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Phase 3A Revision > Obs + Gynae II > Flashcards

Obs + Gynae II Flashcards

1
Q

Crown rump length required for diagnosis of miscarriage

A

> 7mm
At <7mm, may be too early to tell if pregnancy is viable but very early, or if it is non-viable
Foetal heartbeat expected once CRL >7mm

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2
Q

Repeat USS in potential miscarriage

A

If CRL <7mm without foetal heartbeat, scan repeated at least one week later to ensure heartbeat develops
CRL >7mm, without a foetal heartbeat, scan repeated one week later to confirm a non-viable pregnancy
If mean gestational sac diameter >25mm without a foetal pole, scan repeated after one week to confirm an anembryonic pregnancy

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3
Q

Measurements relevant in miscarriages

A

CRL = 7mm, foetal heartbeat expected once CRL >7mm
Mean gestational sac diameter = 25mm, foetal pole expected once diameter >25mm

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4
Q

Investigation/management in miscarriage <6 weeks

A

USS not useful, perform repeat urine pregnancy test after 7-10 days. Negative –> confirms miscarriage
Expectant management, unless bleeding continues, or pain occurs, or risk factors e.g. previous ectopic

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5
Q

Follow-up for low-grade cervical intraepithelial neoplasia (CIN 1)

A

Screen again at 12 months in the community

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6
Q

Most common type of vaginal cancer

A

Overall = secondary (metastatic cancer), usually from cervix, ovary or endometrium
Prumary cancer = squamous cell carcinoma

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7
Q

Features of vaginal cancer

A

Post-coital bleeding is common
May be followed by an offensive watery discharge

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8
Q

Follicular phase of menstrual cycle

A

Granulosa cells surround oocytes –> follicles
FSH stimulation –> further development of follicles
Granulosa cells secrete oestrogen as follicles grow –> negative feedback –> reduced FSH/LH secretion
Oestrogen –> cervical mucus is more permeable
Dominant follicle forms
LH surge –> dominant follicle release ovum

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9
Q

Luteal phase of menstrual cycle

A

After ovulation, follicle collapses –> corpus luteum –> secretes progesterone –> maintains endometrial lining, thickens cervical mucus
Also secretes some oestrogen

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10
Q

What happens to the corpus luteum when fertilisation occurs

A

Syncitiotrophoblast of the embryo secretes hCG –> maintain corpus luteum –> produces progesterone + oestrogen

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11
Q

What happens if no fertilisation occurs in menstrual cycle

A

No hCG production –> corpus luteum degenerates –> stops producing oestrogen + progesterone
This causes endometrium to break down + menstruation occurs
Stromal cells of endometrium release prostaglandins –> encourage breakdown of uterus + contraction
LH + FSH levels rise

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12
Q

Process of foetal descent through birth canal

A

Descent
Engagement (<2/5 palpable)
Flexion
Internal rotation
Crowning
Extension of presenting part
External rotation of head
Delivery (of shoulders and rest of body)

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13
Q

Management of asymptomatic bacteriuria in pregnancy

A

Confirm presence of bacteria with second culture (contamination of first sample possible)
Offer an immediate antibiotic prescription, taking into account urine culture + susceptibility
e.g. Nitrofurantoin (avoided at term), amoxicillin (if results available + susceptible), cefalexin

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14
Q

Diagnosis of polyhdramnios

A

Amniotic fluid index >24cm (or 2000ml+)
AFI >95th centile for gestational age

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15
Q

Diagnosis of oligohydramnios

A

Amniotic fluid index <5cm (or <200ml)
AFI <5th centle for gestational age

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16
Q

Timings of amniotic fluid

A

Increases steadily until 33 weeks gestation
Plateaus from 33-38 weeks
Declines –> approx 500ml at term

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17
Q

Causes of polyhdramnios

A

Idiopathic = 50-60% cases
Conditions preventing foetus from swallowing
Duodenal atresia
Anaemia
Foetal hydrops
Twin-to-twin transfusion syndrome
Genetic or chromosomal abnormalities
Macrosomia

Maternal diabetes
Maternal use of lithium
Viral infections

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18
Q

Management of polyhydramnios

A

No medical intervention required for majority
Aminoreduction if severe maternal symptoms (risk of infection + placental abruption)
Indomethacin –> enhance water retention –> reduce foetal output (premature closure of PDA so not used beyond 32 weeks)
Examine baby if idiopathic

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19
Q

Risks of polyhydramnios

A

Malpresentation
–> higher risk of cord prolapse
Postpartum haemorrhage

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20
Q

Causes of oligohydramnios

A

Preterm prelabour rupture of membranes
Placental insufficiency (blood flow to brain –> reduced foetal urine output)
Renal agenesis (Potter’s syndrome)
Non-functioning foetal kidneys
Obstructive uropathy
Genetic/chromosomal abnormalities
Viral infections

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21
Q

Management of oligohydramnios

A

Depends on underlying cause
P-PROM –> induction of labour if relevant, steroids for foetal lung development, antibiotics for infection
Placental insufficiency –> deliver before 36-37 weeks

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22
Q

Complication of oligohydramnios

A

Foetal muscle contractures due to inability to move limbs in utero

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23
Q

Points to remember for epilepsy in pregnancy

A

Risk of uncontrolled epilepsy > risk to foetus
Take 5mg folic acid per day prior to conception –> 12 weeks (risk of neural tube defects)
Aim for monotherapy

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24
Q

Epilepsy medications in pregnancy

A

Avoid sodium valproate (NTD)
Carbamazepine is least teratogenic of older antiepileptics
Phenytoin –> risk of cleft palate, given vitamin K in last month of pregnancy to prevent clotting disorders in newborn
Lamotrigine –> seems safe, may need increased dose
Most anti-epileptics safe in breastfeeding

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25
Q

Blood tests for hypothalamic/pituitary causes of secondary amenorrhoea

A

Low levels of gonadotrophins (FSH + LH)
Low levels of oestradiol (from ovaries)
FSH + LH should rise in response to low oestrogen –> hypothalamic dysfunction

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26
Q

What is postpartum thyroiditis

A

Changes in thyroid function within 12 months of delivery
Affects women without a history of thyroid disease
Can be hyper/hypothyroidism, or both

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27
Q

Typical pattern of postpartum thyroiditis

A
  1. Thyrotoxicosis (usually in first three months)
  2. Hypothyroid (usually from 3-6 months)
  3. Thyroid function gradually returns to normal (usually within 1 year)
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28
Q

Blood tests in postpartum thyroiditis

A

Thyrotoxicosis: Raised T3/T4, low TSH
Hypothyroidism: Low T3/T4, raised TSH
Thyroid peroxidase antibodies found in 90% patients

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29
Q

Management of thyrotoxic phase of postpartum thyroiditis

A

Propanolol for symptom control
Not usually treated with anti-thyroid drugs
Annual monitoring of TFTs

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30
Q

Management of hypothyroid phase of postpartum thyroiditis

A

Levothyroxine
Annual monitoring of TFTs

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31
Q

Risk factors for GDM

A

BMI >30
Previous macrosomic baby weighing 4.5kg+
Previous GDM
First degree relative with diabetes
Family origin with a high prevalence of diabetes e.g. South Asian

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32
Q

Indications for GDM screening

A

Any risk factor present
Large for dates foetus
Polyhydramnios
Glucose on urine dipstick

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33
Q

Cut-offs for GDM on OGTT

A

Fasting = 5.6 mmol/L
2 hours = 7.8 mmol/L
5, 6, 7, 8

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34
Q

Management of GDM

A

Fasting glucose <7: diet + exercise for 1-2 weeks, then metformin, then insulin
Fasting glucose >7: start insulin +/- metformin
Fasting glucose >6 + macrosomia/other complications: start insulin +/- metofmrin
Glibenclamide (sulfonylurea) can be used if decline insulin/cannot target metformin

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35
Q

Blood glucose targets for women with GDM

A

Fasting: 5.3 mmol/L
1-hour post-meal: 7.8 mmol/L
2 hours post-meal: 6.4 mmol/L
Avoid 4mmol/L or below

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36
Q

Management of pre-existing diabetes in pregnancy

A

Take 5mg folic acid from preconception to 12 weeks gestation
Weight loss for women with BMI >27
Stop oral hypoglycaemic agents (apart from metformin) and commence insulin
Retinopathy screening
Planned delivery 37-38+6 weeks gestation

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37
Q

Insulin use in labour

A

Sliding-scale insulin regime for T1DM
Dextrose + insulin infusion titrated to blood usgar levels
Also considered for women with GDM or T2DM with poorly controlled blood sugars

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38
Q

Postnatal care for GDM

A

Can stop diabetic medications immediately after birth
Test fasting glucose at least 6 weeks later

Regular BG checks for neonatal hypoglycaemia - aim >2mmol/L

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39
Q

Postnatal care for women with existing diabetes

A

Insulin sensitivity increases after birth, and with breastfeeding –> lower insulin doses + be aware of hypoglycaemia

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40
Q

Complications of diabetes in pregnancy

A

Neonatal hypoglycaemia
Polycythaemia
Jaundice
Congenital heart disease
Cardiomyopathy

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41
Q

Investigation for placenta praevia

A

Gold standard = transvaginal ultrasound, can be used to determine position of the placenta
Avoid digital vaginal examination as may provoke a severe haemorrhage

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42
Q

Contraception use in women who are menopausal (even if using HRT)

A

<50 years old: 2 years after last menstrual period
>50 years old: 1 year after last menstrual period
Appropriate methods: barrier, IUD/IUS, POP, Progesterone implant, sterilisation, depot injection (if <45)
- Depot can cause weight gain and reduce bone mineral density
NB: COCP can be used up to age of 50

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43
Q

Contraindications to HRT

A

Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Endometrial hyperplasia or cancer
Uncontrolled hypertension
VTE
Liver disease
Acive angina or MI
Pregnancy

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44
Q

Principles of HRT to reduce risks

A

Progesterone required in women who have a uterus, to avvoid endometrial hyperplasia and cancer associated with unopposed oestrogen
Patches > pills to avoid VTE risk

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45
Q

Non-hormonal treatments for menopausal symptoms

A

Lifestyle changes e.g. diet, exercise, weight loss, smoking cessation, alcohol/stress/caffeine reduction
CBT
Clonidine: lowers BP + reduces HR. Useful for vasomotor symptoms
SSRIs
Venlafaxine
Gabapentin

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46
Q

Indications for HRT

A

Premature ovarian insufficiency, even without symptoms
Reducing vasomotor symptoms
Improving symptoms e.g. low mood, decreased libido, poor sleep + joint pain
Reducing risk of osteoporosis in women <60

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47
Q

Risks of HRT

A

Increased risk of breast cancer (esp with combined HRT)
Endometrial cancer
VTE
Stroke + coronary artery disease (with long term use in older women)

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48
Q

Considerations when choosing HRT formulation

A

Local symptoms –> topical treatment
Systemic symptoms –> systemic management –>

No uterus –> oestrogen-only HRT
Uterus –> combined HRT –>

Perimenopausal –> cyclical combined HRT
Postmenopausal (>12 months since last menstruation) –> continuous combined HRT

49
Q

Options for oestrogen delivery in HRT

A

Oral (tablets)
Transdermal (patches or gels)
- Patches mroe suitable for women with poor control on oral treatment, higher risk of VTE/CVD/headaches

50
Q

Options for progesterone delivery in HRT

A

Women with period in past 12 months –> cylical progesterone for 10-14 days per month
No period –> continuous progesterone
- Last 24 months if <50
- Last 12 months if >50
Oral
Transdermal
IUS (e.g. Mirena) –> licensed for 4 years

51
Q

Progesterone vs Progestogens vs Progestins

A

Progesterone = hormone naturally produced in body
Progestogens = any chemical that targets and stimulates progesterone receptors
Progestins = synthetic progestogens

52
Q

Types of progesterone used in HRT

A

C19 progestogens - derived from testosterone e.g. norethisterone, levonorgestrel, desogestrel
- May be helpful for women with reduced libido
C21 progestogens - derived from progesterone (more female in effects) e.g. progesterone, dydrogesterone, medroxyprogesterone
- May be helpful for women with side effects such as depressed mood or acne

53
Q

Description of primary dysmenorrhoea

A

No underlying pelvic pathology
Usually appears within 1-2 years of menarche

Pain typically starts just before or within a few hours of period starting
Suprapubic cramping pains - may radiate to the back or down the thigh

54
Q

Management of primary dysmenorrhoea

A

NSAIDs e.g. mefenamic acid + ibuprofen (inhibit prostaglandin production)
COCP used as 2nd line

55
Q

Description of secondary dysmenorrhoea

A

Result of underlying pelvic pathology
Typically develops many years after menarche

Pain usually starts 3-4 days before onset of period

Causes:
- Endometriosis
- Adenomyosis
- PID
- Intrauterine device
- Fibroids

56
Q

Management of secondary dysmennorhoea

A

Referral to gynaecology for investigation
Use analgesia in the meantime

57
Q

Management of rhesus incompatibility in pregnancy

A

Prevention of sensitisation - give IM anti-D injections
Routinely given:
- 28 weeks gestation (may also give at 34 weeks)
- Birth (if baby’s blood group is found to be rhesus-positive)
Also given if sensitisation may occur
Given within 72 hours of a sensitisation events
500IU if >20GW, 250IU if <20GW

58
Q

Situations that may lead to sensitisation in Rhesus -ve women (and therefore Anti-D given)

A

Antepartum haemorrhage
Amniocentesis procedures/chorionic villus sampling/foetal blood sampling
Abdominal trauma
Delivery of Rh +ve infant
Termination of pregnancy (if >10 GW)
Miscarriage >12 GW
Ectopic pregnancy (if managed surgically)
External cephalic version

59
Q

Investigation to detect feto-maternal haemorrhage in a suspected sensitising event in Rhesus -ve mothers

A

Kleihauer test - used to detect amounts of foetal haemoglobin in the mothers bloodstream
Used to determine if the correct amount of Anti-D has been given

60
Q

Management of eclampsia

A

1st line: magnesium sulphate
- Treats seizures
- Neuroprotection for foetus
Fluid restriction to avoid fluid overload

61
Q

Contraception in active breast cancer

A

Injectable progesterone UKMEC4 contraindicated (e.g. depo-provera)
Recommended to use barrier methods or IUD, as progesterone is contra-indicated

62
Q

Investigations for reduced foetal movements

A

If past 28 weeks gestation:
- Initially handheld Doppler to confirm foetal heartbeat
- If no heartbeat detectable –> immediate ultrasound
- If heartbeat present –> CTG should be used for at least 20 minutes
24-28 weeks:
- Handheld doppler to confirm foetal heartbeat
<24 weeks + previous movements felt
- Handheld doppler
Not felt by 24 weeks –> referral to maternal-foetal medicine unit

63
Q

Management of P-PROM at 24-33 weeks

A

Monitor for signs of chorioamnionitis
Advise avoid sexual intercourse
Prophylactic erythromycin 250mg QDS 10 days
Corticosteroids (as less than 34+6)
Aim expectant until 34 weeks

64
Q

Management of P-PROM at 34-36 weeks

A

Monitor for signs of chorioamnionitis
Advise avoid sexual intercourse
Prophylactic erythromycin 250mg QDS 10 days

65
Q

Missed pill rules - COCP

A

If 1 pill missed - take ASAP, even if taking two in same day, no additional contraception needed
If 2+ pills missed -
- Take last pill ASAP, leave any other missed pills
- Use condoms/abstain from sex until taken pills for 7 days in a row
- If pills missed in week 1: consider emergency contraception if UPSI in pill-free interval, or in week 1
- If pills missed in week 2: no need for emergency, as 7 days consecutively have been taken
- If pills missed week 3: finish current pack, and omit pill-free interval

66
Q

Management of bleeding <6 weeks gestation

A

Important to rule out ectopic pregnancy
If no pain/risk factors –>
- Return if bleeding continues, or pain develops
- Repeat urine pregnancy test after 7-10 days and return if it is positive (negative means miscarriage)

67
Q

Drugs to avoid whilst breastfeeding

A

Antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
Psychiatrics: lithium, benzodiazepines
Aspirin
Carbimazole
Methotrexate
Sulfonylureas
Cytotoxic dugs
Amiodarone

68
Q

Cervical screening in pregnancy

A

Usually delayed until 3 months post-partum unless missed screening, or previous abnormal smears

69
Q

HRT in women with history of migraine with aura

A

HRT not contraindicated
Topical > oral

70
Q

HRT in women with family history of DVT

A

HRT not contraindicated
Topical > oral

71
Q

When to suspect a vesicovaginal fistula

A

Continuous dribbling incontinence
After prolonged labour
From an area with limited obstetric services

72
Q

COCP and surgery

A

Preferably should be discontinuted 4 weeks before major elective surgery, and all surgery to legs or surgery which involves prolonged immbolisation of lower limbs
Progesterone-only contraceptive may be offered as an alternative
Oestrogen-containing contraceptive can be restarted after mobilisation

73
Q

Pregnancy tests after pregnancy termination

A

Urinary pregnancy test often remains positive for up to 4 wees following termination
+ve test beyond 4 weeks indicates incomplete abortion, or persistent trophoblast

74
Q

Risk factors for Group B Streptococcus infection

A

Prematurity
Prolonged rupture of membranes
Previous sibling GBS infection
Maternal pyrexia e.g. secondary to chorioamnionitis

75
Q

Management of group B streptococcus

A

Benzylpenicillin = GBS prophylaxis
Offered to:
- Women with GBS in previous pregnancy (50% chance recurrence) (or testing late in pregnancy, then abx)
- Previous baby with early, or late-onset GBS disease
- Preterm labour
- Pyrexia >38 during labour

76
Q

Contraception postpartum

A

Women only require contraception 21 days from giving birth

77
Q

What is hydrops foetalis

A

Occurs when extra fluid accumulates in two or more areas in the foetus including ascites, pleural effusion, pericardial effusion, and skin oedema

78
Q

Immune cause of hydrops foetalis

A

Blood group incompatibility (e.g. rhesus status) between mother and foetus –> anaemia + haemolysis

79
Q

Non-immune causes of hydrops foetalis

A

Chromosomal abnormalities e.g. trisomy 13, 18 or 21, Turner’s: most common in early pregnancy
Structural abnormalities
Cardiac abnormalities or arrhythmias
Anaemia - congenital parovirus B19 infection, alpha thalassaemia major, massive materno-feto haemorrhage
Infection - toxoplasmosis, rubella, CMV, varicella
Twin-twin transfusion syndrome (in recipient twin)
Chorioangioma

80
Q

Investigation of foetal hydrops

A

US assessment: including echocardiography + assessment of middle cerebral artery
Maternal blood tested: Kleihauer and parovirus, CMV and toxoplasmosis IgM testing
Foetal blood tested if anaemia suspected
Blood testing and/or amniocentesis for karyotyping

81
Q

Management of foetal hydrops

A

Cure only possible when anaemia (transfusion) or compression by fluid collection such as pleural effusions (vesicoamniotic shunting) have caused hydrops

82
Q

What factors are considered in BISHOP score

A

Foetal station (0-3)
Cervical position (0-2)
Cervical dilatation (0-3)
Cervical effacement (0-3)
Cervical consistency (0-2)

83
Q

Score used to determine whether to induce labour

A

Bishop score (0-13)
Score of 7+ predicts successful induction
Score <4 suggests cervical ripening may be required to prepare the cervix

84
Q

Indications for induction of labour

A

Prolonged gestation: offered at 40+0 to 40+14 in women with uncomplicated pregnancies
Premature rupture of membranes >37 weeks (or expectant management for max 24 hours)
If <37 weeks, consider on a risk vs benefits
Maternal health problems e.g. pre-eclampsia, diabetes
Foetal growth restriction
Intrauterine foetal death

85
Q

Contraindications for induction of labour

A

Relative:
- Breech presentation
- Triplet or higher order pregnancy
- 2+ previous low transverse C-sections
Absolute:
- Cephalopelvic disproportion
- Major placenta praevia
- Vasa praevia
- Cord prolapse
- Transverse lie
- Active primary genital herpes
- Previous classical C-section

86
Q

Methods of induction of labour

A

Vaginal prostaglandins - ripen the cervix, and have a role in contraction of smooth muscle of the uterus
- Tablet/gel: 1st dose, plus 2nd dose if labour not started 6 hours later
- Pessary: 1 dose over 24 hours
Amniotomy: articificial rupture of membranes using amnihook (Bishop score calculated first) –> syntocinon infusion
Membrane sweep at 40 and 41GW to nulliparous women, and 41 to multiparous women: adjunct to IOL as increases likelihood of spontaneous delivery

87
Q

Complications of induction + augmentation of labour

A

Failure of induction –> operative delivery
Uterine hyperstimulation
Nausea, vomiting + diarrhoea (due to prostaglandins)
Uterine rupture

88
Q

Features of foetal alcohol syndrome

A

Baby may show symptoms of alcohol withdrawal at birth e.g. irritable, hypotonic, tremors
Short palpebral fissure
Hypoplastic upper lip
Smooth/absent filtrum
Learning difficulties
Microcephaly
Growth retardation
Epicanthic folds
Cardiac malformations

89
Q

Criteria for termination of pregnancy

A
  1. <24 weeks
  2. Continuation will involve more risk to life of pregnant woman, or existing children in the family, than termination
  3. Prevent permanent injury to physical/mental health of mother
  4. Mother’s life at risk if continued
  5. Risk of severe/physical abnormalities
90
Q

Legal requirements for abortion

A

Two registered medical practitioners must sign to agree abortion is indicated (cannot be FY1)
Must be carried out by a registered medical practitioner in an NHS hospital or approved premise

91
Q

Medical abortion

A

Mifepristone (anti-progestogen) –> halts pregnancy + relaxes cerviz
Misoprostol (prostaglandin analogue): 1-2 days later –> softens cervix + stimulates uterine contractions
- From 10 GW, additional misoprostol doses (e.g. every 3 hours) required until expulsion
Anti-D if >10GW

92
Q

Surgical abortion

A

Can be performed at any gestional age
Medications for cervical priming: misoprostol, mifepristone or osmotic dilators
<14GW: cervical dilatation + suction of contents of the uterus
14-24GW: cervical dilatation and evacuation using forceps
Anti-D prophylaxis (considered if <10GW)

93
Q

Moulding

A

Degree of overlap of foetal skull bones

94
Q

Caput

A

Localised swelling found on baby’s head due to pressure from cervix or pelvic inlet
Capit succedaneum = diffuse swelling of the scalp, unlike cephalohaematoma (which does not cross suture lines)

95
Q

Risk of artificial rupture of membranes

A

Cord prolapse
Especially possible if there is a high head/presenting part/malpresentation, polyhydramnios or foetal growth restriction
If there is –> may be prudent to perform ARM in theatre

96
Q

Measuring size of foetus

A

<14GW: Crown-rump length is the most reliable method
If CRL >84mm (correlates to >14GW) –> head circumference becomes a more reliable indicator

97
Q

Estimated delivery date

A

Can be calculated from date of last menstrual period (LMP)
40 weeks after first day of LMP (not date of conception)
Only true if cycle is 28 days and regular - if shorter or longer, days can be added or subtracted

98
Q

Complications of rubella infection in pregnancy

A

Teratogenic effects worse + higher chance of passing on infection to foetus at earlier gestations

Sensorineural deafness
Cataracts
Congenital heart disease - patent ductus arteriosus
Glaucoma

Growth retardation
Purpuric skin lesions
‘Salt and pepper’ Chorioretinitis
Hepatosplenomegaly
Microphthalmia
Cerebral palsy

99
Q

Complications of cytomegalovirus infection in pregnancy

A

Low birth weight
Purpuric skin lesions
Sensorineural deafness
Microcephaly

Visual impairment
Learning disability
Encephalitis/seizures
Pneumonitis
Hepatosplenomegaly
Anaemia
Jaundice
Cerebral palsy

100
Q

Complications of toxoplasmosis infection in pregnancy

A

Cerebral calcification
Chorioretinitis
Hydrocephalus

Anaemia
Hepatosplenomegaly
Cerebral palsy

101
Q

What is twin-to-twin transfusion

A

Anastomosis of vessels in single placenta of monochorionic twin pregnancies –> one gains at the others expense

102
Q

Consequences of twin-to-twin transfusion

A

One twin: anaemic, hypovolaemic, oligohydramnios + growth-restricted
Other twin: polycythaemia, hypercolaemia, polyuria + polyhydramnios

103
Q

First degree perineal tear

A

Injury to skin only
No need for routine suturing unless haemostasis is an issue

104
Q

Second degree perineal tear

A

Injury to perineum involving perineal muscles
No involvement of anal sphincter
Can be sutured on the ward

105
Q

Third degree perineal tear

A

Injury to perineum involving anal sphincter complex
Must be sutured in theatre with adequate analgesia
3a - <50% external anal sphincter thickness torn
3b - >50% external anal sphincter torn
3c - both EAS and internal anal sphincter torn

106
Q

Fourth degree perineal tear

A

Involves anal sphincter complex + anal/rectal epithelium
Must be repaired in theatre

107
Q

Beta-hCG level required to visualise gestational sac on TVUS

A

> 1000IU
(>3500IU for abdominal scan)

108
Q

Differentials of positive pregnancy test with empty uterus

A

Complete miscarriage (fall in hCG)
Very early intrauterine pregnancy (increase in hCG)
Ectopic pregnancy (normally plateau hCG)
–> use serial beta-hCG measurements

109
Q

Uterine inversion

A

Rare complication of birth
Fundus of uterus drops down through uterine cavity + cervix
Incomplete = descends, but not as far as the introitus
Complete = descends to the introitus

110
Q

Presentation of uterine inversion

A

Large postpartum haemorrhage
Maternal shock/collapse (shock out of proportion with haemorrhage due to vagal stimulation)
May be felt with manual vaginal examination or seen at the introitus

111
Q

Management of uterine inversion

A

Johnson manoeuvre: use hand to push back up + then oxytocin to cause contraction
Hydrostatic methods: fill vagina with fluid to ‘inflate’ uterus back to normal position. Requires tight seal at entrance of vagin
Surgery

112
Q

Risk factors for uterine inversion

A

Uterine atony
Previous uterine inversion
Fundal placenta - especially if too much traction put on cord during delivery of placenta

113
Q

Management of atrophic vaginitis

A

Lubricants + moisturisers
Topical oestrogen cream may also be considered

114
Q

Symptoms of atrophic vaginitis

A

Dryness of vagina
Local irritation i.e. pruritus, pressure + burning pain
Painful intercourse
Vaginal bleeding e.g. haematuria, or post-coital bleeding
Urinary symptoms
Vaginal discharge: usually white or yellow, sometimes malodorous

115
Q

Examination findings of atrophic vaginitis

A

Reduced pubic hair
Loss of labial fat pad
Narrowing of vaginal introitus
Thinning of labia minora
Smooth, shiny vaginal mucosa with loss of skin folds
Dryness of mucosa
Loss of vaginal muscle tone
Erythema or bleeding

116
Q

When does acute fatty liver of pregnancy occur

A

Rare complication
May occur in third trimester or in the period immediately following delivery

117
Q

Features of acute fatty liver of pregnancy

A

Abdominal pain
Nausea + vomiting
Headache
Jaundice
Hypoglycaemia
Severe disease may result in pre-eclampsia

118
Q

Investigations in acute fatty liver of pregnancy

A

LFTs: ALT typically elevated (hepatic derangement)
USS: Steatosis

119
Q

Management of acute fatty liver of pregnancy

A

Supportive care
Once stablised, delivery is the definitive management

Phase 3A Revision (12 decks)

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