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Obstetrics Flashcards

1
Q

Clinical features of an ectopic pregnancy

A 
Pain- pelvic or lower abdominal classically, can be referred to shoulder tip 
\+/- 
Vaginal bleeding
Vaginal discharge- brown 'prune juice'
History of amenorrhoea 
Haemodynamically unstable 
Signs of peritonitis
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2
Q

Differentials of an ectopic pregnancy

A 
Miscarriage
Ovarian cyst accident- torsion, cyst haemorrhage or rupture 
Acute PID
UTI
Appendicitis 
Diverticulitis
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3
Q

Investigations for ectopic pregnancy

HINT: When should a laparoscopy be offered?

A

Pregnancy test for urinary beta HCG
+ then transvaginal USS
MRI second line

If pregnancy of unknown origin (cannot be identified on USS) then 48 hours later beta HCG
Should double if early intrauterine
Half if miscarriage
>1500 then ectopic until proven otherwise- diagnostic laparoscopy

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4
Q

Management of an ectopic pregnancy

A

If haemodynamically unstable then (haemorrhage protocol), ABCDE

Expectant/ conservative- PUL, stable, minimal or no symptoms

Medical- IM methotrexate (offered first line), monitor beta HCG levels (<1500), unruptured ectopic with a small adnexal mass

Surgical- laparoscopic salpingectomy (if no contralateral tubal damage), significant pain, mass >35mm, fetal heartbeat on USS, serum HCG >5000
Anti-D immunoglobulin

Follow up to see serum HCG decreasing at acceptable rate

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5
Q

`Up to what age is an early medical abortion (EMA)? Where can this be done?

A

10/40
Home or clinic
After this until 12 weeks the medical abortion must be done in a clinic

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6
Q

Medical abortion management up to 12/40

A

Mifepristone- anti-progesterone orally

Vaginal misoprostol- prostaglandin analogue to cause uterine contraction to expel

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7
Q

What to expect from an EMA

A 
Dizziness
Flushing 
Diarrhoea 
Nausea
Period like cramping
Vaginal bleeding, may be heavy with clots up to 2/52
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8
Q

Medical abortion management 12/40+

A

Inpatient stay
Mifepristone followed by 3 hourly misoprostol
Feticide recommended in late second trimester- digoxin or potassium chloride

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9
Q

Surgical abortion options

A

Vacuum aspiration up to 14/40

Dilation and evacuation 14/40+ (with forceps as well as the vacuum aspiration)

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10
Q

Differentials for continued bleeding after medical or surgical abortion

A

Retained products of conception- persistent pain and/or bleeding
Infection- endometritis
Contraception
Failure of procedure- uterine perforation

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11
Q

Signs of endometritis

A 
Pain
Bleeding
Deep dyspareunia 
Vaginal discharge
Fever
Cervical motion tenderness
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12
Q

Management of endometritis

A

Sepsis 6 if systemically unwell
(H) ABCDE if haemodynamically unstable
Broad spectrum antibiotics
Empty uterus if indicated

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13
Q

Signs of tubal rupture and intra-abdominal bleeding

A 
Pallor
Tachycardia
Hypotension
Shock or collapse 
Shoulder tip pain (from diaphragmatic irritation due to intraperitoneal blood)
Vomiting and diarrhoea
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14
Q

What should ALWAYS be checking in a bleeding obstetric history?

A

Rhesus status

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15
Q

Vaginal bleeding and slight abdominal discomfort 30/40 pregnant differentials

A 
Placenta praevia 
Placental abruption
Endometritis 
Haemorrhage 
Trauma
Vasa praevia 
Early labour
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16
Q

Vaginal bleeding and slight abdominal discomfort 30/40

Investigations

A

History
General examination for signs of haemodynamic compromise
Urine dip
FBC, LFTs, U&Es
Transabdominal ultrasound- looking for placenta
CTG- Fetal heart rate and situation
Speculum examination- trying to localise the cause of bleeding

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17
Q

Factors associated with recurrent miscarriages

A 
Antiphospholipid syndrome
DM and thyroid disease
PCOS 
Anatomical malformations- uterine or cervical, fibroids, Asherman's syndrome 
Infection 
Lifestyle
Advancing maternal age
Inherited thrombophilia- factor V leiden
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18
Q

Investigating recurrent miscarriage

A

Blood tests- antiphospholipid antibodies (anticardiolipin, lupus anticoagulant and glycoprotein B2)
Karotyping
Imaging- pelvic USS

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19
Q

Clinical features of placental abruption

A

Painful vaginal bleeding (may not be visible if concealed)
Woody hard uterus and may be pain on palpation
May be haemodynamically unstable

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20
Q

Triad of vasa praevia

A

Vaginal bleeding
Rupture of membranes
Fetal compromise (rapid deterioration due to loss of fetal blood from the umbilical cord vessels)

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21
Q

Investigations for placental abruption

A

FBC, clotting profile
Kleihauer test- to determine amount of anti-D required
Group and save- if unknown
Cross match
U&Es, LFTs- HELLP
Ultrasound scan- poor negative predictive value though

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22
Q

Management of placental abruption

A

Conservative- marginal abruption no compromise
Induction of labour
Emergency delivery if mother or fetal compromise- C/section
ANTI-D within 72 if rhesus negative

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23
Q

Clinical features of placenta praevia

A

Classically painless vaginal bleeding

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24
Q

Useful questions to ask regarding antepartum haemorrhage

A 
How much bleeding and timescale (how many pads)
Details of the blood
Could the waters have broken
Provoked or not
Abdo pain
Fetal movements normal
Risk factors for abruption
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25
Differentials for antepartum haemorrhage
Placental abruption Placenta praevia Vasa previa Uterine rupture Local genital causes- polyps, carcinoma, ectropion Traumatic Infections- candida, bacterial vaginosis, chlamydia
26
Placenta praevia management
Minor or major USS scans at 36 and 32 weeks respectively Planned C-section at 38 weeks ABCDE if significant haemorrhage Give anti-D within 72 hours of onset of bleeding if rhesus negative
27
High risk factors for pre-eclampsia
Chronic HTN previous pregnancy HTN, pre or eclampsia CKD DM Autoimmune diseases- SLE, antiphospholipid syndrome
28
Prophylaxis for pre-eclampsia
75mg daily aspirin if 1 high risk factor or 2 moderate risk factors From 12 weeks
29
Clinical features of pre-eclampsia | Including criteria
HTN on two occasions Significant proteinuria In a women >20 weeks pregnant Headaches, blurred vision, halos, photopsia, epigastric pain, sudden onset oedema, hyperreflexia
30
Complications of pre-eclampsia
``` HELLP syndrome Eclampsia DIC AKI ARDS HTN post-partum Cerebrovascular haemorrhage Death ``` Fetal- growth restriction, placental abruption, death
31
Pregnancy induced hypertension
New onset after 20 weeks gestation
32
Management of pre-eclampsia
Monitoring of maternal and fetal wellbeing- regular blood pressure check, urinalysis, blood tests, fetal growth scans and cardiotocography Venous thromboembolism prevention- low molecular weight heparin Antihypertensives- labetalol (1) or nifedipine (2) or methyldopa Delivery- the definitive cure Monitor mother until 24 hours post-partum
33
To diagnose hyperemesis gravidarum
More than 5% pre-pregnancy weight loss Dehydration Electrolyte imbalances
34
Management of hyperemesis gravidarum
Mild- community, oral antiemetics, oral hydration, dietary advice, reassurance Moderate- ambulatory daycare- IV fluids, parenteral antiemetics and thiamine Severe- inpatient care
35
Fetal complications of gestational diabetes
``` Macrosomia Organomegaly Erythropoiesis Polyhydramnios Increased rates of pre-term delivery ```
36
Gestational diabetes plasma glucose tests
Fasting >5.6mmol/L | 2hr post-prandial >7.8mmol/L
37
Management of gestational diabetes
Patient education and careful monitoring and control of BM Consultant lead care Metformin (1) Sulphonylurea (2) Insulin if fasting glucose >7.0mmol/L at diagnosis Aim to deliver 37-38 weeks
38
What is the definition of a major PPH?
>1000ml of blood loss within 24 hours of delivery
39
Causes of primary post-partum haemorrhage
Tone- uterine atony- inadequate contraction Tissue- retention, preventing uterine contraction Trauma- vaginal or cervical tears- instrumental, episiotomy, C-section Thrombin- vascular abnormalities (abruption, HTN, pre-eclampsia) or coagulopathies (von Willebrand's disease, haemophilia, ITP, DIC, HELLP)
40
Clinical features of PPH
PV bleeding May be signs of hypovolaemia May be signs of local trauma
41
Management of PPH | HINT: TRIM
Teamwork ``` Resuscitation- ABCDE Protect airway 15L of 100% via non-rebreathe Cap refill, HR, BP and ECG monitoring, two large 14G cannulas, give cross matched blood, up to 2L of warmed crystalloid and 1-2L of warmed colloids until blood available Monitor GCS Expose to identify bleeding sources ``` Investigations and monitoring- every 15 mins, consider catheter and central line insertion Measures to arrest bleeding Atony- Bimanual compression, pharmacological management, surgical intrauterine balloon tamponade Hysterectomy always last resort Repair of any trauma Administration of oxytocin to remove placenta, or manual removal Correction of coagulation abnormalities with haematology team advice
42
Obstetric history
``` Previous obstetric history - gestation period - mode of delivery - gender - birth weight - complications (any assistance required) - who was involved in the care - miscarriages/ terminations/ gestation periods of these/ ectopics GRAVIDITY and PARITY ``` ``` Current pregnancy Gestational age and EDD Use of folate Singleton or multiple Any screening- any fetal anomalies Placenta position Amniotic fluid index ```
43
Gynaecological history
PC- type and site of symptoms, timing (cyclical, continuous/intermittent), exacerbating and relieving factors, previous episodes + treatment, other symptoms PV bleeding- intermenstrual, post-coital, post-menopausal SOCRATES Vaginal discharge- colour, consistency, amount, smell Menstrual history- frequency, duration, volume Other symptoms- dyspareunia, vulval itching, skin changes, infertility- assisted conception, investigations PMH- pregnancies, deliveries, complications Cervical smear Surgical history Previous gynae problems or STIs DH- allergies, contraception, HRT, recent abx, any other (recreational or OTC) FH- Breast/ cervical/ ovarian/ endometrial cancer DM, bleeding disorders
44
Causes of post-coital bleeding
Cervical ectropion Infection Vaginitis Malignancy
45
Causes of intermenstrual bleeding
``` Infection Malignancy Fibroids Endometriosis Pregnancy Hormonal contraception ```
46
Causes of post-menopausal bleeding
Malignancy Vaginal atropy HRT use
47
Clinical features of uterine fibroids
``` Majority asymptomatic Pressure symptoms +/- abdo distension- constipation, urinary retention Menorrhagia Subfertility Red degeneration- acute pelvic pain ```
48
Investigations for uterine fibroids
Routine bloods if unclear what the diagnosis is | Pelvic ultrasound
49
Management of uterine fibroids
Medical- tranexamic or mefenamic acid Hormonal contraception to control menorrhagia- COCP, POP and Mirena IUS GnRH analogues, progesterone receptor modulators Surgical- hysteroscopy and transcervical resection of fibroid Myomectomy- to preserve uterus Uterine artery embolisation Last resort hysterectomy
50
Clinical features of endometriosis
Cyclical pelvic pain Dysmenorrhoea, dyspareunia, dysuria, subfertility O/E, general tenderness, may be nodularity
51
Differentials of endometriosis
PID Ectopic pregnancy Fibroids IBS
52
Investigating endometriosis
Pelvic USS | Gold standard is laparoscopy- chocolate cysts, adhesions, peritoneal deposits
53
Management of endometriosis
Pain- NSAIDs Medical- Ovulation suppression for 6 months can cause atrophy of the lesions- COCP, progesterone agonist or Mirena coil Surgical- excision, fulgaration (destruction with diathermy), laser ablation
54
Risk factors for endometrial cancer
``` Early menarche/ late menopause Low parity PCOS- due to oligomenorrhoea HRT with oestrogen alone Tamoxifen use Increasing age Obesity Hereditary factors that predispose to cancer- Lynch syndrome ```
55
Clinical features of endometrial cancer
Post-menopausal bleeding - 75-90% present like this Clear or white vaginal discharge Abdo pain or weight loss if advanced
56
Investigations for endometrial cancer
Transvaginal ultrasound if >4mm then endometrial biopsy If high risk case then hysteroscopy with biopsy FIGO staging
57
Management of endometrial cancer
MDT and supportive therapy Stage dependent Hysterectomy and bilateral salpingo-oophorectomy even at stage 1, any larger and radical with radiotherapy and chemotherapy Hyperplasia or atypia may precede malignancy and should be treated and surveyed
58
Causes of heavy menstrual bleeding
``` Polyp Adenomyosis Leiomyoma (fibroids) Malignancy and hyperplasia Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not classified ```
59
Investigating heavy menstrual bleeding
FBC, TFT, other hormones if suspicious (prolactin) Coag screen and test for von Willebrand's disease USS pelvis- transvaginal Smear up to date High vaginal and endocervical swabs for infection Pipelle endometrial biopsy If pathology identified or inconclusive- hysteroscopy and endometrial biopsy
60
Management of heavy menstrual bleeding
Mirena coil if contraception needed Tranexamic acid or mefenamic acid if not COCP or POP Surgical- endometrial ablation or hysterectomy
61
Two most common hormonal abnormalities in PCOS
Excess luteinising hormone- generating too many androgens | Insulin resistance
62
Clinical features of PCOS
``` Oligomenorrhoea or amenorrhoea Infertility Hirsutism/ acne/ acanthosis nigricans/ male pattern baldness Obesity Chronic pelvic pain Depression ```
63
Differentials for PCOS
Hypothyroidism Hyperprolactinaemia Cushing's disease
64
Investigating PCOS
Blood tests- raised testosterone, raised LH, normal FSH, low progesterone, TFTs, serum prolactin, oral glucose tolerance test Imaging- pelvic USS- transvaginal
65
Managing PCOS
Weight management through lifestyle changes Induction of bleeds through COCP use to protect the endometrium from hyperplasia Infertility- clomifene +/- metformin Anti-androgen medication- spironolactone can lower levels

ISCE prep (6 decks)

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