Obstetrics and Gynaecology Flashcards
1
Q
Management of ovarian enlargement in post menopausal women
A
Urgent referral to gynaecology
2
Q
Management of ovarian enlargement in premenopausal women
A
Conservative
Repeat ultrasound in 8-12 weeks and refer if persists
3
Q
How many couples are affected by infertility?
A
1 in 7
4
Q
Causes of infertility
A
Male factor - 30%
Unexplained - 20%
Ovulation failure - 20%
Tubal damage - 15%
5
Q
Basic investigations for infertility
A
Semen analysis
Serum progesterone 7 days prior to expected next period (day 21 ish)
6
Q
Interpretation of progesterone for infertility
A
<16 = repeat, if consistently low refer
16-30 = repeat
> 30 = ovulation
7
Q
Key counselling points for couples with infertility
A
92% conceive within 2 years
Folic acid
Aim BMI 20-25
Sex every 2-3 days
Smoking/drinking advice
8
Q
Treatment for Bartholin’s abscess
A
Antibiotics
Ward catheter
Marsupialization
9
Q
Presentation of Bartholin’s cyst
A
Asymptomatic
Soft painless lump in labium
10
Q
What is a cervical ectropion?
A
Larger area of columnar epithelium present on ectocervix
due to elevated oestrogen levels
11
Q
Causes of superficial dyspareunia
A
Lack of sexual arousal
Vaginal atrophy (e.g. post menopause)
Vaginitis secondary to infection
Painful episiotomy scar
Vaginismus
12
Q
Causes of deep dysparenunia
A
PID
Endometriosis
Cervicitis secondary to infection
Prolapsed ovaries in the pouch of douglas
Adenomyosis
Fixed retroverted uterus
13
Q
Management of endometrial hyperplasia
A
Simple without atypia = high dose progesterones with repeat sampling in 3-4 months
Atypia = hysterectomy
14
Q
Type 1 female genital mutilation
A
Partial or total removal of clitoris and/or prepuce
15
Q
Type 2 female genital mutilation
A
Partial or total removal of the clitoris and labia minor, with or without excision of labia majora
16
Q
Type 3 female genital mutilation
A
Narrowing of vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or labia majora, without or without excision of the clitoris
17
Q
What is fibroid degeneration?
A
Growth of uterine fibroid outstrips blood supply
18
Q
Presentation of fibroid degeneration
A
Low grade fever
Pain
Vomiting
19
Q
Management of fibroid degeneration
A
Rest, analgesia
Should resolve in 4-7 days
20
Q
What is vulval intraepithelial neoplasia?
A
Pre-cancerous skin lesion of the vulva, risk of squamous skin cancer
21
Q
Presentation of vulval intraepithelial neoplasia
A
Itching, burning
Raised, well defined skin lesions
22
Q
Risk factors for vulval intraepithelial neoplasia
A
HPV 16 and 18
Smoking
HSV 2
Lichen planus
23
Q
Features of vulval carcinoma
A
Lump or ulcer on labia majora
Inguinal lymphadenopathy
Itching, irritation
24
Q
Vaginal discharge in trichomonas vaginalis
A
offensive, yellow/green, frothy
25
Vaginal discharge in bacterial vaginosis
offensive, thin, white/grey, fishy odour
26
When should semen analysis be performed?
After a minimum of 3 days and maximum of 5 days abstience
Needs to arrive at the lab within 1 hour
27
Normal semen volume
>1.5ml
28
Normal semen pH
>7.2
29
Normal sperm concentration
>15 million/ml
30
Normal sperm morphology
>4% normal forms
31
Normal sperm motility
>32% progressive motility
32
Normal sperm vitality
>58% live spermatozoa
33
Define recurrent miscarriage
3 or more consecutive spontaneous miscarriage
34
Causes of recurrent miscarriage
Antiphospholipid syndrome
Endocrine disorders e.g. diabetes/thyroid, PCOS
Uterine abnormality e.g. uterine septum
Parental chromosomal abnormalities
Smoking
35
Causes of pruritis vulvae
Irritant contact dermatitis e.g. latex condoms, lubricants
Atopic dermatitis
Seborrhoeic dermatitis
Lichen planus
Lichen sclerosus
Psoriasis
36
Management of pruritis vulvae
Take showers not baths
Clean with emollient e.g. diprobase
Clean only once a day
Topical steroids
Steroid-antifungal if seborrhoeic dermatitis suspected
37
Medical options for management of premenstrual syndrome
Combined oral contraceptive pill e.g. Yasmin
SSRI either continuously or during luteal phase
38
Indication for letrozole
Ovulation induction in PCOS
39
Side effects of letrozole
Fatigue
| Dizziness
40
Side effects of clomifene
Hot flushes
N+V
Abdo distension and pain
41
What is ovarian hyperstimulation syndrome?
Ovarian enlargement with multiple cyst spaces, fluid shifts from intravascular to extra vascular space
42
Complications of ovarian hyperstimulation syndrome
Hypovolaemic shock
Acute renal failure
Venous or arterial thromboembolism
43
Management of ovarian hyperstimulation syndrome
Fluid and electrolyte replacement
Anticoagulation therapy
Abdominal ascitic paracentesis
Pregnancy termination if critically unwell
44
What type of ovarian cyst is called 'chocolate cyst'?
Endometriotic cyst
45
Most common cause of first trimester miscarriage?
Antiphospholipid syndrome
46
How does combined oral contraception work?
Inhibits ovulation
47
How does progesterone only pill work?
Thickens cervical mucus
48
How does injectable contraceptive work?
Inhibits ovulation
also: thickens cervical mucus
49
How does implantable contraceptive work?
Inhibits ovulation
also: thickens cervical mucus
50
How does intrauterine contraceptive device work?
Decreases sperm motility and survival
51
How does the intrauterine system work?
Prevents endometrial proliferation
also: thickens cervical mucus
52
How to stop implant, POP, or IUS in women age 50
Check FSH
Stop if FSH >30
or stop at 55 years
53
How to stop depo-provera in women age 50
Switch to non-hormonal method and stop after 2 years amenorrhoea
or switch to progesterone
54
When to stop non-hormonal contraception in women over 40
Stop after 2 years amenorrhoea if <50
Stop after 1 year amenorrhoea if >50
55
What are the methods of emergency contraception?
Levonorgestrel
Ulipristal
Intrauterine contraceptive device
56
How does levonorgestrel work?
Inhibits ovulation
57
How does ulipristal work?
Inhibits ovulation
58
How does intrauterine contraceptive device work?
Toxic to sperm and ovum
| Inhibits implantation
59
Contraception in obese patients
Transdermal patch less effective over 90kg
COCP is class 2 for BMI 30-34, class 3 for BMI >35
People with bariatric surgery cannot have oral contraception including emergency contraception
60
What is dianette licensed for?
Severe acne in women
| Moderately severe hirsuitism
61
Female sterilisation failure rate
1 per 200
62
Complications for female sterilisation
Increased risk of ectopic if sterilisation fails
| Complications of GA/laparoscopy
63
Success rate of female sterilisation reversal
50-60%
64
How soon after childbirth can an intrauterine device or system be inserted?
Within 48 hours or after 4 weeks
65
When after childbirth can you start combined oral contraception?
6 weeks if breastfeeding
Sooner if not
Additional contraception first 7 days
66
How long after abortion can you start combined oral contraceptive?
Immediately
Protected from pregnancy straight away
67
How long until the IUD gives effective contraception?
instant
68
How long until the POP gives effective contraception?
2 days
69
How long until the COCP gives effective contraception?
7 days
70
How long until depro vera gives effective contraception?
7 days
71
How long until the implant gives effective contraception?
7 days
72
How long until the IUS gives effective contraception?
7 days
73
Which cancers does the COCP increase your risk of?
Breast and cervical
74
Which cancers does COCP decrease your risk of?
Ovarian, endometrial and colorectal
75
What is the best method of contraception for patients who are taking enzyme inducers?
Depro Vera
76
How long after giving birth do you need to start contraception?
21 days
77
How does IUD work?
Prevents fertilisation by causing reduced sperm motility and survival
78
How long does it take IUD to work?
immediate
79
How long does IUD last?
5 to 10 years depending on type
80
How does IUS work?
Prevents endometrial proliferation
| Causes cervical mucous thickening
81
How long does it take IUS to work?
7 days
82
How long does IUS last?
5 years if for contraception
4 years if for HRT reasons
83
How long does Jaydess work?
3 years
84
How long does Kyleena work?
5 years
85
Rate of uterine perforation with coil insertion
2 in 1000
| Higher if breastfeeding
86
Risks with coil insertion
Perforation
Ectopic pregnancy proportion higher
Higher risk of PID for 20 days
Expulsion
87
Rate of expulsion in coil insertion
1 in 20
88
How long after delivery can you have a coil?
in the first 48 hours or after 4 weeks
89
Absolute contraindications to progesterone only pill
Breast cancer in the last 5 years
90
POP - missed a pill >12 hours late
Take pill and continue pack
| Extra precautions for 2 days
91
How does POP work?
Inhibits ovulation
92
How long does POP take to give protection?
Immediate if started up to day 5 of cycle
Otherwise 2 days
93
How long does POP take to give protection if switching from COCP?
Immediate if continued from end of pill packet
94
Adverse effects of injectable progesterone (depo provera)
irregular bleeding
weight gain
increased risk of osteoporosis (not good for adolescents)
95
How does depo provera work?
inhibits ovulation
secondary effects - cervical mucous thickening, endometrial thickening
96
How long does it take for fertility to return after stopping depo provera?
up to 12 months
97
How long does nexplanon take to give protection?
7 days
98
How does nexplanon work?
Prevents ovulation
99
How long after termination of pregnancy can nexplanon be inserted?
Immediately
100
Differences of nexplanon to implanon
Applicator prevents deep insertion
| Radioopaque
101
How do you use the combined patch?
Wear for three weeks, changing each week
| One week off
102
What to do if patch change delayed at the end of week 1 or week 2
If <48 hours then change immediately, no further action
If >48 hours then change immediately and extra measures for 7 days
103
What to do if patch change is delayed at the end of week 3
Remove patch
New patch applied on usual start date
No extra measures
104
What to do if patch is delayed at the end of patch free week
Barrier contraception for 7 days
105
Options for emergency contraception
Levonorgestrel (levonelle)
Ulipristal (ella one)
Intrauterine device
106
How does levonorgestrel emergency contraception work?
Stops ovulation
| Inhibits implantation
107
Within what time frame do you have to use levonorgestrel?
72 hours
108
Dose of levonorgestrel
1.5mg stat
DOUBLE DOSE if BMI >26 or weight lover 70kg
109
How does ulipristal emergency contraception work?
inhibits ovulation
110
Within what time frame do you have to use ulipristal?
120 hours
111
How long after ulipristal can you start hormonal contracpetion?
5 days
112
Which patient group should you avoid giving ulipristal to?
Asthmatics
113
In what time frame can you use the intrauterine device for emergency contraception?
Within 5 days or up to 5 days after the likley ovulation date
114
How does intrauterine device work for emergency contraception?
Inhibits fertilisation or implantation
115
Which UKMEC for COCP?
| Migraine with aura
UKMEC 4
116
Which UKMEC for COCP?
| >35 years and smoke >15 cigarettes
UKMEC 4
117
Which UKMEC for COCP?
| History of VTE, stroke or IDH
UKMEC 4
118
Which UKMEC for COCP?
| Breastfeeding less than 6 weeks post partum
UKMEC 4
119
Which UKMEC for COCP?
| >35 years smoking <15 cigarettes
UKMEC 3
120
Which UKMEC for COCP?
| BMI >35
UKMEC 3
121
Which UKMEC for COCP?
| FHx of thromboembolism in a first degree relative under 45
UKMEC 3
122
Which UKMEC for COCP?
| Uncontrolled HTN
UKMEC 4
123
Which UKMEC for COCP?
| Current gallbladder disease
UKMEC 3
124
COCP - missed 1 pill
Take the last pill, no extra measures
125
COCP - missed 2 pills in week 1 of cycle
Emergency contraception
Take pill
Condoms for 7 days
126
COCP - missed 2 pills in week 2 of cycle
As long as taken for 7 days before then don't need extra measures
127
COCP - missed 2 pills in week 3
Finish pill in current pack then start new pack, missing the free pill week
Condoms for 7 days
128
Patterns of bleeding with nexplanon
2 in 10 amenorrhoeic
3 in 10 infrequent bleeding
2 in 10 prolonged bleeding
Fewer than 1 in 10 have frequent bleeding
129
How long does it take COCP to be effective?
Immediately if in first 5 days
Otherwise 7 days
130
Management of urge incontience
Bladder retraining
Oxybutynin
Tolerodine
Micabegron
131
Drug management of urge incontinence in elderly/frail
Micabegron
132
Management of stress incontience
Pelvic floor muscle training
Surgery
Duloxetine
133
How often do you have to do pelvic floor muscle training exercises in stress incontience management?
8 contractions three times a day for three months
134
Management of pelvic inflammatory disease
Oral ofloxacin + oral metronidazole
OR
IM ceftriaxone + oral metronidazole
135
Risk of infertility with pelvic inflammatory disease
10-20%
136
Complications from pelvic inflammatory disease
Perihepatitis
Infertility
Chronic pelvic pain
Ectopic pregnancy
137
Management of hersutism in PCOS
Oral contraceptive pill
| Topical eflornithine
138
Management of infertility in PCOS
Weight reduction
Clomifene
Metformin
139
Investigations in PCOS
Pelvic US - multiple cysts
Low FSH, high LH
Normal or slightly high testosterone
Normal or high prolactin
140
What is premature ovarian failure?
Onset of menopausal symptoms and elevated gonadotrophin levels before age 40
141
Investigations for premature ovarian failure
Raised FSH and LH (fsh >40)
Low oestradiol (<100)
142
Causes of premature ovarian failure
Idiopathic
Bilateral oophorectomy
Radio/chemo
Infection e.g. mumps
Autoimmune disorders
Resistant ovary syndrome due to FSH receptor abnormalities
143
What percentage of women get uterine fibroids?
20% white women
| 50% black women
144
Medical management to shrink uterine fibroids
GnRH agonists
145
Management of vaginal candidiasis
Clotrimazole pessary
Fluconazole 150mg
Only local treatments if pregnant
146
What counts as recurrent vaginal candidiasis?
≥ 4 episodes per year
147
Management of recurrent vaginal candidiasis
oral fluconazole every 3 days for 3 doses
Then oral fluconazole weekly for 6 months
148
Which conditions should you exclude in recurrent vaginal candidiasis?
Swab to confirm diagnosis
Exclude diabetes
Exclude lichen sclerosis
149
Investigations for ovarian cancer
CA125 - if >35 then urgent ultrasound
Ultrasound
Diagnosis lap
150
What can cause CA125 to be raised?
Ovarian cancer
Endometriosis
Menstruation
Benign ovarian cysts
151
Main type of ovarian cancer
70% are serous carcinomas
152
Risk factors for ovarian cancer
BRCA1 or BRCA2
Many ovulations - early menarche, late menopause, nullparity
153
How long to keep using contraception for after menopause?
12 months after last period if age >50
24 months after last period if age <50
154
Average age of menopause in the UK
51
155
Risks of HRT
Increased VTE in oral HRT but not transdermal
Increase stroke in oral oestrogen
Increased CHD in combined HRT
Increased breast cancer risk but no increase in breast cancer deaths
Increase ovarian cancer
156
Management of vasomotor symptoms in menopause
Fluoxetine
Citalopram
Venlafaxine
157
Management of psychological symptoms in menopause
Self help
CBT
antidepressants
158
Management of urogenital symptoms in menopause
Vaginal oestrogen
Vaginal moisturisers/lubricants
159
Contraindications to HRT
Current or past breast cancer
Oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial bleeding
160
Medication used to quickly stop heavy PV bleeding
Norethisterone 5mg TDS
161
Causes of menorrhagia
Dysfunctional uterine bleeding
Anovulatory cycles
Uterine fibroids
Hypothyroidism
Copper IUD
PID
Bleeding disorders e.g. von willebrand
162
Management of menorrhagia if doesn't need contraception
Mefenamic acid 500mg TDS or tranexamic acid 1g TDS
| Start on day 1 of period
163
Management of menorrhagia if does need contraception
Mirena
Combined oral contraceptive
Long acting progesterones
164
Hyperemesis gravidarum - diagnostic criteria
5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance
165
Hyperemesis gravidarum - referral criteria
Continued nausea, unable to keep down liquids or oral medication
Ketonuria and/or weight loss despite oral antiemetics
Confirmed or suspected comorbidity
166
What percentages of pregnancies have hyperemesis gravidarum?
1%
167
When do women experience hyperemesis gravidarum?
between 8 and 12 weeks
| rarely up to 20 weeks
168
Hyperemesis gravidarum - associations
Multiple pregnancies
Trophoblastic disease
Hyperthyroidism
Nulliparity
Obesity
169
What is the effect of smoking on hyperemesis gravidarum?
Reduces the incidence
170
Hyperemesis gravidarum - complications
Wernicke's encephalopathy
Mallory Weiss tear
Central pontine myelinolysis
Acute tubular necrosis
To the fetus: small for dates, preterm birth
171
1st line management of hyperemesis gravidarum
Antihistamines - promethazine
| Cycline
172
2nd line management of hyperemesis gravidarum
Ondansetron
| Metoclopramide
173
Endometriosis - examination findings
Reduced organ mobility
Tender nodularity in posterior vaginal fornix
Visible vaginal endometrial lesions
174
What percentage of women have endometriosis?
10%
175
Endometriosis - management in primary care
NSAIDs, paracetamol
| Combined oral contraceptive pill or progesterone
176
Endometriosis - management in secondary care
GnRH analogues (induce a pseudomenopause)
Laparoscopic excision and laser treatment of endometriotic ovarian cysts
177
Who gets called for cervical screening?
Women aged 25-64
178
Cervical screening frequency age 25-49
Every 3 years
179
Cervical screening frequency age 50-64
Every 5 years
180
When to do cervical screening during pregnancy?
3 months post partum
181
Cervical screening - management if inadequate sample
Repeat in 3 months
If 2 x inadequate samples then refer to colposcopy
182
Cervical screening - management if HPV negative
Return to normal screening unless on another specific pathway
183
Cervical screening - management if HPV positive and cytology abnormal
Colposcopy
184
Cervical screening - management if HPV positive and cytology normal
Repeat in 12 months
If HPV positive and abnormal cytology then refer to colposcopy
If HPV positive and normal cytology then further smear in 12 months
If HPV positive and normal cytology at 24 months then refer to colposcopy
If HPV negative then return to normal recall
185
What is primary amenorrhoea?
Failure to establish menstruation by age 15 in a girl with normal secondary sexual characteristics
186
Causes of primary amenorrhoea
Gonadal dysgenesis e.g. Turners
Testicular feminisation
Congenital malformations of genital tract
Functional hypothalamic amenorrhoea (e.g. anorexia)
Congenital adrenal hyperplasia
Imperforate hymen
187
What is secondary amenorrhoea?
Cessation of menses for 3-6 months if previously normal or 6-12 months if previously had oligomenorrhoea
188
Causes of secondary amenorrhoea
Hypothalamic amenorrhoea (e.g. stress, exercise)
PCOS
Hyperprolactinaemia
Premature ovarian failure
Thyrotoxicosis
Sheehan's syndrome
Asherman's syndrome
189
Investigations for amenorrhoea
Exclude pregnancy
FBC U+E ceoliac TFT
Gonadotrophins - low if hypothalamic, high if ovarian
Prolactin
Androgen
Oestradiol
190
Most important risk factor for cervical cancer
HPV 16, 18, 33
191
What is primary dysmenorrhoea?
Excessive pain during menstrual cycle with no underlying pathology
192
When does the pain typically start in primary dysmenorrhoea?
In the first few years of menses
With the period
193
What is secondary dysmenorrhoea?
Due to underlying pathology
194
When does pain typically start in secondary dysmenorrhoea?
Years after menarche
Pain starts a few days before period
195
Management of dysmenorrhoea
NSAID
| Combined oral contraceptive pill
196
Causes of secondary dysmenorrhoea
```
Endometriosis
Adenomyosis
PID
Copper IUD
Fibroids
```
197
Examples of physiological ovarian cysts
Follicular cysts
| Corpus luteum cyst
198
Most common ovarian cyst
Follicular cyst
199
Examples of benign epithelial ovarian tumours
Serous cystadenoma
| Mucinous carcinoma
200
Examples of benign germ cell tumours
Dermoid cysts
201
Who gets a 2ww urgent referral for PV bleeding?
≥ 55 with post menopausal bleeding
202
Investigations for endometrial cancer
Transvaginal U/S - endometrium thickness should be <4mm
| Hysteroscopy with endometrial biopsy
203
What is protective for endometrial cancer?
Combined oral contraceptive pill
| Smoking
204
Risk factors for endometrial cancer
Obesity
Nulliparity
Early menarche, late menopause
Unopposed oestrogen
Diabetes
Tamoxifen
PCOS
HNPCC
205
What should the symphysis fundal height be?
Match gestational age in weeks within 2cm after 20 weeks
206
Causes of nuchal translucency on ultrasound during pregnancy
Down's syndrome
Congenital heart defects
Abdominal wall defects
207
Causes of hyperechogenic bowel during pregnancy
Cystic fibrosis
Down's syndrome
Cytomegalovirus infection
208
When do fetal movements first start?
week 18-20
209
How to manage reduced fetal movements if over 28 weeks
Handheld doppler ultrasound for heartbeat
Immediate ultrasound if no heartbeat
CTG for 20 minutes if heartbeat
210
How to manage reduced fetal movements before 28 weeks
Handheld doppler ultrasound for heartbeat
211
What is puerperal pyrexia?
Temperature >38 in the first 14 days following delivery
212
Causes of puerperal pyrexia
Endometritis (most common)
UTI
Wound infection
Mastitis
VTE
213
Management of endometritis
IV clindamycin and gentamicin until afebrile for more than 24 hours
214
Pregnancy causes of jaundice
Intrahepatic cholestasis of pregnancy
Acute fatty liver of pregnancy
HELLP syndrome
215
What is HELLP syndrome?
Haemolysis
Elevated Liver enzymes
Low platelets
216
Maternal complications of diabetes in pregnancy
Polyhydramnios
| Preterm labour
217
Neonatal complications of diabetes in pregnancy
Macrosomia
Hypoglycaemia
Respiratory distress syndrome
Polycythaemia and more neonatal jaundice
Still birth
Shoulder dystocia
Low Mg, Low Ca
218
When are pregnant women screened for anaemia?
```
Booking visit (weeks 8-10)
28 weeks
```
219
When should pregnant women be treated for anaemia?
at booking visit <11
at 28 weeks <10.5
220
What causes increased AFP?
Neural tube defects
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy
221
What causes decreased AFP?
Down's syndrome
Trisomy 18
Maternal diabetes
222
When is amniocentesis offered?
Screening tests indicated high risk of fetal abnormality
Women is high risk e.g. over 35
223
When is amniocentesis performed?
16 weeks
224
Risk of fetal loss from amniocentesis
0.5-1%
225
Conditions that may be diagnosed from amniocentesis
Neural tube defects
Chromosomal disorders
Inborn errors of metabolism
226
Management of nausea in pregnant women
Ginger, acupuncture
| Antihistamines first line - promethazine
227
Dose of vitamin D taken by pregnant women
10 micrograms daily
228
What is an antepartum haemorrhage?
PV bleeding after 24 weeks pregnant, prior to delivery of the fetus
229
Presentation of placental abruption
Shock out of keeping with visible blood loss
Constant pain
Tender, tense uterus
Normal lie and presentation
Fetal heart beat - absent or distressed
Coagulation problems
230
Presentation of placenta praevia
Shock in proportion to visible blood loss
No pain
Uterus not tender
Lie and presentation may be abnormal
Fetal heart beat - normal
Small bleeds before large
231
Causes of 1st trimester bleeding
Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole
232
Causes of 2nd trimester bleeding
Spontaneous abortion
Hydatidiform mole
Placental abruption
233
Causes of 3rd trimester bleeding
Bloody show
Placental abruption
Placenta praevia
Vasa praevia
234
Presentation of hydatidiform mole
Bleeding in first or early second trimester
Exaggerated symptoms of pregnancy e.g. hyperemesis
Uterus large for dates
Very high hCG
235
Presentation of vasa praevia
Rupture of membranes followed immediately by vaginal bleeding
Fetal bradycardia
236
Treating nipple candidiasis whilst breastfeeding
Miconazole cream for mother
| Nystatin for baby
237
Treatment of mastitits
Flucloxacillin for 10-14 days
238
When to treat mastitis?
Unwell
Nipple fissure
Doesn't improve in 24 hours of regular milk removal
Culture indicates infection
239
Conditions that mean breast feeding is contraindicated
Galactosaemia
| Viral infections - HIV
240
Drugs that can't be given during breastfeeding
Ciprofloxacin, tetracycline, cloramphenicol, sulphonamides
Lithium
Benzodiazepines
Aspirin
Carbimazole
Methotrexate
Sulfonylureas
Cytotoxic drugs
Amiodarone
241
Risk factors for breech presentation
Uterine malformations, fibroids
Placenta praevia
Polyhydramnios or oligohydramnios
Fetal abnormality
Prematurity
242
Management of breech
At 36 weeks do external cephalic version (success rate 60%)
Planned c section or vaginal delivery
243
Contraindications for external cephalic version
```
Where c section is required
Antepartum haemorrhage in the last 7 days
Abnormal cardiotocography
Major uterine abnormaly
Ruptured membranes
Multiple pregnancy
```
244
What is included in the combined test for Down's syndrome?
Nuchal translucency measurement
Serum beta HCG
Pregnancy associated plasma protein A (PAPP-A)
245
When should the combined test for Down's syndrome be performed?
between 11 and 13+6
246
What results from a combined test suggest Down's syndrome?
High HCG
Low pregnancy associated plasma protein A
Thickened nuchal transluency
Trisomy 18 and 13 have similar result but PAPP-A tends to be lower
247
What is the test for Down's syndrome for a woman who books in late?
Triple or quadruple test between 15 and 20 weeks
Triple: alpha-fetoprotein, oestriol, hcg
Quadruple: as above + inhibin A
248
Dietary sources of folic acid
Green leafy vegetables
249
Causes of folic acid deficiency
Phenytoin
Methotrexate
Pregnancy
Alcohol excess
250
Consequences of folic acid deficieincy
Macrocytic, megaloblastic anaemia
| Neural tube defects
251
Which women are considered high risk of neural tube defect?
Partner has NTD, previous affected pregnancy, family history
Woman taking anti-epileptic drugs, had coeliac disease, diabetes or thalassaemia trait
Women is obese
252
Folic acid dosage in pregnancy
400 mcg daily till 12th week
High risk then take 5mg from before conception till 12th week
253
What is a galactocele?
Build up of milk creates a cystic lesion in the breast
Painless, no infection signs
Women that have recently stopped breastfeeding
254
Risk factors for group B streptococcus infection in the neonate
Prematurity
Prolonged rupture of the membranes
Previous sibling with GBS infection
Maternal pyrexia
255
How many women have group B streptococcus in their bowel flora?
20-40%
256
If a woman has had group B strep what is the risk of maternal carriage in this pregnancy?
50%
257
Management of women who have previously had group B strep
Intrapartum antibiotic prophylaxis
OR
testing at late pregnancy and antibiotics if still positive
258
When should women be swabbed for group B strep?
35-37 weeks or 3-5 weeks before anticipated delivery
259
Which women should be offered intrapartum antibiotic prophylaxis for group B strep?
Previous group B strep
Previous baby with early or late onset group B strep disease
Preterm labour
Pyrexia during labour
260
Antibiotic for group B strep prophylaxis
benzylpenicillin
261
Management of mothers with chronic hep B or acute hep B during prengnacy
Complete vaccination course and hepatitis B immunoglobulin for the baby
262
Can mothers with hepatitis B breastfeed?
Yes
263
What percentage of pregnant women in london are HIV positive?
0.4%
264
Factors that reduce vertical transmission of HIV
Maternal antiretroviral therapy
C-section
Neonatal antiviral therapy
Bottle feeding
265
High risk groups for pre-eclampsia
Hypertensive disease during previous pregnancies
Chronic kidney disease
Autoimmune disorders - SLE, antiphospholipid syndrome
T1DM or T2DM
266
Management of women who are high risk for pre-eclampsia
Aspirin 75mg OD from 12 weeks till birth
267
What are the normal changes in blood pressure seen in pregnancy?
Falls in the first trimester (particularly the diastolic)
Continues to fall till 20-24 weeks
After this increases to pre-pregnancy levels by term
268
Define hypertension in pregnancy
Systolic >140 or diastolic >90
OR
Increase in booking readings of >30 systolic or >15 diastolic
269
Features of pre-existing hypertension in pregnancy
History of hypertension or elevated BP >140/90 before 20 weeks gestation
No proteinuria, no oedema
270
Features of pregnancy-induced hypertension
HTN after 20 weeks
No proteinuria, no oedema
Resolves after birth
271
Features of pre-eclampsia
Pregnancy induced hypertension with proteinuria (>0.3g/24h)
May have oedema
Occurs in 5% pregnancies
272
What does parity mean?
Number of pregnancies a woman has carried to viable age (24 weeks)
273
What does gravida mean?
The number of times the uterus has contained a fetus
274
Placental abruption - associated factors
```
Proteinuric hypertension
Cocaine
Multiparity
Maternal trauma
Increasing maternal age
```
275
What tool is used to screen for postnatal depression?
Edinburgh post natal depression scale
>13 suggestions depressive illness of varing severity
276
Stages of post-partum thyroiditis
1) thyrotoxicosis
2) hypothyroidism
3) normal thyroid function
277
Antibodies found in post-partum thyroiditis
thyroid peroxidase antibodies in 90%
278
Management of post-partum thyroiditis
Propranolol for symptom control in thyrotoxic phase
Thyroxine in hypothyroid phase
279
How many antenatal visits do pregnant women get in their first pregnancy if uncomplicated?
10
280
How many antenatal visits do pregnant women get in subsequent pregnancies if uncomplicated?
7
281
Booking blood tests
FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
Hep B, syphilis, HIV
282
Complications from the use of SSRIs during pregnancy
Congenital heart disease
>20 weeks then persistent pulmonary hypertension
Late pregnancy risk neonatal withdrawal symptoms
283
How long does karyotyping results from amniocentesis take?
3 weeks
284
SSRI choice in breastfeeding women
Paroxetine
| Sertraline
285
Psychiatric drugs to avoid whilst breastfeeding
Lithium
| Benzodiazepines
286
Antibiotics to avoid whilst breastfeeding
Ciprofloxacin
Tetracycline
Chloramphenicol
Sulphonamides
287
What is a low risk result for Down's syndrome?
Lower than 1 in 150
288
What percentage of Down's syndrome pregnancies are not detected by screening tests?
15%
289
What is a high risk result for Down's syndrome screening?
Above 1 in 150
Refer to diagnostic testing
290
How long after delivery do you do a fasting glucose in women who had gestational diabetes?
6-12 weeks
291
When is the booking visit?
8-12 weeks
292
When is the early scan to confirm dates?
10 to 13+6
293
When is the Down's syndrome screening including nuchal scan?
11 to 13+16
294
When is the anomaly scan?
18 to 20+6
295
Definition of pre-eclampsia
New onset of BP ≥ 140/90 after 20 weeks of pregnancy
AND either proteinuria or other organ involvement (e.g. renal insufficiency, liver, neuro, haem)
296
Features of pre-eclampsia
Headache
Visual disturbances
Brisk reflexes
Haemorrhage
Liver involvement
HELLP syndrome
Proteinuria +++
Eclampsia
297
Moderate risk factors for pre-eclampsia
1st pregnancy
Age ≥40
Pregnancy interval >10 years
BMI ≥ 35
Family history
Multiple pregnancy
298
High risk factors for pre-eclampsia
HTN in previous pregnancy
CKD
Autoimmune disease - SLE or antiphospholipid
T1DM or T2DM
Chronic HTN
299
What is prophylactic treatment for pre-eclampsia?
Aspirin 75mg OD from 12 weeks
300
Who gets prophylactic treatment for pre-eclampsia?
≥ 1 High risk
| ≥ 2 Moderate risk
301
Management of pre-eclampsia
Refer all for same day assessment
1st line oral labetalol
2nd line nifedipine, hydralazine
Delivery of baby
302
Define primary PPH
Haemorrhage within 24 hours of delivery
303
Causes of primary PPH
Uterine atony in 90%
Genital trauma
Clotting factors
304
What is PPH?
>500ml blood loss
305
Define secondary PPH
Haemorrhage 24 hours to 12 weeks after delivery
306
Causes of secondary PPH
Retained placenta tissue
| Endometritis
307
Management of primary PPH
```
ABCDE, access
IV syntocin (oxytocin)
IM camboprost
Intrauterine balloon tamponade
Other surgical options
```
308
When do baby blues start?
3-7 days after delivery
309
How many women are affected by baby blues?
60-70%
310
Features of baby blues
Anxious, tearful, irritable
311
How many women are affected by post natal depression?
10%
312
Management of post natal depression
CBT
SSRI options - paroxetine or sertraline
313
How many women are affected by puerperal psychosis?
0.2%
314
Features of peurperal psychosis
Severe mood swings
| Disordered perception e.g. auditory hallucinations
315
Management of puerperal psychosis
Admit to mother and baby unit
316
Risk of recurrence of puerperal psychosis with further pregnancies
25-50%
317
When does puerperal psychosis present?
2-3 weeks after birth
318
Placenta previa - associated factors
Multiparity
Multiple pregnancy
Previous c-section
319
What is placenta previa?
placenta lying wholly or partly in the lower uterine segment
320
Intrahepatic cholestasis of pregnancy - features
Pruritis - palms, soles, belly
No rash
Raised bilirubin
Jaundice in 20%
321
Intrahepatic cholestasis of pregnancy - management
Ursodeoxycholic acid for symptom relief
Weekly LFTs
Vit K supplement
Women induced at 37 weeks
322
Intrahepatic cholestasis of pregnancy - fetal complications
Increased risk of preterm birth and stillbirth
323
Acute fatty liver of pregnancy - features
Abdo pain
N+V
Jaundice
Headache
Hypoglycaemia
Severe disease may cause pre-eclampsia
324
Acute fatty liver of pregnancy - investigations
ALT elevated
| Hypoglycaemia
325
Acute fatty liver of pregnancy - management
Supportive care
| Delivery
326
What is a complete hydatidiform mole?
Benign tumour of trophoblastic material
Empty egg fertilised, sperm duplicates own DNA so all DNA is paternal
327
Features of complete hydatidiform mole
```
Bleeding in 1st or early 2nd trimester
Exaggerated symptoms of pregnancy e.g. nausea
Uterus large for dates
Very high hCG
HTN and hyperthyroidism
```
328
Risk from a molar pregnancy
choriocarcinoma
329
What percentage of women with complete hydatidiform mole develop choriocarcinoma?
2-3%
330
What is a partial hydatidiform mole?
Normal haploid egg may be fertilised by 2 sperm or by 1 sperm with duplication of paternal chromosomes
331
Gestational diabetes - risk factors
BMI > 30
Prev macrosomic baby weighing > 4.5g
Prev gestational diabetes
1st degree relative with diabetes
Family origin with high prevalence (south asian, black caribbean, middle eastern)
332
How are women with previous gestational diabetes screened in a new pregnancy?
OGTT at booking and at 24-28 weeks
333
How are high risk women screened for gestational diabetes?
OGTT at 24-28 weeks
334
Gestational diabetes - glucose levels for diagnosis
Fasting ≥ 5.6
| 2 hour glucose ≥ 7.8
335
Diabetes (all types) - target glucose for self monitoring
Fasting 5.4
1 hour after meals 7.8
2 hours after meals 6.4
336
Gestational diabetes - management if fasting glucose <7.0
2 week trial of diet and exercise
If not met target after 2 weeks then start metformin
If still doesn't meet target start insulin
337
Gestational diabetes - management if fasting glucose >7.0
Start insulin
338
Gestational diabetes - management if fasting glucose 6-6.9 and evidene of macrosomia or hydramnios
Start insulin
339
Gestational diabetes - management option for women who don't want insulin and can't tolerate metformin/metformin is insufficient
Glibenclamide
340
Management of pregnant women with pre-existing diabetes
Stop oral hypoglycaemics except metformin and start insulin
5mg folic acid
Detained anomaly scan at 20 weeks
Tight glycaemic control
341
Birth defects associated with sodium valproate
Neural tube defects
| Neurodevelopmental delay
342
Which anti-epileptic is considered least teratogenic?
Carbamazepine
343
Birth defects associated with phenytoin
cleft palate
344
If a pregnant woman is taking phenytoin, what additional medication does she need?
Vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn
345
Is breastfeeding safe with anti-epileptics?
Yes except barbituates
346
Rate of congenital defects in women not taking anti-epileptics vs. women taking anti-epileptics
Not taking anti-epileptics = 1-2%
Taking anti-epileptics = 3-4%
347
Chickenpox in pregnancy - risk to mother
5x greater risk of pneumonitis
348
Fetal varicella syndrome - risk if exposed
1% if exposed before 20 weeks
| No cases when exposed over 28 weeks
349
Fetal varicella syndrome - features
Skin scarring
Eye defects (microphthalmia)
Learning disability
Limb hypoplasia
Microcephaly
350
Chickenpox in pregnancy - fetal risks
Fetal varicella syndrome
Shinges in infancy
Severe neonatal varicella
351
When is neonatal varicella a risk?
If mother develops rash between 5 days before and 2 days after delivery
Fatal in 20%
352
Management of chickenpox in pregnancy
specialist advice
| oral aciclovir within 24 hours if >20 weeks
353
Management of chickenpox exposure in pregnancy
- check varicella antibodies if any doubt about woman's exposure history
- if pregnant < 20 weeks + not immune then VZIG
- if pregnant > 20 weeks + not immune then VZIG or antivirals on day 7 to 14 of exposure
354
Management of an obese pregnant woman
5mg folic acid
Screen for gestational diabetes at 24-28 weeks with OGTT
BMI >35 deliver in consultant led unit
BMI >40 need to meet anaesthetic consultant
355
Fetal risks from an obese mum
Congenital anomaly
Prematurity
Macrosomia
Stillbirth
Increased risk of obesity and metabolic disorder in
childhood
Neonatal death
356
Maternal risks from obesity in pregnancy
Miscarriage
VTE
Gestational diabetes
Pre-eclampsia
Dysfunctional or induced labour
PPH
Would infection
Higher rate of c-section
357
Rhesus negative pregnancy - features in an affected fetus
Oedematous
Jaundice, anaemia, hepatosplenomegaly
Heart failure
Kernicterus
358
When do rhesus negative mothers get anti-D?
If they are non-sensitised then at 28 and 34 weeks
359
Events that should trigger additional anti D being given
Delivery of rhesus positive infant
Termination
Miscarriage >12 weeks
Ectopic pregnancy surgically managed
External cephalic version
APH
Amniocentesis or chorionic villus sampling
Abdominal trauma
360
Rubella in pregnancy - what percentage of fetus' are affected?
90% in first 8-10 weeks
Damage rate after 16 weeks
361
Congenital rubella syndrome - features
sensorineural deafness
congenital cataracts
congenital heart disease
hepatosplenomegaly
purpuric skin lesions
salt and pepper chorioretinitis
microphthalmia
cerebral palsy
362
Management of rubella in pregnancy
discuss with health protection unit
offer MMR when post natal, not when pregnant or TTC
363
Black cohosh - risks to warn women about
liver toxcitiy
| "menoherb"
364
Ginseng - risk to warm women about
may cause sleep problems and nausea
365
Red clover - risk to warn women about
theoretical risk of endometrial hyperplasia and stimulating hormone sensitive cancers
366
Evening primrose oil - risks to warm women about
may potentiate seizures
367
Dong Quai - risks to warn women about
May cause photosensitivity
| Interferes with warfarin
