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PACES - Histories > Obs & Gynae > Flashcards

Obs & Gynae Flashcards

1
Q

Menopause definition

A

Absence of menses for 12 months without another reason for amenorrhoea (pregnancy, hormone therapy, medical condition)

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2
Q

Menopause symptoms

A 
Amenorrhoea
Irregular menstrual cycle
Hot flushes
Night sweats
Vaginal symptoms (dryness, itching, dyspareunia)
Mood changes
Sleep disturbance
Mild memory impairment
Heavy menstrual bleeding
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3
Q

Premature menopause definition

A

Menopause before age 40

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4
Q

Premature menopause causes

A 
Spontaneous
Idiopathic
Surgery (e.g. bilateral oophorectomy)
Radiation of the pelvis
Chemotherapy
Autoimmune disease
Fragile x syndrome
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5
Q

Premature ovarian insufficiency definition

A

Amenorrhoea, hypo-oestrogenic status and elevated gonadotrophins due to decline in ovarian function before the age of 40

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6
Q

Perimenopause definition

A

The transition from cyclic menstrual bleeding to a total cessation of menses which may occur over several years; marked by menstrual irregularity and periods of amenorrhoea due to declining progesterone and oestradiol levels

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7
Q

(Premature) Menopause investigations

A 
Pregnancy test (negative)
FSH (>30)
Serum estradiol (<110)
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8
Q

Menopause management: mild vasomotor symptoms

A

Lifestyle changes - weight loss; exercise; avoid alcohol, caffeine, spicy food, warm environments, stress.

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9
Q

Menopause management: moderate/severe vasomotor symptoms +/- reduced libido

A

Menopausal, with a uterus: continuous combined regimen

Menopausal, without a uterus: oestrogen

Perimenopausal: sequential regime (oestrogen + cyclical progestin)

SSRIs (paroxetine), gabapentin or clonidine may also improve vasomotor symptoms

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10
Q

Menopause management: urogenital atrophy only

A

Vaginal oestrogen
Vaginal moisturiser
Oral ospemifene (selective oestrogen receptor modulator)

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11
Q

Menopause management: reduced libido only

A

Combination oestrogen-androgen

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12
Q

Menopause management: urinary stress incontinence only

A

Pelvic floor rehabilitation

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13
Q

HRT complications

A

Vaginal bleeding (common within first 6 months of oestrogen-progestogen)
Breast tenderness
VTE and stroke (transdermal has lower risk than oral)
Oestrogen (combination therapy only)

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14
Q

Premature menopause management

A

Continuous combined HRT
Counselling and support
If pregnancy is desired: donor oocyte and embryo transfer

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15
Q

Premature menopause complications

A

Osteoporosis

Cardiovascular disease

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16
Q

Barrier contraceptive options

A

Diaphragm and cervical cap - initially fitted by clinicians, must be filled and coated with spermicide before intercourse
Male condom
Female condom

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17
Q

Diaphragm: adverse effects/disadvantages

A

Skin irritation
Spermicide may increase HIV transmission risk
Increased risk of UTIs

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18
Q

Cervical cap: adverse effects/disadvantages

A

Skin irritation

Spermicide may increase HIV transmission risk

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19
Q

Condoms: adverse effects/disadvantages

A 
Friction/noise (female)
Latex allergy (male)
Slippage/breakage (female>male)
Loss of sensation
Inconvenience
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20
Q

Behavioural contraceptive options

A 
Lactational amenorrhoea (breast feeding 4-hourly during the day and 6-hourly at night; until first menstrual period/6 months postnatal/infant nursing less often)
Periodic abstinence (5 days before ovulation to 2 days after: charting menstrual cycles; checking cervical mucus, urinary hormone levels, basal body temperature)
Withdrawal
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21
Q

Hormonal contraceptive options

A

Combined oestrogen/progestogen contraception
-pills (3 weeks + 1 placebo week)
-patch (1/week for 3 weeks, one week off, repeat)
-vaginal ring (insert for 3 weeks, take out for 1, then new ring and repeat)
Progestogen-only contraception
-pill (24 active tablets, 4 inactive tablets)
-injection (LARC - 8 weeks)
-implant (LARC - 3 years)
-IUS (LARC - 3-6 years)

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22
Q

Absolute contraindications to oestrogen-containing contraceptives

A 
Migraine with aura
Smoking (if age >35 and >15/day)
Hx of ischaemic heart disease
Stroke
Severe cirrhosis/liver tumour
Major surgery with prolonged immobilisation (stop oestrogen 4-6 weeks before)
Hx of DVT
Hypertension (>160/100)
Postnatal (<21 days)
Breast cancer within past 5 years
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23
Q

Relative contraindications to oestrogen-containing contraceptives

A

Smoking (age >35 and <15 cigarettes/day)
Concurrent treatment with hepatic enzyme-inducing drugs
Hypertension (140/90 - 159/99)
Hx of breast cancer (>5 years ago)

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24
Q

COC side effects

A 
Irregular bleeding (all)
Nausea (pill, patch)
Headaches (pill, patch)
Breast tenderness (pill, ring)
Skin irritation (patch)
Increased vaginal discharge (ring)
Low abdominal pain (ring)
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25
Q

Progestogen-only contraceptives: mechanism

A

Thickening cervical mucus +/- suppression of ovulation +/- make endometrium less hospitable to implantation

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26
Q

Progestogen-only contraceptives: absolute contraindications

A

Current breast cancer

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27
Q

Progestogen-only contraceptives: relative contraindications

A

Anti-phospholipid antibodies
Severe liver cirrhosis
Hx of breast cancer

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28
Q

Progestogen-only contraceptives: adverse effects

A 
Changes in bleeding patterns (all)
Headaches (all)
Mood changes (all)
Nausea (IUS)
Breast tenderness (pill, IUS)
Weight changes (implant, injection)
Acne (implant, IUS)
Abdominal pain (implant, injection)
Decreased libido (injection)
Loss of bone mineral density (injection)
Up to 1 year delay in fertility returning (injection)
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29
Q

IUD risks

A 
Ectopic pregnancy (increased relative risk but decreased overall risk)
Expulsion (5% in first year, more if nulliparous or insertion postnatal or after termination)
Uterine perforation (2 in 1000, higher in breastfeeding women)
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30
Q

Emergency contraception options

A

Progestogen-only (levonorgestrel) - within 96 hours of UPSI
Selective progesterone-receptor modulator (ulipristal)
Copper IUD
Oestrogen/progestogen (Yuzpe regimen)

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31
Q

Progestogen-only emergency contraception

A

52-100% effective
Single dose or two doses 12 hours apart
Adverse effects: headaches, nausea, dysmenorrhoea
Repeat if vomiting within 3 hours of taking
Available OTC if age >16

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32
Q

Ulipristal emergency contraception

A

90% effective
Take within 5 days
Contraindications: severe asthma controlled by oral steroids
Adverse effects: headache, nausea, dysmenorrhoea

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33
Q

Copper IUD as emergency contraception

A

Nearly 100% effective within 5 days

Adverse effects: changes in bleeding patterns (prolonged/heavy/irregular/painful)

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34
Q

Oestrogen/progestogen emergency contraception

A

75% efficacy
Take within 72 hours
Two doses 12 hours apart
Adverse effects: nausea and vomiting (more than POP/ulipristal)
Repeat if vomiting within 3 hours of taking

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35
Q

Endometriosis definition

A

Chronic inflammatory condition defined by endometrial strong outside of the uterine cavity, most commonly affecting the pelvic peritoneum and ovaries

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36
Q

Endometriosis aetiology

A

Retrograde menstruation
Deficient cell-mediated immune response (ineffective mechanism for clearing menstrual effluent)
Differentiation of coelomic epithelium into endometrial glands
Vascular and lymphatic dissemination

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37
Q

Endometriosis signs and symptoms

A

Dysmenorrhoea (particularly if progresses to become acyclic)
Chronic/cyclic pelvic pain
Dyspareunia (distorted pelvic anatomy, rectovaginal involvement)
Subfertility (scarring, prostaglandin over-production)
Pelvic mass (endometrioma)
Fixed, retroverted uterus (peritoneal fibrosis, pelvic adhesions)
-> uterine tenderness
Depression

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38
Q

Endometriosis investigations

A

TVUSS (endometrioma, deep pelvic endometriosis)
MRI pelvis
Diagnostic laparoscopy

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39
Q

Endometriosis management (immediate fertility not desired; pain without endometrioma or suspected severe/deep disease)

A

COCP or POP to induce atrophy of endometrial implants
NSAIDs
GnRH agonists to induce hypo-oestrogenic state; >6 months use can lead to irreversible decrease in bone mineral density)
Androgen to induce hypo-oestrogenic state
Laparoscopy
Hysterectomy with bilateral salpingo-oophorectomy and excision of visible peritoneal disease + HRT

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40
Q

Endometriosis management (immediate fertility not desired; pain with endometrioma or suspected severe/deep disease)

A

Surgery (radical excision of affected areas with restoration of normal anatomy; risk of reintervention is 50%)
If surgery does not result in complete removal of implants, postoperative therapy with GnRH agonist/progestogen/androgen may be indicated

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41
Q

Endometriosis management (immediate fertility desired)

A 
Controlled ovarian hyper stimulation (clomifene or letrozole; risk of ovarian hyperstimulation syndrome and higher-order multiple gestations)
IVF
Surgery (endometrioma excision carries a small risk of ovarian failure)
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42
Q

Calculating estimated date of delivery

A

Naegele’s rule – add 7 days and 9 months from the first day of the last menstrual period; if cycle is longer than 28 days, add the additional number of the days to the date calculated

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43
Q

Diagnosis of confirmed miscarriage

A

Can be diagnosed on ultrasound if there is no cardiac activity and:

  • The crown-rump length is greater than 7mm or
  • The gestational sac is greater than 25mm
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44
Q

Management of confirmed miscarriage

A

Expectant management:

  • First-line for the first 7 to 14 days after a confirmed diagnosis of miscarriage
  • Consider other options if:
    • Increased risk of haemorrhage (e.g. in late 1st trimester)
    • Previous adverse and/or traumatic experience associated with pregnancy (stillbirth, miscarriage, antepartum haemorrhage)
    • Increased risk from the effects of haemorrhage
    • Evidence of infection
    • Expectant management is not acceptable to the patient
  • If pain and bleeding resolve in 7-14 days, advise to take a UPT after 3 weeks and return if positive
  • Offer a repeat scan if, after the period of expectant management, bleeding and pain:
    • Have not started (suggesting process of miscarriage has not yet begun) or
    • Are persisting and/or increasing (suggesting incomplete miscarriage)

Medical management:

  • Vaginal or oral misoprostol for missed or incomplete miscarriage
  • Inform the woman what to expect, including:
    • Length and extent of bleeding
    • Potential side effects (pain, diarrhoea, vomiting)
  • Offer pain relief and anti-emetics as needed

Surgical management:

  • Manual vacuum aspiration under local anaesthetic in an outpatient or clinic setting or
  • Surgical management in theatre under general anaesthetic
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45
Q

What is a threatened miscarriage?

A

Painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
The bleeding is often less than menstruation
Cervical os is closed
Complicates up to 25% of all pregnancies

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46
Q

Threatened miscarriage investigations

A

TVUSS to confirm intrauterine pregnancy and look for fetal heartbeat

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47
Q

Threatened miscarriage management

A

If bleeding gets worse, or persists beyond 14 days, return for further assessment
If bleeding stops, start/continue routine antenatal care

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48
Q

What is a missed miscarriage?

A

A gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
Mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
Cervical os is closed
When the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’

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49
Q

What is an inevitable miscarriage?

A

Heavy bleeding with clots and pain

Cervical os is open

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50
Q

What is an incomplete miscarriage?

A

Not all products of conception have been expelled
Pain and vaginal bleeding
Cervical os is open

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51
Q

Investigation of a lower UTI in pregnancy

A

Send MSU for culture

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52
Q

Management of a lower UTI in pregnancy

A

Advise paracetamol for pain, and to keep well hydrated
Offer immediate antibiotics:
-First-line: nitrofurantoin for 7 days (avoid at term)
-Second-line: amoxicillin (only if culture results show susceptibility) or cefalexin for 7 days
-Treatment of asymptomatic bacteriuria: nitrofurantoin, amoxicillin or cefalexin, depending on culture and susceptibility results

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53
Q

Management of pyelonephritis in pregnancy

A

Paracetamol for pain +/- weak opioid e.g. codeine
Offer antibiotic
-First-line oral antibiotics: cefalexin for 7-10 days
-First-line IV antibiotics: cefuroxime
-Second-line: consult microbiologist
Seek medical help if symptoms worsen, or do not improve after 48 hours of Abx

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54
Q

Fibroids: definition

A

Benign tumours of the uterus primarily composed of smooth muscle and fibrous connective tissue; round, firm, and well-circumscribed nodules; subserosal/intramural/submucosal

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55
Q

Fibroids: signs and symptoms

A

Asymptomatic
Menorrhagia
Irregular firm central pelvic mass
Pelvic pain/pressure

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56
Q

Fibroids: investigations

A 
USS (TV is preferable)
Endometrial biopsy (normal; rule out endometrial cancer)
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57
Q

Fibroids: differential diagnosis

A

Adenomyosis may present with the same symptoms; distinguished by uterine biopsy and histopathology

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58
Q

Fibroids: management (fertility desired)

A

Medical therapy: leuprorelin (GnRH agonist) or mifeprostine (antiprogestogen) – both cause vasomotor symptoms
Levonorgestrel IUD
Myomectomy

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59
Q

Fibroids: management (fertility not desired)

A 
Medical therapy then:
-Uterine preservation desired:
•	Uterine artery embolization
•	Myomectomy
-Uterine preservation not desired:
•	Hysterectomy
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60
Q

Urogenital prolapse: definition

A

Loss of anatomical support for the uterus, typically surrounding the apex of the vagina; the anterior and/or posterior vaginal wall may also be involved
Cystocoele – bladder prolapse
Rectocoele – rectum/large bowel prolapse
Enterocoele – small bowel

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61
Q

Urogenital prolapse: risk factors

A 
Vaginal childbirth
Advancing age
Increasing BMI
Prior pelvic surgery
Excessive straining
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62
Q

Urogenital prolapse: signs and symptoms

A

Vaginal protrusion/bulge
Sensation of vaginal pressure
Urinary incontinence or retention (cystocoele)
Constipation (rectocoele)

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63
Q

Urogenital prolapse: investigations

A

Assessment of post-void residual volume (>100mL)
Urinalysis (normal unless concomitant UTI)
Urodynamics (distinguishes stress incontinence and/or urge incontinence)

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64
Q

Urogenital prolapse: management

A

Asymptomatic:
-Observation
-Pelvic floor exercises
Symptomatic:
-Pessary (restores prolapsed organs to their normal position; may require oestrogen cream if erosion occurs)
-Reconstructive surgery (often performed with concomitant hysterectomy; ureteral injury is the most common complication)
• Sacrocolpopexy (abdominally or laparoscopically)
• Uterosacral ligament suspension (vaginally or abdominally)
• Sacrospinous ligament suspension
• +/- continence procedures (mid-urethral sling or Burch urethropexy)

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65
Q

Infertility: causes

A

Ovulatory dysfunction
Tubal or other anatomical disorders
Endometriosis
Unexplained failure to conceive over a 2-year period

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66
Q

Infertility: risk factors

A 
Age >35
Irregular/absent menses
Inflammatory pelvic processes (Hx of STI, previous surgery)
Pelvic pain, dyspareunia (endometriosis)
Very high or low body fat
Smoking (may accelerate menopause)
IBD
SLE
Dopaminergic medications increasing prolactin
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67
Q

Infertility: investigations

A

TVUSS
Urinary LH (positive indicates imminent ovulation)
Luteal-phase progesterone (<9.5nm/L if anovulatory)
Hysterosalpingogram (tubal blockage)
Semen analysis

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68
Q

Infertility: management

A

Lifestyle modification (obesity, smoking, UPSI with multiple partners)
Regular UPSI
Optimisation of medical management if associated with medical condition
Counselling, controlled ovarian stimulation/oocyte donation, IVF

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69
Q

Medical termination up to 10+0

A 
Interval treatment (24-48 hours) with mifepristone and misoprostol
Consider expulsion at home and offer clinic or telephone follow-up
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70
Q

Medical termination between 10+1 – 23+6

A

Mifepristone, followed by misoprostol 36-48 hours later then every 3 hours until expulsion
Anti-D prophylaxis

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71
Q

Surgical termination up to 13+6

A

Cervical priming with misoprostol

Anti-D prophylaxis from 10+0

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72
Q

Surgical termination between 14+0 – 23+6

A

Cervical priming with misoprostol or osmotic dilators or mifepristone
Anti D prophylaxis

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73
Q

Support after termination

A

What aftercare and follow-up to expect
What happens if they have any problems, including who to contact out-of-hours
Explain that it is common to experience a range of emotions after a termination
Advise women to seek support if they need it – friends and family, support groups, counselling or psychological interventions
Discuss contraception

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74
Q

Molar pregnancy (hydatidiform moles): definition

A

Chromosomally abnormal pregnancies have the potential to become malignant (gestational trophoblastic neoplasia)
Complete hydatidiform moles (46XX/46XY) are typically the result of fertilisation of a chromosomally empty egg with a haploid sperm that then duplicates
Partial hydatidiform moles (69XXX/69XXY) usually arise from fertilisation of a haploid ovum by a single sperm, and duplication of paternal haploid chromosomes

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75
Q

Molar pregnancy: signs and symptoms

A

First trimester
Vaginal bleeding
Unusually large uterus for gestational age
Hyperemesis gravidarum

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76
Q

Molar pregnancy: investigations

A 
Serum beta HCG (often >100,000; abnormally elevated for gestational age)
Pelvic USS (abnormal with uterine enlargement; snow-storm appearance of uterine cavity and absence of fetal parts (complete); small placenta with partial fetal development (partial))
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77
Q

Molar pregnancy: management

A

Dilation and evacuation with IV oxytocin and suction
Strict adherence to contraception during 12-month period of follow-up
Serum beta HCG monitoring over this period for gestational trophoblastic neoplasia
If future fertility is not desired, hysterectomy may be appropriate

78
Q

Ovarian cyst: definition

A

A fluid-filled sac in the ovarian tissue, which may be physiological, infectious, benign, neoplastic, malignant neoplastic, or metastatic

79
Q

Ovarian cyst: signs and symptoms

A

Pelvic pain
Bloating and early satiety
Palpable adnexal mass

80
Q

Ovarian cyst: investigations

A

TVUSS (enlarged ovary or portion of ovarian tissue; may be cystic, solid, or mixed)

81
Q

Ovarian cyst: management

A

Suspected torsion or rupture – laparoscopy or laparotomy

Non-pregnant, pre-menopausal – conservative management with serial USS
-If solid cyst – laparotomy and gynae-oncology referral

Post-menopausal, simple cyst – conservative management with serial USS
-If complex or solid cyst – laparotomy and gynae-oncology referral

Pregnant:

  • Asymptomatic, <8cm – conservative
  • Symptomatic and/or >8cm – laparoscopy
  • Solid cyst – laparotomy
82
Q

Ovarian cancer: risk factors

A

Age
Family history of breast and/or ovarian cancer
Never used OCP
BRCA1 and BRCA2 mutations

83
Q

Ovarian cancer: signs and symptoms

A

Pelvic mass
GI symptoms (bloating, nausea, dyspepsia, early satiety, diarrhoea, constipation)
Urinary urgency

84
Q

Ovarian cancer: investigations

A

Pelvic USS (solid, complex, septated, multi-loculated mass; high blood flow)
CT scan
CA-125 (>35 units/mL)
Histopathology

85
Q

Ovarian cancer: management

A

Early: comprehensive surgical staging +/- chemotherapy
Advanced: debaulking surgery + IV chemotherapy +/- intraperitoneal chemotherapy

86
Q

Cervical cancer: risk factors

A 
Age 45-59
HPV infection
Multiple sexual partners
Early onset of sexual activity (<18)
Immunosuppression
87
Q

Cervical cancer: signs and symptoms

A 
Abnormal vaginal bleeding
Postcoital bleeding
Dyspareunia
Pelvic/back pain
Cervical mass
Cervical bleeding
88
Q

Cervical cancer: investigations

A

Colposcopy (abnormal vascularity, white change with acetic acid)
Biopsy
HPV testing

89
Q

Cervical cancer: management

A

Non-metastatic: surgery (radical hysterectomy + lymphadenectomy) + chemo
Metastatic: chemo

90
Q

HPV strains covered by vaccine

A

6, 11, 16, 18

91
Q

CIN I definition

A

low-grade lesion with mildly atypical cellular change in lower third of epithelium

92
Q

CIN II definition

A

high-grade lesion with moderately atypical cellular changes confined to basal two-thirds of epithelium

93
Q

CIN III definition

A

severely atypical cellular changes encompassing greater than two-thirds of the epithelial thickness and includes full-thickness lesions (severe dysplasia and carcinoma-in-situ)

94
Q

Most common type of endometrial cancer

A

Adenocarcinoma

95
Q

Endometrial cancer: risk factors

A 
Obesity, insulin resistance
Age >50
Unopposed endogenous oestrogen (anovulation, low parity, early menarche, late menopause, obesity)
Unopposed exogenous oestrogen (HRT)
Tamoxifen use
FHx of endometrial, breast or ovarian cancer
PCOS
o	Lynch syndrome
96
Q

Endometrial cancer: symptoms

A

Post-menopausal vaginal bleeding

97
Q

Endometrial cancer: investigations

A 
TVUSS (endometrial thickening >5mm)
Outpatient endometrial biopsy (+/- hysteroscopy + histopathology)
Cervical cytology (atypical glandular cells)
98
Q

Endometrial cancer: management

A

Surgery +/- chemotherapy +/- radiotherapy

99
Q

Antenatal care: 10-12 weeks

A

Comprehensive history
Lab work (FBC, blood type, Rhesus status and antibody screen)
Urine testing to detect asyptomatic bacteriuria (+ culture)
Screening (Rubella immunity, syphilis, gonorrhoea, chlamydia, hep B surface Ag, HIV antibody, cervical cytology if appropriate)
Education about pregnancy health
BMI
Physical examination
USS if unknown LMP or size-dates discrepancy on initial exam

100
Q

Antenatal care: 11-13 weeks

A

First trimester USS

Maternal serum screening

101
Q

Antenatal care: 16-18 weeks

A

Maternal serum alpha fetoprotein (elevated AFP associated with omphalocele, gastroschisis, and neural tube defects)

102
Q

Antenatal care: 15-22 weeks

A

Quadruple marker serum screening

Amniocentesis (if required)

103
Q

Antenatal care: 18-20 weeks

A

Fetal anatomy USS

104
Q

Antenatal care: 28 weeks

A 
FBC
Antibody testing
Glucose challenge testing
Syphilis screen
HIV antibody test
Administer anti-D Ig if needed
105
Q

Antenatal care: 33-36 weeks

A

Gonorrhoea and Chlamydia screen
Determine newborn care provider
Offer childbirth education classes

106
Q

Antenatal care: 36+ weeks

A

Determine fetal presentation

107
Q

Antenatal care: 35-37 weeks

A

Screen for Group B Streptococcus

108
Q

Antenatal care: 41 weeks

A

Offer induction of labour

109
Q

Vaccination during pregnancy

A

Influenza (October – May)

Tetanus, diphtheria, pertussis (27-36 weeks)

110
Q

Routine antenatal testing:

A 
FBC
Blood type
Urinary glucose
Urine dipstick and culture
Rhesus status
Rubella status
Review of last cervical screening
Consider STI screening
USS
111
Q

Pregnancy complications related to obesity

A 
Gestational hypertension
Gestational diabetes
Cardiac disease
Pulmonary disease
Obstructive sleep apnoea
Caesarean delivery
Venous thromboembolism
Selected fetal malformations and stillbirth
112
Q

Labour: definition

A

Painful contractions leading to dilatation of the cervix

113
Q

First stage of labour

A

Initiation to full cervical dilatation
Latent phase – up to 4cm, may take several hours
Active phase – 4cm to fully dilated, at around 1cm/hour in nulliparous women and 2cm/hour in multiparous women
Monitor with a partogram

114
Q

Second stage of labour

A

Full cervical dilatation to delivery of the fetus
Passive stage – from full dilatation until the head reaches the pelvic floor and the woman experiences the desire to push
Active stage – when the mother is pushing, around 40 minutes in nulliparous women and 20 minutes in multiparous women
If the active stage lasts >1 hour, spontaneous delivery becomes increasingly unlikely

115
Q

Third stage of labour

A

Delivery of the fetus to delivery of the placenta
Normally lasts about 15 minutes
Normal blood loss is up to 500mL

116
Q

Mechanical factors determining labour

A

Power (contractions)
Passage (pelvic dimensions)
Passenger (fetal head dimensions)

117
Q

General care of women in labour

A

Temperature and blood pressure monitoring every 4 hours
Pulse check every 1 hour (first stage) then every 15 minutes (second stage)
Contraction frequency recorded every 30 minutes

118
Q

Diagnosis of slow progress in labour

A

<2 cm dilatation in 4 hours
Most often caused by inefficient uterine action
Common in nulliparous women and induced labour

119
Q

Managing slow progress in labour

A

Augmentation: artificial rupture of membranes; if this fails to further cervical dilatation in 2 hours, artificial oxytocin is administered, which will usually increase cervical dilatation within 4 hours if it is going to be effective

120
Q

Types of fetal damage attributable to labour

A

Fetal hypoxia
Infection/inflammation in labour (e.g. GBS)
Meconium aspiration leading to chemical pneumonitis
Trauma, usually due to obstetric intervention (e.g. forceps)
Fetal blood loss

121
Q

Active management of the third stage of labour

A

Oxytocin or Syntometrine (oxytocin + ergometrine)

122
Q

Methods of induction of labour

A

Prostaglandin gel (either starts labour, or ripens the cervix to allow ARM)
ARM with amnihook; start IV oxytocin within 2 hours if labour has not ensued
Oxytocin alone following SROM
Cervical sweep (passing a finger through the cervix to strip between the membranes and the lower segment of the uterus) – reduces chance of induction and post-dates pregnancy; may be uncomfortable

123
Q

Indications for induction of labour

A 
Prolonged pregnancy
Suspected IUGR or compromise
Antepartum haemorrhage
Poor obstetric history
PROM
Pre-eclampsia
Maternal diabetes
124
Q

Absolute contraindications to induction of labour

A

Acute fetal compromise
Abnormal lie
Placenta praevia
Pelvic obstruction

125
Q

Relative contraindications to induction of labour

A

One previous c-section

Prematurity

126
Q

Gestational diabetes: definition

A

Glucose intolerance diagnosed after the first trimester of pregnancy, most often at 24-28 weeks on the basis of abnormal glucose tolerance testing

127
Q

Gestational diabetes: risk factors

A 
Advanced maternal age (>40)
Elevated BMI (>30)
PCOS
Non-white ancestry
FHx of T2DM
Previous gestational DM
128
Q

Gestational diabetes: signs and symptoms

A

Polyuria
Polydipsia
Fetal macrosomia

129
Q

Gestational diabetes: investigations

A

75g OGTT performed in the morning after an overnight fast (>=5.1 fasting; >=10.0 at 1 hour; >=8.5 at 2 hours)

130
Q

Gestational diabetes: management

A

Diet (30kcal/kg), exercise, and glucose monitoring are often sufficient
Insulin therapy
Antepartum fetal monitoring from 32-34 weeks
Intrapartum glycaemic control during labour; anticipate large reduction in insulin requirement following placental delivery, which may cause a hypo

131
Q

Gestational diabetes: complications

A 
Maternal hypertension
C-section
Fetal macrosomia
Birth injuries
Neonatal death
Neonatal hypoglycaemia
Neonatal jaundice
Neonatal polycythaemia
Type 2 Diabetes
132
Q

Gestational hypertension: definition

A

BP >=140/90 on two occasions at least 4 hours apart during pregnancy after 20 weeks’ gestation in a previously normotensive patient, without features of pre-eclampsia

133
Q

Gestational hypertension: risk factors

A 
Nulligravidity
Black or Hispanic ethnicity
Obesity
Mother being small for gestational age
T1DM
134
Q

Gestational hypertension: investigations

A

Urinalysis (negative or <1+ protein)

FBC, U+Es, LFTs (within pregnancy-specific thresholds)

135
Q

Gestational hypertension: management

A

<37 weeks gestation, <159/109

  • Lifestyle modification
  • Antihypertensive treatment (labetalol, nifedipine, methyldopa)

<37 weeks gestation, >160/110
-Lifestyle modification and antihypertensive treatment (labetalol/nifedipine/methyldopa)

> 37 weeks gestation, <159/109
-Induction of labour

> 37 weeks gestation, >160/110
-Antihypertensive treatment (labetalol/hydralazine/nifedipine) and induction of labour

136
Q

Indications for induction of labour/delivery in gestational hypertension

A

Labour or ROM
Abnormal fetal testing
IUGR
Development of pre-eclampsia (depending on gestational age and severity) or eclampsia
Evidence of end-organ damage (neurological, hepatic or renal dysfunction)

137
Q

Gestational hypertension: complications

A

Cardiovascular disease in the mother in later life

Fetal/neonatal complications (macrosomia, c-section, NICU admission)

138
Q

Pre-eclampsia: definition

A

A disorder of pregnancy associated with new-onset hypertension (>140/90), which occurs most often occurs after 20 weeks of gestation and frequently near term

139
Q

Pre-eclampsia: pathophysiology

A

Failure of the normal invasion of trophoblast cells leading to maladaptation of maternal spiral arterioles

140
Q

Pre-eclampsia: risk factors

A 
Primiparity
Pre-eclampsia in previous pregnancy
FHx of pre-eclampsia
BMI >30
Maternal age >40
Multiple pregnancy
Pre-existing diabetes
141
Q

Pre-eclampsia: signs and symptoms

A 
Hypertension
Headache (usually frontal; classifies pre-eclampsia as severe)
Upper abdominal pain (usually RUQ; HELLP syndrome)
Reduced fetal movement
Fetal growth restriction
Oedema
Visual disturbances
Hyperreflexia and/or clonus
142
Q

Pre-eclampsia: investigations

A 
Urinalysis (proteinuria; >0.3g protein in 24 hours)
Fetal ultrasound (growth restriction)
CTG
FBC (low platelets in HELLP)
LFTs (elevated transaminases in HELLP)
Placental growth factor (low)
143
Q

Pre-eclampsia: management

A 
Hospital admission and monitoring
Decision regarding delivery (delivery is the definitive management)
Corticosteroids if <34 weeks
Antihypertensive therapy
Magnesium sulfate for eclamptic seizures
144
Q

Pre-eclampsia: complications

A 
IUGR
Seizures
Stillbirth
Placental abruption
Pulmonary oedema
Pregnancy-associated stroke
Renal failure in later life
145
Q

Obstetric cholestasis: definition

A

A pruritic condition during pregnancy caused by impaired bile flow allowing bile salts to be deposited in the skin and placenta; bile acids have a vasoconstricting effect on human placental chorionic veins, which can cause sudden asphyxial events.

146
Q

Obstetric cholestasis: risk factors

A

Hx (personal or family) of obstetric cholestasis
Hx of hep C
Age >35

147
Q

Obstetric cholestasis: signs and symptoms

A

Pruritis, sparing the face
Excoriations without rash
(Mild jaundice)

148
Q

Obstetric cholestasis: investigations

A

o Bile acids (11-40 mmol/L – mild; >40 mmol/L – severe)
LFTs (elevated transaminases and alk phos)
Clotting (occasionally increased PT due to vitamin K depletion)
Fasting serum cholesterol (greater elevation than usually seen in pregnancy)
Hepatitis C virology

149
Q

Obstetric cholestasis: management

A

Mild disease

  • Antihistamines (to reduce pruritis)
  • Consider colestyramine (to disrupt enterohepatic circulation and resorption of bile acids) and vitamin K (as colestyramine causes malabsorption of fat-soluble vitamins)
  • Consider ursodeoxycholic acid
  • Topical antihistamines
  • Loose, cotton clothes
Severe disease
-C-section or induction if >37 weeks
-If <37 weeks:
•	Ursodeoxycholic acid
•	Weekly/twice-weekly fetal surveillance including USS
•	Corticosteroids if <34 weeks
•	C-section/induced delivery
150
Q

Obstetric cholestasis: complications

A

Vitamin K deficiency in the mother
Premature labour
Intrauterine fetal demise
Respiratory distress syndrome in pre-term infants

151
Q

Hyperemesis gravidarum: definition

A

Severe nausea and vomiting in pregnancy, characterised by persistent vomiting, volume depletion, ketosis, electrolyte disturbance, and weight loss

152
Q

Hyperemesis gravidarum: risk factors

A

Hx (personal or family) of hyperemesis gravidarum
Multiple gestation
Gestational trophoblastic disease
Increased placental mass (triploidy, trisomy 18 or 21, hydrops fetalis)

153
Q

Hyperemesis gravidarum: investigations

A

FBC, LFTs, (normal)
U+Es (hyponatraemia, hypochloraemia)
Urinalysis (ketonuria)
Fetal USS with nuchal translucency

154
Q

Hyperemesis gravidarum: management

A

Ginger supplements (raw/tea/tablets)
Smaller, more frequent meals
Avoid trigger foods; preference bland-tasting, high-carb, low-fat foods
Sour/tart liquids (e.g. lemonade) may be tolerated better than water
Pyridoxine (vitamin B6) and/or doxylamine (antihistamine)
Anti-emetics
IV hydration
TPN in extreme cases

155
Q

Hyperemesis gravidarum: complications

A 
Symptoms may persist throughout pregnancy
Fetal growth restriction
Pre-eclampsia
Mallory-Weiss tears
Wernicke’s encephalopathy
156
Q

Multiple pregnancy: management

A

Obstetric-led care
Consider selective fetal reduction
Monitoring: monochorionic – 2-weekly growth and Doppler from 16 weeks; dichorionic – 4-weekly growth and Doppler from 20 weeks
Monitor for IUGR – do not use SFH

157
Q

Multiple pregnancy: complications

A

Greater likelihood of Down syndrome
Greater likelihood of needing invasive tests
Twin-twin transfusion syndrome
Hypertension
Preterm birth
Increased risk of foetal death after 38 weeks (twins) or 36 weeks (triplets)

158
Q

Management of hypothyroidism in pregnancy

A

Check TFTs every 2-4 weeks

Increase thyroxine by 25 mcg as soon as pregnancy is confirmed

159
Q

Management of hyperthyroidism in pregnancy

A

Check TFTs every 2-4 weeks

Carbimazole/propylthiouracil at lowest acceptable doses according to TFTs

160
Q

Placental abruption: definition

A

The premature separation of a normally located placenta from the uterine wall that occurs before delivery of the fetus

161
Q

Placental abruption: risk factors

A 
Direct abdominal trauma (causing separation of the placenta)
Indirect trauma (shearing the placenta)
Cocaine use (causing vasospasm leading to placental separation)
Chronic hypertension
Pre-eclampsia
Smoking
Chorioamnionitis
Uterine malformations
Oligohydramnios
Prior placental abruption
162
Q

Placental abruption: investigations

A

Fetal monitoring (abnormalities on CTG)
Hb and Hct (normal/low)
Clotting (abnormal)
USS

163
Q

Placental abruption: management

A

Stabilise mother (prevent hypovolaemia, anaemia, DIC)
Monitor mother and fetus (initially continuous CTG)
Anti-D Ig if Rh-negative mother
If live fetus >34 weeks: delivery (c-section if unstable fetal/maternal status)
If live fetus <34 weeks: monitor, steroids, and tocolytics if stable; c-section if unstable
If fetal demise: vaginal delivery if mother stable; c-section if mother unstable

164
Q

Prophylaxis of postpartum haemorrhage

A

Uterotonics in third stage and for c-section (IM/IV oxytocin)

165
Q

Management of minor PPH (500-1000 mL, no shock)

A

IV access
Urgent bloods – G&S, Cross-match, FBC, clotting
Pulse, RR and BP monitoring every 15 minutes
Warm crystalloid infusion

166
Q

Management of major PPH (>1000 mL)

A 
Call for help
ABC approach
Position patient flat
Keep patient warm
10-15L oxygen
2 large bore cannulae
Urgent bloods – G&S, Cross-match, FBC, clotting
Transfuse blood ASAP
Foley catheter to measure urine output
IV/IM syntocinon or IM ergometrine or syntometrine
IM carboprost
Bakri balloon tamponade
Other surgical measure (B-lynch suture, hysterectomy)
167
Q

Management of fetal demise

A

If membranes intact, offer expectant management or induction of labour
If rupture of membranes, infection or bleeding, immediate induction is preferred (mifepristone followed by prostin or misoprostol)

168
Q

Rhesus disease: definition

A

Destruction of fetal RBCs from transplacental passage of maternally derived IgG antibodies, usually against the RhD antigen, causing progressive fetal anaemia and eventually hydrops fetalis and death

169
Q

Causes of maternal sensitisation to RhD antigen

A

History of delivery of a Rh-positive fetus to a Rh-negative mother
Fetomaternal haemorrhage
Invasive fetal procedures
Placental trauma
Abortion (threatened, spontaneous or induced)
Omission (or inadequate dosing) of appropriate Rh immunoprophylaxis following a potentially immunising obstetric event in a previous or current pregnancy
Multiparity (enhanced response to sensitisation when a secondary immune response is generated)

170
Q

Rhesus disease: investigations

A

Maternal blood type (Rh-negative)
Maternal serum Rh antibody screen (positive)
Paternal blood type (Rh-positive)
Fetal USS (subcutaneous oedema, ascites, pleural effusion, pericardial effusion)
Fetal blood typing (amniocentesis or maternal circulation)

171
Q

Rhesus disease: management

A

Give anti-D immunoglobulin at sensitising events, at 28 weeks, and at 40 weeks or delivery of a Rh-positive infant (whichever occurs first)
Can give the fetus intravascular intrauterine blood transfusions to treat hydrops fetalis
For neonates with erythroblastosis, consider exchange transfusion/phototherapy/ IVIG

172
Q

Breech presentation: definition

A

Baby presents with the buttocks or feet rather than the head first (cephalic)

173
Q

Breech presentation: risk factors

A 
Premature fetus
SGA
Nulliparity (SGA)
Fetal congenital abnormalities (SGA)
Previous breech delivery
Uterine abnormalities
Oligohydramnios
Polyhydramnios
174
Q

Breech presentation: investigations

A

Transabdominal/transvaginal USS

175
Q

Breech presentation: management

A

From 37 weeks, can attempt ECV
Give anti-D at ECV if Rh-negative
If ECV is unsuccessful, consider vaginal vs caesarean delivery

176
Q

Contraindications to ECV

A

Multiple pregnancy (except after delivery of a first twin)
Ruptured membranes
Current/recent (<1 week) vaginal bleeding
Rhesus isoimmunisation
Other indications for a c-section (placenta praevia, uterine malformation)
Abnormal CTG

177
Q

Complications of breech delivery

A 
Cord prolapse
Placental abruption
Pre-labour rupture of membranes
Perinatal mortality
Fetal distress (HR<100)
Preterm delivery
Lower fetal weight
40% risk of needing an emergency c-section
178
Q

Risks of ECV

A

50% failure rate
Placental abruption
Fetal distress requiring an emergency c-section

179
Q

PROM: risks

A 
Cord prolapse (rare)
Infection – risk increased by vaginal examination, presence of GBS, and increased duration of membrane rupture
180
Q

PROM: management

A

Wait for spontaneous labour for up to 24 hours

After 18-24 hours, prescribe antibiotics against GBS, and induce labour

181
Q

PPROM: management

A

Offer oral erythromycin for a maximum of 10 days or until the woman is in established labour
Monitor for signs of chorioamnionitis and pre-term labour
Consider admission/regular outpatient monitoring
Consider corticosteroids
Offer IV magnesium sulphate to women between 24+0 – 29+6 who are in established preterm labour or have a planned preterm birth within 24 hours
Aim for delivery at 37 weeks

182
Q

Risks of PPROM

A

Infection

Prematurity

183
Q

PPROM: risk factors

A

Smoking
STIs
Previous PPROM
Multiple pregnancy

184
Q

Indications for vaginal progesterone

A

TVUSS at 16-24 weeks showed cervical length <25mm with or without history of spontaneous preterm or mid-trimester loss

185
Q

Indications for cervical cerclage

A

History of spontaneous preterm or mid-trimester loss (16-34 weeks) and TVUSS at 16-24 weeks showed cervical length <25mm

186
Q

Placenta praevia: definition

A

The placenta overlying the cervical os; may be complete, partial, marginal, or low-lying (all except complete may resolve as the pregnancy progresses); may be associated with an abnormally adherent placenta (attaches to myometrial layer) in women with a scarred uterus

187
Q

Placenta praevia: risk factors

A 
Uterine scarring (usually due to prior c-section)
IVF
Prior placenta praevia
Advanced maternal age
Multiple pregnancy
Smoking
188
Q

Placenta praevia: investigations

A

Uterine USS with colour flow Doppler analysis
FBC (low Hb in acute bleeding)
Group and save, crossmatch

189
Q

Placenta praevia (bleeding): management

A

Resuscitation and stabilisation; if not stabilised by resuscitation, urgent c-section
Stabilised, not in labour – corticosteroids (<34 weeks), anti-D
Stabilised, in preterm labour – tocolytics (terbutaline), corticosteroids, anti-D
Stabilised, at term – C-section, anti-D

190
Q

Placenta praevia (no bleeding): management

A

Preterm, not in labour – monitoring, pelvic rest (no SI or pelvic douching), consider corticosteroids
Premature labour – tocolytics (terbutaline), corticosteroids, anti-D
At term – c-section; can consider vaginal delivery if marginal/low-lying placenta praevia

191
Q

Placenta praevia: complications

A 
Anaemia
Preterm birth
Haemorrhage and DIC
IUGR
Fetal death
192
Q

Vasa praevia: definition

A

The fetal vessels lie over the internal cervical os

PACES - Histories (3 decks)

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