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Obstetrics & gynaecology Flashcards

1
Q

What hormonal changes occur in pregnancy?

A

increased:
steroid hormones
T3/4
prolactin
melanocyte stimulating hormone
oestrogen
progesterone
HcG

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2
Q

What cardiovascular changes occur in pregnancy?

A

increased:
blood volume
plasma volume
cardiac output

decreased:
vascular resistance
blood pressure

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3
Q

What respiratory changes occur in pregnancy?

A

Increased:
tidal volume
resp rate

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4
Q

What renal changes occur in pregnancy?

A

Increased:
blood flow
GFR
sodium reabsorption
water reabsorption
protein excretion

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5
Q

What haematological changes occur in pregnancy?

A

Increased:
RBC production
WBC
Clotting factors
ALP

decreased:
Platelets
Haematocrit
Albumin

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6
Q

What skin changes occur in pregnancy?

A

Linear Nigra
melasma
striae gravidarum
spider naevi
Palmar erythema

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7
Q

When does labour and delivery normally occur?

A

between 37 and 42 weeks gestation

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8
Q

What are the 3 stages of labour?

A

The first stage is from the onset of labour (true contractions) until 10cm cervical dilatation.
The second stage is from 10cm cervical dilatation to delivery of the baby.
The third stage is from delivery of the baby to delivery of the placenta.

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9
Q

What is the role of prostaglandins in labour?

A

Ripening of cervix
uterine contractions

can use prostaglandin E2 pessaries to induce labour

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10
Q

What are the 3 phases of the first stage of labour?

A

Latent phase: From 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
Active phase: From 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
Transition phase: From 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.

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11
Q

What 3 factors does the second stage of labour depend on?

A

Power: strength of contraction
Passenger: size, attitude(posture), lie, presentation
Passage: size and shape of pelvis/birth canal

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12
Q

What are the 7 cardinal movements of labour?

A

Engagement
Descent
Flexion
Internal Rotation
Extension
Restitution and external rotation
Expulsion

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13
Q

How is decent of the baby measured?

A

position of baby’s head in relation to ischial spines
-5: when the baby is high up at around the pelvic inlet
0: when the head is at the ischial spines (this is when the head is “engaged”)
+5: when the fetal head has descended further out

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14
Q

What 2 factors should prompt active management of the 3rd stage of labour?

A

Haemorrhage
more than 60 minute delay in delivery of placenta

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15
Q

What is active management of the 3rd stage of labour?

A

IM oxytocin
traction to the umbilical cord

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16
Q

What are some causes of primary amenorrhoea?

A

Abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
Abnormal functioning of the gonads (hypergonadotropic hypogonadism)
Imperforate hymen or other structural pathology

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17
Q

What is secondary amenorrhoea?

A

when the patient previously had periods that subsequently stopped

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18
Q

What are some causes of secondary amenorrhoea?

A

Pregnancy (the most common cause)
Menopause
Physiological stress due to excessive exercise, low body weight, chronic disease or psychosocial factors
Polycystic ovarian syndrome
Medications, such as hormonal contraceptives
Premature ovarian insufficiency
Thyroid hormone abnormalities
Excessive prolactin, from a prolactinoma
Cushing’s syndrome

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19
Q

What are some differentials for irregular menstruation?

A

Extremes of reproductive age
Polycystic ovarian syndrome
Physiological stress
Medications, particularly progesterone only contraception, antidepressants and antipsychotics
Hormonal imbalances, such as thyroid abnormalities, Cushing’s syndrome and high prolactin

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20
Q

What are some differentials for intermenstrual bleeding?

A

Hormonal contraception
Cervical ectropion, polyps or cancer
Sexually transmitted infection
Endometrial polyps or cancer
Vaginal pathology, including cancers
Pregnancy
Ovulation can cause spotting in some women
Medications, such as SSRIs and anticoagulants

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21
Q

What are some differentials for dysmenorrhoea (painful periods) ?

A

Primary dysmenorrhoea (no underlying pathology)
Endometriosis or adenomyosis
Fibroids
Pelvic inflammatory disease
Copper coil
Cervical or ovarian cancer

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22
Q

What are some differentials for menorrhagia?

A

Dysfunctional uterine bleeding (no identifiable cause)
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
Pelvic inflammatory disease
Contraceptives, particularly the copper coil
Anticoagulant medications
Bleeding disorders (e.g. Von Willebrand disease)
Endocrine disorders (diabetes and hypothyroidism)
Connective tissue disorders
Endometrial hyperplasia or cancer
Polycystic ovarian syndrome

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23
Q

What are some differentials for postcoital bleeding?

A

Cervical cancer, ectropion or infection
Trauma
Atrophic vaginitis
Polyps
Endometrial cancer
Vaginal cancer

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24
Q

What are some differentials for pelvic pain?

A

Urinary tract infection
Dysmenorrhoea (painful periods)
Irritable bowel syndrome (IBS)
Ovarian cysts
Endometriosis
Pelvic inflammatory disease (infection)
Ectopic pregnancy
Appendicitis
Mittelschmerz (cyclical pain during ovulation)
Pelvic adhesions
Ovarian torsion
Inflammatory bowel disease (IBD)

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25
Q

What are some differentials for excessive, discoloured or foul-smelling discharge?

A

Bacterial vaginosis
Candidiasis (thrush)
Chlamydia
Gonorrhoea
Trichomonas vaginalis
Foreign body
Cervical ectropion
Polyps
Malignancy
Pregnancy
Ovulation (cyclical)
Hormonal contraception

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26
Q

What are some causes of pruritis vulvae?

A

Irritants such as soaps, detergents and barrier contraception
Atrophic vaginitis
Infections such as candidiasis (thrush) and pubic lice
Skin conditions such as eczema
Vulval malignancy
Pregnancy-related vaginal discharge
Urinary or faecal incontinence
Stress

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27
Q

How do you define primary amenorrhoea?

A

Not starting menstruation:
By 13 years when there is no other evidence of pubertal development
By 15 years of age where there are other signs of puberty, such as breast bud development

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28
Q

What is hypogonadotropic hypogonadism?

A

deficiency of LH and FSH

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29
Q

What is hypergonadotropic hypogonadism?

A

lack of response to LH and FSH by the gonads (the testes and ovaries)

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30
Q

What are some causes of hypogonadotropic hypogonadism?

A

Hypopituitarism
Damage to the hypothalamus or pituitary, for example, by radiotherapy or surgery for cancer
Significant chronic conditions can temporarily delay puberty (e.g. cystic fibrosis or inflammatory bowel disease)
Excessive exercise or dieting
Constitutional delay in growth and development
Endocrine disorders such as growth hormone deficiency, hypothyroidism, Cushing’s or hyperprolactinaemia
Kallman syndrome

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31
Q

What are some causes for hypergonadotropic hypogonadism?

A

Previous damage to the gonads (e.g. torsion, cancer or infections such as mumps)
Congenital absence of the ovaries
Turner’s syndrome (XO)

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32
Q

What is Kallman syndrome?

A

genetic condition causing hypogonadotrophic hypogonadism, with failure to start puberty. It is associated with a reduced or absent sense of smell (anosmia)

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33
Q

What causes congenital adrenal hyperplasia?

A

congenital deficiency of the 21-hydroxylase enzyme. This causes underproduction of cortisol and aldosterone, and overproduction of androgens from birth
Autosomal recessive

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34
Q

What is androgen insensitivity syndrome?

A

tissues are unable to respond to androgen hormones (e.g. testosterone), so typical male sexual characteristics do not develop. It results in a female phenotype

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35
Q

What structural pathology can cause primary amenorrhoea?

A

Imperforate hymen
Transverse vaginal septae
Vaginal agenesis
Absent uterus
Female genital mutilation

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36
Q

What initial investigations should be done to assess for underlying medical conditions in primary amenorrhoea?

A

Full blood count and ferritin for anaemia
U&E for chronic kidney disease
Anti-TTG or anti-EMA antibodies for coeliac disease

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37
Q

What blood tests can be done to assess for hormonal abnormalities in primary amenorrhoea?

A

FSH and LH will be low in hypogonadotropic hypogonadism and high in hypergonadotropic hypogonadism
Thyroid function tests
Insulin-like growth factor I is used as a screening test for GH deficiency
Prolactin is raised in hyperprolactinaemia
Testosterone is raised in polycystic ovarian syndrome, androgen insensitivity syndrome and congenital adrenal hyperplasia

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38
Q

What imaging can be useful to assess causes of primary amenorrhoea?

A

Xray of the wrist to assess bone age and inform a diagnosis of constitutional delay
Pelvic ultrasound to assess the ovaries and other pelvic organs
MRI of the brain to look for pituitary pathology and assess the olfactory bulbs in possible Kallman syndrome

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39
Q

What is the definition of secondary amenorrhoea?

A

no menstruation for more than three months after previous regular menstrual periods

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40
Q

What medication can be given to treat hyperprolactinaemia?

A

Dopamine agonists such as bromocriptine or cabergoline

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41
Q

What should an assessment of secondary amenorrhoea involve?

A

Detailed history and examination to assess for potential causes
Hormonal blood tests
Ultrasound of the pelvis to diagnose polycystic ovarian syndrome

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42
Q

What hormone tests suggest primary ovarian failure?

A

High FSH

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43
Q

What hormone tests suggest PCOS?

A

High LH, or LH:FSH ratio
raised testosterone

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44
Q

How can you reduce the risk of osteoporosis in secondary amenorrhoea?

A

adequate vitD and calcium
COCP or HRT

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45
Q

What is premenstrual syndrome?

A

psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation

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46
Q

What are some symptoms of premenstrual syndrome?

A

Low mood
Anxiety
Mood swings
Irritability
Bloating
Fatigue
Headaches
Breast pain
Reduced confidence
Cognitive impairment
Clumsiness
Reduced libido

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47
Q

What are the management options for premenstrual syndrome?

A

General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep
Combined contraceptive pill (COCP)
RCOG recommends COCPs containing drospirenone first line (i.e. Yasmin). Drospironone as some antimineralocortioid effects, similar to spironolactone. Continuous use of the pill, as opposed to cyclical use, may be more effective.
SSRI antidepressants
Cognitive behavioural therapy (CBT)

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48
Q

What investigations can be done for heavy menstrual bleeding?

A

Pelvic examination with a speculum and bimanual
Full blood count, coag screen, ferritin
Outpatient hysteroscopy
Pelvic and transvaginal ultrasound

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49
Q

What are the management options for heavy menstrual bleeding when the patient does not want contraception?

A

Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)

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50
Q

What is the management of heavy menstrual bleeding when contraception is wanted?

A

Mirena coil (first line)
Combined oral contraceptive pill
Cyclical oral progestogens, such as norethisterone 5mg three times daily from day 5 – 26 (although this is associated with progestogenic side effects and an increased risk of venous thromboembolism)

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51
Q

When medical management has failed what are the options for treatment of heavy menstrual bleeding?

A

endometrial ablation and hysterectomy

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52
Q

What are the 4 types of fibroids?

A

Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.
Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
Submucosal means just below the lining of the uterus (the endometrium).
Pedunculated means on a stalk.

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53
Q

How may fibroids present?

A

Heavy menstrual bleeding
Prolonged menstruation
Abdominal pain, worse during menstruation
Bloating or feeling full in the abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia (pain during intercourse)
Reduced fertility

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54
Q

what may abdominal and bimanual examination reveal in fibroids?

A

palpable pelvic mass or an enlarged firm non-tender uterus

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55
Q

What investigations can be done for fibroids?

A

Hysteroscopy
pelvic ultrasound
MRI

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56
Q

If fibroids are over 3cm what are the management options?

A

referral to gynaecology
Symptomatic management with NSAIDs and tranexamic acid
Mirena coil – depending on the size and shape of the fibroids and uterus
Combined oral contraceptive
Cyclical oral progestogens

Surgical options for larger fibroids are:
Uterine artery embolisation
Myomectomy
Hysterectomy
GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), may be used to reduce the size of fibroids before surgery.

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57
Q

What are the potential complications of fibroids?

A

Heavy menstrual bleeding, often with iron deficiency anaemia
Reduced fertility
Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
Constipation
Urinary outflow obstruction and urinary tract infections
Red degeneration of the fibroid
Torsion of the fibroid, usually affecting pedunculated fibroids
Malignant change to a leiomyosarcoma is very rare (<1%)

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58
Q

What is red degeneration of fibroids?

A

ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.
presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia
common in pregnancy

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59
Q

What is endometriosis?

A

condition where there is ectopic endometrial tissue outside the uterus

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60
Q

What are chocolate cysts ?

A

Endometriomas in the ovaries

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61
Q

What are the symptoms of endometriosis?

A

Cyclical abdominal or pelvic pain
Deep dyspareunia (pain on deep sexual intercourse)
Dysmenorrhoea (painful periods)
Infertility
Cyclical bleeding from other sites, such as haematuria

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62
Q

What may examination reveal in endometriosis?

A

Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
A fixed cervix on bimanual examination
Tenderness in the vagina, cervix and adnexa

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63
Q

How is endometriosis diagnosed?

A

Pelvic ultrasound
Laparoscopic surgery = gold standard

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64
Q

What staging system may be used for endometriosis?

A

American Society of Reproductive Medicine (ASRM)

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65
Q

What are the hormonal management options for endometriosis?

A

Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
Progesterone only pill
Medroxyprogesterone acetate injection (e.g. Depo-Provera)
Nexplanon implant
Mirena coil
GnRH agonists

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66
Q

What are the surgical management options for endometriosis?

A

Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
Hysterectomy

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67
Q

What is Adenomyosis?

A

endometrial tissue inside the myometrium (muscle layer of the uterus)

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68
Q

What are the presenting features of adenomyosis?

A

Painful periods (dysmenorrhoea)
Heavy periods (menorrhagia)
Pain during intercourse (dyspareunia)

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69
Q

How is adenomyosis diagnosed?

A

1st line = transvaginal ultrasound
MRI/transabdominal ultrasound
Gold = histology following hysterectomy

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70
Q

What pregnancy complications are associated with adenomyosis?

A

Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm premature rupture of membranes
Malpresentation
Need for caesarean section
Postpartum haemorrhage

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71
Q

when can a diagnosis of menopause be made?

A

after a woman has had no periods for 12 months

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72
Q

What is the average age of menopause?

A

51 years

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73
Q

what is postmenopause?

A

describes the period from 12 months after the final menstrual period onwards.

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74
Q

What is perimenopause?

A

time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards

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75
Q

What is premature menopause?

A

menopause before the age of 40 years. It is the result of premature ovarian insufficiency.

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76
Q

What are the hormonal changes in menopause?

A

Oestrogen and progesterone levels are low
LH and FSH levels are high, in response to an absence of negative feedback from oestrogen

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77
Q

describe the physiology of menopause

A

decline in development of follicles -> reduced production of oestrogen -> no negative feedback -> increased LH and FSH

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78
Q

Name some perimenopausal symptoms

A

Hot flushes
Emotional lability or low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness and atrophy
Reduced libido

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79
Q

What are you at increased risk of with low oestrogen e.g. menopause

A

Cardiovascular disease and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence

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80
Q

when is it recommended to do an FSH test to diagnose menopause?

A

Women under 40 years with suspected premature menopause
Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle

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81
Q

when is contraception required after menopause?

A

Two years after the last menstrual period in women under 50
One year after the last menstrual period in women over 50

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82
Q

What are some management options for perimenopausal symptoms?

A

No treatment
Hormone replacement therapy (HRT)
Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors
Cognitive behavioural therapy (CBT)
SSRI antidepressants
Testosterone can be used to treat reduced libido (usually as a gel or cream)
Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT)
Vaginal moisturisers

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83
Q

What are some causes of premature ovarian insufficiency?

A

Idiopathic (the cause is unknown in more than 50% of cases)
Iatrogenic, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. oophorectomy)
Autoimmune, possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease
Genetic, with a positive family history or conditions such as Turner’s syndrome
Infections such as mumps, tuberculosis or cytomegalovirus

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84
Q

What are the 2 HRT options for premature ovarian insufficiency?

A

Traditional hormone replacement therapy
Combined oral contraceptive pill

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85
Q

What are the risks of HRT?

A

breast cancer (particularly combined HRT)
endometrial cancer
Increased risk of venous thromboembolism (2 – 3 times the background risk)
stroke and coronary artery disease with long term use in older women

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86
Q

How can you reduce the risks of HRT?

A

The risk of endometrial cancer is greatly reduced by adding progesterone in women with a uterus
The risk of VTE is reduced by using patches rather than pills

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87
Q

What are essential contraindications to HRT?

A

Undiagnosed abnormal bleeding
Endometrial hyperplasia or cancer
Breast cancer
Uncontrolled hypertension
Venous thromboembolism
Liver disease
Active angina or myocardial infarction
Pregnancy

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88
Q

What needs to be assessed before starting HRT?

A

Take a full history to ensure there are no contraindications
Take a family history to assess the risk of oestrogen dependent cancers (e.g. breast cancer) and VTE
Check the body mass index (BMI) and blood pressure
Ensure cervical and breast screening is up to date
Encourage lifestyle changes that are likely to improve symptoms and reduce risks

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89
Q

What is essential when prescribing HRT to a woman with a uterus?

A

progesterone needed for endometrial protection

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90
Q

How do you know when cyclical vs continuous HRT should be used?

A

Perimenopausal: give cyclical combined HRT
Postmenopausal (more than 12 months since last period): give continuous combined HRT

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91
Q

What are some side effects of HRT?

A

Oestrogenic side effects:
Nausea and bloating
Breast swelling
Breast tenderness
Headaches
Leg cramps

Progestogenic side effects:
Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin

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92
Q

What criteria is used to diagnose PCOS?

A

Rotterdam Criteria
diagnosis requires at least two of the three key features

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93
Q

What are the features of the Rotterdam criteria?

A

Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
Hyperandrogenism, characterised by hirsutism and acne
Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)

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94
Q

What are some key presenting features of PCOS?

A

Oligomenorrhoea or amenorrhoea
Infertility
Obesity (in about 70% of patients with PCOS)
Hirsutism
Acne
Hair loss in a male pattern

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95
Q

What are some differential diagnoses for hirsutism?

A

PCOS
Medications
Ovarian or adrenal tumours that secrete androgens
Cushing’s syndrome
Congenital adrenal hyperplasia

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96
Q

What can help reduce insulin resistance in PCOS?

A

Diet, exercise and weight loss

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97
Q

What blood tests are recommended to diagnose PCOS and exclude other pathology that may have a similar presentation?

A

Testosterone
Sex hormone-binding globulin
Luteinizing hormone
Follicle-stimulating hormone
Prolactin (may be mildly elevated in PCOS)
Thyroid-stimulating hormone

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98
Q

What will hormonal blood tests in PCOS typically show?

A

Raised luteinising hormone
Raised LH to FSH ratio (high LH compared with FSH)
Raised testosterone
Raised insulin
Normal or raised oestrogen levels

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99
Q

What is the diagnostic criteria for ovarian cysts on PCOS?

A

12 or more developing follicles in one ovary
Ovarian volume of more than 10cm3

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100
Q

Options for reducing the risk of endometrial hyperplasia and endometrial cancer in PCOS?

A

Mirena coil for continuous endometrial protection
Inducing a withdrawal bleed at least every 3 – 4 months with either:
Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)
Combined oral contraceptive pill

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101
Q

What are the options for managing infertility in PCOS?

A

Weight loss
Clomifene
Laparoscopic ovarian drilling
In vitro fertilisation (IVF)

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102
Q

What are the management options for hirsutism in PCOS?

A

Co-cyprindiol (Dianette) is a combined oral contraceptive pill
Topical eflornithine

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103
Q

what is the 1st line management option for acne in PCOS?

A

combined oral contraceptive pill

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104
Q

What can multiple ovarian cysts appear as on ultrasound?

A

string of pearls

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105
Q

What symptoms may ovarian cysts cause?

A

Pelvic pain
Bloating
Fullness in the abdomen
A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)

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106
Q

What are some non-malignant causes of a raised CA125

A

Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy

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107
Q

What is the risk of malignancy index?

A

estimates the risk of an ovarian mass being malignant, taking account of three things:

Menopausal status
Ultrasound findings
CA125 level

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108
Q

State 3 key complications of ovarian cysts

A

Torsion
Haemorrhage into the cyst
Rupture, with bleeding into the peritoneum

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109
Q

What triad is seen in Meig’s syndrome?

A

Ovarian fibroma (a type of benign ovarian tumour)
Pleural effusion
Ascites

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110
Q

What is the main cause of ovarian torsion?

A

ovarian mass larger than 5cm, such as a cyst or a tumour

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111
Q

What is the main presenting feature of ovarian torsion?

A

sudden onset severe unilateral pelvic pain.
The pain is constant, gets progressively worse and is associated with nausea and vomiting

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112
Q

What will examination show in ovarian torsion?

A

localised tenderness
may be a palpable mass

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113
Q

What is the 1st line investigation for ovarian torsion and what will it show

A

Pelvic ultrasound (ideally transvaginal)
will show whirlpool sign - free fluid and oedema or the ovary

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114
Q

How is a definitive diagnosis of ovarian torsion made?

A

laparoscopic surgery

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115
Q

What are the management options for ovarian torsion?

A

laparoscopic surgery to either:

Un-twist the ovary and fix it in place (detorsion)
Remove the affected ovary (oophorectomy)

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116
Q

What is Asherman’s syndrome?

A

adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus

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117
Q

What are some risk factors for Asherman’s syndrome?

A

dilation and curettage
uterine surgery
severe pelvic infection

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118
Q

What are the presenting features of Asherman’s syndrome?

A

Secondary amenorrhoea (absent periods)
Significantly lighter periods
Dysmenorrhoea (painful periods)
It may also present with infertility.

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119
Q

What are the options for establishing a diagnosis of Asherman’s syndrome?

A

Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions
Hysterosalpingography, where contrast is injected into the uterus and imaged with xrays
Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed
MRI scan

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120
Q

What is the management of Asherman’s syndrome?

A

dissecting the adhesions during hysteroscopy

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121
Q

What is cervical ectropion?

A

columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix).

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122
Q

What are some risk factors for cervical ectropion?

A

younger women
COCP
pregnancy

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123
Q

What are the presenting symptoms of a cervical ectropion?

A

increased vaginal discharge
vaginal bleeding (postcoital)
dyspareunia (pain during sex).

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124
Q

What will speculum examination show in a patient with a cervical ectropion?

A

well-demarcated border between the redder, velvety columnar epithelium extending from the os (opening), and the pale pink squamous epithelium of the ectocervix. This border is the transformation zone

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125
Q

what are the management options for cervical ectropion?

A

no treatment if not causing problems
if problematic bleeding - cauterisation with silver nitrate or cold coagulation during colposcopy

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126
Q

What are Nabothian cysts?

A

fluid-filled cysts often seen on the surface of the cervix

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127
Q

what is a uterine prolapse ?

A

uterus itself descends into the vagina

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128
Q

What is a vault prolapse?

A

women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina

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129
Q

What is a rectocele?

A

defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina

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130
Q

What symptoms are particularly associated with rectoceles?

A

Constipation and faecal loading, urinary retention

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131
Q

What is a cystocele?

A

defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (urethrocele). Prolapse of both the bladder and the urethra is called a cystourethrocele.

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132
Q

What are some risk factors for a pelvic organ prolapse

A

Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining

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133
Q

What are the presenting symptoms of a pelvic organ prolapse?

A

A feeling of “something coming down” in the vagina
A dragging or heavy sensation in the pelvis
Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
Bowel symptoms, such as constipation, incontinence and urgency
Sexual dysfunction, such as pain, altered sensation and reduced enjoyment

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134
Q

What can be used to grade the severity of a pelvic organ prolapse?

A

pelvic organ prolapse quantification (POP-Q) system:
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina
A prolapse extending beyond the introitus can be referred to as uterine procidentia.

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135
Q
A
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136
Q

What are some conservative management options for a pelvic organ prolapse?

A

Physiotherapy (pelvic floor exercises)
Weight loss
Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
Vaginal oestrogen cream

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136
Q

What are the 3 management options for a pelvic organ prolapse?

A

Conservative management
Vaginal pessary
Surgery

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137
Q

Name 4 types of vaginal pessaries

A

ring
shelf/gellhorn
cube
donut
hodge

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137
Q

What are some possible complications of pelvic organ prolapse surgery?

A

Pain, bleeding, infection, DVT and risk of anaesthetic
Damage to the bladder or bowel
Recurrence of the prolapse
Altered experience of sex

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138
Q

What are the 2 types of urinary incontinence?

A

urge
stress

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139
Q

What causes urge incontinence?

A

overactivity of the detrusor muscle of the bladder

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140
Q

What is the cause of stress incontinence?

A

weakness of the pelvic floor and sphincter muscles

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141
Q

when does overflow incontinence occur?

A

chronic urinary retention due to an obstruction to the outflow of urine

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142
Q

What are some risk factors for urinary incontinence?

A

Increased age
Postmenopausal status
Increase BMI
Previous pregnancies and vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions, such as multiple sclerosis
Cognitive impairment and dementia

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143
Q

What are some modifiable lifestyle factors that can contribute to urinary incontinence?

A

Caffeine consumption
Alcohol consumption
Medications
Body mass index (BMI)

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144
Q

What grading system can be used to assess strength of pelvic muscles on bimanual examination?

A

modified Oxford grading system

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145
Q

What investigations should be done for urinary incontinence?

A

bladder diary
urine dipstick
post-void residual bladder volume
Urodynamic testing

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146
Q

What are the management options for stress incontinence?

A

Avoiding caffeine, diuretics and overfilling of the bladder
Avoid excessive or restricted fluid intake
Weight loss (if appropriate)
Supervised pelvic floor exercises for at least three months before considering surgery
Surgery
Duloxetine is an SNRI antidepressant used second line where surgery is less preferred

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147
Q

What are some surgical options for stress incontinence?

A

Tension-free vaginal tape
autologous sling procedures
colposuspension
intermural urethral bulking

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148
Q

what are the management options of urge incontinence?

A

Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line
Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin
Mirabegron is an alternative to anticholinergic medications
Invasive procedures where medical treatment fails

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149
Q

What is Mirabegron contraindicated in?

A

uncontrolled hypertension

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150
Q

What are some invasive options for treating urge incontinence?

A

Botulinum toxin type A injection into the bladder wall
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
urinary diversion

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151
Q

What is atrophic vaginitis?

A

dryness and atrophy of the vaginal mucosa related to a lack of oestrogen

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152
Q
A
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153
Q

What are some presenting symptoms of atrophic vaginitis?

A

Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding due to localised inflammation

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154
Q

what are the management options of atrophic vaginitis?

A

vaginal lubricants
topical oestrogen e.g. cream, pessary

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154
Q

what will examination of atrophic vaginitis show?

A

Pale mucosa
Thin skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair

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155
Q

What areas does lichen sclerosis usually affect in women?

A

labia, perineum, perianal skin

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156
Q

What is lichen sclerosis?

A

chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin

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157
Q

What are the presenting symptoms of lichen sclerosis?

A

Itching
Soreness and pain possibly worse at night
Skin tightness
Painful sex (superficial dyspareunia)
Erosions
Fissures

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158
Q

What is the appearance of lichen sclerosis?

A

“Porcelain-white” in colour
Shiny
Tight
Thin
Slightly raised
There may be papules or plaques

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159
Q

What is the management of lichen sclerosis?

A

potent topical steroids e.g. dermovate
Emollients

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160
Q

What are some complications of lichen sclerosis?

A

SCC of vulva
Pain and discomfort
Sexual dysfunction
Bleeding
Narrowing of the vaginal or urethral openings

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161
Q

What are the 4 types of female genital mutilation?

A

Type 1: Removal of part or all of the clitoris.
Type 2: Removal of part or all of the clitoris and labia minora. The labia majora may also be removed.
Type 3: Narrowing or closing the vaginal orifice (infibulation).
Type 4: All other unnecessary procedures to the female genitalia.

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162
Q

What are some immediate complications of female genital mutilation?

A

Pain
Bleeding
Infection
Swelling
Urinary retention
Urethral damage and incontinence

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163
Q

What are some long term complications of female genital mutilation?

A

Vaginal infections, such as bacterial vaginosis
Pelvic infections
Urinary tract infections
Dysmenorrhea (painful menstruation)
Sexual dysfunction and dyspareunia (painful sex)
Infertility and pregnancy-related complications
Significant psychological issues and depression
Reduced engagement with healthcare and screening

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164
Q

embryonically where does the upper vagina, cervix, uterus and fallopian tubes develop from?

A

paramesonephric ducts (Mullerian ducts)

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165
Q

What are some typical complications of a Bicornuate uterus?

A

Miscarriage
Premature birth
Malpresentation

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166
Q

What is the inheritance pattern of androgen insensitivity?

A

X-linked recessive

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167
Q

What are the 2 main ways androgen insensitivity presents?

A

inguinal hernias containing testes in infancy
primary amenorrhoea

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168
Q

What will hormonal tests show in androgen insensitivity syndrome?

A

Raised LH
Normal or raised FSH
Normal or raised testosterone levels (for a male)
Raised oestrogen levels (for a male)

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169
Q

What is the genotype and phenotype in androgen insensitivity syndrome?

A

XY
female phenotype

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170
Q

What is the management of androgen insensitivity syndrome?

A

Bilateral orchidectomy (removal of the testes) to avoid testicular tumours
Oestrogen therapy
Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length

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171
Q

What type of cancer are 80% of cervical cancers?

A

squamous cell carcinoma

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172
Q

What is cervical cancer strongly associated with?

A

human papilloma virus

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173
Q

what are the 2 types of HPV responsible for the majority of cervical cancers?

A

type 16 and 18

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174
Q

what are risk factors for catching HPV?

A

Early sexual activity
Increased number of sexual partners
Sexual partners who have had more partners
Not using condoms

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175
Q

Apart from contracting HPV what are some other risk factors for cervical cancer?

A

non-engagement with cervical screening
Smoking
HIV
COCP
Increases number of full term pregnancies
family history
exposure to diethylbestrol

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176
Q

what are the presenting features of cervical cancer?

A

Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
Vaginal discharge
Pelvic pain
Dyspareunia (pain or discomfort with sex)

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177
Q

What appearances on speculum examination may suggest cervical cancer?

A

Ulceration
Inflammation
Bleeding
Visible tumour

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178
Q

what are the grades of cervical intraepithelial neoplasia?

A

CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer if untreated

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179
Q

who is invited for cervical cancer screening?

A

women (and transgender men that still have a cervix):

Every three years aged 25 – 49
Every five years aged 50 – 64

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180
Q

how often are patients with HIV screened for cervical cancer?

A

annually

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181
Q

how should different smear test results be managed?

A

Inadequate sample – repeat the smear after at least three months
HPV negative – continue routine screening
HPV positive with normal cytology – repeat the HPV test after 12 months
HPV positive with abnormal cytology – refer for colposcopy

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182
Q

What are the FIGO stages for cervical cancer?

A

Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis

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183
Q

what are the management options for cervical cancer?

A

Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy
Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Stage 2B – 4A: Chemotherapy and radiotherapy
Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care

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184
Q

what strains of HPV cause genital warts?

A

6 and 11

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185
Q

What type of cancer are the majority of endometrial cancers?

A

adenocarcinoma

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186
Q

What is endometrial hyperplasia?

A

precancerous condition involving thickening of the endometrium

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187
Q

How is endometrial hyperplasia managed?

A

Intrauterine system (e.g. Mirena coil)
Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)

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188
Q

what are the risk factors for endometrial cancer?

A

Increased age
Earlier onset of menstruation
Late menopause
Oestrogen only hormone replacement therapy
No or fewer pregnancies
Obesity
Polycystic ovarian syndrome
Tamoxifen
Type 2 diabetes
Hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome

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189
Q

What are some protective factors against endometrial cancer?

A

Combined contraceptive pill
Mirena coil
Increased pregnancies
Cigarette smoking

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190
Q

what is the number 1 presenting symptoms of endometrial cancer?

A

postmenopausal bleeding

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191
Q

Apart from post-menopausal bleeding what are some other symptoms of endometrial cancer?

A

Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count

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192
Q

what investigations can be done to diagnose endometrial cancer?

A

Transvaginal ultrasound for endometrial thickness
Pipelle biopsy
Hysteroscopy

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193
Q

What endometrial thickness is normal in post-menopausal women?

A

<4mm

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194
Q

what are the FIGO stages of endometrial cancer?

A

Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis

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195
Q

what is the main management of endometrial cancer

A

total abdominal hysterectomy with bilateral salpingo-oophorectomy

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196
Q

state 3 types of ovarian cancer

A

Epithelial cell (most common)
dermoid cysts/germ cell tumours
sex cord-stromal tumours

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197
Q

what is a Krukenberg tumour?

A

metastasis in the ovary, usually from a gastrointestinal tract cancer
“signet-ring” cells on histology

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198
Q

what are the risk factors for ovarian cancer?

A

Age (peaks age 60)
BRCA1 and BRCA2 genes (consider the family history)
Increased number of ovulations (early-onset periods, late menopause, no pregnancies)
Obesity
Smoking
Recurrent use of clomifene

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199
Q

what are some protective factors against ovarian cancer?

A

Combined contraceptive pill
Breastfeeding
Pregnancy

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200
Q

what are some presenting features of ovarian cancer?

A

Abdominal bloating
Early satiety (feeling full after eating)
Loss of appetite
Pelvic pain
Urinary symptoms (frequency / urgency)
Weight loss
Abdominal or pelvic mass
Ascites

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201
Q

what are the initial investigations for suspected ovarian cancer?

A

CA125 blood test (>35 IU/mL is significant)
Pelvic ultrasound

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202
Q

What factors are taken into account in the risk malignancy index of ovarian cancer?

A

Menopausal status
Ultrasound findings
CA125 level

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203
Q

Women under 40 years with a complex ovarian mass require which tumour markers for a possible germ cell tumour?

A

Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)

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204
Q

what are some non-malignant causes of a raised CA125?

A

Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy

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205
Q

what are the FIGO stages of ovarian cancer?

A

Stage 1: Confined to the ovary
Stage 2: Spread past the ovary but inside the pelvis
Stage 3: Spread past the pelvis but inside the abdomen
Stage 4: Spread outside the abdomen (distant metastasis)

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206
Q

how is ovarian cancer managed?

A

combination of surgery and chemotherapy

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207
Q

what type are 90% of vulval cancers?

A

squamous cell carcinomas

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208
Q

what are the risk factors for vulval cancer?

A

Advanced age (particularly over 75 years)
Immunosuppression
Human papillomavirus (HPV) infection
Lichen sclerosus

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209
Q

what is the management of vulval intraepithelial neoplasia?

A

Watch and wait with close followup
Wide local excision (surgery) to remove the lesion
Imiquimod cream
Laser ablation

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210
Q

what are the symptoms of vulval cancer?

A

Vulval lump
Ulceration
Bleeding
Pain
Itching
Lymphadenopathy in the groin
Vulval cancer most frequently affects the labia majora, giving an appearance of:

Irregular mass
Fungating lesion
Ulceration
Bleeding

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211
Q

what staging system is used for vulval cancer?

A

FIGO

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212
Q

what are the management options for vulval cancer?

A

Wide local excision to remove the cancer
Groin lymph node dissection
Chemotherapy
Radiotherapy

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213
Q

What causes bacterial vaginosis?

A

loss of the lactobacilli “friendly bacteria” in the vagina - the pH rises. This more alkaline environment enables anaerobic bacteria to multiply

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214
Q

What are some examples of anaerobic bacteria associated with bacterial vaginosis?

A

Gardnerella vaginalis (most common)
Mycoplasma hominis
Prevotella species

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215
Q

What are the risk factors for bacterial vaginosis?

A

Multiple sexual partners
Excessive vaginal cleaning
Recent antibiotics
Smoking
Copper coil

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216
Q

What are the presenting features of bacterial vaginosis?

A

fishy-smelling watery grey or white vaginal discharge

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217
Q

How is bacterial vaginosis investigated?

A

Vaginal pH >4.5
vaginal swab for microscopy (clue cells)

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218
Q

What is the antibiotic of choice for bacterial vaginosis?

A

Metronidazole

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219
Q

What are some complications of bacterial vaginosis in pregnancy?

A

Miscarriage
Preterm delivery
Premature rupture of membranes
Chorioamnionitis
Low birth weight
Postpartum endometritis

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220
Q

what is the most common cause of Candidiasis?

A

Candida albicans

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221
Q

What are some risk factors for candidiasis?

A

Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
Poorly controlled diabetes
Immunosuppression (e.g. using corticosteroids)
Broad-spectrum antibiotics

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222
Q

what are the main 2 symptoms of candidiasis

A

Thick, white discharge that does not typically smell
Vulval and vaginal itching, irritation or discomfort

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223
Q

What investigation can confirm a diagnosis of candidiasis?

A

charcoal swab with microscopy

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224
Q

what are the management options for candidiasis?

A

A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night
A single dose of clotrimazole pessary (500mg) at night
Three doses of clotrimazole pessaries (200mg) over three nights
A single dose of fluconazole (150mg)

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225
Q

what are charcoal swabs used to diagnose in GUM clinics?

A

Bacterial vaginosis
Candidiasis
Gonorrhoeae (specifically endocervical swab)
Trichomonas vaginalis (specifically a swab from the posterior fornix)
Other bacteria, such as group B streptococcus (GBS)

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226
Q

What do NAAT tests test for in GUM clinics?

A

Chlamydia and gonorrhoea

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227
Q

what are some symptoms of chlamydia in women?

A

Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding (intermenstrual or postcoital)
Painful sex (dyspareunia)
Painful urination (dysuria)

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228
Q

What are some symptoms of chlamydia in men?

A

Urethral discharge or discomfort
Painful urination (dysuria)
Epididymo-orchitis
Reactive arthritis

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229
Q

what are some examination findings of chlamydia?

A

Pelvic or abdominal tenderness
Cervical motion tenderness (cervical excitation)
Inflamed cervix (cervicitis)
Purulent discharge

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230
Q

What is first-line for uncomplicated chlamydia ?

A

doxycycline 100mg twice a day for 7 days

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231
Q

what are some complications of chlamydia?

A

Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lymphogranuloma venereum
Reactive arthritis

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232
Q

What are some pregnancy related complications of chlamydia?

A

Preterm delivery
Premature rupture of membranes
Low birth weight
Postpartum endometritis
Neonatal infection (conjunctivitis and pneumonia)

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233
Q

what is Lymphogranuloma venereum?

A

condition affecting the lymphoid tissue around the site of infection with chlamydia

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234
Q

what type of bacteria is Neisseria gonorrhoeae?

A

gram-negative diplococcus

235
Q

how may gonorrhoea present in women?

A

Odourless purulent discharge, possibly green or yellow
Dysuria
Pelvic pain

236
Q

How may Gonorrhoea present in men?

A

Odourless purulent discharge, possibly green or yellow
Dysuria
Testicular pain or swelling (epididymo-orchitis)

237
Q

What is the diagnostic test for gonorrhoea?

A

Nucleic acid amplification testing (NAAT)

238
Q

What is the management of gonorrhoea?

A

IM ceftriaxone 1g
oral ciprofloxacin 500mg if sensitivities known

239
Q

what are some complications of gonorrhoea?

A

Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Epididymo-orchitis (men)
Prostatitis (men)
Conjunctivitis
Urethral strictures
Disseminated gonococcal infection
Skin lesions
Fitz-Hugh-Curtis syndrome
Septic arthritis
Endocarditis

240
Q

what symptoms does disseminated gonococcal infection cause?

A

Various non-specific skin lesions
Polyarthralgia (joint aches and pains)
Migratory polyarthritis (arthritis that moves between joints)
Tenosynovitis
Systemic symptoms such as fever and fatigue

241
Q

Mycoplasma genitalium may lead to:

A

Urethritis
Epididymitis
Cervicitis
Endometritis
Pelvic inflammatory disease
Reactive arthritis
Preterm delivery in pregnancy
Tubal infertility

242
Q

what investigation is done for mycoplasma genitalium?

A

nucleic acid amplification tests (NAAT)

243
Q

What is the management of mycoplasma genitalium?

A

Doxycycline 100mg twice daily for 7 days then;
Azithromycin 1g stat then 500mg once a day for 2 days

244
Q

what are the 3 main causes of pelvic inflammatory disease?

A

Neisseria gonorrhoeae tends to produce more severe PID
Chlamydia trachomatis
Mycoplasma genitalium

245
Q

what are some risk factors for pelvic inflammatory disease?

A

Not using barrier contraception
Multiple sexual partners
Younger age
Existing sexually transmitted infections
Previous pelvic inflammatory disease
Intrauterine device (e.g. copper coil)

246
Q

what symptoms may a women with pelvic inflammatory disease present with?

A

Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding (intermenstrual or postcoital)
Pain during sex (dyspareunia)
Fever
Dysuria

247
Q

what may examination findings reveal in pelvic inflammatory disease?

A

Pelvic tenderness
Cervical motion tenderness (cervical excitation)
Inflamed cervix (cervicitis)
Purulent discharge

248
Q

what is the management of pelvic inflammatory disease?

A

A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium)
Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)

249
Q

what are some complications of pelvic inflammatory disease?

A

Sepsis
Abscess
Infertility
Chronic pelvic pain
Ectopic pregnancy
Fitz-Hugh-Curtis syndrome

250
Q

what is Fitz-Hugh-Curtis syndrome?

A

complication of PID, inflammation and infection of liver capsule leading to adhesions between liver and peritoneum, right upper quadrant pain

251
Q

what are some symptoms of Trichomoniasis?

A

Vaginal discharge
Itching
Dysuria (painful urination)
Dyspareunia (painful sex)
Balanitis (inflammation to the glans penis)

252
Q

what may be seen on examination in trichomoniasis?

A

frothy yellow-green discharge (may be fishy)
strawberry cervix

253
Q

How is Trichomoniasis diagnosed?

A

charcoal swab for microscopy

254
Q

what is the treatment of trichomoniasis?

A

metronidazole

255
Q

what strain of herpes is associated with genital herpes ?

A

HSV-2

256
Q

what are some signs and symptoms of genital herpes?

A

Ulcers or blistering lesions affecting the genital area
Neuropathic type pain (tingling, burning or shooting)
Flu-like symptoms (e.g. fatigue and headaches)
Dysuria (painful urination)
Inguinal lymphadenopathy

257
Q

how can a diagnosis of genital herpes be confirmed?

A

viral PCR swab from lesion

258
Q

what is the treatment of genital herpes?

A

Aciclovir

259
Q

How can HIV be transmitted?

A

Unprotected anal, vaginal or oral sexual activity
Mother to child at any stage of pregnancy, birth or breastfeeding (called vertical transmission)
Mucous membrane, blood or open wound exposure to infected blood or bodily fluids (e.g., sharing needles, needle-stick injuries or blood splashed in an eye)

260
Q

what are some AIDS defining illnesses?

A

Kaposi’s sarcoma
Pneumocystis jirovecii pneumonia (PCP)
Cytomegalovirus infection
Candidiasis (oesophageal or bronchial)
Lymphomas
Tuberculosis

261
Q

how is HIV monitored?

A

CD4 count
HIV RNA indicates viral load

262
Q

What is the management of HIV

A

antiretroviral therapy

263
Q

what is given to prevent pneumocystis jirovecii pneumonia is HIV patients?

A

Prophylactic co-trimoxazole

264
Q

HIV viral load under what indicates normal vaginal delivery is safe?

A

<50

265
Q

what is given as an infusion during labour and delivery if the viral load is unknown or above 1000 copies/ml.

A

IV zidovudine

266
Q

what bacteria causes Syphilis?

A

Treponema pallidum

267
Q

what are the stages of syphilis?

A

Primary syphilis involves a painless ulcer called a chancre at the original site of infection (usually on the genitals).

Secondary syphilis involves systemic symptoms, particularly of the skin and mucous membranes. These symptoms can resolve after 3 – 12 weeks and the patient can enter the latent stage.

Latent syphilis occurs after the secondary stage of syphilis, where symptoms disappear and the patient becomes asymptomatic despite still being infected. Early latent syphilis occurs within two years of the initial infection, and late latent syphilis occurs from two years after the initial infection onwards.

Tertiary syphilis can occur many years after the initial infection and affect many organs of the body, particularly with the development of gummas and cardiovascular and neurological complications.

Neurosyphilis occurs if the infection involves the central nervous system

268
Q

How does primary syphilis present?

A

A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks.
Local lymphadenopathy

269
Q

How does secondary syphilis present?

A

Maculopapular rash
Condylomata lata (grey wart-like lesions around the genitals and anus)
Low-grade fever
Lymphadenopathy
Alopecia (localised hair loss)
Oral lesions

270
Q

What are the symptoms of tertiary syphilis?

A

Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
Aortic aneurysms
Neurosyphilis

271
Q

what are some symptoms of neurosyphilis?

A

Headache
Altered behaviour
Dementia
Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
Ocular syphilis (affecting the eyes)
Paralysis
Sensory impairment

272
Q

what can be used to screen for syphilis?

A

Antibody testing

273
Q

what 2 tests can be done to confirm the presence of T.pallidum?

A

Dark field microscopy
Polymerase chain reaction (PCR)

274
Q

what two non-specific but sensitive tests are used to assess active syphilis ?

A

rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL)

275
Q

What is the management of syphilis?

A

single deep intramuscular dose of benzathine benzylpenicillin

276
Q

what are the levels of risk in the UKMEC?

A

UKMEC 1: No restriction in use (minimal risk)
UKMEC 2: Benefits generally outweigh the risks
UKMEC 3: Risks generally outweigh the benefits
UKMEC 4: Unacceptable risk (typically this means the method is contraindicated)

277
Q

what contraception should you avoid in Wilsons disease?

A

Copper coil

278
Q

how affective is lactational amenorrhea?

A

98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic

279
Q

when can an IUD/IUS be inserted after birth?

A

either within 48 hours of birth or more than 4 weeks after birth

280
Q

how long should you avoid the combined oral contraceptive pill for when breast feeding?

A

should be avoided in breastfeeding (UKMEC 4 before 6 weeks postpartum, UKMEC 2 after 6 weeks)

281
Q

what is the mechanism of action of the COCP?

A

Preventing ovulation (this is the primary mechanism of action)
Progesterone thickens the cervical mucus
Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation

282
Q

what COCP are considered first line for premenstrual syndrome?

A

Yasmin and other COCPs containing drospirenone

283
Q

what COCP are recommended for acne and hirsutism?

A

Dianette and other COCPs containing cyproterone acetate (i.e. co-cyprindiol)

284
Q

what are the side effects of the COCP?

A

Unscheduled bleeding is common in the first three months and should then settle with time
Breast pain and tenderness
Mood changes and depression
Headaches
Hypertension
Venous thromboembolism
Small increased risk of breast and cervical cancer, returning to normal ten years after stopping
Small increased risk of myocardial infarction and stroke

285
Q

what types of cancer does the COCP reduce the risk of?

A

endometrial
ovarian
colon

286
Q

what are the UKMEC4 criteria for the COCP?

A

Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura (risk of stroke)
History of VTE
Aged over 35 and smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
Systemic lupus erythematosus (SLE) and antiphospholipid syndrome

287
Q

what are the missed pill rules (>72hrs) for the COCP?

A

Take the most recent missed pill as soon as possible
Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight
If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex
If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required
If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period.

288
Q

when should you stop the COCP before a major operation?

A

4 weeks

289
Q

what is the UKMEC4 criteria for the progesterone only pill?

A

active breast cancer

290
Q

what are the differences between the traditional and desogestrel-only pill?

A

The traditional progestogen-only pill cannot be delayed by more than 3 hours. Taking the pill more than 3 hours late is considered a “missed pill”.

The desogestrel-only pill can be taken up to 12 hours late and still be effective. Taking the pill more than 12 hours late is considered a “missed pill”

291
Q

what are the side effects of the progesterone only pill?

A

unscheduled bleeding
breast tenderness
headaches
acne

292
Q

when is emergency contraception required for the POP?

A

if they have had sex since missing the pill or within 48 hours of restarting the regular pills

293
Q

what are the side effects of the progesterone only injection?

A

Weight gain
Acne
Reduced libido
Mood changes
Headaches
Flushes
Hair loss (alopecia)
Skin reactions at injection sites
Osteoporosis
Irregular bleeding

294
Q

what are the 2 types of coil?

A

Copper coil (Cu-IUD): contains copper and creates a hostile environment for pregnancy
Levonorgestrel intrauterine system (LNG-IUS): contains progestogen that is slowly released into the uterus

295
Q

what are contraindications to a coil?

A

Pelvic inflammatory disease or infection
Immunosuppression
Pregnancy
Unexplained bleeding
Pelvic cancer
Uterine cavity distortion (e.g. by fibroids)

296
Q

what are some causes of non-visible threads on a coil?

A

Expulsion
Pregnancy
Uterine perforation

297
Q

what are the 3 options of emergency contraception and when can they be taken?

A

Levonorgestrel should be taken within 72 hours of UPSI
Ulipristal should be taken within 120 hours of UPSI
Copper coil can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation

298
Q

what is the dose of levonorgestrel for emergency contraception?

A

1.5mg as a single dose
3mg as a single dose in women above 70kg or BMI above 26

299
Q

what are some side effects of levonorgestrel?

A

N+V
Spotting and changes to the next menstrual period
Diarrhoea
Breast tenderness
Dizziness
Depressed mood

300
Q

how long should you wait before starting COCP or POP after taking ulipristal?

A

5 days
Extra contraception (ie. condoms) is required for the first 7 days of the combined pill or the first 2 days of the progestogen-only pill.

301
Q

when should Ulipristal be avoided?

A

Breastfeeding should be avoided for 1 week after taking ulipristal (milk should be expressed and discarded)
Ulipristal should be avoided in patients with severe asthma

302
Q

what is cut during a Vasectomy?

A

Vas deferens

303
Q

what percentage of couples with conceive within 1 year of regular unprotected sex?

A

85%

304
Q

when should you investigate infertility?

A

over 12 months
6 months if woman over 35

305
Q

what are the common causes of infertility?

A

Sperm problems (30%)
Ovulation problems (25%)
Tubal problems (15%)
Uterine problems (10%)
Unexplained (20%)

306
Q

what is the general advice for infertility?

A

The woman should be taking 400mcg folic acid daily
Aim for a healthy BMI
Avoid smoking and drinking excessive alcohol
Reduce stress as this may negatively affect libido and the relationship
Aim for intercourse every 2 – 3 days
Avoid timing intercourse

307
Q

what investigations can be done in primary care for infertility?

A

Body mass index (BMI)
Chlamydia screening
Semen analysis
Female hormonal testing
Rubella immunity in the mother

308
Q

how is anovulation managed?

A

weight loss
Clomifene
Letrozole
Gonadotrophins
Ovarian drilling
Metformin

309
Q

what factors can affects sperm quality and quantity?

A

Hot baths
Tight underwear
Smoking
Alcohol
Raised BMI
Caffeine

310
Q

what are the stages of IVF?

A

Suppressing the natural menstrual cycle
Ovarian stimulation
Oocyte collection
Insemination / intracytoplasmic sperm injection (ICSI)
Embryo culture
Embryo transfer

311
Q

what are the main complications of IVF?

A

Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyperstimulation syndrome

312
Q

what are the features of ovarian hyperstimulation syndrome?

A

Abdominal pain and bloating
Nausea and vomiting
Diarrhoea
Hypotension
Hypovolaemia
Ascites
Pleural effusions
Renal failure
Peritonitis from rupturing follicles releasing blood
Prothrombotic state (risk of DVT and PE)

313
Q

what are the risk factors for ectopic pregnancy?

A

Previous ectopic pregnancy
Previous pelvic inflammatory disease
Previous surgery to the fallopian tubes
Intrauterine devices (coils)
Older age
Smoking

314
Q

what gestation does ectopic pregnancy typically present?

A

6-8 weeks

315
Q

what are the classic features of an ectopic pregnancy?

A

Missed period
Constant lower abdominal pain in the right or left iliac fossa
Vaginal bleeding
Lower abdominal or pelvic tenderness
Cervical motion tenderness
dizziness/syncope
shoulder tip pain

316
Q

what is the investigation of choice for ectopic pregnancy?

A

transvaginal ultrasound

317
Q

what are the 3 management options for ectopic pregnancy?

A

Expectant management (awaiting natural termination)
Medical management (methotrexate)
Surgical management (salpingectomy or salpingotomy)

318
Q

what are the criteria for expectant management of an ectopic pregnancy?

A

Follow up needs to be possible to ensure successful termination
The ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No significant pain
HCG level < 1500 IU / l

319
Q

women treated with methotrexate are advised to not get pregnant for how long following treatment?

A

3 months

320
Q

what would indicate surgical management of an ectopic pregnancy?

A

Pain
Adnexal mass > 35mm
Visible heartbeat
HCG levels > 5000 IU / l

321
Q

what is the 1st line surgical management of an ectopic pregnancy?

A

Laparoscopic salpingectomy

322
Q

what is the difference between an early and late miscarriage?

A

Early miscarriage is before 12 weeks gestation. Late miscarriage is between 12 and 24 weeks gestation.

323
Q

what is a threatened miscarriage?

A

vaginal bleeding with a closed cervix and a fetus that is alive

324
Q

what is an inevitable miscarriage?

A

vaginal bleeding with an open cervix

325
Q

what is an incomplete miscarriage?

A

retained products of conception remain in the uterus after the miscarriage

326
Q

what is the investigation of choice for a miscarriage?

A

transvaginal ultrasound scan

327
Q

at what crown-rump length is a fetal heartbeat expected?

A

7mm

328
Q

how is a miscarriage <6w gestation with no bleeding managed?

A

expectantly
repeat pregnancy test after 7-10d

329
Q

what is given for medical management of miscarriage?

A

Misoprostol (prostaglandin analogue)

330
Q

what are the surgical management options for a miscarriage?

A

Manual vacuum aspiration
Electric vacuum aspiration
misoprostol given before

331
Q

what is recurrent miscarriage classed as?

A

three or more consecutive miscarriages

332
Q

what are some causes of recurrent miscarriage?

A

Idiopathic (particularly in older women)
Antiphospholipid syndrome
Hereditary thrombophilias
Uterine abnormalities
Genetic factors in parents (e.g. balanced translocations in parental chromosomes)
Chronic histiocytic intervillositis
Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE)

333
Q

how is risk of miscarriage reduced in patients with antiphospholipid syndrome?

A

Low dose aspirin
Low molecular weight heparin (LMWH)

334
Q

up to what gestation is abortion legal?

A

24 weeks

335
Q

when can an abortion be performed at any time of pregnancy?

A

Continuing the pregnancy is likely to risk the life of the woman
Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped

336
Q

what are the legal requirements for an abortion?

A

Two registered medical practitioners must sign to agree abortion is indicated
It must be carried out by a registered medical practitioner in an NHS hospital or approved premise

337
Q

what is given in a medical abortion?

A

Mifepristone (anti-progestogen)
Misoprostol (prostaglandin analogue) 1 – 2 day later

338
Q

what are complications of an abortion?

A

Bleeding
Pain
Infection
Failure of the abortion (pregnancy continues)
Damage to the cervix, uterus or other structures

339
Q

what is the diagnostic criteria for hyperemesis Gravidarum?

A

More than 5 % weight loss compared with before pregnancy
Dehydration
Electrolyte imbalance

340
Q

what is the management of nausea and vomiting of pregnancy?

A

Prochlorperazine
Cyclizine
Ondansetron
Metoclopramide

341
Q

when is admission considered for N+V of pregnancy?

A

Unable to tolerate oral antiemetics or keep down any fluids
More than 5 % weight loss compared with pre-pregnancy
Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant)
Other medical conditions need treating that required admission

342
Q

what is the management of severe N+V of pregnancy?

A

IV or IM antiemetics
IV fluids (normal saline with added potassium chloride)
Daily monitoring of U&Es while having IV therapy
Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
Thromboprophylaxis (TED stocking and low molecular weight heparin) during admission

343
Q

what is a complete mole?

A

two sperm cells fertilise an ovum that contains no genetic material

344
Q

what is a partial mole?

A

two sperm cells fertilise a normal ovum

345
Q

what are the features that indicate a molar pregnancy?

A

More severe morning sickness
Vaginal bleeding
Increased enlargement of the uterus
Abnormally high hCG
Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)

346
Q

what will USS show in a molar pregnancy?

A

snowstorm appearance

347
Q

what are the different trimesters of pregnancy in weeks?

A

The first trimester is from the start of pregnancy until 12 weeks gestation.

The second trimester is from 13 weeks until 26 weeks gestation.

The third trimester is from 27 weeks gestation until birth.

348
Q

when do fetal movements start from?

A

20 weeks gestation

349
Q

when should a dating scan be carried out?

A

between 10 and 13+6

350
Q

when is an anomaly scan carried out?

A

between 18 and 20+6

351
Q

when should a glucose tolerance test be carried out?

A

between 24 – 28 weeks

352
Q

what gestation are anti-D injections given to rhesus negative women?

A

28 and 34 weeks

353
Q

what 2 vaccines are offered to all pregnant women?

A

Whooping cough (pertussis) from 16 weeks gestation
Influenza (flu) when available in autumn or winter

354
Q

what general lifestyle advise should be given to pregnant women?

A

Take folic acid 400mcg from before pregnancy to 12 weeks
Take vitamin D supplement (10 mcg or 400 IU daily)
Avoid vitamin A supplements and eating liver or pate
Don’t drink alcohol
Don’t smoke
Avoid unpasteurised dairy or blue cheese (risk of listeriosis)
Avoid undercooked or raw poultry (risk of salmonella)
Continue moderate exercise but avoid contact sports
Sex is safe
Flying increases the risk of venous thromboembolism (VTE)
Place car seatbelts above and below the bump (not across it)

355
Q

alcohol in early pregnancy can lead to what complications?

A

Miscarriage
Small for dates
Preterm delivery
Fetal alcohol syndrome

356
Q

what are the features of fetal alcohol syndrome?

A

Microcephaly (small head)
Thin upper lip
Smooth flat philtrum (the groove between the nose and upper lip)
Short palpebral fissure (short horizontal distance from one side of the eye to the other)
Learning disability
Behavioural difficulties
Hearing and vision problems
Cerebral palsy

357
Q

smoking during pregnancy increases the risk of what?

A

Fetal growth restriction (FGR)
Miscarriage
Stillbirth
Preterm labour and delivery
Placental abruption
Cleft lip or palate
Sudden infant death syndrome (SIDS)

358
Q

what are the guidelines of flying during pregnancy?

A

37 weeks in a single pregnancy
32 weeks in a twin pregnancy

359
Q

What booking bloods are taken?

A

Blood group, antibodies and rhesus D status
Full blood count for anaemia
Screening for thalassaemia (all women) and sickle cell disease
HIV, HepB, Syphilis

360
Q

apart from bloods what other things are tested at a booking clinic?

A

Weight, height and BMI
Urine for protein and bacteria
Blood pressure
Discuss female genital mutilation
Discuss domestic violence

361
Q

what medications should be avoided during pregnancy?

A

NSAIDs
beta-blockers (except labetalol)
ACEi/ARBs
Opiates
Warfarin
Sodium valproate
Lithium
SSRIs (balance risk and benefit)
Isotretinoin

362
Q

what are the features of congenital rubella syndrome?

A

Congenital deafness
Congenital cataracts
Congenital heart disease (PDA and pulmonary stenosis)
Learning disability

363
Q

what are the features of congenital cytomegalovirus?

A

Fetal growth restriction
Microcephaly
Hearing loss
Vision loss
Learning disability
Seizures

364
Q

what is the classic triad of congenital toxoplasmosis ?

A

Intracranial calcification
Hydrocephalus
Chorioretinitis (inflammation of the choroid and retina in the eye)

365
Q

what are the complications of Parvovirus B19 in pregnancy?

A

Miscarriage or fetal death
Severe fetal anaemia
Hydrops fetalis (fetal heart failure)
Maternal pre-eclampsia-like syndrome

366
Q

what is a Kleihauer test?

A

checks how much fetal blood has passed into the mother’s blood during a sensitisation event. This test is used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required.

367
Q

how is small for gestational age defined?

A

fetus that measures below the 10th centile for their gestational age

368
Q

what are some causes of small for gestational age ?

A

Constitutionally small
Fetal growth restriction e.g. pre-eclampsia, smoking, alcohol, anaemia, malnutrition, infection, genetic abnormalities, structural abnormalities, fetal infection, errors of metabolism

369
Q

apart from a fetus being SGA what other features indicate fetal growth restriction?

A

Reduced amniotic fluid volume
Abnormal Doppler studies
Reduced fetal movements
Abnormal CTGs

370
Q

what are some complications of fetal growth restriction?

A

Fetal death or stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia

371
Q

what are the risk factors for SGA?

A

Previous SGA baby
Obesity
Smoking
Diabetes
Existing hypertension
Pre-eclampsia
Older mother (over 35 years)
Multiple pregnancy
Low pregnancy‑associated plasma protein‑A (PAPPA)
Antepartum haemorrhage
Antiphospholipid syndrome

372
Q

what is measured to assess SGA?

A

symphysis fundal height (SFH)

373
Q

When a fetus is identified as SGA, investigations to identify the underlying cause include:

A

Blood pressure and urine dipstick for pre-eclampsia
Uterine artery doppler scanning
Detailed fetal anatomy scan by fetal medicine
Karyotyping for chromosomal abnormalities
Testing for infections

374
Q

when is early delivery considered in SGA?

A

growth is static on the growth charts, or other problems are identified (e.g. abnormal Doppler results)

375
Q

when are babies classed as large for gestational age?

A

Newborn is more than 4.5kg at birth
During pregnancy, an estimated fetal weight above the 90th centile

376
Q

What are some causes of Macrosomia?

A

Constitutional
Maternal diabetes
Previous macrosomia
Maternal obesity or rapid weight gain
Overdue
Male baby

377
Q

what are the risks to the mother of macrosomia ?

A

Shoulder dystocia
Failure to progress
Perineal tears
Instrumental delivery or caesarean
Postpartum haemorrhage
Uterine rupture (rare)

378
Q

What are the risks to the baby of macrosomia?

A

Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia)
Neonatal hypoglycaemia
Obesity in childhood and later life
Type 2 diabetes in adulthood

379
Q

what are the investigations for a large for gestational age baby?

A

Ultrasound to exclude polyhydramnios and estimate the fetal weight
Oral glucose tolerance test for gestational diabetes

380
Q

what type of twins have the best outcomes?

A

diamniotic, dichorionic

381
Q

What do dichorionic diamniotic twins look like on ultrasound?

A

membrane between the twins, with a lambda sign or twin peak sign

382
Q

what do monochorionic diamniotic twins look like on ultrasound?

A

membrane between the twins, with a T sign

383
Q

what are some risks to the mother of multiple pregnancy?

A

Anaemia
Polyhydramnios
Hypertension
Malpresentation
Spontaneous preterm birth
Instrumental delivery or caesarean
Postpartum haemorrhage

384
Q

what are some risks to the fetuses and neonates of multiple pregnancy?

A

Miscarriage
Stillbirth
Fetal growth restriction
Prematurity
Twin-twin transfusion syndrome
Twin anaemia polycythaemia sequence
Congenital abnormalities

385
Q

what is twin-twin transfusion syndrome?

A

one fetus (the recipient) may receive the majority of the blood from the placenta, while the other fetus (the donor) is starved of blood. The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios. The donor has growth restriction, anaemia and oligohydramnios

386
Q

when is planned birth offered for multiple pregnancies?

A

32 and 33 + 6 weeks for uncomplicated monochorionic monoamniotic twins
36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins
37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins
Before 35 + 6 weeks for triplets

387
Q

what is the management of a UTI in pregnancy?

A

7 days nitrofurantoin (avoid in 3rd trimester)
Amoxicillin (only after sensitivities are known)

388
Q

why does Nitrofurantoin need to be avoided in the 3rd trimester?

A

risk of neonatal haemolysis

389
Q

When is anaemia routinely scanned for in pregnancy?

A

Booking clinic
28 weeks gestation

390
Q

what is the normal rage for haemoglobin post partum?

A

> 100g/l

391
Q

what are the risk factors for VTE in pregnancy?

A

Smoking
Parity ≥ 3
Age > 35 years
BMI > 30
Reduced mobility
Multiple pregnancy
Pre-eclampsia
Gross varicose veins
Immobility
Family history of VTE
Thrombophilia
IVF pregnancy

392
Q

The RCOG guidelines (2015) advise starting VTE prophylaxis from:

A

28 weeks if there are three risk factors
First trimester if there are four or more of these risk factors

393
Q

what is given as VTE prophylaxis in pregnancy?

A

low molecular weight heparin (LMWH) e.g. enoxaparin

394
Q

how long after birth should you continue LMWH for?

A

6 weeks

395
Q

what is the management of VTW in pregnancy?

A

LMWH

396
Q

what is the triad of features of pre-eclampsia?

A

Hypertension
Proteinuria
Oedema

397
Q

after what week gestation does pre-eclampsia occur?

A

after 20 weeks

398
Q

what is the pathophysiology of pre-eclampsia?

A

high vascular resistance in the spiral arteries and poor perfusion of the placenta causes oxidative stress leading to systemic inflammation and impaired endothelial function

399
Q

what are the high-risk factors for pre-eclampsia?

A

Pre-existing hypertension
Previous hypertension in pregnancy
Existing autoimmune conditions (e.g. systemic lupus erythematosus)
Diabetes
Chronic kidney disease

400
Q

what are the moderate-risk factors for pre-eclampsia?

A

Older than 40
BMI > 35
More than 10 years since previous pregnancy
Multiple pregnancy
First pregnancy
Family history of pre-eclampsia

401
Q

what are women offered that are at risk of pre-eclampsia and when?

A

aspirin from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors

402
Q

what are some symptoms of pre-eclampsia?

A

Headache
Visual disturbance or blurriness
Nausea and vomiting
Upper abdominal or epigastric pain (this is due to liver swelling)
Oedema
Reduced urine output
Brisk reflexes

403
Q

how is a diagnosis of pre-eclampsia made?

A

Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 90 mmHg
PLUS any of:
Proteinuria (1+ or more on urine dipstick)
Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

404
Q

what is the medical management of pre-eclampsia?

A

Labetolol is first-line as an antihypertensive
Nifedipine (modified-release) second-line
Methyldopa third-line (needs to be stopped within two days of birth)
Intravenous hydralazine in critical care in severe pre-eclampsia or eclampsia
IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures
Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

405
Q

what is the management of Eclampsia

A

IV magnesium sulphate

406
Q

what is help syndrome and what are the key characteristics?

A

complication of pre-eclampsia and eclampsia
Haemolysis
Elevated Liver enzymes
Low Platelets

407
Q

what are the main complications of gestational diabetes?

A

large for dates fetus, macrosomia
shoulder dystocia
developing type 2 diabetes

408
Q

when are women screened for gestational diabetes?

A

oral glucose tolerance test at 24 – 28 weeks gestation.

409
Q

what are the risk factors for gestational diabetes?

A

Previous gestational diabetes
Previous macrosomic baby (≥ 4.5kg)
BMI > 30
Ethnic origin (black Caribbean, Middle Eastern and South Asian)
Family history of diabetes

410
Q

what are the normal results of a oral glucose tolerance test?

A

Fasting: < 5.6 mmol/l
At 2 hours: < 7.8 mmol/l

411
Q

what is the management of gestational diabetes with a fasting glucose <7mmol/l

A

trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin

412
Q

what is the management of gestational diabetes with a fasting glucose >7mmol/l

A

start insulin ± metformin

413
Q

what is the management of gestational diabetes with a fasting blood glucose >6mmol/l plus macrosomia?

A

start insulin ± metformin

414
Q

what are the target blood sugar levels in gestational diabetes?

A

Fasting: 5.3 mmol/l
1 hour post-meal: 7.8 mmol/l
2 hours post-meal: 6.4 mmol/l
Avoiding levels of 4 mmol/l or below

415
Q

babies of mothers with diabetes are at risk of what?

A

Neonatal hypoglycaemia
Polycythaemia (raised haemoglobin)
Jaundice (raised bilirubin)
Congenital heart disease
Cardiomyopathy

416
Q

Obstetric cholestasis is associated with an increased risk of what?

A

stillbirth

417
Q

what are the symptoms of obstetric cholestasis?

A

pruritis (mainly palms and soles)
fatigue
dark urine
pale, greasy stools
jaundice

418
Q

what are some differentials of obstetric cholestasis?

A

Gallstones
Acute fatty liver
Autoimmune hepatitis
Viral hepatitis

419
Q

what investigations are done in obstetric cholestasis and what will they show?

A

Abnormal liver function tests (LFTs), mainly ALT, AST and GGT
Raised bile acids

420
Q

what is the management of obstetric cholestasis?

A

pruritis = emollients, antihistamines e.g. chlorphenamine
water soluble vitamin K if PT deranged

421
Q

what is the most common cause of acute fatty liver of pregnancy?

A

long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus

422
Q

what are the presenting symptoms of acute fatty liver of pregnancy?

A

General malaise and fatigue
Nausea and vomiting
Jaundice
Abdominal pain
Anorexia (lack of appetite)
Ascites

423
Q

what will LFT’s show in acute fatty liver pregnancy?

A

elevated liver enzymes (ALT and AST).

424
Q

what is the management of acute fatty liver of pregnancy?

A

obstetric emergency and requires prompt admission and delivery of the baby

425
Q

what are some pregnancy-related rashes?

A

polymorphic eruption of pregnancy
Atopic eruption of pregnancy
Melasma
Pyogenic granuloma
Pemphigoid Gestationis

426
Q

how is a low lying placenta defined?

A

placenta is within 20mm of the internal cervical os

427
Q

how is placenta praevia defined?

A

when the placenta is over the internal cervical os

428
Q

what risks are associated with placenta praevia?

A

Antepartum haemorrhage
Emergency caesarean section
Emergency hysterectomy
Maternal anaemia and transfusions
Preterm birth and low birth weight
Stillbirth

429
Q

what are the 4 grades of placenta praevia?

A

Minor praevia, or grade I – the placenta is in the lower uterus but not reaching the internal cervical os
Marginal praevia, or grade II – the placenta is reaching, but not covering, the internal cervical os
Partial praevia, or grade III – the placenta is partially covering the internal cervical os
Complete praevia, or grade IV – the placenta is completely covering the internal cervical os

430
Q

what are the risk factors for placenta praevia?

A

Previous caesarean sections
Previous placenta praevia
Older maternal age
Maternal smoking
Structural uterine abnormalities (e.g. fibroids)
Assisted reproduction (e.g. IVF)

431
Q

when is placenta praevia diagnosed?

A

20-week anomaly scan

432
Q

what is the management of placenta praevia?

A

repeat transvaginal USS at 32 and 36w
Corticosteroids between 34-35+6w
planned delivery considered between 36-37w

433
Q

what is the main complication of placenta praevia?

A

haemorrhage

434
Q

what is vasa praevia?

A

fetal vessels are within the fetal membranes (chorioamniotic membranes) and travel across the internal cervical os

435
Q

what are the 2 types of vasa praevia?

A

Type I vasa praevia – the fetal vessels are exposed as a velamentous umbilical cord
Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental lobe

436
Q

what are the risk factors for vasa praevia?

A

Low lying placenta
IVF pregnancy
Multiple pregnancy

437
Q

what is the management of vasa praevia?

A

Corticosteroids, given from 32 weeks gestation to mature the fetal lungs
Elective caesarean section, planned for 34 – 36 weeks gestation

438
Q

what is placental abruption?

A

when the placenta separates from the wall of the uterus during pregnancy

439
Q

what are the risk factors for placental abruption?

A

Previous placental abruption
Pre-eclampsia
Bleeding early in pregnancy
Trauma (consider domestic violence)
Multiple pregnancy
Fetal growth restriction
Multigravida
Increased maternal age
Smoking
Cocaine or amphetamine use

440
Q

what is the typical presentation of placental abruption?

A

Sudden onset severe abdominal pain that is continuous
Vaginal bleeding (antepartum haemorrhage)
Shock (hypotension and tachycardia)
Abnormalities on the CTG indicating fetal distress
Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage

441
Q

what are the initial steps in a major or massive haemorrhage?

A

Urgent involvement of a senior obstetrician, midwife and anaesthetist
2 x grey cannula
Bloods include FBC, UE, LFT and coagulation studies
Crossmatch 4 units of blood
Fluid and blood resuscitation as required
CTG monitoring of the fetus
Close monitoring of the mother

442
Q

what is placenta accreta, increta and percreta?

A

Superficial placenta accreta is where the placenta implants in the surface of the myometrium, but not beyond
Placenta increta is where the placenta attaches deeply into the myometrium
Placenta percreta is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder

443
Q

what are some risk factors for placenta accreta?

A

Previous placenta accreta
Previous endometrial curettage procedures (e.g. for miscarriage or abortion)
Previous caesarean section
Multigravida
Increased maternal age
Low-lying placenta or placenta praevia

444
Q

placenta accreta is a cause of significant ________ _________?

A

postpartum haemorrhage

445
Q

how is placenta accreta diagnosed ?

A

antenatally by ultrasound

446
Q

what are the 3 management options during caesarean section of placenta accreta?

A

Hysterectomy with the placenta remaining in the uterus (recommended)
Uterus preserving surgery, with resection of part of the myometrium along with the placenta
Expectant management, leaving the placenta in place to be reabsorbed over time

447
Q

when is delivery planned in placenta accreta?

A

between 35 to 36 + 6 weeks gestation

448
Q

what are the 4 types of breech?

A

Complete breech, where the legs are fully flexed at the hips and knees
Incomplete breech, with one leg flexed at the hip and extended at the knee
Extended breech, also known as frank breech, with both legs flexed at the hip and extended at the knee
Footling breech, with a foot is presenting through the cervix with the leg extended

449
Q

when can External cephalic version be performed?

A

After 36 weeks for nulliparous women (women that have not previously given birth)
After 37 weeks in women that have given birth previously

450
Q

what is given to women before ECV?

A

tocolysis to relax the uterus e.g. subcutaneous terbutaline
anti-D if needed

451
Q

how is stillbirth defined?

A

birth of a dead fetus after 24 weeks gestation

452
Q

what are the common causes of stillbirth?

A

Unexplained (around 50%)
Pre-eclampsia
Placental abruption
Vasa praevia
Cord prolapse or wrapped around the fetal neck
Obstetric cholestasis
Diabetes
Thyroid disease
Infections, such as rubella, parvovirus and listeria
Genetic abnormalities or congenital malformations

453
Q

what factors can increase the risk of stillbirth?

A

Fetal growth restriction
Smoking
Alcohol
Increased maternal age
Maternal obesity
Twins
Sleeping on the back

454
Q

There are three key symptoms to always ask during pregnancy. Women would report these immediately if they occur:

A

Reduced fetal movements
Abdominal pain
Vaginal bleeding

455
Q

what is the investigation of choice for intrauterine fetal death?

A

Ultrasound scan to visualise the fetal heartbeat

456
Q

what is the first line management for most women after IUFD?

A

vaginal birth

457
Q

what can be used to suppress lactation after stillbirth?

A

Dopamine agonists (e.g. cabergoline)

458
Q

what can be tested to determine the cause of stillbirth ?

A

Genetic testing of the fetus and placenta
Postmortem examination of the fetus (including xrays)
Testing for maternal and fetal infection
Testing the mother for conditions associated with stillbirth, such as diabetes, thyroid disease and thrombophilia

459
Q

what are the 3 major causes of cardiac arrest in pregnancy?

A

Obstetric haemorrhage
Pulmonary embolism
Sepsis leading to metabolic acidosis and septic shock

460
Q

what are the causes of massive obstetric haemorrhage?

A

Ectopic pregnancy
Placental abruption
Placenta praevia
Placenta accreta
Uterine rupture

461
Q

what is the solution to aortocaval compression?

A

place the woman in the left lateral position, lying on her left side, with the pregnant uterus positioned away from the inferior vena cava

462
Q

after what gestation should a pregnant woman not lie on her back?

A

after 20 weeks

463
Q

Resuscitation in pregnancy follows the same principles as standard adult life support, except for:

A

A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta
Early intubation to protect the airway
Early supplementary oxygen
Aggressive fluid resuscitation (caution in pre-eclampsia)
Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR

464
Q

when is an immediate caesarean section performed in a pregnant woman receiving CPR?

A

There is no response after 4 minutes to CPR performed correctly
CPR continues for more than 4 minutes in a woman more than 20 weeks gestation

465
Q

at what gestation does labour and delivery normally occur?

A

between 37 and 42 weeks gestation

466
Q

what are the 3 stages of labour?

A

First stage – from the onset of labour (true contractions) until 10cm cervical dilatation
Second stage – from 10cm cervical dilatation until delivery of the baby
Third stage – from delivery of the baby until delivery of the placenta

467
Q

what are the 3 phases of the first stage of labour?

A

Latent phase – from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
Active phase – from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
Transition phase – from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.

468
Q

what are the signs of labour?

A

Show (mucus plug from the cervix)
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination

469
Q

what are the symptoms of the latent first stage of labour?

A

Painful contractions
Changes to the cervix, with effacement and dilation up to 4cm

470
Q

what are the signs of established first stage of labour?

A

Regular, painful contractions
Dilatation of the cervix from 4cm onwards

471
Q

what is preterm prelabour rupture of membranes (P‑PROM):

A

amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm).

472
Q

what is prolonged rupture of membranes (also PROM)?

A

The amniotic sac ruptures more than 18 hours before delivery

473
Q

How is prematurity defined?

A

birth before 37 weeks gestation

474
Q

at what gestation are babies considered non-viable?

A

below 23 weeks gestation

475
Q

what is the World Health Organisation classification of prematurity?

A

Under 28 weeks: extreme preterm
28 – 32 weeks: very preterm
32 – 37 weeks: moderate to late preterm

476
Q

What can be given as prophylaxis of preterm labour?

A

Vaginal progesterone
Cervical cerclage

477
Q

what women are offered cervical cerclage?

A

cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation, who have had a previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy)

478
Q

how is rupture of membranes diagnosed?

A

speculum examination revealing pooling of amniotic fluid in the vagina.

479
Q

if there is doubt about the diagnosis of rupture of membranes, which tests can be performed?

A

Insulin-like growth factor-binding protein-1 (IGFBP-1) is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes
Placental alpha-microglobin-1 (PAMG-1)

480
Q

what is the management of premature rupture of membranes?

A

Prophylactic antibiotics
Induction of labour may be offered from 34 weeks to initiate the onset of labour

481
Q

what are the management options for improving the outcomes of preterm labour?

A

Fetal monitoring (CTG or intermittent auscultation)
Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour
Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality
IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain
Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth

482
Q

what are the key signs of magnesium toxicity?

A

Reduced respiratory rate
Reduced blood pressure
Absent reflexes

483
Q

when is induction of labour offered?

A

between 41 and 42 weeks gestation
Prelabour rupture of membranes
Fetal growth restriction
Pre-eclampsia
Obstetric cholestasis
Existing diabetes
Intrauterine fetal death

484
Q

what is the Bishop score?

A

scoring system used to determine whether to induce labour

485
Q

what are the features of the Bishops score?

A

Fetal station (scored 0 – 3)
Cervical position (scored 0 – 2)
Cervical dilatation (scored 0 – 3)
Cervical effacement (scored 0 – 3)
Cervical consistency (scored 0 – 2)

486
Q

what does a bishops score of 8 or more indicate?

A

predicts a successful induction of labour

487
Q

what are the options for inducing labour?

A

Membrane sweep
Vaginal prostaglandin E2 (dinoprostone)
Cervical ripening balloon
artificial rupture of membranes with an oxytocin infusion

488
Q

what is used to induce labour where intrauterine fetal death has occured?

A

Oral mifepristone (anti-progesterone) plus misoprostol

489
Q

what are the 2 means for monitoring during the induction of labour?

A

Cardiotocography (CTG) to assess the fetal heart rate and uterine contractions before and during induction of labour
Bishop score before and during induction of labour to monitor the progress

490
Q

what is the main complication of induction of labour with vaginal prostaglandins?

A

Uterine hyperstimulation

491
Q

what are the 2 criteria for uterine hyperstimulation?

A

Individual uterine contractions lasting more than 2 minutes in duration
More than five uterine contractions every 10 minutes

492
Q

what can uterine hyperstimulation lead to?

A

Fetal compromise, with hypoxia and acidosis
Emergency caesarean section
Uterine rupture

493
Q

what is the management of uterine hyperstimulation?

A

Removing the vaginal prostaglandins, or stopping the oxytocin infusion
Tocolysis with terbutaline

494
Q

what are the indications for continuous CTG monitoring during labour?

A

Sepsis
Maternal tachycardia (> 120)
Significant meconium
Pre-eclampsia (particularly blood pressure > 160 / 110)
Fresh antepartum haemorrhage
Delay in labour
Use of oxytocin
Disproportionate maternal pain

495
Q

what are the 5 key features to look for on a CTG?

A

Contractions – the number of uterine contractions per 10 minutes
Baseline rate – the baseline fetal heart rate
Variability – how the fetal heart rate varies up and down around the baseline
Accelerations – periods where the fetal heart rate spikes
Decelerations – periods where the fetal heart rate drops

496
Q

what baseline rate on CTG is reassuring?

A

110 – 160

497
Q

what variability on CTG is reassuring?

A

5 – 25

498
Q

what causes decelerations?

A

fetal heart rate drops in response to hypoxia

499
Q

what are the 4 types of deceleration?

A

Early decelerations
Late decelerations
Variable decelerations
Prolonged decelerations

500
Q

what type of decelerations are considered normal?

A

early decelerations

501
Q

what is the “rule of 3’s” for fetal bradycardia when they are prolonged?

A

3 minutes – call for help
6 minutes – move to theatre
9 minutes – prepare for delivery
12 minutes – deliver the baby (by 15 minutes)

502
Q

what structure can you follow to assess the features of a CTG?

A

DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG)
C – Contractions
BRa – Baseline Rate
V – Variability
A – Accelerations
D – Decelerations
O – Overall impression (given an overall impression of the CTG and clinical picture)

503
Q

what is the role of oxytocin?

A

stimulates the ripening of the cervix and contractions of the uterus during labour and delivery. It also plays a role in lactation during breastfeeding

504
Q

what can infusions of oxytocin be used for in labour?

A

Induce labour
Progress labour
Improve the frequency and strength of uterine contractions
Prevent or treat postpartum haemorrhage

505
Q

what is progress in labour influenced by?

A

Power (uterine contractions)
Passenger (size, presentation and position of the baby)
Passage (the shape and size of the pelvis and soft tissues)

506
Q

Delay in the first stage of labour is considered when there is either:

A

Less than 2cm of cervical dilatation in 4 hours
Slowing of progress in a multiparous women

507
Q

what is recorded on a partogram?

A

Cervical dilatation (measured by a 4-hourly vaginal examination)
Descent of the fetal head (in relation to the ischial spines)
Maternal pulse, blood pressure, temperature and urine output
Fetal heart rate
Frequency of contractions
Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium
Drugs and fluids that have been given

508
Q

Delay in the second stage is when the active second stage (pushing) lasts over:

A

2 hours in a nulliparous woman
1 hour in a multiparous woman

509
Q

Delay in the third stage is defined by the NICE guidelines (2017) as:

A

More than 30 minutes with active management
More than 60 minutes with physiological management

510
Q

what is active management of the third stage of labour?

A

intramuscular oxytocin and controlled cord traction

511
Q

what are the main management options for failure to progress?

A

Amniotomy (artificial rupture of membranes) for women with intact membranes
Oxytocin infusion
Instrumental delivery
Caesarean section

512
Q

what are the pain relief options in labour

A

paracetamol in early labour
Gas and Air (Entonox)
IM Pethidine or Diamorphine
Patient controlled IV remifentanil
Epidural

513
Q

what are the possible adverse effects of an epidural?

A

Headache after insertion
Hypotension
Motor weakness in the legs
Nerve damage
Prolonged second stage
Increased probability of instrumental delivery

514
Q

what is cord prolapse?

A

when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes

515
Q

what is the most significant risk factor for cord prolape?

A

fetus is in an abnormal lie after 37 weeks gestation (i.e. unstable, transverse or oblique)

516
Q

what is the management of cord prolapse?

A

Emergency caesarean section
left lateral position (with a pillow under the hip) or the knee-chest position (on all fours), and tocolysis whilst waiting

517
Q

What is shoulder dystocia?

A

when the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered.

518
Q

What is shoulder dystocia often caused by?

A

macrosomia secondary to gestational diabetes

519
Q

what are 2 signs of shoulder dystocia?

A

failure of restitution
turtle-neck sign

520
Q

what is the management of shoulder dystocia?

A

Episiotomy
McRoberts manoeuvre
Pressure to the anterior shoulder
Rubins manoeuvre
Wood’s screw manoeuvre
Zavanelli manoeuvre

521
Q

what are some complications of shoulder dystocia?

A

Fetal hypoxia (and subsequent cerebral palsy)
Brachial plexus injury and Erb’s palsy
Perineal tears
Postpartum haemorrhage

522
Q

what should be given after instrumental delivery to reduce maternal infection?

A

co-amoxiclav

523
Q

what are some key indications for instrumental delivery?

A

Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in various fetal positions

524
Q

Having an instrumental delivery increases the risk to the mother of:

A

Postpartum haemorrhage
Episiotomy
Perineal tears
Injury to the anal sphincter
Incontinence of the bladder or bowel
Nerve injury (obturator or femoral nerve)

525
Q

what are the key risks to the baby of instrumental delivery?

A

Cephalohaematoma with ventouse
Facial nerve palsy with forceps

526
Q

what are rare serious risks of instrumental delivery?

A

Subgaleal haemorrhage (most dangerous)
Intracranial haemorrhage
Skull fracture
Spinal cord injury

527
Q

what are the features of femoral nerve palsy?

A

weakness of knee extension, loss of the patella reflex and numbness of the anterior thigh and medial lower leg.

528
Q

what are features of obturator nerve injury?

A

weakness of hip adduction and rotation, and numbness of the medial thigh.

529
Q

Perineal tears are more common with:

A

First births (nulliparity)
Large babies (over 4kg)
Shoulder dystocia
Asian ethnicity
Occipito-posterior position
Instrumental deliveries

530
Q

what are the 4 degrees of perineal tear?

A

First-degree – injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin
Second-degree – including the perineal muscles, but not affecting the anal sphincter
Third-degree – including the anal sphincter, but not affecting the rectal mucosa
Fourth-degree – including the rectal mucosa

531
Q

what are the subcategories of third-degree tears?

A

3A – less than 50% of the external anal sphincter affected
3B – more than 50% of the external anal sphincter affected
3C – external and internal anal sphincter affected

532
Q

what additional measures are taken to reduce risk of complications of perineal tears?

A

Broad-spectrum antibiotics to reduce the risk of infection
Laxatives to reduce the risk of constipation and wound dehiscence
Physiotherapy to reduce the risk and severity of incontinence
Follow up to monitor for longstanding complications

533
Q

what are some short term complications of perineal tear repair?

A

Pain
Infection
Bleeding
Wound dehiscence or wound breakdown

534
Q

what are some long lasting complications of perineal tears?

A

Urinary incontinence
Anal incontinence and altered bowel habit (third and fourth-degree tears)
Fistula between the vagina and bowel (rare)
Sexual dysfunction and dyspareunia (painful sex)
Psychological and mental health consequences

535
Q

how should an episiotomy be cut?

A

mediolateral

536
Q

what are the classifications of PPH?

A

Minor PPH – under 1000ml blood loss
Major PPH – over 1000ml blood loss

537
Q

what are the sub-classifications of major PPH?

A

Moderate PPH – 1000 – 2000ml blood loss
Severe PPH – over 2000ml blood loss

538
Q

what is the difference between primary and secondary PPH?

A

Primary PPH: bleeding within 24 hours of birth
Secondary PPH: from 24 hours to 12 weeks after birth

539
Q

what are the 4 causes of PPH?

A

T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)

540
Q

what are some risk factors for PPH?

A

Previous PPH
Multiple pregnancy
Obesity
Large baby
Failure to progress in the second stage of labour
Prolonged third stage
Pre-eclampsia
Placenta accreta
Retained placenta
Instrumental delivery
General anaesthesia
Episiotomy or perineal tear

541
Q

Several measures can reduce the risk and consequences of postpartum haemorrhage:

A

Treating anaemia during the antenatal period
Giving birth with an empty bladder (a full bladder reduces uterine contraction)
Active management of the third stage (with intramuscular oxytocin in the third stage)
Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients

542
Q

what is the management of a PPH?

A

Resuscitation with an ABCDE approach
Lie the woman flat, keep her warm and communicate with her and the partner
Insert two large-bore cannulas
Bloods for FBC, U&E and clotting screen
Group and cross match 4 units
Warmed IV fluid and blood resuscitation as required
Oxygen (regardless of saturations)
Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion

543
Q

what are the mechanical treatment options to stop PPH?

A

Rubbing the uterus
Catheterisation

544
Q

what are the medical treatment options for PPH?

A

Oxytocin (slow injection followed by continuous infusion)
Ergometrine (contraindicated in hypertension)
Carboprost
Misoprostol (sublingual)
Tranexamic acid (intravenous)

545
Q

what are the 2 main causes of secondary PPH?

A

retained products of conception (RPOC) or infection (i.e. endometritis).

546
Q

what are the surgical options for PPH?

A

Intrauterine balloon tamponade
B-Lynch suture
Uterine artery ligation
hysterectomy

547
Q

what are some indications for an elective caesarean section?

A

Previous caesarean
Symptomatic after a previous significant perineal tear
Placenta praevia
Vasa praevia
Breech presentation
Multiple pregnancy
Uncontrolled HIV infection
Cervical cancer

548
Q

what are the 4 categories of emergency caesarean section?

A

Category 1: There is an immediate threat to the life of the mother or baby. Decision to delivery time is 30 minutes.
Category 2: There is not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Decision to delivery time is 75 minutes.
Category 3: Delivery is required, but mother and baby are stable.
Category 4: This is an elective caesarean, as described above.

549
Q

what are the layers of the abdomen that need to be dissected during a caesarean section?

A

Skin
Subcutaneous tissue
Fascia / rectus sheath
Rectus abdominis muscles
Peritoneum
Vesicouterine peritoneum
Uterus (perimetrium, myometrium and endometrium)
Amniotic sac

550
Q

what anaesthetic is used in elective caesarean sections?

A

Spinal

551
Q

what is given to reduce risks of a caesarean section?

A

H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) before the procedure
Prophylactic antibiotics during the procedure to reduce the risk of infection
Oxytocin during the procedure to reduce the risk of postpartum haemorrhage
Venous thromboembolism (VTE) prophylaxis with low molecular weight heparin

552
Q

what are some contraindications to vaginal birth after caesarean?

A

Previous uterine rupture
Classical caesarean scar (a vertical incision)
Other usual contraindications to vaginal delivery (e.g. placenta praevia)

553
Q

what are 2 key causes of sepsis in pregnancy?

A

Chorioamnionitis
Urinary tract infections

554
Q

what are some signs/symptoms of chorioamnionitis?

A

Abdominal pain
Uterine tenderness
Vaginal discharge

555
Q

what are the main risk factors for amniotic fluid embolus?

A

Increasing maternal age
Induction of labour
Caesarean section
Multiple pregnancy

556
Q

how does amniotic fluid embolism present?

A

Shortness of breath
Hypoxia
Hypotension
Coagulopathy
Haemorrhage
Tachycardia
Confusion
Seizures
Cardiac arrest

557
Q

what are the risk factors for uterine rupture?

A

Vaginal birth after caesarean (VBAC)
Previous uterine surgery
Increased BMI
High parity
Increased age
Induction of labour
Use of oxytocin to stimulate contractions

558
Q

what are the signs and symptoms of uterine rupture?

A

Abdominal pain
Vaginal bleeding
Ceasing of uterine contractions
Hypotension
Tachycardia
Collapse

559
Q

what is the management of uterine rupture?

A

Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy)

560
Q

what is uterine inversion?

A

fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out.

561
Q

how does uterine inversion typically present?

A

large postpartum haemorrhage. There may be maternal shock or collapse.

562
Q

what are the 3 management options for uterine inversion?

A

Johnson manoeuvre
Hydrostatic methods
Surgery

563
Q

in the days after delivery what is routine postnatal care?

A

Analgesia as required
Help establishing breast or bottle-feeding
Venous thromboembolism risk assessment
Monitoring for postpartum haemorrhage
Monitoring for sepsis
Monitoring blood pressure (after pre-eclampsia)
Monitoring recovery after a caesarean or perineal tear
Full blood count check (after bleeding, caesarean or antenatal anaemia)
Anti-D for rhesus D negative women (depending on the baby’s blood group)
Routine baby check

564
Q

The topics that are covered at the six-week check include:

A

General wellbeing
Mood and depression
Bleeding and menstruation
Scar healing after episiotomy or caesarean
Contraception
Breastfeeding
Fasting blood glucose (after gestational diabetes)
Blood pressure (after hypertension or pre-eclampsia)
Urine dipstick for protein (after pre-eclampsia)

565
Q

how long does lochia typically last for?

A

should settle within six weeks

566
Q

why can you get slightly more bleeding during episodes of breastfeeding?

A

Breastfeeding releases oxytocin, which can cause the uterus contract

567
Q

Bottle-feeding women will begin having menstrual periods from when?

A

3 weeks onwards

568
Q

when does fertility return after birth?

A

21 days after giving birth

569
Q

Postpartum endometritis can present from shortly after birth to several weeks postpartum. It can present with:

A

Foul-smelling discharge or lochia
Bleeding that gets heavier or does not improve with time
Lower abdominal or pelvic pain
Fever
Sepsis

570
Q

what investigations can help to establish a diagnosis of endometritis?

A

Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)
Urine culture and sensitivities

571
Q

what is a significant risk factor for retained products of conception?

A

Placenta accreta

572
Q

how may retained products of conception present?

A

Vaginal bleeding that gets heavier or does not improve with time
Abnormal vaginal discharge
Lower abdominal or pelvic pain
Fever (if infection occurs)

573
Q

what is the 1st line investigation for retained products of conception?

A

Ultrasound

574
Q

what is the management of retained products of conception?

A

dilatation and curettage

575
Q

what is Asherman’s syndrome?

A

adhesions (sometimes called synechiae) form within the uterus

576
Q

what is the management of post partum anaemia?

A

Hb under 100 g/l – start oral iron (e.g. ferrous sulfate)
Hb under 90 g/l – consider an iron infusion in addition to oral iron (e.g. Monofer, CosmoFer or Ferinject)
Hb under 70 g/l – blood transfusion in addition to oral iron

577
Q

what are the symptoms of baby blues?

A

Mood swings
Low mood
Anxiety
Irritability
Tearfulness
(usually in 1st week)

578
Q

what are the presenting features of mastitis?

A

Breast pain and tenderness (unilateral)
Erythema in a focal area of breast tissue
Local warmth and inflammation
Nipple discharge
Fever

579
Q

what is the management of mastitis?

A

1st: continued breastfeeding, heat packs, analgesia
2nd: Flucloxacillin

580
Q

what are some presenting features of candida of the nipple?

A

Sore nipples bilaterally, particularly after feeding
Nipple tenderness and itching
Cracked, flaky or shiny areola
Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash

581
Q

what is the management of candida of the nipple?

A

Topical miconazole 2% after each breastfeed
Treatment for the baby (e.g. miconazole gel or nystatin)

582
Q

what is postpartum thyroiditis?

A

changes in thyroid function within 12 months of delivery, affecting women without a history of thyroid disease. It can involve thyrotoxicosis (hyperthyroidism), hypothyroidism, or both.

583
Q

what are the 3 stages of postpartum thyroiditis?

A

Thyrotoxicosis (usually in the first three months)
Hypothyroid (usually from 3 – 6 months)
Thyroid function gradually returns to normal (usually within one year)

584
Q

what causes Sheehan’s syndrome?

A

complication of post-partum haemorrhage, where the drop in circulating blood volume leads to avascular necrosis of the pituitary gland

585
Q

what part of the pituitary gland does Sheehan’s syndrome affect?

A

anterior pituitary gland

586
Q

what hormones does the anterior pituitary release?

A

Thyroid-stimulating hormone (TSH)
Adrenocorticotropic hormone (ACTH)
Follicle-stimulating hormone (FSH)
Luteinising hormone (LH)
Growth hormone (GH)
Prolactin

587
Q

what are the presenting features of Sheehan’s syndrome?

A

Reduced lactation (lack of prolactin)
Amenorrhea (lack of LH and FSH)
Adrenal insufficiency and adrenal crisis, caused by low cortisol (lack of ACTH)
Hypothyroidism with low thyroid hormones (lack of TSH)

588
Q

what is the management of Sheehan’s syndrome?

A

Oestrogen and progesterone as hormone replacement therapy for the female sex hormones (until menopause)
Hydrocortisone for adrenal insufficiency
Levothyroxine for hypothyroidism
Growth hormone

Finals (21 decks)

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