obs & gynae Flashcards

Question

examination findings in ectopic pregnancy

Answer 1

Examination findings * abdominal tenderness * cervical excitation (also known as cervical motion tenderness) - excrutiatting pain on bimanual * adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended

Answer 2

med = o Offer vaginal misoprostol (or oral preparation) surg = manual vacuum aspiration (NB  Vaginal or sublingual misoprostol if often used to ripen the cervix to facilitate cervical dilatation for suction insertion )

Answer 3

* Risk Factors: advanced maternal age, previous miscarriages, chronic conditions (e.g. uncontrolled diabetes), uterine or cervical anomalies, smoking, alcohol and illicit drug use, underweight or overweight

Answer 4

Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy

Answer 5

abdo pain amenorhhea vaginal bleeding - peritoneal bleeding --> shoulder tip pain - dizziness, fainting, syncope

Answer 6

expectant - make sure you do serial bHCG measures medical - IM methotrexate (if able to attend follow up) surgical - salpingectomy / salpingotomy

Answer 7

* Significant pain * Ruptured ectopic * Adnexal mass > 35 mm * Ectopic pregnancy with a foetal heartbeat visible on ultrasound scan * Serum β-HCG > 5000 iU/L

Answer 8

* No significant pain * Unruptured ectopic pregnancy with adnexal mass < 35 mm with no visible heartbeat * Serum β-hCG < 1500 iU/L * Not suitable if co-existing intrauterine pregnancy (confirmed by USS) * Able to return for follow up

Answer 9

This can only be done if: o Size < 35 mm o Unruptured o Asymptomatic o No foetal heartbeat o Serum hCG < 1000 IU/L (may consider 1000-1500) o Able to return for follow up o Compatible if there is another intrauterine pregnancy

Answer 10

1st line: Suction curettage for complete and partial* molar pregnancies molar pregnancies

Answer 11

Must be within 72hrs of UPSI (95% effective 0-24hrs, 84% effective 48-72hrs) * Class: progestogen * 1.5 mg single oral dose * Mechanism: Inhibits ovulation for next 5 days – less effective in late follicular phase (just before ovulation) * Safe and well tolerated (may cause slight menstrual cycle disturbance) Levonorgestrel * Can be used more than once in a menstrual cycle if needed * Warning: If vomiting occurs within 2 hours of dose, should be repeated

Answer 12

Must be within 120hrs of UPSI (95% effective) * Class: selective progesterone receptor modulator * 30 mg single oral dose * Mechanism: Delays ovulation until sperm no longer viable * Should NOT be used with levonorgestrel * If patient normally uses hormonal contraception, they should restart it 5 days after ulipristal (and use barrier contraception in the meantime. This is between 2-9 days depending on the type of contraception) * Caution if severe asthma * Can be used in more than one cycle if needed * Warning: If vomiting occurs within 3 hours of dose, should be repeated

Answer 13

Ideally within 120hrs of UPSI or within 5 days after the earliest estimated date of ovulation (99% effective) * Class: intrauterine contraceptive method * Most effective method of emergency contraception, only method effective after ovulation * Mechanism: Spermicide and prevents fertilisation and implantation * STI screening if at high risk of STI * May be left in for long-term contraception * Not known to be affected by BMI/weight or by other drugs

Answer 14

* Explain that Cu-IUD is most effective and most recommended. If a woman cannot have Cu-IUD (e.g. because of current STI) then explain why

Answer 15

* IMPORTANT: with all abortion patients, discuss the insertion of long-acting reversible contraception (e.g. copper IUD, LNG-IUS, Nexplanon) * IMPORTANT: 2 doctors need to sign a form agreeing to termination of pregnancy (they don’t both need to see the patient)

Answer 16

* Important: for women with a bodyweight > 70 kg or a BMI > 26 o EllaOne is the recommended method (continue oral contraception after 5 days) o Levonelle: if Levonelle is taken, give a double dose (3 mg) and the woman should start ongoing contraception immediately

Answer 17

Features * subfertility and infertility * menstrual disturbances: oligomenorrhoea and amenorrhoea * hirsutism, acne (due to hyperandrogenism) * obesity * acanthosis nigricans (due to insulin resistance)

Answer 18

* Diagnosis using Rotterdam Criteria for PCOS (at least 2 of the following) o Oligo/anovulation (> 2 years) o Clinical or biochemical features of hyperandrogenism o Polycystic ovaries on ultrasound (> 12 in one/both ovaries measuring 2-9 mm or ovarian volume > 10cm3)

Answer 19

1. lifetsyle advice (weight/ diet ) 2. COCP 3. treat hirsutism / androgenic sx if planning pregnancy 1. clomiphene 2. gonadotropins

Answer 20

medical= * 200 mcg Mifepristone (oral) followed 24-48 hours later by misoprostol (vaginal, buccal, or sublingual) surgical < 14 weeks vacuum aspiration 13- 24 weeeks - dilatation and evacuation (D&E) NB - misoprostol is used to ripen cervix

Answer 21

Primary amenorrhoea * gonadal dysgenesis (e.g. Turner's syndrome) - the most common causes * testicular feminisation * congenital malformations of the genital tract * functional hypothalamic amenorrhoea (e.g. secondary to anorexia) * congenital adrenal hyperplasia * imperforate hymen Secondary amenorrhoea (after excluding pregnancy) * hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise) * polycystic ovarian syndrome (PCOS) * hyperprolactinaemia * premature ovarian failure * thyrotoxicosis* * Sheehan's syndrome * Asherman's syndrome (intrauterine adhesions)

Answer 22

* Ovulation induction - clomiphene or FSH

Answer 23

* Look at early follicular phase FSH, LH and oestradiol levels (day 2-3) * Anti-Mullerian hormone (AMH) is helpful for assessing ovarian reserve o It is independent of the menstrual cycle o Produced by granulosa cells and does not change in response to gonadotrophins, so it is the most successful biomarker of ovarian reserve * Mid-luteal progesterone should also be measured to confirm ovulation * If irregular menstrual cycle: TFTs, prolactin and testosterone may also be useful

Answer 24

Ovarian hyperstimulation syndrome (OHSS) is a complication seen in some forms of infertility treatment. It is postulated that the presence of multiple luteinized cysts within the ovaries results in high levels of not only oestrogens and progesterone but also vasoactive substances such as vascular endothelial growth factor (VEGF). This results in increased membrane permeability and loss of fluid from the intravascular compartment Whilst it is rarely seen with clomifene therapy is more likely to be seen following gonadotropin or hCG treatment. Up to one third of women who are having IVF may experience a mild form of OHSS

Answer 25

Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH. Whilst BV is not a sexually transmitted infection it is seen almost exclusively in sexually active women. Features vaginal discharge: 'fishy', offensive asymptomatic in 50% Amsel's criteria for diagnosis of BV - 3 of the following 4 points should be present thin, white homogenous discharge clue cells on microscopy: stippled vaginal epithelial cells vaginal pH > 4.5 positive whiff test (addition of potassium hydroxide results in fishy odour) mx = asymptomatic = nothing sompotamic = oral metronidazole

Answer 26

Features * 'cottage cheese', non-offensive discharge * vulvitis: superficial dyspareunia, dysuria * itch * vulval erythema, fissuring, satellite lesions may be seen Investigations a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis mx pregnant = clotrimazole pessary or cream (local) non-pregnant= itraconazole 200 mg PO BD for 1 day or fluconazole 150 mg PO stat

Answer 27

Causative organisms * Chlamydia trachomatis * + the most common cause * Neisseria gonorrhoeae * Mycoplasma genitalium * Mycoplasma hominis Features * lower abdominal pain * fever * deep dyspareunia * dysuria and menstrual irregularities may occur * vaginal or cervical discharge * cervical excitation Investigation * a pregnancy test should be done to exclude an ectopic pregnancy * high vaginal swab * these are often negative * screen for Chlamydia and Gonorrhoea mx = * Outpatient Antibiotic Regimen o Ceftriaxone 1g IM (single dose), o Doxycycline 100 mg BD (oral) for 14 days, & o Metronidazole 400 mg BD (oral) for 14 days

Answer 28

Follow-Up * If managed as outpatients, should be seen within 72 hours to assess response * If no improvement, admit for IV antibiotics * Further follow-up at 2-4 weeks to: o Ensure resolution o Reiterate importance of STIs o Reassure that if compliant, fertility is not affected * Complications: o Infertility o Ectopic pregnancy o Chronic pelvic pain

Answer 29

There are two strains of the herpes simplex virus (HSV) in humans: HSV-1 and HSV-2. Whilst it was previously thought HSV-1 accounted for oral lesions (cold sores) and HSV-2 for genital herpes it is now known there is considerable overlap Features * painful genital ulceration * may be associated with dysuria and pruritus * the primary infection is often more severe than recurrent episodes * systemic features such as headache, fever and malaise are more common in primary episodes * tender inguinal lymphadenopathy * urinary retention may occur Investigations * nucleic acid amplification tests (NAAT) is the investigation of choice in genital herpes and are now considered superior to viral culture * HSV serology may be useful in certain situations such as recurrent genital ulceration of unknown cause Management * general measures include: * saline bathing * analgesia * topical anaesthetic agents e.g. lidocaine * oral aciclovir * some patients with frequent exacerbations may benefit from longer-term aciclovir

Answer 30

General lifestyle advice * Losing weight if BMI >30kg/m2 * Avoiding heavy lifting * Prevent/ treat constipation Medical * Pelvic floor exercises (16-week course) * Oestrogens – pill, patch, cream or implant (can help with symptom relief + if woman also has signs of vaginal atrophy) * Vaginal ring pessary (changed every 6 months) o Side-Effects: unpleasant discharge, irritation, UTI, interference with sex (sex is not possible with a shelf pessary) Surgical * No preference regarding preservation of uterus o Vaginal hysterectomy ± vaginal sacrospinous fixation (removal of the uterus ± stitching the top of the vagina to a ligament in the pelvis) o Vaginal sacrospinous hysteropexy (cervix is stitched to a ligament in the pelvis) o Manchester repair (shortening of the cervix to support the uterus) o Sacro-hysteropexy with mesh (mesh used to attach the uterus to sacral vertebra) * Preservation of uterus o Vaginal sacrospinous hysteropexy o Manchester repair (unless the woman wishes to have children in the future) * Vault prolapse o Vaginal sacrospinous fixation o Sacrocolpopexy (mesh used to attach the vagina to sacral vertebra) * Colpocleisis = only offered if the woman does not intend to have penetrative sex or they are at high surgical risk (the procedure involves closure of the vagina)

Answer 31

This patient is presenting with secondary amenorrhoea and infertility on a background of extensive gynaecological surgery. Asherman syndrome is characterised by the formation of intrauterine adhesions leading to amenorrhoea due to physical obstruction of the cervix or destruction of the endometrial lining. It typically occurs in patients who have had several gynaecological operations (e.g. caesarean section, myomectomy, dilatation, and evacuation). As it causes amenorrhoea by creating a mechanical obstruction, the hormone profile will be normal. It is diagnosed by hysteroscopy, during which adhesiolysis can be performed to help relieve symptoms. * Surgical breakdown of intrauterine adhesions (hysteroscopic adhesiolysis) + insertion of paediatric Foley catheter or intrauterine device for 4-8 weeks to prevent re-formation * 2 cycles of cyclical oral oestrogen and progesterone given after to aid endometrial proliferation

Answer 32

vaginal dryness, dyspareunia and occasional spotting. On examination, the vagina may appear pale and dry. Must exclude malignancy (endometrial cancer) * Vaginal lubricants before intercourse and regular moisturisers * Topical oestrogens and inform patient will be relieved after 3 weeks of treatment o Ring can be inserted into vaginal posterior fornix and changed every 3 months * Systemic HRT if co-existent menopausal Sx * Reconsider alternative Dx if continued treatment failure

Answer 33

* Asymptomatic (smaller) cyst = conservative approach with sitz bath/ warm compression * Symptomatic (larger) cyst = marsupialisation/ catheter drainage ± oral broad-spectrum antibiotics. May also be managed using surgical excision, silver nitrate cauterisation or sclerotherapy o Marsupialisation of the cyst = involves suturing the internal aspect of the cyst to the outside of the cyst to prevent the cyst from reforming o Catheter drainage = uses a Word catheter, which is in place for 4-6 weeks * Abscess = conservative management (sitz bath and analgesia) or incision and drainage may be required + broad spectrum antibiotics o May require marsupialisation or catheter insertion

Answer 34

chronic pelvic pain secondary dysmenorrhoea pain often starts days before bleeding deep dyspareunia subfertility non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements) on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen Investigation laparoscopy is the gold-standard investigation o Conservative: NSAIDs o Medical: COCP, LNG-IUS, GnRH agonsits (not suitable if trying to conceive) o Surgical: diagnostic laparoscopy and excision/ablation (can offer hysterectomy if completed family)

Answer 35

Features * may be asymptomatic * menorrhagia * lower abdominal pain: cramping pains, often during menstruation * bloating * urinary symptoms, e.g. frequency, may occur with larger fibroids * subfertility ix = TVUSS mx = Explain the management – in the context of their fertility plans * 1st line symptomatic: LNG-IUS o Other options: tranexamic acid, COCP o GnRH agonists may be used to reduce the size of the fibroid (usually only in the short-term prior to surgery) * Surgery: minimally invasive hysteroscopy, myomectomy, hysteroscopic endometrial ablation, hysterectomy * Interventional Radiology: uterine artery embolisation

Answer 36

1. conservative (stress , alchol , exercise etec) 2. COCP 3. SSRI if severe

Answer 37

* General advice o Shower vulval area with emollient (avoid using water only or soap), dab dry after o Avoid OTC, wet wipes, perfumed products, tight-fitting clothes, fabric softener, spermicide condoms o Liberal use of emollients o Antihistamine at bedtime to help if sleep affected * Manage underlying cause o Contact dermatitis – remove irritant exposure and use emollients as soap substitutes  1% hydrocortisone if mild  Betamethasone or clobetasol if severe/lichenified  Refer to dermatology if irritant removal has not resolved the condition o Lichen simplex – treat underlying sin condition  Potent topical corticosteroid betamethasone for 14 days  Emollient as soap substitute o Lichen sclerosus – see condition above o Unknown cause – emollient and mildly anxiolytic antihistamine hydroxyzine for symptomatic treatment  Consider 1% hydrocortisone  Refer to derm/gynae/vulval clinic AND use emollient + antihistamine while waiting if Sx persist * Refer to secondary care if symptom persist despite known cause + treatment/unclear cause/pre-malignant condition * Refer to specialist under 2 week wait if cancer suspected/lymphoma

Answer 38

increased vaginal discharge vaginal bleeding dyspareunia (pain during sex). Intercourse is a common cause of minor trauma to the ectropion, triggering episodes of postcoital bleeding. Examination of the cervix will reveal a well-demarcated border between the redder, velvety columnar epithelium extending from the os (opening), and the pale pink squamous epithelium of the ectocervix. This border is the transformation zone. Asymptomatic ectropion require no treatment. Ectropion will typically resolve as the patient gets older, stops the pill or is no longer pregnant. Having a cervical ectropion is not a contraindication to the combined contraceptive pill. Problematic bleeding is an indication for the treatment of cervical ectropion. Treatment involves cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy.

Answer 39

Features * Usually the sudden onset of deep-seated colicky abdominal pain. * Associated with vomiting and distress * fever may be seen in a minority (possibly secondary to adnexal necrosis) * Vaginal examination may reveal adnexial tenderness IX Ultrasound may show free fluid or a whirlpool sign (do a pregnancy test as well) Mx Laparoscopy is usually both diagnostic and therapeutic.

Answer 40

causes =including fibroids, adenomyosis, pelvic inflammatory disease, and polyps, however, often there is no identifiable cause ix = fbc to check for anaemia + other ix mx = 1. intrauterine system (Mirena) should be considered first-line 2. combined oral contraceptive pill 3. long-acting progestogens

Answer 41

Human papillomavirus (HPV), particularly serotypes 16,18 & 33 is by far the most important factor in the development of cervical cancer. Other risk factors include: * smoking * human immunodeficiency virus * early first intercourse, many sexual partners * high parity * lower socioeconomic status * combined oral contraceptive pill

Answer 42

Women are investigated first using a transvaginal ultrasound scan (TVUSS) to evaluate endometrial thickness. Those with an endometrial thickness of >5mm undergo endometrial biopsy as confirmatory diagnostic testing.

Answer 43

Unopposed oestrogen action: may be a result of both endogenous and exogenous oestrogen production. It results in the proliferation of the glandular endometrial cells, producing a greater gland:stroma ratio than is seen in normal endometrium. Factors include: * Polycystic ovary syndrome (PCOS) * Nulliparity * Early menarche and late menopause * Unopposed exogenous oestrogen action * Hormone replacement therapy * Tamoxifen therapy used in the management of breast cancer * Metabolic syndrome * Includes obesity and T2DM * Fat cells contain the enzyme aromatase which enables them to synthesise extra-ovarian oestrogen. * As well as this, anabolic insulin can stimulate the proliferation of endometrial cells via IGF-1 activation.

Answer 44

Clinical features are notoriously vague (can sometimes be similar to IBS symptoms but IBS won’t present at like 50 y/o- that’s your clue) * abdominal distension and bloating * abdominal and pelvic pain * urinary symptoms e.g. Urgency * early satiety * diarrhoea Ix * NICE recommend a CA125 test is done initially. Endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level * if the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered Dx * Diagnosis is difficult and usually involves diagnostic laparotomy Risk of malignancy index (RMI) can help to derive the risk of ovarian cancer. * RMI = U X M X Ca125 (>250 then referral to gynae) o M = menopausal status (1 – pre, 2 – post) o U = ultrasound score inc: multilocular cyst, solid areas, mets, ascites, bilateral lesions (0 - no features, 1 – 1 feature, 2 - ≥2 features) o Ca125 = units/ml

Answer 45

Summary * Localised disease: total abdominal hysterectomy with bilateral salpingo-oophorectomy * High risk patients may receive radiotherapy * Progestogen therapy is used in frail elderly women who are not suitable for surgery

Answer 46

* Down's syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency

Answer 47

The first trimester is from the start of pregnancy until 12 weeks gestation. The second trimester is from 13 weeks until 26 weeks gestation. The third trimester is from 27 weeks gestation until birth.

Answer 48

It is worth noting that fetal movements start from around 20 weeks gestation, and continue until birth.

Answer 49

Before 10 weeks Booking clinic Offer a baseline assessment and plan the pregnancy Between 10 and 13 + 6 Dating scan An accurate gestational age is calculated from the crown rump length (CRL), and multiple pregnancies are identified 16 weeks Antenatal appointment Discuss results and plan future appointments Between 18 and 20 + 6 Anomaly scan An ultrasound to identify any anomalies, such as heart conditions 25, 28, 31, 34, 36, 38, 40, 41 and 42 weeks Antenatal appointments Monitor the pregnancy and discuss future plans

Answer 50

* Subdivided into: o Latent phase  Begins with the onset of contractions and ends with 3-4cm cervical dilatation and full effacement o Active phase  Begins with 3-4cm cervical dilatation and ends with full (10cm) cervical dilatation  Normal progress = cervical dilatation of at least 1cm every 2 hours  Abnormal progress = cervical dilatation of <2cm in 4 hours

Answer 51

* Begins with full cervical dilatation (10cm) and ends with the birth of the baby * Subdivided into: o Passive phase  Begins with full dilatation until head reaches pelvic floor and ends with the onset of involuntary expulsive contractions o I.e. there is no maternal urge to push o Active phase  Begins with the onset of involuntary expulsive contractions and ends with the birth of the baby o I.e. there is maternal urge to push  Prolonged = lasting >2 hours in a nulliparous woman, or >1 hour in a multiparous woman (allow an extra hour if the woman has an epidural)

Answer 52

* Begins with the birth of the baby and ends with complete delivery of the placenta and membranes * Average duration = 5-10 mins * Management of the 3rd stage can be described as: o Physiological  Where the placenta is delivered by maternal effort  Associated with heavier bleeding  Prolonged = lasting >60mins o Active  Recommended to all women  Involves administering 10 iU oxytocin IM to the mother (with the birth of the anterior shoulder or immediately after delivery)  Controlled traction of umbilical cord after signs of separation of the placenta  Reduces incidence of PPH (from 15% → 5%)  Prolonged = lasting >30mins

Answer 53

 Prolonged = lasting >2 hours in a nulliparous woman, or >1 hour in a multiparous woman (allow an extra hour if the woman has an epidural)

Answer 54

< 37 weeks

Answer 55

Prelabour rupture of membranes (PROM): The amniotic sac has ruptured before the onset of labour. Preterm prelabour rupture of membranes (P‑PROM): The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm).

Answer 56

1. admit antenatal ward 2. IM betamethasone (fetal lung maturation) 3. tocolytics (nifidepine) - delay delivery 4. magnesium sulphate - for neural protection of neonate if birth within 24 hours (beware mag sulph tox can cause resp depression/arryhtmias) - calcium gluconate is antidote

Answer 57

o Beware: toxicity can result in respiratory depression and arrhythmias  Monitor for signs of toxicity every 4 hours (HR, BP, RR, deep tendon reflexes)  Antidote: 10ml 10% calcium gluconate over 10mins (and stop magnesium sulphate infusion)

Answer 58

1. admit 2. do not perform bimanual due to increased risk of infection 3. give oral erythromycin 4. IM betamethasone - fetal lung maturation 5. Offer IV magnesium sulphate (for neuroprotection of the neonate) if birth is expected within the next 24 hours

Answer 59

breech at <36 weeks, wait and re-scan at 36/40 at which point if foetus is still breech: * Offer external cephalic version (ECV) to all women – unless absolute contraindication o Performed at 36 weeks if nulliparous, or 37 weeks if multiparous

Answer 60

1. emergency buzzer 2. tell them stop pushing 3. external manouvre - mcroberts (thighs to abdo on back) +/- suprapubic pressure 4. consider episiotomy 5. internal manouevres (rubin II manouevre, wood screw manouevre, devlier posterior arm) 6. chnage position to all fours 7. 6. Third-line manoeuvres (foetal cleidotomy, maternal symphisiotomy or Zavanelli)

Answer 61

Summary: * Induction: o Membrane sweep to stimulate physiological prostaglandins for bishops < 6 o Vaginal PGE2 or Mechanical balloon for bishops > 6 o If still no ROM, then ARM (amniotomy - using amnihook) o After 2hrs of ARM, start IV Syntocinon bishops > 8 then likely to go into spontaneous labour

Answer 62

* Contraindications of VBAC: o RELATIVE:  ≥2 previous C-sections  Need for IOL  Previous labour outcome suggestive of cephalopelvic disproportion o ABSOLUTE:  Previous classical C-section  Previous uterine rupture  Other absolute contraindications to vaginal birth that apply irrespective of the presence or absence of a scar (e.g. placenta praevia)

Answer 63

When diagnosed: * Call for senior help, continue foetal monitoring with CTG, theatre for immediate delivery. * If the cord is out of introitus → avoid handling the cord (as this can cause cord vasospasm) o Keep warm and moist, but do not force it back inside * Prevent further cord compression by: o Elevating the presenting part (manually or by filling the urinary bladder) o Re-positioning mother into either:  All fours  Knee-to-chest position  Left lateral position (with head down) * Consider tocolysis while preparing for C-section if after attempts to prevent compression there are still foetal heart rate abnormalities, * ASAP delivery by quickest route possible – Emergency CS (recommended if vaginal delivery is not imminent) or expedited vaginal delivery.

Answer 64

blood loss of > 500 ml after a vaginal delivery and may be primary or secondary.

Answer 65

When uterine atony is the suspected cause, follow: * Massage the uterus to stimulate uterine contractions * Stepwise approach to pharmacological and surgical options: o Phamacological:  Step 1: 5iU oxytocin (syntocinon) slow IV infusion  Step 2: 0.5mg ergometrine/ syntometrine slow IV infusion or IM (contraindicated in HTN)  Step 3: Oxytocin IV infusion (40iU in 500ml isotonic crystalloids)  Step 4: IM Carboprost (contraindicated in asthmatics) o Surgical:  Step 5: intrauterine balloon tamponade i.e. Bakri balloon.  Step 6: other surgical measures (e.g. B lynch sutures, iliac artery ligation, uterine artery embolization IR, hysterectomy)

Answer 66

Lochia is vaginal discharge consisting of blood, mucus, and uterine tissue that occurs for up to 4–6 weeks following delivery. The bleeding is initially heavy, bright red, and may contact clots. Over a matter of weeks, it gradually becomes dark brown and lighter. The bleeding may become heavier when breastfeeding, as a neuroendocrine reflex arc stimulates the uterus to contract. This may be accompanied by crampy period-like pain. The patient should be reassured that this is a normal process, however, they should be discouraged from using tampons as this increases the risk of infection.

Answer 67

Minor PPH (500-1000 mL without shock) * Alert midwife in charge and first-line obstetric and anaesthetic staff * ABCDE approach o 1x IV access o Urgent bloods for: FBC, clotting (including fibrinogen), G&S (if not done previously) and cross-match 4 units o Commence warmed crystalloid infusion * HR, RR and BP every 15 mins Major PPH (>1000 mL) * Call for senior help and initiate major obstetric haemorrhage MOH protocol (obstetric consultant, anaesthetic team, haematologist and blood transfusion lab) * ABCDE approach o Position the patient flat o Keep patient warm o 2x large bore IV cannulae o Urgent bloods for: FBC, clotting, G&S (if not done previously) and cross-match 4 units, baseline U&E and LFTs o Transfuse blood as soon as possible o Until blood is available, infuse upto 3.5L of warmed clear fluids (initially 2L warmed crystalloid) * Continuous HR, BP and RR monitoring * Monitor temperature every 15minutes * Catheterise * If the placenta is undelivered → attempt removal by controlled cord traction * If the placenta is delivered → check for completeness (empty uterus and vagina of clots)

Answer 68

any hypertension before 20 weeks gestation (>140 / 90) * Antenatal o Conservative  Give advice regarding weigth management, exercise, healthy eating and salt intake. o Monitoring  BP monitoring (weekly if HTN poorly controlled, every 2-4 weeks if HTN well controlled)  Aim for BP <135/85 mmHg  Serial growth scans every 4 weeks from 28-36 weeks o Medical  Labetalol, nifedipine or methyldopa based on side effect profile as above.  Low-dose aspirin 75-150mg OD from 12 weeks gestation until birth (to prevent pre-eclampsia). * Intrapartum o As long as BP is <160/110, induction <37 weeks gestation should not be offered o If >160/110 mmHg, senior input and patient involvement is required * Postnatal o Monitoring  BP monitoring * Daily for the first 2 days after birth * At least once between day 3 and day 5 after birth * As clinically indicated if antihypertensive treatment is changed after birth  Aim to keep BP <140/90 mmHg  Arrange F/U at 2 weeks with GP or specialist for antihypertensive review.  If prescribed methyldopa intrapartum, stop within two days after birth and change to an alternative antihypertensive (due to risk of postnatal depression)

Answer 69

lamotrigine and carbamazepine is good sodium valproate is contraindicated also these patients should be on high dose folic acid

Answer 70

o 1st line = IM stat benzylpenicillin or doxycycline BD for 14 days. * Note: If the woman is not treated during pregnancy, treat the baby immediately after delivery

Answer 71

o 1st line = spiramycin (3-week course of 2-3g OD) which may reduce the risk of transmission to the foetus

Answer 72

summary = no tx * No prenatal treatment available * Refer to foetal medicine specialist for regular foetal surveillance o Foetal US examination every 2-4 weeks from diagnosis o ± Foetal MRI at 28-32 weeks gestation o Audiology + ophthalmology F/U * If there is evidence of foetal infection on US discuss the options: o Continuation of pregnancy with expectant management o TOP * Offer postnatal antiviral therapy for the baby (e.g. valganciclovir, ganciclovir) for 6 months and start within 4 weeks of life.

Answer 73

exposure non-immune women exposed to chickenpox (if there is doubt about immunity check maternal varicella antibodies): o If <20 weeks’ gestation, give VZIG immediately (only effective up to 10 days post-contact). o If >20 weeks’ gestation, give either VZIG or antivirals (acyclovir or valacyclovir) 7-14 days after exposure. rash * If ≥20 weeks’ gestation and presents within 24hrs onset of rash: o Prescribe oral acyclovir (800mg 5/day for 7 days). o If <20 weeks’ gestation, consider oral acyclovir “with caution”.

Answer 74

fetal medicine specialist

Answer 75

conservative mx

Answer 76

Antibiotics * 1st line = IV amoxicillin 2g every 6 hours for 14 days, as gram-positive bacilli. Prevention: avoid high-risk foods (unpasteurised milk, uncooked soft cheeses, pâté, undercooked food)

Answer 77

Refer to GUM clinic (to confirm or refute infection using PCR and to screen for other STIs) * If first episode of genital HSV: o Treat HSV infection with oral acyclovir (400mg TDS for 5 days) o If infection occurred in the 1st or 2nd trimester (until 27+6 weeks’ gestation):  Recommend daily suppressive oral acyclovir (400mg TDS) from 36 weeks’ gestation until delivery  Offer vaginal delivery o If infection occurred in the 3rd trimester (from 28 weeks’ gestation):  Prescribe oral acyclovir (400mg TDS) until delivery  Recommend delivery by elective C-section, particularly if infection within 6 weeks of delivery.  If the woman chooses vaginal delivery: * Recommend intrapartum IV acyclovir to the mother (and IV acyclovir to the neonate after birth) o Avoid artificial rupture of membranes and invasive procedures during labour if there are genital lesions * If recurrent episode of genital HSV: o 400mg TDS oral acyclovir from 36 weeks’ gestation until delivery o Episodes are usually self-limiting, and resolve in 7-10 days without treatment o Offer vaginal delivery o Avoid artificial rupture of membranes and invasive procedures during labour if there are genital lesions

Answer 78

* Intrapartum antibiotic prophylaxis o 1st line = IV benzylpenicillin 3g as soon after the onset of labour, and 1.5g 4-hourly thereafter until delivery o Alternatives if penicillin allergic:  If mild allergy = cephalosporin  If severe allergy = vancomycin o Note: antibiotics are not required if undergoing an elective C-section in the absence of labour and with intact membranes * Monitor newborn baby for the first 12 hours of life o If there is evidence of neonatal infection, treat with postnatal antibiotics o 1st line = IV penicillin and gentamicin

Answer 79

Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks) No proteinuria, no oedema

Answer 80

Antenatal * Consider admission to antenatal ward if severe hypertension (>160/110 mmHg) until BP is controlled * Monitoring o BP and urinalysis 1-2x/week until BP is controlled, thereafter weekly o Bloods (FBC, LFTs, U&Es) weekly o US foetal surveillance (growth, liquor, UA blood flow) every 2-4 weeks o PlGF-based testing on 1 occasion if suspicion of pre-eclampsia * Medical o Antihypertensives (1st line = labetalol, 2nd line = nifedipine, 3rd line = methyldopa) if blood pressure consistently >140/90 mmHg  Aim for BP <135/85 mmHg

Answer 81

Prevention * Measure BP and test urine for proteinuria at each antenatal appointment o If dipstick 1+ → use albumin:creatinine or protein:creatinine ratio to quantify proteinuria  30mg/mol threshold for protein:creatinine  8mg/mol threshold albumin:creatinine * Offer aspirin 75-150mg OD from 12 weeks gestation until delivery in women with 1 high-risk right factor or ≥2 moderate-risk risk factors: o High-risk risk factors:  Hypertensive disease in a previous pregnancy  Pre-existing maternal disease (chronic hypertension, renal disease, diabetes, autoimmune disease [SLE, antiphospholipid syndrome]) o Moderate-risk risk factors:  First pregnancy (primigravid)  Age >40 years  Pregnancy interval of >10 years  BMI >35 at booking visit  FH of pre-eclampsia  Multiple pregnancy o N.B. NICE states to consider more frequent BP measurements for women with any of the above risk factors

Answer 82

* Offer aspirin 75-150mg OD from 12 weeks gestation until delivery in women with 1 high-risk right factor or ≥2 moderate-risk risk factors: o High-risk risk factors:  Hypertensive disease in a previous pregnancy  Pre-existing maternal disease (chronic hypertension, renal disease, diabetes, autoimmune disease [SLE, antiphospholipid syndrome]) o Moderate-risk risk factors:  First pregnancy (primigravid)  Age >40 years  Pregnancy interval of >10 years  BMI >35 at booking visit  FH of pre-eclampsia  Multiple pregnancy

Answer 83

Definition; The current formal definition is as follows * new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following: * proteinuria * other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction

Answer 84

Eclampsia is a serious complication of pregnancy characterized by the onset of seizures or convulsions in a woman with preeclampsia 1. IV magnesium sulphate 2. labetalol 3. expedite delivery

Answer 85

Features * Potential consequences of pre-eclampsia * eclampsia other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata * fetal complications intrauterine growth retardation prematurity * liver involvement (elevated transaminases) * haemorrhage: placental abruption, intra-abdominal, intra-cerebral * cardiac failure Features of severe pre-eclampsia * hypertension: typically > 160/110 mmHg and proteinuria as above * proteinuria: dipstick ++/+++ * headache * visual disturbance * papilloedema * RUQ/epigastric pain * hyperreflexia * platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Answer 86

* fasting glucose is >= 5.6 mmol/L * 2-hour glucose is >= 7.8 mmol/L mx 1st line = diet and exercise if fasting glucose < 7 2nd line = metformin 3rd line = add insulin (if fasting glucose > 7 go straight for insulin, if fasting glucose 6-6.9 + macrosomia, hydramnios), offer insulin staright away )

Answer 87

defined by Hb <110g/l in 1st TM, <105g/l in 2nd/3rd TM , <100g/l postpartum mx =  Once Hb in normal range, continue oral iron for 3 months and until 6 weeks postpartum (to replenish iron stores) o Increased animal food in diet and advice  Iron – green leafy vegetables, nuts, beans, seeds  B12 – meat and dairy  Folate – green leafy vegetables, nuts, yeast, liver * Intrapartum o Advise to deliver in labour ward o IV access and group and screen on admission o Active management of 3rd stage o Active management of PPH o Consider prophylactic syntocinon infusion

Answer 88

1. conservative measures like clothing loose 2. topical emollients 3, ursodeoxycholic acid

Answer 89

Diagnosis digital vaginal examination should not be performed before an ultrasound as it may provoke a severe haemorrhage placenta praevia is often picked up on the routine 20 week abdominal ultrasound the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe

Answer 90

Placenta mediated growth restriction refers to conditions that affect the transfer of nutrients across the placenta: * Idiopathic * Pre-eclampsia * Maternal smoking * Maternal alcohol * Anaemia * Malnutrition * Infection * Maternal health conditions Non-placenta medicated growth restriction refers to pathology of the fetus, such as: * Genetic abnormalities * Structural abnormalities * Fetal infection * Errors of metabolism

Answer 91

* Symptomatic placenta praevia (with painless bleeding): o ABCDE approach  Gain IV access  Bloods (FBC, Rhesus status, cross-match, clotting screen)  Continuous foetal monitoring o Give anti-D immunoglobulin in Rh-negative women o Decide on delivery:  If mother is haemodynamically unstable or there is evidence of foetal distress * Emergency C-section (irrespective of gestation)  If mother is haemodynamically stable, with no evidence of foetal distress → * Give steroids and admit until bleeding has stopped (and for a further 48 hours for observation) * Re-scan at 36 weeks o If still low-lying/praevia → recommend elective C-section at 34-36 weeks gestation and a history of vaginal bleeding or other factors at risk of preterm delivery

Answer 92

* Definitions: (apply after 16 weeks) o Placenta praevia = placenta lies directly over the internal os o Low-lying placenta = placental edge lies <2 cm from the internal os

Answer 93

* Heavy bleeding leads to faintness and collapse, as may signs of shock. * Abdominal discomfort * Back pain

Answer 94

placental abruption

Answer 95

Kleihauer Test The Kleihauer test checks how much fetal blood has passed into the mother’s blood during a sensitisation event. This test is used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required. The Kleihauer test involves adding acid to a sample of the mother’s blood. Fetal haemoglobin is naturally more resistant to acid, so that they are protected against the acidosis that occurs around childbirth. Therefore, fetal haemoglobin persists in response to the added acid, while the mothers haemoglobin is destroyed. The number of cells still containing haemoglobin (the remaining fetal cells) can then be calculated.

Answer 96

Dichorionic-diamniotic twin Monochorionic-diamniotic twin

Answer 97

Amniotic fluid embolism (AFE) is an obstetric emergency that occurs when foetal antigens enter the maternal circulation exposure to foetal antigens during delivery triggers an inflammatory cascade that results in organ damage and activation of the coagulation cascade, resulting in disseminated intravascular coagulation (DIC). * ABCDE approach o Supportive management (largely in ITU)  Fluid resus  Inotropes  Correct coagulopathy (FFP, platelets, cryoprecipitate, transfuse etc)  Uterine atony  PPH management o No specific treatment available * If delivery hasn’t yet occurred: o Aim to stabilise the mother’s condition first o In a situation of peri-arrest → category 1 CS (with the aim to both save the foetus’ life and improve the effect of resuscitation on the mother) `

Answer 98

* ABCDE approach o Gain 2x IV access o Bloods (FBC, Rhesus status, cross-match and clotting screen) o Continuous foetal monitoring o Kleihauer test and anti-D if needed o Fluid, antifibrinolytics, blood, or blood-product replacement, as indicated * Give anti-D immunoglobulin in Rh-negative women * Decide on delivery: o Foetus alive <36 weeks and:  Foetal distress  emergency C-section  No foetal distress  observe closely, give steroids. No tocolysis, threshold to deliver depends on gestation o Foetus alive >36 weeks and:  Foetal distress  emergency C-section  No foetal distress  vaginal delivery may be trialled o Dead foetus  induce vaginal delivery

Answer 99

* For dichorionic-diamniotic and monochorionic-diamniotic twin pregnancies, vaginal delivery is possible provided the first twin is in a cephalic presentation * Advise to deliver in labour ward, with continuous CTG monitoring * If 'suspicious' or 'pathological' CTG, and vaginal birth cannot be achieved within 20 minutes, discuss caesarean section * Inform of small 4% risk of second twin requiring C-section * For monochorionic-monoamniotic twin pregnancies and triplet pregnancies, recommend delivery by elective C-section

Answer 100

* 5% pre-pregnancy weight loss * dehydration * electrolyte imbalance

Answer 101

1. promethazine 2. ondansetron

Answer 102

* miscarriage * ectopic pregnancy the most 'important' cause as missed ectopics can be potentially life-threatening * implantation bleeding a diagnosis of exclusion * miscellaneous conditions o cervical ectropion o vaginitis o trauma o polyps

Answer 103

Red’ degeneration describes the breakdown of myocytes secondary to ischaemia and is the most common form of fibroid degeneration. It most commonly presents in pregnancy, when fibroids tend to outgrow their blood supply owing to increased circulating oestrogen. Typical presentation is in the second trimester of pregnancy with acute pain and low-grade fever. Management during pregnancy consists of symptom management, and myomectomy can be performed after delivery.

Answer 104

Symptoms of SPD include pain in the pubic area, lower back, hips, and thighs, difficulty walking or standing, and a clicking or popping sensation in the pelvis. * discomfort and pain in the suprapubic or low back area, which may radiate to the upper thighs and the perineum * discomfort can vary from mild to severe pain * pain on walking, climbing stairs, turning in bed, standing on one leg or weight-bearing and rising from a chair. * clicking of the lower back, hip joints and sacroilliac joints when changing position Signs: * tenderness of the symphysis pubis and/or sacroiliac joint * pain on hip abduction * pain at symphysis when standing on one leg * waddling gait

Answer 105

C – Contractions – look for frequency, length and regularity of electrical activity (in labour aim for 4 contractions every 10 minutes; 4:10)

Answer 106

BRA – Baseline Rate – calculated as the average heart rate over a period of 5-10mins (normal = 110 – 160 bpm)

Answer 107

V – Variability – calculated as the heart rate variability over a period of 5-10mins, excluding decelerations and accelerations (normal = >5 bpm)

Answer 108

A – Accelerations – defined as a rise from baseline heart rate of at least 15bpm lasting at least 15 seconds (normal = >2 accelerations on a 20-30mins CTG trace) * Absent accelerations = foetal hypoxia

Answer 109

O – Overall – each feature can be described as ‘reassuring’, ‘non-reassuring’ or ‘abnormal’ and used to define the CTG overall as: normal, suspicious or abnormal Normal = no amber or red features Suspicious = any 1 feature is amber Pathological = any 1 feature is red, or 2 or more features are amber

Answer 110

D – Decelerations – defined as a fall from baseline heart rate of at least 15bpm lasting at least 15 seconds (normal = no decelerations) * Decelerations present = foetal hypoxia, umbilical cord compression * 3 types of decelerations: o Early – when deceleration occurs during a uterine contraction * Usually benign (uniform in depth, length and shape), due to a normal response to head compression during labour o Variable – where the time and shape of decelerations varies in relation to uterine contraction * Classically reflect cord compression o Late – when decelerations occur during contractions and persist after the end of the contraction * Always abnormal, suggestive of foetal hypoxia.

Answer 111

DR C BRAVADO define risk - why are they getting the CTG contractions - 4 every 10 mins normal baseline rate - 110-160 = normal accelerations - increase in 15bpm lasting 15 seconds variability - 5bpm change 5/10 min period decelerations - decrease in 15 bpm lasting 15 secs overall - – each feature can be described as ‘reassuring’, ‘non-reassuring’ or ‘abnormal’ and used to define the CTG overall as: normal, suspicious or abnormal

Answer 112

increased fetal urine production = maternal cardiac or renal disease maternal diabtes multiple pregnancy hydrops fetalis inability for fetus to swallow or absorb = neuro or muysclar absnormality duodenal atresia downs sx idiopathic = 30-50% cases

Answer 113

leakage of amniotic fluid = rupture of membranes reduced fetal urine output = post dates renal tract malformation intratuertine fgrwoth restriction other = pre eclampsia

Answer 114

rapid access clinic