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Ob/gyn > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Do a speculum exam to assess bleeding in early pregnancy

A

e.g. is the os opened/ closed

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2
Q

What are the 5 different types of miscarriage?

A

1) Threatened (os closed)
2) Inevitable (os opened )
3) Incomplete (os open)
4) Complete (closed)
5) Missed (closed)

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3
Q

What investigations should you do in a lady with bleeding in early pregnancy?

A 
FBC
G&S
BHCG
USS
Tissue sample for analysis?
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4
Q

Advice for threatened miscarriage

A

Rest, 75% will settle

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5
Q

Management options for a miscarriage?

A

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)

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6
Q

Define recurrent miscarriage

A

Loss of 3 consecutive pregnancies before 24 weeks

Causes:
Balanced translocation
Uterine abnormally
Anti-phospholipid 
Thrombophilia (2nd trimester loss)
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7
Q

Management of anti-phospholipid syndorme in pregnancy?

A

1) Aspirin 75mg PO from +ve pregnancy test

2) LMWH e.g. enoxaparin when fetal heart is detected

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8
Q

Investigation of suspected ectopic pregnancy

A

IV access
FBC, G&S
Urinary and serum bHCG
USS (transvaginal)

(Free fluid in the pouch of Douglas is an useful sign)

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9
Q

Advice for patient starting methotrexate to treat miscarriage?

A

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

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10
Q

‘Grape like clusters’

A

Molar pregnancy

chorionic villi are swollen with fluid

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11
Q

Snowstorm appearance on USS

A

Complete mole

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12
Q

Complete mole

A

1 or 2 sperm fertilise an ‘empty’ egg —> overgrowth of placental tissue and no fetus

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13
Q

Partial mole

A

Usually triploidy e.g. 2 sperm fertilise 1 egg

A fetus begins to develop but will miscarry

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14
Q

Features of molar pregnancy

A

1) Early pregnancy loss ‘grape like clusters’
2) Hyperemesis
3) large for dates

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15
Q

Management of molar pregnancy

A

1) Surgical evacuation
2) monitor bHCG for at least 6 months
3) Anti-D if required
4) 10% give rise to Choriocarcinoma

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16
Q

All patients with persistent PV bleeding after pregnancy should be investigated for Choriocarcinoma

A

It is a highly malignant tumour which often metastases but is sensitive to chemotherapy

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17
Q

What is chorionic haematoma?

A

Pooling of blood between the endometrium and embryo
Can present like a ‘threatened miscarriage’
Usually self limiting

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18
Q

Risk factors for candida infection

A

1) Recent antibiotics
2) High estreogen e.g. pregnancy
3) DM
4) Immunocompromised

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19
Q

Management of candida infection

A

Clinical diagnosis
Can do high vaginal swab for culture
Topical clotimazole OR oral fluconazole

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20
Q

Acute bacterial prostatitis presents with UTI symptoms + abdo/ back/ penile pain + tender prostate

How do you manage

A

Diagnose with clinical signs + MSSU for culture
+ first pass for chlamydia/ gonorrhoea

Treat with ciprofloxacin for 28 days

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21
Q

What is the predominate bacteria in healthy vaginal flora?

A

Lactobacillus

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22
Q

What is normal vaginal pH/

A

4-4.5 (will be higher in BV)

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23
Q

How to diagnose BV?

A

1) Fishy discharge (KOH)
2) Clue cells
3) High pH

Treatment is with a 5 day course of metronidazole

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24
Q

What are the 3 serological groupings of chlamydia?

A

A - C = trachoma (not an STI)
D - K = genital infection
L1 - L3 = lymphogranuloma venerum

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25
Q

Treatment of chlamydia

A

Azithromycin 1g oral dose

OR doxycycline 100mg bd for 7 days

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26
Q

Chlamydia diagnosis

A

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

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27
Q

What does gonorrhea look like?

A

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

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28
Q

Management of gonorrhoea?

A

IM ceftriaxone and oral azithromycin

Test of cure for all patients

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29
Q

Diagnosis of syphillus

A

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!)

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30
Q

Management of syphilus

A

Long acting penicillin

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31
Q

Diagnosis of genital herpes

A

Swab deroofed blister and send in virus culture medium

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32
Q

Define large for dates

A

Based on US the estimated fetal weight is >90th centile

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33
Q

What must be excluded in a lady with a large for dates pregnancy?

A

Diabetes
Twins
Poly hydra bios

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34
Q

List some causes of polyhdramnios

A

1) DM
2) Fetal anomaly
3) Monochorionic twins
4) Hyrops fetalis - Rh disease or erythroviurs B19 infection

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35
Q

On US, how is polyhydramnios diagnosed?

A

1) Amnioticx fluid index >25

2) Deepest vertical pocket >8cm

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36
Q

What are the risks associated with polydramnios?

A

PPH
Cord prolapse
Premature birth
Underlying fetal abnormality

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37
Q

How should a pregnancy with polydramnios be managed?

A

Look for causes e.g. OGTT
Serial USS
IOL by 40 weeks

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38
Q

What is the difference between monozygotic and dizygotic twins?

A

Monozygotic = a single fertilised egg splits

Dizygotic = 2 eggs fertilised by 2 sperm

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39
Q

Which twins are at highest risk?

A

Monochorionic, monozygotic twins

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40
Q

On US, dichorionic twins = Lambda signs

A

On US, monochorionic twins = T sign

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41
Q

When is a twin pregnancy usually confirmed on USS?

A

12 weeks

Often on a background of large for dates and hyperemesis gravidarum

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42
Q

Risks associated with twin pregnancy

A

Fetal:

  • congenital abnormality
  • prematurity
  • cerebal palsy (6x)
  • growth restriction

Mother:

  • complications e.g. Pre-eclampsia, anaemia
  • Pre-term labour
  • LSCS
  • bleeds
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43
Q

What medications should all mothers with multiple pregnancy be on?

A

1) Fe - high anaemia risk
2) Aspirin - high pre-eclampsia risk
3) Folic acid

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44
Q

When should twins be delivered?

A

Monochorionic dizygotic twins = 36 weeks

Dichorionic dizygotic twins = 37-38 weeks

All triplets and above need a section

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45
Q

What are the risks of pre-existing DM in pregnancy?

A
  • Congenital abnormalities
  • Miscarriage
  • IUD

The above are specific to pre-existing

All (inducing GDM):

  • Macrosomia + shoulder dystocia
  • PE
  • Neonatal hypoglycaemia
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46
Q

When should you screen for GDM?

A

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

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47
Q

When should women with GDM be offered hypoglycaemic agent?

A
  • diet and exercise have not provided sufficient control

- fetal macrosomia on US

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48
Q

When should women with DM be delivered?

A

Pre-gestational:
- 38 weeks onwards

GDM:

  • Insulin = 38
  • Metformin = 39-40
  • Diet = 40-41
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49
Q

Role of progesterone, oestrogen and oxytocin in labour?

A

Progesterone = keeps uterus settled down/ not responding

Oestrogen = makes uterus contract and stimulates prostaglandins

Oxytocin = initiates and sustains contraction - promotes prostaglandin release

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50
Q

Ferguson reflex

A

Name given to the self-sustaining cycle of uterine contractions in response to cerix pressure

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51
Q

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?

A

1-2cm/ hour

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52
Q

When is the 2nd stage prolonged?

A

No epidural = 2 hours (prim), 1 hour (multi)

Epidural = 3 hours (prim), 2 hours (multi)

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53
Q

What is the normal duration of the 3rd stage?

A

Average = 10 min

After 1 hour = removal under GA

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54
Q

What is active management of 3rd stage?

A 
Give oxytocin (10u)
Cord clamping and cutting + controlled cord traction

Used to reduce risk of PPH

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55
Q

Which pelvis is best for delivering a baby?

A

Gynaecoid pelvis

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56
Q

What is the normal fetal position?

A
  • longitudinal lie
  • cephalic presentation
  • occipito-anterior head engagement
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57
Q

What is the mnemonic for the mechanism of labour

A

Every - engagment
Day - descent
Food - flexion
Is - internal rotation
Cheap and Easy - crowning and engagement
Reliable and Exquisite - restitution and external rotation

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58
Q

What is the most common type of placental separation?

A

Matthew Duncan

marginal separation

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59
Q

What is bleeding after birth called?

A

Lochia

Initially red followed but brown and yello
Last 10-14v days after birth

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60
Q

What are usual booking bloods?

A

FBC,UE, LFT, blood group and antibodies
Blood glucose
Hep B, HIV and syphillus, rubella
Screen for thalassaemia/ sickle

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61
Q

Which systems are mainly affected by pre-eclampsia?

A

Kidney - protein
Liver - RUQ pain, LFT, HELLP
Brain/ eyes - visual problems, headache
Placenta - IUGR, death - Must do regular growth scans and Doppler

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62
Q

ACEI and ARB must be stopped in pregnancy. What antihypertensive can you use?

A

1) Labetolol
2) Methyldopa
3) Nifidepine (if dual therapy required)
4) Hydralazine (IV used for severe hypertension)

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63
Q

Target HbA1c for mother with DM?

A

Pre-conception <6% (avoid conceiving if >10%

Keep BM at 4-6

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64
Q

A LSCS is recommended for all patients with DM with an estimated fetal weight of >4kg

A

LSCS if DM and fetal weight >4kg

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65
Q

In terms of clotting factors, why is pregnancy a hyper-coagulable state?

A

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

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66
Q

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?

A

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

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67
Q

How long should LMWH be continued post-nasally?

A

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

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68
Q

In pregnancy, left DVT are 8x as common as left DVT

A

The D-Dimer test is useless in pregnancy as it is already elevated

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69
Q

What features of PE may be visible on a CXR?

A

May be normal

  • atelectasis
  • pleural effusion
  • opacity
  • elevated diaphragm
  • area or infarction
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70
Q

What does a CTPA increase the risk of in pregnancy?

A

Breast cancer

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71
Q

Warfarin is teratogenic in the first trimester and should be avoided throughout pregnancy

A

Warfarin is safe in breastfeeding

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72
Q

What is the risk of a child having epilepsy if the mother is affected?

A

5% if one parent

15-20% if both affected

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73
Q

Which epilepsy drug associated with neural tube defects?

A

Sodium valproate

And carbamazepine

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74
Q

Which epilepsy drug associated with cleft palate?

A

Phenytoin

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75
Q

Which epilepsy drug associated with cardiac defects?

A

Phenytoin and valproate

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76
Q

Carbamazepine is often the drug of choice for epilepsy during pregnancy

A

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

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77
Q

Define bleeding in late pregnancy

A

Bleeding after 24 weeks

Includes APH and PPH

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78
Q

RF for placental abruption - the major cause of APH

A 
Trauma
HT/ PET
Smoking/ cocaine,
DM 
Multiple pregnancy etc
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79
Q

Management of placental abruption

A 
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

80
Q

Where is the lower segment of the uterus?

A

Inferior to the attachment of utero-vesical peritoneal pouch and superior to the pouch of Douglas

81
Q

What is the major risk factor for placenta praevia?

A

Previous C-section

Also associated with high presenting part and malpresentation e.g. breech

CTG is usually normal

82
Q

Management of delivery in placenta praevia

A

Placenta <2cm from os = c-section with consultant present

Vaginal delivery possible if >2cm from os and no malpresentation

83
Q

A uterine rupture is the full thickness opening of the uterus. What are the features?

A

PV bleeding
Severe abdo pain
Shoulder tip pain
Maternal collapse

84
Q

What is vasa praevia?

A

Unprotected fetal vessel cover the membrane over internal os. When the membrane rupture —> sudden bleeding —> fetal death

Mortality is up to 60%

85
Q

Define PPH

A

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

86
Q

What is placenta percreta + accrecta?

A

Percreta = placenta invades through uterus to other organs e.g. bladder

Accrete = placenta invades myometrium

87
Q

What are the 4 T’s of PPH

A

Tone
Trauma
Tissue
Thrombin

88
Q

PPH management

A 
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.

89
Q

Which drug is typically used for epidural anaesthesia in labour?

A

Levobupivacaine +/- opiate

Very effective - T11 - S5

90
Q

What are the main complications of an epidural?

A

Atonic bladder
Hypotension
Rural puncture
Headache

91
Q

What is the smallest fetal skull diameters?

A

Sub-occipito-bregmatic diameter

if head is really well flexed

92
Q

How often should the fetal heart be auscultated in labour?

A

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

93
Q

What 4 things should you document in every CTG?

A

Baseline rate
Variability
Acceleration/ deceleration

—> Normal, suspicious or pathological

94
Q

What do you do if fetal blood sample pH = 7.23?

7.19?

A
  1. 23 = borderline - normal is >7.25 —> repeat in 30 minutes

7. 19 = abnormal —> deliver now

95
Q

What are you feeling for on a PV exam for urinary incontinence?

A

Atrophy
Fistula
Prolapse

Also check anal tone and for masses on PR

96
Q

Anti muscarinic are first line drug therapy for urge incontinence. Give 2 examples

A

Oxybutynin

Tolteridone

97
Q

In over-active bladder, when might desmopressin be useful?

A

If they have nocturnal

98
Q

How might an anterior prolapse present?

A

Anterior = cystoceole

Bladder symptoms, painful sex etc

99
Q

What is middle prolapse?

A

Prolapse of the vaginal vault

100
Q

How might a posterior prolapse present?

A

Rectal prolapse —>

Bulge, Bowery symptoms

101
Q

4 things to ask all patients with a suspected prolapse?

A

Bowel symptoms
Bladder symptoms
Sexual function
Pressure symptoms

102
Q

Prolapse is staged using the POP-Q system which considers relation of structures to the hymen. What are the different stages?s

A 
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
103
Q

Define HT in pregnancy

A

> 140/90 on 2 occasions
160/110 on one occasion
30/15 rise from booking

104
Q

What is the transitional zone of the cervix?

A

Junction between ectocervix (squamous) and endocervix (columnar)

105
Q

HPV 6 + 11 = genital warts

A

HPV 16 +18 = cervical cancer

106
Q

What is the presence of koilocytes characteristic of?

A

Cervical neoplasia

CIN is graded depending on cell differentiation, nuclear abnormalities and excess mitotic activity

107
Q

Difference between CIN 1,2 and 3

A

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

108
Q

What is the commonest type of cervical cancer?

A

SQUAMOUS

> 75%

109
Q

How is cervical cancer staged?

A 
1 = confined to cervix
2 = spread to adjacent structures e.g. vagina
3 = spread to pelvic wall
4 = distant mets or bladder/ bowel
110
Q

What is the most important prognostic factor for vulval squamous cell cancer?

A

Whether it has spread to inguinal lymph nodes
No —> 5 year survival >90%
Yes —> 5 year survival <60%

111
Q

3 inadequate smears =

A

Refer to colposcopy

112
Q

What is the major risk of a transverse lie?

A

Cord prolapse
Remember to try external cephalic version -

C-section if cannot turn

113
Q

When should magnesium’s sulphate be stopped in pre-eclampsia?

A

24 hours after last seizure or delivery of the baby

114
Q

If a lady has a Bisphops score of 4, what is the most appropriate action?

A

Will need vaginal prostaglandins to ripen

A score >5 suggests spontaneous labour likely

115
Q

How do you treat BV and trichomanis vaginalis?

A

Both with oral metronidazole

116
Q

Pregnant lady with fever, tachycardia + neutrophils + uterine tenderness =

A

Always exclude chorioamnionitis

117
Q

First line for a menopausal lady with only vasomotor symptoms?

A

SSRI e.g. fluoxetine

118
Q

Which steroid is used to prevent RDS in the newborn if PROM?

A

Dexamthasone

119
Q

Remember levonelle = long acting (72hours) BUT Ella one (ulipristal acetate) = ultra long 120 hours!

A

Remember levonelle = long acting (72hours) BUT Ella one (ulipristal acetate) = ultra long 120 hours!

120
Q

Pregnant lady with brisk tendon reflexes?

A

Think pre-eclampsia

More specific than other signs e.g. HT and oedema

121
Q

Methyldopa which can be used for BP in pregnancy is contraindicated in depression

A

Methyldopa which can be used for BP in pregnancy is contraindicated in depression

122
Q

What is medical management of a missed miscarriage?

A

Vaginal misoprostol

123
Q

Treatment of a lady with fibroids who wants to conceive

A

Myomectomy

124
Q

What is an early and premature menopause?

A

Early = <45

Premature <40

125
Q

Benefit and risk of HRT

A

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

126
Q

Differential for DUB in a post-menopausal lady

A

Polyps
Hyperplasia - simple or complex
Endometrial cancer

127
Q

What are the 2 main type of endometrial tumour?

A

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

128
Q

An endometrial tumour in a 35 year old lady shows microsatellite instability. What should be excluded?

A

Lynch syndrome - autosomal dominant disease due to defective DNA repair

High risk of bowel, endometrial and ovarian cancer

129
Q

Remember grade is how well differentiated the cells are

A

Stage is how much the cancer has spread e.g. local invasion —> distant mets

130
Q

What is the most common uterine sarcoma?

A

Leiomyosarcoma

Usually has spindle cell morphology

131
Q

What is your differential for a pelvic mass?

A

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
132
Q

What are the different types of fibroids?

A 
Pedunculated
Intramural
Sub-mucosal
Subserosal
Intra-cavity
133
Q

What hormones can ovarian stromal tumours secrete?

A

Granuloma cell —> oestrogen

Theca/ leydig cell —> androgens —> hisutism

134
Q

Remember that ovarian tumours can produce loads of weird things e.g.

Malignant germ cell tumours —> HCG —> false +ve pregnancy test

A

Dermoid cysts can produce thyroid tissue —> thyrotoxicosis

135
Q

Ovarian cancer has early transperitoneal spread

A

Varied presentation so always consider in an older lady

136
Q

What 2 tumour markers and 2 imaging test should you do for suspected ovarian cancer?

A

CA 125 and CEA (to exclude mets from GI primary)

USS and CT (spread)

137
Q

Differential for raised CA125

A

Endometriosis
Pregnancy
Ascites
Pancreatitis

138
Q

What is the risk of malignancy score for ovarian cancer?

A

Menopausal status x CA 125 x ultrasound findings

139
Q

If benign ovarian thing then a laparoscopy is ok

A

If ovarian cancer suspected then need to do a laparotomy

140
Q

What is the main pathological feature of pre-eclampsia?

A

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

141
Q

4 organs mainly affected by pre-eclampsia?

A

Kidneys
Eyes
Liver
Brain

142
Q

A patient with pre-eclampsia develops hyperreflexia. What does this suggest?

A

She is at high risk of seizures

143
Q

What is the cut-off for mild, moderate and severe hypertension in pregnancy?

A 
Mild = >140/90
Mod = >150/100
Severe = >160/110
144
Q

When should baby be delivered in pre-eclampsia?

A

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

145
Q

What are the 3 main congential abnormalities associated with anti-epileptic medications?

A
  • heart defects
  • neural tube defects
  • cleft palate
146
Q

How do we prevent transmission of HIV from mother to fetus?

A
  • HAART in pregnancy
  • C-section
  • no breastfeeding

Risk is <2% (less if viral load unidentifiable)

147
Q

Rubella infection is high risk in the 1st trimester. What are the potential effects on the baby?

A

Sensorineural deafness
Cataracts
CHD
Developmental delay

(no treatment is available if infected so prevention is key)

148
Q

What are the features of congential varicella syndrome?

A

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

149
Q

Pregnant lady develops primary herpes at 35 weeks gestation. What is the best course of action?

A

Deliver by c-section as she has developed primary herpes within 6 weeks of birth

150
Q

Which intra-uterine infection causes intra-cerebral calcification?

A

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

151
Q

Incidence of Down’s syndrome?

A

Depends on mother age
1 in 2500 at 25
1 in 100 at 40

152
Q

Hydrous Fetalis is the main complication and rhesus incompatibility. How does hydrous fetalis present?

A

At birth with fetal ascities, hepatosplenomegaly, pleural and pericardial effusions

153
Q

What are the risks of multiple pregnancy?

A

Maternal:

  • miscarriage
  • symptoms e.g. hyperemesis
  • operative delivery
  • pre-eclampsia
  • GDM

Fetal:

  • pre-term
  • twin to twin transfusion
  • cerebral palsy
  • IUGR
154
Q

Define an IUD

A

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

155
Q

Remember if a pregnant lady presents with vaginal bleeding it is really useful to compare to previous US scans

A

The placenta may have been near/ covering the os (—> placenta praevia) - it may r may not have moved away

156
Q

What is vasa praevia?

A

Fetal blood vessels run across the os —> when membranes rupture torrential bleeding occurs

157
Q

Placenta Accreta = abnormally attached to the uterine muscle (normally there is a fibrous layer between the uterus and placenta)

A

Placenta Increta = placenta Invades through the uterine muscle

Placenta percreta = placenta Pushes through uterus and invades other structures e.g. bladder

158
Q

For Rh -ve women without any sensitising events, anti-D is given at 28 and 34 weeks

A

For Rh -ve women without any sensitising events, anti-D is given at 28 and 34 weeks

159
Q

HCG can be detected in the maternal blood stream up to 8 days after conception. Which cells release it?

A

Syncytiotrophoblast

Main role is to maintain corpus luteum

160
Q

AFP is high in NTD and abdominal wall defects e.g. omphalocoele

A

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

161
Q

How do you distinguish between pre-existing HT, gestational HT and pre-eclampsia?

A

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

162
Q

How do you manage cord prolapse?

A
  • 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
163
Q

When is extra-cephalic version offered for breech?

A

36 weeks if nulliparous

37 weeks if multi-parous

164
Q

Cholestasis of pregnancy = pruritis with raised bilirubin and obstructive LFT

A

Acute fatty liver of pregnancy = non-specific features e.g. abdo pain, NV, jaundice, Hypoglycaemia and very very high ALT

165
Q

What is the management of pre-term prelabour rupture of membranes?

A

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

166
Q

Poor uterine tone is the major cause of PPH. What are the risk factors for low tone?

A

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

167
Q

Placenta Accreta is a big risk factor for retained tissue which can cause PPH

A

Remember that as the placenta has invaded the muscle it is less likely to separate

168
Q

1st line investigation for ANYONE with painless vaginal bleeding

A

US you MUST rule out placenta praevia

169
Q

When is OGTT performed?

A

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

170
Q

How is GDM managed?

A

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

171
Q

Remember that a breech pregnancy is a risk factor for cord prolapse

A

Remember that a breech pregnancy is a risk factor for cord prolapse

172
Q

Baseline HR on CTG?

A

110-160

Also the variability should be at least 5 bpm

173
Q

What are the indications for induction of labour?

A
  • post-maturity
  • pre-eclampsia
  • suspected IUGR
  • PROM
  • IUD
174
Q

Lady is 41+4 and is wanting to discuss induction of labour. How is labour induced?

A
  • membrane sweep
  • use of prostaglandins e.g. vaginal pessary
  • if induction fails then options are repeat induction with prostaglandins or consider LSCS
175
Q

What are the 4 degrees of perineal trauma?

A

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

176
Q

Always remember that suicide is a leading cause of maternal mortality

A

Suicide is a leading cause of maternal mortality

177
Q

In hyperemesis gravidarum the level of hCG is related to severity

A

Explains why twins and molar pregnancy have higher rates

178
Q

Other than dehydration, what 2 complications are associated with hyperemesis gravidarum?

A

1) Thyrotoxicosis - hCG and TSH have similar sub-units so can act similarly
2) Wernicke’s encephalopathy - B1 deficiency

179
Q

Medical management of miscarriage = misoprostol

A

Surgical management = evacuation of retained products (manual vacuum aspiration or in theatre)

180
Q

List a few risk factors for an ectopic?

A
  • previous PID
  • previous ectopic
  • IUD
  • assisted reproduction

(after 1 ectopic the risk increases to around 15% —> early US scan is recommended in future)

181
Q

Babies heart beat is usually detected around 6-7 weeks

A

Gender at 20 weeks and baby movements at around 20 weeks (often earlier if this is not first pregnancy

182
Q

Frequency of smear tests in scotland

A

Every 3 years from age 25

Every 5 years from 50-64

183
Q

What to do if smear results show ‘inadequate smear’

A

Repeat in 3 months

184
Q

Mild dyskariosis = test for HPV
+ve = colposcopy
-ve = return to normal screening

A

Moderate/ severe dyskariosis = colposcopy

185
Q

The vast majority of endometrial cancers are adenocarcinoma. What are the risk factors?

A
  • obesity
  • alcohol
  • HRT
  • early menarche, late menopause
  • Tamoxifen
  • genetics e.g. Lynch syndrome
186
Q

In molar pregnancy, hCG levels are used to monitor disease - should fall gradually

A

If high levels persist —> need chemotherapy

Molar pregnancies are twice as common in Asian women compared with Caucasian

187
Q

Mild PID can be treated as an outpatient with:

Ofloxacin and Metronidazole for 14 days

A

Moderate/ severe PID is treated as an inpatient with:

IV ceftriaxone, PO doxycycline and IV metronidazole

188
Q

Don’t forget to do TFT when discussing menorrrhagia

A

Don’t forget to do TFT when discussing menorrrhagia

189
Q

Define primary amenorrhoea

A
  • 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
190
Q

What are the side effects of a surgical evacuation of the products of conception e.g. after a miscarriage?

A
  • 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
191
Q

Pregnant people with previous VTE =

A

High risk

Need LMWH throughout pregnancy and 6 weeks post partum

192
Q

Patients with 4 or more VTE risk factors e.g. 36 y/o with BMI>30 who smokes and is having twins =

A

LWMH from 1st trimester and at least 10 days post-partum

193
Q

Patients with 3 risk factors for VTE e.g. 36 year old smoker having twins =

A

Thromboprophylaxis from 28 weeks and at least 10 days post-partum

194
Q

How is GDM diagnosed?

A

Fasting glucose >5.6mmol/L
OR random >7.8

The test is with a 75g 2 hour OGTT

195
Q

Tone is the major cause of PPH. What are the risk factors?

A 
Multiple pregnancy
Fetal macrosoma
Previous PPH
Prolonged 3rd stage 
GA
196
Q

PPH = loss of >500ml go blood from genital tract within 24 hours of birth of baby

A 
Minor = 500-1000
Major = 1000 + or shock

Ob/gyn (4 decks)

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