Obstetrics Flashcards
how is SGA determined
<10% on customised growth chart
what does a customised growth chart take into account
mothers BMI parity ethnicity previous birth weights single/multiple pregnancy
what are some constitutional causes of SGA
asian ethnicity, low maternal BMI, nulliparity and female fetal gender
what are some maternal causes of IUGR
existing disease like CVS, renal, hypertension, celiacs, diabetes
or smoking/drug use
malnutrition, low BMI
what are some uteroplacental causes of IUGR
pre-eclampsia, multiple pregnancy, uterine malformations, placental insufficiency
what are some fetal causes of SGA
female fetuses, chromosomal abnormalities, vertically transmitted infections
some complications of SGA and IUGR
stillbirth, c-section, long term handicaps, fetal distress
only reduced fetal movements mean that the baby is IUGR - true or false
false, only a very poorly baby will stop moving,
how is IUGR diagnosed?
ultrasound scan
management of SGA at preterm and at >37 weeks
preterm - growth rechecked in 2-3 weeks interval
> 37 weeks, induced or if umblical dopplers are normal and above 3rd centile, wait for due date
management of IUGR <34 weeks
repeat dopplers twice a week, if abnormal and <32 weeks, C section, if <32 weeks, CTG monitoring and deliver with fetal in distress.
what should the mother be given if she delivers before 34 weeks
magnesium sulphate
management of IUGR between 34-37 weeks
if normal doppler, wait till 37 weeks.
if abnormal, then induce or c-section if CTG is abnormal
management if IUGR after 37 weeks
induce if normal CTG, csection if abnormal
which ages are most common for endometrial cancer
50-60s, most are postmenopausal
the screening program for endometrial cancer is effective - T or F
False, there is no such thing
what is type 1 and type 2 endometrial cancers
type 1 is estrogen sensitive, obesity related, low grade endometroid cells and slow growing
type 2 are estrogen insensitive, not obesity related, faster growing an usually high grade endometroid, clear cell, serous or carcinosarcomas
what is the main risk factor for endometrial cancer
endogenous and exogenous estrogen exposure
examples of endogenous estrogen exposure that can increase risk of endometrium cancer
PCOS high BMI nulliparity early menarche/late menopause older age
examples of exogenous estrogen exposure that can increase risk of endometrium cancer
unopposed estrogen therapy HRT without progesterone
typical endometrial hyperplasias should be treated immediately - T or F
false, most regress and don’t progress to cancer
presentations of someone with endometrial cancer
postmenopausal bleeding post coital bleeding vaginal discharge pelvic pain (intermenstrual bleeding)
who to refer in suspected endometrial cancer
PMB w/o continuous HRT, on sequential HRT for more than 2 years
repeated bleeding
PCB more than 4 weeks
how to investigate endometrial cancer
TV US
> 5mm then pipelle biopsy
can escalate to hysteroscopy and biopsy
how is endometrial cancer diagnosis made
histologically from biopsy
most common endometrial cancer pathology
endometroid adenocarcinoma
how to stage endometrial cancer
1 - within uterus
2 - to cervix
3 - to pelvis
4 - distant sites
surgical treatment for endometrial cancer
total lap hyst + bilateral salpingoophrectomy
what is peritoneal washing done for in endometrial cancer treament
peritoneal cavity is flushed with saline and then analysed for malignant cells to stage spread
common causes of antepartum haemorrhage (APH)
placenta praevia
placenta abruption
undertermined origin
what is a bloody show
mucus plug of cervix mixed with blood, excreted just before labour
what is a vasa praevia
when fetal vein is attached to membrane of placenta, rupture of which can lead to fetal death
what is placenta praevia
when a placenta is in the lower segment of the uterus
what is the grading of placental praevias
marginal praevias have placentas not covering the cervical os. major praevias partially or completely cover the os
risk factors for placenta praevia
twins
high parity women
older women
previous c-section
complications of placenta praevia
obstructs natural lie and delivery
might require c-section
PPH
placenta accreta or placenta percreta
what is placenta accretea and percreta
accreta is when the placenta has embeded itself deeper than it usually would
percrete is when it has gone through the uterus and into the surrounding organs (e.g. intestines)
clinical features in history of placenta praevia
intermittent painless PV bleeding with increasing frequency and intensity
can be asymptomatic
what would an examination of someone with placenta praevia find?
breech and transverse lies are common
how to investigate and diagnose placenta praevia
ultrasound - repeat at 32 weeks
what to assess in someone with placenta praevia
maternal and fetal wellbeing
CTG, FBC, clotting and cross matching
when to admit someone with placenta praevia
bleeding
what to do when someone with placenta praevia is admitted
cross match
anti-D for Rh-ve
IV access
steroids if <34 weeks
how to deliver someone with placenta praevia
c-section
what is placenta abruption
separation of part or all of the placenta before delivery
where can blood go during a placenta abruption
into the amniotic sac or out through the vagina
bleeding always happens in placenta abruption, T or F
false, it can bleed into the amniotic sac
complications of placenta abruption
fetal death
haemorrhage - shock
risk factors of placenta abruption
IUGR
pre-eclampsia
autoimmune disease
hx of placental abruption
multiple pregnancy
high maternal parity
trauma
smoking
cocaine use
clinical features of placenta abruption
sudden localised painful bleeding
more bleeding = more severe placenta abruption, T or F
False, blood can bleed into the amniotic sac
findings on examination of someone with placental abruption
shock and blood loss
tender uterus
contractile uterus
when to admit with suspected placenta abruption
when there is pain and uterine tenderness, even without blood
delivery management for someone with placenta abruption
fetal distress => emergency CS
no fetal distress by term => induction + ARM
no fetal distress and preterm => give steroids and monitor
if a 31 week pregnant lady is admitted with abdominal pain with some bleeding but no fetal distress is found on CTG; symptoms which then subsqeuntly subside after 2 days. what should be done next?
if fetus is confirmed to be viable and healthy, then discharge but class as high risk pregnancy and arrange for serial fetal growth scans
what is a cervical ectropian
when endocervical columnar cells evert into the ectocervix causing redness and some vaginal discharge and/or PCB
how to treat a cervical ectropian?
exclude carcinoma, then cryotherapy
what are 3 benign conditions of the cervix
cervical ectropian
cervical polyps
acute/chronic cervicitis
what can cause cervicitis
STIs, prolapses, pessaries
what ligaments support the uterus
uterosacral
transverse ligament
what is the junction called where cervical columnar cells meet squamous cells
squamocolumnar junction
what is CIN
cervical intraepithelial neoplasia - dyskariotic cell changes on the cervix
what does CIN I - III mean
CIN I is when atypical cells are limited to lower thirds of the epithelium
CIN II is when cells are found in lower 2/3rds of epithelium
CIN III is when the atypical cells are found in the full thickness of the epithelium
what is CIN III also called
carcinoma in situ aka pre-invasive
why is CIN III dangerous
it has the potential to invade through the basement membrane and become malignant
what strains of HPV are associated with ca cervix
16 18 31 33
what are the risk factors for ca cervix
hpv
smoking
long term steroid use
what is the cervical screening schedule
> 25 years old every 3 years till 49 then every 5 years till 65.
what happens if a smear comes back abnormal
they are invited back for another smear/colposcopy/hysteroscopy with biopsy.
what is colposcopy
using speculum to visualise the cervix, acetic acid or iodine is added to stain any dyskariotic cells which are then looked thru a microscope. biopsy can be taken during this
what is the treatment for CIN I II and III
CIN I is only monitored
CIN II and III are usually excised using LLETZ
what is LLETZ
large loop excision of transformation zone
who tend to be diagnosed with cervical cancer
women who dont go for their smears
peaks of incidence for cervical cancer
30s and 80s
what cell types are most cervical cancers
90% squamous, 10% adenocarcinomas
which cell type cancer has a worse prognosis
adenocarcinoma
history clinical features of cervical cancer
PCB
offensive vaginal smell
PMB
pain, urinary symptoms if advanced stage
how to confirm the diagnosis of cervical cancer
biopsy
what causes chronic pelvic inflammatory disease
infections that lead to adhesions, obstructed tubes and hydrosalpinx
what can chronic pelvic inflammatory disease lead to
adhesions, obstructed tubes and hydrosalpinx
common symptoms of chronic pelvic inflammatory dsiease
lower abdominal pain dysmenorrhea/menstrual irregularity deep dyspareunia chronic vaginal discharge subfertility
what is usually found on examination in someone with chronic pelvic inflammatory disease
uterine tenderness, adnexal tenderness, abdominal pain, fix retroverted uterus
how to investigate and diagnose chronic pelvic inflammatory disease
laparoscopy
what can cause chronic pelvic pain
PID, chronic PID endometriosis adenomyosis fibroids abscess ovarian cysts IBS adhesions
what is one non-gynaecological differential for chronic pelvic pain
IBS
how to investigate chronic pelvic pain
history, examination, bloods, TVUS, MRI, laparoscopy
what is hyperemesis gravidarum defined as
severe nausea and vomitting during pregnancy
what are some differentials for hyperemesis gravidarum
infections (gastroenteritis) GI disorders (HPB) metabolic disorders (addison's diabetic ketoacidosis, thyrotoxicosis)
management of hyperemesis gravidarum
IV rehydration
antiemetic (metoclopromide)
nutritional supplements
What is the UK law on terminations of pregnancies?
It is allowed under 1 of 5 different clauses which account for maternal risk, fetal risk, existing children risk, including mental health risks and fetal wellbeing after birth
How many physicians are required to sign off on a TOP in england?>
2
What is the risk of unsafe abortions
Infection, haemorrhage, PID, death, injury to organs, sepsis, infertility
What is done during an abortion consultation
Pelvic US to determine gestation, viability, single/multiple, intrauterine
Advise on contraception
Counselling alternatives
History
Blood tests (anti-D)
Swabs and STI screening
Consent
What is the medical management for abortions
Mifepristone (anti progesterone)
Misoprostol (prostaglandin)
What is the surgical management for abortion
Suction and curretage, dilation and evacuation
Complications of termination of pregnancies
Haemorrhage, infection, damage to organs, failure, retention of products, psychological impact
What is the definition of a breech presentation
Buttocks presenting first
Describe the types of breech presentations
Frank is when feet are high but buttocks are low
Complete breech is when legs are cross with arms around face
Footling breech is when one foot is engaged while the other isn’t
What are risk factors for breech
Past hx Twins Placenta praevia Tumours/fibroids Oligohydramnios Prematurity of fetus
Complications in breech deliveries
Cord prolapse Cord compression Brain compression Spinal cord trauma Prematurity
When should an ECV be done if at all
After 37 weeks or if mother is labouring
Risk factors in failure of ECVs
Obesity White caucasians Nulliparous Engaged breech Reduced liquor volume
What should be done immediately after performing ECV?
CTG and anti-D
What are the contraindications for an ECV
Twins Placental praevia Ruptured membranes Fetal compromise APH
Indications for caeseran in breech
Elective Fetal distress Failure to progress Footling presentation SGA or LGA babies
Post natal complications in breech baby
Organ damage
Hypoxia
Autism and other conditions
fetal risks in preterm labour
perinatal mortality
cerebral palsy
chronic lung disease
blindness
risk factors for preterm labour
hx of preterm labour lower SEC uterine abnormalities/fibroids extremes of maternal age maternal disease pregnancy complications
how does a preterm labour present?
before 37 weeks
painful contractions
vaginal bleeding
PPROM
how to prevent preterm labour?
treat any medical disease
cervical cerclage
fetal reduction
progesterone supplementation
what should be given acutely to a mother in preterm labour
steroids
antibiotics
tocolytic (oxytocin receptor antagonist, nifedipine)
magnesium sulphate
name 5 methods of monitoring fetal wellbeing
ultrasound assessment of fetal size
doppler umbilical artery
doppler fetal arteries (MCA and ductus venosus)
ultrasound assessment of amniotic fluid and biophysical profile
CTG
a one-off normal CTG is a good prognostic indicator of fetal wellbeing - T or F?
F - CTG only shows acute status, needs to be serially done to assessment wellbeing.
what are 2 maternal maneuvers that can be done in shoulder dystocia
Mcrobert’s maneuver (legs and knees hyperflexed and brought to chest)
mother on all four limbs
what is the first thing that should be done in shoulder dystocia
call for senior support
in shoulder dystocia when should internal vaginal access be considered
after trying McRobert’s maneuver and mother-on-4-limbs,
In Mcrobert’s maneuver, where should pressure be applied?
externally on suprapubic area
difference between primary and secondary postpartum haemorrhage?
primary is within 24 hours of birth
what are the 6 types of miscarriages
threatened - bleeding, but still viable 25% chance death
inevitable
incomplete
complete
septic
missed - miscarriage before pregnancy known
in miscarriage, what are 3 patterns of HCG trends
viable pregnancy: 66% rise over 48 hours
miscarry: 50% decrease over 48 hours
ectopic: >66% rise or >50% decrease over 48 hours
3 forms of gestational trophoblastic disease?
hydatidiform mole
invasive mole
chorioncarcinoma
difference between invasive mole and chorioncarcinoma?
no mets in invasive mole
subcategories of hydatidiform mole?
complete - 1 sperm fertilise 1 empty oocyte
incomplete - 2 or more sperms fertilise 1 oocyte
what is a ‘snowstorm’ appearance on US scan suggestive of?
gestational trophoblastic disease
what is the diagnostic test for GTD?
histological
percentage of causes of subfertility
30% unexplained
30% ovulation d/o
25% tubal damage
25% male factor
definition of oligospermia
<15 million/ml semen
which of these drugs have a higher chance of multiple pregnancies - clomifene, gonadotrophins, metformin
clomifene and gonadotrophins
which if these can cause OHSS clomifene, gonadotrophins, metformin
gonadotrophins
possible complications of fertility treatment
multiple pregnancy
OHSS
most common endometrial cancer pathology?
endometroid adenocarcinoma
what is involved in the triple screening?
US for nuchal translucency
PAPP-A (low = higher risk)
beta-HCG (high = higher risk)
when should the quadruple test be offered instead of the triple test?
when it is >15+0 weeks and before 20+0 weeks
what is involved in the quadruple test? what levels are associated with downs syndrome?
beta hcg - high
papp-a - low
inhibin A - high
estriol - low
what does an open os in early pregnancy indicate
inevitable miscarriage
what is the diagnosis if someone is suspected to have a miscrriage, the Os is closed, and there is no fetus found in the uterus?
ectopic
symptoms of a molar pregnancy
hyperemesis, nausea
bump on palpation
+/- bleeding
US -> snow storm appearance
which of these is not a risk factor for hyperemesis gravidarum
Primip Multiple pregnancy PMH grand multiparity Molar pregnancy Young
grand multiparity
difference between normal morning sickness and hyperemesis gravidarum
normal MS comes and goes in waves, symptoms don’t stay for the whole day, can usually eat/drink a little in between attacks.
HG stays for the entire day without relenting, food/drink is near impossible without vomiting everything out. signs of dehydration/malnutrition is possible
