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PACES Summarised > OG > Flashcards

OG Flashcards

1
Q

Itchy Hands and Feet During Pregnancy

A

Obstetric Cholestasis

induction of labour at 37 weeks is common practice but may not be evidence based
ursodeoxycholic acid - again widely used but evidence base not clear
vitamin K supplementation

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2
Q

Acute SOB, Hypotension. Then CVS Failure and Coagulopathy and then convulsions, leading to coma and death in unmanaged. Happens in the end stages of labour

A

Amniotic Fluid Embolism

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3
Q

140/90 BP. RUQ pain, headaches, blurry vision, oedema and nausea. If they have convulsions…then it is..

A

Pre-Eclampsia. Then it is eclampsia if not managed

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4
Q

Painless PV Bleeding during pregnancy

A

Placenta Praevia

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5
Q

Abdominal pain, PV bleeding and woody hard uterus

A

Placental Abruption

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6
Q

Acute severe abdominal pain during labour, PV bleed, maternal hypotension and foetal hypoxia

A

Uterine Rupture

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7
Q

Turtle sign, failure of delivery of the foetus after head comes out.

A

Shoulder Dystocia

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8
Q

Cord Presentation vs Cord Prolapse

A

Presentation is when cord descends below with membranes intact. Prolapse is when cord presents after rupture of membranes

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9
Q

Blood loss within first 24 hours of birth

A

Primary PPH. Can be minor (500-1000) or major (>1000)

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10
Q

Blood loss within 24 hours and 12 weeks of birth

A

Secondary PPH. Often due to retained products of conception or endometritis

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11
Q

LIF pain in a young fertile woman

A

Ectopic unless proven otherwise

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12
Q

Shouldertip pain, pelvic pain, PV bleeding. Maybe a collapse in a young fertile woman

A

Ruptured ectopic

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13
Q

Severe pelvic pain with hypovolaemic shock. Not Pregnant

A

Ovarian Cyst Torsion/Rupture

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14
Q

Abnormal uterine bleeding, especially post coital and inter menstrual must rule out

A

Cervical Carcinoma

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15
Q

Post menopausal bleeding, must rule out

A

Endometrial Carcinoma

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16
Q

Non-specific symptoms of abdo pain, weight loss, flaws, distension. Management

A

Ovarian Carcinoma. Surgery and Chemo

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17
Q

PV Discharge, pelvic pain fever, abnormal bleeding in a young woman

A

PID

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18
Q

Thick curdy cheese like discharge. Diagnosis and management

A

Candida Albicans. Do a high vaginal swab. Give clotrimazole

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19
Q

Fishy discharge, clue cells, abnormal pH, whiff test positive

A

BV, gardnerella vaginosis, Do a high vaginal swab, treat with metronidazole

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20
Q

Asymptomatic intracellular gram negative pathogen. Most common STI

A

Chlamydia Trachomatis, endocervical swab, give doxycycline. Azithromycin in pregnancy

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21
Q

Asymptomatic gram negative diplococci

A

Neisseria Gonorrhoea, endocervical swab, give ceftriaxone

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22
Q 
Smears first age
3 yearly dates
5 yearly dates
How to do smear
Risk factors for cervical cancer
A
  1. Uses liquid based cytology to collect cells from transformation zone of the cervix.
    25-49 is 3 yearly and 50-64 is 5 yearly
    Get patient exposed from the waist down, lie down on the table, legs up to bum and let them drop to the side. Insepction, then pull vulva apart with right hand, insert speculum with left. Make sure it is inserted sideways then turn it up. Open it and lock it. Use brush to take sample rotating around 10 times clockwise at cervical area. Remove it all. Thank the patient etc..
    Risk factors include HPV, smoking, sexual activity, COCP and immunodeficiency
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23
Q

Stress incontinence management

A

Weight loss, stop smoking, pelvic floor exercises

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24
Q

Urge incontinence management

A

Avoid caffeine, bladder training, maybe oxybutynin.

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25
Q

Prolapse management

A

Conservative: Pelvic floor exercises, possible pessary.
Surgical: Fixation of ligament to prevent prolapse

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26
Q

Dr C BraVADO

A

Define Risk, Contractions, Baseline rate, Variability, Accelerations, Deceleration, Overall

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27
Q

Post Natal Depression Scale

A

Edinburgh Depression Scale. Mother should fill it herself without discussing with others. Scored out of 30

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28
Q

Small for dates cuases

A

Pre-eclampsia, Oligohydroamnios, Smoking, Drugs, Maternall Illnesses, IUGR which can be symmetrical or Asymmetrical

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29
Q

Large for dates causes

A

Polyhydroamnios, Diabetes

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30
Q

Combined Test

A

11-14 weeks: PAPP-A and b-hCG and nuchal translucency

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31
Q

Triple Test

A

14-20 weeks: AFP, hCG and oestriol.

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32
Q

Quadruple Test

A

14-20 AFP, b-HCG, osteriol and inhibin A

33
Q

Antepartum Haemorrhage and management

A

Placenta Praevia, Vasa Praevia, Placental Abruption

Management: ABCDE approach
Give oxygen, fluids, analgesia if required. Then do baseline obs and abdominal examination.
Bloods include FBC, U+E, LFT, TFT, CRP, ESR, G+S/Cross-match.
Imaging include TVUS for diagnosis.
Admit patient and monitor regularly. May require a cesarean section

34
Q

Preterm labour. Diagnosis and management

A

Before 37 weeks.
Consider tocolytics and steroids to develop lungs.
As well as Abx for PPROM.
Magnesium Sulphate IV considered for foetal brain development

35
Q

PPROM

A

Abx for 10 days, do GBS swab, may go home if labour doesn’t start within 48 hours. Strict safety netting. So any pain, discharge, bleeding, foetal distress needs to come back

36
Q

Risks of prematurity to foetus

A

Intraventricular Haemorraghe, RDS, Necrotising Enterocolitis, Hypothermia, Hypoglycaemia

37
Q

Reduced foetal movements History, Diagnosis and Management

A

Consider risk of stillbrithy and IUGR. May require emergency cesarean. Ask about GDM, Smoking, Alcohol, Drugs, Screening for abnormalities

38
Q

Primary PPH Cause, Management and 4T’s

A 
Uterine Atony is the most common cause
Cross-match bloods and do FBC for possible transfusion
Uterine massage
Examination for retained products or tears
Oxytocin
Ergometrine
Carboprost
Balloon tamponade
Ligation of the uterine artery
B-lynch suture
Emergency life-saving hysterectomy

4 T’s are Tone, Tissue, Trauma, Thrombin

39
Q

Breech Presentation at 37 weeks

A

ECV, advice on planned cesarean if ECV fails. Ideally avoid breech vaginal delivery

40
Q

Pre-eclampsia Management

A

Labetalol
Nifedipine and Methyldopa to be considered
Regular follow ups to monitor BP and Urine
Regularly do LFT’s and U+E’s
Monitor foetal growth regularly
Consider induction of pregnancy at 37-38 weeks or cesarean

41
Q

Gestational Diabetes Management

Cut off for GDM

A

OGTT test
Regularly self monitor
Diet and exercise
Metformin, Insulin
Plan to induce at around 38 to 40
Feed baby soon after they’re born as higher risk of hypoglycaemia
Cut off is fasting 5.6 and 2 hour OGTT 7.8
Target fasting glucose is 5.3. Start metformin or insulin.
Increased folic acid dose

42
Q

Ectopic Pregnancy Management

A

Expectant: May resolve itself, but needs monitoring
Medical: Methotrexate, avoid pregnancy for 3months
Surgical: Laparoscopy salpingotomy or salpingectomy. with anti-D prophylaxis

43
Q

Vaginal Discharge Causes

A

Ectropion, Physiological, Neoplasia, STI, Foreign Body, PID

44
Q

Cesarean Section Risks

A

Risks to mother: Infection of the wound, poor healing, increased blood loss, DVT, damage to bladder
Risks to baby: Some minor bruising and TTN
Future pregnancies: Placenta preavia, increased stillbrith risk, placenta accreta/increta/percreta
Also may require thromboembolic prophylaxis so consider LMWH and Ted stockings.

45
Q

Vaginal Birth Risks

Also VBAC

A

May require instrumental delivery and episiotomy, maternal blood loss, PPH, tears in the peineal region, may require emergency cesarean anyway, bladder incontinence
VBAC is not a problem for most women, but risks of uterine rupture, blood loss, and may require a cesarean anyway

46
Q

Hyperemesis Gravidarum Management

A

ABCDE: If severe, admit with fluids and correct electrolyte imbalances. Give pabrinex as they may be deficient. If being admitted, also thromboprophylaxis so TED stockings and consider LMWH
Small bland meals that are frequent,
Some people say ginger and acupuncture helps, can try
Medication: Pyridoxine, Doxylamine which are OTC. Can be prescribed Metoclopramide or Promethazine

47
Q

HIV in Pregnancy

A

Screen for HIV
Start on anti-retroviral therapy (ziduovudine)
Specialist referral
Advise C-section if viral load not controlled
Neonatal ART, give infusion during labour period if needed
No breast feeding

48
Q

Secondary Amenorrhoea

A 
Pregnancy
Hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
Polycystic ovarian syndrome (PCOS)
Hyperprolactinaemia
Premature ovarian failure
Thyrotoxicosis*
Sheehan's syndrome
Asherman's syndrome (intrauterine adhesions)
49
Q

Dysmenorrhoea Causes and Management

A

Primary: Mefanemic acid or ibuprofen
Secondary: Due to endometriosis, adenomysosis, PID, IUD and fibroids. Treat underlying cause

50
Q

Menorrhagia Causes

A 
Dysfunctional Uterine Bleeding
Anovulatory Cycles
Fibroids
Hypothyroidism
IUD
Progesterone Contraception
Bleeding Disorders
51
Q

Menorrhagia Investigations and Management

A

Baseline Obs
Bloods: FBC, CRP, LFT, TFT, CA125
Imaging: TVUS
Management: IUS (first), COCP (second), Tranexamic Acid (if contraception not needed)

52
Q

Fibroids Diagnosis, Investigations and Management

A

Presents as menorrhagia, dysmenorrhoea, with urinary/GI symptoms and subfertility
USS
Medical: IUS, COCP, Tranexamic acid, consider GnRH agonists short term to shrink
Surgical: Myomectomy

53
Q

Early Pregnancy PV Bleed

A 
Miscarriage Stuff
Molar Pregnancy
Ectopic Pregnancy
Fibroids
Polyps
PID
Hyperplasia
Malignancy
If non-pregnant: IUD and progesterone pills and atrophic vaginitis
54
Q

Endometriosis Investigations and Management

A

Laparoscopy is the gold standard diagnosis
Management with NSAIDs, then COCP or progesterone contraception. GnRH analogues are next
Surgical management may help. Laser ablation

55
Q

PE in Pregnancy

A

ABCDE approach
VQ scan, CTPA if VQ scan is not possible
LMWH throughout pregnancy until 6 weeks post natally

56
Q

Atrophic Vaginitis Management

A

Rule out sinister causes

Management with lubricant cream and moisturizers , consider oestrogen cream

57
Q

Post Coital Bleeding Causes

A 
Idiopathic
Ectropion
PID
Polyps
Trauma
Hyperplasia
Malignancy
58
Q

Intermenstrual Bleeding Causes

A 
Physiological
Vaginitis
PID
Polyps
Ectropion
Fibroids
Adenomysosis
Endometritis
Trauma
Drug Induced
Malignancy
59
Q

Contraception

Contraindications

A

Barrier: Condoms, male and female
Hormonal: COCP or Progesterone pills and injection
Implants: IUS, IUD, Implants
Natural: Using body temperature kit in accordance with cycle to estimate ovulation
Emergency: Levonestrogel (3 days), Ullipristal (5 days) and IUD (up to 5 days after ovulation date)

Avoid all hormonal methods in cancers, avoid COCP if UKMEC 4 such as migraine, thromboembolic disease, HTN, age over 35 and smoking over 15 a day, up to 6 weeks post partum, CVD, Liver Disease and poor diabetes control.

60
Q

Epilepsy in Pregnancy

A

Lamotrigine seems to be the best one from data.
Risks of uncontrolled epilepsy is generally greater than the risks of harm to the baby.
Increase folic acid dose
Valproate- Neural Tube Defects, development delay
Phenytoin- Cleft palate
Breast feeding is generally safe
Specialist referral and monitoring

61
Q

Asthma in Pregnancy

A

No problems with medication during pregnancy or breast feeding.
Avoid triggers, don’t smoke,
Risks of medicine are quite small and the risks of a poorly controlled asthma are higher and linked to SGA

62
Q

Bartholin’s Cyst Management

A

Self help measures initially if not problematic. Soak in warm water, analgesia.
If unsuccessful, may require drainage of the cyst. Abx if abscess is formed.
Surgical: Referral to surgery to stitch the glands so they can’t get inflammed (marsupialisation).

63
Q

Lichen Sclerosus

A

White plaques in genital area, steroid cream, emollients and barrier creams help, good hygiene so loose clothes, etc.. Recurrence is common

64
Q

Premenstrual Syndrome

A

Lifestyle management so good diet, exercise, avoid stress and cut down on alcohol and smoking
Medical management: COCP, CBT and consider Mefanemic acid if pain is key symptom
Specialist referral if still not managed

65
Q

Post Menopausal Bleeding

A 
Atrophic Vaginitis
Endometrial Atrophy
Polyps
Hyperplasia
Trauma
Drug Induced
Malignancy
66
Q

COCP Contraindications

A 
Migraine with aura
35 and smoking over 15
Thromboembolic disease
HTN (160/100)
CVD
6 weeks post partum
Diabetes badly controlled
Breast cancer
Messed up liver full on
67
Q

HRT

A

Hot flushes, mood swings, tiredness, poor concentration, dry vagina,

Increased cancer risk of endometrial, ovarian, colorectal, increased risk of VTE, increased risk of strokes, increased risk of fractures

68
Q

Miscarriage Diagnosis and management

A

Early pregnancy PV bleed. Can be painful or painless. Do an abdominal exam and then a speculum exam to visualise cervical os and USS to monitor foetus status. ABCDE approach first as always.

If threatened miscarriage, say to get some rest and stuff and come back if anything happens.
If complete miscarriage, then same
If incomplete miscarriage, can do expectant management or give misoprostol vaginally. May require surgical evacuation of retained products of conception.
Consider counselling for patient if planned pregnancy or difficulty conceiving
If recurrent, then investigations for anti-phospholipid syndrome, check diabetes, PCOS, other endocrine conditions and smoking

69
Q

Smoking in Pregnancy Diagnosis and Management

A

Diagnosis is from history, baby is often SGA, there is chances of IUGR so baby won’t reach it’s full growth potential. There’s increased risks of problems with their breathing. Increased risk of complications in the pregnancy, increased risks of stillbirth/SGA/premature babies.

Management
Stop smoking, support with stopping smoking, refer to a specialist midwife who can help with that,
If partner is smoking, support with him stopping too
Follow up on patients attempts to stop too
If she declines, be impartial, but say the offer is always open
NHS Stop Smoking Service, and also a NHS in Pregnancy Smoking Service, they will probably give CBT and stuff like that.
Nictoine replacement therapy can be used if you can’t stop without it.
Even an e-cigarette is better than cigarettes, but none is best of course.

70
Q

PCOS Diagnosis and Management

A

Presents as subfertility, hirsutism, acne, oligomenorrhoea and typically obese.
Investigations: Raised LH, raised FSH, USS shows cysts, testosterone and prolactin may be mildly elevated
Management
Conservative: Lose weight, stop smoking, so lifestyle
Medical: COCP for hirsutism and acne if not aiming for fertility. If aiming for fertility, clomifene or metformin
Will have to have regular sex for 2 years before trying IVF and stuff

71
Q

Termination of Pregnancy Management

A

Assess competence
Check legal requirements are met (by 24 weeks)
2 registered medical practitioners must sign a document confirming abortion. Also rule out STI’s as they can increase complications
Before 9 weeks: Mifepristone and then misoprostol after 48 hours to initiate contractions
After 9 weeks: Surgical evacuation which is surgical dilation and suction. Early surgical is local, late surgical may require general

Complications:
Infection, bleeding, failure of termination, poor wound healing, trauma to cervix or uterus, small chance of fertility

72
Q

PE/DVT in Pregnancy

A

Can present as chest pain, radiating to the back, or may be an emergency with fluids. May have had a history of a swelling in the legs prior.
Management is via ABCDE. Ensure patient is stable so give oxygen, fluids, analgesia if appropriate. Do VQ scan and then give LMWH for the remainder of the pregnancy and for four to six weeks after delivery.
Also lifestyle stuff, stay hydrated, move around enough, .
Delivery shouldn’t be in birthing centre and should be done in the labour ward

73
Q

STI/PID Diagnosis and Management

A

STI can be asymptomatic, if not, can be present with pain, dysuria, discharge and maybe bleeding.
Investigations include doing endocervical swab and microscopy to look for suspected organism and give antibiotics accordingly.

If PID, they will more likely have pain, urine, discharge, bleeding symptoms. Also may have a fever and dyspareunia. May present as infertility due to previous STI’s. Will need more Abx. Ceftriaxone, Metronidazole and Doxycycline

If they have IUS or IUD, may require removal. Counsel patient on safe sex behaviour

74
Q

Acute Gynae Pain Differentials, Diagnosis and Management

A

ABCDE approach, ensure patient is table
Give oxygen, fluids, analgesia as required
Bloods for cross-match or G+S if needed

Differentials include ectopic pregnancy, miscarriage, PID, ovarian torsion, ruptured ovarian cyst, ruptured fibroid, appendicitis

Investigations: Bloods, Imaging
Management: Depends on underlying cause, give Abx if needed and surgical management mostly.

75
Q

Infertility Differentials and Management

A

In history, ask about all the symptoms, rule out fibroids, endometriosis, PCOS, PID, male factor, blocked tubes, premature ovarian failure

Investigations: FSH and LH (day 3), progesterone levels 7 days before the end of period, prolactin levels, TFT’s, FBC, U+E, LFT’s, do USS to check ovaries and tubes, do STI screen, semen analysis, Hysterosalpingography

76
Q

Substance Abuse in Pregnancy and Management

A

Take a good through history. Ask about all drugs. Ask about social situation, ask about the father.

Management is focused on specialist referral. Antenatal care should be consultant led, look at social support for the patient herself if it is poor. Also involve a specialist substance abuse midwife. Patient should have a key worker that can follow up on them throughout the pregnancy and afterwards. Take an MDT approach.

Regular monitoring of foetus, and at birth, will likely require admission to a neonatal unit NICU/SCBU.

77
Q

How to take blood pressure

A

Explain that you’ll be doing the BP
Put cuff around
Place diaphragm over brachial artery
Inflate cuff until you can’t hear anything. Then slowly deflate it until you hear something. That is systolic
Then you keep deflating until the sound disappears, that is the diastolic blood pressure.

78
Q

How to examine the pregnant abdomen

A

Inspect the abdomen: Signs include linea nigra, striae gravidarum and striae albicans
Palpation of the abdomen
Fetal lie (can be longitudinal, oblique or transverse)
Fetal presentation (can be cephalic or breech)
Measure symphysio-fundal height
Fetal engagement
Use pinard stethoscope to measure heart or doppler

79
Q

Secondary PPH

A

Most common cause is endometritis, can just be infection
ABCDE approach, fluids, oxygen, analgesia as required.
Give antibiotics, lots of them, consider the best ones if in doubt. May require examination under anaesthesia with surgical evacuation of retained products
May require iron supplementation or transfusion depending on the severity

PACES Summarised (3 decks)

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