Obs & Gynae Flashcards
Management of pre-eclampsia ?
CTG fetal monitoring. Call obsetrician for advice.
Asymptomatic, incidental finding, no severe features: Close outpatient monitoring. Labetalol. IOL at 37 weeks
If rural, send to Adelaide for monitoring
Symptomatic or any features of HELLP: hospitalisaion and IOL
Future pregnancies need prophylacic aspirin
Invetigation for suspected polyhydramnios?
AFI (Amniotic Fluid Index) >24 cm
Risk factors for preterm labour?
Smoking, alcohol use, illicit drug use
Previous preterm labour
Twins
Previous cervical surgery
Chorioamnionitis
Preeclampsia + placental abruption
Placenta previa
Management of PCOS?
Non med: weight loss, mx metabolic syndrome (lipids, glucose, HTN)
If not concerned about infertility:
Med: OCP (or Metformin if OCP contraindicated)
If concorned about infertility:
Med: Ovulation induction wth clomiphene
Pre-menopausal bleeding, clots, open oss. Ix, Dx, Mx?
Doppler US + transvaginal USS
Incomplete abortion
Expectant management +/- misprostol (prostagladin) + Anti-D (625 IU)
Investigation (2) and Mx (1) of prolactinoma?
Visual fields
MRI head
Dopamine agonists (cabergoline)
Clinical features pre-eclampsia (8)?
High BP + proteinuria
RUQ Abdominal pain (vasospasm to liver)
Blurred vision (raised ICP and vasospasm to retinal artery)
Peripheral swelling (d/t proteinuria)
SOB (pulmonary oedeam d/t proteinuria)
Headaches (raised ICP from cerebral oedema amd HTN)
Hyperreflexia + Clonus
Eventually cerebral oedema (from severe proteinuria) causes seizures
Screening tests in 3rd trimester?
Morphology scan 20 weeks
Oral GTT 24 weeks
GBS swab 36 weeks
(Give Anti-D at 28 and 34 weeks for Rh- mother)
Normal CTG (cardiotocography)?
HR normal range is 110-160 bpm
Variability of HR is normal (5-25 bpm)
Accelerations (>15bpm for 10 minutes) reflects fetal movement
Early deceleration (decline of >15 bpm) during contractions
When can you have vaginal birth after C section ? When contraindicated? Risk of what?
Indicated: After low transverse incision C section
Contraindicated: Classical (vertical) incision, multiple gestation
Risk of uterine rupture
Features of HELLP syndrome?
Hemolysis (H)
Haemolysis: low Hb, low haptoglobin, high LDH, high unconjugated bilirubin
Elevated Liver (EL) enzymes
Low Platelet (LP) count
Late deaccelerations reflect what?
Deaccelerations after contraction curve
Reflect placental inufficiency and hypoxia. Problem!
How’s this CTG? What does it represent?
Late deaccelerations during labour. Low variability, deaccelerations occur after contraction finish. Indicates Placental insufficiency, hypoxia + Problem!
Chlamydia mx?
Doxycycline 100mg PO, BD 7 days
OR
Azithromycin 1g PO, stat
Contact tracing back 6 months. Notifiable
When to use tocolytics?
Tocolytics (nifidipine/calcium channel blocker)
Indicated in pre-term labour when wanting to allow steroids to work (<34 weeks) or transfer to tertiary hospital
Contraindicated:
Haemodynamic instability in abuptio placentae
Cervical dilation > 4cm
Chorioamnionitis
Nonreassuring fetal signs
Cord prolapse
Uncomplicated genital gonorrhoea mx?
STAT IM ceftriaxone and oral azithromycin
Contact tracing back two months. Notifable
Main mechanism of action for progesterone implant?
Inhibits ovulation
Investigation of bleeding during pregnancy?
Resuscitate if needed
Abdominal examination: SFH, fetal lie
Bloods – CBE, group and save, Kleihauer, coagulation studies
CTG for fetal distress
Tranvaginal USS to assess position of placenta
NO digital vaginal exam
Mx of placenta previa ?
If Rh-ve give Anti-D
If bleeding stopped and HD stable –
Lives <20 minutes from hospital and have supports can go home
Lives >20 minutes stay in hospital until no bleeding for 24 hours
If still bleeding and HD stable –
Admit and monitor, send for group and hold
Conider steroids if <34 weeks
Will ultimately need C-section when mature fetus
If not stable -> emergency C-section
Investigations for suspected molar pregnancy? Mx?
B-HCG ++++++
USS: snowstorm
Chest CXR + LFTs to check for haematogenous spread of invasive disease (or choriocarcinoma)
Dilation and curettage. Normal reproduction after, higher risk of molar pregnancy
New onset rash in pregnancy. Diff Dx (4)?
Pruritic urticarial papules and plaques of pregnancy (PUPPP)/ Polymorphic eruption of pregnancy (PEP)
Atopic eruption of pregnancy
Potentially harmful to fetus:
Pemphigoid gestationis (self limiting)
Obsetetric cholestasis (very itchy on hands and feet) (IOL or ursodeoxycholic acid)
Risk factor for ovarian cancer (1)?
HPV 16/18
How to establish labour?
Regular contractions (3 every 10 minutes) and cervical dilitation
Can test for premature labour with fetal fibronectin if <35 weeks
Cervical USS to see if effacement if occuring (normal >3cm)
When should a pregnant lady be offered high dose folate supplementation (6)?
BMI >35
On anti-epileptics
On methotrexate
Diabetes
Inflammatory bowel disease
Family history of neural tube defects
Risk factors for endometrial cancer? (3)
Unopposd oestrogen exposure
Tamoxifen (oestrogen stimulator in endometrium, inhibits in breast)
PCOS
Mx of preterm labour?
Admit and consider transfer to tertiary centre with NICU
Steroids if <34 weeks – betamethasone
Tocolysis (nifedipine) unless contraindicated (infection or bleeding) to delay labour for 48 hours to allow steroids to work
MgSO4 for neuro protection (reduce risk of cerebral palsy) <32 weeks
ABx prophylaxis for GBS penicillin G
Treat chorioamnionitis (Ampicillin + Gentamicin + Metronidazole) or abruption (Fluid resuscitation and blood transfusion)
Free fluid in Pouch of Douglas? (2)
Ruptured Ovarian cyst
PID
Missed OCP today, last OCP taken 2 days ago. Had unprotected sex last night. At start of active pills (ended start sugar pills 2 days ago). How to manage?
Take missed pill now (2 in one day). As >48 hours since last pill, use condoms for 7 days
As just finished sugar pills, consider emergency conaception.
Gonorrhoea dx?
Men: first pas urine NAAT
Women: endocervical swab NAAT
Post menopausal bleeding differential diagnosis (3)?
Endometrial cancer
Endometrial polyp or hyperplasia
Atrophic vaginitis
Clamydia dx?
First pass urine NAAT
Screening tests in 2nd trimester?
2nd trismester chromosomal abnormality screen (if missed first): HCG + Alpha fetoprotein + estriol + inhibin A) (14-20 weeks)
Asymptomatic bacteuria screen (12 weeks)
Pre-menopausal bleeding, no clots, closed oss. Ix, Dx, Mx?
Doppler US + transvaginal USS
Threatened abortion
Reversible, watch and wait. Anti-D (625 IU)
What is the best test for ovulation?
Progesterone 7 days before expected menstruation
Contraindications to OCP (4)
Women over 35 who smoke
Previous VTE
Migraines with aura
Previous stroke, CVD
Pre-exising HTN vs Gestational HTN vs Pre-eclampsia?
Pre-existing HTN (>140/90) prior to 20 wk GA, persisting >7 wk postpartum
Gestational HTN: sBP >140 or dBP >90 developing after 20th wk GA in a woman known to be normotensive before pregnancy
Preeclampsia: pre-existing or gestational hypertension with new onset proteinuria
Pre-menopausal bleeding, no clots, open oss. Ix, Dx, Mx?
Doppler US + transvaginal USS
Inevidable abortion
Expectant management +/- misprostol (prostagladin) + Anti-D (625 IU)
Investigation of urge incontinence? (2)
Bladder diary
Urodynamic testing
Differentials for SGA fetus?
Symmetrical (small head=body): Chromosomal, TORCH infection
Asymmetrical (big head>>body): Placental dysfunction: abruption, infarction, previa, chorioamnionitis, matenal issue leading to insufficient nutrients or O2, smoking, alcohol
Complications of pre-eclampsia? (9)
Maternal: ARDS, placental abruption, cerebral heamorrhage
Fetal: IUGR, pre-term birth
Long term: HTN, ischemic heart disease, stroke, venous thromboembolism
In developing females, what order of changes during puberty? (4)
Boobs, Pubes, Grow & Flow
Breasts (8)
Axillary hair (9)
Growth spurt (10)
Menache (11)
Hyperemesis gravidarum dx?
Loss of weight
Ketouria
Routine screening at start of pregnancy? (5)
Blood type (for Rh- and APO incompatability, may need blood transfusion in future)
CBE (anaemia) and iron studies
Viral immunology (esp. Rubella)
Viral serology (HIV, Hep C, Hep B, Syphillis, TORCH infections, STIs)
Cervical screen
Main mechanism of action for intrauterine progestrrone device?
Prevents endometrial proliferation
When is the OCP effective?
If taken in first 5 day of menstrual cycle (from first day of bleed) -> effective immediately
If not, takes 7 days
Test for premature ovarian failure?
FSH/LH (will be increased), FSH:LH ratio >1.0
CVD screen
Bone density screen
Causes of polyhydramnios + investigations
Twins
Maternal diabetes
Reduce fetal swallowing (oesophagial atresia, duodental atresia)
Amniotic Fluid Index >25cm
Fetal wellbeing CTG, Morphology USS
Ectopic pregnancy haemodynamicaly unstable. Mx? (2)
Rupture: salpingectomy (tube removal)
If contralateral fallopian tube not viable: salpinostomy (tube preserving) (+ Rh- mothers need Anti-D 625 IU)
When does cervical screening start?
What tests does it involve (2)?
Pathways?
At age of 25 years or 2 years after the last pap smear (whatever is later)
HPV testing
If 16/18 deteced -> Liquid Based Cytology + referral (colposcopy)
If 16/18 not detected -> Liquid Based Cytology
High grade lesion -> referral (colposcopy)
Low grade lesion or negative LBC -> repeat HPV testing in 12 months
If after 12 months had repeated positive HPV (any type) -> referral (colposcopy)
Investigations for preeclampsia?
Urine dipstick. urinalysis + 24 urine collection + urine protein-creatine ratio
EUC for renal function
CBE – haemolysis bloods, anaemia, platelets (HELLP)
LFTs (HELLP)
US – foetal growth restriction (complication)
Milky fishy odor discharge from vagina. Dx, Mx?
Bacterial vaginosis
Metronidazole
Dysmenorrhea differential dx (3)?
PID
Endometrisosis
Adenomyosis
What is Kleihauer test used for?
The amoutn of maternal-fetal blood expure during a pregnancy bleed
Helps determine how much Anti-D is needed.
Big fundal height compared to gestational weeks + bHCG++++. Next investigation, dx?
Transvaginal USS (snowstorm appearance)
Molar pregnancy
Bishop’s score cut offs?
<5 needs cervical ripening (misoprostol or sweeping of membranes)
<6 not ready for vaginal birth (not ready for IOL)
Variable deaccelerations reflect what?
Reflect cord compression: change maternal position
Colicky lower abdominal pain during pregnancy differentials?
Preterm labour
Braxton Hicks contractions
Placental abruption
UTI, appendicitis
Diff dx of bleeding during pregnancy?
Placental abruption
Placenta previa
Preterm labour
Miscarriage
Cervical pathology – cancer, ectropion, STI
Diagnosis of PCOS?
Needs 2/3:
Clinical or lab evidence of hyperadrogenism (increased testosterone, 3:1 LH:FSH)
Anovulation
Polycystic ovaries on USS
Contraindications for HRT (4)?
>60 or >10 years since LMP
Established cardiovascular disease
Previous VTE
Suspicion for endometrial cancer or breast cancer
Which are cancerous HPV strains?
16 and 18
Atrophic vaginitis mx (1)?
Topical oestrogen
Risk factors for umbilical cord prolapse (5)?
Breech
Multiple pregnancies
Premature birth
Polyhydramnios
What is the Rh- protocol?
For Rh- mothers (assuming Rh+ infants):
Anti-D given routinely at 28, 34 and post birth
Any bleeding during 2nd and 3rd trimesters
Any surgical intervention (ie miscarriage, ectopic pregnancy, D&C, termination)
HPV 16/18 came up on cervical screening. Next step?
LBC and referral for colpscopy
Follow up of Molar pregnancy?
Esure no invasive disease (CXR)
Serum BHCG 48 hours after surgery, every 1–2 weeks while this value is elevated, and then monthly for 6 months.
Mx of urge incontinence (2)?
Referral to incontinence nurse
Anticholingergics (oxybutynin)
Investigations for SGA fetus?
Serial USS + plot growth
Amniotic fluid index (AFI <5 Oligohydramnios)
Umbilical artery doppler
MCA doppler
Waveform
TORCH screen
Karyotyping
Calculating estimated date of delivery:
What do you need to know?
How to do it?
Need to know:
1) LMP? 2) Regular cycle? 3) How long is cycle?
Calculate using Naegele’s rule: Date of LMP + 7 days (+ x days) - 3 months + 1 year
‘x’ days is amount over normal 28 day cycle. Ie if 35 day cycle:
Date of LMP + 14 days - 3 months + 1 year.
If LMP not known or irregular cycle: need US scan between 7-14 (8-11) weeks (max growth time so most accurate results).If more than 5 day discrepency, use USS
Thick, white, adherent non offensive vaginal discharge in diabetic, post Abx steroid user.
Dx?
Mx?
Candidal vulvovaginitis
Topcial antifngal (clotrimazole, miconazole)
Causes and mx of post partum haemorrhage?
Tone (uterine atony)
Trauma (perineal tears)
Tissue (retained placenta, placenta accreta)
Thrombin (coagulation disorders)
Turned inside out (uterine eversion)
ALS and Fluid resuscitation -> Check cause (high SFH for uterine atony, trauma of vagina)
Bimanual uterine massage + ocytocin + tranexamic acid -> intrauterine balloon tamponade -> Uterine artery Embolisation
Contraception options if on anticonvulsant?
Use Mirena, Copper IUD or barrier
All hormonal mehtods interacts with anticonvulsants
Mx of normal vomiting in pregnancy?
Dietary changes: small frequent meals + avoid spicy, odorous, high-fat, and acidic foods
Ginger +/- pyridoxine (B6) +/- doxylamine (H1-receptor antagonist)
TORCH infections?
Toxoplasmosis
Others (including Syphillis, Listeria, Varicella Zoster, Parvovirus B19),
Rubella virus
Cytomegalovirus (CMV)
Herpes simplex virus (HSV)
Complication of PCOS?
Higher risk of endometrial cancer
Infertility
Metabolic syndrome: T2DM, CVD
OSA
Causes of menorrhagia or abnormal uterine bleeding (9)?
Menorrhagia = heavy bleeding
PALM (structural) COEIN (physiological)
Polyps
Adenomyosis
Leiomyoma (fibroids)
Malignancy (endometrial cancer)
Coagulopathy
Ovulation dysfunction
Endometrisosi
Iatrogenic
Not classified
Complaints about prolapse (7)?
ADD B2 + S2
Asymptomatic
Discomfort (dragging)
Dysfunction (Bladder + Bowel)
Sexual issue
pSychiatric concerns (afriad of cancer)
What are the screening tests for chromosomal abnormalities ?
First trimester: Pregnancy Associated Plasma Protein (PAPP-A) + b-hCG + nucheal translucency USS
Second trimester: Alpha feto-protein + HCG + ucongugated estriol
Confirm with CVS or amniocentesis
Copious thin white, discharge with fishy odour. >4.5 pH. Dx? Ix? Mx?
Bacteial vaginosis
Clue cells on wet prep from vaginal swab
Metronidazole
Karyotype of Turner’s syndrome + other features (5)
45XO
Widely space nipples
Webbed neck
Hypergonadotropic hypogonadism (low oestrogen, low androgens, high FSH/LH) + Primary amenorrhoea
Coarctation of aorta
Short stature
Indications for induction of labour (6)
Matenal:
Mild preclampsia after 37 weeks (severe at any time, consider steroid before 34 weeks)
Maternal request
Gestational diabetes at 39 weeks (reduce risk of shoulder dystocia)
Fetal:
Post term pregnancy
Prelabour prterm rupture of membranes
Chorioamnionitis
Benefits to HRT? (3)
Reduce menopausal symptoms
Cadioprotective (if no current CVD)
Protects against osteoporosis
What contraception contraindicated with carbemazapine?
Systemic hormonal (COCP, implanon, POP)
Main mechanism of action for COCP?
Inhibits ovulation
Post coital bleeding young women differential dx? (4)
Cervical ectropian (new OCOP use)
STI
Hormonal contraception
Cervical malignancy
Missed OCP today, last OCP taken 24 hours ago. Had unprotected sex last night. How to manage?
As <48 hours since last pill, the pill is still working.
Take missed pill now (2 in one day) and continue regular cycle
A 57-year old post-menopausal woman is referred to the gynaecology clinic by her general practitioner following the incidental discovery of an ovarian cyst on ultrasound. She is otherwise completely well. The ultrasound report describes “a 5cm left sided ovarian cyst with solid components. Right ovary normal.” She has had bloods performed and her CA-125 level is 25. Management?
3 for post menopausal x 1 for one US finding x 25 CA-125 level
RMI: 75 (3 x 1 x 25)
Moderate risk of RMI (25-200) -> laparoscopic salpingo-oophorectomy
High risk (>200) -> staging laparotomy
Mx of PID?
Ceftriaxone, metronidazole, doxycycline
Complicatons of PID (3)?
Infertility
Ectopic pegnancy
Fitz-Hugh-Curtis syndrome: adhesions that cause chronic pain
How’s this CTG? What does it represent?
Norml CTG showing early deaccelerations during labour (head compression)
Which HPV strains cause warts?
6 and 11
Goals of therapy in PCOS? (4 +1)
Reduce irregular menses (OCP, Metformin)
Reduce endometrial hyperplasia + risk of endometrial cancer from unopposed oestrogen (OCP)
Reduce androgen production (OCP)
Control metabolic syndome (weight loss, metformin)
Induce ovulation if wanting pregnancy: letrozole
How’s this CTG? What does it represent?
Variable deaccelerations. Demonstrates cord compression.
Pre-menopausal bleeding, no clot, closed oss. No fetal heart beat, Dx, Mx?
Missed abortion
Misprostol (prostagladin) + Anti-D (625 IU)
Mx of Hyperemesis gravidum? (7)
Urine dipstick (for ketones). EUC to check for AKI. Urine MCS for pyelonephritis
Ultrasound on admission -> higher risk of IUGR
IV Fluids. consider thiamine + glucose for prolonged vomiting (prevent Wenicke’s encephalopathy)
Pharmacological:
1st line: Metoclopramide or doxylamine
2nd line: Ondansetron for severe hyperemesis gravidarum
Features of endometriosis (4)?
Dysmenorrhoea
Dyspareunia
Pelvic pain
Infertility
Posterior vaginal labial swelling differentials (2) and mx?
Bartholin gland cyst or abscess
Abscess: I&D
Cyst: Marsupialisation
Screening tests in 1st trimester?
Dating USS 8-12 weeks
Serology screen (HIV, Hep B, Hep C, Syphillis, TORCH)
Blood type
1st trimester chromosomal abnormalities screen: b-HCG, PAPP-A + nuchal translucency scan (11-14 weeks)
Risk factors for ovarian cancer?
BRCA + Lynch syndrome
Factors that lead to increased number of ovulation cycles:
Nulliparity
Early menarche, late menopause
COCP adds protective effect!
Previous cervical screening 12 months ago showed LSIL. Now HPV testing shows HPV11. Mx?
LBC and referral for colpscopy
Thin, frothy, yellow, malodourous, strawberry cervix, >4.5 pH. Dx, Mx?
Trichomonas vaginalis
Single dose 2g tinidazole or 2g metronidazole
Approximate fundal heights per gestational week (3)?
12 weeks palpable above pubic bone
20 weeks palpable at umbilicus
36 weeks palpable at sternum
Investigations for suspected pre-term labour?
Abdominal palpation
CTG
Do not perform vaginal examination (infection risk, unsure if low lying placenta)
US for cervical length (ie start of cervical effacement). If <3cm, high risk of delivery in next 7 days. Needs hospitalisation
GBS status
CBE and CRP to check for infection
Midstream urine
High and low cervical swab
Amnistick or ferning
Fetal fibronectin test (if <35 weeks)
Missed OCP today, last OCP taken 2 days ago. Had unprotected sex last night. At end of active pills (about to start sugar pills tomorrow). How to manage?
Take missed pills now (2 in one day). As >48 hours since last pill, use condoms for 7 days
As about to start sugar pills, change to new cycle and start active pills
Mx of shoulder dystopia?
Ask for help
Perform McRobert’s manoeuvre (flex and abduct hips)
Apply suprapubic pressure
Attempt to manually rotate the anterior shoulder (Rubin manoeuvre)
Pre-menopausal bleeding, clots, closed oss. Ix, Dx, Mx?
Doppler US + transvaginal USS
Complete abortion
Anti-D (625 IU)
Complications of IUD insertion? (4)
Device expulsion (usually next period)
PID
Device migration to peritoneal cavity
Uterine perforation
Ectopic pregnancy haemodynamicaly stable. Mx?
Methotrexate (+ Rh- mothers need Anti-D 625 IU)
Causes of oligohydramnios (3) + investigations? (2)
Placental insufficiency (dugs use, smoking, placental abruption)
Decreased fetal urination: renal agenesis, posterior urethral valves
Amniotic Fluid Index <5cm
Fetal CTG, Fetal morphology US
Risk factors ovarian cancer (2)?
BRCA mutations
Lynch syndrome (CEO = colorectal, endometrial, ovarian)
Causes of increased SFH compared to gestational age?
Wrong gestational age/ EDD
Multiple pregnancies (twins)
Polyhydramnios: Fetal abnormality (structural causing difficulty swallowing), TORCH infection
LGA (from gestational diabetes)
If early in pregnancy with no USS -> Gonadotrophic hyadid/Molar pregnancy
Is warfarin safe in breast feeding? Does it cross the plaenta?
Yes and yes (not safe in pregnancy)
Risks to HRT ? (3)
Breast cancer risk if for more than 4-5 years (needs oestogen+progesterone)
Endometrial cancer risk if uterus + oesotrogen alone
Stroke and ischemic heart disease if established VTE or coronary artery disease
Previous cervical screening 12 months ago showed LSIL. Now negative HPV. Mx?
Back to 5 yearly screen
How’s this CTG? What does it represent?
Normal CTG during labour.
Normal HR,normal variability, normal accelerations associated with contractions.
Post menopausal bleeding investigation (3)?
Transvaginal USS (>4mm has high risk)
Endometrial biopsy
Hystoscopy
What pathogen are we worried about in gastroenteritis in pregnancy? What’s more common (2)?
Listeria
More common: rotavirus + norovirus
Causes of seconday ammenorrhoea? (7)
Pregnancy
Meds: Anti-psychotics + metoclopramide (dopamine antagonists -> nothing opposes prolactin -> inhibits GnRH)
Hypothalamus issue: Physiological stress, anorexia, excssive exercise
Pituitary issue: Hypothryoidism (TRH+++ stimulates prolactin -> inhibits GnRH), Prolactinaemia (prolactin inhibits GnRH), Sheehan’s syndrome
Ovarian issue: PCOS, premature menopause
Endometrial issue: Ashemann’s syndrome post procedure
Contraindication to Neagles rule? (2)
Alternative?
Irregular cycle, hormonal contraception in last 12 weeks.
Crown-rump ratio by USS 7-14 weeks
Milky fishy odour with alkalotic pH, smear shows clute cells. Dx and Mx?
Bacterial Vaginosis
Metronidazole, must be treated in pregnancy, higher risk of fetal complicaitons (miscarriage, preterm labour)
