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Obstetrics + Gynaecology Flashcards

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USMLE® Step 1 flashcards
1
Q

O+G history - general

  1. Gynaecology systems review
  2. More about bleeding (4 times)
  3. More about periods
  4. Other important systems to consider
  5. Obstetrics systems review (2 broad)
  6. Sexual systems review
A
  1. 4 Ps - PV discharge, PV bleeding, pregnancy, periods, cervical smear, STIs
  2. Bleeding - heavy, intermenstrual, post-coital, post-menopausal
  3. Periods - cycle, bleeding heaviness/length/regularity, pain, menarche, LMP, other bleeding, smear history
  4. Urinary (UTIs, incontinence), GI
  5. Any pregnancies (for each one - term, problems, mode of delivery, miscarriages, ectopics), any terminations, HTN, DM, thrombocytopaenia
  6. Contraception, most recent partner (male or female, type of sex, contraception), how many partners in last 6 months, any pain/discomfort, bleeding, STIs infertility
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2
Q

Menorrhagia (excess volume/duration)

  1. Causes - systemic
  2. Causes - local
  3. Causes - iatrogenic
  4. History - important red flags (2)
  5. History - subjective assessment of severity
    6, Linked disease (+ symptoms to check for)
  6. Referral - urgent if (2)
  7. 2ww if
  8. Management - interim between urgent referral
  9. 1st line in community - hormonal
  10. 2nd line (if declined/contraindicated)
  11. Surgical (+ when not suitable)
A
  1. Clotting disorder, hypothyroidism
  2. Dysfunctional uterine bleeds, fibroids, polyps, PID, endometriosis, endometrial carcinoma
  3. Copper coil
  4. Intermenstrual, post-coital
  5. Clots, flooding, nocturnal soiling, level of sanitary protection, interfering with work/social events
  6. Anaemia (palpitations, pale, lethargy, SOB)
  7. Ascites, pelvic/abdominal mass not obviously due to fibroids
  8. Pelvic mass + any other sign of cancer
  9. TXA (thrombosis) / NSAIDs
  10. Mirena progesterone IUS
  11. TXA / NSAIDs / contraceptive pill
  12. Endometrial ablation (not if wishing to conceive). Take endometrial biopsy if failed treatment + thick
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3
Q

Other abnormal uterine bleeding (AUB)

  1. Inter-menstrual - causes
  2. Post-coital - causes
  3. Post-menopausal - causes
  4. Test in AUB if 45+
A
  1. Endometrial cancer (>40), polyps, cervicitis/vaginitis, IUCD
  2. Cervical trauma / polyps / carcinoma, vaginal
  3. Endometrial cancer until proven otherwise,atrophic vaginitis, carcinoma (cervical / vulval)
  4. Endometrial biopsy
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4
Q

Pregnant abdomen - examination

  1. Inspection - general (4)
  2. Skin signs (4)
  3. Foetal heartbeat - (rough) location
  4. To complete exam, do what (2)
  5. Increased bump size for dates - causes
  6. Decreased bump size for dates - causes
  7. Polyhydramnios - causes
  8. Oligohydramnios - definition/causes
A
  1. Distension, foetal movements, scars, skin changes
  2. Straie (gravidarum/albicans), linea nigra, umbilicus, excoriations (obstetric cholestasis)
  3. Half way between umbilicus and ASIS
  4. BP, urine dip
  5. Macrosomia, polyhydramnios, multiple pregnancy, wrong dates, fibroids
  6. Oligohydramnios, growth restriction, small baby
  7. DM, foetus swallowing amniotic fluid, foetal infection
  8. < 500 ml at 32-36 weeks; premature membrane rupture, foetal renal problem, IUGR, pre-eclampsia
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5
Q

Mechanism of labour - stage one

  1. Parts (2)
  2. Cervical dilatation - L stage
  3. Cervical dilatation - A stage
  4. Expected rate - primiparous
  5. Expected rate - multiparous
  6. Clinical signs
  7. What happens to foetus in stage 1
  8. Complications - 3 Ps (+ examples)
  9. Interventions - to precipitate initiation of labour
  10. For cervical dilatation
  11. For contractions
A
  1. Latent, active
  2. 0-3 cm
  3. 3-10 cm (fully dilated)
  4. 1 cm every 2 hours
  5. 1 cm every hour
  6. Regular painful contractions, progressive cervical dilation, “show” (bloodstained mucus), membrane rupture
  7. Head descends into the pelvis
  8. Passenger (foetal malpresentation)
    Passage (Fibroids / cervical stenosis)
    Power (Uterine inertia)
  9. Prostaglandin gel
  10. Artificial membrane rupture
  11. Oxytocin
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6
Q

Mechanism of labour - stage two

  1. What happens (briefly)
  2. Primiparous - time
  3. Multiparous - time
  4. First foetal movement (+ head position)
  5. Stage 2 (+ head position)
  6. Stage 3
  7. Stage 4 (+ shoulder position)
  8. Stage 5
  9. Complications - ‘dytocia’ (3)
  10. Delayed labour - diagnosed/suspected
A
  1. Expulsion of foetus
  2. 15-45 minutes
  3. 45-120 minutes
  4. Flexion of the head as it descends and engages
    body (occipitotemporal)
  5. Head internal rotation (occipitoanterior)
  6. Head extension (around pubic symphysis) + delivery
  7. Restitution/external rotation (shoulders AP position)
  8. Shoulder delivery (anterior first)
  9. Secondary uterine intertia, persistent occipito-posterior position, narrow mid-pelvis
  10. 1 (multiparous) / 2 (nuliparous) hours after S2 start (suspected after 30/60 minutes of inadequate progress)
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7
Q

Mechanism of labour - stage 3

  1. What happens (briefly)
  2. What to give to speed up
  3. Time taken (with and without)
  4. Signs (2)
  5. Complications - primary PPH definition
  6. Primary PPH - causes (4 Ts)
  7. Commonest cause (90%) + risk factors
  8. Atony - management
  9. PPH - further management
  10. Secondary PPH - cause
  11. PPH - preventative measures
  12. Placenta in situ + PPH - management
  13. Other (2)
A
  1. Expulsion of placenta
  2. Syntometrine (oxytocin + ergometrine)
  3. 5-10 / 30-60 minutes
  4. Gush of blood (50-100 ml), cord lengthening
  5. > 500 ml loss in < 24 hours
  6. Tone, Tension, Trauma, Thrombosis
  7. Uterine atony (multple current/previous pregnancies, macrosomia, polyhydramnios, fibroid uterus, prolonged labour, previous APH/PPH)
  8. Massage uterine fundus to stimulate contraction, oxytocin, prostaglandin
  9. Bimanual compression, catheter, prostaglandin, TXA
  10. Retained tissue/clot
  11. Treat anaemia before labour, avoid long traumatic labour, active 3rd stage management
  12. Deliver via controlled cord traction or manual removal under GA
  13. Retained placenta, uterine inversion
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8
Q

COCP

  1. Mechanism of action
  2. How to take
  3. When to start
  4. If miss
  5. Pros
  6. Side effects
  7. Contraindications
  8. Increased risk of which cancers (2)
  9. Protective against which cancers (3)
A
  1. Stops ovulation, increases cervical mucus production, thins endothelium
  2. Every day for 3 weeks, around same time each day, then one week off
  3. Day 1 of cycle, or use condom for first 7 days
  4. Use the advice on the packaging, if >1 not covered + use barrier contraception
  5. Regulate periods, improve acne
  6. Headaches, nausea, mood changes, breast tenderness - often resolve
  7. Migraine with aura, VTE history, Smoke 35+, breastfeeding
  8. Breast, cervical
  9. Ovarian, endometrial, colorectal
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9
Q

Progesterone only pill

  1. Mechanism of action
  2. How to take
  3. When to start
  4. If miss
  5. Pros
  6. Side effects
  7. Contraindications
A
  1. Increases thickness of cervical mucus, thins endothelium
  2. Same time of day, every day (7 placebo pills)
  3. Day 1 of cycle, or use condom for first 7 days
  4. Take straight away, if >3 hrs use condom for 2 days, consider emergency contraception of had sex 2-3 days before or after missed pill
  5. Can make periods lighter/stop them
  6. Mood swings, acne, headaches, tender breasts
  7. Breast cancer, undiagnosed PV bleeding, liver disease
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10
Q

Progesterone depot injection

  1. Mechanism of action
  2. Given how often
  3. Side effects
  4. Contraindications
  5. Can take how long for fertility to return after stopping
A
  1. Stops ovulation, increased/thickened cervical mucus, thins endothelium
  2. IM injection every 3 months
  3. Mood swings, weight gain, acne, headache, tender breasts, irregular periods
  4. Cancer, liver disease, undiagnosed PV bleed
  5. 18 months
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11
Q

Progesterone implant

  1. Mechanism of action
  2. Inserted how + immediate side effects
  3. Side effects
  4. Post-insertion red flags
A
  1. Stops ovulation, increased cervical mucus, thins endothelium
  2. Inserted under the skin, under LA, can cause bleeding / bruising / infection / scarring
  3. Mood swings, weight gain, acne, headache, tender breasts
  4. Red and sore arm, discharge, systemically unwell
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12
Q

Mirena coil (progesterone IUS)

  1. Mechanism of action
  2. To do before inserting
  3. Covered immediately when
  4. Lasts for how long
  5. Periods often become what
  6. Check strings how often
  7. Post-insertion red flags
  8. Contraindications
A
  1. Stops ovulation, increase cervical mucus, thins endothelium
  2. STI check
  3. Inserted in first 7 days of cycle (if not, condom for 7 days)
  4. 3-5 years
  5. Lighter, shorter, less painful; often get irregular bleeding or spotting
  6. Every 4 weeks
  7. Severe pain, smelly discharge, fever
  8. PID <3m ago, STI, gynaecological cancer, small uterine cavity, undiagnosed PV bleed
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13
Q

Copper coil

  1. Mechanism of action
  2. Starts working, for how long
  3. Impact on periods
  4. Absolute contraindication
A
  1. Spermicide, alters cervical mucus
  2. Immediately, for up to 10 years
  3. Can become heavier/more painful
  4. Pelvic inflammatory disease
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14
Q

Emergency contraception

  1. Levonorgestrel - how long works after sex
  2. Ellaone pill - how long works after sex
  3. Cannot use if
  4. Impact on progesterone contraception
  5. Medication in it, which meds reduce efficacy (2)
  6. Copper coil - how long works after sex
  7. Does what
  8. Which ECs don’t affect contraception

History

  1. Sexual history
  2. Contraception history
  3. Period type
  4. PMH
  5. FH
  6. Social history
  7. STIs
  8. Pregnancy, other
  9. Counselling
  10. Eggs last how long
  11. Sperm last how long
A
  1. 3 days (1.5 mg stat dose)
  2. 5 days
  3. Previously used in a cycle
  4. May reduce efficacy
  5. Ulliprestel; PPI + ranitidine
  6. 5 days
  7. Prevents implantation
  8. Levonorgestrel, copper coil
  9. When, who, consensual, regular partner
  10. Any current, type, reason for failure, why EC needed, previously used EC in this cycle
  11. LMP, cycle length, current day of cycle
  12. HTN, migraine with aura
  13. VTE, stroke, migraine with aura
  14. Smoking, drinking
  15. Discharge, bleeding, warts, test
  16. Any chance of current pregnancy, smear, medications
  17. Future contraception options, STI risk, take test in 3 weeks, ectopic safety net, retake if vomit in < 2 hours
  18. 1 day
  19. 5 days
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15
Q

Pelvic inflammatory disease (PID)

  1. Presentation (4)
  2. Commonest causative organism
  3. Fitz Hugh Curtis Syndrome - what
A
  1. Fever, bilateral lower pelvic pain, dyspareunia, vaginal discharge
  2. Chlamydia
  3. Peri-hepatic inflammation/adhesions secondary to Chlamydia - forms ‘Glisson’s capsule’
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16
Q

Uterine fibroids

  1. Definition
  2. Grow if (+ why)
  3. Shrink if (+ why)
  4. Pain type and causes (3)
  5. Other symptoms (3)
  6. Risk factors
  7. Protective factors
  8. Complications - gynaecological
  9. Pregnancy
  10. Imaging - 1st line, then gold standard
  11. Management - indications for treating
  12. Adjunct to surgical removal (myomectomy)
  13. Invasive alternative to surgical removal
A
  1. Benign tumour of the myometrium
  2. Pregnancy - hyper-oestrogenic state
  3. Menopause - hypo-oestrogenic state
  4. Pain localised and constant; caused by degeneration, pelvic varices, uterine ligament stretch
  5. Subfertility, urinary symptoms (press on bladder), bloating (press on rectum)
  6. Black, increasing age, never pregnant, obesity
  7. Smoking, COCP, full-term pregnancy
  8. Degeneration, torsion if pedunculated, malignancy (very small risk of leimyosarcoma)
  9. Infertility, obstructed labour, PPH
  10. USS, then MR
  11. Symptomatic, rapidly growing, causing infertility
  12. GnRH analogues - reversible, temporary, chemical menopause
  13. Uterine artery ablation (does not preserve fertility)
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17
Q

Early pregnancy complications

  1. History - important questions (5)
  2. Cervical shock - what it is
  3. Presentation
  4. Other differentials (2)
  5. If unsure between above 2, do what test
  6. Viable - result
  7. Miscarriage - result
  8. Ectopic - result
A
  1. LMP, last smear, bleeding, discharge, pain
  2. Vagal response to dilation caused by products of conception distending the cervical canal
  3. Low pulse, low BP
  4. Miscarriage, ectopic pregnancy
  5. beta hCG 48 hours apart
  6. Doubled
  7. Significantly reduced
  8. Stayed same/increased slightly
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18
Q

Miscarriage

Definitions

  1. Threatened
  2. Inevitable
  3. Missed/delayed/silent
  4. Complete
  5. Incomplete
  6. Risk factors - general
  7. Iatrogenic
  8. Examination
  9. Management - options (3)
  10. Expectant - latest gestation, wait for how long
  11. Recurrent - definition/causes (4 broad)
  12. Terminations - < 9 weeks
  13. 9-13 weeks
  14. 13-23 weeks
A
  1. Painless light bleeding < 24 weeks, cervix closed
  2. Heavy painful bleeding < 24 weeks, clots, cervix open
  3. Scan shows no viable foetus / empty intrauterine sac, cervix closed, maybe no bleeding
  4. No products of conception on scan, cervix closed, has had bleeding
  5. Scan shows products of conception, cervix open, has had painful bleeding
  6. Fetal abnormality, infection, maternal age/illness
  7. Intervention e.g. amniocentesis, CVS
  8. Abdomen soft, >12 weeks then uterus may be palpable
  9. Expectant, medical (misoprostol), surgical
  10. 13 weeks, wait to see if happens in next 1-2 days
  11. 3+ consecutive; antiphospholipid, poorly-controlled endocrine (DM/thyroid disorder/PCOS), uterine abnormality, smoking
  12. Mifepristone (anti-progestogen), then misoprostol 48 hours later to stimulate uterine contractions
  13. Surgical dilation and suction
  14. Surgical dilation and evacuation / late medical
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19
Q

Ectopic pregnancy

  1. Risk factors
  2. Haemorrhage - signs
  3. Examination - Unruptured ectopic
  4. Ruptured ectopic
  5. Expectant management - if
  6. Management - medical (alternative to expectant)
  7. If hCG > 1500, which options
  8. Surgical - indications
  9. Advice post-medical management
A
  1. PID, tubal surgery, peritonitis / pelvic surgery, IUS in situ, endometriosis, IVF pregnancy
  2. Pulse weak + fast, low BP, pale, sweaty, collapse
  3. Uterus not palpable, tender on affected side, maybe some guarding/rebound tenderness
  4. Entire abdomen tense, guarding, rebound tenderness
  5. Clinically stable, painless, < 3.5cm, hCG < 1000
  6. Methotrexate (static / rising hCG)
  7. Methotrexate or surgical management (salpingectomy, salpingotomy)
  8. Mass > 4cm, unstable, failed medical, previous ectopic
  9. Can’t get pregnant for 3 months after
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20
Q

Endometritis

  1. Presentation
  2. Complication of what
A
  1. Fever, malaise, lower abdominal pain, change in vaginal bleeding
  2. ERCP
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21
Q

Vaginal discharge

  1. STI causes (3)
  2. Non-STI causes (2)
  3. Inflammatory causes (3)
  4. Malignant causes (3)
  5. Other causes (2)
  6. Investigations - general (2)
  7. If suspecting PID
  8. If suspecting malignancy
  9. Bacterial vaginosis - presentation
    Management
  10. Trichomonas vaginalis - presentation (4)
    Management
  11. Candidiasis - presentation
A
  1. Chlamydia, trichomas vaginalis, neisseria gonorrhoea
  2. Candida albicans, bacterial vaginosis
  3. Atrophic changes, allergic reaction, post op granulation tissue
  4. Vulval / cervical / uterine carcinoma
  5. Foreign body, fistula
  6. Microbiology swabs, MSU
  7. Laparoscopy
  8. Vulval biopsy, cervical smear / biopsy, pelvic USS, endometrial sampling, hysteroscopy
  9. Grey/green, ‘fishy’ discharge, vulval itching, burning with urination
    Metronidazole PO 5-7 days
  10. Offensive frothy yellow / green discharge, vulvovaginitis, strawberry cervix
    Metronidazole
  11. Cottage cheese discharge, vulvitis, vulval erythema, burning with urination, dyspareunia
22
Q

Endometriosis

  1. Definition
  2. Clinical features (5)
  3. Investigation - Gold standard
  4. Prior imaging option
  5. Analgesia management - 1st line
  6. Hormonal management - offer to all
  7. Above management does not do what
  8. Surgical management (2)
A
  1. Growth of endometrial tissue outside of the uterine cavity
  2. Chronic pelvic pain, premenstrual dysmenorrhoea, menorrhagia, deep dyspareunia, subfertility
  3. Laparoscopy
  4. Ultrasound
  5. Paracetamol +/ ibuprofen
  6. COCP, progestogen, mirena coil
  7. Improve subfertility
  8. Laporascopic excision / ablation
23
Q

Menopause

  1. Diagnosis - < 50
  2. Diagnosis - 50+
  3. Premature menopause - age
  4. Symptoms (+ duration)
  5. Tests if suspected (3)
  6. Management - initial
  7. Hormone replacement therapy - benefits (2)
  8. Risks
  9. Contraindications
  10. HRT if no oestrogen (no uterus) / IUS in last 5 years
  11. HRT if <1 yr since LMP + uterus
  12. Continuous HRT - used when
  13. If high thrombotic risk, which is preferred oestrogen
  14. Regimen if irregular periods + uterus, give what
  15. Reduced libido
  16. Vaginal atrophy only
  17. Non-HRT management - vasomotor, dryness, mood, atrophy
A
  1. 24 months after LMP
  2. 12 months after LMP
  3. < 40
  4. Menorrhoea / irregular cycles, hot flushes, night sweats, vaginal symptoms, mood change, sleep disturbance (last 2-5 years)
  5. Pregnancy test, FSH, serum oestradiol
  6. Lifestyle - weight loss, exercise, no alcohol / caffeine
  7. Reduced osteoporosis / coronary artery disease
  8. Cancer: ovarian (all types) / breast (if combined) / endometrial, VTE (if oral), stroke (if oral oestrogen), IHD (if combined)
  9. Undiagnosed PV bleeding, pregnancy, acute liver disease, uncontrolled HTN, oestrogen-dependent cancer, breast cancer, VTE, recent stroke/MI/angina
  10. Continuous oestrogen-only therapy, or SSRI (2nd line)
  11. Cyclical combined HRT
  12. Cyclical combined for 1+ year / 1+ year since LMP (2+ if premature menopause)
  13. Transdermal
  14. Sequential
  15. Oestrogen and androgen combined
  16. Vaginal oestrogen +/- vaginal moisturiser
  17. Fluoxetine/citalopram/venlafaxine, moisturisers, CBT, vaginal oestrogen
24
Q

Cervical cancer

  1. Symptomatic presentation
  2. Risk factors
  3. Screening - intention
  4. Smears every 3 years
  5. Smears every 5 years
  6. Yearly smears
  7. Borderline changes / low grade dyskaryosis
  8. Moderate/high grade dyskaryosis / suspected cancer
  9. Intraepithelial neoplasia - management (3)
  10. Cervical ectropion - cause/histology
A
  1. Bleeding (inter-menstrual, post-coital, post-menopausal), persistant discharge
  2. HPV infection, early sex, many partners, poverty, smoking, partner with prostatic/penile cancer, HIV
  3. To detect pre-malignant change
  4. 25-49 years old
  5. 50-64 years old
  6. HIV positive
  7. HPV test - if positive then colposcopy in 6 weeks, if not then routine screening
  8. 2ww colposcopy
  9. Large loop excision, needle excision, core biopsy
  10. High oestrogen (ovulation, pregnancy, COCP) result in more columnar epithelium on ectocervix (less stratified squamous)
25
Q

Ovarian hyperstimulation syndrome

  1. Pathophysiology
  2. Presentation - severe
  3. Complications (3)
A
  1. High oestrogen levels, vascular permeability, 3rd space fluid build up - leads to intravascular fluid depletion
  2. N+V, painful abdominal distension, fluid shift (ascites and pleural effusion)
  3. Hepatorenal failure, ARDS, VTE
26
Q

Polycystic ovary syndrome (PCOS)

  1. Common features
  2. Associated conditions (3)
  3. Examination - findings
  4. Management - 1st line
  5. Periods
  6. Acne
  7. Hirsuitism
  8. Diagnostic criteria (2/3 of)
A
  1. Hirsutism, acne, irregular/infrequent periods, weight gain, infertility, scalp hair loss
  2. Insulin resistance/T2DM (OGTT screen), sleep apnoea, metabolic syndrome, CVD
  3. Hirsutism, sweating/oily skin, acne, acanthosis nigricans
  4. Diet + exercise
  5. Medroxyprogesterone / COCP / IUS
  6. COCP
  7. Waxing/shaving, COCP
  8. 2003 Rotterdam Consensus Criteria (2+ of: 1) oligo/anovulation, clinical/biochemical signs of hyperandrogenism, polycystic ovaries
27
Q

Gynaecological malignancies

  1. Endometrial carcinoma - commonest presentation
  2. Risk factors
  3. Referral when, 1st line
  4. 1st line management
  5. Management if frail
  6. Protective factors
  7. Ovarian - main blood test (can also be raised by)
  8. Commonest presentation
  9. Risk factors
  10. Imaging (1st, then next)
  11. Vulval/vaginal carcinoma - presentation
A
  1. Post-menopausal bleeding
  2. Obesity, unopposed oestrogen, tamoxifen (uterus oestrogen agonist), DM, many ovulations (early menarche/late menopause), Lynch syndrome, PCOS
  3. 2ww if >55 + post-menopausal bleeding, do TV USS
  4. Local (total abdo hysterectomy with bilateral salpingo-oophorectomy), post-op radiotherapy if high risk
  5. Progesterone therapy
  6. COCP, smoking
  7. CA 125 (endometriosis, menstruation, ovarian cyst)
  8. Bloating/abdominal pain, early satiety, loss of appetite (12+ times/month)
  9. BRCA 1/2, many ovulations
  10. USS firstly, then CT to stage
  11. Itching, bleeding, lesions on that area
28
Q

Molar pregnancy

  1. USS findings
A
  1. ‘Snowstorm’
29
Q

Dysmenorrhoea

  1. Classification - primary
  2. Usually starts
  3. Classification - secondary
  4. Common causes (4)
  5. Investigations
A
  1. No pelvic pathology
  2. 6-12 after first period
  3. Present pelvic pathology
  4. Endometriosis, chronic PID, fibroids, polyps
  5. Pregnancy, swabs, bloods (clotting, FBC, CRP), TV USS
30
Q

Antenatal appointments / investigations

  1. First appointment (booking) - when
  2. Bloods
  3. Other tests
  4. Hb measured again when
  5. Routine date scan - when
  6. Anomaly scan - when
A
  1. < 10 weeks
  2. Hb, platelets, infectious diseases (HIV, syphilis, Hep B), blood group/antibody status, sickle cell, thalassaemia
  3. BMI, BP, MSU
  4. 28 weeks
  5. 8-13 weeks
  6. 18-20 weeks
31
Q

Antenatal syndrome screening

  1. Combined test - which syndromes
  2. When
  3. Comprised of what (2)
  4. Increased NT indicates what (3)
  5. If too late/can’t do NT, do what Quad test - which syndrome, when
  6. When
  7. Bloods (4)
  8. Interpretation
  9. Down syndrome - NHS diagnostic tests + weeks (2)
  10. Risk of these
  11. Private diagnostic test
A
  1. Downs (T21), Edwards (T18), Patau (T13)
  2. 10-14 weeks
  3. Bloods (PAPP-A, bhCG), nuchal translucency
  4. Downs, congenital heart/abdominal wall defect
  5. Quad test (Downs), mid-pregnancy scan (E/P)
  6. 14-20 weeks
  7. AFP, inhibin A, oestriol, b-hCG
  8. Low (lower than 1 in 150 chance, 19/20) vs
    higher (greater than 1 in 150 change, 1/20)
  9. Chorionic villous sampling (11-14), amniocentesis (15+)
  10. Miscarriage in 0.5-1 in 100
  11. Cell free foetal DNA test
32
Q

Diabetes in pregnancy

  1. Effect of pregnancy on DM
  2. Effect of DM on mother
  3. Effect of hyperglycaemia on foetus
  4. Higher risk of what in foetus
  5. Existing DM - mothers do what before pregnancy
  6. Medication changes
  7. Gestational - risk factors
  8. Diagnostic test/criteria
  9. If previous GDM, do what
  10. BM - check how often (+ targets)
  11. Additional growth USS - when
  12. Delivery - offer what
  13. Must have C-section if
A
  1. Increased insulin (more hypos), neuropathy/retinopathy worse
  2. Higher risk of: pre-eclampsia, infection, needing induction, C-section, worsening renal disease
  3. Foetal hyperglycaemia, so increased foetal insulin production, leading to macrosomia + polyhydramnios
  4. Miscarriage, shoulder dytocia, unexplained stillbirth, congenital malformations
  5. Weight loss, quit smoking/alcohol, good sugar control (HbA1C < 48), retinopathy/nephropathy screening
  6. Folic acid for 3 months, switch to metformin/insulin
  7. BMI >30, GDM FH/PMH, PCOS, ethnic, previous big baby
  8. 28 weeks OGTT, fasting > 5.6 or 2 hour plasma > 7.8
  9. Earlier OGTT at 12-16 weeks
  10. Pre-meal (< 5.3), 1 hour post-meal (< 7.8), bedtime. Always keep above 4
  11. Monthly from 28 weeks
  12. Elective at 37-38 weeks, earlier if complications
  13. Estimated foetal weight > 4.5 kg
33
Q

Anti-D

  1. What for
  2. Potential sensitising events
  3. Test to check level of foeto-maternal haemorrhage
  4. Prophylaxis (RAADP) - when to give (general)
  5. Post-natal Anti-D - when/indications
  6. Risks of RAADP (2)
  7. Rhesus disease - symptoms/signs
  8. Management
  9. Complications
A
  1. To prevent sensitisation if rhesus negative mother exposed to rhesus positive blood - RhD negative antigens neutralised so antibodies not produced
  2. Foetal loss (spontaneous miscarriage, abortion), trauma (invasive procedures, placental abruption, foeto-maternal haemorrhage), blood transfusions
  3. Kleihauer test
  4. 28 weeks, or divided dose (28 + 34 weeks)
  5. Within 72 hours post-birth, if cord blood rhesus positive
  6. Allergic rash/flu, infection from donor plasma
  7. Foetal haemolytic anaemia, jaundice
  8. Blood transfusions, IVIG, phototherapy
  9. Hydrops (fluid accumulation), brain damage, deafness, blindness, stillbirth
34
Q

Foetal/intrauterine growth restriction (FGR/IUGR)

  1. Definition
  2. Determined via which measurements
  3. Risk factors
  4. Management
  5. TORCH infections - which
  6. Associated with what
  7. Small for dates - definition
  8. Causes - other
  9. Large for dates - causes
A
  1. Baby not reaching growth potential
  2. Abdo/head circumference, femur length
  3. Previous small baby, HTN/pre-eclampsia, reduced foetal movements, maternal disease (anaemia, HTN, other), maternal TORCH infections, smoking/alcohol, placental insufficiency
  4. Exclude underlying causes, monitor (size), timely delivery (monitor foetal HR / blood flow), C-section
  5. Toxoplasmosis, other (syphilis, varicella-zoster, parvovirus B12), rubella, CMV, herpes
  6. Increased risk of congenital abnormalities
  7. Foetal weight below 10th percentile
  8. Constitutional, incorrect G.A., oligohydramnios
  9. DM (macrosomia, polyhydramnios), constitutional, incorrect G.A., polyhydramnios, lots of weight gain
35
Q

Pregnancy-induced HTN

  1. Definition
  2. Management if high-risk of developing pre-eclampsia
  3. Existing HTN - advice
  4. Target BP
  5. When to admit
  6. Pre-eclampsia - definition
  7. Quantifying proteinuria
  8. Risk factors
  9. Symptoms
  10. Bloods
  11. Monitoring
  12. Management - other
  13. Eclampsia - definition
  14. Seizure management (or if severe of others)
  15. Severe (160/110) HTN in critical care - management
  16. Other monitoring
  17. At risk of what (+ signs)
A
  1. HTN after 20 weeks
  2. 75-150mg aspirin OD from 12 weeks until birth
  3. ACE-i/ARB/thiazide (likes) - stop as abnormality risk
  4. 135/85
  5. BP >160/110
  6. HTN after 20 weeks with proteinuria
  7. If 1+ protein on dipstick, do P:CR (>30) or A:CR (>8)
  8. 1st pregnancy, twins/triplets expected, >40 yo, previous pre-eclampsia, pre-existing DM / HTN / kidney disease / SLE / anti-phospholipid syndrome, FH
  9. Oedema, headache, vision problems, epigastric/RUQ pain, N+V, brisk reflexes
  10. U+E, LFT, urate, FBC
  11. USS (growth restriction), placental function
  12. Early delivery (37-38 weeks), regular monitoring, labetalol if >160
  13. HTN, proteinuria, seizures
  14. IV magnesium sulfate 4g loading then infusion
  15. Labetalol / nifedipine if asthmatic / hydralazine
  16. Urine output, RR, reflexes, SpO2. Limit fluids
  17. HELLP syndrome (haemolysis, elevated liver enzymes, low platelets)
36
Q

Other diseases in pregnancy

  1. Obesity - increased risk of
  2. Target BMI before pregnancy
  3. Vitamin requirements
  4. Anaemia - threshold for treating - booking
  5. 28 weeks
  6. 1st-line management
  7. VTE - risk factors
  8. At risk how long post-delivery
  9. Highest risk group and how they are managed
  10. Suspected PE - initial and subsequent imaging
  11. 1st line management + what to avoid
  12. Acute fatty liver - presentation
  13. Morning sickness - when
  14. Hyperemesis gravidarum - diagnostic requirements
  15. HG - score to quantify
  16. HG - management
A
  1. Miscarriage, congenital malformations, pre-eclampsia, gestational DM, macrosomia, VTE, labour complications (induced, obstruction, longer, C-section)
  2. < 30
  3. High (5mg) folic acid to 12 weeks, 10mcg Vit D to birth
  4. < 11 dg/L
  5. < 10.5 dg/L
  6. Diet, ferrous sulphate
  7. Thrombophilia, 35+ yo, BMI > 30, parity > 3, smoking, immobility, large VVs, co-morbidities, systemic infecton
  8. Up to 6 weeks
  9. C-section; 7 days of LMWH
  10. CXR, then V/Q if normal or CTPA if abnormal
  11. LMWH (if confirmed DVT then start 1st before chest imaging), not warfarin
  12. Epigastric/RUQ pain, N+V, anorexia, malaise
  13. 4-7 weeks to 13 weeks (second trimester)
  14. Dehydration, weight loss
  15. Pregnancy-Unique Quantification of Emesis (PUQE)
  16. Hartmann’s, cyclizine IV, maybe PPI, vitamin replacement (thiamine, folic acid)
37
Q

Pregnancy - general tips

  1. Bad habits
  2. Diet
  3. Supplements
  4. Exercise
A
  1. Stop smoking / drinking
  2. Balanced, normal amount, avoid uncooked soft cheese with white rinds/blue, raw eggs/meat
  3. Folic acid 400mcg OD from 3 months before to 12 weeks or 5mg if higher risk (FH, DM, PMH, AEDs, obese). Also vitamin D (10mcg until breast feeding), maybe iron/B12
  4. Good, but no impact sports
38
Q

Abdominal pain in 2nd and 3rd trimesters

  1. Obstetric causes
  2. Gynaecological causes
  3. GI causes
  4. Presentation - symphysis pubis dysfunction
  5. Ligament pain
  6. Ovarian cyst rupture
A
  1. Labour, placental abruption, symphysis pubis dysfunction, ligamental pain, pre-eclampsia, HELLP
  2. Ovarian torsion, cyst rupture / haemorrhage, uterine fibroid degeneration
  3. Constipation, pyelonephritis, gallstones/cholestasis, pancreatitis, peptic ulcer, cystitis, renal stones
  4. Low/central pain, tender SP, worse on movement
  5. Sharp/bilateral pain, worse on movement
  6. Unilateral, intermittent, associated with N+V
39
Q

CTG

  1. Used from how many weeks
  2. Interpretation - DR C BRAVADO
  3. Foetal heart rate - normal range
  4. Suspicious CTG - conservative management
  5. Pathological CTG - management
  6. Urgent intervention required - CTG findings (2)
A
  1. 26
  2. Define risk, contractions, baseline, rate, accelerations, variability, decelerations, overall assessment
  3. 110 - 160 bpm
  4. Mobalise the mother, change position, IV fluids if hypotensive, stop oxytocin, offer tocolytic drug (e.g. terbutaline)
  5. Conservative measures, urgent review by an obstetrician and a senior midwife, offer digital foetal scalp stimulation, consider foetal blood sampling / expediating birth
  6. Acute bradycardia, single deceleration > 3 mins
40
Q

Antepartum haemorrhage (APH)

  1. Over 50% caused by (2)
  2. Other uterine causes (2)
  3. Lower genital causes
  4. Placenta problems - suggestive findings (2)
  5. Placenta praevia - definition
  6. Commoner when
  7. Examination
  8. What to avoid if suspected
  9. Follow up scan when
  10. C-section when
  11. Potential complication
  12. Definition - placenta accreta
  13. Vasa praevia
  14. Placental abruption - what is it
  15. Presentation
  16. Risk factors
  17. Complications of blood loss (3)
  18. What is Sheehan’s syndrome (+ symptoms)
A
  1. Placenta praevia, placental abruption
  2. Vasa praevia, circumvallate placenta
  3. Cervical ectropion/polyp/carcinoma/cervicitis, vaginitis, vulval varices
  4. Foetal vessel resistance, reduced liquor volume
  5. Low lying after 20 weeks of pregnancy
  6. Previous C-sections, smoking, fertility treatment
  7. Uterus SNT, non-engaged/malpresentation, minor bleeding
  8. Digital exam
  9. 36 weeks
  10. If placenta within 2 cm of cervical os
  11. PPH
  12. Placenta stuck to womb lining
  13. Foetal blood vessels run near uterine opening (membrane rupture then painless bleeding + foetal bradycardia)
  14. Placental attachment to uterus disrupted by haemorrhage as blood dissects under placenta
  15. Mild-severe pain and vaginal bleeding, uterus tender and tense, may be signs / symptoms of pre-eclampsia
  16. Pre-eclampsia, previous abruption, older woman, smoking, multiparity, abdominal trauma, cocaine use, external cephalic version
  17. DIC, renal failure, Sheehan’s syndrome
  18. Hypopituitarism from ischemic necrosis - difficulty breastfeeding, little/no menstruation
41
Q

Induction of labour

  1. Timing indications
  2. Maternal indications
  3. Foetal indications
  4. 1st step
  5. 2nd step
  6. 3rd step
  7. ARM - complication
A
  1. 10 days post-full term if no problems (41-42 weeks)
  2. Severe pre-eclampsia, recurrent APH, pre-existing disease
  3. Prolonged pregnancy, IUGR, rhesus disease
  4. Cervix ripening - membrane sweep, then prostaglandin pessary/pill if that doesn’t work
  5. Artificial membrane rupture - when cervix ready but not happened after 24 hours
  6. Syntocinon infusion - when membranes ruptured but labour not started
  7. Amniotic fluid embolism
42
Q

Breech presentation

  1. Complications
  2. Management - when to discuss
  3. Options (3)
  4. ECV - contraindications
  5. ECV - performed how
  6. Success rate
  7. Medication to give alongside
  8. Vaginal breech - EFW cut-off
  9. Advised against if
A
  1. Increase in perinatal mortality/ morbidity, difficult to deliver head (entrapment), rapid foetal head compression and decompression
  2. If still breech at 36 weeks
  3. External cephalic version (ECV), elective c-section, planned vaginal breech
  4. Pelvic mass, APH, placenta praevia, previous C-section/hysteroscopy, multiple pregnancy, ruptured membranes
  5. On labour ward, monitoring, tocolytics, USS control
  6. 50% of time
  7. Anti-D
  8. > 4 kg
  9. Footling, pre-eclampsia, placenta praevia, large/small
43
Q

Shoulder dytocia

  1. Risks
  2. 1st line management
A
  1. Previous, DM, BM >30, induced/long labour, assisted vaginal delivery
  2. McRoberts manoeuvre
44
Q

Assisted vaginal delivery

  1. Ventouse - maternal indication + cause
  2. Foetal indication (2) + cause
  3. Can be used from
  4. Required from mother (2)
  5. Foetal complications
  6. Forceps - types (2)
  7. Not required from mother
  8. Maternal indication (2)
  9. Foetal indications
  10. Foetal complications (3)
  11. Maternal complications of both (2)
A
  1. Second stage delay due to maternal exhaustion
  2. Abdnormal CTG / second stage delay due to foetal malposition
  3. 34 weeks
  4. Adequate maternal effort, regular contractions
  5. Scalp oedema / subperiosteal bleeding
  6. Tractional, rotational
  7. Adequate maternal effort, regular contractions
  8. Medical conditions complicating labour, unconscious
  9. < 34 weeks, face presentation, foetal bleeding disorder, head delivery in breech
  10. Bruising / facial nerve palsy / depression skull fracture
  11. Genital tract trauma - haemorrhage/infection
45
Q

C-section

  1. Maternal indications
  2. Foetal indications
  3. Complications
  4. Preparations ahead of complications
  5. VBAC - can occur when
  6. Contraindications (2)
A
  1. Two previous LSCS, maternal disease/request, placenta praevia, active genital HSV, HIV
  2. Breech presentation, twin if 1st not cephalic, cord prolapse, 1st stage problems (abnormal CTG, abnormal foetal blood sample, delay from malpresentation/position)
  3. Haemorrhage, gastric aspiration, visceral injury, foetal laceration, infection, higher future pregnancy complication risk
  4. Crossmatch, group + save, routine antacids, maybe prophylactic ABX
  5. If C-section due to unrepeatable cause e.g. foetal distress
  6. Previous uterine rupture, classical C-section scar
46
Q

APGAR score

  1. Stands for
  2. Calculated when (2)
  3. Normal score
  4. Score indicating neurological damage
A
  1. Appearance, pulse, grimmace, activity, respiration
  2. 1 and 5 minutes
  3. 7+
  4. < 3
47
Q

Pregnancy - physiological changes

  1. Cardiovascular (3)
  2. Respiratory
  3. Blood
  4. Urinary system
  5. Biochemistry
  6. Liver
  7. Uterus
A
  1. Increased HR/cardiac output, reduced diastolic BP in trimesters 1+2, decreased venous return (uterus blocking) so ankle oedema/supine hypotension/VVs
  2. Pulmonary ventilation up 40% despite needs only up by 20%, so fall in CO2 can lead to dyspnoea
  3. Maternal volume up 30%, plasma more than Hb so anaemia, increased clotting/fibrinogen, platelets down, WCC/ESR up
  4. Increased protein loss, increased GFR
  5. Increased calcium requirements + absorption, ionised levels stable but serum levels lower, crosses placenta
  6. No change in hepatic flow, high ALP, low albumin
  7. 100g - 1100g, hyperplasia then hypertrophy
48
Q

Infertility

  1. Causes
  2. Initial investigations (2)
  3. Progesterone - interpretation
  4. Premature ovarian failure/primary ovarian insufficiency - definition
  5. Causes (4)
  6. Bloods
  7. Hormone origin/functions - FSH
  8. LH
  9. Oestrogen
  10. Progesterone
  11. If irregular cycle and subfertile, which other tests
A
  1. Male factor, unexplained, ovarian failure, tubal damage
  2. Semen analysis (2nd 3 months later if abnormal), LH/FSH (assesses ovarian reserve), serum progesterone 7 days before period (mid-luteal phase, confirms ovulation)
  3. < 16 refer, 16-30 repeat, >30 indicates ovulation
  4. Onset of menopausal symptoms and elevated gonadotrophin levels < 40 years old
  5. Idiopathic, chemotherapy, radiation, autoimmune
  6. Raised FSH / LH, low progesterone
  7. Anterior pituitary; stimulates follicular growth in ovaries and oestrogen release
  8. Anterior pituitary; surge causes ovulation; corpus luteum forms
  9. Ovaries; thickens endometrium, inhibits LH/FSH for most of cycle but stimulates release pre-ovulation
  10. Ovaries; thickens endometrium, inhibits LH/FSH
  11. Oestrogen (ovarian function), prolactin, free testosterone
49
Q

HPV

  1. Which strains cause genital warts (2)
  2. Which cause cervical cancer (2)
  3. Linked to which other malignancies (5)
  4. Symptoms
  5. Caught how
  6. Vaccination - offers to who, what age
  7. Given as
  8. Why given so young
A
  1. 6, 11
  2. 16, 18
  3. Anal, vulval, vaginal, mouth, throat
  4. Usually none; most will not know they’re infected
  5. Any sexual touching, most can clear but some don’t
  6. 12-13 year old boys + girls (up to 25 years old if missed)
  7. Gardasil, 2 doses - 2nd dose 6-12 months after 1st
  8. Best protection before sexual activity starts
50
Q

Chickenpox exposure in pregnancy

  1. Risk to mother - 5x greater risk of
  2. Foetal varicella syndrome - occurs if exposure
  3. Clinical features
  4. Other risks to foetus (2)
  5. Management of exposure - 1st investigation
  6. If not immune, give what
  7. If present within 24 hours of rash, give woman what
A
  1. Pneumonitis
  2. <20 weeks (1% risk)
  3. LDs, skin scars, smalle eyes/head, limb hypoplasia
  4. Shingles in infancy (2-3rd trimester exposure)
    Severe neonatal chickenpox (if maternal rash 5 days before / 2 days after delivery)
  5. Varicella antibody test if unsure about past exposure
  6. Varicella zoster immunoglobulin (VZIG) up to 10 days post-exposure
  7. PO aciclovir

Medical School (28 decks)

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