Obstetrics Revision 2 Flashcards
This scan was for an anomaly scan.
What sign can be seen? [1]
What pathology does this indicate? [1]
Lemon sign - spina bifida
This scan was for an anomaly scan.
What sign can be seen? [1]
What pathology does this indicate? [1]
Banana sign - spina bifida
- banana sign describes the way the cerebellum is wrapped tightly around the brainstem as a result of spinal cord tethering and downward migration of the posterior fossa contents
What is the difference between anencephaly and acrania? [1]
What anomaly is seen in this US scan? [1]
An anamoly scan is given and they detect holoprosencephaly.
What is this? [1]
Holoprosencephaly:
- birth defect (congenital condition) that causes the fetal brain to not properly separate into the right and left hemispheres (halves).
What anomaly is seen in this US scan? [1]
Talipes
- Talipes, commonly known as clubfoot, is a congenital deformity of the foot and ankle where the foot is twisted out of its normal position. This condition can vary in severity and may affect one or both feet.
Lecture
Which anomolies can be detected on the anomaly scan? [+]
Spina bifida
Anencephaly
Hydrocephalous
Major heart problems
Exomphalos/g astrochisis
Major kidney problem
Major limb
Abnormalities
Lecture
Which soft markers on US at anomaly scan would indicate a baby has Down’s Syndrome? [5]
- Ventriculomegaly
- Choroid plexus cyst
- Hyperecogenic bowel - Echogenic foci in heart ‘golf ball’
- Bilat RPD
- Sandal gap (large gap between the big toe and the second toe)
- Polydactyly
Describe the different classifications of ovarian cancer [+]
Epithelial tumours: 90%: - Majority arised from ovarian surface epithelium. Lots of subtypes:
- Serous (60-70%); develop from fallopian tube epithelium
- Endometrial
- Clear cell
- Mucinous
- Transitional cell (Brenner tumours)
Non-epithelial ovarian carcinomas:
- Germ cell tumours: most common non-epithelial ovarian cancer and in women < 35
- Sex cord and stromal tumours
- Carcinosarcoma
- Small cell cancer
What are the risk factors for ovarian cancer?
- Hormonal [3]
- Env [6]
- Genetic [3]
Risk increases with number of ovulatory cycles and age
Hormonal:
* Nulliparity (never having given birth)
* Early menarche & late menopause (as leads to longer ovulatory cycle)
* HRT
Genetic:
* Positive family history
* BRCA 1/ BRCA 2
* Lynch syndrome
Environmental:
* Talcum powder: The use of talcum powder in the genital area has been associated with a slight increase in risk, possibly due to inflammation caused by talc particles.
* Diet: High-fat diet and consumption of animal fats have been implicated in ovarian cancer risk. However, the evidence remains inconclusive.
* Endometriosis: Women with endometriosis have a higher risk of developing certain types of ovarian cancer, particularly clear cell and endometrioid carcinomas. Disputed link
* Smoking
* Asbestos
* Obesity
Describe the clinical features of ovarian cancer [5]
Often asymptomatic / has non specific symptoms so is diagnosed late - silent killer!
Symptoms:
* abdominal distension and bloating
* abdominal and pelvic pain
* urinary symptoms e.g. Urgency
* early satiety
* diarrhoea
TOMTIP: An ovarian mass may press on the obturator nerve and cause referred hip or groin pain. The obturator nerve passes along the inside of the pelvic, lateral to the ovaries, where an ovarian mass can compress it.
State stages I-IV of ovarian cancer [4]
- Stage I: Cancer is confined to one or both ovaries.
- Stage II: Cancer has spread to other pelvic structures.
- Stage III: Cancer has spread beyond pelvis or to retroperitoneal lymph nodes.
- Stage IV: Distant metastasis has occurred, such as in liver or lung parenchyma.
Germ cell tumours may have which hormones raised? [2]
Germ cell tumours may cause raised alpha-fetoprotein (α-FP) and human chorionic gonadotrophin (hCG).
Describe what is meant by a Krukenburg tumour [1]
What is their defining histological feature? [1]
A Krukenberg tumour refers to a metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly the stomach.
Krukenberg tumours have characteristic “signet-ring” cells on histology, which look like signet rings on under a microscopy.
Refer directly on a 2-week-wait referral if a physical examination reveals: [3]
Ascites
Pelvic mass (unless clearly due to fibroids)
Abdominal mass
If you suspect cancer (but not indicated for a 2ww), what initial investigation should you perform? [1]
What level of ^ would indicate further imaging? [1]
What further imaging? [2]
if the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered
Name 4 TVUS findings that would indicate ovarian cancer [4]
- solid areas within the cyst
- irregularity of the cyst wall or septa
- presence of ascites
- increased vascularity on Doppler flow studies.
Which serum marker is used alongisde CA125 to improve S&S? [1]
HE4 (Human epididymis protein 4): This serum marker is used alongside CA-125 to improve sensitivity and specificity in predicting malignancy.
How would you differentiate ovarian cancer from endometriosis - symptoms [3]; exam [1]’ TVUS [1]
Symptoms:
- cyclic pelvic pain that correlats with menses
- dyspareunia
- infertility
Physical exam:
- tender nodules in posterior fornix
TVUS:
- characteristic ‘chocolate’ cysts.
Endometriosis is characterised by the presence of endometrial tissue outside the uterus
How would you differentiate ovarian cancer from ovarian cysts on TVUS [1]
The key difference lies in imaging studies: ultrasound findings for ovarian cysts typically show simple fluid-filled cavities without any solid components or septations. In contrast, malignant lesions such as ovarian cancer often display complex features including thick walls or septa and solid areas within the cyst.
Ovarian cysts are fluid-filled sacs within or on an ovary’s surface. Patients
Describe the management plan for ovarian cancer [+]
PassMed:
1. The primary treatment for most ovarian cancers is surgical debulking, aimed at removing all visible disease. The extent of surgery may include total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and lymph node dissection.
2. Chemotherapy: is typically administered postoperatively to treat any residual disease. The standard regimen is a combination of carboplatin and paclitaxel. Neoadjuvant chemotherapy may be considered in cases where optimal debulking is not achievable initially.
3. Targeted Therapy: For patients with advanced ovarian cancer, particularly those with BRCA mutations or homologous recombination deficiency, targeted therapies like PARP inhibitors (e.g., olaparib, niraparib) may be indicated.
Describe what is meant by primary debulking surgery for ovarian cancer [+]
Aim: Apply maximum surgical effort to achieve achieve complete cytoreduction removing all visible disease – R0:
* TAH BSO
* Omentectomy
* +/- Bowel resection
* +/- Stripping of peritoneal surfaces
* Removal of any large tumour masses or suspicious nodes or appendix (mucinous tumours
What is placental abruption and what are the causes? [2]
What are the two types? [2]
Placental abruption refers to when the placenta separates from the wall of the uterus during pregnancy.
- The site of attachment can bleed extensively after the placenta separates.
- Unknown cause
Types:
- Placental abruption can be either concealed (bleeding remains within the uterus and is not visible) or revealed (visible vaginal bleeding).
Describe the clinical features of placental abruption [5]
The typical presentation of placental abruption is sudden constant pain with or without dark red vaginal bleeding (>24 weeks gestation). The pain is continuous
Shock (hypotension and tachycardia)
Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage. Uterus is extremely hard and tender, and it does not relax.
Back pain
Associated with fetal distress
NB: In 20% of cases it is possible for the blood to become trapped inside the uterus (concealed), so even with a severe placental abruption, there might be no visible bleeding.
Describe the difference in pathophysiology of important ddx to placental abruption [1]
Abnormal vaginal bleeding during the second half of pregnancy is usually due to either placental abruption or placenta praevia. It is important to differentiate these two conditions.
- With placental abruption, the placenta partially or completely detaches itself from the uterine wall before delivery
- With placenta praevia, the placenta is located over or near the cervix, in the lower part of the uterus.
Describe what occurs in the < 10 weeks ‘booking clinic’?
Booking visit
* general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
* BP
* urine dipstick
* check BMI
Booking bloods/urine
* FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
* hepatitis B, syphilis
* HIV test is offered to all women
* urine culture to detect asymptomatic bacteriuria
* Screening for thalassaemia (all women) and sickle cell disease (women at higher risk)
When does screening for DS occur? [1]
11-14 weeks
What are the Edward’s syndrome quadraple tests like? [4]
When do you test for abnormal breech presentations? [1]
How do you do this? [3]
Abdominal palpitation & confirm with USS @ 36 weeks
Delivery options are:
- external cephalic version
- breech vaginal delivery
- c-section
How do you specifically measure date a pregnancy? [1]
date the pregnancy measuring the crown-rump
length
What is appropriate growth of fetus - using fundal height landmarks for 12, 20, 36 and 37-40 weeks?
