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Year 4 > Obstetrics & Gynaecology > Flashcards

Obstetrics & Gynaecology Flashcards

1
Q

Reason for folic acid supplementation in pregnancy

A

↓ risk of neural tube defects

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2
Q

Standard folic acid supplementation in pregnancy

A

400 micrograms/day for ~3 months before conception until 12th week of pregnancy

take 5mg/day if high risk group

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3
Q

Groups requiring 5mg folic acid supplementation

A 
previous neural tube defects
family history of NTDs
Diabetes
Coeliacs
Thalassaemia 
Anti-epileptic medication
obese women (>30kg/m^2)
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4
Q

recommendation for alcohol intake in pregnancy

A

recommended to not consume any alcohol

but if women choses to drink ≤1-2 units/week

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5
Q

Complications of smoking in pregnancy

A 
IUGR
low birth weight
miscarriage
still birth
premature delivery
placental issues
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6
Q

foods to avoid in pregnancy

A

uncooked meat/fish, raw egg, unpasteurised milk, soft cheese, raw shellfish

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7
Q

epilepsy medication considered safe in pregnancy

A

lamotrigine

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8
Q

dangerous anti epileptics in pregnancy

A

sodium valproate

phenytoin

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9
Q

Antidepressants safe in pregnancy

A

Fluoxetine

amitriptyline

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10
Q

Mood stabiliser to avoid in pregnancy

A

lithium

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11
Q

Diabetes drugs and pregnancy

A

discontinue all hypoglycaemic agents except metformin

supplement metformin with insulin if needed

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12
Q

anithypertenisve medication in pregnancy

A

Stop ACE-Is & ARBs

Stop Statins

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13
Q

Timing of booking appointment

A

8-12 weeks

ideally at <10weeks

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14
Q

Purpose of booking visit (8-12 weeks)

A

General info e.g. diet/folic acid/Vit D/alcohol/smoking
BP
Urine dipstick
BMI check
Booking bloods (FBC,HIV, Hep B, Syphilis, Rhesus status, red cell allo antibodies, haemoglobinopathies)
Urine culture (for asymptomatic bacteriuria)
GDM screen if risk factors

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15
Q

10-13+6 weeks check

A

early scan to confirm dates & exclude multiple pregnancy

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16
Q

11-13+6 weeks check

A

Down syndrome screening (nuchal translucency, beta-hCG, PAPPA)

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17
Q

18 - 20+6 week check

A

anomaly scan (USS)

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18
Q

Extra antenatal care dates for primips

A

25 weeks
31 weeks
40 weeks

all routine care (BP, urine dip, SFH)

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19
Q

28 week check

A 
routine care (BP, urine dip, SFH)
second anaemia screening
Give first dose of anti-D prophylaxis if Rh -ve
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20
Q

34 week check

A 
routine care (BP, urine dip, SFH)
Birth planning/labour info
Give second dose of anti-D prophylaxis if Rh -ve
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21
Q

36 week check

A 
check presentation & offer external cephalic version if indicated
routine care (BP, urine dip, SFH)
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22
Q

Conditions screened for in all pregnant women

A 
anaemia
bacteriuria
blood group
Rh status
anti-red cell antibodies
Down's syndrome
fetal anomalies
Hep B
HIV
NTDs
syphilis
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23
Q

Down syndrome screening

A

11-13+6 weeks gestation

consisting of nuchal translucency, beta-hCG, PAPP-A)

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24
Q

Results suggesting Trisomy 21

A

↑nuchal translucency
↑beta-hCG
↓PAPP-A

NB trisomy 13/18 give similar results but lower PAPP-A values

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25
Q

Triple/Quadruple test for Down syndrome screening

A

used if booked late, so offered at 15-20 weeks

Triple test = AFP, uncojugated oeastriol (uE3), beta-hCG, Quadruple test =AFP, uncojugated oeastriol (uE3), beta-hCG, inhibit-A

results suggestive of Downs:
AFP ↓, uncojugated oeastriol (uE3) ↓, beta-hCG ↑, inhibit-A ↑

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26
Q

Positive Down syndrome prenatal diagnosis

A

offer diagnostic testing with chronic villous sampling (<13 weeks) or amniocentesis (<15 weeks)

if diagnosed offer TOP or continue pregnancy with appropriate support

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27
Q

chronic villous sampling (<13 weeks) or amniocentesis (<15 weeks) risk of miscarriage

A

~1% (1/100)

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28
Q

Antenatal rubella infection

A

suspected Rubella infection in pregnancy should be discussed with health protection unit

offer MMR vaccination in postnatal period

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29
Q

Antenatal Varicella Zoster infection

A

Risk of fatal varicella syndrome

Management:
check maternal blood for varicella immunity

if not immune:
<20 weeks: give varicella-zoster immunoglobulin (VZIG)
>20 weeks: give VZIG or aciclovir days 7-14 post exposure

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30
Q

antenatal CMV infection

A

no effective treatment

ensure good personal hygiene and avoid infected individuals

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31
Q

HIV infection in pregnancy

A

screened for in all pregnant women

  • Maternal antiretroviral therapy (Zidovudine + 2 other antiretrovirals)
  • Elective C-section at 38-39 weeks (consider delaying to >39 weeks if viral load >50copies/ml)
  • neonatal antiretorviral therapy (Zidovudine)
  • avoid breastfeeding (bottle feeing only)

if all prophylactic steps taken then mother to child transmission <1%

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32
Q

Hep B in pregnancy

A

screened for in all pregnant women

give full immunisation + Hep B immunoglobulin to baby of Hep B infected mother

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33
Q

define theses alloimmunisation

A

Rh -ve mothers may develop anti-D IgG antibodies if sensitised e.g. previous Rh +ve pregnancy, delivery, miscarriage, TOP, ectopic pregnancy, antepartum haemorrhage

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34
Q

preventing Rh alloimmunisation

A

test for anti-D antibodies for all Rh -ve mothers at booking
routine anti-D prophylaxis at 28&34 weeks if not sensitised
if sensitising event in 2nd/3rd trimester = large dose of anti-D & perform Keinhauer test

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35
Q

When to give anti-D immunoglobulin

A

Give within 72h of event

delivery of Rh +ve infant (stillbirth/live)
TOP
Miscarriage at >12 weeks gestation
ectopic pregnancy
ECV
antepartum haemorrhage
amniocentesis
chorionic villous sampling
fatal blood sampling
abdominal trauma
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36
Q

Nausea & vomiting in pregnancy

A

affects ~75% of pregnancies
usually resolves by 16 weeks of gestation
symptoms beginning at >12 weeks usually have other causes

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37
Q

hyperemesis gravidarum

A

severe protracted nausea & vomiting associated with weight loss >5% of pre-pregnancy weight, fluid loss, dehydration, electrolyte imbalance

usually occurs between 8-12 weeks

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38
Q

Admission criteria for hyperemesis gravidarum

A

continued N&V + unable to keep down liquids/oral antiemetics

continued N&V + ketonuria and/or weight loss >5%

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39
Q

Obstetric cholestasis/intrahepatic cholestasis of pregnancy

A

pruritic condition of pregnancy due to impaired bile flow allowing bile salts to be deposited into the skin & placeenta

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40
Q

risk of recurrence of ectopic pregnancy

A

10-20%

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41
Q

Conditions associated with obstetric cholestasis/intrahepatic cholestasis of pregnancy

A

↑ risk of foetal distress
↑ risk of intrauterine death
↑ risk of premature birth
↑ maternal morbidity

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42
Q

Investigating obstetric cholestasis/intrahepatic cholestasis of pregnancy

A

Bile acid ↑
LFTs (AST ↑, ALT ↑, Gamma-GT ↑, ALP ↑)
Bilirubin↑

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43
Q

Management of obstetric cholestasis/intrahepatic cholestasis of pregnancy

A

weekly LFTs
Ursodeoxycholic acid
Vit K supplement
induction of labour at 37-38 weeks

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44
Q

Gestational diabetes mellitus (GDM)

A

a degree of glucose intolerance with its first onset during pregnancy & usually resolving shortly after delivery

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45
Q

Diagnostic criteria for gestational diabetes mellitus (GDM)

A

Fasting glucose ≥ 5.6mmol/L
2h postprandial glucose ≥7.8mmol/L

NB: the rule is 5678

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46
Q

Screening for gestational diabetes mellitus (GDM)

A

oral glucose tolerance test at booking & 24-28 weeks

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47
Q

Managing gestational diabetes mellitus (GDM)

A

1st line: blood glucose monitoring, diet & exercise, weight loss

2nd line: add metformin if not controlled by diet after 1-2 weeks

3rd line: insulin

NB if fasting glucose ≥7mmol/L start insulin

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48
Q

Complications of gestational diabetes mellitus (GDM)

A 
macrosomia
large for gestational age
pre-eclampsia
↑ risk of shoulder dystocia
↑ risk of neonatal hypoglycaemia
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49
Q

Managing pre-existing diabetes in pregnancy

A

aim for BMI<27
stop all oral hypoglycaemics except metformin & commence insulin
folic acid 5mg pre-conception till 12 weeks gestation

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50
Q

Pre-existing hypertension in pregnancy

A

BP >140/90 either at booking or prior to 20 weeks gestation, no protein uria/oedema

Stop ACE-Is & ARBs and switch medication
aim for BP <150/100

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51
Q

Gestational hypertension

A

BP >140/90 after 20 weeks gestation without proteinuria / oedema
usually resolves spontaneously after birth

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52
Q

Termination of pregnancy (TOP)

also referred to as termination or abortion

A

medically directed miscarriage prior to independent viability using surgical/pharmacological means

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53
Q

complications of gestational hypertension & pre-existing hypertension in pregnancy

A 
↑ risk of placental abruption
↑ risk of cerebrovascular event
↑ risk of DIC
↑ risk IUGR
↑ risk of prematurity 
↑ risk of intrauterine death
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54
Q

Pre-eclampsia

A

condition seen at >20 weeks gestation characterised by new onset hypertension >140/90 associated with proteinuria & oedema

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55
Q

Eclampsia

A

pre-eclampsia with the development of seizures/convulsions

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56
Q

Risk factors for pre-eclampsia/eclampsia

A 
Primiparity
BMI >30
↑ maternal age (>40 yrs)
multiple pregnancy 
FHx of pre-eclampsia/eclampsia
pre-existing diabetes/HTN/CKD/SLE/antiphospholipid syndrome
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57
Q

Preventing pre-eclampsia/eclampsia

A

75mg - 150mg of aspirin from week 12 till delivery

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58
Q

Presentation of pre-eclampsia/eclampsia

A 
BP >140/90 + ≥1+ protein on urine dipstick
headaches
upper abdo pain
oedema
visual disturbances/blurry vision
papilloedema

Seizures if eclampsia

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59
Q

Investigating pre-eclampsia/eclampsia

A

Urinalysis
FBC/LFTs/U&Es/renal function
USS to assess foetal growth/amniotic fluid levels

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60
Q

Severe pre-eclampsia

A

BP >170/110 + proteinuria
or
proteinuria 3+/4+

headache, visual disturbances, blurry vision, papilloedema, RUQ/epigastric pain, hyperrefelxia

platelets <100x10^9/L
abnormal LFTs
HELLP syndrome

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61
Q

Management of pre-eclampsia/eclampsia

A

4x daily BP monitoring, 2-3x weekly FBC/U&Es/LFTs/renal function

Antihypertensives:
1st line: labetalol
2nd line: nifedipine

Seizure control:
Magnesium sulphate (4g loading dose over 5-10min then 1g/h for 24h)

Delivery = only curative treatment, generally try to deliver at >34 weeks

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62
Q

HELLP syndrome

A 
complication of pregnancy presenting in women with pre-eclampsia/eclampsia
characterised by:
-Haemolysis (H)
-Elevated liver enzymes (EL)
-Low platelets (LP)
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63
Q

Presentation of HELLP syndrome

A 
nausea&vomiting 
hypertension
brisk tendon reflexes 
RUQ pain
headache
oedema
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64
Q

Investigating HELLP syndrome

A 
FBC (↓ Hb, ↓platelets)
Blood film (fragmented RBCs)
LDH (↑ >600IU/L)
LFTs (AST/ALT ↑ >70IU/L)
platelets (<100x10^9/L)
bilirubin (↑)
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65
Q

Managing HELLP syndrome

A

definite treatment = delivery of baby

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66
Q

Chorioamnionitis

A

medical emergency, due to ascending infection leading to inflammation of the foetal membranes

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67
Q

Chorioamnionitis risk factors

A

Preterm premature rupture of membranes (PPROM)
smoking
alcohol use
↑ number of vaginal examinations

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68
Q

Chorioamnionitis presentation

A 
maternal fever
uterine tenderness
baseline fetal tachycardia (>160)
maternal leucocytosis
purulent cervical discharge
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69
Q

Chorioamnionitis management

A

IV Abx e.g. ampicillin

prompt delivery of fetus

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70
Q

Anaemia in pregnancy

A

normal physiological changes in pregnancy include the ↑plasma volume causing haemodilution so the Hb drops to ~115g/L
most frequently caused by iron deficiency (↓MCV)
often asymptomatic

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71
Q

screening for anaemia of pregnancy

A

at booking visit & 28 weeks

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72
Q

definition of anaemia in pregnancy

A

Hb <110g/L at booking, or Hb <105/L in 2nd/3rd trimester

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73
Q

Management of placenta accreta

A

C-section (open at site distant to placenta, have blood products ready)
if placenta acreata confirmed do not remove it (high risk of major obstetric haemorrhage), but perform hysterectomy

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74
Q

Polyhydramnios

A

abnormally large amount of amniotic fluid associated with adverse pregnancy outcomes
uterus presents large for date on examination

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75
Q

Polyhydramnios causes

A 
most often idiopathic
congenital abnormalities/genetic disorders
Gestational diabetes
multiple pregnancy 
congenital infections
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76
Q

Oligohydramnios

A

too little amniotic fluid (<500ml at 32-36 weeks) associated with IUGR & ↑perinatal mortality

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77
Q

Oligohydramnios causes

A 
rupture of membranes 
congenital absence of functional renal tissue (renal agenesis)
↓ renal perfusion
post-term gestation 
placental abruption 
drugs (ACE-Is, indomethacin)
pre-eclampsia
PROM
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78
Q

VTE in pregnancy

A

pregnancy is a physiological hypercoaguable state, leading to a 10x ↑ risk compared to non pregnant women

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79
Q

Risk factors for VTE in pregnancy

A 
hereditary hypercoaguable states e.g. Factor V Leiden
obesity (BMI>30)
immobilisation
previous thrombotic event
cancer
antiphospholipid syndrome
↑ maternal age
pre-eclampsia
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80
Q

VTE management in pregnancy

A

LMWH (prophylaxis & treatment)
NB IV UFH treatment of choice in acute VTE management
continue treatment till at least 6-12 weeks postpartum

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81
Q

Ectopic pregnancy

A

fertilised ovum implanting & maturing outside the uterine endometrial cavity, 97% are tubal, most commonly in the ampulla

NB the most dangerous place is an ectopic in the isthmus

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82
Q

Risk factors for an ectopic pregnancy

A 
previous ectopic
damage to tubes (e.g. PID)
endometriosis
IVF
IUD/IUS
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83
Q

Ectopic pregnancy presentation

A

6-8 weeks of amenorrhoea
lower abdo pain/pelvic pain
abdo tenderness on palpation
PV bleeding ± clots

If ruptured: dizziness, fatigue, syncope, haemodynamic instability

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84
Q

Investigating an ectopic pregnancy

A

beta-hCG
transvaginal USS
if pregnancy of unknown location = serious beta-hCGs

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85
Q

Expectant management for ectopic pregnancy

A

if size <35mm, unruptured, asymptomatic, no fetal heart beat, serum eta-hCG <1000IU/L

monitor over 48h, if symptoms develop/ ↑ beta-hCG = intervene

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86
Q

Medical management of ectopic pregnancy

A

if size <35mm, unruptured, no significant pain, no fetal heart beat, serum eta-hCG <1500IU/L

single dose methotrexate
3-6 months of contraception as methotrexate = teratogenic

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87
Q

Surgical management of ectopic pregnancy

A

if size >35mm, ruptured/unruptured, significant pain, visible fetal heart beat, serum eta-hCG >1500IU/L

usually laparoscopic salpingectomy
laparoscopic salpingotomy if other infertility risk factors

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88
Q

risk of recurrence of ectopic pregnancy

A

10-20%

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89
Q

Miscarriage

A

involuntary loss of pregnancy before 24 weeks gestation

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90
Q

Threatened miscarriage

A

painless PV bleeding at <24 weeks with a closed cervical OS

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91
Q

Inevitable miscarriage

A

heavy PV bleeding + clots, painful, open cervical OS

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92
Q

Incomplete miscarriage

A

incomplete expulsion of products of conception, may often be unrecognised missed miscarriage

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93
Q

complete miscarriage

A

products of contraception fully expelled i.e. no pregnancy tissue on USS

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94
Q

Missed miscarriage

A

gestational sac containing dead fetus without symptoms of expulsion, often presents with light bleeding + dark brown discharge

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95
Q

recurrent miscarriage

A

≥3 consecutive pregnancies lost spontaneously at <24 weeks
most common causes include antiphospholipid syndrome, endocrine disorders e.g. PCOS, parental chromosomal abnormalities, cervial incompetence

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96
Q

Investigating miscarriage

A 
Transvaginal ultrasound (TVUS)
serum beta-hCG (2 tests 48h apart)
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97
Q

Expectant management of miscarriage

A

waiting for a spontaneous miscarriage

wait 7-14 days then repeat pregnancy test

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98
Q

Medical management of miscarriage

A

vaginal misoprostol (stimulates contractions)
review if bleeding not started in 24h
perform pregnancy test 3 weeks later

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99
Q

Surgical management fo miscarriage

A

vacuum aspiration (suction curettage) or surgical removal (evacuation of retained products of contraception -ERPC)

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100
Q

The law around termination of pregnancy (TOP)

A

1967 abortion act (amended in 1990)
2 registered medical professionals must sign a legal document (HSA1 form)

TOP legal before 24 weeks gestation

  • if it reduces the risk to a woman life
  • if it reduces risk to her physical/mental health
  • if it reduces the risk of physical/mental health of her existing children
  • if baby has substantial risk of being seriously mentally/physically handicapped

No limit to gestational age if

  • risk to mother’s life
  • risk of grave/permanent injury to mothers physical/mental health
  • substantial risk that child born would have such physical mental abnormalities as to be seriously handicapped
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101
Q

Medical termination of pregnancy (TOP)

A

mifepristone followed after 48h by misoprostol

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102
Q

surgical termination of pregnancy (TOP)

A

cervical dilation followed by suction of uterine contents

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103
Q

Complete hydatiform mole

A

benign tumour of trophoblastic material, empty egg fertilised by 1 sperm

features: bleeding in 1st/early 2nd trimester with exaggerated symptoms of pregnancy & a large for date uterus

very high beta-hCG levels

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104
Q

partial mole

A

normal haploid egg fertilised by 2 sperms/1 sperm with duplicated paternal chromosomes

fetal parts may be seen

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105
Q

Breech presentation

A

when the caudal end of the fetus occupies the lower segment instead of the cephalic presentation

associated with ↑ morbidity & mortality for mother and baby

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106
Q

Management of breech presentation

A

offer external cephalic version (ECV) at 36 weeks if nulliparous or 37 weeks if multiparous

if unsuccessful then the mode of delivery is C-section

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107
Q

contraindications for external cephalic version

A 
antepartum ahemorrhage in last 7 days
abnormal CTG
major uterine abnormality
ruptured membranes
other indications for c-section
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108
Q

Monoamniotic monozygotic twins risks

A

↑ risk of spontaneous miscarriage
↑ perinatal mortality
↑ rate of malformation/IUGR/prematurity
↑ risk of twin to twin transfusion syndrome

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109
Q

Fetal movements

A

first movements usually around 18-20 weeks

Red flag if not established by 24 weeks

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110
Q

Fetal distress

A

presents as ↓ fetal movements

investigate with handheld doppler to confirm heartbeat
consider USS if no heartbeat
otherwise monitor with CTG

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111
Q

Placenta praevia

A

defined as placenta overlying the cervial OS i.e. low-lying placenta that is partially/fully inserted into the lower segment
commonest cause of antepartum haemorrhage (bleeding at >24 weeks)

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112
Q

Risk factors for placenta praevia

A

uterine scarring (e.g. pervious c-section)
multiparity
multiple pregancy
prior placenta praevia

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113
Q

Presentation of placenta praevia

A

often incidental finding on USS e.g. at 20 week scan
Painless PV bleeding (usually sudden & profuse)
abnormal lie/presentation
NO uterine tenderness

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114
Q

Investigations for placenta praevia

A

have a high clinical suspicion PV bleeding at >20weeks gestation
TVUS/Abdominal ultrasound

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115
Q

Management of placenta praevia

A

if major placenta praevia do C-section at 37-38 weeks

if pt has bleeding then encourage hospital admission from 34 weeks

NB do not attempt vaginal examination if pt is actively bleeding

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116
Q

Placenta accreta

A

describes the attachment of the placenta to the myometrium due to defective decidua basalis, meaning the placenta is unable to properly separate during labour =↑ risk of PPH

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117
Q

Types of placenta accreta

A

defined by depth of implantation
accreta = attach to myometrium
increta = attach in myometrium
percreta = penetrate into peritoneum

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118
Q

Conditions associated with placenta accreta

A

retained placental products
PPH
preterm delivery

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119
Q

Risk factors for placenta accreta

A

previous C-section
placenta praevia
↑ maternal age

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120
Q

Placental abruption

A

premature separation of a normally located placenta from the uterine wall occurring before delivery of the fetus

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121
Q

Types of placental abruption

A

concealed: ~20%, haemorrhage confided to uterine cavity, more severe form as blood loss often underestimated
revealed: ~80%, blood draws from cervix, usually less severe, often incomplete detachment of palcenta

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122
Q

Presentation of placental abruption

A 
PV bleeding
constant abdo pain
uterine contraction
level of shock not correlating to visible blood loss
tense, tender, woody uterus on palpation
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123
Q

Risk factors of placental abruption

A 
smoking
cocaine use
trauma
multiple pregnancy
pre-eclampsia 
uterine malformation
previous abruption
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124
Q

Investigating placental abruption

A 
USS
CTG
platelet count
FBC
cross match blood
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125
Q

Management of placental abruption

A

NB Mother takes priority

fetus alive >36 weeks = emergency c-section if fetal distress otherwise vaginal delviery

fetus alive <36weeks = emergency c-section if fetal distress, otherwise close monitoring + corticosteroids

dead fetus = induced vaginal delivery

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126
Q

Uterine rupture

A

usually occurs during labour however C-section scars from previous pregnancies may rupture during the 3rd trimester

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127
Q

Dehiscence

A

incomplete separation of a uterine scar with intact serosa and ↑ risk of uterine rupture

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128
Q

Presentation of uterine rupture

A 
sudden tearing uterine pain
vaginal haemorrhage 
cessation of uterine contractions
regression of fetus 
CTG abnormalities
Scar pain/tenderness
fetal parts may be palpable per abdomen as they pass into abdominal cavity
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129
Q

Management of uterine rupture

A

urgent surgical delivery

uterine repair or hysterectomy

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130
Q

Cord prolapse

A

involved the umbilical cord descending ahead of the presenting part of the fetus, if untreated can lead to cord compression or cord spasm which may cause fatal hypoxia

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131
Q

Risk factors of cord prolapse

A 
prematurity
multiple pregnancy
breech/transverese lie
placenta praevia
high fetal station
cephalopelvic disproportion
artificial rupture of membranes (ARM)*
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132
Q

Presentation of cord prolapse

A

may occur with no outward physical features/normal fetal heart trace

ill fitting/non presenting part on abdominal examiantion
cord prolapse felt PV
cord visible beyond introitus
abnormal CTG

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133
Q

Management of cord prolapse

A

pushing presenting part back into uterus to avoid cord compression
use of tocolytics e.g. indomethacin/nifedipine
place pt on all fours (pt in doggy position as she is grown a tail i.e. the cord)
usually need emergency C-section

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134
Q

Most important risk factor for cord prolapse

A

artificial rupture of membranes (ARM)

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135
Q

Post partum haemorrhage (PPH)

A

excessive bleeding post delivery, usually defined as >500ml

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136
Q

Types of post partum haemorrhage (PPH)

A

Primary: within 24h of delivery

Secondary: 24h - 12 weeks after delivery

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137
Q

Causes of primary post partum haemorrhage (PPH)

A

4T’s of PPH

Tone (uterine atony, ~90% of PPH)
Trauma (to uterus/cervix/vagina)
Tissue (e.g. retained placenta i.e. delayed 3rd stage)
Thrombin (pre-existing/acquired coagulopathies)

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138
Q

Risk factors for primary PPH

A 
previous PPH
prolonged labour
pre-eclampsia
↑ maternal age
emergency C-section
placenta praevia/accreta
BMI >35
assisted vaginal delivery
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139
Q

Presentation of primary PPH

A

bleeding which fails to stop after delivery of placenta

signs of shock e.g. hypotension (this is then defined as a major obstetric haemorrhage (MOH), usually >1500ml lost)

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140
Q

Management of primary PPH

A

ABCDE assessment
bilateral large bore cannulas
cross match blood & make units ready

Medication:
syntocinon (5 unit bolus + 40 units IV)
TXA (1g IV)
Ergometrin (500 micrograms)
Carboprost (250 micrograms every 15 min up to 5 doses)
Misoprostol (800 micrograms)

Surgical/physical:
Bimanual uterine compression & stimulation
Balloon tamponade
B-lynch compression sutures
ligation of uterine/internal iliac arteries
hysterectomy

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141
Q

Active management of 3rd stage of labour

A

done to ↓ risk of PPH
5 units of syntocinon IM
consider following with 40 units IV if necessary

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142
Q

Secondary post partum haemorrhage (PPH) causes

A

infection especially endometritis

retained products of conception

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143
Q

Presentation of secondary PPH

A 
prolonged/excessive bleeding
fever
abdo pain
offensive smelling lochia 
dyspareunia
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144
Q

Managing secondary PPH

A

Oral/IV Abx for endometritis
elective curetage + Abx if retained products

NB 95% of endometritis treated with Abs improves within 48-72h, if this is not the case you must reassess

145
Q

Lochia

A

vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth.

146
Q

Sheehan’s syndrome

A

postpartum pituitary necrosis leading to hypopituitarism which is usually caused by massive PPH leading to hypotension & shock

Presents as failure to lactate, breast convolution, amenorrhoea

147
Q

Shoulder dystocia

A

a complication of vaginal cephalic delivery, which entails the inability to delivery the body of the fetus using gentle traction after the head has been delivered as the anterior shoulder impacts on maternal pubic synthesis

148
Q

Associated injuries to fetus in shoulder dystocia

A

brachial plexus injuries (Erb’s/Klumpke’s palsy)

149
Q

Risk factors for shoulder dystocia

A 
Gestational diabetes
fetal macrosomia 
BMI >30
induced labour
prolonged labour
150
Q

Management of shoulder dystocia

A

call additional help ASAP
Stop mother from pushing & avoid downward traction on fetal head

McRobert’s manoeuvre: hyper flex & abduct mothers hips (i.e. knees to chest) to flatten lumbrosacral angle

episiotomy to facilitate secondary manoeuvres e.g. Rubin’s & woods’ screw

consider C-section

151
Q

Amniotic fluid embolus

A

when fetal cells/amniotic fluid enters the maternal systemic circulation & stimulates a sudden cardiovascular collapse

152
Q

presentation of amniotic fluid embolus

A 
sudden cardiovascular collapse
acute LV failure
pulmonary oedema 
DIC
bleeding diathesis
respiratory distress (similar to PE)
uterine atony
shivers, seizures, LOC
arrythmia
153
Q

Diagnosing amniotic fluid embolus

A

diagnosis of exclusion

154
Q

Classic presentation of amniotic fluid embolus

A

older multiparous women in advanced labour that suddenly collapses

155
Q

Preterm premature rupture of membranes (PPROM)

A

PPROM = rupture of membranes prior to onset of labour in a pt <37 weeks gestation

PROM = rupture of membranes occurring prior to onset of labour in a pt ≥37 weeks gestation

156
Q

Preterm premature rupture of membranes (PPROM) risk factors

A

smoking
previous preterm delivery
vaginal bleeding during pregnancy

157
Q

Presentation of Preterm premature rupture of membranes (PPROM)

A

popping sensation/ gush of fluid PV
continuous watery liquid draining PV after initial gush
wet pad/underwear
pooling of amniotic fluid in posterior vaginal vault on sterile speculum examination

158
Q

Examinations to avoid in Preterm premature rupture of membranes (PPROM)

A

DO NOT perform a vaginal examination as it ↑ risk of ascending infection

159
Q

management of Preterm premature rupture of membranes (PPROM)

A

admission & CTG monitoring
oral erythromycin for 10 days
antenatal corticosteroids
monitor for infection

160
Q

Perineal tear classifications

A

1st degree: superficial damage with no muscle involvement

2nd degree: injury to perineal muscle but on involvement of anal sphincter

3rd degree: injury to perineum involving anal sphincter complex

4th degree: injury to perineum involving anal sphincter complex & rectal mucos

161
Q

Risk factors for perineal tears

A

primigravida
macrosomia
shoulder dystocia
forceps delivery

162
Q

Episiotomy

A

controlled cutting of the perineum to prevent tearing which is performed during the 2nd stage of labour

163
Q

Complications of perineal tears

A

urinary/faecal incontinence
pain
infection

164
Q

Prolonged labour

A

inability of women to proceed with childbirth upon going into labour

165
Q

Failure to progress

A

can occur in 2 phases of labour :

  • latent phase
  • active phase (this is where problems arise)
166
Q

Causes of failure to progress/prolonged labour

A

fetal malpresentation
poor uterine contractions
cervical stenosis
dystocia

167
Q

Presentation of failure to progress/prolonged labour

A

labour >18h
maternal exhaustion
pain
fetal distress

168
Q

Management of failure to progress/prolonged labour

A

assisted vaginal delivery

C-section

169
Q

Requirements for assisted vaginal delivery

A 
fully dilated cervix
occipital-anterioir posiiton
ruptured membranes
cephalic presentation
engaged presenting part
pain relief adequate
sphincter (bladder) empty
170
Q

Indications for assisted vaginal delivery

A

maternal/fetal distress in 2nd stage of labour

failure to progress/inadequate progress in 2nd stage of labour (>3h)

171
Q

Symphysis pubis dysfunction

A

pregnancy associated pain, instability & dysfunction of the symphysis pubis joint and/or the sacroiliac joint. Due to ligament laxity in response to hormonal changes occurring during pregnancy

common, effecting ~20% of pregnancies

172
Q

Presentation of symphysis pubis dysfunction

A

pain over pubic synthesis
difficulty walking/ waddling gait
trouble weight bearing
pain/discomfort lying in certain positions

173
Q

Management of pubic symphysis dysfunction

A

exercise
physiotherapy
analgesia

NB pain generally resolved within 6 months of delivery

174
Q

Induction of labour

A

the process of starting labour artificially

used in ~20% of pregnancies

175
Q

Bishops score

A

to calculate the chance of successful induction of labour

made up of:
cervical position, cervical consistency, cervical effacement, cervical dilation, fetal station

Score <5 indicates natural labour unlikely to start without induction
score >9 indicates labour will likely commence spontaneously

176
Q

Indications for induction of labour

A

prolonged pregnancy
PROM where labour doesn’t spontaneously start
diabetic mother >38weeks
Rh incompatibility
IUGR
HTN/pre-eclampsia
planned delivery is in best interest of baby

177
Q

Method of inducing labour

A

membrane swee/artificial rupture of membranes (ARM)

prostaglandin gell/pessary

Oxytocin + ARM

178
Q

Postnatal blues

A

seen in ~50% of women

usually 3-10 days post delivery mother is tearful, anxious, irritable

Key is reassurance

179
Q

Postnatal depression

A

seen in ~10% of women

screened for using Edinburgh postnatal depression scale

usually starts within 1 month of birth, with peak at 3 months

features include anhedonia, loss of libido, low mood, low energy, low self-esteem, feelings of worthlessness

Managed with reassurance, CBT, Sertraline (1st line med) or paroxetine

180
Q

Puerperal psychosis

A

~0.2% of women post delivery

onset within 2-3 weeks post birth

features: mood swings, disordered perception, schizophrenic symptoms, major depression, may have high suicidal drive

requires urgent admission to mother-baby unit

181
Q

Postpartum contraception

A

should be discussed within 1 week postpartum, with earliest date fo ovulation being at 27 days post partum contraception is needed from 21 days post partum

182
Q

From when is postpartum contraception needed

A

21 days post partum

183
Q

Recommendations regarding inter pregnancy periods

A

avoid pregnancy for at least 1 year postpartum

184
Q

Options for post partum contraception

A

POP:
can be used while breastfeeding
give any time postpartum

COCP
contraindicated while breastfeeding

IUD/IUS
can be inserted immediately post birth or at 4 weeks

Lactational amenorrhoea method (LAM)
in women who is fully breastfeeding & amenorrhoeic <6 months post partum

185
Q

Polycystic ovarian syndrome (PCOS)

A

complex condition of ovarian dysfunction, common in women of reproductive age

aetiology not fully understood

NB the majority of women with polycystic ovaries do not have PCOS

186
Q

Polycystic ovarian syndrome (PCOS) presentation

A

sub fertility/infertility
menstrual disturbance (oligomenorrhoea/amenorrhoea)
hirsutism, acne, acanthosis nigricans, alopecia
obesity/difficulty loosing weight
psychological symptoms

187
Q

Rotterdam criteria

A

diagnostic criteria for PCOS
pt with 2/3 of the following
-polycystic ovaries (≥12 follicles / ↑ovarian volume ?10cm^3)
-oligo-ovulation/anovulation
-clinical/biochemical signs of hyperandrogegism

188
Q

Investigating Polycystic ovarian syndrome (PCOS)

A

Pelvic USS (multi cystic ovaries)
FSH/LH/prolactin/TSH/Testosterone (all ↑)
OGTT (commonly shows impaired glucose tolerance)

189
Q

Management of Polycystic ovarian syndrome (PCOS)

A

Weight control/↓ weight & exercise (improve fertility & metabolic features)
COCP (to regulate cycles + manage hirsutism/acne)
Topical eflornithine (if hirsutism/acne don’t respond to COCP)
metformin/clomifene

190
Q

Management of Polycystic ovarian syndrome (PCOS) related infertility

A

Weight loss

Clomifene (1st line) or metformin or both

191
Q

Complications of Polycystic ovarian syndrome (PCOS)

A 
↑ risk of CVS
diabetes
OSA
endometrial hyperplasia/cancer
infertility
192
Q

Endometriosis

A

Presence of endometrial tissue outside the uterine cavity most commonly in the peritoneal cavity
A chronic oestrogen dependent condition

193
Q

Adenomyosis

A

invasion of the myometrium by endometrial tissue

194
Q

Risk factors for endometriosis

A 
positive family history
nulliparity
early menarche
late menopause
late first sexual encounters
195
Q

Presentation of endometriosis

A 
dysmenorrhoea
chronic/cyclical pelvic pain
dyspareunia (especially deep)
subfertility
bloating, lethargy, constipation, lower back pain, urinary symptoms 
posterior fornix/adnexal tenderness
196
Q

Investigating endometriosis

A 
laparoscopy (gold standard)
Transvaginal USS (TVUS)
197
Q

Management of endometriosis

A

NSAIDs + paracetamol for pain relief

1st line: COCP (suppress ovarian function) or progesterones (e.g. medroxyprogesterone)

2nd line: IUS

surgical (laparoscopic excision / laser ablation)

198
Q

Uterine fibroids

A

also known as leiomyomata, are benign tumours of the uterus primarily compromised of smooth muscle & fibrous connective tissue

199
Q

Epidemiology of uterine fibroids

A

very common
~20% of white women
~50% of black women (more common in afro carribbean population)

200
Q

Presentation of uterine fibroids

A

1/2 will be asymptomatic
usually presents between 30-50 yrs of age
menorrhagia
lower abdo pain (cramping pain often during menstruation)
bloating
sub fertility
palpable mass

201
Q

Investigating uterine fibroids

A 
Transvaginal USS (TVUS)
endometrial biopsy
202
Q

Management of uterine fibroids

A

Mirena coil (IUS)/COCP
TXA
GnRH agonist (to ↓ size of fibroids)
surgical: myomectomy to retain fertility or hysterectomy

203
Q

Complications of uterine fibroids

A

red degeneration: haemorrhage into fibroid often occurring during pregnancy

204
Q

Pelvic inflammatory disease (PID)

A

a spectrum of inflammatory disorders of the upper female genital tract usually due to ascending infection from cervix

205
Q

Causes of Pelvic inflammatory disease (PID)

A

Chlamydia trichromatis
Neisseria gonorrhoea
mycoplasma genitalium
mycoplasma hominis

NB in 50% of cases no organism is identified

206
Q

Presentation of Pelvic inflammatory disease (PID)

A 
often mild/absent/atypical symptoms
lower abdo pain
deep dyspareunia
abnormal PV bleeding (post-coital, intermenstrual, menorrhagia)
purulent vaginal/cervical discharge
fever
cervical motion tenderness
207
Q

Investigating Pelvic inflammatory disease (PID)

A

pregnancy test (rule out ectopic)
cervical/high vaginal swabs
vaginal secretion sampling for gonorrhoea/chlamydia
laparoscopy (gold standard)

208
Q

Management of Pelvic inflammatory disease (PID)

A

Abx (if clinically suspected) e.g. IM ceftriaxone (Gonorrhoea) + PO metronidazole + PO doxycycline (chlamydia)

consider IUD removal

management of sexual partners including STI screening

209
Q

complications of Pelvic inflammatory disease (PID)

A

perihepatitis (Fitz-Hugh Curtis syndrome)
infertility/subfertility
↑ risk of ectopic pregnancy

210
Q

Normal physiological discharge

A

white/clear, non offensive discharge that varies with menstrual cycle
thickness/stickiness varies with hormonal cycle

211
Q

bacterial vaginosis

A

most common cause of abnormal vaginal discharge in women of reproductive age, caused by overgrowth of predominantly aerobic bacteria in the vagine e.g. gardenella vaginalis which replace lactobacilli =↓lactic acid production leading to ↑pH

212
Q

Presentation of bacterial vaginosis

A

offensive fishy smelling vaginal discharge

generally thin, off white/greyish discharge

213
Q

Amsel’s criteria for diagnosis of Bacterial vaginosis

A

3/4 of the following

  • thin white homogenous discharge
  • clue cells on microscopy (stippled vaginal epithelia cells)
  • vaginal pH >4.5
  • positive whiff test (add KOH = fishy odour)
214
Q

Management of bacterial vaginosis

A 
avoid vaginal douching, wash outside of vagina only with  pH neutral soap
PO metronidazole (5-7 days)

NB do not treat asymptomatic women unless pregnant (may cause preterm labour/chorioamnionitis in pregnancy)

215
Q

Vaginal candidiasis

A

yeast infection of the lower female reproductive tract, 90% of which are caused by candida albicans

also known as thrush

peak incidence age 20-40 yrs

216
Q

Risk factors for vaginal candidiasis

A

diabetes
Abx/steroid treatment
pregnancy
immunosuppression

217
Q

Presentation of vaginal candidiasis

A 
white, 'cottage cheese' on offensive thick discharge
pruritus vulvae
vulval soreness
dyspareunia
vulval erythema/vaginal mucosa erythema 
satellite lesions/excortications
218
Q

Treatment of vaginal candidiasis

A

no internal cleaning & good personal hygiene

1st line: intravaginal clotrimazole/miconazole pessary

2nd line: oral anti fungal e.g. fluconazole (if severe/systemic symptoms)

219
Q

Recurrent candidiasis

A

≥4 episodes in 1 year

confirm initial diagnosis via high vaginal swab

220
Q

Trichomonas vaginalis

A

common STI caused by a protozoa

221
Q

Presentation of trichomonas vaginalis

A

green-yellow, frothy, offensive discharge
vulvovaginitis (erythema of vulva&vaginal mucosa)
strawberry cervix

222
Q

Investigating trichomonas vaginalis

A

high vaginal swab for NAAT
pH > 4.5
wet microscopy (at GUM clinic)
contact tracing

223
Q

Management of trichomonas vaginalis

A

avoid intercourse for minimum 1 week post treatment

2g single dose PO metronidazole (treat both partners)

224
Q

Other causes of vaginal discharge

A

Chlamydia trachomatis: purulent/mucopurulent discharge

Neisseria gonorrhoea: purulent discharge

Foreign object e.g. tampon: foul smelling, bloody purulent discharge

Erosive lichen plans: visible on examination

225
Q

Indications for emergency contraception

A

no contraception used in a consensual sexual intercourse/rape/sexual assault
contraceptive failure e.g. barrier methods
incorrect use of contraception
unprotected sexual intercourse (UPSI)

226
Q

Levornogestrel emergency contraception MOA

A

stops ovulation & prevents implantation

can be used more than once per menstrual cycle

227
Q

Levornogestrel emergency contraception timing

A

must be taken within 72h of UPSI as single 1.5mg dose

generally well tolerated, but repeat dose if vomiting within 3h of administration

228
Q

Ulipristal (ellaOne) emergency contraception MOA

A

inhibits ovulation

can be used more than once per menstrual cycle

229
Q

Ulipristal (ellaOne) emergency contraception timing

A

can be taken up to 120h post UPSI as single 30mg dose

can be used more than once per menstrual cycle

230
Q

Ulipristal (ellaOne) emergency contraception interaction with hormonal contraception

A

may reduce effectiveness, so restart hormonal contraception 5 days after taking ellaOne & use barrier methods in the mean time

231
Q

Copper IUD as emergency contraception MOA

A

inhibits fertilisation & implantation

most effective form of emergency contraception

232
Q

Copper IUD as emergency contraception timing

A

insert within 5 days of UPSI

if ≥5 days after UPSI then can be fitted within 5 days of the likely ovulation date (usually length of period in days -14 i.e.if 28day cycle then day 14)

233
Q

Copper IUD as emergency contraception removal

A

can be kept in long term as ongoing contraception

if client wants IUD removed then must stay in till at least the next period after insertion

234
Q

Important points for emergency contraception

A

return for pregnancy test if no normal period within 7 days of their normal expected period date or if regular bleeding

235
Q

Combined oral contraceptive pill (COCP) MOA

A

works by inhibiting ovulation, thickens cervical mucus, inhibits implantation

236
Q

Risks of taking Combined oral contraceptive pill (COCP)

A

↑ risk of breast cancer
↑ risk of cervical cancer
↑ risk fo VTE
↑ risk of MI/Stroke

237
Q

Advantages of the Combined oral contraceptive pill (COCP)

A

↓risk of ovarian/endometrial/colorectal cancer
menses tends to be lighter
improves PMS

238
Q

Contraindications for Combined oral contraceptive pill (COCP)

A 
migraine + aura
BMI >35
smoking >15 cigarettes at age >35
history of VTE
breastfeeding <6 weeks postpartum
uncontrolled HTN
breast cancer
history of stroke/IHD
>20 yrs of diabetes
239
Q

Drugs ↓ effectiveness of Combined oral contraceptive pill (COCP)

A

rifampicin
phenytoin
carbamazepine

240
Q

Starting the Combined oral contraceptive pill (COCP)

A

start on first day of menstrual bleed/within 5 days of this day = no additional contraception required

if started on other days of cycle must use other form of contraception for first 7 days

241
Q

How to take Combined oral contraceptive pill (COCP)

A

take pill at same time everyday
take 21 days then 7 day pill free window

may be able to tricycling (3x 21 day packets back to back)

242
Q

1 missed Combined oral contraceptive pill (COCP)

A

1 pill missed anywhere in packet, i.e. >24h without pill

take last pill asap even if it means taking 2 pills in one day, then continue as normal & take 7 day break as normal

NB if they are in week 4 of their packet i.e. the sugar pills then no action required (day 22-28)

243
Q

≥2 missed Combined oral contraceptive pill (COCP)

A

take last missed pill ASAP & omit any earlier pills + used additional contraception for next 7 days

If pills missed in week 1 (days 1-7): consider emergency contraception if unprotected intercourse in pill free interval/week 1

If pills missed in week 2 (days 8-14): no need for emergency contraception if pills taken correctly the last 7 days, finish packets as normal

if pills missed in week 3 (days 15-21): finish current packet as per usually and omit pill free break

244
Q

Progesterone only pill (POP) MOA

A

inhibits ovulation & thickens cervical mucous

245
Q

Progesterone only pill (POP) contraindications

A

past breast cancer

SLE

246
Q

Progesterone only pill (POP) advantages

A

can be used while breastfeeding
can be used when oestrogen contra indicated e.g. VTE
can be used when having major surgery

247
Q

Starting the Progesterone only pill (POP)

A

if commenced up to & including day 5 of the cycle it provides immediate protection

otherwise requires 2 days of additional contraception after commencing

248
Q

How to take Progesterone only pill (POP)

A

must be taken at exactly same time everyday (within a 3h window of when pill was taken previous day)

> 3h late = missed pill

249
Q

Missed pill for Progesterone only pill (POP)

A

if a pill is >3h late = missed

If missed pill, then take missed pill as soon as possible, use extra contraception until regular pill taking reestablished for 48h

250
Q

Injectable contraceptive (Depo Porvera) MOA

A

inhibiting ovulation & thickening cervical mucous

Slowly releases progestogen

251
Q

How Injectable contraceptive (Depo Porvera) is used

A

IM injection every 12 weeks

252
Q

Disadvantages of Injectable contraceptive (Depo Porvera)

A

not quickly reversible
weight gain*
irregular bleeding

253
Q

Injectable contraceptive (Depo Porvera) contraindications

A

current/past breast cancer

avoid in <18y/o due to ↓ bone mineral density

254
Q

Contraceptive proven to cause weight agin

A

injectable contraceptive (Depo Provera)

255
Q

Implantable contraceptive (Nexplanon) MOA

A

inhibits ovulation & thickens cervical mucous

Slowly releases progestogen

256
Q

how the Implantable contraceptive (Nexplanon) works

A

lasts 3 years

inserted in the proximal non-dominant arm, just overlying the tricep

take additional contraception for 7 days if not inserted on day 1-5 of cycle

257
Q

Intrauterine contraceptive device (IUD)

A

also known as the copper coil

inhibits fertilisation & is cytotoxic for sperm

lasts for 5-10years

effective immediately after insertion

258
Q

Intrauterine contraceptive device (IUD) complications

A

heavy/prolonged periods

↑risk of ectopic pregnancy

259
Q

Intrauterine system (IUS) (mirena coil)

A

levornogestrel releasing device

inhibits endometrial proliferation = prevents implantation and thickens cervical mucous

lasts for 5 years

260
Q

Intrauterine system (IUS) (mirena coil) advantages

A

can be used to manage menorrhagia, as HRT, endometrial hyperplasia, endometriosis
often lighter menses/amenorrhoea

261
Q

Contraceptive of choice in younger people

A

Implantable contraceptive (nexplanon) is the LARC of choice in young people

262
Q

Age of consent for sexual encounters

A

Age < 13 means a pt is unable to consent, so if a child comes in this should trigger child protection meausres

generally age of consent = 16 but can be lower if fraser competent

263
Q

The Fraser guidelines

A

Used in those <16 years old

The following points should be fulfilled:

  • the young person understands the professional’s advice
  • the young person cannot be persuaded to inform their parents or allow the professional to contact them on their behalf
  • the young person is likely to begin, or continue having, sexual intercourse with or without contraceptive treatment
  • unless the young person receives contraceptive treatment, their physical or mental health, or both, is likely to suffer
  • the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent
264
Q

Menopause

A

onset of menopause is defined as the cessation of menses for at least 12 consecutive months without other causes of amenorrhoea

as women move towards menopause their mensturation may become erratic but if there is still bleeding it is not menopause

average age = 51 yrs

265
Q

Contraception and menopause

A

contraception is indicated until 12 months after last period if >50y/o

if <50y/o contraception is indicated till 24 months after last period

266
Q

Presentation of menopause

A 
menstrual irregularity
hot flushes/sweats
vaginal dryness & atrophy
urinary frequency
sleep disturbances
mood changes (anxiety, depression, difficulty concentrating)
↓ libido
267
Q

Management of menopausal symptoms (excluding HRT)

A

lifestyle modifications e..g weight loss, regular exercise etc

fluoxetine/citalopram/venlafaxine for hot flushes/vasomotor symptoms

lubricants & moisturisers for vaginal dryness

vaginal oestrogen’s for vaginal atrophy

268
Q

HRT (hormone replacement therapy)

A

in women with uterus = oestrogen + progestogen
in women without uterus = only oestrogen

give continuous combined regime if amenorrhoea >12 months/sequential HRT received for >12 months
give sequential combined regimes if amenorrhoea <12 months

269
Q

HRT (hormone replacement therapy) contraindications

A

current/past breast cancer
oestrogen-sensitive cancer
undiagnosed vaginal bleeding
untreated endometrial hyperplasia

270
Q

Complications of HRT (hormone replacement therapy)

A

↑ risk of breast cancer
↑ risk of endometrial cancer
↑ VTE risk

271
Q

Premature ovarian failure

A

onset of menopausal symptoms & ↑ gonadotrophin levels before the age of 40

272
Q

Investigating premature ovarian failure

A 
FSH ↑
LH ↑
estradiol ↓
TVUS
TFTs
prolactin
273
Q

Management of premature ovarian failure

A

specialist referral
Sex steroid replacement till at least 51 yrs of age (e.g. via HRT or COCP)
egg donation if attempting conception

274
Q

Female genital mutation (FGM)

A

also known as female circumcision is widely practiced throughout africa & the middle east

WHO definition: all procedures that involve the partial or total removal of the external female genitalia or other injuries to the female genital organs for non medical reasons

275
Q

Type I Female genital mutation (FGM)

A

clitoridectomy: partial/complete removal of the clitoral glans and/or the prepuce/clitoral hood

276
Q

Type II Female genital mutation (FGM)

A

excision: partial or total removal of the clitoris & labia minor with or without excision of the labia major

277
Q

Type III Female genital mutation (FGM)

A

infibulation: narrowing of the vaginal orifice with the creation of a covering seal by cutting/repositioning the labia minor and/or labia major

278
Q

Type IV Female genital mutation (FGM)

A

all other harmful procedures to the female genitalia for non medical purposes e.g. piercing, pricking, scraping, cauterising

279
Q

Female genital mutation (FGM) and the law

A

all HCPs are required to report/record FGM if they see it in a patient or if there is a family history of FGM

It is an offence for UK nationals/permanent UK residents to carry out FGM in the UK or abroad as well as to aid/abet/counsel/procure the carrying out of FGM abroad even in countries where the practice is legal

280
Q

Cervical cancer

A

a human papilloma virus (HPV) related malignancy of the uterine cervical mucosa, 80% are SCC

peak incidence in those aged 29-25 yrs

281
Q

HPV subtypes implicated in cervical cancer

A

types 16 & 18

282
Q

Risk factors for cervical cancer

A 
HPV infection*
smoking
early first intercourse
multiple sexual partners
immunosuppression (invasive cervical cancer = AIDS defining illness)
lower socioeconomic class
283
Q

Presentation of cervical cancer

A

often detected at routine cervical screening
abnormal vaginal bleeding (post coital/intermenstrual/postmenopausal)
vaginal discomfort
vaginal discharge
urinary/bowel symptoms
abnormal appearance of cervix on examination

284
Q

Investigating cervical cancer

A 
vaginal/speculum examination
colposcopy
cervical biopsy
HPV testing (usually +ve)
CT
285
Q

Staging cervical cancer

A

FIGO staging
Cervical intraepithelial neoplasia (CIN)
-CIN I confined to lower 1/3 of epithelium
-CIN II confined to lower 2/3 of epithelium
-CIN III full thickness of epithelium affected

Stage I - confined to cervix
Stage II - spread beyond cervix but not to pelvic wall/ lower 1/3 of vagina
Stage III - tumour extends to pelvic wall/ into lower 1/3 of vagina
Stage IV - tumour spreads beyond pelvis, or involves bladder/bowel

286
Q

Managing cervical cancer

A

Early on: radical hysterectomy ± lymph node clearance (Gold standard)
NB cone biopsy/local excision to retain fertility

Later on: radical hysterectomy + chemo/radiotherpay

287
Q

Complications of cone biopsy/local excision of cervical cancer

(LLETZ procedure = loop excision of transformation zone)

A

↑ risk of preterm labour due to shortened cervix (cervical incompetence) but can be treated with cervical cerclage

cervical stenosis

pyometra (A pyometra is a collection of pus distending the uterine cavity. It occurs principally when there is a stenosed cervical os)

288
Q

Prevention of cervical cancer

A

HPV vaccination for all boys & girls aged 12-13

quadrivalent vaccine vs types 16,18 (cervical cancer) & 6,11 (genital warts)

289
Q

Cervical cancer screening

A

smear test offered to all women aged 25-64
age 25-49 = 3 yearly
age 50-64 = 5 yearly

screens for high risk HPV, if +ve then cytology is performed

290
Q

Cervical screening in pregnancy

A

usually delayed until 3 months post partum unless missed screening or previous abnormal smear

291
Q

Inadequate sample protocol for cervical smear

A

repeat sample after 3 months

if inadequate again then perform colposcopy

292
Q

If negative cervical smear

A

normal recall

i.e.
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening

293
Q

if positive cervical smear with abnormal cytology

A

colposcopy

294
Q

if positive cervical smear with normal cytology

A

repeat in 12 months time

if positive smear with normal cytology at 12 months then repeat in 12 months

if positive smear with normal cytology at 24 months then colposcopy

if repeat test after 12/24 months is negative then return to normal recall

295
Q

Endometrial cancer

A

an epithelial malignancy of the uterine corpus mucosa usually in the form of an adenocarcinoma, its an oestrogen dependent tumour

classically seen in postmenopausal women

296
Q

hormone related to endometrial cancer

A

oestrogen

297
Q

Risk factors for endometrial cancer

A 
nulliparity
obesity 
early menarche/late menopause
PCOS
endometrial hyperplasia
unopposed oestrogen
tamoxifen
diabetes
298
Q

Presentation of endometrial cancer

A

classically postmenopausal PV bleeding

abnormal/intermenstrual PV bleeding if premenopausal

299
Q

investigating endometrial cancer

A

TVUS

endometrial biopsy ± hysteroscopy

300
Q

Management of endometrial cancer

A

if localised = radical hysterectomy + bilateral sapling-oophrectomy ± radiotherapy

progestogen therapy in those not fit for surgery

301
Q

Ovarian cancer

A

malignancy arising form the ovaries often epithelial (cystadenocarcinoma) (90%)
leading cause of death from gynaecological cancer in the UK

peak incidence ~60 y/o

302
Q

Risk factors for ovarian cancer

A 
BRCA 1/BRCA2
smoking
obesity
nulliparity
early menarche/late menopause
303
Q

Protective factors for ovarian cancer

A

COCP

304
Q

Presentation of ovarian cancer

A 
insidious onset & vague early symptoms
abdominal distension/bloating
abdo discomfort
early satiety
diarrhoea
urinary symptoms
pelvic/abdo mass
ascites
305
Q

Investigating ovarian cancer

A

CA125 (>35IU/ml)
pelvic USS/ TVUS
CT/MRI pelvis

306
Q

Management of ovarian cancer

A

explorative laparotomy + histopathology/staging

total abdominal hysterectomy + bilateral sapling-oophrectomy + platinum based chemo

307
Q

Prognosis of ovarian cancer

A

~80% present with advanced disease

~5% of all UK female cancer death are due to ovarian cancer

308
Q

Endometrial hyperplasia

A

abnormal proliferation of the endometrium greater than the normal proliferation that occurs during the menstrual cycle

309
Q

Risk factors for endometrial hyperplasia

A 
obesity
tamoxifen
unopposed oestrogen
PCOS
diabetes
310
Q

Presentation of endometrial hyperplasia

A

abnormal PV bleeding (intermenstrual/irregular bleeding/menorrhagia/post menopausal bleeding)

311
Q

Investigating endometrial hyperplasia

A

endometrial biopsy via hysteroscopy (if atypical hyperplasia = premalignant)

TVUS (↑ endometrial thickness, >3-4mm if postmenopausal, >7mm if premenopausal)

312
Q

Management of endometrial hyperplasia

A

progestogen therapy
1st line = IUS (levornogestrel)
2nd line = continues oral progestogen (e.g. POP)

if atypical hyperplasia then total hysterectomy is advised

313
Q

Adenomyosis

A

characterised by the presence of endometrial tissue within the myometrium leading to thickened utuerus

presents with dysmenorrhoea, menorrhagia, enlarged globular uterus

investigate with TVUS

managed with simple analgesia, IUS/COCP or GnRH agonist (e.g. danazol)

314
Q

Cervical ectropion

A

when columnar epithelium of the endocervix is displayed beyond the cervical OS, ie a change in the cervical transformation zone

usually due to ↑ oestrogen levels (e.g. COCP use or pregnancy)

315
Q

Presentation of cervical ectropion

A

often asymptomatic
vaginal discharge
post coital PV bleeding
red ring around cervical OS on examination

316
Q

Management of cervical ectropion

A

stop COCP & conservative management

317
Q

Ovarian cysts

A

very common benign growth that generally occur in premenopausal women

318
Q

Presentation of ovarian cysts

A 
mostly asymptomatic 
dull ache/pain in lower abdomen
lower back pain
dyspareunia
palpable mass on examination
torsion/rupture = serve abdo pain often after exercise
319
Q

Investigating ovarian cysts

A

TVUS (gold standard)
pregnancy test
CA125
CT/MRI

320
Q

Management of ovarian cysts

A

small cysts (<50mm) = usually self resolve, no follow up neded

larger cysts (>50mm) or complex cysts need USS follow up and consider surgical treatment fi conservative approach fails

321
Q

Types of ovarian cysts

A

Follicular = most common, due to non rupture of dominant follicle, often regress spontaneously

Corpus luteum cysts = failure of corpus lute to break down, often presents as intraperiotneal bleeding

Dermoid cysts = may contain hair/nails/skin, most common benign tumour in <30y/o

serous cyst adenoma = most common bening epithelial tumour, may resemble serous carcinoma

mucinous cyst adenoma = often large and may become massive, may rupture causing pseudomyxoma peritonea (mucin in peritoneal cavity)

322
Q

genitourinary prolapse

A

descent of one or more of the pelvic organs including the uterus/blader/rectum/vaginal vault

323
Q

Risk factors of genitourinary prolapse

A 
↑ age
↑ parity/multiparity
vaginal delivery
obesity
previous hysterectomy
previous prolapse
324
Q

Presentation of genitourinary prolapse

A 
mild prolapse is often asymptomatic
sensation of pressure/fullness/heaviness
sensation of bulge/protrusion
difficulty retaining tampons
feeling of bearing down
urinary symptoms (incontinence, frequency, urgency, incomplete emptying)
dyspareunia
constipation
325
Q

Management of genitourinary prolapse

A

conservative : weight loss, pelvic floor exercises, ring pessary

Surgical management

326
Q

Urinary incontinence

A

involuntary loss of urine

common problem especially in elderly female,

327
Q

Types of urinary incontinence

A

stress incontinence: involuntary leak on effort/exertion/sneezing/coughing , usually small amounts

urge incontinence: involuntary leak immediately proceed by urgency of micturition

Mixed: mix of urgency & stress

overflow incontinence: usually due to chronic bladder outflow obstruction

328
Q

Risk factors for urinary incontinence

A 
↑ age
previous pregnancy/childbirth
vaginal delviery
↑ BMI
FHx
hysterectomy
pelvic organ prolapse 
congiuntive impairment
329
Q

Investigations for urinary incontinence

A

bladder diary
vaginal/speculum examination
urine dipstick & culture
urodynamic studies

330
Q

Management of urge urinary incontinence

A

1st line bladder retraining

2nd line bladder stabilising drugs (antimuscarinics e.g. oxybutynin, tolterodine)

331
Q

Management of stress urinary incontinence

A

pelvic floor exercises
duloxetine
surgical management

332
Q

Management of mixed urinary incontinence

A

pelvic floor exercises + bladder retraining

333
Q

Infertility/subfertility causes

A 
male factors ~30%
unexplained ~25%
ovulation failure/ovulatory disorders ~25%
tubal damage ~15%
other causes ~10%
334
Q

Investigating Infertility/subfertility

A 
semen analysis (after min 3 days abstinence)
serum progesterone (7 days prior to next expected period, so for 28 day cycle = day 21, <16nmol/L = abnormal, >30nmol/L indicated ovulation)
FSH/LH
335
Q

Ovarian hyperstimulation syndrome (OHSS)

A

complication of induced ovulation as part of assisted conception

presents as bloating, abdo pain, ascites, anuria, acute respiratory distress

336
Q

Bartholin’s cysts/abscess

A

Bartholins glands are a pair of glands located next to the entrance fo the vagina, the ducts of these glands may occlude leading to cyst formation

generally unilateral

usually in women of childbearing age

337
Q

Bartholin’s cysts/abscess presentation

A

small cysts often asymptmatic
vulval/perineal mass
vulval pressure/fullness

abscesses may be painful, labial oedema/erythema

on examination = unilateral labial mass
cysts = soft, fluctuant, non-tender
abscess = tesne, ahrd, painful with surrounding erythema

338
Q

Management of Bartholin’s cysts/abscess

A 
conservative therapy (if small)
simple incision & drainage 
Marsupialisation (gold standard & definitive treatment)
339
Q

Postmenopausal bleeding

A

vaginal bleeding occurring after >12 months of amenorrhoea in a women at the age where menopause cane expected

340
Q

Causes of postmenopausal bleeding

A 
vaginal atrophy (most common)
HRT
endometrial hyperplasia
endometrial cancer
trauma 
polyps
341
Q

Investigating postmenopausal bleeding

A

TVUS
urine dipstick
CA-125
endometrial biopsy/hysteroscopy

342
Q

Managing vaginal atrophy

A

topical/vaginal oestrogens + lubrication

343
Q

Dysmenorrhoea

A

characterised by excessive pain during menstrual periods

344
Q

Primary dysmenorrhoea

A

no underlying pathology, affects ~50% of menstruating women, often developing soon after menarche

pain usually starts just before/within a few hours of period starting

management: NSAIDs e.g. mefenamic acid
COCP (2nd line)

345
Q

Secondary dysmenorrhoea

A

often due to underlying pathology, generally develops years after menarche

pain starts 3-4 days pre period

Causes: PID, endometriosis, adenomysosis, fibroids

refer to gynaecologist

346
Q

Menorrhagia

A

menstrual blood loss which interferes with a women physical/emotional/social/maternal QoL

generally if quantity >80ml or bleeding >7days

peak age 30-49 yrs

347
Q

Causes of menorrhagia

A 
dysfunctional uterine bleeding (DUB) i.e. primary menorrhagia, ~50% of cases
anovulatory cycles
fibroids
endometrial polyps
endometriosis 
adenoymyosis
PID
copper coil
348
Q

Investigating menorhagia

A

TVUS
FBC
TFTs

349
Q

Management of menorhagia

A

mefenamic acid + TXA 1g

Mirena coil (1st line if contraception required)

350
Q

Amenorrhoea

A

absence or cessation of menstruation, which may be physiological as before the menarche, due to pregnancy, or after menopause

351
Q

Primary amenorrhoea

A

Menses has not occurred by the time of expected menarche i.e. age 14 if absence of secondary sexual characteristics or age 16 if secondary sexual characteristics present

Causes include constitutional delay, imperforate hymen, ovarian failure, hypothalamic failure

352
Q

Secondary amenorrhoea

A

menstruation absent for ≥6months but having previously been established

causes: pregnancy, hypothalamic amenorrhoea, PCOS, hyperprolactinaemia, premature ovarian failure

353
Q

Investigations for amenorrhoea

A 
pregnancy test
gonadotrophin levels i.e. FSH/LH (↑ if ovarian cause, ↓ of hypothalamic cause) 
prolactin 
androgen levels
TFTs
pelvic USS
354
Q

Complications of forceps delivery

A

Maternal:
perineal tear, vaginal lacerations, sphincter injury, pelvic organ prolapse

Fetal:
facial lacerations, ocular trauma, skull fracture, subgaleal haematoma

355
Q

Complications of ventouse delviery

A

maternal:
extension of vaginal laceration, perineal tears

fetal:
scalp laceration, cephalohaematoma, retinal haemorrhage

356
Q

Use of GnRH agonist in fibroids

A

e.g. Triptorelin or Goserelin

used to ↓ size of fibroids, especially in the short term while awaiting surgery

357
Q

Hypothalamic amenorrhoea

A

Due to ↓GnRH = ↓ LH & ↓ FSH

causes include excessive weight loss, eating disorders, obesity, stress

358
Q

Causes of inadequate cervical smear

A

failure to sample full 360° of cervical circumference
blood on smear
cervical inflammation
age related atrophic changes

359
Q

Imperforate hymen

A

cause of primary amenorrhoea

usually presents as lower abdominal pain, which gets worse from time to time (usually when periods would be)
in a girl with present secondary sexual characteristics

usually treated with incision of the hymen

Year 4 (12 decks)

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