Obstetrics and Gynaecology Flashcards
1
Q
What is Anaemia
A
Low concentration of Haemoglobin in the blood
2
Q
What is the function of Haemoglobin
A
iron in the cell attracts oxygen and carries it around the body
3
Q
why is anaemia more common in pregnancy?
A
blood plasma increases due to demand for 2 humans - this waters down the haemoglobin concentration
4
Q
Consequences of anaemia in pregnancy?(5)
A
- prematurity of baby
- blood loss
- loss of baby
- baby with anaemia
- child with developmental delays
(all due to poor nutrition)
5
Q
symptoms of anaemia in pregnancy? (4)
A
- SOB
- Fatigue
- dizziness
- pallor
6
Q
when is anaemia monitored in pregnancy?
A
twice
- booking appointment (8-10 weeks)
- 28 weeks gestation
7
Q
what is the Hb supposed to be at booking and 28 weeks?
A
booking: >110
28 weeks: >105
8
Q
what does low MCV indicate?
A
iron deficiency
9
Q
what does normal MCV indicate?
A
physiological anaemia
10
Q
what does raised MCV indicate?
A
B12/folate deficiency - intrinsic factor, pernicious anemia
11
Q
drug name for iron tablet?
A
ferrous sulfate
12
Q
dugs needed for low B12?
A
IV hydroxcobalamin or oral cyanocobalamin
13
Q
what should all women be taking in regards to anaemia to prevent neural tube defects
A
folate,5mg if high risk 400mg if low risk
14
Q
issues with atrophic vaginitis?
A
makes the vaginal pH and microbial flora more inclined to brew infections
14
Q
what is atrophic vaginitis?
A
when women have a lack of oestrogen causing dryness, thinning and more inflamed vagina, less elasticated as well
15
Q
3 signs of atrophic vaginitis
A
- pale and dry
- reduced skin folds
- sparse pubic hair
16
Q
treatments for atrophic vaginitis?
A
rings
pessary
lubricants
moisturisers
oestrogen creams
17
Q
what is the cause of BV
A
loss of friendly bacteria leading to higher pH causing anaerobic bacteria to multiply
18
Q
what is BV
A
bacterial vaginosis
19
Q
what bad bacteria is associated to live in BV
A
- gardnerella vaginalis
- mycoplasma hominis
- prevotella species
20
Q
what good bacteria is lost leading to develop BV
A
lactobacilli (lac of bacilli)
21
Q
5 risk factors of BV
A
- multiple partners
- smoking
- copper coil
- excessive cleaning
- antibiotics
22
Q
common presentation of BV?
A
fishy smelling watery grey discharge
23
Q
test for BV?
A
pH paper >4.5 = positive for BV
24
what can be found on microscopy if BV is present?
clue cells
25
what are clue cells in the context of BV
epithelial cells from the cervix that have bacteria stuck inside them - usually gardnerella vaginalis
26
treatment for BV?
metronidazole OR clindamycin
27
metronidazole contraindication?
alcohol
28
risks of BV? (5)
miscarriage
preterm delivery
PROM
low birth weight
postpartum endometriosis
29
30
What is Atrophic vaginitis
Vaginal dryness, can be painful and present with spotting and dysparaneuria(painful sex)
Usually in women post-menopause
Treated with moisturiser and lubricants but also vaginal oestrogen cream if no improvements
31
What is BV - symptoms, diagnosis, management
Bacterial vaginosis
Increased growth of anaerobic bacteria leading to increased pH.
Amsels criteria used 3/4 for diagnosis
1. Fishy odour (whiff test)
2. Thin homogenous white discharge
3. Clue cells on microscopy
4. PH >4.5
Can be asymptomatic = no treatment
Symptomatic = 1. Oral metronidazole 5-7 days OR stat dose 2g oral metronidazole
2. Topical metronidazole
3. topical clindamycin
32
What bacteria is related to BV?
Gardeners Vaginalis
33
Most common epidemiology for cervical cancer?
Women under 45
Usually 25-29 in age
Squamous cell cancer is most common then adenocarcinoma
34
Which hPV strains are most commonly linked with cervical cancer?
16,18 and 33
35
How is cervical cancer usually detected?
1. Cervical smear
2. Post-coital bleeding, intramenstrual bleeding, post-menopausal bleeding
36
What hPV strains are associated with genital warts?
6 & 11
37
what signs are seen on microscopy of cervical cancer cells?
1. enlarged nucleus
2. Irregular nuculear membrane morphology
3. Hyperchromasia (stains darker than normal)
4. A perinuclear halo seen
38
What staging is used for cervical cancer?
FIGO
39
What criteria is used for diagnosis of BV?
Amstels
40
Rough idea of FIDO staging and treatment?
1A - confined to cervix and ONLY SEEN on microscopy
1B - confined to cervic and seen with clinical eye
2 - cervix + upper 2/3 of vagina NOT PELVIC WALL
3 - cervix + lower 1/3 of vagin and in pelvic wall
4 - cervix and pelvic wall and bladder/rectum
1a - hysterectomy
1b-4 radiation and chemo
4 may be palliative in 4b
41
Describe the cervical screening rules for the UK?
Every woman aged 25-64.
25 to 49 = 3 yearly screening
50 to 64 = 5 yearly screening
64 + = no screening done
Annually for those with CIN or HIV
Never for those who have had hysterectomy or not sexually active.
Pregnant women wait 3 months post partum
42
What is umbilical cord prolapse and its risk and management
Umbilical cord comes out before the baby.
If it is far past the intoritus then immediate c-section with mum on all fours waiting is first line
Tocolytics to reduce contractions can be beneficial
Avoidance of touching the cord to avoid vasospasm
What cold happen with umbilical cord prolapse?
- compression
- hypoxia
- oxygen starvation for the foetus
- permanent brain damage or death
43
Ectopic Pregnancy - what is it?, what are the different management types (3)? Investigations?
When a fertilised egg is implanted in an area other than the uterus
Presents with:
1. Lower abdominal pain
2. Bleeding (brown)
3. Amenorrhoea in her history (6-8 weeks)
Investigations:
1. Pregnancy test
2. Transvaginal ultrasound
Expectant management:
1. <35mm, unruptured, asymptomatic, no foetal HB, bHcg <1,000
2. Compatible with other pregnancy
3. Watch and wait - close monitor for 48 hours and if rise in bhcg or symptoms occur = escalate
Medical management:
1. <35mm, unruptured, no foetal Hb, <1,500 bhcg, no significant pain
2. Not compatible with other pregnancy
3. Methotrexate and recheck follow up
Surgical management:
1. >35mm, ruptured, pain, foetal HB, >5,000 bhcg
2. Compatible with other pregnancy
3. Salpingectomy (removal) if no contraindications or infertility problems/ salpingotomy (sparing) if infertility is an issue.
44
What are the terms for depression?
1. Less severe depression (PHQ-9 score of <16)
2. More severe depression (PHQ-9 score of >16)
45
Less severe depression management?
It is preferred for less intrusive and less resourceful management
It is also preferrred not to give meds initially
1. Self guided help (what we are grateful for diaries)
2. Group CBT —> individual CBT
3. Group BA ——> individual BA
4. Group sessions
5. Meditation and mindfulness group session
6.interpersonal psychotherapy
7. Counselling
8. SSRIs (medication)
46
What is the management for more severe depression according to NICE?
Still a shared approach between clinician and patietn
1. Combination of individual CBT and antidepressant
2. Individual CBT
3. Individual BA
4. Antidepressant medications
- SSRI
-SNRI
-MOA etc
5. Counselling
6. Interpersonaly psychotherapy
7. Then group sessions and guided self-exp
47
What are the screening methods for depression?
1. HAD (hospital anxiety and depression scale)
- 14 questions - 7 about anxiety, 7 about depression
2. PHQ-9 ( public health questionnaire)
- 9 questions about whether they have experience certain things within the last 2 weeks (including self-harm)
Both are rated 0-3.
HAD: 0-7 =normal 8-11=borderline 11+ = case
48
What are the 2 key symptoms according to the DSM-5 to be included in diagnosing depression?
1. Avolition ( no-little interest or pleasure in day to day activities)
2. Depressed mood
They have to be within 2 weeks of the other 4 symptoms needed for diagnosis
49
What is the DSM-5 criteria for depression?
Either 1 of the 2 MAIN CRITERIA (depressed mood/avolition)
AND:
- significant weight loss or decrease in appetite
- insomnia or hypersomnia nearly every day
- fatigue or loss of energy
- feelings of worthlessness or inappropriate guilt
- diminished ability to think or concentrate or indecisiveness (nearly every day)
- recurrent thoughts of death
50
What are the rules from swapping antidepressant drugs (fluoxetine)
Stop/withdraw drug for 4-7 days then restart new drug at a reduced dose and build up
51
What are the rules of SSRI-SSRI?
If not fluoxetine then DIRECT SWAP
52
What are the rules for swapping SSRI to TCA?
Cross-tapering
Reducing dose of SSRI and crossing it with new TCA whilst slowly increasing that
53
Rules for swapping SSRIs to venlafaxine (SNRI)
Direct swap but cautious if paroxetine
54
What drug is first line in depression?
SSRI
1. Citalopram usually
2. Fluoxetine in younger adults and kids
3. Sertraline in those with previous cardiac history
55
Cautions with SSRIs?
1. Can cause GI problems (nausea/vomiting/ bloating/ constipation/diarrhoea)
2. Increased risk of GI bleed (PPI needed if taking NSAID)
3. Counselling required when starting drug as it can increase anxiety and depression in first weeks
4. Fluoxetine and paroxetine have higher drug interactions
5. Citalopram and QT interval
- to not be taken with those with congenital/pre-existing long qt-syndrome
56
Which SSRIs have an increased association with drug side effects?
Fluoxetine and paroxetine
57
What interactions are there with SSRIs
1. NSAIDS - need PPI
2. Warfarin/heparin
3 aspirin
4. Triptans - increased risk of serotonin syndrome
5. MAOIs - increased risk of serotonin syndrome
58
When should SSRIs be reviewed and taken until?
<25 review in a week take for up 6 months post remission
>25 review in 2 weeks take fro up to 6 months post remission
Reduced over last 4 weeks of taking
59
Risk of SSRIs in the first trimester?
Small increase of congenital heart defects
Paroxetine = congenital malformations if taken
60
Risk of taking SSRIs in the third trimester of pregnancy?
Persistent pulmonary hypertension of the newborn
61
What is endometrial cancer? - causes, exacerbating and relieving factors, symptoms, epidemiology, investigations and management?
Increased oestrogen/unopposed oestrogen in the body = cancer
- early menarche
- late menopause
- HRT
-nulliparity
Metabolic syndrome (obesity, diabetes, PCOS)
Tamoxifen use
Protective factors:
- smoking
- COCP
- multiparity
Sympotms:
- post menopausal bleeding getting heavier
- intermenstrual bleeding or menorrhagia in younger women
Epidemiology = usually post-menopausal women.
Investigations = TVUS, hysteroscopy and biopsy
Management - total hysterectomy
End stage disease hysterectomy + radiotherapy
Older people who cant deal with surgery = progesterone supplementation
62
How is breast cancer managed?
Dependent on staging and patietn health
Surgery is usually offered unless frail and unwell/elderley with mets (hormonal therapy then used)
63
how are women with no palpable lymphadenopathy managed?
Axillary ultrasound
If negative sentinel node biopsy to assess nodal burden
64
How are women with palpable lymphadenopathy investigated and managed in breast cancer?
Axillar node clearance indicated primary surgeyr
65
When can women have an abortion in the UK?
2 registered medical professionals sign it off, 1 medical registered body to do it
24 weeks or less
medical management usually <10 weeks
66
what is the expectant management for termination?
if incomplete miscarriage has occurred wait 7-14 days until starting medical management if women is well and has no traumatic history to indicate otherwise
67
what is the medical management for termination?
oral mifepristone 2 days wait then vaginal/oral misoprostol if no bleed
2 days bleed if not refer for surgical management then 2 weeks later pregnancy test
68
What is the surgical management for termination?
D+E with contraception insertion
MVA/EVA
69
what is a threatened miscarriage?
closed cervical os
light bleeding
no pain
usually 6-9 weeks but <24 weeks
70
what is a incomplete miscarriage?
open cervical os
bleeding
pain
products to all expelled
71
what is a missed/delayed miscarriage
gesttsaionl sac dies usually >25mm
happens <20 weeks
light bleeding
no pain
cervical os closed
72
what is an inveitable miscarriage?
heavy bleeding clots
pain
open cervical os
73
what is the treatment for incomplete miscarriage/delayed miscarriage?
oral mifepristone
2 days
oral/vaginal misoprostol if products haven't come
74
what is mifepristone and how does it work?
progesterone receptor antagonist
thins endometrial wall causing gestational sac detachment, cervical and uterus dilation and contractions
75
what is misoprostol and how does it work
prostaglandin analogue
more intense contractions
76
what is the difference between placental abruption and praaevia?
ABRUPTION:
- pain
- excess bleeding and shock
- foetal hr decreases
- coagulability is abnormal
- position and lie of baby normal
PRAEVIA:
- no pain
- little to lots of bleeding
- foetal HR ok
- coagulability normal
- position and lie of baby abnormal
77
what puts you at risk of miscarriage?
smoking, obesity, alcohol
diabetes uncontrolled, thyroid disorders
antiphospholipid syndromes also or chromosomal disorders
78
when is it termed recurrent miscarriages?
3 or more consecutive miscarriages
79
what is placenta praevia?
when the placenta is low-lying/covers the internal os
it is in 4 grades
1 = low lying but not touching the internal os
2 = low lying touching edge of internal os
3 = low lying partially covering internal os
4 = completely covering internal os
80
investigations you should and should NOT do for placenta praevia and why?
NO VE due to risk of haemorrhaging the placenta
TVUS
81
when is placenta praevia usually picked up?
20 week scan
82
mangement of placenta praevia if bleeding heavy?
emergency c section to avoid full haemorrhage
83
management of placenta praevia grad 1/2 detected at 20 week scan?
re-scan 32 weeks and assess if still grad 1/2 re scan every 2 weeks
if grade 3/4 elective c-section weeks 37-38
84
what is the leading cause of death of placenta praevia?
PPH
85
