Obstetrics/Gynaecology (NEW) Flashcards

Question 1

Q

Chlamydia trachomatis background

Answer

A

Epidemiology

most common bacterial infection
> more common in women
risk factors
> young adult (<25yrs)
> new/multiple sex partner
> partner with chlamydia
> infrequent condom use
> previous STD
> urban
coinfection common
> gonorrhoea
> trichomonas
> m genitalium

Aetiology

sexual transmission
> cervix < - > urethra (approx 75% partners affected)
> urethra < - > rectum (transmission rate much lower)
infects
> columnar epithelial cells cervix
> urethra
> bartholins glands
> fallopian tubes
> anus
does not infect squamous cells of vagina

Pathophys

structure
> gram negative bacteria
> obligate intracellular organism
life cycle
> spore like elementary body attaches to epithelium
> enter and surround by vacuole (inclusion)
> transforms to larger/metabolically active reticulate body
> replicates over 3 days
> transforms back into elementary bodies
> cell rupture and spread
incubation period up to 2 weeks

Question 2

Q

chlamydia trachomatis syndromes

Answer

A

Women

cervicitis
> vast majority asymptomatic
urethritis
> 50% of infections
PID and sequelae
pregnancy
> premature rupture of membranes
> preterm birth
> low birth weight
> chorioamnionitis

Men

urethritis
epididymitis
> unilateral pain/tenderness
> hydrocele
> swollen epididymis

Common to men and women

conjunctivitis
> by direct inoculation with genital secretions
> erythematous injection of conjunctiva
> non purulent
reactive arthritis
> acute onset several weeks post infection
> asymmetric, oligoarticular
> enthesitis
> dactylitis
> inflammatory lower back pain
reiters syndrome (classic triad)
> arthritis
> conjunctivitis/uveitis
> urethritis/cervicitis
proctitis
> pain
> discharge
> bleeding
> tenesmus
> constipation

Question 3

Q

Miscarriage (<20 weeks) background

Answer

A

Epidemiology

early pregnancy loss (first trimester)
> 10% clinically recognisable pregnancies
early second trimester loss (<20 weeks)
> less than 1% of pregnancies
almost half of parous women have EPL

Risk factors (ADIPOSE)

Age
> maternal
> possible paternal
Diabetes
> euglycaemia risk is baseline
Infection
> CMV
> syphilis
> parvovirus B19
Previous miscarriage
> OR for 1 = 1.5
> OR for 2 = 2.2
Obesity
Substances
> medications
> alcohol, smoking, cocaine
Exposures
> lead/arsenic
> air pollution
> radiation

Aetiologies

chromosomal abnormalities
> approx 3/4 of miscarriages
uterine abnormalities
> ashermans syndrome
> fibroids
> polyps
direct trauma
> violent
> iatrogenic (chorionic villus sampling)

Question 4

Q

Miscarriage (<20 weeks) evaluation

Answer

A

Hx

confirm pregnancy
> LMP
> pregnancy test results
bleeding
> clots
> tissue
pain
> cramping
> shoulder tip
loss of pregnancy symptoms
syncope
> hypovolaemia
infection
> fever
> purulent discharge
obstetric hx
> previous pregnancies
> previous miscarriages
> assisted conception
gynaecological hx
> surgeries
> significant conditions
previous investigations
> US
> b HCG

Exam

vitals
> fever/tachycardia/hypotension = infection
> tachycardia/hypotension = hypovolaemia
> bradycardia/hypotension = tissue in cervical canal
abdo
> tenderness/guarding
> distension
> enlarged uterus
speculum
> bleeding from cervix
> open os
> tissue in cervical canal
bimanual
> cervical motion tenderness
> uterine tenderness in infection
> adnexal mass

Investigations

b HCG
> urine
> serum
FBC
blood group and antibodies
> transfusion
> sensitising event
Coags
Consider
> MSU
> STD
Initial transvaginal ultrasound
> IUP
> ectopic pregnancy
> absence of findings (PUL/complete miscarriage)
> GTD

Question 5

Q

Suspected miscarriage investigation pathway

Answer

A

Intrauterine pregnancy

Confirmation
> yolk sac/embryo within gestational sac in endometrial cavity
Viable
> fetal heart present
Non viable incomplete miscarriage
> loss of cardiac tones in confirmed intrauterine
> MSD >25mm, no yolk sac/embryo
> CRL >7mm w no cardiac tones
Viability cannot be assess (MSD <25mm)
> repeat TVU when MSD expected to be 25mm
> assume MSD grows 1mm/day

Ectopic

Confirmed
> gestational sac with yolk sac/embryo at ectopic site
> adnexal mass/empty uterus/free fluid
> consider heterotopic
Likely
> pseudosac
> complex extra ovarian adnexal mass
> tubal donut sign
> adnexa ring of fire sign on doppler

PUL

DDx
> early IUP/non viable IUP
> ectopic
b HCG >3500 w. no findings
> almost certainly ectopic
> proceed with treatment
b HCG >2000 w. no findings
> ectopic/multiple gestation
> consider serum progesterone (low = non viable)
> expectant treatment as ectopic justifiable
> consider repeat TVU in 3 days (MSD visible at 3mm )
b HCG <2000 w. no findings
> repeat b HCGs over 48 hrs
serial b HCGs
> doubled = probably viable
> falling = likely unviable (including aborted ectopic)
> suboptimal rise (determined by initial level ) = ectopic or non viable IUP

Question 6

Q

Miscarriage psych management

Answer

A

Breaking bad news

setting
> as soon as possible
> ideally both parents present
> offer and facilitate presence of support person
> minimise waiting times
> private, preferably away from maternity wards
principles
> provide as much information as possible
> don’t speculate
> talk about ‘baby’ or use name if given

Counselling

principles
> allow time for questions, grief and discussion
> discuss potential experience of grief/depression
memories
> offer to provide momento (eg. US picture)
> offer to see baby (prepare them for image)
supports
> discuss personal supports
> mental health services
> medicare pregnancy support counselling services
consider
> risk factors for psychological morbidity
> suicide risk (leading cause of maternal mortality)

Question 7

Q

Miscarriage general management

Answer

A

Disposal of fetal tissue

if state requirements for birth registration met
> death certificate
> cremation or burial
birth registration requirements not met
> early pregnancy loss certificate can be provided
> hospital cremation
> private funeral director
> burial on private property

Histopath

products of conception sent to laboratory
> confirm pregnancy
> exclude ectopic
> exclude GTD
collection
> during surgery/inpatient miscarriage
> provide labelled specimen jar if expectant at home

Safety net

seek emergency assistance
> severe pain
> shoulder tip pain
> soaking more than 1 pad every hour
> syncope
> fever
return of period
> resolution of complications/completion of care
ongoing bleeds (>2 weeks)
> incomplete delivery
> GTD

Question 8

Q

Expectant management non-viable pregnancy

Answer

A

Indications

> patient preference
> incomplete miscarriage

Contraindications

> later than first trimester
> unstable
> evidence of infection
> high risk of haemorrhage or coagulopathy
> suspected GTD

Risks

> 20% unsuccessful
> prolonged bleeding
> high rate of unplanned admission
> low and comparable infection rate (2-3%)
> 2% risk of transfusion

Benefit

> similar success rate as medical management
> avoid medication/surgery
> managed at home

Follow up with GP/EPAS

> repeat b HCG in a week
> US if b HCG decrease <90%

Question 9

Q

Medical management non viable pregnancy

Answer

A

Indications

> patient preference
> incomplete miscarriage

Contraindications

> later than first trimester
> unstable
> evidence of infection
> high risk of haemorrhage or coagulopathy
> prostaglandin allergy

Risks

> heavier and prolonged bleeding than surgical
> 20% unsuccessful
> low and comparable infection rate (2-3%)
> 1% risk of transfusion

Benefits
->faster process than expectant

Procedure

> outpatient/day procedure
> misoprostol per vagina single dose
> analgesia and anti-emetics

Expect

> bleeding within 24 hrs
> bleeding heavier than menses
> cramping pain
> pain and bleeding gradual get worse
> peaks for 2-4 hours
> occasional bleeding/dull ache/cramping for 2 weeks
> SE = diarrhoea and vomitting

Follow up with EPAS

> b HCG day 1 and 8 (confirm levels falling)
> US if b HCG decrease <90%
> repeat dose after 2-7 days if no response

Question 10

Q

surgical management non viable pregnancy

Answer

A

Indication

first/early second trimester
patient preference
unstable/severe haemorrhage
evidence of infection
suspected GTD
unsuccessful medical/expectant management

Contraindication
-no absolute

Risks

standard procedure/anaesthesia risks
low and comparable infection rate (2-3%)
complications 1-2%

Benefits

shorter time to completion
lower rate unplanned hospital admissions
lowest rate of blood transfusion

Procedure

misoprostol PV 4hrs pre op
dilation and curettage (suction recommended)
general anaesthetic in OR

Follow up

GP if ongoing concerns
no b HCG or US

Question 11

Q

Clinical manifestations and diagnosis pregnancy

Answer

A

Hallmarks signs/symptoms

typical presentation
> within 8 wks gestation
> hx of sex without contraception
common
> amenorrhea
> nausea +/- vomiting (until 10 weeks)
> breast enlargement/tenderness
> fatigue
> urinary frequency

Additional hx

Neuro
> mood changes
> difficulty sleeping
> orthostatic presyncope
> carpal tunnel
Skin
> hyperpigmentation
> palmar erythema
> spider angiomas
Abdo
> mild uterine cramping
> adnexal discomfort
> bloating
> constipation
> GORD
> food cravings and aversions
Genitourinary
> bleeding
> nocturia
Resp
> nasal congestion
> SOB

Exam

uterus above symphysis after 12 wks
vulva/vaginal/cervix mucous
> congested and bluish after 12 weeks
breasts
> areolar darkens
> veins more visible

B HCG

serum vs urine
> serum much more sensitive and quantitative
> urine rapid, cheap but quantitative
serum
> can detect 1-2 mili IU
> level >5IU confirms pregnancy
> earliest detected 2 weeks after first day LMP
normal trajectory starts
> double every 48hrs for first month
> starts to decline after 10 weeks
> plateaus for second and third trimester

TVU

gestational sac
> 4-5 weeks
yolk sac
> 5-6 weeks
fetal pole w cardiac activity
> 6 weeks

Question 12

Q

Gonorrhoea background

Answer

A

Epidemiology

approx 5/10,000 gen pop
> 200 times more common in ATSI
risk factors
> ATSI
> MSM
> under 25yrs
> new/multiple sex partners
> partner with STD
> inconsistent condom use
> past STD

Aetiology

penetrative sex
> oral
> vagina
> rectum
transmission rate
> male to female = 60%
> female to male = 25%

Pathophys

attaches to mucosal epithelium
chromosomal plasticity
> evades immune system
> high rate of antimicrobial resistance
> reinfection common
incubation period
> approx 3 days in men
> longer in women

Question 13

Q

Gonoccocal syndromes

Answer

A

Women

cervicitis
> most common
> usually asymptomatic
urethritis
> almost always with cervicitis
> usually asymptomatic
PID and sequelae
bartholinitis
> with cervicitis
> perilabial pain and discharge
> oedematous/tender labia
pregnancy
> PPROM
> premature delivery
> low birth weight
> chorioamnionitis

Men

urethritis
prostatitis
> lower back pain
> dysuria
> frequency/urgency
epididymitis/orchitis uncommon

Both

proctitis
> pain
> discharge/bleeding
> tenesmus/constipation
pharyngitis
> oral sex
> pharyngitis
> exudate
> cervical lymphadenopathy
conjunctivitis
> by direct inoculation with anogenital secretions
> hyperacute (symptoms within 12 hrs)
> copious purulent discharge
> red and irritated
> chemosis/swollen eyelids
> preauricular lymphadenopathy
> sight threatening
purulent arthritis (disseminated disease)
> acute onset
> distal/asymmetric/oligoarticular arthritis)
> otherwise well
arthritis-dermitis syndrome (disseminated disease)
> several weeks post infection
> flu like illness with fever
> asymmetric, migratory polyarthritis
> tenosynovitis
> pustular/vesicular lesions on extremities

Question 14

Q

Initial antenatal visit

Answer

A

Hx

obstetric Hx
edinburgh post natal depression scale
genetic counselling
> aneuploidy screening
> carrier screening

Advice

potential teratogens
lifestyle
> smoking, drinking, drugs
> diet and supplements
> exercise
> general restrictions
infection prevention
> immunisation
> precautions
ongoing care
> care team
> frequency of visits
> antenatal education courses available

Exam

height, weight, BMI
BP
Uterine
> size
> consistency
> position

Ultrasound

confirm
> pregnancy
> number
> location
> cardiac tones
GA
morphological anomalies
> poor sensitivity

Bloods

FBC
> haemoglobin (anaemia)
> MCV (thalassaemia/iron deficiency)
> platelets (thrombocytopenia)
Blood group and antibodies
MSU
> dipstick for proteinuria
> midstream culture
Diabetes screening
> random glucose
> HbA1c if high risk
Rubella
> antibody titre
Varicella
> documented previous chickenpox/shingles
> previous vaccination
Syphilis
> trepanemal assay
Chlamydia/gonorrhoea
> high risk
> under 25
HIV
> EIA + western blot
HBV
> HBVsAg

Consider

CMV
> if contact with lots of children
HCV
> if high risk
TSH
> if high risk
sickle cell and thalasaemia screeing
> if high risk

Cervical screening
-if due

Question 15

Q

Determining GA

Answer

A

Best estimates

US is best estimate of EDD if
> before 22 weeks
> discrepancy with LMP larger than expected for GA
most accurate estimate of EDD overall
> CRL during first trimester
accepted/unchanged EDD
> earliest sonographic assessment made

Ultrasound

indications
> offered to all before 22 weeks
> irregular periods
> LMP unknown
> conception with hormonal contraception
> uterine size differs from LMP
technique
> TVU preferred during first trimester
> TAU for remainder
limitations
> multiple gestation
> morphology abnormalities
initial scan in first trimester
> use CRL
initial scan in second/third trimester
> BPD, HC, AC, FL

Clinical assessment

Naegele’s rule
> minus 3 months + 7 days
> assumes 28 day period with fertilisation on 14th
Uterine size (archaic)
> 8 = plum/10 = orange/12 = grapefruit
> above symphysis at 12/at umbilicus at 20
> cm above umbilicus after 20
> invalid with fibroids, obesity, twins, retroverted

Question 16

Q

Aneuploidy screening

Answer

A

Combined first trimester screening

timing
> 11-13+6 weeks
components
> NT = >95th centile
> PAPP-A = low
> b HCG = high
> maternal age
> gestational age
conditions tested (66% of all aneuploidies)
> trisomy 21 (Down)
> trisomy 13 (Patau)
> trisomy 18 (Edwards)
performance for 21
> sensitivity = 85%
> FPR = 5%
soft markers increase sensitivity/specificity
> nasal bone/DV waveform/tricuspid flow
confounders
> maternal weight
> smoking
> IVF
report of results
> risk of disease

Cell free DNA

timing
> from 10 weeks
> consider as secondary screen
components
> maternal serum taken
> fetal fraction and number of sequence specific chromosomes = presence of aneuploidy
> offer early anatomy US @ 11-13 weeks
conditions
> autosomal trisomies (21/13/18)
> sex chromosome aneuploidies
> micro deletions (diGeorge) not recommended
unable to provide a result in approx 5%
> early GA
> suboptimal collection
> low FF in obese mothers/fetal karyotype/IVF
private cost approx $400
trisomy 21 performance
> sensitivity = 99%
> specificity = 99%
> PPV = 90%
causes of inaccuracies
> placental mosaicism
> maternal mosaicism
> vanishing twin
> copy number variants
> maternal cancer
report of results
> positive/negative
> high risk/low risk

Second trimester testing

maternal serum screening (PPV = 3%)
> at 15-20 weeks
> maternal age
> AFP
> b HCG
> UE3
> Inhibin
cfDNA (from 10 weeks)

Question 17

Q

Initial antenatal genetic counselling

Answer

A

Discuss

patient hx
> concerns
> family hx
> risk factors
genetic conditions
> information on common genetic conditions
> risks for pregnancy, baby and beyond
> concept of phenotypic variability
genetic testing
> description of available tests
> benefits and limitations of different tests
> screening vs diagnosis
> risk of unexpected findings without solutions
> private costs
implications
> continue or terminate pregnancy
> palliate baby with terminal illness
> timing and restriction of abortion methods
supports and further information
> referral to genetic counselling
> written information
> support groups

Aneuploidies

screening tests
> combined first trimester screening
> second trimester screening
> cell free DNA
diagnostic tests
> amiocentesis
> chorionic villus sampling

Carrier screening

pre-conception screening preferred
> pre-implantantion genetic testing etc
monogenic diseases tested
> fragile X
> cystic fibrosis
> spinal muscular atrophy
> haemoglobinopathies
most adults +ive for 3 severe recessive disorders
> most are autosomal
couples or sequential screening
extended panel
> offered to at risk groups

Question 18

Q

Down syndrome prenatal diagnostic tests

Answer

A

Indications

> patient preference (before screening)
> postive genetic screen

Relative contraindication

> alloimmunisation
> HIV
> Hep B/C

Amniocentesis

timing
> from 15 weeks gestation
> before = high risk adverse outcomes
procedure
> withdraw amniotic fluid using needle
> ultrasound guidance
post procedure care
> uterine cramping normal
> spotting/amniotic fluid leak immediately after
risks
> rupture of membranes
> indirect fetal injury (talipes/respiratory)
> direct fetal injury (rare
> fetal loss = 0.5% (1/200)
> infection (rare)

Chorionic villus sampling

timing
> from 11 weeks
> before = high risk complications
procedure
> tertiary institute
> ultrasound guided
> transabdominal/transcervical approach
> placental tissue aspirated into syringe
> mild pain
post procedure care
> no exercise or sex 24hrs
> some light spotting is normal
risks
> fetal loss approx 1% (1/100)
> transverse limb reduction defects
> sampling failure
> vaginal bleeding
> infection (rare)

Assessment of sample

extremely low false negative rate
> variants of unknown significance in 5%
methods
conventional karyotyping
FISH
chromosomal microarray

Question 19

Q

Diet advice initial antenatal visit

Answer

A

Diet

opportunity for intervention
> importance of well balanced diet
> referral to dietician/written information
caloric intake
> no need for increase in first trimester
> increase is only small in second/third trimester
> eating for two is misnomer
avoid
> raw/smoked meats/fish (listeria/toxoplasmosis)
> soft cheeses/pate (listeria)
> unpasteurised milk/cheese (brucellosis)
> large predatory fish (mercury)
> high caffeine intake
> sugar sweetened beverages (childhood obesity)
> artificial sweeteners appear safe
vegetarian
> balanced diet probably ok
> supplement vitamin D/E and iron
vegan
> also deficient in calcium, B12, omega 3 fatty acids
low carbohydrate
> deficient in folate

Supplements

multivitamin
> may not be needed in well nourished mothers
> prudent to presribe empirically
goals
> iron 30mg
> calcium 1000mg
> vitamin D 600IU
> folic acid 0.4-0.8mg (increase with gestation)
iodine
> adequate intake avoids hypothyroidism
> 250mcg recommended
> may be replete is consuming fortified foods (eg salt)
> excess intake can cause fetal goiter
vitamin A
> main concern is excess intake (teratogenic)
> avoid supplements containing >1500mcg

Question 20

Q

Lifestyle advice initial antenatal visit

Answer

A

Substance use

Alcohol
> FASD = neurodevelopmental/ID/craniofacial
> possibly preterm/LBW/IUGR
> consider withdrawal and thiamine
Smoking
> approx 1.5 x miscarriage/still birth/SIDs
> approx 3x PPROM/preterm/LBW/abruption
Cannabis
> approx 3x perinatal morbidity/mortality
> risk of preterm/low birth weight
> long term neurodevelopment delay/ADHD
Amphetamines
> approx 3x fetal/neonatal death and preterm
> many other obstetric complications
Cocaine
> approx 3x preterm and LBW
> placental abruption
Opioid
> broad range of obstetric/neonatal complications
> heroin = Rh/HIV/IE/Hep B/C risk
> methadone substitution recommended

Exercise

standard exercise prescription
> controls gestational weight gain
> less lower back pain
> potential reduction pre-eclampsia/GD
small risk
> trauma leading to abruption
caution
> high intensity for long duration
> high level in IUGR/threatened pre term

Infection control

Influenza vaccine
> at any stage if during winter
DPT booster
> in third trimester
STDs
> advise barrier method if high risk
CMV and parvovirus
> good hand hygiene
> caution around children
Varicella
> pre conception vaccination
> IvIg available if unvaccinated exposure

Question 21

Q

Labour protraction/arrest background

Answer

A

Epidemiology
-approx 20% labours

Aetiology

risk factors
> highest risk in nullips
> abnormal pregnancy/fetal abnormality
> short stature/obesity/macrosomia/post term
> neuraxial anaesthesia

Pathophys

hypocontractile uterus
> diagnoses by palpation/tocodynamometry
> weak/infrequent (<3-4/10)/short (<50seconds)
cephalo-pelvic disproportion
> usually due to malposition (extension/OP/OT)
> floating head at 7cm
non occiput anterior positioning
> length of labour/caesarian risk correlates with rotation
> often start OT/OP and rotate
bandl’s ring
> rare complication of second stage
> hourglass contracture between upper/lower uterus
neuraxial anaesthesia
> does not impact on first stage
> longer second stage/more oxytocin and instrumentation

Question 22

Q

Evaluation and management prolonged labour

Answer

A

Review 3 P’s

Power
> uterine contractility
> maternal effort
Passenger
> presentation/position
> physical abnormalities
Passageway
> history of pelvic trauma etc
> maternal size, known anatomical abnormalities

Additional signs

CTG
> baseline/variability/accelerations/decelerations
liquor
> clear = reassuring
> bloody = normal if clears
> meconium stained = mature or distressed baby
obstructive signs
> caput
> moulding (significant override of sutures)
> haematuria (irritation of bladder)

Latent first stage protraction

definition
> no accepted threshold
> can be many hours or days
management
> counselling on normality/reduce anxiety
> therapeutic rest if tired (morphine <20mg)
> oxytocin if ready
> neuraxial anaesthesia

Active first stage protraction

definition
> dilating <1cm/hr after 6cm
> more than 7hrs for 4 to 5cm
> more than 4hrs for 5 to 6cm
high dose oxytocin (vs low dose)
> increased tachysystole (avoid in VBAC)
> decreased caesarian/increased vaginal delivery
> similar maternal/neonatal outcomes
amniotomy
> chemical stimulation/mechanical advantage
> contraindicated when not engaged (cord prolapse)
> best evidence when combined with oxytocin

Active first stage arrest

definition
> 6cm with ruptured membranes plus
> no change >4hrs with good contractions
> no change >6hrs with inadequate contractions
management
> caesarian section

Second stage

failure to progress
> 2hrs for nulip (95th = 3.5hrs)
> 1hr for multip (95th = 2hrs)
> longer for neuraxial anaesthesia
consider oxytocin after 60-90mins
consider passive decent
> one hour without pushing if high station
consider manual rotation manoeuvres
consider operative delivery
> fetal/maternal demise with high change of success
consider need for caesarian
> failure to progress
> denies or contraindication for operative delivery

Question 23

Q

management first stage labour

Answer

A

Initial assessment

review
> pregnancy/complications/fetal wellbeing
> routine bloods/Rh/GBS/STDs
vitals
> BP/HR/temp
> frequency/quality/duration contractions
> fetal heart rate
abdo
> lie (longitudinal/transverse/oblique)
> presentation (cephalic/breech)
digital exam
> baseline cervix status (dilation and effacement)
> integrity of membranes
> presence of bleeding
> position (occiput position)
> > station (-5 to +5/ischial spines = 0)
investigations
> UA for protein (pre-eclampsia) if membranes intact

General management

fluid and foods
> avoid foods where possible
> clear fluids improve outcome (consider anaesthetic risk)
> consider dextrose/fluid infusion
infection prophylaxis
> GBS
> no need for empiric antibiotics
positioning and activity
> no evidence for any preference
> move and position as comfortable
pain control
>
fetal heart rate monitoring (low risk)
> consider 30 mins external continuous upon admission
> intermittent auscultation preferred
> every 30 mins during active first stage
> every 15 mins second stage
> intermittent auscultation
fetal heart rate monitoring (high risk)
> continuous external from admission
additional monitoring
> external tocodynamometry
> cervical progress every 4 hrs

Question 24

Q

Intrapartum fetal heart rate monitoring

Answer

A

Types of monitoring

External fetal heart rate
> continuous doppler on maternal abdo
> intermittent auscultation (90s during + 30s post)
Internal fetal heart rate
> bipolar spiral electrode on fetal scalp
> less noise, more accurate RR
Continuous compared to intermittent auscultation
> no difference in death or long term neuro outcomes
> more caesarians and instrumental/less vaginal births

FHR signals

Normal baseline
> 110-160
Baseline bradycardia
> hypothermia/oxaemia/glycaemia/thyroidism
> heart block
Baseline tachycardia
> infection/maternal fever
> hyperthyroid
> anaemia
> catecholamines
> arrhythmia
> hypoxaemia
HRV
> normal =5-25bpm
> presence of normal variability is reassuring
> absence/reduced is poor predictor of acidaemia/hypoxia
Accelerations (>+15 for 15s)
> presence is reasurring
> absence is poor predictor of acidaemia/hypoxia
Early decelerations (normal response to fetal head compression
> with peak of uterine peak contractions
Late deceleration
> occur post peak uterine contraction
> fetal hypoxia due to constriction of uterine arteries
> insignificant when with good variability and accelerations
> recurrence with minimal variability/accelerations is bad
Variable decelerations
> due to cord compression
> initial compression of umbilical veins = increase FHR
> compression of umbilical artery follows = decrease FHR
> uterine relaxation = effects occur in reverse
> concerning, requires close attention
Prolonged deceleration (due to fetal hypoxia of any cause
> up to 2 mins = non reassuring
> more than 3 mins = abnormal
> more than 10 mins = new baseline (severe hypoxia)
Sinusoidal pattern
> 3-5 cycles/minute for 20 minutes with no variability
> severe hypoxia or fetal anaemia
> rare and very concerning

Question 25

Q

Operative delivery

Answer

A

operative delivery indications
> maternal exhaustion/prolonged second stage
> engaged/position known/cephalic/adequate anaesthesia
> consider for maternal/fetal compromise
operative delivery containdications
> three prior attempts
> extremely premature
> bone or bleeding disorder
> face or brow presentation/unengaged/unknown
> cephalopelvic disproportion

Question 26

Q

POCS background

Answer

A

Epidemiology
-approx 10% of women of reproductive age

Aetiology

unknown
heritability = approx 75%
> multiple genes contributing small risk
environmental
> obesity and hyperinsulinaemia
> congenital adrenal hyperplasia and androgenism

Pathophys

Functional ovarian hyperandrogenism
> dysregulated LH driven thecal androgen production
> causes hirsutism
> high androgens = increased primary follicle recruitment
> increased synergism with FSH = premature luteinization
> increased recruitment + premature luteinization = PCOM + oligo-anovulation
Insulin resistant hyperinsulinism
> causes and worsened by obesity
> sensitises theca cells to LH = increased androgens
High LH
> androgen excess disturbs sex steroid inhibition of LH
> high insulin decreases SHBG by liver
Excess adrenal androgens
> enhanced responsiveness to ACTH
> similar action to ovarian androgens

Question 27

Q

PCOS evaluation

Answer

A

Hx

often presents in puberty
hirsutism/acne/alopecia
oligo-anovulation
> primary amenorrhoea (no menarche by 15)
> secondary amenorrhoea (no menses for three cycles)
> oligomenorrhoea = <9 menses/year (less during puberty)
> AUB = menses <21 apart/ >7 days long/ very heavy
weight gain
infertility
medications associated with hirsutism?

Exam

HTN
hyperandrogenism
> male hair growth/loss
> acne
> deep voice/clitoromegaly/increased muscle mass
obesity
acanthosis nigricans
abdo exam
> adrenal tumour
pelvic exam
> ovarian tumour

Investigations

Androgens (day 3 follicular phase)
> total and free (SHBG) testosterone
> dehydroepiandrosterone sulfate (DHEA-S)
> androstenedione (A4)
17 hydroxyprogesterone
> early morning during (day 3 follicular phase )
> anytime if amenorrhea
> low rules out non classic congenital adrenal hyperplasia
Luteal phase (7 days before menses) progesterone
> high levels = ovulation
Rule out other causes oligomenorrhoea/anovulation
> b HCG = pregnancy
> prolactin = prolactinoma
> TSH = hypothyroidism
> LH:FSH = >3 in PCOS, low in hypothalamic disease
Tranvaginal ultrasound (if criteria not already met)
> PCOM = ovarian volume >10mL/12 follicles in either
Additional tests
> GTT
> lipids

Diagnosis

2/3 (all three for puberty) of Rotterdam criteria
> oligo/an-ovulation (present for 2yrs if pubertal)
> PCOM
> clinical or biochemical hyperandrogenism
exclude other causes

Question 28

Q

Hirsutism ddx

Answer

A

PCOS + CODEIN

Cushings
> disease (corticotroph adenoma)
> syndrome (adrenocortical tumour)
Ovarian tumour
> sertoli-leydig
> theca-granulosa
Endocrine
> hypothyroidims
> prolactinoma
> acromegaly
Idiopathic
Non classical congenital adrenal hyperplasia

Question 29

Q

Primary amenorrhoea background

Answer

A

Epidemiology
-<0.1%

Aetiology

Hypothalamus
> constitutionally delayed growth and puberty
> idiopathic hypogonadotropic hypogonadism
> Kallman’s syndrome
Pituitary
> prolactinoma
Ovaries
> PCOS
> primary hypogonadism (Turner’s/injury/insult)
> androgen insensitivity syndrome
Uterus/cervix/vagina
> mullerian agenesis
> transverse vaginal septae
> imperforate hymen
Adrenal
> NCCAH
Thyroid
> hypothyroidism
Systemic (functional hypothalamic amenorrhoea)
> anorexia nervosa
> excessive weight gain/loss
> stress
> female athlete triad

Question 30

Q

Menopause background

Answer

A

Epidemiology

average is 51yrs
> 5% <45
> 5% >55

Aetiology

family history of age
smoker = earlier
hysterectomy with persevered ovaries = earlier

Pathophys

several million oocytes present by approx GA 15
primary follicles form at this time
continuous follicular atresia
> begins in utero
> steady decline in oocytes over lifespan
late reproductive (40’s)
> lower inhibin and progesterone
> declining fertility
> ovulatory cycles with shorter follicular phase
perimenopause
> significant depletion of oocytes
> variable length (yrs)
> high FSH/low inhibin/low AMH
> highly variable estrogen and low luteal progesterone
> irregular/anovulatory periods
menopause
> process continues until 12 months of amenorrhea
post menopause

Question 31

Q

Evaluation peri/menopause

Answer

A

Clinical manifestations

late productive
> infertility
perimenopause
> irregular menses
> prolonged time between cycles
> occasionally heavier bleeding
hot flash (most common symptom)
> can begin in late reproductive
> most common late peri/early post
poor sleep
> often due to hot flushes or anxiety/depression
depression
> mostly perimenopausal
vaginal atrophy
> dryness
> irritation
> dyspareunia
dyspareunia
> decreased lubrication
> vagina is shorter, narrower and less elastic

Complications of oestrogen withdrawal

cardiovascular disease
> increase in LDL
bone health
> decreased BMD and increased osteoporosis
decreased collagen content in skin
impaired balance
central adiposity

bHCG
Consider
-FSH
-TSH
-prolactin

Question 32

Q

Primary amenorrhoea evaluation

Answer

A

Hx

no menarche by age 15 +/- pubarche
Hypothalamus
> pubertal development (constitutional delay)
> stress/weight gain and loss/eating/ exercise
> anosmia
Pituitary
> headaches
> blurred/loss vision or diplopia
> galactorrhea
Ovaries
> stature relative to family (Turners)
> hirsutism/acne/weight (PCOS)
Uterus
> cyclical pelvic pain (anatomical abnormality)
Adrenals
> neonatal crisis (NCCAH)
Additional
> family hx of delayed puberty (constitutional)
> medications

Exam

height/weight/BMI
inspect
> acne/hirsutism/pigmentation/virilisation
> syndromic features
> pubertal development
> outflow tract abnormalities
consider
> neuro exam for pituitary mass
> bi manual for outflow tract abnormalities

bHCG
TSH
prolactin
FSH and estradiol
-high FSH/low estradiol = primary ovarian failure (Turners)
-low FSH/low estradiol = hypothalamic failure

Ultrasound pelvis
-presence/absence of uterus/ovaries/cervix

Consider

Karyotyping
> if uterus present/high FSH = Turners
> if uterus absent = 46 XX (genesis)/46XY (androgen insensitivity syndrome)
Androgens (PCOS)
> presence of hirsutism/acne/virilisation
MRI brain (sellar mass)
> if uterus present/low FSH/no breast development
> no mass = constitutional/functional hypothalamic/idiopathic hypogonadotropic hypogonadism

Question 33

Q

Background secondary amenorrhoea

Answer

A

Epidemiology
-approx 3%

Aetiology

Hypothalamus
> weight loss/athlete triad/anorexia
Pituitary
> prolactinoma (inhibits GnRH)
Thyroid
> hypothyroid (high TRH increase prolactin release)
Ovaries
> PCOS
> premature ovarian failure (radiation/chemo/fragile X/autoimmunity)
Uterus
> pregnancy
> ashermans

Hx

pregnancy risk/symptoms
hypothalamus
> stress/eating/exercise
> medications (COCP/antipsychotics/metaclopramide)
pituitary
> headache/vision changes/galactorrhoea
ovaries
> hirsutism/acne/virilisation
> menopause symptoms
uterus
> bleeding/infection/curretage

Exam

height/weight/BMI
inspect
> virilisation/pigmentation
> galactorrhoea
> vaginal atrophy

bHCG
FSH and estradiol 
->both low = hypothalamus/pituitary disease
->FSH high/estradiol low = POI
prolactin
TSH

Consider

PCOS testing
karyotyping if FSH high
MRI brain if FSH/estradiol low
progestin challenge if normal labs
> 10mg medroxyprogesterone for 10 days
> absence of bleeding supports ashermans

Question 34

Q

PCOS treatment

Answer

A

Desiring fertility

weight loss
> ovulation in approx 80%
> may take 6-9 months
metformin
> 500mg TDS titrated over 4-6wks
> 1500-2000mg once daily extended release
> take with food
> may take 6-9 months to worse
> may be less effective in overweight/obese
fertility pharm
IVF
laparoscopic drilling
> pregnancy in approx 50%
> similar efficacy to fertility pharm/less multiple pregancy
> no evidence for POI

Not desiring fertility/hyper-androgenism

weight loss
> less effective
COCP
> anything but levonorgestrel
Eflornithine cream BD
> effective in about 1/4 by 2 months
> can cause local reactions/acne
Spirinolactone (anti-androgen)
> 50-100mg BD
> combine with OCP (teratogenic)
Consider adding metformin to OCP/spirinolactone

Not desiring fertility/oligo-amenorrhoea

weight loss
> returns ovulation in up to 80%
> may take 6-9 months
OCP
> progestogen protects endometrium
> avoid levonorgestrel
progesterone (protect endometrium)
> mini pill
> Mirena

Question 35

Q

GBS infection

Answer

A

Epidemiology

10-20% colonisation of vagina/rectum
> neonatal colonisation rate = 40-50%
> early infection rate = 0.5-0.05%

Aetiology

Risk factors
> prematurity
> prolonged rupture of membranes (>18hrs)
> maternal fever
> heavy maternal colonisation
> low level maternal/fetal serotype specific Ig
> previous infant with early GBS disease
Neonatal infection
> intra-amniotic infection (with intact membranes)
> passage through birth canal
> contact with outside environment

Pathophys

early onset <24hrs
> sepsis (most common)
> pneumonia
> meningitis
late onset <90 days
> fever/bacteraemia (most common)
> meningitis
> septic arthritis/osteomyelitis
> cellulitis
mortality
> overall = 3%
> pre-term early = 30%
morbidity
> CP
> ID
> seizures
> hearing/vision loss

Question 36

Q

GBS colonisation screening and management

Answer

A

Screening

rectovaginal swap/culture for all women
> false negative approx 5%
timing
> general = 35-37wks
> high risk for preterm = 3-5wks prior to EDD
exceptions
> GBS bacteruria/previous infant GBS = empiric rx

Labour management

Intrapartum antibiotics
> IV penicillin G or ampicillin
> at least 4hrs prior to delivery
> reduces risk of early disease by 80%
> risk of late onset unchanged
Indication for intrapartum antibiotics
> GBS+/GBS bacteruria
> previous early GBS disease
> unknown status + preterm labour/PPROM/prolonged rupture of membranes/intrapartum maternal fever

Scenarios

Caesarian
> not indicated for GBS+
> abx not indicated for caesarian with intact membranes
Intrapartum procedures
> no indication for change in practice if intrapartum abx
PROM at term
> GBS+ = induction + intrapartum antibiotics
> GBS unknown = culture and risk assessment
Preterm labour GBS unknown
> intrapartum antibiotics until culture -ive
PPROM GBS unknown
> consider 48hrs of antibiotics
> take cultures
> intrapartum antibiotics
PPROM GBS+
> if >34wks = induction + intrapartum antibiotics
> if <34wks = normal PPROM management

Question 37

Q

Caesarian section request

Answer

A

Compared to normal vaginal delivery

Positives
> delivery date known
> avoids post-term neonatal mortality increase
> avoids risk of emergency caesarian
> lower rate urinary and bowel incontinence
> lower rate pelvic organ prolapse/perineal tear
> lower rate HIE/birth injury/asphyxia
> less vertical transmission HIV/HSV
Negatives
> higher rate TTN/RDS (only if <39 weeks)
> higher neonatal mortality
> longer hospitalisation/recovery time
Same
maternal mortality rate
post partum sexual function
pain 4 months post partum

Complications (HOISTED)

Haemorrhage
> approx 1L
> less than 5% need transfusion
Obstructed bowel (ileus)
> 15%
Infection
> 2%
Surgical error (rare)
> bowel/bladder perforation
> laceration to baby
Thrombosis (stroke/MI/VTE)
> 3x vaginal delivery risk
> 0.25% for VTE
Endometritis
Death
> less than 0.1%

Anaesthetic risk

neuraxial
general

Long term risk

abnormal placentation
> placenta accreta/previa/abruption
adhesions
hernias
nerve pain around scar

VBAC

uterine rupture
> TOLAC = 0.5% (< if previous successful delivery)
> twice as high as risk with repeat caesar
outcome of rupture
> 1/3rd hysterectomy
> neonatal death <3%
neonatal
> mortality 2-3x higher with TOLAC (very low)
> resus 2x higher with TOLAC

Question 38

Q

Caesarian section timing

Answer

A

Categories

1 = immediate threat to maternal/fetal life (30mins)
2 = compromise with no threat to life (1hr)
3 = earlier than planned without compromise
4 = maternal request
> possible if harm/benefit understood by patient

Timing of planned/maternal request

before 39 wks
> increased risk of blood transfusion
> higher rates RDS/TTN
> higher neonatal mortality
at 39 wks
> approx 10% will require emergency CD prior to 39wks
> emergency has 2x risk of complications
after 39 wks
> increase perinatal mortality
> macrosomia
> dysmaturity syndrome

Question 39

Q

IUGR background

Answer

A

Epidemiology
-approx 10% births

Aetiology

Fetal
> genetic abnormality
> TORCH infections
Placenta
> pre-eclampsia
> abruption
Maternal (ACHINGS)
> age (extremes of)
> CKD
> HTN
> Insulin resistance
> nutritional deficiency
> genetics (previous SGA or personally SGA)
> SLE
Exposures
> teratogenic meds
> alcohol/smoking/cocaine/heroin/marujuana

Pathophys

Foetal response to compromised nutrient supply
> redirect blood flow to brain/heart/adrenals
> reduces overall size/fat/BMD/glycogen stores
> reduces renal blood flow and oligohydramnios
> preserve brain growth
> accelerate lung maturation
> increased RBCs
> decrease
Symmetric
> proportional reduction of body components
> chromosomal or infection
> occurs early in gestation
Asymmetric (majority)
> weight/abdominal size reduced more than length/HC
> adaptation to pathological stressor
> occurs later in gestation

Question 40

Q

IUGR evaluation

Answer

A

Hx

PC
> unwell lately?
> headaches/vision changes
> loss of blood or fluid
> pain?
> fetal movements
This pregnancy
> any complications
> scans (morph + aneuploidy) + serology
Past obstetric
> G/P
> G/A and route
> small babies
> HTN/diabetes
Past medical
> any chronic illnesses
Allergies
Medications
Supplements and food avoidance
Social
> Smoking/drinking/drugs
> contact with children
> proximity for follow

Exam

Height/weight/BMI
BP
Abdo palp
Fundal height
Doppler

Confirm diagnosis with ultrasound

Urgent CTG
SGA
> weight below 10th centile in second trimester
> may be constitutional or restricted growth
> consider AC/AFI/growth velocity

Determine cause

Fetal survey
> doppler (umbilical/uterine/middle cerebral arteries)
> BPP
Anatomy scan
> if abnormal, consider cell free DNA for aneuploidy
> if negative, consider amniocentesis for microarray
Infection workup
> maternal CMV/rubella/varicella seropositivity

Question 41

Q

IUGR management

Answer

A

Monitoring

Usually monitored as outpatients
Weight
> review every 2 weeks if concerned
> consider velocity (normal in constitutional)
US doppler
> umbilical artery most useful
> review every 2 weeks if first two are normal
> review weekly if abnormal or concerned
> reduced/absent end-diastolic flow = consider delivery
BPP or NST with AFI
> not needed if mild
> twice weekly if severe
> daily if abnormal doppler

Delivery consideration

Issue
> pre term delivery has high mortality/morbidity
> each day in utero between 26-29wks increases survival up to 2%
> mortality in IUGR rises sharply at time (placental insufficiency)
GRIT trial
> randomised to immediate or delayed delivery
> when obstetrician was uncertain
> immediate group = fewer stillbirths/more neonatal deaths
> long term neurodevelopment outcome similar
DIGITAT trial
> randomised to spontaneous/expectant at term
> spontaneous had lower birth weight
> same adverse events/same caesarian rate/long term developmental outcomes
Consider
> dopplers/BPP/NST/risk factors
> gestational age
> patient preference
> need for caesarian delivery if poor dopplers
> corticosteroids and magnesium sulfate

Intrapartum

Issues
> intrapartum heart rate abnormalities
> birth asphyxia/HIE
> meconium aspiration
> polycythaemia
> hypothermia
> hypoglycaemia
Approach
> continuous fetal heart monitoring
> low threshold for emergency caesarian
> neontal support present
> umbilical blood gas and glucose at birth

Long term

catch up growth
CVD/diabetes/renal disease/neurodevelopment

Question 42

Q

ectopic pregnancy background

Answer

A

Epidemiology

approx 1% of all pregnancies
up to 15% of first trimester bleeding

Aetiology

risk factors (ASEPTIC)
> age (older)
> smoking
> ectopic pregnancy in previous pregnancy
> PID
> tubal abnormalities
> infertility and IVF
> contraception failure (IUD/COP)

Pathophys

anatomic sites
> fallopian tubes (more than 95%)
> ovarian
> interstitial
> abdominal
> cervical
> hysterectomy scar
> intramural
> heterotopic

Question 43

Q

Evaluation ectopic pregnancy

Answer

A

Hx

onset of symptoms usually after 8 weeks gestation
vaginal bleeding
lower abdo pain
> sharp or dull (not crampy)
> diffuse or localised
pregnancy related symptoms
rupture
> acute severe pain
> severe bleeding
> syncope
> shoulder tip pain
> tenesmus = blood in pouch of douglas
review risk factors
review surgical/medical fitness

Exam

often unremarkable
vitals
> assess for shock
> postural hypotension
abdo
> tenderness
> acute abdomen in rupture
speculum
> source of bleeding
pelvic
> adnexal mass/tenderness
> cervical motion tenderness with rupture

Investigations

unstable
> FAST scan for intraperitoneal haemorrhage
b HCG (urine or serum)
> confirms pregnancy
FBC
> anaemia
> baseline for methotrexate
blood group and antibodies
> hold if significant bleeding
> sensitising event (anti D)
EUCs and LFTs
> methotrexate baseline
Transvaginal ultrasound

Transvaginal ultrasound

Confirms ectopic
> gestational sac with yolk sac/embryo at ectopic site
> adnexal mass/empty uterus/free fluid
Suggests ectopic
> pseudosac
> complex extra ovarian adnexal mass
> tubal donut sign
> adnexa ring of fire sign on doppler
> consider heterotopic
Suggests rupture
> fluid in morrisons or douglas’ pouch
Absence of findings
> follow PUL protocol

Question 44

Q

medical management ectopic pregnancy

Answer

A

Indications

> patient preference
> stable
> b HCG <5000
> no cardiac tones / ectopic mass <3-4cm

Contraindications

> unstable
> evidence of threatened rupture
> viable IUP/heterotopic
> liver/renal/pulmonary disease
> immunosuppression or peptic ulcers
> abnormal FBC, EUCs, LFTs
> breastfeeding

Risks

approx 1/3 experience side effects
> stomatitis
> conjunctivitis
treatment failure approx 20%

Benefits

> avoids surgical complications
> similar efficacy to surgery when adequate doses given
> similar fertility outcomes to surgery
> similar risk as surgery of further ectopic pregnancies

Procedure
-IM single dose

Monitoring

b HCG on days 4 and 7
b HCG weekly until 0
inadequate decrease
> repeat dose (no more than three total)

Advice

> avoid conception for 4 months
> avoid folic acid supplements and NSAIDs
> avoid sunlight
> mild pain at 1 week is common
> severe pain needs to be investigated

Question 45

Q

surgical management ectopic pregnancy

Answer

A

Indications

any b HCG level
unstable
rupture or impending rupture
heterotopic ectopic
methotrexate contraindications
methotrexate failure

Contraindications
-no absolute

Risks
-surgical and anaesthetic risks

Procedure

salpingectomy vs salpingostomy
> similar rate of future fertility
> salpingostomy = higher rate of retained/future ectopics
laparoscopic vs laparotomy
> laparoscopic preferred
> laparoscopic = less blood loss, faster operation, recovery and discharge
> consider laparotomy for interstitial or unstable

Follow up

salpingostomy
> GP 3 weeks post op
> weekly b HCG until negative
> insufficient b HCG decrease = methotrexate
salpingectomy
> post op b HCG unnecessary if histopath confirmed
future conception
> no solid data
> 0-3 months common

Question 46

Q

expectant management ectopic pregnancy

Answer

A

Indications

asymptomatic
no TVU findings of ectopic pregnancy
low (<1500) and decreasing b HCG
aware of risks
access to emergency treatment and close follow up

Contraindications
-any of indications absent

Risks
-rupture can occur with low and falling b HCG

Benefits

similar success rate (80%) to medical management
similar treatment time as medical management

Procedure

b HCG every 48hrs for 8 days
> then weekly until negative
abandon expectant management if
> any symptoms
> b HCG not decreasing
avoid conception until sonographic resolution

Question 47

Q

Rh incompatability

Answer

A

Epidemiology

Rh -ive
> 15% of caucasians
> 7% africans
incompatibility in 10% pregnancies

Aetiology

Rh -ive mother
Rh +ive baby
> inherited from father

Pathophys

sensitising event
> occurs in majority of pregnancies
> fetomaternal haemorrhage (most placental insults)
> passage of fetal cells across placenta
formation of maternal anti-D Ig
> formation of memory B lymphocytes
> future challenge leads to plasma cell Ig production
haemolytic disease of the new born
> maternal Ig cross placenta attache to fetal RBC
> RBCs sequestered in spleen and destroyed
> extramedullary haematopoeisis
> hepatosplenomegaly/pHTN/HF/cerebral hypoxia
> hydrops fetalis/intrauterine death

Screening for incompatibility

blood group, Rh status, antibodies
> first antenatal visit
> Rh -ive repeated at 24-28wks
> after any sensitising event

Diagnosing incompatibility

if mother Rh antibody +ive
> paternal blood group
Paternal zygosity if Rh +ive (PCR for RHD genes)
> if homozygous = fetus Rh +ive
> if heterozygous = 50% chance fetus Rh +ive
Amiocentesis (>15wks) or cfDNA (>10wks) if heterozygous

Monitoring incompatability

Baby Rh +ive
> serial (monthly) maternal indirect coombs
If antibody titre rises above critical threshold
> doppler MCA for severe anaemia ever 1-2wks
If suspected sensitising event
> rosette test = presence of fetal RBC in maternal blood

Sensitisation prevention

Rh incompatibility diagnosed
> maternal Ig present = no benefit of anti-D
> routine prophylaxis = anti-D at 28wks
> fetomaternal haemorrhage = anti-D
> sensitising procedure = anti-D 72hrs prior
> delivery = additional anti-D 72hrs prior
Dosage
> Kleihauer test/flow cytometry = %fetal RBC

Question 48

Q

Diabetes pregnancy background

Answer

A

Epidemiology

GD = approx 10% pregnancies
pre-existing = 2% pregnancies

Aetiology

pre-existing
GD risk factors
> older age
> personal hx
> family hx
> obesity
> physical inactivity
> high GI/low fibre diet
> smoking
> PCOS

Pathophys GD

relative insulin resistance normal part of pregnancy
> ensures adequate glucose delivery to fetus
> most marked resistance in 3rd trimester
diabetogenic hormones released by placenta
> growth hormone
> prolactin
> lactogen
> progesterone
GD develops when maternal beta cells are overwhelmed

Shared complications

short term
> LGA = preterm/caesarian/instrumental/dystocia/injury
> polyhydramnios = BPD/preterm/malposition
> pre-eclampsia
> neonate = hypoglycaemia/jaundice/CMP/cardiac/resp
long term
> increased risk of T2DM
> child = obesity/metabolic syndrome/diabetes

Pre-existing complications

Congenital defects
> 2-4%x base (incidence apex 5%)
> CCHD/neural tube defects
IUGR
Pre-eclampsia/HTN
Miscarriage
Aggravates underlying micro/macrovascular disease
DKA more common
> occurs at higher BGL
> more lethal for mother (fetal demise also common)

Question 49

Q

Diabetes pregnancy evaluation and non BGL management

Answer

A

Screening

first antenatal visit
> all women
> low risk GD = BGL/high risk GD = GTT
> pre-existing = HbA1c/UACR/GFR/TSH/fundoscopy
24-28wks
> all women GTT

Diagnosis

GTT
> NBM for 8hrs prior
> fasting glucose
> 75g glucose
> glucose at 1 hr
> glucose at 2hrs
GDM criteria
> fasting = >5.1
> 1hr = >10.0
> 2hr = >8.5
pre-existing diabetes
> if diagnostic criteria met <1st trimester

1st trimester

Pre-existing
> cease ACEI/ARB
> low dose aspirin after 12wks
> higher folic acid supplementation

2nd trimester
-morph/neural tube scan at 20wks

3rd trimester

GD and good control/lifestyle only
> fetal movements may be sufficient
> growth scans close to term
Poor control/pre-existing
> NST/ST/BPP from 32 wks
> serial growth scans from 32 wks
> increase insulin if steroids given

Labour

Timing
> consider induction after 39/before 40wks
Route
> consider delivery at term for macrosomia
> consider caesarian for macrosomia >4.5kg
Intrapartum
> maternal glucose monitoring (fetal hypoglycaemia)
> continuous FHR
Post partum
> neonatal glucose monitoring
> loss of insulin resistance with placental delivery
> monitor glucose for 24-72hrs (unrecognised T2DM)

Question 50

Q

Diabetes pregnancy BGL management

Answer

A

Diet

referral to dietician
> caloric needs individualised
> determined by baseline and GA
best evidence for low GI diet (vs low carb/calorie restricted)
> less insulin requirements
> lower birth weights
some evidence for increasing folic acid supplementation

Exercise

moderate intensity exercise
> increased muscle mass = increased insulin sensitivity
> lower blood glucose levels
> less insulin requirements

Insulin therapy

after lifestyle trial for 2-4wks
trial intermediate acting basal insulin at bedtime
> approx 6 units
assess fasting BGL over week
> more than 3 > 5 = increase by 2 units
> more than 3 > 6 = increase by 4 units
> more than 3 > 8 = increase by 6 units
avoid prolonged fasting at night
> paradoxically raises morning fasting levels
consider adding pre-prandial rapid acting bolus
> split approx 50% of total daily dose across meals

Glucose self monitoring

4x daily
> fasting/waking
> post prandial (1-2hrs)
log in book

Glucose targets

fasting <5.3
1hr post prandial <7.8
2hr post prandial <6.7

Question 51

Q

Causes cervicitis

Answer

A

Infectious

endocervix
> chlamydia (most common overall)
> gonorrhoea
ectocervix
> HSV
> trichomonas
other
> tuberculosis
> mycoplasma genitalium
> GAS

Non infectious

mechanical
> condoms/diaphragms/tampons
> surgical instrumentation
chemical
> latex
> douching
> spermicides
systemic disease
> bechets
> lichen planus

Question 52

Q

evaluation cervicitis

Answer

A

Hx

mucopurulent discharge
abnormal bleeding
> post coital
> intermenstrual
dyspareunia
vulvovaginal irritation/pruritis/burning
with concomitant urethritis
> dysuria
absence
> abdo/pelvic pain
> fever
presence of risk factors

Exam

abdo
> tenderness?
speculum
> erythematous/oedematous vulva (may be normal)
> erythematous/tender vagina
> oedematous/erythematous/friable cervix with discharge
typical lesions
> strawberry cervix = trichomoniasis
> ulcerations/vesicles = HSV
bimanual to exclude PID
> cervical motion/uterine/adnexal tenderness?

Investigations

b HCG
NAAT
> men = first catch urine/urethral swab
> women = first catch urine/self swab/endocervical swab
Culture (gonorrhoea sensitivity)
> thayer martin/charcoal enriched swab
> male = clinician urethral
> female = endocervical
Gram stain (provisional dx from gram -ive diplococci)
> male urethritis only (clinician collected)
Consider if typical lesions
> HSV serology
Consider if high risk/STI confirmed
> HIV
> syphilis
> Hep B/C

Empiric management

if concern for PID in high risk
> empiric PID treatment
if high risk
> consider empiric chlamydia treatment

Gonorrhoea management

targeted antibiotics
> ceftriaxone 500mg IM single dose
test of cure unnecessary
contact tracing/prophylactic treatment
> sexual partners for past 2 months
avoid sex for 7 days
> post treatment of index patient and partner

Chlamydia management

targeted antibiotics
> azithromycin 1g oral single dose
> doxycycline 100mg oral BD 1 week
test of cure at 3 weeks
> pregnant
> PID
contact tracing/prophylactic treatment
> sexual partners for past 6 months
avoid sex for 7 days
> post treatment of index patient and partner

Question 53

Q

PID background

Answer

A

Epidemiology

most common gynaecological reason for hospitalisation
risk factors
> under 25
> multiple partners/new partner
> infrequent condom use
> previous STD/partner with STD

Aetiology

majority
> chlamydia
> gonorrhoea
occassionaly
> mycoplasma genitalium
> gram negative enterics
> haemophilus influenzae

Pathophys

infection of cervix with chlamydia/gonorrhoea
> disruption of protective barrier
> ascent of micro-organisms
complications
> recurrence
> chronic pain
> tuba-ovarian abscess
> hydro-salpinx
> ectopic pregnancy
> infertility (<20%)
> fitz-hugh curtis syndrome

Question 54

Q

PID evaluation

Answer

A

Hx

may be asymptomatic
lower abdo pain
> often bilateral
> worse with jarring movements
> may have RUQ pain
nausea/vomiting
abnormal vaginal bleeding
> intermenstrual
> post-coital
> menorrhagia
mucopurulent discharge

Exam

fever
abdo
> tenderness (bilateral)
> rebound tenderness/bowel sounds?
speculum
> discharge at endocervix
bi-manual
> cervical motion tenderness
> uterine tenderness
> adnexal tenderness
Beta HCG
Vaginal discharge wet mount
> absence of WCC has negative predictive value
Endocervical swab
> NAAT for gonorrhoea/chlamydia
> culture for gonorrhoea
FBC
CRP/ESR
Consider
> blood cultures
> US of fallopian tubes/ovaries/endometrium (severe)
> CT (peritonitis/equivocal US)
> laparoscopy (complicated/resistant/ddx suspected)
If high risk
> HIV/HBV/HCV/syphilis

Question 55

Q

PID management

Answer

A

Empiric management

criteria
> high risk
> lower abdo pain/positive bi-manual
regime
> cetriaxone 500mg IM single dose
> azithromycin 1g oral single dose
> metronidazole 500mg BD for 10 days

Additional

Analgesia
Patient education
> causes/risks/prevention
> prognosis/complications
> avoid intercourse for 7 days post treatment
Insufficient evidence for removal of IUD
Disposition
> generally outpatient
> inpatient if resistant/severe/complications
Safety net
> reassess in 24-48hrs
> present to hospital if its gets worse
Contact tracing
> any partner within 60 days = investigation
> no partner within 60 days = last partner
> consider empiric treatment
Test of cure
> repeat chlamydia/gonorrhoea within 3 months

Question 56

Q

Menopause treatment

Answer

A

Opportunity for general health check

cst
mammogram
smoking/alcohol advice
cvd risk factors
weight control

Non pharm

exercise and weight loss
> CVD risk
avoid alcohol/caffeine/spicy foods
> VMS
layered clothes/cool water/sprays
> VMS

Intact uterus (including post-ablation) HRT

Perimenopausal (need contraception)
> low dose OCP
> Mirena + oestrogen
> cyclical HRT + barrier
1-5 years post menopause
> continuous combined HRT
> Mirena + oestrogen
> Tibolone (no progestogen needed)
Over 5 years post menopause
> continuous very dose combined HRT
> Mirena + very low dose oestrogen
> caution with Tibolone
> vaginal oestrogen alone for genitourinary

No uterus HRT

Under 5 years amenorrhoea
> oestogen alone
> tibolone
Over 5 years
> low dose oestrogen alone
> caution with tibolone
Hx endometriosis
> consider adding progestogen (poor evidence)

Non hormonal

Indication
> HRT contraindicated
> significant mood component
> personal choice
Effect
> significant reduction of VMS (less than HRT)
Options
> paroxitine
> venlafaxine
> clonidine

Urogenital symptoms only

Question 57

Q

Infertility background

Answer

A

Epidemiology

fecundability
> 85% over 12 months regular unprotected sex
> 25% in first 3 months, then decreases

Aetiology

Risk factors
> age >35
> obesity/low BMI
> smoking
> previous STD

Pathogenesis

Female factors (1/3rd)
> diminished ovarian reserve with age (majority)
> oligo/anovulation (PCOS/prolactin/hypogonadism/hypothalamus)
> tubal (post infection/endometriosis/pelvic adhesions)
> uterine (adhesions/mullerian abnormalities)
> smoking/obesity
Male factors (10%)
> oligo/azoospermia (majority idiopathic)
> primary/secondary hypogonadotrophinism
> congenital testicular disorder (klinefelter/cryptochordism)
> acquired testicular disorder (infection/drugs/exposure)
Combined factors (1/3rd)
Idiopathic 5%

Question 58

Q

Female factor infertility evaluation

Answer

A

Hx

Menstrual hx
> regular menses/moliminal symptoms = ovulatory
> long = anovulation
> short = anovulation/endometrial dysfunction
Sexual hx
> timing and regularity
> dyspareunia (PID/endometriosis/adhesions/uterine abnormality)
Hypothalamus
> stress/weight loss/exercise
> anosmia
Pituitary
> headache/vision changes/nipple discharge
Ovaries
> acne/hirsuitism/overweight/irregular periods
> SLE/UC
Tubes
> pelvic surgery/STD
> endometriosis/pelvic pain/menorrhagia/dysmenorrhea
Uterus
> procedures/instrumentation
Social
> smoking
> alcohol and substances
> stress/mood/psychiatric disorders
> occupational exposure

Exam

height/weight/BMI
inspection
> hirsutism/acne
> galactorrhea
> secondary sex characteristics/syndromic features
pelvic
> abnormal shape uterus
> nodular pouch of douglas (endometriosis)
> adnexal mass/tenderness

Assess ovulation

serum progesterone
> 7 days before menses
> ovulation if high
urine LH sticks
> serial assessments at home
> predicts ovulation approx 24hrs in advance
serial ultrasounds
> usually restricted to during treatment
if anovulatory
> FSH/LH (hyper/hypogonadotrophic hypogonadism)
> androgens (PCOS)
> TSH
> prolactin
> karyotyping

Anatomical assessment

Imaging
> transvaginal ultrasound (uterine/tubal/ovarian morph)
> hysterosalpingography (uterine/tubal path)
> saline infusion sonography (uterine path)
> MRI (uterine path pre-op planning)
Surgical
> laparoscopy (endometriosis/adhesions) with chromotubation (tubal patency)
> hysteroscopy (uterine path)

Ovarian reserve testing

Basal FSH on day 3
> less than 2 = hypogonadotrophinism
> greater than 10 = possible reduced ovarian reserve
> greater than 30 = menopausal/ovulatory surge
Antral follicle count on day 3
> transvagianl ultrsound
> less than 4 indicates diminished reserve
AMH on any day
> less than 1 ng/mL indicates diminished reserve

Question 59

Q

Infertility management

Answer

A

Non pharm

Diet
> limited evidence
> beneficial for future pregnancy
Weight loss
> high BMI or PCOS
Weight gain
> athlete/low BMI/anorexia
Reduce smoking/drinking/substances
Psychology support
> high stress associated with infertility
> stress/psychological morbidity risk factor for infertility

Ovarian stimulation

Clomiphene
> indicated for normogonodotrophic ovulatory dysfunction
> ineffective in hypogonadotrophic hypogonadism
Letrozole
> indicated for normogonadotrophic ovulatory dysfunction
Gonadotrophin therapy
> failed first line treatment
> hypogonadotrophic hypogonadism

Tubal abnormalities

IVF
> failed ovulation treatment
> tubal abnormality
> male infertility
> uterine abnormalities with surrogate
Tubal patency improving procedures
> distal occlusion may be treated/proximal should not
> fimbrioplasty (lysis of adhesions/dilation of strictures)
> neosalpingostomy (new tubal opening)

Uterine abnormalities

Setate
> some evidence for surgical intervention
Fibroids
> consider surgery if other treatments failed
> best evidence for submucosal
Polyps
> polypectomy for large endometrial polyps

Specific aetiologies

Endometriosis
> first line = IVF
> surgical ablation of impants/adhesiolysis
PCOS additional treatments
> ovarian stimulation
> metformin
> ovarian drilling
Hyperprolactinaemia
> bromocriptine

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