Obs & Gynae Flashcards
What drug is used to reduce the risk of/ treat seizures in a pre-eclamptic woman?
Magnesium sulfate
At 5mins post birth what is a normal APGAR score?
> 7
A baby is 5 minutes old, crying strongly, pink centrally but blue in the peripheries. There is use of accessory muscles and strong breathing, a pulse of 110 and some limb movements, what is this babies APGAR score?
8/10
A= 1 (Blue peripheries) P= 2 (over 100) G= 2 (strong cry) A= 1 (some limb movement) R= 2 (strong resps)
Name 5 common drugs which could be used for the management of PPH?
Syntocinon Carboprost Syntometrine Ergometrine Misoprostol Transexamic acid
A woman presents at 24 weeks with a diffuse abdominal pain and a large for date pregnancy (fundal height 34cm). She is tender in the suprapubic area and has urinary frequency but no dysuria. She has a singleton pregnancy, what is the most likely cause of her pain?
Uterine fibroids
Very common, oestrogen dependent and so increase in size during pregnancy
Tx is best rest and analgesia
Does sexual intercourse increase the risk of miscarriage?
No - there is no evidence for this
A 28yoF has just had an ectopic pregnancy followed by a salpingectomy - how should she be counselled about future pregnancies? (3)
If other fallopian tube normal still good chances of conceiving
10% risk future pregnancies will be ectopic, so needs US at 7 weeks if gets pregnant again
Can start again straight away, no risk starting sooner
A 67 year old woman presents to GP asking if she needs a cervical smear test, she’s forgotten he last few and last attended when she was 52. Does she need a smear under the national screening program?
NO Starts at 25 3 yearly from 25-49 5 yearly from 49-65 After this only if not been screened since the age of 50 or if abnormal tests/ symptoms
A 67 year old woman presents to GP asking if she needs a cervical smear test, she’s forgotten he last few and last attended when she was 48. Does she need a smear under the national screening program?
YES Starts at 25 3 yearly from 25-49 5 yearly from 49-65 After this only if not been screened since the age of 50 or if abnormal tests/ symptoms
A culture from a patients vaginal discharge shows Gardenerella vaginalis and clue cells, what is the diagnosis and treatment?
Bacterial vaginosis
Tx: Metronidazole
A patient presents to the maternity triage department at 35 weeks with 500 ml of painless vaginal bleeding and a transverse lie on abdominal examination. MLD?
Placenta praevia classically presents as non-painful bleeding and may be associated with an abnormal lie as the low lying placenta may prevent engagement of the presenting part.
A rhesus negative G3P2 presents with post-coital bleeding. She had her Routine Antenatal Anti-D Ig Prophylaxis (RAADP) yesterday. Management with regard to her rhesus status? (3)
FBC, KLEIHAUER TEST & PROPHYLACTIC ANTI-D
Although she had her RAADP the previous day this should be considered separate from any sensitising event, and as she is Rh-ve requires Anti-D prophylaxis.
What is the Kleihauer test and what is it’s cut off value?
The Kleihauer test detects the presence of fetal red cells in the maternal circulation. If there is more than a 5ml estimated feto-maternal haemorrhage then a further dose of Anti-D will be needed.
What is the difference between primary and secondary arrest of labour?
Primary - Failure to progress in active phase
Secondary - Failure to progress in active phase following a previously normal progression
Name 3 risk factors for instrumental delivery?
Primiparous Epidural anaesthesia Large fetal size Maternal age >35 Induced labour Supine and lithotomy positions (upright or L lateral are much better)
What pneumonic is used to assess CTG traces?
DR C BRAVADO Dr- Define risk C- Contractions Bra- Baseline rate V- Variability A- Accelerations D - Deceleration's Overall
What are the three indications for operative vaginal delivery (assuming c-section not needed)?
- Presumed fetal compromise
- Maternal - to reduce effects of labour on pre-existing conditions such as cardiac or neurovascular disease
- Inadequate progress (definition discussed in other questions)
When is labour in the second stage classed as delayed?
Active second stage (add one hour if epidural)
- More than 2 hours in primip
- More than 1 hour in multip
What are the three most common adverse effects if there is a prolonged second stage?
Chorioamnionitis
Third/ fourth degree tears
Uterine atony
What are the requirements for an instrumental delivery?
FORCEPS F- Fully dilated cervix O- OA position R- Ruptured membranes C- Cephalic E- Engaged presenting part P- Pain relief S- Sphincter (bladder) is empty
When should operative vaginal delivery be abandoned?
No evidence of progressive decent following three contractions of correctly applied instrument by experienced operator
Name 3 complications of emergency cesarean in second stage of labour?
Uterine, cervical and high vaginal injuries
PPH/ needs transfusion
Sepsis
Increased LoS
Admission to intensive care (mum and baby)
You have made the decision to deliver. On examination, the head is 2/5th palpable abdominally, the cervix is fully dilated, the membranes are ruptured, the head is in a right occiptotransverse (ROT) position at -1 station with 2+ of moulding and 3+ of caput.
What mode of delivery would you choose?
Emergency cesarean!
If the head is 2/5th or more palpable abdominally and the presenting part is above the level of the ischial spines, then this would be classed as high-cavity and not suitable for operative vaginal delivery
What is the advantage to performing ventouse over forceps?
Ventouse is less likely to be associated with maternal perineal or vaginal trauma
What is the advantage to using forceps over ventouse? (4)
Ventouse is more likely to fail
Ventouse more associated with cephalohaematoma and retinal haemorrhage and maternal worries about baby
A 36 year old mother with a BMI of 39 is at 35 weeks gestation. She has been having 4 weekly growth scans given her high risk status. However, as the baby began crossing centile lines this was moved to 2 weekly growth scans. This alongside SFH measurements have shown fairly static growth for the last three weeks. How should she be managed?
Deliver
(Give steroids if delivered by C/S)
High risk women who are >34 weeks and show static growth for more than 3 weeks should be delivered
When doing smears and swabs what order should they be performed in?
1st: Smear
2nd: High vaginal
3rd: Endocervical
The levator ani muscle is innervated by which nerves?
Pudendal nerve
S2,3,4
“S2,3,4 keeps the pelvis off the floor”
What is first line treatment of post-natal depression in a women who has had no previous history of depression?
CBT
- If this is refused then SSRI can be trialled
A 27 year old primiparous woman presents 4 days post birth feeling anxious, tearful and irritable. What is the most appropriate management?
Reassurance and support
Baby blues commonly occurs D3-D7. Anxiety, tearfulness and irritability. This is not postnatal depression and reassurance is the best management.
What percentage of women experience baby blues?
60-70%
Tend to last the first week post-partum
What percentage of women experience postnatal depression?
10%
In relation to birth, when are most cases of postnatal depression seen?
Start within first month and typically peak around 3 months.
What percentage of women experience puerperal psychosis?
0.2%
Onset usually in first 2-3 weeks following birth (severe mood swings and disorders of perception)
A 19-year-old primigravida at 9 weeks presents with vaginal bleeding and suprapubic pain. Tissue has passed through her vagina. The cervix is closed and blood is pooled in the vagina. Ultrasound shows an empty uterine cavity. What is the diagnosis?
Complete miscarriage
You are an FY-1 working in general practice. A 52-year-old lady comes in to see you with distressing hot flushes, these are worse at night and impacting her quality of life. She wants to discuss hormone replacement therapy (HRT). Her last period was 4 months ago. What is the main risk factor for oestrogen-only HRT as opposed to combined oestrogen and progesterone HRT?
Endometrial hyperplasia developed due to unopposed oestrogen stimulation
A 35-year-old nulliparous lady with Factor V Leiden has come for her first antenatal appointment; she has previously had an unprovoked venous thromboembolism (VTE). The attending doctor discusses thromboprophylaxis with her due to her history. Based on her risk, which treatment should be used?
LMWH antenatally + 6 weeks postpartum
What are the criteria for VTE prophylaxis at booking?
A woman with >4 RF’s should be immediately treated with LMWH until 6 weeks postpartum
A woman with 3 RF’s should be treated from 28 weeks until 6 weeks postpartum
A 27 year old at 36 weeks gestation develops a DVT. What is the most appropriate management?
LMWH for at least 5 days
Anti-coagulation treatment for at least 3 months as with all patients with provoked DVT
A young woman at 30 weeks gestation, presents with painless bright red vaginal bleeding, she reports two previous scanty episodes of painless vaginal bleeding, but feels that this episode has been much more severe.
What is the most likely diagnosis?
Placenta Praevia
The bleeding associated with placenta praevia is painless and usually bright red. Meanwhile the bleeding associated with placental abruption is associated with pain and is usually dark red. The pattern of previous bleeding also favours placenta praevia.
What is vasa praevia and the common symptoms?
Sx: Painless bleed, fetal bradycardia, membrane rupture
Vasa praevia, also spelled vasa previa, is a condition in which babies’ blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.
A 23-year-old woman presents at 20 weeks gestation of her second pregnancy. She is complaining of lower backache, fever and a slight vaginal loss of cloudy white viscous fluid. On examination she has a pyrexia of 38.2 centigrade and a pulse of 98 beats/minute. Routine examination of the patient’s abdomen reveals that there is tenderness suprapubically. Speculum examination reveals a slightly open cervix and fluid draining. What is the most likely diagnosis?
Chorioamnionitis
An acute inflammation of the foetal amnion and chorion membranes, typically due to an ascending bacterial infection in the setting of membrane rupture. However, chorioamnionitis can also occur with intact membranes
What are the 4 main signs of Chorioamnionitis?
Key clinical features of chorioamnionitis include uterine tenderness, rupture of the membranes with a foul odour of the amniotic fluid and maternal signs of infection (for example tachycardia, pyrexia, and leukocytosis)
You are the junior doctor on the labour ward, and are called by a midwife to a delivery in which the baby’s head has been delivered, but the shoulders will not deliver with normal downward traction.
What is your first step in management?
Ask mother to hyperflex their legs and apply suprapubic pressure
(This is McRobert’s manouvere).
It works in 90% of cases and is the first line treatment for shoulder dystocia.
A 24-year-old woman presents to the emergency department with a 1 day history of nausea and severe constant pain localised since onset to the left iliac fossa. She had vomited once but has no other symptoms. She has a 28 day menstrual cycle, her last menstrual period started 7 days ago. She is sexually active and has always used condoms for contraception. There is no vaginal bleeding. What is the most likely diagnosis?
Ovarian torsion is the most likely diagnosis. This is common in women of reproductive age. Ovarian torsion is associated with iliac fossa pain that can radiate to the loin, groin or back. Nausea and vomiting are commonly associated symptoms. On examination the patient may have an adnexal mass, which is commonly an ovarian cyst or neoplasm, which has disrupted the normal lie of the ovary to cause the torsion. Patients also sometimes present with a low-grade fever, especially for longer durations of torsion where ovarian necrosis may be present.
A 27-year-old woman presents complaining of heavy menstrual bleeding. She reports saturating her pads with blood regularly and frequently has to change them hourly. She is otherwise asymptomatic and has no desire to have children in the near future. Following a normal examination, what is the most appropriate management?
IUS
A 27 year old woman presents with menorrhagia. What investigation should be performed?
FBC only (unless signs of structural or histological abnormality - i.e. intermenstrual or post-coital bleeding, pelvic pain or pressure symptoms).
A 27 year old woman presents with menorrhagia and postcoital bleeding. What is the most appropriate next step?
Arrange routine TVUS
A 27 year old woman presents with menorrhagia. She does not want children in the near future, what is the most appropriate management?
IUS
2nd: COCP
3rd: Long-acting progestogen (Depo-Provera)
A 27 year old woman presents with menorrhagia. She is currently trying for a baby, what is the most appropriate management?
Mefenamic acid (500mg TDS) - NSAID OR Tranexamic acid (1g TDS)
- Mefenamic acid is better if associated with pain
A patient has a very heavy menstrual bleed, and desperately needs it to stop ready for her gymnastics competition tomorrow. What can be given short term to stop the bleed?
Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.
What is the diagnostic criteria for PCOS?
Exclude other causes then 2 of 3 Rotterdam criteria is diagnostic:
• Polycystic ovaries (either >10cm3 or more than 12 peripheral follicles)
• Oligo-ovulation or anovulation (<9 periods/ year)
• Clinical (hirsutism, acne, alopecia) and/or biochemical (elevated free testosterone) hyperandrogenism
A woman presents at 34 weeks gestation with itching all over her body, she is otherwise well and has not noticed any rashes. What is MLD and suggested management?
Obstetric cholestasis
- Check LFT’s
- Ursodeoxycholic acid to relive symptoms
- Typically induced at 37 weeks
When is the combined test for Down Syndrome performed and what does it involve?
10-14 weeks (12 week scan normally)
- Nuchal translucency
- beta-hCG and PAPP-A
A woman is at 16 weeks gestation, and thus has missed the window for the combined DS test. What should be offered and what does it consist of?
Quadruple test (14-20 weeks)
- AFP
- beta-hCG
- unconjugated oestriol
- inhibin A
What is the first line treatment for pre-eclampsia (assuming 33 weeks gestation)?
Labetalol (unless asthma history, in which case nifidipine). Safe during breast feeding also.
Pre-eclampsia should be management conservatively until what point when same day delivery becomes an option?
34 weeks
Name 5 complications of pre-eclampsia
Eclampsia Prematurity and IUGR Placental abruption, intra-abdominal and inter-cerebral bleeds Heart failure HELPP syndrome
When would medication be started in pre-eclamptic patients?
Guidelines suggest aiming below 150/90
What is first line management for urge incontinence?
Bladder training (at least 6 weeks including increasing intervals and pelvic floor exercises)
What is second line management for urge incontinence
Anticholinergics
- Oxybutynin and tolterodine
(First is bladder training)
What is the main effect of prescribing oestrogen unopposed with progesterone?
Increased risk of endometrial proliferation (and endometrial cancer etc.)
How quickly is the implant (progesterone only) effective as contraception (2 answers)?
Immediate (if D1-5)
Need 7 days contraception if on any other day
Name 4 advantages to the progesterone implant?
- Highly effective
- Long-acting: lasts 3 years
- Doesn’t contain oestrogen so can be used if past history of thromboembolism, migraine etc
- Can be inserted immediately following a termination of pregnancy
Name 5 RF’s for endometrial cancer?
Obesity Nulliparity Early menarche Late menopause Unopposed oestrogen Diabetes PCOS
What is first line investigation in suspected endometrial cancer?
TVUS
(Endometrial thickness <4mm) has a high negative predictive value
A 24yo woman presents asking for the morning after pill, what are the two options and which is most effective?
EllaOne (Ulipristal) - Best
Levonelle (Levonorgestrel)
(note copper coil is the most effective method but is not a pill)
How soon after UPSI do each of the emergency contraception tablets have to be taken?
Levonelle - 72 hours
EllaOne- 120 hours
What 4 things should a patient who has just been given emergency contraception be counselled on?
STD Risk
SE (Nausea, tiredness, headache)
Signs of ectopic (pain, bleeding)
Referral to GUM
What is the definitive gold standard for emergency contraception?
Copper coil
- Have 120 hours
(EllaOne > Levongestrel if not wanting coil).
Name 3 brands of progesterone only pills?
Norgeston, Cerazette, Cerelle, Micronor, Noriday
What advice should a patient be given regarding taking their progesterone only pill (2)
Same time each day (3 hours)
Take every day with no breaks
How quickly is the POP effective?
D1-5: Immediate
Other: Condoms for 48 hours
What should a patient do if they have missed a dose of the POP? (2)
Take next dose as soon as remember (even if two in one day)
Use barrier methods for 48 hours
What advice should a girl be given when starting POP with regard to her periods?
Should make lighter
20% stop, 40% lighter, 40% no change
What are the four most common SE’s of the POP?
Most: Irregular bleeding
Other:
Breast tenderness, spotty skin and headaches
Should resolve within 3 months
A patient is start on the POP, when should you arrange to see her next?
10-12 weeks
Then every 12 months