Obstetrics - Corrections pt2 Flashcards
What treatment is offerec to help prevent miscarriage in antiphospholipid syndrome?
High-dose aspirin + LMWH
Role of aspirin in preventing miscarriage in antiphospholipid syndrome?
Aspirin reduces the risk of thrombosis by inhibiting platelet aggregation and subsequent pregnancy loss in APS.
Role of LMWH in preventing miscarriage in antiphospholipid syndrome?
LMWH augments the activity of antithrombin III and prevents the conversion of factor Xa to its activated form.
This results in the prevention of prothrombin to thrombin.
This helps to stabilise fibrin clot.
When is the first dose of anti-D prophylaxis administered to rhesus negative women?
28 weeks
What is the most common type of ovarian cyst?
Follicular cyst
When do follicular cysts occur?
These occur during the menstrual cycle when a follicle does not release an egg in ovulation
Which nutrient is deficient in breast milk?
Vitamin K
Vitamin K traverses the placenta poorly and is present in LOW concentrations in breastmilk.
Newborns are prophylactically injected with IM vitamin K immediatley after birth to prevent haemorrhagic disease of the newborn.
What investigation can be carried out to confirm the diagnosis of PROM?
Actim-PROM vaginal swab.
This detects IGFBP-1 in vaginal fluid.
What does a ‘boggy’ uterus refer to?
Uterus that isn’t contracted
What would you want to test in pre-eclampsia?
Reflexes –> can get hyperreflexia in pre-eclampsia.
What PCR indicates pre-eclampsia?
> 30
When do the majority of seizures occur in eclampsia?
In the postnatal period (44%), but they can also occur in the antepartum (38%) or intrapartum (18%) settings.
What are some high risk risk factors for eclampsia?
- Chronic HTN, pre-eclampsia or eclampsia in previous pregnancy
- Pre-existing CKD
- Diabetes mellitus
- Autoimmune diseases (e.g. SLE, antiphospholipid syndrome)
What is the hallmark feature of eclampsia?
A new onset tonic-clonic type seizure, in the presence of pre-eclampsia (new onset HTN and proteinuria after 20 weeks’ gestation).
Clinical presentation of eclampsia?
- Seizures
- Headache
- Hyperreflexia
- N&V
- Generalised oedema
- RUQ pain +/- jaundice
- Visual disturbances e.g. flashing lights, blurred or double vision
- Change in mental state
What are some maternal complications of eclampsia
- HELLP syndrome
- DIC
- AKI
- Adult respiratory distress syndrome
- Cerebrovascular haemorhage
- Permanent CNS damage
- Death
What are some foetal complications of eclampsia?
- IUGR
- Prematurity
- Infant respiratory distress syndrome
- Intrauterine foetal death
- Placental abruption
Give 3 differentials for eclampsia
Hypoglycaemia
Pre-existing epilepsy
Haemorrhagic stroke
Investigations in eclampsia?
- FBC
- U&Es
- LFTs
- Clotting studies
- Blood glucose (exclude hypoglycaemia)
- US: estimate the gestational age and to rule out placental abruption
- CTG monitoring
What is a reversible cause of seizures?
Hypoglycaemia
FBC results in eclampsia?
Low Hb & low platelets
U&E results in eclampsia?
Raised urea, raised creatinine, raised urate, low urine output
LFT results in eclampsia?
Raised ALT, raised AST, raised bilirubin
What are the 5 main principles to address in the management of eclampsia?
1) Resuscitation:
- ABCDE
- Patient should lie in the left lateral position
2) Cessation of seizures
3) BP control
4) Prompt delivery of baby and placenta
5) Monitoring
1st line treatment of eclamptic seizures?
Magnesium sulphate
What is a CTG sinusoidal trace usually due to?
Foetal anaemia e.g. vasa praevia
Causes of prolonged deceleration (>3 minutes)?
1) cord prolapse
2) placental abruption
3) uterine rupture
4) uterine hyperstimulation syndrome (by oxytocin or spontaneous increased activity)
5) maternal hypotension (usually 2ary to supine hypotension or epidural top up)
Women who have been treated for CIN require follow up cervical screening.
When should this follow up be?
6 months after treatment for a test of cure repeat cervical sample.
Is the IUS affected by enzyme inducers/inhibitors?
No
Management of women with a positive pregnancy test and at least one of the following: vaginal bleeding, abdominal, pelvic or cervical motion tenderness?
Refer for immediate assessment at the Early Pregnancy Unit
What is the treatment for choice for stage I and II endometrial cancer?
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
Steps of PPH management:
1) ABCDE
2) 2x peripheral cannulae & commence warmed crystalloid infusion
3) Mechanical:
- uterine fundus compression
- catheterisation to prevent bladder distension and monitor urine output
4) Medical:
- IV oxytocin (slow IV injection followed by IV infusion)
- ergometrine (slow IV or IM) unless history of HTN
- carboprost IM (unless history of asthma)
- misoprostol sublingual
5) Surgical:
- intrauterine balloon tamponade (1st line)
- hysterectomy
In monochorionic twin pregnancies, what is the main pathology that ultrasound monitoring performed between 16 and 24 weeks gestation aims to detect?
Twin to twin transfusion syndrome
What is the most reliable test to confirm ovulation?
Progesterone level
When is the earliest time you can offer ECV?
36 weeks gestation
Sex hormone binding globulin (SHBG) conc in PCOS?
Normal to low
What is SHBG?
SHBG is a plasma protein that binds the steroid hormones oestrogen, testosterone, and dihydrotestosterone.
Low concentrations of SHBG increase the concentration of unbound, biologically active testosterone and dihydrotestosterone, leading to features of hyperandrogenism associated with PCOS.
Where is the most appropriate place to insert the implant?
Subdermal, non-dominant arm
What is the recurrence rate of postnatal psychosis?
25-50%
Women needs a specialist referral to a perinatal mental health team.
What weight loss in the first week of life indicates a need for referral to a midwife-led breastfeeding clinic?
> 10%
For patients assigned female at birth receiving testosterone therapy, which forms of contraception are contraindicated?
Contraceptives containing OESTROGEN only
What are some risk factors for gestational diabetes (that then warrant an OGTT at 24-28 weeks)?
1) BMI >30
2) Previous macrosomic baby (>4.5kg)
3) Previous gestational diabetes
4) 1st degree relative with diabetes
5) Family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
What is the first-line non-hormonal treatment for menorrhagia?
Tranexamic acid
1st line maangement of candida (thrush) in pregnancy?
Clotrimazole pessary
Note –> oral fluconazole is CONTRAINDICATED due to its association with congenital abnormalities.
What is the most likely location of the ectopic pregnancy?
Ampulla of fallopian tube
What is 1ary management of ovarian cancers staged 2-4?
Surgical excision of the tumour (may be accompanied by chemo).
What is the only effective treatment for large fibroids causing problems with fertility if the woman wishes to conceive in the future?
Myomectomy
What are the 2 SSRIs of choice in breastfeeding women?
Setraline & paroxetine
When can an ECV be coffered?
From 36 weeks in nulliparous
From 37 weeks in mutliparous
What are the 3 stages of postpartum thryoiditis?
1) Thyrotoxicosis
2) Hypothyroidism
3) Normal thyroid function (but high recurrence rate in future pregnancies)
What Abs are found in 90% of patients with postpartum thyroiditis?
Thyroid peroxidase antibodies
How is the thyrotoxic phase of postpartum thyroiditis managed?
Propanolol (for symptom control)
Note - not usually treated with anti-thyroid drugs as the thyroid is not overactive.
How is the hypothyroid phase of postpartum thyroiditis managed?
Treated with thyroxine
What are 4 medications that can be used in the management of urge incontinence?
Antimuscarinics:
- oxybutynin
- solifenacin
- tolterodine
- darifenacin
Is oxybutynin immediate or modified release used in urge incontinence?
Immediate release
However, immediate release oxybutynin should be avoided in ‘frail older women’.
What is the most important risk factor for developing placenta accreta?
Previous c sections
Is there a screening programme for ovarian cancer?
No
What injury is the ‘waiter’s tip hand’ seen in?
Erb’s palsy
What is required for a diagnosis of pre-eclampsia?
New onset BP ≥140/90 after 20 weeks AND ≥1 of proteinuria, organ dysfunction.
Management of gestational diabetes if fasting plasma glucose is <7 mmol/l?
1) Trial of diet and exercise for 1-2 weeks
2) If targets not met –> add metformin
3) If still not met –> add insulin
What does a Bishops score of ≥8 indicate?
The cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour
Is lithium safe in breastfeeding?
NO
In a LSCS, what layers do you cut though to reach the fetus?
1) Skin
2) Superficial fascia
3) Deep fascia
4) Anterior rectus sheath
5) Rectus abdominis muscle
6) Transversalis fascia
7) Extraperitoneal connective tissue
8) Peritoneium
9) Uterus
What is sometimes referred to as chocolate cysts due to the external appearance?
Endometriotic cyst
What is the most common ovarian cancer?
Serous carcinoma
When is a CVS vs amniocentesis performed?
CVS: 11-13 weeks
Amniocentesis: from week 15 onwards
Where is a swab taken from for TV?
Posterior fornix
Depending on your local guidelines, for vaginal swabs, you may be expected to take “double swabs” or “triple swabs”.
What does a double swab and triple swab involve?
Double swab –> NAAT swab (vulvovaginal) + high vaginal Amies (charcoal) medium swab.
Triple swab –> NAAT swab (vulvovaginal) + high vaginal Amies (charcoal) medium swab + endocervical Amies (charcoal) medium swab.
What are the 3 key features of disseminated gonococcal infection?
1) tenosynovitis
2) migratory polyarthritis
3) dermatitis (lesions can be maculopapular or vesicular)
Azithromycin, erythromycin & clarithromycin in pregnancy?
Azithromycin & erythromycin –> most acceptable
Clarithromycin –> less acceptable
What is the most acceptable macrolide Abx in pregnancy?
Erythromycin
What are some potential pregnancy related complications of chlamydia?
1) Preterm delivery
2) Premature rupture of membranes
3) Low birth weight
4) Postpartum endometritis
5) Neonatal infection (conjunctivitis and pneumonia)
What is Lymphogranuloma venereum (LGV)?
A condition affecting the lymphoid tissue around the site of infection with chlamydia.
Caused by a serotype of Chlamydia trachomatis.
Who does LGV most commonly present in?
MSM presenting with anal discharge and pain, or anyone presenting with rectal chlamydia.
Management of LGV?
Longer course of doxycycline (21 days)
What is a crucial differential diagnosis of Chlamydial Conjunctivitis and should always be tested?
Gonoccocal conjunctivitis –> can result in severe complications such as vision loss if the bacteria penetrate further and cause corneal ulceration.
Why should a standard charcoal endocervical swab also be taken from the symptomatic area in all patients with symptoms of gonorrhoea?
This is to test for sensitivities and monitor patterns of antimicrobial resistance.
NAAT tests only determine if a gonococcal infection is present or not - does not give information about specific bacteria and their Abx sensitivities.
1st line management for gonorrhoea?
IM ceftriaxone
what class of antibiotic is ceftriaxone?
Cephalosporin
what class of antibiotic is cirpofloxacin?
Fluoroquinolone
Why should ALL patients with gonorrhoea have a follow up ‘test of cure’ 2 weeks after treatment?
Given the high antibiotic resistance.
What is disseminated gonococcal infection (GDI)?
A complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints:
- polyarthralgia
- migratpry polyarthritis
- tenosynovitis
- systemic symptoms e.g. fever & fatigue
- non-specific skin lesions
Causative organism of syphilis?
Treponema pallidum
What is Bechet’s syndrome? What classic triad is seen?
A complex multisystem disorder associated with presumed autoimmune-mediated inflammation of the arteries and veins.
Classic triad:
1) Oral ulcers
2) Genital ulcers
3) Anterior uveitis
Features of 1ary syphilis?
- Chancre: painless ulcer at the site of sexual contact
- Local non-tender lymphadenopathy
- Often not seen in women (the lesion may be on the cervix)
Why is 1ary syphilis often not seen in women?
Lesion may be on cervix
When does 2ary syphilis occur?
6-10 weeks after 1ary infection
Features of 2ary syphilis?
- systemic symptoms: fevers, lymphadenopathy
- rash on trunk, palms and soles
- buccal ‘snail track’ ulcers (30%)
- condylomata lata (painless, warty lesions on the genitalia )
Features of 3ary syphilis?
- gummas (granulomatous lesions of the skin and bones)
- ascending aortic aneurysms
- general paralysis of the insane
- tabes dorsalis
- Argyll-Robertson pupil
What does a negative non-treponemal test + positive treponemal test indicate in syphilis treatment?
Successfully treated syphilis
What organism causes pubic lice infestation?
Parastite –> Phthirus pubis.
How is pubic lice treated?
Insecticides –> either malathion lotion or permethrin cream.
Both should be applied to the whole body and washed off after 12 hours.
Mx of 1ary herpes infection in pregnancy?
Elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at >28 weeks gestation.
Mx of 1ary herpes infection in 3rd trimester of pregnancy?
Oral aciclovir 400mg TDS until delivery
1st line management of syphilis?
IM benzathine penicillin
What cells are seen on microscopy in BV?
Clue cells
Mx of trichomonas vaginalis?
Oral metronidazole
What is the investigation of choice in genital herpes?
NAAT
Mx of solitary, keratinised genital wart?
Cryotherapy
Mx of multiple, non-keratinised warts?
Topical podophyllum
What infection should be suspected in contact lens associated keratitis?
Pseudomonas aeruginosa
What should an outbreak of genital herpes be treated with?
Oral aciclovir
In needle-phobic patients, what is the Mx of gonorrhoea?
Oral cefixime + oral azithromycin
What is the most sensitive and specific test for the diagnosis of Chlamydia in females?
Vulvovaginal swab for NAAT
What is acanthamoeba keratitis?
A cause of contact lens-associated eye disease commonly associated with contact lens use in bodies of water such as the sea or swimming pools.
What is the Jarisch-Herxheimer reaction?
Reaction following antibiotic administration for syphilis (benzathine penicillin).
Presents with fever, rash, chills and headache.
In contrast to anaphylaxis, there is no wheeze or hypotension.
What is the management of the Jarisch-Herxheimer reaction?
no treatment is needed other than antipyretics if required
What organism causes BV?
Gardnerella vaginalis
Pain in genital ulcer caused by syphilis vs herpes?
Syphilis –> chancre is painless
Herpes –> painful
Does the diagnosis of vaginal candidiasis require a high vaginal swab if the symptoms are highly suggestive?
No - can be clinical
What can parvovirus B19 infection in pregnant women lead to?
Can cross the placenta and cause hydrops fetalis.
Which form of emergency contraception should be used with caution in patients with severe asthma?
Ulipristal (EllaOne)
1ary mechanism of action of the implant?
Inhibits ovulation
Is trimethoprim in breastfeeding safe?
Yes
Describe stage 1-4 of ovarian cancer
1: confined to ovary
2: tumour outside ovary but within pelvis
3: tumour outside pelvis but within abdomen
4: distant metastasis
1st line for infertility in PCOS (after weight loss)?
Clomifene
What investigations are recommended for all pre-menopausal women with complex ovarian cysts?
Serum CA-125, AFP + b-HCG
What is b-HCG levels for expectant, medical and surgical management of an ectopic?
Expectant: <1000
Medical: <1500
Surgical: >5000
Is migraine with aura a contraindication for HRT?
No (unlike the COCP)
However, topical preparations are preferred rather than oral.
What is the only form of contraception licensed to be used as the progesterone component in HRT?
Mirena coil
How long is the Mirena coil licensed for as HRT?
4 years
