Obstetrics and Gynaecology Flashcards
What is the definition of term?
Term 37-40 weeks
Full term 40 weeks
Post term 40-42 weeks
Pre term <37 weeks
What are the causes of pre-term birth?
Iatrogenic causes - FGR, pre-eclampsia, etc
Spontaneous - ruptured membranes/spontaneous labour, recurrent in future pregnancies, can lead to pregnancy loss or neonatal death, preventable with interventions, modifiable outcomes (steroids, magnesium, place of birth)
What are the different stages of labour?
Labour - 1st Stage
Primigravida 8-18 Hours, multigravida 5-12 hours
Latent phase - a period of time, not necessarily continuous when -
There are painful contractions AND
There is some cervical change, including cervical effacement and dilation up to 4cm
Active phase/established
There are regular painful contractions AND
There is progressive cervical dilatation from 4cm
Labour - 2nd Stage
Passive 2nd stage - full dilatation of the cervix before/in the absence of involuntary expulsive contractions
Active 2nd stage - full dilatation and expulsive contractions/active maternal effort to delivery of the foetus
Labour - 3rd Stage
Time from birth of the baby to the expulsion of the placenta and membranes
What are the three P’s of pathological labour?
Passage
This relates to the shape of the pelvis
There can be racial differences in pelvic shapes and it can also be affected by previous pelvic fractures or pathology causing obstruction such as a large cervical fibroid or pelvic tumour
Powers
This relates to uterine contractions
Effective coordinated contractions are required to efface and then dilate the cervix and then allow expulsion of the foetus
Passenger
This relates to the foetus
Variables include the size of the foetus, what part of the foetus is presenting and what position the presenting part is in
Firstly the foetal head descends and flexes, then rotates through 90 degrees and then delivers by extension
This is to help facilitate the smallest diameters of the foetal head presenting to the largest diameters of the female pelvis
Describe how the foetus moves through he birth canal during a normal labour ?
Engagement
The foetal head engages in the pelvis in the transverse position often some weeks before labour starts
Descent and Flexion
The foetal head descends into the vagina through the dilated cervix during the second stage of labour
To aid delivery the foetal head flexes to present a smaller diameter to the true pelvis
Internal Rotation
As the foetus descends it rotates to an occipito-anterior position (OA)
Extension
As the foetal head hits the sacrum it climbs up the sacral curve by extension of the neck
Restitution
The foetal head (now external to the mother) returns to the transverse position in line with the foetal shoulders
External Rotation
The foetal shoulders corkscrew to come under the symphysis pubis and allow delivery of the torso
What are the options for pain relief in labour?
Maternal choice should always be paramount for analgesic choice
Coping strategies - breathing and relaxation techniques, massage techniques, water
Non-pharmacological analgesia - transcutaneous electrical nerve stimulation (TENS) - do not offer in established labour
Inhalational analgesia - Entonox (50:50 mix of O2 and NO)
Opioids - pethidine, diamorphine
Regional anaesthesia - epidural or combined spinal-epidural
What pharmacological or non-pharmacological agents could be used to induce labour?
Non-Pharmacological: Cervical dilatation - balloon catheter or osmotic dilators
Pharmacological: Prostaglandins
Artificial rupture of membranes (ARM)
Oxytocin infusion
What are the 2 different management options for the 3rd stage?
Active Management
Uterotonic drugs (oxytocin 10IU IM)
Deferring clamping and cutting the cord
Controlled cord traction (CCT) after signs of placental separation
Prolonged if >30 mins
Physiological Management
No uterotonic drugs
No clamping of the cord until pulsation has stopped
Delivery of the placenta by maternal effort
Prolonged is >60 mins
What is the APGAR score?
Forms an assessment of foetal neonatal wellbeing and scored from 0-10
A - Appearance:
0 = Blue all over
1 = Blue extremities
2 = No blue colouration
P - Pulse
0 = No pulse
1 = <100
2 = >100
G - Grimace
0 = No response to stimulation
1 = Grimace when stimulated
2 = Sneezing, coughing or pulling away when stimulated
A - Activity
0 = No movement
1 = Some movement
2 = Active movement
R - Respiration
0 = No breathing
1 = Weak, slow or irregular
2 = Strong
What is considered normal progress in the different stages of labour?
0.5cm per hour is the minimum acceptable progress
What are the complications of unrecognised slow progress?
Foetal acidemia, postpartum haemorrhage and uterine rupture
What are the complications of Caesarean section?
Intrapartum/postpartum haemorrhage (common)
Bladder injury and rarely bowel (rare)
Deep vein thrombosis (significantly increases risk)
Pain and reduced mobility
Infection - would or endometritis (common)
What are the complications of instrumental delivery?
Postpartum haemorrhage (common)
Perineal pain (common)
Infection (common)
Perineal injury - episiotomy (common) or anal sphincter (uncommon 2%)
Foetal injury - scalp or face (rarely serious)
What is the management of postpartum haemorrhage?
ABCDE - call for help (2222)
Oxygen
Flatten bed
Uterine massage and bimanual compression
Observations - urine output, temperature, pulse, oxygen saturations
2x large bore IV cannulae
Bloods - FBC, U&E, LFT (preeclampsia), ABG
IV fluids - crystalloids (warmed if possible)
Consider blood transfusion - o negative if urgent or await type specific or crossmatched
Uterotonics - oxytocin bolus or infusion, ergometrine, carboprost (misoprostol)
Procoagulants - tranexamic acid (1g), clotting factors
Surgical procedures - B-Lynch sutures, Bakri balloon, hysterectomy
What are the risk factors for spontaneous pre-term birth?
Previous preterm birth
Uterine anomaly
Previous knife cone biopsy (and previous cervical cancer, likely HPV infection)
Previous early miscarriage (smaller effect size)
Smoking
Extremes of BMI
Extremes of maternal age
Inter-pregnancy interval under 18 months
Previous second stage Caesarean section (when 10cms dilated)
Previous mid-trimester loss (also known as ‘late miscarriage’ but this term is often not as acceptable to patients)
Previous surgical management of miscarriage or surgical termination of pregnancy
Socio-economic deprivation (and potentially pollution exposure)
What are the maternal complications of pre-eclampsia?
Abruption
Stroke
Seizure - eclampsia
Cerebral haemorrhage
Disseminated intravascular coagulopathy (DIC)
What are the foetal complications of pre-eclampsia?
Stillbirth
Iatrogenic preterm delivery
Foetal growth restriction
What are the long term risks of pre-eclampsia?
Persistent hypertension after pregnancy
Increased risk of later life hypertension and CVS disease
Recurrence in future pregnancies - aspirin can reduce risk
What blood tests are performed at 8-12 weeks?
FBC - to detect anaemia - should be repeated at 28 weeks in a singleton pregnancy
Blood group - to identify the blood group and Rhesus status to determine if anti-D may be required
Haemoglobinopathies - performed in conjunction with family origin questionnaire
Infection screen - HIV, Hep B, syphilis
Other blood tests may be performed depending on the patients PMH
What scans are performed in ante-natal care?
The dating scan
Performed between 8-14 weeks to date the pregnancy and produce the estimated date of delivery
If the first scan is performed as part of the combined test - it will be undertaken between 11.0 and 13+6 weeks
Looks for viability, confirm intrauterine pregnancy, estimated date of delivery (EDD) by measurement of the crown rump length (CRL) of the foetus, single/multiple pregnancies and neural tube defects
The anomaly scan
Performed between 18+0 and 20+6 weeks
The purpose of the scan is to identify foetal anomalies
This will allow parents to make reproductive choices, make preparation for treatment after delivery, plan delivery in a tertiary setting, identify if intrauterine procedures may be needed
Limitations to routine scanning include different conditions of foetus, maternal BMI and foetal position can also affect detection rates
The NHS foetal anomaly screening programme (FASP) identify the images that must be taken at an anomaly scan and provide data on the detection rates of different conditions
What supplements should be taken in pregnancy?
Folic acid is recommended for women planning to conceive and to be continued for the first 12 weeks of pregnancy to prevent neural tube defects - recommended dose is 400mcg
Women should be advised to take vitamin D supplements (10mcg) during pregnancy which can be found in most multi-vitamins - especially for women with darker skin and who have less exposure to sunlight
Iron is not recommended as routine in the pregnancy unless iron deficiency is suspected
Women should be advised that vitamin A should be avoided
How should nausea and vomiting be managed in pregnancy?
Nausea and vomiting are common in early pregnancy, symptoms usually subside by 16- 20 weeks
Dietary advice can be given
Non-pharmacological preparations - such as ginger
Antiemetics can be given - such as cyclizine and stemetil
In severe sickness (hyperemesis) hospital admission may be required for rehydration
In extreme situations when sickness is prolonged and does not respond to treatment, steroids can be considered as a dietary stimulant
How should heartburn be managed in pregnancy?
Heartburn is frequently experienced by pregnant women and can worsen with advanced gestation
Women should be given dietary and lifestyle advice to help with their symptoms
Antacid treatment can be instigated including: Gaviscon, Ranitidine or Omeprazole
What are the risks of obesity in pregnancy?
Increased risk of GDM – requires glucose tolerance test between 26-28 weeks
Should receive high dose folic acid in the 1st trimester (5mg)
Increased risk of pre-eclampsia - appropriate cuff size must be used to assess BP
Increased VTE risk
Consider serial scans due to inaccurate symphysial fundal height (SFH) with increased BMI
Consider intrapartum needs - foetal monitoring, IV access, increased risk postpartum haemorrhage (PPH), postnatal VTE risk
How should gestational diabetes be managed?
Monitoring of home blood glucose about 4x/day
Advise change in diet (low carbohydrate) and refer to dietician for support
Regular exercise
Medications - metformin or insulin as required for glycaemic control
Planned delivery (induction of labour) around 38-40 weeks depending on glycaemic control and medication (earlier with insulin)
What are the complications of gestational diabetes?
Antenatal - hypertensive disorder (PIH/PET), foetal growth problems (SGA or macrosomia), polyhydramnios
Intrapartum - shoulder dystocia, maternal perineal trauma, increased CVS risk
Neonatal - hypoglycaemia, RDS, increased risk if metabolic syndrome/DM
What are the investigations for menorrhagia?
Bloods - FBC (microcytic anaemia) and TFTs (hypothyroidism)
Physical examination - fibroids
USS - fibroids, adenomyosis
What is the medical management of menorrhagia?
Levonorgesterol releasing intrauterine system
Tranexamic acid (antifibrinolytic)
COCP
Analgesia/NSAIDs - antiprostaglandin effect
What is the surgical management of menorrhagia?
Endometrial ablation
Myomectomy (fibroids)
Hysterectomy
What examinations should be performed in patients presenting with menorrhagia?
Not indicated unless structural or histological abnormality is possible so if straight forward regular HMB no examination is recommended by NICE
If there is a possibility of STD or anatomical abnormality then examine
If the uterus is palpable and not pregnant arrange USS and arrange review
Perform cervical cytology only if patient is due screening
If cervix looks abnormal refer to colposcopy without taking cervical cytology on 2WW
What is the PALM-COEIN classification of abnormal uterine bleeding?
P - Polyp A - Adenomyosis L - Leiomyoma M - Malignancy and hyperplasia C - Coagulopathy O - Ovulatory disorders E - Endometrial dysfunction I - Iatrogenic N - Not otherwise classified
What are the symptoms of endometriosis?
Pelvic pain - dyspareunia, classical is before a period relieved during period
Abdo pain - generalised
Pain on defaecation - bowel deposits
Infertility/ectopic pregnancy - tubal deposits
What are the investigations for endometriosis?
History and examination
Pelvic examination
Laparoscopy
How should endometriosis be managed?
Analgesia
COCP
Androgens or progestogens
Gonadotrophin releasing hormone antagonists
Levonorgesterol releasing intrauterine system
Surgical Mx - ablation or excision
What does endometriosis mean for fertility?
Endometriosis is associated with infertility, however most women will not have difficulty conceiving
> 80% of couples will conceive within 12 months of regular unprotected sexual intercourse
Once pregnant the endometriosis will have no effect upon pregnancy outcome, unless there are already dense adhesions which may cause difficulty if caesarean section is required
How should chlamydia be treated and managed?
General advice: avoid any sexual activity until they and their partners have completed treatment
Partner notification: all sexual partners should be encouraged to take up, full STI screening, including HIV testing and if indicated, hepatitis B screening and vaccination
Test of Cure (TOC) is not routinely recommended for uncomplicated genital chlamydia infection, because residual, non-viable chlamydial DNA may be detected for 3–5 weeks following treatment
But… TOC recommended in pregnancy, where poor compliance is suspected and where symptoms persist
Standard first line treatment - doxycycline 100mg twice daily for seven days or azithromycin if compliance may be a concern
What are the complications of chlamydia infection?
Chronic PID secondary to adhesions – Fitz-Hugh-Curtis syndrome (peri-hepatic adhesions)
Pelvic abscess
Tubal infertility
Ectopic pregnancy
Define gestational trophoblastic disease
This is a term used to describe a group of pregnancy related tumours. These can be pre-malignant conditions (molar) or malignant (choriocarcinoma and placental trophoblastic disease).
What is a molar pregnancy?
This arises from an abnormality in chromosomal number during fertilisation. Partial molar pregnancies occur when one ovum with 23 chromosomes is fertilised by two sperm, each with 23 chromosomes. A complete molar pregnancy is where one ovum, fertilised by one sperm, duplicates. These tumours are usually benign but can become malignant known as invasive moles. These invade into the uterine myometrium and disseminating around the body.
What is a choriocarcinoma?
A malignancy of the trophoblast cells of the placenta. It commonly but not exclusively co-exists with molar pregnancies. This type of GTT characteristically metastasises to the lungs.
What are the clinical features of gestational trophoblastic disease?
Clinical features include hyperemesis because there is an increase titre of B-hCG which is thought to be linked to nausea in pregnancy. Hyperthyroidism is caused by gestational thyrotoxicosis due to stimulation of the thyroid by high HCG levels. Anaemia is also a feature.
What are the other rare types of GTD?
Placental Site Trophoblastic tumours: A malignancy of the intermediate trophoblasts, which are normally responsible for anchoring the placenta to the uterus. They occur after normal pregnancies, molar pregnancy or miscarriage.
Epithelioid Trophoblastic Tumour: A malignancy of the trophoblastic placental cells, which can be very difficult to distinguish from choriocarcinoma. It mimic the cytological features of squamous cell carcinomas.
Risk factors include a maternal age between 20-35, previous gestational trophoblastic disease, previous miscarriage and use of contraceptive pill.
How is GTD managed?
After treatment of a molar pregnancy a histological examination of the products of conception may be required.
Management is suction curettage as the most effective treatment for moles and non-viable partial moles. There is a theoretical risk of embolization of the trophoblastic tissue if medical management with oxytocic agents is used. If not contusive to surgical management then medical management is required. In all cases anti-D prophylaxis is recommended if the mother is Rhesus negative.
What is placental abruption?
This is where part or all of the placenta separates from the wall of the uterus prematurely. It is an important cause of antepartum haemorrhage (vaginal bleeding from week 24 of gestation until delivery).
Abruption in thought to occur following the rupture of the maternal vessels within the basal layer of the endometrium. Blood accumulates and splits the placental attachment from the basal layer. The detached portion of the placenta is unable to function, leading to rapid fatal compromise.
There are two types of placental abruption revealed (bleeding tracks down from the site of placental separation and drains through the cervix causing vaginal bleeding) and concealed (the bleeding remains within the uterus, and typically forms a clot retro placentally. This bleeding is not visible but can be severe enough to cause systemic shock).
What are the risk factors for placental abruption?
Risk factors include placental abruption in a previous pregnancy, pre-eclampsia or other hypertensive disorder, abnormal lie (transverse), polyhydramnios, abdominal trauma, smoking, cocaine use, haematoma identified in the first trimester, underlying thrombophilias and multiple pregnancy.
What are the clinical features of placental abruption?
Clinical features include painful heavy vaginal bleeding. On examination the uterus may be woody (tense all the time) and painful on palpation. The patient will be extremely distressed, pallor, peripheral cyanosis and poor capillary refill. Avoid speculum until placenta praevia has been excluded by USS. A triple genital swab can be taken to exclude infection if bleeding is minimal and digital vaginal examination can be useful in identifying if the cervix is dilating.
Differential diagnoses include placenta praevia (most important), marginal placental bleed, vasa praevia, uterine rupture and local genital causes.
How should placental abruption be managed?
Management is with the A-E approach. Emergency delivery is indicated in the presence of maternal and/or fetal compromise and usually this is by caesarean section unless spontaneous delivery is imminent or operative vaginal birth is achievable. Induction of labour for haemorrhage at term without maternal or fetal compromise, induction of labour is usually recommended to avoid further bleeding.
Conservative management for some partial or marginal abruptions not associated with maternal or fetal compromise. In all cases, give anti-D within 72 hours of the onset of bleeding if the woman is Rhesus negative.
What is placenta praaevia?
This is where the placenta is fully or partially attached to the lower uterine segment. It is an important cause of antepartum haemorrhage. Minor placenta praevia is where the placenta is low but does do not cover the internal cervical os. Major placenta praevia is where the placenta lies over the cervical os.
A low-lying placenta is more susceptible to haemorrhage, possibly due to a defective attachment to the uterine wall. Bleeding can be spontaneous or provoked by mild trauma. Additionally, the placenta may be provoked as the presenting part of the foetus moves into the lower uterine segment in preparation for labour.
What are the risk factors for placenta praaevia?
Risk factors include previous caesarean section, high parity, maternal age greater than 40, multiple pregnancy, previous placenta praevia, history of uterine infection (endometritis) and curettage to the endometrium after miscarriage or termination.
What are the clinical features for placenta praaevia?
Clinical features include antepartum haemorrhage with A-E assessment. It classically presents with painless vaginal bleeding, which may be spotting or massive haemorrhage. There can be pain if the woman is in labour. The uterus is usually non-tender on palpation.
How should placenta praaevia be managed?
Management is with A-E approach and investigations simultaneous to fluid resuscitation. Placenta Praevia may be identified at the routine 20 weeks scan. If placenta preavia minor then this can be reassessed at 36 weeks. If major then this should be reassessed at 32 weeks. In cases of confirmed placenta preavia caesarean section is the safest mode of delivery.
What are the recommenced anti-emetic treatments in pregnancy?
First line: • Cyclizine • Prochlorperazine • Promethazine • Chlorpromazine
Second line:
• Metoclopramide (maximum 5 days due to risk of extrapyramidal side effects)
• Domperidone
• Ondansetron
Third line:
• Hydrocortisone IV
Once symptoms improve, convert to prednisolone PO and gradually reduce dose until lowest maintenance dose is reached
Describe the pathology of endometrial cancer
The most common form of endometrial cancer is adenocarcinoma which are caused by stimulation of the endometrium by oestrogen, without the protective effects of progesterone. This is known as unopposed oestrogen. Unopposed oestrogen can also cause endometrial hyperplasia. This can predispose people to atypia which is a precancerous state.
What are the risk factors for endometrial cancer?
Risk factors include early menarche/late menopause, low parity, polycystic ovarian syndrome, hormone replacement therapy and tamoxifen use. The peak incidence of endometrial cancer is between 65-75 years. 40% of cases are associated with obesity because the greater the amount of subcutaneous fat, the faster the rate of peripheral aromatisation of androgens to oestrogen which increases unopposed oestrogen levels. There are also hereditary factors such as hereditary non-polyposis colorectal cancer (HNPCC) which predispose patients to endometrial cancer.
What are the clinical features of endometrial cancer?
The main clinical feature is postmenopausal bleeding defined as bleeding once year after periods have stopped. It is possible that patients will present with clear or white vaginal discharge, or with abnormal cervical smears. Advanced endometrial cancer may manifest with abdominal pain or weight loss. On examination there may be abdominal or pelvic masses, vulval/vaginal atrophy or cervical lesions.
How should endometrial cancer be investigated?
Investigations are with transvaginal ultrasound scan is the first line investigation. Endometrial thickness of >5mm on ultrasound is indicative of endometrial cancer. If greater than 4mm then an endometrial biopsy should be taken. If malignancy is confirmed then an MRI and CT may be needed for staging. FIGO staging is often used.
FIGO stages:
- Stage 1: Carcinoma confirmed to within uterine body
- Stage 2: Carcinoma may extend to cervix but is not beyond the uterus
- Stage 3: Carcinoma extends beyond uterus but is confined to the pelvis
- Stage 4: Carcinoma involves bladder or bowel or has metastasised to distant sites.
What is adenomyosis?
This is the presence of functional endometrial tissue within the myometrium of the uterus. This is benign invasion of the middle layer of the uterine wall which has been described as a variant of endometriosis. The main symptoms of adenomyosis are menorrhagia and dysmenorrhoea. It frequently occurs alongside fibroids.
This is thought to occur when endometrial stroma (connective/supporting tissue) is allowed to communicate with the underlying myometrium after uterine damage such as in pregnancy and childbirth, caesarean section, uterine surgery (endometrial curettage) and surgical management of miscarriage or abortion.
The invasion of the endometrium can be focal or diffuse and is more common in the posterior wall of the uterus. When a collection of endometrial glands form grossly visible nodules, they are described as an adenomyoma. Oestrogen, progesterone and androgen receptors are found in the ectopic endometrial tissue making them responsive to hormones.
What are the risk factors for adenomyosis?
Risk factors include high parity, uterine surgery (endometrial curettage and endometrial ablation), previous caesarean section and hereditary occurrence. Clinical features are menorrhagia, dysmenorrhoea, deep dyspareunia and irregular bleeding. The dysmenorrhoea is commonly progressive, beginning as cyclical pain becoming daily pain. On examination a symmetrically enlarged tender uterus may be palpable.
How should bacterial vaginosis be investigated and treated?
Investigations include microscopy of a high vaginal smear or assessment of vaginal pH greater than 4.5. The KOH whiff test is where alkali is added to the vaginal discharge and a strong fishy odour is indicative. Asymptomatic women may not need treatment, but antibiotics such as metronidazole can be used orally or topically. Clindamycin or tinidazole or also options. The patient should be advised to stop vaginal douching, scented shower gels, antiseptic agents and certain shampoos. Management is based on the BASHH guidelines.
Untreated bacterial vaginosis in pregnancy can cause complications of premature birth, miscarriage and chorioamnionitis.
How should trichomonas vaginalis be treated?
Trichomoniasis can be managed successfully with anti-protozoan antibiotics. Current guidance for men and non-pregnant, non-breastfeeding women:
- Metronidazole 2g orally in a single dose or
- Metronidazole 400-500mg twice daily for 5-7 days
Alternatives to the recommended regimes:
• Tinidazole 2g orally in a single dose
The patient’s current partner(s) and any sexual partners of the preceding four weeks should also be tested and treated simultaneously.
Patients should be advised to abstain from sexual intercourse whilst being treated or at least one week following the single dose. Test of cure is not necessary unless the patient is not responding to treatment or if they are re-infected.
