Obstetrics & Gynae Flashcards
What is the most common cause of primary PPH?
Uterine atony (failure of contraction)
How would you manage PPH?
- Bimanual uterine compression to manually stimulate contraction
- IV oxytocin and/or ergometrine
- IM carboprost
- Intramyometrial carboprost
- Rectal misoprostol
- Surgical intervention such as balloon tamponade
What drugs are contraindicated in breast feeding?
- Antibiotics: ciprofloxacin, tetracycline, chloramphenicol, doxycycline, sulphonamides
- Psychiatric drugs: lithium, benzodiazepines, avoid clozapine
- Aspirin
- Carbimazole
- Methotrexate
- Sulphonylureas
- Cytotoxic drugs
- Amiodarone
If group B strep is identified on high-vaginal swab how should this be managed?
Intrapartum IV benpen to reduce neonatal transmission.
Alternative: Clindamycin
Mx Mastitis?
Flucloxacillin for 10-14 days, continue breast feeding.
What kind of contraception is absolutely contraindicated in women < 6 weeks post-partum if breast feeding?
COC
Give 6 moderate risk factors for pre-eclampsia?
Management?
- Primip
- > 40
- Pregnancy interval >10 years
- BMI >35
- Family history
- Multiple pregnancy
Mx: Aspirin 75mg OD from 12 weeks.
Mx menorrhagia if:
- Contraception required (1st, 2nd, 3rd line)?
- Not? + Pain?
When are they taken? When would you refer?
If required:
1: Levonorgestrel-releasing IUS (Mirena)
2: COCP
3: long-acting progestogens (Depo-provera)
If not: Tranexamic acid 1g TDS during period only.
If also dysmenorrhoea (pain) give Mefenamic acid 500mg TDS during period only (= NSAID)
Both started on first day of period, if ineffective refer and trial other drug.
What is the most common complication of surgical TOP?
Infection (up to 10%) - Abc routinely given.
What is vasa praevia? What is it’s classic triad?
Foetal blood vessels crossing or running close to the internal orifice of the uterus. Easily compromised when membranes rupture.
Rupture of membranes followed by painless vaginal bleeding and foetal bradycardia.
No major maternal risk, but significant foetal mortality.
What is primary dysmenorrhoea?
Mx?
Excessive pain during period, with no underlying pelvic pathology. Pain typically starts just before or within a few hours of the period starting - whereas secondary is typically 3/4 days before.
Mx: First-line = NSAIDs (mefenamic acid or ibuprofen), effective in up to 80%
Second line- COCP
What is the most likely cause of recurrent first-trimester spontaneous miscarriage?
Antiphospholipid syndrome (Antiphospholipid antibodies (aPL) are present in 15% of women with recurrent miscarriage)
What is a threatened miscarriage?
Threatened miscarriage: any painless vaginal bleeding (not spotting) occurring before 24 weeks, but typically occurs at 6 - 9 weeks.
- Bleeding is often less than menstruation
- Cervical os is closed
- Complicates up to 25% of all pregnancies
Pregnancy continues
What is Meig’s syndrome?
Rare condition usually occurring in women over 40.
The three features of Meig’s syndrome are:
- a benign ovarian tumour (usually a fibroma)
- ascites
- pleural effusion
What are the UKMEC 4 conditions (absolute contraindications to COCP use)?
- more than 35 years old and smoking more than 15 cigarettes/day
- migraine with aura
- history of thromboembolic disease or thrombogenic mutation
- history of stroke or ischaemic heart disease
- breast feeding < 6 weeks post-partum
- uncontrolled hypertension
- current breast cancer
- major surgery with prolonged immobilisation
What is the Mx of severe pre-eclampsia?
Delivery
IV labetalol +/- Magnesium sulphate as seizure prevention
How is chickenpox exposure in pregnancy managed?
If there is any doubt about previous exposure, urgently check VZV antibodies
If non-immune:
- Give VZ immunoglobulin (VZIG) as soon as possible (with 10 days of exposure)
- VZIG has no benefit once rash has started, can give aciclovir within 24 hours of rash onset.
What is a complete hydatidiform mole?
Benign tumour of trophoblastic material, occurring when an empty egg is fertilised by a single sperm that then duplicates its own DNA - all 46 chromosomes are paternal.
Around 2-3% go on to develop choriocarcinoma
What are the features of hydatidiform mole?
Features:
- bleeding in first or early second trimester
- exaggerated symptoms of pregnancy e.g. hyperemesis
- uterus large for dates
- very high serum levels of human chorionic gonadotropin (hCG)
- hypertension and hyperthyroidism (hCG can mimic TSH) may be seen
What is the management of complete hydatidiform mole?
- urgent referral to specialist centre - evacuation of the uterus is performed
- effective contraception is recommended to avoid pregnancy in the next 12 months
What factors are associated with increased risk of miscarriage?
Increased maternal age Smoking in pregnancy Consuming alcohol Recreational drug use High caffeine intake Obesity Infections and food poisoning Health conditions, e.g. thyroid problems, severe hypertension, uncontrolled diabetes Medicines, such as ibuprofen, methotrexate and retinoids Unusual shape or structure of womb Cervical incompetence
What is Sheehan’s syndrome a complication of? Signs? Diagnosis?
Complication of severe PPH.
Pituitary gland undergoes ischaemic necrosis which can manifest as hypopituitarism.
Most common sign: lack of postpartum milk production and amenorrhoea following delivery.
Dx: inadequate prolactin and gonadotropin stimulation tests in patients with a history of severe PPH.
What is the Mx of moderate gestational hypertension?
What about with Hx of asthma or depression?
Oral labetolol.
CI in asthma so give nifedipine or methyldopa.
Methyldopa CI in depression.
What diabetes medications are CI in pregnancy?
Gliclazide and liraglutide
Metformin and insulin are both fine.
What is placenta accreta? What are the risk factors?
Attachment of the placenta to the myometrium (due to defective decidua basalis). Risk of PPH as placenta does not separate properly during labour.
RF:
- Previous CS
- Placenta previa
What is alpha-fetoprotein?
What is the relevance of measuring?
= Protein produced by developing foetus
Low: Neural tube defects, abdo wall defects, multiple pregnancy
Decrease: Down’s, Trisomy 18, Maternal DM
What is a Kleihauer test?
Test for foeti-maternal haemorrhage which detects foetal cells in the maternal circulation and if present estimates volume allowing calculation of additional anti-D immunoglobulin.
Required for any sensitising event after 20 weeks gestation, give 1 dose immediately then calculate.
What is chorioamniotitis?
What is the major risk factor?
A potentially life-threatening condition (medical emergency) as a result of ascending bacterial infection of the amniotic fluid/membranes/placenta.
RF: Preterm premature rupture of membranes.
What is the most common site for ectopic pregnancy?
Tubal, specifically ampulla.
What are the components of the combined Down’s syndrome test?
What weeks of gestation is it done?
What would the results be if positive?
beta-hCG
Pregnancy associated plasma protein A (PAPP-A)
+ Nuchal translucency on US
10-14 weeks
In pregnancies with Down Syndrome, PAPP-A is low and beta-hCG raised.
What are the components of the quadruple Down’s syndrome test?
What weeks of gestation is it done?
- Alfa-fetoprotein (AFP)
- Unconjugated oestriol
- beta-hCG
- inhibin A.
14-20 weeks.
In pregnancies with Down Syndrome, AFP and unconjugated oestriol are low and beta-hCG and inhibin A are raised.
What is the first-line treatment in small (<35mm) unruptured ectopic pregnancy with no visible heartbeat, a serum B-hCG level of <1500 IU/L, no intrauterine pregnancy and no pain?
Methotrexate (provided the patient is willing to return for follow-up)
What is the first-line management of ectopic pregnancy if ectopic is larger than 35mm, is causing severe pain or if the B-hCG level is >1500?
Laparoscopic salpingectomy.
Risk of infertility if a problem arises with the remaining tube in the future.
What is placental abruption?
How does it typically present?
Separation of a normally-sited placenta from the uterine wall, resulting in maternal haemorrhage.
Features:
- Shock out of keeping with visible loss
- Pain constant
- Tender, tense uterus (woody)
- Normal lie and presentation
- Foetal heart: absent/distressed
- Coagulation problems
- Beware pre-eclampsia, DIC, anuria
Give 5 risk factors for breech presentation?
- Uterine malformations, fibroids
- Placenta previa
- Polyhydramnios or oligohydramnios
- Foetal abnormality (CNS, chromosomal)
- Prematurity
What is the Mx of breech presentation?
Depends on gestation:
- If <36 weeks many foetuses turn spontaneously
- If still breech at 36 weeks attempt external cephalic version (ECV) - has a success rate of around 60%
- If still breech then can plan CS or vaginal delivery
What is the primary mode of action of the contraceptive implant? (Etonogestrel)
Inhibits ovulation.
Also thickens cervical mucus
How does the COCP work?
Inhibits ovulation
How does the progesterone-only pill work? (Except desogestrel)
Thickens cervical mucous
How does metformin action in PCOS?
Increases peripheral insulin sensitivity
What is the Bishop scoring system used for?
What would a score less than 5 mean? What about above 9?
To assess the need for induction, taking into account cervical position, consistency, effacement, dilation and foetal station.
<5: Induction likely be necessary
>9: Labour will likely occur spontaneously
How does the desogestrel-only pill work?
Primary: Inhibits ovulation
Also: thickens cervical mucus
What is the third stage of labour?
What is active management of the 3rd stage of labour?
Why is it recommended?
Stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered
Active management lasts less than 30 minutes and involves the following:
- Uterotonic drugs
- Deferred clamping and cutting of cord, over 1 minute after delivery but less then 5 minutes
- Controlled cord traction after signs of placental separation
Recommended to reduce post-partum haemorrhage
How is urge incontinence managed?
- Bladder retraining (for min 6 weeks)
- Bladder stabilising drugs: anti-muscarinic is first line (Oxybutynin, tolterodine or darifenacin).
Avoid immediate release oxybutynin in ‘frail older women’
How is stress incontinence managed?
- Pelvic floor muscle training (at least 8 contractions TDS for a minimum of 3 months)
- Surgery
How are menopausal symptoms treated?
- HRT is most effective
NB. Tibolone is unsuitable for use within 12 month of last menstrual period as may cause irregular bleeding
Non-hormonal methods (may help vasomotor symptoms):
- SSRIs and venlafaxine
- Clonidine (use often limited by SE such as dry mouth, dizziness and nausea)
- A progestogen such as norethisterone
Lifestyle advice:
Regular exercise, avoid caffeine/spicy foods and lighter clothing
Vaginal symptoms:
- Vaginal atrophy may be helped by topical oestrogens
- If the symptoms are predominately vaginal dryness then a lubricant or moisturiser
What is the Mx of atypical endometrial hyperplasia in pre- and post- menopausal women?
Pre-menopausal: Total hysterectomy
Post-menopausal: Total hysterectomy with bilateral salpingo-oophorectomy
Risk of malignant progression.
What is the Mx of simple endometrial hyperplasia?
Simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used.
What is the Mx of obstetric cholestasis?
- Induction at 37 weeks is common practice
- Ursodeoxycholic acid
- Vitamin K supplementation
How long is it until the following contraceptives are effective (if not first day of the period):
- IUD
- POP
- COC, injection, implant, IUS
IUD: instant
POP: 2 days
COC, injection, implant, IUS (7 days)
What is the first line treatment for induction of ovulation in PCOS?
How long can it be used for?
SE?
What would you use as an alternative?
Clomifene (anti-oestrogen)
Given on days 2 to 6 of each cycle to initiate follicular maturation.
If no follicles develop then the dose can be increased from 50mg/day to 100mg/day and finally 150mg/day in subsequent cycles. It is limited to 6 months use and increases the risk of multiple pregnancy to 11%.
Alternative: Metformin (can be used in addition to clomifene). Used alone it has a lower live birth rate compared to clomifene, but increases the effectiveness of clomifene in clomifene-resistant women. It also treats hirsutism and may reduce the risk of gestational diabetes and early miscarriage.
What would you use if Clomifene and metfromin are ineffective in inducing ovulation in PCOS?
What if this is ineffective?
Ovarian diathermy
Gonadotropin induction: daily S/C FSH and/or LH. Stimulates follicular growth, monitor by US. Once a follicle has reached approximately 17mm in size, the process of ovulation is artificially stimulated by injection of hCG or LH.
Third-line: IVF
If mastitis doesn’t improve after 12-24 hours of conservative management what are the 1st and 2nd line Mx?
1st: Oral flucloxacillin 500mg Qds for 14 days, continue breast-feeding.
Erythromycin if allergic.
2nd: Co-amox.
What is the initial imaging modality for suspected ovarian cysts/tumours?
US
What is the management of ovarian cysts?
Premenopausal women:
- Conservative approach if small, simple cyst - highly likely benign ( corpus callosum remnant). Repeat US in 8-12 weeks and refer to gynae if persists.
Postmenopausal:
Regardless of nature or size refer to gynaecology.
Why is folic acid taken in pregnancy? What dose and for how long?
What if there is a previous affected pregnancy or family history?
To prevent neural tube defects.
400 micrograms OD whilst trying to conceive and until 12th week of pregnancy.
If Hx then increase to 5mg.
How does the COCP alter risk of breast, cervical, ovarian and endometrial cancers?
Increased risk: Breast, cervical
Protective against: Ovarian and endometrial
What is the safest drug to use in pregnancy with epilepsy?
Lamotrigine
What should you do if POP dose is missed?
What is the difference with cerazette/desogestrel?
Micronor, Noriday, Nogeston, Femulen:
- If less than 3 hours late, take and no further action required.
- If more, then take missed pill asap (only take 1 if more than 1 missed), take the next pill at the usual time (even if means taking 2 pills in one day) and condom use until pill taking established for 48 hours.
Desogestrel:
- If less than 12 hours late, take pill and continue as normal.
- If more, then advice as above
What are the risk factors for perineal tears?
- primigravida
- large babies
- precipitant labour
- shoulder dystocia
- forceps delivery
What is a first degree perineal tear?
Superficial damage with no muscle involvement
What is a second degree perineal tear?
Injury to the perineal muscle, but without involvement of the anal sphincter
What is a third degree perineal tear?
- 3a?
- 3b?
- 3c?
Injury to perineum involving the anal sphincter complex (external anal sphincter and internal anal sphincter)
- 3a: Less than 50% EAS thickness torn
- 3B: More than 50% EAS torn
- 3C: IAS torn
What is a fourth degree perineal tear?
Injury to perineum involving anal sphincter complex (EAS and IAS) and rectal mucosa
Name 8 associations with endometrial hyperplasia?
- Taking oestrogen unopposed by progesterone
- Obesity
- Late menopause
- Early menarche
- Aged over 35-years-old
- Being a current smoker
- Nulliparity
- Tamoxifen
What is done on the booking visit?
What gestation is this?
8-12 weeks, ideally <10 weeks.
- General info: Diet, EtOH, Smoking, Folic acid, Vit D, antenatal classes
- BP
- Urine dipstick and culture to detect asymptomatic bacteria
- Check BMI
- HIV, hep B, syphillis, rubella testing
- FBC, blood group, rhesus status, red cell alloantibodies, haemohglobinopathies
What is the initial assessment if a woman has not conceived after 1 year, in the absence of any known cause of infertility?
- Semen analysis
- Serum progesterone 7 days prior to expected next period (usually day 28)
What is the Mx of pre-existing diabetes in pregnancy?
- Weight loss if BMI >27
- Stop oral hypoglycaemic agents except metformin, commence insulin
- Folic acid 5mg/day until 12 weeks
- Detailed anomaly scan at 20 weeks
- Tight glycemic control (test: daily fasting, pre and 1 hour post meals, pre bed)
- Treat retinopathy as can worsen during pregnancy
What are the risk factors for endometrial cancer?
- Increased age
- Nulliparity
- Unapposed oestrogen therapy
- Early onset menarche, late onset menopause
- Obesity
In women presenting with PMB, what are you trying to exclude?
What would be your first and second-line investigations?
Endometrial ca
- First: Speculum
- Second: Endometrial biopsy and hysteroscopy
What are the two types of caesarian sections?
Lower segment caesarian section (=99%)
Classic/vertical caesarean section : LT incision in upper segment of uterus.
Both approaches are conducted via a pfannenstiel incision 2cm above the pelvic brim
What are the absolute contraindications to VBAC?
- Classical/vertical caesarian scars
- Previous episodes of uterine rupture
- Placenta previa
- Absolute cephalo-pelvic disproportion
What is the regimen for anti-D prophylaxis?
What does this attempt to prevent?
What if the mother is already sensitised?
Test for D antibodies in all Rh -ve mothers at booking
Give anti-D at 28 and 34 weeks if non-sensitised. Can also give a single dose at 28 weeks.
Prevent anti-D IgG antibodies forming and crossing the placenta in subsequent pregnancies, causing haemolysis in the foetus.
If already sensitised then anti-D is not given. Specialist care, may require foetal transfusions.
What tests should be preformed on all babies born to Rh -ve mothers?
Cord blood taken at delivery: FBC, blood group, direct Coombs test
Coombs: direct anti-globulin, will demonstrate RBCs of baby.
What are the adverse effects of the depo provera?
- Irregular bleeding
- Weight gain
- May potentially increase osteoporosis risk
- Delay of up to 1 year in resumption of fertility
What is the commonest type of ovarian cyst?
What causes it?
Follicular
Due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle. Commonly regresses after a couple of cycles.
What is the most common benign ovarian tumour in women <25?
How do they usually present?
Dermoid cyst (teratoma) Normally asymptomatic, torsion more likely than with other ovarian tumours.
What is the most common benign ovarian epithelial tumour in women overall (not <25)?
What is the second?
Serous cystadenoma (NB. bilateral in around 20%)
Second: Mucinous cystadenoma (typically quite large, if ruptures can cause pseudomyxoma peritonea)
What is foetal fibronectin (fFN)?
Why is it measured?
How would a raised level be managed?
A protein released from the gestational sac. A high level is related to early labour. The level can be used to calculate probabilities of delivery within one week, two weeks etc. Not definitive, some women go to term with raised levels.
Give 2 doses IM steroids, swabs and urine cultures to screen for infection.
What is the initial investigation for suspected ovarian ca?
What might confuse the result?
CA125 level
Endometriosis, menstruation, benign ovarian cysts may raise level.
What would be the next step if a raised CA125 was found?
If >35IU/mL then urgent US of abdomen and pelvis
What is the prognosis of ovarian ca?
80% have advanced disease at presentation.
All stage 5-year survival is 46%
What is the Mx of ovarian ca?
Combination of surgery and platinum-based chemo.
What are the requirements for instrumental delivery?
Mneumonic
FORCEPS:
- F ully dilated cervix (2nd stage)
- O A presentation, preferably. OP possible with Keillands forceps and ventouse
- R uptured membranes
- C ephalic presentation
- E ngaged presenting part (i.e. head at/below ischial spines and not palp abdominally)
- P ain relief
- S phincter (bladder) empty, usually catheter
What are some indications for a forceps delivery?
- Foetal distress in the 2nd stage
- Maternal distress in the 2nd stage
- Failure to progress in the 2nd stage
- Control of head in breech delivery
What is the stepwise mx of PPH? How much blood loss is defined as PPH?
500mls + (Minor: 500-1000ml, Major: >1000ml)
1: Syntocinon 5 units by slow IV injection
2: Ergometrine (CI in HTN)
3: Syntocinon infusion
4: Carboprost (CI in asthma)
5: Misoprostol 1000mg PR
6: Surgical haemostasis
What are the 4 T’s - causes of primary PPH?
Which is the most common?
Tone - Uterine atony (most common- 90%)
Tissue - Retained products of conception
Trauma
Thrombin
What is secondary PPH?
Cause?
Haemorrhage between 24 hours and 12 weeks.
Due to retained placental tissue or endometriosis
What is the cause of PID?
Organisms?
Which is the most common?
Usually as a result of ascending infection from the endocervix
- Chlamydia trachomatis (most common)
- Neisseria gonorrhoeae
- Mycoplasma genitalium
- Mycoplasma hominis
What are the features of PID?
- Lower abdo pain
- Fever
- Deep dyspareunia (difficult/painful intercourse)
- Dysuria and menstrual irregularities may occur
- Vaginal or cervical discharge
- Cervical excitation
What is the Ix and Mx of PID?
Ix: Screen for Chlamydia and Gonorrhoea
Mx: Difficult to diagnose, so have low treatment threshold.
- Oral ofloxacin + oral metronidazole OR
- IM ceftriaxone + oral doxycycline + oral metronidazole
In mild cases intrauterine devices may be left in, but may have better ST outcomes if removed.
What are the possible complications of PID?
- Infertility (may be as high as 10-20% after 1 episode)
- Chronic pelvic pain
- Ectopic pregnancy
What is the McRoberts position? When is it used?
In shoulder dystocia
Hyperflexion of the mothers legs onto her abdomen and apply suprapubic pressure
What is the Rubin manoeuvre? When is it used?
In shoulder dystocia.
Press on the posterior shoulder to allow anterior shoulder extra room
What is the Woodscrew manoeuvre? What position should the mother be in?
Used in shoulder dystocia
Put a hand into the vagina and rotate the foetus 180 degrees to attempt to ‘dislodge’ the anterior shoulder from pubic symphysis.
Put her in the McRoberts position.
In shoulder dystocia, what if the McRobert’s, Rubin and Woodscrew manoeuvres fail?
Try these again with the woman on all fours.
If they fail then push the head back in and do emergency CS.
What factors are associated with development of hyperemesis gravidarum?
- Multiple pregnancy
- Trophoblastic disease
- Hyperthyroidism
- Nulliparity
- Obesity
NB. Smoking is associated with a decreased incidence.
What triad should be present before diagnosing hyperemesis gravidarum?
- 5% pre-pregnancy weight loss
- Dehydration
- Electrolyte imbalance
Most common between 8 and 12 weeks, may persist up to 20 weeks, very rare beyond.
What is the step-wise mx of hyperemesis gravidarum?
1: Antihistamines - either promethazine or cyclizine
2: Odansetron and metoclopramide
If any suggestion of Wernicke’s (diplopia, ataxia) then supplement thiamine and a vitamin B and C complex (Pabrinex)
Admission may be needed for IV hydration
Ginger and P6 (wrist) acupuncture can be tried but little evidence base
At what gestation is the first US scan? What is its purpose?
10-13+6 weeks.
Confirm dates, exclude multiple pregnancy.
What is ovarian hyperstimulation syndrome?
How does it present? + Classification into mild, mod, severe + critical.
Who is particularly at risk?
OHSS is a complication seen in some forms of infertility treatment. (presence of multiple luteinized cysts within the ovaries, high levels oestrogens and progesterone but also vasoactive substances such as VEGF -> fluid shifts.
Seen in up to a third of women undergoing IVF.
Mild: Abdo pain, bloating
Mod: + Mild nausea and vomiting. Ascites on US
Severe: + Clinical evidence ascites. Oliguria. Haematocrit >45%. Hyperproteinaemia
Critical: + Thromboembolism. ARDS. Tense ascites
Women with PCOS who undergo IVF are particularly at risk.
What are the 3 contraceptives that are unaffected by enzyme-inducing drugs (EIDs)?
e.g. phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine, lamotrigine
- Copper intrauterine device
- Progesterone injection (Depo-provera)
- Mirena intrauterine system
What emergency contraception would you give in a woman taking an enzyme-inducing drug?
Copper intra-uterine device is the best option.
If levonorgestrel (Levonelle) is used then double the standard dose is recommended. Ulipristal acetate (elleOne) is not recommended.
What are the factors associated with developing uterine fibroids?
Afro-carribbean Reproductive age (rare before puberty, develop in response to oestrogen, tend not to progress after menopause)
How are uterine fibroids diagnosed?
Transvaginal US
What are the features of uterine fibroids?
May be asymptomatic
- Menorrhagia
- Lower abdo pain, cramping. Often during menstruation
- Bloating
- Urinary symptoms, urgency (with larger fibroids)
- Subfertility
What is the Mx of uterine fibroids?
If less than 3cm and not distorting the uterine cavity, try medical treatment:
Levonorgestrel-releasing intrauterine system is first line. Alternatives: Tranexamic acid, COCP
GnRH agonists may reduce the size of the fibroid, so are often used prior to surgery
Surgery: Myomectomy, endometrial ablation, hysterectomy
What is the potential complication of uterine fibroids? When does this commonly occur?
Red degeneration - haemorrhage into tumour.
Commonly occurs during pregnancy.
How is premature ovarian failure defined?
The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years.
Occurs in 1 in 100 women.
What is a footling breech? How is is different to frank or complete breeches?
Why are they the most risky form of breech?
Incomplete breech, with one or both hips extended, foot presenting.
Frank: Hips flexed, knees extended (pike position)
Complete: Hips flexed, knees flexed (cannonball)
Rare.
5-20% risk of cord prolapse, which can obstruct foetal blood flow and is an obstetric emergency.
What regimen is used for thromboprophylaxis if necessary in pregnancy?
What are the risk factors and how do they determine what is given?
RF: Age > 35 Body mass index > 30 Parity > 3 Smoker Gross varicose veins Current pre-eclampsia Immobility Family history of unprovoked VTE Low risk thrombophilia Multiple pregnancy IVF pregnancy
If 4+ RF present: Treat with LMWH until 6 weeks post-natal.
If 3: LMWH from 28 weeks and continue until 6 weeks postnatal.
How long should contraception be continued after the menopause?
If >50 years: 12 months after the last period
If <50 years: 24 months after last period
How is thrush treated in pregnancy?
Oral fluconazole is CI due to risk of congenital abnormalities.
Give clotrimazole pessary instead, 500mg PV stat
Cream can also be used.
Can epidural anaesthesia be used in pre-eclampsia?
Yes. Should help to reduce blood pressure (reactive hypotension due to the inhibition of the symapthetic nervous system, -> functional imbalance in parasympathetic tone, resulting in arteriolar and venous vasodilation)
What is Asherman’s syndrome?
Intrauterine adhesions. Can occur after dilation and curettage for miscarriage or TOP. Leads to amenorrhoea as the endometrium does not respond to oestrogen as well. Or cervix can be blocked by adhesions.
What would you expect if you tested B-hCG, TSH and T3/4 in molar pregnancy?
High B-hCG, low TSH, high T3/4.
This occurs because B-hCG in high levels can stimulate the thyroid gland -> T4 which is converted to T3 and therefore gives negative FB to pituitary.
-> Signs and symptoms of thyrotoxicosis.
In a woman (especially if >50), what symptoms on a regular basis would warrant a CA125?
- Abdominal distension/bloating
- Early satiety or loss of appetitie
- Pelvic or abdominal pain
- Increased urinary urgency +/- frequency
What are the RF for babies developing Group B strep?
How are high-risk women managed?
Consequence?
Largest RF: Previous affected baby Others: - Prematurity - PROM - Maternal pyrexia
Intrapartum Abx (BenPen)- no need for abx prior to labour.
About 50% of babies born to GBS +ve mothers will become carriers, 1% will be ill themselves.
What contraceptive advice should be given when prescribing abx in woman taking POP?
No need for extra protection
What is an amniotic fluid embolism?
What is the clinical presentation?
When foetal cells/amniotic fluid enter the mothers blood stream, causing sudden onset cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.
Majority of cases occur in labour, but can also occur in CS and immediately post-partum.
What is a Wertheim’s hysterectomy?
Pelvic node clearance, hysterectomy, removal or parametrium and upper third of vagina
How does blood pressure physiologically change in pregnancy?
When can you diagnose gestational HTN?
Usually fails in the first trimester and until 20-24 weeks. After this the BP usually increases to pre-pregnancy levels by term.
Pregnancy-related HTN can only be diagnosed after 20 weeks. Usually defined as >140/90 or a increase of >30 systolic or >15 diastolic above booking readings.
How is anaemia defined in pregnancy?
1st trimester: <110
2nd/3rd: <105
Post-partum <100
How is anaemia in pregnancy treated?
If normocytic or microcytic trial oral iron.
If no improvement after 2 weeks then further ix.
From when is contraception required postpartum?
21 days.
PID is an absolute CI to what method of contraception?
Copper coil
Up to what period following intercourse are ulipristal and levonorgestrel licensed to be used?
Ulipristal:
120 hours.
Levonorgestrel:
72 hours.
May be given after this time but unlicensed indication (+less effective)
What would you suspect if a patient presented with continuous, dribbling incontinence?
How would you investigate this?
Vesicovaginal fistulae (esp if prolonged labour and from a country with poor obstetric services)
Urinary dye studies.
When can an IUD be inserted following delivery?
4 weeks postpartum, unless fitted within 48 hours of delivery. (Perforation and infection)
What is the first-line treatment for mod-severe depression in pregnancy or post-natal period?
CBT
Who should you avoid prescribing oxybutynin for? (Urge incontinence)
‘Frail older women’
How is the combined contraceptive patch worn/changed?
What is the advice is the patch change is delayed?
What if the patch removal is delayed at the end of W3? Or application delayed after withdrawal?
Patch cycle lasts 4 weeks. Worn every day for the first 3 weeks, changed each week.
During the 4th week not worn and withdrawal bleed.
If patch change delayed at end W1/W2 by <48 hours: it should be changed immediately and no further precautions are needed.
If patch change delayed at end W1/W2 by >48 hours: the patch should be changed immediately and a barrier method of contraception used for the next 7 days.
If UPSI during patch-free interval or last 5 days, then emergency contraception needs to be considered.
If patch removal delayed at end of W3: remove asap and apply new patch on the usual day. No additional contraception.
If patch application delayed after W4 withdrawal then use barrier contraception for 7 days.
What is the most common abnormality on US in IVF pregnancies?
Placenta praevia
What is the Mx of a baby born to Hep B surface antigen positive mother?
- Hep B vaccine and 0.5mL of HBIG within 12 hours of birth
- Further Hep B vaccines at 1-2 months and 6 months
NB. Cannot be transmitted via breast feeding.
What is the Mx of moderate/severe dyskaryosis on cervical smear?
Urgent (2ww) colposcopy
What is the Mx of borderline or mild dyskaryosis on cervical smear?
Test for HPV (16, 18, 33)
If neg: Back to routine recall
If positive: Colposcopy
What is the Mx of inadequate smear?
What if this reoccurs?
Send repeat sample.
If 3 inadequate samples then send for colposcopy
What is the Mx of a woman with no Rubella immunity?
(Checked at booking)
Keep away from people who might have rubella
Offer MMR vaccination in post-natal period
What hormone would you measure on day 21 of a normal 28 day cycle to test for ovulation?
Progesterone
What are the features of cervical ectropion?
Vaginal discharge
Post-coital bleeding
At what gestation is the anomaly scan?
18 - 20+6 weeks
At what gestation is the Down’s syndrome screening (Nuchal)?
11-13+6
What is the Pearl index in contraception? How would you interpret a result of 0.2?
The number of pregnancies that would be seen if one hundred women were to use the contraceptive method in question for one year.
So if medication is adhered to perfectly, we would expect to see 0.2 pregnancies for every hundred women using the pill for one year - or 2 for every thousand.
What should you advise a woman called for cervical screening whilst pregnant?
Wait until 12 week postpartum.
If a previous smear has been abnormal then seek specialist advice, although it may be performed mid-trimester as long as no CI e.g. low lying placenta.
If the COCP is not started on the first day of the cycle, how long does it take until it can be relied on for contraception?
7 days
What is galactocele?
Galactocele typically occurs in women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct. A build up of milk creates a cystic lesion in the breast. The lesion can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.
What is Rovsing’s sign?
When palpation of the left iliac fossa causes increased tenderness in the right iliac fossa. It may be seen in cases of appendicitis.
What would you suspect if a whirlpool sign was seen on US?
Ovarian torsion, or when bowel twists on itself causing a volvulus.
What are the RF for endometrial cancer?
NB. Any PMB is endometrial cancer until proven otherwise
HTN Obesity DM PCOS Tamoxifen use Late menopause High oestrogen (oestrogen-only HRT) Early menarche Nulliparity
If treated for CIN when should a woman have her next smear?
6 months.
What is the most common type of epithelial cell tumour?
Serous cystadenoma
What type of cyst rupture may cause pseudomyxoma peritonei?
Mucinous cystadenoma
What might severe lower abdo pain and bleeding after giving birth suggest if you are unable to palpate the uterine fundus, but a vaginal mass is palpable?
Uterine inversion.
Mx:
ABCDE
Immediate uterine repositioning:
Theatres must be prepared for a potential laparotomy, and tocolytics can be considered to allow uterine relaxation (this may aggravate haemorrhage, however).
Uterine repositioning is best done manually and quickly, firstly using Johnson’s method. This involves slowly and steadily pushing the uterus upwards towards the umbilicus. If this fails, O’Sullivan’s technique can be utilised, which involves infusion of warm saline into the vagina.
Give three causes of increased nuchal translucency on US?
- Down’s syndrome
- Congenital heart defects
- Abdo wall defects.
Give three causes of hyperechogenic bowel on US?
- CF
- Down’s
- CMV
What is the Mx of TTTS?
- Indomethacin to reduce foetal urine output
- Laser obliteration of placental vascular communications
- Selective foetal reduction
- After birth, the donor may require blood transfusions to treat anaemia. The recipient twin may need exchange transfusions/ heart failure medications.
How often should cervical smears be offered in HIV +ve patients?
Annually
What dose of folic acid should be given in epileptic planning pregnancy?
5mg per day, starting now
How do you decide if cyclical or continuous combined HRT should be prescribed?
Women should be prescribed cyclical combined HRT if their LMP was less than 1 year ago.
Continuous combined HRT if they have:
- taken cyclical combined for at least 1 year or
- it has been at least 1 year since their LMP or
- it has been at least 2 years since their LMP, if they had premature menopause (menopause below the age of 40)
What is the score used to classify the severity of N+V in pregnancy?
Pregnancy-Unique Quantification of Emesis (PUQE)
What should patients taking the COCP do if they are undergoing elective surgery?
Stop the pill 4 weeks before surgery and restart 2 weeks after.
What would you suspect if a baby had adduction and internal rotation of the arm, with pronation of the forearm? Following what is this common?
Erb’s palsy (Waiter’s tip)
Due to damage of the upper brachial plexus, most commonly following shoulder dystocia.
What are the symptoms of ovarian torsion?
Iliac fossa pain that can radiate to the loin, groin or back.
Nausea and vomiting are common.
Can also present with a low-grade fever, especially for longer durations of torsion where ovarian necrosis may be present.
What is the main mode of action of POPs? (Except desogestrel)
Thickens cervical mucous
What is the primary action of the injectable contraceptive?
Inhibits ovulation
What is the primary action of the IUS?
Prevents endometrial proliferation
What investigation would you do in suspected placenta previa?
Transvaginal US
What are the risks of cocaine in pregnancy?
Maternal:
- HTN, including pre-eclampsia
- Placental abruption
Foetal:
- Prematurity
- Neonatal abstinence syndrome
What antibiotics are considered safe in breast feeding?
Penicillins, Cephalosporins, Trimethoprim
What drugs should be avoided in pregnancy? (NOT Abx or psych drugs)
Aspirin Carbimazole Methotrexate Sulphonylureas Cytotoxics Amiodarone
