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AKT > Obstetrics and Gynaecology > Flashcards

Obstetrics and Gynaecology Flashcards

1
Q

Management of ovarian enlargement in post menopausal women

A

Urgent referral to gynaecology

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2
Q

Management of ovarian enlargement in premenopausal women

A

Conservative

Repeat ultrasound in 8-12 weeks and refer if persists

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3
Q

How many couples are affected by infertility?

A

1 in 7

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4
Q

Causes of infertility

A

Male factor - 30%

Unexplained - 20%

Ovulation failure - 20%

Tubal damage - 15%

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5
Q

Basic investigations for infertility

A

Semen analysis

Serum progesterone 7 days prior to expected next period (day 21 ish)

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6
Q

Interpretation of progesterone for infertility

A

<16 = repeat, if consistently low refer

16-30 = repeat

> 30 = ovulation

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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

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8
Q

Treatment for Bartholin’s abscess

A

Antibiotics
Ward catheter
Marsupialization

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9
Q

Presentation of Bartholin’s cyst

A

Asymptomatic

Soft painless lump in labium

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10
Q

What is a cervical ectropion?

A

Larger area of columnar epithelium present on ectocervix

due to elevated oestrogen levels

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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

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12
Q

Causes of deep dysparenunia

A

PID

Endometriosis

Cervicitis secondary to infection

Prolapsed ovaries in the pouch of douglas

Adenomyosis

Fixed retroverted uterus

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13
Q

Management of endometrial hyperplasia

A

Simple without atypia = high dose progesterones with repeat sampling in 3-4 months

Atypia = hysterectomy

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14
Q

Type 1 female genital mutilation

A

Partial or total removal of clitoris and/or prepuce

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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

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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

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17
Q

What is fibroid degeneration?

A

Growth of uterine fibroid outstrips blood supply

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18
Q

Presentation of fibroid degeneration

A

Low grade fever
Pain
Vomiting

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19
Q

Management of fibroid degeneration

A

Rest, analgesia

Should resolve in 4-7 days

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20
Q

What is vulval intraepithelial neoplasia?

A

Pre-cancerous skin lesion of the vulva, risk of squamous skin cancer

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21
Q

Presentation of vulval intraepithelial neoplasia

A

Itching, burning

Raised, well defined skin lesions

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22
Q

Risk factors for vulval intraepithelial neoplasia

A

HPV 16 and 18

Smoking

HSV 2

Lichen planus

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23
Q

Features of vulval carcinoma

A

Lump or ulcer on labia majora

Inguinal lymphadenopathy

Itching, irritation

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24
Q

Vaginal discharge in trichomonas vaginalis

A

offensive, yellow/green, frothy

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25
Q

Vaginal discharge in bacterial vaginosis

A

offensive, thin, white/grey, fishy odour

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26
Q

When should semen analysis be performed?

A

After a minimum of 3 days and maximum of 5 days abstience

Needs to arrive at the lab within 1 hour

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27
Q

Normal semen volume

A

> 1.5ml

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28
Q

Normal semen pH

A

> 7.2

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29
Q

Normal sperm concentration

A

> 15 million/ml

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30
Q

Normal sperm morphology

A

> 4% normal forms

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31
Q

Normal sperm motility

A

> 32% progressive motility

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32
Q

Normal sperm vitality

A

> 58% live spermatozoa

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33
Q

Define recurrent miscarriage

A

3 or more consecutive spontaneous miscarriage

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34
Q

Causes of recurrent miscarriage

A

Antiphospholipid syndrome

Endocrine disorders e.g. diabetes/thyroid, PCOS

Uterine abnormality e.g. uterine septum

Parental chromosomal abnormalities

Smoking

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35
Q

Causes of pruritis vulvae

A

Irritant contact dermatitis e.g. latex condoms, lubricants

Atopic dermatitis

Seborrhoeic dermatitis

Lichen planus

Lichen sclerosus

Psoriasis

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36
Q

Management of pruritis vulvae

A

Take showers not baths

Clean with emollient e.g. diprobase

Clean only once a day

Topical steroids

Steroid-antifungal if seborrhoeic dermatitis suspected

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37
Q

Medical options for management of premenstrual syndrome

A

Combined oral contraceptive pill e.g. Yasmin

SSRI either continuously or during luteal phase

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38
Q

Indication for letrozole

A

Ovulation induction in PCOS

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39
Q

Side effects of letrozole

A

Fatigue

Dizziness

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40
Q

Side effects of clomifene

A

Hot flushes
N+V
Abdo distension and pain

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41
Q

What is ovarian hyperstimulation syndrome?

A

Ovarian enlargement with multiple cyst spaces, fluid shifts from intravascular to extra vascular space

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42
Q

Complications of ovarian hyperstimulation syndrome

A

Hypovolaemic shock
Acute renal failure
Venous or arterial thromboembolism

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43
Q

Management of ovarian hyperstimulation syndrome

A

Fluid and electrolyte replacement
Anticoagulation therapy
Abdominal ascitic paracentesis
Pregnancy termination if critically unwell

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44
Q

What type of ovarian cyst is called ‘chocolate cyst’?

A

Endometriotic cyst

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45
Q

Most common cause of first trimester miscarriage?

A

Antiphospholipid syndrome

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46
Q

How does combined oral contraception work?

A

Inhibits ovulation

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47
Q

How does progesterone only pill work?

A

Thickens cervical mucus

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48
Q

How does injectable contraceptive work?

A

Inhibits ovulation

also: thickens cervical mucus

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49
Q

How does implantable contraceptive work?

A

Inhibits ovulation

also: thickens cervical mucus

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50
Q

How does intrauterine contraceptive device work?

A

Decreases sperm motility and survival

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51
Q

How does the intrauterine system work?

A

Prevents endometrial proliferation

also: thickens cervical mucus

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52
Q

How to stop implant, POP, or IUS in women age 50

A

Check FSH
Stop if FSH >30

or stop at 55 years

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53
Q

How to stop depo-provera in women age 50

A

Switch to non-hormonal method and stop after 2 years amenorrhoea

or switch to progesterone

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54
Q

When to stop non-hormonal contraception in women over 40

A

Stop after 2 years amenorrhoea if <50

Stop after 1 year amenorrhoea if >50

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55
Q

What are the methods of emergency contraception?

A

Levonorgestrel
Ulipristal
Intrauterine contraceptive device

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56
Q

How does levonorgestrel work?

A

Inhibits ovulation

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57
Q

How does ulipristal work?

A

Inhibits ovulation

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58
Q

How does intrauterine contraceptive device work?

A

Toxic to sperm and ovum

Inhibits implantation

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59
Q

Contraception in obese patients

A

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

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60
Q

What is dianette licensed for?

A

Severe acne in women

Moderately severe hirsuitism

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61
Q

Female sterilisation failure rate

A

1 per 200

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62
Q

Complications for female sterilisation

A

Increased risk of ectopic if sterilisation fails

Complications of GA/laparoscopy

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63
Q

Success rate of female sterilisation reversal

A

50-60%

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64
Q

How soon after childbirth can an intrauterine device or system be inserted?

A

Within 48 hours or after 4 weeks

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65
Q

When after childbirth can you start combined oral contraception?

A

6 weeks if breastfeeding
Sooner if not
Additional contraception first 7 days

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66
Q

How long after abortion can you start combined oral contraceptive?

A

Immediately

Protected from pregnancy straight away

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67
Q

How long until the IUD gives effective contraception?

A

instant

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68
Q

How long until the POP gives effective contraception?

A

2 days

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69
Q

How long until the COCP gives effective contraception?

A

7 days

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70
Q

How long until depro vera gives effective contraception?

A

7 days

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71
Q

How long until the implant gives effective contraception?

A

7 days

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72
Q

How long until the IUS gives effective contraception?

A

7 days

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73
Q

Which cancers does the COCP increase your risk of?

A

Breast and cervical

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74
Q

Which cancers does COCP decrease your risk of?

A

Ovarian, endometrial and colorectal

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75
Q

What is the best method of contraception for patients who are taking enzyme inducers?

A

Depro Vera

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76
Q

How long after giving birth do you need to start contraception?

A

21 days

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77
Q

How does IUD work?

A

Prevents fertilisation by causing reduced sperm motility and survival

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78
Q

How long does it take IUD to work?

A

immediate

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79
Q

How long does IUD last?

A

5 to 10 years depending on type

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80
Q

How does IUS work?

A

Prevents endometrial proliferation

Causes cervical mucous thickening

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81
Q

How long does it take IUS to work?

A

7 days

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82
Q

How long does IUS last?

A

5 years if for contraception

4 years if for HRT reasons

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83
Q

How long does Jaydess work?

A

3 years

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84
Q

How long does Kyleena work?

A

5 years

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85
Q

Rate of uterine perforation with coil insertion

A

2 in 1000

Higher if breastfeeding

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86
Q

Risks with coil insertion

A

Perforation
Ectopic pregnancy proportion higher
Higher risk of PID for 20 days
Expulsion

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87
Q

Rate of expulsion in coil insertion

A

1 in 20

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88
Q

How long after delivery can you have a coil?

A

in the first 48 hours or after 4 weeks

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89
Q

Absolute contraindications to progesterone only pill

A

Breast cancer in the last 5 years

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90
Q

POP - missed a pill >12 hours late

A

Take pill and continue pack

Extra precautions for 2 days

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91
Q

How does POP work?

A

Inhibits ovulation

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92
Q

How long does POP take to give protection?

A

Immediate if started up to day 5 of cycle

Otherwise 2 days

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93
Q

How long does POP take to give protection if switching from COCP?

A

Immediate if continued from end of pill packet

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94
Q

Adverse effects of injectable progesterone (depo provera)

A

irregular bleeding
weight gain
increased risk of osteoporosis (not good for adolescents)

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95
Q

How does depo provera work?

A

inhibits ovulation

secondary effects - cervical mucous thickening, endometrial thickening

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96
Q

How long does it take for fertility to return after stopping depo provera?

A

up to 12 months

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97
Q

How long does nexplanon take to give protection?

A

7 days

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98
Q

How does nexplanon work?

A

Prevents ovulation

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99
Q

How long after termination of pregnancy can nexplanon be inserted?

A

Immediately

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100
Q

Differences of nexplanon to implanon

A

Applicator prevents deep insertion

Radioopaque

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101
Q

How do you use the combined patch?

A

Wear for three weeks, changing each week

One week off

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102
Q

What to do if patch change delayed at the end of week 1 or week 2

A

If <48 hours then change immediately, no further action

If >48 hours then change immediately and extra measures for 7 days

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103
Q

What to do if patch change is delayed at the end of week 3

A

Remove patch
New patch applied on usual start date
No extra measures

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104
Q

What to do if patch is delayed at the end of patch free week

A

Barrier contraception for 7 days

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105
Q

Options for emergency contraception

A

Levonorgestrel (levonelle)
Ulipristal (ella one)
Intrauterine device

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106
Q

How does levonorgestrel emergency contraception work?

A

Stops ovulation

Inhibits implantation

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107
Q

Within what time frame do you have to use levonorgestrel?

A

72 hours

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108
Q

Dose of levonorgestrel

A

1.5mg stat

DOUBLE DOSE if BMI >26 or weight lover 70kg

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109
Q

How does ulipristal emergency contraception work?

A

inhibits ovulation

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110
Q

Within what time frame do you have to use ulipristal?

A

120 hours

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111
Q

How long after ulipristal can you start hormonal contracpetion?

A

5 days

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112
Q

Which patient group should you avoid giving ulipristal to?

A

Asthmatics

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113
Q

In what time frame can you use the intrauterine device for emergency contraception?

A

Within 5 days or up to 5 days after the likley ovulation date

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114
Q

How does intrauterine device work for emergency contraception?

A

Inhibits fertilisation or implantation

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115
Q

Which UKMEC for COCP?

Migraine with aura

A

UKMEC 4

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116
Q

Which UKMEC for COCP?

>35 years and smoke >15 cigarettes

A

UKMEC 4

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117
Q

Which UKMEC for COCP?

History of VTE, stroke or IDH

A

UKMEC 4

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118
Q

Which UKMEC for COCP?

Breastfeeding less than 6 weeks post partum

A

UKMEC 4

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119
Q

Which UKMEC for COCP?

>35 years smoking <15 cigarettes

A

UKMEC 3

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120
Q

Which UKMEC for COCP?

BMI >35

A

UKMEC 3

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121
Q

Which UKMEC for COCP?

FHx of thromboembolism in a first degree relative under 45

A

UKMEC 3

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122
Q

Which UKMEC for COCP?

Uncontrolled HTN

A

UKMEC 4

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123
Q

Which UKMEC for COCP?

Current gallbladder disease

A

UKMEC 3

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124
Q

COCP - missed 1 pill

A

Take the last pill, no extra measures

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125
Q

COCP - missed 2 pills in week 1 of cycle

A

Emergency contraception
Take pill
Condoms for 7 days

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126
Q

COCP - missed 2 pills in week 2 of cycle

A

As long as taken for 7 days before then don’t need extra measures

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127
Q

COCP - missed 2 pills in week 3

A

Finish pill in current pack then start new pack, missing the free pill week

Condoms for 7 days

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128
Q

Patterns of bleeding with nexplanon

A

2 in 10 amenorrhoeic

3 in 10 infrequent bleeding

2 in 10 prolonged bleeding

Fewer than 1 in 10 have frequent bleeding

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129
Q

How long does it take COCP to be effective?

A

Immediately if in first 5 days

Otherwise 7 days

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130
Q

Management of urge incontience

A

Bladder retraining

Oxybutynin

Tolerodine

Micabegron

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131
Q

Drug management of urge incontinence in elderly/frail

A

Micabegron

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132
Q

Management of stress incontience

A

Pelvic floor muscle training
Surgery
Duloxetine

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133
Q

How often do you have to do pelvic floor muscle training exercises in stress incontience management?

A

8 contractions three times a day for three months

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134
Q

Management of pelvic inflammatory disease

A

Oral ofloxacin + oral metronidazole

OR
IM ceftriaxone + oral metronidazole

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135
Q

Risk of infertility with pelvic inflammatory disease

A

10-20%

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136
Q

Complications from pelvic inflammatory disease

A

Perihepatitis

Infertility

Chronic pelvic pain

Ectopic pregnancy

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137
Q

Management of hersutism in PCOS

A

Oral contraceptive pill

Topical eflornithine

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138
Q

Management of infertility in PCOS

A

Weight reduction
Clomifene
Metformin

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139
Q

Investigations in PCOS

A

Pelvic US - multiple cysts

Low FSH, high LH

Normal or slightly high testosterone

Normal or high prolactin

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140
Q

What is premature ovarian failure?

A

Onset of menopausal symptoms and elevated gonadotrophin levels before age 40

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141
Q

Investigations for premature ovarian failure

A

Raised FSH and LH (fsh >40)

Low oestradiol (<100)

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142
Q

Causes of premature ovarian failure

A

Idiopathic

Bilateral oophorectomy

Radio/chemo

Infection e.g. mumps

Autoimmune disorders

Resistant ovary syndrome due to FSH receptor abnormalities

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143
Q

What percentage of women get uterine fibroids?

A

20% white women

50% black women

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144
Q

Medical management to shrink uterine fibroids

A

GnRH agonists

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145
Q

Management of vaginal candidiasis

A

Clotrimazole pessary
Fluconazole 150mg

Only local treatments if pregnant

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146
Q

What counts as recurrent vaginal candidiasis?

A

≥ 4 episodes per year

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147
Q

Management of recurrent vaginal candidiasis

A

oral fluconazole every 3 days for 3 doses

Then oral fluconazole weekly for 6 months

148
Q

Which conditions should you exclude in recurrent vaginal candidiasis?

A

Swab to confirm diagnosis

Exclude diabetes
Exclude lichen sclerosis

149
Q

Investigations for ovarian cancer

A

CA125 - if >35 then urgent ultrasound
Ultrasound
Diagnosis lap

150
Q

What can cause CA125 to be raised?

A

Ovarian cancer

Endometriosis

Menstruation

Benign ovarian cysts

151
Q

Main type of ovarian cancer

A

70% are serous carcinomas

152
Q

Risk factors for ovarian cancer

A

BRCA1 or BRCA2

Many ovulations - early menarche, late menopause, nullparity

153
Q

How long to keep using contraception for after menopause?

A

12 months after last period if age >50

24 months after last period if age <50

154
Q

Average age of menopause in the UK

155
Q

Risks of HRT

A

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
Q

Management of vasomotor symptoms in menopause

A

Fluoxetine

Citalopram

Venlafaxine

157
Q

Management of psychological symptoms in menopause

A

Self help

CBT

antidepressants

158
Q

Management of urogenital symptoms in menopause

A

Vaginal oestrogen

Vaginal moisturisers/lubricants

159
Q

Contraindications to HRT

A

Current or past breast cancer

Oestrogen-sensitive cancer

Undiagnosed vaginal bleeding

Untreated endometrial bleeding

160
Q

Medication used to quickly stop heavy PV bleeding

A

Norethisterone 5mg TDS

161
Q

Causes of menorrhagia

A

Dysfunctional uterine bleeding

Anovulatory cycles

Uterine fibroids

Hypothyroidism

Copper IUD

PID

Bleeding disorders e.g. von willebrand

162
Q

Management of menorrhagia if doesn’t need contraception

A

Mefenamic acid 500mg TDS or tranexamic acid 1g TDS

Start on day 1 of period

163
Q

Management of menorrhagia if does need contraception

A

Mirena
Combined oral contraceptive
Long acting progesterones

164
Q

Hyperemesis gravidarum - diagnostic criteria

A

5% pre-pregnancy weight loss

Dehydration

Electrolyte imbalance

165
Q

Hyperemesis gravidarum - referral criteria

A

Continued nausea, unable to keep down liquids or oral medication

Ketonuria and/or weight loss despite oral antiemetics

Confirmed or suspected comorbidity

166
Q

What percentages of pregnancies have hyperemesis gravidarum?

167
Q

When do women experience hyperemesis gravidarum?

A

between 8 and 12 weeks

rarely up to 20 weeks

168
Q

Hyperemesis gravidarum - associations

A

Multiple pregnancies

Trophoblastic disease

Hyperthyroidism

Nulliparity

Obesity

169
Q

What is the effect of smoking on hyperemesis gravidarum?

A

Reduces the incidence

170
Q

Hyperemesis gravidarum - complications

A

Wernicke’s encephalopathy

Mallory Weiss tear

Central pontine myelinolysis

Acute tubular necrosis

To the fetus: small for dates, preterm birth

171
Q

1st line management of hyperemesis gravidarum

A

Antihistamines - promethazine

Cycline

172
Q

2nd line management of hyperemesis gravidarum

A

Ondansetron

Metoclopramide

173
Q

Endometriosis - examination findings

A

Reduced organ mobility
Tender nodularity in posterior vaginal fornix
Visible vaginal endometrial lesions

174
Q

What percentage of women have endometriosis?

175
Q

Endometriosis - management in primary care

A

NSAIDs, paracetamol

Combined oral contraceptive pill or progesterone

176
Q

Endometriosis - management in secondary care

A

GnRH analogues (induce a pseudomenopause)

Laparoscopic excision and laser treatment of endometriotic ovarian cysts

177
Q

Who gets called for cervical screening?

A

Women aged 25-64

178
Q

Cervical screening frequency age 25-49

A

Every 3 years

179
Q

Cervical screening frequency age 50-64

A

Every 5 years

180
Q

When to do cervical screening during pregnancy?

A

3 months post partum

181
Q

Cervical screening - management if inadequate sample

A

Repeat in 3 months

If 2 x inadequate samples then refer to colposcopy

182
Q

Cervical screening - management if HPV negative

A

Return to normal screening unless on another specific pathway

183
Q

Cervical screening - management if HPV positive and cytology abnormal

A

Colposcopy

184
Q

Cervical screening - management if HPV positive and cytology normal

A

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
Q

What is primary amenorrhoea?

A

Failure to establish menstruation by age 15 in a girl with normal secondary sexual characteristics

186
Q

Causes of primary amenorrhoea

A

Gonadal dysgenesis e.g. Turners

Testicular feminisation

Congenital malformations of genital tract

Functional hypothalamic amenorrhoea (e.g. anorexia)

Congenital adrenal hyperplasia

Imperforate hymen

187
Q

What is secondary amenorrhoea?

A

Cessation of menses for 3-6 months if previously normal or 6-12 months if previously had oligomenorrhoea

188
Q

Causes of secondary amenorrhoea

A

Hypothalamic amenorrhoea (e.g. stress, exercise)

PCOS

Hyperprolactinaemia

Premature ovarian failure

Thyrotoxicosis

Sheehan’s syndrome

Asherman’s syndrome

189
Q

Investigations for amenorrhoea

A

Exclude pregnancy

FBC U+E ceoliac TFT

Gonadotrophins - low if hypothalamic, high if ovarian

Prolactin

Androgen

Oestradiol

190
Q

Most important risk factor for cervical cancer

A

HPV 16, 18, 33

191
Q

What is primary dysmenorrhoea?

A

Excessive pain during menstrual cycle with no underlying pathology

192
Q

When does the pain typically start in primary dysmenorrhoea?

A

In the first few years of menses

With the period

193
Q

What is secondary dysmenorrhoea?

A

Due to underlying pathology

194
Q

When does pain typically start in secondary dysmenorrhoea?

A

Years after menarche

Pain starts a few days before period

195
Q

Management of dysmenorrhoea

A

NSAID

Combined oral contraceptive pill

196
Q

Causes of secondary dysmenorrhoea

A 
Endometriosis
Adenomyosis
PID
Copper IUD
Fibroids
197
Q

Examples of physiological ovarian cysts

A

Follicular cysts

Corpus luteum cyst

198
Q

Most common ovarian cyst

A

Follicular cyst

199
Q

Examples of benign epithelial ovarian tumours

A

Serous cystadenoma

Mucinous carcinoma

200
Q

Examples of benign germ cell tumours

A

Dermoid cysts

201
Q

Who gets a 2ww urgent referral for PV bleeding?

A

≥ 55 with post menopausal bleeding

202
Q

Investigations for endometrial cancer

A

Transvaginal U/S - endometrium thickness should be <4mm

Hysteroscopy with endometrial biopsy

203
Q

What is protective for endometrial cancer?

A

Combined oral contraceptive pill

Smoking

204
Q

Risk factors for endometrial cancer

A

Obesity

Nulliparity

Early menarche, late menopause

Unopposed oestrogen

Diabetes

Tamoxifen

PCOS

HNPCC

205
Q

What should the symphysis fundal height be?

A

Match gestational age in weeks within 2cm after 20 weeks

206
Q

Causes of nuchal translucency on ultrasound during pregnancy

A

Down’s syndrome

Congenital heart defects

Abdominal wall defects

207
Q

Causes of hyperechogenic bowel during pregnancy

A

Cystic fibrosis

Down’s syndrome

Cytomegalovirus infection

208
Q

When do fetal movements first start?

A

week 18-20

209
Q

How to manage reduced fetal movements if over 28 weeks

A

Handheld doppler ultrasound for heartbeat
Immediate ultrasound if no heartbeat
CTG for 20 minutes if heartbeat

210
Q

How to manage reduced fetal movements before 28 weeks

A

Handheld doppler ultrasound for heartbeat

211
Q

What is puerperal pyrexia?

A

Temperature >38 in the first 14 days following delivery

212
Q

Causes of puerperal pyrexia

A

Endometritis (most common)

UTI

Wound infection

Mastitis

VTE

213
Q

Management of endometritis

A

IV clindamycin and gentamicin until afebrile for more than 24 hours

214
Q

Pregnancy causes of jaundice

A

Intrahepatic cholestasis of pregnancy

Acute fatty liver of pregnancy

HELLP syndrome

215
Q

What is HELLP syndrome?

A

Haemolysis
Elevated Liver enzymes
Low platelets

216
Q

Maternal complications of diabetes in pregnancy

A

Polyhydramnios

Preterm labour

217
Q

Neonatal complications of diabetes in pregnancy

A

Macrosomia

Hypoglycaemia

Respiratory distress syndrome

Polycythaemia and more neonatal jaundice

Still birth

Shoulder dystocia

Low Mg, Low Ca

218
Q

When are pregnant women screened for anaemia?

A 
Booking visit (weeks 8-10)
28 weeks
219
Q

When should pregnant women be treated for anaemia?

A

at booking visit <11

at 28 weeks <10.5

220
Q

What causes increased AFP?

A

Neural tube defects

Abdominal wall defects (omphalocele and gastroschisis)

Multiple pregnancy

221
Q

What causes decreased AFP?

A

Down’s syndrome

Trisomy 18

Maternal diabetes

222
Q

When is amniocentesis offered?

A

Screening tests indicated high risk of fetal abnormality

Women is high risk e.g. over 35

223
Q

When is amniocentesis performed?

224
Q

Risk of fetal loss from amniocentesis

225
Q

Conditions that may be diagnosed from amniocentesis

A

Neural tube defects

Chromosomal disorders

Inborn errors of metabolism

226
Q

Management of nausea in pregnant women

A

Ginger, acupuncture

Antihistamines first line - promethazine

227
Q

Dose of vitamin D taken by pregnant women

A

10 micrograms daily

228
Q

What is an antepartum haemorrhage?

A

PV bleeding after 24 weeks pregnant, prior to delivery of the fetus

229
Q

Presentation of placental abruption

A

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
Q

Presentation of placenta praevia

A

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
Q

Causes of 1st trimester bleeding

A

Spontaneous abortion

Ectopic pregnancy

Hydatidiform mole

232
Q

Causes of 2nd trimester bleeding

A

Spontaneous abortion

Hydatidiform mole

Placental abruption

233
Q

Causes of 3rd trimester bleeding

A

Bloody show

Placental abruption

Placenta praevia

Vasa praevia

234
Q

Presentation of hydatidiform mole

A

Bleeding in first or early second trimester
Exaggerated symptoms of pregnancy e.g. hyperemesis
Uterus large for dates
Very high hCG

235
Q

Presentation of vasa praevia

A

Rupture of membranes followed immediately by vaginal bleeding
Fetal bradycardia

236
Q

Treating nipple candidiasis whilst breastfeeding

A

Miconazole cream for mother

Nystatin for baby

237
Q

Treatment of mastitits

A

Flucloxacillin for 10-14 days

238
Q

When to treat mastitis?

A

Unwell
Nipple fissure
Doesn’t improve in 24 hours of regular milk removal
Culture indicates infection

239
Q

Conditions that mean breast feeding is contraindicated

A

Galactosaemia

Viral infections - HIV

240
Q

Drugs that can’t be given during breastfeeding

A

Ciprofloxacin, tetracycline, cloramphenicol, sulphonamides

Lithium

Benzodiazepines

Aspirin

Carbimazole

Methotrexate

Sulfonylureas

Cytotoxic drugs

Amiodarone

241
Q

Risk factors for breech presentation

A

Uterine malformations, fibroids

Placenta praevia

Polyhydramnios or oligohydramnios

Fetal abnormality

Prematurity

242
Q

Management of breech

A

At 36 weeks do external cephalic version (success rate 60%)

Planned c section or vaginal delivery

243
Q

Contraindications for external cephalic version

A 
Where c section is required
Antepartum haemorrhage in the last 7 days
Abnormal cardiotocography
Major uterine abnormaly
Ruptured membranes
Multiple pregnancy
244
Q

What is included in the combined test for Down’s syndrome?

A

Nuchal translucency measurement

Serum beta HCG

Pregnancy associated plasma protein A (PAPP-A)

245
Q

When should the combined test for Down’s syndrome be performed?

A

between 11 and 13+6

246
Q

What results from a combined test suggest Down’s syndrome?

A

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
Q

What is the test for Down’s syndrome for a woman who books in late?

A

Triple or quadruple test between 15 and 20 weeks

Triple: alpha-fetoprotein, oestriol, hcg
Quadruple: as above + inhibin A

248
Q

Dietary sources of folic acid

A

Green leafy vegetables

249
Q

Causes of folic acid deficiency

A

Phenytoin
Methotrexate
Pregnancy
Alcohol excess

250
Q

Consequences of folic acid deficieincy

A

Macrocytic, megaloblastic anaemia

Neural tube defects

251
Q

Which women are considered high risk of neural tube defect?

A

Partner has NTD, previous affected pregnancy, family history

Woman taking anti-epileptic drugs, had coeliac disease, diabetes or thalassaemia trait

Women is obese

252
Q

Folic acid dosage in pregnancy

A

400 mcg daily till 12th week

High risk then take 5mg from before conception till 12th week

253
Q

What is a galactocele?

A

Build up of milk creates a cystic lesion in the breast

Painless, no infection signs
Women that have recently stopped breastfeeding

254
Q

Risk factors for group B streptococcus infection in the neonate

A

Prematurity

Prolonged rupture of the membranes

Previous sibling with GBS infection

Maternal pyrexia

255
Q

How many women have group B streptococcus in their bowel flora?

256
Q

If a woman has had group B strep what is the risk of maternal carriage in this pregnancy?

257
Q

Management of women who have previously had group B strep

A

Intrapartum antibiotic prophylaxis

OR
testing at late pregnancy and antibiotics if still positive

258
Q

When should women be swabbed for group B strep?

A

35-37 weeks or 3-5 weeks before anticipated delivery

259
Q

Which women should be offered intrapartum antibiotic prophylaxis for group B strep?

A

Previous group B strep
Previous baby with early or late onset group B strep disease
Preterm labour
Pyrexia during labour

260
Q

Antibiotic for group B strep prophylaxis

A

benzylpenicillin

261
Q

Management of mothers with chronic hep B or acute hep B during prengnacy

A

Complete vaccination course and hepatitis B immunoglobulin for the baby

262
Q

Can mothers with hepatitis B breastfeed?

263
Q

What percentage of pregnant women in london are HIV positive?

264
Q

Factors that reduce vertical transmission of HIV

A

Maternal antiretroviral therapy
C-section
Neonatal antiviral therapy
Bottle feeding

265
Q

High risk groups for pre-eclampsia

A

Hypertensive disease during previous pregnancies

Chronic kidney disease

Autoimmune disorders - SLE, antiphospholipid syndrome

T1DM or T2DM

266
Q

Management of women who are high risk for pre-eclampsia

A

Aspirin 75mg OD from 12 weeks till birth

267
Q

What are the normal changes in blood pressure seen in pregnancy?

A

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
Q

Define hypertension in pregnancy

A

Systolic >140 or diastolic >90

OR

Increase in booking readings of >30 systolic or >15 diastolic

269
Q

Features of pre-existing hypertension in pregnancy

A

History of hypertension or elevated BP >140/90 before 20 weeks gestation

No proteinuria, no oedema

270
Q

Features of pregnancy-induced hypertension

A

HTN after 20 weeks

No proteinuria, no oedema

Resolves after birth

271
Q

Features of pre-eclampsia

A

Pregnancy induced hypertension with proteinuria (>0.3g/24h)

May have oedema

Occurs in 5% pregnancies

272
Q

What does parity mean?

A

Number of pregnancies a woman has carried to viable age (24 weeks)

273
Q

What does gravida mean?

A

The number of times the uterus has contained a fetus

274
Q

Placental abruption - associated factors

A 
Proteinuric hypertension
Cocaine
Multiparity
Maternal trauma
Increasing maternal age
275
Q

What tool is used to screen for postnatal depression?

A

Edinburgh post natal depression scale

> 13 suggestions depressive illness of varing severity

276
Q

Stages of post-partum thyroiditis

A

1) thyrotoxicosis
2) hypothyroidism
3) normal thyroid function

277
Q

Antibodies found in post-partum thyroiditis

A

thyroid peroxidase antibodies in 90%

278
Q

Management of post-partum thyroiditis

A

Propranolol for symptom control in thyrotoxic phase

Thyroxine in hypothyroid phase

279
Q

How many antenatal visits do pregnant women get in their first pregnancy if uncomplicated?

280
Q

How many antenatal visits do pregnant women get in subsequent pregnancies if uncomplicated?

281
Q

Booking blood tests

A

FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies

Hep B, syphilis, HIV

282
Q

Complications from the use of SSRIs during pregnancy

A

Congenital heart disease

> 20 weeks then persistent pulmonary hypertension

Late pregnancy risk neonatal withdrawal symptoms

283
Q

How long does karyotyping results from amniocentesis take?

284
Q

SSRI choice in breastfeeding women

A

Paroxetine

Sertraline

285
Q

Psychiatric drugs to avoid whilst breastfeeding

A

Lithium

Benzodiazepines

286
Q

Antibiotics to avoid whilst breastfeeding

A

Ciprofloxacin

Tetracycline

Chloramphenicol

Sulphonamides

287
Q

What is a low risk result for Down’s syndrome?

A

Lower than 1 in 150

288
Q

What percentage of Down’s syndrome pregnancies are not detected by screening tests?

289
Q

What is a high risk result for Down’s syndrome screening?

A

Above 1 in 150

Refer to diagnostic testing

290
Q

How long after delivery do you do a fasting glucose in women who had gestational diabetes?

A

6-12 weeks

291
Q

When is the booking visit?

A

8-12 weeks

292
Q

When is the early scan to confirm dates?

A

10 to 13+6

293
Q

When is the Down’s syndrome screening including nuchal scan?

A

11 to 13+16

294
Q

When is the anomaly scan?

A

18 to 20+6

295
Q

Definition of pre-eclampsia

A

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
Q

Features of pre-eclampsia

A

Headache

Visual disturbances

Brisk reflexes

Haemorrhage

Liver involvement

HELLP syndrome

Proteinuria +++

Eclampsia

297
Q

Moderate risk factors for pre-eclampsia

A

1st pregnancy

Age ≥40

Pregnancy interval >10 years

BMI ≥ 35

Family history

Multiple pregnancy

298
Q

High risk factors for pre-eclampsia

A

HTN in previous pregnancy

CKD

Autoimmune disease - SLE or antiphospholipid

T1DM or T2DM

Chronic HTN

299
Q

What is prophylactic treatment for pre-eclampsia?

A

Aspirin 75mg OD from 12 weeks

300
Q

Who gets prophylactic treatment for pre-eclampsia?

A

≥ 1 High risk

≥ 2 Moderate risk

301
Q

Management of pre-eclampsia

A

Refer all for same day assessment

1st line oral labetalol

2nd line nifedipine, hydralazine

Delivery of baby

302
Q

Define primary PPH

A

Haemorrhage within 24 hours of delivery

303
Q

Causes of primary PPH

A

Uterine atony in 90%
Genital trauma
Clotting factors

304
Q

What is PPH?

A

> 500ml blood loss

305
Q

Define secondary PPH

A

Haemorrhage 24 hours to 12 weeks after delivery

306
Q

Causes of secondary PPH

A

Retained placenta tissue

Endometritis

307
Q

Management of primary PPH

A 
ABCDE, access
IV syntocin (oxytocin) 
IM camboprost
Intrauterine balloon tamponade
Other surgical options
308
Q

When do baby blues start?

A

3-7 days after delivery

309
Q

How many women are affected by baby blues?

310
Q

Features of baby blues

A

Anxious, tearful, irritable

311
Q

How many women are affected by post natal depression?

312
Q

Management of post natal depression

A

CBT

SSRI options - paroxetine or sertraline

313
Q

How many women are affected by puerperal psychosis?

314
Q

Features of peurperal psychosis

A

Severe mood swings

Disordered perception e.g. auditory hallucinations

315
Q

Management of puerperal psychosis

A

Admit to mother and baby unit

316
Q

Risk of recurrence of puerperal psychosis with further pregnancies

317
Q

When does puerperal psychosis present?

A

2-3 weeks after birth

318
Q

Placenta previa - associated factors

A

Multiparity
Multiple pregnancy
Previous c-section

319
Q

What is placenta previa?

A

placenta lying wholly or partly in the lower uterine segment

320
Q

Intrahepatic cholestasis of pregnancy - features

A

Pruritis - palms, soles, belly

No rash

Raised bilirubin

Jaundice in 20%

321
Q

Intrahepatic cholestasis of pregnancy - management

A

Ursodeoxycholic acid for symptom relief

Weekly LFTs

Vit K supplement

Women induced at 37 weeks

322
Q

Intrahepatic cholestasis of pregnancy - fetal complications

A

Increased risk of preterm birth and stillbirth

323
Q

Acute fatty liver of pregnancy - features

A

Abdo pain

N+V

Jaundice

Headache

Hypoglycaemia

Severe disease may cause pre-eclampsia

324
Q

Acute fatty liver of pregnancy - investigations

A

ALT elevated

Hypoglycaemia

325
Q

Acute fatty liver of pregnancy - management

A

Supportive care

Delivery

326
Q

What is a complete hydatidiform mole?

A

Benign tumour of trophoblastic material

Empty egg fertilised, sperm duplicates own DNA so all DNA is paternal

327
Q

Features of complete hydatidiform mole

A 
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
Q

Risk from a molar pregnancy

A

choriocarcinoma

329
Q

What percentage of women with complete hydatidiform mole develop choriocarcinoma?

330
Q

What is a partial hydatidiform mole?

A

Normal haploid egg may be fertilised by 2 sperm or by 1 sperm with duplication of paternal chromosomes

331
Q

Gestational diabetes - risk factors

A

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
Q

How are women with previous gestational diabetes screened in a new pregnancy?

A

OGTT at booking and at 24-28 weeks

333
Q

How are high risk women screened for gestational diabetes?

A

OGTT at 24-28 weeks

334
Q

Gestational diabetes - glucose levels for diagnosis

A

Fasting ≥ 5.6

2 hour glucose ≥ 7.8

335
Q

Diabetes (all types) - target glucose for self monitoring

A

Fasting 5.4

1 hour after meals 7.8

2 hours after meals 6.4

336
Q

Gestational diabetes - management if fasting glucose <7.0

A

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
Q

Gestational diabetes - management if fasting glucose >7.0

A

Start insulin

338
Q

Gestational diabetes - management if fasting glucose 6-6.9 and evidene of macrosomia or hydramnios

A

Start insulin

339
Q

Gestational diabetes - management option for women who don’t want insulin and can’t tolerate metformin/metformin is insufficient

A

Glibenclamide

340
Q

Management of pregnant women with pre-existing diabetes

A

Stop oral hypoglycaemics except metformin and start insulin

5mg folic acid

Detained anomaly scan at 20 weeks

Tight glycaemic control

341
Q

Birth defects associated with sodium valproate

A

Neural tube defects

Neurodevelopmental delay

342
Q

Which anti-epileptic is considered least teratogenic?

A

Carbamazepine

343
Q

Birth defects associated with phenytoin

A

cleft palate

344
Q

If a pregnant woman is taking phenytoin, what additional medication does she need?

A

Vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn

345
Q

Is breastfeeding safe with anti-epileptics?

A

Yes except barbituates

346
Q

Rate of congenital defects in women not taking anti-epileptics vs. women taking anti-epileptics

A

Not taking anti-epileptics = 1-2%

Taking anti-epileptics = 3-4%

347
Q

Chickenpox in pregnancy - risk to mother

A

5x greater risk of pneumonitis

348
Q

Fetal varicella syndrome - risk if exposed

A

1% if exposed before 20 weeks

No cases when exposed over 28 weeks

349
Q

Fetal varicella syndrome - features

A

Skin scarring

Eye defects (microphthalmia)

Learning disability

Limb hypoplasia

Microcephaly

350
Q

Chickenpox in pregnancy - fetal risks

A

Fetal varicella syndrome

Shinges in infancy

Severe neonatal varicella

351
Q

When is neonatal varicella a risk?

A

If mother develops rash between 5 days before and 2 days after delivery

Fatal in 20%

352
Q

Management of chickenpox in pregnancy

A

specialist advice

oral aciclovir within 24 hours if >20 weeks

353
Q

Management of chickenpox exposure in pregnancy

A
  • 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
Q

Management of an obese pregnant woman

A

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
Q

Fetal risks from an obese mum

A

Congenital anomaly

Prematurity

Macrosomia

Stillbirth

Increased risk of obesity and metabolic disorder in
childhood

Neonatal death

356
Q

Maternal risks from obesity in pregnancy

A

Miscarriage

VTE

Gestational diabetes

Pre-eclampsia

Dysfunctional or induced labour

PPH

Would infection

Higher rate of c-section

357
Q

Rhesus negative pregnancy - features in an affected fetus

A

Oedematous

Jaundice, anaemia, hepatosplenomegaly

Heart failure

Kernicterus

358
Q

When do rhesus negative mothers get anti-D?

A

If they are non-sensitised then at 28 and 34 weeks

359
Q

Events that should trigger additional anti D being given

A

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
Q

Rubella in pregnancy - what percentage of fetus’ are affected?

A

90% in first 8-10 weeks

Damage rate after 16 weeks

361
Q

Congenital rubella syndrome - features

A

sensorineural deafness

congenital cataracts

congenital heart disease

hepatosplenomegaly

purpuric skin lesions

salt and pepper chorioretinitis

microphthalmia

cerebral palsy

362
Q

Management of rubella in pregnancy

A

discuss with health protection unit

offer MMR when post natal, not when pregnant or TTC

363
Q

Black cohosh - risks to warn women about

A

liver toxcitiy

“menoherb”

364
Q

Ginseng - risk to warm women about

A

may cause sleep problems and nausea

365
Q

Red clover - risk to warn women about

A

theoretical risk of endometrial hyperplasia and stimulating hormone sensitive cancers

366
Q

Evening primrose oil - risks to warm women about

A

may potentiate seizures

367
Q

Dong Quai - risks to warn women about

A

May cause photosensitivity

Interferes with warfarin

AKT (20 decks)

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