Obs n Gynae Flashcards
define preterm labour
<37 weeks gestation
define prolonged labour
no definite time period
cervical dilatation <2 cm in 4 hours during active labour
describe the first stage of labour
onset to contractions to full dilatation
early latent phase = cervix becomes effaced, shortens and dilates up to 4 cm
active phase = 4 cm cervical dilatation to full dilatation (10 cm)
describe the 2nd stage of labour
full dilatation to delivery of fetus
passive stage = full dilatation prior to or in absence of persistent involuntary expulsive contractions
active stage = when baby is visible OR persistent involuntary expulsive contractions/active maternal effort with a finding of full dilatation
describe the 3rd stage of labour
delivery of fetus to delivery of placenta and membranes
how long can the 3rd stage of labour last
usually 5-10 minutes after delivery
> 30 minutes = abnormal
how long does labour normally last
first labour = average 8 hours
subsequent labours = average 5 hours
when is delay in labour diagnosed
nulliparous: active second stage has reached 2 hours
multiparous: active second stage has reached 1 hour
what is the difference between physiological and active management of the 3rd stage of labour
physiological: uterotonic drugs (oxytocin) are not used, cord not clamped until pulsations have ceased, placenta is delivered by maternal effort
active management: use of oxytocin before cord stops pulsating, bladder catheterisation, deferred clamping and cutting of the cord, controlled cord traction after signs of separation of the placenta
what are the signs that indicate separation of the placenta and membranes
uterus contracts, hardens and rises
umbilical cord lengthens permanently
gush of blood variable in amount
placenta and membranes appear at introitus
when should you change from physiological to active management of 3rd stage of labour
excessive bleeding or haemorrhage
failure to deliver placenta within 1 hour
patient’s desire to shorten 3rd stage
what are clinical signs of onset of labour
regular, painful contractions which increase in frequency and duration and produce progressive cervical dilatation
passage of blood-stained mucus from the cervix is associated with onset of labour nut not an indicator
rupture of membranes not always at start of labour
what is the definition of prelabour rupture of membranes
> 4 hours between rupture of membranes and onset of painful contractions
can be preterm or term
what are Braxton hicks contractions
non-labour contractions towards the end of gestation
which hormones are involved the initiation of labour
decreased progesterone
increased oestrogen and prostaglandin
oxytocin promotes PG release and initiates/sustains contractions
what are special features of uterine myocytes
contract and shorten, and return to precontraction length
contain ion channels that influence the influx of calcium ions into the myocytes and promote contraction of myometrial cells
affected directly by hormones such as relaxin, activin A (cAMP)
describe changes in the cervix leading up to labour
contains myocytes and fibroblasts
towards terms, there is a decrease in collagen (becomes softer and stretchy)
increased hyaluronic acid reduces the affinity of fibronectin for collagen and affinity of hyaluronic acid for water causes cervix to soften and stretch
what are the cardinal movements of labour
engagement descent flexion internal rotation extension external rotation expulsion
describe engagement (1st cardinal movement)
passage of widest diameter of the presenting part to a level below the plane of the pelvic inlet
engagement is measured in fifths (proportion of fatal head that is unpalpable)
describe descent (2nd cardinal movement)
downward movement of the presenting part through the pelvis
describe flexion (3rd cardinal movement)
flexion of the fatal head occurs passively as the head descends due to the shape of the bony pelvis and resistance by soft tissues
describe internal rotation (4th cardinal movement)
rotation of the presenting part from its original position (usually transverse with regard to the birth canal) to the anterior position as it passes through the pelvis
describe extension (5th cardinal movement)
occurs once the fetus has reached the introitus, and the base of occiput is in contact to the inferior margin of the pubic symphysis
describe external rotation/restitution (6th cardinal movement)
return of the fetal head to the correct anatomical position in relation to the fatal torso and shoulders
describe expulsion (7th cardinal movement)
delivery of rest of fetal body
what are causes of abnormal labour
malpresentation malposition too early (preterm <37 weeks) too late (post-term >42 weeks) too painful too quick (<2 hours) too long (failure to progress, obstruction) fetal distress
what is malpresentation
non-vertex presentation
vertex is bounded by the anterior and posterior fontanelles and the parietal eminences
involves breech presentation, transverse, shoulder/arm, face or brow presentation
what is malposition (labour)
occipitoposterior or occipitotransverse
what are the main causes of failure to progress
powers: inadequate contractions either in strength or frequency
passages: trauma, shape, cephalopelvic disproportion
passenger: big baby, malposition causing a relative cephalopelvic disproportion
what are potential complications of obstructed labour
sepsis: ascending genitourinary tract infection postpartum haemorrhage fistula formation fetal asphyxiation neonatal sepsis uterine rupture obstructed acute kidney injury
how is progress in labour assessed
how often should it be performed
vaginal examination every 4 hours
cervical dilatation
descent of presenting part
signs of obstruction (moulding, caput, anuria, haematuria, vulval oedema
what are the three main types of forceps
outlet forceps
mid-cavity/low-cavity forceps
rotational forceps
indications for outlet forceps
fetal scalp is visible without separating the labia
the fatal skull has reached the pelvic floor
sagittal suture is in the AP diameter or right or left occiput anterior or posterior position (not >45 degrees)
fatal head is at or on perineum
can be used for lift-out deliveries at c-section
indications of mid/low-cavity. forceps
when fatal head is 1/5 palpable abdominally
leading point of the skull is above station +2 but not above the ischial spines
rotation of <45 degrees
indications for rotational forceps
should be performed in theatre with effective regional anaesthesia
what are the indications for FORCEPS
fully dilated (10 cm)
occipitoposterior position
ruptured membranes
cephalic presentation
engaged presenting part (fetal head must not be palpable abdominally and must be below the ischial spines)
pain relief
sphincter (bladder) empty (catheterisation)
standard indications: failure to progress in 2nd stage, fatal distress, maternal exhaustion
what are the advantages of operative vaginal delivery over C-section
80% will have a spontaneous vertex delivery subsequently
reduced analgesic requirements
shorter hospital stay and quicker recovery
less physical restrictions on bonding with the baby
what are the advantages of c-section compared to operative vaginal delivery
avoids tears to perineum and therefore problems with long term urinary and faecal incontinence
no injury to cervix or high vaginal areas
less change of neonatal trauma
what are disadvantages of operative vaginal delivery compared to c-section
neonatal trauma
urinary symptoms if retention occurred around the time of delivery
high risk of postpartum haemorrhage
shoulder dystocia as the traction applied cases head to deflex and shoulders to abduct, widening their diameter
what types of neonatal trauma can occur as a result of operative vaginal delivery
intracranial haemorrhage
skull fracture
jaundice due to cephalohaematoma and caput succedaneum (ventouse)
facial nerve palsy
forceps leave mark on face
brachial plexus injury
disadvantages of c-section compared to operative vaginal delivery
haemorrhage/infection visceral injury VTE longer hospital stay risk of uterine rupture in future labours and placenta accreta in future pregnancy greater maternal mortality transient tachypnoea of newborn
advantages and disadvantages of ventouse delivery
less perineal trauma but more likely to fail than forceps
more likely to cause cephalohaematoma, chignon (swelling on baby’s heads) and retinal haemorrhage
contraindications to ventouse delivery
prematurity <34 weeks face presentation suspected fatal bleeding disorder eg haemophilia fetal predisposition to fracture maternal HIV or HepC
describe caput succedaneum in terms of onset, pathology, site, associated features and management
onset: present at birth
pathology: due to pressure of the presenting part against the cervix
site: tissue swelling that forms over the vertex and crosses suture lines
features: prolonged labour; soft puffy swelling; skin over swelling may look bruised; often with moulding
management: conservative, resolves in days
describe cephalohaematoma in terms of onset, pathology, site, associated features and management
onset: several hours after birth
pathology: subperiosteal haemorrhage due to prolonged second stage or instrumental delivery
site: forms below the first layer of periosteum, limited by suture lines
features: jaundice in newborn; often following operative delivery; swelling is firm with distinct margins; no skin discolouration; increases in size 12-24 hours after birth
management: conservative unless hyperbilirubinaemia in neonate, resolves over months
what is a chignon
temporary swelling after a ventouse suction cap has been used
2 hours - 2 weeks
describe subgleal haemorrhage in terms of onset, pathology, site, associated features and management
onset: at delivery and may progress rapidly
pathology: severing of the emissary veins that are located between the dural sinuses that cover the skull and scalp
site: forms above the periosteum, between the skull and the scalp aponeurosis; crosses the suture lines and covers a greater area than cephalohaematoma
features: delay in recognition may lead to neonatal encephalopathy, seizures, death; diffuse ill-defined swelling may shift when palpated and shift with reposition of the head; forceps/ventouse deliveries
management: resus and blood transfusions, assess for coagulopathies
what are the main diagnostic features of amniotic fluid embolism
occurs during or within 30 minutes of labour
respiratory distress, hypoxia, hypotension
after 30 minutes of physiological management of 3rd stage of labour and placenta still hasn’t been delivered
abs are stable and blood loss is minimal - what is the next best step
observe for 30 mins with IM syntocinon and breastfeeding
can wait up to 30 minutes total for physiological management of 3rd stage of labour
give syntocinon IM rather than In infusion
breastfeeding will stimulate spontaneous expulsion
29 yo primiparous women in prolonged labour following induction at 41 wks
6 cm dilated, fatal head is 1 cm above ischial spines
fetal heart rate is progressively dropping, <100 bpm, not recovered for more than 3 minutes
management?
category 1 C-section
fetal HR <100 bpm is a worrying sign
not fully dilated to instrumental delivery in theatre may not be advised
when is terbutaline given?
given in premature labour to reduce contractions
which of the following is not an indication for induction of labour?
prolonged pregnancy diabetes in pregnancy macrosomia pre-eclampsia at term IUGR
macrosomia
a baby born 4 hrs ago by forceps has a swelling in the parietal region which does not cross suture lines
what is it
cephalohaematoma
31 yo due to have induction of labour at 38 wks due to cholestasis of pregnancy
bishop’s score of 1 calculated with the station at -1 but her cervix is closed and firm
treatment?
vaginal prostaglandins (PGE2)
PGs will ripen the cervix and cause a dilation allowing ARM to occur later
what is syntometrine used for?
management of postpartum haemorrhage
38 yo prim at 39+3 presents in spontaneous labour
she has only dilated 3 cm in last 6 hrs
she is now 6 cm dilated, CTG shows no fatal distress, uterine contractions are palpable but irregular and not very strong
management?
vaginal examination followed by amniotomy and reassess after
PV exam to assess dilatation, position and presentation of fetus
membranes are intact, so amniotomy is performed to accelerate progress of labour
CTG monitoring continued
what is the average rate of dilation in a primiparous woman
1 cm per hour
indications for induction of labour
prolonged pregnancy (>42 weeks) pre-eclampsia placental insufficiency and IUGR antepartum haemorrhage (includes abruption) Rh immunisation diabetes mellitus chronic renal disease
what does the bishop score measure
assessment of the cervix to predict outcome following induction
dilatation effacement station cervical consistency cervix position
a bishop score of ____ is strongly predictive of labour following induction
>6 = labour follows induction <5 = needs cervical ripening
what are the criteria of the Bishop’s score
dilatation: 0, 1-2, 3-4, 5+
effacement (?%): 0-30, 40-50, 60-70, 80-100
station: -3, -2, -1, >0
cervical consistency: firm, medium or soft
cervix position: posterior, middle, anterior
all criteria start at a score of 0 and up to a max of 3
what are mechanisms of induction of labour
stripping of membranes artificial rupture of membranes medical induction following amniotomy medical induction and cervical ripening mechanical cervical ripening
stripping of the membranes
requirements and hazards/precautions
requirements
aseptic conditions: finger is inserted into cervix and the fetal membranes are separated from the lower segment
hazards/precautions:
if 7 people have sweeps, only 1 will labour in 48 hours
artificial rupture of membranes (amniotomy)
requirements and hazards/precautions
requirements:
aseptic conditions to prevent infection
cervix should be soft, effaced and at least 2 cm dilated
head should be engaged in pelvis and should be presenting by the vertex
hazards/precautions:
cord prolapse, vasa praevia )make sure to assess the fetal membranes and make sure there are no pulsating vessels present before amniotomy)
need to monitor fetal heart rate on CTG
medical induction following amniotomy using synthetic oxytocin infusion (syntocinon)
requirements and hazards/precautions
requirements:
aseptic conditions to prevent infection
cervix should be soft, effaced and at least 2 cm dilated
head should be engaged in pelvis and should be presenting by the vertex
hazards/precautions:
uterine hyperstimulation (>5 contractions in 10 minutes); reduces uterine blood flow and results in fetal asphyxia
discontinue infusion if excessive uterine activity or signs of pathological fetal heart rate of concern
can cause uterine rupture, particularly if there is a uterine scar
medical induction of labour and cervical ripening by administration of PGE2
requirements and hazards/precautions
requirements:
method of choice when the membranes are intact or where the cervix is unsuitable for surgical induction
oral route: causes nausea and vomiting and not commonly used
pessaries: most commonly used; 3 mg doses if no response repeat after 6 hours
hazards/precautions:
PG contraindicated if previous uterine scar (risk of hyper stimulation and uterine rupture)
if hyperstimulation, remove pessary and use a bolus of short acting tocolytic eg terbutaline
what is mechanical cervical ripening
insertion of balloon catheter through the cervix which is used to distend the cervical canal over a 12 hour period and then removed to allow amniotomy
what is measure on a cartogram
fetal heart rate cervical dilatation duration of labour colour of liquor frequency and duration of contraction caput and moulding station/descent of the head maternal heart rate, BP and temperature
how is descent of fetal head/station measured
assessing the level of the presenting part in cm above or below the ischial spine and marked as +1/2/3 if below the spines and _1/2/3 if above the spines
pros and cons of narcotic analgesia in labour
pros:
suitable for women who can’t have regional analgesia eg women on anticonvulsants
remifentanil is ultra-short acting and is superior to pethidine
cons:
maternal: nausea and vomting (give anti-emetic too)
fetal: respiratory depression
pros and cons of inhalation analgesia (gas and air)
pros:
easy to administer
short-acting
cons:
may cause nausea
sometimes inadequate as labour progresses
contraindication to regional anaesthesia
maternal refusal coagpulopathy local or systemic infection uncorrected hypovolaemia inadequate or inexperiences staff/facilities
pros and cons of epidural anaesthesia
pros:
complete pain relief in majority
can be commenced at any time and does not increase risk of C-section
can be controlled by patient
can be topped up to allow operative deliveries
cons: may reduce desire to bear down in second stage of labour due to lack of sensation at the perineum and reduced uterine activity increased risk of a assisted delivery causes abnormal fetal HR hypotension accidental dural puncture postural headache high block which may cause resp depression in mother atonic bladder
describe how an epidural anaesthetic works
fine catheter placed into lumbar epidural space (L3-4) and a local anaesthetic agent such as bupivacaine is injected
adding an opioid to the local anaesthetic reduces dose requirements to spare motor function of the lower limbs and reduced complications eg hypotension and abnormal fetal HR
describe a pudendal nerve block
injection of local anaesthetic around the pudendal nerve at the level of the ischial spine
pros and cons of pudendal nerve block
pros:
used in operative vaginal delivery
cons:
risk of haemorrhage from pudendal artery
risk of lignocaine toxicity if inadvertent intravascular injection
can be ineffective
describe a spinal anaesthetic
catheter is placed at L3-4 and inserted into the subarachnoid space where anaesthetic agent is injected
pros and cons of spinal anaesthesia
pros:
commonly used for operative delivery
cons:
not used in pain control because of superior safety of epidural and its ability to top up with doses or as continuous infusion to get pain relief over a long period of time
maternal indication for continuous electronic fetal monitoring
gestation <37 weeks or >42 weeks
induced labour
administration of oxytocin
ante/intrapartum haemorrhage
maternal illness
pre-eclampsia
previous uterine scar (C-section or myomectomy)
contractions >5 in 10 mins or lasting >90 seconds
during/following insertion of epidural block
maternal request
fetal indication for continuous electronic fetal monitoring
abnormal doppler artery velocimetry
known or suspected IUGR
oligohydramnios or polyhydramnios
malpresentation
meconium stained liquor
multiple pregnancy
suspected small for gestational age or macrosomia
reduced fetal movements in the last 24 hours reported by mother
two vessel cord
prolonged ROM >24 hours unless delivery imminent
rise in baseline, repeated decelerations or slow to recover decelerations or overshoots
fetal structural abnormalities
which mnemonic is useful while interpreting CTGs and what does it stand for
DR BRAVADO
Define Risk: why are they on CTG (pre-eclampsia, antepartum haemorrhage, maternal obesity, DM, HTN etc)
Contractions: normal = 3-5 contractions/10 minutes
Baseline RAte: fetal HR 110-160 bpm
Variability: good 5-25 bpm, reduced <5 bpm,
Accelerations: rise in fetal HR of at least 15 bpm for 15 seconds (fetal movement), occur with contractions, at least 2 every 15 mins
Decelerations: reductions of 15 bpm for 15 secs, generally abnormal, early or late in relation to contractions (late decelerations are worse)
Overall impression: reassuring or not, BE AWARE of terminal bradycardia (<100 bpm for 10 mins) and terminal decelerations (HR drops and doesn’t recover for 3 mins)
describe a normal CTG in terms of baseline, variability and decelerations
baseline: 100-160
variability: 5 or more accelerations
decelerations: none of early
describe a non-reassuring/suspicious CTG in terms of baseline, variability and decelerations
baseline: 161-180
variability: <5 accelerations for 30-90 minutes
decelerations: variable decelerations dropping <60 bpm, recovering in <60 secs, present for over 90 minutes, occurring with >50% of contractions
OR
variable decelerations dropping >60 bpm, recovers in >60 secs, present for up to 30 minutes, occurring with >50% of contractions
OR
late decelerations present up to 30 minutes, occurring with 50% of contractions
describe an abnormal/pathological CTG in terms of baseline, variability and decelerations
baseline: >180 or <100 bpm, sinusoidal pattern
variability: <5 for >90 minutes
decelerations: non-reassuring variable decelerations still observed 30 mins after conservative management
OR
late decelerations present over 30 mins, do not improve with conservative measures, with >50% of contractions
OR
bradycardia or single prolonged deceleration lasting >3 mins
definition and management of normal CTG
baseline, variability and decelerations all normal
Continue CTG and normal care
definition and management of non-reassuring CTG
1 non-reassuring features and 2 normal features
inform senior, move to left lateral position, encourage fluids (IV or oral), stop oxytocin, consider tocolysis
definition and management of abnormal CTG
1 abnormal feature or 2 non-reassuring features
inform senior, start conservative measures, offer fetal blood sampling
exclude factors indicating need for immediate delivery (cord prolapse, uterine rupture, hyperstimulation, abruption)
treat dehydration, hyperstimulation, hypotension and change position
definition and management of pathological CTG
bradycardia or a single prolonged deceleration with baseline <100 bpm for >3 minutes
inform senior, start conservative measures, make preparations for urgent birth (c-section)
early decelerations
definition, cause and management
drop in fetal HR of >15 bpm for >15 min that occurs at the beginning of the contraction with the lowest point occurring at the peak of the contraction and recovery when contraction stops
often due to head compression during a contraction and increased vagal tone, occurs in late first and second stage of labour
physiological management
late decelerations
definition, cause and management
occurs well after contraction is established and does not return to normal baseline rate until at least 20 seconds after contraction is completed
due to placental insufficiency and may indicate fetal hypoxia (maternal hypotension, pre-eclampsia, uterine hyperstimulation)
call senior help, get fetal blood sample to check for hypoxia, may need to expedite delivery
reduced variability
definition and cause
variability of <5 bpm for >40 minutes OR more than 25 bpm 15-25 minutes
fetal sleeping (<40 mins), fetal acidosis and hypoxia, fetal tachycardia, drugs, prematurity, congenital heart problems
variable decelerations
definition, cause and management
vary in timing and amplitude and may not have a relationship to uterine contractions
cord compression
change position of mother, increase monitoring
what makes a variably deceleration more concerning
shoulders of deceleration are accelerations before and after a deceleration: indicate the fetus is not yet hypoxic and is adapting to the reduced blood flow
variable decelerations without shoulders suggest that the fetus is hypoxic
sinusoidal pattern (CTG) definition, cause and management
smooth irregular wave-like pattern, no beat-to-beat variability, stable baseline of 120-160 bpm
severe fetal hypoxia, fetal anaemia, fetal/maternal haemoarhage
urgent C-section
how often is fetal heart rate monitored in the first and second stage of labour
1st stage: every 15 mins for a period of 1 minute soon after a contraction
2nd stage: every 5 mins or after every other contraction for 1 minute
how is a fetal blood sample taken
amnioscope used to obtain blood from fetal scalp
cervix must be at least 3 cm dilated to allow insertion
what is the normal fetal pH
7.25-7.35
what does management of fatal distress involve
changing maternal position
maternal assessment (pulse, BP, abdomen palpation, PV)
IV fluids
stopping contraction (stop/reduce syntocinon or start terbutaline)
scalp stimulation during PV (should have an acceleration)
fetal blood sampling
operative delivery
what is maternal collapse
acute event involving the cardiorespiratory systems and/or brain resulting in reduced or absent conscious level
what are the 4H’s of maternal collapse
hypovolaemia: bleeding, relative hypovolaemia of dense spinal block, septic or neurogenic shock
hypoxia: peripartum cardiomyopathy, MI, aortic dissection, large vessel aneurysms
hypo/hypoerkalaemia (and other electrolytes)
hypothermia
what are the 4T’s of maternal collapse
thromboembolism: amniotic fluid embolism, PE, air embolus, MI
toxicity: local anaesthetic magnesium
tension pneumothorax
tamponade (cardiac)
how does amniotic fluid embolism cause maternal collapse
amniotic fluid enters the maternal circulation and triggers a syndrome similar to anaphylaxis and septic shock
if the woman survives the amniotic fluid embolism what is she at risk of developing
disseminated intravascular coagulopathy
which dietary supplements are recommended during gestation
folic acid 400 mcg from before conception to 12 weeks (reduce neural tube defects)
up to 5 mg if DM, anti-epileptics, BMI >30, previous neural tube dect
10 mg vitamin D, through pregnancy + breastfeeding
250-300 extra calories
what is the guidance for smoking and drinking during pregnancy
drinking: no safe limit (risk of fetal alcohol syndrome)
smoking: avoid, increased risk of miscarriage, low birth weight, prematurity
side effects of cocaine, amphetamines and ecstasy in pregnancy
maternal: hypersensitive disorders including pre-eclampsia, placental abrupt, death via stroke and arrhythmias
fetal: prematurity, neonatal abstinence syndrome, teratogenicity, IUGR, preterm labour, miscarriage, developmental delay, sudden infant death syndrome, withdrawal
side effects of opiates in pregnancy
risk of neonatal abstinence syndrome, IUGR, SIDS, stillbirth, maternal deaths
side effects of cannabis in pregnancy
cognitive defects, miscarriage, fetal growth restrictions
side effects of nicotine in pregnancy
increased risk of miscarriage
increased risk of preterm labour and IUGR
increased risk of still birth, SIDS
side effects of alcohol in pregnancy
fetal alcohol syndrome (smooth philtre, thin vermillion, small palpebral fissures)
IUGR and postnatal restricted growth
learning difficulties
risk of miscarriage
withdrawal
Wernicke’s encephalopathy and Korsakoff’s syndrome
microcephaly
how is substance abuse managed in pregnancy
consider methadone programme (avoid chaotic lifestyle)
child protection and social work referral
smear history (put measures in place to ensure the woman gets involved with a screening programme)
breastfeeding education (HIV+ should bottle feed)
labour plan regarding analgesia and labour ward delivery
early IV access
postnatal contraception plan (ASAP)
when does a booking visit take place and what does it consist of
10-12 weeks by community midwife
History: medical, drug, social and family, LMP, planned pregnancy, ethnicity of parents
obstetric history: previous pregnancy, mode of delivery, previous miscarriages/terminations
Ix: mother’s blood group, Hb levels, haemoglobinopathies, blood borne infections (HIV/AIDs, syphilis, hep B/C)
when does the anomaly scan take place and which conditions does it screen for
18-20+6 weeks
anencephaly, open Spina Bifida, cleft lip, diaphragmatic hernia, gastroschisis, exomphalos, serious cardiac anomalies, bilateral renal genesis, skeletal dysplasia, trisomy 18/13
when is the first stage of Down’s syndrome testing and what does it consist of
11-13+6 weeks
combined test = blood test and US
US: nuchal translucency >3.5 mm
bloods: serum PAPP-A, AFP, beta-hCG (down’s = low PAPP-A and aFP, high beta-hCG)
what is the 2nd stage of Down’s syndrome testing andwhe does it take place
15-16 weeks
quadruple test = blood test checking aFP, inhibin, estriol and total hCG
how many routine midwife appointments with nulliparous and multiparous women have during pregnancy
nulli: 10
multi: 7
women with pre-existing diabetes or gestational diabetes are offered extra monitoring during pregnancy - why?
monitor fetal growth and amniotic fluid volume
increased risk of stillbirth, congenital malformation and polyhydramnios
how does exposure to Rh antigen expose future pregnancies to risk of haemolytic disease on newborn
when mothers are first exposed to the RH antigen, they form IgM antibodies that are too big to cross the placenta and harm the current fetus
in futur pregnancies when the mother is exposed to the same antigen from the foetus’s red cells, the body forms IgG antibodies which are smaller and can cross the placenta to harm the fetus
how does anti-D work?
removed the rhesus positive blood cells from mother’s circulation before antibodies are formed
who is anti-D given to
Rh negative mothers who have been exposed to a sensitising event
should be given within 72 hours of the event
prophylactic anti-D given at 28 weeks to cover silent sensitising events, regardless of other sensitising events
what is a sensitising event (in the context of anti-D)
placental abruption any abdominal trauma amniocentesis or CVS external cephalic version IU surgery/transfusion fetal death vaginal bleeding from 12 weeks surgical management of miscarriage at <12 weeks evacuation of retained products of conception and molar pregnancy termination of pregnancy ectopic pregnancy delivery (baby is Rh+)
what should always be undertaken before vaginal examination
abdominal examination
what equipment is needed to perform a bimanual examination
apron alcohol hand rub sterile gloves lubricant eg aqua gel towel or sheet to cover the woman inco pad
PV examination: inspection
inspect the clitoris (size, trauma, ulcers)
external urethral meatus (discharge, prolapse) and 2 para urethral glands at the 3 and 9 o’clock position
remnants of the hymenal ring
vaginal canal (mucosa for colour, texture and rugosity)
vaginal discharge (colour, texture and odour)
older women: ask to cough to demonstrate urinary incontinence or utero-vaginal prolapse
what do you assess the cervix for in PV examination
cervical os: open/closed
length of cervix
directed posteriorly (anteverted) or anteriorly
consistency (usually firm when normal but hard in fibrosis/cancer and soft in pregnancy)
cervical excitation tenderness: gently move the cervix from side to side simultaneously assessing the patient’s face to ascertain if painful (positive in PID or ectopic pregnancy)
how to assess the uterus in bimanual examination
vaginal fingers are pushed on or behind the cervix to elevate the uterus upwards and towards the anterior abdominal wall and the left hand is placed suprapubically to palpate the uterus between the two hands
size, shape, consistency, position, tenderness, mobility
how to assess the adnexa in bimanual examination
vaginal fingers are moved to one of the lateral fornices with the abdominal hand moving into the corresponding iliac fossa
presence of ovary/Fallopian tube, adnexal masses, size, shape, tenderness
what is shoulder dystocia
when the baby’s head has been born but one of the shoulders becomes tuck behind the mother’s pubic bone, delaying the birth of the baby’s body
how to manage shoulder dystocia (emergency situation)
stop pushing
reposition into all fours position to increase pelvic diameter
OR
lie the woman on her back with her legs pushed outwards and up towards her chest (McRoberts manoeuvre)
ideally have two helpers to abduct each knee to the woman’s chest
press on the abdomen just above the pubic bone in an attempt to dislodge the fetal shoulder
what is the definition of post part haemorrhage
loss of >500 ml of blood from the genital tract within 24 hours of the birth of a baby
indications for examination of pregnant abdomen
at each antenatal assessment from 24 wks to assess growth
prior to auscultation fo fetal heart and use of CTG (to work out where to listen)
prior to vaginal examination
during labour
which gestational ages are associate with the following fundal heights:
pubic symphysis
umbilicus
xiphoid process of the sternum
pubic symphysis: 12 weeks
umbilicus: 20 weeks
xiphoid process: 36 weeks
what is the relationship between the SFH and gestational age
gestational age +/- 2 cm
where should you place the stethoscope to listen to the fetal heart rate
between the shoulders
which swabs are used for; trichomonas vaginalis bacterial vaginosis chlamydia gonorrhoea
TV and BV: blue swab, vaginal
chlam and gon: orange swab, vulvovaginal
management of miscarriage
expectant: up to 14 days
medical: misoprostol
surgical: evacuation of uterus (manual vacuum or electric vacuum)
when to give anti-D in case of miscarriage
Rh negative AND >12 weeks or <12 weeks and surgical management
where is most common site of ectopic pregnancy
tubes
risk factors for ectopics
smoking, PID, previous ectopic, previous tubal surgery
investigation of suspected ectopic pregnancy
check HCG 48 hours apart if stable or cannot see pregnancy (PUL)
if >63% rise, likely IUP and offer USS (if HCG >1500)
if >50% drop, likely a failing pregnancy and check urine pregnancy test in 14 days
when is expectant management of ectopic appropriate
HCG <1500 and dropping
no significant pain
empty uterus
mass <35 mm and no FH (unruptured)
medical management of ectopic
when/what
best if HCG <3000 but up to 5000
methotrexate
side effects of methotrexate management of ectopic
bloating and flatulence
transient elevation of LFTs
stomatitis
presentation of molar pregnancy
irregular bleeding
hyperemesis
hyperthyroidism
what is a complete molar pregnancy
duplication of haploid sperm following fertilisation of an empty ovum
no fetal tissue
USS snowstorm appearance/IU cystic mass
management of complete molar pregnancy
surgical evacuation
15% chance of chemo
what are the risks of molar pregnancy
becomes invasive and potentially cancer-y
what is a partial molar pregnancy
triploid = 2 sets of paternal genes and 1 set of maternal
might be fetal tissue
management of partial molar pregnancy
medical management if large fetal tissue
or surgical
0.5% chance of chemo
what is the guidance for future pregnancies after molar pregnancy
no pregnancy for 6 months
or 1 year if chemo
fibroids are most common in pre- or post menopausal women
pre menopausal
IU masses in post-menopausal women are cancer until proven otherwise
symptoms of fibroids
none (50% incidental finding) HMB dysmenorrhoea pressure effects (frequency, hydronephrosis if compress ureters) infertility
what further medical complications can be caused by fibroids
anaemia if heavy bleeding
degeneration (pain)
torsion if pedunculated
infection
management of fibroids <3 cm
Mirena 1st line tranexamic acid and NSAIDs other contraception (COCP, POP) if submucosal can have transcervical resection endometrial ablation hysterectomy
management of fibroids >3 cm
tranexamic acid and NSAIDs Mirena coil/COCP/POP uterine artery embolisation myomectomy hysterectomy GnRH analogues (switch off hormone production from ovaries, 3 months pre-op)
tumour marker of ovarian cancer
Ca125
what is a complex ovarian cyst
multiloculated
has solid parts in it
in any way suspicious of cancer
what is an RMI (risk of malignancy index) in ovarian cancer
USS features x menopausal status x ca123
<200 low risk (repeat in USS 3 months or benign surgery)
>200 refer to gynae onc MDT and CT chest abdo pelvis
who is offered cervical screening
25-64 year olds
what is tested in cervical screening
HPV
if negative - recall in 5 years
if positive do cytology
cytology
if negative HPV in 12 months
if positive colposcopy
when would you diagnose someone with the menopause
cessation of menstruation for >1 year
risks of HRT
VTE: increased with oral, no increase with transdermal
stroke: increased with oral, not with transdermal
CVS: if <60 no increase
BrCa: increased, no increase if oestrogen only
osteoporosis: reduced risk
when to give combined or oestrogen only HRT
if no uterus = oestrogen only
if uterus = combined (oestrogen and progesterone)
what are the two main diagnostic tests available to high risk pregnancies
chorionic villous sampling and amniocentesis
what is NIPT
non-invasive prenatal testing
analyses cell-free DNA in the mother’s blood from the fetus
better sensitivity and specificity than 1st trimester DS screening
risk factors for multiple pregnancy
assisted conception eg clomid, IVF ethnicity (African) family history on maternal side increased maternal age increased parity tall women > short women
define zygosity and chorionicity
monozygotic: splitting of a single fertilised egg
dizygotic: fertilisation of 2 ova by 2 sperm
dichorionic: 2 placentas, always dichorionic diamniotic
monochorionic: 1 placenta, may be mono- or diamniotic
how is chorionicity determined
USS, at booking scan
DCDA: lambda sign
MCDA: T-sign
how does management differ between DC and MC twins
MC twins need 2 weekly USS to pick up early signs of Twin-Twin transfusion syndrome
signs and symptoms of multiple pregnancy
exaggerated pregnancy symptoms (eg hyperemesis gravid arum)
high AFP
large for dates uterus
multiple fetal poles
fetal complications of multiple pregnancy
congenital anomalies IU death (single and both) preterm birth growth restriction (equal, discordant) cerebral palsy TTTS (monochorionic pregnancies)
maternal complications of multiple pregnancy
hyperemesis gravidarum anaemia pre-eclampsia GDM antepartum haemorrhage (abruption, praaevia) preterm labour c-section
describe antenatal management of multiple pregnancy
consultant led care
antenatal clinic every 2 weeks if MC and 4 weeks if DC
iron and folic acid supplements
low dose aspirin to prevent HTN
USS from 16th week with deep vertical pool, bladder and umbilical artery assessment
anomaly scan 18-20 weeks
what is TTS
disproportionate blood supply to foetuses in MC pregnancies
one twin has reduced blood supply leading to decreased urine output, anaemia and oligohydramnios while the other twin has increased urinary output, polyhydramnios, polycythaemia and eventually heart failure
management of TTS
fetoscopic laser ablation before 26 weeks
after 26 weeks amnioreduction/septostomy and aim to deliver at 34-36 weeks
timing of delivery in DCDA and MCDA twins
DCDA 37-38 weeks
MCDA 36+0 with steroids
mode of delivery of multiple pregnancies
triplets c-section
MCMA: c-section
one cephalic twin: aim for vaginal but may need to with to CS
labour management of multiple pregnancy
epidural to facilitate operative delivery
continuous use of CTG for both
syntocinon after twin 1 to maintain contractions
USS to confirm presentation
intertwine delivery time <30 mins
what are the different types of breech presentation
complete breech: legs folded with the leet level with the bottom
footling breech: on or both feet point down so will emerge first
frank breech: feet are up at the baby’s head so bottom emerges first
what is external cephalic version
attempting to manually turn the fetus into a cephalic presentation
50% successful
what is prolonged pregnancy
> 42 weeks
risks of prolonged pregnancy
stillbrith
meconium aspiration
respiratory distress
when should induction be offered in prolonged pregnancy
21-42 weeks
role of USS in early pregnancy
assessment of viability IU or ectopic date pregnancy using CR L determine chorionicity off Down syndrome screening
role of USS in 2nd trim
fetal anomaly scans
placental site
screen maternal uterine artery resistance
role of USS in 3rd trim
monitor fetal growth (abdominal circumference, head circumference, femur length - calculate EFW)
fetal hypoxia
anaemia
how can USS assess for fetal anaemia/hypoxia
umbilical artery increases its resistance in fetal hypoxia and middle cerebral artery decreases resistance
MCA shows increased peak systolic volume in anaemia
how many USS does an uncomplicated pregnancy get
2: booking and anomaly scan
risk factors for maternal morbidity and mortality
black/asian ethnicity age >40 deprivation VTE mental health issues
define still birth
baby born with no signs of life at or after 28 weeks gestation
major causes of stillbirth
labour complications post-term pregnancy maternal infections eg malaria, HIV maternal disorders eg DM, HTN fetal growth restriction congenital abnormalities
what are the features of gestational HTN
develops after 20 weeks gestation, no proteinuria or oedema
systolic >140 or diastolic >90
or increase above booking readings of >30 or >15
what ar the features of pre-eclampsia
after 20 weeks gestation, HTN with proteinuria (>0.3 g/24 hours)
complications of pre-eclampsia
fetal prematurity and IUGR eclampsia haemorrhage due to placental abruption cardiac failure stroke VTE DIC and HELLP pulmonary oedema multi-organ failure
investigations for PET
BP
urinalysis (protein)
Hb, PLT, U&Es, coag screen, rate
management of pre-existing HTN
switch from ACEI (teratogenic) to labetalol, nifedipine, methyldopa
consider patient’s allergies and PMH
management of pregnancy induced HTN (if <20 weeks)
labetalol
nifedipine
methyldopa
hydralazine
management of PET >20 weeks
labetalol, nifedipine, methyldopa, hydralazine
IV MgSulphate
definitive treatment is delivery of baby
steroids if early delivery
secondary preventions in women with history of PET or risk factors for PET
low dose aspirin started at 12 weeks
increased surveillance for signs and symptoms of PET
regular growth scans
risk factors for GDM
previous GDM obesity BMI >30 Fix of a first degree relative with GDM ethnicity (SE asian, Middle Eastern, black Caribbean) previous big baby
signs of GDM
polyhydramnios
glycosuria
complications of GDM
overgrowth of insulin sensitive tissues and macrosomia
shoulder dystocia and vaginal trauma
assisted delivery/c-section
hyperaemic state in utero (risk of stillbirth)
short term metabolic complications (fetal hypoglycaemia post-delivery)
long term risk of obesity, insulin resistance and diabetes in baby
complications of pre-exisiting diabetes in pregnancy
congenital anomalies (increased risk of NTD and cardiac anomalies) miscarriage (<24 weeks) IU death (>24 weeks)
pre-pregnancy counselling in T1DM or T2DM
HbA1c monitoring: aim for 48 avoid pregnancy if >86 stop embryopathic medication determine micro-microvascular complications high dose folic acid low dose aspirin from 12 weeks
when to deliver in GDM
metformin: 39-40 weeks
diet controlled: 40-41
insulin: 38 weeks
describe screening and diagnosis of GDM
assess risk factors at booking
previous gestational diabetes
blood glucose monitoring and OGTT in 1st trim (if normal repeat at 24-28 weeks)
fasting: >5.1
2 hour: >8.5
blood sugar targets in pregnancy
fasting: 3.5 - 5.5
1 hours post-meal: <7.8
which medications can be used to control GDM if diet and exercise fail
metformin
insulin
postnatal care in GDM
increased risk of T2DM
fasting BG measured 6-8 weeks
if results suggest T2DM, OGTT at 6 weeks
annual screening for diabetes by GP
aetiology of PROM
infection
cervical incompetence
over-distension of uterus
vascular causes eg placental abruption
risk factors for PROM
previous pre-term labour multiple pregnancy smoking uterine anomalies parity ethnicity poor socioeconomic status drugs (esp cocaine)
what are the complications of PROM
neonatal mortality and morbidity (prematurity, sepsis, pulmonary hypoplasia)
chorioamnionitis
how to diagnose PPROM
maternal history followed by sterile speculum examination (pooling of blood in posterior vaginal fornix)
USS: oligohydramnios
avoid digital vaginal examination due to risk of infection, unless suspicion woman may be in labour
management of PROM
monitor for signs of chorioamnionitis (maternal pyrexia, tachycardia, leucocytosis, uterine tenderness, discharge, fetal tachycardia)
Abx to prevent ascending infection (erythromycin)
tocolytics (nifedipine if 26-33+6)
maternal steroids
magnesium sulphate
causes of fetal anaemia
Rh antibodies parvovirus CMV syphilis toxoplasmosis Hb-opathies feto-maternal haemorrhage MC tiwn complications
what is hydrops fetalis
abnormal accumulation of fluid in 2 r more compartments and manifests as ascites, plural effusion, skin oedema, pericardial effusion
causes of APH
placenta praaevia placental abruption local causes (cervical ectropion, polyps, infection, cervical cancer) vasa praevia uterine rupture indeterminate preterm labour
how can blood loss by quantified in APH
spotting: staining, streaking or blood spotting noted on underwear or sanitary pad
minor haemorrhage: <500 ml that has settles
major: 500-1000 ml with no signs of shock
massive: >1000 ml and/or signs of shock
define placenta praaevia
placenta covering or within 2 cm of the cervical os
investigation of placenta praaevia
if early scan (anomaly scan) shows low-lying placenta, another scan is done at 32 weeks to check if the placenta has moved
if unclear offer transvaginal scan
presentation of placenta praaevia
bright red painless bleeding
risk factors of placenta praaevia
age
previous c-section
previous praaevia
define placental abruption
separation of a normally implanted placenta either partially or totally before the birth of the fetus
consequences of placental abruption
IU death and fetal hypoxia
primary post part haemorrhage
risks of massive bleeding (DIC, low BP, multi-organ failure, risk of death)
risk factors for placental abruption
PET/HTN trauma smoking, cocaine, amphetamine medical thrombophilia, renal disease or diabetes polyhydramnios abnormal placenta previous abruption multiple pregnancy, PROM
symptoms of placental abruption
severe, continuous abdominal pain backache with posterior placenta bleeding (concealed) preterm labour maternal collapse
signs of placental abruption
unwell distressed patient
signs may be inconsistent with revealed blood
uterus large for dates or normal
uterine tenderness
woody, hard uterus
fetal parts difficult to identify
may be in preterm labour with heavy show
fetal heart rate may be absent or bradycardia
CTG shows irritable uterus
management of placental abruption
resuscitate mother
urgent c-section and replacing blood products
fetal resuscitation if needed
manage complications: anti-D
define vasa praevia
fetal blood vessels I the membranes overlying close to the internal cervical os
presentation of vasa praaevia
membranes are ruptured followed by small amount of dark vaginal bleeding and acute fetal bradycardia and decelerations
how to prevent vasa praaevia
always feel for pulsations or any cord-like structures before performing amniotomy
check fetal head is presenting and engaged before inducing labour or ARM
what are the types of vasa praaevia
type 1: vessel connected to velamentous umbilical cord
type 2: when it connect to the placenta with a succenturiate or accessory lobe
risk factors for vasa praaevia
placental abnormalities (bilobed, succinturiate lobes)
low lying placenta in 2nd trim
multiple pregnancy
IVF
management of vasa praaevia
antenatal diagnosis:
steroids at 32 weeks
inpatient management if risks of preterm birth (32-34 weeks)
elective c-section before labour (34-36 weeks)
diagnosed during labour:
emergency c-section, might need blood transfusion for baby
presentation of uterine rupture
acute constant abdominal pain even when the uterus is relaxed which may be referred to the shoulder tip
sudden collapse
fetal parts easily palpable as may be in abdominal cavity
maternal chicken pox infection in last 4 weeks of pregnancy
avoid planned pregnancy for 7 days to allow transfer of maternal Ig
pregnancy woman who has never had chicken pox is in contact with chicken pox
blood test to check IgG antibodies to varicella zoster will confirm immunity
if not immune offer varicella zoster Ig as post-exposure prophylaxis (effective within 10 days)
effects on fetus of CMV infection in pregnancy
hearing loss
visual impairment or blindness
mild to severe LD
epilepsy
clinical features of congenital CMV
jaundice petechial rash hepatosplenomegaly microcephaly SGA
how long is a person with parvovirus infectious for
1 day after rash develops
parvovirus B19 in fetus causes
severe anaemia, heart failure, hydrops fetalis
symptoms of congenital rubella
sensorineural learning loss
congenital heart disease (PDA)
ocular abnormalities (congenital glaucoma, cataracts)
HIV viral load
<50 copies/ml
babys born the HIV positive mothers receive what postnatal
testing at birth and at regular intervals up to 2 yo
should HIV positive women pbreast feed?
formula is safest way to feed baby
safe to breast feed if:
undetectable viral load and mother is taking ART
exclusive breastfeeding for first 6 months and not mixing formulas or cow’s milk
avoid breastfeeding at high risk times eg mastitis, cracked nipples, detectable viral load, D+V in mother or baby
diagnosis f DVT
swelling
oedema
leg pain or discomfort
increased leg temperature
testing for DVT in peurperium
compression duplex US
if normal but high suspicion repeat in one week to exclude an extending thrombosis and give therapeutic dose of LMWH
consider MRI venography if iliac vein thrombosis suspected
symptoms and signs of PE
dyspnoea chest pain faintness collapse haemoptysis raised JVP focal signs in chest symptoms and signs of DVT
diagnosis of PE
CTPA or V/Q scan
management of PE
heparins
risk factors for preterm birth
previous preterm labour multiple pregnancy uterine anomalies age parity (mulligan's- or grand) ethnicity poor socio-economic status smoking drugs (cocaine) Low BMI (<20)
what is SGA
estimated fetal weight or abdominal circumference below the 10 decile in both population and customised gentiles
what is LGA
> 90th centile
SFH >2cm for gestational age
causes of LGA
polyhydramnios
multiple pregnancy
macrosomia due to GDM
wrong dates in late bookers
what is polyhydramios
excess of amniotic fluid with AFI >25 cm or deepest vertical pool >8 cm
risks associated with LGA
clinician and maternal concern
shoulder dystocia
PPH
symptoms and signs of polyhydramnios
abdominal discomfort PROM preterm labour cord prolapse large for dates malpresentation shiny, tense abdomen inability to feel fatal parts
innervation of detrusor muscle
parasympathetic nerves derived from the pelvic splanchnic S2-4
innervation of urethral smooth muscle
sympathetic nerves from spinal cord at T10-L2
descend to bladder and urethra via the hypogastric nerves
innervation of the striated urethral sphincter and pelvic floor (levator ani) muscles
pudendal nerve S2-4
describe the three levels of support the pelvic floor gives the vagina
cervix and upper vagina
supported by uterosacral, transverse cervical and pubocervical ligaments
middle vagina
supported by pelvic fascia
lower vagina
supported by levator ani muscles and perineal body
contents of deep perineal pouch in females
part of urethra vagina clitoral neuromuscular bundle extensions of ischioanal fat pads smooth muscle external urethral sphincter and compressor urethrae
contents of deep perineal pouch in males
part of urethra bulbourethral glands neuromuscular bundle of penis extension of sischioanal fat pads smooth muscle external urethral sphincter and compressor urethrae
contents of superficial perineal pouch (female)
clitoris and crura bulbs of vestibule bulbospongiosus ischiocavernosus vestibular glands superficial transverse perineal muscle internal pudendal vessels internal pudendal nerve
contents of superficial perineal pouch (male)
bulb of penis and crura bulbospongiosus ischiocavernosus internal pudendal vessels pudendal nerve superficial transverse perineal muscle
causes of pelvic floor weakness
increased intra-abdominal pressure:
obesity, chronic cough, occupational or recreational exercise, constipation, intra-abdominal mass
pelvic floor muscle trauma and denervation:
obstetric trauma, pelvic fracture or surgery, congenital
connective tissue disorder:
age related, oestrogen deficiency, congenital or acquired connective tissue disorder, drug related (steroids)
common features of stress incontinence
after childbirth, pelvic surgery and oestrogen deficiency
triggers: coughing, sneezing, exercise
investigations for stress incontinence
exclude UTI
frequency/volume charts (normal frequency and bladder capacity)
urodynamic studies
management of stress incontinence
lifestyle: weight loss, smoking cessation, avoid constipation, avoid heavy lifting, caffeine reduction
conservative: pelvic floor exercises for 3 months, use of pads
medical: duloxetine (not first line)
surgical: bulking agents, autologous rectus fascial sling, colposuspension, artificial urinary sphincters
side effects of duloxetine for stress incontinence
difficulty sleeping headache dizziness blurred vision change in bowel habit nausea and vomiting dry mouth sweating decreased appetite weight loss decreased libido
features of urge incontinence
triggers: hearing running water, cold weather
larger volumes that SUI
“I have to go immediately”
investigations of urge incontinence
frequency/volume charts (increased frequency)
urodynamic testing shows over-activity of detrusor muscle
management of urge incontinence
lifestyle: decrease fluid intake, minimus caffeine and alcohol, use of pads
bladder retraining
medical: tolterodine/solifenacin (oxybutynin not recommended due to cognitive impairment), mirabegron, topical oestrogen, desmopressin in nocturia
surgery: botox, percutaneous sacral nerve stimulation, augmentation cystoplasty
causes of overflow incontinence
inactive detrusor muscle: neurological conditions (eg MS)
involuntary bladder spasms: CV disease, diabetes
cystocele or uterine prolapse
investigation of overflow incontinence
frequency/volume charts
urodynamic testing shows inactivity of detrusor muscle
management of overflow incontinence
treat the cause
what are the stages of prolapses
stage 1: mild protrusion on examination (-1 cm)
stage 2: prolapse present at introitus (-1 to +1 cm)
stage 3: beyond +1 cm from the introitus
stage 4: prodicentia (complete inversion)
risk factors for prolapse
increasing age (40% post menopausal) multiparity vaginal deliveries obesity Spina Bifida
clinical signs of prolapse
sensation of pressure, heaviness, bearing down
urinary incontinence, frequency, urgency
management of prolapse
if mild and asymptomatic may not need treatment
lifestyle: weight loss, avoid constipation, smoking cessation, avoid heavy lifting, caffeine reduction
pelvic floor training: kegels, pilates, supervised PFE with physio
ring pessary
surgery
surgical options for prolapse
cystocele/cystourethrocele: anterior colporrhaphy
uterine prolapse: hysterectomy, sacrohysteropexy, Sacrospinous fixation (sutured placed in Sacrospinous ligament medial to ischial spine to fix prolapse in place)
rectocele: posterior colporrhapy
symptoms of UTI
dysuria increased frequency/urgency cloudy/offensive urine lower abdo pain fever/malaise delirium in elderly
management of UTI in in non-pregnant women
urine culture if >65 yo or haematuria
trimethoprim or nitrofurantoin for 3 days
management of symptomatic UTI in pregnancy
urine culture
nitrofurantoin in 1st and 2nd trim
trimethoprim in 3rd trim
management of symptomatic UTI in pregnancy
urine culture should be done at 1st antenatal visit
high risk of preogressing to acute pyelonephritis
immediate course of nitrofurantoin (avoid near term), amoxicillin or cefalexin for 7 days
urine culture after treatment for test of cure
briefly describe the processes of fertilisation and implantation
at ovulation the egg is released into the fallopian tube where it is normally fertilised
cells divide and progress to a morula, then blastocyst as it travels along tube to uterus
blastocyst implants into uterine lining during days 5-8
the inner cells develop into the embryo and the outer cells invade the endometrium to become the placenta
what are the four outcomes of fertilisation
normal pregnancy: normal embryo in normal locations
miscarriage: normal/abnormal embryo in normal location
ectopic: normal embryo in abnormal location
molar: abnormal embryo in normal location
how do HCG values change during a normal pregnancy
should double every 48 hours in a normal pregnancy
when does HCG level reach peak
12-14 weeks
N+V normally reduce after this time
what is the effect of human placental lactogen
when does it start to be released
growth-hormone like effects and decreases insulin resistance in the mother
also involved in breast development (tenderness)
week 5
what are common non-hormonal changes in pregnancy
increased cardiac output due to increased blood volume (raised HR, ECG changes, functional murmurs)
increased plasma volume causes decreased Hb by dilution
what is implantation bleeding
how does it present and when
occurs when the fertilised egg implants into the uterine wall
normally about 10 days after ovulation
generally light brown and limited (earlier and lighter than a period)
what is a subchorionic haematoma
what are its symptoms
collection of blood between the chorion and uterine wall
symptoms vary by size but include bleeding, cramping and threatened miscarriage
large haematomas may lead to miscarriage, infection or irritability
what type is present in the two parts of the cervix
ectocervix: tough, squamous epithelium
endocervix: columnar epithelium
how does pregnancy affect the location of the transitional zone of the cervix
what can occur as a result
location of transitional zone changes as a physiological response to pregnancy
exposes the endocevical (columnar) epithelium to the external environment of the vagina
can cause erosion (ectropion) which may bleed
what are causes of bleeding in early pregnancy
implantation bleeding polyps cervical erosion infection (STI, herpes, bacterial infection) suchorionic haematoma malignancy miscarriage
someone presenting with bleeding in early pregnancy may be experiencing non-PV bleeding
what other sources of bleeding should be considered?
haematuria: UTI, kidney stones, malignancy
PR bleeding: haemorrhoids, anal fissures, gastroenteritis, IDB, malignancy
miscarriage can occur up to ______ weeks gestation
23+6
what is a threatened miscarriage
risk to the pregnancy
bleeding +/- cramping
cervical os is closed
USS signs of threatened miscarriage
intrauterine pregnancy
foetal pole is present and if measures >7 mm a foetal heart should be present
what is an inevitable miscarriage
symptoms consistent with miscarriage and the pregnancy can’t be saved
open os, possibly products of conception at the os
USS signs of inevitable miscarriage
may show viable pregnancy
products that are in the process of expulsion
what is an incomplete miscarriage
some products have passed, but there are some products remaining in the uterus
what is a septic miscarriage
infection alongside incomplete or complete miscarriage
symptoms of septic miscarriage
fevers, riggers, uterine tenderness, bleeding, offensive discharge and pain
recurrent miscarriage is defined as
3 or more consecutive pregnancy losses
what is a missed miscarriage
no symptoms or a history of threatened miscarriage but on USS there is no viable pregnancy
what are USS signs of early foetal demise
pregnancy in situ that has mean sac diameter of >25 mm and/or a foetal pole >7 mm but no heart beat
causes of miscarriage
- embryo
- maternal factors
- uterine factors
- immunologic
- infections
- iatrogenic
embryo: chromosomal abnormalities
maternal factors: PCOS, uncontrolled DM, increasing age, heavy smoking, alcohol/drugs (cocaine), severe HTN, obesity
immunologic: APS
infections: CMV, rubella, toxoplasmosis, listeria
iatrogenic: CVS or amnio
which antibodies are associated with APS
what effect do they have on pregnancy
lupus anticoagulant
anticardiolipin antibodies
anti-B2 glycoprotein-1
inhibiting trophoblastic function and differentiation
create localised inflammatory response at maternal-foetal interface
cause thrombosis of uteroplacental vasculature
what is cervical shock and how does it present
occurs during incomplete miscarriage where the products are sitting in the cervix
cramps, severe abdo pain, N+V, sweating, fainting, bradycardia, hypotension
why might IV fluids not correct hypotension in cervical shock
due to vagal stimulation of the products sitting in the cervix
management of cervical shock
remove products from cervix
can be done with a speculum and sponge forceps
presentation of ectopic pregnancy
localised pelvic pain light PV bleeding shoulder tip pain SOB dizziness passage of tissue rectal pressure or pain on defecation
signs of Coptic pregnancy
pallor, haemodynamic instability
peritonism, guarding, general abdominal or pelvic tenderness, adnexal tenderness
cervical motion tenderness, abdominal distension, enlarged uterus
presentation of molar pregnancy
hyperemesis funds large for dates varied bleeding grape-like tissue SOB
assessment of woman presenting with suspected miscarriage
asses haemodynamic stability
FBC, G&S, Rh status
serum HCG (should halve every 48 hours)
investigations for ectopic pregnancy
FBC, G&S, HCG and TVUSS
suboptimal HCG (doesn’t double every 48 hours)
empty uterus on TVUSS or presence of pseudo sac
free fluid in pouch of Douglas = suspect ruptured ectopic
signs of molar pregnancy
raised levels of HCG
typical snowstorm appearance on USS
with or without fetus
management of miscarriage
threatened: watchful waiting
missed/incomplete and stable : conservative, medical or surgical management
missed/incomplete and unstable: ABCDE, resus, surgical management normally safest option
what are the surgical options for miscarriage
surgical evacuation under GA
manual vacuum aspiration under local anaesthetic
advice for women with recurrent miscarriage/APS
low dose aspirin and daily fragmin injection for future pregnancies
when is surgical management indicated in ectopic pregnancy
significant pain
adnexal mass >35 mm
visible heart beat on USS
conservative management of ectopic
patients asked to return for serum HCG measurements on days 2, 4 and 7 after original test
if they fall by at least 15% from previous value they can be repeated weekly until a negative (<20 IU/L) is obtained
medical management of ectopic
single of 2 separate doses of methotrexate and continued HCG monitoring
surgical management of ectopic
laparoscopic salpingotomy or salpingectomy
management of molar pregnancy
surgery
send tissue for histological examination
what is hyperemsis gravid arum
vomiting that is excessive, prolonged and begins to alter the woman’s quality of life
consequences of unmanaged hyperemesis gravid arum
dehydration, ketosis, electrolyte and nutritional imbalance, weight loss, altered liver function
other causes of excessive vomiting in pregnancy
UTI gastritis peptic ulcer viral hepatitis pancreatitis
management of hyperemesis gravid arum
IV fluids and electrolytes
anti-emetic (PO or IV)
first line is cyclising or prochlorperazine
nutritional supplements: thiamine, pabrinex (Vit B/C)
if severe NG/TPN
ranitidine/omeprazole for reflux
steroids if super bad
consider thromboprophylaxis
define the following: menorrhagia metrorrhagia polymenorrhoea polymenorrhagia menometrorrhagia amenorrhoea oligomenorrhoea
menorrhagia: prolonged and increased bleeding (heavy menstrual bleeding)
metrorrhagia: regular Intermenstrual bleeding
polymenorrhoea: menses occurring at <21 day interval
polymenorrhagia: increased and frequent cycle
menometrorrhagia: prolonged menses and Intermenstrual bleeding
amenorrhoea: absence of menstruation >6 months
oligomenorrhoea: menses with interval >35 days OR presence of <5 menstrual cycles in a year
assessment of menorrhagia
thorough history
general exam for signs of anaemia
abdominal and pelvic examination
smears and swabs if necessary
what is dysfunctional uterine bleeding
menorrhagia in the absence of other pathology
a diagnosis of exclusion, found in 50% of women with abnormal uterine bleeding
what are the two types of DUB and what are their characteristics
anovulatory: 85% of DUB occurs at extremes of reproductive life irregular cycle more common in obese women
ovulatory:
more common in 35-45 yo
regular heavy periods
due to inadequate progesterone production by corpus luteum
investigations for DUB
FBC
TFTs (hypothyroid features)
coagulation screen (very heavy bleeding or signs of bleeding tendency)
TVUSS (endometrial thickness, fibroids, other masses)
endometrial sampling (pipette biopsies, hysteroscopy, D&C)
smear (if due - opportunistic, not a test for DUB)
refer to colposcopy if abnormal cervix
what are options for medical management of DUB
progestogen releasing IUCD (Mirena): 1st line treatment, may cause breakthrough bleeding for 3-9 months after insertion
COCP: compliance issues, check UKMEC for contraindications
antifibrinolytics (tranexamic acid): during menstruation, if contraception not wanted
NSAIDs (mefenamic acid): during menstruation, CI in duodenal ulcers or severe asthma
oral progestogens (norethisterone, medrocyprogesterone)
GnRH analogues: act on pituitary to stop oestrogen production resulting in amenorrhoea, can cause osteoporosis
danazol: synthetic androgen that acts on HPO axis
surgical management of DUB
endometrial resection/ablation
hysterectomy
disadvantages of surgical management of DUB
anaesthetic risks
loss of fertility in hysterectomy
complications in future pregnancy after ablation (placenta accreta)
causes of intermenstrual bleeding
cervical ectropion PID and STI endometrial or cervical polyps cervical cancer endometrial cancer undiagnosed pregnancy/complications of Hyatidiform molar disease
psychological and physical manifestations of PMS
psych: depression, irritability and emotional lability
phys: fluid retention, weight gain, breast tenderness
diagnosis of PMS
menstrual diary of symptoms for at least 2 cycles
management of PMS
severe symptoms: SSRIs daily or during luteal phase of cycle and CBT
mild: lifestyle eg stress reduction, alcohol and caffeine reduction, exercise
medical: COCP, transdermal oestrogen, short-term GnRH
hysterectomy with bilateral salpingo-oophorectomy as last resort (trial of GnRH before surgery)
how do GnRH analogues work to reduce PMS, improve endometrisos and shrink fibroids
give some examples
if GnRH receptors are constantly simulated, they are desensitised, reducing GnRH release and thus reducing LH and SH release
Buserelin and goserelin
causes of postcoital bleeding
cervical ectropion cervical carcinoma trauma Atrophic vaginitis cervicitis due to STI polyps idiopathic
what do the NICE guidelines say about post menopausal bleeding
women over the age of 55 with PMB should be investigated within 2 weeks by USS for endometrial cancer
causes of PMB
Atrophic vaginitis (most common and benign) endometrial polyps endometrial hyperplasia endometrial carcinoma cervical carcinoma ovarian cancer (esp theca cell tumours) vaginal cancer (rare)
investigations of PMB
USS (transvaginal > abdominal): endometrial thickens >4 mm, further investigation needed (5 mm cut off if taking HRT)
if taking tamoxifen, endometrium will be thickened, irregular and cystic so do hysteroscopy and biopsy instead
further imaging: CT/MRI
management of PMB
Atrophic vaginitis: topical oestrogen and vaginal lubricants, HRT
endometrial hyperplasia: D&C, progestogen treatment, Mirena IUS, oral progestogens
endometrial cancer: refer to oncology
cervical cancer: refer to oncology
what are the Rotterdam criteria
used to diagnose PCOS, presence of two of the following:
clinical or biochemical evidence of hyperandorgenism (hirsutism, acne, hah free testosterone, low sex hormone binding globulin, high free androgen index)
polycystic ovaries on USS (ovarian volume >10 cm^3, at least 12 follicles in one ovary measuring 2-9 mm diameter)
oligo/amenorrhoea
features of PCOS
obesity/overweight
hypertension
acanthosis nigricans (thickening and pigmentation of skin of neck, axillae, skin folds)
acne and hirsutism
alopecia
insulin resistance, diabetes, lipid abnormalities
irregular periods
why are people with PCOS at higher risk of endometrial hyperplasia/carcinoma
oligo/amenorrhoea in presence of pre-menopausal levels of oestrogen
hormonal changes in PCOS
increase in LH:FSH ratio, LH levels very high and FSH low/nomral
management of PCOS
dependent on how patient presents and what their main concern is
optimise BMI
endometrial protection with hormonal contraception
management of infertility in PCOS
weight loss 5-10% indicated before ovulation treatment if BMI >30
first line: clomifene
add metformin (improve glucose tolerance, decreases androgen levels and improves ovulation)
ovarian drilling
gonadotrophin injunctions
IVF as last resort
what is clomifene
how does it work
what are its side effects
selective oestrgoen receptor modulator
block oestrogen negative feedback on hypothalamus resulting in more pulsatile GnRH secretion and therefore FSH and LH
side effects: hot flushes, sweating, increased risk of multiple pregnancy, ovarian cancer (long term use)
what is ovarian drilling
use in women who fail to conceive on clomifene
diathermy to destroy ovarian storm which reduces androgen-secreting tissue leading to restoration of normal LH:FSH ratio and a fall in androgens
how can acne be managed in PCOS
co-cyrprindol (Dianette): effective against acne and hirsutism, contains anti-androgen which block action of androgens on pilosebaceous glands
COCP: improves hyperandrogenism and gives withdrawal bleed (endometrial protection), inferior to co-cyrprindol
management of amenorrhoea in COCP
COCP: withdrawal bleed
cyclical medrocyprogesterone or Mirena coil can reduce risk of endometrial hyperplasia
what is the difference between primary and secondary dysmenorrhea
primary: no underlying pelvic pathology
- pain starts just before or within hours of period starting
- suprapubic cramping, may radiate to back or down thigh
secondary: due to underlying pathology
- starts 3-4 days before period
causes of secondary dysmenorrhoea
endometriosis adenomyosis (endometrium between muscle layers of the uterus) PID intrauterine devices (copper cold) fibroids
clinical features and examination findings of primary dysmenorrhoea
features:
pain precedes and accompanies menstruation
onset with or shortly after menarche
examination:
normal exam ind investigations
clinical features and examination findings of endometriosis
features:
associated with heavy periods and dyspareunia
examination:
uterosacral modularity and/or tenderness
fixed retroverted uterus
clinical features and examination findings of adenomyosis
features:
associated with prolonged, heavy periods
examination:
bulky uterus
clinical features and examination findings of fibroids
features:
menstrual pain
pressure effects on the adjacent organs
fibroid red degeneration during pregnancy
examination:
pelvic mass
clinical features and examination findings of chronic PID
features:
history of STI
pain not limited to menstruation
examination:
mucopurulent discharge
cervicitis
findings suggesting Fitz-Curtis-Hugh syndrome on laparoscopy
what is fitz-curtis-hugh syndrome
inflammation of the peritoneum and tissues surrounding liver
complication of PID
leads to formation of adhesions in the abdomen
investigations for dysmenorrhea
high vaginal and endocervical swabs (PID, clam or gon) pelvic USS (endometriomas, adenomyosis, fibroids) diagnostic laparoscopy (endometriosis, other investigations normal)
management of dysmenorrhoea
NSAIDs: menfanamic acid, ibuprofen
COCP
Mirena
GnRH analogues
what are the two types of amenorrhage
primary: failure of mestruation by 16 yo
secondary: absence of menstruation for at least 6 months in female with history of regular cyclic bleeding
causes of primary amenorrhoea
genital tract abnormalities: imperforate hymen, vaginal agenesis, cervical stenosis (amenorrhoea + secondary sexual characteristics)
mullerian agenesis (absent mullerian ducts –> absent uterus)
premature ovarian failure/insufficiency
genetic causes (turner’s, androgen insensitivity)
hypothalamic disorders (kallmans)
iatrogenic
autoimmune
endocrine causes (hypothyroid, constitutional delay, congenital hyperplasia, PCOS)
pituitary disorders
what is premature ovarian failure/insufficiency
cessation of periods <40 yo
can be due to chemo, radiotherapy, turner’s, autoimmune causes
causes f secondary amenorrhoea
physiological (excessive exercise, weight loss, stress)
autoimmune
pituitary (Sheehan, hyperprolactinaemia, haemochromatosis)
iatrogenic
endocrine (hypo/hypoerthyroid, PCOS)
uterine problems (endometrial atrophy, cervical stenosis, Ashermann’s)
pregnancy/lactation
what is Ashermann’s syndrome
acquired condition that occurs when adhesions form inside the uterus often secondary to endometrial surgery or infection
it prevents menstruation, reduces fertility and can cause placental abnormalities
management/investigation of amenorrhea
thorough history
general exam: BMI, secondary sexual characteristics, signs of endocrine disorders
visual fields if possible pituitary
examination of external genitalia
pregnancy test essential
what causes the menopause
loss of ovarian follicular activity leading to a fall in oestradiol levels below that needed for endometrial stimulation
how to confirm premature menopause
<45 yo
2 measurements at least 2 weeks apart
physical effects of the menopause
vasomotor symptoms eg hot flushes and night sweats
joint aches and pains
dry and itchy skin
hair changes
vaginal dryness and soreness (dyspareunia)
recurrent UTI, urgency
urogenital prolapse
osteoporosis increasing risk of fractures
CVD
dementia
psychological effects of menopause
labile mood, anxiety, tearfulness
loss of concentration, poor memory
loss of libido
what type of HRT is best suited for women with personal or family history of VTE or liver problems
oestrogen patches
skip first pas metabolism so less likely to affect liver or production of clotting factors
what different cycles of HRT are available
who are they most appropriate for
continuous combined: menopausal, taken every day
cyclical combined: perimenopausal, oestradiol everyday and progestogen on last 14 days
what can be used to treat reduced libido in menopause
testosterone
what are non-hormonal treatment options for menopause
SSRIs eg fluoxetine
CBT
how long should contraception be continued after menopause
2 years after LMP of <50
1 year if >50
side effects of NRT
oestrogen: breast enlargement, leg cramps, dyspepsia, fluid retention, nausea, headaches
progestogen: fluid retention, breast tenderness, headaches, mood swings, acne, depression, irritability, constipation, increased appetite
risks of HRT
breast cancer
VTE (PE and stroke)
endometrial cancer
absolute contraindications for HRT
suspected pregnancy breast cancer endometrial cancer active liver disease uncontrolled HTN known VTE known thrombophilia otosclerosis
relative contradictions for HRT
investigated abnormal bleeding large uterine fibroids past history of benign breast disease unconfirmed personal history or strong FH of VTE chronic stable liver disease migraine with aura
presentation of lichen sclerosis
pruritus and skin irritation of vulva hypo pigmented skin atrophy (shiny appearance) hair loss white polygonal papule that coalesce to form plaques figure 8 pattern
complications of untreated lichen sclerosis
persistent inflammation and healing scar formation atrophy and fusion of labia stenosis of introitus difficulties in defecation vulvar intraepithelial neoplasia
management of lichen sclerosis
3 months of high dose steroids eg dermovate
2nd line topical calcineurin inhibitors eg tacrolimus, imiquimod (immunosuppressant to reduce inflammation)
if treatment resistant, biopsy to rule out malignancy
what is Paget’s disease of the vulva
uncommon intraepithelial adenocarcinoma
itching, pain, irritation, hyperpigmentation or leukoplakia
management of Paget’s disease of the vulva
often a sign of malignancy elsewhere
full work up
describe normal, physiological changes to discharge
during more fertile days: thin and clear
non-fertile days: thicker, hostile to sperm
which bacteria are important in the maintenance of vaginal pH
lactobacilli
what are risk factors for pelvic infection
age <25 years multiple sexual partners unprotected sex recent insertion of IUD recent change in sexual partner
symptoms of pelvic infection
lower abdominal pain fever abnormal vaginal bleeding offensive vaginal discharge dysuria or menstrual irregularities
examination signs of pelvic infection
cervical motion tenderness
adnexal tenderness
management f pelvic infection
acutely unwell: sepsis 6
partner notification
oral ofloxacin and oral metronidazole OR IM ceftriaxone and oral doxy and met
which populations are functional cysts, germ cell tumour and benign epithelial tumours most common in
functional: young women or reproductive age
germ cell: young women
benign intraepithelial: older women
what are concerning features of an ovarian cyst
thick wall septa
solid and cystic components
recommended investigation for complex ovarian cysts
Inhibin, b-HCG, CA125
features of functional ovarian cysts
simple, uniloculated cysts >3 cm
regress after several menstrual cycles
what causes functional ovarian cysts
non-rupture of dominant follicle or failure of stress of a non-dominant follicle
features of benign germ cell tumours
often lined with epithelial tissue, may contain hair, teeth
often very big so at risk of torsion
types of benign epithelial ovarian tumours
serous cystadenomas
mutinous cyst adenomas
gynae causes of acute abdo pain
ectopic pregnancy ovarian torsion ovarian cyst rupture or haemorrhage PID tubo-ovarina abscess endometriosis fibroids miscarriage mittelschmirz
signs/symptoms, diagnosis and management of uterine fibroids
S&S:
asymptomatic, menorrhagia and dysmenorrhoea, lower abdo pain during menstruation, sub fertility, pressure symptoms
Dx:
TVUSS
management:
Mirena, myomectomy, hysterectomy, short-term GnRH analogues, uterine artery embolisation
signs/symptoms, diagnosis and management of endometriosis
S&S:
dysmenorrhoea, deep dyspareunia, sub fertility, non-gynae signs (dysuria, urgency, dyschezia)
Dx:
often via laparoscopy, tender modularity on posterior fornix
management:
NSAIDs/paracetamol (symptomatic relief), COCP or progestogens, surgery (excisions of lesions)
signs/symptoms, diagnosis and management of ovarian torsion
S&S:
sudden onset deep colicky pain, vomiting, distress, adnexal tenderness/acute abdomen
Dx:
USS will show classical whirlpool sign
management:
laparoscopy to untwist ovary and remove cyst
oophorectomy if necrotic
signs/symptoms, diagnosis and management of PID
S&S:
vaginal discharge, bilateral lower abdo pain
Dx:
FBC, high vaginal or endocervical swab
may need pelvic imaging if doesn’t respond to Abx or pelvic mass
management:
Abx, drainage of pelvic abscess
signs/symptoms, diagnosis and management of mittelschmerz
S&S:
mid cycle pain
often
Dx:
exclusion of other things
management:
simple analgesia and reassurance
how long does the puerperium normally last
6 weeks
describe the changes in vaginal discharge in the first 3 weeks postpartum
3-4 days after birth
- fresh red discharge
- rubra
4-14 days after birth
- brownish-red, watery
- serosa
10-20 days after birth
- yellow
- alba
what changes occur in the uterus postpartum
endometrial lining regenerates by day 7
funds of uterus returns to physiological position by 2 weeks
uterine weight decreases to 5% of pregnancy weight
what is colostrum
thick, yellowish substance produced by mammary tissue
first milk a baby is fed
contains more protein and vitamins that normal milk
essential for immunological protection to the newborn
what initiates lactiation
expulsion of the placenta
decrease in oestrogen and progesterone levels
high levels of oestrogen and progesterone during pregnancy prevent release of prolactin (it is still produced but not released)
drop in oestrogen and progesterone so prolactin is released
how is prolactin production maintained during breastfeeding
positive feedback from the infant suckling
what is the let-down reflex
oxytocin stimulates myoepithelial cells surrounding breast alveoli to contract and squeeze milk out of breast
triggered by suckling
what is the WHO guidance related to breastfeeding
exclusive breastfeeding for 6 months
then up to 2 years along with introduction of solid foods
what to ask if patient presents saying she has ‘insufficient milk’ when trying to breastfeed
any pain while breastfeeding or skin changes to nipples
is baby irritable after a feed
ask to assess technique
risk factors for lactational nastitis
improper breastfeeding technique (trauma to breast, milk stasis and ineffective milk release –> harbours bacteria)
smoking
foreign body (breast implant or piercing)
what are the main features of a focussed history of mastitis
MAIDS
Milk stasis (decreased milk output)
Abscess (tender lump)
Inflammation (warmth, pain, swelling, firmness, erythema)
Discharge
Systemic symptoms (fever, malaise, myalgia)
what is duct ectasia
blocked duct
management of mastitis
fluclox 500 mg orally every 6 hours
or co-amoxiclav 625 mg every 8 hours for 7 days
breastfeeding should continue, use breast pump for infected breast if preferred
management of breast abscess
USS and aspiration for culture
define PPH
primary and secondary?
minor and major?
PPH = blood loss =/>500 ml after the birth of the baby
primary = within 24 hours of delivery secondary = 24 hours - 6 weeks post delivery
minor = 500-1000 ml major = >1000 ml or signs of cardiovascular collapse
what are the 4 main causes of PPH
4T’s
tone: uterine atony
trauma: vaginal tear, cervical laceration, rupture
tissue: retained products of conception, placenta
throbbing: coagulopathy
antenatal risks for PPH
placental problems (praaevia, accreta) Hx of retained placenta, c-section, PPH multiple pregnancy polyhydramnios obesity fetal macrosomia
intrapartum risk factors for PPH
operative vaginal delivery syntocinon/syntometrine use retained placenta c-section labour >12 hours perineal tear/episiotomy
ABCDE management of PPH
oxygen via non-rebreather mask at 15 l/min
IV access (grey/orange cannula)
bloods: G&S, FBC, coagulation screen, fibrinogen, U&Es, LFTs, lactate
cross-match 6 units of packed red cells
check vitals every 15 mins
determine cause of bleeding (4Ts)
massive haemorrhage protocol
tranexamic acid 0.5-1 g IV to stop bleeding
how to stop the bleeding in PPH (non-surgical)
tone/tissue:
uterine massage using bimanual compression
administer IV syntocinon
insert urinary catheter to minimise bladder pressure on uterus
ergometrine, carboprost, misoprostol
thrombin:
expel clots manually
trauma: repair trauma
surgical management of PPH
examine under anaesthetic (trauma, RPOC, rupture)
balloon insertion to put pressure on bleeding vessels
arterial embolisation
B-lynch sutures
uterine artery/internal iliac ligation
hysterectomy (last resort)
fluid replacement in PPH
2 large bore IV access
rapid fluid resus: warmed crystalloid (eg hartmann’s), 0.9% saline
blood transfusion early (O- if life-threatening)
in DIC/coagulopathy give FFP, cryoprecipitate, platelets
use blood warmer
classifcation of perineal tears
1st degree: involving skin only
2nd degree: involving skin and levator ani (usually needs stitches)
3rd/4th degree: extend to anal sphincter muscle (may stretch pudendal nerve –> faecal incontinence)
what is an episiotomy
surgical cut made by medical professional with patient’s consent
psychiatric red flags in postnatal period
recent significant chage in mental state or emergence of new symptoms
new thoughts or acts of violent self-harm
new and persistent expression of incompetency as a mother or estrangement from their baby
when to consider admission to a mother and baby unit
a rapidly changing mental state suicidal ideation pervasive guilt or hopelessness beliefs of inadequacy as a mother evidence of psychosis
who is most at risk of postnatal mental health problems
young, single domestic issues lack of support substance abuse unplanned/unwanted pregnancy pre-existing mental health problems
when to refer a new mother to psychiatry
severe anxiety/depression Hx of BPSD or schizophrenia Hx of puerperal psychosis current psychosis developed mental illness in later stages of pregnancy/peurperium FHx of significant mental illness
features of baby blues
brief period of emotional instability where more become tearful, irritable, anxious and confused
arises day 3 postnatally and continues for about a week
features of puerperal psychosis
sleep disturbance, confusion, irrational ideas, mania, delusions, hallucination
presents 2 weeks postnatally
emergency admission to mother and baby unit
when does postnatal depression present and how long does it last
2-6 weeks postnatally
can last weeks/months or even up to a year or more
how long do the following fetal circulatory adaptions take to close up
foramen ovale ductus arteriosus umbilical arteries umbilical vein ductus venosus
foramen ovale: minutes ductus arteriosus: hours umbilical arteries: hours umbilical vein: days ductus venosus: days
what are the parts of the APGAR score
appearance:
blue/pale; blue extremities; no cyanosis
pulse:
absent; <100; >100
grimace:
no response; grimace/feeble cry when stimulated; cry or motor response
activity:
none; some flexion; flexed limbs that resist extension
respiration:
absent; weak/irregular gasping; strong cry
how often is the APGAR performed
60 seconds after delivery
5 mins after
which conditions are tested for on heelprick test
PKU CF congenital hypothyroidism MCADD sickle cell disorder maple syrup urine disease isovaleric acidaemia glutamic aciduria type 1 homocystinuria
what is PKU
excess phenylalanine in the blood usually from an inherited deficiency of the enzyme that converts it to tyrosine
what is CF
inherited mutation of the genes encoding the CFTR protein responsible for producing bodily secretions causing them to become thick and sticky
what is congenital hypothyroidism
congenital thyroxine deficiency as a result of poorly developed/absent thyroid
what is MCADD
inherited deficiency of an enzyme responsible for breaking down fats to make energy
what is maple syrup urine disease
deficiency of an enzyme needed to break down amino acids in food and milk, including breast milk
what is isovaleric acidaemia
deficiency of an enzyme needed to break down leucine in milk to isovaleric acid causing harmful build up of acid in blood and urine
what is glutaric aciduria type 1
deficiency of an enzyme needed to break down glutamic acid from food and milk, high levels of glutamic acid exists in the blood as a result and causes illness
what is homocystinuria
lack of CBS enzyme, resulting in a build up of homocysteine and methionine
when is heel prick testing done
what is the latest time?
ideally 5 days after birth
can do it up to 1st birthday, apart from CF which must be done before 8 weeks
what is the most common uterine malignancy
endometrial adenocarcinoma
risk factors for endometrial cancer
high levels of oestrogen: PCOS, late menopause, nulliparity, obesity, unopposed oestrogen HRT, tamoxifen, carbohydrate intolerance, oestrogen secreting tumours
presenting symptoms of endometrial cancer
abnormal uterine bleeding
- any PMB or irregular bleeding in premenopausal women >40 should be investigated
vaginal discharge (blood, watery, purulent)
pain (normally related to mets)
what are the 4 main investigations of endometrial cancer
TVUSS: measures endometrial thickness (>4 mm is concerning)
endometrial biopsy: histological analysis
D&C: scrape away endometrium under GA
hysteroscopy: biopsy/curretage can also be performed
histological signs of endometrial hyperplasia
increased gland-to-stromal ratio
treatment of endometria lhyperplasia
progestogens in young women (Mirena)
if atypical –> hysterectomy
what is the common pattern of spread of endometrial carcinoma
direct spread to myometrium and cervix
haematogenous or lymphatic spread can occur
what are the two types of endometrial cancer
type I: endometrioid
- more common, shortly after menopause
- oestrogen dependent
type II: serous and clear cell
- older women, poorer prognosis, more aggressive
- not related to oestrogen
- spreads along Fallopian tubes and peritoneal surfaces so may present with extrauterine disease
precursor lesions of endometrial cancer
endometrioid: atypical endometrial hyperplasia
serous/clear cell:
serous endometrial intraepithelial carcinoma
how is endometrial cancer staged
I A/B: confined to uterus, >50% myometrial invasion
II: cervical stromal invasion, not beyond uterus
III A/B/C: tumour invades serosa or adnexa; vaginal or parametrical involvement; node involvement (pelvic/para-aortic)
IV A/B: bladder or bowel invasion; distance mets
grading of endometrial tumours
1: 5% or less solid growth
2: 6-50% solid growth
3: >50% solid growth
management of endometrial cancer
surgery: hysterectomy and bilateral salpino-oophorectomy +/-lymphadenectomy
radiotherapy or high dose progestogens if not suitable for surgery
chemo if widespread disease
smooth muscle tumours in the myometrium
leiomyoma aka fibroids
leiomyosarcoma: rare, poor prognosis
risk factors for ovarian cancer
increased number of ovulation
genetic predisposition
Lynch syndrome/BRCA
endometriosis
what is the most common ovarian cancer
serous epithelial
precursors for serous ovarian cancer
high grade: serous tubal intraepithelial carcinoma
low grade: serous borderline tumour
types of epithelial ovarian cancer
serous mucinous endometrioid clear cell Brenner
types of stromal tumours
granulose cell tumours
thecoma/fibroma
sertoli/leydig cell tumours
types of germ cell ovarian tumours
teratoma
dysgerminoma
yolk sac tumour
choriocarcinoma
which primary cancers often metastasise to the ovaries
endometrial cancer
breast cancer
pancreatic
GI
presentation of ovarian cancer
often present late with non-specific symptoms
abdominal distension, GI symptoms
what is the risk of malignancy index
used to separate benign and malignancy lesions
RMI = USS score x menopausal score x CA125 level
>200 cancer likely
what USS features are suspicious of ovarian cancer
how are they scored on the RMI
complex mass with solid + cystic area mulitloculated thick separations associated ascites bilateral disease high doppler flow in solid areas
no features = 0
1 feature = 1
2+ features = 3
which other markers may be raised in ovarian cancer
Carcino-embryonic antigen: particularly mutinous tumours
serum hCG
AFP
staging of ovarian cancer
I A/B/C: one ovary/both ovaries/on surface of ovary
II A/B: spread to Fallopian tube/bowel or bladder
III A/B/C: microscopic cancer in peritoneum/cancer <2 cm in peritoneum/lymph node involvement
what are the precursor lesions of cervical cancer
squamous: cervical intraepithelial neoplasia
adenocarcinoma: cervical glandular intraepithelial neoplasia
what is the classification of CIN
CIN I: abnormal cells in basal third of epithelium
CIN II: abnormal cells in middle third
CIN II: abnormal cells in full thickness
which types of CIN need treatment
what is done
CIN II/III need treatment
large loop excision of transformational zone (LLETZ)
thermocoagulation
presentation of cervical cancer
post-coital bleeding intermenstrual bleeding menorrhagia pelvic pain offensive vaginal discharge
advanced: backache, leg pain, haematuria, weight loss, anaemia, bowel habit changes
common chemotherapy drugs in cervical cancer
cisplatin
carboplatin/paclitaxel
inter-pregnancy interval of <12 moths is associated with which outcomes
increased risk of preterm labour, fetal growth restriction, stillbirth and perinatal mortality
when should sex be avoided if using the fertility awareness-based method of contraception
7 days prior to ovulation and 2 days after
sperm can survive in genital tract for up to 7 days
ovum can survive up to 2 days after ovulation
when does ovulation normally occur
10-16 days before the start of the next cycle
what are different methods of fertility-awareness contraception
temperature measuring: increase in temp for 3 days in a row indicate fertility has decreased
cervical mucous: moist, sticky, white and creamy mucous indicates start of fertile period, watery/clear indicates peak fertility
mobile apps can be used to track symptoms
pros and cons of fertility awareness
pros:
no side effects, acceptable to all faiths and cultures, avoids hormones, increased awareness of cycle
cons:
higher rate of failure, user-dependent, restricts timing of intercourse, menstrual cycle can change or become irregular, requires constant monitoring, medication can interrupt cervical mucous, not suitable following pregnancy or if irregular cycle
pros and cons of male condom
pros:
protection against STI, no hormones
cons:
failure rate high with typical use, user dependent, not suitable with oil-based lubricants
how to use contraceptive diaphragm
reusable circular dome inserted into vagina before sex
must be used with spermicide
leave in place for 6 hours after sex
disadvantages of diaphragm
lack of spontaneity
user dependent
no protection against STIs
increased risk of cystitis
need refitted if gain/lose >3 kg, deliver baby/miscarriage/abortion
latex and spermicide can cause irritation
does COCP provide contraceptive protection immediately
if taken in the first 5 days of cycle then YES
if taken after 5 days then NO, needs to be taken for 1 week
if started by day 21 post partum then immediately effective
missed pill rules COCP
1 pill missed:
take last pill, even if two pills are taken that day
no additional contraception
2 pills missed:
take last pill missed but omit any other previous pills missed
use condoms for 7 days
- if pill missed in week 1, consider emergency contraception if UPSI in pill-free interval or in week 2
- if pill missed in week 2 no EC needed
- if pill missed in week 3, current pack should be finishedand new pack started immediately
pros and cons of COCP
pros:
improves painful/heavy bleeding, endometriosis symptoms and PMS
reversible effects upon stopping
reduced risk of ovarian, endometrial and colorectal Ca
cons:
taken around same time every day
interactions with other medicines
increased risk of cervical and breast Ca
increased risk of VTE, stroke, IHD (risk factors)
hormonal side effects
irregular bleeding
relative contraindications to COCP
disadvantages outweigh the advantages (UKMEC 3)
>35 yo and smoking <15 cigarettes/day BMI >35 FHx of VTE in family member <45 controlled HTN immobility cancer mutations eg BRCA gallbladder or liver disese complicated DM
absolute contraindications for COCP
should be avoided (UKMEC 4)
> 35 and smoking >15 cigarettes/day
migraine with aura
PMHx of VTE, thrombogenic mutation, stroke, IHD
uncontrolled HTN
current breast cancer
major surgery with prolonged immobilisation
how to use transdermal contractpive patch
wear for 7 days
change on the 8th
wear for 3 weeks then a patch-free week
if patch removed for >48 hours additional contraception for 7 days
how to use combined vaginal ring
have in vagina for 3 weeks, remove for 1 week, new ring
if out of vagina >3 hours in weeks 1/2 additional protection for 7 days
new ring no later than 7 days after last one removed
how is the contraception injection given
every 13 weeks
depoprovera IM
sayana press SC (self-administered)
pros and cons of contraceptive injection
pros: long-acting and less user dependent no oestrogen can lead to amenorrhoea useful in HMB, dysmenorrhoea, endometriosis
cons:
non-reversible once injected
delayed retrun to fertility (up to 12 months)
irregular bleeding common in first 3 months
potential for weight gain
long term use associated with osteoporosis
missed pill rules for POP
pill taken <12 hours later than usual time, take pill as normal
>12 hours, take missed pill ASAP and continue with rest of pack - use condoms until pill has been taken for 48 hours
older POPs have 3 hours window
pros and cons of POPs
pros:
few contraindications
immediately reversible
cons:
irregular bleeding
D&V (assume missed pill)
liver enzyme inducers may reduce effectiveness
CI if PMHx of Br Ca or active liver disease
pros and cons of implant
pros: most effective form of contraception non-user decedent can be used if not suitable for oestrogen safe in breastfeeding and postpartum reduce painful/heavy bleeding
cons:
irregular bleeding common in first 6/12
headache, ausea, breast pain, skin changes
efficacy reduced by enzyme inducing drugs (AEDs, rifampicin)
CI in current Br Ca and active liver disease
risks of IUS
uterine perforation in 2/1000
increased risk of ectopic pregnancy compared to other contracptive but not compared to no contraception
small risk of PID in first 20 days
1/20 risk expulsion in first 3 months
different types of IUS
Mirena: 52 mg LNG, 5 years, HMB etc, HRT
kyleena: 19.5 mg LNG, 5 years, smaller so less side effects, not for HMB or HRT
jaydess: 13.5 mg LNG, 3 years, more irregular bleeding
when should dose of LNG EC be doubled
BMI >26
over 70 kg
taking enzyme inducing drugs
how does LNG EC work
delays/prevent ovulation and reduced successful implantation
must be taken within 72 hours
how does Uliprsital EC work
delays/inhibts ovulation
taken within 120 hours of UPSI
when is breastfeeding a suitable contraceptive
exlcusive breastfeeding
up to 6 months
no periods
which types of contraception are safe in postnatal periods
implant and POP can be used anytime after birth
depo safe anytime if not breastfededing
IUS/IUD can be inserted with 48 hours of SVD or wait at least 4 weeks
delay CHC for at least 3 weeks due to risk of VTE
when is abortion permitted after 24 weeks
woman’s life is in danger
severe foetal abnormality
woman at grave risk of physical or mental injury
how is medical abortion carried out
mifepristone (antoprogesterone)
48 hours laters
misoprostol (prostaglandin)
<10 weeks: at home
10+1 - 23+6 wks: admission to hospital or clinic advised, multiple doses of misoprostol may be required (5 doses in 24 hours)
risks of medical abortion
heavy and prolonged bleeding, may need transfusion
incomplete ro failed procedure
pain
infection
risks increase with increased age
how does surgical abortion take place
misoprostol to soften and dilate cervix
vacuum aspiration up to 14 weeks; dilation and evacuation >14 weeks (not in Scotland)
local/regional/general anaesthetic or conscious sedation
post abortion management
if uncomplicated can go home same day, accompanied if under anaesthesia
contraception discussed (can be given same day)
anti-D if >9+6 weeks and Rh -ve
function of sertoli cells
blood-testes barrier: protect sperm from antibodies, maintain fluid composition of testes
provide nutrient
destroy defective sperm
secrete seminiferous tubule fluid, androgen binding globulin, Inhibin hormone and activin hormone
what is the function of the substance secreted by the Sertoli cells
seminiferous tubule fluid: essential for carrying spermatozoa to epididymis
androgen binding globulin: binds testosterone, for sperm production
Inhibin/activin: regulation of FSH secretion and control of spermatogenesis
where does spermatogenesis take place
where does it go after
seminiferous tubules
rete testes
epididymis (storage and maturation)
briefly describe the HPG axis in males
GnRH released in bursts from hypothalamus every 2-3 hours
anterior pituitary releases LH and FSH
LH stimulates testosterone secretion from leydig cells
testosterone and FSH surges stimulate spermatogensis in seminiferous tubules
inhibin from Sertoli cells decreases FSH secretion and testosterone decreases GnRH secretion
what is capacitation
biochemical and electrical events that allow the sperm to penetrate the cell layer surrounding the oocyte
sperms’s tail movement increases in speed and strength to propel it forwards
common causes of obstructive male infertility
endocrinological features
cystic fibrosis (obstructed or absent vas) vasectomy
normal LH, FSH and testosterone
common non-obstructive causes of male infertility
cryptorchidism klinefelter's syndrome (47 XXY) microdeletions of Y chromosome robertsonian translocation infection (mumps, STI) endocrine (pituitary tumours, hypothalamus disorders, thyroid, DM, DAH) testicular tumours
what is globozoospermia
rounded head, no acrosome
can’t fuse with zone pellucida
hypothalamic causes of anovulatory infertility
anoerixa, bulimia, excessive exercise
Low FSH, LH and estradiol
pituitary causes of anovulatroy infertility
hyperprolactinaemia
Sheehan’s syndrome
pituitary adenomas
ovarian causes of anovulatory infertility
PCOS
premature ovarian failure
causes of ovulatroy infertility
infection (PID, transperitoneal spread etc)
endometriosis
salpingitis isthmicya nodosa: nodular scarring of Fallopian tube
uterine polyps/fibroids
important parts of infertility history
duration of infertility
primary or seconda
frequency of sexual activity
history of sexual function
libido
females: previous pregnancies, full obestetric Hx, menstrual history
both: general health, medical/surgical Hx, medications
normal testicular volume
12-25 mls
how to ensure good quality semen anaylsis
assessed quickly after production (<1 hour ideally) kept at body temperature patient in good health avoid ejaculation for 72 hours prior avoid caffeine/alcohol
investgiation oftubal patency
laparoscopy
hysterosalpingogram
endocrine tests for males and females with infertility
male: LH and FSH, prolactin, TSH
female: LH and FSH, oestradiol, mid-luteal progesterone, free androgen index, testosterone and SHBG, prolactin, TSH
what is IUI
what are the indications
intrauterine insemination
directly putting sperm inside the uterus
healthy sperm, ovulation is occuring and no tubal disease
sexual dysfunction, female same-sex with donor sperm, male same-sex with surrogate
what IVF
what are the indication
In-vitro fertilisation
fertilising egg outside of body
unexplained infertility, pelvic disease, anovulatory infertility
what is ICSI
what are the indictions
intra-cystoplasmic sperm injection
sperm injected directly in cytoplasm of oocyte
severe male factor infertility, previous failed IVF, pre-implantation genetic diagnosis
how to harvest eggos
down regulation: synthetic GnRH used to shut down menstrual cycle, allows cycles to be scheduled
ovarian stimulation: gonadotrophin hormone injection to to stimulate relase of eggs
oocytes collection: under USS guidance, needle is inserted transvaginally and ovarian follicle aspirate
at what stage are embryos transferred for IVF/ICSI
day five normally (blastocyst stage
