Obstetrics and Gynaecology Flashcards
Features of polycystic ovary syndrome?
PCOS PAL
P - polycystic ovaries on ultrasound.
C - cycles are erratic or amenorrhoea.
O - obesity and hirsutism.
S - subfertility.
P - prolactin elevated (mildly).
A - androgens elevated (modestly).
L - LH elevated (significantly).
PCOS is linked to which other medical conditions?
- Insulin resistance.
- Hypertension.
- Lipid abnormalities.
- Increased risk of cardiovascular disease.
- Acne.
- Hirsutism.
What (usually) happens to production of GnRH in hypothalamic disease?
Decreased GnRH > decreased LH and FSH from anterior pituitary.
Describes FSH serum levels in primary (or premature) ovarian failure?
Elevates.
How might you distinguish Cushing’s syndrome from PCOS by blood results?
Cushing’s - suppression of LH and FSH.
PCOS - significantly elevated LH.
Hypertension and proteinuria in a pregnant woman?
Pre-eclampsia - URGENT ASSESSMENT.
Classical triad of pre-eclampsia?
PRE
- Proteinuria ++.
- Rising BP - generally >140/90mmHg.
- Oedema.
Complications of pre-eclampsia?
D - disseminated intravascular coagulation. R - renal failure. C - cerebral haemorrhage. O - oligohydramnios. G - intrauterine growth retardation.
DDx of vaginal bleeding with a positive pregnancy test?
- Miscarriage.
- Ongoing pregnancy.
- Ectopic pregnancy.
- Cervical pathology (e.g. ectropion, polyp, cancer).
- Menstrual period (if pregnancy test not yet performed).
- THREATENED MISCARRIAGE.
DDx of RIF pain with positive pregnancy test?
- Ectopic pregnancy.
- Ongoing normal pregnancy.
- Appendicitis with concurrent pregnancy.
DDx of hyperemesis, positive pregnancy test, vaginal spotting and ketones 4+?
- Normal pregnancy with hyperemesis.
- Miscarriage.
- Molar pregnancy.
- Exclude other causes of vomiting.
How is a threatened miscarriage managed?
- Discharge home with safety netting.
- Bleeding in early pregnancy is not uncommon, though cervix is closed it is impossible to predict what will happen.
- Offer an early pregnancy contact card if appropriate.
How is a pregnancy of unknown location initially managed in a clinically well patient?
Allow home.
- Safety net regarding seeking urgent help if in pain / faint / unwell.
- Repeat HCG in 48 hours.
Management of ruptured ectopic?
- ABCDE.
- Call for immediate help.
- IV access x 2.
- Fluid resus.
- Urgent blood transfusion (O neg If unknown).
- Immediate theatre for emergency laparotomy / diagnostic laparoscopy.
TVUSS shows enlarged uterus with a multi cystic appearance (bunch of grapes) and enlarged yolk sac for gestation - diagnosis?
Molar pregnancy - needs histopathological diagnosis.
How is a suspected molar pregnancy managed?
- Histopathological diagnosis.
- Surgical evacuation of the uterus.
- If high suspicion - refer to specialist molar service prior to results for HCG tracking and potentially requiring chemotherapy.
How does molar pregnancy occur?
As a result of abnormal fertilisation.
What is a partial molar pregnancy?
2 sperm + 1 egg = foetal parts (69 XXX, 69 XXY, 69 XYY).
What is a complete molar pregnancy?
Sperm fertilises “empty egg” - 46XX - all androgenic material.
What is choriocarcinoma?
A malignant trophoblastic cancer.
Where there is infertility due to oligospermia what is an appropriate treatment?
Intracytoplasmic sperm injection (ICSI) - reduces chance of failed fertilisation.
Why should a hormone profile (LH, FSH, testosterone) be carried out in male infertility?
- If FSH is high > spermatogenesis failure.
How might cystic fibrosis or y chromosome deletion contribute to male infertility?
Can produce oligospermia / azoospermia.
What impact is PCOS likely to have on menstrual cycles?
- Causes anovulatory cycles.
Treatment options for infertility due to PCOS?
- Weight loss.
- Clomiphene induction following hysterosalpingogram to ensure tubal patency.
- ROTTERDAM CRITERIA.
In unexplained fertility, at which point would intervention take place and what would this be?
93% will fall pregnant naturally within 2 years.
After 2 years, IVF is recommended.
Not ICSI unless fertilisation fails.
In pregnancy, persistent breathlessness or chest pain warrants what?
Investigation for cardiac causes.
Cardiac causes account for 23% of maternal deaths and are often overlooked.
What steps should be taken when pregnant or post-partum women complain of ill health?
- Red flag: escalate to senior doctors and obstetricians before discharge.
RCOG guidance - pregnant women may look well but can deteriorate rapidly.
What steps should be taken for pregnant women who experience their first seizure / worsening epilepsy?
Urgent phone referral due to high risk.
NEVER stop meds without seeking expert advice.
Explain the term human factors.
Describes the interaction between individuals at work, a task and the workplace.
(Seeks to understand how people perform under different circumstances e.g. stress/ fatigue/ time constraints in order to create systems to reduce mistakes.)
What is an alternative approach to ABCDE in maternal collapse?
Head, heart, chest, abdomen, vagina, legs.
(head - AVPU, heart - CRT / HR / BP / murmur, chest - bilateral air entry / RR / O2 sats / breath sounds / trachea, abdomen - acute rebound or guarding / tenderness uterine or non-uterine / is the foetus alive CTG / need for laparotomy or emergency delivery, vagina - bleeding / what stage is labour / is there an inverted uterus, legs - DVT)?
What are contraindications to fluid resuscitation in maternal collapse?
- Pulmonary oedema.
- Severe pre-eclampsia.
- Renal failure.
What investigations to consider in maternal collapse?
- ABG.
- Troponin.
- Blood glucose.
- Lactate.
- Blood cultures.
- ECG.
- CXR.
- US abdomen.
- High vaginal swab.
- CT / MRI / ECHO.
We want to monitor with continuous ECG, RR, HR, BP, pulse oximetry.
Can consider arterial and CVP lines.
What are potential causes of maternal collapse originating in the head?
- Eclampsia (seizures).
- Epilepsy.
- CVA.
- Intracranial haemorrhage.
- Vasovagal response.
What are potential causes of maternal collapse originating in the heart?
- MI.
- Arrhythmia.
- Peripartum cardiomyopathy.
- Congenital heart disease.
- Dissection of thoracic aorta.
What are potential causes of maternal collapse due to hypoxia?
- Asthma
- PE
- Pulmonary oedema
- Anaphylaxis
What are potential causes of maternal collapse due to haemorrhage?
- Placental abruption.
- Uterine atony.
- Genital tract trauma.
- Uterine rupture.
- Rupture aneurysm.
What are potential systemic causes of maternal collapse?
- Hypoglycaemia.
- Amniotic fluid embolism.
- Sepsis.
- Trauma.
- Complications of anaesthesia.
- Anaphylaxis.
Most likely diagnosis?
22 YO F feeling unwell 1 day post SVD with 300ml blood loss at the time.
She has just passed a clot of 200ml and is complaining of faintness. She feels clammy and the uterine fundus is felt above the umbilicus.
PPH.
Consider: tone, tissue, trauma, thrombin.
In this case it is most likely tone.
How to manage PPH?
- O2.
- Expel clots and massage uterus.
- IV access, IV fluids and bloods: FBC, coagulation screen, cross match 4 units.
- Uterotonics: syntocinon, ergometrine, Carboprost.
- Tranexamic acid.
- Urinary catheter.
- If drugs aren’t improving situation > theatre for intrauterine balloon / interventional radiology / laparotomy - B-Lynch suture, uterine or internal iliac artery ligation / hysterectomy.
Likely diagnosis and management?
28 week pregnant F with T1DM who was admitted with vomiting secondary to a UTI collapses.
Hypoglycaemia and sepsis.
Hypoglycaemia: if below 3mmol/L give 50ml of 20% or 100ml of 10% glucose solution IV.
Sepsis: sepsis 6.
Likely diagnosis?
20 YO F with sudden onset severe abdominal pain radiating to her shoulder. She is around 6 weeks pregnant and is complaining of dizziness. This is her first pregnancy.
Ruptured ectopic.
Needs fluid resuscitation and surgical management for acute abdomen.
Likely diagnosis?
30 YO F with heavy vaginal bleeding at 10 weeks gestation. The bleeding started 3 hours ago and contains palm sized clots. Approximately 500ml has been lost so far.
Miscarriage.
Needs fluid resuscitation and surgical evacuation of the uterus (in cases of haemorrhage).
Likely diagnosis. 30 YO F who is acting “oddly” 2 days post emergency lower segment caesarean section (LSCS). She has a Hx of bipolar disorder but was stable throughout pregnancy though her husband feels she is now acting paranoid and is not her usual self.
Puerperal psychosis.
Need to diagnosis ASAP to minimise risk to both mother and baby.
Patient needs psychiatry review and transfer to mother and baby unit.
Likely diagnosis?
32 YO F on labour ward who the midwife feels is “breathing funny and making funny noises” and is complaining of breathlessness. She went into spontaneous labour and has Group B Strep for which she is receiving Group B Strep as per protocol.
Anaphylaxis.
STOP ANTIBIOTICS.
- Give O2.
- Adrenaline 500 MICROGRAMS intramuscularly repeated every 5 minutes if necessary.
- IV fluids.
- Chlorphenamine 10mg IM or IV.
- Hydrocortisone 200mg IM or IV.
- Nebulised salbutamol.
Management of sepsis as a result of endometritis / wound infection / UTI?
Sepsis 6:
- Antibiotics.
- High flow oxygen.
- Fluid challenge.
- Measure urine output.
- Lactate.
- Blood cultures.
Management of retained products of conception and endometritis?
- Antibiotics.
- Surgical evacuation of uterus.
How would you manage a para 2 day 1 post SVD with a history of puerperal psychosis?
(currently midwives have no concern).
- Observation.
- Daily midwife support.
- Possible elective admission to mother and baby unit.
How would you manage a para 3, three days following elective C-section for placenta praevia (EBL 2L) who is now complaining of right calf pain.
- MEOWS: T36.8, HR 80bpm, BP 120/80, O2 sats 98% air.
DDx: DVT.
- Give treatment dosage of fragmin.
- Consider prophylactic fragmin in next pregnancy.
Differential and management for:
Female day 6 post SVD.
- Admitted 2 days ago with fever and right breast pain.
- Currently breastfeeding.
- Fevers persistently swinging despite antibiotics and continued breastfeeding.
DDx: mastitis, breast abscess.
- Provide breast feeding support.
Day 3 post elective c-sec complaints of discharging wound growing increasingly red.
- Patient has BMI of 55.
Differential and management?
Wound infection.
- Wound swab.
- Monitor for sepsis.
- Inflammatory markers.
- Risk of VTE - fragmin prophylaxis.
- Advice regarding risk of future pregnancies e.g. risk of accreta, uterine rupture. Should wait at least one year post delivery to conceive.
- Weight management advice / referral.
- Contraception plan.
Patient found collapsed on floor with a pool of blood visible between her legs and visibly staining her pyjamas.
- Differential and management.
Differential: maternal collapse due to massive PPH.
- Call 2222 emergency obstetric team declare massive obstetric haemorrhage.
- ABCDE.
- Cause of PPH - likely atonic so give uterotonics and tranexamic acid.
- IV fluids and ask for shock pack.
- If bleeding ongoing > bimanual compression while transferring to theatre for examination under anaesthetic and possible uterine balloon or laparotomy.
What is the TORCH screen?
- Toxoplasmosis.
- Rubella.
- Cytomegalovirus.
- HIV.
What is the purpose of amniocentesis karyotyping?
- To detect balanced and unbalanced chromosomes.
- Detect any changes to number of chromosomes.
What is HELLP syndrome?
- Haemolysis.
- Elevated liver enzymes (liver damage).
- Low platelet count.
Usually occurs in last trimester or after childbirth associated with pre-eclampsia or eclampsia.
Management of an overactive bladder?
- Reduce caffeine intake.
- Weight loss.
- Bladder training > refer to incontinence team.
Management of lichen sclerosis of the vulva area?
- Discuss vulval skin care.
- Prescribe soap substitutes and emollients.
- Dermovate daily for 2 weeks then on alternate days for 2 weeks and then once or twice a week for 2 weeks.
- GP follow up.
Management of suspected dermoid cyst of ovary?
- Need to rule out malignancy.
- Schedule for outpatient MRI.
- Tumour markers ca125, HCG, AFP.
- Refer to gynae for further review.
- See patient in clinic with results.
- Dermoid cysts removed surgically.
Management of cervical polyp?
Remove with polyp forceps and send to histopathology. Patient will receive results in post (obviously in person if malignant).`
Investigation of heavy, painful intermenstrual bleeding?
Want to rule out any endometrial pathology.
- Swabs for infection.
- Endometrial biopsy.
- Transvaginal US.
- Review when results available.
Management of prolapse (cystocele) in patients who decline surgery?
- Vaginal pessary with review for change in 6 months.
- Provide contact details if any issues with pessary arise.
At what gestation should a pattern of foetal movements develop?
By 24 weeks.
What can cause reduced sensation of foetal movements before 24 weeks?
Anterior placenta.
But after 24 weeks the location of placenta has no bearing on movements
