Obstetrics and gynae Flashcards
1
Q
when is a pregnancy considered full term
A
37-40 weeks
2
Q
differnetials to post menopausal bleeding
A
- atrophic vaginitis
- endometrial polyp, hyperplasia or cancer
- cervical polyps or cancer
3
Q
risk facors for endometrial cancer
A
- unopposed oestrogen (HRT)
- early menarche, late menopause
- nulliparity
- obesity
- PCOS
- tamoxifen
- FH (Lynch, HNPCC)
4
Q
symptoms of endometrial cancer
A
- postmenopausal bleeding
- premenopausal change in intermenstrual bleeding
5
Q
investigations for endometrial cancer
A
- women > 55 with PMB: 2WW
- transvaginal ultrasound (normal thickness <4mm)
- hysterectomy and endometrial biopsy
6
Q
management of endometrial cancer
A
- localised disease: total abdominal hysterectomy with bilateral salpingo-oopherectomy (+ maybe post operative radiotherapy)
- progesterone if women frail and not suitable for surgery
7
Q
def parity
A
nb of times pregnant beyond 24 weeks
8
Q
def gravidity
A
nb of times women pregnant (including miscarriages and abortions)
9
Q
how do you write the nb of pregnancies (including abortions/miscarriages)
A
Para x + y
x: parity
y: gravity
10
Q
Trimester dates
A
T1: up to w12
T2: w13-w28
T3: w29-w40
11
Q
beta HCG (curve of production and function)
A
- detectable 24-48h after implantation, peaks at 3 months
- produced by placenta to keep corpeus luteum alive (to produce oestrogen and progesterone)
12
Q
progesterone if pregnancy (curve of production and function)
A
- continuously rising throughuot pregnancy, drops just before birth (produced by CL first then placenta)
- function: smooth muscle relaxant, maintains uterine lining, strengthens cervical mucus, stimulates growth of breast tissue
13
Q
oestrogen during pregnancy (curve of production and function)
A
- continuously rises throughout pregnancy, drops just before birth (produced by CL and the placenta)
- function: increases nb of oxytocin receptors in uterus , increases uterine blood flow, stimulates breast tissue
14
Q
changes to resp system during pregnancy
A
- increase in intraabdominal pressuer leading to more of a diaphragmatic breathing
- relative hyperventilation
- increase tidal volume
15
Q
changes to cardiovascular system during pregnancy
A
- increase in CO
- drop in BP in T1 and T2
- heart and valves displaced to the right
16
Q
changes to haematological system during pregnancy
A
- increase in plasma volume (oedema and anaemia (disproportionate increase in plasma volume over red blood cell volume)
- reeduced platelets (does not increase bleeding risk)
- hypercoaguability
- immunodeficient (protective to fetus)
17
Q
changes to MSK system during pregnancy
A
- increase in BMI
- lower back pain
- lordosis
- carpal tunnel syndrome
- siatica
- muscle cramps
18
Q
endocrine changes during pregnancy
A
- bHCG, oestrogen, progesterone, placental lactogen and GH
- hypertophy of ant pituitary gland
- increase in thyroid hormones
- increase in aldosterone and renin
- increase in relaxin (to loosen pelvis)
19
Q
dermatological changes during pregnancy
A
- increase in skin pigmentation
- distention and proliferation of blood vessels
- spider angiomata, facial flusing and striae gravidarum
20
Q
gynaecological changes during pregnancy
A
- breast enlargement
- areolar pigmentation
- uteric hypertrophy and stretching
- cervical gland hypertrophy (softening of cervix + mucus plug)
- vagina lactobacilli proliferation: increase in lactic acid, decrease in pH
21
Q
breast changes during pregnancy
A
oestrogen
- increase adipose tissue
- increase lactiferous duct system
progesterone:
- breast lobule enlargement
- milk production
22
Q
change to urological system during pregnancy
A
- renal blood flow increased (increase eGFR and kidney size)
- increase chance of UTI (uteric stretching + decrease in uteric motility)
23
Q
change to GI system during pregnancy
A
- oesophageal relaxation (GORD)
- increase intraabdominal pressure (haemorhoids)
- reduced bowel motions
24
Q
planning pregnancy management
A
LIFESTYLE
- folic acid 400 micrograms for 12/52 before pregnancy (or 5mg if diabetes, FH neuraal tube defects or on antiepileptic meds)
- vit D
- smoking: stop
- alcohol
- weight: BMI <25/30
PMH
- optimise health conditions: diabetes, epilepsy, cardiac, resp & GI disease, coeliac disease, psychiatry disorders
- seek pre- pregnancy counselling
VACCINATION
- flu
- MMR
- whooping
25
how do you calculate date of birth
- take first day of last period, add 1 year and substract 3 months then add 7 days
- ultrasound
26
ilpact of overweight on baby
- high BP
- blood clots
- miscarriage
- gestational diabetes
27
affect of smoking on baby
- time of birth
- weight of baby
- miscarriage
- sudden infant death syndrome
- breathing problems in first 6/12 of life
28
risk factors for high risk pregnancy
- age <20, >40
- ethnicity
- PMH
- previous surgery
- IVF treatment
- previous C section
- previous pb in pregnancy (hypertension FGR, fetal abnormalities, premature labour, APH/PPH, preeclampsia, thrombocytopaenia, 3rd/4th degree tear, previous stillbirth, late miscarriage or noeonatal death)
- FH
- SH (domestic abuse, homelessness, addition, financial support)
29
what needs to be assessed at each antenatal visit
- BP
- urine
- symphysiofundal height
- fetal movements
30
how do you assess for gestational age on USS
crown rump length
| if > 84mm: use head circumference
31
timeline antenatal care for normal pregancy
- first contact: planning pregnancy
- 8 weeks: booking appointment
- 10+0 - 13+6: dating USS and nuchal fold measurement
- 16w: appointment for discussion
- 18+0 to 20+6: USS for fetal abnormalities/anatomy
- 25 weeks: routine appointment for nulliparous
- 26-28 weeks: glucose tolerance test
- 28 weeks: antiD (if at risk)
- 31w: appointment for nulliparous
- 34w: 2nd dose antiD
- routine appointments at 36, 38 and 40w
- 41w: induction
32
what is done at a booking appointment
- Hx taking
- discussion about: dvlpt of baby, nutrition and diet, exercise, place of birth, pregnancy care pathway, breastfeeding, screening, mental health
- bloods: Hb, platelets, infection (HIV, hep B, syphylis), blood group and ab status
33
screening in normal pregnancy
- infections (HIV, heep B, syphilis)
- sickle cell and thalassaemia (if high risk)
- down syndrome: nuchal translucency, PAPP-A, HCG
- gestational diabetes at 28 weeks
- pre eclampsia from
- placenta praevia
- bloods to check for anaemia, clotting etc
34
hormones prodcued by placenta to regulate insulin
human placental lactogen: increase insulin resistance
| - human chorionic somatommatrophin: increase production of insulin
35
pathophysiology of gestational diabetes
- increase insulin resistance
- reduced glucose tolerance
- reduced renal tubular threshold for glucose
36
risk factors for GDM
- BMI > 30
- previous macrosomic baby > 4.5kg
- previous GDM
- FH of diabetes
- ethnicity
- PCOS
37
screening for GDM
- at 24-28 weeks (12-16 weeks if previous GDM)
- 2h 75g glucose tolerance test
- diagnostic criteria:
fasting glucose levels > 5.6 mmol/L
2h blood glucose levels >7.8 mmol/L
38
treatment of GDM
- diet and excercise
- metformin
- insulin
- monitoring before and after each meal
39
birth plan for GDM
offer delivery at 40+6 weeks
40
complications of GDM
- more likely to develop diabetes later (mother)
| - same as diabetes in pregnancy (for baby)
41
pb of diabetes in pregnancy for baby
- glucose crosses placenta
- from w10, fetus produces insulin; increase fetal growth: macrosomia, polyhydramniosis, organomegaly, chronic fetal hypocia, shoulder dystocia, intrauterine fetal death, hypoglycaemia at birth, defects (cardiac, neural tube and renal abnormalities)
42
effect of pregnancy on diabetes
- insulin requirements increase during T2 and T3
- tight glycaemic control may worsen diabetic retinopathy
- increased hypoglycaemic attacks
43
effects of diabetes on pregnancy
- increased incidence of preeclampsia
- UTI
- miscarriage
- worsening renal disease
- increase C section
44
management of diabetes in pregnancy
- measure blood glucose fasting, pre and post meals and bedtime
- metformin or insulin
- aspirin 75mg (before 12/40 to educe risk of preeclampsia)
45
target blood glucose levels during pregnancy for women with diabetes
- fasting < 5.3
| - 1h post meal: < 7.8
46
timeline of antenatal appointments for diabetic pregnancy
- booking appointment 10w
- USS 7-9 weeks
- 16w: retinal assessment (if retinopathy persent)
- 20w: USS fetal abnormalities
- 28w: USS fetal growth and liquor volume + retinal assessment (+ those with GDM enter pathway) and antiD
- 31w: routine invest (nulliparous)
- 32w: USS fetal growth and liquor volume
- 34w: antiD
- 36w:: USS fetal growth and liquor volume + info about delivery
- 37+0 - 38+6: offer induction/C section
- 38 and 39 weeks: offer test of fetal wellbeing
47
how many appointments should a nulliparous women with normal pregancy have
10
48
how many appointments should a parous women with normal pregancy have
7
49
how often should anomaly scan be done for women with diabetes
from 20 weeks, every 4 weeks
50
birth plan for pregnancy with diabetes
- delivery should be at 38w
- offer LSCS or IOL (esp if macrosomia), give steroids if before 39 weeks
- if T1DM: insulin dextrose sliding scle during labour
- first feed should be within 30mins and fetal blood sugars check every 2-4h
51
which medications should be avoided during pregnancy
- ACEi/ARB
- statins
- glibenclamide
- diuretics
- warfarin
- epileptic drugs: phenobarbitone, phenytoin, sodium valproate
- sex hormones, radioactive iodine
- methotrexate, cyclosphamide, NSAIDs
- trimethroprim (in T1) and nitrofurantoin (at term)
52
which meds are commonly used during pregnancy for the following
- diabetes, hypertension, clotting disorder, epilepsy, endocrine, inflammatory conditions, UTI, antiemetics
- diabetes: metformin, insulin
- hypertension: labetalol, nifedipine, methyldopa
- clotting: LMWH
- epilepsy: lamotrigine
- endocrine: carbimazole, propylthiouracil (only in T1)
- inflam: sulfazalazine, mesalazine, prednisolone
- UTI: nitrofurantoin
- antiemetics: cyclizine
53
hypertensive disorders in pregnancy
- chronic hypertension
| - pregnancy induced hypertension /gestational hypertension
54
def pre-eclampsia
hypertension edveloping after 20 weeks gestation with 1+ of following:
- proteinuria
- maternal organ dysfunction (renal insufficiency, liver involvement, neurological, haematological
- fetal growth restriction
55
what are the maternal organ dysfunction in pre-eclampsia
- renal insufficiency: creatinine <90
- liver: elevated transaminase, RUQ or epigastric pain
- neuro: altered mental status, blindness, stroke, hyperreflexia, severe headache
- haematological: thrombocytopaenia, DIC, haemolysis
56
def eclampsia
Neurological involvement (generalised tonic clonic convulsiuons) in women with pre-eclampsia
57
BP curve during pregancy
- T1: normal
- T2: decreases
- T3: increases back to normal
58
def pregnancy induced hypertension
hypertension ( >140/90) in second half of pregnancy in absence of proteinuria or other markers of pre-eclampsia
59
treatment of hypertension in pregnancy
nifedipine and labetalol
60
risk factors for pre-eclampsia
- first pregnancy
- FH
- extremes of age
- obesity
- PMH: pre-existing hypertension, renal disease, acquired/inherited thrombophilia, connective tissue disease, DM
- obstretics factors: multiple pregnancies, previous pre-eclampsia, triploidy, inter-pregnancy interval > 10y, IVF
61
pathophysioogy of pre-eclampsia
- abnormal immunological response and genetic predisposition leading to poor placental development.
hypoperfused placenta and release of circulating factors which leads to activated vascular endothelium --> hypertension and organ damage
62
symtoms of preeclampsia
- sevre headache
- severe RUQ or epigastric pain
- sudden swelling of hands, face or feet
- visual disturbances (burring, flashing, scotomas)
- vomiting
- restlessness/agitation
63
signs of pre-eclampsia
- hypertension and proteinuria
- hyperreflexia and clonus
- serum creatinine raised
- decreased platelet count
- haemolytic anaemia
- elevated liver enzymes
- retinal haemorrhage and papilloedema
64
investigations for pre-eclampsia
- BP monitoring
- urine dipstick
- bloods: FBC, U&Es, coag, LFTs
- fetal assessment: SFH, fetal mvnt, USS (liquor volume and umbilical artery)
65
diagnosis of pre-eclampsia
- >140/90 on 2 occasions, 4h appart
| - proteinuria > 300mg/24h or >30mg on spot test proteine creatinine ratio
66
management of pre-eclampsia
- consultant led care
- BP < 160: labetalol, nifedipine, hydrallazine
- aspirin 75mg qd from 12/40 to birth
- lifestyle advice + fluid restriction
- management of HELLP
- induction of labour/C section at 37-38w
67
complications of pre-eclampsia (maternal and neonatal)
- maternal: placental rupture, DIC, HELLP syndrome, pulmonary oedema, aspiration, eclampsia, liver failure/haemorrage, stroke, death, long term CV mortality
- neonatal: pre-term delivery, intrauterine growth restriction, hypoxia neurological delay, perinatal death, long term CV morbidity (low birth weight association)
68
def small for gestational age
fetus with weight less than 10th centile (in personlised growth chart)
69
def fetal growth restriction
failure of fetus to reach predetermined growth potential due to pathology
(faltered growth)
70
types of FGR
- symmetrical: head and abdominal size are equally small. due to insult early in pregnancy/chromosomal/congenital abnormalities, Intrauterine infections, substance abuse
- assymetrical: inadequate nutrition: redistribution of blood flow to head/brain and heart. usually due to insult later in pregnancy: PET, essential hypertension, maternal smoking
71
risk factors for FGR
- mat age > 40
- pat or mat SGA
- prev SGA or stillbirth or PET
- nulliparity
- pregnancy interval < 6m or >6y??
PMH: renal impairement, chronic HTN, DM with vascular disease, APS, heavy BVP
- IVF
- low PAPP-A
- smoking
- cocaine use
72
investigations if risk factors for FGR
- uterine artery doppler scan at 20w if low risk (if normal, single scan in T3 and if abnormal, serial scans from 28 weeks)
- if high risk; serial scans from 28 weeks
73
aetiology of FGR
- gas exchange and nutrient delivery to fetus impaired (impaired maternal oxygen carrying and delivery, placental damage)
- instrinsic pb with fetus (chromosal or congenital abnormalities, intrauterine inf)
74
implications for fetus of FGR
short term:
- premature birth
- low APGAR
- hypoglycaemia and hypocalcaemia
- NICU stay
long term:
- learning difficulties
- short stature
- failure to thrive
- cerebral palsy
- HTN
- DMT2
- heart disease
75
management of FGR
- early onset < 32w: suggestive of congenital infection or chromosomal abnormalitie: USS and amniocentesis, steroids and intensiive monitoring
- late onset: >32w: surveillance and delivery if needed (36w with steroids)
76
management of iron deficiency anaemai in pregnancy
oral iron for 2 weeks, then test again. if not come up,, do follow up tests
77
uterine relaxants
```
magnesium
relaxin
nefedipine
terbutaline
atosiban
oxytoxin
endothelin
misoprostol
nitric oxide
indomethacin
```
78
uterine stimulants
```
oxytoxin
endothelin
misoprostol
prostin
ergometrine
```
79
risk factors for ectopic pregancy
- previous ectopic pregnancy
- previous/current PID
- previous surgery to tubes
- IUS/IUD
- assisted concetion, especially in vitro
- smoking (reduces cilia function)
80
sites of occurance of ectopic pregnancy
- Fallopian tube (mainly ampulla)
- ovary
- cervix
- interstitial
- C section scar
- heterotopic (multiple pregnancies, one implanted right, the other ectopic)
- abdominal
81
presentation of ectopic pregnancy
- usually by 5-7 weeks
- pelvic tenderness
- adnexal tenderness
- abdominal tenderness
+ cervical excitation
- rebound tenderness or peritoneal signs
- pallor
- abdominal distention
- enlarged uterus
- tachycardia, hypotension/ shock, collapse
- free fluid in pouch of douglas
- referred pain to shoulder
82
investigations for ectopic pregnancy
bloods: baseline, HCG (baseline and 48h), G&S, progesterone
| - transvaginal USS
83
management of ectopic pregnancy
- call for help and refer to EPAU
- conservative: monitor and pain relief
- medical: methotrexate up to two doses
- surgical: salphingectomy or salphingotomy
- give anti D (if rhesus neg)
- book scan if pregnant again
84
what must be communicated in medical management of ectopic pregnancy
delay pregnany for 3 months after due to methotrexate teratogenicity
85
what must be communicated in medical surgical of ectopic pregnancy
salphinotomy can increase risk of future ectopic pregnancies
86
miscarriage definitions
- loss of pregnancy <24weeks
- early miscarriage: before 12w
- late miscarriage: 12-24w
87
causes of miscarriage
- unknown
- chromosoma, fetal or placental abnormalites
- infection (listeria, toxoplasmosis, VZV, malaria)
- other: multiple pregnancies, smoking, advanced paternal/paternal age, stress, high BMI, alcohol, assisted conception
88
def threatened miscarriage
pregnancy confirmed
| presenting with vaginal bleeding
89
def inevitable miscarriage
cervix open on exam
| miscarriage likely imminent
90
def complete miscarriage
when all pregnancy tissue has passed form uterus
91
def incomplete miscarriage
when some pregnancy tissue remains in uterus
92
def delayed miscarriage
when pregancy has stopped growing or fetus died but no signs of bleeding
93
management of miscarriage
- expectant: may take few days/weeks, follow up 2-3 weeks later
- medical: misoprolol
- surgical: vaccum aspiration or surgery
- antiD
94
risk of miscarriage management
infection
haemorrhage
similar outcomes in future pregnancy
95
diagnosis of miscarriage
2 transvaginal USS 7 days difference:
- crown rump length of embryo 7 mm with no fetal heart rate
- mean sac diameter of 25mm gestational sac w/ no sac or embryo
96
causes of bleeding in pregnancy
Lower ano-genital tract:
- post coidal bleeding
- anal fissure
- vaginal infections
- cervical dilation
- cancer
Placental:
- placenta praevia
- placental abruption
- vasa praevia
unexplained
97
investigations of bleeding in pregnancy
rh, FBC, G&S
ABCDE
fetal HR (CTG)
kleinhauer test (fetal red cells in maternal circulation)
USS (not useful acutely but for fetal growth)
98
def placenta praevia
low lying placenta: in lower uterine segment
| on USS: extends 5cm from cervical os
99
risk factors for placenta preavia
previous C section
- multiparity
- multiple pregnancy
100
presentation of placenta praevia
- USS of 20w
- non painful bleeding
- may be associated with abnormal lie or presentation
101
classification of placenta praevia
- minor: encroaches lower uterine segment ot reaches internal os (marginal)
- major: covers internal os (partly or completely)
102
delivery with placenta praevia
- if minor: can deliver safely
- if placenta edge is <2cm from internal os should have elective surgery planned at 38-39w (haemorrhage in later inevitable)
103
def placental abruption
retroplacental haemorrage (between placenta and uterus) and usually involves some degree of placental seperation
104
risk factors for placental abruption
- maternal thombophilia
- abdominal trauma
- previous abruptions
- > 35y
- multiple pregnancies
- PET
- smoking
- cocaine use
105
symptoms and signs of placental abruption
- bleeding
- abdo pain
- uterine tenderness and woody hardness
- maternal shock
- DIC
106
types of placentaal abruptions
revealed and concealed
107
management of placental abruption
- minor: expectant (esp <37w), w/ monitoring and steroids <36w
- immediate delivery if fetal or maternal compromise
108
complications of placental abruption
- ischemia of underlying myometrium
- couvelaire uterus (bleed into myometrium)
- fetal death in utero
- maternal coagulopathy
109
uterine rupture risk factors
previous CS
110
signs and symptoms of uterine rupture
- abdo pain
- hypovolaemic shock
- CTG abnormalities
- uterine contraction may stop
- palpation of fetus outside uterus
111
def PPH
primary: blood loss > 500ml within 24h of delivery
| - secondary: any significant loss between 24h-12 weeks post delivery
112
causes of primary PPH
Tissue, Tone, Trauma, Thrombin
- vaginal trauma
- uterine atony
- placental (retained products pr placenta accreta)
113
causes of secondary PPH
- retained products
- infection
- dysfunction uterine bleeding
114
risk factors for primary PPH
- grand multiparities
- women > 35
- multiple pregnancies
- fibroids
- placenta praevia
- long labour or instrumental delivery
- past Hx of PPH
- macrosomia/polyhydrramniosis
115
prevention of PPH
- treat anaemia in antenatal period
- give uterotonic w/ delivery of baby's anterior shoulder
- in future pregnancies, must be in consultant led labour ward
116
management of PPH
- atony: fundal or bimanual massage and syntocinon for uterine contraction
- placental removal
- compression baloon
- stitch
- uterine artery ligation
- hysterectomy
+ crystalloid/blood to maintain circulating volume
117
secondary PPH management
- conservative management w/ antibiotics
| - if antibiotics fail: OCC
118
risk factors for VTE in bleeding
>35
>3 babies
previous VTE
FH
thrombophilia
PMH heart diesase, lung disease or arthritis
severe varicose veins
overweight
wheelchair user
during pregnancy: multiple prenancies, admitted to hospital, dehydration, PET
after birth: long labour, CS, haemorrage, received blood transfusion
119
management of VTE in pregnancy
LMWH
120
investigations for heavy menstrual bleeding
- bimanual and speculum
- bloods: FBC, TFTs, coag
- ultrasound
- hysteroscopy and endometrial biopsy
- cervvical cytology (if cervix suspicious)
121
treatment of heavy menstrual bleeding
- IUS (try for 6 months)
- tranexamic acid
- NSAID
- CCP
- cyclical oral progesterone
- if fibroids: GnRH agonists to shrink fibroid
surgical (if tried others for 3 months)
- endometrial ablation
- hysterectomy
- myomectomy
122
causes of abnormal uterine bleeding
```
PALM COIN
polyps
fibroids
leiomyoma
malignancy
coagulopathy
PCOS
STIs
thyroid
```
123
norml endometrial thickness
premenopausal:
- during menstruation: 2-4 mm
- early proliferatice: 5-7mm
- in secretatory phase: 7-16mm
postmenopausal: <5mm
124
uterine fibroids def
benign tumours of myometrium
125
symptoms of uterine fibroids
- asymptomatic
- menstrual dysfunction (menorrhagia or dysmenorrhea)
- pelvic discomfort/pressure/mass
- infertility/subfertility
- miscarriage
- bloating
- dyspareunia
- increase frequency of mictruition
126
symtoms of bacterial vaginosis
- thin, white/grey homogenous discharge
- fishy small
- vaginal ph > 4.5
127
treatment of bacteriial vaginosis
- metronidazole 400 mg bid for 7 days
| - intravaginal clindamycin cream for 7 days
128
symptoms of candidal infection
- cottage cheese discharge
- vulvitis: superficial dyspareunia, dysuria
- itch
- vulval erythema, fissuring, satellite lesions
129
treatment of candidal infections
azole antifungals
130
symptoms of trichomonas vaginalis
- offensive yellow/green, frothy disharge
- vulvovaginitis
- strawberry cervix
- ph>4.5)
131
treatment of trichomonas vaginalis
metronidazole
132
symptoms and signs of chlamydia trachomatis or neisseria gonorrhoeae
- vaginal discharge
- dysuria
- post coidal bleeding
- dyspareunia, lower abdo pain, intermenstrual bleeding (if spread beyond cervix)
- mucopureulent cervititis and/or contact bleeding
- rectal itch and/or pain with gonorrhea
133
diagnosis of lower genital tract infections
NAAT (swabs) of vagina, cervix, rectum, throat and urine
134
treatment of chlamydia
- azithromycin or doxycycline (both single doses)
- abstain from sex (1-2w)
- tell other partners to get treated
135
complications of chlamydia or gonorrheea
- if spread beyond lower genital tract: gland abscess, endometritis, saphingitis, perihepatitis
- PID (tubal complications)
- if pregant: miscarriage, pre-term birth, postpartum infection, neonatal occular and resp inf)
- reiter syndrome: reactive arthritis (genetically susceptible)
- increase chance of acquiring HIV
136
treatment of neisseria gonorrheae
- ceftriawone single dose AND
- azithromycin single dose
- abstain from sex (for 1-2w)
137
def PID
inf goes from cervix/vagina into upper genital tract
138
examples of PID
endometritis
salphingitis
tubo-ovarian abscess
pelvic peritonitis
139
risk factors for PID
- more than one sexual partner
- STD/previous PID
- bacterial vaginosis
- sexual intercourse during menses
- vaginal douching
- IUD
- procedures involving uterine cavity
140
symptoms/signs of PID
- cervitits
- lower abdo pain/local pain
- abnormal discharge (purulent)
- vaginal and post coidal bleeding
- general: nausea, fever, malaise
- cervical excitation
- tachycardia
141
investigations in PID
- speculum exam: absence of pus cells from cervix or vaginal wall is sensitive marker for absence of PID
- pregnancy test
- triple swab: high vaginal, endocervical and vulvuvaginal
- bloods: ESR, CRP, WBC, U&Es
- blood cultures if pyrexia
- urine dip
- laparoscopy (GOLD standard)
- ultrasound
142
differentials of PID
- ectopic pregnancy
- acute appendicitis
- endometriosis
- IBS
- UTI
- functional pain
143
treatment of PID
- ceftriaxone single dose IM AND
- azithromycin single dose AND
- metronidazole oral 14 days
- appropriate analgesia
- sex abstination
- removal of IUD after 24-48h
- test partners
144
complications of PID
- tubal damage
- tubal infertility
- ectopic pregnancy
- abdominal/pelvic pain > 6 months
- hysterectomy
- repeat infections
- salphingitis spread to liver capsule: perihepatitis (Fitz-Hugh-Curtis syndome)
145
cervical intraepithelial neoplasia def
- develops in 'transformation zone' of cervix: cervical epithelium that has unedrgone change
146
classification of CIN
CIN I: mild (low grade)
CIN II: moderate (high grade)
CIN III: severe (high grade)
147
if test pos for CIN changes what investigations to do
colposcopy (binocular microscope)
148
treatment of CIN
- abnormal cells often return to normal on their ow^n
- treat CIN II and III: see and treat during colposcopy: LLETZ or biopsy and treat after
- follow up: 'test of cure' smear test after 6 months
149
indications for colposcoy
- suspicious looking cervix
- invasive carcinoma on cytology
- CIN II or III
- persisting (> 12-18months) CIN I
- persistent unsatuisfactory quality of cytology
- infection with HPV
150
differentials of post coidal bleeding
cevical carcinoma
cervical ectropian
cervical polyp
151
differntials for vaginal discharge
```
normal
STI
non seually transmitted infection
PID
foreign body (ie tampon)
genital tract malignancy
```
152
normal labour def
onset of reg uterine activity associated with effacement and dilation of the cervix and descent of the presentinf part through the cervix
153
effect of niitric oxide during pregnancy
cervival ripeing
154
effect of relaxin during pregnancy
loosens pelvic ligaments and pubic symphyasis joint + dilates cervix during labour
155
prolabour factors
- oestrogen (increases oxytocin receptors on uterus)
- oxtocin (stimulates uterine contractibility and production of prostaglandins)
- corticotrophin-releasing hormon (increease prostaglandin levels
- prostaglandin dehydrogenase
- inflammatory mediators (cervical ripening and membrane rupture)
156
onset of partruition
- fetal stress stimulates ACTH release from fetal brain which stimulates cortsol release
cortisol: decreases prog and oestro prod and increas prostaglandin prod by placenta
- mechanical push of baby on cervix: nerve fibres: released oxytocin from mother hypothalamus
157
stages of labour
```
Stage 1:
A: latent
- 'the show' mucus
- regular painful contractions
- rupture of membranes
- effacement (thinning of cervix ): dilation up to 3 cm
B active:
- continuous dilation of cervix up to 10 cm
```
Stage 2: from full cervical dilation (10cm) until baby is born
Stage 3: delivery of placenta
158
def premature rupture of membranes
<37 weeks
159
contraindications of artificial rupture of membranes
breech position
| placenta praevia
160
monitoring in delivery
- uterine pattens (interval from onset of one contraction to the onset of the next and palpable fundus)
- fetal HR (every 15mins in 1st satge, every 5 mins in second stage, CTG if high risk)
161
mechanism of delivery for explanation
1. flexed fetus descends (decends and engages)
2. internal rotation (until faces towards maternal back, head at level of ischial spines)
3. extension of head (head extends towards pubic symphasis until delivered)
4. restitution/external rotation (after head delivered, fetus rotates back to orignal position: shoulders sideways)
5. delivery of shoulders
162
complications at each stage of labour
FIRST STAGE
- passenger: cephalopelvic disproportion, fetal malrepresentation
- passage: fibroids/cervical stenosis
- power: primary uterine inertia
SECOND STAGE:
- second uterine inertia
- persistent occipito-posterior position
- narrow mid pelvis
THIRD STAGE:
- PPH
- retained placenta
- inversion of uterus
163
interventions in labour
first stage: prostaglandin gel (initiation of labour), artificial rupture of membranes (cervical dilation), oxytosin (contractions)
SECOND STAGE:
- maternal/fetal distress, incomplete intenal rotation causing failure to progress
- instrumental delivery, CS
164
failure to progress
stage 1
latent phase: >20h (null), >14h (multi)
active phase: dil <1.2cm/hr (null), <1.5cm/hr (mutli)
165
different perineal tears
- first degree: small tear affecting skin
- second degree: muscle of peritoneum and skin, usually requires stitches
- third/fourth degree: extends to anal sphincter, requires surgery
166
apgar score
```
appearance
pulse
grimace
activity
respirations
```
calculated at 1, 5 and 10 mins after birth
167
breastfeeding mechanism
- alveolar cells make milk, stored in alveolus
- myoepithelial cells squeeze milk down the ducts
hormones involved:
- human placental lactogen, progesterone, prolactin
stimulation of milk letdown: reflex of suckling
168
breastfeeding benefits
- free
- skin to skin contact
TO BABY
- lower rates of allergies, ear/lung inf, obesity, sudden infant death
- healthier weight gain
TO MOTHER
- reduce uterine bleeding
- burns calories
- reduces risk of breast/ovarian/uterine cancer, osteoporosis, arthritis, T2DM, heart disease
169
places of birth
- home
- free standing midwifery led unit
- alongside midwifery unit
- obstetrics unit
170
indications for instrumental vaginal delivery
- suspected fetal compromise (fetal abnormalities)
- second stage delay due to maternal exhaustion, fetal malposition (occipitotransverse or posterior), cephalopelvic disproportion
171
risk factors for instrumental vaginal delivery
primiparous women
supine or lithotomy positions
epidural anaesthesia
172
complications of instrumental vaginal delivery
- failure with chosen instrument (CS or use of other instrument)
- fetal-neonatal complications (low APGAR score, fetal acidosis, cerebral trauma, cerebral haemorrhage, brachial plexusinjury or fracture)
- maternal complications (perineal tear, PPH, perineal inf, urinary or bowel incontinence, dyspareunia, subsequent fear of childbirth)
173
types of instrumental delivery
ventouse
| forceps
174
when should operative vaginal delivery be abandonned
- no evidence of progression with moderate traction during each contraction or delivery not imminent with 3 contractionw with instrument
- high risk of failure: >30 BMI, EFW>4kg, OP position, mid cavity delivery or 1/5th head palpable per abdomen
175
reasons CS
- absolute cephalopelvic disproportion (ie macrosomia)
- placenta praevia
- pre-eclampsia
- IURG
- post maturity
- fetal distress in labour/prolapsed cord
- failure of labour to progress
- malpresentation
- placental abruption (if dead, deliver vaginally)
- vaginal infection (ie active herpes)
- cervical cancer
176
complications of CS
FREQUENT
- wound/abdo discomfort for months after surgery
- risk of repeat CS
- readmission to hospital)
- haemorrage
- infection
- laceration of baby
SERIOUS
- emergency hysterectomy
- surgery at further date
- admission ICU
- thromboembolic disease
- bladder injury
- uteric injury
- death
- uterine rupture in future pregnancies
- antepartum stillbirth
- placenta praaevia or accreta in future pregnancies
177
primary causes of amenorrhoea
delayed puberty (hypothalamic physiological delay)
- anatomical (absence of uterus, imperforate hymen)
- PCOS
- low BMI/excessive excercise
178
management of amenorrhoea
- exclude pregnancy or menopause
- weight changes (BMI), drugs, medical disorders, thyroids disorders?
- check visual fields
- presence of hirtuism
- check LH, FSH, prolactin, testosteone, TFTs,
179
def of subertility
inability of couple to achieve pregnancy within 12 months of beginning regular unprotective intercourse (can be primary or secondary)
180
causes of infertility
- ovulation disorders
- sperm (azoospermia, oligospermia, asthenospermia, teratospermia, sperm delivery pb)
- unexplaoned
- tubal factors
- endometriosis related infertility
181
risk factors for infertility
- age
- not previously conceived
- intercourse not around ovulation
- uterine pb (endometrial pb, fibroids, polyps)
- duration of trying
- lifestyle: high BMI, excessive alcohol, smoking, stress, lack of excerise
- PMH: PCOS, CF
182
initial investigations for subfertility
female:
- early folicular phase LH, FSH, oestradiol (ovarian reserve and pituitary function)
- anti-Müllerian hormone (ovarian reserve)
- rubella
- lutheal phase serum progesterone (ovulation)
- test tubal patency (HSG)
male:
- semen analysis done at day 1 and 3 months later
183
data interpretation for subertility
FSH/LH:
- low: hypothalamic/pituitary pathology
- normal: disrupted folliculogenesis but oocyte present
- high: low nb/absence of oocytes
oestradiol:
- low in everything except PCOS
AMH:
- indication of oocyte reserve
184
treatment of subertility
- tubal pb: IVF
- endometriosis: prevention (see further)
- sperm pb: lifestyle/meds, IVF
- unexplained: IVF
- PCOS: metformin and clomiphene
185
symptoms of PCOS
- signs of androgen excess: hirsutism/Acne
- obesity
- irregular menses/amenorrhea/infertility
186
PCOS rotterdam criteria
MUST HAVE 2
- irregular menses
- clinical evidence of androgen excess (clinically or biomedically)
- polycystic ovaries on ultrasound
187
biomedical findings of PCOS
increased serum testosterone
increased LH and FSH (especially LH)
prolactin may be slightly elevated
188
treatment of PCOS
- OCP
- weight loss
- pregnancy wanted: metformin and clomiphene
189
on visualisation, what does endometriosis look like
- clear, white lesions
- powder burn lesions
- dark red or blue domes
190
symptoms/signs of endometriosis
SYMPTOMS
- dymenorrhea
- dyspareunia
- infertility
- painful bowel movement
- rectal bleeding
SIGNS
- fixed, non mobile retroverted uterus secondary to adhesions
- ovarian endometriomas
- uterosacral nodularity
191
investigations for endometriosis
direct visualisation of tissue and biopsy
192
management of endometriosis
- analgesia
- OCC, progesterone therapy
- GnRH agonist (induce menopause)
- surgical: excision and ablation, hysterectomu
193
pre conception advice
- manage medical conditions
- weight: 19-30
- both gender stops smoking and recreational drugs
- alcohol: not excessive
- intercourse: at least twice from 6 days prior to ovulation to 2 days after
- folic acid: 400 micrograms daily or 5mg (diabetes, epilepsy or previous NTD)
- check rubella immunity
- cervical smears: keep up to date
194
what increases risk of ovarian cancer and what decreases the risk
increase:
- nulliparity
- early menarche
- late menopause
- high ovulation events
- FH
reduce:
- breast feeding
- the more children you have
- 1st child before 25
- oral contraception
195
investigations for ovarian cancer
- CA125
| - ultrasound
196
staging of ovarian cancer
stage 1: ovaries
stage 2: extends to tubes and uterus or other pelvic tissue
stage 3: peritoneal spread
stage 4: distal metastases
197
treatment of ovarian cancer
like chronic disease
- surgery (bilateral oophorectomy, hysterectomy, omentectomy)
- chemo
- PARP inhibitors (if BRCA pos)
198
types of urinary incontinence
- stress
- urge
- overflow
199
pathophyisology of stress incontinence
urethral hypermobility
| intrinsic sphincter deficiency
200
risk factors for stress incontinence
```
high BMI
athetic
multiparity
childbirth
smoking/COP (chronic chough)
```
201
symptoms of stress incontinence
- incontinence when bladder under pressure (sneezing, coughing, laughing, exercise)
- symptoms worsen when oestrogen is low + post menopause
202
treatment of sttress incontinence
- lifestyle advice: weight loss if BMI>30 and smoking cessation
- pelvic floor muscle training
- surgical (synthetuc mid urethral tape, coposuspension, sling)
- drugs: duloxetine
203
pathophysiology of urge incontinence
- detrusor muscle contraction
204
risk factors for urge incontinence
- bladder infection
- bladder cancer
- stroke/MS/spinal cord
- alcohol/diuretucs
205
symptoms of urge incontinence
need to void that cannot be deferred
206
management of urge incontinence
- lifestyle chage (reduce excessive intake of alcohol, caffeine, water)
- bladder training (6 weeks min)
- drugs: antimuscarinic (oxybutinine)
- secondary referral: botulin injection into bladder, sacral nerve stimulation urinary diversion)
207
types of pelvic organ proplapse
```
cystocele (ant wall of vagina)
rectocele (post wall of vagina)
enterocele (peritoneum of cul de sac)
uterine prolapse
vaginal vault prolapse
```
208
causes of pelvic organ prolapse
- pelvic floor muscle and tissue weakened
- pregnancy/childbirth
- old age, menopause
- overweight
- long term constipation
- hysterectomy
- heavy lifting
209
symptoms of pelvic organ prolapse
- dragging sensation in vagina (worse on activity)
- heaviness in pelvis
- dyspareunia
- urinary symptoms
- faecal symptoms
210
what tool is used to quantify pelvic organ prolapse
POP-Q: pelvic organ prolapse quantification
211
management of pelvic organ prolapse
- lifestyle: loose weight, stop heavy lifting, treat constipation
- pelvic floor muscles training
- hormonal treatment: vaginal oestrogen or oestrogen ring
- vaginal pessaries
212
investigations for urinary incontinence
- bladder diairies for at least 3 days (how often, how much, leackage, what were you doing, urge, drink/food, pads used)
- vaginal exam tto exclude pelvic organ prolapse
- urine dip to exclude UTI
- urodynamic studies
213
urodynamic studies: what are we looking for
- pattern and speed of emptying
- post void residual
- pressure catheter: in bladder for vesical pressure and vagina and rectum for intraabdominal pressure
- bladder filled with water to measure detrusor muscle function
