10 weeks

267
Q

Premature ovarian insufficiency

A

Onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years

menstrual periods absent for at least 12 months

268
Q

Causes of premature menopause

A

Idiopathic (most common cause, may be FHx)
Bilateral oophorectomy
Radiotherapy
Chemotherapy
Infection
Autoimmune disorders
Resistant ovary syndrome (FSH receptor abnormalities)

269
Q

How should FSH levels be investigated in premature ovarian insufficiency

A

Elevated FSH levels should be demonstrated on 2 blood samples taken 4-6 weeks apart

no negative feedback from ovaries = FSH and LH are very high

270
Q

Management primature ovarian insufficiency

A

HRT or COC until 51 years

HRT does not provide contraception in case spontaneous ovarian activity resumes

271
Q

2nd degree perineal tear

A

Injury to the perineal muscle, but not involving the anal sphincter

Requires suturing on the ward

272
Q

3rd degree perineal tear

A

Injury to the perineum involving the anal sphincter complex (external and internal)

Requires repair in theatre

273
Q

4th degree perineal tear

A

Injury to the perineum involving the anal sphincter complex and rectal mucosa

274
Q

Risk factors for perineal tears

A

Primigravida
Large babies
Precipitant labour
Shoulder dystocia
Forceps delivery

275
Q

Location of injury for Erb’s palsy

276
Q

Erb’s palsy

A

Arm paralysis or weakness after birth trauma (typically shoulder dystocia)

Brachial trunks C5-C6

277
Q

Termination of pregnancy 1990 Act Amendment

A

Reduced upper limit from 28 weeks gestation to 24 weeks gestation

Two registered medical practioners must sign a legal document

278
Q

Medical management of TOP

A

Mifepristone (anti-progesterone) followed 48 hours later by misoprostol (prostaglandin) to stimulate uterine contractions

279
Q

What is required 2 weeks after medical management of TOP

A

Multi-level pregnancy test (level of hCG)

280
Q

Surgical management of TOP

A

Vacuum aspiration, electric vacuum aspiration and dilation and evacuation

Cervical priming with misoprostol +/- mifepristone

An intrauterine contraceptive can be inserted immediately after evacuation

281
Q

Medication of choice for tocolysis

A

Nifedipine

Tocolysis can be used between 24 and 33+6 weeks gestation to delay delivery and buy time

282
Q

Prophylaxis of preterm labour (2)

A

Offered to women with a cervical length < 25 mm between 16 and 24 weeks

  1. Vaginal progesterone
  2. Cervical cerclage (previous premature birth or cervical trauma e.g. colp/cone biopsy)
283
Q

4 signs prolactinoma

A

Galactorrhoea
Menstrual disturbance
Amenorrhoea
Infertility

284
Q

Management if vomiting occurs within 3 hours of taking levonorgestrel or ulipristal acetate

A

Repeat dose

285
Q

Management if levonorgestrel or ulipristal are indicated more than once in a menstrual cycle

A

They can both be used more than once in the same cycle

286
Q

How soon can hormonal contraception be started after using levornogestrel

A

Immediately

287
Q

How soon can hormonal contraception be started after using Ulipristal

A

Pill, patch or ring contraception should be started 5 days after having ulipristal

288
Q

Breastfeeding indications in use of ulipristal and levonorgestrel

A

Delayed for one week after taking ulipristal, no restrictions on use of levonorgestrel

289
Q

At what point does a positive pregnancy test following TOP require investigation

290
Q

1st line management of mastitis

A

Continue breastfeeding

if pain prevents, encourage expressing

291
Q

Indications for antibiotics in mastitis (4)

A
  1. Systemically unwell
  2. Nipple fissure
  3. Symptoms do not improve after 12-24 hours of effective milk removal
  4. Culture indicates infection
292
Q

1st line antibiotic mastitis

A

Oral flucloxacillin for 10-14 days

breastfeeding or expressing should continue during Abx treatment

293
Q

Most common organism causing infective mastitis

A

Staph aureus

294
Q

Features of ovarian tumours

A

Hirsutism (testosterone secretion)
Acute abdomen (ovarian torsion)
Rupture or haemorrhage
Thyrotoxicosis (struma ovarii)
Amenorrhoea

295
Q

FIGO staging for cervical cancer

A

1A = confined to cervix + only visible by microscopy + < 7mm
1B = confined to cervix + clinically visible + > 7mm
2 = extension of tumour beyond cervix + not to pelvic wall
3 = extension of tumour beyond cervix + to pelvic wall
4 = extension of tumour beyond the pelvis or involvement of bladder or rectum

296
Q

Management of stage 1A cervical tumours

A

Gold standard = hysterectomy +/- lymph node clearance

Patients wanting to maintain fertility = cone biopsy

297
Q

Treatment of stage 1A cervical cancer

A

Gold standard: hysterectomy +/- lymph node clearance
Fertility maintained preference: cone biopsy with negative margins + close follow up

298
Q

Haematocolpos

A

Accumulation of menstrual blood in the vagina, usually due to an imperforate hymen

Usually presents with primary amenorrhoea and pelvic pain in young women

299
Q

Ovarian hyperthecosis vs PCOS

A

Ovarian hyperthecosis accounts for most of the cases of hyperandrogenaemia in postmenopausal women

Hyperthecosis presents with more severe hyperandrogenism and virilisation: testosterone levels are much higher than PCOS

300
Q

Gonadotrophin levels in anorexia nervosa

A

Suppressed gonadotrophins with low oestradiol

note: thyroid levels will be normal, ruling out panhypopituitarism

301
Q

4 increased incidences after C section

A

Abdo pain
Hysterectomy
Bladder/ureteric injury
VTE

302
Q

Hyperemesis gravidum investigations

A

FBC (raised haematocrit)
LFT (raised transaminases and lowered albumin)
U&E (low potassium, sodium, metabolic hypercholeremic alkalosis)
Urinalysis (ketones)

303
Q

Complications of gestational diabetes

A
  1. Polyhydramnios
  2. Macrosomia
  3. Preterm birth
  4. Stillbirth
  5. Pre-eclampsia
  6. Neonatal hypoglycaemia
304
Q

Sodium valproate congenital abnormalities

A

Hypospadias - MOST COMMON
Spina bifida
Septal defect
Cleft palate
Polydactyly - least common

305
Q

Marfan’s syndrome inheritance pattern

A

Autosomal dominant

306
Q

Main risk of Marfan’s syndrome

A

Aortic dissection and rupture

307
Q

Causes of primary post-partum haemorrhage

A

Tone e.g. uterine atony (most common cause)
Trauma e.g. in the genital tract
Thrombin e.g. coagulation disorders
Tissue e.g. retained placenta

308
Q

Definition of postpartum haemorrhage

A

Blood loss of > 500ml after a vaginal delivery

309
Q

Primary postpartum haemorrhage time definition

A

Within 24 hours

310
Q

Risk factors primary PPH

A

Previous PPH
Prolonged labour
Pre-eclampsia
Increased maternal age
Polyhydramnios
Emergency C section
Placenta praevia, placenta accreta
Macrosomia

311
Q

2 mechanical steps after an ABC approach in postpartum haemorrhage

A

Palpating the uterine fundus (to stimulate contractions)
Catheterising the patient (prevent bladder distention)

312
Q

Medical management of PPH

A

IV oxytocin
IV or IM Ergometrine (C/I hypertension)
IM Carboprost (C/I asthma)
Sublingual Misoprostol

313
Q

1st line surgical intervention for PPH caused by uterine atony

A

Intrauterine balloon tamponade

314
Q

Secondary postpartum haemorrhage timed definition

A

24 hours - 12 weeks

typically due to retained placental tissue or endometritis

315
Q

Who should be offered IV benzypenicillin (intrapartum antibiotic prophylaxis) during labour

A

Women who’ve had GBS detected in a previous pregnancy (OR offer testing in late pregnancy (35-37 wks) and then antibiotics if positive)
Previous baby with early or late-onset GBS disease
Preterm labour
Pyrexia during labour (>38C)

316
Q

Three features of toxoplasmosis congenital infection

A

Cerebral calcification
Chorioretinitis
Hydrocephalus

317
Q

4 features of cytomegalovirus congenital infection

A

Low birth weight
Purpuric skin lesions
Sensorineural deafness
Microcephaly

318
Q

Risk of malignancy index

A

CA125
US score
Menopausal status

319
Q

Risk factors for endometriosis

A

Factors that prolong amount of bleeding a woman has in her lifetime
Early menarche
Delayed childbearing
Nulliparity

Family history
Vaginal outflow obstruction
White ethnicity
Low BMI
Autoimmune disease

320
Q

1st line investigation in menorrhagia

A

Full blood count (iron deficiency = heavy blood loss that requires treatment)

321
Q

Cystocele surgical management

A

Anterior colporrhaphy

322
Q

Rectocele surgical management

A

Posterior colporrhaphy

323
Q

Management of primary dysmenorrhea (appears within 1-2 years of menarche)

A

NSAIDs e.g. mefenamic acid and ibuprofen (inhibit excessive prostaglandin production)

2nd line: COC

324
Q

Causes of secondary dysmenorrhea (5)

A

Endometriosis
Adenomyosis
PID
Copper coil
Fibroids

325
Q

Management of secondary dysmenorrhea

A

Refer all patients to gynaecology for investigation

326
Q

When should the APGAR score be routinely assessed

A

1 and 5 minutes of age

if the score is low, repeat at 10 minutes

327
Q

chickenpox exposure in pregnancy - main risk to the mother

A

pneumonitis

328
Q

Features of fetal varicella syndrome

A

Skin scarring
Eye defects (microphthalmia)
Limb hypoplasia
Microcephalic
Learning disabilities

329
Q

Post-exposure prophylaxis of chickenpox exposure in pregnancy

A

If there is any doubt about the mother previously having chickenpox: maternal blood should be urgently checked for varicella antibodies

Once confirmed not immune to varicella:

<20 weeks gestation: varicella-zoster immunoglobulin ASAP - up to 10 days post-exposure

> 20 weeks gestation: VZIG or antivirals (aciclovir) 7 to 14 days after exposure

330
Q

Chickenpox infection >20 weeks gestation and presents within 24 hours of onset of the rash

A

Oral aciclovir

under 20 weeks, aciclovir should be considered with caution

331
Q

When do most cases of cord prolapses occur

A

At artificial rupture of the membranes: fetal heart rate becomes abnormal and the cord is palpable vaginally

332
Q

Management of cord prolapse

A

Signs of compression (CTG decelerations):
1. Elevate presenting part manually or by filling bladder
2. Ask the patient to go on ‘all fours’ until immediate C-section is ready to be carried out

If fetal heart rate anomalies continue after mechanical methods, initiate tocolytics e.g. terbutaline

Definitive: C-section

the cord should be kept warm and moist with minimal handling to avoid vasospasm

333
Q

Management of pre-existing diabetes in pregnancy (7)

A
  1. HbA1c and proteinuria at booking
  2. Stop oral hypoglycaemic agents (apart from metformin) and commence insulin
  3. Folic acid 5mg/day from pre-conception to 14 weeks gestation
  4. Aspirin 150mg once daily from 12 weeks to delivery
  5. Continuous glucose monitoring devices and ketone strips
  6. Detailed anomaly scan at 20 weeks
  7. Fetal growth scans at 28, 32 and 36 weeks
  8. Retinopathy screened for and treated in 1st and 3rd trimester
334
Q

Normal blood pressure pattern in pregnancy

A

falls in 1st trimester (particularly diastolic) and continues to fall until 20-24 weeks, then increases to pre-pregnancy levels by term

335
Q

Pre-existing hypertension in pregnancy definition

A

BP > 140/90 before 20 weeks gestation

ACE inhibitors or ARBs should be stopped immediately and alternative e.g. labetalol should be commenced whilst waiting for review

336
Q

When is it recommended to use contraception until in a menopausal woman (2)

A

12 months after the last period in women > 50
24 months after the last period in women < 50

337
Q

Menopause diagnosis

A

Clinical diagnosis when a woman has not had a period for 12 months

338
Q

4 menopausal symptoms with lifestyle modifications

A
  1. Hot flushes: regular exercise, weight loss, reduce stress
  2. Sleep disturbances: avoid late evening exercise, good sleep hygiene
  3. Mood: sleep, regular exercise, relaxation
  4. Cognitive symptoms: regular exercise, sleep hygiene
339
Q

Contraindications to HRT use in menopause (4)

A
  1. Current or past breast cancer
  2. Any oestrogen-sensitive cancer
  3. Undiagnosed vaginal bleeding
  4. Untreated endometrial hyperplasia
340
Q

Who can have unopposed oestrogen in HRT treatment

A

Women without a uterus i.e. previous hysterectomy

341
Q

HRT risks

A

VTE (no increased risk with transdermal)
Stroke (no increased risk with transdermal)
Coronary heart disease
Breast cancer (by combining with progesterone)
Endometrial cancer (oestrogen only)

342
Q

4 symptoms of menopause and medical management (non-HRT)

A
  1. Vasomotor symptoms i.e. hot flushes (fluoxetine, citalopram)
  2. Vaginal dryness (vaginal lubricant)
  3. Psychological symptoms (self-help, CBT, antidepressants)
  4. Urogenital symptoms (urogenital atrophy can be treated with vaginal oestrogen)
343
Q

Atrophic vaginitis

A

Occurs in post-menopausal women presenting with vaginal dryness, dyspareunia and occasional spotting

treatment = 1st vaginal lubricants, 2nd topical oestrogen cream

344
Q

Asherman’s syndrome

A

Intrauterine adhesions causing pelvic pain, abnormal uterine bleeding (very light periods) and fertility issues

Usually the patient will have had surgery on their uterus in the past e.g. hysteroscopy, C-section, cancer

345
Q

Management of simple endometrial hyperplasia without atypia

A

High dose progesterones with repeat sampling in 3-4 months (levonorgestrel IUD may be used)

346
Q

Management of atypical endometrial hyperplasia

A

Hysterectomy with bilateral salpingo-oophorectomy

347
Q

Main feature of endometrial hyperplasia

A

Abnormal vaginal bleeding e.g. intermenstrual

348
Q

Features of complete hydatidiform mole (molar pregnancy) (4)

A
  1. painless vaginal bleeding
  2. Uterus size greater than expected for gestational age
  3. Abnormally high serum hCG
  4. Ultrasound: snow storm appearance
349
Q

Molar pregnancy definition

A

non-viable (lacking maternal nucleus) fertilised egg implants in the uterus

350
Q

Baby-blues presentation

A

3-7 days following birth
More common in primiparous women
Anxious, tearful and irritable

351
Q

Management of baby blues

A

Reassurance, support and follow-up

352
Q

Postnatal depression presentation

A

Most cases start within a month and typically peak at 3 months
Depressive symptoms i.e. anhedonia, loss of appetite

353
Q

Postnatal depression

A

Reassurance and support
CBT
SSRIs for severe symptoms e.g. Sertraline and paroxetine (secreted in breast milk but not thought to be harmful to the infant, fluoxetine is secreted in high levels)

354
Q

Puerperal psychosis presentation

A

Usually within the first 2-3 weeks following birth
Severe swings in mood (similar to bipolar) and disordered perception (auditory hallucinations)

355
Q

Management of puerperal psychosis

A

Admission to hospital is usually required (ideally a Mother & Baby unit)

25-50% risk of recurrence in future pregnancies`

356
Q

Oligohydramnios definitoon

A

Reduced amniotic fluid: less than 500ml at 32-36 weeks and AFI < 5th percentile

357
Q

Causes of oligohydramnios

A

Premature rupture of membranes
IUGR
Post-term gestation
Pre-eclampsia
Potter sequence/renal agenesis in the infant

358
Q

When are pregnant women screened for anaemia

A

Booking visit (8-10 weeks)
28 weeks

359
Q

Management anaemia in pregnancy

A

Oral ferrous sulfate or ferrous fumarate (continued for 3 months after iron deficiency is corrected)

360
Q

1 COC pill missed management

A

Take the last pill (even if it means 2 pills in one day) then continue as normal/no additional protection needed

361
Q

2 COC pills missed management

A

General:
Take the last pill (even if means taking 2 pills in one day), leave any earlier missed pills and continue taking pills daily

Use condoms or abstain from sex until 7 days of the pill have been taken in a row

Week specific advise:
Pill-free interval/Days 1-7: emergency contraception
Days 8-14: 7 consecutive days so no need for EC
Days 15-21: finish current pack and start new pack next day (omit pill free interval)

362
Q

Pregnancy thyroid investigation results

A

Normal levels of free T4 and T3 but raised total T4 and T3 = due to an increase in the levels of thyroxine-binding globulin (TBG)

363
Q

Risks of untreated thyrotoxicosis/Grave’s in pregnancy (3)

A
  1. Fetal loss
  2. Maternal heart failure
  3. Premature labour
364
Q

Transient gestational hyperthyroidism

A

Activation of the TSH receptor by HCG

(HCG levels will fall in 2nd and 3rd trimester)

365
Q

Management of thyrotoxicosis in pregnancy

A

1st trimester: Propylthiouracil
After 1st trimester: Switch back to carbimazole

Thyrotophin receptor stimulating antibodies should be checked at 30-36 weeks gestation (to determine risk of neonatal thyroid problems)

366
Q

Management of hypothyroidism

A

Thyroxine is safe during pregnancy and breast feeding
Increase the dose of thyroxine by up to 50% as early as 4-6 weeks of pregnancy
Serum thyroid-stimulating hormone measured in each trimester and 6-8 weeks post partum

367
Q

Most common cause of hypothyroidism in children in the UK

A

Autoimmune thyroiditis

Most common cause in developing world = iodine deficiency
Other causes = post total-body irradiation e.g. child treated for ALL

368
Q

Risk factors for shoulder dystocia (4)

A
  1. fetal macrosomia (hence association with maternal diabetes mellitus)
  2. high maternal body mass index
  3. diabetes mellitus
  4. prolonged labour
369
Q

1st line management of shoulder dystocia

A

McRoberts manoeuvre:

flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen (increases the relative anterior-posterior angle of the pelvis)

+ suprapubic pressure (improves effectiveness)

370
Q

Management of shoulder dystocia if McRoberts doesn’t work

A
  • Rubin manoeuvre (press on the posterior shoulder to allow the anterior shoulder extra room)
  • Wood’s screw manoeuvre (putting a hand in the vagina and rotating the foetus 180 degrees in attempt to ‘dislodge’ the anterior shoulder from the symphysis pubis)
  • You can also try these with the woman on all fours
  • if this fails you need to push the head back in and do an emergency caesarean section
371
Q

Complications of shoulder dystocia (2 maternal, 2 fetal)

A

maternal:
- postpartum haemorrhage
- perineal tears

fetal
- brachial plexus injury
- neonatal death

372
Q

Hyperemesis gravidum diagnostic criteria triad

A

5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance

373
Q

Risk factors hyperemesis gravidarum (4)

A
  1. Increased levels of b-hCG (multiple pregnancies, trophoblastic disease)
  2. Nulliparity
  3. Obesity
  4. Family or personal history NVP

smoking is associated with a decreased incidence

374
Q

Referral criteria for nausea and vomiting in pregnancy (3)

A
  1. Unable to keep down liquids or oral antiemetics
  2. Ketonuria and/or weight loss (> 5% of body weight) despite treatment with oral antiemetics
  3. Confirmed or suspected comorbidity (e.g. cannot tolerate oral antibiotics for UTI)
375
Q

Management of Hyperemesis gravidum

A

Supportive

1st line:
Antihistamines e.g. oral cyclizine or promethazine
Phenothiazines e.g. oral prochlorperazine or chlorpromazine

2nd line:
Oral ondansetron (small risk of cleft lip/palate)
Oral metoclopramide (may cause EPSIs, not recommended for more than 5 days)

376
Q

Treatment of woman admitted to hospital for Hyperemesis gravidum

A

IV Normal saline with added potassium

377
Q

Side effects of copper coil insertion

A

spotting or cramping after insertion, heavier periods, more painful periods, infection, it can fall out

378
Q

Management endometrial cancer

A

total abdominal hysterectomy with bilateral salpingo-oophorectomy

High risk disease patients may have postoperative radiotherapy

Progesterone therapy for frail elderly women not suitable for surgery

379
Q

Who needs 5mg of folic acid until 12 weeks

A

Anti-epileptic drug
Coeliac disease
Diabetes
BMI > 30
Neural tube defect risk

380
Q

Category 1 C-section

A

Definition: Immediate threat to life of the mother or baby

Time: within 30 minutes

Examples:
Suspected uterine rupture
Major placental abruption
Cord prolapse
Fetal hypoxia
Persistent fetal bradycardia

381
Q

Category 2 C-section

A

Definition: Maternal or fetal compromise is not immediately life-threatening

Time: within 75 minutes

382
Q

Category 3 C-section

A

Delivery is required, but mother and baby are stable

383
Q

Category 4 C-section

A

Elective caesarean

384
Q

When is vaginal birth after caesarean appropriate

A

gestational age of current pregnancy > 37 weeks with a single previous caesarean delivery

385
Q

Contraindications to VBAC

A

Previous uterine rupture
Classical caesarean scar (upper uterine segment - 1% of c-sections)

386
Q

when are NSAIDs contraindicated in pregnancy

A

3rd trimester (from week 28)

387
Q

Methotrexate management in a couple trying to conceive

A

Methotrexate should be stopped in both male and female patients at least 6 months prior to attempting conception as it can damage both gametes

388
Q

4 causes of folate deficiency

A

phenytoin
methotrexate
pregnancy
alcohol excess

389
Q

contraindications to depo injection

A

breast cancer (current = UKMEC4, past = UKMEC3)

390
Q

Fertility therapy for PCOS patients

A

Weight loss
Metformin
Letrozole (aromatase inhibitor - increases FSH) or Clomifene

391
Q

risk of unopposed oestrogen in HRT

A

endometrial cancer

392
Q

Definition of prematurity

A

Born before 37 weeks

393
Q

Preterm parturition syndrome / preterm birth causes

A
  1. Cervical remodelling due to uterine over distention
  2. Decidual haemorrhage
  3. Cervical insufficiency
  4. Infection and inflammation
394
Q

Most common route of intrauterine infection

395
Q

Inherent defences against infection in the productive tract (4)

A

Vaginal acidic pH
Cervical mucus
Epithelial barrier
WBCs / innate immune system receptors

396
Q

Main risk factors for preterm birth

A

Infection
Cervical insufficiency
Previous PTB
Multiple pregnancy
Previous cervical surgery
Smoking
BV
Short cervix on ultrasound

397
Q

bedside tests to predict risk of preterm birth

A

Foetal fibronectin

abnormal finding in cervicovaginal fluid after 20 weeks which indicates disruption of membranes to decidua

398
Q

Treatment options to reduce preterm birth (secondary prevention)

A

Synthetic progesterone
Cervical cerclage
Cervical pessary
Antibiotics

399
Q

Management to prepare for preterm delivery (tertiary preventative measures) (4)

A
  1. Antenatal corticosteroids (fetal lungs)
  2. MgSO4 (to reduce cerebral palsy risk)
  3. Transfer to suitable unit
  4. Tocolysis (nifedipine (CCB) and atosiban (oxytocin receptor antagonist))
400
Q

Cervical insufficiency

A

Premature cervical ripening which leads to mid-trimester pregnancy loss

Risk factors: LLETZ, congenital abnormalities, infection

401
Q

Role of progesterone in pregnancy

A

Promotes uterine quiescence
Inhibits cervical ripening
Reduces pro-inflammatory cytokines

402
Q

Guidelines for preterm birth screening

A

Offer ultrasound cervical length screening to high risk women (+/- FFN)

403
Q

2 changes to glucose handling that occur as a result of pregnancy

A

Decreased fasting levels of glucose
Increased post-prandial levels

404
Q

Normal insulin requirement changes in pregnancy

A

Doubles from the end of trimester 1 to trimester 3

405
Q

Anti-insulin hormones secreted by the placenta in normal pregnancy (3)

A

Human placental lactose
Glucagon
Cortisol

406
Q

Fasting and 1 hour post meal targets in gestational diabetes

A

Fasting: < 5.3
1 hour post meal: < 7.8

407
Q

obstetric management for GD (3)

A
  1. Pre-eclampsia monitoring (BP and urine)
  2. Fetal growth scans (28, 32 and 36 weeks)
  3. Timing of delivery (uncomplicated = delivery by 40+6, complicated = 37-38+6)
408
Q

Pre-disposing factors to developing DKA in pregnancy

A

Infection
Vomiting
Poor control/non-compliance
Antenatal corticosteroids

409
Q

Intrapartum care of diabetes

A
  1. variable rate insulin infusion if 2 x blood glucose levels > 7
  2. Hourly blood glucose monitoring
410
Q

Care of neonate from diabetic pregnancy (3)

A
  1. Feed baby within 30 minutes (reduce hypoglycaemia)
  2. Blood glucose testing at 2 to 4 hours
  3. Minimum 24 hour hospital stay
411
Q

HbA1c level where pregnancy should be advised against

412
Q

FGM definition

A

All procedures involving partial or total removal of female external genitalia or other injury to female organs for non-medical reasons

413
Q

Types I-IV FGM

A

I: clitoridectomy
II: excision (clitoris +/- labia minora)
III: infibulation: narrowing of the vaginal orifice (creation of a covering seal)
IV: all other harmful procedures

414
Q

Obstetric or gynaecological complications of FGM

A

Chronic pain
Dyspareunia
Keloid scar formation
Dysmenorrhea (e.g. haematocolpos)
Recurrent UTI
PPH
C-section

415
Q

Oligomennorhea

A

Menses more than 35 days apart

416
Q

Benzodiazepine use in pregnancy

A

Associated with cleft palate, neonatal withdrawal symptoms and floppy baby syndrome

417
Q

Puerperium definition

A

Time frame from delivery of placenta to six weeks following birth

  • return to pre-pregnant state
  • initiation of lactation, increase of prolactin
  • decrease in human placental lactose, hCG, oestrogen and progesterone
418
Q

3 stages of puerperium / postpartum bleeding and discharge

A

Lochia rubra (day 0-4)
Lochia serosa (day 4-10)
Lochia alba (day 10-28)

419
Q

Prolactin response

A
  1. Suckle stimulus
  2. Anterior pituitary releases prolactin
  3. Lactometers produce milk
  • more secreted at night
  • suppresses ovulation
  • levels peak after the feed (to produce milk for next feed)
420
Q

Oxytocin reflex

A
  1. Suckle stimulus
  2. Oxytocin released by posterior pituitary gland
  3. Myo-epithelial cells contract and expel milk
  • helped by sight, sound and smell of baby
  • hindered by anxiety, stress, pain
421
Q

4 acute infant conditions that breastfeeding reduces the risk of

A

GI disease
Resp disease
otitis media
NEC

422
Q

Lactoferrin role (4)

A

Iron absorption
Anti-microbial
Bone marrow function
Immune system

423
Q

Sepsis definition

A

Infection with systemic manifestations

424
Q

Severe sepsis definition

A

Sepsis with sepsis-induced organ dysfunction

425
Q

Septic shock definition

A

Persistence of hypoperfusion despite adequate fluid replacement therapy

426
Q

Signs of postnatal sepsis

A

3 T’s white with sugar

Temperature
Tachycardia
Tachypnoea
WCC
Hyperglycaemia

427
Q

Sepsis interventions in pregnant women (Sepsis 6 plus 2)

A

BUFALO (blood cultures, urine output, fluid, antibiotics, lactate, oxygen)
Consider delivery
VTE prophylaxis

428
Q

VTE prophylaxis after C-section

A

LMWH 10 days

429
Q

Postpartum urinary retention definition

A

Inability to completely micturate requiring urinary catheterisation over 12 hours after giving birth or not being able to void spontaneously 6 hours after giving birth

430
Q

3 risk factors for post partum urinary retention

A

Epidural
Prolonged second stage
Instrumental delivery

431
Q

Maternal death definition

A

Any death of a woman whilst pregnant or within 42 days after the end of pregnancy

Cardiac disease is the major cause, suicide is the main cause within a year after pregnancy

432
Q

Sheehan’s syndrome

A

Postpartum hypopituitarism

433
Q

When do post partum women require contraception

A

After 21 days

434
Q

Postpartum contraception

A

POP can start any time (use additional contraception for the first 2 days after day 21)

COCP is C/I if breastfeeding and should not be used in first 21 days due to VTE

Intrauterine device can be inserted within 48 hours of childbirth or after 4 weeks

Lactational amemorrhoea method is 98% effective (if amenorrhoeic and <6 months PP)

435
Q

12 week dating scan (4)

A

Heart beat to assess viability
Crown rump length to date the pregnancy
Number of foetuses
Nuchal translucency

436
Q

20 week anomaly scan

A

Detailed whole body scan to detect any abnormality
Assess nature of abnormality (viability)
Extent of abnormality (referral to specialist)
Assess placenta and location

437
Q

What is Tanner’s staging

A

Breast development and public hair growth stages 1-5

438
Q

Worst prognosis subtype of breast cancer

A

HER-2 positive

439
Q

Indications for surgical repair of prolapse

A

Symptomatic
Conservative measures have failed
Severe prolapse

440
Q

2 surgical options for treatment of prolapse

A

Scarospinus fixation
Sacrocolpopexy

441
Q

Risk factors for vaginal wall prolapse

A

Age
Obesity
Vaginal delivery
Chronic straining

442
Q

Prolapse grading system

A

Based on how far past the hymen

443
Q

Factors that shift the oxygen saturation curve

A

PH
Temperature
Co2
2,3-DPG

444
Q

Pregnancy ABG

A

compensated respiratory alkalosis

445
Q

Name 4 cardiovascular changes in pregnancy

A

Increased cardiac output (increased stroke volume + increased heart rate)
Decreased BP in early and middle
Peripheral vasodilation (flushing and hot sweats)
Increased plasma volume

446
Q

Name 2 respiratory changes in pregnancy

A

Increased tidal volume
Increased respiratory rate

447
Q

Name 4 renal changes in pregnancy

A

Increased blood flow to kidneys
Increased GFR
Increased aldosterone (Na+ and water retention)
Increased protein excretion

448
Q

3 haematological changes in pregnancy

A

Increased RBC production (higher iron, folate and B12 requirement)
High plasma volume (therefore Haemoglobin concentration and haematocrit fall, resulting in anaemia)
Increased clotting factors (fibrinogen, factor VII, VIII and X)

449
Q

Skin changes in pregnancy

A

Increased skin pigmentation (increased melanocyte stimulating hormone - linea nigra)
Striae gravidarum/stretch marks
Pruritus (may indicate obstetric cholestasis)
Spider naevi

450
Q

4 options for pain relief in labour

A

Simple analgesia (paracetamol, avoid NSAIDs)
Gas and air (entonox - NO and O2)
IM opioids (Pethidine or diamorphine)
Epidural (more likely to need instrumental)

451
Q

Definition of cervical ripening

A

Increased softening, distensibility, effacement and dilation of the cervix

Occurs prior to the onset of labour

452
Q

Breech presentation definition

A

Foetal buttock occupies the lower pole of the uterus

453
Q

Oncogenic types of HPV

454
Q

Inadequate smear test result management

A

Repeat in 3 months

455
Q

Contraceptives time until effective (if not first day period)

A

Instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS

456
Q

Lactation suppressing medication

A

Cabergoline (dopamine receptor agonist which inhibits prolactin)

457
Q

Contraception contraindicated where fibroids distort the uterine cavity

458
Q

FGM - record / report

A

Under 18: report to police
Over 18: record in notes

459
Q

Routine smear recall over the age of 50

A

Every 5 years

460
Q

Most common explanation for short episodes (<40 mins) of decreased variability on CTG

A

Sleeping foetus

461
Q

Causes of decreased variability on CTG

A

Maternal drugs (benzos, opioids, methyldopa)
Foetal acidosis (hypoxia)
Prematurity (<28 weeks)
Foetal tachycardia (>140)
Congenital heart abnormalities

462
Q

Investigations reduced fetal movements

A

1st: Handheld Doppler
* No fetal heartbeat: immediate ultrasound (AC, EFW, AFV)
* Fetal heartbeat: CTG for 20 minutes

If fetal movements have not yet been felt by 24 weeks, refer to maternal fetal unit

463
Q

Pregnant women with blood pressure ≥ 160/110 mmHg management

A

likely to be admitted and observed

464
Q

Vitamin D in pregnancy

A

NICE recommend ‘All women should be informed at the booking appointment about the importance for their own and their baby’s health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding’

465
Q

Management if NSAIDs/COCP have not controlled endometriosis symptoms

A

GnRH analogues

466
Q

Travel advice pregnancy

A

Avoid air travel:
> 37 weeks with singleton pregnancy + no risk factors
> 32 weeks with uncomplicated multiple pregnancy

467
Q

Most common identifiable cause of postcoital bleeding

A

Cervical ectropian

468
Q

PCOS investigations

A

Pelvic ultrasound
FSH
LH
Prolactin
TSH
Testosterone
Sex hormone-binding globulin

469
Q

Management of bleeding > 6 weeks gestation

A

Referral for assessment
TV ultrasound is the most important investigation

470
Q

Management of bleeding < 6 weeks with no pain

A

Expectant management and advice to repeat pregnancy test after 7-10 days and return if positive

471
Q

Medication associated with endometrial hyperplasia

A

tamoxifen (anti-oestrogenic effects on the breast but pro-oestrogenic effects on the endometrium)

472
Q

Streptococcus agalactiae

473
Q

Ruptured ovarian cyst presentation

A

Sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity
Tender lower abdomen
Ultrasound shows free fluid in the pelvic cavity

474
Q

4 or more / 3 or more risk factors for VTE in pregnancy

A

4 or more: immediate LMWH until 6 weeks postnatal
3 or more: LMWH from 28 weeks until 6 weeks postnatal

475
Q

Most common adverse effect of POP

A

Irregular vaginal bleeding

476
Q

Missed pills > 3 hours POP

A

Take missed pill as soon as possible and continue with the rest of the pack
Extra precautions for 48 hours

477
Q

Procedure for COCP before surgery

A

Stop the pill 4 weeks before and restart 2 weeks after

478
Q

Most common cause of recurrent 1st trimester miscarriages

A

Antiphospholipid syndrome

479
Q

Preferred contraceptive option for patients taking epileptic medication

A

Copper coil

480
Q

Drug to reverse respiratory depression caused by magnesium sulphate

A

Calcium gluconate

3a PTS - PM - ZTF (8 decks)

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