Obstetrics and Gynaecology Flashcards
Investigation of Choice
Suspected Ectopic Pregnancy
Transvaginal USS
Sensitising Events Rhesus Disease (3)
Miscarriage >12 weeks
Abdominal Trauma
Invasive Antenatal Testing
Delivery of Anti-D in Rh -VE
Exception
- At 28 weeks
- At birth on confirmation that baby is Rh +VE
Cannot give to sensitised women
Vaccines and Anti-D Injection
Cannot give live vaccines e.g. MMR within 3 months of anti-D injection
Surfactant Production and Delivery
Catecholamines and cortisol released by the foetus at delivery stop the production of surfactant
Umbilical Arteries Carry
Dexoygenated blood
From foetus to the placenta
Umbilical Vein Carries
Oxygenated blood
From placenta to the foetus
Result of Reduced Oxygen Delivery to Foetus (2)
Reduced growth
Reduced movements
Medical TOP
Early VS Late
Early = up to 9+6 Late = from 10+0
Medical TOP Regimen
Oral anti-progesterone
+
Oral or Vaginal Prostaglandin 24-48 hours later
e.g. 200mg mifepristone + misoprostol
Surgical TOP Methods (2)
Vacuum Aspiration = 6-12 weeks
Dilation and Evacuation = 13-24 weeks
Post-Procedure TOP Care
Pregnancy Test should be given at 2-3 weeks
Contraception should be given
Not progesterone contraception - could reverse TOP
Transfer to CTG
Indications (5)
Decelerations after a contraction
Oxytocin augmentation
Pyrexia 37.5 >2 occassions
FHR <110 or >160
Heart Rate Parameters
Normal = 110-160 Non-Reassuring = 161-180 Abnormal = <110 or >180
Decelerations (pathophysiology, relation to contractions)
- Early
- Late
Early = associated with head compression: sync with contraction Late = mediated by chemoreceptors, recovery lasts beyond the contraction
Hyperstimulation =
> 5 contractions in 10 minutes
CTG Signs of Foetal Compromise (3)
Absent accelerations
Decreased baseline variability
Shallow decelerations
Maternal Cardiac Changes (2)
Increased cardiac output - peaks week 24-28
SBP - slight drop in 2nd trimester
Maternal Respiratory Changes (3)
Reduced functional capacity ( < elevation of diaphragm)
Increased tidal volume
Mildly compensated respiratory alkalosis
Maternal Endocrine Changes (4)
Insulin resistant
Reduced bone density
Increased thyroid hormone requirements
Vitamin D deficiency
Maternal Haematological Changes (4)
Iron deficiency anaemia
Hypercoagulable
+ WBC
Gestational thrombocytopaenia
Definition of Gestational HTN
= hypertension + no proteinuria: usually after 20 weeks and resolves within 6 weeks
Investigation of Pre-Eclampsia/HELLP
Bloods = FBC, LFTs, U&Es, coagulation, blood film
Urinary protein: creatinine ratio
Management of Eclamptic Seizures
IV MgSO4
Blood Sugar Parameters in Diabetes
FBG = <5.3
1 hour Post Prandial = <7.8
Definition of Peripartum Cardiomyopathy
= heart failure 2y to LVSD towards the end of pregnancy
EF usually <45%
Often present in pulmonary oedema/symptoms of cardiac failure
Acute Fatty Liver of Pregnancy
- Presentation (4)
- Findings (5)
- Management
Pres: vomiting, abdominal pain, encephalopathy, polydipsia
Findings: Elevated bilirubin Hypoglycaemia Elevated AST/ALT Renal impairment Disordered coagulation
Management: supportive, delivery of baby, N-acetylcysteine
Examples of Prostaglandins used in Labour (3)
Propress
Prostin
Misoprost - medical miscarriage, where intrauterine death has occured
Oxytocin
- Method of Action
- Foetal Distress
Action = stimulates uterine contractility, cervical ripening
= increases contraction frequency and resting tone
FD = bradycardia, transient acidosis
Syntometrine
- Action
- When to Use
= results in sustained tonic uterine contraction
- Only post-natally, if accidentally given antenatal need to deliver immediately
Use of Tocolysis
Used to halt or slow pre-term labour
e.g. atosiban, ritodrine, terbutaline
Pethidine
- Delivery
- Foetal Effects
= IM injection
Can cause decreased FHR variability: directly acts on the foetal myocardial conducting system
Testing for Chlamydia or Gonorrhoea
- Male
- Female
Male = first void urine NAAT Female = self-taken vulvo-vaginal swab
Describing a foetus as engaged
More than 2/5ths of the foetus are in the pelvis
Maternal Screening in Pregnancy
Sickle Cell and Thalassaemia: should be done by 10 weeks
Infection: should be done by 12 weeks, if refuse re-offer at 20 weeks
HIV, Hepatitis B, Syphilis
Needs to be done every pregnancy
If maternal Hepatitis B infection
Give foetus vaccine at 0,4,8,12,16 and 52 weeks
Combined Trisomy 13, 18 and 21 Testing
11-14 weeks
= maternal age + crown-rump length + nuchal translucency + BhCG + PAPP-A
Quadruple Testing
14-20 weeks
= maternal age + AFP + BhCG + unconjugated oestradiol + inhibin A
When is anomaly scan offered?
18-20+6 weeks
Blood Spot Test Post-Natal
Usually between days 5-9
= sickle cell disease, cystic fibrosis, congenital hypothyroidism, IMDs
USS for assessment of hip dysplasia
Abnormal Exam = USS within 2 weeks
Risk Factors = USS within 6 weeks
1st line assessment of Newborn Hearing
Automated otoacoustic emission
Management of pre-eclampsia and eclamptic seizures
- 2nd Choice
Magnesium sulphate
Initial management of seizures = 4g MgSO4 IV over 5 minutes
Can use IV diazepam for prolonged seizures
Acceleration Definitions
= increase in FHR of at least 15 BPM for more than 15 seconds
Deceleration Definitions
= decrease in FHR of at least 15 BPM for more than 10 seconds
2nd Stage Decelerations
= normal
The variability and baseline should be preserved
Limit age for foetal movements
24 weeks
Lithium in Pregnancy
Potentially teratogenic
Try and use other mood stabilisers
Epilepsy Medications Safe in Pregnancy (2)
Lamotrigine
Levetiracetam
Testing for haemoglobinopathies
- Factor
Depends on prevalence
High = lab test
Low = questionnaire
Testing for Gestational Diabetes
- Risk Factors
- Previous Gestation Diabetes
RF = OGTT between 24-28 weeks
Previous Gestational = OGTT at/as close as to booking
- Repeat at 24-28 weeks if normal
Diagnosis of Gestational Diabetes
Fasting glucose >5.6
2 hour glucose >7.8
Insulin threshold for Gestational Diabetes
Treat with insulin if fasting glucose >7
Breech at 36 weeks
Offer External Cephalic Version at 37 weeks
Giving Anti-D in Rhesus Negative
500 units at 28 and 34 weeks
Management of DVT/PE
LMWH
Titrated to booking weight - dose also depends on whether prophylaxis or treatment dose
Heparin and Delivery (2)
Therapeutic = stop 24 hours before delivery Prophylaxis = stop 12 hours before delivery
Difference between threatened and inevitable miscarriage
Cervical os closed and open respectively
Partial Molar Pregnancy =
= 2 sperm with 1 egg, contains 69 chromosomes, foetal parts may be present
Complete Molar Pregnancy =
= egg without DNA: no foetus
Which cord blood gas best reflects the condition of the foetus?
Arterial blood gas
Difference between arterial and venous cord blood gas
- Small
- Big
Small = suggests chronic problem, compensated Big = acute event e.g. cord compression
Reducing frequency and intensity of contractions (2)
- Slowing/reducing oxytocin infusions
- Giving an IV fluid bolus
When does the autonomic nervous system mature? Order? What does this mean?
28 weeks
Sympathetic before parasympathetic
Means that pre-term babies have a higher baseline and reduced variability
Association with variable decelerations
Cord compression
When to avoid methyldopa (2)
Liver dysfunction
Post-partum period
Immunosupressants (3)
Tacrolimus
Azathioprine
MMF - teratogenic, can’t use in pregnancy
Drug Levels and Pregnancy
As pregnancy goes on haemodiluted and increased renal clearance and metabolism = reduced drug levels
Painkiller to avoid in Pregnancy
= NSAIDs
Strawberry Cervix
= trichomonas vaginalis
Window Periods
- Chlamydia
- Gonorrhoea
- HIV
- Syphilis
- Hepatitis B
2 weeks = chlamydia and gonorrhoea
45 days = HIV
90 days = syphilis and hepatitis B
Emergency Contraception Time Periods
UPA = can be used up to 120 hours
Levonorgestrel = can be used up to 72 hours
Copper Coil = can be used up to 120 hours
Investigation to confirm ovulation
Midluteal progesterone level
e.g. day 21 in 28 day cycle
Normal semen analysis
> 15 million sperm count
Management of Chlamydia
100mg doxycycline for 7 days
Management of PID
14 days
Doxycycline 100mg bd
Metronidazole 400mg bd
Ceftriaxone 1g IM
Management of Syphilis
Penicillin G IM
Contact Tracing
- Chlamydia
- Gonorrhoea
Chlamydia = last 6 months Gonorrhoea = last 3 months
Production of hCG
Produced by placental cells to maintain corpus luteum to produce progesterone
Peaks at 9 weeks, from 12 weeks placenta produces progesterone
Management of Ectopic Pregnanacy
Medical = methotrexate Surgical = laparoscopic, preference is removal or tube
Use of Foetal Scalp Electrode
- When used (3)
- Contraindications (3)
Used = ruptured membranes, cervix >2cm, presenting part well presented Contraindications = HIV, herpes, hepatitis
Diagnosis of IUGR (2)
Head and abdominal circumferences
USS doppler of umbilical artery
Signs of Uterine Rupture (4)
Foetal bradycardia
Upward displacement of presenting part
Loss of contractions
Maternal hypotension
Management of Premature Ovarian Failure (2)
Combined Pill
HRT
Types of Breech Presentation (3)
Frank
Complete
Footling
4 Ts of PPH
Tone
Tissue
Trauma
Thrombin
Management of Shoulder Dystocia (5)
McRobert's Suprapubic Pressure Episiotomy Internal Manoeuvres All Fours
Triad for Hyperemesis
Dehydration (e.g. ketones in urine)
Weight loss >5%
Electrolyte disturbance
Risk associated with ondansetron
Cleft palate
Delay in return of fertility - contraceptive method
Depo-Provera
Screening for Abnormalities
- Screening tests
- Non Invasive Pre-Natal Testing
- Amniocentesis or CVS
Hormonal Options in Chronic Pelvic Pain (2)
OCP
GnRH analogue
Management of HTN in PET (2)
- Labetalol
2. Hydralazine
Maternal Sepsis ABx (Tayside)
IV Co-Amoxiclav and Gentamicin
Sheehan’s Syndrome =
- Cause
= necrosis of the pituitary gland
Occurs due to hypovolaemia due to PPH
Improving Uterine Tone
- 40 IU oxytocin in 500mls of saline
2. Consider PR Misoprostol or IM carboprost + bimanual compression
Copper Coil Time Period Contra-Indications
Between 48 hours and 28 days postpartum
Stopping the C-OCP before surgery
Need to stop 28 days before
Management of asymptomatic bacteriuria (pregnancy)
Antibiotics
Medication used in Stress Incontinence
Tolteradine
Foetal pole measurement where would expect to see heartbeat
> 7mm
Time taken for contraceptive to work
POP - 2 days
Everything else - 7 days
Whirpool Sign =
= ovarian torsion
Management of
- Bacterial Vaginosis
- Trichomonas
BV = metronidazole Trichomonas = metronidazole
Painkiller contra-indicated in pregnancy
Aspirin
Can cause Reye’s Syndrome (brain disease, bad)
AFP in pregnancy: associations
- High
- Low
High = neural tube defects Low = Down's Syndrome
Management of Premature Rupture of the Membranes
Oral erythromycin
Boggy, tender uterus =
= adenomyosis
Infection associated with foetal death and hydrops
Parvovirus
Switch from rivaroxaban to what in pregnancy
LMWH heparin
All NOACs are contra-indicated in pregnancy
Contraindication for using ergometrine for active 3rd stage
Hypertension
Thrush + Pregnant
Topical clotrimazole
Oral medications are contra-indicated
Mx of fibroids + causing difficulty conceiving
Myomectomy
Investigation of mild oligozoospermia
Repeat sperm analysis after 3 months
Risk factor for cord prolapse
Artificial rupture of the membranes
Which part of the fallopian tube is the most dangerous for ectopic pregnancies?
Isthmus
part nearest the uterus
<6 weeks pregnant + bleeding
= manage expectantly
Group B streptococcus =
Streptococcus agalacticae
<20 weeks pregnant exposed to chicken pox
Single dose of immunoglobulin
> 20 weeks pregnant exposed to chicken pox
Oral aciclovir
Need to present within 24 hours of symptoms
