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Progress test packs > Obs & Gynae > Flashcards

Obs & Gynae Flashcards

0
Q

Uterine causes of abnormal bleeding

A

Endometrial cancer (PMB)

Fibroid (menorrhagia)
Polyps

Endometriosis
Adenomyosis
(painful, cyclical)

PID
(discharge, pain +/- fever)

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1
Q

Causes of abnormal mestruation

A

Reproductive tract:

  • pregnancy related
  • uterine lesions
  • cervical lesions
  • iatrogenic

Systemic:

  • coagualopathy
  • hypothyroidism
  • cirrhosis

Dysfunctional uterine bleeding (DUB)

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2
Q

Cervical causes of abnormal bleeding

A

Generally present with PCB

  • erosion (aka ectropion)
  • trauma
  • cervicitis (more likely discharge)
  • polyp
  • cancer
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3
Q

Pregnancy related causes of abnormal bleeding

A

hCG is first line investigation of abnormal bleeding

Miscarriage (irregular, IMB)
- cramping pain

Ectopic (irregular, IMB)
- severe pain and tenderness

Gestational trophoblastic disease

Implantation bleeding (spotting)

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4
Q

Investigation of abnormal vaginal bleeding

A

Bloods

  • anaemia?
  • clotting probs?
  • TFT

Pregnancy test

VE

  • lower genital tract / cervical lesion?
  • swab

TV TA US

  • growth in uterus?
  • if > 4mm inc thickness do hysteroscopy and biopsy
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5
Q

Menorrhagia differentials

A

DFPTC

DUB (no organic pathology)
Fibroids
Polyp
Thyroid
Clot: von Willebrand's

(IMB: cancer, pregnancy, contracep; PCB: cervix; PMB: A.V., cancer; pain: endometriosis)

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6
Q

What to ask about in menorrhagia history

A 
Cycle pattern (duration of bleed)
Number towels/tampons used per day 
Other bleeding (IMB, PCB)
Impact on lifestyle 
Duration of problem 
Other symptoms, especially:
Dysparenunia 
Pain 
Bleeding from other sites 
Discharge
Thyroid sx
Obstetrics
Contraceptive history 
Smear
PGH (inc surgery)
Sexual history

Drugs
Smoking

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7
Q

Investigations menorrhagia

A

Abdominal and bimanual pelvic exam
FBC to assess need iron
TFT to see if hypothyroid
Consider clotting studies

If suspect cancer or fail to respond to treatment after 3 months:

  • TV TA US (more than 4mm growth)
  • endometrial biopsy with hysteroscopy if USS abnormal
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8
Q

Management of menorrhagia

A

No structural probs (or only small fibroids): medical

  • Marena IUD
  • COCP
  • Tranexamic acid
    • pro uterine haemostasis (antifibrinolytic)
  • Mefenamic acid (if pain)
    • nsaid (anti prostoglandin)

Structural problems present: Surgery

  • GnRH agonist prior to surgery (need ‘add back’ hormones if >6month)
  • ablation
  • embolisation (fibroid)
  • myomectomy (fibroid)
  • hysterectomy
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9
Q

Fibroids

intramural (70%), subserosal, submucosal

A 
Affect 20% by 40yrs - reproductive years
Mainly asymptomatic
Presentation
  - menorrhagia 
  - pelvic mass/bloating 
  - infertility
  - urinary Sx - frequency, retention
  - dystocia in labour
Red degeneration in pregnancy - pain fever vomiting
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10
Q

Management of fibroids

A

Surgery: hysterectomy, myomectomy, uterine artery embolisation

Medical: GnRH agonists

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11
Q

Treatment menorrhagia compatible w conception

A

Antifibrinolytics- eg tranexamic acid.
- CI thromboembolytic disease

NSAID (anti prostaglandins) - mefenamic acid.

  • helpful if dysmenorrhea also.
  • CI peptic ulcers

Both taken during bleeding

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12
Q

Treat menorrhagia with no poss of conception

A

Danazol

  • expensive and effective however
  • associated with androgenic side effects,
  • inhibits ovulation but unreliably so not lisenced as contraceptive

COCP
- effective, CI in some women

Mirena coil

  • very effective, reduce fibroid volume, similar satisfaction ratings to hysterectomy
  • SE: irregular menses for first 3-6 months after insertion

Surgical treatment- if family complete.

  • endometrial resection by laser, diathermy, ablation
  • embolisation of fibroid
  • hysterectomy
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13
Q

Primary amenorrhoea details

A

Absence of menstruation by 16 years
1-2%

Familial?

Hypothalamic dysfunction (stress, wt, exercise) 30%

  • low FSH
  • T: the Pill

Gonadal failure: Turner’s Syndrome (45 xo) 35%

  • high FSH
  • streak gonads (fibrous tissue instead of ovary)
  • no breast development
  • T: the Pill

Anatomical outflow obstruction

  • vaginal agenesis
  • imperforate hymen
  • transverse vaginal septum

Testicular feminization syndrome

  • 46 XY (genetically male) but insensitive to androgens
  • so male genitalia never develops (testes never descend)
  • female phenotype
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14
Q

Causes primary amenorrhoea

A

Familial late puberty

Hypothalamic
- stress, exercise, weight loss

Has she got normal external secondary sexual characteristics?
Are internal genitalia normal?

Turners syndrome
- Webbed neck, shield chest, short, cubitus valgus

Testicular feminization

Reproductive outflow tract disorders
- imperforate hymen

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15
Q

Causes secondary amenorrhoea

A

Pregnancy

Hypothalamic
- exercise, weight loss, stress,

Pituitary disorders

  • adenomas eg prolactinoma,
  • pituitary necrosis eg Sheehan’s syndrome (rare)

Ovarian causes

  • PCOS (US:cysts, high LH, low FSH)
  • tumours
  • ovarian failure (premature menopause)
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16
Q

Secondary amenorrhoea details

A

Absence of menstruation for >6months after prev regular cycles

Pregnancy

Hypothalamic 35%

  • stress, weight, exercise
  • treat with the Pill to increase oestrogen

PCOS 30%

  • low FSH, high LH
  • assoc w obesity, hirsuitism, acne, infertility
  • treat with the Pill to increase suppress LH, raise oestrogen

—–with these two causes you get withdrawal bleed after a week of progestin, showing normal uterine lining (unless severe hypothalamic dysfunction)

Pituitary disease

  • tumour or apoplexy causing low Gn’s
  • prolactin (macroadenoma)
  • Sheehan’s

Premature ovarian failure (like menopause)

  • FSH levels high
  • HRT
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17
Q

Secondary amenorrhoea - history

A

Full menstrual history

  • menarche
  • normal cycle, previous probs

Could you be pregnant?

  • sexually active?
  • contraception (progesterone can cause amenorrhea)

Noticed weight loss or gain?
- intentional?

Tumour symptoms (galactorrhoe, headache)

PCOS symptoms
- hair growth, acne, weight gain

Stress, emotional issues

Rest of gynae history

  • family history of gynae probs
  • prev gynae history
  • smear
  • obstetric
  • drugs
  • smoking
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18
Q

Amenorrhoea investigations

A

Pregnancy test
Serum LH + testosterone (increased in PCOS)
FSH (very high in premature menopause)
Prolactin (increased by stress, prolactinomas, some drugs)

can give progesterone withdrawal test if further investigation required

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19
Q

Causes dysmenorrhoea and pelvic pain

Primary
Endometriosis/adenomyosis
Fibroids (menorr)
PID
Ovarian disease
A

Primary painful periods

  • no organic pathology
  • excessive prostaglandins > painful uterine contractions
  • ‘pelvic congestion’
  • manage in primary care - mefenemic acid

Not settled? > Secondary

US may show:

  • fibroids
  • adenomyosis
  • ovarian cyst

Infection screen
- PID

Finally, laparoscopy may be needed to find
- endometriosis

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20
Q

Treatment dysmenorrhoea

A

NSAIDs- mefenamic acid, naproxen, ibuprofen (vs prostaglandin synthesis)
COCP
Mirena coil

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21
Q

Ovarian cyst and torsion presentation

A

intermittent, unilateral dull ache
w/ intercourse

torsion:
sudden unilateral lower abdo pain
may be brought on by exercise
w/ nausea and vom

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22
Q

ovarian cyst types

A

physiological cysts - common in reprod age

  • follicular (common)
  • corpus luteum

benign tumours

germ line - dermoid cyst = teratoma
- common under 30 yrs

epithelial - serous or mucinous cystadenoma

stromal - fibroma
(Meigs = fibroma + ascites + pl eff)

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23
Q

Causes postcoital bleeding

A

Cervical

  • trauma
  • polyps
  • carcinoma
  • cervicitis (w discharge)
  • erosion

Vaginal cancer/infection

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24
Q

Features of polycystic ovarian syndrome (PCOS)

A
  • Hypo-androgenism, oligo-ovulation, polycystic ovaries
  • Acne, hirsutism, obesity >40% clinically obese
  • Acanthosis nigricans (darkened skin on neck, skin flexures)
  • Oligomenorrhoea/amenorrhoea -from anovulation
    Subfertility (75% difficulty conceiving)
    Recurrent miscarriage
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25
Q

Long term risks PCOS

A

Ovarian and endometrial cancer risk
- unopposed oestrogen

Diabetes, especially if also obese

MI, stroke, IHD
Hypertension

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26
Q

Diagnosis PCOS

A 
Diagnosis of exclusion 
Usually have increased LH:FSH 
Increased testosterone 
Increased fasting insulin 
5 or more ovarian follicles on USS
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27
Q

Treatment PCOS

A

Detect + treat diabetes, hypertension, hyperlipidaemia
Encourage weight loss + exercise

Clomifene if trying to conceive (induces ovulation)

Combined pill if not trying to conceive- will control bleeding + reduce risk of unopposed oestrogen on endometrium (risk endometrial carcinoma)

Treat hirsutism with cyproterone acetate (androgen receptor antagonist)- in Dianette COCP

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28
Q

Causes postmenopausal bleeding

A 
Endometrial carcinoma (PMB is endometrial carcinoma until proven otherwise) 
- unopposed estrogen?

Endometrial hyperplasia, or polyps

Cervical malignancy
- esp post- coital

Atrophic vaginitis

  • spotting
  • assoc w dryness, dyspareunia
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29
Q

Investigations postmenopausal bleeding

A

Full Hx, pelvic exam, cervical smear

USS- if endometrial thickness <3mm endometrial carcinoma risk is low

if >3mm (or 5mm if on HRT) – endometrial biopsy with/without hysteroscopy

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30
Q

Endometrial cancer presentation

A

Generally post menopausal women (75%, with 20% between 40yrs and menopause)

PMB (= endometrial cancer until proved otherwise)
- initially slight, infrequent

75% present at stage one - confined to uterus

Pain/discomfort is late feature

Premenopausal women get IMB or irregular periods

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31
Q

Endometrial cancer risk factors

A

Nulliparous/low parity
Late menopause
(COCP is protective)

FH - ovarian/breast/colon

Diabetes
PCOS
Obesity

Endometrial hyperplasia

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32
Q

Endometrial cancer prognosis

A

If confined to uterus (stage 1) = 80% 5 year survival

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33
Q

Endometrial hyperplasia

A

Due to prolonged unopposed oestrogen stimulation
With or without ‘cytological atypia’
- without is benign, with has 20% risk of progression

Presentation: abnormal uterine bleeding (esp PMB)

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34
Q

Bacterial vaginosis

A

Non puritic
Fishy white/grey vaginal discharge - homogenous
Discharge will raise ph of vagina >4.5
Clue cells

If pregnant - risk of prem labour/miscarriage

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35
Q

Treatment bacterial vaginosis

A

Metronidazole 400mg bd 7 days

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36
Q

Candidiasis

A

Intense puritis
Vulvovaginal erythema
Non smelly thick ‘cottage cheese’ like discharge
pH<4.5

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37
Q

Treatment candidiasis

A

Topical clotrimazole or oral fluconazole

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38
Q

Trichomoniasis

A

Protozoan infection - seen on wet film (not hvs)
Std
Profuse smelly discharge - green/yellow
May get post coital bleeding
Strawberry cervix (red petechiae), erythema
pH>4.5

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39
Q

Treatment trichimoiasis

A

Metronidazole 400bd 7days

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40
Q

Gonorrhoea

A

Profuse odourless creamy discharge
Non irritating
diplococcus

Can progress to acute salpingitis or disseminated infection - fever, pelvic pain..

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41
Q

Treatment gonorrhoea

A

Ceftriaxone 500mg im and 1g azithro

Or cefixime 400mg po and 1g azithro

(Single doses)

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42
Q

Chlamydia

A 
Most common std
Often asymptomatic 
Purulent mucoid discharge 
Pcb
Vaginitis

In pregnancy - risk of neonatal conjunctivitis
Diag - endocervical swab

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43
Q

Treatment chlamydia

A

Oral doxycycline 100mg bd 7 days

or azithromycin 1g (single dose)

partner notification last 6 months (treat then test)
-unless symptomatic man: last 4 weeks

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44
Q

Genital warts

A

Caused by hpv (usually 6, 11)

Warts may be dotted about or confluent

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45
Q

Treatment genital warts

A

Cryotherapy

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46
Q

Syphilis

A

Systemic disease

Painless solitary genital ulcer plus rash

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47
Q

Treatment syphilis

A

IM benzathine penicillin

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48
Q

Genital herpes

A

Herpes simplex virus type 1 or 2 (most type 2)
Genital ulcers
Burning pain and puritis
Latent and active phases

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49
Q

Treatment genital herpes

A

Acyclovir

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50
Q

STI counselling

A

Ask about sexual partners - need to contact

Talk about risk of PID and long term sequelae
Risk of TOA (tubuloovarian abcess)

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51
Q

Unopposed oestrogen

A

Obesity
- due to conversion of androgens

Tamoxifen
- has oestrogenic effect on uterus

PCOS

Oestrogen HRT (without progestins)

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52
Q

Uterine sarcoma

A

5% of uterine cancers

Rare, aggressive

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53
Q

Cervical cancer: risk & epidemiology

A

Sexually active women
Mean age 52 years
Higher risk: early first coitus, numerous partners.
HPV is causative agent in majority of cases (16,18,39)
SMOKING

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54
Q

Cervical cancer screening

A

25 to 49 (every 3 years)

50 to 64 (every 5 years)

Look for dyskaryosis or CIN (abnormal cells)
Refer for colposcopy +/- biopsy

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55
Q

HPV and cervical cancer

A

Look out for symptoms
- irreg bleeding (especially post coital), pain, discomfort

Prevention: 2 measures

  • vaccinate vs HPV (6,11,16,18)
  • screen all women from 25 (earlier too many false positives)
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56
Q

Cervical intraepithelial neoplasia - CIN

A 
Precursor to cancer
Starts at transitional zone
Detected on Pap smear film
Stage 1 - 3
Refer for colposcopy and biopsy
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57
Q

CIN treatment

A

BORDELINE

  • repeat smear in 6 months
  • or test sample for hpv 16,18,39

DYSKARIOSIS
Loop electrosurgical excision procedure (LEEP)
- removes affected tissue
Cryotherapy/ ablation may also be used to destroy lesion

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58
Q

Cervical cancer stages

A

1: Confined to cervix
Treatment: biopsy/excision, simple hysterectomy

2: surrounding
T: radical hysterect

3: further local inv to lower vag/pelvis
T: chemoradio

4: bladder, rectum, mets
Palliative

59
Q

Ovarian cancer: risk and protective factors

A

Mean age 60

Risk:

  • FAMILY HISTORY
  • low parity

Protective:

  • multiparous
  • breast feeding
  • COCP
60
Q

Presentation of ovarian cancer

A

75% present late (stages 3/4)
- already peritoneal spread
Highest mortality for gynae-oncology

Abdominal distension ‘bloating’
Feeling full/ loss of appetite
Urinary symptoms

Ascites or mass on examination

Do serum CA125 levels
Do TV TA US

61
Q

Hereditary link in ovarian cancer

A

5-10% have hereditary link

If 2 relatives (1st or 2nd degree) have had ovarian cancer or pre-menopausal breast cancer: REFER for genetic counselling

Associated with BRCA 1 and BRCA 2 mutations

Offer prophylactic BSO (at 35 or once family finished)
- reduces risk of both ovarian and breast ca

62
Q

Management of ovarian cancer

A

Surgery

  • TAH, BSO
  • exploratory laparotomy
  • peritoneal wash/biopsy
  • lymph nodes
  • omentectomy

Chemo: Carboplatin

Surveillance: CA125

80% relapse: second chemo or palliation

63
Q

Vulval cancer

A

5% of gynae cancers
Mean age 65
Risk: poor personal hygiene

Present: pruritis, lump, 70% labia major
Refer for biopsy

Can also get VIN (precancerous), melanoma and pagets disease

64
Q

Vaginal cancer

A

Very rare as primary
Secondary to cervical is most common form
Radiotherapy

65
Q

Gestational trophoblastic disease

A

Hydatidiform moles

  • complete
  • partial

Gestational trophoblastic neoplasia

  • choriocarcinoma
  • placental-site trophoblastic tumour
66
Q

Hydatidiform moles

A

“Abnormal form of pregnancy, with implantation of non-viable fertilised egg, resulting in growth of a mass from the placenta which may or may not contain fetal tissue”

Risk

  • maternal age > 35
  • prior GTD
  • long term Pill
67
Q

Partial vs complete hydatidiform moles

A

Partial

  • growth contain malformed fetal tissue
  • leads to missed abortion by 10-15 weeks - needs evacuation
  • hCG normal or marginally raised

Complete (more common)

  • from fertilized ovum containing no DNA
  • no fetal tissue (just grape-like vesicles)
  • presents with abnormal bleeding
  • may get anaemia, hyperemesis, preeclampsia (irritable, htn, dizzy)
  • hCG++, enlarged uterus
68
Q

Hydatidiform mole mx

A

FBC - anaemia?
Clotting - look out for DIC
CXR - look out for trophoblastic emboli

Cross match blood

Under GA - evacuate by dilation, suction & curettage (w oxytocin vs blood loss)
Anti D if needed

Then monitor hcg for up to 2 years to ensure return to norm

69
Q

Emergency contraception

A

Levonorgestrel pill within 72 hours

Or IUD within 5 days
- still 99.9% effective

Follow up in 3 weeks

70
Q

COCP

A

Take on first day of cycle: 3 weeks active, 1 week placebo (or no pill) - bleed
Can back-to-back to control timing of bleed

If miss a day, take when remember
If miss 2+ days - use condoms for 7 days
- use condoms anyway vs STI

Prevents ovulation, thin lining, thicken mucus

Pros

  • over 99% effective
  • protect vs colon, ovarian, endometrial cancer
  • help vs painful, heavy periods
  • can help vs acne
71
Q

Pill contraindications

A

Breast feeding (or 6 weeks postpartum)

FH or PH breast cancer, VTE, migraine

Smoker over 40

72
Q

Pill pros and cons

A

Cons

  • compliance
  • contraindications

Pros

  • safe effective
  • acne
  • periods
  • cancer
73
Q

vs COCP

A

Pros

  • over 99% effective
  • protect vs colon, ovarian, endometrial cancer
  • help vs painful, heavy periods
  • can help vs acne

Cons
- must take daily
- breast cancer risk (and cervical)
- SE: headaches, mood, breast tender, nausea
(can change type of pill for less oestrogenic effects)
- HTN

Contraindications

  • breast feeding
  • migraine w aura
  • thromboembolic disease (stroke/ihd)
  • FH breast cancer
  • smoker over 35 (compounds arterial risk)
  • htn
74
Q

“Mini Pill”

cerazette

A

Progesterone only
Creates mucus plug in cervix
Less effective than COCP (still around 99%)

Take at same time each day (or within 12hr window). No break for bleed.
If miss 12hour window use condoms for 48hrs

Use if COCP doesn’t suit or is contraindicated

Commonly periods can be irregular/unpredictable - spotting (1/3 none/light, 1/3 same, 1/3 heavier)

Also breast tenderness, libido change, acne

75
Q

Implant

A

Subdermal implant
3 (implanon) or 5 years (norplant)
Prevents ovulation

One of most effective

Irregular or no periods
Uncomfortable removal
Delay in return to normal

76
Q

Mini pill pros and cons

A

Pros
- no contraindications

Cons

  • compliance
  • irregular bleeding
  • breast tender, acne, mood
77
Q

Depo-injection

A

IM injection every 12weeks
Slow release progesterone
Prevents ovulation

One of most effective

Irregular vaginal bleeding (1/3)
Amenorrhoea (1/3)
Osteoporotic link - avoid if pre-existing, and in adolescents
SE: Weight gain, reduced libido

Can take a while (up to 12 months) to return to normal cycle

78
Q

Injections or implants pros and cons

A

Pros

  • v v effective
  • compliance easy

Cons

  • irregular bleeding
  • delay in return to normal fertility
79
Q

Condoms

A

93% effective

Protect vs STI’s

80
Q

Mirena IUD

A

Long term but reversible
Hormone release in uterus - vs implantation

Risk of infection, perforation
- swabs before

Helps vs heavy, painful periods

81
Q

Mirena pros and cons

A

Pros

  • extremely effective
  • long term easy compliance
  • periods
  • no delay to fertility

Cons

  • small procedural risk - swabs before
  • ectopic (tiny)
82
Q

Intra-uterine coil

A

5 or 10 years
Prevents fertilisation and implantation

Reversible - can remove at any point

Risk of introducing infection to uterus
Risk of perforation

Can get heavy, painful periods

83
Q

Sterilisation

A

Consider as irreversible
- must have finished family

Male more effective than female

Vasectomy - takes up to 12 to be fully effective - need two consecutive blank samples

84
Q

Sterilisation

A

Female

  • surgery - laparoscopy
  • ectopic
  • less effective than mirena

Male

  • very effective
  • day case
  • risk pain, swelling, infection
  • 12 weeks to work - take semen samples
85
Q

Infertility

A

Sperm (25% - 40%)

Tubules - PID, surgery
Endometriosis

Amen causes

  • hypothal
  • pcos
  • ov fail (early menop)
  • pituitary

Cause often unknown

86
Q

Common minor problems to expect in pregnancy

A 
70% get morning sickness
Reflux
Urinary frequency
Lower back pain
Candida vaginalis
Constipation
87
Q

Haematological changes in pregnancy

A

Plasma volume up 40%
No. of RBC’s up 20% (more if take iron supplement)
But overall, HCT falls (haemodilution)
Increase in clotting

88
Q

CV and respiratory changes in pregnancy

A

CO up 40%
BP falls initially then returns to normal later
Increase in tidal volume

89
Q

Renal changes in pregnancy

A

50% increase GFR
Decrease in serum creatinine/urea
Glycosuria common (does not mean diabetes)

90
Q

Insulin in pregnancy

A

Insulin resistance due to placental hormones

Should increase production to prevent hyperglycaemia

91
Q

Antenatal counselling

A

Any concerns?
Obstetric Hx
Health probs and FH
Smoking and drinking

Early advice

  • folic acid
  • lifestyle - smoking and drinking
  • Vit D
  • avoid certain foods
Appointments
 < 10 Hb variants
8-12 
- HIV, hep B (transmit)
- syphillis, rubella (disable)
- rh and blood group
10-14 and 16 Down's screening
18-20 Fetal anomaly
92
Q

Nutrition in pregnancy

A 
Avoid uncooked meat/fish/eggs - toxoplasmosis (also cat litter)
Avoid soft cheese - listeria
Avoid alcohol (no clear safe level)
Supplements - folic acid, Vit D, iron(?)
93
Q

Folic acid

A

All should take 400 micrograms daily when trying to conceive and up to 12 weeks.
Higher dose of 5mg if diabetic, coeliac, obese, previous neural tube defects

94
Q

Alcohol in pregnancy

A 
Developmental delay
Behaviour problems
Growth retardation
Learning difficulties
Facies
95
Q

Smoking in pregnancy

A

Small baby
- infection and trauma

Miscarriage
Still birth
SIDS

Respiratory probs eg. Asthma

96
Q

Problems with diabetes in pregnancy

A

Mum

  • HTN/preeclampsia
  • UTI
  • future DM

MISCARRIAGE
Risk of deformities - detailed scan

Big baby/sac

  • preterm
  • difficult labour

Neonatal

  • hypoglycaemia
  • RDS
97
Q

Assessment of miscarriage

A

LMP, normal cycle, other bleeds

Amount of bleeding

  • heavy suggests incomplete
  • minimal brown loss - missed?

Pain

  • minimal pain in threatened
  • severe pain, preceding bleed more chac of ectopic
  • shoulder tip pain? Ectopic

Examine

  • cv status - shock?
  • abdo exam (v tender in ectopic)
  • VE: cervical excitation? Cervix open?
98
Q

Causes of bleed in early pregnancy

A

Ectopic
Miscarriage
Lower genital tract lesion
Implantation bleed

99
Q

Types of miscarriage

Nb pain precedes bleeding - ectopic more likely

A

Threatened

  • bleeding but cervix close and poc remain
  • 25% progress to inevitable

Inevitable

  • dilated cervix
  • considerable bleeding
  • abdo pain
  • passed products (complete or incomplete)

Incomplete

  • some products retained despite inevitable miscarriage
  • need evacuation
  • US shows whether products retained

Missed (later on than threatened)

  • fetal death but remains in utero
  • no/little bleeding
  • closed cervix
  • small uterus for age
  • fetal heart/movements absent
100
Q

Complications of miscarriage

A

Bleed
Infection
Psycho

Rhesus sensitivity

101
Q

Miscarriage management

A

US
Pregnancy test

90% have surgical evacuation for retained products
- prevent risk of infection and continued bleeding

Expectant management can be considered

  • esp with incomplete
  • should have 24 hour access
  • follow up scan (2 weeks)

Medical miscarriage

  • misoprostol and mifepristone
  • inc pain and bleeding

Surgical

  • STI swab first
  • suction curettage
102
Q

Causes of antenatal haemorrhage (post 24 weeks)

A 
Lower genital tract lesion (polyps/erosion)
Early labour
Placenta previa (20%)
Placental abruption (30%)
Vasa previa (rare)
103
Q

Ectopic

A

Period of ammenorhea (often about 6 weeks)
Onset of pain and bleeding
+/- vomitting

O/e

  • lower abdo tender, peritonism?
  • adenexa tender (+ mass?),
  • cervical excitation
  • -> check bp stable

Serial hcg measures
- raised but not doubling within 48hrs (as in norm preg)
TV TA US
- locate mass?
- up to half cannot = preg of unknown location

Mx laparotomy
Anti d if rh negative

Risk: pid, prev ectopic, prev abortion, tubal surgery
Consequences - red fertility

104
Q

Complications of diabetes in pregnancy

A

Maternal HTN/preeclampsia (mainly assoc w/ pre gestational diabetes)
- risk of having sustained diabetes

Fetal - macrosomia (injury/caesarean)

     - congenital abnormalities 2-3 x risk (esp cardiac, cns, skeletal)
     - spontaneous abortion
     - premature delivery
     - neonatal hypoglycaemia
106
Q

Gestational diabetes

A

screening if

  • obese
  • prev big baby
  • prev gdm, fh dm
  • ethnic - black/asian

Ix: ogtt around 24 weeks
(earlier if prev gdm 16w)

management

  • diet and exercise sufficient
  • metformin if nec
  • check bp and proteinuria closely
  • check BM 6 weeks post partum
106
Q

Diagnosis of gestational diabetes

A

24-28 weeks
Fasting glucose > 7mmol/L
Glucose tolerance test >11.1mmol/L

107
Q

Management of diabetes in pregnancy

A

Preconception

  • folic acid 5mg
  • tight control
  • eyes and kidney checks
DISH
Non-drug - weight, diet, exercise
Insulin (metformin also allowed)
Regular blood glucose monitoring 
- plus antenatal monitoring of renal function and retinopathy
Glucagon for hypos - may be masked

Detailed anomaly scan around 18 weeks

Offer caesarean/induction at 38 weeks
Sliding scale and dextrose intrapartum
Feed baby asap (and do BM)
Follow up

108
Q

GDM screening

A

Obese
Previous macrosomic baby or GDM
FH DM
Ethnicity

24-28 weeks OGTT

OGTT > 11.1
Random > 7
New onset

109
Q

Diagnosis of pre-eclampsia

A

After 20 weeks
New onset HTN (>140/90)
New proteinuria (>300mg over 24hrs)
+/- non-dependant oedema (hand/face swelling)

Presentation

  • headache
  • alter vision
  • peripheral oedema
110
Q

Management of pre-eclampsia

A

Prophylactic Aspirin if high risk
Monitor BP, proteinuria regularly

1) BP control
- labetalol
- ! avoid ACE-i and diuretics

2) Delivery
- If mild wait, expectant management (ie wait until 35 weeks)
- If any ‘severe’ symptoms deliver baby asap (generally caesarean)

111
Q

Management of eclampsia

A 
Magnesium Sulphate (monitor for toxicity - resp rate, reflexes)
Treat concurrent HTN
112
Q

Features of ‘severe’ pre-eclampsia

A 
Headache / blurred vision 
RUQ pain
BP > 160/110
HELLP
Pulmonary oedema
Seizures (eclampsia)
IUGR (fetus)
113
Q

Strong risk factors for pre-eclampsia

A 
HTN in previous pregnancy
Chronic kidney disease
Autoimmune disease (SLE, antiphospholipid syndrome etc)
Diabetes (1 or 2)
Chronic HTN
---> offer low dose aspirin to prevent
mod:
Nulliparous
African
Young or old
First time/short time with partner
Family history
114
Q

Serious complications of pre-eclampsia

A 
Eclampsia + cerebral haemorrhage
HELLP
DIC
Placental abruption (with severe haemorrhage due to thrombocytopenia)
Still birth
115
Q

Miscarriage

A

Fetal loss before 24 weeks (majority before 13)
10 - 20 % of pregnancies affected
Majority not known about - within 2 weeks

Bleeding (heavier more clots than normal menses)
Cramping pain

116
Q

Placenta previa

A

Painless bleed soft uterus

1-4 stages (proximity/occlusion of os)

Do not examine

US

Admit from 34 weeks
Deliver by caesarean from 37
Risk of PPH

117
Q

Placenta previa

A

Painless vaginal bleeding
Soft, non-tender uterus

Major: complete, partial
Minor: marginal, low-lying

If seen on US in early preg, 90% resolve by 32 weeks

118
Q

Placental abruption

A

Separation of placenta from uterine wall
80% revealed 20% concealed

Abdominal pain (+/- back ache)
Uterine hardness and tenderness
Vaginal bleeding
Fetal distress

119
Q

Risk factors for placenta previa

A

Multiparous/older mum
Smoking
Previous previa
Previous caesarean

120
Q

Management of placenta previa

A

If suspected (painless bleed) do not do VE unless excluded by US
If confirmed, monitor up to 34 weeks then admit
Mostly deliver by caesarean at 38 weeks
Earlier delivery if fetal distress or major hemorrhage
Need cross matched blood - high risk of PPH

121
Q

Abruption

A

Pain bleed hard tender uterus
Fetal distress

Mx - stabilise w blood

Baby - US and deliver

Risk: HTN, smoke, coke, trauma
- anomaly, old, multp,previous

122
Q

Breech

A

3-4%

Frank (bum first legs by ears)
complete (cross legged)
footling

US

Risk

  • prem, previous, pp, polyhyd.
  • multiparous, multiple preg
  • abnormal uterus, fetus

Complications

  • prem
  • cord prolapse
  • fetal and maternal injury
123
Q

Breech management

A

37 weeks exteral cephalic version
- w epidural, tocolytic, US fetal monitoring

Diff if twins, fibroids

Risk membranes>labour,
- abruption, fetal distress

50-70% success

Or delivery by caesarean

124
Q

PPH

A

Atonic

  • risk twins, macro, poly
  • prevented by giving oxytocin injection

Coagualopathy

Accreta

Retained

125
Q

Risk factor for abruption

A 
HTN
Trauma
Smoking
Cocaine
Uterine anomaly (eg fibroid)
Multiparous/older mum
Previous abruption
126
Q

Management of placental abruption

A

Bloods from mum
- assess clotting (risk of DIC)
- do crossmatch
Volume replacement - fluid, blood, FFP

US and fetal heart trace (CTG)

  • if distress: caesarean
  • no distress: monitor until 36 weeks, steroids (for fetal lungs)
127
Q

Distocia

A

Power
- atonic

Passenger and passage

  • cephalopelvic disproportion
  • malpresentation

Mx

  • syntometrin (oxytocin + ergometrin)
  • position of mum
  • caesarean
128
Q

Cord prolapse

A

Fetal brady
Pulsatile cord palpable

Emergency

  • replace cord manually
  • caesarean

Risk- previous, malpres, pmature

129
Q

Shoulder dystocia

A

Injury
- fractures of clavicle humerus skull

  • neurological ie brachial plexus (c5-c8,t1)
  • erbs palsy (5% permanent) ‘waiter tip’
130
Q

Home delivery

A

Personal importance of labour
Control, relaxation, familiarity, less medicalised
3% of births nationally

Eligibility in discussion with consultant (no national guidelines)

CAPO

  • conception probs?
  • age?
  • problems in pregnancy (bleed, breech, HTN, GDM)
  • obstetric history (not good idea for first baby)
131
Q

Downs screening

A

RISK
11-14 weeks Nuchal translucency
16 weeks Blood tests
Maternal age

DIAGNOSIS
Amniocentesis
- 1% miscarriage

DOWNS

  • LD
  • short
  • heart defects
  • duod atres
  • facies
  • hearing and vision
  • coeliac, epilepsy, thyroid, leuk, dem
132
Q

Breast feeding

A

Bond with baby

Baby’s health

  • infection
  • brain devel and growth
  • less atopy

Cheap and convenient

Difficulties

  • can be hard
  • can be sore

Antenatal advice
First feed straight after delivery and on demand for first few days
Mum needs nutrition and rest
150ml per kg per day

4-6months weaning onto purée etc
6 months meals of finger food
12 chopped up proper food, proper milk

133
Q

Mastitis

A

Erythema, hot, tender
Feel unwell

Continue breast feeding
- if ducts block can get spasmodic shooting pains

Can be complicated by abscess

T: augmentin
Massage, hot bath, cold cabbage leaves

134
Q

Toxoplasmosis

A

Undercooked meat
Cat faeces
Mum gets general Sx - fatigue, myalgia, lymphadenopathy
Neonate gets chorioretinitis, seizures, organomegaly

135
Q

Rubella

A

Antenatal screening is routine (for susceptibility)
Mum gets mild viral illness (inc rash, conjunctivitis, coryzal, lymphad)
Neonate gets mental defects, deafness, cataracts, heart defects

136
Q

Herpes simplex

A

Mum gets systemic symptoms and genital lesion -which recurs after latent periods
Neonate gets skin/mouth lesions, possible sepsis, possible neurological probs (acute and long term)

137
Q

Listeriosis

A

Causes neonatal sepsis
Mum gets flu-like illness
Soft cheeses

138
Q

chickenpox exposure in pregnancy

A

first step: check varicella antibodies
if not immune give VZIg

if present with rash - give oral aciclovir

aim to prevent fetal varicella syndrome - skin, eye, neuro

139
Q

Menopause

A

What?
Est/Prog levels fall
Egg production stops
Periods stop

Transition 2 years but variable
80% symptoms
50% disruptive

Transition changes

  • irratic periods
  • hot flushes
  • night sweats
  • sleep disturb
  • mood

Long term changes

  • osteoporosis
  • skin/join tab
  • urogenital
    • dryness, dyspar, UTI, incont
140
Q

urogenital prolaps

A

chronic pelvic pain seen in older women
sensation of pressure, heaviness, ‘bearing-down’

urinary symptoms: incontinence, frequency, urgency

141
Q

HRT

A

To help ease transition - generally only started now if early onset <45
- protects vs osteoporosis

Not for long term

  • risk of breast cancer, stroke/CVD, clotting
  • check for breast lumps

No uterus - estrogen only
Uterus - estrogen and progesterone (cont or cyclical)

Vasomotor - systemic (can use non hormonal first line - clomidene)
Urogenital - topical (gel, pessary)

142
Q

Unopposed oestrogen

A

Obesity
- due to conversion of androgens

Tamoxifen
- has oestrogenic effect on uterus

PCOS

Oestrogen HRT (without progestins)

143
Q

What to ask in history?

A 
Obstetrics
Any menstrual problems?
Current contraception? Problems?
Sexual history?
- infections
- partner

Family history of breast cancer?
Thromboembolic disease?
Liver disease?

Plans for future pregnancy - how soon?
Lifestyle - regular? hectic?

145
Q

Hormone pill to temporarily stop periods if erratic

A

Norethisterone

  • high levels of progesterone
  • use if wedding holiday etc
146
Q

puerperal pyrexia

A

temp >38 w/in 2 weeks of childbirth

usually due to endometritis

admit for iv abx

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