obs n gyne Flashcards
gestatonal diabetes
5678
pregnancy induced hypertension definition
htn after 20weeks gest
no protenuria no oedema
resolves after birth
in risk of future pre eclampia or htn later in life
on acei for htn before pregnancy
stop and give labetolol while awaiting review
labetolol CI = nifedipine and hydralazine
pre eclampsia
preg induced htn w proteinuria (>0.3g/24hrs)
abx avoid in breastfeeding
ciprofloc
tetracylines
chloramphen
sulphonamides
psych drugs avoid in breastfeeding
Lithium benzo
drugs to avoid in breastfeading
aspirin
carbimazole
methotrex
sulfonyurea
cytotoxic dx
amiodarone
placeta acreta
attacthment of placenta to myometrium
doesnt properly seperate in labour there is a risk of PPH
placenta acreta, increta, percreta
chorionic villi attached to myometrium
invade myometrium
invade thru perimetrium
postpartum thyroiditis
immune attack of thyroid within 6 mths of giving birth
3 phases
thyrotoxicosis
hypothyroidism
normal thyroid function in 12 ths (high rate of recurrence in future pregnancies
hyperthyroid phase = propanolol
hypo = thyroxine
postpartum thyroiditis abs
thyroid peroxidase
ssri breastfeeding
sertraline paroxetine
folic acid
women 400mcg OD 3 months before conception until 12 weeks gestations
risk factors gestational diabetes
bmi>30kg
previous big baby 4.5kg+
prev gest diabetes
1st degree relative diabtes
family origin w high prev ie south asian, black cariibean, middle eastern.
NOACs in pregnancy
CI therefore change to LMWH ie enoxaparin
retinopathy of prematurity
visaul impairment in premmie <32 weeks
contributing fx is overoxygenation eg bc venilation == prolif retinal blood vessels (neovascurlisation)
loss of red reflex
screening done in at risk groups
airtravel in preg
not recommended post 37 wks in uncomp singlton preg
32wks if uncomplicated multiple preg
symphysis fundal height
top of pubic bone to uterus in cm
should match gest age in weeks
within 2cm after 20 weeks
fetal movements
start 18-20 weeks and increase until plataue after 32 weeks
16-18 weeks in multiparous
should be established by 24 weeks
what fetal position may make movement less noticable
anterior fetal position
causes of oligohydramnios
prom
pottor sequence
interauterine growth restriction
post term gestation
pre eclampsia
Group b strep proph
benzylpeniciliin
high risk factors for preeclampsia
htn in prv preg
CKD
autoimmune ie SLE or antiphosphollipid
type 1 or 2 diabetes
chronic htn
mod risk factors for preclampsia
1st preg
40+ or preg interval 10 yrs
bmi>35kg at first visit
fam hx preclampsi
multiple preg
reducing risk of hypertensive disroders
1+ high rf
2+ mod rf
= aspirin 75-150mg daily from 12 weeks gestation until birth
when need 5mg folic acid
either partner NTD, prev preg w NTD, Fam hx NTD
women taking antiepileptic
coeliac disease
diabetes
thalassaemia trait
obese bmi>30
drug cuases folate deficiency
Phenytoin
methrotrexate
pregnancy
alcohol excess
gestational diabetes in previous pregnancy
offer OGTT asap after booking
and at 24-28 weeks
antiepileptics in pregnancy
usually all safe except barbituates
phenytoin in pregnancy
associated w cleft palate
if taking in preg = take vit K last month of pregnancy to prevent clotting disorders in newborn
what to monitor w pt on mg sulphate
urine output
reflexes
resp rate
o2 saturations
abruption risk factors
ABRUPTION
A abruption prev
B blood pressure (HTN/preclampsia_
R ruptured membranes (premature or prolonged)
U uterine injury (trauma to abdo)
P polyhydramnios
T Twins or multiple gestation
I infection in uterus ep chorioamionitis
O older (>35)
N Narcotic use ie cocaine and amphetamines
nausea and vomiting in pregnancy
natural : ginger and p6 point acupuncture on wrist
1st line antihistamines ie promethazine
mx of pprom
admission
regular observation to see chorioamnionitis
oral erythromycin
corticosteriods (to reduce risk of resp distress)
criteria for surgical management of ectopic
which one
Size >35mm
ruptured or not
pain
fetal heartbeat
hCG >5000
(fine if theres another intrauterine preg)
salpingectomy 1st line if no other RF for infertility
otherwise salpingotomy
medical management criteriaof ectopic
n what is it
<35mm
unruptured
no signifcant pain
no heartbeat
hCG<1500
Methotrexate
(not suitable if another intrauterine preg)
Only done if pt willing to attend follow up
tx herpes simples genital ulcers tx
primary infection = Valaciclovir 10 days
recurrence = 3 days
risk factors umbilical cord prolapse
prematurity
multiparity
polyhydramnios
twin pregnancy
cephalopelvic disproportion
abnormal presentations e.g. Breech, transverse lie
oestrogen secreted
theca granulosa cells in ovaries
progesterone produced by
corpus luteum
HRT w uterus
oestrogen and progesterone
HRT no uterus
oestrogen only
combined hrt risk
breast cancer
oestrogen only hrt risk
endometrial cancer (thats why do not give if have uterus)
risk of vte w hrt
increased when prog as well
transdermal doesnt inc risk
risk of IHD w HRT
only 10 years after menopause
risks of hrt overall
cancers etc
vte
stroke
IHD
rotterdam criteria PCOS
2 of 3
- Oligoovulation/anovulation – irregular, absent periods
- Hyperandrogenism – hirsutism, acne
- Polycystic ovaries on USS
pcos path
Insulin resistance – insulin = higher levels of androgens and suppresses SHBG
which suppresses androgens usually
pcos blood findings
Raised LH, raised LH:FSH ratio, raised testosterone
ovarian cysts
Functional cysts –
Corpus luteum cysts –
Dermoid cysts/germ cell tumours –
harmless, disappear
often early pregnancy
teratomas, may contain skin/teeth/hair/bone
ashermans syndrome
path
causes
sx
adhesions connecting areas of uterus that wouldnt usually be connected
because of damage to it
ie D&C, uterine surgery, endometritis
painful lighter periods (2ndry amen)
cervical ectropian path
Columnar epithelium of endocervix extended out to ectocervix (stratified
squamous epithelium)
bc elevated oestrogen
= exposed to erosion
cervical ectropian sx
post coital bleeding
vaginal discharge
pelvic organ prolapse
Uterine prolapse –
Vault prolapse –
uterus into vagina
hysterectomy – vault into vagina
pelvic organ prolapse
Rectocele –
Cystocele –
posterior vaginal wall defect – rectum prolapses into vagina –
constipation, urinary retention, lump
anterior vaginal wall defect – bladder into vagina
organ prolapse grading
Grading
- 1 = lowest part >1cm above introitus
- 2 = lowest part within 1cm of introitus
- 3 = lowest part >1cm below introitus
- 4 = full descent
endometrioma
chocolate cysts in endometriosis
if rutpure
= sudden intense pain
USS = free fluid in pelvis
oestrogen only HRT and breast cancer ?
doesnt increase risk if used for less than 10 years
uterine fibroids mx in meantime of op
GnRH agonst - triptorelin
only short term
to shrink fribroids
oesteoporosis RF
glucorticoid
RA
Alcohol excess
hx of parental hip frac
low bmi
current smoking
long term complications PCOS
Subfertility
Diabetes mellitus
Stroke & transient ischaemic attack
Coronary artery disease
Obstructive sleep apnoea
Endometrial cancer
complications inc in pts who are obese
acute urinary retention causing meds
anticholinergics, tricyclic antidepressants, antihistamines, opioids and benzodiazepines.
cause of necrotising facitis in pt w chicken pox
b haemolytic group a steptociccus
uterine fibroid <3cm
not distorting uterurine cavity tx
medical treatement
MIrena coil (IUS) tranxemic acid
cocp
pop
risk malignancy index (RMI) in ovarian ca components
CA125
menopausal status
US findings
rubella in pregnancy when is biggest risk
1st 8-10 weeks risk of damage to fetus v high
damage rare after 16 weeks
congenital rubella sx fx
sensorineural deafness
congen cataracts
congen heart disease (PDA)
growth retardation
hepatosplenomeg
purpuric skin lesions
salt and pepper chorioretinitis
microphthalmia
cerebral palsy
vaginal prostaglandin
dinoprostone
oral prostaglandin e1
misoprostol
what to moniter if given mg sulpate
reflxes and resp rate
bishop score 0 points
Cervical position
Cervical consistency
Cervical effacement
Cervical dilation
Fetal station
Cervical position - posterior
Cervical consistency - firm
Cervical effacement - 0-30%
Cervical dilation - <1cm
Fetal station - (-3)
bishop score things that score 1
Cervical position = intermediate
Cervical consistency = intermediate
Cervical effacement = 40-50%
Cervical dilation = 1-2cm
Fetal station = -2
bishop scores 2
Cervical position - Anterior
Cervical consistency - soft
Cervical effacement - 60-70%
Cervical dilation - 3-4cm
Fetal station -1, 0
bishop score 3
Cervical position -
Cervical consistency -
Cervical effacement 80%
Cervical dilation >5cm
Fetal station +1,+2
bishop score >6
amniotomy and IV oxytocin
stage 1 labour
onset of true labour to full dilation
latent= 0-3cm takes 6 hrs
active = 3-10cm dilation, 1cm/hr
most likely place to rupture ectopic
isthmus
antenatal visit booking visit
8-12 weeks
diet, alcohol, smoking, folic, vitD, classes
BP urine dip BMI
Bloods= fbc, group, rhesus status, hep b, syhphyllys
HIV
Urine culture for asympotmatic bacteriuria
11-13+ 6 weeks antenatal visit
early scan confirm dates
excluse multple preg
downsyndrome nuchal scan
16 weeks antenatal visit
bp and urine drip
routine
18-20+6 week antenatal scan
anomaly scan
25 weeks only if primip
bp
urine dip
symphysis fundal height
28 week scan
Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women
down syndrome preg testing results
low afp
low oestriol
high bHCG
low PAPP-A
thickened nuchal translucency
risk factors for ovarian ca
many ovulations ie
early menarche
late menopause
nulliparity
implant contraceptive ie nexplanon
adverse effets
irregular/heavy bleeding (coprescribe COCP)
‘prog effects’ ie headache, nausea, breast pain
risk factors for hyperemesis gravida
inc leveks of bHCG ie
- multiple gest
- trophoblastic disease
nulliparity
obesity
family or personal hx of n&V of pregnancy `
hyperemeisis gravida ddx criteria triad
5% pre preg wt loss
dehydration
electrolyte imbalance
4 Ts - causes of PPH
Tone (uterine atony): the vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)
when are pregnant women screened for anaemia
booking visit 8-12 wks
28 weeks
oral iron therapy cut off in pregnancy
and tx
1st tri if <110
2nd/third <105
postpartum <100
oral ferrous sulphate or fumarate
contin for 3 mths after corection to replenish stores
cocp inc risk and dec risk of what
increased risk of breast and cervical cancer
protective against ovarian and endometrial cancer
puerperal pyrexia def and cause
temp>38 in 14 days postpartum
endometritis: mc cause
uti
wound infections (tear/c section)
mastitis
VTE
endometritis tx
admit iv abx clindamycin and gentamicin until afebrile 24 hrs
women for gest diabetes rf screening
booking scan
and 24-28 weeks
pcos hirsutism and acne tx
cocp
no response
= topical eflotnithine
spironolactone flutamide and finasteride under specilaist
nexplanon implant time back to normal fertility
4 weeks
contraception in pt w gastric sleeve/bypass/duodenal switch
never oral again
cervical canvcer epid type and virus
screening
under 45 yo
squamous cell
HPV16&18
3yrs 25-49
5 yrs 50-64
cervical ca RF
hpv 16 18
smoking
early first intercourse, many partners
high parity
cocp
low socioecon status
cervical ca staging
FIGO
1a only cervix not visible
1b only cervix but visible
2 beyond cervix but not pelvic wall
3 reached pelvic wall (hydronephrosis)
4 beyond pelvic wall ->blader n rectum
endometrial cancer type
adenocarcinoma
rf endmetrial ca
unapposed oestrogen
older
early menarch
later menopause
obesity
diabetes
ovarian ca type
epithelial usuall serous carcinoma
germ cell tumor = high afp and hcg
ovarian ca why does cocp help
risk caused by more ovulations
cocp = lowers ovulations
where can ovarian ca spreas
paraaortic lymph nodes
vulval cancer type
scc
vulval Ca Rf
age
hpv
immunosupression
lichen sclerosis
features vulval Ca
lump or ulcer on the labia majora
inguinal lymphadenopathy
may be associated with itching, irritation
Benign breast conditions
Duct ectasia
Papilloma
Galactorrhoea
Nodularity
– yellow/green, thick, maybe bloody. Expectant management.
– bloody/clear. Microdorchectomy.
– milky
– normal – cyclical
breast cysts
40-60 – aspirate
Infection – S. aureus
- Lactational/peripheral – fluclox
- Non-lactational / central – fluclox and metro
progest only contraception n SEs
- Implant – 3 years, hormonal SEs
- Injection – 12 weeks, SEs hormonal, weight gain, reduced bone density
- POP – daily (breast ca risk)
- IUS – 6 years, hormonal SEs
Ulipristal
when
types
works when
breastfeeding?
CI?
within 120 hours. Pill, patch, ring – start 5 days after. If breastfeeding,
wait 1 week. Not in severe asthma
Postpartum contraception
- Anytime if no risks
POP, implant, injection
Postpartum contraception
3 weeks / 6 weeks breastfeeding
COCP, patch, ring
Postpartum contraception
48 hours/4 weeks
IUD/IUS
POP missed pills
Desogesterel/cerazette
Less than 12 hours late – no action
More than 12 hours late – take missed pill ASAP and next one at usual
time – extra cautions for 48 hours
Others
Same as above but 3 hours
miscarriage medical mx missed
oral mifepristone. 48hrs later misoprostol unless gestational sac has
passed.
(preg test after 3 weeks)
miscarriage medical mx incomplete
single dose misopristol
(preg test after 3 weeks)
when is combined test done
what tested
11-14 weeks
PAPP-A
BHCG
nuchal translucency
when quadruple test done
up to 20 weeks
when is chronioc villois sampling done
10-13wks
amniocentisis timw
15-20wks
Causes of oligohydramnios (AFI<5)
- Renal agenesis
- Placental insufficiency
- ROM
- Pre-eclampsia
Causes of polyhydramnios (AFI>24)
- Maternal DM
- Multiple GIT
- CNS issues
lithium in preg =
ebsteins anomaly
SSRI complication in preg
tri 1 congenital heart defects / tri 3 pulmonary
HTN
induction of labour
Vaginal PGE2 reassess at 6 hours oxytocin infusion amniotomy
cervical ripening balloon
shoulder dystocia
Help
Episiotomy
Mcrobert’s – hyperflexion of mother at hip
Suprapubic pressure – pressure to anterior shoulder
Rubin’s – pressure of posterior aspect of anterior shoulder
Woodscrew’s – same time as above – pressure anterior aspect
Replace head – zavanelli manoeuvre
LCSC
PPH mx
ABC -> palpate uterus -> catheterise -> IV oxytocin -> IM carboprost ->
intramyometrial carboprost -> rectal misoprostol -> balloon tamponade
Secondary – up to 12 weeks
conditions to take 5mg folic acid
if epilepsy, coeliac disease, DM, high BMI, neural tube defect risks
CTG rate
110-160
<100/>180 = abnormal
ctg decelerations
- Early = head decompression
- Variable = cord compression
- Late = hypoxia
hellp syndrome features
haemolysis
elevated liver enzymes
low plts
mc benign ovarian tumour in women under the age of 25 years
dermoid cyst (teratoma)
meigs syndrome
benign ovarina tumor (fibroma)
associated w ascites and pleural effusion
androgen insensitovity syndrome (AIS)
x linked
resistance to testoesterone
= 46XY but phenotype female
extra androgen converted to oestrogen may have breast development
lumps in groinundescended testes = ca risk
how to check if 2ndy amen is primary ovarian failure
high FSH
4 weeks amenorhea
2 samples 4 weeks apart
indications for HRT
vasomotor sx ie flushing, headaches, insomnia
premature menopause
reasons for hrt in younger women
prevent osteoporosis
other hrt benefits
reduce risk of colorectal ca
hrt if risk VTE
transdermal
se hrt
nausea
breast tenderness
fluid retention and weight gain
cylical combined hrt
perimenopausel (ie period in last 12 mths)
given 10-14 days per month
monthtly breakthru bleed
can swtitch to combined after 12mths if >50 and 24 mths if<50
continuous hrt
for post menopausal
no period 12 mths >50yo
no period 24mth < 50yo
primary ovarian insufficiency
menopause before 40
hypergonadotropic hypogonadism
(Under-activity of the gonads (hypogonadism) means there is a lack of negative feedback on the pituitary gland, resulting in an excess of the gonadotropins (hypergonadotropism))
hormones =
raised LH and FSH (gonadotropins)
low oestradiol
autoimmune causes of primary ovarian insuff
coeliac
adrenal insufficiency
type 1 dm
thyroid
risk of what w primary ovarian insuff
and tx
dementia
parkinsons
OP
stroke
svd
either HRT till 51
or cocp
emergency contra
copper iud - 5 days or ovulation
levenogestrel - 72hrs restart cocp asap
ulipristal - 120 hrs
cervical/endometrial ca avoid which contra
mirena
breast ca contraception
avoid hormonal
barrier or copper coil
wilsons contraception
avoid copper coil
monochorionic diamniotic twins
t sign
dichorionic diamniotic
twin peak sign
monochorionic USS
every 2 weeks from 16 wks
dichorionic USS
2 weekly from 20 wks
planned birth for twins
32 MCMA
36 MCDA
37 DCDA
obstetric cholestasis
uro acid
calamine lotion
antihistamine
PTT deranged = water soluble vit K
HELLP Syndrome
haemolysis
elevated liver enzymes
low plts
causes of polyhydramnios
maternal DM
multiple gest
CNS issues
kleihauser test
see how much fetal blood mixed in maternal
BV in pregnancy
metronidazole 400mg bd 7 days
tocolytic
relax uterus
ie in prolapse b4 c section
disseminated gonococcal infection
micro
and triad
gram -ve diplocci
tenosynovitis
migratory polyarteritis
dermatitis (maculopap or vesicular)
syhphyllis ulcer
painless and lymphade
lymphogranuloma venerum
tender swollen inguinal LNs
Haemophilus ducreyi
painful ulcer
antepartum haemorrhage def
bleeding from genital tract after 24 wks before delivery of baby
fetal lie presentation in abruption
normal ie
longitudinal lie and cephalic presentation
why may shock be out of keeping with visual loss in abruption
bleed is retropalcental ie doesnt escape from uterus
clotting studies post major abruption
low fibrinogen
placental damage = thromboplastin release in circulation
= DIC bc all clotting factors esp fib used up
sx and signs of ectopic
abdo pain
shoulder pain
vag bleeding
tachy
hypotension
amenorhea
cervical excitation adnexal mass
bedside tests for suspected ectopic
urine bhcg
ectopic rf
PID
prev ectopic
pop
intrauterine
emdometriosis
prev tubal surgery
where may fertilised ovum implant
follopian tubes
ovary
cervix
peritoneum
liver
hyperemesis gravid rf
high levells of bhcg
1st pregnancy
young age
multiple preg
molar preg
hypethyroid
pre hx motion sickness
bedside test in hyperemesis gravid
urine dip for ketones
suggesting starvation and ketosis
complications of hypermesis
aki
wernickes enceph (give thiamine)
oesphagitis, mallory weiss tear
VTE
signs on exam suggesting malignancy
visible mass
ulceration
inflammation
bleeding
bv rf
excessive vag douching
smoking
multiple partners
copper coil
recent abx
apgar categories
color
tone/activity
resp effort
pulse
reflex irritability
first tri markers
downsyndrome
PAPP-A hCG Nuchal trans
low high increased
triple test markers
hcg AFP estriol
what test added if quad test 2nd tri
inhibin A
triple test markers downs
in hcg
dec afp
dec estriol
(inc inhibin a)
how does gest dm lead ro macrosomia
inc foetal Blood glusose
= feotal hyperinsulinaemia
= inc fat deposition
reassuring CTG
feotal hr 110-160
accelerations
variability of greater than 5 beats per min
absence of deceleraions
how do women inc o2 intakein oreg
tidal volume
normal feotal ph
7.25
