Obstetrics

Question 0

How is polyhydramnios diagnosed?

Answer 0

Increased fundal height, >2L of amniotic fluid, single vertical pocket >10cm, AFI >25cm or >95th centile

Question 1

Name 4 causes of oligohydramnios

Answer 1

Premature rupture of membranes, congenital renal, cardiac and neural tube abnormalities, exposure to ACE inhibitors, uteroplacental insufficiency, congenital infection, NSAIDs, TTTS

Question 3

Name 5 causes of polyhydramnios

Answer 3

Isoimmunisation (leading to immune hydrops fetalis), DM, hydrops fetalis, multigestation, fetal diabetes insipidus, defects of fetal swallowing - GI obstruction, achalasia, CNS abnormalities, placental chorioangioma

Question 4

What are the risks of diabetes in pregnancy?

Answer 4

Miscarriage, stillbirth, congenital abnormalities, macrosomia, birth trauma, neonatal hypoglycaemia, long-term health problems for child (metabolic syndrome, obesity)

Question 5

What are the risk factors for gestational diabetes?

Answer 5

BMI >30, PMH of gestational diabetes, >25 years old, FH diabetes, non-caucasian, previous stillbirth or delivery of large baby

Question 6

How is diabetes managed in pregnancy?

Answer 6

Aim for glucose: before 12 weeks - f <8. Be aware that DKA is more rapid in pregnancy. Monitor diabetic complications, may worsen in pregnancy. Monitor fetal growth and AFI, monitor for pre-eclampsia. Use sliding scale during labour with 5% glucose

Question 7

Give diagnostic values for pre-eclampsia

Answer 7

Diastolic BP >/= 110 or 90 taken twice 4 hours apart,
with
Proteinuria: 24hr urinary protein >/= 300mg, or 2 MSU taken 4 hours apart with >/= 2+ protein

Question 8

What are the risk factors for pre-eclampsia?

Answer 8

DM, Anti-phospholipid syndrome, PMH pre-eclampsia, multiple pregnancy, nulliparous, FH, increased BMI, >40 years, diastolic BP >80, teenage mother, donor insemination

Question 9

How is pre-eclampsia managed?

Answer 9

Uterine artery Doppler - poor placental perfusion, low-dose aspirin, calcium, vitamin C and E, antenatal corticosteroids, treat only if severe! - >170/110, MAP >125 - hydralazine, labetalol

Question 10

What are the complications of pre-eclampsia?

Answer 10

Placental insufficiency - IUGR, abruption, eclampsia (seizures - give diazepam or magnesium sulphate), pulmonary oedema, renal failure (due to low BP after PPH), premature labour (often induced), HELLP, DIC, neurological complications (ICH, clonus), platelet consumption, hypoalbuminaemia

Question 11

What are symptoms related to pre-eclampsia?

Answer 11

Headaches, visual disturbance, nausea, vomiting, epigastric pain, SOB (pulmonary oedema)

Question 12

Give 3 complications of oligohydramnios

Answer 12

Amniotic band syndrome - serious deformities e.g. limb amputation, chorioamnionitis, fetal infection, preterm labour, uterine compression - MSK deformities

Question 13

What are the features of primary dysmenorrhoea?

Answer 13

Begins with onset of ovulation (6m-2yr after menarche), FH, early menarche, associated N/V/D/dizziness, improves after first child, pain is lower abdominal/pelvic radiating to anterior thigh, only occurs in ovulatory cycles

Question 14

What is primary dysmenorrhoea and what is its pathophysiology?

Answer 14

Painful menstruation in the absence of any significant pelvic pathology - caused by excessive myometrial contractions leading to uterine ischaemia in response to local release of prostaglandins from endometrium

Question 15

What is the management of primary dysmenorrhoea?

Answer 15

Explanation and reassurance, diet - vitamin B1 supplements, avoid smoking, take up exercise, heat pack on lower abdomen, NSAIDs (inhibit prostaglandin synthesis e.g. ibuprofen, naproxen, mefenamic acid, aspirin), if do not respond in 3 cycles - COCP (suppress ovulation and reduce prostaglandin synthesis), can also use progestogen only methods

Question 16

What is endometriosis?

Answer 16

Extrauterine endometrial like tissue often surrounded by inflammation.

Question 17

Where do deposits occur in endometriosis?

Answer 17

Ovaries (over surface or as endometrioma - may rupture), uterosacral ligament, rectovaginal septum, pelvic peritoneum (uterus, tubes, rectum, colon, bladder), lap scars, umbilicus

Question 18

How could you investigate secondary dysmenorrhoea?

Answer 18

Pelvic exam, cervical smear, swabs for infection/STI screen, TVUS or pelvic US, diagnostic laparoscopy

Question 19

What is the management of endometriosis?

Answer 19

Medical - suppress ovulation (oral progestogens or other progestogen) - also danazol, GnRH agonists, aromatase inhibitors
Surgical - excision of visible lesions

Question 20

How can endometriosis present?

Answer 20

Pelvic pain, infertility, severe dysmenorrhoea, dyspareunia, dysuria, dyschezia (difficulty defecating) - severe dysmenorrhoea in adolescence

Question 21

What are the features of pain in secondary dysmenorrhoea?

Answer 21

Pain often precedes start of period and may last throughout, heavy, dragging pain, may radiate to back, loins and legs

Question 22

What are the causes of secondary dysmenorrhoea?

Answer 22

Endometriosis, fibroids, adenomyosis, pelvic infections, adhesions, developmental anomalies

Question 23

What are the different types of fibroids?

Answer 23

Intramural (in myometrium, most common), subserosal (serosal surface, outer, extend outwards, deform uterus - can be pedunculated), submucosal (inner surface of endometrium, extend into cavity, distort or fill, can be pedunculated)

Question 24

What is red degeneration?

Answer 24

Haemorrhage into leiomyoma associated with pregnancy - fever, pain, vomiting, usually in mid-trimester, possibly caused by rapid growth and outgrowth of blood supply

Question 25

What is the epidemiology of fibroids?

Answer 25

More common in afro-caribbean, overweight, nulliparous, PCOS, DM, hypertension, FH
Pregnancy - enlargement
Menopause - involution

Question 26

What are the symptoms of fibroids?

Answer 26

50% asymptomatic, abnormal uterine bleeding (SM and IM), pain (ass with heavy menstrual bleeding), acute pain (torsion, prolapse of SM through cervix, red degeneration), pressure (on bladder, rectum), pregnancy complications (recurrent miscarriage SM, red degen, obstruct labour, increased PPH, increase preterm and perinatal morbidity), infertility (SM and IM)

Question 27

How can fibroids be managed?

Answer 27

Reduce size using GnRH analogues or mifepristone, uterine artery embolization, surgical (hysterectomy, removal, myomectomy, endoscopic resection of SM)

Question 28

What is adenomyosis?

Answer 28

Invasion of endometrial glands and stroma into myometrium with surrounding smooth muscle hyperplasia

Question 29

How does adenomyosis present and how is it managed?

Answer 29

Typicall in parous women, 40s, heavy menstrual bleeding and dysmenorrhoea of increasing severity, symmetrically enlarged and tender uterus (boggy), regresses after menopause
Diagnose with TVUS, MRI
Treatment - IUS, prostaglandin synthetase inhibitors (indomethacin), UAE, hysterectomy