Obs & Gynae Cards Flashcards
1
Q
what is the normal change in blood pressure during pregnancy
A
falls by about 30/15mmHg in second trimester (both nohmal and chronically hypertensive women experience this)
by term it will have risen to pre-pregnant levels
2
Q
urine protein excretion in pregnancy should stay below what
A
0.3g/24hrs
3
Q
in what percentage of pregnancies does pre-eclampsia occur
A
6%
4
Q
draw the flow diagram of HTN in pregnancy
A
5
Q
what is the definition of pre-eclampsia
A
this is HTN >140/90mmHg AND proteinuria 0.3g/24hrs
6
Q
when does pre-eclampsia occur
A
- early onset pre-eclampsia
- occurs before 34 weeks
- typically foetus is growth restricted
- late onset pre-eclampsia
- occurs after 34 weeks
- not associated with growth restriction
- fetal death may still occur
7
Q
what is the pathophys of pre-eclampsia
A
- first step in early onset
- oxidative stress caused by poor perfusion of the placenta due to incompletely formed spiral arteries
- first stage in late onset
- apparently normal placenta outgrows its blood supply and poor perfusion also causes oxidative stress
- second step
- oxidative stress makes placenta secrete proteins that regulate angiogenesis
- sFlt-1 INCREASES
- PlGF DECREASES
- these factors lead to
- vasoconstriction
- widespread endothelial cell damage
- clotting dysfunction
- oxidative stress makes placenta secrete proteins that regulate angiogenesis
8
Q
pre-eclampsia is severe if
A
- HTN > 160/110mmHg
- there are symptoms
9
Q
what is regarded as significant proteinuria
A
>30mg/nmol protein:creatinine ratio
>0.3g/24hr collection
10
Q
when to give aspirin in early pregnancy
A
- any of the following
- hypertensive disease during previous pregnancy
- CKD
- SLE
- antiphospholipid syndrome
- TIDM or TIIDM
- chronic hypertension
- any two of the following
- nulliparous
- age >40
- pregnancy interval >10yrs
- BMI >35
- family history of pre-eclampsia
- multiple pregnancy
11
Q
management of pregnant women with HTN
A
- if no proteinuria and HTN is <160/110mmHg they’re managed as outpatients
- regular BP and urinalysis
- USS every 2-4 weeks
- admission if
- HTN>160/110
- OR
- Proteinuria >0.3g/24hrs or PCR 30mg/nmol
12
Q
clinical features of pre-eclampsia
A
usually asymptomativc
oedema
headaches
visual disturbances
drowsiness
hypertension usually the first sign
epigastric tenderness would suggest impending consequences
13
Q
what would be an indication for delivery in pre-eclampsia REGARDLESS of gestation
A
- eclampsia
- i.e. the presence of grand mal seizures
- cerebrovascular haemorrhage
- HELLP syndrome
- DIC
- renal failure
- pulmonary oedema
14
Q
what is HELLP syndrome
A
15
Q
fetal complications of pre-eclampsia
A
abruption
IUGR (early onset)
increased risk of mortality and morbidity
16
Q
Ix for admitted woman with pre-eclampsia
A
24hr urine collection
urea creatinine ratio
FBC (rapid drop in platelets indicative of HELLP)
LFT (for HELLP)
U&E (raised creatinine indicative of renal failure)
USS (to check for foetal growth)
umbilical artery doppler (for foetal wellbeing)
SflT-1:PlGF ratio (increases with risk)
17
Q
drugs in pre-eclampsia
A
- if they have HTN they should already be on labetalol
- more antihypertensives given if BP reaches over 150/110
- 1st line is oral nifedipine
- 2nd line is IV labetalol
- these do not change course of disease but they increase safety for mum
- magnesium sulphate prevents eclampsia
- increases cerebral perfusion
- toxicity severe so surveillance important
- if mag sulf is indicated then so is delivery
- steroids to promote pulmonary maturity of baby if delivery is indicated
18
Q
timing of delivery in hypertensive pregnancies
A
pre-eclampsia should be delivered by 36 weeks
as a general rule complications will ensue within two weeks of onset of proteinuria
gestational HTN is delivered by 40 weeks as usual
19
Q
mode of delivery in pre-eclampsia
A
- c-section
- if before 34 weeks
- if there is severe growth restriction
- induction with prostaglandins
- if after 34 weeks
- maternal pushing should be discouraged if BP reaches 160/110mmHg in 2nd stage
- oxytocin should be used rather than ergometrin for 3rd stage as latter can raise blood pressure
20
Q
post natal care of patient with pre-eclampsia
A
- LFTs, platelets and renal function monitored closely
- BP maintained below 140/90 with
- 1st line: labetalol
- 2nd line: nifedipine
21
Q
which blood pressure meds are teratogenic and shouldn’t be used in pregnancy
A
ACE inhibitors
22
Q
what is the definiton of gestational diabetes
A
carbohydrate intolerance that is diagnosed in preganancy and may not resolve after pregnancy
23
Q
how often does gestational diabetes occur
A
16% of pregnancies
24
Q
how do you diagnose gestational diabetes
A
- fasting glucose >5.6mmol/L
- glucose tolerance test:
- >7.8mmol/L 2hrs after a 75g glucose load
25
what are the fetal complications from diabetes
* congenital abnormalities
* cardiac and neural tube increases with poor glucose control
* preterm labour
* fetal lung immaturity at any gestation
* high birthweight
* birth trauma
* shoulder dystocia
* polyhydramnios
* fetal compromise
* sudden fetal death
26
maternal complications of gestational diabetes
* UTI
* wound/endometrial infection more common following birth
* pre-eclampsia is more common
* c-section of instrumental delivery is more common
* diabetic nephropathy could lead to massive proteinuria and decline in renal function
27
management of pre-existing diabetes in pregnancy
* consultant lead
* precise glucose control
* monthly HbA1c
* metformin and insulin
* hypoglycaemic drugs are stopped
* statins are stopped
* folic acid given
* aspirin daily from 12 weeks
28
what should glucose levels be in pregnancy
* fasted in the morning
* \<5.3mmol/L
* 1hr after meals
* \<7.8mmol/L
29
mode and timing of delivery in gestational diabetes
delivery between 37 and 39 weeks
elective c section is often the choice if foetal weight exceeds 4kg
30
the puerperium in gestational diabetes
* neonate may develop hypoglycaemia
* neonatal blood sugar should be checked within 4hrs of birth
* breastfeeding is strongly advised
* mother's dose of insulin needs to be rapidly changed
31
risk factors for gestational diabetes
BMI \>30
previous baby \>4.5kg
previous unexplained stillbirth
first degree relative with diabetes
being south asian, carribean or middle eastern
32
when would you screen women with a glucose tolerance test
if they have risk factors screen at 24-28 weeks
where there is polyhydramnios or persistent plycosuria (remember there can be glycosuria at normal blood surgar levels during pregnancy)
if there is a previous history of gestational diabetes screen at 18 weeks
33
what are the 6 main considerations of infection in pregnancy
name an example for each
1. maternal illness could be worse - e.g. varicella
2. maternal complications could occur - e.g. HIV = high risk for pre-eclampsia
3. pre-term labour is associated with infection - e.g. BV
4. vertical transmission of otherwise mild infections could cause miscarriage or be teratogenic - e.g. rubella
5. neurological damage is more common with infection
6. abx limited in pregnancy
34
what percentage of women develop cytomegalovirus subclinically in pregnancy
1%
35
what is the rate of vertical transmission of CMV
neonatal effects of cytomegalovirus
* vertical transmission occurs in 40% of infections
* NEONATAL EFFECTS
* IUGR
* pneuomonia
* thrombocytopenia
* deafness
* learning disability
* death
36
what happens if maternal CMV infection is confirmed
amniocentesis 6 weeks following confirmation of infection will confirm or refute vertical transmission
37
management of CMV in pregnancy
amniocentesis 6 weeks following confirmed maternal infection
because most maternal infections do not result in neonatal sequalae and amniocentesis involves risk, routine screening is not advised
there is no treatment, screening or vaccination
38
what is the organism for toxoplasmosis
toxoplasmosis gondii - protozoa
39
what is the treatment for proven infetion with toxoplasmosis
spiramycin
40
what are the serious sequalae of maternal toxoplasmosis infection
learning disability
convulsions
spasticity
visual impairment
41
what percentage of women carry group B strep
25%
42
what is the other name for group B strep
strep agalactiae
43
what is the neonatal effect of group B strep
foetus usually infected during labour
can cause sepsis and has high mortality
44
45
what are the risk factors for group B strep infection of newborn
maternal fever in labour
prolonged labour (rom \>18hrs)
if preterm
positive urine culture for GBS
previous affected neonate
46
management of group B strep
* vertical transmisson can be prevented with high dose IV abx during labour
47
treatment of maternal chickenpox
oral acyclovir
48
foetal abnormalities caused by rubella
deafness
cardiac disease
eye problems
mental retardation
probability of malformation decreases with progression of pregnancy
49
how does parvovirus affect pregnancy
* maternal slapped cheek appearance
* suppresses foetal erythropoiesusm causing anaemia
* thrombocytopenia
* foetal death may also occur
* may cause hydrops from cardiac failure due to anaemia
50
investigation and management of parvovirus infection in pregnancy
* anaemia detectable on ultrasound as increased blood flow velocity in MCA
* IgM testing will confirm diagnosis
* where hydrops is detected it's treated with in utero transfusion
* spontaneous resolution of anaemia and hydrops will occur in about 50%
51
effect of hepatitis B on foetus
management as well
* vertical transmission occurs at delivery
* 90% of infected neonates become chronic carriers compared with just 10% of infected adults
* maternal sceening is routine in the UK
* neonatal immunisation reduces risk of infection in \>90% and is given to all positive women
52
what is the worldwide incidence of hepatitis C
3%
53
what percentage of people infected with Hep C get chronic infection
80%
54
how does HIV affect pregnancy?
pregnancy does not hasten progression to AIDS
pre-eclampsia is more common in HIV affected individuals
55
neonatal effects of HIV
* increased risk of stillbirth
* increased risk of pre-eclampsia
* growth restriction
* prematurity
* vertical transmission
56
how common is vertical transmission of HIV
with no preventave measures it's 15%
vertical transmission is most common with low CD4 count and high viral load i.e. very early and very late disease
57
management of HIV in pregnancy
* maternal HAART
* neonatal HAART 6/52
* elective C-section
* avoidance of breast feeding
58
what is the increase in cardiac output during normal pregnancy
40%
59
what is the blood volume increase in normal pregnancy
40%
60
what is the change in vascular resistance during normal pregnancy
50% reduced vascular resistance
61
murmers in pregnancy
increased blood flow causes an ejection systolic murmur in 90% of pregnant women
62
what is the leading cause of maternal death in the UK
cardiac disease
63
what are the principles of management of cardiac disease in pregnancy
warfarin and ACE inhibitors are contraindicated
existing thromboprophylaxis should be continued usually with aspirin and LMWH
Regular checks for anaemia
64
what is the dose of aspirin for pre-eclampsia prophylaxis
75mg OD
65
what is antiphospholipid syndrome
* this is when lupus anti-coagulant and/or anticardiolipin antibodies occur in association with adverse pregnancy complications or thrombotic events
* placental thrombosis causes
* IUGR
* Recurrent miscarriage
* early pre-eclampsia
66
67
management of antiphospholipid syndrome in pregnancy
the antibodies are found in many pregnant women but treatment should be reserved for those with the syndrome
treatment is aspirin and LMWH
68
How much is the incidence of VTE increased in pregnancy
6x
69
symptoms of PE
chest pain
dyspnoea
tachycardia
raised JVP
raised respiritory rate
70
what is the diagnosis of PE in pregnancy
* as for a non-pregnant woman it is
* CTPA
* chest x ray
* ABG
71
management of VTE in pregnancy
* weight based dose of LMWH
* NO WARFARIN
* both lmwh and warfarin are safe for breastfeeding women
72
maternal risks associated with obesity in pregnancy (8 things)
* VTE
* pre-eclampsia
* diabetes
* C section
* wound infection
* surgical difficulty
* PPH
* maternal death
73
foetal risks associated with obesity of mother
congenital abnormalities such as NTDs
diabetes
pre-eclampsia
74
managment of obesity in pregnancy
pre-conceptual weight advice
weightloss during pregnancy is not advised
folic acid and vitamin D supplementation
75
epilepsy treatment in pregnancy
* treatment should be continued as epilepsy is a significant cause of maternal death but there is a risk of congenital abnormalities
* generally neural tube defects
* risks are dose and drug dependent
* newborns have 3% risk of epilepsy
* carbamazepine and lamotrigine are the safest drugs
* supplementation with folic acid
76
hyperthyroidism in pregnancy
* anti-thyroid antibodies cross the placenta and this can cause neonatal thyrotoxicosis and goitry
* carbimaxole is substituted for propylthiouracil
* the lowest possible dose is used and thyroid function is tested monthly
77
how common is postpartum thyroiditis
5-10% of women
it is permanent in 20% of these
78
what is postpartum thyroiditis
it is a usually transient subclinical hyperthyroidism about 3 months postpartum this is usually followed by about 4 months of hypothyroidism
79
what is the clinical picture of intrahepatic cholestasis of pregnancy
otherwise unexplained pruritis
abnormal LFTs
80
what is the cause of intrahepatic cholestasis of pregnancy
abnormal sensitivity to cholestatic effects of oestrogens
81
how common is intrahepatic cholestasis of pregnancy
0.7% of women in the west
82
what are the risks of intrahepatic cholestasis of pregnancy
* increased risk of
* sudden stillbirth (1% risk)
* meconium passage
* postpartum haemorrhage
83
management of intrahepatic cholestasis of pregnancy
* ursodeoxycholic acid relieces itching and reduces obstetric risks
* vit K from 36 weeks
* induction by 38 weeks if bile levels high
84
common and rare causes of antepartum haemorrhage
* common
* undetermined origin
* placenta praevia
* plcental abruption
* rarer
* uterine rupture
* vasa praevia
85
risk factors for placenta praevia
* multiple pregnancy
* previous C section - implants in scar
* more common with increasing age
*
86
management of placenta praevia
* C section by 39 weeks unless it is very marginal
* haemorrhage common as lower segment of uterus does not contract well
87
how common is placental abruption
1% of pregnancies
88
what is the clinical picture of placental abruption
* may be small amount of bleeding - dark in colour
* pain
* may be shocked
* severe tenderness of uterus and may be contracting
* uterus may be hard and woody
* US may be normal
* foetal distress and death may follow
* there may be tachycardia which could suggest profound blood loss
89
risk factors for placental abruption
90
management of placental abruption
* if less than 37 weeks and there's foetal distress
* C-section
* If less than 37 weeks and there's not foetal distress
* conservative management
* If more than 37 weeks
* induction by amniotomy
91
investigations for antepartum haemorrhage (5 things)
* CTG
* FBC
* Clotting
* Group and save
* USS
92
management of antepartum haemorrhage
1. admit
2. fluid resus
3. steroids if \<34 weeks
4. Anti-D (if Rh-ve)
5. C-section if \<37 weeks and foetal distress
6. induction by amniotomy if \>37 weeks
7. conservative management if \<37 weeks and no foetal distress
93
tell me about ruptured vasa praevia
brisk, painless bleeding at ROM
1/5000 pregnancies
Massive foetal bleeding follows
C-section often not quick enough to save foetus
94
risk factors for ruptured uterus and see what happens
* sudden stop in contractions and foetal distress
* it's very rare
* risk factors
* uterine scars or congenitally abnormal uterus
95
what is the inheritance pattern of sickle cell
autosomal recessive
96
maternal complications of sickle cell
acute painful crises
pre-eclampsia
thrombosis
97
foetal complications of sickle cell
miscarriage
IUGR
preterm labour
98
management of sickle cell in pregnancy
hydroxycarbamide is teratogenic and stopped
penicillin is continued
high dose folic acid is given
aspirin and LMWH are often indicated
99
what is the definition of FGM
partial or total removal of the female external genitalia or other injury to the female genital organs for non-medical reasons
100
what are the names (just the names) of the 4 classifications of FGM
* Type 1: clitoridectomy
* Type 2: excision
* Type 3: infibulation
* Type 4: other
101
what is type 1 FGM
* clitoridectomy – partial or total removal of the clitoris
102
what is type 2 FGM
* excision – partial or total removal of the clitoris and the labia minora +/- the labia majora
103
what is type 3 FGM
* infibulation – narrowing of the vaginal opening by cutting and repositioning the labia, with or without removal of the clitoris
104
how common is shoulder dystocia
1/200 pregnancies
105
risk factors for shoulder dystocia
large baby
previous shoulder dystocia
obesity
106
will excessive traction work in shoulder dystocia and why
no
obstruction is at the pelvic inlet
excessive traction will cause erb's palsy
107
what is erb's palsy
palsy caused by excessive traction
"waiter's tip"
this is permanent in 10%
108
steps for shoudler dystocia
1. mcroberts manouvre and suprapubic pressure
2. episiotomy to allow hand to enter vagina
3. wood's screw manouvre
4. posterior arm is grasped, flexed at the elbow and brought down, narrowing the obstructed diameter by the width of the arm
5. as last resort pysmphysiotomy - but by this time foetal damage is usually irreversible
109
untreated, what will happen to a cord prolapse
cord becomes compressed and/or will go into spasm and the baby will rapidly become hypoxic
110
how common is cord prolapse
1/500 pregnancies
more than half happen at artificial amniotomy
111
what are the risk factors for cord prolapse?
112
management of cord prolapse
* presenting part pushed back in to stop compression
* tocolytics given e.g. terbutaline
* patient goes on all fours while preparation for C section is made
113
what is an amniotic fluid embolism
this is when the liquor enters maternal circulation
this causes anaphylaxis
there is sudden dyspnoea, hypotension and hypoxia
seizures cardiac arrest
DIC
very rare
114
what is the neonatal mortality in uterine rupture
10%
115
how common is uterine rupture
1/1500
116
what is the definition of primary amenorrhoea
no menarche by 16
117
what is delayed puberty
this is when there is no secondary sex characteristics in a girl by the age of 14
118
if there are secondary sex characteristics but no menstruation then what is the likely problem
outflow problem
119
what is secondary amenorrhoea
this is where previously normal menstruation ceases for 3 months or more
120
what is oligomenorrhoea
this is where menstruation occurs every 35 days to 6 months
121
physiological amenorrhoea examples
pregnancy, after the menopause and during lactation
122
locations of pathology in amenorrhoea
* hypothalamus
* pituitary
* thyroid
* ovary
* uterus
* outflow tract
123
two drugs that can cause amenorrhoea
progestogens and antipsychotics
124
what are the three most common causes of secondary amenorrhoea or oligomenorrhoea
premature menopause
PCOS
hyperprolactinaemia
125
what can cause hypothalamic hypogonadism
* psychological stresses
* anorexia/low weight
* excessive exercise
* tumours are a rare cause
126
what are the GnRH, FSH, LH and oestradiol levels in hypothalamic hypogonadism
GnRH levels are reduced
therefore LH, FSH and oestradiol levels are reduced
127
what is the aetiology of pituitary amenorrhoea
hyperprolactinaemia
this is usually due to pituitary hyperplasia or benign adenomas
128
most common congenital cause of ovarian cause of amenorrhoea
turners
129
what is turners
one X chromosome is absent
45XO is the karyotype
short stature
poorly formed secondary sexual characteristics
normal intelligence
130
what are the acquired causes of ovarian amenorrhoea
PCOS
premature menopause
rare virilising tumours of the ovary
131
how common is premature menopause
1/100
132
name some outflow tract problems of amenorrhoea and how they might present
133
when is a couple subfertile
when they have not conceived after a year of regular unprotected menopause
134
what is primary infertility
the female has never conceived before
135
what is secondary infertility
the female has previously conceived
136
what are the conditions for pregnancy
and how often does subfertility lie in each of these categories being faulty
1. an egg must be released (30% cases are anovulation)
2. adequate sperm must be released (male factor is 25%)
3. sperm must reach the egg (tubal problems are 25%)
* but this also includes coital problems and cervical
4. fertilized egg must implant (this is unknown but could account for the 30% of subfertility cases that are unknown)
137
investigating ovulation as a cause of subfertility
if ovulation has happened they should have elevated serum progesterone 7 dayse before the first day of menstruation
AKA day 21 progesterone
138
what is PCO
* PCO describes a TVU appearance of 12 or more small (2-8mm) follicles in an enlarged ovary
* this is found in abotu 20% of all women - the majority of whom are regular and fertile
139
what proportion of anovulatory subfertility is caused by PCO
80%
140
what percentage of all women are affected by PCOS
5%
141
what is the diagnostic criteria for PCOS
hirsuitism (clinical or biochemical)
PCO on US
irregular periods \>5 weeks apart
142
what investigations would you use to exclude other causes for the symptoms of PCOS
* FSH
* raised in premature menopause
* low in hypothalamic hypogonadism
* normal in PCOS
* AMH
* high in PCOS
* low in premature menopause
* Prolactin
* to exclude prolactinoma
* TSH
* to exclude thyroid pathology
143
complications of PCOS
* 50% of women with PCOS develop T2DM later in life]
* 30% develop gestational diabetes
* endometrial cancer is more common
* no increased mortality
144
management of PCOS if fertility is not required
* weight normalisation - improves symptoms and helps with insulin regulation
* OCP regulates menstruation and treats hirsuitism
145
management of PCOS for fertility
* clomifene if BMI \>30
* metformin if BMI \<30
* second line is them both combined
* gonadotrophins can also be used
146
how does clomifene work
blocks oestrogen receptors on the hypothalamus and pituitary
hypothalamus and pituitary think there's low oestrogen
pituitary releases FSH and LH
it is taken between day 2-6 of cycle
147
side effects of artificial ovulation induction
* multiple pregnancy is more common with every treatment except for metformin
* ovarian hyperstimulation syndrome (OHSS)
* gonadotrophin therapy overstimulates the follicles which become very large and painful
148
what is prolactinoma and what is the investigation and how do you treat it
* excess prolactin secretion
* reduces GnRH release
* usually caused by benign tumours of hyperplasia
* associated with PCOS
* patient may have headaches +/- bitemporal hemianopia
* CT is indicated
* treatment is with dopamine agonist called bromocriptine
149
what is azoospermia
no sperm present
150
what is oligospermia
\<15million sperm /ml
151
what is severe oligospermia
\<5million sperm /ml
152
what is asthenospermia
poor sperm mobility
153
what are the common causes of abnormal semen analysis
smoking
alcohol
drugs
inadequate local cooling (truck drivers)
genetic factors
anti-sperm antibodies
154
what are the causes of disorders of fertilisation
* it's almost always tubal
* infection is the main cause (PID due to chlamydia or gonorrhoea)
* this causes adhesions
* can also be
* endometriosis
* previous surgery/sterilisation
* sexual problems
155
diagnosis of tubal problems
156
management of ectopic pregnancy
* 3 approaches
1. expectant
* monitor for 48hrs
2. medical
* methotrexate
3. surgical
* salpingectomy or salpingotomy
157
when would you manage an ectopic expectantly
\<30mm
unruptured
asymptomatic
no-foetal heartbeat
158
when would you manage an ectopic medically
if \<35mm
if unruptured
asymptomatic
no foetal heartbeat
159
when would you manage an ectopic surgically
if \>35mm
if symptomatic
if ruptured
160
causes of early pregnancy vaginal bleeding
subchorionic haemorrhage
twin demise
gesatational trophoblastic disease
161
what is subchorionic haemorrhage
bleeding between uterine wall and chorionic membrane
it increases risk of abruption and preterm labour
162
what is the most common cause of post-coital bleeding
cervical ectropian
163
when does hyperemesis gravidarum occur
8-12 weeks
164
what are the dangerous complications of hyperemesis gravidarum
wernicke's encephalopathy
mallory weiss tear
foetal growth restriction
165
what is the lie of the foetus
relationship with long axis of the uterus
longitudinal oblique or transverse
166
when does diagnosis of abnormal lie become important
37 weeks - early pregnancy they often turn around
167
management of breech presentation
* ECV attempted from 37 weeks
* planned c section at 39 weeks
* or
* planned vaginal breach birth
* difference in risk is very small
168
what proportion of pregnancies are twins
1/80
169
what is the difference between DCDA and MCDA and what does this mean
* DCDA
* dichorionic diamniotic
* division before day 3
* happens in 30% of cases
* MCDA
* monochorionic diamniotic
* division between day 4 and day 8
* happens in 70% of cases
170
risk factors for multiple pregnancy
* increasing maternal age
* increasing parity
* assisted conception
* family history
* IVF
* clomifene assisted
171
complications of all types of multiople pregnancy
prematurity
IUGR
172
complications of monochorionicity
* twin to twin transfusion syndrome
* co twin death
173
what type of twins does TTTTS occur
MCDA
174
what happens in th TTTTS and how often does it happen
* happens in 15% of MCDA twins
* unequal blood flow through shared placenta
* donor twin
* anaemi
* IUGR
* oligohydramnios
* recipient twin
* volume overloaded
* polycythaemia
* cardiac failure
* massive polyhydramnios
175
what happens in co twin death
* one twin dies
* the drop in their blood pressure leads to loss from survivor
* 30% of cases result in death or neurological damage
* this is not a risk for dichorionic twins
176
what is the mode of delivery for twins
vaginal delivery is indicated if the first twin is cephalic
c section if the first twin is breach or transverse
177
diagnosis of labour
painful, regular uterine contracctions WITH dilation and effacement of the cervix
178
179
mechanical factors that affect progress of labour
* the powers
* the passenger
* the passage
180
what does attitude describe
the degree of flexion
i.e. vertex, brow or face
181
what does presentation describe
the part of the foetus that occupies the lower segment of the pelvis
i.e. head
182
describe the first stage of labour
* initiation to full cervical dilation
* latent stage
* 0-4cm
* established first stage
* regular painful contractions AND progressive cervical dilation from 4cm
183
describe the second stage of labour
* full cervical dilation to delivery of foetus
184
movements of the head in labour
1. engagement in OT
2. descent and flexion
3. rotation to OA
4. descent
5. extension to delivery
6. restitution and delivery of the shoulders
185
reassuring number of baseline beats/minute on CTG
110-160
186
non reassuring beats/minute on CTG
100-109
or
161 to 180
187
abnormal beats/minute on CTG
below 100
or
above 180
188
reassuring variability on CTG
5-25
189
non-reassuring variability on CTG
\<5 for 30-50 mins
\>25 for 15-25 mins
190
abnormal variability on CTG
\<5 for more than 50 minutes
or
\>25 for more than 25 minutes
or
sigmoidal
191
what do decelerations mean on CTG
no decellerations or early decellerations are reassuring
variable decellerations or late decellerations can be non-reassuring or abnormal but this depends on loads of factors and i wouldn't bother learning them
192
indications for CTG pre-labour
pre-eclampsia
IUGR
previous C section
induction
193
indications for CTG in labour
meconium
use of oxytocin
presence of temperature \>38
auscultation abnormalities
194
management of foetal distress
* in utero resuscitation
* left lateral position
* oxygen and IV fluids
* VE to exclude cord prolapse or very rapid progression
* confirmation of distress and delivery
* FBS
* if pH \<7.2 delivery expedited
* if \>7.2 then another FBS in 30 mins
195
pain relief in labour
* inhalational entonox (NO and O2)
* systemic opiates
* pethidine IM
* epidural anaesthetic
* fentanyl and bupivicaine
* into epidural space between L3 and L4
196
complications of epidural
* spinal tap
* headache worse on standing
* if present \>48hrs then treat with blood patch
* IV injection causes cardiac arrest
* injection into the CSF and progression up the spinal cord can cause total spinal analgesia and respiratory paralysis
197
methods of induction of labour
* prostaglandin
* prostaglandin E inserted into the posterior vaginal fornix
* best option in nulliparous women
* either starts labour or ripens cervix enough to allow amniotomy
* amniotomy
* amnihook used to rupture forewaters
* axytocin infusion is then started within 2 hrs if labour hasn't ensued
* oxytocin infusion alone can be used if SROM has already occured
198
7 indications for induction
prolonged pregnancy
IUGR
pre-labour term rupture of membranes
antepartum haemorrhage
pre-eclampsia
diabetes
in utero death
199
absolute contraindications for induction
abnormal lie
abnormal CTG
placenta praevia
200
how much milk can be produed per day
a litre
201
what is colostrum
milk passed in the first three days - contains IgA and lots of fat
202
describe the physiology of lactation
prolactin (from AP) stimulates milk secretion
prolactin antagonised by oestrogen and progesterone
the rapid decline in oestrogen and progesterone after birth causes milk secretion
suckling causes oxytocin release from posterior pituitary which causes ejection
203
when should contraception be started post delivery and which is most suitable
4-6 weeks following delivery
remember COCP is contraindicated if breastfeeding
Progesterone only pill or depot is safest if breastfeeding
Mirena is safe
204
what is the definition of primary postpartum haemorrhage
\>500mL of blood loss \<24hrs following delivery
(or 1000mL following caesarian)
205
how common is primary postpartum haemorrhage
10% of women
206
what is massive obstetric haemorrhage
\>1500mL of blood loss which is continuing
207
causes of postpartum haemorrhages
* 4 Ts
* Tissue
* retained placenta
* Tone
* atonic uterus
* Thrombophilia
* thromboprophylaxis should have been stopped 12hrs before labour
208
management of postpartum haemorrhage
* resus
* no site of trauma found then oxytocin or ergometrine is given IV to contract uterus
* persistent haemorrhage gets rusch balloon
209
what is secondary postpartum haemorrhage
excessive blood loss between 24hrs and 6 weeks following delivery
210
what is the most common cause of secondary postpartum haemorrhage and what is the management
* normally endometritis +/- retained placental tissue
* there may be an enlarged and tender uterus with it
* most commonly managed with evacuation of retained products of conception
211
what is the definition of delivery before term
delivery between 24 and 37 weeks gestation
212
what is late miscarriage
fetal death between 16 and 23+6 weeks
213
what happens to babies born at 24 weeks
1/3 will be fine
1/3 will be disabled
1/3 will die
214
if delivered by 32 weeks what is the risk of death and permanent disability
\<5%
215
risk factors for pre-term delivery
* Think of this as a castle holding ‘defenders’ in
* 1 – too much inside
* Multiple pregnancy, polyhydramnios
* 2 – defenders escape
* IUGR, pre-eclampsia
* 3 – weak wall
* Cervix
* 4 – enemy
* Bacteria in vagina
* 5 – enemy
* Bacteria elsewhere
216
investigation of suspected pre-term labour if cervix is uneffaced
foetal fibronectin
-ve result means delivery within next week is unlikely
217
management of pre-term labour
* steroids given to women within 23 to 34 weeks
* tocolysis with nifedipine or atosiban
* shouldn't be used for more that 24hrs
* allow time to act
* mag sulphate is neuroprotective for the neonate if given \<12hrs before pre-term delivery
218
what is the principle complication of preterm, prelabour rupture of membranes
delivery will occur within 48hrs in most cases
219
management of preterm prelabour rupture of membranes
* chorioamnionitis or funisitis may cause or be caused by the SROM
* so infection is investigated with
* high vaginal swab
* FBC
* CRP
* foetal wellbeing assessed with CTG
* risk of delivery must be balanced with risk of infection
* if gestation is 34-36 weeks then delivery is normally undertaken
220
what is foetal hydrops
this is when extra fluid accumulates in two or more areas of the foetus
221
causes of foetal hydrops
* can either be immune or non-immune
* immune
* anaemia and haemolysis due to maternal antibodies
* non-immune
* chromosomal abnormalities
* structural (pleural effusions)
* cardiac abnormalities or arrhythmias
* anaemia causing cardiac failure
* TTTTS
222
potentially sensitising events for red blood cell isoimmunisation
termination
erpc
ectopic pregnancy
vaginal bleeding
ECV
invasive uterine procedures such as CVS or amniocentesis
intrauterine death
delivery
223
what is anti-d for
exogenous anti-d given to mother stops her producing maternal anti-D as it mops up baby's red cells that have crossed over to mum
should be given before any sensitising event if mother is -ve and baby's status is unknown
224
how can rhesus disease cause hydrops
* there may be enough haemolysis to cause neonatal anaemia
* this is when it becomes haemolytic disease of newborn
* if disease is even more severe it may cause in utero anaemia and as this worsens cardiac failure
* cardiac failure leads to ascites and anaemia --\> hydrops
* foetal death will likely follow
225
management of isoimmunisation
* identifying women at risk of foetal haemolysis and anaemia
* assessing how severely the foetus is anaemic
* doppler US of MCA peak systolic velocity has high sensitivity
* blood transfusion in utero or delivery for affected foetuses
226
describe the classifications of perineal tears
1. first degree
* injury to skin only
2. second degree
* involving perineal muscles but not anal sphincters
3. third degree
* 3a: \<50% anal sphincter is torn
* 3b: \>50% of anal sphincter is torn
* 3c: internal anal sphincter is also torn
4. fourth degree
* involves anal sphincter and anal epithelium
227
risk factors for third and fourth degree tears
forceps delivery
large babies
nulliparity
228
indications for instrumental delivery
prolonged second stage
foetal distress in second stage
when maternal pushing is contraindicated
229
6 prerequisites for instrumental delivery
cervix fully dilated
position of head known
head deeply engaged and mid-cavity or below
adequate analgesia
empty bladder
valid indication
230
how often is C-section used
25% of births
231
emergency C section indications
acute anteopartum problems such as abruption
prolonged first stage of labour (i.e. delivery nor imminent by 12-16hrs)
foetal distress
232
when is elective c section USUALLY done
39 weeks
if done earlier steroids should be given
233
absolute indication for elective c section
placenta praevia
severe antenatal compromise
uncorrectable abnormal lie
previous vertical c section
gross pelvic deformity
234
what is SGA
small for gestational age
aka small for dates
weight is \<10th centile for its gestation
many of these will simply be constitutionally small
235
what is IUGR
intrauterine growth restriction
failed to reach growth potential
just as a malnourished tall person may weigh more than a shorter healthier one, an IUGR foetus may not be SGA
236
what is foetal distress
acute situation such as hypoxia
may result in foetal death or damage if not reversed or delivered urgently
237
foetal compromise
this is a chronic situation
when conditions for optimal growth and development are not met
238
how is the pattern of smallnes on US relevant
if growth restricted the abdomen will stop enlarging before the head (which is spared)
so reduction in rate of growth of \>30% of abdomen is suggestive of iUGR
239
how do doppler waveforms of foetal cerebral circulation inform on IUGR
* doppler measures resistance in MCA
* with foetal compromise the MCA often develops a low resistance pattern in comparison with the thoracic aorta or renal vessels
* this reflects head sparing
* velocity of flow will also increase with anaemia
240
causes of constitutionally small babies without IUGR
nulliparity
low maternal weight and height
asian
female foetal gender
241
nine causes of iugr
pre-existing maternal disease such as renal disease
maternal pregnancy complications such as pre-eclampsia
multiple pregnancy
smoking
drug usage
CMV
extreme exercise
malnutrition
congenital abnormalities
242
what time is the booking appointment and what happens there
* 8-12 weeks
* investigations
* thalassaemia
* anaemia
* sickle cell
* rhesus
* HIV
* HepB
* Syphilis
* Blood pressure
* BMI calculation
243
when is the dating scan
8-14 weeks
244
what happens at the dating scan
combined test for down's syndrome
advised to get whooping cough vaccine from 16 weeks
245
down's syndrome screening
* optional
* Combined test offered between 11 and 13 weeks +6
* Nuchal translucency (thickened in downs)
* Beta-human chorionic gonadotrophin (high in downs)b-hCG
* Pregnancy associated plasma protein A (low in downs) PAPPA
* If it’s not possible to measure nuchal translucency due to foetal position or raised BMI then women should be offered serum screening between 15 and 20 weeks
246
when is the anomaly scan
18-20 weeks
247
what 11 conditions does the anomaly scan look for
anencephaly
open spina bifida
cleft lip
diaphragmatic hernia
gastroschisis
exomphalos
serious cardiac abnormalities
bilateral renal agenesis
lethal skeletal dysplasia
Edwards' syndrome, or T18
Patau's syndrome, or T13
248
when would they have their first anti-d treatment if rhesus neg
28 weeeks
249
when would they have their second anti-d treatment if rhesus neg
34 weeks
250
what are the types of miscarriage
1. threatened miscarriage
2. inevitable miscarriage
3. incomplete miscarriage
4. complete miscarriage
5. septic miscarriage
6. missed miscarriage
251
what happens in threatened miscarriage
bleeding but foetus is still alive
uterus is the size expected for dates
os is closed
only 25% will go on to miscarry
252
what happens in inevitable miscarriage
heavier bleeding
os is open
foetus may be alive but miscarriage is iminent
253
what happens in incomplete miscarriage
some foetal parts have been passed
the os is usually open
254
what happens in complete miscarriage
all foetal tissue has been passed
bleeding is diminished
uterus is no longer enlarged
cervical os is closed
255
what happens in septic miscarriage
contents of uterus are infected causing endometritis
vaginal loss is usually offensive
fever can be absent
uterus is tender
may be abdominal pain and peritonism
256
what happens in missed miscarriage
foetus is dead
this is not recognised until bleeding occurs or there is an US scan
uterus is smaller than is expected for the dates and the os is closed
257
what is PUL
* PUL is when it is not possible to use US to differentiate between:
* an early viable pregnancy
* a failing intrauterine pregnancy
* a complete miscarriage
* an ectopic pregnancy
* all of these can show an empty uterine cavity with no abnormal adnexal fluid or masses
258
what is the management of PUL
* women with PUL have ectopic pregnancy until proven otherwise
* beta hCG levels normally increase by \>63% in 48hrs with viable intrauterine pregnancy
* a decline by more than 50% in beta hCG over 48hrs indicates non viable pregnancy
* a change in beta hCG of between 50 and 63% over 48hrs indicates ectopic
* rhesus typing
* if neg needs anti-D before management of miscarriage
259
what is the definition of recurrent miscarriage
three or more miscarriages occuring in succession
260
what percentage of couples are affectd by recurrent miscarriage
1%
261
what is the chance of miscarriage in fourth pregnancy if a couple has had three consecutive miscarriages
still only 40%
262
what are the causes of recurrent miscarriage
* antiphospholipid antibodies
* thrombosis in the uteroplacental circulation
* treat with aspirin and LMWH
* parental chromosomal defects
* antomical factors
* thyroid dysfunction
* PCOS
* could be responsible but would mainly be through raised BMI
263
investigation of recurrent miscarriage
* antiphospholipid antibody screen
* karyotyping of foetal miscarriage tissue
* thyroid function
* pelvic ultrasound
264
describe the medical methods of TOP
* the antiprogesterone mifepristone is given
* 36-48hrs later the prostaglandin E1 analogue such as misoprostol
* will work at any gestation
* from 22 weeks feticide is performed first to prevent live birth
265
which method of TOP based on gestation
* 0-7 weeks: medical
* 7-14 weeks: suction and curettage
* 14-24 weeks: medical or dilation and evacuation
266
what happens in dilation and evacuation
* antibiotic prophylaxis must be given
* cervix must be prepped with vaginal misoprostol
267
worldwide, what percentage of abortions are thought to be unsafe
50%
268
What is thelarche and when does it normally occur
beginning of breast develpment
9-11 years
269
what is adrenarche and when does it normally occur
growth of pubic hair
11-12 years
270
what is menarche and when does it normally occur
it is onset of menstruation
western average is 13 years
271
normal blood loss during menstruation should be less than what
80mL
272
what is the definition of abnormal menstrual bleeding
* any variation from the normal menstrual cycle and includes changes in the regularity and frequency of menses, in duration of flow and amount of blood flow
273
what is the most common type of abnormal menstrual bleeding
heavy menstrual bleeding
274
causes of abnormal menstrual bleeding
the nine main categories can be remembered with the acronym PALM COEIN
* structual causes - PALM
* Polyps
* Adenomyosis
* Leiomyomas
* Malignancy
* non-structural causes - COEIN
* Coagulopathy
* Ovulatory dysfunction
* Endometrial
* Iatrogenic
* Not yet specified
275
what is the definition of heavy menstrual bleeding
Excessive menstrual blood loss which interferes with the woman’s physical, emotional, social and material quality of life and which can occur alone or in combination with other symptoms
276
what is the definition of irregular menstrual bleeding
Cycle to cycle variation \>20 days
277
what is the definition of oligomenorrhoea
Bleeding at intervals \>38 days apart
278
what is the definition of frequent menstrual bleeding
Bleeding at intervals \<24 days apart
279
what is the definition of prolonged menstrual bleeding
\>8 days
280
what is the definition of shortened menstrual bleeding
\<3 days
281
what is precocious menstruation
bleeding before the age of 9
282
what are the causes of heavy menstrual bleeding
* mostly there is no cause found
* most common causes found are
* fibroids
* polyps
* other causes are
* thyroid disease
* haemostatic disorders
* anticoagulant therapy
283
investigations of heavy menstrual bleeding
* to assess the effect of blood loss
* Hb
* to exclude systemic causes
* coagulation screen
* thyroid function test
* to exclude local structural causes
* TVUS
284
when would you want to exclude endometrial cancer or hyperplasia in a woman presenting with HMB and how would you do this
* in women over 40 with HMB
* in those with bleeding that doesn't respond to medical therapy
* in younger women with risk factors for endometrial cancer
exclude with TVUS
285
what is the normal endometrial thickness in a pre-menopausal woman
4mm in follicular phase
to
16mm in luteal phase
286
draw the flow chart for treatment of menorrhagia
287
what is the hormone released by the IUS
preogestogen called levonogestrel
it is also called the mirena
288
what effect do copper IUDs have on menstrual flow
they increase them
289
which NSAID can be used for heavy menstrual bleeding
mefanemic acid
290
how does mefanemic acid affect menstrual flow
it reduces it by inhibiting prostaglanding synthesis and reducing blood loss by 30%
it also helps with pain
291
which surgeries may be useful for heavy menstrual bleeding
polyp removal
endometrial ablation
hysteractomy as a last resort
trans cervical resection of fibroid (TCRF)
292
when would you biopsy endometrium if there was heavy menstrual bleeding
if they're over 40
HMB with IMB
if they have risk factors for endometrial cancer
HMB that is unresponsive to medical therapy
if TVU suggests polyp or focal thickening
if the abnormal bleeding has resulted in an acute admission
293
what is associated with painful menstruation
high prostaglandin levels in the endometrium
294
what causes period pains
contraction of the uterus and ischaemia
295
what is primary dysmenorrhoea
this is when no organic cause can be found
296
what is secondary dysmenorrhoea
this is when the pain is due to pelvic pathology
297
main causes of secondary dysmenorrhoea
fibroids
adenomyosis
endometriosis
PID
298
what is premenstrual syndrome
Psychological, behavioural and physical symptoms that are experienced on a regular basis during the luteal phase of the menstrual cycle and often resolve by the end of menstruation
299
management of debilitating PMS
* SSRIs are either given continuously or given only in the second half of the cycle
* cycle ablation with COCP or GnRH agonists
300
what are the locations that a fibroid can be in from most external to most internal
* Subserous polyp
* Subserous fibroid
* Intramural fibroid
* Submucosal fibroid
* Intracavity polyp
301
a transverse section of the fibroid has a ______ appearance
'whorled'
302
what is the aetiology of a fibroid
they are oestrogen and progesterone dependent
during pregnancy they can grow, shrink or show no change
they regress during menopause due to reduction in circulating sex hormones
303
what percentage of fibroids are asymptomatic and discovered at US
50%
304
relate symptoms of fibroid to their location
* asymptomatic --\> likely to be subserosal
* bleeding --\> submucosal
* hydronephrosis --\> pressing on ureters
* urgency and frequency --\> pressing on bladder
305
complications of fibroids in pregnancy
premature labour
malpresentation
postpartum haemorrhage
obstructed labour
306
complications of fibroids
torsion of a pedunculated fibroid
degeneration --\> pain
malignant transformation into leiomyosarcoma
307
management of fibroids
treatment of symptoms
TCRF
open laporoscopic myomectomy
radical hysterectomy
308
309
how common is adenomyosis
it occurs in 40% of hysterectomy specimens
310
symptoms of adenomyosis
symptoms can be absent
painful, regular, heavy menstruation is common
311
what are polyps made of
they are usually of endometrial origin
they can be fibroid
t
312
what are the symptoms of polyps
they can be asymptomatic
they can cause menorrhagia or IMB
313
what is the management of uterine polyps
resection by diathermy or cutting
this cures bleeding problems
314
what is the most common gynae cancer
endometrial cancer
315
what is the age at which prevalence of endometrial cancer is highest
60
316
what are the types of endometrial cancer
* type 1: the majority
* oestrogen dependent
* low grade
* less aggressive
* type 2: the minority
* not oestrogen dependent
* more aggressive
317
risk factors for endometrial cancer
* endogenous oestrogen excess
* obesity
* early menarche
* late menopause
* PCOS
* nulliparity
* exogenous oestrogen excess
* unapposed oestrogen therapy
* tamoxifen
* Misc
* diabetes --\> (higher BMI?)
318
symptoms of endometrial cancer
PMB
younger patients: IMB or new menorrhagia
319
why does endometrial cancer have better 5 yr survival than ovarian
because it tends to be found in early stages
75% of patients present at stage 1
people wrongly think it is because it is a less aggressive cancer but stage for stage the 5yr survival is similar to ovarian
320
what is the treatment for endometrial cancer
laporoscopic hysterectomy and bilateral salpingooopherectomy
if high risk for late stage disease (staging can only happen following hysterectomy) they may be given external beam radiotherapy as adjuvant
321
322
what is the 5yr survival of endometrial cancer
75%
323
what are the pre-malignant conditions of the cervix
* CIN I: mild dysplasia
* CIN II: moderate dysplasia
* CIN III: severe dysplasia
324
what is CIN I
* mild dysplasia
* atypical cells found in only the lower third of the epithelium
* often regresses spontaneously
325
what is CIN II
* moderate dysplasia
* atypical cells found in bottom two thirds of the epithelium
326
what is CIN III
* severe dysplasia
* atypical cells occupy the full thickness of the epithelium
* this is carcinoma in situ
* malignancy ensues if these cells invade the basement membrane
327
what is the management of the smear result: NORMAL
routine recall
328
329
what is the management of the smear result: BORDERLINE
If HPV negative then back to routine recall
if HPV positive then colposcopy
330
what is the management of the smear result: LOW GRADE DYSKARYOSIS
331
what is the management of the smear result: HIGH GRADE DYSKARYOSIS
colposcopy
332
if untreated, what proportion of women with CIN II or III will develop cervical cancer over the next ten years?
1/3
333
what is the screening schedule for cervical cancer
from age of 25 every three years unti age of 49
every five years between 50 and 64
334
how do they look for CIN in colposcopy
grades of CIN have characteristic appearances when treated with 5% acetic acid
diagnosis is only confirmed histologically
335
what is the treatment for CIN
* CIN II or III is treated with excision of the transformations zone with cutting diathermy
* this is called large loop excision of transforming zone
* this is diagnosis and treatment at the same time
336
what is the most common age of diagnosis of cervical cancer
there are two peaks of incidence
in 30s and 80s
337
what are the symptoms of cervical cancer
* PCB
* offensive vaginal discharge
* IMB
* PMB
* smears may have been missed
338
stages of cervical cancer
* stage 1: lesions confined to cervix
* stage 2: invasion into the upper vagina but not the pelvic side wall
* stage 3: invasion of lower vagina or pelvic wall or causing ureteric obstruction
* stage 4: invasion of bladder or rectal mucosa or beyond true pelvis
339
investigation of cervical cancer
* Examination
* Ulcer or mass may be visible
* With early disease the cervix may appear normal to the naked eye
* To confirm diagnosis
* Tumour is biopsied
* To stage the disease
* MRI
340
treatment of cervical cancer
* depends on stage
* early: cone biopsy
* middle: simple hysterectomy
* late: radical hysterectomy
* above stage 2b: chemoradiotherapy alone is used
341
prognosis of cervical cancer
5yr survival ranges from 95% to 10% depending on stage
342
what are the ovarian cyst 'accidents'
* rupture of ovarian cyst
* haemorrhage into a cyst
* ovarian cyst torsion
* urgent surgery required to save ovary
343
what does the term ovarian cyst actually mean
* The word cyst is often interpreted to mean cancer by patients but can mean anything from the malignant to the physiological
344
types of ovarian cysts
endometriotic cysts
functional cysts
345
what are endometriotic cysts
endometrial tissue accumulates in 'chocolate cysts' in the ovary
rupture is painful
346
what are functional cysts of the ovary
these are persistently enlarged follicles or corpora lutea
they're only found in premenopausal women
OCP protects against them by stopping ovulation
if symptoms are absent then they are not removed and the cyst is just observed
because of the possibility of malignancy, if a functional cyst is \>5cm then CA125 is measured and laparoscopy to drain and/or remove the cyst is considered
347
what is the 10yr survival of ovarian cancer
40-50%
348
lifetime risk of developing ovarian cancer in the UK is \_\_\_\_
1/60
349
what type of cancer is ovarian cancer most commonly
serous adenocarcinoma
350
if a woman is \<30 with ovarian cancer it is likely \_\_\_\_\_\_
germ cell tumour
this is very rare
351
risk factors for ovarian cancer
early menarche
late menopause
nulliparity
352
protective factors against ovarian cancer
pregnancy
lactation
use of OCP
353
gene mutations that contribute to ovarian cancer risk
BRCA1 and/or BRCA2 or HNPCC gene mutations
354
diagnosis of ovarian cancer
* risk of malignancy index is used
* UxMxCA125
* U is the ultrasound score
* M is the menopausal status
* 1 point for premenopausal
* 3 points for postmenopausal
* women with an RMI of over 250 are referred to speciaist MDT
* women who are pre-menopausal also have alpha fetoprotein (AFP) and hCG measured since these are raised in germ cell tumours
355
how do you calculate the ultrasound score in the risk of malignancy index for ovarian cancer
* 1 point for any of the following
* multi-locular cysts
* solid areas
* metastases
* ascites
* bilateral lesions
* 3 points for 2 or more of the above
356
treatment for ovarian cancer
total hysterectomy and bilateral salpingoophorectomy and partial omentectomy
adjuvant chemo
357
what is the hallmark presentation of pelvic inflammatory disease
bilateral lower abdo pain with deep dysparenunia
358
investigations for PID
endocervical swabs for chlamydia and gonorrhoea
359
symptoms of PID
abnormal vaginal discharge
bilateral lower abdo pain
deep dyspareunia
fever in acute cases
360
differentials of acute PID
how would you differentiate them
appendicitis
ovarian cyst accident
ectopic pregnancy
361
treatment for acute PID
* analgesics
* IM cephalosporin such as ceftriaxone
* doxycycline and metronidazole
* if they are febrile it should be IV
362
what is it called if fallopian tubes are filled with fluid
hydrosalpinx
363
what's it called if fallopian tubes are dilated with pus
pyosalpinx
364
common symptoms of chronic inflammatory disease
chronic pelvic pain
dysmenorrhoea
deep dyspareunia
chronic vaginal discharge
heavy and irregular menstruation
365
what is the treatment for chronic PID
metronidazole and ofloxacin
366
itch, cottage cheese discharge +/- vulvitis is most likely \_\_\_\_\_
candidiasis
367
malodourous discharde that is worse with intercourse and not associated with vulvovaginitis is most likely \_\_\_\_\_\_\_
bacterial vaginosis
368
what percentage of women are diagnosed with endometriosis
1-2%
369
what are the symptoms of endometriosis
* chronic pelvic pain
* dysmenorrhoea before onset of menstruation
* deep dyspareunia
* subfertility
* pain on passing stool (dyschezia)
* in severe cases the uterus is retroverted and immobile due to adhesions
370
differentials of endometriosis
adenomyosis
chronic PID
other causes of pelvic masses
IBS
371
management options for endometriosis
* medical
* NSAIDs
* COCP
* Progestogen
* GnRH analogues
* IUS
* surgical
* see and treat with scissors, diathermy or laser during diagnostic lap
* hysterectomy and BSO for severe cases
372
what are the principles of medical treatment for endometriosis
* hormonal treatment is based on the observation that symptoms regress
* during pregnancy
* progestogens and cocp mimic pregnancy
* in the post-menopausal period
* GnRH analogues mimic menopause
* under the influence of androgens
* danazol is an androgen
373
using the COCP for endometriosis
* tricycling
* not suitable for older women, smokers or people who wish to conceive
374
using progestogen for endometriosis
cyclical or continuous
causes PMS
causes weight gain
can cause erratic bleeding
375
GnRH analogues for endometriosis
induces temporary menopause
overstimulation of the pituitary leads to down regulation of it's GnRH receptors
menopausal side effects limit therapy to 6 months although if you use adback hormone replacement then it can be used for up to two years
376
what is the median age of menopause
51
377
what is premature menopause and how common is it
menopause before 40 and it affects 1% of women
378
causes of post menopausal bleeding
endometrial cancer
endometrial hyperplasia +/- atypia and polyps
cervical carcinoma
atrophic vaginitis
cervicitis
ovarian carcinoma
cervical polyps
379
symptoms and consequences of the menopause
* cardiovascular disease
* vasomotor symptoms
* urogenital problems
* sexual problems
* loss of bone density
380
Investigations of menopause
* FSH
* increased levels suggest fewer oocytes remaining in the ovaries
* if they are having regular periods then it's done on day 2 and day 5 of the cycle
* if they're not then two samples are taken two weeks apart
* AMH
* low levels consistent with ovarian failure
* stable so can be measured at any point throughout cycle
381
when is unapposed oestrogen therapy fine
if they have had a hysterectomy
382
what are the two progestogens used in HRT
levonogestrel and norethisterone
383
HRT risks
* combined but NOT OESTROGEN ALONE increases risk of breast cancer
* risk begins to fall when therapy is stopped and five years later it's the same as anyone else
* unapposed oestrogen --\> endometrial cancer
* VTE: increases risk with highest risk being in the first year of use
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what's the difference between an enterocoele and a rectocoele
* enterocoele
* prolapse of the upper posterior wall of the vagina
* pouch often contains loops of small bowel
* rectocoele
* prolapse of lower wall of the vagina
* involves anterior wall of rectum
385
what is the baden walker classification of prolapse
* 0 – no descent of pelvic organs during straining
* 1 – leading surface of the prolapse does not descend below 1cm above the hymenal ring
* 2 – leading surface of the prolapse extends to between 1cm above the hymenal ring and 1cm below the hymenal ring
* 3 – leading surface of the prolapse extends more than 1cm past the hymenal ring but without complete vaginal eversion
* 4 – vagina completely everted (complete procidentia).
386
risk factors for vaginal prolapse
large infant
prolonged second stage
instrumental delivery
abnormal collagen metabolism e.g. ehlers danlos
increasing age
obesity
constipation
chronic cough
heavy lifting
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symptoms of vaginal prolapse
* Sense of heaviness or draggin g
* Sexual difficulty
* Cystocoele could cause frequency or incomplete bladder emptying
* Stress incontinence is common but may be incidental
* Rectocoele occasionally causes difficulty defacating
389
management of vaginal prolapse
* weight reduction
* pelvic floor physio
* ring or shelf pessaries
* need changing every 6-9 months
* surgery
390
surgery for uterine prolapse
* Vaginal hysterectomy
* 40% will have subsequent vaginal vault prolapse
* Hysteropexy
* Uterus and cervix attached to sacrum with mesh
391
surgery for vaginal vault prolapse
* Sacrocolpopexy
* Vault fixed to sacrum with mesh
* Sacrospinous fixation
* Suspends vault to sacrospinous ligament
392
surgery for vaginal wall prolapse
* Anterior and posterior repairs are used for the relevant prolapse but as several prolapses can occur at once they are often combined into one procedure
393
surgery for urodynamic stress incontinence
* Tension-free vaginal tape (TVT)
* Transobturator tape (TOT)
* Burch colposuspension
