Obstetrics Flashcards
Do a speculum exam to assess bleeding in early pregnancy
e.g. is the os opened/ closed
What are the 5 different types of miscarriage?
1) Threatened (os closed)
2) Inevitable (os opened )
3) Incomplete (os open)
4) Complete (closed)
5) Missed (closed)
What investigations should you do in a lady with bleeding in early pregnancy?
FBC G&S BHCG USS Tissue sample for analysis?
Advice for threatened miscarriage
Rest, 75% will settle
Management options for a miscarriage?
1) Expectant - if mild symptoms and little retained products
2) If very symptomatic = evacuation of retained products
3) Can Use mifepristone and misoprostol but many will need ERCP anyway (done under general anaesthetic)
Define recurrent miscarriage
Loss of 3 consecutive pregnancies before 24 weeks
Causes: Balanced translocation Uterine abnormally Anti-phospholipid Thrombophilia (2nd trimester loss)
Management of anti-phospholipid syndorme in pregnancy?
1) Aspirin 75mg PO from +ve pregnancy test
2) LMWH e.g. enoxaparin when fetal heart is detected
Investigation of suspected ectopic pregnancy
IV access
FBC, G&S
Urinary and serum bHCG
USS (transvaginal)
(Free fluid in the pouch of Douglas is an useful sign)
Advice for patient starting methotrexate to treat miscarriage?
1) Need to visit regularly for serial measurement to bHCG
2) Methotreaxate is teratogenic - need effective contraception for at least 3 months
3) Folate antagonist so will need folate supplements
4) There is a chance that surgery will be required
‘Grape like clusters’
Molar pregnancy
chorionic villi are swollen with fluid
Snowstorm appearance on USS
Complete mole
Complete mole
1 or 2 sperm fertilise an ‘empty’ egg —> overgrowth of placental tissue and no fetus
Partial mole
Usually triploidy e.g. 2 sperm fertilise 1 egg
A fetus begins to develop but will miscarry
Features of molar pregnancy
1) Early pregnancy loss ‘grape like clusters’
2) Hyperemesis
3) large for dates
Management of molar pregnancy
1) Surgical evacuation
2) monitor bHCG for at least 6 months
3) Anti-D if required
4) 10% give rise to Choriocarcinoma
All patients with persistent PV bleeding after pregnancy should be investigated for Choriocarcinoma
It is a highly malignant tumour which often metastases but is sensitive to chemotherapy
What is chorionic haematoma?
Pooling of blood between the endometrium and embryo
Can present like a ‘threatened miscarriage’
Usually self limiting
Risk factors for candida infection
1) Recent antibiotics
2) High estreogen e.g. pregnancy
3) DM
4) Immunocompromised
Management of candida infection
Clinical diagnosis
Can do high vaginal swab for culture
Topical clotimazole OR oral fluconazole
Acute bacterial prostatitis presents with UTI symptoms + abdo/ back/ penile pain + tender prostate
How do you manage
Diagnose with clinical signs + MSSU for culture
+ first pass for chlamydia/ gonorrhoea
Treat with ciprofloxacin for 28 days
What is the predominate bacteria in healthy vaginal flora?
Lactobacillus
What is normal vaginal pH/
4-4.5 (will be higher in BV)
How to diagnose BV?
1) Fishy discharge (KOH)
2) Clue cells
3) High pH
Treatment is with a 5 day course of metronidazole
What are the 3 serological groupings of chlamydia?
A - C = trachoma (not an STI)
D - K = genital infection
L1 - L3 = lymphogranuloma venerum
Treatment of chlamydia
Azithromycin 1g oral dose
OR doxycycline 100mg bd for 7 days
Chlamydia diagnosis
Swabs for NAAT/ PCR
(nuclei acid amplification tests)
Males = first pass urine Female = high vaginal or vulvovaginal swab OR endocervial swab if speculum exam being performed
Also rectal/ throat/ eye swab if required
What does gonorrhea look like?
It is a gram negative diplococcus so look like 2 kidney beans facing each other
Remember it is far less rare and far more likely to be symptomatic than chlamydia
Management of gonorrhoea?
IM ceftriaxone and oral azithromycin
Test of cure for all patients
Diagnosis of syphillus
Swab of primary or secondary lesion for PCR
Syphilus combined IgM and IgG
Serology e.g. VDRL and RPR (not specific but good for monitoring response!)
Management of syphilus
Long acting penicillin
Diagnosis of genital herpes
Swab deroofed blister and send in virus culture medium
Define large for dates
Based on US the estimated fetal weight is >90th centile
What must be excluded in a lady with a large for dates pregnancy?
Diabetes
Twins
Poly hydra bios
List some causes of polyhdramnios
1) DM
2) Fetal anomaly
3) Monochorionic twins
4) Hyrops fetalis - Rh disease or erythroviurs B19 infection
On US, how is polyhydramnios diagnosed?
1) Amnioticx fluid index >25
2) Deepest vertical pocket >8cm
What are the risks associated with polydramnios?
PPH
Cord prolapse
Premature birth
Underlying fetal abnormality
How should a pregnancy with polydramnios be managed?
Look for causes e.g. OGTT
Serial USS
IOL by 40 weeks
What is the difference between monozygotic and dizygotic twins?
Monozygotic = a single fertilised egg splits
Dizygotic = 2 eggs fertilised by 2 sperm
Which twins are at highest risk?
Monochorionic, monozygotic twins
On US, dichorionic twins = Lambda signs
On US, monochorionic twins = T sign
When is a twin pregnancy usually confirmed on USS?
12 weeks
Often on a background of large for dates and hyperemesis gravidarum
Risks associated with twin pregnancy
Fetal:
- congenital abnormality
- prematurity
- cerebal palsy (6x)
- growth restriction
Mother:
- complications e.g. Pre-eclampsia, anaemia
- Pre-term labour
- LSCS
- bleeds
What medications should all mothers with multiple pregnancy be on?
1) Fe - high anaemia risk
2) Aspirin - high pre-eclampsia risk
3) Folic acid
When should twins be delivered?
Monochorionic dizygotic twins = 36 weeks
Dichorionic dizygotic twins = 37-38 weeks
All triplets and above need a section
What are the risks of pre-existing DM in pregnancy?
- Congenital abnormalities
- Miscarriage
- IUD
The above are specific to pre-existing
All (inducing GDM):
- Macrosomia + shoulder dystocia
- PE
- Neonatal hypoglycaemia
When should you screen for GDM?
If previous GDM:
- OGTT at 18 weeks
- if normal repeat at 28 weeks
If RF e.g. previous big baby, obesity, FH etc:
OGTT at 24-28 weeks
When should women with GDM be offered hypoglycaemic agent?
- diet and exercise have not provided sufficient control
- fetal macrosomia on US
When should women with DM be delivered?
Pre-gestational:
- 38 weeks onwards
GDM:
- Insulin = 38
- Metformin = 39-40
- Diet = 40-41
Role of progesterone, oestrogen and oxytocin in labour?
Progesterone = keeps uterus settled down/ not responding
Oestrogen = makes uterus contract and stimulates prostaglandins
Oxytocin = initiates and sustains contraction - promotes prostaglandin release
Ferguson reflex
Name given to the self-sustaining cycle of uterine contractions in response to cerix pressure
The latent phase of first stage of labour can last a few days. What is the normal rate of progression in the active 1st phase?
1-2cm/ hour
When is the 2nd stage prolonged?
No epidural = 2 hours (prim), 1 hour (multi)
Epidural = 3 hours (prim), 2 hours (multi)
What is the normal duration of the 3rd stage?
Average = 10 min
After 1 hour = removal under GA
What is active management of 3rd stage?
Give oxytocin (10u) Cord clamping and cutting + controlled cord traction
Used to reduce risk of PPH
Which pelvis is best for delivering a baby?
Gynaecoid pelvis
What is the normal fetal position?
- longitudinal lie
- cephalic presentation
- occipito-anterior head engagement
What is the mnemonic for the mechanism of labour
Every - engagment
Day - descent
Food - flexion
Is - internal rotation
Cheap and Easy - crowning and engagement
Reliable and Exquisite - restitution and external rotation
What is the most common type of placental separation?
Matthew Duncan
marginal separation
What is bleeding after birth called?
Lochia
Initially red followed but brown and yello
Last 10-14v days after birth
What are usual booking bloods?
FBC,UE, LFT, blood group and antibodies
Blood glucose
Hep B, HIV and syphillus, rubella
Screen for thalassaemia/ sickle
Which systems are mainly affected by pre-eclampsia?
Kidney - protein
Liver - RUQ pain, LFT, HELLP
Brain/ eyes - visual problems, headache
Placenta - IUGR, death - Must do regular growth scans and Doppler
ACEI and ARB must be stopped in pregnancy. What antihypertensive can you use?
1) Labetolol
2) Methyldopa
3) Nifidepine (if dual therapy required)
4) Hydralazine (IV used for severe hypertension)
Target HbA1c for mother with DM?
Pre-conception <6% (avoid conceiving if >10%
Keep BM at 4-6
A LSCS is recommended for all patients with DM with an estimated fetal weight of >4kg
LSCS if DM and fetal weight >4kg
In terms of clotting factors, why is pregnancy a hyper-coagulable state?
There is an increase in factor 7, 8, 9, 10 and 12 as well as a decrease in antibthrombin
Effect on both intrinsic and extrinsic pathway
Calculate the VTE risk for all pregnant women. Obviously having a thrombophilia or previous VTE is really high risk but a 36 year old who has a BMI >30 and smokes also has a score of 3. What action should be taken?
LMWH from 28 weeks
If she had antother risk factor e.g. twin pregnancy then LMWH from 1st trimester
If <3 RF —> lower risk so advice mobilisation and avoidance of dehydration
How long should LMWH be continued post-nasally?
High risk e.g. previous VTE = at least 6 weeks
Intermediate risk e.g. LSCS, BMI >40 or multiple RF e.g. >35 and smoker
—> at least 10 days
<2 RF = low risk —> early mobilisation and avoid dehydration
In pregnancy, left DVT are 8x as common as left DVT
The D-Dimer test is useless in pregnancy as it is already elevated
What features of PE may be visible on a CXR?
May be normal
- atelectasis
- pleural effusion
- opacity
- elevated diaphragm
- area or infarction
What does a CTPA increase the risk of in pregnancy?
Breast cancer
Warfarin is teratogenic in the first trimester and should be avoided throughout pregnancy
Warfarin is safe in breastfeeding
What is the risk of a child having epilepsy if the mother is affected?
5% if one parent
15-20% if both affected
Which epilepsy drug associated with neural tube defects?
Sodium valproate
And carbamazepine
Which epilepsy drug associated with cleft palate?
Phenytoin
Which epilepsy drug associated with cardiac defects?
Phenytoin and valproate
Carbamazepine is often the drug of choice for epilepsy during pregnancy
It is an enzyme inducer so patients should take Vit K from 36 weeks to protect against haemorrhagic disease of the newborn
Remember general advice of avoid baths and medication compliance
Define bleeding in late pregnancy
Bleeding after 24 weeks
Includes APH and PPH
RF for placental abruption - the major cause of APH
Trauma HT/ PET Smoking/ cocaine, DM Multiple pregnancy etc
Management of placental abruption
2 large bore cannula FBC, UE, LFT, X-match 4-6 units RBC Kleihauer test IV fluids Catheterise
Assess fetus - CTG is best as US will fail to detect 3/4
Where is the lower segment of the uterus?
Inferior to the attachment of utero-vesical peritoneal pouch and superior to the pouch of Douglas
What is the major risk factor for placenta praevia?
Previous C-section
Also associated with high presenting part and malpresentation e.g. breech
CTG is usually normal
Management of delivery in placenta praevia
Placenta <2cm from os = c-section with consultant present
Vaginal delivery possible if >2cm from os and no malpresentation
A uterine rupture is the full thickness opening of the uterus. What are the features?
PV bleeding
Severe abdo pain
Shoulder tip pain
Maternal collapse
What is vasa praevia?
Unprotected fetal vessel cover the membrane over internal os. When the membrane rupture —> sudden bleeding —> fetal death
Mortality is up to 60%
Define PPH
Blood loss >50ml after birth of baby
Primary <24 hours after birth
Secondary 24hours - 6/52 after birth
Minor 500-100ml + no signs of shock
Major >100ml / signs of shock
What is placenta percreta + accrecta?
Percreta = placenta invades through uterus to other organs e.g. bladder
Accrete = placenta invades myometrium
What are the 4 T’s of PPH
Tone
Trauma
Tissue
Thrombin
PPH management
ABCDE Uterine massage IV syntocinon Foley catheter IV ergometrine Manage any tears/ trauma
Other options - carboporst, misoprostol, tranexamic acid etc
There are a variety of surgical and non-surgical techniques e.g.
Which drug is typically used for epidural anaesthesia in labour?
Levobupivacaine +/- opiate
Very effective - T11 - S5
What are the main complications of an epidural?
Atonic bladder
Hypotension
Rural puncture
Headache
What is the smallest fetal skull diameters?
Sub-occipito-bregmatic diameter
if head is really well flexed
How often should the fetal heart be auscultated in labour?
Stage 1 = at least every 15 minutes (during and after a contraction)
Stage 2 = at least every 5 minutes (during and after contraction for 1 minute)
Remember that high risk pregnancies e.g. pre-eclampsia, sepsis, IOL, epidural etc need continuous monitoring
What 4 things should you document in every CTG?
Baseline rate
Variability
Acceleration/ deceleration
—> Normal, suspicious or pathological
What do you do if fetal blood sample pH = 7.23?
7.19?
- 23 = borderline - normal is >7.25 —> repeat in 30 minutes
7. 19 = abnormal —> deliver now
What are you feeling for on a PV exam for urinary incontinence?
Atrophy
Fistula
Prolapse
Also check anal tone and for masses on PR
Anti muscarinic are first line drug therapy for urge incontinence. Give 2 examples
Oxybutynin
Tolteridone
In over-active bladder, when might desmopressin be useful?
If they have nocturnal
How might an anterior prolapse present?
Anterior = cystoceole
Bladder symptoms, painful sex etc
What is middle prolapse?
Prolapse of the vaginal vault
How might a posterior prolapse present?
Rectal prolapse —>
Bulge, Bowery symptoms
4 things to ask all patients with a suspected prolapse?
Bowel symptoms
Bladder symptoms
Sexual function
Pressure symptoms
Prolapse is staged using the POP-Q system which considers relation of structures to the hymen. What are the different stages?s
Stage 0 = no prolapse Stage 1 = 1cm above hymen Stage 2 = -1 and +1 beyond hymen Stage 3 = >1cm beyond hymen Stage 4 = complete vaginal eversion
Define HT in pregnancy
> 140/90 on 2 occasions
160/110 on one occasion
30/15 rise from booking
What is the transitional zone of the cervix?
Junction between ectocervix (squamous) and endocervix (columnar)
HPV 6 + 11 = genital warts
HPV 16 +18 = cervical cancer
What is the presence of koilocytes characteristic of?
Cervical neoplasia
CIN is graded depending on cell differentiation, nuclear abnormalities and excess mitotic activity
Difference between CIN 1,2 and 3
CIN 1= abnormal cells in basal 1/3 only
CIN 2 = abnormal cells extend up to middle 1/3
CIN 3 = abnormal cells occupy full thickness of epithelium
What is the commonest type of cervical cancer?
SQUAMOUS
> 75%
How is cervical cancer staged?
1 = confined to cervix 2 = spread to adjacent structures e.g. vagina 3 = spread to pelvic wall 4 = distant mets or bladder/ bowel
What is the most important prognostic factor for vulval squamous cell cancer?
Whether it has spread to inguinal lymph nodes
No —> 5 year survival >90%
Yes —> 5 year survival <60%
3 inadequate smears =
Refer to colposcopy
What is the major risk of a transverse lie?
Cord prolapse
Remember to try external cephalic version -
C-section if cannot turn
When should magnesium’s sulphate be stopped in pre-eclampsia?
24 hours after last seizure or delivery of the baby
If a lady has a Bisphops score of 4, what is the most appropriate action?
Will need vaginal prostaglandins to ripen
A score >5 suggests spontaneous labour likely
How do you treat BV and trichomanis vaginalis?
Both with oral metronidazole
Pregnant lady with fever, tachycardia + neutrophils + uterine tenderness =
Always exclude chorioamnionitis
First line for a menopausal lady with only vasomotor symptoms?
SSRI e.g. fluoxetine
Which steroid is used to prevent RDS in the newborn if PROM?
Dexamthasone
Remember levonelle = long acting (72hours) BUT Ella one (ulipristal acetate) = ultra long 120 hours!
Remember levonelle = long acting (72hours) BUT Ella one (ulipristal acetate) = ultra long 120 hours!
Pregnant lady with brisk tendon reflexes?
Think pre-eclampsia
More specific than other signs e.g. HT and oedema
Methyldopa which can be used for BP in pregnancy is contraindicated in depression
Methyldopa which can be used for BP in pregnancy is contraindicated in depression
What is medical management of a missed miscarriage?
Vaginal misoprostol
Treatment of a lady with fibroids who wants to conceive
Myomectomy
What is an early and premature menopause?
Early = <45
Premature <40
Benefit and risk of HRT
Benefit =
- symptoms
- bone health
- bowel cancer
Risks:
- clots (2-7 / 1000)
- CVA
- breast cancer (6 extra/ 1000)
Always ask about personal and FH of clots and breast cancer
Differential for DUB in a post-menopausal lady
Polyps
Hyperplasia - simple or complex
Endometrial cancer
What are the 2 main type of endometrial tumour?
Type 1 (80%) = endometrioid —> related to unopposed oestrogen and endometrial hyperplasia
Type 2 = serous +clear cells
—> not related to unopposed oestrogen and usually P53 mutation
An endometrial tumour in a 35 year old lady shows microsatellite instability. What should be excluded?
Lynch syndrome - autosomal dominant disease due to defective DNA repair
High risk of bowel, endometrial and ovarian cancer
Remember grade is how well differentiated the cells are
Stage is how much the cancer has spread e.g. local invasion —> distant mets
What is the most common uterine sarcoma?
Leiomyosarcoma
Usually has spindle cell morphology
What is your differential for a pelvic mass?
Non-gynae:
Constipation
Urinary retention
Bowel/ bladder cancer
Mets from anywhere
Gynae:
Ovarian - cyst/ tumour Endometrial - polyp, tumour Uterine - polyp etc Vagina tumour Pregnancy Endometriosis
What are the different types of fibroids?
Pedunculated Intramural Sub-mucosal Subserosal Intra-cavity
What hormones can ovarian stromal tumours secrete?
Granuloma cell —> oestrogen
Theca/ leydig cell —> androgens —> hisutism
Remember that ovarian tumours can produce loads of weird things e.g.
Malignant germ cell tumours —> HCG —> false +ve pregnancy test
Dermoid cysts can produce thyroid tissue —> thyrotoxicosis
Ovarian cancer has early transperitoneal spread
Varied presentation so always consider in an older lady
What 2 tumour markers and 2 imaging test should you do for suspected ovarian cancer?
CA 125 and CEA (to exclude mets from GI primary)
USS and CT (spread)
Differential for raised CA125
Endometriosis
Pregnancy
Ascites
Pancreatitis
What is the risk of malignancy score for ovarian cancer?
Menopausal status x CA 125 x ultrasound findings
If benign ovarian thing then a laparoscopy is ok
If ovarian cancer suspected then need to do a laparotomy
What is the main pathological feature of pre-eclampsia?
The spiral arteries which are normally dilated to provide a good blood supply become fibrosed and narrow
—> consequence = a poorly perfused placenta —> IUGR, fetal death
Release of pro-inflammatory proteins —> endothelial cell dysfunction —> vasoconstriction and salt/ water retention
Very high BP —> stroke, placental abruption
local vasospasm - kidney problems, blurred vision, hepatomegaly (RUQ pain)
Lots of thrombi —> haemolysis
Increased vascular permeability —> oedema, pulmonary oedema, cerebral oedema (—>seizures)
Remember that ALL the problems depend on placental dysfunction
4 organs mainly affected by pre-eclampsia?
Kidneys
Eyes
Liver
Brain
A patient with pre-eclampsia develops hyperreflexia. What does this suggest?
She is at high risk of seizures
What is the cut-off for mild, moderate and severe hypertension in pregnancy?
Mild = >140/90 Mod = >150/100 Severe = >160/110
When should baby be delivered in pre-eclampsia?
Mild = delivery at 37 weeks
Severe = delivery at 32 to 34 weeks
Severe pre-eclampsia with evidence of maternal or fetal compromise —> within 24 hours
What are the 3 main congential abnormalities associated with anti-epileptic medications?
- heart defects
- neural tube defects
- cleft palate
How do we prevent transmission of HIV from mother to fetus?
- HAART in pregnancy
- C-section
- no breastfeeding
Risk is <2% (less if viral load unidentifiable)
Rubella infection is high risk in the 1st trimester. What are the potential effects on the baby?
Sensorineural deafness
Cataracts
CHD
Developmental delay
(no treatment is available if infected so prevention is key)
What are the features of congential varicella syndrome?
Problems are worst if infected up to 20 weeks
Mental retardation Skin scarring Eye defects e.g. cataracts Hypoplastic limbs Deafness
Can give VCZ immunoglobulin to susceptible women if high risk exposure
Pregnant lady develops primary herpes at 35 weeks gestation. What is the best course of action?
Deliver by c-section as she has developed primary herpes within 6 weeks of birth
Which intra-uterine infection causes intra-cerebral calcification?
Toxoplasmosis and CMV
Spiramycin is used to reduce risk of transmission of toxo from mother to child
Pyrimethamine is used if fetal infection is confirmed
Incidence of Down’s syndrome?
Depends on mother age
1 in 2500 at 25
1 in 100 at 40
Hydrous Fetalis is the main complication and rhesus incompatibility. How does hydrous fetalis present?
At birth with fetal ascities, hepatosplenomegaly, pleural and pericardial effusions
What are the risks of multiple pregnancy?
Maternal:
- miscarriage
- symptoms e.g. hyperemesis
- operative delivery
- pre-eclampsia
- GDM
Fetal:
- pre-term
- twin to twin transfusion
- cerebral palsy
- IUGR
Define an IUD
Intra-uterine death is the birth of an infant >24 weeks gestation with no signs of life
Occurs in 1 in 200 births
Causes include infection, chromosomal, maternal disease, abruption, pre-eclampsia and smoking
Remember if a pregnant lady presents with vaginal bleeding it is really useful to compare to previous US scans
The placenta may have been near/ covering the os (—> placenta praevia) - it may r may not have moved away
What is vasa praevia?
Fetal blood vessels run across the os —> when membranes rupture torrential bleeding occurs
Placenta Accreta = abnormally attached to the uterine muscle (normally there is a fibrous layer between the uterus and placenta)
Placenta Increta = placenta Invades through the uterine muscle
Placenta percreta = placenta Pushes through uterus and invades other structures e.g. bladder
For Rh -ve women without any sensitising events, anti-D is given at 28 and 34 weeks
For Rh -ve women without any sensitising events, anti-D is given at 28 and 34 weeks
HCG can be detected in the maternal blood stream up to 8 days after conception. Which cells release it?
Syncytiotrophoblast
Main role is to maintain corpus luteum
AFP is high in NTD and abdominal wall defects e.g. omphalocoele
AFP is low in chromosomal abnormalities and DM
(In DS, things that begin with vowels - AFP and UE3 are low and things not are high
How do you distinguish between pre-existing HT, gestational HT and pre-eclampsia?
Pre-existing = BP>140/90 or rise more than 30/15 BEFORE 20 weeks of pregnancy
Gestational BP >140/90 after 20 weeks
No proteinuria or oedema
Pre-eclampsia = BP >140/90 after 20 weeks with protein >0.3g/day
How do you manage cord prolapse?
- push presenting part back into uterus
- keep cord warm
- Get patient on all 4’s
- consider the use of tocolytics
- get help and arrange an immediate c-section
When is extra-cephalic version offered for breech?
36 weeks if nulliparous
37 weeks if multi-parous
Cholestasis of pregnancy = pruritis with raised bilirubin and obstructive LFT
Acute fatty liver of pregnancy = non-specific features e.g. abdo pain, NV, jaundice, Hypoglycaemia and very very high ALT
What is the management of pre-term prelabour rupture of membranes?
Perform a sterile speculum exam to confirm - do not do a PV due to risk of of infection
10 day course of oral erythromycin
Admit and monitor closely
Deliver at 34 weeks - trade off between maternal chorioamnionitis and respiratory distress of baby
Antenatal corticosteroids
Poor uterine tone is the major cause of PPH. What are the risk factors for low tone?
Anything which causes over-stretching e.g.
- multiple pregnancies
- twins/ triplets
- polyhydramnios
Remember that the insertion of a catheter is super important as it can prevent uterine contraction
Placenta Accreta is a big risk factor for retained tissue which can cause PPH
Remember that as the placenta has invaded the muscle it is less likely to separate
1st line investigation for ANYONE with painless vaginal bleeding
US you MUST rule out placenta praevia
When is OGTT performed?
As soon as possible after booking if previous GDM
Repeat at 24-28 weeks if 1st is normal
All other women with risk factors = 24-28 weeks
How is GDM managed?
If fasting glucose
<7mmol/l then trial of diet control with frequent checking of blood glucose for 1-2 weeks
If not controlled add in metformin
If >7mmol/l at time of diagnosis then start insulin
Remember that a breech pregnancy is a risk factor for cord prolapse
Remember that a breech pregnancy is a risk factor for cord prolapse
Baseline HR on CTG?
110-160
Also the variability should be at least 5 bpm
What are the indications for induction of labour?
- post-maturity
- pre-eclampsia
- suspected IUGR
- PROM
- IUD
Lady is 41+4 and is wanting to discuss induction of labour. How is labour induced?
- membrane sweep
- use of prostaglandins e.g. vaginal pessary
- if induction fails then options are repeat induction with prostaglandins or consider LSCS
What are the 4 degrees of perineal trauma?
1 - skin only
2 - skin + perineal muscle
3 - involves anal sphincter
4 - internal/ external anal sphincter and mucosa
90% of women have some form of tear, 1% have grade 3/4
Always remember that suicide is a leading cause of maternal mortality
Suicide is a leading cause of maternal mortality
In hyperemesis gravidarum the level of hCG is related to severity
Explains why twins and molar pregnancy have higher rates
Other than dehydration, what 2 complications are associated with hyperemesis gravidarum?
1) Thyrotoxicosis - hCG and TSH have similar sub-units so can act similarly
2) Wernicke’s encephalopathy - B1 deficiency
Medical management of miscarriage = misoprostol
Surgical management = evacuation of retained products (manual vacuum aspiration or in theatre)
List a few risk factors for an ectopic?
- previous PID
- previous ectopic
- IUD
- assisted reproduction
(after 1 ectopic the risk increases to around 15% —> early US scan is recommended in future)
Babies heart beat is usually detected around 6-7 weeks
Gender at 20 weeks and baby movements at around 20 weeks (often earlier if this is not first pregnancy
Frequency of smear tests in scotland
Every 3 years from age 25
Every 5 years from 50-64
What to do if smear results show ‘inadequate smear’
Repeat in 3 months
Mild dyskariosis = test for HPV
+ve = colposcopy
-ve = return to normal screening
Moderate/ severe dyskariosis = colposcopy
The vast majority of endometrial cancers are adenocarcinoma. What are the risk factors?
- obesity
- alcohol
- HRT
- early menarche, late menopause
- Tamoxifen
- genetics e.g. Lynch syndrome
In molar pregnancy, hCG levels are used to monitor disease - should fall gradually
If high levels persist —> need chemotherapy
Molar pregnancies are twice as common in Asian women compared with Caucasian
Mild PID can be treated as an outpatient with:
Ofloxacin and Metronidazole for 14 days
Moderate/ severe PID is treated as an inpatient with:
IV ceftriaxone, PO doxycycline and IV metronidazole
Don’t forget to do TFT when discussing menorrrhagia
Don’t forget to do TFT when discussing menorrrhagia
Define primary amenorrhoea
- absence of menses by 14 in patients with no secondary sexual characteristics
- absence of menses by 16 in patients with normal development of secondary sexual characteristics
What are the side effects of a surgical evacuation of the products of conception e.g. after a miscarriage?
- heavy bleeding
- incomplete treatment e.g 5 in 100 may need further management
- infection e.g. use pads not tampons
- uterine perforation
- the risks of general anaesthesia
Pregnant people with previous VTE =
High risk
Need LMWH throughout pregnancy and 6 weeks post partum
Patients with 4 or more VTE risk factors e.g. 36 y/o with BMI>30 who smokes and is having twins =
LWMH from 1st trimester and at least 10 days post-partum
Patients with 3 risk factors for VTE e.g. 36 year old smoker having twins =
Thromboprophylaxis from 28 weeks and at least 10 days post-partum
How is GDM diagnosed?
Fasting glucose >5.6mmol/L
OR random >7.8
The test is with a 75g 2 hour OGTT
Tone is the major cause of PPH. What are the risk factors?
Multiple pregnancy Fetal macrosoma Previous PPH Prolonged 3rd stage GA
PPH = loss of >500ml go blood from genital tract within 24 hours of birth of baby
Minor = 500-1000 Major = 1000 + or shock
