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
The following are all different types of ovarian cancers. Which can secrete oestrogen and therefore cause endometrial hyperplasia?
Granulosa cell tumour
Endometrioid
Theca cell tumours
Sertoli-Leydig cell tumour
Clear cell
The following are all different types of ovarian cancers. Which can secrete oestrogen and therefore cause endometrial hyperplasia?
Granulosa cell tumour
Endometrioid
Theca cell tumours
Sertoli-Leydig cell tumour
Clear cell
What is clinically significant about granulosa cell tumours? [2]
They can secrete oestrogen - which causes endometrial hyperplasia and risk of endometrial cancers
Which part of the large bowel does ovarian cancer commonly met. to? [1]
Colorectal
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).
Name 5 risk factors for placental abruption [5]
Alcohol ingestion:
- it accumulates on the fetus and amniotic fluid after crossing the placenta. It causes vasospasm in the placenta and umbilical cord, which might lead to abruption of the placenta.
Advanced maternal age
Cigarette smoking
Pre-eclampsia
Cocaine usage during pregnancy
- the high blood pressure and increased levels of catecholamines released by cocaine are considered to be responsible for the vasoconstriction in the uterine blood vessels that causes placental separation and abruption.
Abdominal trauma:
- injuries cause separation of the placental attachment from decidua.
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 investigations used for placental abruption [3]
Ultrasound Imaging
- should have an ultrasound scan performed to confirm or exclude placenta praevia if the placental site is not already known.
Cardiotocograph (CTG):
- should be performed in women above 26 weeks gestation to assess fetal wellbeing.
- Abruption can result in fetal hypoxia and abnormalities of the fetal heart rate pattern
Blood Tests
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 the difference in speed of presentation of placental abruption and placental praevia [1]
placental abruption:
- onset of symptoms is acute and severe
- Haemorrhage may be visible or concealed
- abdominal pain are intense and acute
- Fetal hearts sounds are absent or may show distress
placental praevia:
- quiet and insidious
- Haemorrhage may be external and visible
- Fetal hearts sounds are normal
Describe the mx of placental abruption (include delivery and post-natal mx) [5]
Initial resuscitation
Delivery of baby:
1. If < 36 weeks and no foetal distress:
- admit and give mother steroids
2. If < 36 weeks and foetal distress:
- C-section
3. If > 36 weeks and no foetal distress:
- deliver vaginally
4. If > 36 weeks and foetal distress:
- C-section
Post natal: it is highly recommended to provide active management of the third stage of labour in these patients for the prevention of postpartum haemorrhage.
The risk of preterm births is increased in placental abruption and therefore RCOG suggests a single dose of [] may offer between 24th and 34th weeks of gestation.
Corticosteroids: the risk of preterm births is increased in placental abruption and therefore RCOG suggests a single dose of corticosteroid may offer between 24th and 34th weeks of gestation.
QuesMed flashcard
How is placental abruption diagnosed?
Placental abruption is diagnosed clinically.
An USS is performed to rule OUT placenta praevia
How many weeks are the: first, second and third trimester? [3]
1st trimester: 0-12 weeks
2nd trimester: 13-26 weeks
3rd trimester: 27-50
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)
At the ‘booking clinic’ a risk-assessment is performed. What is the based off a patients’ history?
PMH [2]
Previous obstetric history: [1]
Demographic characteristics: [2]
Test results: [1]
PMH:
- Diabetes
- Hypertension
Previous obstetric history:
- previous still birth
Demographic characteristics:
- High BMI
- Black ethnicity
Test results:
- Rh-ve
Non –white ethnicity have a higher risk for gestational diabetes.
What is the screening test and when would it occur? [3]
Book screening by OGTT between 24-28 weeks if have risk factors
- women who’ve previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
Which screening tests are performed at the booking test and what are they screening for? [4]
Blood group & Rh D status:
- Rhesus D mothers will be offered a blood sample to establish fetal genotype from DNA.
- If fetus predicted to be Rhesus +, Anti-D will be administered in the 3rd trimester and if any significant bleeding
Full blood count:
- Screening for anaemia
Screening for hemoglobinopathies (Hb electrophoresis):
- Screening for thalassemia (allwomen)
- Screening for sickle cell (onlyhigh-riskwomen)
- If women are carrier, also partners are tested .If both partners are carriers, prenatal diagnosis can be offered
Sexual health and ID:
- HIV, Hep B and Syphilus
When does screening for DS occur? [1]
11-14 weeks
Describe the first process of screening for DM [3]
The combined test is the first line and the most accurate screening test. It is performed between 11 and 14 weeks gestation and involves combining results from ultrasound and maternal blood tests:
Ultrasound measures nuchal translucency, which is the thickness of the back of the neck of the fetus.
- Down’s syndrome is one cause of a nuchal thickness greater than 6mm.
Blood tests
* Beta‑human chorionic gonadotrophin (beta-HCG) – a higher result indicates a greater risk
* Pregnancy‑associated plasma protein‑A (PAPPA) – a lower result indicates a greater risk
State which tests exists for screening for DS and when they occur [+]
11-14 weeks: Combined test
- Nuchal translucency (US): > 6mm
- Maternal blood tests (bHCG - high; PAPPA - low)
14-20 weeks: Triple test:
- bHCG - higher indicates greater risk
- AFP - lower result indicates greater risk
- Serum oestriol - lower result indicates greater risk
14-20 weeks: Quadruple test
- bHCG - higher indicates greater risk
- AFP - lower result indicates greater risk
- Serum oestriol - lower result indicates greater risk
- Inhibin-A: - higher indicates greater risk
Describe what amniocentesis or chorionic villus sampling involve when testing for DS? [2]
Chorionic villus sampling (CVS)
- involves an ultrasound-guided biopsy of the placental tissue. This is used when testing is done earlier in pregnancy (before 15 weeks).
Amniocentesis
- involves ultrasound-guided aspiration of amniotic fluid using a needle and syringe.
- This is used later in pregnancy once there is enough amniotic fluid to make it safer to take a sample.
Describe what is meant by Non-invasive prenatal testing (NIPT) [1]
It involves a simple blood test from the mother. The blood will contain fragments of DNA, some of which will come from the placental tissue and represent the fetal DNA
- These fragments can be analysed to detect conditions such as Down’s
- NIPT is not a definitive test, but it does give a very good indication of whether the fetus is affected.
NIPT is gradually being rolled out in the NHS as an alternative to invasive testing (CVS and amniocentesis) for women that have a higher than 1 in 150 risk of Down’s syndrome.
What are the Edward’s syndrome quadraple tests like? [4]
When does screening for congenital anomalies and placental location occur?
18-22weeks
- detailed assessment of the fetus by ultrasound and evaluation of placental location
NB: 16 weeks = information on the anomaly and the blood results.
What are the risk factors for gestational diabetes? [4]
- BMI of > 30 kg/m²
- previous macrosomic baby weighing 4.5 kg or above
- previous gestational diabetes
- first-degree relative with diabetes
- family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
When does a second screen for anameia and atypical red cell alloantibodies occur? [1]
How would you manage abnormal results? [1]
28 weeks:
* If Hb < 10.5 g/dl consider iron
* First dose of anti-D prophylaxis to rhesus negative women
When is the first and second dose of anti-D prophylaxis given? [2]
First dose: 28 weeks
Second dose: 34 weeks
How do you screen for growth problems? [1]
When does it occur? [1]
Screen via symphysis-fundal- height (SFH) at 28 weeks
If a patient is identified as high risk for growth problems, what screening do they have and when? [1]
this is carried out by serial ultrasound scans in the third trimester (28, 32, 36 weeks gestation)
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
All women in the NHS are offered 2 ultrasound scans.
When are they? [2]
What are they for? [2]
Dating scan (11-14 weeks)
- The crown-rump length (CRL)
- The nuchal translucency (NT) - if parent consents
Anomaly scan (18-22 weeks):
* To exclude congenital defects in the fetus
* To assess fetal size
* To assess amniotic fluid volume
* To assess placental location
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?
What is normal SFH growth? [1]
When do you start thinking there is something significantly wrong? [1]
Appropriate growth is usually estimated to be the number of weeks gestation in
centimetres (e.g.: 24 weeks =
24 cm +/- 2 cm)
- Difference 3cm or more is significant
How can you work out gestational age? [1]
Use Naegele’s rule (LMP + 1 year + 7 days) – 3 months
