Obs+Gynae Flashcards

1
Q

Management of Shoulder Dystocia

A

Call for help
Evaluate for episiotomy
McRoberts manoeuvre - bending maternal thighs on abdomen
Pressure on posterior aspect of fatal shoulder
Enter manoeuvres to internal rotation of fatal shoulders
Roll patient fours
Last resort: Clavicular #, symphoysiotomy, GA + Zavanelli

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2
Q

Management of Cord Prolapse

A

Trendelenburg position - manually elevate the fatal head and urgent C section (instrumental vaginal delivery can be done if fully dilated and head low in pelvis)
Tocolysis may be used
If cord is below Introits - keep warm and moist and do not push back in

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3
Q

PPH Management

A

Initial management: Get senior help + activate Major Haem Protocol. A-E approach (flat if poss, protect airway, 2x large cannula). Rapid infusion of fluids.

STOP THE BLEED: bimanual compression - empty bladder - IM Sent - Ergometrine .5mg - Syntometrin infusion - Caboprost IM (CI in asthma) - Carboprost myometrium injection - Misoprostol 100mg

Surgical: Balloon tamponade - compression sutures - uterine artery ligation
If uterine rupture or placenta acreta: Hysterectomy!

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4
Q

Management of Breech Presentation

A

25% of pregnancies are breech at 28 weeks but most resolve spontaneously!
ECV offered at 36 weeks if still breech (60% effective) CI: if going for C-section, APH in <7days, worrying CTG, Major uterine abnormality (fibroids) Multiple pregnancy or PROM

If unsuccessful: planned vaginal delivery or C-Section

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5
Q

Managing OP poisiton

A

Most cannot deliver vaginally as the position of baby’s head circumference. Typically presents with delay in 2nd stage.
10% begin OP but 3/4 of these will resolve to an OA position during labour.

Kielland’s Rotational forceps can be used if: prolonged labour and 1/5th below spines!

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6
Q

What are the indications fo IOL?

A

Pregnancy that is >42 weeks (most common reason, risk of: still birth, meconium passage, placental insufficiency)
PROM beyond 34 weeks
Maternal health concerns (HTN, pre-eclampsia, GDM, APH)
Fetal concerns (IUGR, Placental insufficiency)

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7
Q

What are the Contraindications to being induced?

A
Cephalopelvic disproportions 
BREECH 
Fetal distress 
Placenta Praevia 
Cord presentation
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8
Q

What are the complications of IOL?

A

Uterine rupture
Overstimulating the uterus (excess contractions, fatal hypoxia, abnormal CTG)
Cord prolapse (if ARM’d if the head is high)
Need for analgesia
Longer duration of labour
No association with increased risk of C-section

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9
Q

What is the management of Prolonged labour?

A

1st stage: Augmentation with oxytocin (careful in twins and no more than 4-5:10 contractions)
Artificial ROM

2nd stage: Artifical rupture of membranes
Augmentation with oxytocin (after obstetric review)
Instrumental delivery [must be 10cm dilated, head below the spines, analgesia]

3rd stage: oxytocin with cord traction

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10
Q

Pre-eclampsia management?

A

[75mg of aspirin given from 12w gestation if deemed at high risk: HTN in previous pregnancy, CKD, autoimmune, diabetes]

If presenting with pre-eclamisa: HTN + Oedema + proteinuria (300mg/24hrs)

Tight HTN control with oral or IV labetalol / nifedipine
MgSO4 given as seizure prophylaxis
Steroids given for lung maturation <34 weeks
Delivery definitive treatment

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11
Q

Management of Pre-term labour

A

<37 weeks (affects around 6% of pregnancies)
RF: multiple preg, infection, cervical incompetence, uterine abnormalities, smoking and PROM.

Admit with senior review 
2x doses of IM steroids 12 hrs apart 
Tocolysis (CI: choreoamnitis, foetal death, thyroid disease, cardiac disease) 
Antibiotics 
MgSO4 (to reduce cerebral palsy risk)
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12
Q

Management of PROM?

A
Admit for 48-72hrs observation 
Steroid administration 
Erythromycin 250mg QDS for 10d 
Regular CTG monitoring 4hrl temps 
Can be managed as an outpatient after initial monitoring - but must do daily temp with aim to delivery @~34 weeks (trade off between chorioamniitis + RDSS)
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13
Q

Ectopic pregnancy management:

A

Expectant: <30mm, enraptured, asymptomatic, no FHR (good if another viable pregnancy in womb), B-HCG<200
Closely monitor over 48 hours, intervene if becomes symptomatic or increasing b-HCG.

Medical Mx: <35mm, no pain, no FHR, serum HCG<1500. 
Give methotrexate (as long as patient willing and able to attend follow-up) 

Surgical: >35mm, ruptured, pain, visible FHR, bHCG>1500, compatible with other uterine pregnancy
Salpingectomy vs Salpingotomy (1in5 need rather treatment with methotrexate as not that effective)

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14
Q

Management of hyperemesis?

A

Triad of: >5% pre-pregnancy weight loss, dehydration and electrolyte imbalance.
Inv: Bloods, Urine dip (ketones indicate extremem dehydration, USS (to rule out molar/multiple pregnancies)

Admit for observation 
Adequate hydration, nutrition and rest 
1st line: cyclizine 
Metacloperamide 
Ginger and acupuncture! 
If severe: steroids and TPN!
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15
Q

NICE guidelines on endometriosis?

A

10% of women have some degree of endometriosis!

1st line: NSAIDs + paracetamol
COCP or Progestrones can be tried

If not management by this, REFER
GnRH analogues induce ‘pseudomenopause’
Surgery: Laparoscopic excision and laser

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16
Q

Key Counselling advise for infertility management?

A

Take folic acid
Aim for a BMI of 20-25
Regular sex 3-4x/week
Reduce smoking and drinking

First line investigation is a day 21 progesterone to see if ovulating (P>30 implies ovulation, 16-30: repeat test)
If this is normal, they should be sent for semen analysis.
[Check TFTs, Prolactin levels]

17
Q

PCOS management

A

Inv: weight + BP, Bloods (TFTs, Prolactin, FSH, LH Testosterone, Free androgen), PUSS >12 cysts in one ovary.

Diet and exercise (spontaneous ovulation with normal BMI)
Medical: induce a withdrawal bleed with progesterone, then assess endometrial thickness, then begin COCP or IUS.
Co-cyprindiol/spironolactone/finasteride for hirsutism and acne

Need to assess Q-risk if >35
All women should be offered a Glucose Tolerance Test
Increased risk of endometrial hyperplasia and cancer!

18
Q

What is the definition of Menorrhagia?

A

excessive menstrual loss >80mls (with impact of woman’s life)

Invx: Bloods (FBC, TFTs, LFTs and clotting), USS pelvis (fibroids/polyps), Microbio, papelee biopsy, hysteroscopy.

19
Q

What is the management of menorrhagia?

A

Depends on patients choice, pathology and fertility requirements:
Medical: Hormonal [Mirena - COCP - Norethisterone or Depot]
TXA 1g TDS
NSAIDs (mefanamic acid 500mg TDS)

Surgical: endometrial ablation, hysteroscopy for polyp removal, lapoacscopic hysterectomy.
Fibroid: uterine artery embolisation + hysterectomy

20
Q

Management of chronic HTN in pregnancy

A

Defined as HTN before 20 weeks gestation:

Stop any ACEi or ARBs
Offer alternative meds (labetalol or methyl-dopa) to aim for a BP of <150
USS scan @ 28 and 32 weeks

21
Q

Management of gestational diabetes?

A

Defined as HTN that begins >20 weeks gestation

Mild: 140-149 - do not treat but weekly monitoring
Mod: 150-159/100 - offer labetalol and twice weekly monitoring
Sever: >160/110: labetalol. Measure BP QDS and admit

22
Q

Mx of Chlamydia

A

100mg Doxycycline 7/7
Contact tracing: 4 week is symptomatic / 6 month if asymptomatic (+ve partners offered treatment before test)
Avoid sex until completion of treatment.

If pregnant: azithromycin/erythromycin/amox

23
Q

Management of Gonorrhoea

A

1g IM Ceftriaxone
Contact tracing: 2 weeks is symptomatic / 3 months if asymptomatic

Screen for other STI, safe sex, abstain until both partners are treated

S/S of disseminated gonococcal infection: septic arthritis in young, tenosynovitis, migratory polyarthritis and dermatitis.

24
Q

Management of Genital Herpes

A

Treat with acyclovir [up to 5 days since presentation] if primary infection (rest, fluids, stay off work if unwell)

Recurrent outbreaks tend to be shorter and less severe: painkillers, vasoleen, ice packs and acyclovir. 1/3rd rule.

> 5 outbreaks in a year suggests immune compromise

C-section if primary outcome is in last trimester, women should be offered suppressive threrapy throughout pregnancy if recurrent outbreaks.

25
Q

Treatment of Genital Warts

A

1st line: podophyllotoxin BD for 3d a week if multiple wars
If few warts - cryotherapy [10s burst of cold, 3x separate treatments

2nd line (if still there after 4 weeks): imiquimod 5% OD alternate days for 3d/week. 20-30% recurrence after each treatment.

In pregnancy: only offer cry therapy and surgical excision

26
Q

What is the difference between trichomonad and BV?

A

T: motile, protozoan parasite STI with offensive yellow/green discharge, strawberry cervis and ph>4.5.
Rx with Metronidazole for 5-7d

BV: overgrowth of anaerobic G. Vaginalis that increases pH
Amsel’s criteria 3/4 needed: thin, white homogenous discharge
Clue cells (stripe epithelial cells)
Vaginal ph>4.5
Positive whiff test (+KOH gives fishy odour)
Also treated with Metronidazole 5-7d.

27
Q

Treatment of Pelvic inflammatory disease

A

14d course of Doxycycline + Ceftriaxone + Metronidazole